Managing Problems Complications

MANAGING PROBLEMS AND COMPLICATIONS PART I & II
Khaled Q Al Hamad BDS MSc MRD RCSEd 4th year, Dent 445
References
1. Complete Prosthodontics problems, diagnosis, and management (Grant, Heath, McCord) Chapter: Problem solving 2. Lecture notes
Appearance 2. Function
1.
1. Looseness of dentures Decreased retentive forces

Lack of peripheral seal. Air beneath the impression surface Xerostomia Neuromuscular control Denture border problems (over extension in length & width) Post dame too deep Poor fit Denture not sited in optimal space( also neuro muscular control)
Increased displacing forces

Problems in occlusion Support problems

1.
2.
Lack of ridge Bony prominence Non- resilient soft tissue Pain- avoidance mechanisms
Comfort Speech Psychological Other.
Appearance
May
arise at the delivery visit ! Arise when communication has broken down. May arise. when relative dislikes the results.
The the try-in home Or ask the pt to bring his relative at the try-in
Solutions:
Shade: staining or resetting Teeth positions: grinding or repositions Polished surface: grinding
Looseness of dentures
especially in the lower.

Due to atrophic Mandibular ridge Solved may be by placing implants.
Patients
may describe this as:
Rocking Falling Lifting or rising Too big Bulky and occupy too much space..
Upper denture most possess a seal to prevent easy access of air and saliva to impression surface. Seal has two components:
Buccal & labial flanges should fill functional depth and width of the sulci. Seal across posterior border should be effective.
It may be possible to develop similar seal around the lower.
Examining the seal

Upper:
Labial & buccal border: pull down on anterior teeth Post dam: pull out on incisors Distobuccal sulcus and tuberosity: pull out on canine on the contra lateral side.
Lower:
Left with tip of probe placed in the anterior interdental area.
1.



1.
2.
Presentation
Lack of peripheral seal border under extension in length & width

On delivery When speaking When eating When opening wide After adjustment
Examination:
Direct vision Diagnostic addition of tracing compound
Overcoming
Adding tracing compond to relevant borders, mould and trim excess. Send to the lab for the compound to be replaced with acrylic. For semi-permanent option: modify in a similar manner by adding butyl methacrylate resin-provide butt joint between old and new resin
Avoiding:
Proper primary & secondary impression. Proper pouring
Posterior border of upper denture
Recognizing
Observe soft palate movement when say aah Diagnostic addition of tracing compound
Management
Over-extension: adjust the add post dam as below Under-extension: extend border with tracing compound and refine fit with wash impression. Cut grooves for post dam in master cast.
Avoiding
See picture
Post dam of insufficient width
Causes
of Lack of Retention
Decreased retentive forces

Lack
of peripheral seal. Air beneath the impression surface Xerostomia Neuromuscular control

Denture
border problems (over extension ) Occlusal problems
Decreased retentive forces- lack of seal

Torus
where the post dam should be sited.
Note junction line between mobile and non mobile tissues. Palpate to determine size of torus and displaceability of tissues anterior and posterior to it. Adjust borders until optimal seal achieved. Replace post dam.
Resorption
Lapse
of residual ridge
Recognizing:
of time Denture may rock with finger pressure Fibrous displasia due to denture overextension
Management
If polished surface acceptable, teeth in neutral zone, free way space not more than 6mm, and occlusion satisfactory, then reline denture
Avoiding
Prolong wearable life of immediate denture by repeated relining with tissue conditioner (3 weeks maximum ). Review complete denture yearly to determine the need for reline/remake.
Inelasticity
of cheeks (aging, scleroderma, submucous fibrosis)

Recognizing
Patient
medical history Observation of mobility of tissues Palpation of displaceability of lips and cheeks
Management
Adjust
borders by adding tracing compound and then replacing it with acrylic. border moulding
Avoiding
Proper
Causes

Lack
of peripheral seal. Air beneath the impression surface

Poor fit Changes in tissue fluid Undercut residual ridge Excessive relief over areas of reduced displaceability
Xerostomia
Neuromuscular Denture
control

Trapped air expands as denture moves away from supporting structure until air bubble reaches the borders and seal broken. Poor fit may be due to :
Deficient impression Damaged cast Warped dentures Over adjustment of dentures Changes in tissue fluid Resorption of residual ridge Excessive relief
Recognizing
Denture may rock under pressure Visual inspection: gaps may be seen around flanges Through deterioration of occlusion f denture has warped Through the application of thin layer of low viscosity disclosing agent.
Management
If polished surface acceptable, teeth in neutral zone, free way space not more than 6mm, and occlusion satisfactory, then reline denture
Management
If polished surface acceptable, teeth in neutral zone, free way space not more than 6mm, and occlusion satisfactory, then reline denture. Before taking the impression, relieve heavy contacts.
Avoiding
When making the 2nd impression ensure:

Uniform
thickness of impression material achieved No pressure from tray Impression poured before distortion occurs. Borders are adequately supported
Cast must not be over trimmed or damaged Optimum curing cycle used. Denture must not be heated when trimmed and not be cleaned through boiling.
Causes

Lack

Xerostomia
control

Changes in tissue fluid
Lack of recovery from old denture(90 min gap) Medications (diuretics) Heart failure If prolonged seating pressure by cotton pellets restore retention, reline/rebase using minimum pressure technique. consult with the physician Ensure old denture not worn for 90 minutes before the impression
management
Causes

Lack

Xerostomia
control

Undercut residual ridge

Determine displaceability
High:
check if after addition of tracing compound the denture can be painlessly inserted and removed. Low : assess if angles path would help. If yes add tracing compound and replace it with acrylic.
Avoiding:
With
high displaceability request the lab to process acrylic into undercuts. Low displaceability- assess if angled path will help. If yes, process acrylic into undercut. If no, request lab to block out undercut and accept compromised retention
Causes

Lack

Xerostomia
control

Excessive relief over areas of reduced displaceability

Recognizing
Palpate
Management
area and compare it with amount of relief provided Use disclosing material.
Reline/rebase:
Avoidance
outline
outline area to be relived on the casts or on the impression and indicate amount of relief. area to be relived on the casts or on the impression and indicate amount of relief.
Causes

Lack

Xerostomia
control

XEROSTOMIA
Lack
of saliva due to
or disease of salivary gland Medications Irradiation of the head and neck

Reduce
ability to form seal along borders. Management

Consider prescribing
Sugar
free acidic sweets, chewing gums, artificial saliva.
Consult with the physician. Design denture to maximize retentive forces and minimize displacing forces.
Causes

Lack

Xerostomia
control

Basic shape of denture incorrect. cross section of the posterior region should be triangular. Occlusal surface sited within confines of borders and polished surfaces being slightly concave
Recognizing
Lower molar too lingually placed. Lingual polished surface convex Upper buccal flange insufficiently wide.
Management
Narrow lower teeth lingually Adjust lingual polished surface Add tracing compound to adjust buccal flange
Decreased retentive forces/Neuromuscular control

Other
causes
On delivery On eating On speaking After adjustment
Motor neuron disorder

Presentation:
Change in shape to the old dentures

Try
to adjust dentures to be similar to the old ones. Consider template techniques
High Occlusal plane on lower denture Patient des not appreciate the need for active control.
High Occlusal plane
Recognizing
Usually associated with high VD if the upper incisal level is correct
Management
If upper occlusal plane correct hen:
If
increased VD is under 1.5 mm: mount on the articulator and adjust lower using selective grinding If more than 1.5mm : reset t the correct VD
Patient des not appreciate the need for active control.
Recognizing
Ask patient to close on your finger by the anterior teeth and observe position of the tongue. Ideally should take the position shown on the figure.
Management
Train the patient to use his tongue to retain the denture by placing small beading of resin on the posterior border of the upper and lingual to the anteriosr.
When patient has been with out posterior teeth, tongue adapts to increased available space. Consider
Use of small occlusal table Remove most distal posterior teeth Consider using special impression techniques: neutral zone technique.
Causes of Lack of Retention

Lack

Xerostomia

Denture
Neuromuscular
control
border problems (over extension in length & width) Poor fit to supporting structures Deep post dam Occlusal problems
Increased Displacing Forces
Overextension (in length) :

Recognition
Direct
vision and gentle manipulation of cheeks and lips, and movement of the tongue. Look for sign of inflammation t the reflection of the sulcus.
Overextension (in width):

Buccal to tuberosities (encroachment on coronoid) Lingual & labial flanges: if thick could be lifted by the tongue and mentalis
Management
Reduce bulk- use disclosing agent if needed- and repolish
Avoidance:
Proper border moulding and impressioning.

Lack

Xerostomia

Denture
Neuromuscular
control
border problems (over extension in length & width) Deep post dam Poor fit to supporting structures Occlusal problems
Deep
post dam
Recoil of tissues pushes denture downwards Recognizing

Pt
complain of pain in region of the post dam. Deep groove in palatal tissues with inflammation ranging from hyperemia to ulceration.
Management
Reduce
depth-use disclosing agent if needed- be aware of over reduction as the tissues may heal and lack of seal may develop

Lack

Xerostomia

Denture
Neuromuscular
control
Poor
fit to supporting structures
Recoil of displaced tissues lifts denture. Recognizing

Denture
falls when teeth not in contact.( not to be confused with overextension or denture not sited in optimal space) polished surface acceptable, teeth in neutral zone, free way space not more than 6mm, and occlusion satisfactory, then reline denture-using minimal pressure technique. Before taking the impression, relieve heavy contacts and ensure old dentures not worn for 90 minutes before making the impression
Management
If

Lack

Xerostomia

Denture
Neuromuscular
control
Uneven
Initial Contacts
causes dentures to tilt on supporting tissues, thus disrupting retentive seal. Also prevents even seating of loosening dentures on supporting tissues when teeth occluded. Recognizing:
ask
Aim
patient to close slowly into RCP until teeth just touch

is to adjust occlusion until even contact in RCP is achieved.
Management
Minor errors: use chair side techniques- difficult as dentures move on supporting tissues producing errors in markings Major errors: use laboratory techniques. Remount the maxillary denture on semi adjustable articulator using a face bow and the Mandibular denture with Pre-tooth contact registration. Then adjust the occlusion on the articulator using articulating paper. Gaps more than 1.5mm (vertically) or errors in antero-posterior relation more than half a cusp require cannot be adjusted by selective grinding and requires re setting.
Lack
of freedom between RCP & ICP
Patient with inaccurate control of Mandibular movement may not adapt to exact cusp-fossa relationship casing dentures to move and disrupt peripheral seal. Recognizing
Age/
medical history: patient has difficulty in achieving reproducible occlusal relationship. Patient able to eat using old dentures with flattened, worn teeth.
Management
Remount
dentures, adjust teeth to produce area of freedom. If adjustment will result in loss of occlusal balance, reset/remake using cuspless teeth.
Avoidance
Always
allow 1-1.5mm of easy anterior movement of mandible from RCP. Consider use of cuspless teeth (non-anatomic) teeth set in occlusal balance during lateral and protrusive movement (this produces no vertical overlap- possible effect on aesthetics)
Lack
of occlusal balance in excursive movements
Causes dentures to shift on supporting tissues and disrupt retentive seal. Many patient wear denture successfully without occlusal balance, however, as retentive forces decreases , displacing forces generated by lack of balance assume greater significance. Recognizing
Hold
the dentures in place on supporting tissues. Request patient to close until teeth just touch, then to rub from one side to side and forwards. By observation, note if teeth slide easily without causing dentures to move over supporting tissues.
Lack of balance commonly associated excessive vertical overlap of anterior teeth.
Management
Adjust
teeth until balancing contacts us achieved. Could be done chair side, but remount procedures is preferred. If achievement of balancing contacts would necessitate mutilation of teeth ( excessive shortening of lower incisors) then reset teeth or remake dentures.
Excessive
vertical overlap of anterior teeth
Recognizing
Detection
of interferences during speech: request the patient to produce (S) sounds. Upper and lower teeth should just not touch.
Management
Shorten
the lower anterior teeth, this may result in aesthetic problem If up to 1.5mm of free way space is requiredremount and selectively alter occlusal contacts to reduce vertical dimension at occlusion. if extra freeway space required exceeds 1.5mm, remove the posterior teeth from the denture with incorrect occlusal plane and re register then re set or remake the dentures.
last lower tooth too posteriorly placed

Teeth overlies crest of the residual ridge as this rises towards crest of the retromolar pad. Pressure on these teeth causes denture to slip up.
Recognize
Apply finger pressure on the last tooth and observe if denture moves.
Management
Remove most posterior teeth from dentures
Orientation of the occlusal plane not parallel to ridge.

Mastication produces forces that tend to move the dentures over supporting tissues. Problems can occur with large tuberosities, as these can depress occlusal plane posteriorly and this may place the lower denture at a forward force.
Management
Reset the teeth or remake the dentures
Problems
Appearance Function
Looseness of dentures Problems in occlusion Support problems

Comfort Speech Psychological
Other.
Support Problems
Lack
of ridge Fibrous displaceable ridge Bony prominence covered by thin mucosa Non- resilient soft tissue
Lack of Ridge
Little resistance to forces in lateral and anteroposterior directions; denture liable to move, and thus disrupting retentive seal. Recognizing
Observation of ridge. May be associated with a shallow palate. Denture may move easily with finger pressure.
Management
Minimize displacing forces and maximize retentive forces
Fibrous displaceable ridge
Forces of mastication cause denture to sink into and tilt on supporting tissues, thus disrupting retentive seal. Observation
Palpation of the residual ridge to determine displaceability. Denture may sink into tissues under finger pressure. Presence of history of presence of natural teeth (usually lower anteriors) Teeth may appear to meet evenly under forceful occlusion, but when the teeth just meet, incorrect occlusion often appear.
Management
Reline/rebase
Precautions Remove acrylic from impression surface until no contact is evident-you could check with disclosing material. Add vent holes in the labial /buccal flange of the dentures. Use low viscosity material. Provide best possible posterior teeth.
Non-
resilient soft tissue
Does not adapt to impression surface May be associated with Endocrine /Nutritional deficiencies. Management is similar to fibrous displaceable ridge
Bony prominence covered by thin mucosa

e.g. :Prominent maxillary midline suture, denture rocks about fulcrum produced by area of reduced tissue displaceability and thus disrupting the seal. Recognizing
Denture rocks on finger pressure. Inflammation of thin mucosa Palpation to determine degree of displaceability
Overcoming
Remove acrylic from impression surface (indicated by disclosing agent)

Beware of excessive creation of space beneath the denture Beware of over thinning of the denture base-possible fracture
Provide optimal occlusal contacts.
Pain Avoidance Mechanisms
1.



1.
2.
1.

Lack of peripheral seal. Air beneath the impression surface Xerostomia Neuromuscular control Denture border problems (over extension in length & width) Post dame too deep Poor fit Denture not sited in optimal space( also neuro muscular control) Occlusal errors

2. Problems in occlusion 3. Support problems

1.
Comfort
Speech Psychological Other.
Causes of Discomfort
Related
to
Impression surface Polished surface Occlusal surface
Discomfort Related to the Impression Surface
Pressure areas due to:

Faulty impression Damage to the working cast Warping of the base during processing Immersing in too hot water
Denture base not relieved in a region of undercut Pearls of acrylic or sharp ridges on the fitting surface of the denture Lack of appropriate relief over tori, atrophic mucosa. Overextension of peripheries, unrelieved frenal /muscle attachment Pressure on mylohyoid ridge. Atrophic mucosa, spiky ridge Postdam too deep
Discomfort Discomfort
Related to the Polished Surface Related to the occlusal Surface
Maxillary denture constraining coronoid process. Slide form RCP to ICP Lack of incisal overjet Lack of appropriate freeway space Lack of occlusal contacts
Discomfort Related to Other Causes

Instability
of Dentures Burning Mouth Syndrome Xerostomia TMD
1.



1.
Comfort
Speech
Psychological Other.
Noise
on speaking:
Recognizing:
Excessive
OVD Occlusal interferences Loose dentures
Sibilants,
Count
e.g. S
from 60-70, anterior teeth should be just out of contact
Recognizing:
Bilabial
Lip
sounds, e.g. P B
Recognizing:
approximation: is it easily attained? Incisal position: is it incorrect?
Labio
dental sounds, e.g. F V
The vermilion border of mandibular lip rest against the incisal edges of the upper teeth? On swallowing, does the Mandibular lip overlap the labial surface of the maxillary incisors?
1.



1.
Comfort
Speech
Other.
Psychological
Gagging
Desensitization programmes
Use
soft tooth brush
Hypnosis Training plates Fixatives Professional psychological counselor
Other
problem areas
Burning Mouth Syndrome Denture Stomatitis/Angular chelitis Allergy Temporomandibular Joint Disorders (TMD)

Managing Problems Complications

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MANAGING PROBLEMS AND COMPLICATIONS PART I & II

1. Looseness of dentures Decreased retentive forces

Increased displacing forces

Problems in occlusion Support problems

Comfort Speech Psychological Other.

especially in the lower.

may describe this as:

It may be possible to develop similar seal around the lower.

Examining the seal

Left with tip of probe placed in the anterior interdental area.

1. Looseness of dentures Decreased retentive forces

Increased displacing forces

Problems in occlusion Support problems

Comfort Speech Psychological Other.

Lack of peripheral seal border under extension in length & width

Direct vision Diagnostic addition of tracing compound

Posterior border of upper denture

Post dam of insufficient width

Decreased retentive forces

Increased displacing forces

border problems (over extension ) Occlusal problems

Decreased retentive forces- lack of seal

where the post dam should be sited.

of cheeks (aging, scleroderma, submucous fibrosis)

Decreased retentive forces

of peripheral seal. Air beneath the impression surface

Increased displacing forces

When making the 2nd impression ensure:

Decreased retentive forces

of peripheral seal. Air beneath the impression surface

Increased displacing forces

Changes in tissue fluid

Decreased retentive forces

of peripheral seal. Air beneath the impression surface

Increased displacing forces

Undercut residual ridge

Decreased retentive forces

of peripheral seal. Air beneath the impression surface

Increased displacing forces

Excessive relief over areas of reduced displaceability

Decreased retentive forces

of peripheral seal. Air beneath the impression surface

Increased displacing forces

or disease of salivary gland Medications Irradiation of the head and neck

ability to form seal along borders. Management

free acidic sweets, chewing gums, artificial saliva.

Decreased retentive forces

of peripheral seal. Air beneath the impression surface

Increased displacing forces

Decreased retentive forces/Neuromuscular control

Motor neuron disorder

Change in shape to the old dentures

to adjust dentures to be similar to the old ones. Consider template techniques

High Occlusal plane

Patient des not appreciate the need for active control.

Causes of Lack of Retention

of peripheral seal. Air beneath the impression surface

Increased displacing forces

Increased Displacing Forces

Overextension (in length) :

Overextension (in width):

Causes of Lack of Retention

of peripheral seal. Air beneath the impression surface