Denture Insertion and Post Insertion Problems

DENTURE INSERTION AND POST
INSERTION PROBLEMS
Maj Madhul Singhal
3/30/2013
INTRODUCTION
The insertion appointment is the process of

eliminating errors.
- FJ Kratochvil, 1966
REVIEW OF LITERATURE
Carl R. Rodegerdts 1964 conducted a study & results indicate:
1. A low correlation between pressure spots in final impressions and mucosal

irritations.
2. Pressure-indicating paste lacks accuracy in predicting mucosal irritations.
3.The most frequent sites of pressure spots were lateral and distal to the
maxillary tuberosities.
Leland R. 1995 conducted a study to determine the patient's ability to localize
adjustment sites on the mandibular denture.
Results of this study indicate that patient-perceived locations rarely coincided

with the actual area on the denture that required adjustment as determined with
the use of a dye-transfer indicating method.
Basker RM, Beck CB, et al 1993

technical errors in denture construction accounted for the presenting complaint
Champion H et al in 1995
Pain and lack of retention, mainly due to occlusal discrepancies and excessive
VDO.
Muller F et al, 1995

good denture retention facilitates the adaptation process
Yoshida M, Sato Y, Akagawa Y. 2001 did a study on the correlation between the
quality of life (QOL), defined as overall satisfaction with daily life, and denture
satisfaction in elderly complete denture wearers .
Concluded that edentulous elderly people who are well satisfied with their daily
lives are also satisfied with their complete dentures .
Roessler DM et al. 2003 Before treatment even begins, the patient's motivation
for denture treatment and emotional attitude towards dentures must be

evaluated.
Finally, patients must be informed that continued success depends on regular

denture maintenance.
THE INSERTION APPOINTMENT
Final adjustment of prosthesis
Final psychological evaluation, education and counselling
EVALUATION OF THE DENTURES

DENTIST
EVALUATION
PATIENT
EVALUATION
FRIENDS
EVALUATION
Dentists evaluations
Be critical to your own efforts
Be honest (at least to yourself)
Patients evaluation
Hopeful confidence
Fear/apprehension
Friends evaluation
Judgement may be inaccurate
Compliments and comments do matter
Only 50% of work is done
Additional appointments may be required for adjustments
THE DENTURE IS NEW
It is a prosthesis not your natural teeth
PATIENT EDUCATION
Sore areas with New Dentures
Speaking with New Dentures
Chewing with New Dentures
Increased saliva with New Dentures
Longevity of Dentures
Limitations of Dentures
Expected tissue response
How to care for Dentures and tissues
Follow up protocol
REMEMBER THE KIND OF PATIENT WITH

WHOM YOU ARE DEALING!!
Philosophical Rational, sensible,

organized and overcomes conflicts
(Expectations are real)
Exacting Methodical, precise and

accurate; places severe demands (Must
reach an understanding before starting
treatment)
Indifferent Apathetic, uninterested,

uncooperative and lacks motivation;
blames dentist for poor health; pays no
attention to instructions (Unfavorable
prognosis)
Hysterical Emotionally unstable,

excitable, apprehensive (Psychiatric help
may be required)
WHAT TO EXPECT FROM DENTURES
The dentist should neither oversimplify nor overcomplicate the procedures.
Perfectly normal to feel awkward with new dentures.
Artificial teeth are placed in positions that will provide compatibility with the
surrounding environment in speech, swallowing, and masticating.
An excessive flow of saliva frequently accompanies the insertion of new dentures.
The dentures will feel looser or tighter throughout the day.
Vary with the amount of blood in the tissues.
The dentures particularly, the lower may dislodge during speech and eating.
POSSIBLE INACCURACIES IN PROCESSED

DENTURE
Technical errors/errors in judgment by dentist
Technical errors in laboratory
Inherent deficiencies of materials used
LABORATORY REMOUNT
Before removing deflasked denture from cast, place it back to articulator using the
indices of original mounting
If incisal pin does not touch incisal guide table re-establish OVD
LABORATORY REMOUNT
Silk ribbon/think articulating
paper/articulating
ribbon/carbon paper is used to
check the interceptive occlusal
contacts
LABORATORY REMOUNT
ERRORS IN CENTRIC OCCLUSION AND THEIR CORRECTION
Pairs of opposing teeth too long , holding remaining teeth out of occlusion.
Fossae of the teeth in question are deepened . The cusp tips should not be shortened .
The cusp tips of opposing teeth appear to be nearly tip to tip .

Grind on the inclines so as to move the upper cusp inclines buccally and the lower cusp
inclines lingually. In so doing the central fossae are made broader, the lingual cusp of the
upper teeth narrowed, and the buccal cusp of the lower teeth are also narrowed. The cusp
tips should not be shortened.
Upper teeth too buccal in relation to the lower.

Broaden the central fossae, and the buccal cusps of the lower teeth are moved buccally by
broadening the central fossae. The cusp tips should not be shortened.
LABORATORY REMOUNT
After incisal pin touches the incisal guide

table prepare plaster index
Reexamine the tissue side of the dentures and

carefully remove any bubbles present with a
Kingsley scraper or other sharp instrument.
Feel with finger or use cottonwool to recognize

sharp bubbles or projections
Prior to delivery the dentures must be soaked in

water for 72 hours.
EVALUATING ESTHETICS
Check Verify:
Lip support
Cheek support
Vertical height
Low and high lip line
Smile line
Although it has to be stressed that the appearance

cannot be fully assessed until four to six weeks
after insertion of the finished dentures.
This is because of the adaptation of the lip and
facial muscles to the underlying teeth and denture
bases. This is the basis of the problem of judging
the appearance at the trial stage.
EVALUATE RETENTION AND STABILITY

Check
Peripheral seal
PPS
Displacements during chewing/speech etc
EVALUATE PHONETICS
Whistle on s sounds too narrow an air space on the

anterior part of palate
Lisp on s sounds too brad an air space on the

anterior part of palate
th and t sounds indistinct inadequate interocclusal

distance
t sounds like th upper anterior teeth too far lingual
f and v sounds like indistinct improper position of

upper anterior teeth horizontally or vertically
EVALUATE PHONETICS
Check the thickness of the maxillary palatal portion.
A common problem is excessive thickness.
Reevaluate the position of the maxillary anterior

teeth.
If everything appears normal it may be a matter of

time for the patient to adapt.
Open vertical dimension of occlusion Problems with

Phonetics
INSERTION APPOINTMENT SEQUENCE
Adjust denture base
Adjust denture borders
Remount in centric relation
Equilibrate in lateral excursions
Patient education
Old dentures must be left out of the mouth for at least 24 hrs prior to insertion
appointment
ADJUSTING THE DENTURE BASE
Pressure indicating paste - Detects improper adaptation
Sequence
Dry denture surface
Brush a thin even layer of PIP onto the surface of
the denture
Seat the denture with pressure in the first molar
region
Remove immediately Inspect and adjust bearing
surface as necessary
Place two cotton rolls between the

posterior teeth and have the patient bite
down for 5 minutes.
Excessive pressure in area overlying torus
This area is adjusted with an acrylic burr.
When completed the brush marks are mostly absent and the posterior palatal seal
bead is showing.
Apply PIP the mandibular denture
Use smooth even brush strokes
Carefully insert denture so as to avoid

wiping off PIP in undercut areas
Adjust as necessary
Pay particular attention to the mylohyoid

ridge region.
Note the areas of excessive tissue pressure on

the labial and buccal slopes of the ridge.
These are carefully adjusted with an acrylic bur.
When completed with this procedure most of the

brush marks should be obliterated and there
should no areas of tissue displacement noted.
ADJUSTING THE DENTURE BORDERS
Disclosing wax is used to check the length of

the denture borders.
Temper the wax in the syringe in a water bath.
Apply disclosing wax to the dried denture

border.
Carefully insert the denture and mold the

borders of the selected area.
Carefully adjust the denture flange as necessary.
Reapply, border mold and adjust until areas of overextension are eliminated.
COMMON AREAS TO ADJUST
Median raphe
Incisive papilla
Distal buccal flange of the maxillary dentures
Zygomatic process
Frenum areas
COMMON AREAS TO ADJUST
Frenum areas
Genial tubercle
Mylohyoid ridges
RELIEF OF FRENI
CLINICAL REMOUNT
Purpose
Adjusted denture bases seat more accurately than record bases
To accommodate for errors made during the making of centric relation records
REMOUNT CASTS
Remount casts are made to enable the dentist to mount the dentures back on the
articulator after they are polished.
The maxillary cast can be mounted on the articulator prior to the denture insertion
appointment.
This mounting serves to preserve the facebow transfer record.
If there was no index made of this relationship, another facebow recording must be
made
The mounting of the maxillary cast is

accomplished by placing the polished
denture on a remount index that was made
before the maxillary denture was removed
from its cast.
Mandibular remount cast cannot be mounted

until a new centric relation record is made.
This record must be done after the dentures

are adjusted by using pressure indicator
paste (PIP) and fit the mouth securely.
Remount Casts
Remount Casts
Remount Casts
Remount Casts
Remount Casts
Mounting the Maxillary Cast
Occlusal Equilibration
Adjusting in Centric Relation
Use a round-nosed acrylic bur in a straight handpiece to establish centric

occlusion.
Smaller burs will remove too much and leave a rough surface.
Deepen fossae only. (Do not cut down cusp tips when correcting in centric!)
RE-ESTABLISHMENT OF CO
Problem: Teeth too long

Solution: Deepen the fossae
Problem: Teeth too nearly end to end

Solution: Grind Inclines
Problem: Too much horizontal overlap
Solution: Broaden central fossae
AFTER THE CO RE-ESTABLISHMENT.
DO NOT:
Reduce maxillary lingual cusps.
Reduce mandibular buccal cusps.
Deepen the fossae.
Centric Relation
Right side
Straight on
Left side
Centric Relation
Adjusting in Lateral Excursions

It is important to note that when adjusting a denture in a lateral
excursion, the condylar element on the rotating (balancing) side is
locked back in centric.
The condylar element on the translating (working) side is opened
only enough to allow the buccal cusps of the maxillary first molar to
line up with the buccal cusps of the mandibular first molar.

A balanced occlusion is achieved when the cusps of the
working side contact simultaneously with the a posterior
teeth on the balancing side.
The anterior teeth should never contact during the lateral
excursions.
CORRECTION OF WORKING SIDE OCCLUSAL ERRORS.
Reduce lingual inclines of buccal cusps of

maxillary teeth.
Reduce buccal inclines of lingual cusps of

mandibular teeth.
ON WORKING SIDE ONLY!!!
Problem: Buccal and lingual

cusps too long.
Solution: Change inclines of
balancing cusps.
Problem: Buccal cusps are too

long
Solution: Change lingual incline
of maxillary buccal cusp
Problem: Lingual cusp too

long.
Solution: Change buccal
incline of lingual cusp of
mandibular tooth.
Upper buccal / lingual cusp mesial to intercuspal position . Grind to move mesial
inclines of upper buccal cusps distally and distal inclines of lower mesially.
Upper buccal/ lingual cusp distal to intercuspal position. Grind distal of upper
cusps and mesial of lower cusps.
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CORRECTION OF BALANCING-SIDE ERRORS.
Reduce lingual inclines of mandibular buccal cusps; or
Decide which supporting cusp maintains CO and reduce its opponent.
CORRECTION OF BALANCING-SIDE ERRORS.
Grind the lingual incline

of the mandibular
buccal cusp.
ELIMINATING OCCLUSAL ERRORS IN NONANATOMIC TEETH
Interocclusal CR record is made.
Dentures mounted and gross premature contacts are removed.
Final adjustments with articulating paper.
CHECKING FOR THE ERRORS OF OCCLUSION
Look for touch and slide when patient slowly closes his mandible
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CORRECTING OCCLUSION
In centric relation
Articulator locked in CR position and incisal pin is lifted
Tap upper and lower denture with interposed articulating paper
Markings are reduced with grinding stone till there is maximum uniform contact
Should not touch cusp tips of functional cusps
Reduce opposing fossa and cuspal inclines of the functional cusps
Incisal pin is lowered over the table
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Lateral excursion
Condylar nuts are loosened
Movements of articulator made with interposed articulating paper
Continue selective grinding till pin remains on table during lateral excursion
83
Adjustments for lateral relationships are made by

following the rule of BULL, and the posterior teeth
should contact simultaneously on both sides in
working, balancing and protrusive relationships.
The anterior teeth should not contact except in

protrusive relationship and then simultaneously
with the posterior teeth.
A.Working side prematurities:

Rule of BULL (buccal upper/lingual lower)
. Reduce maxillary buccal cusps.
. Reduce mandibular lingual cusps.

B. Balancing side prematurities:
Rule of BULL
Reduce buccal inclines on upper lingual cusps.
Reduce lingual inclines on mandibular buccal cusps.
Adjusting in Protrusive
It is important to note that when adjusting a denture in a
protrusive relationship, the condylar elements are opened only
enough to allow the maxillary central incisors to line up end-toend with the mandibular central incisors when the midlines of
the maxillary and mandibular dentures line up.
Balanced occlusion is achieved when the incisors contact
simultaneously with posterior teeth on both sides.
POST INSERTION PHASE
After 24 hours
After 1 week
3 weeks
3 - 4 months
Once in every year
89
24 HOURS CHECK
Inquire about the patients problems and

conduct a thorough oral examination
Check the denture for pressure areas

and adjust the denture as needed with
Check borders for overextension with

disclosing wax and adjust as needed
Evaluate occlusion, refine equilibration

as necessary, and recheck finish and
polish
24 HRS CHECK
Note the ulcer associated with

the denture border overlying
the canine eminence
24 HOURS CHECK
Note the PPS seal area:
The bead is too deep and sharp
Note the ulcer at the midline
24 HOURS CHECK
Note the lesions with the

anterior mandibular
denture border
They correspond to the

PIP pattern
24 HOURS CHECK
This area represents a bony spicule

just beneath the mucosa.
Unless the denture is properly adjusted

in this area, the irritation will progress
to ulceration
24 HOURS CHECK
Inspect frenum areas
Most common frenum to become irritated from denture overextension is maxillary

anterior frenum
Adjust it with aid of disclosing wax using small acrylic bur in slow speed handpiece
24 HOURS CHECK
Beware of the inferior alveolar nerve
In patients with severe resorption of alveolar ridge, a portion of
the inferior alveolar nerve may be exposed
Pressure in these areas may cause significant pain.
24 HOURS CHECK
Evaluate for
occlusion
If you observe a
change repeat the
clinical remount
procedure
POST INSERTION PROBLEMS
Post-insertion treatment is that phase of the complete denture procedure that

involves any necessary alteration of the dentures, tissue treatment and patient
education.
MOST COMMON PROBLEMS

Mandibular denture
Discomfort
Poor retention and stability
Lack of support
Maxillary denture
Poor retention and stability
Esthetics and phonetics
DISCOMFORT
Secondary to:
Open vertical dimension of occlusion
Inaccurate centric relation record
Lack of occlusal balance
Poor denture base adaptation
Inappropriate denture base extensions
RETENTION AND STABILITY

Compromised by:
Occlusal discrepancies
Poor denture base adaptation
Inadequate denture extensions
These factors are controlled by the

dentist
Moderate to severe resorption

Unfavorable floor of mouth posture
Retruded tongue position
Reduced salivary flow
Poor neuromuscular control
These factors are beyond the control of the

dentist
FACTORS CAUSING POST INSERTION

PROBLEMS
Adverse intra-oral anatomical factors eg atrophic mucosa.
Clinical factors eg poor denture stability.
Technical factors eg failure to preserve the peripheral roll on a master cast.
Patient adaptional factors.
FACTORS RESULTING IN DISCOMFORT RELATED

TO THE IMPRESSION SURFACE OF DENTURES
Discrete painful areas
Pearls or sharp ridges of acrylic on the fitting surface arising from deficiency in
laboratory finishing
Locate with finger, or snagging dry cotton wool fibres. Use disclosing material to
assist locality to ease denture

Pain on insertion and removal, possibly inflamed mucosa on side(s) of ridges
Denture not relieved in region of undercuts
Use disclosing material to adjust in region of wipe off. Exercise care as excessive
removal may reduce retention. Also clinician should only insert denture and then
remove it - the patient should not occlude as this may confuse an occlusal fault with
support problems

Areas painful to pressure
Pressure areas resulting e.g. from faulty impressions, damage to working cast,
warpage of denture base. Consider also residual pathology (eg retained root), lack
of relief for active frena, non-displaceable mucosa over bony prominence (eg torus)
Use disclosing material to accurately locate area to be relieved. If severe, remake

may be required. Consider removal of root

Over-extension of lingual flange. Painful mylohyoid ridge; denture lifts on

tongue protrusion;
Painful to swallow
Over-extended lower impression: instructions to laboratory not clear or non-existent
Determine position and extent of over-extension using disclosing material and

relieve accordingly

Generalised pain over denture-supporting area
Under-extended denture base - may be the result of over-adjustment to the

periphery, or impression surface. Check for adequacy of FWS
Extend denture to optimal available denture support area. If insufficient FWS,

remake may be required

Lack of relief for frena or muscle attachments; pinching of tissue between

denture base and retromolar pad or tuberosity.
Sore throat, difficulty in swallowing
Peripheral over-extension resulting from impression stage and/or design error.

Palatal soreness as post dam too deep
Relieve with aid of disclosing material. Care with adjustment of post dam - removal
of existing seal and its replacement in greenstick prior to permanent addition may be
required
FACTORS RESULTING IN DISCOMFORT - RELATING TO

OCCLUSAL SURFACES OF DENTURES
Pain on eating in presence of occlusal imbalance (no support problems)
Anterior prematurity or posterior prematurity, incisal locking, lack of balanced

articulation
Determine where occlusal prematurities exist. Adjust occlusion by selective

grinding. If severe error remount using facebow and new interocclusal records

Pain lingual to lower anterior ridge
If no over-extension present, look for protrusive slide from RCP to ICP
Mark deflecting inclines of posterior teeth with thin articulating paper. If slide
exceeds half a cusp width, re-register and reset

Pain and/or inflammation on labial aspect of lower ridge
If no impression surface defect, may be lack of incisal overjet causing incisal

locking
Reduce incisal vertical overlap. If appearance compromised, resetting the incisors

may be required

Pain about periphery of dentures possibly accompanied by pain in masseter

and posterior temporalis muscles (classically pain increases as the day
progresses)
Vertical dimension of occlusion more than patient can tolerate
If excess less than 1.5 mm, grind to provide FWS. If greater than 1.5 mm, reregister to reset dentures at new OVD

Cheek and or lip biting
For cheeks - likely that functional width of sulcus was not restored. For lips - poor
lip support/inadequate anterior horizontal overlap
For cheek biting, restore functional width of sulcus and/or reset. For lips, grind
lower incisors to provide a more appropriate incisal guidance angle

Tongue biting
Lack of lingual overjet - teeth generally placed lingual to lower ridge
Remove lower lingual cusps, or reset teeth

POLISHED SURFACES OF DENTURES
Pain at posterior aspect of upper denture on opening
Flange on buccal aspect of tuberosity too thick and constraining coronoid process
Use disclosing material to accurately define area involved, relieve and repolish
FACTORS RESULTING IN DISCOMFORT - FACTORS WITH

POSSIBLE SYSTEMIC ASSOCIATIONS.
Burning sensation over upper denture supporting tissues, but may involve
other intra-oral tissues, e.g. tongue.
Burning mouth syndrome often seen in middle-aged or elderly females. Denture

faults must be excluded, also general organic and pyschogenic factors
Correction of any denture faults, may require multivitamin/nutrition advice and

treatment. Possibly antidepressant therapy. Refer to Consultant in Oral Medicine

Beefy red tongue, possibly glossodynia
Vitamin B12/folate deficiency
Refer for medical treatment

Frictional lesions related to dentures, mucosa may adhere to probing finger,

may be complaint of dry mouth
Xerostomia, commonly side effect of prescribed drugs
Where some saliva flow is present, sugar-free citrus lozenges may help. Where
there is an obvious paucity of saliva, artificial saliva may be considered

Tongue thrusting. Empty mouth chewing. Often seen in elderly patients
May have neurological or psychological aspects. Possibly drug related
Difficult to manage. Treatment may be required to include occlusal adjustment

and/or occlusal pivots

Presence of herpetiform ulcers in mouth
Herpes simplex or Herpes zoster virus. History and distribution of lesions to confirm
Dentures merely coincidental to the condition. May be useful to suggest preventive

remedy (e.g. acyclovir) for some sufferers

Painful click related to TMJ on opening and/or closing mouth and/or

tenderness of muscles of mastication
TMJ pain dysfunction syndrome may be related to rapid change on OVD (either
gross increase or decrease) on production of new denture. May have psychological
aspects, occasionally part of general joint disease
If denture faults present, careful correction required with special care to registration
and vertical dimension

Patient complains of allergy to denture material
Rare symptoms may relate to higher residual monomer content of acrylic
If excess residual monomer detected, rebase denture using controlled heat cure
cycle. May need to consider remaking denture using polycarbonate resin

Painless erythema of mucosa related to support of (usually) upper denture,

may be accompanied by angular cheilitis
Denture-related stomatitis. Often has a frictional element due to ill-fitting denture

plus opportunistic candidal infection. Occasionally related to iron or folate deficiency
Best to leave denture out until condition clears, then remake. If not possible, correct
denture faults, e.g. using occlusal pivots, regularly supervised and replaced tissue
conditioners prior to remake. If angular cheilitis present, combinations of antifungal
and antibacterial agents (e.g. miconazole) useful
FACTORS RESULTING IN LOOSENESS OF DENTURES ARISING FROM DECREASED RETENTION FORCES
Lack of peripheral seal
Border under-extension in depth
Border under-extension in width. Often a particular problem in disto-buccal aspects of upper

periphery which may be displaced by buccinator on mouth opening.
Posterior border of upper denture
Add softened tracing compound to relevant border, mould digitally and by functional movements
by patient. Replace compound with acrylic resin. As a temporary measure a chairside reline
material may be used as described above
Check border is correctly sited on fixed tissue at junction with mobile tissue of soft palate. Trace
thin string of softened tracing compound along impression surface of posterior border and seat
denture firmly in mouth. Replace compound with acrylic resin. For temporary solution, use
butymethacrylate resin as above
Inelasticity of cheek tissues
Consequence of ageing process; scleroderma, submucous fibrous
Mould denture borders incrementally using softened tracingcompound as functional

movements are performed - aim to slightly under-extend depth and width of denture
periphery. Repeated treatment may be required as inelasticity progresses
Air beneath impression surface. Denture may rock under finger pressure. May see
gap between periphery of flange and ridge. Occlusal error subsequent to warpage
Deficient impression. Damaged cast. Warped denture. Over-adjustment of impression

surface. Residual ridge resorption. Undercut ridge. Excessive relief chamber. Change in
fluid content of supporting tissues
Reline if design parameters of denture satisfactory, otherwise remake as required.

Ensure that areas of heavy contact between denture and tissues are relieved prior to
impression making. Where change in tissue fluid distribution is suspected check
medication (eg diuretics) posture (eg heart failure) lack of recovery of tissues from
effects of old denture prior to working impressions being obtained. Stabilise fluid content
of tissues and use minimal pressure impression method
Xerostomia Reduces ability to form a suitable seal
Medication by many commonly prescribed drugs, irridation of head and neck

region, salivary gland disease
Design dentures to maximise retention and minimise displacing forces. Prescribe

artificial saliva where appropriate / salivary reservoir dentures
Neuromuscular control Essential for successful denture wearing: speech and eating
difficulties occur
Basic shape of denture incorrect, lower molars too lingual; occlusal plane too high:
upper molars buccal to ridge and buccal flange not wide enough to accommodate this;
lingual flange of lower convex. Patient of advanced biological age, infirm
Correct design faults by, eg removal of lingual cusps of posterior teeth. Flatten
polished lingual surface of lower from occlusal surface to periphery, fill sulci to optimal
width. May require remake to optimal design. Use information from successful
previous denture if available. Denture adhesives may be deemed to be necessary
FACTORS RESULTING IN LOOSENESS OF DENTURES:

ARISING FROM INCREASED DISPLACING FORCES
Denture borders Over-extension in depth Slow rise of lower denture when mouth
half open, line of inflammation at reflection of sulcal tissues; ulceration in sulcal
region. Deep post dam on upper base may cause pain, ulceration
If buccal to tuberosities, denture displaces on mouth opening, or cheek soreness

occurs. Thickened lingual flange enables tongue to lift denture; thick upper and
lower labial flanges may produce displacement during muscle activity
Slightly under-extend denture flange and accurately mould softened tracing

compound. Check borders of record rims and trial dentures at the appropriate
stages. Deep post dam to be cautiously reduced and denture worn sparingly until
inflammation clears

Overextension in width Cheeks appear plumped out. In lower, the buccal flange
may be palpated lateral to external oblique ridge
Design error
Reduce over-extension. Use disclosing material to determine what is excessive

Poor fit to supporting tissue
Recoil of displaced tissue lifts denture
Poor/inappropriate impression technique especially in posterior lingual pouch area
Reline if all other design parameters satisfactory, otherwise remake. Ensure

denture is removed from mouth 90 mins prior to impression

Denture not in optimal space
Molars on lower denture lingual to ridge, optimum triangular shape of dentures absent
Posterior occlusal table too broad, causing tongue trapping
Thick lingual flanges encroaching on tongue space, causing lifting. Excess lip pressure to
lower anterior aspect - teeth anterior to ridge, thick periphery
Excess pressure from upper lip to upper denture arising from teeth too labially sited to acute
naso-labial angle; or failure to adequately seat denture during relining impression procedure
Remove lingual cusps and lingual surface from relevant area, repolish. If triangular form not
restored, reset teeth or remake dentures Narrow posterior teeth and/or remove most distal
teeth from dentures. Reshape lingual polished surface Thin lower labial flange, ensure optimal
extension to retromolar pads to resist displacement, reset anterior teeth if necessary Usually
requires remaking denture
FACTORS RESULTING IN LOOSENESS OF DENTURES - ARISING

FROM INCREASED DISPLACING FORCES - OCCLUSAL AND
ANATOMICAL FACTORS
Occlusal errors
Uneven tooth contact causing ttilting of dentures and prevents even seating of
loosened appliances ICP and RCP not coincident - disrupts border seal and
prevents accurate reseating Lack of freedom in ICP (occlusal-locking) dentures will
shift on supporting tissues for those patients with poor control of mandibular
movements
Adjust occlusion until even initial contact in RCP obtained. If gaps between teeth
exceeds 1.5 mm reset teeth or remake dentures. For gaps less than 1.5 mm it may
still be necessary, in the interest of accurate diagnosis, to remount the dentures, as
a patients mouth may be too tender to permit chairside adjustment. Adjust occlusion
for coincident ICP/RCP contact. If error is greater than half width of cusp, all teeth
on at least one denture need resetting. Remount dentures on adjustable articulator
and adjust area of occlusal contact. Allow 1.5 mm of anterior movement from RCP.
May use cuspless teeth where appropriate

ANATOMICAL FACTORS
Ulceration labial to lower ridge
Excessive vertical overlap of anterior teeth. Lack of balance and anterior tooth contact may
cause tilting, soreness in lower ridge Last mandibular molars placed too far posteriorly and lie
over retromolar pad or ascending part of ramus. Occlusal contact on this inclined plane
causes denture to slip forward Occlusal plane/s not orientated appropriately and masticatory
forces tend to move dentures over supporting tissues
Reduce height of lower anteriors. Aesthetic problems may necessitate resetting of teeth
Remove most posterior teeth from denture
Usually requires teeth to be reset or dentures to be remade

ANATOMICAL FACTORS
Fibrous displaceable ridge
Masticatory forces tend to cause denture to sink into and tilt towards supporting
tissues
Reline after removal of acrylic from impression surface until no contact with
displaceable tissue, provide many vent holes, low viscosity impression material,
maximise posterior border seal

ANATOMICAL FACTORS
Bony prominence covered by thin mucosa (e.g. tori)
Denture rocks over prominence which may be covered with inflamed tissue
Remove acrylic from impression surface where disclosing material shows excessive
loading of supporting tissues. Do not create excessive relief or loss of retention
may result

ANATOMICAL FACTORS
Non-resilient soft tissue
Does not adapt to impression surface of denture reducing support and retention
factors
Reline dentures to obtain optimal border extensions in depth and width, use low
viscosity impression material

ANATOMICAL FACTORS
Pain avoidance mechanisms
Use of excessive amounts of fixative, or self-applied reline material, or even cotton

wool, to attempt to relieve contact with supporting tissues
Eliminate the cause of pain
DENTURE PROBLEMS ASSOCIATED WITH

PROBLEMS OF ADAPTATION
Noise on eating/speaking.
May be apparent on first insertion or may appear as resorption causes

dentures to loosen
May be lack of skill with new dentures, excessive OVD, occlusal interference, loose
dentures, or poor perception of patient to denture wearing
Where unfamiliarity present, reassurance and persistence recommended.
Address specific faults or remake as required

Eating difficulties
Dentures move over supporting tissues
Unstable dentures. Check that retentive forces are maximised and displacing forces
minimised and all available support has been used
Construct dentures to maximise retention and minimise displacing forces

Blunt teeth
Broad posterior occlusal surfaces which replaced narrow teeth on previous denture.
Non anatomical type teeth used where cusped teeth previously used
Where non-anatomical teeth used, careful explanation of rationale is required, may

be possible to reshape teeth. Routine use of narrow tooth moulds recommended.

Jaws close too far
Lack of OVD, so that mandibular elevator muscles cannot work efficiently
May increase up to 1.5 mm by relining but if deficiency is greater, remake denture

Cannot open mouth wide enough for food.
May be speech problems and facial pain especially over masseter region
Excessive OVD
Can remove up to 1.5 mm from occlusal plane by grinding, but if more is required,
remake dentures

Speech problems
Uncommon, but presence is of great concern to patient. May affect sibilant

(e.g. s), bilabial (e.g. p,b), labiodental (e.g. f,v)
Cause may not be obvious. May be unfamiliarity - check that problem not present
with old dentures
Check for vertical dimension accuracy, and that vertical incisor overlap not
excessive. Palatal contour should not allow excessive tongue contact or air leakage
- assess using disclosing paste over denture palate while sound is made.
It is recommended that the patients speech is assessed at trial insertion visit

Gagging
May be volunteered by patient prior to treatment, or apparent at commencement of

treatment or on insertion of denture
May be loose dentures, thick distal border of upper denture: lingual placement of upper
posterior teeth or low occlusal plane causing contact with dorsal aspect of tongue
Construct dentures to maximise retention and minimise displacing forces.
Use condition appliance e.g. fully extended base for home use.
Psychological assessment if indicated

Appearance
Complaints may arise from patient or relatives. Common complaints include: shade of
teeth too light or dark; mould too big/small; arrangement too even or irregular or lacking
diastema
Patient failed to comment at trial stage, or has subsequently been swayed by family or
friends.
Perhaps the change from the old denture to the replacement denture is too
sudden/severe
Accurate assessment of patients aesthetic requirements. Ample time for patient

comments at trial stage.
Use any available evidence to assist - photographs, previous dentures.

Too much visibility of teeth
Level of occlusal plane unacceptable, teeth placed on upper anterior ridge and
no/poor lip support
Accurate prescription to laboratory via optimally adjusted occlusal rim

Creases at corners of mouth
Labial fullness and anterior tooth position may be inaccurate.
OVD may be inadequate
Adjust tooth position as appropriate. If OVD problem, re-register jaw relations

Colour of denture base material

unnatural
Patients skin colour not taken into

account in determining colour of base
material
Remake using suitable base material
OTHER POSSIBLE SOLUTIONS
Osseointegrated implats
Permanent soft liners
Denture adhesives
OSSEOINTEGRATED IMPLANTS
Improved retention. Note denture snaps onto retention

bar.
Improved stability (from the implants and the retention

bar).
Improved support (anteriorly).
Better control of the bolus (tongue no longer must

position denture and control bolus simultaneously and
can concentrate on control of the bolus).
PERMANENT SOFT LINERS

SILICONE ELASTOMERS
Indications
Limited to mandibular dentures
Poor ridge height
Chronic soreness
Bruxers
No attached gingiva
Contraindications
Poor oral hygiene
Patients with xerostomia
Must be replaced more frequently
Special burs required for adjustment
DENTURE ADHESIVES
Powder
Cream
Pads
Generally discouraged
In very few cases for short periods of time adhesive may help
keep new dentures in place.
Denture retention, particularly in the mandible, is a matter of
neuromuscular control which is gained by practice and time
PATIENT EDUCATION
Ask patient to use the denture as much as possible (adaptation element) especially
speech (read newspaper aloud).
If significant discomfort - soreness - the denture should be removed - but try to

replace at least 6hrs before the next appointment - to observe tissue response
Diet recommendation, cut food and place on back teeth - up and down motion (a
new skill to be acquired)
Caution - may feel some fullness early on and excessive salivation in the first few
weeks - should resolve
DENTURE MAINTENANCE
Chemical agents
Don't use strong bleaching agent
Immersion in sodium hypochlorite solution for preventing bad odor
Buffalo university recommendation
1 table spoon house hold bleach
114 cc of water
Removal of calculus
Overnight immersion in 114 cc of white vinegar
155
MAINTENANCE OF TISSUE HEALTH

Adequate tissue rest
Removal of denture at least for 8 hours a day
To allow tissue rest
Reduce RRR
Improve blood supply
156
Mechanical cleansing
Overnight soaking in water
Soft brush and mild detergents
Not to use abrasive tooth pastes
Sonic cleansers
Employ vibratory energy
Effective in removing stains
157
Cleaning of soft liners

Gentle washing in cold running water with soft cotton
When soaked in water denture should rest over teeth
Commercial cleansers are avoided
158
TISSUE HYGIENE
Gentle brushing of residual ridges
Through oral hygiene and tongue cleaning
159
OVER THE COUNTER DENTURE PRODUCTS
Educate the pt on dangers of

Excessive use of denture adhesives
Home reliners
Self adjustment kits
DO NOT
adjust
the
denture
s
160
DENTURE ADHESIVES
Temporary measure
Available forms
Powders, gels, pastes and wafers
Method of application and cleaning
161
CARE OF THE DENTURE
To avoid dropping of denture
To avoid self adjustments
Good oral and denture hygiene

Cleaned after each meal
Not to use boiling water
Denture should be kept in water or dilute antiseptic solution
162
Avoid biting with front teeth
Sneezing and coughing can dislodge the denture
Denture should be removed while traveling in mountain sickness
163
Periodic recall for the oral examination

12 month interval is the suggested time
Inform the patient regarding occlusal adjustments and reline procedures
associated with the use of dentures
164
CONCLUSION
CD is not a substitute for natural teeth but only a prosthetic solution for no teeth
It requires patience on the part of patient, skill and experience on the part of
dentists to correct problems associated with the use of dentures
165
THANK YOU

Denture Insertion and Post Insertion Problems

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DENTURE INSERTION AND POST

Maj Madhul Singhal

The insertion appointment is the process of

Carl R. Rodegerdts 1964 conducted a study & results indicate:

1. A low correlation between pressure spots in final impressions and mucosal

2. Pressure-indicating paste lacks accuracy in predicting mucosal irritations.

Leland R. 1995 conducted a study to determine the patient's ability to localize

adjustment sites on the mandibular denture.

Results of this study indicate that patient-perceived locations rarely coincided

Basker RM, Beck CB, et al 1993

Muller F et al, 1995

for denture treatment and emotional attitude towards dentures must be

Finally, patients must be informed that continued success depends on regular

THE INSERTION APPOINTMENT

Final adjustment of prosthesis

Final psychological evaluation, education and counselling

EVALUATION OF THE DENTURES

Only 50% of work is done

Additional appointments may be required for adjustments

THE DENTURE IS NEW

It is a prosthesis not your natural teeth

Sore areas with New Dentures

Speaking with New Dentures

Chewing with New Dentures

Increased saliva with New Dentures

Expected tissue response

How to care for Dentures and tissues

REMEMBER THE KIND OF PATIENT WITH

Philosophical Rational, sensible,

Exacting Methodical, precise and

Indifferent Apathetic, uninterested,

Hysterical Emotionally unstable,

WHAT TO EXPECT FROM DENTURES

The dentist should neither oversimplify nor overcomplicate the procedures.

Perfectly normal to feel awkward with new dentures.

An excessive flow of saliva frequently accompanies the insertion of new dentures.

The dentures will feel looser or tighter throughout the day.

Vary with the amount of blood in the tissues.

POSSIBLE INACCURACIES IN PROCESSED

Technical errors/errors in judgment by dentist

Technical errors in laboratory

Inherent deficiencies of materials used

The cusp tips of opposing teeth appear to be nearly tip to tip .

tips should not be shortened.

Upper teeth too buccal in relation to the lower.

After incisal pin touches the incisal guide

Reexamine the tissue side of the dentures and

Feel with finger or use cottonwool to recognize

Prior to delivery the dentures must be soaked in

Low and high lip line

Although it has to be stressed that the appearance

EVALUATE RETENTION AND STABILITY

Displacements during chewing/speech etc

Whistle on s sounds too narrow an air space on the

Lisp on s sounds too brad an air space on the

th and t sounds indistinct inadequate interocclusal

t sounds like th upper anterior teeth too far lingual

f and v sounds like indistinct improper position of

Check the thickness of the maxillary palatal portion.

A common problem is excessive thickness.

Reevaluate the position of the maxillary anterior

If everything appears normal it may be a matter of

Open vertical dimension of occlusion Problems with

INSERTION APPOINTMENT SEQUENCE