denture looseness cd & rpd occlusionocclusion denture base (fit & contour)denture base (fit...

Denture LoosenessDenture LoosenessCD & RPDCD & RPD


• OcclusionOcclusion

• Denture base (fit & contour)Denture base (fit & contour)

• Poor anatomyPoor anatomy




Denture LoosenessDenture LoosenessCD & RPD: CD & RPD: OcclusionOcclusionDenture LoosenessDenture Looseness

CD & RPD: CD & RPD: OcclusionOcclusion

Typical HistoryTypical History

Adequate retention initially Adequate retention initially

Gets worse with timeGets worse with time

Clinically:Clinically:

No discomfort when press firmly No discomfort when press firmly on 1on 1stst molars molars


Adequate retention initially Adequate retention initially

Gets worse with timeGets worse with time


No discomfort when press firmly No discomfort when press firmly on 1on 1stst molars molars



Perpetually Loose Maxillary DenturePerpetually Loose Maxillary Denture• Heavy anterior interferences can cause Heavy anterior interferences can cause

loosening at posteriorloosening at posterior

• Tuberosity mucosa grows into spaceTuberosity mucosa grows into space

• Space develops under midline of denture baseSpace develops under midline of denture base

Perpetually Loose Maxillary DenturePerpetually Loose Maxillary Denture• Heavy anterior interferences can cause Heavy anterior interferences can cause

loosening at posteriorloosening at posterior

• Tuberosity mucosa grows into spaceTuberosity mucosa grows into space

• Space develops under midline of denture baseSpace develops under midline of denture base

TuberosityTuberosity



Tilting Growth Loss of retentionTilting Growth Loss of retentionTilting Growth Loss of retentionTilting Growth Loss of retention

InclinedInclinedResidual RidgeResidual Ridge

InclinedInclinedResidual RidgeResidual Ridge

LipLipLipLip

Denture LoosenessDenture LoosenessCD & RPD: OcclusionCD & RPD: Occlusion

Denture LoosenessDenture LoosenessCD & RPD: OcclusionCD & RPD: Occlusion

• Incisors placed too far labiallyIncisors placed too far labially

• Denture displaces lingually.Denture displaces lingually.

• Inclined ridge provides no Inclined ridge provides no resistance.resistance.

• Incisors placed too far labiallyIncisors placed too far labially

• Denture displaces lingually.Denture displaces lingually.

• Inclined ridge provides no Inclined ridge provides no resistance.resistance.

Denture LoosenessDenture LoosenessCD & RPD: CD & RPD: OcclusionOcclusionDenture LoosenessDenture LoosenessCD & RPD: CD & RPD: OcclusionOcclusion

Tilting/jiggling caused by:Tilting/jiggling caused by:

• Contacts not Contacts not centered over ridgecentered over ridge

• Contacts on inclined Contacts on inclined portion of ridgeportion of ridge

Tilting/jiggling caused by:Tilting/jiggling caused by:

• Contacts not Contacts not centered over ridgecentered over ridge

• Contacts on inclined Contacts on inclined portion of ridgeportion of ridge


Check for looseness in excursions with fingers Check for looseness in excursions with fingers on canineson canines

Check for looseness in excursions with fingers Check for looseness in excursions with fingers on canineson canines


• Check centric position Check centric position (articulating paper)(articulating paper)

– even, stable contacts both sideseven, stable contacts both sides

– stop patient upon initial stop patient upon initial contactcontact

• Check centric position Check centric position (articulating paper)(articulating paper)

– even, stable contacts both sideseven, stable contacts both sides

– stop patient upon initial stop patient upon initial contactcontact

Denture LoosenessDenture LoosenessCD & RPD: CD & RPD: Denture BaseDenture Base



Loose/discomfort immediately on Loose/discomfort immediately on insertioninsertion


Discomfort when press firmly on 1Discomfort when press firmly on 1stst molarsmolars

Pressure up/outward from lingual of Pressure up/outward from lingual of canine causes loosenesscanine causes looseness


Loose/discomfort immediately on Loose/discomfort immediately on insertioninsertion


Discomfort when press firmly on 1Discomfort when press firmly on 1stst molarsmolars

Pressure up/outward from lingual of Pressure up/outward from lingual of canine causes loosenesscanine causes looseness

Denture LoosenessDenture LoosenessMandibular lingual flange too thickMandibular lingual flange too thick

Denture LoosenessDenture LoosenessMandibular lingual flange too thickMandibular lingual flange too thick

TongueTongueTongueTongue

Flange bulges into tongue space, lifts denture Flange bulges into tongue space, lifts denture during function. Flange is not too long. during function. Flange is not too long. Flange bulges into tongue space, lifts denture Flange bulges into tongue space, lifts denture during function. Flange is not too long. during function. Flange is not too long.

“Eyes in Your Fingers” Blanchard, JPD 2:36

“Eyes in Your Fingers” Blanchard, JPD 2:36



Short flangeShort flange • PIP streaksPIP streaks

• Looks short of vestibuleLooks short of vestibule

• Often displaces easilyOften displaces easily

Short flangeShort flange • PIP streaksPIP streaks

• Looks short of vestibuleLooks short of vestibule

• Often displaces easilyOften displaces easily



Long flangeLong flange • PIP burnthroughPIP burnthrough• Retentive until speaking, Retentive until speaking,

eatingeating• Watch when seating Watch when seating

denturedenture- Flange touches vestibular Flange touches vestibular

depth, denture continues to depth, denture continues to seatseat

Long flangeLong flange • PIP burnthroughPIP burnthrough• Retentive until speaking, Retentive until speaking,

eatingeating• Watch when seating Watch when seating

denturedenture- Flange touches vestibular Flange touches vestibular

depth, denture continues to depth, denture continues to seatseat



• If flange too thickIf flange too thick– Seal may be maintained at restSeal may be maintained at rest– Pulls during function - dropsPulls during function - drops

• If flange is short or longIf flange is short or long– Displacement as lips or cheeks moveDisplacement as lips or cheeks move– Allows air to break vestibular sealAllows air to break vestibular seal

• If flange too thickIf flange too thick– Seal may be maintained at restSeal may be maintained at rest– Pulls during function - dropsPulls during function - drops

• If flange is short or longIf flange is short or long– Displacement as lips or cheeks moveDisplacement as lips or cheeks move– Allows air to break vestibular sealAllows air to break vestibular seal



PrinciplePrinciple

Always have the patient Always have the patient demonstrate how a denture demonstrate how a denture

loosensloosens

PrinciplePrinciple

Always have the patient Always have the patient demonstrate how a denture demonstrate how a denture

loosensloosens



Lack of post dam/ Lack of post dam/ retrozygomal sealretrozygomal seal

• Pull upward and Pull upward and outward on canineoutward on canine

• Test hypothesis:Test hypothesis: add add compound/functional compound/functional wax -opposite sidewax -opposite side

Lack of post dam/ Lack of post dam/ retrozygomal sealretrozygomal seal

• Pull upward and Pull upward and outward on canineoutward on canine

• Test hypothesis:Test hypothesis: add add compound/functional compound/functional wax -opposite sidewax -opposite side



• Poor base adaptationPoor base adaptation

• Fulcrum on bony Fulcrum on bony structuresstructures

• Test hypothesis: Test hypothesis: PIPPIP

• Poor base adaptationPoor base adaptation

• Fulcrum on bony Fulcrum on bony structuresstructures

• Test hypothesis: Test hypothesis: PIPPIP



Periphery terminates on Periphery terminates on bony structuresbony structures

– Hard palateHard palate

– ZygomaZygoma

– External oblique ridgeExternal oblique ridge

– Before retromolar padBefore retromolar pad

• No seal, discomfortNo seal, discomfort

• Eventual resorptionEventual resorption

Periphery terminates on Periphery terminates on bony structuresbony structures

– Hard palateHard palate

– ZygomaZygoma

– External oblique ridgeExternal oblique ridge

– Before retromolar padBefore retromolar pad

• No seal, discomfortNo seal, discomfort

• Eventual resorptionEventual resorption

Dry MucosaDry MucosaDry MucosaDry Mucosa



PrinciplePrinciple

Denture peripheries always terminate on Denture peripheries always terminate on displaceable soft tissuesdisplaceable soft tissues

Retromolar pads, Vestibular tissues, Vibrating line Retromolar pads, Vestibular tissues, Vibrating line (nonmoveble soft palate), Hamular notches(nonmoveble soft palate), Hamular notches

PrinciplePrinciple

Denture peripheries always terminate on Denture peripheries always terminate on displaceable soft tissuesdisplaceable soft tissues

Retromolar pads, Vestibular tissues, Vibrating line Retromolar pads, Vestibular tissues, Vibrating line (nonmoveble soft palate), Hamular notches(nonmoveble soft palate), Hamular notches

Gagging with DenturesGagging with DenturesGagging with DenturesGagging with Dentures

• Usually not soft palate contactUsually not soft palate contact• Denture contact with Denture contact with tonguetongue : :

– thick posterior border rubs on tonguethick posterior border rubs on tongue– posterior border drops onto tongue:posterior border drops onto tongue:

- Occlusal interferencesOcclusal interferences- Terminates on hard palate (no seal)Terminates on hard palate (no seal)

• Usually not soft palate contactUsually not soft palate contact• Denture contact with Denture contact with tonguetongue : :

– thick posterior border rubs on tonguethick posterior border rubs on tongue– posterior border drops onto tongue:posterior border drops onto tongue:

- Occlusal interferencesOcclusal interferences- Terminates on hard palate (no seal)Terminates on hard palate (no seal)

Denture LoosenessDenture LoosenessDenture Base: Denture Base: Coronoid InterferenceCoronoid Interference

Denture LoosenessDenture LoosenessDenture Base: Denture Base: Coronoid InterferenceCoronoid Interference

• Thick flange in retrozygomal areaThick flange in retrozygomal area

• Coronoid gets closer to tuberosity Coronoid gets closer to tuberosity as patient opens or moves jaw to as patient opens or moves jaw to sideside

• Dislodges maxillary dentureDislodges maxillary denture

• Thick flange in retrozygomal areaThick flange in retrozygomal area

• Coronoid gets closer to tuberosity Coronoid gets closer to tuberosity as patient opens or moves jaw to as patient opens or moves jaw to sideside

• Dislodges maxillary dentureDislodges maxillary denture

Denture LoosenessDenture LoosenessDenture Base: Denture Base: Pterygomandibular RaphePterygomandibular Raphe

Denture LoosenessDenture LoosenessDenture Base: Denture Base: Pterygomandibular RaphePterygomandibular Raphe

• Raphe from area of Raphe from area of hamular notchhamular notch

• Very tight in some Very tight in some patients patients

• Easily displaceable, but Easily displaceable, but raphe can displace raphe can displace denture opening widedenture opening wide

• Raphe from area of Raphe from area of hamular notchhamular notch

• Very tight in some Very tight in some patients patients

• Easily displaceable, but Easily displaceable, but raphe can displace raphe can displace denture opening widedenture opening wide

Denture LoosenessDenture LoosenessDenture Base: Denture Base: Palatal CleftPalatal Cleft

Denture LoosenessDenture LoosenessDenture Base: Denture Base: Palatal CleftPalatal Cleft

• In some patients midline soft In some patients midline soft palate fissurepalate fissure

• Can Can ““tenttent”” during function during function

• Allows air to leak under Allows air to leak under denturedenture

• In some patients midline soft In some patients midline soft palate fissurepalate fissure

• Can Can ““tenttent”” during function during function

• Allows air to leak under Allows air to leak under denturedenture

Denture Looseness or Pain Denture Looseness or Pain CD & RPDCD & RPD

Denture Looseness or Pain Denture Looseness or Pain CD & RPDCD & RPD

PrinciplePrinciple

Always have the patient rate Always have the patient rate improvement (0-100) after improvement (0-100) after

adjustment. If below 90%, more adjustment. If below 90%, more diagnosis/adjustment is requireddiagnosis/adjustment is required

PrinciplePrinciple

Always have the patient rate Always have the patient rate improvement (0-100) after improvement (0-100) after

adjustment. If below 90%, more adjustment. If below 90%, more diagnosis/adjustment is requireddiagnosis/adjustment is required

Denture LoosenessDenture LoosenessCD & RPD: CD & RPD: Poor AnatomyPoor Anatomy

Denture LoosenessDenture LoosenessCD & RPD: CD & RPD: Poor AnatomyPoor Anatomy

• Many sets of denturesMany sets of dentures

– Use articulatorUse articulator

–More involved/precise impression & More involved/precise impression & jaw relation proceduresjaw relation procedures

– ImplantsImplants

– ReferRefer

• Many sets of denturesMany sets of dentures

– Use articulatorUse articulator

–More involved/precise impression & More involved/precise impression & jaw relation proceduresjaw relation procedures

– ImplantsImplants

– ReferRefer

OverviewOverviewOverviewOverview

• Deal with denture problems systematicallyDeal with denture problems systematically• Use a differential diagnosisUse a differential diagnosis• Address probable causes until problem Address probable causes until problem

eliminatedeliminated• If canIf can’’t identify problem, refert identify problem, refer

• Deal with denture problems systematicallyDeal with denture problems systematically• Use a differential diagnosisUse a differential diagnosis• Address probable causes until problem Address probable causes until problem

eliminatedeliminated• If canIf can’’t identify problem, refert identify problem, refer

Phonetic ProblemsPhonetic ProblemsPhonetic ProblemsPhonetic Problems

LispingLisping::– too much overjettoo much overjet

– triangular spaces between max. & mand. teethtriangular spaces between max. & mand. teeth

– palatal contour too constrictedpalatal contour too constricted

– insufficient tongue spaceinsufficient tongue space

LispingLisping::– too much overjettoo much overjet

– triangular spaces between max. & mand. teethtriangular spaces between max. & mand. teeth

– palatal contour too constrictedpalatal contour too constricted

– insufficient tongue spaceinsufficient tongue space

Difficult Denture PatientsDifficult Denture PatientsDifficult Denture PatientsDifficult Denture Patients

• Anatomic ProblemAnatomic Problem

• Diagnosis ProblemDiagnosis Problem

• Adaptive ProblemAdaptive Problem

• Psychologic ProblemPsychologic Problem

• Anatomic ProblemAnatomic Problem

• Diagnosis ProblemDiagnosis Problem

• Adaptive ProblemAdaptive Problem

• Psychologic ProblemPsychologic Problem


PrinciplePrincipleIf you canIf you can’’t determine the problem using t determine the problem using

indicating medium: indicating medium: 1. Tell the patient1. Tell the patient

2. Don2. Don’’t adjustt adjust

3. Refer3. Refer

PrinciplePrincipleIf you canIf you can’’t determine the problem using t determine the problem using

indicating medium: indicating medium: 1. Tell the patient1. Tell the patient

2. Don2. Don’’t adjustt adjust

3. Refer3. Refer


PrinciplePrinciple

Never pretend to adjust a dentureNever pretend to adjust a denture

Reinforces maladaptive behaviour - harder Reinforces maladaptive behaviour - harder for the next guyfor the next guy

PrinciplePrinciple

Never pretend to adjust a dentureNever pretend to adjust a denture

Reinforces maladaptive behaviour - harder Reinforces maladaptive behaviour - harder for the next guyfor the next guy

Difficult Denture PatientsDifficult Denture PatientsAdaptive ProblemAdaptive Problem


• Elderly take more time to adaptElderly take more time to adapt• More teeth missing, less adaptation More teeth missing, less adaptation

(loss of PDM receptors)(loss of PDM receptors)

• Better perception - less adaptiveBetter perception - less adaptive

• Elderly take more time to adaptElderly take more time to adapt• More teeth missing, less adaptation More teeth missing, less adaptation

(loss of PDM receptors)(loss of PDM receptors)

• Better perception - less adaptiveBetter perception - less adaptive



• Denture may be the cause of the problemDenture may be the cause of the problem

• Patient response may also be part of the Patient response may also be part of the problemproblem

• Denture may be the cause of the problemDenture may be the cause of the problem

• Patient response may also be part of the Patient response may also be part of the problemproblem

Difficult Denture PatientsDifficult Denture PatientsAdaptive/Adaptive/PsychologicPsychologic Problem ProblemDifficult Denture PatientsDifficult Denture Patients

Adaptive/Adaptive/PsychologicPsychologic Problem Problem

DentistDentist’’s response to patient may also affect s response to patient may also affect the patient response to the denturethe patient response to the denture

““Laying on of HandsLaying on of Hands””

DentistDentist’’s response to patient may also affect s response to patient may also affect the patient response to the denturethe patient response to the denture

““Laying on of HandsLaying on of Hands””

Adaptive, Psychologic ProblemAdaptive, Psychologic ProblemPreventionPrevention

Adaptive, Psychologic ProblemAdaptive, Psychologic ProblemPreventionPrevention

• Good interview techniqueGood interview technique

• Tips Tips – Many denturesMany dentures

– Disparaging previous dentures/dentistsDisparaging previous dentures/dentists

– Body Language/ DeportmentBody Language/ Deportment

• Good interview techniqueGood interview technique

• Tips Tips – Many denturesMany dentures

– Disparaging previous dentures/dentistsDisparaging previous dentures/dentists

– Body Language/ DeportmentBody Language/ Deportment

Adaptive, Psychologic ProblemAdaptive, Psychologic ProblemPrevention: InterviewPrevention: Interview


1. Recognize & 1. Recognize & AcknowledgeAcknowledge Problem Problem– Open ended questionsOpen ended questions

– Let patient identify problemLet patient identify problem

– If you identify the wrong problem - failIf you identify the wrong problem - fail

1. Recognize & 1. Recognize & AcknowledgeAcknowledge Problem Problem– Open ended questionsOpen ended questions

– Let patient identify problemLet patient identify problem

– If you identify the wrong problem - failIf you identify the wrong problem - fail



2. Explore and Identify Problems2. Explore and Identify Problems– Let the patient talk (silence)Let the patient talk (silence)– Watch for nonverbal cluesWatch for nonverbal clues– Short verbal clues may be significant Short verbal clues may be significant

((““...and I guess the appearance...and I guess the appearance””))

– DonDon’’t be afraid of questions relating to emotional t be afraid of questions relating to emotional healthhealth

2. Explore and Identify Problems2. Explore and Identify Problems– Let the patient talk (silence)Let the patient talk (silence)– Watch for nonverbal cluesWatch for nonverbal clues– Short verbal clues may be significant Short verbal clues may be significant

((““...and I guess the appearance...and I guess the appearance””))

– DonDon’’t be afraid of questions relating to emotional t be afraid of questions relating to emotional healthhealth



3. Interpret & Explain Problems3. Interpret & Explain Problems– Advise patient of your viewAdvise patient of your view

– Use care in dealing with emotional problemsUse care in dealing with emotional problems

– DonDon’’t be afraid to address emotional componentt be afraid to address emotional component

3. Interpret & Explain Problems3. Interpret & Explain Problems– Advise patient of your viewAdvise patient of your view

– Use care in dealing with emotional problemsUse care in dealing with emotional problems

– DonDon’’t be afraid to address emotional componentt be afraid to address emotional component



4. Offer a Solution4. Offer a Solution– If chance denture will not be a success, state at If chance denture will not be a success, state at

outsetoutset

– If sense trouble, refer or address immediatelyIf sense trouble, refer or address immediately

– If suggest a therapist, patient will run or say yesIf suggest a therapist, patient will run or say yes

4. Offer a Solution4. Offer a Solution– If chance denture will not be a success, state at If chance denture will not be a success, state at

outsetoutset

– If sense trouble, refer or address immediatelyIf sense trouble, refer or address immediately

– If suggest a therapist, patient will run or say yesIf suggest a therapist, patient will run or say yes



If bells go off in your head, listen to If bells go off in your head, listen to them, talk more, donthem, talk more, don’’t proceed past t proceed past

interview, until satisfiedinterview, until satisfied

If bells go off in your head, listen to If bells go off in your head, listen to them, talk more, donthem, talk more, don’’t proceed past t proceed past

interview, until satisfiedinterview, until satisfied



• Remember: Most patients are not problem Remember: Most patients are not problem patientspatients

• 80-85% are satisfied80-85% are satisfied

• Better adaptation than eyeglass wearersBetter adaptation than eyeglass wearers

• Remember: Most patients are not problem Remember: Most patients are not problem patientspatients

• 80-85% are satisfied80-85% are satisfied

• Better adaptation than eyeglass wearersBetter adaptation than eyeglass wearers

Adaptive, Psychologic ProblemAdaptive, Psychologic ProblemAdaptive, Psychologic ProblemAdaptive, Psychologic Problem

Rule out objective findingsRule out objective findings

Chart findings objectivelyChart findings objectively

Rule out objective findingsRule out objective findings

Chart findings objectivelyChart findings objectively

OverviewOverviewOverviewOverview

• Deal with denture problems systematicallyDeal with denture problems systematically

• Use a differential diagnosisUse a differential diagnosis

• Address probable causes until problem Address probable causes until problem eliminatedeliminated

• If canIf can’’t identify problem, refert identify problem, refer

• Deal with denture problems systematicallyDeal with denture problems systematically

• Use a differential diagnosisUse a differential diagnosis

• Address probable causes until problem Address probable causes until problem eliminatedeliminated

• If canIf can’’t identify problem, refert identify problem, refer

denture looseness cd & rpd occlusionocclusion denture base (fit & contour)denture base (fit...

Documents

labially denture

midline of denture base

midline of denture basespace

inclined ridge

ridge contacts

inclined residual ridge

occlusion check

initial contact slide