managing problems complications

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MANAGING PROBLEMS AND

COMPLICATIONS

PART I IIKhaled Q Al Hamad

BDS MSc MRD RCSEd

4 th

year, Dent 445



References

1. Complete Prosthodonticsproblems, diagnosis, and management

(Grant, Heath, McCord)

Chapter: Problem solving

2. Lecture notes



1. Appearance

2. Function1. Looseness of dentures Decreased retentive forces

► Lack of peripheral seal.► Air beneath the impression surface

► Xerostomia

► Neuromuscular control

Increased displacing forces► Denture border problems (over extension in length & width)

► Post dame too deep

► Poor fit► Denture not sited in optimal space( also neuro muscular control)

Problems in occlusion Support problems

1. Lack of ridge

2. 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 mostpossess a seal to preventeasy access of air andsaliva to impressionsurface. Seal has two

components: Buccal & labial flanges

should fill functional depthand width of the sulci.

Seal across posterior bordershould be effective.

► It may be possible todevelop similar seal aroundthe lower.



Examining the seal

►Upper:

Labial & buccal border: pull down on anteriorteeth

Post dam: pull out on incisors

Distobuccal sulcus and tuberosity: pull out oncanine on the contra lateral side.

►Lower: Left with tip of probe placed in the anterior

interdental area.



1. Appearance


► Lack of peripheral seal.► Air beneath the impression surface

► Xerostomia




► Poor fit► Denture not sited in optimal space( also neuro muscular control)


1. Lack of ridge

2. Bony prominence

► Non- resilient soft tissue► Pain- avoidance mechanisms

• Comfort

• Speech

• Psychological

• Other.

L k f i h l l



Lack of peripheral sealborder under extension in length &

width►Presentation

On delivery

When speaking

When eating When opening wide

After adjustment

►Examination:

Direct vision

Diagnostic addition oftracing compound



► Overcoming

Adding tracing compond torelevant borders, mould andtrim excess. Send to the lab

for the compound to bereplaced with acrylic.

For semi-permanent option:modify in a similar mannerby adding butyl

methacrylate resin-providebutt joint between old andnew resin

► Avoiding:

Proper primary & secondary

impression. Proper pouringand re aration of the cast-



Posterior border of upper denture

► Recognizing

Observe soft palate movementwhen say “aah”

Diagnostic addition of tracingcompound

► Management Over-extension: adjust the add

post dam as below

Under-extension: extend borderwith tracing compound andrefine fit with wash impression.

Cut grooves for post dam inmaster cast.

► Avoiding

See picture



►Causes of Lack of Retention

Decreased retentive forces

►Lack of peripheral seal.

► Air beneath the impression surface

►Xerostomia

►Neuromuscular control

Increased displacing forces►Denture border problems (over extension )

►Occlusal problems



Decreased retentive forces- lack ofseal

►Torus where the post dam should be sited.

Note junction line between mobile and non mobiletissues. Palpate to determine size of torus and

displaceability of tissues anterior and posterior to it. Adjust borders until optimal seal achieved. Replace postdam.

►Resorption of residual ridge

Recognizing:►Lapse 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 byrepeated 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 thenreplacing it with acrylic.

Avoiding►Proper border moulding



►Causes of Lack of Retention Decreased retentive forces

►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 control

Increased displacing forces►Denture border problems (over extension )►Occlusal problems



► Trapped air expands as denturemoves away from supportingstructure until air bubble reachesthe 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, teethin neutral zone, free way space notmore than 6mm, and occlusionsatisfactory, 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 theimpression, 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 becleaned through boiling.



► Changes in tissue fluid Lack of recovery from old

denture(90 min gap)

Medications (diuretics)

Heart failure

► management If prolonged seating

pressure by cotton pelletsrestore retention,reline/rebase using minimumpressure technique.

consult with the physician Ensure old denture not worn

for 90 minutes before theimpression



► Undercut residual ridge Determine displaceability

► High: check if after additionof tracing compound the

denture can be painlesslyinserted and removed.

► Low : assess if angles pathwould help. If yes addtracing compound andreplace it with acrylic.

Avoiding:►With high displaceability –

request the lab to processacrylic into undercuts.

► Low displaceability- assessif angled path will help. If

yes, process acrylic intoundercut. If no, request labto block out undercut andaccept compromisedretention



► Excessive relief over areasof reduced displaceability Recognizing

► Palpate area and compare itwith amount of relief

provided► Use disclosing material.

Management► Reline/rebase: outline area

to be relived on the casts oron the impression andindicate amount of relief.

Avoidance► outline area to be relived on

the casts or on theimpression and indicateamount of relief.





Poor fit

Changes in tissue fluid



► Xerostomia►Neuromuscular 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 andminimize displacing forces.





Poor fit

Changes in tissue fluid







► Basic shape of dentureincorrect. cross section of theposterior region should betriangular. Occlusal surface sited

within confines of borders andpolished surfaces being slightlyconcave

► Recognizing

Lower molar too linguallyplaced.

Lingual polished surface convex

Upper buccal flangeinsufficiently wide.

► Management

Narrow lower teeth lingually

Adjust lingual polished surface

Add tracing compound to adjustbuccal flange

Decreased retentive



Decreased retentiveforces/Neuromuscular control

►Other causes Motor neuron disorder

►Presentation:

On delivery

On eating On speaking

After adjustment

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 levelis correct

► Management If upper occlusal plane

correct hen:

► If increased VD is under 1.5mm: mount on the

articulator and adjust lowerusing selective grinding

► If more than 1.5mm : resett the correct VD

Patient des not appreciate the need



Patient des not appreciate the needfor active control.

► Recognizing Ask patient to close on your

finger by the anterior teethand observe position of thetongue. Ideally should take

the position shown on thefigure.

► Management Train the patient to use his

tongue to retain the denture

by placing small beading ofresin on the posterior borderof the upper and lingual tothe anteriosr.



► When patient has beenwith out posterior teeth,tongue adapts to increasedavailable space.

► Consider Use of small occlusal table

Remove most distal posteriorteeth

Consider using specialimpression techniques:neutral zone technique.



► Causes of Lack of Retention Decreased retentive forces

► 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


Increased displacing forces

►Denture border problems (over extension in length & width)► Poor fit to supporting structures

► Deep post dam




Increased Displacing Forces

► Overextension (in length) : Recognition

► Direct vision and gentle manipulation of cheeks and lips, andmovement 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 andmentalis

► Management Reduce bulk- use disclosing agent if needed- and repolish

► Avoidance: Proper border moulding and impressioning.







► Xerostomia



► Denture border problems (over extension in length & width)►Deep post dam

► Poor fit to supporting structures




►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 inflammationranging from hyperemia to ulceration.

Management►Reduce depth-use disclosing agent if needed- be

aware of over reduction as the tissues may heal andlack of seal may develop







► Xerostomia



► Denture border problems (over extension in length & width)► Deep post dam





►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 inoptimal space)

Management►If polished surface acceptable, teeth in neutral zone,

free way space not more than 6mm, and occlusionsatisfactory, then reline denture-using minimal

pressure technique. Before taking the impression,relieve heavy contacts and ensure old dentures notworn for 90 minutes before making the impression







► Xerostomia



► Denture border problems (over extension in length & width)► Deep post dam





►Uneven Initial Contacts

causes dentures to tilt on supporting tissues, thusdisrupting retentive seal. Also prevents even seating of

loosening dentures on supporting tissues when teethoccluded.

Recognizing:

►ask patient to close slowly into RCP until teeth just touch

Management► Aim is to adjust occlusion until even contact in RCP is achieved.

Minor errors: use chair side techniques- difficult as dentures moveon supporting tissues producing errors in markings

Major errors: use laboratory techniques. Remount the maxillary

denture on semi adjustable articulator using a face bow and theMandibular denture with Pre-tooth contact registration. Thenadjust the occlusion on the articulator using articulating paper.

Gaps more than 1.5mm (vertically) or errors in antero-posteriorrelation more than half a cusp require cannot be adjusted by

selective grinding and requires re setting.



k f f d b &



► Lack of freedom between RCP & ICP Patient with inaccurate control of Mandibular movement

may not adapt to exact cusp-fossa relationship casingdentures to move and disrupt peripheral seal.

Recognizing► Age/ medical history: patient has difficulty in achieving

reproducible occlusal relationship. Patient able to eat using olddentures with flattened, worn teeth.

Management►Remount dentures, adjust teeth to produce area of freedom. If

adjustment will result in loss of occlusal balance, reset/remakeusing 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 (thisproduces no vertical overlap- possible effect on aesthetics)

► Lack of occlusal balance in excursive movements



► Lack of occlusal balance in excursive movements Causes dentures to shift on supporting tissues and

disrupt retentive seal. Many patient wear denturesuccessfully without occlusal balance, however, as

retentive forces decreases , displacing forces generatedby 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 slideeasily without causing dentures to move over supportingtissues.

Lack of balance commonly associated excessive vertical overlap ofanterior teeth.

Management

► Adjust teeth until balancing contacts us achieved. Could bedone chair side, but remount procedures is preferred. Ifachievement of balancing contacts would necessitate mutilationof teeth ( excessive shortening of lower incisors) then resetteeth 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 teethshould 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 required-

remount and selectively alter occlusal contacts toreduce vertical dimension at occlusion.

► if extra freeway space required exceeds 1.5mm,remove the posterior teeth from the denture withincorrect occlusal plane and re register… then re setor remake the dentures.



► last lower tooth tooposteriorly placed

Teeth overlies crest of theresidual ridge as this risestowards crest of theretromolar pad.

Pressure on these teethcauses denture to slip up.

► Recognize

Apply finger pressure on thelast tooth and observe ifdenture moves.

► Management Remove most posterior teeth

from dentures



► Orientation of the occlusalplane not parallel to ridge. Mastication produces forces

that tend to move thedentures over supporting

tissues. Problems can occur with

large tuberosities, as thesecan depress occlusal planeposteriorly and this mayplace the lower denture at aforward force.

► Management Reset the teeth or remake

the dentures



Problems

► Appearance

►Function

Looseness of dentures


►Comfort

►

Speech►Psychological

►Other.



Support Problems

►Lack of ridge►Fibrous displaceable ridge

►Bony prominence covered by thinmucosa

►Non- resilient soft tissue



Lack of Ridge► Little resistance to forces

in lateral and antero-posterior directions;denture liable to move,and thus disruptingretentive seal.

► Recognizing Observation of ridge. May be

associated with a shallowpalate.

Denture may move easily

with finger pressure.► Management

Minimize displacing forcesand maximize retentiveforces

Fibrous displaceable ridge



Fibrous displaceable ridge► Forces of mastication

cause denture to sink into

and tilt on supportingtissues, thus disruptingretentive seal.

► Observation Palpation of the residual

ridge to determinedisplaceability. Denture maysink into tissues under fingerpressure.

Presence of history of

presence of natural teeth(usually lower anteriors)

Teeth may appear to meetevenly under forcefulocclusion, but when theteeth just meet, incorrect

occlusion often appear.

M t



►Management Reline/rebase►Precautions

Remove acrylic from impression surface until no contact isevident-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



Bony prominence covered by thinmucosa

e.g. :Prominent maxillary midline

suture, denture rocks about fulcrumproduced by area of reduced tissuedisplaceability and thus disruptingthe 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 disclosingagent)► 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. Appearance


►

Lack of peripheral seal.► Air beneath the impression surface

► Xerostomia




► Poor fit

► Denture not sited in optimal space( also neuro muscular control)


1. Lack of ridge

2. Bony prominence

► Non- resilient soft tissue

► Pain- avoidance mechanisms

• Comfort

• Speech

• Psychological

• Other.



1. Appearance


►

Lack of peripheral seal.► Air beneath the impression surface

► Xerostomia




► Poor fit


► Occlusal errors

2. Problems in occlusion3. Support problems

1. Lack of ridge

► Bony prominence



• Comfort• Speech

• Psychological

• Other.



Causes of Discomfort

►Related to

Impression surface

Polished surface

Occlusal surface

Discomfort Related to the



Discomfort Related to theImpression 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 Related to the Polished Surface

Maxillary denture constraining coronoid process.

►Discomfort Related to the occlusal Surface

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

A



1. Appearance




► Xerostomia




► Poor fit


► Occlusal errors


1. Lack of ridge

► Bony prominence



• Comfort

• Speech• Psychological

• Other.

►Noise on speaking:



►Noise on speaking: Recognizing:

►Excessive OVD►

Occlusal interferences►Loose dentures

►Sibilants, e.g. “S” Recognizing:

►Count from 60-70, anterior teeth should be just out of contact

►Bilabial sounds, e.g. “P” “B” Recognizing:

►Lip 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?

A



1. Appearance




► Xerostomia




► Poor fit


► Occlusal errors


1. Lack of ridge

► Bony prominence



• Comfort

• Speech• Psychological

• Other.



►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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