postinsert problems lect 5th class.pdf

Lect. Prosthodontics Dr. Thekra Ismael Hamad 5th class Post insertion problems in complete denture Treating a completely edentulous patient and being able to restore some degree of function, esthetics, and the individuals self- esteem can be a very s...

Lect. Prosthodontics Dr. Thekra Ismael Hamad 5th class Post insertion problems in complete denture Treating a completely edentulous patient and being able to restore some degree of function, esthetics, and the individuals self- esteem can be a very satisfying experience for a dentist. Or it can be an extremely frustrating experience if things fail to go smoothly and the patient comes back repeatedly with complaints about the quality of the denture and the capability of the dentist. It is unlikely that any dentist can solve all the problems that patients may present. Certainly the best approach is to avoid as many problems as possible. This can be accomplished most effectively by selecting a satisfactory technique and by using care in diagnosis and all phases of treatment. Adequate patient education is also essential. Factors which may limit the prognosis of treatment must be explained to the patient. Post insertion care is a critical phase in the treatment of the edentulous patient. Scheduled and systemic follow up care can uncover minor problems and complaints which can become major problems if not treated promptly. There are problems arises subsequent to the insertion of complete dentures. These problems may be transient and may be essentially disregarded by the patient, or they may be serious enough to result in the patient being unable to tolerate the dentures. Some complication requiring a quick solution. Another difficulty would be the adaptation of the patient to the required changes in their day time habit pattern which, is not easy. Complete denture problems are divided into many general categories. Specific problems are listed in each category and their probable causes, specific diagnostic procedures, and appropriate corrective measures are present Complete denture fabrication techniques, and placement of a complete denture are not the final steps in the treatment of edentulous, patients and patient's visit to the dentist continues long after that. Two thirds of the denture wearers surveyed in a study reported that they were “very satisfied“ with their maxillary denture as compared with 51% for mandibular dentures, of the individuals who wore their dentures “all day”, 5% were “very dissatisfied” with at least one of their dentures. Many practitioners will experience a situation, when a patient with newly fabricated 1 complete dentures continues the experience difficulty in adapting to them; this can Page lead to a long period of appointments that may not result in resolution of the problem. Therefore, it is often concluded that there is some patient factor either age, gender, medical or psychological status that is hindering the success of treatment. Treatment challenges for such patients have traditionally been described as a combination of function, comfort, and aesthetics. Often there is not total agreement between the patient and the dentist as to the adequacy of their dentures. Several authors cite the most frequent complaints with complete dentures are those pertaining to aesthetics, retention and stability, comfort while eating, and the accumulation of food under the appliance. The factor that most often appears to have an impact on either success or failure of complete dentures is aesthetics. Sometimes the appearance of their dentures prevents from wearing them. The way in which the patient believes he should look is not always in accordance with the clinician’s perception of a pleasing appearance. Other studies reported complete denture patients experiencing difficulties with their dentures most frequently complained of looseness of their dentures, aesthetics, difficulty while eating, and accumulation of food under the appliance. Many factors may influence patients’ satisfaction with their dentures: 1. Quality of bone tissue and 2. Oral mucosa of denture bearing area, tissue changes that occur on denture bearing area due to alveolar ridge resorption lead to poorer denture retention and stability which consequently affects patients’ satisfaction. 3. The adaptability of the neuromuscular mechanism, 4. Individual feeling of security by denture wearing, 5. Influence of the surrounding muscles on denture flanges, 6. Viscosity of saliva, 7. Patient’s age, 8. Position of occlusal plane, 9. Occlusion, 10. Hygiene, type of food, etc. Classification of denture complaints According to the time of delivery: Immediate complaints. 2 Page Delayed complaints.  General classification Complaints about comfort of the denture: - Sore spots - Burning sensation - Redness - Pain in TMJ - Tongue & cheek biting - Swallowing & sore throat - Nausea & gagging - Deafness - Fatigue of the muscles of mastication Complaints about function of the denture: - Instability or poor fit - Interference a) When swallowing b) Clicking Complaints about esthetics: - Fullness under the nose - Depressed philtrum or naso-labial sulcus - Upper lip sunken in - Too much of teeth exposed - Artificial look Complaints about phonetics: 3 Page  - Whistle on “S” sounds - Lisp on “S” sounds - Indistinct “TH” & “T” sounds - “T sound like “TH” - “ F” & “V” sounds indistinct. PROBLEMS RELATED TO SOFT TISSUE Complaints/area Causes Treatments Sore spots – mandible Peripheral areas Overextension Adjust denture accordingly Unpolished or sharp edge Polish denture borders Herpetic or apthous ulcer Leave denture out as much as possible and wait 7-10 days Crest of ridge Bone spicules Identify the area in denture with pressure – indicating paste and provide relief over spicule and/or surgically remove spicule Spinous ridge crest Provide relief in the denture Pressure spots at time of Use PIP or indelible pencil to impression determine the areas and adjust accordingly Occlusal prematurities Correct occlusal defects, recheck vertical dimension and clinical remount Side of ridge-anterior Overextension Use pressure indicating paste 4 Page and adjust denture border area involved Maximum intercuspation Enlarge centric area; grind not in harmony with centric mesial inclined planes of relation maxillary teeth and distal inclined planes of mandibular teeth using a clinical remount Side of ridge-bicuspid Lingual tori ( nonyielding Provide adequate relief in area areas) denture base Pressure spots at time of Adjust denture accordingly impression Shrinkage of denture during Rebase denture processing ( dimensional changes) Error in occlusion - occlusal Check occlusion on the prematurities opposite side of arch from the sore spot Pressure on mental foramen Provide adequate relief if ridge is greatly resorbed Side of ridge-posterior Overextension in lateral Shorten posterior of lingual area throat area flange Error in occlusion Check teeth diagonally across the arch from the sore area Spinous projection of Correct undercut surgically; mylohyoid ridge you must under extend the distolaterally ( feeling of denture. Relieve denture if not sore throat) severe Overextension in anterior Adjust peripheral area (causes rotation of overextension distal flanges) 5 Under lingual flange Maximum intercuspation Enlarge centric area and adjust Page  not in harmony with centric local area- relation (drives mandibular denture forward) Under labial flange Excessive overbite Adjust anterior occlusion Habit- mastication in Train patient to masticate in protrusive relation centric Generalized soreness Heavy biting force- strong Reduce buccolingual width of and redness musculature teeth; reduce vertical dimension; use soft lining if necessary Excessive vertical Reduce vertical dimension dimension of occlusion Locked occlusion Enlarge centric area Failure to provide freedom Reduce cusps to a for Bennett movement nonanatomical plane or reset (soreness usually on teeth working side Improperly processed base Rebase denture material Sore spots – maxilla Peripheral areas Overextension Adjust denture accordingly Unpolished or sharp edge Polish denture borders Herpetic or apthous ulcer Leave denture out as much as possible for 7-10 days Maxillary frenum Overextension Open a V-shaped notch for the labial frenum and widen the buccal frenum areas Posterior border of Sharp edge at the post dam Adjust sharp edge slightly 6 denture area without reducing dam area Page Midline of denture Prominent midsuture or Provide some relief over the torus palatinus area Generalized discomfort Improper occlusion Correct occlusion (clinical remount) Maximum intercuspation not in harmony with Enlarge centric area (clinical centric relation remount) Excessive vertical dimension of occlusion Reduce vertical dimension (clinical remount) Burning sensation Maxillary anterior Pressure on anterior Relieve area over foramen hard palate and palatine foramen anterior alveolar ridge area Maxillary bicuspid Pressure on posterior Relieve area over foramen area or molar palatine foramen tuberosity Mandibular anterior Pressure on mental foramen Relieve area over foramen region Generalized Improperly processed Reline denture; replace as much as possible base material with new acrylic resin Tongue Allergic reaction xerostoma Redness Fiery redness - All Denture base allergy (very Remake denture and use all tissue contacted by unusual) metal base (after allergy test) denture including 7 Page tongue and cheeks Bearing tissues Ill-fitting denture, Remake or rebase dentures. Avitaminosis Employ vitamin therapy regimen Tongue and cheek biting Thin or under extended periphery (base material Build out thin areas, or extend does not provide enough support for the cheek) the short periphery Insufficient interarch clearance between distal parts Thin maxillary denture over of denture bases tuberosity; if more space is required, remove it from the retromolar area of the mandibular denture Inadequate amount of horizontal overlap in molar Re-contour buccal surface of region mandibular molars and bicuspids; eliminate the tight contact of the maxillary buccal cusps on the mandibular buccal surfaces Pain in TMJ Insufficient vertical dimension of occlusion Increase vertical dimension of occlusion Maximum intercuspation not in harmony with Make new occlusal record, centric relation regrind and remount occlusion Arthritis Treat with analgesics Trauma Treat with analgesics Gagging 8 Immediately upon Maxillary denture Adjust denture or thin posterior Page insertion overextended or too thick in border posterior border Lack of retention Reline denture Mandibular denture too Reduce thickness or thick in distolingual flange distolingual flange Delay (2 weeks - 2 Incomplete border seal Increase border seal with self- months after insertion) allowing saliva under curing acrylic resin ( possibly denture at the posterior palatal border Improper occlusion causing Correct occlusion (clinical denture to loosen and remount) allowing saliva under denture Deafness Decrease vertical dimension of occlusion (rare) Increase vertical dimension of occlusion Fatigue of the muscles of mastication Excessive vertical dimension of occlusion Reduce vertical dimension of occlusion Insufficient vertical dimension of occlusion Increase vertical dimension of occlusion 9 Page PROBLEMS RELATED TO FUNCTION Complaints/area Causes Treatments Instability Looseness of mandibular Error in occlusion Correct faulty occlusion denture (maximum intercuspation by remount and regrind not in harmony with centric procedure relation) Reset teeth at a lower Occlusion plane too high plane Underextension of Rebase denture periphery (inadequate providing proper impression) extension Use denture adhesives Inability of patient to to help develop skill in master denture handling denture ( for a short time only) Tongue position (retracted tongue) Looseness Occasionally Correct with self-curing of Underextension in some acrylic resin; first check maxillary area with compound for denture diagnostic purpose Faulty occlusion Correct Occlusion Overextension of Adjust denture peripheries accordingly 10 Page  Dehydration of tissue due Remove cause to alcoholism Correct surgically; modify impression Displacement of flabby technique to change tissues when making primary denture stress- impression bearing area to the buccal shelf When eating on Nonyeilding area in hard either side palate (ridge tissue yields Provide relief chamber under chewing stresses; over non-yielding area denture rocks on hard area Rebalance in lateral Incorrect tooth position excursions; reset teeth (teeth may beset too far where nature should buccally off ridge have had them Instruct patient to maintain soft diet until Chewing resistant foods mouth is conditioned to wearing denture Approximately Prescribe astringent every 2 hours mouthwashes and Heavy mucinous saliva regular scrubbing of dentures; reduction of carbohydrate Correct surgically; Incorrect tooth position ( change primary denture teeth may be set too far stress -bearing area to buccally and labially 11 the buccal shelf Page  Train patient to Improper incising habits masticate in centric relation Loss of posterior palatal Increase postpalatal seal seal (seal on hard palate; with self-curing acrylic posterior limit not in resin; first use compound hamular notches; as a diagnostic aid insufficient valve seal) When yawning Denture base too thick in or opening wide buccal posterior area (coronoid process exerts Reduce thickness of forward and downward denture base force on posterior of denture upon opening) Shorten denture until pterygomaxillary Overextended in hamular ligament does not exert notch tension on posterior border when mouth is opened wide Increase postpalatal seal Inadequate posterior with self-curing acrylic palatal seal resin When talking Increase postpalatal seal Inadequate posterior with self-curing acrylic palatal seal resin Shorten posterior until Overextended in posterior soft palate does not lift region 12 upward and break contact with the denture Page  base When occluding Improper occlusion Correct occlusion in centric relation Correct surgically; Poor denture change primary denture foundation (flabby tissues stress-bearing area to over ridge) the buccal shelf Incorrect tooth position Reset teeth (teeth set too far buccally) Maximum intercuspation not in harmony with centric Enlarge centric area region Nonyielding area in hard Provide relief in area plate Only a feeling of looseness (support and Provide relief chamber, retention are Large area of nonyeilding adequate to permit present yet tissue in hard plate denture to be properly denture feels seated suspended in mouth Interference When swallowing Maxillary denture too thick Reduce thickness or or over-extended in adjust posterior posterior region Mandibular denture too Reduce thickness or 13 thick or overextended in adjust posterior lingual Page  posterior lingual flange area flange area Insufficient vertical Reduce vertical dimension of occlusion dimension Excessive vertical Reduce vertical dimension of occlusion dimension Incorrect tooth position (posterior teeth set too far Reset teeth lingually - tongue crowded Clicking Excessive vertical Reduce vertical dimension of occlusion dimension Ill-fitting dentures New dentures Overextended lower Reduce peripheral length dentures 14 Page PROBLEMS RELATED TO ESTHETICS Complaints Causes Treatments Reduce length or Labial flange of maxillary denture Fullness under nose thickness of labial too long or too thick flange Increase length or Labial flange of maxillary denture Depressed philtrum thickness of labial too short flange Maxillary anterior teeth set too Reset anterior teeth Upper lip sunken in far lingually labially Too much of the teeth Reduce the vertical Excessive vertical dimension of are exposed dimension of occlusion occlusion Reset teeth at higher Incisal plane too low plane Cuspids and lateral incisors too Adjust accordingly prominent Artificial appearance Individualize by Technique setup (teeth are too rotating and regular in alignment) shortening some teeth Choose different but complimentary All teeth in same shape shades; use staining 15 techniques Page  Grind incisal edges Lack of individualization of teeth and angles Individualize gingival Lack of individualization of contour and color of denture base denture base PROBLEMS RELATED TO PHONETICS Complaints Causes Treatments Whistle on "S" sounds Increase the palatal resin convex Air stream passes unimpeded contours lingual to the or with inadequate impedance maxillary central between the dorsal surface of incisors to impede the the tongue and the anterior air stream passing palate between the tongue and palate. Create rugae if necessary Lisp on "S" sounds The air stream passing between the tongue and anterior palate is excessively impeded, usually Thin the palatolingual by rugae or excessive resin area contour(to small anterior air space). Maxillary & Mandibular Reduce occlusal vertical incisors or premolars Occlusal vertical dimension too dimension until contact during sibilant (s, great premolars no longer 16 sh, z, ch) sounds contact during speech Page  Clinician observes that Evaluate lip support incisal edges of maxillary and overall appearance incisors contact the of anterior teeth as lower lip 1 mm or more they are labial to the wet/dry positioned. Reset to a junction of lower lip more lingual postiion as Maxillary teeth may be set too when "F" & "V" sounds needed. incisal edge of far labially are made maxillary incisiors should contact the wet dry junction ro just lingual to it during production of the "F" & "V" sounds. A study done for CD complains. The results showed that the number of mandibular dentures requiring adjustments was significantly higher than maxillary dentures in all the post-insertion appointments. Most frequently injured maxillary areas were posterior palatal seal area in the soft palate (27%), in the mandible, the most frequently injured areas were retromylohyoid area (48.6%). The least common locations for maxillary ulcerations were hard palate and mid-palatal suture (0%), incisive papilla and rugae (0.65%), tuberosity (2.6%), and buccal and labial sulci (4.6%). The lowest frequency of lesions in the mandible was seen in the sublingual fold (0%), labial sulcus and mylohyoid region of the lingual sulcus (1.2%) and buccal frenum and buccal shelf (2.1%). No significant differences were detected between males and females in terms of mucosal injuries in the above-mentioned anatomic areas of the maxilla and mandible. The most frequently observed faults in denture construction related to retention and vertical and horizontal jaw relationships. There is significant relationship between 17 inadequate retention and in proper intermaxillary relationships and patient’s complaints of looseness and difficult eating. Page Clinician must carefully evaluate the denture for faults in horizontal and vertical jaw relationships before concluding that the patient’s complaint is related to age, gender, or general medical condition Limitations of Dentures Dentures are less efficient than natural teeth Some people can eat all foods easily, but these are the exception Generally the better the ridge form, the fewer problems are encountered. Patients with minimal ridges should be advised that their dentures will likely move (especially the mandibular) and their efficiency will therefore be reduced. Patients with minimal ridges will likely encounter more sore spots than others. It is wise to point out these limitations to patients prior to the delivery appointment so that it is viewed as an explanation, rather than an excuse. Adaptation to Dentures Adaptability is affected by: 1. Length of time wearing dentures. 2. Amount of residual ridge remaining. 1.3. Degree of changes made in new dentures. 4. Individual variation (e.g. patients with more acute oral sensory perception have more difficulty adapting). Adaptation to Chewing may be affected if: 1. CO has been changed to coincide to CR. 2. Tooth positions (esp. incisors) have changed. 3. Vertical dimension has changed. These patients may experience initial decreased efficiency, cheek or lip biting. Adaptation may be improved by initially eating soft foods, increasing to hard foods, cutting food into smaller pieces, and placing food towards the corners of the mouth. Adaptation may be accompanied by an initial, transitory increase in saliva. Patients should be advised of the need to persevere while their neuromusculature adapts to the new prostheses. 18 Speaking may be affected by changes in: Page  1. Tooth position (esp. anteriors). 2. Tongue space (particularly if patients have been without dentures for some time). 3. Palatal contours. Initial speaking problems are usually transitory, since the tongue is very adaptable – tooth positions must be close at delivery, however). Appearance may be changed in some individuals. These changes are usually due to: 1. Increasing length of incisors (worn). 2. Changes in vertical dimension. 1.3. Improved lip support (not help with wrinkles). 19 Page