Post insertion problems/ dental crown & bridge courses
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This document discusses four main factors that can cause post-insertion problems with dentures: 1) adverse intra-oral anatomical factors such as sharp ridges on the denture surface or over-extended flanges, 2) clinical factors like poor denture stability from decreased retention or increased displacing forces, 3) technical factors related to the denture fabrication process, and 4) patient adaptation factors involving issues with wearing or adjusting to the new dentures. Specific examples are provided for each category along with potential treatments.
Post insertion problems/ dental crown & bridge courses
- 1. Post Insertion Problems INDIAN DENTAL ACADEMY Leader in continuing Dental Education www.indiandentalacademy.com
- 2. • Factors causing post insertion problems may be grouped, essentially into four causes. • Adverse intra-oral anatomical factors • Clinical factors eg poor denture stability. • Technical factors. • Patient adaptional factors. www.indiandentalacademy.com
- 3. Adverse intra-oral anatomical factors Symptoms/clinical findings Cause Treatment Related to impression surface 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 toease 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. Areas painful to pressure Pressure areas resulting eg from faulty impressions, damage to working cast, warpage of denture base. 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 www.indiandentalacademy.com
- 4. 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 www.indiandentalacademy.com
- 5. • Clinical factors eg poor denture stability. – arising from decreased retention forces – arising from increased displacing forces • occlusal and anatomical factors www.indiandentalacademy.com
- 6. Arising From Decreased Retention Forces Symptoms/clinical findings Cause Treatment 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 chair side reline material may be used Inelasticity of cheek tissues Consequence of ageing process; scleroderma, submucous fibrous Mould denture borders incrementally using softened tracing compound as functional movements are performed - aim to slightly under-extend depth and width of denture periphery. www.indiandentalacademy.com
- 7. 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. Xerostomia Reduces ability to form a suitable seal Medication by many commonly prescribed drugs, irradiation of head and neck region, salivary gland disease Design dentures to maximise retention and minimise displacing forces. Prescribe artificial saliva where appropriate 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, 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. www.indiandentalacademy.com
- 8. Arising From Increased Displacing Forces Symptoms/clinical findings Cause Treatment 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 racing 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. www.indiandentalacademy.com
- 9. 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 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 www.indiandentalacademy.com
- 10. Patient adaptional factors. Symptoms/clinical findings Cause Treatment 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 maximized and displacing forces minimized 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 www.indiandentalacademy.com
- 11. ’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 (eg s), bilabial (eg p,b), labiodental (eg 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 - 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 www.indiandentalacademy.com
- 12. 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 patient’s aesthetic requirements. Ample time for patient comments at trial stage. Use any available evidence to assist - photographs, previous dentures. Consider template prosthesis 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 www.indiandentalacademy.com