19. Dent Trble Shoot 2 .ppt

Denture LoosenessDenture LoosenessCD & RPDCD & RPD


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

•Poor anatomyPoor anatomy



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

Typical HistoryTypical History

Adequate retention Adequate retention initially initially

Gets worse with timeGets worse with time

Typical HistoryTypical History

Adequate retention Adequate retention initially initially

Gets worse with timeGets worse with time


Perpetually Loose Maxillary Perpetually Loose Maxillary DentureDenture• Heavy anterior interferences Heavy anterior interferences can cause loosening at can cause loosening at posteriorposterior

• Tuberosity mucosa grows into Tuberosity mucosa grows into spacespace

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

Perpetually Loose Maxillary Perpetually Loose Maxillary DentureDenture• Heavy anterior interferences Heavy anterior interferences can cause loosening at can cause loosening at posteriorposterior

• Tuberosity mucosa grows into Tuberosity mucosa grows into spacespace

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

TuberosityTuberosity


Tilting Growth Loss Tilting Growth Loss of retentionof retention

Tilting Growth Loss Tilting Growth Loss of retentionof retention

InclinedInclinedResidual RidgeResidual Ridge

InclinedInclinedResidual RidgeResidual Ridge

LipLipLipLip

Denture LoosenessDenture LoosenessCD & RPD: OcclusionCD & RPD: OcclusionDenture LoosenessDenture Looseness

CD & RPD: OcclusionCD & RPD: Occlusion

•Incisors placed Incisors placed too far labiallytoo far labially

•Denture displacesDenture displaceslingually.lingually.

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

•Incisors placed Incisors placed too far labiallytoo far labially

•Denture displacesDenture displaceslingually.lingually.

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


Tilting/jiggling Tilting/jiggling caused by:caused by:• Contacts not Contacts not centered over centered over ridgeridge

• Contacts on Contacts on inclined portion inclined portion of ridgeof ridge

Tilting/jiggling Tilting/jiggling caused by:caused by:• Contacts not Contacts not centered over centered over ridgeridge

• Contacts on Contacts on inclined portion inclined portion of ridgeof ridge


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

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


• Check centric Check centric position position (articulating (articulating paper)paper)–even, stable contacts even, stable contacts both sidesboth sides

–stop patient upon stop patient upon initial contactinitial contact

• Check centric Check centric position position (articulating (articulating paper)paper)–even, stable contacts even, stable contacts both sidesboth sides

–stop patient upon stop patient upon initial contactinitial contact

Denture LoosenessDenture LoosenessMandibular lingual flange Mandibular lingual flange

too thicktoo thick

Denture LoosenessDenture LoosenessMandibular lingual flange Mandibular lingual flange

too thicktoo thick

TongueTongueTongueTongue

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

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

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

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

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

CD & RPD: CD & RPD: Denture BaseDenture Base

Short flangeShort flange •PIP streaksPIP streaks•Looks short of Looks short of vestibulevestibule

•Often displaces Often displaces easilyeasily

Short flangeShort flange •PIP streaksPIP streaks•Looks short of Looks short of vestibulevestibule

•Often displaces Often displaces easilyeasily



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

• Watch when seating Watch when seating denturedenture- Flange touches Flange touches vestibular depth, vestibular depth, denture continues to denture continues to seatseat

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

• Watch when seating Watch when seating denturedenture- Flange touches Flange touches vestibular depth, vestibular depth, denture continues to denture continues to seatseat



• If flange is too thick, seal If flange is too thick, seal may be maintained at restmay be maintained at rest

• If flange is also short or If flange is also short or long, displacement may occur long, displacement may occur as lips or cheeks move, as lips or cheeks move, allowing air to break allowing air to break vestibular sealvestibular seal

• If flange is too thick, seal If flange is too thick, seal may be maintained at restmay be maintained at rest

• If flange is also short or If flange is also short or long, displacement may occur long, displacement may occur as lips or cheeks move, as lips or cheeks move, allowing air to break allowing air to break vestibular sealvestibular seal



PrinciplePrinciple

Always have the Always have the patient demonstrate patient demonstrate

how a denture loosenshow a denture loosens

PrinciplePrinciple

Always have the Always have the patient demonstrate patient demonstrate

how a denture loosenshow a denture loosens



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 Poor base adaptationadaptation

•Fulcrum on bony Fulcrum on bony structuresstructures

•Test hypothesis: Test hypothesis: PIPPIP

•Poor base Poor base adaptationadaptation

•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 Denture peripheries always terminate on displaceable terminate on displaceable

soft tissuessoft tissues

Retromolar pads, Vestibular tissues, Retromolar pads, Vestibular tissues, Vibrating line (nonmoveble soft Vibrating line (nonmoveble soft

palate), Hamular notchespalate), Hamular notches

PrinciplePrinciple

Denture peripheries always Denture peripheries always terminate on displaceable terminate on displaceable

soft tissuessoft tissues

Retromolar pads, Vestibular tissues, Retromolar pads, Vestibular tissues, Vibrating line (nonmoveble soft Vibrating line (nonmoveble soft

palate), Hamular notchespalate), 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 Coronoid

InterferenceInterference

Denture LoosenessDenture LoosenessDenture Base: Denture Base: Coronoid Coronoid

InterferenceInterference

• Thick flange in Thick flange in retrozygomal arearetrozygomal area

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

• Dislodges maxillary Dislodges maxillary denturedenture

• Thick flange in Thick flange in retrozygomal arearetrozygomal area

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

• Dislodges maxillary Dislodges maxillary denturedenture

Denture LoosenessDenture LoosenessDenture Base: Denture Base: Pterygomandibular Pterygomandibular

RapheRaphe

Denture LoosenessDenture LoosenessDenture Base: Denture Base: Pterygomandibular Pterygomandibular

RapheRaphe

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

•Very tight in some Very tight in some patients patients

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

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

•Very tight in some Very tight in some patients patients

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

Denture LoosenessDenture LoosenessDenture Base: Denture Base: Palatal CleftPalatal Cleft

Denture LoosenessDenture LoosenessDenture Base: Denture Base: Palatal CleftPalatal Cleft

•In some patients In some patients midline soft palate midline soft palate fissurefissure

•Can “tent” during Can “tent” during functionfunction

•Allows air to leak Allows air to leak under dentureunder denture

•In some patients In some patients midline soft palate midline soft palate fissurefissure

•Can “tent” during Can “tent” during functionfunction

•Allows air to leak Allows air to leak under dentureunder denture

Denture LoosenessDenture LoosenessCD & RPD: CD & RPD: Poor AnatomyPoor AnatomyDenture LoosenessDenture Looseness

CD & RPD: CD & RPD: Poor AnatomyPoor Anatomy

• Many sets of denturesMany sets of dentures• Use articulator, more complex Use articulator, more complex impression and jaw relation impression and jaw relation proceduresprocedures

• ImplantsImplants• ReferRefer

• Many sets of denturesMany sets of dentures• Use articulator, more complex Use articulator, more complex impression and jaw relation impression and jaw relation proceduresprocedures

• ImplantsImplants• ReferRefer

OverviewOverviewOverviewOverview

•Deal with denture problems Deal with denture problems systematicallysystematically

•Use a differential diagnosisUse a differential diagnosis•Address probable causes until Address probable causes until problem is eliminatedproblem is eliminated

•If can’t identify problem, If can’t identify problem, referrefer



•If can’t identify problem, If can’t identify problem, referrefer

Phonetic ProblemsPhonetic ProblemsPhonetic ProblemsPhonetic Problems

LispingLisping::–too much overjettoo much overjet–triangular spaces between triangular spaces between embrasures of max. & mand. teethembrasures of max. & mand. teeth

–palatal contour too constrictedpalatal contour too constricted–insufficient tongue spaceinsufficient tongue space

LispingLisping::–too much overjettoo much overjet–triangular spaces between triangular spaces between embrasures of max. & mand. teethembrasures of 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 Psychologic ProblemProblem

•Anatomic ProblemAnatomic Problem•Diagnosis ProblemDiagnosis Problem•Adaptive ProblemAdaptive Problem•Psychologic Psychologic ProblemProblem


PrinciplePrincipleIf you can’t determine the If you can’t determine the problem using indicating problem using indicating

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

2. Don’t adjust2. Don’t adjust

3. Refer3. Refer

PrinciplePrincipleIf you can’t determine the If you can’t determine the problem using indicating problem using indicating

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

2. Don’t adjust2. Don’t adjust

3. Refer3. Refer


PrinciplePrinciple

Never pretend to adjust a Never pretend to adjust a denturedenture

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

PrinciplePrinciple

Never pretend to adjust a Never pretend to adjust a denturedenture

Reinforces maladaptive behaviour Reinforces maladaptive behaviour - harder for the next guy- harder for 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 More teeth missing, less adaptation adaptation (loss (loss of PDM receptors)of PDM receptors)

•Better perception - less Better perception - less adaptiveadaptive

•Elderly take more time to adaptElderly take more time to adapt•More teeth missing, less More teeth missing, less adaptation adaptation (loss (loss of PDM receptors)of PDM receptors)

•Better perception - less Better perception - less adaptiveadaptive



•Denture may be the cause of the Denture may be the cause of the problemproblem

•Patient response may also be part Patient response may also be part of the problemof the problem

•Denture may be the cause of the Denture may be the cause of the problemproblem

•Patient response may also be part Patient response may also be part of the problemof the problem

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

Dentist’s response to patient Dentist’s response to patient may also affect the patient may also affect the patient

response to the dentureresponse to the denture

““Laying on of Hands”Laying on of Hands”

Dentist’s response to patient Dentist’s response to patient may also affect the patient may also affect the patient

response to the dentureresponse to the denture

““Laying on of Hands”Laying 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 Disparaging previous dentures/dentistsdentures/dentists

– Body Language/ DeportmentBody Language/ Deportment

•Good interview techniqueGood interview technique•Tips Tips

– Many denturesMany dentures– Disparaging previous Disparaging previous dentures/dentistsdentures/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 - If you identify the wrong problem - failfail

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 - If you identify the wrong problem - failfail



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”)

–Don’t be afraid of questions relating to Don’t be afraid of questions relating to emotional healthemotional health

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”)

–Don’t be afraid of questions relating to Don’t be afraid of questions relating to emotional healthemotional health



3. Interpret & Explain Problems3. Interpret & Explain Problems–Advise patient of your viewAdvise patient of your view–Use care in dealing with emotional Use care in dealing with emotional problemsproblems

–Don’t be afraid to address Don’t be afraid to address emotional componentemotional component

3. Interpret & Explain Problems3. Interpret & Explain Problems–Advise patient of your viewAdvise patient of your view–Use care in dealing with emotional Use care in dealing with emotional problemsproblems

–Don’t be afraid to address Don’t be afraid to address emotional componentemotional component



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

–If sense trouble, refer or address If sense trouble, refer or address immediatelyimmediately

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

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

–If sense trouble, refer or address If sense trouble, refer or address immediatelyimmediately

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



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

interview, until satisfiedinterview, until satisfied

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

interview, until satisfiedinterview, until satisfied



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

•80-85% are satisfied80-85% are satisfied•Better adaptation than eyeglass Better adaptation than eyeglass wearerswearers

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

•80-85% are satisfied80-85% are satisfied•Better adaptation than eyeglass Better adaptation than eyeglass wearerswearers

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

Rule out objective findingsRule out objective findings

Chart findings objectivelyChart findings objectivelyRule out objective findingsRule out objective findings

Chart findings objectivelyChart findings objectively

OverviewOverviewOverviewOverview



•If can’t identify problem, referIf can’t identify problem, refer



•If can’t identify problem, referIf can’t identify problem, refer

19. Dent Trble Shoot 2 .ppt

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