TROUBLE SHOOTING IN COMPLETE DENTURE PROSTHESIS
1. It can be said that complete denture treatment is an unnatural
treatment of oral tissues left over after loss of teeth.
2. The oral tissues are exposed to the presence of a foreign body which
sandwitches the oral mucosa against the hard bone.
3. It may be understood that the oral tissues have not evolved to accept
the ravages of such large foreign bodies. It is therefore natural that
an initial copious flow of saliva is a proof of rejection of the oral
tissues of invading agency.
4. If however the tissues are compelled to accept them, rationally
speaking they have got to be formulated keeping in mind the tissue
biology and the mechanical needs of retention and stability.
5. The dentures are simply placed on tissues without anchors and the
patient is expected to acquire neuromotor skills in holding them. In
this exercise the dentures are expected to remain seated during
various functional excursions.
6. The neuromuscular attainment of skill is more easily said than done
since the learning potential of patiens vary at every age level and
hence in advanced age the patients face a situation of tight rope
walk. This itself constitutes yet another genesis for trouble shooting.
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7. It is to be reckoned that the foundations present varying degrees of
different morphology and altered physiology.
8. Infact the dentures reveal a lot of skidding effect adding to the
problem of sensitive oral mucosa.
9. Similarly food habits manifest diversity to a point that patient
needing to use the dentures successfully, has to accept the changes
in life style.
10. Emotional disturbances and more so in advancing age are yet
another manifestation that causes irritation of tissues and the
resulting tissue loss. It is for these reasons the following text is
presented to present classified information in respect of tissue
injuries and the impared functions. Therefore the purpose of this
presentation is to concentrate on tissue injuries with the intention of
knowing how to treat these conditions.
It is difficult to discuss every complaint made by a patient, but the
following are the most common and will give a comprehensive outline of
how the dentist may diagnose their cause and how they should be treated.
Grossly these problems can be grouped under these categories.
A. Tissue Injury
B. Impaired function
C. Miscellaneous
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A. Tissue Injury
a) Involving supporting and stabilizing areas
- Mucosa of the crest
- Slopes of the ridge
- Mucosa of palate
- Bone
Truamatic lesions of the stress bearing mucosa of the crest of the
residual ridge, slopes of the ridge and palate are usually the result of (i)
imperfections in or on the tissue side of the denture base (ii) Pressure areas
on the tissue side of the denture that were developed either in the
impression procedures or as a result of damage to the master cast and (iii)
disharmony in occlusion in either the centric or the eccentric jaw positions.
Lesions:
1. Punched out areas
2. Whitish areas
3. Hyperaemic and painful areas
4. Localized or generalized areas of inflammation
5. Hypertrophy
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1. Punched out lesions and the surrounding hyperaemic mucosa are
usually the result of imperfections in denture base, trauma from food
particles when the dentures were not in the mouth.
2. Lesions particularly of the crest are whitish due to the presence of
excess Keratin (whitish may also be due to ischaema improper
impression technique).
3. Lesions that are hperaemic and painful are encountered over the
mylohyoid ridges, the cuspid eminences, the alveolar tubercles and
areas of exostosis. It is usually seen when undercuts are present in
the lateral aspect of maxillary tuberosites. It is produced by the
flanges of the denture during the placement and removal of denture
from the mouth or from excessive friction when the denture moves
during function.
Hyperaemic, painful and detached areas of epthelium that develop on
the slopes of residual ridge are usually the result of disharmony of
occlusion when the teeth are making unbalanced contacts in eccentric
jaw positions.
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4. Localized or generalized areas of inflammation
Causes
Lack of Rest: Some patients do not remove
their dentures and hence do not allow rest to the tissues. The constant
pressure of the dentures retards the normal blood supply, which
oxygenates the tissue and removes waste products.
Dentures instability: It may be due to a faulty
impression technique, or when posterior teeth are placed too far
buccally or when there is inequillibrium between resilient and non
resilient areas.
Inadequate free way space: A generalized
hyperaemia of the crest and slopes of the ridges accompanied by pain in
the muscles attached to the mandible, the production of hyperKeratin
and a looseness of the dentures are often the result of insufficient
interocclusal distance.
Poor oral hygiene can result in inflammatory
reactions; e.g. in Xerostomia
A complete denture opposing natural teeth or a
partial denture may cause localized hyperaemia and edema.
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An unbalanced diet and avitaminosis contribute
to inflammatory conditions in all age groups. Alcoholism and senility
may lead to malnutrition, which is reflected in the inability of the oral
mucosa to the resist the pressure of dentures.
Endocrine gland disturbances and parafunction
resulting from neurosis can cause inflammation of the oral mucosa.
Systemic debilitating diseases contribute to
poor tissue tone and poor tissue resistance of dentures. E.g.
Hypertension, diabetes.
Allergic reactions of the supporting tissues to
denture base materials.
5. Hypertrophy:
An abnormal increase in size of the stress bearing oral mucosa is
unusual. In the midpalatal suture area, particularly when a relief is placed
in the tissue side of the denture base, hypertrophy of the mucosa does
occur. Small nodules which are defined as ‘papilloma-like hypertrophy’
develop throughout the area. The incisive papilla is another area that
becomes enlarged, hyperaemic and painful if it is not relieved in the
dentures. When the cause is not removed the tissue becomes pendulous.
Problems involving bone:
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Alveolar residual ridge is the major bony support for the denture
base to resist torquing and horizontal forces.
Isolated spinous processes may develop on the surface of the bone.
The soft tissue covering is caught between the hard dentures base and the
spine of bone with resulting discomfort and pain.
Bone growth on the surface and exostosis results in a thinning of the
over lying mucosa. These areas of bony growth act as fulcrums and
pressure points.
Sharp and prominent mylohyoid ridge acts like a knife edge and also
creates an undercut area.
Bone sore mouth a rarely encountered condition in senile patients
shows no soft tissue damage but expresses a feeling of constant soreness
and desire to remove the dentures.
b) Tissue Injury in Contact with Denture Periphery:
These lesions are mostly encountered in following areas and in the
order named:
- Frenum attachments
- Retromylohyoid space
- Retromolar pad
- Masetteric notch
- Hamular notch
- Vestibular fornix
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- Floor of the mouth
- Soft palate
Lesions seen are
- Slit like fissures and
- Ulcers
- Hypertrophy
Causes i) Over extensions of dentures periphery
ii) Sharp, thin unpolished borders
Hypertrophy at the junction of tightly and loosely attached mucosa
is caused by initial trauma which may be a result of disharmony of
occlusion in the eccentric positions. This is especially true when the forces
of occlusion are directed towards the anterior residual ridges in biting. The
bone loss results in a loose denture and a loose denture produces more
trauma.
Hypertrophy in the labial flange area often occurs following the
insertion of an immediate complete denture when the occlusion and
denture base have not been altered to meet the changes taking place in the
basal seat.
c) Tissue Injury in Contact with Polished Surface of Teeth:
Areas involved are lips, cheeks and tongue.
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Lesions seen are
- Cheek biting
- Tongue bititing
- Irritation of mucosa
Causes
1. Improper placement of teeth in horizontal or vertical
direction can lead to tongue biting or cheek biting.
2. Rough margins of teeth, an unpolished denture base or
porous dentures can lead to irritation of mucosa.
Treatment procedures:
Dentures that are essentially satisfactory can be ruined by
indiscriminately altering the denture base or the teeth. To determine the
etiology, the dentist must conduct these procedures in a systemic manner.
1. Examine each denture for stability and retention with the mouth at rest
and with the mouth in function. To check functional stability and
retention instruct the patient to speak, laugh, yawn, wipe the lips with
the tip of tongue and swallow.
2. Check the dentures for indications of undercut areas. Apply pressure
disclosing paste to the tissue side of either maxillary or mandibular
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denture. Instruct the patient to place and remove the dentures from the
mouth. An undercut is detected where the paste is removed from the
denture as if it were dragged from the surface. When it has been
definitely established that an undercut exists, alter the tissue side of the
denture base with an acrylic bur. One should be careful during this
procedure since tissue contact with the denture must be maintained.
Smooth and polish all ground areas.
3. Apply pressure indicating paste to the entire tissue side of the maxillary
denture. Instruct the patient to place both the dentures and tap the teeth
together with the jaws in centric relation. An area of displaced paste in
the tissue side of the denture is a sign of pressure. The pressure area
may result from premature tooth contact or imperfection of the denture
base.
4. To determine if the pressure area is produced by faultly occlusion,
institute patient remount procedures.
Steps:
Make a face bow record
Remount the dentures on an adjustable articulator
Adjust protrusive condylar and incisal guidance
Correct the occlusion
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5. The steps mentioned are done after tissue conditioning. Patient is
advocated only with soft food during the entire course of treatment.
When problem arises from loose and illfitting dentures, either remake
or rebase the dentures. It is possible that both the occlusion and denture
base may need correction.
6. When a generalized inflammatory condition exists or hyperkeratosis
is present in the stress bearing mucosa, evaluate interocclusal distance.
If the interocclusal distance is not adequate, alter the teeth to provide
space or remake the prosthesis.
7. When traumatic lesions are present in relation to the denture border,
apply disclosing wax to the borders of one denture at a time. Instruct
the patient to speak, swallow, laugh, yawn, wipe the lips with the tip of
the tongue in the buccal and labial vestibular spaces. If the wax is
moved from the border of the denture, overextention is indicated.
Remove the overextended area by grinding with an acrylic bur.
Smoothen the ground surface with wet pumice on a wet rag wheel.
8. Hypertrophy of the mucosa which does not include fibrous
hyperplasia is usually reversible and will resolve when the source of
trauma is removed.
9. When abrasions and ulcerations of the tongue and cheek occur, the
vertical and horizontal positions of the teeth must be evaluated. A loss
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of muscle tonus allow the cheek to sag and the result may be cheek
biting.
Tongue biting can occur in patients who have disease of the nervous
system such as epilepsy.
10. Xerostomia or Asialorrhoea
Results from regressive changes in salivary glands particularly of the
cells lining the intermediate ducts causing decreased flow of saliva.
Causes: Diabetes, Nephritis, Pernicious anaemia, Menopausal women,
Vitamin deficiency, X-ray irradiations, Medications.
Treatment for xerostomia:
- Frequent lubrication with petroleum jelly, silicone fluid and
improving hydration of the patient.
- If glandular function is present administration of sialogogues –
pylocarpine hydrochloride or pylocarpine nitrate 5 mg dose before
meals.
- Therapeutic dose of nicotinamide (250-400) mg TDS for 2 weeks.
Dentures are to be used minimally as tissues are fragile. These
patients are prone to conditions and chlorhexidine is the treatment of
choice.
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11. Surgical procedures or systemic theraphy usually resolve problems
involving bone.
B. Impaired Function
Esthetics:
Mental and emotional responses to the appearance of dentures vary.
What is acceptable to one person may be unacceptable to another.
Regardless of age or sex, esthetics is an important factor in denture
acceptance.
Common problems
1. Dissatisfaction with appearance
2. Dissatisfaction with teeth colour
3. Dissatisfaction with teeth position
1. Dissatisfaction with appearance: The number of patients who are
dissatisfied with their appearance with final dentures can be much
reduced if the dentist insists on a relation or a candid friend being
present at the trail stage, although it has to be stressed that the
appearance cannot be fully assessed until four to six weeks after
placement of finished dentures. This is because, the lip and muscles
have to adapt to the dentures.
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2. Dissatisfaction with teeth colour: The complaint is almost
invariably that the teeth are too dark or too yellow, but before
changing them it must be explained to the patient that natural teeth
darken with age and that very light shaded teeth look more artificial
than darker ones.
Treatment: Comply if possible with the patients request for lighter
teeth, usually by a compromise between the shade chosen by the
operator and that chosen by the patient.
3. Dissatisfaction with teeth position: The complaint may be that the
upper incisal edges are too low and therefore too much tooth is
showing. If there is a fault in the orientation of the occlusal plane,
the anterior teeth may be removed and replaced at a higher level but
usually this is unsatisfactory as it spoils the acrylic matrix and ruins
the protrusive tooth contacts. The best solution in such cases is to
remake the dentures.
The complaint may also be that the teeth are too far back in the
mouth or too far forward. A fear is sometimes expressed that moving the
teeth anterior to the ridge in the position the natural teeth occupied, will
affect the stability of the denture. But it is not so. Stability will be
jeoparadised much more by encroaching on the tongue.
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Phonetics:
When complete dentures are first worn, there is always some
temporary alteration in speech owing to the thickness of the denture
covering the palate, necessitating slightly altered positions of the tongue.
Commonly this is only a temporary inconvenience, most rapidly overcome
by the patient reading aloud. However, some knowledge of phonetics in
relation to dentures is necessary, inorder to correct speech defects that may
occur in denture wearers, and also to act as a guide for the more accurate
design of complete dentures.
Factors in denture design affecting speech
The vowel sounds:
These sounds are produced by a continuous air stream passing
through the oral cavity which is in the form of a single chamber. All vowel
sounds involve the tongue which has a convex configuration. The tip of the
tongue, in all the vowel sounds, lies on the floor of the mouth either in
contact with or close to the lingual surfaces of the lower anterior teeth and
gums. The application of this in denture construction is that the lower
anterior teeth should be set so that they do not impede the tongue
positioning for these sounds.
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Consonant sounds:
- Labial sounds – They are b, p and m formed mainly by the lips
- Labiodental sounds – They are f and v made between the upper
incisors when they contact the posterior 1/3 of the lower lip. Most
important information to be sought while the patient makes these
sounds is the relation ship of incisal edges to lower lip.
Dental and alveolar sounds:
Dental sounds such as ‘th’ are made with the tip of the tongue
extending slightly between the upper and lower anterior teeth. This sound
is closer to the alveolar than the tip of the teeth. Careful observation of the
amount of tongue that can be seen can provide information regarding
labiodental position of anterior teeth.
The sibilants s, z, sh, ch and j are alveolar sounds because the
tongue and alveolus form the controlling valve. When these sounds are
made, the upper and lower incisors should approach each other end to end,
but they should not touch.
The ‘S’ sound can be considered dental and alveolar speech sounds
because they are produced equally well with two different tongue
positions. Most people make the ‘S’ sound with the tip of the tongue
against alveolus in the area of rugae with small space for escape of air
between tongue and alveolus. Size and shape of this small space will
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determine the quality of the sound. If the opening is too small, a whistle
will result. If the opening is too broad, the ‘S’ sound will be developed as
an ‘Sh’. Frequent cause of undersired whistles with denture is a posterior
dental arch form that is too narrow.
A cramped tongue space, especially in the premolar region forces
the dorsal surface of the tongue to form too small an opening for the escape
of air. The procedure for correction is to thicken the center of the palate so
that the tongue does not have to extend up so far into the narrow palatal
vault.
Posterior palatal seal area: Errors of construction in this region
involves the vowels ‘u’ and ‘o’ and the consonants ‘k’, ‘g’. A denture
which has a thick base in the posterior seal area or a posterior edge finished
square instead of chamfered, will probably irritate the dorsum of the
tongue, impeding speech and possibly producing a feeling of nausea.
Mastication
Inability to eat:
This complaint is mainly confined to patients who are wearing
complete dentures for the first time, and are impatient at the time spent in
acquiring new habits of eating. Careful attention by the operator to the
psychological approach to denture wearing, will eliminate his complaint
except in rare cases.
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Difficulty may be encountered with certain fibrous foods and this is
likely to be due to low-cusp or zero cusp posterior teeth or lack of
interdigitation of posterior teeth.
An overextended periphery may cause a denture to dislodge. (This is
because movements during eating are more extensive than those employed
when moulding the periphery of the impression. Intelligent observation by
the patient of the exact movements which cause the instability will
eventually enable the operator to locate the overextention).
Retention and Stability
Patients more often complain that the lower denture lifts than that
the upper one drops.
Causes
Over extension, Tight lips, Under extension, Lack of saliva, when
coughing or sneezing, Upper denture drops when patient yawns, Lower
denture raises when mouth is partly open, Lower denture unseats with
various tongue movements, Upper denture drops while patient is talking,
Dislodgement of dentures on taking fluids.
Overextention :
It is due to incorrect moulding of the impression or incorrect
outlining of the denture on the cast and is visible in the mouth as an area of
hyperaemia or an ulcer.
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With the help of pressure indicating paste the overextention can be
detected and corrected.
Tight lips:
It can be the most difficult problem if the mandibular ridge is flat
and atrophic. The inward pressure from the lips will push the lower denture
backwards up the ascending ramus.
Treatment: Remake the lower denture with the lower anterior teeth set
more lingually, with a labial concavity an the denture. Surgical
vestibuloplasty must be considered.
Tongue space
It the lower posterior teeth are tilted or set lingually they produce an
undercut area into which the wide middle third of the tongue will get
locked. Movements of the tongue then lift the denture.
Treatment: Reduce the width of the lower posterior teeth by grinding off
the lingual cusps.
Underextention:
Maximum retention cannot be obtained without covering the
greatest possible denture bearing area.
It can be corrected by proper border moulding procedures with low
fusing compound and a conventional reline can then be carried out.
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Lack of saliva: already discussed under xerostomia. Serous salva produces
better cohesive force than mucous saliva.
When coughing or sneezing: occasionally a new denture wearer will
complain that his upper denture falls and his lower denture lifts whenever
he coughs or sneezes.
Treatment: It must be explained to the patient that when coughing or
sneezing the soft palate rises suddenly and the air pressure is considerable
so that the peripheral seal of the upper denture is broken and it is liable to
fall; the usual muscular movement will cause the lower denture to lift.
There is no way of preventing these movements of the dentures, but
covering the mouth with a hand or handkerchief is an obvious suggestion.
Upper denture drops when patient yawns:
During the act of yawning the mouth is opened
to its fullest extent, and the border tissues pull down against the
borders of the denture. If there is an area of irritation, the borders are
overextended and should be reduced. If there is no evidence of
overextention, the patient should be cautioned to refram from
opening the mouth too wide.
Distobuccal flange of the denture may be too
thick so that they interface with the action of ramus. A side to side
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movement of the jaw will loosen the denture. If this occurs, reduce
the thickness of the distal ends of the buccal flanges.
Denture is inadequate in posterior palatal seal.
This leads to a poor palatal seal and air is permitted to enter under
the posterior border of the denture.
Buccal surfaces of the teeth are placed too far
towards the cheek. When this occurs, and the mouth is opened the
muscles of the cheek pull against the buccal surfaces of teeth and
tend to unseat the denture.
Denture is overextended in the pteregomixillary
notch. When this occurs, the functional activity of the
pteregomandibular raphae is interfered with and during jaw
movements the denture is unseated.
Lower denture rises when the mouth is partly
open
Lingual flanges are over extended in the mylohyoid
region.
Lower posterior teeth are too far to the buccal.
Overextention of the buccal flangs.
Upper denture drops while patient is talking
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Poor border seal
Improper frenum relief in the denture.
Dislodgement of dentures on taking fluids
The patient should be told that when the dentures are delivered it is
possible for him or her to experience a loosening of dentures while
drinking. During swallowing, the soft palate rises and the posterior palatal
seal may be lost. The tongue and floor of the mouth are raised by the
tongue muscles. The mandible is prevented from moving downwards by
the suprahyoid muscles. So the mandibular denture rises during
swallowing.
However, this will not persist when the tongue, lips and cheeks learn
to manipulate the dentures.
Gagging:
One of the most bewildering problems encountered in complete
denture prosthodontics is that presented by the patient referred to as
“gagger”.
“Gagging is an involuntary retching reflex that may be stimulated
by something touching the posterior palatal region”. The retching may lead
to actual vomiting and is accompanied by lacrimation, salivation and
flushing. These symptoms are usually triggered by tactile stimulation of the
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soft palate by the maxillary denture, but may also be caused by virtually
any intraoral procedure.
The maxillary denture of the gagging patient usually has either of
the two characteristic contours. It may have a posterior palatal margin that
is so concave that it almost terminates on the hard palate, or it may have a
palate which has a marked downward slope away from the soft palate. In
either case the dentures can exert only minimal pressure against the soft
palate.
The most paradoxical feature found in almost every gagging patient
is although the soft palate is extremely sensitive to the contact of the
denture or any instrument, the patient seldom gags on foods and liquids of
his diet which contact this same area during swallowing.
It can thus be seen that the picture presented by the average gagger
can be separated into –
i) Acute
ii) Chronic
Shortening of palatal margin does not decrease the tendency to gag
but may actually increase it. Even in a non gagger light touch or pressure
against the soft palate can cause tickling sensation, whereas firm pressure
is much less apt to do so. A similar experiment can be performed by
touching the back of one’s hand with the lightest possible pressure; this
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will usually cause a tickling sensation. However if the pressure on the same
area is firm, no tickling is felt. And so, too, with the maxillary denture; it is
much more apt to cause a tickling sensation if it exerts too little pressure
against the soft palate than if it exerts too much.
So the consistent feature of the acute phase is a maxillary denture
which feels “too long” and causes gagging which is not relieved by palate
shortening.
Chronic phase:
In this phase the gaggers history resembles a simple conditioned
reflex in that the gagging becomes so intimately associated with the
denture that ultimately any procedure involving the denture, or the oral
cavity, can set off the reflex. Even the thought of such contact may cause
gagging.
Kovats and Krol mentioned that the gag reflex can be markedly
diminished if the patient’s complete attention is diverted by having him
maintain a leg in an elevated position.
Treatment:
There are a number of methods of dealing with the problem. It is
important to give the patient a feeling of confidence of on the part of the
dentist.
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Prior to the impression making, the patient should be instructed to
breathe through the nose slowly and audibly and at the same time to
rhythmically tap his right leg on the floor. By doing so the patients
attention would be diverted enough to allow the making of mandibular
impression without incident.
The palate may be sprayed with surface anesthetic or ethylchloride
prior to recording the impression. Posterior third of the tongue which is
often implicated in the retching reflex can also do anesthetized.
It is wise to have the patients head upright and to record the lower
preliminary impression first an impression compound with minimal
flow is recommended eg. Medium fusing compound. Either silicone or
heavy bodied polysulphide is suitable for final impression.
For registration of centric relation, virtually the entire palate of the
maxillary occlusal rim was removed in order to reduce to an absolute
minimum the area of contact between rim and palatal tissue. In addition, a
thin film of adhesive was sprinkled onto the record base for retention, and
an anesthetic was sprayed onto the palate. Patient followed instructions
regarding breathing and foot tapping.
Prior to actual placing of new dentures, the patient was prepared for
a temporary period of discomfort, but was assured that although initially
uncomfortable, it would be short lived.
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Lower denture should be placed first. The maxillary denture should
then be placed and the patient is requested to close into centric occlusion in
centric relation. The patient should be made to nose-breathe in a deep slow
fashion. Although initially very severe, the gagging will subside over a
period of (4-5) minutes.
Hypnotheraphy is also used as are various types of behaviour
therapy. Barbiturates may be used to depress the CNS, antihistamines to
lower the feeling of sickness or pararymphathetic depressants to reduce the
salivary flow which increases at the outset of retching.
Miscellaneous:
1. Burning tongue (glossopyrosis) and burning mouth (stomatipyrosis)
these symptoms are frequently seen in complete denture patients.
However complete dentures are not always the etiologic factor.
It is almost impossible to make a clear cut diagnosis of the cause of
stomatopyrosis. Severe burning mouth is most frequently found in
menopausal women between 40 and 60 yrs of age.
Other causes:
Deficiency : Vit B12, Folate, Iron
Infections : Staphylococcal, Candidiasis
Psychogenic : Cancerophobia, depression
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Prosthetic : Occlusal faults, bony irregularities, allergy to denture base
material.
Treatment:
- Occlusion should be balanced in all positions
- Check for roughness on the tissue and polished surface of the
denture.
- Treat the causative systemic diseases.
- Reconstruct the dentures, if porous and unhygienic
- Change denture base material if necessary
- A balanced diet rich in vitamins and essential minerals should be
prescribed.
- Whenever indicated, hormones should be administered
- Psychotherapy can be instituted.
2. Food under the denture
This compliant is usually made by patients wearing dentures for the
first time and who have not yet leant how best to control the food. A
perfect peripheral seal will prevent the ingress of food beneath the denture,
but perfection is not always attained and owing to alveolar resorption,
never maintained.
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Treatment: Covering maximum possible area of the edentulous foundation
and obtaining an adequate peripheral seal
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3. Clicking of teeth
The main causes are:
- Excessive vertical dimension of occlusion causes the denture to
contact during speech, particularly the sibilant sounds, as the
mandible moves vertically through the speaking space.
- Movement of the lower denture from whatever cause is very liable
to lead to clicking of teeth.
- Excessive incisive guidance angle usually means that the horizontal
overjet is inadequate in relation to the vertical overlap. This means
that during speech, in which there is often a pronounced horizontal
movement of mandible the incisors contact each other and cause
clicking.
- Porcelain teeth by nature of the material creates more impact noise
than acrylic.
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TROUBLE SHOOTING IN COMPLETE DENTURE PROSTHESIS
- INTRODUCTION
- CLASSIFICATION OF PROBLEMS
- DESCRIPTION OF THE PROBLEMS WITH THEIR ETIOLOGY
- MANAGEMENT OF THE PROBLEMS
- SUMMARY AND CONCLUSION
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