managing problems in complete dentures_lecture
TRANSCRIPT
Managing Problems in Managing Problems in
Complete Dentures Complete Dentures
Dent 445Removable Prosthodontics (4) Dr Esam Alem
Textbook Reference: Chapter 17
Complete Prosthodontics: Problems, diagnosis and managementAA Grant, JR Heath, JF McCordp. 33-88
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
II. Indirect from denture
III. Related to patients
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
B. Related to denture function
C. Related to esthetics
D. Related to phonetics
II. Indirect from denture
III. Related to patients
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
1. Borders
2. Fitting surface
3. Polished surface
4. Teeth
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
1. Borders
a. Overextension
b. Underextension
c. Overcontoured flanges
d. Undercontoured flanges
SHORT TERM
COMPLAINTSLONG TERM
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
1. Borders
a. Overextension
1
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
1. Borders
a. Overextension
i. Immediate effect
- Pain
- Bleeding and ulcer
- Loss of retention before functional movements
- Loss of retention during functional movements
- Seen as areas exposed through PIP
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
1. Borders
a. Overextension
ii. Delayed (late) effect
- Ulcer
- Erythema (red area)
- Fibroma
- Hyperkeratinized mucosa
- TMD
- Loss of retention on functional movements
Managing overextensionsManaging overextensions
� Method 1 – Patient complaint
� Let the patient point to the area
� Problems with this
technique:
� Patient may not point
correctly to the area
� Reductions are not
controlled in amount or location
� Not all overextensions cab be detected by this method
Managing overextensionsManaging overextensions
� Method 2 – Indelible (Copier) pencil
– Locate area of erythema or ulceration
– Mark it with copier (indelible) pencil
– Seat the denture and allow the copier pencil ink to imprint on the denture
Managing overextensionsManaging overextensions
� Method 3 -
– Locate area of tissue reaction lesion
– Place PIP / disclosing wax
– Paste
– Wax
– Rubber
– Perform functional movements in the affected area
– Trim the denture flange where the border is exposed through the disclosing wax
– Repeat until no PIP / wax is displaced
• Note the ulcer associated with the denture border
overlying the canine eminence.
2
Note the posterior palatal seal area: The bead is too Note the posterior palatal seal area: The bead is too
deep and too sharp. Note the ulcer at the midline.deep and too sharp. Note the ulcer at the midline.
• Disclosing wax is tempered in a water
bath.
• Apply PIP or disclosing wax to the dried
denture border.
• Carefully insert the denture and mold the
borders of the selected area.
PIP or disclosing wax is used to check the length PIP or disclosing wax is used to check the length
of the denture borders. In this example it has of the denture borders. In this example it has
been placed in a disposable syringe.been placed in a disposable syringe.
• Carefully adjust the denture flange as necessary.
• Reapply, border mold and adjust until areas of overextension are eliminated.
• Other examples of commonly overextended
areasThese flanges are too thickThese flanges are too thick
These flanges are too longThese flanges are too long
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
1. Borders
a. Overextension
i. Delayed (late) effect
- Ulcers under labial flange
Causes: Overextended Flanges → Shorten
Excessive overbite → Adjust anterior occl.
Habitual mastication in protrusive relationship→ train patient to masticate in CR
These flanges are too thickThese flanges are too thick
These flanges are too longThese flanges are too long
3
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
1. Borders
b. Underextensions
i. Immediate effect
- Loss of retention before functional movement
- Loss of retention during functional movement
Managing Managing underextensionsunderextensions� Method
� Check for overextensions
� Check retention� Anterior retention
� Lateral retention
� Posterior retention
� Add green stick to build in the area under suspicion → Border mold with functional movements intra-orally
� Recheck retention
� Replace green stick with cold-cure acrylic (partial reline)
Anterior (labial flange) Anterior (labial flange)
retention check retention check →→
Hold anterior teeth and pull Hold anterior teeth and pull
denture down denture down labiallylabially
Lateral (Lateral (buccalbuccal flange) flange)
retention check retention check →→
Hold Hold contralateralcontralateral posterior posterior
teeth and rotate flange away teeth and rotate flange away
from from sulcussulcus
Posterior (post dam) Posterior (post dam)
retention check retention check →→
Place finger palatal to Place finger palatal to
anterior teeth and push anterior teeth and push
upward to rotate denture upward to rotate denture
down down posteriorlyposteriorly
Posterior (Posterior (hamularhamular notch) notch)
retention check retention check →→
Press upwards on Press upwards on
contralateralcontralateral canine to rotate canine to rotate
denture down denture down posteriorlyposteriorly in in
hamularhamular notch areanotch area
4
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
2. Fitting Surface
a. Lateral Ridge Slopes
i. Nerve compression
ii. Unfavorable undercuts
b. Flat Areas
i. Palatal rugae area
ii. Palatal suture area
c. Crest of residual ridges
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
2. Fitting Surface
a. Lateral Ridge Slopes
i. Nerve compression
- Inferior Dental Nerve
- Mental Nerve
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
2. Fitting Surface
a. Lateral Ridge Slopes
i. Nerve compression
- Inferior Dental Nerve
- Mental Nerve
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
2. Fitting Surface
a. Lateral Ridge Slopes
i. Nerve compression
- Inferior Dental Nerve
- Mental Nerve
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
2. Fitting Surface
a. Lateral Ridge Slopes
ii. Unfavorable undercuts
5
Managing Denture ProblemsManaging Denture Problems
ii. Unfavorable Undercuts
• Maxillary
• Natural – due to anatomy of ridges
• Tuberosities
• Premaxillary (anterior) area
• Uncompressed extraction sockets
• Mandibular
• Natural
• Anterior area
• Internal oblique ridge
• Mylohyoid ridge
• Mandibular tori
• Uncompressed extraction sockets
Managing undercutsManaging undercuts
� Leave engaged
� No trauma
� A path of insertion present
� Minimal undercut
� E.g. normal max. ant. and tuberosity undercuts
� Lingual undercuts in lateral wall of ling. pouch
Managing undercutsManaging undercuts
� Leave but partially block on cast
� Minimal trauma
� A path of insertion is present
� Minimal undercut
� Block undercut with dental stone before
flasking and packing
Managing undercutsManaging undercuts
� Reduce one side
� Minimal trauma
� Minimal undercut
� Reduce both sides without compromising retention
Managing undercutsManaging undercuts
� Preprosthetic surgical removal or
block-out and use implant-retained prosthesis
� If undercut is severe
� If blockout/relief of denture will compromise retention
� If undercuts encircle more than 180º
6
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
2. Fitting Surface
b. Flat Areas
i. Palatal rugae area
nasopalatine nerve compression
ii. Palatal suture area
thin mucoperiostium – check post dam
iii. Lateral palate
posterior palatine nerve compression
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
2. Fitting Surface
c. Crest of residual ridges
i. From ridge:
Bone spicules, knife edge, impacted roots, impacted teeth, cysts, nerves, thin mucosa
ii. From denture:
Denture surface may include sharp prominences
or irregularities
iii. From occlusion:
Heavy occlusal interferences
7
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
3. Polished surface
•• Finish borders with an acrylic bur. Finish borders with an acrylic bur. Remove excess resin beyond the Remove excess resin beyond the land. Be careful to preserve the land. Be careful to preserve the border width and contour. border width and contour.
•• Remove all plaster or stone.Remove all plaster or stone.
•• Smooth the denture bases to the Smooth the denture bases to the proper contour with your acrylic proper contour with your acrylic burs.burs.
•• Bubbles and other irregularities Bubbles and other irregularities around the denture teeth can be around the denture teeth can be removed with chisels or scrapers.removed with chisels or scrapers.
�� Remove small particles of stone from the Remove small particles of stone from the
proximal areas with a brush wheel.proximal areas with a brush wheel.
�� The palatal portion should be about 3 mm The palatal portion should be about 3 mm
thick (minimum 2 mm).thick (minimum 2 mm).
•• Check the bearing Check the bearing surfaces of the surfaces of the dentures for bubbles dentures for bubbles and sharp and sharp projections.projections.
•• Use a very wet rag wheel with liberal amounts of wet Use a very wet rag wheel with liberal amounts of wet
pumice to polish the palatal, lingual, labial and buccal areas. pumice to polish the palatal, lingual, labial and buccal areas. The periphery of the denture must also be carefully The periphery of the denture must also be carefully polished. Use the edge of the wheel as shown during polished. Use the edge of the wheel as shown during
polishing to avoid burning the acrylic resin. Do not polishing to avoid burning the acrylic resin. Do not overpolish and thereby loose the contours that were overpolish and thereby loose the contours that were developed during festooning.developed during festooning.
8
Polished denturesPolished dentures
Note that the borders are rounded and smooth, Note that the borders are rounded and smooth,
and the palate is highly polished and the proper and the palate is highly polished and the proper
thicknessthickness
Do not over polishDo not over polish
Be careful not to overpolish the occlusal or incisal Be careful not to overpolish the occlusal or incisal
surfaces of the denture teeth.surfaces of the denture teeth.
•• Reexamine the tissue side of the dentures Reexamine the tissue side of the dentures
and carefully remove any and carefully remove any bubblesbubbles present present
with a sharp instrument.with a sharp instrument.
•• Prior to delivery the dentures must be soaked in Prior to delivery the dentures must be soaked in
water for 72 hours.water for 72 hours.
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
4. Teeth
a. Cheek-biting
b. Tongue biting
c. Unfamiliarity with modifications
Managing Denture ProblemsManaging Denture Problemsa. Cheek-biting
Causes
• Thin or overextended periphery
(denture base material does not provide enough support for the cheek)
• Loss of tone of cheek musculature in old
patients
• Insufficient inter-arch clearance between distal part of denture
• Inadequate horizontal overjet in molar region (posterior edge-to-edge occlusion)
9
Managing Denture ProblemsManaging Denture Problemsa. Cheek-biting
Treatment
• Build out thin areas, or extend the short
periphery
• Trim maxillary denture buccal to tuberosityand/or from over retromolar pad of mandibular
denture
• Tooth positions
• Re-set teeth in correct relationship
• Recontour and polish buccal surface of mandibular posterior teeth to create horizontal overjet
Managing Denture ProblemsManaging Denture Problemsb. Tongue-biting
Causes
• Artifcial teeth positioned too far lingually
• Occlusal plane of is too low
• Large tongue : if lower posterior teeth missing for long time,
tongue muscles will lose muscle tone and
tongue will become broad and flattened. Tongue will regain normal contour with time
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
B. Related to denture function
C. Related to esthetics
D. Related to phonetics
II. Indirect from denture
III. Related to patients
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
B. Related to denture function
1. Denture Instability
a. Looseness of mandibular denture
b. Looseness of maxillary denture
2. Denture Interference
a. During swallowing
b. Tooth clicking
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
B. Related to denture function
1. Denture Instability
a. General looseness of mandibular denture
i. Causes
• Error in occlusion (centric occlusion not in harmony with centric relation)
• occlusal plane too high
• underextension of periphery (deficient
impression)
• Inability of patient to adapt and control denture
• Poor tongue position (retracted/guarded tongue position)
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
B. Related to denture function
1. Denture Instability
a. General looseness of mandibular denture
i. Treatments
→ Correct faulty occlusion by remount procedures and occlusal adjustment
→ Reset teeth at lower occlusal plane
→ Reliner/rebase denture providing proper
extension
10
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
B. Related to denture function
1. Denture Instability
a. Looseness of mandibular denture
i. While yawning or opening wide
ii. While rinsing
iii. While talking
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
B. Related to denture function
1. Denture Instability
a. Looseness of mandibular denture
i. While yawning or opening wide
ManidibleManidible -- While yawning or rinsingWhile yawning or rinsing
Causes
� Denture base too thick in buccal
posterior area (masseter exerts
forward force on posterior part of
denture)
� Overextended in retromolar area
(pterygomandibularraphe interference)
Treatment
� Reduce thickness of denture base
� Shorten denture until pterygomandibular
ligament does not
exert tension on posterior border
when mouth opens wide
Mandible Mandible -- While talkingWhile talkingCauses
� Inadequate seal in lingual pouch area
� Lingual flange overextensions
Treatment
� Correct seal with reline
� Shorten overextensions until
tongue does not
interfere causing lifting up of denture
and breakage of seal
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
B. Related to denture function
1. Denture Instability
b. Looseness of maxillary denture
i. Occasional
ii. When eating on sides
iii. Approximately every 2 hours
iv. While yawning/opening wide
v. While rinsing
vi. While bending over
vii. While talking
viii. Looseness when occluding in centric relation
Maxilla Maxilla –– occasional loosenessoccasional loosenessCauses
� Underextension in localized area
� Faulty occlusion
� Overextension of peripheries
� Xerostomia
� Displacement of
flabby tissues during impression
Treatment
� Reline
� Correct occlusion
� Adjust denture
� Treat cause
� Modify impression technique to change
primary denture bearing area
11
Maxilla Maxilla –– when eating on sideswhen eating on sidesCauses
� Non-yielding area in hard palate-midpalatine raphe(crestal ridge tissues yield under chewing stresses so denture rocks or “see-saws”across mid-palatal fulcrum)
� Incorrect tooth position (too far buccally)
� Chewing resistant foods
Treatment
� Provide relief area over rigid area
� Rebalance in lateral excursions; reset teeth in correct relationship to ridge
� Instruct patient to maintain soft diet until mouth is conditioned to wearing dentures
Maxilla Maxilla –– approx. every 2 hrsapprox. every 2 hrsCauses
� Heavy mucinoussaliva
� Incorrect tooth position (teeth too far
buccally or labially)
� Improper incising habits
� Loss of posterior
palatal seal (seal on palate; posterior limit
not in hamularnotches)
Treatment
� Prescribe astringent mouth wash; regular
cleaning of dentures; reduction of
carbohydrate intake may help
� Train patient to
masticate in centric relation
Maxilla Maxilla -- While yawning or rinsingWhile yawning or rinsingCauses
� Denture base too thick in buccal
posterior area (masseter exerts
forward force on posterior part of
denture)
� Overextended in retromolar area
(pterygomandibularraphe interference)
Treatment
� Reduce thickness of denture base
� Shorten denture until pterygomandibular
ligament does not
exert tension on posterior border
when mouth opens wide
Maxilla Maxilla –– while bending overwhile bending overCauses
� Overextended in posterior palatal seal
area
� Overextended in
hamular notch area
Treatment
� Reduce thickness/extension
of posterior palatal seal area
� Valsalva maneuver /
pip
Maxilla Maxilla –– while talkingwhile talkingCauses
� Inadequate posterior palatal seal area
� Overextended in posterior region
Treatment
� Reline posterior palatal seal
� Shorten posterior extension until soft
palate does not lift
upward and break contact with denture
base
Maxilla Maxilla –– in RCPin RCPCauses
� Incorrect occlusion
� Poor denture
foundation (flabby tissues over ridge)
� Teeth set too far
buccally / labially
� Centric occlusion not in harmony with
centric relation
� Midpalatine suture fulcrum
Treatment
� Correct occlusion
� Selective pressure
impression / special impression /
preprosthetic surgery
� Reset teeth
� Enlarge centric area
� Provide relief in area of midpalatine suture
12
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
B. Related to denture function
1. Denture Instability
a. Looseness of mandibular denture
b. Looseness of maxillary denture
2. Denture Interference
a. During swallowing
b. Tooth clicking
When swallowingWhen swallowingCauses
� Maxillary denture too
thick or overextended in posterior region
� Mandibular denture too
thick or overextended in posterior lingual flange area
� Insufficient VDO
� Excessive VDO
� Incorrect tooth position (posterior teeth set too far
lingually – tongue is crowed)
Treatment
� Reduce thickness or
adjust posterior area
� Reduce thickness or adjust posterior lingual flange area
� Increase VDO
� Reduce VDO
� Reset teeth
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
B. Related to denture function
C. Related to esthetics
D. Related to phonetics
II. Indirect from denture
III. Related to patients
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
C. Related to esthetics
1. Fullness under nose
2. Depressed philtrum
3. Upper lip sunken in
4. Too much of the teeth are exposed
5. Artificial appearance
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
C. Related to esthetics
1. Fullness under nose
a. Cause: labial flange of denture too long or thick
b. Treatement: reduce flange length or thickness
2. Depressed philtrum
a. Cause: Labial flange too short
b. Treatment: increase length or thickness of flange
3. Upper lip sunken in
a. Cause: maxillary teeth set too far lingually
b. Treamtent: reset anterior teeth labially
4. Too much of the teeth are exposed
5. Artificial appearance
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
C. Related to esthetics
4. Too much of the teeth are exposed
a. Causes:
i. excessive VDO
ii. Incisal plane too low
iii. Cuspids and lateral incisors too prominent
b. Treatment:
i. Reduce VDO
ii. Reset teeth at higher plane
iii. Adjust
5. Artificial appearance
13
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
C. Related to esthetics
5. Artificial appearance
a. Causes
i. Technique setup (teeth are too regular in alignment
– too perfect)
ii. All teeth have same shape – lack of individualization
b. Treatment
i. Individualization by rotating and shortening some
teeth
ii. Choose different but complimentary shades/ use
staining techniques
iii. Grind incisal edges and angles
iv. Individualize gingival contour and color
Anterior Maxilla Pattern of ResorptionAnterior Maxilla Pattern of Resorption
•• Following extraction, resorption is from labial Following extraction, resorption is from labial
towards the lingual. Therefore anterior teeth should towards the lingual. Therefore anterior teeth should
NOTNOT be placed directly over the ridge.be placed directly over the ridge.
Labial incisal positionLabial incisal position
On average the distance On average the distance
from the center of the from the center of the
incisal papillae to the incisal papillae to the
labial surface of the labial surface of the
central incisor is 8central incisor is 8--10 10
mm. This average mm. This average
influenced by the age influenced by the age
and gender of the and gender of the
patient.patient.
FemaleFemale
Young 8Young 8
Middle 7Middle 7
Old 6Old 6
MaleMale
Young 6Young 6
Middle 5Middle 5
Old 4Old 4
Average Value Positions
8
Maxillary incisal lengthMaxillary incisal length
On the average the position of the On the average the position of the
maxillary central incisor edge is 22mm maxillary central incisor edge is 22mm
measured from from the labial sulcus measured from from the labial sulcus
adjacent to the labial adjacent to the labial frenumfrenum..
Visibility of the central incisor should be Visibility of the central incisor should be
approximately 1.0 with an average length approximately 1.0 with an average length
upper lip in a middle aged patient. upper lip in a middle aged patient.
In older patients or in patients with longer In older patients or in patients with longer
lips the visibility decreases.lips the visibility decreases.
In younger patients or with patients with In younger patients or with patients with
shorter lips visibility increasesshorter lips visibility increases
Average Value Positions
Tooth Length Tooth Length -- estheticsesthetics
•• Incisor length is important for those patientIncisor length is important for those patient’’s who have a s who have a
significant display of anterior teeth.significant display of anterior teeth.
•• We normally expect to see approximately 2/3 We normally expect to see approximately 2/3 –– 3/4 of the 3/4 of the
facial surfaces of the maxillary anterior teeth when the facial surfaces of the maxillary anterior teeth when the
patient smiles widely. However, the degree of display of patient smiles widely. However, the degree of display of
maxillary anterior teeth varies greatly between individuals.maxillary anterior teeth varies greatly between individuals.
•• An average An average ““high smile linehigh smile line”” is one where the patientis one where the patient’’s s
upper lip lies approximately 6upper lip lies approximately 6--7 mm above the 7 mm above the incisalincisal edge edge
of the maxillary wax rim when the patient smiles or laughs.of the maxillary wax rim when the patient smiles or laughs.
•• If a patient has an average If a patient has an average ““high smile linehigh smile line”” 7 mm above 7 mm above
the the incisalincisal edge, then an appropriate length of tooth to edge, then an appropriate length of tooth to
select for good esthetics would be: 7 x 3/2 = 10.5 mm select for good esthetics would be: 7 x 3/2 = 10.5 mm
Tooth Length Tooth Length –– resorption of residual ridgeresorption of residual ridge
•• In some cases the amount of residual ridge resorption will In some cases the amount of residual ridge resorption will
take precedence over the take precedence over the ““high smile linehigh smile line”” and esthetics and esthetics
when tooth length is concerned.when tooth length is concerned.
•• In patients who have had recent extraction, the residual In patients who have had recent extraction, the residual
ridges are large because ridge resorption has not ridges are large because ridge resorption has not
progressed significantly yet.progressed significantly yet.
•• When the maxillary anterior residual ridge is large then the When the maxillary anterior residual ridge is large then the
overlying occlusal rim will be relatively short and there will overlying occlusal rim will be relatively short and there will
only be limited height for the anterior teeth to be set. only be limited height for the anterior teeth to be set.
•• In such cases, shorter teeth are often selected to make In such cases, shorter teeth are often selected to make
setting easier without the need of trimming the root end setting easier without the need of trimming the root end
(ridge(ridge--lap) end of the artificial teeth.lap) end of the artificial teeth.
14
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
A. Related to denture surfaces
B. Related to denture function
C. Related to esthetics
D. Related to phonetics
II. Indirect from denture
III. Related to patients
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
D. Related to phonetics
1. Whistle “S” sound
2. Lisp “S” sound (“S” sounds like “Th”)
3. Upper and lower incisors contact during “S/
Ch/ J” sounds
4. “F” sounds like “V”
5. “These/Those” sound like “Dese/Dose”
6. General speech difficulty
Phonetic ConsiderationsPhonetic ConsiderationsThe anterior teeth, tongue, and lips act as a part of the The anterior teeth, tongue, and lips act as a part of the
valvingvalving mechanism which modifies the flow of air to produce mechanism which modifies the flow of air to produce
speech soundsspeech sounds
LinguopalatalLinguopalatal sounds: sounds: ““ss””, , ““shsh””
�� are made by contact between the tip of the tongue and the are made by contact between the tip of the tongue and the
palate at the palate at the rugaerugae area with a small space for the escape of area with a small space for the escape of
airair
LabiodentalLabiodental sounds: sounds: ““ff”” ““vv””
�� are produced by contact between the maxillary incisors are produced by contact between the maxillary incisors
and the posterior oneand the posterior one--third of the lower lip (vermillion border)third of the lower lip (vermillion border)
Labial sounds: Labial sounds: ““pp”” ““bb””�� if the lips are not supported properly by the teeth theseif the lips are not supported properly by the teeth these
sounds may be defectivesounds may be defective
Linguopalatal sounds: Linguopalatal sounds: ““ss””
The The ““ss”” sound is made by contact sound is made by contact
between the tip of the tongue and the between the tip of the tongue and the palate at the rugae area with a small palate at the rugae area with a small space for the escape of air.space for the escape of air.
If the space is too small a whistle usually If the space is too small a whistle usually results and if the space is too broad and results and if the space is too broad and
thin, the thin, the ““ss”” sound is replaced by the sound is replaced by the ““shsh””sound which sounds like a lisp. sound which sounds like a lisp.
(1) This is affected by the shape and (1) This is affected by the shape and thickness of the denture base in the thickness of the denture base in the palatal region.palatal region.
(2) The (2) The ““ss”” and and ““shsh”” sounds also indicates sounds also indicates
whether the whether the (anterior(anterior--posterior position) of posterior position) of the upper incisorsthe upper incisors is correct. If the patient is correct. If the patient
says says ““shsh”” when he means to say when he means to say ““ss””, then the , then the
teeth may be too far forward.teeth may be too far forward.
Teeth set too far
labially
Teeth set too far
palatallyNormal position
Linguopalatal sounds: Linguopalatal sounds: ““ss”” –– closest speaking spaceclosest speaking space
(3) The (3) The ““ss”” sound also indicates whether the patient has adequate sound also indicates whether the patient has adequate ““freeway spacefreeway space””
or or interocclusalinterocclusal clearance. clearance.
When we speak, our upper and lower teeth do not normally contactWhen we speak, our upper and lower teeth do not normally contact each other. each other.
(They only contact during function and swallowing).(They only contact during function and swallowing).
During speech, our teeth come closest together (1.0 mm) during tDuring speech, our teeth come closest together (1.0 mm) during the pronunciation he pronunciation
of the of the ““ss”” or or ““sibilantsibilant”” sounds.sounds.
(They also come close together during (They also come close together during ““chch”” and and ““jj”” sounds). sounds).
During pronunciation of all other sounds, the space between the During pronunciation of all other sounds, the space between the upper and lower upper and lower
teeth is larger than this.teeth is larger than this.
That is why we call the 1.0 mm space between the upper and lowerThat is why we call the 1.0 mm space between the upper and lower teeth during teeth during
speech the speech the ““closest speaking spaceclosest speaking space””
If we donIf we don’’t give the patient enough t give the patient enough ““freeway spacefreeway space”” during during ““jaw relation recordsjaw relation records””, , then the patientthen the patient’’s denture teeth will start hitting each other when the patient s denture teeth will start hitting each other when the patient
pronounces the pronounces the ““ss”” sound.sound.
15
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
D. Related to phonetics
1. Whistle “S” sounda. Cause:
i. Existence of too narrow an air space on the anterior part of the palate for the tongue (mis-shapen palate)
ii. Anterior teeth (i.e. central incisors set too far forward; increased horizontal overjet)
iii. Anterior part of tongue is crowded by maxillary premolars set too far palatally
b. Treatment
i. Reshape palatal contour correctly to mimic underlying palatal contour (remove thick acrylic in rugae area if necessary)
ii. Correct overjet and anterior/premolar tooth positions if necessary
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
D. Related to phonetics
2. Lisp “S” sound (“S” sounds like “Th”)
a. Cause:
i. Existence of broad air space on the anterior part
of the palate
ii. When anterior palatal air channel is obliterated
iii. Anterior teeth placed too far palatally
b. Treatment:
i. Adjust thickness of anterior palatal area; reduce thickness of palatal acrylic if necessary
ii. Reposition teeth further anteriorly if necessary
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
D. Related to phonetics
3. Upper and lower incisors contact during “S/
Ch/ J” sounds
a. Cause:
i. Vertical dimension of occlusion too great
ii. Reduced horizontal overlap (lower anterior teeth set too far anteriorly)
b. Treatment:
i. Reduce vertical dimension of occlusion
ii. Reset lower anterior teeth for increased horizontal overlap
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
D. Related to phonetics
4. “F” sounds like “V”
a. Cause:
i. Upper anterior teeth set too inferior (long)
ii. (Occasionally, upper anterior teeth too far palatal and inferior)
b. Treatment:
i. Reset upper anterior teeth in a more superior
position (shorter)
Labial Labial ––dental dental ““FF”” & & ““VV”” soundssounds
The The ““ff”” and and ““vv”” sounds indicate sounds indicate
whether the whether the length (superiorlength (superior--
inferior position) of the upperinferior position) of the upper
incisorsincisors is correct.is correct.
The upper lip contacts the the The upper lip contacts the the
wetwet--dry line of the lower lip dry line of the lower lip
during speech production of during speech production of
““ff”” and and ““vv”” sounds.sounds.
If the upper anterior teeth are set If the upper anterior teeth are set
too long, then a too long, then a ““vv”” sound is made sound is made
when the patient means to make when the patient means to make
an an ““ff”” sound.sound.
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
D. Related to phonetics
5. “These/Those” sound like “Dese/Dose”
a. Cause: Upper anterior teeth set too far lingually
b. Treatment: Reset teeth anteriorly
6. General speech difficulty
a. Initial disturbance of speech is to be expected (especially for patients who are first-time denture
wearers)
b. Increased vertical dimension of occlusion
c. Poor retention
16
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
II. Indirect from denture
III. Related to patients
Managing Denture ProblemsManaging Denture Problems
II. Indirect from denture
A. Generalized discomfort
B. Generalized soreness (pain)
C. Generalized burning sensation
D. Gagging
E. Temperomandibular joint pain
F. Fatigue of muscles of mastication
G. Difficulty during mastication
H. Excessive salivation
I. Unpleasant taste
Managing Denture ProblemsManaging Denture Problems
II. Indirect from denture
A. Generalized discomfort1. Cause:
i. Improper occlusion
ii. Centric occlusion not in harmony with centric
relation
iii. Excessive vertical dimension of occlusion
2. Treatment
i. Correct occlusion
ii. Enlarge centric contact area
iii. Reduce vertical dimension of occlusion
Managing Denture ProblemsManaging Denture ProblemsII. Indirect from denture
B. Generalized soreness (pain)1. Cause:
i. Heavy biting force – strong musculature
ii. Excessive vertical dimension of occlusion (VDO)
iii. Locked occlusion (no freedom of movement in CR)
iv. Failure to provide freedom for Bennett movement (soreness usually on working side only)
v. Improperly processed base acrylic material
2. Treatment
i. Reduce buccolingual width of teeth, reduce VDO, use soft lining material if necessary)
ii. Enlarge centric relation contact area to allow some “freedom of movement in centric relation”. Possibly change occlusal scheme from anatomic to flat monoplane occlusion
iii. Rebase acrylic of denture if necessary
Managing Denture ProblemsManaging Denture ProblemsII. Indirect from denture
C. Generalized burning sensation1. Common during menopause in middle-aged females
2. Allergy to acyrlic resin (but this condition is very rare) → remake material using alternative polymers or metal base
3. Dentures incorrectly processed (excessive free unpolymerized monomer remains) → rebasing may be necessary
4. Pressure on nerve
a. Maxillary anterior ridge generalized burning sensation due to pressure on anterior palatine nerve → relieve area over incisive papilla
b. Maxillary premolar/molar/tuberosity generalized burning sensation → relieve area greater+lesser palatine nerves
c. Mandibular anterior region generalized burning sensation → relieve area over mental foramen
Managing Denture ProblemsManaging Denture Problems
II. Indirect from denture
D. Generalized gagging
1. Alteration of the vertical dimension of
occlusion:
a. Decreased vertical dimension results in crowding of the tongue and soft tissues →
gagging
b. Increased vertical dimension results in loss of freeway space which can cause
exhaustion and spasm of the levator and tensor veli palatini muscles of the palate →
gagging
17
Managing Denture ProblemsManaging Denture ProblemsII. Indirect from denture
E. Temperomandibular joint pain
1. Cause:
a. Insufficient VDO
b. Centric occlusion not in harmony with centric relation
c. Arthritis
d. Truama
2. Treatment:
a. Increase VDO
b. Make new centric relation record (clinical remount) →correct occlusion
c. Refer to physician
d. Remove dentures and treat with analgesics
Managing Denture ProblemsManaging Denture ProblemsII. Indirect from denture
F. Fatigue of muscles of mastication
1. Excessive VDO → decrease VDO
2. Reduced VDO → increase VDO
G. Difficulty during mastication
Most patients who have trouble chewing at first, have not had posterior teeth for several years. The patient has lost the neuromuscular skills required to use the posterior teeth in grinding the food. The patient should be informed that a reasonable period of time is necessary to relearn the masticatory process. The length of time will depend, to some extent, on the patient’s innate neuromuscular coordination and on the duration of the edentulous state.
Managing Denture ProblemsManaging Denture Problems
II. Indirect from denture
F. Difficulty during mastication1. Food under denture ← due to movement, flabby ridge,
or poor adaptation to tissues and general lack of
retention
2. Blunt cusps or worn down cusps of teeth
3. Increase or decrease in VDO
4. Pain and soreness under denture prevents patient from
chewing normally
5. Occlusal disharmonies
6. Excessive bulk/thickness of denture
7. Patient takes too much food into the mouth at once
8. The patient should be advised to avoid extremely tough, stringy, or sticky food, especially during the initial
period of adjustment
Managing Denture ProblemsManaging Denture Problems
II. Indirect from denture
G. Excessive salivation
This is often a normal physiological response to a foreign body by the autonomic nervous system. It usually persists for a short period of time and then secretion returns to normal.
H. Unpleasant taste
1. If metal base is used (metallic taste)
2. If denture is not kept clean
3. If denture is incorrectly polymerized, residual
monomer may create bad taste
Managing Denture ProblemsManaging Denture Problems
I. Direct from denture
II. Indirect from denture
III. Related to patients
Managing Denture ProblemsManaging Denture Problems
III. Related to patients
A. Patient psychology: remember House’s classification: which patient is most likely to find fault with the denture? Philosophical, critical, skeptical, orindifferent.
B. Disabilities: neuromuscular, Parkinsons, etc.
C. Medical conditions
D. Systemic medications
18