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1*Head of the Unit of Prosthodontics, 2Emeritus Professor of Restorative

Identification of complete denture problems: a summary

J. F. McCord,1 and A. A. Grant,2
In this part, we will discuss: Factors resulting in discomfort associated with dentures Factors resulting in looseness of the dentures Factors associated with problems of adaptation

In this section, guidelines to the diagnosis of complete denture problems are presented in tabular form. Suggestions to the management of these problems are listed.

Dentistry, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester M15 6FH *Correspondence to: Prof. J. F. McCord email: [email protected]
REFEREED PAPER

British Dental Journal 2000; 189: 128134

here is, inevitably, the potential for problems to arise subsequent to the insertion of complete dentures. These problems may be transient and may be essentially disregarded by the patient or they may be serious enough to result in the patient being unable to tolerate the dentures.

Factors causing problems may be grouped, essentially into four causes. Adverse intra-oral anatomical factors eg atrophic mucosa. Clinical factors eg poor denture stability. Technical factors eg failure to preserve the

Table 1

List of factors resulting in discomfort related to the impression surface of dentures

Cause Treatment

Symptoms/clinical findings

Related to impression surface Discrete painful areas Pain on insertion and removal, possibly inflamed mucosa on side(s) of ridges

Pearls or sharp ridges of acrylic on the fitting surface arising from deficiency in laboratory finishing Denture not relieved in region of undercuts

Locate with finger, or snagging dry cotton wool fibres. Use disclosing material to assist locality to ease denture Use disclosing material to adjust in region of wipe off. Exercise care as excessive removal may reduce retention. Also clinician should only insert denture and then remove it - the patient should not occlude as this may confuse an occlusal fault with support problems Use disclosing material to accurately locate area to be relieved. If severe, remake may be required. Consider removal of root

Areas painful to pressure

Pressure areas resulting eg from faulty impressions, damage to working cast, warpage of denture base. Consider also residual pathology (eg retained root), lack of relief for active frena, non-displaceable mucosa over bony prominence (eg torus) Over-extended lower impression: instructions to laboratory not clear or non-existent Under-extended denture base - may be the result of over-adjustment to the periphery, or impression surface. Check for adequacy of FWS Peripheral over-extension resulting from impression stage and/or design error. Palatal soreness as post dam too deep

Over-extension of lingual flange. Painful mylohyoid ridge; denture lifts on tongue protrusion; painful to swallow Generalised pain over denture-supporting area

Determine position and extent of over-extension using disclosing material and relieve accordingly Extend denture to optimal available denture support area. If insufficient FWS, remake may be required Relieve with aid of disclosing material. Care with adjustment of post dam - removal of existing seal and its replacement in greenstick prior to permanent addition 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

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Table 2

List of factors resulting in discomfort - relating to occlusal and polished surfaces of dentures
Cause Treatment

Symptoms/clinical findings

Related to occlusal surfaces Pain on eating in presence of occlusal imbalance (no support problems) Pain lingual to lower anterior ridge

Anterior prematurity or posterior prematurity, incisal locking, lack of balanced articulation

Determine where occlusal prematurities exist. Adjust occlusion by selective grinding. If severe error remount using facebow and new interocclusal records Mark deflecting inclines of posterior teeth with thin articulating paper. If slide exceeds half a cusp width, re-register and reset Reduce incisal vertical overlap. If appearance compromised, resetting the incisors may be required If excess less than 1.5 mm, grind to provide FWS. If greater than 1.5 mm, re-register to reset dentures at new OVD For cheek biting, restore functional width of sulcus and/or reset. For lips, grind lower incisors to provide a more appropriate incisal guidance angle Remove lower lingual cusps, or reset teeth Use disclosing material to accurately define area involved, relieve and repolish

If no over-extension present, look for protrusive slide from RCP to ICP If no impression surface defect, may be lack of incisal overjet causing incisal locking Vertical dimension of occlusion more than patient can tolerate

Pain and/or inflammation on labial aspect of lower ridge Pain about periphery of dentures possibly accompanied by pain in masseter and posterior temporalis muscles (classically pain increases as the day progresses) Cheek and or lip biting

For cheeks - likely that functional width of sulcus was not restored. For lips - poor lip support/inadequate anterior horizontal overlap Lack of lingual overjet - teeth generally placed lingual to lower ridge Flange on buccal aspect of tuberosity too thick and constraining coronoid process

Tongue biting Related to polished surfaces Pain at posterior aspect of upper denture on opening

peripheral roll on a master cast. Patient adaptional factors. By far the most critical factors are the patient adaptional factors. Many patients with positive stereotypes may overcome errors of prescription. Some patients, however, are unable to adapt physically and/or psychologically to dentures that satisfy clinical and technical prosthodontic norms. Clearly it would be in the best interests of the clinician and the patient to determine this at the assessment stage, and was referred to in Part 2. The prescribing clinician is responsible for planning complete dentures after diagnosing potential problems; be they anatomical, physiological, pathological or emotional. Once a denture-wearing problem becomes apparent, it is important that it is addressed in

a logical and systematic way. That is to say, an adequate history of the problem must be obtained and a careful examination of the mouth carried out so that an accurate diagnosis can be made, and an appropriate treatment plan devised. Without doubt listening to the patient (as their difficulties are described) is the most important first step in the process, and its importance cannot be overemphasised. Because of the plethora of potential complete denture problems, this section is largely confined to those that are most commonly encountered at the time of insertion of replacement dentures or during review appointments in the days and weeks after insertion. For a comprehensive overview of the diagnosis and management of complete denture problems, readers are referred to

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Table 3

List of factors resulting in discomfort - factors with possible systemic associations. Some of these conditions may occur several months post insertion
Cause Treatment

Symptoms/clinical findings

Burning sensation over upper denture supporting tissues, but may involve other intra-oral tissues, eg tongue. Beefy red tongue, possibly glossodynia Frictional lesions related to dentures, mucosa may adhere to probing finger, may be complaint of dry mouth Tongue thrusting. Empty mouth chewing. Often seen in elderly patients Presence of herpetiform ulcers in mouth

Burning mouth syndrome often seen in middle-aged or elderly females. Denture faults must be excluded, also general organic and pyschogenic factors Vitamin B12/folate deficiency Xerostomia, commonly side effect of prescribed drugs

Correction of any denture faults, may require multivitamin/nutrition advice and treatment. Possibly antidepressant therapy. Refer to Consultant in Oral Medicine Refer for medical treatment Where some saliva flow is present, sugar-free citrus lozenges may help. Where there is an obvious paucity of saliva, artificial saliva may be considered Difficult to manage. Treatment may be required to include occlusal adjustment and/or occlusal pivots Dentures merely coincidental to the condition. May be useful to suggest preventive remedy (eg acyclovir) for some sufferers If denture faults present, careful correction required with special care to registration and vertical dimension

May have neurological or psychological aspects. Possibly drug related Herpes simplex or Herpes zoster virus. History and distribution of lesions to confirm TMJ pain dysfunction syndrome may be related to rapid change on OVD (either gross increase or decrease) on production of new denture. May have psychological aspects, occasionally part of general joint disease Rare symptoms may relate to higher residual monomer content of acrylic

Painful click related to TMJ on opening and/or closing mouth and/or tenderness of muscles of mastication

Patient complains of allergy to denture material

If excess residual monomer detected, rebase denture using controlled heat cure cycle. May need to consider remaking denture using polycarbonate resin Best to leave denture out until condition clears, then remake. If not possible, correct denture faults, eg using occlusal pivots, regularly supervised and replaced tissue conditioners prior to remake. If angular cheilitis present, combinations of antifungal and antibacterial agents (eg miconazole) useful

Painless erythema of mucosa related to support of (usually) upper denture, may be accompanied by angular cheilitis

Denture-related stomatitis. Often has a frictional element due to ill-fitting denture plus opportunistic candidal infection. Occasionally related to iron or folate deficiency

standard prosthodontic texts. Problems reported by patients shortly after provision of replacement dentures include discomfort, looseness or general problems in relation to adaptation. Some of these problems/difficulties may have a very large number of possible causes, and, indeed, can be multifactorial in origin. For simplicity the problems will be discussed in the order they tend to occur most frequently. In the following tables, a list of causes and suitable forms of treatment to address the problems are summarised.

Discomfort associated with dentures Many patients experience some discomfort for a period of up to a few days following receipt of new or replacement dentures. The great majority of patients achieve comfortable co-existence with their appliances following a short period of adjustment to the new conditions. This can be greatly assisted by a careful, detailed explanation of any difficulties that the operator might anticipate. For some, however, especially where potential problems were not identified at examination or at the time of insertion, the consequent

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Table 4

List of factors resulting in looseness of dentures - arising from decreased retention forces
Cause Treatment

Symptoms/clinical findings

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 chairside reline material may be used as described above Check border is correctly sited on fixed tissue at junction with mobile tissue of soft palate. Trace thin string of softened tracing compound along impression surface of posterior border and seat denture firmly in mouth. Replace compound with acrylic resin. For temporary solution, use butymethacrylate resin as above Mould denture borders incrementally using softened tracingcompound as functional movements are performed - aim to slightly under-extend depth and width of denture periphery. Repeated treatment may be required as inelasticity progresses Reline if design parameters of denture satisfactory, otherwise remake as required. Ensure that areas of heavy contact between denture and tissues are relieved prior to impression making. Where change in tissue fluid distribution is suspected check medication (eg diuretics) posture (eg heart failure) lack of recovery of tissues from effects of old denture prior to working impressions being obtained. Stabilise fluid content of tissues and use minimal pressure impression method Design dentures to maximise retention and minimise displacing forces. Prescribe artificial saliva where appropriate

Inelasticity of cheek tissues

Consequence of ageing process; scleroderma, submucous fibrous

Air beneath impression surface. Denture may rock under finger pressure. May see gap between periphery of flange and ridge. Occlusal error subsequent to warpage Xerostomia Reduces ability to form a suitable seal

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 Medication by many commonly prescribed drugs, irridation of head and neck region, salivary gland disease 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, infirm

Neuromuscular control Essential for successful denture wearing: speech and eating difficulties occur

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. Use information from successful previous denture if available. Denture adhesives may be deemed to be necessary

discomfort can be prolonged. In addition, discomfort may arise some time after apparently successful prosthodontic provision as a result of intra-oral or systemic changes or of denture wear or damage. Discomfort is most frequently but not exclusively associated with the lower denture supporting area. The Tables (Tables 1, 2 and 3) summarise commonly experienced sources of discomfort, and means of addressing the causative factors.

Looseness of dentures Looseness of dentures (Tables 4, 5 and 6) is more commonly associated with the lower denture, and may be referred to by patients as their denture rocking, falling (complete upper) or rising (complete lower), shifting or sometimes that they feel too big. In simple terms, retention and stability of complete dentures may be likened to a simple balance ie on one side retaining forces and on the other displacing forces. If the latter exceed the former, instability/looseness will arise. It

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Table 5

List of factors resulting in looseness of dentures: arising from increased displacing forces
Cause Treatment

Symptoms/clinical findings

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 Overextension in width Cheeks appear plumped out. In lower, the buccal flange may be palpated lateral to external oblique ridge Poor fit to supporting tissue Recoil of displaced tissue lifts denture Denture not in optimal space

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 Design error

Slightly under-extend denture flange and accurately mould softened tracing 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 Reduce over-extension. Use disclosing material to determine what is excessive

Poor/inappropriate impression technique especially in posterior lingual pouch area Molars on lower denture lingual to ridge, optimum triangular shape of dentures absent Posterior occlusal table too broad, causing tongue trapping Thick lingual flanges encroaching on tongue space, causing lifting. Excess lip pressure to lower anterior aspect - teeth anterior to ridge, thick periphery Excess pressure from upper lip to upper denture arising from teeth too labially sited to acute naso-labial angle; or failure to adequately seat denture during relining impression procedure

Reline if all other design parameters satisfactory, otherwise remake. Ensure denture is removed from mouth 90 mins prior to impression 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 Thin lower labial flange, ensure optimal extension to retromolar pads to resist displacement, reset anterior teeth if necessary Usually requires remaking denture

must be stressed, however, that the fulcrum is the patient, or rather the patients ability to adapt to dentures this is less easy to anticipate. This is illustrated in Figure 1, which is a line drawing of factors influencing complete denture stability. Problems relating to an inability to adapt to dentures There are a variety of symptoms which may be functionally-related (ie eating associated prob-

Retaining forces

Displacing forces

Patients ability to control dentures can increase apex of fulcrum and stability
Fig. 1 Factors influencing complete denture stability

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Table 6
Symptoms/ clinical findings

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List of factors resulting in looseness of dentures - arising from increased displacing forces - occlusal and anatomical factors
Cause Treatment

Occlusal errors

Uneven tooth contact causing ttilting of dentures and prevents even seating of loosened appliances

ICP and RCP not coincident - disrupts border seal and prevents accurate reseating Lack of freedom in ICP (occlusal-locking) dentures will shift on supporting tissues for those patients with poor control of mandibular movements Ulceration labial to lower ridge Excessive vertical overlap of anterior teeth. Lack of balance and anterior tooth contact may cause tilting, soreness in lower ridge Last mandibular molars placed too far posteriorly and lie over retromolar pad or ascending part of ramus. Occlusal contact on this inclined plane causes denture to slip forward Occlusal plane/s not orientated appropriately and masticatory forces tend to move dentures over supporting tissues Masticatory forces tend to cause denture to sink into and tilt towards supporting tissues Denture rocks over prominence which may be covered with inflamed tissue

Adjust occlusion until even initial contact in RCP obtained. If gaps between teeth exceeds 1.5 mm reset teeth or remake dentures. For gaps less than 1.5 mm it may still be necessary, in the interest of accurate diagnosis, to remount the dentures, as a patients mouth may be too tender to permit chairside adjustment. Adjust occlusion for coincident ICP/RCP contact. If error is greater than half width of cusp, all teeth on at least one denture need resetting. Remount dentures on adjustable articulator and adjust area of occlusal contact. Allow 1.5 mm of anterior movement from RCP May use cuspless . teeth where appropriate Reduce height of lower anteriors. Aesthetic problems may necessitate resetting of teeth Remove most posterior teeth from denture

Usually requires teeth to be reset or dentures to be remade

Fibrous displaceable ridge

Reline after removal of acrylic from impression surface until no contact with displaceable tissue, provide many vent holes, low viscosity impression material, maximise posterior border seal Remove acrylic from impression surface where disclosing material shows excessive loading of supporting tissues. Do not create excessive relief or loss of retention may result Reline dentures to obtain optimal border extensions in depth and width, use low viscosity impression material Eliminate the cause of pain

Bony prominence covered by thin mucosa (eg tori)

Non-resilient soft tissue

Does not adapt to impression surface of denture reducing support and retention factors Use of excessive amounts of fixative, or self-applied reline material, or even cotton wool, to attempt to relieve contact with supporting tissues

Pain avoidance mechanisms

lems, speech etc), psychologically-related or may relate to patience. Clearly there is a need to diagnose the former at the planning stage of treatment and to avoid the latter by virture of trial denture visits which focus on the functional and aesthetic components of the compete dentures. Some of the psychologically-related problems may be recognised at an early stage but even if psychological assessments are taken, not all are infallible.

A brief list of factors affecting adaptation to dentures including their causes and modes of treament are listed in Table 7. Summary This chapter has attempted to summarise in a tabular form a list of factors that are commonly found at recall visits. The tables themselves are self-explanatory and serve as a useful tip list. For more detailed lists, readers are referred to standard prosthodontic text.

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Table 7 List of denture problems associated with problems of adaptation
Cause Treatment

Symptoms/clinical findings

Noise on eating/speaking May be apparent on first insertion or may appear as resorption causes dentures to loosen Eating difficulties Dentures move over supporting tissues

May be lack of skill with new dentures, excessive OVD, occlusal interference, loose dentures, or poor perception of patient to denture wearing Unstable dentures. Check that retentive forces are maximised and displacing forces minimised and all available support has been used Broad posterior occlusal surfaces which replaced narrow teeth on previous denture. Non anatomical type teeth used where cusped teeth previously used Lack of OVD, so that mandibular elevator muscles cannot work efficiently Excessive OVD

Where unfamiliarity present, reassurance and persistence recommended. Address specific faults or remake as required Construct dentures to maximise retention and minimise displacing forces

Blunt teeth

Where non-anatomical teeth used, careful explanation of rationale is required, may be possible to reshape teeth. Routine use of narrow tooth moulds recommended. May increase up to 1.5 mm by relining but if deficiency is greater, remake denture Can remove up to 1.5 mm from occlusal plane by grinding, but if more is required, remake dentures Check for vertical dimension accuracy, and that vertical incisor overlap not excessive. Palatal contour should not allow excessive tongue contact or air leakage assess using disclosing paste over denture palate while sound is made. NB It is recommended that the patients speech is assessed at trial insertion visit Construct dentures to maximise retention and minimise displacing forces. Use condition appliance eg fully extended base for home use. Psychological assessment if indicated Accurate assessment of patients aesthetic requirements. Ample time for patient comments at trial stage. Use any available evidence to assist - photographs, previous dentures. Consider template prosthesis Accurate prescription to laboratory via optimally adjusted occlusal rim

Jaws close too far

Cannot open mouth wide enough for food. May be speech problems and facial pain especially over masseter region 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

Gagging May be volunteered by patient prior to treatment, or apparent at commencement of treatment or on insertion of denture 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 Too much visibility of teeth

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 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 Level of occlusal plane unacceptable, teeth placed on upper anterior ridge and no/poor lip support Labial fullness and anterior tooth position may be inaccurate. OVD may be inadequate Patients skin colour not taken into account in determining colour of base material

Creases at corners of mouth

Adjust tooth position as appropriate. If OVD problem, re-register jaw relations Remake using suitable base material

Colour of denture base material unnatural

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