DR SHRADDHA RATHI D0 PROSTHODONTICS INTRODUCTION Denture insertion represents the elimination of a series of carefully considered and exacting procedures on the part of the dentist It represents also the movement eagerly awaited by the patient who has cooperated both in time and efforts towa ID: 916020
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Slide1
DENTURE INSERTION AND PATIENT education
DR SHRADDHA RATHI, D/0 PROSTHODONTICS
Slide2INTRODUCTION
Denture insertion represents the elimination of a series of carefully considered and exacting procedures on the part of the dentist.
It represents also the movement eagerly awaited by the patient, who has co-operated both in time and efforts towards this event.
The
goal of denture insertion
usually wished to be obtained are:
Patient comfort.
Adequate function.
Good
esthetics
.
Slide3PATIENT NEEDS
In Denture insertion and after care the dentist has to meet certain needs of a patient:
Physical Needs.
Physiologic Needs.
Psychologic Needs
Slide4PHYSICAL NEEDS
This involves delivery of dentures that function without trauma to the foundation tissues.
It should be a comfortable state and should remain for a reasonable number of years if the biologic demands of the arch tissues are met.
Slide5PHYSIOLOGIC NEEDS
This is met when the dentures supply the scaffolding and support needed by the
molds
of the
stomatognathic
system in the effective chewing of all types of food.
Without such support tough foods cannot be chewed adequately and hence will either be avoided or swallowed whole.
Slide6PSYCHOLOGICAL NEEDS
This represents a peculiar blend of what the patient wants and what the dentist, as an expert, knows he needs If the patients wishes run counter to his needs, the dentist should convince him of these needs.
Psycologic
needs include functional expectations of the patient,
esthetic
expectations etc.
Slide7PREPARATION FOR TRIAL PLACEMENT
Remounting of dentures on articulator.
Clearance at the heels.
Clearance of anterior teeth.
Checking posterior teeth in centric occlusion for simultaneous contacts.
Accuracy of reproduction of vertical dimension.
Excursive clearance from centric position.
Separating dentures from the casts.
Slide8Remounting of dentures on articulator:
Split cast plates made use of and the articulator upon which the case was waxed is retained. The waxed – up casts are sent to the lab for processing.
The technician ‘
deflasks
’ the case; but does not ‘
decast
’ it.
The dentist with the aid of the split-cast plates, remounts the case on the articulator.
This is the only way to be sure that Jaw-relation records are not changed during fabrication.
Clearance at the heels:
Dentures remounted on the articulators.
Tested for clearance at the heels, i.e., between the tuberosity and retromolar pad, vertical clearance in centric occlusion; and clearance in lateral and protrusive positions.
Slide9Clearance of anterior teeth
:The 6 anterior lower teeth should not be in contact in centric occlusion.
A strip of articulating paper interposed between the upper and lower anterior teeth should not mark them in centric occlusion.
Checking posterior teeth in centric occlusion for simultaneous contacts
:
-
A 4 mm. strip of articulating paper placed between the posterior teeth should meet with equal resistance when pulled between these teeth.
It tests balanced occlusion in centric position.
Slide10Accuracy of reproduction of vertical dimension :-
The incisal pin of articulator placed in its proper relation.
When articulator is closed, the pin should make contact with the incisal table and the teeth should also contact.
If teeth do not contact, VD has been closed.
If teeth meet and incisal pin does not contact the table, VD has been opened.
Excursive clearance from centric position:-
When the
Neutro
centric occlusal concept is employed, there is excursive clearance laterally and
antero
posteriorly.
It is always wise to test for a free sliding contact within a 3 mm range of centric position.
Slide11Separating dentures from the casts:- A mallet should not be used to remove the cast from the dentures.
The cast should be removed carefully, a section at a time with a hand saw.
The dentures are then roughly finished for trial placement.
They are placed in glass bowl containing a
flavored
mouth wash
Slide12TRIAL PLACEMENT OF DENTURES
The Steps involved in the trial placement of dentures are:-
Inspecting the processed dentures.
Evaluating interferences to seating of dentures.
Checking fullness of mouth.
Checking degree of tooth and mucosa visibility.
Checking clearance at heels of denture.
Checking clearance at anterior region.
Testing occlusal pattern for
prematurities
.
Testing for coincidence of centric occlusion and centric relation.
Testing periphery of dentures for excessive thickness, height, snugness.
Slide13Inspecting the processed dentures
:- Inspect the tissue side carefully for beads or modules of acrylic resin.
They should be removed by grinding or scraping.
Evaluating interferences to seating of dentures
:
-
Flanges of the dentures examined for the presence of
undecuts
that may bruise the tissues and prevent seating of the dentine.
Care should be taken to gently seat the denture, and not to snap it in place, until all severe undercuts have been located and relieved.
Slide14Checking fullness of mouth:-
The facial contour is scrutinized to see that it is pleasing. Excessive fullness of lips and at the base of nose should be corrected.
Checking degree of tooth and mucosa visibility:-
The human mucosa can be imitated in appearance as effectively as the natural teeth.
At delivery of denture, patients must be told to expect some of the simulated gingival tissue to show when they smile or laugh.
They must be helped in realizing that if they are to display a sufficient area of teeth while talking; they should expect to show some gingival tissue when they laugh or smile.
Slide15Checking clearance at heels of denture:-
Clearance of the dentures in the area of tuberosity and retro molar pad in the mouth should be rechecked.
If lack of clearance suspected patient requested to close into disclosing was placed on the tuberosity. If clearance not present, denture base will show through.
Checking clearance at anterior region :-
When dentures are in mouth; recheck for anterior clearance from canine to canine.
A piece of articulating paper should be drawn through freely when teeth are in centric relation.
Slide16Testing occlusal pattern for
prematurities
:-
The checking of the occlusion varies depending on the nature of occlusal pattern employed.
When the occlusal pattern is anatomic
, testing for
prematurities
involve not only centric but eccentric positions as well. There should be simultaneous contact
protrusively
and laterally.
When the
neutro
centric occlusal concept is employed
, testing the occlusal pattern for
prematurities
involves securing simultaneous contact of the front and back, left and right sectors of the occlusal pattern in centric position only.
No attempt is made to secure simultaneous contact front & back, left and right in eccentric positions.
Slide17Testing for coincidence of centric occlusion and centric relation :-
when occlusal inclines are present on a denture, it is impossible to check in the mouth the precise coincidence of centric occlusion and centric relation.
Unless one can detect slight shifts of the denture on its base, a minor eccentric movement will go unnoticed.
Slide18DENTURE INSERTION
During the insertion appointment the completed dentures are evaluated using a sequence of procedures as follows :
1. Retention
2. Stability
3. Extension
4. Undercuts
Slide19retention
Retention is checked by trying to remove the denture in an occlusal direction.
Forward and downward presume applied to the upper incisors will tip the posterior edge of the denture down if the posterior palatal seal is defective or extensions of the dentures insufficient.
Slide20stability
Stability is checked by applying finger pressure to the occlusal surface.
Force is then applied to alternate sides of the arch.
Slide21extension
Over extended dentures tend to be un-retentive and recoil when seated. This can be corrected by the use of a disclosing paste an wax.
Under extended dentures may be un-retentive. Flange can be corrected with greenstick compound or a similar material and the denture processed with self curing resin.
Periphery of the upper denture should be checked in the maxillary tuberosity and hamular notch region.
Slide22undercuts
The denture should be painted with a thin coat of pressure disclosing paste.
Where tissue undercuts are present, paste will be dragged from the denture base in the area of tissue contact.
The undercut area can be ground with an acrylic bur until adequate relief obtained.
Slide23CHECKING BOTH DENTURES TOGETHER
With both the dentures in the mouth, the following are checked.
1. Occlusion
2. Vertical Dimension
3. Aesthetics
Slide24occlusion
The centric occlusion and centric relation must coincide. There should be a good balance in lateral and protrusive excursions.
Adjusting of occlusion done in 3 ways :-
a) By mounting the dentures before insertion back on the articulator on which they were originally set up.
b) By taking a eccentric record after insertion and remounting the dentures on an articulator.
c) In the mouth using articulating paper or occlusal indicating paste.
Slide25Occlusal disharmony
Occlusal disharmony in complete dentures due to :a) Processing changes
b) Undetected errors in registering jaw relations
c) Errors in mounting casts on articulators.
d) Difference in tissue adaptation between processed denture bases and record bases used in recording maxillo-mandibular relations.
e) Changes in supporting structures since impressions were made.
Slide26CORRECTING OCCLUSAL DISHARMONY
a) Articulating paper:- They must be placed an both sides of the arch. If placed on one side, the patient may close towards or away from that side.
b) Central bearing Devices
:-
Correlator
, a type of central bearing device can be used. They serve to hold the dentures and an articulating ribbon can be used to detect the errors.
Goble device
, another type of central bearing device has a central bearing pin without a spring.
C) Occlusal Wax :-
Adhesive green wax placed an the occlusal surfaces of the mandibular denture. Points of penetration that occurs upon closing with the jaws in centric relation can be relieved where indicated.
D) Abrasive paste
–
Carborandum
.
Slide27TYPES OF OCCLUSAL ERRORS AND CORRECTION
If opposing teeth too long and hold other teeth out of contact.
Correction
–
Fossae of teeth deepened by grinding so that teeth telescope into each other. Cusps not shortened.
Upper and lower teeth nearly end to end.
Correction
–
Grinding on inclines of cusps so that upper cusp incline moves buccally and lower cusp incline moves lingually.
Slide28WORKING SIDE OCCLUSAL ERRORS
Both upper buccal and lower lingual cusp too long:
Correction
- Length of these cusps reduced by grinding to change the incline extending from central fossa to cusp tip.
Buccal cusps make contact, but lingual cusps don’t :-
Correction
- Buccal cusps of upper teeth ground from central fossa to cusps tip to shorten the cusp and change the lingual incline of the cusps so that it is less steep
Slide29Lingual cusps make contact, but buccal cusps don’t :-
Shorten the lower lingual cusps by changing the buccal incline of the lower lingual incline so that it is not so steep. Upper lingual cusp is not shortened and central fossa not made deeper.
Upper Buccal / Lingual cusps musical to their inter
cusping
position:
May occur with any of above 3 situations.
Grinding done to move the mesial inclines of the upper buccal cusps distally and distal inclines of lower ground to move them forwards.
Slide30Upper Buccal / lingual cusps distal to their inter
cusping positions may occur with buccolingual errors. Grind from distal side of upper cusps and mesial side of lower cusps.
Teeth on working side may not contact
Slide31TYPES OF BALANCING
SIDE ERRORS
1)
Balancing side contact so heavy that working side teeth out of contact -
grind buccal cusps of lower teeth to decrease incline of part of the cusp that is preventing teeth on working side from contact.
2)
No balancing contact an balancing side.
Shorten buccal cusps of upper teeth and lingual of lower on working side.
Slide32PATIENT EDUCATION
Patients must be educated about the limitation of dentures as mechanical substitutes for living tissues.
Patients must be forewarned so that it will make them more tolerant of problems and less likely to relate them to the fit of dentures.
Patients must be reminded that their mental and oral conditions are individual in nature and that they must not compare with another person wearing dentures.
Slide33APPEARANCE
Appearance with new dentures usually become more natural with time.
Initially they will feel strange and bulky in the month and will have a feeling of fullness of lip and cheeks.
This is over come only with passage of time and patients are advised to persevere during this period of adjustment.
Slide34MASTICATION WITH NEW DENTURES
Learning to chew satisfactorily with new dentures require a period of at least 6-8 weeks.Patients become discouraged unless they are aware that this learning period should be expected.
The muscles of the tongue, cheeks, lips must be trained in maintaining the dentures masticatory process.
Patient must begin chewing soft food cut into small pieces. Chewing must be done an both sides of the mouth at the same time so that tendency of the dentures to tip will be reduced. Incisors should not be used for incision.
Slide35SPEAKING WITH NEW DENTURES
The adaptability of the tongue to compensate for changes is so great that most patients master speech with new dentures within a few weeks.
Speaking normally with dentures requires practice.
Patients should be advised to read aloud and repeat words or phrases that are difficult to pronounce.
Slide36ORAL HYGIENE
Dentures must be thoroughly washed 3 times daily and rinsed after meals. Cleaned with a soft brush, dishwashing detergent or a toothpaste low in abrasives.
Soaking dentures in a bowl of water containing a mixture of 1 teaspoon of
calgon
+ 1 table spoon of Clorox for 30 minutes once a week removes most of the stains.
Mucosa and dorsum of the tongue should be brushed daily with a soft brush.
Slide37Slide38IngredientsDilute
sodium hypochlorite (i.e. a mild bleach) is the main constituent of several brands of denture cleanser.Other ingredients include such chemicals as:sodium bicarbonate
- or baking soda, which alkalizes the water, cleaning the dentures.
citric acid
- removes stains.
sodium
perborate
sodium polyphosphate
potassium
monopersulfate
- cleaning and bleaching agent
EDTA
Slide39Examples of commercial brandsDentural (sodium hypochlorite solution)Milton (sodium hypochlorite solution)
Mildent (sodium hypochlorite solution)Steradent (alkaline peroxides)PolidentRenew Denture Cleaner
Efferdent
Novadent
Slide40Preserving residual ridges
Dentures must be left out of the mouth at night to provide needed rest from the stresses that they create on residual ridges..
Slide41EDUCATIONAL MATERIAL FOR PATEINTS
Since education of patients is so critical to the success of new dentures, written instructions must be given.
Oral instructions not enough as people remember less of what they hear than of what they see.
Slide42MAINTENANCE
Treatment with complete dentures not really successful unless patients wear them.
Complete dentine service not adequate unless patients are used for after dentures placed in the mouth.
Complete co-operation of the patient essential during the initial adjustment period.
Slide43EXAMINATION
:ADJUSTMENTS RELATED TO OCCLUSION
a) Soreness on the crest of residual ridges
- from pressure created by heavy contact of opposing teeth in the same region.
b) Soreness on the slopes of residual ridges
- result of shifting of denture bases from deflective occlusal contacts.
c) Small lines on the buccal mucosa of the cheek in line with the occlusal plane
- indicate cheek bite during mastication. Lesion is located and adjustment done to the offending tooth
Slide44ADJUSTMENTS RELATED TO DENTURE BASES
Over extended denture flanges or sharp borders of dentures cause lesions of the mucosa.
Labial notch of denture may be sharp and frenum may become inflamed.
Lesions posterior to hamular notch
- dentine base over extended.
Lesions on the hamular notch
- PPS creating too much pressure.
Soreness along crest of the lower edge
= spiny projections of bone may be remaining.
Lesions on
retromylohyoid
fossa region
- excess pressure or length of denture flange
Soreness during swallowing
- Excess pressure or irritation in the region of mylohyoid ridges.
Slide45PERIODIC RECALL
At the end of adjustment appointments, patient can be recalled at 3-4 months interval.
Every denture patient should be placed on a recall programme. Patient told that occlusal correction, relining, new dentures may be indicated as changes in oral cavity continue to occur.
Slide46Changing trends in after care
The patient should be instructed to observe carefully the type of discomfort he faces, during smiling, speaking and mastication and should be advised not to compare the skill he once enjoyed in these fields, with those he is going to acquire with the dentures.
The patient should be made aware that his fine grade proprioceptive mechanism is in a handicapped condition and it is hard labour to achieve normal function with the denture.
Even though the impression procedures take care of placing the soft tissues in a functionally compressed form avoiding much discomfort, we cannot be sure of achieving a similar form under a functional denture.
Slide47Soft tissue injury is thus unavoidable and which at present is troubleshooted in an arbitrary manner.
The use of pressure indicating paste will remove the arbitrariness. Patients should be recalled within the 1st fortnight
atleast
once, for an evaluation using pressure indicating paste.
Slide48Slide49Post
insertion complaints
Classification of post insertion
denture
problems
Manageme
n
t
Common C
o
m
plai
n
ts
Uncommon Complaints
Complains
on aesthetics
of the
denture
Complains
on
phonetics
Complains on comfort of
the denture
Slide50“ Most of the complaints associated with complete
dentures are actual and not psychological, contrary to the belief of most
clinicians.”
Verma.M
,Post Insertion Complaints in Complete Dentures - a never
Ending Saga; Journal of Academy of Dental Education,
Vol
1, No 1 (2014), Pg:
1-8
“There was no statistically significant
relationship
between patient age,
gender,
systemic health and denture complaints; but statistically significant relationship exist between types of denture, denture faults and
complaints.”
Ogunrinde.T.J,
The Influence Of Demographic Factors And Medical Conditions On Patients Complaints
With
Complete Dentures. Ann Ibd.
Pg. Med 2012.
Vol.10,
No.2
16-21
Slide51Classification of post insertion denture
problems
Complaints abut comfort of the
denture:
Sore spots
Burning
sensation
Redness
Pain in
TMJ
Tongue
& cheek
biting
Swallowing & sore
throat
Nausea &
gagging
Fatigue of the muscles of
mastication.
Post
insertion complaints
Classification of post insertion
denture
problems
Manageme
n
t
Common C
o
m
plai
n
ts
Uncommon Complaints
Complains
on aesthetics
of the
denture
Complains
on
phonetics
Complains on comfort of
the denture
Slide52Complaints about function of
the
denture:
Instability or
poor
fit
Interference
When
swallowing
Clicking
Complaints about
esthetics:
Fullness under
the
nose
Depressed philtrum or naso-labial
sulcus
Upper lip sunken
in
Too
much of teeth
exposed
Artificial
look
Slide53Complaints about
phonetics:
Whistle
on
“S”
sounds
Lisp
on
“S”
sounds
Indistinct “TH” & “T”
sounds
“T sound
like
“TH”
“
F”
& “V” sounds
indistinct
Slide54According to
Sharry
Frequent
Complaints
:
Excessive
bulk
Speech
difficulties
Masticatory
shortcomings
Insufficient
retention
Mucosal
irritation
Unattractive
Apperence
Sharry.J.J
Complete denture Prosthdontics, 3rd edition, chapter 17, pg
358
Slide55
Uncommon
Complaints:
Whistling
Ear
ache
Difficult
swallowing
Loss of taste
sensation
Saliva under the
dentures
Peculiar
taste
Food under
the
denture
Rough & sharp
surfaces
Dull
teeth
Halitosis
Dry
mouth
Noisy
teeth
cheek, lip & tongue
biting
nausea &
gagging
Dislodgement
on
sneezing - tingling of the lower
lip
Dislodgement
on
drinking - burning of
mouth
Drooling at the corner of the
mouth
Inability to chew with equal vigor on both
side.
Slide56According to
Grant.A.A
POST
INSERTION
PROBLEMS CAN BE
BROADLY
GROUPED
INTO:
Looseness of
dentures
Decreased retentive
forces
Increased displacing
forces.
Discomfort associated with
dentures
Related to impression surface of
denture
Related to occlusal
surface
Related to polished
surface
Related to possible systemic
association
Slide57
Support problems
Problems associated with retention and
stability
Other
difficulties
Noise on eating and
speaking.
Speech
problems.
Eating
difficulties.
Altered
taste
sensation. b.Gagging (nausea).
A.A.Grant, J.R.Heath,
J.F.McCord-
complete prosthodontics
problems,
diagnosis & management
(1994)
Slide58Denture Complaints in relation to time of
delivery
Immediate
complaints.
Delayed
complaints.
Problems without
complaints.
Slide59Presentation of patient with complaints
Informed patient
of possible
problems.
Un-informed
patient:
Sense of
pain.
Sense of loss (waste of
time
and
money).
Sense of
deceit.
Slide60Pain
Over extension of
borders
Poor
fitting
or rough surface
dentures
Error during impression
making
Incorrect centric relation or cuspal
interferences.
Excessive vertical
dimension
Uneven occusal balance and anterior contact at
CR
Inadequate relief to the prominent genial tubercle
&
myloid
ridge
Slide61Loose
denture
PPS is not successfully
made.
Lingually placed posterior
teeth
Labially placed mandibular anterior
teeth
Dryness of
mouth
Occusal
discrepancies
Inaccurate impression
making
Rocking, tilting
dentures
(poor
retention)
Nodules of
acrylic- faulty
impression
/poor
processing
techniques
Slide62Faulty
esthetics:
Unrealistic
expectations
Over supported or under supported
dentures
Altered vertical
dimension
Defective
speech:
increased vertical
dimension
deficiency
of
palatal
contour
Poor
PPS
region
Thick
lingual flanges
or
restricted
tongue
movements
Slide63Inefficacy
Discrepancies in
vertical
dimension and
CR
Worn off
teeth
Zero degree
posteriors
Lack of occlusal
balance
Occusal
plane se at
higher
level
Nausea &
Gagging
Over
extended posterior
limit of maxillary
denture
Thick
posterior borders
or loose
denture
Uncommon
belief
Slide64Fibrous
hyperplasia
Continous
wearing of ill
fitting
denture
Usually
painless
Microbial
Infection
Poor
oral
&
denture hygiene
maintainance
Diabetes and oral
habits
Slide65Costen’s
syndrome:
Prolonged
over
closure
Deafness, tinnitus,
Tenderness
over the
TMJ
Dryness
of
mouth
Neuralgic
symptoms – burning sensation of
tongue, throat and headache.
Slide66Uncommon
complaints
Whistling
:
high vault
palate
Ear
ache
: TMJ
problem
Food
&
saliva under denture
:
may be deficient
of
borders
Loss of
taste
Cheek biting
:
lack
of horizontal overlap, decreased
VD
or buccal placement
of
teeth
Drooling
saliva
: inadequate
VD
Allergy
:
pigment or
residual
monomer
of
denture
resin
Slide67Slide68Slide69Slide70Slide71Slide72Slide73Slide74Slide75Slide76C
ON
C
L
U
S
ION
At the end, we must mention that thorough counselling according to the nature of the patient is very important for the patient as well as the clinician. Patient will thereby gain a realistic expectations of what can and can not be achieved, and dentists will understand what the patient really wants.
Patient need to be advised on taking proper nutrition supply
.
Slide77C
ON
C
L
U
S
ION
Finally, patient must be informed that continued success depends on regular denture maintenance at home, combined with periodic consultation with the dentist.
Slide78Refe
rences
Nair KC
, A
primer
o
n
com
p
le
t
e
de
n
tur
e
fabricatio
n,
1
st
edition, 2013, Ahuja publication, India Pp 158 -166
Win
k
l
e
r
S
, Ess
e
ntials
o
f
comple
t
e
de
n
tur
e
Prosthodontics 2
nd
edition, 2012, AITBS Publishers, pp 318
–
330
Sh
a
r
r
y JJ,
C
o
mp
l
ete
D
e
nture
Prosth
od
ontics,
3
rd
edition, USA, Mcgraw-Hill Book
Company,
1974, pp
289-294.
Heartwell
C
M ,
Syllabus of
complete dentures,
4
th
edition,
1984,
Varghese
Publishing House, 407
–
420
Slide79prosthodontics
G
r
ant
A
.
A
,
Heath
.J.
R
,
McCordJ
.
F
,
complete problems
,
diagnosis& management
(1994)
McCord
J.
F.
and Grant
A.
A.
,
Identification of
complete
denture problems: a
summary,
British Dental
Journal 2000; 189:
Pp:128–134
Jethlia.H, Post Insertion
Problems
And
Their
Management
In
Complete Denture journal of Evolution of
Medical
and Dental
Sciences.Vol
2(3)
Jan,
2013 pp
194-99
Verma.M
,Post Insertion
Complaints
in
Complete
Dentures
-
a
never
Ending
Saga; Journal of Academy of Dental Education,
Vol
1, No 1 (2014), Pp:
1-8