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Reducing The Risk of Failure Incomplete Denture Patients
Reducing The Risk of Failure Incomplete Denture Patients
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Simon B Critchlow
The clinical management of some Unfortunately, not all patients are in a given to the rigorous and well-conducted
edentulous patients can be a source of position to receive implant overdentures studies. The best available data shows
frustration for both patient and clinician as, and the aim of this article is, firstly, to patients with a poorly formed lower ridge
despite best efforts, patients remain unable consider which dentist and patient factors are least likely to be satisfied with their
to adapt to wearing the dentures that have have a robust evidence base that supports lower denture.9 Indeed, this study goes
been provided. Often the patients who fall their role in determining success or failure further, proposing a mechanism as to why
into this category have had poor previous and, secondly, to outline some techniques this may be; mandibular ridge anatomy
experience of denture-wearing and may and strategies for maximizing the potential was shown to have a strong influence
arguably have unrealistic expectations. of conventional complete dentures, based on the accuracy of jaw relations and this
Nonetheless, repeated adjustments, or on the best evidence available. not only significantly influenced patient
even remakes, can significantly add to the Factors that may influence the satisfaction with dentures, but also had a
cost of denture construction and this can satisfaction of a denture patient can be significant influence on the patients’ usage
result in a negative experience for both categorized according to the strength of of their dentures.
the clinician and patient. In recent years, their evidence base (Table 1). Managing the severely resorbed
the evidence base for implant-supported mandibular ridge can be a problem for
overdentures, especially in the mandible, the clinician. The flat aspect of the ridge
has strengthened the argument for this
Patient-centred problems offers little bracing against lateral or
particular strategy, and for many patients Mandibular ridge anatomy antero-posterior movement. Often the
this should become the gold standard.1,2 The evidence with regard mentalis muscle is attached close to the
to the influence of ridge anatomy on residual ridge ‘crest’, leading to posterior
prosthodontic outcomes is variable, displacement of the denture. This is
SB Critchlow, BDS, MSc, MFDS RCS(Ed), both in terms of research quality and in exacerbated when the denture does not
Specialist Registrar in Restorative the conclusions of the available studies. extend fully past the pear-shaped pads,
Dentistry, The Royal London Dental Some studies have shown residual ridge and partially onto the retromolar pads.
Hospital, JS Ellis, BDS(Hons), PhD, FDS anatomy to be of no influence on patient The mucosa overlying the ridge is often
RCS(Ed), PGCE, Senior Lecturer and satisfaction,2-7 whereas others show a atrophic and can become painful when
Honorary Consultant in Restorative positive relationship in the maxilla; the pressure is applied, or if the denture moves
Dentistry, Newcastle University and JC better the ridge form, the more satisfied excessively in function. There may also be
Field, BSc(Hons), BDS, MDFS RCS(Ed), the patient.8 Other studies have shown prominent mentalis or genial tubercles, or
MFGDP RCS(Eng), PGCAP, Cert(Clin)Ed, a similar relationship in the mandible.9,10 a large tongue. When they present at the
DipEd, FHEA, Clinical Fellow in Restorative In drawing conclusions from seemingly same time, these problems can sometimes
Dentistry, Newcastle University, UK. contradictory data, more weight must be seem insurmountable.
Patient neuroticism Patient age and socio-demography techniques affect patient satisfaction, the
Patient neuroticism has been Neither of these factors evidence base is still largely incomplete
shown to be problematic in a number of has been shown to have any influence and it is difficult to recommend one
studies, with neurotic patients being less on patient satisfaction with his/her technique over any other. Each study
satisfied with their dentures than non- dentures.3–7 The fact that age is included was carried out in a hospital setting by
neurotic patients.11,12 In these studies, in this category may come as a surprise prosthodontic specialists. It is impossible
neurotic traits were identified using a to many as it is often said that older to say how the results would change if the
variety of personality questionnaires. As patients may have more difficulty in dentures were manufactured by dentists
it is highly unlikely that dentists have adapting to a new set of dentures, yet this within primary care.
the time, or the relevant psychology association has never been demonstrated. It is perhaps more appropriate
qualifications, to administer or interpret Older patients may have more difficulty to ensure a good understanding of basic
these questionnaires in practice, it is tolerating the transition to the edentulous principles, good communication with the
debatable how helpful having this insight state, but no studies exist to confirm or patient and laboratory and a passion for
would be to the general practitioner. refute this theory. Socio-demographic quality, which are likely to be the critical
details examined have included sex, factors. Thereafter, clinicians will often
marital status, housing status, social adopt the technique and materials which
Previous denture-wearing experience
status, occupation and hobbies, amongst they perceive work best for them. The
If a patient has worn
others.5,6,15–17 following section considers the two stages
complete or partial dentures in the
past, is he or she better able to cope of denture construction that perhaps incite
with new dentures than a first time the greatest debate between clinicians.
denture wearer? A number of studies
Clinician-centred problems
have investigated this area.3,8,13–15 Only a small number of
Unfortunately, the conclusions reached randomized controlled trials exist Recording the fitting surface/taking an
are varied, with some showing that regarding the methods of conventional impression
previous denture-wearing experience denture construction. Maximizing the area from which
is an advantage and these patients It has been shown that, for a mandibular denture can gain support
will be more satisfied with their new patients with an atrophic lower ridge, an is particularly important when faced with
dentures.8,13,14 In contrast, others have admix (a mixture of greenstick and red an atrophic mandibular ridge. Additional
shown that having a previous set of impression compound in a 7:3 ratio) or support can be gained by extending the
dentures has little or no effect,3 or the silicone secondary impression produces denture base onto the buccal shelves
wearing of a previous set of dentures to a more satisfactory lower denture than (Figure 1, arrows).
be a disadvantage.15 In light of the mixed one made using zinc oxide eugenol.18 The pear-shaped pads
evidence, it would seem sensible to take A lingualized occlusal scheme has also (representing the keratinized scar tissue
each patient on his/her individual merits proved to be superior in terms of patient from the last standing molar) and part
in terms of experience, tolerance and satisfaction.19 While these well-conducted of the retromolar pads (representing the
expectation. studies have shown how different clinical glandular, non-keratinized mucosa distal to
result in problems. A common example patient in the aesthetics of his/her denture that factors involved with continued
is that of asking for registration blocks will most likely contribute to patient dissatisfaction with dentures include
to be made on primary impressions. satisfaction at the end of the treatment. prosthetic secrecy,24,27 social isolation and
Once the major impression is cast up, withdrawal28,29 and dissatisfaction with
invariably the registration blocks will sexual relations.30–32 Whilst it would be
be too overextended to sit accurately Technical problems difficult to ask questions about a denture
onto the cast. The technician has to patient’s sexual relations without causing
make a ‘best’ guess’ about how the Construction of technically correct dentures embarrassment, dentists could easily ask
block relates to the model, often What constitutes a technically if a patient’s partner or family knows they
leading to large occlusal errors at correct denture is a matter for debate. wear dentures, establishing an estimation
try-in. Therefore, constructing a Does it imply that the denture covers the of levels of prosthetic secrecy. Similarly,
registration block on primary casts is optimal denture-bearing area, and restores a few casually asked questions about
not recommended. facial features and aesthetics to within the whether the patient regularly sees family
norm? Or does it imply that the patient is members or friends may give a clue into
absolutely happy with his/her prosthesis, the level of the patient’s social withdrawal.
Aesthetics and can use it for its intended function? Regardless of research findings, it is worth
It is reasonable to assume This difference was demonstrated in one taking these factors into account as they
more ‘natural’ looking dentures will study that examined the proportions might give some important clues regarding
result in a more satisfied patient. of patients that were using what were the likely outcome of complete denture
However, some studies have tended considered to be ‘optimal’ dentures. The therapy in individual cases.
to conclude that aesthetics have figure quoted was 20%.3 Most dentists will Finally, we must also consider
only a weak influence on patient have examined a patient who is perfectly failure to meet the patient’s expectations.
satisfaction.3,23 A unique focus-group- happy with his/her ill-fitting, mobile and Without absolute openness and honesty
based study asked edentulous patients maloccluded dentures. Indeed, patient from the patient about what he/she would
what they wanted from their dentist ratings for satisfaction with their dentures like, the dentist is almost destined to fail. It
when attending for complete dentures. have been shown to change significantly is worth remembering though that, unless
One of the main themes that emerged over time. patients are made to feel relaxed and
was that the patients did not want any This illustrates the influence of accepted whilst in the dental chair, they are
changes to their appearance.24 The idea adaptive capacity on patient satisfaction unlikely to be open about their needs. Five
of patient involvement with a choice with dentures, however, this should not be or ten minutes spent actively listening to
of aesthetics was first identified in the used as an excuse for poor prosthodontic denture patients about why they actually
1970s.25 Patients were given the choice work, as the need to rely on adaptive want new dentures would be time worth
of four differing anterior tooth set-ups capacity will be minimized by producing spending.
before their treatment began. In some technically correct dentures. Not all
cases, the patients then received their patients display such adaptive capacity.
first choice tooth set-up. In other cases, Additionally, there is a small number of
the researchers gave the patients their studies that demonstrate that technically Conclusions
least preferred set-up. Incredibly, the correct dentures will better satisfy patients Successful prosthodontic
levels of satisfaction with the aesthetics than poor quality ones.9,16,26 therapy is multi-factorial. Factors which
were the same in both groups, despite Regardless of the integrity and have been shown to carry a high risk of
a number of the participants being strength of these studies, they collectively failure include:
deliberately given their least preferred point to the existence of a group of people Dentist-related factors;
choice. It was postulated that it is who cannot tolerate complete dentures, Inaccurate jaw relations;
patient involvement with aesthetic even if they are technically excellent. Not involving patients in aesthetic
choices which is important, rather No-one really knows why this group exists choices;
than the aesthetics themselves. In a and there is little information in the dental Poor impression-taking;
wide-ranging study of what influences literature about what unites them or how Patient-related factors;
patient satisfaction with complete to identify them. Neurotic patients;
dentures, the only factor found to be Since dentures are essentially A severely resorbed lower ridge.
significant were others’ opinions of replacement body parts, there may be It is suggested that, if these
the patient’s new dentures.4 It may clues as to the make-up of this group patient-related factors are present, the
therefore be worthwhile, in some contained within research done on patients patient should be considered high risk
cases, asking the patient to take the with other prostheses. These studies may for non-adaptation to new complete
try-in home, prior to finishing, so that give us a greater insight into the nature dentures. This should be discussed with
he/she can show friends or relatives of wearing dentures from the patient’s the patient prior to commencing treatment
and gauge their reactions. Whatever perspective. Work done in amputee, as well so that expectations can be appropriately
approach is adopted, involving the as in edentulous populations, suggests managed.
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