Management of Prominent Premaxilla in Completely Edentulous Arches Using Flangeless

Complete Denture

Abstract

It takes skill to restore labial fullness in a patient who has completely lost all the teeth. There are
certain clinical circumstances where the labial flange of the complete denture contributes to poor
facial aesthetics. The proclined maxillary anterior ridge is typically the main problem for
majority of instances. In this case report, a flangeless denture is used to treat and produce optimal
aesthetics in an excessively contoured maxillary ridge with a significant labial undercut without
any surgical intervention.

Keywords: Flangeless Complete Denture, Prominent Premaxilla, Labial Fullness, Lip Support.

Introduction
Esthetic requirements can differ from patient to patient and between a patient and a dentist due to
their considerable subjectivity. However, when restoring facial aesthetics, there are a few
fundamental objectives to be met. To create a suitable quantity of labial fullness with the denture
flange is one of the objectives of complete denture care. [1] Both labial fullness and lip support
can be improved with denture teeth and denture flange. To distinguish between a
pathophysiologic support and a physiologic support, it is important to comprehend the nature of
the normal support offered to the lips by the underlying natural teeth and alveolar bone. [2] The
prosthodontist must make a distinction between the two when inserting a patient with a complete
denture prosthesis because either situation may or may not require preprosthetic mouth
preparation. It is also crucial to distinguish between distinct systemic diseases that prevent an
[3]
individual from using the surrounding musculature to support the prosthesis. The choice of
whether to include or exclude the denture flange in the labial vestibule when there is insufficient
vestibular space depends on a number of considerations. Since failing to consider those factors
could lead to poor or lost retention of the denture, rendering it worthless. Most cases that lack
[4]
adequate vestibule space are due to the prominent anterior part of maxilla (premaxilla). This
article describes management of prominent premaxilla through fabrication of flangeless denture.
Case Report

An elderly female patient reported to the department of prosthodontics for replacement of her
missing teeth. Medical and other related history was non-contributory. Extra oral examination
revealed hypertonic and tight maxillary lip and increased lower third dimensions of the face.
Intraoral examination revealed a well-formed, prominent maxillary (Figure 1A) and mandibular
residual alveolar ridges (Figure 1B,C). Treatment options were discussed and the patient
consented for the conventional complete denture due to the financial restraints. Routine clinical
and laboratory procedures for complete denture fabrication were done till the stage of jaw
relations when while developing the profile contour of the maxillary occlusal rims, it was
observed that provision of denture flange in that area would result in increased lip fullness. A
clinical decision was taken and conveyed to the patient that the maxillary denture would be
without the labial flange which could indirectly affect the retention and stability of the denture.

Figure 1: A) Intraoral view depicting prominence of pre-maxilla, B) Intraoral maxillary view, C)

Intraoral mandibular view, D) Primary impressions, E) Secondary impression of the maxillary
arch, F) Secondary impression of the mandibular arch.

Primary impressions were made using irreversible hydrocolloid material (Figure 1D) and
primary casts were obtained. Incremental border molding was done and final impression was
recorded using medium body polyether rubber base material (Figure 1E, F) and master casts
were obtained (Figure 2A, B). While recording jaw relation (Figure 2C), an increased labial
fullness was observed and the outcomes were explained to patient. Transfer of face bow was
done to Hanau semi-adjustable articulator and mounting of occlusal rims was carried out (Figure
2D). While arranging the artificial teeth, anterior portion of the maxillary acrylic denture base
was removed and replaced by a tin foil followed by anterior teeth arrangement and subsequently
the posterior teeth arrangement (Figure 2E).

Figure 2: A) Maxillary master cast, B) Mandibular master cast, C) Recording of jaw relation, D)
Mounting of occlusal rims following facebow transfer, E) Teeth arrangement, F) Trial of
denture.

The denture was tried in the patient’s mouth and evaluated for the retention, stability, function
and esthetics (Figure 2F). After taking the approval from the patient and her spouse, the
complete denture was processed as a flangeless denture with a modified denture processing
procedure (Figure 3A, B). Dentures were delivered, post-care instructions were given and the
patient was kept on a follow-up protocol (Figure 3 C,D,E). Special instructions pertaining to the
modified denture which would undermine certain features of the denture prosthesis were stressed
to the patient so that a negative outcome towards the denture was avoided. The esthetic outcome
of the flangeless denture was satisfactory to the patient (Figure 3F).
 Figure 3: A) Final prosthesis, B) Finished and polished flangeless complete denture, C) Denture
insitu, D) Post-rehabilitative left lateral view, E) Post-rehabilitative right lateral view, F) Post-
rehabilitative smile view.

DISCUSSION

The flangeless maxillary denture technique can be used to preview the aesthetic outcomes, but in
some cases the final denture must incorporate the same design. Different names for flangeless
[3]
dentures include gum fit, ridge grip, and wing denture. The mucosa covering the inner side of
the lip and the mucosa covering the gingiva are separated by a region known as the labial
vestibule. The area gets bigger as the labial cortical plate of the alveolar bone starts to disappear.
[5]
The majority of completely edentulous cases where space is eliminated or reduced are either
the result of recent extractions where the labial cortical plate has experienced minimal or no
resorption, or they are the result of low maxillary anterior remnant alveolar ridge. It could also
occur if the socket is not compressed following extraction. [6,7]

However, the absence of vestibule space may be related to two significant clinical findings made
during the extraoral examination that is, the presence of a stretched-out, hypertonic lip and a
conspicuous modiolus on either side of the lips. Together, these can result in insufficient
vestibular space. When teeth are missing, the buccinators and orbicularis oris muscles contract
without resistance, causing the lips to sag inward. In these situations, the conspicuous modiolus
is also altered, primarily medially inward and medially posteriorly. If the labial cortical plate
does not significantly resorb, the vestibule space will continue to contract when paired with
hypertonic maxillary lips. The most likely cause is the inward positioning of the maxillary lip
because the patient was completely edentulous for the previous four years and neither the
primary nor final impressions showed any abnormalities of the labial cortical plate in terms of
bulk or inclination. [8,9] This case report discusses a simple and feasible approach to enhance the
esthetics in an elderly patient through a flangeless denture.

CONCLUSION

Complete denture fabrication is impacted by labial vestibule obliteration. Labial vestibule can be
destroyed by an overactive modiolus and a hypertonic maxillary lip. These two factors should be
incorporated into routine patient data collection during clinical examination of completely
edentulous patients. Fabrication of a flangeless complete denture in these cases may be an
alternative to enhance the esthetics particularly where patient does not opt for the surgical
correction.

REFERENCES

1. Chaturvedi S, Shah M, Ghodpage SL, Kulkarni M, Gill S. Unconventional prong

dentures - a case report.Int. J.Dent.Clinics. 2013;5(1): 49-50. Manjreker N.S.et al.
Flangeless Denture: a simple yet novel approach for management of severe labial
undercuts in edentulous patients. IOSR Journal of Dental and Medical
Sciences.2017;16(1);44-46.
2. Srivastava V et al. Gum t denture an alternative to Alveoloplasty. Journal of Dental
Sciences & Oral Rehabilitation.2011;3:59-62 .
3. Shah RJ, Parmar P, Soni A, Vyas S, Zala M. Unconventional complete dentures:
Innovative approach in prosthodontics. International J. of Healthcare and Biomedical
Research.
4. Neves FD, Mendonca G, Fernandes Neto AJ. Analysis of influence of lip line and lip
support in esthetics and selection of maxillary implantsupported prosthesis design. J
Prosthet Dent. 2004;91:286-8.
5. Krall E et al. How dentition status and masticatory function affect nutrient intake. J Am
Dent Assoc. 1998;129(9):1261-9.
6. Ashish R Jain et al. Ridge grip esthetic prosthesis: an alternative conventional removable
partial denture- a case report. American Journal of Oral Medicine and Radiology
2015;2(1):44-6.
7. Lawson W. A. Objectives of preprosthetic surgery. British Journal of Oral Surgery.
1972;10(2):175-85.
8. Soren Hillerup. Preprosthetic surgery in elderly. J Prosthet Dent 1994;72:551-8.
9. Ogle RE. Preprosthetic surgery. Dent Clin North Am 1977;21(2):219-36