Faults and trouble shouting in

Complete denture

Dr.M.Ezzat
 Overview
the most frequently identified denture faults
are related to patient complaints
Deal with denture problems systematically
Use a differential diagnosis
Address probable causes until problem
eliminated If can’t identify problem,
refer to another speciality
there are opportunities for improvement in the
treatment of the edentulous population.
This may be achieved by adopting a broader
therapeutic strategy focused not solely on technical
aspects of an oral prosthesis. Instead, a wider array
of clinical features of the edentulous patient should
be addressed.
A contemporary strategy may include concerns
for prevention of tooth loss, evaluation of residual
alveolar ridge resorption, and related issues of
denture function, continual evaluation of oral
mucosal health, compassionate
management of maladaptive patients, a rationale for
timely replacement of dentures
 Common faults of complete denture
construction
Poor retention(Denture looseness)
Base design )a( •
Overextension of denture bases — •
Underextension of denture bases — •
Poor tissue contact made )b( •
Lower denture base — •
Upper denture base — •
Both upper and lower denture bases — •
Inadequate post dam )c( •
 Common faults of complete denture
construction
Incorrect jaw relationships
Anteroposterior relationships )a(
Posterior premature tooth contact —
Anterior premature tooth contact —
b) Incorrect occlusal vertical dimension •
Too small — •
Too large — •
At the time of examination, the patients’ comments regarding the adequacy of
.their dentures were recorded
Five divisions were used to group the various complaints the patients
.presented with
Those patients who stated that they experienced pain and discomfort on
inserting or removing the dentures or pain while at rest or in function were
”.grouped under “Pain
Those patients who experienced difficulties incising and masticating their food
or instability when in such function were grouped under
”.Eating“

Complaints of loose dentures or dropping dentures or complaints attributable

”.to insufficient retention were grouped under “Looseness

Finally, patients whose complaints related to food accumulation around or

under the appliance and those whose complaints related to lisping,
whistling, or distorted phonetics were grouped under “Food” and “Speech,”
respectively. Patients with multiple complaints were listed under more than
one grouping
 Complaints •
Eating
Food
Loose
Pain
Speech
Appearance
 Faults rgarding to examination and
diagnosis

Many practitioners will experience a situation, •

whereby a patient with newly fabricated complete
dentures continues to experience difficulty in
adapting to them. This can lead to a protracted
period of discouraging “adjustment appointments”
that may not result in the eventual resolution of the
problem. Therefore it is often concluded that there is
some patient factor, either age, gender, medical, or
psychologic status that is hindering the success of
treatment
Although many complete denture patients are
elderly and may suffer from a variety of
medical or mentally compromising conditions,
these factors together with patient gender are
not frequently related to ongoing denture
difficulties. The clinician is advised to carefully
determine the adequacy of the patient’s
dentures before suspecting another patient-
related cause
The fact that a denture of poor quality may be •
well tolerated in one person, while a well-
made one may be a failure in another has
been a frequent source of confusion and
frustration.4, 6 and 7 It is our opinion that this has
led many dentists away from taking proper
care in the construction and provision of good
quality dentures in the belief that the patient
will adapt to almost anything, irrespective of
.the quality
Several authors cite the most frequent
complaints with complete dentures are those
pertaining to retention and stability, esthetics,
comfort while eating, and the accumulation of
food under the appliance.5, 11, 14, 15 and 16 The
factor that most often appears to have an
impact on either the success or failure of
complete dentures is esthetics.14
A patient may find it difficult to volunteer the
fact that it is the appearance of their dentures
that prevents them from wearing them. The
way in which the patient believes he or she
should look is not always in accordance with
the clinician’s perception of a pleasing
appearance
systemic medical conditions and local physical
factors may make successful wearing of a
removable prosthesis difficult. Medication
required for systemic or local disease can
adversely affect oral tissues and the quantity
.and quality of saliva produced
The psychologic status of a patient also appears •
to have great bearing on his or her ability to
manage removable prostheses.8 and 10 It has been
reported that with advancing age, both men and
women experience difficulty in learning to adapt
to and manage removable prostheses.6, 9 and 11
Attention has been focused on women who are
experiencing menopausal changes. It is believed
that they are prone to experience more difficulty
because of the physical and emotional changes
they undergo during and after this time
 Difficult Denture Patients
Anatomic Problem •
Diagnosis Problem •
Adaptive Problem •
Psychologic •
Problem
 Attention has also been focused on patient’s •
expectations of their dentures. Patients may have
unrealistically high expectations of their
dentures, often believing that the dentures will
be comparable to their natural teeth.3, 4, 7, 14, 19, 20 and
21
It has been stated that these high expectations
of dentures are more prevalent in older age
groups.20 Fiske et al.21 stated that there is also a
social dimension to ongoing denture complaint in
the elderly, as visits to the dentist for
adjustments provide these elderly patients with
.something to do
The condition of the patient’s denture bearing
tissues was assessed at the initial
appointment. The examination screened for
ulceration, presence of infection, or any other
abnormalities such as hyperplasia or
neoplasm. Accordingly, patients were grouped
as ulceration or infection “Present” or “Not
Present.
Retention incorporated perceived errors in base
design (underextension or overextension of
denture bases in the maxilla and/or
mandible), poor tissue contact (observed in
mandibular bases only or both mandibular
and maxillary bases), and inadequacies in the
posterior palatal seal (either incorrect position
.anterior-posteriorly or inadequately formed)
 Difficult Denture Patients
Adaptive Problem

Denture may be the cause of the problem •

Patient response may also be part of the •
problem
 Denture Looseness
CD & RPD: Occlusion

Check for looseness in excursions with

fingers on canines
 Denture Looseness
CD & RPD: Denture Base

Principle
Always have the patient
demonstrate how a
denture loosens
 Denture Looseness
CD & RPD

Occlusion •
Denture base (fit & contour) •
Poor anatomy •
 Denture Looseness
CD & RPD: Occlusion

Perpetually Loose Maxillary Denture

Heavy anterior interferences can cause •
loosening at posterior
Tuberosity mucosa grows into space •
Space develops under midline of denture •
base
 Denture Looseness
CD & RPD: Occlusion

Tuberosity

Tilting Growth Loss of retention

 Denture Looseness
CD & RPD: Occlusion

Incisors placed too far labially • Lip

.Denture displaces lingually •

Inclined ridge provides no •
.resistance

Inclined
Residual Ridge
 Denture Looseness
CD & RPD: Occlusion

Tilting/jiggling caused
:by
Contacts not •
centered over
ridge
Contacts on •
inclined portion of
ridge
This patient had multiple sorespots associated with the denture, and previous
adjustments to the denturebases had not provided any relief. The denture midlines
are off, and the denture teeth in the second and third quadrants are meeting cusp
to cusp,which suggests that poor occlusion could be the cause of the patient
.problems
 Denture Looseness
CD & RPD: Occlusion

Check centric position •

(articulating paper)
even, stable contacts both –
sides
stop patient upon initial –
contact
 Denture Looseness
CD & RPD

Occlusion •
Denture base (fit & contour) •
Poor anatomy •
 Denture Looseness
CD & RPD: Denture Base

Typical History
Loose/discomfort immediately on
insertion
:Clinically
Discomfort when press firmly on
1st molars
Pressure up/outward from lingual
of canine causes looseness
 Denture Looseness
Mandibular lingual flange too
thick

”Eyes in Your Fingers“

Blanchard, JPD 2:36

Tongue

Flange bulges into tongue space, lifts denture

.during function. Flange is not too long
Avoid Setting Teeth in Tongue
Space

Tongue
 Denture Looseness
CD & RPD: Denture Base
Short flange
PIP streaks •
Looks short of vestibule •
Often displaces easily •
Underextension
Fig. 3. Impression of mandibular denture bearing area was
used to fabricate study cast and periphery of planned new
denture was marked
Existing denture reseated on cast illustrates
underextension of borders

Gross underextension in primary denture

supporting area of retromolar pad
.demonstrated
.Fig
Principle 2: Identify Variations from Normal :
Tissues & Dentures
Managing underextensions •
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 acrylicpartial reline
 Pressure Pastes:
Goal: Relatively Even, Minimal Streaks
 Avoid Impinging on the Mylohyoid
Ridge

X-section through
Mandibular ridge
in 2nd Molar region
Buccal

A problem if
prominent or sharp Mylohyoid
Ridge

Attachments
To Hyoid
 Denture Looseness
CD & RPD: Denture Base
Long flange
PIP burnthrough •
Retentive until •
speaking, eating
Watch when seating •
denture
Flange touches vestibular •
depth, denture continues
to seat
 Denture Looseness
CD & RPD: Denture Base

If flange too thick •

Seal may be maintained at rest –
Pulls during function - drops –
If flange is short or long •
Displacement as lips or cheeks move –
Allows air to break vestibular seal –
 Denture Looseness
CD & RPD: Denture Base

Principle
Denture peripheries always terminate
on displaceable soft tissues
Retromolar pads, Vestibular tissues, Vibrating line
(nonmoveble soft palate), Hamular notches
Review of Indicating Media
Loney & Knechtel,J Prosthet Dent 2009;101:137-141
More the colour of indicating medium
than denture

Insufficient
Correct Amount Amount
with Streaks

Too Much
w/o Streaks
Fig. 6. Pressure disclosing cream applied to
tissue surface ofdenture base shows areas of
high pressure over retromolar pad
Fig. 7. Intraoral examination reveals expected
.ulceration aboveretromolar pad
Overextension of Denture Borders
Slight overextension is preferred to slight
underextension.
Remember, however, overextension is prejudicial to
denture retention.
To examine the lower denture for overextension:
Instruct patient to protrude tongue slightly until the
tip rests upon the lower lip
Place your index fingers on the occlusal surfaces of
the lower teeth to determine if the lower denture
remains firmly seated on the denture-supporting
structures
If the denture lifts, consider 3 possiblities:
Overextension in the region of the genioglossus
muscle (contracts w/ forward movement of the
tongue to dislodge denture) Anterior portion of
denture lifts
Overextension in the region of the premolar-molar
area (denture dislodges by contraction of
mylohyoid) Entire denture lifted from position
Overextension of the extreme distolingual border of
the lower denture (dislodgement of the forward
movement of the retromylohyoid curtain) Entire
denture dislodged from position and moved forward
 • To test buccal and labial flanges of the lower
denture for retention, cheeks and lips are drawn
outward. Keep index finger of the other hand on
occlusal surface of the teeth on the same side. If
denture lifts, border may be overextended.
• Test buccal and labial flanges of the upper denture
for retention the same way except hold index finger
of the opposite hand in contact with palatal vault
Managing 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 notcontrolled in amountor location
Not all overextensioncab be detected by this method
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
 Denture Looseness
CD & RPD: Denture Base

Lack of post dam/

retrozygomal seal
Pull upward and •
outward on canine
Test hypothesis: add •
compound/functional
wax -opposite side
 Denture Looseness
CD & RPD: Denture Base

Poor base adaptation •

Fulcrum on bony •
structures
Test hypothesis: PIP •
 Denture Looseness
CD & RPD: Denture Base

Periphery terminates on
bony structures Dry Mucosa
Hard palate –
Zygoma –
External oblique ridge –
Before retromolar pad –
No seal, discomfort •
Eventual resorption •
 Denture Looseness
Denture Base: Coronoid Interference

Thick flange in retrozygomal •

area
Coronoid gets closer to •
tuberosity as patient opens or
moves jaw to side
Dislodges maxillary denture •
 Denture Base: Pterygomandibular
Raphe

This patient has very tight pterygomandibularraphes (arrows). As the raphes

tighten during opening, they pull on the posterior border of the denture, causing it to
loosen (the patient’s chief concern). Relief for these structures should be provided
duringthe making of the impressions. This caseemphasizes that anatomic variations
must beidentified to minimize denture problems
 Denture Looseness
Denture Base: Pterygomandibular Raphe

Raphe from area of •

hamular notch
Very tight in some •
patients
Easily displaceable, but •
raphe can displace
denture opening wide
 Denture Looseness
Denture Base: Palatal Cleft
In some patients midline soft •
palate fissure
Can “tent” during function •
Allows air to leak under denture •
 :Loose Denture
Prominent Midline Fissure, Soft Palate

In this patient, the deep midline

soft-tissue fissure at the posterior of the
palate caused a break in the seal of the
denture, which in turn caused looseness and
dropping of the denture. Special attention is
needed to ensure that the posterior palatal
seal of the denture maintains tissue contact to
provide adequate retention
 Denture Looseness or Pain
CD & RPD

Principle
Always have the patient rate
improvement (0-100) after
adjustment. If below 90%, more
diagnosis/adjustment is
required
 Denture Looseness
CD & RPD

Occlusion •
Denture base (fit & contour) •
Poor anatomy •
 Denture Looseness
CD & RPD: Poor Anatomy

Many sets of dentures •

Use articulator –
More involved/precise impression –
& jaw relation procedures
Implants –
Refer –
 Denture Looseness
CD & RPD: Occlusion

Typical History
Adequate retention
initially
Gets worse with time
:Clinically
No discomfort when press
firmly on 1st molars
Interference
Swallowing •
Upper –
Over-extension in the posterior •
Too thick in posterior •
Lower –
Over-extension in the lingual •
Too thick lingual posterior flanges •

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 Instability
When not occluding •
Over-extension of border and posterior limit –
Under-extended border –
Loss of posterior palatal seal –
Posterior palatal seal on hard palate •
Posterior limit not in hamular notches •
Insufficient posterior palatal seal •

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 Instability
When not occluding •
Dehydration of tissues due to alcoholism –

Flabby tissues displaced when making impression –

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 Instability
When incising food •
Loss of posterior palatal seal –
Anterior teeth placed too far labially –
Poor denture foundation (flabby anterior tissues) –
Improper incising habits –
Neutral zone concept
Maximizing lower denture retention
Fig. 9. Harmonious tooth contact was established
after dentures were remade
Fig. 8. Anterior premature tooth contact and posterior tooth
disclusion is seen when patient is guided back to centric relation
position
• Faulty Vertical Dimension
• One of the most common denture faults
• Always check for this regardless of how remote the
patient’s complaint may be
• Vertical Dimension is a combination of relaxed muscles,
lips at rest, varying freeway space, harmony between
lower and middle 1/3 of the face, ability to speak
without bite rims contacting, tongue room for making
the "th" sound, satisfaction of the patient’s tactile
sense, and a consistent rest position measurement
• Two types of patient’s need a freeway space far in
excess of the 2 – 3 mm generally recommended
The patient accustomed to occluding in a very over- •
closed relationship for a long period of time (not a
good idea to open a patient 10 – 12 mm all in one
operation – important to rely on patient judgement,
too)
A good way to check VDO (provided the upper incisors are set in a
normal position) = Push the lower lip with your index finger with the
joints in centric occlusion. If the lower lip tends to slide under the
incisors instead of impinging on them the VDO is generally opened
too far ( however, horizontal overlap may do the same thing)
The "th" sound is a good phonetic cue to correct vertical dimension.
When the patient says words beginning with "th" his tongue should •
.pop forward between the bite rims
If the VDO is excessive, the forward movement of the tongue, is
restricted by the height of the rims or set teeth
FREEWAY SPACE
Measuring the occluding face height and the resting
face height should check the amount of freeway space.
In addition to measuring the freeway space, the clinician
should also assess this visually. If there is too much tooth
showing, or if the patient is struggling to put their lips
together, there may be insufficient freeway space. The
patient should be asked to speak and if their speech
sounds incorrect, this may indicate that there is
insufficient
freeway space. If there is too much freeway space,
then the patient will look over closed and will show too
 Denture Pain:
Occlusal Vertical Dimension (OVD)
Insufficient OVD
lack of chewing power •
minimal ridge •
discomfort
angular chelitis •
:esthetic complaints •
chin prominent •
poor lip support •
Fig. 10. A, Frontal and B, profile views of patient demonstrating overclosure and collapse of
.nasolabial features due to VDO that is reduced
Fig. 11. Autopolymerizing acrylic resin has been added to mandibular posterior
denture teeth ( A) to reestablish esthetic (B) and physiologically (C) acceptable
.VDO
 Denture Pain:
Occlusal Vertical Dimension (OVD)

Excessive OVD
Sore over entire ridge •
Gets worse during day •
Muscle/joint pain •
’Dentures ‘click •
Esthetic complaints: too •
full
Fig. 12. Anterior teeth have been set too far out into labial sulcus
(A) resulting in incompetence of the resting lips (B), and excessively
.full lip appearance (C)
A significant relationship was observed between
an unhealthy denture bearing mucosa and complaints
.relating to pain
The most frequently observed faults in denture
construction
related to retention, and vertical and horizontal
jaw relationships. There were significant relationships
between inadequate retention and improper
intermaxillaryrelationships and patient complaints of
loosenessand difficulty eating, respectively
 Phonetic Problems

Lisping:
– too much overjet
– triangular spaces between max. & mand.
teeth
– palatal contour too constricted
– insufficient tongue space
Speech Problems
It takes patients from 2 – 3 weeks to accustom themselves to
dentures, so it is difficult to judge this early on, but some
things to think about are:
Patients are adaptable and generally will correct speech
difficulties (not directly related to technical error) within 2 or
3 weeks, so most patients can be assured they will get past
the difficulty
The pronunciation of the letter "s" is the most common speech
problem; the patient may even have involuntary hissing or
whistle. This can be caused by:
Rugae area too thick or too thin or the maxillary anterior teeth
may be set too far lingually. If the patient has a heavy
anterior ridge and the denture is thick, the rugae area should
be thinned to allow more space for air to escape. If the
anterior ridge is small and thin, likely too much air is escaping
and wax on the palatal surface should correct the problem
(autopolymerizing resin can then be added if the wax shows
this to be an effective correction
). If the maxillary anterior teeth are set too lingually, they
must be reset or you may try heavy festooning just
lingual to the teeth. If these remedies don’t work,
sometimes adding a median ridge will help.
Inability to speak clearly may be due to the lack of tongue
room posteriorly on the mandibular denture.
Overextension of the upper denture onto the soft palate
results in speech difficulties, as the patient has to make
a conscious effort to keep the denture in position
when talking
Complaints about the phonetics
with the dentures and causes
Whistle on “S” sounds •
Lips on “S” sounds •
Th” and “T” sounds indistinct“ •
”T” sounds like “Th“ •
F” and “V” sounds indistinct“ •

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• Fullness under nose
• Depressed philtrum and/or nasolabial sulcus
• Upper lip sunken in
• Shows too much of the teeth
• Artificial look
• Whistle on "S" sound
• Lisp on "S" sound
• "Th" and "T" sounds indistinct
• "T" sounds like "Th"
• "F" and "V" sounds indistinct

• Muscles of mastication become fatigued

• General feeling dentures are not right, but with
absence of pain (patient has high pain tolerance)
 Phonetics
Whistles on “S” sounds
Too narrow an air space on the anterior part of the
palate
Lisp on “S” soundsLisp “S” sound (“S” sounds •
like “Th”)
Too broad and air space on the anterior part of –
the palate

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 Gagging with Dentures

Usually not soft palate contact •

: Denture contact with tongue •
thick posterior border rubs on tongue –
:posterior border drops onto tongue –
Occlusal interferences •
Terminates on hard palate (no seal) •
 Pain: Occlusion
Diagnostic Strategies

Eliminate as potential cause •

Remount denture on an articulator •
Centric relation & protrusive records •
Mark centric & excursive contacts, adjust •
 Denture Pain:
Occlusal Vertical Dimension (OVD)

:Solution
Check physiologic rest postion and •
phonetics carefully to confirm
Provide time to ensure no adaptation •
Reset teeth as adjustment alone •
usually not possible
Don’t Adjust Occlusion Intraorally

Contact on inclines can •

cause denture
movement
May cause pain, or reflex •
avoidance
May make interference •
difficult to mark
Adjusting Occlusion Intra-Orally

Net Result
Can’t see real Problem
Can’t eliminate the Problem
 Adjusting Occlusion

Use an articulator •
Eliminates denture •
movement
Can visualize interferences •
easily
Saves time removing & •
replacing dentures
 Pain: Occlusion
Clinical Exam

Patient •
demonstrates
problem by biting
where pain occurs

Ulcer or sore spots on sides of •

ridges
Pain: Occlusion
Clinical Exam

Occlusal contact not •

centered over ridge
Tilting forces cause •
displacement,
abrasion, ulceration
Worse if xerostomia, •
malnourished,
debilitated or poor
adaptability
 Pain: Occlusion
Avoid Contact on Inclines

No teeth set over •

ascending portion of
ramus
 Pain: Denture Base
Hamular Notches Commonly sharp
flange Sometimes long
Use PIP
A sharp, thin or overextended
periphery in the hamular notch area can cause
painful ulcers. Use of indicating medium is
critical for adjustment of these areas, because
removal of acrylic in the wrong area can result
in a breach of the posterior palatal seal, which
will result in loosening of the denture and little
relief of the discomfort
 Pain: Occlusion
Avoid Contact on Inclines

No contact on •
inclines of denture
bases
 Pain: Denture Base
Retromylohyoid Overextension

Sore throat •
Denture moves when swallow •
From retromolar pad, flange •
should go straight down or
angle forward, never
backward
 Avoid Impinging on the Mylohyoid
Ridge

X-section through
Mandibular ridge
in 2nd Molar region
Buccal

A problem if
prominent or sharp Mylohyoid
Ridge

Attachments
To Hyoid
Pain: Denture Base
Severe Tissue Undercuts

If the ridge is severely

undercut, the flange
cannot be placed to
the depth of the
vestibule, otherwise
the denture will not
seat or ulceration
will occur
 Sore spots
Sore spots in vestibule •
Over-extended border –
Sore spots posterior limit of upper •
Posterior palatal seal too deep –
Sharp posterior palatal seal –
Over-extension –

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 Sore spots
Single sore spots over ridge •
Malocclusion in that area –
Inaccurate denture base –
Bubbles of acrylic resin –
Generalized soreness over the ridge •
Vertical dimension too great –
Inaccurate denture base –

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 Sore spots
Soreness under lingual flange of lower
Centric occlusion not in harmony with centric, drives
lower denture forward
Over-extended lingual flange
Soreness under labial flange of lower
Too much overbite
Patient’s habit, wants to masticate in protrusive
Over-extended labial flange

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Ulcers, sore spots or areas of hyperkeratosis on
the sides of the ridges, which are not
identified by pressure indication medium, are
.typically caused by tipping of the denture
Tipping is frequently associated with
occlusal problems
Areas of inflammation orulceration that are caused by the denture
base are often discrete and cannotbe distinguished from similar areas
.related to occlusal problems
The diagnosismust be established through the history, a clinical examination and
indicatingmedium. The definitive diagnosiis often determined by exclusion o
other possible causes
For pain related to occlusion •
Hurts only when chewing •
Gets worse with chewing •
Gets worse as the day progresses •
Patient may have to remove prosthesis late in •
the day because
of discomfort •
For pain related to denture base fit •
Problem starts when the patient inserts the •
denture, which often
feels tight or causes soreness •
Patient has discomfort even when not •
chewing
May or may not get worse as the day •
progresses
For pain related to occlusal vertical dimension (OVD)
)Insufficient OVD
Lack of chewing power
Minimal ridge discomfort
Angular cheilitis
Chin prominent
Minimal display of vermilion border

Excessive OVD
Soreness over entire ridge
Worse during the day (increased occlusal contact)
Dentures “click” when speaking
Mouth feels “too full,” patient has difficulty getting lips together
Tongue and cheek biting
Posterior teeth edge to edge •
Over-closure •
Posterior teeth too far lingual or buccal •

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 Burning sensation
Anterior hard palate and anterior alveolar •
ridge areas
Pressure on anterior palatine foramen –
Bicuspid area to molar tuberosity •
Pressure on posterior palatine foramen –
Lower anterior ridge •
Pressure on mental foramen –

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