Pain induced from occlusal errors of removable prosthesis

Occlusion of Removable Prosthodontics.
Pain induced from occlusal errors of removable prosthesis

1. Pain induced from Occlusal errors of removable prosthesis

2. It is a distressing, uncomfortable, nuisance and unpleasant sensory feeling often Definition Pain It can be steady, throbbing, stabbing, aching, pinching, or described in many other ways. caused by intense or damaging stimuli.

3. Pain is the most COMMON reason clients seek medical advice. Pain is a protective mechanism or a warning of potential or actual injury to prevent further injury. Pain

4. ACTUAL AND NOT PSYCHOLOGICAL , contrary to the belief of most clinicians. Pain Most of the complaints associated with complete dentures are

5. location Aetiology Duration Intensity Nociceptive Pain Acute Chronic Neuropathic Central Peripheral Mild Moderate severe Diffuse Localized Generalized Course Continuous Intermittent Incident irruptive

6. Location 1. Localized Pain: Pain in a specific region of the supportive tissues: a. Pain in the Mucosa and alveolar ridge b. Pain resulting from biting the lips and cheeks c. Pain in the tongue d. Pain that occurs at the TMJ 2. Generalized pain: Pain involving a major part of the supportive tissues 3. Diffuse pain: Pain involving all the supportive tissues .

7. Aetiology (Cause) Nociceptive pain: Pain associated with actual or potential tissue damage or tissue injury . Process through which peripheral pain receptors transmit information about current (or potential) tissue damage centrally as pain 2. Neuropathic pain: arises from damage to the nervous system itself, central or peripheral. it’s more likely to lead to chronic pain: nerves don’t heal well . 3. Mixed between tissue damage and damage of nerves. 4. Idiopathic. 5. Psychogenic.

8. Acute pain: Usually comes on suddenly and is caused by something specific such as burns or cuts , infection and dental work. Chronic pain: is pain that  lasts longer than 3 months . It is also called persistent pain or long-term pain.  Duration

9. REFERED PAIN The pain sensation produced in some part of the body is felt in other structures away from the place of development. PAIN OF SPECIAL INTEREST The deep pain and some visceral pain are referred to other areas. But superficial pain is not referred.

10. Sensory Pathway Stimulus of skin receptors Sensory receptor (= transducer ) Afferent sensory neurons CNS CNS Integration, perception Thalamus Post central gyrus

11. Sensory Pathway Stimulus of skin receptors Sensory receptor (= transducer) Spinothalamic tract ( spinal cord or medulla) Thalamus Cerebral cortex (Post central gyrus). Thalamus Post central gyrus

12. Diagram showing the pathway of pain Process of pain physiology Transduction Transmission Central perception of pain Modulation of pain Thalamus Post central gurus

13. Transduction: Pain stimuli is converted to electrical energy. This electrical energy sends an impulse across a peripheral nerve fiber ( nociceptor ). Thalamus Post central gyrus

14. Thalamus Post central gyrus Transmission: The pain impulse is transmitted: from the  site of transduction along the nociceptor fibres to the dorsal horn in the spinal cord ; from the spinal cord to the brain stem; through connections between the thalamus, cortex and higher levels of the brain .

15. Transmission: A delta fibers ( myelinated ) send sharp, localized and distinct sensations. C fibers ( unmyelinated ) relay impulses that are poorly localized, burning and persistent pain. Pain stimuli travel- spinothalamic tracts .

16. Thalamus Post central gyrus Central perception Person is aware of pain – somatosensory cortex identifies the location and intensity of pain. Person unfolds a complex reaction, Physiological and behavioral responses is perceived.

17. Thalamus Post central gyrus Modulation: Refers to the process by which the body alters a pain signal as it is transmitted along the pain pathway, Inhibitory neurotransmitters like endogenous opioids work to hinder the pain transmission. (  Endorphins are released by the hypothalamus and pituitary gland in response to pain or stress).

18. Thalamus Modulation: This explains , why individual responds to the same painful stimulus sometimes in different way. This inhibition of the pain impulse is known as modulation. Endorphins   Primarily helps one deal with stress and reduce feelings of pain. Post central gyrus

19. Endorphins are released by the hypothalamus and pituitary gland in response to pain or stress, this group of  peptide hormones  both relieves pain and creates a general feeling of well-being. The name of these hormones comes from the term "Endogenous morphine." "Endogenous" because they're produced in our bodies.

20. Presentation of patient with Complaints Inform patient of possible problems. Un-informed patient: Sense of pain. Sense of loss (waste of time and money ). Sense of deceit.

21. Diagnosis Causes Treatment Managed by Listen , examine & treat Visual and digital examination of oral cavity. Adjustment to eliminate any problem. Complaints

22. Within 3 to 7 days 3 to 4 months for difficult patients 12 month interval for most Examination to detect potential problems. Patient should point to problem. Corrected in early stage. Eliminate pain or discomfort. Patients should be checked within 24 hours Periodic recall appointments

23. Causes are attributed to Patient's dissatisfaction Denture settling Most of the complaints associated with complete dentures are actual and not psychological, contrary to the belief of most clinicians. Complaints Denture errors

24. Patient's dissatisfaction are attributed to Denture problems Types of patient Indifferent Philosophica l Hysterical Exacting Complaints

25. Philosophical: Rational, sensible, organized and overcomes conflicts (Expectations are real ). Exacting : Methodical, precise and accurate; places severe demands (Must reach an understanding before starting treatment ). Indifferent: Apathetic, uninterested, uncooperative and lacks motivation; blames dentist for poor health; pays no attention to instructions (Unfavorable prognosis). Hysterical: Emotionally unstable, excitable, apprehensive (Psychiatric help may be required ). House’s Classification of Patients’ types:

26. Denture problems Old denture Loose fit New denture Over extension Over closure (Low VD ) Complaints

27. The majority of the patients with new denture may face one or more of the following problems (Common complaints): Pain

28. Uncommon complaints: According to Sharry Sharry.J.J Complete denture Prosthodontics, 3 rd edition, chapter 17, p. 358

29. Patient's Factors Denture's Factors Denture errors Clinical faults Laboratory Faults Denture settling Chemical irritation High occlusal forces Patient experience Reduced tolerance Localized Fact. e.g. roots, bony spicules Systemic Factors Psychogenic Reduced denture bearing area Function and para -function Low pain threshold X erostomia Occlusal Errors Causes of Pain are attributed to

30. Pain from Denture’s Errors Improper extension of the periphery Severe Undercuts Insufficient relief Incorrect occlusion, and t eeth off the ridge Poor fit Irregular and knife edge ridge. Rough fitting surface Difficulty in swallowing and Sore throat Retained roots, unerupted tooth or sharp bony spicules Denture Stomatitis Infection with Candida Albicans Papillary Hyperplasia Allergy

31. Questions to ask when assessing oral pain Site .. Where is the pain? . Is the pain in a specific area or widespread ? Onset ..   When did it start ? How long has the pain been continuing, Does the pain disappear after the removal of the dentures? Is there continuous pain during the wearing of the dentures, or is the pain increasing only at certain times, for example, while eating ? Character.. Can you describe the pain?

32. Chewing only Occlusion Gets worse throughout day Occlusion When first insert dentures Denture Base Pressure on first molars Denture Base History of Chief Complaint.. When?

33. If the patient is feeling severe pain during the insertion and removal of the dentures: Undercut areas . If the patient is feeling pain as soon as the denture is inserted and this pain becomes more acute when chewing force is applied : Irregularities on the tissue surface. Overextensions. Pressure areas . If the pain gets worse with chewing and g ets worse during the day: Errors in occlusion .

34. If pain upon pressing firmly on 1 st molars, adjust denture base first until no pain . Use finger pressure, Do NOT use occlusion to apply pressure >> Occlusion could introduce tipping forces. Chew Test: Denture dislodges or shifts when patient occludes (tilting, twisting, tipping, sliding ). What are the Methods of Detecting Occlusal Errors? Diagnosis of Pain due to Occlusal error

35. Chew Test: Chew on cotton ball on both side. Identify teeth that cause problem when chewing. Use articulating paper in excursions on those teeth to remove tipping contacts: Heavy contacts Contacts buccal to the ridge. Contacts on inclines. Diagnosis of Pain due to Occlusal error

36. Never adjust without locating exact position of the problem, Use P. I. paste

37. Ridge VD Denture Borders Over-extension Basal Seat Uneven pressure Occlusion Cuspal interference Poor fit Mental Foramen Pressure area Improper impression Warpage of denture base Improper cast CO # CR Teeth off ridge Roughness Allergy DD Patch test Remaining Root undercut Under-extension ( disto - lingual area) Rough border. Sharp border Pain

38. Incorrect Occlusion VD CO # CR Uneven Pressure and Cuspal interference Improper tooth Position White sore area on the site of pressure VD (Neurological pain) VD ( white patch) Contacts on inclined portion of ridge Heavy anterior interferences Pain Teeth off ridge

39. Incorrect Occlusion due to improper tooth Position Teeth off ridge Cramped tongue Contacts on inclined portion of ridge Heavy anterior interferences U pper buccal sulcus of working side Tight lip Vertical height of mandibular posterior Teeth.

40. 1.Localized pain —pain in a specific region of the supportive tissues.   2.Generalized pain —pain involving a major part of the supportive tissues.   3.Diffuse pain —pain involving all the supportive tissues.   4.Pain resulting from biting the lips and cheeks.   5.Pain in the tongue. 6.Pain that occurs at the TMJ ad ear ache. Generally, pain that occurs in the oral tissues can be collected under six headings:

41. Incorrect Occlusion that cause pain Incorrect vertical dimension Low vertical dimension or High vertical dimension Incorrect Tooth Position Heavy anterior interferences Teeth off the ridge. Labially placed mandibular anterior teeth. Setting of upper posterior teeth far buccally . Setting of lower posterior teeth too far lingually. Avoid Contacts on inclined portion of ridge. Vertical height of mandibular posterior Teeth . Occlusal discrepancies Wrong anteroposterior relationship (Incorrect centric occlusion) Uneven pressure or Severe disclusion of posterior teeth in excursions (lack of balance). Cuspal Interference .

42. 1. Incorrect vertical dimension Solutions ???

43. Error during registration stage. Or, Incomplete closure of the denture flasks . Excessive OVD Obliterated free-way space

44. P oor processing techniques Poor laboratory technique can result in the movement of individual teeth or in an increase in occlusal vertical dimension of the denture .

45. Failure to close the flasks completely during processing ( Incomplete closure of flask causes tooth movement). Too much pressure in closing flasks Shrinking of acrylic, processing changes

46. Pain Involving All the Supportive Tissues (Diffuse Pain) There are more than one reason for this type of pain : Increased vertical dimension. 2 . Patient’s allergy to the denture base material. 3. Incompatible CO. and CR.

47. Pain gets worse during day. Muscle/joint pain. Small white patches + painful areas. Pain returns within few days of immediate relief over patches. Pain on crest of lower ridge. D entures “click”, clatter, and Distorted appearance. Effect of Excessive OVD Obliterated free-way space

48. Effect of Excessive OVD Distorted appearance : Elongated appearance of face and inharmonious facial proportions. Discomfort to patient : Obliterated free-way space lead to inability to find comfortable resting position. Loss of biting power . Pain and muscular fatigue : The lips are unnaturally separated and have a strained appearance. the stretching of facial muscles causing pain. Clicking of teeth : Teeth are liable to contact causing noisy sounds during speech and mastication. Interference with speech. Increased risk of trauma & pain of the basal seat areas of denture, due to clenching of teeth. Generalized hyperemia and soreness of the residual ridge . Rapid bone resorption . Difficulty in swallowing and gagging sensation . Loss of stability of dentures .

49. Treatment: The vertical dimension should be reduced by grinding. If upper occlusal plane is acceptable, replace teeth on lower denture or make a new lower denture. Otherwise remake upper and lower denture with a correctly determined vertical dimension. High Vertical Dimension Flabby Tissue Excessive OVD

50. Establishing the occlusal vertical dimension in centric: Occlusal VD is maintained by occlusion of palatal upper cusp and buccal lower cusp (in normal occlusion). ( Supporting cusps)

51. The vertical dimension should be reduced by grinding. Minor r eduction of the supporting cusps without causing anterior interferences. Establishing the occlusal vertical dimension in centric:

52. Effect of Insufficient OVD Cheek Biting Either results from wrong jaw relation records. Or from the alveolar ridge resorption and/or acrylic teeth attrition. This condition is often a delayed not immediate. Indefinite location of pain. May be associated with temporomandibular joint dysfunction. Angular Chelitis

53. Indefinite pain location Lack of chewing power Angular (commissural) Chelitis Esthetic complaints: Chin prominent Poor lip support Cheek biting/ tongue biting/ lip biting Pain in temporomandibular joint and sore muscles. Costen’s syndrome . Cheek Biting Cheek Biting Angular Chelitis Effect of Insufficient OVD

54. Commissural Chelitis Inflammation of the angles of mouth. Attributed to excessive interocclusal distance . It usually develops when occlusal plane of the lower teeth is too high. This prevents the regular action of the cheek from eliminating the saliva from the lower buccal vestibule, so saliva will exit through the corners of mouth indicating spread of infection to the angles of mouth. Advisable to construct new dentures .

55. Costen's syndrome : Described by james. B. Costen in 1934. He claimed that the symptoms forming his syndrome were produced by over-closure of the mandible >> Retruded condyles press on the tympanic nerve, and that "opening the bite" would clear up these symptoms.

56. The symptoms can be summarized as follows : Otological symptoms : Tinnitus. Otalgia (ear pain ),Hearing loss, Ear fullness or stuffiness in the ear, Noises in the ear: Humming, ringing, crackling sounds, Vertigo and Dizziness. Facial pain . Headache and neck pain :  e.g. pain in the  occipital region  (the back of the head), or the forehead or other types of facial pain including  migraine, tension headache or   myofascial pain. Pain typical of "sinus disease." Burning sensations and pain in the tongue ( glossodynia ), throat and side of the nose and eye, as well as a metallic taste. (Burning mouth syndromes) TMJ symptoms and pain: Tenderness and pain to palpation of the temporomandibular joint and the muscles of mastication. Limited range of mandibular movement, which may cause difficulty in eating, Noises from the joint during mandibular movement, Joint noises may be described as clicking popping, or crepitus (grating).

57. Prolonged over closure Mild Deafness, tinnitus, blurring of vision Tenderness over the TMJ Dryness of mouth Neuralgic symptoms – burning sensation of tongue, throat, nose and headache. In Summary These symptoms may be resulted from …………………………….?????? Costen’s syndrome due to Insufficient OVD

58. A. Chorda Tympani B. Nerve to Mylohyoid C. Inferior Alveolar Nerve D. Lingual Nerve E. Mandibular Nerve These symptoms may be resulted from pressure of the retruded condyle on the auriculo-tympanic nerve (A)

59. Treatment: Use of occlusal pivots to stabilize the occlusion, followed by new dentures . Add tooth coloured self curing resin on the posterior occlusal surfaces of the mandibular denture to increase VDO gradually ,

60. Treatment: When the patients closes the mouth with the mandible guided to the centric relation position , the occlusal surfaces of maxillary posterior teeth are recorded in the resin. Trim the resin to reestablish the contours of the teeth.

61. Incorrect Occlusion that cause pain Incorrect vertical dimension Low vertical dimension or High vertical dimension Incorrect Tooth Position Heavy anterior interferences Teeth off the ridge. Labially placed mandibular anterior teeth. Setting of upper posterior teeth far buccally . Setting of lower posterior teeth too far lingually. Avoid Contacts on inclined portion of ridge. Vertical height of mandibular posterior Teeth . Occlusal discrepancies Wrong anteroposterior relationship (Incorrect centric occlusion) Uneven pressure or Severe disclusion of posterior teeth in excursions (lack of balance). Cuspal Interference .

62. 2. Incorrect Tooth Position Heavy anterior interferences Teeth off the ridge. Labially placed mandibular anterior teeth. Setting of upper posterior teeth far buccally . Setting of lower posterior teeth too far lingually. Setting of Teeth on inclined portion of ridge. Vertical height of mandibular posterior Teeth.

63. REMEMBER >> RULES Whatever the concept Try-in ???

64. a. Heavy anterior interferences The horizontal overlap between upper and lower anterior teeth is automatically decided by the relation between the upper and lower residual ridges. The horizontal overlap should be consistent throughout the anterior region. At this stage it should be about 1.5 mm.

65. It is a destructive contact: Flabby ridge(mobile or extremely resilient alveolar ridge ): Is due replacement of bone by fibrous tissue. Seen in anterior part of maxilla, as a sequelae of excessive load of residual ridge and unstable occlusal conditions.

66. Perpetually Loose Maxillary Denture Can cause loosening at posterior. Tuberosity mucosa grows into space. Space develops under midline of denture base. Heavy anterior interferences

67. Tuberosity Tilting Growth Loss of retention

68. Inclined Residual Ridge Lip Incisors placed too far labially Denture displaces lingually. Inclined ridge provides no resistance. a. Labially placed mandibular anterior teeth. B. Teeth off the ridge

69. Placement of upper and lower incisors excessively labially The stability of the denture is disturbed. For the new denture, the lower anterior teeth should be arranged as their position before the extraction of the teeth. Excessive labial placing of the lower anterior teeth, to provide a normal overjet for patients with skeletal class II, leads to the movement of lower denture when the patient opens his/her mouth or laughs.

70. Pain in upper buccal sulci and tuberosities . Upper teeth are often too far buccally (to meet occlusion in cases of skeletal class III ). b. Setting of upper post. teeth far buccally During function, upper denture will tilt, digging the periphery into the mucosa on the working side, and pulling it down the tuberosity on the opposite side.

71. Occlusal contact not centered over ridge Tilting forces cause displacement, abrasion, ulceration. Worse if xerostomia, malnourished, debilitated or poor adaptability. With Clinical Exam:

72. Patient demonstrates problem by biting where pain occurs Ulcer or sore spots on sides of ridges Clinical Examination Pain Upper buccal sulci and maxillary tuberosities .

73. Treatment : Remove the last four posterior teeth and reset and reduce the bulk of acryl over the tuberosities and reset. New dentures

74. Cramped tongue Instable denture Pain and discomfort Inefficient mastication c. Setting of lower post. teeth too far lingually

75. Tilting/jiggling No teeth set over ascending portion of ramus>> lateral forces>> instable denture . C. Teeth on inclined portion of ridge

76. Avoids ascending portion of ridge. Drop 2 nd premolar if necessary. Ensures adequate occlusal table (maintains 2 molars ).

77. 2/3 of Retromolar pad D. Vertical height of mandibular posterior Teeth

78. Incorrect Occlusion Incorrect vertical dimension Low vertical dimension High vertical dimension Incorrect Tooth Position Heavy anterior interferences Teeth off the ridge. Labially placed mandibular anterior teeth. Setting of upper posterior teeth far buccally . Setting of lower posterior teeth too far lingually. Avoid Contacts on inclined portion of ridge. Vertical height of mandibular posterior Teeth . Occlusal discrepancies Wrong anteroposterior relationship (Incorrect centric occlusion) Uneven pressure Severe disclusion of posterior teeth in excursions (lack of balance). Cuspal Interference .

79. Check centric position (articulating paper) Even, stable contacts both sides. Stop patient upon initial contact. Occlusal discrepancies

80. a b Wrong anteroposterior relationship ( Incorrect centric occlusion)

81. Mismatch of ICP and RCP. Interdigitation of teeth locks the dentures together, while the patient will not feel comfortable in that situation Trials to Retrude the mandible will rub the denture against the mucosa. This will cause pain and looseness .

82. Incompatible centric occlusion and centric relation, lower denture moves forward (anteriorly) and irritation areas occur on the anterior lingual part of the lower jaw .

83. It is a relatively flat area having a length of 0.5-1mm, created between centric relation and maximum intercuspal position on the occlusal surfaces of the teeth, gives the mandible freedom to close in Centric or slightly anterior to it without any interference . Freedom of centric ( Long centric)

84. “LONG” CENTRIC No Anterior Contacts The coincidence of Centric Occlusion & Centric Relation (CO = CR), when there is freedom for the mandible to move slightly forwards from that occlusion in the same sagittal and horizontal plane (Freedom in Centric Occlusion). No anterior Interference, no change in VDO.

85. Nonequivalent contacts due to inadequate centric occlusion. View of the dentures inside the mouth and outside the mouth. Moderately wide, hyperemic (red), diffuse and painful area.

86. Mild error : chair side occlusal spot grinding. Moderate errors: Clinical remount and Selective grinding of teeth . Gross errors either replace posterior teeth or remake denture . Treatment

87. Uneven pressure Error in setting artificial teeth , or / Lack of occlusal balance. resulting in the tilting of dentures . (Uneven distribution of occlusal contacts) Error in Centric Positions

88. Inaccurate centric occlusion (early contacts on the right side) >> Irritation area over the right crest. Correction of inadequate occlusion according to the severity of the case. Localized Pain : Pain is confined to the crest of the ridge on one side .

89. Traumatic ulcer or sore spots as a result of unbalanced occlusion Localized Pain : Pain is related to buccal aspect of the ridge on one side and lingual aspect of the ridge on the other side as the problem causes tilting of the denture (it is mainly the lower).

90. Lesser degrees of errors can be detected by a celluloid strip or articulating paper on either side with the patient closing just to hold it without reaching the tilting point of the denture bases If more it is detected with a wax knife . Diagnosis:

91. Treatment: Slight error: chair side occlusal grinding. Moderate errors: clinical remount. Severe errors: remake denture or replace posterior teeth.

92. 3. Cuspal Interference ( Premature contacts on one or both sides)

93. The presence of premature contacts on the occlusion cause an increase of the forces over the crests in certain areas. Inflammatory changes can be easily noted visually and are observed in these areas. Correction of inadequate occlusion by: grinding in centric relation After Before . Re-establishment of C.O.

94. A Dragging action will be exerted on both dentures during lateral and protrusive movements with teeth in contact if cusped posterior teeth are used or if excessive incisal guidance angle has been used. Dragging will cause pain With Well Fitting Retentive Dentures Or Instability with poorly retained dentures. Pain is widely distributed, and only experienced on eating. Sore areas on buccal or lingual surfaces of the ridges or on the ridge crest .

95. (a) Existence of premature contact in the premolar region. ( b ) Irritation or hyperemic areas on the ridge crests. 1. Pain in the Premolar Region

96. a. Overextended flanges in the anterior area of the denture. 2. Pain at the Peripheral Regions of the Denture Pain in the anterior lingual margin of the lower jaw. There are two reasons for pain in the lingual margin of the lower jaw: The denture flange areas should be shortened

97. b. The presence of premature contact in the posterior region . As a result of the premature contact, the lower denture comes forward, causing pain in the lingual margin. Grinding is made, thereby determining the premature contact areas .

98. (a) A posterior premature contact, resulting in forward movement of the lower denture (dotted arrow), produces inflammation of the mucosa on the lingual aspect of the alveolar ridge in the anterior region. (b) Lateral displacement of the lower denture produces inflammation of the mucosa in areas closely related to the occlusal error.

99. This is mostly seen in the lower jaw, which has less supportive area. After being determined, the premature contacts arising from the occlusion are grinded until they are balanced. 3. Moderately wide, red, and painful diffuse area

100. Error in Eccentric Excursions Irritation of the Crest of the Ridge Localized Lesion Generalized Lesion Hyperkeratotic Ridge Occlusal Prematurity Lesion – same side as error

101. Severe disclusion of posterior teeth in excursions (lack of balance). Eccentric prematurities (protrusive or lateral)

102. Three-point contact in lateral movement. Three-point contact in protrusive movement

103. (a) Lack of balance on the posterior teeth in protrusive movement . ( b ,  c ) Providing balance on the posterior region in protrusive movement.

104. Mild : Chair side grinding or clinical remount. Gross : New dentures with balanced occlusion. Treatment

105. The sequence of steps should be as follows Restore the vertical dimension Re-establishment of C.O. Correction of working side occlusal errors. Correction of balancing side errors. Correction of protrusive relation.

106. p B If the cusp is high in centric and eccentric relation, reduce cusp. If the cusp is high in centric but not eccentric, deepen fossa. Re-establishment of Centric occlusion:

107. Correction of occlusion done by reducing buccal incline of upper Lingual cusp and Lingual incline of lower buccal cusp or deepening their corresponding fossae. p B Re-establishment of Centric occlusion: Do not grind the cusp tips unless it is high in every excursion, but rather reduce the fossa or inclined plane of the cusp .

108. After re-establishment of Centric Occlusion DO NOT Reduce maxillary lingual cusps. DO NOT Reduce mandibular buccal cusps. These cusps are essential to maintain the recorded vertical dimension DO NOT Deepen the fossae.

109. “LUBL rule on the balancing side "Bull rule on the working side " Correction of protrusive interferences Re-establishment of eccentric occlusion:

110. Briefly Occlusal VD is maintained by occlusion of palatal upper cusp and buccal lower cusp (in normal occlusion). Reduce cusps : If the cusp is high in centric and eccentric relation. Deepen fossa : If the cusp is high in centric but not eccentric. Re-establishment of C.O. BULL rule in: Working side interferences. LUBL rule in: Non-working side interferences. DUML rule in: Protrusive interferences .

111. Cheek and lip biting could be due to: Lack of horizontal overlap: Premolar and molar teeth that occlude edge to edge… grinding the buccal cusps of the mandibular posterior teeth. Pain resulting from Cheek and Lip biting Reduced VDO, cheeks tend to collapse into the occlusal area Incorrectly positioned occlusal plane . Monoplane teeth .

112. Monoplane . Heavy Bite . No Horizontal Overlap . Pain resulting from Cheek and Lip biting

113. a. Insufficient horizontal overlap on the posterior region. b . Irritation area on the cheek

114. The horizontal overlap prevents biting of cheek & lips. Horizontal overlap Beumer J, DDS, MS and Michael Hamada DDS: 16. Occlusal Schemes - Lingualized Occlusion Division of Advanced Prosthodontics, Biomaterials and Hospital Dentistry UCLA School of Dentistry.

115. a. Lack of horizontal overlap on the left posterior region of the lower denture . b. Existence of cheek biting . c. Providing adequate horizontal overlap in the posterior area by changing the position of teeth.

116. ( a ) Low vertical dimension . ( b ) Patient bites cheek even though there is sufficient overjet on posterior teeth. ( c ,  d ) Chronic cheek biting

117. Inadequate teeth arrangement, cheeks are supported by the denture base . Cheeks go between the teeth in cross bite . The solution is to make the upper denture base thicker . Cheek biting caused by cross-bite

118. Tongue biting could be due to : Reduced VDO. Arrangement of teeth lingually limits the tongue space > Cramped tongue. Too low occlusal plane. Irregular areas on the teeth or the lingual surfaces of the dentures base. Pain in the Tongue

119. a. Arrangement of teeth lingually limits the tongue space. b . Irritation area on the tongue caused by insufficient tongue space. If the area of the tongue is restricted, there might be pain related to cramps, and if the teeth are placed excessively to the lingual, the tongue could be bitten. There is intense burning sensation on the tongue. Pain resulting from tongue biting

120. Pain in the  TMJ The joints are complex structures consisting of tendons, muscles, and bone. Injury to any part of these structures can cause the symptoms associated with TMJ disorders.

121. Low VDO: Costen’s syndrome. High VDO: Insufficient interocclusal distance. Due to inaccurate jaw relation records . Incompatibility of centric occlusion and centric relation and Occlusal discrepancies. Poor fitting complete dentures > > can lead to jaw disc displacement, which can increase the risk of TMJ disorders. TMJ pain is generally caused by Pain in the TMJ

122. Clicking or Popping when moving the jaw. Problems moving the jaw or inability to move the jaw normally. Pain in the jaw that can occur with motion or rest Headaches and  neck pain. Ringing in the ears, dizziness, vertigo, or ear pain. The most common symptoms include: Pain in the TMJ and Ear ache

123. TMJ can be difficult to diagnose Because these symptoms can be vague and some of them, such as headaches or problems with the ears, may seem unrelated to the jaw or denture. Pain in the TMJ

124. Even dentures that are perfectly made can lead to problems if not worn at night, or if they are not replaced as needed. Just like ill-fitting shoes, poorly fitted dentures aren’t going to become more comfortable over time. Pain in the TMJ

125. Blood dyscrasia Thin wiry ridge Dentures may place stress on some of the muscles or tissues of the mouth ( Incisive papilla, Thin wiry ridge ). Inadequate tongue space . None acceptable vertical and/or horizontal relation. Presence of candidal infection. Allergy to denture material. Burning Sensation Incisive papilla (Burning mouth syndrome, BMS)

126. None acceptable retention and/or stability. Inadequate denture extension. Common sites are tongue and upper denture bearing tissues. Less common sites are the lips and lower denture bearing tissues. Burning Sensation (Burning mouth syndrome, BMS)

127. Commissural Chelitis and drooling saliva Inflammation of the angles of mouth. Attributed to excessive interocclusal distance. Too high occlusal plane of the lower teeth.

128. Commissural Chelitis and drooling saliva This prevents the regular action of the cheek from eliminating the saliva from the lower buccal vestibule, so saliva will exit through the corners of mouth indicating spread of infection to the angles of mouth. Advisable to construct new dentures.

129. Looseness of dentures or poor fit usually results due to lack of stability and/or retention of the denture. Denture movement over the mucosa will cause pain and areas of inflammation might be present. LOOSE DENTURE

130. Denture base (fit, contour & periphery) Occlusion Poor anatomy Poor denture fit LOOSE DENTURE

131. PPS is not successfully made. Lingually placed mandibular molar teeth Labially placed mandibular anterior teeth. Premature contacts and Occusal discrepancies. Lack of interocclusal distance. Higher occlusal plane than normal (tongue). Freedom in Centric. Use of cusped teeth on the atrophic crest LOOSE DENTURE The reasons of stability loss (Rocking , tilting dentures during function) are:

132. Faults in the polished surfaces Dryness of mouth. Inaccurate impression making. Use of cusped teeth on the atrophic crest Improper relief of hard structures. Nodules of acrylic on the fitting surface Poor processing techniques. LOOSE DENTURE The reasons of stability loss are:

133. Principle Always have the patient demonstrate how a denture loosens LOOSE DENTURE

134. Typical History Loose/discomfort immediately on insertion DENTURE LOOSENESS due to denture base defect

135. DENTURE LOOSENESS due to improper occlusion Typical History Adequate stability initially Gets worse with time

136. Treatment: According to the cause. Relining using tissue conditioner of old denture or Construct a new denture . LOOSE DENTURE

137. Pain on eating, gets worse with time. Pain / Ulceration lingual to lower anterior ridge. Pain / ulceration labial aspect of lower ridge and incisive papilla on upper ridge. Pain / Excessive vertical dimension. Prolonged over-closure, Costen’s syndrome. Cheek / lip biting / or Tongue biting. Pain in TMJ. And ear ache Burning sensation. Discomfort and pain Related to Occlusal Surface

138. • Patients can have multiple problems. Examples: • Denture base with sharp edge that doesn’t cause problems until occlusion causes tiling of denture. • OVD problem with an occlusal interference – makes symptoms worse. • Use history and exam to identify etiology. Remember !

139. Bruxism Increased V.D. CO # CR Oral hygiene Allergy Xerostomia With ill fitting denture base Eccentric occlusal interference Generalized tissue irritation Incompatible centric occlusion and centric relation, lower denture moves forward Remember !

140. Denture shifting anteriorly Increased VD CO # CR No contact on the other side Eccentric occlusal interference Clicking of teeth Another denture Grinding Grinding Generalized tissue irritation

141. Occlusion Occlusal interferences Over extension Border Ridge Spicules & remaining roots. Denture Pressure (PIP) Basal Seat Unpolished Tooth off ridge Localized tissue irritation Remember !

142. Single irritation point on the alveolar crest Malocclusion on the related area Ill-fitting denture base Acrylic pearls inside the denture base. Remember !

143. Why is it difficult to detect occlusal errors in the mouth? Negative attitude (assume an error exists and try to find it) What is the ideal occlusal contact ? At first contact, even maximum intercuspation at CR without denture shifting or instability & without pain. Remember !

144. Adjustment of Occlusion Intraorally • Contact on inclines can cause denture movement. • May cause pain, or reflex. • May make interference difficult to mark.

145. Adjusting Occlusion Reduces adjustment time. Saves time removing & replacing dentures. Remount denture on an articulator Eliminates denture movements. Can visualize interferences easily. Centric relation & protrusive records. Mark centric & excursive contacts, adjust.

146. Mounting the lower cast with new CJRR. Make sure the denture bases are not contacting posteriorly. Clinical Remounting Procedure

147. Barnes L (2009). Surgical pathology of the head and neck, vol. 1 (3rd ed.). New York: Informa Healthcare. pp. 220–221.  ISBN978 -0849390234 Cawson RA, Odell EW (2002).  Cawson's essentials of oral pathology and oral medicine (7. ed.). Edinburgh: Churchill Livingstone. pp. 275–276.  ISBN   978-0443071065 . de Arruda Paes -Junior, Tarcisio José; Cavalcanti , Sâmia Carolina Mota ; Nascimento , D. F.; Saavedra Gde , S.; Kimpara , E. T.; Borges, A. L.; Niccoli-Filho , W.; Komori, P. C. (1 January 2011).  "CO2 Laser Surgery and Prosthetic Management for the Treatment of Epulis Fissuratum " .  ISRN Dentistry.  2011 : 282361.  doi : 10.5402 /2011/282361 .  PMC   3170081 .  PMID   21991461 . Dorfman J, The Center for Special Dentistry.  http:// www.nycdentist.com /dental-photo-detail/2446/215/Oral-Pathology-Dental-Medicine-diagnosis-treatment-cyst James, William D.; Berger, Timothy G. (2006). Andrews' Diseases of the Skin: Clinical Dermatology. Saunders Elsevier.  ISBN   978-0-7216-2921-6 . Kahn, Michael A. Basic Oral and Maxillofacial Pathology. Volume 1. 2001. Laskaris , George (2003).  Colour Atlas of Oral Diseases . Theme. p. 216.  ISBN   9781588901385 . Naderi , NJ; Eshghyar , N; Esfehanian , H (May 2012).  "Reactive lesions of the oral cavity: A retrospective study on 2068 cases" . Dental Research Journal.  9  (3): 251–5.  PMC   3469888 .  PMID   23087727 . Neville BW, Damm DD, Allen CA, Bouquot JE (2002). Oral & maxillofacial pathology (2. ed.). Philadelphia: W.B . Saunders. pp. 440–442.  ISBN   978-0721690032 . Pocket Dentistry: Recall Procedure s, Fastest Clinical Dentistry Insight Engine, WordPress theme by UFO themes, Jan 19, 2015 | Posted by  mrzezo  in Prosthodontics. Scully C (2008). Oral and maxillofacial medicine : the basis of diagnosis and treatment (2nd ed.). Edinburgh: Churchill Livingstone. p. 352.  ISBN   9780443068188 . Thomas, GA (1993). "Denture-induced fibrous inflammatory hyperplasia ( epulis fissuratum): research aspects". Australian Prosthodontic Journal.  7 : 49–53.  PMID   8695194 . Yasemin   K .  Özkan : Complete Denture Prosthodontics, Post Insertion Problems in Complete Dentures, pp 145: 195. References

148. البر لا يبلى .. و الذنب لا ينسى .. و الديان لا يموت ... فاعمل ما شئت ... كما تدين تدان

149. Thank You