troubleshoting in Complete Denture final.pptx

troubleshooting in complete denture

1. Troubleshooting in Complete denture prosthesis JOURNAL CLUB Kashyap Sawant

2. Introduction Complete dentures often require adjustments to the oral cavity during insertion or post insertion appointments. Greater experience and more training are required to accomplish both proper relief of pain from dentures and denture correction than are required for the initial construction.

3. This article has been published in four parts:- Part 1 :- Oral mucosa and border extensions Part 2 :- Lesions of the oral mucosa and their correction Part 3 :- Traumatic Injuries Part 4 :- Proper adjustment procedures

4. Part 1

5. Part 1 :- Oral mucosa and border extensions Diagnostic problem solving :- Depends on observation , artistic skills and scientific preparation . To treat a disease , knowledge of the disease is necessary Knowledge of the disease is based on the understanding of the etiology

6. Modes of correctional procedures:- Etiological mode Empirical mode Etiological mode uses knowledge of disease's cause and therapeutic agents' action. Empirical mode provides cures/improvements without understanding why. Eg:- Relieving a denture at the wrong position may make it more unstable as it will lose its basal seat support

7. The surface form and structure of the mucosa, its consistency, color, looseness and turgescence, degree of keratinization or cornification, and its many other physiologic attributes should be studied carefully Differential diagnosis between normal and abnormal mucosa is important.

8. Types of oral mucosa Masticatory mucosa: Covers alveolar ridges, attached to bone, endures mastication. Specialized mucosa: Covers dorsal tongue surface, with various papillae. Lining mucosa: Thin epithelium, variable submucosa, found in different zones.

9. Masticatory Mucosa and Palatal Vault It covers both alveolar ridges and is attached directly and rigidly to the periosteum of the underlying bony structures. It endures pressure and friction during mastication Palatal vault : dense bands of connective tissue present between the masticatory mucosa and periosteum During mastication, food is thrown and held firmly against palatal vault

10. Protective qualities present in masticatory mucosa Upper layer of stratified sq. epithelium is highly keratinized, and the lowest layer is attached firmly and rigidly to the periosteum. The high degree of physiologic keratinization imparts greater resistance to pressures of various kinds and magnitudes, while the firm attachment is also a protective device.

11. presence or absence of a distinct submucous layer permits the subdivision of the masticatory oral mucosa Masticatory mucosa is further divide into Cushioned zone :- present in hard palate contains adipose tissue anteriorly and mucous glands posteriorly This layer acts as a hydraulic cushion Non-cushioned zone :- it consists of the gingiva and the mid palatine raphe.

12. Specialized mucosa Dorsal tongue surface has varied papillae, some with taste buds. Classification of papillae based on shape and function Filiform papillae Fungiform papillae Circumvallate papillae

13. Lining mucosa Thin, lightly/ c ornified epithelium; thin lamina propria. Variable attachment to underlying structures Firmly attached in muscles (buccinator , orbicularis oris ) but is highly elastic Lacks submucous layer in ventral surface of tongue Loosely attached in vestibular fornix region safeguarded from injury due to these features

14. Pathologic Conditions Induced by Dentures Each type of mucosa reacts differently to injury according to location Each manifests a distinct type of ulceration irritation and vascularization.

15. Acute and chronic soreness can be divided acc. To location into :- Situated in lining mucosa caused by overextension situated on masticatory mucosa caused by traumatic occlusion of various types situated on the specialized mucosa and caused by tongue biting or by friction of the dorsal surface of the tongue against the occlusal surfaces of the artificial teeth situated on the undersurface of the masticatory mucosa and caused by friction of the mucosa against the underlying bone.

16. Acute traumatic lesions in the lining mucosa Slit-like fissures in the lining mucosa Varied length and depth according to the particular zone and amount of overextension of denture Largest fissure ulcerations  caused by overextension of the distolingual border of the lower denture In severe acute conditions the fissure sloughs at its periphery and is intensely red at the base.

17. Curtain connecting soft palate to the tongue medially palatoglossus muscle and laterally by pterygomandibular raphe curtain moves with all movements of the tongue and muscles of the floor of the mouth

18. There exists a 2-3 mm neutral zone at the junction of masticatory and lining mucosa which is slightly mobile and has properties of both mucosa is movable and soft only to the extent that it can adapt and mold itself against the denture borders and impart a border seal. It is not so resistant and elastic that it would tend to displace the denture. The denture borders should extend till the neutral zone.

19. PPS is an area of meeting of masticatory and lining mucosa Neutral zone can be extremely narrow in this region postpalatal seal should displace only the neutral zone between the hard and soft palate Overextension  causes a slitlike or irregular, pressured ulceration.

20. Adjustment of Dentures for Border Overextension Dentists tend to over reduce the overextension because the patient is in pain If a convex area of the denture border causes a 1 cm. Long ulceration, the dentist should not reduce the border of the denture by that same amount. In reality, the original irritation is probably caused by the most convex middle 3 mm of the border. So the length of the denture border to be reduced should be 3 mm Proper border reduction prevents underextension and damage.

21. The depth of relief should be as shallow as possible. Frequently 0.5 mm. of relief in depth is adequate According to the author , the patient shouldn’t be completely pain free, patient should only state that pain is slightly reduced.

22. Two fissure-like ulcerations in the adjacent lining mucosa can be observed in instances of considerable overextension of the extreme distal end of the lingual border of the lower denture. caused by tongue movements to the right and left side, and are usually found close and parallel or concentric to each other. Reduction should be such that it remains 2 mm below the mylohyoid ridge In the alveololingual sulcus , ulcerated fissure is caused by movement of mucosa against the denture border , rolling off the border is sufficient.

23. If a certain irritated spot is suspected upon visual examination, a digital examination should follow for verification. procedure after ascertaining denture overextension:- The denture spot corresponding to the irritation in the mouth is determined by careful examination of the denture and is marked on the denture border with an indelible pencil. The oral mucosa of the affected area is dried and the denture is replaced quickly with pressure. Denture border is judiciously reduced after this and polished highly

24. Part 2

25. Traumatic occlusion Traumatic occlusion refers to a misalignment of the teeth that interferes with natural jaw movements. This misalignment can occur either horizontally, affecting lateral and protrusive jaw movements, or vertically, when teeth do not make even contact in the centric occlusion position Horizontal induces pain and discomfort Vertical causes hinderance in the bite

26. Traumatic lesions of the masticatory mucosa Lesion often appears round or irregular shaped Not slit-like in form Detecting such lesions requires careful examination, with digital assessment proving more effective than visual inspection. The presence of pain can be indicated by muscle quivering upon gentle touch

27. Procedure :- The identification process involves marking the denture and transferring the mark to the mouth if coloring matter remains within a small, concave area on the mucosa, it confirms the presence of a traumatic ulceration caused by occlusal issues. may also arise due to friction between the lower denture and the lingual slope of the ridge.

28. Addressing these traumatic lesions requires a thorough understanding of the oral anatomy, occlusion, and proper adjustment techniques. Timely recognition and management of these lesions are essential to prevent further discomfort and complications.

29. Traumatic Lesions of Specialized Mucosa of the Tongue They can develop on the specialized mucosa of the tongue due to various factors, such as tongue biting, friction against denture surfaces, or improper tooth placement. Poorly aligned dentures can restrict tongue movement, leading to issues in speech and swallowing.

30. If upper teeth are set too far lingually off the ridge especially lingual cusp of the 1st premolar The tongue in this situation, may not be able to assume a position of rest in the oral cavity proper because of lack of space for it to stretch and relax. The only direction the tongue can expand or extend is toward the throat, and breathing is made less comfortable. the lingual cusps of premolars can often be reduced and polished thoroughly in order to provide the needed space for the anterior third of the tongue.

31. Anterior third of the palate may handicap dorsal surface of tongue because Denture base is too thick Artificial rugae are excessively high. Insufficient vertical dimension of occlusion may lead to frequent and excessive friction of dorsal surface against denture base

32. Adjustments should focus on maintaining a balanced occlusion to allow natural tongue movements. (neutral zone) The careful reduction of lingual cusps and adequate relief on the palatal vault can alleviate discomfort and improve denture stability. Denture construction should consider the physiological and anatomical aspects of the tongue, ensuring that artificial teeth facilitate normal functions without causing irritation or friction.

33. Traumatic Lesions of Undersurface of Masticatory Mucosa Loose masticatory mucosa can lead to significant problems for denture wearers. When the mucosa is detached from the underlying bone due to periodontal disease or traumatic occlusion, it can cause discomfort, pain, and inflammation. This situation results in denture instability and friction, leading to further damage to both mucosal tissues and alveolar bone

34. Detecting and treating loose mucosa is challenging, as early signs of inflammation may not be readily visible. Differentiating between loose mucosa, hypertrophied gingival tissue, and movable cartilage-like tissue is essential.

35. Treatments involve careful relief adjustments during denture construction and striving for balanced occlusion to minimize denture movement. In certain cases, surgical intervention may be necessary to ensure optimal denture support Maintaining the integrity of the masticatory mucosa is crucial for denture stability, patient comfort, and overall oral health

36. Etiological classification Acute and chronic inflammatory conditions can be classified on the basis of their respective etiological factors :- Neuromuscular traumatic injuries arising from dentures with or without balanced occlusion. Traumatic injuries of the oral mucosa resulting from traumatic occlusion of various kinds. Inflammatory conditions of the oral mucosa resulting from the mere presence and action of the denture as a foreign body. Poor oxidation and ventilation of oral mucosa covered by dentures.

37. Inflammatory conditions of the oral mucosa resulting from inadequate retention of the dentures. Inadequate resistance of the oral mucosa caused by various systemic diseases. Inflammatory conditions of the oral mucosa induced by endocrinologic and nervous disturbances of various kinds. Inflammatory conditions of the oral mucosa caused by accumulation of infectious material on the undersurface of the dentures.

38. Chemotoxic injuries to the oral mucosa caused by denture-base materials. Poor nutrition and avitaminosis of various kinds. Allergic reactions of the oral mucosa to denture-base materials.

39. Part 3

40. Neurogenic Traumatic Injuries Neurogenic traumatic injuries have been a relatively understudied topic in dental literature, yet they hold significant implications for mucosal disorders. Individuals with pronounced neurotic tendencies may channel their nervous tensions through aggressive behaviors like grinding, gnashing, and forceful biting with dentures.

41. Relation to bruxism While there are similarities between neurogenic traumatic injuries and bruxism, they diverge in key aspects. Bruxism, particularly with natural teeth, often represents a local manifestation of a broader condition involving conscious and unconscious aggressive tendencies. In contrast, neuromuscular traumatic injuries, frequently associated with dentures, can result from factors like malocclusion in centric and eccentric positions.

42. Establishing the root cause, whether habit formation or deep-seated psychoneurosis, is essential for effective treatment. Grinding, gnashing, and biting forcefully with dentures also may be due to a deep-seated neurosis, but frequently is attributable to the dentures themselves. Malocclusion in centric and eccentric positions of newly constructed dentures may lead to the habit of grinding and gnashing.

43. Excessive muscular forces Occlusal interferences in centric and eccentric positions are largely remediable. The most troublesome denture adjustments are those in which the magnitude of forces of the patient’s muscles is out of proportion to the tolerance of the oral mucosa. There can be no control over the forces that the patient’s muscles of mastication exert upon the dentures.

44. One has only to visualize a patient whose natural teeth have undergone considerable attrition. Whether this attrition is neuromuscular in origin (when the patient is emotionally involved) or physio muscular (when there is application of excessively strong, natural muscular forces during mastication) The destructive effect upon the tooth substance or periodontal structures is severe.

45. Treatment :- The highest type of balanced occlusion must be attained. The buccolingual diameter of the posterior teeth should be as narrow as possible. The vertical dimension of occlusion is reduced, below what would otherwise be considered normal, for severe problems. Mucosal irritations are relieved as soon as they appear Removing the dentures from the mouth for an hour or so affords the tissues a rest and gives some relief to the patient.

46. Constructing two lower dentures to the same upper denture permits frequent interchange of the dentures. The sharp bony projections in the lower anterior segment of the ridge should be relieved with tin foil in accordance with a definitely established procedure. The patient may be advised to suck on diabetic candy as a decoy against grinding his teeth. Psychotherapy may be instituted to improve the patient’s emotional status. Tincture of Merthiolate (1 : 1OOO) is prescribed for painting the irritated mucosa in order to afford temporary relief from pain. (not used now)

47. Traumatic injuries caused by traumatic occlusions Traumatic occlusion in a vertical direction occurs when the patient closes the mouth and some of the occlusal surfaces of the artificial teeth come into contact prematurely . The deflective occlusal contact may be limited to one tooth, to one cusp of one tooth, or to many teeth-the entire right side, the entire left side, all of the anterior teeth, or, as it most frequently happens, the last molars on both sides. The severity ‘of the injury and the intensity of the pain depend upon the nature of the trauma, the teeth involved, and the susceptibility of the patient.

48. Traumatic occlusion in a horizontal direction implies that the trauma to the supporting structures is caused by the interferences which the mandibular teeth encounter when gliding in contact over the maxillary teeth. This usually occurs when the centric occlusion of the teeth is not associated with the centric relation of the jaws. When the patient closes in centric relation, he encounters cusp interferences that force him to glide the dentures into abnormal relations and cause trauma to the supporting structures, when high-cusp teeth are used and no consideration is given to balanced occlusion, cusp interference in lateral and protrusive movements happens

49. Part 4

50. Proper Adjustment of New Dentures: Ensuring Comfort and Relief The adjustment of new dentures is a crucial aspect of providing relief from pain and discomfort for denture wearers. Achieving this relief necessitates accurate diagnosis and understanding of the patient's experiences.

51. Addressing the following questions becomes essential: Identifying Pain Patterns: Is the pain localized or widespread? By pinpointing the pain's specific location, we can better diagnose and treat the underlying issue. Pathologic Characteristics: Can the source of pain be linked to observable features such as vascularization, irritation, or ulceration? Recognizing these characteristics aids in determining the cause of discomfort.

52. Specific or Vague Complaints: Does the patient describe precise soreness or a general discomfort on one side of the mouth? Distinguishing between specific and vague pain descriptions helps in targeted treatment. Extent and Nature of Pain: Does the patient experience acute, severe pain, or a more dull and depressing sensation? Understanding the nature of pain aids in gauging its severity and potential causes.

53. Treating traumatic occlusions A diffuse inflammatory condition over an extended area of the lower ridge is caused frequently by premature contact of the posterior teeth on the affected side. This inflammation is characterized by redness, with dispersed small granulations over the entire area.

54. Mandibular lesions lesion of the masticatory mucosa on the lower ridge may be small and circumscribed, with a minute ulceration in the center. lesion may be caused by displacement of the tissue by the impression, or by premature contact of one high cusp. If denture base is at fault it is reduced and if a high cusp is responsible dentures are remounted and cuspal heights are reduced

55. Longitudinal lesions which measure about 1.5 cm. in length and 5 to 6 mm. in width also occur on the lingual slope of the lower ridge. The surface texture is rough, and a thin, white surface membrane is about to exfoliate from the ulcerated area. The tissue under the membrane is raw, red, and inflamed. The lesion is located by means of an indelible pencil and the denture base is reduced about 0.5 mm in depth with a round bur. The patient is instructed not to wear the dentures for 24 hours, to use a mild alkaline mouthwash, and to return for observation 48 hours after the denture has been worn.

56. Maxillary lesions There are certain zones on and about the palatal vault that are afflicted frequently by sores . One of these zones is the torus palatinus In former years, large “suction” chambers were placed over the large area of the palatal vault, including the torus. Now the torus palatinus is relieved either on the cast or in the impression, but in most instances the relief is excessive.

57. If no relief were provided for the tori, upper dentures would be more stable because the palatal vault is the most important retentive area for the upper denture Furthermore, if the upper ridge is either flat or flabby, the average torus palatinus becomes the most important anchor for stability of the upper denture. However, should the upper denture settle upon its supporting structures (as most dentures do), premature contact between the tissue surface of the denture and the most prominent point of the torus is inevitable.

58. The denture should be relieved for the torus in the adjustment period, when it is more feasible to determine the amount and rate of settling. Premature contact should be relieved as it appears, but the physiologic contact between the torus palatinus and the denture should be fully preserved.

59. It has 2 methods Functional method :- hard part of the torus is marked with inedible pencil intraorally and intaglio surface of denture is coated with white compound and flamed and tempered Denture is placed firmly against the palate Pencil mark is transferred on the white compound in premature contact areas functional method of relieving the torus palatinus is indicated definitely when providing retention and stability of the upper denture represents a serious problem.

60. Preventive method :- Relief of the torus by scraping the impression or by placing tin foil on the cast upon which the denture is to be constructed pterygomaxillary or hamular notch, particularly its buccal aspect, also is susceptible to injury blunt instrument may be used to locate the exact spot of the initial injury, and only the corresponding limited spot should be reduced on the denture.

61. Dentures as Foreign Bodies: Individualized Care and Adaptation Dentures can impact oral tissues as foreign bodies, leading to various reactions. Some patients experience hypersalivation or dry mouth upon denture insertion. Patients' responses vary, and individualized care is essential. Factors such as wearing dentures at night, adaptation to tongue placement, and mastication capabilities differ among patients. Both physiological and psychological factors play roles in denture adaptation and comfort.

62. Summary In conclusion, ensuring the proper adjustment of new dentures requires a comprehensive understanding of the patient's experiences and needs. By addressing specific pain patterns, occlusal issues, and mucosal lesions, dentists can provide targeted relief and promote optimal denture functionality.