DentureProsthodontics
J Fraser McCord
Philip Smith and Sachin Jauhar
Complete Dentures Revisited
Abstract: The aim of the article is to assist practitioners in the diagnosis and management of complete denture problems by addressing
the problems from a theoretical viewpoint and in a clinically diagnostic way.
Clinical Relevance: To assist practitioners and undergraduates to understand the clinical basis of complete denture prosthodontics.
Dent Update 2014; 41: 250–259
In 1984, Applebaum wrote:1
“...a man with no eyes cannot
see, a man with no legs cannot run but a man Clinical Skills
with no teeth expects to eat and chew with
dentures as well as he did when he had
natural teeth.”
While the second statement
has since been disproved, via prostheses,
this aphorism is still apt when complete
dentures are considered. It underlines
the importance of appreciating the Dental Staff Patient Attitude
contribution the patient can make to the and Skill
success of dentures, in addition to the
overall value of the dental team operating
optimally. This is demonstrated in Figure 1,
which summarizes the four essential factors
involved in creating a good outcome for
complete denture treatment.
The foremost is of course
the patient and, unless the patient is
accepting of her/his edentulous state and,
Technical
Skills
J Fraser McCord, BDS, DDS, FDS DRD,
RCS(Ed) FDS(Eng), FDS RCPS(Glas), FCD(HK)
CBiol, FSB, Retired Professor, Stockport, Figure 1. The four basic components of the denture team. All four must contribute optimally for
Philip Smith, BDS, PhD, FDS DRD, MRD optimal results.
RCS(Ed), FDS(Rest Dent) RCS(Ed), Senior
Lecturer in Restorative Dentistry, Liverpool
Dental School and Sachin Jauhar, BDS,
further, is capable of some denture control, which patients cannot tolerate; they will also
MSc, MFDS FDS(Rest Dent), Consultant
then a favourable outcome is doubtful. doubtless recall examining patients who
in Restorative Dentistry, Glasgow Dental
Experienced clinicians will recall delivering have coped, or are coping quite well with
School, UK.
prosthodontically acceptable dentures dentures which fly in the face of conventional
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DentureProsthodontics
(prosthodontic) wisdom. The importance, of factors such as allergy, xerostomia,
therefore, of determining the expectations atypical pain and stomatitis/angular
and denture-wearing history cannot be cheilitis and TMJ Pain Dysfunction
under-emphasized. syndrome; although some of these affect
The purpose of this article is to function directly, there may be other
give guidelines as to the identification and symptoms which affect success of the
diagnosis of complete denture problems. dentures indirectly.
Intrinsically, there are
objective normative means by which
Diagnosis of complete denture problems may be diagnosed
denture problems and also indirect means via anamnestic
In their fine articles outlining symptoms related to the clinician. For Figure 2. This shows a typical ‘flabby’ ridge
the basics of complete denture simplicity, objective normative means (arrowed) which presents support problems that
prosthodontics, in 1983 Jocobsen will be confined to support, retention have an impact on (upper) denture stability.
and Krol listed and defined the three and stability. Guidelines to deductions
principal features as being: 2 from anamneses will also be presented
1. Support: that property of the in tabular form.
denture-bearing tissues which resists
movement of the denture towards
these tissues. Theoretical recognition of
2. Retention: the resistance to complete denture problems
displacement of the denture base Recognition of support problems
away from the ridge (this might more It is not the purpose of this
appropriately be termed the peri- article to carry out a resumé of the oral
denture tissues). and facial anatomy relevant to complete
3. Stability: the resistance of the denture prescription; nevertheless,
dentures to horizontal or rotational it could be argued that this facet should Figure 3. This shows areas of blanched tissue
forces (perforce, this is a paradigm be the easiest for the practitioner which indicate potential support problems which
of muscle and occlusal harmony or to identify. may be detected on palpation.
‘balance’). The absence of well-defined
While all three of the above ridges means that, in theory, there is
have implications on function, there are, less denture-bearing tissue to carry the
additionally, several other areas which functional loads and this should highlight
need to be considered: problems of support. Careful examination
Appearance: while aesthetic dentistry of the denture-bearing areas of both
has developed into an apparent sub- arches is therefore required but this does
specialty, this invariably falls into the not mean a reliance on visual scanning.
domain of Operative Dentistry and the This will give little meaningful information
art of complete dentures has received on the ability of the denture-bearing
scant attention since the days of Frush tissues to withstand pressure7 (although
and Fischer3 (1956–1959). More recent it may draw the clinician’s attention to
reviews, by Smith and McCord4 and potential problems (Figure 2). Figure 4. This shows the presence of a torus and
Critchlow et al,5 mention the need to also a spur of bone near the (left) canine area.
Further assessment, for
involve the patient in formulating the example by digital pressure over the
appearance, even as far as allowing dental-bearing areas, is therefore essential
the patient to take the try-in home to identify where problems are (Figure 3).
for approval (if he/she so desires). This will help the clinician to plan which
Unfortunately, no hard and fast rules impression material to use (vide infra) in
apply and, in 2012, Cooper et al6 addition to helping her/him to prescribe
demonstrated significant differences appropriate relief if required, eg over a
between aesthetic perceptions among torus or bony prominence (Figure 4).
dentists, technicians and patients and
also recommended that the ‘individual
variability in patient response should Recognition of retention problems Figure 5. The presence of a muscle attachment
be taken into account during treatment Retention of complete on the ridge (arrowed) means that a peripheral
dentures is principally achieved via seal is impossible. Stability will also be
planning’ of complete dentures.
a peripheral seal; anything which compromised.
Miscellaneous: this covers a variety
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DentureProsthodontics
prevents/impairs the potential for a caused by clinical displacement of the
peripheral seal therefore should be mandibular denture in accordance
identifiable as a potential problem in with the principles of an inclined plane
the successful prescription of complete (Figure 10). It is perhaps prudent here
dentures. High muscle attachments, to indicate that, while the authors
which are attached to the crest of a accept that it is highly unlikely that
ridge, therefore will not only affect clinicians will be able to prescribe
stability of a denture, but will make balanced articulation clinically, the
the achievement of a peripheral seal minimal requirement, prosthodontically
impossible (Figure 5). Similarly, the speaking, for complete dentures is
presence of a palatal fissure in the balanced occlusion in Retruded Contact
postdam area will present problems Position (RCP). As instability occurs when
which will require modification of the spaces occur between dentures, then
master cast (vide infra) (Figure 6). In the concept of balanced articulation
the same way that digital pressure is was introduced as a means of improving Figure 6. The presence of a palatal fissure
recommended in the identification of stability. This should be achievable on (arrowed) means that a peripheral seal is
support problems, it is recommended all cases on an articulator. Sadly, semi- impossible. The master cast will require to be
that the clinician determines the relative adjustable articulators do not equate modified.
displaceability of the tissues of the to the ginglymo-diarthrodial TMJ
post dam, as there tends to be more apparatus of patients and true balanced
glandular and connective tissue laterally articulation is probably achieved only
than there is centrally (Figure 7). rarely. This, however, should not mean
Although it has been stated that the clinician does not aspire to
that the principal factor in retention is achieve it!
peripheral seal, proximity of fit of the In addition to the above,
denture base to the tissues is also of good common sense and careful history-
importance, as is surface tension; factors taking might alert the clinician to the
influencing these may also therefore potential for denture-wearing problems.
affect the retention of a complete Figure 11 shows a patient who obviously
denture. This will be dealt with later. wears spectacles. The pressure of the
spectacles on the keratinized tissues
on the bridge of the nose would lead
Recognition of stability problems one to be sceptical about the ability of
As was described earlier, the (non–keratinized) tissues overlying Figure 7. The post dam area exhibits differing
stability of complete dentures, if the residual ridges to withstand robust areas of thickness which ought to be so identified
achieved, is a paradigm of muscle oral function; this is also a useful guide on the master cast. This is the responsibility of
balance and occlusal balance. The to the biological age of the patient. the clinician.
achievement of successful stability The mention of function does raise the
is, in the opinion of the authors, important question of what functions are
the single-most difficult thing for being sought. If we include appearance
a clinician to achieve. While careful as a function (strictly speaking it is not),
impression techniques may ensure a then there are four principal functions of
good peripheral seal, eccentricities of complete dentures:
muscle form may displace a proficiently 1. Speaking;
made denture. On the other hand, 2. Eating (chewing and clenching);
patients with neuro-muscular diseases/ 3. Swallowing;
conditions may have uncontrollable 4. Appearance.
tremors which make it almost impossible Although the diagnosis
to achieve acceptable muscle balance. of these problems in these areas will
While not all occlusal problems may be be dealt with later, it is important to
overcome, each clinician should be able determine the functional needs of a
to identify where occlusal tables are too patient before commencing treatment.
long (Figure 8) and too broad (Figure Speech problems may not always be Figure 8. The occlusal plane here is too long
as the second molar is encroaching on the
9). In addition, where prosthodontic treatable via replacement dentures and
ascending portion of the ridge; this overextension
guidelines are disregarded and not all foods may be tackled as with a
will induce a protrusive slide on closure by dint of
inappropriate occlusal planes are natural dentition; nevertheless, it would
an inclined plane effect.
prescribed, the result can be instability be sensible to know how a patient
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Figure 9. The occlusal plane here is too broad Figure 10. The occlusal plane here drops
and the presence of lingual undercuts (arrowed) posteriorly. This would impart a protrusive slide
will induce instability. from RCP.
Figure 11. Note the inflamed nature of the
tissues under the nose rests of the spectacles.
This may indicate that the biological age of the
patient is greater than the chronological age and,
eats. By giving a patient a biscuit and Speech problems: relate principally therefore, consideration should be given to the
observing how he/she eats; a guide to to appropriate freeway space and also denture-supporting tissues.
posterior tooth form may be gleaned. labio-dental sounds; the appropriate
If mandibular movements are vertical, positioning of the maxillary teeth is
then it may be quite acceptable to critical.
prescribe flat-cusped teeth. If, however, Miscellaneous problems: these range
ruminatory movements take place, then from problems of appearance to social References
cusped teeth will be required to prevent problems to problems of more obscure 1. Appelbaum M. Plans of occlusion.
destabilizing spacing between dentures. origin, eg allergy. Dent Clin N Am 1984; 28: 273–276.
In conclusion, although it is For simplicity, these 2. Jacobsen TE, Krol AJ. A
recommended that the clinician is aware complaints will be presented in tabular contemporary review of the factors
of the philosophical basis of complete form (Table 1). involved in complete denture
denture prosthodontics, such problems As is normal in clinical retention, stability and support. J
rarely fall into one category and care has practice, however, diagnosis is just part Prosthet Dent 1983; 49: 5–15; 165–
to be taken to take into account what of the problem. The next problem is how 172; 306–313.
the clinician sees but also what he/she to manage the problem (more often 3. Frush JP, Fisher RD. Complete dentures:
palpates and hears. For that reason, the it is more than one problem) and this the dynesthetic interpretation of the
next section in this article will be on article has given a brief introduction to dentogenic concept. J Prosthet Dent
diagnosis of symptoms reported by the most of the common ones and readers 1958; 8: 558–581.
patient (anamnestic reports). are referred to a standard textbook 4. Smith PW, McCord JF. What do
The symptoms will relate of Prosthodontics7 for more detailed patients expect from their complete
to commonly presenting symptoms coverage of the matter. dentures? J Dent 2004; 32: 158–170.
such as: 5. Critchlow SB, Ellis JS, Field JC.
Looseness: this is typically the Reducing the risk of failure in
mandibular denture but may also be Conclusion complete denture patients. Dent
the maxillary denture, especially if This manuscript has been Update 2012; 39: 427–436.
copious easing of undercut areas has written in an attempt to facilitate diagnosis 6. Cooper GE, Tredwin NT, Cooper
been performed, or in cases where of complete denture. Reference has been NT, Petrie A, Gill DS. The influence
considerable residual ridge resorption made4,5,6 to the need to take the patient’s of maxillary central incisor height-
has occurred. views into account before commencing (as to-width ratio on perceived smile
Pain: again this is commonly associated well as during) the provision of dentures. aesthetics. Br Dent J 2012; 212:
with atrophic mandibular ridges but may A recent article, however,8 raises the 589–599.
be a feature of undercut ridges, retained question of the need for practitioners 7. McCord JF, Smith PW, Grey NJA.
roots, tori or induced support problems to keep abreast of the literature as this Treatment of the Edentulous Patient.
(eg surface imperfections on newly- critical systematic review of the literature London: Elsevier Books, 2004.
prescribed dentures). Lack of appropriate indicated that, while some patients 8. Carlsson GE, Örtorp A, Omar R.
freeway space is also classically described. may benefit from traditional elaborate What is the evidence base for the
Problems eating: this may be a techniques and impression materials, for efficacies of different complete
consequence of problems of support, many patients, simple techniques have denture impression procedures? A
retention and stability and needs careful been demonstrated to serve the needs of critical review. J Dent 2013;
assessment. many edentulous patients. 41: 17–23.
April 2014 DentalUpdate 255
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Table 1. (1–5) Identification of denture problems from symptoms reported by patient (pre-construction of C/C).
1. Looseness of Dentures
Descriptor Likely Cause
All the time, lower only May be under- or over-extended. Occlusal surface may be too large. May have high
muscle attachments, ie retention and stability problems. May require template dentures.
All the time, both As per above, but loose maxillary denture may also have a support problem (eg flabby
anterior ridge).
On eating – lower only Occlusal problem most likely – may be related to position of maxillary anterior teeth.
On eating – both Unlikely to be solely occlusal with the upper – probably muscle balance problem.
After a time (2 hours post insertion) Likely to be related to tissue contact and possibly salivary flow. Is patient on diuretic
medication or is he/she diabetic?
‘When I purse my lips’ Likely to be a consequence of lack of appropriate border moulding.
‘When I talk’ Stability problem. Could be problems associated either with over-extension of the
denture base or the occlusion.
2. Pain
Descriptor Likely Cause
On insertion May be a support problem, eg retained root, undercut, torus or a pearl of PMMA on tissue
surface of denture.
On insertion and removal Undercut(s)
On eating May be support or stability (over/under-extension) or occlusal problem. May be neural, eg
pressure on mental nerve(s).
On yawning Posterior buccal flange is impinging on coronoid process(es).
As day progresses This is pathognomonic of insufficient freeway space (FWS).
All the time Likely to be support problem such as atrophic mandibular arch.
Even with C/C out Do not start treatment. Should have this investigated by a consultant in oral medicine.
3. ‘Can’t eat’
Descriptor Likely Cause
‘Painful to eat’ Most likely reason is support, directly as in an atrophic ridge but could be under-
extension of denture base. Occlusal causes also likely.
‘Dentures move’ Muscle imbalance and/or occlusal imbalance likely.
‘No room to eat’ Likely cause is inappropriate freeway space.
‘Teeth lock’ Inappropriate selection of posterior teeth. May also be poor positioning of anterior teeth,
creating a locked occlusion.
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4. ‘Can’t speak clearly’
Descriptor Likely Cause
‘Dentures too big’ Periphery perhaps over-extended. Perhaps too big a change from previous denture.
‘Dentures move too much’ Check for over/under-extension of lower denture.
‘Sounds muffled’ Check for sufficient freeway space/closest speaking space. Also check for appropriate
restoration of upper lip.
5. ‘Don’t like them’
Descriptor Likely Cause
‘Don’t like the look of them’ May happen even after several trial visits. If the dental team has worked accurately, may
be a good time to exit!
‘Don’t like the colour’ Sometimes bleaching of the bases can occur when dentures are placed in bleach or
boiling water.
‘My family don’t like them’ This highlights the importance of determining what the needs and expectations are.
Again a good reason where indicated, to prescribe a template technique.
‘Experiencing burning sensation’ May be an allergic response or Burning Mouth Syndrome – refer to consultant in oral
medicine.
‘Don’t like the overlap’ Patients may not realize that wear of older dentures occurs and that overjets (anterior and
buccal) are reduced. Clinicians should explain what they are attempting to do by way of
rehabilitation.
‘You’ve given me fewer teeth than my old Sometimes, and for perfectly good reasons, a clinician will not prescribe 2 premolars and
dentures’ 2 molars in each posterior quadrant. Patients should be told why this is being done – they
will certainly be aware of the difference!
Table 1. (1–5) Identification of denture problems from symptoms reported by patient (pre-construction of C/C).
April 2014 DentalUpdate 259
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