1. Trouble Shooting Complete & Removable Partial Dentures
Robert W. Loney, DMD, MS
Professor & Chair
Dept. Dental Clinical Sciencs
Faculty of Dentistry, Dalhousie University

2. The Gunshot Approach
If it hurts - GRIND
If its loose - RELINE

3. Problem for Albert Einstein
Avert Imminent World Disaster
Time Constraint: One Hour
His solution:
55 minutes identifying problem
5 minutes fixing the problem

4. Lesson
Spend more time thinking
Spend less time grinding

5. Five Principles For Troubleshooting
Establish differential diagnosis
Identify variations from normal
Have patient demonstrate problems
Always use indicating medium when adjusting
Have patient rate improvement after adjustment

6. Principal 1 Establish a Differential Diagnosis
Form a list of possible causes
Try to prove problem is not caused by “X” by eliminating possible causes
Expect resolution within days
If no resolution, eliminate something else

7. Principle 1: Differential Diagnosis
Prioritize from common to rare
Eliminate common etiologies first, because:
Common things occur commonly
Rare entities occur rarely

8. Differential Diagnosis: CD or RPD Pain
Occlusion
Remount, Articulating Paper, Adjust
Denture Base
PIP, Adjust
Vertical Dimension
Time to Adapt,
Reset Teeth
Infection
Tests, Referrals,
Medications
Systemic Condition
Allergy
Patch Tests, Referrals,
Change Materials
Occlusion
Denture Base
Vertical Dimension
Infection
Systemic Condition
Allergy
Attempt to eliminate problem.
Re-evaluate results in days

9. Principles of Diagnosis
Don’t limit list too early in diagnosis
Keep an open mind
Revisit possible causes when contradictory evidence is found

10. Information Gathering
Chief Complaint
History of C.C.
History
Medical
Dental
Clinical Exam

11. Dental and Medical History
Often inadequately investigated
Spend more time talking to narrow possibilities

12. Gathering Information
Ask open ended questions:
“How does that feel?”
Not
“Does that feel better?”

13. History of Chief Complaint Where?
Have patient point to problem
Partially ignore patient’s position
Dentist locates with stick, instrument or paste

14. History of Chief Complaint When?
Chewing only - Occlusion
Gets worse throughout day - Occlusion
When first insert dentures - Denture Base
Pressure on 1st molars - Denture Base

15. History of Chief Complaint Details
How long?
does it last?
since it began?
Anything make it better/worse?

16. Principle 2: Identify Variations from Normal : Tissues & Dentures

17. Prominent Midline Fissure, Soft Palate
Loose Denture:
Prominent Midline Fissure, Soft Palate

18. Dealing with Variations From Normal
If denture alone is not normal
Correct it
If anatomy/patient not normal
vary method to address variation

19. Principle 3: Have Patient Demonstrate Problem
Eliminate cause - should resolve in days

20. Principle 4: Always Use Indicating Media
Never adjust without locating exact position of the problem
Use paste, indelible stick, or articulating paper

21. Principle 5: Rate Improvement
After adjustment
Ask patient to rate improvement
0%-100%

22. Principle 5: Rate Improvement
100% Perfect Now
75% Feels a lot better
Better when:
Sigh of relief
‘Yes!’
‘You got it’
50% Better, but still not right
0% Still Same, Can’t Tell

23. Denture Pain CD & RPD Occlusion Denture base (fit & contour)
Vertical dimension
Infection
Systemic disease/condition
Allergy (rare)

24. Most Overlooked Problem
Occlusion
Don’t want the problem to be occlusion - so we look for other causes

25. Occlusion Takes time to remount (prep time) Reduces adjustment time
Net savings of time

26. Pain: Occlusion Diagnostic Strategies
Eliminate as potential cause
Remount denture on an articulator
Centric relation & protrusive records
Mark centric & excursive contacts, adjust

27. Don’t Adjust Occlusion Intraorally
Contact on inclines can cause denture movement
May cause pain, or reflex avoidance
May make interference difficult to mark

28. Adjusting Occlusion Intra-Orally
Net Result
Can’t see real Problem
Can’t eliminate Problem

29. Adjusting Occlusion Use an articulator Eliminates denture movement
Can visualize interferences easily
Saves time removing & replacing dentures

30. Pain: Occlusion Dental History & Exam
No pain when press firmly on1st molars
Only when chewing
Causes tilting, twisting, tipping, sliding
Gets worse with chewing
Gets worse during the day
May have to remove late in day

31. Pain: Occlusion Diagnosis: Pain from Denture Base
If pain upon pressing firmly on 1st molars
Adjust denture base first until no pain
Use finger pressure
Do NOT use occlusion to apply pressure
Occlusion could introduce tipping forces

32. Pain: Occlusion Diagnosis - Chew Test
Chew on cotton ball size of a pea
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

33. Pain: Occlusion Clinical Exam
Patient demonstrates problem by biting where pain occurs
Ulcer or sore spots on sides of ridges

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

35. Pain: Occlusion Avoid Contact on Inclines
Don’t set teeth set ascending portion of ramus

36. Occlusal Point of LoadingM D L B C
Browning, JPD 1986
Removable partial dentures
Loaded centrally, M, D, L, B
B caused unseating
Central loading better than distal loading

37. Clinically Drop 2nd premolar if necessary
Ensures posterior contacts not too distant
Avoids ascending portion of ridge
Ensures adequate occlusal table (maintains 2 molars)

38. Clinically
Place load over the mandibular ridge

39. Pain: Occlusion Avoid Contact on Inclines
No contact on inclines of denture bases

40. Pain: Occlusion Clinical Exam
Severe Curve of Spee

41. Pain: Occlusion Clinical Exam
Minimal overjet (horizontal) of anterior and/or posterior teeth

42. Pain: Occlusion Clinical Exam
Severe disclusion of posterior teeth in excursions (lack of balance)

43. Avoid Setting Teeth in Tongue Space

44. Denture Pain CD & RPD Occlusion Denture base (fit & contour)
Vertical dimension
Infection
Systemic disease/condition
Allergy (rare)

45. Pain: Denture Base Dental History
Firm pressure over molars - pain
Problem starts in AM
tight, sore
Discomfort present when not chewing
Often not progressive through day

46. Pain: Denture Base Clinical Exam
Discrete area of inflammation or ulceration
Similar to appearance of occlusal problems

47. Review of Indicating Media Loney & Knechtel,J Prosthet Dent 2009;101:137-141

48. Applying Pressure Indicating Paste
Dry denture
Thin coat with stiff brush
Leave streaks

49. Seat Denture Firmly Avoid lips/ridge when inserting
Pressure over first molars (not palate)
Remove from oral cavity by breaking seal - finger pushing height of vestibule

50. Denture Base Adjustment
Relieve pressure spots - large acrylic burs
Take care with undercuts
Looks like burn-through
May not require adjustment

51. Repeat Until Denture Fully Seats
Relatively uniform contact
Minimal streaks
No gross burn-through

52. Visually Check Peripheries
Seat denture & border mold
Flanges should fill vestibule but not be dislodged by manipulation
If denture dislodges, use PIP to adjust

53. Pressure Pastes: Goal: Relatively Even, Minimal Streaks

54. 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

55. Pain: Occlusion Clinical Exam
Indelible sticks : show position but not degree of problem
Use in immediate denture (paste in sockets)

56. Pain: Occlusion Clinical Exam
Expect some burnthrough close to undercuts
Denture should seat easily, otherwise adjust undercut

57. Pain: Denture Base Retromylohyoid Overextension
Sore throat
Denture moves when swallow
From retromolar pad, flange should go straight down or angle forward, never backward

58. 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

59. Pain: Denture Base Hamular Notches Commonly sharp flange
Sometimes long
Use PIP

60. Pain: Denture Base Labial frenum Should be thin and deep, not broad
Round internal and external angles

61. Denture Pain CD & RPD Occlusion Denture base (fit & contour)
Vertical dimension
Infection
Systemic disease/condition
Allergy (rare)

62. 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

63. Denture Pain: Occlusal Vertical Dimension (OVD)
Insufficient OVD
lack of chewing power
minimal ridge discomfort
angular chelitis
esthetic complaints:
chin prominent
poor lip support

64. Denture Pain: Occlusal Vertical Dimension (OVD)
Solution:
Check physiologic rest position and phonetics carefully to confirm
Provide time to ensure no adaptation
Reset teeth as adjustment alone usually not possible

65. Remember! 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

66. Summary Five Principles For Troubleshooting
Establish differential diagnosis
Identify variations from normal
Have patient demonstrate problems
Always use indicating medium when adjusting
Have patient rate improvement after adjustment

67. Clinical Management of Denture Problems
Take a detailed history
Make a WRITTEN list of all problems
Patient demonstrates problem if possible
List all possible causes for each problem

68. Clinical Management of Denture Problems
Begin with most common cause – test hypothesis, try to eliminate
Patient rates improvement after adjustment
If no immediate relief, problem should be eliminated in 7-10 days

69. Denture Pain CD & RPD Occlusion Denture base (fit & contour)
Vertical dimension
Next Day We Will Discuss:
Infection
Systemic disease/condition
Allergy (rare)