1. Denture Placement & Occlusion Correction
Rola M. Shadid, BDS, MSc

2. Causes of Denture Errors
Clinical errors
Technical errors
Inherent deficiencies in the material itself

3. Evaluation Procedures
Processing
Polished surfaces
Tissue fit and comfort
Retention, stability and support
Jaw relations
Occlusion
Esthetics
Speech

4. Evaluation of Processing *
Inspect for processing errors, e.g. porosity
Inspect for inadequate polishing
Run your finger along the borders & impression surface to check if sharp edges or acrylic spicules exist
Examine frenal notches for sharp edges
Examine for adhered plaster or stone fragments
It is imperative that clinician examine the denture thoroughly before inserting
Corrections are made by scraping or grinding with knife, sandpaper, or stone burs

5. Patient Education & Preparation *
First oral feeling with fullness is normal & will disappear over time
Excessive salivation
(compulsive spitting or rinsing should be avoided, instead swallowing encouraged to remove excess saliva)
The pt should be aware that only after the dentist has completed evaluation and adjustment of denture in the mouth and is satisfied with it, will the pt be allowed to view it.

6. Evaluation of Tissue Fit & Comfort
Pressure Indicating Paste (PIP)*
Every new denture must be checked with PIP to identify and determine if pressure areas exist to reduce them.
Commercial preparations are available. PIP can be prepared in clinic by mixing zinc oxide eugenol base paste with Vaseline. Light body elastomeric impression paste can also be used as PIP

7. Evaluation of Tissue Fit & Comfort
Never adjust unless you can see exactly where to adjust
Use indicator medium
(PIP, indelible marker, etc)

8. Place Paste with Streaks

9. How to Read PIP? Streaks - no contact (N) No Paste - Impingement (I)
Paste, no streaks - normal contact (C)

10. Evaluation of Tissue Fit & Comfort
Severe undercuts
Cause abrasion and soreness in seating and removal
Management
Relieve with extreme caution with aid of PIP

11. Evaluation of Tissue Fit & Comfort
Overextended borders
Denture appears to rise or has inadequate retention
Management
Identify the offending borders, mark with indelible marker inside the pt mouth and carefully reduce

12. Evaluation of Retention, Stability & Support
Test for retention*
Test for posterior palatal seal
The finger is placed on the ridge and a rolling pressure is applied away from the side being checked. The denture should resist dislodgment.
Posterior palatal seal is checked by applying pressure in anterior region

13. Test for Rocking
Apply alternating finger pressure on occlusal surfaces of R & L sides
Rocking around fulcrum point
Midpalatal raphe is a common fulcrum point if inadequate relief has been provided *
* The fulcrum point must be identified and relieved with the aid of PIP.

14. Evaluation of Occlusion
Denture processing almost always causes changes in occlusion due to dimensional changes in resin
These changes are usually manifested as increase in OVD

15. Causes of Occlusal Errors
Errors in impressions
Ill-fitting trial denture bases
Inaccurate jaw relation records
Errors during transfer of the records to articulator
Incorrect arrangement of posterior teeth
Dimensional changes during curing
Processing faults……..*
*Failure to close flask completely, too much pressure while closing the flask, tooth movement during flasking or packing, failure to cool flask before deflasking, distortion due to improper flasking, warpage due to overheating during polishing

16. Why is it difficult to detect occlusal errors in the mouth? *
Negative attitude (assume an error exists and try to find it)
*shifting of denture bases, incorrect closure by pt.

17. What is the ideal occlusal contact?
At first contact, even maximum intercuspation at CR without denture shifting or instability & without pain *
*sliding of denture bases or uneven pressure caused by faulty occlusion can lead to ulceration of mucosa.

18. Types of Occlusal Errors
CO not coincide with CR
Premature contact (high point) in one or both sides
Uneven distribution of occlusal contacts
Eccentric movement prematurities (protrusive & lateral)

19. What are the Methods of Detecting Occlusal Errors?
Touch & slide method (Refer to lecture 9)
Denture dislodges or shifts when pt occludes
Pt complains of pain beneath denture bases *

20. Correction of Occlusal Errors
Laboratory remounting
Clinical remounting
Direct intraoral correction

21. Laboratory Remounting *
Disadvantages Cannot correct errors made while recording jaw relations Cannot correct errors made while mounting the casts on the articulator Does not compensate changes caused by settling of the denture bases
Made in laboratory after processing and before the denture is inserted in mouth. The aim is to regain the original OVD that was disturbed by processing
It is believed that adjusting the balanced occlusion is not necessary at this stage (immediately after processing and before insertion in mouth) because of settling of denture bases that occur after insertion. Settling changes the occlusal relationship; so it is wiser to wait for settling to occur before adjusting the balanced occlusion.

22. Clinical Remounting with New Interocclusal Records *
Advantages
Correct errors made during recording of jaw relations, or while mounting cast on articulator
Less chair side time
Corrections away from the patient’s view
No saliva which makes detection by articulating paper difficult
No shifting of dentures or incorrect closure by pt
*the dentures are remounted on to an articulator from new interocclusal records made in patient’s mouth. Corrections are done by selective grinding on articulator.

23. The Aim of Clinical Remounting
The prematurities are ground until multiple, uniformly distributed and even contacts are obtained bilaterally

24. Clinical remounting is currently the most commonly preferred method of occlusal correction

25. Clinical Remounting Procedure
Ask patient to bite on cotton rolls for 10 min.
Guide mandible into CR several times.
Bite registration material is placed on the post. teeth of the mandibular denture

26. Clinical Remounting Procedure
Guide mandible into CR
Obtain interocclusal record of CR.

27. Clinical Remounting Procedure
Mount upper denture using remounting jig
Mount lower denture

28. Clinical Remounting Procedure

29. Selective Spot Grinding *
*Articulating paper is used to identify the prematurities. Articulating paper should be placed bilaterally. The articulator is raised and closed with sharp repeated tapping motions. The prematurities are identified and reduced with a small conical stone bur or another suitable bur.
The art of reducing premature contacting surfaces, so that an equal pressure exists at all points with interference at no point.

30. How to Recognize Premature Contacts?
A dark ring with a light center usually denotes a premature contact
You should distinguish betw. marks made by normal occlusal contacts and those of premature contacts
Articulating paper should not be reused many times and should be changed often.

31. Selective Spot Grinding
Make grinding until even (same intensity), stable, and multiple marks spread over wide area in both sides

32. Eliminating Occlusal Errors
Re-establishment of CO.
Correction of protrusive relation.
Correction of working side occlusal errors.
Correction of balancing side errors.
Initially, centric occlusion errors are corrected, followed by protrusive, R & L lateral interferences.

33. Basic Tooth Positions Balancing Contacts Centric Occlusion
Working Contacts

34. Selective Grinding Rules to Obtain CO
After the first few taps on the articulating paper only a few high contacts appear.
The marking process and the grinding are repeated until all except the anterior teeth contact in CO.
Ideally all holding cusps * of the maxillary and mandibular posterior teeth will make simultaneous contacts.
It is not uncommon for one or two functional cusps not to make contact after establishing the final CO.
It is not necessary to continue adjusting until these cusps make contacts because aggressive adjustment will sacrifice the established OVD
Holding, supporting or functional cusps are the maxillary palatal and mandibular buccal.
The balancing non-functional cusps are upper buccal and lower lingual (BULL)

35. Selective Grinding Rules to Obtain CO
As far as possible, avoid grinding cusp tips especially centric holding cusps, instead grind the opposing fossae or marginal ridges where the centric holding cusps occlude
If the high contact is on the centric holding cusp inclines, the cuspal inclines can be reduced, thereby gradually moving the contact more toward the bearing cusp tip.
A centric holding cusp may be reduced when it interferes with another centric holding cusp or when makes interferences in centric and eccentric positions

36. Re-establishment of CO
Problem: Teeth too long
Solution: Deepen the fossae

37. Re-establishment of CO
Problem: Teeth too nearly end to end
Solution: Grind Inclines

38. Re-establishment of CO
Problem: Too much horizontal overlap
Solution: Broaden central fossae

39. After the CO re-establishment….
DO NOT:
Reduce maxillary lingual cusps.
Reduce mandibular buccal cusps.
Deepen the fossae.

40. Correction of Protrusive Relation
The teeth are brought edge to edge
Any interferences to smooth anterior gliding of dentures are eliminated by grinding
Elimination of protrusive interferences along a path of 3 to 5 mm is sufficient

41. Correction of Working Side Occlusal Errors
BULL rule
buccal upper-lingual lower

42. Correction of Working Side Occlusal Errors
Reduce lingual inclines of buccal cusps of upper teeth.
Reduce buccal inclines of lingual cusps of lower teeth.
ON WORKING SIDE ONLY!!!

43. Correction of Working Side Occlusal Errors
Problem: Buccal and lingual cusps too long.
Solution: Change inclines of balancing cusps.

44. Correction of Working Side Occlusal Errors
Problem: Buccal cusps are too long
Solution: Change lingual incline of maxillary buccal cusp

45. Correction of Working Side Occlusal Errors
Problem: Lingual cusp too long.
Solution: Change buccal incline of lingual cusp of mandibular tooth.

46. Correction of Balancing Side Errors
On the balancing side, the cusps usually involved are the functional cusps and therefore grinding becomes more confusing

47. Correction of Balancing Side Errors
Decide which supporting cusp maintains CO and reduce its opponent.

48. Correction of Balancing Side Errors
Grind the lingual incline of the mandibular buccal cusp.

49. Direct Intraoral Correction
Disadvantages
Requires a lot of pt cooperation
Pt should have good neuromuscular control
Saliva
Inaccurate closure by pt
Misleading due to resiliency of tissues and shifting of denture bases

50. References
Boucher's Prosthodontics Treatment for Edentulous Patients. Twelfth Edition.Chapter 20.
Dalhousie continual education
Complete Denture Prosthodontics, 1st Edition, 2006 by John Joy Manappallil, Chapter 19