1. Denture Looseness CD & RPD OcclusionOcclusion Denture base (fit & contour)Denture base (fit & contour) Poor anatomyPoor anatomy OcclusionOcclusion Denture base (fit & contour)Denture base (fit & contour) Poor anatomyPoor anatomy

2. Denture Looseness CD & RPD: Occlusion Typical History Adequate retention initially Gets worse with time Clinically: No discomfort when press firmly on 1 st molars Typical History Adequate retention initially Gets worse with time Clinically: No discomfort when press firmly on 1 st molars

3. Denture Looseness CD & RPD: Occlusion Perpetually Loose Maxillary Denture Heavy anterior interferences can cause loosening at posteriorHeavy anterior interferences can cause loosening at posterior Tuberosity mucosa grows into spaceTuberosity mucosa grows into space Space develops under midline of denture baseSpace develops under midline of denture base Perpetually Loose Maxillary Denture Heavy anterior interferences can cause loosening at posteriorHeavy anterior interferences can cause loosening at posterior Tuberosity mucosa grows into spaceTuberosity mucosa grows into space Space develops under midline of denture baseSpace develops under midline of denture base

4. Tuberosity Denture Looseness CD & RPD: Occlusion Tilting Growth Loss of retention

5. Inclined Residual Ridge Inclined LipLip Denture Looseness CD & RPD: Occlusion Incisors placed too far labiallyIncisors placed too far labially Denture displaces lingually.Denture displaces lingually. Inclined ridge provides no resistance.Inclined ridge provides no resistance. Incisors placed too far labiallyIncisors placed too far labially Denture displaces lingually.Denture displaces lingually. Inclined ridge provides no resistance.Inclined ridge provides no resistance.

6. Denture Looseness CD & RPD: Occlusion Tilting/jiggling caused by: Contacts not centered over ridgeContacts not centered over ridge Contacts on inclined portion of ridgeContacts on inclined portion of ridge Tilting/jiggling caused by: Contacts not centered over ridgeContacts not centered over ridge Contacts on inclined portion of ridgeContacts on inclined portion of ridge

7. Denture Looseness CD & RPD: Occlusion Check for looseness in excursions with fingers on canines

8. Denture Looseness CD & RPD: Occlusion Check centric position (articulating paper)Check centric position (articulating paper) – even, stable contacts both sides – stop patient upon initial contact Check centric position (articulating paper)Check centric position (articulating paper) – even, stable contacts both sides – stop patient upon initial contact

9. Denture Looseness CD & RPD OcclusionOcclusion Denture base (fit & contour)Denture base (fit & contour) Poor anatomyPoor anatomy OcclusionOcclusion Denture base (fit & contour)Denture base (fit & contour) Poor anatomyPoor anatomy

10. Denture Looseness CD & RPD: Denture Base Typical History Loose/discomfort immediately on insertion Clinically: Discomfort when press firmly on 1 st molars Pressure up/outward from lingual of canine causes looseness Typical History Loose/discomfort immediately on insertion Clinically: Discomfort when press firmly on 1 st molars Pressure up/outward from lingual of canine causes looseness

11. Denture Looseness Mandibular lingual flange too thick TongueTongue Flange bulges into tongue space, lifts denture during function. Flange is not too long. “ Eyes in Your Fingers ” Blanchard, JPD 2:36 “ Eyes in Your Fingers ” Blanchard, JPD 2:36

12. Denture Looseness CD & RPD: Denture Base Short flange PIP streaksPIP streaks Looks short of vestibuleLooks short of vestibule Often displaces easilyOften displaces easily Short flange PIP streaksPIP streaks Looks short of vestibuleLooks short of vestibule Often displaces easilyOften displaces easily

13. Denture Looseness CD & RPD: Denture Base Long flange PIP burnthroughPIP burnthrough Retentive until speaking, eatingRetentive until speaking, eating Watch when seating dentureWatch when seating denture -Flange touches vestibular depth, denture continues to seat Long flange PIP burnthroughPIP burnthrough Retentive until speaking, eatingRetentive until speaking, eating Watch when seating dentureWatch when seating denture -Flange touches vestibular depth, denture continues to seat

14. Denture Looseness CD & RPD: Denture Base If flange too thickIf flange too thick – Seal may be maintained at rest – Pulls during function - drops If flange is short or longIf flange is short or long – Displacement as lips or cheeks move – Allows air to break vestibular seal If flange too thickIf flange too thick – Seal may be maintained at rest – Pulls during function - drops If flange is short or longIf flange is short or long – Displacement as lips or cheeks move – Allows air to break vestibular seal

15. Denture Looseness CD & RPD: Denture Base Principle Always have the patient demonstrate how a denture loosens Principle

16. Denture Looseness CD & RPD: Denture Base Lack of post dam/ retrozygomal seal Pull upward and outward on caninePull upward and outward on canine Test hypothesis: add compound/functional wax -opposite sideTest hypothesis: add compound/functional wax -opposite side Lack of post dam/ retrozygomal seal Pull upward and outward on caninePull upward and outward on canine Test hypothesis: add compound/functional wax -opposite sideTest hypothesis: add compound/functional wax -opposite side

17. Denture Looseness CD & RPD: Denture Base Poor base adaptationPoor base adaptation Fulcrum on bony structuresFulcrum on bony structures Test hypothesis: PIPTest hypothesis: PIP Poor base adaptationPoor base adaptation Fulcrum on bony structuresFulcrum on bony structures Test hypothesis: PIPTest hypothesis: PIP

18. Denture Looseness CD & RPD: Denture Base Periphery terminates on bony structures –Hard palate –Zygoma –External oblique ridge –Before retromolar pad No seal, discomfortNo seal, discomfort Eventual resorptionEventual resorption Periphery terminates on bony structures –Hard palate –Zygoma –External oblique ridge –Before retromolar pad No seal, discomfortNo seal, discomfort Eventual resorptionEventual resorption Dry Mucosa

19. Denture Looseness CD & RPD: Denture Base Principle Denture peripheries always terminate on displaceable soft tissues Retromolar pads, Vestibular tissues, Vibrating line (nonmoveble soft palate), Hamular notches Principle Denture peripheries always terminate on displaceable soft tissues Retromolar pads, Vestibular tissues, Vibrating line (nonmoveble soft palate), Hamular notches

20. Gagging with Dentures Usually not soft palate contactUsually not soft palate contact Denture contact with tongue :Denture contact with tongue : –thick posterior border rubs on tongue –posterior border drops onto tongue: -Occlusal interferences -Terminates on hard palate (no seal) Usually not soft palate contactUsually not soft palate contact Denture contact with tongue :Denture contact with tongue : –thick posterior border rubs on tongue –posterior border drops onto tongue: -Occlusal interferences -Terminates on hard palate (no seal)

22. Denture Looseness Denture Base: Coronoid Interference Thick flange in retrozygomal areaThick flange in retrozygomal area Coronoid gets closer to tuberosity as patient opens or moves jaw to sideCoronoid gets closer to tuberosity as patient opens or moves jaw to side Dislodges maxillary dentureDislodges maxillary denture Thick flange in retrozygomal areaThick flange in retrozygomal area Coronoid gets closer to tuberosity as patient opens or moves jaw to sideCoronoid gets closer to tuberosity as patient opens or moves jaw to side Dislodges maxillary dentureDislodges maxillary denture

23. Denture Looseness Denture Base: Pterygomandibular Raphe Raphe from area of hamular notchRaphe from area of hamular notch Very tight in some patientsVery tight in some patients Easily displaceable, but raphe can displace denture opening wideEasily displaceable, but raphe can displace denture opening wide Raphe from area of hamular notchRaphe from area of hamular notch Very tight in some patientsVery tight in some patients Easily displaceable, but raphe can displace denture opening wideEasily displaceable, but raphe can displace denture opening wide

24. Denture Looseness Denture Base: Palatal Cleft In some patients midline soft palate fissureIn some patients midline soft palate fissure Can “ tent ” during functionCan “ tent ” during function Allows air to leak under dentureAllows air to leak under denture In some patients midline soft palate fissureIn some patients midline soft palate fissure Can “ tent ” during functionCan “ tent ” during function Allows air to leak under dentureAllows air to leak under denture

25. Denture Looseness or Pain CD & RPD Principle Always have the patient rate improvement (0-100) after adjustment. If below 90%, more diagnosis/adjustment is required Principle

26. Denture Looseness CD & RPD OcclusionOcclusion Denture base (fit & contour)Denture base (fit & contour) Poor anatomyPoor anatomy OcclusionOcclusion Denture base (fit & contour)Denture base (fit & contour) Poor anatomyPoor anatomy

27. Denture Looseness CD & RPD: Poor Anatomy Many sets of denturesMany sets of dentures – Use articulator –More involved/precise impression & jaw relation procedures – Implants – Refer Many sets of denturesMany sets of dentures – Use articulator –More involved/precise impression & jaw relation procedures – Implants – Refer

28. OverviewOverview Deal with denture problems systematicallyDeal with denture problems systematically Use a differential diagnosisUse a differential diagnosis Address probable causes until problem eliminatedAddress probable causes until problem eliminated If can ’ t identify problem, referIf can ’ t identify problem, refer Deal with denture problems systematicallyDeal with denture problems systematically Use a differential diagnosisUse a differential diagnosis Address probable causes until problem eliminatedAddress probable causes until problem eliminated If can ’ t identify problem, referIf can ’ t identify problem, refer

29. Phonetic Problems Lisping: – too much overjet – triangular spaces between max. & mand. teeth – palatal contour too constricted – insufficient tongue space Lisping: – too much overjet – triangular spaces between max. & mand. teeth – palatal contour too constricted – insufficient tongue space

30. Difficult Denture Patients Anatomic ProblemAnatomic Problem Diagnosis ProblemDiagnosis Problem Adaptive ProblemAdaptive Problem Psychologic ProblemPsychologic Problem Anatomic ProblemAnatomic Problem Diagnosis ProblemDiagnosis Problem Adaptive ProblemAdaptive Problem Psychologic ProblemPsychologic Problem

31. Difficult Denture Patients Principle If you can ’ t determine the problem using indicating medium: 1. Tell the patient 2. Don ’ t adjust 3. Refer Principle If you can ’ t determine the problem using indicating medium: 1. Tell the patient 2. Don ’ t adjust 3. Refer

32. Difficult Denture Patients Principle Never pretend to adjust a denture Reinforces maladaptive behaviour - harder for the next guy Principle Never pretend to adjust a denture Reinforces maladaptive behaviour - harder for the next guy

33. Difficult Denture Patients Adaptive Problem Elderly take more time to adaptElderly take more time to adapt More teeth missing, less adaptation (loss of PDM receptors)More teeth missing, less adaptation (loss of PDM receptors) Better perception - less adaptiveBetter perception - less adaptive Elderly take more time to adaptElderly take more time to adapt More teeth missing, less adaptation (loss of PDM receptors)More teeth missing, less adaptation (loss of PDM receptors) Better perception - less adaptiveBetter perception - less adaptive

34. Difficult Denture Patients Adaptive Problem Denture may be the cause of the problemDenture may be the cause of the problem Patient response may also be part of the problemPatient response may also be part of the problem Denture may be the cause of the problemDenture may be the cause of the problem Patient response may also be part of the problemPatient response may also be part of the problem

35. Difficult Denture Patients Adaptive/Psychologic Problem Dentist ’ s response to patient may also affect the patient response to the denture “ Laying on of Hands ” Dentist ’ s response to patient may also affect the patient response to the denture “ Laying on of Hands ”

36. Adaptive, Psychologic Problem Prevention Good interview techniqueGood interview technique TipsTips –Many dentures –Disparaging previous dentures/dentists –Body Language/ Deportment Good interview techniqueGood interview technique TipsTips –Many dentures –Disparaging previous dentures/dentists –Body Language/ Deportment

37. Adaptive, Psychologic Problem Prevention: Interview 1. Recognize & Acknowledge Problem –Open ended questions –Let patient identify problem –If you identify the wrong problem - fail 1. Recognize & Acknowledge Problem –Open ended questions –Let patient identify problem –If you identify the wrong problem - fail

38. Adaptive, Psychologic Problem Prevention: Interview 2. Explore and Identify Problems –Let the patient talk (silence) –Watch for nonverbal clues –Short verbal clues may be significant ( “...and I guess the appearance ” ) –Don ’ t be afraid of questions relating to emotional health 2. Explore and Identify Problems –Let the patient talk (silence) –Watch for nonverbal clues –Short verbal clues may be significant ( “...and I guess the appearance ” ) –Don ’ t be afraid of questions relating to emotional health

39. Adaptive, Psychologic Problem Prevention: Interview 3. Interpret & Explain Problems –Advise patient of your view –Use care in dealing with emotional problems –Don ’ t be afraid to address emotional component 3. Interpret & Explain Problems –Advise patient of your view –Use care in dealing with emotional problems –Don ’ t be afraid to address emotional component

40. Adaptive, Psychologic Problem Prevention: Interview 4. Offer a Solution –If chance denture will not be a success, state at outset –If sense trouble, refer or address immediately –If suggest a therapist, patient will run or say yes 4. Offer a Solution –If chance denture will not be a success, state at outset –If sense trouble, refer or address immediately –If suggest a therapist, patient will run or say yes

41. Adaptive, Psychologic Problem Prevention: Interview If bells go off in your head, listen to them, talk more, don ’ t proceed past interview, until satisfied

42. Adaptive, Psychologic Problem Prevention: Interview Remember: Most patients are not problem patientsRemember: Most patients are not problem patients 80-85% are satisfied80-85% are satisfied Better adaptation than eyeglass wearersBetter adaptation than eyeglass wearers Remember: Most patients are not problem patientsRemember: Most patients are not problem patients 80-85% are satisfied80-85% are satisfied Better adaptation than eyeglass wearersBetter adaptation than eyeglass wearers

43. Adaptive, Psychologic Problem Rule out objective findings Chart findings objectively Rule out objective findings Chart findings objectively

44. OverviewOverview Deal with denture problems systematicallyDeal with denture problems systematically Use a differential diagnosisUse a differential diagnosis Address probable causes until problem eliminatedAddress probable causes until problem eliminated If can ’ t identify problem, referIf can ’ t identify problem, refer Deal with denture problems systematicallyDeal with denture problems systematically Use a differential diagnosisUse a differential diagnosis Address probable causes until problem eliminatedAddress probable causes until problem eliminated If can ’ t identify problem, referIf can ’ t identify problem, refer