Lec 17 4th grade

INSERTION APPOINTMENT
OF COMPLETE DENTURES
The overall objective when fitting complete dentures is to ensure that the
patient is given the best possible start with the new prostheses. This may be
achieved by checking that:

 There is no pain when the dentures are inserted and removed from the
mouth, or when the teeth are brought into occlusal contact;
 The teeth meet evenly;
 The dentures stay in place when inserted and during normal opening of the
mouth;
 The patient understands:
  How to control the dentures;
  What to expect of them;
  How to clean them.

As a result of this preparation the patient should be reasonably confident when

meeting family and friends. It should be remembered that to achieve this
satisfactory outcome with a patient who has not worn dentures previously will
require very careful advice and instruction by the clinician. The main changes in
the dentures since the try-in stage are in the impression and occlusal surfaces.

INSPECT THE DENTURES

Before the placing of dentures in the patient’s mouth, each denture should be
examined for cracks, porosities, and other processing defects. The dentures should
be inspected digitally and by magnifying loupes to be sure that the tissue surface
has no imperfections; Sharp ridges and tags of acrylic resin are revealed by wiping
the surface with dry gauze or cotton roll and removed with a bur designed to cut
acrylic resin. Adhered plaster and stone fragments should be detected and
removed. The polished surface is smooth, the denture flanges have no sharp angles
and are not too thick, and the denture borders are round and smooth with no
obvious overextension.

INFORM THE PATIENTS

Ideally the patient should be instructed to keep any previous dentures out of the
mouth for 12 to 24 hours immediately before the insertion appointment. This is
essential if the new dentures are to be seated on healthy and undistorted tissues.
Many patients will find leaving the dentures out of their mouth for 12 to 24 hours
an unreasonable request. An acceptable alternative is to have the existing dentures
relined with a soft temporary material to minimize tissue distortion problems.

INSERTING THE DENTURES

When the patient arrives, each denture can be assessed individually in the
mouth and adjusted for comfort, support, and retention before the occlusal contacts
are assessed.

EVALUATION OF THE TISSUE FIT & COMFORT

 Severe undercut: it can cause problems in seating and removal; this will
cause abrasion and soreness of the mucosa in its path.
 Overextended border: the denture appears to gradually rise or to have
inadequate retention.
 Pressure spots: pressure spots can be identified using pressure disclosing
paste then these spots are carefully relieved by trimming and procedure is
repeated until no more areas are evident.

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Adjustment of denture base:

The use of pressure-indicating paste (PIP) is essential to evaluate and improve

the adaptation of the denture to the tissue. Causes of pressure area:

 Processing changes can create a slight contraction of the maxillary denture

base, and it is common to relieve the lateral surfaces in the tuberosity area to
compensate for processing changes.
 Bilateral undercuts on the residual ridge can interfere with the initial
placement of dentures and relief may be needed to allow comfortable
insertion and removal.
 The thin mucosa over the lingual bony prominence of the mylohyoid muscle
insertion.
 With advanced resorption, the mental and incisive canal nerves may have so
little tissue over them that they require relief to avoid discomfort.

Dry the denture first and then run the brush with the same direction and apply a
thin even layer of PIP onto the surface of the denture. The painted surface may be
wetted with water. Carefully seat the denture with firm finger pressure on the first
molar areas. Extreme pressures are not desirable because this will distort the tissue.

Do not have your patient bite when using PIP at this point because the
uncorrected occlusal errors may shift the denture and create an erroneous PIP
pattern. Remove the denture immediately and inspect the pressure spots. Pink
acrylic show-through spots indicate excessive tissue contact and pressure. These
pink marks in the paste indicate where the denture base should be adjusted to
relieve the interference. Remove the grindings and moisture with a gauze pad and
apply PIP, repeating the above procedure until pressure areas are eliminated.

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Adjustment of denture borders:

Apply disclosing wax on an incremental dried denture border and warm up

the wax in the water bath for 5 seconds. Seat the denture firmly with even finger
pressure. Instruct the patient to go through the necessary border molding
movement. Carefully remove the denture without smearing the wax. Adjust any
visible pressure area or overextension. Repeat the procedure until no more
overextended border is indicated. Finally, frenum relief should examine.

EVALUATION OF THE RETENTION, STABILITY & SUPPORT

Certain procedures are carried out during insertion to assess denture retention,
stability and support.

Retention

The retention test evaluates the peripheral seal of dentures. The retention test
for the upper denture is performed by positioning the finger on the palatine region
of the upper incisors to perform an anterior-superior movement against this region
and evaluate the effectiveness of posterior palatine sealing. If it loosens, the usual
causes are muscles that need more freedom to contract around the periphery of the
base (i.e., overextended peripheral flanges) or an inadequate peripheral seal along
the post-dam or lateral to the maxillary tuberosity. The base can be adjusted with
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an acrylic-cutting bur to provide more space for the muscles, whereas an
inadequate seal can be detected by adding impression compound to the expected
area of the leak. If the compound improves retention, it is replaced with an auto-
polymerizing resin suitable for use directly in the mouth. Alternatively, the
compound can be replaced in the laboratory by a full reline of the denture with a
heat-processed resin; however, full relines are very rarely necessary on a new
denture unless major errors occurred when the resin was processed.

The retention test for the lower denture is performed with the application of
force upwards considering that retention of this denture is reduced in comparison
with the upper complete denture. The patient should be able to lick the upper lip
and control the position of the mandibular denture without the denture moving
noticeably. If this movement is obviously excessive and disturbing the patient, the
muscles in the floor of the mouth might need more freedom to contract around the
denture. Unless it is obvious clinically where the flanges of the mandibular denture
are overextended, the patient should use the denture for a few weeks if possible to
assess the extent of the problem before the shape of the base is changed because
retention of the mandibular denture can improve dramatically with experience.

Stability

Denture stability is tested by digital pressure on the occlusal surface of the

posterior teeth and incisal edge of the anterior teeth, dentures may appear to rock
when one applied alternating finger pressure on occlusal surfaces of the right and
the left sides. Horizontal displacement should not result in a shift of the centre line
of more than 2 mm.

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Support

The size, shape, and resilience of the residual ridges and palate influence the
support for the dentures. The maxilla usually gives much more support than the
mandible, and a denture on firm mucosa overlying a firm residual ridge will be
substantially more stable than a denture on loose mucosa over a soft fibrous ridge.
The test may be conducted with an intrusion force on the complete denture against
the basal area. So, support would be demonstrated by the level of denture base
intrusion in the alveolar mucosa.

EVALUATION OF THE OCCLUSION & JAW RELATIONS

Occlusal harmony in complete dentures is necessary if the dentures are

comfortable, to function efficiently and to preserve supporting structures. The
occlusion of the dentures is checked once completions of the adjustments
mentioned above have ensured that:

Each denture can be inserted and removed from the mouth without
discomfort;
Firm pressure can be applied to the occlusal surface without eliciting pain.
The causes of Occlusal Errors

1. Inaccurate maxillo-mandibular relation record by the dentist.

2. Errors in the transfer of maxillo-mandibular relation records to the articulator.
3. Ill-fitting record bases.
4. Incorrect arrangement of the posterior teeth.
5. Failure to close the flask completely during processing.
6. Warp of the dentures by over-heating during polishing.
7. Dimensional changes in the denture base resin material.

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 All errors in occlusion should be corrected and equilibrated by laboratory
remount and clinical remount. Failure to correct occlusion before the patient
wears the dentures can cause destruction of the residual alveolar ridges.

Laboratory remount and occlusal equilibration

This remount done in laboratory while processed dentures are deflasked, but
still on master casts. This procedure will do before finishing and polishing
dentures, in another word, before the delivery of the completed dentures.

The expansion after denture processing may create a slightly increased vertical
dimension of occlusion (VDO). When the master casts with the processed dentures
still on them are returned in their original mountings in the articulator, this slightly
increased VDO can be noticed because the incisal pin is slightly away from the
incisal table (about 1-3 mm) on the articulator during the laboratory remount. The
processing changes may create initial occlusal contacts in the posterior teeth first.
Modifying the occlusal surfaces of the teeth by selective grinding will eliminate
most of the errors caused by processing changes.

Laboratory occlusal errors can be effectively corrected by using the split-cast

technique. This technique involves replacing the processed dentures, still on their
casts, back on to the articulator in exactly the same jaw relationship as when the
trial dentures were produced.

The goal of the laboratory remount and occlusal reequilibration is to bring back the
preprocessing VDO, and the incisal pin contacts the incisal table again on the
articulator.

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 Selective grinding by using articulating paper to adjust all initial occlusal
contacts at centric position, The goal is to maintain the integrity of the functional
cusp tips in both arches (maxillary lingual and mandibular buccal cusps) without
the risk of decreasing the VDO. The functional cusp tips are not reduced, but rather
the opposing fossae are made deeper and/or wider. Also, if the “high” contact is on
the functional cusp inclines, the cuspal inclines can be reduced, thereby gradually
moving the contact more toward the functional cusp tip. By using red articulating
paper to mark these “supporting occlusal” contacts and avoid adjusting them
further. Use blue articulating paper and make protrusive and lateral excursions.
Adjust these blue contacts using the acronyms of “BU-LL,” buccal upper and
lingual lower, and “MU-DL,” mesial upper and distal lower to remove
interferences on excursions without damaging the red occlusal support contacts.
This selective occlusal adjustment by grinding can create a balanced articulation to
the limits of excursions to the cusp tips and incisal edges. Finally, removing the
processed dentures from their master casts and finishing and polishing the
completed dentures.

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Clinical remount and occlusal equilibration

The greatest amount of change occurs when the dentures are removed from the
casts. Further change may occur if too much heat is generated in polishing the
dentures. Denture base acrylic resins also absorb water and saliva. This absorption
causes a 1% to 3% expansion and can alter the relationships of the cusps’ inclined
planes. After finishing of the dentures, the prostheses should be maintained in
water so this dimensional change occurs before the final occlusal refinement that is
accomplished at the insertion appointment. If all appropriate precautions have been
taken while processing the dentures, any remaining occlusal errors can detected
when the dentures are placed in the mouth.

The clinical occlusal errors can be corrected by Selective Grinding. There are
two types of selective grinding:

Intra-oral (chair-side)
Extra-oral (clinical remount)

1. Intra-oral (chair-side)

In general, small occlusal discrepancies in the absence of a horizontal slide can

be corrected effectively by chair side adjustment following a thorough intra-oral
assessment using the methods described in the following.

Occlusal indicator wax

 By using strip wax on mandibular denture, pointes of penetration are

occurring on closing in centric relation marked with pencil & relieved then.
 Disadvantage: is shifting of dentures over resilient supporting tissues in
eccentric jaw position will give false marking.
 It’s excellent for correcting occlusion in the centric position.
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Abrasive Paste

 Disadvantage: is shifting of base as a result of premature contact may result

in altering the occlusion so that centric occlusion dose not corresponds to
centric relation.
 Functional cusps that maintain the vertical dimension may be destroyed.

Articulating Paper

It should be remembered that articulating paper marks can be very misleading.

False marks can readily be created because of the following reasons:

 Even thin articulating paper may fill the space between non-occluding teeth
and mark areas of the occlusal surfaces that are not actually contacting.
 Mucosal displacement and tipping of the dentures can bring non-occluding
teeth into contact with the articulating paper.
 The vertical overlap of teeth associated with cusp/fossa relationships and
vertical overlap of anterior teeth can ‘crimp’ the articulating paper and
produce false marks.

Intraoral, a piece of thin horseshoe-shaped articulating paper is inserted

between the teeth and the patient is asked to repeat the jaw movements. A single
strip of articulating paper should not be placed on only one side of the dental
arch as this is likely to induce jaw movement to that side. Instructing the patient
how to occlude onto the articulating paper needs to be carried out with care. Ask
the patient to ‘close on your back teeth’ will encourage a normal closure pattern.
Once the desired position has been obtained the patient is requested to tap the teeth
together several times in that position in order to mark the occlusal surfaces.

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 Adjustment of the occlusal surfaces should be made only on those markings
made by the articulating paper which coincide with the patient’s comments. The
process is repeated until the patient reports that the teeth meet evenly.

Selective grinding by using articulating paper in centric and eccentric position

should be done similar to that in laboratory remount.

SPECIAL INSTRUCTIONS TO THE PATIENT

Educating patients to the limitations of dentures as mechanical substitutes for

living tissues must be a continuing process from the initial patient contact until
adjustments are completed. However, certain difficulties that will be encountered
with new dentures and the information related to the care of dentures should be
reinforced at the time of initial placement of the dentures.

INDIVIDUALITY OF PATIENTS

Denture complaints that are annoying and painful to some patients may be of
secondary importance to others. Chewing and speech patterns considered
successful by some persons may be interpreted as unsuccessful by others. Patients
tend to forget the severity of problems with the passage of time.

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 Adaptability to new dentures is modified by age. Persons who make the
adjustment to new dentures during middle age may experience considerably more
difficulty with dentures 51years later, even though the new dentures may be
technically superior to the original ones.

INSERTION AND REMOVAL OF NEW DENTURES

The patient is taught to remove and wear the denture repeatedly. The patient
should insert the prosthesis along the path of insertion. It is usually preferable to
wear the upper denture first followed by the lower denture as upper is more
retentive and larger. Again for the same reason, it is preferable to remove the lower
denture followed by the upper denture. In the presence of a unilateral undercut, the
patient is taught to insert the denture into the undercut first, and then rotate the
prosthesis into its final position.

APPEARANCE WITH NEW DENTURES

Patients must understand that their appearance with new dentures will
become more natural with time. Initially, the dentures may feel strange and bulky
in the mouth and will cause a feeling of fullness of the lips and cheeks. The lips
will not adapt immediately to the fullness of the denture borders and may initially
present a distorted appearance. Patients should be instructed to refrain from
exhibiting their dentures to curious friends until they are more confident and
competent at exhibiting them.

MASTICATION WITH NEW DENTURES

Learning to chew satisfactorily with new dentures usually requires at least 6

to 8 weeks. The muscles of the tongue, cheeks, and lips must be trained to maintain
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the dentures in position on the residual ridges during mastication. Patient comfort
and mastication may be impaired because of the elicited excess flow of saliva for
the first few days after placement of new dentures. However, in a relatively short
time the salivary glands accommodate to the presence of the dentures, and normal
production of saliva returns.

Patients should begin chewing relatively soft food that has been cut into small
pieces and place on the posterior teeth and chewed slowly both side
simultaneously. Not to open the mouth too wide when placing the food inside.
Biting or incising is not advised as it cause tipping of denture and damage the
anterior portion of the ridge; biting if necessary should done from the premolar
region .Finally, the patient should be instructed to avoid sticky food.

SPEAKING WITH NEW DENTURES

Speaking normally with dentures requires practice. Patients should be advised

to read aloud and repeat words or phrases that are difficult to pronounce.
Adaptability of tongue is such that patients overcome this problem quickly.

Dentists should have an appreciation of tooth position, palatal contours, and

lingual contours of the mandibular denture, and these should be technically
addressed at try-in and insertion, rather than complete reliance on patient
adaptation.

Patients should be instructed that extreme and sudden movements like sneezing
and coughing can dislodge the dentures; this can be avoided by covering the mouth
with a handkerchief.

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ORAL HYGIENE AND MAINTENANCE WITH NEW DENTURES

Dental plaque is an etiological factor in denture stomatitis, inflammatory

papillary hyperplasia, chronic candidiasis, and offensive odors, and it must be
removed. Patients should be instructed to rinse their dentures and their mouths
after meals whenever possible. Once a day, it is essential that the dentures be
removed and placed in a soaking type of cleanser for a minimum of 30 minutes.
An inexpensive alternative soaking cleanser is one that can be made up with 1
teaspoon of household bleach in 1 cup of water. This alternative soaking cleanser
should only be used for complete dentures containing no metals because the
sodium hypochlorite may pit or corrode the metals. Patients need to be instructed
that the brushing is required to remove plaque because the soaking will not do so.
The dentures should be brushed over a basin partially filled with water or covered
with a wet washcloth to prevent breakage in case they are dropped. Dentures
should never place in hot water nor should hot water be used to clean dentures.
(Thermal changes can result in distortion).

Patients should be informed that dentures must be left out of the mouth at
night to provide needed rest from the stresses they create on the residual ridges.
Failure to allow the tissues of the basal seat to rest may be a contributing factor in
the development of serious oral lesions, such as inflammatory papillary
hyperplasia, or it may increase the opportunity for microbial infections, such as
candidiasis.When dentures are left out of the mouth, they should be placed in a
container filled with water to prevent drying and possible dimensional changes of
the denture base material.

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RECALL AND FOLLOW-UP WITH NEW DENTURES

The dentist is responsible for the care of the patient throughout this period, and
this occasionally requires a number of follow-up appointments. The complete
cooperation of the patient during the adjustment period is essential. An
appointment for (1 to 3 day) adjustment should be made routinely. Patients who do
not receive this attention have more trouble than those who are cared for the first
several days after the insertion of the new dentures. This is the critical period in the
denture-wearing experience of the patient.

The end

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