Part VIII.

Interferences With Anatomic Structures*

JOSEPHS. LANDA,D.D.S.
NewYork,N.Y,

E FFECTIVE AND EFFICIENT TROUBLE SHOOTING does not depend solely upon re-
lieving sore spots, but more so upon the ability of the dentist to determine
when and why a denture should be remade,After a certain number of adjustments,
a decisionto make a new lower denture may savea lot of trouble to the patient and
dentist alike.
There are important biomechanicand psychologic reasonswhy these dentures
should not be relined or rebased.First, the patient is psychologicallyimpressedwith
the dentist’s good will in making a new denture, and second,the lower denture may
haveto be radically changed (denture outline, degreeof jaw separation,etc.).

HIGH,KNIFEEDGESHARPRIDGE

There are two important phasesto consider when dealing with the high, knife
edge ridge : (1) the relief of the sharp ridge on the cast with tinfoil and (2) a
reduction of the degree of jaw separation.In many instances,both of these require-
ments must be satisfied.The denture, having been relieved on the crest of the ridge,
should lean firmly against the tissueson both sides of the ridge. In addition, when-
ever possible, such a denture should be slightly overextended buccally to derive
additianal support from contact with the externaloblique line (Fig. 1).
The masticatory mucosaof the ridge crest of these patients is situated between
a knife edgebony ridge underneath and a rigid denture above.Therefore, the lighter
the load that falls upon the lower denture the better. To achievethis, the new lower
denture should be built with the shortest possible vertical dimension of occlusion
that is compatiblewith estheticappearance.In this way, the forces of the masticatory
muscles may be reduced to a level more tolerable to the high and sharp ridge.
i\nother way of achieving the same results is to relieve the crest of the ridge in
the impression. However, this requires skillful and careful execution and depends
upon the impressionmaterial used.Plaster of Paris lends itself best for this purpose.
The right way to tackle the difficult ridge problems is to cautiously relieve the
sore spots as they arise. Parallel with this are the checking and correction of the
occlusion.If the patient still complains after a series of adjustments over approxi-
mately 4 weeks,it is time to plan a remakeof the lower denture.

DEN.9:978-987,1959:Part II, 10:42-46,1960;Part III, 10:263-269,1960:Part

*Part I, J. PROS.
IV, 10:490-495,1960;Part V, 10:682-687,1960;Part VI, 10:887-890,1960;Part VII, 10:1022-1028,
1960.
79
 J. Prora Den.
80 LANDA Jan..Feb.. :Pb:

The type of soreness observed in high, sharp lower ridges varies with rile
quality of the denture. However, with the average denture there is widesproatl + <t-c.
ness over almost the entire occlusal surface of the sharp ridge. ‘The more pai!M
areas are usually grayish in appearance and are definitely established onlv aitrr :L
careful digital examination. Severe soreness is manifested by white edematous, ~rr;t~
which look bruised or are about to open up. Such soreness must be relit,\ ect m~.m
generously than the simple grayish irritations. However, caution must be e.ucrci>ctl.
because “overrelieving” places a double burden 011the adjacent tissues. It is ai\\:t,~
safest to relieve judiciously and not replace the denture for a night or 24 hours. i?r
that time, the edema is reduced so that when the adjusted denture is placed in :he
mouth it causes no pain.
The situation becomes more complicated if the masticatory mucosa is deta&rri
from the periosteum. The movable mucosa rubs against the bone when the IO-Jt’i
denture moves in function.
illveolectomy may be the cause when the mucosa becomes detached from li~ca
periosteum. If the objective of the surgical procedure is to remove the bulk oi’ s&r
tissue that is in the way of the construction of a prosthesis, the operation is often
successful. However, reattachment of the mucosa to the periosteum usuallv &KA~
not occur. More often, the area of detachment of the mucosa from the periosteunl
becomes larger.

THE MUSCLES OF MASTICATION AND EXPRESSION

When making a diagnosis and prognosis for dentures, most of our attention
is focused on the strwtures with which we deal. If we engage in a study of function
of the individual parts, we can learn only fragmentarily about them. Thus, R‘P
examine visually the contraction and relaxation of the pterygomandibular raphe and
may reinforce this by a digital examination to determine the intensity of its con”
traction. We may apply the same exploratory procedures to the masseter, buccinator.
mylohyoid, genioglossus, and palatoglossus muscles. All of this will give us only 3
superficial idea of the structure and positional relationship of the parts involved. It.
is the ensemble, the collective, creative activity of all the muscles and their mutual
interplay that determines, in the final analysis, the function of the masticator)
mechanism.
Slight overextension of the denture border is preferred to slight underexteti-
sion. However, excessive overextension is prejudicial to denture retention. During
the examination of the lower denture for overextension, the patient is instructed to
protrude the tongue slightly until the tip rests upon the lower lip. By placing tht>
index fingers on the occlusal surfaces of the lower teeth, we can determine if thr
lower denture remains firmly seated on the denture-supporting structures. The
mouth should not be opened wide for this test, just enough to insert the tw(*
index fingers.
If the denture is lifted from its position, three possibilities are to be considered :
(X > the denture is overextended in the region of the genioglossus muscle, and the
contraction of this muscle with the forward movement of the tongue dislodged the
denture ; (2) the denture is overextended in the bicuspid-molar region and is dis-
Vo1ume ii1
Number TROUBLE SHOOTING IN COMPLETE! DENTURE PROSTHESIS. VIII 81

Fig. I.-A high and extremely sharp lower ridge requires special treatment during the
construction of dentures. The sharp crest of the residual ridge is relieved with tinfoil (28 or 21
gauge depending upon the degree of sharpness). Posterior teeth with a very narrow buccolingual
diameter are used, and the vertical dimension of occlusion should not be excessive. If anything,
a slight overclosure is preferable.

lodged by contraction of the mylohyoid muscle; and (3) the extreme distolingual
border of the lower denture is overextended, and the denture is dislodged by the
forward movement of the retromylohyoid curtain, formed by the palatoglossus
muscle medially and the pterygomandibular raphe laterally. In the first instance,
the denture is usually lifted anteriorly. In the second instance, the entire denture
is lifted from position. In the third instance, the entire denture is dislodged from
position and moved forward.
In. testing the buccal and labial flanges of the lower dentures for retention, the
cheeks and lips are drawn outward until they become almost perpendicular to the
ridge. The index finger of the other hand is kept on the occlusal surfaces of the
teeth on the same side. If the denture lifts up from its position, the border may be
overex.tended. The buccal and labial flanges of the upper denture are tested in a
similar manner, except that the index finger of the opposite hand is held in contact
with the denture vault.
There are many other ways of studying denture retention. For instance, while
the patient opens his mouth slowly, the dentist observes whether or not the dentures
remain in position. The patient is asked also to move the tongue to the right and
left corners of the mouth to determine whether he experiences any loosening of the
dentures.
All tests for denture efficiency- retention, stability, centric occlusion, phonetics,
esthetics, etc.-are more accurate and more reliable when explored carefully during
the adjustment period than at any time during the construction of the dentures.
This is because it is more convenient to handle a finished denture that is already
XL

functioning in the patient’s mouth and because d the valuable information wnich
may be elicited from our patients. The subjective feeling of the patient when &zfcEIi-
gently elicited is of tremendous help in denture prosthesis, so fascinating, but Jso
deeply permeated with so many invisible and intangible causes for failures
If the patient is furnished with dentures that are constructed scientifically, hut-
which he cantlot wear, our efforts and the patient’s money have gone to waste. If,
on the other hand, the dentures are constructed without regard to basic scientific
principles and, yet, the patient reconciles himself to these restorations, the dentist
has sold the patient a commodity instead of a health service. Dentures are successful
only if the dentist is satisfied with his work from a biologic and technologic stand-
j joint and the patient is happy with their performance in function

TIIE CORONOID PROCESS

As a rule, there is ample space between the maxillary tuberosity and the coro-
noid process to allow for free movements of the coronoid process with an upper
denture in position. Occasionally, however, the maxillary tuberosity descends as a
result of missing mandibular posterior teeth over a long time, and/or there is an
overgrowth of the tuberosity in a buccal direction.
When an upper denture is constructed over such tuberosities and the flanges
are too thick, the coronoid process may meet interference in function. If the inter-
ference is severe, it will be easily detected. Either the patient himself will point out
the soreness and the nature of the trouble, or else after 24 or 48 hours of wearing
the dentures, there will appear redness and tenderness of the tissue involved.
The buccal surface of the denture flange over the tuberosity must be thinned
until the discomfort is eliminated. Care should be esercised not to perforate the
denture or otherwise mutilate it in that area, because retention is usually lost
together with the loss of the buccal flanges. -2 remake of the denture is then
necessary, because attempts at repairing these flanges most frequently terminate
in failures.
Mild interference of the buccal flange of the upper denture with the movements
of the coronoid process is much more difficult to detect and may be more trouble-
some. The irritation of the buccal mucosa is not sufficient to aid in detection, and
the rather vague complaints of discomfort of the patient often misdirect the dentist’s
efforts.
A study of the anatomy and morphology of the coronoid process does tiiii
suggest any momentous relationship between this osseous structure and the function
of complete dentures. However, if we consider the complex function of the various
fibers of the powerful temporal muscle that is attached to the coronoid process, we
get a different perspective of its significance.

WHARTON'S (SUBMAXILLARY) DUCT

Wharton’s duct in a static state may be far enough from the lower lingual
denture border so as not to warrant the existence of interference. Yet, there are
instances in which the insertion of a lower denture causes complete or partial
closure of Wharton’s duct.
“N:r’,‘,‘1’ TROUBLE SHOOTING IN COMPLETE DENTURE PROSTHESIS. VIII 83

Clinically, the closure is manifested by the enlargement of the submaxillary

gland to a point that the patient gets frightened, mistaking this condition for a
sudden and serious abscess. Actually, the gland usually returns to normal soon
after the denture is removed from the mouth. In instances in which the compression
of this duct is slight or of short duration with long intervals, or when no contact
whatever is effected between the denture border and the duct, the diagnosis of this
condition becomes more difficult. Some patients complain that the gland becomes
swollen slightly when they eat. With others, it occurs only when they drink fruit
juices. When asked to call at the office immediately upon occurrence of the swelling,
they invariably state that it is of too short duration. Experimentation with some
patients with fruit juice drinks in the dental office failed to evoke the same reaction.
In severe instances of compression of the lumen of the duct by the denture border,
judicious relief brings immediate relief.
In all mild duct closures, the treatment is symptomatic. In many instances, this
mild discomfort disappears by itself during the period of adjustment to the dentures.
In other instances, a reduction of the thickness of the lingual flange, without dis-
turbing the border, affords the patient the desired relief. Therefore, it may be
assumed that while Wharton’s duct in a static state is rather far away from the
border of the lower denture, there are exceptions to the rule. Second, it may be
assumed also that when the muscles of the floor of the mouth and the adjacent
structures are functioning actively, Wharton’s duct or its innervation occasionally
contacts with the denture border. This, in turn, may cause reflex symptoms. We
must exercise great care not to mutilate the lower denture by excessively reducing
its borders.
136 EAST 54~~ ST.
NEW YORK 22, N. Y.