Addressing Problems in Complete Dentures
October 2007
by Eugene LaBarre, DMD Lola Giusti, DDS Gabriela Pitigoi-Aron, DMD
Compendium
Abstract
The authors have compiled a set of solutions to the most common issues influencing the success of complete denture cases. A brief review and discussion of occlusal vertical dimension is presented, followed by a troubleshooting guide to problems such as inadequate retention and stability, discomfort, and other problems affecting treatment outcome.
Many prosthetic dentists feel qualified to provide diverse services to their patients requiring re?habilitation. Of those generalists and specialists, a good number admit that the completely edentulous patient presents difficulties that trigger feelings of inadequacy or anxiety in the practitioner (F. Fendler, DDS, oral communication, September 2007). Most clinicians will make mistakes as they learn denture fabrication, which can be costly, as laboratory procedures are often involved in their rectification. These errors cause many dentists to lose confidence. Competence in fabricating complete dentures is primarily a matter of completing enough cases to establish mastery of each phase in the sequence from initial exam to postinsertion adjustments. The authors' view is that most practitioners can achieve general competence in complete denture fabrication after completing approximately 50 patient cases.
Basic instruction in complete denture techniques is increasingly crowded out of the curriculum in most un?dergraduate dental schools by instruction in implant procedure (R.H. Ahlstrom, DDS, oral communication, July 2007). As a result, young practitioners must be extremely motivated to become adept in complete denture techniques. Some troubleshooting strategies are presented here with the goal of accurately addressing the most common denture-related problems encountered in dental practice. This article addresses occlusal vertical dimension (OVD) and vertical dimension of rest (VDR) because they are so often implicated in the problems presented with existing dentures. The bulk of the article is organized in a table providing solutions to the various complaints patients report when they are having problems with complete dentures. The information is the result of many years the authors have spent troubleshooting prostheses.
Establishing Occlusal Vertical Dimension
Figure 1ÛPatient with wax rim set between VDR and OVD. Low mark is VDR; upper mark is OVD. Marks made with pressure indicating paste.
First and foremost, it is essential to understand and accurately establish OVD, the vertical dimension of the face when the teeth or occlusion rims are in contact in centric occlusion. It is worthwhile first to quickly review methods of establishing VDR, the vertical dimension of the face with the jaws in the rest relation, before establishing OVD, which is always a lesser number. VDR minus OVD equals the freeway space, ie, the interocclusal gap. Young patients, and those receiving immediate dentures, for example, have less freeway space than older patients with greater interalveolar dimension.1 These methods of determining VDR may involve "dots" placed on the nose and chin with a marker and subsequently measured with a tongue depressor or Boley gauge, or another technique described here using a vertical dimension recorder, shown in Figure 1.a If these ideas are not immediately clear, the reader should review a textbook on the basic methodology of finding OVD and VDR.
Rest position may be located a number of ways. Earl Pound was a proponent of using speaking space to assist the operator in locating the VDR.2 The patient is asked to count from 50 to 55, for example, and rest with the lips touching. Alternatively, the patient may open as wide as possible, then rest with the lips touching.
Figure 2ÛEstablishing rest position with vertical dimension recorder.
Another method is to measure with a verticorder (Figure 2).3 The verticorder is positioned on the hard part of the chin and rotated to a location on the nose. Because it is used on the hard part of the chin, this instrument can reduce errors because of the movement of soft tissues.3 To cross-check the measurement, a patient might repeat the "mmmm" sound, and then rest. Three repeatable measurements are usually adequate to set a measurement of the rest position.4 Patients who have not been wearing prostheses may take more than 3 measurements to reach a repeatable rest position.
The lesser measurement of the OVD, located above the previously established VDR, can then be determined using the verticorder.5 The verticorder also may be used to duplicate the OVD in an existing set of complete dentures, if the patient is doing well with it.6 When the patient is in centric occlusion with the dentures in place, a mark may be made on the nose with a pen or pressure indicating paste at that measurement, and the wax rims for the new dentures will be reduced to that mark. The verticorder should not be adjusted between the VDR and centric relation (CR)/OVD measurements; rather, it is the mark on the nose that will move upward at the decreased dimension. The CR record should be verified at that same measurement. The first mark is made at VDR, and the second mark will be at CR/OVD. Thus, the verticorder can be used at the records appointment in the fabrication of new prostheses as well as in duplicating an old denture. It also may be used at the trial denture appointment, an often overlooked step, to verify CR/OVD vs VDR before processing.
Errors in establishing OVD are extremely common, in both the CR record and in the trial denture. Failure to confirm this dimension at the trial denture appointment is another typical error. If an error transpired at the records appointment, it can easily be corrected at the trial denture appointment with a new record and remount of the mandibular cast. Undetected, however, it may doom the future success of the case.
Conclusion
Errors in OVD contribute to a large percentage of patient complaints and ultimate dissatisfaction with a set of complete dentures (Table, downloadable PDF ).6 Of all the factors presented in the table, however, probably the most critical determinant of success in complete denture treatment is patient attitude. A patient who is receptive to guidance greatly influences a positive outcome.7 Ideally, that pa?tient also will possess good neuromuscular control. In that situation, the likelihood of successful treatment approaches 100% (I.M. Zlotolow, DMD, oral communication, March 2007).
The support of a competent, caring technician is essential to delivering high-quality removable prostheses. An experienced laboratory professional can guide a novice dentist in many ways and accelerate the practitioner's progress in mastering complete denture fabrication. The practitioner is encouraged to seek out high-quality laboratory support to minimize frustration for all concerned.
Although the percentage of completely edentulous adults is decreasing, the overall number of patients requiring complete dentures is on the rise because of the increasing population. The demand for dentists to serve the needs of this patient population is therefore on the rise.8 The ability to provide high-quality prosthetic services can be satisfying for the practitioner. The authors hope that more practitioners will attempt to achieve general competence in the discipline through persistence and study, and thereby minimize their difficulties in complete denture technique.
Disclosure
The authors have no commercial interest in the verticorder device and acknowledge that other methods can be used, such as a tongue blade measurement, in establishing VDR and OVD.
a DSG Heumann and Associates, Topeka, KS.
References
1. Zarb GA, Bolender CL, Carlsson GE. BoucherÌs Prosthodontic Treatment for Edentulous Patients. 11th ed. St. Louis, Mo: The C.S. Mosby Co; 1997.
2. Pound E. Controlling anomalies of vertical dimension and speech. J Prosthet Dent. 1976;36:124-135.
3. LaBarre EE. Clinical Instructions for Complete Dentures. A Chair?side Guide. San Francisco, Calif: University of the Pacific, Eugene LaBarre, DMD, MS; 2003:1-14.
4. Morikawa M, Kozono Y, Nogushi BS, Toyoda S. Reproduci?bility of the vertical dimension of occlusion with an improved measuring gauge. J Prosthet Dent. 1988; 60:58-61.
5. Geerts GA, Stuhlinger ME, Nel DG. A comparison of the accuracy of two methods used by pre-doctoral students to measure vertical dimension. J Prosthet Dent. 2004;91:59-66.
6. Bissasu M. Use of a patientÌs old complete denture to determine vertical dimension of occlusion. J Prosthet Dent. 2001;85:413-414.
7. Levin B, Richardson GD. Complete Denture Prosthodontics: Clinical and Laboratory Procedures. 19th ed. Los Angeles, Calif: University of Southern California School of Dentistry, 1995.
8. Beumer J. Vital and Health Statistics, Clinical Slide Series, UCLA Complete Den?ture Teach?ing Materials, University of California at Los Angeles, 2004.
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Linda McChesnie says: | 2010-03-23 08:11:55 |
| Have had complete set of dentures made. top fine bottom will not hold with fixident etc.& hurt when I try to eat unless food is soft. Have been back 5 times now & still not right. Help please. | ||
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