Treating the modern complete denture patient: A review of the literature

John R. Ivanhoe, DDS,a Roman M. Cibirka, DDS, MS,b Gregory R. Parr, DDS, MSc School of Dentistry, Medical College of Georgia, Augusta, Ga.
This article reviews the physical and mental compromises of todays patients, techniques, materials, occlusion, impressions, and soft liners and makes recommendations as to managing these compromises when fabricating complete dentures. References used were primarily from the classical literature, and an effort was made to ascertain whether these treatment recommendations are appropriate for todays more difcult patients. An effort was made to incorporate recent recommendations where appropriate. (J Prosthet Dent 2002;88:631-5.)

he subject of complete denture problem solving has been reported frequently and completely in the literature.1-16 Jacobs17 points out that most prosthodontic literature is clinically generated and disseminated and does not follow the dictates of controlled scientic research. Although this is true, this alone does not make the literature wrong. A large number of the classic articles, although empiric in nature, have served as the basis of successful prosthodontic practices over the years and, in many situations, decades. Although it is desirable, controlled or procedural research in the human setting is difcult, expensive, and in some instances ethically questionable. Therefore at this time we must often rely on the successful treatment regimes recommended over many years. When the classic literature was developed, typical complete denture patients lost teeth in their early life, often before age 30. These patients could generally be characterized as young and healthy with large residual alveolar ridges covered with rm, healthy mucosa able to withstand large functional forces. Patients expected good esthetics and comfortable function for long periods of time with little maintenance. Cusped porcelain teeth were often selected for the sake of esthetics, mechanical balance, and longevity. Cross-linked acrylic resin teeth did not exist. The purpose of this article is to describe management of a contemporary denture patient and to make recommendations for solving complete denture problems.

PORTRAIT OF TODAYS DENTURE PATIENT

It has been reported that the typical complete denture patients of today have a greater mean age, live independently, are nancially able to afford care, and are retaining more teeth.1,18-26 Additionally, missing teeth are being replaced by more xed partial dentures, more removable partial dentures, and more implant-supa

Associate Professor, Department of Oral Rehabilitation. Associate Professor, Department of Oral Rehabilitation. c Professor, Department of Oral Rehabilitation.
b

ported prostheses.23 These trends are viewed as positive and are reective of the advances in dental prevention, personal oral hygiene, and maintenance.18-20 A large complete denture population exists and a study by Douglass et al27 suggests that this population will continue to increase over the next 20 years. It has been documented that there are fewer totally edentulous patients and fewer complete dentures being done in practice.19,21 Difculty exists in accessing the size of this population as evidenced by the following. Catovic et al28 examined 120 elderly nursing home residents and determined that 82% needed some form of prosthetic intervention. Garrett et al29 determined that 55% of patients assessed were moderately to fully satised with dentures that examining dentists found in need of replacement. In another study, Nevalainen et al30 evaluated the complete dentures of 144 patients over 75 years old. They found that depending on the criteria used, between 10% and 80% of the dentures were in need of replacement. These studies demonstrate the difculty of determining the actual present and future needs of complete denture patients. Unfortunately, the number of cognitively impaired adults in institutional settings is increasing.31-33 This is perhaps the most difcult group of edentulous patients to manage, as their ability to cooperate in their own care is signicantly reduced.34-37 The current denture population may be characterized as having a larger number of medical problems that require the care of 1 or more physicians.20,38 These patients are frequently taking a large number of medications, often prescribed by different physicians, without collaboration.39-40 These factors may result in tissue responses to complete dentures being less satisfactory and reduce the healing capacity of the oral tissues.11,41-46 Subsequently, it may be more difcult to manage the edentulous patient with predictable success. Clinically, many of these patients are seen with severely resorbed residual ridges and prominent anatomic landmarks or bony abnormalities. The soft tissues are often redundant and unsupported. Maxillary arches frequently demonstrate enlarged tuberosities and redunTHE JOURNAL OF PROSTHETIC DENTISTRY 631

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dant anterior tissues resultant to the use of maxillary complete denture opposing a mandibular removable partial denture with natural anterior teeth as described by Kelly.47 Occasionally patients have reconditioned their prostheses with over-the-counter soft liners or tissue paper resulting in tremendous debilitation of the residual ridges. Anterior teeth on existing prostheses are often in occlusal contact because of wear and loss of vertical dimension.48 Some patients expect the anterior teeth of the new dentures to contact in a manner similar to their natural teeth. In many situations, the restoration of natural anterior tooth contacts could result in compromised function and esthetics, making it necessary to educate the patient about the need to modify the tooth position and tooth contact to facilitate an acceptable functional prognosis.

PATIENT EDUCATION
Many common characteristics of an aged population, such as decreased neuromuscular coordination, reduced ability to sense where the mandible is in relation to the maxilla (oral awareness), and impaired ability to position the mandible or tongue in desired locations (oral dexterity), will complicate the complete denture treatment process.37,49-51 Patients generally expect new dentures to t and function better than their existing dentures. Most patients anticipate that their new dentures will be an improvement over their previous dentures but are resigned to understanding that compromises may be necessary. Those few who demand similar esthetics to the former denture may prove to be a difcult management situation. Careful patient education and preparation for replacement dentures is critically important.52,53 A thorough examination is invaluable for proper diagnosis, treatment planning, and identication of realistic goals or expectations. Many patients are aware that physical changes have occurred in their bodies, but some are unaware of the impact on their oral cavities.32,33,54-56 Other problems can also complicate treating these patients. Burnett et al57 points out that attempts to improve denture hygiene (habits) of veteran denture wearers with either verbal or written instructions were equally ineffective in changing the habits when reviewed 6 months after the instructional material was delivered. Yemm58 suggests incorporating surface features of the old prostheses so the patient will nd it easier to cope with and adjust to new dentures.

quate tissue rest by way of denture removal for a period of days is a common method of correction.62,63 The use of tissue conditioners is the next procedure that can help return the tissues to a healthy condition.64,65 Tissueconditioning therapy is often requisite to surgical procedures and can provide suitable modication of an existing complete denture for use during the treatment phase. Preprosthetic surgery may be viewed as a questionable treatment recommendation by an experienced denture wearer unaware of the deleterious tissue response that has developed. One of the more frequent treatment recommendations is the surgical management of large tuberosities. Failure to recognize and manage enlarged tuberosities may impede the clinicians ability to develop proper vertical dimension and occlusal plane orientation. Both of these considerations impact the forces applied to the denture bases during function and parafunction. Denture base movement and lack of stability is a common cause of soreness and lack of retention. Another preprosthetic procedure frequently overlooked is soft tissue removal from the superior and lingual surfaces of the retromolar pad. This procedure provides a rm retromolar pad with a shallower slope in the molar area. When unrecognized, this region may be distorted during impression making, potentially resulting in tissue impingement and patient soreness. The removal of redundant tissues covering a sharp or highly resorbed residual ridge, or augmentation of redundant tissue with articial materials has fallen into disfavor because of frequent complications.66

IMPRESSIONS
Special impression procedures, often time consuming, are frequently required when abnormal anatomy or redundant tissue is present. No impression material solves impression-making difculties with easily distorted, unsupported soft tissues that cannot be surgically managed. Advanced mandibular resorption frequently results in prominent genial tubercles covered by thin friable tissue. Frequently, lip and cheek tissue attachments have migrated so that only a narrow band of attached tissue remains. For proper impressions a custom acrylic resin tray should be designed to be narrow enough to allow for functional border molding of the denture bearing area, but rigid enough to resist distortion and breakage. Tray modication by the placement of holes to allow excess material to escape and to reduce hydraulic pressure should follow the completion of border molding. A dual tray procedure that captures mobile redundant tissue in a relaxed state has previously been described and may be required.67
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PREPROSTHETIC CARE
Long-term denture use, especially of a poorly maintained or ill-tting denture, can lead to tissue trauma and chronic soreness.59-61 These conditions must be corrected before new denture fabrication by use of tissue rest, tissue conditioning, or preprosthetic surgery. Ade632

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INTEROCCLUSAL RECORDS
Elderly patients have physical limitations to successful denture use that become increasingly important. Ridge resorption, loss of oral awareness and dexterity combine to complicate accurate and repeatable jaw relation records due to denture base instability or inability to cooperate. Materials used to register jaw relation records should allow for dynamic movements of the mandible while setting, or be quick-setting as older patients frequently nd it difcult to posture the mandible still for extended periods of time. Record bases can be stabilized manually or with denture adhesive while making jaw relation records.

SOFT LINERS
The use of processed soft liners for purposes of cushioning or stress distribution to protect the frail residual ridges is desirable conceptually, although no liner fullls all of the reported necessary criterion for a satisfactory material.79-83 Continued development of these materials provides great hope for the future of the elderly denture population with diminished residual ridge support.

INSERTION AND POSTINSERTION

Postoperative adjustments and initial use after insertion should not be regarded as a correction for errors created during fabrication but as one of the last steps in the complete denture process. This is the last opportunity to reinforce patient education and instruction. It is the dentists responsibility to fabricate the dentures and instruct patients regarding realistic expectations and use.4,57,84-86 Patients remember and expect denture retention, but they have often forgotten that tongue control aided in the retention of the mandibular denture. The effect of tongue movement on mandibular denture retention cannot be underestimated and must be reinforced. Patients must understand that adjusting to new dentures takes time, practice, and patience. The patient must actively participate in this step with our assistance. A patients initial goal in the adaptation process should be to become comfortable with the dentures in the mouth, followed by adaptation to masticating soft, then harder foods. The use of denture adhesive during this adaptation period may be helpful to reduce control difculties before the patient becomes discouraged. Denture adhesive use should be carefully instructed and monitored. Denture adhesives are currently being recommended more than they have in the past and are also sought more often by patients.87 The long-term use of denture adhesive as a crutch during the adjustment period or as a substitute for lost neuromuscular control may also be necessary. Adhesive use should not offset inadequate prosthodontics. Patients should be encouraged to reduce their dependency on adhesive over time and perhaps eliminate its use all together.88 The length of the adjustment period varies with the patient.89

ESTHETICS
Our desire to develop a natural appearance by placing teeth where they once were in nature, and to create complicated occlusal reconstructions suffers proportionally with patient age. Fortunately, most patients realize compromises are required and often do not demand the esthetics of their youth. Awareness of esthetic compromises must be discussed and understood by the patient before the initiation of treatment and reinforced throughout the treatment phase. The authors believe that restoring a large loss in the vertical dimension of occlusion should not be completed in 1 step. Excellent procedures for the stepwise additions of conventional impression compound followed by autopolymerizing resin are outlined by Stout and others.68-70

OCCLUSION
The Class II occlusal relationship also necessitates patient education and reinforcement. The patient should understand that the maxillary anterior teeth are set for proper lip support and esthetics while the mandibular anterior teeth are arranged more posterior favoring stability. Once the patient has accepted the concept, the chances for success via better control of mechanics increase. Patients are often quick to point out that their natural teeth were not located in this manner and will not accept the ideal relationship if not properly educated. The ability of patients to masticate with complete dentures is an important consideration; however, studies have reported masticatory ability is not inuenced by occlusal scheme.39,71-74 Posterior occlusal schemes, such as neutrocentric occlusion or lingual contact nonbalanced occlusion, are desirable because they allow for increased freedom in centric relation and use of various jaw closure positions by the patient possibly offsetting the clinicians inability to capture accurate jaw relation records.75-78
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RECOMMENDATIONS
1. It is critically important to impress on the typical geriatric complete denture patient the fact that they should return for yearly recalls to keep their complete dentures tting well. However, many elderly patients, especially those in institutions, reach a point where, because of health or mental status, they are totally unable to cooperate during retting of their dentures. Retting of their dentures is difcult and may be impossible as a certain degree of patient understanding and cooperation is required.
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2. Consider using a simple occlusal scheme in elderly patients where inability to cooperate because of poor neuromuscular control or denture base movement as a result of severe ridge resorption makes jaw relation records difcult. In both of these circumstances adjustment of the dentures after insertion is also difcult. 3. Reduce iatrogenic problems via proper selection and careful application of denture fabrication techniques. This is not the place for short-cut techniques. Perform each step carefully and accurately to minimize potential problems. Remember, many of these patients have a reduced capacity to adapt to denture created problems. 4. Provide patient education to the fullest extent possible using verbal, visual, and written modalities, beginning at the rst appointment. Review your recommendations often to reinforce them.
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74. Pound E. Utilizing speech to simplify a personalized denture service. J Prosthet Dent 1970;24:586-600. 75. Kapur KK, Soman S. The effect of denture factors on masticatory performance, III: The location of the food platforms. J Prosthet Dent 1965;15: 451-63. 76. Kapur KK, Soman S. The effect of denture factors on masticatory performance, IV: Inuence of occlusal patterns. J Prosthet Dent 1965;15:662-70. 77. Kapur KK, Soman S, Shapiro S. The effect of denture factors on masticatory performance, V. Food platform area and metal inserts. J Prosthet Dent 1965;15:857-66. 78. Garrett NR, Perez P, Elbert C, Kapur KK. Effects of improvements of poorly tting dentures and new dentures on masticatory performance. J Prosthet Dent 1996;75:269-75. 79. Williamson RT. Clinical application of a soft denture liner: a case report. Quintessence Int 1995;26:413-8. 80. Wright PS. Observations on long-term use of a soft lining material for mandibular complete dentures. J Prosthet Dent 1994;72:385-92. 81. Soni A. Management of severe undercuts in fabrication of complete dentures. N Y State Dent J 1994:60:36-9. 82. Duncan JD, Clark LL. The use of a soft denture liner for chronic residual ridge soreness. J Am Dent Assoc1985;111:64-5. 83. Bell DH, Jr. Clinical evaluation of a resilient denture liner. J Prosthet Dent 1970;23:394-406. 84. Samant A, McDermott I, Cinotti WR. Delivery complete dentures: preventing problems after insertion. Gen Dent 1984;32:229-31. 85. Rufno AR. Complete denture problems: a review of post-insertion correction. N Y State Dent J 1983;49:668-74. 86. Boos RH. Preparation and conditioning of patients for prosthetic treatment. J Prosthet Dent 1959;9:4-10. 87. Kapur KK. Clinical evaluation of denture adhesives. J Prosthet Dent 1967; 28:550-8. 88. Ghani F, Likeman PR, Pciton DC. An investigation into the effect of denture xatives in increasing incisal biting forces with maxillary complete dentures. Eur J Prosthodont Restor Dent 1995;3:193-19. 89. Vinton P, Manly RS. Masticatory efciency during the period of adjustment to dentures. J Prosthet Dent 1955;5:477-80. Reprint requests to: DR JOHN R. IVANHOE MEDICAL COLLEGE OF GEORGIA SCHOOL OF DENTISTRY AUGUSTA, GA 30912-1250 FAX: 706-721-6276 E-MAIL: jivanhoe@mail.mcg.edu Copyright 2002 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2002/$35.00 0 10/8/130147 doi:10.1067/mpr.2002.130147

New product news

The January and July issues of the Journal carry information regarding new products of interest to prosthodontists. Product information should be sent 1 month prior to ad closing date to: Dr. Glen P. McGivney, Editor, UNC School of Dentistry, 414C Brauer Hall, CB #7450, Chapel Hill, NC 27599-7450. Product information may be accepted in whole or in part at the discretion of the Editor and is subject to editing. A black-and-white glossy photo may be submitted to accompany product information. Information and products reported are based on information provided by the manufacturer. No endorsement is intended or implied by the Editorial Council of The Journal of Prosthetic Dentistry, the editor, or the publisher.

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