Complete dentures are functioning in the oral cavity of geriatric
patients; they must be fabricated in such a way that
they are in harmony with the normal neuromuscular function.
All oral functions, such as Phonetics, mastication,
Esthetics, swallowing, smiling, and laughing, involve the
synergistic actions of muscles of the tongue, lips, cheeks,
and floor of the mouth which are very complex and highly
individual. Failure to give the cardinal importance to position
of tooth and polished surface often results in dentures
which are unstable and unsatisfactory, even though they were
skillfully planned, designed and expertly constructed. The
coordination of complete dentures with the neuromuscular
function is the foundation of successful, stable dentures .
After loss of all teeth, there exists within the oral cavity a void
which is the potential denture space. The neutral zone is the
potential space between the lips and cheeks on one side and
the tongue on the other, that area or position where the forces
between the tongue and cheeks or lips are equal . Improper
arrangement of teeth & polished surface may lead to failure of
the prosthesis. This is particularly true for patients with reduced
mandibular residual ridges, yielding flat or concave foundations
due to severe bone loss. The unstable lower complete
denture is a continuing problem for Dental Practitioners .
A 78-year-old male patient had referred to the Department
of Prosthodontics at Swargiya Dadasaheb Kalmegh
Smruti Dental College & Hospital, Nagpur with the
complaints of not being able to chew properly, loosening
of upper and lower denture and poor esthetics for
the past 3 years. He also had complaint of movement
of mandibular denture while swallowing and speaking.
In extra- oral examination of patient, hollow cheeks with loss
of support for lips & cheeks can be readily made out (figure 1).
Intra-oral clinical Examination of the patient revealed poorly
resorbed Maxillary & Mandibular Ridges. Flabby & mobile
tissue was tissue was present in maxillary anterior area (figure 2). Poorly resorbed knife edge Mandibular ridge was clearly
evident (figure 3). Orthopantomogram (OPG) confirmed the
extensive bone loss in both the arches with knife edge ridge
in mandibular arch (figure 4). Vical & swoop Analyses was
made to quantify the bone loss in mandibular arch (figure 5).
Examination of existing denture, made 10 years back,
showed overextended flanges & severe attrition of occlusal
surface of artificial teeth. Denture had lost vertical & centric
Relations. Extrinsic Stains can be seen on polished surface
& even tissue surface appears to be smooth (figure 6). Patient was On Insulin for uncontrolled Diabetes mellitus
for last 13 years. Four months back, Patient had undergone
Coronary Artery Bypass Graft (CABG) Surgery for
cardiac ailment. He was on anti- hypertensive & anti- coagulant
therapy. So, the patient was informed of all the options
available for the treatment including implants, but due
to his dearranged medical profile, implant was discarded
from treatment options and treatment chosen was esthetically
and functionally viable for him. This article describes
a simple clinical approach for fabrication of denture, which
had good retention, stability, and esthetics for the patient.
While designing Treatment plan, special emphasis was given
to improve Support, retention, stability, esthetics, Comfort &
Preservation of remaining tissues. Maximal extension of the
denture base with maximal area of contact between mucosa
membrane and denture base so as to have intimate contact of
the denture base and its basal seat was important to get our goal.
First, the primary impression of maxillary & mandibular
edentulous ridges was made by irreversible hydrocolloid
on the stock metal tray to record the mucosa in static form
(figure 7). Cast was poured in Type II Gypsum Product
(Dental plaster). Over the cast, Mark the flabby ridge area
on the cast & special tray with proper spacer was fabricated
using Tray material resin. The tray was trimmed 2 mm short
of margin & verified for extension in the mouth. Border
molding was done using Low fusing impression compound
in segments with proper tempering to avoid tissue injury.
After removing spacer, the maxillary wash impression using
Zinc Oxide Eugenol impression paste was made. A window
was made on the marked area for flabby tissue & again verified
intra-orally. Paint Impression Plaster on the area of flabby
tissue using hair brush to record the tissue in most passive
form so that distortion of the tissue can be avoided. After setting
of impression plaster, the entire tray was removed from
maxillary arch. For mandibular ridge, after removing spacer,
tray adhesive was applied on tissue surface & allowed to
dry for 10 minutes. Then, light viscosity addition silicone
was loaded on the tray & immediately wash impression was
made & material is allowed to set for 4 minutes (figure 8). After disinfection, Final Cast was poured in Type III Gypsum
Product (Dental Stone).
The temporary record bases were prepared on the final cast using
Auto-polymerizing Acrylic resin. By using spring bow, the
maxillary cast was oriented to the Hanau wide view articulator.
The vertical & centric Jaw relation was done using Niswonger's
Technique & Inter-occlusal wax check bite record method respectively.
To improve the Stability, extra care was given on the
occlusal plane level, Teeth arrangement in Neutral Zone & use
of Non Anatomic teeth. The mandibular occlusal plane was
kept 2/3rd to the retromolar pad so that horizontal movement
of the mandibular denture can be prevented.
For Neutral Zone recording, maxillary & mandibular rim is
made in medium fusing impression compound & adjusted as
in normal registration for a complete denture. Only core portion
of Impression compound is left to record Neutral Zone.
Tissue conditioner is applied on facial as well as palatal & lingual
surfaces of compound rim & patient is asked to talk and
swallow, and drink some water. After 10 minutes of dynamic
manipulations of lips, cheeks & tongue, the entire assembly
was removed from oral cavity & cleaned (figure 9). The Tissue
conditioner would have been molded by the patient's musculature
into a position of balance. The plaster indices were made
on the assembly (figure 10).
The Non Anatomic Teeth arrangement & waxing of polished
surface of the denture was done by using plaster indices to have
maximum stability (figure 11). Try-in of the denture was done
in patient (figure 12). After patient's consent, the denture was
processed using Heat cured polymethyl methacrylate denture
base resin. Laboratory remount was done & minute processing
error was rectifies. The polished denture was ready for denture
insertion (figure 13). There was tremendous improvement of
Extra-oral & Intra- oral appearance of the patient. Patient was
appeared to have regained confidence on his face (figure 14).
The instruction regarding maintenance & recall were given.
Patient recalled immediately 24 hours after denture delivery &
minor occlusal correction was done. Recall was monitored for
1week, 1 month, 3 months, 6 months & for 1 year. Patient was
completely satisfied in terms of retention, mastication, speech,
comfort & esthetics.
The residual alveolar ridge consists of denture-bearing mucosa,
submucosa, periosteum, and underlying alveolar bone
. Residual bone is that part of alveolar ridge which remains
after the teeth have been lost. After the loss of tooth, the alveoli
that contained root are filled with new bone. This alveolar process
becomes the residual ridge which is the foundation for the
denture. The mean denture-bearing area of maxilla & mandible
is 22.96 & 12.25 cm2 respectively. We have used the clinical
techniques to improve support, retention, and stability of
the lower denture. We ensured the maximal contact between
mucosa membrane and denture base and intimate contact of
denture base and basal seat area.
In this case, we had flabby tissue in maxillary anterior region,
where probably, the resorption of the alveolar process was
rapid and sophisticated; the mucosa has no bone support and
becomes loose and flabby . The mucosa is highly movable
and loosely attached to underlying periosteum of the bone.
The presence of displaceable denture-bearing tissues often
presents a difficulty in making complete dentures. . Soft tissues
that are displaced during impression making tends to return
to their original form, and complete dentures fabricated using
this impression will not fit accurately on the recovered tissues.
This results in loss of retention, stability discomfort and gross
occlusal disharmony of the dentures. So recording of those
tissues in static form was utmost important. Hence, Primary
impression was made in Irreversible Hydrocolloid. For Final
Impression of maxillary ridge, the technique was selected
aiming at recording the flabby tissue in an un-displaced or in
an undistorted. Zinc oxide Eugenol impression paste is first
used for making impression and then tissue is painted using
impression plaster onto the displaceable tissue. Impression
plaster is a Mucostatic impression material and produces little
pressure. In this way, maxillary anterior area was recorded in
Jaw relation was made in a usual method with extra emphasis
on providing optimum free way space during Vertical jaw
relationship. Neutral Zone is defined as a Potential space between
lips and cheeks on one side and tongue on other side
(or) the area or position where the forces between the tongue
and cheeks or lips are equal . Neutral zone was recorded by
means of tissue conditioner and tooth was set exactly in the
neutral zone. After the wax trial was completed, it was seen
whether the patient's tongue was at par with the lingual cusp
of the lower posterior teeth. This was done in order to gain
maximum stability to mandibular denture.
All Prosthodontist wants to provide Successful prosthesis to
satisfy the need of the patient. A thorough history making, an
investigating eye in clinical examinations and other diagnostic
tools leads to careful selection of optimum treatment based on
sound knowledge is the key for Success in Complete denture