Diagnosis and management of problems at review Flashcards
ILO 2.6a: be familiar with the design and choice of materials used in the production of partial dentures, along with knowledge of laboratory procedures
what are some common issues a patient may report at the review appointment?
- pain
- retention
- instability
- occlusion
- occlusal vertical dimension
- patient acceptance
- problems eating
- aesthetics
- speech
- food traping
what are some patient factors affecting the production or design of RPDs?
- confusion or uncertainty
- percieved pain over the full denture bearing area or persistent pain
- immediate intolerance
- multiple consecutive sets of dentures
- lack of experience wearing removable prostheses
- history of non perseverence, anxiety or depression
- poor neuromuscular control or dexterity (affects muscles that support and maintain denture in place)
what are some of the clinical factors affecting the production and design of RPDs?
- restricted intra oral access
- dry mouth
- hyperactive tongue or lateral spread
- gag reflex
- ulceration (esp. if medication-induced)
- superficial nerves due to advanced resorption
- atypical facial pain
- tori impeding extensions or paths of insertion
what technical factors affect the production and design of RPDs?
- poor communication
- suboptimal clinical or technical work
- damage to work in transit
what is the order of RPD design and a mnemonic?
- Saddles - Something
- Rests - Really
- Clasps - Complicated
- Indirect retention - Is
- Bracing - Best
- Reciprocation - Resolved in
- Major and minor connectors - Many
- Simplification - Steps
where can problems in RPD manufacture go wrong?
- assessment
- impressions
- jaw registration
- tooth trial
- fit
what can go wrong in the denture assessment stage?
- does patient have good denture-wearing history?
- assessment of current dentures
- what are the patient’s goals
- patient selection
what can go wrong with impressions?
- size/shape of tray - inaccurate impression = poorly firring special tray = inacurate master impression = poor denture fit
- material selected
- not surveyed
- poor design
what can go wrong with the jaw registration stage?
- incorrect occlusion
- pain
- denture dislodges
- fracture
what can go wrong in the tooth trial stage?
- incorrect occlusion
- tooth position
- over/under extension
- appearance - shade, mould, buccal corridors (record in notes)
what can go wrong when fitting the denture?
- is denture correct
- roughness / blebs
- undercuts - difficulty/pain inserting/removing
- over-extension - only to functional depth of sulcus
- fraenal relief
- muscle attachments
- occlusion
- speech
what can cause loss of retention in a denture?
- xerostomia
- changes in tissues
- poor/altered neuromuscular control
- poor engagement or loss of undercuts
- post dam too deep
- home alterations by patient
what can cause increased displacement in a denture?
- lack of ridge support due to remodelling or fibrous ridges
- overextension
- deep post dam
- teeth not in the neutral zone
- teeth not placed over the ridges
- displacing occlusal contacts
- intolerance of the retruded arc of closure
what can cause base irregularities in RPDs?
- sharp or unfinished parts of the fitting surface
- fracture
what can cause problems with the occlusion?
- excessive occlusal vertical dimension (OVD) - pain on ridges
- excessive freeway space - pain in TMJ
- heavy occlusal contacts
when a patient reports pain, what should you check for?
- check soft tissues for areas of trauma and ulceration
- check the denture to see if anything obvious on it corresponds e.g. acrylic nodules
if the patient complains of pain on insertion/removal, what is causing it and how do you fix it?
caused by acrylic rubbing against mucosa
* use pressure indicating paste on denture area
* insert and boulder mould then remove
* bare spots where paste has rubbed off in areas of excess pressure
* relieve with acrylic trimming bur
* repeat until paste is no longer rubbing off
if the patient is complaining of the denture digging in, what is causing it and how do you fix it?
denture is overextended and impinging on muscle attachments
* insert denture and move muscles by ‘muscle trimming’ (border moulding) and see if denture dislodges
* can pinpoint specific area with pressure indicating paste - adjust adn repeat
* polish again when happy
if the patient is complaining of pain with/without ulceration on or around the frenum, what is causing it and how do you fix it?
acrylic is encroaching on fraenal attachments so inadequate space for fraenum
* make fraenal relief more pronounced (v-shape)
* re-insert denture and check fraenum has space to move
if the patient is complaining of pain on biting, what is causing it and how do you fix it?
incorrect occlusion causing pressure points in certain areas
* use articulating paper to identify high spots
* use acrylic trimming bur to reduce
* re-check and repeat as necessary
if the patient is complaining of the denture dislodging when eating or speaking, what is causing it and how do you fix it?
flanges are overextended and impinging on muscle attachments
* check for overextension using pressure indicating paste
* border mould and remove
* relieve with acrylic bur in a straight handpiece
if the patient is complaining of the denture dislodging and not feeling tight, what is causing it and how do you fix it?
clasps not tight enough with tooth surface
* use Adam’s pliers to adjust clasp so that tip is sitting on tooth surface, engaging undercut
* do not just adjust the clasp tip
* use very small, careful movements
* if unsuccessful, check design if there was an undercut on the tooth
if the patient is complaining of the denture dislodging when eating, what is causing it and how do you fix it?
early occlusal contact - causing the denture to tip around this point and dislodge
* use articulating paper to identify early contacts
* selectively grid these chairside with acrylic trimming bur
* re-check
if the patient is complaining of the denture being unstable (usually lower), what is causing it and how do you fix it?
lower teeth have not been set in a neutral position over the ridge or the tongue muscles are interfering with the denture space causing it to dislodge
* if mild, may be able to adjust buccal or lingual surfaces of denture teeth
* may need to remove denture teeth, replace with wax blocks and re-record occlusion and send to lab to reset the teeth
if the patient is complaining of biting on certain teeth/side before others, what is causing it and how do you fix it?
early occlusal contact in a specific area
* use articulating paper to identify heavy contacts
* selectively grid high spots with acrylic trimmin bur
* repeat
if the patient is complaining of pain over entire bearing area, pain/discomfort that worsens as teh day goes on, struggling to speak, or TMJ/MOM pain, what is causing it and how do you fix it?
no/not enough freeway space
* take note of OVD with new denture in
* remove denture teeth and add wax blocks in their place
* re-record occlusion to a smaller OVD that is less than resting face height to make freeway space
if the patient is complaining of the way their denture looks, what is causing it and how do you fix it?
issues with appearance not identified at try in stage
* remake denture
* remove clasps but retention may be compromised
if the patient is complaining of trouble with saying specific sounds (commonly ‘s’), what is causing it and how do you fix it?
tip of tongue and palatal aspect of upper teeth not harmonious
* add a small amount of acrylic on polished surface between upper central incisors (incisive palatal area)
* remove teeth, replace with wax blocks, re-record occlusion and reset teeth
* remake
if the patient is complaining of being unable to tolerate denture/gagging/sick, what is causing it and how do you fix it?
post dam stimulating gag relfex
* reduce palatal extension
* have multiple post dams if this is identified at assessment
* warn pt. of possible reduced retention
if the patient is complaining of a fractured denture, what is causing it and how do you fix it?
impact, occlusion, flexural fatigue, rocking/flexing around tori etc.
* depends on reason for fracture
* look at design, materials, occlusion, relief for tori
* consider high impact resin
* repair - no impression if parts can be put back together or get impression if parts are missing or not obvious
if the patient is complaining of being unable to wear the denture, after clinical checks you are unable to find what is wrong, or often have multiple sets of dentures, what is causing it and how do you fix it?
unrealistic expectation of dentures or poor neuromuscular control
* you** can’t fix it**
* referral to specialist?
* referral for implants?
