Trouble Shooting Complete & Removable Partial Dentures

1. Trouble Shooting Complete & Removable Partial Dentures Robert W. Loney, DMD, MS Professor & Chair Dept. Dental Clinical Sciencs Faculty of Dentistry, Dalhousie University

2. The Gunshot Approach • If it hurts - GRIND • If its loose - RELINE

3. Problem for Albert Einstein • Avert Imminent World Disaster • Time Constraint: One Hour • His solution: • 55 minutes identifying problem • 5 minutes fixing the problem

4. Lesson • Spend more time thinking • Spend less time grinding

5. Five Principles For Troubleshooting • Establish differential diagnosis • Identify variations from normal • Have patient demonstrate problems • Always use indicating medium when adjusting • Have patient rate improvement after adjustment

6. Principal 1Establish a Differential Diagnosis • Form a list of possible causes • Try to prove problem is not caused by “X” by eliminating possible causes • Expect resolution within 10-14 days • If no resolution, eliminate something else

7. Principle 1: Differential Diagnosis • Prioritize from common to rare • Eliminate common etiologies first, because: Common things occur commonly Rare entities occur rarely

8. Differential Diagnosis:CD or RPD Pain Attempt to eliminate problem. Re-evaluate results in 10-14 days

9. Principles of Diagnosis • Don’t limit list too early in diagnosis • Keep an open mind • Revisit possible causes when contradictory evidence is found

10. Information Gathering • Chief Complaint • History of C.C. • History • Medical • Dental • Clinical Exam

11. Dental and Medical History • Often inadequately investigated • Spend more time talking to narrow possibilities

12. Gathering Information Ask open ended questions: “How does that feel?” Not “Does that feel better?”

13. History of Chief ComplaintWhere? • Have patient point to problem • Partially ignore patient’s position • Dentist locates with stick, instrument or paste

14. History of Chief ComplaintWhen? • Chewing only - Occlusion • Gets worse throughout day - Occlusion • When first insert dentures - Denture Base • Pressure on 1st molars - Denture Base

15. History of Chief ComplaintDetails • How long? • does it last? • since it began? • Anything make it better/worse?

16. Principle 2: Identify Variations from Normal : Tissues & Dentures

17. Prominent Midline Fissure, Soft Palate Loose Denture:

18. Dealing with Variations From Normal • If denture alone is not normal • Correct it • If anatomy/patient not normal • vary method to address variation

19. Principle 3: Have Patient Demonstrate Problem • Eliminate cause - should resolve in 10-14 days

20. Principle 4: Always Use Indicating Media Never adjust without locating exact position of the problem Use paste, indelible stick, or articulating paper

21. Principle 5: Rate Improvement After adjustment Ask patient to rate improvement 0%-100%

22. Principle 5:Rate Improvement 100% Perfect Now • Better when: • Sigh of relief • ‘Yes!’ • ‘You got it’ 75% Feels a lot better 50% Better, but still not right 0% Still Same, Can’t Tell

23. Denture PainCD & RPD • Occlusion • Denture base (fit & contour) • Vertical dimension • Infection • Systemic disease/condition • Allergy (rare)

24. Most Overlooked Problem Occlusion Don’t want the problem to be occlusion - so we look for other causes

25. Occlusion • Takes time to remount (prep time) • Reduces adjustment time • Net savings of time

26. Pain: OcclusionDiagnostic Strategies • Eliminate as potential cause • Remount denture on an articulator • Centric relation & protrusive records • Mark centric & excursive contacts, adjust

27. Don’t Adjust Occlusion Intraorally • Contact on inclines can cause denture movement • May cause pain, or reflex avoidance • May make interference difficult to mark

28. Adjusting Occlusion Intra-Orally Net Result Can’t see real Problem Can’t eliminate Problem

29. Adjusting Occlusion • Use an articulator • Eliminates denture movement • Can visualize interferences easily • Saves time removing & replacing dentures

30. Pain: OcclusionDental History & Exam • No pain when press firmly on1st molars • Only when chewing • Causes tilting, twisting, tipping, sliding • Gets worse with chewing • Gets worse during the day • May have to remove late in day

31. Pain: OcclusionDiagnosis: Pain from Denture Base • If pain upon pressing firmly on 1st molars • Adjust denture base first until no pain • Use finger pressure • Do NOT use occlusion to apply pressure • Occlusion could introduce tipping forces

32. Pain: Occlusion Diagnosis - Chew Test • Chew on cotton ball size of a pea • Identify teeth that cause problem when chewing • Use articulating paper in excursions on those teeth to remove tipping contacts: • Heavy contacts • Contacts buccal to the ridge • Contacts on inclines

33. Ulcer or sore spots on sides of ridges Pain: OcclusionClinical Exam • Patient demonstrates problem by biting where pain occurs

34. Pain: OcclusionClinical Exam • Occlusal contact not centered over ridge • Tilting forces cause displacement, abrasion, ulceration • Worse if xerostomia, malnourished, debilitated or poor adaptability

35. Pain: OcclusionAvoid Contact on Inclines • Don’t set teeth set ascending portion of ramus

36. M D L B C Occlusal Point of Loading Browning, JPD 1986 • Removable partial dentures • Loaded centrally, M, D, L, B • B caused unseating • Central loading better than distal loading

37. Clinically • Drop 2nd premolar if necessary • Ensures posterior contacts not too distant • Avoids ascending portion of ridge • Ensures adequate occlusal table (maintains 2 molars)

38. Clinically • Place load over the mandibular ridge

39. Pain: OcclusionAvoid Contact on Inclines • No contact on inclines of denture bases

40. Pain: OcclusionClinical Exam • Severe Curve of Spee

41. Pain: OcclusionClinical Exam • Minimal overjet (horizontal) of anterior and/or posterior teeth

42. Pain: OcclusionClinical Exam • Severe disclusion of posterior teeth in excursions (lack of balance)

43. Avoid Setting Teeth in Tongue Space Tongue

44. Denture PainCD & RPD • Occlusion • Denture base (fit & contour) • Vertical dimension • Infection • Systemic disease/condition • Allergy (rare)

45. Pain: Denture BaseDental History • Firm pressure over molars - pain • Problem starts in AM • tight, sore • Discomfort present when not chewing • Often not progressive through day

46. Pain: Denture BaseClinical Exam • Discrete area of inflammation or ulceration • Similar to appearance of occlusal problems

47. Review of Indicating MediaLoney & Knechtel,J Prosthet Dent 2009;101:137-141

48. Applying Pressure Indicating Paste • Dry denture • Thin coat with stiff brush • Leave streaks

49. Seat Denture Firmly • Avoid lips/ridge when inserting • Pressure over first molars (not palate) • Remove from oral cavity by breaking seal - finger pushing height of vestibule

50. Denture Base Adjustment • Relieve pressure spots - large acrylic burs • Take care with undercuts • Looks like burn-through • May not require adjustment