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Minimizing postinsertion problems: A procedure for removable partial denture placement
Minimizing removable
thprtion prob&ems: A procedure fur prtial dtirrturk placement
Richard Bauman, D. D. S. * U.S. Army Dental Corps, Ft. Carson, Colo.
A he problems necessitating extensive postinsertion adjustments can often be identified and corrected during the placement visit. Patient acceptance of a prosthesis will be enhanced if postinsertion discomforts are minimized, All predictable causes of irritation to the hard and soft tissues should be eliminated before the patient is dismissed with the prosthesis. This objective can be accomplished if the dentist adopts a step-by-step procedure for removable partial denture placement that includes: 1. Correction of denture base extensions and pressure spots 2. Establishment of occlusal harmony 3. Home care instructions
CORRECTION EXTENSIONS
OF DENTURE
BASE Fig. 1. Regions of overextension
Most removable partial dentures are fabricated on casts made from irreversible hydrocolloid (alginate) impressions.’ This material can be considered adequate if its limitations are recognized. A removable partial denture fabricated on such a cast must be carefully checked for stability at the time of placement. If instability is detected, a rebase procedure should be done. Irreversible hydrocolloid impressions are usually overextended. These overextensions must be corrected during the placement procedure. By carefully inspecting the tissue surface of the denture base under a strong light, it is possible to note the inner aspect of the border roll, which represents the attempt of the vestibular tissues to displace the impression material. These areas may be marked on the base (Fig. 1) and gross overextensions reduced
The views and statements of the author do not purport to reflect the position of the Department of the Army. *Colonel; Chief, Removable Prosthodontic Service.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
marked on the denture
base. before the removable partial denture is fitted in the patient’s mouth. The tissue surface of the denture base is then coated with pressureindicator paste* and sprayed as directed, and the denture is inserted. The patient is instructed to perform functional muscular movements similar to those used when making impressions for complete dentures. These movements will displace the paste from regions of excessivepressure and denture base overextension (Fig. 2). Such regions are relieved and the procedure repeated until pressure spots and overextensions have been eliminated.
ESTABLISHMENT
OF OCCLUSAL
HARMONY
Removable partial denture occlusion should usually be designed to harmonize with and comple*Mizzy, Inc., Clifton Forge, Va.
381
BAUMAN
Fig. 2. Pressure indicator overextension.
Fig.
3.
paste has been wiped away from regions of excessive pressure and
The patient’s
centric occlusion
ment the patient’s natural occlusal contacts. Exceptions may be made for patients with abnormal jaw relations or severe loss of vertical dimension of occlusion, where the dentist may decide to deliberately alter the natural occlusal pattern for therapeutic reasons. Generally, however, the objective of occlusal adjustment at the denture placement visit is the elimination of contacts which are premature relative to the patient’s natural occlusion. Auditory and visual senses are the most reliable guides in determining whether interceptive occlusal contacts are present. The patient’s occlusion should first be examined with the prosthesis out of the mouth. Regions are selected anteriorly and posteriorly on both sides of the arch, and the natural tooth contacts in these regions are observed as the patient 382
without
the denture
in place.
closes the teeth in centric occlusion. The prosthesis is then inserted, the patient is instructed to close until an initial contact is made, and the same regions are reexamined. Altered natural tooth contacts indicate that the prosthesis occlusion is premature. Comparison of Figs. 3 and 4 and Figs. 5 and 6 illustrate this situation. The dentist’s auditory sense may also be used to determine if interceptive occlusal contacts are present. The patient is instructed to “tap rapidly on the back teeth” with the prosthesis out of the mouth. The sound produced is carefully noted. Next, the denture is inserted and the tapping procedure repeated. If premature contacts are present, an alteration in the sound will be produced. If the presence of interceptive contacts has been OCTOBER
1979
VOLUME
42
NUMBER
4
MINIMJZING
POSTINSERTION
PROBLEMS
Fig. 4. Lack of natural tooth contact in the canine and first premolar regions removable partial denture in place.
Fig.
5.
Natural tooth contacts in centric occlusion without
Fig.
6.
M@.
THE
JOURNAL
Co..
Romulus,
Mich
OF PROSTHETIC
DENTISTRY
thv
prosthesis in place.
Lack of natural tooth contact with the prosthesis in place.
detected, occlusal indicator wax* and thin (0.0025 inch) articulating paper may be used to determine their location. Indicator wax has the advantage of revealing interferences before the wax has been perforated (Fig. 7). Tooth-to-tooth contact with possible tipping of the denture base is thus avoided. Articulating paper should be used with care. False markings are common, and injudicious grinding of *Kerr
the
with
blue marks may result in loss of occlusal contact, The correct appearance of an interceptive contact registered with articulating paper is a blue halo surrounding a clear zone. Marking and grinding procedures are continued until the centric occlusal contacts of the prosthesis harmonize with those of the natural teeth. The final determination of occlusal harmony should be made through visual and auditory checking, as previously described. Equilibration of the lateral and protrusive excursions should then be done. For most patients. 383
BAUMAN
Fig. 7. Occlusal
indicator
wax reveals interferences
the prosthesis should be equilibrated so that guidance for eccentric excursions is maintained on the natural teeth.
HOME CARE INSTRUCTIONS The placement procedure is not complete until the patient has been instructed in home care of the prosthesis and oral tissues. This aspect of the procedure is important, as inadequate home care is an etiologic factor in the development of lesions of the denture-supporting tissues.‘-’ The memory-span limitation of the individual necessitates presentation of a set of written instructions. Certain key sections of the instructions are emphasized and reinforced by the dentist. An instructions adequate set of printed should include: 1. Explanation of the limitations of dental prostheses and the importance of the patient’s role in their successful use. 2. Description of initial difficulties (speech problems, mastication, cheek biting, gagging sensations) which the patient may expect to experience, along with reassurance that these problems are transitorY. 3. Instructions for cleaning the remaining natural teeth. The patient should be informed of the importance of plaque control and the consequences of its neglect. Emphasis should be placed on making special efforts to clean those surfaces of the teeth
384
before the wax is perforated.
which are in contact with components of the prosthesis.’ 4. Requirements that prostheses be left out of the mouth approximately 6 to 8 hours out of every 24-hour period.g-‘3 Although many patients may be reluctant to comply with this recommendation,” professional responsibility requires that it be clearly stated. The patient may, however, be instructed that the hours need not be consecutive, and that they may be overnight or at a time during the day when the patient is alone. The patient must make the final determination of when the prosthesis can be left out of the mouth. The dentist’s responsibility is to inform the patient that continuous wear of prostheses has been clearly and repeatedly linked to the development of oral pathology.‘+, ” 5. Instructions for cleaning the prosthesis, including use of soaking solutions and brushing with a nonabrasive agent. Emphasis should be placed on frequent and careful cleaning of those surfaces of the prosthesis which contact the teeth and soft tissues. 6. Instructions to contact the dentist if any soreness of the teeth or soft tissues is experienced. The patient should realize that pain is a sign that the prosthesis probably needs adjustment. Since severe tissue damage is often seen as a result of patients’ determination to tolerate ill-fitting prostheses, the tendency to “put up with it” should be discouraged. 7. Instruction to return for routine evaluation of
OCTOBER
1979
VOLUME
42
NUMBER
4
MINIMIZING
POSTINSERTION
PROBLEMS
the prosthesis at least once a year. Emphasis should be placed on the importance of routine reevaluation even if the prosthesis seems to be functioning well and causing no difficulties. Patients should be alerted to the possibility that the tissues underlying the prosthesis may change. Tissue changes may require corrections of the prosthesis to maintain an accurate fit. SUMMARY
5.
6.
7. 8.
9.
A procedure for removable partial denture placement has been described. This procedure involves correction of pressure spots and overextensions, harmonizing of occlusion, and patient home-care instructions. Use of this procedure does not eliminate the need for postinsertion observations. Postinsertion adjustments, however, may be minimized by careful attention to each step at the placement visit.
10. 11. 12. 13. 14.
REFERENCES 1. 2. 3.
4.
Sykora, 0.: Extracoronal removable partial denture service in Canada. J PROSTHET DENT 39:37, 1978. Lambson, G. 0.: Papillary hyperplasia of the palate. J PROSTHET DENT l&636, 1966. Love, W. D., Goska, F. A., and Mixson, R. J.: The etiology of mucosal inflammation associated with dentures. J PROSTHET DENT l&515, 1967. Bhaskar, S. N., Beasley, J. D., and Cutright, D. E.: Inflammatory papillary hyperplasia of the oral mucosa: Report of 341 cases. J Am Dent Assoc 81:949, 1970.
Journal
adopts
new policy
15.
Sheppard, I. M., Schwartz, L. R., and Sheppard, S. M.: OraI status of edentulous and complete denture-wearing patients. J Am Dent Assoc 83:614, 1971. Bauman, R.: Inflammatory papillary hyperplasia and homecare instructions to denture patients. ) PROWHET DENT 37:608, 1977. Welker, W. A.: Prosthodontic treatment of abused oral tissues. J PROSTHET DENT 37:259, 1977. Brill, N., Tryde, G., Stoltze, K., and El Ghamrawy, E. A.: Ecologic changes in the oral cavity caused by removable partial dentures. J PROSTHET DENT 38: 138, 1977. Jones, P. M.: Complete dentures and the associated soft tissues. J PROSTHET DENT 36:136, 1976 Miller, E. L.: Clinical management of denture-induced inflammations. J PROSTHET DENT 38:362. 1977. Lambson, G. O., and Anderson. R. R.: Palatal papillary hyperplasia. J PROSTHET DENT 18:528, 1967. Wagner, A. G.: Instructions for the use and care of removable partial dentures. J PROSTHET DENT 26:477. 1971. Tautin, F. S.: Should dentures be worn continuously? .J PROSTHET DENT 39:372, 1978. Straus, R., Sandifer, J. C., Hall, D. S., and Haley, J. V.: Behavioral factors and denture status. J PROSTHET DENT 37:264, 1977. Ettinger, R. L.: The etiology of inflammatory papillary hyperplasia. J PROSTHET DENT 34:254. 1975.
Reprint requests to: DR. RICHARD BAUMAN U. S. ARMY DENTAC FT. CARSON, COLO. 80913
for illustrations
in color
The Editorial Council and publisher of THE JOURNAL OF PROSTHETIC DENTISTRY have agreed to publish articles that contain color illustrations at a reduced cost to authors. Authors will pay only $225 per color page, or part thereof, and can present from one to eight illustrations on each page. Two high-quality 35 mm color transparencies (an original and duplicate) must be submitted for each illustration, and manuscript length cannot exceed 10 to 12 double-spaced typewritten pages. The Editor and his reviewers have final authority to determine if color illustrations afford the most effective presentation. Articles containing color will appear in selected issues beginning in 1980. Authors are requested to include a statement when they submit their manuscript agreeing to pay $225 for each page of color. Billing will come from the publisher after the author has approved color proofs and the article is scheduled for publication. Manuscripts and illustrations will be accepted immediately for evaluation.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
385
thprtion prob&ems: A procedure fur prtial dtirrturk placement
Richard Bauman, D. D. S. * U.S. Army Dental Corps, Ft. Carson, Colo.
A he problems necessitating extensive postinsertion adjustments can often be identified and corrected during the placement visit. Patient acceptance of a prosthesis will be enhanced if postinsertion discomforts are minimized, All predictable causes of irritation to the hard and soft tissues should be eliminated before the patient is dismissed with the prosthesis. This objective can be accomplished if the dentist adopts a step-by-step procedure for removable partial denture placement that includes: 1. Correction of denture base extensions and pressure spots 2. Establishment of occlusal harmony 3. Home care instructions
CORRECTION EXTENSIONS
OF DENTURE
BASE Fig. 1. Regions of overextension
Most removable partial dentures are fabricated on casts made from irreversible hydrocolloid (alginate) impressions.’ This material can be considered adequate if its limitations are recognized. A removable partial denture fabricated on such a cast must be carefully checked for stability at the time of placement. If instability is detected, a rebase procedure should be done. Irreversible hydrocolloid impressions are usually overextended. These overextensions must be corrected during the placement procedure. By carefully inspecting the tissue surface of the denture base under a strong light, it is possible to note the inner aspect of the border roll, which represents the attempt of the vestibular tissues to displace the impression material. These areas may be marked on the base (Fig. 1) and gross overextensions reduced
The views and statements of the author do not purport to reflect the position of the Department of the Army. *Colonel; Chief, Removable Prosthodontic Service.
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
marked on the denture
base. before the removable partial denture is fitted in the patient’s mouth. The tissue surface of the denture base is then coated with pressureindicator paste* and sprayed as directed, and the denture is inserted. The patient is instructed to perform functional muscular movements similar to those used when making impressions for complete dentures. These movements will displace the paste from regions of excessivepressure and denture base overextension (Fig. 2). Such regions are relieved and the procedure repeated until pressure spots and overextensions have been eliminated.
ESTABLISHMENT
OF OCCLUSAL
HARMONY
Removable partial denture occlusion should usually be designed to harmonize with and comple*Mizzy, Inc., Clifton Forge, Va.
381
BAUMAN
Fig. 2. Pressure indicator overextension.
Fig.
3.
paste has been wiped away from regions of excessive pressure and
The patient’s
centric occlusion
ment the patient’s natural occlusal contacts. Exceptions may be made for patients with abnormal jaw relations or severe loss of vertical dimension of occlusion, where the dentist may decide to deliberately alter the natural occlusal pattern for therapeutic reasons. Generally, however, the objective of occlusal adjustment at the denture placement visit is the elimination of contacts which are premature relative to the patient’s natural occlusion. Auditory and visual senses are the most reliable guides in determining whether interceptive occlusal contacts are present. The patient’s occlusion should first be examined with the prosthesis out of the mouth. Regions are selected anteriorly and posteriorly on both sides of the arch, and the natural tooth contacts in these regions are observed as the patient 382
without
the denture
in place.
closes the teeth in centric occlusion. The prosthesis is then inserted, the patient is instructed to close until an initial contact is made, and the same regions are reexamined. Altered natural tooth contacts indicate that the prosthesis occlusion is premature. Comparison of Figs. 3 and 4 and Figs. 5 and 6 illustrate this situation. The dentist’s auditory sense may also be used to determine if interceptive occlusal contacts are present. The patient is instructed to “tap rapidly on the back teeth” with the prosthesis out of the mouth. The sound produced is carefully noted. Next, the denture is inserted and the tapping procedure repeated. If premature contacts are present, an alteration in the sound will be produced. If the presence of interceptive contacts has been OCTOBER
1979
VOLUME
42
NUMBER
4
MINIMJZING
POSTINSERTION
PROBLEMS
Fig. 4. Lack of natural tooth contact in the canine and first premolar regions removable partial denture in place.
Fig.
5.
Natural tooth contacts in centric occlusion without
Fig.
6.
M@.
THE
JOURNAL
Co..
Romulus,
Mich
OF PROSTHETIC
DENTISTRY
thv
prosthesis in place.
Lack of natural tooth contact with the prosthesis in place.
detected, occlusal indicator wax* and thin (0.0025 inch) articulating paper may be used to determine their location. Indicator wax has the advantage of revealing interferences before the wax has been perforated (Fig. 7). Tooth-to-tooth contact with possible tipping of the denture base is thus avoided. Articulating paper should be used with care. False markings are common, and injudicious grinding of *Kerr
the
with
blue marks may result in loss of occlusal contact, The correct appearance of an interceptive contact registered with articulating paper is a blue halo surrounding a clear zone. Marking and grinding procedures are continued until the centric occlusal contacts of the prosthesis harmonize with those of the natural teeth. The final determination of occlusal harmony should be made through visual and auditory checking, as previously described. Equilibration of the lateral and protrusive excursions should then be done. For most patients. 383
BAUMAN
Fig. 7. Occlusal
indicator
wax reveals interferences
the prosthesis should be equilibrated so that guidance for eccentric excursions is maintained on the natural teeth.
HOME CARE INSTRUCTIONS The placement procedure is not complete until the patient has been instructed in home care of the prosthesis and oral tissues. This aspect of the procedure is important, as inadequate home care is an etiologic factor in the development of lesions of the denture-supporting tissues.‘-’ The memory-span limitation of the individual necessitates presentation of a set of written instructions. Certain key sections of the instructions are emphasized and reinforced by the dentist. An instructions adequate set of printed should include: 1. Explanation of the limitations of dental prostheses and the importance of the patient’s role in their successful use. 2. Description of initial difficulties (speech problems, mastication, cheek biting, gagging sensations) which the patient may expect to experience, along with reassurance that these problems are transitorY. 3. Instructions for cleaning the remaining natural teeth. The patient should be informed of the importance of plaque control and the consequences of its neglect. Emphasis should be placed on making special efforts to clean those surfaces of the teeth
384
before the wax is perforated.
which are in contact with components of the prosthesis.’ 4. Requirements that prostheses be left out of the mouth approximately 6 to 8 hours out of every 24-hour period.g-‘3 Although many patients may be reluctant to comply with this recommendation,” professional responsibility requires that it be clearly stated. The patient may, however, be instructed that the hours need not be consecutive, and that they may be overnight or at a time during the day when the patient is alone. The patient must make the final determination of when the prosthesis can be left out of the mouth. The dentist’s responsibility is to inform the patient that continuous wear of prostheses has been clearly and repeatedly linked to the development of oral pathology.‘+, ” 5. Instructions for cleaning the prosthesis, including use of soaking solutions and brushing with a nonabrasive agent. Emphasis should be placed on frequent and careful cleaning of those surfaces of the prosthesis which contact the teeth and soft tissues. 6. Instructions to contact the dentist if any soreness of the teeth or soft tissues is experienced. The patient should realize that pain is a sign that the prosthesis probably needs adjustment. Since severe tissue damage is often seen as a result of patients’ determination to tolerate ill-fitting prostheses, the tendency to “put up with it” should be discouraged. 7. Instruction to return for routine evaluation of
OCTOBER
1979
VOLUME
42
NUMBER
4
MINIMIZING
POSTINSERTION
PROBLEMS
the prosthesis at least once a year. Emphasis should be placed on the importance of routine reevaluation even if the prosthesis seems to be functioning well and causing no difficulties. Patients should be alerted to the possibility that the tissues underlying the prosthesis may change. Tissue changes may require corrections of the prosthesis to maintain an accurate fit. SUMMARY
5.
6.
7. 8.
9.
A procedure for removable partial denture placement has been described. This procedure involves correction of pressure spots and overextensions, harmonizing of occlusion, and patient home-care instructions. Use of this procedure does not eliminate the need for postinsertion observations. Postinsertion adjustments, however, may be minimized by careful attention to each step at the placement visit.
10. 11. 12. 13. 14.
REFERENCES 1. 2. 3.
4.
Sykora, 0.: Extracoronal removable partial denture service in Canada. J PROSTHET DENT 39:37, 1978. Lambson, G. 0.: Papillary hyperplasia of the palate. J PROSTHET DENT l&636, 1966. Love, W. D., Goska, F. A., and Mixson, R. J.: The etiology of mucosal inflammation associated with dentures. J PROSTHET DENT l&515, 1967. Bhaskar, S. N., Beasley, J. D., and Cutright, D. E.: Inflammatory papillary hyperplasia of the oral mucosa: Report of 341 cases. J Am Dent Assoc 81:949, 1970.
Journal
adopts
new policy
15.
Sheppard, I. M., Schwartz, L. R., and Sheppard, S. M.: OraI status of edentulous and complete denture-wearing patients. J Am Dent Assoc 83:614, 1971. Bauman, R.: Inflammatory papillary hyperplasia and homecare instructions to denture patients. ) PROWHET DENT 37:608, 1977. Welker, W. A.: Prosthodontic treatment of abused oral tissues. J PROSTHET DENT 37:259, 1977. Brill, N., Tryde, G., Stoltze, K., and El Ghamrawy, E. A.: Ecologic changes in the oral cavity caused by removable partial dentures. J PROSTHET DENT 38: 138, 1977. Jones, P. M.: Complete dentures and the associated soft tissues. J PROSTHET DENT 36:136, 1976 Miller, E. L.: Clinical management of denture-induced inflammations. J PROSTHET DENT 38:362. 1977. Lambson, G. O., and Anderson. R. R.: Palatal papillary hyperplasia. J PROSTHET DENT 18:528, 1967. Wagner, A. G.: Instructions for the use and care of removable partial dentures. J PROSTHET DENT 26:477. 1971. Tautin, F. S.: Should dentures be worn continuously? .J PROSTHET DENT 39:372, 1978. Straus, R., Sandifer, J. C., Hall, D. S., and Haley, J. V.: Behavioral factors and denture status. J PROSTHET DENT 37:264, 1977. Ettinger, R. L.: The etiology of inflammatory papillary hyperplasia. J PROSTHET DENT 34:254. 1975.
Reprint requests to: DR. RICHARD BAUMAN U. S. ARMY DENTAC FT. CARSON, COLO. 80913
for illustrations
in color
The Editorial Council and publisher of THE JOURNAL OF PROSTHETIC DENTISTRY have agreed to publish articles that contain color illustrations at a reduced cost to authors. Authors will pay only $225 per color page, or part thereof, and can present from one to eight illustrations on each page. Two high-quality 35 mm color transparencies (an original and duplicate) must be submitted for each illustration, and manuscript length cannot exceed 10 to 12 double-spaced typewritten pages. The Editor and his reviewers have final authority to determine if color illustrations afford the most effective presentation. Articles containing color will appear in selected issues beginning in 1980. Authors are requested to include a statement when they submit their manuscript agreeing to pay $225 for each page of color. Billing will come from the publisher after the author has approved color proofs and the article is scheduled for publication. Manuscripts and illustrations will be accepted immediately for evaluation.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
385