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 compromiseswhen fabricating complete dentures. References used were primarily from the classical literature, andan effort was made to ascertain whether these treatment recommendations are appropriate for todaysmore difficult patients. An effort was made to incorporate recent recommendations where appropriate.(J Prosthet Dent 2002;88:631-5.)

The subject of complete denture problem solvinghas been reported frequently and completely in the lit-erature.1-16 Jacobs17 points out that most prosthodonticliterature is clinically generated and disseminated anddoes not follow the dictates of controlled scientific re-search. Although this is true, this alone does not makethe literature wrong. A large number of the classicarticles, although empiric in nature, have served as thebasis of successful prosthodontic practices over the yearsand, in many situations, decades. Although it is desir-able, controlled or procedural research in the humansetting is difficult, expensive, and in some instances eth-ically questionable. Therefore at this time we must oftenrely on the successful treatment regimes recommendedover many years.

When the classic literature was developed, typicalcomplete denture patients lost teeth in their early life,often before age 30. These patients could generally becharacterized as young and healthy with large residualalveolar ridges covered with firm, healthy mucosa able towithstand large functional forces. Patients expectedgood esthetics and comfortable function for long peri-ods of time with little maintenance. Cusped porcelainteeth were often selected for the sake of esthetics, me-chanical balance, and longevity. Cross-linked acrylicresin teeth did not exist.

The purpose of this article is to describe managementof a contemporary denture patient and to make recom-mendations for solving complete denture problems.

PORTRAIT OF TODAYS DENTUREPATIENT

It has been reported that the typical complete den-ture patients of today have a greater mean age, live in-dependently, are financially able to afford care, and areretaining more teeth.1,18-26 Additionally, missing teethare being replaced by more fixed partial dentures, moreremovable partial dentures, and more implant-sup-

ported prostheses.23 These trends are viewed as positiveand are reflective of the advances in dental prevention,personal oral hygiene, and maintenance.18-20

A large complete denture population exists and astudy by Douglass et al27 suggests that this populationwill continue to increase over the next 20 years. It hasbeen documented that there are fewer totally edentu-lous patients and fewer complete dentures being done inpractice.19,21 Difficulty exists in accessing the size of thispopulation as evidenced by the following. Catovic et al28examined 120 elderly nursing home residents and deter-mined that 82% needed some form of prosthetic inter-vention. Garrett et al29 determined that 55% of patientsassessed were moderately to fully satisfied with denturesthat examining dentists found in need of replacement.In another study, Nevalainen et al30 evaluated the com-plete dentures of 144 patients over 75 years old. Theyfound that depending on the criteria used, between 10%and 80% of the dentures were in need of replacement.These studies demonstrate the difficulty of determiningthe actual present and future needs of complete denturepatients.

Unfortunately, the number of cognitively impairedadults in institutional settings is increasing.31-33 This isperhaps the most difficult group of edentulous patientsto manage, as their ability to cooperate in their own careis significantly reduced.34-37

The current denture population may be characterizedas having a larger number of medical problems that re-quire the care of 1 or more physicians.20,38 These pa-tients are frequently taking a large number of medica-tions, often prescribed by different physicians, withoutcollaboration.39-40 These factors may result in tissue re-sponses to complete dentures being less satisfactory andreduce the healing capacity of the oral tissues.11,41-46Subsequently, it may be more difficult to manage theedentulous patient with predictable success.

Clinically, many of these patients are seen with se-verely resorbed residual ridges and prominent anatomiclandmarks or bony abnormalities. The soft tissues areoften redundant and unsupported. Maxillary arches fre-quently demonstrate enlarged tuberosities and redun-

aAssociate Professor, Department of Oral Rehabilitation.bAssociate Professor, Department of Oral Rehabilitation.cProfessor, Department of Oral Rehabilitation.

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dant anterior tissues resultant to the use of maxillarycomplete denture opposing a mandibular removablepartial denture with natural anterior teeth as describedby Kelly.47 Occasionally patients have reconditionedtheir prostheses with over-the-counter soft liners or tis-sue paper resulting in tremendous debilitation of theresidual ridges. Anterior teeth on existing prostheses areoften in occlusal contact because of wear and loss ofvertical dimension.48 Some patients expect the anteriorteeth of the new dentures to contact in a manner similarto their natural teeth. In many situations, the restorationof natural anterior tooth contacts could result in com-promised function and esthetics, making it necessary toeducate the patient about the need to modify the toothposition and tooth contact to facilitate an acceptablefunctional prognosis.

PATIENT EDUCATION

Many common characteristics of an aged population,such as decreased neuromuscular coordination, reducedability to sense where the mandible is in relation to themaxilla (oral awareness), and impaired ability to positionthe mandible or tongue in desired locations (oral dex-terity), will complicate the complete denture treatmentprocess.37,49-51

Patients generally expect new dentures to fit andfunction better than their existing dentures. Most pa-tients anticipate that their new dentures will be an im-provement over their previous dentures but are resignedto understanding that compromises may be necessary.Those few who demand similar esthetics to the formerdenture may prove to be a difficult management situa-tion. Careful patient education and preparation for re-placement dentures is critically important.52,53

A thorough examination is invaluable for proper di-agnosis, treatment planning, and identification of realis-tic goals or expectations. Many patients are aware thatphysical changes have occurred in their bodies, but someare unaware of the impact on their oral cavities.32,33,54-56Other problems can also complicate treating these pa-tients. Burnett et al57 points out that attempts to im-prove denture hygiene (habits) of veteran denture wear-ers with either verbal or written instructions wereequally ineffective in changing the habits when reviewed6 months after the instructional material was delivered.Yemm58 suggests incorporating surface features of theold prostheses so the patient will find it easier to copewith and adjust to new dentures.

PREPROSTHETIC CARE

Long-term denture use, especially of a poorly main-tained or ill-fitting denture, can lead to tissue traumaand chronic soreness.59-61 These conditions must becorrected before new denture fabrication by use of tissuerest, tissue conditioning, or preprosthetic surgery. Ade-

quate tissue rest by way of denture removal for a periodof days is a common method of correction.62,63 The useof tissue conditioners is the next procedure that can helpreturn the tissues to a healthy condition.64,65 Tissue-conditioning therapy is often requisite to surgical pro-cedures and can provide suitable modification of an ex-isting complete denture for use during the treatmentphase.

Preprosthetic surgery may be viewed as a question-able treatment recommendation by an experienceddenture wearer unaware of the deleterious tissue re-sponse that has developed. One of the more frequenttreatment recommendations is the surgical manage-ment of large tuberosities. Failure to recognize andmanage enlarged tuberosities may impede the clini-cians ability to develop proper vertical dimension andocclusal plane orientation. Both of these consider-ations impact the forces applied to the denture basesduring function and parafunction. Denture basemovement and lack of stability is a common cause ofsoreness and lack of retention.

Another preprosthetic procedure frequently over-looked is soft tissue removal from the superior and lin-gual surfaces of the retromolar pad. This procedure pro-vides a firm retromolar pad with a shallower slope in themolar area. When unrecognized, this region may be dis-torted during impression making, potentially resultingin tissue impingement and patient soreness. The re-moval of redundant tissues covering a sharp or highlyresorbed residual ridge, or augmentation of redundanttissue with artificial materials has fallen into disfavor be-cause of frequent complications.66

IMPRESSIONS

Special impression procedures, often time consum-ing, are frequently required when abnormal anatomy orredundant tissue is present. No impression materialsolves impression-making difficulties with easily dis-torted, unsupported soft tissues that cannot be surgicallymanaged. Advanced mandibular resorption frequentlyresults in prominent genial tubercles covered by thinfriable tissue. Frequently, lip and cheek tissue attach-ments have migrated so that only a narrow band ofattached tissue remains. For proper impressions a cus-tom acrylic resin tray should be designed to be narrowenough to allow for functional border molding of thedenture bearing area, but rigid enough to resist distor-tion and breakage. Tray modification by the placementof holes to allow excess material to escape and to reducehydraulic pressure should follow the completion of bor-der molding. A dual tray procedure that captures mobileredundant tissue in a relaxed state has previously beendescribed and may be required.67

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INTEROCCLUSAL RECORDS

Elderly patients have physical limitations to successfuldenture use that become increasingly important. Ridgeresorption, loss of oral awareness and dexterity combineto complicate accurate and repeatable jaw relationrecords due to denture base instability or inability tocooperate. Materials used to register jaw relation recordsshould allow for dynamic movements of the mandiblewhile setting, or be quick-setting as older patients fre-quently find it difficult to posture the mandible still forextended periods of time. Record bases can be stabilizedmanually or with denture adhesive while making jawrelation records.

ESTHETICS

Our desire to develop a natural appearance by placingteeth where they once were in nature, and to createcomplicated occlusal reconstructions suffers propor-tionally with patient age. Fortunately, most patients re-alize compromises are required and often do not de-mand the esthetics of their youth. Awareness of estheticcompromises must be discussed and understood by thepatient before the initiation of treatment and reinforcedthroughout the treatment phase. The authors believethat restoring a large loss in the vertical dimension ofocclusion should not be completed in 1 step. Excellentprocedures for the stepwise additions of conventionalimpression compound followed by autopolymerizingresin are outlined by Stout and others.68-70

OCCLUSION

The Class II occlusal relationship also necessitatespatient education and reinforcement. The patientshould understand that the maxillary anterior teeth areset for proper lip support and esthetics while the man-dibular anterior teeth are arranged more posterior favor-ing stability. Once the patient has accepted the concept,the chances for success via better control of mechanicsincrease. Patients are often quick to point out that theirnatural teeth were not located in this manner and willnot accept the ideal relationship if not properly edu-cated.

The ability of patients to masticate with completedentures is an important consideration; however, studieshave reported masticatory ability is not influenced byocclusal scheme.39,71-74 Posterior occlusal schemes, suchas neutrocentric occlusion or lingual contact nonbal-anced occlusion, are desirable because they allow forincreased freedom in centric relation and use of variousjaw closure positions by the patient possibly offsettingthe clinicians inability to capture accurate jaw relationrecords.75-78

SOFT LINERS

The use of processed soft liners for purposes of cush-ioning or stress distribution to protect the frail residualridges is desirable conceptually, although no liner fulfillsall of the reported necessary criterion for a satisfactorymaterial.79-83 Continued development of these materialsprovides great hope for the future of the elderly denturepopulation with diminished residual ridge support.

INSERTION AND POSTINSERTION

Postoperative adjustments and initial use after inser-tion should not be regarded as a correction for errorscreated during fabrication but as one of the last steps inthe complete denture process. This is the last opportu-nity to reinforce patient education and instruction. It isthe dentists responsibility to fabricate the dentures andinstruct patients regarding realistic expectations anduse.4,57,84-86

Patients remember and expect denture retention, butthey have often forgotten that tongue control aided inthe retention of the mandibular denture. The effect oftongue movement on mandibular denture retentioncannot be underestimated and must be reinforced. Pa-tients must understand that adjusting to new denturestakes time, practice, and patience. The patient must ac-tively participate in this step with our assistance. A pa-tients initial goal in the adaptation process should be tobecome comfortable with the dentures in the mouth,followed by adaptation to masticating soft, then harderfoods. The use of denture adhesive during this adapta-tion period may be helpful to reduce control difficultiesbefore the patient becomes discouraged. Denture adhe-sive use should be carefully instructed and monitored.Denture adhesives are currently being recommendedmore than they have in the past and are also sought moreoften by patients.87 The long-term use of denture adhe-sive as a crutch during the adjustment period or as asubstitute for lost neuromuscular control may also benecessary. Adhesive use should not offset inadequateprosthodontics. Patients should be encouraged to re-duce their dependency on adhesive over time and per-haps eliminate its use all together.88 The length of theadjustment period varies with the patient.89

RECOMMENDATIONS

1. It is critically important to impress on the typicalgeriatric complete denture patient the fact that theyshould return for yearly recalls to keep their completedentures fitting well. However, many elderly patients,especially those in institutions, reach a point where, be-cause of health or mental status, they are totally unableto cooperate during refitting of their dentures. Refittingof their dentures is difficult and may be impossible as acertain degree of patient understanding and cooperationis required.

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2. Consider using a simple occlusal scheme in elderlypatients where inability to cooperate because of poorneuromuscular control or denture base movement as aresult of severe ridge resorption makes jaw relationrecords difficult. In both of these circumstances adjust-ment of the dentures after insertion is also difficult.

3. Reduce iatrogenic problems via proper selectionand careful application of denture fabrication tech-niques. This is not the place for short-cut techniques.Perform each step carefully and accurately to minimizepotential problems. Remember, many of these patientshave a reduced capacity to adapt to denture createdproblems.

4. Provide patient education to the fullest extentpossible using verbal, visual, and written modalities, be-ginning at the first appointment. Review your recom-mendations often to reinforce them.

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