Case• 24. A problem overdenture
A 67-year-old lady is referred to your general dental practice complaining that her denture has never ‘seemed right’ from the day it was fitted.
The patient complains that a small filling has recently been lost from one of the upper canine roots below her overdenture. However, it quickly becomes clear that this has caused no symptoms (the tooth is root-treated) and that she is dissatisfied primarily with her upper complete overdenture. She can wear the denture in the morning, but by about three o’clock in the afternoon it becomes too uncomfortable and if she is at home she likes to take it out.
History of complaint
The patient successfully wore an acrylic upper partial denture until 6 months ago, but failure of restorations and root treatments led to loss of several upper teeth. She was provided with an upper overdenture on the two retained upper canine roots. The denture was fitted 3 months ago, reviewed on four occasions and minor adjustments were made to the base extension. The patient is happy with the retention and fit of the denture. It does not move during eating. She reports no problem with her lower teeth.
The patient is taking low dose aspirin (75 mg/day) following a myocardial infarction and a statin for raised serum cholesterol.
There is no lymphadenopathy. The temporomandibular joint is free of crepitus and clicks, and no muscle tenderness can be elicited in the muscles of mastication. With the denture in place, there is no facial asymmetry. The patient has a slightly open lip posture at rest.
The patient has a well-developed upper alveolar ridge with limited resorption consistent with the relatively recent loss of several upper teeth. There is slight redness of the palate under the denture-bearing area, but the ridge is not tender on palpation at any site and there is no bleeding on probing around the canine roots and no detectable sinus. One of the root-treated canine teeth has lost a small restoration from the access cavity. The remainder of the oral mucosa is normal.
There is an almost complete lower arch of natural teeth. These are adequately restored, many with large amalgam restorations, and there is no caries. The occlusal plane is relatively even. There has been slight mesial tipping of the lower second molars as a result of loss of both first molars.
The denture appears clean and without obvious defects and there is a definite post dam along its posterior margin.
▪ On the basis of what you know so far, what are the likely diagnoses and why?
The patient has successfully worn a denture and the transition to an overdenture from an upper acrylic partial denture should have been relatively straightforward. It might have been more difficult if the previous denture had been metal based. If the patient has persevered for 3 months without success she almost certainly has a valid complaint.
There appears to be no problem of displacement of the denture during eating, speaking or other facial movements. This makes it unlikely that the overdenture is poorly adapted, overextended or that the teeth lie outside the neutral zone. Occlusal discrepancies of some kind would appear to be the most likely cause and the vagueness of the complaint, predominantly inability to tolerate the denture, is consistent with an occlusal problem. A further reason to suspect an occlusal problem is the difficulty arising from a complete upper denture occluding against a lower natural arch.
It must also be borne in mind that some denture patients are particularly conscious of appearance and the construction of dentures that satisfy the expectations of such patients can be very demanding. Sometimes a mismatch between the denture appearance and desired facial self-image may manifest as dislike of the denture or complaints about relatively minor features. There is always a potential cosmetic problem of an overcontoured labial flange when canine roots support an upper overdenture because the roots preserve the labial aspect of the alveolar bone.
▪ What specific features of the dentures would you examine and how?
All features of the denture should be reviewed (Table 24.1). Denture complaints may be multifactorial and only by examining all features can an accurate diagnosis be made.
|Check base extension. Is the denture correctly extended into the sulcus?||This is done visually where possible, checking the relationship between the denture border, sulcus depth and soft tissue mobility at rest and under tension. In less visible areas, such as lateral to the tuberosity, palpation may be required.|
|Does the posterior border extend back to the vibrating area?||Identify the vibrating area by observing the soft tissue movin/>|