Hypnosis: Principles of this treatment are using relaxation, anxiety
control, conditioning/desensitization and confidence-boasting
• Engage the patient in interesting conversation.
• Ask the patient to count rapidly.
• Ask the patient to breath audibly.
• Ask the patient to tap the foot rhythmically.
• Ask the patient to raise the leg and hold it in air.
Saliva plays an important role in providing stability and retention to
complete dentures. The amount and consistency of the saliva
primarily affects these properties and provides comfort to the wearer.
Normally, there should be serous type of saliva with moderate flow,
which provides excellent retention and stability to the dentures.
Saliva can be classified on basis of amount and consistency as
Class 1: Normal quantity and quality of saliva.
• It should be serous type of saliva with moderate flow which
provides ideal cohesive and adhesive properties.
• Provides excellent retention and stability.
Class 2: Excessive saliva; more mucous type.
• Thick and ropy-type saliva; complicates impression making because
of heavy secretion of mucus formed from the palatal glands, under
• Results in loss of retention and stability.
• Can also cause gag reflex while making the impression.
Class 3: Xerostomia; lack of saliva.
• Absence of saliva causes the cheeks and lips to stick to the denture
base. Solution: Petrolatum jelly can be applied on the surface of the
• Saliva provides the physical factors of retention such as adhesion,
cohesion, capillary action and interfacial surface tension. (See
Pre-extraction records and their
• Pre-extraction records serve as guides in the proper fabrication of
• These provide vital information regarding shape, form, colour and
position of the natural teeth, vertical dimension of occlusion,
support of lips and relationships of the teeth to lips.
• These include previous photographs, diagnostic casts, tattooing of
intraoral structures, measurements of extraoral structures, charts of
remaining teeth and radiographs.
1. Photographs • Photographs showing natural teeth provide information regarding tooth size, shape,
position and display during facial expression
• Extremely effective tools in achieving patient aesthetics and satisfaction
• These serve as guide to place artificial teeth
• These give an indication about the vertical dimension of occlusion
3. Tattooing • Records of the vertical dimension of occlusion can be made by tattooing the attached
• Distance between the tattoos is measured
• A window is placed in the record base in the area of the tattoo while establishing the
vertical dimension of occlusion
• Permanent landmarks on the face such as scars, moles or warts can serve as guide for
establishing the correct vertical dimension of occlusion
• Acrylic mask can be made on the cast made after making impression of the face when
• After extraction of the teeth, the face is repositioned into the mask
approximated by measuring the dentures
• The aesthetics and phonetics can be checked with old dentures
• Charts can be made of remaining teeth. A sketch can show colour, stains, cracks,
existing restorations and incisal edges
7. Radiographs • Preoperative radiographs can provide useful information about size and form of the
• Image magnification and shortening should be taken into consideration
Radiographs are important diagnostic aids in evaluating the
submucosal conditions in the patients seeking prosthodontic
• Radiographic examination should be advised to rule out any bony
conditions that could affect the treatment.
• A panoramic radiograph can reveal many conditions that affect the
treatment plan and prognosis of the case.
• The radiograph is useful in the following instances:
• Determine thickness of the body of mandible
• To see remaining bone density and quality
• To keep as treatment records
Classification is based on radiographic interpretation of the osseous
structures which provide support for the prosthesis.
Class 1: Dense bone provides optimum foundation for the dentures.
• Trabeculae are compact and medullary spaces are few.
• Cortex is solid and well defined. These structures show little or slow
Class 2: Cancellated bone gives adequate support, if occlusal loading
is within physiological limit.
• The trabeculae and medullary spaces are evenly balanced.
• Cortex is defined but lighter in contrast.
Class 3: Noncortical bone is radiolucent and poor in organic salts.
• No definite cortex, margins are feathery, thin and often apiculated.
• Offers poor bone support for denture.
• Higher rate of resorption and discomfort.
Extraoral radiographs are useful in providing an overview of
patient’s denture foundation and surrounding structures.
Presently, charged couple device and complementary metal oxide
semiconductor image sensing systems are becoming popular because
of less radiation exposure to the patient.
Nutritional requirement of edentulous
Nutrition is defined as ‘the science of food, the nutrients and other
substances their actions, interaction and balance in relation to health
and disease and the processes by which the organism ingests, digests,
absorbs, transports, utilizes and excretes food substances’.
Adequate nutrition with proper quantity of proteins, carbohydrates,
fats, vitamins and minerals is important to maintain the health of oral
tissues of edentulous patients.
• To provide adequate energy (calories) in young adults, growing
• The amount, proportion and type of macronutrients and
micronutrients should be correct.
• To establish a balanced diet; this is consistent with the physical,
social, psychological and economical background of the individual.
• As the patient becomes older, the amount of protein required per
kilogram of the body weight is increased.
• About 1.4 g/kg body weight is optimum.
• Too much protein never damages the health of the elderly person.
• Milk is an ideal source of protein for this age group.
• Best sources of proteins are meat and fish.
• Protein deficiency can decrease salivary flow and enlarges the
• Promote normal bowel activity.
• Prevent diverticular diseases.
• Because of the evidences of the link between dietary intake of
saturated fat, cholesterol and occurrence of heart diseases and
obesity, adults are advised to reduce fat intake to 30% of the total
• Saturated fat (animal fat): 8–10% of total calories.
• Unsaturated fat (vegetable oil): 10–15%.
Vitamin intake should be increased for the following reasons:
• Provides resistance to bacterial infections.
• Improves digestive efficiency by aiding in the use of carbohydrates
and utilization of mineral elements.
• Intake of mainly vitamins A, B-complex, C and D should be
• Deficiency of vitamin B-complex can result in angular cheilitis,
angular stomatitis and glossitis.
• Minerals are of considerable importance to the aged persons.
• Calcium loss contributes to bone fragility.
• The patients often experience a rapid and excessive ridge resorption
under complete dentures, which may be related to negative calcium
balance. Calcium deficiency is one of the prime causes of
• Poor nutrition has been linked to an increased risk of many diseases,
including heart disease and diabetes.
• Human body requires both macronutrients, which are the main
source of calories, and micronutrients (approximately 40 essential
minerals, vitamins and other biochemicals), which are required for
virtually all metabolic and developmental processes.
• Comprises about 60% of the body weight
• Chief component of blood plasma
• Aids in temperature regulation
• Shock absorber in eyes, spinal cord and amniotic sac (during
• Active participant in many chemical reactions
Role of nutrition in prosthodontics
• A denture is a mechanical object intended to function in a biological
environment that is vital and constantly changing.
• The functional demands of the prosthesis must be kept within the
metabolic ability of the tissues which supports the prosthesis.
• The success of complete denture prosthesis depends on the health
and integrity of the denture-bearing tissues. The realization of these
factors forms the entire basis for the essential role of nutrition in
• Posterior palatal seal area is used to complete the peripheral valve
seal across the distal border of the denture.
• Abfraction is the pathologic loss of hard tooth substance caused by
• Angular cheilitis is the inflammation of the angles of the mouth
causing redness and the production of the fissures. It is also called
• Class I type of soft palate is the most favourable to the complete
denture retention, as it allows more tissue coverage for the palatal
• Snow shoe principle enhances the support of complete denture by
using the maximal coverage within the normal functional limits.
• Mean foundation plane is the mean of the various irregularities in
form and inclination of the basal seat.
• V-shaped palatal vault is associated with class III soft palate.
• Flat palatal vault is associated with class I and class II soft palate.
• Palpation of the temporal muscle is used to check the retrusion of
• The posterior palatal seal is around 1–1.5 mm high and 1.5 mm
• The stability of the lower denture is enhanced when the tongue
rests on the occlusal surfaces of the lower teeth at rest.
• Masseteric notch in the distobuccal corner of the mandibular
denture is due to action of the masseter on the buccinator.
• Mean denture-bearing area of the maxilla is 22.96 cm2
• Mean denture-bearing area of the mandible is 12.25 cm2
• Engrams are the setting of the memorized pattern of the muscle
activity due to repeated proprioceptive signals of the teeth.
Minor Pre-prosthetic Surgical Procedures, 36
Ideal Requirements of Resilient Liners, 43
Role in Edentulous Patient, 43
Role of Tissue Conditioners, 44
Composition and Characteristics, 44
Treatment of Abused Tissues, 44
Before undergoing a complete denture prosthesis, it is always
necessary to examine the mouth of the patient to identify the potential
problem areas. These problem areas can be corrected by various
nonsurgical and surgical methods.
The following methods are commonly used to prepare the mouth to
(ii) Surgical method or preprosthetic surgery
Objectives of Mouth Preparation
• Improves the ridge relations
• Restoration of form and function of the stomatognathic system
Nonsurgical methods of preparing mouth for complete dentures are
Preprosthetic surgery is defined as ‘surgical procedures designed to
facilitate fabrication of prosthesis or to improve the prognosis of
prosthodontic care’. (GPT 8th Ed)
• Pre-prosthetic surgery attempts to create an environment that can
support the complete dentures and enhances its longevity and
• It is aimed to prepare the edentulous jaw to accept the best possible
• The edentulous jaw is aimed to provide an ideal shape and form.
Minor preprosthetic surgical procedures
• Least bone resorption takes place, if the sockets are digitally
compressed after simple extraction.
• Surgical technique of alveoplasty is to reflect the mucoperiosteal
flap and reduce the bone with rongeurs or a rotary bur.
• When there is adequate ridge height but bony undercut occurs on
the buccal aspect of the jaw, intraseptal alveoloplasty with cortical
bone repositioning is indicated.
• It is defined as surgical excision of the frenum.
• Frenectomy or frenotomy is indicated when a band of fibrous tissue
attaches near the crest of residual ridge or the thick frenum
continuously displaces the denture during function.
• Hypertrophic maxillary labial frenum most commonly interferes
with denture function followed by lingual frenum and maxillary
• Diamond excision is the most common technique used to release
maxillary and mandibular labial frena.
• Z-plasty technique is used when frenum is broad and short (Fig. 3-
• V–Y advancement technique is used when concomitant decrease in
• During mandibular frenectomy, it is advisable to give tongue
traction suture in order to improve visibility and control of tongue.
• Broad frena in the maxillary bicuspid molar region are best treated
FIGURE 3-1 Z-plasty technique used in frenectomy: (A) ‘Z’-
shaped incision; (B) reflection and detachment of frenum from
alveolar process; (C) sutures closing the wound.
Excision of redundant soft tissues, papillary
hyperplasia or epulis fissuratum
• Surgical excision may be required to remove excess
noninflammatory tissues caused due to long-term wearing of a
• Care should be taken that there is minimal trauma to the remaining
• Epulis fissuratum is surgically removed by sharp excision,
electrocautery, cryosurgery and laser excision.
• Laser excision offers better haemostasis and reduced postoperative
• Cryosurgery may require several appointments.
• Palatal papillary hyperplasia is caused by poorly fitting complete
denture and sometimes by candidal infection.
• Attempt should be made to reduce the size of the lesion
preoperatively by providing relief of the denture and using tissue
conditioners and antifungal agents.
• Soft tissue removal can be accomplished by surgical excision,
curettage, electrosurgery and reduction using large rotary bur or
Maxillary tuberosity reduction and exostosis
• Excess tissue in the region of maxillary tuberosity commonly
interferes with the construction of denture.
• This excess tissue may be soft redundant tissue or a bony undercut.
• Articulated casts are valuable to plan the amount and location of
• The excessive soft tissue is surgically excised and sutured to obtain
• To remove excessive bony undercut, an ellipsoid incision is made
and the mucoperiosteum is reflected and rongeur or rotary bur is
Tori can be palatal or lingual.
• These are usually located at the centre of the palate and are more
• These are composed of entirely cortical bone and occasionally may
Removal of palatal tori is indicated when the following
• Extremely large torus fills the palatal vault (Fig. 3-2).
• Torus extending beyond the posterior dam area.
• Mucosa is traumatized over the torus.
• Interferes with functions such as speech, swallowing.
• Psychological reasons (fear of malignancy).
• Smaller torus does not require removal and relief in the denture is
• However, large torus requires surgical removal.
FIGURE 3-2 Large maxillary torus in the centre of the palate.
• Anteroposterior incision is made over the middle of the torus with a
Y-shaped releasing incision at each end.
• Full thickness mucoperiosteal flap is raised carefully and the torus is
• Sectioned torus is removed in pieces with chisel.
• A large rotary bur may also be used to grind the torus away.
• Mucosal tissues are approximated and sutured to achieve primary
• A stent or denture is used to support the palatal tissues to avoid
• Possible complications: Nasal perforation, oronasal or antral fistula
formation, palatal tissue necrosis and haematoma.
• These can be single, multiple or lobulated.
• These are commonly located on the lingual aspect of the premolar
• Osteotome is used to remove the torus by creating a groove in the
lingual cortex with a fissure bur.
• Alternatively large rotary bur can also be used.
• Bone is smoothened with bone file and the primary closure is
• Possible complications: Haemorrhage of the floor of the mouth, and
FIGURE 3-3 Removal of lingual torus: (A) lingual torus; (B)
grooving and removal of torus; (C) sutures placed.
• Vertical bone resorption of the bone in the posterior mandible
• It limits the extension of the lingual flange of the lower denture.
• Incision is made in the posterior aspect of the mandible on the crest
• Mucoperiosteal flap is reflected and a rotary bur or bone file is used
to reduce the prominence of the ridge.
• Primary closure is achieved after suturing and a stent or modified
denture is immediately placed to position the muscle inferiorly.
Augmentation is defined as ‘to increase in size beyond the existing size. In
alveolar ridge augmentation, bone grafts or alloplastic materials are used to
increase the size of an atrophic alveolar ridge’. (GPT 8th Ed)
Rationale of ridge augmentation
Rationale of ridge augmentation is to recreate an edentulous ridge
having features compatible with the requirements of denture wearing.
Factors affecting ridge augmentation success
• Type of augmentation material, i.e. autografts, allograft or alloplast
• Surgical and prosthodontic design
• Physical and mental condition of the patient
• Skill of the surgeon and prosthodontist
Diagnosis and treatment planning
• Through medical and dental history.
• Complete radiographic evaluation.
• Frontal and profile photographs.
• Radiographs and photographs are obtained after satisfactory jaw
• Mock surgery performed on the cast to determine the surgical
approach to be used and the level of desired correction.
• Minimum of 16–18 mm of interarch space is required to construct
The techniques commonly used for ridge augmentation are as
• In this technique, the buccolingual dimension of the mandible is
split and the lingual cortical bone is repositioned superiorly.
• Some authors have suggested decreased postoperative bone
resorption and good vertical bone augmentation.
• Incidence of paraesthesia of the mandibular nerve is high.
• Postoperative ridge form following this technique is poor.
• When bony support in the maxilla and mandible is inadequate.
• When the residual vertical bone height between the mental foramen
• In this technique, autogenous bone from the iliac crest has been used
to augment the atrophic maxilla or mandible.
• Drawback is high rate of resorption of the onlay graft.
• Secondly, another surgery is performed to increase the depth of the
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