Postinsertion Problems Onur Geckili 19.1 Defini Acrylic resin Any of a group of thermoplastic resins made by polymerizing esters of acrylic ‘or methylmethacrylate acids Alveolar bone ‘The bony portion of the mandi- ble or maxillae in which the roots of the teeth are held by fibers ofthe periodontal ligament Articulating paper Ink-coated paper strips used 10 locate and mark occlusal contacts Deflective occlusal contact A contact that dis- places a tooth, diverts the mandible from its intended movement, or displaces a removable denture from its basal seat Gag An involuntary contraction of the muscles Of the soft palate or pharynx that results in retching Hard palate The bony portion of the roof of the ‘mouth Incisive papilla ‘The elevation of soft tissue cov- cing the foramen of the incisive or nasopala- tine canal ‘Occlusal prematurity Any contact of opposing teeth that occurs before the planned intercuspation (©, Geckli, DDs, PHD Faculty of Dentistry, Department of Prosthadonics, Istanbal University, Istanbul, Turkey email: geckii@istanbul ede (© Springer Interationsl Publishing Switzerind 2016 19 Occlusal reshaping ‘The intentional alteration of the occlusal surfaces of teeth to change their form Pressure-indicating paste Any substance applied to a dental prosthesis, which, when seated on a structure, demonstrates the adapta- tion ofthe prosthesis to the structure it opposes Remount procedure Any method used to relate restorations to an articulator for analysis and! or to assist in the development of a plan for ‘occlusal equilibration or reshaping Residual ridge crest ‘The most coronal portion of the residual ridge Retention That quality inherent in the dental prosthesis acting to resist the forces of dis Todgment along the path of placement Stability The quality of a removable dental prosthesis to be firm, steady, or constant, to resist displacement by functional horizontal or rotational stresses ‘Trauma An injury or wound, whether physical ‘or psychie Patients rehabilitated with RPDs should be recalled the day after the insertion of the prosthe- sis. If anything more than a minor tissue damage is observed, they should be seen in the following. 2 or 3 days to ensure the healing of the damaged tissues, 1 week after, and every 6-month interval for periodic oral evaluations, The patients susceptible to caries or having periodontal prob- Jems may be recalled more often. a7 ©. $akar (ed), Removable Partial Dentures: A Prcttioners' Manual, ‘DOI 10,1007/978-3-319-20556-4_19218 [Link] ‘The recall visits should be long enough to give the patient confidence that required adjustments, will be provided and to give waming that an appointment is needed for future adjustments ‘without intruding the clinician's routine schedule. Tis not feasible to make an intraoral examina- tion immediately after the patient is seated. The clinician should ask questions about the function, esthetics of the RPDs, and the condition of the ‘remaining dentition prior to intraoral examination Intraoral examination should be performed in detail with and without the RPDs even if no com- plaints exist afterward, It should be remembered that some minor tissue damages or premature ‘occlusal contacts which ate not perceived by the patient can be detected and corrected by the clini- cian, and future pain and discomfort problems may ’be prevented, The problems associated with wear- ing an RPD may be classified into six categories: ‘+ Pain and discomfort related to soft tissues or remaining teeth + Difficulty seating or removing the RPD + Lack of retention and stability + Functional problems + Esthetic problems + Compromised periodontal health and mucosal Tesions 19.2 Painand Discomfort Related to Soft Tissues or Remaining Teeth Pain and discomfort may be associated with the ‘remaining (eeth, soft tissues surrounding the den ture base, or both and classified as one of the ‘most usually seen RPD postinsertion problems. "The areas of tissue trauma may be in the incisive papilla, hard palate, residual ridge crest, the peripheral borders of the RPDs, or the mucosa not covered by the RPDs such as lips and cheeks. Tissue trauma reveals as increased redness or translucency in the oral mucosa, Increased red- ness is the symptom of the ulcerations, and a transluceney may occur just before ulgeration exists. Overextension of the denture bases and the pressures on the fragile tissues such as incisive Fig. 19.1. An ulceration due to tissue trauma caused by the averextension ofthe lingual border of an RPD Fig. 19.2 An indelible penil may be used to mark the ulceration area papilla or occlusal prematurities are the main causes of these ulcerations. Ulcerations due 10 tissue trauma (Fig, 19.1) develop generally at the initial recall appointments and can be solved eas- ily by relieving the denture base parts touching the pain area, In case of overextension, ill-fiting, RPDs, or acrylic irregularities, the areas can be identified by the aid of an indelible pencil or pressure-indicating paste, Nevertheless, it is much better to prefer an indelible pencil because using a pressure-indicating paste or cream for termining these areas may cause faulty results as the paste is easily displaced due to its softness. The indelible peneil is used t mark the uleer~ ation area (Fig. 19.2), and after the area is trans- ferred to the RPD (Fig. 19:3), these parts are gently removed using a tungsten carbide bur, ‘The ulcerations appearing on the residual ridge crests are usually due to occlusal prematurities; bbut they may also be because of the irregularities of the acrylic resin on the intaglio surface of the19. Postinsertion Problems 219 Fig. 19.3 The uleration area is transferred to the PD. The marked pars may be easily removed using 3 tungsten carbide br afterward denture base. These irregularities may be recog- nized by clinicians by examining the denture base ‘with fingertips and eliminated before the delivery of the RPDs. Additionally, denture base rough- ness can be corrected after using a pressure-indi- cating paste and identifying the exact areas causing the discomfort. After the adjustment, the pressure-indicating paste should be reapplied for verification, Topical agents may be used to relieve pain and stimulate healing 19.3 Difficulty Seating or Removing the RPD ‘The difficulties in seating or removal of an RPD ‘are usually seen in the insertion period, but this, complaint may also appear after the RPD has been in use for some time. This complaint may be classified into three categories. 19.3.1 Incomplete Seating of a Rest and Clasp Assembly on the Related Abutment If the rest and clasp assembly is not fully seated onthe abutment (ig. 19.4), itmay apply nonaxial forces to the abutment. These forces may cause significant discomfort, tooth movement, or metal- lurgical fatigue of the clasp arms due to being Fig. 19.4 A rest and clasp assembly not fully seated will, probably apply nonaxil forces othe abutment roth active all the time. This may usually occur because of design erors. I a proper path of insertion was not designated atthe time of treatment planning, the RPD may not fully seat on the abutments. The guiding planes should be carefully examined, and if there isa minor incongruity, the RPD may seat after preparing the guiding planes. IF itis not pos- sible to seat the RPD by modifying the guiding planes, refabricating procedure may be the only solution .2. Seating Problems Due to Pronounced Soft Tissue Undercuts Soft tissue undercuts may create problems if any component of an RPD passes over them during insertion or removal of the prosthesis, These problems usually involve pain and discomfort due to injuries of these soft tissues. These soft tissue undercuts should be surgically corrected prior to definitive treatment (see Chap. 6); but if they appear after the treatment, the RPDs may be rebased, relined, or remade according (0 the extent of the surgical procedure. 19.3.3 Patient-Related Factors Patient-related factors may be inability to manip- ulate or distortion of the RPD after usage. Elder RPD users may have systemic neurologic disorders. Therefore, it is not feasible to use complicated RPD designs which have more than20 [Link] ‘one path of insertion. ILis very important to show the patient how to insert and remove the prosthe- sis and ask him/her to manipulate withthe practi- tioner in the first and the following early appointments. Distortion of the RPD may occur if the patient tries to tighten the RPD or uses the clasps while insertion and removal. The distorted clasps may be changed with wrought wires or cast clasps by the laboratory after making an impression with the RPD. 19.4 Lack of Retention and Stability Retention or stability loss of an RPD may origi- nate from the following situations: 1. Broken clasps or loss of the precision attachments 2. Decrease in the function ofthe clasps or preci- sion attachments 3. Overextended or underextended denture bases 4, Deflective occlusal contacts Retention or stability loss may be due to one fo all of these situations, The clinician must ‘examine the origin ofthe looseness and make the appropriate treatment. 19.4.1 Broken Clasps or Loss of the Precision Attachments Broken clasps are usually due to fatigue of the RPD components and will be discussed in detail in Chap. 20. 19.4.2 Decrease in the Function of the Clasps or Precision Attachments Function of a clasp may decrease after some time ‘of usage because of multiple insertion and remov- als performed by the patient and this problem may be easily solved by bending the retentive farms into the undercut arcas with the aid of an “lk Fig. 19.5 Ifthe funetion ofthe clasp decreases, it can be reactivate using plies and bending the retentive arm into the undercut area Fig. 19.6 The clasp assemblies may Tose their retentive properties due to caries of the abtment tet appropriate plier (Fig. 19.5). The bending force are generally applied vertically in order to reach the undercut area properly. However, excessive bending should be avoided in order not to cause aan accelerated fatigue of the clasp. Clasps may not function properly in case of wear of the abut- ‘ments due (0 caries (Fig. 19.6), abrasion, or ero- sion on the facial or proximal surfaces or because of patient misuse. However, it should be under- lined that these may be the reasons only if the RPD has been designed properly. The design must have been completed using a surveyor for deciding the path of insertion and for tracing the survey line to obtain efficient retentive clasps, If19. Postinsertion Problems 21 Fig. 19.7. Precision attachments may lose their etention properties due to wear of plastic components. Wom pls- ‘ie components a) are removed (b) and replaced with new Fig. 19.8 CEKA attachments may be changed to origi- ‘al position or setvated using the driver provided bythe manufacturer this procedure has not been employed before, the clasps of the RPD are obliged to be loosened every time, If wear exists on the abutments, the nonfunctioning clasps may be changed to func tioning by adding composite material to the teeth surfaces and bending the retentive arms into the deepened undercuts with pliers. ‘The function ofthe precision attachments may bbe abridged in time because of the wear of plastic ‘components, and this should have been told to the patients prior to the insertion of the prosthesis. "The consistent replacement has to be a standard, process of the planned patient maintenance, The worn plastic components should be replaced with new ones regularly in accordance with the manu- facturer'srecommendations (Fig, 19.7). Activation of the precision attachments is also possible in some atlachment types (Fig. 19.8). ‘ones (¢ repuly in secondance with the manufacturer's recommendations Fig. 19.9 Overextended denture bases may eause the muscles and frena to dislodge the RPDs and may also ‘eause tse ierittion and subsequent uleerations 19.4.3 Overextended or Underextended Denture Bases ‘An overextended denture base (Fig. 19.9) may ccause the muscles and frena to dislodge the RPD, and an underextended denture base (Fig. 19.10) may affect stability; the RPD may not be stabi- lized under lateral forces and may result in food entrapment, (Overextended denture base areas should be cor- rected by using @ laboratory bur and the flange should be rounded thoroughly while it is being shortened. Underextended denture base of an RPD. may be elongated by relining or rebasing with a suitable functional impression method, However, if the borders are too short to be relined, the den- ture base of the RPD may be remade by com- pletely removing the resin and the artificial teeth if the framework exhibits a clinically acceptable fitmm [Link] wy Fig. 19.10. Underextended denture bases say affect the stability ofthe RPDS and food entrapment i inevitable in such cates 19.4.4 Deflective Occlusal Contacts Deflective occlusal contacts usually affect the stability of the RPDs and therefore should be climinated. Ifthe deflective occlusal contacts are ‘minor, they may be removed by occlusal reshap- ing with the aid of articulating papers; but if they fare gross, the artificial teeth may be changed fol- Towing a new interocclusal record. Ifthe RPD is ‘atooth-supported one, occlusal reshaping should bbe completed using intraoral methods; but if itis a distal extension RPD, the grinding procedures should be performed using remount procedures with the aid of an articulator, However, it should >be emphasized that the final grinding procedures should be completed intraorally to compensate the resiliency of the supporting soft tissues with articulating papers having various thicknesses. 19.5 Functional Problems Functional problems are classified into five parts in this section as gagging; eating, or chewing difficul- ties; phonetic problems; tongue or cheek biting; and {food impaction or collection on the RPD borders. 19.5.1 Gagging ‘Gag reflex isa somatic response in which the body tries to abolish forcign bodies from the oral cavity by muscle contraction at the base of the tongue and the pharyngeal wall. Unstable or poorly retained RPDs, increased occlusal vertical dimen- sion, overextension of the mandibular RPDS in the retromylohyoid space, and the overextended or too thick borders of the maxillary RPDs in the posterior regions can intrude the “trigger zones” and produce gagging. Gagging may usually be observed as a problem of the first-time RPD users and mostly disappears after using the prosthesis for several days. However, patients with severe gagging problems present big difficulties in using the RPDs. Therefore, the RPD design and denture borders should be fabricated with caution taking into consideration the abovementioned factors “The patient and the RPD should be examined thor- ‘oughly to find the reason of gagging. Unstable or poorly retained RPDs may be relined or rebased; clasps or precision attachments may be activated or changed, or the RPD may be remade if these are not sufficient enough to maintain adequate reten- tion. To correct the problem of overextensions, the posterior lingual and palatal borders should be shortened and thinned, Correction of the increased. ‘occlusal vertical dimension requires reestablish- ing of the appropriate occlusal vertical dimension and removing and rearranging the artificial teeth of the RPDs. Poor adaptation of the maxillary RPDS to the tissues because of faulty impressions may also induce gagging. If the denture base is acrylic, relining may be the solution of this prob- lem, but if the denture base is metal like most of the cases, the RPD should be remade, Placement of posterior denture teeth lingually may also restrict the tongue space and induce gagging. This cean be corrected after removing and rearranging the artificial teeth in correct positions. Alternative tweatment options such as hypnosis may also be applied to the patients with stubbom gagging problems. 19.5.2 Eating or Che culties Patients usually report chewing or eating problems before prosthodontic treatment. It should be under- Jined that these problems decrease rapidly after tucated with fixed partial dentures but slowly after RPD treatment due to an adaptation period for the new prosthesis. Moreover, it has been shown that19. Postinsertion Problems 23 PD treatment improves the ability to reduce the bolus particle size but is not able to fully restore the masticatory function especially if it is a distal extension one. However, it has been indicated that perceived chewing ability is an important compo- nent of perceived oral health, and therefore these problems should be taken into aecount seriously. Patients should be advised not to eat tough and sticky food during the early period of adjustment. "The occlusal surfaces of the atticial teeth should be examined with an articulating paper, and the ‘occlusal prematurities should be eliminated or the artificial teeth of one or both sides should be reset ‘where an occlusal adjustment is not adequate 10 ‘overcome occlusal problems, or if some artificial teeth ack occluding the opposing arch. Difficulties ay also be related to retention, stability, or vert cal dimension. These factors should also be evalu- ated and corrected if necessary. 19.5.3 Phonetic Problems Unlike complete dentures, RPDs usually do not generate speech difficulties. However, the loca tion of the anterior teeth especially on a maxillary PD should be correct in order to allow the tongue and other articulators to work accurately. Also, changes in the contour of the anterior palate and ‘occlusal vertical dimension may show phonetic difficulties. Speech problems are usually seen in the first few days after the insertion of the RPDs especially when the patient is a first-time denture set. It bas been shown that most of the patients ‘with these problems show remarkable improve ‘ments after 1 week of use, If no improvement is, achieved, alterations in the RPD design or tooth arrangement should be considered. Additionally, itshould be noted that since degenerative changes in auditory abilities exhibit difficulties to adapt to new prosthesis in older patients, adaptation is usu ally much easier to achieve in younger patients 19.5.4 Tongue or Cheek Biting ‘Tongue, cheek, of lip biting is a common con plaint among patients receiving prosthodontic treatment. Patients bite their cheeks mostly Fig. 19.11 The cheeks may be trapped between the occluding surfaces of the posterior artificial teeth, and painful ulcerations may be seen inpatients wearing RPDs ‘with inadequate posterior teeth overlap because of the inadequate occluding posterior teeth overlap, With the use of monoplane poste- rior artificial teeth, this problem is seen more often because the teeth are arranged with no hori- zontal overlap. The checks are trapped between the occluding surfaces of the posterior artificial teeth and painful ulcerations may be seen (Fig. 19.11). To overcome the problem of insuf- ficient overlap, the posterior teeth might be gen- tly rounded and reduced in size buccally or all the posterior teeth may be reduced buecally to move away from the soft tissues. However, it should be remembered that reducing the artificial teeth size ‘may reduce the chewing ability of the patients. In those circumstances, the artifical teeth should be changed and rearranged, Cheek biting may be seen in patients who have lost their posterior teeth a long time ago and have never used RPDs. In this situation, the buccinator muscle drops down to the space between the edentulous resid- ual ridge crests, After an adaptation period, the size of the muscle tums back to original, and this complaint is resolved most of the time. Additionally, if the interocelusal space between the posterior denture bases of maxillary and man- dibular RPDs is too small, the patient may bite higher cheek. Grinding the acrylic bases to lengthen the space is the only solution in those situations ‘Tongue biting may be seen if the artificial teeth have been arranged too lingually or the ‘mandibular posterior teeth have been missing for28 [Link] 4 Jong time and the tongue is broadened. The lin- ‘gual cusps of the mandibular artificial teeth should be broadened to resolve the problem. In the case of long-time missing posterior teeth sce- narios, the patients stop biting their tongue after the tongue turns to its normal size if the teeth ‘were set in correct position. Lip biting may be scen with the presence of wrong anterior teeth relations and is usually resolved by reshaping the labial surface of man- dlibular canine teeth. 19.5.5 Food Impaction or Collection on the RPD Borders Food impaction happens usually when the acrylic denture base is not well adapted to the abutments, (Fig. 19.12). The reason is usually starting the treatment without restoring the abutment teeth ‘Therefore, restarting the treatment with proper planning including restoring the abutments rather than relining is more appropriate in these situa- tions. However, if the food trap is due to an insuf- ficiently extended denture base, the solution may bbe a relining. Food collection on the borders may ‘occur in the ease of poorly contoured or not well polished acrylic surfaces or if the patient has a reduced salivary flow. Appropriately contouring and polishing the surfaces will easily solve the Fig. 19.12 When the acrylic denture base ofthe RPD is ot well adapted to the abutment tooth, fod impaction is ‘unavoidable problem. If a reduced salivary flow is present, ‘medications increasing the flow rate may be pre- scribed or chewing gums and fluids stimulating. the flow may be recommended to the patients. ‘Some RPD designs such as lingual bar with cin- gulum bar and designs requiring deep reliefs because of anatomic restrictions or insufficient beading may also cause food impaction, which may only be corrected by refabricating the RPDs with a move appropriate planning. 19.6 Esthetic Problems RPDs replacing the anterior teeth may cause esthetic problems. ‘These problems may be related to several factors. But before explaining. these factors, it is very important to describe the esthetic zone and its effect on RPD treatment options. 19.6.1 Esthetic Zone Esthetic zone is the observed teeth and soft tis sues when a patient makes @ usual smile or laugh. However, Preston describes the esthetic zone as the place wherever the patient thinks it is, meaning that even if the patient does not show metal while laughing, he/she still may believe that itis seen. Therefore, itis essential to describe the esthetic zone to the patients before the treatment because they might not ‘want to receive any metal on the facial surfaces even if itis not in the esthetic zone. The open smiles of patients were divided into three cate- gories as high smile, average smile, and low smile in a former study. I is easier to mask the ‘metal components in a low smile which displays, less than 75 % of the anterior teeth; but every component is visible in a high smile that shows all the anterior teeth and a contiguous band of gingiva. Therefore, it is much better to select, alternative designs in these circumstances such as precision attachments or rotational path designs (see Chaps. 12 and 16) which do not show the metal components. However, it should. bbe underlined that most of the patients have19. Postinsertion Problems 22s average smile in which the cervical to incisal length of the maxillary anterior teeth is dis- played to either the first or second premolar. Therefore, itis very important to eliminate the ‘metal components until the maxillary premolars for the majority of individuals. Additionally, some precautions should be considered about the maxillary denture base contours. The ante- rior flange should not be thick and extend to the reflection of the mucolabial fold to prevent the horizontal border of the flange from being visi- ble during smiling. ‘Mandibular anterior teeth should be taken into account if they are to be replaced with an PD. Most of the patients show 50 % of the man- dibular anterior teeth and less than SO % of the ‘buccal surfaces of the premolars in the esthetic zone; similarly, the occlusal surfaces of the pre- molars are usually displayed. Most of the esthetic problems of RPDs are due to display of the metal components such as clasp assemblies or frameworks in the esthetic zone. ‘These problems may be solved mostly with replacement dentures which follow the rules of the esthetic zone. Therefore, itis very important to plan the RPD before the treatment according to the esthetic zone of the patient. Additionally, the esthetic problems may be due to inappropriate ‘axial inclination of the artificial tooth positions, discoloration or abrasion of the acrylic teeth, and 100 low or too high occlusal plane. These prob- lems may be solved by replacing the artificial teeth with new ones. 19.7 Compromised Periodontal Health and Mucosal Lesions "The existence of the RPD in the oral cavity affects, the microbial ecosystem onto both the remaining teeth and the oral mucosa because of plaque accumulation and hygienic maintenance. Although it has been publicized that if precise hygienic techniques and regular recalls are being applied, RPDs may not cause an increase of plaque accumulation; the majority of the studies focusing on this subject reported increased sus- ceptbility to plaque accumulation with the use of RPDs. The proliferation of Spirochetes and Fusobacteria upsurges with the presence of RPDs. While @ rise of gingival inflammation at the ‘marginal gingiva of the tecth in contact with the components of the RPD has been reported in a ‘number of stadies, others failed to find any differ- ence atthe gingival margin ofthe teeth that are in contact or not with the RPDs, Most ofthe studies showed an increase in the depth of the pockets in RPD users. However, there are also investiga- tions pointing out no changes, Bergman and Ericson showed that 3 years after RPD treatment, periodontal parameters were much better in patients who paid an annual check to a dentist as compared with those who did not. It was pre sented in a comparative study that both the RPD. users and nonusers showed an increase in peri- odontal parameters after 8 or 9 years showing. that this increase should not be related directly 10 PD usage. Nevertheless, there still seems to be 4 controversy regarding the effect of RPDs on gingival inflammation or pocket depth in the den- tal literature. 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