1. 3. History and Exam
John Beumer III, DDS, MS
and
Robert Duell, DDS
Division of Advanced Prosthodontics,
Biomaterials and Hospital Dentistry
UCLA School of Dentistry
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2. History and Clinical Exam
• Medical and dental history
• Orofacial exam
• Prosthodontic assessment
• Prognosis
• Preliminary impressions
• Tissue conditioning

3. Medical History
 Potential medical emergencies
 Effects on denture supporting
tissues
 Effects on oral neuromuscular
control

4. Effects of Smoking
 Predisposition to oral
cancer
 Predisposition to
periodontal disease
 Success – failure rates
of osseointegrated
implants

5. Oral Facial Exam:
Oral cancer screening exam
Exam for other pathology
Local
Systemic
Prosthodontic assessment

6. Intraoral and Extraoral Exam
Palpate the temporomandibular joint
Checking for:
• Clicking
• Popping or crepitus

7. Intraoral and Extra Oral Exam
Conduct a thorough oral cancer screening
exam
• Lips and cheeks
•Lateral border of the tongue
•Floor of the mouth
•Tonsillar region and the soft palate
•Base of the tongue
•Oropharynx
•Neck

8. Extraoral Exam
Lymphatics
The first sign of oral cancer is often a palpable lymph node
Lips and cheek

9. Examination of the Lips and Cheeks
Visual inspection
Palpation
Bidigital
You are palpating for:
• Lumps and bumps, indurations etc.

10. Intraoral Exam
 Examine the denture bearing
surfaces, the soft palate,
tonsillar region, the vestibules
and the buccal mucosa.
Hamular notch

11. Intraoral Exam
Examine the lateral
borders of the tongue
Examine the ventral
surface of the tongue
and the floor of the
mouth.

12. Oral Lesions and Disease Factors
Impact on Complete Dentures
Diabetes (long term insulin
dependent)
Epithelium is thinner and
less keratinized.
Result:
Compromised, support
and impaired tolerance of
complete dentures.

13. Disease Factors
Wickham’s striae
Oral Lichen Planus –
Erosive lesions and subsequent
scarring in the buccal shelf area
limit denture extension in this
region and make it difficult for
some patients to tolerate their
dentures.
Result – Compromised support
and tolerance of the mandibular
denture.

14. Disease Factors
Pemphigoid – Chronic
ulceration with subsequent
scarring of the oral mucosa.
Result – Limited denture
extensions compromising
support, stability, retention
and tolerance of complete
dentures.

15. Chronic Candidiasis
Mild Low saliva flow
Candidiasis rates leads to
increased numbers
of fungal organisms
Severe leading to a high
Candidiasis incidence of chronic
Candidiasis.
Angular cheilitis
secondary to chronic
Candidiasis.

16. Clinical Manifestations
Burning and irritation of the denture
bearing mucosa, making tolerance of
complete dentures difficult. In addition
the fungus is keratolytic, further
compromising support and tolerance.

17. Treatment
Topical antifungal therapy followed
by relining of the dentures (Nystatin
is the drug of choice. It can be
dispensed as a cream, a powder or
an oral lozenge).

18. Common Oral Lesions
Inflammatory fibrous hyperplasia
Begins as a traumatic ulcer secondary to an overextended denture flange.

19. Common Oral Lesions
Inflammatory fibrous hyperplasia
Continued denture wear and irritation
leads to inflammatory fibrous hyperplasia
(epulis fissuratum).
Therapy – Surgical excision

20. Common oral lesions
Inflammatory papillary hyperplasia
Secondary to ill fitting maxillary dentures. Usually complicated by
chronic candidiasis.
Therapy:
Antifungal medications applied topically. In extreme
cases,surgical excision.

21. Therapeutic Approaches – Palatal Papillary
Hyperplasia**with Associated Candida Albicans
Antifungal therapy*
a) Reline or remake denture
b) Nystatin powder (100,000 units per gram) Apply to undersurface of denture
three times per day for 3-4 weeks
c) Nystatin cream – Best used for lesions associated with the corners of the
mouth
d) Reline denture with temporary reline material
Surgical excision with electrosurgery (when antifungal therapy has reached an
end point)
*Nystatin rinse is generally ineffective. Nystatin oral or vaginal
suppositories used as an oral lozenge are reserved for fungal
infestations that extend beyond the denture bearing surfaces.
**Is this a premalignant lesion? No!!!!

22. Other Oral Lesions of Importance
Premalignant Lesions
Leukoplakia Erythroplakia
Both these lesions can transform into Squamous Cell Carcinomas

23. Other Oral Lesions of Importance
 Squamous cell carcinomas
Unless detected early most patients with squamous carcinoma have a
survival of less than 50%. Early detection dramatically improves survival.

24. Other Oral Lesions of Importance
Squamous Cell Carcinoma
A
•A thorough oral cancer screening exam must be
performed on all patients
considered for complete dentures.
•Early oral cancers (A) are difficult to
detect and may be confused with other
phenomenon, but the cure rates are high.
B •Advanced oral cancers (B,) are easy to detect,
but cure rates are very low.
•Our challenge is to detect oral cancers
when they are small, localized, and
treatable.

25. Oral Exam
Clinical Factors Influencing
Stability, Retention, and Support of
Complete Dentures

26. Definitions – Removable Prosthodontics
 Retention – Resistance to vertical
displacement of the denture away from the
denture bearing surface during.
 Stability – Resistance to lateral displacement
of the denture during function.
 Support – Resistance to vertical forces of
occlusion. Factors of the bearing surface that
resist or absorb occlusal loads during
function.

27. What factors associated with the
denture bearing tissues influence
the quality of retention,
stability, and support provided
the complete denture?

28. Quality of Bearing Surface Mucosa Affects Support.
a) Degree of keratinization
b) Amount of attached mucosa vs unattached mucosa
Stratum corneum
Stratum granulosum
Stratum
spinosum
Basal layer
Keratinized Lamina propria
Less keratinized
The more keratinized attached mucosa available,
particularly in the mandible, the better the support.

29. Keratinized Attached mucosa is the
Remnant of Attached Gingiva.
Mucogingival junction
Attached Gingiva Keratinized attached mucosa
The more available on the denture bearing surfaces, the better the support.

30. Maxilla vs Mandible
Note the
amalgam tattoo
Maxilla – Abundance of Mandible – Narrow zone of
keratinized attached mucosa. keratinized attached mucosa.
Covers entire palate and alveolar Confined to the alveolar ridges.
ridges.

31. Loss of Keratinized Attached Mucosa
Result:
(a) Reduced support.
(b) Reduced tolerance to occlusal load.
Zone of
keratinized
mucosa

32. Ridge Resorption
What is the impact of bone
resorption on retention, stability,
and support?
All three are negatively impacted.

33. Pattern of Ridge Resorption*
 The rate of resorption is much higher
in the mandible than in the maxilla.
*Talgren, 1964

34. Ridge Resorption
Resorption patterns in the
edentulous patients*
*From Zarb et al, 1983

35. Ridge Resorption
Note the sharp mylohyoid ridge (arrow)

36. Mandible – Prime Support Areas
Retromolar pad
Buccal shelf
Alveolar process
*Of the above, the alveolar process is most affected by the process of bone resorption

37. Retromolar Pad
One constant, relatively unchanging structure on the mandibular
denture bearing surface is the retromolar pad (dotted line).
The pad contains glandular tissue, loose areolar connective tissue,the lower margin of
the pterygomandibular raphe, fibers of the buccinator, and superior constrictor and fibers
of the temporal tendon. The bone beneath does not resorb secondary to the pressure
associated with denture use. It is one of the primary support areas.

38. Buccal Shelf
Masseter
groove
Boundaries of the buccal
area
shelf: The external oblique
line and the crest of the
alveolar ridge (area within
the dotted lines).
Buccinator
limits the
extension in
this area
The buccal shelf is a prime support area because it is parallel to the occlusal
plane and the bone is very dense. It is relatively resistant to resorption.

39. Buccal Shelf
Buccal shelf area (area within the dotted lines). The greater the access to
the buccal shelf the more support there is available for the denture. Access
is determined by the attachment of the buccinator.

40. Patterns of Resorption - Mandible
Mandible – initially buccal lingual dimension of the alveolar
ridge is narrowed, compromising support (A, B, C).
A B
C

41. Patterns of Resorption - Mandible
E
D
But thereafter, the height is affected compromising
support,stability, and retention (D,E).

42. Patterns of Resorption - Mandible
Mylohyoid ridge Continued calcification of the
attachment of the mylohyoid muscle
leads to the development of a sharp
bony projection on the lingual surface.
The mucosa overlying this region is
poorly keratinized and prone to
perforation secondary to trauma from
complete dentures.

43. Pattern of Resorption - Maxilla
Labial plate
Following extraction,
resorption is from buccal-
labial towards the lingual.
Result: Some compromise of stability and support.

44. Patterns of Resorption - Maxilla
Continued resorption leads to loss of vertical height of the alveolus.
Result:
a. Significant compromise of stability of the denture.
b. Pseudo-class III jaw relation.
c. Secondary affect – compromised retention because of
compromised stability. Peripheral seal of the denture is more easily broken
because there is little resistance to lateral displacement of the denture
during function.

45. Combination Syndrome
It produces a very specific pattern of resorption of the maxilla.
It is caused by edentulous maxilla opposing dentate mandible where
anterior dentition has been retained and where the denture has not been
properly balanced.
Note steep anterior guidance. There are no contacts in working,
balancing or protrusive when the patient goes through the chewing cycle.
As a result, during the chewing cycle , the denture tips anteriorly,
compressing the mucoperiosteum of the premaxilla, leading to resorption
of the bone of the premaxillary area.

46. Combination
Syndrome Result:
(a) Resorption of premaxilla
(b) Hypertrophy (fibrous
Resorbed hyperplasia)
premaxilla of maxillary tuberosity.
(c) Occlusal plane problems.
Hypertrophic
maxillary
tuberosities
Occlusal plane

47. Mandible – Similar Phenomenon Observed
Resorption can be so severe as to require augmentation with bone grafts
in order to prevent pathologic fracture of the mandible.

48. Measures to Prevent or Slow Resorption
.
1. Well adapted and properly extended dentures with
properly designed and executed occlusion.
2. Retention of residual tooth roots in key locations.
3. Use of osseointegrated implants
Retained roots and osseointegrated implants are useful because they
absorb much of the occlusal load locally, thereby preventing compression
of the periosteum and in turn preventing resorption of the adjacent bone.

49. A Preventive Measures
Retained root tips (A) and
Osseointegrated implants
B (B, C)
The denture rests on the
implants or root tips.
Compression of the
C mucoperiosteum is minimized,
preventing resorption of the
underlying bone.

50. Preventive Measures
Note tissue bar connected to the implants
Bar facilitates retention, stability and
provides support in the anterior region.

51. Other Factors – Frenum Attachments
Frenum – Folds of mucus membrane containing fibrous
connective tissue (A) (arrows).
A B
Frenum are of little consequence. However, they may limit
denture extensions (B) (arrows) or make seal difficult to
maintain, and occasionally affect the retention of the maxillary
denture.

52. Other factors – Frenum attachments
Lingual frenum  Mandibular frenum.
If they are prominent they
may affect denture
extensions, particularly
the lingual frenum
Buccal frenum

53. Floor of Mouth Posture and Tongue Position
A Floor of mouth posture and
tongue position (depth of
retromylohyoid space) affect
stability and retention.
Favorable anatomy as seen
B here (A, B,) permits
development of a longer
lingual flange.
Result: Improved stability and
retention of the mandibular denture

54. Favorable Floor of Mouth Posture
Impressions and dentures made for patients with
favorable floor of mouth posture and favorable
(anterior) tongue position. Note length of lingual
flange. Stability and retention are enhanced.

55. Unfavorable Floor of Mouth Posture and
Retruded Tongue Position
Patients with unfavorable floor of mouth posture and tongue
position (A, B). The tip of the tongue has lost its definition
and is retruded and the floor of the mouth is elevated.
A B
Result: Length of lingual flange of the denture will be limited, compromising
stability, retention and the ability of the patient to control the lower denture.

56. Determining Floor of Mouth Posture
Carefully examine the
retromylohyoid space to
determine the floor of mouth

57. Solutions - Retruded Tongue Position and
Unfavorable Floor of Mouth Contour.
1. Dentures retained with osseointegrated implants
Result:
a. Improved retention. Note denture snaps onto retention bar.
b. Improved stability (from the implants and the tissue bar).
c. Improved support (anteriorly).
d. Better control of the bolus (tongue no longer must position denture and control
the bolus simultaneously).

58. Solutions - Retruded Tongue Position and
Unfavorable Floor of Mouth Contour.
2. Skin graft vestibuloplasty
This surgical procedure
has been used to
overcome problems
Residual Skin grafted areas
keratinized
caused by a retruded attached mucosa
tongue position,
unfavorable floor of mouth
posture and a narrow
residual zone of
keratinized attached
tissue.
Muscle attachments in the floor of the mouth are lowered and the zone of attached
keratinized tissue is widened with the skin graft.
a.Result: Improved stability and retention of the denture because the
lingual flange is lengthened.
b.Result: Improved support, because the zone of attached keratinized
tissue is dramatically widened.

59. Impact of Saliva and Salivary Glands
Palatal glands

60. Posterior Palatine Salivary Glands
The presence of these
glands permit compression
of the tissues helping to
overcome poor adaptation of
Glandular tissue the denture in this area
secondary to shrinkage of
Posterior palatal the acrylic resin during
seal area processing. Peripheral seal
of the denture is thereby
maintained.

61. Posterior Palatine Salivary Glands
When making impressions this area of tissue is compressed, allowing us to
compensate for shrinkage of the acrylic resin during polymerization and
movement of the denture base during function.
Result: Tissue adaptation of the denture is maintained and therefore peripheral
seal and retention of the maxillary complete denture is maintained.
When these glands atrophy, the tissue become less compressible making
it more difficult to obtain and maintain peripheral seal.

62. Posterior Palatal Seal Area
Shrinkage of acrylic resin is also accounted for by
scoring the cast in the postdam area (arrow).

63. Salivary Flow and Retention
Low flow rates
• Difficult to achieve and maintain
peripheral seal of the maxillary
denture
• Compromised adhesion and
cohesion.

64. Saliva as a Lubricant
Low flow rates
• Primarily affects the mandibular denture
bearing surfaces.
• Results in more friction at the mucosa-
denture interface as the mandibular
denture slips and slides over the denture
bearing surface during function.

65. Neuromuscular Control
• Some patients have the ability to manipulate
their lower denture and control the bolus
simultaneously, regardless of the quality of the
design and construction of the denture.
• Many patients with good neuromuscular control
can overcome unfavorable bearing surface
contours and anatomy and chew efficiently with
their complete dentures and the converse is also
true.

66. Tissue Factors Affecting Support
Mandible: Maxilla:
• Retromolar pad • Amount of keratinized
• Alveolar ridge contours (the mucosa
broader the more support) • Alveolar ridge contours
• Amount of attached • Palatal shelf area and
keratinized mucosa (the contour
more present the better
the support)
• Buccal shelf area (the more
access and the greater
the surface area the
better the support

67. Tissue Factors Affecting Stability
Mandible: Maxilla:
• Alveolar ridge height • Alveolar ridge height
• Floor of mouth contour • Presence of well formed
(favorable vs. unfavorable) maxillary, moveable
• Tongue position denture bearing
(anterior vs. retruded) surface tissues
• Neuromuscular control tuberosities
• Presence of flabby, • Presence of flabby
moveable denture
bearing surface
tissues.

68. Tissue Factors Affecting Retention
Mandible: Maxilla:
• Shape of the palatal vault (peripheral
Primary Factors: seal)
• Tongue position • Drape of the soft palate - House
• Floor of mouth posture classification (peripheral seal)
• Neuromuscular control • Quality and quantity of saliva
(peripheral seal)
Secondary Factors • Compressibility of posterior palatal seal
• Peripheral seal area (peripheral seal)
• Adhesion • Presence of well shaped tuberosities
• Cohesion • Height of alveolar ridge (resistance to
lateral displacement)

69. Clinical exam - Prosthodontic Assessment
 Assessment of existing dentures
• Retention
• Stability
• Vertical dimension of occlusion
• Centric relation
• Esthetics

70. Prosthodontic Assessment
 Posterior teeth
• Tooth forms
• Materials
• Wear

71. Prosthodontic Assessment
Retention - Maxilla
Apply a tipping force to the incisors in an attempt to break seal

72. Prosthodontic Assessment
Stability - Maxilla

73. Prosthodontic Assessment
Stability and Retention - Mandible

74. Prognosis based upon:
• Bearing surface anatomy, tongue
position and floor of mouth posture
• Neuromuscular control
• Denture history
• Psychological classification

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