Single complete denture

DR.HARSHA VARDHAN K.V

SVSIDS

The prevalence of the condition where one edentulous arch opposes

a natural or restored dentition is quite common. The primary
consideration for a complete denture service is the preservation of that
which remains, a single conventional denture may be desirable when it is
to oppose any one of the following:-

1) Natural teeth that are sufficient in number not to necessitate a fixed

or removable partial denture.
2) A partially edentulous arch in which the missing teeth have been
replaced by a FPD.
3) A partially edentulous arch in which the missing teeth will be/ have
been replaced by RPD.
4) An existing CD.
Most commonly, it is the maxillary arch which is the edentulous
arch, the reason being that it is easier to retain, maxillary, CD in position
because it is more stable, better tolerated by patients and easier to
fabricate than mandibular dentures.

DIAGNOSIS AND TREATMENT PLANNING:

The commonly cited long term goal in prosthodontics is the
preservation of that which remains salient considerations are:a) Acceptable interocclusal distance
b) Stable jaw relationship with bilateral tooth contacts in retruded
closure.
c) Stable tooth quadrant relationship, with axially directed forces.
d) Multidirectional tooth contact throughout a small range (2mm) of
mandibular movements.
These are the physiological characteristics seen mainly in dentate
patients but when only one arch is edentulous, unfavourable force
distributions may cause adverse tissue changes. It is therefore, important
to identify some clinical changes and correct them.
1. Extensive morphologic changes in denture foundation resulting in
arch relationship and occlusal plane discrepancies.
2. Jaw relationship extremes.
3. Excessively displaceable denture displacing tissues.

1) Routine morphologic changes occur following extractions leading to a

smaller maxilla than in the dentulous state. Thus, creating a horizontal
discrepancy between arches anteriorly and posteriorly. This makes it
difficult to direct the occlusal forces to the denture bearing areas as the
support is at a distance from the tooth contact.
Solution: Reverse horizontal overlap or crossbite placement of artificial
teeth.
Disadvantage: Such a solution is not possible for anterior defect due to
the esthetic impact on the lip because of such tooth positions.
2) Excessively displaceable tissues:
Main problem here is one of differential support capability of the
same load. The forces of occlusion are resisted by the mucoperiosteum,

which allows some movement of denture base by virtue of its resiliency.

But when movement of denture under load is great in one area than other
dislodgement.
These tissue changes ultimately lead to what is called as the single
denture syndrome in which patient compliances of loose or tilting
dentures and on examination damage to the mucosa and ridge resorption
can be observed.
Management includes treatment with reliners and tissue
conditioners which temporarily cure the problem but the cycle of trauma,
resorption and looseness continues.
The patient becomes dissatisfied and edentulous ridge continues
getting resorbed.
I) Single Maxillary C.D. opposing natural mandibular teeth:
More commonly seen than the single mandibular CD is single
maxillary CD. The number of mandibular considerations should include 1 st
molars and anterior in Class I and II jaw. In Class III anteriors and
premolars.
The occlusal form of natural teeth act as guides for the occlusal
form of artificial teeth. In most situations it is the cusp form but if natural
teeth are present than monoplane teeth can be used.
For acceptable aesthetics:1. Reposition mandibular anterior teeth orthodontically
2. Alter the clinical crowns by grinding or with restoration
3. Balanced occlusion in CR and not eccentric restoration
II) Single maxillary CD opposing mandibular arch with fixed
prosthesis:
III) Single maxillary CD opposing mandibular arc with RPD.
Especially completing edentulous maxillae and partially edentulous
and mandible with only anterior teeth remaining is a common situation
combination syn.

THE SINGLE COMPLETE MAXILLARY DENTURE:

May be opposing all or some of mandibular natural dentition.
Difficulties encountered in such situations can be due to:a) Malposed or supraerupted teeth in lower making it differ to achieve
a harmonious balanced occlusion.
b) The position of mandibular anterior teeth may make the esthetic
and phonetic placement of maxillary anterior teeth difficult without
introducing anterior interference in eccentric functional movement.
c) Another problem is that of abrasion of artificial teeth if acrylic resin
used or of natural teeth if porcelain artificial teeth are used.

Diagnosis and Treatment Planning:

I) The first method was originally described by Swenson (1964).
The maxillary and mandibular casts are mounted on the articulator
using a provisional CR record at an acceptable vertical dimension. A
maxillary base is made and the denture teeth are set, if they are seen to
interfere with the lower teeth, this areas are marked on the cast and the
natural teeth are modified using this cast as the guide.
If more
modification are required the procedure can be repeated once the
modification are satisfactory the denture is prepared for a try-in.
II) Method by Yurkstas (1968):
A U-shaped metal template, slightly convex on the lower surface is
placed on the occlusal surface of remaining teeth and the cusps to be
adjusted are identified. The stone cast is modified to an acceptable
occlusal relationship. These areas are marked with a pencil and this cast
is then used as guide for making modification on natural teeth.
III) By Bruce (1971):
The lower diagnostic cast is mounted as in the earlier procedures
and necessary modifications are made on stone cast occlusal surfaces. A
clear acrylic resin template is fabricated over this modified stone cast.
The inner surface of this template is coated with pressure indicating paste
and it is then placed in patients mouth. The required areas are identified
and adjusted till the template seats properly.

IV) Boucher et al. (1975)

Casts are mounted in similar manner. Maxillary artificial teeth are
set to obtain best possible occlusal balancing contacts, any interferences
are removed by movement of maxillary porcelain over mandibular stone
teeth. After denture fabrication a comparison of stone teeth with natural
dentition is made and interferences are removed.
The occlusion is refined using an arch shaped base plate wax and
guiding the patient to dose in CR.
Common occlusal disharmonies:
A common pattern of tooth loss involves the complete edentulous
maxillary area opposing a mandibular partially edentulous arch with
missing first molars or second premolars.
The remaining molar are often severely mesially inclined with distal
halves supraerupted. If this situation is left unaltered, there would be no
occlusion in protrusive and lateral excersions except for contact on distal
half of lower molar. The maxillary denture being easily dislodged during
functional movements.

If the molars are not severely fitted, they may be reshaped by

selective grinding. Stephens suggest that in this situation the distal half of
occlusal surface should be ground flat and denture teeth set to occlude
only with that area, leaving the mesial cusps out of contact, therefore
preventing the contact of denture teeth on an inclined plane.
When more than a moderate amount of tooth reduction is found
necessary, the ideal treatment is to restore the tilted molars with cast
gold crowns, onlays or FPD if a large edentulous space exist mesial to the
molars, another alternative is to design a RPD that would restore the
mesial of the molars.
Another possible treatment would be orthodontic repositioning of
tilted molars and if the above treatments are not possible than extraction
is necessary.
Methods used to Achieve a harmonious balanced occlusion:
Various techniques have been described and these fall basically in
2 categories:I)
Those that dynamically equilibrate the occlusion by a functionally
generated path.
II)
Those that statistically equilibrate the occlusion using an
articulator programmed to simulate the patients jaw movements.
I) Functional Chew in techniques:
Stansberry (1928) First technique using an upper CD against lower
natural teeth. He suggested using a compound maxillary rim trimmed
buccally and lingually so that the occlusion is free in lateral excursions.
Carding wax is then added to the compound rim and patient instructed to
perform eccentric chewing movements thus molding the carding wax.
The generated occlusion rim is now removed from the mouth, and stone is
vibrated into wax path of the cusps. The upper cast is articulated, the
stone cusp path record is secured to the lower member, so now there are
2 lower casts, one duplicate of lower teeth and other a replica of
functionally generated path. After the esthetics have been tried in patient
mouth, the lower cast is removed and lower chew in cast record is then
secured to the articulator, all interfering spots are ground until incisal pin
guides prevent further closure.
Thus, maximum bilateral balanced
occlusion can be achieved.
Vig (1964) described a similar technique using a Fin of resin placed
into the central grooves of lower posterior teeth which maintains the
vertical dimension and also helps to diagnose the interfering cusps.
Sharry (1968), mentions a simple technique of using a maxillary rim
of softened wax. Lateral and protrusion chewing movements are made,
so that wax is abraided generating the functional path of lower cusps. This
is continued until vertical dimension has been established.
Articulator Equilibration:

If the denture base lacks stability or the patient is physically unable

to perform chew in record, articulator equilibration techniques are used.
1. Upper cast is mounted on articulator using face bow (with orbital
pointer) and lower cast oriented to the upper cast at centric relation
at an established vertical dimension.
2. Denture teeth are arranged if the denture teeth appear to be too
far buccal when articulated with the lower buccal cusps. They are
reset to oppose the lower lingual cusps. Similarly if they appear too
far lingual to the lower lingual cusps then they are arranged to
articulate with buccal cusps.
Occasionally, because of tipped and inclined lower teeth, the buccal
cusps may be used on some and lingual on others. Once the
holding cusps have been selected, the inclines of remaining cusps
are reduced for a cusp to fossa relation between upper and lower
teeth. Thus, at centric occlusion the only areas of contact in
denture should be in central fossae.
At the time of try-in, eccentric records are made and condylar
inclinations are set on the articulator. So, that the upper posterior
teeth can be set as close to balanced as possible. After the denture
has been processed, it is again oriented to the mounted lower cast
with a new centric interocclusal record and the condylar inclinations
are reset.
Once the centric holding cusps are reestablished,
eccentric balance is achieved by selectively grinding the interfering
buccal and lingual cuspal inclines of upper teeth.
The end result would be a perfectly balanced occlusion
maintaining maximum bilateral contacts in functional and
parafunctional activities.
OCCLUSAL MATERIALS FOR SINGLE DENTURES:
1) Porcelain teeth:- Wear slowly and vertical dimension of occlusion is maintained.
- Cause fracture and chipping when opposed to natural teeth and
are difficult to equilibrate.
- Cause wear of natural teeth.
2) Acrylic resin teeth (teeth of choice):
- Easy to equilibrate and cause no wear of natural teeth
- Disadvantages: These teeth wear after a period of time and
cause loss in vertical dimension.
3) Acrylic resin with amalgam stops:
Amalgam inserts reduce occlusal wear
Less expensive and time consumig
4) IPN Resin:

Consists of unfilled highly, cross-linked, interpenetrating polymer

network. Wear is significantly less as compared to acrylic resin.

Acrylic resin with amalgam stops:

Amalgam inserts reduce the occlusal wear, the technique is simple,
less time consuming and less expensive than those used for fabrication of
gold occlusals.
Technique:- After the acrylic teeth have been balanced, occlusal preparations
are made in the acrylic teeth, extending to include as much of the
articulating paper tracing as possible.
- Amalgam is condensed into these preparations and articulator is
gently closed, going side to side, back and forth until the incisal gide
plane is again flush with the guide pan. Thus, the centric holding
area as well as some of the excursions are recorded in amalgam by
the articulator that has been programmed to closely simulate the
patients jaw movements.
5) Gold occlusals:
These are considered one of the best materials to oppose natural
teeth though it is an expensive and a time consuming process. However,
when one or more gold occlusal surfaces are provided on either side of the
single complete denture, they will stop the abrasion between unlike
materials and protect the other teeth from wear.

Technique for fabrication of gold occlusals:

Once the occlusion has been balanced and perfected after the try-in,
the plastic teeth to be converted are removed from the trial denture base.
The occlusal surfaces are cut off with a separating disk at right angles to
the long axis of each tooth. A wax retention loop is attached to the cut
surface, and the sprue for casting is also attached to the surface. The
wax and resin patterns are invested, burned out and cast, and the
castings are polished. Inlay wax is used to restore the original buccal and
lingual contours of the teeth. Then the gold occlusal surfaces with their
wax buccal and lingual surfaces are invested and tooth colored acrylic
resin is processed to the gold occlusal surfaces.
These gold and occlusal teeth are replaced in the position they
occupied when they were made only of acrylic resin. Since the occlusal
surfaces have been corrected before the castings were made, the gold will
assist in their being replaced in the original positions as guided by the
opposing occlusion.
Esthetics:

One of the basic requirement of a complete denture treatment is

esthetic acceptability. The fixed positions of mandibular teeth limit the
ability to esthetically position maxillary anterior teeth and at the same
time allow for balancing the occlusion in eccentric movements.
Ideally, enough horizontal overlap should be created to allow
freedom to balance in eccentric movements but if that it not possible, and
the esthetics dictate a certain amount of vertical overlap, then the only
alternative is to steepen the posterior cusp angles so that the posterior
teeth will disocclude the anterior teeth during eccentric movements. This
is not desirable as steeper cusps reduce the stability of the denture base
so as far as possible efforts should be made to alter the crowns of the
present mandibular anterior teeth by selective grinding or restorations.
COMBINATION SYNDROME:
Changes caused by a mandibular removable partial denture
opposing a complete denture constitute syndrome referred to as
combination syndrome.
According to Kelly changes seen:1. Loss of bone from maxillary anterior region
2. Overgrowth of the tuberosites
3. Papillary hyperplasia in hard palate
4. Extrusion of lower anterior teeth
5. Loss of bone under RPD bases
Saunder described 6 other changes:1. Loss of vertical dimension of occlusion
2. Occlusal plane discrepancy
3. Anterior spatial repositioning of mandible
4. Poor adaptation of prosthesis
5. Epulis fissurata
6. Periodontal changes
Pathology:The early loss of bone from anterior part of maxillary jaw is the key to the
other changes of the combination syndrome.

a flabby hyperplastic connective tissue makes up the anterior part of ridge

This hyperplastic tissue does not support the denture base and usually it
folds forwards forming a characteritic deep fold/ crease anteriorly

Maxillary anterior ridge continues to resorb with resultant large

tuberosities (mostly made up of fibrous tissue)

Occlusal plane migrates upwards

Lower anterior teeth also migrate upwards, upper anterior teeth disappear
beneath the lip, and both dentures migrate downwards in the posterior
region

Esthetics are poor

Excessive bony resorption under the lower removable partial denture and
often papillary hyperplasia develops in the palate
Treatment:
1. Mandibular removable partial denture should provide positive
occlusal support from remaining natural teeth and have maximum
coverage of basal seat beneath distal extension bases.
2. Design should be rigid providing maximum stability and minimising
excessive stress on the remaining teeth.
3. Occlusal scheme should be of proper vertical and centric relation.
4. Anterior teeth be used for cosmetic and phonetic purposes only.
5. Posterior teeth in balanced occlusion.

Mandibular single complete denture:

Such a condition is rarely seen but does occur as a result of surgery,
or accidental trauma or irradiation etc.
Three factors of particular
importance are:1) Preservation of residual alveolar ridge for the continued satisfactory use
of a mandibular denture, the residual alveolar ridge must be preserved in
the mandible.
The force of closure with natural teeth than that with artificial
dentures and greater the force, more is the resorption.
The mandible is the movable member of somatognathic system.
Therefore, it is more difficult to stabalize the mandibular denture.
Also, because of the proximity of the tongue more stresses are
applied on the mucosa and the bone.
Another factor is the minimal availability of mucosa and tightly
attached submucosa for mandibular denture support.
Hence, in view of above mentioned factors, the prescription of a
mandibular single complete denture should never be made. However,
when a patient insists for such a treatment he should be made aware of
the possible consequences.
2) Necessity for retaining maxillary teeth:The maxillary teeth may be needed to retain a prosthesis especially
in patients with congenital defects like cleft lip, palate, stoma etc. The
primary consideration for these patients is to speak properly and to
swallow foods and fluids without their passing into the nasal cavity.

3) Mental trauma:
The loss of teeth is a traumatic experience for some patients and
they may even get depressed. Hence, in such patients who have lost their
mandibular teeth, the removal of maxillary teeth may be even more
traumatic. Thus, the necessity for retaining the maxillary teeth in spite of
the potential long term side effects.
In some, patient education and psychiatric help may help to counter
the situation.
Diagnosis:
- Bone morphology of the residual ridge
- Maxillo-mandibular relationship.
Amount of resorption can be classified as,
Class I Pattern: Approximately 2/3rd of amount of alveolar bone present.
Class II Pattern: Approximately 1/3rd 2/3rd of alveolar bone present.
Class III Pattern: Approximately 1/3rd or less of alveolar bone present.
Recommendations for retention of remaining maxillary teeth when
opposing an edentulous mandible.
Resorption
Pattern

Orthognathic
angle class I

Retorgnathic
class II

Class I

Consider

Consider

Class II

Consider
under
special cases

Consider
special case

Class III

Do not retain

Do not retain

Prognathic
class III
Strongly consider
in

Consider
Do not retain

In such situations, it has often been said that the patients are better
off with all their teeth extracted. A useful analogy can be presented, i.e.
the force concentration encountered when a small hammer is swing
against a large anvil. Here, a small hammer (mandible), the dentate
maxilla (large anvil). The arm holding the hammer is vulnerable (as the
mandible) and the force generated can only lead to denture dislodgement
and/or tissue trauma. However, it is not always possible to convince the
patient for the extractions of the restored maxillary teeth.
Indications for a mandibular complete denture:
1. Class III geno relations where the size and form of residual ridge is
adequate to resist forces from natural teeth.
2. In case of cleft palate patients, maxillary teeth are retained to help
maintain a prosthetic restoration.
3. Mental trauma where a mandibular teeth are already lost, patient
may not be able to tolerate the additional loss of maxillary teeth
(psychological complications).

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The procedure for fabrication of mandibular single complete denture

is similar to maxillary complete dentures. A resilient liner in mandibular
denture seems to be quite useful to reduce stresses on the residual ridge.
Thus, a stress breaking or stress reducing appliance might compensate for
the gross imbalance of available areas in the edentulous mandible to cop
with the functional and parafunctional pressures i.e. 45 cm 2 of periodontal
ligament for the maxillary dentition versus 12cm 2 or less of mucosa
covered mandibular residual ridge.

References
1. JJ Sharry, Complete Denture Prosthodontics, 3 rd Edition, Blakinston
Publication.
2. Arthur Rahn, Syllabus of Complete Dentures, 4th Edition, BC Decker.
3. Sheldon Winkler, Essentials of Complete Denture Prosthodontics, 2nd
Edition, AITBS Publishers.
4. Zarb, Bolender, Prossthodontic Treatment forEdentulous patients, 12 th
Edition, Elsevier.
5. Ejvind Budtz-Jorgensen, Dr Odont, Prosthodontics for the Elderly
Diagnosis & Treatment, Quintessence Books.
6. Stansbury, C. B.: Single denture construction against a non-modified
natural dentition. J Prosthet Dent 1951:1;692-699.
7. Ellinger CW, Rayson JH, Henderson D. Single complete dentures. J
Prosthet Dent 1971;26:4-10.
8. Bruce RW. Complete dentures opposing natural teeth. J Prosthet Dent
1971;26:448-55.
9. Rudd KD, Morrow RM. Occlusion and the single denture. J Prosthet Dent
1973;30:4-I0.
10.Wallace DH. The use of gold occlusal surfaces in complete and partial
dentures. J Prosthet Dent 1964;14:326-33 .
11.Beyli MS, van Fraunhofer JA. An analysis of causes of fracture of acrylic
resin dentures. J Prosthet Dent 1981:46:238-41.
12.Schneider RL. Diagnosing functional complete denture fractures. J
Prosthet Dent 1985;54:809-14.
13.Han-Kuang Tan. A preparation guide for modifying the mandibular teeth
before making a maxillary single complete denture. J Prosthet Dent
1997;77:321-322.
14.Carl F .Driscoll, Radi M. Masri. Single maxillary complete denture. Dent Clin N
Am 2004;48:567-583
15.Nishtha Madan, Kusum Datta. Combination syndrome. J Ind Prosthet Soc
2008;8: 10-13.

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