Prosthodontics CLINICAL

Complete dentures: an update on clinical assessment

and management: part 2
R. Y. Jablonski,*1 J. Patel1 and L. A. Morrow1

Key points
Provides an overview of the indications, strengths Highlights a range of different management Provides clinical advice on the management of
and limitations of the copy denture technique strategies for patients with gag reflexes, for example, anatomical challenges such as prominent tori and
and outlines the key clinical and laboratory stages behaviour modification, distraction and systematic microstomia.
involved. desensitisation.

The ability to provide high quality complete dentures remains an important skill for general dental practitioners. The
prevalence of edentulism is increasingly concentrated within an older patient cohort and general dental practitioners may
face challenges associated with providing care for these patients. This two-part series explores various aspects of complete
denture provision and is designed to act as a refresher on the management of edentulous patients. This second part focuses
on the copy denture technique as well as discussing strategies for assessing and managing gag reflexes, prominent palatal
and lingual tori and microstomia.

Introduction Copy dentures consideration of the patient’s denture history

and appraisal of the previous set of dentures.9
The first article in this two-part series outlined Introduction Copy denture techniques allow favourable
a variety of UK trends that will influence Adapting to new dentures can be challenging for features to be replicated while allowing minor
complete denture provision in the future. patients especially for those with long serving improvements.8 Consequently, copy dentures
These include the concentration of edentulism dentures.6 It has been suggested that older are appropriate for situations where reduced
within the oldest age groups and the challenges patients may experience difficulties in adapting adaptive capacity is presumed, only relatively
associated with transitioning to complete to new dentures due to a reduced capacity for minor alterations to the dentures are required,
dentures later in life.1 In addition, negative learning new muscle activity patterns.7 Anecdotal or when the appearance of the denture is to
societal perceptions of removable prostheses evidence suggests that utilising ‘copy’ or ‘replica’ be replicated.6,8 It is likely that conventional
may increase patient expectations,2 whereas techniques may help older patients adapt more processes will be more appropriate to dentures
declining levels of undergraduate complete easily to new dentures. These techniques allow with significant deficiencies warranting greater
denture teaching may result in reduced con- favourable features from an existing denture to changes to avoid the same errors being copied
fidence when managing edentulous patients be copied (for example, the shape of the polished to the new set.8
in general dental practice.3–5 The first part also surfaces) while also allowing for alterations to less Copy denture techniques typically involve
provided a refresher on the assessment and favourable features (for example, worn occlusal fewer stages and less clinical time than con-
management of unstable lower dentures and surfaces).8 There is, however, little evidence to ventional processes.9 Various authors have
fibrous replacement ridges. This second article suggest that patients will adapt to copy dentures described modifications to the copy denture
will provide an update on the management of any more successfully than to correctly con- technique in the literature.8,9 One key variation
other conditions that may be encountered by structed conventional dentures.9 Patient satis- relates to obtaining impressions before or after
a general dental practitioner including habitu- faction with new complete dentures has a strong recording the occlusion. Clark et al. suggest
ation, gagging, tori and microstomia. relationship with the quality of new dentures and that if the occlusion is recorded first, then the
also the residual mandibular alveolar  ridge.10 position of the replica denture bases will alter
Therefore, clinicians should focus on optimising when the impression material is placed in them
denture design whether conventional or copy and would consequently be prone to occlusal
1
Leeds Dental Institute, The Worsley Building,
Clarendon Way, LS2 9LU techniques are used. errors.9 The following modifications to the
*Correspondence to: Rachael Jablonski copy denture technique are proposed:
Email: [email protected]
Management • First clinical stage: moulds of the original
Refereed Paper. Accepted 24 August 2018 The decision to proceed with conventional dentures are obtained in silicone putty
DOI: 10.1038/sj.bdj.2018.1023
dentures or copy dentures requires careful (Fig. 1).9 If the dentures are underextended

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Fig. 1 Copy denture technique. A decision was made to replicate the favourable features from the previous denture using the copy denture
technique. a) The denture was initially border moulded using a thermoplastic material to improve the palatal extension. b) A silicone putty
mould was obtained. c) Temporary rigid base with wax teeth was created. The wax teeth were subsequently adjusted to ensure correct
occlusal vertical dimension, occlusal plane, centreline and bucco-lingual tooth positions. A closed mouth light bodied wash impression was
then taken and a retruded jaw record was obtained

important to understand the aetiology of

Table 1 Classification of Gagging Problem (CGP) index as described by Sakamoto et al.15,16 this phenomenon to enable the provision
Code Clinical parameters of high quality dental care. Gagging is a
broad term used to describe a ‘normal’
G1 Periodontal pockets in the entire oral cavity can be measured with a probe
defence mechanism that prevents foreign
G2 Periodontal pockets in the entire oral cavity cannot be measured without triggering gag reflex bodies from entering the trachea, pharynx,
or  larynx. 11 Sakamoto et  al. describe the
G3 Posterior teeth cannot be assessed with a dental mirror without triggering gag reflex
response via two additive mechanisms. 15
G4 Anterior teeth cannot be assessed with a dental mirror without triggering gag reflex Firstly, a physiological response related to
afferent nerve impulses and secondly, an
G5 Dental mirror cannot be placed within oral cavity without triggering gag reflex
emotional response thought to result in
stimulation of the gagging centre via sympa-
then the peripheral extension can be • Fourth clinical stage: the dentures are thetic nervous activation. Both mechanisms
modified with a suitable material (for checked intra-orally. A check record are important as different factors may play
example, greenstick compound [ISO procedure may be undertaken as required. differing roles in individual patients. The gag
Functional Sticks, GC]) prior to taking the reflex correlates strongly with high levels of
silicone mould6 Summary anxiety trait.11
• First laboratory stage: temporary rigid Successful use of the copy denture technique
bases are produced in light cured or self- relies on clinicians correctly diagnosing Classification
cured acrylic with wax teeth favourable and unfavourable features of In the context of complete denture provision, a
• Second clinical stage: the wax is adjusted to previous dentures. This technique provides gag reflex is generally assessed by determining
ensure correct occlusal vertical dimension, benefits through fewer clinical stages. whether the entire maxillary denture bearing
occlusal plane, centreline and bucco-lingual Anecdotal evidence suggests that copying area can be palpated with a finger without
tooth positions.9 A closed mouth light features from old dentures may help older triggering the gag reflex. There are also a
bodied wash impression is taken with both patients adapt more easily to new dentures. number of classification systems which exist
maxillary and mandibular bases in  situ. However, the technique is inappropriate if for assessing gagging from the perspective
The retruded jaw record is obtained and a there are any major inadequacies with previous of providing general dental treatment. The
facebow record is made if appropriate dentures. Clinicians should focus on optimis- Classification of Gagging Problem (CGP)
• Second laboratory stage: the impressions ing support, retention and stability regardless index is summarised in Table  1.15,16 This
are cast, articulated and a trial set up is of whether conventional or copy techniques provides a relatively simple and user-friendly
constructed are undertaken. assessment, however, it is subject to bias due to
• Third clinical stage: the trial dentures the lack of explicit definition of clinical param-
are inserted, evaluated and modified as Gagging eters. For example clinicians may position a
required. The position of the new post dam dental mirror differently when assessing the
is scribed on the master model Introduction same teeth. Fiske and Dickinson published a
• Third laboratory stage: any final adjust- Gagging is a common problem faced by Gagging Severity Index in 2001 which is at
ments are undertaken and the dentures clinicians and patients. It can impede the risk of similar sources of bias.17 Furthermore,
are processed. The dentures are removed effective delivery of dental procedures and various tools exist for assessing the severity
from the flask, checked on the articulator may lead to non-attendance or avoidance of a gag reflex from the patient’s self-reported
for processing errors and polished of preventative measures.11–14 It is therefore perspective, for example, the Gagging Problem

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should be reassured that gagging is commonly

Fig. 2 Pathway for assessing gag reflex in the context of the proposed dental treatment
encountered by dental professionals and can
often be managed by simple techniques. Prior
to impression taking, both stock and special
Ideas, concerns, expectations,
motivations towards treatment trays should be assessed for overextension
History
History of previous treatment including and trimmed if overextended. An impression
successes and failures material with a thicker consistency and shorter
set time may be beneficial for patients with a
gag reflex. For primary impressions, a ther-
moplastic impression material (for example,
Impression Compound, Kerr) may be useful
Is the response physiological or are there signs of as the tray can be readily removed during a
What type of response? anxiety and an emotional response? gagging episode and the material can be repeat-
Is there guarding with tongue posture? edly warmed, soften and reseated until the
desired impression is obtained. Alternatively, if
using alginate, mixing the material with warm
water will shorten the set time and a stiffer mix
Physiological or emotional response to tactile is likely to be more tolerable to the patient.
sensation in a region of the oral cavity
Impression materials should be carefully
What triggers gagging? May involve response to smell or taste
handled, with care taken to avoid overloading
of material
Emotional response to environmental cues the impression trays. The loaded tray should
be first seated at the posterior aspect before
seating the tray anteriorly to ensure that excess
material is not expressed at the posterior
aspect of the tray. Patients should be reassured
Dental events - e.g. loss of control
Is the response throughout the impression procedure and
during a dental procedure
associated with a
significant event? Non-dental events - e.g. near drowning, encouraged to perform basic breathing, relaxa-
suffocation, sexual abuse tion or distraction exercises. Patients should
be encouraged to tilt their head forwards and
breathe through their nose if they find this
is more comfortable. A saliva ejector can be
Is the patient motivated to overcome utilised to aspirate any excess saliva. Careful
the underlying factors? handling of impression material and constant
Explore findings Would the patient benefit from involvement patient reassurance or distraction may be
with patient of other specialities? all that is necessary to obtain a satisfactory
Explanation of the condition, management
impression.
strategies, patient benefits and individual targets

Relaxation, hypnotherapy and sedation

Relaxation techniques for managing anxiety
and aberrant behaviours (including gagging)
Assessment questionnaire (GPA).18,19 Although Behaviour modification have been researched in many fields. This
not commonly used in normal clinical practice, The vast majority of patients with a gag reflex can be useful in managing unhelpful thought
these indices may be useful to help assess or will contribute cognitively to the gagging processes and help the patient gain control over
monitor the severity of a gag reflex. response via the emotional response pathway.20 an unpleasant event such as a dental impres-
Consequently, it has been suggested that all sion. It has also been suggested that adjuncts
Management disruptive gagging should be presented to such as hypnotherapy and acupuncture can be
Patients may be divided into three broad man- the patient as a behavioural response which is useful in the management of a gag reflex.22,23
agement categories: a) those that are able to amenable to modification.20 Behaviour modi- Clinical experience suggests that this is rarely
tolerate impressions with distraction; b) those fication is reported to be the most successful necessary if other techniques are employed
that are unable to tolerate impressions and need long-term management for gagging.21 This correctly. Some of these techniques only tem-
pharmacological aids (for example, sedation) approach is outlined in Figure 2. porarily increase compliance and may therefore
to enable impressions to be undertaken; and c) have limited utility in denture provision (for
those that are unable to tolerate the dentures and Impression techniques and distraction example, acupuncture). Furthermore, sedation
may need modifications to the prostheses. The It is important to build a good rapport with techniques may be utilised to aid impression
following sections provide an overview of some the patient and adopt a positive and sympa- taking. However, techniques which impair
useful techniques that may be implemented thetic approach to help build the patient’s patient awareness are only suitable with appro-
when managing patients with a gag reflex. confidence with dental procedures. Patients priate training, planning and consent.22–24

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Systematic desensitisation
Where patients are unable to tolerate a pros-
theses, systematic desensitisation techniques
can be useful to slowly increase a patient’s
exposure to a stimulus that would normally
trigger gagging.25 Many different desensitisa-
tion techniques have been described.20,26,27
Contemporary techniques involve the patient
holding a toothbrush or empty stock tray in
their mouth and progressing with location Fig. 3 Systematic desensitisation with a training plate. a) An example of a clear acrylic
training plate with multiple post dams to allow for modification. b) Once the optimal
targets (for example, inserting further poste-
extension of the training plate had been determined, progression with complete denture
riorly) or time targets (for example, retaining construction was possible. The denture base extension matched the training plate
for longer). One of the most commonly utilised
techniques involves acrylic training plates
which comprise a well retained and stable recommend the construction of a horseshoe- Classification
denture plate base that the patient wears for shaped maxillary denture with a severely There is a lack of research to provide an evi-
increasing time periods (Fig.  3).25 The base reduced palatal extension only when other dence-based classification of tori. Management
plate should ideally be constructed of a rigid treatment modalities have failed.30 is usually based on clinical characteristics iden-
material such as clear heat cure acrylic to ensure tified during assessment. It should be noted
optimal fit. It often has multiple post dams to Implant-supported rehabilitation that radiographic assessment of tori is usually
allow for modification and can be supported In severe cases it may be appropriate for the not necessary as the information is unlikely
with an anterior rim to facilitate placement patient to receive implant-supported rehabilita- to influence diagnosis or management unless
and removal thus ensuring patient control.25 tion. It is important to note that these cases may surgical intervention is being considered. In
On occasion, denture teeth can be added to the still require some attenuation of a gag reflex to such an eventuality it is important to conform
training plate to help with motivation. ensure they are able to both undergo treatment to principles of radiographic exposures for
With systematic desensitisation, patient procedures associated with implant placement medical investigations.
communication and planning are key to ensure and restoration, in addition to tolerating the final
adequate progress is achieved and the patient prosthesis. Nonetheless, an implant-supported Location
does not become disheartened or frustrated rehabilitation may be beneficial in patients who Palatal tori typically present as a solitary mass
with either an overly lengthy process or one are unable to progress further with the manage- in the midline of the palate and are most often
where the patient is required to adapt to large ment strategies described above but would be symmetrical, although slight variation on this
changes too quickly. Both the clinician’s and able to tolerate a palateless overdenture. may occur. Larger palatal tori may present with
patient’s expectations must be aligned with the a central fissure or a bilobed appearance. Lingual
patient’s ability to adapt. A controlled stepwise Summary tori typically present as two or more masses in
approach with individual targets is usually rec- Gagging is a common problem that may be a symmetrical pattern in the canine/premolar
ommended although some authors recommend influenced by physiological or psychological region. Lingual tori can be sufficiently prominent
more regimented protocols.11 Many authors factors. Management strategies should be that their incorporation into the denture base
suggest patients wear their desensitising training tailored to the individual and may comprise a design is ill-advised due to the impact on comfort
plates when they are otherwise occupied or combination of behaviour modification, dis- and invasion of the tongue space.
distracted.25 Once the optimal extension of the traction and systematic desensitisation. These
training plate is determined, progression with should be clear, managed collaboratively with Condition of overlying tissues
complete denture construction is often possible the patient, and supported by a good patient- Soft tissues overlying tori are often healthy but
and the denture base extension can be designed clinician rapport. may present with areas of displaceable mucosa
to match the existing training plate extension. overlying bony prominences or undercuts. It is
Tori also important to examine for signs of inflam-
Horseshoe-shaped maxillary dentures mation, ulceration or overgrowth which may be
Patients may request the construction of a Introduction attributable to denture trauma or stomatitis.31,32
palateless or horseshoe-shaped maxillary Tori are bony protrusions that constitute normal Such problems should be effectively managed
denture with the expectation that this would anatomy. They can affect the palate (where they before undertaking master impressions.
help with their gag reflex. Unfortunately, these often present in the midline), or the mandible
dentures often have compromised stability (where they often present symmetrically affecting Contour
and retention as a result of the reduced palatal the lingual alveolus). They are diagnosed based The contour of tori should be considered to
extension. This approach is therefore more on clinical examination and are often consistent determine the likely impact on the path of
likely to stimulate a gag reflex and will often with healthy soft tissues with single or multiple insertion of a prosthesis and the need to block
result in a compromised outcome with patient bony protuberances. History will confirm an out undercuts. Undercuts may present on the
dissatisfaction.20,28,29 Some authors therefore unchanging appearance over time. posterior edges of palatal tori and inferior

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Surgical removal
The surgical removal of tori is rarely necessary
and there is a lack of consensus or high-quality
evidence to guide planning. If surgical removal
is being considered, then referral to specialist
services should be made for further assessment.
This would involve an initial prosthodontic
assessment, followed by surgical and radio-
graphic assessment if surgical intervention is
considered.

Summary
Tori should be managed on a case-by-case basis
following assessment of the location, relationship
to denture borders, contour and the condition
of the overlying tissues. Minor tori can often
be incorporated into the denture design and
covered with the denture base whereas larger
palatal or lingual tori may need more significant
modifications. It is important to remember that
Fig. 4 Management of a large palatal torus. a & b) A patient presented with a large palatal a staged approach is often necessary which will
torus extending close to the anticipated post-dam region. c) The previous horse-shoe shaped involve the provision of dentures with optimised
maxillary denture provided unsatisfactory retention and bracing. d) A new full coverage
coverage in the first instance. Should this prove
complete denture was designed to optimise retention and bracing. Care was taken to ensure
unsuccessful, alternative approaches may be
acrylic was of sufficient thickness in the post-dam region and not too bulky over the torus.
High impact acrylic offered rigidity and strength necessary such as provision of dentures with
compromised tissue coverage or in rare cases
surgical removal of tori.
edges of lingual tori. The potential impact of to cover. There is a lack of research reporting on
the tori in relation to anticipated soft tissue the management of such cases. While not con- Microstomia
undercuts and path of insertion may be easier ventional practice, some authors have utilised
to evaluate on a primary cast. ring connectors with a window in the palate to Introduction
accommodate a large palatal torus.33 This type Microstomia is defined as an abnormally small
Management of design is likely to compromise maintenance oral  orifice34 and can be associated with a
Relief of tori of a border seal and impair retention. variety of acquired or congenital conditions.35
Historically there has been debate as to whether The location of a torus may compromise the Microstomia can be a consequence of facial
tori should be relieved during the denture man- posterior border seal by significantly reducing burns, the management of head and neck cancer,
ufacturing process. Previous clinical guidance the anteroposterior dimension of the major or scarring following surgery or trauma.35–37 It
suggests that relief of tori is not necessary.31 connector. High impact acrylic or a metal denture can also present as a clinical manifestation of
However, relief can be provided where there base should be considered where the mechanical systemic connective tissue diseases (such as
is concern that the morphology may result in integrity of the major connector is compromised scleroderma) or congenital syndromes.37,38
trauma to the overlying tissues during denture – this should be balanced with the relative weight Restricted oral access can complicate oral
wear for example, in cases with significant of each material and the anticipated retention of hygiene, provision of dental treatment and
undercuts or thin overlying mucosa. Relief is the prosthesis. Figure 4 highlights the role of prosthetic rehabilitation.36,38 It may also result
typically performed by applying foil (usually these factors in effective treatment planning. in functional difficulties such as speech impair-
0.5 mm thickness) over areas of interest on the Lingual tori may be sufficiently prominent ment, distortion of facial expression and diffi-
working cast. This is then carefully adapted to that their incorporation into the denture base culties with mastication and deglution.36,38
the soft tissue contour and burnished. Relief design is ill-advised due to the impact on both
is often only provided over areas where it is comfort and invasion of the tongue space. In Classification
deemed necessary. such cases, they are often avoided in the design Some authors measure the intrinsic vertical
of the major connector. It may be necessary mouth opening as an indication of the severity
Denture border extension to utilise a denture base material with better of microstomia. It has been suggested that
Minor palatal tori can often be incorporated mechanical properties in narrow section (for the average intrinsic vertical mouth opening
into the design of a denture by extending the example, cobalt-chrome). Surgical interven- measures 40–50 mm, a reduced opening of
major connector over the torus. Large palatal tion may be rarely considered, although the 25–35 mm is “functional” and an opening of
tori may significantly reduce the available risks of this procedure must be weighed against 10–24 mm is “severely limiting”.36 Additionally,
surface area for retention, support and bracing the benefits to any rehabilitation and subse- an index of oral access has been proposed to aid
of a maxillary denture and may be impractical quent quality of life in the long-term. clinicians in diagnosing, recording, treatment

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Fig. 5 Management of a patient with moderate microstomia. a & b) 56-year-old patient with systemic sclerosis. Complete denture
construction had been unsuccessful in general practice due to her reduced oral aperture. c) Significant modification was required to the
stock trays to allow insertion. d & e) Successful rehabilitation with complete dentures was possible, however, some compromises were
necessary eg, accepting a class III incisal relationship and reduced lip support. e) The final denture which was appropriately extended to
avoid impinging on the fibrous tissues

planning and monitoring the severity of micro- (Fig. 5). Impressions may be aided by reducing increased manual dexterity for insertion.
stomia.35 This grades the severity of access for the height of the impression trays, using a rota- In addition, some case reports have utilised
restorative dental treatment depending on tional path of insertion, applying petroleum flexible denture materials either in isolation44
whether the clinician can access all areas of the jelly to the commissures and asking the patient or in conjunction with rigid superstructures
dentition or if modifications are necessary to to half close their mouth.37 At the wax try-in to rehabilitate patients with microstomia.35
facilitate impressions and prosthesis design.35 stage, the positioning of the denture teeth The literature supporting the use of flexible
should be carefully appraised. A compromise denture base materials in such cases is
Management may need to be made between optimal aesthet- limited in relation to longevity.45,46
General management ics/lip support and the likelihood of denture
General management strategies for improving displacement by the fibrotic tissues. The size Summary
the oral aperture will vary depending upon the of the denture teeth and occlusal table should The effective management of patients with
aetiological factors and severity of symptoms. be reduced appropriately.40 microstomia should be based on careful
Conservative management strategies include In more severe cases, more significant assessment of the degree of oral access and
scar massage, daily stretching exercises and modification may be required. Where a anticipation of other potential challenges
use of oral stretching devices.36,39 Surgical patient has previously successful complete associated with its cause. Provision of
approaches (for example, commisuroplasties) dentures, a copy denture technique may removable prostheses for patients with mild
may also be advocated in severe cases which be useful.37 Sectional impression trays have microstomia may be successfully managed in
are refractory or not amenable to conservative been advocated in the literature for both general dental practice with relatively simple
management.36 primary and secondary impressions.41 These adjustments to impression technique. More
tend to record the ridge in two parts and severe cases may need referral for specialist
Prosthetic management can be disassembled before relocating them input due to more complex impression and
Provision of removable prostheses can be outside the mouth.37,41 prosthesis manufacturing procedures. In
challenging for patients with microstomia. In The use of sectional or collapsible denture extreme cases, prosthetic rehabilitation may
addition, patients may experience other factors materials have been reported to aid denture not be possible.35
associated with the aetiology which would insertion. These reports have used a range of
further limit their ability to tolerate dentures. mechanisms to connect the different parts of Conclusion
For example, patients with systemic sclerosis the denture including clasps, cobalt-chrome
may suffer from xerostomia, mucosal ulcera- hinges, swing-lock attachments, stud attach- Complete dentures have been the traditional
tion, and reduced manual dexterity.38 ments, rods and magnets.35,42,43 Construction standard of care for edentulous patients for
In patients with mild – moderate micros- of these dentures can involve more complex many years and for many patients, this has
tomia, relatively simple modifications may clinical and laboratory stages compared to allowed them to function in society more
be required to facilitate denture construction conventional dentures and would require easily than without any prosthesis.47 It is

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