Flexible denture flanges for patients exhibiting undercut tuberosities and

reduced width of the buccal vestibule: A clinical report

Leonard Garth Lowe, BDS, MSc(Dent)a
School of Dentistry, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa

Buccal undercut of the maxillary tuberosity together with reduced width of the buccal vestibule can
complicate denture fabrication. This clinical report describes the treatment options for this situation, the
rationale for the design and use of flexible denture flanges in the maxillary posterior buccal vestibule, and
the laboratory procedure for incorporation of flexible denture flanges in the undercut area. (J Prosthet
Dent 2004;92:128-31.)

U nilateral or bilateral undercuts on the buccal

aspect of the maxillary tuberosity are frequently
When the mouth is opened, the posterior buccal
vestibule is bounded laterally by the coronoid process
encountered and may complicate successful fabrication and medially by the maxillary tuberosity.8 Where the
of a complete maxillary denture. Management in these maxillary tuberosity is bulbous, the width of this space
situations includes alteration of the denture-bearing is reduced. When designing a denture to manage an
area, adaptation of the denture base, careful planning of undercut on the buccal aspect of the maxillary tuber-
the path of insertion, and the use of resilient lining osity, the available vestibular dimension should be
materials. Alteration of the denture-bearing area refers considered.
to the elimination of the undercut by surgical reduction This clinical report describes an alternative denture
of the tuberosity.1 Following surgery, a good border seal design in which optimal flange height and thickness can
can generally be attained. be achieved in situations where the maxillary tuberos-
Adaptation of the denture base involves either ities are bilaterally undercut and bulbous, and the
blocking out the undercut on the cast and finishing vestibular width is limited, using a resilient liner material
the denture to the full available height of the vestibule for the flange. The design allows attainment of a border
or, alternatively, reducing the height of the flange of the seal and prevention of anatomical dislodgement by the
denture to the crest of the undercut (to the survey line coronoid process. This design is especially useful where
when the cast has been surveyed). A reduced border seal surgical intervention is contraindicated.
may accompany such denture base adaptation.
A preplanned rotational path of placement may be
used when a unilateral undercut of the tuberosity CLINICAL REPORT
occurs,2 allowing the buccal undercut to aid retention A healthy 58-year-old man being seen in the Oral
of the denture. Good border seal in this situation is and Dental Hospital, University of Pretoria, South
generally achievable. Sectional lining of the denture base Africa, was referred from the Department of
with resilient lining material in the area of the undercut Periodontology to the Department of Prosthetics for
can allow engagement of the undercut with resultant fabrication of dentures. Examination of the patient
increased denture retention.3,4 This procedure is usually revealed 9 remaining maxillary teeth and remaining
limited to shallow undercuts and does not affect the roots (right first premolar to left second premolar) and
border seal. 10 remaining mandibular teeth (right second premolar
Novel means of managing undercuts in other areas of to left second premolar). The maxillary teeth and
the mouth have the possibility of adaptation for use in remaining roots required extraction due to severe
undercut areas in the posterior region. Abrams5 re- periodontal disease and caries. As the mandibular teeth
ported on the use of resilient lining material supported were periodontally sound, adequately restored, and
by a harder but flexible base extended into the undercut caries free, they were retained.
area. Such a bilaminate periphery may be too thick in The planned treatment was placement of a maxillary
situations where the width of the vestibule is limited. immediate complete denture and a mandibular interim
Other methods of incorporating an undercut into the acrylic resin removable partial denture (RPD). After
design of a denture include sectional dentures6 or hinge allowing sufficient time for healing and initial alveolar
mechanisms.7 These options are complex and may resorption, the dentures were to be replaced by a
require specialized technical skills. definitive maxillary complete denture and a mandibular
cobalt chromium-based removable partial denture.
The maxillary tuberosities were moderately enlarged
and bulbous (Fig. 1). In addition, numerous small (2-3
a
Principal Dentist and Lecturer, Department of Prosthetic Dentistry. mm) cobblestone-like exostoses were present on the

128 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 92 NUMBER 2

LOWE THE JOURNAL OF PROSTHETIC DENTISTRY

of the available vestibular space in the maxillary

tuberosity area was thus achieved. Definitive casts were
made to record the vestibular space. The casts were
surveyed, and the crest of the undercut buccal to the
maxillary tuberosity was marked. The maxillo-
mandibular relationship was determined. Salient
features of the denture were evaluated at the trial
placement appointment. The mandibular acrylic resin
provisional RPD, which incorporated wrought stain-
less steel retentive clasps and occlusal rests (Remanium
1.75 3 0.9 half-round hard wire No.308-518;
Dentaurum, Ispringen, Germany), was processed in
the laboratory. It was fitted but not placed at an
appointment prior to tooth extraction.
The remaining maxillary teeth were conservatively
removed from the stone cast, and the stone was trimmed
Fig. 1. Section of stone cast in area of left maxillary tuberosity to a smooth contour.10 The final tooth arrangement was
illustrating undercut (viewed posteriorly). Dotted line indi-
completed and invested in the conventional manner.11
cates approximate position of inner aspect of cheek when
The flask was packed with heat-polymerized polymethyl
mouth was open.
methacrylate (PMMA) (Vertex Rapid Simplified; Vertex
Dental B-V; Zeist, The Netherlands) mixed according
to the manufacturer’s instructions, and was trial closed.
buccal surface of the tuberosities. These were covered After 2 hours at room temperature, the flask was
by firmly attached and well keratinized gingival opened.12 The acrylic resin was now of firm consistency.
mucosa. The total amount of undercut was thus 3 to Using scalpel blades (Numbers 12 and 15; Swann-
5 mm (Fig. 1). When the mouth was open, the buccal Morten, Sheffield, England), the resin filling the buccal
vestibule was 3 mm wide, as it was reduced in width by undercut area (the area apical the marked survey line)
the forward movement of the coronoid process of the was cut away. The cut was angled to leave a long bevel
mandible. Width reduction was greatest in the depth of facing the intaglio surface of the denture. The feather-
the vestibule. This reduced width prevented extension edge of the bevel was trimmed. This bevel increased the
of the flange to the full depth of the vestibule if the area of bonding between the PMMA and the resilient
undercut was blocked out. silicone (Molloplast-B; Detax GmbH) that was to
With the aim of maximizing the border seal to ensure replace the resin that was removed. The angulation of
retention, the decision was made to incorporate flexible the bevel allowed the acrylic resin to support the flexible
flanges in the undercut tuberosity region using resilient material on insertion of the denture, at which time these
silicone lining material (Molloplast-B; Detax GmbH, flanges would be flexed in a buccal direction. The
Ettlingen, Germany)9 to allow optimal height (exten- resilient silicone was packed in the areas from which the
sion) and thickness (width) of the denture flange. The resin had been removed, and the flask was closed and
denture flange was designed to fill the entire available processed. Deflasking and finishing was accomplished in
vestibular space. the conventional manner12,13 (Figs. 2 and 3).
Preliminary impressions were made, and custom On the day of denture placement the maxillary teeth
trays with 1.5-mm spacing were fabricated. In the area were extracted. Care was taken to preserve alveolar
of the undercut, the tray was extended as far as the crest bone.14 Fitting and placement of the maxillary denture
of the undercut. At the definitive impression appoint- was uneventful. The previously fitted mandibular in-
ment, the entire border, except the undercut section of terim RPD was placed. The occlusion was evaluated for
the maxillary tray, was border molded using modeling discrepancies and corrected, and patient instructions
plastic impression compound (Green Impression were given.15
Compound; Kerr Dental, Orange, Calif ). Definitive At the 24-hour follow-up appointment, redness was
impression material (Impregum F; 3M ESPE, St. Paul, noted on the buccal side of the bulbous tuberosities. It
Minn) was syringed into the undercut and adjacent was judged that this redness was due to the flexible
buccal vestibule and the loaded tray placed and correctly flange being pressed against the tissues by the coronoid
positioned. Functional movements performed by the process of the mandible when the mouth was opened.
patient while making the maxillary definitive impression Resilient silicone material was thus removed from the
included opening the mouth to allow forward move- buccal (external) surface of the flange to reduce the
ment of the coronoid process to define the width of the thickness of the flange. The patient reported improved
posterior maxillary buccal flange. Accurate impression comfort.

AUGUST 2004 129

THE JOURNAL OF PROSTHETIC DENTISTRY LOWE

Fig. 2. View from posterior of intaglio surface of maxillary Fig. 3. View of left side posterior buccal flange of denture
denture illustrating bilateral flexible flanges in area of illustrating position of resilient silicone flexible flange.
maxillary tuberosity.

has limited width due to the anatomical dimensions and

At the 7-day recall appointment, the denture was movement of the coronoid process. The rationale for
relieved in a number of areas, as would be expected for using flexible flanges is to aid retention by ensuring seal
an immediate denture. The articulation was evaluated, around the entire border of the denture. The clinical and
and minor adjustments were made. Further recall laboratory steps used in the treatment of the patient
appointments were uneventful. The denture has been were described.
worn for 10 months, and the flexible flanges, although
slightly discolored, remain well adhered to the acrylic
resin base. Flexible flanges are planned for the definitive REFERENCES
1. Moore UJ, Cowpe JG, Meechan JG, Postlethwaite KR, Thomson PJ.
denture. Principles of oral and maxillofacial surgery. 5th ed. Oxford: Blackwell
Publishers; 2001. p. 147.
2. Basker RM, Davenport JC. Prosthetic treatment of the edentulous patient.
DISCUSSION 4th ed. Oxford: Blackwell Publishers; 2002. p. 65.
3. Qudah S, Harrison A, Huggett R. Soft lining materials in prosthetic
The method described above allows the flange of dentistry: A review. Int J Prosthodont 1990;3:477-83.
a maxillary complete denture to accurately duplicate the 4. Jagger DC, Harrison A. Complete dentures–the soft option. An update for
shape and dimensions of the vestibular space adjacent to general dental practice. Br Dent J 1997;182:313-7.
5. Abrams S. A technique for using maxillary anterior soft-tissue undercuts
an undercut (and bulbous) maxillary tuberosity, thereby in denture placement: a case report. J Can Dent Assoc 2002;68:
ensuring maximal border seal and aiding retention of the 301-4.
denture. This can be achieved even when vestibular 6. Matsumura H, Kawasaki K. Magnetically connected removable sectional
denture for a maxillary defect with severe undercut: a clinical report. J
width is reduced. Both clinical and laboratory pro- Prosthet Dent 2000;84:22-6.
cedures fall easily within the scope of general prosthetic 7. Jaggers JH, Boyd M. Bilaterally hinged complete denture for a severely
practice, and no special equipment is needed. Fee undercut maxillary arch. Solution to a problem. J Prosthet Dent 1979;41:
373-6.
implications for the patient are minimal. 8. Davenport JC, Basker RM, Heath JR, Ralph JP, Glantz PO. A clinical
Disadvantages include discoloration and microor- guide to removable partial denture design. London: BDJ Books; 2000.
ganism colonization of the silicone resilient lining p. 31.
9. Baysan A, Parker S, Wright PS. Adhesion and tear energy of a long-term
material and increased hygiene measures for the patient. soft lining material activated by rapid microwave energy. J Prosthet Dent
Failure of adhesion to the acrylic resin and tearing of the 1998;79:182-7.
resilient liner may occur. Resilient liners may also be 10. Seals RR Jr, Kuebker WA, Stewart KL. Immediate complete dentures. Dent
Clin North Am 1996;40:151-67.
difficult to trim, finish, and polish. 11. Anusavice KJ, Phillips RW. Phillips’ science of dental materials. 11th ed.
St. Louis: Elsevier Science; 2003. p. 721-34.
12. Schmidt WF, Todo J, Bolender CL. Laboratory management of Mollo-
SUMMARY plast-B-lined dentures. J Prosthet Dent 1986;56:113-8.
13. Pesun IJ, Hodges J, Lai JH. Effect of finishing and polishing procedures on
This clinical report presents a method for fabricating the gap width between a denture base resin and two long-term, resilient
a flexible denture flange using a resilient silicone denture liners. J Prosthet Dent 2002;87:311-8.
material. The flange extends into the bilateral tissue 14. Bruce RW. Immediate denture service designed to preserve oral
structures. J Prosthet Dent 1966;16:811-21.
undercuts on the buccal aspect of the maxillary 15. Bates JF, Stafford GD. Immediate complete dentures. Brit Dent J 1971;131:
tuberosity area, an area that in the situation presented 500-3.

130 VOLUME 92 NUMBER 2

LOWE THE JOURNAL OF PROSTHETIC DENTISTRY

Reprint requests to: 0022-3913/$30.00

DR L. GARTH LOWE Copyright ª 2004 by The Editorial Council of The Journal of Prosthetic
UNIVERSITY OF PRETORIA SCHOOL OF DENTISTRY Dentistry
BOPHELO ROAD
PRINSHOF
PRETORIA 0002
SOUTH AFRICA
FAX: 27 12 325 0561
E-MAIL: [email protected] doi:10.1016/j.prosdent.2004.04.026

AUGUST 2004 131