Enhanced CPD DO C ProstheticsAndOralMedicine

Wouter Leyssen

Noha Abdelaziz and AD Walmsley

Mouth Preparation for

Complete Dentures
Abstract: The success of complete dentures is highly dependent on the anatomy of the oral cavity. Several conditions can affect the final
denture fit. Disorders of the soft tissues, such as denture hyperplasia, denture stomatitis and mucosal pathology may play a role. There
are also difficulties related to the shape of the bone, including excessively large undercuts/bony exostoses, tori, enlarged tuberosities and
flabby ridges and other factors, such as xerostomia to be considered. The aim of this article is to help diagnose these conditions and to
suggest ways of overcoming the individual problems with which patients present before starting denture construction.
CPD/Clinical Relevance: The diagnosis of several oral conditions and their appropriate management may help achieve an optimal
outcome when constructing complete dentures.
Dent Update 2021; 48: 851–856

The success of complete dentures is hyperplasia, denture stomatitis and folds. The lesions can originate in a
highly dependent on a favourable mucosal pathology, and difficulties narrow fibrous stem or, alternatively,
anatomy of the oral cavity. Retention related to the shape of the bone, which have a broad base. Denture-induced
and stability of a removable prosthesis include excessively large undercuts/bony hyperplasia is present in 3% of the
require good adaptation to the exostoses, tori, enlarged tuberosities denture-wearing population.1
underlying tissues. Therefore, time and flabby ridges. There are also In the maxilla, this type of lesion is
spent ensuring that both the oral difficulties related to other factors, such as described as a cauliflower-like tissue
tissues are healthy and outliers in xerostomia (Table 1). This article describes that may occur under, or at the edge
anatomical variation are managed these conditions and offers solutions for of the denture (Figure 1). Commonly, it
appropriately, will contribute to a their clinical management. occurs when constructing immediate
successful outcome for the patient. dentures or in those who have worn
Mouth preparation may be an essential dentures for a longer period of time (ie
step after the denture assessment has
Difficulties related to more than 5 years).1,2 Bone resorption
been completed whereby diagnosis and
soft tissues allows a space to form inside the flange
treatment planning should be taken Denture hyperplasia of the denture over time, and the ill-
into consideration. The clinical picture of denture-induced fitting denture irritates the soft tissues.
There are several conditions that hyperplasia can be described as one or This in turn stimulates the soft tissues
may affect the final denture fit and more folds of hyperplastic tissue induced to grow down into the space inside
these can be separated into disorders by trauma from the border of the denture. the denture. Over time, the tissues
of the soft tissues, such as denture Ulceration may be present between the enlarge and congregate outside the
denture flange.2
Wouter Leyssen, BDS, MJDF, MSc, Specialty Dentist, Restorative Dentistry, Birmingham Treatment would include
Dental Hospital. Noha Abdelaziz, BDS, MFDSRCSEng, MSc, Specialty Dentist, Oral generously reducing the flange by at
least 1 mm free of the lesion. This may
Medicine, Birmingham Dental Hospital. AD Walmsley, PhD, MSc, BDS, FDSRCPS, Professor
be combined with a soft or hard reline
of Restorative Dentistry, College of Medical and Dental Sciences, University of Birmingham
of the denture. Alternatively, the patient
School of Dentistry.
should be advised to stop wearing the
email: wouter.leyssen@nhs.net
denture until (some) regression of the
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 ProstheticsAndOralMedicine

Difficulties related to the Difficulties related to Difficulties related to

soft tissues the bone other factors
 Denture hyperplasia  Large undercuts/  Xerostomia
 Denture stomatitis bony exostoses
 Mucosal pathologies  Tori
– Traumatic ulcerative  Enlarged tuberosities
lesions  Flabby ridges
– Recurrent aphthous
stomatitis
Figure 1. Maxillary hyperplastic tissue. – Oral lichen planus
– Oral cancer
Table 1. Conditions that could affect complete denture fit.

 Denture trauma considered to be of interest in relation

 Denture hygiene to progression of the condition.5 It
 Smoking is accepted that the most common
 Dietary habits and high aetiological factor of denture stomatitis
carbohydrate intake is unsatisfactory denture hygiene. One
 Continuous denture wearing study demonstrated that the incidence
 Underlying medical conditions of severe inflammation and hyperplasia
 Reduced salivary flow is 10 times greater among those who
 Allergic reactions sleep with their dentures.4,5 Despite
denture-wearing patients being aware
Table 2. Factors associated with
denture stomatitis. of the potential risks of not removing
the dentures at night, a proportion will
not comply for reasons of self esteem
inside and outside the denture flange.2 and social implications.
They are managed in a similar manner to It would be unwise to start
maxillary hyperplasia. impression taking and denture
construction before the denture
Denture stomatitis stomatitis has been treated.
Denture stomatitis may vary in its clinical Inflammation of the denture-bearing
Figure 2. Mandibular hypertrophic mucosa.
presentation and is classified as follows:3 area will inevitably lead to inaccurate
 Newton Type I: localized master casts and therefore, a
inflammation or pinpoint erythema; suboptimal fit of the dentures.
 Newton Type II: diffuse erythema Not surprisingly, the first line of
of part or all of the denture- treatment is to remove the dentures
at night and improve overall denture
bearing area;
hygiene. The application of coatings
 Newton Type III: papillary hyperplasia
such as nanopolymers (eg GC Optiglaze,
(Figure 3).
GC, Europe) or nanosilica to the
The prevalence of denture stomatitis dentures reduces surface roughness
is estimated to range between 15% and inhibits biofilm formation.5 Once
and 77.5% of the denture-wearing denture stomatitis is established,
Figure 3. Denture stomatitis Newton III.
population and is mainly found in the it is suggested that disinfection of
maxilla.4 Most cases would be classified the dentures will be as effective as
lesion is noted.1,2 It is thought that the time as Newton Type I and II. Its origin is using antifungals.5 A 0.002% sodium
required for severely hyperplastic tissues to thought to be multi-factorial and could hypochlorite solution (available in
return to normal is about the same as that be due to one or a combination of factors the UK from local chemists as Milton's
required for the lesion to develop. However, (Table 2).5 Associations have been made solution) used for 15 minutes has been
some lesions do not resolve and will require with micro-organisms, with the main proven to reduce the fungal load on
surgical removal.1,2 focus on Candida albicans; however, acrylic surfaces. Chlorhexidine 2%
Mandibular hyperplastic lesions are Staphylococcus aureus, Pseudomonas would be an alternative; however,
described as a roll of fibrous tissue (Figure 2). aeruginosa, C. glabrata, Prevotella spp, disinfection may produce staining with
Folds of hyperplastic tissue may be situated Veillonella spp and others are now prolonged use.3
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 ProstheticsAndOralMedicine

Minor RAS Major RAS Herpetiform RAS

Morphology Round or oval lesions Round or oval lesions Gray- Small, deep ulcers that
Gray-white pseudomembranes white pseudomembranes commonly converge
Erythematous halo Erythematous halo Irregular contour
Distribution Lips, cheeks, tongue, floor Lips, soft palate, pharynx Lips, cheeks, tongue, floor of
of mouth mouth, gingiva
Number of ulcers 1–5 1–10 10–100
Size of ulcers <10 mm >10 mm 2–3 mm
Prognosis Lesions resolve in 4–14 days Lesions persist >6 weeks Lesions resolve in <30 days
No scarring High risk of scarring Scarring uncommon
Table 3. Clinical features of minor, major, and herpetiform recurrent aphthous stomatitis (RAS).6,19

dentures could be new dentures or steroids, immunosuppressants, and

dentures that are several years old. An other types of medication such as
over-extended denture flange will cut dapsone, thalidomide and colchicine.7
through the mucosa and invade the
underlying submucosa and muscle Oral lichen planus
tissue.2 When the extension has been Oral lichen planus (OLP) is a chronic
corrected, the lesion will heal with mucocutaneous disorder that can affect
formation of scar tissue. Without the skin as well as the oral mucosa
denture adjustment this could lead to (Figure 4). It can also affect the lips,
the formation of denture hyperplasia. nails, scalp and other mucosal surfaces.
Approximately 1–4% of the general
Recurrent aphthous stomatitis (RAS) population is affected. It is more
Figure 4. Erosive/reticular oral lichen planus Recurrent aphthous ulcers are common in middle-aged women, but
affecting the buccal mucosa. commonly encountered by general rare in children.8
dental practitioners. They are recurrent Oral lichenoid reactions are
oral ulcers that present in otherwise usually caused by the use of
healthy individuals.6 systemic medications, for example
For patients with underlying Three forms of RAS exist: minor antihypertensives, oral hypoglycaemics
medical conditions and/or where local (>70% of cases), major (10%) and and non-steroidal anti- inflammatory
measures do not resolve the denture herpetiform (10%). These types differ in drugs. It can also occur in relation to
stomatitis, antifungal agents may be their morphology, distribution, severity amalgam restorations or other dental
prescribed. Miconazole oral gel 24 mg/ and prognosis (Table 3).6 Treatment materials, such as composites or
ml applied four times daily is a topical usually depends on the severity of glass ionomer.8
agent for the fit surface of the dentures. the condition. It starts with topical OLP presents clinically as reticular,
Caution should be taken when treatments, such as chlorhexidine papular, erosive, plaque-like, ulcerative
prescribing for patients on warfarin 0.2% mouthwash, which helps in or bullous lesions.8 Treatment depends
as there is a well-recognized drug preventing secondary infections. on the severity of the disease, starting
interaction. Fluconazole and nystatin Temporary relief can be achieved using with topical anaesthetic and topical
oral suspension are systemic fungal topical anaesthetic preparations that steroid preparations. For more severe
agents that can be considered in more contain benzydamine hydrochloride cases appropriate referral to an oral
severe cases.3 For a small number of or lidocaine.6 Topical steroids, such as medicine clinic is needed to discuss
patients, the condition will develop to betamethasone 5 μg soluble tablets as further treatment options, including
Newton Type III, and they will present a mouth wash, fluticasone propionate systemic steroids and steroid-
with papillary hyperplasia, which is spray or mouthwash, may also be sparing medications.8,9
more challenging to treat. Surgery used.6 Long-term use of topical steroid Severe OLP could impact on
may be indicated and an oral surgery preparations carries a risk of oral denture success if not treated or
opinion will be required.4 candidiasis.7 For severe cases of RAS, managed successfully prior to denture
appropriate referral to an oral medicine construction. Modification of the
Traumatic ulcerative lesions clinic will be required because systemic treatment plan is frequently indicated.
They are commonly caused by over- medications might be necessary. Traditional removable dentures
extended or ill-fitting dentures. The Systemic treatments include systemic can be difficult to tolerate for patients
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 ProstheticsAndOralMedicine

In the UK, head and neck cancers occur on the midline of the hard palate
contribute to 3% of all cancer cases.11 in the maxilla and often bilaterally on
Most are diagnosed as squamous cell the lingual aspect of the mandible
carcinomas (Figure 5). Risk factors where they are most frequently located
include tobacco consumption and in the canine area.12
excessive alcohol consumption.6 Oral Mandibular tori (Figure 6) are found
cancer most commonly presents as a in up to 64% of different population
non-healing ulcer, white patches or groups. Tissue covering these tori is
erythematous lesions. Patients may also often delicate and thin. Frequently tori
present with increased tooth mobility, extend into the region of the lingual
bleeding, numbness or pain.6 functional sulcus depth and therefore
Figure 5. Squamous cell carcinoma of the
Patients with suspicious lesions may need to be removed.12,13 Maxillary
buccal mucosa. should be referred urgently as tori (Figure 7) are found in up to 61.7%
appropriate for an oral medicine or oral of different population groups.12,13
surgery opinion. Palatal tori are only removed if they
are excessively undercut or in certain
Difficulties related to the situations where they extend onto the
hard tissues vibrating line. Tinfoil relief or arbitrary
removal of acrylic on the denture
Excessive large undercuts and
fitting surface should be undertaken
bony exostoses
to prevent pain and instability during
Most bony undercuts will not require
function. Unadjusted dentures in these
any surgical intervention. They may be
areas might lead to fracture lines or
blocked out by the laboratory before
complete fractures of the denture.
the processing of the denture. Usually,
Figure 6. Lingual tori.
tinfoil relief can be added onto the
master cast to ensure there is spacing Enlarged tuberosities
between the processed denture base Enlarged fibrous tuberosities are
and the affected denture-bearing area. suboptimal in providing support. They
This in turn will limit friction during also limit the inter-arch clearance and
function. Large bony undercuts can there may only be sufficient space for
often be left on one side and surgically one denture.14 If the patient prefers
corrected on the opposite side. to wear a denture in the upper jaw,
Dentures can engage some degree it could lead to damage to the lower
of undercut because the hard, bony edentulous ridge. Similarly, if the
tissues are covered with a layer of soft patient prefers to wear a denture in
tissue that allows for some degree the opposing jaw, the tuberosities can
Figure 7. Palatal torus.
of compression. Undercuts will aid be traumatized continuously, which
in retention, and might be beneficial may be uncomfortable and distressing
for denture-wearing comfort during for patients. To partially overcome
function. Surgical bony reductions in the issues with space, the teeth will
with OLP because of the fragility of the
the anterior segment should only be need to be set up towards the buccal
oral mucosa. Ill-fitting dentures can
carried out for extreme undercuts, and aspect of the tuberosity. Alternatively,
lead to trauma, which can exacerbate
it is known that healing after surgery to create space for a denture, the
oral lesions and lead to ulcerations
is not always predictable.12 Patients tuberosities may be surgically reduced
or erosions.10 Implant-supported
should be informed that reoccurrence if the anatomy of the sinus allows
prosthetic devices may stabilize
of the bony interference is possible for this procedure to be undertaken.
prostheses and minimize trauma to the Another solution would be to construct
and/or that removal may not always
oral mucosa, thus improving denture address all problems. a denture under-extended towards the
function and patients’ quality of life.10 Li vibrating line (avoiding the tuberosity/
et al described a case of severe OLP in tuberosities); however, retention will
Tori
which implant-retained over dentures most likely be suboptimal.
Tori are bony enlargements that are
were used.10
considered anatomical variations and
are not pathological. The aetiology is Flabby ridges
Oral cancer considered to be multifactorial with Fibrous ridges can be defined as
Although oral cancer is a relatively rare genetics and environmental factors edentulous ridges of a displaceable
condition, it should be highlighted. playing a role in their formation.13 They nature. The bony tissue will have been
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replaced with tissue of a more fibrous and denture adhesive appears to be 8. Robledo-Sierra J, van der Waal I. How
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issues where invasive procedures
cancers incidence statistics. Available
should be minimized. In addition, the Compliance with Ethical Standards at: www.cancerresearchuk.org/health-
excision of these tissues will reduce Conflict of Interest: The authors declare professional/cancer-statistics/statistics-
the ridge height to an extent where that they have no conflict of interest. by-cancer-type/head-and-neck-cancers/
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