A failed complete denture in a patient demanding "fixed teeth"
A 68-year-old woman has been edentulous in the maxilla for 15 years and wears a 12-year-old complete denture. She reports looseness when speaking, food collecting under the denture, and sore spots on the anterior ridge. The maxillary ridge is severely resorbed with a flat anterior segment and only 2 mm of keratinized tissue; there is a prominent incisive papilla and a 3 mm torus palatinus. The existing denture shows 4 mm of lost vertical dimension of occlusion, 8 mm of freeway space, and heavily worn posterior teeth. She has had two previous remakes elsewhere and says she wants "fixed teeth" this time. Her medical history is unremarkable and she takes no medications. Her budget is limited.
1. Explain her complaints and decide whether to adjust, reline, or remake the existing denture.
Read the worked answer
Cause-by-cause:
- Looseness: loss of border seal and denture-base adaptation as the ridge resorbed; worsened by the reduced vertical dimension, which drops the tongue and cheeks into unfavorable positions.
- Food under the denture: lost posterior seal and worn occlusal surfaces that no longer cut food.
- Sore spots anteriorly: the base is now resting on the incisive papilla and thin mucosa over a flat ridge, concentrating load.
Decision: a soft reline or a spot-grind will buy comfort for weeks, not solve the problem - the vertical dimension, the occlusal surfaces, and the border seal are all compromised, and two prior remakes suggest the issue is the record/technique, not one bad laboratory.
Plan: relieve the painful areas so she can function while a new prosthesis is made; then remake with verified records. Tell her explicitly that "another remake" will look different because the vertical dimension and border molding will be redone deliberately, not copied from the old denture. Do not simply duplicate the existing denture.
2. She insists on "fixed teeth." Compare the realistic options given her anatomy and budget, and state what determines feasibility.
Read the worked answer
Option A - implant-supported fixed prosthesis (4–6 implants): requires adequate bone width and height and anterior-posterior spread. With severe resorption she likely needs grafting or sinus augmentation, or tilted/zygomatic approaches; this means high cost, multiple surgeries, and a real chance the answer is "not without grafting." Feasibility is decided by CBCT, not by the panoramic film.
Option B - two to four implants with an overdenture: the realistic middle ground. Much improved retention and chewing, less bone requirement, far lower cost, and removable for hygiene. It is not "fixed," and she must hear that distinction clearly - patients who expect fixed and receive an overdenture often report the result as a failure even when it is technically excellent.
Option C - conventional new denture: lowest cost, addresses her comfort and function but not retention.
What I would do: CBCT and a frank cost/benefit conversation, present C and B as the honest options and A as conditional. Document that fixed prosthodontics was discussed and why it may not be feasible. A patient with two failed remakes needs expectation management more than a heroic plan.
3. Outline the record and impression plan for a new maxillary denture that addresses the flat ridge, the torus, and the lost vertical dimension.
Read the worked answer
Records: preliminary alginate impression in a stock tray; custom tray with wax spacers over the torus and incisive papilla; facebow or at minimum an accurate orientation record; interocclusal records at the intended vertical dimension.
Impression: border molding with modeling compound to capture the functional sulcus, then a light-bodied wash in a spaced custom tray. Use a window or relieved area over the torus so it cannot act as a fulcrum; relieve the incisive papilla. Selective pressure is appropriate - the goal is support from the primary stress-bearing areas with the movable tissue uncompressed.
Vertical dimension: restoring the full 4 mm at once is likely to be rejected. Open approximately 2 mm and reassess phonetics, esthetics, and comfort at the wax try-in; a second, later increase is easier than retreating from a patient who cannot tolerate the new position. Target a freeway space of roughly 2–4 mm.
Try-in: verify midline, incisal display, and speech before processing; a phonetic check often exposes an over-opened vertical dimension before the denture is finished.