Review article

Insertion and follow-up of complete dentures: a literature

review

Marcelo Coelho Goiato, Humberto Genneri Filho, Daniela Micheline dos Santos, Valentim
Adelino Ricardo Barão and Amilcar Chagas Freitas Júnior
Department of Prosthodontics and Dental Materials, UNESP–São Paulo State University, São Paulo, Brazil

doi: 10.1111/j.1741-2358.2010.00368.x
Insertion and follow-up of complete dentures: a literature review
Objective: The aim of this study was to present the importance of clinical procedures related to insertion
and follow-up of complete dentures in elderly patients.
Materials and Methods: The success of rehabilitation with complete dentures results from the accuracy
of clinical and laboratorial procedures that makes the denture insertion an important step of treatment.
Conclusion: The follow-up and professional maintenance of function and hygiene facilitates long-term
efficiency.

Keywords: elderly, complete denture, denture insertion, patient follow-up.

Accepted 19 October 2009

fessional maintenance evaluating function and

Introduction
Although advances in preventive dentistry have
been observed, partial or complete edentulism is
found mainly in elderly patients. In addition,
despite the success of osseointegrated implants for
prosthetic rehabilitation, treatment with conven-
tional complete dentures is still common for this
group of patients.
In the edentulous patients, the denture pros-
thesis restores teeth and oral tissues reproducing
where possible the original anatomy. The objective
of dentures is to rehabilitate the stomatognathic
system improving not only masticatory efficiency
but also the phonetic and aesthetic appearance of
the patients. Therefore, this type of rehabilitation
can improve the patients’ quality of life and their
social activity.
For partial or completely edentulous patients,
dental prostheses restoring teeth and oral tissues go
some way to reproducing the original anatomy.
The main objective of a prosthesis is to rehabilitate
the stomatognathic system without aesthetic or
phonetic complication. Success depends on accu-
rate clinical and laboratory procedures with the
insertion of the prosthesis as the culmination of
treatment. Furthermore, the follow-up and pro-
hygiene allows long-term efficiency.
The aim of this study was to present the clinical
procedures related to the insertion and follow-up of
complete dentures.
Literature review
Oral rehabilitation with complete dentures can
restore chewing, phonetics, aesthetics, self-esteem
and dignity of the patient1,2. Several clinical and
laboratory procedures are necessary during this
process and insertion is considered as a significant
step for treatment1,2. During treatment, the
complete denture is adjusted to the supporting
tissues to favour retention, stability and comfort3
and certain clinical protocols should be considered
during this process to assess the accuracy of the
procedures.
Procedures previous to insertion
Before prosthesis insertion, the presence of bubbles
or resin excess in any metallic framework should
be verified to avoid difficulty of the fit. Irregular
surfaces or sharp edges should be removed to avoid
lesions forming on the mucosa4 (Fig. 1). Dental

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198 M. C. Goiato et al.
(a) (b)
stone or other materials may remain on the inter-
nal and external surfaces of the prosthesis and
should be removed4. Furthermore, it is suggested
that the patient should not wear the old dentures
during the 12–24 h before insertion to allow the
insertion of the new dentures on supporting tissues
without compression4.
Prosthesis margins
The thickness and extension of prosthesis flanges
are evaluated after insertion in the mouth and the
edges should not be tapered and thick. The
appropriate peripheral seal is achieved by round,
smooth and juxtaposed margins4. In addition, if
the border moulding process is carried out accu-
rately, minor or no adjustment is often all that is
necessary.
Over-extended flanges interfere with insertion of
the prosthesis base on the supporting area and
adjustment in these areas is necessary to allow
proper adaptation of frenum and attachments5.
Over-extended areas may be identified though
movements of facial musculature during speech,
smiling, gape and swallowing6. Zarb and Bolender4
suggested the application of a thick layer of indi-
cator paste in the region with presumed over-
extension. According to the authors, after this
procedure, the prosthesis should be carefully
introduced in the mouth and the professional
(a) (b)
Ó 2010 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2011; 28: 197–204
Figure 1 Evaluation of irregular
surfaces and cutting edges in the (a)
upper complete denture and in the
(b) lower complete denture.
should assess the musculature. Thus, the com-
pressive and over-extended areas are identified4.
However, on many occasions, the over-extended
areas are detected only during post-insertion fol-
low-up (Fig. 2). Irritations or lesions in the buccal
mucosa are frequently caused by thin or over-
extended margins4,6. Injuries in the hamular fossa,
mylohyoid region and mandibular buccal region
are also frequently reported4,6.
Under-extended flanges may also jeopardise
prosthesis retention and are identified through
palpation and visual analysis7. A high-viscosity
material such as wax or equivalent may be applied
to these areas to assess prosthesis retention and
stability7.
Compressive area
Despite the efforts of the dentist and laboratory
technician, the fabrication of complete dentures
can generate some imbalance in the resin denture
base during polymerisation8 or deflasking9 and this
can result in a greater need for adjustment of the
denture base during insertion.
The misfit of the denture base leads to com-
pressive areas that generate pain, discomfort, bone
resorption and lesions of the mucosa10. Detection
of the compressive areas (Fig. 3) between the
denture base and the supporting mucosa is neces-
sary as the appropriate fit of the prosthesis allows
Figure 2 Some over-extended areas
detected in post-insertion follow-up.
(a) Over-extended upper complete
denture and (b) injury caused by
the over-extended denture in the
posterior area.

(a)
(b)
Figure 3 Evaluation of compressive areas in the
dentures. The device shows the compressive area: (a)
upper denture and (b) lower denture.
physical and psychological comfort and functional
efficiency to the patient11.
The assessment of the compressive areas may be
carried out by digital or occlusal pressure6,12. A
digital pressure avoids the action of possible
deflective cusps that would represent compressive
areas on mucosa. Russi et al.12 did not find signifi-
cant difference for detection of the area between
either techniques, but reported that the occlusal
pressure technique is only indicated for prostheses
submitted to previous occlusal adjustment or when
cotton pellets are interposed between occlusal
surfaces.
An indicator of medium consistency with
appropriate physical characteristics may be also
used to evaluate the adaptation of the denture base
and identify the areas under compression13. There
is a variety of pastes, specific or not, named
pressure-indicator pastes and some studies dem-
onstrated that certain pastes for detection of com-
pressive areas are more efficient12,14. The use of the
Ó 2010 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2011; 28: 197–204
Denture insertion and follow-up 199
pressure-indicator paste to assess areas that need
adjustment may avoid the discomfort generated by
complete dentures with improper adaptation.
However, unnecessary or random adjustment may
result in further problems and necessitate relining.
This may discourage the patient who anxiously
waits for treatment to be completed satisfactorily.
Occlusion
The adjustment of occlusal contacts should be
carried out after comfortable adaptation of com-
plete dentures in the mouth. It is not correct to
adjust occlusal surfaces before appropriate adjust-
ment of the denture base.
The harmony of occlusal contacts is a significant
factor for the interaction between complete den-
tures and the stomatognathic system4. Neglect of
occlusal adjustment, such as premature or sliding
contacts, may jeopardise denture stability and
retention which affects masticatory function,
comfort and maintenance of residual ridge4. Addi-
tionally, many dentists believe that occlusal errors
can be corrected by displacement of mucous and
submucous tissues under the prosthesis. However,
the subjacent bone tissue presents higher plasticity
and may experience resorption to relieve the
pressure on the mucosa generated by premature
contacts4.
Occlusal adjustment should preserve where
possible the anatomy of artificial denture teeth and
careful adjustment of occlusal surfaces is frequently
necessary to improve masticatory efficiency.
The bilateral balanced occlusion is the most
accepted occlusal concept for complete dentures15–19.
According to the Glossary of Prosthodontics
Terms20, the form of occlusal concept determines
simultaneous contacts between antagonist arches
in the right and left posterior regions and in the
anterior region. At least three contacts, one
between the posterior teeth in each side and one
between the anterior teeth, are established in
eccentric movements. This type of occlusion allows
stability of the prosthesis base during mandibular
movements which can increase masticatory effi-
ciency4,18, and should be applied for all cases pre-
senting with a complete denture in antagonist arch.
However, some authors believe that canine
guidance in complete denture wearers does not
influence masticatory function of the patient21. For
these authors, this type of disocclusion provides
improved results regarding retention of the lower
denture, aesthetics and masticatory ability21.
In general, the occlusal contacts in removable
partial dentures should respect the disocclusion
200 M. C. Goiato et al.
pattern of the patient. When the patient does not
exhibit this pattern, the re-establishment of occlu-
sion may be achieved by canine guidance or
bilateral balanced occlusion. The occlusal correc-
tion during insertion of a removable partial denture
aims to (i) maintain the contacts between remain-
ing natural teeth and (ii) establish occlusal
harmony during all centric and eccentric mandib-
ular movements21.
The consequences of improper occlusal equilib-
rium are more evident for rehabilitation with free-
end removable partial dentures. The premature
contacts during mandibular movements may gen-
erate loading of the metallic framework that is
harmful for residual ridge and supporting teeth. So,
special attention is required during this step of
treatment. In this case, the use of adjustable artic-
ulators and teeth with resistant occlusal surface are
suggested to allow establishment and long-term
maintenance of occlusal equilibrium21.
Ivanhoe and Plummer22 reported that simulta-
neous and bilateral multiple contacts for the
intermaxillary relationship are obtained during
mounting of teeth in wax. However, these contacts
are lost after denture processing. According to the
authors, this occlusal imbalance would damage the
temporomandibular joint, neuromuscular system,
mucosa and residual ridge. Remounting of the
complete dentures on the articulator for adjust-
ment is suggested to correct occlusal alterations
resulting from laboratory processing4,23–26. How-
ever, the occlusal errors resulting from separation
of the denture from the model and polishing are
not eliminated4. It has been suggested that new
interocclusal records are made during denture
insertion to allow for adjustment on a semi-
adjustable articulator25,26.
Adjustment of retentive clasp
The retention provided by direct retainers is not
assessed until denture insertion3. After adaptation
of the denture to the supporting tissues and
adjustment of the occlusion, the professional can
evaluate the retentive characteristics of the clasps.
In general, no adjustment in the direct retainers
should be indicated during insertion. However,
adjustment in clasp extension may be necessary to
limit force application on fixtures and provide
enough retention from a removable partial den-
ture3. The clasps should be progressively adjusted,
followed by evaluation to confirm the results3.
Excessive adjustments of a clasp may generate
accelerated fatigue and result in fracture; so,
excessive folding should be avoided3.
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Retention, stability and support
The muscular activity performed by the patient is
important in maintaining adaptation of the sur-
rounding tissues to denture flange27. Considering
that this ability may not be achieved, ideal condi-
tions should be provided to overcome this limitation.
For complete dentures and some cases of
removable partial prostheses (Kennedy Class I and
II), retention, stability and support are related to
the basal area, appropriate adaptation of dental
base to this area and edge to fornix4. Certain pro-
cedures are carried out during insertion to assess
denture retention, stability and support.
Retention is defined as resistance to vertical and
torsion forces or a force contrary to denture adap-
tation4,28 and the retention test evaluates the
peripheral seal of dentures. For this test, the finger
is positioned on the palatine region of the upper
incisors to perform an anterior-superior movement
against this region4,11 and evaluate the effective-
ness of posterior palatine sealing4,11. The retention
test for the lower denture is performed with the
application of force upwards considering that
retention of this denture is reduced in comparison
with the upper complete denture4.
Stability is the resistance of the denture to hori-
zontal forces and it represents the effect of the
supporting area of the denture base on adapta-
tion28. In addition, stability may be defined as the
quality of a prosthesis to remain in position when
submitted to horizontal and rotational forces. So, a
complete denture that displaces during chewing
can present with inappropriate stability even with
adequate retention4. Denture stability is tested by
digital pressure on the occlusal surface of the pos-
terior teeth and incisal edge of the anterior teeth,
but other tests are also reported in the literature4.
Support is related to the area for adaptation of
the denture base and is considered an important
element for denture stability4. The test may be
conducted with an intrusion force on the complete
denture against the basal area. So, support would
be demonstrated by the level of denture base
intrusion in the alveolar mucosa4.
For removable partial dentures, especially for
Kennedy Class III and IV, retention is generated by
retentive clasps, stability results from harmony of
all structures, and support is provided by occlusal,
incisal and cingulum rests.
Aesthetics and phonetics
The aesthetics of a prosthesis depends on the
natural positioning of teeth and reproduction of

shape and colour of the oral tissues29 to restore
facial appearance, function and harmony30. Clini-
cal steps including impression, record of maxilla–
mandibular relationship, contour of prosthesis base
and selection of artificial teeth should be accurately
conducted31.
The alignment of artificial denture teeth may be
reproduced by inclinations and rotations similar to
natural teeth. Besides tooth selection considering
facial profile, the shape and contour of teeth should
be modified depending on the patient’s age. A
natural appearance of the edentulous patient is one
of the factors that can be improved by rehabilita-
tion with complete dentures31.
The positioning of artificial denture teeth also
significantly influences phonetics29 and reproduc-
tion of the palate and palatal surface of the upper
teeth is important during speech32. Phonetic eval-
uation is frequently neglected during fabrication of
the denture in comparison with aesthetics, func-
tion and comfort33. Although the majority of
patients adapt to new dentures within weeks34,
some patients still report difficulties during speech,
especially for certain sounds35. The dentist may
help a patient on diction through instructions for
correct movement and placement of tongue and
lips during pronounciation4.
Phonetics may be evaluated by palatography
during functional clinical evaluations. This test
consists of evaluating contact between the tongue
and the palate through phonetics. Additionally,
appropriate contour of the upper denture base in
the palatal region, positioning of upper anterior
teeth and the vertical dimension can be confirmed
during the pronunciation of different phonemes4.
Kong and Hansen32 demonstrated the need to
personalise the palatal contour of a maxillary
denture in relation to tongue as this procedure can
reduce the period for adaptation to the prosthesis.
Instructions for the patient
A good relationship between the professional and
the patient from the beginning of treatment
favours prosthesis insertion, as effective commu-
nication is achieved when the professional knows
the requirements of the patient7. Deficient com-
munication affects patient co-operation and may
not lead to treatment success7; so, verbal and
written instructions should be provided by the
professional36.
The patient should be instructed regarding the
wearing of new dentures and the functional
limitations of a prosthesis. However, considering
difficulties that may occur with new dentures,
Ó 2010 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2011; 28: 197–204
Denture insertion and follow-up 201
information about prosthesis care should be rein-
forced during insertion.
Comparison with other denture wearers should
be avoided and the professional should highlight
the individuality of each case4. It is recommended
that the new dentures should not be highlighted to
curious friends until the patient feels secure4. Ini-
tially, the patient may report the uncomfortable
sensation of an increased volume of lips and
cheeks4 and it is important to clarify that the new
dentures will become more natural with time. After
denture insertion, the patient should eat soft food
of small size and chew bilaterally4. Hard food may
lead to ‘improper’ movements that generate ridge
overload and injuries to the alveolar mucosa4. A
period of 6–8 weeks is necessary to allow satisfac-
tory use with the new dentures as this period has
the potential to establish new memory patterns for
the masticatory muscles4,27,37.
Salivary excess may make chewing difficult
during the initial period of prosthesis wearing.
However, salivary glands adapt to the new dentures
and decrease the quantity of saliva production after
a short period of time4.
Tongue positioning is also important to stabilise
the lower complete denture, especially during
chewing, as the tongue should rest within the
lingual portion of the prosthesis4. Speech with
the new dentures is often not so difficult, as the
majority of patients adapt within weeks4. In addi-
tion, adequate phonetics is achieved when the
patient reads aloud and repeats words and sen-
tences which are difficult to pronounce.
The patient should be instructed about proper
oral hygiene to maintain tissue health38 as poor
hygiene generates plaque accumulation, calculus
and staining. Plaque is an aetiological factor for
prosthetic stomatitis (Fig. 4), inflammatory hyper-
plasia, chronic candidiasis and bad breath39,40, and
denture hygiene after meals is essential4,18.
It is important to clean not only the dentures
(Fig. 5) but also the mucosa and dorsal surface of
the tongue4. So, a soft toothbrush and a low
abrasive dentifrice are often recommended, as
abrasives may generate grooves and loss of finish of
prostheses, which can favour plaque accumulation
and make hygiene more difficult4,41. Cleaning of
the tongue and mucosa removes plaque and
improves blood circulation in these tissues4.
The hygiene of the denture may be carried out by
a number of chemical agents. This procedure
consists of immersion of the denture in solutions
that present solvent, detergent, bactericidal and
fungicidal actions. The chemical agents include
alkaline hypochlorite, alkaline peroxide, diluted
202 M. C. Goiato et al.
Figure 4 Prosthetic stomatitis caused by improper
hygiene.
Figure 5 Manual method of denture hygiene.
acids, chlorhexidine and enzymes42,43. It is impor-
tant to highlight that chloride solutions are coun-
ter-indicated for hygiene of removable partial
dentures as they damage the metallic frame-
work44,45. The association between mechanical
(Fig. 5) and chemical methods would be ideal to
provide effective cleaning46.
Patients wearing removable partial dentures
should have meticulous hygiene to avoid dental
disease. Some studies demonstrate a significant
increase in the quantity of Streptococcus mutans 48 h
after insertion47,48 and so, specific brushing tech-
niques and use of dental aids are indicated for
at-home routine.
It is essential to instruct the patient about inser-
tion and removal of the prostheses, but the ability
to carry out this task depends on dexterity,
muscular coordination, visual acuity and physical
conditions. The denture should be removed during
sleeping as continuous use is associated with a
prevalence of denture stomatitis49–51. Furthermore,
Ó 2010 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2011; 28: 197–204
if tissue irritation occurs, the patient should consult
with the professional to carry out appropriate
adjustments52.
Follow-up
The patient should return to the dental surgery
24 h after denture insertion. In general, the irrita-
tion promoted by a denture is not immediately
reported by the patient but is identified by the
dentist. The correction of these initial difficulties
avoids pain and discomfort4, and it is necessary to
retrain the patient in relation to denture hygiene,
feeding habits, phonetics and the adaptation time
of the patient to their dentures.
Before clinical examination, the patient should
report specific problems and the clinician will
endeavour to determine and eliminate the possible
causes. The main complaints are related to four
main aspects: pain and discomfort of soft and hard
tissue of edentulous ridge; prosthesis instability;
injury to the tongue and cheeks; and difficulty with
speech and/or chewing.
The professional should explain that these
problems can be readily and easily solved and even
if there is no complaint, the mouth should be
carefully examined with and without the dentures.
The instructions provided during the insertion
session should be reinforced at the follow-up. It is
also important to assess the denture hygiene being
carried out by the patient and to inform them of the
consequences of poor hygiene, such as by Candida
infection (Fig. 4). In many cases, the period of post-
insertion adjustment is crucial for denture success
rather than failure, and the professional is respon-
sible for providing patient care during this period as
adaptation is specific for each patient, and may
require several months to be achieved27,37.
Conclusion
Post-denture insertion, the patient should be
motivated to wear their new dentures and
instructed about the limitations. Furthermore,
instructions for care and hygiene should be pro-
vided and the rehabilitation will be concluded only
after follow-up. This post-insertion period is crucial
as a patient’s perception regarding denture success
occurs during this period of adaptation.
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Correspondence to:
Marcelo Coelho Goiato, Department of Dental
Materials and Prosthodontics, UNESP–Araçatuba
Dental School, José Bonifácio, 1193, Araçatuba,
Sao Paulo, 16015-050, Brazil.
Tel.: +55(0)-1836363287
Fax: +55(0)-1836363245
E-mail: goiato@foa.unesp.br