Recently, a 79-year-old lady presented to me wanting a new maxillary denture (an "upper plate" as she called it). She had three other dentures made by local dentists and a popular dental chain, none of which she could wear. She kept reverting back to her denture of 50 years because the other dentures "just wouldn't bite anything and made my jaws hurt." Her mandibular incisors had severe bone loss and were class III mobile. She presented with a substantial skeletal class II, which appeared as a pseudo-class I due to lost VDO and overclosure of the mandible. She had severe maxillary ridge and mandibular posterior edentulous ridge atrophy. These are photos of her presentation:

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She also presented with painful vertical loading of the right TMJ and crepitus in the left TMJ. She also had a feeling of right side ear fullness. Here are images from her CBCT:

[image:cepholometric_view.jpg][image:Left_TMJ.jpg][image:right_TMJ.jpg]

The diagnosis was: Right TMJ retrodiscitis, left degenerative joint disease, partial edentulism, severe chronic periodontitis, partial edentulism.

In collaboration with a periodontist, we decided the best treatment plan would involve extracting the mandibular teeth and placing two implants for Locator retention of a mandibular denture. The patient agreed to this approach.

3 months after the teeth were extracted and implants were placed, I began denture fabrication using mounted models from a facebow transfer. We worked with the patient to customize the appearance, and an anterior ramp was fabricated for occlusion of the mandibular teeth due to the severe overjet. Upon seating the denture (implants not engaged), the patient had pain in the right TMJ. Occlusion on the right molar caused pain. I relieved the occlusion on the right mandibular molar, establishing balanced occlusion elsewhere on the denture, and the pain resolved. I reset the mandibular right molar out of occlusion for cosmetics. (I can only hypothesize that the molar occlusion created just enough distalizing load to flare up the retrodiscal tissues, but I'd love to hear what others think.) The last step was to seat Locator abutments and retrofit the mandibular denture. (I choose to retrofit because I find this technique to be more predictable than taking impressions and having the lab seat them. In this case, it saved excessive costs with the tooth reset.) This is the completed case:

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I would argue that this is one of the most difficult denture prostheses that can be made. The patient is happy and comfortable with her new dentures.

Any thoughts on how I might have been able to improve the results of this case?