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Table of Contents   
ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 2  |  Page : 145-148
Palateless custom bar supported overdenture: A treatment modality to treat patient with severe gag reflex


1 Department of Prosthodontics and Dental Materials, Shree Bankey Bihari Dental College and Research Centre, Ghaziabad, Uttar Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, Shree Bankey Bihari Dental College and Research Centre, Ghaziabad, Uttar Pradesh, India

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Date of Submission04-Jan-2011
Date of Decision06-May-2011
Date of Acceptance13-Feb-2012
Date of Web Publication3-Sep-2012
 

   Abstract 

Objective: To suggest a custom bar supported overdenture treatment modality for prosthodontic management of patients with severe gag reflex.
Background: Some patients have a severe gag reflex and cannot tolerate conventional maxillary complete dentures with maximum palatal coverage and extensions of all borders. The condition further gets complicated in patients suffering from respiratory problems along with severe gag reflex. Severe gagging acts as a barrier to treat such patients with accepted clinical procedures and prevent patients from wearing the prosthesis. By saving some of the remaining natural teeth and fabricating, a horse shoe shape palateless simple tooth or bar supported overdenture can be successfully used for treating such patients.
Materials and Methods: The remaining maxillary right and left canines were prepared with the tapered round end diamond bur to receive copings of custom bar after intentional root canal treatment of same teeth. Impression was made with light body and putty of the polyvinyl siloxane elastomer with double step putty wash technique. Impression was poured with die stone. Wax pattern of copings with bar was fabricated with inlay wax which was invested and casted. After retrieving the bar, it was finished and its fit was evaluated. The coping-bar assembly was finally cemented with the glass ionomer cement. Palateless overdenture was fabricated by conventional technique used for the fabrication of complete denture.
Conclusion: Palateless custom bar supported overdenture procedure can be successfully used for the management of patients with severe gag reflex with improved denture retention, stability, chewing efficiency and comfort of the patient.

Keywords: Bar supported, gagging, metal copings, overdenture, palateless

How to cite this article:
Singh K, Gupta N. Palateless custom bar supported overdenture: A treatment modality to treat patient with severe gag reflex. Indian J Dent Res 2012;23:145-8

How to cite this URL:
Singh K, Gupta N. Palateless custom bar supported overdenture: A treatment modality to treat patient with severe gag reflex. Indian J Dent Res [serial online] 2012 [cited 2014 Sep 17];23:145-8. Available from: http://www.ijdr.in/text.asp?2012/23/2/145/100416

   Introduction Top


Gagging is a normal, protective defense mechanism, which prevents foreign bodies from entering the trachea, pharynx, or larynx. [1] Unwanted, irritating or toxic material is ejected from the upper respiratory tract by the contraction of the oropharyngeal muscles. Gag reflex is present from birth. Gagging reactions range from mild choking when the palate is inadvertently touched with a mouth mirror to violent, uncontrolled retching during impression making. All regions of mouth are not equally sensitive to stimuli, which produce gag reflex. Five regions of oral cavity having maximum sensitivity are known as trigger areas which are base of the tongue, fauces, palate, uvula and posterior pharyngeal wall. Some patients had a reduced or absent gag reflex while other have severe pronounced one. Severe gag reflex can compromise all aspects of the dental treatment. Prosthodontists and general dentists frequently serve patients who have such extreme oral sensitivity that, they are unable to tolerate a foreign substance in the mouth.

There are many classifications of gagging, but it has been generally classified as either psychogenic or somatogenic. [2] Psychogenic gagging is induced by anxiety, fear and apprehension. [3] It may be a manifestation of underlying the psychologic problems, or it may result from the somatogenic stimuli, which uncorrected, could result in total psychologic rejection of the denture. Behavioral management therapy or psychotherapy should be considered strongly in the management of the psychogenic gagging patient. Somatogenic gagging results from insufficient retention, incorrect occlusal vertical dimension, malocclusion, lack of tongue space, thick posterior borders and inadequate posterior palatal seal. The inadequate posterior palatal seal can be avoided through correct palatal coverage to maintain firm contact with the soft palate during function and phonation.

Gagging from psychogenic origins may persist even after psychologic counseling. From a clinical viewpoint, dentures may be acceptable to the dentist, but totally unacceptable to the patient. Such patients are very difficult to treat. Gagging from somatogenic causes can be eliminated with proper denture design. Wright [4] in a classical study reported that, 43.4% of the patients gagged only after having dentures, and 83% associated the condition with stimulation and touching of the palate or back of the mouth. In addition, 24.5% felt that a reduction in palatal length greatly improved their ability to wear dentures due to decrease in touching and stimulation of the palate by the denture.

Many techniques have been described for successful prosthodontic management of completely and partially edentulous patients with gagging problems, but unfortunately only few of them are successful with research evidence base. Although custom bar supported palateless overdenture is not a routine prosthodontic treatment modality, but by saving few of remaing natural teeth and fabricating a palateless custom bar supported overdenture, it can be effectively used for treating patients with extreme gagging problems.


   Case Report Top


A 55 years old male reported to our dental center for prosthetic evaluation. Patient had received a maxillary acrylic resin removable partial denture. He had major complaint of difficulty in wearing the prosthesis due to severe gag reflex, difficulty in chewing and unsatisfactory esthetics due to poor designing of partial denture. Intraoral examination of patient revealed intact mandibular arch and absence of all maxillary teeth except maxillary right and left canines [Figure 1]. Clinical and radiographic examination revealed that maxillary canines were periodontally sound with no mobility, no periapical pathology. There was insufficient buccal sulcus depth bilaterally in maxillary posterior region due to early loss of posterior teeth and alveolar bone loss. Patient did not want extraction of remaining maxillary teeth and did not agree for implant supported over denture, due to poor economic and medically compromised conditions. Patient was suffering from diabetes mellitus, bronchial asthma, and had undergone cardiac surgery. He was also a chronic smoker. All these conditions preclude the fabrication of palateless implant supported overdenture.
Figure 1: Maxillary remaining natural teeth

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Due to severe gag reflex and presence of sufficient interarch space for the placement of metal bar, copings, denture base and teeth arrangement, it was decided to fabricate maxillary palateless custom bar supported overdenture. After intentional root canal treatment of abutments [Figure 1], they were prepared with tapered round end diamond point with chamfer finish line [Figure 2]. The finish line should be prepared subgingivally. After abutments preparation, a small size stock tray, which covers the abutments and anterior part of hard palate, was selected and impression was made with putty (Aquasil soft putty/regular set, Dentsply, Germany) and light body (Aquasil LV, Dentsply, Germany) of polyvinyl siloxane elastomeric impression material, by double step putty wash technique. The impression was poured into the die material (Ultrarock, Kalabhai Karson Pvt.ltd., Mumbai, India) to obtain cast on which, pattern of copings and bar was fabricated with inlay wax (blue inlay wax, Kemdent, United Kingdom). The pattern of copings were dome shaped, and that of a bar was rectangular. The pattern was then sprued (wires of sprue wax, Bego, Germany), invested (Bellasum, Bego, Germany), burnout and casted into base metal alloy (BEGO Wirocast S, Bego, Germany). After retrieving casting from the investment (Bellasum, Bego, Germany), it was finished and its fit was evaluated in the patient mouth after which copings and bar assembly was cemented on the abutments [Figure 3] with glass ionomer cement (Hy-bond Glasionomer CX, Shofu INC, Japan). An impression was made after cementation of copings, and a palateless custom acrylic resin tray was fabricated on the cast. After adjusting the custom tray, single step border molding was done with medium body polyvinyl siloxane (Reprosil, Dentsply, Germany) and secondary impression was made with light body (Aquasil LV, Dentsply, Germany). Master cast was obtained by pouring the secondary impression into type IV gypsum product - die stone (Ultrarock, Kalabhai Karson Pvt.ltd., Mumbai, India)
Figure 2: Prepared dome shaped maxillary canines

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Figure 3: Rectangular custom bar with metal copings

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Bar and copings on master cast were covered with wax, and trial denture base was fabricated with chemically cured acrylic resins (Rapid Repair acrylic resin. DPI, Mumbai, India) after applying separating media (Separating liquid, DPI, Mumbai, India) over master cast. The placement of wax over bar and copings prevent the fracture of abutments or bar on master cast during removal of temporary acrylic trial denture base at the time of dewaxing. Occlusion rims were fabricated over trial denture base. Horizontal and vertical maxillomandibular records were obtained with record bases and occlusion rims, transferred to a semi-adjustable articulator using a face bow. Artificial teeth were selected and arranged on the record base for a trial denture arrangement and evaluated intraorally for phonetics, esthetics, occlusal vertical dimension and centric relation. After wax up, the denture was processed in heat cure acrylic resin (Lucitone 199 denture base material, Dentsply, Germany), finished, polished and inserted [Figure 4] and [Figure 5]. [Figure 6] shows tissue surface of the palateless overdenture. The patient was scheduled for follow-up visits every 3 months and reported no complaints during 1 year of follow-up.
Figure 4: Prostheses in patient's mouth

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Figure 5: Palateless overdenture in occlusion

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Figure 6: Tissue surface of palateless custom bar supported overdenture

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   Discussion Top


A palateless denture technique for the management of gagging patients has been previously described by Booth. [5] Most patients accepts the custom tray and border molding procedures readily. Gagging episodes can usually be diminished to the point that, a final impression can be made with the conventional impression materials. Most patients whose gagging is of a psychologic nature, overcome their problem before denture procedures, are completed and comfortable with well-constructed prostheses. However, severe gag reflex in some of the patients make it difficult to perform each and every step of denture fabrication properly. Border molding and making of secondary impression by conventional approach is difficult. In such patients, a modified custom tray that does not completely cover the palate can be constructed and used as an impression tray. Instead of segmental border molding procedure, a single step border molding with medium body polyether/ polyvinyl siloxane elastomer is preferable procedure. The secondary impression can be made with the light body elastomer.

Conventional palateless denture has less retention and stability, which further gets compromised by extensive ridge resorption, lack of vestibular depth and a shallow palatal vault. Saving few remaining periodontally sound natural teeth and fabricating palateless overdenture has better retention and stability than removable complete dentures. Fabricating, a rectangular bar between two anterior abutments, further increase the stability and retention by the frictional contact between the copings-bar assembly and denture base.

Custom bar supported overdenture is a good alternative treatment modality for prosthodontic management of patients with severe gag reflex and large inoperable maxillary torus (with few remaining natural teeth), because of its improved retention, stability, better chewing efficiency and also decrease in alveolar bone resorption, because of the presence of periodontal ligament. It is very much comfortable to patient because of the less palatal coverage, better heat, cold and taste perception which is not possible in case of conventional complete denture because, acrylic denture base is a poor conductor of heat. Stability and chewing efficiency is further enhanced by a well balanced non-interfering occlusion.


   Conclusion Top


Palateless custom bar supported overdenture is definitive a benefit for patients having sever gag reflex with a history of unsuccessful denture wearing and for patients with a large inoperable maxillary torus. It has better retention, stability and chewing efficiency than conventional palateless dentures.

 
   References Top

1.Conny DJ, Tedesco LA. The gagging problem I prosthodontic treatment. Part I: Description and causes. J Prosthet Dent 1983;49:601-6.  Back to cited text no. 1
[PUBMED]    
2.Krol AJ. A new approach to the gagging problem. J Prosthet Dent 1963;13:611.  Back to cited text no. 2
    
3.Means CR, Flenniken IE. Gagging-A problem in prosthetic dentistry. J Prosthet Dent 1970;23:614.  Back to cited text no. 3
[PUBMED]    
4.Wright SM. Medical history, social habits, and individual experiences of patients who gag with dentures. J Prosthet Dent 1981;45:474.  Back to cited text no. 4
[PUBMED]    
5.Booth L. Palateless dentures. Oral Health 1947;32:118.  Back to cited text no. 5
    

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Correspondence Address:
Kunwarjeet Singh
Department of Prosthodontics and Dental Materials, Shree Bankey Bihari Dental College and Research Centre, Ghaziabad, Uttar Pradesh
India
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DOI: 10.4103/0970-9290.100416

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
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