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| CASE REPORT |
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| Year : 2020 | Volume
: 4
| Issue : 3 | Page : 124-128 |
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Nonsurgical approach for torus palatinus management in full denture rehabilitation
Niko Falatehan1, Gracia Anfelia2
1 Department of Prosthodontics, Faculty of Dentistry, Trisakti University, West Jakarta, Indonesia
2 Dentia Dental Private Practice, West Jakarta, Indonesia
| Date of Submission | 17-Jun-2020 |
| Date of Decision | 13-Jul-2020 |
| Date of Acceptance | 01-Sep-2020 |
| Date of Web Publication | 17-Oct-2020 |
Correspondence Address:
Niko Falatehan
Department of Prosthodontics, Faculty of Dentistry, Trisakti University, West Jakarta
Indonesia
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/SDJ.SDJ_21_20
Background: Tooth loss in individuals more commonly occurs with increasing age. In a dental practice, many patients present with torus palatinus, which is usually caused by problems and complications resulting from denture fabrication. Therefore, a nonsurgical approach in which horseshoe-shaped complete dentures are fabricated is considered to be a viable option to address torus palatinus. Case Report: A 59-year-old edentulous male came to the Prosthodontic Department, Faculty of Dentistry, Trisakti University, with a chief complaint of the instability of his maxillary complete dentures, and he requested new dentures. The patient had been wearing the dentures for approximately 5 years. Based on the intraoral examination, the patient had a large, single lobule torus palatinus that extended posteriorly through the junction between the hard palate and the soft palate (AH line). It was covered with thin mucosal tissue, and it did not interfere with his speech, his ability to chew, or other oral functions without the dentures. After the problems were thoroughly diagnosed and corrected, horseshoe-shaped complete dentures were chosen as the appropriate solution, and the dentures were fabricated. Conclusion: Torus palatinus tends to have very thin mucosa that causes discomfort and irritation during routine usage of acrylic dentures. Therefore, the horseshoe-shaped dentures facilitated good retention and stability, and they did not irritate the torus palatinus.
Keywords: Complete denture, horseshoe-shaped dentures, torus palatinus
How to cite this article:
Falatehan N, Anfelia G. Nonsurgical approach for torus palatinus management in full denture rehabilitation. Sci Dent J 2020;4:124-8 |
| Background | |  |
Tooth loss is one of the most common changes in the oral cavity that is often found in elderly patients; it appears to be more common with increasing age.[1] According to the 2013 Basic Health Research data, 25.9% of the population of Indonesia has dental and oral health problems such as dental caries, periodontitis, and tooth loss. The prevalence rate of tooth loss in the 55–64-year age group is 10.13% and that rate is 17.05% for people 65 years or older.[1] Losing a tooth without replacing it can have a negative esthetic impact on an individual; it can also cause mastication and speech problems and result in temporomandibular disorder (TMD). To resolve those problems, missing teeth need to be replaced with dentures.[1],[2]
Problems in the anatomical oral cavity and technical errors often make complete denture treatment unsuccessful.[3] Patients present with normal variations in their oral soft-tissue structures, for example, torus palatinus, which clinically affects the denture fabrication, especially that of complete dentures.[4] A study by Ali showed that the prevalence of torus palatinus in Indonesia was 22.3%, which is high for this condition.[5]
The most common problem associated with torus palatinus is denture interference, leading to denture instability.[3] Denture instability adversely affects the support and retention of the prosthetic device, resulting in deleterious forces on the edentulous ridges during its usage.[6] A large torus palatinus with an undercut often complicates the placement of the tray when taking impressions or inserting the dentures, thereby reducing the retention and stability of acrylic dentures causing inflammation on the mucosa due to friction from the prosthetic.[7] On the other hand, the overextension of the posterior palatal seal causes gagging. Traditional management of torus palatinus can be either surgical or nonsurgical. However, some studies only recommend surgical removal of the torus palatinus in extreme cases, as it could cause several complications such as perforation of the nasal cavities, nerve damage, and fracture of the palatal bone.[8]
Various nonsurgical approaches are considered to be a viable option to overcome this problem such as making an accurate design of a complete denture or constructing a window in the dentures to accommodate the torus palatinus so that retentive, stable, and comfortable dentures can be fabricated.[9] This paper reported a simple procedure to accommodate torus palatinus by fabricating horseshoe-shaped complete dentures.
| Case Report | | |
A 59-year-old edentulous male patient who works as a driver came to the Prosthodontic Department, Faculty of Dentistry, Trisakti University; his chief complaint was the instability of his maxillary complete dentures, and he requested new dentures. He had been using dentures for approximately 5 years, but now, the maxillary dentures felt loose and unstable while chewing [Figure 1]. He also complained of having difficulty pronouncing specific words, especially words with a palatal consonant. Moreover, he was concerned about his poor facial appearance because of a lack of adequate support for his lips and cheek.
The patient's overall oral hygiene was fair, and intraoral examination revealed that he had a large, single lobule torus palatine [Figure 2]. The torus was oblong; in its most prominent region, it was 12 mm long and 5 mm wide, and it extended posteriorly through the junction between the hard palate and the soft palate (AH line). It was covered with thin mucosal tissue, and it did not interfere with the patient's speech, chewing, or other oral functions without the dentures.
The posterior palatal seal plays an important role in enhancing the retention of maxillary dentures. The seal is achieved by incorporating a postdam to create a raised area or ridge along the posterior border on the fitting surface of the maxillary denture.[10] Commonly, the posterior palatal seal is formed through the fovea palatine and across the AH line.[11] The presence of the torus palatinus and its extension to the posterior region of the AH line prevents the creation of a good posterior palatal seal.[12] To overcome this problem, the posterior palatal seal is modified so that it does not press the torus area, and the postdam follows the posterior peripheral border of the U-shaped posterior palatal seal.
The patient had an ovoid maxilla, normal soft-tissue mucosa underlying the normal and slightly irregular-shaped alveolar ridge, and a high-vaulted palate opposing the natural dentition on the mandibula. The soft-tissue mucosa was normal, and the opposing natural teeth required occlusal adjustment. Before the prosthodontic treatment, the patient received dental health education and underwent scaling. The patient provided written informed consent to participate in the case report including a statement that the case report would be published in a journal. The main objective of the treatment plan was to reestablish a proper vertical relation based on phonetic and masticatory function, facial appearance, and functional position of the jaw.
Surgically removing the torus palatinus, followed by the use of an implant prosthesis, was not a recommended treatment plan for the patient due to his economic status and age. Instead, upper horseshoe-shaped acrylic complete dentures were chosen. The primary impression of the edentulous maxilla and mandibular natural teeth was obtained using an irreversible hydrocolloid impression material taken with a stock tray to produce a diagnostic case made of artificial stone. The main concern was the accuracy of the impression due to the existence of torus palatinus. Thus, a custom tray was fabricated with Shellac material.[13] A greenstick compound was used as the border molding before the second impression, which consisted of zinc oxide eugenol. Finally, the master cast was made with Type III dental stone to obtain the accurate mouth representation needed for the procedure after fabricating the horseshoe-shaped upper acrylic complete dentures. To increase the retention and stability due to the selection of the design, the postdam was made to surround the entire surface of the denture in the palatal area.
The vertical dimension of the occlusion was reestablished by the occlusion rim, which was well constructed and contoured to create adequate lip and cheek support. The anterior artificial teeth were selected and arranged to enhance the esthetics of the outcome, while the posterior teeth were arranged to fulfill the requirements of balanced occlusion. Balanced occlusion preserves the stability of complete dentures and simultaneously facilitates the realization of the tooth contacts at the working side and the balancing side. All the artificial teeth were arranged on the articulator in the centric occlusion position so that the centric relation records could be verified. A try-in of the waxed upper complete dentures was performed to verify the correct occlusion, shade, and mold, followed by acrylization of the complete dentures with heat-polymerizing acrylic resin [Figure 3]. Verification of the retention and stability, phonetics, and esthetics of the acrylic complete dentures was done, and the patient was satisfied [Figure 4]. The patient was given postinsertion instructions regarding maintenance, nutrition, and hygiene.
| Discussion | | |
Torus palatinus is one of the normal variations of the oral soft-tissue structures in the form of the protuberance in the area of the hard palate that is commonly found in the maxilla of patients with complete denture treatment needs.[9] Generally, the existence of a large torus palatinus often causes difficulties in the fabrication of dentures, and it results in discomfort and irritation to the palatal mucosa due to its inability to withstand normal pressures from the denture base.[7]
To overcome this situation, several conventional approaches can be feasibly employed. One approach is to surgically remove the torus. Surgery is generally performed on the torus palatinus, which significantly affects the oral function of an individual, thereby reducing the function of phonetics, mastication, and breathing. Surgical removal is also an indication when the torus palatinus interferes the construction of a dental prothesis.[14] Individuals that are unable to maintain oral hygiene, or those with recurring pathological irritation in the area of the torus palatinus and suspicion of a malignancy condition, should undergo surgical treatment.[7] Surgery is considered to be an alternative that can permanently resolve a patient's complaints; however, that treatment is very expensive, and it may result in complications such as nasal perforation, oroantral fistula formation, palatal tissue necrosis, and hematoma; thus, it might not be the best choice.[8],[9],[15]
To avoid surgery, various techniques can be used to fabricate a complete set of dentures such as modifying the impression technique, changing the denture material that is used, and altering the design of the dentures. The two-tray system is one way to modify the impression taking technique. However, it was not appropriate to use this technique on this patient because of the intraoral finding (i.e., the torus palatinus was located in the posterior region of the AH line and without an undercut). Hence, this alternative technique is not necessary. In terms of the material used to make the dentures, it is possible to apply a slight modification called the triple laminating technique; however, due to limited resources, this method was not used.[16]
The best alternative for this patient was to modify the design of the complete dentures. There are two design alternatives: the windowing technique and horseshoe-shaped dentures.[17] Considering the size of the torus palatinus in the patient in this case study and its extension into the posterior region of the AH line, horseshoe-shaped dentures are the best way to accommodate torus palatinus.[18] Given that the main retention of the upper complete dentures depends on the soft-tissue mucosa of the palate, in this case, to maximize retention and stability, the acrylic plate release was limited to the torus palatinus.[19] Eventually, the optimal retention and stability of the dentures can be maintained, oral health and quality of life can be improved, and the occurrence of TMD can be prevented.[20],[21] The windowing technique is considered to be less appropriate in this case because the torus palatinus was situated posteriorly through the AH line.[9] Therefore, the horseshoe-shaped design was chosen as the most viable option for this case.
| Conclusion | | |
In daily clinical practice, many patients with torus palatinus require complete denture treatment, which creates obstacles and challenges during fabrication. Torus palatinus tends to have very thin mucosa, which causes intolerance to normal pressure from the denture base, resulting in discomfort and irritation during routine usage of acrylic dentures.
Based on the anamnesis, extraoral examination, and intraoral examination, the proper management of the upper complete dentures in this patient entailed using the horseshoe-shaped design, due to the size of the torus palatinus, the undercut, and the posterior extension to the AH line. Moreover, this design has been proven to facilitate good retention and stability, and it does not irritate the torus palatinus.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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