CLINICAL AND LABORATORY PROCEDURES IN CONSTRUCTION OF COMPLETE DENTURES

*Complete Denture definition:

-A dental prosthesis that replaces all of the natural dentition and associated structures (the mucosa and the bone) of maxilla and mandible. -Most of the time it is supported by mucosa or sometimes by dental implants.

*Objectives of complete denture

hetic.

*Steps in fabrication of complete denture:

1-Clinical examination 2-Tray selection 3-Primary impression 4-Primary cast 5-Secondary impression 6-Secondary cast

7-Denture base fabrication and Occlusal rim 8-Articulation

9-Setting of teeth, Flasking, dewaxing and curing 10-Trimming and polishing

*First: HISTORY AND EXAMINATION FOR EDENTULOUS PATIENTS -So after you opened a file for the patient, you'll include in it his name, gender, occupation, medical history, past dental history and why he is coming here. Q: Why do we need to examine and record the history of the patient? 1- Recognition of relevant anatomical, physiological and psychological conditions, for example the patient might have some anatomical difficulties in his jaw that will make you unable to make a satisfactory complete denture, or if he has a psychological disorder so you can't deal with him so you'll refer him 2-Understand significance of medical status, because medical condition of the patient is very important. - e.g.: if he has diabetes then you have to consider that this patient might have reduced salivary flow or he is taking medications that reduces saliva, or his mucosa might be more prone to trauma more than other patients, or if he has bleeding disorders, so you have to be very careful in the selection of the trays and taking your impressions in order not to traumatize the tissues. 3- Development of treatment plan (prescription of prosthesis), what you are going to do for this patient for example if he has several difficult anatomical land marks, or a flabby ridge or a enlarged maxillary tuberosity so you might need a help from a surgeon to reduce it or you can use special impression technique. 4- Assessment of existing dentures, so the patient is coming to you to get a new denture, so you want to investigate what was the problem with
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the old denture and why he is going to replace it? Is it about the stability, the retention, the function or the appearance? In order to avoid these problems in the next denture. 5-Why the patient is seeking this treatment. *Extra-oral examination -The extra-oral examination should look for: 1- Temporomandibular joint (TMJ): so you want to investigate if the patient is opening his mouth normally or not, is the opening sufficient to insert the tray inside the patient mouth? - or for example if he has pain or a problem in the TMJ you cannot proceed making complete denture for this patient, you have to refer him for a specialist in oral medicine or in oral surgery to investigate and solve this problem, because if you construct a complete denture for this patient you'll aggravate the problem rather than solving it, because there may be increased or reduced vertical dimension, so you should palpate externally and from inside the ear: pain, clicking, limitation of movement, extreme deviation. 2- The patients face height, because it will affect the vertical dimension. 3- Any facial asymmetry including the centre line; usually we make the center line of the face between the two central incisors along the mid line of the face and the middle of the nose and the philtrum. -some patient might have deviated center line and you need to consider this during the try-in or delivering the denture, and the patient preference if he want the centre line as normal or shifted toward his mid line. 4- The lip line, some patient have short lip and some of them have long lip, so if he have short lip this means that too much of the acrylic of the denture will be shown, or if he have long lip and you're going to construct the conventional complete denture this means that there is going to be not much of the denture shown.

-Lips also include the smile line as all these features will need to be transferred to the patients' dentures. - The degree of over closure will also need to be assessed and this will help with deciding on how you want to make the denture. -this means if the patient has deep overbite, for example if the patient closes his mouth there is no space between the upper and the lower edentulous ridge, and this means that you are not allowed to increase the vertical dimension very much, so it need to be assessed and this will help with deciding on how you want to make the denture. -All of these points are concentrating of the extra oral examinations; what about intra oral examination? *Intra-oral Examination -You need to examine in the patient mouth by eyes and fingers, we examine: 1- Soft tissue: to see if there is a trauma for example or any important lesion to know if you need to refer him. 2- Salivary flow: to see if the saliva is normal or increased or reduced so you might have an underlining medical problem. 3- Sulcus depth: as it affects the retention of your denture, if he has flat ridge for example and no sulcus, then you expect your denture to have reduced amount of retention, so you consider that, for example by taking special impression technique or telling your supervisor that this patient is not suitable for me at this level. 4- Ridge anatomy: does the ridge have enough height and depth, and it's form (firm or flabby) 5- Inter-ridge relationships: class 1, 2 or 3. -class 1 is normal and easy -class 2 might be difficult and it's prognathic - Class 3 is the more difficult which is retrognathic.

- If already wearing dentures: denture assessment: fit, retention, stability and occlusion or the patient might ask you to copy the denture if it is already satisfactory? -The first step in intraoral examination is to open the mouth and to look for anything abnormal, like the color, consistency and appearance of the mucosa. *Maxillary arch: the most important thing here it to look for the maxillary tuberosity (the red circles), in most patients it's normal, in some of them it's enlarged, either bony or fibrous enlargement.

- If it's enlarged it will affect your impression so you'll need a consultation by special prosthodontist or a surgeon. - If the enlargement is fibrous then you can do your conventional technique without problems - If it's bony you cannot do it because there will be too much undercut and this means that you have to refer the patient to oral surgery to excise some of this bone *Mandibular Arch: the two most important areas here we have retromolar pad and the mylohyoid ridge. -the retromolar pad is used for several things: 1. It indicates extension of the lower complete denture, by extending to the anterior one third of it
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2. It is important in the retention and occlusal plan, it indicates the level of the lower occlusal plan (2/3 of retromolar pad) - The mylohyoid ridge in some patient might be prominent and it will be sharp, if you construct your denture in such a way the final denture will traumatize the patient, so you need to consider that this might be a source of pain for the patient.

*Second: IMPRESSIONS FOR COMPLETE DENTURES Definition: A negative likeness of the tissues so that a model can be made from which a denture can be constructed. -The impression material is held against the tissues and is supported by an impression tray. The material shows plastic flow in the initial stages and then hardens. -A model is then formed using model stone or plaster. For maximum accuracy a 2 stage impression procedure is adapted. -Impression with a stock tray is first taken called a primary or preliminary impression

*IMPRESSION TRAYS
-Two types of impressions trays are used stock and special trays *Properties: 1-Must be clean and smooth 2-Must be rigid and strong 3-Should permit correct thickness of impression material to be used (3mm) 4- Handle must be shaped and attached to the tray so that it doesnt displace the lip when the impression is taken 5- Must hold the impression material in the correct position in the mouth and consequently must cover the whole area of the jaw required in the impression. 6- Must prevent distortion of the impression material during setting and removal from the mouth -Stock tray means universal tray, it's not specific for one patient, we can use it for all patient with a similar size of the jaw, and the tray should be selected to cover all anatomical land marks, how do you check for this? -You insert the tray inside the patient mouth (for this case the maxillary arch) it should relief the frenum and should cover the maxillary tuberosity, the whole edentulous ridge and posteriorly the vibrating line or the post dam area.

-We have different sizes we have small, medium, large and X- large Size - If you use a small size tray then your impression will be very small and not representing the jaw, and if you use a very large tray then you'll distort your impression

*Types of stock tray:

1) Box trays: RPD. 2) Trays for edentulous arches 3) Combination trays: Distal extension base

*Disadvantages of the stock tray:

1- Variation in thickness of impression material: because they are not suitable for the patient, the thickness for example in the anterior area might be different from the thickness in the posterior area 2- Localized pressure on oral tissues: it might press for example on the left side and not press on the other side. 3- Incomplete coverage of oral tissues: so sometimes you have to modify this tray by adding some wax to it on the borders in order to reach the full depth of the sulcus

-in this pic the patient have a deep palate that why we added wax on this area.
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4- Distortion of the impression material: because the tray is not suitable to that patient. *Impression compound (Modeling compound) - It's the most common material that you'll find in your clinics, thermoplastic Material which means it can be softened with heat for over all adaptation.

*properties of impression compound:

- Greatest pressure asserted to the center of its mass - Can be softened in wet heat for over- all adaptation, or it can be softened in small areas by dry heat for localized modifications. - Softening not > 60 C -for the maxillary we need two cakes (two pieces). -Kneading of compound with our fingers to obtain a uniform consistency (rope or ball) Warming of tray Adaptation to tray with grooving (like the pic below) to receive crest of ridge (the lingual aspect 3mm deeper than labial anteriorly and 6mm posteriorly)

*Impression compound advantages: 1- Can be added and re-adapted: which means that if you get your impression out of the patient Mouth and you saw a deficient area you are going to soften impression compound and then add it and insert back in the patient mouth. 2- Used in combination with other materials, we can use it for example with alginate, so if we took impression several times and still there is lack of surface details we can spray and adhesive over this tray and mix alginate and add a very thin layer to it and take another impression, so we call this corrective alginate wash, like the pics below.

*Note: Corrective alginate wash

To obtain greater surface details the initial compound impression is used as a tray to record a further impression in alginate Shake alginate tin to avoid condensing?? Powder or water first?? Primary impression with impression compound lack any surface details so here we need corrective alginate wash impression

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3- Pouring of impression may be delayed: you might not send the impression till two hours, so we can delay it not like alginate which have to be poured in 30 mins. *Impression compound disadvantages: 1- Does not reproduce fine surface details, and for this reason sometimes we go for corrective alginate wash. 2- Should not be used in undercuts, because it's very stiff (rigid) material, if you use it for patient with sever maxillary undercut in the maxillary tuberosity area it will not come out and the patient will be hurt. 3- Re-softening/unhygienic, this material can be re-softened for 3 or 4 times for the same patient several times in order to take the final impression, and this can be unhygienic.

*Alginate
- composed of Sodium alginate, calcium sulphate, trisodium phosphate - Trays should be Perforated (perforations are means of mechanical retention, so the alginate will go inside them and stick to the tray), while impression compound can be used with perforated or non-perforated trays. - Sometimes we add adhesive to the tray before we mix alginate (polyamide in isoprpyl alcohol) - Impression poured immediately ( imbibition and syneresis) within 30 minutes - Record good surface detail with a minimum of tissue displacement - Accuracy depends upon the accuracy of the tray Easily distorted

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* Alginates advantages:
Excellent surface details. Elastic: so we can use it in undercuts. Different viscosities: we have high, medium and low thickness alginate.

*Alginates disadvantages:
Not flow in areas not supported by tray Cannot be added: if you have a problem with you alginate impression you have to repeat it, but if you have problem with impression compound you can add to it. Liable to distortion at laboratory. *which impression should we take first maxillary or mandibular? -We usually go for mandibular impression and this has been found by research, but for some patient you can start with the maxillary first. But if you started with maxillary you'll see: 1- Increased salivation 2- Retching (gagging) reflex 3- Chocking by impression So to avoid these take the mandibular first. -sometimes when we use impression compound it's hot, you'll mix it in 60 degree and then we you will temper it , but if you take it as 60 degrees and put it in the patient mouth cause this will burn him, so you temper it in the tempering rubber bowel and then to the patient mouth, for these reasons if you forget to temper the impression compound and you put on the maxilla you'll burn the palate because it's a very sensitive area. - If this has been done in the lower jaw it will not cause that trauma as if you were doing the upper jaw.

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*Preliminary Impressions *Common faults: (lower impression)

1Edge of the tray showing:

-Incorrect centring of the tray -Use of too large or too small tray -Forward thrust of tongue not been countered by backward pressure on the tray in the anterior region

2Insufficient depth at lingual pouch:

-Short flange -Lack of compound -Too little force applied -Tongue trapped
*Common faults: (Upper impression)

Deficiency in midline of palate

-Insufficient compound -Insufficient pressure -Compound cold -Trapped air
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-So we opened a file for the patient, we finished the examination, we took primary impression with impression compound, what is next? I'm going to send these to the lab, so I'll send a piece of paper to the technician to tell him what I'm going to do, what type of stone to pour, amount of spacer, and do we need modification of the tray like perforations or not *Diagnostic cast -The cast that come after pouring the impression, we ask the technician to pour the impression with dental plaster, so why do we need a primary cast? 1- Analyze feasibility of various treatment measures. 2- Foundation for special trays 3- Help the dentist to discuss possible treatment forms with patient or technician: sometimes you'll not be able to see all the anatomical structures inside the mouth very clearly, so once you get the impression you'll see it more clearly. 4- Analyze occlusion and articulation: these are not for complete denture patients, these are for RPD patients.

*CASTS MATERIAL (properties of ideal cast material) -We cannot pour impression with any type of stone, it should be: 1- Compatible with all types of impression materials. 2- Reasonable setting and working time: we don't need it to set for example within 2 hours, we need it to set very fast. 3- Reproduce surface details. 4- Exhibit surface hardness: which means that it cannot be scratched.

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*EDENTULOUS CASTS -Posterior border of cast stops 8 mm from maxillary tuberosity or retromolar pad - The outer surface of the cast is trimmed to about 3mm from the maximum convexity (Land area) - At least 10 mm thick

*Special trays
-These are made of type of material called acrylic material, they can be light cured, or you can mix them and apply them on the flame.

-Note that on the lower special tray we have stops, and they are used to press the tray on the posterior part of the mandible, because it's difficult to stabilize the tray inside the patient mouth (Called finger rest) *Before fabrication of the custom tray we do conditioning of the primary cast, first of all the technician needs to draw the borders of the tray, you can see two lines on the cast below, on is black and the other is red, so the special tray material will reach these lines.

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- notice that he is adding wax, this is called block out, which is inserting wax in the undercuts, and we do this because when we cure the special tray if these undercuts are not blocked out the tray will not come out or will be fractured. -you can see in the picture below, the spacer which provides space for impression material, which could be zinc oxide eugenol or silicon or alginate. - With zinc oxide eugenol we don't need a spacer, we don't need a space below the tray, but with alginate and silicon they are thick so we need two layers of wax to provide enough space for it to prevent tearing -Notice in the picture that the spacer was on the anterior ridge, we don't need a spacer posteriorly, why? Because the anatomy of the anterior one is flabby so we need spacer.

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-Usually we use modeling wax as spacer, now what are the requirements of special tray? 1-First of all you need to write for the technician to make the tray from light cured acrylic 2- if you need it with perforations or without, for example if you won't zinc oxide eugenol you don't need perforations 3-if you need a spacer or not, again if zinc oxide eugenol you won't need a spacer. *Note: in our clinics we use spacer with the upper which is "spaced" while in the lower we don't use spacer and we call it "close fit". -Spaced trays are used with impression plaster and alginate. The mould is covered with a wax spacer and an acrylic sheet of at least 2mm thickness is then used to construct the tray. If the sheet is too thin, there will be no rigidity thus causing distortion of the impression -Close fitting trays are constructed with the undercuts blocked out on the cast but without spacer.
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-Now , there is an important thing that the technician should know ,that the special tray borders shouldnt reach the full depth of the sulcus ,it should be 2 mm away from the full depth of the sulcus (not like the stock tray that reach the the full depth of the sulcus . -why do we leave that space? Because we will do border molding and in another word to be distinctive from stock tray so it will be specific to that patient. -Sometimes the tray is 2 mm away from the borders of full depth of the sulcus , once you put it inside the patient mouth it reaches the full depth of the sulcus , why is that ? because most of primary impression that we send it to the technician - are over extended, so to solve this we put the tray inside the patient mouth and we give a pencil and put a mark on it to be 2 mm away from the full depth, then cut the tray by trimmer or acrylic bur to be in the suitable distance.

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-After that we will start the first procedure of secondary impression that is border molding. - in this procedure we will use a material like impression compound or material called green stick (molding stick) , it the same of impression compound its thermoplastic material , contain wax and resin but it differs from it by the amount of fillers ( we can put impression compound in a rubber container that contain 60 C water but green stick we can't depend on water to soft it , we put it on the flame because the amount of filler in it is more , so softening on flame then apply on the borders)

-These borders should be very accurate, why? bcz they are representing the borders of the final denture ( if border molding accurate your secondary impression will be accurate , your secondary cast accurate and your final denture will be accurate) .

*How to check that our border molding is accurate?

-look inside the patient mouth , it reach the full depth of the sulcus , and try to remove the tray : for the upper , if your border molding is accurate the tray will not come out because we closed the peripheral seal ( after we do border molding the air will be under the tray and we closed on it so there will be negative pressure ) , in the lower the same thing but in most cases lower retention( 75% )not like upper retention (100% )because of two reasons: 1- The flat lower ridge so it's difficult to close on the air and get negative pressure 2- The second thing is the movement of the tongue will prevent also negative pressure, so if we can apply 75% negative pressure this will be good.
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- We can use alginate and polysulphide material to take secondary impression but Zinc oxide eugenol the most common material. *Secondary impression materials: 1. Impression plaster (with anti-expansion liquid) 2. Zinc-oxide eugenol impression paste (most commonly used) 3. Alginate 4. Elastomers (Polysulphides and Silicons)

**The advantages of ZOE Excellent surface details Dimensionally stable Can be added and re-adapted **The disadvantages Not used in undercuts Can only be used as wash material Require border moulding of the tray Eugenol sensetivity -Muscle trimming (border moulding). Patient lips and nearby skin should be lightly covered with facer cream or petroleum jelly. Orange oil or chloroform to remove ZOE paste from patient or operator skin *Aim OF SECONDARY IMPRESSION: to record functional depth and width of sulcus -By this we finished the secondary impression Now we send it to the lab and ask the technician to pour them and should be so accurate (special care not like primary) and no irregularities by boxing impression.

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-we put utility wax on the borders of the tray then we bring boxing wax (red) and make a sealing on the tray and pour it by dental stone, why is that? -bcz the secondary cast (master cast) should tolerate pressure, so it should be accurate and made from strong material.

- Now we will put record blocks on the master cast. - Record block has two parts: 1) Denture base (acrylic material that reach the full depth of the sulcus on the upper or lower) 2) Wax rim on the top of it (representing upper teeth and lower teeth).

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- We can use the acrylic resin to made denture base. Shellac and compound was in the past and can be distorted by the mouth temperature.

- The requirement of record base:

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*NOTEs:

- The labial surface of anterior teeth supports the lips and is between 10 12mm labial to incisive papilla - The centre of the last molar is nearly opposite the centre of the tuberosity and its buccal surface is 3-5mm buccal to centre of tuberosity - On average, the distance from the functional sulcus to incisal edge of centrals is about 20mm and to the occlusal surface of first molar is about 18mm. in another meaning, the record blocks will come from lab, we will care about the dimensions of the wax it should be ant 3-5 mm, premolar area 5-7 mm and posterior area 8-10 mm in width

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- The functional depth of sulcus should be 22 mm in incisal area and posterior 8 mm. this is for upper.

-If the difference is so far away from the correct one we need to send it back to the technician *For lower record blockfunctional depth anteriorly 15-18 mm, and the wax should reach 2/3 of the retromolar pad area. The rest dimensions like the upper nearly.

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*JAW RELATIONS: - Centric occlusion :( its tooth to tooth relationship) Static tooth contacts in maximum intercuspation (termination of masticatory closure). - Centric relation: (the most used term, bone to bone relation) most retruded position of mandible to maxilla from which lateral movement can be made at a given degree of jaw separation - Vertical dimension: the distance between alveolar process of maxilla and mandible in centric relation - Occlusal plane: the position and angle of a plane to which the occlusal surfaces of teeth relate *The relations that we will use: 1-Orientation relation: relation to the cranium 2-Vertical relation: amount of jaw separation 3-Horizontal relation: anterio-posterior and lateral relations - when we need to use hotplate we will begin with the upper

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