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‫بسم اهلل الرمحن الرحيم‬

Complete Denture Revision

Ridge classification (Atwood's classification):

Class I : pre-extraction.

Class II : post-extraction .

Class III : high, well rounded ( most favorable )

Class IV : knife edge .

Class V : low, well rounded.

Class VI : depressed.

About class V, there is a common question in Viva exam : ( if you have a patient with Atwood's
classification V , and you have a problem in the lower denture retention and stability, what would
you do ) ?

1 -Special impression technique ( eg : admix technique and neutral zone impression technique ).

2 -Implants .

3 -Change 2 things in occlusal table : 1) make it shorter ( this will give more space to the tongue )

2) make it narrower

And also maximum extension for maximum support .

4 -Suitable occlusal scheme.

Primary Bearing area in Mandible :

This is a common question in viva exam

## What is the primary support/bearing area in mandible ?

The buccal shelf area ( others : retromolar pad area, crest of the ridge if it's well formed, YOU have
to start with The buccal shelf area )

The border of the buccal shelf area (also a common question in viva exam) :

1) anteriorly : buccal frenum.

2) posteriorly : retromolar pad.

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 3) medially :the ridge .

4) laterally : external oblique ridge .

## Why buccal shelf area is the primary bearing area ?

1) It's cortical bone (can tolerate forces better) .

2) It's vertical to the occlusal plane.

## Which better for load toleration, firm or loose tissues, keratinized or non keratinized tissues ?

Firm, keratinized tissues.

But the buccal shelf area is loose, non keratinized tissues, but still has the other advantages.

Genial Tubercle :

It's also cortical bone, it's an insertion of muscle attachment, it's considered a relief area in mandible
(because it's covered with thin mucosa; so it's easy ulcerated).

Other relief area in mandible : frenum, mental foramen & mylohyoid ridge .

Primary & Secondary Bearing area in Maxilla :

Primary : Horizontal hard palate.

Secondary : posterior slope of ridge & tuberosities.

Relief Area in Maxilla :

Rugae area ( although some consider is a secondary bearing area ), incisive papilla & frenum.

Classification of Hard Palate :

Class I : U shaped ( most favorable ).

Class II : V shaped ( usually associated with class III soft palate ).

Class III : flat ( not favorable ).

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 Vibrating Line ( very important subject for the viva)

It's the junction between movable and immovable part of soft palate , also called "ah" line.

( the vibrating line is to determine the post dam area of the denture ).

So; the area anterior to the vibrating line will be immovable.

## Fovea Palatine : helpful landmark to determine the vibrating line, the vibrating line usually

The relation between vibrating line and post dam area of the denture :

Post dam : thick part of posterior border of the denture, it's butterfly shape, pressing against the
area anterior to vibrating line.

## Why it's butterfly shape ?

Because we know from anatomy that these lateral area will be thicker ( in the denture ) because
there is greater compressibility on it than the midline; that’s why it will be wider and thicker
posteriolateral (1.5) whereas narrower and shallower in the midline (0.5) ; and that’s why it's
butterfly shape.

## How it's related to House classification of soft palate ( very important ) ?

We know that class I soft palate is the best, why ? because the immovable (compressible) area is
the widest when I have class I soft palate ( 5-12 mm) that’s means the post dam can be thicker.

Whereas in class II it's going to be (3-5 mm) & in class III nearly there's nothing .

Border Molding ( very important ) :

-The main aim is to shape the border of the denture .

-We have 2 techniques : sectional ( by green stick, type I low fusing compound ) &single stage
method ( by polyether )

-In the upper we do it in 4 sections ( anteriolabial, posteriorbuccal, posterior palatal seal area ).

( The movements are very important )

## important question, why we ask the patient to move the mandible from side to side when record

-In the lower we do it in 6 sections :

1- anteriolabial : lip movement : outward, upward, inward.

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 2- buccal sides : cheek movement and ask the patient to close while we pressing downward
pressure ( to activate masseter muscle which has effect on distobuccal border of lower denture )

3- anterior-lingual :- put the tongue against anterior part of palate ( determine thickness of flange)

-protrude the tongue (determine length of flange)

4- posterior-lingual : we concerned about mylohyoid muscle : ask the patient to say K and protrude
the tongue

5- distal end : -protrude the tongue ( to activate superior constrictor muscle )

-close while applied downward pressure ( to activate medial pterygoid muscle )

-open wide ( to activate pterygomandibular raphe ).

The fiber of mylohyoid muscle is posterior ( it's start lower and goes more higher as it's goes
posteriorly), that's why we concerned about mylohyoid muscle in disto-lingual region not anteriorly,
because anteriorly the fibers very low.

Impression Material :

We have choices, it can be alginate, zinc oxide eugenol, elastomers.

Specific Impression Techniques :

1) Admix Technique : indicate for patient with flap atrophic Mandibular ridges, to improve comfort
( reduce discomfort ), not to improve denture stability.

About the technique : 1- the special tray 2 mm spaced, with 3 stub handles.

2- the idea is to used a mixture of red compound 30% and greenstick 70%

3- do border molding as usual and after that take the impression with this mixture

2) Neutral Zone Impression Technique : to improve denture stability, it's good in all cases.

About the technique : - we complete all the stages until JRR, register the bite and ask the lab to
set upper teeth only, for the lower we ask the lab to remove the wax and form lower base plate
(superstructure); in order to make retention ways for the impression material in neutral zone, after
that I will take the impression, for the impression the material should be with slow setting, why ??

Because we want the material to take the shape of the tissues during function ( ask the patient to do
tongue movement, speaking, swallowing,…) ,,, this impression isn’t for fitting surface but for the
polish surface.

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 3) Specific Impression Technique used for Fibrous Unemployed Mandibular Ridge : can't apply to
many situation, it's to load some areas more than other areas, because some areas are firm and
better support the denture and other areas are movable, easily ulcerated and less able to tolerate
loads; so we choose to maximize loads on the firm tissue and reduce it on the movable areas. This
technique commonly associated with knife edge ridge ( but the point is the tissues are displaceable
and can be easily ulcerated) , it's the same concept of window technique.

About the technique : the idea is to use the peripheral tissues (buccal shelf mainly) which are
more able to tolerate loads and reduce loads on the ridge. How to take the impression ?? we can use
for example medium viscosity for firm tissues and light viscosity for displaceable tissues ( this is the
concept, you can change the material ).

4) Window Technique used for Flappy Maxillary Ridge : flappy ridge may be result of combination
syndrome, the aim is to reduce pressure on anterior area and maximize pressure and support on
posterior area.

About the technique : we will ask the technician to make a special tray, and to be with stub
handles sited over areas of firm tissues ( middle of palate ), then we check the extension of the tray,
do border molding, take impression (with ZOE for example), then cut a window in the impression
material anteriorly (that’s why the handle is posterior), then used light silicon to take impression for
displaceable tissue.

JRR :

It's important thing in viva exam to know about VDO ( vertical dimension of occlusion), VDR
(vertical dimension of rest) and freeway space. We know that at rest our teeth will not be together
so there will be a distance between teeth nearly 2-4 mm, and this distance known as freeway space.
And during closure this distance will become smaller and the teeth will be in contact and the
freeway space will be gone. This difference between rest and occlusion called the freeway space .
In denture freeway space is very important; for speech and for function of the denture. We always
need to have difference between VDO & VDR 2-4 mm, what if I have VDO equal or more VDR ??

Increase VDO means decrease freeway space & Decrease VDO means increase freeway space,
because the VDR is constant .

Consequences of Increase VDO : 1) decrease freeway space 2)muscle spasm

3)TMJ problem 4)effect speech
5)displacement of the denture 6)acceleration bone resorption
7) esthetic will not be good (elongated face appearance).

## How can we detect Increase VDO from speech ?? from "S" sound, when the patient says sixty six

Consequences of decreased VDO : 1) increase freeway space 2)collapse facial profile

3)drooling of saliva 4)angular cheilitis
5)the appearance will be like pseudo class 3

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 Speech Sounds :

Classification according to the anatomical parts :

1) Bilabial Sounds : ( B,P and M ), formed by upper and lower lips.

2) Labiodental Sounds : ( F and V ), formed by upper anterior and labiolingual center of posterior
third of lower lip. This sound will give 2 important information for the setting of upper & lower
anterior : #1 : The length; if "V" more like "F" >> so upper anterior teeth are too short/// if "F" more
like "V" >> so upper anterior teeth are too long.
#2 : Anterioposterior position of upper & lower teeth.

3) linguodental Sounds : ( TH ), formed by the tongue protrudes between upper and lower teeth.
While making these sounds "3mm" of tongue should be visible, if less than "3mm" that’s means the
anterior teeth are set too far forward, if more than "3mm" that’s means the anterior teeth are set
too far backwards.

4) Linguoalveolar Sounds : ( T,D,S,Z and L ), contact the tip of tongue with most anterior part of the
palate, the most important is "S" sound {{it's very important in viva and final}} .

"S" Sound : with "S" sound there is what's called the closest speaking space ( teeth come very close
to each other but still not contact) , during pronunciation of "S" the lateral portion of tongue is
higher than the midline; because of that a channel will be formed in midline and this will allows air
to escape ( and production of S sound ), if this channel formed is broad the "S" will change to "Sh", if
it's too small will change to whistle.

- Excessive palatal contour in canine regions (broader space) replace "S" by "Sh".

- If anterior teeth set too far backwards "S" will be "Th" .

- If anterior teeth set too far forwards "S" will be "Sh" .

( it's important to check the anterioposterior position of the teeth, VDO and thick of flanges ).

Occlusion :

In dentate there is what's called intercuspal position, in edentulous no more intercuspal position, so
we look for another position to set the teeth so that the new intercuspal position will be in that
position .

In retruded contact position the condyles of the mandible will be in what we called terminal hinge
access position. Why we go for this position ? because it's reproducible and stable position.

The patient doesn’t have only one RCP position, for each vertical dimension there is a different RCP.

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 ( in centric relation the condyle will be in the upper more most position of glenoid fossa, there are 2
types of movement when we open our jaws : pure rotation of mandible and with more opening
there will be more forward & downward movements, if the condyle is in the centric relation the first
mm of opening will be pure rotation ( retruded arch of closure ) .

- In dentate usually the RCP is behind the ICP (1-2 mm posterior to ICP).

- In dentate we don’t have balanced occlusion ( balanced occlusion means that I will maintain the
contact between the teeth in all excursions. We need this in denture because denture is movable so
I need to maintain contact between teeth in excursions, so no displacement of denture happened,
this what called Christensen Phenomenon in dentate.

-In balanced occlusion there's no separation between the teeth, how could we achieve this ? by
*reducing the incisal guidance *compensatory curves ( curve of Spee & curve of Wilson ).

- The occlusal scheme will determine the pattern of occlusal contacts between teeth in centric
relation & excursions, and this is important for denture stability and it will affect the forces that will
transfer from the denture to the ridges, in order to determine an occlusal scheme we are concerned
about 2 things : 1) the tooth form 2) whether it's balanced or not balanced ( it's better to have
balanced occlusion ; as we said it will improve denture stability ).

Balanced Occlusion ( Anatomical Teeth ) :

The most common type ( balanced is better but since teeth are have cusps in excursions there will
be lateral components of forces ) so we make sure to have well developed ridges for this type.

##Why we use it ?? because it good in esthetics (anatomical teeth) and has chewing efficiency.

We try to make the overjet 1-2 mm, overbite 0.5mm .

(As we said to achieve balanced occlusion we reduce the incisal guidance ( incisal guidance is the
overlap between upper & lower so as overbite decrease the incisal guidance decrease and as overjet
increase the incisal guidance decrease). When the incisal guidance reduced so it will have minimal
effect on separation between teeth but since that I still have some separation, how do I compensate
for it ?? by compensatory curve; so I will set the teeth so that they go higher as go posterior, if they
go higher the contact will be maintain between posterior teeth and no separation happened.

Compensatory curve : 1) anterioposterior component : curve of spee

2) lingueobuccally component : curve of Wilson ( this will compensat
separation during lateral movement.

Balanced Occlusion ( Non-Anatomical Teeth ) :

It's more difficult because it depends more on compensatory curves, because there will be no cusps.

Or we can use a second molar ramp to accomplish balanced occlusion .

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 This is indicated when the ridge is more resorbed ( to eliminate the lateral forces ).

Lingualized Occlusion :

Upper anatomical & lower flat ( good esthetic because upper are anatomical and no lateral
components because lower are flat [good chewing and stability] )

Monoplane Occlusion :

The doctor not recommended this type.

It's flat against flat , the only indication is if the patient has un-controlled closure (parkinson's
disease ); because it's not balanced .

Conclusion :

Balanced Anatomical : good stability, good esthetic, good chewing efficiency but we need to have
well developed ridges , class I relationship.

Monoplane : not balanced, non anatomical teeth, it's only indicated if the patient has uncontrolled
jaw movements , and bone resorption .

{This script doesn’t contain the slides that doctor showed in the lecture, so please refer back to them and for
more information and details about every concept here go back for our past scripts and slides that contain
these topics, this script summarize the important things in viva and final exams}.

Best Wishes ☺

Done By : Bayan Al-Abdullah

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