WAX TRYIN APPOINTMENT

Procedures for this appointment

1. Check vertical dimension methods: external measurements,
phonetics, swallowing.
2. Prove centric jaw relation and remount if necessary.
3. Make protrusive record and set articulator condyles.
4. Esthetic and phonetic evaluations.
5. Characterize anterior teeth.
6. Remind patient to remove denture 24 hours before next appointment.
7. Make insertion, 24 hour and one week
appointments. NEEDED: Trial denture(s) with
teeth set in wax.

Reference:

Rahn & Heartwell, 5th Ed. Esthetics, pg. 339-349; Tooth Setup forTryin; pg. 351-371.

ARMAMENTARIUM

1) Articulator, wax trial dentures, extra mounting ring

2) Warm (110 °F) w ater bath
3) Mouth mirror
4) Hand mirror
5) Alcohol torch
6) Wax spatula
7) Boley gauge
8) Baseplate wax
9) Tongue blade
10) Indelible marking stick
11) Bite Registration Paste and ISO compound sticks
12) Quick setting plaster
13) Denture adhesive powder

GENERAL COMMENTS

The trial denture appointment is used to evaluate and change, if necessary, the vertical dimension of
occlusion, centric relation, mold, shade and esthetic arrangement of anterior teeth, and other characteristics
of the denture before final processing. Any changes indicated should be made at this time since later
alterations will be costly in terms of chair time and laboratory charges. The trial denture appointment is
also of great importance because the patient, for the first time, has the opportunity to critically evaluate the
appearance of the fin ished denture. At this time the patient is usually very alert and may even be
hypercritical. However, he/she is usually receptive to suggestions and explanations. This is the time to
point out any peculiarities of color, form, size, and arrangement of teeth, and also to tell how these
irregularities improve appearance. This also provides an opportunity to comment on some of the
characteristics of the denture which might not come to the patient's attention until

later. It is alsoa good idea to have a close relative or friend of the patient present at the
denture
trial
appointment especially if the patient is indifferent or indecisive.

It is important to adhere to set

a routine of evaluating
the wax trial dentures. This will save much time
and confusion. It is tempting to consider appearance first, but a remounting will often require changes in
the anterior teeth. Your
correct order of consideration is:

1. Vertical dimension of occlusion and rest.

2. Accuracy of the centric relation mounting.
3. Protrusive articulator setting.
4. Postpalatal seal, if not determined previously.
5. Esthetics and phonetics.

EVALUATING VERTICAL DIMENSION AND PHONETICS:

Vertical dimensionof occlusion should be considered first since any gross changessitate
necesremaking
the centric relation record.
Phoneticscan also be considered at this time since speech is one of the means
by which the vertical dimension of occlusion is evaluated. Further, phonetics should be considered early in
the appointment, for the patient will appear
more natural when he is concentrating on phonetic sounds than
when his attention is concen
trated on appearance.

1. Insert the moistened trial dentures. Make certain the patient is comfortable and
adequate
there isretention.
It may be necessary to dust in a light coating of denture adhesive powder.

2. Record thevertical dimension of rest on a tongue blade using 2 reference points with the wax trial
dentures in patient's mouth. One point should be placed on the tip nose
of theand another on the tip of the
chin, as described previously. Insert the trial dentures and record vertical
the dimension of occlusion.
Compare this measurement with the vertical dimension of rest. It should be about 1 - 4 millimeters less
than rest vertical dimension. Confirm there is an interocclusal "freeway" space with both trial denture bases
in the mouth.

3. Observe the patient at rest and when swallowing. The patient should swallowunstrained
in an manner
and there should be a slight shortening of the face as the patient goes through the act of swallowing from
rest vertical to tooth contact.

4. Ask the patient toread, speak,or count rapidlyfrom sixty to seventy, and to raise his finger every time
there is tooth contact during speech. Should there be any tooth contact, ask whether or not contact occurs
with the anterior or the posterior teeth. Posterior tooth contact may indicate a need to decrease the vertical
dimension of occlusion. Anterior tooth contact does not necessarily indicate a need to reduce vertical, but
may indicate faulty positioning of the anterior teeth such as inadequate horizontal or vertical overlap.

5. The vertical dimension of occlusion is excessive if the teeth touch during speech,
lowing
swalis difficult,
the face appears strained, the lips cannot readily contact or there
no space
is between the upper and lower
posterior teeth when the patient is relaxed. To correct
this problem:

a) Estimate the amount of closure necessary.

b) Place the trial dentures on your articulator.
c) Raise the pin to the extent you feel will properly reduce the vertical dimension.
d) Gently heat the wax around either the upper or lower posterior teeth with your torch (usually
the upper if the mandibular teeth are set to occlusal planemarks)land until the wax is
slightly softened.
e) Close the articulator to incisal pin contact.
f) Straighten out deranged teeth, smooth the wax and try again. Repeat until there is an
adequate interocclusal space.

6. If the space between the teeth seemsexcessiveduring speech or as measured on the tongue blade, the
incisal guide pin is opened to the estimated amount of correction. The wax is warmed and the teeth are then
reset to contact at the new, increased VDO level.

EVALUATING AND PROVING CENTRIC RELATION:

1. Instruct patient to hold the lower jaw in a relaxed manner. Place your forefinger
lightly on the chin and
ask the patient to tap-tap on the posterior teeth. Note the interdigitation of theCarefully
teeth. observe any
shift of the upper denture
other than the slight movement of the dentures after first contact.

2. M ake an interocclusal record.You shoulduse ISO compound(or Bite Registration Paste) to prove
registration records. Do not use flexible materials (polyvinylsiloxane,foretc.)
dentures.

a) Rehearse the patient in closing to the most retruded, unstrained position (RCP) just
short of tooth contact. Stablize the mandibular trial denture base
with your forefingers on the buccal area of the mandibular denture and your thumbs under
the mandible. Do not vibrate or pushon patient's mandible!

b) Place two 1" pieces of ISO compound in the water bath°Fat(use

110the ther
mometer to get
the correct temperature). Place the compound on the mandibu lar, posterior occlusal
surfaces.

c) Have the patient close gently into the compound, as rehearsed and to the retruded
most
position, just short of tooth contact. Stabilize the mandibular base
with your forefingers on the buccal denture area and your thumbs under the mandible.
Maintain this position while quietly encouraging patient to relax rest
and (Fig. 43).

3. When thecompound has hardened, remove the trial dentures from the mouth.Trim the recordwith a
very sharp knife until
only the occlusal indentations
of the upper teethremain (Fig. 44).

Fig. 43. Stabilize the mandibular den
ture with your index fingers and thumbs. The
patient should make the retruded closure,
relaxed and short of tooth to tooth contact.
Fig. 44. The modeling compound
retruded record is hardened in cool water and
trimmed with a sharp scalpel so that only
occlusal indentations remain. This record is
used to confirm the articulator mounting or to
make a new remount.

4. Place the dentures on the articulator and gently close the instrument.
If the maxillary teeth contact the
indentations exactlyas they did in the mouth, you have proven that your original centric record was
correct. The articulator must close in the hinge position without
condylar displacement.
5. If two or more registrations indicate thatmounting
the is not correct, remount
the lower cast, using one
of the new records which was verified in the mouth. Then performfollowing
the steps.

a) Carefully separate the lower cast from its mounting.

b) Wet the cast and seat the new record on the upper teeth. While inverted, sticky wax the
dentures together. Use the mandibular remount jig to hold the articula
tor upside-down
while the lower cast is being reattached with plaster.
This is alaboratory procedure to be
done in the lab not in the clinic!

6. When the mounting plaster has set, make a new pair of records in the mouth and compare on the
articulator. If the new mounting cannot be proven, it must be incorrect.
a pair
Useof records that seem
more correct, remount, and recheck until the mounting is proven.

PROTRUSIVE RECORD:

Prior to this point, we have used the articulator in its centric relation position only. Since are now
we
reasonably certain that our mounting is accurate, we can record the condylartions inclina
(protrusive
record), mark the postpalatal seal area, and finalize the anterior andrior
poste
teeth arrangements.

Make a protrusive jaw position record so that you can set the articulator's condylar inclina
tions. Practice
the required movement with the patient before making the record. Warm another pair of ISO compound one
inch sticks in the 110 °F water bath. Place your recording medium on the occlusal surfaces of the
mandibular posterior teeth. Stabilize the mandibular denture as was done for the centric relation record.
Ask the patient to move the mandible forward to an edge to edge relationship and close, short of tooth
contact. Keep an eye on a midline reference point to see that the patient is making a straight protrusive
rather than a lateral protrusive movement. The patient must make a forward movement of the mandible of
4-6 mm.Replace the bases on the articulator and
set the condvlar elements.(Fig. 45, 46).

Fig. 45. The operator stabilizes the
mandibular denture. The patient moves the
mandible 4-6 mm forward and closes into soft
compound, short of tooth contact. Have an
assistant cool the compound with the air sy
ringe.
Fig. 46. The condylar elements are set
with the protrusive record. Set the articulator
on a hard, stable surface. Use one hand to
press in the center of the articulator. Cast,
record bases, and the record must not move.
Rock each condylar element gently to deter
mine the setting.

ESTABLISH THE POSTPALATAL SEAL

The posterior palatal seal is placed for two reasons. Shrinkage of the acrylic resin across this area results in
a space during processing. Secondly, a small amount of tissue displacement
is needed in order to maintain
denture tissue contact during small denture movements,cially
espe after the palatal glands have emptied
(impaired retention).

The post-dam (posterior palatal seal) area of the palate

palpated,
is using the round edge of your
mouth mirror to determine the compressibility of the mucosa in the
dianme
suture area and across
the bilateral posterior palatine gland areas.

The posterior border of the denture was marked on the stone cast. If this has not been done, transfer
the vibrating line to the base and then to the cast by the procedure earlier described for the tentative
jaw records appointment.

Draw a line on the cast 1 mmanterior to the posterior extension of the denture. Draw second
a line
anterior to the first in butterfly
a patternas illustrated. The butterfly pattern should go around the
anterior portions of the bilateral gland beds but should not be on a torus nor on the tuberosities. A
bead seal on a torus will cause acute pain and tissue ulceration. A bead seal on a tuberosity will
cause rebound of the denture and premature second molar contact (the tuberosity cannot be even
slightly displaced in contrast to the palatal gland areas).Carve the sealswith the cleoid-discoid
instrument using thecleoid end.The grooves should be 1 mm deep,feathering out in thehamular
notches (Fig. 47).

Fig. 47. The most posterior line and end

of denture indicates the vibrating line as de
termined in the patient's mouth using the
record base and marking stick. The first bead
seal is cut into the cast 1-2 mm forward of
vibrating line. The second seal is cut to go
around the gland areas and avoid any torus
or bony midline.

ESTHETIC EVALUATION:

The teeth may require at least a partial resetting if the centric relation records require a remounting
of the mandibular cast. This must be done before the patient can be engaged the final
in esthetic
adjustments, refinements, and approval.
Another appointment may be needed if extensive teeth resetting and
festooning are required. Waxing and festooning must be very close to the final denture contours so the
esthetic approval is fair and valid. Waxing festooning,
and as well as the teeth, affect esthetics and
phonetics.

Evaluate the facial support, esthetics and phonetics. Patient should be able to make clear and"F"
"V"
sounds with maxillary incisal edges against the lower lip. There should be no ing""hiss
or air loss in
speech including the "S" and "Z" (sibilant) sounds. Evaluate midline and occlusal plane, left to right and
anteroposteriorly. Is the smile line and anterior tooth display appropriate? Can patient speak without
anterior or posterior teeth "clicking" (touching)? Evalu
ate occlusal plane, a critival factor for function and
esthetics. The lateral tongue borders should be slightly above the mandibular teeth. An occlusal plane too
low will result in exces
sive tongue biting, too high will result in food entrapment in the buccal corridor.

You now have made all the major changes in tooth positions. You can now theclean
trial
updenturesso that
you, the patient andhis or her principal critic,together with your instructor, can evaluate patient's
appearance.It is important that the dentures be seen at their best.
(Fig. 48)

Fig. 48. Centric relation record has been

made and proven and condylar settings deter
mined. Vertical dimension of rest and occlu
sion are appropriate. Postpalatal seal has been
indicated. The wax trial dentures are now ready
for final esthetic and phonetic adjustments, criti
cal festooning, and the patient's approval.

Fig. 49. The wax trial dentures must be

approved by the patient. The waxed dentures
should be a realistic representation of how
the final dentures will look.

When you are satisfied that you have done your very best, remove the patient's napkin and take
him or her to a big mirror. Have patient stand about four feet from the mirror while
discuss
youhis
appearance. Get patient to talk and smile while looking at himself or herself. Discuss possible
changes either you or the patient feel might be appropriate. Make tions
correcas necessary until
everyone feels that the dentures look their best (Fig. 49).

Complete the wax-up being careful remove

to all wax from exposed coronal tooth surfaces.
Carefully festoon and stipple the wax surfaces for best esthetic and hygienic results.
tooning
Fes
will affect esthetics and lip support. You should have second
a confirmation tryinwith
completely waxed andfestooned setup for patients that are critically concerned with
appearance.The patient deserves to see and evaluate what will actually be delivered.

Obtain the patient's signatureon the prosthodontic form that indicates patient approves the
appearance. Remind patient thatchangesin teeth after the dentures are processed
are difficult
and will require a substantial
extra cost.