COMPLETE DENTURES FOR THE GRADUATE STUDENT IN PROSTHODONTICS

1996 REVISED 2005

James S. Brudvik
Professor Emeritus Graduate Prosthodontics University of Washington

TABLE OF CONTENTS
INTRODUCTION ____________________________________________________________________7 1. EVALUATION OF THE PATIENT ___________________________________________________9 1.1 PATIENT'S CHIEF COMPLAINTS _________________________________________________________9 1.2 EVALUATION OF EXISTING DENTURES/CRITICAL DECISION AREAS ______________________________9 1.3 DIAGNOSIS/PROGNOSIS _______________________________________________________________9 1.4 PATIENT LETTER/INFORMED CONSENT __________________________________________________10 1.4.1 Treatment options _____________________________________________________________10 1.4.2 Time requirements _____________________________________________________________10 1.4.3 Cost of care __________________________________________________________________10 1.4.4 Follow-up care________________________________________________________________10 1.4.5 Prognosis ____________________________________________________________________11 2. RESTORATION OF EXISTING DENTURES (TEMPORARY) __________________________14 2.1 2.2 2.3 2.4 TISSUE CONDITIONING ______________________________________________________________14 BORDERS ________________________________________________________________________15 OCCLUDING VERTICAL DIMENSION (OVD) _______________________________________________15 CONTACT IN CENTRIC RELATION (CR) __________________________________________________15

3. TOOTH SELECTION _____________________________________________________________17 3.1 PHILOSOPHY ______________________________________________________________________17 3.1.1 Timing ______________________________________________________________________17 3.1.2 Patient Involvement ____________________________________________________________17 3.2 ANTERIOR TEETH __________________________________________________________________17 3.2.1 Molds _______________________________________________________________________17 3.2.2 Shades ______________________________________________________________________18 3.3 POSTERIOR TEETH __________________________________________________________________18 3.3.1 Molds _______________________________________________________________________18 3.3.2 Shades ______________________________________________________________________18 3.3.3 Cusp forms ___________________________________________________________________18 4. IMPRESSIONS ___________________________________________________________________19 4.1 PRELIMINARY _____________________________________________________________________19 4.1.1 Utilizing existing dentures _______________________________________________________19 4.1.2 Alginate impressions ___________________________________________________________20 4.1.3 Outline drawing _______________________________________________________________20 4.1.4 Pouring the preliminary impression _______________________________________________20 4.2 FINAL ___________________________________________________________________________21 4.2.1 Tray construction______________________________________________________________21 4.2.2 Border molding _______________________________________________________________21 4.2.3 Final wash impression__________________________________________________________22 4.2.4 Posterior palatal seal __________________________________________________________23 4.3 BOXING/POURING CASTS _____________________________________________________________23 4.3.1 Materials for boxing ___________________________________________________________24 4.3.2 Dental stone and pouring _______________________________________________________24 4.3.3 Cast trimming ________________________________________________________________24 5. RECORD BASES AND OCCLUSION RIMS __________________________________________24 5.1 MATERIALS/TECHNIQUES ____________________________________________________________24 5.1.1 Auto polymerizing _____________________________________________________________24 5.1.2 Processed base________________________________________________________________25 5.1.3 Metal base ___________________________________________________________________26

5.2 OCCLUSION RIM ___________________________________________________________________26 5.3 SPECIAL EFFECTS __________________________________________________________________26 5.3.1 Rim handles __________________________________________________________________26 5.3.2 Wax cone ____________________________________________________________________26 5.3.3 Tooth inserts _________________________________________________________________27 6. CENTRIC JAW RELATION RECORDS _____________________________________________27 6.1 VERTICAL DIMENSION DETERMINATION _________________________________________________27 6.1.1 Definition____________________________________________________________________27 6.1.2 Face height __________________________________________________________________27 6.1.3 Speaking space _______________________________________________________________28 6.1.4 Resting vertical dimension ______________________________________________________28 6.2 CENTRIC RELATION ________________________________________________________________28 6.2.1 Definition____________________________________________________________________28 6.2.2 Training _____________________________________________________________________29 6.2.3 Recording ___________________________________________________________________29 6.3 FACE BOW RECORD _________________________________________________________________30 6.4 ARTICULATOR MOUNTING ___________________________________________________________30 6.5 PROVING THE RECORD/MOUNTING _____________________________________________________30 7. TOOTH POSITIONING ___________________________________________________________30 7.1 PHILOSOPHY ______________________________________________________________________31 7.1.1 Esthetic evaluation ____________________________________________________________31 7.1.2 SPA Factors (Sex/Personality/Age)________________________________________________31 7.1.3 Patient's preference ____________________________________________________________31 7.1.4 Incisal guidance ______________________________________________________________32 7.1.5 Plane of occlusion _____________________________________________________________32 7.1.6 Food table ___________________________________________________________________32 7.1.7 compensating curve/cusp height __________________________________________________33 7.1.8 Occlusal relationships __________________________________________________________33 7.2 TECHNIQUE FOR THE PLACEMENT OF ANTERIOR TEETH _____________________________________33 7.2.1 Cast diagnosis and marking _____________________________________________________34 7.2.2 Midline marking ______________________________________________________________34 7.2.3 Tooth preparation _____________________________________________________________34 7.2.4 Maxillary central incisor ________________________________________________________34 7.2.5 Maxillary incisors _____________________________________________________________35 7.2.6 Mandibular central incisor ______________________________________________________35 7.3 TECHNIQUE FOR POSTERIOR TEETH _____________________________________________________36 7.3.1 Four bicuspid placement ________________________________________________________36 7.3.2 Mandibular posterior placement__________________________________________________36 7.3.3 Maxillary posterior placement ___________________________________________________36 7.3.4 Cross-bite ___________________________________________________________________37 7.3.5 Working side contacts __________________________________________________________37 7.3.6 Balancing side contacts_________________________________________________________37 7.3.7 Protusive contacts _____________________________________________________________38 7.4 WAXING _________________________________________________________________________38 7.4.1 General contours______________________________________________________________38 7.4.2 Interproximal contours__________________________________________________________38 7.4.3 Palatal and lingual contours _____________________________________________________39 8. CLINICAL TRY-IN _______________________________________________________________39 8.1 EVALUATION OF VERTICAL DIMENSION OF OCCLUSION______________________________________40 8.2 RECORDS ________________________________________________________________________40 8.2.1 Check record _________________________________________________________________40 8.2.2 Protrusive record _____________________________________________________________41

8.3 FINAL EVALUATION ________________________________________________________________41 9. PROCESSING/FINISHING_________________________________________________________41 9.1 9.2 9.3 9.4 9.5 FINAL TOOTH POSITIONING ___________________________________________________________42 FINAL WAXING ____________________________________________________________________42 INVESTING _______________________________________________________________________42 DENTURE BASE TINTING _____________________________________________________________43 FINISHING AND POLISHING ___________________________________________________________43

10. INSERTION_____________________________________________________________________43 10.1 TISSUE-BASE RELATION ____________________________________________________________44 10.2 PATIENT REMOUNT PROCEDURES _____________________________________________________45 10.3 PATIENT INSTRUCTIONS _____________________________________________________________45 11. POST-INSERTION ISSUES _______________________________________________________46 11.1 11.2 11.3 11.4 SORENESS _______________________________________________________________________46 INADEQUATE RETENTION ___________________________________________________________47 PROBLEMS IN MASTICATION _________________________________________________________47 SPEECH _________________________________________________________________________48

12. SPECIAL TOPICS IN COMPLETE DENTURES _____________________________________48 12.1 12.2 12.3 12.4 12.5 12.6 12.7 OVERDENTURES __________________________________________________________________49 METAL BASES____________________________________________________________________50 RESILIENT LINERS _________________________________________________________________52 METAL OCCLUSAL SURFACES ________________________________________________________53 MAXILLARY SINGLE DENTURES ______________________________________________________53 RELINES/REBASES _________________________________________________________________55 TEMPORARY DENTURES ____________________________________________________________57

13. IMMEDIATE DENTURES ________________________________________________________58 13.1 13.2 13.3 13.4 CONVENTIONAL IMMEDIATE DENTURES ________________________________________________59 INTERIM ________________________________________________________________________59 TRANSITIONAL ___________________________________________________________________60 SURGICAL STENT _________________________________________________________________61

14. IMPLANT-SUPPORTED/RETAINED COMPLETE DENTURES _______________________61 14.1 EVALUATION OF CURRENT DENTURES__________________________________________________62 14.2 RADIOGRAPHIC AND SURGICAL STENTS ________________________________________________63 14.3 DENTURE WEAR DURING IMPLANT HEALING _____________________________________________64 14.4 ALTERATION OF THE DENTURE AT STAGE TWO SURGERY ___________________________________65 14.5 FINAL IMPRESSIONS FOR IMPLANT-SUPPORTED COMPLETE DENTURES _________________________65 14.6 POURING THE FINAL IMPRESSION _____________________________________________________66 14.7 CONSTRUCTION OF A BAR AND CLIP MECHANISM AND ITS HOUSING ___________________________66 14.8 TRY-IN OF THE BAR ________________________________________________________________68 14.9 CONSTRUCTION OF THE RESIN HOUSING ________________________________________________69 14.9A CONSTRUCTION OF A METAL HOUSING ________________________________________________70

INTRODUCTION

This manuscript is intended to supplement the standard syllabi and texts currently used in undergraduate courses. Complete, immediate and implant dentures treated by specialists are often far more complex than those found in the general practice of dentistry and require modifications of philosophy of care as well as of techniques and materials. The thoughts here expressed originated during the Viet Nam conflict where the need to construct a complete denture in one day forced this author and Dr. John Wormley (Col. USA RET), to reevaluate standard techniques and materials to reduce treatment time to the absolute minimum without sacrificing quality. In the following 40 years, these techniques have been modified to suit the demands of a specialty private practice in prosthodontics. Our philosophy of care and the standards we set were based on reviewing every component of the construction of complete dentures and evaluating every step of treatment without regard to established techniques. Wherever possible, scientifically valid studies were reviewed and their results given preference over techniques and materials derived from personal anecdotes. The manuscript is intended to challenge readers to think for themselves at every decision point accompanying the construction of complete and immediate dentures. Only those areas requiring critical decision-making will be addressed. Many of the techniques currently used in standard denture construction will be applicable to even the most complex and demanding patient. The specialist is obligated to treat all patients, and especially complex patients, with dentures that are superior to those expected from the general practitioner. To that end this manuscript is dedicated. Knowing the answer may not be as important in the final analysis as knowing the question!

1. EVALUATION OF THE PATIENT 1.1 Patients chief complaints. When examining patients and their existing dentures, the clinician almost always feels that improvements can be made. The question that must be answered is, "Will the new prosthesis result in a treatment that the patient will perceive as being an obvious improvement in function, esthetics or the preservation of tissue?". If the response to this question is negative, then the acceptance of the patient for treatment should be very seriously considered. This question leads to an analysis of the patients chief complaint(s). Great emphasis must be given to the complaint, even if it does not appear to have clinical merit. The patient will not be satisfied with a new prosthesis if it perpetuates a condition that the patient saw as being unacceptable. In some cases, it will be necessary to inform the patient that it will not be possible to achieve the desired result. In these situations, the patient letter (informed consent document) must address the issue in full. 1.2 Evaluation of existing dentures/critical decision areas. Thorough evaluation of patient history and tissue health is obviously necessary and required both by law and the standards of care. Critical decision areas (CDA's) are: Does the soft and/or hard tissue need conditioning of any sort before construction begins and is that conditioning possible for that particular patient? Ex.: Orthognathic surgery may produce an ideal jaw relationship but may be beyond the patients financial possibilities. Is the current denture(s) adequate? Border coverage, tissue-base relations, retention and stability, occluding vertical dimension, esthetics, occlusal form and contact in centric relation must each be evaluated and a decision made on whether these conditions require pretreatment correction. Ex.: Should a greatly over closed vertical dimension of occlusion be corrected with a resin addition or overlay to evaluate the patients ability to adapt to a more normal dimension before construction begins? Can the patient make the required jaw relation movements with ease or must he be taught to assume centric relation and to practice getting to that position? Can the patients expectations be met? If the expectations are unrealistic, then either they must be modified or care should not begin. 1.3 Diagnosis/prognosis. The establishment of a diagnosis for both the patients complaints and the existing dentures (if appropriate) is essential for the development of a prognosis. The prognosis is the patients principle concern. Not only must the prognosis be clearly stated to the best of the clinicians ability, but the patient must have the opportunity to question this prognosis and to have his questions addressed.

1.4 Patient letter/informed consent. The patient letter should contain references to the following categories (where appropriate) in whatever order seems logical for the specific case. With the advent of the office computer, the development of a wide range of letters and specific paragraphs is simple and efficient. Definitive treatment should never be undertaken without a treatment letter/informed consent document. 1.4.1 Treatment options. All reasonable treatment options must be included even though, for example, it may be obvious from the initial examination that the patient may not be able to afford a certain treatment. The clinician has little, if any, legal response to the patient who claims that, "the dentist never told me about that possibility. 1.4.2 Time requirements. A review of the proposed treatment time is essential to the patients informed consent. The patients should never be told that a treatment will take X number of appointments. Instead, they should be informed that results of the highest quality often require that certain procedures be redone when complications arise and that the clinician will not sacrifice quality for expediency. It is possible to give a general timetable once the patients accept that caveat. 1.4.3 Cost of care. The fee presented should always be modified with the statement that it will change if the treatment plan must be changed, either for technical reasons or to fulfill the patients needs. Any changes will require a supplemental treatment letter breaking down treatment costs. Any charges relative to the discontinuation of care, should the patient and the clinician find the relationship unacceptable, must be included as well. 1.4.4 Follow-up care. To avoid unpleasant confrontations during post-insertion care, both the time for which adjustments will be made without charge and the amount of charges for care after that grace period must be specified as a part of informed consent. Structural failures present a more complex situation for the clinician since the patient has every right to expect structural integrity for some specified period of time. On the other hand, the clinician cannot be expected to repair dentures for an unlimited time.

10

1.4.5 Prognosis. A complete prognosis usually contains an overall prognosis and one or more specific prognoses. For example, the overall prognosis might be fair for overdenture therapy but guarded for one of the abutments. The general categories to be considered are poor, guarded, fair, good and excellent (or some similar hierarchy). It may well be that a prognosis that is conservative in nature will provide the best basis for care. EXAMPLE LETTER Sven Swenson 200 James Street, #101 Edmonds, WA 98020 Chart #267539 Dear Mr. Swenson, Thank you for coming to the University of Washington Graduate Prosthodontic Clinic for treatment. Following your clinical examination, I have prepared a summary of my findings and an outline of your treatment needs. An estimate of the cost of your treatment is included. The findings are as follows: Your present dentures are over 20 years old and no longer stay in your mouth when you laugh or cough. Many of the denture teeth are cracked and worn. You have a number of ulcerated areas under your dentures that are causing you pain at the present time. You have been wearing your dentures 24 hours a day and as a result have a chronic denture sore mouth with generalized inflammation under the dentures. You have lost considerable bone support in the lower jaw since the current dentures were made and consequently have lost vertical dimension of occlusion resulting in a collapsed look to your face. I propose the construction of new dentures for you after first bringing your mouth to a healthy state through a series of temporary relines of your current dentures. You will be asked to leave the dentures out of your mouths as much as possible until your tissues have returned to health. Treatment time for your new dentures will be approximately 3 months depending on the time required to restore the health of your tissues. You can expect an additional 4 to 6 weeks until you have fully adapted to your new dentures. Should you continue to experience problems beyond that point it is very likely that you will require the placement of an implant(s) to improve your situation. 11

Estimated Treatment Cost: (see current fee schedule) Upper denture Lower denture Total Estimated Prosthetic Fee

$600.00 600.00 $1,200.00

The above is only an estimate of the cost of the treatment to be performed by this graduate division and this total fee may vary if there are any changes during the course of treatment. Fee estimates for any procedures performed by other graduate divisions may be obtained from the respective graduate departments. On occasion, care must be obtained from specialists in private practice when the treatment cannot be performed in the Dental School. Please contact Des Apostolou, Clinic Coordinator of Graduate Prosthodontics, Room D258, (Tel.: (206)685-7522) to discuss financial policy, payment and signing of your contract. In case you get our voice mail, please leave your name, telephone number and a detailed message and Ms. Apostolou will return your call. The patient shall assume responsibility for all charges regardless of any insurance coverage. While there may be some assistance from U.W staff in obtaining a pretreatment estimate from an insurance plan or in filing insurance claims on behalf of the patient, these services are offered as a courtesy only. Patients are responsible for knowing the limitations of their coverage and managing any inquiries or disputes that may arise between themselves and their insurance carriers. The Graduate Program will assume responsibility for maintenance of the prosthodontic portion of your treatment for a period of two years* from the date of final placement of the restorations. This assumption will, however, require that you follow all post-insertion instructions and make yourself available for follow-up appointments. I hope that I will be able to complete your care myself, but in the event that your treatment extends beyond my three years here, the director may find it necessary to transfer you to another student for completion. I will do my utmost to provide you with the best possible care. I look forward to treating you. If you should have any questions, please feel free to contact me at 685-1092. Sincerely,

_____________________________ James Dean, DDS, Student Graduate Prosthodontics

______________________________ Ariel Radgrowski, DDS, MS, FACP Director Graduate Prosthodontics

I have read this letter and understand the treatment proposed. I wish to begin this course of care and agree to the terms stated. I realize that I have treatment options and that I

12

have had the opportunity to ask for an explanation of any aspect about which I have questions. I assume responsibility for all charges regardless of any insurance coverage.

_____________________________ Sven Swenson, Patient

_______________________________ Date

*Actual length of time to be determined by the Director.

13

2. RESTORATION OF EXISTING DENTURES (TEMPORARY) Are the deficiencies in the existing denture so obvious that they are outside the limits of current standards of care? Can the existing denture be modified to acceptable contours, adequate tissue-base relations, and uniform contact in centric jaw relation at a reasonable occluding vertical dimension? Does the patient understand the need to modify his old denture and will he permit this procedure knowing that it may be irreversible? It has been said that one should correct what is wrong, at least superficially, with existing dentures before beginning construction of new dentures. Practically, this implies correction of major discrepancies, i.e., very short borders, grossly over closed occluding vertical dimension, poor tissue-base relations with instability and lack of retention, and major anterior slides of the lower denture with closure. One can also expect an increase in stability and retention as a side effect of the tissue conditioning. 2.1 Tissue conditioning. If plasticized materials are to be added to the existing denture, it must be with the patients consent as the procedure is often irreversible. Short-term analysis of restored uniform internal contact and border extension can be done with the addition of an elastomeric impression material in the denture without adhesive. If a material such as Lynal is to be used, space must exist for the material to be effective. Determination of the space existing internally is difficult without introducing some material into the denture. Ex.: One scoop of alginate combined with a double measure of hot water will result in a mixture that will fill the existing space internally with minimum tissue displacement and, because of the hot water, set quickly. The resulting layer of alginate can indicate where space exists and at what thickness as well as where there is no space for a tissue conditioning material, where space must be created before placing the liner. An absolute minimum of 2 mm's must be available for any tissue conditioning liner. Studies on the flow of tissue conditioning materials indicate that the duration of the flow is brief. The amount of tissue improvement from the flow of the material is probably small. A more significant effect results from having the denture supporting tissues in full contact with a resilient base. The optimum effect of this tissue contact will come when the material is introduced into the mouth after the denture has been out of the mouth for a reasonable period of time, (overnight or, better yet, after the weekend), and after the patient has massaged the tissues with his toothbrush or finger as suggested by Bolender. It is recommended, therefore, that the patient be instructed to leave the denture(s) out of the mouth overnight and to come first thing in the morning to have the tissue conditioning material placed. For optimum results, this procedure will be repeated each time the

14

conditioning material is replaced. Experience has shown that the time for a return to health is reduced with this regime. For long-term wear of a Lynal-like material, the denture should be placed in a pressure pot with warm water at 20 psi for 10 minutes. It will then be possible to trim and polish the borders using slow speed on the dental lathe with very wet pumice without burning or otherwise distorting the material. One can expect edema, inflammation and Candida infection to be reduced in the patient free of systemic disease within 3-4 weeks of this regime. When the response is poor, systemic disease, nutritional disorder, local infections or poor compliance must be suspected and the decision to begin treatment questioned. 2.2 Borders. The clinician must attempt to see all of the existing denture space, first with the old dentures out of the mouth, and then with the dentures in place in order to determine the adequacy of the border extensions. By placing photographic cheek retractors in the mouth and spreading the cheeks, the denture space can be easily identified, with the exception of the retromylohyoid space. If the existing borders are within 2-3 mms of the obvious denture space, then the existing denture makes the ideal initial impression tray (see preliminary impressions). One can expect to extend the borders to their optimum position with the tissue conditioning material. The patients ability to tolerate extension into the retromylohyoid space is best evaluated with a reversible procedure. 2.3 Occluding vertical dimension (OVD). As one would expect, the vertical dimension of occlusion in the old denture will often be over closed, generally through wear and/or resorption of the mandible, although original construction will often bear at least a portion of the blame. Again, one can expect the tissue conditioning material to increase the OVD from 2-3 mms. Beyond that point, stops will need to be placed in the denture at some determined dimension before the tissue conditioning material is placed. Green Stick compound makes an ideal stop material as it is inexpensive and, properly conditioned, will have sufficient body to support the increase in the vertical dimension. Four stops of compound are softened in the flame and placed into the dried lower denture in the area of the cuspids and second molars. The patient is guided into centric relation and is told to close lightly until the appropriate face height is established. The stops are then trimmed to a band of 2-3 mms in width and extending from border to border. Both the OVD and the contact in centric relation must be verified after trimming and before the tissue conditioning material is added. After the required setting in the mouth, the denture should be placed in the pressure pot in warm water for 10 minutes at 20 psi. Should the tops protrude through the conditioning material, they can be relieved and additional conditioning material placed. The borders can then be polished at slow speed with copious amounts of wet pumice. 2.4

15

Contact in centric relation (CR). When there is a major discrepancy in centric relation, a decision must be made as to whether the occlusion can be adjusted by spot grinding or whether the occlusion must be modified with an actual rebuilding of the denture teeth. The most logical way to make this decision is to remount the dentures on the articulator after the dentures have been stabilized with the tissue conditioning material. If the conditioning material has been cured in the pressure pot, one can safely construct remount casts without distorting the conditioner. A patty of fast set plaster is placed upon a glass slab and the denture set into the plaster to just cover the majority of the denture borders. As soon as the plaster has become firm, (3-5 min), the denture is removed from the base, leaving the border impression, while any excess plaster that might have been in an undercut breaks away. 3-4 minutes after the material has set, the base can be removed from the slab and the remount procedure completed. A face bow may be used to position the master cast although, for the purpose of this evaluation and possible revision, any error introduced by using an arbitrary mounting will be of no clinical significance. Centric relation records must always be made as near to the vertical dimension of occlusion as possible. If the OVD has been re-established with the tissue conditioning material, then only one thickness of Aluwax should be used to record centric relation. If the occluding vertical dimension is over closed, then sufficient wax must be used to allow the record to be at the ideal OVD. Once the dentures have been remounted, the evaluation process begins with the decision as to whether the desired result can be obtained through equilibration of the denture teeth. If this is not possible, then consideration must be given to removing and repositioning the teeth or to adding tooth-colored resin to the occlusal surfaces of one arch (usually the lower), assuming that the old teeth were of resin. In the short term, simply grinding the occlusal surface to a flat plane and adding resin (Jet or similar) and closing the articulator to the appropriate OVD once the resin has lost its sheen will allow a restoration of occlusion at centric relation. The resulting tooth surfaces must be reshaped and sluiced to approximate normal occlusal contour. If the old denture has porcelain teeth, they can easily be removed from the lower arch by heating them with the alcohol torch and prying the hot tooth out of the base with an instrument. They may then be replaced with tooth colored resin at the new vertical dimension. Should the patient be severely overclosed ( > 8mm) an onlay for the mandibular denture can be made by lubricating the existing denture teeth with Vaseline or a similar separating agent before the tooth colored resin is added to the lower teeth, which have not been touched, to include the incisors. Once the resin onlay is fully cured it is removed , trimmed and attached to the existing teeth with small additions of resin scattered around the arch. The patient can now use the denture for mastication at the new and hopefully acceptable occluding vertical dimension.

16

Should the patient find that an adaptation to the increased OVD cannot be made and decides to abandon treatment then the onlay can easily be detached by grinding the attaching spots and returning the denture to its original dimension and occlusal relation. 3. TOOTH SELECTION Will the current dentures require changes in tooth selection, either mold or shade, to conform to the patients desires and/or the clinicians intuition? Can the clinician imagine the appearance that might be created for this patient? Will denture teeth have to be dramatically modified to create a lifelike appearance? Will the patients esthetic demands compromise the proposed treatment? 3.1 Philosophy 3.1.1 Timing. While the selection of the denture teeth for the new denture can be made at any time, it is a distinct advantage to make the selection as early as possible in the construction. The most ideal moment is at the impression appointment (either preliminary or final). Selection at this point permits the patient to view the teeth before the jaw relation appointment and allows an exchange if required. Should there be any doubt as to the appropriate shade or mold or even manufacture of the teeth, the clinician will order a number of different tooth combinations so that the final selection can be made with the patient when the actual teeth are present. 3.1.2 Patient involvement. If the subject of tooth selection is addressed at the first visit, the patient has an opportunity to bring photographs of natural teeth to the impression appointment. Time spent discussing tooth selection with the patient allows the clinician to evaluate the sex, personality and age aspects (SPA, see 7.1.2) of the patients dental appearance. At the very minimum, the patients comments and the clinicians evaluation of the existing denture can occur early on. When any dramatic change is contemplated, patients will generally be easier to deal with if they have had some time to think about their self-image from the aspect of dental esthetics. 3.2 Anterior teeth

3.2.1 Molds. Recent studies confirm that the anterior molds available will be smaller both in width and length than the dimensions of natural teeth. The average denture can be criticized for having anterior teeth that are too small for the patients face. Often the 17

contour of the incisal edges does not match the incisal wear that would be expected based upon the patients age. The most obvious solution to this problem is to use anterior teeth that are slightly larger than one might select at first glance and then be prepared to customize the teeth with selective reshaping. Should photos of the patients natural teeth be available, it is obvious that they should be used as a starting point. If patients have no strong opinions, it may be best to show them the anterior teeth only after they have been properly placed on the record base with appropriate wax contours. 3.2.2 Shades. Shade determination is very much a matter of the patients self image. The average patient will request a shade that is far too light for his age. A discussion of the clinicians desire to make the patient appear as natural as possible will often result in the patient at least being willing to see an appropriate shade at try-in. Since shade has no technical affect, the patients wishes should be respected in the matter of shade selection with less freedom of choice for the mold selection. 3.3 Posterior teeth 3.3.1 Molds. Again, the mold sizes available to the profession are going to be smaller in all dimensions than natural teeth. Rather than use the manufacturers recommended mold to accompany the selected anterior molds, it is appropriate to select a posterior tooth that is large enough to look real. The often-repeated supposition that a narrower posterior tooth will penetrate the food mass with less effort and greater efficiency is not born out by clinical studies. Some manufacturers provide molds with realistic root forms that are appropriate for the older patient where some recession is to be expected. 3.3.2 Shades. Shade selection of posterior teeth is not normally an issue for the complete denture patient since tooth manufacturers provide an adequate range of posterior shades. In the removable partial denture, where natural teeth are adjacent to denture teeth, the result is often a shade selection dilemma. 3.3.3 Cusp forms. The selection of the cusp form to be utilized has always been a matter of personal preference and considerable conflict. It has been said that the greater the imagined skill of the prosthodontist (or the greater the ego), the steeper the cusp form that will be chosen for all patients. It has also been suggested that if a flat or very shallow cusp form is used, a reduction in the lateral movement of the mandibular denture base may be expected. The literature does not provide much guidance since the various reports are often anecdotal and conflicting. An occlusal scheme using a relatively shallow compensating curve with lingualized occlusal contacts has become the occlusion of choice in most recent times. Certainly, the patients experience with his current dentures plays a great part in the selection. Since most occlusions (especially those using resin teeth) will be worn shallow with time, the selection of a

18

steep cusp form for the replacement denture does not make good sense, especially in the geriatric patient for whom adaptation to changes in the oral cavity is often compromised. It is generally held at this time that any occlusal form placed with care, which gives a bilateral simultaneous contact in the posterior teeth in centric relation and with a freedom in anterior contact for at least a millimeter from centric relation, will result in an acceptable occlusal scheme. Perhaps the most esthetic and simple scheme is to employ a cusped tooth for the maxillary, where its superior esthetic potential can be realized, against a very shallow or flat cusp form in the mandible in a lingualized occlusal format.

4. IMPRESSIONS Are the tissues healthy enough to impress immediately or will they require alteration? What are the appropriate impression materials for this individual patient? Can I foresee problems with the impression procedure for this patient? 4.1 Preliminary. The preliminary impression has three purposes, two of which are obvious. The impression provides us with a cast that can be used for diagnostic purposes and for final tray construction. It also provides evidence of the patients ability to cooperate with the clinician on such matters as gagging tendency, low pain threshold, talkativeness during treatment, etc. 4.1.1 Utilizing existing dentures. When the existing dentures have ideal border extensions then the most obvious means of creating a preliminary cast is to pour plaster into the denture to include the denture border roll. While this is seldom the case, the technique for doing so must be understood. If there are no undercuts in the denture base then fast set plaster can be poured directly into the denture, taking care not to bury the denture borders. Dentures with undercuts of any magnitude will obviously require a variation in technique in order to be able to remove the denture from the preliminary cast. These undercuts are best blocked out with a laboratory silicone putty that fills the undercut area and has been shaped to provide retentive contours to hold them to the cast. A fast set plaster base is then poured into the blocked out denture and allowed to set before the denture is removed. For those existing dentures that have less than ideal border extensions, the most practical means of obtaining a preliminary impression is to utilize the patients existing denture as a tray. If, on evaluation of the existing dentures, the dentures are 19

found to have adequate extensions, (with 2-3 mm of under extension), then a wash impression made with an elastomeric impression material should give borders that are very accurate and provide an excellent representation of the denture bearing area. Even if the borders are slightly shorter, a material like Impregum will extend the borders 3-4 mms. Overextensions in the existing dentures, while seldom seen, create more of a problem since reducing them would alter the patients existing denture and should only be done with the patients permission. Obviously, no adhesive should be placed in the denture. The wash material will stick quite well to a dry denture. The impression is poured in fast set plaster and recovered. The impression material is easily removed and the dentures returned to the patient. Should a denture be underextended more than the 3-4 mms., it can still be used to make the preliminary impression by adding modeling compound to the area in question, usually the retromolar segments of the mandibular denture, doing conventional border moulding to establish the desired extensions and then making the wash impression. The compound can be easily removed from the denture after recovery and those areas polished before the denture is returned. 4.1.2 Alginate impressions. The classic preliminary alginate impression has always been presented as needing to be overextended. The wisdom of this requirement can be questioned since the desired result is a properly extended final tray. Every attempt must be made to create an impression that has borders that closely approximate the desired tray extension. The use of an injection syringe to place alginate in the borders is essential for developing accurate borders. The advantage of placing 1/3 of the total amount of alginate in the mouth before placing the tray is that it reduces the need to overseat the impression tray, thereby minimizing the tendency to overextend. A secondary advantage is that, with less alginate in the tray, it can be more accurately placed in the mouth since the tray is more visible to the clinician. This procedure is especially important for impressing the distal buccal areas of the maxillary impression and the retromolar areas of the mandibular 4.1.3 Outline drawing. Since alginate always tends to overextend, it will be necessary to identify the denture bearing area and transfer the desired tray extension to the alginate with an indelible marker. Key areas, such as frenum extensions and retromolar pads, may be marked in the mouth before the alginate is made. In order to keep the marking material from washing out with saliva, the mouth must be dried with gauze and the marking lines placed, immediately followed by the impression. Once the impression is removed from the mouth and rinsed, it should be gently dried and the marked line redrawn. In areas where the outline is questionable, measurements are made, either by eye or with a perio probe, and the extension marked for the entire border. The results of this approach can be expected to be more accurate than attempting to identify border extensions on an overextended model without the patient present. 4.1.4

20

Pouring the preliminary impression. The pouring of the preliminary cast is an area where personal preference plays a greater role than science. The impression can be boxed, double poured, inverted on a glass slab, etc. These casts can be poured in either plaster or stone since their only purpose is diagnostic and as a base for final tray construction. The only real requirement is that the tongue area of the mandibular cast should be clear of excess stone to provide access for tray construction. 4.2. Final. Both materials for the final impressions and tray construction techniques are dependent upon ones philosophy of tissue placement. For denture bases that are to be made in resin, an impression that disturbs the supporting tissues minimally seems to provide satisfactory results. Metal bases require a more mucostatic impression to reduce the need for adjustments, since the distortion of the metal is minimal. Processed soft liners do best with a functional impression (to be described in section 12). 4.2.1 Tray construction. A tray made without arbitrary block out is indicated for all impression techniques. A tray made in this fashion is more apt to be retentive while the borders are evaluated. The prime purpose of the tray is to record the borders of the denture space with the secondary purpose of tissue reproduction of the bearing areas. Borders are always more important than internal fit since that quality is subject to constant change. The quality tray will therefore have borders that not only are suitably short of the desired denture extension but also are of a thickness that will support the impression material during the forming of the borders ( about 3 mms). The extension of the tray border is determined by the viscosity of the material chosen for border molding, either as a separate act or as a part of the final wash impression. Polyether (Impregum) can be counted on to extend the tray border up to 4 mm. If the border extension is short beyond this dimension then either compound or some addition of resin will be required. Should the tray borders be 2 mms short uniformly, then any of the final wash materials can be counted on to develop a proper border with a single wash impression. The tray handles must not interfere with the normal drape of the lips. In order to accomplish this, they should have the length and inclination of the teeth. A role of wax can be added to the polymerized and trimmed tray much as if it were to be used as a bite rim. This rim extends from first molar to first molar and thereby supports the lips and cheeks during the impression. The extended rim serves as an excellent means of supporting the tray bilaterally with equal pressure during the set of the wash material. The tray must be free of sharp contours but should never be polished, as the formed material provides maximum adhesion of the wash material. 4.2.2

21

Border molding. The properly extended tray does not necessarily require border molding. In fact, the goal of the preliminary impression and tray construction should be to produce a tray that requires no border molding, being uniformly short the desired amount. The only areas where problems of border determination and impression are expected are in the retromylohyoid space of the mandible. This area is often established arbitrarily and should be tested with some form of independent border molding. Either compound or heavy bodied elastomeric material can be used, with compound being favored for the more complex mouth, since it can be reformed repeatedly with heat until the desired result is obtained. After acceptance or correction of the tray borders, the soft tissue relief is cut into the tray. Areas suited for planned relief are most likely the ridge crests, any vertical wall in the anterior of the maxilla, tori, mylohyoid ridges and areas of redundant tissue in either arch. At least one hole the size of a number 8 bur is cut in the center of the palate of the upper tray. The more redundant the tissue, the greater the need for more holes and the more tray material that must be removed. These holes provide for the escape of excess wash material to minimize the distortion of soft tissue. When the anterior tissue is excessively redundant and pendulous, an opening is cut in the tray after the border molding is complete. (After the wash impression, the unsupported area is painted in with a separate mix of very fluid impression material.) The width as well as the height of the border molding material must be evaluated. If an excess of material was put on the tray, the result will often be a border that is accurate in the vertical dimension but far too wide in the horizontal. Overlooking this factor will result in a border that will require arbitrary recontouring in both the record base and the finished denture. 4.2.3 Final wash impression. The object of the final wash impression is to record the denture bearing tissue. As previously stated, if an ideal impression tray can be made with a uniform and accurate border predictably short of the desired extension, the final impression can capture both the tissue detail and the borders at the same time. In general, the selection of the material for the final wash is dependent upon the type of tissue to be impressed and the type of denture base to be constructed (see 4.2). There is a tendency to overseat final impressions resulting in pressure spots. Only experience will overcome this problem. The use of stops in the tray is not indicated since they suggest to the clinician that the tray be seated firmly until the stops make positive contact. The tissue distortion from the stops must be dealt with both in the record base and the final base. It is better to develop a touch in the placement of the final impression and to learn to take it to place slowly with a slightly rotating motion than to make a quick, direct vertical seating. This circular movement allows excess impression material to flow from the tray slowly and minimize tissue distortion. It should be obvious that the tissue to be impressed should be in an optimum state of health and should be in a resting state at the time of the impression. This is best accomplished by having the old denture fitting well with uniform occlusal contacts and then to leave that denture out of the mouth 12-24 hours before the final

22

impression is made. If the patient is unable or unwilling to leave the denture out for the prescribed period, then the minimum that is acceptable is for the patient to come in for the final impression early and to have a period without the denture in the office. Alternating hot and cold rinses and a gentle brushing with a soft tooth brush will help prepare the tissue. 4.2.4 Posterior palatal seal. A functional post palatal seal can best be created by tracing the vibrating line on the tissue, evaluating the motion of the palate when plosive sounds are made, and then reinserting the final impression and transferring the line to the impression. A line is easily transferred to a Zinc Oxide based impression material but silicone and polyurethane impression materials do not reproduce the line as clearly. When the impression is removed from the mouth, the line is redrawn and mouth temperature wax is placed in excess anterior to the line and through the hamular notches. It is tempered and then placed in the mouth under firm pressure for 1 minute. At this time, the retention and stability of the impression must be critically analyzed since the final retention will never be better than what is found at this stage. There is no good indication that a functional placement of the posterior palatal seal is superior to one arbitrarily cut into the master cast as long as the position of the seal is identical. Since the purpose of the seal is to ensure contact in the posterior palate after the stress inherent in processing the final base is released, any method that ensures this contact seems to be acceptable. As stated, the functional method does allow testing of the retention obtained in the final impression before the patient is released. Again, this functional wax posterior seal registration is easier to accomplish when using ZnOe since it sets harder than the elastomeric materials. The posterior palatal can also be created by arbitrarily scraping the master cast in the proscribed area. If clear orthodontic resin is used for the record base a line drawn on the desired posterior extension can be seen through the base and the base trimmed to that line and verified. When this approach is taken the record base should be initially overextended posteriorly to assure that the seal limit will be anterior to the base extension. Once the desired extension is obtained the cast is scored with a sharp blade at the posterior edge of the record base and the arbitrary relief created anterior to the line at a later time.

4.3 Boxing/pouring casts. The goal in boxing the final impression is to protect the border roll. Once the impression has been accepted, the outer turn of the usable border roll is marked on the impression with a felt tipped pen as a guide to the technician. The boxing material is placed at this line in sufficient width to provide an adequate land area. The boxing material of choice is the tacky caulking material, which can be reused indefinitely. Wax strips can also be used but it is more difficult to attach them to elastomeric impression materials

23

4.3.1 Materials for boxing. The former for the cast can be made with tape or with wax. It must be placed with care so that the boxing material is not disturbed. Special care must be given to the tongue space so that area does not require excessive trimming to gain access to the denture border. A mark placed on the former will indicate the desired cast thickness to reduce the need for trimming the cast base again. 4.3.2 Dental stone and pouring. Yellow stone is selected for all resin base dentures since it allows adequate strength for the mold but permits quick removal with the walnut blaster. Die stone is selected for metal base dentures since the fitting of the casting is more precise against a harder material. Stones are to be vacuum mixed and vibrated only to the point of covering the impression. Excessive vibration may lead to the dislodgment of the boxing material and the resulting leakage of stone through the former. 4.3.3 Cast trimming. A land area of 3 mms is adequate. A cast base height of 1", as measured from the deepest portion of the cast, will provide a cast of adequate strength without taking up excessive room in the flask. Care must be taken to see that the border roll is protected during the trimming. It is not possible to re-establish this vital extension once it is lost. 5. RECORD BASES AND OCCLUSION RIMS Given what I know about the patient at this point in treatment, is there one type of denture base that will be clearly superior? Have I identified all contours and dimensions for my technician? 5.1 Materials/techniques. The key to successful jaw relation records is to have the optimum fit of the denture base during the making of the records. This can be accomplished in two ways. The most obvious method is to process the final denture base as a separate step in the construction process and then to use this base for records and continue on to the final denture where the teeth and associated resin contours are processed in a second flasking. Concern for distortion that might occur with the reheating of the base has limited the use of this technique, but recent studies have shown that the amount of distortion that occurs with the addition of a minimal amount of resin will have no clinically discernible effect on the fit of the base. The more common approach is to construct a separate record base, preferably from autopolymerized resin, that will have an intimate fit and not distort during the subsequent laboratory procedures. 5.1.1

24

Autopolymerized bases. The critical steps in the construction of accurately fitting bases are associated with the management of undercuts in the denture bearing area. If there are no undercuts relative to any one path of insertion, then the base can easily be made by painting a rehydrated cast with a tinfoil substitute and sprinkling the polymer directly onto the cast and wetting with monomer (the material of choice is Caulk Ortho Resin). The goal here is to create a base that completely fills the border roll of the impression (so that the borders can be properly evaluated) and has a controlled amount of material over the ridge crest. 2 mms will be adequate for the strength of the base. To aid in removing the base without chipping the cast, an addition of resin to the base in the first molar area that extends over the land area will provide a purchase point for the removal of the base once polymerized. A lab knife can be placed under this "handle" and the base freed from the cast. Once the flash has been removed from the base it must be returned to the cast to see if distortion has occurred. If the base rocks at all it must be sectioned and rejoined with the addition of a small amount of resin. A base that is unstable is unacceptable since the clinician will never know just which side of the rock is the proper position of the base on the cast. When undercuts exist, they must be eliminated in some fashion. Undercuts of greater than 2-3 mms must be partially blocked out with wax. Anything less than this amount will be included in the base in a plasticized material, usually a resin such as Lynal, which will adhere chemically to the base. The Lynal is mixed to the consistency of peanut butter so it will not flow and placed in any remaining undercut. The orthodontic resin is immediately sprinkled on the cast and wet with monomer until the desired contour is established. If the Lynal is tacky to the touch on removal of the base, the base should be placed in warm water in the pressure pot for a few minutes to set the resin. Any wax remaining on the cast should be removed before the base is completed and the fit evaluated. 5.1.2 Processed base. The processed base is waxed to fill the peripheries and to bring the palate to final contours. An evaluation of the existing space between the teeth and the ridge should be made so that the amount of wax over the ridges and under the teeth will require only a minimum of additional wax to complete the wax-up on the finished base. By keeping the addition of resin for the second curing to a minimum, the distortion that might occur from bringing the base up to the curing temperature will be slight. As a very minimum, one sheet of baseplate wax must be present over the ridge. A finishing line must be established both buccally and palatally or lingually in such a position that a normal contour can be developed when the teeth are added to the base. The finishing line can be made by laying a bead of 18 or 16 ga wax to the desired outline and then blending in the base contour to the line. The base is then sealed to the cast and processed in the denture base resin of choice. The occlusion rim is added to the processed base in the same fashion as with the auto polymerizing resin base.

25

5.1.3 Metal base. Metal bases for complete dentures offer many advantages over those made of resin. Since there is an additional cost involved, their use is generally restricted to patients for whom more strength is required or when minimal space exists for the denture (usually in maxillary dentures opposing natural or reconstructed mandibular dentitions). Additional advantages include heat transfer and improved retention due to the very minimal distortion that is found with the metal casting (see 12.1). 5.2 Occlusion rim. The standard wax rim can be placed on any of the aforementioned bases. In order to reduce laboratory procedures at chairside, a decision on the incisalgingival length of both the maxillary and the mandibular rims is determined by an evaluation of the old dentures. The desired height of rim should be recorded and prescribed to the technician so that a very minimum of wax recontouring at the chair is necessary. For the jaw registration technique described in this syllabus, the maxillary rim should be made to extend 2 mms beyond the upper lip at rest and extend posteriorly to the area of the mesial of the second molar. The mandibular rim will be of such a height that the occluding vertical dimension of the combined rims will be 5-8 mms over closed. If these dimensions are used, there will be no need for any wax recontouring at the jaw relation appointment. The facial contours of both rims must be placed to support the lips as with any standard technique. 5.3 Special effects 5.3.1 Rim handles. Perhaps the most difficult task in the making of a centric jaw relation record is to maintain the lower base in place while guiding the patient into an unstrained hinge closure. This procedure is complicated by the fact that the routine mandibular record base and rim have no horizontal area on which the clinician can place the index fingers to position the rim. The addition of a bilateral platform made of wax that attaches to the rim buccal to the area of the 1st-2nd bicuspid will provide excellent stabilization for the rim. The dimensions of this platform will be no greater than 8 x 10 mm so as not to interfere with the border contours. The index fingers are placed on the "rim handles" to stabilize the rim as the patient's mandible is retruded gently with the thumbs placed below the chin. In this manner, the risk of a distal movement of the record base during the registration is small. 5.3.2 Wax cones. The most common method of establishing the occluding vertical dimension is to repeatedly trim the wax of the rims until an acceptable dimension is obtained. This can be a lengthy procedure and is unnecessary. Since the vertical dimensions of the occlusal rims are planned to be 5-8 mms closed from the optimum OVD, the quickest and most accurate means of establishing the desired dimension is to place a wax cone on the lower rim in the midline. The cone will have the dimensions and form of the tip of a common lead pencil and will be of sufficient

26

height so that its initial contact with the upper rim will result in an OVD that is obviously over opened. 5.3.3 Tooth inserts. The maxillary rim in most standard techniques is leveled with the desired plane of occlusion and then grooves are cut in the wax into which the recording material, placed on the lower rim, will extrude. A more accurate means of providing a positive record relation is to place the occlusal surface of two posterior cusped denture teeth on the maxillary rim in the area of the second bicuspid and first molar bilaterally. Actual denture teeth can be used or an analog of the occlusal surfaces can be created in resin by impressing the denture teeth and pouring the mold in ortho resin. The penetration of the cusp forms into the recording material requires far less pressure than the standard grooves and results in a visually positive repositioning of the rims. 6. CENTRIC JAW RELATION RECORDS Do I have confidence in my patients ability to reproduce a hinge closure on request or must further patient training occur before making records? If I have modified the patients existing dentures, have the results been as I had hoped so that I can copy the modified occluding vertical dimension? 6.1 Vertical dimension determination 6.1.1 Definition of occluding vertical dimension. It is now common knowledge that the vertical dimension of occlusion and that of rest is postural, and varies with many factors. Nevertheless, some dimension must be established at which the centric jaw relation record is to be made. The initial vertical dimension must be over closed rather than over opened since all subsequent procedures will increase that dimension. The chosen dimension must result in an acceptable face height, allow intelligible speech sounds (especially sibilants) and provide for some space at rest. It will always be easier to evaluate this dimension when the denture teeth have been set in their proper position in the face so the initial dimension must be considered tentative. It is technically easier and faster to "open the bite" at the try-in appointment than to close it. If the OVD is slightly over closed at that time, then the verification record of centric jaw relation will be made at a dimension closer to the desired face height. 6.1.2 Face height. The first factor in developing the occluding vertical dimension is that of face height in occlusion. The wax cone, suitably tempered in the water bath, provides the easiest means for evaluating face height quickly. The patient is taught to retrude the mandible as part of the original examination and evaluation, so by this time they

27

should be able to assume that position with ease. The patient closes slowly on the wax cone until the clinician decides that the face height is appropriate and tells the patient to stop and hold still. Obviously, experience in looking at many people of different ages with natural teeth and consciously evaluating the face height will make the determination of an optimum dimension much easier. Should the patient close beyond the desired dimension, it is easy to retemper the cone and extend it for another try. When the desired dimension is obtained, the cone is chilled in ice water to reduce future distortion. 6.1.3 Speaking space. Since the maxillary rim was constructed to show 2 mms below the upper lip, it is easy to evaluate speaking space by observing the relation of the cone to the upper rim in speech. Since speech is bound to be affected by the change in the contour of the record bases when compared with the existing dentures, this area of evaluation must not receive too much emphasis at this time. It will be possible to evaluate the sibilant sounds. Should the cone be firmly held against the maxillary rim during the "S" sounds, it will serve as an indication of an increased occluding vertical dimension and the face height must be immediately reevaluated. If the cone just touches the rim and quickly separates, the dimension is probably within normal limits. 6.1.4 Resting vertical dimension. The final component of the evaluation procedure is that of the resting vertical dimension. To properly evaluate this aspect, the patient should be out of the chair, standing straight and with the jaw at rest. The clinician gently parts the lips and evaluates the space between the cone and the rim. Depending upon the type of jaw relation (Class I, II or III) a varying distance will be seen. The Class II patient can be expected to have a greater resting space (in the range of 5 mms), with the Class I around 3 mms and the Class III, less. This dimension must be reevaluated in relation to the face height and speaking space should any changes be made.

6.2 Centric relation 6.2.1 Definition. Dentistry has struggled with the definition of this term throughout its history. For the complete denture situation it can be defined as an unstrained, patientassumed relation of the mandible to the maxilla from which border movements can be easily made. The mandible must not be forced into this relationship by the clinician since the patient will close in a strained manner and any occlusal contacts established at the forced position will only result in horizontal movement of the lower base.

28

Whenever possible, the recording of this three-dimensional position must be at, or very near, the chosen occluding vertical dimension. 6.2.2 Training. Since the patient must not be forced into this position, he must be trained to assume it on command. Many patients can do this after being shown the relaxed arcing that is required. Some have great difficulty with the task and will fight any attempt of the clinician to guide them to the retruded position. The time to ascertain the patients ability to place his mandible in this position and to arc to the OVD is at the examination appointment. Nothing is more frustrating than to spend unplanned time trying to reproduce a centric record when the patient is fighting the placement of the mandible. The patient should first be shown the retruded position on the clinicians mandible by placing his index finger on the clinicians chin while the mandible is retruded and arced. Then the clinician places his finger on the patients chin and the procedure is repeated. If the patient goes easily to the retruded position, then a reference is made to the fact that the patient will have to perform this critical step later on in the construction process. If the patient struggles with the concept, then the patient should be told to practice in front of a mirror and that his progress will be reevaluated at the impression appointment. This should be done in a relaxed manner so that the patient does not overreact and become frustrated. With practice, most patients can learn to assume the centric position by the time of the jaw relation appointment. 6.2.3 Recording. A variety of materials can be used to record the centric relation position. Most clinicians employ some form of thermoplastic material, i.e., wax or compound. It is also possible to use impression plaster, ZnO bite paste, silicone registration material or fast-setting resinous materials. The metallic waxes are most often used for the average patient. They have the advantage of remaining in a plastic state for a reasonable length of time. Their disadvantage is that they are subject to distortion by careless handling since they remain soft at room temperature. For the patient who may have trouble holding his mandible steady during the cooling period of the wax, green or gray stick compound is the material of choice. Since compounds are hard at room temperature, they are also indicated when records are shipped through the mail or taken long distances by courier. Once the occluding vertical dimension is established, an estimation of the space that exists between the tooth inserts and the lower rim is made and the amount of recording material needed to make the record is calculated. There is no advantage to having any more recording material than what is required to pick up the imprint of the cusp tips. The thermoplastic material chosen must be attached to the lower rim and then tempered in the water bath in such a way that the cone will not come in contact with the hot water. Once the material is uniformly soft, the record is made with the index fingers placed on the rim handles and the base positioned with a light contact only. As the patient closes into the recording material, the fingers are gradually

29

removed from the handles but left in light contact to ensure that the base has not moved on the supporting tissues. The patient is told to stop and hold as soon as the clinician sees the cone stop against the upper rim. The centric relation record must be allowed to cool for a moment before the patient is instructed to open. The mandibular rim is removed from the mouth and the recording chilled. Any material in excess of the cusp tips is removed with a sharp scalpel blade and the record refined by re-tempering and remaking. This step is always required since there can be no guarantee that an equal volume of thermoplastic material was present on both sides. The inevitable shrinkage of the bulk of the material will result in an inaccurate recording. The second recording will be made with only the outer surface of the material being softened and the shrinkage minimized. This recording is either accepted or rejected and remade based on clinical observation. 6.3 Face bow record. The value of a face bow record in complete dentures is questionable. However, since it is easily and quickly made, most clinicians who mount their casts on semi-adjustable articulators in their own office will elect to use this record. It can be made either before the occluding vertical dimension recording or after the centric jaw record. If it is done later, then care must be taken not to distort the maxillary rim or the tooth inserts since any change in the maxillary rim will not allow an accurate repositioning of the centric recording. If the clinician elects not to use the face bow, then an arbitrary mounting with the position of the mandibular central incisor 10 cm anterior to the axis of the articulator will give an average value. 6.4 Articulator mounting. Any articulator capable of maintaining the vertical dimension can be used for complete dentures. Most clinicians are comfortable with a semiadjustable articulator of the Hanau/Dentatus type. These articulators have a special advantage in complete dentures because the condylar ball is visible and its relation to the posterior stop easy to evaluate when checking a centric relation record against a previous mounting. The mounting of the master casts should be done initially with the minimum mounting plaster that can be depended on to hold the cast to the ring. A more esthetic addition of plaster can be added later to minimize distortion through the shrinkage or expansion of the mounting plaster. 6.5 Verification. In order to be confident enough in the record and the mounting to make it practical to expend time and effort on the set-up of the denture teeth, there must be a process of verification. If thermoplastic materials are used as the recording material, they need only be reheated and any evidence of the cusp tips removed before tempering the record and remaking the centric jaw relation record. The new record must be checked against the articulator with care to see if the original record and mounting can be verified. Philosophically, the clinician must approach the verification with distrust, attempting to prove that the records do not match. Only when it is certain that the records are identical should placement of the teeth begin.

7. TOOTH POSITIONING 30

Are the esthetic requirements of the patient clear to both the patient and the clinician? How much recontouring of the anterior teeth will be needed before the teeth are ready for positioning? Can I foresee the vertical and horizontal overlaps of the anterior teeth based upon an analysis of the existing dentures? Have the appropriate decisions relative to the instructions to the technician been made? 7.1 Philosophy 7.1.1 Esthetic evaluation. As a part of the initial examination, the patients self-image is discussed and an effort is made to decide how this particular patient will appear when his teeth have been positioned in their most esthetic relationship. Obviously, the patients wishes will need to be taken into consideration. The evaluation should begin with an inquiry regarding the patients natural teeth and how they looked. Does the denture he now wears reproduce the look of his natural teeth? Would he like to make any changes in his dental appearance? Until the clinician has a good idea of how the patient might look, the esthetic reconstruction can't begin. In general, the existing dentures will not appear to match the patients age and personality. They will be too small for his face, too light in color, and too regular and recessed. Many patients can be converted to a more natural selection if they are told that the esthetic objective is to make them look as much their age as possible so that no one will know that they have dentures.

7.1.2 SPA Factors (Sex, Personality and Age). It has been suggested that these three factors are the essentials of esthetics. A review of Fisher and Frush provides a basis for the selection and placement of denture teeth. They are also a good starting point for a conversation with the patient to assess his self-image as affected by his teeth. We are seldom bold enough in interpreting these factors, so when the dentures are completed, the patients appearance is still not truly natural. Dentures that look real in the mouth will often appear questionable out of the mouth because they are too dramatic a departure from the standard denture look. 7.1.3

31

Patients preference. If the patient expresses a specific esthetic demand that is either anatomically impossible or unrealistic, his opinion may be modified if he can only see himself with another "look". Tell the patient that you would like to show him an esthetic option and ask him to reserve judgment until he sees what you have planned for him. At the completion of the placement of the anterior teeth (7.2.5) when the gingival contours are neatly waxed, the patient can be shown his "new look" and the decision to proceed can be made. When the patient has photographs of his natural teeth to compare with his dentures, he is often amazed at the sterile nature of the denture look and can successfully be offered the option of looking real. 7.1.4 Incisal guidance. One of the most difficult decisions to be made affecting the esthetics of the dentures is found in establishing the vertical and horizontal overlap of the anterior teeth which will result in the establishment of the incisal guidance. This term is often misunderstood as it relates to complete dentures since the discluding guidance is most often found on the bicuspids rather than on the incisors as could be expected in natural teeth. To establish a relationship of the anteriors that will be both esthetic and functional in speech, the evaluation of tooth placement must be made with the patient present. To escape the denture look, the anterior guidance must relate to the Class I, II, and III system with the Class II patient having a steeper angle and a Class III having a shallow one. The overlap established will be affected by the amount of wear that is created on the lower incisors so the age factor must be considered as the teeth are positioned. The only requirement that must not be overlooked in the determination of the incisal guidance is the need for a small amount of horizontal freedom in centric relation between the incisors. If a freedom of 1.25 mms is established, the great majority of functional contacts that will occur between the dentures will be within this limit and thereby allow for a vertical overlap greater than the classic 1 mm of the standard denture occlusion without fear of dislodging the bases. 7.1.5 Plane of occlusion. For the purposes of complete denture construction, the plane of occlusion can be described and determined as a plane that passes through the tip of the cuspid and runs posteriorly to the junction of the middle and distal third of the retromolar pad when the casts are mounted at a reasonable vertical dimension of occlusion. This definition places the food table where it was in the dentate mouth and contributes to optimum masticatory efficiency. There is no need to trim the maxillary rim to this plane as in the standard technique, since the positioning of the anterior teeth in the patients mouth will determine the anterior point of reference with the posterior points taken from the mounted cast relationship. 7.1.6 Food table. It is important to realize that the only factor in tooth positioning that has shown any effect on function (mastication) is the position of the food table relative to the ridge, tongue and buccinator. For these considerations the lingual cusps of the mandibular teeth must lie within the triangle formed by the center of the residual

32

ridge and the medial aspect of the retromolar pad as these lines join at the cuspid position. The resultant table will neither crowd the tongue nor make the lower denture unstable. The vertical component of the table is established with the plane of occlusion. 7.1.7 Compensating curve/cusp height. The compensating curve and the cusp height are factors of occlusion that are within the control of the clinician. These factors are generally minimized to provide a relatively flat plane until the anterior guidance is verified at the full esthetic try-in and the protrusive registration made. It is the consensus that a shallow curve and minimal cusp heights will reduce the lateral shifting of the lower denture base during function. A true monoplane occlusion using totally flat teeth has long been seen as the optimum occlusion for those patients who appear to have problems repeating centric relation records or who have difficulty managing the lower denture. A disadvantage of this type of occlusion is the unesthetic look of the bicuspids, should they be visible. Often the appearance can be improved by placing a cusped tooth in the first bicuspid position and keeping it from providing disclusion by shortening the cusps. 7.1.8 Occlusal relationships. Dentures can be constructed with cuspid guidance (disclusion), working contacts only and, of course, full cross tooth and cross arch balance. The original standards of quality specialty care demanded a fully balanced occlusion. The Kentucky studies, longitudinal for 20 years, showed no difference between this classic occlusion and a simplified "centric only" occlusion. The decision as to which type of occlusion to employ is in some way determined by the occlusion on the existing dentures. There seems little point in arbitrarily changing tooth form unless there is a demonstrated problem relating to this issue. In the same manner, unilateral and bilateral crossbite relations should be undertaken only in response to some identified problem when remaking dentures. As resorption continues, the indications for cross-bite relationships multiply so that a change to this form of occlusion may be indicated to increase lower denture stability. The need for classic non-working and protrusive balance is questionable. The nature of protrusive contacts in the posterior teeth is misleading in that the tendency is to think of what happens on the articulator as replicating what occurs in the mouth. Protrusion is a component of incision; that is, the patient reaches protrusive contact of the anteriors as a result of opening, protruding and then bringing the anterior teeth into contact. Moving from centric relation to protrusive contact with the teeth in contact is a bruxing movement and should be discouraged. If the patient dislodges the maxillary denture with excessive force in an incisive protrusive contact, he must be taught to incise his food in the cuspid/first bicuspid area. Classic protrusive balance in the posterior teeth does little to stabilize the dentures with a bolus of food between the teeth. 7.2

33

Technique for the placement of anterior teeth. The classic method for determining the position of anterior teeth is to adapt the wax rims to such a contour that the facial surface occupies the same place in space as will the facial surface of the denture teeth. This is time-consuming and, since it delegates the actual placement of the teeth to the laboratory technician without the presence of the patient, a denture look can be expected at try-in. Either this look is maintained or considerable chair time is expended to reposition teeth. It is far more practical to place these teeth with the patient present and bypass the contouring of the wax rim completely. 7.2.1 Cast diagnosis and marking. Before any teeth are placed, the casts should be analyzed and certain key landmarks identified and marked on the land areas of the master casts. These areas are: Maxilla: ridge crest lines, the line perpendicular to the mid-sagittal line through the center of the incisive papilla, the extension of the ridge crest line to the back of the cast. Mandible: the ridge crest line with back extension and the line perpendicular to the mid-sagittal plane and passing through the bearing area of the anterior residual ridge. 7.2.2 Midline marking. The midline of the maxillary teeth must be established. This position is not necessarily the midline of the face, rather it is the result of an attempt to put the dental midline in the most esthetic position for that particular patient. When there is some question as to where that line should be, a piece of black suture cord can be used to analyze the midline of the face. The assistant holds the suture from behind and the clinician views the patient from the front. 7.2.3 Tooth preparation. A considerable amount of time can be saved if the denture teeth are prepared beforehand. This task is one for the dental assistant and allows the clinician to maximize chair time. The teeth are removed from the card, all evidence of the carding wax eliminated and the surface of the ridge lap ground away. When the clinician predicts insufficient inter-ridge space, the teeth can be further modified to something approaching the desired dimension as a part of this preparation phase. All anterior teeth, maxillary and mandibular, are treated in this fashion. The positioning of the posterior teeth is a laboratory procedure and is not included here. 7.2.4 Maxillary central incisor. The positioning of the anterior teeth is begun just as soon as the centric jaw relation record has been proven after mounting the master casts. With the midline of the teeth marked on the wax rim, the wax to one side of the midline is removed down to the record base and as far posteriorly as the area of the first bicuspid. The two denture teeth, placed in the posterior maxillar,y wax rim, must remain so the occluding vertical dimension is maintained while the anterior 34

teeth are being positioned and verified. So often the denture teeth are placed in the occlusion rim. This is time-consuming and difficult since the amount of wax that forms the rim is almost always more than is needed to restore contour and since the mass of the wax is cold, moving the tooth once it has been placed requires warming not only the wax around the tooth but the adjacent wax as well. The technique that will be used here is to place the tooth into a cone of wax, duplicating the labial gingival contour at the same time, place the cone on the record base, and then move the tooth in its cone to the desired position when the base is in the mouth. This approach allows the clinician to "sculpt" the position of the tooth to the patient. The cone is prepared with an eye to the amount of wax that will be required to bring the tooth to the estimated vertical position. The cone surface is passed through the flame to melt the surface and thereby to bond the tooth to the wax. Then the first central incisor is placed to contact the midline that has been preserved in the wax rim. A hot spatula is used to join the cone to the base and the base placed in the patients mouth. Decisions are made regarding the midline, the vertical placement, and the labial-lingual position and inclination. Since the mass of the wax cone is still warm, the tooth can be moved to any or all of these positions without removing the base from the mouth. The placement of a small amount of sticky wax on the ridge lap of the denture teeth before adding the cone will reduce the chances of tooth separation. 7.2.5 Maxillary incisors. Once the first central incisor is in an acceptable position, the base is returned to the articulator and the remainder of the maxillary teeth is positioned according to the predetermined esthetic plan. The gingival contours are created to match the desired esthetics since the esthetic result depends upon the look of the gingiva as well as upon the tooth position. When the six teeth are in place, the entire anterior segment is tempered in the water bath and returned to the mouth where the tooth position is modified to conform to the smile line, etc. The incisal edges are modified at this time since the aging contours are needed before the incisal guidance can be established. The lingual contours should approximate the final palatal form although it is not necessary to make them ideal at this time. Leaving a lumpy and rough lingual may cause some loss of confidence in the process even though the patient may make no comment.

7.2.6 Mandibular central incisors. The most difficult aspect of placing the anterior teeth is to determine the vertical and horizontal relationship of the incisor teeth. This step is often left to the technician in the standard techniques and, as a result, the incisal guidance tends to be identical for all patients. A good place to start is to remove wax on the lower record base in the area of the 4 incisors and to place the two central incisors with a vertical overlap of 2 mms and a horizontal overlap of 1 mm. The bases are returned to the mouth and the esthetics and speech evaluations made. There is no magic formula for attaining ideal incisal guidance. Its determination is a part of

35

the art of prosthodontics. In the final analysis, the teeth must look right in the mouth and not contact in centric relation. Since the jaw relation record has not been removed from the bases, the OVD is stable and allows esthetic evaluation without overclosure. If the incisor relationship is satisfactory, the remaining mandibular incisors are placed as a part of the laboratory phase continuing the incisal guidance from cuspid to cuspid. 7.3 Placement of posterior teeth. The placement of the posterior teeth can be relegated to the technician since all the information necessary to complete the trial set-up is now available. Instructions for the placement of the posterior teeth can be given using the position of the anterior teeth and the diagnostic lines previously drawn on the casts. 7.3.1 Four bicuspid placement. The transition from the anterior teeth to the posteriors must be a deliberate one since, once the first bicuspids are placed and in the desired centric, working and balancing relationships, the remaining posterior teeth are easily placed to harmonize with those bicuspids. The maxillary first bicuspids are placed to compliment the esthetic arrangement of the anterior teeth. When the mandibular first bicuspids are placed, the relationship is seldom as desired. Either diastemas must be left to move the cusp tip to the distal or the distal of the maxillary cuspid reduced to move the maxillary bicuspid anteriorly. A cusp-to-marginal ridge relationship is not essential even though it is the standard technique. As the relationship moves to a cusp-to-fossae relationship, the disclusion becomes steeper and the risk of an anterior open bite becomes greater. Diastemas offer an esthetic advantage and should not be avoided if they offer a chance to create a tooth-to-marginal ridge relationship. One of the giveaways of a denture look is finding the bicuspids jammed together and perfectly regular. The bicuspids can be rotated or staggered slightly without affecting the occlusion any more than can be managed with slight spot grinding. In some instances esthetics will dictate that the second bicuspids in both arches be placed in the same manner. 7.3.2 Mandibular posterior placement. The relationship of the mandibular posteriors to the center of the supporting ridge is critical. If the food table created by the lower posteriors crowds the tongue, the patient can be expected to experience problems in mastication or retention of the lower base as the tongue borders lift the base. The lower posteriors are occasionally set too far buccally when the height and width of the lower ridge is excessive, since the tendency will be to not want to take the time to reduce the trial base or the ridge lap of the teeth. The result may well affect the stability of the base since the table will be off the ridge to the buccal. 7.3.3 Maxillary posterior placement. Once the mandibular teeth are properly related to the lower ridge, the maxillary second bicuspids and the molars are placed. The only decision here is that of determining the need for a cross-bite relationship, either bilateral or unilateral. By reviewing the diagnostic lines that were carried over onto

36

the posterior surface of both casts, the relationship between the ridges can be visualized. When the mandibular ridge line is more than 8 mms outside the maxillary, the cross-bite relationship should be considered. 7.3.4 Cross-bite. Due to the different resorption patterns of the two jaws, this relationship occurs far more often in complete dentures than it does in the dentate situation. The changeover point of the cross-bite must also be considered as it needs to be made with consideration of the amount of horizontal overlap, be it regular or reverse. In most situations, (except for severe Class III's), the transition can be made at the first molar which will allow the bicuspids to be more normal in appearance. Some manufacturers produce a cross-bite tooth that is intended to make the positioning less of a problem but, in most instances, the affected denture teeth will have to be modified since denture teeth seldom have adequate lingual cusps. In addition, the opposing fossae may need to be deepened to allow for working contacts extending up to 2 mms from centric relation. 7.3.5 Working side contacts. In the conventional fully balanced set-up, the working side contacts are simple to develop once the first bicuspids have been properly positioned. If the anterior guidance is steep, the compensating curve will be greater to permit working contacts. Since the protrusive records have not, as yet, been taken, this curve is only approximated at this time. When the teeth are set tooth-to-marginal ridge, the working side contacts appear as a by-product of a proper centric positioning. When the teeth are in a tooth-to-tooth relationship, the cuspal inclines will require recontouring to achieve this harmony of eccentric contact. The working side contacts should extend to the point where the anterior teeth begin to come into contact. In the severe Class II patient, it is often impossible to extend the working contacts until the anteriors contact. The guidance here is that of the first bicuspids. By the time the anteriors come into working contact, the posteriors may have gone beyond the cusp tip contact. This is not a concern clinically since the patient will seldom use such a wide range of lateral functional movement with the teeth in contact. 7.3.6 Balancing side contacts. The need for balancing contacts is not well documented in any scientific way but, since it can theoretically be claimed that contact on the nonworking side will aid in denture stability, it seems reasonable to attempt to gain some contact on the balancing side in harmony with the working side contacts. If a contact in centric relation provides for full contact of the holding cusps in their opposing fossae, some balancing contact is apt to occur without any special effort. If contact is not achieved, then either the working inclines need to be reduced or a greater compensating curve established. Even in a flat occlusal plane type of occlusion, one balancing point can usually be obtained by adjusting the tilt of the second molars in both the frontal and sagittal planes. The compensating curve developed with this tilting will also aid in providing for a minimal protrusive posterior contact.

37

7.3.7 Protrusive contacts. The protrusive contact is the least valuable of any of the border position contacts. Clinical evidence shows that the range of protrusive contact actually used by patients is less than in either working or balancing contacts. What is more to be desired is to have smooth transitions in both straight and lateral protrusive so that there is no one tooth that is the sole contact. When a steep vertical overlap is required for esthetics and speech, the anterior teeth will always open the posteriors in a protrusive movement beyond the horizontal overlap of the anterior teeth. Some attempt must be made to allow a multiple contact of the anteriors when they are brought edge-to-edge. Since the masticatory efficiency of denture teeth is far below that of natural teeth, the patient needs a well-defined incisive contact to enable him to manage foods that must be incised (i.e., salads, breads, etc.). In the attempt to create posterior protrusive contacts, care must be taken to insure that the ramping effect of an increased compensating curve does not bring the plane of occlusion above that of the posterior determinant of the plane of occlusion, 7.4 Waxing. The thickness of the denture base and the contour of the flanges are the critical elements of the waxing process. The contour of the palate is critical for effective sound production. The standard festooning of the labial surfaces is of little value unless that portion of the denture base is seen in normal speech. An evaluation of the contours of the existing dentures will often indicate the contours of the new dentures even if they appear abnormal since the patient has already adapted to these contours and to change them to please the esthetic eye of the clinician is perilous. 7.4.1 General contours. The established border contour is completed in the wax-up for tryin. Unless these contacts mimic those of the final denture, there is no way that they can be fully evaluated. The contour between the border and the neck of the denture tooth should follow the contours of the existing denture unless some objective indication exists to alter the form. The palate should also mimic the old denture except in those instances where the denture has excessive thickness. Then this observation should be presented to the patient who should be allowed adequate time to fully evaluate the change. Special attention should be given to the rugae area and the contour immediately lingual to the teeth. Some thickness in this area is normally required to allow acceptable sibilant sounds. 7.4.2 Interproximal contours. The interdental papillae must accomplish two things that at first glance might appear to be mutually exclusive. They must fill the interproximal space to provide a contour that discourages the retention of plaque, debris and calculus. They must also appear to be lifelike and enhance age-related esthetics by complimenting the shape and placement of the teeth. The work of Fisher and Frush describes a papilla that is bi-convex: This contour is essential in the posterior teeth. It may be modified in the anteriors by creating tiny diastemas between anterior teeth that will need to be maintained by the patient just as they would have to do with

38

natural teeth. These diastemas, created by passing waxed dental floss through the contacts of the teeth to remove the thin film of wax that will normally be found as a by-product of the waxing process, will give depth to the teeth and reduce the denture look by making the teeth stand out individually. Lingual interproximal contours are created to maintain an easily cleaned embrasure since they are not visible. 7.4.3 Palatal and lingual contours. The proper palatal contour for the try-in requires a record base that is uniformly thinner than the dimension desired in the final denture. Wax must be added to blend in the lingual embrasure contours of the teeth and to establish a smooth, anatomically correct palatal form. This does not imply that the rugae area will be reproduced if the existing denture has a smooth contour in that area. Only if the patient had problems with speech, should an attempt be made to return to a more anatomic palatal form. For immediate and first-time dentures, an irregular rugae area will reduce the risk of speech problems as it provides a stopping area for the tongue as certain sounds are produced. The use of modern high-impact resins for the denture base allows a palatal thickness of 3 mm that will stand up to most normal loads. Patients with a history of denture fracture should be considered for a metal base denture rather than for a thickening of the resin palate. The contour of the lingual surfaces of the mandibular denture should not crowd the tongue, nor should a trough be created for the tongue since the lateral borders may catch in the groove and raise the tongue unnecessarily. Again, it is wise to copy the thickness of the existing dentures if they have been accepted by the patient. In both arches, all areas of the record bases must be covered with at least a thin coat of wax so that a smooth surface can be created for the try-in. The patient must have the opportunity to evaluate the exact contour of the denture for the try-in to be totally valid. To overlook this requirement in the name of expediency is to ask for postinsertion rejection by the patient.

8. CLINICAL TRY-IN What are my criteria for accepting or rejecting the trial dentures? Have I given the patient adequate time and opportunity to accept the trial dentures so that there will be no surprises after completion of the treatment? The clinical try-in appointment is the critical time for self-evaluation of all aspects of the dentures and the treatment plans of the clinician. Adequate time must be available to allow evaluation of the vertical dimension of occlusion, centric jaw relation, speech and, above all, esthetics. In addition, a protrusive record may be made for those using a semi-adjustable articulator to its maximum potential. The

39

esthetic and speech components of the try-in are the most taxing and time-consuming. They can best be evaluated by allowing the patient to take the waxed dentures home for an open-ended try-in for esthetics and phonetics in the presence of his family and chosen friends (if he/she is willing).

8.1 Evaluation of the vertical dimension of occlusion. The try-in appointment begins with an evaluation of the OVD. The three components of this dimension are reevaluated in the same sequence as at the initial jaw relation record making. Face height should be checked with the patient in a variety of positions: sitting, standing, relaxed, at rest and smiling, and closed lightly in maximum contact. The patient is then asked about some subject in which he has expressed an interest previously, a hobby or a course of study, for example, and finally, is asked to read from a book of his own or a handy magazine. The clinician is trying to answer only one question: "Can this be an appropriate OVD for this patient?" Only when this question has been answered in the affirmative should the actual resting space be checked by softly parting the lips when the patient is standing in a relaxed position. In this manner, the patient is most apt to present a natural relaxed reading of the OVD, one unconstrained by their position in the dental chair. 8.2 Records. Even though the occlusion may appear to be exactly as desired in the mouth, it is appropriate to make a check record at this appointment as a means of refining the original provisional mounting. An intraocclusal record will have to be made at this time at an increased occluding vertical dimension (assuming the OVD was initially correct). When a centric record is made at an increased OVD, the thickness of the recording material should be kept to a minimum. If Aluwax is used, that means one thickness of wax. Should the provisional mounting be obviously incorrect or the vertical dimension over opened, the mandibular posterior teeth should be removed from the trial bases. These teeth will have to be repositioned in any case and, in their absence, the check record can be made at a more suitable occluding vertical dimension. It is also appropriate to make a protrusive record once the centric relation mounting has been verified. This record will require a thickness in excess of the vertical overlap of the anterior teeth since the patient will have to protrude at least 6 mms to register a usable protrusive record. 8.2.1 Check record. One thickness of wax or an equivalent amount of compound is warmed and adapted to the interproximal areas of the mandibular teeth. If any problem is anticipated in maintaining the mandibular trial base in proper relation to the mandible rim, handles should once again be placed in the bicuspid area. Since the recording material is so thin, only a feather touch is required to create indentations to verify centric. If compound is used, the first closure should be ignored. Once the

40

excess material is removed with a sharp blade, a second record perfects the contacts. The goal is to verify that a repeatable record has been made, either initially or by remounting and rechecking at this time. 8.2.2 Protrusive record. After the centric record is verified, two more layers of wax or an equal amount of compound are placed on the lower posterior teeth. A straight protrusive record is made on the articulator at least 6 mms anterior to centric relation. Excess wax is removed and the material reheated in the water bath. The mandibular trial denture is taken to the mouth and, using the indentations made on the articulator as markers, the patient is asked to open, to protrude the mandible until told to stop, and then to make and hold a protrusive closure. Using this record, the condylar elements of the semi-adjustable articulator are set. Once the mechanical evaluation is completed by the clinician the patient is given the dentures with instructions not to use them for anything but speech and to evaluate the esthetics. They are requested to write a detailed explanation of any aspect of the trial dentures with which they are unhappy. They must be told that some of their requests will be impossible to fulfill but that every attempt to adjust the dentures to their desires will be made, and that they will be kept informed and given the opportunity to question those areas where modifications cannot be made. The patient is requested to bring the dentures back only when they have completed their evaluation of the trial dentures. The results of this method will prove invaluable in identifying potential problem areas and in demonstrating to the patient the thoroughness of the clinician.

8.3 Final evaluation. When the patient returns any complaints or requests are evaluated and the dentures modified if appropriate. Depending on the problems encountered, a second try-in appointment may be required. The patient should then sign a chart entry attesting to the fact that they have had ample opportunity to evaluate the trial set-up and approve the appearance in every aspect. Before dismissing the patient, a final evaluation of the gingival wax contours should be made since any deliberate tooth movement may have distorted the contours. The need for a stippled surface should be identified based upon the amount of "attached gingiva" that the patient shows in a wide smile. There will be occasions when the patient completely rejects the trial denture for any number of reasons. The clinician must then decide whether to continue treatment. When the patients desires can be met without altering basic principles then it is appropriate to make minor changes, even though these modifications may depart from what the clinician knows is proper. When the demands are bizarre and irrational, nothing but problems can be expected if these demands are met. Far better to discontinue treatment, with proper chart entries, of course.

9. PROCESSING / FINISHING 41

Have the standards for the laboratory procedures been clearly presented to the technician via the authorization document? Will tinting of the denture base be required and can the desired shade, texture and tinting requirements be successfully transmitted to the lab? 9.1 Final tooth positioning. It is only after completion of the try-in appointment, when all records are accepted, that the final positioning of the posterior teeth is done. The desired occlusal scheme may have to be modified to accommodate both the incisal and condylar guidance. If it appears that considerable tooth modification will be required to attain the desired occlusal contacts, it may be advisable to increase the OVD at the pin by 1 mm to provide for adequate tooth stock. It must be remembered that the processing procedure will inevitably increase the vertical dimension a slight amount and that this increase is usually adequate in the average case. 9.2 Final waxing. Final waxing should be a simple matter if the trial denture has been waxed according to the methods described here. The base is waxed to the peripheral roll and that contour blended into the facial contours. As a final measure, a sharp, fine-bladed instrument is used to remove all traces of wax from the juncture of the tooth and the wax. Waxed floss is used again to remove interproximal wax. Stippling is restricted to those areas that are going to be visible. A very natural stippling can be created by lightly warming the wax with a brush flame and then tapping the appropriate areas with a stiff denture brush. Remember that stippling does not normally extend to the gingival roll and is limited to the attached gingiva. A final application of the brush flame rounds the brush marks and creates a lifelike stippled appearance. This type of stippling is always preferable esthetically to a stipple created after processing using a bur. Therefore the area of the denture to be stippled should be waxed exactly to the desired contours since no further finishing will be done in this area. The surface of the palatal wax should be as smooth as possible since it is most difficult to finish and polish in a concavity. All undesirable roughness is removed with burnishing followed by flaming and a final polish applied with cold water and cotton. The resulting palate will need no finishing and will approximate the surface texture of the natural tissue of the palate. 9.3 Investing. The objective of the investing process is to create a bubble free layer of stone that will result in the sharpest possible mold for the processing of the resin. Once the first half of the flasking is complete, the second half stone is vacuum mixed to a thin consistency and is applied with a finger and some pressure to the tooth-wax junction. Immediately after completion of this critical step, the remainder of the stone is added to the flask with a minimum of vibrating. Standard techniques are used to boil out the flask and prepare the mold for packing. Since the goal is to

42

produce a denture that requires no finishing around the necks of the teeth, care must be taken in the removal of any tags of stone that are evident after boilout. The application of the separating media must also be done with care to keep the thinnest possible layer around the necks of the teeth. 9.4 Denture base tinting. When no portion of the base will be visible in any functional activity up to the widest possible smile, there is no reason to tint the denture base. The only esthetic modification required is to remove the red fibers from the resin that will form the area of labial attached gingiva. This can easily be done by sifting the fibers out of a small amount of the resin and placing that resin in the attached gingival area prior to completing the packing. The result will not necessarily be perfect but will reduce the chances of finding a red fiber in the interdental papilla, a dead giveaway to a denture look. When the denture base is visible, tinting of the base is indicated. The skills gained in tinting the complete denture will prove invaluable for the much more critical tinting of partial denture flanges. Unfortunately, there is no way other than practice to learn to create lifelike gingiva. The clinician must create a series of shade tabs with recorded amounts of the various colored resins used to communicate his specifications to the dental technician. The tab blank is made in the form of the anterior gingiva and a silicone mold made of the blank. Molten wax is poured into the form to create a number of wax tabs and these are invested side by side in a standard denture flask. The tinting must always be backed up with the denture base resin that will be used in the actual dentures since the color of the base material affects the tinting result. For that reason, the wax tabs must have the approximate thickness of an anterior flange. TheDenture Stain Kit from Kay-See Dental Mfg. Co., which was developed for use with Dr. Earl Pound's technique, is the standard of the industry although other pigments have been developed for tinting, especially for the heavily patterned, pigmented gingiva. 9.5 Finishing and polishing. If the waxing and investing have been properly executed, the finishing should be limited to shell blasting, removal of the peripheral flash and removal of the residual interproximal stone with a stone solvent in the ultrasonic cleaner (the use of the stone solvent takes a good deal of time if there are many fine diastemas present). The borders will need to be pumiced and high-shined. The palate should be left in the as-processed state as this surface simulates the texture of the palatal mucosa. Frena should be carefully examined since they are often slightly displaced in the impression and are apt to be overextended. They must not be overopened laterally beyond their actual dimension.

10. INSERTION What are the standards for acceptable occlusal contacts at insertion?

43

At what point will this appointment be aborted if the occlusion is far from acceptable and what options exist for correcting serious occlusal discrepancies? The insertion appointment often consists of simply giving the patient his denture with adjustments postponed until the denture has settled". An important clinical study has examined the results of a comprehensive insertion appointment relative to the number of post-insertion visits required to satisfy the patient and found that a procedure that includes an evaluation of the tissue-base relation and a patient remount procedure can be expected to dramatically reduce the need for further adjustments. The patient should leave the office with the new dentures in as ideal a state as possible with all corrections made. 10.1 Tissue-base relation. When resin bases are removed from the master cast after curing the resin, they will always have some distortion from the inherent polymerization shrinkage that must occur. (A metal base denture will not show this distortion.) This distortion will affect the fit of the denture and may influence the occlusion as well. The tissue-base relation will need to be evaluated using some form of disclosing material and areas of pressure must be adjusted prior to the patient remount procedure. It must be remembered that the relationship of pressure paste markings to resulting areas of soreness are, at best, 60% correlated. Not every pressure marking is removed at this time since only hyper contact will result in a denture sore. The pressure indicator paste must be applied evenly and uniform brush strokes left to serve as indicator lines. The pressure paste works reasonably well in identifying internal pressures but is of little value on border extensions. Areas of overextension should be few if the impressions were properly made. There are two tissue-base relationships that must be evaluated separately. First, the static relationship is identified. It is in this area that pressures from distortion and errors in the final impressions will be found. The clinician places the dentures one at a time with firm pressure on the ridge and identifies and adjusts the pressure patterns. The first time the dentures are placed in the mouth, they must be seated slowly and the patient asked to indicate if any sharpness or pinching is felt. Imagine the loss of confidence that will occur if the new denture causes pain on the first insertion. This careful placement is especially critical when there are opposing undercuts. The second relationship is a functional one that can only be identified by simulating functional movements of the bases. Asking the patient to chew bilaterally on moist cotton rolls will often identify a functional pressure spot the adjustment of which will reduce or eliminate a post-insertion problem. This procedure will need to be repeated until the patient indicates that no pain is felt. He must be warned that this procedure is not guaranteed to eliminate all functional pressures since only the test of time will tell. The experienced denture wearer is well aware of this fact. It is the patient receiving his first denture who may not be able to comprehend the relationship of functional demands to denture irritations.

44

10.2 Patient remount procedures. After all possible internal adjustments have been made, the dentures must be returned to the articulator to perfect the occlusion. Many clinicians feel that they can adequately perform this equilibration in the mouth in the same fashion as they would with a fixed prosthesis. Unfortunately, the movement of the bases, especially the lower, makes this impossible. Since the tissue-base relation is now different from what it was when the try-in check record was made, the occlusion will never be exactly the same. The final processed bases will have a different fit from that of the autopolymerized record bases. It is the malocclusion that occurs from this difference in adaptation that accounts for the majority of occlusal discrepancies, not the processing changes (which will be very minor in the well-made denture). The clinician should approach this appointment with the maxillary remount cast in place on the articulator (using the face-bow saver), and the mandibular remount cast ready for mounting. The remount casts must retain the dentures against dislodgment and can best be made by seating the finished dentures into a patty of fast-set plaster so that all the borders are engaged. As soon as the plaster reaches initial set, the dentures are removed from the casts. Any plaster that had entered an undercut area will break off leaving a positive and slightly retentive border outline. The assistant should have applied the pressure indicator paste to the bases. Recording material should be prepared and the water bath brought to the proper temperature. The object of this preparation is to allow the critical appointment to be completed as quickly as possible without compromising the final base fit and occlusion. Again, the mounting must be proven with a second record. The final occlusal equilibration should result in a minimum of evenly spaced contacts in CR. While it may seem that a maximum of contacts would be desirable, there is no evidence that this is so. Minimum contacts centered between the distal of the first bicuspids and the distal of the first molars should provide a stable occlusion without unduly increasing the frictional resistance to smooth eccentric movements. Eccentric contacts should likewise be harmonized, with special care taken to allow incisor contact in both protrusive and lateral protrusive movements. An anterior open bite is unacceptable in complete dentures. 10.3 Patient instructions. Post-insertion problems and acceptance of the dentures are directly related to the patients expectations. It is the clinicians responsibility to spend adequate time with the patient to fully describe and explain what the patient can expect with the new dentures. In this discussion, the clinician should indicate some initial pessimism as to the speed with which the patient will adapt to the dentures. A written document covering the same areas as the oral presentation must be given to the patient to reinforce the patient instructions. Patients should be shown how to clean the dentures with suitable equipment (special emphasis on the removal

45

of plaque from the internal contour). All aspects of the patient instructions are to be reinforced on the first recall appointment, which should occur no longer than three days from insertion (two days is preferable to forestall denture irritations becoming frank tissue trauma).

11. POST-INSERTION ISSUES What happens if the patient rejects the dentures out of hand? Have I prepared the patient adequately for the problems that they will encounter during the adjustment period? What are the ethical implications of limited follow-up care for dentures without further charges to the patient? Since success in complete denture therapy is so greatly influenced by patient acceptance and the effort they make to adapt to the dentures, any post-insertion problem that is a concern to them must be addressed in such a way as to instill confidence in the clinicians ability to manage the problem. The advantage of a careful and exhaustive initial examination and a reasonable prognosis is that the clinician can address any and all possibilities in the patient letter/informed consent document. Any issues not identified and resolved at that time may be seen as excuses after the fact. The response to the patients question at the beginning of treatment, How many visits will all this take, Doctor? must always be answered, It will take as many appointments as it takes to do it right!" The patient must realize that he is not purchasing a commodity; he is paying for health care. 11.1 Soreness. In the initial stages of post-insertion care, it may be difficult to determine whether a denture-related sore spot is caused by a problem in the static relationship of the denture with the denture-supporting tissues or by a dynamic problem that could be denture-related or simply caused by the patient as he learns to manipulate his new prosthesis. In many situations these causes overlap, thereby making diagnosis and treatment even more difficult. Common sense and a careful examination of the mouth and the denture (with some form of disclosing material) will identify the cause of most problems. For the intractable, the clinician must review the functional demands of the patient and the tissue strength of the support. The patient may often have to take the responsibility of reducing the load they place on the prosthesis. Under no circumstances should adjustments be made when no cause can be identified upon careful examination. Mindless grinding on the denture base can only transfer the load from one potential problem area to another. Referred pain must also be considered as a potential source of confusion for both patient and clinician.

46

The intelligent use of a disclosing medium will demand discriminating between true pressure areas requiring adjustment and those marks that are not valid. Remember that studies show a correlation of 60% between pressure marks and eventual soreness. The best indicator of an area that needs adjustment is a halo effect in the paste around the pressure mark. When the internal resin is adjusted, the surface should be returned to a "polished" state by the use of rubber wheels and/or points when the acrylic bur used for the adjustment leaves a rough surface. Finely flued burs are available which leave a refined surface and these should be the instruments of choice for internal adjustments. 11.2 Inadequate retention. Retention problems in either arch do occur even in the most carefully constructed dentures. These can be caused by both over and under extended borders and occasionally by occlusal imbalances. In the maxilla, they can be caused by a difference in the tissue-base relationship from the conditions that existed at the time of the final impression to that of the day of insertion. If the existing denture was extremely ill-fitting and nothing was done to correct the fit before beginning the treatment except for leaving the denture out for 48 hours before the final impression, then a readjustment of the tissues to the new denture is necessary before optimum retention is established. In most cases, this readaptation occurs in the first 24 hours or so. If the retention is not ideal initially and no overextensions of borders or frenum areas are found, the patient can be assured that retention will improve with time. Very slight underextensions, particularly those buccal to the tuberosities, can be harder to detect and often do not manifest themselves until the patient has been using the dentures in mastication and complains of a loss of retention. Retention problems associated with the mandibular denture often require time for the patient to adjust to unfamiliar contours. When a dramatic change is made without going through the reconditioning of the old denture, the patient can expect a period of readaptation before the tongue and the buccinator relearn their retentive functions. Again, the patient must be informed of the learning curve as a part of informed consent. 11.3 Problems in mastication. Since it is impossible to duplicate the tooth position and occlusal form of the old dentures, the patient will need to adapt to the new positions, occlusal relationships and sometimes even textures before he is able to masticate his food as efficiently with the new dentures as with the old. Barring errors in tooth placement or the vertical dimension of occlusion, the patient eventually learns where the new food table is and how to use it effectively. This adaptation process must be presented as part of the informed consent document/letter. The condition causing the greatest problem is an increase of the occluding vertical dimension greater than that which the patient can accommodate. In the case of the patient who has been dramatically over closed, the return of the OVD to an acceptable face height may exceed his ability to adjust. A general rule of thumb is

47

that any increase of over 6 mms should be made in stages as part of the reconditioning of the old dentures. Patients who are over closed rarely have the same level of difficulty in mastication. It is always appropriate to discuss with the patient his techniques of preparing food prior to placing it in the mouth and his instinctive chewing movements. He must be taught that chewing techniques, which are perfectly acceptable and effective when natural teeth are present, are not normally efficient with dentures. Specifically, the patient must be instructed to divide his food into two portions each half the size of the one portion they might have ingested when dentate, place one portion on each side of the arch and attempt to chew bilaterally. In this manner masticatory efficiency is likely to be improved. Likewise, when incising, it will help to move the point of incision to the corner of the mouth and to use a lateral protrusive movement of the mandible rather than one that is a straight protrusive. The patient will also find a mechanical advantage in bringing the bolus straight up to centric occlusion and then triturating the food while sliding laterally from that centric position, instead of trying to grind his food from an eccentric position to centric occlusion. As a final attempt to solve a mastication problem, the clinician should refer once again to the patients old dentures (assuming that the patient had no particular problem in mastication with these dentures), and evaluate any changes that may have been made in the placement of the food table. Often the older patient cannot adapt to the change in position of the teeth even if the teeth in his old denture were in an abnormal position. 11.4 Speech. Problems with speech are often the most difficult to solve since speech is perceptual; the patient hears his speech sounds differently than do those with whom he converses. When the patient has problems with certain sounds, the first place to look is the old dentures. Have there been changes in tooth position or in palatal contours? If changes have been made, the dentures should be modified, either by reshaping the existing resin base or by adding wax to areas of under contour. When there is no apparent difference, the patient must be informed that a period of time is required to adapt to the dentures since the dentures cannot adapt to them. No matter how well made the new dentures are, if his speech does not appear to him to be normal, the patient will reject the dentures. Fortunately, the problem that cannot be resolved is rare. Most texts on complete dentures examine the possible etiology of speech problems in great depth and serve as resource documents for the clinician.

12. SPECIAL TOPICS IN COMPLETE DENTURES The specialist must be able to provide a number of special services required by the more complex types of patients that may be referred. The construction of metal and resilient bases and metal occlusal surfaces is often indicated. In addition, the specialist must be prepared to construct a complete denture in one arch (usually the 48

maxillary) against a reconstructed opposing arch. Both the function and the esthetics of the resulting denture must be in harmony with the natural or reconstructed arch. The final component of complete denture construction is maintenance. This most often involves relining and rebasing procedures which must not be taken lightly as they have the potential of destroying a well-made denture. 12.1 Overdentures. What are the predictors of success with overdentures? What precision or semi-precision attachments are available for overdenture retention and on what basis is the decision to employ an attachment made? At what point is the decision made to give up on the overdenture concept and go to the conventional denture or to the implant supported/retained denture? There are two areas requiring critical decisions that are specific to the construction of overdentures. The most obvious one relates to the selection of those teeth that will serve as abutments. Except for the cost involved in the endodontic treatment of the teeth there is no inherent reason while any mandibular tooth which can be restored and which has a reasonable periodontal prognosis should not be considered. In the maxillary arch it is harder to justify the retention of multiple overdenture abutments since there is seldom sufficient space in the premaxilla for adequate thickness of resin over the abutment with the threat of fracture always present. When the patient is young and there are mandibular anterior teeth remaining, it is always in the patients best interest to oppose the remaining teeth with overdenture abutments. It appears that the presence of two maxillary abutments will provide adequate protection for the premaxillary bone. The morbidity that occurs when an abutment is lost is slight except in financial terms. It must be realized that an abutment tooth does not have to be endodontically treated to qualify. In the older patient, a simple recontouring procedure should be considered if secondary dentin deposits have been adequate. When strong abutments remain in the mandible, the potential use of attachments should be considered and presented to the patient. It is not critical that the attachment option be undertaken initially since the added retention may not be needed. It is important to plan for the future use of attachments so that the new denture can be converted to an attachment-retained denture rather than requiring remaking. Individual external stud-type attachments or splinted bar-clip attachments are the retentive devices of choice. The second critical area concerns the extension of the flanges in the area of the overdenture abutments. The undercuts labial to retained roots will not resorb and if a full flange is used here it will mean that resin has been placed in an area where no 49

resorption has occurred. The thickness of the flange will distort the face and the muscles of the obicularus oris can catch on the flange and lift the lower denture or break the seal on the upper. Since overdenture abutments are most often found on the lower arch, shortening the flange to just beyond the height of contour will not result in the loss of retention. In fact, it usually improves the retention when the extraneous resin is removed. In the maxillary arch, the short flange is most often found in the immediate denture where it will be augmented as resorption occurs. The height of contour should be established on the surveyor before the record base is made as that will allow a test of the contours. The path is selected with a posterior tilt that brings the lingual slope to the vertical. The flange should be extended to just beyond the height of contour (1-1.5 mms). If the tissue can tolerate a slight compression, having the undercut engaged adds considerably to the retention. 12.2 Metal bases. The indications for a metal base for a complete denture are few but, when the need is apparent, there is no good reason not to make a metal base since the cost of this casting is insignificant when compared to the price of not making one. The most obvious indication is a need for additional strength, so, when the denture base is weakened by anatomical or functional demands, the inclusion of a casting can eliminate the problem of breakage. The metal base is therefore used primarily in maxillary bases opposing natural teeth (or a reconstruction) or in mandibular bases where insufficient width in the midline area makes flexure and subsequent fracture likely. A second indication is a need for additional retention. While the debate over the concept of mucostatics will never be settled, it does appear that the more accurate the adaptation of the base to the tissue, the greater the potential for adhesion and cohesion through saliva film. The transfer of heat through the palate can definitely be considered an advantage of the metal-based maxillary denture as well. Metal bases, either full or partial, must be seriously considered when implant support and retention are involved. Fracture of a resin denture base over an implant is a distinct possibility since the implants retentive component may act as a point of force concentration with failure of the resin. In many cases a metal housing made to accept the retentive elements with mesh extensions into the posterior denture base areas is sufficient to strengthen the base against fracture. Obviously, design and technical considerations are in a state of flux at present since long term studies of mechanical difficulties are not available. Since adjustments on metal bases are difficult at best, every attempt to make an impression without any evidence of pressure must be made. The impression material chosen should be the most free flowing available (historically, zinc oxide-eugenol materials have been used). Preliminary impressions and tray construction must be of the highest quality so that the wash impression can be made without pressure areas, with the supporting tissues at rest. Redundant and poorly supported tissue must be captured in its most relaxed state so the existing dentures must be left out of the mouth prior to making the final impression. Special attention is given to relief space and the placement of escape holes in the tray. Lastly, a critical appraisal of the final wash impression before acceptance is essential.

50

The most common form of metal base for the maxillary arch is one in which the base coverage extends to the posterior limit of the denture space and to the height of contour of the labial soft tissue. All borders other than the posterior will be in resin. The placement of the palatal finishing line must be determined with a knowledge of where the denture teeth are to be placed so that the transition from the thin palatal casting allows an anatomic contour of the palatal resin from the finishing line to the tooth. When this tooth position is not obvious, the metal base is not made until after the clinical try-in (a normal resin record base is used as for a conventional denture). When insufficient space remains for the placement of denture teeth (almost always when a single denture opposes natural teeth) the metal base may be waxed to include metal occlusal surfaces with veneered windows for processed tooth-colored resin. This means that the refractory cast must be mounted against the opposing arch...not an easy task. When this special type of occlusal formation is required, the cost of the metal base must reflect the time required to wax, finish and veneer the casting in addition to the normal cost. Resin retention for the metal base is generally provided by placing beads (No. 14, approximately 1 mm or greater in diameter) or nail heads in the wax-up. Loops of 18 ga wax may also be used. The original design of a metal base had the metal in the center of the palate only with retentive mesh around its periphery. More modern forms have either a full metal palate with mesh retention extending over the ridge and at the posterior border or, and this is currently the design of choice, full metal with bead retention over the ridges and the posterior border in metal only. The resin addition to the post palatal seal area was always presented as a safety factor should that area need adjustment. Careful attention to detail will develop a post dam that will need no adjustment. The mandibular metal base extends to within 2-3 mms of the denture border to ensure that the borders remain in resin even after adjustments. Obviously, the final impression must accurately reproduce these borders. Unlike the maxillary, the lower base is completely covered by resin so the retentive beads or other devices are positioned over the entire base. The thickness of each base should be in the range of 0.4-0.7 mm. Since only the bottom half of the beads will offer resin retention, the thickness at the bead, once the top half has been ground away, should be 1.1-1.3 mms. If the width in the midline is greatly restricted, a vertical strut running from 2nd bicuspid to 2nd bicuspid should be included in the casting. The internal finish of the castings can be either as cast or electro-polished (this procedure removes up to 50 microns which should not affect the precise fit of the casting). After the boil-out procedure and prior to packing, the metal base is glued to the cast with a small amount of super glue. Finishing will normally consist of carefully removing the fine flash that will be found at the finishing lines.

51

12.3 Resilient liners. What are the factors on which the decision to utilize a resilient base is made?

What fall back position is available if the resilient liner proves unsatisfactory?

The need for a resilient liner (Molloplast B or similar) has been reduced by the widespread use of implant-supported dentures. There remains, however, a need for these materials for those patients for whom implants are not indicated. The resilient liner offers a cushioning effect for vertical forces when processed into denture bases with a thickness of 2-3 mms. Unfortunately, the silicone material does not offer the same cushioning effect in shear, so not every patient can be helped with this type of base. The obvious potential problem with the resilient base is that it provides no strength to the base and, when space is limited, the removal of the 2-3 mms does not leave sufficient resin to withstand the loads placed upon the denture. Adding a metal base to this type of denture is complicated and results in a final denture base that is so thick that it may not be acceptable to the patient for either speech or mastication. Resilient liners are almost always found in the lower denture only because of the need for bulk which could result in an unacceptably thick maxillary denture. Aside from this restriction, there is no technical reason why the material cannot be used in the maxillary denture. The major clinical problem with these materials is the difficulty with which they are adjusted after processing. Special burs and stones have been developed to shape and polish the resilient liner but it is never possible to return to the as-processed surface once it has been adjusted. For this reason, the final impression must be adapted to the material in such a way as to eliminate the need for adjustment. This is obviously impossible with a static impression, so some type of functional impression offers the best chance for success. In order to develop a functional impression, the denture is processed without the resilient material and, after the patient remount procedure has been completed, a uniform amount of resin is removed from the tissue side of the base and replaced with a tissue-conditioning material (Lynal or equivalent). The patient then wears the denture with necessary modifications and additions of the tissue conditioner until any problems of borders or internal irritations are eliminated. The resilient liner is then added as a reline procedure. Unfortunately, this requires that the denture be taken from the patient for processing, a period of two days on the average. The functional impression will not reproduce great detail so adjustment of ridges and grooves should not be necessary. The processing of the Molloplast B-like

52

materials is technique-sensitive and must be done by experienced technicians if the expected 6-year average life expectancy is to be attained. 12.4 Metal occlusal surfaces. Does the wear of the current denture teeth justify the construction of metal occlusals? When previous dentures have shown severe wear of the occluding surfaces or when the denture is opposed with natural or reconstructed teeth, the placement of metal occluding surfaces is indicated as the only means of maintaining the chosen occlusal relationships. There are many published techniques for this procedure, none of which has any great superiority over the others. There is some value in allowing the patient to wear the dentures for a short time before adding the metal surfaces. Slight prematurities in eccentric contacts will be more obvious and may even be worn away. Once the occlusion has stabilized, the surface of the resin teeth is captured in either a stone or a silicone putty matrix that includes the associated denture base as a point of reference. The denture is then returned to the patient remount cast on the articulator. Reduction of the denture teeth can be accomplished quickly by removing an equal amount over the desired surfaces (0.75 mm) and adding a central, slightly tapered box form. The teeth are lubricated with a die lubricant and molten wax added to the teeth. The previously formed matrix is forced to place, reproducing much of the original occlusion. Any corrections or additions are made and the patterns carefully removed and sprued from the underside. A retentive groove is now cut in the box extension to provide mechanical retention for the tooth-colored resin that will be used to cement the casting to the denture teeth. The denture is now ready to be returned to the patient and to be worn as-is until the patterns have been cast and finished. The patient will return for the cementing of the castings and final adjustment. The castings are bonded to place when the denture is on the remount base in the articulator with tooth colored auto polymerized resin, aided when possible with modern bonding agents. Patients do not seem to have any particular problem wearing the denture with the missing tooth structure for the few days it takes to complete the castings. The castings can be made in Type VI gold or chrome-based alloys, depending on the patients preference. Either alloy will outlast the rest of the denture and can be expected to eliminate clinically detectable wear. 12.5 Maxillary single dentures. How are the appropriate occlusal plane and compensating curve for the opposing arch determined?

53

What occlusal surface is appropriate for a fixed restoration in the dentate arch opposing the single denture? The single denture is often a greater challenge than complete dentures since, not only are the opposing occlusal contours preexisting, but the patient can be expected to place greater force on the denture. As a result, the single maxillary denture may be less stable and retentive than the upper denture of conventional dentures. Every effort must be made to gain control of the plane of occlusion of the natural arch. This might include: equilibration, restoring the dentition, and resisting the temptation to bring the posterior denture teeth into maximum contact with the opposing natural teeth when those teeth do not have an ideal plane. The clinician is also faced with the difficulty of controlling the incisal guidance since esthetic demands dictate the position of the maxillary anterior teeth and the option of recontouring the mandibular teeth is limited. It is essential, however, that there is no contact in centric relation between the denture and the opposing anterior teeth. The result of initial contact in this area is a denture that contacts only in the anterior once resorption and wear have altered the posterior contacts. Eventually the destruction of premaxillary bone and the formation of redundant tissue masses will occur, resulting in an unstable denture with reduced retention and eventual patient unhappiness. As previously stated, a metal-based denture is often indicated under these circumstances along with metal occlusals. In many situations, there will be less than a full compliment of opposing teeth against which to construct the denture. A decision to replace the missing lower posterior teeth with a removable partial denture must take into consideration the effect of the lack of occlusal support on the stability of the upper denture. In the Class II patient, bicuspid occlusion will often suffice since the retruded contact will extend to the middle of the denture anterior-posteriorly. Class III patients, on the other hand, will require molar support to keep the upper denture stable. If a fixed prosthodontic restoration is considered in the mandible, the extension of a cantilevered pontic distal to the second bicuspid will eliminate the need for a distal extension partial denture. When a removable partial denture is needed in the opposing arch, it should be used to level the plane of occlusion whenever possible. This implies the use of onlay extensions on the occlusal surfaces of malposed teeth. When natural teeth alone make up the opposing dentition, the plane of occlusion of the single denture should be maintained in order to retain maximum stability in function. Not every natural tooth need contact the denture if, in bringing that tooth into contact, the denture tooth becomes a real or potential dislodging factor. Protrusive balance is very difficult to obtain when the opposing occlusal plane is given. The best that can be hoped for is posterior protrusive contacts until the anterior teeth come into first contact. Likewise, extended balancing contacts may be impossible to achieve if the compensating curve that exists on the lower arch is not

54

steep enough. Relatively uniform working side contacts are usually possible and should be created up to the point where anterior disclusion takes place. Dental tooth manufacturers recommend posterior tooth molds to be used with their anterior molds. The size of these posterior teeth is universally smaller, both buccolingually and mesio-distally, than corresponding natural teeth. When selecting posterior teeth for the single denture, it is therefore prudent to choose a tooth that will be in harmony with the opposing natural tooth or fixed replacement. This will usually mean a tooth two sizes larger than that recommended by the manufacturer. In order to position posterior teeth in harmony with the opposing natural teeth, modification of the occlusal surface will be required, as these teeth were designed to be articulated with opposing denture teeth. There are two generally accepted techniques for accomplishing this tooth modification. One is to open the pin on the articulator 1-2 mm, position the teeth esthetically and then adjust the occlusion by grinding the denture tooth to return to the desired occluding vertical dimension. This is time consuming since only one tooth at a time can be positioned. A quicker and, I believe, a more effective method is to recontour all the denture teeth to match the opposing dentition as they are taken off the card. This will usually require reducing the cusp height and widening the fossae, regardless of the mold selected. The teeth are then positioned normally with only minor modifications to tighten the occlusal contacts. When metal occlusals are to be constructed against fixed restorations, it is possible to copy the occlusal surface of the teeth intended to be used opposing the denture, i.e. if a maxillary denture is to be made opposing a mandibular reconstruction, mandibular denture teeth of the same mold as the maxillary teeth are impressed in alginate to cover the occlusal 1/3 of the tooth. When the alginate is set, the teeth are removed and molten wax is poured into the individual tooth molds. These occlusal replicas can then be positioned on the waxed crown copings in harmony with the opposing denture teeth. The result will be an occlusion that is comparable to a conventional denture set-up. 12.6 Relines/rebases. How is the decision to reline or rebase a denture made? The successful reline or rebase of a complete denture is perhaps the most difficult of all clinical procedures since it requires obtaining a quality impression while maintaining or restoring the occluding vertical dimension of occlusion and, at the same time, maintaining maximum contact in centric jaw relation. There is always a tendency not to get the denture seated far enough up and back to achieve the desired result. Many an adequate but loose denture can be rendered useless when this

55

procedure is not carefully done. The most important step is the preparation of the denture base for the impression. The difference between a reline and a rebase lies in the need to re-establish the borders of the denture. When the extension of the existing borders is adequate, then a reline is indicated. When borders must be altered, as in the case of an immediate denture, then a rebase is required. Identification of the contact, or lack thereof, between the denture base and the supporting tissues is essential to determine the amount of relief of the base required to allow the denture to be properly seated during the impression without unduly loading the tissues. This can be accomplished by placing any one of a number of materials into the denture and placing the denture in the mouth. Syringe-weight impression material, very thin alginate mixed with hot water, fit checker or even pressure indicator paste can be used. The creation of 1-2 mms of uniform space is essential with additional relief in the labial flange area of the maxillary denture base and over or adjacent to tori or undercuts in either base. In addition, a relief hole must be placed in the anterior palate of the maxillary base to allow for the escape of excessive amounts of impression material. When both dentures require relines, the least stable denture of the two should be chosen for the first impression. Once the impression has made that denture stable and retentive, the opposing denture impression is made. Relief in the base of the latter is placed only after the initial impression is made. Every reline procedure can be expected to increase the occluding dimension somewhat no matter how much care is taken. When the existing occluding vertical dimension is only slightly over closed it can be re-established in the impression phase. When there is more than 1-2 mms overclosure, then a variation of the regular reline procedure is indicated. The impressions are made without bringing the teeth into occlusion. After both impressions are made and corrected, the dentures are returned to the mouth and a centric relation record is made (usually in wax or compound) at the desired occluding vertical dimension. Before separating the reline impressions, both dentures are mounted in the articulator using the centric relation record. The lower denture (where most of the loss of ridge and of vertical dimension occurs) is separated from the resultant cast and repositioned against the maxillary denture in maximum occlusal contact. It is held in place against the upper denture with sticky wax while the base is sealed to the cast by filling in the flange areas with wax. In this manner, the lost vertical dimension of occlusion is restored and maximum tooth contact re-established in centric jaw relation. The denture must now be flasked and reprocessed in heat cured resin to obtain maximum results. The most common method of performing a laboratory reline is to use a reline jig and auto polymerizing resin. The denture is placed in the jig before the impression is separated and removed to clean up the denture prior to placing the reline material in

56

the denture. Modern reline resins are quite color-stable and should provide an acceptable internal surface. The rebase procedure often requires that the denture be flasked when any dramatic change in the base contour or extensions is made. This procedure obviously takes longer than the reline, often requiring that the patient go without the denture for a full day or occasionally overnight. Rebases of metal based dentures are done in much the same way as for conventional dentures, the only difference being that the cast must be poured as a separate step and, when the stone has set, replacement grooves are cut into the base before the denture is placed in the reline jig. Once the denture has been separated, the cast is removed from the mounting plaster and sent to the laboratory for the construction of the new cast base. The patient is able to wear the original denture, usually with the addition of some tissue conditioning material, for a short time. After the new casting is made, the teeth and associated resin are cut from the old denture the casting and the teeth and resin are returned to the jig and waxed together. Additional wax is added to restore the desired contour and the rebase returned to the laboratory for processing. This procedure also is more time-consuming and more costly that the standard rebase. Since the reline/rebase re-establishes both the internal surfaces and the occlusion, the restored denture must be treated as a new denture. A patient remount procedure is indicated in all complete denture situations. Occasionally a single maxillary denture can be equilibrated in the mouth, but it is always kinder to the patient to have the occlusal adjustments done in the laboratory as a part of a remount procedure. Follow-up care of the relined or rebased denture should be the same as for any new denture. 12.7 Temporary dentures. The need occasionally arises to construct an "emergency" complete denture. Most often, the emergency denture will be for the patient who has lost a denture and cannot wait through the standard appointment series for a conventional denture. An overextended alginate impression in a stock tray that has the desired extensions marked with an indelible marker starts the procedure. By drawing the limits with the patient present, any areas of possible over-extension are usually eliminated. The impression is poured in yellow stone mixed with dense slurry so that little time is lost in setting. An auto polymerizing base is made and two wax rims are added to the base in the bicuspid to second molar area leaving the anterior free. The OVD is quickly established by warming the wax in the water bath and having the patient close in centric relation, either with the anterior teeth of the opposing arch or the opposing complete denture. Once the OVD is established, any excess wax is removed and the record refined so that it is acceptable as a centric jaw relation record.

57

Denture teeth from a mold guide are placed in the mouth with the anterior six teeth being positioned while the posterior wax blocks maintain the occlusion. Once the anteriors have been placed, the wax blocks are removed and a block of four teeth (Dentsply or Ivoclar) is placed on the base with a piece of rope boxing wax. The block of teeth is initially set above the desired occlusal plane and the patient guided into a centric closure using the anterior teeth as a stop. The blocks of four can be easily positioned into an acceptable relation with the opposing occlusal surfaces even if ideal occlusion is impossible. The base is removed from the mouth and the blocks stabilized with baseplate wax. A quick wax-up is completed with attention given only to the contours at the gingival area. The base is returned to the cast and waxed to place. The denture is flasked in the base of the flask, again using slurry. For the second half of the flasking, a roll of silicone putty is placed on the teeth but not allowed to contact the cast. Once this material is polymerized the flasking is completed, making sure that the slurry stone encompasses the putty so that it will not separate from the mold. As soon as the slurry has reached initial set, the flask is placed in boiling water and then separated. The mold guide teeth are removed from the silicone, tooth-colored resin of the desired shade is mixed and immediately poured into the silicone portion of the mold, and the flask is placed in the pressure pot with warm water at 20 lbs. psi for 5 minutes. The flask can then be separated and, if the resin is hard, the arch of "instant" teeth removed and trimmed. The arch is returned to the silicone mold and the flask packed with auto polymerizing base resin. Normal deflasking and finishing procedures complete the temporary denture. If the tissue base relation of this denture is not acceptable, a tissue-conditioning resin (Lynal) can be quickly added. The resulting temporary denture will be compromised esthetically but, since it can be easily constructed in a few hours, the patients are generally satisfied.

13. IMMEDIATE DENTURES How is the decision made between the immediate denture, the overdenture, or the removable partial denture when the patient has only a few questionable teeth remaining? When is a patient truly ready to accept an immediate denture? The immediate denture is presented in the average undergraduate syllabus with little additional discussion required. There are, however, a few specific areas where some further consideration is necessary at the specialists level. Conservative management of the denture base tissue immediately after insertion and for the next few weeks makes a major difference in the patients experience. Whenever possible, no flaps should be used, no bone of any kind should be removed and no sutures placed. The

58

denture should cause no irritation to the supporting tissues so that the only discomfort for the patient is that of the extractions themselves. If the denture is relined immediately with a resilient material such as a tissue conditioner (Lynal), the potential irritation from the hard resin base can be eliminated. For any liner to be effective there must be a minimum of 1 mm of material overall. When only a few teeth are remaining a sectional immediate lining with the tissue conditioner is advocated to reduce the possibility of increasing the occluding vertical dimension. A finishing line is cut around the area that would correspond to the extraction site and the Lynal separator liquid painted on the resin adjacent to the site so that any excess of material that flows over the finish line can be easily removed. Areas of potential loading (on the cuspid eminence, over tori and adjacent to any osseous recontouring) will require a thicker layer for patient comfort. When a large number of teeth are to be extracted a full immediate reline with Lynal is indicated. For these cases the processed base must be uniformly relieved in addition to these critical areas as part of the clinical preparation for the insertion appointment. Where the anticipated ridge undercuts are going to be greater than 2-3 mms, the associated flanges must be shortened to just beyond the height of contour (see Section 12.1, Overdentures). The denture base should be returned to hard resin as soon as initial healing has taken place. Normally, by the end of a month, unless bony recontouring was necessary, auto polymerizing hard resin can be placed after removing all the soft material. At this time, a patient remount procedure is required to bring the dentures into proper occlusion. 13.1 Conventional immediate dentures. This procedure is indicated primarily for those patients who have mature posterior edentulous ridges, most of whom have worn bilateral removable partial dentures successfully for many years and who want minimum changes in the position of their anterior teeth. In all other situations, the interim immediate denture is preferred. The border extensions of the conventional immediate should be identical to that of a complete denture so that a rebase will not be needed. Therefore, a custom tray must be made and the borders established as they would be for the complete denture. A definitive laboratory reline must be done as part of the treatment, usually at the 1-year recall. Temporary relines may be needed during that first year to maintain stability and retention. Most long-term problems with immediate dentures can be traced to not relining the denture after that first year. 13.2 Interim immediate dentures. The major considerations for the interim immediate are related to the border extensions, occluding vertical dimension, tooth selection and placement and post-insertion care. Since this type of denture is made from an alginate in a stock tray, the determination of the border extension will have to be made on an overextended impression. The previously described techniques for identifying and marking the borders on the impression are essential to this procedure. Since the interim will be relined immediately after extraction of the teeth, the borders

59

are to be deliberately short overall by 2-3 mms to assure that the borders cause no irritations. The Lynal reline will functionally extend the borders to approximately the proper extension. Subsequent hard relines will further refine the borders. Every post-extraction addition to the interim immediate will increase the occluding vertical dimension with the potential of intruding on the resting space. The initial OVD must be over closed slightly to allow for these subsequent additions. The patient will always be more comfortable during the initial healing period if there is ample space at rest. The clinician will be faced with the decision of whether to place inexpensive resin teeth in the interim or to copy the patients own dentition in tooth colored resin. This decision is an economic one as well as a technical one. The cost of the least expensive teeth may be far less than a technician would have to charge to flask the denture in silicone and to make an exact copy of the patients teeth in auto polymerized, tooth colored resin, trim them and then process the denture. It is only when the patient wants to copy the teeth exactly that the latter procedure is chosen since the time required to shape denture teeth to match natural teeth exactly makes this approach costly. In order for the interim approach to succeed, the follow-up care must permit an ongoing evaluation of the changes in the supporting ridge and the soft and hard relines necessary to maintain stability and retention. The first hard reline of the interim will occur as soon as the initial healing is complete, usually at a month or 6 weeks. At that time, the occlusion is perfected with a patient remount and the contours corrected. Since the denture required placing resin in areas where there was as yet no loss of contour, the patient may have found that the flanges were bulking out the face in an unnatural way. Once the hard resin has been added, the labial flanges can be thinned from the outside to regain the normal lip support. If this recontouring is to take place, there is little point in doing any festooning or stippling to the original base. The patients who have had their teeth duplicated must expect a darkening of the teeth as the year progresses. In some instances, this change will actually make the denture more lifelike. The patient who can be carried on the interim denture for a full year can be expected to have a reduced need for an early reline of the conventional denture that follows. 13.3 Transitional. The transitional denture is indicated for those patients for whom an interim immediate denture is indicated but who are not, as yet, psychologically ready to become totally edentulous (on the arch in question or in the entire mouth). Often these patients are in pain from caries or, more commonly, from periodontal disease. The transitional immediate differs from the interim only in that it retains teeth, some of which may be clasped. The clasp of choice is always the wire I-bar since it does not cross the occlusal surface and therefore poses no problems for the occlusion. The purpose of the transitional denture is to provide for esthetics, speech and mastication until the patient requests the extraction of the remaining teeth and the conversion of

60

the transitional to an interim immediate denture. Some creativity is required to manage the resin on the lingual surfaces of the remaining teeth since the bases must have sufficient strength to resist flexure. The base must provide full coverage of the denture bearing tissues so that the conversion to the interim immediate denture can be made with a minimum of time and expense. The plane of occlusion should be made as even as possible even though all natural teeth are not in contact with it. Natural tooth reduction is often required to place the plane in such a position that it will be acceptable when the transitional is converted to the interim. 13.4 Surgical stents. When an alveoplasty is required, a surgical stent is of value in establishing the tissue-base relation. In order to be optimally effective, the stent must be an exact replica of the denture base internally. If the processed denture base is adjusted internally as part of preparation for the insertion appointment, it will be necessary to reproduce the internal contours on a cast to be used for processing the stent. An alginate impression is made of the adjusted internal surface of the denture base and then a second alginate is made of the first impression. Since alginate will not adhere to itself once set, the second alginate is separated and poured up to serve as the processing cast for the stent. After the impression for the surgical stent is made, the denture can be further relieved to allow space for the immediate placement of the tissue conditioning material.

14. IMPLANT SUPPORTED/RETAINED COMPLETE DENTURES No discussion of complete dentures is relevant to modern practice if the subject of implant support and retention is not discussed and in great detail. Texts of varying quality abound and it is the intent of this monograph to limit the discussion to the prosthodontic aspects of treatment even though many prosthodontists are currently placing their own implants. There are a number of questions that must be addressed before the planning phase begins. Some of these will have clear answers for the particular treatment in mind, others will be rhetorical at best.

Has the patient had long enough to try to adjust to a properly made complete denture before the decision to add implants is made? Has the patient had an opportunity to speak with other patients with a similar oral situation for whom implants have been used successfully? What are the number and type of implants best suited for this type of patient situation?

61

Will the retentive device(s) connect to the implant fixture or to a trans-mucosal abutment? What type of retention is indicated in this situation and what are the demands that this particular patient will place upon that retention? Are the patients current dentures of sufficient quality that they can be used as a definitive indicator of ideal tooth placement and vertical dimension of occlusion or must a diagnostic set-up of both arches be made before implant location can be determined? Certainly, other questions of equal importance will come to mind. Because of the permanent nature of the implant situation, once integration has occurred, greater diagnostic efforts must be made before final treatment plan options are presented to the patient. 14.1 Evaluation of current dentures. Patients in need of implant support for their complete dentures will enter our practices either with conventional complete dentures, recent immediate dentures or dentate, with a clear indication that their remaining teeth cannot, or should not, be saved. While it is possible to treat the patient needing extraction of all teeth with immediate loaded implants to support some form of complete denture, most patients will go through the immediate denture phase to bring the condition of their mouths to optimum health and to give them a chance to experience all the pleasures of conventional complete dentures. Those whose experience is very positive may wish to defer any thought of implant involvement although they must be advised of the bone-saving potential of endosseous implants. Those patients with current conventional complete dentures must be evaluated initially in the same manner as was described earlier for the construction of new complete dentures. In addition, the position of the existing denture teeth must be evaluated for any changes desired by the patient for esthetics or by the clinician for technical reasons. If the original dentures are acceptable, then they may be duplicated for the construction of radiographic or surgical stents. Given the state of complete denture care in the population at large, it is far more probable that errors in tooth position will be found which require taking the patient through the try-in appointment to be sure that ideal tooth position and vertical dimension have been established. Final impressions of the edentulous arches are not indicated at this time since many months are likely to pass before the patient is ready for the final prostheses. Preliminary alginate impressions can be made of the edentulous arches with emphasis on border extensions or, if the old dentures have reasonable border extensions, they can be copied by placing a silicone putty into any internal undercut areas before 62

pouring in dental stone. The putty must have retentive features on its surface so that it will not separate from the cast upon removal of the denture, as was discussed earlier. If the old dentures are used to create the initial working casts, then an approximate centric relation and vertical dimension of occlusion can be obtained by mounting the casts in a plane line articulator before the dentures are separated from those casts. This procedure relies on the interdigitation of the old denture teeth being positive enough to indicate centric occlusion. Jaw relation records made on resin record bases, as described earlier in this text, will be done in the same way as any complete denture.

Radiographic and surgical stents. Once the ideal tooth position has been established and verified, as described earlier, the fully-waxed trial dentures are placed on the working casts and a putty matrix is made of the labial surface of the teeth and associated gingival contours. The land area of the cast will need to be prepared by cutting positive positioning grooves that will relate the putty to the cast once the denture has been removed. A lingual putty matrix will also be required for the mandibular denture. When completed, the matrices will indicate the desired tooth positions in relation to the residual ridges. They can now be used to locate the optimum position for the chosen implant design, be it a single midline mandibular implant or a multiple implant-supported and retained open palate maxillary metal base denture. The matrices will also indicate the amount of space available adjacent to the proposed implants for the resin denture base. Where little space is found some form of a metal base for the implant denture is indicated. The cost of a cast base is insignificant when compared to the problems of post insertion fracture over the implants. In order to construct clear resin stents, the wax dentures must be duplicated with colloid, either reversible or irreversible, and the mold poured in clear resin. A duplicating flask of any sort can be used to form the mold. Clear Ortho Resin is mixed 2:1 and poured into the mold and then placed in the pressure pot until polymerized. When processed, the clear denture form is finished and polished. If CT scans are to be taken, then radio opaque markers can be placed in proposed implant sites using a 2 mm twist drill to create the holes over the sites and then filling those holes with Hypaque (Diatrizoate Sodium, USP). After the clear resin denture has been used for radiographic analysis of the proposed implant sites, it can easily be converted to a surgical template by removing the Hypaque and sufficient resin to allow the surgeon access for implant placement. Controversy exists on the design of the template in the surgical area. Some prefer to keep the labial contour of the denture and others the lingual. Sometimes it is possible to retain both labial and lingual contours and leave a slot over the proposed implant area. Mandibular stents are notoriously unstable during implant surgery and are best

63

managed by connecting them to a maxillary stent of some sort to maintain their position. These decisions must be made with the surgeon before the surgical appointment. As long as the implants end up in a usable position that does not require the use of additional components, the form the template takes is immaterial. Final decisions on the management of the edentulous ridge must be made at this time as well. The decision as to the planned reduction of the bone is dependent on the space available and the contour of the remaining ridge in the implant site. By knowing the height of the desired implant components and their relation to the planned position of the denture teeth and the plane of occlusion, measurements from bone to the occlusal plane can be made and reductions planned. These measurements cannot be accurately assessed from the normal pantograph films because of the distortion. By placing a steel ball of known dimensions in the stent and marking the occlusal limits of the planned prosthesis with radiopaque material, the actual height of the bone can be established. 14.3 Denture wear during implant healing. Presently, most implant systems require that the patient go without any prosthesis for a period of two to three weeks after implant placement. The clinician is responsible for assisting the patient in selecting the foods they eat during this time. With all the nutritional supplements on the market, there is no reason for any real change in a well-balanced diet. Once the initial healing period is complete, the patients old dentures or temporary ones that may have been constructed for provisional wear must be adapted to the mouth via soft relines. Before any soft reline is considered, the clinician must be certain that there is sufficient space in the old denture to accommodate the addition of the reline material. The denture base material in the area of the implants must be removed and space created for the soft lining material. Fit Checker works well as an indicator of existing space since it sets quickly and cleans up easily. Once the denture base has been relieved, the remaining resin must be evaluated for its residual strength. If insufficient hard resin remains, then an addition of auto polymerizing resin on the outside of the denture (the kind that would be used for a laboratory reline), will be required. The addition of wires, mesh or fibers can also be used to strengthen the denture base. These problems are most often found in association with the mandibular denture. Initially the reline material of choice is a plasticized resin, Lynal being a good example. Once the denture base has been adapted to the altered tissue contours in the area of the implants with the reline material, the denture should be placed in the pressure pot at 20 psi and in 100o F water. In 10 minutes or so, the soft reline material will have sufficient body to withstand polishing with watery pumice at slow speeds. The patient should now have an uneventful healing period up to second stage. If, for whatever reason, the plasticized resin does not hold up well, it will need constant changes. Normally, a hard resin reline in this area is not indicated, unless repeated breakage occurs.

64

14.4 Alteration of the denture at stage two surgery. When the patient returns for stage two surgery to uncover the implants, the denture will again require adjustment. The best plan is to maintain maximum bulk in the denture by placing transmucosal abutments of minimum height onto the implants at this time. If a variety of abutment lengths are available and a decision has been made as to the desired height of the abutment above tissue, then whoever does the stage two surgery can connect the ideal abutment to the implant and thereby eliminate the need for later replacement of the abutments with all the problems that procedure entails. If a bar-clip is the intended device, then the ideal abutment height will be just above the tissue since the placement of the bar onto the gold cylinders is not restricted by the abutment height. For any of the stud attachments, the ideal abutment height will vary according to the requirements of the stud. Once the abutments have been placed and capped, the denture is again relined with the plasticized relined resin. Should there have been fractures during the healing period, the denture can be first with a hard chairside resin to take the place of the original soft resin and then only enough resin removed to allow the soft reline over the abutments. Occasionally, additional resin will have to be added to the outer surface of the denture base to strengthen it, even though doing so will add unpleasant contours for the patient to deal with over the short term. The patient can be expected to wear this denture for a few months until the final prosthesis is completed and, given the great increase in stability and retention that the patient will experience because of the abutment support, there will be increased loading. Patients are usually very pleased at this point since they can see some of the desired results of treatment. 14.5 Final impressions for implant-supported complete dentures. Once healing adjacent to the abutments has occurred, normally at three to four weeks, final impressions that include implant impression copings must be made. There are two commonly used impression techniques for this procedure. Closed tray impressions require an impression tray that has a reinforced opening above the abutments that will allow the implant impression copings to extend through and slightly above the top of this opening. The tray can be border molded and, before the wash impression is made, the opening is covered with a sheet of wax that has been luted to the tray. The tray is reseated and the tops of the impression copings indented into the wax to indicate the position of the copings after the impression is made. When the final wash impression has set, the wax sheet is removed and the impression coping screw access areas are uncovered by cutting away the small amount of impression material that remains, unscrewing the coping screws and removing the impression. Controversy exists on the need to splint the impression copings together with resin before making the final wash. A variety of techniques for splinting with resin have been published and are available in almost all current texts. The use of heavy bodied impression material, such as Impregum, may well make this step unnecessary.

65

Open tray impressions, more apt to be indicated for mandibular implant-supported complete dentures that will be tissue-supported in the posterior segments and therefore require ideal borders, are made with a tray very similar to the one used for the closed tray impression. The only difference will be the requirement for a larger opening around the impression copings. Before attaching the implant impression copings, the tray is treated exactly as it would be for a conventional edentulous impression. Ideal tray borders are developed through techniques described earlier in this text. A final wash impression is made (using the appropriate viscosity of impression material) and, if acceptable, the impression material that fills the hole over the abutments is completely removed, leaving a butt joint in the impression material. Now the impression copings are screwed to place and the final impression reinserted in the mouth. With the impression held in its ideal position, a small amount of low viscosity impression material, compatible with the final wash material, is injected into the opening only to cover the exposed gingival tissues. A second injection of high viscosity material is immediately added into the opening to complete the covering of the implant impression copings, except for the screw access holes. The impression is removed in the same fashion as was described for the closed tray impression. The advantage of the multi-stage open tray impression is that it allows the final impression of all but those tissues immediately adjacent to the implants to be made without the interference of the impression copings and can be expected to result in better border extensions than can be obtained in the one-shot final impression. The low viscosity material at the tissue level is necessitated by the difficulty of injecting high viscosity material down into the opening without creating voids in the impression. The high viscosity material that completes the impression is required to register the exact position of the impression copings without fear of distortion that might occur if only low viscosity material were used. 14.6 Pouring the final impression. These final impressions are boxed and poured in exactly the same manner as any conventional complete denture except for the addition of the laboratory analogues to the impression copings before the boxing and pouring occurs. The analogues, initially made of brass and later of steel, are carefully screwed in place onto the impression coping using the coping screw. Obviously, no torquing of the impression coping in the impression can be allowed so the analogue is held with a hemostat while the screw is tightened. If no contact is made with the impression coping then the possibility of distortion is greatly reduced. The impression is poured in yellow stone to make recovery of the resin base easier. If fixture level impressions are made, the use of a gingival mask of silicone must be considered so that access to the fixture analogue can be achieved without cutting stone from the cast. The silicone mask material is placed around the analogue and allowed to set before the impression is poured. The mask can be removed and replaced as needed during the construction of the implant components. 14.7

66

Construction of a bar and clip mechanism and its housing. In the majority of cases, a bar-clip support and retentive device is constructed as the next procedure for either dental arch. It consists of gold copings that attach, either to the abutments (most commonly) or directly to the implant, connected with some type of precious metal bar with a section that will accept a commercially made clip assembly. The clips were originally gold but can now be made in a plastic material as well. Before constructing the bar, it is essential that the exact position of the denture teeth and base contours be established. There will be instances where the desired position of the teeth and base contours will require the addition of a metal base casting to ensure adequate strength of the prosthesis. In many maxillary situations, a palateless metal base can be used, obviously requiring advance knowledge of the ideal tooth position. Sprinkle-on record bases are made for both arches with appropriate blockout over and around the abutment replicas. If no abutment caps are available to screw on to the laboratory analogues, then an arbitrary addition of wax can be used to simulate their contour. It may be helpful to add one cut-down impression coping to the lower base so that the base may be screwed to place, making the ensuing jaw relation records more dependably reproducible. The cone technique described earlier can be modified for use with this attached base by reversing the position of the cone and the denture teeth. The cone will be placed on the upper base and the occlusal surface analogues added to the lower rim. In other respects, the record-making procedure is identical to that of a conventional denture. Once a repeatable centric jaw relation record has been made, the teeth are arranged as for a conventional denture and the patient allowed the time necessary to ensure his acceptance of tooth position and base contours. These are captured with the use of putty matrices, both labial and lingual, and a spider (our jargon for a device made of either plaster or light cured resin that will relate the position of the teeth to the master cast and allow them to be separated from the trial base and precisely repositioned later). To construct the spider, a minimum of three, or preferably five, repositioning groves will have to be cut into the land area of the cast. These grooves are lubricated and the spider formed by laying down strips of light-activated resin across and along the occlusal surface of the arch, connecting this strip to the grooves with additional strips. The same result can be obtained by laying down strips of impression plaster, though this technique is more sensitive and the plaster is liable to break later if not carefully manipulated. Once the plaster is set, or the resin activated, the spider can be removed, the wax eliminated and the base taken from the master cast. The denture teeth are attached to the spider with sticky wax and the assembly used to evaluate the established tooth position relative to the abutments. The putty matrices will indicate the ideal established contours of the denture base. With the information now available, the gold cylinders can be selected and attached to the lab analogues and the bar waxed into the best possible position.

67

In situations where there is obviously more than adequate space for the bar-clip or stud attachments, this initial record and tooth positioning is not essential and the construction of the bar can be begun directly after the recovery of the master cast. Gold cylinders of appropriate height are placed on the lab analogues and the lab screw tightened slightly (but not over-tightened, or torqued to place). A small amount of auto polymerizing resin is painted in the central groove of the cylinder and allowed to set. The rough outer surface of this resin makes it easier for the wax that will be used to join the bar to the cylinders to adhere. The plastic pattern of the bar needs to be placed with its axis identical to the desired path of insertion of the finished denture. This may mean that soft tissue undercuts will dictate the path of insertion. The plastic bar, or the preformed gold bars (e.g., the Dolder Bar) are cut short of the distance between the cylinders and joined to those cylinders with hard wax. The main reason for having the bar 2-3 mms short of the available space is that this allows the connector area to be hand-waxed, allowing it to rise above the gingival tissues adjacent to the cylinders. A space that will allow the passing of thick floss or cotton yarn must be created to allow access for cleaning and stimulation of the tissues. 2-3 mms of wax are added all around the circumference of the cylinder to complete the wax-up. This wax must remain at least 1 mm from the interface with the abutment analogue to ensure that no metal that could alter the interface is cast to the cylinder. If more than one bar-clip component is to be used, then a positioning device for the dental surveyor must be constructed. A negative of the lateral surface of the bar can be made of Duralay and joined to the analyzing rod of the surveyor with additional resin. The plastic bar pattern can be attached to this device with a small amount of sticky wax and carried to place while attached to the surveyor with the master cast at the proper tilt relative to the chosen path of insertion. When the bar segments are parallel to one another, the wear of the plastic clips will be minimized. The completed assembly is sprued, much as a fixed partial denture casting would be, and the lab screws released to remove the pattern from the cast. The bar assembly is then cast to the gold cylinders using a Type IV Dental Gold or similar alloy. When finishing the unit, the cylinder-abutment interface must be protected by screwing polishing abutments to the cylinders. All of the bar, except for the area where the clip will be placed, can be polished in the usual manner. Bar-clip combinations can also be made to fit directly to the implant fixtures using appropriate component parts. This approach is commonly used when space is at a premium as it might be in certain maxillary overdenture situations. 14.8 Try-in of the bar. A passive fit of the bar onto the abutments in the mouth is mandatory and is most often accomplished with the two-screw test in which all the cylinders are consecutively engaged with a screw while the clinician watches the interface under magnification for signs of movement during the tightening of the screws. Obviously, if the fit is not passive, the bar assembly must be cut, related in the mouth and soldered. The test is then performed again until a satisfactory fit is obtained. If the bar needs to be sectioned and soldered, it may well not fit back on

68

the lab analogues of the master cast. If the discrepancy is very slight, it can be held in place with only one screw while the resin housing for the clip is constructed. If the misfit is gross then one of the lab analogues will have to be cut from the cast and repositioned, using the bar as the guide. It can be rejoined to the master cast with an addition of dental stone. 14.9 Construction of the resin housing. The clip and its metal housing must be added either to resin housing made of auto polymerizing material or to a processed denture base. There are a variety of techniques described in the literature for this procedure. If a metal base is required for strength then the master cast, with the clip and its metal housing in place, is sent to the laboratory for duplication, refractory wax-up, casting and finishing, much as for a removable partial denture framework. For the most commonly used housing, made of an auto polymerizing resin of a shade similar to the color of the final denture base, the bar assembly is blocked out with baseplate wax on the master cast. The blockout will cover almost the entire assembly, exposing only the top of the bar 3 to 4 mms on either side of the clip and the clip housing itself. The contact of the denture base with the top of the bar ensures that the entire load placed on the denture in function will not be transferred to the bar through the clip alone. Only enough wax is added to the lateral surfaces to create space for the rotation of the clip on the bar in function. The clip, depending on the manufacturers design, will allow a certain amount of rotation before it binds so 1 to 2 mms relief will normally suffice. When the blockout is complete, a small amount of unfibered resin is added to the outer surface of the metal clip housing to ensure the best possible retention of the clip in the resin housing. Once this resin is polymerized, the housing is completed by adding resin over all the assembly down to contact with the master cast and the cast is placed in the pressure pot for curing. When the resin is fully polymerized, the cast is placed in hot water to soften the blockout wax that is now on the internal of the housing before attempting to remove the housing. Once this has been done, all wax is removed from the internal surface and the housing replaced on the master cast. If sprinkle-on record bases have been constructed, then the posterior extensions are cut off and added to the housing in preparation for replacing the denture teeth and going on to final try-in. For those situations in which no diagnostic set-up has been done, a record base is added to the housing using ortho resin as described earlier. The obvious difference in color and texture of the two resins will make it easy to identify the junction at final processing. At boilout, the ortho resin components are cut away and the housing is reseated on the flasked master cast. At this time, the inside of the housing is filled with Fit Checker or some silicone of similar weight, the housing is reseated on the bar, the excess silicone is cut away and the final packing completed. The presence of the silicone inside the housing reduces the likelihood that any resin will be forced into the internal of the blocked out housing and allows easy removal of the denture base from the cast after processing. The housing protects the bar assembly from taking the full load of the packing procedure. Should there be any

69

concern that the assembly might bend under the packing force, the assembly is removed prior to packing. Again, the presence of the silicone will support the housing against the force of packing. 14.9.1 Construction of a metal housing. There will be occasions where insufficient space is available, most commonly on the maxilla, to construct a housing in resin. Especially in the midline of the mandibular denture base, thin sections of unsupported resin can only lead to fracture later. In these situations, the construction of a metal housing that will strengthen the midline section as well as protect the bar-clip or any other superstructure) and serve as the point of attachment for the clip or other retentive device is money well-spent since the cost of this type of casting is less than the cost of repairing a broken denture base. The metal housings are custom made and exist in many forms. Most of them will simulate a removable partial denture framework with a major connector, retentive meshwork, and appropriate finishing lines. They can be completely covered with resin or have exposed highly polished metal. Retentive beads or nail heads are the most common form of resin retention. Openings through which the clips or other retentive devices are attached to the castings are formed by placing them on the bar as part of the blockout procedure, thus duplicating their form in the refractory cast. When the wax is applied to the refractory, the projections, representing the clips and their metal housings, will create a precise space in the finished casting with suitable retentive devices, i.e., beads or nail heads, adjacent to the openings. The clips are attached to the casting using auto polymerizing resin after the fit of the casting is verified. Thin and very comfortable castings can give the required rigidity and strength to the denture base. In the maxilla, it is common practice to eliminate most of the palatal coverage if 6 or more implants are available to support the bar. In these situations, the strength and support that comes from covering the palate is no longer required, much to the pleasure of the patient. The most common cast housing, however, is just a thinner version of the auto polymerized resin housing described earlier. It is possible to cast chrome alloys to a thickness of 0.5 mm and still have sufficient strength available for the denture base. This housing will have raised meshwork extending distal to the area occupied by the bar assembly with an internal finish line roughly 3 mms distal to the abutment. The position of the external finishing lines varies greatly but, in general, the lingual border of the denture base is in metal with the resin finishing line just above the border. The metal base is flasked and packed as any partial denture would be. The only exception is that the metal housing must be filled with Fit Checker just before sealing the periphery of the waxed base for investing. Housings for other forms of retention and support all follow this basic description. Most manufacturers of implant devices offer detailed explanations of the procedures required for their use. In addition, there are many fine texts that cover the subject and should serve as additional reading for anyone interested in using this treatment

70

modality. Stud attachments, also commonly used for complete denture retention with implants, can easily be added to processed bases or even completely processed dentures since they can be picked up directly from the mouth without much difficulty. The major drawback to their use is the need for the implants supporting them to be placed nearly parallel to each other. The long axis of the studs must be within roughly 15o of each other or the attachment rings or snaps will not withstand the off angle forces of insertion and removal and will wear out quickly. Very recently, this problem has been somewhat reduced through the use of swiveled studs or angled stud attachments that are cemented to place after being aligned with each other. In the final analysis, the choice between the bar-clip and stud attachments will depend on a number of factors, but the decision between the splinted implant or the freestanding one would appear to be a matter of individual preference. Early on, it was thought that implants that splint each other will do better than those that do not. This may still be the case in maxillary implant situations or where the bone is limited in quality and/or quantity. It would appear from current literature that there is no difference in implant survival for the anterior mandible. An ever changing variety of other implant options are available for the totally edentulous patient, both in the final prostheses and in the various stages of temporary prostheses. These totally implant supported prostheses are the equivalent of fixed restorations and most likely appear on the mandibular arch against a conventional maxillary denture. Tooth placement and gingival contours are greatly influenced by implant placement but generally are very similar to those of the implant supported overdenture previously discussed. While these types of prostheses offer a restoration that generally corresponds to the natural dentition the cost of treatment is often beyond what the average patient can afford. Any attempt to offer more than a very basic presentation of implant-related subjects will quickly become outdated. The principles found in this chapter are intended to acquaint the student with a starting level of knowledge so that future innovations in this aspect of prosthodontics can be seen in relation to basic concepts. Good luck!

71