Complete Denture - Final 01

  1. Anterior teeth are primarily selected to satisfy ________ requirements; Posterior teeth are primarily selected to satisfy _______ requirements.
    • esthetic
    • masticatory/occlusion
  2. Guidelines for selecting teeth
    • Pre-extraction records (photos, diagnostic casts, old
    • x-rays)
    • Existing dentures
    • Patient’s facial characteristics
    • Patient’s sex, personality and age
    • Arch size and shape
    • Patient’s preferences (may override all others)
  3. Dentogenics concept (Frush and Fisher)
    selection of teeth integrated into an esthetic system governed by the sex, personality and age of the patient (S.P.A)
  4. SPA - Sex
    • Male - rugged with square teeth & bold central incisors
    • Female - pronounced curvatures, rounded point angles
  5. SPA - Personality
    • vigorous or delicate
    • most influence than the other two
  6. SPA - Age
    • Young - tapered, ovoid, rounded teeth
    • Middle - somewhere between young and old
    • Old - square, sharp corners
  7. Sequence of Anterior Tooth Selection
    • 1. Size (width and length): first width (small, medium, large), then length (short -> long); the most critical factor in anterior tooth selection.
    • 2. Mould form: “soft” and “bold” based on Fisher and Frush
    • 3. Shade
  8. Size selection
    • Teeth width - the junction of the commissure of the lips represents approximately the distal proximal surface of the canine, plus flexible ruler; OR facial meter based on width of nose
    • Teeth length - direct measurement from wax rim
  9. Shade selection
    • two principal colors: yellow and gray
    • four major shades: differ in hue; the true color (by wavelength); A: yellow; B: brown; C: green; D: grey
    • A1, A2, ...: differ in value; the darkness/brightness of the color; the higher the value, the lighter
    • chroma: concentration of the color
    • Match with skin, hair, eye colors.
  10. Factors Affecting Anterior Teeth Position
    • Esthetics:
    • 1- Lip Support
    • 2- Incisal edge position
    • 3- Occlusal plane
    • 4- Smile line
    • Phonetics:
    • 1- Fricative sounds (F,V)
    • 2- “S” Sounds (closest speaking space)
  11. Lip Support:
    • primarily from anterior teeth position (Wax Rim), not from labial flange thickness.
    • In severe ridge resorption the labial flange thickness plays an important role in lip support along with anterior teeth position.
  12. Incisal edge position:
    • - the incisal edge of the central incisor is 1-2 mm below vermilion border of the relaxed maxillary lip
    • - determines the hight of occlusal plane
  13. Occlusal plane:
    the line passing between the incisal edge position and the midpoints of the retromolar pads bilaterally
  14. Smile Line:
    • - A line formed by the lower lip during smiling.
    • - Ideally the incisal edges of the maxillary anterior teeth, cusp tips of canines and premolars are in harmony with this line (reverse smile line when non- harmonious).
    • - The central incisors and canines are aligned with the occlusal plane and the laterals are elevated 1-2 mm off the occlusal plane.
  15. Phonetics:
    Clinically determined by the assessment of the dynamic position of “teeth” during speech utilizing wax occlusion rims and wax trial denture set-up.
  16. Fricative Sounds:
    The incisal edges of the Maxillary incisors should touch the wet line of the lower lip when the patient makes a fricative “F” and “V”sound.
  17. Sibilant “s” sounds:
    The mandible travels down and forward to create a small space (1mm) between the maxillary and mandibular incisors during the production of sibilant sounds.
  18. Cast landmarks for teeth setting:
    Midline, Incisive Papilla, Anterior land area, Crest of the Ridge, and the Midpoint of the Retromolar Pad.
  19. Maxillary Central Incisor:
    • Facial View
    • - The incisal edge touch the occlusal plane
    • - The long axis shows a slight distal inclination (5˚)
    • Lateral View
    • - The cervical aspect slightly depressed.
    • - the incisal 1/3 perpendicular to the occlusal plane
    • Incisal View
    • - Follow the inner edge of the land area.
    • - Follow the arch form.
  20. Maxillary Lateral Incisor:
    • Facial View
    • - incisal edge 1/2 to 1 mm above the occlusal plane - long axis shows distal inclination (10˚).
    • Lateral View
    • - cervical aspect is more depressed and flared
    • - incisal 1/3 perpendicular to the occlusal plane
    • Incisal View
    • - Follow the inner edge of the land area.
    • - Follow the arch form.
  21. Maxillary Canine:
    • Facial View
    • - The tip touches the occlusal plane.
    • - Distal inclination (15˚)
    • Lateral View
    • - prominent cervical 1/3 perpendicular on the plane of occlusion.
    • Incisal View
    • - Follow the inner edge of the land area.
    • - When viewed from the anterior, only the mesial
    • plane should be visible.
  22. A straight line should touch the necks of the central, lateral and canine simultaneously, which confirms that the lateral’s neck is depressed, while the canine’s neck is prominent.
  23. The curved template on the Trubyte ruler should superimpose over the incisal edges of the maxillary anterior teeth. This confirms the arrangement is not too flat.
  24. A try in, limited to the anterior teeth only, is a wise step in treatment. An incorrect midline can be easily corrected if only the anterior teeth have been set. If the anterior teeth are arranged accurately in the clinic, a technician can correctly arrange the posterior teeth in the lab.
  25. Mandibular Anterior Teeth
    • - Incisal edges are parallel to the occlusal plane.
    • - The labial surface of the central and lateral incisor is perpendicular to the occlusal plane. The teeth are slightly labially inclined.
    • - neck of Canine prominent and distally inclined
    • - horizontal overlap is 1.5 mm
    • - vertical overbite depends on the type of occlusion and posterior teeth. 0 mm in Monoplane Occlusion and up to 2 mm in Balanced Occlusion .
    • - No contact in Centric Occlusion
  26. The Smile Line: A line formed by the lower lip during smiling. Ideally the incisal edges of the maxillary anterior teeth, cusp tips of canines and premolars are in harmony with this line.
    • a. true Correct
    • b. false
  27. phonetics can check the anterior teeth position, the following letter may be used to check the incisal edge position of the maxillary central incisor:
    • a. f Correct
    • b. m
    • c. p
    • d. b
    • e. s
  28. Goals of Complete Denture Occlusion
    • - Minimize trauma to the supporting structures
    • - Preserve remaining structures
    • - Enhance stability of the dentures
    • - Facilitate esthetics and speech
    • - Restore mastication efficiency to a reasonable level
  29. Posterior Tooth Forms
    • - Anatomic, Cusped 33 degree teeth, first
    • introduced by Dr. Alfred Gysi 1913 (True-Bite
    • teeth)
    • - Semi-Anatomic (10,20 degree)
    • - Non- Anatomic, 0-degree, Monoplane teeth first
    • introduced by Sears 1928 (Channel teeth)
  30. Concepts of Complete Denture Occlusion
    • - Bilateral balance Concept
    • - Neutrocentric Concept
    • We prefer bilateral balance because it limits tipping of the dentures during parafunctional habits.
  31. Bilateral Balanced Denture Occlusion
    • - stable simultaneous contact of opposing upper and lower teeth in centric relation position
    • - smooth bilateral gliding contact to any eccentric position within the normal range of mandibular function
    • - developed to lessen or limit tipping or rotation
    • - can be achieved by:
    • 1- Cusped teeth cross-tooth/cross-arch balance: both the buccal and lingual cusps for the laterotrusive side (cross tooth balance) and buccal cusp for the mediotrusive side against max L cusp (cross arch)
    • 2- Monoplane teeth with balancing ramps - In all lateral excursions at least three points of contact bilaterally.
  32. Balance in Monoplane teeth
    • Minimize vertical overlap
    • no incisal guidance
    • simultaneous contacts in the front and back
    • has to have accurate jaw relationship, precise mounting, minimize lab errors
  33. Monoplane Occlusion (Neutrocentric Concept)
    • By De Van 1954
    • - neutralization of inclines
    • - centralization of occlusal forces on the denture foundation.
    • - assumes the occlusal plane be parallel to the denture foundation area and not dictated by condylar inclination (no condyle guidance).
    • - no curve of Wilson or Spee (compensating curve) incorporated into the set up.
    • - no vertical overlap of the anterior teeth.
    • - patient is instructed not to incise the bolus. “the patient will become a chopper, not a chewer or a grinder.”
  34. Five factotors involved in arrangement of teeth w/ Monoplane Occlusion (Neutrocentric Concept):
    • - position: central position
    • - proportion: reduction of 40%
    • - pitch: the occlusal plane is parallel to the ridge.
    • - form: cusps are flat w/o affecting chewing
    • efficiency
    • - Number: eliminate second molar/premolar in cases of setting on inclined plane
  35. Monoplane Occlusion (Neutrocentric Concept) - protrusive
    • - separation in the posterior regions
    • - leading to tipping
    • - may be disadvantageous in patients w/ para-functional grinding habits
  36. Lingualized Occlusion
    • - a special teeth arrangement in which max lingual cusp in contact w/ central fossae of opposing lower teeth.
    • - The cuspal inclines of the mandibular teeth are flat or relatively flat (Semi Anatomic), resulting in potentially less lateral forces and displacement during function.
    • - only max posterior lingual cusps are in contact in centric and eccentric movements
    • - realized by making the buccal cusp 0.5-1mm shorter
  37. Lingualized Occlusion - Indications
    • - High esthetic demands
    • - Severe mandibular ridge atrophy
    • - Displaceable supporting tissues
    • - Malocclusion
    • - Previous successful denture with Lingualized Occlusion
  38. Lingualized Occlusion - advantages
    • - Good esthetics
    • - Freedom of teeth (no interlocking)
    • - Potential for bilateral balance
    • - Centralizes vertical forces
    • - Minimizes tipping forces
    • - Facilitates bolus penetration (mortar and pestle effect)
  39. Hanau’s Quint - Five Factors Affecting Occlusal Balance
    • 1.Condylar Inclination (Guidance)
    • 2.Incisal Guidance
    • 3.Occlusal Plane Inclination
    • 4.Compensating Curve
    • 5.Cuspal Inclination
  40. Inter-relationship of Hanau's Quint may be described by Theilman’s Formula
    • C = Condylar Inclination x Incisal Guidance / (Occ Plane x Cuspal Inclinationx Comp Curve)
    • To maintain a balanced occlusion, C needs to be minimized
  41. Of Hanau's Quint,
    • - the patient presents you with Condylar Inclination
    • - Occlusal Plane cannot be altered substantially since functional requirements dictate its position and orientation
    • - The remaining three factors can be controlled by the dentist
    • - Within the confines of esthetics and phonetics, minimize Incisal Guidance in Complete Dentures to minimize tipping forces, Adjust remaining factors to maintain balance
  42. Is “Balance” Necessary? - Tests of Balanced and Non-balanced Occlusions, Trapozzano, 1960
    • 1) No patient preference
    • 2) Balanced slightly more efficient
    • 3) Should only used in patients with para-functional habits.
  43. “Simplification of Occlusion in Complete Denture Practice: Posterior Tooth Form and Clinical Procedures” - Dale Smith, 1970.
    • 1) Advocates cuspless teeth primarily for ease of use
    • 2) May use balanced occlusion but can’t prove that it is necessary
  44. Complete Denture Occlusion
    • Investigators have not shown one type of denture occlusion to be :
    • - Superior in function
    • - Safer to oral structures
    • - More acceptable to patients
    • Neuromuscular control may be the single most significant factor in the successful manipulation of complete dentures under function.
    • Tongue function and denture wearing experience are essential factors for patients acceptance.
  45. Factors Affecting Posterior Tooth Selection
    • 1.Resorbed or flabby ridges - avoid anatomical
    • 2.Physical condition of the patient - monoplane occlusion, non-anatomical teeth
    • 3.Patients who clench or brux - monoplane occlusion, non-anatomical teeth
    • 4.Previous denture occlusion - depends
    • 5.Ridge relationship - non-anatomical for class II or III
    • 6.Opposing arch
  46. Resorbed or flabby ridges
    • - difficult to obtain accurate intraoral records
    • - permit movement of the denture bases during function
    • - poor stability
    • - best served with semi anatomic, none anatomic or lingualized occlusion teeth.
  47. Physical condition of the patient
    • - poor neuromuscular control -> difficulty accommodating to anatomic occlusions
    • - potential poor follow up
    • - best served with monoplane occlusal scheme with monoplane (none anatomic) teeth.
  48. Patients who clench or brux
    • - Anxious, nervous individuals
    • - especially traumatic to the supporting structures when anatomic posterior denture teeth are used.
    • - best served with monoplane occlusal scheme with monoplane (none anatomic) teeth.
  49. Previous denture occlusion
    • - If the present is anatomic, not severely ground or worn, alveolar ridges not severely resorbed -> anatomic teeth can be used.
    • - If existing denture teeth have been worn flat -> none anatomic teeth.
  50. Ridge relationship
    class II & III requires non-anatomic posterior teeth w/ open fossae which permit multiple contact positions (anterio-posterior) w/o occlusal interferences.
  51. Opposing arch
    • opposing natural dentition -> Anatomic or Semi Anatomic teeth
    • Since artificial teeth have their own morphology, they do not occlude well against natural teeth. Both artificial & natural teeth need to be re-contoured to better receive the opposing teeth.
  52. Indications for Non-anatomic
    • Poor Residual Ridges
    • Poor Neuromuscular control & Potential poor follow-up
    • Bruxers & clenchers
    • Previously successful with Monoplane Dentures or Severely worn occlusion on previous denture
    • Arch discrepancies - Class II or III & Cross-bite
  53. Indications for anatomic/semi-anatomic
    • Good Residual Ridges
    • Well Coordinated Patient
    • Previously successful with anatomic dentures
    • Denture opposes natural dentition
  54. Non-anatomic (monoplane occlusion) - Advantages
    • Reduction of horizontal forces
    • CR can be developed as an area instead of a point
    • Freedom of movement
    • Can develop solid occlusion despite arch alignment discrepancies
    • Easily adapted to situations prone to denture base shifting
    • Easy to set and adjust teeth
  55. Non-anatomic (monoplane occlusion) - disadvantages
    • No vertical component to aid in shearing during mastication
    • Esthetically limited (don’t look like natural teeth)
  56. Anatomic/semi-anatomic - Advantages
    • Definite point of positive intercuspation may be developed
    • Esthetically similar to natural dentition
    • Tooth-to-tooth and cusp-to-cusp balanced occlusion can be achieved
    • Maintains some shearing ability after moderate wear
  57. Anatomic/semi-anatomic - Disadvantages
    • Difficult to set
    • Less adaptable to arch relation discrepancies
    • Horizontal force development due to cusp inclinations
    • Harmonious balanced occlusion is lost with time
    • Requires frequent follow-up and may require more frequent relines to maintain proper occlusion
  58. Non-Anatomic teeth are characterized by their lack of cuspal inclinations. This occlusal scheme is indicated when the philosophy is to reduce horizontal forces of occlusion.
  59. Typically when selecting Non-Anatomic denture teeth the Neutocentric concept is used as a guide for setting the teeth.
  60. monoplane teeth don't have to use monoplane occlusion, can use balanced occlusion too.
  61. Begin by adjusting the condylar indication to a zero degree, and check to ensure that the incisal guide pin is set at zero and in contact with the flat incisal guide table.
  62. Pound’s triangle
    • - The triangle from the mesial contact of the canine to the buccal and lingual aspects of the retromolar pad
    • - can be used as a guide for positioning of mandibular posterior denture teeth
    • - lingual surfaces of posterior lower teeth should be within this triangle
  63. Posterior Teeth Setting
    • - Position the posterior mandibular teeth over the crest of the ridge.
    • - The mandibular occlusal table should end prior to the ascending ramus.
    • - The distal surface of most posterior maxillary denture tooth should extend 1-2mm distal to the most posterior mandibular denture tooth.
    • - align the lingual cusps of all four posteriors to a straight line
    • - align the buccal cusps of the two premolars and the mesio buccal cusp of the first molar to a straight line, and also align the 2 buccal cusps of the first molar and the 2 buccal cusps of the second molar to a straight line, the two lines creating a 15 degree.
    • - Occlude the mandibular teeth to the maxillary teeth w/ approx. 1.5 mm of buccal overjet, which is essential to prevent “cheek biting".
  64. There is a root part that makes the bone bulge out, Interdental papilla should be concave and the bone part should be convex. To reporduce this wavy contour is called festooning.
  65. Benefits of properly contoured dentures
    • - Improved esthetics for patients w/ high smile line
    • - Provides appropriate support and contour of lip and cheek
    • - Improved tolerance and comfort
    • - Facilitates stability and control.
    • - Prevents chronic biting of the lip or cheek.
  66. Esthetics
    • - crown: exposed up to CEJ; longest at canine, gradually decrease posteriorly
    • - Gingiva: slightly rolled and seals the tooth
    • - Interdental papilla: flat or slightly convex; more natural appearance; avoid food impaction
    • - Gingival margins: progressively superior from central to lateral to canine.
    • - Interproximals: free of wax by fine floss
  67. stipple
    • a) Esthetics – reflection of light
    • b) Keeps food particles from traveling up to the periphery of the denture
  68. Lip Support
    • - thickness of labial flange impacts lip contours
    • - primarily developed during border molding
    • - Maxillary & Mandibular cuspid eminence enhance
    • lip support and contour.
    • - Proper contours will also minimize biting of the lips
    • and cheeks.
  69. Prevention of Cheek Biting
    • - Proper development of the maxillary& mandibular cuspid eminences helps displace the corners of the mouth and the lip away from the biting zone
    • - combination of gingival roll, slight concavity between gingival roll, and periphery of the denture in the posterior region helps to displace the buccal mucosa away from the biting zone.
  70. Prevention of Tongue Biting
    Lingual contour of the mandibular denture should be concave and there should be a slight gingival roll to prevent tongue biting and to anchor the denture teeth within the acrylic resin.
  71. Denture Stability
    This lingual concavity also facilitates stability and control of the denture. During mastication, the tongue is pressed against this concave lingual surface while simultaneously placing the bolus onto the occlusal table. The action of the buccinator prevents the denture from being displaced laterally.
  72. Palate must be smooth and approximately 3 mm thick
    promote proper speech articulation and reduce the incidence of gagging.
  73. Technique used for building denture from waxup
    lost wax technique
  74. Denture processing
    • - Festooning
    • - Seal periphery of the denture flange to the inner edge of the land of the cast, preventing moving
    • - soaking and separating casts from mountings, good for lab remounting
    • - flasking
  75. Flasking
    • - Land area should be a little bit lower than the side of the flask; enough space around; 5-6 cm space on top.
    • - vaseline everything for future separating
    • - making the mold w/ mounting stone; fill the bottom; push the cast in until flush w/ the land area; clean the excess - metal-to-metal contact; convergent contour - no interlocking between the top and bottom molds
    • - vaseline the entire top surface except the teeth (teeth will be attached to the top mold)
    • - coat the top w/ microstone, which has more working time
    • - put top half of the flask on, metal-to-metal
    • - fill the flask w/ microstone, slowly, on vibrator; make sure there is excess when putting the cover on - void free
    • - set for 45 min
    • - machine using lost wax technique; hot water; 20 min
    • - remove the record bases and wax gently
    • - put in a machine w/ high temperature water/steam to clean off the wax
    • - coat w/ Alcote, separating material, liquid alginate, tin foil substitute, not vaseline, which cannot separate in heat
    • - packing: put acrylic in (3:1); stages go through: sandy -> sticky -> doughy (longest, not sticky, working stage) -> rubbery -> hard; close, remove excess, close under pressure (w/ celluloid paper, takes time, and removes detail; or not) for at least 30min
    • - curing: in water bath w/ pressure on; overnigt at 165F, vaporize the monomer most thoroughly, or 165F for 1.5hr and boiling for 1hr; too hot too fast will boil monomer and leave bubbles
    • - deflask: break off the stone, approaching from the top, keeping the denture on the cast and clean as much as possible.
  76. Alternative Processing Methods - according to the Heat source:
    • • electric heat
    • • infrared
    • • microwave radiation
  77. Alternative Processing Method - Injection processing
    • electronic packing
    • reduced shrinkage
    • less airborne monomer
  78. Lab Remount and Occlusal Equilibration
    • Corrects occlusal errors that occurred in processing (7% shrinkage)
    • Returns dentures to correct vertical dimension of occlusion
    • Restores bilateral balanced occlusion
  79. Lab remount corrects the lab processing errors (by selective grinding), not clinical error like CR relationship
  80. Remount w/ superglue
  81. Finishing and polishing
    • - Remove Dentures from Master Casts by cracking the cast piece by piece; clean the stone w/ ultrasonic cleaner overnight
    • - finish borders with an acrylic bur
    • - preserve the border width and contour
    • - maintain concave mandibular lingual & buccal
    • - remove stone from proximal areas with a brush wheel
    • - palate should be 2 mm thick
    • - polishing: not the internal (intaglio) surface; only the external (polished) surface is polished with wet pumice and rag wheel; use the lathe on slow to avoid burning acrylic
    • - remove bubbles around teeth with chisels
  82. Dentures must remain in water for 72hours before delivery
  83. Support, Stability, Retention are achieved by
    • - Appropriate occlusion
    • - Polished surface contour - neuromuscular control
    • - Intaglio surface adaptation - maximum adhesion and cohesion
    • - Peripheral seal - maximize negative atmospheric pressure (suction)
  84. Posterior Palatal Seal (PPS) is used to compensate for the shrinkage, not to create negative pressure (secondary function, not the most important)
  85. Ah-line can only be determined from function, not anatomy.
  86. In between the Ah line and the posterior border of the hard palate you build the PPS area, also called post-dam.
  87. Wider soft palate means wider area, from the end of hard palate to the Ah line, called Class I; Class II, Shorter; Class III, Even shorter.
  88. Determination of the PPS
    • - Transfer ink to record base
    • - Trim record base to vibrating line
    • - Copy extent of displaceable tissue to cast
  89. Posterior palatal seal forms
    • - Single bead
    • - Double bead
    • - Continuous
  90. Overdenture
    • Complete denture covering natural tooth
    • keep 4-5 teeth, cut down to gum (1.5mm above)
    • dome shape - protect the denture, no sharp angle
    • root canal
    • higher ridge, better support
  91. Overdenture Advantages
    • - Preserve alveolar bone
    • - Improved proprioception
    • - Potential for ↑ stability and retention - Only with attachments
    • - Neuromuscular and Sensory Feedback
    • - Proprioception of denture 50% of teeth
  92. Overdenture Requirements
    • - Minimum 5mm root in bone
    • - Endodontic therapy
    • - No tissue undercuts - otherwise the flange is too bulky, lip gets pushed on too much
    • - inter-arch space
  93. Residual Ridge Height - Mandibular Resorption
    • - 4X more than maxilla
    • - decreased width ↓ support
    • - decreased height ↓ stability and retention
  94. Overdenture Abutments
    • Casting - Post and dome
    • Direct restoration - Seal endo access; Composite, amalgam
  95. Abutment preparation for casting
    • Follow ridge contours and support gingiva
    • 1mm emerges from gingiva, can't be too high; 2/3 on the lingual side, longer slope
  96. Overdenture Maintenance
    • Denture recall - Reline PRN (As Needed)
    • Dental recall - Prophylaxis; Endodontic eval; Caries control
    • Daily fluoride - Two drops in each abutment
  97. Implant doesn’t give stability (bone lost already; support provided by soft tissue), but gives retention; casting/abutment gives stability, but not much retention.
  98. Implant Overdentures
    • 2 implants
    • - Implant retained, mucosa supported
    • - Retention- significant in mandible
    • - Stability- minor
    • - Support- negligible
    • Contraindicated in maxilla
    • - Negative atmospheric pressure? If 4 maxillary implants, no need for palatal part of the denture.
  99. Locator attachment
    • 3.17-4.5mm; shorter than the others
    • metal housing, nylon retention
    • “dual-retention” design = 2X retention of ERA
    • laboratory test = 28X longer lasting than ERA
    • Self-aligning feature
    • Resilient and pivoting
    • Need 4.5mm of space
  100. The nylon part
    • Blue (1.5 lbs.)
    • Green (Extended range)
    • Black Processing male
    • Pink light retention male (3 lbs)
    • Clear full retention male (5 lbs; for young people or wide angle)
    • Block-out spacer ring
    • last four included in Locator Processing Package for chairside pick-up
  101. Overdenture Delivery
    • - Denture base contacts abutments after tissue
    • compression
    • - White block-out ring placed over each locator abutment
    • - Then black processing male placed onto locator abutment
  102. Tighten the implant with
    Locator Abutment Driver
  103. Try on the denture with implants on
    • Metal housign, processing male and block-out spacer ring come off together with the denture
    • take the processing male off with the male removal tool
    • Using the Male Seating Tool to put the right retention male into the metal housing
Card Set
Complete Denture - Final 01
Complete Denture - Final 01