224
The Resorptive Pattern Landa LS. Dent Clin North Am 1977;21:285-98.
The Resorptive Pattern
Landa LS. Dent Clin North Am 1977;21:285-98.
Muscles of Facial Expression
Vertical Dimension Evaluation
Preextraction Records
A Revealing Composite
Diagnostic Records
Diagnostic Records
A Triptych
Biometrics
• Mold • Size • Proportion • Midline • HP of MAS • Arch Form
Mold
Brodbelt RH et al. J Prosthet Dent 1984;52:588:92.
Trubyte Bioform System
Size
Scandrett FR, et al. J Prosthet Dent 1982;48:15-22.
16 TO 1
Cesario VA Jr, Latta GH Jr. J Prosthet Dent 1984;52:641-3.
Size
IPD/6.6=MDW of CI
Mean MDW (male)= 9mm
Mean MDW (female)= 8.5mm
Abdullah MA. J Prosthet Dent 2002;88:16-20.
Size
MDW CI = .618 X ICD 2
Mean MDW = 8.9 mm males
8.68 mm females
Is Beauty Reducible to Proportions?
Golden Proportion
89/55
1.618/1
Levin EI. J Prosthet Dent 1978;40:244-52.
Marquardt’s Analysis
Nefertiti circa 1400BC Roman 164 AD Marilyn Monroe
A Handy Ratio
The Perceived Width of Maxillary Anteriors
Preston JD. J Esthet Dent 1993;5:247-51.
Preferences of Anterior Tooth Proportion
Rosenstiel S, et al. J Prosthodont 2000;9:123-36.
n gp
70% 80%
Preferences of Anterior Tooth Proportion
Rosenstiel S, et al. J Prosthodont 2000;9:123-36.
CI W/H ratio = 0.75
A
B
n
70%
gp
80%
Normal or Short Teeth
70-80% ratio
Midline
Anatomic Landmarks ?
Latta GH Jr. J Prosthet Dent 1988;59:681-3.
Midline
Midline
Pinho S, et al. J Orthod Dentofacial Orthop 2007;132:748-53.
Horizontal Plane of Maxillary Central Incisors
Schiffman P. J Prosthet Dent 1964;14:469-72.
Horizontal Plane of Maxillary Central Incisors
Horizontal Plane of Maxillary Central Incisors
Park Y-S, et al. J Prosthet Dent 2007;98:312-18.
Men>AL<PMD than Women
CI Women>labially pos. to canine than men
Law of Harmony Facial Form and Arch Form
Square Diastemas 24% incidence
Facial Form and Arch form
Tapering Crowding 31% incidence
Dentogenics
Frush JP, Fisher RD. J Prosthet Dent 1955;5:586-95.
Dentogenics
SPA
Burchett PJ Jr., Christensen LC. J Prosthet Dent 1988;59:175-9.
Arrangement of Teeth
Axial Asymmetry
Cuspid Rotation
Lateral Incisor Rotation
Physiologic Wear
Dynamic Rotation
Anterior Arrangements
Anterior Set-up
Size
Shade Considerations
Hassel AJ, et al. J Prosthet Dent 2008;99;101-6.
Higher values associated with lighter eye color/females
Lower saturation of chroma for females
Tooth Display
1.9 mm Average maxillary central incisor exposure 3.4 mm
Visual Harmony
Lip Support
Krajicek DD. J Prosthet Dent 1969;21:122-31.
Lip Thickness
Anterior Tooth Display
Papillameter
Grant AA et al, Complete Prosthodontics: Problems, Diagnosis and Management. 1994
Smile Line
Smile Line
Smile Line
Phonetic Keys
Fricatives
Incorrect Fricatives
F sound like V-TL
V sound like F-TS
Anterior/Posterior Malpositioning
Phonetic Keys
Sibilants
Phonetic Keys
Sibilants
A L S
Mandibular Anterior Display
Sackstein M. Int J Prosthodont 2008;21:149-51.
Mandibular Anterior Arrangement
Buccal Corridor
Posterior Teeth Esthetics
Facial Width Compensation
Golub-Evans J. Dent Today 2003;22:66-68.
Posterior Occlusal Plane
Completed Wax-up
Anterior Teeth Set-up
Anterior Try-in
Esthetic Zone
You be the Judge
Denture Tooth Selection
Subjects Per Width
Width of Anteriors on Curve
LaVere AM, et al. J Prosthet Dent 1994;72:381-4.
Subjects per width
Phonetic Keys
Sibilants
A L S
Occlusal Schemes for the Edentate
Terrell WH. J Prosthet Dent 1958;8:740-52.
Circa 1600
Advantages of Balanced Occlusion
1) Chewing 2) Swallowing 3) Parafunctional
movements 4) Christensen
Phenomenon
Brewer AA, Hudson DC. J Prosthet Dent 1961;11:62-72.
Bilateral Balance vs Canine Guidance
Rehmann P, et al. Int J Prosthodont 2008;21:60-61.
38 patients 2 week/4 week evaluation 63%/47%
Occlusal Schemes for the Edentate
• Balanced • Monoplane • Lingualized
Lang BR. Dent Clin North Am 1996;40:85-101.
Balanced Occlusion
working
balancing protrusive
Hanau’s Quint
• Condylar Inclination • Incisal Guide Angle • Orientation Plane • Compensating Curve • Cusp Inclination
Levin B. J Prosthet Dent 1978;39:254-8.
Protrusive Guidance
45o
30o
15o
Mandibular Anterior Set-up
15o Pro 5o Lat
MacEntee MI. The Complete Denture: A Clinical Pathway 1999;Quintescence Pub Co.
Arrangement of Mandibular Anterior Teeth
Verify Centric and Protrusive Jaw Relationship
Langer A, Michman J. J Prosthet Dent 1969;21:599-606.
Maxillary Posterior Teeth
Occlusal Plane Verification
Occlusal Plane Verification
Dynamic Spiral
Mandibular Posterior Teeth
Completed Set-up
Balanced Occlusion
working
balancing protrusive
Anatomic Teeth Advantages • More efficient
chewing • Can harmonize with
TMJ and muscles • Resist rotation • Enhanced esthetics • Aids in verticalizing
chewing cycle
Disadvantages • Technique sensitive
• Reline more exacting
• Jaw discrepancies more difficult
• Requires NMC for CR
• Lateral torque in eccentric positions
Indications for Monoplane Teeth
Nonanatomic Occlusion
Nonanatomic Occlusion
Centric Relation Centric Relation
Protrusive Protrusive
Protrusive Excursion Options
Nonanatomic Teeth Advantages • Simpler technique and
articulation • Minimize horizontal
pressures • Centric relation an area
rather than a point • Offridge relations easier • Accommodate resorptive
changes better
Disadvantages • Less efficient in mastication
• Encourage a higher degree of lateral chewing
• Often inadequate food escapeways
• Inferior esthetics.
Lingualized Occlusion
Kimoto S, et al. Int J Prosthodont 2006;19:103-9.
28 patients LO/BBO
LO-Retention rated higher
Lingualized Occlusal Scheme
Lateral Excursions Right Working
Right Balancing Left Working
Left Balancing
Medial Lateral Curve
Advantages of Lingualized Occlusion
• Centers the occlusal forces over ridge • Only one contact point • Buccalization of buccal cusps • Simplification of set-up • Can be used for all ridge morphologies
Lingualized vs Monoplane Occlusal Scheme
• 30 patients • 3 week evaluation • Crossover study • Questionnaire
Clough HE, et al. J Prosthet Dent 1983;50:176-9.
RESULTS
67% preferred lingualized design
a) Masticatory ability
b) Comfort
c) Esthetics
The Procedure
Reinforced Registration Bases
Denture Base Systems
PMMA heat-cured PMMA auto-cured Triad Eclipse
Ali IL, et al. J Prosthodont 2008;17:545-49.
Higher flexural strength
Higher elastic modulus
Maxillomandibular Relations
Anterior Try-in
Anterior Posterior Wax-up
Intraoral Verification
Right Lateral Left Lateral
Centric Relation Protrusive
Posterior Set-up Vis a Vis the Tongue Position
Esthetic Evaluation
Esthetic Evaluation
Centric Relation Record
Posterior Deflection
A. Apparent Interdigitation
B. Actual Contact
Aluwax Remount
Eccentric Records
Protrusive Left lateral
Right lateral
Wash Impression
Rearticulate Casts
Selection of Denture Base Color
Processed Dentures
Inspection of Arch Form
Verification of Vertical and Horizontal Records
Equilibration
High Cusp
Grind the Fossa
Equilibration
Max. Molars Too Far Buccal
Grind Buccal Inclined Planes of Max. Grind Buccal Inclined Planes of Max. Lingual Cusps and Lingual Inclined Planes of Mand. Buccal Cusps
Equilibration
Max. Molars Too Far Lingual
Grind the Lingual Inclined Planes of Max. Buccal Cusps and Buccal Inclined Planes of the Mand. Lingual Cusps
Equilibration
High in Centric High in Working
High in Balancing Cusp Reduced
Equilibration
High in Centric OK in Balancing
OK in Working Deepen the Fossa
Intraoral Evaluation
CR Protrusive
RW LW
Reduced Processing Time
Cleaner
Superior Adaptation
Porosity (Thick)
Processsing
Compression Molded
Injection Molded
Microwave Polymerized
Keenan PL, et al. J Prosthet Dent 2003;89:37-44.
Characterizing the Base
Application of Tints
Stage
Characterized Complete Denture
Complete Denture Education Preliminary imp.- 87% VLC record base- 70% Semiadj. articulator- 98% Semianatomic teeth- 70% Protrusive record- 80% EO, S, E technique VD- 59% Facebow registration- 75% Clinical remount- 91% Compression tech.- 84% Petropoulos VC, et al. Petropoulos VC, et al. J Prosthodont 2005;14:191-7.
Placement Appointment
Inspection of Intaglio Surface
Management of Tissue Surface Discrepancies
Evaluation of Peripheries
Correction of Occlusal Discrepancies
Centric Relation Registration
Remount Procedure
Shigli K, et al. J Prosthet Dent. 2008 Jan;99:66-72.
Equilibration
Occlusal Balance Verification
Kerr’s Occlusal Wax
Viscogel Refit
Elsemann RB, et al. Int J Prosthodont 2008;21:486-88.
Technique for Application of Tissue Conditioner
• Relieve 1-2 mm • 2.5/2 P/L ratio for
30s, 3 min. stand • Lubricate, roll into
ribbon 1/4’’ diameter • Place on periphery • Allow patient to
make functional movements- 5-10m
• 1:1 L/P ratio for intaglio
Landesman HM. J Prosthet Dent 1980;43:348-51.
Durable Tissue Conditioner
Patient Instructions
Burnett CA, et al. Eur J Prosthodont Restor Dent 1993;2:79-83.
Written and Verbal Instructions
Post-Insertion Adjustments
Lipstick and PIP
Overextensions
Fit Checker
Kerr Disclosing Wax
Correcting Posterior Palatal Seal
Kim Y, et al. J Prosthodont 2008;17:211-18.
Phonetic Evaluation
Kong H-J, Hanson CA. J Prosthet Dent 2008:99:243-8.
‘Sh’
Palatograms
Protocol for Phonetic Resolution
1. Compare new set with old one 2. Attempt to mimic distorted sound 3. Make necessary modifications with wax 4. Have the patient’s hearing evaluated 5. Refer to a speech pathologist
Functional Refit
Adaptol wax sticks
10 drops of vegetable oil
Laboratory Reline
Sadowsky SJ. J Calif Dent Assoc 1992;20:59-62.
Resilient Denture Liners • Reduce localized
pressure • Acrylic/silicone
based liners • Heat-polymerized
silicone liners-higher bond strength/lower hardness.
Mese A, Guzel KG. J Prosthet Dent 2008;99:153-9.
HPA ASB
ARB
Molloplast-B
• Mandibular denture satisfaction
• Candida growth • Life span • Cratex wheel
adjustment
Mutluay MM, et al. Dent Mater J. 2008;27:44-7.
Denture Tooth Retention
Meijer GJ, Wolgtren PJ. J Prosthet Dent 2007;98:327-8.
Denture Repairs
• Poor fit • Poorly balanced occl. • Faulty fabrication • Stress on denture
base after yrs of use • High loading forces
The Single Denture
Combination Syndrome
Shen K, Gongloff RK. J Prosthet Dent 1989;62:642-4.
24%
Combination Syndrome In Extremis
Factors Affecting Strength of Denture Repairs
Repair Material APMM 60%-65% OS, HPMM 75%-80% OS Reinforcement Metal wires- sandblasting/silanization woven polyethylene fibers- glass fibers- Surface treatment MM monomer- (3min)
Seo RS, et al. J Prosthodont 2007:16:302-10.
Butt Joint
45 Bevel
Rounded joint
O
Mechanical Treatment
Lin CT, et al. J Oral Rehabil 2000;27:190-8.
1.5-3.0 mm
Denture Maintenance
ProTech
1-800-872-8898
Paranhos HF, et al. Gerodontology 2007;24:162-89.
Patient Education • First oral feelings • Excess Saliva • Speech • Eating • Tongue position • Maintaining tissue
health • Over-the-counter
aids
Ortman LF. Dent Clin North Am 1977;21:359-67.
Adhesives
Neutral pH
Minimal toxicity
Adhesive bond- 12-16 h
Acemannan
Super Wernet’s
Super Poli Grip
DeVengenie, et al. Int J Prosthodont 1997;61-72.
Patient Complaints and Proposed Solutions
Generalized Discomfort
Sore Spots
• Excess OVD • CR errors • Poor fit • Errors in processing
• Internal or occlusal
prematurity
LaBarre E, et al. Compendium 2007;28:538-42. Left MHR
Patient Complaints and Proposed Solutions
Loose Mandibular Denture • Underextended-reline add peripheries
especially in RMH space
• Overextended-reduce periphery
• Poor fit-reline • Retruded tongue-
educate patient • Incorrect arch form-
check 1st bicuspids for neutral zone problem
• Atrophic ridge-discuss IOD.
Patient Complaints and Proposed Solutions
Loose Maxillary Denture • Inadequate posterior palatal seal-add
• Excessive posterior palatal seal-relieve
• Internal prematurity esp. on borders
Patient Complaints and Proposed Solutions
Cheek Biting • Inadequate tooth overlap
• Contact of bases • Inadequate VDO
Patient Complaints and Proposed Solutions
Lip Biting Tongue Biting
• Anterior overlap
• Narrow arch- NZ violation
Patient Complaints and Proposed Solutions
Clicking During Speech
• Inadequate IOD • Loose denture • Patient with poor NMC
Patient Complaints and Proposed Solutions
Difficulty with Speech • Lisping or slushy
speech-anterior teeth set too far forward, or insufficient IOD
• Whistling-recontour, reposition anterior teeth if set too far lingually Farley DW, et al. J Prosthodont 1998;7:84-90.
Patient Complaints and Proposed Solutions
Difficulty Chewing • Poor interdigitation-remount, counsel patient on chewing strategies
Patient Complaints and Proposed Solutions
Gagging • Posterior border overextended
• Inadequate posterior palatal seal
• Excess OVD • Patient rejection of
dentures • Excessive lingual
bulk • Occlusal plane too
high
Patient Complaints and Proposed Solutions
Painful Swallowing • Linqual flange too long
• Maxillary denture overextended
Patient Complaints and Proposed Solutions
Numb or Tingling Ridge • Pressure on mental nerve or incisive papilla
Technique for Application of Tissue Conditioner
• Relieve undercuts and 1-2 mm of acrylic resin lingual to the crest of the ridge
• Mix 2 parts liquid and 2.5 parts powder for 30 seconds and allow to sit for 3 minutes
• Lubricate fingers and roll the material into a ribbon ¼ to 3/8 inch in diameter
• Place on lingual border or entire periphery • Seat denture and allow patient to perform
functional movements for 5-10 minutes
Landesman HM. J Prosthet Dent 1980;43:348-51.
Vertical Dimension Reference
Gold Occlusals
Final Wax Try-in
Technique for Application of Tissue Conditioner
• Remove denture and trim excess with sharp scapel blade
• Make a second mix of same liquid/powder ratio and allow this mixture to sit for 2 minutes
• Place on polished surface where indicated • Insert denture and instruct patient to make
functional movements for 5-10 minutes • Make a third mix 1:1 L/P ratio and place on
intaglio surface • Seat, functional movements, remove, trim,
place, and instruct for home use, 24 hr recall, 7-14 day function and rebase
Laboratory Fidelity
Wear of Acrylic and Composite Resin Artificial Teeth
Brand Name VH
Dentron 20.2
Bioform IPN 18.8
SR Orthosit PE 28.3
Loyaga-Rendon PG, et al. J Prosthet Dent 2007;98:141-9.
Attrition
A New Polymer
A New
Polymer
Vicker’s Hardness
80-100 kgf/mm2
Gold Occlusals
Gold Occlusals
Conversion to Gold Occlusals
Registration Bases
Disadvantages
1. Unaesthetic
2. Anterior overlap may need to be minimized
3. Lack penetration of food
4. Inadequate sluiceways
Indications for Nonanatomic Teeth
1. Minimize lateral force transmission to residual ridge
2. Knife-edge and flat ridges
3. Large interridge space
4. Broad chewing pattern
5. Compromised muscle neuromuscular coordination
Functional Tissue Conditioning
Working and Balancing Guidance
Setting an Average Bennett Angle
L=H/8+12 L= 17o
Langer A, Michman J. J Prosthet Dent 1970;23:381-6.
82% of 139 patients achieved BB with 17o Bennett angle
