Try-in Of The Waxed Up Denture

PRESENTED BY: DR. ANURAAG SHARMA

Purposes of the try in: There is a good deal more to be checked about the dentures at the try in stage, than just appearance. Two main objectives should be to compare the general tooth and arch position with the way the teeth might have grown. We are used to hearing the expression, set the teeth on the ridge, but this expression should be changed to say set the teeth as nearly as possible to where they grew! Physiologically the mouth and all its functions have matured in a certain pattern of conditioned reflexes and proprioceptive guidances. The more we deviate from this pattern, more the adaptation required by the patient.

Since so many points require checking, it is sound practice to get into the habit of working to a definite plan during the trial stage, and the following order is suggested.
1. The lower denture by itself (a) Peripheral outline (i) Buccal and labial (ii) Lingual (iii) Posterior extension (iv) Underextension (b) Stability to occlusal stresses (c) Tongue space (d) Height of the occlusal plane

2. The upper denture by itself.

(a) Peripheral outline (i) Buccal and labial (ii) Posterior border
(b) Stability to occlusal stresses (c) Retention.

3. Both dentures together (a) Position of occlusion (i) Horizontal relationship (ii) Vertical dimension (occlusal face height)

(b) Evenness of occlusal contact

(c) Appearance (i) Centre line (ii) Anterior plane

(iii) Profile and lip form (iv) Amount of tooth visible (vii) Phonetics (vii) Freeway space

(e) Approval of appearance by the patient.

 Before carrying out these checks, remove the dentures from the articulator and place them in a bowl of cold water. It is important that the waxed dentures should be frequently placed in cold water as wax softens appreciably at mouth temperature and, if left in the mouth too long, the teeth may be displaced and the bases may distort. The method of carrying out these checks is as follows.

Trying the lower denture by itself:

Place the denture in the mouth and seat it on the ridge. Peripheral outline The entire periphery should be checked to ensure that it is not over-, or under-extended
.

The buccal and labial periphery

Hold the denture in place with light pressure on the occlusal surfaces of the teeth and move the cheek on one side upwards and inwards, thus simulating the action it makes when chewing.

 Now relax the pressure on the teeth and observe if the denture rises from the ridge. If it does, trim the periphery where it is seen to be overextended until little or no movement occurs. Pay particular attention to the buccal frena and ensure that they have adequate clearance. Repeat for the opposite side and for the lip. Note the bulk and shape of the buccal aspect of the denture. It should take the form of a gentle convexity in the molar region but concave in the premolar region Such a contour will aid the muscular control of the denture as the cheek will tend to fit against the surface and hold the denture down.

The lingual periphery

Hold the denture in place with light pressure and ask the patient to protrude his tongue sufficiently to moisten his lips if the denture lifts at the back, it is over-extended in the region of the lingual pouch. Next, ask the patient to put the tip of his tongue up to the back of his palate; if the denture lifts in the front, it is over-extended anteriorly, probably in the region of the lingual frenum.

 Such over-extension must be relieved, but care should be taken to avoid over-trimming, which occurs very easily owing to the difficulty of seeing the functional depth of the lingual sulcus when the denture is in place

Final adjustments are more easily and more accurately made after the finished denture has been worn for a few days, when areas of slight inflammation will indicate the precise location of over-extension.

Posterior extension

Ensure that the heels of the lower denture are extended as high up the ascending ramus of the mandible as is practicable; the purpose of this is to buttress, the denture against the backward pressure of the lower lip

Under-extension

Though of less common occurrence than overextension, it is equally important that the periphery should not be under-extended since dentures must cover the greatest possible area if maximum retention and support are to be obtained.

If the denture is found to be under-extended in any part of the periphery as shown by the presence of a gap between it and the functional position of the surrounding mucosa, replace the denture on the cast and check whether the base has been carried to the full extent of the impression at this point.

 If it has, it implies an inaccuracy in the impression which must be retaken before proceeding further. An alternative is to proceed to the finish stage and then rebase the denture to rectify the peripheral error.
Stability under occlusal load

This test is used to determine if occlusal stresses will be transmitted unfavourably. Apply pressure with the ball of the finger in the premolar and molar regions of each side alternately; this pressure must be directed at right angles to the occlusal surface. If pressure on one side causes the denture to tilt and

 If pressure on one side causes the denture to tilt and rise from the ridge on the other side, it indicates that the teeth on the side on which pressure is applied are set too far outside the ridge.

It may also indicate lack of adaptation of the base on the side being loaded or under-extended flanges on the side which rises.

Tongue space Natural teeth occupy a position in the mouth where the inward pressure of the cheeks and lips is equalled by the outward pressure of the tongue, and it is into this zone of neutral pressure that the artificial teeth must be placed. The tongue, being more mobile than the cheeks, will cause greater instability of the lower denture if the teeth are set on the lingual side of the neutral zone than if they are set on the buccal side. If the tongue is cramped by the denture, lateral pressure will be exerted, producing instability when the tongue moves.

You can test for lack of tongue space as follows:

Ask the patient to relax the tongue, making sure that the denture is seated on the ridge, and then request him to raise the tongue. If the tongue is cramped, the denture will begin to rise immediately the tongue moves. This immediate reaction of the denture tends to differentiate the movement caused by a cramped tongue from the movement caused by lingual flange overextension; movement due to the latter cause does not occur until the tongue has risen some distance.

The causes of lack of tongue space are: 1. Posterior teeth set inside the ridge. 2. Molar teeth which are too broad buccolingually. Such teeth should be replaced by smaller ones or their width reduced by grinding the lingual aspect (if the teeth are porcelain take care not to damage the retentive diatoric hole; if they are acrylic they should be polished before being finally set).

3. Molar teeth leaning inwards. This will not always cause cramping of the tongue, but should never be allowed to occur as it interferes with the free vertical movements of the tongue.

4. Setting the upper teeth over the ridge almost invariably leads to the occluding lower teeth lying too far lingually.

Height of the occlusal plane

To obtain maximum stability of a lower denture, the occlusal plane of the lower teeth should be very slightly below the bulk of the tongue, so that the tongue performs the majority of its movements above the denture and thus tends to keep the denture down . The denture must therefore be examined to see if the tongue, when relaxed, lies above or below the occlusal plane.

 Ask the patient to relax and place the tip of the tongue comfortably and without strain behind the lower front teeth, which is the normal relaxed position of the tongue, and then open his mouth without moving his tongue. If the height of the occlusal plane is correct, the tongue will be seen to lie on top of the lingual cusps.
If the lower denture still tends to rise unduly after the lingual periphery has been checked, and as much lateral space as possible for the tongue has been allowed, it may be necessary to reset the teeth completely, lowering the occlusal plane. This may be especially necessary in those patients who have a low tongue position

 The height of the occlusal plane is also of importance for the following reason: the greater the height of the lower denture, the longer will be the lower front teeth and the greater the surface exposed to the unfavourable pressure of the lower lip. This concludes the examination of the lower denture alone, and it should be removed from the mouth and placed in a bowl of cold water.

This concludes the examination of the lower denture alone, and it should be removed from the mouth and placed in a bowl of cold water.

Trying the upper denture by itself

Place the upper denture in the mouth and examine in the following manner. Peripheral outline 1. The buccal and labial periphery is checked as for the lower denture. 2. The position of the posterior border is verified to check that the posterior edge is situated on the soft palate and that the postdam area on the cast has been placed correctly

Stability Stability under occlusal load may be carried out as for the lower denture, but is intended to check the closeness of adaptation of the base against the mucosa and the future support of the denture in those cases where the mucosa is unevenly displaceable.

Retention Retention is checked by seating the denture with a finger on the vault of the palate and then attempting to remove the denture at right angles to the occlusal plane. Load is then applied upwards and outwards in one canine region to check the retentive force in the contralateral corner of the denture, i.e. in the region of the tuberosity vestibular space and pterygomaxillary notch. Then check the other side in the same way.

Both dentures together Remove the upper denture from the mouth, replace on its cast to confirm the fit, and chill in cold water for a few seconds. Then place both dentures in the mouth. If it is found necessary to improve the retention of the dentures when using a shellac type of base-plate, adhesive powder may be sprinkled on their fitting surfaces.

Position of occlusion
Horizontal relation Hold the lower denture in position on the ridge and ask the patient to relax, then to 'close on your back teeth' gently and maintain them in occlusion while the examination is carried out. If the registration is accurate, the teeth will interdigitate in the mouth in exactly the same manner as they do on the articulator, but if the registration is wrong, the teeth will not interdigitate correctly and may even occlude cusp to cusp on one or both sides.

 The clinician must make quite certain that the occlusion he sees in the mouth is not due to movement of the dentures on the ridges, tilting of either denture or dropping of the upper denture. This is best tested by asking the patient to keep the teeth together and then trying to separate the posterior teeth by means of a thin spatula or Le Cron blade. This test should be carried out on each side of the mouth alternately. The teeth should be brought into occlusion several times, using any of the registration aids, in order to make certain that the position of occlusion is correct or, ifit is incorrect, to ascertain the type of error.

 i.e. whether the mandible can be retruded from the previously recorded jaw relationship, whether a lateral deviation has occurred, or whether there is a premature contact on one side before the other.

Observation of the upper and lower centre lines in relation to each other, with the dentures on the articulator and then in the mouth, will indicate a lateral deviation, if present.

When the lower centre line is seen to be to one side of the upper centre line, with the dentures in the mouth, in contrast to the coincidence of these lines when viewed on the articulator, it is possible that the original registration was incorrect and that a lateral position has been recorded; this may be checked by the occlusion of the posterior teeth.

If the original position was incorrect, the lower cusps will be slightly farther back on one side indicating a greater retrusion of the condyle on that side. Should the lower cusps be slightly forward on one side, it indicates that the original recording of the occlusion was correct and the patient is now giving a lateral position

Major errors in the position of occlusion are easily detected, but minor errors may pass un-noticed; therefore it is extremely important to watch for any slight movement of the dentures on their respective ridges from the time the teeth first make contact until they reach the position of complete interdigitation

 the reason being that the cusp inclines of the teeth guide the dentures into occlusion and will move the dentures in relation to the ridges when only a slight error of jaw relationship exists from that which was obtained when taking the records. Care is needed when holding the lower denture in place on the ridge to avoid pushing it backwards. When errors of occlusion are noted at this trial stage they must be corrected by re-recording the position of occlusion as follows

 The dentures are seated on the casts on the articulator and the posterior teeth removed from one of the dentures and replaced by wax which should be trimmed to occlude with the posterior teeth of the other denture without altering the vertical dimension as set on the articulator.
In this way considerable time may be saved in trimming the blocks in the mouth, as then only minor adjustments are necessary to produce evenness of occlusal contact.

 The position of occlusion is recorded by adding a little softened base-plate wax to the chilled blocks, placing the dentures in the mouth and asking the patient 'to close on the back teeth, thus impressing the cusps of the opposing teeth into the wax without effecting any alteration in the vertical height.
Care must be taken to see that the new position of occlusion gives the necessary correction. Points which may help in this are observations of overlap, overjet, and the relation of the centre lines.

When correcting a lateral deviation care must be taken to see that the lower anterior teeth do not impinge on the upper teeth, as this may cause the mandible to be guided into another incorrect position, or the dentures to tilt. If any contact of the anterior teeth occurs the offending lower teeth should be removed and the position retaken.

 The advantage of removing posterior teeth from the upper trial denture is that in the re-recording the softened wax on the occlusal surface of the blocks is not interfered with by the operator's index fingers which are being used to control the lower denture.

The disadvantage is that the orientation of the occlusal plane, as determined by the upper posterior teeth, is temporarily lost.

 Removal of lower posterior teeth, on the other hand, means that the softened wax replacing the teeth is almost bound to be displaced or disturbed by the controlling index fingers.

It is better, therefore, to remove the upper teeth rather than the lower when rectifying an occlusal error

Check the vertical height

Ask the patient to relax with the lips closed. Watch the point of the chin and then ask the patient to close the teeth together; the chin should move upwards a small but definite amount. If it is impossible to obtain this movement in spite of repeated attempts, it can be assumed that the vertical height is too great and, if this is excessive, there will also be a strained appearance when the lips are brought into contact with each other.

It should be remembered that patients who are mouth breathers relax with their lips parted, and frequently have a large freeway space. An overclosed vertical height will be associated with a large freeway space, and when the teeth are in occlusion the lips will be seen to be pressed too firmly together with some loss of the vermilion border. In order to correct the vertical height the posterior teeth are removed from one of the dentures and replaced by wax blocks.

The articulator should be closed or opened approximately the amount assessed to establish a suitable freeway space, and the blocks then trimmed to occlude with the opposing teeth at the new vertical height. Final adjustments for evenness of occlusal contact, and for the production of the correct freeway space, are carried out in the mouth. Once these are satisfactory, the record blocks should be chilled in cold water, and a little registration paste added to their occlusal surfaces to record the impressions of the opposing teeth when registering the retruded contact position.

Evenness of occlusal contact

Provided the horizontal and vertical relationships are correct, the evenness of the occlusion is next checked As the teeth close, they should occlude evenly and with equally distributed pressure all round. It frequently occurs that the teeth on one side of the mouth occlude slightly before those on the other, or the molars before the premolars.

This may be due to:

1. Pressure on the blocks being heavier on one side than the other when the records were taken. 2. A slight error when sealing the casts and blocks together or when mounting them on the articulator. 3. Warpage of the base-plates.

To test for evenness of occlusal pressure, place two pieces of thin mylar tape between the teeth in the molar region, one on each side. Request the patient to close and then endeavour to remove the tapes simultaneously, holding one with each hand, by pulling them out between the closed teeth. Any difference in the force required to remove the strips will be readily appreciated, and if this force is interpreted in terms of occlusal pressure, an assessment may be made of whether or not it is even. Repeat the test in the premolar regions.

Remember at all times to hold the dentures in place with the index fingers until final contact

Appearance
This aspect of the trial stage is a matter more for individual judgement, and sometimes the patient's ideas, than for set rules. However, certain factors need to be checked as routine Centre line.

Stand in front of the patient, some distance away. A wrong centre line will be obvious. Minor errors may be corrected by adjusting the maxillary anterior teeth at the chairside but if the error is more than 1 mm the whole case may have to be reset

Anterior plane

This may be observed from the same position and any tendency for this plane to slope markedly up or down should be noted and corrected

It is important to ask the patient to smile and if one side of the face rises more than the other it is good practice to set the anterior plane to run slightly up towards the elevated side. This has the effect of making the smile less crooked and harmonizes the lip-tooth relationship. Thought should also be given to the smile curve, i.e. the incisal edges of the maxillary incisors lying parallel to the smiling lower lip, as in most faces this produces a pleasing appearance.

Profile and lip form

Observe the patient's profile and note if the lips are either excessively distended or unduly sunken In the first case, remove some wax from the labial flange and try the dentures again. If this produces insufficient improvement, examine the denture to see if the teeth should be set farther in, or if smaller teeth can be used. If the lips are sunken and inverted consider the need to set the anterior teeth further forward.

Amount of tooth visible. Note how much tooth shows. In this connection remember that a smiling person usually only shows the upper teeth. If much of the lower incisors are visible, or only these teeth show, examine the amount of overlap and, if excessive, reduce it by altering the lower teeth. If this does not effect an improvement, the position of the occlusal plane may require to be altered Usually 1 to 2 mm of upper teeth should be visible at phonation.

phonetics
tooth positions are sometimes critical for sound production An analysis of these sounds may be an indirect guide to correct placement of teeth. Clinical experience suggests that s and t can cause most problems in a prosthodontic context. The s sound and its relationship to the vertical dimension has been advocated to be used in denture construction, both for correct tooth positioning and for correct physiological VDO determination.

 If the there is too little space, the VDO is too large and speech distortions will occur. Sounds such as s, sh , and th may be affected negatively. During the pronunciation of the s sound, the interincisal seperation should average 1 to 1.5 mm.

Vertical length of anterior teeth during production of s

 Horizontal relation of anterior teeth during production of s

 Other sounds like f and v are also used as guides. Are made between the upper incisors and the labiolingual centre to the posterior third of lower lip. If the upper anterior teeth are too short ( set too high up),the v sound will be more like an f

If they are too long( set too far down), the f Will sound more like a v

Freeway space The teeth do not contact in the premolar region when the patient enunciates the sound m and s Usually 2 to 4 mm of space should be present in the premolar region. This also provides an indirect view of the correct positioning of the teeth.

Approval of appearance by the patient It is always wise for the dentist to obtain the patient's approval of the appearance of the trial dentures before they are returned to the laboratory for finishing, as this allows for any mild adjustments. Some patients are quite prepared to leave the question of appearance to the dentist,while others are extremely fussy over the smallest detail. When dealing with the former, the dentist should still insist that they consider the matter of their appearance, otherwise when the dentures are finished the patient may react unfavourably.

 In the case of the fussy patient, much time and trouble must be spent on getting the shade, shape and setting of the teeth just as the patient wishes, but it is very important to obtain final approval before finishing the dentures. In this connection the dentist often needs to use his restraining influence to avoid extremely bad errors of aesthetics and much waste of time.

Anterior try in Sometimes only the anterior teeth may be arranged and the patient called for an anterior try in. This helps in knowing the exact relationship of the teeth to the surrounding musculature, phonetics and also esthetics. Patients views may also be obtained regarding the esthetical value and accordingly adjustments may be made. Phonetics is also used as a guide to know the correct placement of teeth at the anterior try in stage. Later the patient is recalled for a posterior try in when the posteriors have been arranged in accordance with the anterior try in done earlier.

 It should be remembered that other people will see more of a patient's dentures than the patient will, and if the dentures are not aesthetically pleasing in the opinion of his relations and friends he will usually become dissatisfied. It is, therefore, advisable to ask the patient to bring a relation or candid friend with him at the trial denture stage and the approval or criticism of this second individual should be sought as well as that of the patient himself.