Completedenture Theory and Practice

COMPLETEDENTURE
THEORYANDPRACTICE
Mostafa Fayad
Lecturer of Removable Prosthodontic
Faculty Of Dental Medicine
Al-Azhar University
Cairo- Egypt
2011
2nded
COMPLETE DENTURE THEORY AND PRACTICE
Dr.mostafa.fayad@gmail.com
Table of contents
Subjects
1 introduction
2 Anatomy and Physiology in Complete Denture
3 diagnosis
4 ImpressionTrays and techniques
5 Relief Areasandpost dam
6 RecordBase and occlusion rim
7 JAW RELATION
8 Occlusion & articulators
9 SELECTION , arrangement of artificial teeth andWAXING-UP
10 try in
11 Processing Dentures
12 Denture insertion
13 Complaints
14 SEQUALAE OF WEARING CD
15 PREPARATION OF THE MOUTH
16 Management of Problematicpatients
17 FAILURE OF C. D
18 Nausea & gagging
19 SINGLE COMPLETE DENTURE
20 Combination syndrome
21 TEETH supported OVERDENTURE
22 Implant Overdentures
23 Geriatric Edentulous Patient
24 Duplication
25 Relining and rebasing
26 Repair
27 Biomechanics
28 Neutral Zone
29 Esthetics in Complete Denture
30 phonetics in Complete Denture
31 masticatory function
32
33
COMPLETE DENTURE THEORY AND PRACTICE Introduction to CD1
Dr.mostafa.fayad@gmail.com 1
Introduction
Prosthetics : It is the art and science of designing, supplying and fitting artificial replacement for
missing part of the human body.
Prosthesis : Is the artificial appliance which replaces a lost part of the human body.
Prosthodontics: It is a branch of dental science which deals with replacement of missing teeth
and associated structures by using artificial devices to restore function and esthetics.
Prosthodontics
1- Fixed prosthodontics.
2- Removable prosthodontics : a- complete denture b- partial denture
3- Maxillofacial prosthodontics.
Removable Prosthodontics is the art and science of replacement of missing teeth and oral
tissues with a prosthesis designed to be removed by the wearer. It includes removable complete
and removable partial prosthodontics.
Dentulous : A condition in which natural teeth are present in the mouth.
Edentulous : A condition in which all natural teeth are lost.
Partially Edentulous : A condition in which some of the natural teeth are lost.
Retention is a quality inherent in a prosthesis acting to resist dislodging forces along the path
of placement.
Stability is the quality of prosthesis to be firm, steady, or constant, to resist displacement by
functional horizontal or rotational forces.
Support is the quality of prosthesis to resist vertical tissue ward force.
Supporting area is the foundation area on which a dental prosthesis rests.
Complete Denture Prosthodontics : It involves the replacement of the lost natural dentition and
associated structure of the maxilla and mandible for patients who have lost all their natural teeth.
Objectives of Complete Denture Prosthodontics
1- Restoration of the masticatory function.
2- Restoration of the normal appearance.
3- Correction of speech defects resulting from loss of natural teeth.
4- Preservation of the alveolar bone and tempromandibular joints.
5- Satisfaction and comfort of the patient .
Denture surfaces
Complete denture consists of denture base that rest on the supporting structure and to
which an artificial teeth attached to it.
It has three surfaces:
1-Fitting surface, (intaglio surfaces, impression surface) determined by the impression.
2-Polished surface; includes the facial (labial and buccal) and lingual and palatal
surfaces.
3-Occlusal surface that makes contact with the opposingdenture.
Denture borders: The margin of the denture base at the junction of the polished and
impression surface.
Denture flanges
The vertical extension of the denture base that extends from the cervix of the teeth to the
borders of the denture flanges; they are named according to location into:
Labial flange; the portion of flange that occupies the labial vestibule.
Buccal flange; the portion of flange that occupies the buccal vestibule.
Lingual flange; the portion of mandibular denture flange that occupies the alveololingual
sulcus.
The differences between natural teeth and artificial teeth
Natural Teeth Artificial Teeth
Type of support
The teeth are supported by periodontal tissue
which gives support, positional adjustment of
teeth and proprioceptive response.
Area of support in both jaws
About 90 cm square.
Amount of masticatory forces
From 5 - 17.5 pounds.
Effect of masticatory forces
The masticatory forces are transmitted to the
bone in the form of tension through the
periodontal ligament. This tension is well
accepted by the alveolar bone and may even
service as stimulus for alveolar bone remolding
Effect of pressure on teeth
Each tooth receives individual pressure and
moves independently.
Effect of non-vertical components of forces
Well tolerated.
Incising forces
Not affect posterior teeth.
Proprioceptive response
The proprioceptive mechanism act as a useful
alarm protecting both the supporting structures
of the tooth and the substance of the crown
from the effects of excessively vigorous
masticatory movements.
All teeth are on bases and supported by mucosa
which is not created to be covered.
About 35 cm square of edentulous mouth.
About 10- 15% of its value in natural dentition.
The force is not directed to the entire alveolar
bone but is applied only on its surface in the
form of compression. This compression has
limited tolerance by the bone and may cause
alveolar bone resorption.
Teeth move as a unit on a base.
Cause trauma to the supporting tissue and
reduce stability to the denture.
Cause tipping of the denture base specially if
the teeth are not balanced articulated.
By the loss of natural teeth there is no
proprioceptive mechanism.
Steps of Complete Denture Construction
Clinical Steps Laboratory Steps
1-History taking and examination of the
mouth.
-Preparing the mouth for dentures.
2-Taking of preliminary impressions
(in stock trays)
5-Taking of final impressions (in special
trays) and determining of the posterior
palatal seal.
8-Recording of jaws relations, face bow
transfer and selection of teeth.
11-Trying in the waxed denture.
15-Registration of new centric relation and
face bow transfer for clinical remount
(if needed).
17-Delivery of the finished denture and
instruction for their use.
18-Review of the denture (inspection and
aftercare).
3-Casting of the preliminary impression (using
plaster of paris).
4-Construction of special trays.
6-Boxing in and casting of the final impression
(using dental stone).
7-Construction of occlusion record blocks.
9-Mounting of the casts with the record blocks
on the articulator.
10-Setting-up of the teeth and waxing-up.
12-Processing of the denture (flasking, wax
elimination, packing, curing and
deflasking).
13-Laboratory remounting of the denture and
correction of occlusion by selective
grinding.
14-Finishing and polishing.
16-Remount of the denture on articulator for
adjustment of occlusion (if needed).
Classification System for Complete Edentulism
The American College of Prosthodontists has developed a classification system for
complete edentulism based on diagnostic findings. These guidelines may help
practitioners determine appropriate treatments for their patients. Four categories are
defined, ranging from Class I to Class IV, with Class I representing an uncomplicated
clinical situation and a Class IV patient representing the most complex and higher-risk
situation.
Each class is differentiated by specific diagnostic criteria. This system is designed for use
by dental professionals who are involved in the diagnosis of patients requiring treatment
for complete edentulism.
Potential benefits of the systeminclude:
1)better patient care,
2) improved professional communication,
3) more appropriate insurance reimbursement,
4) a better screening tool to assist dental school admission clinics, and
5)standardized criteria for outcomes assessment.
Diagnostic Criteria
The diagnostic criteria used in the classification system are.
1. Bone height--mandibular
2. Maxillomandibular relationship
3. Residual ridge morphology maxilla
4. Muscle attachments
Bone Height: Mandible only
The results of a radiographic survey of residual bone height measurement are affected by
the variation in the radiographic techniques and magnification of panoramic machines of
different manufacturers.
To minimize variability in radiographic techniques, the measurement should be made on
the radiograph at that portion of the mandible of the least vertical height.
A measurement is made and the patientis classified as follows:
Type I (most favorable): residual bone height of 21mm or greater measured at the least
verticalheight of the mandible
Type II: residual bone height of 16 to 20 mmmeasured at the least vertical height of the
mandible
Type III: residual alveolar bone height of 11 to 15mm measured at the least vertical
height of the mandible
Type IV: residual vertical bone height of 10 mm or less measured at the least vertical
height of the mandible
The continued decrease in bone volume affects:
1) denture-bearing area;
2) Tissuesremaining for reconstruction;
3) Facial muscle support/attachment;
4) Total facial height; and
5) Ridgemorphology.
Residual Ridge Morphology: Maxilla Only
Residual ridge morphology is the most objective criterion for the maxilla, because measurement
of themaxillary residual bone height by radiography is not reliable.
Type A (most favorable)
Anterior labial and posterior buccal vestibular depth that resists vertical and horizontal
movement of the denture base.
Palatal morphologyresists vertical and horizontal movement of the denture base.
Sufficient tuberosity definition to resist vertical and horizontal movement of the denture
base.
Hamular notch is well defined to establish the posterior extension of the denture base.
Absence of tori or exostoses.
Type B
Loss of posterior buccal vestibule.
Palatal vault morphology resists vertical and horizontal movement ofthe denture base.
Tuberosity and hamular notch are poorly defined, compromising delineation of the
posterior extension of the denture base.
Maxillary palatal tori and/or lateral exostoses are rounded and do not affect the posterior
extension of the denture base.
Type C
Loss of anterior labial vestibule.
Palatal vault morphology offers minimal resistance to vertical and horizontal movement
of the denture base.
Maxillary palatal tori and/or lateral exostoses with bony undercuts that do not affect the
posterior extension of the denture base.
Hyperplasic, mobile anterior ridge offers minimum support and stability).-of thedenture
base.
Reduction of the post malar space by the coronoid process during mandibular opening
and/or excursive movements.
Type D
Loss of anterior labial and posterior buccal vestibules.
Palatal vault morphology does not resist vertical or horizontal movement of the denture
base.
Maxillary palatal tori and/or lateral exostoses (rounded or undercut) that intcrfere with
the posterior border of the denture.
Hyperplasic, redundant anterior ridge.
Prominent anterior nasal spine.
Muscle Attachments: Mandible only
The effects of muscle attachment and location are most important to the function of a mandibular
denture .these characteristics are difficult to quantify.
Type A (most favorable)
Attached mucosal base without undue muscular impingement during normal
function in all regions.
Type B
Attached mucosal base in all regions exccpt labial vestibule
Mentalis muscle attachment near crest of alveolar ridge.
Type C
Attached mucosal base in all regions except antcrior buccal and lingual vestibules
(canine to canine).
Genioglossus and mentalis muscle attachments near crest of alveolar ridge.
Type D
Attached mucosal basc only in the posterior lingual region.
Mucosal base in all other regions is detached.
Type E No attached mucosa in any region.
Maxillomandibular Relationship
It characterizes the position of the artificial teeth in relation to the residual ridge and/or to
opposing dentition. Examine the patient and assign a class as follows:
Class I (most favorable): Maxillomandibular relation allows tooth position that
has normal articulation with the teeth supported by the residual ridge.
Class II: Maxillomandibular relation requires tooth position outside the normal
ridge relation to attain esthetics, phonetics, and articulation (eg, anterior or
posterior tooth position is not supported by the residual ridge; anterior vertical
and/or horizontal overlap exceeds the principles of fully balanced articulation).
Class III: Maxillomandibular relation requires tooth position outside the normal
ridge relation to attain esthetics, phonetics, and articulation (ie crossbitc-anterior
or posterior tooth position is not supported by the residual ridge).
Factors Influencing the Outcome of Prosthetic Treatment
The successful outcome of prosthetic treatment depends upon
(1) The dentist who makes a diagnosis, prepares a treatment plan and undertakes the
clinical work.
(2) The dental technician who constructsthe various items which culminate in the
finished dentures.
(3) The patient who is faced with coming to terms with the loss of all the natural teeth
and then of having to adapt to the dentures and accept their limitations.
The patients contribution
Thepatient must:
Be able to come to terms with the loss of thenatural teeth and their artificial
replacement
Become accustomed to the sensation of the dentures, a process known as habituation
Learn to control the dentures
Accept and hopefully appreciate the new appearance.
Psychological effects of tooth loss
In an investigation of patients receiving prosthetic treatment, most having lost their
remaining natural teeth several years previously and seeking replacement dentures, 45%
admitted to having found it difficult to accept the loss (Davis et al. 2000).
Many of those who had difficulties took longer than a year to get over the loss, and more
than a third had still not accepted it by that time.
They expressed feelings of sadness, anger and depression and many felt that these last
extractions had made them feel prematurely old and lost a part of themselves.
There was loss of confidence, a restriction in choice of food and a lowered enjoyment of
that food. Relationships with others were affected and many patients avoided looking at
themselves without their dentures in place.
Habituation
Habituation has been defined as: A gradual diminution of responses to continued or
repeated stimuli.
When new dentures are placed in the mouth, they stimulate mechanoreceptors in the oral
mucosa. Impulses arising from these receptors, which record touch and pressure, are
transmitted to the sensory cortex with the result that the patient can feel the dentures.
For the first-time denture wearer this bombardment of the sensory nervous systemalmost
inevitably results in pronounced salivation which, fortunately, only lasts for afew hours.
The continuing stimulation of these receptors does not result in a corresponding
continuous stream of impulses. The receptors adapt to this stimulation and as a
consequence the patient begins to lose conscious awareness of the new shapes in the
mouth.
Control of the dentures
The patients ability to control dentures involves a learning process that, initially, is a
conscious endeavour.
The learning process has come to the rescue. As aresult of repetition, new reflex arcs
have been set up in the central nervous system andthe conscious effort has been replaced
by a subconscious behaviour pattern.
The patients perception of appearance
Because a pleasing appearance is a subjective evaluation, there is obviously room for the
dentist and patient to have differing opinions. However, open disagreement does not
predispose to successful treatment and so it is vitally important that the dentist should
take careful notice of a patients views on appearance.
Factors predicting treatment outcome
Age of the patient:
- In general, as patients grow older, it takes longer for them to adapt
successfully to new dentures
Quality of care provided and previous complete denture experience
- In cases where examination of the mouth indicates that the prognosis for
dentures is poor, it is essential for the dentist to warn the patient in advance of
the difficulties and to describe the steps that will be taken to minimize them.
The patients expectations and attitude towards dentures
- a patients attitude to dentures can be a useful predictor of satisfaction or
dissatisfaction.
Opinion of a third party
- Negative comments from friends and relationscan cause disappointment
and rejection of the prostheses, while positive comments can promote
cheerful acceptance of the treatment.
General health.
- Significant impairment of general bodily or mental health may affect the
learning process adversely, with the result that the patient becomes
discouraged because of major difficulties in mastering new dentures.
Transition from the Natural to the Artificial Dentition
Methods of transition
The various methods of making the transition from natural to artificial dentition may be
considered under the following headings.
Transitional partial dentures
Transitional partial dentures restore existing edentulous areas. They may be worn for a
short period of time before the remaining natural teeth are extracted and the dentures are
converted accordingly.
Overdentures
Overdentures are fitted over retained roots and derive some of their support from that
coverage. Special attachments may be fi xed to the root faces to provide mechanical
retentionfor the denture. If, in due course, the roots have to be extracted, the overdenture
can be converted into a complete denture.
Immediate dentures
Immediate dentures are constructed before the extraction of the natural teeth and are
inserted immediately after removal of those teeth.
Clearance of remaining natural teeth before making dentures
This approach differs from all those mentioned previously in that, after the extractions,
time is allowed for initial healing and alveolar bone resorption to occur before providing
complete dentures.
It is common practice for a period of several months to be allowed for healing and initial
alveolar modelling. This delay before taking impressions will produce more stable
supporting areas for the dentures, although resorption will continue indefinitely but at a
slower rate.
Disadvantages:
Loss of masticatory function and appearance during the healing period.
The undesirable mental and physical effects on a patient.
Tongue and cheeks may invade the future denture space, making adaptation to
subsequent dentures more difficult.
Difficulty in assessing vertical and horizontal jaw relationships when
constructing new dentures.
The difficulty in restoring appearance if all information on the natural dentition
has been lost.
Factors influencing the decision of remaining teeth extraction:
1. The condition of the teeth and supporting tissues
Useful teeth can be retained if:
It is feasible to undertake appropriate treatment to eliminate any disease present
If there is confidence in the patients ability to maintain good oral health.
The presence of gross caries or advanced periodontal disease, coupled with no patient response
to oral hygiene instruction, makes the decision of whether or not to extract the teeth a simple one
2. The position of the teeth
a)Natural teeth opposing an edentulous ridge
Thenatural teeth generate high occlusal loads onof the denture, which may result in:
Rapid destruction of the denture-bearing bone
The production of a flabby ridge
Complaints of a loose denture
A deteriorating appearance as the denture sinks into the tissues
Fracture of the denture base.
Only in extreme cases should the dentist consider trying to reduce the occlusal loads by
extracting sound teeth in the opposing arch.
b)Over-eruption of the teeth
Extraction of over-erupted teeth may be required because they:
Excessively reduce the vertical space available for the opposing prosthesis
Have a poor appearance.
endodontic therapy followed by decoronation of over-erupted teeth
3. Age and health of the patient
It is truethat early extractions may reduce problems of adaptation to dentures, but this
advantage must be balanced against the immediate probability of reduced oral function
and comfort in a patient who may be happy with a few remaining natural teeth and,
perhaps, a partial denture.
One view that is regularly propounded is that every effort should be made to retain
useful, strategic teeth which may either help to stabilize a partial denture or which may
be converted into overdenture abutments.
4. The patients wishes
Thefollowing two scenarios occur occasionally and might cause the dentist some difficulty:
(1) Hopeless teeth that the patient wants to retain.
The dentist should carefully explain to the patient about the condition of the teeth and the
possible harmful consequences of retaining them.
(2) Sound, useful teeth that the patient wants extracted.
Thedentist explainsto the patient the nature of the clinical situation and to emphasise the
harm that unnecessary extraction of the remaining teeth would cause. If the patient still
need tooth extraction , the appropriate action by the dentist is most likely to withdraw
from the case, as to extract theteeth without clinical justification would be unethical.
COMPLETE DENTURE THEORY AND PRACTICE Anatomy and Physiology2
Anat omy and Physi ol ogy I n Rel at i on t o
Compl et e Dent ur e Const r uc t i on
Effect of tooth loss
Anatomy
Anatomical Landmarks of Prosthetic Interest
Musculuture
Oral Mucosa
Salivary glands
Physiology
Physiology of bone
Physiology of muscles
Physiology of mucous membrane
Histology
Tooth Extraction
Extraction of teeth may be indicated upon several lines of thought including:
Extensive caries,
Development problems i.e. hypoplastic enamel,
Periodontally compromised teeth with severe mobility and/or furcation involvement.
Such teeth have poor prognosis and the clinician may convey this unto the patient and offer
possible treatment alternatives that may include extraction.
Prior to delving into the concept of immediate dentures, one must understand what tooth
extraction entails. The dentist must understand possible sequelae, time taken for bone healing
and possible consequences. Below describes the pathological processes that take upon an
immediate precedent once extraction occurs.
Extraction of teeth emulates processes similar to fracture healing. The
large cavitation formed where the tooth used to be required a large amount
of epithelial migration, collagen deposition, contraction and remodeling
during healing; thus, due to the nature of the cavitation bone healing at the
socket undergoes secondary intention.
Immediately following injury, bleeding occurs from torn vessels with subsequent formation
of a haematoma with presenting accumulating granular leukocytes. Tissue damage signals an
acute inflammatory response insinuating five cardinal. Connective tissue changes that
accompany the inflammatory response cause a loosening of the periosteal attachment to the
bone; the haematoma attains a fusiform shape.
Two to three days later, macrophages invade the clot to remove fibrin, red cells,
inflammatory exudates and debris. Bone fragments undergo necrosis and are attacked by the
infiltrating macrophages. Post-demolition, ingrowth of capillary loops and mesenchymals
cells occurs; these cells have osteogenic potential contributing to the haematoma. Migration
of epithelium occurs at the bony crest and eventually migrates until it becomes level with the
adjacent gingiva.
Following one week post-extraction, young fibrous tissue has penetrated most of the
socket; the proliferating epithelium may be tenous with possible complete coverage. There
may be initial signs of osteogenesis on parts of the socket wall and trabecular bone.
After two to three weeks, the invading cellular infiltrate has reduced but continued
vascularity with development of new fibrous tissue and woven bone. Furthermore,
osteoclastic activity occurs on the alveolar crests, labial plate and young bone in the base of
the socket; connective tissue beneath the surface epithelial layers matures.
After several months, the woven bone still undergoes remodeling while the overlying oral
mucosa has fully developed; the alveolar crests are being reabsorbed via osteoclasts.
Complete replacement by lamellar bone occurs after two to three years.
Effect of tooth loss
When natural teeth are present the occlusal forces are absorbed by the hydrodynamic
effect of the periodontal ligament. This complete mechanism is related to the maintenance of
integrity of the alveolar process. But the loss of teeth deprives these processes of the stimulus.
Under dentures all forces are transmitted to surface of the alveolar process as pressure.
Control of excessive pressure is an important consideration in CD construction.
After loss of Teeth
Alveolar bone resorbed
The orbicularis oris muscle loses its support
The amount of vermillion border shown on the
upper lip is reduced
The philtrum becomes flattened.
The Nasolabial Sulcus becomes more prominent
with aging due to loss of teeth and loss of vertical
dimension.
The mandible become closure to the nose .
Lack of support of the facial muscles
The shape and size of the alveolar ridges change when the natural teeth are
removed. The alveoli become mere holes in the jawbone and begin to fill up with
new bone, but at the same time the bone around the margins of the tooth sockets
begin to shrink away. This shrinkage, or resorption, is rapid at first, but it
continues at a resorbed rate throughout life.
The maxilla resorbs upward and inward while the mandible resorb downward and
out word so many patient appear pragmatic.
Maxilla
The shape and size of the alveolar ridges change when natural teeth are removed.
The alveoli become mere holes in the jawbone and begin to fill up with new bone, but at
the same time the bone around the margins of the tooth sockets begins to shrink away.
This shrinkage or resorption is rapid at first, but continues at a reduced rate throughout
life.
The resorption of the alveolar process causes the foundation of the maxillary denture to
become smaller and otherwise change shape. If the denture is made soon after teeth are
removed, the apparent foundation may be large, but it also may be tender to pressure.
This is the result of in complete healing and a lack of cortical bone over the crest of the
residual alveolar ridge.
If teeth have been out for many years, the residual ridge may become quite small and the
crest of the ridge may lack smooth cortical bony surface under the mucosa.
There may be large nutrient canals and sharp bony spicules. These conditions limit the
amount of pressure that can be applied on the denture without creating pain.
Mandible:
When teeth are removed the bony foundation offer mandibular denture becomes shorter
vertically and narrower buccolingually.
The bony crest of residual ridge becomes narrower and sharper. Often sharp bony
spicules remain and cause tenderness when pressure is applied by denture.
The total width of bony foundation becomes greater in the molar region as resorption
continues; the reason being the width of inferior border of mandible from side to side is
greater than width of alveolar process from side to side.
Shrinkage of alveolar process in anterior region moves RR lingually first. Then as
resorption continues the foundation moves progressively further forward. Bone loss
continues on the mandible below level of alveolar process.
With resorption of alveolar process occlusal contours of RR often develop that make
them curved from a low level anteriorly to a high level posteriorly causing severe
problems in denture stability.
The total area of support from the mandible is significantly less than from maxillae. The
available denture bearing area for edentulous mandible is 14cm2 whereas for edentulous
maxillae its 24cm2. This means that mandible is less capable of resisting occlusal forces
than the maxilla are and extra care must be taken if available support is to be used to
advantage.
The rate of resorption in the mandible is much higher (4X) than in the maxilla
The Dentition Function Curve
0
20
40
60
80
100
120
5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80
Age
F
u
n
c
t
i
o
n

(
%
a
g
e
)
Dentate Partially dentate Edentulous
A model
for
understanding
dental
function
over time
The Dentition Function Curve
Ideal maxillary ridge:
Abundant keratinized attached tissue
Square arch
Palate U-shaped in cross-section
Moderate palatal vault
Absence of undercuts
High frenum attachments
Well-defined hamular notches
Ideal mandibular ridge:
Well defined retromolar pad
Blunt mylohyoid ridge
Deep retromylohyoid space
Low frenum attachments
Absence of undercuts
Abundant attached keratinized
mucosa
Adequate alveolar height
A classification of jaw form following tooth loss
Zarb classified the edentulous anterior jawbone into shape (quantity) and quality.
Quantity, Shape (types A though E) reflects a range of resorptive patterns relative to the
demarcation of the alveolar and basal jawbone.
A: most of the alveolar ridge is present.
B: Moderate alveolar ridge resorption has occurred.
C: Only basal bone remains.
D: Some resorption of the basal bone has taken place
E: Extreme resorption of the basal bone has taken place
Quality (types 1 through 4) reflects a range of cortical and cancellous patterns:
1. Almost the entire jaw is comprised of homogenous compact bone.
2. A thick layer of compact bone surrounds a core of dens trabecular bone.
3. A thin layer of cortical bone surrounds a core of dense trabecular bone.
4. A thin layer of cortical bone surrounds a core of low density trabecular bone.
Both parameters have been employed frequently in planning oral implant treatment.
Alveolar Ridge preservation
Residual ridge is the portion of the residual bone and its soft tissue covering that remains
after the removal of teeth
One of the most important objectives of prosthodontic restoration is the
preservation of the supporting structures rather than the restoration of the missing
parts.
The success or failure of a removable complete denture is dependent on many
factors, which include the condition of the alveolar ridge ,health of oral mucosa and
amount of the masticatory force of the opposing dental arch.
Causes of Alveolar Ridge resorption see flat ridge
Alveolar ridge maintenance
1) Periodontal diseases prevention
2) Conservation of remaining teeth. Retention of residual tooth roots in key locations
3) Root submergence
4) A traumatic extraction
5) Alveolar ridge maintenance (ARM) deals with the placement of osteo promotive
materials at extraction sites in an attempt to maintain the physiologic and anatomic
integrity
6) The impression should allow the fabrication of denture base that will provide the best
distribution of physical forces by accurate impression
7) Role of vertical dimension
- High vertical dimension will increase stress on residual ridge leading to ridge
resorption
- Jaw relation technique
- Occlusal plane
8) The occlusal table play an important role in ridge preservation
9) Role of occlusal surface morphology
- anatomical teeth cause more stresses on the ridge
- Semi anatomical teeth cause less stresses on the ridge
- flat teeth cause the least stresses on the ridge
10) Role of selected teeth material
- Acrylic teeth less stresses
- porcelain teeth more stresses
11) Premature contacts need to clinical remounting to decrease stress on the alveolar ridge
12) Balanced occlusion - Different Occlusal schemes
13) Denture base material and Well adapted and properly extended dentures base
14) over denture to slow down or prevent the resorption of residual ridge
15) role of implant in ridge preservation
16) Alveolar Ridge Augmentation
17) alveolar ridge augmentation using autogenous bone grafts from the iliac crest
18) Vertical Ridge Augmentation Using Alveolar Distraction Osteogenesis
Anatomical Landmarks of Prosthetic Interest
These are anatomical guides that help in denture construction. These landmarks are either bony
landmarks or soft tissue landmarks.
a- BONY LANDMARKS :
Some bony landmarks are difficult to palpate, while others are easily palpated and
identified.
The bony landmarks have the advantage of their being fixed in place.
The measurement produced by bony landmarks can be duplicated with more
accuracy than measurements between soft tissue landmarks .
b- SOFT TISSUE LANDMARKS
Easily identified
Have the disadvantage of changing their relation according to their mobility
[ I ] Ex t r a-or al Landmar k s Of Pr ost het i c I mpor t anc e
Landmar k Desc r i pt i on Si gni f i c anc e
1- I nt er -pupi l l ar y l i ne - Imaginary line running between the
two pupils of the eye when the pt. is
looking straight forward.
- Establishing the anterior Occlusal
plane of the artificial teeth of the
denture.
2- Al a-t r agus l i ne
(Camper's line)
- Imaginary line running from the
Inferior border of the ala of the nose
to the superior border of the tragus of
the ear.
- Establishing the posterior occlusal
plane of the artificial teeth of the
denture.
3- Cant hus-t r agus l i ne - Imaginary line running from the
outer canthus of the eye to the
superior border of the tragus of the
ear.
- Locating the position of the
condyles.
4- Naso-l abi al sul c us - Depression that extends from the ala
of the nose in a downward and lateral
direction to the corner of the mouth.
The sulcus becomes more prominent
with aging and due to loss of teeth
and vertical dimension. It can be
modified by proper degree of jaw
separation and tooth positioning.
Plumpers (thick denture flanges)
improve the condition but it may
interfere with muscular activity.
5- Ver mi l l i on bor der - The transitional epithelium between
the mucous membrane of the lip and
the skin.
The amount of vermillion border
shown on the lips depends on
1-The bulk of the orbicularis oris
muscle.
2- The amount of the labial alveolar
bone.
3-The alignment of the anterior teeth.
After loss of teeth, the amount of
vermillion border shown on the
upper lip is reduced. The condition
can be corrected by thickening of the
labial flange of the denture and
proper positioning of the anterior
teeth.
6- Ment o-l abi al sul c us - Depression runs horizontally
between the lower lip and chin.
Its curvature indicates the character
of the maxillo-mandibular
relationship and the degree of over-
closure.
Class 1 normal ridge
relationship: The sulcus
shows a gentle curvature
with obtuse angle
Angle class II (retruded
mandibular relation): The
sulcus forms an acute angle
Angle class III (protruded
mandibular relationship):
sulcus forms an angle of
almost 180
7- Phi l t r um - It is a diamond shaped depression at
the center of the upper lip and base of
the nose.
After loss of teeth, the philtrum
becomes flattened. This condition
can be improved by construction of
proper denture with an appropriate
arch-form and tooth alignment .
8- Modi ol us - The point of meeting of buccinator
and other facial muscles distal to the
angle of the mouth. The modiolus is
held in position by the arch-form of
the maxillary teeth.
With the loss of teeth the modiolus
drops. The appearance can be
improved by proper positioning of
the maxillary teeth.
Narrowing of the lower denture base
related to the modiolus is usually
necessary to avoid displacement
9- Angl e of t he mout h
(commissure of the lips)
- Point of meeting between the upper
and lower lip.
- (Angular Chilitis): Inflammation
and ulceration as a result of:
1- Prolonged edentulism.
2- vertical dimension of complete
denture.
3- Vitamin B deficiency.
10- The Angl e of t he
Mout h and t he Out er
Cant hus of t he Eye
The distance from the outer canthus
of the eye to the angle of the mouth
was used by Wills to determine the
vertical dimension of the edentulous
patient at rest by making the distance
from the base of the nose to the
lower edge of mandible equal to it.
A, The Philtrum, naso-labial sulcus, commissure of the lips& mento-labial sulcus.
B, Modiolus and Orbicularis Oris muscle.
The muscles contributing to the modiolus (dotted circle)
[ I I ] I nt r a-or al l andmar k of pr ost het i c i mpor t anc e
The denture base must extend as far as possible without interfering in the health or
function of the tissues. The amount of biting force an edentulous ridge will tolerate is directly
proportional to the amount of surface area covered
Force directed to a large bearing area is more equally distributed and much less per sq.
mm. than the same force directed against a smaller area. Consequently, if we hope to assist a patient
to achieve maximum biting force and preserve the supporting structure over a longer period of time, The
maximum amount of denture bearing area must be covered.
The denture foundation can be divided into:
Denture bearing/stress bearing areas. (denture foundation area) it is the surfaces of the
oral structures available to support a denture. or the tissues (teeth and/or residual ridges)
that serve as the foundation for removable partial or complete dentures.
Peripheral limiting or sealing areas
Anatomic Landmarks of the Denture Bearing Area (supporting structures):
I n t he Max i l l a I n t he Mandi bl e
1-The residual ridge and hard palate
2- The incisive papilla
3- The palatine rugae
4-Median palatine raphe
5- Maxillary tuberosity
6- Torus palatinus
7- Fovea palatinae
8- Incisive fossae
9- Canine eminence
10- Buttress of the zygomatic bone
11- Palatal gingival vestige
1- Residual alveolar ridge
2- Retromolar pad
- 3- Internal oblique ridge
(mylohyoid ridge).
- 4- External oblique ridge
- 5- Buccal shelf of bone
- 6- Mental foraman
- 7- Genial tubercles
- 8- Torus mandibularis
Anatomic Landmarks that Limit the Periphery of the Denture (limiting structures):
I n Rel at i on t o Max i l l ar y Dent ur e I n Rel at i on t o Mandi bul ar Dent ur e
1- Labial frenum
2- Labial vestibule
3- Buccal frenum
4- Buccal vestibule
5- Pterygo maxillary notch (Hammular
notch)
6- Vibrating line.
1- Labial frenum
2- Labial vestibule
3- Buccal frenum
4- Buccal vestibule
5-Masseter muscle influencing area
6-Retromolar pad and inferior border of the
ramus
7- Pterygomandibular raphe
8- Plato glossal arch
9- Lingual pouch
10-Mylohyoid muscle influencing area
11- Lingual frenum
ANATOMY OF MAXILLARY DENTURE FOUNDATION
The maxillary denture is supported by two maxillae and the palatine bones. The palatine
processes of the maxillae are joined together at the midline in the median suture
The two palatine processes of the maxillae and the palatine bone form the foundation of the hard
palate and provide considerable support for dentures.
There are two maxillae, each consisting of a central body and three processes.
(a) The frontal process of the maxillae is directed upwards. It articulates anteriorly with
the nasal bone, posteriorly with the lacrimal bone and superiorly with the frontal bone.
(b) Zygomatic process of maxilla is short but stout and articulates with the zygomatic
bone.
(c) The alveolar process of maxilla bears sockets for teeth. The alveolar process arises
from lower surface of the maxilla. It consists of two parallel plates of cortical bone
buccolingual or labiolingual, which unite behind the last molar tooth to form the alveolar
tubercle. When teeth are present the cortical plates are connected by inter alveolar or
interdental septa.
Zygomatic process or malar process which is located opposite first molar region is one of
the hard areas found in mouths that have been edentulous for a long time. Some dentures
requires relief over this area to aid in retention and prevent soreness of underlying tissues.
The crest of the residual alveolar ridge
covered with a layer of fibrous connective tissues,
Most favorable for supporting the denture because of its firmness and position.
The residual ridge and most part of the hard palate are considered the major or primary
stress bearing areas in upper jaw.
The resorption of residual ridge limits its ability to support unlike the palate which is
resistant to resorption, so the residual ridge may be considered as secondary supporting
area. (ZARB)
Factors that influence the form and size of supporting bone of basal seat include.
(1) Its original size and consistency.
(2) The patients general health and resistance.
(3) Forces developed by surrounding musculature.
(4) Severity and location of periodontal disease.
(5) Forces accruing from wearing of dental restorations.
(6) Surgery at the time of removal of teeth.
(7) The relative length of time the different parts of jaws have been edentulous.
Hard palate
It is a partition between oral and nasal cavities.
Its anterior two thirds are formed by palatine process of maxillae and its posterior
1/3 by horizontal plates of palatine bone.
The center of the palate may be very hard because the layer of soft tissue covering
the bone in the region of median palatal suture is extremely thin.
The soft tissue covering the hard palate varies considerably in consistency and
thickness in different locations even though the epithelium is keratinised
throughout. Antero laterally the submucosa of hard palate contains adipose tissue
and posterolaterally it contains glandular tissue. The tissues should be recorded in
a resting condition, because when they are displaced in the final impression, they
tend to return to normal form within completed denture base creating an unseating
force on denture base or causing soreness in patients mouth. Proper relief of final
impression trays aids in recording these tissue in an undistorted form. In addition
the secretions from the palatal glands can be an important factors in selection of
final impression material.
The glandular region of either side of the mid line in the posterior part of the
hard palate should be covered by the denture so it can aid in retention, but it
should not provide significant support for the denture because of the relatively
higher resiliency at this site. The mucous glands in this region are relatively thick
and they cover the blood vessels and nerves coursing forward in the palate from
greater palatine foramen. These vessels and nerves anastomose with vessels and
nerves passing through the nasopalatine canal and into the region of basal seat of
incisive papilla.
Incisive papilla
It covers the incisive foramen and is located on the line immediately behind and
between the central incisions.
Its position varies with different patients. It is located on the centre of ridge after
resorption has occurred in mouths that have been edentulous for long time.
The location of incisive papilla gives an indication as to the amount of resorption
of residual ridge and thus is an aid in determining vertical dimension and proper
position teeth.
Incisive foramen (Nasoplatine foramen)
The Nasoplatine nerves and blood vessels in submucosa exit the palate at right angles to
the margins of this bony fossa or foramen. Therefore even though the foramen is covered
with protective pad of fibrous CT called incisive papilla, the denture base should be
relieved over this area. Failure to relieve the denture base will result in pressure on the
nerves and blood vessels with resultant decrease in blood supply to anterior part of palate
and nerve irritation with accompanying burning symptoms.
The location of incisive foramen gives an indication as to the amount of resorption of the
Residual ridge. It comes nearer to crest of the ridge as resorption progresses. thus aid in
determining the vertical dimension and the proper position of maxillary anterior teeth.
Palatine rugae
The rugae in the anterior part of the hard palate are irregularly shaped rolls of soft tissue.
They should not be distorted in an impression technique since rebounding tissue tends to
unseat the dentures.
This area contributes to stress bearing role as well as retention, though in secondary
capacity.
Median palatine suture (mid palatal suture)
The two horizontal palatine processes of the maxillary bone fuse in the midline to form
the mid palatal suture.
The submucosa in this region is extremely thin and non resilient little or no stress can be
placed in this region during find impression making or the completed denture lest the
denture tend to rock over the center of palate when vertical forces are applied to the teeth.
In addition this part of mouth is highly sensitive and excess pressure can create
excruciating pain.
Proper relief in the impression tray or completed denture is essential for accommodating
this nature of tissue.
Posterior nasal spine, greater/lesser palatine nerves and vessels
The posterior border of the horizontal plates of the palatine bones unites in midline to
form the sharp posterior nasal spine. The posterior margins of the hard palate serve as the
anterior attachment for aponeurosis of soft palate.
On each side of the hard palate the greater palatine foramen is located medial to the
third molar at the junction of the maxilla and horizontal plate of palatine bone. A groove
extends anteriorly from the foramen and contains the anterior (greater) palatine nerve and
blood vessels. Because the nerve and blood vessels course though a groove, rarely must
the denture base over the area be relieved.
In some instance bony spines are located near the greater palatine foramen. If these bony
projection present problems, the denture base should be relieved over these areas, or the
spines should be surgically removed.
Tuberosity region
The tuberosity region often hangs abnormally low because the maxillary posterior teeth
are retained after the mandibular molars have been lost and not replaced, the maxillary
teeth extrude bringing the process with them often the low lying tuberosity is complicated
by excess fibrous connective tissue.
This excess soft tissue can prevent proper location of occlusal plane if not removed. In
addition rough and irregular bone can be irritated by denture base.
Palatine fovea
They are ductal openings into which ducts of other palatal mucosal glands drain. They
serve no function. According to Lye the fovea palatine are located on average of 1.31mm
anterior to anterior vibrating line.
Sharp spiny process
There are sharp spiny processes on the maxillary and palatine bone, usually they have no
problem with complete denture but with resorption they can irritate the soft tissue lies
between them and denture base.
ANATOMY OF PERIPHERAL OR SEALING AREAS
The functional anatomy of the mouth determines the extent of basal surface of a denture.
The denture base should include the maximum surface possible within the limits of health
and function of the tissues it covers and contacts.
Labial frenum
The lip movement near the maxillary labial frenum is
vertical and thus the notch becomes long and narrow.
If the frenum is pulled too far laterally during border
molding, the notch will become too wide and the
peripheral seal will be lost.
In some cases depressions are recorded beside the labial frenum notch due to muscle
band consisting of the origins of the nasal septal depressor muscle and the orbicularis
oris. In these cases the denture must be adequately relieved as not to disturb the function
of these muscles.
Labial vestibule
In region of labial vestibule, three objectives of an impression should be fulfilled.
The impression must supply sufficient support to the upper lip to restore the relaxed
contour (for appearance) of the lip. The thickness of labial flange must be developed
according to amount of bone that has been lost from labial side of ridge.
Secondly the labial flange of impression must have sufficient height to reach the
reflecting mucous membrane of the labial vestibular space without distorting it.
Thirdly there must be no interference of labial flange with action of lip in function.
Buccal frenum
The muscle movements around the buccal frenum are both vertical
and horizontal thus a wider notch should be formed compared with
the labial frenum. It will become a V-shaped notch.
Generally the frenum runs obliquely and posteriorly therefore its
anterior movement should be recorded by pursing the lips such as when whistling during
border molding.
Buccal vestibule
The size of the buccal vestibule varies with the contraction of the buccinator, the
position of the mandible and the amount of bone lost from the maxilla.
The thickness of the distal end of buccal flange of denture must be adjusted to
accommodate the ramus and coronoid process and the masseter as
they function. When mandible moves forwards or to the opposite
side the width of buccal vestibule is reduced. When masseter
contracts under heavy closing pressure it also reduces the size of
space available for distal end of buccal flange.
If border molding in the buccal space is inadequate, the denture will lose its seal because
of the ingress of air under the denture base when the buccal vestibule is opened during
situations in which the patient laughs and opens the mouth widely.
In the rare case when it is hard to determine the width of the vestibule and thus the width
of the denture border due to severe alveolar ridge resorption, the appropriate width of the
vestibule can be estimated by using the remnants of the lingual gingival margin as a
guide. [HAYAKAWA]
The buccolingual breadth of the dentate alveolar ridge (the horizontal breadth of
the alveolar process from the lingual gingival margin to the maximal projection of
the buccal surface of the ridge) is remarkably constant for every tooth position. So
the remnants of the lingual gingival margin can be located in the edentulous
mouth, the cheek position can also deduced by using it as a landmark.
For example , the average measurement of the buccolingual breadth BLB in the
dentate molar region is 10-12 mm, However, after extraction of the teeth, the
remnant move outward 3-4 mm from the position in the dentate mouth, so the
width of the vestibule should be estimated by deducting this value from the mean
buccolingual breadth of dentate patient. [See Palatal gingival vestige]
Pterygoid process
It projects downwards from the greater wing and body of sphenoid behind the
third molar tooth. Inferiorly it divides into medial and lateral pterygoid plates,
which are fused anteriorly but separated posteriorly by the v-shaped pterygoid
fossa.
The fused anterior borders of the two plates articulate medially with the plate of
palatine bone and are separated laterally from the posterior surface of the body of
maxilla by pterygomaxillary fissure.
The medial pterygoid plate is directed backwards. It has medial and lateral
surfaces and a free posterior border. The upper end of this border divides to
enclose a triangular depression called scapoid fossa. Medial to this fossa there is a
small pterygoid tubercle, which projects into the foramen lacerum. It hides from
view the posterior opening of the pterygoid canal. The lower end of the posterior
border is prolonged downwards and laterally to form the pterygoid hamulus.
The lateral pterygoid plate is directed backwards and laterally. It has medial and
lateral surfaces and a free posterior border. The lateral surface forms medial wall
of infra-temporal fossa. The medial surface gives origin to muscles. The posterior
border sometimes has a projection called pterygo spinous process, which projects
towards the spine of sphenoid.
Pterygo maxillary (hamular) notch
The pterygoid hamulus is a thin, curved process at the terminal end of medial
pterygoid plate of sphenoid bone. The exact position of hamular process is located
2-4 mm posteromedial to distal limit of maxillary residual ridge
Although the pterygoid hamulus does not help in support of dentures, the area
between the maxillary tuberosity of maxilla and the hamulus is critical to design
of maxillary denture. It is used as a boundary of the posterior border of maxillary
denture back of tuberosity.
The posterior palatal seal must be placed through the centre of the deep part of
hamular notch since no muscle or ligament is present at a level to prevent the
placement of extra pressure. The submucosa of mucous membrane is thick and
made up of loose areolar tissue.
Additional pressures also can be placed on this tissue at the centre of the notch to
complete the posterior palatal seal.
Posterior palatal seal
It is divided into two separate but confluent areas based on anatomic boundaries.
The posterior palatal seal extends medially from one tuberosity to another.
Laterally the pterygo maxillary seal extends through the pterygo maxillary notch
continuing for 3-4mm antero laterally approximating the mucogingival junction.
The pterygo maxillary seal occupies the entire width of pterygo maxillary notch,
which is defined as band o loose CT lying between the pterygoid hamulus of
sphenoid bone and distal portion of maxillary tuberosity.
The notch is covered by pterygo mandibular fold, which extends from posterior aspect of
tuberosity posterior-inferiorly to insert into retromolar pad. This fold of tissue can influence the
posterior border seal if the mouth is in a wide-open position during final impression procedure.
Vibrating lines
The PPS lies between the anterior and posterior vibrating lines.
It is an imaginary line across the posterior part of the palate marking the division
between the movable and immovable tissues of the soft palate. This can be
identified when the movable tissues are functioning
It should be described as area not line
The anterior vibrating line located at the junction of attached tissues overlying
the hard palate and movable tissues of the immediately adjacent soft palate. This
should not be confused with anatomic junction of hard and soft palate.
It can be located by patient performing Valsalva Maneuver or instructing patient
to say Ah in short vigorous bursts. This places the soft palate inferiorly at its
junction with hard palate.
Due to projection of posterior nasal spine the anterior vibrating line is not a
straight line between the hammular processes. The anterior vibrating line is
always on soft palatal tissues. As soft palate extends posteriorly the action of
palatal muscles become more exaggerated.
The posterior vibrating line is an imaginary line at the junction of aponeurosis
of tensor veli palatini muscle and muscular portion of soft palate.
It represents the demarcation between that part of soft palate has limited or
shallow movement during function and the remainder of soft palate that is
markedly displaced during functional movements.
It can be visualized by instructing patient to say Ah in normal unexaggerated
fashion. The posterior vibrating line marks the most distal extension of denture
base. The vibrating line is located and marked using an indelible pencil or marker,
and the impression tray is trimmed to this line
The distal end of the denture : should extend at least to vibrating line and in some instances it
may extend 1 to 2 mm posterior to vibrating line .[ ZARB] Should cover the tuberosity and
extend to hamular notch.
Techniques used in locating the vibrating line.
1- The clinician will often visualize the position of this line by having the patient say
"Ahh" and noting that the soft palatal tissues will usually lift while the hard palatal tissues
remain immobile. When the patient says "ah" the oft palate rises up and returns to its original
position when the patient relaxed
2- The Valsalva maneuver in which the patient is asked attempt to blow air through their
nose while the nostrils are gently pinched closed. While gently holding the tongue down with
a mouth mirror, the clinician will often easily visualize the line because the soft palate will
drop dramatically at the vibrating line using this technique. Blowing out through the nose
while closing the nostril causes a downward expansion of the soft palate
3- Other features indicating the position of this line may include a rather sharp color
change between the hard and soft palatal tissues at the vibrating line
4- Presence of the fovea near the line. According to Lye the fovea palatine are located on
average of 1.31mm anterior to anterior vibrating line.
5- Lastly, and often the easiest to visualize, may be the rather significant angular change
between the rather flat hard palate and the moderately to severely sloping soft palate. This
junction indicates the vibrating line.
A = "clinical" junction of hard and soft palates.
B=ah-line ,
C=fovea palatinae ,
D: anatomical junction of hard and soft palates.
The hard palate possesses a portion made up of a 4-5 mm thickness of submucosa which
contain muscle insertions a well as glandular tissue. Even though the hard palate is
supported by bone, it is affected by the Levator and tensor muscles of the velum palatini
and so it is considered to be movable.
Clinically, from only inspection and palpation, it is difficult to
determine whether the palate is supported by bone or not. So, the term,
"clinical' hard and soft palates, should be advocated
In the posterior part of the submucosa of the palate, the palatine glands
extend anteriorly from the soft palate to the first molar region taking the
shape of a mountain on either side of the midline.
The thickness is 4-6 mm in the soft palate and 2-3 mm even in the anterior part on the
hard palate. Thus there is no need to be anxious regarding how far the posterior border can be
extended. If the border is placed only on these palatine glands which possess a cushioning
effect, this would be adequate for retention, even if it is placed slightly anteriorly. A little
more extension may not lead to much better retention. If it is overdone the situation will be
worse than that of under extension and will lead to a gag reflex and irritation of the movable
mucosa. Therefore it is recommended that the posterior border is determined by carefully
avoiding the portion moving around the vibrating line whilst saying "ah".
Some clinicians might extend the posterior border posteriorly so as to cover the foveae
palatinae by considering the anatomical junction of the two palates, but this concept is not re-
commended. [HAYAKAWA]
Classification of soft palate
Based on angle that soft palate makes with hard palate. The more acute the angle, the
more muscle activity that will be necessary to achieve velopharyngeal closure (closing
nasopharynx).
The more the soft palate is markedly displaced in function, the less that can be covered
by denture base.
The more resorbed the edentulous ridge, more difficult in determining the soft palatal
configuration.
A Broad PPS
B - Medium width PPS
C Narrow PPS
Class I
Horizontal.
Minimal muscular activity.
Allows wide PPS but not very deep.
Since more tissue surface is covered it yields more retentive denture base.
Class III
The most acute contour.
Marked elevation of the musculature to create velopharyngeal closure.
Usually seen in conjunction with high v-shaped palatal vault.
Small area for posterior seal.
Deeper than class I
Class II
Designates those palatal contours that lie some where between class I and class III.
ANATOMY OF MANDI BULAR DENTURE FOUNDATI ON
The mandible is the movable membrane of the stomatognathic system. The body of
mandible is horse-shoe shaped. The distal portion of each site continuous upwards and
backward into the mandibular ramus.
The ramus divides superiorly into the condylar process and coronoid process. The
condyle (head) is the articular surface of the condylar process.
The connection of condyle with ramus is the slightly constricted mandibular neck.
Superior to the neck, the condyle is bent anteriorly so that the articular surface faces upward and
forward.
The coronoid process is a triangular bony projection that varies in size and shape. The
convex anterior border of coronoid process continues in to anterior border of ramus.
When the mandible is protruded the anterior border of ramus extends towards the
alveolar tuberosity, which is medial to ramus. If the distobuccal flange of denture is too thick, it
will cause discomfort when mandible is protruded and may dislodge denture during lateral
excursions.
The total area of support from the mandible is significantly less than from maxillae. The
available denture bearing area for edentulous mandible is 14cm2 whereas for edentulous
maxillae its 24cm2. This means that mandible is less capable of resisting occlusal forces than the
maxilla are and extra care must be taken if available support is to be used to advantage.
Crest of residual ridge
The underlying bone of crest of RR is cancellous made up of spongy trabeculae.
Therefore crest of lower RR may not be favourable as primary stress bearing area for
lower denture.
Proper relief to be provided for crest of lower ridge during making final impression.
Retro molar region and pad
The distal end of mandibular denture region is bounded by the
anterior border of ramus, thus including the retro molar pad
posteriorly, which defines the posterior limit.
The retro molar which is triangular soft pad of tissue at distal end of
lower ridge must be covered by denture to perfect the seal.
It contains some glandular tissue, some fibers of temporalis tendon, fibers of superior
pharyngeal constrictor enter it from lingual and pterygo mandibular raphe enters the pad
at its supero posterior inside corner. The action of these limits the denture during
impression procedures.
The posterior half of the retromolar pad is filled with resilient glandular tissues. The
peripheral seal of the denture can be obtained when the denture border is placed on this
tissue. The distal end of the denture should be placed at a point 213 of the way up the
retromolar pad .
As the ternporalis muscle fibers attach to the distal portion of the retromolar pad,
stimulation from this muscle prevents the pad from resorption. So, the retromolar pad is
also used as a landmark for orientation of the occlusal plane. Therefore the retromolar
pad must be included in the impression. [HAYAKAWA]
Retromolar pappilea is small pear shape area just anterior to the retromolar bad it is
dense fibrois connective tissue. [HEARTWELL]
Mylohyoid ridge
If the denture border is short of the mylohyoid ridge, it will dig into
the residual ridge and cause pain. The border is shortened to remove
this pain, but shortly after, the shortened border again impinges upon
the residual ridge. This repetition will make the denture into a cord-
like and has poorer retention and stability.
Border molding of the mylohyoid ridge area should be performed to
cover the ridge 4-6 mm beyond it. At the insertion appointment the
impression surface of the denture on the mylohyoid ridge is relieved so
that pain during mastication will be diminished.
In addition, when the lingual denture border is extended properly as
mentioned above, the lingual polished surface can be shaped into a
concave form(the concave shelf) which is important [or the retention and
stability of the denture]
When making an impression of this region, some think that the movement
of the mylohyoid muscle would be recorded by moving the tip of longue toward the
opposite side, However, tongue movement is due to the action of the genioglosus muscle,
The mylohyoid muscle contracts during swallowing.
The patient is instructed to slightly touch the corner of the mouth with
the tongue. A exaggerated tongue movements during impression making
will be the cause of under extended borders, excessive movements
should be avoided. If the tongue is protruded over the dental arch, the
lingual sulcus will become shallow and an extremely shortened border will be obtained.
During ordinary function like mastication the tongue is not protruded outside dental arch
The impression should be made to cover 4-6' mm beyond the mylohyoid ridge. This is
the length of the denture border in the mylohyoid ridge area. [HAYAKAWA]
The outline of the denture base can be determined easily and automatically by using these
indexes. It is just necessary to connect the index lines, namely lines placed 1 mm beyond
the external oblique ridge, 2\3 of the way from the anterior border of the retromolar pad
and 4 to 6 mm below the mylohyoid ridge. [HAYAKAWA]
Lingual tuberosity
It is an irregular bony prominence on distal end of mylohyoid line.
When this area is excessively prominent or rough it may present an undesirable undercut
requiring surgical intervention.
External oblique ridge (line)
It is a ridge of dense bone extending from just above the mental foreman in a superior
and distal direction to become continuous with anterior border of ramus.
In most individuals the external oblique ridge is the anatomic guide for lateral
termination of buccal flange of mandibular denture.
Buccal shelf area
The area between the buccal frenum and the anterior edge of the masseter muscle. The
buccal shelf may be very wide and is at right angles to vertical occlusal forces, providing
excellent resistance to such forces.
Some buccinator fibers are located under the buccal flange because the mandibular
attachment of this muscle is close to crest of ridge in molar region. The inferior part of
buccinator is attached to buccal shelf of mandible and thus contraction of muscles does
lift the lower denture.
Mental foremen
It is located on the lateral surface of body of mandible between the first and second
bicuspids about halfway between the lower border of mandible and the alveolar crest.
If the loss of RR is extensive, the foramen occupies a more superior position and denture
base must be relieved over the foramen to keep the denture base from irritating the
mental neurovascular bundle failing which the pressure exerted will cause numbness of
lower lip.
Mental spines (Genial tubercles)
They are situated on lingual aspect of mandibular body in midline slightly above the
body. These bony elevations are often divided into a superior and an inferior section and
sometimes into right and left prominences.
When loss of RR is extensive these spines are more superior position than crest of
existing ridge, requiring surgically intervention.
The denture flange covering the genial tubercles may be widely
eliminated in many dentures for fear that the tubercle would be
irritated by settling of the denture due to occlusal forces.
However, if the denture border ends on the hard tissues, no
peripheral seal will be possible. The denture border must be
extended over the genial tubercles (and proper relief is done) in favor of improving the
peripheral seal.
Lingual ledge
On side of genial eminence, a sharp bony ridge or crest which projects horizontally
toward the tongue and then falls off abruptly maybe palpated. This is a frequent source of
annoyance to denture. The ledge is a crescent shaped prominence located bilaterally
between genial tubercle and anterior end of mylohyoid ridge, which maybe continuous. It
exists in normal mandible as a slightly curved elevation but becomes more and more
prominent as the resorptive process reduces mandibular ridge and body.
In mouths containing moderately resorbed RR, the lingual ledge maybe palpated for
below the level of the floor of the mouth and is not involved in denture impressions
unless the impression tray is over - extended. Where slightly resorbed the high
mandibular ridges are present, the ledge is not palpable. The presence of soreness of
lesions in this region explains the denture border impinging on the thin overlying mucosa,
thus not covering the lingual ledge completely.
Labial frenum
Usually a single narrow band but may consist of two or more band. The activity of this
area tends to be vertical so the labial notch in denture should be narrow.
The mandibular labial frenum is usually shorter and often wider than maxillary labial
frenum.
Labial sulcus
The part of denture extending from labial frenum to buccal frenum is labial flange or
labial sulcus in edentulous mouth.
This flange is limited in extension because the fibers of orbicularis oris and incisive labi
inferioris are fairly close to ridge crest. Muscles fibres are mainly horizontal. Mentalis
muscle originates from mental tubercles and inserts into lower lip (orb oris). It is a
vertical muscle and may be very active in some patients.
The orbicularis oris is the major muscle in this region. as its
muscle fiber run horizontally, care must be taken not to
overextend the impression border in cases with weak muscle
tension in this region.
The mentalis muscle is one of the muscles constituting the lower
lip. Its muscle fibers are vertical and the origin attaches high on
the mandibular alveolar process therefore the labial vestibule becomes narrow when this
muscle contract .
However, if the lip is pulled too much as a result of being over conscious about this
contraction during border molding, the vestibule will become too shallow because the
attachment of the muscle is higher than the base of the labial vestibule
Excessive activity in this area results in short flange which may not provided seal for
finished dentures.
In patient exhibiting strong muscle tension of these muscles
in this region, this causes the lower up to fall inward and the
impression border becomes thin and short. As a result, the
completed denture might have an insufficient peripheral seal.
In general, the instruction is given to bite the operator's
fingers which are placed between the tray and the maxillary ridge. A the masticatory
muscles become tense and the lower lip becomes loose as a reflex, the impression is then
made in this situation
When ridge is fair to good the labial borders should be thin (1-2mm) since thicker border
will distort the lips. When ridge is flat a thicker border is needed for lip and checks
support and to provide better seal.
In general a thicker border creates better seal than thin border. Wider borders tend to
create favourable inclined plane and reduce the potential of losing peripheral seal.
Thicker border should be used with discretion, since they may cause discomfort poor
esthetics or interference with normal muscle movements.
Buccal frenum
It is usually in the area of first premolar. It may be a single band but often two or more
bands.
The oral cavities in this are horizontal as well as vertical (i.e. movements such as
puckering, grinning etc) so wider clearance is usually needed.
The contour of denture will be little narrower in this area due to activity of depressor
anguli oris muscle.
Buccal vestibule
Extends from buccal frenum posteriorly to outside back corner of retromolar pad and
from crest of RAR to cheek.
The buccinator in cheek extends from modiolus (ant) to pterygomandibular raphe (post).
Labial and buccal borders are not as critical for borders seal because they shape of the
lips and checks create a facial seal. That is why it is possible to have a denture with open or short
flange (often used for immediate dentures) and still have good retention.
Masseter region
Pain may occur on the buccal side of the retromolar
pad region during mastication even though the de-
nture is properly designed. This is due to the
masseter muscle, a strong elevator, which is lateral
to the retromolar pad and covers the buccinator
muscle.
When the masseter muscle contracts, its
enlargement presses the denture border with the cramped buccinator muscle. As the
denture occludes it cannot move during function of the elevators. When the distobuccal
border of the denture base is extended into the functioning area of the masseter muscle,
the mucosa will be pressed against the denture base leading to pain.
to avoid such a situation, the movement of the masseter muscle is recorded in the
impression by creating its reactive contraction through pushing the tray during the border
molding procedure. The tension of the masseter muscle will make a concavity in the
distobuccal outline of the impression. Another way is to reduce the over lengthened
border through observing the redness or displacement of the denture after insertion of
the new denture made by connecting the index line.
An active masseter muscle will create a concavity in the outline of distobuccal border.
The distobuccal border of mandibular impression encounters
the action of masseter to a greater or lesser degree depending on
the shape of the mandible and the origin of muscle.
If ramus of mandible has a perpendicular surface and origin of
muscle on zygomatic arch is medial ward; the muscle pulls
more directly across the distobuccal denture border, therefore it forces buccinator and
tissues inward, reducing the space in this region. If the opposite is true, greater retention
is allowed on distobuccal portion of mandibular impression.
The relative size of masseter will influence its action on the buccinator; a masseter that is
of smaller diameter will have less influence (perhaps none) on the border.
Distal extension of mandibular impression
The distal extent of mandibular impression is limited by the ramus of mandible, the
buccinator fibers that cross from the buccal to lingual as they attach to the pterygo
mandibular raphe and the superior constrictor and sharpness of lateral bony borders of
retro molar fossa (formed by continuation of external and internal oblique ridges
ascending the ramus).
If the impression extends on to the ramus, the buccinator and the adjacent tissues will be
compressed between hard denture border and the sharp external oblique ridge, which will
not only cause soreness but also limit the function of buccinator, which is a part of the
kinetic chain of swallowing.
The desirable distal extension is slightly lingual of these bony prominences and includes
the pear-shaped retro molar pad which forms a splendid soft tissue seal.
Pterygomandibular raphe
The pterygo mandibular raphe or ligament originates from the pterygoid hamulus of
medial pterygoid plate and attaches to distal end of pterygoid ridge.
It is partly the origin of buccinator muscle laterally and the superior constrictor muscle
medially.
It is quite prominent in some patients and may even require and notch like clearance in
maxilla denture. A simple wide-open digital and visual inspection will usually determine
whether clearance is required or not.
If extreme opening is allowed in making the impression the pterygo mandibular ligament
make a notch distal to alveolar tubercle
Alveololingual sulcus
It is the space between the residual ridge and tongue. It extends posteriorly from lingual
frenum to retromylohyoid curtain. Part of it is available for the lingual flange of denture.
The alveololingual sulcus can be considered in 3 regions
1. The anterior region (Premylohyoid fossa)
This extends from lingual frenum to where the mylohyoid ridge curves down below the
level of sulcus.
This fossa results from the concavity of mandible joining the convexity of mylohyoid
ridge.
Lingual border of impression in anterior region show make definite contact with mucous
membrane of mouth when tip of tongue touches upper incisors.
Anterior lingual flange area
The border of the impression in this area is mainly influenced by the lingual frenum and
the genioglossus muscle. The genioglossus muscle and the Lingual frenum which lie over the
muscle move actively and are easily traumatized therefore their movement and tension must
be recorded exactly during border molding. Thus the patient must be instructed to make
appropriate tongue movements in order to record the exact depth and width of the notch
made by the lingual frenum.
To provide adequate clearance in this area the patient is instructed to make some overactive
movement such a licking the Lower lip , by moving the tip of the tongue from side to side.
Inadequate clearance may result in pain or inflammation. Tongue movement is never
requested during, impression making. However this is the only area where functional
movement of the tongue is necessary.
Lingual frenum
Fibrous band of tissue that overlies the centre of genioglossus muscle. It is usually a
narrow single band of tissue but may be broad and exist as two or more frenums.
It is rather shallow, sensitive and resistant. It should be registered in function because at
rest the height of its attachment is deceptive. In function it comes quite close to crest of
ridge although at rest it is much lower.
It originates at midline from under surface of tongue and often terminates at the
sublingual (salivary) caruncles. In other instances it crosses and bisects the sublingual
crescent space and attaches to lingual aspect of mandibular ridge. Often it fans out to find
a broad insertion in alveolar mucosa.
This structure should be palpated for tension during tray adjustment procedure. Careful
clearance is needed in the denture because the lingual frenum is attached to tongue and
inadequate clearance may result in pain or displacement of denture.
They may be attached or near the crest of ridge. The lingual frenum maybe very short or
tongue-tie the patient can hardly protrude the tongue. Accessory frenums may occur in
almost any area of vestibule.
It is influenced by genioglossus muscle and some what by anterior portions of sublingual
glands. The action of these muscles may raise and protrude the tongue.
Frenums are basically fibrous connective tissue. They do not contract or expand like
muscles but rather are ligaments. They are accessory limiting structures for tongue, lips,
and muscles of cheek.
2. The middle region
The part of alveololingual sulcus extends from premylohyoid fossa to distal end of
mylohyoid ridge curving medially from the body of mandible.
When mylohyoid muscle and tongue are relaxed, the muscle drapes back under
mylohyoid ridge.
If the lingual flange slopes towards the tongue, the tongue can rest on top of flange and
aid in stability of lower denture on RR it also prevents displacing the denture during
tongue movements and swallowing thus maintaining the seal.
The length and width of mylohyoid flange is determined by membranes attachment of
tongue to mylohyoid ridge and width of hyoglossus muscle and can only be determined
by skilful border molding and impression.
The lingual borders in mylohyoid areas are formed by contact with mylohyoid muscles in
a functional but not extreme contracted or elevated position.
As Blanchard pointed out these borders leave a space when mylohyoid muscles are at
rest. The average mylohyoid border is 4-6mm below mylohyoid ridge fair-good ridge-
width 2-3mm flat-ridge 4-5mm.
Sub mandibular fossa
It is a concave area in mandible that is inferior and distal to mylohyoid ridge. It is a bony
landmark and has little significance in impression making except it is necessary to be
aware of configuration.
SUBLINGUAL GLAND AREA
The relationship of sublingual gland to lingual border is
controversial and confusing.
They are located above mylohyoid muscle. They vary in
size and sometimes appear immense, that they seem higher
than RR. The position of gland is elevated when mylohyoid
muscles are in function (during swallowing) and they
appear to eliminate the lingual vestibules unless quite firm, which is rare, the sublingual
glands can be virtually disregarded during impression making.
Similar to impression making in the mylohyoid ridge area the patient is never instructed
to perform any movements of the tongue, but asked only to relax the tongue comfortably.
The mouth is nearly closed and the tongue lies on the floor of the mouth completely. This
is the "impression position" of the tongue.
Tongue movements ate made by pressing the anterior portion
of the tongue with the forefinger. Such an amount of tongue
movement is recommended for those who want to make
tongue movement.
Through border molding, the depth of the Lingual vestibule
is recorded in this situation and this will in turn be used as the length of the lingual flange
in the sublingual gland area, so that the lingual border seal can be established effectively.
The lower denture will not be lifted up, even though the
sublingual gland is raised, as the upper and lower teeth are
in contact when swallowing.
On the other hand, the sublingual gland serves as a cushion
due to its soft and resilient nature and therefore it will
neither lift the denture nor will it covering mucosa be traumatized by the denture.
If the denture border is made short to relieve the raised
sublingual gland a space will occur between the denture
border and the mucosa when the mylohyoid muscle is at
rest and thus the peripheral seal will be lost.
3. The posterior region (Retromylohyoid fossa/space)
The space distal to the mylohyoid muscle is referred to as the
retromylohyoid fossa. It lies at the distal end of the alveolingual sulcus and
extends from end of mylohyoid ridge to retromylohyoid curtain
It is bounded medially by anterior tonsillar pillar. posteriory by
retromylohyoid curtain and superior constrictor, laterally by mandible .
Anteriorly by lingual tuberosity. inferiorly by mylohyoid muscle .
[HEARTWILL]
It is bounded by the mylohyoid muscle anteriorly the retromolar pad laterally, the
superior constrictor muscle posterolaterally, the palatoglossus muscle posteromedially
and the tongue medially. [HAYAWAKA]
At this time, the posterior limit of the lingual border is defined by the palatoglossus
muscle[A] and the Lingual slip of the superior constrictor muscle[B]. This is called the
retromylohyoid curtain
The retromylohyoid curtain is formed posteriorly by superior pharyngeal constrictor. The
action of the muscle and the tongue determine the posterior extent of lingual flange.
In the retromylohyoid fossa the lingual flange not affected by mylohyoid muscle so the
flange can turn laterally toward the ramus to fill the fossa and complete the typical S form of
correctly shaped lingual flanges. ZARB
Pouch shaped retromylohyoid space is lined completely with loosely attached mucosa.
There are no supporting structures here since the medial surface of mandibular body
slope obliquely outward from mylohyoid ridge to mandibular border forming
submandibular fossa.
Distal to mylohyoid muscle the space dips toward and outward to permit formation of
retromylohyoid eminence of mandibular denture. However denture flange should not
completely fill this area. it is necessary that the lining mucosa maintain continuous
contact with basal surface of flange which should not inhibit the tongue movement. The
external surface of retromylohyoid eminence is in continuous contact with lateral and
ventral surface of tongue, which limits flange thickness in accordance
with size and functional movements.
During border molding, the border in this area is pushed into the
retromylohyoid fossa by the strong intrinsic and extrinsic tongue
muscles, it will show the so-called S-curve as viewed from the impression surface
Lateral throat form/ Distolingual vestibule/ Retromylohyoid fossa
This anatomical area is probably least understood and frequently mismanaged. It is
bounded by :
Anteriorly - by mylohyoid muscle Laterally - pear shaped pad
Postero-laterally - superior constrictor muscle
Postero-medially - palatoglossus muscle and Medially tongue
The so called s- curve of mandibular denture as viewed from lingual results from the
stronger intrinsic and extrinsic tongue muscles which usually place the retromylohyoid
borders more laterally towards retromylohyoid fossa, as they appose weaker superior
constrictor muscle.
The posterior limit of mandibular denture is determined by palatoglossus muscle and
somewhat by weaker superior constrictor muscle. This area is called Retromylohyoid
curtain.
Classification of lateral throat form
Neil described that the denture could have three possible lengths, depending on tonicity, activity
and anatomic attachments of the adjacent structures.
Class III
minimum length and thickness
Border 2-3 mm below mylohyoid ridge or sometimes at the ridge
Thickness no more than approx- 2mm
Knife-edge border if border terminates at mylohyoid ridge
Class I
Wide and long and wide flange.
Thickness varies
The Retromylohyoid curtain area (most distal border )should be thinner
Class II
it is half as long and narrow as class I and twice as long as class III
Most edentulous mouths have class I and class II lateral throat from class III is rare.
Besides border seal, another important reason for extending the lingual flanges into lingual
vestibules as for possible within their anatomical and functional limits. These flanges present
favourable inclined planes to the tongue resulting in vectors of force that helps maintain the
mandibular denture in place.
Lingual flange affected
Distal extent - glossopalatine arch formed by glossopalatine and lingual extension of
superior constrictor.
Medially - influenced by mylohyoid muscle attached to mylohyoid ridge.
The buccal surface of flange rests on soft tissue and not on mucous membrane in contact
with bone.
The mucolingual fold (the line of flexure of mucous membrane as it passes from tongue
to floor of mouth) is extremely flexible and mobile because of the type of tissue and due
to mobility of entire floor of mouth.
The anterior part of lingual flange over sublingual gland is shallow because of mobility of
tissues that are controlled indirectly by mylohyoid muscle. The mylohyoid muscle in this
region extends nearly to inferior border of mandible and yet the glandular and other
tissues move above it. The combination of typical arch form of lingual side is projection
of mylohyoid ridge toward the tongue and existence of a retro mylohyoid fossa at distal
end of alveololingual sulcus causes the border of lingual flange to assume its typical s-
shape when viewed from impression surface.
The mucous membrane lining the vestibular spaces and alveololingual sulcus is thin non-
keratinised epithelium. The submucosa is formed of loosely arranged CT fibres mixed
with elastic fibres. Thus the mucous membrane is freely movable. Anteriorly the
submucosa of mucous membrane lining the alveololingual sulcus contains components of
sublingual gland and is attached to genioglossus muscle. In molar region, the submucosa
attaches to mylohyoid muscles and the mucous membrane of retromylohyoid curtain is
attached by its submucosa to superior constrictor. Posterior to superior constrictor, which
runs in horizontal direction is medial pterygoid muscle running in vertical direction.
FLAT MANDIBULAR RIDGES
On the labial surface of anterior region of the mandible several muscles are close to the
crest of ridge especially in badly resorbed ridges. This proximity accounts for the short
flanges necessary in this region. The muscles should not be impinged on since their
action is nearly at right angles to the flange. Many edentulous mandibles are extremely
flat because of loss of cortical bone.
The surface is weakened and changes in form by the more rapid resorption of cancellous
portion of mandible. The denture-bearing surface often becomes concave, allowing the
attaching structures, especially on lingual side of ridge to fall over the ridge surface. Such
conditions require displacement of these tissues by the impression, which will gradually
establish a suitable bearing surface. The crest of greatly resorbed ridges is often at the
level of mental foramina and the nerves and blood vessels are easily compressed unless
the area is palpated and relieved on impression.
Insufficient space b/w maxillary tuberosity and mandible
The maxillary sinus enlarges throughout life, if it is not restricted naturally by presence of
teeth or dentures.
The angle of mandible becomes more obtuse by early loss of posterior teeth with
retention of anterior teeth. This destroys the necessary counterbalance against muscle pull
at angle of mandible. Such straightening of mandible reduces the maxilla mandibular
space in posterior region and creating lack of space for teeth and denture bas causing
denture failures.
ANATOMIC LANDMARKS OF THE MAXILLA
A] The Denture Bearing Area (Supporting Structures)
1- Resi dual r i dge - The portion of the alveolar
process& it's soft tissue
covering that remains after
extraction.
- It covers by a dense connective
tissue fibers so, it can be act as a
1
ry
stress bearing area.
vaul t of t he pal at e The vault of the palate has
different forms according to the
pattern of development of the
maxillary processes. The palatal
arch may be V-shaped, U-
shaped or flat.
The moderately high U-shaped
vault is the more common and is
more desirable for denture
stability.
2- I nc i si ve papi l l a - Pear-shaped elevation present
in the midline behind the 2
centrals.
- After extraction of teeth it
migrates to the crest of the ridge.
- It should be relieved to avoid the
burning sensation of the palate.
3- Pal at i ne r ugae ar ea - It is irregular elevations
radiates from the midline of the
anterior part of the palate.
- 2
ry
stress bearing area.
- Prevent forward movement of
the denture.
- If it is sensitive or prominent it
should be relived.
4- Medi an pal at i ne r aphe - The mucoperiostium that
covers the median palatine
suture.
- When it is prominent it should
be relieved.
- Lack of relief cause:
1- rocking of the denture due to
bone resorption.
2- Tissue ulceration.
3- Mid-line denture fracture.
5- Max i l l ar y t uber osi t y - Bony prominence located
posterior to the upper 3
rd
molar.
- Aid in support, retention and
stability of the complete denture.
- When it is large:
1- Relieved.
2- Modify the path of insertion.
(unilateral enlargement).
3- Surgical removal.
6- Tor us pal at i nus - Bony prominence present at
both sides of the midline of the
palate.
- present in 20% of the
population.
- It should be:
1- Relieved.
- Fovea pal at i nae
10-
- Two openings of minor
salivary glands present in both
sides of the midline posterior to
junction of hard and soft palate.
- It determines the posterior
extension of the upper complete
denture to be 2mm posterior to it.
8- I nc i si ve f ossa It is a slight depression in the
labial surface of the maxilla
opposite the region previously
occupied by the root of upper
lateral incisor.
9-Cani ne emi nenc e It is found in the labial surface
of the maxilla. It is a rounded
bulge at the corner of the mouth
opposite the region previously
occupied by the root of the
maxillary canine.
10-But t r ess (r oot ) of t he
zygomat i c bone
It is formed by the lower portion
of the zygomatic process of the
maxilla which flares upward
and outward from the area
above the first molar
This area provides excellent
resistance to vertical forces as its
almost at right angles to the
occlusal forces.
- avoid vertical over-extension
in the first molar region, as
mucosal injury may result from a
sandwiching of the soft tissues
between the denture border and
the zygomatic process of the
maxilla.
With resorption the denture may
require relief over it
Pal at al gi ngi val vest i ge It is the remains of the palatal
gingivae. After tooth extraction
the position of the vestige
remains relatively constant, the
same as the incisive papilla
This can be a very helpful pointer
for posterior tooth positioning
during complete denture
construction. See buccal vestibule
B] Border structures that limit the periphery of maxillary denture
Max i l l ar y l abi al f r enum It is a fibrous band covered by
mucous membrane that extends
from the labial aspect of the residual
alveolar ridge to the lip. It may be
single or multiple and may be
narrow or broad.
It contains no muscle so it can be
surgically exiseced if it attach near
the crest of the ridge.
A labial notch must be
provided in the midline of the
denture border opposite to the
frenum. This notch prevents
ulceration of the frenum or
displacement of the denture.
A shallow bead can be formed
in the denture base around the
notch to help perfect the seal.
Labi al vest i bul e The labial vestibule extends in both
sides between the labial frenum and
the buccal frenum.
The labial flange of the
maxillary denture occupies the
space bounded by the residual
alveolar ridge, and the lip.
The major muscle in this area
is orbicularis oris.
Buc c al f r enum It is a fold or folds of mucous
membrane extend from the buccal
mucous membrane reflection
towards the slope or crest of the
residual ridge. They vary in size,
number and position.
Associated muscles are:
Buccinator
Orbicularis oris
Levator anguli oris
It requires more clearance in
the denture flange for its
action. Inadequate provision
for the buccal frenum or
excess thickness of the flange
distal to the buccal notch can
cause dislodgment of the
denture.
Buc c al vest i bul e It extends from the buccal frenum to
the hamular notch.
It houses the buccal flange of
the denture between the ridge
and the cheek.
the distal end of the buccal
flange of the demure must be
adjusted to accommodate the
coronoid process of the
mandible
Pt er ygomax i l l ar y (hamul ar )
not c h
It is a depression lies between the
pterygoid hamulous posteriorly and
the maxillary tuberosity anteriorly
It is a displaceable area about 2mm
wide
It is used as a boundary of the
posterior border of the
maxillary denture. The tissue
in this notch is easily
compressed and the post dam
line of the upper denture
should be carried into this
region to ensure an adequate
peripheral seal.
Bases short of the hamular
notch will end on the thin -
nonflexible tissue of the
tuberosity and will
consequently lack retention.
Vi br at i ng l i ne of t he pal at e The vibrating line is an imaginary
line drawn across the posterior part
of the palate that marks the
beginning of motion in the soft
palate when the patient says "ah."
may also be identified by Valsalva
maneuver by asking the patient to
close his nose using his fingers and
asking him to blow gently through
the nose .
It extends from one
pterygomaxillary notch to the other
notch on other side
A, Diagram of the upper arch.
B, Diagram of the lateral surface of the maxilla.
ANATOMI C LANDMARKS OF THE MANDI BLE
A] t he Dent ur e Bear i ng Ar ea (Suppor t i ng St r uc t ur es)
1- r esi dual r i dge - The portion of the alveolar
process& it's soft tissue
covering that remains after
extraction.
- Don't used as 1
ry
stress
bearing area Covered by
movable fibrous connective
tissue.
- Don't Provide stability or
support.
2- Ex t er nal obl i que r i dge - Bony ridge running
downward and forward from
ramus to reach mental
foramen.
In the impression, the external
oblique ridge shows a groove.
The impression should record
the ridge
- It is a limiting structure to
the complete denture and not
extend to it.
if the denture border is over
extended beyond the external
oblique ridge (over 1-2mm),
the denture will be widened
over the buccinator muscle
attachment and thus located on
the buccinator muscle fiber .
If the denture border is under
extended in this area, it is dif-
ficult to mould the convex
buccal flange correctly leading
to food accumulation in the
buccal sulcus and under the
denture base [HAYAKAWA]
3- Buc c al shel f ar ea - Bony area extends between
the external oblique ridge and
the residual ridge.
The buccal shelf area can
range from 4-6 mm wide on an
average mandible to 2-3 mm
or less in narrow mandible.
- Used as 1
ry
stress bearing
area:
1- Perpendicular to the vertical
masticatory force.
2- Formed from compact
bone.
3- provide support.

4- Ment al f or amen - It's located on the Buccal
surface of the mandible
between the roots of 1
st
and 2
nd
premolar.
- Lack of relief numbness
of the lower lip.
5- Ret r omol ar pad - Pear-shaped area located
distal to the lower 3
rd
molar.
It consists of mucous glands ,
temporal tendon , fibers of the
buccinators and superior
constrictor muscle .
- Shock absorbent.
- Gives retention not support.
- Determine the level of the
Occlusal plane.
6- Tor us mandi bul ar i s - Bony prominence located at
the inner surface of premolar
area.
- It should be:
1- Relieved.
7- I nt er nal obl i que r i dge
(Mylohyoid ridge)
- Irregular bony ridge of
median surface of the
mandible which the
Mylohyoid muscle attached.
- It should be relieved during
complete denture construction.
11- Geni al t uber c l e (Mental spine) - Two bony projections present
at the median surface of
mandible at midline of each
side of symphesis.
- Represent the attachment of
geniohyiod and genioglossus
muscles.
- If it's prominent, it should be
relieved.
9-Li ngual f or amen Radiolucent hole in center of
genial tubercles.
Lingual nutrient vessels pass
through this foramen.
B- Bor der st r uc t ur es t hat l i mi t t he per i pher y of mandi bul ar dent ur e
1-mandi bul ar l abi al
f r enum
It is a fibrous band covered by
mucous membrane that extends from
the labial aspect of the residual
alveolar ridge to the lip. It may be
single or multiple and may be narrow
or broad.
A labial notch must be provided
in the midline of the denture
border opposite to the frenum.
This notch prevents ulceration of
the frenum or displacement of the
denture
2- Labi al vest i bul e The labial vestibule extends in both
sides between the labial frenum and
the buccal frenum.
The labial flange of the
mandibular denture occupies the
space bounded by the residual
alveolar ridge, and the lip.
3- Buc c al f r enum It is a fold or folds of mucous
membrane extend from the buccal
mucous membrane reflection towards
the slope or crest of the residual ridge.
Like the labial frenum it contains no
muscle fibers. They vary in size,
number and position.
It requires clearance in the
denture flange for its action.
Inadequate provision for the
buccal frenum or excess thickness
of the flange distal to the buccal
notch can cause dislodgment of
the denture.
4-Buc c al vest i bul e It extends from the buccal frenum to
the hamular notch.
It houses the buccal flange of the
denture between the ridge and the
cheek.
5-Masset er musc l e
i nf l uenc i ng ar ea
The distobuccal comer of the
mandibular denture must
converge rapidly to avoid
displacement due to contracting
pressure of the masseter muscle
Li ngual Vest i bul e: It can be divided into three areas
Anterior vestibule/ sublingual
crescent area/ anterior
sublingual fold
the middle vestibule/
mylohyoid area
the distolingual vestibule/
lateral throat form/
retromylohyoid fossa
12- 6- The l i ngual pouc h \
r et r omyl ohyoi d
f ossa \ c ur t ai n \ spac e
lies at the distal end of the
alveolingual sulcus.
The lingual pouch boundaries:
Medially; the tongue.
Laterally; the mandible;
Posteriorly; the palatoglossus
arch, which is formed in part by the
palatoglossus muscle, and in part by
the lingual extension of the superior
constrictor muscle.
Anteriorly; the posterior 3 mm of
the mylohyoid muscle.
- The so called s curve of the
lingual flange of the mandibular
denture results from stronger
intrinsic and extrinsic tongue
muscles, which usually place the
retromylohyoid borders more
laterally and towards the
retromylohyoid fossa, as the oppose
weaker superior constrictor muscle.
- Over extension of the
distolingual border of the lower
denture will cause sore throat due
to the pressure on the
palatoglossus arch muscles.
- The posterior limit of the
mandibular denture is
determined mainly by the
palatoglossus muscle and
somewhat by weaker superior
constrictor muscle this is area is
called posterior/ retromylohyoid
curtain.
the denture could have three
possible lengths, depending on
the tonicity, activity, and
anatomic attachments of the
adjacent structures-
Class I throat form: The
horizontal border is usually 2-3
mm thick, but a thicker border of
4-5 mm should be used for better
seal if the ridge is flat. The
retromylohyoid curtain area
should be thinner, about 2-3 mm,
and very rounded and smooth.
Class II throat form is about half
as long and narrow as class I and
about twice as long as class III.
Class III lateral throat form has
minimum length and thickness.
The border usually ends 2-3 mm
below the mylohyoid ridge or
sometimes just at the ridge.
7- Subl i ngual sal i var y
gl and ar ea \ Subl i ngual
f ol ds
Formed by the superior surface
of the sublingual glands and the
ducts of the submandibular glands.
The lingual flanges of the lower
denture should not extend in
this area
8- Li ngual f r enum It is the anterior attachment of
the undersurface of the tongue to the
floor of the mouth in the midline. It
is very resistant, active and often
wide.
The denture borders should be
well rounded in this area. A
notch should be provided in the
lingual flange to avoid
displacement of the lower
denture.
9-pt er ygomandi bul ar
Raphe
It is a raphe formed by the buccinator
muscle fibers and the superior
constrictor muscle of the pharynx.
The distal extension of the
mandibular denture is limited by
the Pterygo-mandibular Raphe
10- Pl at o gl ossal Ar c h The palato glossal arch is formed
mainly by the palato glossus muscle.
The distal end of the lingual
flange is related to the palato
glossal arch.
Over-extension of the lingual
flange in this area will cause sore
throat.
Diagram showing the mandible: A, Buccal view. B, Lingual view.
Musculature
Muscles of facial expression
Muscles of mastication
Suprahyoid and Infrahyoid muscles
Muscles of the neck and throat
Extrinsic and intrinsic tongue muscles
Palatal muscles
Tendons: Attach muscles to bones
Aponeurosis: A very broad tendon
Muscles Origin or head: Muscle end attached to more stationary of two bones
Insertion: Muscle end attached to bone with greatest movement
Belly: Largest portion of the muscle between origin and insertion
Isotonic contraction: It is shortening of the muscle under constant load. It is used to produce
movement. Elevation of the mandible is an example of isotonic contraction of Masseter muscle
Isometric contraction: It is contraction of muscle without shortening It is used to produce
tension within the muscle to resist an external
force. Elevator ms. Contract isometrically to keep
the mandible at rest (tension without shortening)
Classes of Levers
A- MUSCLES OF FACIAL EXPRESSION
Zygomaticus major, zygomaticus minor, levator labial superioris alaque nasi, levater labi
superioris, levater anguli oris, mentalis, depressor labi inferioris, depressor anguli oris, r[soris,
platysma, orbicularis oris and buccinator muscles are responsible for expressions seen in lower
half of face.
The actions of these muscles
are responsible for various facial
expressions including smiling,
laughing and frowning. The actions
of these muscles reflect the
emotional status and mood of an
individual.
The perioral muscles do not insert
into bone and need support from
natural or artificial substitutes for
proper function.
The insertions of these various muscles around the oral cavity both superficially and
deep are important. These muscles insert partly into CT of skin and partly into mucous
membrane of lips.
In an area situated laterally and slightly above the corner of mouth is a concentration of
many fibres of this muscle group called muscular node or modiolus and represents an area
where the extrinsic perioral muscles decussate with intrinsic fibres of orbicularis oris muscle.
The origins of several muscles of facial expression are near enough to the denture
bearing areas that their actions must be considered as definitely influencing the denture borders.
The higher the residual ridge, the less influence these muscle attachments will exert.
1- Mentalis
This muscle is found around the chin
It raises the lower lip, causing the chin to wrinkle
It will give a doubt facial expression
Importance of MENTALIS muscle in relation to complete denture construction
Contraction of the mentalis m. raise a soft tissues of the chin, thus reducing the width and
depth of the lingual sulcus.
If there has been marked resorption of the underlying bone , this muscle can exert
considerable pressure on the labial flange of the denture, resulting in posterior and
upward displacement
Because it raises the lower lip, causing the chin to wrinkle its Contraction indicates high
V.D. of the denture
The mentalis muscle renders the lower vestibule shallower when it contracts; dislodging the
denture, with residual ridge is same height as the fornix of vestibule, dictating the extension of
lower denture flange
2- Incisive labi superioris and inferioris
They arise from maxillary and mandibular alveolar process respectively. They coarse laterally to
blend with orbicularis oris muscle. Their action is similar to mentalis muscle on vestibular
fornix. They are small muscles, their actions alone may not influence the denture.
3- Buccinator
Buccinator: from L. n. bucina = trumpet,[ bucinator = trumpeter]
It is an accessory m. of mastication , occupy the gap between
mandible and maxilla forming important part of the cheek.
Origin: alveolar bone of the upper and lower three molars and
pterygomandibular ligament . The ligament serves as a function
between the buccinator and superior constrictor of pharynx.
Course and insertion ;
Upper fibers inserted into upper lip,
Lower fibers inserted into lower lip,
Middle fibers decussate at the angle of the mouth, the upper fibers pass to lower lip while
the lower fibers pass to the upper lip .
Nerve supply Motor enervation is the buccal branch of facial nerve
Sensory impulses: carried by mand. branch of trigeminal nerve
Blood supply ; Facial artery .
Action : Prevents the accumulation of food in the vestibule of mouth
Importance of BUCCINATOR Muscle In Relation To Complete Denture
Construction
The buccinator muscle is divided into:
Superior fibres : act to seat the maxillary denture
Middle fibres :control the bolus of food
Inferior fibres:contribute to the stability of the mandibular denture
While the middle fibres contract, controlling the bolus, the inferior fibres relax to form a
pouch capable of storing food until needed to form another bolus.
Extension of a concave denture base into this pouch allows the cheek to lie over the
flange.
The nature of buccinator was not able to changes to contour of the denture base.
Because learning and adaptation appear to be limited, the denture contours should be
designed to harmonise with exiting buccinator muscle function.
The neutral zone concept is based on the belief that the muscles should functionally
mold not only the border and the artificial teeth but also the entire polished surface.
facial and lingual forces generated by the musculature of the lips, cheeks and tongue are
balanced
Contraction of the buccinator m. raise a soft tissue band at about the level of the
occlusal plane. The polished surface of the buccal flange should be shaped so that the
pressure falling on it from B. activity will have a component of force which is directed
towards the ridge and which will therefore help to retain, rather than dislodge, the
denture.
In lower jaw due to extreme resorption of the RR, the buccinator and mylohyoid cover
the bony support from area of first molar to retromolar pad. Fortunately the action of
buccinator does not dislodge the denture as its fibres run parallel to plane of occlusion,
but run at right angles to masseter. When masseter is activated it pushes buccinator
medially against denture in area of retro molar pad.
The position and attachment of buccinator muscle in upper jaw determines the vertical
height of distobuccal flange of maxillary denture. The fibres attach to the thin
periosteum and possibly into bone proper.
4- Orbicularis oris
It is the sphincter muscle of the mouth. It has no skeletal attachments except through the
attachments of incisivus labii superioris and inferioris muscles and nasolabialis muscles.
A Intrinsic part deepest strata very thin sheet: Originates from superior incisivus in maxilla,
inferior incisivus in mandible Insert into angle of mouth
B Extrinsic part, two strata formed by converging muscles: Originates from thickest middle
strata derived from buccinators thick superficial stratum from elevators and depressors of lips
and angles of mouth. Insert into lips and angles of mouth
This muscle surrounds the mouth constitutes upper and lower lips and is continuous with
buccinator on either sides.
It is used to purse the lips, and closes the mouth
It is used to pout and kiss
Importance of ORBICULARIS ORIS muscle in relation to complete denture
construction
Proper contouring of the labial and buccal flange is necessary to support the lips and cheeks.
Proper shaping of the denture flanges to be concave rather than convex, will allow the lips,
cheeks and tongue to seat the denture.
5- Risorius
This muscle extends diagonally from the corners of the mouth
It draws the mouth corners outwards
Used when smiling
6- Zygomaticus :
This muscle extends diagonally from the corners of the mouth
Lifts the mouth corners, upwards and outwards
Is used when smiling and laughing
Importance of REZYOMATIC SPACE In Relation To Complete Denture
Construction
The buccal space or REZYOMATIC SPACE
A region that often causes problems in
maintaining border seal
When the mandible is moved laterally, the cronoid
process on the non-working side comes into close
relation to the buccal aspect of the maxillary
tuberosity.
The buccal sulcus in this region is thus reduced in width, limiting the space available for
a buccal flange.
But must be filled to avoid ingress of air beneath the denture base
7- Depressor labii
This muscle extends over the chin
It draws down the mouths corners
Is used when sulking
8- Platysma
This muscle is found at the sides of the neck
It draws down the mouths corners downwards and backwards
It is used when we are scared frightened (fear, horror)
9- Orbicularis oculi
This muscle surrounds the eyes
It closes the eyelid
Used when winking
10- Corrugator
This muscle is found between the eyebrows
It draws the eyebrows together
Making your frown
11- Occipital-frontalis
This muscle is found at the forehead, and runs to the
occipital region
This muscle raises the eyebrows
Giving a surprised facial expression
12- triangularis muscle
The triangularis muscle, which attached in the region of the mandibular buccal frenum,
and the mentalis m. which may be active in the region of the labial flange.
Both should accompany any border molding procedure
IMORTANCE OF FACIAL MUSCLES IN RELATION TO COMPLETE DENTURE
CONSTRUCTION
Modiolus:It is a node or depression, below and distal to the corner of the
mouth, contributed to The union of the lip and cheek muscles. Because.
These ms. have more than one bony attachment. they depend on
fixation of the modiolus to allow isometric contractionthat allowing the
buccinator to control the food bolus
The denture base must be contoured to permit the modiolus to fnction freely.
The premolar region of the mand. Dent, should exhibit both a shortened and narrow flange to
permit the action that draws the vestibule superiorly and the mod. Medially against the denture .
With loss of teeth the Modiolus will become flattened . the replacement of teeth should restore
its normal shape
B: buccinator m.
DAO: depressor anguli oris m. (triangularis)
II: Incisivus inferior m.
IS: incisivus superior m.
LAO: levator anguli oris m. (caninus)
OO: orbicularis oris m.
ZM: zygomaticus major m.
Muscles that influence the border of complete denture
B- Muscle of mastication
They are masseter, medial pterygoid and lateral pterygoid and temporalis. As a group, the
muscles of mastication are very powerful only one of these muscles directly influences the
contour of the denture base. The contraction of masseter forces the buccinator muscle medially
towards the retro molar pad.
the muscles of mastication is a collective term reserved for four pairs of muscles involved : -
Prime movers: TEMPORALIS AND MASSETER
- Grinding movements: PTERYGOIDS AND BUCCINATORS
Muscles of mastication develop from the mesoderm of the first pharyngeal arch.
They are innervated by the Mandibular division of the trigeminal nerve (all from the anterior
division except the medial pterygoid from the main trunk) .
They are functionally classified as:
Jaw elevators:
Masseter
Temporalis
Medial pterygoid
Upper head of lateral pterygoid
Jaw depressors
Lower head of lateral pterygoid
Anterior digastric
Geniohyoid
Mylohyoid
- Other muscles that play an important role in mastication include
Orbicularis oris: Anterior oral seal
Buccinator and Tounge: Help to keep the bolus of food on the occlusal
Surface of teeth
Masseter muscle : Masseter muscle influencing area:
1. The distobuccal corner of the mandibular denture is in relation to
the masseter muscle .
2. In this area the buccal flange must converge medially to avoid
displacement due to contraction of the masseter muscle because the
muscle fibers in that area are vertical and oblique .
MEDIAL PTERYGOID
The medial pteregygoid contraction influences the contour of the distolingual flange by
causing a bulge in the posterior wall of the retromylohyoid space.
Adequate seal can be obtained by gently compressing the tissues on the lateral wall of the
retromylohyoid fossa lingual to the retromolar pad and tucking the distolingual flange
laterally against the mucosa overlying the Sup. Cons. M. superiorly and the loose C.T.
Of the mandible inferiorly.
Maximum posterior extension into the fossa is not necessary. ( The inf. Ling. ext. is
dependent on the mylohyoid muscle.)
Lateral Pterygoid
The Lat. Pterygo. advance the condyles, thereby opening the mouth (depressing the mandible),
with the assistance of the Digastric.
The oblique orientation of the Masseter and Med. Pterygo. create a sling. The non-working side Med.
Pterygo. contracts simultaneously with the opposite side working Masseter
In normal chewing function, the mandible opens, and then, while initiating closing, there is a shift slightly
to the side of the bolus, due to the orientation of the masseter and medial pterygoid.
Due to the orientation of the Lateral Pterygoids and the oblique alignment of the condyles in relation to
each other, contraction of the Lat. Pt. initiates an instantaneous translation of the condyles. The slope of
the eminence provides for immediate mandibular depression and disocclusion of the teeth
Although Lat. Pt. are intended to work together to depress the mandible, a voluntary unilateral activity
results in an excursive movement to the contralateral side
C- Suprahyoid and Infrahyoid muscles :
Hyoid Bone: Only bone not directly articulated with other bones
Attaches via ligaments to temporal bone, larynx
Functions Moveable base for tongue , Attachment for
sternohyoid, thyrohyoid and Superior attachment for larynx
Suprahyoid muscles
These muscles attach the hyoid bone to the mandible
and are partly attached to the base of the skull.The
functions of suprahyoid muscles are to elevate the hyoid
bone and larynx and depression of mandible they are: Digastric,
mylohyoid, stylohyoid and geniohyoid muscles. The mylohyoid
and geniohyoid muscles may influence the borders of mandibular
denture.
Infrahyoid Muscles
These muscles attach the hyoid bone to the sternum. They pull the
hyoid bone downward
Mylohyoid muscle
It is a thin sheet that arises from the whole length of the mylohyoid
line. The posterior fibres are inserted into body of hyoid bone. The
remaining fibres are inserted into a median fibrous raphe extending
from symphysis of mandible to hyoid bone. It constitutes the muscular floor of mouth. It
elevates hyoid bone, the tongue and the membranous floor of mouth during swallowing.
If denture flange is extended below and under mylohyoid line, it will impinge on this
muscle and can affect its action adversely or conversely its action can unseat the denture.
Because the fibres are directed downward, the denture flange can extend below but not
under the mylohyoid line. This places the inferior border of denture in a compatible
position with the tongue. In instances of extensive bone loss, the mylohyoid can be
surgically detached from its periosteal attachment and reattached more inferiorly on body
of mandible without apparent impairment in function.
Mylohyoid muscle influencing area [internal oblique ridge]
The mylohyoid muscles anatomically and functionally form the floor of the mouth.
They elevate the tongue and depress the mandible.
Their O is the mandible and I is the upper border of the hyoid bone.
Problems
Movable floor of the mouth difficulty in establishing a lingual border seal
problem with retention
Lack of ideal ridge height and conformation minimize denture stability
The mylohyoid muscle act anteriorly as well as posteriorly to raise the floor of the mouth.
The lingual flange should extend to the mucolingual sulcus as determined by the extent of
the functional movement of the muscle .
The contour and inferior extension of the lingual flange are dependent on the action and
anatomy of the Mylohyoid muscle
The lingual flange slopes medially away from the mandible to allow for the action of the
Mylohyoid muscle
This inclination also enhances the ability of the tongue to control the mandibular denture,
providing a seating force to the denture.
The mandibular attachment of the Mylohyoid muscle extends anteroinferiorly along the
mylohyoid ridge in the molar region to the genial tubercle in the midline.
Posterior fibres extends vertically to attach to the hyoid bone while the anterior fibres
extend horizontally to meet the fibres of the contralateral side to form a midline tendinous
raphe.
This explains why the lingual flange can be made longer posteriorly despite a more
superior mylohyoid muscle attachment.
The inferior extension of the posterior lingual flange is determined by the displaceability
of the soft tissue and underlying Mylohyoid muscle when the floor of the mouth is at its
most superior position.
At rest The level of the floor of the mouth may be inferior to the lingual flange.
The tongue, by contacting the lingual denture surface is able to promote seal in this
region and enhance retention
Accurate border molding and imp. Procedures ensure adequate border seal.
The mandibular attachment of the Mylohyoid muscle extends anteroinferiorly along the
mylohyoid ridge in the molar region to the genial tubercle in the midline.
Posterior fibres extends vertically to attach to the hyoid bone while the anterior fibres
extend horizontally to meet the fibres of the contralateral side to form a midline tendinous
raphe.
This explains why the lingual flange can be made longer posteriorly despite a more
superior mylohyoid muscle attachment.
Geniohyoid muscle
It arises from inferior mental spine (genial tubercles) which is located on inner aspect of
symphysis menti just above anterior attachment of mylohyoid muscle. This muscle presents no
problem in CD construction unless there is extensive loss of RR.
In this situation the attachments of paired genioglossus and geniohyoid muscles to
mental spines maybe problematic. Like mylohyoid, the geniohyoid can be surgically detached
from periosteum and reattached more inferiorly on mandible without apparent impairment of
function.
The geniohyoid muscles are found next to each other, on each side of the midline,
directly on top of the mylohyoid muscle. They have the same origin and function as the
mylohyoid muscle.
Digastric muscles
Digastric muscles is not a muscle of mastication but it play an important role in mandibular
function
The combined efforts of the Digastrics and Lateral Pterygoids provide for natural jaw opening
D- Muscles of the neck and throat
Pharyngeal muscles
Of the several pharyngeal muscles, the
superior constrictor is one of most interest
in CD construction. It has four sites of
origin
The posterior border of
medial pterygoid plate and
pterygoid hamulus.
The pterygo mandibular
raphe.
The posterior end of mylohyoid line.
The side of the tongue.
I: posterior medial raphe of pharynx
Importance of THE SUPERIOR CONSTRICTOR MUSCLES in relation
to complete denture construction
Collaborated in The border seal of the distal extension of the lingual flange
The action of part of this muscle exerts pressure against the distal extremity of the mandibular
denture. Over extension in this area is very painful to the patient, as the denture will perforate the
tissue and create a painful lesion.
The anatomy of the Retromylohyoid space
More posteriorly the lingual flanges are related to the lingual pouch with its boundaries which
are :
Posteriorly : The palatoglosssus muscle and Superior constrictor muscle
Anteriorly : The Mylohyoid muscle.
Medially : The tongue .
Laterally : The medial aspect of the mandible.
The posterolateral portion of the retromylohyoid curtain overlies the superior constrictor
muscle and the posteromedial aspect covers the palatoglossus m. and lateral s. of the
tongue.
the inferior wall of the retromylhyoid fossa overlies the submandibular gland, which fills
the gap between the superior constrictor and the most distal attachmrent of the mylohyoid
muscle
Border molding must allow for the muscular function of this region.
Denture overextension in this area will cause sore throat.
The medial pteregygoid contraction influences the contour of the distolingual flange by
causing a bulge in the posterior wall of the retromylohyoid space.
Adequate seal can be obtained by gently compressing the tissues on the lateral wall of the
retromylohyoid fossa lingual to the retromolar pad and tucking the distolingual flange
laterally against the mucosa overlying the Sup. Cons. M. superiorly and the loose C.T.
Of the mandible inferiorly.
Maximum posterior extension into the fossa is not necessary.
( The inf. Ling. ext. is dependent on the mylohyoid muscle.)
Sublingual salivary gland area
The lingual flanges of the lower denture should not extend in this area because with excessive
resorption of the mandible the gland may bulge superiorly above the body of the mandible.
Sublingual Folds
When the tongue is elevated, the sublingual folds raised and may greatly reduce the depth and
width of the lingual sulcus. This phenomena is most marked when advanced resorption of the
ridge has occurred.
Snoring is a rough, raspy noise that can occur when a sleeping person inhales through the mouth
and nose. The noise usually is made by vibration of the soft palate but also may occur as a result
of vocal cord vibration.
Laryngospasm is a tetanic contraction of the muscles around the opening of the larynx. In
severe cases, the opening is closed completely, air no longer can pass through the larynx into the
lungs, and the victim may die of asphyxiation. Laryngospasm can develop as a result of, for
example, severe allergic reactions, tetanus infections, or hypocalcemia.
E- THE TONGUE
The Oral Cavity
The boundaries of the mouth are:
1. vestibule
2. hard palate
3. soft palate
4. uvula
5. palatoglossal arch
6. palatine tonsil
7. palatopharyngeal arch
8. posterior wall of oropharynx
9. pterygoid hamulus
Tongue elevated:
1. Frenulum of tongue
2. Ridge formed by deep lingual vein
3. Sublingual fold
4. Sublingual caruncle
5. Opening of submandibular duct
Primary functions of tonuge include:
1.Mechanical processing: Compression, abrasion, and distortion
2. Assistance in chewing and swallowing
3. Speech production
4. Sensory analysis by touch, temperature, and taste receptors (Houses taste buds =
gustation)
5- Secretion: - mucins - enzyme lingual lipase
Innervation
Motor = Hypoglossal (CN XII)
Sensory = Mandibular (CN V3), Facial (CN
VII), Glossopharyngeal (CN IX)
Structure of the Tongue
Anterior body (oral portion)
Posterior root (pharyngeal portion)
Five taste sensations
Sweet front middle
Sour middle sides
Salty front side/tip
Bitter back
umamiposterior pharynx
Muscles of the tongue
A- Extrinsic muscles :
Genioglossus
Hyoglossus
Palatoglossus
Styloglossus
Mylohyoid

The extrinsic muscles attach the tongue to the hyoid bone, mandible, soft palate, and
the styloid process of the temporal bone.
These muscles are in contrast to the intrinsic muscles of the tongue which lie entirely
within the tongue.
The extrinsic muscles reposition the tongue, while the intrinsic muscles alter the shape
of the tongue for talking and swallowing.
B- Intrinsic muscles
Inferior and Superior Longitudinal Muscle:
Go the length of the tongue
moves tip up and down
Transverse Muscle:
Go across the tongue
narrows and lengthens the tongue
Vertical Muscle:
Go up and down in the tongue
flattens and depresses the tongue
Importance of PALATOGLOSSUS MUSCLE in complete denture construction
The palatoglossus m. originates from the palatine aponeurosis; it depresses the soft palate,
moves the palatoglossal fold towards the midline, and elevates the back of the tongue.
The palatoglossus is the only muscle of the tongue not innervated by the hypoglossal
nerve, instead it is innervated the pharyngeal branch of vagus nerve.
The ever active tongue can be easily displace even best fitting denture and the dental
acrobat can manipulate ill-fitting dentures with greatest of ease.
Wright, Swartz and Godwin have shown that tongue position is very important. To
evaluate the tongue position, instruct patients to open just wide enough for a small portion of
food and observe the different positions of tongue. In normal position, the tongue appears
relaxed and completely fills the lower arch with its apex lightly contacting the lingual of lower
teeth. This position is important for lingual border seal.
MISCELLANEOUS ANATOMIC STRUCTURES
The styloglossus muscle is inferior to and medial to lingual flange. The geniohyoid is under
genioglossus muscle and inferior to lingual flange. The medial pterygoid is a powerful and active
elevator but is normally too distal to affect the lingual flange, only if it is overextended.
Lingual nerve is closely related to lingual flange but problems due to denture irritation have
not been identified.
Submandibular (Whartons) duct can be blocked by over extended lingual flange but this
rarely occurs. When it does patient returns with large swelling under mandible, normal
temperature and little if any pain but usually with great anxiety patients is instructed to leave the
denture out for few days and retained saliva is quickly drained. Over extended border is carefully
adjusted.
Other structures such as facial artery, hypoglossal nerve, platysma and digastric muscle
all have little or no effect on denture borders but have been included for better orientation and
understanding.
F- Palatal muscles
Palate
Hard palate (anterior): Tongue pushes food against it during chewing, made of
bone
Soft palate (posterior): Closes nasopharynx during swallowing; made of muscle
Palatal muscles
Levator veli palatini
Tensor veli palatini muscle
Musculus uvulae
Palatoglossus muscle
Palatopharyngeus muscle
Musculus uvulae
The Musculus uvul (Azygos uvul)
arises from the posterior nasal spine of
the palatine bones and from the palatine
aponeurosis; it descends to be inserted
into the uvula.
Origin:hard palate
Insertion: palatine aponeurosis
Oral Mucosa
Lining of oral cavity
Stratified squamous Keratinized Epithelium Covers only regions exposed to severe
abrasion
Nonkeratinized, and delicate Epithelial Lining of cheeks, lips, and inferior surface of
tongue is relatively thin,
Salivary glands
Functions include:
Lubrication, moistening, and dissolving food to taste
Initiation of digestion of complex carbohydrates (starch)
Bind food together
Neutralize mouth acid
Kill harmful microorganisms
Promote beneficial bacteria
Types
- Major
Parotid,
sublingual,
submandibular
- Minor In mucosa of tongue, lips, palate, cheeks
Muscles that influence the border of complete denture
Physiology
The requirements of a successful complete denture are demanding and include
Compatibility with the surrounding oral environment.
Restoration of masticatory efficiency within limits.
Ability to function in harmony during mastication, speech, respiration, and speech and
deglutition.
Esthetic acceptability.
Preservation of that which remains.
To fulfill these requirements, the prosthodontist needs to have knowledge of the
functions and vital processes of the body although a denture is not living tissue, it must
function with and become a part of the body.
A- Physiology of bone
Although considerable study has been devoted to the physiology of bone, the functions
and vital processes of osseous RR supporting a denture need further study. Much of the
knowledge pertaining to all bone is applicable because the RR is bony tissues covered by oral
mucous membrane.
It is easy to understand why a study of bone supporting dentures is extremely difficult.
Vivisections reveal only the reaction of one section of bone to one denture.
Bone responses vary among individuals sometimes in paradoxic ways.
Roentogenographic studies are inconclusive as related to stress bearing potential of bone.
Bone is one of the most unstable tissues of the body.
Alveolar process
The alveolar process appears to be the bony support most affected by dentures. The
alveolar processes support natural teeth and provide most vertical support for dentures. When
natural teeth are present, the roots occupy most of space between the compact bony plates.
This is particularly true in anterior regions of the arches.
Healing of bony sockets after tooth extraction is similar to that of bone fractures:
Primary clot formation in the socket.
Organisation of clot by proliferating young CTs.
Gradual replacement of young CTs by coarse fibrillar bone.
Reconstruction by resorptive activity on one side and replacement of immature bone by
mature bone on the other and ,
Epithelialisation and healing of the surface occurring simultaneous with other reparative
processes.
The reconstructive process leads generally to loss of alveolar bone in the area. This loss in
quantity during normal healing after extraction is one of the reasons awaiting period of 6 weeks
to 2 months is often advocated before placement of dentures. To allow the immature bonevto
replace the young CT is another reason.
Bone tissue
It is continuous flux throughout life. The remodeling of bone is the result of destruction
of old bone by action of osteoclasts and other processes and the formation of new bone by
osteoblasts. This regenerative reconstruction, although continuous throughout life is not constant.
During the period of general body growth, the rate of bone formation exceeds the rate of
bone resorption. In the adult, the two processes are more nearly balanced. In the aged or in any
person with local or systemic disease, the rate of bone resorption exceeds that of formation. This
is only one of the many reasons some dentures appear to be physiologically tolerated over a
period of time and then seem to fail.
Change in function
According to Wolffs Law - that change in form follows change in function owing to alteration
in internal architecture and external conformation of the bone, in accordance with mathematical
laws.
Newheld found In some specimens studied, the trabecular pattern was arranged in such a way
that it indicated that there was some adaptation of the structure of bones to presence of an
appliance in region near superior surface of alveolar process.
Blood supply
The blood supply to bone of maxillae and mandible is derived principally from medullary and
periosteal vessels that form plexuses, which anatomize with one another.
When teeth are present, intra-osseous vessels supply pulpal, periodontal and alveolar
branches. These various vessels anastomose with periosteal, gingival and other vessels supplying
the surrounding soft tissues.
However, in edentulous patient, the pulpal, periodontal and depending on extent of
alveolar bone resorption the alveolar branches are lost.
Broadly suggested that with age the inferior alveolar artery often becomes blocked which
changes the blood supply from centrifugal to centripetal in nature. In other words the blood to
the mandible comes from branches facial, buccal and lingual arteries instead of inferior alveolar
artery. The relationship between these and other changes in the blood supply to RR may
influence the biologic responses of denture supporting tissues to preprosthetic surgery and to the
success of subsequently fabricated dentures.
Reaction to pressure
The continuous presence of dentures can exert pressure of sufficient intensity to produce
resorption. This is particularly true in mandibular arch, because gravity exerts a steady pull on
the denture. When pressure diminishes or destroys the blood supply of bone tissue or interferes
with its venous drainage resorption results. A denture is potentially capable of exerting steady
pressure and intermittent heavy pressure that can interrupt the blood supply.
The dentures must therefore be removed at least and 8 of every 24 hours. With a limited
knowledge of physiology of bone it is possible to institute procedures in impression making,
selection of teeth, management of teeth, extension of denture base and instructions to patients
that will help ensure a denture that should be more acceptable to bony support. The following
represent some ways the dentist and patient can help make a denture better tolerated by bony
support.
1. Record tissues in impression at their rest position.
2. Decrease the number of teeth.
3. Decrease size of food table.
4. Develop and occlusion that eliminates, as much as possible horizontal and torque
forces.
5. Extend denture base for maximum coverage within tissue limits.
6. Eat by placing small masses of food over the posterior teeth where supporting bone is
best suited to resist forces.
7. Remove dentures for 8 hour of every 24 hour.
B- Physiology of muscles
A muscle is made up of large number of fibres bound together by CT into bundles or fascicles.
These bundles are surrounded by CT sheaths and grouped together into still larger bundles. The
whole muscle is enveloped by a CT sheath, the epimysium. Blood vessels enter a muscle and
branch into smaller vessels that course through these CT to reach the individual muscle fibres,
which are also muscle cells.
The effectors of body are muscles and glands. The muscles that are intimately involved in CD
function are skeletal muscles controlled by sensory nerves system. When a sensory nerve ending
is stimulated, an afferent nerve carries the impulse to the CNS, where after one or more
synapses, an efferent nerve will be activated, which will ultimately result in muscle contraction.
This is called reflex action as opposed to voluntary action.
Muscle is of primary interest because it performs mechanical work. Resting muscle is relatively
firm but extensible. Like most tissues, it does not obey Hooks Law but becomes less extensible
the greater the elongation. On stimulation there is sudden change in its properties, it becomes
hard, develops tension, resists stretching and can shorten and lift a weight. The contraction
occurs in direction of long axis of muscles.
Many of skeletal muscles involved in CD construction have a bony origin but insert in to an
aponeurosis, a raphe or another muscle. The orbicularis oris has no bony origin or insertions, and
its primary function is to close the oral orifice (sphincter). When origin and insertions are on
bone there is limitation to the positions and actions of the muscles. When attachment is in an
aponeurosis, a raphe or another muscle a more flexible situation exists.
The muscles of facial expression, the muscles of tongue, the suprahyoid muscles, the muscles of
soft palate and the pharyngeal muscles do not have both origins and insertions in bone. These
are the muscles primarily involved with determining the extent of denture borders, the contour of
denture bases and the positions of the teeth. Impression techniques are influenced by these
attachments. The muscles should not be stretched or left unsupported during an impression. The
teeth not the denture borders support the muscles of facial expression. The available vestibular
spaces should be used to their fullest extent but not overfilled.
A muscle contraction is said to be isometric when the length of muscle does not shorten during
contraction. A muscle contraction is said to be isotonic when muscle shortens, but the tension
remains the same. In isometric contraction the muscle does not work, but tension of muscle
becomes a greater. Muscles contract both isometrically and isotonically in the body with most
contractions being a combination of the two. The contraction of the retractor and elevator
muscles of mandible during jaw closure is both isotonic and isometric. That is isotonic to move
the mandible and isometric to brace the jaw when teeth contact.
When load is applied to muscle the muscle elongates and within limits, the greater the load, the
greater the stretch. When load is released, the muscle shortens almost to its original length. It
load is excessive; the muscle relaxes reflexly to keep from injuring the muscle.
C- ORAL MUCOUS MEMBRANE
The oral mucous membrane, which covers the bone of the maxilla and mandible, provides
support for the complete dentures. The denture comes in direct contact with the mucous
membrane and thus, their features must be analysed how best the support can be utilized.
The oral mucosa can be divided into three categories depending on its location in the mouth and
its function. They are
1. Masticatory mucosa - which covers the crest of residual ridge, including residual attached
gingiva, firmly adherent to supporting bone. Secondly the hard palate
The masticatory mucosa is characterized by well-keratinized layer on its outer most
surfaces that is subject to changes in thickness depending on whether dentures are worn and on
the clinical acceptability of dentures.
2. Lining mucosa - is generally found to cover the mucous membrane in the oral cavity that is the
firmly attached to periosteum of the bone. It forms the covering of lips and cheeks, the vestibular
spaces, the alveololingual sulcus, the soft plate, the ventral surface of tongue, and the unattached
gingiva found on slopes of residual ridges. It is devoid of keratinized layer and is freely movable
with the tissues to which it is attached because of its elastic nature of lamina propria.
3. The specialized mucosa - covers the dorsal surface of tongue. The mucosal covering is
keratinised and includes specialized papillae on upper surface of tongue. The mucous membrane
is composed of two layers, the mucosa and the submucosa. The mucosa in the oral cavity is
formed by stratified squamous epithelium (often keratinised on its outer surface) and a subjacent
narrow layer of connective tissue known as lamina propria.
The nature of mucous membrane in different parts of mouth varies between patients and within
the some patient. The keratinised layer of epithelium (stratum corneum) maybe totally absent in
some instances and extremely thick in others.
The submucosa is formed by CT that varies in character from dense to loose areolar tissue and
also varies considerably in its width and thickness, depending on its location in the mouth. The
submucosa may contain glandular, fat or muscle cells and transmit the blood and nerve supply to
mucosa. When mucous membrane is attached to bone, the attachment occurs between the
submucosa and periosteal covering of bone.
The thickness and consistency of submucosa are largely responsible for support that the
soft tissues afford the dentures since in most instances the submucosa makes up the bulk of
mucous membrane.
In a healthy mouth, the submucosa is firmly attached to periosteum of the underlying
bone of RR and will usually successfully withstand the pressures of dentures. When submucosal
layer is thin over the bone, the soft tissue will be non resilient and small movements of denture
will tend to break retentive seal. When submucosal layer is loosely attached to periosteum of RR
or is inflamed or edematous the tissues are easily displaceable and stability and support of
dentures are adversely affected.
D- The physiology of the TMJ
Basic mandibular movements:
The basic mandibular movement classified into four movements of prime importance to
complete denture construction, which are hing-like movement, protrusive and retrusive
movements, as well as, lateral movement.
The backward glide movement is a short backward path movement starting from centric
occlusion (maximum inter-cuspasion) to centric relation (most
retruded contact position).
The most retruded contact position is a position, in which the
mandible can hold back and up by either the patient using the
active conscious construction of the retractors of mandible
(posterior fibers of the temporal muscle), and / or passively by the operator pressing on the
symphasis menti when the patient is completely relaxed. This position is called terminal
hinge position, which denotes the posterior functional range of the mandible. The position of
centric occlusion in complete closure is determined by the
maximum inter-cuspasion of teeth and called centric occlusion.
All mandibular motions are either rotation or translation or more
commonly a combination of these. Rotation occurs as movement
within the inferior cavity of the joint it is thus movement between
the superior surface of the condyle and the inferior surface of the articular disc. The
mandibular translation occurs within the superior cavity of the joint, between the superior
surface of the articular disc and the inferior surface of the articular fossa. Both rotation and
translation occur simultaneously, that is, while the mandible is rotating around one or more
of the axes, each of the axes is translating.
In centric relation the mandible can be rotated around the horizontal axis to a distance 20-25
mm as measured between the incisal edges of the maxillary and mandibular incisors. At the
point of opening, the TM ligaments tighten after which continued opening results in an
anterior and inferior translation of the condyles resulting in the second stage of the posterior
opening border movement.
The opening movements are divided into posterior opening and anterior opening where the
range between them is limited primarily by the ligaments and morphology of the TMJ.
The mandibular axes :
Rotational movements of the mandible can occur in the three reference planes: horizontal,
frontal and sagittal. In each plane, it occurs around an axis. These axes were defined as
Transverse hang axis: an imaginary line around which the mandible rotate in the sagittal
plane.
Vertical axis: an imaginary line around which the mandible rotate in the horizontal plane.
Sagittal axis: an imaginary antero-posterior line around which the mandible rotate in the
frontal plane
Histological features
MUCOUS MEMBRANE
The denture bases rest on the mucous membrane, which serves as a cushion between the
bases and the supporting bone.
The mucous membrane is composed of two layers
Mucosa
Submucosa
mucosa
It is formed by the stratified squamous epithelium and a subjacent layer of connective
tissue known as the lamina propria.
submucosa
It is formed by connective tissue. It may contain glandular , fat , or muscle cells and
transmits the blood and nerve supply to mucosa.
The thickness and consistency of submucosa are largely responsible for the support that
the soft tissue affords the denture, since in most instances the submucosa makes up the
bulk of the mucous membrane.
In a healthy mouth the submucosa is firmly attached to the periosteum of the underlying
bone of the residual ridge and will usually successfully withstand the pressure of the
denture.
HISTOLOGY OF THE MUCOUS MEMBRANE
COVERING CREST OF THE RESIDUAL RIDGE
BONE
PERIOSTEUM
SUBMUCOSA
MUCOSA
CLASSIFICATION OF ORAL MUCOSA:
The oral mucosa is divided in three catogories depending on its location in the mouth
A) Masticatory mucosa :
covers the crest of the ridge ,the residual attached gingiva firmly
adherent to the supporting bone , hard palate.
It is characterized by a well defined keratinized layer on its outermost
surface subject to changes in thickness.
B) Lining mucosa :
is generally devoid of the keratinized layer.
It is found to cover the : mucous membrane of lips, cheek , vestibular
spaces , alveolingual sulcus , soft palate, ventral surface of the tongue
and, the unattached gingiva found on slopes of residual ridge.
C) Specialized mucosa : covers the dorsal surface of the tongue. This mucosal
covering is keratinized.
Upper residual ridge crest
Microscopically the mucous membrane covering the crest of upper residual ridge in healthy
mouth is firmly attached to periosteum of bone of maxillae by connective tissue of sub mucosa.
The stratified squamous epithelium is thickly keratinised.
The sub mucosa is devoid of fat or glandular cells and thus does not become edentulous but
characterised by dense collagenous fibers that are contiguous with lamina propria. The
submucosa though relatively thin in comparison to other parts of mouth is still sufficiently thick
to provide adequate resiliency for primary support of the denture.
The mucous membrane covering the crest is comparable to attached gingiva in edentulous mouth
except submucosal layer in edentulous mouth is usually thicker than is found in attached gingiva
of dentulous mouth.
The outer surface of bone in crest of upper RAR is compact in nature made of haversian
systems. The compact bone in combination with tightly attached mucous membrane makes the
crest of upper RR histologically best able to provide primary support to maxillary denture. One
should take advantage of this nature of tissue when providing additional stress to be placed on
crest of ridge of upper jaw during final impression making.
As mucous membrane extends from crest along the slope of the upper RR to reflection, it tends
to lose its firm attachment to underlying bone, marking the end of residual attached mucous
membrane. The loosely attached mucous membrane in this region is non-keratinised or slightly
keratinized.
Submucosa contains loose CT and elastic fibers. This type of tissue will not withstand forces of
mastication or other stress transmitted through denture base and firmly attached over ridge crest.
Less stress is placed on movable tissue of slope of ridge during impression making because the
impression material is closer to escape ways (border of impression tray) than material over crest
of ridge. This follows the principles that in a semi confined container impression material
farthest from the escapeways is under greatest pressure.
Note: the thick submucosal layer compact bone making it the primary stress bearing area
-----------------------------------------------------------------------------------------------
Hard palate
Histology of mucous membrane in a) Anterolateral part of palate b) Posterolateral part of
palate
-------------------------------------------------------------------------------------------------------
Histology of midpalatine suture area Note: thin submucosal layer unsuitable for support of
the denture
Vestibular space
Histologically the mucous membrane lining the vestibular space depicts a relatively thin
nonkeratinised epithelium. The submucosal layer is thick and contains large amounts of loose
areolar tissue and elastic fibres. The nature of submucosa in vestibular space makes tissue easily
movable. Thus the labial flanges and buccal flanges of upper impression can easily be over
extended or under extended.
Histology of lining areas . Note :loose areolar tissue and elastic fibers permit relatively large
movement of tissues at the reflection.
-----------------------------------------------------------------
Crest of lower residual ridge
The crest of ridge is covered by keratinised layer of FCT firmly attached but its submucosa to
periosteum of mandible. The extent of attachment to bone varies considerably.
In some patients the submucosa is loosely attached to bone over entire crest of RR and soft tissue
covering is quite movable. In relatively few patients the submucosa is relatively firmly attached
to bone on both crest and slopes of lower residual ridge. The mucous membrane of ridge crest is
histologically capable of providing proper soft tissue support for the lower denture. However, the
underlying bone of crest of RR is cancellous made up of spongy trabeculae. Therefore crest of
lower RR may not be favourable as primary stress bearing areafor lower denture. Proper relief to
be provided for crest of lower ridge during making final impression.
-----------------------------------------------
The bone of buccal shelf is very dense because the resultant forces of elevator muscles are
directed to this area and trabeculation is arranged perpendicular to occlusal forces.
The mucous membrane covering the buccal shelf area is loosely attached and less keratinised
than mucous membrane covering the crest of lower edentulous ridge. The submucosal layer is
thicker. The fibers of buccinator are located horizontally in submucosa.
Although the mucous membrane may be not be suitable to provide primary support than mucous
membrane overlying crest of ridge, the bone of buccal shelf area is a layer of compact (with
haversion systems)bone.
----------------------------------------------------------
THE BONE
The success of complete denture prosthesis is particularly dependent on the degree of stability
that the underlying bone can maintain. The structure of alveolar ridge has a direct relation on
stability and retention of completed prosthesis.
Bone is a type of connective tissue derived from the multi potential embryonic mesenchymal
cells. It consists of an organic portion composed of collagenous fibrils and an amorphous ground
substance, mainly mucopolysaccharide and an in organic compound of calcium phosphate
complexes.
Bone of maxilla and mandible is formed by outer cortical bone and central meduallary cavity
filled with red or yellow bone marrow.
The marrow cavity is intercepted throughout its length by reticular network of trabecular
(alternatively cancellous or spongy bone). These internal trabeculae act as reinforcement rods to
support outer thicker cortical crust of compact bone.
Surrounding every compact bone is osteogenic (bone forming) CT membrane Periosteum
consists of 2 layers.
Inner layer - next to bone surface consists of bone cells their precursors and a rich micro
vascular supply.
Outer layer - is fibrous layer giving rise to sharpey fibres. Both internal surface of
compact bone and entire cancellous bone is covered by single layer of bone cells the
endosteum, which physically separates bone surface from bone marrow.
1
William C. Scarfe
Maxillary and Mandibular
Anatomic Radiographic
Landmarks
Intraoral Radiography
William C. Scarfe
Principles
Normal is a range, not an ideal or
absolute.
Appearance of landmarks depends upon
projection geometry and contrast.
Radiolucent vs. Radiopaque
Radiopacity is relative
Law of Cube of Atomic Density
Law of Summation
Rule of Tangency
2
William C. Scarfe
Radiographs are
two-dimensional
representations of
objects that occupy
three dimensions.
Facial, central and
lingual features are
superimposed.
All landmarks are
NOT clearly
demonstrated on
radiographs from all
individuals.
Image(s) courtesy Dr. Allan G. Farman
Remember
Radiographs are two-dimensional
representations of objects that occupy
three dimensions.
Facial, central and lingual features are
superimposed.
All landmarks are NOT clearly
demonstrated on radiographs from all
individuals.
3
William C. Scarfe
Tooth and
supporting
structures
Enamel
radiopaque
Dentin and
Cementum
radiopaque
Pulp space
radiolucent
Lamina dura
radiopaque
Periodontal ligament
space
radiolucent
Alveolar bone
radiopaque
William C. Scarfe
Enamel
Dentin
Dentin-enamel
junction
Cemento-
enamel junction
Pulp space
Lamina dura
pdl space
Alveolar bone
4
William C. Scarfe
Anatomic
Landmarks
MAXILLA
ZYGOMATIC BONE
Central Incisor View (Maxilla)
Premaxillary/median palatal suture
(radiolucent).
Incisive fossa and foramen (radiolucent).
Nasal passages (radiolucent).
Nasal septum (radiopaque).
Anterior nasal spine (radiopaque).
Bracket-shaped line (radiopaque).
Soft tissues of nose and lips (radiopaque).
5
William C. Scarfe
Central incisor region: Features
Anterior Nasal Spine
William C. Scarfe
Incisive Fossa / Foramen
6
William C. Scarfe
Nasal Septum
William C. Scarfe
Pre-maxillary / Median Palatine Suture
7
William C. Scarfe
Inferior Concha / Turbinates
William C. Scarfe
Nasal Fossa / Cavity / Meatus
8
William C. Scarfe
Incisive / Nasopalatine Canal
William C. Scarfe
Ala Cartilage Nose & Lip Line
9
William C. Scarfe
Incisive / Nasopalatine Canal
William C. Scarfe
Anterior nasal
spine
Nasal septum
Premaxillary
suture
Nasal passage
Maxillary Anterior
10
William C. Scarfe
Incisive fossa
Premaxillary
suture
Anterior Maxilla
William C. Scarfe
Premaxillary suture
Incisive fossa
Anterior nasal spine
Pulp
Lamina dura
space
Anterior Maxilla
11
William C. Scarfe
Dental caries
Premaxillary
suture
Soft tissue
shadow of nose
Anterior nasal
spine
Nasal passage
Nasal septum
Nasal passage
William C. Scarfe
Floor of nasal
passage
Soft tissue shadow
of nose
12
William C. Scarfe
Nasal septum
Inferior conchae
Bracket-shaped
line
(anterior nasal spine and
lower wall of nasal passage)
Inferior meatus
William C. Scarfe
Incisive fossa
Cartilagenous nasal
septum
Bony nasal septum
Edentulous
anterior maxilla
Inferior conchae
13
William C. Scarfe
Incisive fossa or periapical lesion?
The periodontal
ligament spaces
intact.
SLOB Rule
Same Lingual
Opposite Buccal
The incisive fossa
being lingually
situated moves on
the resulting image
in the same direction
as the movement of
the tubehead.
William C. Scarfe Image(s) courtesy Dr. Allan G. Farman
14
William C. Scarfe
Central and lateral projections
Note how shadow of the incisive fossa moves
in the direction of the movement of the tubehead.
The fossa becomes superimposed over the root
apex of the central incisor.The periodontal ligament
space is intact.
15
William C. Scarfe
Lateral/Canine region: Maxilla
Structures found on central incisor view
are displaced
lingual structures appearing more
posteriorly and facial structures more
anteriorly.
Inverted Y
Lateral wall of nasal passage and anterior
medial wall of maxillary sinus.
William C. Scarfe
Lateral/Canine region: Features
Canine Fossa
16
William C. Scarfe
Canine Fossa
William C. Scarfe
Antral /
Inverted
Y
17
William C. Scarfe
Antral /
Inverted
Y
William C. Scarfe
Anterior Sinus
18
William C. Scarfe
Nasal passage
Anterior nasal spine
Canine fossa
Canine eminence
William C. Scarfe
Anterior wall of
nasal passage
Soft tissue shadow
of nose
Canine fossa
19
William C. Scarfe
Maxillary sinus
Anterior wall of
maxillary sinus
Lateral wall of
nasal fossa
Inverted Y
William C. Scarfe
Lateral wall of
nasal fossa
Anterior wall of
maxillary sinus
(antrum)
Inverted Y
20
William C. Scarfe
Inverted Y
Locule in maxillary
sinus: note tooth
periodontal ligament
space intact
Septum in maxillary
sinus
Bridge unit in porcelain
fused to metal
Radiolucent anterior
filling material
Premolars (maxilla)
Maxillary sinus (radiolucent).
Maxillary sinus floor and septums
(radiopaque).
Nutrient canals (radiolucent).
Occasionally: lateral wall of nasal
passage (radiopaque).
Soft tissue shadow of lips/cheeks.
21
William C. Scarfe
Premolar region: Features
Nasolabial Fold
William C. Scarfe
Maxillary Sinus
22
William C. Scarfe
Nutrient Canals
William C. Scarfe
Premolar region: maxilla
23
William C. Scarfe
Floor of maxillary sinus
William C. Scarfe
Maxillary molar region showing septum in sinus
Septum in
sinus
Zygomatic
process of
maxilla
Soft tissue
over
tuberosity
24
First/Second Molar (Maxilla)
Maxillary sinus floor and septums
(radiopaque).
Nutrient canals (radiolucent).
Zygomatic process of the maxilla (U-
shaped radiopacity).
Zygomatic arch/zygoma (radiopaque).
Less commonly: Lateral wall of nasal
passage (radiopaque).
William C. Scarfe
Zygomatic
bone
Zygomatic
process of
maxilla
Zygomatic process (temporal bone)
Articular eminence
Structures anterior
to green line seen
on intraoral
radiographs
Molar region: maxilla
Zygomatic
Arch
25
William C. Scarfe
Zygomatic process
of the maxilla
Zygomatic
arch
shadow
Floor of
maxillary
sinus
Maxillary
tuberosity
Endodontically
treated tooth
William C. Scarfe
Zygomatic process
of the maxilla
Floor of
maxillary
sinus
Shadow of
zygomatic arch
Coronoid
Process
(mandible)
26
William C. Scarfe
Zygomatic
arch
Zygomatic process
of maxilla
Floor of
maxillary
sinus
Nutrient
canal
Second/Third molar (maxilla)
Coronoid process of mandible (radiopaque).
Maxillary tuberosity (radiopaque).
Posterior wall of maxillary sinus (radiopaque).
Pterygoid hamulus (radiopaque).
Pterygoid notch (radiolucent).
Lateral pterygoid plate (radiopaque).
27
William C. Scarfe
Coronoid
process of
mandible
Zygomatic
process
of maxilla
Zygomatic
arch
3
rd
molar region: maxilla
William C. Scarfe
Maxillary tuberosity Maxillary sinus
28
William C. Scarfe Zygomatic process of the maxilla
Dental
follicle
space
Tuberosity
William C. Scarfe
Pterygoid
hamulus
Air space
Posterior wall of maxillary sinus
29
William C. Scarfe
Coronoid
process of
mandible
Zygomatic process of maxilla
Zygomatic
arch
Pterygoid
hamulus
Pterygoid
plate
William C. Scarfe
Pterygoid
hamulus
(medial
Pterygoid)
Lateral
pterygoid
plate
Maxillary tuberosity
3
rd
30
William C. Scarfe
Pterygoid hamulus
3
rd
Coronoid
process of
mandible
Zygomatic process
of maxilla
Zygomatic arch
31
William C. Scarfe
Pterygoid
hamulus
Coronoid process of mandible
Maxillary
tuberosity
Shadow of zygomatic arch
William C. Scarfe
Anatomic Landmarks
MANDIBLE
32
William C. Scarfe
Incisor region: mandible
Lingual foramen
radiolucent
Genial tubercles
radiopaque
Soft tissue shadow of lower lip
radiopaque
Mental ridges
radiopaque
Nutrient canals
radiolucent
William C. Scarfe
Facial
Mental
depression
Mental
ridge
Lingual
groove
Genial
tubercles
Lingual
33
William C. Scarfe
Mental ridge
Soft tissue
shadow of lower lip
Cortex of
lower border of
mandible
William C. Scarfe
Lingual foramen
Mental ridge
Genial tubercles
Cortical plate of
lower border of
mandible
Soft tissue shadow of
lower lip
34
William C. Scarfe
Mental ridge
Embossed
(locating) dot
William C. Scarfe
Second shadow of
periodontal ligament
space due to shape
of root
space
35
William C. Scarfe
Nutrient canals
William C. Scarfe
Nutrient canals
36
William C. Scarfe
Nutrient canals in
anterior mandible
William C. Scarfe
Lingual foramen
Embossed dot
37
William C. Scarfe
Mandibular tori
Genial tubercles
Mental ridge
William C. Scarfe
Canine/Premolar region: mandible
Mental foramen
Radiolucent
usually situated between and just beneath
roots of the premolars.
Soft tissue shadow of reflected cheek
radiopaque
Mandibular canal
radiolucent
38
William C. Scarfe
Canine region: mandible
William C. Scarfe
Mental
foramen
Premolar region: mandible
39
William C. Scarfe
Mental
foramen
Mandibular
canal
Submandibular fossa
Mylohyoid ridge
William C. Scarfe
Periapical granuloma, abscess or cyst
(periodontal ligament space not intact)
Mental
foramen
40
William C. Scarfe
Mental foramen
Mylohyoid
ridge
Submandibular fossa
William C. Scarfe
Molar region: mandible
Mandibular canal
radiolucent
External oblique
ridge
radiopaque
Mylohyoid ridge
(internal oblique
ridge)
radiopaque
Submandibular
fossa
radiolucent
Cortex of lower
border
radiopaque
41
William C. Scarfe
Mandibular canal
William C. Scarfe
External oblique ridge of mandible
42
William C. Scarfe
External oblique ridge of mandible
William C. Scarfe
External oblique ridge
Mandibular canal Image(s) courtesy Dr. Allan G. Farman
43
William C. Scarfe
Internal oblique (mylohyoid) ridge of mandible
William C. Scarfe
Internal oblique (mylohyoid) ridge of mandible
44
William C. Scarfe
Submandibular fossa
Lower
cortex of
mandible
External
oblique
ridge
Internal
oblique
ridge
William C. Scarfe
Lower cortex of mandible
External
oblique
ridge
Internal
oblique
ridge
45
William C. Scarfe
Lower cortex of mandible
External
oblique
ridge
Internal
oblique
ridge
William C. Scarfe
Anatomical Variations
Mandibular torus.
Palatal torus.
High vs. low mandibular canal.
Double mandibular canals.*
Stafnes bone cavity (static bone cyst).*
*usually seen only on extra-oral radiographs.
46
William C. Scarfe
Mandibular torus
Syn: lingual exostoses, torus mandibularis
William C. Scarfe
Mandibular torus
47
William C. Scarfe
Mandibular torus
William C. Scarfe
Maxillary torus
Syn: torus palatinus
48
William C. Scarfe
Maxillary torus
William C. Scarfe
Maxillary torus
49
William C. Scarfe
Maxillary torus
28-11-2010
1
Dr Honey Arora
Post Graduate Student
Department of Prosthodontics and Implantology
1
Its Role in Removable Prosthodontic
INTRODUCTION
OSTEOLOGY
MUSCLE ATTACHMENT OF THE MANDIBLE
GROWTH AND DEVELOPMENT
MANDIBLE IN COMPLETE DENTURE
2
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2
The mandible is derived from Latin word
mandibula, "jawbone.
Also referred as inferior maxillary bone
Is the largest and strongest bone of the face, serves
for the reception of the lower teeth. It consists of a
curved, horizontal portion, the body, and two
perpendicular portions, the rami.
3
4
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3
BODY OF MANDIBLE
corpus mandibulae
The body is curved somewhat like a horseshoe
and has two surfaces and two borders.
- 2 surfaces External
Internal
- 2 borders Superior or Alveolar
Inferior
5
MENTAL FORAMEN-
It lies below the interval between the premolar
teeth, on the either side, midway between the upper
and lower borders of the body.
It is the passage of the mental vessels and nerve.
descends slightly in edentulous individuals
Absence of mental foramen and accessory mental
foramina has also been
reported.[1][2]
shape of the MF was oval in
most of the cases.[3] [4]
Central African Journal of Medicine
6
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4
MENTAL PROTUBERANCE-
It is a median triangular projecting area in the
lower part of the midline.
- The inferolateral angles of the protuberance from the
mental tubercules.
7
EXTERNAL OBLIQUE LINE
It is a faint ridge running backward and
upward from each mental foramen and is continuous
with the anterior border of the ramus.
8
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5
INCISIVE FOSSA
It is a depression that lies just below the
incisor teeth on the either side of the symphysis.
(no. 11 is incisive fossa)
9
MENTAL SPINES (GENIAL TUBERCULE / GENIAL
APOPHYSIS)
There are 2 pairs of spines .
1. Superior pair of spine . It gives origin to the Genioglossi and
2. Inferior pair of spines lies immediately below the first pair,
gives origin of the Geniohyoid.
SPECIAL CASES
- May be fused to form a single eminence.
- A median foramen and furrow
are sometimes seen above
the mental spines( spinous
Foramen)[6]
10
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6
ATTACHMENT OF ANTERIOR BELLY OF
DIGASTRIC
It is an oval depression on the either side of the
mid line jus below the mental spines for the
attachment of anterior belly of digastric .
11
MYLOHYOID LINE
It extends upward and backward on either side from
the lower part of the symphysis .(figure b)
- It gives origin to the mylohyoid.
- posterior part of this line - gives attachment to a small
part of the superior constrictor and to the
pterygomandibular raphe.
-Above the anterior part of this line - is a smooth
triangular area against which
the sublingual gland rests.
- below the hinder part, an
oval fossa for the submaxillary
gland.
12
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7
13
SUPERIOR OR ALVEOLAR BORDER
- wider behind than in front
- is hollowed into cavities, for the reception of the teeth;
these cavities are sixteen in number.
- outer lip of the superior border - on either side, the
buccinator is attached as far
forward as the first molar tooth.
14
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8
INFERIOR BORDER
- rounded, longer than the superior, and thicker in front
than behind.
- point where it joins the lower border of the ramus - A
shallow groove; for the FACIAL ARTERY , may be
present.
15
ramus mandibul; perpendicular portion
The ramus is quadrilateral in shape, and has
two surfaces, four borders, and two processes
16
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9
LATERAL SURFACE
- Lateral surface is flat and marked by
oblique ridges at its lower part.
- It gives attachment nearly
the whole of its extent to the
masseter.
17
MEDIAL SURFACE
MANDIBULAR FORAMEN
It provides entrance for the inferior alveolar
nerve and vessels.
18
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10
LINGULA OR LINGULAE MANDIBULAE
it is a sharp spine present in front of
mandibular foramen opening .
- It gives attachment to the spenomandibular ligament
19
MYLOHYOID GROOVE
From the lower and back part of the lingulae
mandibulae is a notch from which the mylohyoid
groove runs obliquely downward and forward.
- It lodges the mylohyoid vessels and nerve.
20
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11
MANDIBULAR CANAL
The mandibular canal is a canal within the
mandible that contains the inferior alveolar nerve
,inferior alveolar artery, and inferior alveolar veins.
runs obliquely downward and forward in the ramus
then horizontally forward in the body
communicates with alveoli
by small openings
21
Types of mandibular canal [5]
1. TYPE III - the canal is located close to the lower
border of the mandible is the most common,
2. TYPE II -the canal is noted between the apices of the
first and second molars and the lower border of the
mandible
3. TYPE I -the canal is in close contact with the apices
of the first and the second molars
22
Hell Period 1990
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12
LOWER BORDER
Is marked by oblique ridges on each side, for the
attachment of the Masseter laterally, and the
pterygoideus internus medially; the
sphenomandibular ligament is attached to the angle
between these muscles.
23
ANTERIOR BORDER
Is thin above, thicker below, and continuous with
the oblique line.
POSTERIOR BORDER
Is thick, smooth, rounded, and covered by the
parotid gland.
24
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13
UPPER BORDER
Is thin, and is surmounted by
2 processes -
the coronoid in front
the condyloid behind,
separated by a deep concavity, the mandibular notch.
25
processus condyloideus
Is thicker than the coronoid, and consists of
two portions: the condyle, and the constricted portion
which supports it, the neck.
It forms the articular surface for articulation with
articular disk of tempromandibular joint.
26
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14
THE CONDYLE
- It presents an articular surface for
articulation with the articular disk
of the temporomandibular joint
- At the lateral extremity of the
condyle is a small tubercle for the
attachment of the
temporomandibular ligament.
27
THE NECK
The neck is flattened from backward, and
strengthened by ridges which descend from the
forepart and sides of the condyle.
- Its posterior surface is convex
- its anterior surface presents a depression for the
attachment of the Pterygoideus externus.
28
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15
processus coronoideus
Is a thin, triangular eminence, which is
flattened from side to side and varies in shape and size.
The Coronoid process (from Greek korone, "like a
crown")
29
BORDERS
anterior border - is convex and is continuous below
with the anterior border of the ramus.
posterior border- is concave and forms the anterior
boundary of the mandibular notch.
30
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16
SURFACES
Lateral Surface - affords insertion to the Temporalis
and Masseter.
Medial Surface -provides insertion to the Temporalis
and presents a ridge from apex till last molar
Between This Ridge And The Anterior Border - is a
grooved triangular area, the upper part of which gives
attachment to the Temporalis, the lower part to some
fibers of the buccinator.
31
It is the faint ridge on the median line
of the external surface of the
mandible.
This ridge divides below and
encloses a triangular
eminence, the mental protuberance,
the base of which is depressed
in the center but raised on either
side to form the mental tubercule.
It serves as the origin for the
Geniohyoid and the Genioglossus
32
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17
It is the junction of the lower border of the ramus of
the mandible with the posterior border of body of
mandible
Provides attachment
- Masseter laterally
- the Pterygoideus internus medially
- the stylomandibular ligament
is attached to the angle
between these muscles.
33
Sub-mandibular: run along the underside of the jaw
on either side, drains the structures in the floor of the
mouth also drain mandibular teeth except the central
incisors.
Sub-mental: These nodes are just below the chin.
They drain the central incisors and midline of lower lip
and tip of the tongue.
34
28-11-2010
18
mainy by the 3
rd
division of trigeminal nerve ->
mandibular nerve
INFERIOR ALVEOLAR NERVE, branch of the
mandibular division -> enters mandibular foramen
and runs forward in the mandibular canal, supplying
sensation to the teeth->at mental foramen the nerve
divides into two terminal branches: incisive and
mental nerves-> The incisive nerve runs forward in the
mandible and supplies the anterior teeth. The mental
nerve exits the mental foramen and supplies sensation
to the lower lip.
35
INTERNAL SURFACE
36
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19
EXTERNAL SURFACE
37
MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE
SUPPLY
ACTION & CLINICAL
SIGNIFICANCE
MASSETER
musculus
masseter
( Greek word
chewing ,
associated
with anger )
ORIGIN
Zygomatic arch
Blood supply
Masseteric
Artery
Nerve supply:
Masseteric
Nerve
Elevationand
retraction of the
mandible
Antagonist muscle
platysma
INSERTION
Coronoid process
and ramus of
mandible
TEMPORALIS
musculus
temporalis
ORIGIN
Temporal line on the
parietal bone of the
skull
Blood supply :
Deep temporal
artery
Nerve supply:
Mandibular
nerve
Elevationand
retraction of the
mandible
Antagonist muscle -
platysma
INSERTION
Coronoid process of
mandible
38
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20
MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE SUPPLY
ACTION
MEDIAL
PTERYGOID
musculus
pterygoideus
internus
ORIGIN
Medial surface of lateral
pterygoid plate of
sphenoid, palatine bone ,
pterygoid fossa
Blood supply:
Medial pterygoid
artery
Nerve supply:
Medial pterygoid
Nerve
Elevates
mandible, closes
jaw, helps lateral
pterygoids in
moving the jaw
from side to side
INSERTION
Inner surface of ramus ,
Angle of the mandible
LATERAL
PTERYGOID
m.
pterygoideus
externus
ORIGIN
Superior head: lateral
surface of the greater
wing of the sphenoid
Inferior head: lateral
surface of the lateral
pterygoid plate
Blood supply:
Lateral pterygoid
artery
Nerve supply:
lateral pterygoid
Nerve
Depresses
mandible,
Protrude
mandible, side to
side movement of
mandible
INSERTION
neck of the mandibular
condyle , articular disk of
the TMJ 39
MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE SUPPLY
ACTION
DEPRESSOR
ANGULI
ORIS
(musculus
depressor
anguli oris)
ORIGIN
along the oblique line of
mandible
lateral aspect of mental
tubercle of the mandible
Blood supply:
Facial artery
Nerve supply:
Mandibular branch
of facial Nerve
Depresses the
mouth as in
frowning
INSERTION
modiolus
DEPRESSOR
LABII
INFERIORIS
musculus
depressor labii
inferioris
ORIGIN
Oblique line of mandible,
between symphysis and
mental foramen
Blood supply:
Facial artery
Nerve supply:
Mandibular branch
of facial Nerve
Draws the lip
downward and
laterally
INSERTION
Skin of the lower lip
40
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21
MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE SUPPLY
ACTION
BUCCINATOR
musculus
buccinator
ORIGIN
Posterior alveolar process
of maxilla and mandible
Blood supply
:
Buccal artery
Nerve supply:
buccal branch of
facial nerve
The buccinator
compresses the
cheeks against the
teeth and is used in
acts such as
blowing. It is an
assistant muscle of
mastication
(chewing).
INSERTION
modiolus
ORBICULARIS
ORIS
ORIGIN
Near midline on anterior
surface of maxilla and
mandible and modiolus
at angle of mouth
Blood supply :
Facial artery
Nerve supply:
buccal branch of
facial nerve
Narrows orifice of
mouth, purses lips
and puckers lip
edges
INSERTION
Mucous membrane of
margin of lips and raphe
with buccinator at
modiolus 41
MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE SUPPLY
ACTION
MENTALIS
(so named
because it is
associated with
thinking or
concentration
and use to
express doubt)
ORIGIN
Symphysis of mandible
Blood supply
:
Buccal artery
Nerve supply:
mandibular
branch of facial
nerve
elevates and
wrinkles skin of
chin, protrudes
lower lip
INSERTION
Skin of chin
PLATYSMA ORIGIN
subcutaneous tissue of
infraclavicular and
supraclavicular regions
Blood supply :
branches of the
Submental
artery and
Suprascapular
artery
Nerve supply:
cervical branch
of the facial
nerve
Draws the corners
of the mouth
inferiorly and
widens it (as in
expressions of
sadness and fright).
Also draws the skin
of the neck
superiorly when
teeth are clenched
INSERTION
base of mandible; skin of
cheek and lower lip;
angle of mouth;
orbicularis oris
42
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22
MUSCLE ORIGIN AND
INSERTION
BLOOD&
NERVE SUPPLY
ACTION
GENIOGLOSSUS
musculus
genioglossus
ORIGIN
Superior part of mental
spine of mandible
Blood supply:
Lingual artery
Nerve supply:
Hypoglossal
nerve
Inferior fibers
protrude the
tongue, middle
fibers depress the
tongue, and its
superior fibers draw
the tip back and
down
INSERTION
Dorsum of tongue and
body of hyoid
GENIOHYOID
musculus
geniohyoideus
ORIGIN
Inferior mental spine on
the inner surface of the
symphi
Blood supply :
Lingual artery
Nerve supply:
C1 and
Hypoglossal
nerve
Elevates the
tongue, depress
the mandible ,
helps in
deglutition
INSERTION
Body of hyoid bone
43
MUSCLE ORIGIN AND
INSERTION
BLOOD& NERVE
SUPPLY
ACTION
ANTERIOR
BELLY OF
DIGASTRIC
musculus
digastricus
ORIGIN
digastric fossa
(mandible)
Blood supply:
anterior belly -
Submental branch of
facial artery;
Nerve supply:
mandibular division
(V3) of the trigeminal
(CN V) via the
mylohyoid nerve
Opens the jaw
when the masseter
and the temporalis
are relaxed.
INSERTION
Intermediate tendon
(hyoid bone)
MYLOHYOID
musculus
mylohyoideus
ORIGIN
inner surface of
mandible off the
mylohyoid line
Blood supply :
mylohyoid branch of
inferior alveolar
artery
Nerve supply:
mylohyoid nerve
Raises oral cavity
floor, elevates
hyoid, elevates
tongue, depresses
mandible
INSERTION
body of hyoid bone
and median raphe
44
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23
MUSCLE ORIGIN AND
INSERTION
BLOOD& NERVE
SUPPLY
ACTION
SUPERIOR
CONSTRICTOR
ORIGIN
pterygoid hamulus,
pterygomandibular
raphe, posterior end of
the mylohyoid line of the
mandible, and side of
tongue.
Blood supply:
Ascending pharyngeal
artery and tonsillar
branch of facial artery
Nerve supply:
pharyngeal plexus of
nerves(IX , X and
cervical sympathetic
ganglion )
deglutition
INSERTION
median raphe of pharynx
and pharyngeal tubercle.
45
LIGAMENT ORIGIN AND INSERTION DESCRIPTION
STYLOMANDIBULAR
LIGAMENT
ORIGIN
Apex of styloid process of the
temporal bone
Paired , it is the
thickening of parotid
fascia,
from its deep surface
some fibers of the
Styloglossus take origin.
INSERTION
to the angle and posterior
border of the angle of
mandible
SPHENOMANDIBUL
AR
LIGAMENT
ORIGIN
the ligament that attaches to
the spine of the sphenoid
bone superiorly
paired; pterygoid fascia
thickening and is a
remnant of the Meckel's
cartilage
limit distension of the
mandible in an inferior
direction.
its related to lateral
pterygoid (laterally )
and medial pterygoid
(medially)
INSERTION
the lingula of the mandible
inferiorly
46
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24
PTERYGOMANDIBULAR
RAPHE (LIGAMENT)
Tendinous band of
buccopharyngeal fascia
passes between the tip of
the hamulus of the
pterygoid bone and the
internal surface of the
mandible at a point just
posterosuperior to the
posterior limit of the
mylohyoid ridge
medial surface - covered
by the mucous
membrane.
lateral surface - is
separated from the
ramus of the mandible
by a quantity of adipose
tissue.
posterior border- gives
attachment to the
superior pharyngeal
constrictor muscle.
anterior border attaches
to the posterior edge of the
buccinator
47
48
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25
Prenatal
Week 6 - Intramembranous ossification center develops lateral to
Meckel's cartilage.
Week 7 - Coronoid process begins differentiating.
Week 8 - Coronoid process fuses with main mandibular mass.
Week 10 (approx) - Both condylar and coronoid processes are
recognizable and anterior portion of Meckel's cartilage begins to ossify.
Weeks 12-14 - Secondary cartilages for the condyle, coronoid, and
symphysis appear.
Weeks 14-16 - Deciduous tooth germs start to form.
Birth
At birth mandible still has separate right and left halves.
Postnatal
Year 1 - Fusion of right and left halves of mandible at the symphysis.
Infancy and childhood - Increase in both size and shape of the
mandible; eruption and replacement of teeth.
Year 12-14 - All permanent teeth emerged except third molars.
49
The mandible makes its structure in the sixth week of
foetal life.
It is ossified in the fibrous membrane covering the outer It is ossified in the fibrous membrane covering the outer
surfaces of surfaces of Meckel's Meckel's cartilages, cartilages, derrivative derrivative of first brachial arch of first brachial arch
These These cartilages cartilages form form the the cartilaginous cartilaginous bar bar of of the the mandibular mandibular
arch arch and and are are two two in in number, number, aa right right and and aa left left. .
50
28-11-2010
26
Their proximal or cranial ends are connected with the
ear capsules, and their distal extremities are joined to
one another at the symphysis by mesodermal tissue.
51
INCUS
51
MALLEUS
Meckels cartilage has a close, relationship to the
mandibular nerve, at the junction between posterior
and middle thirds, where the mandibular nerve divides
into the lingual and inferior alveolar nerve.
52
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27
The lingual nerve passes forward, on the medial side
of the cartilage, while the inferior Alveolar lies lateral
to its upper margins & runs forward parallel to it and
terminates by dividing into the mental and incisive
branches.
53
LINGULA is replaced by fibrous tissue, which persists to
form the sphenomandibular ligament & the perichondrium
of the cartilage persist as sphenomallular ligament.
Between the lingula and the canine tooth the cartilage
disappears, while the portion of it below and behind the incisor
teeth becomes ossified and incorporated with this part of the
mandible.
54
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28
Greater part of Meckels cartilage disappears without
contributing to the formation of mandible.
Small part of cartilage near the midline is the site of
endochondral ossification. Here it calcifies and is
destroyed by chondroblasts and are replaced by
connective tissue and then by bone.
Small irregular bones known as mental ossicles
develop in it and by the end of first year fuse with the
mandibular body.
At the same time two halves of mandible unite by
ossification of the symphyseal fibrocartilage.
55
The ramus of the mandible develops by a rapid spread of
ossification backwards into the mesenchyme of the first
branchial arch diverging away from Meckels cartilage.
This point of divergence is marked by the mandibular
foramen.
56
Mandible of human embryo 95 mm. long. Outer aspect. Nuclei of
cartilage stippled.
28-11-2010
29
Somewhat later, accessory nuclei of cartilage make
their appearance:
a wedge-shaped nucleus in the condyloid process and
extending downward through the ramus.
a small strip along the anterior border of the coronoid
process.
.
57
Mandible of human embryo 95 mm. long. Outer aspect.
Nuclei of cartilage stippled.
The condylar cartilage:
Carrot shaped cartilage appears in the region of the
condyle and occupies most of the developing ramus. It
is rapidly converted to bone by endochondral
ossification (14
th
. WIU) it gives rise to -> Condyle
head and neck of the mandible.
The posterior half of the ramus to the level of inferior
dental foramen
58
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30
The coronoid cartilage:
It is relatively transient growth cartilage center ( 4
th
. -
6
th
. MIU). it gives rise to -> Coronoid process.
The anterior half of the ramus to the level of inferior
dental foramen
59
60
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31
61
Growth of the mandible
I. Growth by secondary cartilage
II. Development of the alveolar process
III. Subperiosteal bone appositionand bone resorption
62
I. Growth by secondary cartilage
( mainly condylar cartilage )
Increase in height
of the mandibular ramus
Increase in the over all length
of the mandible
Increase of the inter condylar
distance
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32
II DEVELOPMENT OF ALVEOLAR PROCESS
bone apposition occurs at the crest of the alveolar process and
the fundus of the alveolus contributing to the growth of
mandible in height.
63
Bone deposition Bone deposition Bone resorption Bone resorption Result in Result in
External surface External surface
of the mandible of the mandible
Inner surface of Inner surface of
the mandible the mandible
Increase the Increase the
transeverse transeverse
dimension dimension
Posterior border Posterior border
of the of the ramus ramus
Anterior border Anterior border
of the of the ramus ramus
Adjust the Adjust the
thickness of the thickness of the
ramus ramus
Anterior border Anterior border
of the of the coronoid coronoid
process process
Posterior border Posterior border
of the coronoid of the coronoid
process process
Displacement of Displacement of
the the coronoid coronoid
process process
Chin region Chin region Modeling Modeling of the of the
lower face lower face
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65
The available area of support from an edentulous mandible is 14 14
cm2 cm2 while the same for the edentulous maxilla is 24cm2 24cm2 .
The landmarks can be broadly grouped into:
Limiting structures:
Labial frenum
Labial vestibule
Buccal frenum
Buccal vestibule
Lingual frenum
Alveololingual sulcus
Retromolar pads
Pterygomandibular raphe.
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34
Supporting structures:
Buccal shelf area
Residual alveolar ridge
Relief areas:
Crest of the residual alveolar ridge
Mental foramen
Genial tubercles
Torus mandibularis.
67
These are the sites that will guide us in having an optimum
extension of the denture so as to engage maximum surface
area without encroaching upon the muscle actions
Encroaching upon these structures will lead to dislodgement
of thedenture and/or soreness
of thearea while failure to
cover the areas upto the
limiting structurewill imply
decreased retention stability
and support.
68
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35
Masticatory forces produce quite a pressure on the
underlying structures and not everyplace beneath
the denture can take such stress hence we need to
know the areas which can bear the stresses well.
These can be divided into-
1.Primary stress bearing area
2.Secondary stress bearing area
69
PRIMARY STRESS BEARING AREA
These are the areas that are most capable to take
the masticatory load providing a proper support
to the denture.
- Are at right angle and usually do not resorb
easily ( buccal shelf area )
Properties :-
1.Tightly adherent sufficient fibrous connective
tissue with an overlying keratinized mucosa
2.Presence of cortical bone cover
3.Should be at right angles to the vertical occlusal
forces.
4.No underlying structures should be present that will
get harmed due to stress.
70
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SECONDARY STRESS BEARING AREA
Area of edentulous ridge that are greater than or at
right angle to occlusal forces but tend to resorb under load.
Mandibular:- ridge slopes
71
Secondary stress bearing area
Secondary stress bearing area
These are the areas which either resorb under constant
load or have fragile structures within or are covered by
thin mucosa which can be easily traumatized
& hence should be relieved.
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37
Fibrous band extending from
the labial aspect of the residual
alveolar ridge to the lip.
Give attachment to orbicularis oris and incisivus.
Active and sensitive frenum
The activity of this area tends to be vertical so the
labial notch on the denture should be narrow.
73
Extends from the labial frenumto the buccal frenumon
each side.
Potiential space bounded by
- mucolabial fold
- orbicularis oris
- labial aspect of residual alveolar ridge
Mentalis quite active in this region.
74
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CLINICAL SIGNIFICANCE
Extent of denture is limited because of
muscle inserted close to the ridge .
Muscles of lip actively pull across the
denture.(on opening mouth wide
orbicularis muscle is stretched->
narrowing the sulcus -> displacing
denture )
Impression are narrower in this region.
Tone of the skin of lip and orbicularis
depends on the thickness & position of
the flange.
HISTOLOGY
-Epithelium is thin and non-keratinized
- Submucosa formed by loosely
arranged connective tissue fibre mixed
with elastic and muscle fibre.
75
It overlies the depressor anguli oris muscle
Clinical significance
- Clearance must be achieved in the denture to avoid
dislodgement of the denture
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39
77
Accomodated within
sublingual cresent area .
Vary in width and height.
Overlies the genioglossus
muscle which takes
origin from mental spine
Fold of mucous
membrane from tongue
to the residual ridge is
sublingual fold.
It extends posteriorly form buccal frenumto the retromolar
pad .
Houses the buccal flange
- Impression is wide in this region
- It is nearly 90 degree to the biting forces , providing
denture with greates surface for the resistance to the
vertical occlusal forces.
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Buccinator muscle in buccal vestibule
The extent of the buccal flange is highly
influenced by the buccinator muscle, which extends
from
- Modiolus (anteriorly)
- Pterygomandibular raphe ( posteriorly )
Clinical significance:-
- Denture should completely
cover the vestibule and
buccal shelf
- Action of buccinator muscle
moulds the buccal flange.
79
External oblique ridge
It is a ridge of dense bone extending from jus
above the mental foramen and distally , becoming
continous with anterior border of the ramus
- Gives attachment to buccinator muscled fibres.
- Can be used as guide for extent of denture laterally
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It accomodates the masseter muscle in the
distobuccal area of the denture
Magnitude of its force is exerting the molar region.
Clinical significance :-
- Overextension soreness of the tissue &
dislodgement of the denture
81
It is recorded by masseter muscle contraction, its
fibres runs ouside and behind the buccinator ->
contraction of masseter ->pushes inward against the
buccinator muscle -> producing bulge.
Movements
- downward pressure in 2
nd
premolar region by dentist
and forces exerted by the closing of the mouth.
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Relief area
Microscopically
- Mucous membrane ->
keratinized layer
- submucosa is attached to the
periosteum.
- Covered by fibrous connective
tissue.
- Bone -> cancellous and
without good cortical plate
covering.
- Should be relieved during
impression making.
83
Primary stress bearing area
Consist of horizontal shelves 0f bone so
called buccal shelf (by sheldon winkler
2
nd
edition )
Bounded by :-
- medially -> crest of residual
alveolar ridge
- anteriorly -> buccal frenum
- laterally -> external oblique
ridge
- distally -> retromolar pad
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43
Wide and perpendicular to the vertical occlusal forces ,
so offers excellent resistance to such forces -> serving
as primary stress bearing area.
Buccinator muscle fibres runs anteroposteriorly,
paralleling the bone and denture doesnot resist the
contracting forces of the muscle.
85
Microscopically
- Mucous membrane -> loosely attached and less
keratinized than crest of residual ridge
- Thicker submucosal layer
- Fibres of buccinator are found running horizontally in
submucosa
- Bone -> compact thus making it suitable as primary
stress bearing area
- Buccinator fibres -> runs horizontally allows denture
to rest without damage to the muscle or dislodgement
of denture
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44
Irregular rough, bony crest extending from the 3
rd
molar region
to the lower border of the mandible
Prominent -> 3
rd
molar the 2
nd
bicuspid.
Levels of attachments of mylohyoid muscle :-
- anteriorly-> close to the
inferior border of mandible
- posteriorly ->close to the
alveolar crest
87
88
- Mucous membrance can be easily traumatized by
denture.
- Area under ridge is undercut
- Lingual flange of the mandible should extend
inferior but not lateral to the mylohoid line
Buccal Buccal
Attachments Attachments
To Hyoid To Hyoid
Mylohyoid Mylohyoid
Ridge Ridge
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Irregular area of bony prominence at the distal
termination of the mylohyoid line
Prominent -> acts as undercut
89
It is located on the lateral surface of the mandible,
between the 1
st
and 2
nd
bicuspid , halfway between the
lower border and the alveolar crest.
- Extensive loss of alveolar
ridge -> foramen occupies
more superior position.
- Should be relieved over
the foramen
- If not relieved -> can
occlude the mental nerve and
blood vessels -> causing numbness of the lip
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Situated on the lingual aspect of the symphysis area
slightly above the border.
Divided into :-
- superior -> genioglossi attachment
- inferior -> genohoid attachment
- Extensive loss -> superior
positioning of spine ->
soreness -> surgical
procedure indicated.
91
Pear shaped pad
Triangular soft pad of the tissue at the distal end of the
lower ridge.
Microscopically
- Composed of a thin nonkeratinized epithelium and loose
areolar tissue
- Submucosa contains :
> glandular tissue
> fibres of buccinator and superior constrictor
>pterygomandibular raphe
> tendons of temporalis
92
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47
93
- Usable guide on the cast for the
distal extension of denture
- Action of the muscles in
retromolar pad , limits the extent
of the denture -> So denture base
should extend approximately to
2/3
rd
over the retromolar pad.
(zarb-bolender 12
th
edition )
- Should be covered by denture
(sheldon winkler 2
nd
)
- Aids in the stability of the denture
by adding another plane to resist
movement of the denture.
Is a small pear shaped area of gingival tissue that
remains fused to the scar after loss of the last molar.
This small , hard pale pear shaped tissue is situated at
the base of the retromolar pad, approximately at the
centre of the ridge.
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48
It can be divided into three areas
anterior vestibule/sublingual crescent area/ anterior
sublingual fold
the middle vestibule/ mylohyoid area
the distolingual vestibule/ lateral throat form/
retromylohyoid fossa
95
Anterior lingual vestibule Anterior lingual vestibule
This extends from the lingual frenumto where the
mylohyoid ridge curves down below the level of sulcus.
Here a depression the premylohyoid fossa can be palpated.
This is mainly influenced by the genioglossus muscle,
lingual frenumand some part by anterior portion of
sublingual glands .
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49
Middle vestibule Middle vestibule:
This is the largest area and is mainly influenced by
mylohyoid muscles and somewhat by sublingual glands.
The mylohyoid muscle is the largest muscle in the floor of
the mouth whose principal function occurs during
swallowing. Its intra oral appearance is misleading because
the membranous attachment makes the muscle appear to
be horizontal when contracting.
97
Nagel and sears have shown that at maximum contraction
the fibers are still in a downward and forward direction so
that a denture can be extended below the muscle
attachment along the mylohyioid ridge.
The lingual borders in the mylohyoid areas are formed by
contact with the mylohyoid muscle in functional, but not
extreme, contracted or elevated positions.
The average mylohyoid border is 4-6 mm beyond the
mylohyoid ridge in fair to good ridge it is about 2-3 mm . If
the ridge is flat it is often advantageous to make mylohyoid
border thicker (4-5mm or more).
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50
Distolingual Distolingual vestibule vestibule:
The lateral throat form is bounded anteriorly by mylohyoid
muscle, laterally by pear shaped pad, posterolaterally by
superior constrictor, posteromedially by palatoglossus and
medially by tongue.
The so called s curve of the lingual flange of the
mandibular denture results from stronger intrinsic and
extrinsic tongue muscles, which usually place the
retromylohyoid borders more laterally and towards the
retromylohyoid fossa, as the oppose weaker superior
constrictor muscle.
99
The posterior limit of the mandibular denture is
determined mainly by the palatoglossus muscle and
somewhat by weaker superior constrictor muscle this is
area is called posterior/ retromylohyoid curtain.
Neil described this area and noted that the denture could
have three possible lengths, depending on the tonicity,
activity, and anatomic attachments of the adjacent
structures-
Class III lateral throat form has minimum length and
thickness. The border usually ends 2-3 mm below the
mylohyoid ridge or sometimes just at the ridge.
100
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51
Class I throat form: The horizontal border is usually 2-3
mm thick, but a thicker border of 4-5 mm should be used
for better seal if the ridge is flat. The retromylohyoid
curtain area should be thinner, about 2-3 mm, and very
rounded and smooth.
Class II throat form is about half as long and narrow as
class I and about twice as long as class III.
101
102
Maxilla-
1.Has more supporting
areas
2.Limiting structures are
less in number and
have a less stronger
influence over the
denture border
Mandible-
1.Has less supporting
area.
2.Limiting structures
are more in number
and have a stronger
influence over the
denture border
28-11-2010
52
1. de Freitas V, Madeira MC, Toledo Filho JL, Chagas
CF. Absence of the mental foramen in dry human
mandibles. Acta Anat (Basel). 1979; 104(3): 353-355.
2. Dharmar S. Locating the mandibular canal in
panoramic radiographs. Int J Oral Maxillofac
Implants. 1997; 12: 113-117.
103
3. Mbajiorgu EF, Mawera G, Asala SA, Zivanovic S.
Position of the mental foramen in adult black
Zimbabwean mandibles: a clinical anatomical study.
Central African Journal of Medicine 1998; 44: 24-30.
4. Gershenson A, Nathan H, Luchansky E. Mental
foramen and mental nerve: changes with age. Acta
Anatomica 1986; 126: 21-8.
5. Zografos J, Kolokoudias M, Papadakis E Dental
School, University of Athens, Greece. Hell Period
Stomat Gnathopathoprosopike Cheir. 1990
Mar;5(1):17-20.
104
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53
6. Sheller WR and wisewell OB. Lingual foramen on the
mandible. Anat rac 1954; 119 387-390
7. Sheldon winkler 2
nd
edition OF ESSENTIALSOF
COMPLETE DENTURE PROSTHESIS
8. Charles m. heartwell, Jr, urthur O. Rahn . Syllabus of
complete denture 4
th
edition
9. Grays anatomy 39
th
edition
10. Zarb and Bolender 12
th
edition . Prosthodontic
treatment of edentulous patient
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11/28/2010
1
BY :- DR.MOHIT DHAWAN
M.D.S 1
ST
YEAR
PG. DEPT. OF PROSTHODONTICS
B.R.S DENTAL COLLEGE
SULTANPUR(PANCHKULA)
Its Role in Removable Prosthodontic
introduction
Functions
External features
Mucous membrane
Muscles
Arterial supply
Venous supply
Nerve supply
Lymphatic drainage
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2
Prosthodontic
considerations
Influence and action of
floor of the mouth
Applied anatomy
Tongue is always the most
integral part of oral anatomy.
every prosthodontist should
have a proper knowledge of its
anatomy to implement it for
delivering a retentive denture.
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FUNCTIONS OF
THE TONGUE
Taste, mastication and deglutition.
The tongue takes part in the functions of
sucking, swallowing, receiving food into
the mouth, mastication,vocalizationand
speech.
In speech, this is the most accurate and
fastest mechanisms of the body.
It plays an intrinsic part in the formation
of sounds of vowels and consonants.
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Control guide to direct the
flow of the food and liquids to
the pharynx.
Its a contributing factor in
aiding normal positioning of
erupting teeth in the dental
arches as a counter pressure
to facial muscles on the labial
and buccal side of the teeth.
Acts as an additional thermal
guide
EPITHELIUM
Anterior 2/3:- I
st
brachial arch.
Posterior 1/3:- III
rd
brachial arch .
Posterior most :- 4
th
brachial arch.
MUSCLES from Occipital myotomes
CONNECTIVE TISSUES from the local
mesenchyme
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EXTERNAL
FEATURES
11/28/2010
6
Body has 2 surfaces:
The dorsum, convex, curved upper
surface.
The ventral surface, inferior surface.
The dorsum of the tongue is divided into:
1. an oral part( anterior two third)
2. A pharyngeal part ( posterior one
third)
The parts are separated by a faint v
shaped groove, the sulcus terminalis.
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7
It is placed on the floor of the mouth.
It is covered by mucous membrane
which consists of a layer of
connective tissues & lined by
stratified squamous epithelium.
its margins are free &are in contact
with the gums &teeth.
in front of the palatoglossal
arch each margin show 4-5
vertical folds foliate
papillae.
SUPERIOR SURFACE of the
oral part shows a median
furrow which is rough and
covered with papillae.
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INFERIOR
SURFACE
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9
It is covered with a smooth mucous
membrane, which shows a median fold
called frenulumlingulae.
On either side prominence by deep lingual
veins
Laterally fold called plica fimbriata
directed towards the tip of the tongue.
The folds converge anteriorly & terminate
on either side of the lingual frenumin a small
elevation called the sublingual caruncula or
papilla. (wartons duct opens here).
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Lies beneath the palatoglossal
arches and the sulcus
terminalis.
The mucous membrane has no
papillae, but has many lymphoid
follicles collectively
constitute the lingual tonsil.
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11
The posterior part of the tongue is
connected to the epiglottis by three
folds of mucous membrane.
These are the median, right and left
glossoepigloticfolds.
On either side of the median fold
there is a pouch called the Vallecula.
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12
PAPILLAE OF
THE TONGUE
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13
11/28/2010
14
Large 1-2mm diameter.
8-12 in no.
Situated in front of sulcus terminalis.
Cylindrical projection.
Walls raised above the surface.
FUNGIFORM PAPILLAE: FUNGIFORM PAPILLAE:
Numerous
Near tip and margins
Smaller than vallate but larger than filliform.
Narrow peduncle and rounded head
Bright red colour.
VALLATE PAPILLAE: VALLATE PAPILLAE:
FILLIFORM PAPILLAE: FILLIFORM PAPILLAE:
Cover the presulculararea of the dorsum.
Velvety appearance.
Smallest and numerous.
Pointed and covered with keratin.
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The mucous membrane of the
tongue contains the receptors
for the special sensory modality
of taste.
Other sensory nerve endings
permit the tongue to detect
particle size of food, pain,
temperature, pressure & even
defects on natural teeth or a
denture.
Mucous membrane forms papillae,& is
adherent to the muscles.
Numerous glands, both serous &
mucous lie deep to the mucous
membrane.
Numerous taste buds are distributed
throughout the mucous membrane.
Taste buds are not present in the
middle of the tongue.
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16
MUSCLES OF
THE TONGUE
It contains 4 intrinsic and 4
extrinsic muscles.
Intrinsic
(I) superior longitudinal
(II) inferior longitudinal
(III) transverse
(IV) vertical
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Extrinsic muscles:
(I) genioglossus
(II) hyoglossus
(III) styloglossus
(IV) palatoglossus.
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18
Superior
longitudinal
Shortens & makes the dorsum concave. lies
beneath mucous membrane.
Inferior
longitudinal
Shortens &makes the dorsum convex. Close
to inferior surface between genioglossus
and hyoglossus.
Transverse Makes the tongue narrow & elongated.
Extends from median septum to margins.
Vertical Makes the tongue broad & flattened. Found
in the borders of anterior part of tongue.
Origin
Upper genial tubercle
Insertion
Upper fibers: tip
middle: dorsum
Lower: hyoid bone
Action
Retract the tip,
Depress tongue,
Protrude the tongue
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It is a lingual fixing muscle of the lower
denture.
The movements of the tongue esp the contraction is in
conjunction with the lingual vertical and the
genioglossus muscle that helps in the drawing of the
tongue anteriorly towards the floor of the muscle.
Hence, it increases the pressure which the tip of the
tongue can exert on the floor of the oral cavity and
the alveolar process.
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20
Origin
Greater cornu & lateral part of body of hyoid bone
Insertion
Side of the tongue between
styloglossus & inferior
longitudinalmuscle of
the tongue
Action
Depress the tongue,
Retrudes the tongue
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21
Origin
Tip and anterior surface of the
styloid process
Insertion
Side of the tongue
action
Pull the tongue upward and
forward
When the muscle contract
Terminating part of Alveolingual

sulcus is lifted alongwith
the mucousa.
Dislocating the denture

Generally, its a LINGUAL DISLOCACTING MUSCLE.
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Origin
Oral surface of palatine aponurosis.
Insertion
Side of the tongue at the junction of oral and
pharyngeal part of palatoglossal arch.
Action
Touches the palate. thus preventing the
bolus from coming out.
It is also a lingual dislocating
muscle.
It is having the same action as that of
the styloglossus muscle.
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MOTOR NERVES:
Intrinsic & extrinsic muscles except
palatoglossus- Hypoglossal nerve.
Palatoglossus Cranial part of Accessory
n. through Pharyngeal plexus.
SENSORY NERVES
Anterior 2/3 Chorda Tympani (Facial
Nerve).
General sensation -Lingual nerve.
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Posterior 1/3 general taste &sensation-
Glossopharyngeal nerve.
Posterior most- Vagus nerve.
Lingual artery which is
a branch of external
carotid artery .
The root is supplied by
tonsillar & ascending
pharyngeal arteries.
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Deep lingual vein is
the principal vein.
Runs backwards
&unite to form
lingual vein.
Ends in either
common facial vein
or internal jugular
vein.
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26
Tip bilaterally to Submental nodes.
The remaining right & left halves of anterior 2/3s
drain unilaterally to submandibular nodes.
Posterior 1/3 drains bilaterally into jugulo-omohyoid
nodes. (lymph nodes of the tongue).
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27
A common nodular varicose
enlargement of superficial veins on the
undersurface of the tongue is seen.
Becomes smooth &glossy or red
&inflamed in appearance.
Lingual mucosa soreness, burning or
abnormal taste sensations. (in elderly
&postmenopausal women)
The presence of a retracted tongue affects
the complete denture construction;
however, its effect on denture function
remains questionable. (J.Oral Rehab:2005 jun397-
402)
Focal collections of chronic inflammatory
cells are common, because of the infiltration
of microorganisms or toxins through the thin
epithelium of this region.
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28
As the age increases the motor skills
of the tongue decreases.
For complete denture wearers, the
tongue plays an important role in the
retention and stability of dentures.
Here, BRODIE spoke about the
Antagonistic muscle groups.
It can be used to stabilize the dentures.
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29
The resting muscles can be made to fix
a denture by 2 condtions:-
By the inclination of the polished
surfaces of the dentures.
By the polished surfaces of the
denture between the cheeks and the
lower lip on the one side and the
tongue on the other side.
The buccal flanges of the lower denture must
slope inferiorly and laterally.
The lingual flanges also must extend
inferiorly and medially below the anterior and
lateral parts of the tongue, and as far as
posteriorly by the range of the action of
tongue and internal pterygoid muscle.
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30
The position of the polished surfaces should
be such that it can be wedged between the
supporting structures.
It should be in equilibrium with the forces
acting on both side.
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31
Prosthodontic
considerations
Tongue thrusting habit tend to displace
mandibular denture and sometimes
maxillary denture also.
Measurement of the tongue force and
fatigue indicate that long span
edentulous state effects the
musculature of the tongue. The tongue
becomes stronger and this increase in
strength must be considered.
(JPD 1963,,VOL 13,857-865, by Philip Rinaladi)
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32
IMPRESSIONS:
Small narrow tongue easy to make
impressions. Poor border seal.
Broad thick tongue makes impression
making tough but provides good lingual
seal.
HOUSES CLASSIFICATION OF TONGUE
SIZES.
Class I: normal in size ,development &
function.
Class II: teeth have been absent long
enough to permit a change in form &
function of the tongue.
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Class III: the tongue is retracted &
depressed into the floor of the mouth ,with
the tip curled upward, downward or
assimilated into the body of tongue.
Class I is ideal for prostheses .
Class II & III Unfavorable
WRIGHT S CLASSIFICATION OF TONGUE
POSITION.
Class I: Tongue lies in the floor of the
mouth with the tip forward & slightly
below the incisal edges of the
mandibular anterior teeth.
Class II : The tongue is flattened &
broadened but the tip is in a normal
position.
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Class III: the tongue is retracted &
depressed into the floor of the mouth ,with
the tip curled upward, downward or
assimilated into the body of tongue.
Class I is ideal for prostheses .
Class II & III Unfavorable.
This is an area posterior to mylohyoid muscles.
Bounded by retromylohyoid curtain.
Posterolateral- overlies the superior constrictor
muscle.
Posteromedial- covers the palatoglossal muscle.
Inferior- overlies submandibular gland.
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The denture border should extend
posteriorly to contact retromylohyoid
curtain when the tip of the tongue is placed
against the front part of upper residual
ridge.
Protrusion of the
tongue
causes the
retromylohyoid
curtain to move
forward.
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36
The space between the residual ridge and the
tongue which extends from lingual frenum to
the retromylohyoid curtain.
Can be considered in 3 regions.
1. Anterior region : This extends from
lingual frenum to where the mylohyoid curves
down below the level of the sulcus. This
depression is called premylohyoid fossa.
This results from the concavity of the
mandible joining the convexity of the
mylohyiod ridge.
The lingual border of the impression in this
anterior region should extend down to
make definite contact with the mucous
membrane floor of the mouth when the tip
of the tongue touches the upper incisors
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37
Extends from the premylohyoid fossa to the distal
end of mylohyoid ridge curving medially from body of
the mandible. The curvature is caused by prominence
of mylohyoid ridge.
When the mylohyoid muscle and the tongue are
relaxed, the muscle drapes back under the mylohyoid
ridge. If the impression is made under these
conditions,the muscle will be trapped under the
ridge when the tongue is placed against upper
incisors
A slope of the lingual flange towards the
tongue in the molar region allows the
mylohyoid muscle to contract and raise the
floor of the mouth without displacing the
denture.
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This part is the retromylohyoid space or
fossa.
It extends from the end of the mylohyoid
ridge to the retromylohyoid curtain (
glossopalatine and superior constrictor
muscles).
The denture border should extend
posteriorly to contact the retromylohyoid
curtain( the posterior limit of
alveololingual sulcus) when the tip of the
tongue is placed against the front part of
upper residual ridge.
The distal end of the
lingual flange turns
buccally to fill the
retromylohyoid
fossa.
When the lingual
flange is developed
in this manner the
border has a typical
s shaped curve
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If the floor is too low ,so the dentist tends
to over extend the denture flange, which
leads to loss of retention because the
denture flange impinges on the tissue & gets
dislodged during the activation of the floor
of the mouth.
The mandibular denture should be stable
enough to resist a gentle push on the
mandibular incisors by the tongue.
Tongue position has an important bearing on
impression making and subsequent ability of
the patient to manage with the mandibular
denture.
All procedures leading to completing a
lower impression should be done with
tongue in its normal position.
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According to the degree of activity and
functional type:
1.occupational tongue.
2. Still tongue.
3.normal tongue.
4.habitual tongue.
JPD 1955,vol.5,629-635,by Barnett kessler.
Apply to those whose activities require
increased tongue action: jurist, teachers.
Lecturers.
This implies that the organ has developed a
greater range of power movements which may
results in trauma where flexibility in range is
interfered with or restricted by prosthetic
appliance.
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41
2. Still:Limited activity due to injury or deformity.
Can not project the tongue forward much.
Passive tongue: tongue- tie.
3. Normal :Welcomed by prosthodontists as they give a
range within limit2. s in effecting desirable
rehabilitation.
4. Habitual: describes those disturbing power movements
developed by habit.
The base of the tongue is thick and
powerful and dislodging force is most
offending to prosthetic denture.
It is suggested that the lower 2 molar in the
prosthesis may be reduced buccolingually
and may be set buccal to the ridge crest for
stability
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The actions of the tongue & cheek along
with the esthetics ,primarily determine the
lateral limits of the mandibular posterior
teeth.
The teeth shouldnt be placed more lingual
than the extent of the ridge, since elevation
of the tongue may dislodge the prosthesis.
At rest after swallowing the tip gently
touches the lingual surface of the lower
anterior teeth.
The anterior teeth must not be set too far
labially as the tongue normally rests on
the anterior teeth.
The tongue assumes a position in which its
lateral border is at the level of lingual
contour of the lower natural posterior
teeth.
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The dorsal surface is nearly at the level of
the occlusal plane of posterior teeth.
It can be used as a good guide for the height
of occlusal plane of artificial posteriors.
In prolonged edentulous patients the tongue
is hypertrophied.
Applied anatomy
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Injury to the hypoglossal nerve produces
paralysis of the muscles of the tongue on
the side of the lesion.
The lesion may be either infranuclear or
supranuclear.
Infranuclear:- gradual atrophy of the
affected half of the tongue.
Muscular twitching are also observed.
Seen typically in motor neuron
disease & in syringobulbia.
Supranuclear lesions:- produce
paralysis without wasting.
Seen in pseudobulbar palsy where the
tongue is stiff & small
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Glossitis is usually a part of generalized
ulceration of the mouth cavity.
The presence of a rich network of lymphatic &
of loose areolar tissue,in the substance of
the tongue is responsible for enormous
swelling of the tongue in acute glossitis.
The tongue fills up the mouth cavity &
protrudes out.
The under surface of the tongue is a good site
(along with the bulbar conjunctiva) for
observation of jaundice.
In unconscious patients the tongue may fall
back & obstruct air passages.
This can be prevented by lying the patient on
one side with head down (the tonsil position)
or by mechanically pulling the tongue out.
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In patients with grand mal epilepsy the tongue is
commonly bitten between the teeth during the attack.
This can be prevented by hurriedly putting a mouth gag
at the onset of the seizure.
Carcinoma of the tongue is quite common.
It is treated by radiotheraphy than by surgery.
Carcinoma of the posterior 1/3
rd
of tongue is more
dangerous due to bilateral lymphatic spread.
Lingual cusps of upper premolars protrude
lingually and restrict lateral border of
anterior 3
rd
of the tongue- needs reduction
and trimming of premolars.
Positioning of lower posteriors lingually off
the ridge causes restriction of tongue
movement- lack of space for the tongue to
stretch and relax- tongue extend towards the
throat- difficulty in breathing.
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Insufficient vertical dimension causes
excessive friction of the dorsum against the
palatal vault and occlusal surfaces of
upper teeth- Affects phonetics an
deglutition.
When dentures are worn for many years
with insufficient vertical dimension,
papillae in the anterior 3
rd
and middle 3
rd
are obliterated leading to smooth and shiny
tongue.
A total glossectomy or laryngectomy results
in loss of basic vital functions and loss of
speech.
In these patients fabrication of a mandibular
tongue prosthesis can be done.
Procedure:
Diagnostic casts are made and articulated.
Mandibular RPD is constructed with a chrome
cobalt alloy mesh work which extends to the
floor of the mouth.
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Superior portion of the tongue is concave in
form to permit food and liquid to pass
posteriorly towards the pharynx.
This tongue prosthesis is effective in
improving esthetics and function of the
patient.
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Superior portion of the tongue is concave in
form to permit food and liquid to pass
posteriorly towards the pharynx.
This tongue prosthesis is effective in
improving esthetics and function of the
patient.
B.D.Chaurasias-Human anatomy
Bouchers-Prosthodontic treatment for edentulous
patients.
Clinically oriented anatomy- Moore and Dalley.
Winklers-Essentials of complete denture
prosthodontics.
Wikipedia
Gray,s anatomy
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50
JPD-1955,VOL 5,629-635.
JPD-1963,VOL 13,857-865.
JPD-1978,VOL 39,652-655.
(J.Oral Rehab:2005 jun397-402)
Hps online .com
COMPLETE DENTURE THEORY AND PRACTICE Diagnosis and treatment planning
Diagnosis and Treatment Planning
Diagnosis in complete dentures is a very important process and is not accomplished in a
short time. The dentist should be the first to recognize the problem and be ready to change the
treatment plan to meet the new findings. Treatment does not terminate with the construction
and delivery of complete dentures, and the patient should be so advised.
Diagnosis and treatment planning are the most important parameters in the successful
management of a patient. Inadequate diagnosis and treatment planning are the major reasons
behind the failure of a complete denture.
S.O.A.P.
Subjective (What the patient tells us)
Objective (What we see)
Assessment (What we deduce)
Plan (What we offer to do) (Tx Plan)
The following items will be disscussed:
Diagnosis
-Patient Evaluation
-Clinical History Taking
-Clinical Examination of the Patient
-Radiographic Examination
Assessment
Treatment Plan
Prognosis
Prosthodontic Care
Definitions
Diagnosis
(1) The act or process of deciding the nature of a diseased condition by examination.
(2) A careful investigation of the facts to determine the nature of a thing,
(3) The determination of the nature, location, and causes of disease.
Treatment planning is a consideration of all of the diagnostic findings, systemic and local,
which influence the surgical preparations of the mouth, impression making, maxillomandibular
relation records, occlusion to be developed, form and material in the teeth, the denture base ma-
terial, and instructions in the use and care of dentures.
The factors in these findings will be governed by
(1) The patient's mental attitude,
(2) The patient's systemic status,
(3) Past dental history, and
(4) Local oral conditions.
Factors evaluated to arrive at a proper diagnosis and treatment planning.
1-diagnosis:
a-Patient Evaluation
- Gait
- Complexion
- Cosmetic Index
- Mental Attitude
b-History taking:
Personal history
- Name
- Age
- Sex
- Occupation
- Race
- Location
- Religion
Medical History
Debilitating Diseases
Diseases of the Joints
Cardiovascular Diseases
Diseases of the Skin
Neurological Disorders
Oral Malignancies
Climacteric Conditions
Dental History
Chief Complaint
Expectations
Period of Edentulousness
Pre-treatment Records:
Previous Denture
Current Denture
Pre-extraction Records
Diagnostic Casts
Denture Success
c- Clinical Examination of the patient
Extraoral
Facial examination:
- Facial Form
- Facial Features
Muscle Tone
Muscle Development
Complexion
Lip Examination
TMJ Examination
Neuromuscular Examination
- Speech
-Co-ordination
Intraoral:
Existing teeth (If any)
Mucosa:
- Colour of the mucosa
- Condition of the Mucosa
-Thickness
Saliva
Residual Alveolar Ridge:
- Arch Size
- Arch Form
- Ridge Contour
- Ridge Relation
- Ridge parallellism
- Inter-arch Space
Ridge Defects
Redundant Tissue
Hyperplastic Tissue
Hard palate
Soft palate and palatal Throat Form
Lateral Throat Form
Gag Reflex
Bony Undercuts
Tori
Muscle and Frenum Attachments
- Border Attachments of the Mucosa
- Frenal Attachments
Tongue
Floor of the Mouth G
d- Radiographic Examination
Bone Quality
e- Examination of the Existing Prosthesis
2-TREATMENT PLANNING:
Adjunctive care:
Elimination of Infection
Elimination of Pathosis
Pre-prosthetic Surgery
Tissue Conditioning
Nutritional Counselling
Prosthodontics care
Patients destined to be edentulous:
Immediate or Conventional Denture
Definitive or Interim Denture
Implant or Soft Tissue Supported Denture
Patients already edentulous:
Soft Tissue Supported
Implant Supported(fixed or removable)
Material of Choice
Selection of Teeth
Anatomic Palate
1-DIAGNOSIS
Essential diagnostic data obtained from patient interview, definitive oral examination,
consultation with medical and dental specialists, radiographs, mounted and surveyed diagnostic
casts should be carefully evaluated during treatment planning.
A - PATIENT EVALUATION
The dentist should begin evaluating the patient as soon as he/she enters the clinic. This
is to obtain a clear idea of what type of treatment is necessary for the patient.
Gait
People with neuromuscular disorders show a different gait. Such patients will have
difficulty in adapting to the denture.
Complexion and Personality
Evaluating the complexion helps to determine the shade of the teeth. Executives require
smaller teeth.
Cosmetic Index
It basically speaks about the aesthetic expectations of the patient. Based on the cosmetic
index, patients can be classified as:
- Class I: High cosmetic index. They are more concerned about the treatment and wonder
if their expectations can be fulfilled.
- Class II: Moderate cosmetic patients. They are patients with nominal expectations.
- Class III: Low cosmetic index. These patients are not bothered about treatment and the
aesthetics. It is very difficult for the dentist to know if the patient is satisfied with the
treatment or not.
Mental Attitude of Patients
A doctor should evaluate the patient's hair colour, height, weight, gait, behaviour, socio-
economic status, etc right from the moment he/ she enters the clinic. A brief
conversation will reveal his/her mental attitude.
De Van stated, "meet the mind of the patient before meeting the mouth of the patient". Hence,
we understand that the patient's attitudes and opinions can influence the outcome of the
treatment.
Based on their mental attitude, patients can be grouped under two classifications.
1-Dr. MM House proposed the first one in 1950, which is widely followed.
House's Classification
Dr.MM House in 1950 classified patient's psychology into four types:
Class I: Philosophical
a. Those who have presented themselves prior to the extraction of their teeth, have had no
experience in wearing dentures, and do not anticipate any special difficulties in that regard.
b. Those who have worn satisfactory dentures, are in good health, are a well-balanced type,
and are in need of further denture service.Generally they can be described as mentally well
adjusted, cooperative and confident of the dentist. These patients have excellent prognosis.
Class II: Exacting
a. Those who, while suffering from ill health, are seriously concerned about appearance
and efficiency of artificial dentures. They are reluctant to accept the advice of the
physician and the dentist and are unwilling to submit to the removal of their artificial teeth.
b. Those wearing dentures unsatisfactory in appearance and usefulness, and who doubt the
ability of the dentist to render a satisfactory treatment, and those who insist on a written
guarantee or expect the dentist to make repeated attempts to please them.
These patients are precise, above average in intelligence, concerned in their dress and
appearance, usually dissatisfied by their previous treatment, do not have confidence in the
dentist. It is very difficult to satisfy them. But once satisfied they become the dentist's
greatest supporter.
Class III: Hysterical
a. Those in bad health with long neglected pathological mouth conditions and who are
positive in their minds that they can never wear dentures. They are emotionally unstable
and tend to complain without justification.
b. Those who have attempted to wear dentures but failed. They are thoroughly
discouraged. They are of a hysterical, nervous, very exacting temperament and will
demand efficiency and appearance from the dentures equal to that of the most perfect
natural teeth. Unless their mental attitude is changed it is difficult to give a successful
treatment.
They have unrealistic expectations and want the dentures to be better than their natural
teeth. They are the most difficult patients to manage. They show poor prognosis.
Class IV: Indifferent
Those who are unconcerned about their appearance and feel very little or no necessity for
teeth for mastication. They are, therefore uncooperative and will hardly try to become
accustomed to dentures. They will not maintain the dentures properly and do not
appreciate the efforts and skills of the dentist.
2-other Classification
Patients may also be classified under the following categories:
a-Cooperative
These patients represent the optimum group. They may or may not recognize the need for
dentures but they are open-minded and are amenable to suggestion. Procedures can be
explained with very little effort and they become fully cooperative.
b- Apprehensive
Even though these patients realize the need for dentures they have some problem, which
cannot be overcome by ordinary explanation. The approach to all of these patients is to
talk with them and to make them speak out their thoughts about dentures.
Apprehensive patients are of different types namely:
Anxious: These patients are anxious and upset about the uncertainities of wearing
dentures. They often put themselves into a neurotic state. In extreme and rare
cases they may be psychotic.
Frightened: Some fear the development of cancer; others fear that they will not be
able to wear the teeth; still others fear that the teeth will not look well. Extreme
cases should be referred to a psychiatrist.
Obsessive or exacting: These persons are naturally of an exacting nature and are
accustomed to giving directions to others. They state their wants and are inclined
to tell the dentist how to proceed. Patients of this type must be handled firmly.
They should be told tactfully at the outset that they would not be allowed to direct
the denture construction.
Chronic complainers: They are a group of people who are habitually faultfinding
and dissatisfied. Appreciating their cooperation and incorporating as many of
their ideas as possible with good denture construction is the best way to handle
them. It is best to have an understanding with such patients before work
commences. In this way they are made to share responsibility for the outcome.
Self-conscious: The apprehension here centres chiefly on appearance. It is wise to
give overt reassurance to the self-conscious patient and permit participation in the
reconstruction as far as feasible in order to establish some responsibility in the
result.
c- Uncooperative
These patients present themselves usually upon being urged by relatives or friends. They
do not feel a need for dentures, though the need exists. Their general attitude is negative.
They constitute an extremely difficult group of potential denture wearers and tax the
dentist's patience to the limit. In many cases, an attempt to make dentures for these
individuals is a waste of time.
Along with analyzing the mental attitudes of the patient, the dentist must collect information
about the patient's habits, diet, past dental history and the physical characteristics, etc. The
expectations of the patient should be taken into consideration to achieve patient satisfaction.
B- HISTORY TAKING
History taking is a systematic procedure for collecting the details of the patient to do a proper
treatment planning. Personal and medical particulars are gathered to rule out general diseases
and to determine the best form of treatment for that patient.
Personal history
Name
The name should be asked to enter it in the record. When the patient is addressed by his
name, it brings him some confidence and psychological security. The name also gives
an idea about the patient's family and community.
Age
Some diseases are limited to certain age groups. Hence, age can be used to rule out
certain systemic conditions apart from determining the prognosis.
Patients belonging to the fourth decade of life will have good healing abilities and
patients above the sixth decade will have compromised healing.
Increasing age decreases the readiness to form new habits and also muscular efficiency is often
impaired. Young people adapt themselves more readily than do the aged. They are usually more
demanding in esthetics. Age has a definite relation to the selection of teeth, not only in their
size, shape and color, but also in various degrees of abrasion, attrition and erosion.
Sex
Generally the mentality of the patient is affected by the gender. Certain diseases are
confined to a particular sex. so, sex can be used to rule out certain systemic conditions.
Male patients are generally busy people who appear indifferent treatment. They are
only bothered about comfort and nothing else. On the other hand, female patients are
more critical about aesthetics.
Factors such as menopause are an influencing factor in the overall success of dentures.
Menopause is often reflected in symptoms of a burning mouth, which most patients will
attribute to the prosthetic appliance rather than to systemic disturbances.
Occupation
Executives and sales representatives require more idealistic teeth. While other people
who work in places with high physical exertion require rugged teeth. And people with
higher income have greater expectations. People who are very busy will be more critical
about comfort.
This will frequently have a relation to the design of the dentures and the technique used
in impression making, for example:
a- With most professional men whose occupation entails intimate contact with their
fellows, appearance and retention are more important than efficiency. They are
more demanding of artificial replacements as they constantly deal with people.
b- Public speakers and singers require perfect retention and particular attention to
palatal shape and thickness because of the importance of these in phonation.
Race
It helps to select the shade of the teeth.
Location
Some endemic disorders like fluorosis are confined to certain localities. People from
that locality may want characterization (pattern staining) in their teeth for a natural
appearance.
Religion and Community
Gives an idea about the dietary habits and helps to design the denture accordingly.
Medical History :The following medical conditions should be ruled out.
Debilitating Diseases
Complete denture patients, most of whom are geriatric, may suffering from debilitating
diseases like diabetes, blood dyscrasias and tuberculosis.
These patients require specific instructions on denture/tissue care. They also require
special follow-up appointments to observe the response of the soft tissues to the denture.
Diabetic patients show excessive rate of bone resorption, hence, frequent relining may
be necessary. And Epithelium is thinner, less keratinized and more sensitive to trauma.
Result in Compromised, support and impaired tolerance of complete dentures.. In
planning a denture for a diabetic, we should consider a reduced occlusal table, an
increased amount of free way space together with frequent scheduled adjustments and
recalls. The diabetic shows a tendency toward edema during periods of imbalance. This
must be considered in scheduling impression procedures.
Diseases of the Joints
Complete denture patients with osteoarthritis affecting the finger joints may find it
difficult to insert and clean dentures.
Osteoarthritis plays an important role in complete denture construction when it affects
the TMJ. With limited mouth opening and painful movements of the jaw, it becomes
necessary to use special impression trays. It may also become necessary to repeat jaw
relations and make post-insertion occlusal adjustments due to changes in the joint.
Osteoporosis
Although this condition has already been mentioned with respect to the denture-bearing
tissues, it is appropriate to mention that it can lead to a hunched posture, or kyphosis,
which requires the dentist to ensure that work is undertaken with the patient in the
sitting position with the head and neck adequately supported.
Cardiovascular Diseases
It is always advisable to consult the patient's cardiologist before commencing treatment.
Cardiac patients will require shorter appointments.
Angina
Angina can cause pain that is experienced around the left body of the mandible or even
the left side of the palate. This usually occurs in association with chest pain and the
onset is usually related to physical exertion.
Congestive heart failure, chronic bronchitis and emphysema
Elderly patients with these conditions are likely to become breathless if the dental chair
is tipped back into the supine position.
Cerebro-vascular accident
The occurrence of a stroke may result in unilateral paralysis of the facial muscles,
making it more difficult for the patient to control dentures, especially the lower denture.
The patient may also have difficulty clearing food which has lodged in the buccal
sulcus.
Speech may be affected, making it difficult for the patient to communicate with the
dentist.
Diseases of the Skin
Skin diseases like Pemphigus have oral manifestations, which vary, from ulcers to
bullae. Such painful conditions, make the denture use impossible without medical
treatment.
Neurological Disorders
Diseases such as Bell's palsy and Parkinson's disease can influence denture retention
and jaw relation records. Patients should understand the difficulty in denture fabrication
and usage.
Anemia
The anemia results in poor nervous disorders reflecting lack of coordination and
extreme irritability. Parkinson's disease affects the ability of the patient to wear
dentures, and increase the hazards of denture procedures.
Transmitted diseases:
Hepatitis, T.B., influenza, H.I.V.
Hazards From communicated blood, saliva, aerosol& instruments.
Impression should be immediately disinfected.(Chemical sterilization)
Pemphigus Vulgaris:
Before 1959 the disease is fatal.
Bulla with gradual extension. Chronic ulceration withsubsequent scarring of the oral
mucosa.
Acute phase: Oral discomfort& dryness of the mouth are common pain& loose
denture.
Limited denture extensions compromising support, stability, retention and tolerance of
complete dentures. Borders should be smooth& polished to prevent irritation.
Post-insertion care.
Oral Lichen Planus
Erosive lesions and subsequent scarring in the buccal shelf area limit denture extension
in this region and make it difficult for some patients to tolerate their dentures.
Result - Compromised support and tolerance of the mandibular denture.
Chronic Candidiasis
Low saliva flow rates lead to increased numbers off fungal organisms leading tto a high
incidence of chronic candidiasis..
Burning and irritation of the denture bearing mucosa, making tolerance of complete
dentures difficult. In addition the fungus is keratolytic, further compromising support
and tolerance.
Treatment: Antifungal therapy*
Nystatin powder (100,000 units per gram). Apply to undersurface of denture
three times per day for 3-4 weeks
Nystatin cream Best used for lesions associated with the corners of the mouth
Reline or remake denture
*Nystatin rinse is generally ineffective. Nystatin oral lozenges are reserved for fungal
infestations that extend beyond the denture bearing surfaces.
Parkinson disease:
Rhythmic contractions of the musculature (muscles of mastication).
Severe cases (Impossible for a pt. to insert& remove the denture).
Impression procedures may be compromised by the presence of excessive saliva in this
case.
Acromegaly:
Pt. may have a large Mandible.
Frequent examination to evaluate fit& function.
Paget's disease:
Pt. with disease may have enlarged maxillary tuberosity (affects fit& occlusion).
Surgical re-contouring or relief.
Frequent recall appointments.
Oral Malignancies
Some complete denture patients with oral malignancies may require radiation therapy
before prosthetic treatment.
A waiting period should elapse between the end of radiation therapy and the beginning
of complete denture construction. Only the radiotherapist determines this waiting
period.
Tissues having bronze colour and loss of tonicity are not suitable for denture support.
Once the dentures are constructed, the tissues should be examined frequently for
radionecrosis.
Climacteric Conditions
Climacteric conditions like menopause can cause glandular changes, osteoporosis and
psychiatric changes in the patient. These can influence treatment planning and the
efficiency of the complete denture.
Other common manifestations in and around the oral cavity must be considered. These include
tempromandibular joint disturbances, facial neuralgias, various types of neurosis, multiple
sclerosis, coordination, intelligence, and even the desire to wear dentures.
Nutritional deficiencies
Deficiencies of the vitamin B complex, folic acid and iron can lead to pathology of the
mucosa and to widespread discomfort or burning.
Psychiatric disorders
Depression is the most common mental disorder in later life. The prevalence of
depression requiring clinical intervention in the over 65s is between 13% and 16%).
This condition can result in poor appetite and weight loss, and can adversely affect
motivation and self-care.
Evaluating the effect of drugs on Dental& Prosthetic ttt:
1- Anticoagulants:
Medical consultation is required when surgical preparation for the prosthodontic
restoration is required.
2- Antihypertensive Agents:
Syncope may occur when pt. change it's position suddenly into upright position
(It occurs when the pt. rises from dental chair).
Saliva& dry mouth may be found.
3- Endocrine therapy:
Endocrine therapy may lead to Xerostomia& oral discomfort.
4- Saliva Inhibiting drugs:
Atropine& their derivatives (used to control excessive salivation).
These drugs should be avoided in Prostatic hypertrophy& Glaucoma and the
salivary secretion controlled mechanically.
Xerostomia is produced by certain antidepressants, diuretics, antihypertensives and
antipsychotics. Lack of saliva adversely affects the retention of dentures, increases the
possibility of oral infection and, through the absence of lubrication, can result in generalised
soreness or even a burning sensation.
Certain drugs, such as steroid inhalers used in the treatment of asthma, immunosuppressive
drugs and broad-spectrum antibiotics used over a long period, can alter the oral flora thus
predisposing to candida infection.
Tardive dyskinesia is a condition characterized by spasmodic movements of the oral, lingual
and facial muscles. These uncontrollable movements can make it extremely difficult, or even
impossible, to provide stable dentures. The condition is brought on by extensive use of drugs
such as antipsychotics and tricyclic antidepressants.
Dental History
Chief Complaint
It should be recorded in the patient's own words. It gives ideas about the patient's
psychology.
Expectations
The patient should be asked about his/her expectations. The dentist should evaluate the
patient's expectations and classify them as realistic or attainable and unrealistic.
If prior to being rendered edentulous, a partial denture was worn with comfort and
efficiency, the same will be expected of complete dentures. It should be explained to
such patients that, although partial denture experience is helpful in relation to complete
dentures, the latter require a considerably greater degree of control because they are not,
as were the partial dentures, retained or supported by the natural teeth.
If complete dentures are already being worn and they have been comfortable and
efficient, the same will be expected of the new dentures. If the old complete dentures
were troublesome, the attitude may be expectant of better results with the new dentures
or pessimism that nothing better can be hoped for.
If no previous denture experience exists, friends or relations may have colored the
patient's mind with their own attitudes. In such cases the efficient control and use of
complete dentures depends to a very large extent on the formation of new habits and a
new pattern of muscular movement. This demands time and some patience on the part
of the wearer. Many complete denture troubles can be traced to the fact that no
preparation of the patient's mind preceded the fitting of the dentures.
Information regarding the loss of the natural teeth:
A history of difficult extractions should be followed by a radiographic examination of
the jaws to verify the absence of retained roots.
Questioning should be directed to eliciting the general order in which the teeth were
lost. For example if all the posterior teeth were extracted some years before the anterior
ones and no partial dentures were worn in the meantime, then a habit of eating with the
front teeth will have been formed which, if persistent, will have a pronounced
unstabilizing effect on complete dentures.
A similar condition will exist in individuals who have been edentulous for a
considerable length of time and have not worn dentures, as a result they are only able to
approximate their jaws in the anterior region and consequently forward travel of the
mandible is necessary all the time during eating.
When there is a history of abnormal mandibular function or movement, then difficulty
can be anticipated when registering the anteroposterior occlusal relationship.
Period of Edentulousness
This data gives information about the amount and pattern of bone resorption. The cause
for the tooth loss should be enquired (caries, periodontitis, etc.)
Pre-treatment Records
The pre-treatment record is a very valuable information. Pre-treatment records include
information about the previous denture, current denture, pre-extraction records and
diagnostic casts. It includes pre-extraction radiographs, photographs, diagnostic casts,
etc. They can be used to reproduce the anterior aesthetics.
Previous denture
It denotes the dentures, which were worn before the current denture. The reason for the
failure of the prosthesis should be enquired with the patient. The patients who keep
changing dentures in a short period of time are difficult to satisfy and are risky to deal
with.
Current denture
The existing denture, which is worn by the patient at present, should be examined
thoroughly. The reason for wanting a replacement should be evaluated. This denture
gives us information about the denture experience, denture care, dental knowledge and
para-functional habits of the patient.
Denture success
The patients should be asked about the aesthetics and functioning of the existing
denture. Based on the patient's comment, the denture success should be classified as
favourable or unfavourable.
The following factors should be noted on the existing prosthesis:
The period for which the patient has been wearing the denture should be determined. The
amount of ridge resorption should be assessed to determine the amount of expected ridge
resorption after placement of the new prosthesis.
Anterior and posterior teeth shade, mould and material.
Centric occlusion and also the patient profile in centric relation. (Centric occlusion is "the
centered contact position of the occlusal surfaces of the mandibular teeth against the occlusal
surfaces of the maxillary teeth"'-GPT). It should be marked as acceptable or unacceptable.
Vertical dimension at occlusion. It should be marked as acceptable or unacceptable.
Plane of orientation of the occlusal plane. Improperly-oriented plane will have teeth
arranged in a reverse smile line.
The tissue surface and the polished or cameo surface of the palate should be examined.
Reproduction of rugae should be noted.
The patient's speech pattern should be noted for any valving nasal twang.
The posterior extension of the maxillarydenture should be noted.
The posterior palatal seal should beexamined. It should be marked as acceptableor
unacceptable.
Proper basal seat coverage and adaptationshould be noted. It should be marked as acceptable
or unacceptable
The midline of the denture should be checked. At-least the maxillary denture should coincide
with the facial midline.
Characterization or purposeful staining of the denture for esthetics should be recorded.
Wear or breakage. This may be an indication of bruxism. Denture wear can be classified as:
1. Minimal
2. Moderate
3. Severe.
Diagnostic cast
Sometimes, intraoral examination may be inaccurate because the patient moving his jaws and
altering ridge relationship. In such cases it may be necessary to prepare diagnostic casts and
mount them in an articulator in a tentative jaw relation. This set-up serves to assess the inter-
ridge space, ridge form and ridge shape.
C- CLINICAL EXAMINATION OF THE PATIENT
A- Extraoral Examination
The patient's head and neck region should be examined for any pathological condition.
Facial colour, tone, hair color and texture, symmetry and neuromuscular activity are noted. It
includes facial examination, examination of muscle tone and development, lip examination,
TMJ examination and neuromuscular examination.
Facial Examination: An edentulous patient should be examined facially in front and
profile views.
1. The fullness and normal contour of the upper lip is lost due to the lack of support by
the loss of teeth.
2. The normal lip line and natural vermilion border of the upper lip is changed due to
this falling in and the philtrum looks unsupported.
3. The nasal folds are deepened, the mental tip is exaggerated and facial wrinkles may
result as the person has been without teeth for sometime
It includes the evaluation of facial features, facial form, facial profile and lower facial height.
a-Facial Features The following features should be noted during diagnosis of the patient:
Length of the lips.
Lip fullness.
Apparent support of the lips.
Philtrum.
Nasolabial fold.
Mentolabial sulcus or labiomental groove.
Labial commissures and modiolus.
Width of the vermillion border. It influences the degree of tooth display.
Size of the oral opening. It also influences the degree of tooth display.
Texture of the skin: (rough or smooth)
All the above-mentioned factors aid to determine the shade, shape and arrangement of teeth
b-Facial form
House and Loop, Frush and Fisher, and Williams classified facial form based on the outline of
the face as square, tapering, square tapering and ovoid.
Examining the facial form helps in teeth selection
c-Facial profile
Angle classified facial profile as:
Class I: Normal or straight profile
Class II: Retrognathic profile.
Class III: Prognathic profile
Examination of the facial profile is very important because it determines the jaw relation and
occlusion.
d- Lower facial height
If the face appears collapsed, it indicates the loss of vertical dimension (VD). Decreased VD
produces wrinkles around the mouth. Excessive VD will cause the facial tissues to appear
stretched
Determining the lower facial height is important to determine the vertical jaw relation . For
those patients who are already wearing a complete denture, the lower facial height is examined
under occlusion.
Muscle Tone
House classified muscle tone as:
Class I: Normal tension, tone and placement of the muscle of mastication and facial
expression. No degeneration. It is common in immediate denture patients because all
other patients generally show degeneration.
Class II: Normal muscle function but slightly decreased muscle tone.
Class III: Decreased muscle tone and function. It is usually accompanied with ill-
fitting dentures, decreased vertical dimension, decreased biting force, wrinkles in the
cheeks and drooping of commissures.
House classified muscle development as:
Class I; Heavy
Class II: Medium
Class III: Light.
Muscle tone can affect the stability of the denture. People with excessive muscle development
have more biting force.
Complexion
The colour of the eye, hair and the skin guide the selection of artificial teeth.
Pale skin colour is indicative of anaemia and should be treated.
Lip Examination
Lip support: Based on the amount of lip support, lips can be classified as
adequately supported or unsupported.
Lip mobility: Based on the mobility, lips are classified as
normal (class 1),
reduced mobility (class 2) and
paralysed (class 3).
Thickness of the lips: Thick lips need lesser support from the artificial teeth and
the labial flange. Thus, the operator is free to place the teeth to his wishes. On the other
hand, thin lips rely on the appropriate labiolingual position of the teeth, for their fullness
and support.
Length of the lips: It is an important determinant in anterior teeth selection.
Health of the lips: The lips are examined for fissures, cracks or ulcers at the
corners of the mouth. If present these indicate vitamin B deficiency, candidiasis, or
prolonged overclosure of the mouth due to decreased VD.
TMJ Examination
The joint should be examined for range of movements, pain, muscles of mastication, joint
sounds upon opening and closing.
TMJ plays a major role in the fabrication of a CD. Severe pain in the TMJ indicates increased
or decreased VD.
Neuromuscular Examination
It includes the examination of speech and neuro-muscular coordination.
Speech
Speech is classified based on the ability of the patients to articulate and coordinate it.
Type 1: Normal. Patients who are capable of producing an articulated speech with their
existing dentures can easily accommodate to the new dentures.
Type 2: Affected. Patients who have impaired articulation or coordination of speech
with their existing dentures require special attention during anterior teeth arrangement
(setting).
Patients whose speech was altered due to a poorly-designed denture require more time to adapt
to a proper articulated speech in the new denture.
Neuromuscular coordination
The patient is to be observed from the time he/she enters the clinic. The patient's gait,
coordination of movements, the ease with which he moves and his steadiness are
important points to be considered.
Any deviation from the normal will indicate that the patient is suffering from
neuromuscular diseases like Parkinson's disease, hemiplegia, cerebellar disease or even
the use of psychotropic drugs. These conditions also produce their manifestations on the
face.
Neuromuscular coordination of a patient can be classified as:
Class I: Excellent.
Class II: Fair.
Class III: Poor.
Patients with good neuromuscular coordination can easily learn to manipulate dentures.
B- Intraoral visual Examination
a- Existing Teeth :
The condition of the existing teeth is of importance for single complete dentures. The
state of the remaining teeth influence the success of tooth-supported overdentures.
b- Mucosa
Colour of the mucosa The mucosa should have a healthy pink colour. colour changes
such as white patches or redness should be noted .
White patches may indicate an area of frictional keratosis.
Redness may indicates an inflammatory change. This may be due to ill-fitting denture,
smoking, infection or a systemic disease. Inflamed tissues provide a wrong recording while
making an impression. it may be due to inflammation caused by irritation, which may be due to
mechanical, chemical or bacteriological causes.
Common prosthetic causes:
1- Overextension of the periphery of the denture: this is frequently seen as a bright red line,
which may break down to ulceration if the irritation is continued. It may be due to
overextension of the periphery of new dentures or the altered position of existing dentures due
to alveolar absorption. In some cases this irritation if continued over a long period of time, will
cause a proliferation of the mucous membrane, which is visible as a ridge, flap or series of flaps
(Denture fissuratum).
2- Dirty, ill fitting dentures: the inflammation usually appears as an ill-defined red area, which
varies with the extent of the mucous membrane most constantly in contact with the denture.
3- Continuous wearing of the denture: it may cause a chronic inflammation of the underlying
mucosa.
4- Faulty articulation of teeth (traumatic occlusion): Inflammation may be found on the crest of
the alveolar ridge if the occlusion is too heavy in one particular spot, or on the sides of the ridge
if there is a lateral drag caused by cuspal interference.
5- Traumatic injury: the edentulous mouth frequently sustains injuries to the mucosa from sharp
pieces of food such as crusts or small bones.
6- Small spicules of alveolar bone: sharp edges of both sockets not yet rounded by absorption
frequently cause inflammation of Ire mucosa covering them. Also, small pieces of bone
fractured during the extraction of the teeth ad in the process of being exfoliated may cause
inflammation.
7- Allergy: it is very rare. Most of the cases are due to dirty, ill-fitting dentures.
8- Other causes of color variation:
These are most frequently signs of some general systemic disturbances for which reference
should be made to textbooks on oral pathology, and the only safe rule to follow is never to
proceed with prosthetic work until the cause of color variation has been investigated.
Condition of the mucosa House classified the condition of the mucosa as:
Class I: Healthy mucosa.
Class II: Irritated mucosa.
Class III: Pathologic mucosa.
Thickness of the mucosa The quality of the mucoperiosteum may vary in different parts of the
arch. House classified thickness of the mucosa as:
Class I: Normal uniform density of mucosal tissue (approximately 1 mm thick).
Investing membrane is firm but not tense and forms ideal cushion for denture basal seat.
Class II: It can be of two types:
a. Soft tissues have a thin investing membrane and are highly susceptible to irri-
tation under pressure.
b. Soft tissues have mucous membranes that are twice the normal thickness.
Class III: Soft tissues have excessively thick investing membranes filled with redundant
tissues. This requires tissue treatment
Variations in the thickness of mucosa make it very difficult to equalize the pressure under the
denture and to avoid soreness
Inflammatory Fibrous Hyperplasia (Epulis Fissuratum)
Continued denture wear and irritation leads to inflammatory fibrous hyperpllasiia
(epulliis ffiissurattum).. Therapy - surgical excision
Inflammatory Papillary Hyperplasia
Papillary hyperplasia is secondary to ill-fitting maxillary dentures and is sometimes
complicated by chronic candidiasis. Therapy: Antifungal medications applied topically.
In extreme cases, surgical excision.
c- Saliva
All major salivary gland orifices should be examined for patency. The viscosity of the
saliva should be determined. Saliva can be classified as:
Class I: Normal quality and quantity of saliva. ideal cohesive and adhesive properties
Class II: Excessive saliva. Contains much mucus.
Class III: Xerostomia. Remaining saliva is mucinous.
Thick ropy saliva alters the seat of the denture because of its tendency to accumulate between
the tissue and the denture. Thin serous saliva does not produce such effects.
Xerostomic patients show poor retention and excessive tissue irritation wheras excessive sali-
vation complicates the clinical procedures.
d- Residual Alveolar Ridge
While examining the residual alveolar ridge the arch size, shape, inter-arch space, ridge
contour, ridge relation and ridge parallelism should be noted.
Arch size : Arch size can be classified as follows:
Class I: Large (ideal retention and stability)
Class II: Medium (good retention and stability)
Class III: Small (difficult to achieve good retention and stability)
Arch should be observed for two main reasons:
Denture bearing area increases with arch size and in turn increases the retention.
Discrepancy between the mandibular and maxillary arch sizes can lead to difficulties in
artificial teeth-arrangement and decrease the stability of the denture resting in the smaller one of
the two arches.
Arch form : House classified arch form as:
Class I: Square
Class 11: Tapering
Class III: Ovoid
This plays a role in support of a denture and in tooth selection. Discrepancies between the
maxillary and mandibular arch forms can create problems during teeth setting.
Ridge contour :Ridges should be both inspected and palpated. The ridge should be
palpated for bony spicules which produce pain on palpation.
Ridges can be classified as based on their contour as:
High ridge with flat crest and parallel sides (most ideal)
Flat ridge
Knife-edged ridge
There is another classification for ridge contour. According to that classification, the
maxillary and mandibular ridges are classified separately.
Classification of maxillary ridge contour:
Class I: Square to gently rounded.
Class II: Tapering or 'V shaped.
Class III: flat.
Classification of mandibular ridge contour:
Class I: Inverted 'U' shaped (parallel walls, medium to tall ridge with broad ridge
crest)
Class II: Inverted 'U' shaped (short with flat crest)
Class III: Unfavourable
Inverted W
Short inverted V
Tall, thin inverted V
Undercut (results due to labioversion or linguoversion of the teeth
Ridge relation
Ridge relation is the positional relation of the mandibular ridge to the maxillary ridge" - GPT.
Ridge relation refers to the anterior posterior relationship between the ridges.
Angle classified ridge relationship.
Class I: Normal Class II: Retrognathic Class III: Prognathic
While examining ridge relation, the pattern of resorption of the maxillary and mandibular
arches should be remembered (maxilla resorbs upward and inward while the mandible resorbs
downward and outward).
Ridge parallelism
Ridge parallelism refers to the relative parallelism between the planes of the ridges. The ridges
can be relatively parallel or non-parallel.
Teeth setting is easy in relatively parallel-ridge
Inter-arch space
Inter-arch space The amount of inter-arch space should be measured and recorded.
Inter-arch space can be classified as follows:
Class I: Ideal inter-arch space to accommodate the artificial teeth (Fig. 2.38).
Class II: Excessive inter-arch space (Fig. 2.39).
Class III: Insufficient inter-arch space to accommodate the artificial teeth
Increase in inter-arch space will be due to excessive residual ridge resorption. These patients
will have decreased retention and stability of their dentures.
Decrease in inter-arch space will make teeth-arrangement a difficulty. However, stability of the
denture is increased in these patients due to decrease in leverage forces acting on the denture
e- Ridge Defects
Ridge defects include exostoses and pivots that may pose a problem while fabricating a
complete denture.
f- RedundantTissue
It is common to find flabby tissue covering the crest of the residual ridges. These
movable tissues tend to cause movement of the denture when forces are applied. This
leads to loss of retention.
g- HyperplasticTissues
The most common hyperplastic lesions are epulis fissuratum, papillary hyperplasia of
the mucosa and hyperplastic folds. Treatment for these lesions includes rest, tissue
conditioning and denture adjustments. Surgery is considered if the above mentioned
treatments fail.
h- Hard Palate
The shape of the vault of the palate should be examined.
Hard palates can be classified as:
U-shaped: Ideal for both retention and stability
V-shaped: Retention is less, as the peripheral seal is easily broken
Flat: Reduced resistance to lateral and rotatory
i- Soft Palate and Palatal Throat Form
While examining soft palates, it is important to observe the relationship of the soft palate to
the hard palate. The relationship between the soft palate and the hard palate is called palatal
throat form.
Classification of soft palates
Class I: It is horizontal and demonstrates little muscular movement. In this case
more tissue coverage is possible for posterior palatal seal
Class II: Soft palate makes a 45 angle to the hard palate. Tissue coverage for
posterior palatal seal is less than that of a class I condition (Fig. 2.45).
Class III: Soft palate makes a 70 angle to the hard palate. Tissue coverage for
posterior palatal seal is minimum
It should be observed here that a classIII soft palate is commonly associated with a V-shaped
palatal vault and classI or classII soft palates are associated with a flat palatal vault.
j- Gag Reflex and Palatal Sensitivity
Some patients may have an exaggerated gag reflex, the cause of which can be due to a
systemic disorder, psychological, extraoral, intraoral or iatrogenic factors.
House classified palatal sensitivity as:
Class I: Normal
Class II: Subnormal (Hyposensitive)
Class III: Supernormal (Hypersensitive)
The management of such patients is through clinical, psychological and pharmacological
means. If the patient lacks progress he/she should be referred to a specialized consultant.
k- Bony Undercuts
Bony undercuts do not help in retention, rather they interfere with peripheral seal.
Bony undercuts are seen both in the maxilla and the mandible.
In the maxillary arch, they are found in the anterior region and laterally in the
region of the tuberosities. In the mandibular arch, the area under the mylohyoid
ridge acts as an undercut.
In case of maxillary arch, surgical removal of the undercut is not necessary, providing relief is
enough. In case of the mylohyoid ridge, surgical reduction or repositioning of the mylohyoid
attachment can be done. Bilateral undercuts should be eleminated.
l- Tori
Tori are abnormal bony prominences found in the middle of the palatal vault and on the
lingual side of the mandible in the premolar region.
It is not necessary to remove maxillary tori surgically unless they are very big. On the
other hand, lingual tori are a constant hindrance to complete denture construction and
have to be removed surgically.
In order to prevent injury to the thin mucosa covering the tori, adequate relief should be pro-
vided in that region during complete denture fabrication. Rocking of the denture around the tori
will occur in cases with excessive residual ridge resorption.
m- Muscle and Frenal Attachments
Muscular and frenal attachment should be examined for their position in relation to the
crest of the ridge. In cases with residual ridge resorption, it is common to see the
maxillary labial and lingual frenal attachments close to the crest of the ridge.
These abnormal attachments can produce displacement of the denture during muscular action.
These muscular and frenal attachments should be surgically relocated.
n- Tongue
The tongue should be examined for the following:
o Size: Presence of a large tongue decreases the stability of the denture and it is
hindrance to impression making. Tongue-biting is common after insertion of the
denture. A small tongue does not provide adequate lingual peripheral seal.
o Movement and coordination: Tongue movements and coordination are
important to register a good peripheral tracing. They are also necessary in
maintaining the denture in the mouth during functional activities like speech,
deglutition and mastication, etc.
o- Floor of the Mouth
o The relationship of the floor of the mouth to the crest of the ridge is crucial in
determining the prognosis of the lower complete denture.In some cases, the floor
of the mouth is found near the crest of the ridge, especially in the sublingual and
mylohyoid regions. This decreases the stability and retention of the denture.
o The floor of the mouth can be measured with a William's probe. The patient
should touch his upper lip with the tongue to activate the muscles of the floor of
the mouth.
C- Intraoral Digital Examination
Before starting to explore the mouth with the fingertips the patient should be asked to indicate
immediately if any pain is felt and the cause of such pain must be found. Any area, which is
painful to the pressure of a soft finger, is unlikely to tolerate the pressure of a hard denture.
1- Firmness of the ridge:
Placing a finger on each side of the ridge and applying alternate lateral pressure most
conveniently tests this. Flabby fibrous ridge may be encountered in all parts both of
upper and lower jaws.
2- Regularities of the alveolar ridge:
Alveolar absorption is never uniform and hard nodules, sharp edges, spikes and
irregularities are frequently felt and pain on pressure over these areas is common. The
prosthodontist must at this stage decide whether surgical correction is needed, whether
they will remedy themselves in time in course of normal absorption or whether relief of
the denture alone will be satisfactory.
3- Variations of mucous membrane:
The ideal mucosa on which to seat complete dentures should be:
a- Firmly bound down to the sub-adjacent bone by union with the periosteum, thus
prevent the denture and mucosa moving together in relation to the supporting bone.
b- Slightly compressible: to allow the denture to bed comfortably into place because
the mucosa will adjust itself slightly to the fitting surface of the denture. This will very
materially increase the retention by adhesion and cohesion because the film of saliva
between the denture and the mucous membrane will be very thin. It will also allow
maximum retention from atmospheric pressure because the denture bedding slightly into
the tissue will prevent air leaks. In addition such mucosa will act as a cushion to the
normal stresses of mastication and prevent the development of sore spots
c- Even thickness: Thin mucosa covering a well-defined torus palatinus and flanked by
thick compressible membrane will result in a denture, which rocks during function
causing pain to the patient and frequently fracture of the denture due to the repeated
flexure the base is required to undergo during mastication.
4- Maxillary tuberosities:
There may be found on visual examination to be bulbous and to have a definite undercut
area above them, but only by palpation can it be determined whether the bulbous portion
is composed of hard or soft tissues.
5- Mylohyoid ridges:
Some of these ridges are felt to be pronounced and sharp and others are felt ill-defined
and rounded.
6- Lingual pouch:
The extent of the pouch with the tongue at rest and with the tongue protruded
sufficiently to lick the lips and also during the act of swallowing should be noted. This
is done by gently inserting the index finger into the pouch and asking the patient to
perform the above actions.
Determination of functional depth of alveolingual sulcus
Carefully examine the retromylohyoid space to determine
the floor of mouth posture.
After placing the mirror in the retromylohyoid space,
instruct the patient to move the tongue to opposite side.
The less your mirror is displaced the more favorable the
floor of mouth posture and the longer the distal lingual
flange can/should be.
D- RADIOGRAPHIC EXAMINATION
The radiograph of choice for the examination of a completely edentulous patient is panoramic
radiograph because they image the entire mandible and maxilla.
Considerations During Radiographic examination
The jaws should be screened for retained root fragments, unerupted teeth, rarefaction,
sclerosis, cysts, tumours and TMJ disorders
The amount of ridge resorption should be assessed.
Wical and Swoope devised a method for measuring ridge resorption. According to
them, the distance between the lower border of the mandible and the lower border of
the mental foramen multiplied by three will give the original alveolar ridge crest
height. The lower edge of the mental foramen divides the mandible into upper two-
thirds and lower one-third.
The amount of resorption can be classified as follows:
Class I: (mild resorption) loss of upto one-third of the vertical height.
Class II: (moderate resorption) loss of upto two-thirds of the vertical height
Class III: (severe resorption) loss of more than two-thirds of the vertical height.
The quantity and quality of the bone should be assessed.
Branemark et al classified bone quantity radiographically as Classes A,B,C,D and E .
He classified bone quality radiographically as Classes 1,2,3 and 4 .
X-ray photographs should l be taken to confirm or assist in diagnosis in the following cases:
1- Buried roots.
2- Sinuses.
3- Unilateral swellings.
4- Rough alveolar ridges.
5- Areas painful to pressure.
6- Impacted teeth. Cysts.
E- Examination of the Existing Prosthesis
Extra-oral examination of the dentures
The dentures are removed from the mouth and a detailed and systematic extra-oral
examination is made of their impression, polished and occlusal surfaces. Any relevant
findings are recorded.
Impression surface
The presence or absence of a post-dam and palatal relief.
Width of borders.
The amount and distribution of plaque, an important cause of denture stomatitis . Painting
disclosing solution on the impression surface will help to visualize the plaque.
Evidence of adjustments, relines or repairs.
Surface roughness.
Polished surface
Shape and inclination. In essence, is the shape such that it will allow the muscles to help
rather than hinder the control of the denture?
Condition and general cleanliness of the denture material.
Occlusal surface
Amount of wear; presence of shiny facets.
Teeth acrylic or porcelain; size, shape and colour.
Intra-oral examination of the dentures
Each denture is then placed in the mouth separately and examined for:
Stability
Retention
Border extension.
The dentures are then examined together to assess the:
Occlusion
Occlusal vertical dimension
Appearance.
Additionai Diagnostic Inormaton
Diagnostic casts
They are very helpful to further evaluate the anatomy and condition of the residual ridges.
Generally diagnostic casts are made from preliminary impressions made wii irreversible
hydrocolloid (alginate) in stock trays. Good diagnostic casts should include the retromolar
pads and border tissues as well as the pterygomaxillary notch and the posterior palatal seal
area
Prosthodontic Diagnostic Index (PDI).
Another tool to help the dentist identify' the complexity of their denture patient is called the
Prosthodontic Diagnostic Index (PDI). The American College of Prosthodontists has
recommended that practioners use the PDI to classify edentulous patients. This system is said
to help better identify difficult denture patients.
[For details see: introduction]
2-Prosthodontic assessment
-Clinical factors influencing stability, retention, and support of complete dentures
- Previous denture assessment
3- TREATMENT PLAN
Elimination of Infection
Sources of infection like infected necrotic ulcers, periodontally weak teeth, and
nonvital teeth should be removed. Infective conditions like candidiasis, herpetic
stomatitis, and denture stomatitis should be treated and cured before commencement
of treatment.
Elimination of Pathology
Pathologies like cysts and tumours of the jaws should be removed or treated before
complete denture treatment begins. The patient should be educated about the harmful
effects of these conditions and the need for the removal of these lesions. Some
pathologies may involve the entire bone. In such cases, after surgery, an obturator may
have to be placed along with the complete denture.
Preprosthetic Surgery
Preprosthetic surgical procedures enhance the success of the denture. Some of the common
preprosthetic procedures are:
Labial frenectomy.
Lingual frenectomy.
Excision of denture granulomas.
Excision of flabby tissue.
Reduction of enlarged tuberosity.
Excision of hyperplastic retromolar
pad.
Alveoloplasty.
Alveolectomy
Reduction of genial tubercle.
Reduction of mylohyoid ridge.
Excision of tori.
Vestibuloplasty.
Lowering the mental foramen.
Ridge augmentation procedures.
Implants
Tissue Conditioning
The patient should be requested to stop wearing the previous denture for at least 72
hours before commencing treatment. He/she should be taught to massage the oral
mucosa regularly.
Special procedures should be done in patients who have adverse tissue reactions to the
denture. Denture relining material should be applied on the tissue side of the denture
to avoid denture irritation. Treatment dentures or acrylic templates can be prepared to
carry tissue-conditioning material during the treatment of abused tissues.
Nutritional Counseling
Nutritional counseling is a very important step in the treatment plan of a complete
denture. Patients showing deficiency of particular minerals and vitamins should be
advised a proper balanced diet. Patients with vitamin B2 deficiency will show angular
cheilitis. Prophylactic vitamin A therapy is given for xerostomic patients. Nutritional
counseling is also done for patients showing age-related changes such as osteoporosis.
Following the diagnosis, a treatment plan is formulated. Possible treatment options include:
No treatment.
Preparatory treatment such as denture adjustment or a short-term reline
Definitive denture modifi cations such as reline, rebase, repair or cleaning.
Replacement dentures.
There are several approaches to designing and constructing complete dentures.
Thedentist should make a positive decision at the treatment plan stage as to which is
appropriate for the patient.
(1) Copy dentures. Where dentures have provided satisfactory service for the patient in the
past, it may be advisable to base the design of replacement dentures on the well-accepted
features of the old ones. Although such an approach is particularly appropriate for the
treatment of elderly patients who have a reduced ability to adapt, it can also be of value in a
number of other clinical situations. A potentially accurate method of maintaining the well-
accepted features of existing dentures is to use a copy technique.
(2) Carving record rims. The shape, or design, of the dentures may be determined by the
dentist carving the record rims as described in Chapter 11, so that the upper rim provides
adequate lip support and the lower rim lies in the neutral zone.
(3) Biometric guides. Another approach to design involves the use of biometric guides
measurements from certain anatomical landmarks which allow the denture teeth and base to
be placed in positions similar to those formerly occupied by the natural teeth and alveolar
bone. The desirability of so doing has been a source of controversy for many years but has
received a considerable measure of support. Anatomical guidelines have now been researched
which assist the dentist in trying to achieve this aim.
(4) Functional neutral zone impression. When there are particular problems in achieving
stability of a lower denture for example, if there is abnormal muscular activity or intra-oral
anatomy the dentist can record the neutral zone by getting the patient to mould a soft record
rim into a position of stability between the tongue and cheeks and lips by means of
swallowing and speaking. A lower denture is then produced whose shape is derived from the
neutral zone impression. This clinical technique has been shown to enhance the tongues
retentive ability over a conventional design.
4- PROGNOSIS
It based upon:
Bearing surface anatomy, tongue position and floor of mouth posture
Neuromuscular control
Denture history
Psychological classification
After reviewing the Complete Denture Evaluation, Diagnosis, and Treatment Planning
Form as well as the Prosthodontic Diagnostic Index (PDI) the practitioner should be able
to make some judgment about the prognosis of their patient.
A patient who has a Class 1 antero-posterior ridge relationship, has proper size and
function of the tongue, has normal quality and quantity of saliva, has U-shaped (cross-
section) ridges that approximate the opposing arch, has successfully worn complete
dentures in the past, and is a philosophical patient (PDI I) will have a good prognosis.
A patient who is in very poor health, has a Class II antero-posterior ridge relationship, a
retracted tongue, maxillary posterior bilateral undercuts in need of pre-prosthetic surgery;
ropy saliva, and an indifferent attitude (PDI 1V) will have a poor prognosis.
5- PROSTHODONTIC CARE
The type of prosthesis, denture base material, anatomic palate, tooth material and teeth shade
should be decided as a part of treatment planning. Depending upon the diagnosis made, the
patient can be treated with an appropriate prosthesis. For example:
For a patient with few teeth, which are likely to be extracted an immediate or conventional,
definitive or interim, implant or soft tissue supported dentures can be given.
For a patient who is already edentulous a soft tissue supported or implant supported denture
can be given.
For patients with acquired or congenital deformities, a denture with an obturator can be
given.
COMPLETE DENTURETHEORY AND PRACTICE Impression Trays4
Dr.mostafa.fayad@gmail.com Mostafa Fayad 1
Impression Trays
Impression: a negative likeness or copy in reverse of the surface of an object; an imprint of the
teeth and adjacent structures for use in dentistry
Impression material: any substance or combination of substances used for making an
impression or negative reproduction
Impression tray: a receptacle into which suitable impression material is placed to make a
negative likeness 2: a device that is used to carry, confine, and control impression material while
making an impression 3 a device used to carry the impression material into the mouth,
maintaining it in position during setting, and supporting it during removal from the mouth and
when casting the impression.
A cast or model is a positive reproduction of the form of the tissue of the upper or lower arch,
which is made in an impression.
Preliminary cast: a cast formed from a preliminary impression for use in diagnosis or the
fabrication of an impression tray [Diagnosticcast study cast ]
Preliminary impression: a negative likeness made for the purpose of diagnosis, treatment
planning, or the fabrication of a tray
Final impression: the impression that represents the completion of the registration of the surface
or object 2 An impression made for the purpose of fabricating a prosthesis
Master cast: A replica of the tooth surfaces, residual ridge areas, and/or other parts of the dental
arch and/or facial structures used to fabricate a dental restoration or prosthesis.[working cast
final cast ]
Stock tray: a prefabricated impression tray typically available in various sizes and used
principally for preliminary impressions
Custom tray: an individualized impression tray made from a cast recovered from a preliminary
impression. It is used in making a final impression
Component parts
The tray consists of a body and a handle. The body consists of a floor and flanges. the upper has
a palatal portion while the lower has lingual flanges.
Requirements of impression trays
1- They should be strong and rigid to avoid distortion of the impression on removal.
2- They should be smooth, clean and can be sterilized if they are not disposable .
3- They should confine the impression material and hold it in correct position in the mouth and
cover the whole area of the jaw which is required for the impression.
4- They should allow for equal thickness of impression material over the entire fitting surface.
5- The flanges of the tray must reach the functional position of the sulci and frena but not
displace them.
6- They should provide for mechanical locking of the impression material to the tray through
rim-lock undercut or perforation. Otherwise, adhesives should be used for the elastic impression
materials.
7- The stock trays should be available in different size and shapes.
8- They must be inexpensive.
Types of impression trays
1- Stock trays.
2- Special, individual or custom trays.
3- Bite registration trays: They record the occlusal surfaces of both arches and used to
relate the upper and lower casts in the lab in the same manner as in the patients mouth.
4-Triple tray(double bite tray): It takes an impression of the prepared teeth, opposing
teeth and a bite registration at the same time.
I- Stock Trays
These are ready-made trays available in different shapes and sizes.
Types:
1- Size: Most commonly, they are supplied in small, medium, large and extra large
sizes.
2- The shape of the tray differs according to the case whether it is dentulous, edentulous
or partially edentulous.
For dentulous patients:
The tray has flat floors, high flanges and the handle is in-line with
the floor of the tray. The trays for dentulous patients may be
perforated, rim-lock trays or water-cooled trays. The rim-lock tray is
the tray of choice because it is rigid and it confines the impression
material, helping to force it into all the areas to be included in the impression. Although,
perforated trays are rigid, they dont confine the material as the rim-
lock tray.
For edentulous patients :
The trays having round floor and short flanges to conform the shape
of the ridge. The handleis bent in the form of L-shaped and joined at
right angle to the floor of the tray to clear the lip and allows proper
border moulding in the labial portion of the impression.
For partially-edentulous patients:
In this type, part of the tray has flat floor and high flanges in the
dentulous area and the other part has rounded floor and short flanges
in the edentulous area.
3- Material : The stock trays can be made fromdifferent materials
Metallic as nickel silver, stainless steel, aluminum tin
plastics. The plastic stock trays are usually disposable.
4- Stock trays may be perforated or rim lock for hydrocolloid
impression materials. Non perforated trays are used for
compound. water-cooled trays used for reversible hydrocolloid
impression materials
5- The Border-Lock tray has been developed especially to develop
dynamic pressure when highly fluid materials are used.The
Border-Lock tray has excellent mechanical retention.
Uses:
The stock trays are used for making the preliminary impression. The tray must be selected to
conform nearly the shape and size of the arch. Incorrect selection of the tray results in a distorted
impression.
If a short tray is used the impression material leaves the tissue and will be unsupported. These
impressions give an inaccurate cast and cause discomfort to the patient.
Modification
Some dentists prefer to modify stock trays to improve their fitness.
These modifications include bending the flanges to provide adequate
space for impression material, or cut the flanges to accommodate for
labial or buccal frena or to reduce over extended flanges. Also
modeling plastic may be used to improve adaptation or to prolong the
short flanges.
Problems in using stock trays
The problem in using stock trays is that the impression
material is of various thickness which can lead to distortion
The flow of the impression material cannot be guaranteed to
cover all the areas of the teeth or tissues required
Pressure points can occur when using a stock tray. the patient can experience discomfort
during impression taking due to the large amount of impression material used in the tray.
in order to overcome these problems, special tray should be constructed.
N.B. Many edentulous patients who need a new complete denture are already having old denture.
The old denture may be relined with tissue conditioning material and used to produce primary
cast .
If undercut is present in the fitting surface the cast may produce preferably in silicon putty which
have elasticity to removed from undercut and is rigid enough to allow for fabrication of custom
tray
Construction of primary, study or diagnostic casts:
The study cast is made from the preliminary impression and the working
cast is made from the final impression, and over which denture bases or
other dental restoration may be fabricated.
The impression should not subjected to pressure or tension. Before the
impression is poured the surface of impression is sprinkled with dry plaster then rinsed to
remove any free alginic acid that may be detrimental to surface of stone cast [Geering , Kelsey]
1. The study cast is made by measure powder liquid ratios provided by the manufacturer's
instructions appropriate to the models to be poured (approximately one part water to two
parts plaster). Add powder to water rather than water to
powder.
2. Mix the material thoroughly assuring that all dry stone is
wet, and a smooth mixture with minimal bubbles is
achieved. For best results, vacuum mixing is
recommended. A vibrator set to a medium to low speed should be used when pouring the
impression. High speed vibration will often trap air bubbles in the cast in critical areas.
3. For alginate impressions rinse the impression. All excess water is carefully removed from
the impression by gently blowing with an air pressure hose. However, the impression
material must not be allowed to become dried.
4. Gently vibrate the plaster into the impression and allow it
to set. The stone is carefully and slowly vibrated into the
anatomical areas of the impression in small increments
until the impression is completely filled and borders
covered
5. Do not invert the impression, as this will cause the plaster to flow away from the
impression surface and lose detail.
6. When the plaster has set, prepare a thick mix of plaster to form a base and invert the
impression onto the plaster patty. A base of approximately 15-17 mm (3/4 inch) in height
and slightly wider than the initial pour of the impression is formed. Allow to set for at
least one half hour.
7. Remove the impression tray and alginate and recover the diagnostic cast. In case of
compound impression, the impression with the set plaster is immersed in warm water for
few minutes to soften compound and facilitates removal of cast.
8. Adjust the peripheries of the diagnostic cast using the
model trimmer in preparation for the construction of the
custom tray.
9. Once the base of the cast is properly formed, the sides of
the cast can be trimmed to create land areas approximately
3 mm (1/8 inch) in width in the labial and buccal areas and 6 mm (1/4 inch) posterior to
the retromolar pads and hamular notches. The land areas will be trimmed vertically to
create vestibules no deeper than 3 mm (1/8 inch).
10. The bottom should be trimmed so that the ridge crests are
parallel to the bottom, or bench top, and the thinnest portion
of the base of the cast is approximately 12 mm (1/2 inch)
thick.
Plaster mix is always added to the same area to avoid trapping
of air until the impression is filled. Excess plaster is poured over a glass slab and filled
impression is inverted over it. The border is then smoothed and shaped by the use of spatula.
After setting of the plaster the impression is removed from the plaster cast then the periphery of
the cast is trimmed
Spacer or shim
The Special trays are either made directly on the study cast or made over a shim (spacer)
to provide a room of even thickness in the special tray for the impression material.
The thickness of the shim depends on the impression techniques to be used for taking the
final impression.
Advantages of spacer:
It provides a space of even thickness in the tray for the impression material. Thus;
1- Any dimensional change in the material will be equal throughout the impression.
2- The shape of the tissues may be recorded with minimal displacement.
3- In case of plaster impression, the suitable thickness will help in reassembling the
fractured pieces.
Methods of shim constructions
a- Modeling wax
1-The outline of the denture bearing is penciled on the cast. On the
primary cast the periphery is outlined with an indelible marker. The
outline for wax spacer is drawn on the cast; the edges are usually 2 to 3
mm short of the tray borders
2- The cast is then dusted by talcum powder or immersed in a water for 10
minutes to prevent sticking of the softened wax to it.
3- One or two layers of the modeling wax are adapted evenly on the cast
and are cut down to the denture outline.
The posterior palatal seal area on the maxillary cast is not covered with the wax spacer. Thus the
tray will contact the posterior palatal seal to prevent the final impression material from sliding
down into the pharynx.
b- Molten wax
The outlined cast is immersed in water for few minutes, then the cast is dipped in molten wax
(54.5 C) repeatedly until the desired thickness is built up on the cast. Three dips are usually
sufficient to produce the spacer. The excess wax beyond the outline is trimmed away.
For the maxillary cast, the posterior palatal seal area is left uncovered with the wax spacer.
Thus the tray will contact the posterior palatal seal to prevent the final impression material
from sliding down into the pharynx.
For the mandibular cast, The buccal shelves are left uncovered with the wax spacer. Thus the
tray will contact the mucosa in these regions to place additional pressure when the final
impression is made. Extra wax can be placed over the lingual slopes of the mandibular cast to
provide additional space for the action of the mylohyoid muscles when the final impression is
made.
An asbestos substitute or shellac-base plate may be adapted on the primary cast to the
desired outline and act as shim. With thermoset plastic vinyl sheets special tray a shim is
prepared by placing appropriate thickness of wet paper towels.
The use of stops:
Placing stops in the tray before checking and correcting the borders ensuring a uniform thickness
of about 23 mm of impression material, and stabilizingthe tray during impression taking.
(a) Tray in contact with the mucosa the border appears to be correctly extended. (b) Tray separated from the
mucosa by the impression material tray border under-extended.. Placing stops in the tray before checking and
correcting the borders will overcome this problem,
Basker stated that In the lower tray these stops are placed in incisal region and over the pear-
shaped pads. In the upper tray theyare placed in incisal region and along the line of the post-dam
There are several ways that stops can be produced:
(1) During construction of an acrylic tray in the laboratory.
Windows are cut in the wax spacer at appropriate locations. The
stops are produced by the acrylic dough flowing into these windows
and contacting the model. This is the preferred method of producing
stops as it is accurate and saves chairside time.
For mucostatic impression technique, stops are made by perforating the shim. Four stops (4 mm
squares), two in the anterior and two in the molar regions are usually made. The stops should
touch oral mucosa during impression making and should be lightly scraped later before casting.
(2) At the chairside in mouth. Compound is applied to the tray and tempered in
water to avoid burning the mucosa. tray is then seated in mouth to mould the
compound to the ridge tissues creating required space between tray and mucosa.
(3) At the chairside on the cast. compound is applied to the tray as in (2) above and the tray is
then seated on the dampened cast. it has the advantage over method (2) in that it is easier to
check visually that the tray is centred correctly on the ridge while the stops are being formed.
II- Special trays
The need for special trays
The edentulous ridges show variation of shape, size and contours. In the same patient the
ridge shows different amounts of resorption and irregularities which affect the shape and contour
of the ridge. A stock tray can only fit the ridge in a very arbitrary manner, while a specially
constructed tray permits even thickness of impression material. For this reason the special trays
are used for making the final impression.
Advantages of special tray
It fits the arch more accurately.
It provides even thickness of impression material.
It minimizes tissue displacement and sore spots in the finished denture.
It allows for proper extension of the flanges and facilitates border moulding whichhelps
in better retention of dentures.
The bulk of the impression material is reduced; this is more economic, more comfortable
for patients and gives less distortion of impression by dimensional changes.
Controlled distortion of tissues.
- Muco-static: pertaining to the normal, relaxed condition of mucosal tissues
covering alveolar ridges and denture related surfaces.
- Muco-compressive: pertaining to pressure on mucosal tissues covering
alveolar ridges and denture related surfaces.
Materials used for special trays
A - Metallic special trays
B- Non metallic special trays
1- Acrylic resin
2- Shellac-base plates
3- Thermoset plastic vinyl sheets.
4- Compound impression
5- Old denture
Special trays are either made directly on the primary cast or made over a shim (spacer) prepared
over the cast.
A- Metallic special trays
This type can be used for any impression materials, but it is required only when
compound is to be used.
Types :
1- Swaged : can be made by swaging nickel silver between dies and counter
dies
2- Casted metal may be used in construction of special trays. An alloy of tin and
lead or tin alone may be used for casting special trays.
Swaged or casted metal special trays are not commonly used because the production of these
trays is difficult, time-consuming and expensive.
B- Non metallic special trays
1- Shellac base special trays
Disadvantages of shellac special trays:
1- Low strength.
2-Easily distorted by load and temperature.
3- Improper adaptation to the cast.
2- Acrylic resin special trays
This type of trays is mainly made from self-curing acrylic
resin. It can also be made from heat-curing acrylic resin
and Light-cure resins , but the use of heat-curing resin is
more difficult and time consuming.
Advantages of self-cure acrylic resin special trays:
1- Easier to make.
2- Rigid.
3- Can be easily trimmed.
4- Light in weight.
5- Can accept tracing material without warpage.
Visible light cure (VLC) dimethacrylate resins
Although the material is relatively expensive, require special light-curing unit for processing and
difficult to trim when cured, trays made from this material has sufficient rigidity to be used in
fairly thin section and excellent dimensional stability. VLC resins can be disinfected by
immersing into commonly used disinfectant solution such as 1000 ppm sodium hypochlorite .
This can also be used in patients who are allergic to PMMA resins, because of no residual
polymers in set material.
3- Thermoset plastic vinyl sheets
It is a ready-made sheet used for construction of special trays by
vacuum.
On the stone cast the undercuts are blocked and a shim is
prepared by placing appropriate thickness of wet paper towels.
The cast is placed in its position on the vacuum machine. Vinyl
sheet is inserted in the frame located below the heat source.
Heating should be continued until the sheet is softened and
begins to sag.
The supporting frame carrying the softened sheet is lowered onto
the cast and the vacuum is turned on to adapt the sheet.
The heater is turned off and the base is allowed to cool then
removed and trimmed.
A cold cure acrylic handle can be fabricated.
4- Compound impression
Sometimes compound impressions are used as special trays after
scraping the fitting surfaces and the flanges of the primary
impression to provide space for the impression material.
A scraping of 2mm is sufficient for plaster, 0.5mm for zinc oxide
eugenol ZOE and 3-4 mm plus perforation is required for
alginate.
5- Old denture
The existing denture may be used as a special tray as in case of taking
zinc oxide eugenol ZOE impression for relining or rebasing the denture.
Construction of Shellac base special trays
A shim of 2-3 mm thickness is made to give space for plaster
impression material and a shim of 4-5 mm should be made for
alginates.
Outline the depth of vestibule
Block-Out Undercuts
The upper tray is made by softening an upper base plate over a flame
and adapting it on the shim of the upper cast.
The palatal portion is adapted first and allowed to harden then the
outer portion, one side at a time.
The excess shellac is trimmed by scissors to the drawn outline and
the edge is smoothed with file.
A handle is made by rolling softened piece of shellac and attaching it
to the base of the tray on the anterior area in such a way that avoids distortion of the lip.
The mandibular tray is made by softening a lower base plate and adapting it on the shim of the
lower cast, section by section.
Excess materials are cut and the edges are rolled out to strengthen the tray. The handle is made in
the same manner as the upper tray. The upper and lower trays should be perforated if alginate
impression material is to be used.
Construction of self-curing acrylic special trays
A self-curing special tray may be adapted directly on the cast after
blocking out the undercuts by plaster or wax. It may also be
constructed over a shim depending upon the impression technique
used.
A self-curing resin dough is formed by mixing the polymer and the
monomer. The dough is flattened to a sheet of 2-3 mm thickness.
This sheet is then adapted over the dusted cast or shim and trimmed
to the previously drawn outline.
A resin handle is attached to the anterior region of the tray .
A finger rest is attached to the lower tray. This finger rests are used
to seat the lower impression tray and hold the fingers away from the
periphery to avoid distortion of sulci.
When the resin is cured it is separated from the cast and spacer and the
periphery is rounded and smoothed with stone.
Extension: 2 mm short of the peripheral role
These acrylic resin trays should not be used before 24 hours after fabrication because the resin
may not be dimensionally stable before that time. Visible light-cured resins exhibit dimensional
stability immediately after curing, thus allowing immediate clinical use after fabrication.
[INTERNATIONAL DENTISTRY SA 2009 VOL. 12, NO. 3]
Construction of acrylic special trays with stops for mucostatic impression technique
The construction of this tray is exactly the same as the usual acrylic trays except that For
mucostatic impression technique, stops are made by perforating the shim. Four stops (4 mm
squares), two in the anterior and two in the molar regions are usually made. The stops should
touch the oral mucosa during impression making and should be lightly scraped later before
casting.
Construction of acrylic special trays with occlusion rims for functional impression techniques
- Constructing special trays with occlusion rims facilitates
functional impression made under biting forces.
- The occlusion rims should be designed to facilitate
swallowing and other functional movement used to mold the
impression and must meet evenly to distribute the forces all-
over the denture-supporting area at a suitable vertical
dimension.
- To construct these occlusion rims, the patient is asked to close on a softened (T-shaped)
wax block at the time of obtaining the primary impression. This wax block is used to
mount the primary casts on a simple articulator. The trays are made and the occlusal rims
are attached to them.
Construction of acrylic special trays with relief wax for selective pressure impression
techniques
- the impression tray must be fabricated so that only those areas of the tray that overlie
primary and secondary stress-bearing areas are in physical contact with those tissues
during theimpression procedure. The primary and secondary- stress-bearing areas should
be outlined on the diagnostic castsas an aid to the laboratory technician
- There should be no tray/ tissue contact in those areas that overlie non stress-bearing
tissues.
- Mushroom-shaped non stress-bearing area of the maxillary arch has been outlined.
The relief chamber is created by applying one thickness of baseplate wax over all non
stress-bearing areas of the diagnostic cast prior to fabricating the impression tray, This
wax is commonly called "relief wax."
-
- to allow tray removal from the diagnostic cast, all excessive undercuts
and tissue irregularities present on the diagnostic cast are minimally
relieved or blocked out using a baseplate wax. This is often referred to as
"block out" wax.
Design of custom impression trays IJ MDS www.ijmds.org- 2009;1(1) 29-39
1. Material of choice for making custom trays
2. Optimum extension of customtrays
3. Spacer design and thickness used
4. Tissue Stops
5. Relief holes
6. Tray handles
7. Maturation time
8. Tin Foil
1. Material of choice for making custom trays see previous
2. Optimum extension of custom trays
The periphery of the tray should incorporate all dentures bearing area without
distorting the tissue of the vestibules through over extension.
Marking primary cast with pencil 2 mm short of the vestibule, guides the lab technician
to make optimum extensions of custom impression trays which saves clinicians time.
In partially edentulous situations, the custom impression trays should be kept 3 to 5 mm
away from the gingival margin and about 3 mm beyond the most distal tooth.
In correcting the distal extension of the maxillary custom tray, one important feature to
locate is the vibrating line. Extension of the denture beyond the vibrating line will result
in the denture terminating on excessively movable tissue and often cause lack of retention
or irritation to the tissue. [See anatomical landmark for detail]
A properly shaped mandibular impression tray will most often exhibit the following
three features:
First the labial and lingual flanges in the anterior area
will be approximately the same length unless the
patient has had some type vestibular extension surgical
procedure or severe loss of the residual ridge.
Second, the distal-buccal flange will gradually taper
from the vestibule to the crest of the residual ridge, often
at approximately a 45 to 60 angle, and continuously flow
into the retromylohyoid area, The longest part of the tray
should be just lingual to the crest of the ridge with a
smooth curvature mimicking the shape of the
retromylohyoid curtain.
Lastly, the lingual flange will begin at the level of the
labial fiange in the anterior area and gradually become
longer than the buccal flange as it approaches the
retromylohyoid area. It generally exhibits a smooth
continuous form, not an irregular shape, as it progresses
from the anterior to the posterior.
3. Relief design and thickness used:
Thickness of wax spacer for complete and partially edentulous situations is 1 mm and
2-3 mm respectively. Wax spacer thickness may vary according to load bearing
capacity of the tissue and attachment of soft tissue with periosteum. Presence of
flabby and mobile tissue over the ridges demands for extra thickness of spacer to
allow their undistorted recording in the impressions.
The design of custom trays for complete dentures depends upon choice of impression
material and technique to be used.
Mucocompressive technique is used for making primary impression of edentulous
arches and thus does not require any spacer.
Mucostatic technique require full spacer with 2 to 4 tissue stops with in custom
trays, thus allowing wash impression material (ZOE paste) to record tissue details
under minimum pressure as recording of tissues under no-pressure is not practically
possible. This technique does not demand for border extension into vestibules, thus
border molding was not suggested. Thus custom trays with borders app. 2 mm short
of vestibules are recommended here.
A variant of mucostatic technique can be used in cases with very prominent mid palatine
raphae, excessively flabby and knife edge ridges by making recess within custom trays in
appropriate areas and recording them with very light viscosity impression materials such as
impression plaster, ZOE and light body addition silicone.
The spacer design for the selective pressure is directly governed by the knowledge of
the stress bearing and relief areas.
o The stress bearing areas in the maxillary arch are the horizontal plates of the
palatine bone and the relieving areas are mid-palatine raphae and the incisive
papilla.
o For mandible, the primary stress bearing area is buccal-shelf area and
relieving area is sharp mylohyoid ridge and crest of alveolar ridge.
Theviews of different authors on how to achieve selective pressure impression
Author Spacer Tissue stops
RoyMac Gregor Metal foil spacer in incisive papilla and mid palatine raphe
Neill 0.9mm casting wax full spacer/relief except PPS.
Sharry Base plate wax spacer all area
including PPS
4 tissue stops,
2 mm wide in molar and cuspid region,
extended from
Palatal aspect to mucobuccal fold.
Bouchers 1 mm base plate wax spacer except PPS in maxilla,
In mandible buccal shelf area and retro molar pad.
Morrow, Rudd, rhoads Full wax spacer 2mm short of borders 3 tissue stops,
4x4mm equidistance from each other
Barnard Levin 1 layer of pink base plate wax about 2mm thick all over theridges except PPS and
buccal shelf area.
4) Tissue Stops:
Placement of four tissue stops of 2mm width in cuspid and molar regions which
extends from palatal aspect of ridge to the muco buccal fold are usually
recommended in completely edentulous cases.
In situations requiring fixed partial dentures, tissue stops are placed on widely
separated three or four non-functional cusps of teeth which do not require
preparation (buccal of maxillary and lingual of mandibular).
If all teeth are involved a large soft tissue stop can be placed on the crest of the
alveolar ridge or in the centre of the hard palate.
Tissue stops are made by removing wax at an angle of 45
0
to the occlusal surface of three
or four teeth that have a tripod or quadrangular arrangement in the arch. This provide stability to
the tray and the 45
0
angulated stops will help centre the tray during insertion
5) Relief holes:
After removing wax spacer from inside of the tray, a series of holes are prepared,
about 12.5 mm apart in the center of alveolar groove and the retro molar fossa with
a no. 6 round bur.
The relief holes provide escape way for the final wash impression material and
relieve pressure over crest of the residual ridge and the retro molar pads when the
final impression is made.
Relief holes are of no importance in partially edentulous situations as neither relief
nor adhesion between impression material and custom tray is provided. For good
adhesion between impression material and custom trays, use of tray adhesives
should be encouraged.
6) Tray handles:
Tray handles are useful in loading, orienting and placing custom impression trays in
the patient mouth. Tray handles if not properly made or placed can cause potential
inaccuracy in complete denture as they distort the lip form and hence the functional
sulcus resulting into overextended borders.
The handle should be 25 mm long from the edge of the labial border of tray. The
handle is positioned in the approximate position of the upper anterior teeth so that it
doesnt distort the upper lip when the tray is in position.
For mandibular custom trays, the anterior handle should be 25 mm long from the
edge of the labial border to the top and 12 mm wide. A handle made this way
enables the clinician to securely grasp the tray without any interference with the
tongue and lips.
Two additional handles, one on each side are placed in the first molar region. These
handles are centered over the crest of the residual ridge at its lowest point and are
approximately 19 mm in height. The posterior handles are used as finger rests to
complete the placement of the tray on the residual ridges and to stabilize the tray on
the correct position with minimal distortion of soft tissue while the final impression
material sets.
One anterior handle and one or two posterior handles are required for partially
edentulous situation with unilateral and bilateral distal extension bases respectively
7) Maturation time:
Maturation time is the time interval between fabrication of custom trays and using it
for making final impression. This is characterized by polymerization of residual
monomer resulting into polymerization shrinkage which exerts significant effect
upon the linear dimensional accuracy of master cast.
All custom tray materials show linear dimensional changes up to 9 hours, but
maximum shrinkage occurred up to 30 minutes after tray fabrication. Thus custom
trays should be used after 9 hr of fabrication.
If clinical situation demand early use, than custom tray seated over the casts should be
placed in boiling water for 5 minutes and then cooled to room temperature. In complete dentures
there is no significance of maturation time, thus clinicians can use the custom impression tray
immediately after fabrication.
8) Tin Foil:
Tin foil should be placed over wax to prevent conduction of heat from resin to wax
spacer preventing wax spacer from melting. It also allows easy and clean removal of
wax spacer from tray
Boxing-in the impression and making the casts:
Impression : An impression is a negative reproduction of the tissue of the upper and lower
jaw, made in a tray using impression material. An impression is made to reproduce a positive
form of the shape of the same oral tissue (cast or model).
Cast: It is used as to describe an accurate, positive reproduction of the maxillary or
mandibular dental arch, which is made in an impression, and over which denture bases or
other dental restorations may be made. in which case a descriptive to gives a more specific
meaning, such as: Diagnostic cast, Master cast, Duplicating cast, Refractory cast and altered
cast.
Model: It is a reproduction for demonstration or display purposes; accuracy is in no way
implied.
Boxing of impression
Boxing-in an impression is the process of building up vertical walls around the final
impression to produce the desired size and form of the base of model, preserve certain
details of the impression and to keep the stone mix during vibration.
Beading: the purpose of beading impressions is to define the impression surfaces and also
to aid in supporting the impressions during pouring. The impression surface is defined by
creating shoulders outside the impressed tissue surfaces of the impression. beading is
often done with a rope-type wax, Play-doh or a mixture of stone and pumice
Advantages of boxing
1-The borders of impression are preserved.
2-The thickness of the model can be controlled.
3-Since all the mixed stone can be vibrated, the model will contain fewer air bubbles and
a stronger model will be produced.
4-It is time saving, because trimming may not be required.
5-Material is economized.
Methods of Boxing:
I- Wax Boxing Method:
1- On the maxillary impression:
A strip of square beading wax 5mm wide is placed around the
periphery buccal and labial and luted at the non-critical edge (about
2 mm from the impression border) and parallel to it. The beading wax
should not be extended across the posterior border of the
impression.
2- On the mandibular impression
A strip of square beading wax is placed around the entire periphery
buccal, labial and lingual and luted at the non critical edges of the
impression.
The tongue space in the lower impression is blocked with wax before
boxing. This wax is attached to the impression at the level of the lingual
beading wax to provide aflat lingual shelf in the master cast just below
the lingual border on both sides.
3- A sidewall is then wrapped around each impression to contact the
beading wax to form a cylinder. The vertical walls of the boxing are
made of sheets of bees-wax. This wall should extend inch (10 to 15
mm ) above the impression and mainly made of boxing wax or base plate
wax. The end of the wax walls is joined together with hot spatula.
A lead sheet or cardboard may be used to make the wall and attached to the carding wax by
means of rubber band.
Wax boxing procedures cannot be used on impression made in hydrocolloid material because the
material will not adhere to the impression or because the impression will be distorted.
2- Boxing-in the impression with Plaster of Paris and Pumice:
The beading wax does not adhere to alginate and rubber base impression
materials, so the plaster & pumice boxing mix is used:
A mix of half plaster and half pumice is made, poured on glass slab and
smoothed by spatula.
The tray is placed with the under surface over the mix. The material is
raised by the spatula to a height of 3-4mm below the border of the
impression and of 5mm thick.
The mix around the impression is allowed to set and then it is removed
from the slab and trimmed to the desired height and width.
Boxing wax is adapted to the impression to be 1cm above the borders
and sealed to the outer surface of the mix. The exposed surface of the
plaster and pumice is painted with separating medium.
Thin a mix of stone is vibrated into the impression.
3- Boxing-in the impression with Play-doh:
The Play-doh should be built up approximately 75 cm in height and
extended at least 3 mm beyond ail border of the impression. This will
support the impression and provide for a proper land area on the master
cast.
The material will be boxed with two pieces of red boxing wax. They
should be joined together with the tape. Approximately 7.5 cm of tape is
left extended beyond the wax on one end.
To allow for sufficient thickness of stone, the boxing wax chimney
should extend 16 to 18 mm above the highest surface of the
impression (usually a flange).
Pouring the cast
The stone is mixed carefully according to the manufacturers instruction and placed in
small quantities into the boxed impression. The stone should be carefully vibrated
after each pouring to avoid trapping air bubbles.
The stone is allowed to set for 30-45 minutes, then the wax strap is removed and the
model is carefully separated from the impression.
Plaster of Paris is usually used for casting the preliminary impression, and the final impression
should be cast into dental stone.
Treatment of final casts
Each cast must be carefully examined and the necessary correction should be done. These
corrections include:
1- Removal of any nodules on the surface of the cast that
resulted from trapping of air bubbles in the impression surface.
2- Filling of any voids that found on the surface as a result of
trapping air bubbles in the dental stone.
3- Trimming the cast to provide adequate access to the border
reflections. In the posterior areas, the final cast is trimmed so
that the integrity of the essential contours and dimensions of the border reflections are
maintained. Incorrect trimming of this area will ultimately have an adverse effect on the
retention of the denture.
4- In the anterior portion only a slight amount of the area beyond the greatest depth of the
reflection must be maintained. The thickness of the denture base in this area can be more
accurately determined clinically.
5- Block out of undercuts with a suitable plastic material as wax,
modeling clay or white asbestos. This procedure permits removal
and replacement of the bases and prevents scoring, abrading or breaking the surface of the cast.
6- Positive defects (bubbles), if any, must be in non-vital areas and small enough to be easily
removed (1-mm diameter or less as a guide).
7-Negative defects (voids), if any, should be small and in non-critical areas. These should be
filled with stone to blend with the surrounding anatomy.
Master cast criteria
Acceptable master casts should be of the proper thickness, bubble and void free, and include an
accurate representation of all impressed tissue surfaces and surrounding finished borders, often
called land areas.
1- The master cast must include all anatomical surfaces in the final impression
2- Base thickness must be 1/2-inch (13 mm) minimum for strength. This is measured from the
deepest part of the palate on the upper or the "floor of the mouth" on the lower.
3-After trimming, the base of the model must be parallel to the residual ridge.
4-The base must be indexed for mounting and remounting. Place rounded notches
(indexes) onthe bottom of the master cast. Thesenotches index the casts and will later
be used to remount the processed dentures back onto the articulator mountings. The
notches should be placed on the back and on the sides of the casts.
5-The depth of the buccal sulcus is approximately 2-mm below the land area.
6-Land Area = 4mm Wide. At least 3mm in thickness to prevent fracture and loss of
vestibular contours during denture fabrication
Diagramatic view of desired dimensions of a trimmed diagnostic or master cast.
X: thickness of cast (12-18 mm in thinnest area).
Y: width of land area (2-3 mm).
Z: depth of vestibules (2-3 mm).
Indexing and Mounting Master Casts
Prepare four small remount indices into the bottom of the base of the cast. A
medium-sized acrylic resin bur can be use.
Broad buccal frenum
Land area too high - makes
trimming of acrylic and
removal fromcast dif ficult
Lateral view, Mandibular Tray Anterior view, Maxillary Tray
Base of Cast
Narrow notch
for labial frenum
Land area too high - makes
trimmingof acrylicandremoval
fromcast difficult
Auxillary handle
COMPLETE DENTURE THEORY AND PRACTICE IMPRESSION MAKING4
IMPRESSION MAKING IN COMPLETE DENTURE
Developing an analogue\ substitute for denture bearing area
Ideal impression must be in the mind of the dentist before it is in his hand. He must literally
make the impression rather than take it - M.M. Devan
The impression procedure is a means of recording the detail of the basal seat area so that a
stone replica can be poured .The impression should cover the maximum possible area without
interfering with normal muscle movements.
The Objectives of an Impression Are to Provide:-
1- Preservation of the remaining residual alveolar ridge: - The impression technique and
impression material have an effect on the accuracy of denture base, which has an effect
on the continued health of both the soft and hard tissues of the jaws. Patients with
special cases need some precautions during impression making to prevent tissue
damage.
2- Support: - maximum coverage distributes applied forces over as wide an area as
possible.
3- Stability close adaptation to the undistorted mucosa is most important for stability of the
denture to resist horizontal movement. Stability decreases with the loss of the vertical
height of the ridges or with the increase in flabby, movable tissue.
4- Esthetic: - border thickness should be varied with the needs of each patient in
accordance with the extent of the residual ridge loss. Impression should perfectly
reproduce the width and height of the entire sulcus for the proper fabrication of the
flanges.
5- Retention: - it should be readily seen that if the other objectives are achieved, retention
will be adequate. [see retention]

Requirements for an impression:
1- The tissues of the mouth must be healthy.
2- Proper space for selected impression material should be provided within the tray.
3- A physiological type of border-molding procedure should be performed.
4- The border must be in harmony with the anatomical limitations of the oral structures.
5- The impression should extend to include all of the supporting and limiting tissues.
6- The impression must be removed from the mouth without damage to the mucousa.
7- The tray and the impression material should be made of dimensionally stable materials.
8- The external shape of the impression must be similar to the external form of denture.
BIOLOGIC CONSIDERATIONS FOR MAXILLARY IMPRESSIONS
The anatomy of the supporting and limiting structures must be understood for:
1. The selective placement of forces by denture bases on supporting tissues
2. The form of the denture borders that will be harmonious with normal function of limiting
structures around them.
3. The fibrous band running along the residual ridge is the vestige of the palatal gingivae
and, like the incisive papilla, remains relatively constant in position during the remodeling of
the ridge which follows extraction of the natural teeth. These two structures can therefore be
used as landmarks allowing teeth on complete dentures to be placed in positions similar to
those of their natural predecessors. This biometric approach requires specific design features
to be incorporated into the impression trays
The anatomical landmarks in the maxilla are:
Supporting Structures:
Relief areas
Diagram of the upper arch showing average distances from the palatal gingival vestige of the furthest
horizontal extent of the denture flange in the incisal (A), canine (B), premolar (C) and molar (D) regions (the
biometric approach). The line (XX) passing through the posterior border of the incisive papilla can be used as a
guide to positioning the tips of the canines.
Buccal anatomical relations of the upper denture
BIOLOGIC CONSIDERATIONS FOR MANDIBULAR IMPRESSIONS
The considerations for the mandibular impressions are generally similar to that for those of
maxillary impressions and yet there are many differences owing to the following facts:
The basal seat of mandible is different in size and form from the maxillary
counterpart.
The submucosa in some parts of mandibular basal seat contains anatomic
structures different from those in the upper jaw.
The nature of the supporting bone on the crest of residual ridge usually differs
between the two jaws.
The presence of the tongue complicates the impression procedures.
The available area of support from an edentulous mandible is 14 cm
2
while the
same for the edentulous maxilla is 24cm
2
.
The supporting and the peripheral sealing areas will be in contact with the
dentures fitting or impression areas. The support for the mandibular denture is
derived from the body of
mandible.
The anatomical landmarks in the mandible are:
Supporting Structures:
Relief areas:
Anatomy of the sulcus tissues
Anatomical relations of the lower denture.
Impression can be classified as :
1. depending on the theories of impression making:
a. mucostatic/passive impression.
b. Mucocompressive/functional impression
c. Selective pressure impression.
2. depending on the technique:
a. open mouth technique
b. closed- mouth technique
3.Based on the method of manipulation for border molding.
1. Hand manipulation 2. Functional movements
4. Depending of the type of tray:
a. stock tray impression
b. custom tray impression
5. depending on the purpose of the impression :
a. diagnostic impression
b. primary impression
c. secondary impression
6. depending on the material used:
a. reversible hydrocolloid impression
b. irreversible hydrocolloid impression
c. modeling plastic impression
d. plaster impression
e. wax impression
f. silicone impression
g. Thiokol rubber impression.
Preparation of the Mouth
The oral tissues should be healthy before impressions are made. Any distortion or inflammation
of the denture foundation tissues must be eliminated before the impressions are made as the
following:-
1- patients should leave their dentures out of the mouth for 48 hours prior to impressioning. If
the patient inserts a denture for even five minutes the tissues may be quickly distorted, and
proper tissue recovery may require two or more additional hours of not wearing the
denture. Therefore patient should not "just wear their dentures into the dentist's office."
2- For patients who are wearing complete dentures requiring refabrication, ensure soft tissue
health by serially relining with a 10- to 14-day period of conditioning with soft acrylic
resin every 3 to 4 days.
3- Oral Physiotherapy
4- Anti-microbial agents
5- Surgical removal of abused tissues
Preliminary (primary) Impressions
A preliminary impression is an impression made for the purpose of diagnosis or for the
construction of a tray
1- The Position of the Patient:-
For most prosthetic operations the dental chair is set in the upright
position. When the patient is seated the chair should be adjusted so that the
head and neck, are in line with the trunk.
If the head is allowed to bend backwards from the neck the supra and
infrahyoid muscles will be tense and difficulty in swallowing will result, also should a fragment
of impression material break away from the main impression, it can more easily fall into the
throat and possibly cause obstruction in the airway.
A suitable covering in the form of apron or large towel should be provided to protect the
patient's clothing and also, a warm, flavored mouth wash with which remaining fragments of
impression can be rinsed away on instruction from the operator.
Position of the operator for maxillary impression
o When making a mandibular impression, the operator
should be standing between the 9 oclock and 12 oclock
position - The patients upper jaw should be
approximately between the level of the operators elbow
and shoulder
Position of the operator for mandibular impression
o When making a mandibular impression, the operator
should be standing between the 6 oclock and 9 oclock
position. - The operators elbow should be approximately
level with the patients lower jaw
2- Selection of the Stock Tray:-
The alveolar ridges and palate are examined for shape and size, and
from a selection of previously sterilized stock trays a suitable upper
and lower ones are chosen and tested in the mouth for their
approximation to the oral structures.
Stock Tray Selection:
1. According to impression materials:
1. Compound : solid tray
2. Alginate : perforated tray
3. Agar agar : water coolant tray
2. According to patient mouth:
Based on size of the arch select the tray size which must be large enough to cover
all supporting areas and seal areas with about 2 mm space and shorter about 5 mm
from the full depth of the sulcus.
3. According to presence of teeth
For dentulous patients: The tray has flat floors, high flanges and the handle is in-
line with the floor of the tray.
For edentulous patients : The trays having round floor and short flanges to
conform the shape of the ridge. The handle is bent in the form of L-shaped and
joined at right angle to the floor of the tray to clear the lip.
For partially-edentulous patients: part of the tray has flat floor and high flanges
in the dentulous area and the other part has rounded floor and short flanges.
It may be necessary to bend the tray slightly with pliers to provide adequate
space and in others to cut and trim the flange to accommodate frena and prevent
pressure on bony structures such as the zygomatic process of the maxilla.
Shortness in the flanges can be corrected by the addition of a little
warmed composition, or wax attached to the flanges of the dried tray. The
corrected tray is reinserted in the mouth and the periphery is moulded.
If the tray is too large, this will:-
1- Distort the tissues around the borders of the impression.
2- Pull the soft tissues under the impression away from the bone.
3- Distort the dimensions of the sulcus.
If it is too small:- The border tissue will collapse inward onto the residual
ridge.
3- The Preliminary Impression:-
Impression materials generally used for preliminary impression:
1- Impression compound.
2- Irreversible hydrocolloid (alginate).
I- Impression compound
The composition is heated in a water bath at 55 to 70
o
C. Since the
material has a low thermal conductivity, it must be immersed in the water
bath for sufficient time to ensure complete softening. The composition is,
then, removed from the water bath and kneaded, the composition is placed
in the tray and placed into the mouth and the patient is asked to do
functional movements.
The tray is held in place for one minute or two, removed and
chilled thoroughly in cold water. In general, composition is not considered as an accurate
impression material and it should never be reused because of fear of cross infection.
The surface of the compound can be lightly flamed to improve its fl ow, tempered in
warm water and coated with petroleum jelly
In case of the maxillary impression; the material is formed into a ball, dried and loaded
in the center of the palate of the tray after warming it over a flame.
Then spread the compound over the tray and shaping it roughly like
arch.
In case of mandibular impression; the material is formed into a
roll, dried and loaded in the tray after warming it over a flame. Then
spread the compound over the tray and shaping it roughly like arch
Advantages of compound impression::
1- Addition and correction can be done.
2- Ease of manipulation.
3- Well tolerated by the patients.
4- Accuracy is not essential for primary impressions
II - The alginate wash impression (Prosth ttt of Edentulous Patient& HAYAKAWA)
When the dentist might require a more accurate picture of the mucosa so
that the potential denture-bearing area can be visualised more easily. This
can be achieved by refining the initial compound impression with a wash
impression in alginate as follows:
Obtain the best possible impression in compound and dry it thoroughly.
Trim back the borders and the fitting surface of the impression by 12 mm
with a sharp knife.
Apply a thin layer of alginate adhesive to the impression surface.
Load the compound impression with a small amount of low viscosity
alginate, seat it fully on the tissues and complete border trimming as before.
III- the alginate impression
The alginate impression material can be used as a preliminary and final impression material.
Indications for its use in completely edentulous cases:
1- Some authors recommend the use of alginate for all
completely edentulous cases.
2- Severe undercuts.
Contra-indications:
1- Nausea to the patient.
2- Flat ridges.
Advantages:
1-Alginate produces excellent surface detail.
2-It is elastic and can be withdrawn over undercuts.
Disadvantages:
1- It cannot be added to if faulty.
2-Dimensional instability:
a-Even in the humidor, imbibition may take place.
b-The stresses induced in the material are released slowly, and the sooner it is
cast, the less the stresses will have been released and so the less it will have
warped.
3- The alginates will not adhere to the tray of their own accord. Attachment of the
alginate to the tray is essential because if it pulls away a distorted impression will result
which may easily pass unnoticed since the detail of the surface will remain unchanged.
Some properties of alginate impression material
1- Compatibility with gypsum:
A- Saliva and blood interfere with the setting of gypsum during impression pouring, and
if free water accumulates, it tends to collect in the deeper parts of the impression and
dilute the model material, yielding a soft, chalky surface.
B- lf the alginate impression is stored for a half hour or more before preparing the model,
it should be rinsed with cool water to remove any exudate on the surface caused by
syneresis of the alginate gel because it will retard the setting of gypsum.
C- The set gypsum model should not remain in contact with the alginate impression for
periods of several hours because contact of the slightly soluble calcium sulfate dihydrate
with the alginate gel containing a great deal of water is detrimental to the surface quality
of the model.
2- Disinfection
The effect of disinfection in 1% sodium hypochlorite or 2% potentiated glutaraldehyde
solutions on accuracy and surface quality has measured after 10- to 30-minute
immersion.
the changes were 0.1%, and the quality of the surface was not impaired. Such changes
would be insignificant for clinical applications.
3- Adherence to the tray
Fixation may be effected by one of the following methods:
1- Small holes may be bored in the tray through which some of the
alginate will flow securing the impression firmly to the tray.
2- Ready made adhesive solutions or spray can be applied to the inside
of the tray.
3- Rim lock tray.
Time should be allowed after application of the adhesive for it to become tacky, a
process which can be speeded up considerably by dispersing the adhesive over the surface
of the tray with a stream of air from a triple syringe.
A thin layer of adhesive is applied to the internal surface of the tray and should extend
several millimeters beyond the borders of the tray. The adhesive is allowed to dry for at
least 15 minutes prior to the impression procedure.
Also, it is important to remember that each adhesive is specific to the impression
material (ie, a polysulfide adhesive can not be used with an addition silicone impression
material)
Impression procedure
The lower impression is usually taken first as it is easier for the patient to tolerate
than the upper. When the impression is seated in the mouth the patient is asked to
raise the tongue to contact the upper lip and to sweep the tongue to touch each
cheek in turn before returning to maintain contact with the upper lip until the
alginate has set.
Buccal and labial border moulding is achieved by firm stretching of the relaxed
lips and cheeks with the fingers.
Precautions for alginate impression:
When alginate is used as an impression material the following points
should be observed in order to obtain the best results:
1-The clearance between the tray and the model should be approximately 4-
5 mm. The extension of the border of the tray is corrected by compound, if
underextended. Also, the palatal portion of the try is build by compound in
case of high palatal vault.
2-The container of powder should be shaken before use to get an even
distribution of constituents.
3-The powder and water should be measured, as directed by the manufacturer.
4-Room temperature water is usually used, slower or faster setting time can be achieved, if
required, by using cooler or warmer water, respectively.
5-There should be vigorous mixing-by spreading the material against the side of the bowl-for the
spatulated time, usually one minute.
6- Prior to inserting the impression tray, the patient should be asked to
swallow to eliminate excess saliva. Impression material should be
placed, by finger, into any areas that the clinician feels may not be
adequately reached by the impression tray. These areas often include
the palatal vault, retromylohyoid spaces, and/or buccal vestibules.
If the sulci buccal to the maxillary tuberosities are deep, air may be trapped as the loaded
impression tray is inserted. To overcome this problem, these areas can be prepacked with
alginate before seating the tray.
The labial and buccal vestibules can be molded by asking the patient to suck down onto
the tray. in addition , the patient should be asked to move the mandible from side to side then
open widely
During setting of the material it is important that the impression should not be moved. The
reaction is faster at higher temperature, and so the material in contact with the tissues sets first.
Any pressure on the gel due to movement of the tray will set up stresses within the material,
which will distort the alginate after its removal from the mouth.
7-An alginate impression, when sets, develops a very effective peripheral seal so before trying to
remove it from the mouth this seal should be freed by running the finger round the periphery.
8-An alginate impression should be displaced sharply from the tissues this sudden displacement
ensures the best elastic behavior. A gentle, long continued, pull will frequently causes the
alginate to tear or pull away from the tray.
9-On removal from the mouth, the impression should be washed with cold water to remove
saliva, covered with a damp napkin to prevent syneresis, and cast up as soon as possible,
preferably not more than 10 minutes after making the impression
10-An alginate impression is particularly susceptible to dimensional change developing as a
result of an increase or decrease in its water content. These two processes are:
imbibition the absorption of water
syneresis the loss of water..
Determination of the borders of the custom tray:-
Two choices are available. Either the periphery of
impresion is outlined with a disposable indelible marker at
the chairside (the preferred option), or arbitrarily marked on
the poured cast in the laboratory.
The completed impression should be observed next to the patient's mouth and the junction of the
attached and unattached mucosal tissue visually identified on the border of the impression.
Construction of primary, study or diagnostic casts:
See IMPRESSION TRAYS
N.B. Many edentulous patients who need a new complete denture are already having old denture.
The old denture may be relined with tissue conditioning material and used to produce primary
cast .
If undercut is present in the fitting surface the cast may produce preferably in silicon putty which
have elasticity to removed from undercut and is rigid enough to allow for fabrication of custom
tray
The laboratory prescription
After the preliminary impressions have been obtained the following information should normally
be entered on the laboratory prescription by the dentist:
(1) Confirmation that all items sent from the clinic to the laboratory have been disinfected.
(2) Materials to be used for the special trays.
(3) Details of the design of the special trays including:
Spaced or close fitting
Size and location of any stops to be pre-formed in spaced special trays
Perforated or not
Type of handle and any finger rests
Any special requirements, e.g. a special tray for a flabby ridge.
(4) The written prescription can be supplemented by the dentist marking the required extension
of the special trays on the preliminary impressions with an indelible pencil if the impression is in
alginate, or with the tip of a wax knife if the impression is in impression compound.
The Final Impression
(The Secondary or Working Impression)
The preliminary impressions are cast into plaster of Paris. Special trays are then constructed on
the plaster of Paris models to make the final impressions.
Theories of Final Impressions:- Journal of Prosthodontics 18 (2009) 97105
A- Minimal pressure impression technique (mucostatic impressions or open mouth
impression, PASSIVE IMPRESSION)
In 1938 Harry.L.Page introduced the mucostatic concept. Other consider it was proposed
by Richardson and later popularised by Harry Page.
. Mucostatic impression technique is one in which the soft tissues are in no way compressed or
distorted and therefore the impression material must flow readily; and impose no pressure on the
mucosa.
Plaster of Paris is the only true mucostatic impression material though the hydrocolloids
often give equally good clinical results.
Mucostatic impressions were based on the use of recording materials that duplicated the
tissues in a passive state. The borders of the dentures were also confined to only the stress-
bearing mucosal areas, and were not refined to make a border seal.
The mucostatic technique results in a denture, which is closely adapted to the mucosa of
the denture-bearing area but has poor peripheral seal.
The choices of impression material in these cases were thin zinc oxide eugenol pastes
that accurately recorded the denture-bearing areas.
Trays constructed for this technique require a spacer with stops and one or two holes to
allow escape of the material. These combined features can reduce the pressures by almost half
what is encountered without these features
Requirements:
1. Fluid impression materials are used to record the supporting area without distortion and
pressure.
2. Rigid special tray with perforation and/or spaced with definite stoppers.
3. The ideal impression material is plaster of paries but zinc-oxide can be used also in
addition to alginate impression material.
4. Used open mouth technique.
Advantages:
1- The operator can see and insure proper border molding and muscle movements are more
easily accomplished.
2- There is less distortion to the mucosa.
3- It is the technique of choice for flabby and thin wiry ridges.
Disadvantages
1- The mucosal topography is not static over a 24-hour period.
2- It neglects the principle of distributing masticatory forces over the largest possible basal
seat area.
3- REALEF concept of Hanau is exaggerated when using this technique which affect
denture retention and occlusion.
Material
I- Plaster of Paris
II- The alginate impression
III- The zinc oxide-eugenol paste
IV- Rubber base impressions (elastomers)
B- Definitive pressure (mucofunctional or compression impressions,Closed mouth
impression technique)
Given by Carole Jones Functional impression technique is one in which the soft tissues are
under biting force while the impression material sets. The impression material most commonly
used for this technique is zinc oxide and eugenol paste. Trays require occlusion blocks set at the
required vertical dimension.
It uses patients musculature in stabilizing a record base or occlusion
rim. This philosophy was introduced in the early 1900s and often used
wax, modeling plastic compound, or more recently, tissue conditioning
material.
To properly use the closed-mouth technique, well-fitting record bases, accurately occluding
rims, and an acceptable vertical dimension is needed.
Construct custom trays with compound occlusion rims.The blocks are tried in and the
periphery adjusted so that there is no overextension.
The bases are dried and zinc oxide-eugenol impression paste is used to coat the fitting
surface.
The lower is inserted first and muscle trimmed lingually.
The upper is inserted and the patient instructed to closer into centric occlusion. Fairly firm
pressure is maintained for 3 to 4 minutes whilst the material is setting. During this time the
patient is encouraged to swallow several times; to muscle trim the postero-lingual area.
The impressions are removed.
This technique may also be used for reline impressions of existing complete dentures and
may be used with a linear or a branched denture construction technique.
A linear technique is well understood and commences with recording of the tissues with
impressions, recording centric position and eccentric pathways, trial tooth arrangements, and
insertion procedures.
A branched technique includes the use of a diagnostic prosthesis to accommodate for
tongue thrusting habits, maxillomandibular discrepancies and other scenarios that create
difficulties in obtaining comfort and function with complete dentures. This diagnostic prosthesis
aids in making the functional impression and gives indication if the patient can comfortably
function. The functional impression is inclusive within the branched technique and is effective in
achieving an accurate recording in relation to stable occlusal relationships.
The use of functional impression material, such as a tissue conditioner, in its flowable state,
accurately records the tissues in a functional state. These soft acrylic resins do not set hard. They
have properties that allow them to flow when forces are placed upon them, optimizing the shape
and distribution of the material dependent upon the functional displacement of the tissue beneath
the denture base. Some tissue conditioners have extended periods of flow, conforming to tissues
during several hours of eating, speaking, and swallowing. After a suitable evaluation period of
several days, the patient returns, the denture base is inspected for retention and stability, and, if
satisfactory, it is invested and cast in newly polymerized acrylic resin
In some patients, a moderate variation in mucosal compressibility may be present.
A mucostatic impression, particularly in the case of the lower jaw, results in a denture that
distributes the occlusal loads unevenly with consequent mucosal injury and associated
discomfort.
In this situation, it may be advisable to record the shape of the mucosa in a displaced state by
using an impression material of high viscosity. The load applied during the impression-taking
procedure should be the same as that occurring during function. A method which fulfi ls these
requirements is known as a functional impression technique
Requirements:
1. Impression materials used should have a relatively longer setting time and not be easy
flow, to allow functional movements of border tissues.
2. Rigid, non-perforated special tray with closed fit and occlusion rim are used.
3. The ideal impression material is zinc-oxide impression material.
4. Used closed mouth technique.
Advantages: -
1- The patient can exert his own masticatory force on the impression material.
2- It permits adequate trimming of the lingual borders of the lower impression.
3- Its the technique of choice in cases need to increase the capability of support .
Disadvantages: -
1- Dentures constructed from such an impression do not fit well at rest, as the compressed
tissues tend to rebound .This results in premature contacts..
2- An overextended denture may result due to improper border molding.
3- It interferes with blood supply and this may accelerate ridge resorption.
C- Selective pressure impressions
Given by Boucher in 1950. This technique combines pressures over areas and little pressure on
others. Some of these concepts were advocated by the Green Brothers in 1907 and were
considered a significant advance in impression making
This is useful if the tissues in any area are exceptionally flabby and distortion to be avoided.
Primary stress bearing areas are recorded under pressure
The secondary stress bearing areas are recorded with minimal pressure
Peripheral areas are recorded under compression to develop seal
The pressure can be selectively applied to the tissue by the custom trays for making final
impression
1- The Splint Method:
A loosely fitting tray is selected or a special tray made with heavy relief over the flabby areas.
Plaster is mixed and applied over the flabby area to a thickness of about 1/8 in. This is allowed
to set. The tray is then filled with second mix of plaster and the impression is made; the initial
coating of the flabby areas thus acting as a "splint" whilst the impression is made and being
removed with the impression.
2- The Composite Method:
This technique is used if the flabby tissue is in the anterior part of the mouth. A metal or acrylic
tray is made covering the normal area only. The impression of this area is then made using zinc
oxide paste. Whilst the impression is still in the mouth, plaster is painted around the flabby
tissues, and built up in thickness sufficient to allow its withdrawal with the rest of the composite
impression
3-Zinc oxide paste or plaster wash for compound impression:
A correctly muscle trimmed composition impression is made in a metal tray. The area of the
mobile tissue is then cut away and the removed -composition is replaced with zinc oxide paste
or plaster and the impression reinserted into the mouth of the patient.
4- Spacer and Holes Technique:
Spacers are placed over the relieved areas only. Acrylic resin tray is adapted to the jaws.
Holes are drilled over the relieved areas to allow escaping for the material through it. Zinc oxide
eugenol & elastomeric impression material can be used.
The holes are done in the tray over the following areas:
1- The median palatal raphe.
2- The anterolateral and posterolateral regions of the hard palate.
3- Residual ridge sites where the soft tissues are mobile and displaceable.
4- Over the retromolar pads.
making holes to avoid recording denture-bearing tissues in displaced or distorted position.
5-Heavy and light silicon method:
Impression is made by heavy body silicon, which removed over the flabby area. Holes are drilled
over the relieved areas to allow escaping for the material through it Wash impression by light
body silicon is carried out
PROCEDURES FOR RECORDING THE FINAL IMPRESSION:
1. Checking and adjusting the special tray.
2. Border molding the special tray.
3. Final impression making.
4. Checking the impression.
5. Beading, boxing and pouring the impression.
I . Chec k i ng and adj ust i ng t he spec i al t r ay: see tray extension in impression trays
The tray should be well adapted to the cast, following the outline but 2
mm shorter than the vestibule.
The border should be smoothened with V-shaped notches around frena.
The tray is then checked visually and digitally for extension and
adaptation in the patient's mouth. Any adjustments should be made.
The diagnostic impression
A rapid and effective way of checking tray extension is to take a diagnostic impression with
alginate. For this it is not necessary to apply adhesive to the tray, which simplifies subsequent
removal of the impression material from the tray once it has served its purpose.
The tray well adapted to the cast & 2mm shorter than the vestibule.
Do not cover the post palatal seal area with wax spacer. Completed custom tray will contact the
post palatal seal area so Additional stress can be placed at this area during impression making
Provide tissue stops at the molar and incisal regions.
If the custom tray is constructed on a cast taken from the optimized previous denture, it can
be presumed that the tray already reflects the border molding developed with the tissue condi-
tioner that has been used to reline the denture. Hence, further border molding is very likely un-
necessary.
Correction of over-extension
Over-extension must be corrected by trimming away the offending acrylic resin with a
bur or stone until the height of the flange has been reduced by the appropriate amount.
the over-extended flange will injure the tissues; in addition, elastic recoil of the displaced
sulcus tissues will cause instability of the denture.
Correction of under-extension
Under-extension is corrected by extending the tray in the region of the deficiency with a
border-trimming material.. It should be remembered that the common areas of under-
extension of the upper denture are the posterior border and around the tuberosities, while
the lower denture is often under-extended in the regions of the pear-shaped pads and
lingual pouches
If an under-extended tray is not corrected, there are two possible sequelae:
(1) The impression material is not carried to the full depth of the sulcus, so that
the fi nished denture is under-extended.
(2) The impression material reaches the full functional depth of the sulcus, but is
not supported by the under-extended tray. When the cast is poured, the weight of
the artificial stone will distort the unsupported part of the elastic impression
material, resulting in a denture which is an inaccurate fit
I I . Bor der mol di ng (Func t i onal l y t r i mmed bor der s of t he spec i al t r ay,
Ref i ni ng c ust om t r ay, per i pher al mol di ng, per i pher al t r ac i ng ) :
It is the shaping of the border areas of an impression tray by functional or manual manipulation
of the tissue adjacent to the borders to duplicate the contour and size of the vestibule.
The correction is completed using a soft but slightly viscous impression material that becomes at
least semi-rigid as it cools, or polymerizes.
a- Objective of border molding:
The objective of border molding is to determine the contours and width of the
borders of the completed denture and to register this width and contour on the final
impression. This procedure fulfills impression-making objectives of maximum area
coverage and border seal.
The requirements of a material to be used for molding of all borders are:
(1) Have sufficient body to remain in position on the borders during loading of the tray.
(2) Allow some reshaping of the form of the borders without adhering to the fingers.
(3) Have a adequate setting time of 3 to 5 minutes.
(4) Retain adequate flow while the tray is seated in the mouth.
(5) Allow finger placement of the material into deficient parts after the tray is seated.
(6) Not cause excessive displacement of the tissues of the vestibules.
b-Materials of border molding:
1- Green stick compound and red impression compound:
One end of the stick is heated over a flame without burning.
The heated compound is added to the tray in the area to be molded and
built to a height of 3 or 4mm. The compound on the tray is then
tempered in a water bath at 140F. The tray is then quickly inserted in
the patient's mouth to proceed with molding.
Advantages:
If the final impression must be remade, often the impression material can be
removed from the impression tray and the modeling compouiid border molding can
be reused.
Because of its rigidity, it can be used to extend custom impression trays whose
borders have become excessively short, more than 3-4 mm, of the desired final
extension. Once chilled in ice water, this rigidity also allows the trimming of the
material without fear of distortion.
Even when acceptably soft for border molding purposes, it is generally sufficiently
viscous to retain its form. This often provides an ideal width (2-.S mm) to the tray
flange.
Disadvantages
the need for planned preparation and the use of several pieces of equipment and
materials, including a water bath, a Bunsen burner, petrolatum jelly, sharp trimming
knife, and an alcohol torch.
Modeling compound is acceptably soft and yet not uncomfortably hot, between
approximately 49C (120 F) and 60 C (140F). Setting the hot water bath to the
upper limit of this range provides an acceptable but minimal working time.
Therefore only reasonably small areas of the borders can be corrected before the
material cools and becomes too rigid to be useful.
The material must be very soft to be used effectively and therefore must remain in
the mouth for approximately 15 seconds to be sufficient!)' rigid not to distort when
being removed from the mouth.
It must immediately be immersed in ice water and become rigid before attempting
to trim any excess material. A sharp knife blade must be used to allow for trimming
of the material rather than breakage.
, once cooled, because of its rigidity it is often difFicult to place and remove from
bilateral undercut areas, particularly the retromylohyoid areas, without causing
trauma to the tissues and discomfort to the patient.
2- Autopolymerizing acrylic resins have been used for recording the entire border
simultaneously however, they have a long setting time; do not attain proper consistency
immediately after mixing, which means that there is a waiting time before insertion; and
they are difficult to trim.
3-Polyether impression materials is prefer because they are
well suited for this purpose and meet all of the requirements listed
previously.
4- Heavy body vinylpolysiloxane
Advantages
1. Simple material to work with that requires minimal
equipment. The working times of varieties of VPS vary,
from approximately two to eight minutes, the clinician can
select the one that best fits his/her impression technique.
Generally a material with a working time of about two or
three minutes in the mouth provides plenty of time to border mold and is ideal.
2. Even when polymerized, it can be removed from undercut areas with minimal
discomfort to the patient.
3. the extended working time compared to modeling compound, permit to border
mold an extended border of an impression tray at one time as opposed to having
to complete it one smaller section at a time, as is necessary with modeling
compound.
4. If an area of the border molding must be redone, it is quite simple to add
additional material and repeat the procedure.
Disadvantages
1. To border molding and making the final impression with VPS is that the border
molding and impression materials bond during polymerization and cannot be
separated when desired. Therefore, if the final impression is not acceptable and
must be remade, the border molding material will often be lost during the process
of removing the impression material from the tray, resulting in the necessity of
repeating the border molding procedure.
2. Adhesive must be used to bond the material to the impression tray requiring
several minutes to set. This time may simply be lost to the clinician if the
impression procedures are not properly planned.
3. VPS does not have the viscosity or rigidity of modeling compound and therefore
cannot be used to correct borders that are under extended by more than 4-5 mm.
Also if not supported by the impression tray, VPS cannot be depended on to
form tray flanges 2-3 mm in thickness. This is especially noticeable in the
retromylohyoid areas, where the distal extent of the border molding and final
impression is often thinned by the tongue to a "knife edge." This may result in a
master cast with an indistinct shape in this area, which could result in a
completed denture with an inaccurate border length and thickness.
5- Wax
6. Other materials such as Iso Functional (GCCorporation,
Tokyo,Japan) can provide this functional molding of the denture
borders without trauma or undue tissue distortion.(Tissue Management and
Impression Techniques Journal of Prosthodontics 18 (2009) 97105)
C-Technique of border molding
5- An acrylic base is constructed on a model from the preliminary
impression. It is helpful, but not essential, to use clear acrylic in order to
see any particular pressure points under the base when in position.
6- A properly extended custom tray is needed that is 2 to 4 mm short of full
extension to accommodate space for border-molding materials.
7- This may be carried out either in sections, recording one part of the
border at a time, or recording the entire border simultaneously.
It is unsuitable for recording the entire border simultaneously as it is almost
impossible to get the material softened over the full length of the border.
Recording the entire border simultaneously has two general advantages: First, the number
of insertions of the tray is reduced to one; second, developing all borders simultaneously
avoids propagation of errors caused by a mistake in one section affecting the border contours
in another.
Many clinicians find border molding half the tray at one time a much more
controllable procedure. Depending on the complexity of the impression and the
experience of the clinician, even smaller segments may be done with the VPS
material.
8- Tray wax spacer remains in place during border molding procedures . Do
not remove the wax spacer until final impression is made
9- Dry periphery of tray (Compound will not stick to tray otherwise)
10- Heating and applying the compound: Heat about one third the length
of the green stick compound until it just begins to slump-then apply to
tray periphery.
11- Do not overheat if catches fire or boils, it will not mold properly.
12- Apply over periphery of tray, in a thickness just slightly narrower than
the compound stick .
13- Temper in a water bath (135-140F) for approximately 5 to 8 seconds
to Prevent burning and Hot water bath will keep compound soft for an
extended period .
14- allowed to stay in the mouth for approximately 15 seconds following
the border molding procedure.
15- The impression tray is removed and immediately placed in ice water
until rigid. It then must be examined and trimmed as necessary. The
material has a dull, matte, surface when properiy formed.
16- Trim excess over wax spacer or external material that is thicker than
4-5 mm .
17- Each area must be totally completed prior to starting another area
18- Assessing Peripheral Role :
- Proper thickness: average denture border usually is between 2 to 4 mm.
- the height of the border molding material above the tray should be no more
than 2-3 mm because that was the amount of space created between the soft
tissue and the impression tray prior to border molding.
- should smoothly flow from one area to the next without visible lines of
demarcation
- No evidence of overextension: the material is then rechecked intraorally to
ensure complete fill of the border and yet show.
If border is sharp or has seams, re-flame, temper and readapt intraorally . Repeat until periphery
is completed. The labial flange should not be thinner than 2 mm at tiie completion of the border
molding procedure, or it will not adequately support the final impression material. It should also
not be more than 4 mm thick.
If the soft tissues are being displaced more than a slight amount, the material is overextended and
the border molding technique must be repeated.
If the impression tray is showing through the material, the material must be removed, the tray
shortened, and the border molding repeated.
VENT HOLES: Caution: Do not drill the palatal relief hole(s) in the maxillary tray until
the borders have been molded and peripheral seal demonstrated.
Purpose of the Vent Hole
1) To permit proper seating of the loaded master impression tray
while making the final impression.
2) To relieve the pressure over incisive papilla and the rugae.
3) To prevent entrapment of air bubbles in the impression.
Maxillary Border Molding:
1- The buccal space and the zygomatic process area:
a. Apply the green stick compound over the surface of the tray in the
Hamular notch area and on the buccal space and the zygomatic arch
area.
b. Insert and seat the tray and the cheek may be drawn in the
direction of the buccinators fibers. The patient is asked to move his
jaw to the opposite side. This motion will enable the coronoid
process to displace the material, which would interfere with the
jaw movement.
2- The buccal frenum area:
a. Green stick compound is added to the borders of the denture from the previously
molded area to a point anterior to the buccal frenum.
b. In the region of the buccal frenum, the cheek is elevated and then pulled
outward, downward, and inward and moved backward and forward to simulate
movement of the frenum.
3- The anterior arch area and labial frenum:
a. Green stick compound is applied to the borders of the denture from the previously
molded area to the same area on the opposite side of the arch (cross the midline). This
area is border molded by pulling the upper lip outward, downward, and inward. A
side-to side movement is not indicated because the labial frenum does not function in
this manner.
b. Tray is inserted and seated. The vestibule is massaged in the direction of the fibers of
the orbicularis oris. Avoid pulling the lip down except in the corners of the mouth. In
these areas excess material squeezed laterally by the molding action in the vestibule may
create an overextension in the buccal frenum area. If this occurs re-soften and repeat .
4. The posterior border:
a. The green stick compound is added over the posterior section of the tray. Because
the tray has been trimmed to the proper length, to the vibrating line, the compound
should be placed within the tray and not extended beyond posterior extent of the tray.
The compound should be no more than 1-2 mm in thickness and 3-4 mm in width. Heat
is applied carefully to avoid distortion of the tray itself (if shellac is used).
c. The tray is inserted and seated firmly.
d. When the material has set torquing the tray may test the peripheral seal. A positive
resistance to dislodgement must be demonstrated before proceeding.
The addition of the border molding material over the posterior border:
Completes the peripheral seal by displacement of the tissue along the posterior border to
permit evaluation of the overall border seal.
Insures intimate fit of the tray in the posterior palatal seal area. Possibly aids in preventing
excessive posterior flow of final impression material.
The Mandibular Border Molding:
1- The retro molar, disto-buccal and buccal shelf area:
a. Compound is placed along the border of the tray from the most
lingual extent of the retromolar pad to an area approaching the
buccal frenum.
b. The tray is inserted & seated and the patient is asked to close
against the downward force of the dentist's finger on the tray in the
premolar area. This motion permits the tissues displaced by closing
action to mold the disto-buccal portion of the tray ( masseter notch).
c. Along the external oblique ridge the border is molded by massaging the cheek to
displace the compound , which has extended beyond the external oblique ridge.
2. The buccal frenum area:
a. border molding material is added to tray, inserted and seated.
b. The cheek is grasped in the corner of the mouth and drawn upward
and inward, back and forth to permit full freedom of movement area.
3. The anterior labial arch:
The green stick compound is added and the patient is asked to suck or draw his lip
upwards and/or the dentist gently massages the lip in an upward direction.
4. The sublingual flange (to sublingual crescent area):
a. The border molding material is placed on one border of the tray.
b. The tray is inserted and seated into position.
c. The patient is asked to extend his tongue so that the tip of the tongue is placed just
outside the corner of the mouth on the side opposite that which is being molded.
d. The procedure is then repeated on the opposite side.
5. The sublingual crescent area:
a. A piece of green stick compound is softened in a water bath, attached to the tray, and
molded with a finger into a shelf extended out area over the crescent area
b. The material is softened to a (lowing consistency, tempered,
inserted and seated into position.
c. The patient is asked to close and relax. The tongue should assume
its normal rest position with the tip approximating the position of the
lingual surfaces of lower anterior teeth.
When border molding with polyether impression material, the following
procedure should be followed:
1. An adhesive is placed on the both inside and outside of the border.
2. The polyether material is mixed with slightly less catalyst, and introduced into
a plastic "impression" syringe.
3. The polyether material is syringed around the border and across the posterior
palatal seal area. The material is quickly reshaped to proper contours with fingers
moistened in cold water.
4. The tray is placed in the mouth.
5. The border is inspected to ensure that impression material is
present in the vestibule. If insufficient material is present, excess
material from an adjacent site should be transferred with a finger
moistened in the patient's saliva.
6. When the impression material is set, the tray is removed from the mouth.
7. The border molding is examined to determine that it is adequate. The contour
of the border should be rounded. Any deficient sites can be corrected with a small
mix of polyether material added to the appropriate area. Overextensions are
readily detected because the tray will protrude through the polyether material and
be adjusted as necessary.
Refining the maxilla custom tray
1- In the anterior region the lip is elevated and extended out, downward, and
inward.
2- In the region of the buccal frenum the cheek is elevated and then pulled
outward, downward, and inward and moved backward and forward to simulate
movement of the frenum.
3- Posteriorly, the buccal flange is border molded by extending the cheek
outward, downward, and inward. The patient is asked to open wide and move the
mandible from side to side.
Refining the mandibular custom tray:-
1- The labial flange is molded by lifting the lower lip outward, upward, and
inward.
2- In the region of the buccal frenum, the cheek
is lifted outward, upward, inward, backward, and
forward to simulate movement of the frenum.
3- Posteriorly, the cheeks are pulled outward,
upward and inward. The effect of the masseter muscle
on the border of the impression is recorded by asking
the patient to exert a closing force while a downward pressure is exerted on the
tray by the dentist.
4- The anterior lingual flange is molded by asking the patient to protrude the
tongue and then to push the tongue against the front part of the palate.
Protruding the tongue determines the length of the lingual flange of the tray in this
region, whereas pushing the tongue against the anterior part of the palate causes the base
of the tongue to spread out and develop the thickness of the anterior part of the flange.
Protruding the tongue activates the mylohyoid muscle, which raises the floor of
the mouth. This helps in determine the length and slope of the lingual flange in the molar
region. Apparent protrusion of the tongue can be achieved by contraction of the intrinsic
muscles of the tongue, but this does not raise the floor of the mouth. Some clinicians get
the patient to make a k sound, as this activates the mylohyoid muscle.
5- The distal end of the lingual flange is molded by again asking the patient
to protrude the tongue.
This action activates the superior constrictor muscle, which supports the
retromylohyoid curtain. The patient is then asked to close as the dentist applies
downward force on the impression tray.
6- Finally, the patient is asked to open wide. If the tray is too long, a notch
will be formed at the posteromedial border of the retromolar pad. indicating
encroachment of the tray on the pterygomandibular raphe, and the tray must be
adjusted accordingly.
When the tray is removed from the mouth, the border molding is examined to
determine that it is adequate. The contour of the border should be rounded.
Stick impression compound is adjusted with a scalpel; the polyether is adjusted using
either a scalpel or a bur.
The material over the posterior area is not adjusted. This serves three functions.
First, it slightly displaces the soft tissues at the distal end of the denture to enhance
posterior border (palatal) seal. Second, it serves as a guide for positioning the tray
properly for the final impression. Third, it helps prevent excess impression material from
running down the patient's throat.
I I I - The f i nal i mpr essi on:
The final impression should result in achievement of the final two previously discussed
objectives of impression-making namely; accurate reproduction of tissue detail and equalization
of forces. For routine edentulous final impression making, the materials used are zinc oxide and
eugenol paste and rubber base materials.
A- Preparing the Tray for the Impression
1- Any "relief wax" is removed from the tray. For the selective pressure technique, this
creates a void or chamber between the nonprimary stress-bearing tissues of the arches
and impression trays. This chamber minimizes the possibility of physical pressure from
the tray to the tissues during the impression-making procedure.
2- Any sharp ridges at the resin/wax interface are smoothed with an acrylic bur.
3- Additionally, approximately five #8 round bur sized holes are cut through the tray in the
chamber areas These holes allow the relief of hydraulic pressures that
will build because of the viscous impression material being squeezed
between the tissues and the impression tray.
4- No relief of the border molding material is normally required because
most impression materials will be minimally viscous and therefore no
extra space is required for the material. If a viscous impression material is selected, then
approximately 0.5 millimeter of the border molding material should be removed.
5- Adhesive specific to the particular impression material being used is applied to the entire
tissue side of the tray and extends onto the labial and buccal surfaces approximately 4
mm. All impression compound border molding material sbould be coated with the
adhesive.
B- Materials used for final impression making:
Characteristics of an ideal material
minimally viscous,
polymerizing (setting) intraorally within 2-3 minutes,
being hydrophyllic,
being thixotropic,
not flowing once removed from the mouth,
not being excessively rigid,
not being excessively expensive,
being well tolerated by the tissues,
being exacting in recording and maintaining tissue details,
The ability to be poured in a dental stone more than once.
1-The alginate impression
It has already been discussed under the title of preliminary impressions. The peripheral
impression is made either by using composition tracing stick, polyether or silicon
impression materials
2-The Zinc Oxide-Eugenol Paste ( ZOE )
Indications:
a- As a final wash material when border moulded special trays are used
(functionally trimmed impression)
b- Relining of dentures.
c- In cases having pronounced nausea.
d- Muco-functional impression (Closed mouth technique).
Contra-indications:
1- When more than a slight undercut exists as distortion will occur on removal
over undercuts.
2- Excessive salivation.
Procedure:
1- The acrylic special trays used for this material require no clearance and are
adapted directly on to the preliminary model.
2- The pastes are mostly supplied in two tubes, one containing basically zinc
oxide and the other basically eugenol.
3- For the lower impression about 6 cm and for the upper 10 cm of each are
squeezed on to the mixing block, thoroughly spatulated and evenly distributed
over the fitting surface of the carefully dried tray.
4-Before starting to mix the paste the patient's lips and neighboring skin should be
lightly covered with face cream or Vaseline to prevent the paste adhering to these
dry surfaces should it touches them during the insertion of the tray. Many
operators also treat their fingers in the same way.
Should some zinc oxide paste accidentally touch a patient's or operators dry skin,
a napkin moistened with chloroform , orange oil or Dettol solution can remove it.
5-These impression materials are sufficiently fluid to record the fine detail in the
mouth. There are probably little or no dimensional changes associated with the
setting process. The set material is not elastic, so will not record undercuts. This
material will not produce a satisfactory impression of the periphery unless
supported by a very accurately adapted tray.
6-Removal of the impression is sometimes a little difficult owing to the excellent
peripheral seal obtained, but it can be facilitated by introducing a few drops of
water from syringe around the periphery of the set impression.
7-Some patients may complain of burning sensation when the impression is in the
mouth, this is due to the slight irritation caused by the oil of cloves or eugenol.
The treatment by mouthwashes is all that is required.
Functionally trimmed borders are first achieved using the following technique:
1- An acrylic base is constructed on a model from the preliminary impression.
2- It is helpful, but not essential, to use clear acrylic in order to see any particular
pressure points under the base when in position.
3- The borders are carefully trimmed to be 2 mm short of the correct peripheral
contour.
4- The peripheral impression is made using composition tracing stick so that the
maximum extent of the functional periphery
is recorded.
5- The central part of the base, bordered by
the tracing stick, is now filled with a thin
layer of zinc oxide-eugenol paste and the
final impression is recorded.
3-Rubber base impressions (Elastomers)
These are elastic impression materials, which are classified into three chemical
types: Polysulphide, silicone and polyether.
They are used in making secondary impressions for
complete dentures. Functionally trimmed borders are better
achieved before impression making.
The rubber base impressions will not adhere to the tray
and the use of an adhesive or perforation of the tray is
required.
The impression material is usually supplied in two collapsible tubes and
occasionally as a base paste and a catalyst liquid. A uniform mixing is essential. These
materials are also supplied in a range of viscosities and after setting they are elastic in
behavior.
In general, elastomers can record fine details, and are tolerated well by the
patients. They should be displaced sharply from the tissues to ensure elastic behavior.
These materials are in general compatible with model and die materials and
consequently, no separating medium is required.
As the shelf life of these materials is not ideal they should be kept in a
refrigerator.
The spacer of the acrylic resin special tray should be 2-3 mm in thickness to
obtain the best results. Functionally trimmed borders are better achieved before
impression making.
4-Plaster of Pairs
Impression plaster is a good impression material primarily for the upper
edentulous jaw where there are no bony undercuts. Plaster of Paris had been used in the
past for routine edentulous final impression making because of its high fluidity and
accuracy. But some of its disadvantages limited its use to excessive flabby tissue cases
only.
If there are undercuts present, the plaster impression
will fracture on removal from the mouth. Impression plasters
may be unpleasant for the patient because they produce dry
sensation in the mouth.
Before pouring a model in plaster or dental stone, the plaster impression must be
treated with a separating medium. The possibility of scratching the model during removal
of the impression is present.
It had been used in the past for many years as a final impression for complete
edentulous ridges. But some of its disadvantages limited it use. It can be used for making
impression for flabby tissues.
Impression plaster has the following properties which are clinically relevant:
(1) Rigid when set. However, if small bony undercuts are present the use of impression
plaster is not ruled out. The material which enters the undercut area will break off when
the impression is removed from the mouth and can then be re-attached to the impression
as mentioned above.
(2) Dimensionally stable.
(3) Low viscosity. Impression plaster is therefore a good material to use when a
mucostatic impression is required.
(4) Susceptible to excess saliva. It is difficult to obtain a satisfactory lower impression in
patients who salivate profusely because the saliva mixes with the plaster and a rough,
friable surface is produced.
Disadvantages:-
1- Produces dry sensation in the mouth.
2- Before casting a model in plaster or dental stone, the plaster impression must be
treated with a separating agent
3- If there are undercuts present, the plaster impression will fracture on removal
from the mouth with a fear of choking from small pieces of impression.
Making the Final Impression
The selected impression material is mixed according to the manufacturer's
directions
Applied evenly to the tray to a thickness of approximately 3 mm, being careful to
avoid capturing air bubbles within the material.
Because most impression materials are hydrophobic, while the impression tray is
being loaded, the tissues to be captured in the impression should be freed of
moisture. The patient should swallow all excess saliva, and the tissues should be
carefully dried with 2x2 sponge gauze.
When inserting the impression tray, the clinician mast carefully observe the
seating of the tray onto the tissues. Before completely seating the impression, the
clinician must properly position the impression tray over the ridge so that the
anterior flange of the tray will seat properly and completely into the labial
vestibule.
When seating the mandibular impression tray, the clinician must take special
care to not capture any fatty roll of tissue in the masseter muscle area as part of
the impression. This can be accomplished by pulling this roll of tissue from
beneath the tray on one side of the arch, slightly seating that side of the tray,
pulling the opposing roll of tissue from beneath that side of the tray, and then
partially seating this side of the tray.
For the final seating, the patient should be asked to lift the tongue and, as the
impression is being seated, the patient should be directed to relax the tongue. This
procedure will minimize capturing the tongue, salivary glands, and other non
desirable areas within the impression.
A similar procedure is accomplished when making the maxillary impression
with the addition of having the patient move the mandible in extreme lateral
motions as part of the impression procedure.
This movement will cause the coronoid processes to help contour the lateral
borders of the impression in the tuberosity areas.
Border molding of the impression must be initiated before the impression
material begins to polymerize and must continue until the material begins to
polymerize. If tissue manipulation is stopped prior to the initial polymerization,
the material may again flow beyond the desired extensions, causing excessive
thinning of the borders and overextension of the impression.
Manufacturer's directions are followed for mixing and setting times of all
materials.
Care is often required to minimize patient discomfort when removing an
impression. On the maxillary arch this discomfort may be caused by excessive
retention of the impression within the mouth. Generally an index finger can be
used to lift the tissues away from one of the flange areas, which breaks the border
seal by allowing air under the impression. On the mandibular arch this discomfort
may be caused by the impression extending into bilateral undercuts in the
retromylohyoid areas.
The impressions should be rinsed and then disinfected before further handling.
The maxillary impression is trimmed back to within 1 mm of the vibrating line.
Every impression must be objectively evaluated by the clinician to insure its
accuracy and remade when necessary.
I V. Chec k i ng t he ac c ur ac y of t he i mpr essi on
The impression should accurately reproduce the tissue details.
REASONS FOR REMAKING IMPRESSIONS
1- Incorrect tray position in the mouth:
A thick buccal border on one side with a thin buccal border on the opposite side.
This indicates that the tray was out of position in the direction of the thick border
(poorly centralized).
A thin labial border with the tray showing on the inside surface of the labial
flange. This indicates that the tray was placed too far posteriorly and not centered
correctly over the anterior ridge.
A thick lingual border on one side with a thin lingual border on the opposite side.
This indicates that the lower tray was out of position in the direction of the thin
border.
A thin anterior lingual border with the tray showing on the inside surface of the
lingual flange. This suggests that the lower tray was too far forward in relation to
the residual ridge. It will be accompanied by a thick labial border. In a similar
manner, a thick labial border in the upper arch with the tray showing through over
the anterior slope of the palate. This indicates that the tray was too far forward in
relation to the residual ridge.
Pressure spots on the lingual surface of the maxillary labial flange usually indicate
that the tray was not fully seated. Pressure spots on the anterior part of the
mandibular lingual flange indicate that the mandibular tray is too far forward in
the mouth, in many instances as a result of action of the tongue,
If the tray is correctly positioned in the mouth, errors in the impression indicate that the tray
needs to be modified before another impression is made. The tray should not be modified unless
it was positioned correctly when the impression was made.
2- A The tray showing through the impression material
Tray showing through the impression material over the fitting surface of the
tray and the borders showing through the final impression material. This
indicates that the tray has been seated on the residual ridge with too much
pressure.
Tray showing through the impression material over the border with the
correct thickness of material over the fitting surface of the tray, suggests that
the tray is overextended in that area.
If the tray shows through the impression material in a small area, scrapping could relieve that
area. If this area is large, the impression is preferably repeated.
3- Movement of the tray while the final impression material was setting it result in
wrinkled areas necessitate repeating the impression
4- Pulling the impression material away from any area of the tray.
5- Contact between cusps of teeth and the impression tray.
6- Incorrect border molding procedures.
7- Incorrect border foundation as a result of incorrect border length of the tray. A sharp
border usually indicates that the impression is underextended in that area.
8- Incorrect consistency of the final impression material when the tray was positioned in the
mouth (granular impression with poor tissue details).
9- A material unsupported by the borders of the tray:
Excess thickness of impression material over the fitting surface of the tray
and material unsupported by the borders of the tray. This indicates that the
tray was not seated down sufficiently on the residual ridge.
The correct thickness of material over the fitting surface of the tray, but
material extending beyond the border of the tray so that it is unsupported by
the tray, suggests that the tray is under extended in that area.
10- Voids or discrepancies those are too large to be corrected accurately on the cast. Some
voids may be corrected by adding new impression material to the impression and
reinserting however any impression with a void this large generally should be remade in
its entirety. Small voids may be correctable on the master cast since they will result in
positive bubbles that can be removed with a cleoid/discoid instrument.
11- Using either too much or too little impression material.
12- Sticking the impression material to the teeth.
13- Layered impression.
14- Trapping lip, cheek, tongue or floor of the mouth.
15- Tearing of an area of impression.
16- Poor detail in the impression because of a poor mixing technique or because the material
had begun to set before the impression was fully seated
Problems and solutions of alginate impression
V. Pour i ng t he Fi nal I mpr essi ons
The impression should be poured as soon as possible to
avoid distortion of the impression. Beading and boxing are
of utmost importance to preserve the borders of the
impression and to produce the landmark areas
Boxing-in the impression and making the
casts
See IMPRESSION TRAYS
Special Impression Techniques
Flabby ridge impression technique :
Two stage (Sectional) impression technique
One part impression technique
Controlled lateral pressure
Unemployed ridge impresion technique
Mandibular Flat Ridge impresion techniques
McCord and Tyson impresion technique
Butterfly impression technique:
Dynamic impression technique:
Functional Imp. Tech.:
1. Tissue conditioner imp. tech.
2. Neutral zone imp. tech.
Sectional Impression Tray and Sectional Denture for a Microstomia Patient
Modified Functional Impression Technique
A Layering Technique Using Multiple Viscosities of Impression Material
Accu -Dent System (Ivoclar)
Frame Cut Back Tray
Obtaining Impressions for Implant-Supported Restoration
Flabby ridge impression techniques british dental journal volume 199 no. 11 dec 10 2005
Two part impression technique: Mucostatic and mucodisplacive combination
Two part impression technique: (Mucostatic and mucodisplacive combination)
Acrylic special tray is constructed having a window opposite the area of flabby
tissues Border moulding is carried out in the usual manner and zinc oxide and
eugenol impression is made and excess passing through the widow is trimmed
out.
The flabby area is recorded using plaster impression material applied with a
brush several times with the secondary impression in place. After the impression
plaster sets, an overall impression using a suitable stock tray loaded with
impression plaster is used to remove both sections together
light-bodied PVS was used if a medium-bodied one was used) and paint
or syringe these onto the displaceable tissue to record them in a
minimally displaced position. Once setting, it should be apparent that a
peripheral seal has been re-established.
The design of this modified special tray can vary from a completely uncovered section of
the arch to a window overlying the unsupported mucosa.
In the fibrous anterior maxilla, modification of the handle position is often required.
A rim handle design has the benefit of aiding prevention of unset impression material
falling to the back of the mouth when the patient is supine.
The advantage of a window design means that the appropriate
border correction can be undertaken and checked around the
entire sulcus before the second stage of the impression is
completed.
One part impression technique (Selective perforation tray)
1. Preliminary impressions are taken in stock trays using low-viscosity alginate after
appropriate border correction.
2. A spaced special tray is fabricated from the primary cast for use with a low viscosity
impression material, such as impression plaster, low-viscosity silicone or alginate.
3. Pressure on the unsupported, displaceable soft tissue can be minimised further by the
use of perforations in the tray overlying these areas
Special tray is constructed on the primary cast Perforations are made in front of the
fibrous area Impression is taken with low viscosity silicone
Controlled lateral pressure
Tracing compound (green stick) is used to record the denture bearing area using a
correctly extended special tray.
A heated instrument is then used to remove the greenstick related to the fibrous crestal
tissues and the tray is perforated in this region.
Light bodied silicone impression material is then syringed onto the buccal and lingual
aspects of the greenstick and the impression gently inserted.
The excess material is extruded through the perforations and theoretically the fibrous
ridge will assume a resting central position having been subjected to even lateral
pressures.
Palatal splinting using a two-part tray system
In 1964, Osborne described an impression technique involving two
overlying impression trays used for recording maxillary arches with
displaceable anterior ridges.
The aim of this technique is to maintain the contour of the easily
displaceable tissue while the rest of the denture bearing area is
recorded.
A primary model is constructed using the fitting surface contour of a
previous denture. From this a palatal tray is fabricated with wax being
used to create space on the palatal aspect of the mobile area and
extending to the ridge crest around the arch.
In this acrylic resin palatal tray, a low viscosity zinc oxide paste
impression is taken of the palate. An upward force is maintained until
it is apparent that the mobile ridge is just beginning to have pressure
applied to it. Once this has set, a second special tray impression is made completely
encompassing the first tray.
It should be inserted from in front, backwards, and the presence of
the supporting zinc oxide should prevent backward displacement of
the mobile ridge.
A neat modification of this approach was described by Devlin in
1985, in which a locating rod is positioned in the centre of the
palatal tray, but proclined to allow the second special tray
impression to be guided in an oblique upward and backward
direction to envelope the palatal tray.
The palatal tray accurately locates the second part special tray
using a stop, thereby allowing for a pre-planned even thickness of impression material.
Selective composition flaming
1. A preliminary impression in a fluid material such as alginate is cast producing a model of a
relatively undistorted ridge.
2. A 3-4 mm spaced rigid special tray is constructed and used to take a composition impression
of the primary cast.
3. The impression periphery is carefully softened and functionally
trimmed. The fibrous part of the ridge can be outlined on the impression
surface.
4. The composition overlying the firm denture bearing areas is softened
with a flame before the tray is seated under heavy pressure, attempting to
replicate functional force.
By performing the impression in this way, the original relatively
undistorted shape of the fibrous tissues is retained while the tissues more
capable of functional denture support are recorded in a displaced state.
Unemployed ridge impresion technique.
Definition:
Fibrous (unemployed) mandibular ridge: this condition may be recognized by the presence of a
thin, mobile thread-like ridge which is essentially fibrous in nature.
When the customized tray has been adequately checked for peripheral extension, it is
loaded with tracing compound (green-stick) and an
impression of the denture-bearing area recorded.
Remove the greenstick relating to the crestal tissues and
perforate the tray in this region.
Downward finger pressure of the modified impression, in
the mouth, should elicit no discomfort. Inject light-bodied
PVS onto the greenstick or Zinc Oxide, and gently insert
the impression.
Excess material will be extruded through the perforations,
and the fibrous ridge will assume a resting central
position, having been subjected to even buccal and lingual pressures.
Mandibular Flat Ridge impresion techniques.
Definition:
Flat (atrophic) mandibular ridge covered with atrophic mucosa. These ridges may be
complicated by folds of atrophic and/or non-keratinized tissue lying on the ridge.
McCord and Tyson impresion technique
This technique is specific for this clinical situation. The philosophy is
that a viscous admix of impression compound and tracing compound
removes any soft tissue folds and smoothes them over the mandibular
bone; this reduces the potential for discomfort arising from the 'atrophic
sandwich', ie the creased mucosa lying between the denture base and the mandibular bone.
The impression medium here is an admix of 3 parts by
weight of (red) impression compound to 7 parts by weight of
greenstick; the admix is created by placing the constituents
into hot water and kneading together.
Using a standard impression technique on a special tray , the
lower impression is recorded. The working time of this
admix is 1-2 minutes and this enables the clinician to mould
the peri-tray tissues to give good peripheral moulding
Once setting, applied a thin mix of Zinc Oxide impression material as a wash impression.
Butterfly impression technique:
This technique is indicated in case of advanced resorbed ridge with projecting sublingual glands.
- A suitable metal tray is selected and the lingual border is made nearly flat to cover the
sublingual crescent area and a primary impression is made using alginate impression material.
- Using the resulting cast, an acrylic resin special tray is fabricated with a butterfly extension
over the sublingual crescent area and an occlusion rim is added to simulate the height and
position of the anterior and posterior teeth.
- The borders are adjusted so that the lingual flange and sublingual crescent area are in
harmony with the adjacent tissues during rest and function.
- Three applications of tissue conditioning material are used for making this impression with
closed mouth technique.
- Two application of a viscous tissue conditioning material.
Each application is allowed to remain in the mouth for 8-10 minutes pressure areas are corrected
after each application.
- Then, the third and final wash is made using either a soft tissue conditioning material or a light-
bodied rubber base impression material.
- The end result is an impression that has tissue placing effect, very thick and confirming buccal
borders, relatively thick lingual and sublingual crescent areas and covering the maximum
possible basal seat area within the functional limits of the adjacent tissues.
Dynamic impression technique:
- This technique is used to record the range of muscle action as well as spaces into which the
denture can be extended without displacement,
- In this technique, complete utilization of the active and passive tissues is obtained as the
impression material is being shaped by the function of the muscles and muscle attachments
allowing properly formed denture borders.
- A special tray of activated acrylic resin is constructed on the primary cast.
- Three stops of impression compound are added to the fitting surface of the tray, one at the
anterior region and one at each side posteriorly in the first molar region to allow a room of two
millimeters between the tray and the surface of the cast.
- Mandibular rests of impression compound are placed bilaterally on the occlusal surface of the
tray in the molar region.
- Also, a compound tongue rest is added in the anterior region to secure a correct tongue position
during impression making.
- Final impression is made using a thin mix of alginate impression material. The loaded tray is
seated in the patient's mouth and pressed gently until the stops are firmly seated on the residual
ridge.
- Then, the patient is asked to close slowly until the mandibular rests firmly contact the
maxillary arch and keep his tongue in contact with the tongue rest.
- The patient is instructed to swallow 3-4 times and forcefully protrude the lips forwards.
The resulting impression covers the maximum possible basal seat area and the borders are in
harmony with the adjacent moving tissues.
Functional Imp. Tech.:
3. Tissue conditioner imp. tech.
4. Neutral zone imp. tech.
Tissue conditioner relining imp. tech.
On occasion, dentures may exhibit looseness, not arising primarily from retention problems but
because of localized areas of poor functional adaptation.
For modification of Local areas, application of a thin mix of
a chairside resilient lining material (eg Visco-Gel, Dentsply
Limited Surrey UK) may be used. The mixed material is
added to the fitting surface of the denture and the patient is
instructed to wear the denture for one hour. After one hour of
functional moulding the denture is then removed from the
mouth and the conventional relining process completed.
Even Pressure by closing in CR/MI
Border Mould
Hold in light contact for 15 mins
Inspection to the fitting surface
the patient is instructed to wear the denture for one hour
Even 2 mm thick
No bare spots
Peripheral Roll
Maintain VDO
Remove the excess
Neutral zone imp. tech.
Neutral Zone: The neutral zone is, in fact, the zone previously occupied by the
natural teeth, which hold in its place by the controlling action of the cheeks, lips, and
tongue.
Thus, the same forces that helped to position the natural teeth in the dental arches can
help to maintain the artificial teeth in their places.
It is designed for patients with poor track records of (lower) denture stability, a large
tongue or other anatomical anomaly.
Sectional Impression Tray and Sectional Denture for
a Microstomia Patient Journal of Prosthodontics 19 (2010) 161165
Microstomia is is defined as an abnormally small oral orifice.
A limited oral opening can be caused by
surgical treatment of orofacial cancers,
head and neck radiation,
reconstructive lip surgery,
burns,
trauma,
microinvasion of muscles of mastication,
temporomandibular joint (TMJ) dysfunction syndrome,
and genetic disorders.
Scleroderma is a connective tissue disease of the skin, joints, and sometimes internal
organs. Facial skin and oral mucosa become thin and taut, and wrinkles disappear,
resulting in a mask-like appearance and a reduced oral opening.
Treatment modalities of microstomia
Microstomia Orthoses: It is dynamic opening devices used in treatment of microstomia.
surgery,
Modification of denture design : Sectional and collapsible dentures have been described
for these patients. different
Mechanisms for connecting sectional dentures include cast Co-Cr hinges, swing-lock
attachments, stud attachments, orthodontic expansion screws, pins, bolts, telescope
system, rods, clasps, cast locking recesses, and magnets.
Impression procedures
The insertion of a standard complete arch stock impression tray may be impossible if there is
a severely limited oral opening. Management includes flexible modified stock trays and
sectional trays.
Primary impression: A flexible tray was prepared by manually dispensing silicone putty
impression material intraorally. The impression putty was soft during initial insertion. Once
placed intraorally, it was carefully positioned onto denture-bearing areas and molded to
appropriate contour using functional and manual manipulation. The impression was then
made with light body poly(vinyl siloxane) impression material, , which duplicated the details
to obtain a primary impression.
These were then stabilized in a non-displacing mix of dental stone prior to pouring them in
dental plaster to obtain the primary cast.
Final impression: Custom impression trays were
fabricated with autopolymerizing acrylic resin and tried in
the patients mouth.
It was noted that a maxillary tray could be introduced in
the patients mouth with some amount of difficulty;
however, a mandibular custom tray could not be placed. Therefore, it was planned to section
a mandibular impression tray into two halves to insert into the mouth. Press buttons were
fixed to the handle of the sectional custom tray so the tray could be
exactly reassembled.
Border molding was alternatively made for the right and left halves
of the sectional tray. Following this procedure, Zinc Oxide Eugenol
(ZOE) impression paste was used to make the definitive impression.
The impression paste was placed in the right half of the tray, which
was inserted initially.
After the impression material set, the left half of the sectional tray with impression paste was
inserted.
After the impression was completed, the sectional trays were separated intraorally and
reassembled externally.
The impressionwas boxed and poured using ADA type 4 dental stone.
The conventional method was used to make the maxillary impression.
Jaw relations : Jaw relations and teeth setting were completed with a sectional
impression tray using the press button.
Denture design and fabrication
The denture was processed in a single piece using heatpolymerized
acrylic resin with a conventional compression molding technique
according to manufacturers instructions. The denture was then
deflasked, trimmed, and polished.
The patient could insert the maxillary denture; however, the mandibular denture could not be
inserted in the mouth. Hence, a mandibular sectional denture was designed in two pieces with
a locking mechanism using magnets.
Prior to sectioning the denture, a stone index was prepared by
investing the occlusal and polished surface of the denture in dental
stone for a correct alignment of sectioned segments. The denture
design incorporated sectioning in the molar region in step-design
fashion.
Stainless steel encased iron-neodymium-boron button magnets with a 5-mm circumference
were placed on the horizontal cut section to provide resistance to vertical dislodgement. The
two sections could be connected intraorally, providing a rigid connection due to a strong
attractive force
Sectional Impressions and Simplified Folding Complete Denture
for Severe MicrostomiaJournal of Prosthodontics 19 (2010) 299302
The final impressions were made with sectioned acrylic resin custom
impression trays with interlocking handles to intraorally relate the left
and right sides.
A maxillary record base was then fabricated on the master cast using a
folding design. This was accomplished by incorporating a simple
hinge into the record base.
To keep the denture in the unfolded position in the mouth, a denture
lock mechanism was formed using a plunger attachment
Modified Functional Impression Technique Braz Dent J 16(2) 2005
A major requirement for final impression of
complete dentures is to develop the peripheral contours to
accommodate normal muscular function and to ensure
peripheral adaptation without allowing air penetration
between the future denture base and the mucous membrane.
Functional tray handles can be used with any individual
acrylic resin trays. These handles are made in a L-shaped metal master die (70 mm length and 7
mm in diameter), which is flasked in brass flasks to obtain the tray handle. Thereafter, the handle
is finished and polished.
Once the individual tray is prepared, the handle can be attached to its midline, positioned on the
area corresponding to the crest of the ridge. For the
maxillary arch, the handle can be fixed to the tray using
acrylic resin. For the mandible, an acrylic resin base (15 mm high with a 10-mm-diameter upper
central hole) should be prepared and fixed to the individual tray on the residual ridge at its
midline. The functional handle is further attached to the upper central hole with a bolt that is 11
mm long and has a diameter of 2 mm.
This functional handle can be readily removed from the tray to facilitate molding of lingual and
sublingual flanges borders with low fusion impression compound. The patient can freely move
the tongue without interference from the tray handle. During this procedure, the tray is held in
place by digital pressure of the dentists right and left index fingers on the acrylic resin supports
existing in the region of the tray corresponding to the first and second mandibular premolar.
During impression of buccal and labial flange borders, the functional handle is reattached to the
tray and the patient is asked to perform a suction movement.
The final impression is carried out in two stages using two types
of materials. The first stage consists of border molding with low
fusing impression compound. In the second stage, a zinc oxide-
eugenol paste is applied to the main supporting surface of the
impression.
The impression is then completed with zinc oxide-eugenol paste
and the loaded tray is gently seated in the patients mouth. The
patient is asked to suck on the functional handle again, while the
dentist holds the tray in position.
For lower border molding, the functional handle is removed from
the base by disconnecting the bolt, in such a way that the patient
can move his/her tongue freely during the impression of the sublingual and lingual flanges. The
dentist uses the acrylic resin molar supports at both sides of the tray, to keep it in position during
this phase of the impression procedure.
For vestibular border impression, the handle is reattached to help introduce and hold the tray in
place into the mouth and to facilitate suction by the patient.
For lower impressions, during suction, the tray is balanced by the dentists thumb pulling up and
the index finger pressing down, a procedure opposite to that used for upper impressions.
As the border of the impression has been completed, the next step is to record the main
supporting surface of the final impression. The tray is loaded with zinc oxide-eugenol paste and
gently seated into the patients mouth. Once the tray is properly positioned with the material
overflowing, the handle is removed again for recording the lingual and sublingual flanges. At
this time, the dentist keeps the tray in position by pressing the resin molar supports while the
patient performs tongue movements, as previously described, for approximately 20 s.
Finally, the handle is quickly reattached to the tray without removing the tray from the patients
mouth and the patient is asked to repeat the suction movements with the operator firmly holding
onto the tray handle.
A Layering Technique Using Multiple Viscosities of Impression
Material (Compendium / August 2006 Vol. 27, No. 8)
It is a newly designed type of edentulous impression tray is used to
Capture all the fine detail of the edentulous arches in a single
appointment.
Eliminating the necessity and expense of two appointments and
the fabrication of custom impression trays.
Employs the use of different viscosities of polyvinyl siloxane
impression material to capture the fine anatomic details with the appropriate amount of
pressure (related to the type of tissue) and optimal vestibular extension.
the appropriate viscosity of impression material selected is based on evaluation of the
tissue character and mobility classification
Evaluation and Classification of Tissue Quality
The tissue character can be assessed using digital/tactile evaluation.
The clinician uses tactile manipulation to assess the character of
the tissue overlying the bony support in the edentulous arches and
classifies the tissue as either coarse and fibrotic, average, or thin and
fragile.
The soft tissue overlying the residual ridges should be assessed
using a blunt instrument to determine the relative amount of
displacement or mobility. After tactile assessment, the tissue can
then be classified and recorded as one of the following: attached,
low mobility, low displacement; average, clinically acceptable
displacement; or high mobility, high displacement.
Soft tissue that is categorized as attached and less mobile overlying the alveolar ridge generally
results in better adaptation of the removable prosthesis.
Requirement
a-It is important to use an impression material that
maintains dimensional stability
have high percentage of recovery from deformation.
It is also important that the clinician be allowed to apply multiple viscosities sequentially
and simultaneously
will set to form a homogeneousmass of impression material, regardless of the viscosity
used.
The materials selected for this technique must exhibit high tear strength (resistance to
tearing) across the multiple viscosities used in this procedure.
The use of the multiple viscosities of impression material should be such that there is a
colamination between the layers of material and an anatomically correct and detailed
reproduction that captures all aspects of the edentulous arches.
polyvinylsiloxane (PVS) materials appear to meet all of the requirements that support the use of
this layering impression technique. The impression material used to demonstrate this technique is
a hydrophilic, PVS material and a specially designed disposable edentulous tray. The authors
chose Aquasil Ultra PVSa.
Four different viscosities of impression material were used to build and complete the final
impression. High viscosity (green), medium viscosity (purple),low viscosity (teal), and ultra low
viscosity (orange)
b-Impression trays
Recently developed edentulous impression trays were used to accomplish final
maxillary and mandibular
The trays are available in five different sizes for the maxillary and mandibular
arches.
A unique sizing caliper has been developed to measure the maxillary and mandibular arch sizes.
The corresponding tray size number is displayed, and the appropriate tray
is selected for initial try-in
Clinical Application
1- Create tissue stops : The high viscosity PVS impression material with
low strain in compression is used initially to create tissue stops before
proceeding.
The tissue stops
create adequate tissue relief for the impression material,
Help to reposition the impression intraorally, and center and
stabilize the tray on the edentulous residual ridge.
The tissue stops provide the clinician with a predictable position on
tray re-insertion, helping to prevent over-seating the tray during
functional border molding.
2-border molding:
High viscosity PVS is then added to the borders of the
maxillary impression tray, then border molded.
The medium or heavy viscosity PVS is placed on the borders of the mandibular
impression tray, then border molded.
After removal of the border-molded impression tray, it should be examined to determine if any
areas of the tray are showing through the impression material. Areas of show-through should be
trimmed away one to two millimeters prior to taking the final impression of the loadbearing
areas
3- Material selection
the appropriate viscosity of impression material selected is based on
evaluation of the tissue character and mobility classification
For example, the premaxilla and anterior mandibular areas displayed
poor tissue character and mobility, which required the extra light
viscosity material, Lower-viscosity wash material is used when the
tissue is fragile and/or highly mobile, which is a situation that often
occurs when replacing an old lower denture or when no teeth have
been present for a long period of time.
while the posterior maxillary and mandibular arches displayed
average tissue character and mobility, which suggested the need for
low or average viscosity PVS material
Multiple viscosities of PVS impression materials are being
dispensed in the maxillary tray. In this instance, the ultra low
viscosity is applied to the premaxilla area, which had been evaluated
as loose and having a spongy character upon tactile evaluation. The low viscosity was
applied to the mid-maxillary area where the tissue exhibited average tissue character
and average mobility.
To preserve and protect the peripheral detail of the vestibular borders of the
impressions, each final impression is boxed using the alginate boxing method.
Accu -Dent System (Ivoclar)
The Accu-Dent System 1 is an irreversible hydrocolloid-based
impression system that is recommended by the manufacturer for
producing complete denture master casts.
The system uses the Accu-Gel impression materials, which are
chemically compatible, irreversible hydrocolloid materials that
differ in viscosity.
The low-density (syringe) material is injected into the vestibular areas while the high-
density (tray) material is used in the tray to support the syringe material and form a type of
"custom tray" in the mouth.
The system comes with special, autoclavable, plastic, perforated
impression trays that Ivoclar Vivadent claims can be easily modified for
special cases.
The Accu-dent impression materials are said to be accurate not only for
preliminary impressions but also for final impressions for denture
fabrication.
The Accu-gel impression materials met ANSI/ADA requirements
for alginate materials but failed to meet the higher detail reproduction
and gypsum compatibility standards of ANSI/ADA No. 19 for typical
final impression materials.
ADVANTAGES:
Kit comes with all items needed for making irreversible hydrocolloid impressions.
Is a suitable impression material for the fabrication of immediate dentures.
Impression trays were rated highly by clinical evaluators.
Easy to mix and dispense.
Well tolerated by patients.
Acceptable working and setting times.
Meets ANSI/ADA Specification No. 18 requirement for
gypsum compatibility and detail reproduction for
irreversible hydrocolloid impression materials.
DISADVANTAGES:
- Does not meet ANSI/ADA Specification No. 19 requirement for
gypsum compatibility and detail reproduction for elastomeric
impression materials.
- Impression material is not suitable for the fabrication of
complete denture master casts.
- Tray material is too viscous.
- Requires water cooler than room temperature for mixing.
- Impression material more expensive than other commonly-used
irreversible hydrocolloid products.
Frame Cut Back Tray PRACTICE IN PROSTHODONTICS, Vol.43, No.5 2010.9
(hereafter called FCB Tray) or as commonly called a frame-less tray
it is designed to reduce the frame of Tray around above the retromolar pad and to prevent from
deforming the pad by relieving impression pressure applied to the pad toward externally from the
Tray. And next feature has another reduction of about two thirds of frame size around the buccal
shelf area in order to prevent from overextension into the buccal side.
If overextension of mucous membrane made buccally in the external direction, it tends to lose
closure of denture base on and around the retromolar pad.
Features of FCB Tray (distributed by Morita Corp.)
Frame reduction in the retromolar pad,
Buccal frame reduction,
Extensive tongue space,
Recess that tongue tip touches,
Line indent to indicate locating tray when seated,
Tray handle that is easy to bite
Modification in Impression Techniques
Hayakawa & Watanabe (2003)
2- Zarb et al 2004
4-Alternate Custom Tray Design
Shetty et al (2007)
Obtaining Impressions for Implant-Supported Restoration
There are many choices of impression technique BDJ, VOLUME 187, NO. 9, NOVEMBER 13 1999
The standard approach is an impression made of the implant abutment using a transfer
impression coping.
There are two types of implant transfer impression coping: pick-up and re-seating copings.
A- indirect (closed tray)
In the closed-tray technique, impression posts (straight or conical)
are secured onto the implant abutments and remain attached to the
implant fixtures throughout the procedure
1- a custom tray is fabricated ensuring that there is adequate
relief to surround the height of the transfer impression
posts
2- Using a syringe, light-body, low-viscosity impression
material (Aquasil LV, DENTSPLY Caulk, Milford, DE)
is delivered to the mouth. Each transfer post should be
adequately surrounded by the impression material,
including the sulcus
The soft tissue replication is enhanced with a dual-phase material (Aquasil
Monophase/Aquasil LV, DENTSPLY Caulk, Milford, DE).
When working with multiple implant abutments, it is absolutely necessary to achieve a passive
or tension-free relationship between the superstructure and the underlying fixtures.
3- Complete impression with medium viscosity Aquasil
Monophase
4- After setting, the impression is removed from the patients
mouth, leaving the transfer posts attached to the implants.
Upon inspection, sharp, accurate margins of the occlusal surface
and shoulder of the transmucosal abutment should be replicated in
the impression.
5- Each transfer post is carefully removed from the patient. It is
advisable to remove one post at a time and attach each to the
specific transfer analog.
6- The analog/post combination is then placed back into the
impression in the same site that it occupied in the mouth,
generally with an audible click verifying a positive seat
The re-seating impression coping
It is used with a conventional impression tray and syringing technique and the coping remains in
place on the implant after the impression material has set and the impression removed from the
mouth.
The transfer coping is then unscrewed from the implant and attached to the
laboratory replica outside the mouth and the coping/replica is re-inserted into the
impression before pouring with dental stone.
This technique is useful in clinical situations where there is limited space to allow for
screwdrivers to undo the long retaining screws of the pick-up technique.
B- Direct (open tray); the pick-up implant impression coping
The open-tray technique requires a tray which has been fabricated
to accommodate the larger two-piece transfer post design.
The transfer post for an open-tray technique consists of a square shaped
post and a fixation screw allowing precise connection to the implant. The
tray should have an open window to allow for the internal screw to be removed, as the body of
the transfer post will remain within the impression
The Aquasil LV is delivered via syringe to surround each transfer post, as previously described.
The custom tray is then filled with the impression material (Aquasil Monophase) and delivered
over the square transfer posts and lower arch. The transfer post bodies will then be incorporated
into the impression.
It is used with a open faced impression tray. The tray allows access to a retaining screw that
secures the impression coping to the implant.
The retaining screw must extend 23 mm above the impression tray
opening. Impression material in injected around the impression
copings first and then the tray is seated in the mouth. After the
impression material has set and before removing the tray, the retaining
screw is unscrewed leaving the pick-up impression coping inside the impression.
The implant laboratory replica is then attached to the coping before pouring the impression with
dental stone.
The direct technique may use splinted or non splinted implant transfer copings.
The materials used to splint copings are composite resin, plaster, or acrylic resin.
Spector et al indicated that splinting is unnecessary once the acrylic resin used for splinting the
copings suffers polymerization shrinkage, which can cause some distortion, because splinting the
pick-up transfer copings can take more clinical time.
However, Assif et al showed that the technique using acrylic resin to splint pick-up impression
copings was significantly more accurate than the unsplinted technique. Although some previous
investigations showed no difference between implant impression techniques with splinted or
unsplinted pick-up impression copings
`
Digital intraoral scanning (Digital impression)
Factors which complicate impression making
1- Uncooperative patient 2- Excessive salivation
3- Dry mouth (xerostomia) 4.Nausea during Impression Making
Uncooperative patient
Some patients exhibit intolerance to prosthodontic procedure. This is may due to
fear or psychological problem
Consultation with physician and premedication is usually prescribed
Excessive salivation (Sialorrhea)
Excessive amounts of saliva, particularly of the thick mucous type, will displace the alginate
impression material and will contribute to an inaccurate impression especially in partially
edentulous patients.
1- Clinical management
Placing cotton rolls in upper buccal vestibule to control saliva from the parotid
gland
Placing cotton rolls in the floor of the mouth to control saliva from sublingual and
sub mandibular salivary gland
Ask the patient to rinse with astringent and cold mouth wash
Use saliva ejector
packing the mouth with unfolded 2 x 2 inch gauze:
In the maxillary arch one gauze strip is placed in the right buccal vestibule and
another in the left vestibule. The dentist must wipe the palatal area just before
making the impression.
In the mandibular arch one gauze strip is placed in each of the buccal vestibules
and another is placed in the linguoalveolar sulcus by having the patient raise the
tongue, placing the gauze in the sulcus, and then having the patient relax the
tongue to hold the gauze in position. The gauze is removed immediately before
the impression is made.
2- Drugs
The excessive saliva can be controlled by having the patient rinse the mouth with
an astringent mouthwash followed by a rinse of cold water
The parasympathetic nervous supply to the salivary glands is mediated by
cholinergic terminals. Therefore, antisialogogues are primarily anticholinergic
drugs, such as atropine and scopolamine, or drugs that have anticholinergic
properties (phenothiazines and ganglionic-blocking agents) in addition to other
effects. Oral administration of anticholinergic drugs in acceptable doses reduces
salivary output but not arrest salivation.
With excessive amount of thick mucinous saliva from the palatal salivary glands, the patients
should be instructed to rinse with an astringent mouth rinse. Then 2 x 2-inch sponges moistened
in warm water should be used to place pressure over the posterior palate in an attempt to milk the
glands. This is followed by an ice water rinse immediately before the impression is made.
With copious amounts of saliva, the use of an antisialagogue in combination with mouth rinses
and gauze packs effectively controls this salivation. (A 15-mg Pro-Banthine tablet taken 30
minutes before the impression appointment)
Dry mouth (Xerostomia)
Persistent dry mouth commonly referred to as xerostomia. Xerostomia is known with
others names such as Aptyalism, Asialia, Dry mouth, Hypo salivation, oral dryness,
salivary secretion decease.
If the teeth are too dry, alginate has a tendency to stick to them. Therefore the teeth
should not be air dried before making an impression.
Function of saliva
Help in Food digestion
Protects teeth from decay
Prevents infection by controlling bacteria and fungi III the mouth (antibacterial)
Help in chewing, swallowing
Lubrication of the oral mucosa
Retention of removable dentures
Diagnosis of xerostomia
It may based on evidence obtained from the patient's history, examination of the oral cavity and \
or silometry (collection device placed over salivary gland duct orifices, and saliva is stimulated
with citric acid).
The normal salivary flow for unstimulated saliva from the parotid gland is 0.4 to 1.5 ml
/min. the normal flow rate for unstimulated "resting" whole saliva is 0.3 to 0.5 ml/min, for
stimulated saliva Ito 2 ml/min. values less than 0.1 ml/min are typically considered xerostomic,
although reducedflow may not always be associated with complaints of dryness.
Symptoms
Patients often complain of a sticky, dry sensation in the mouth. They encounter problems with
chewing, swallowing, tasting or speaking.
Causes of dry mouth
Medications: Many commonly prescribed medications, particularly in elderly
individuals, have xerostomia as a possible side effect.
Aging: Salivary flow may diminish in some individuals with age.
Illnesses: Specific illnesses and disease processes are associated with xerostomia, such as
chronic diarrhea, liver dysfunction, diabetes, anemia, Sjogren's syndrome.
Radiation therapy: The radiation treatment of cancer patients, particularly when affected
areas involve the head and neck regions, may result in dry mouth. The type and amount
of radiation used will determine the extent of damage caused to the oral salivary glands
and, in turn, the degree of saliva reduction.
Oral habits: as Chronic mouth breathing and inadequate fluid consumption.
Why is saliva important to denture wearers? In order for dentures to be comfortably stable in
the mouth, intimate contact between the dentures and the underlying gums must be achieved
during chewing, swallowing, and speaking. When the denture fits accurately, the physical
adherence of saliva to the denture and to the gums provides a force which aids in denture
retention and stability. In the absence of salivas the lubricating effects, the gum, cheek and lip
tissues may become irritated as the dentures move during chewing, swallowing and speaking.
Management of dry mouth
Modify medications: consultethe patients physician topermit substitution to an equally
effective drug that does not cause dry mouth, or causes it to a lesser extent.
Saliva can be stimulated by :
1.Mechanical (Masticatory, Gustatory sialagogues) Stimulants
Foods which require mastication (apples, carrots, celery, hard breads and rolls, meats,
etc)
Sugarless Gums Sugarless Tablet
2. Chemical Stimulants
Mouth-Kote Solution : Mucopolysaccaharide Sol., contains citric acid
Optimoist Solution : Contains citric acid
3. Electrical Stimulant
4. Pharmacologic Stimulant, sialagogues (parasympathomimetic)
Salagen (Pilocarpine HCl); Cholinergic agonist
Evoxac (Cevimeline HCl); Cholinergic agonist
5. Oral Moisturizers / Salivary Substitutes
Solutions
WATER
Regularly drinking of water may both hydrate tissues and facilitate
some increase in saliva production.
Salivart
Contain carboxymethyl cellulose and hydroxyethyl cellulose Oralube
Xero-Lube
Plax Water-glycerin agent
Gel Oral Balance Glycerate polymer
6. Acupuncture
Are there alternative denture treatments for patients suffering from xerostomia?
Those patients who are not able to comfortably wear conventional dentures, due to severe
xerostomia, should consider implant-supported dentures. The increased denture stability offered
by dental implants may reduce tissue irritation caused by movement of the denture during
chewing, swallowing and speaking. These patients should understand that when dental implants
are used to support dentures, intense oral hygiene practices are required to maintain healthy
implants in the presence of reduced salivary production.
Consultation with a qualified dentist will help the patient determine which treatment approach is
best for them.
Nausea during Impression Making, Pakistan Oral & Dental Journal Vol 27, No. 1\\ IJMDS- 2009;1(1) 54-65
Gagging is an involuntary contraction of the muscles of the soft palate or pharynx that results in
retching. it is a normal protective reflex to prevent foreign bodies from entering the trachea. In
some cases this problem is so severe that it requires definite treatment.
Gagging has been generally classified as either
somatogenic, or
psychogenic. Psychogenic gagging is induced by anxiety ,fear, and apprehension
Etiology of gagging.
1. Local and systemic disorders
2. Anatomic factors
3. Psychological factors
4. Physiologic factors
5. Iatrogenic factors
A. Local and systemic disorders-
1. Nasal obstruction
2. Postnasal drip
3. Sinusitis
4. Nasal polyp
5. Mucosal congestion of URTract
6. Dry mouth
7. Chronic GI disease
8. Chronic gastritis peptic ulceration
9. Carcinoma of stomach
10. Hiatus hernia
11. Uncontrolled diabetes
12. Catarrh and alcoholism
B. Anatomic factors-
Anatomic abnormalities, oral and pharyngeal sensitivity predispose a patient to gag when
dentures are poorly constructed.
1. A long soft palate
2. Sudden drop at the junction of hard and soft palate
3. An atonic and relaxed soft palate elicits gagging by allowing the uvula to contact the
tongue and the soft palate to touch the posterior pharyngeal wall.
C. Psychological factors- like fear, noise, and smell can also trigger this response.
Some Systemic conditions that have psychosomatic components are-
1. Temporomandibular pain dysfunction syndrome
2. Atypical facial pain
3. Denture intolerance
4. Burning mouth syndrome
D. Physiologic factors-
Extraoral stimuli:
The mere sight of a mouth mirror or impression tray is stimulus enough to cause some
patients to gag..
Acoustic stimuli- The sound of the wife gagging was sufficient to precipitate an attack of
gagging in the husband.
Olfactory stimuli - certain smells may cause a patient to gag. The smell of various dental
substances, cigarette smoke on the dentist fingers and even perfume have been reported
as olfactory stimuli to the gag reflex.
Intraoral stimuli-
The palate is divided into hyposensitive and hypersensitive regions. Line drawn through
the fovea palatinae demarcated relatively hyposensitive anterior and hypersensitive
posterior portion.
The tongue was similarly divided into the hyposensitive anterior and hypersensitive
posterior one third.
Landa reported that the upper surface of the posterior one third of tongue is the most sensitive
area in oral cavity.
5. Iatrogenic factors-
Sensitive tissues may be stimulated because of rough or careless technique and temperature
extremes of instruments or because of-
From prosthodontic point of view,
use of thin consistency of impression material,
large size impression tray or
Tactile stimulation of soft palate, posterior part of tongue, fauces can also induce
gagging.
Inadequate PPS and loose denture
Overloaded impression trays
Unstable & poorly retained prosthesis-produced movement of the denture base, which
produces a tingling sensation and gagging.
Overextended border of prosthesis particularly in the posterior area of palate and
retromylohyoid space, distolingual part of mandibular denture- this impinges one or more
of the trigger areas and thus produce gagging.
Placing maxillary teeth too far in a palatal direction and mandibular teeth too far
lingually, so that dorsum of the tongue is forced into pharynx during the act of
swallowing.
Symptoms
Extra oral symptoms-
These include excessive salivation, lacrimation, coughing, fainting or in minority of patients, a
panic attack and sweating; at times a full-body response may occur.
Intra oral symptoms-
The patient who gags may present with a range of disruptive reaction; from simple contraction of
palatal or circumoral musculature to spasm of the pharyngeal structures, accompanied by
vomiting.
Trigger Zone of gag reflex-
Gagging may be elicited by nontactile and tactile stimulation of certain intraoral structures.
Five intraoral areas are known as trigger zones:
palatoglossus & palatopharyngeal folds,
Base of tongue,
Palate,
Uvula and
Posterior pharyngeal wall
Nontactile sensations such as-
Visual,
Auditory and
Olfactory stimuli
Gagging severity index (GSI) : The gagging reflex is:
I -Very mild, occasional and controlled by the patient
II.- Mild, and control is required by the patient with reassurance from the dental team
Ill.- Moderate, consistent and limits treatment options
IV -Severe and treatment is impossible
V -Very severe: affecting patient behavior, dental attendance and making treatment impossible.
Management
Before starting any dental procedure detailed history must be taken. Enquire any un pleasant
previous dental treatment experience.
A positive history about gagging will require certain precautionary measures.
a) Psychological management
A firm sympathetic manner of self-confidence on the operator's part.
Assure the patient that no difficulty will be experienced if instructions are
followed and that the discomfort will be minimized as much as possible, being
in any case, only for a short time.
Behavior modification- Generally the objective is to reduce anxiety and
unlearn the behavior that provokes gagging. Relaxation, distraction,
suggestion and systemic desensitization.
Hypnosis
Praise patient
Pleasant environment
Acupuncture-Acupuncture is a system of
medicine in which a fine needle is inserted
through the skin to a depth of a few
millimeters, left in place for a time,
sometimes manipulated and then withdrawn.
Dental treatment was then carried out and the
effectiveness of acupuncture is assessed.
The technique involves the insertion of one, fine, single-use disposable needle of
7mm length into the anti-gagging point of each ear to a depth of 3 mm. The needles
are manipulated for 30 seconds prior to carrying out dental treatment. The needles
remain in Situ throughout treatment and are removed before the patient is discharged.
Acupressure- stimulate the points with gentle finger pressure rather than fine
needles and therefore is a less invasive technique.
To make use of it locate the REN24 point.[ Chengjiang (REN-24)
is an effective acupressure point for controlling the gag reflex during
impression making. ]
It is situated in the horizontal mentolabial groove. Approximately
midway between the chin and the lower lip. Apply light finger pressure with the
index finger progressively increase the finger pressure until the patient feels
discomfort and distension.
The acupressure should start at least 5 min before impression making, continue
through the impression procedure, and be terminated only after the impression has
been removed from the patients mouth. Pressure can be applied by the patient,
dental assistant, or dentist.
Placebo effect
The placebo or suggestive effect of treatment can be very powerful. A recent
systematic review has confirmed that the placebo effect is mediated via
endogenous opioids.
b) Clinical techniques
Marble technique- Singers marble technique is a method by which the gag reflex
can be exhausted. It consist of seven steps-
at Ist visit- no oral examination of any kind was made at the first office visit.
Five rounded, multicolored, glass marbles approximately inch in diameter were
placed on a tray in front of the patient. The patient was told to put the marbles in
his mouth, one at a time at his leisure, until all five marbles were in his mouth.
Since the fear of swallowing the foreign object can induce a gag reflex, the patient
was assured that if he swallows the marble, it could not harm him. Continual
assurance that he would be able to wear dentures was given to the patient at each
weakly visit. He was urged to keep five marbles in his mouth continuously for one
week, except when eating and sleeping.
Roofless Denture- maxillary denture can be reduced to a U-shaped border
situated approximately 10mm from the dental arch.
Matte finish denture : a smooth highly polished surface which is coated with
saliva may produce a slimy sensation which is sufficient to cause gagging in
some patients; a matte finish has been advocated as more acceptable in this
situation.
Training bases- patient is supplied with a series of small to full sized denture
bases. A thin acrylic denture base without teeth is fabricated and the patient is
asked to wear it at home, gradually increasing the length of the time the
training base is worn. Initially 5 min once each day, then twice each day and
so on. After 1 week; 3 min each day, then 15 min, 30 min & 1 hr. anterior
teeth are added and when the patient is able to tolerate it, posterior teeth are
added.
Progressive desensitization: As sensitive patients will experience the same
difficulty at each succeeding visit and as the wearing of the finished denture
will be difficult, it is advisable to construct a fitting base plate in acrylic on
the first impression and give it to the patient with instructions to practice
wearing it for increasingly longer periods each day until it can be worn for at
least an hour without discomfort.
Modification of edentulous maxillary custom tray- to prevent gagging-attach
a disposable saliva ejector to the base plate in the midline of the tray. It is
easy to fabricate these trays using disposable saliva ejectors at their distal
aspects so that the excess impression materials flow through these ejectors
without triggering the soft palate area.
Increasing the interocclusal distance by either remounting and grinding the
teeth or remaking the denture when the discrepancy was gross. the
interocclusal distance was inadequate in patients with serious gagging
problems.
Teaching the patient to swallow with their mouth open- it has been
suggested that all patient who gag characteristically swallow with their teeth
clenched, using the teeth, lips and cheeks as a buttress for the tongue to push
against. Teaching the patient to swallow with teeth apart, the tip of the tongue
placed anteriorly on the hard palate, and orbicularis oris relaxed, has been
advocated.
soft blow down splint can be used both in dentate and edentulous patients. It
can be fabricated and adjusted very easily. It guides the tongue to more
favourable position rather than pharyngeal guarding posture.
Soft swallow method by asking the patient to hold the tip of the tongue
behind the upper anterior teeth and undulate the tip back and forthand then do
swallowing with the teeth apart is also found successful to prevent gagging.
c) Pharmacological management
1. Locally acting- peripherally acting drugs/ local anesthesia:
They may apply in the form of sprays, gells or lozenges or by injection. The
effectiveness of these agents is limited. When mucosal surface is desensitized, the
patient is less likely to gag.
The deposition of LA around the posterior palatine foramen has been used for patient
who gags.
However, the administration of a local injection may not be possible and may itself
provoke gagging. Further more injection of LA solution may distend the tissue
resulting in an inaccurate impression, which may compromise retention of prosthesis.
A topical anesthetic containing benzocaine (14%), butyl aminobenzoate(2%0 and
tetracaine hydrochloride (2%) can be sprayed on a gauze pad and placed on the back
of the upper arch until the area is obtained.
LA solution and impression material mix : Dispense 1 capsule of LA solution 8ml
of 2% lidocaine with 1 part in 100,000 epinephrine to the plastic measuring cylinder
and then add water to the correct volume. Now to this solution add impression
material, mix thoroughly. Insert the loaded tray gently in the patients mouth and
press until set.
2. Centrally acting drug- it is only a short term solution for severe gagging problem and
should not be used routinely
1. Tranquilizers like chlorpromazine are useful in patient under strain/tension 25-
100mg
2. Semi hypnotic, antihistamines, parasympatholytics.
3. General anesthesia- a minority of patient does not respond to any form of sedation
or behavioral therapy and dental treatment under GA may be appropriate as a last
resort.
3. Conscious sedation-. The use of conscious sedation with inhalation, oral or intravenous
agents may temporarily eliminate gagging during treatment while maintaining reflexes that
protect the patients airway.
Oral sedation may be useful in mild gagging
Intravenous sedation is often much more predictable than oral sedation, and canbe
of use in patient were inhalation sedation is ineffective.
1. Desensitize the surface of the mucous membrane with:
a- Phenol mouth washes of one part phenol to eighty parts of cold water.
b- Sucking a tablet made for this purpose.
c-The application of a surface type of local anaesthetic either in the form of cream or
spray. the hard palate, soft palate, cheeks, lips and tongue were swabbed with 2%
pentocaine solution in order to produce topical anesthesia.
d) Surgical technique
Leslie advocated an operationto shorten and tighten the soft palate on healing
the removal of the uvula, This solution has not been accepted.
e) Prosthodontic Management
Reduction of stimuli
The patient should blow the nose to clear any nasal obstruction and then
encouraged in deep, nasal breathing.
Explain to the patient that, as soon as the impression is seated, the head may
be brought well forward over the lap and that a bowl will be provided to hold
under the chin to catch any saliva that may run out of the mouth.
Carry out the impression technique using as little material as possible. Avoid
touching the dorsum of the tongue with the back of the tray and seat the
impression as quickly as possible.
Avoid using impression material of thin consistency.
Select appropriate size of the impression tray. Over extensions should be carefully
avoided.
Use fast set material
Use saliva ejector to remove excess saliva
Have the patient sit in upright position with the head tilted slightly downward to
prevent material running to throat
Patients dislike plaster of Paris more than any other material, even when it is flavoured, the
alginates are tolerated slightly better; composition is usually tolerated well, probably owing to its
putty-like consistency and its heat; zinc oxide paste seems to be disliked least of any but this may
be largely due to its only being used in a tray which already fits, though its flavour of cloves
undoubtly helps in some cases.
Distraction maneuvers
Talking to the patient and engaging him in some topics of special interest to distract him
Asking him to breath deeply and audibly through the nose
Asking the patient to raise his hand or foot
Asking the patient to tap his foot rhythmically on the floor
Progressive desensitization:
Construct a fitting base plate in acrylic on the first impression and give it to the
patient with instructions to practice wearing it for increasingly longer periods each day
until it can be worn for at least an hour without discomfort.
Singers marble technique: the patient is asked to practice with marble in his mouth,
gradually the number of marble increased
Patient is allowed to take the tray home and practice insert tray in the mouth every day
Patient is instructed to make presuure on the palate by tooth brush witout making
himself rech.
Summary
Procedures that will help to prevent gagging include:
1. The dentist should:
a) Not mention the subject of gagging
b) Ask whether the patient has had impressions made previously.
2. Before the impression is made:
a) Ask the patient to use astringent mouth rinse and cold-water rinses
b) Seat the patient in an upright position with the occlusal plane parallel with the floor.
c) Ask the patient to take a deep breath and hold the breath while the dentist quickly
checks the size and fit of the tray.
d) Correct the maxillary tray with modeling plastic and leaving sufficient unrelieved
modelling plastic at the posterior border.
3. The impression material must:
a) Have the consistency of thick whipped cream
b) Fast-setting alginate.
c) Set up to a rubbery consistency in few minutes.
4. During the impression procedure:
a) Not overfill the tray with impression material.
b) Seat the posterior part of the tray first and then rotate the tray into position.
c) Force excess alginate in an anterior direction.
d) Ask the patient to: Keep the eyes opened and focused on some small object.
Breathe through the nose.
5. The leg lift procedure is used before and during the making of the impression.
6. Giving all instructions to the patient in a firm, controlled manner.
7. The use of an anesthetic spray is usually contraindicated.
COMPLETE DENTURE THEORY AND PRACTICE Relief areas and post dam5
Relief Areas
Relief means release or elimination of pressure from a specific area in the denture-
supporting structure. The mucous membrane covering the denture bearing area is varying
in thickness, softness and sensitivity.
So denture relieves are made to reduce pressure on the hard and the sensitive areas.
Hard areas : Areas covered by thin mucoperiosteum are usually hard and require relief to avoid
pain and/or rocking of the denture. The hard areas which require relief include:
1- Median palatine raphe.
2- Maxillary tuborosity if prominent.
3- Zygomatic process of the maxilla
4- Torus palatinus and torus mandibularis.
5- Mylohyoid ridge of the mandible.
6- Prominent genial tubercles
7- Any bony nodule.
Relation between ridge and median palatine raphe
If the alveolar ridge is covered by highly compressible mucosa, more relief than average is
needed over the hard median palatine raphe. If the alveolar ridge is firm and the palate center is
compressible, little or no relief is needed.
Sensitive areas : Relief of pressure over sensitive areas is needed for patient comfort and to
avoid pain. The sensitive areas requiring relief include:
1- Incisive papilia.
2- Enlarged rugae areas (especially when they are undermined).
3- Mental foramen areas (especially in flat lower ridges).
4- Crest of thin lower ridge.
Methods of relief
A- Automatic relief
This type of relief can be obtained at the time of making the impression by using a
muco-compression impression technique.
B -Direct relief
1) In the impression
By scraping the final impression to the desired width and depth over areas
corresponding to the hard or sensitive areas. This method is only used with
plaster of paris impression material.
2) On the cast (The commonly used method)
The area to be relieved is outlined on the cast and
covered by one or more layers of tin foils of the
desired shape and thickness. The tin foil is
burnished over the cast by a blunt instrument and
fixed in place by cement.
Depth and shape of the relief
The depth of relief depends mostly upon resistance or yield of the area to be relieved as
compared with that of the surrounding area. The probable amount of settling of the dentures must
be considered in estimating the depth of the relief areas to prolong the denture services.
The shape of the relief is determined according to the extent of the hard or the sensitive
areas. Generally, in the upper model the relief area will normally be pear-shaped with the
broadest part anteriorly. It should not extend to the crest of the ridge except over the incisive
papilla.
Advantages of relief
1- Preventing pain and rocking of the denture and giving comfort to the patient.
2- Improving the denture stability and preventing it from teetering.
3- Compensating for tissue displacement over the ridge during settling of dentures and due to ridge
resorption, as resorption takes place mainly in the alveolar process and the central area of the
palate changes very little throughout life.
4- Compensating for some technical discrepancies occuring during processing or repairing the
denture. Relief in the maxillary denture compensates for the shrinkage of acrylic resin during
processing. Shrinkage makes the upper denture slightly narrower across the tuberosities and
higher in the palatal vault areas.
Relief is also required to compensate for stresses and strains produced in the impression material.
Pressure is high in more confined areas, as in the center of the vault. Most impressions, if not
relieved, will produce undesirable heavy pressure in the center of the palate.
Disadvantages of relief
It may affect the retention gained by accurate adaptation of denture base and oral tissue
because there is no actual contact between denture base and the tissue at the areas of relief.
Posterior Palatal Seal [PPS] (Post-damming)
The posterior palatal seal area is that area of the soft tissue
along the junction of the hard and soft palates on which pressure
within the physiological limits of the tissue can be applied by the
denture to aid in the retention of the denture.
Post dam is a slight elevation at the posterior border of
maxillary denture.
The post-dam should be placedin the region of compressible tissue
just distal to the hard palate, but it must beanterior to the vibrating line.
Peripheral seal is the area of contact between the lip and cheek mucosa and the denture
borders that prevent passage of air between the base and the tissues.
The peripheral seal depends on proper extension (width and height) of the denture borders that
fill the mucobuccal space and contact the cheek tissue laterally. There are no cheek tissues
posteriorly to seal the denture border. Therefore, the posterior palatal seal is necessary.
Functions of post-damminmg
1- It slightly displaces the soft tissue at the distal end of the
maxillary denture to enhance theposterior border seal
2- Increases retention of the denture by atmospheric pressure. As
the denture borders terminateon resilient tissue so it maintain a proper denture seal.
3- Prevents air and food from getting under the denture
4- Decreases reflex irritationand gag by:
a- Decreasing patients awareness of this area, as no separation occurs between
denture base and soft palate during normal functional movement.
b- Reducing the thickness of the denture base conspicuous to the tongue.
4- Compensates for dimensional changes that are inherent in the laboratory procedures,
and for minor denture base functional movements
5- During taking the impression, the post dam acts as a guide for positioning the tray and
prevents the impression material from sliding into the pharynx
If the denture/tissue contact (seal) around the denture borders has been lost and air is
freely allowed between the denture and the underlying tissues. A loss of this seal is often caused
by resin shrinkage during polymerizadon.
Acrylic resin shrinks toward the area of greatest bulk of the denture, which is
generally around the denture teeth. On the maxillary arch, this shrinkage usually results in the
creation of a good seal around the labial and buccal sides of the denture and loss of seal at distal
extent of the denture as it crosses the palate. In this area, as the resin shrinks toward the denture
teeth, it tends to lift away from the cast resulting in a future loss of the seal and hence loss of
denture retention.
This shrinkage must be anticipated and steps taken to help ensure that resin/tissue contact
will exist following processing. Some newer injection molding techniques minimize this
problem. Be sure to check with the material manufacturer regarding recommendations
concerning palatal seal areas.
Dimensions of post-dam
The post dam extends from the hamular notch on one side to the other
hamular notch of the other side. The post dam is usually narrow in its
central part (due to the posterior nasal spine), wider as it extends laterally
on each side, and narrow again as it approaches the hamular notch to fade
out behind the tuberosity called butterfly post dam or Cupids bow.
The post dam should be wide to avoid cutting or irritating the tissues (about 4mm
wide in its widest part) the depth or thickness of the post dam should vary for different
individuals and, for the same individual from the different parts. The average thickness is
1 mm.
Depth of post-dam: The post dam is deepest at a point 1/3
of the distance from the posterior edge of the groove and the
midpoint between the midline and hamular notches. It becomes
gradually shallower anterposteriorly and laterally.
The depth or thickness of the post dam should vary in
different individuals and different parts of the same mouth
according to compressibility of the tissue. The mucosa at the
midline of the palate is less compressible than that at the sides, so
that the deepest area of the seal is located on either side of the
midline (1.5-2 mm). Its depth is about 0.5 mm at the midline and
at hamular notches.
The post dam is deepest at the posterior limit and gradually
becomes shallower as it progresses forward to merge with the rest
of soft tissues at the anterior limit
CLASSIFICATION OF SOFT PALATE
The width of the posterior palatal seal depends on the curvature of the soft
palate. The soft palates are classified into three classes based upon the angle that the soft
palate makes with the hard palate.
Class I;
It indicatessoft palate that is rather horizontal as it extend posteriorly with
minimum muscular activity.
Thesoft palate has a gentile curve and allows a broad post dam.
There is considerable separation between anterior & posterior vibrating
line does having white PPS area yielding more retentive denture base.
Its width will be 1mm at the midline, 5-6 at the widest portion on the sides
and o.5 mm medial to the hamular notch.
Class II;
Thesoft palate has a medium degree of curvature and allows for a medium
width of the post dam (3-4 mm at the widest area).
Palatal contour lie between classI &classIII.
Class III;
It is seen in conjugation with high V shape palatal vault. There is few mm
separation of anterior & posterior vibrating line thus there is small PPS
area & less retention.
The soft palate has abrupt curvature and allows a narrow area for post
damming (1-2 mm at its widest area).
ANATOMIC & PHYSIOLOGIC CONSIDERATION
The PPS is divided in two anatomic separate boundaries-
1.Post palatal seal 2. Pterygomaxillaryseal
The post palatal seal is extending formonetuberosity to other.
Pterygomaxillary seal
Band of loose connective tissue lying between the pterygoid hamulus of sphenoid bone
and distal portion of maxillary tuberosity
Extend through pterygo maxillary notch continuing for 3-4 mm anterolaterally
approximation the mucogingival junction. It also occupies the entire width of
pterygomaxillary notch.
The vibrating line runs from about 2 mm buccal to the center of the hamular notch on one
side of the arch, follows the junction of the hard and soft palates across the palate, and
ends about 2 mm buccal to the center of the opposite hamular notch.
Vibrating lines
The PPS lies between the anterior and posterior vibrating lines.
It is an imaginary line across the posterior part of the palate marking the division
between the movable and immovable tissues of the soft palate. This can be
identified when the movable tissues are functioning
It should be described as area not line
Anterior vibrating line
Located at the junction of attached tissues overlying the hard palate and slightly
movable tissues of the immediately adjacent soft palate. This should not be
confused with anatomic junction of hard and soft palate.
It can be located by patient performing Valsalva Maneuver or instructing patient
to say Ah in short vigorous bursts. This places the soft palate inferiorly at its
junction with hard palate.
Due to projection of posterior nasal spine the anterior vibrating line is not a
straight line between the hammular processes. The anterior vibrating line is
always on soft palatal tissues. As soft palate extends posteriorly the action of
palatal muscles become more exaggerated.
Posterior vibrating line
It is an imaginary line at the junction of aponeurosis of
tensor veli palatini muscle and muscular portion of soft
palate. it is straight line
It represents the demarcation between that part of soft palate has limited or
shallow movement during function and the remainder of soft palate that is
markedly displaced during functional movements.
It can be visualized by instructing patient to say Ah in normal unexaggerated
fashion. The posterior vibrating line marks the most distal extension of denture
base.
Techniques used in locating the vibrating line.
1- The clinician will often visualize the position of this line by having the patient say
"Ahh" and noting that thesoft palatal tissues will usually lift while the hard palatal tissues
remain immobile.
2- The Valsalva maneuver in which the patient is asked attempt to blow air through their
nose while the nostrils are gently pinched closed. While gently holding the tongue down with
a mouth mirror, the clinician will often easily visualize the line because the soft palate will
drop dramatically at the vibrating line using this technique.
3- Other features indicating the position of this line may include a rather sharp color
change between the hard and soft palatal tissues at the vibrating line
4- Presence of the fovea near the line. According to Lye the fovea palatine are located on
average of 1.31mm anterior to anterior vibrating line.
5- Lastly, and often the easiest to visualize, may be the rather significant angular change
between the rather flat hard palate and the moderately to severely sloping soft palate. This
junction indicates the vibrating line.
2. A ="clinical" junction of hard and soft palates.
3. B=ah-line ,
4. C=fovea palatinae ,
5. D: anatomical junction of hard and soft palates.
The distal end of the denture : should extend at least to vibrating line and in some
instances it may extend 1 to 2 mm posterior to vibrating line .[ ZARB]
The position of fovea palatine also influences the position of posterior border of the
denture. denture can extend 1-2mm across it. In patients with thick saliva, the fovea palatine
should be left uncovered or else thick saliva flowing between the tissue and the denture can
increase the hydrostatic pressure and displace the denture.
Posterior extent of denture in this region should end in the hamular notch & not extend
over the hamular process as this can lead to severe pain during denture wear
Determining the position of the post-dam
The soft palate is divided into non-movable anterior part that is
adjacent to the hard palate and movable posterior part.
The operator first discovers the position of the vibrating line by
asking the patient to say a prolonged ah, with the mouth widely opened,
and noting the line from which the soft palate moves.
The tissue in front of this line is exposed with a blunt instrument
and the area of soft compressible tissue noted. For future reference it is
useful to mark this line on the palate with an indelible pencil.
The posterior border can be accurately located if it is possible to see
the two small pits (fovae palatinae) one on each side of the midline on the
anterior part of the soft palate. The fovae are usually, though not invariable,
present and are situated just anterior to the vibrating line thus marking the
posterior limit of the denture.
The posterior palatal seal should extend from one hamular (pterygomaxillary) notch to
the other, following the contour of the hard palate anterior to the vibrating line. The fovea
palatinae are usually located anterior to the vibrating lines.
Methods of post-damming
A- CONVENTIONAL APPROACH
After the special tray is fabricated there are certain instructions given to the patients:-
1 To rinse with an astringent mouth wash that is remove to stringy saliva that might
prevent clear transfer marking.
2. Location of pterygo maxillary notch is done by moving the T burnisher posterior angle
to the maxillary tuberosity until it drops into the pterygo maxillary notch. This is necessary
as there are times when small depression in the residual ridge may resemble pterygo
maxillary notch.
3. Identification of posterior vibrating line the patient asked to say AH in normal
unexaggerated fashion
4. Identification of the anterior vibration line. This is done by asking the patient to say
AH with short vigorous bursts (Valsalva Maneuver can also be used)
5- PROCEDURE
o A line is placed with an indelible pencil (Thomson sanitary colour transfer
applicators) through the pterygo maxillary notch & extended 3-4 mm antero-
laterally the tuberosity approximating the mucogingival junction same is done on
the opposite side. This complete the out lining of pterygo maxillary seal.
The posterior vibrating line is marked with an indelible pencil by connection the
line through the pterygomaxillary seal with line just drown demarcation the post
palatal seal
o The resin or shellac tray inserted into the mouth & seated firmly to place. Upon
removal from the mouth, theindelible lines will be transferred to the tray.
o Sometimes it is necessary to redefine transfer marking. The tray in return to master
cast to complete the transfer of the complete posterior border.
The tray is trimmed until the posterior vibration line so that it decides the post
extent denture border.
o Returning to the mouth the palatal fissure is palpated with the T barnisher or
mouth mirror to determine their compressibility in width & depth.
o The termination of glandular tissue usually coincides with the anterior vibrating
line. The anterior vibrating line now marked and transeferred to master cast .this
complete the transferring the outline of posterior palatal seal.
The visual outline is in the shape of cupid bow the area between the anterior
posterior vibrating line is usually narrowest in the mid palatal region because of the
projection of the posterior nasal spine.
Kingsley scraper used to score the cast the deepset area are located on either side
of midline, one third the distance anteriorly from the posterior vibrating line. It is
usually scraped to a depth of approximately 1-1.5 mm . The tissue covering the
medial palatal raffae as little sub mucosa & cannot withstand same compressive
force as the tissue lateral to it
This area is scraped to depth of approximately 0.5-1 mm within the outline of cupid
bow & cast is scrapped to depth of half amoung to palatal tissue in that area can be
compressed being tapered posteriorly.
Failure to taper the seal posterior mainly to tissue irritation.
ADVANTAGE
1. The trail base will be more retentive. This can produce more accurate maxillo
mandibular records.
2. Patient will be able to experience the retentive qualities of the trail base, giving
them the psychologic security of knowings that retention will not be a problem in
the completed prosthesis.
3. The practioner will be able to determine the retentive qualities of the finished
denture, leaving nothing to chance at the insertion appointment.
4. The new denture wearer will be able to realize the posterior extent of the denture
which may ease the adjustment periods.
DISADVANTAGES
1. It is not a physiologic technique & therefore depends upon accurate transfer of the
vibrating lines & careful scraping of the cast.
2. The potential for over compression of the tissue is great.
B-FUNCTIONAL METHOD:
This method is carried out at the time of impression making.
After finishing the impression, post dam area will be determined anda
strip of melted wax or low fusing compound is traced on the
impression over the post dam area.
The impression is seated in the mouth under gentle pressure
until it hardens. Meanwhile, the patient is asked to raise the soft palate
by breathing deeply from the nose.
The added material will spread out and form a raised
strip across the distal end of the impression. The final
impression with the posterior border seal is carefully boxed and
poured in stone.
Advantages:
1-The displacement of the tissues is within its
physiologic limit. Over compression of the tissues is
avoided.
2-posterior palatal seal is incorporated in the trial denture base for added
retention.
The rational for the placement of a seal in the impression tray as follows:-
1. To establish positive contact posteriorly to prevent the final impression material
from sliding down the pharynx.
2. To serve as a guide for positioning the impression tray, especially if a shim has
been used within the tray to establish the borders.
3. To create slight displacement of the soft palate.
4. To determine if adequate retention & seal of the potential denture border is
present.
C- FLUID WAX TECHNIQUE
The marking are recorded in final impression one of the four type of wax can be used for
their technique:-
1. Iowa wax white developed by Dr. Earl S. Smith.
2. Korecta wax no. 4, orange developed byDr. O.C. Applegate.
3. H.L. physiologic paste, yellow-whitedeveloped by Dr. C.S. Harkins.
4. Adaptol green developed by Nathan G.
These wax are designed to flow at mouth temperature temperature. The melted wax is
painted into the impression surface & in the outline at seal area , the wax applied in
slightly & excess of the estimateddepth & allowed to cool to blow mouthtemperature to
increase its consistency& make it more resistent of flow.
The impression is carried to mouth & held under gentle pressure 4-6 minute to allow the
material flow position of head & tongue during this is procedure.
The soft palate should be impression in it most functionally depressed positions that is by
keeping frankfort plane 30 below the Hz & the tongue is firmly positioned against
mandibular anterior teeth.
ADVANTAGE-THIS POSTION
Soft palate is impression in its most functionally depressed position.
The flow of saliva & impression material into the pharynx is prevented.
After 4-6 minutes impression tray is removed from the mouth & examined for uniform contact.
If the tissue contact has not established the wax will appear dull.
If the tissue contact has been established it will appear glossy.
If excess wax protruded out of the tray it should be removed.
A Secondary impression is reinserted & held for 3-5 minutes under gentle pressure followed
by 2-3 minutes of firm pressure applied to mid palatal area of the impression tray, upon removal
of tray from the mouth it is careful examined to see wax terminate in feathered edge near the
anterior vibrating line.
Advantages
1. It is physiologic technique displacing tissues within their physiologically acceptable
limits.
2. Over compression of tissue is avoided.
3. Posterior palatal seal is incorporated into the trail denture base for added retention.
4. Mechanical scrapping of the cast is avoided.
Disadvantages
1. More time is necessary during the impression appointment.
2. Difficulty in handling the materials & added care during the boxing procedure.
D- ARBITRARY METHOD:
This method is carried out during jaw relation recording
or at the try-in stage.
The vibrating line is observed in the patient's
mouth as the patient says a series of short "ah" and marked
by indelible pencil.
The trial denture base is inserted so the indelible
pencil line marked on vibrating line of the soft palatewill
be transferred from the soft palate to the trial denture base,
and then to the cast (The posterior limit o f the post dam).
The tissues anterior to the vibrating line are palpated
with a mouth mirror to determine their compressibility both
in widthand depth and marked with the indelible pencil, then
transferred to the cast (The anterior limit of the post dam).
The cast is then scraped to the desired depth and width.
-
E-SCRAPING OF MASTER CAST:
This technique is the least accurate and un-physiologic as the
technician attempts to place the posterior palatal seal. A line is
drawn across the posterior border of the cast between the two
hamular notches passing behind the fovea palatinae.
Another line is drawn anterior to the first line in the shape
of butterfly. The cast is scrapped by a sharp knife or carver to the
post dam between theses two lines.
The post dam is usually narrow in its central part (due to the projection of
posterior nasal spine), wider as it extends laterally on each side, and narrow again as it
approaches the hamular notch to fade out behind the tuberosity. It is sometimes called
butterfly (Cupid's bow) post dam .
Damming of the lower denture
A lower denture may be post-dammed at each distal extremity by slightly compressing the
retromolar pads. The amount of compression must be determined at the time of impression
taking.
Adding a posterior palatal seal to an existing denture:
The deficiency may be either in depth or in length of the denture base, or in both. Prior to
taking any corrective measures, the dentist should evaluate the entire prosthesis. If, in addition to
an insufficient posterior border, one or more of these criteria are not met, then it is more than
likely that a new prosthesis will have to be made. If the correct esthetic and phonetic
requirements have been fulfilled, the proper vertical dimension and centric relation position's
established, and the remaining denture borders correctly extended, then one should undertake the
correction of the posterior seal area. This can be done by three methods:
a. Light cured resin can be utilized for intraoral correction of the posterior palatal seal.
Self cure acrylic resin is irritant to the mucosa. The denture is tested in the mouth till
sufficient peripheral seal is obtained.
b. Impression material can be used for this purpose (compound impression or wax) and
then duplicated in self cure acrylic resin.
c. Scraping a cast poured on the denture as before, and then the cast is provided with
escape ways to allow excess self-curing repair material to escape. The cast is coated with
separating medium and self-cure repair material is added to the denture at the posterior
portion. The denture is then seated firmly on the cast excess material will escape through
the escape ways.
ERRORS IN RECORDING OF PPS
1. UNDER EXTENSION
This is the most common cause for poor posterior palatal
seal. It may be produced due to one of the following reason:-
1. The denture does not cover the fovea palatina, the tissue
coverage is reduced & the posterior border of the denture is not in contact with the soft
resilient tissue which will move along with the denture border during functional
movements.
2. Reduce the patient anxiety to gagging.
3. Improper delineation of the anterior & posterior vibrating line.
Prevention: Excessive trimming of the posterior border of the cast.
2. OVER EXTENSION
1. The denture base can lead to ulceration of the soft palate & painful deglutition.
2. The most frequent complaint from the patient will be that swallowing is painful &
difficult.
3. The hamuli are covered by the denture base , the patient will experience sharp pain,
specially during function.
4. The pterygoid hamuli must never be covered by the denture base.
5. The overextension can be removed with a bur & then carefully repolished.
Prevention: These region are trimmed & poslished
3. UNDER POSTDAMMING
1. This can occur due to improper head positioning &
mouth positioning. E.g. the mouth is wide open while
recording the posterior palatal seal the mucosa over the
hamular notch becomes stretched. This will produce a
space between the denture base & tissue.
2. Inserting a wet denture into a patients mouth &
inspecting the posterior border with the help of mouth
mirror. If air bubble are seen to escape under the
posterior border it indicates under damming.
Prevention: The master cast can scraped in the posterior palatal area or the fluid wax
impression can be repeated with proper patient position.
4. OVER POSTDAMMING
1. This commonly occur due to excess scraping of the master cast. It occur more commonly
in the hamular notch region.
2. Pterygo maxillary seal area, then upon insertion of the denture the posterior border will
be displaced inferiorly.
Prevention: Reduction of the denture border with a carbide bur, followed by lightly
pumishing the area while maintaining its convexity.
Positioning the posterior border of the upper denture [BASKER]
If an existing denture is under-extended in this region there may be uncertainty as to
whether the patient can tolerate the desired correction of the underextension.
Under such circumstances, if a fully extended new denture is fitted which subsequently
cannot be tolerated, the palate of the replacement denture will have to be shortened. The
post-dam will be lost as a result, the border seal broken and the retention of the denture
reduced.
As an insurance against this eventuality it is wise practice to cut two post-dam lines,
one in the position of that on the old denture and one at the vibrating line. If, after
wearing the new denture for a few days, the patient reports that the new position of the
posterior border is intolerable, the extension of the palate can be cut back to the old post-dam
line without the danger of breaking the continuity of the border seal.
Recording Bases and Occlusion Rims6 COMPLETE DENTURE THEORY AND PRACTICE
Recording Bases and Occlusion Rims
Record blocks are generally made of occlusion rims attached to well fit trial denture base.
The recording base (trial denture base) is a temporary form that closely resembles the final
base of the denture under construction. It is used for recording maxillo-mandibular jaw
relationships and for setting the artificial teeth.
Requirements of an ideal recording base
1- Dimensionally stable, both on the cast and in the mouth.
2- They must be rigid and strong.
3- They must be well adapted to the cast and accurately fit the denture area.
4- They should retain their shape at mouth temperature.
5- They should have smooth and round borders.
6- They should be non-irritant
7- They should be easy to manipulate.
8- Easily contoured and polished
9- should be of proper thickness (about 2 mm in the hard palate area and 1 mm over crest
and facial slope of ridge to avoidinterfere with teeth placement
Types of recording bases
I- Temporary recording bases
These bases are used during the various steps and will later be replaced by the permanent denture
base. The materials used for temporary bases are:
1- Shellac baseplate
2- Cold curing acrylic resin
3- Vacuum formed vinyl or polystyrene.
4- Baseplate wax.
5- Swaged tin baseplate.
II- Permanent recording bases
It is the base of the finished denture. The materials used for permanent bases are:
1- Heat-curing acrylic resin
2- Casted metal (gold, chromium-cobalt alloy and chromium nickel).
Temporary recording bases
1- Shellac baseplate
It is a commonly used material for recording bases.
Construction
1- All undercuts of the casts should be blocked out.
2- To prevent the shellac from sticking to the cast, the cast should be treated by
one of the following methods:
a- Dusting the cast with talcum powder
b- Soaking the cast in water for few minutes
c- Adapting a layer of tin foil (0.001 inch) to the cast.
3- The shellac is softened on a flame then adapted to the cast by wet fingers. The
adaptation is started with the palatal portion of the maxillary cast or with the
lingual surface of the mandibular cast followed by the crest of the ridge and the
reflections.
4- The material is trimmed with scissors leaving approximately 5mm beyond the
edge of the cast.
5- This excess is heated and folded onto themselves to form a smooth rounded
border. Overheating should be avoided to prevent burning of the shellac.
To increase strength and rigidity of shellac base plates, reinforcing wires of 12-14
gauge should be embedded across the posterior palatal seal area for the upper trial denture
base and in the lingual flange of the lower one .
Advantages
1- Easily and quickly made.
2- Stronger than wax.
3- Laboratory time is saved.
4- Inexpensive.
Disadvantages
1- It is difficult to obtain good retention.
2- It is not adequately strengthened, distortion may occur when left for a long time in the
mouth.
3- It is a brittle material.
4- The bond between the shellac base and the wax is less than that of acrylic base.
2- Cold-curing acrylic resin
Non -flasking method (Finger adapted dough method)
1- The cast is prepared by blocking out the undercuts with
wax and applying a separating medium.
2- The auto polymerizing resin is mixed and allowed to
reach the dough stage, then rolled to a sheet of 2-3 mm
thick.
3- While the acrylic sheet is still soft, it is adapted to the
cast and the excess resin is trimmed with sharp knife.
4- After polymerization has been completed, the acrylic
base is removed and retrimmed with bur, the external
surface of the resin base can be polished with wet pumice.
5- The thickness of the resin base over the crest of the ridge is reduced to about
1mm.
Flasking method
1- A wax is adapted to the cast and flasked. After setting of the investment
material wax elimination is carried out.
2- An autopolymerizing resin is mixed in a glass jar and packed into the mold
when it reaches the doughy stage, then the flask is closed.
3- Resin is allowed to polymerize under pressure for 20 to 30 minutes.
4- The base is removed from the flask, trimmed, and polished. If undercut is
present that will interfere with seating the base on the cast, it must be relieved
before seating is attempted.
This method requires considerable time for, fabrication and more costly.
Since breakage of the master cast is possible with this technique it is advisable to duplicate the
cast and to construct the recording base on the duplicated model.
Alternating application of cold-curing powder and liquid (sprinkle-on method):
1- Undercuts are blocked out and tin foil or petrolatum is applied to the cast.
2- A thin layer of powder (polymer) is dusted over a small surface area of the
cast and sufficiently wetted with liquid (monomer) to produce a slight flow.
3- Alternate applications of powder and liquid are made until a thickness of 2 to
3mm has been developed.
4- The completed base is kept to polymerize, then removed, trimmed and
polished.
Well adapted base can be formed using this method; since any shrinkage that occurs in first
application is partially compensated for by each subsequent application and polymerization
shrinkage is kept minimal.
Advantages
1- They are strong and have accurate fit.
2- Do not soften or warp at mouth temperature.
3- They are not easily distorted
4- Any type of occlusal rims can be mounted to it.
Disadvantages
1- The retention may be reduced due to blocking out of the undercuts on the cast.
2- They may take up space needed for setting the teeth, necessitating some grinding
of the resin base in required areas.
3- Vacuum -formed vinyl or polysterene
1- The cast is prepared by blocking out the undercuts.
2- The cast is placed in its position on the vacuum machine.
3- Vinyl or polysterene sheet is inserted in the frame located below the heat
source.
4- Heating should be continued until the sheet is softened and begins to sag.
5- The supporting frame carrying the softened sheet is lowered onto the cast and
the vacuum is turned on to adapt the sheet.
6- The heater is turned off and the base is allowed to cool then removed and
trimmed.
The vacuum method is very easy, fast and gives accurate results.
4- Baseplate wax
1- The wax is softened over a flame and adapted.
2- Excess wax is trimmed and the borders are rounded.
3- A strengthening wire is adapted in the posterior palatal seal
area of the upper base or incorporated into the lingual flange
of the lower base to increase both the rigidity and the
resistance to distortion.
These types are used in conjunction with wax occlusal rim. To prevent the wax from sticking to
the cast, talcum powder is applied to the cast.
Advantages
1- Easily to construct.
2- Inexpensive.
Disadvantages
1- It is softened and distorted at mouth temperature.
2- It does not withstand the pressure requiredfor recording jaw relationship.
3- It is very weak and not commonly used.
To increase stability and retention of shellac, resin, or wax-recording bases reline the
recording base with soft liner, zinc oxide eugenol or light bodies rubber base . The lining
procedure is done over the master cast after blocking out the undercuts and covering the cast
with a well-adapted layer of tin foil.
5- Swaged tin base plate
1- Three tin layers of gauge (5) can be swaged one above the other on a
metal die and trimmed to the proper extend.
2- The inside layers can be cemented together with wax or zinc oxide
egeanol.
Advantages
1- It does not warp at mouth temperature.
2- It gives a uniform thickness.
3- It has a suitable fitness.
Stabilization of temporary recoding bases:
Tin foil is adapted to the cast. A thin mix of zinc-oxide paste is distributed on the fitting
surface of the base plate. Then the base is placed and pressed on the foiled cast. The paste will
adhere to the foil. The excess material is removed and the base is left till the material set.
In case where the residual ridge exhibits moderate to severe undercut, light-bodied
rubber base impression material or soft denture liner is used to adapt the record base. The
fitting surface of the base is painted by adhesive before applying the lining material.
The "flexible augmented flange technique" for fabricating complete denture record
bases Ouintessence Int 2001:32:361-364
A technique for fabricating complete denture record bases that features flanges
augmented with resilient liner is reintroduced and recommended. It is coined the "flexible
augmented flange technique."
The technique takes advantage of the elastic properties of tissue conditioner, available
anatomic undercuts in definitive casts, and the rigidity of record base resin to create
stable, retentive, well-fitting, and comfortable record bases that minimally abrade casts.
Tissue conditioner, which strongly bonds to the intaglio surface of record base flanges,
replaces blackout wax to form augmented flanges with flexible inner sections that are
sufficiently elastic to engage and then release from undercuts. The flexibility of the inner
section of theflanges permits a traumatic insertion and removal from a patients mouth,
despiteoverall record base rigidify.
Permanent denture bases
1-Heat-curing acrylic resin
These recording bases are permanent and become part of the finished denture.
Technique
1- The wax pattern of desired shape is directly
adapted onto the cast without blocking out the
undercuts.
2- The definite outlines are obtained and the
pattern is invested in a flask. The wax is eliminated with hot water,
and then tin foil substitute is applied. The mixed acrylic resin is
packed into the mold and processed according to the manufacturers
directions.
3- The denture base is removed from the cast and finished.
4- The artificial teeth are attached to the acrylic base by wax to form the
trial denture. When satisfactory, the trial denture is flasked, processed.
Either cold-curing or heat-curing resin may be used to attach the teeth to the
processed base.
Advantages
1- The bases are rigid, accurate and stable.
2- It does not warp at mouth temperature.
3- The bond between the wax rim and the base is strong.
4- Any type of occlusal rim can be used.
5- Retention and stability can be tested in the mouth before the finishing of
the denture.
Disadvantages
1- Time consuming
2- Warpage always occurs when acrylic resin is reprocessed. However, this
can be prevented by attaching the teeth to the base by cold-curing acrylic
resin. It is not advisable to finish the denture on these bases.
2- Cast alloys
These recording bases are permanent and become part of the
finished denture.
Technique
1- Refractory casts are first prepared from the
final cast. A wax pattern is formed on the
refractory cast, spurred, invested, burned out and the molten
alloy cast into its mold.
2- On cooling, the casting is removed from the investment,
finished and polished and then returned to the final cast.
Occlusion rims are attached to these metal bases to register the
jaw relationship. The artificial teeth are attached to the metal
base by acrylic resin.
Advantages
1- The bases are rigid, accurate and dimensionally stable.
2- They add more weight to mandibular denture and more thermal
conductivity to maxillary denture.
Disadvantages
1- They are more costly than other types of bases.
2- They require more time for fabrication.
Occlusion Rims
They are horseshoe shaped occluding surfaces attached to the temporary or final denture
base for the purpose of recording jaw relations and arranging of teeth.
The occlusion rims are used for:
1- Establishing accurate maxillo mandibular jaw relations (vertical dimension and centric
relation).
2- Establishing the proper lip and cheek support (fullness of the lips and cheeks).
3- Choice of teeth
a- High and low lip lines; the distance between each of them and the occlusal plane
determines the length of the upper and lower teeth.
b- Canine lines; the distance between the canine lines determines the width of the
maxillary anterior teeth.
c- The distance between the canine lines and the posterior end of the occlusion rim
determines the mesiodistal width of the posterior teeth.
4- Arrangement of the artificial teeth; occlusion rim helps in the determination of:
a- The proper occlusal plane.
b- The neutral zone and the shape of the arch.
c- The labial surface of the teeth.
d- Position of mid line of the arch for the correct placement of the central
incisors.
e- Generally the occlusion rims form the medium in which the teeth are set up.
Types of occlusion rims:
1-Base plate wax rim:
Procedures of construction:
1. Dry the record base thoroughly as wax will not adhere to a wet surface.
Roughen the area of the record base where the wax will be adapted.
2. Uniformly soften a sheet of hard pink baseplate wax. Flame the wax on a
Bunsen burner flame slowly by passing the wax quickly through the flame many
times. When the wax is thoroughly softened, fold the wax in half. Continue to
flame the wax to soften it. Repeat the folding and warming until the required roll
is formed.
3. Form thewax into a horseshoe shape and adapt the wax to the record base over
the ridge crest area. Begin at one posterior end and continue to the anterior and to
the opposite end.
4. Seal it to the record base with molten wax using a hot spatula. Add wax as
needed to contour the rim. Sticky wax can also be used to attach the occlusion
rims.
5. The rim should approximate the position of the natural teeth. Remember the
facial surfaces of the maxillary central incisors are 8-10 mm anterior to the center
of the incisive papilla. The wax rim must be anterior to the crest of the maxillary
ridge.
6. Use a heated wax spatula to develop a flat occlusal plane.
7. Adjust the height and width of the wax rims to the previously mentioned
dimensions.
Method of construction
1- Ready made rims: by a device called occlusion rim former .
2- Freehand molded rims: wax rolled and shaped to the arch form .
2-The composition (compound) rim:
The use of compound rim is indicated when it is desired to obtain more than one
jaw relation record or when Gothic arch tracing is to be taken.
3-Plaster and pumice rim:
When a functional recording of mandibular movements are to be made, a mixture
of plaster and pumice rims is used. In this technique the patient grind the maxillary and
mandibular rims together and produces the occlusal plane conforming to the mandibular
movements.
This plaster-pumice combination is mixed (equal parts) with water into a thick
consistency and a roll of it is placed on to the base. These plaster-pumice rims shouldbe
used through 24 hours before they became hard.
The following factors should be considered during fabrication of occlusion rims:
1- The relationship of the neutral teeth to the alveolar bone
The fabrication of successful, functional and esthetic prosthesis can be
accomplished if the artificial teeth are placed in the same position that was
occupied by the natural teeth they are replacing.
The upper and lower anterior teeth are inclined slightly forward of the alveolar
bone.
The maxillary posterior teeth are positioned slightly buccal to the alveolar ridge.
The mandibular posterior teeth are inclined inward.
2- Relation of occlusion rims to edentulous ridge
The occlusion rims replace the natural teeth both in dimension and in their relationship to
anatomic structures. These relationships should be re-established by the occlusion rims even if
resorption of the residual ridge has occured.
Characteristics of occlusion rims:
1-The occlusion rims should be approximately the same size and shape as the natural
teeth being replaced.
2- Wax rims are smooth and have a flat occlusal surface. They are about as wide
buccolingually as denture teeth wider in the posterior, narrower in the anterior.
3-occlusal rim must be centered buccolingually over and parallel to residual ridge crest.
4- The occlusal rim is properly sealed to the baseplate without any voids
Maxillary occlusal rim
1. Labial surface of the natural central incisors
averages 6-8 mm anterior to the middle of the
incisal papilla.
2. The rims incline at approximately a 15" angle
labially to provide adequate support for the lip
3. Theplane of occlusion on the maxillary arch
should be approximately 22 mm in height, as measured from the bottom of the
notch createdby the labial frenulum.
4. The posterior maxillary wax rim height is 16 mm
from the deepest point of the buccal flange. (The
maxillary occlusion rim should be approximately 12
mm in height from the record base at the crest of the
ridge in the tuberosity areas).
5. It should gradually taper toward the occlusal plane
and be approximately 8-10 mm in width in the
posterior, and 6-8 mm in width in the anterior region.
6. The upper rim terminates at the anterior aspect of the maxillary tuberosity. The
posterior of the maxillary occlusion rim should slope occlusally at approximately
a 45 degree angle from the record base, beginning approximately 8 mm from the
posterior extent of the record base. This will generally provide space for the
mandibular record base once placed intraorally
Mandibular occlusal rim
1. plane of occlusion runs parallel with base of cast, which
was trimmed to be parallel with residual ridges
2. the plane of occlusionanteriorly on the mandibular arch
should be approximately 18 mm in height, as measured
from the bottom of the notch created by the labial frenulum,
3. in the posterior mandibular region the height is equal to a point representing two
thirds the height of the retromolar pad.
4. It should be approximately 8-10 mm in width in the posterior, and 6-8 mm in
width in the anterior region.
5. rimsincline at a 15" angle labially to provide adequate support for the lip.
6. The lower rim terminates anterior to the retromolar pad. The rims are beveled
posteriorly towards the base to not interfere during recording of jaw relationships
N.B.: In the lower jaw resorption occur more labially in anterior region and equally at
buccal and lingual in premolar region and more lingually in molar region.
The occlusion rim is is contoured as a guide for arranging artificial teeth which placed
labially anteriorly and on the ridge in premolar area and lingually at molar area. Boucher
One line is drown from the lingual to retromolar bad and extend anteriorly to a point just
lingual to premolar region, this line aid in poisoning the lingual surface of posterior teeth
Height : Width: ( U. & L. )
a- Upper: ant. =20-22 mm a-ant. =4-6 mm
post. =16-18 mm
b- Lower: ant. =16 mm. b-post. =8-10 mm
post. =14 mm or 2/3 the
retromolar pad height
Maxillary and Mandibular Occlusion Rim Measurements
CUSPID LINES
HIGH LIP LINE
MIDLINE
OCCLUSAL
PLANE
MIDLINE
22 mm
(APPROX
.)
18 mm
(APPROX.)
18mm (APPROX.)
VERTICAL
DIMENSION
LABIAL CONTOUR
OCCLUSAL
PLANE
JAW RELATION 7 COMPLETE DENTURE THEORY AND PRACTICE
JAW RELATION
Jaw relation is defined as, "Any relation of the mandible to the maxilla"-GPT.
Various Terms Used in Jaw Relation
Orientation relation "The mandible which is kept at its most posterior portion, it can
rotate in the sagittal plane around an imaginary transverse axis passing through or near
the condyles".
Vertical relation amount of separation between maxilla and mandible in frontal plane
Horizontal relation "Maxillomandibular relationship in which the condyles articulate
with the thinnest avascular portion of their respective discs with the complex in the
anterosuperior direction against the slopes of articular eminence."
Centric jaw relation "The most posterior relation of the mandible to the maxillae at the
established vertical dimension" -GPT.
Eccentric jaw relation "Any jaw relation other than centric jaw relation" -GPT.
Median jaw relation "Any jaw relation when mandible is in the median sagittal plane".
Posterior border jaw relation: "The most posterior relation of the mandible to the maxillae
at any specific vertical relation"- GPT.
Protrusive jaw relation "A jaw relation resulting from a protrusion of the mandible"- GPT.
Rest jaw relation "The habitual postural jaw relation when the patient is resting
comfortably in an upright position and the condyles are in an neutral, unrestrained
position in the glenoid fossa"- GPT.
Unstrained jaw relation "The relation of the mandible to the skull when a state of
balanced tonus exists among all the muscles involved". "Any jaw relation that is attained
without undue or unnatural force and which causes no undue distortion of the tissues of
the temporomandibular joint" -GPT.
Jaw relation record "A registration of any positional relationship of the mandible
in reference to the maxilla. These records may be any of the many vertical, horizontal,
orientation relations." -GPT.
Terminal jaw relation record "A record of the relationship of the mandible to the maxilla
made at the vertical dimension of occlusion and at the centric relation. "-GPT.
THEORETICAL CONSIDERATIONS
Basic mandibular positions
(1) Rest position. It is the vertical and horizontal position the mandible assumes when
the mandibular musculature is relaxed and the patient is upright.
When the mandible is in the rest position there is a space between the occlusal surfaces
of the teeth which is known as the freeway space or interocclusal rest space. This space
is wedge-shaped, being larger anteriorly where the separation between the teeth is most
commonly within the range 24 mm.
(2) Muscular position. The muscular position is the vertical and horizontal position of
the mandible produced by balanced muscle activity raising the mandible from the rest
position into initial tooth contact.
(3) Intercuspal position. The intercuspal position is the vertical and horizontal position
of the mandible in which maximum occlusal contact occurs. In the denture wearer, the
intercuspal and muscular positions should coincide.
(4) Retruded contact position. With light tooth contact maintained, movement of the
mandible in a posterior direction from the intercuspal position is usually possible. This
posterior position is known as the retruded contact position and is separated from the
intercuspal position by approximately 1 mm.
The rest position
(1) Constructing or assessing dentures.
(2) Relaxation of the masticatory apparatus.
Control of the rest position: The rest position of the mandible at any one time is
the result of a balance of forces .
Passive forces
(1) Muscles attached to the mandible.
(2) Gravity.
(3) Reduced intra-oral air pressure.
(4) The elastic properties of the capsules and
ligaments of the temporomandibular joints.
Active forces
(1) Mass of the mandible.
(2) Changes in position of the mandible.
(3) Pain, drugs and emotional stress.
Variation in the rest position
(1) Short term variables.
Patient supine Reduced
Head tilted
a. Back Increased b. Forwards Reduced
Insertion of lower denture or record block Increased
Stress Reduced
Pain Reduced
Drugs Variable
(2) Long-term variables. If the same dentures are worn for many years and are
not maintained, a reduction in the occlusal vertical dimension occurs as a result
of alveolar resorption and occlusal wear. The rest position of the mandible adapts
to this change and takes up a position closer to the maxilla.
BIOLOGIC CONSIDERATION IN JAW RELATION AND JAW
MOVEMENTS
Mandibular movements
It is complex in nature, vary greatly among individual and within the same
person.
Dynamics of mandibular movements :
A. Muscles move the mandible.
B. Up bolstered bone guides it.
C. Ligaments and fascia limit it "other anatomical structures such as the coronoid
process are also limiting factor.
D. Nervous function controls it.
Purposes of mandibular movements :
A. Functional
1. Chewing " mastication"
2. Swallowing "deglutition"
3. Speech " phonetics"
4. Facial expression.
5. Wetting the lips.
B- Non-functional: or Para functional or perverted
1. Bruxism
2. Clenching
3. Habits " pipe smoking, pencil biting, and other habits"
Determinants of mandibular movements :
1. Posterior determinants (right and left TMJ), not under control of
dentist except via oral surgery.
2. Anterior determinants (Teeth) can be modified by dentist-phonetics
and esthetics are limiting factors.
3. Proprioceptive neuromuscular mechanism (TMJ, pulps, and
periodontal tissues send nerve impulses to muscles to work-conditioned
reflex) can be directly modified to a degree by modifying teeth.
4. Emotional status, stress or tension of the patient (C.N.S.). Emotional
stress contributes to bruxism, muscle spasms, and TMJ. complaints.
Factors that regulate mandibular movement
Any mandibular movement is the result of the interaction of a number of biologic
factors. These include:
A. Influence of opposing tooth contacts.
B. Influence of TMJ.
C. Muscular involvement in mandibular movements
D. Influence of mandibular ligaments
E. Neuromuscular regulation
F. Influence of the tongue.
A. Influence of opposing tooth contacts:
The manner in which the teeth contact is related not only to the occlusal surface
of teeth, but also to muscles, TMJ, and neurophysiologic components including
the patients mental well being.
Variations in condylar movement have been observed when deflective occlusal
contacts or steep incisal guidance from opposing canines change the pathway of
mandibular movements. Thus the inclined planes of artificial teeth must be so
positioned that they are in harmony with other factors that regulate mandibular
movement, failure to develop this kind of occlusion can disturb the stability of
complete dentures.
B. Influence of TMJ:
The joint is much more stable with the teeth in occlusion than when the jaw is
open.
In occlusion, teeth stabilize the mandible on maxilla and no strain is thrown on
the joint when an upward blow is received on the mandible.
Forward movement of the condyle is prevented by the prominence of the
eminentia and by contraction of the posterior fibers of temporalis.
Backward movement is prevented by TMJ ligament and contraction of the
lateral pterygoid muscle.
In the open position, the joint is less stable rotating and the condyle lies forward
on the slope of the eminentia.
Movements of the joint:
1. Rotation, which occurs in the lower compartment of TMJ
due to tight attachment between meniscus, capsule and
condyle. Every point of the mandible makes an arc around the
stationary center of rotation
2. Translatory; which occurs in the upper compartment of TMJ due to loose
attachment between the capsule, skull and meniscus.
Every point of the mandible moves a certain distance in the
same direction.
Movement up to 8 mm. between condyle and meniscus from
retruded to full opening was revealed.
The flexibility of the condylar movements and the fact that
there are 2 condyles makes three-dimensional space in which any one point of
the mandible can move with considerable freedom. It can move from one limit or
border position to another without going through a central or median position
such as the rest position. This type of movement is called circumductory
movement.
Axes of mandibular rotation
Rotational movements of the mandible are made around three axes.
1. Transverse axis:
During opening and closing movements the
mandible moves in the sagittal plane around
transverse axis that passes through both condyles.
Transverse axis can be located when opening
and closing movements occur with the mandible in its
most retruded position (Terminal hinge axis).
2. Vertical axis
In lateral excursion, the mandible rotates around a
vertical axis passing through the condyle on the working side.
Since it is physiologically impossible to make a lateral
mandibular movement with no translation of the condyle on
the working side, again the vertical axis is moving and tilting along with
the mandible.
3. Sagittal axis:
During a lateral mandibular movement, the condyle on the
balancing side that is moving forward and medially
also moves downward because of the slope of the
articular eminence.
This downward movement of the condyle on
the balancing side causes the mandible to rotate
around a sagittal axis passing through the condyle on
the working side.
The sagittal axis also moves with working side condyle as it
translate, laterally, anteriorly, posteriorly, upward or downward
depending on the movement itself and the anatomic form of the glenoid
fossa, the condyle and the articulator disc.
C Muscular involvement in mandibular movements
The masseter and medial pterygoid:
The direction of both muscles in slightly
backward so that equal contraction of both pairs
produces a forwards as well as an upward movement.
Stronger contraction of the left medial pterygoid and
right masseter will result in upwards and lateral
movements of the mandible to the right. The masseter
has 3 parts, superficial, intermediate and deep.
Contraction of deep fibers produces a backwards pull
on the mandible, aided by the distal fibers of temporalis.
The temporalis and lateral pterygoid:
- These are the muscles, which produce horizontal
movements, and positioning of the condyles and
mandible as the teeth comes into occlusion.
- Temporalis provides upward and backward
movements of the mandible with less power.
- Some lateral pterygoid fibers are inserted into
the anterior part of the meniscus through the
capsule causing movement of these tissues.
- The lateral pterygoid muscles acting together pull the condyles
forward and downward.
- When the left muscle contracts, while the other relaxes the mandible
moves to the right, this contraction helps to pull the mandible bodily to
the right "Bennet movement".
A significant feature of lateral pterygoid is its sole responsibility for
protraction of the condyle; there is no opposing muscle inserted
posteriorly in the condyle to retract it which is provided by contraction of
posterior temporalis and deep fibers of the masseter muscle and partly by
relaxation of lateral pterygoid.
Digastric and geniohyoid muscles :
- They depress the mandible in a down and backward direction- the hyoid
bone has to be fixed and this is achieved by the opposing contractions of
the stylohyoid and infra-hyoid muscles.
- When the mandible is fixed in the intercuspal position, the contraction
of these muscles will raise the hyoid bone, which occurs during
deglutition.
Suprahyoids :
Geniohyoid, digastric, mylohyoids and steriohyoids,
all these muscles function as a group to elevate the
hyoid bone and to depress the mandible when the
hyoid bone is fixed.
Infrahyoids :
Thyrohyoids, sternohyoids, sternothyroid and omohyoid, their function is
to lower the hyoid bone and larynx and to steady the hyoid bone, which
will allow then the suprahyoids to depress the mandible
Summary for muscular involvement in mandibular motion:
1- Mandibular elevators:
Muscle Origin Insertion Action Innervation
Masseter Maxilla
Zygomatic
arch
Ramus
Angle of mandible
Elevation Mandibular division of
trigeminal nerve
Medial
pterygoid
Medial
surface of
pterygoid
process of
sphenoid and
maxilla
Ramus
-Angle of mandible
trigeminal nerve (V)
Temporalis Parietal bone -Ramus -Coronoid
process of mandible
trigeminal nerve (V)
2- Mandibular depressors:
Lateral
pterygoids.
Lateral
surface of
pterygoid
plate.
Greater wing
of sphenoid
bone.
Condyle process of mandible. Depression. Mandibular division of Trigeminal
nerve (V).
Digastrics. Digastric fossa
of mandible.
Mastoid notch of the
temporal bone.
Hyoid bone attached by the
intermediate tendon.
Depression Facial nerve (VII). Trigeminal nerve
(V).
3-Mandibular protrusion:
Inferior Lateral
pterygoid.
Greater wing of
sphenoid bone
Lateral surface of
pterygoid plate.
Condyle process of
mandible.
Protrusion. Mandibular division of trigeminal
nerve (V).
Masseter Maxilla
Zygomatic arch
Ramus and angle
of mandible.
Protrusion andibular division of trigeminal
nerve (V).
Medial pterygoids Medial surface of
pterygoid process
of sphenoid
bone.
Maxilla.
Ramus and angle
of mandible.
Protrusion. Mandibular division of trigeminal
nerve (V).
4-Retraction of the mandible:
Temporals. Parietal bone. Ramus and coronoid
process of mandible.
Retraction andibular division of
Trigeminal nerve (V).
Digastrics. Digastric fossa
of mandible.
-Mastoid notch
of the temporal
bone.
Hyoid bone attached
by the intermediate
tendon.
Retraction Facial nerve (VII).
Superior Lateral
pterygoid
Greater wing of
sphenoid bone.
Condyle process of
mandible.
Retraction Mandibular division of
trigeminal nerve (V).
5-Lateral movement:
Temporals. Parietal bone
Ramus and
coronoid
process of
mandible.
Retraction.
Mandibular division of
Medial pterygoids
Medial surface of
pterygoid process
of sphenoid bone.
-Maxilla.
Ramus and
angle of
mandible.
Retraction.
Inferior Lateral pterygoid
Lateral surface of
lateral pterygoid
plate.
-Maxilla.
Condyle process
of mandible
Retraction.
D. Influence of mandibular ligaments
They provide limits or borders of the circumductory mandibular movements and
are of value when transferring mandibular movements and position to
articulators.
E. Neuromuscular regulation of mandibular movements
- The impulses, may arise at the conscious level producing voluntary mandibular
activity, or arise from subconscious level of C.N.S. producing involuntary
movements or modification of voluntary movements.
- There are nerve endings within the capsules, which relay information on
positions and movement of the condyles to the C.N.S.
- Certain receptors in mucous membranes of the oral cavity can be stimulated by
touch, thermal changes, pain or pressure. These receptors are named
extroceptors.
- Other receptors located in the periodontal ligament, mandibular muscle and
ligaments provide information about location of the mandible in space and are
called proprioceptors.
- The impulses that are generated by stimulation of these oral receptors travel to
the sensory nucleus of the trigeminal nerve (in case of extroceptors) or to the
mesencephalic nucleus (in case of proprioceptors) from these 2 nuclei the
impulses can be transmitted:
1. By way of thalamus to the conscious level producing voluntary
change in the position of the mandible.
2. To the motor nucleus of the trigeminal nerve and directly back to the
mandibular muscles (in a reflex arc) producing involuntary movements
(e.g. away from a source of pain while making jaw relation record or a
modification in the physiological resting position because of soreness of
the mouth from dentures.
3. A combination of the two types.
F. Influence of the tongue on mandibular movements
e.g.procedure of asking the patient to place the tongue against the posterior part
of the trial denture base in order to obtain the centric relation.
Basic mandibular movements
four movements of great importance to complete denture service:
A. The hinge-like movement: This is used in opening and closing the mouth for
the introduction of food and to a limited degree, for crushing of certain types of
brittle food.
B. Protrusive movements with tooth contact until the protruded contact position
and retrusive gliding movement to the intercuspal position. The protrusive
movement is used for grasping and incision of food.
C Right or left lateral movements for use in reduction of fibrous as well as other
types of foods.
D. Bennet movement: The bodily side shift of the mandible..
There are another 2 movements:
I. Backward gliding movement from the intercuspal position to the retruded
contact position (ligamentous position or hinge axis position).
2. Unilateral vertical movement of the condyle in the glenoid fossa. This
movement can occur when a resistant object is placed between posterior teeth on
one side and pressure is applied on the opposite side the interocclusal distance on
the working side will be more than on the non-working side. This movement
cannot be reproduced in a mechanical substitute for TMJ.
Another classification of Basic mandibular movements :
a. Opening and closing movements.
b. Forward movement with tooth contact, protrusion and backward gliding
movement to the intercuspal position,
c. Backward gliding movement, retrusion from the intercuspal position
,
d. Lateral gliding movements from the intercuspal position.
Another classification of mandibular movements
1. Contact and non contact movement
From a practical point of view, it is essential to distinguish between movements
taking place with contact, between the upper and lower teeth (contact movement,
gliding movements or articulation) and movements without contact of the
opposing teeth.

2. Border and intra-border movement
Movements on the boundaries of the movement space are called border
movements. Movements within the boundaries of movement space can be
designated as intra-border movements. Border movements of the mandible are
reproducible .The border movements constitute the general framework inside
which the functional movement patterns take place.
3. Rotational and translatory movement
The terminal hinge movement can be performed over a range, which separates
the upper and lower incisors from 20 to 25 mm. (from the retruded contact
position (R.C.)
Further course of the posterior opening occurs when the posterior border
movement exceeds the range of the terminal hinge opening and the condyles
translate downward and forward (From the maximum hinge opening to the
maximal open position .
The small movement from the rest position (postural position) to the intercuspal
position (centric occlusion), in most cases is largely a rotation.
In further opening from the postural position relatively more translation takes
place, whereas the last part of the habitual opening movement is mainly rotation
4. Functional, parafunctional and non functional movement
Functional movements occur during functional activity of the mandible. They
usually take place within the border movements and therefore are considered free
movements. They include swallowing, speech and chewing. While
parafunctional movement include bruxism and clenching.
Arcs of mandibular closure
A. Skeletal arc of closure:
It is determined by skeletal structures and C.N.S. It is the arc of closure taken
by the mandible if there are no tooth interferences or deflection. This closure
is into centric relation or terminal hinge position. The functional act of
swallowing occludes the teeth in this position on the arc of closure.
Centric relation has been given many names such as: the posterior border
position, retruded mandibular position, hinge axis position, ligamentous
position and retruded contact position when the teeth are present.
It is the most retruded physiologic relation of the mandible to maxilla to and
from which the individual can make lateral movements. It can exist at
various degrees of jaw separation. It occurs around terminal hinge axis.
It is unstrained anteroposterior bone-to-bone relation. Stuart and Stallard
defined centric relation as " the rearmost, midmost and uppermost
untranslated hinged position of the condyles ". It is a strained relation that
can be statically repeated-for some people centric relation may induce feeling
of strain and for others it is not possible because of tired or stiff muscle.
Many authorities now feel that the latter position of the first definition "from
which lateral movements can be made" is not applicable, because lateral
movements are possible from practically all-mandibular positions.
The position of centric relation remains constant or nearly so, throughout life,
except in the event of injury or disease of the TMJ.
B. Adaptive arc of closure
It is an arc directed by a conditioned reflex, guided by proprioceptive
neuromuscular mechanism. Such closure is into centric occlusion or
maximum intercuspation of teeth. This adaptive arc of closure is the one
used in chewing or when you tell the patient to close his back teeth
together.
It can be changed by various stimuli thus altering the conditioned reflex
"protective mechanism", i.e. if a tooth becomes sensitive either pulpally
or periodontally, the neuromuscular mechanism will program a new
conditioned reflex to protect the involved tooth.
It is referred to as habit centric, and is learned during infancy and is
permanently imprinted in the higher centers of C.N.S. controlling the
masticatory functions.
Because it is changeable, so its clinical reproducibility is in doubt and not
used as reference for mounting casts on articulators.
C. Voluntary arc of closure :
Voluntary control over mandibular movements, which is normally never
used. It requires thought and therefore cannot be carried out over long
periods of time "like voluntary control over respiration.
Recording mandibular movement
a) Graphic methods :
1- Gothic arch tracing was introduced by Gysi as an extra-oral
method to program an adjustable articulator.
2- A pantograph is an instrument used to graphically record, in one or
more planes, paths of mandibular movement and to provide
information for the programming of an articulator.
pantograph used for registering the left and right border
movements of the mandible while the teeth are separated by a
central bearing screw. It also registers the protrusive movement,
which is not a border movement but begins and ends at a border
position.
The pantograph consists of
- An upper and lower frame each consisting of three bars bolted
together. The side arms of the lower frame can be adjusted so
that the condyle pointers touch the axis marks.
- The lower frame is, in fact, the axis
locator to which are added six
writing tables, three on each side, in
different planes.
- The upper frame carries six styli at
right angles to each opposing table.
- The frames are attached to the upper and lower teeth
respectively by means of clutches either seated securely or
temporarily cemented.
They are separated by central bearing screw adjusted to the
closest distance between the teeth but permitting unrestricted
lateral movement between the clutches.
In some pantographs the writing tables are attached to the
upper frame & the six styli on the lower.
Pantography is the most accurate and complete means of recording jaw
movement and border positions available.
Types of pantograph include mechanical, electronic-stylus, and
optoelectronic.
Mechanical pantography is accurate and reliable, but the time and complexity
involved in recording movements and setting the articulator from the tracings
are major shortcomings.
An electronic-stylus, computerized pantograph was developed to quickly
analyze patient movements and minimize articulator-programming errors by
generating numerical condylar values.
Optoelectronic computerized pantographs have been developed. It can
quickly, accurately and reliably determine the transverse horizontal axis
(THA), posterior condylar settings. It can be used in diagnosis of TMJ
disorders.
An electronic pantograph (Cadiax Compact- 3-D TMJ registration system)
was introduced to produce joint analysis quickly for the diagnosis of TMJ
disorders as well as for articulator programming.
3- Minigraph:- It consists of only two anterior recording plates which are
related to casts mounted to the hinge axis. It can be applied when a full
pantographic tracing would not be feasible.
4- Mandibular motion analyzers as the Whip-Mix quick set recorder
and the Panadent quick analyzer recorder
b) PHOTOGRAPHIC METHODS
Luce first introduced a photographic method with a single camera and one
stationary photographic plate in 1889. In 1914 Thouren introduced another
method, which included photography using a number of successive
photographic plates-cinematography.
c) ROENTGENOGRAPHIC METHODS
In 2007, Yuuda introduce a new four dimensional (4D) visualizing system of
stomatognathic function
In 2008, Terajima introduce a new 4-dimensional (4D) analyzing system of
stomatognathic function by using 3D CT of the cranium and mandible, dental
surface imaging from a noncontact 3D laser scanner, and mandibular
movement by using a 6 degrees of freedom jaw-movement analyzer.
d) ELECTRONIC AND TELEMETRIC METHODS
A novel robotic articulator that reproduced a six-degree-of-freedom jaw
movement was developed and it has been demonstrated to be a useful
device. The Virtual Articulator (VA) is intended to be an analyzing tool for
the complex static and dynamic situations during the occlusion.
e) MAGNETOMETRY
In 2006 a new technique for recording the kinematics of the TMJ and
incisors, using an electromagnetic tracking device (3Space Fastrak,
Polhemus, Inc.), laptop-based data collection software (The Motion
Monitor, Innovative Sports Training, Inc), and custom dental appliances.
f) ELECTRONIC METHODS
The new opto-electronic system called "Mac Reflex" (Qualisys AB,
Partlle; Sweden) was described by Hamborg &Karlsson in 1996. This
equipment consists of three basic units: two video cameras with a detecting
lens sensitive to infrared light, a video processor, and a software package
in a Macintosh computer.
MANDIBULAR MOVEMENTS IN DIFFERENT PLANES
A- Mandibular movements in relation to the sagittal plane
The posterior border movement:
The posterior opening movement starts with
intercondylar axis rotation and is then followed by both
translation and rotation of the condyles. Since during
the first part of the movement the hinge axis is in its
midmost location, the movement is designated the
terminal hinge movement.
The terminal hinge movement can be performed
over a range, which separates the upper and lower
incisors from 20 to 25 mm. (from the retruded contact
position (R.C.) to the maximum hinge opening.
Further course of the posterior opening occurs
when the posterior border movement exceeds the range
of the terminal hinge opening and the condyles translate downward and forward
(From the maximum hinge opening to the maximal open position
The anterior border movement :
This is the movement path made by the incisal point from
the protruded contact position till the maximal opening
position distance about 4.5 cm.
Superior border movement;
A. Forward:
It starts from the habitual intercuspal position (centric occlusion) and the
incisal point has to move downward and forward along the incisal path and then
straight forward to clear the incisors (edge-to-edge. The incisal point then moves
upward to reversed vertical overlap and forward to the protruded contact
position. This path becomes more regular with attrition of teeth and loss of
vertical overlap.
The incisal path is the path taken by the incisal edges of the lower incisors on the
palatal surface of the upper incisors until the teeth touch edge to edge.
The incisal path angle (incisal guidance) is the angle between the incisal path and the
horizontal.
B. Backward:
There is a short movement path that can be recorded between centric
relation and centric occlusion when the teeth are brought into contact in centric
relation and the patient squeeze his jaws together into centric occlusion. The
movement is called "slide in centric" it is often combination of forward and
lateral movements. The average distance of slide is about 1mm.
Centric relation. Intercuspal position.
Edge to edge position Reverse overlap
The habitual (automatic) opening and closing :
These paths are carried out inside the movement space i.e. intraborder
movement. The small movement from the rest position (postural position) to the
intercuspal position (centric occlusion), in most cases is largely a rotation. In further
opening from the postural position relatively more translation takes place, whereas the
last part of the habitual opening movement is mainly rotation.
Envelope of function:
Normal function takes place within only a small area of the border Movement
diagram begin around intercuspal position. Rest position is located approx. 2-4 mm
below intercuspal position.

Mandibular movement in sagittal plane (Posselt's diagram).Left; CR; Retruded contact.
CO; intercuspal position. F; Full protrusion. MO; Maximal open position . MHO;
Maximum hinge opening. R; Rest position. Right; envelope of function.
Mandibular movements in sagittal plane for class II jaw relation:
A. Class II jaw relation patients: Tracings of the sagittal plane jaw movements differ
considerably from that generally published for a class I jaw relation:
1. The maximum opening is less due to the smaller size of the mandible.
2. The protrusive movement is greater and configuration varies according to the
amount of horizontal and vertical overlap.
3. The arc of hinge opening is smaller due to the size of the mandible.
4. The interocclusal clearance is greater.
B. Class III jaw relation patients: The mandibular movements in the sagittal plane is
different from the class I jaw or class II jaw relationships
1. The protrusive movement is smaller.
2. The maximum opening is greater because of the length of the mandible.
3-The arc of hinge opening is greater because of the jaw size.
4-The interocclusal rest space is less.
Class I Class II Class III
B- Mandibular movements in relation to horizontal plane
Registrations of the horizontal border movements can be carried out by pantograph,
The incisor point border movements (in the horizontal plane:
On the anterior horizontal plate
The border movements for the incisor point can be traced on the anterior
horizontal plates of pantograph or by Gothic arch or Gysi's tracing in the
horizontal plane.
The point "A" corresponds to centric relation (also
called the arrow point in Gysi's tracing).
As the mandible moves in retrusive lateral excursions
and the condyle moves from B 1 to B2,
The incisal point records the line from A, to D. From D
the mandible can be moved forward and medially to
point F. A similar tracing can be done for the other side
to point E from point A.
Envelope of function:
The incisal point is at point C.R, when the condyles
are in centric relation and at point C.O. when the
teeth are in centric occlusion.
The small dark area MR2 is the approximate region
of function during the latter stages of mastication.
The larger stippled area MR1, extending to point
I.E.C. (incisal point contact is the approximate region of function in earlier stages of
mastication).
The pantographic tracing on the posterior horizontal plate:
o On the balancing side the orbiting condyle usually does not follow
a straight line, but rather some form of curved path as indicated in
the pantographic tracing.
o The timing of mandibular side shift (Bennet movement) affects the
amount lateral condylar path angle.
o Enlarged horizontal pantographic tracing near the condyle. I.S.S., the immediate
side shifts. PSS, the progressive side shifts. C.R, centric relation. P, protrusive.
LL, left lateral. RL, right lateral. The immediate side shift is usually 1mm at the
center of rotation.
o When the mandible shifts to the side its movement can be described in two
segments, an immediate side shift and a progressive side shift.
o During the immediate side shift, the major direction of movement is
mediolateral, although some anterior direction is evident.
o As the progressive side shift begins and continues the major direction of
movement is anterior, although some mediolateral direction continues.
The pantographic tracing on the posterior vertical plate:
It shows the path of the descending condyle in the vertical plane during
protrusion and lateral movement. The balancing condyle (NW) shows a steeper
downward and forward path than the protruding condyle. This difference (about 5
degrees) demonstrates the Fischer angle.
Enlarged pantographic tracing on the
vertical plate. CR, centric relation. P; protruding
path. NW; non working condyle path, and W;
work condyle path. The difference between the
protruding and balancing condyle paths is the
Fischer angle.
Tooth contacts during articulation In bilateral balanced occlusion:
On the working side the movement of these
teeth is linguobuccal, i.e., much more laterally than
anteriorly and the mandibular buccal cusps oppose the
maxillary buccal cusps and inclines. The upper and
lower cusps pass each other with minimal lift or
change in the occlusal vertical dimension in the
working side.
On the balancing side the molars and premolars of
the mandible move obliquely forwards and medially
(diagonally). The mandibular buccal cusps and inclines are in
contact to the maxillary lingual cusps and inclines.
The path of this movement causes a separation between the opposing balancing
segments determined jointly by the slopes of the ridges involved and the downward and
inward path of the balancing side condyle.
Each working and balancing path made by a cusp on the opposing tooth traces a
miniature Gothic arch .
The lower canine cusp and mesial cusp ridge glides along the disto-lingual
surface of the upper canine on the working side and pass between the canine and first
premolar cusp ridges. The working side lateral and central incisors maintain contact. On
the balancing side contact is lost
During protrusive movement:
The incisal edges of the lower incisors and canines make articular contact with
the lingual surfaces of the upper incisors and canines.
The mesial buccal and lingual cusp ridges of the lower molars and premolars make
articular contact with the distal buccal and lingual cusp ridge of the upper teeth.
C- Mandibular movement in relation to the frontal plane
In regard to border movement in the frontal
plane, it roughly resembles a shield.
The tracing begins with the teeth in centric
occlusion at point co. As the mandible is moved to
the right with the opposing teeth maintaining
contact, the dip in the upper line of the tracing is
created as the upper and lower canines pass edge to
edge.
The mandibular movement is continued as
far to the right as possible. Then the opening occurs
at point MO, the mandible is moved in an extreme left lateral position as it is closed
until the opposing teeth make contact. Then with the opposing teeth maintaining contact,
the mandible is moved from the extreme left lateral position back to centric occlusion
co.
The dotted line indicated by the upward pointing arrows represents
the upward component of a masticatory cycle as the patient chewed a
bolus of food on the left side. The masticatory cycle moves over to the
right when the patient opens from centric occlusion as indicated by
downward dotted line (downward pointing arrows).
With excellent occlusions and with uninhibited masticatory movements,
the masticatory cycle has a fairly uniform, wide oval form, tear drop
appearance
Envelope of Motion
By combining mandibular border movements in the three planes (sagittal,
horizontal, and frontal), a three-dimensional envelope of motion can be produced that
represents the maximum range of movement of the mandible. Although the envelope has
this characteristic shape, differences are found from person to person. The superior
surface of the envelope is determined by tooth contacts, whereas the other borders are
primarily determined by ligaments and joint anatomy that restrict or limit movement.
Clinical applications of mandibular movement
1-The rest position lies within the parcel of movement. Its significance is the constancy
of its vertical and horizontal relationship to the maxilla and its value is a reference
position for vertical dimension determination.
2-The opening and closing retruded arc movement (terminal hinge opening) is
reproducible and is used for determining the transverse hinge axis.
3-The retruded condylar position (terminal hinge position) is a repeatable and reliable
and is used to record the centric relation.
4-On protrusion and lateral movements the condyles move downward and forward at a
measurable angle (horizontal or sagittal condylar path angle) to the horizontal
plane. The angle of descent can be measured by inserting a wax wafer between the
posterior teeth just prior to protruded or lateral occlusion and by transferring this
record to casts mounted on an adjustable articulator.
5- The horizontal condylar path can be traced on a card attached
to the patients face by means of face bow and similar
devices. The angle of the path to a horizontal reference plane
is measured and transferred to the articulator. quick set analyzer used to trace the
condylar path.
6-During lateral movement the balancing condyle moves medially making an angle
with the median plane (the lateral condylar path angle or Bennett angle). This
angle can be recorded and transferred to the articulator using right and left lateral
interocclusal record.
7-The Bennett shift (immediate side shift) cause the condyles to shift away from the
midline and produce a medial shift in the final position of the translating condyle.
This will case balancing interference if the Bennett movement was not recorded and
transferred to the articulator.
To record the Bennett shift an interocclusal record in extreme lateral jaw position is
made. The records are then put between mounted casts and the wall of condylar
boxes are adjusted approximately. An alternative method is to measure the jaw
movement on the hinge axis over the surface of the skin in front of the ear using face
bow.
8-All mandibular movements take place within the envelop of motion and seldom reach
a border except in retruded closure which sometimes used in forceful closure.
However, if cusp interference prevents movement towards a border position
disturbance may result in musculature. So the border movements should be recorded
and transferred to the articulator.
9-The pantographic tracing can be transferred to an articulator so that various
adjustment angles and axes of rotation are copied on the articulator.
The pantronic is an electronic pantograph, which provides a computer printout of
numerical condylar measurements.
10-Intra-oral plastic record (stereographic record) of the lateral border and protrusive
movements is achieved by cutting studs, which mould pathways into fast-setting
acrylic resin. These records are used to customize the condylar guidance of
gnathalogical articulator.
11- The incisal path angle should be kept minimal in balanced occlusion. However,
esthetics may necessitate large vertical overlap. This calls for large overjet to
decrease the incisal guidance.
Condylar path angles and Bennett movement
Condylar path: path traveled by the mandibular condyle in the
temporomandibular joint during various mandibular movements.
Sagittal (horizontal ) condylar path is defined as the path followed by the
mandibular condyles during protrusive movement or balancing condyle during lateral
movement.while the sagittal condylar path angle is the angle between the sagital path
and occlusal plane.
Lateral condylar path angle: The Bennett angle (Progressive Side Shift) refers
to the angle, in the horizontal plane, between the sagittal plane and the downward,
inward and forward path of the nonworking condyle.
The condylar movement:
The protruding condyles:
Translation of the condyle forward and downward occurs
during protrusion. The path of the condyle during this
movement is termed the horizontal (sagittal) condylar path.
It forms an angle with the horizontal plane termed the horizontal condylar path
angle. This angle varies in individuals and even in the same individual.
A separation of the posterior teeth occurs during protrusion
due to the downward and forward translation of the condyles.
This is called Christensens phenomenon and used to record
horizontal condylar path angle.
When the mandible moved to the right, the right condyle is therefore called the rotating
condyle, since the mandible is rotating around it. The left condyle during this movement
is called the orbiting condyle, since it is orbiting around the rotating condyle.
The working condyle:
During lateral movements, the working side or rotating condyle may
rotate around sagittal and vertical axes and move laterally The lateral component
is termed the Bennett movement. The first part is called immediate sideshift and
is measured on average at 0.5 mm. The progressive sideshift describes a more
gradual lateral movement.
The balancing condyle: The balancing condyle moves down, forward and
inward and makes an angle with the median plane when projected
perpendicularly on the horizontal plane. This angle is called Bennet angle.
Importance of Condylar path angles
Importance of sagittal Condylar angle
Okeson stated that the condylar guidance is considered to be a fixed factor,
because it is unalterable in the healthy patient. It can be altered, however, under
certain conditions (e.g. trauma, pathosis, and surgical procedure). The anterior
guidance is considered to be a variable rather than a fixed factor. It can be altered
by dental procedures, such as restoration, orthodontia, and extractions.
Accurate determination of the condylar guidance is necessary for proper
positioning of teeth and for restorations to be in harmony with mandibular
movements.
A higher condylar guidance angle in a patient with dentures may be better than a
lower angle because the posterior teeth may need adjustment with the higher
angle, whereas the anterior teeth may require adjustment with a lower angle.
Balkwill believed that it was impractical to measure the angle of the condylar
inclination in the living subject. However, he introduced an instrument for measuring
the angle formed between the plane of two lines drawn from the articulating surfaces of
the condyles to the [incisor point] and the [occlusal plane] which is near enough to use.
He estimated this angle, now known as Balkwills Angle, to be an average of 26
degrees.
Effect of variation in HCPA on complete denture occlusion
The variation of the condylar path angle will affect the relationship between
the upper and lower teeth in mandibular excursion. a change in the condylar
path inclination of l0 degrees resulted in a vertical change of 0.5mm at the
molar area in lateral excursions.
Importance of lateral Condylar path angle
The degree of lateral shift depends on the Bennett angle, the greater the
Bennett angle the more the lateral shift.
This angle used to adjusts the Bennett shift on the adjustable articulator.
Effect of variation in LCPA on complete denture occlusion
The arbitrary decrease of the Bennett angle of the balanced condylar
guidance, leads to more rotation and less Bennett shift of the working
condyle. Therefore increase the posterior working cusp inclines.
If protrusive interocclusal record is used alone to simulate right and left
lateral condylar inclinations without adjusting the lateral condylar
inclination, then the occlusion developed in the laboratory might be heavy
on the working side and light on the balancing side.
Factors affecting condylar path:
Steepness of the articular eminences : The flatness or steepness of the articular
eminences dictates the path of condylar movement as well as the degree of
rotation of the disk over the condyle.
Age : The patients eminence angle was relatively stable over time (changing
rapidly only due to disease or acute trauma. some authors believe that the
condylar path inclination angle (CPIA) increases with age. There is no
significant differences between the right and left sides either in the child group or
the adult group.
Gender : there is no significant differences in the condylar path inclination angle
between male and female.
Condylar guidance and TMJ disorder: The condylar path in patients with
anterior disk displacement with reduction (ADDW) was steeper than in subjects
with normal disk position.
Condylar guidance and mandibular morphology: Condylar guidance appears
to vary with variations of the morphology of the temporomandibular joint.
Mean Condylar Guidance
Sagittal condylar path angle
it ranged from 22-65, with the average of 38. According to Gysi, the sagittal
condyle path in the individual varies from 40 to 65 with 33 average inclination
Lateral condylar path angle: The mean Bennett angle is 7.5.
Sagittal condylar path inclination in consideration of Fischer's angle
Fischers angle is defined as the angle formed by the intersection of the
protrusive and non-working side condylar paths as viewed in the sagittal plane.
It is believed that the lateral condylar path in the sagittal plane on the non-
working side is longer in length and steeper in inclination than the protrusive
condylar path. Bergstrom called the difference in condylar inclination between
these two paths the Fischer angle, the value of which was about 5 degree,
Determining the sagittal condylar path inclinations
1- intraoral or positional wax method
Anterior check bite method (protrusive intraoral record) is preferred as the
usual method for reproducing them in a semi-adjustable articulator. However, it
has often been suggested that the sagittal condylar path inclinations obtained by
this method are unstable
The various materials used for the intraoral method have been wax (some
supported with metal)modeling compound, zinc oxide/eugenol paste, and
polyether impression materials
The ideal amount of protrusion for making the record is the exact equivalent of
the amount of protrusion necessary to bring the anterior teeth end to end.
- A 2 mm was the functional range of movement, and it is the most suitable
distance for physiologic reasons. But if this functional range of movement is
recorded, the condylar paths on the articulator cannot be adjusted by means
of such a record except within a wide range of errors.
- The mechanical limitations of most articulators require a protrusive
movement of at least 6 mm so the condylar guidance can be adjusted.
- Some authors found these values provide the best information because this
area belongs to the central part of the eminence and therefore enables an
exact measurement.
Intraoral recording are dependent on many factors:
The resilience of the mucosa
Pressure exerted during recording,
The kind of saliva
The accurate "fitting" of the baseplates or the prostheses plates have
The consistency of the "checkbite" material of great importance.
Lack of muscle coordination in the patient
Type of articulator used
2- A graphic method
mandibular facebow
pantograph
Mandibular motion analyzers as the Whip-Mix quick set recorder and the
Panadent quick analyzer recorder.
In 1999 a simplified recording device was introduced, electronic hinge axis
tracing device (Cadiax compact ) in measuring the horizontal condylar
inclination (HCI) and the Bennett angle. The Cadiax Compact is purported to
calculate condylar settings over 3 condylotrack distances, 3, 5, and 10 mm from
the centric relation position.
3- Digital mandibular movement analyzing systems:
Digital six degree of freedom mandibular movement analyzing system Gnatho-
Hexagraph could be used to measure sagittal condylar path inclinations
4- The radiographic method :
By tracing the condyle and fossa in centric occlusion and superimposed on the
tracing of the protrusive position. A tangent drawn to the 2 condyle outlines
gave the condylar path.
Determining the lateral condylar path inclinations (Bennett angle)
1- Interocclusal record : When the Bennett angle was measured by interocclusal
records, the immediate side shift and the progressive side shift could be recorded
simultaneously
2- Hanau fromula: The Hanau formula determine the average lateral condylar
guidance as related to the horizontal condylar guidance. [L = H/8 + 12] where L :
lateral condylar inclination in degrees; H : horizontal condylar inclination in degrees
as established by the protrusive record.
3- Gothic arch method: The right and left lateral condylar guidance on the
articulator are derivecl from the forrnula L = 1.06 BP - 46. where BP is the angle
between the lateral border parhs of the patients and the articulator protrusive path.
Bennett movement
Bennett movement : it is lateral bodily shift of the mandible.
The first part is called immediate sideshift and is measured on average at 0.5
mm. The progressive sideshift describes a more gradual lateral movement.
a) amount:
up to approximately 3mm.
b) direction:
The lateral movement may have a retrusive or protrusive or
more straight laterally. The movement may end at any point in
the 60-degree triangle outward superior or inferior. The
envelope of these possible movements is analogous to a right
circular cone with the vertex at the condyle. Sagittal displacement of the rotating
condyle may occur to any point within the cone.
c) Timing of mandibular lateral translation: It may be:
1-Progressive side shift occurs at a rate/ amount proportional to the forward
movement of the working condyle as it leaves centric relation.
2-Immediate side shift where the non working condyle moves almost straight
medially as soon as it begins to leave centric relation.
3- Early side shift where the greatest portion of lateral movement occurs in the
first 4 mm of forward movement as the non working condyle leaves centric
relation.
4- Distributed side shift where the greatest rate of the shift is distributed
throughout the first 4 mm of forward movement as the non working condyle
leaves centric relation.
Schematic representation of the condylar shift on the working side. Movements
up to approximately 3 mm may occur to any point within the 60-
degree circular cone.
Line AR represents the center of rotation of the condyle.
Viewed from the horizontal plane (H), the movement from W may be
straight lateral (SL), lateral and protrusive (LP), or lateral and retrusive (LR). Viewed in
the vertical plane (V) the movement from W may be straight lateral, lateral and inferior
(LI), or lateral and superior (LS).
The importance of Bennett movement
The immediate mandibular lateral translation of the articulator changed the width
of the central groove and the origin of the distobuccal groove on the occlusal
surface of the mandibular first molar in the horizontal plane.
The magnitude of this movement was almost directly proportional to the amount
of immediate mandibular lateral translation that was programmed in the condylar
element.
Alteration of the progressive mandibular translation from 0 to 25 degrees
changed the angle of cusp travel and, therefore, the angle of the distobuccal
groove of the opposing mandibular first molar from 50 to 36 degrees in the
horizontal plane.
Effect of mandibular lateral translation movement on cusp height:
The lateral translation movement has three attributes amount, timing, and
direction. The amount and timing are determined in part by the degree to which
the medial wall of the mandibular fossa departs medially from an arc around the
axis in the rotating condyle. They are also determined by the degree of lateral
movement of the rotating condyle permitted by the TM ligament. The more
medial the wall from the medial pole of the orbitating condyle, the greater the
amount of lateral translation movement and the looser the TM ligament attached
to the rotating condyle, the greater the lateral translation movement. The
direction of lateral translation movement depends primarily on the direction
taken by the rotating condyle during the bodily movement.
As the amount of lateral translation movement increases, the bodily shift of the
mandible dictates that the posterior cusps be shorter to permit lateral translation
without creating contact between the maxillary and mandibular posterior teeth. A
lateral movement with laterosuperior direction of the rotating condyle will
require shorter posterior cusp than will a straieht lateral movement, likewise
lateroinferior movement will permit longer posterior cusps than will a straight
lateral movement. When the lateral translation movement occurs early, a shift is
seen even before the condyle begins to translate from the fossa. This is called an
immediate lateral translation movement or immediate side shift. lf it occurs in
conjunction with an eccentric movement, the movement is known as a
progressive lateral translation movement or progressive side shift. The more
immediate the side shift, the shorter the posterior teeth.
Effect of mandibular lateral translation movement on ridge and groove
direction:
It influences the directions of ridges and grooves. As the amount of it increases,
the angle between the laterotrusive and mediotrusive pathways generated by the
centric cusp tips increases. The direction that the rotating condyle shifts during a
lateral translation movement influences the direction of laterotrusive and
mediotrusive pathways and resultant angles if the rotating condyle shifts in a
lateral and anterior direction, the angle between the laterotrusive and
mediotrusive pathways will decrease on both maxillary and mandibular teeth. if
the condyle shifts laterally and posteriorly, the angles generated will increase.
It was further demonstrated that the immediate mandibular lateral translation of
the articulator changed the width of the central groove and the origin of the
distobuccal groove on the occlusal surface of the mandibular first molar in the
horizontal plane. The magnitude of this movement was almost directly
proportional to the amount of immediate mandibular lateral translation that was
programmed in the condylar element.
Recording of Bennett shift
The immediate Bennett shift [IBS] adjustment on adjustable articulators can be set by
measurement of
pantographic tracings,
intcrocclusal wax records,
direct measurement with simple device that measures Bennett shift near the
skin over the nonworking condyle (Whip-Mix Quick Set Recorder) has been
introduced
RECORDING JAW RELATIONSHIPS
There are three different types of jaw relations they are listed in order of the procedure:
Orientation jaw relation.
Vertical jaw relation.
Horizontal jaw relation.
RECORDING JAW RELATIONSHIPS
1. Check denture foundation.
2. Establish facial contour.
3. Establish occlusal plane.
4. Maxillary face-bow record.
5. Determination of vertical dimension of centric occluding relation.
6. Determine centric relation at the accepted vertical dimension.
7. Locking device ( recording the C.O.R. )
1- Checking denture foundation and establishing
facial contour
After the occlusion rims have been completed the upper base-plate is inserted in the
patients mouth and the following checks and further steps of procedure are carried out:
1- Check the base plate for retention and stability:
If it does not appear to be satisfactory it would be wise to check on the steps
of procedure up to this stage to determine whether an improvement over the
condition could be made and, if necessary, the impression should be retaken
before undertaking succeeding procedures.
2- Correct shaping of the labial, buccal and palatal surfaces of the wax rim
Labial fullness: If retention, stability and outline-form of the base are
satisfactory, the labial and buccal positions of the occlusion rim are shaped
until a pleasing and harmonious lip and facial contour is established.
Adequate lip support depends upon the position and inclination of the labial
face of the wax rim. For achieving correct shape
Lips should be unstrained
Naso-labial angle 90.
The labial surface of the rim almost always inclines labially from
the border of the record base at about a 15 degree angle and
It is approximately 6-8 mm labially from the center of the incisive papilla. [RAHN]
The tips of maxillary canine are 1 mm anterior to the center of incisive papilla.
Boucher
It is essential that the position of the labial surface of the rim is compatible with the
stability of the record block. The further forward the rim the greater will be the displacing
force of the lip muscles acting on the labial surface. Also it should be remembered that the
displacing force occurring on incising food when the finished denture is worn will also be
increased. If prognosis for retention of upper denture is unfavourable as a result of
extensive post-extraction resorption of bone it may be necessary to place the rim palatally
for greater stability.
Shaping the buccal surface
The record rim posteriorly should be shaped so that it fills the buccal
sulcus and slightly displaces the buccal mucosa laterally. This will
contribute to retention by achieving an efficient facial seal.
The rim itself will usually be slightly buccal to the crest of the ridge by
an amount proportional to the amount of resorption that has occurred.
Reference to biometric guides will help to identify an appropriate position. However,
care should be taken not to place the rim too far buccally, as it will then be outside the
neutral zone and increased force from the buccinator muscle will cause displacement.
The buccal and palatal surfaces of the rim should be shaped to converge
occlusally so that pressure from the cheeks and tongue has a resultant force
towards the ridge, thus aiding neuromuscular control.
Check support is probably not affected as much as lip support since the buccinator is
stretched between the pterygomandibular raphe and modiolus muscles. The buccal
surface of the rim is slightly slanted toward the palate to create an acceptable space
between the rim and the cheeks. This space is called buccal corridor and created
between the buccal surface of posterior teeth and corner of the mouth when the patient
smiles. Heartweal
Shaping the palatal surface
It is essential to create adequate space for the tongue by
ensuring that the rim is not placed too far lingually
reducing the width of the rim where necessary by removing wax
2- Occlusal plane height and orientation
1- Establishing the level of the occlusal plane :
The anterior height of the rim:
The length of the upper occlusion rim is established to 2
mm. below the upper lip when it is in a relaxed position.
When most individuals with natural teeth say five fifty
five the incisal edges of the maxillary central incisors
contact the vermillion border of lower lipat the junction of moist and dry mucosa.
Heartweal
A greater length of teeth than normal will be shown if the patient has:
- A short upper lip.
- Superior protrusion.
And less will be shown in patients:
- With a long upper lip.
- In most old people, due to attrition of the natural teeth and some loss of tone of the
orbicularis oris muscle.
Touches wet line of lower lip when F or V sounds
A very effective way of establishing the position of the incisal
edge in the vertical plane is to measure the distance on the existing
denture between the incisive papilla and the incisal edge with a
specially designed gauge (Alma gauge).
If this instrument is not available a measurement of the
distance between the incisive papilla to the incisal edge can be made
using figure-of-eight calipers.
The posterior height of the rim
It made to be concide with Campers line
At first molar , it is established at inch below the orifice of Stensens duct
Factors affecting the height of occlusal plane:
1. Aesthetic appearance in relation to the length of the upper lip, interpupillary line
and ala-tragal line.
2. Function,
a) Chewing, the relation of the occlusal plane to the tongue.
b) Speech, the relation of the occlusal plane to the lower lip.
3. Principle of physics and mechanics.
a) Leverage action.
b) Parallelism.
Test the length of the upper lip can be estimated by placing the
index finger on the incisive papilla with relaxed upper lip
extending down over the finger. The finger length covered by the
upper lip indicates the length of the upper lip.
2- Adjustment in the coronal plane: The anterior plane:
From the frontal view of the patient, the occlusion rim is
adjusted parallel to an imaginary line
Joining the pupils of the eyes (inter pupillary line) or the
supra-orbital ridges.
Alternatively, at right angles to the long axis of the
patients face.
Fox plane can be used
Failure to follow these guidelines, will result in an unsightly, lopsided appearance of the
finished dentures.
3- Adjustment in the sagittal plane : The Antro- posterior plane:
From a sagittal view of the patient, the occlusal rim is
adjusted to be parallel to the naso-auricular line (ala-tragus or
Compers line). It is an imaginary line running from the
inferior border of the ala of the nose to the superior border of
the tragus of the ear. The line drawn on the face is referred to
as Campers Line, named so after Petrus Camper, who first
recognized this line in 1780.
Hanau refers to this imaginary line as the plane of
orientation. Swenson wishes to call the plane established with
the occlusion rim the orientation of the plane since it is a
plane to be determined. It is advisable to use an occlusal plane
indicator (Fox plane) for obtaining the correct anterior and antero-posterior planes.
The upper denture tends to move anteriorly and lower denture tends to move posteriorly
due to occlusal force, a shunting effect occurs leading to denture instability. If the occlusal
plane is higher in anterior region and is tipping posteriorly, the shunting effect will be the
opposite.[HAYAKAWA]
Failure to conform to this guideline is likely to detract from the aesthetic result. It
can also have adverse consequences for stability; for example, if the occlusal plane on the
lower denture is tilted up posteriorly it may become so high that the denture is displaced by
the tongue rather than being controlled by it.
Determination of the occlusal plane
Factors must be considered:
1- Aesthetic base: the height of occlusal plane should be 1-2 mm. below the upper lip
anteriorly
2- Functional base (chewing and speech):
During chewing: The height of occlusal plane should be convenient and at a level
familiar to the tongue to perform its action easily and stop food escaping to the
floor of the mouth. The occlusal surface of the teeth should be below the greatest
convexity of the tongue. This also improves the stability of lower denture.
During speech, the tongue pushes against the sides of the teeth to produce a seal
for better pronunciation of words.
3- Physical and mechanical (leverage action and parallelism)
Principle of Physics and Mechanics
1) Leverage action : The amount of leverage or torque exerted on occlusal plane is a
function of the height of the plane above the ridge. Torque X = force (f) x Distance
from fulcrum (R).
The nearer the occlusal plane to the basal bone of the jaws, the less the leverage
action and the better the stability.
2) Parallellism : The occlusal plane should be parallel to both supporting ridges. In
this way the biting forces are vertical on the ridges and there is no tendency for
horizontal displacement of the dentures.
3) Arch form
Both the width of the occluding surfaces and the contour of the arch
form of the occlusion rims should be individually established to
simulate the desired arch form of artificial teeth
If the occlusal plane is parallel to the lower and upper ridge the
denture will gain optimum stability. [HAYAKAWA]
6- Guidelines
When the rim has been trimmed to these planes it indicates the plane
of orientation for setting up the artificial teeth. The adjustments to the
upper block are complete with the recording of certain guidelines:
a- The center line :
A vertical line is scored on the labial surface of the upper rim
where it is crossed by an imaginary line from the center of the
eyebrows to the center of the chin and immediately below the center
of the philtrum, the labial tubercle and incisive papilla or labial
frenum.
b- The high lip line: gum line , smiling line
This is a line just in contact with the lower border of the upper
lip when it is raised so high as possible as in smiling or laughing.
It is marked on the labial surface of the rim and indicates the
amount of denture that may be seen under normal conditions and thus
helps in determining the length of teeth needed.
c- The corner lines: cuspid line, canine line
These mark the corners of the mouth when the lips are relaxed and
are supported to coincide with the tips of the upper canine teeth but are
only accurate to within 3 or 4 mm. These lines indicate the width taken by the six anterior
teeth from tip to tip of the canines.
d- The low lip line: speaking line, relaxed lip line [Heartweal]
It is horizontal line that extends between the commissures of the lip at the inferior
border of the upper lip during serious speaking or relaxation.the maxillary rim is extended
1-2 mm below this line
it is used to determine the vertical incisal length.
Mandibular Occlusion Rim Adjustment
Posteriorly, the occlusion rim intersects 1/2 - 2/3 up the retromolar pad .
Anterior height even with the corners of the mouth when the lip is relaxed.
1-2 mm horizontal overjet in anterior & posterior in centric position
Note
Eliminate contacts between record bases, record base/occlusion rims
The occlusal plane J Prosthet Dent 2007;98:348-352
Usually, the term, plane, is related to a flat surface. However, this is not the case
with the occlusal plane. Instead of a flat surface, the plane of occlusion represents
the average curvature of the occlusal surface.
The position of the anterior teeth is determined by esthetics, the demand for anterior
guidance, and phonetic considerations. Posterior teeth positions are defined by 2
curves, an anteroposterior curve, referred to as the curve of Spee, and the
mediolateral curve, referred to as the curve of Wilson.
Based on anthropological observations in 1919, Monson proposed that the
anteroposterior curve forms part of a 3-dimensional sphere, the center of rotation of
which is located in the region of the glabella. The radius of this curve is reported to
be an estimated 4 inches (10.4 cm), as proposed by Monson.
The 3 most commonly used methods for establishing an acceptable plane of
occlusion are
direct analysis on natural teeth through selective grinding,
indirect analysis of facebow-mounted casts with properly set condylar
paths,
indirect analysis using the Pankey-Mann-Schuyler (PMS) method with
the Broderick occlusal plane analyzer (BOPA) with a semiadjustable
articulator to determine the correct curve of Spee for the occlusal plane.
The BOPA has now been adapted to only a few articulator systems,
such as the Denar Anamark Fossae
VERTICAL JAW RELATION
It is defined as, "The length of the face as determined by the amount of separation of the jaws" -
GPT. It can also be defined as the amount of separation between the maxilla and
mandible in a frontal plane.
A] Factors Affecting Vertical Jaw Relation
Teeth : These act as occlusal vertical stops and establish the relationship of the mandible to the
maxilla in a vertical direction in dentulous patients.
Musculature : The opening and closing muscles tend to be in a state of minimal tonic contraction.
This determines the vertical jaw relation.
Muscles that produce elevation of the mandible (closing muscles) and gravity also help to
control the tonic balance that maintains the physiologic rest position.
B] Importance of Vertical Jaw Relation
The effects of altered vertical dimension:
Decreased vertical dimension
Decreased lower-facial height.
Angular chelitis due to folding of the corner of the mouth.
Pain, clicking, discomfort of the temporomandibular joint
accompanied with headache and neuralgia. (Customs syndrome).
Loss of lip fullness.
Obstruction of the opening of the Eustachian tube due to the elevation
of the soft palate due to elevation of the tongue/mandible.
Loss of muscle tone.
Corners of the mouth are turned down.
Thinning of the vermilion borders of the lip.
Decreased volume or cubical space of the oral cavity.
Comparatively lesser trauma to the denture-bearing area.
Cheek biting.
Inefficiency: reduces biting force
Impaired hearing : due to loss of cubical space of the oral cavity with tendency to push the
tongue toward the throat with encroachment of adjacent tissue which may lead to
obstruction of opening of Eustachian tube
In all above cases the complete denture is constructed as treatment denture with increasing
the vertical dimension gradually
Increased vertical dimension
Increased trauma to the denture-bearing area.
Increased lower-facial height.
Cheek biting
Difficulty in swallowing and speech.
Pain and clicking in the temporomandibular joint.
Increased volume or cubical space of the oral cavity.
Stretching of facial muscles.
Clicking of teeth may occur during speech and mastication.
Generalized soreness of the residual ridge .
.Difficulty in swallowing and gagging sensation (Discomfort).
Loss of biting power and muscular fatigue.
Interference with speech.
Pain under the basal seat and trauma to the supporting structures.
Accelerate bone resorption.
C] Vertical Jaw Relation Recording:
Vertical Jaw Relation can be recorded in Two Positions
Vertical dimension at rest position
Vertical dimension at occlusion
Both these relations should be recorded. In a normal dentulous patient, the teeth
do not maintain contact at rest. The space between the teeth at rest is called the 'free-way
space.
The free-way space exists only at rest. During occlusion, the teeth come in contact with
one another and the space is lost. The same relationship should be produced in the
complete denture.
Once the vertical dimension at occlusion is recorded, it should be verified with the
vertical dimension at rest (the vertical dimension at occlusion should always be 2-4
mm lesser than the vertical dimension at rest). The denture is fabricated in vertical
dimension at occlusion so that the free-way space is formed at rest.
I. Vertical Dimension at Rest
It is defined as, "The length of the face when the mandible is in rest position"
This is the position of the mandible in relation to the maxilla
when musculature are in a state of tonic equilibrium. This
position is influenced by the muscles of mastication, muscles
involved in speech, deglutition and breathing.
The balance between gravity and the resting muscle tone = REST POSITION
The physiologic rest position accurately referred as range of posture rather
than single rest position because EMG activity indicate that the clinical rest position
in not correspond to minimal muscle activity which is lower than clinical rest
position by several millimeter. Boucher
Interocclusal rest space: interocclusal clearance formerly known as freeway space
The distance between the occluding surfaces of the maxillary and mandibular teeth
when the mandible is in its physiologic rest position
VD at rest = VD at occlusion + interocclusal distance*
The vertical dimension at rest should be recorded at the physiological rest position of
the mandible and the patient at upright position to avoid effect of gravity.
The mandible is at the physiological rest position when the muscles that open and close
the jaw are in state of minimal tonic contraction. A range of reduced muscle tension has
been reported up to an interocclusal record of 10 mm.
In patients with prolonged edentulousness, the mandible shifts to a habitual rest
position. The complete denture should not be fabricated using the habitual rest position.
Hence the physiological rest position should be determined in these patients before
recording vertical jaw relation.
When functional movements (swallowing, wetting the lips) are performed, the mandible
comes to the physiological rest position before going to the habitual rest position.
Variables Affecting V D R
Short Term Variables
1. Position of the patient's head .
2. Respiration .
3. Stress Situations .
Long Term Variables
1. Loss of the properioceptives impulses from the periodontal ligament .
2. Age .
Interocclusal distance may vary and may be affected by many factors, including
age, physical/emotional conditions, fatigue, medications, and expected normal
variation
The position of the mandible is influenced by gravity and the posture of the
head. Hence while recording vertical jaw relation the patient should be
asked to sit upright, with his/her head upright and eyes looking straight in
front. The Reid's base line should be parallel to the floor.
Since we are recording a physiological rest position, all the muscles affecting this
record should be relaxed.
Presence of any neuromuscular disease in the patient can influence the rest position.
The patient cannot maintain the physiological rest position for an indefinite period of time.
Hence, it should be recorded quickly.
Incorrect measurement of the rest position can lead to faulty recording of the vertical dimen-
sion at occlusion and can lead to injury to the supporting structures and the
temporomandibular joint.
Vertical Dimension at Occlusion: It is defined as, "The length of the face when the teeth
(occlusal rims, central-bearing points, or any other stop) are in contact and the mandible is in
centric relation or the teeth are in centric relation" - GPT.
The vertical dimension at occlusion is a constant position and can be maintained for
indefinite time. Unlike vertical dimension at rest, the mandible need not be in centric relation
while recording this relation.
For Measuring the vertical dimension
Patient sitting upright as Soft tissue position affected by posture
Check with three techniques to ensure acceptable OVD
No one technique 100% correct
Measuring the vertical dimension at rest:
Facial measurements after swallowing and relaxing
Tactile sense
Measurement of anatomic landmarks
Speech
Facial expression
Measuring the vertical dimension at Occlusion
Mechanical methods
Pre-extraction records
Profile photographs
Profile silhouettes
Radiography ;
Articulated casts
Acrylic face mask (suggested by Swenson)
Ridge relation
Distance from the incisive papilla to mandibular incisors.
Parallelism of ridges.
Facial measurements Dakometer Willis gauge
Sorensens profile guide
Measurement from former dentures
Physiological Methods
Power point Using wax occlusal rims
Physiological rest position Phonetics
Aesthetics Facial esthetics
Willis method (Facial proportions)
Swallowing threshold Tactile sense or neuromuscular perception
Patient's perception of comfort. Electromyography
5- Gnathodynamometer ( bimeter ).
6- Functional performance ( point and gauge ).
I. Measuring the vertical dimension at rest
A- Facial Measurements after Swallowing and Relaxing [two-dot technique]
The patient is asked to sit upright and relax.
Two reference points are marked with the help of a triangular piece of
adhesive tape on the tip of the nose and the tip of the chin.
The patient is asked to perform functional movements like wetting
his lips and swallowing.
The patient is instructed to relax his shoulders. This is done to relax the
supra- and infrahyoid muscles.
Once the patient performs the above-mentioned movements, his
mandible will come to its physiological rest position before going to its
habitual rest position. The distance between the two reference points is
measured when the mandible is in its physiological rest position.
Small dots under columnella & mid-symphisis .Use Boley Gauge, not
ruler
B- Tactile Sensation
The patient is asked to stand erect and open his mouth wide till he feels discomfort
in his muscles of mastication.
Next, the patient is asked to close his mouth slowly. The patient is instructed to stop
closing when he/she feels that his/her muscles are totally relaxed and comfortable.
The distance between the two reference points is recorded and compared to the
measurement recorded by the swallowing method.
This method relies on patient's perception of relaxation, and will vary for each
individual. Hence, at least one additional method should be carried out to confirm
these readings.
C- Anatomic Landmarks
The distance (A) between the pupil of the eye and the rima oris
(corners of the mouth) and the (B) distance between the anterior nasal
spine and the lower border of the mandible should be measured using a
Willis guide.
If both these distances are equal, the jaws are considered at rest.
Its accuracy is questionable in patients with facial asymmetry.
The shape of the chin may prevent positive location of the
sliding arm of the Willis gauge. So Sliding arm may be modified
to allow more accurate positioning.
D- Speech
There are two methods by which the rest position can be recorded with the help of
speech.
In the first method the patient is asked to repeatedly pronounce the letter 'm',
a certain number of times and the distance between the two reference points is
measured immediately after the patient stops.
In the second method the dentist keeps talking to the patient and he measures the
distance between the reference points immediately after the patient stops talking.
E- Facial Expression
The following facial features indicate that the jaw is in its physiological rest
position:
Skin around the eyes and chin should be relaxed. It should not be stretched,
shiny or excessively wrinkled.
The nostrils are relaxed and breathing should be unobstructed.
The upper and lower lips should have a slight contact in a single plane. If the
mandible is protruded, the lower lip will be in front and without contact. If the
mandible is retruded, the upper lip will be in front.
II. Measuring the vertical dimension at Occlusion
A-Mec hani c al Met hods
These methods are called so because they do not require any functional movement. They are
measured using simple mechanical devices.
a- Pre-extraction Records
Profile photographs
These photographs are made before extraction. They should be taken in maximum
occlusion as the patient can easily maintain this position during photographic
procedures. The photographs should be enlarged to the actual size of the patient
and the distance between the anatomical landmarks should be measured and
compared with that of the patient.
Profile silhouettes
silhouette means outline. An accurate silhouette is made with cardboard or
contoured with wire using the patient's photograph. This silhouette can be used as
a template and positioned on patient's face while recording vertical dimension.
Radiography
Cephalometric profile radiographs are used to determine the vertical jaw
relation. But their use is limited due to the inaccuracy in the technique.
Articulated casts
When the patient is dentulous, the maxillary cast is mounted in the articulator
using a face-bow transfer. An inter-occlusal record is made in the patient's mouth. This
inter-occlusal record is used to articulate the mandibular cast with the maxillary
cast. This is used as the pre-extraction record.
After extraction the edentulous casts are articulated in a separate articulator. The
inter-arch distance between the edentulous casts is compared with that of the
articulated dentulous casts.
Acrylic face mask(Swenson's technique) : By using facial impression and cast
Niswonger's method : It can be applied if a small red tattoo is used on the skin.
b) Ridge relation
It is defined as, " The positional relationship of the mandibular ridge to the maxillary ridge" - GPT.
It can be measured by two methods namely:
Distance from the incisive papilla to mandibular incisors.
Parallelism of ridges.
Distance from the incisive papilla to mandibular incisors
Incisive papilla is a stable landmark that does not change a lot with the resorption of the alveolar
ridge.
The distance of the papilla to the maxillary incisor edge is 6 mm. Usually the vertical overlap
between the upper and lower incisors is 2 mm (overbite). Hence the distance between the inci-
sive papilla and the lower incisors will be approximately 4 mm. Based on this value, the vertical
dimension at occlusion can be calculated.
Distance between the incisive papilla of the maxilla and the incisal edge of the
lower incisor can be used as a reference to determine vertical jaw relation
Key: a =usually 6 mm, b =usually 2 mm, Hence c =4 mm
Ridge parallelism
The mandible is parallel to the maxilla only at occlusion. The mandible of the patient
is adjusted to be parallel to the maxilla. This position associated with a 5
opening of the jaw in the temporomandibular joint gives a correct amount of
j aw separation.
In patients where the upper and lower teeth are extracted together, the upper and
lower ridges will be parallel because the length of the clinical crowns of the
opposing anterior and posterior teeth will be equal.
Sears suggests that an indication of the correct vertical height can be obtained
from the parallelism of the upper and lower posterior ridges plus a 5degree opening in the
posterior region.. Excessive divergence from the parallel, seen when the casts have been
set on an articulator, indicates that the vertical height is probably wrong and should again
be checked.
This method cannot be taken as a standard in patients who had periodontal
disease and in patients who lost their teeth at different periods of time.
C. Facial measurements
Dakometer The instrument is positioned on the bridge of the nose \vi: compound.
The chin piece is screwed till it touches the front of the A A spring pressure gauge
controls pressure. An incisor attachment ream position of the central incisors.
..Records are noted and the compoun nosepiece preserved for reassembly after
extraction.
Willis gauge One arm contacts the base of the nose. The other arm moved along the
slide till it touches the base of the chin. Willis gauge not accurate as there may be
variations in applying pressure
Sorensens profile guide This is another device for recording fad
measurement.
Golden proportion: The Golden Ruler enables the dentist to
measure the vertical dimension easily and simply.
D -Measurement from former dentures
Patient's existing denture is a valuable pre-extraction record. A Boley's gauge is used to
measure the distance between the border of the maxillary and the mandibular denture
when both these dentures are in occlusion. This measurement is used to determine the vertical
dimension at occlusion.
B-PHYSI OLOGI CAL METHODS
a- Power Point: (by Boos)
;
A metal plate (central bearing plate) is attached to the maxillary record
base. Abimeter is attached to the mandibular record base. This bimeter
has a dial, which shows the amount of pressure acting on it.
The record bases are inserted into the patient's mouth and the patient is asked to bite on the
record bases at different degrees of jaw separation. The biting forces are transferred from the
central bearing point to the bimeter. The pressure reading in the bimeter is noted. The highest value
is called the Power point. The bimeter is observed when the power point is reached.
This device registers the biting force at varying degrees of jaw separation. The theory
is that the patient registers the maximum amount of biting force when the teeth first
contact in centric occlusion. The muscles of mastication will exert their greatest
degree of force when their origin and insertion are this exact distance apart.
b- Using Wax Occlusal Rims
A tentative vertical dimension is measured with occlusal rims and the casts are
articulated in a tentative centric relation. A tracing device can be attached to the occlusal
rims for a graphic tracing. The facial expression and aesthetics are used for the final value.
Procedure
The vertical dimension at rest is established and the difference between the
reference points (between the nose and chin) is recorded.
An approximate vertical dimension at occlusion, about 2 to 5 mm less than that of
the vertical dimension at rest is considered. The facial expression can also be used as
a guide for determining this value.
The occlusal surface of the maxillary occlusal rim is coated with petrolatum and
seated in the mouth. Denture adhesive powder may be used in cases with
inadequate retention.
A thin roll of modeling wax with a triangular cross-section is
softened in a water bath at 130 F and placed over the mandibular
occlusal rim with its apex towards the maxillary rim.
The added wax is softened again with a Blowtorch and the
mandibular rim is seated into the mouth.
The patient is asked to close his mouth slowly and stop at a comfortable position
based on his tactile sensation. This gives the vertical dimension at occlusion.
The wax is allowed to cool within the patient's mouth.
It is removed and articulated in a tentative centric relation.
(Note: Do not confuse this method with the "Nick and Notch" method used in
centric relation.)
c- Physiological rest position: (Niswonger and Thomson in 1934)
This is also called as Niswonger's method. Niswonger suggested using a 4/32-inch
interocclusal or freeway space as a guide to determining the vertical dimension of
occlusion. J Prosthodont 2003;12:30-36.
It is not considered as an accurate method because it requires patient's cooperation,
which is variable, and alterations in jaw position can occur during this procedure.
Procedure
Patient is asked to sit upright with his head unsupported and the eyes looking
straight.
Upper and lower occlusal rims which were modified according to the clinical
guidances (refer occlusal rim fabrication) are inserted and the patient is asked to
swallow and relax.
When the relaxation is obvious, the lips are carefully parted to reveal the space
present between the occlusion rims. This space is called the free-way space.
The space between the occlusal rims should be about 2-4 mm. The formula "VD at rest
=VD at occlusion + Free-way space" can be used to evaluate the vertical dimension at
occlusion. If the free-way space is more than 4 mm, the vertical dimension at occlusion is
considered to be small and if the space is less than 2 mm, the vertical dimension at
occlusion may be too great.
In the following 2 instances, dont try to get proper VDO by subtracting 3 mm from
rest position
- The patient accustomed to occluding in a very over-closed relationship for a long
period of time (not a good idea to open a patient 10 12 mm all in one operation
important to rely on patient judgement, too)
- The mouth breather lower jaw has been in an opened relationship for a long
period of time (a tactile closure into soft wax is a good way to determine the
vertical dimension in this case)
d- Phonetics
This involves observing the movements of the oral tissues during speech and more
importantly listening and analyzing the speech of the patient. There are two common
methods in which phonetics is used to determine jaw relation. They are:
Silverman's closest speaking space.
The "F" or "V" and "S" speaking anterior tooth relation.
Silverman's Closest Speaking Space
It was first described by Silverman.
When sounds like ch, s, j are pronounced, the upper and lower teeth reach their
closest relation without contact. This minimal amount of space between the upper
and lower teeth in this position is called the Silverman's closest speaking space
This space indicates the vertical dimension of the patient. In an ideal case, the
lower incisor should almost touch the palatal surface of the upper incisor.
According to him the closest speaking space measures the vertical dimension when
the mandible is in function.
Before the remaining teeth are extracted, a line is scribed on the anterior
mandibular teeth reflecting the position of the maxillary anterior teeth while the patient
is in maximum intercuspation; this is called the centric occlusion line.
Then the closest speaking line is drawn on the same anterior teeth, reflecting the
position of the maxillary teeth when the patient pronounces the sibilant sound, s, as in
the words yes and Mississippi.
Silverman believed that the closest speaking space, or the difference between the
centric occlusion line and the closest speaking line, should be 0 to 10 mm
J Prosthodont 2003;12:30-36.
Silverman's closest speaking space
Increase in the free-way space between the upper and lower incisors indicates an
inadequate vertical dimension at occlusion.
A decrease in the closest speaking space will indicate an excessive vertical dimension at
occlusion. Contact of the incisal edges during speech also indicates an excessive
vertical dimension at occlusion.
This differs from the Niswonger's and Thomson's method in that the Niswonger's method
measures the vertical dimension when the muscles controlling the mandible are at rest
or physiological tonus where as in this method the muscles are active.
The "For "V' and "S" Speaking Anterior Tooth Relation: (Pound and Murrel)
In this method, the incisal guidance is established by arranging the anterior teeth on the
occlusal rim before recording the vertical dimension at occlusion.
The anterior teeth are arranged on the occlusal rim and modified in the patient's mouth
based on the pronunciation of certain alphabets.
The position of the anterior teeth is determined by the position of the maxillae when the
patient pronounces words beginning with "F" or "V".
The position of the lower anterior teeth is determined by the position of the mandible
when the patient pronounces words beginning with the letter "S".
Procedure
An occlusal rim is fabricated over the maxillary record base. The maxillary occlusal
rim is inserted into the patient's mouth.
The base plate wax in the maxillary occlusal rim is adjusted using a fox plane and
made parallel to the Camper's line.
The patient is asked to repeatedly pronounce the words "fist" and "van". When the
patient says these words his upper lip should provide a facial seal. The maxillary
occlusal rim should be contoured to obtain the seal. The midline is marked on the
occlusal rim.
The upper central incisors are set in their position and checked in the patient's
mouth. The record base is removed from the patient's mouth and the anterior teeth
are set. The maxillary record base with the anterior teeth is inserted and corrected.
3/4 inch of speaking wax (Beeswax) is added over the occlusal plane of the
mandibular occlusal rim. Both record bases are inserted into the patient's mouth.
The mandibular occlusal rim with the speaking wax is inserted and the patient is
asked to pronounce the words "sixty" and "sixty-five". The midline is marked and
the record base is removed from the patient's mouth.
The speaking wax is removed to set the artificial teeth. The mandibular record base
is inserted and the setting is verified.
After verifying the anterior teeth arrangement, soft wax or zinc oxide eugenol
(ZnOE) impression paste or impression compound or dental plaster is added as an
inter-occlusal record on the posterior part of the occlusal surface of the mandibular
occlusal rim.
The upper and lower record bases are inserted and the patient is asked to close the
mouth till the anterior teeth occlude to their proper position. This procedure is
repeated to check for errors. The inter-occlusal material placed on the mandibular
occlusal rim records the vertical dimension at occlusion.
Pound and Murrel's method
e- Aesthetics
Facial esthetics An experienced dentist evaluates facial expression. In the normal
relaxed position, the lips are even anteroposteriorly and in slight contact. The nares
and the skin around the eyes and chin are relaxed. If the face appears strained, the
vertical height may be too much. If the corners of the mouth droop, making the chin
appear too close to the nose, then vertical dimension may be too less.
Skin If the vertical dimension is too high the skin of the cheeks will
appear very stretched and the nasolabial fold will be obliterated, the
nasolabial angle will be increased. The skin on the perioral areas can be
compared with skin over other areas of the face for reference. It should
also be remembered that there are other factors like the age of the
patient, which can influence the appearance of the skin.
Lips The contour and fullness of the lip is affected by the thickness of the
labial flange. The occlusal rims should be contoured to aid in lip
support. A flattened appearance of the lip indicates lack of lip support.
In such cases vertical dimension should not be increased to provide
lip support, as it would lead to failure of the denture.
Willis method (Facial proportions) Theoretically, the distance between the outer
canthus of the eye and the corner of the mouth should be equal to the distance
between the lower border of the septum of the nose and the lower border of the chin
f- Swallowing Threshold
It is considered that at the beginning of swallowing, the teeth of the upper and lower
jaws almost come in contact. This factor can be used as a guide to determine vertical
A conical occlusal rim made of soft wax is fabricated on the mandibular record
base. The upper and lower record bases are inserted in the patient's mouth.
Salivation is stimulated and the patient is asked to swallow. The height of the
conical wax rim is reduced due to the pressure developed while closing the
mandible during swallowing. The conical wax rim may also be softened to
reduce the resistance to closing.
Laird reported that with dentures at the accepted vertical dimension the patients
swallowed with the denture teeth in occlusion. This suggests that patients who
swallow without denture tooth contact may be functioning at a reduced vertical
dimension. J Prosthodont 2003;12:30-36
g- Tactile Sense or Neuromuscular Perception (Lytle's method)
The patient's tactile sense or sense for comfort is used to asses the vertical
In this method a central bearing screw/ central bearing
plate apparatus is used. The central bearing screw fits
into the depression of the central bearing plate. The
central bearing plate is attached to the maxillary occlusal rim
and the central bearing screw is fixed to the mandibular
occlusal rim.
Procedure
The occlusal rims with the central bearing screw and plate are inserted into the patient's
mouth.
The central bearing screw is progressively tightened. This
tightening will bring both the occlusal rims towards each other.
After a certain limit the patient will feel discomfort in his jaws due
to over-tightening. This point is recorded.
The same procedure is repeated with the central bearing plate in the mandibular rim and
the central bearing screw in the maxillary rim.
The central-bearing point is slowly reduced till the patient indicates a comfortable jaw
relationship.
The procedure is repeated to avoid errors. Disadvantages include foreign body
obstruction,etc.
h- Patient's Perception of Comfort
It is a very simple and easy method of determining the vertical relation. Here, the
record bases with excessively tall occlusal rims are inserted in to the patient's
mouth and the excess base plate wax is removed stepwise till the patient perceives
the occlusal height as comfortable.
The disadvantage of this technique is that it depends on the patient's co-operation
for accurate readings.
i- Electromyography
By recording the minimal activity of masticatory muscles
postural position or rest position can be determined by means of
electromyography which would record minimal activities of muscles as all
muscles showed greater activities (in other position) than when the jaw is at rest".
j- open rest method
Douglas and Maritato evaluated patients at an open rest position and
suggested that the occlusal plane should be established in terms of its
relationship to the commisures of the lip, with the maxillary occlusal plane 3
mm above and the mandibular occlusal plane 2 mm below the commisures. J
Prosthodont 2003;12:30-36.
On many occasions, however, it is necessary to increase the occlusal vertical
dimension to compensate for wear of the old occlusal surfaces and resorption of the
alveolar bone.
It is necessary to have a clear idea of the magnitude of change required and to
decide whether such an increase, if added to the upper rim, will improve or detract
from the appearance of the patient or, if added to the lower rim, will so increase the
height of the occlusal plane that the stability of the lower denture will be impaired.
Clinical Techniques to Increase Vertical Dimension
The clinician must take care to avoid creating a vertical dimension in which the patient
cannot function.
Hansen technique J Prosthodont 2003;12:30-36
Hansen described a technique using clear thermoplastic resin splint material
with tooth-colored autopolymerizing resin.
After the maxillary and mandibular denture are mounted, the
autopolymerizing resin is added until the predetermined appropriate vertical
dimension is obtained on the articulator.
The mandibular denture is used to restore vertical dimension, because
mandibular alveolar bone resorbs more quickly than maxillary bone.
The final occlusal adjustment is made intraorally. The diagnostic splint is
then placed over the existing andibular denture to diagnostically restore the
vertical dimension.
Mays technique J Prosthodont 2003;12:30-36
A new set of dentures was used as a diagnostic treatment prosthesis to
gradually evaluate patient ability to adapt .
The dentures were relined with a
tissue conditioner, and methyl
methacrylate resin was applied in
small increments to the occlusal
surfaces of the mandibular denture
teeth over a 60-day period to
establish a vertical dimension 5 mm greater than the vertical dimension of his
original dentures.
The tissue conditioner was changed
approximately every 3 weeks throughout
the treatment. The patient wore the
treatment occlusal prosthesis for 3 weeks
with an increase of 2 mm; it was then
increased to 5 mm for a total treatment time
of 2 months.
During this time, the patients TMD pain resolved and crepitus and clicking
decreased.
Occlusal device for diagnostic evaluation of maxillomandibular
relationships JPD 2004;91:586-90.
Diagnostic modification of OVD prior to complete denture therapy is often
indicated for patients who have worn existing prostheses for many years.
For these patients, clinical examination may reveal the following conditions:
severe decrease in lower face height yielding poor facial esthetics, inadequate fit of
complete dentures, worn denture teeth, clinically discernible deficiency in OVD,
acquired protrusive maxillomandibular relationship,angular cheilitis, or
temporomandibular joint sounds on auscultation.
The procedure involves modification of existing or duplicate complete dentures
to evaluate proposed alterations of the existing OVD. The primary advantage of this
procedure is that functional surfaces of the occlusal device are intraorally generated by
patient-induced mandibular movements limited by a central bearing device.
TECHNIQUE
1- Modifications may be done on duplicate complete dentures.
2- When indicated, condition the denture-supporting soft
tissues prior to diagnostic modification of the complete
dentures. Provide adequate and even reduction of the
intaglio surfaces of the dentures before applying tissue-
conditioning material. even denture base reduction by
painting the intaglio surfaces with disclosing ink.
3- Subject the prostheses to definitive laboratory reline or rebase procedures.
4- The rest vertical dimension (RVD) is recorded,. Use a Boley gauge to record the
distance between the marks on the nose and chin. subtract approximately 4 mm,
accounting for the necessary interocclusal distance, to arrive at the diagnostic
OVD.
5- Use a central bearing device to stabilize the
mandibular denture during jaw movements and
maintain the desired OVD during diagnostic
denture modifications.
6- Apply a doughy mass of autopolymerizing, tooth
colored, acrylic resin to the posterior occlusal
surfaces of the mandibular complete denture.
lubricate the occlusal surfaces of the maxillary
denture teeth with a suitable lubricant.
7- Instruct the patient to close to the predetermined
OVD, bringing the central bearing point into
contact with the bearing plate. Direct the patient to
perform mandibular movements through all
eccentric jaw positions while maintaining contact
between the central bearing point and the bearing
plate.
8- Remove the prostheses from the patients mouth. Following complete
polymerization, trim excess acrylic resin.
9- Assure that the functional occlusal objectives of this diagnostic therapy are met,
including: (1) multiple, even occlusal, contacts coincident with CR at the
established OVD, and (2) bilaterally balanced occlusion, if desired. Instruct the
patient to wear the occlusal device throughout the diagnostic phase of therapy
and report complications.
10- Inform the patient that use of the occlusal device will be continued until stable
and comfortable maxillomandibular relationships are achieved
HORIZONTAL JAW RELATION
It is the relationship of the mandible to the maxilla in a horizontal plane. It can
also be described as the relationship of the mandible to the maxilla in the anteroposterior
direction.
Horizontal jaw relation can be of two types namely centric and eccentric jaw
relations.
Centric relation denotes the relationship of the mandible to the maxilla when the
mandible is at its posterior most position.
Eccentric relation denotes the relationship of the mandible to the maxilla when
the mandible is at any position other than the centric relation position.
Centric Relation
The glossary of prosthodontic terms (GPT) enumerates seven different definitions for
centric relation. They are:
1. "The maxillomandibular relationship in which the
condyles articulate with the thinnest avascular portion
of their respective discs with the complex in the
anterior-superior position against the slopes of the
articular eminences. This position is independent of
tooth contact. This position is clinically discernible
when the mandible is directed superior and anteriorly.
It is restricted to a purely rotary movement about the transverse horizontal axis"
(GPT-5) (most accepted definition).
2. "The most retruded physiologic relation of the mandible to the maxilla to and from
which the individual can make lateral movements. It is a
condition that can exist at various degrees of jaw separation. It occurs around
the terminal hinge axis" (GPT-3)
3. "The most retruded relation of the mandible to the maxilla when the condyles
are in the most posterior unstrained position in the glenoid fossa from which
lateral movements can be made, at any given degree of jaw separation" (GPT-l)
4. "The most posterior relation of the lower to the upper jaw from which lateral
movements can be made at a given vertical dimension" (Boucher)
5. "A maxilla to mandible relationship in which the condyles and discs are thought
to be in the midmost, uppermost position. The position has been difficult to
define anatomically but is determined clinically by assessing when the jaw can
hinge on a fixed terminal axis (up to 25 mm). It is a clinically determined
relationship of the mandible to the maxilla when the condyle disc assemblies
are positioned in their most superior position in the mandibular fossa and
against the distal slope of the articular eminence" (Ash)
6. "The relation of the mandible to the maxilla when the condyles are in the
uppermost and rearmost position in the glenoid fossae. This position may not be
able to be recorded in the presence of dysfunction of the masticatory system"
(Ach 1993 , Lang)
7. "A clinically-determined position of the mandible placing both condyles into
their anterior uppermost position. This can be determined in patients without
pain or derangement in the TMJ" (Ramsfjord l993).
GPT-5 definition is commonly used and accepted. Generally speaking, centric
relation can be described as the most posterior relation of mandible to the maxilla
at the established vertical dimension from which lateral movements could be
made. Any position of the mandible other than that of the centric relation is called
an eccentric position.
Note: Centric relation is the most posterior relation of the mandible to the maxilla
and the antero-superior relation of condyle to the glenoid fossa.
These definitions are somewhat different; they all agree that the CR is determined by
the TMJ structure and not by the dentition. Most of them relate to the THA, some of
them mentioned the retruded or posterior position, and other emphasis the uppermost
position of the condyles .

HARMONY BETWEEN CR AND CO
o Intercuspal Position: is the position of the mandible when the teeth are in
intercuspal occlusion.
o Centric occlusion: The occlusion of opposing teeth when the mandible is in
centric relation. Formerly Maximum Intercuspation
o In 90% of people the CR is not coincide with CO. In the natural dentition CO
is usually located anterior to CR, the average distance being 0.5to 1 mm. In
the young age and complete denture the CR and CO are coincide to each
other.
o The confusion in terminology has been aggravated by controversy over the
correlation between the CR and centric occlusion CO i.e., the intercuspal or
maximum intercuspation position. The current definition of CO is the
occlusion of opposing teeth when the mandible is in CR. this may or may not
coincide with maximum intercuspation.
o Another argument for this concept the distance between the maximum
intercuspation position and the CR are increase in long-term CD wearers,
even if they coincide when constructed.
CENTRIC OCCLUDING RELATION
This exists when the jaws are in centric relation and the teeth
(0cclusal surface ) are in centric occlusion. It is the most important
basic relationship of the body of the mandible to the maxillae.
Coincidence of C.R. and C.O. (Centric occluding relation):
Complete denture prosthodontists have established that slower ridge
resorption occurs, greater chewing efficiency results and greater stability
of the denture bases exist, when denture patients are provided with
coincidence of C.O. (centric occlusion) and C.R. (centric relation).
Periodontists have established that greater potential for preservation of
supporting structures results and more rapid healing of diseased tissues
occurs when coincidence of C.O. and C.R. exists.
Detrimental effects may occur when these positions do not harmonize.
1. masticatory efficiency is reduced: Maximum muscle load is required to
produce minimum work i.e.
2. deflective malocclusion :Slide frequently exists between C.R. and C.O.. The
slide introduces adverse forces not in line with long axis of teeth. These adverse
forces tend to accentuate periodontal problems. The resultant deflection can
produce wear and instability of the teeth in the dental arch This deflection also
tends to predispose to muscle tension and spasm or other complaints associated
with TMJ. problems.
3. Two arcs of closure coupled with emotional stress appear conductive to
bruxism or clenching habits.
4. Two arcs of closure produce two different vertical dimensions of occlusion,
which in turn may produce muscle inefficiency.
5. If C.R. and C.O. are not made to coincide, all lateral eccentric excursions are
apt to be in conflict with TMJ. guidance.
6. Because C.R. is the only maxillo-mandibular relationship that can be routinely
repeated, so it is logical to have C.O. coincide with it to maintain a more constant
anatomical relationship between the jaws and consequently between the teeth in
occlusion.
THE CENTRIC AND VERTICAL RELATIONS
Many vertical relations (VR) are possible between the mandible and the
maxillae. However, there is a most retruded position of the mandible for
each VR and there is a change in CR for each change in the vertical
dimension .
The CR record must be made at the established vertical dimension of
occlusion when an arbitrary face-bow transfer is used to orient the cast to
the opening axis of the articulator. While, when the cast are mounted with
the correctly located T H A, the operator can change the VD without change
in the CR.
Importance of Centric Relation (Significance)
1- The centric relation position acts as a proprioceptive centre to guide the
mandibular movements. The proprioceptive impulses (impulses of three-dimensional
spatial orientation) guide the mandibular movements.
In dentulous patients the proprioceptive impulses are obtained from the periodontal
ligament. Edentulous patients do not have any proprioceptive guidance from their teeth
to guide their mandibular movements. The source of the proprioceptive impulses for an
edentulous patient is transferred to the temporomandibular joint.
2- The centric relation has the following salient features:
It is learnable, repeatable and recordable position which remains
constant throughout life.
It is a definite learned position from which the mandible can move to
any eccentric position and return back involuntarily. It acts as a centre
from which all movements can be made.
If the mandible has to move from one eccentric position to another it
should go to the centric relation before advancing to the target eccentric
position.
Functional movements like chewing and swallowing are performed in
this position, because it is the most unstrained position.
The muscles that act on the temporomandibular joint are arranged in
such a way that it is easy to move the mandible to the centric position from
where all movements can be made.
3- The casts should be mounted in centric relation because it is the point from
which all the movements can be made or simulated in the articulator.
The accurate CR record will orient the lower cast to the opening axis of the
articulator and the mandible.
It is helpful in adjusting condylar guidance in an articulator to produce
balanced occlusion.
It is a definite entity so it is used as a reference point in establishing centric
occlusion.
Centric relation is a learned position (not a default position) and the dentist
should teach the patient with patience to move his mandible from the centric relation
position.
4- The irregular loss of teeth often creates deflective occlusal contacts that guide the
mandible into slightly protrusive or lateral positions, or both. The muscles, bone,
ligaments, teeth, and all related structures grow into coordinated center for
muscular activity. To change this center for muscular activity is to imperil the
stability of denture .
5- If the CR is not recorded, premature contact will be built in the denture particularly
when the mandible moves backward to the CR.
Retruding the Mandible
The mandible should be in its most posterior position while recording
centric relation. Some patients may show difficulties in retruding the mandible due to
certain systemic conditions. These difficulties can be overcome by conditioning the
patient psychologically using special jaw relating apparatus, etc.
Method of Retruding the Mandible
Relaxing the patient. Making him feels comfortable.
Massaging or palpation of the temporalis and masseter muscles to relax them. In
the terminal hinge position, closing the mandible then the
temporalis muscle can be felt by the dentist.
Roll the tongue backwards .The patient should be instructed
to touch the posterior border of the upper record base with his
tongue. Knob for tongue retrusion
Protrude and retrude the mandible repeatedly, while patient
hold finger lightly against the chin.
Tilting the head backwards tends to pull the mandible backward because of
tension on the infrahyoid muscles.
Swallow and close. The disadvantage is that a patient can swallow: slight
eccentric positions also.
The mandibular occlusal rim should be tapped gently with a finger. This would
automatically make the patient to retrude his mandible.
The patient is asked to try to bring his upper jaw forward.
Push the upper jaw out and close on the back teeth.
Boos stretch-relax exercises Open wide and relax, move the jaws the left and
relax, right and relax, forward and relax. This helps the patient to coordinate
movements and follow the dentist's instruct
Tapping rims together rapidly and repeatedly.
The patient may be further encouraged at this stage to make contact in the
retruded position by reducing the height of the lower rim anteriorly by about
1 mmso that the rims occlude only in the premolar and molar regions.
Difficulties in Retruding Mandible
Difficulties in retruding the mandible can be classified as
Biological
Physiological
Mechanical.
Biological causes
Lack of co-ordination between groups of opposing muscles when the patient is
requested to close the mouth in the retruded position.
Habitual eccentric jaw relation.
Physiological causes
Inability of the patient to follow the dentist's instructions is one of the major
psychophysiological factors, which produce difficulty in retruding the mandible.
This is overcome by instituting stretch relax exercises, training the patient to open
and close his mouth, etc. Central bearing devices can also be used to retrude the
mandible in these patients.
Mechanical causes
Poorly fitting base plates produce difficulty in retruding the mandible. The base
plates should be checked using a mouth mirror for proper adaptation.
Amount of pressure that the patient exerts at the time of CR registration.
Muscles involvement in CR
Centric relation is not a resting or postural position of the mandible. Contraction
of muscles is necessary to move and fix the mandible in it. The posterior and
middle parts of the temporal and the suprahyoid muscles are move and fix the
mandible in its most retruded position relative to maxillae. The temporal,
masseter, and medial pterygoid muscles elevate the mandible to a particular
vertical relation with the maxillae. The lateral pterygoids show little activity
when the mandible is in CR.
Recording centric relation Synonyms Bite registration
There are two schools regarding pressure used while recording centric relation.
A. Minimal closing pressure
A minimal pressure is advocated so that tissues are not displaced. Thus, the
opposing denture teeth will touch uniformly and simultaneously at first contact.
B. Heavy closing pressure
to produce same displacement of soft tissues that occurs during function.
Advantage : Occlusal forces are evenly distributed over the residual ridge under
heavy loads.
Disadvantage
1. If soft tissues have uneven thickness, the teeth contact uneven at first contact.
2. Uneven contacts may cause clenching in nervous patients
Methods of recording CR
A- STATIC RECORDING
Interocclusal registration (check-bite interocclusal registrations, Wax wafer method)
B- DYNAMIC RECORDING
I-Functional recordings (physiologic techniques)
a- Excursive functional recording (chew-in):
1- Pumice and plaster occlusal rims (Patterson)
2- Needles and needles house techniques
3- Functional movement of soft wax occlusion rims covered by tin
foil (Meyer)
4- Occlusal pathway in single dentures: Chew in or functional
record method, Functional generating path.
5- Stereograph.
b-Non-excursive function recordings : Swallowing (physiologic or
deglutition) techniques.
II- Graphic recording : - Gothic arch tracing - Pantograph - Minigraph
III- Terminal hinge axis recording
IV- Radiographical methods : - Cephalometric - Transcranial - C T scan
A-STATIC RECORDING
(Interocclusal registration of CR)
Interocclusal records are made with a recording medium between the occlusal rims, the
trial denture bases. The patient close into the recording medium with the lower jaw is in the
most retruded position and stops the closure at the predetermined vertical relation
The common materials for the interocclusal records in order of accuracy are as the
follows: polyether, zinc oxide and eugenol past, plaster, autopolymerizing acrylic resin,
condensation type silicones, and wax. Recently, addition type silicones have been proposed
as registration material to improve the accuracy of condensation type silicones.
Requirement of the ideal interocclusal recording material:
1- Low viscosity, 2- Low resistance to closing of the jaws,
3- Precision in detail, 4- Dimensional stability,
5- Plasticity, 6- Elasticity,
7- Ease of use; adequate working time, rapid hardening, simple operation, and
8- Acceptability by the patient.
Technique
a- Three check lines are drawn with a wax knife from one rim to
the other, one in the midline and one either side in the premolar
regions. These lines
Enable the blocks to be located outside the mouth to establish whether there is any
premature contact on the posterior aspects of the rims or bases.
In addition, the check lines allow the clinician to judge whether the patient continues
to close in a consistent manner.
b- Two millimeters of wax was removed from the mandibular occlusal rim. Two V-shaped
notches were cut in the occlusal surface of the lower rim. Depth 1-2 mm
1- Remove 3 mm of the mandibular rim from the mandibular first premolar area distally
to the end of wax rim on both sides. On the maxillary rim in the corresponding areas cut two
or three notches. If desired, the record medium can be placed on the maxillary recording base
and grooved placed in the mandibular wax occlusion rim serves as index. (Winkler 1988)
2- Place the index on the occlusal surface in the regions of upper first molars. Make the
index by placing transversely a step that is approximately 2 mm deep anteriorly, tapering
distally to nothing. (Syllabus 1980)
3- Other placed the index in the areas of upper premolar in form of buccolingual H shape,
and the wax interocclusal record confined to the second bicuspid molar area of lower
occlusion rim. (Cairo 73).
c- The occlusal surfaces of the upper and lower wax rim were smeared with a thin film of
Vaseline.
d- Four mm of softened base palate wax was attached to the occlusal surface of the
mandibular rim.
e- The blocks were placed into the mouth. Then the patient was guided to close in centric
relation by asking him or her to place the tip of the tongue as a back on the palate as
possible, keep it there and close the record blocks together until they were met at the
predetermined vertical relation.
f- The record blocks were removed from the mouth, and
chilled with cold tap water. Then the interocclusal wax
record was separated from the wax rims and kept in cold
water.
g- The record blocks can be sealed by using sablets
Indications
1- In situations of abnormal related jaws.
2- Excessively displaceable supporting tissues.
3- Large awkward tongue.
4- Uncontrollable or abnormal mandibular movements.
5- To check teeth those have been arranged in trial dentures.
6- To check the occlusion of the teeth in the existing dentures.
7- For clinical remounting of complete dentures.
8- In almost all case of complete dentures.
Other material used
Alluwax
Must be dead soft
Zinc-oxide paste is used as interocclusal material
DYNAMIC RECORDING
I-Functional recording
a-Excursive functional recordings
1-Pumice and plaster occlusion rims or plaster and carborundum (Patterson).
In this method the record block made from wax occlusal rim. Correct VD and CR are
determined (as discussed in interocclusal record method).
The record blocks are mounted on the articulator, the incisal post is open by about 4
mm.
A trench is made in each occlusal rim, and mixture of plaster and pumice or
carborundum is placed in the trench.
The plaster mixture should be allowed to set for at least 24 hours before begin used.
The patient instructed to grind the blocks together in both lateral and protrusive
movements. But only to use the minimum pressure necessary to keep the block in
contact. The grinding should be continued until the correct VD is obtained.
Then the patient instructed to retruded the mandible and the occlusal rims are joined
together with metal staples.
The main object of this technique is to obtain the degree of curvature of the compensative
curve. The record is also used as the CR record.
Stability of record block is essential for accuracy since there will be a considerable lateral
and protrusive drag, owing to friction, during the process of grinding, and therefore, the base
should be made of acrylic resin.
2- Needles and Needles-House technique
Needles 1923 used compound occlusal rims with three studs on maxillary rim. When
the mandible moves, the studs are cut arrow tracing into mandibular rim. After removal from
mouth, the rims are assembled with the functional grooves.
While the Needles-House, used four styli instead of three studs in the maxillary rim.
When the mandible moves, the styli are cut four diamonds shaped tracings. The tracing
incorporated the movement in three planes, and the records are placed on a suitable
articulator to receive and duplicate the record. The record can also be used as the CR record
on the other types of articulators.
3. Functional movement of soft wax occlusion rims covered by tin foil.
Meyer (1934) used soft wax occlusion rims. Tin foil was placed over the wax and
lubricated. The patient performed the function movements to produce the wax path. A plaster
index was made of the wax and the teeth were set to the plaster index.
4- Occlusal pathway in single complete dentures
functionally generated chew-in techniques (FGPT):
This technique provide the most accurate method of recording occlusal patterns.
Requirement of FGPT:
The record base should be stable and retentive
The patient must have the neuromuscular control to perform the desired jaw
movements and the mental competence effectively cooperate.)
Functional Chew-In Techniques
In (1928) Stansbury described the first functional chew in technique for an upper
complete denture opposing lower natural teeth. By using a compound maxillary rim
trimmed buccally and lingually so that the occlusion free in lateral excursions.
Carding wax is added to the compound rim, and the patient instructed to perform,
eccentric chewing movements. The carding wax is slowly molded to the functional
movements, while the compound in the central fossa acts as a guide to preserve the
vertical dimension. The generated occlusion rim is now removed from the mouth,
and stone is vibrated into the wax paths of the cusps. The upper cast is again
fastened to the articulator with the generated occlusion rim and the stone cusp path
record. The stone cusp path record is secured to the lower member of the articulator
with plaster. We now have the upper cast mounted on the articulator and two lower
casts. One is a duplicate of the lower teeth and the other is a replica of the generated
path. The denture teeth are first set to the lower cast of the patient's teeth. After the
esthetics have been approved at the try-in, the lower cast is removed and the lower
chew-in cast record is then secured to the articulator. All interfering spots are
carefully ground until the incisal guide pin prevents further closure. Thus. in centric
and in eccentric movements maximum bilateral balanced occlusion will have been
established.
In1964 Vig described a similar technique, by using of a fin of resin placed into the
central grooves of the lower posterior teeth, instead of using compound as
mentioned by Stansbury. The resin fin maintains the vertical dimension and also
helps to diagnostically locate the interfering lower cusp in eccentric movements the
lower cusp tips are ground until equal contact occurs between the teeth and resin.
The fin is then built up using a soft wax, and a functional path is recorded.
In 1968 Sharry mentions a simple technique of using a maxillary rim of softened
wax. Lateral and protrusive chewing movements are made so that the wax is
abraded, generating the functional paths of the lower cusps. This is continued until
the correct vertical dimension has been established.
In 1973 Rudd used a compound maxillary rim as the same way. A thickness of
recording matrix, made up of three sheets of medium-hard pink baseplate wax and
two sheets of red counter wax, is added to the buccal and lingual surfaces of the
compound rim. He also using two maxillary bases, one for recording the generated
path and the other for setting the teeth. The advantage of this is to reduce the
number of appointments necessary for the construction of the upper denture.
5- Stereograph
All border movements can be accurately recorded in three diminutions by means of
simple intraoral clutches that are stabilized by a central bearing point.
The TMJ instrument designed by Kenneth Swanson in 1965 is representative of this
class.
An intraoral registration is generated by studs in autopolymerizing resin similar to the
technique utilized with the House articulator. The stereographic recording is then
placed on the articulator and used to mold fossae in autopolymerizing resin.
It is claimed that these fossae produce an accurate analog of the patient's
temporomandibular joint function.
b- Non-excursive function recordings (Swallowing, physiologic or deglutition
technique)
Soft cones of wax are placed on the lower trial denture base. The wax cones contact
the occlusal surface of the upper occlusion rim when the patient swallows.
This provides a record of the horizontal relation of the mandible to the maxillae.
Unfortunately, the mandibular position recorded by this method is not necessarily
consistent with CR and is not repeatable.
II- Graphic recording
1- Gothic arch tracing (arrow point tracing, central bearing point):-
I. Intra-oral tracings;
The intraoral device consists of
a) A carrier through the centre of which is threaded a pointed
stylus (tracing point controlled by a locking nut
b) A locking disc and
c) A tracing plate
After the correct vertical height has been obtained, the
carrier is fitted to the lower rim so that the tracing point is
placed centrally across a line joining the premolars. The
tracing point serves, also, as a central bearing point.
The tracing plate is inserted parallel to and just below, the occlusal surface of the
upper rim.
Place the blocks in the mouth with the stylus adjusted to hold the rims slightly apart.
The patient now performs lateral jaw movements, keeping the tracing point in contact
with the plate the whole time.
When the operator is satisfied that the patient can perform these movements
correctly, the upper blocks is removed and after the tracing plate has been filmed with
blue inlay wax the blocks are replaced in the mouth.
Lateral and protrusive movements are made, the tracings
examined, and if clearly defined arrow has been recorded the
retruded position has been obtained.
The locking disc is a transparent plastic disc having a hole in the
centre and which can be secured to the tracing plate in any
desired position. The disc is placed over the tracing plate and its
hole is adjusted to the apex of the Gothic arch. The disc is then secured to the
underlying plate.
The tracing point is then readjusted just to make the rims in contact. The blocks are
returned to the mouth and the patient is asked to move the mandible until the stylus
slips into the hole of the disc.
The blocks should now be in even contact and no longer held apart by the screw. The
blocks are united in the mouth with hot wire staples or a mix of plaster.
II- extraoral tracing:-
The extra tracing apparatus is similar to the
intraoral except that the stylus and tracing plate are
outside the mouth, being attached to the record blocks
by rods which pass between the lips. The tracing plate
is attached to the lower rim.
No locking discs or plate are required to ensure that
the mandible is in most retruded position. This is can be known from the tracer out side the
mouth.
A double needle-point tracing, one anterior to the other, also can be made by increasing or
decreasing the V D at which the tracing is scribed. This to tracings afford an excellent
illustration of how to the centric position varies at different levels of the V D.
Many needle-point tracing are not indicative of an exact C R because of the roundness of
the apex. The lateral movement should be made until the apex is sharp to indicate the true
retruded position of mandible. The dull or rounded apex on a tracing may be caused when
the condyles do not reach their most posterior positioning the TMJ, or when the recording
bases move on their basal set.
Errors may be introduced in the graphic tracing procedure:
When central bearing point is not mounted in the center of the lower basal seat
area.
When central bearing plates are not positioned parallel to each other and to
ridges.
When patient closes too hard causing unequal tissue displacement under the
bases.
When the tissue conditions are unfavorable as in conditions of hypertrophy
which could cause shifting of the bases.
When the arch relationships are unfavorable, as in severe angle class II or III,
which can result in a tipping of the upper base even when the central bearing
point is adjusted to be in the center of the lower arch.
Further, when central bearing plates are used the operator must be certain that
there is no interference in the occlusion rims in the posterior regions during
movement of the mandible.
Limitation of excursive recordings
The trial denture bases should remain seated during recording of the gothic arch
tracing. In Angles class II&III, it is impossible to centralize the biting load on the
trial denture bases by the use of a central bearing device. This is due to the
anatomical variation in size of the upper and lower jaws.
Excursive recordings are more suitable in angle class I cases. In the presence of
flat of flabby ridges it is difficult to stabilize the trial denture bases. Often the
inability to obtain a precise apex in the tracing is due to shifting of the base.
In an attempt to stabilize the bases and obtain a three-dimensional tracings. House
used sharp studs set in the upper rim. These studs cut the movement path into a
compound rim on the lower trial denture base. This technique is suitable for
patients with good ridges.
2- Pantograph:- see mandibular movement
3- Minigraph:- see mandibular movement
III- Terminal hinge axis recording:-
When a record centric relation is made, it can be assumed that the anteroposterior
relation of the mandible to maxillae at the terminal hinge position is the same as centric
relation.
Techniques for recording the hinge axis location:-
The kinematic face bow is first-fastened to the mandibular rim and kept in close
adaptation to the lower ridge by a clamp under the chin that hold the mandibular
block in place.
The patient is put through simple opening and closing movements 20 mm. This
movement of the mandible shows whether the condyle rods are on the rotational
centre. If they are not, concentric circular movements of the condyle rod points will
be made. These points are adjusted during the opening movements until they rotate
without any concentric arcing.
When the hinge axis centre is determined, it is marked with indelible pencil. The
condyle rods are provided by adjustment screws that allow the rods to move in
various directions to enable the operator to ascertain the hinge axis without altering
the "fork to rim" relation
Using the Palate for the Interocclusal RecordJ of Prosthodontics 19 (2010) 245246
o This technique may be used in full-arch rehabilitations involving either natural
teeth or osseointegrated implants.
o Obtaining the interocclusal record using the palate as an area of registration takes
advantage of the limited tissue mobility of the region, and does not require
segmentation of interim prostheses at the midline. Moreover, it maintains the
previously established OVD, allowing the casts to be mounted in the articulator for
the fabrication of the framework.
Technique
1. Manipulate the silicone putty elastomer (Zetaplus, Zhermack,
Badia Polsine, Italy) and place it over the hard palate and occlusal
surfaces of the interim prostheses on the maxillary arch (covering
the incisal/occlusal third of the teeth).
2. Ask the patient to close his/her mouth into maximum
intercuspation.
3. Trim the excess registration material, covering the cast with a
scalpel blade.
4. Mount the maxillary cast in the articulator with a facebow
transfer. Fix the cast to the platform with stone (Vel-Mix,Kerr,
Romulus, MI).
5. Verify that the interocclusal record is seated correctly over the
mandibular cast.
6. The silicone must be in intimate contact with the hard palate in
the maxillary cast and with the occlusal and incisal surfaces in the
mandibular cast.
7. Fix the mandibular cast to the platform with stone.
8. The casts on the articulator are now ready for laboratory procedures. An additional
advantage of this technique is that the record of the incisal edge position of the interim
prosthesis may function as a guide for the production of the framework of the prosthesis
Eccentric Jaw Relationships
Any jaw relation other than centric relation
Protrusive Record
Right Lateral Record
Left Lateral Record
Methods of Registration
Wax registration method.
Graphic tracing method.
Chew in or Functional method as by Needle House and Patterson
techniques
1- Wax wafer Method:
It is based on Christensen phenomenon:
a) Protrusive record:
The wax wafer used in recording centric relation is removed
carefully and replaced by another softened wax wafer of 4 mm
thickness which is placed on the lower occlusion block. The
upper and lower blocks are inserted in the patients mouth and
the patient is instructed to close in protrusion about 46 mm.
This record is needed in case of using semi-adjustable condylar
path articulator to adjust to horizontal condylar path, while the lateral
condylar path will be calculated indirectly by the formula.
This protrusive record is subsequently used to adjust the angle of the
condylar track to the horizontal plane. It is placed on the lower record rim
on the articulator and then, as the upper rim is seated in the record, the
condylar track is caused to rotate. The resulting condylar angle can be read
from the scale on the side of the joint assembly.
b) Lateral records:
Two softened wax wafers of 4 mm thickness are needed. When one wafer
is inserted the patient is instructed to close on one side (e.g. right side).
This record will help to adjust the condylar inclination of the left side.
Whereas the other wax wafer is used and the patient is instructed to close
on the left side to adjust the condylar path inclination of the right side.
These right and left lateral records are used for the fully adjustable
condylar path articulators. Where both horizontal and lateral condylar
path inclinations are adjusted according to the patients records.
2- Graphic Tracing Method:
When the stylus is in the desired eccentric position (either protrusive or lateral
position), the upper and lower occlusion blocks are locked together with plaster
and then transferred to the articulator to adjust the condylar guidance of the
articulator.
(a) The condylar angle the angle of the condylar track to the horizontal plane. (b) The
Bennett angle the angle of the condylar track to the sagittal plane.
Obtaining balanced occlusal contact
Balanced occlusion: Balanced occlusion is present when there are simultaneous contacts
between opposing artifi cial teeth on both sides of the dental arches. This term describes a
static situation and applies when upper and lower dentures meet in any position.
Balanced articulation: Balanced articulation is a dynamic situation in which there are
bilateral, simultaneous, contacts of opposing teeth in central and eccentric positions as the
mandible moves into and away from the intercuspal position.
Working and non-working sides: The working side is that to which the mandible moves, for
example, in order to break up a bolus of food. The opposite side of the arch is termed the
non-working, or balancing side.
Condylar path : The condylar path is the route taken by the mandibular condyle as it moves
forwards and downwards from the glenoid fossa to the articular eminence.
Condylar angle : the angle between the condylar path and the Frankfort plane.
Condylar axis: The condylar axis is a line between the mandibular condyles close to a hinge
axis around which the mandible can rotate without translatory movement.
Advantages of occlusal balance
Masticatory forces are transmitted as widely as possible over denture-bearing tissues.
the even contact positively assists in retaining the dentures
Balanced occlusion and articulation are only relevant when the teeth make contact.
This situation occurs during the so-called empty mouth contacts while swallowing saliva,
clenching or grinding the teeth.
During mastication, in the early stages, the bolus is generally too large or too firm for the
teeth to penetrate fully and to come into contact. Thus, occlusal balance does not operate at
this stage, a situation reflected in the old adage, Enter food, exit balance.
It is only in the later stages of comminuting of the bolus that the food is broken down and
softened enough for the teeth to contact and for occlusal balance to come into play.
Relating the maxilla to the hinge axis by face bow
Hinge axis [posterior reference point]
(Transverse horizontal mandibular axis, terminal hinge axis, kinematic axis)
The hinge axis, or transverse horizontal axis, is an imaginary line around which the
mandible may rotate within the sagittal plane. This rotation averages about 12
o
or 18-25mm
of incisal opening, and occurs during centric relation.
This movement is most likely performed in the lower part of the temporomandibular
joint between the surfaces of the condyle and the articular disc.
Many hinge-axes exist; there are at least twelve hinge-axes in every head; three in
each temporomandibular joint and three in each mandibular angle. Only the three in each
joint require consideration:
(1) The transverse hinge-axes that govern jaw rotation in the sagittal plane (opening and
closing),
(2) The vertical hinge-axes that govern jaw rotation in the horizontal plane (side-to-side),
(3) The sagittal hinge-axes that govern jaw rotation in the transverse plane.
Importance of the hinge axis:
1. Accurate location of the hinge axis is of clinical importance for the orientation of the
maxillary cast on the articulator and the subsequent mounting of the mandibular cast with
the centric relation record.
2. If the casts are not mounted on the hinge axis, then, an articulator cannot be adjusted to
reproduce jaw movements accurately.
3. Alteration of occlusal vertical dimension on the articulator is possible with hinge axis
mountings.
4. With the use of hinge axis transfers, a cusp form (anatomic) posterior teeth are indicated
with minimal adjustment.
5. The use of hinge axis transfers develops an occlusion, which would preserve and restore
oral functions, with minimal remounting procedures to perfect the occlusal scheme.
6- Without the hinge axis for the transfer of casts to an articulator, it is impossible to
diagnose an occlusal problem because the teeth on the model would not meet in the same
way as they would in the mouth.
1- If the location of the hinge axis of a patient is precise, centric relation registrations
can be made at an increased vertical dimension of occlusion and transferred to an
articulator. On removal of the interocclusal record, the casts can be brought together in an
occlusal relation that is the same as that of the patient. This is an essential step to consider
when the vertical dimension of occlusion needs to be altered
Existence of hinge axis:
There are four main schools of thought regarding hinge axis theory.
Group 1. Nonbelievers of the transverse axis theory. They believe the hinge axis is
theoretical, but not practical.
Group 2. Absolute location of the hinge axis. These people believe the hinge axis is a
component of every masticatory movement of the mandible and cannot be
disregarded.
Group 3. Arbitrary location of the axis. These people believe the hinge axis is of some
value, but not worth the effort to locate it truly.
Group 4. Split-axis rotation. They believe in the transograph theory. That each
condyle has its own center of rotation.
Presence of hinge axis
Ferrario said a pure rotation did not occur around the intercondylar axis and that the
centre of rotation is movable during every phase of the physiologic (habitual) jaw
movements. Page said a condyle rotates; therefore, any argument against its doing so around
rotational centers or a hinge axes is an argument against the truth.
One or multiple hinge-axis controversy:
Trapozzano reported that there are multiple hinge axis points along the path of the
translatory movement of the condyle so more than one terminal hinge-axis exists
Preston, suggested that a single transverse horizontal axis exists as a fact in
articulating instruments and as a theory in the human craniomandibular complex
Instantaneous center of rotation theory
The instantaneous center of rotation (ICR) is a variable that
describes the position of the center of rotation at any instant of time
during the simultaneous rotatory and translational movement of the
mandible. Such motion differs from hinged axial rotation by having
the center of rotation shifting along a path. According to this theory, the mandible
undergoes both translation and rotation in varying degrees from the initiation of jaw
opening. The center continues to move as the jaw opens.
Relation of hinge axis to condyle controversy
The axis of rotation appears to lie in anatomic center of condyle , anatomical
characteristics of TMJ structures, such as the ligaments, the capsule, the configuration
of condylar surface, influence the hinge movement and hence, location of hinge axis.
Beyron found that the axis point of each condyle was located within the outline of
condyle but not in any regular relationship to any definite part of the latter.
Moss suggested that the mandible rotates about the mandibular foramen, and that
this represents an adaptation to reduce the amount of movement about this region in
order to minimize the potential for trauma of the inferior alveolar nerve. Some
investigators place the center of rotation in the neck of the condyle, at the attachment
of the temporomandibular ligament. Their rationale is that the temporomandibular
ligament is taut during function and acts as a rotational center,
The colinearity- noncolinearitv (split axis) concept:
Some authors believe in the split axis i.e. each condyle rotates independently of the
other and has its own axis of rotation (two axes). Page in his proposal of the
transographic concepts. He postulated the existence of two mutually independent,
noncolinear axes or, simply, that each condyle had its own axis of rotation.
Most authors believe in the existence of a single rotation and a single transverse
horizontal axis.
True, arbitrary hinge-axis controversy
Several investigators recommend accurate location of the patients true transverse
horizontal axis as any deviations between a patients true transverse horizontal axis
(THA) of mandibular rotation and the location of the axle on an articulator will
produce occlusal error and an arbitrary face-bow transfer instrument is considered
acceptable only for patient treatment when the vertical dimension of occlusion
(VDO) will not be altered on the articulator.
some authors consider the anatomical method of locating the axis as an acceptable
technique, and an easily determined point that is consistently close to the kinematic
axis would simplify transfer of the arc of rotation from the patient to the articulator.
Methods of locating terminal hinge axis
I. True hinge axis
A) By using mandibular face bow or hinge axis locator:
In dentulous patient the device is firmly attached to the mandibular teeth
by a clutch. In edentulous case it is maintained in close adaptation to the
mandibular ridge by the use of some external attachment such as clamps
under chin that hold the mandibular occlusion block in place.
The clamp or the clutch is attached to a transverse bar. An adjustable
side armis attached to the transverse arm. In the condylar region pointed
condylar needle is attached to the side arm.
The patient is asked to move the mandible up and down in its most
posterior position and the condylar needle is noticed as it moves in arcs.
The needle is moved to the center of these arcs. The needle is further
adjusted until it rotates in a point "still point". This is the position of terminal hinge axis.
B) Axiograph
The mechanical axiograph has been used to locate the transverse
horizontal axis.
Others prefer the computerized axiograph to document the
biomechanics of the temporomandibular joint (TMJ), analyze condylar
paths in temporomandibular disorders (TMD), or monitor function and
dysfunction before and after TMD treatment.
The Axiotron is a computerized accessory for the mechanical axiograph.
It generates digital records of condylar paths in 3 reference planes.
Electronic axiograph Cadiax Diagnostic utilizes exactly determined
hinge axis. CADIAXdiagnostic, measures translational- and rotational
mandibular movements at the exact hinge axis, using a double-stylus
system
Accuracy of hinge axis location:
Some authors believe that it is impossible to locate the transverse hinge axis kinematically
with accuracy for one or more of the following reasons:
1. The angle of opening movement is small (10-12 degree) and thus the arc of movement
of the styli is small. Also there is a difficulty in training the patient to perform opening
and closing in the terminal hinge position.
2. The edentulous ridge is relatively unstable base on which to affix a record block that
will carry the weight of the hinge axis face bow.
3. The clutches used for dentulous patients can alter the closed position of the condyles
and limit the extent of condylar movement.
4. There may be movement of the skin over the condyles during registration. This
difficulty can be eliminated by the use of flags for the recording procedures.
II. Arbitrary hinge axis :
A. Arbitrary points related to earpiece face bows, which utilize the external auditory
meatus as the posterior point of reference.
B. Arbitrary points selected by anatomical surface marking and dependent upon average
value measurements, these include:
1. Gysi's arbitrary axis Some authors advocated the use of a point anterior to the
tragus on a line extending from the superior border of the tragus of the ear to the
outer canthus of the eye. The authors advocated the use of a point 10-13 mm
anterior to the tragus on the line.
2.The Denar face bow and articulator utilize points 12 mm anterior to posterior
border of tragus and 5 mm inferior to a line extending from the superior border
of tragus to outer canthus of eye.
3. Other authors recommended the use of a line extending from the middle and
posterior border (apex) of the tragus of the ear to the corner of the eye, as the
reference plane. The authors used points from 10-13 mm anterior to the apex of the
tragus on this reference line.
4. Other authors used an inferior reference line extending from the inferior margin
of the tragus of the ear to the outer canthus of the eye. They used 13 mm
measurement anterior to the tragus on this line.
5. Others, used measurements from the center of the external auditory meatus.
6. Bergestrom used a point 10 mm anterior from the center of the external auditory
meatus and 7mm down the Frankfort horizontal plane.
7.Lauritzen and Bodner suggested a point 12 mm anterior of and 2 mm. down from
the center of the external auditory meatus on a line extending from the superior
margin of the tragus to the outer canthus of the eye.
8. Beyron's arbitrary axis 13 mm in front of the posterior margin of the centre of the
tragus on a line extending from the tragus to the lateral angle of the eye.
C. Palpation as described by Dawson, from behind the patient the index finger is placed
over the joint area, and the patient is asked to open widely, As the condyle is translated
forward the finger tip will drop into the depression left by the protruded condyle. The patient
is asked to close and as the condyle is pulled back into centric relation, the fingertip could
locate its position. This is repeated several times to feel the center of condylar rotation.
The arbitrary axis versus the true axis:
Unless the true hinge axis is located and transferred to the articulator, error in
occlusion will be induced when the wax interocclusal record is removed and the
articulator is closed.
The error involved is minimized by having the interocclusal record of wax in centric
relation very thin (less than 3 mm). simulates the anteroposterior error (about o.2
mm) at the second molar that occurs with an interocclusal record of 3 mm thickness
and when there is a 5 mm discrepancy between the true and arbitrary hinge axis.
Also, balancing side occlusal error results from inaccurate location of kinematic
hinge axis.
The anterior points of reference
The selection of the anterior third point of reference determines which plane in the head
will become the plane of reference when the prosthesis is being fabricated.
Anterior points raise or lower the cast about a fixed radius and as it raises it move slightly
forward. However the angle between the face bow and occlusal plane remains constant.
The anteroposterior difference in the position of maxillary cast
appears to produce minimal occlusal error if upward/ downward
position does not exceed 16 mm.
The anterior point of reference raises or lowers the cast . Raising the
cast place it more anterior (A more anterior than B and C). While
the angle y is constant.
Many anterior points have been recommended. These points are:
1. Orbitale: is the lowest point of the infraorbital bony margin. The orbital pointer of the
face bow is adjusted to this point and transferred to the orbital plate of the articulator.
2. Orbitale minus 7mm: It was found that the mean distance of
the hinge axis points to the FHP was about 7 mm. To compensate
for this distance the anterior point of reference is marked 7 mm
below the orbitale on the patient or to position the orbital pointer
of the face bow 7 mm above the orbital indicator of the articulator.
Some articulators compensate automatically for this distance by
placing the orbital indicator 7 mm higher than the condylar horizontal
axis. The axis orbitale -7 mm plane is parallel to the FHP. The
orbital plate of articulator is higher than the condylar axis by 7 mm.
3. Nasion: The Whip-Mix face bow utilizes the nasion as the anterior
point of reference. The nasion relator is designed so that when it is
attached to the face bow and is positioned at the nasion point (bridge
of the nose), the cross bar will be in the approximate region of orbital.
By this way the Whip Mix face bow employs an approximate axis-orbital plane.
4. The incisal pin notch of the articulator: With some
articulators it is recommended to use a notch in the incisal guide
pin of the articulator for the third point of reference. During
mounting the incisal edge of the upper anterior teeth or wax rim
is adjusted at the level of this notch. The incisal edge of wax rim
is placed in level with incisal pin notch.
5. Ala of the nose: This point can be transferred to the
articulator by marking the right or left ala on the patient,
setting the anterior reference point of the face bow to it, and
with the face bow, transferring the ala anteriorly and the hinge
points posteriorly from the patient to the articulators hinge-
orbital indicator plane.
A second method is to make the maxillary occlusion rim parallel with Camper's line and
transferring it to the articulator with a face bow. Its occlusal plane is made parallel with the
upper and lower articulator's arms.
6. A point 43 mm superior to edge of incisor. This distance
is measured above the incisal edge on the patient and its
uppermost point is marked as the anterior point of reference on
the face. This divides the space between the articulator
horizontal axis and the lower member of the articulator and
position the occlusal plane near the midhorizontal plane of the articulator e.g. Denar Mark 2
articulator.
Face-Bows
It is a caliper like device that is used to record the relationship of the jaws to the TMJ.
or the opening axis of the jaws and to orient the cast in the same relationship to the opening
axis of the articulator.
Functions of face-bows :
1. Locate the terminal hinge axis by the use of a kinematic face bow.
2. Relate the maxillary cast to the transverse axis of the articulator in
the same relationship as e maxilla is related to mandibular hinge axis.
3-Relate the mandibular cast to the hinge axis by means of a centric
relation record
Value of the face bow:
The negligence of the use of face bow leads to:
1- Errors in centric occlusion if any change in vertical dimension on the
articulator is made.
2- Incorrect adjustment of condylar guidances of the articulator, which
leads to error on balancing side occlusal contact.
The use of face bow is essential If cusped teeth are used or interocclusal record are
made with the teeth out of contact so the vertical dimension can be changed.
The errors produced by not using the face bow are negligible If zero degree teeth are
used or interocclusal record are made with the teeth in contact . Boucher
Types of face-bows:
A. kinematic face bow (mandibular, hinge axis locator):
The face bow aids in finding the kinematic center (terminal hinge
axis) of the jaw opening as described before
The hinge axis transfer bow: It is similar to the hinge axis
locator but it has two side arms and the clutch tray is replaced by
bite fork. It is used to transfer the relationship between the maxilla
and the predetermined hinge axis to the articulator.
Because the asymmetry of the mandibular condyles, the
kinematic face bows intercondylar distance should not be altered on the articulator. Some
articulators have extendable condylar axis to meet the condylar pointers of the hinge axis
transfer bow.
If the condyle pointers on the face- bow are extended
inward (in order to fit fixed articulator axis) the
orientation of the axis to teeth will differ between
mouth and articulator. results in altered orientation
of cast to axis on articulator. This may be a small
enough distance, but it will alter the paths of vertical
motion relative to the retruded axis when the teeth close together and the starting point of the
lateral border movement.
B- The arbitrary (maxillary) face bow):
The maxillary face bow is the one generally used in the construction
of complete dentures.
It is used to record the position of the upper jaw in relation to the
hinge axis and transferring the relation to a mounting instrument.
It consists of a U- shaped metal bow with two graduated condylar
rods, bite fork and a universal joint.
It is either fascia or ear face bow. The ear face bow is arbitrary
face bow using the external auditory meatus as the posterior reference point.
Errors in maxillary face bow record and transfer:
1-Movement of part of the face bow caused by incomplete tightening of one of the locking
screw.
2-Inadequate stabilization of the bite fork record on the maxillary cast.
3-Poor fit of the maxillary cast into the bite fork indentation.
4- Neglect use of maxillary cast support during mounting causing distortion of the face bow
record.
T- cast support is mounted on the lower member of the articulator to support the bite fork during
mounting the maxillary cast.
Maxillary Face Bow Record
1- Bite fork is heated and inserted into the rim midway its height and
parallel to its plane.
Both are then placed intraorally together with the lower occlusion
block.
2-The condylar axis is then determined either arbitrarly or by using
mandibular face bow record. The rods are then placed on it , so that the
bow surrounds the patients face. The stem of the bite fork is slipped
into the universal joint.
3- When the patients face is centralized in the bow, all clamps are
tightened. Notice position of the condylar rods , infraorbital pointer
& bite fork.
4- Universal joint once tightened, never opened.
Maxillary Face Bow Transfer
1- The slide bar clamp is unscrewd to remove assembly from the face.
2- Assembly is now centralized on the articulator. Again notice
position of - condylar rods -infraorbital pointer , - L shaped bitefork ,
bypassing incisal pin
3- Upper cast is mounted on the articulator.
THE ARTICULATOR AS A PATIENT ANALOGUE
ARTICULATORS
An articulator is a mechanical device to which maxillary
and mandibular casts may be attached, representing the
temporomandibular joints and jaw members.
Articulators can simulate but they cannot duplicate the
mandibular border movements.
Articulators are used to hold casts in one or more
positions in relation to each other for the purposes of diagnosis,
arrangement of artificial teeth, and development of the occlusal
surfaces of fixed restorations.
Other functions of articulators : Mounting the casts for:
a- Diagnosis and treatment planning.
b- Representation to the patient.
c- Pre-extraction record.
d- Setting-up of teeth.
e- Fabrication of occlusal surface of the restoration.
f- Maintaining the desired centric relation and vertical dimension.
g- Determining cusp angle (true condylar guidance).
h- Selective grinding on the adjustable articulator (laboratory & clinical remounting).
i- Increase or decrease in vertical dimension by mounting with face bow.
Types of articulators
I. Simple, hinge or plane line articulators.
II. Mean value or fixed condylar path articulators.
III. Adjustable articulators.
a. Semi-adjustable condylar path articulators.
b. Fully adjustable condylar path articulators.
(a) A simple hinge articulator; (b) an average-movement articulator; (c) a semi-adjustable articulator
(Dentatus)
I-Simple, hinge or plane line articulators
The hinge articulator consists of two metal frames, which are
held apart at a certain distance by a setscrew at the back that
can raise or lower the distance between the two frames and
permitting only the hinge like movement.
It provides only a hinge movements. thus limited to opening
and closing.
a hinge articulator is an instrument whose hinge bears no
measured or transferred relationship to the terminal hinge axis
of the mandible.
It may have a single or double hinge and casts mounted on it
will open and close on an arc, which does not copy mandibular opening or
closing arc (smaller arc).
Uses:
- Maintaining the centric occlusion relationship only.
- Setting-up of teeth.
- Representation to the patient.
The distance between the maxillary cast and the axis of rotation on the articulator is very
short from that of the patient resulting in errors in occlusion on balanced side.
Possible movements: It gives only opening and closing movements.
Records required: 1-Vertical dimension of occlusion. 2- Centric relation record.
Disadvantages:
These articulators do not represent the temporomandibular joint and the
dynamic mandibular movements.
The major limitations of simple articulators include the contact occlusal
relationships in eccentric movements are unrelated to the patient, there is
no provision for movement in centric relation; the centric occlusion
position may not be accurately defined.
The errors which may occur as a result of the limitations of a simple
articulator include premature contacts in centric occlusion, centric
relation, balancing interferences, protrusive and working interferences.
If the casts are mounted, the intercuspal position can be copied and repeated but
not the arc of closure to it. Thus the pre-contact registration (using interocclusal record)
for mounting the casts will results in a different occlusal position than the intercuspal
position in the mouth.
This, type of articulators is of no aid to the operator in establishing occlusal
relationship other than centric occlusion.

Left; the arc of closure of the articulator is smaller than that of the patient. Right; mounting cast
using interocclusal record (A), when the record removed posterior separation occurs (B).
II. Mean value, average or fixed condylar path articulators
In this type the two members of the articulator are joined
together by two joints, which represent the
temporomandibular joint.
In this type, the condylar path is fixed at a certain angle and
the angle is used for all patients. It is especially successful
for those patients whose condylar path approximates this
angle.
As these angles have been arrived at by taking an average over many hundreds of
patients it may be assumed that a good proportion of cases can be treated
successfully with this type of instrument.
In some fixed condylar path articulators the upper cast is
mounted on the upper member of the articulator with a face
bow transfer e.g. Hanau mate articulator where; the
horizontal condylar path is fixed to 30 degree, the lateral
condylar path to 15 degree and the incisal guide table to 10
degree.
Other articulators mounting is carried out according to the Bonwill triangle.
Bonwill mentioned that the distance between the condyles
and the distance from each condyle to the contact point of the lower
central incisors is 4 inches. Bonwill, thus, formulated the theory of
the equilateral triangle and designed an articulator to this theory.
To orient the cast in relation to Bonwill triangle ,the fixed
condylar path articulators usually have a pointer attached to incisal
pin so that it touches the midline of the occlusion rim labially to
locate the tips of central incisors, so that it touches the midline of the
occlusion rim labially and thus helps to orient cast in relation to
Bonwill triangle. and the occlusal plane is oriented parallel to the upper and lower
members of the articulator (horizontal).
On the fixed and most adjustable condylar path articulators the upper members are
movable and the mandibular members are stationary (non-arcon or condylar
articulators) to provide a firm base and facilitate the arrangement of teeth. The fixed
condylar path articulators have their condyles on the upper member and the condylar
guides on the lower member. Therefore, the upper member moves backward and upward
in protrusion. This reverse arrangement (non-arcon) provides a firm base and facilitates
setting up of teeth.
This articulator is classified into two groups:
1- Accept face bow transfer.
2- Does not accept face bow, and transfer mounting is done by:
a- Bonwill triangle.
b- Monson spherical theory.
c- Needle house chew in technique.
Possible movements:
1- Opening and closing.
2- Protrusive movement at a fixed condylar path angle.
Records required:
1- Vertical dimension of occlusion.
2- Centric relation record.
3- Face-bow record: In some designs of these articulators, the upper cast can be
mounted by a face bow transfer.
Disadvantages:
1-Most of these articulators does not accept face-bow record.
2-The condylar path moves to a fixed angle and it is successful in-patients whose
condylar angle approximates that of the articulator.
3- No lateral movements.
Occlusal errors with fixed condylar path articulators:
1-Without the use of face bow or an arbitrary face bow is used; the hinge axis of the
patient will not coincide with that of the articulator leads to occlusal error.
2- Arbitrary location of the anterior point of reference leads to balancing side errors.
3- This articulator may be successful for those patients whose condylar paths
approximate those fixed on the articulator. Improper condylar path angle leads to
error in protrusive and balancing contacts.
4-The condylar path on the patient is curved while on the articulator it is straight, this
leads to occlusal error in both working and balancing side.
5- There is no lateral movement in most types and those types moves laterally moves
to a fixed angle. This may gives balancing side occlusal error.
6- The incisal table is fixed which may produce error during excursions.
7-There is no immediate side shift adjustment, leads to balancing side occlusal error.
8- The intercondylar width on the patient does not coincide with that on the articulator
(non adjustable); this gives a balancing interference.
Procedures for mounting casts on a fixed condylar path articulator:
1- The upper and lower casts are prepared for laboratory remounting by cutting indices
on the undersurface of their base.
2- The upper and lower trial denture bases are sealed together and to the casts.
3- The incisal pin of the articulator is adjusted so that it's top flush with the top of the
upper member (This makes the articulators members parallel).
4- The arms of the articulator to be used are lubricated with Vaseline or oil to facilitate
cleaning of the articulator later on.
5- A piece of clay is placed on the lower member of the articulator and the casts with
attached record blocks are placed on the clay.
6- The occlusal plane of the wax rim is adjusted parallel to the orientation plane of the
articulator. To facilitate the orientation of occlusal plane, a rubber band is warped
around the articulator at level of incisal pin mark anteriorly and the two marks on the
condylar posts posteriorly (Bonwill triangle).
7- The upper member of the articulator is opened and a mix of plaster is placed on the
top of the upper cast. The articulator is closed slowly until the incisal pin touches the
incisal table. This will attach the upper cast to the articulator.
8- After setting of plaster, clay is removed and the lower cast is attached to the
articulator by plaster. The excess plaster is removed while it is still soft and the
mounting plaster is smoothed with a sand paper.
III. Adjustable articulators
The adjustable articulator employs the face bow to transfer the arbitrary or actual
terminal hinge axis of the mandible to the articulator and posses condyle mechanisms
which can be adjusted to copy condyle positions transferred by interocclusal, protruded
and lateral records from the mouth.
A. Semi-adjustable condylar path articulators
A semi adjustable articulator is an instrument whose larger
size allows a close approximation of anatomical distance
between the axis of rotation and the teeth.
With this type of articulators it is said to be possible to
adjust the sagittal condyle path to the same inclination as those of the patient.
The lateral condyle path inclination can be obtained from the following
formula: L=H/8+12
Where L and H are the lateral and horizontal (sagittal) condyle path inclinations.
Some of the semiadjustable articulators have orbital plane guides. The orbital
plane guide allows the casts to be mounted in relation to the axis-orbital plane of
the patient and orients the casts on the articulator in the same relationship to the
bench top as the dental arches are in the patient.
Possible movements:
1-Opening and closing.
2-Protrusive movement according to the horizontal condylar path angle
determined from the patient.
3-Lateral movement to the angle estimated from the Hanau formula.
4-Some types have Bennett movement (immediate side shift).
Records required:
1. A maxillary face bow record to mount the upper cast.
2. Centric occluding relation record (vertical dimension and centric
relation) to mount the lower cast.
3. Protrusive record to adjust the horizontal condylar path inclination of
the articulator.
Disadvantages:
1-The lateral condylar path angle is determined from the formula.
2-Most of these articulators have no Bennett movement.
Hanau semiadjustable articulator.
Arcon versus condylar articulator:
The term arcon is commonly used to indicate an instrument that has its condyles
on the lower member and the condylar guides on the upper member. Instruments that
have the condyles on the upper member and condylar guides on the lower member are
commonly referred to as condylar instrument or as non-arcon instruments.
Left; Hanau 96H2O, non-arcon articulator. Right; Denar Mark II, arcon articulator.
In arcon articulator, the condylar guide moves with the upper member. In a non
arcon articulator, the condylar ball moves with the upper member. So that differences in
angles between arcon and condylar articulator is evident, such as differences in the
angles between the condylar guidance and the shaft housing or hinge axis of upper
member. The angles is reversed, i.e., in one instrument an angle is fixed, whereas in the
other instrument the angle changes.
Left: In condylar articulator; the angle between the condylar guidance and the shaft housing is fixed (F),
while the angle between the condylar guidance and the hinge axis of upper member is changeable (C). In
arcon articulator, the angles are reversed (Right).
In the sagittal plane, as the condylar instrument is opened, the occlusal plane change but
the condylar guidance angle remains fixed. On the arcon type instrument, the condylar
guidance angle change as the articulator is opened.
Increasing the vertical dimension on the articulator. Left; in non arcon articulator, the occlusal plane
inclination change (cp) and the condylar guidance remains fixed, so the angle between the two is changed
(C). Right; in arcon instrument, the occlusal plane and condylar guidance angulations change, so the
angle in between remains constant (F).
The distance between the condyles and the lower teeth in protruded relation will
be the same in the mouth as on arcon articulator. On the condylar articulator, where the
condyles move backward in protrusion, the distance between the condyles and the lower
teeth will be twice the distance which the condyles travel. Since, on the condylar
articulator, the condyle moves upwards as well as backwards. The angle between the
line forming the condyle and upper incisor teeth and the horizontal plane will be steeper
than the angle made by the line joining the same two points in the arcon articulator.
Difference between angle of condyle descent between arcon (A-B) and condylar (X-B) mechanisms.
Occlusal errors with semiadjustable articulators:
1-When arbitrary face bow is used; the hinge axis of the patient does not coincide with
that of the articulator leads to occlusal error.
2- Arbitrary location of the anterior point of reference leads to balancing side
interference.
3- The condylar paths on the patient are curved while on most articulators it is straight;
this leads to occlusal error in both working and balancing side.
4-The lateral condylar path angle (Bennett angle) is calculated from the formula and not
recorded.
5- On many instruments the Bennet movement is reproduced as a gradually deviating
straight line, although several recently introduced semi-adjustable articulators do
accommodate the "immediate side shift".
6- Intercondylar distance does not have total adjustability. They can be adjusted to
small, medium and large (e.g. Whip- Mix articulator). Restorations made on this type of
articulator will have balancing interferences and will require some intra-oral adjustment.
Lateral shift permitted in Hanau (Dentatus) articulator. G; gap. The condyle axis moves straight laterally
during balancing movement From AB to XY.
b. Fully adjustable articulators (axle type articulators)
In this type both horizontal (protrusive or sagittal) and lateral condyle path
inclinations can be adjusted according to records taken from the patients
These articulators are designed to reproduce the entire character of border
movements including immediate and progressive side shift and the curvature
and direction of condylar inclination, Intercondylar distance is completely
adjustable.
This type of instrument is expensive. The techniques required for its use demand
a high degree of skill and time consuming to accomplish. For this reason fully
adjustable articulators are used primarily for extensive treatment, requiring the
reconstruction of an entire occlusion.
Denar combi fully adjustable articulator.
Possible movements:
The same movements of the semi-adjustable articulators. In addition they have
Bennett movement.
Records required:
1. A maxillary face bow record to mount the upper cast.
2. Centric occluding relation record to mount the lower cast.
3. Protrusive record to adjust the horizontal condylar path inclination.
4. Right lateral record to adjust the left lateral condylar path inclination.
5. Left lateral record to adjust the right lateral condylar path inclination.
Disadvantages:
Multiple records are required with the possibility of errors. The semi-adjustable
articulators are usually enough for complete denture construction.
Some authors believe that unavoidable errors that may occur on using such
instruments make their value doubtful. The errors, which may occur, are the following:
1. In some types of these articulators the condylar path is straight while it takes a curved
path in the patients.
2. There is a controversy about the correct methods of orienting the casts on the
articulators.
3. The more the mandibular positions and movements to be transferred to the articulator,
the more will be the probability of errors
Indexing and Mounting Master Casts
See Trays and Treatment of final casts
Setting the Articulator
1) Make sure condylar ball is abutted against centric stop
2) Set condylar inclination to 70 degrees
3) Secure centric lock screws
4) Set the Bennet Angle to 0 (zero) degree
5) Set the Incisal Pin to the zero position (pin flush with the top of
upper member)
6) Trim the maxillary cast so that its base is parallel to the upper
member of the articulator
7) Place Mounting Indices into base of the cast with an acrylic bur
8) Lightly Vaseline Mounting Indices
9) Mounting the Maxillary Master Cast: Add just enough quick
setting plaster to mount maxillary cast
10) Mounting the Mandibular Master Cast: Place Articulator into
the Inversion Stand
11) Add plaster to finish mounting and smooth with wet/dry sandpaper
Note
Cast midlines aligned with articulator centerline
Maxillary and Mandibular Residual ridges symmetrically aligned in Class I relationship
Finished plaster mounts and master casts
Mounting the master casts on the articulator
The maxillary cast should be first attached to the articulator by using a face bow,
because arbitrary mounting of the maxillary cast without a face bow transfer will
introduce errors in the occlusion of the finished denture.
Mounting casts on adjustable articulators
The following records are needed for mounting the casts on fully adjustable articulators:
1- A maxillary face bow record to mount the upper cast.
2- Centric occluding relation record to mount the lower cast.
3- Protrusive record to adjust the horizontal condylar path inclination.
4- Right lateral record to adjust the left lateral condylar path inclination.
5- Left lateral record to adjust the right condylar path inclination.
Mounting maxillary cast
1- The working casts are tapered and indices are cut in them for laboratory remount.
2- The face bow is used to record the relation of the maxilla to the hinge axis.
3- The face-bow is used to orient the maxillary cast to the opening axis of the articulator in
the same way as the maxilla is related to the condylar axis. The condylar rods of the
face bow are placed over the ends of the articulators condylar shaft. The face bow is
adjusted to obtain an equal distance on both sides.
4- The infra-orbital pointer of the face-bow must be oriented to touch the orbital reference
plane of the articulator.
If this infra-orbital pointer is not used then raising or lowering the occlusal plane
during mounting the upper cast will affect the horizontal condylar path inclination.
Some types of face-bows do not have a reference pointer, and also some types of
articulators do not have infra-orbital plate but have a mark on the incisal pin used
for adjusting the level of the occlusal plane on the articulator. In this type, the
occlusal plane is oriented in the vertical plane in relation to the incisal and
condylar guidance of the articulator.
5- The upper cast is then placed accurately in the trial denture base and attached to the
mounting ring of the articulator with plaster. The face-bow is removed after the setting
of plaster.
Mounting mandibular cast
1- The lower occlusion rim is properly related to the upper according to the indices taken
from the patient.
2- Both recording bases are properly seated on their casts.
3- The lower cast is then attached to the mounting ring with plaster
Adjusting the controls of the articulator
A. Adjusting the horizontal condylar guidance
The occlusal wafer used for mounting the lower cast in centric relation is replaced by
the protrusive record. The incisal pin must be opened wide and the condylar
guides are loosened in all respects. The record is set on the lower occlusion rim, and
the condylar guides are manipulated in such a way that the upper and lower
occlusion rims fit their respective casts and the protrusive record exactly. The
protrusive record is maintained by tightening the locknuts.
B- Adjusting the lateral condylar guidance
For the semi-adjustable articulator accepted value of lateral condylar path
inclination is usually obtained from Hanau equation L = H/8 + 12.
COMPLETE DENTURE THEORY AND PRACTICE Complete Denture Occlusion8
Complete Denture Occlusion
Occlusion : It is the relationship between occlusal surfaces of upper and lower teeth when they
are in contact. The termocclusion describes static contact between upper and lower teeth after
jaw movement has stopped and opposing teeth contact.
Centric occlusion : It is the relationship between occlusal surfaces of upper and lower teeth
when they are in maximum contact or intercuspation.
Centric relation : This is an antroposterior bone-to-bone relation between the mandible and
the maxilla that can be defined as, the rearmost, midmost and uppermost untranslated hinged
position of the condyles. It is a strained relation that can be statically repeated.
Centric occluding relation : It is the condition in which the jaws are in centric relation and the
teeth in centric occlusion.
Eccentric jaw relation : Any jaw relation other than centric relation, e.g. protrusive relation,
and right and left lateral relation.
Balanced occlusion : It means that the artificial teeth are set up so that as many teeth as
possible are in occlusion in any occlusal relationship.
Balanced articulation : It means an arrangement of the teeth so that in any occlusal
relationship as many teeth as possible are in occlusion, and when changing from one
relationship to another they move with a smooth, sliding motion, without intercuspation.
Bennett movement : It is the lateral bodily movement of the mandible.
The working side: It is the side on which the chewing is done at the movement
The balancing side : It is theside opposite to the working side, on which there is still at least
one point of contact between the upper and lower teeth.
Occlusal plane : It is an imaginary plane that is related anatomically to the cranium and
theoretically touches the incisal edges of the incisors and the tips of the occlusal surfaces of the
posterior teeth. It is not a plane in the true sense of the word but represents the mean of the
curvature of the surface.
Curve of Spee : It is the anatomic curvature of the occlusion alignment of the teeth, beginning
at the cusp tip of the lower canine and following the buccal cusp tip of the lower premolars and
molars, continuing through the anterior border of the ramus, ending at the anterior surface of
the condyle. This curve is best seen when dental arches are observed opposite to first molar.
Curve of Monson : This is the curve of occlusion in which each cusp and incisal edge touch or
form a segment of the surface of a sphere ( 8 inches in diameter) with its center in the region of
the glabella. Monson put this spherical theory of occlusion and developed Monsons articulator
on this basis. Now this theory is discarded.
Curve of Wilson (Mediolateral curve) : This curve is formed by the facial and lingual cusp
tips on both sides of the dental arch. The occlusal surface of the dental arches appear curved
when viewed from the frontal plane. The mandibular arch is concave but the maxillary arch is
convex.
Compensating curve : This is the antroposterior and midiolateral curvature in the alignment
of the occlusal surfaces and incisal edges of the artificial teeth that are developed to obtain
balanced articulation by compensating the opening influences produced by the condylar and
incisal guidance during excursive movements of the mandible.
Condylar path : This is the path traveled by the mandibular condyle in the tempromandibular
joint during the various mandibular movements.
Sagittal (protrusive) condylar path : This is the path of the condyle when the mandible is
moved forward from its centric position. The condyle moves in a downward and forward
direction .
Lateral condylar path: This is the path of the condyle in the glenoid fossa when a lateral
mandibular movement is made.
Incisal path : This is the path performed by the forward glide of the incisal edges of the lower
teeth from the position of centric occlusion to that of edge-to-edge contact. The incisal path
inclination depends on the vertical and horizontal overlaps combined. The incisal guidance of
the articulator should be adjusted to maintain the incisal guide angle.
Types of Occlusion
1- Centric occlusion : It is the relation of opposing occlusal surfaces which provides
maximum planned occlusal contact or inter-cuspation.
2- Protrusive occlusion : It is the relation of opposing occlusal surfaces when the mandible
is forward in protruded relation to the maxilla.
3- Lateral occlusion : It is the relation of opposing occlusal surfaces when the mandible is
moved laterally.
4- Balanced occlusion : means that the artificial teeth are set up so that as many teeth as
possible are in occlusion in any occlusal relationship.
5- Balanaced articulation : means an arrangement of the teeth so that in any occlusal
relationship as many teeth as possible are in occlusion, and when changing from one
relationship to another they move with a smooth sliding motion, free from cuspal
interference and marinating even contact
Difference between Natural and Artificial Occlusion
Most principles of occlusion are applied for both dentulous and edentulous patients,
however, some principles of occlusion may vary in complete denture occlusion due to
differences between natural and artificial dentition. These are:
1. Natural teeth are attached to bone via highly innervated periodontal tissues. Periodontal
tissues contain receptors called proprioceptors which provide information about
movement and location of the mandible during mastication. While in complete denture
wearers weak proprioception is present only in the mucosa overlying the residual ridges.
2. Bilateral balance is rarely found in natural dentition as there is no balancing side contact
in natural teeth, and if present is considered non working side interference. However,
balancing side contact is necessary in artificial occlusion to establish denture stability.
3. Natural teeth are stable during function as they are firmly attached to bone. While
artificial teeth are attached to denture bases seated on slippery soft tissues. Soft tissues
vary in thickness and have different degree of resiliency and tolerance to pressure.
4. Natural teeth receive individual pressure from occlusal forces and adjust to this pressure
by moving individually, while artificial teeth and denture bases constitute a single unit
and reacts to occlusal pressure by movement of the whole denture.
5. Incisingwith natural teeth have no effect on posterior teeth, while incising with artificial
anterior teeth should be avoided to avoid break of the posterior palatal seal and thus
prevent displacement of the denture.
6. In natural dentition interference with closurein centric relation due to presence of tilted
teeth or mal-posed teeth initiates responses which directs the mandible away from
deflective contact and allows closure of mandible in centric occlusion. Impulses created
by closure in centric occlusion position establishes memory pattern that guides the
mandible to return to this position. This establishes a stable habitual occlusion.
While complete denture wearers cannot control Mandibular movements similarly to avoid
deflective contact resulting in unstabledentures.
Occlusal Forms of Posterior Artificial Teeth see teeth selection
Basic Principles of Complete Denture Occlusion
Denture occlusion should be designed to reduce and control the forces that may hinder the
stability of complete dentures. Thus dentures should be designed with:
-Opposing teeth that contact in centric occlusion while the mandible is in centric relation.
-Absence of deflective occlusal contact,
-Free gliding articulation from centric position to any eccentric position.
This could beachieved by applying the following principles:
1. Even contact at CR and in an area l-2mm forward to it. it is termed long centric.
2. Anterior incisal clearance between upper and lower anterior teeth by providing about
2mm vertical and horizontal overlap guided by esthetic and phonetic requirements.
3. Providing minimal occlusal contact area to reduce pressure applied during mastication.
The smaller the area of tooth on which occlusal force acts, the smaller will be the force
required for crushing food, the less the forces transmitted to the supporting structures.
4. Avoid the transmission of vertical forces on tissues that are inclined. Vertical forces
acting on an inclined plane are resolved and results into lateral destructive forces.
5. Avoid the transmission of forces on denture bases that are supported by resilient yielding
tissues as hyperplastic tissues. This resulting in instability of the dentures.
6. Functional forces should be applied on the crest of the ridge by placing the central fossae
of posterior teeth especially lower teeth on the crest of the ridge. Since vertical, forces
applied outside (lateral) the ridge cause tipping forces and results in denture instability.
Posterior Positions of the Mandible:
1-Posterior border position (centric relation)
This is the extreme unstrained position of the mandible to the maxilla.
It is a repeatable reproducible and thus recordable position. -It is the position from
which mandibular excursions take place
It is the point of intersection of the right and left border positions of the mandible as
evident by the Gothic arch tracing.
2-Tooth position (intercuspal position)
It is also called centric occlusion position.
It is the position where opposing teeth interdigitate.
Maximum intercuspation of natural teeth in most individuals is slightly forwards to the
posterior border position by an average distance of about 0.5-1 mm.
3-Habitual (muscular) position
The habitual position usually develops after partial loss of teeth and the resulting change
in tooth position. This change in tooth position creates deflective occlusal contacts that
usually guide the mandible to close into a slightly forward and lateral position called
the habitual position.
Centric occluding relation:
Denture occlusion is usually established at the centric occluding relation. The jaws are in centric
relation and denture teeth are in centric occlusion at a predetermined vertical dimension.
Centric occluding relation is a three dimensional relation of the mandible to the maxilla, an
antero-posterior relation where the mandible is in the most retruded position, a lateral relation
where the mandible is centrally placed between right and left extremes and a vertical relation at
the predetermined vertical dimension of occlusion.
Denture occlusion is usually established at the posterior border position and adjusted to achieve a
free gliding occlusion from this position to any habitual muscular position thus obtaining a long
centric relation also called freedom in centric.
Balanced Occlusion & Articulation:
Balance is achieved in complete denture when the denture bases are stable on their supporting
structure and in a state of equilibrium when opposing teeth contact and occlusal forces are
developed.
Balanced articulation in complete denture permits teeth to glide evenly without interference on
the working side while maintaining non interfering contact on the balancing side.
Types of balance:
1-Lever balance:
Forces are applied on dentures; hence, some of the principles of physics are applied in denture
construction these include inclined plane action and rules of levers, the rules of lever are applied
in complete denture construction to achieve denture stability. Functional lever balance stabilizes
the denture during mastication until opposing teeth starts to make contact.
Lever balance is achieved by:
1. The wider and larger the supporting ridge, the more is the lever balance. However, the
smaller the ridge and the more the resorption, the less is the expected lever balance.
2. Denture bases should cover the widest possible area of the ridge within physiologic
limits.
3. Using posterior teeth with small occlusal table i.e. teeth that are narrow bucco-lingually.
4. Placement of the teeth closer to the ridge enhances lever balance.
5. Placing lower posterior teeth with the central fossae overlying the crest of the ridge or
with slight lingual inclination in order to direct occlusal forces on the crest of the ridge or
slightly lingual to it.
6. Avoid placement of teeth buccal to the crest of the ridge to avoid poor balance and
denture instability.
II-Occlusal balance
The objective of occlusal balance is to achieve smooth gliding and bilateral occlusal contact from
centric relation to all eccentric positions without occlusal interference. This provides stabilizing
forces to the dentures.
Bilateral occlusal balance is present when the mandible moves laterally. This is achieved when
teeth make contact on both the working and balancing sides.
Protrusive balance is present when the mandible moves forwards while three points of occlusal
contact aremaintained both right and left together with an anterior contact. Protrusive balance is
required to compensate for the space created posteriorly between upper and lower teeth that
occurs when the mandible moves forwards (Christensen's phenomenon).
Factors affecting balanced occlusion:
I-Inclination of the condylar guidance:
The inclination of the condylar guidance on the articulator is a mechanical equivalent of the
patient's condylar path inclination. Since during protrusion the head of the condyle translates
downward and forward forming a horizontal condylar angle with the horizontal plane, hence, the
condylar guidance is adjusted by obtaining a protrusive record from the
patient. It is the only factor controlled by the patient.
II-Inclination of the incisal guidance:
The incisal angle is the angle formed by a line joining the incisal edges of upper and lower
incisors and a line representing the horizontal plane.
The inclination of the incisal angle is affected by the amount of vertical and horizontal overlap
between upper and lower incisor. The greater the horizontal overlap and the smaller the vertical
overlap, the less is the incisal angle.
A steep incisal angle should be avoided because it requires steep cusps and a steep occlusal plane
or compensating curve which are considered destructive inclines in order to achieve balance.
Therefore, the incisal guidance which is the mechanical equivalent of incisal angle on the
articulator should be as near zero as permitted by esthetic and phonetic requirements. Thus,
shallow incisal guidance reduces inclined plane effect and reduces lateral forces which help in
achieving balance occlusion.
III-Orientation of the occlusal plane:
The occlusal plane should be established to favor denture stability guided by anatomical
landmarks. The occlusal plane is made parallel to a line joining the angle of the mouth to two
thirds the height of the retro molar pad. It is also related to the ala- tragus line (Camper's plane).
The occlusal plane thus established will be parallel to the mean of the lower denture foundation
area. The occlusal plane should also be below the maximum convexity of the tongue in order to
achieve balance and stability.
IV-Compensating curve:
Compensating curve is the inclination of the posterior teeth and their vertical relation to the
occlusal plane resulting in a curve harmonious with the condylar guidance posteriorly and the
incisal guidance anteriorly. If the condylar guidance is steep, then a steep compensating curve is
required to obtain occlusal balance, it is performed to achieve balanced occlusal contact during
protrusion of the mandible.
V-Cusp angle:
The inclination of cusp angle of the selected posterior teeth should be in harmony with the slope
of the glenoid fossa and the inclination of the condylar guidance.
The relationship of the factors of balanced articulation:
The above four factors are arranged in scale the first and second factor in one side and the
third and fourth on the other side.
If the condylar guidance as recorded from the patient was great, one or more of the
following adjusts the scale:
a-The incisal guidance can be decreased.
b-The compensating curve can be increased.
C-Increasing the occlusal plane orientation.
CG.IG
CG.IG
C CC.OP.CH
CC.OP.
CG; condylar guidance. IG; incisal guidance. CC; compensating curve. OP; occlusal plane.
The incisal guidance should be maintained law as much as possible. Steep incisal guidance
results in a harmful inclined plane with denture instability and harmful effect on the supporting
structures.
If esthetic necessitate the increase of vertical overlap (increase of incisal guidance), the
compensating curve and the occlusal plane inclination should be increased to adjust the scale.
Occlusal function, parafunction and dysfunction
Occlusal function means the contact that exists between the teeth and between the teeth and
food during the functions of mastication and swallowing
Parafunction (wrong or irregular function) means the contact that exists between the teeth in
the empty mouth during the habits of clenching, tapping, grinding or sliding the teeth together
and of holding or chewing pencils, pipes and other outside agencies. Parafunction is preferred to
bruxism, which, though widely used, implies forceful occlusion, and an associated disturbed
emotional state.
Dysfunction is functional movements of the mandible, which cause a disturbance or disorder.
Comparison between function and Para function:
Factor Function Parafunction
Duration of tooth contact 4-10 minutes 4 hours
Magnitude of applied force 20-40Ib/sq. in Up to 300 Ib/sq. in
Direction of applied force Vertical (accepted) Horizontal lateral (injurious)
Type of muscle contraction Isotonic Isometric
Proprioceptive influence
or protection
Adaptive arc
Tooth interference avoided
Conditioned reflex
Skeletal arc
Neuromuscular protective
mechanism is absent
Mandibular closure position C.O. or C.R.(Centric) Eccentric
Pathological effects None or at least minimal Occur and vary according,
to adaptability of the
individual
Isometric muscle contraction means that the muscle fibers maintain the same length during
contraction and fix or hold a part in particular position. It may produce poor blood circulation
with a build up of lactic acid producing muscle cramps or spasms.
Isotonic muscle contraction means that the muscle fibers shorten during contraction and cause
movement of a part.
NB. One night of bruxism is equal to a lifetime of chewing.
COMPLETE DENTURE THEORY AND PRACTICE Selection & arrangement of artificial teeth9
SELECTION OF ARTIFICIAL TEETH
FOR COMPLETELY EDENTULOUS PATIENTS
Selection of anterior teeth
The objective in selection of the anterior teeth is to obtain a natural appearance. This
should be in harmony with age, sex, personality and occupation of the patient.
Anterior tooth selection is a tentative step, which can be verified only by the dentist
utilizing the trial base and confirmed by the patient and family or friends.
There are three basic considerations when selecting the upper six anterior teeth; These
are form, size, and shade.
1. Form or shape of teeth
There are many factors that aid in selecting the form of the teeth. These factors include:
a- The shape of the edentulous upper arch.
b- The shape of the face.
c- The profile of the face.
d- Dentogenic concept and dynesthetics
a- The shape of the edentulous upper arch
There is some relationship between the shape of the edentulous upper arch form and
the upper incisor teeth e.g. square arch form indicates square incisor teeth and V-
shaped arch indicates incisors which are narrower at theneck than at the incisal edge.
b- The shape of the face or Facial Form
It is believed that there is a harmonious relation between the shape of the upper
central (labial aspect) and the forms of the face when seen from the front. The face
form of the patient must be taken into consideration when selecting the anterior teeth.
The labial surface of the tooth should be in harmony with this form. There are four
basic typical forms of faces: square, square-tapering, tapering, and ovoid.
In order to determine the type of face form, the operator should imagine two lines,
one on each side of the face running through the sides of the forehead, the zygomatic
bone and the angle of the mandible.
- Square: the outline form of the face is square (the
imaginary lines are parallel).
- Square-tapering: very similar to the square, the
difference from the true square occurs from the
zygomatic bone to the angle of the mandible (The
lower parts of the lines are converge toward the
chin.
- Tapering: this face form presents a tapering appearance from the sides of the
forehead to the angle of the mandible, the widest part at the forehead and the
narrowest part at the angle of the mandible.
- Ovoid: the zygomatic width is the widest. The forehead and the angle of the mandible
are less in width.
C- The profile of the face
The labial surface of artificial teeth should be in harmony with the profile of the face.
The three general types of profile are straight, convex and concave.
The labial surface of the artificial teeth when viewed from the incisal edge should be
in harmony with the convexity or flatness of the face
D- Dentogenic Concept and Dynesthetics : The sex , personality, age, (SPA factor) and
occupation of the patient
It was first described by Frush and Fisher. According to them, the sex, personality and
age of the patient determine the form of the anterior teeth.
With age the teeth undergo attrition and characteristic teeth may be used. The colour of
the teeth also changes with age. Inter-occlusal distance reduces with age. Hence,
mandibular teeth are more visible than the maxillary teeth.
For females and for most professional men whose occupation entails intimate contact
with people, appearance is more important and this should be taken into consideration
when selecting the anterior teeth.
For executives, the teeth shouid be relatively smaller and more symmetrically arranged
2. Size of the anterior teeth
Methods used as a guide to select the size of the teeth:
Methods using pre-extraction records
Methods using anthropological measurements of the Patient.
Methods using anatomical landmarks
Methods using theoretical concepts.
Clinical methods
Other factors.
Methods Using Pre-extraction Records
Diagnostic casts
They are prepared before the extraction of the teeth. The operator can obtain an
idea about the size and shape of the teeth from these casts.
The actual size and shape required can be determined but the shade of the teeth
cannot be determined using this method.
Pre-extraction photographs
Photographs showing the lateral, anterior and anterolateral views of the patient should
be taken before extraction.
These photographs must show at least the incisal edges of the anterior teeth. This
method is useful to determine the exact width and outline of the teeth.
photo interpupillary distance \ patient's actual interpupiliary = photo central incisor
width \ distance X (X gives the original width of the patient's central incisor)
Pre-extraction radiographs
This is usually obtained from the patient's previous dentist. Radiographic errors are a
major limitation to this method. The occluso-gingival height and the outline of the teeth
can be recorded. But the contour and size cannot be accurately determined, because the
radiograph is a two-dimensional image.
Teeth of close relatives
This method is usually followed only if the other records are not available. The size and
contour of the patient's son or daughter's tooth is taken as reference.
Preserved extracted teeth
This is the best method to determine the size of the anterior tooth. The exact details about
the size and contour can be recorded from this method.
Methods using Anthropological Measurements of the Patient
Anthropological measurements are usually post-extractionrecords made directly from the
edentulous patient.
Anthropometric cephalic index
The transverse circumference of the head is measured using a
measuring tape at the level of the forehead. The width of the upper
central incisor can be derived from this measurement. Sears called
this formula as the anthropometric cephalic index
Width of the upper central incisor =Circumferenceof the head / 13
Bizygomatic width
The bizygomatic width can be used to determine the width of the central incisor and also
the combined width of the anteriors. The bizygomatic width is the distance measured
between the malar prominences on either side.
This measurement is also used in Berry's Biometric index and H. Pound's formulae.
Total width of the upper anteriors =bizygomatic width / 3.36
Total width of thelower anteriors =the width of the4
th
upper anteriors / 5
Berry's Biometric index
Berry's bimetric index is used to derive the width of the central incisor using the
bizygomatic width and/or the length of the face.
The formula using the length of the face cannot be used for edentulous patients. The
length of the face is the distance measured between the hairline and the tip of the chin
The width of maxillary central incisor =Bi-zygomatic width / 16
The width of maxillary central incisor =Length of the face / 20
H. Pound's formulae
The width of maxillary central incisor =Bi-zygomatic width / 16
The length of maxillary central incisor =Length of the face / 16
Width of the nose
It is measured with a vernier caliper.
The width of the nose is equal tothe combined width of the anterior teeth.
Two further suggestions are offered as guidance when choosing the width of the anterior teeth:
(1) The combined width of the two central incisors is
frequently similar to the width of the philtrum of the upper
lip.
(2) The projection of a line drawn from the inner canthus
of the eye to the ala of the nose passes through the upper
canine tooth. These lines can be scribed onto the record
block and then a flexible ruler curved around the labial
surface of the rim to measure the distance between the lines. Tooth moulds which will fit into
this distance can be identified from a chart.
Tentative measurement
The size of the teeth should be in proportion with the size of the face.
Generally, large or big faces should have largeteeth andsmall faces need small-size teeth
and so females usually need smaller teeth than males.
Central incisor is 1.681 times wider than the lateral incisor in a frontal
view. JPD 40:244-252,1978
Methods using Anatomical Landmarks
Size of the maxillary arch
Distancebetween incisive papilla and hamular notch on one side is added
with distance between two hamular notches. This gives combined width of
all anterior and posterior teeth of maxillary arch
Size and shape of the residual ridges
Although the size and shape of the residual ridges cannot actually determine a specific
mold selection, they are important guides to overall size.
Large maxillary- ridges will usually require teeth with a "width of six anteriors on a
curve" (canine to canine) of at least .53 mm.
Small ridges will usually be less than 50 mm.
Location of canine eminences
A canine eminence is formed in the region between the canine and
the first premolar after extraction of teeth. The distance between the
two canine eminences is measured along the residual ridge.
This measured value gives the combined width of the anterior teeth
Location of the buccal frenal attachments
The attachments of the buccal frenum are marked on the residual ridge.
The distance between the two markings recorded along the residual ridge
gives the combined width of the maxillary anteriors.
Location of the corners of the mouth
The corner of the mouth marks the distal end of the canine. The
corners of the mouth are recorded on the occlusal rim and the
distance is measured between these markings. The anterior teeth
are set within these markings
Location of the ala of the nose
The patient is asked to sit upright and look straight. A line passing
through the midpoint between the eyebrows and the lateral end of the
ala of the nose extended onto the occlusal rim gives the combined
width of the anterior teeth
The interalar distance:
A vertical line extending along the lateral surface of the ala of the
nose will pass through the middle of the upper canines.
Clinicians need to add 7 mm to the interalar measurement to
produce the width of the six maxillary' anterior teeth, from distal of
canine to distal of canine. Rahn
Methods Using Theoretical Concepts
Winklers concept : the teeth should be selected based on three different views,
Physiological-biological
The facial musculature contributes to the aesthetics of a patient Increasing the thickness
of the denture base in the labial and buccal sulci can produce a puffy appearance.
Facial wrinkles fade when the vertical dimension is increased. But this should not be
carried out to avoid other complications. The dentist should evaluate the perioral tissues
and arrange the teeth accordingly
Psychological;
A patient with a positive self evaluationshows abroad smile and the one with a
negativeself-evaluation shows a tight-lipped small smile.
The Camper's line is the psychological plane of orientation.
It is raised in happy people and is tilted downward in depressed people
Biomechnnical
The teeth should be placed suchthat they fulfill the biomechanics of the denture. It is not
necessary to set the teeth on, outside, or inside the ridge. Instead they should be set in the
neutral zone (the zone of balance between thebuccal and lingual musculature).
Typal form theory: Leon Williams (1917)
This theory helps to determine the size and form of the anterior
teeth. According to him, the shape of the teeth should be inverse
of the shape of theface
Concept of Harmony: J W White in 1872
According to him, the size and colour of the teeth should be in harmony with the size of
the head and colour of the eye, respectively
Clinical methods
Canine lines At the corners of the mouth the are marked on the properly contoured
occlusion rim. The distance between the canine lines determines the width of the six
anterior teeth.
High lip line : The distance from the lower edge of the upper occlusion rim to the high
lip line is used as a guide to determine the length of the upper anterior teeth.
Commercial Guides
Many forms of commercial guides are available to the dentist to aid in selection of denture teeth,
including
Physical mold guides : the denture teeth in the
mold guide may be of poor quality and should not
be used in actual dentures
Trubyte Tooth indicator: it can be used for estimating the size as well as outline and
profile forms of maxillary anterior teeth.
- Tooth width and length are based upon an average 16:1 ratio of
the bi zygomatic width and height of the face in relation to the
width and length dimensions of the natural maxillary central
incisor
- The indicator's face plate has two registration bars, one on the
left side and one at the bottom, which are moved along slots
and locked into position against the skin of the zygomatic
region and underside of the chin, with themandible at rest.
- Maxillary central incisor width and length are read directly from the corresponding
scale, as indicated by the position of the bar surface in contact withthe patient's face.
- Outline form is shown by comparing the facial form in relation to the vertical lines of
the indicator, and is classified in the manufacturer's directions as square, square
tapering, tapering, or ovoid
- The Trubyte Tooth Indicator may also be used to determine the patient's profile
formfor matching to the denture teeth. With the device held in place, the operator
observes the relative straightness or curvature of the profile
Ivoclar Vivadent BlueLineForm Selector
- Which features a caliper, the Facial Meter, for correlation of the
patient's inter alar dimension with tooth mould width.
- This system also incorporates cards with actual-sized photographs of
the six maxillary anterior teeth. These cards are helpful in selecting
tooth form {soft or bold) and tooth length (short to long).
Facial Meter from Ivoclar Vivadent
The device is placed against one side of the nose, and a movable arm is
placed against the opposite side. Some studies indicate that a relationship
exists between the width of the nose and the size of the anterior teeth.
Other factors
Size of the face
Inter-arch spacing.
Distance between the distal ends of the maxillary cuspids
Length of the lips
Size and relation of the arches
Length:
The distance from the high lip line and the lower edge of the upper occlusion rim
represents the length of the upper anterior teeth.
The lower edge of upper occlusion rim should be about 2mm below the upper lip at rest.
The amount of upper teeth shown below the upper lip depends on:
A-Length of the upper lip; short lip shows more tooth and vice versa.
B-Mobility of the upper lip; hyper mobile lip shows more teeth.
C-Interarch distance: large space between upper and lower ridge require a long teeth.
3. Color (shade) of the teeth
Electromagnetic waves 400-700 m eliciting retinal response
For single or partial denturethe shade must be harmonized with remaining natural teeth.
For complete denture the color of the teeth is affected by
Thecolor of the skin, hair and eyes.
o Hair Colour: according to Bcucher is not a constant factor and can be
unreliable & inaccurate
o Color of the eyes: According to Heartwell it is an excellent guide but is not
recommended by Boucher as he says that The iris of the eyes is so small
compared to the area of the total face& the eyes are not close to the teeth.
o skin colour :A study by Hallarman showed that there is apparently little
correlation between either natural hair or eye colour and tooth colour. There is
also little correlation between skin colour of the forehead or cheek and
patients own anterior teeth.
The age: Usually older patients require darker teeth than younger ones. In youth the
pulp chamber are large and the red colour of the pulp affects the tooth colour..
Sex of the patient should be taken into consideration when selecting the shade of the
teeth. women require lighter teeth than men.
Buccal corridor
Tooth/Lip ratio
The characteristics of natural teeth color:
a- The neck of the teeth is darker than the incisal edge.
b- The incisal edge is more translucent than other two thirds because it is made entirely
from enamel.
c-The upper central incisors are the lightest followed by the upper laterals, the lower
centrals and laterals, and the upper and lower caninesare the darker.
d- Posterior teeth are usually uniform in color.
e- Natural teeth darken with age as a result of deposition of secondary dentine.
Colour has basically 3 qualities hue saturation and brilliance
Hue
The color or tint e.g. Red, Yellow, Green, Blue
It is the dimension of colour by which the eye distinguishes different wave length of the
visible spectrum.
It is specific colour produced by a specific wave length of light acting on the retina of the
visible spectrum.
It is possible to recognize 2 different hues in artificial teeth ( yellow & red).
The individual teeth of each set, although of the same hue, should vary in their purity the
central incisors being more pure than the lateral incisors and canines. If artificial teeth are
to resemblepleasing natural teeth they, too under all conditions of lighting should appear
to be warm and living.
Saturation (Chroma)
It is the amount of colour/unit area of an object .(saturation of color, purity or intensity
of a color). eg: some teeth appear moreyellow than others.
When more of the hue or less of white is present, there is said to be greater saturation. A
tooth is said to be darker because of an increase in saturation or a decrease in brilliance.
Both brilliance and saturation must be held within limits and must be related to each
other in correct proportions for each hue natural tooth colours are to be imitated.
Brilliance (Value)
Refers to the lightness or darkness of an object.
It is the quantity of light reflected from the surface. The inclination of surfaces, position
of surfaces, character of surfaces and the intensity of the projected light all affect the
lightnessof an object.
Thesame color can appear different due to:
light sources - size differences
directional differences - background differences
Curved surfaces appear more darker than the surfaces at right angles to light.
Surfaces closer to the observer will be lighter than similar surfaces further away.
Polished surface will reflect more of than light received and will be lighter than
roughened surfaces. Surface appear lighter when it is illuminated by Intense light.
Dark teeth in dark complexion appear to be lighter than they are. light teeth in light
complexion appear to be darker than they are
Translucency
It is the property of an object that permits passage of light through it.
Translucency of artificial teeth has the effect of mixing the various colours of teeth. This
results in teeth that look alive. A natural tooth is composed of a slightlytranslucent ivory
colored body covered with a jacket of almost colourless material of greater translucency.
Because the enamel jacket varies a great deal in thicknessin different parts of the mouth,
many characteristic visual effects are produced.
Opacity: Impenetrable by light, neither transparent nor translucent
Transparency: Capable of transmitting light so that objects or images can be seen as
though there were no intervening material
Translucency: Halfway between transparency and opacity, or diffused light transmission.
Metamerism: The same object, without changing color may appear different in color under
different lighting conditions
Primary Colors: Red, Yellow, Blue. These 3 colors are the base colors for every other color
on the color wheel
Secondary Colors: Orange, Green, Purple. These 3 colors are what you get when you mix
the primary
Tertiary Colors: These are those "in-between" colors like Yellow-Green and Red-Violet.
They're made by mixing one primary color and one secondary color together. There can be
endless combinations of tertiary colors, depending on how they're mixed.
Tints, Shades, and Tones : If a color is made lighter by adding white, the result is called a
tint. If black is added, the darker version is called a shade. And if gray is added, the result is a
different tone.
Factors in Determining a Proper Shade Match
Characterizations
Surface Texture
Incisal Shape
Shade selection
The selection of a suitable color for the teeth is a simple
procedure by using a shade guide.
The first step will establish the basic hue, brilliance &
saturation. The 2
nd
will reveal the effect of the colour of
the teeth when the patients mouth is relaxed. The third
will stimulate exposure of the teeth as in a smile.
The colour of the teeth should be observed on a bright day when possible with the patient
located close to natural light.
The 'squint test' may be helpful in evaluating colours of teeth with the complexion of the
face. [With the eyelids partially closed the dentist compares prospective colours of
artificial teeth held along the face of the patient. The colour that fades from view first is
the one that is least consipicious in comparison with the colour of the face].
Shade guides are useful in the shade selection observation of the shade guide should be
made in 3 positions.
1.) Outside the mouth along the side of the nose
2.) Under the lips with only the incisal edge exposed.
3.) Under the lips with only the cervical end covered and
mouth open.
Guidelines for Proper Shade Selection [Vitapan \ 3D- master Shade System]
o Proper Lighting - 5500 Kelvin (replicates natural daylight) balancing all hues in the
spectral curve. (Light quantity should be 150 foot candles)
o Proper Distance 5 to 10mm from the dentition to be matched
o Proper Environment - Shade should be selected in as neutral
environment as possible. Cover bright clothing, remove lipstick and
bright cosmetics .
o 26 shades which most accurately cover known tooth colors, uniformly
positioned throughout tooth color space.
3D-MASTER TOOTH GUIDE
Clinical Decision Tree
Value- 1 of 5
choices
Chroma - 1 of 3
choices
Hue - 1 of 3 choices
3 Steps to follow:
Step 1 Value
Step 2 - Chroma
Step 3 - Hue
Light to Dark
Diluted to Saturated
Neutral Yellow Red
ADVANCED SYSTEMS FOR SHADE SELECTION
The X-Rite System
The Easyshade System
Intraoral Dental Colorimeter
ShadeEye NCC, Shofu, Menlo Park, CA) has been introducedon the market as a suitable device
for intraoral color measurements
Sel ect ion of t he l ower six ant er ior is r el at ivel y simpl e pr ocedur e and
based on t he same cr it er ia t hat used f or sel ect ion of t he upper ant er ior
t eet h.
Selection of posterior teeth
1- The selection of the proper tooth-size or mold is based on:
a- The capacity of the ridge to receive and resist the forces of mastication:
In most complete denture patients the lower ridge offers less support to the forces
generated by the occlusal surface of the teeth. Its smaller area of support and more rapid
resorption pattern progressively narrow and reducesthe height of the lower ridge.
For these reasons, the determinants for selection will be based on the lower ridge. When
the lower ridge is strong, well formed, and covered by a generous area of attached
masticatory mucosa, the full space available can be used because this ridge can tolerate
the masticatory forces.
When the ridge is resorbed, weak and covered by only lining mucosa, the size of the
posterior tooth should be smaller to minimize the forces directed to the ridge.
b- The space available for the posterior teeth is in two dimensions:
The mesiodistal space which extends from the distal of the lower canine
to the apex of the retromolar pad.
- The inter-ridge space or vertical lengths: artificial teeth of the same occlusal
size are manufactured in various vertical lengths (short, medium & long).
The selection of the teeth in this dimension will depend on the vertical space between
upper and lower ridges.
c- The esthetic requirements of posterior teeth
They are largely dependent on the selection of proper-size teeth. It is preferable to use
long posterior teeth for esthetic reasons, so the bicuspids will be in harmony with the
lengthof upper canines.
Buccolingual Width
The buccolingual width of the artificial teeth should be decreased so that the buccal and
lingual surfaces slope out from the occlusal surface to provide a proper path of
escapement of food during mastication.
Reducing the occlusal table leading to reducing the load falling on the ridge. However,
this reduction in width should not be accomplished at the expense of losing support for
the cheek.
- If the buccolingual width increases, the forces acting on the denture will also
increase, leading to increase the rate of ridge resorption.
- Broader teeth encroach into tongue space leading to instability of the denture
- Theteeth should not encroach into buccal corridor space to avoid cheek biting.
Mesiodistal Length
The mesiodistal length of each tooth should beselected such that the combined length of
all theposterior teeth on that side of the arch does not exceed the distance between the
canine and theretromolar pad
- Posterior teeth should not be placed over anteroposterior ridge slope as this would
lead to forward displacement of the denture.
- The teeth should not be placed over displaceable tissues like the retromolar pad as it
will cause tipping of the denture during function.
- In cases with inadequate mesiodistal length the premolar can be omitted.
Occluso-gingival Height
It is determined by the available inter-arch distance. Length of maxillary premolars
should be comparable to that of canine to have proper esthetic effect.
2- Shade
The shade of the posterior teeth should be in harmony with the shade of the anterior teeth.
The maxillary bicuspids may be slightly lighter than the other posterior teeth but not
lighter than the anteriors
3- Occlusal form
Factors that control the selection of the occlusal form
1. Condylar inclination:
Teeth with a high cuspal height are required for patients with steep
condylar guidance
2. Height of the residual ridge
The ridge form can be used as an index for the amount of cusps angulation. The ridge form can
be used as an index for the amount of cusp modification.
The ridge form can be used as an index for the amount of cusp modification.
(A) A denture base, supported by well-formed ridges, has a resistance form as indicated by the
dotted lines to resist the forces due to cusp inclines.
(B) As bone resorption takesplace, the resistance to lateral forces becomes less and reduced cusp
inclines are indicated to keep the base stable.
(C) For flat ridge, the lateral force can be controlled by using flat teeth.
3. Patients age : Teeth with shallow cusps are preferred inolder people.
4. Ridge relationship: 0 or monoplane teeth are preferred for cases with posterior cross
bite Or severeclass II relationship . Flat teeth are usually indicated for patients having
Angle class II or class III as it doesn't seem possible to set anatomic teeth in normal
occlusal alignment. Also because class II cases exhibit weak mandibular ridge and class
III exhibit relatively weak maxillary ridge and weak ridges cannot tolerate forces
transmitted by anatomic teeth.
5. Hanau's quint.
6. Inter-ridge space
Cases exhibiting large inter-ridge space are better supplied with dentures having flat non
anatomic teeth. This is because large inter-ridge space creates a long lever arm through
which horizontal forces created by steep cusp inclines of anatomic teeth may act.
7. The form and contour of the residual ridge
Anatomic teeth are only used in case exhibiting well formed ridges having parallel sides,
flat crest and covered with firm dense mucosa 2-3mm in thickness. These ridges have the
ability to tolerate masticatory forces and resist horizontal forces generated by the inclined
planes of cusped teeth. Flat teeth are indicated for flat ridges, ridges with thin wiry crest
and flabby ridges.
The available three major groups of occlusal forms are:
Anatomic teeth of 30, 33 degrees cusps or more.
Semi-anatomic teeth of 20 degrees cusps.
0 degree, cuspless teeth (flat teeth).
Special Tooth Forms
a) The anatomic teeth
It is made to reproduce the anatomical features of natural teeth. This usually results in a
well-defined cusp formation (e.g. 33-degree teeth) and necessitates the use adjustable
articulator if balanced articulation is to be produced.
They are commonly used for patients having normal ridge relations and well- developed
ridges. give greater efficiency and bilateral balance.
Anatomic teeth are designed with various cusp inclinations. Cusp inclines may vary
between 45 and 33
Cusp inclination is measured by an angle formed by the mesio-buccal cusp incline in
relation to the horizontal plane when the tooth is in vertical relation to the horizontal
plane.
The inclined planes of artificial teeth should be in harmony with the inclination of the
TMJ so that eccentric occlusal contact would be in harmony with mandibular movements
of denture wearers. Thus, with the use of anatomic teeth, it is mandatory to register
protrusive and lateral records and to use adjustable articulators in an attempt to produce
free gliding occlusion without deflective occlusal contacts and thus obtain stable
dentures.
Advantages of anatomic teeth:
Closely resembles natural teeth highly aesthetic.
Proper contours for crushing and triturating.
Presence of adequate sluiceways.
Greater chewing efficiency, excessive chewing pressure is minimized.
More vertical chewing stroke.
Cuspal inclines provide a depth to obtaineccentric balance.
Provides a greater resistance to rotation of dentures.
Provides a comfortable position to return towhen cusps are making contact in fossae.
Disadvantages of anatomic teeth
More difficult and time consuming to obtain balancedocclusion.
Settling results inmore damaging interferences.
Possibilities of more lateral stress in function.
Settling also causes the vertical dimension at occlusion to decrease and the mandible to
move forward.
Settling will lead to residual ridge resorption.
b) Semi-anatomic teeth
They are also known as modified-cusp or low-cusp teeth. They may have 20 or 10
cuspal angulation. 10 semi-anatomic teeth are commonly known as functional ,
anatoline teethor Modified anatomic teeth
These are teeth having a less steep angle than anatomic teeth. Their cusps are usually
inclined to a 20 angle.
They are either manufactured to this angle or anatomic teeth could be by modified by
grinding..
Modified anatomic teeth generate less lateral forces compared to the anatomic form.
Advantages of semi-anatomic teeth
Easier to arrange and obtain balanced occlusion.
Can provide freedom if settling occurs.
Reduction of lateral stresses.
Provides all the advantages of cusp teeth.
Disadvantages of semi-anatomic teeth
Less aesthetic (buccal cusps are shorter) .
Less chewing efficiency (controversial: some claim greater)
c) CusplessTeeth
They are also known as 0, flat, or monoplane teeth
They offer less masticatory efficiency. However, they may be
used in the following cases:
- Cross-bite relationship. - Flat ridge.
- Knife-edge ridges. - Large inter-ridge space.
- Patients with T.M.J problem or neuromuscular in-coordination.
- Milling type of chewing pattern. -Uncoordinated jaw movements
Advantages of flat plane teeth teeth
1- Moreadaptable to universal and class II and class III jaw relations.
2- They are more easily used in cross-bite situations.
3- They permit long centric freedom.
4- They give the patient a sense of freedom as they do not lock the mandible in one
position only.
5- They eliminate horizontal forces that may be more damaging than vertical forces (less
bone resorption).
6- No need for adjustable articulator and setting is easier.
7- Balance obtained bybalances ramp, compensating curve or pleasure curve.
Cuspless teeth can be used for the following occlusal schemes:
Bilateral balance with a compensating curve,
Three-point balance with a balancing ramp.
Flat plane-balance in centric only.
Reverse-pitch (Anti-Monson) curve.
Special Tooth Forms
IncludeFrench's posteriors, cutter bars, masticators, VO posteriors, Sosin-bladed teeth
Advantages
Some can provide moderate to excellent function
To date, most efficient design is Sosin bladedteeth.
Disadvantages
. Often aesthetics ispoor.
Best forms require meticulous execution andskill.
More expensive
Selection of material for artificial teeth
- Acrylic resin. - Porcelain. - IPN resin.
- Acrylic resin teeth with amalgam stops.
- Acrylic resin teeth with gold occlusal surface
Porcelain and acrylic resin teeth
Acrylic resin teeth with amalgam stops
This type of teeth is used to slow and control the occlusal wear when the acrylic teeth
is opposite by porcelain or natural teeth as in case of single denture.
The amalgam stops can be inserted when the teeth are balanced on the articulator
before delivery to the patient, or they can be inserted after a period of patient use so
the individual wear pattern of a generated occlusion is apparent.
Acrylic resin teeth with gold occlusal surfaces
Gold occlusal surfaces are considered the best material to oppose natural teeth as in
case of single denture.
One or more occlusal surfaces on each side of the denture can be casted in gold to
stop the abrasion of the acrylic teeth and protect the opposite teeth from abrasion.
This type of teeth is impractical for most patients because it is expensive and takes
more time for fabrication.
IPN resin
This material consists of an unfilled, highly cross-linked, inter-penetrating polymer
network. The wear resistance of this material is higher than that of the conventional
acrylic resin teeth.
The upper and lower posterior teeth can be both porcelain, both resin, and a combination of
porcelain and resin. The combination of porcelain upper posteriors and lower resin teeth has
the following advantages:
1- The sharp impact sound of porcelain on porcelain is reduced.
2- The high frictional coefficient between porcelain is reduced.
3- The chipping of the teeth in the porcelain teeth is eliminated.
4- The efficiency of sharp cusps is retained in the porcelain cusps.
5- The occlusion is easily adjusted by grinding only the resin teeth.
6- The resin teeth wear easily to functionally adjust to the patients mandibular
movements.
7- The wear of resinteeth can be retarded by placing amalgam stops in their occlusal
surfaces.
Porcelain Teeth Acrylic Resin Teeth
Will not bond to the base material.
The teeth attached to the denture
base by mechanical retention
through pins present in the lingual
surface of the anterior teeth and
diatoric holes in the under surface of
the posterior teeth.
More resistant to staining.
More likely to chip or fracture.
Very hard cause more destruction to
the underlining bone.
There is a chemical bond between the
teeth and the base material.
Tend to stain rapidly than porcelain.
Less likely to chip or fracture.
Acrylic teeth are resilient. Cause less
destruction to the underlining bone.
More resistant to wear and abrasion,
therefore the vertical dimension is
maintained.
Hold their shape for years.
Maintain comminuting efficiency for
years.
Cause abrasion to opposing gold
crowns and natural teeth.
Clicking occurs on contact with the
opposing teeth.
Difficult to grind and fit into close
inter-ridge space.
Can be ground and polished.
The density is high and the impact
strength is low comparing to acrylic
teeth.
Esthetically accepted.
Acrylic teeth wear rapidly resulting
in loss of vertical dimension.
Occlusal surface altered by wear
(In5-7 years they are inefficient).
Loss of comminuting efficiency after
few years.
Minimal wear to opposing natural
teeth and gold crowns .
Do not click and have soft impact
sounds.
Easy to grind and fit into close inter-
ridge space.
Self-adjusting and self-polishing.
The density is low and the impact
strength is high comparing to
porcelain teeth.
Esthetically accepted.
Denture base shade selection and Characterization
o If a custom gingival denture base shade is to be used, it must be
selected at this time
o Some patients have mild to heavy pigmentation of their gingiva. If
available, a gingival shade guide should be used to attempt to match
the gingival shade of the patient.
o Matching the gingival shade can be difficult because the entire
gingiva is not one single shade and in fact often varies dramatically
from one part of the mouth to another. The shade that best blends with the overall
gingival tone should be selected. This shade will be used during the preparation of the
denture base material for the packing and processing of the denture.
Sir Wilfred Fish in his extensive writing on the polished surface of dentures elaborated on
the direct influence of denture base contours on facial esthetics. He says optimum
esthetics depend on adequate soft tissue support which in turn is directly related to proper
base contours.
o Frush & Fisher proposed
Convex, rounded and shortened papilla in older patients.
Exposure of more of cervical root portions of denture teeth in order to simulate
ginglval recession in older individuals.
Finer stippling for females and heavy stippling for males.
Tint the interdental pappila and muscle attachment areas
with deep shade of red.
They used light shades to tint areas of hard tissue.
o Many others have advocated
Festooning. stippling and staining of the denture base.
Use of preformed anatomic palatal and facial gingival forms.
Rugae can be reproduced in denture for natural feel. A 0.003 guage tin foil is
adapted over the rugae area of the edentulous cast of trimmed. This is adapted to
the base plate after wax upso as t reproduced the rugae properly.
Colour Distribution in Gingiva
Basic pink used over hard tissue as attached gingiva. Light red used for papilla & muscle
attachments Medium red tones in mucobuccal folds, rugae etc Purple blue in heavily
plgmented gingiva mostly attached gingiva papilla & marginal gingiva. Brown for
heavily pigmented gingiva.
Characterization
A life like restoration can be obtained by simulating the anatomical characteristics of oral
mucosa with various stains.
It is of particular value in
1. Subjects with active upper lip
2. Persons with prominent pre maxllla
3. Persons like teachers & singers
4. Who expose more of denture base during talking <smiling.
5. Young edentulous patients
Methods of characterization include mild chipping, occlusal wear facets, small
restorations on the teeth, staining to depict the endemic conditions, mild rotations and
alteration in anterior teeth arrangement.
Though these characterizations produce a striking resemblance to natural teeth, patient
prefer to have white, unaltered artificial looking teeth.
Arrangement of Artificial Teeth
Occlusionrims should provide guides for placement of the teeth. These guides are:
1-guide lines (midline, high lip line and canine lines).
2- The proper placement of the occlusal plane.
3- Proper lip support.
4- Correct jaw relationships (vertical dimension of occlusion and centric relation).
The following mechanical factors should be considered in the placement
of teeth:
1-Pattern of bone resorption
The pattern of bone resorption should be studied before setting up the teeth
specially the anterior. The general pattern of bone loss is essentially upwards and
backwards for the maxillary anterior residual ridge and downwards and lingually
for the mandibular anterior residual ridge.
After extraction of the teeth, the maxillary bone shows resorption vertically,
labially and buccally. The crest of the ridge moves back with progressive bone
loss. The anterior teeth should be set labial to the crest of the ridge to restore the
original position of natural anterior teeth.
The mandibular bone shows vertical and lingual resorption. Thecrest of the ridge
moves anteriorly.
The mandibular teeth are positioned in the wax occlusion rim over the crest of the
residual ridge in their ideal buccolingual relationship. The maxillary teeth are set
in a tight centric occlusal arrangement regardless of their buccolingual positions
The incisive papilla is a fixed landmark and can be used as a guide for
setting the maxillary central incisors. The distance from the center of
papilla to gingival margin of central incisor is 8 mm and from papilla
to incisal edge is 10 mm.
Also the distance from labial surface of canine to anterior margin of
rugae is 10.5 mm
2-The neutral zone
The artificial teeth should be placed at a point where the tongue and cheek pressure
balance (neutral zone). The upper neutral zone is usually not a narrow restricted area and
therefore permits some latitude for positioning of the anterior teeth to obtain adequate lip
support for facial appearance, while the lower neutral zone is very critical for denture
stability.
3-The esthetic of the denture
The artificial teeth should be arranged in such a way to simulate to a great extent
the natural teeth.
The midline and the canine lines should be used as guides in the setting-up of
anterior teeth. These lines are marked on the casts to be used as references when
the marks on the occlusion rim are destroyed during setting-up of the teeth.
In order to restore the natural appearance, the teeth should be placed to support
the lip and muscles of expression. The teeth should be placed in the position
formerly occupied by the natural teeth.
Frequently, there are some irregularities in natural teeth which may be
reproduced in complete denture to improve esthetic.
4- The occlusal plane
The upper central incisors should be set up on the plane of occlusion
(approximately 2 mm below the upper lip). The lower teeth should be placed
lower in order to maintain an adequate inter arch space and aid denture stability.
5-The arch form
The teeth should follow the contour of the ridge whether they are oval taper or
square. The maxillary arch is usually 'U' shaped and the mandibular arch is 'V'
shaped.
Aligned Occlusal Groove Concept
- The central grooves of all the maxillary posteriors should lie
on the straight line joining the tip or distal arm of the canine
anteriorly and the midpoint of the occlusal rim posteriorly.
Aligned Buccal Ridge Concept
- According to this concept the line formed by the
central grooves should pass lingual to the canine, and
the buccal ridges of the maxillary canine, maxillary
first premolar, maxillary second premolar and the
mesiobuccal line angle of the maxillary first molar
should lie in a straight line.
- According to this concept, the arch makes a slight
medial curvature at the first molar region
6-The use of phonetics
Phonetics may be used as aids in the placement of the maxillary anteriors e.g. the
incisal edges should be positioned so that the f, v and ph sounds can be correctly
pronounced . These sounds serve as an excellent test or guideline for determining
the proper plane of occlusion and placement of anterior teeth.
Speech is affected by the position of the teeth and the contour and bulk of the
palate.
7-Balanced articulation:
To achieve balanced articulation, the posterior teeth are arranged so that their cusps
present anteroposterior and lateral curves. These curves correspond to the curve of
Spee and curve of Monson (compensating curves). These curves allow for teeth
contact during lateral and protrusive movements because the mandible moves in a
curved path.
In the working side the upper buccal cusps meet the lower buccal cusps. In the
balancing side the palatal cusps of maxillary posterior teeth contact the buccal cusps
of the mandibular teeth
8- Key of Occlusion
Canine Key of Occlusion
According to this principle, usually the distal arm of the lower
canine should align with the mesial arm of the upper canine.
The artificial teeth should be arranged according to this rule.
Molar Key of Occlusion
According to this principle, the mesiobuccal cusp of the
maxillary permanent molars should coincide with the
mesiobuccal groove (also called buccal groove) of the
mandibular permanent molars.
9- Tooth to Ridge Relation
The following factors should be considered:
- The mandibular posterior teeth should be arranged on the ridge for more stability.
- The mandibular anteriors should be inclined such that the incisive forces are transferred
to the crest of the ridge.
- .Generally all posterior teeth should have their long axis co-inciding with the long axis of
the residual ridge.
10- Neutral Zone
Teeth should be arranged in the neutral zone where the forces of the buccal musculature
are compensated by the lingual musculature.
11- Compensating Curves
The compensating curve is incorporated to obtain a balanced occlusion.
Ther e ar e 4 st eps in ar r anging dent ur e t eet h.
1) Proper Orientation of occlusal plane
The oclusal plane lies parallel -.to the campers line in the sagittal plane&parallel to the
inter pupillary line in the frontal plane, Occlusal plane platedesigned by Dr. Frank. Fox
is a most useful tool for determining theserelationships.
The amount of incisal edge visible below the related upper lip mayrange from 0 - several
mm owing to variations in lip length from very short to very long. The incisal length of
the rim is adjusted (by having the patient enuncial F & V sounds) to where the wet or dry
line of the L/lip makes light contact with the incisal edges of maxillary central incisor.
2) Careful development of wax rims in the space intended for artificial teeth.
Wax rims should be developed with great care to fill the space once occupied by the
patientsnatural teeth.
The rims should offer adequatesupport for the soft tissues. They should allow for esthetic
buccal corridors.
Orientation lines should be scribed on the wax rim in the mldline, high lip line and 2
vertical lines in the caninearea directly down from the ala of the nose. Arch form should
be harmonious withfacial & tooth forms.
Heart well & Rahn pointed out that mandibular teeth become morevisible with age. Vig
& Brundo showed that the longer the upper lip, the more visible the mandibular teeth
become with age..
3. Placement of each tooth; in its correct anatomic position.
Should view the positon of each tooth in the frontal, sagittal & occlusal planes.
In the sagittal view: The incisal edges of the CI & canines rest on the occlusal plane. LI
1mmshort of the plane.
In the frontal view: the long axis of LI perpendicular to the occlusal plane LI angle
medially slightly, canines more medially than LI. The tips of the canine should never be
more labial than their necks.
In occlusal view LI face forward, where as the canines are rotated distally. In sagittal
view LI flare slightly in a labial direction. LI flare slightly more in the same direction.
The long axis of canines are nearly perpendicular to the occlusal plane.
Mandibular Teeth.
Frontal View - Long axis of CI perpendicular to theocclusal plane. - LI tipped medially
slightly. - Canines tipped more medially than LI
Sagittal view : LI are tipped in a labial direction slightly, long axis of LI nearly
perpendicular to the occlusal plane canines angle forward slightly.
4. Characterisation of the set up
Lombard! felt that: the LI make the best statement of the patients age, LI cannot the
patients sex. Canines reflect the patients vigor.
Frush & Fisher believedthat dentogenics influence tooth arrangement as well as shade of
tooth selection. To highlight age they accentuated diastemata and rotations. Probably the
most popular characterization technique is to crowed and tilts the mandibular anterior
teeth.
Sequence of arranging the teeth:
One of the following sequences is used for arranging the complete denture teeth:
1- The maxillary anterior teeth, the mandibular anterior teeth, the maxillary posterior
teeth and the mandibular posterior teeth.
2- The maxillary anterior teeth, the mandibular anterior teeth, the mandibular posterior
teeth and the maxillary posterior teeth.
3- The maxillary anterior teeth, the maxillary posterior teeth, the mandibular posterior
teeth and the mandibular anterior teeth.
Setting up of anterior teeth
General Considerations for the Arrangement of the Anterior Teeth
1. The midline of the teeth should coincide with the facial
midline.
2. the position of the incisal edge of the maxillary anterior teeth
provides esthetics and phonetics, while the position of the cervical
portion, or necks, of the teeth and the fullness of the maxillary
denture base determines lip support (fullness of the lips). [Note
that the position of the necks of the teeth and the increased fullness
of the denture base provides more lip support in diagram A than it
does in diagram B.]
3. The labial surfaces of the maxillary anterior teeth should be
placed slightly labial to the surface of die labial flange. When
viewed from the tissue side of the denture, a small amount of
tooth should be present beyond the denture flange.
4. A vertical overlapof the anterior teeth is not indicated unless
specifically determined by the clinician.
The maxillary anterior teeth
The artificial tooth is approximately placed in the position that it was in the
patients natural dentition. Generally the upper anterior teeth are set up first
followed by the lower teeth.
Position of maxillary anterior teeth:
a. Maxillary central incisors
1. The long axis of the tooth should be perpendicular to the horizontal plane (occlusal
plane or the mandibular occlusion rim) when seen from the front.
2. Its long axis should be inclined downwards and slightly labially when seen from the
side.
3. The contact point should coincide with the midline of the face.
4. The incisal edge should touch the mandibular occlusion rim.
5. The facial surface of the central incisors should be 8-10 mm anterior to the center of
the Incisive papilla.
b. Maxillary lateral incisors
1. The long axis should incline slightly distally.
2. The cervical portion of the tooth should incline slightly lingually.
3. The incisal edge of the lateral should be raised approximately 1 mm from the
mandibular occlusion rim.
c. Maxillary canines
1. The incisal edge of the canine should touch the mandibular occlusion rim.
2. The long axis should be vertical or inclined slightly distally (frontal view).
3. The long axis when viewed from proximal is vertical or cervical third is inclined
buccally to achieve some prominence.
4. The mesio- labial aspect of the canine should be visible when viewed from the
anterior. This will be accomplished by tilting the neck of the canine slightly to the distal
(in addition to being tilted to the buccal).
Procedures for arranging the maxillary anterior teeth:
1) Check the articulator settings.
2) Seal the baseplate borders using base plate wax, No wax on
land area.
3) Locate the midline on the maxillary occlusion rim. Extend this
mark onto the land area of the maxillary cast with a pencil.
4) Mark the center of the incisive papilla and extend it to
the land area.
5) Using a warmed knife cut enough wax from the right side of the maxillary occlusion
rim to allow the positioning of the right central incisor.
6) Set the upper central incisor with its incisal edges touching the
mandibular wax rim, its mesial edge at the midline previously marked
using the occlusion rim remaining on the left as a guide. It may be
necessary to grind on the record base with a rotating instrument. It
may also be necessary to adjust the ridge lap portion of the denture
tooth.
7) Seal the tooth in position on the lingual surface with wax.
8) Arrange the right lateral and canine in the same manner.
9) Cut away the left side of the anterior portion of the maxillary occlusion rim and
arrange the left central, lateral, and canine teeth. Evaluate the position of the incisal edges
of these teeth relative to the plane of occlusion using a glass slap.
The 2 central incisors can be set first then the 2 laterals followed by the canines.
The mandibular anterior teeth
Anterior teeth are set to follow the arch form of the patient's residual ridges. The
incisal edges of the anterior teeth should be set to correspond to the shape of the
arch.
Owing to the reduced retention of complete lower dentures it is essential that the
teeth are set on the ridge and not anterior to it.
Position of mandibular anterior teeth:
a. Mandibular central incisors
1. The long axis of the mandibular central incisor should be set
perpendicular to the occlusal plane when viewed from the front.
2. Its long axis slopes labially when viewed from the side.
3. If anatomic posterior teeth are used, 1-1.5 mm horizontal and vertical overlaps are
made.
4. The contact point of mandibular incisors should coincide with the midline of the
maxillary teeth.
b. Mandibular lateral incisors:
1. The long axis of the mandibular incisor should be slightly inclined distally at the
cervical portion of the tooth.
2. From the side it is inclined labially, but its labial inclination is less than that of the
central incisor.
3. The occlusal height should be the same at the central incisors.
c. Mandibular canines
1. The long axis of the mandibular canine is nearly perpendicular to the occlusal plane
with a slight distal inclination.
2. The canine inclines upwards and lingually when seen from the side.
3. The tip of the canine should be at the same occlusal height as the mandibular central
and lateral incisors.
Procedures for arranging the mandibular anterior teeth:
1. Using a warmed knife cut enough wax from the right side of the mandibular occlusion
rim to allow the positioning of the right central incisor.
2. Arrange the lower central incisor with its mesial edge at the midline previously marked
using the occlusion rim remaining on the left as a guide.
3. Seal the tooth in position on the lingual surface with wax.
4. Arrange the right lateral in the same manner.
5- Arrange the canine so that the cusp tip of the mandibular canine is placed between the
maxillary canine and lateral
6. Now, cut away the left side of the anterior portion of the mandibular occlusion rim and
arrange the left central, lateral, and canine teeth.
7- Evaluate the position of the incisal edges of these teeth relative to the plane of
occlusion using a glass slap.
Reference Marks
Maxillary Reference Marks
Midline Position
High Lip Line
Corners of the Mouth
Incisive Papilla
Mandibular Reference Lines
Retromolar Pads
Center of Posterior Ridge : Maxillary lingual cusps should be centered over this
line to Ensures denture stability
Center of Anterior Ridge : If anterior teeth are too facial to center of ridge,
fulcruming tilting and dislodging occur
Mandibular Reference Lines
1/2 way up 1/2 way up
retr omolar retr omolar
Center of ridge Center of ridge
Posterior Posterior
Center of ridge Center of ridge
Anterior Anterior
Mandibular
Cast
Land Area Land Area
Occlusion rim Occlusion rim
Setting up of posterior teeth
General Considerations for Posterior Tooth Arrangeinent
Initially anonbalanced type occlusion is generally created for patients. If, at the
trial insertion appointment the need for vertical overlap becomes obvious, it is
necessary' to make protrusive or lateral interocclusal records to set the condylar
inclination of the articulator. The denture teeth must be rearranged into a balanced
occlusionand the trial insertion appointment repeated.
To minimize mandibular denture dislodgement during function, denture teeth
should not be placed beyond the point at which the residual ridge begins to slope
up toward the retromolar pad. If insufficient anteroposterior space exists to place
all four posterior teeth, the first premolar or second molar
is generally eliminated.
When completing a non balanced occlusion, the
mandibular posterior teeth are arranged on a flat occlusal
plane with the long axes of the posterior teeth arranged
perpendicular to the plane of occlusion.
For balanced occlusion, the posterior teeth are
arranged to a compensating curve. [For a
balanced tooth arrangement, a curved template is
used. This creates an anterior-posterior and
medial-lateral curvature of the occlusal surfaces.
In complete dentures, this is called a
compensating curveand is necessary to create the excursive contacts requiredfor
a balanced occlusion].
The central grooves and centers of the marginal ridges
of the teeth should lie in one continuous line, which
may be straight or have a slight curvature with the
concavity being directed lingually or palatally.
The central groove of the first premolar should align
with either the contact point between the canine and
lateral incisor or the tip of the canine.
Posteriorly the mandibular molars, particularly the
second molar, should be positioned almost directly over the
remaining residual ridges.
To help create this alignment, a line can be drawn along the
crest of the mandibular residual ridges. [Because this line
cannot be seen once the record base is seated, it is
necessary to mark the land areas of the cast, indicating
where a continuation of this line would cross the land
area. A guideline can now be visualized connecting the
anterior (canine) to posterior (crest of ridge) guides.
The correct alignment of the premolars and molars is
indicated when the central grooves are centered on this line and all central
grooves align with each other
Position of maxillary posterior teeth :
The upper first and second premolars:
1-Its long axis is parallel to vertical axis when viewed from front or side.
2-Its palatal cusp touches the occlusal plane and its buccal cusp touches the
occlusal plane or raised about mm.
3- The central sulcus lies directly over the lower ridge crest.
4- The buccal surface is aligned with the canine.
The upper first molar:
1-Its long axis inclined slightly upward mesially when viewed from the front.
2- Its long axis inclined slightly downward and buccally when viewed from the
side.
3- Only its mesiopalatal cusp is in contact with the horizontal plane.
4- The central sulcus lies directly over the lower ridge crest.
5- The buccal cusps of molars are angled slightly inward from line extending
along facial surfaces of canine and premolars.
The upper second molar:
1- Its long axis slopes as the first molar but steeper.
2- All four cusps are short of the horizontal planer but the mesio palatal cusp is
always nearest to it.
The position of mandibular posterior teeth:
The lower first premolars
If the maxillary posterior teeth were set first, space available to lower first
premolar may be small and its mesiodistal width may require reduction
from the mesial contact point.
In the other hand, if the mandibular posteriors were set first, a spacing (1/4
to mm) of the maxillary posteriors will be necessary to achieve the
proper intercuspation.
The buccal cusp of the lower first premolar touches the mesial marginal
ridge of upper first premolar.
The lower second premolar;
1- The buccal cusp should be over the crest of mandibular ridge.
2- The buccal cusp touches distal marginal ridge of first premolar and mesial
marginal ridge of second premolar.
3- Lingual cusp rest lingually between the maxillary first and second premolars.
The lower first molar:
1- The buccal cusp should be over the crest of mandibular ridge or slightly lingual
to it.
2- Its long axis leans upward mesially when viewed from the front
3- Its long axis leans upward lingually when viewed from theside.
4- All the cusps are at a higher level above the horizontal plane, the buccal and
distal cusps being higher than the lingual and mesial.
5-The central fossae are in contact with the lingual cusps of the maxillary molar.
The mesiobuccal cusp of maxillary first molar lies in the mesiobuccal groove of
the lower first molar.
The lower second molar:
The same inclinations and relation to the maxillary teeth as in the first
molar. However, the long axis inclination is more prominent.

First premolar Second premolar First molar
Procedures for setting-up the posterior teeth:
1) Mark the land areas of the mandibular cast with a pencil to serve
as a guide in tooth arrangement. With the mandibular record base
removed, place a mark on the land where the mandibular ridge turns
superiorly. This will represent the posterior limit for tooth arrangement.
2) With a pencil, use a ruler to mark the crest of the mandibular ridge
from the base of the retromolar pad to the canine area. This will identify the
crest of the mandibular ridge.
3) Replace the mandibular record base and occlusion rim, and using a
straight edge, extend the previous markings onto the wax rim to serve as a guide when arranging
the maxillary teeth. Repeat this procedure for the other side.
Arranging the Maxillary Posterior Teeth :
a. Place the right maxillary first premolar with its long axis at right angles to the occlusal
plane. The buccal and lingual cusps are placed on the plane.
b. Place right maxillary second premolar in like manner. Align e buccal surfaces of
premolars and canine with the edge of metal or plastic occlusal plane template.
c. The mesio-buccal and mesio-lingual cusps of the right maxillary first molar touch the
occlusal plane. The disto-buccal cuspis raised about 0.5 mmand the disto-lingual cusp
is raised about 0.5 mmabove the occlusal plane.
d. All of the cusps of the second molar are raised from the occlusal plane following the
position of the first molar. The mesio-buccal cusp should be about 1 mmfrom the
occlusal plane.
e. Follow the same procedure in placing the posteriors on the opposite side.
Buccal view; the maxillary posterior teeth arrangement. Right; occlusal view; buccal ridges of molars are
angled slightly inward from line extending along facial surfaces of canine and premolars.
Arranging the Mandibular Posterior Teeth :
The mandibular 1st molar is a key tooth in articulation. If careful attention is paid
to setting this tooth, it will facilitate considerably articulation of the remaining posterior
teeth.
a. Remove enough wax from the mandibular occlusion rim on the right side to have space
for the posterior teeth.
b. Set the right mandibular first molar in its correct position but slightly high in
occlusion. Close the articulator carefully to bring the mandibular molar into its proper
position. Guide it to the correct occlusal relation with the maxillary first molar and
maxillary second premolar, making certain that the incisal guide pin remains in contact
with the incisal table during all excursions.
c. Follow the same procedure in placing the right mandibular second molar and second
premolar.
d. In some instances, there is not sufficient space for the mandibular first premolar. For
esthetic reasons, it is usually advisable to grind the mandibular first premolar to fit the
available space rather than altering the anteriors.
e. Follow the same procedure in placing mandibular teeth on the left side.
f. Remove all wax from the teeth. Flame the wax to smooth it.
Setting-up the mandibular posterior teeth.
Balancing the Occlusion
a. Set the mechanical incisal guide table of the articulator.
b. To balance the occlusion, place the articulator in the right working position. Check the
working side contacts on the right side and the balancing contacts on the left side. If the
occlusal plane and compensating curve are acceptable, you can reposition the mandibular
posterior teeth until you achieve good working side contacts.
If you find out that your contacts are not ideal, evaluate the position of the maxillary teeth
and correct the contacts by repositioning the maxillary posterior teeth.
c. Check the balancing side for ideal balancing contacts. If one or two contacts exist
between the buccal slopes of lingual cusps of the maxillary posterior teeth and lingual
slopes of buccal cusps of the mandibular posterior teeth, your balancing contacts are
acceptable.
d. Follow the same procedures for the left working side.
e. After stabilizing the lateral balancing contacts, put the anterior teeth in edge-to-edge
position.
You should have at least one contact bilaterally between the maxillary and
mandibular posterior teeth in protrusion
The position of the teeth relative to one another:
1. The six upper anterior teeth overlap the six lower anterior teeth by 2mm.this overlap is
in both a horizontal plane (overjet) and a vertical plane ( overbite).
2. The buccal cusps of the upper posterior teeth overlap those of the lower. The palatal
cusps of the upper posterior teethand the buccal cusps of the lower posterior interdigitate
with the opposing teeth.
3. Every tooth except the two lower central incisors and the two upper last molars
occlude with two teeth in the opposite jaw.
4. The labial surfaces of the six anterior teeth present a curve when viewed from the
occlusal surface, the shape of this curve depending on the shape of the underlying
alveolus.
5. the posterior teeth should be set up in such a way that their buccal surfaces will make
contact with a straight line drawn from the labial surface of the canine, backwards.
6. In any lateral or protrusive position of the mandible, contact between the teeth of the
upper and lower teeth is so disturbed that at least three widely separated points or areas of
occlusion must exist.
Other technique for teeth arrangement
Many texts describe setting the upper posterior teeth first. This procedure, however,
makes it necessary to make many adjustments and alterations when the lower teeth are set to be
in harmony with the oral environment.
Its recommended that the lower posterior teeth be set first for the following reasons:
1- The lower ridge offers reliable landmarks for setting the lower posterior teeth.
2- The position of the lower teeth is more critically limited.
3- Stability of the lower denture is more difficult because it has less support than the upper.
4- It is easier to set the correct compensating curve when the lower teeth are set first.
The following criteria are used as a guide for the setting of the lower posterior teeth:
Anteriorly : The position and height of the first right and left premolar are determined by the
lower anterior teeth, which were checked to be in proper phonetic and esthetic position. The
lower canine and first premolar should be at or very near the level of the commissure of the
mouth at rest and should support the corner of the mouth and the modiolus.
Posteriorly : The last posterior tooth should be just anterior to the apex of the retromolar pad.
Buccally: All areas of the posterior teeth that are buccal to the ridge crest should be tipped out
of occlusal contact for centric and working mandibular positions. This lingualizes the occlusion
and prevents lever activity that would tip the denture bases.
Lingually : The lower posterior teeth should not crowd the tongue or interfere with its normal
functions. The lower teeth are set with their central fossae over the lower ridge crest or slightly
lingual to it. The lingual surfaces of the lower posterior teeth are on vertical line with the
mylohyoid ridge, never lingual to it.
Occlusal plane
The anterior height of the occlusal plane is determined by the lower anterior teeth and the
commissure of the mouth. The posterior height of the occlusal plane should be at the level of the
center of the retromolar pad. The lateral border of the tongue at rest is a check for the proper
height of the occlusal plane.
The lower posterior teeth are set with no inclination so that the occlusal surface of the teeth is
horizontal in a transverse plane.
The use of these antroposterior landmarks also creats an occlusal plane essentially parallel to the
ala- tragus line.
At the time of try-in the lateral border of the tongue at rest is act as guide in evaluating the height
of the occlusal plane.
Compensating curve
The primary function of this curve is to provide balancing occlusal contacts for protrusive
mandibular position, so it helps in the stability of the lower denture.
The compensating curve incorporated in the properly oriented plane of occlusion starts with the
first molar by rising it at the distal and continuing with further rise in the second molar.
Lateral plane of the teeth
The occlusal surface is usually horizontal in a transverse plane.
Setting the mandibular posterior teeth
The correct relationship between the upper and lower canines acts as key to an ideal, anatomic
set-up of the upper and lower posterior teeth.
When upper and lower canines are correctly related, the mesial incline of the upper canine
opposes the distal incline of the lower canine. This is easily accomplished by selecting a
compatible width of the lower anteriors.
If, however, the lower anteriors are too wide, the lower canine as related to the upper canine is
distal to the ideal canine relationship. With this relationship the upper first premolar will be
spaced from the canine when it is set to the proper anatomic inter-digitated position with the
lower premolars.
This problem of a diastema between the maxillary canine and first premolar can be corrected by:
1- Selecting and setting narrower lower anterior teeth,
2- Grinding the distal of the lower canine, or
3- Narrowing the lower first premolar by grinding.
If the lower anteriors are too narrow, so that the lower canine is mesial in its proper relation to
the upper canine. The maxillary first premolar will occlude on the lower second premolar. This
can be corrected by:
1- Selecting and setting wider lower anterior teeth,
2- Grinding the distal of the upper canine when esthetic permits,
3- Narrowing the upper first premolar if esthetic permits, or
4- Movingthe lower posteriors distally.
Preparation of antroposterior guides
The occlusion rims should be removed to evaluate the inter-ridge space and arch form. A mark
should be placed on the distal shoulder of the lower cast as a projection of a line running from
the incisal tip of the mandibular canine to the apex of the retromolar pad. This reference line is
then evaluated in relation to the arch form. If any gross discrepancy exists between the position
of the reference line and the ridge crest, the position of the lower canines should be re-evaluated.
Procedures for setting the lower posterior teeth
Mandibular premolars
A narrow wedge of warmed wax is placed and luted with a hot spatula to one side of the
mandibular baseplate along the antroposterior reference line. Using a hot spatula, prepare a
heated wax bed for the first and second premolars. Set the teeth into this wax and manipulate
them into position so that the occlusal height matches the plane established by the mandibular
anterior teeth, with the buccal and lingual cusps horizontal. The central fossae should be in line
with the antroposterior reference line.
The maxillary first premolar should be set up so that its lingual cusp occludes on the marginal
ridges of the mandibular first and second premolars.
Mandibular molars
The mesial cusps of the first molar are on the plane established by anterior teeth and bicuspids.
The distal cusp of the first molar are raised about 0.5 mm above this plane. The buccal and
lingual cusps are set at the same height to make the transverse plane horizontal. The central fossa
is aligned with the antroposterior reference line.
The second molar continues the cuspal elevation of the compensating curve. The buccal and
lingual cusps are horizontal and the central fossa is aligned with the antroposterior reference line.
The same procedure is repeated for setting the lower teeth on the opposite side. The alignment
and cuspal heights must be symmetric on the two sides.
The marginal ridges of adjacent teeth should be at the same height to present a smooth transition
from tooth to tooth.
Procedures for setting the maxillary posterior teeth
First, set the maxillary teeth for proper position and static cusp contact in centric relation. Once
set and luted in place, they should be checked and refined for dynamic cusp contact in working,
balancing and protrusive movements.
Maxillary premolars
a- A small wedge of wax is heated and placed on one side of the upper posterior ridge and luted
to the upper baseplate. While the wax is still warm and soft, Place the first maxillary premolar in
position next to the canine and then gently close the articulator to its proper vertical and centric
position. The tooth is placed so that the lingual cusp fits into the lower common central fossa at
the midpoint of the distal marginal ridge of the first mandibular premolar and the mesial
marginal ridge of the second premolar. The buccal cusp is raised slightly out of contact.
b- Soften the wedge of wax with a hot spatula for the second premolar. Place the second
premolar into the heated wax and guide the lingual cusp into contact with the central fossa at the
midpoint of the distal marginal ridge of the mandibular second premolar and mesial marginal
ridge of the mandibular first molar (Figure 9-12). The buccal cusp is out of contact slightly more
than the first premolar.
Next, evaluate the functional occlusion. The maxillary buccal cusp should not contact in lateral
excursions. The only contacting maxillary cusps are the lingual cusps .
Maxillary Molars
The maxillary first molar is set with more buccal tilt than the maxillary second premolar. The
degree of compensating curve determines the amount of mesial inclination of the maxillary
molars. In centric occlusion, the mesiolingual cusp sets into the central fossa of the mandibular
first molar and the distolingual cusp contacts the distal marginal ridge of the mandibular first
molar and the mesial marginal ridge of the second molar. The maxillary second molar sets with
more buccal tilt and its mesiolingual cusp contacts the central fossa of the lower second molar
.
Once the teeth are set and luted in place, the right and left lateral excursions are checked. There
should be working and balancing contacts that are in harmony with the condylar incline and
incisal guidance.
The use of non-anatomic (zero-degree) posterior teeth
Non-anatomic posterior teeth were designed to minimizing the horizontal component of force
during mastication and during parafunctional movements.
The basic antroposterior guides and anatomic landmarks for flat teeth are the same as for the
cusped teeth. The upper teeth should be set on the lower ones flat-on-flat rather than with a
cusp on fossa as in cusped teeth. Buccal overjet of approximately half the width of the tooth
should be set to prevent cheek biting. The palatal portion of upper teeth should be in contact with
the center area of the lower teeth.
In the monoplane setup the traditional amount of anterior vertical overlap must be eliminated to
avoid anterior interference inboth lateral and protrusive movement.
Teeth arrangement for abnormal jaw relationship
I- Superior Protrusion Class II Angle classification (retruded mandibular relation)
Anterior teeth arrangement
The maxillary anterior teeth should be set up slightly
posteriorly and their incisor edges incline palataly.
The vertical overlap should be kept as small as
esthetics and phonetics would permit.
The lower canine is more distal in its relation to the
upper canine than in class I.
In severe retruded relations, it is advisable to leave out thelower central or lateral tooth
or to overlap lower teeth to obtain the correct cusped relationship.
Posterior teeth arrangement
Setting of the mandibular posterior teeth
The same criteria described for setting up the lower teeth are used for this case.
The lower anterior or posterior teeth should not be set to an exaggerated labial or buccal
position to avoid unfavorable lever movement of the lower denture during function.
Either anatomic, semi-anatomic, or flat teeth can be used for this case (semi-anatomic or
flat teeth are preferable).
The lower premolars are set first then the upper first premolar set with their lingual cusp
usually opposing the lower buccal cusp (Figure 9-17B). The upper second premolars are
usually set with less buccal overlap because the lower arch is not as far inside the upper
as the set up progresses distally.
When the premolars are set satisfactorily, arrange the lower molar to develop a
compensating curve that is in harmony with the incisal guidance and the condylar
inclination.
Setting the upper posterior teeth
The upper first premolar is set so that its flattened lingual cusp occludes with the
flattened buccal cusp of the lower first premolar .
The upper second premolar is set with the flattened buccal cusp of thelower second
premolar. The amount of maxillary buccal overlapdecreases towards the posterior.
The upper molars are set with their lingual cusps in the modifiedcentral fossae of the
lower teeth.
The lingual cusps are only the occluding elements on the upper teeth.

Use of flat teeth for class II relationship
A flat posterior tooth can be used effectively in class II relationship to increase stability
and reduce the force of occlusion when the lower ridge is severely resorbed .
Setting the lower posterior teeth
All the criteria used for positioning the lower posterior teeth in relation to the lower ridge
are applied to this situation. The only variation is the tilt of the posterior teeth.
To obtain lever balance during function, all the posterior teeth can be set with buccal tilt
(Pleasure curve). With this buccal tilt balancing contact is not possible. To obtain lever
balance and occlusal balance, a revised Pleasure curve should be followed (A buccal tilt
for thepremolars, a horizontal no tilt for the first molar, and lingual tilt for the second
molar.
The first and second premolars are set with lingual tilt to provide stable contact with the
lower premolars. The second premolar does not have as much buccal overlap as the first
premolar.
The molars are set as mentioned before.
II- Inferior Protrusion Class III Angle classification (protruded mandibular relation)
Anterior teeth arrangement
The anterior teeth should be set to be in an edge to
edge relationship.
The upper anteriors should be set more forward
than usual. The lower anteriors should be set as far
lingual as possible without interfering with the
tongue . with this treatment, the patient looks less
prognathic, except in extreme prognathism..
Posterior teeth arrangement
The problem of setting the teeth in class III is that, the lower ridge in class III is in an
abnormal buccal relation to the upper. This requires an atypical arrangement of the
posterior teeth. The buccal cusp of the upper is in the central fossa instead of the lingual
cusp cross-bite occlusion. This may occur either unilaterally or bilaterally depending
on the case.
Setting the lower posterior teeth
The lower posterior teeth are set according to the same criteria used for the normal ridge
relationship.
The first premolars are usually set in conventional relationship to the lower premolars.
The upper lingual cusp is set in the central fossa of the lower premolars. The cusps of the
upper and lower second premolars are flattened and are set buccal-to-buccal and lingual-
to-lingual. The upper molar are set in a cross bite relation.
In cross-bite atypical arrangement, either modified anatomic or nonanatomic teeth can be
used. The nonanatomic tooth is usually indicated when the lower ridge is poor and
markedly resorbed.
Combination of anatomic-nonanatomic posterior setup
The use of anatomic teeth for the upper posteriors and nonanatomic teeth for the lower posteriors
favor the penetrating efficiency of cusped teeth and the control of occlusal forces of the flat
teeth.
A flat incisal guidance or an adequate horizontal overlap is necessary to avoid anterior
interference during function.
Gum fitted anterior teeth
It means fitting the necks of the anterior teeth directly on the ridge of the model without using
anterior flange. It may be necessary for upper denture in cases of extreme undercut areas in the
anterior ridge areas. This will prevent raising the upper lip with poor esthetic results.
The absence of the anterior gumwork has a serious effect upon the retention of the denture in the
mouth. To help retention in these cases wings may be used.
Indication:
a)When normal positioning of the teeth make them too prominent.
b)When the presence of the minimum of gumwork presses the lip out more than
necessary, e. g. in tight-lipped patients.
c)In cases of inferior retrusion when the upper and lower anterior teeth can only be
approximated and overjet reduced by setting the upper anterior on the ridge.
d)In all cases of upper immediate dentures unless alveolectomy is to be earned out at the
time of extraction.
Technique:
Select teeth with a neck if possible. Place the upper centrals in their required position according
to the lip and center line and their relationship to the lower centrals, grind the neck if necessary.
Next grind the teeth so that it fits accurately to the ridge on the model. When it is well fitted hold
it in position and with a fine pointed instrument make a mark round the neck of the teeth, remove
the tooth and carefully scrape away plaster to a depth of not more than one-thirty- second of an
inch just below this mark. Replace the tooth into this depression. Repeat this procedure with all
teeth that are to be gum fitted.
The absence of the anterior gumwork has a serious effect upon the retention of the denture in the
mouth. To help retention in these cases, use may be made of wings. However, as they are of
necessity somewhat thin and hence easily broken, They should not extend too far towards the
midline.
Setting up the teeth for patients who already posses old denture which
have given satisfactory service
The most important fact to remember is not to reduce the tongue space. A satisfactory
method is to take an impression in alginate of the existing dentures and the technician will then
have a model of the dentures to guide him not only in relation to the position of the teeth but, of
equal importance, enable him to reproduce the color of the polished surfaces of the dentures. If
the teeth on the existing dentures have been set off to the ridge it is usually safe to copy them
because the patient will have become used to manipulating dentures with teeth set in this
position.
WAXING-UP OF COMPLETE DENTURES
Definition:
Waxing-up: is the process of waxing and carving of the trial denture into the desired form
to produce a denture base that reproduces the contour of the original tissues in the
dentulous mouthto produce a natural pleasing appearance.
Importance:
The form of the polished surfaces and the proper location and arrangement of the
artificial teeth play a major role in:
1- The aesthetic values of the denture.
2-The stability and retention of the dentures. Properly contoured facial and lingual
surfaces of complete denture allow the tongue, lips and cheeks to closely adapt
themselves to the denture surfaces and help in seating the denture.
Criteria for waxing up complete denture:
The following points should be considered in the waxing-up procedure:
1- The waxed denture should be anatomically carved, labially and buccally, to duplicate
natural gingiva with rounded interdental papillae.
2- The proper contouring of the denture will allow the tongue, lip and cheeks to adapt
themselves to the denture surface and to seat the dentures in place. Improper
contouring may result in disloging the denture.
3- The buccal and labial contours should be concave wherever possible so the lips and
cheeks will help in stabilization of the dentures.
4- The peripheral outline of the waxed denture should be rounded and extended to the
maximum depth of the sulcus without displacing the musculature.
5- The wax denture pattern should be carved as exactly as possible to the desired final
shape and bulk so that only minimal finishing and polishing are required.
Maxillary denture:
1. The peripheries are contoured as in the impression
and should be fully rounded, and highly polished.
2. The anterior portion of the maxillary denture base
should be shaped together with the teethtoprovide a
pleasing form for the lip. The labial waxing may be thickened in order to restore lost
facial contour.
3. The upper labial flange may be thickened by adding a
wax to support the lips and restore the lost facial
contour.
4. The buccal surface (from the first premolar
backwards) should face downwards and outwards. This contour allows the buccinator
muscle to lie against the denture and aids in its retention and stability.
5. Lingual festooning of the six maxillary incisors is highly desirable (especially with
porcelain teeth) to reproduce the normal lingual contours and length of the natural
teeth with their cingula and to reduce anterior palatal bulk, and improve phonetics.
6. The palatal thickness should be even and no more than 2.5 mm is required.
7. Wax is further added and carved to imitate the normal rugae contours of each
individual. An alternate method is to burnish a piece of stiff tin foil on the cast over
the rugae area and then transferring the duplication on the waxed palate. Prefabricated
rugae of different sizes in plastic or metal may be also used.
8. The wax is craved at the cervical line of the artificial teeth to simulate the natural
appearance of the gingival margin and gingival papillae. The gingival papilla should
be convex both occlusogingivally and mesiodistally and should fill the interproximal
space below the contact point.
9. The wax above the roots should be contoured to
simulate the root prominences present in
dentulous mouth. The root prominences should
fade out before the borders are reached. The
cusped eminences are the most definite
prominences in the dental arch to support the lip.
10. Stippling of the facial surface of the waxed up denture is made to simulate the natural
gum (Orange- peel effect). Stippling reduces the shiny appearance of the denture base
material when the denture in mouth and produces a better esthetic results. . However,
stains and calculus may deposits on these roughened areas.
Mandibular denture:
1. The labial surface should be slightly concave as possible to minimize the pressure of
the lower lip on thedenture, possibly causing its displacement. The peripheries should
be fully rounded and highly polished. Thin edges should be avoided.
2. The lower labial flange should not be thickened to minimize the pressure of the lower
lip on the denture which may cause displacement of the lower denture.
3. The buccal surface must be kept flat and wax thin in the premolar region. In the molar
region the wax may be thickened and widened and the surface must face outwards and
upwards.
4. The lingual flange of the mandibular denture should have the least possible amount of
bulk, except at the border which must be quite thick. However, the borders at the
lingual pouch area should be thin so that it does not interfere with normal tongue
movement.
5. The border of the lingual flanges should have considerable thickness to enhance the
seal of the lower denture with the floor of the mouth. There should be no concavity
directly beneath the teeth since the tongue may lie in this undercut and disloge the
denture. A slight concavity away from the teeth in the middle of the flange is
desirable.
6. The contour of the lingual surface must be slightly concave facing downward and
inward without extending the concavity under the lingual surface of the teeth
(concavity in the middle of the flange). A concavity under the teeth acts as an undercut
into which the patient's tongue will slip, thereby causing the denture to be unseated.
7. The wax should be extended to cover the maximum area possible in the retromolar
region.

Left; the labial and lingual flanges are slightly concave. Middle; correct contouring of buccal (B) and lingual
(L) flanges in molar region. Right; incorrect contouring of buccal and lingual flanges in molar region.
Technique of waxing-up complete denture:
1- Spot- lute the base plate to the cast.
2- Bulk waxing; add excess wax to buccal, labial, palatal and lingual aspects of the teeth of
maxillary and mandibular dentures.
3- Gingival trimming; cut round the necks of the teeth at the junction of the crown with the
collar, starting at the second molar of one side and working round to the other side. Then wax
in the palatal and lingual aspects of the teeth is carved around the necks of the teeth.
4- Contouring (Festooning): The gingival margin contouring is made with a wax knife or
wax carver at an obtuse angle to create a definite ledge with uniform width of approximately 1
mm. The gingival papilla and root eminences are also shaped.
5- Shaping the trial denture flange: The labial and buccal flanges are carved to their
approximate thickness. In a normal case a thickness of 2 mm. labially and 3 mm. buccally is
required. Also the lingual flange of mandibular denture is cut to the desired form.
6- Palatal contouring: The wax palate is cut and replaced with a new sheet of wax. This will
ensure a palate of uniform thickness and reduce the bulk of the denture in this area to a
minimum.
Before replacing this palate, any relief foil should be cut, and cemented on the model. Also
scraping of the model for post-dam should be carried out.
7- Stippling: Stippling is produced with a tooth brush placed on lightly flamed wax surface.
8- Polishing the wax surfaces: Preliminary smoothing with a slightly warmed wax knife
may be followed by careful passing it on a fine flame from a wax torch. A high finish may be
given to the wax by polishing with soapy water on cotton wool.
9- A check of occlusion of teeth must be carried out. It may be found that the contraction of
the added wax have caused slight movement of the teeth.
10- Tooth cleaning: Wax solvent is used to remove any wax film from the surface of the
teeth. Otherwise, base material will adhere to the teeth making finishing procedures difficult.
COMPLETE DENTURE THEORY AND PRACTICE Try-in 10
Try-in stage
All details in the waxed-up denture should be checked and the necessary
adjustments and alterations should be made as it is difficult and sometimes impossible
to do alteration in the finished dentures.
The following steps should be checked before the try-in stage:
1- Check the casts:
The casts should be in a good shape free from air bubbles and
scratches.
Each cast must be carefully examined and the necessary correction
should be done. [See: Treatment of final casts]
The casts should be free from wax spots on the palate or ridges,
because these spots may give false information in the try-in stage.
When Wax spot are attached to upper and lower casts, the occlusion of
teeth looks perfect on articulator. But when the wax are left attached to
casts, the occlusal vertical dimension will be incorrect
2- Check the case on the articulator:
- The mounting rings are firmly secured in their places.
- incisal pin of the articulator is in its proper place contacting the
incisal guide table i.e. vertical dimension is correct on articulator
- When the articulator is in centric position, the articulator's joints are firm
and not loose; i.e. no movement is in centric position except hinge movement.
- trial denture bases lie properly on casts and teeth meet evenly in centric.
- If the casts are mounted on an adjustable articulator, the horizontal and
lateral condylar path inclination should coincidewith the readings obtained
from the eccentric jaw relation records and the readings registered on casts.
The articulator moves smoothly from centric to eccentric positions without
interlocking of the teeth.
3- Check the trial denture bases on the casts:
- Trial denture bases should be stable on their casts
- Theperiphery of the trial base should be smooth and rounded.
- Denture base Should not be convex in shape
4- Check the teeth
- Check the teeth shape, size and shade.
- Check that the lower teeth are properly set on the ridge.
- The upper anterior teeth should overlap the lower anterior
teeth, but without contact between them. The only exception is
whenthere is edge to edge.
- The maxillary central incisor should be 8-10 mm anterior to a
linebisecting the incisive papilla.
- There should be maximum interdigitation buccally and
lingually.
The incisive papilla act as a guide line to proper placement of
the maxillary central incisors
- The lower posterior teeth are set with their central fossa over the lower
ridge crest or slightly lingual to it, to increase the stability of the lower
denture.
- The lower posterior teeth are set with no inclination so that the occlusal
surface of the teeth is horizontal; in a transverse plane.
- Evaluate the functional occlusion. The maxillary buccal
cusp should not contact in lateral excursions. The only
contacting maxillary cusps are the lingual cusps . The
maxillary buccal cusp is out of contact and the maxillary
lingual cusp contacting the central fossa of the lower
posterior teeth.
- Check for free articulation and balanced occlusion i.e. no interlockingfrom
centric to eccentric.
Trying the waxed dentures in the mouth
1- Check the upper denture alone for:
a- Peripheral extension and retention.
b- Stability to vertical occlusal stresses.
c- The height and inclination of the occlusal plane in relation to ala-tragus and
inter pupillary lines.
d- Alignment of the teeth and the support of the facial musculature.
2- Check the lower denture alone for:
a- peripheral extension and retention.
b- Stability to vertical occlusal stresses.
c- Neutral zone and tongue space.
d- Height of the occlusal plane in relation to
function movements of the tongue.
3- Check both dentures together for:
a- Vertical dimension. b- Centric relation
c- Eveness of occlusal pressure. d- Balanced articulation.
e- Appearance of face and teeth:
- Central line.
- Shape, shade and size of the teeth.
- Regularity of the set-up.
F- Phonetictests.
4- Patient's approval:
During trying the denture in the mouth, it is important that waxed up dentures should
be frequently placed in cold tap water as wax softens at mouth temperature and, if left
in the mouth too long, the teeth may be displaced.
It is important that waxed-up dentures should be frequently placed in cold water as
wax soften appreciably at mouth temperature and, if left in the mouth too long, the
teeth may be displaced.
The trial denture bases can be stabilized by having a zinc oxide lining impression of
the cast as follows:
- The cast is first tin foiled
- The zinc oxide paste is mixed and applied to the fitting surface of trial base.
- The trial base is replaced on the cast and the articulator is closed in centric.
1- Check the upper trial denture base alone for:
A- Peripheral extension and retention:
Retention
Better information is gained if the trial denture bases are made on the final
denture bases.
If other denture bases are used, their retention expected to be inferior to
retention of the finished denture bases.
Peripheral extension
The entire periphery should be rechecked at the try in stage to ensure that
it is not over-or under-extended.
An over extended denture tends to move away from the tissues when the
seating pressure is removed.
Denture extension can be checked by:
A- Visual examination of the parts that can be easily seen as the labial flanges (after
slight raising of the lip).
b- Palpation of the not-easily seen flanges, such as the buccal flanges.
c- Testing paste as thin mix of alginate, or zinc oxide eugenol paste (thewhite tube
only) and disclosing waxes are useful material. Coating the periphery with a pressure
indicating paste and instruct the patient to perform few functional movements. The
paste or alginate will be wiped off at the overextended area.
d- Ulcer developed in over extended area: after denture insertion.
e- Use indicator medium, indelible marker, and indelible sticks to mark the inflamed
or ulcerated area which then transferred to denture border
e-Apply disclosing wax to the borders of the maxillary denture
f- Clinical examination
To cheek the buccal and labial periphery:
1- Hold the denture in place with light pressure on the occlusal surfaces of the
teeth, and move the cheek on one side gently, but firmly, upwards and inwards, thus
simulating the motion it makes when chewing.
2- 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.
3- Repeat for the opposite side and for the lip.
Thebuccal aspect of thedentureshouldtaketheformof agentleconcavitylookingoutwardsand
upward.
To examine the lingual flange of lower denture for overextension:
Instruct patient to protrude tongue slightly until the tip rests upon the lower lip
Place your index fingers on the occlusal surfaces of the lower teeth to determine if
the lower denture remains firmly seated on the denture-supporting structures
If the denture lifts, consider 3 possiblities:
Overextension in the region of the genioglossus muscle (contracts w/ forward
movement of the tongue to dislodge denture) Anterior portion of denture lifts
Overextension in the region of the premolar-molar area (denture dislodges
by contraction of mylohyoid) Entire denture lifted from position
Overextension of the extreme distolingual border of the lower denture
(dislodgement of the forward movement of the retromylohyoid curtain) Entire denture
dislodged from position and moved forward
Checking post-dam area:
First; the seal must be made in the upper cast.
The trial base should fit fully into the groove of the cast and The posterior limit of
the post dam is marked with a moisten indelible pencil.
Insert the trial denture into the place and ask patient to say Ah.
Remove the trial denture and note the position of the indelible line; The mark
should extend from one hamular notch to the other passing by the fovea palatine.
B- Stability to occlusal stresses and relief area:
Alternating vertical pressure isapplied with the finger on the premolar-
molar regions,
if, this vertical pressure causes the denture to tilt and raiseon the other
side this indicates that the teeth on the side of the applied pressure are
outside the ridge.
If the denture teeters on the middle, it indicates that the relief area is
not adequate.
An alginate test may help to show the denture areas that are seated first and the areas
that need relief.
C- The height and inclination of the occlusal plane :
Height of the occlusal plane [see factors affecting the height of occlusal plane]
For a patient with an average length of upper lip, 2mm of the incisors should
be seen, when the lip is at rest. For a patient with a short lip, perhaps 5 to 6
mm of the incisors should be seen.
Long upper lip may necessitate complete coverage of the anterior teeth, but if
possible their incisal edges should be seen.
Inclination of the occlusal plane
When the length of the plane of occlusion is established, the plane of
occlusion should be parallel with theinter-pupillary line in the front and with
the ala-tragus line on both sides.
Phonetics may be used as an aid in the placement of the maxillary
anterior teeth. E.g. the incisal edge should be positioned so that the F ,
V and PH sounds can be correctly pronounced. These sounds serve as
an excellent test or guide line for determining the proper plane of
occlusion and placement of anterior teeth.
The lower lip is brought into contact with the incisal edge of the upper
anterior teeth during producing of F,V and Ph sounds.
D- Alignment of the anterior teeth and the support of the musculature:
Arrangement of teeth on the articulator gives only partial indication of the way
the teeth will look in the patient's mouth. A better idea is obtained after the
teeth are tried in the mouth and examined with the movement of the lips.
The position of teeth should be in harmony with muscle activity during
swallowing, speaking, laughing, smiling, etc.
The vermilion border of upper lip, angles of the mouth, philtrum and the
nasolabial sulcus should assume a normal contour.
Insufficient lip support : Result of setting the anterior teeth too far posteriorly or
improper waxing up . Characterizedby drooping or turning of the angle of the mouth,
deepening of nasiolabial sulcus, and wrinkles above the vermilion border.
Placing or tilting the anterior teeth more labially and/or proper waxing up of
the flange will improve the appearance.
- Excessive lip-support due to forward placement of anterior teeth or excessive
waxing up of labial flange is characterized by stretched tight appearance and loss of
contour of philtrum.
E. Certain aspects that require to be checked as a routine.
The centre line (the relation between the incisor and midline)
Tooth shape, shade and size as well as the appearance of the face
should be checked.
2- Check the lower trial denture alone for:
A- Peripheral extension and retention:
Denture extension can be examined by many methods as in checking the
upper trial denturebase.
To cheek the lingual periphery
Hold the denture in place with light pressure and ask the patient to protrude the
tongue sufficiently to moisten his lips;
if the denture lifts at the back, it is overextended in the region of the lingual pouch.
Next, ask the patient to put thetip of his tongue as far back on his palate as possible,
if the denture lifts in the front, it is overextended anteriorly; probably in the region of
the lingual frenum.
Ask the patient to place his tongue -successively in each superior buccal sulcus; if
the denture lifts, the lingual extension is deep.
Retention
- A better idea about retention of the lower denture is gained if the patient opens
his mouth slightly and let his tongue touch the cingulae of the lower anterior
teeth.
- Applying outwards pressure on the canine area gives an idea on the retention
of the opposite retromolar area.
Do not break the peripheral seal, by pulling the lips or cheek, during testing the
retention of the dentures.
Properly contoured denture flanges help stability and retention of dentures. The
tongue and the buccinator muscle act favorably upon long concave denture flanges. In
this case the muscle forces are directed to seat the denture.
B- Stability to occlusal stresses
Applying vertical pressure with the ball of the index finger
in the premolar and molar regions of each side alternatively
can check stability this test is used to determine:
If there is warpage in the denture base, the trial denture bases
teeter.
If the vertical occlusal stresses are transmitted outside the ridge the base will
rise on the other side.
Similarly when the mandible moves to one side, there should be contact between the
tooth on the working side and the balancing side.
C- Neutral zone and tongue space:
Neutral zone
The neutral zone is the potential space between the lips and cheek in one side
and the tongue on the other side. Natural or artificial teeth in this zone are
subject to equal and opposite forces from the surrounding musculature.
Tongue space
Test for cramped tongue: 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.
- Movement caused by lingual overextension does not occur until the
tongue has risen some distance.
The causes of tongue cramping:
a- Posterior teeth set inside the ridge.
b- Molar teeth, which are too broad buccolingually.
c- Molar teeth leaning inwards.
D- Height of the occlusal plane in relation to function movements of the
tongue.
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.
Test for correct height of occlusal plane
The patient is asked to place the tip of his tongue behind the lower
anterior teeth and to relax his tongue. The tongue should lie slightly on
the top of the posterior teeth.
If the tongue lies lower to the occlusal plane, it tends to raise the lower
denture from its seat during function; the patient will be unable to
control his lower denture.
E- Ensure that the heels of the lower denture are extended as high up the
ascending ramus of the mandible as practicable. The purpose of this is to buttress
the denture against the backward pressure of the lower lip.
3-Check upper and lower trial denture base together:
a- Centric occluding relation:
Vertical dimension:
The vertical dimension is checked by using the methods used to record the
vertical dimension. When the teeth are in centric occluding relation the
patient's face should produce a pleasing appearance.
When the mandible is in rest position, there should be an interocclusal space
of at least 2mm. The patient should be able to speak without clicking of the
teeth. Clicking of the teeth during speech indicates an excessive occluding
vertical dimension.
-Centric relation:
Ask the parient to relax and try to touch the back of the upper denture with the
tip of the tongue and slowly close the teeth together, making sure that the
bases are stable without movement.
The teeth should interdigitate in the same way as they do on the articulator.
If centric relation is found wrong and the teeth do not occlude into centric
occluding relation in the patient's mouth as they occlude on t he articulator, a
new mouth record of centric occluding relation must be obtained and the
Mandibular cast detached and remounted according to the new record.
Remounting the Mandibular cast according to a new mouth record.
-Remove the Mandibular posterior teeth from the lower
trial denture base.
-Place a small amount of softened wax to replace the
posterior teeth.
-A new record of centric relation is obtained at the
accepted vertical dimension of occlusion.
-The lower cast is detached from the articulator.
-The lower cast is then remounted on the articulator according to the new centric
record.
-The lower posterior teeth are then set up in their new position. The waxing up is
completed. Then the trial dentures are ready for a new try-in.
b- Eveness of occlusal pressure:
To maintain stability of complete dentures, the opposing teeth must meet
evenly on both sides of the dental arch.
This uneven bearing may be due to:
- Unequal pressure on the two sides of the occlusal rims during
registration of COR.
- The trial denture bases are touching heals.
- Errors in seating of the trial denture bases on their casts. This may due
to warpage of the bases ore presence of wax and debris on the casts.
- Errors in mounting thelower cast on articulator.
It is rather difficult to test for the exact equilibrium of the occlusal pressure,
due to the resiliency of the mucosa.
1. The common practice is inserting the blade of the wax knife between
the occlusal surfaces of the upper and lower dentures; this denotes
gross error in the record of centric occluding relation.
2. Another method is to place two pieces of thin celluloid strip between
the teeth in the molar region on each side. Request the patient to close
in centric occlusion while the celluloid strips remain in place.
- Try to remove the celluloid strips simultaneously by pulling
them out between the closed teeth, holding one strip with each
hand.
- Any difference in the force required to remove the strips is
interpreted in terms of oclclusal pressure. Equal forces mean
equal occlusal pressure. Repeat the test in the premolar region.
3. Stabilize the upper and lower dentures with the thump and index
fingers of both hands. Request the patient to close gently and slowly,
and to stop closing at the first tooth contact.
To correct any unevenness of occluding pressure:
If it is very slight, this can be corrected by grinding the teeth after the denture is
processed.
If the unevenness is more than slight, better take a new centric relation record at this
stage. Remove the lower back teeth, replace by softened wax, and remount the lower
cast.
To test whether the front of the denture is rising slightly from the ridge
when the back teeth are occluding, insert the point of a wax knife between
the upper and lower incisors and attempt to push the upper denture upwards
and the lower denture downwards. Any appreciable movement may be
interpreted as excessive pressure in the region of molar and premolar teeth.
c- Balanced Articulation:
With the teeth in a lateral position of occlusion, insert the point of a
wax knife between the teeth on the balancing side and attempt to
separate them; if they do separate, it shows that the occlusion of the
teeth on that side is apparent only and is resulting from the
displacement of the denture bases from the ridges.
The cause of this error may be due to either to an incorrect face bow
recording or to an incorrect condylar path registration.
When the error is considerable, this registrationmust be taken again, the models
remounted on the articulator and the teeth reset; but if error is only slight it may be
corrected by selective grinding after dentures are finished.
d- Appearance of face and teeth:
The face should be studied in front view, in right and left lateral profile views.
The effect of the denture and teeth alignment is noticed while the face is at
rest and while performing various facial expressions.
This includes
- The study of the position of the central line, The central line should
coincide with the general center of the face and the middle of the philtrum.
The central line of the lower denture should coincide with that of the
upper.
- Shape, size and shade and position of the selected teeth. The shape and
size of the teeth should be in harmony with the shape and sizeof the face.
The color of the teeth must be in harmony with the color of the skin, hair
and eyes of the patient. f- Profile. Observe the patient's profile and note if
the lips are either excessively distended or unduly sunken.
- Amount of teeth visible. Ask the patient to smile and note how much
tooth shows.
- Regularity of teeth. Few natural dentitions exhibit perfection and to
perfect a set up in the incisor region, especially in persons of middle age,
tends to emphasize that the teeth are artificial, therefore a little
irregularities is usually desirable.
e- Phonetic tests:
One of the main objectives in complete denture prosthesis is correction of
speech defect.
Bad denture produces speech defects due to one of the following:
- Improper arrangement of the teethin the dentures.
- Improper thickness and shaping of the denture base specially that
part covering the hard palate.
- Faulty extension or fit of the dentures.
- High dimension of occlusion.
- Lack of tongue space.
The position of artificial teeth and contour of denture base affects the
production of speech sounds. These tests involve principally the production of
S and F sounds.
Bilabial sounds . B, P, M are the sounds where the two lips contacts.
Labiodental sounds . F, V are the sounds shows the relationship of the
incisal edges of the maxillary incisors to the lower lip.
Linguodental sounds . eg Th are the made with the tip of the tongue
extending slightly between the upper and lower anterior teeth.
Linguoalveolar sounds . T , D, S, Z, V, L are the sounds which makes the
contact of the tip of the tongue with the most anterior part of the palate.
4- Patient's approval:
The patient should give his approval. It is advisable to ask the patient
to bring a relation or a candid friend with him at the time of trying in
the dentures and the approval or criticism of this second individual
should be sought as well as that of the patient himself.
Aesthetic (anterior) trial dentures: may be done at first to cheek
aestheticand phonetic.
Eccentric jaw relation records and establishment of posterior palatal
seal may be done at try in stage
Denture marking
Markers in dentures can be of immense value for the identification of:
Dentures in dental laboratories, hospitals and care homes.
Individuals following loss of consciousness, memory or life.
Identification of dentures in dental laboratories
This is important in dental laboratories where large numbers of dentures are
being processed. This procedure is widely practiced by technicians and does
not require instructionsfrom the dentist.
Identification of dentures in hospitals and care homes
The ability to identify dentures in hospitals and care homes where elderly and
confusedpatients, and sometimes staff, commonly misplace the dentures is of
great value. Losses are particularly regrettable because the dentures may be
virtually irreplaceable as a result of an elderly persons difficulty in adapting
to new dentures of different design. And yet, surveys into the marking of
dentures in care homes showed that this had been done in only 3547% of
cases.
An identification mark allows a misplaced denture and its owner to be
reunited.
The following steps should be taken routinely to reduce the considerable
number of dentureswhich are actually lost.
(1) The care program for the patient should record whether the patient
possesses dentures, whether they are usually worn and whether they are with
the patient rather than being looked after by relatives.
(2) There should be an understanding within the care team that dentures are
normally in one of two places either in the patients mouth or in a clearly
labeled denture pot. If not a search must be made urgently as the precious
dentures could easily have beenwrapped up in dirty linen or be languishing in
a waste-paper basket.
Identification of individuals
Dentures can be marked to allow identification of patients following loss of
consciousness, memory or life. For this system to be fully effective, the marker needs
to be indestructibleand to incorporate a code which is universally acceptable. As the
latter requirement has not been fulfilled at the present time, such markers are not
widely used ingeneral dental practice. However, they are routinely used in the Armed
Forces and are regulated by law in Sweden, Iceland and in many states in the USA
(Borrman et al.1999).
Requirements for denture markers used for this purpose include that they are:
Biologicallyinert
Inexpensive
Widelyavailable
Easyto inscribe
Retrievableafter an accident
Ableto survive elevated temperatures.
Identification marks fall into two broad categories, surface markers and inclusion
markers.
Surface markers
(1) Scribing the cast.
Marks may be produced on the impression surface of the dentureby scribing
the cast before processing the denture.
The irregularities produced on the denture surface are clinically undesirable
and therefore should be reserved for identifying dentures in laboratories after
processing.
The marks should be removedbefore delivering the denture to the patient.
(2) Pen or pencil.
Marks on a denture can be made by writing with either a spirit-based pen or
with a fine pencil. However, pencil marks require protection with a polymer
varnish. Both techniques offer relatively short-term benefits.
Exposure of spirit pen marks to hypochlorite cleaners can result in rapid
fading. Also, there can be a rapid loss of definition of both pencil and spirit
pen marks if an abrasive cleaner is used. Thus, unless the marks are checked at
regular intervals and renewed as necessary, the methods are perhaps suitable
only for the identification of dentures belonging to patients admitted to
hospital for a short stay.
Inclusion markers
Names can be written or typed on metallic markers, such as the stainless steel
strip of the Swedish ID-band, which has become an international standard and
FDI-accepteddenture marking system (Thomas et al. 1995). Alternative, non-
metallic materials that have been used include tissue paper and ceramic
materials.
Inclusion markers can either be incorporated into a denture at the time of
processing or can be inserted into the processed denture by cutting a recess,
inserting the marker and covering with clear cold-curing acrylic resin. They
should be placed posteriorly in the lingual or palatal areas of the dentures. In
this position, the stresses induced by the markers are unlikely to cause
significant weakening of the dentures. Furthermore, themarkers are less likely
to be destroyed in the event of the patients death by burning.
If identification marks of the inclusion type are required, the appropriate
request must be made to the technician when the trial dentures are sent for
processing.
COMPLETE DENTURE THEORY AND PRACTICE Processing11
Processing Dentures
A- Flasking (investing the denture)
Flask : It is a metal to make sectional mould for processing acrylic resin during
fabrication of denture base and other prosthetic appliances.
Purpose of flasking:To produce a mould of the waxed-up denture for packing and
processing of the acrylic material.
Technique of flasking
The denture should be correctly sealed to the casts by wax to prevent any
plaster or stone from flowing underneaththe trial denture baseduring flasking.
The casts are separated from the articulator and trimmed to fit the flasks
selected. In all cases the cast should be tapered to facilitate deflasking.
Select a flask that is big enough for the model, allowing at least half an inch
between the teeth and the flask edge. The trial denture is tested in the flask to
establish its height in relation to the height of the flask.
The inner walls of the flask should be smeared with a silicone mold release
(separating medium) instead of petrolatum which may contaminates the necks
of the teeth during boil-out. (Some author consider Vaseline as separating
media)
Flasking should be done using only dental stone which is 2 to 3 times
stronger than plaster, more accurate and limits tooth movement better.
The model should be soaked in cold water for 5 minutes so that the flasking
plaster will not come into contact with a dry surface and set prematurely.
The tapered base casts should be covered with soap or
separating agent from the sides and base to facilitate deflasking.
The shallow section of the flask is filled with plaster, and the
model is placed in it. The plaster must reach the edges of the
flask and brought up to the periphery of the wax
Generally, three pours work best.
- The first one should be leveled with the land area of the cast and the lower
half of the flask.
- The second pour is placed over the teeth and wax surfaces and vibrated to
remove any air bubbles, which produce a rough surface of the denture.
- The third one should fill the top section with plaster and excess plaster is
wiped away so that the flask edges are visible and the two sections are
closed together
Soap or plaster separator (not petrolatum) should be used between each of the three
separate pours. A thin layer of silicone painted on the denture immediately before
adding the second pour is desirable to decrease tooth movement and polishing time.
Place the lid on the flask firmly and tap it gently to ensure the flask has been
completely filled, and then allow plaster to set
The top half of the flask is placed in position to ensure that the teeth are not too high
in relation to the top of the flask. If the teeth are too high, the cast must be reduced in
thickness. The artificial rim of the cast should be flush with the bottom half of the
flask to prevent possible breakage of the cast in later separation of the two halves of
the flask.
B- Wax elimination (boil-out)
After setting of the flasking stone, the flask is placed in boiling
water for 3-5 minutes maximum so that wax is not permitted to
penetrate intothe dental stone from prolonged heating.
The flask is then removed and carefully opened and most of the
wax is removed. With a blunt end of plaster knife separate the
flask. It is placed in the slot in the posterior border of the flask,
which is gently opened.
The remaining wax (mainly around the necks of the teeth and in
the ridge undercuts) is washed out with a stream of boiling water.
A brush may be used to remove wax in Spaces between the necks
of the teeth, which may prevent union between acrylic resin teeth
and the base material.
Hot detergent solution must be brushed on all inner flask surfaces,
Followed by clean hot water.
The flask is placed aside to cool
During cleaning, it is better to place the flask over some of fine gauze so that any
tooth that may be loosened by water will not be lost.
Application of separator in the mold
Separating medium is applied to flasking plaster and cast while flasks are
warm and wet (at about 45 degrees) to prevent absorption of monomer into
plaster.
Careshould be used to avoid painting any trace of separator on the teeth. Only
one coat of substitute is necessary on the tissue surface of the edentulous cast.
Advantages of separator
1- Prevents contamination of resin material with moisture during processing.
2- Pevents absorption of monomer into the plaster or stone.
3- Prevents the plaster or stone from attaching the denture by polymerized
monomer.
4- Facilitates separation of the denture from the stone.
Types of separation
a- Tin foil of 0.003 inch thickness, which is burnished to the surface.
b- Tin foil substitute, (sodium alginate solution) which may be applied while
the flask is warm and wet. Care should be taken to avoid painting any trace
of the separator on the teeth (resin or porcelain).
C- Mixing and packing of acrylic resin dough
1- According to the manufacturers recommendation. The correct
powder-to-liquid ratio (3.5 to 1 by volume) are mixed and
allowed in a closed container until the dough stage is reached.
2- By means of a measuring cylinder 6-8 c.c. of monomer is
placed in the mixing container. The polymer is added slowly,
the jar is tapped on the bench and stir to keep the color
uniform.
3- The lid is placed on the mixing vessel till resin reaches the dough stage. During
packing a clean hands and instruments are essential.
4- No more than 4-6 flasks should be packed from one mix of resin, the fewer the
better.
On mixing the polymer and monomer the mix
1. A sandy stage : where a fluid mass occur due to the settling of the polymer into
the monomer.
2. A stringy or fibrous stage: where the monomer starts to attack the polymer. In
this stage the mix is tacky, sticky and adheres to the sides of the mixing jar.
3. Smooth dough like stage: where the monomer diffuses into the polymer.
4. Rubber like stage: further penetration of the monomer into the polymer. In this
stage the acrylic resin cannot be packed or molded being too stiff.
The open flask method
1. The resin dough is packed into the upper half of the flask over the teeth. Two
pieces of cellophane paper, moistened in cold water, are placed over it, and the
two sections of the flask are closed together.
2. The flask is closed and slow pressure is applied until
the two halves of the flask are in contact.
3. The flask is opened, inspected and the cellophane is
stripped off the resin and the excess removed with a
sharp knife. Excess material should be carefully
removed with a sharp knife. Whenever deficiencies of
the material exist, more material is added.
4. This procedure should be repeated until the mould is
completely filled and the two halves of the flask are in contact.
5. The cast is painted with a separating medium and the
two sections of the flask are brought together and final
closure is carried out. No cellophane paper is placed at
this time.
Never add excess resindough prior to final flask closure. Excess resin causes
greater tooth movement, opening of VD, and fracture porcelain teeth.
On all trial and final closures, the press closing force must be applied slowly,
thus permitting adequate time for the acrylic resin dough to flow in the mold
and to become well compressed for optimum density. Rapid and forceful
closures cause poor compression and produce excessive tooth movement.
Once the final pressure has been applied to the material, it must not be
released. If this occurs then the flask opens slightly and a thickened denture
and altered occlusion is resulted.
Ideally the packed flasks should be allowed to stand for 30-60 minutes before
beginning the curing cycle.
The injection method:
In this method a sprue arrangement with a suitable flask is used. Acrylic
resin is constantly fed into the mould during processing through a plunger
and spring tension system.
D- Processing cycle (curing or polymerization)
The packed flask is heated in an oven or water-path; both the temperature and time of
heating must be controlled.
If the material is under-cured the denture may have a high residual monomer. This
should be avoided because:
A-Free monomer may be released from the denture and irritate the oral tissues.
B- Residual monomer will act as a plasticiser and make the resin weaker and flexible.
The rate of temperature rise must not be too high. Monomer boils at 100.3 C. The
resin must not reach this temperature.
polymerization reaction is exothermic, if we put a large mass of non-reacted materials
suddenly into boiling water, the temperature of the resin may rise above 100.3 C.
Vaporizing the monomer causes gaseous porosity.
One of the following processing cycles can be used:
1- Heat at 74 C for 9 hours.
2- Heat at 74 C for 1 hour followed by 30 minutes at 100 C.
3- Rapid curing method: In order to save time, laboratories are frequently using
rapid heating in boiling water for 20 minutes.
4- Heat at 72 C for 16 hours.
5- Heat at 72 C for two hours (most of the monomer is reacted) then the
temperature is raised to 100 C for one hour.
The acrylic resin can also be cured by microwave energy. In this case the flask
should not be made from metal because metal will prevent the microwave rays from
penetrating the flask to reach the acrylic resin.
Cooling
The flask should be cooled slowly on the bench. Sudden cooling is contra-
indicated to minimize internal stress and subsequent warpage of the denture.
Because on cooling, there is a difference of contraction between stone and
acrylic which causesstress within the polymer.
Deflasking
After cooling the two sections of the flask are opened
and the stone surrounding the denture will be carefully
removed.
The denture is left on the cast for laboratory
remounting. The processed denture and the casts are
returned to the articulator (laboratory remount) for occlusal inspection and
selective grinding.
Finishing and polishing
The excess must be removed with a large stone. Make the periphery and frenal
notches rounded so that no sharp edge will press against the mucosa. Also
check the fitting surface for any small bubbles of material and remove it.
Polishing in the first instance may be done with a brush wheel and wet
pumice.
The final polish being obtained with:
a- A rag wheel and felt cone with pumice are good for smoothing the
palatal portion of the upper denture.
b- A single -row brush wheel and a rag wheel about l/4inch (6mm) in
width are used with pumice to smooth the labial and buccal surfaces of the denture
without destroying the contour.
c- A final high polish is given all the surfaces with a rag wheel and polishing material
(Tripoli, tin oxide and water). Tripoli is a ground porous rock, which is mixed with
wax to form a brick of material.
Excessive heating resulting from fraction during finishing and polishing will
cause unnecessary denture base warpage.
The dentures should be placed in a fresh water bath for a few hours to leach
out any small remnant of residual monomer and to permit some water sorption
by the acrylic resin.
Dimensional changes of heat-cured acrylic resin are usually less than 0.2 mm.
Expansion in saliva (0.1 mm) plus thermal expansion to body temperature (0.08
mm) reduces the total discrepancy to only 20 um.
The new dentures are immersed in a cold sterilizing solution for 15 to 30
minutes before delivery.
Errors that may occur after processing of the dentures
1- Porosity of acrylic resin denture bases
Causes Packing of insufficient resin material in the mould.
Packing the resin in a sticky rather than a dough stage.
Too rapid rise of temperature in the initial stage of curing.
Lack of adequate pressure during polymerization.
2- Incomplete cure of the dentures
Causes
a- Inadequate time and temperature of curing.
b- Organic solvents in contact with the acrylicresin.
3- Bleaching of acrylic resin
Causes
a- Incorporation of the tin foil substitute with the acrylic resin on its surface.
b- Incorporating the jelly-like material of wet cellophane into the resin (this may
form on the cellophane when it is soaked in water for a long period).
c- Contamination of the resin material with some organic solvents.
d- Under cured acrylic resin due to incorrect time and temperature of curing.
4-The presence of fine pits in the resin
Causes
a- Lack of pressure.
b- Loss of monomer into the flasking material.
c- Immediate curing after closure of the flasks without allowing the packed
resin to bench set for at least an hour before curing.
5-Crazing of acrylic denture bases and/or acrylic resin teeth
Crazing of resin consists of the formation of small cracks, which may vary, in
size from microscopic dimension to the visible size, it indicates beginning of
fracture. Cross-linking of resin reduces this fault considerably.
Causes:
1. Stresses induced by the contraction of the resin around the tooth by rapid
cooling. Rapid cooling of the cured acrylic resin.
2. The use of solvents to remove wax from the mold before packing.
3. Contamination of the resin bases or teeth with certain organic solvents
(chloroform, acetone, etc.)
4. Rapid rise of temperature during initial curing.
5. Contamination of the acrylic resin with water during curing.
6. Fusion of the separator into the resin.
6-Color streaks in the resin material
Causes
a- Improper mixing of the monomer and the polymer.
b- Adding the resin material in layers during trial packing.
c- Contamination of the acrylic resin mix with dirty hands or instruments
7- A sandy appearance of the resin material
Causes
a- Incorrect powder to liquid ratio (not enough monomer)
b- Evaporation of the liquid.
c- Too much delay in curing after packing. (more than 1/2 hour).
8-Cracked or fractured teeth or denture base
Causes
a- Improper deflasking, as the use of hammer for removing the flasking material.
b- Incorrect flasking technique.
c- Too much monomer in the acrylic mix.
d- Rapid curing in the initial stage.
e- Rapid cooling after curing.
f- Knife blade hit teeth when removing stone cap.
g- Hammer used to tap denture out of the flask.
h- Packing the resin in the rubbery stage making the material too stiff.
i- Excessive and rapid application of pressure during trial packing.
9- Tooth movements:
Teeth may change its position during processing.
Causes:
The use of plaster instead of stone in investing the trial denture.
Incomplete closure of the flask.
Excessive and rapid pressure during trial closure.
Over packing of the mold with resin material before final closure.
10- Stone adhere to the surface of the denture
Causes:
Insufficient separating mediumon the mold before packing.
The application of separating medium contaminated with stone.
Incomplete elimination of wax during washing out thus rendering separating
medium ineffective.
11- Space between the teeth and resin base:
Causes: Delayed curing, leaving the flask without curing for a long time.
The application of separating mediumon the teeth.
Construction of Remounting Casts
Remounting casts serve as an accurate, convenient, and time-saving method
for reorienting completed dentures on the articulator for occlusal corrections.
All undercuts on the tissue surface of the dentures are filled with wet tissue
paper or wet pumice. Remounting casts of fast-setting plaster or artificial stone
are poured into the denture.
After the plaster has set, the excess is trimmed down to the border and the
dentures are removed from the casts. The block-out material is then scraped
from the undercut areas, and the dentures are cleaned.
With remounting index positioned on mandibular member of articulator,
the maxillary denture and remounting cast are placed in the plaster indications.
The maxillary remount cast is attached to the maxillary member of the
articulator by means of fast-setting plaster.
Alternative procedure:
To save time, the plaster index can be made when the wax up is completed just
prior to removal of the casts from the articulator.
After processing of the acrylic, the dentures are removed from the master casts
and are then finished and polished. When the remounting casts have been
made, the occlusal index is placed on the articulator.
The maxillary denture can then be attached to the upper member of the
articulator with fast-setting plaster.
REMOUNTING FOR SELECTIVE GRINDINGsee Occlusal Disharmony in denture
insertion
COMPLETE DENTURE THEORY AND PRACTICE Denture insertion12
Denture insertion
Fitting Complete Dentures
A- Examination of the Finished Dentures
B- Treatment at the Time of Denture Insertion
1- Elimination of Basal Surface Errors
2- Evaluating Borders
3- Elimination of Maxillomandibular Relation Errors
4- Correcting Occlusal Disharmony
5- Final Checks of The Prostheses
6- Patient education and management
7- Instructions to the patient
C- Review of Complete Dentures
Examination of the Finished Dentures
Prior to the placing of dentures in the patient's mouth, the dentures should beinspected to
be sure that
there are no imperfections on the tissue surface, Inspect for
spicules with gauze (snags)
the polished surface is smooth,
the denture flanges have no sharp angles and are not too thick,
Thedenture borders are rounded and smooth with no obvious overextension.
The occlusion of all complete dentures should be perfected before the patient is allowed
to wear the dentures.
Treatment at the Time of Denture Insertion
The patient should have been instructed to keep any previous dentures out of the mouth for
12 to 24 hours immediately before the insertion appointment to get the tissues healthy.
1- Elimination of Basal Surface Errors [fitting surface, Intaglio Surface]
The use of pressure indicating paste is essential to evaluate the accuracy of
tissue contact especially when
- bilateral undercuts on residual ridge interfere with initial placement of
dentures
- When pressure spots are present or suspected in the final
impression.
Dry the denture, The paste is brushed on the tissue surface of the
denture base in a thin layer. Leave streaks in paste
The denture is carefully placed in the mouth and pressure is applied
by the dentist on the teeth to reveal any pressure spots in the denture
base that would displace soft tissue.
Seat firmly over first molars (not palate) .Remove carefully from
oral cavity
A repeat recording should be made for verification of pressure spots,
and the denture base carefully relieved.
Pressure indicator paste should be used for every new denture, and any necessary adjustments
should be made before proceeding with the occlusal adjustment.
Reading PIP
Burnthrough (No paste left)
- Excessive pressure that should be relieved
Streaks remaining
- No tissue contact
- Other areas need to be relieved
Paste remaining with no streaks
- Acceptable contact
2- Evaluating Borders
The best way to detectan over extention:[ see :Denture extension in try in]
The borders are properly relieved to accommodate the frenum
attachments and the reflection of the tissues in the hamular notch area
and the dentures are stable during speech and swallowing.
Apply disclosing wax to borders of maxillary denture in the same
manner as impression compound or heavy bodied vinyl polysiloxane
material that wasapplied during border refining procedures.
Instruct the patient to open the jaws as in yawning, push the lower jaw forward, and move
the lower jaw from right to left.
Burn t hrough
Nor mal Contact
No Contact
Read the
Paste
Non-retentive
Denture
Whats Wrong?
No pal at al
contact
Flange in
1st
quadrant i s
short
3- Elimination of Maxillomandibular Relation Errors:-
Finished Dentures Exhibiting Incorrect Centric Relation
If the difference is not more than a 1/4 cusp it may be corrected by means of
selective grinding.
When the error is gross it will require the removal of all the posterior teeth from
the lower denture as follows:
A- If Acrylic Posterior Teeth Were Used:-
1- teeth are ground down and replaced with wax blocks for new CR registration.
2- The blocks are trimmed to the correct height by trial and CR is retaken.
3- The dentures are then re-articulated, and the block teeth are reset.
4- If the overjet resulting fromthe new record is abnormal, the lower front teeth must
also be removed from the denture and new teeth are reset.
B- If Porcelain Teeth Were Used:-
1- teeth are gently flamed playing the flame actually on porcelain and not acrylic base;
conduction of the heat through the porcelain softens acrylic without burning it.
2- The teeth are removed from the denture.
3- The teeth are then replaced with wax blocks as described before.
In most cases of gross error, the denture need to be completely remade.
Finished Dentures Exhibiting an Incorrect Vertical Dimension
If the occlusal plane of the upper is judged to be correct, a new lower denture with the
correct vertical height should be constructed.
If the occlusal plane is incorrect, new upper and lower dentures should be
constructed.
4- Correcting Occlusal Disharmony (Error)
Errors in Occlusion Can Result From:-
I- Clinical errorsin registering maxillo-mandibular relationship.
II- Errors in mounting models on the articulator.
III- Errors arising during processing of the dentures.
I- Clinical Errors:-
1- Record bases that do not fit accurately as a result of faulty adaptation or warpage of
the bases or the presence of intervening wax on the models.
2- A shifting of the record bases over displaceable tissues.
3- Record bases placed on abuse tissues that have been resulted from ill-fitting dentures.
4- Excessive pressure exerted by the patient during the registering of maxillomandibular
relations.
5- Unequal distribution of stress (uneven bearing) during registering of
maxillomandibular relations. This may be due to premature contact of record rims on
one side of the mouth insecond molar region of both sides or in incisor region.
6- Interference of the record bases in the posterior region during registeration
7- Tooth movement may occur when trying in the waxed dentures.
8- Patients not registering centric relation because of systemic factors such as muscle
spasm, abnormalities of muscle tonus, or because of inability of mental, aged, or
senile patients to understandinstructions-factors beyond the control of the dentist.
9- Failure to use the face-bow with subsequent need to change the vertical dimension of
occlusion on the articulator.
10- Errors in the transfer of rnaxillomandibular relation to the articulator.
II- Errors in Mounting Casts:-
1- Record bases that are not properly seated and secured to casts during mounting
procedures.
2- Occlusion rims not being definitely locked or keyed for correct orientation during the
mounting on the articulator.
3- Distortion of the wax used in sealing the record rims together. For this reason,
softened wax is preferred than soft type waxes because it hardens immediately after
sealing.
4- Interference of casts in the posterior region during mounting.
5- Articulator not maintaining horizontal and vertical relationship of casts e.g.
interfering wax or plaster or loose mounting ring.
6- Inaccuracies introduced by changes in the plaster used to mount the casts.
7- Articulator wears. All articulators are subject to wear and the older and more worn
the articulator the greater will be the errors in occlusion and articulation.
III- Errors Arising During Processing of the Denture:-
1- Irregularities in setting the teeth. The technician when setting teeth is unlikely to
produce a perfectly even contact in centric and lateral occlusions, some teeth will be
in good occlusion whilst other will be slightly out of occlusion, thus producing areas
of heavy pressure.
2- In waxing up. It is possible for teeth to move slightly due to the contraction of wax on
cooling, causing irregularities in the articulation and occlusion of completed dentures.
3- Tooth movement when flasking and packing.
4- Incomplete flask closure. Such an occurrence not only causes increase of vertical
dimension but also results in an upset balanced occlusion.
5- Warpage of the dentures by overheating them during polishing.
Treatment of occlusal disharmony
These errors in occlusion must be eliminated before the dentures are worn, so the soft
tissues interposed between the bone and the denture bases will not be distorted by discrepancies
in the occlusion.
One of the following methods may be used for correcting occlusal disharmony by selective
grinding:
I- Intraoral methods.
II- Direct remount.
III- Remount via new jaw relationship records.
I- Intra-Oral Methods
Methods of occlusal assessment
a-Visual
If a relatively large occlusal discrepancy is present, the dentist will be able to see this without
any difficulty. However, the existence of smaller faults may be deduced from evidence such as
slight tipping or lateral movement of the dentures as they occlude.
b-Patient perception
The patient should be asked if the dentures are contacting evenly. Many patients are able to
detect occlusal unevenness which is so slight that it could be overlooked by the dentist.
c. Feedback from mucosal mechanoreceptors.
A usually reliable guide to identifying occlusal imbalance in dentures is the patients sensory
nervous system, as the mechanoreceptors in the oral mucosa are capable of fi ne pressure
discrimination. They are generally able to detect the presence of a defl ective occlusal contact,
but may not precisely identify the specifi c site that should be adjusted. This will usually require
the use of articulating paper.
d Articulating paper:Articulating paper alone will not give as accurate
indication of premature contacts as some other methods, because:-
1- The resiliency of the supporting tissues allows the
dentures to shift; therefore, the paper markings are
frequently false and misleading.
2- The denture bases can move from the basal seat causing
the teeth in the opposite side of the arch or the opposite
end of the arch to contact prematurely and produce an
incorrect marking.
3- To place articulating paper on one side of the arch may induce the patient to
close to or away from that side. Articulating paper should be placed on both
arches, procedure sometimes difficult to do accurately
e- Occlusal Wax:
Adhesive wax is placed on the occlusal surface of the
mandibular denture and the patient is instructed to close
his mouth in centric relation.
Points of penetration may be marked with a lead pencil
and relieved where indicated. With this method one may
also locate points of interference during functional movements.
f- Abrasive Paste: The use of abrasive paste in the mouth has many disadvantages:-
1. The shifting of the base a result of a premature contact may result in altering the
occlusion so that centric occlusion does not correspond to centric relation.
2. Cusps that maintain the occlusal vertical dimension may be destroyed.
3. Abrasive paste is not selective.
Central Bearing Devices:
To overcome the disadvantages of the articulating paper and
occlusal wax the central bearing devices have been suggested.
It is similar to the intraoral Gothic arch tracer, used to correct
occlusal disharmony in the mouth. The central bearing pin,
works on a spring.
As the patient closes his mouth, the pin in the mandibular mounting should contact a
metal plate in the vault of the maxillary denture. Thus, by holding the maxillary denture
up and the mandibular denture down, the pin creates a tension before the teeth contact.
If a premature contact is made by one tooth, the dentures do not shift because the spring
holds the other teeth apart. The interceptive occlusal contacts are located with articulating
paper.
This method requires careful control of the patient throughout the procedure
Disadvantage of the intra-oral method:-
Shifting of the dentures over resilient supporting tissues in eccentric jaw positions will give
false markings. This is an excellent method for correcting occlusion in the centric position.
II- Direct Remount :( The Split Cast Method or Laboratory Remount)
Steps of direct remounting:-
1- During denture construction the bases of the working
models are tapered and indices are cut in them.
2- A separating medium is also applied to them before
mounting.
3- The working model can, then, be removed from the
articulator mounting with the waxed dentures.
4- Protect the indices by tinfoil during processing.
5- The working models can be returned to the original
plaster mounting of the articulator for selective
grinding after the dentures have been processed in acrylic resin and before
the models are removed for finishing.
This method will only correct errors arising during processing of the denture.
However, it will not eliminate errors produced by the impressions or jaw relation records nor it
will eliminate errors that develop when the dentures are removed from the casts or are polished.
III- Clinical Remount: (Remount via new centric relation record)
A- Clinical Remount with new face-bow record and new centric relationship without Tooth
Contact:
1- Construction of remounting casts and mounting of the upper denture:
a- The undercuts of the finished dentures are blocked out, separating media is applied and
the dentures are poured into dental stone.
b- Mount the maxillary cast on the adjustable articulator according to a new
face-bow record or remounting platform with the occlusal index.
With the remounting index positioned on the mandibular member of the
articulator, the maxillary denture and remounting cast are placed in the plaster indications.
The maxillary remount cast is attached to the maxillary member of the articulator by means
of fast-setting plaster.
2- Centric relation record and mounting the mandibular denture:
a- The upper and lower dentures are removed from the casts, and the upper denture is
seated in position in the mouth.
b- A strip of softened wax of double thickness is placed on the lower denture.
c- The lower denture is seated in mouth and patient requested to close in the retruded
position until teeth are almost in occlusion. It is extremely important that the teeth
are not allowed to make contact, for if tooth contact does occur the lower cusps
by moving along the cuspal inclines of the upper teeth may guide the mandible into
the position of occlusion to which the dentures were constructed and thus, if an
error exists, prevent the desired correction of maxillomandibular relationship.
d- The lower cast was luted to the mounting ring of the lower member of the
articulator by using the interocclusal record.
To make anew centric relation record
Ask patient to bite on cotton rolls for 10 min.
Guide mandible into CR several times.
Aluwax is placed on the post. Teeth of the mandibular denture.
3- Lateral or protrusive records:
a- A strip of softened wax of double thickness is placed on occlusal surface of the
lower denture.
b- The denture is placed in the mouth and the mandible is moved to the right lateral
position and closed almost to tooth contact.
c- A second template records the left lateral position.
d- If patient experiences difficulty in making lateral movements, then a single
protrusive record should be taken with mandible protruded about 1/4 inch.
e- These records are used to set condylar guide paths of the adjustable articulator.
B- Clinical Remount with Face-bow remounting index and new centric relationship
without Tooth Contact:
Face-bow remounting index construction:
To avoid making new face-bow record, plaster index is made when the waxing up of denture is
completed and tried-in in the patients mouth just prior to removal of the casts from the
articulator.
Technique:
1-The lower cast with its mounting ring is removed from the
articulator. And mounting jig is attached to the articulator.
2- A mix of plaster is placed on the mounting jig. The upper
teeth are lubricated and then closed into the soft plaster.
3- After the plaster sets, the articulator is opened. The imprints
of the teeth in plaster are checked and any excess plaster is
removed.
Remounting Maxillary Dentures
Place remount jig on articulator
Seat remount index on jig
Seat maxillary denture in index
Place remount cast into denture
Mount with plaster
In this technique the centric relation record, mounting the mandibular denture and eccentric
records are done as the first technique.
Sel ect ive gr inding
A- For anatomic teeth
The principles of selective grinding should be followed whether intra-oral or direct or clinical
remounting techniques are employed. There are only slight differences in the procedures
between the different techniques as follows:-
a- In the intra-oral technique, the occlusal disharmony is detected inside the mouth
of the patient. While the occlusal disharmony in direct and clinical remounting is
detected in the articulator.
b- The incisal pin should be kept in place in direct remounting to be a guide for the
predetermined occlusal vertical dimension. The incisal pin should be removed in
clinical remounting as new records are undertaken in the present of occlusal
discrepancy and while the opposing teeth are not making contact. Thus, the
presence of incisal pin will not allow any selective grinding to be done to correct
occlusal disharmony and reducing the vertical dimension to the original
predetermined vertical dimension.
I-Grinding In Centric Occlusion:
Articulating paper is used with an open and close movement of the articulator or the
mandible in intraoral method, to discover any traumatic points on the occlusal surfaces of
the teeth. These are removed until even contact throughout the arch is obtained.
In case of direct remounting, contact of the incisal guidance pin on the incisal table
indicates that the correct vertical dimension has been re-established
In the posterior segment the surfaces to be reduced are selected according to two basic
rules:
a- If the cusp is high in both centric and eccentric occlusion, reduce the cusp.
b- If the cusp is high in centric but not in eccentric occlusion, deepen the fossa.

Correction of error in centric occlusion. Left; the cusp high in centric and eccentric.
Right; the cusp high in centric only
II-Grinding To Obtain Occlusal Balance in Lateral Movements:
A- Anterior teeth:
In case of clinical remounting, remove the incisal guidance pin from the articulator. Place
articulating paper between the dentures on the articulator or intraorally and make lateral
movements of the articulator arm or mandible.
Selective grinding of the anterior segments should simulate the wear patterns of the
natural teeth and preserve the aesthetics of the dentures.
If the anterior dentition is found to be in traumatic contact reduce the traumatic areas of
contact using the following rules:
a- Reduce the lingual surfaces of the maxillary incisal edges.
b- Reduce the labial surfaces of the mandibular incisal edges.
c- Reduce the disto-lingual slopes of the maxillary cuspids (canines).
d- Reduce the mesio-labial slopes of the mandibular cuspids.

Correction of error in lateral movements of anterior teeth.
B- Posterior teeth:
Where the posterior dentition is found to be in traumatic contact reduce the traumatic area
of contact using the following rules:
Working side
Grind on 'bull' rule, to avoid the supporting cusps (the upper palatal and the lower
buccal cusps). which preserve the vertical dimension of occlusion
1- Reduce the inner inclines of maxillary buccal cusps.
2- Reduce inner inclines of mandibular lingual cusps.
Correction of errors on the working side: A; The supporting cusps.
B, buccal cusps too long; reduce buccal upper cusp.
C, lingual cusps too long; reduce lingual lower.
Balancing side:
Reduce the inner inclines of the mandibular buccal cusps in preference to the opposing
maxillary slope. This is important because grinding usually involves removal in part or
whole of the cusp, which is an established centric occlusal contact. Therefore the
maxillary cusp is left to provide a more stabilizing effect for the lower denture.
Equilibrating the occlusion in balancing side
III-Grinding to Obtain Occlusal Balance in Protrusive Movements:
1- If the anterior dentition is found to be in traumatic contact reduce the traumatic areas of
contact as described for lateral movements.
2- If the posterior dentition is found to be in traumatic contact reduce the traumatic areas of
contact, grinding in accordance with the BULL Rule
Grind only cuspal slopes, which are not providing centric contact. Grind distal inclines of
maxillary buccal cusps and mesial inclines of mandibular lingual cusps.
Interference of anterior & posterior teeth during protrusion
IV- Milling-In
On completion of selective grinding the dentures should be "milled-in". Place abrasive
paste between the dentitions and make lateral and protrusive movements of the articulator
arm.
This serves to reduce any slight high spots that may be present in dynamic movements
and thus aids the development of balanced articulation.
Finally rubber-stone any ground areas of teeth, carefully remove the dentures from the
articulator and repolish the teeth and any areas of the polished surface of the denture as
necessary.
B- Eliminating Occlusal Errors in Non-anatomical Teeth
An interocclusal CR record is made with the opposing teeth just out of contact. The dentures
are mounted on the articulator, and the following procedures are undertaken:
a- After being detected by articulating paper between the teeth, gross premature contacts in
centric relation, lateral and protrusive occlusions are removed by grinding. In eccentric
occlusion, no grinding is done on the distobuccal portion of the mandibular second molar.
All balancing-side grinding is done on the lingual portion of the occlusal surface of the
maxillary second molar.
b- Abrasive paste is placed on the teeth in the articulator. These teeth are milled when the
upper member of the articulator moves in and out of protrusive and right and left lateral
excursions.
c- Spot grinding is done to correct any small discrepancies in CR that remain after the
grinding with abrasive paste.
Selective Grinding of Lingualized Balanced Occlusion
Correcting occlusal disharmonies in a balanced lingualized occlusion is similar to a
fully balanced occlusion with the exception that only the lingual cusps of the
maxillary teeth or their antagonist surfaces are adjusted.
The same basic approach is used to evaluate where the disharmony exist and then
correct it by reducing the mandibular fossae or marginal ridges in centric relation
position.
After the centric relation position is refined, the eccentric movements are adjusted
on the slopes of the mandibular cusps a-s indicated in the fully balanced occlusal
adjustment section.
Since only the lingual cusps of the maxillary teeth are in contact this balanced set up
is much less complicated to adjust.
Stripping Method for the Occlusal Equilibration of Nonanatomic Teeth
It is simplest technique to refine the occlusion for cuspless, non
anatomic teeth or a non balanced lingualized occlusal scheme
Carborundum stripping technique, originally published by Dr.
Gronas in 1970.
Since a rotary instrument usually produces irregularities in the flat occlusal surfaces.
Waterproof carborundum abrasive paper is the most ideal material to use with this
method. A fine 320-grit paper is used for acrylic resin teeth.
Locate the premature contacts with articulating ribbon or paper. If there is a grossly
tipped tooth that is above the occlusal plane, reduce the tooth with a stone or bur until a
flat occlusal plane is obtained.
Place a carborundum strip of the appropriate width with the abrasive side against the
teeth that are to be reduced (maxillary), and gently close the articulator in centric relation.
Apply tight pressure to upper member of articulator, and pull strip briskly between teeth
5- Final Checks of The Prostheses
Once all adjustments have been made to the denture intaglio surfaces and the occlusion
has been finalized, the dentures should be evaluated for proper contour and thickness.
Improper contour can affect the final fit of the prostheses and make muscles work against
stabilization instead of enhancing it.
Contours of most external surfaces should be slightly concave from the necks of the
teethto the denture borders. Occasionally surfaces are left bulky for lip or cheek support,
but that is an exception to the norm.
Thepalate should be 2-3 mm thick for proper strength and be thinned to blend with the
posterior palate after the posterior palatal seal is finalized.
All surfaces should be smoothand highly polished.
6- Patient education and management
1- Individuality of the patient
Patients must be reminded that their anatomic, psychological, tissue tolerance and oral
conditions are individual in nature. Thus, they cannot compare their progress with new
dentures to other persons experiences
2- Appearance with new dentures
Patients must understand that their appearance with new dentures will become more
natural with time.
A repositioning of the oral and facial muscles and a restoration of the former facial
dimension and contour by the new dentures may seem like too great a change in the
patients appearance.
This can be overcome only with the passage of time, and patients are advised to persevere
during the period.
3- Mastication with new dentures:
Eating may be difficult at first. The food should be cut into small pieces and the patient
should take his time chewing.
Learning to chew satisfactorily with new dentures usually requires at least 6 to 8 weeks.
The most efficient artificial teeth are only about one third as efficient as natural teeth.
Eating habitsmust be changed to compensate for this difference.
Sticky foods or hard foods that require considerable force to masticate should be avoided.
(Most breads become glutinous when chewed)
Difficulty in chewing is due to changes in
- Tissue surface
- Vertical occlusion (interocclusal distance)
- Salivary flow (more saliva with new dentures)
- Soreness
- Psychology: Patients expectations
Patients should begin chewing relatively soft food that has been cut into small pieces. If
the chewing can be done on both sides of the mouth at the same time, the tendency of
the dentures to tip will be reduced.
When biting with dentures, patients should be instructed to place the food between their
teeth toward the corners of the mouth, rather than between the anterior teeth.
Patients should be instructed to divide the normal forkful of food in half and place
each half posteriorly and bilaterally. Placing the food posteriorly, in the area of the first
molar, increases the power of the masticatory stroke andplaces the occlusal load over the
primary bearing area (i.e. the maxillary tuberosities and mandibular buccal shelf).
Biting with the front teeth, even if possible, should be avoided. If this practice is
continued, the support will be lost, and the dentures will become loose. The anterior part
of the maxilla is the weakest part of the upper arch to resist stress, and when the lower
anterior teeth occlude anterior to the basal support, trauma is inevitable.
4-Coughing and sneezing:
Coughing and sneezing often dislodge the dentures. Embarrassment can be avoided by
covering the mouth with a handkerchief.
5-Tasting and swallowing
Taste sensitivity may be reduced when an upper denturecovers the hard palate due to
the fact that
- A smooth denture surface may modify sense of touch within oral cavity.
- itprotect the mucosa from the sensation of hot or cold foods.
- A reduced salivary flow rate also may have anegative effect on taste perception,
because the flavoring agentsin food are less likely to be dissolved.
Swallowing can be poorly coordinated, and dentures can become a major contributing
factor to deaths from choking , as It is difficult to determine the location of food in the
mouth when the palate is covered.
6- Nutritional support
Nutritional support will improve the tolerance of the oral mucosa to new dentures and
prevent rejection of dentures.
Nutrition goals for the denture-wearing patient are to eat a variety of foods, including
protein sources, dairy, fruits, vegetables, grains, and cereals, and to limit salt, fat, and
sugar intake.
Adding one glass of milk or orange juice will make a significant contribution to nutrient
intake.
essential principles of nutrition education:
Principle 1. Food choices are affected by both the ability to chew and the perceptions of
hard-to-chew foods
Somefoods that cause chronic pain or discomfort should be eliminated from the diet and
replaced with foods that can provide equal and adequate nutrition
Principle 2. Essential fruit, vegetable, and dietary fiberintakes are enhanced with
attention to food selection and preparation issues
Vitamins C and E, beta carotene, folate, lutein, and lycopene/zeaxanthin should include
in the patient diet.
Principle 3. Dietary supplementation may play a limited role in maintaining nutritional
status
A simple multivitamin supplement can be suggested in situations where there is an
absence of essential foods or diminished dietary intake of important food groups like
fruits, vegetables, and grains.
Principle 4. Positive aging is associated with an increased need for high-quality protein
The edentulous patients are at an increased risk of malnutrition. So, they should
motivated to consume adequate, and healthy diet with high quality proteins
Principle 5. Adequate hydration may improve masticatory skills
Denture wearers need to maintain a moist oral environment to assure denture placement
and augment mastication through at least eight, 8-oz glasses of water daily.
Epidemiology:
Factors such as ill-fitting dentures, salivary gland hypofunction, or altered taste per-
ception may have a negative effect on the dietary habits and the nutritional status.
Masticatory ability and performance:
The wearing of complete dentures greatly compromises both masticatory ability and
performance as compared with a situation with natural teeth present. There is no striking
evidence that malnutrition could be a direct sequela of wearing dentures
Nutritional status and masticatory function:
Four factors are related to dietary selection and the nutritional status of wearers of
complete dentures: masticatory function and oral health, general health, socioeconomic
status, and dietary habits.
In wearers of complete dentures or that replacement of ill-fitting dentures with well-
fitting new dentures will cause a major improvement of nutrition.
To improve and maintain the nutritional status it is often necessary to modify dietary
habits. Mechanical preparation of food before eating will help mastication and reduce its
influence on food selection. However, it will not stimulate appetite.
7- Tongue position
Patients should be educated to the three basic problems associated with all mandibular dentures.
1- Thearea of the mandibular denture basal seat is approximately one-third the area of
the maxillary dentureandboth are subjected to the same occlusal loads and thrusts.
2- Themandibular denture is surrounded buccally as well as lingually by muscles, all of
which have a potential for denture base disruption.
3- The mandibular denture depends on proper tongue position to maintain adequate
peripheral seal and stability.
Patients, whose tongue normally rests in a retracted position relative to the lower
anterior teeth, should attempt to position the tongue farther forward so it rests on
the lingual surfaces of the lower anterior teeth. This will help develop stability for
the lower denture.
8- Speaking with new dentures:
People who have been edentulous for a considerable period will have adapted
themselves to the prevailing conditions, and probably will have corrected any speech
defects arising from the loss of teeth.
With the insertion of the dentures, the conditions are suddenly changed and the tongue
is conscious of the reduction of the space, and may be cramped temporarily by the bulk
of the lingual flange of the lower denture.
Patients who are likely to experience speech difficulties should be advised to read
loud, and repeat words or phrases that are difficult to pronounce.
Speech adaptation to a new denture usually takes place between 2-4 weeks
Speaking may be affected by:
oChange in tooth Shape, Size & Position (esp. anteriors)
oTongue space
oPalatal contours
9-Maintaining tissue health
Leaving dentures at night :Mucosal Hygiene and Tissue rest
oGenerally, patients should be instructed to remove their dentures at night in order
to rest the tissues which support them. The dentures should be removed for at
least 8 of each 24 hours to allow the tissues to rest.
oRemoval of dentures have many benefits
- Allow the tissues to rest. Failure to allow the tissues to recover from
masticatory forces may result in increased soreness and irritation.
- Many patients clench and brux during sleep. These movements can
severely damage the underlying foundation. Removal of dentures will
eliminate this hazard.
- it provides a convenient time for soaking the dentures in a cleaning
solution
oThe dentures should be stored in water or mild antiseptic to prevent
them drying out and warping.
- A denture produced in a mold with tinfoil substitutes contains some
water. In service, further water absorption can occur up to an equilibrium
value of about 2%. It has been claimed that each 1% increase in weight of the
resin due to water absorption causes a linear expansion of 0.23%. Similarly,
drying out of the material is associated with shrinkage. For this reason,
dentures should be kept wet at all times when not in service
Tissue hygiene and massage
oMassage all of the tissue - this will improve health and stimulates tissue.
oThe mucosal surfaces of the residual ridges and the dorsal surface of the tongue
also should be brushed daily with a soft brush. This will increase the circulation
and remove plaque and debris that can cause irritation of the soft tissue or
offensive odors.
Denture Cleaning (Complete denture hygiene)
The dentures should be removed and cleaned after each meal.
A soft brush with soap and cold water are sufficient. Alternatively, a
proprietary denture cleaner may be used, following manufacturers'
instructions. Brush over water or cloth (no damage if dropped)
The patient should be warned against using harsh abrasive materials
and hard bristle brushes, since both will wear away the surface detail
of the teeth and denture base.
Commercial Chemical Cleaners : Soak overnight to be effective ,
15-30 minutes is not sufficient . Solutions containing phenol must be
avoided as it maycraze surface of the denture.
Ultrasonic Denture Cleaners : True ultrasonic cleaners work well ,
Sonic cleaners are not effective without chemical cleaner (brushing
is more effective)
Denture cleanliness is essential to prevent malodor, poor esthetics,
and the accumulation of plaque/calculus and biofilm which are major etiologic factors
in the pathogenesis of denture stomatitis, inflammatory papillary hyperplasia, and
chronic candidiasis.
When the lower denture is cleaned, it should not be held in the palm of the hand. If
the denture slips, it may snap into two pieces when it is clutched. The patient should
be instructed to grasp the denture between the thumb and the forefinger.
Mechanical
Brushing: removes gross material, but leaves adherent microorganisms
Ultrasonic cleaner: tabletop device; very effective, especially in nursing home or
hospital environments where the relatively high start-up cost is not prohibitive.
Chemical
Bleach soak: kills microbes, but calculus or stains may remain. Bleach may change the
colour of the denture base and metallic parts may acquire a black stain. The addition of
calcium chelating agents (e.g., dishwasher detergent) can help to remove calculus.
Vinegar soak: not as effective as bleach in killing microbes and may leave an
unpleasant odour
Effervescent commercial products: highly effective; kill 99.9 per cent of micro-
organisms in 1020 minutes, more if left overnight. Also contain chelating agents and
fragrances to provide complete cleaning and deodorising. Addition of silicone polymer
may prevent readhesion of microbes to the denture surface.
Microwave radiation: effective in destroying microbes, but unless combined with
mechanical cleaning, non-viable microbes and by-products remain and may elicit an
immune response. Heat may damage the denture base.
Combination
The most effective method of cleaning will usually involve a combination of two or
more of the above methods e.g., brushing combined with soaking in effervescent
commercially available denture cleansers.
Types of immersion cleaners
Alkaline peroxide cleaners
These are the most widely used type of immersion cleaner. Their cleaning action is
largely due to the formation of small bubbles of oxygen which dislodge loosely attached
material from the denture surface.
They are safe, pleasant to use and do not damage acrylic resin or the metals used in
denture construction. However, it has been demonstrated that they are capable of causing
rapid deterioration of certain short-term soft lining materials (Harrison et al. 1989).
They are relatively ineffective cleaners and there is evidence that their ability to remove
microbial plaque is severely limited.
Acid cleaners
One type of acid cleaner contains 5% hydrochloric acid. It may be applied to denturesto
soften calculus, which is then removed by brushing. Care is necessary as damage to
clothing can result if the solution is spilled accidentally.
Corrosion of stainless steel or cobalt-chromium palates might occur if there is frequent
and prolonged contact with theacid.
Another type of acid cleaner consists of sulphamic acid. This too may be used to control
the formation of calculus on dentures. The compatibility of this agent with the commonly
used denture materials, including the metals, is good.
Hypochlorite cleaners
Although investigations into the relative effectiveness of the various denture cleaners
have produced some conflicting results in the case of alkaline peroxides, there is
widespreadagreement as to the effectiveness of the hypochlorite preparations.
These cleaners are not only effective disinfectants, but unlike some others, are good at
removing nonviable organisms and other organic deposits from the denture surface.
Immersion of thedentures in a hypochlorite cleaner for periods in excess of 6 hours will
result in removal of plaque and heavy staining.
Bleaching of the acrylic resin has not been reported but corrosion of cobalt-chromium has
been seen when hypochlorite cleaners have been used.
These cleaners may cause some loss of colour of acrylic and silicone soft lining materials
but neither softness nor elasticity of the linings is affected significantly (Davenport et al.
1986). In addition, fungal invasion, a common cause of soft lining failure, is prevented.
Some of the commonly used short-term soft lining materials are compatible with
hypochlorite cleaners; in fact, the regular use of such a cleaner can extend the useful life
of a tissue conditioner from a few days to several months.
Theimportance of giving advice on the cleaning of dentures cannot be over-stressed, as
there is evidence that a high proportion of patients appear not to have been given
instruction (J agger & Harrison 1995).
10- Denture adhesives
Adhesives, especially home reliners, can modify the position of the denture on the
residual ridge, resulting in a change of occlusal vertical dimension or a change in the
tooth contact in the centric relation position, which may cause irreparable damage to
the residual ridges in a short time.
The use of a denture adhesive is not a treatment modality, per se, but rather an adjunct to
denture treatment. Advice to thepatient regarding the use of denture adhesives should
include
(1) Use theminimum amount necessary to achieve the desiredresult.
(2) Distribute the adhesive evenly over the tissue-bearing surfaces.
(3) Apply or reapply when necessary.
(4) Always apply denture adhesive to a clean tissue-bearingsurface.
(5) Schedule periodic professional oral evaluations.
The patient should be shown the proper use of denture adhesives.
Regardless of the adhesive used, patients should keep both the denture and soft
tissues clean. Adhesives can be very tenacious, if they are not completely removed from
thedenture and the mouth, they can harbor organisms harmful tothe patients oral health.
Pastes and powders work equally well, and the decision should be based on patient
preference. Adhesive pads must be avoided, because they can drastically alter the fit of the
patients dentures.
11-Pain and soreness:
Pain and soreness occur with new dentures. Adjustment may be required. If the pain is
severe, the patient should leave the dentures out and arrange an appointment with his
dentist as soon as possible.
The patient should wear the dentures the day he returns to the dentist so that the sore area
may be seen. The patient should never attempt to adjust the denture himself.
12-Limitations of Dentures
Anatomical
- Denture supporting structures General appearance
- Symmetry Individual variations
Phsyiological
- Neuromuscular control
- Amount of saliva
o Thick saliva can dislodge dentures
o Thin saliva can be isufficient for retention & lubrication
Pathological
- Elimination of pain and infection Address inactive problems
- Neoplasms Hyperplasia
- Inflamation
Psychological
- Are they ready to wear and accept dentures
Esthetics : Society emphasis on appearance
Financial
Denture life expectancy is 5-7 years
The resorption and prosthetic replacement of alveolar bone
The shape of the residual ridge and the amount of resorption is likely to be influenced
particularly by local factors such as
- the inherent quality and size of the ridge,
- the technique used to extract the teeth,
- the healing capacity of the patient
- Theloads applied to the ridge .
An example of the latter can be seen that the lower denture
covers only a small part of the area available to support it and
therefore is not spreading the load sufficiently. This design error
results in increased functional stress. The consequence is the
imprint of the border of the denture can be seen on the residual
ridge; the bone has resorbed and the denture has sunk into the
underlying tissues.
It is suggested that the later stages of resorption are likely to be influenced by systemic
factors such as age, nutrition, drug therapy (e.g. corticosteroids) and hormonal factors.
There is also a view that severe resorption, particularly of the
mandible, is influenced more by systemic than by local factors.
In extreme resorptionthe mandible can be described as pencil-thin.
Restoration of appearance
limitations of complete dentures in restoring tissue loss, and thus supporting the lips and
cheeks fully, can contribute to an appearance of premature ageing in edentulouspatient.
The facial muscles may lose some of their tone through the ageing process, but loss of
tone may also occur because the muscles are unable to function as effectively as before.
This is because the underlying artificial supports (the dentures) are only sitting on the
mucosa and are not attached securely to the rest of the facial skeleton.
Mastication
Chewing efficiency is considerably lower than that of natural teeth. This is due to:
Natural teeth being firmly attached to the surrounding bone whereas dentures are
merely sitting on the mucosa and thus must be actively controlled by the patient;
the pain threshold of the denture-bearing mucosa is relatively easily exceeded so that
the biting force, which is closely correlated with chewing efficiency of complete
dentures, is reduced and may be only a sixth of that of dentate patients.
13- Periodic recall for oral examination
The patient should be seen 24 hours after placement of the dentures to address any
difficulties or to answer any questions the patient may have.
Periodic recall appointments should also be scheduled 1 week and 1 month after
placement for the samepurpose.
It is important to stress the importance of annual recalls to make sure no damaging wear
patterns develop that could cause injury to underlying supporting structures.
14- Educational material for patients
People remember less of what they hear than of what they see. For this reason, it is wise
to provide denture-wearing patients with printed information about their new teeth, about
the careand cleaning of the teeth, about their use.
7- Instructions to the patient
Complete denture wearer should insert the lower denture first.
There might be difficulty in wearing new dentures . Report to the hospital for necessary
adjustments.
It is better to avoid eating hard food with new dentures
It is advised to eat soft food in the beginning and slowly progress to hard food.
Handle dentures carefully ,they can break if dropped.
Dentures should be cleaned after every meal
In the night it is better to discontinue the use of denture
In the morning the denture should be cleaned using soap and brush
Do not clean the dentures using hot water or chemicals
When the dentures are not in use, keep in water
Incase of breakage of dentures report to the hospital for repair
it is imperative that you follow your doctors advice
C- Review of Complete Dentures
The patient should be asked to attend for examination 24hours after the insertion of the
dentures so that the prosthetist may carry out any necessary adjustments (easing).
Soreness may occur in that time due to the fact that functional trimming of the
peripheries at the impression stage rarely reproduce the functional movements, and when
the dentures are first worn there is probably slight overextension somewhere.
The flange of the denture is thus too deep and presses into the tissues of the sulcus
forming, first an angry line, which later breaks down into an ulcer, the depth of which
depends on the degree of overextension of the denture base. Also, in that time the denture
will have settled with possible slight changes in the evenness of occlusion.
A further visit may be necessary for final correction as it is never wise to remove too
much of periphery at one stage, since over-easing may lead to a leak in peripheral seal.
The Technique of Adjustments
1- Overextension:
It is essential to locate the overextended area . this can be done visually, but frequently
the ulcer cannot be seen when the denture is in place in these instances a mark must be
made on the tissues, which will transfer itself to the denture base in the vicinity of the
ulcer such a mark can be made with zinc oxide paste, tooth paste or indelible pencil.
A better method, and one which can be employed even before an ulcer has developed, if,
when fitting the denture one suspects that it is overextended anywhere, is to coat the area
of the periphery or fitting surface in question with a pressure indicating paste, a thin mix
of alginate or, a paste of equal parts of zinc oxide, starch and lanoline, so thicky that the
acrylic cannot be seen through the paste and then insert the denture.
The patient then instructed to chew, swallow and move the lips and cheek because
pressure points frequently develop only in function, the denture is then removed and if
overextension exists it will be readily visible as an area of acrylic completely uncovered
by paste. This area of the denture is then trimmed with a stone or file, highly polished and
the denture reinserted.
In cases of gross overextension resulting in severe ulceration, the patient should be
instructed to leave the denture out for twenty four hours in order to allow the swelling to
subside, otherwise the denture will require being overtrimmed and this may reduce the
retention.
2- Occlusion:
Soreness and ulceration are frequently caused by unbalanced occlusion, or cuspal
interference. It is therefore sound practice always to check the occlusion.
PHONETICS WITH NEW DENTURES
A- Lisping on pronouncing the consonants S, C (soft) and Z.
In the case of these sounds, a slit-like channel is formed between the tongue and the palate
through which the air hisses. If this channel is obstructed a noticeable lisping may be produced.
Lisping may result from one or more of the following:
1- The anterior part of the upper denture, covering the hard palate is thick.
2- The anterior teeth are placed too far back.
3- Lack of near contact of the upper and lower incisors.
B- Whistling on pronouncing the previously mentioned linguopalatal sounds:
If the channel is too narrow, a whistle will result. Whistling may result from one or more of the
following:
1- The dental arch too narrow.
2- Cramped tongue.
3- The anterior teeth are placed too far anteriorly.
The procedure for correcting this condition is to thicken the centre of the palate so that the
tongue does not have to extend up so far into the narrow palatal vault. This allows the escape
way for air tobe broad and thin.
A lisp with dentures can be corrected by reversing the procedure and providing a narrow
concentrated airway for the S sound.
C- Difficulty in pronouncing the consonants F, V, PH.
The labiodental, F, V, and Ph are produced by the air stream being stopped and explosively
released when the lower lip breaks contact with the incisal edge of the upper anterior teeth.
Difficulty in pronouncing these sounds may result from one or more of the followingcauses:
1- 1-If the occlusal plane is set either too high or too low.
2- If the anterior teeth are placed too far palatally.
D- Clicking of the teeth on pronouncing the consonants S, C soft, Z, Ch, J results from
excessive vertical dimensions.
E- Difficulty in pronouncing the sounds I, E, G, NG, C hard and K results if the posterior
border of the upper denture does not merge into the soft tissues.
F-Faulty phonation of consonants Ch, J, Sh, results from thickening of the anterior part of the
denture base covering the hard palate.
COMPLETE DENTURE THEORY AND PRACTICE COMPLAINTS 13
Complaints about Complete Dentures
Recall Procedures
Complete Dentures Failure May Often Be DIRECTLY Related To Faulty Diagnosis of the
Complaint Kingery
How we determining the cause ?
1. History
2. Visual exam
3. Digital exam
4. X-ray
5. Biopsy
Complete Denture problems
Support
Retention
Stability
Appearance
Miscellaneous (e.g. denture induced stomatitis, BMS, allergy, cancer phobia)
Principles of Diagnosing Denture Problems
1. General Principles
Never adjust unless you can see exactly where to adjust
Use indicator medium
(PIP, indelible marker, indelible sticks, articulating
paper, etc.)
Pressure-indicating medium can be used on non-
bearing surfaces of the denture to identify other
undesirable contours
Patients frequently wrong in exactly locating source of
problem
Spend time to look and think
Where?
Dentist needs to locate (PIP, tip of instrument, indelible stick)
When?
(Chewing only?)
How long?
Anything makes it better or worse?
Have patient demonstrate problem
2. Denture Base or support problems
Pain starts when patient inserts the denture, which feels tight or causes soreness
Patient has discomfort even when not chewing
May or may not get worse as the day progresses
Sore all time
If worsens throughout day may be occlusion, not denture base
Check the impression surface of the denture
Examine mucosa overlying ridges
look for exposed roots, mucosal pathology or atrophy
Palpate ridges
detect any tender areas of displaceable mucosa
detect areas of non displaceable mucosa
Reducebiting forces
3. Occlusion problems
Pain Hurts only when chewing
Gets worse with chewing
Pain gets worse through day
Difficult to determine, intraorally - reflex avoidance of pain
Interferences - especially in protrusive
Sore when bite
4. Retention Problems
Short flanges
PIP - still streaky
Fingers on canines outwards (post palatal seal)
Look for space
May be retentive for a while if a lip seal established, until movements
disturbs the lip seal
Long flanges
Burn through (PIP)
Intrudes tissue when placed
May not dislodge if good seal, may loosen after much function
Post-palatal seal
If the denture is short of the vibrating line, the denture may bind on hard
palate, (check with PIP)
Inadequate tissue contact
Food gets underneath
Bubbles as denture is placed (check with PIP)
If over-extended to moveable soft palate
denture loosens during speech, chewing
Xerostomia
Anatomical Factors
- V-shaped palate, flat palate, palatal fissure, cleft palate
- Large undercuts (indirect)
- Flat lower ridge.
5. Stability Problems
Patients with oral tremors
Patients with large tongues/
Littleexperience of wearing complete dentures
High muscle attachments
Patients with ruminatorymandibular movements
Patients with large tuberosities
ill-designed occlusal planes
Flat ridges and locked occlusal planes
Age and late onset of c/c
6. Occlusal Vertical Dimension Problems
Excessive
Continual and generalized pain and fatigue or muscle soreness.
Soreness over entire ridge
Worse during the day (increased occlusal contact)
Dentures click whenspeaking
Mouth feels too full, patient has difficulty getting lips together
Insufficient
Lack of chewing power
Minimal ridge discomfort
Angular cheilitis
Chin prominent
Minimal display of vermilion border
7. Phonetic problems
Wait and allow time for adaptation
Add soft wax to palate and check
If anterior poorly positioned, then remove and replace
Most Common Areas Requiring Adjustments
Maxillary
Hamular notches - ulceration can occur if over-extended
Labial frenum - requires adequate relief (often feels too bulky
to the patient)
Mid-line fulcrum on the bony raphe
Zygomatic impringement
Mandibular
Lingual frenum - impingement can cause displacement of the
denture of ulceration
- anterior mandibular denture border
- Retromylohyoid overextensions
- Sore throat
- Denture moves when swallowing
- Buccal shelf overextension
Most common complaints:
1- Pain
1-Over-extension of the periphery:
2- Poor fit:
3- Insufficient relief
4- Incorrect jaw relationship:
5- Cuspal interference
6-Teeth off the ridge:
7- Retained roots or unerupted tooth or
sharp bony spicules:
8- V shaped ridge.
9-Mental foramen:
11-Allergy:
10-Pathological conditions:
12-Rough fitting surface:
13-Difficulty in swallowing (tonsillitis)
and sore throat:
14- Severe undercuts:
2- Appearance
1-Nose and chin approximating:
2-Cheeks and lips falling in:
3- Angular cheilitis or soreness of the
corners of the mouth:
4-Color, shape and position of anterior
teeth:
5-Amount of tooth showing:
6-General dissatisfaction:
3- Inefficiency
1- Inability to eat anything
2-Inability to eat meat:
3-Dentures dislodged by eating
4- Poor retention
5- Instability
6- Clattering teeth
7- Nausea
8- Discomfort
9- Altered speech
Loss of tone and incorrect phonation
Limited jaw mobility and low intensity of speech production:
Phonation of Sh instead of S
Lisping on pronouncing the consonants S.C,(soft) and Z:
Whistling on pronouncing the previously mentioned lingopalatal
Difficulty in pronouncing the consonants F,V, PH.:
Faulty phonation of consonants Ch, J , Sh:
Difficulty in pronouncing the sounds I, E, G, NG, C hard and K:
Clicking of the teeth on pronouncing the consonants S, C, soft, Z,
Ch,J :
10- Biting the cheek and tongue.
11- Food under the denture.
12- Commissural (Angular) cheilitis
13- Burning tongue and palate
14- Repeated midline fracture of upper denture
15- Sialorrhea (hypersalivation)
16- Xerostomia
17- Traumatic ulcers
1- Pain
Pain or discomfort may be due to:
1-Over-extension of the periphery :
Slight overextension is preferred to slight under extension.
The overextended border causes pressure on the
underlying soft tissue covering the sulcus. It can be visible
in the mouth as hyperemia, red line or spot or as an ulcer.
The best way to detect an over extended area:[ see :Denture extension in try in]
Treatment:
The overextendedarea should be trimmed with a stone, polished and reinserted. The
procedure is repeated until the patient feels comfortable.
Sometimes over-extension may be due to alveolar ridge resorption; in this case,
construction of a new denture is preferable.
Whartons (sub maxillary duct) closure
Occasionally a lower denture can cause complete or partial closure of Whartons duct
This is clinically manifest by enlargement of the sub maxillary gland
The gland will usually return to normal soon after removal of the denture
If mild duct closure, mild discomfort often disappears by itself during the adjustment period
Sometimes a reduction of the lingual flange thickness, without disturbing the border, gives relief
(avoid excessively reducing the border)
2- Poor fit:
This can easily be detected by the poor retention, rocking, tilting and inability to seat
the denture accurately in any position.
Treatment:
New dentures should be constructed, but the old ones can be worn in the meantime
after lining with tissue conditioning material.
3- Insufficient relief
The denture will usually rock on the hard area or causing pain. The painful areas are
red and possibly ulcerated.
Treatment:
Apply a very thin coating of diagnostic paste, or white tooth paste, to the area which
requires relief, insert the denture and on removal the area will be easily marked; grind
that part off the fitting surface until adequate relief is obtained.
4- Incorrect jaw relationship:
This may be due to one or more of the following faults:
a- Wrong anteroposterior relationship
When centric occlusion does not coincide with centric relation, attempts to
retrude the mandible may drag the denture against the mucous membrane
causing pain.
Treatment
If only slight, it canbe corrected by selective grinding.
If gross, new dentures will be required.
b- Uneven pressure
Pain may be due to trauma caused by heavy pressure on one side pressure,
which is usually confined to the crest of the lower alveolar ridge on that side.
Small white areas 4mm to 6mm in diameter are seen as in cases of increased
vertical dimension. Pain may also be due to tilting of either denture, more
usually the lower.
Diagnosis can be made by inserting a spatula between the molar teeth on each
side when they are in firm contact, if it passes through, the error is gross, a
lesser degree of error may also be detected by inserting celluloid strip in
between the molar teeth and try to pull it.
Treatment:
If detectable with a spatula, a new lower denture must be constructed.
If it can be found with celluloid strips, then spot grinding is effective.
c- High vertical dimension:
The presence of one or more small white patches is usually associated with the
painful area, relief of the denture over these white patches usually gives
immediate relief of pain, but within a few days the patient returns with the same
condition but in different area.
In nearly all cases of excessive increased vertical dimension the patient also
complains that the teeth jar, clatter, or " too high" when eating and sometimes
when talking.
Treatment:
If the occlusal plane of the upper is judged to be correct, new lower denture
with a slightly decreased vertical dimension should be correct. Otherwise, new
upper and lower dentures should be constructed.
d- Reduced vertical dimension:
Pain in this case is rarely associated with new dentures. It is almost always the
result of loss of vertical height through lower alveolar ridge resorption. The
pain is often indefinite in locating and frequently resembles neuralgia of the
cheek on one or both sides.
Costen's syndrome may result from reduced vertical dimension. It consists of
the following; mild deafness, tenderness in the TMJ , burning sensation of the
tongue and throat and dryness of the mouth.
Treatment:
New dentures should be constructed at the proper vertical dimension.
5- Cuspal inrterference:
A dragging action may be exerted on both dentures
during excursive movements when the teeth are in
contact if cusped teeth are used.
This dragging may cause pain or even ulceration with
well fitting dentures and also instability with those
having poor retention.
Hold the upper denture gently in place between the fingers and thumb which are
placed above the canine teeth, asking the patient to grind the teeth and the
dragging can easily be felt.
Treatment:
Selective grinding is the most accurate method of correcting this error.
If the interference is gross, correctly articulated new dentures will be required.
Error in C.O. on one side will break seal on opposite side
6-Teeth off the ridge:
In this case, pain is confined chiefly to the upper buccal sulci and maxillary
tuberosities.
It is usually the result of setting the upper teeth far buccally in an attempt to
overcome marked discrepancies between the size of the upper arch and that of
the lower.
Treatment:
New dentures should be constructed.
Sometimes only a new upper denture, with the teeth correctly placed and, if
necessary tilted or mounted to cross bite.
7- Retained roots or unerupted tooth or sharp bony spicules:
Pain in this case is due to the pressure exerted by the denture base on the area having
the retained root or unerupted tooth or even sharp bony spicules especially if coverd
with thin mucosa.
Treatment;
Extraction of the root or tooth is required followed by relining of the denture.
If for some reason extraction is contraindicated, then relief the denture over that area.
8- V shaped ridge.
Pain is usually associated with the lower and caused by pressure during mastication,
pressing the mucous membrane against a sharp ridge of bone.
Treatment:
In the lower , alveoloplasty followed by relining the denture.
In the upper, relief over the crest of the alveolar ridge Is often sufficient since the palate
can resist the masticatory stresses.
9- Mental foramen:
If gross resorption of the alveolar and basal bone has taken place the foramen may
come to lie under the denture causing pain or numbness.
The pain may be localized over the mental foramen, or it may be referred and is then
felt as a neuralgic pain in the side of the face, or more rarely, in the lips or chin
It can be diagnosed by locating the mental foramen and applying firm pressure in that
area, which will cause some type of pain.
Treatment:
Relief the denture so that the nerve cannot be subjected to pressure.
Pressure on the mental foramen may relived by surgical increasing the opening of the
mental foramen downward and toward the inferiot border of the body of the mandible
which permits the mental nerve to exit from the bone at a point lower than it had
previously.
10- Pathological conditions:
These conditions should be treated according to the condition and new dentures are
usually constructed.
11- Allergy:
Fortunately, it is very rare.
Treatment:
New dentures must be constructed in another material.
12- Rough fitting surface:
If a denture has been processed on a poorly poured model, small pimples will be found
on the fitting surface of the denture.
Treatment:
Remove the offending roughness from the denture.
13- Difficulty in swallowing , tonsillitis and sore throat:
The cause in the upper is too thick or over-extension on the soft palate with firm
pressure and good retention, or excessive pressure in the hamular notch.
In the lower it is due to too thick or over-extension distally in the lingual pouch
(palatogloss arch).
Excessive vertical dimension of occlusion.
Incorrect tooth position.
Treatment:
Reduction of the over-extension.
14- Severe undercuts: [see Gross undercuts in CD problems]
The patient complains of pain when dentures are inserted
and or removed. The maximum bulge creating the undercut
area is usually red and painful and is sometimes ulcerated.
Treatment:
The fitting surface must be cut away until the denture can be inserted
comfortably but the periphery must not be reduced in height. Often the flange
will be too thin to allow sufficient removal from fitting surface, if this is the
case the flange must be thickened by addition of more material.
Sometimes an alveoloplasty may be necessary.
If the undercut is on one side it may be possible to train the patient to insert
the denture on the side of the undercut first, then rotate it to the other side and
removed in a reverse direction.
Flexible denture base
2- Appear ance, est het ics pr obl ems
The number of patients who are dissatisfied with their appearance with the final
dentures can be reduced if the operator insists, on a relative or candil friend being
present at the try in stage. Complaints with appearance may be one of the following.
1- Nose and chin approximating:
It is due to a closed bite.
Treatment:
As previously described for reduced vertical dimension.
2- Cheeks and lips falling in:
This is due to lack of tone of the facial muscles and due to labial and buccal
resorption in the maxillary ridge.
Treatment
This consists of building up the upper denture, frequently to a greater extent
than the original tissues to compensate for the loss of muscular tone. This
plumping should be placed in the canine and premolar regioni.e. the region of
the modiolus and not on the anterior region.
Care must be taken when making these additions to the denture to retain a
concavity directed outwards and downwards.
3- Angular cheilitis or soreness of the corners of the mouth:
This frequently results from loss of muscular tone and vertical dimension. The
corners of the mouth fall in and become bathed in saliva and develop fissure,
frequently, however, a secondary infection with Candeda albicans supervenes.
Treatment:
The vertical dimension should be restored and the upper dentures plumped
to help restore the muscle tone.
4- Color, shape and position of anterior teeth:
Colors comply if possible with the patient's request for lighter teeth, usually by
a compromise between the shade chosen by the operator and that chosen by the
patient.
Shape: Remove the teeth complained of and replace them with others until the
patient is satisfied.
Position: The teeth may be too far back in the mouth, or too far forward, more
often the former. New dentures will almost certainly have to be made.
5- Amount of tooth showing:
The dentures should be entirely remade with the occlusal plane raised or lowered as the
case may be, with longer or shorter anterior teeth if necessary.
6- General dissatisfaction:
The cause is usually the appearance. The patients are almost all women at the middle
age specially at the menopausal period.
7-Fullness under the nose
Labial flange of the upper too long or too thick.
Treatment
Reduce length or thickness of labial flange.
8- Depressed philtrum or naso-labial sulcus
Labial flange are too short or too thin.
Treatment
Increase length or thickness of labial flange.
9- Artificial look
Technique set-up (teeth are too regular in alignment.
All teeth same shade.
Lack of grinding incisal edges & angles.
Treatment
- Set up individualized (by rotating & shortening few teeth).
- Choose different shades.
- Grind incisal edges & angles to give a more individualized appearance.
3- Inef f iciency
1- Inability to eat anything:
This complaint is mainly confined to patients who are wearing complete upper and
lower dentures for the first time
Treatment:
The patient must either learn how to eat with the denture until acquiring new habits , or
will define some specific complaint which can be corrected.
2- Inability to eat meat:
It may be due to :
Flattening of the cusps of the posterior teeth.
The use of cuspless posterior teeth.
Reduced vertical dimension, which decreases the muscular efficiency.
The use of acrylic posterior teeth due to their resilience and softness.
Unbalanced articulation.
Cuspal interference.
Inexperience.
Treatment: Proper diagnosis of the cause to remedy the problem.
3- Dentures dislodged by eating :
The common causes are:
Cuspal interference.
Unbalanced occlusion.
Upper teeth outside the ridge, in this casetreatment is to remake the
Dentures possibly with a cross - bite.
Insufficient tongue space.
Overextended periphery.
Inexperience.
Eating causes pain.
Treatment:
Proper diagnosis of the cause to remedy the problem.
remake dentures allowing moretongue space, using narrower posterior teeth
4- Poor r et ent ion
1- When opening the mouth or Laughing:
The following are the usual causes:
-Over-extension.
-Under extension. Periphery terminates on
bony structures
Denture peripheries always terminate on displaceable soft tissues Retromolar pads, Vestibular
tissues, Vibrating line (nonmoveble soft palate), Hamular notches
- -Lack of peripheral seal.
- -Lack of saliva or very thin watery saliva.
- Cramped Tongue
- -Tight lips, remake with the lower anterior teeth set more lingually, with a definite
labial concavity on the denture and with the maximum extension in the region of
the retromolar pads..
- Thick flange in retrozygomal area
- Coronoid gets closer to tuberosity as patient opens or
moves jaw to side
- Pterygomandibular Raphe can displace denture
opening wide
- midline soft palate fissure Can tent during function
Allows air to leak under denture
Treatment:
Proper diagnosis of the cause to remedy the problem.
2- When coughing or sneezing:
If the post dam is correct, there is no way of preventing
these movements of the dentures which is normal, due to
increase in the air pressure, breaking the seal.
Treatment;
The patient should prevent these movements.
3- Maxillary Denture Drops in Function
Too much food
InterferenceIn Eccentric Positions
4- loss of retention after several hours
Error in Eccentric Excursions +Bruxing
Overcompression with Impression as with Well Defined
Rugae
Overextension
5- Loose Mandibular Denture
Physiologic Limitations of Mandibular Bearing Area
Overextension of buccal or Lingual Periphery
the floating denture: underextension
THE BOUNCY DENTURE : OVEREXTENSION
5- Inst abil it y
This problem has already been discussed in relation to its main causes.
1- When eating: as in case of inefficiency.
2- When talking: Incorrect border extension, especially the posterior
border of the upper denture.
3- The defensive tongue: Some individuals have what may best be
described as a defensive tongue, it is primarily concerned with preventing
any foreign body other than food reaching the pharynx or remaining in
the mouth. When dentures are inserted it subconsciously but positively
ejects them and the patient finds it difficult or impossible to train a tongue
of this type to control the denture.
Treatment:
Persuasion of the patient to develop correct tongue habits.
6- Cl at t er ing t eet h
The causes may be due to:
1- Too high a vertical dimension.
2- Gross cuspal interference.
3- Loose dentures.
4- Porcelain teeth may be the cause.
Treatment:
Treat the cause, Change porcelain teeth into acrylic.
7- Nausea & GAGGING
Most common patient complaint: Dentures are too long
CLASSIFICATION OF GAGGING
1. PSYCHOGENIC
anxiety, fear and apprehension personality disorders
2. SOMATOGENIC (Kroz)
Due to local, physical or systemic stimuli during dental treatment, the gag reflex is
mostly induced by tactile stimuli to trigger zones
TRIGGER ZONES SENSITIVE AREA
- Tonsillar pillars Tongue
- Posterior pharyngeal wall Soft palate
- Hard palate
TREATMENT
PSYCHOGENIC GAGGING
1. BREATHING EXCERCISES WITH SPOON
2. DIRECTING PATIENTS ATTENTION AWAY FROM ORAL PROCEDURE
SOMATOGENIC GAGGING
No contact of potential trigger zones with instruments
Correction of technical faults of denture
POST DELIVERY GAGGING
1. IMMEDIATE :
- Tongue Interference With Lingual of Molars
- High Plane of Occlusion
- Retracted Tongue Position
- Dentures slightly over-extended
- Dentures under extended.
- Loose dentures
- Thick posterior border.
2. DELAYED
- Incomplete border seal allowing seepage of saliva under denture
- Malocclusion loosening of dentures
- Placing the upper teeth too far in a palatal direction and the mandibular
teeth too far in a lingual direction so that the dorsum of the tongue is forced into
the pharynx during swallowing.
8- Discomf or t
This may be caused by:
Cramped tongue space.
Altered vertical height. Excess occlusal vertical dimension (OVD). May be caused by
centric relation (CR) record errors, poor record bases, errors in processing
- Requires resetting teeth or new denture
Altered occlusal plane.
Poor centric contact
- Requires remount of denture(s)
Undercured acrylic
- Requires reprocess (do not boil dentures), reline
Bruxism
- Do not wear dentures at night.
Treatment:
Treat the cause.
9- Al t er ed speech
Some phonetic complaints associated with complete denture:
1- Loss of tone and incorrect phonation
Causes:
- Decrease of air volume and loss of tongue room resulting from too narrow
dental arch.
- Unduly thick denture bases (especially this part covering the palate).
- Overextended denture and periphery.
Treatment:
- Broaden and widen arch form.
- Use narrow teeth.
- Reduce the thickness of the denture base.
- Adjust denture periphery.
2- Limited jaw mobility and low intensity of speech production:
Causes:
- Denture looseness; patient tries to suck maxillary denture into position, using
tongue to hold it, hence, mouth does not open widely, speechbecomes muffled,
and jaws move little.
Treatment:
-Check dentures for lack of adaptation, improper border extensions, insufficient
posterior palatal seal and deflective occlusal contacts.
Then correct the defect.
3- Phonation of Sh instead of S
Treatment:
- Have a slight vertical overlap.
- Increase vertical dimension.
-Set lower so incisal edges can approximate maxillary teeth within 1 mm.
4- Lisping on pronouncing the consonants S.C,(soft) and Z:
In the case of these sounds, a slit-like channel is formed between thetongue and
the palate through which the air hisses. If this channel isobstructed a noticeable
lisping may be produced.
Lisping may result from:
-The anterior part of the upper denture covering the hard
palate is thick.
-The anterior teeth are placed too far back.
-Lack of near contact of the upper and lower incisors.
Treatment:
- A lisp with dentures can be corrected by reversing the procedure and
providing a narrow concentrated airway for the S sound.
- The rugae area should be thinned to allow more space for air to escape.
5- Whistling on pronouncing the previously mentioned lingopalatal sounds:
If the channel is too narrow, or excess tongue groove a whistle will result.
Whistling may result from one or more of the
following.
-The dental arch is too narrow.
-Cramped tongue.
-The anterior teeth are placed too far anteriorly.
- Rugae area are too thin
Treatment:
- wax on the palatal surface should correct the problem (autopolymerizing
resin can then be added if the wax shows this to be an effective correction)
- The procedure for correcting this condition is to thicken the center of the
palate so that the tongue does not have to extend up so far into the narrow
palatal vault. This allows the escape way for air to be broad and thin.
6- Difficulty in pronouncing the consonants F,V, PH.:
The air stream being stopped and explosively released when the lower lip
breaks contact with the incisal edge of the upper anterior teeth produces the
labiodental , F,V, and PH.
Difficulty in pronouncing these sounds may
result from one or more of the following
causes:
- If the occlusal plane is set either too
high or too low.
- If the anterior teeth are placed too far palatally.
7- Clicking of the teeth on pronouncing the consonants S, C, soft, Z, Ch,J:
It results fromexcessive vertical dimensions.
8- Difficulty in pronouncing the sounds I, E, G, NG, C hard
and K:
Result if the posterior border of the upper denture does not
merge into the soft tissues.
9- Faulty phonation of consonants Ch, J, Sh:
Results from thickening of the anterior part of the denture base covering the hard
palate.
10- TH MM Sounds
Teeth Too Far Labially
11- P M B W Sounds
Thick Flange
12- Hard Consonants
Excess Base in Molar Bicuspid Area
10- Bit ing t he cheek and t ongue.
1- Biting the cheek:
Reduced vertical dimension
Insufficient horizontal overlap may cause cheek biting.
Treatment:
New lower denture with correct vertical dimension. In this case increase the
buccal over jet and plump the denture, in some cases it may be necessary to
remove the last molar or grind the buccal surfaces of the lower posterior teeth so
that the lingual cusps only will make contact with the upper teeth. In mandibular
prognathism crossbite the posterior teeth.
2- Biting the tongue:
This is almost invariably due to
Decreasein the tongue space occurring when fitting new
dentures for the first time.
No Freeway Space
11- Food under t he dent ur e.
This may be due to:
-Lack of peripheral seal.
-Under extension.
- Improper Flange Thickness
Treatment; New denture with proper peripheral extension.
12- Commissur al (Angul ar ) cheil it is
This may be due to:
- Reduced vertical dimension may cause falling of the corners of the
mouth beyond the vermillion border which may be filled with saliva and
become infected.
-Placing the maxillary posterior teeth too far in a lateral direction
eliminates the buccal corridor. When the crowns of the teeth are against
the cheeks, the saliva collects at the necks of the teeth and makes its
escape in the area of the cuspids. Commissural cheilitis often develops
when these conditions exist.
Treatment:
New denture with proper vertical dimension and correct placement of posterior teeth.
13- St omat opyr osis (bur ning mout h)
Burning tongue and palate
Affects menopausal and post-menopausal older than 50 yearswomen more than men
Somepatients experienceburning sensationin the anterior third of the palate.
Burning tongue and burning palate are often associated with menopause in women. The
burning sensation may also occur in middle aged men. It is extremely difficult to
determine what produces the burning sensation.
The quality of pain is burning sensation associated with a feeling of dry mouth and
persistent altered taste sensation. Other associated symptoms may include headache,
insomnia, decreased libido, irritability, or depression. Aggravating factors include
tension, fatigue, and hot foods, whereas sleeping, eating, and distraction reduce pain
intensity.
Aetiology
BMS has been attributed to a multitude of causes and these broadly fall into three groups:
Local irritants including denture faults
Systemic factors
Psychogenic factors.
a) Local irritation
Denture faults
Errors in denture design which cause a denture to move excessively over the
mucosa, which increase the functional stress on the mucosa or which interfere with
the freedom of movement of the surrounding muscles may initiate a complaint of
burning rather than frank soreness.
Denture design errors have been discovered in 50% of BMS patients.
Residual monomer
High levels of residual monomer in the denture base have been reported and the
tissue damage produced is considered to be the result of chemical irritation rather
than a trueallergy .
It is possible that high levels of residual monomer, which have ranged from three to
ten times the normal value, are due to errors inadvertently introduced into the short
curing cycles whichare popular with manufacturersand dental laboratories.
If the requisite curing temperature of 100C is not achieved inthe relevant part of
the short curing cycle, there is a marked increase in residual monomer content. This
content can be measured by specialised analytical techniques such as gas
chromatography and high-pressure liquid chromatography.
Some authorities may not consider this condition to be an example of BMS where,
classically, the mucosa looks normal. However, a patient who reacts to a high level
of residual monomer complains of a burning sensation and so we feel justifi ed in
including it.
Micro-organisms
The role of micro-organisms in burning mouth syndrome is controversial and
studies have not shown a link between the presence of Candida albicans and the
complaint.
Smoking and mouthwashes
Smoking and the regular use of some mouthwashes are irritants that have been
implicatedin BMS.
Pressure on the nasopalatine area
- relief of the denture over the incisive papilla is usually effective.
Parafunctional activity of the tongue, and undue friction on the mucosa.
Oral disease
Such as candida, fissured tongue, geographic tongue, foliate papillitis,
Carcinoma-burning is localized vs. more widespread as in BMS-burning mouth
syndrome
b) Systemic causes
Contributions from nutritional deficiencies such as iron, vitamin B complex and
folicacid should be highlighted.
Iron deficiencies in 8% and folic acid deficiencies in 6% of BMSpatients.
Low blood levels of vitamin B1 and B6 were found in 40% of patients.
Endocrine disorders
What is apparent is the relative unimportance of the climacteric as a causative
factor, amodern viewpoint which is at variance with past clinical opinion. On rare
occasions, the symptoms are found to be linked with an undiagnosed diabetes
mellitus. Treatment of the medical condition invariably results in complete
resolution of BMS.
Xerostomia
Xerostomia, frequently associated with BMS, it has many causes . One that should
be highlighted here is drug-induced xerostomia. Recent investigations have
produced evidence of a link between Type 2 BMS and reduced parotid gland
function and of antidepressant medication reducing the salivary flow
.It should be recognizedthat the presence of a dry mouth is capable of accentuating
the symptoms initiated by any of the causes of local irritation. This is an example of
themultifactorial nature of BMS.
Xerostomic induced by radiation therapy
Hypersensitivity
True hypersensitivity to constituents of denture base polymer israre and usually results
in local symptoms such as burning or itching.
In one instance where there were systemic symptoms of nausea, dizziness and general
malaise the patient was found to have reacted to dyes used to colour the polymer.
Dentures made of clear polymer proved successful.
In a study of Type 3 patients the avoidance in the diet of such food additives as benzoic
acid, propylene glycol and cinnamon products rendered a significant number of patients
asymptomatic. Interestingly, those patients who were not cured had higher levels of
psychiatric illness.
Parkinsons disease
It has been reported that the prevalence of BMS was 24% in people suffering from
Parkinsonsdisease; this is some five times that found in surveys of general populations
Psychogenic causes
The more common disorders associated with BMS are anxiety, depression,
cancerophobiaand hypochondriasis.
The associated parafunctional activities such as bruxism and abnormal and excessive
tongue movements are capable of inducing mucosal irritation.
Neuralgia
consider help from neurology department
Classification
Three types of BMS have been described (Lamey & Lewis 1989). The classification is useful
as it points the way towards appropriate treatment and a probable prognosis.
(1) Type 1. There are no symptoms on waking. A burning sensation then commences
and becomes worse as the day progresses. This pattern occurs every day.
Approximately 33% of patients fall into this category and are likely to include those
with haematinic deficiencies and defects in denture design.
(2) Type 2. Burning is present on waking and persists throughout the day. This
pattern occurs every day. About 55% of patients are placed in this category, a high
proportion of whohave chronic anxiety and are the most diffi cult to treat successfully.
(3) Type 3. Patients have symptom-free days. Burning occurs in less usual sites such
as the fl oor of the mouth, the throat and the buccal mucosa. This category is made up
of the remaining 12% of patients. A study of this group has shown that the main
causative factors are allergy and emotional instability (Lamey et al. 1994). The
investigation of these patients is likely to include patch testing.
Treatment: Treatment procedures may include the following:
1- Instruct the patient in good oral hygiene; recommend cleaning of the tongue with
gauze, not a brush.
2- Avoid hot spicy food and caustic mouth washes.
3- For vitamins deficiency prescribes vitamins A and B12 for three months,
discontinue for one month and re-evaluate.
4- Prescribe a mild tranquilizer.
5- When this condition is severe and persists, refer the patient to anoral surgeon for
possible surgical intervention.
6- When the condition is persistent and is complicated with other problems that may
be associated with psychicchanges, refer thepatient for psychiatric consultation.
Management
The diagnosis entails a very careful and systematic approach to history-taking and
examination, and usually involves the need for a battery of special tests.
Following the regime outlined below may well involve the establishment of a multi-
disciplinary clinic dedicated to the purpose, as the services of dentist, doctor,
dermatologist, psychiatrist, together with expert technical assistance, are frequently
needed.
Initial assessment (history/examination/special tests).
Provisional diagnosis.
Initial treatment (e.g. elimination of local irritants and investigating and
treating haematinicdeficiencies).
Assessment of initial treatment.
Definitive diagnosis.
Definitive treatment (local/systemic correction/psychological therapy).
Follow-up.
With regard to outcome, analysis of various studies suggests that about two-thirds of
BMS patients are either cured or improved to such an extent that the burning sensation
is no longer an overwhelming problem.
There remain a group of patients for whom the current state of knowledge can offer
relatively little benefit. Some in this small group remain totally resistant to treatment.
However, it should be remembered that even in these refractory cases BMS is not
necessarily a life sentence as spontaneous remissions can eventually occur for no
apparent reason.
14- Repeat ed midl ine f r act ur e of upper dent ur e
This may be due to;
1- Alveolar bone resorption and consequently, rocking of the denture.
2- Presenceof torus palatinus or insufficient relief of the middle area.
3- Teeth outside the ridge.
Treatment:
Repair followed by relining.
Surgical interference, sufficient relief in the midline area or metal plate.
Reset of the teeth or a new denture.
Thefollowing materials have been used to reinforce and stiffen conventional denturebase polymers.
(1) Carbon fibers.
Conventional upper dentures are reinforced by the inclusion of carbon fiber inserts in
the palate to reduce theflexibility of the denture base.
a disadvantage of the methodis the black colour of the insert.
(2) Ultra-high-modulus polyethylene fibres (UHMPE).
denture bases mayreinforced with ultra-high-modulus polyethylene fiber. This material
may be added either as a discrete woven insert into the denturebase or as chopped fibre
incorporated in the polymer powder before the resin is mixed (Braden et al. 1988;
Gutteridge 1988).
(3) Glass fibres.
The inclusion of glass fibres into acrylic resin has been shown to improve fatigue
resistance, flexural strength and impact strength. The fibres are produced either as a
woven mat and inserted into the whole denture, or as individual fibres which are laid
out in the region of a previous weakness.
(4) Metal strengtheners.
Metal wire or mesh has not been shown to effectively reinforcea denture base (Narva
et al. 2001). In fact, metal inserts can actually create areas of stress concentration and
so encourage fracture. Perhaps the most that can be saidis that a metal insert may hold
two pieces of a denture together once fracture hasoccurred.
Debonding of t eet h
The usual reasons for a weak bond between tooth and denture base are:
The presence of tin-foil substitute on the ridge-lap surface of the tooth
The presence of residual wax on the same surface
The use of cross-linked teeth which are incompatible with the particular denture base
polymer.
It occurs more commonly on upper anterior teeth. In the presence of an existing weak bond the
upward and outward force arisingfrom contact by the lower anterior teeth causes bond failure.
recommendations that have been made for minimizingthe risk of debonding :
(1) Choose artificial teeth and a denture base polymer which are compatible by
checking the information sheets provided with the products or by seeking information
from the manufacturers.
Conventional denture teeth tend to achieve a higher bondstrength than cross-linked teeth.
(2) Ensure all traces of wax and tin-foil substitute are removed. The complete removal
of wax is not consistently achieved with boiling water alone and so for optimumbond
strength the use of a wax solvent is recommended.
(3) Drill small channels into the palatal surface of the teeth to increase the area
availablefor the polymerising denture base resin.
(4) Apply a solvent such as dichloromethane to the ridge-lap surface of the teeth. The
solvent creates microscopic pores and channels which promote diffusion of the
polymerizablematerials.
(5) Use a heat-curing denture base polymer. This material polymerises more slowly
thana cold-curing material and ensures better penetration into the tooth substance.
15- Sial or r hea (hyper sal ivat ion)
May be a short-term major problem; patient may actually refuse to wear denture
Usually lasts only a few days and gradually tapers off to normal
Dentist must maintain calm, kind attitude and offer emotional support
Physiologic symptoms noted are a flow of blood through the salivary glands and their
excessive stimulation
Etiology is emotional stress, pain in the oral cavity, reflex stimulation by the dentures, or a
combination
Causes arising from the dentures are:
Incorrect centric jaw relation registrations
Excessive VDO
Overextension of denture borders
Pain and excessive pressure on the oral mucosa
Pressure upon nerves
Excessive stimulation of the salivary glands from the denture acting as a foreign body
Excessive thickness of the dentures restricting the tongue in its static state, as well as in
function
The patients anxiety about possible failure of the dentures
Treatment options:
Small doses of opiates or atropine sulfate for the first day may be desirable
Kind, sympathetic treatment with understanding and reassurance are essential (this alone
may affect the cure)
16- Xer ost omia
Saliva possesses the following functions in the edentulous patient:
It is responsible for the physical retention of complete dentures
It prepares food for swallowing and facilitates the sense of taste
It lubricates and protects the oral mucosa
It helps to preserve a normal balance of the oral fl ora
It promotes clear speech.
Problems of reduced salivary flow
A reduction, or absence of saliva (xerostomia), is likely to cause problems with all
the functions listed above so that a general, and significant, reduction in the quality
of liferesults.
Reduced retention of dentures is a particular problem for edentulous patients.
There may also be an increased susceptibility to denture trauma resulting in
complaints of pain and in some case the burning mouth syndrome, discussed later in
this chapter.
Possible causes:
Insertion of new dentures
Diabetes
Chronic infection
Drugs (antianxiety, antidepressant, antihistamine, antihypertensive, diuretic,
decongestant, antiparkinsonism, antipsychotic, anorexiant)
Biological aging
Sjogrens Syndrome
Vitamin deficiencies
Stress and depression
Tre
atment:
Address etiologicfactors
Prescribe a balanced diet rich in vitiamins and essential minerals
Moisturizing gel such as Oralbalance
Saliva substitutes
Sugar free candy to stimulate saliva production
As there is a definite relationship between fluid intake and secretory performance
it is essential that the patient is kept well hydrated.
Chewing and energetic exercise improve salivary flow, possibly because of
improved blood circulation to the glands (Niedermeier et al. 2000).
Where somefunctional salivary tissue remains, the problem may be alleviated by
sialogogues such as sugar-free chewing gum or ascorbic acid.
In cases where flow rate cannot be improved limited relief may sometimes be
obtained by the use of artificial saliva.
It is very important for a denture patient with a dry mouth to maintain an excellent
level of denture hygiene. The likelihood of proliferation of Candida albicans is
increased in xerostomia and therefore unless denture hygiene is maintained at a
high level the denture is likely to be rapidly colonised by the micro-organism,
resulting in denture stomatitis.
In cases where an intractable dry mouth gives rise to a persistent problem of loose
dentures a denture adhesive will usually provide some improvement in denture
function.
An ethanol-free rinse containing aloe or lanolin, or a water-soluble lubricating
jelly.
For patients whose mouths are dry due to irradiation or an autoimmune disorder
such as Sjogren's syndrome, salivary stimulation through a prescription of 5 to 10
mg of oral pilocarpine three times daily. But this have side effect of increased
perspiration and (occasionally) excess lacrimation.
17- Tr aumat ic ul cer s
Traumatic ulcers or sore spots most commonly develop within 1 to 2 days after
placement of new dentures. The direct cause is usually overextended denture flanges or
unbalanced occlusion
The ulcers are small and painful lesions, covered by a gray necrotic membrane and sur-
rounded by an inflammatory halo with firm, elevated borders.
The sore spots will heal a few days after correction of the dentures.
Failure of complete denture
Physiologic Failures
Weight loss can affect denture fit. Clothes get loose; dentures can get loose
Patients with diabetes or periodontal disease are subject to rapid loss of supporting structures
when dentures are inserted and should be forewarned of frequent re-fittings
Malignant growths can cause dentures to be ill-fitting
Sometimes patients just cant successfullywear dentures; check to see if they are using good
denture "tricks" such as tightening the corners of the mouth against the lower flange when the
mouth is opened wide, trying to chew in an up and down motion with a minimum of lateral
excursion, and keeping the tongue low and well forward in the mouth to stabilize the lower
denture.
COMPLETE DENTURE THEORY AND PRACTICE P R O B L E M S O L V I N G 13
P O S T-P L A C E M E N T P R O B L E M S O L V I N G
PROBLEMS RELATED TO SOFT TISSUE
Complaints/area Causes Treatments
Sore spots - mandibl e
Peripheral areas Overextension Adjust denture accordingly
Unpolished or sharp edge Polish denture borders
Herpetic or apthous ulcer Leave denture out as much as
possible and wait 7-10 days
Crest of ridge Bone spicules Identify the area in denture with
pressure indicating paste and
provide relief over spicule and/or
surgically remove spicule
Spinous ridge crest Provide relief in the denture
Pressure spots at time of
impression
Use PIP or indelible pencil to
determine the areas and adjust
accordingly
Occlusal prematurities Correct occlusal defects, recheck
vertical dimension and clinical
remount
Side of ridge-anterior area Overextension Use pressure indicating paste and
adjust denture border involved
Maximum intercuspation not in
harmony with centric relation
Enlarge centric area; grind mesial
inclined planes of maxillary teeth
and distal inclined planes of
mandibular teeth using a clinical
remount
Side of ridge-bicuspid area Lingual tori ( nonyielding areas) Provide adequate relief in denture
base
Pressure spots at time of
impression
Adjust denture accordingly
Shrinkage of denture during
processing ( dimensional
changes)
Rebase denture
Error in occlusion - occlusal
prematurities
Check occlusion on the opposite
side of arch from the sore spot
Pressure on mental foramen if
ridge is greatly resorbed
Provide adequate relief
Side of ridge-posterior area Overextension in lateral throat
area
Shorten posterior of lingual flange
Error in occlusion Check teeth diagonally across the
arch from the sore area
Spinous projection of mylohyoid
ridge distolaterally ( feeling of
sore throat)
Correct undercut surgically; you
must under extend the denture.
Relieve denture if not severe
Overextension in anterior area
(causes rotation of distal flanges)
Adjust peripheral overextension
Under lingual flange Maximum intercuspation not in
harmony with centric relation
(drives mandibular denture
forward)
Enlarge centric area and adjust
local area-
Under labial flange Excessive overbite Adjust anterior occlusion
Habit- mastication in protrusive
relation
Train patient to masticate in
centric
Generalized soreness and
redness
Heavy biting force- strong
musculature
Reduce buccolingual width of
teeth; reduce vertical
dimension; use soft lining if
necessary
Excessive vertical dimension of
occlusion
Reduce vertical dimension
Locked occlusion Enlarge centric area
Failure to provide freedom for
Bennett movement (soreness
usually on working side
Reduce cusps to a
nonanatomical plane or reset
teeth
Improperly processed base material Rebase denture
Sore spots - maxilla
Peripheral areas Overextension Adjust denture accordingly
Unpolished or sharp edge Polish denture borders
Herpetic or apthous ulcer Leave denture out as much as
possible for 7-10 days
Maxillary frenum Overextension Open a V-shaped notch for the
labial frenum and widen the
buccal frenum areas
Posterior border of denture Sharp edge at the post dam area Adjust sharp edge slightly
without reducing dam area
Midline of denture Prominent midsuture or torus
maxillaries
Provide some relief over the
area
Generalized discomfort
Improper occlusion Correct occlusion (clinical
reline)
Maximum intercuspation not in harmony with centric relation Enlarge centric area (clinical
reline)
Excessive vertical dimension of occlusion Reduce vertical dimension
(clinical reline)
Burning sensation
Maxillary anterior hard palate
and anterior alveolar ridge area
Pressure on anterior palatine
foramen
Relieve area over foramen
Maxillary bicuspid area or molar
tuberosity
Pressure on posterior palatine
foramen
Relieve area over foramen
Mandibular anterior region Pressure on mental foramen Relieve area over foramen
Generalized Improperly processed Reline denture; replace as
much as possible base material
with new acrylic resin
Tongue Allergic reaction xerostoma
Redness
Fiery redness - All tissue
contacted by denture including
tongue and cheeks
Denture base allergy (very unusual) Remake denture and use all
metal base (after allergy test)
Bearing tissues Ill-fitting denture, Avitaminosis Remake or rebase dentures.
Employ vitamin therapy
regimen
Tongue and cheek biting
Thin or under extended periphery (base material does not provide
enough support for the cheek)
Build out thin areas, or extend
the short periphery
Insufficient interarch clearance between distal parts of denture bases Thin maxillary denture over
tuberosity; if more space is
required, remove it from the
retromolar area of the
mandibular denture
Inadequate amount of horizontal overlap in molar region Re-contour buccal surface of
mandibular molars and
bicuspids; eliminate the tight
contact of the maxillary buccal
cusps on the mandibular buccal
surfaces
Pain in TMJ
Insufficient vertical dimension of occlusion Increase vertical dimension of
occlusion
Maximum intercuspation not in harmony with centric relation Make new occlusal record,
regrind and remount occlusion
Arthritis Treat with analgesics
Trauma Treat with analgesics
Gagging
Immediately upon insertion Maxillary denture overextended or
too thick in posterior border
Adjust denture or thin posterior
border
Lack of retention Reline denture
Mandibular denture too thick in
distolingual flange
Reduce thickness or
distolingual flange
Delay (2 weeks - 2 months after
insertion)
Incomplete border seal allowing
saliva under denture
Increase border seal with self-
curing acrylic resin ( possibly at
the posterior palatal border
Improper occlusion causing denture
to loosen and allowing saliva under
denture
Correct occlusion (clinical
remount)
Deafness
Excessive vertical dimension of occlusion Excessive vertical dimension of
occlusion
Fatigue of the muscles of mastication
Excessive vertical dimension of occlusion Reduce vertical dimension of
occlusion
Insufficient vertical dimension of occlusion Increase vertical dimension of
occlusion
PROBLEMS RELATED TO FUNCTION
Complaints/area Causes Treatments
Instability
Looseness of mandibular denture Error in occlusion (maximum
intercuspation not in harmony with
centric relation)
Correct faulty occlusion by
remount and regrind procedure
Occlusion plane too high Reset teeth at a lower plane
Underextension of periphery
(inadequate impression)
Rebase denture providing proper
extension
Inability of patient to master denture
Use denture adhesives to help
develop skill in handling denture
( for a short time only)
Tongue position (retracted tongue)
Looseness
of maxillary
denture
Occasionally
Underextension in some area
Correct with self-curing acrylic
resin; first check with compound
for diagnostic purpose
Faulty occlusion Correct Occlusion
Overextension of peripheries Adjust denture accordingly
Dehydration of tissue due to
alcoholism
Remove cause
Displacement of flabby tissues when
making impression
Correct surgically; modify
impression technique to change
primary denture stress-bearing
area to the buccal shelf
When eating on
either side
Nonyeilding area in hard palate
(ridge tissue yields under chewing
stresses; denture rocks on hard area
Provide relief chamber over non-
yielding area
Incorrect tooth position (teeth may
beset too far buccally off ridge
Rebalance in lateral excursions;
reset teeth where nature should
have had them
Chewing resistant foods
Instruct patient to maintain soft
diet until mouth is conditioned to
wearing denture
Approximately every
2 hours
Heavy mucinous saliva
Prescribe astringent
mouthwashes and regular
scrubbing of dentures; reduction
of carbohydrate
Incorrect tooth position ( teeth may
be set too far buccally and labially
Correct surgically; change
primary denture stress -bearing
Improper incising habits
Train patient to masticate in
centric relation
Loss of posterior palatal seal (seal
on hard palate; posterior limit not in
hamular notches; insufficient valve
seal)
Increase postpalatal seal with
self-curing acrylic resin; first use
compound as a diagnostic aid
When yawning or
opening wide
Denture base too thick in buccal
posterior area (coronoid process
exerts forward and downward force
on posterior of denture upon
opening)
Reduce thickness of denture
base
Overextended in hamular notch
Shorten denture until
pterygomaxillary ligament does
not exert tension on posterior
border when mouth is opened
wide
Inadequate posterior palatal seal
self-curing acrylic resin
When talking
Inadequate posterior palatal seal
self-curing acrylic resin
Overextended in posterior region
Shorten posterior until soft palate
does not lift upward and break
contact with the denture base
When occluding in
centric relation
Improper occlusion Correct occlusion
Poor denture foundation (flabby
tissues over ridge)
Correct surgically; change
primary denture stress-bearing
Incorrect tooth position (teeth set too
far buccally)
Reset teeth
Maximum intercuspation not in
harmony with centric region
Enlarge centric area
Nonyielding area in hard plate Provide relief in area
Only a feeling of
looseness (support
and retention are
present yet denture
feels suspended in
mouth
Large area of nonyeilding tissue in
hard plate
Provide relief chamber, adequate
to permit denture to be properly
seated
Interference
When swallowing Maxillary denture too thick or over-
extended in posterior region
Reduce thickness or adjust
posterior
Mandibular denture too thick or
overextended in posterior lingual
flange area
Reduce thickness or adjust
posterior lingual flange area
Insufficient vertical dimension of
occlusion
Excessive vertical dimension of
occlusion
Incorrect tooth position (posterior
teeth set too far lingually - tongue
crowded
Reset teeth
Clicking Excessive vertical dimension of
occlusion
Ill-fitting dentures New dentures
Overextended lower dentures Reduce peripheral length
PROBLEMS RELATED TO ESTHETICS
Complaints Causes Treatments
Fullness under nose Labial flange of denture too long or too thick
Reduce length or
thickness of labial
flange
Depressed philtrum Labial flange of mandibular denture too short
Increase length or
thickness of labial
flange
Upper lip sunken in Maxillary anterior teeth set too far lingually
Reset anterior teeth
labially
Too much of the teeth are
exposed
Excessive vertical dimension of occlusion
Reduce the vertical
dimension of occlusion
Incisal plane too low
Reset teeth at higher
plane
Cupids and lateral incisors too prominent Adjust accordingly
Artificial appearance
Technique setup (teeth are too regular in
alignment)
Individualize by rotating
and shortening some
teeth
All teeth in same shape
Choose different but
complimentary shades;
use staining techniques
Lack of individualization of teeth
Grind incisal edges and
angles
Lack of individualization of denture base
Individualize gingival
contour and color of
denture base
PROBLEMS RELATED TO PHONETICS
Complaints Causes Treatments
Whistle on "S" sounds
Air stream passes unimpeded or with inadequate
impedance between the dorsal surface of the
tongue and the anterior palate
Increase the palatal
resin convex
contours lingual to
the maxillary central
incisors to impede
the air stream
passing between the
tongue and palate.
Create rugae if
necessary
Lisp on "S" sounds
The air stream passing between the tongue and
anterior palate is excessively impeded, usually
by rugae or excessive resin contour
Reduce occlusal
vertical dimension
until premolars no
longer contact during
speech
Maxillary & Mandibular incisors
or premolars contact during
sibilant (s, sh, z, ch) sounds Occlusal vertical dimension too great
Reduce occlusal
vertical dimension
until premolars no
longer contact during
speech
Clinician observes that incisal
edges of maxillary incisors
contact the lower lip 1 mm or
more labial to the wet/dry junction
of lower lip when "F" & "V"
sounds are made
Maxillary teeth may be set too far labially
Evaluate lip support
and overall
appearance of
anterior teeth as they
are positioned.
Reset to a more
lingual postiion as
needed. incisal edge
of maxillary incisiors
should contact the
wet dry junction ro
just lingual to it during
production of the "F"
& "V" sounds.
Complaints
Diagnosis Causes Treatment
Patient
Dissatisfaction
Denture error Denture
settling
Denture
limitations
Types of
patients
Philosophical Exacting Indifferent Hysterical
Dent ur e Compl ai nt
Problems
Retention Support Muscle Balance Occlusal
Balance
Complaints
1- Over extension Movement interfere with muscle movement ( Stability)
2- Under extension Break the Seal ( Retention)
3- Trimming Thick or thin border (ttt) Boxing.
Pr obl ems of New Dent ur e
[ I ] Ti ssue i r r i t at i on
In the form of :
Hyperemia Cut in vestibule Ulceration
Causes:
Over-extension Pressure by denture Movement of denture Improper occlusion
ttt:
Remove the cause Tissue rest
Types:
Generalized Localized
Acute Chronic
1) Generalized Tissue irritation
2) Localized Tissue Irritation
Tuberosity Retro
Mylohyoid
Median
Palatine
Raphe
Ant. lingual
& Lat. buccal
slop
Vestibule Crest
- Over
extension
- Over
extension
labially lift
the denture
posteriorly.
__ __
Over
extension
(displacing
wax)
- Un polished
(Visual&
digital)
*D.D.
Aphsus ulcer
__
Border
- Bilateral
undercut
(Relief)
- Pressure
area
- Dimensional
changes
(Relief
Rebase)
- pressure - relief
(Denture
rocking)
- support
of 1ry
stress
bearing
area
(Relining
or
Rebasing)
- Pressure
__
-Ridge
(x ray &
visual *Ex)
-Spicules&
remaining
roots
(Visual Ex)
- Denture
pressure
*(P.I.P.)
Basal Seat
__
- Occlusal
interference
on opposite
sideDenture
move in
opposite
direction.
- Anterior
contact in
C.R. *ttt
(Reset)
- Deflective
occlusal
contact
7 7
- *C.O. *C.R.
Loose denture
anteriorly
- Tooth off
ridge
- Deflective
occlusal
contact
Occlusion
D.D. Differential Diagnosis.
Ex. Examination.
P.I.P. Pressure Indicating Paste.
C.O. Centric Occlusion.
C.R. Centric Relation.
ttt Treatment.
C.C. Chief Complaint.
[ I I ] Poor Dent ur e Fi t
Cause: Lack of retention& Support.
Lower denture more than Upper. Why?
Support Saliva Tongue
Chief complaint (C.C.):
Loose denture Too bulky Rocking denture
Related symptoms:
Normal Abnormal
- Open wide (Yawing) Coronoid process. - Speaking.
- Cough& sneezing the pressure. - Eating.
- New denture Saliva. - Pain.
[ I I I ] Pai n

[ I V ] Est het i c pr obl em
Color :
a) Teeth too dark or too yellow.
b) Acrylic resin.
Size:
a) Too larger.
b) Too smaller.

Arrangement:
a) Too even or Irregular.
b) Visibility of anterior teeth (Too for forward) or (Too for backward).
c) Cheeks& lips Falling-in Unsupported lip& cheek Plumping (Building-out
the upper denture to compensate for the loss of muscular tone).
Nose& Chin approximation (closed bite):
- Due to Vertical dimension.
General dissatisfaction:
- Who? Female / middle age.
- Need Kindness& Patience.
[ V ] Speec h di f f i c ul t i es
Anterior teeth:
a- Vertical overlap "S" sound.
b- Improper Labio-lingual positioning "S" sound (Whistling or lisping).
Encroachment on tongue space:
a- Posterior teeth placed too far lingually.
b- Too great Bucco-lingual width of posterior teeth.
c- Excessive thickness of the lingual flange.
d- Poor palatal contour (Rugae area) "S" sound P.I.P.
Poor denture retention.
Excessive salivation.
Vertical dimension P, B, F, V.
N.B. When pronouncing letter "S" the lateral margins of the tongue Contact the lingual
surface of posterior teeth, and the tip of the tongue contact with the palate in rugae area
forming a slit like channel.
a. Whistling: If anterior teeth placed too forward, the channel will be to large& the air
will escape with a whistling sound Resetting the teeth backward or thickening the
denture base behind these teeth.
b. Lisping: If anterior teeth placed too backward, the channel will be obliterated& the
patient may lisp Resetting the anterior teeth forward or reducing the denture base
in the Rugae area.
[ VI ] Nausea
Cause: Contact of the denture with the soft palate or the tongue.
Posterior Periphery of upper denture Loose denture
Over-extension Under-extension Thickness
[ VI I ] I nef f i c i ent eat i ng
Borders Improper.
Basal seat Unstable denture.
Occlusion
Teeth Vertical dimensions
Blunt Flat cusps V.D.O. V.D.O.

Elevate the muscle& don't work. Patient can't open to get food.

[ VI I I ] Cheek , Li p& Tongue Bi t i ng
a) Cheek& Lip biting:
Overlap Lower buccal cusp or Reset.

Laxity of muscle (loose of muscle tone).
Vertical dimension sagging of cheek.
b) Tongue biting:
Teeth set lingual Rounding the lower lingual cusps or Reset.
[ I X ] Al t er t ast e
[ X ] Cl at t er i ng t eet h
Unfamiliarity with Vertical dimension Cuspal interference Unstable denture
New denture.
- Teeth contact sooner.
Pr obl ems of Ol d Dent ur e
COMPLETE DENTURE THEORY AND PRACTICE SEQUELAE OF WEARING COMPLETE DENTURES14
SEQUELAE OF WEARING COMPLETE DENTURES
POST INSERTION CHANGES
I- Changes in the supporting structure as a result of wearing C D.
Changes in the oral mucosa.
Changes in alveolar bone.
Change in muscle of mastication
Change in temporomandibular joint.
II- Change in denture [occlusal wear& effects (habitual eccentric jaw
relation)].
III- Change in the relation of C D to it is supporting tissue.
IV- Changes in jaw relationship after insertion.
V- Post insertion changes in relation to basal skeletal structure.
I- sequel ae on t he suppor t ing st r uct ur es
A-DIRECT SEQUELAE
1. Denture stomatitis see preparation of the mouth
2. Flabby ridge see management of problematic patient
3. Residual ridge resorption see management of problematic patient
4. Denture irritation hyperplasia see preparation of the mouth
5. Oral cancer in denture wearers see preparation of the mouth
6. Burning mouth syndrome see complaint
7. Gagging see Nausea & Gagging
8. Traumatic ulcer see copmlaint.
9. Overdenture abutments: caries and periodontal disease
The wearing of overdentures often is associated with a high risk of caries
and progression of periodontal disease of the abutment teeth. One of the
reasons for this is that the bacterial colonization beneath a close-fitting
denture is enhanced, and good plaque control of the fitting denture surface is
generally difficult to obtain.
Preventive measures & management:
The accumulation of the plaque on the exposed dentine of the abutment
teeth & the root surface should be controlled. With adequate denture-
wearing habits.
Motivate the patient and to introduce regular follow-up examinations at
intervals of 3 to 6 months.
Daily application of gels containing fluoride or fluoride plus
chlorhexidine.
Gel controlled caries development and maintained healthy periodontal
conditions.
Adequate denture-wearing habits.
Periodontal pockets of greater than 4 to 5 mm should be eliminated
surgically.
B- INDIRECT SEQUELAE
a- Nutritional deficiencies see denture insertion
b- Atrophy of masticatory muscles
Maximal bite forces tend to decrease with age. Reduced bite force and chewing
efficiency are sequelae of wearing complete dentures, resulting in impaired
masticatory function.
Preventive measures and management:
The retention of a small number of teeth used as overdenture abutments
seems to play an important role in the maintenance of oral function in
elderly denture wearers.
In the completely edentulous patients, placement of implants usually is
followed by an improvement of the masticatory function and an increase of
maximal occlusal forces.
There is no evidence of a similar benefit following a preprosthetic surgical
intervention to improve the anatomical conditions for wearing complete
dentures.
II- sequel ae on t he compl et e dent ur e
Excessive wear of occlusal and incisal surfaces of current dentures.
Usually it occur due to worn the dentures over many years without modification or
earlier replacement. This occurs usually withmarked resorption of alveolar bone.
The combination of these changes results in:
1- Loss of occlusal face height or an increase in the freeway space often to as much as
10 or 12 mm.
2- Change in anterior-posterior tooth relation.
3- Development of habitual forward posturing of the mandible in order to masticate
the food.
At the examination appointment the patient may complain of loss of masticatory
function, or change in appearance.
The problems which arise are
1- How much reduction in the freeway space the patient can tolerate when
the restoration of the occlusal face height is attempted.
2- How to restore the anterior-posterior tooth relationship and break the
habitual posturing of the mandible.
If an attempt is made to reduce the freeway space suddenly to the classical three
millimetres, this amount of change means that the underlying denture bearing tissues will
be subjected to an increase in load during mastication. This, in turn, can result in soreness
of the mucosa particularly under the lower denture. There for the change must be
gradual.
Treatment:
The restoration of anterio-posterior tooth relationship and curing of the related
habitual forward posture of the mandible which frequently creates problems
during the recording of centric relation can be achieved by modifying the old
offending dentures.
The occlusal face height is increased by adding self-curing acrylic resin to the
occlusal surfaces of the first molar and premolar teeth. This is done in small
increments of two or three millimetres at a time over a period of weeks.
In this way amount of occlusal face height which the patient will accept can
be assessed and at the same time the new occlusal pattern will start the
breakdown of the habitual mandibular protrusion habit.
Pink self curing resincan be usedto restore the occlusion so that if the patient is unable
to tolerate any change the original occlusion can be restored by removing it. This is more
easily done if the addition is pink against the white original teeth.
Method of modification:-
If, due to excessive occlusal wear, the upper occlusal plane is grossly wrong it is
corrected by theaddition of self curing resin to the occlusal surfaces of the molars
and premolars
Petroleum jelly is smeared over whole of occluding surfaces of the upper denture
Self curing resin is placed on to the occlusal surfaces of the molar and premolar
teeth of the lower denture. This is allowed to polymerise until the dough stage is
reached then it is placed into the mouth and the patient is instructed to close and
stopped at the required increase in occlusal face height. Polymerisation is
completed in the hydroflask.
When habituation has been completed the modified old dentures can be used as a
template for the provision of the new dentures.
Occlusal were & it is effect:
The acrylic resin teeth is a low wear resistance this may considered as an advantages (
cushion effect) if through the wear the denture become self adjustment or self balancing.
Although, it can be considered disadvantage if the wear result in
1- Habitual eccentric jaw relationships due to loss of occlusal contact. It was found that
wear of acrylic posterior teeth caused loss of occlusion in centric relation this lead to
protrusion of the mandible
2- Reduce the vertical dimension & a loss of masticatory efficiency.
CONTROL OF SEQUELAE OF WEARING COMPLETE DENTURES
The essential consequences of wearing complete dentures are reduction of the residual
ridges and pathological changes of the oral mucosa. To reduce the adverse sequelae of
residual ridge resorption, the following should be considered:
1. Restoration of the partially edentulous patient with complete dentures should be
considered only if this is the only alternative treatment. In this situation, every effort
should be made to retain some teeth in strategically good positions to serve as
overdenture abutments. The maintenance of tooth roots in the mandible is particularly
important.
2. The patient with complete dentures should follow a regular follow up at yearly intervals
so that an acceptable fit and stable occlusal conditions can be maintained.
3. Edentulous patients should be aware of the benefits of an implant-supported prosthesis.
In young patients, the primary advantage would be reduced residual ridge resorption. In
elderly patients, the main advantages are improved comfort and maintenance of
masticatory function.
COMPLETE DENTURE THEORY AND PRACTICE PREPARATION OF THE MOUTH FOR CD 15
PREPARATION OF THE MOUTH
FOR COMPLETE DENTURES
INTRODUCTION
The oral mucosa (denture bearing mucosa) is not created to be covered or to
carry prosthesis. Deviation from nature always results in changes in the
tissues, which may be pathological. Before theconstruction of new prosthesis,
the supporting structures must be in a healthy condition.
A thorough examination of the mouth prior to construction of complete
dentures is necessary to identify potential problem areas. Potential problem
areas can be made with the aid of mounted diagnostic casts, intraoral
radiographsand panoramic radiography.
A treatment plan calling for surgical correction should be made after alternate
nonsurgical approaches have been considered and evaluated.
A nonsurgical approach to treatment when surgery is contraindicated or
preservation of the height of bone is essential. Fabrication of new dentures
using established prosthodontic would decrease occlusal loading over the
affected area and distribute forces more to the primary support areas like the
mandibular buccal shelf.
Reduction of the width of the occlusal table together with maximum denture
base extension would reduce forces on the supporting tissues chronic.
Temporary resilient liners can be used.
METHODS OF MOUTH PREPARATION
A) Non surgical methods.
B) pre-prosthetic surgical preparation.
A) Non surgical methods
Including the management of abused soft tissues
Causes of abused soft tissues
1- Denturebase hypersensitivity.
2- Chronic poor oral hygiene.
3- Continuous denture wearing.
4- Systemic factors such as : endocrine deficiencies, deficiencies of iron, vitamin
C&B , via lowering the resistance of mucosa to trauma and fungal infection
5- Systemic disease as uncontrolled diabetic patient.
6- After Radiation therapy.
7- Traumaticocclusion.
8- Poor fit denture.
Treatment of abused soft tissues:
1) Rest of the denture supporting tissues.
2) Occlusal correction of the old prosthesis.
3) Good nutrition.
4) Anti fungal therapy.
5) Good oral hygiene.
6) Improvement of denture fitness.
7) Elimination of artificial relief and suction chamber in the maxillary complete
denture.
8) Uses of tissue conditioning material.
9) Adequate relief of complete denture
10) Treatment of oral manifestation of systemic diseases
(1) Rest for denture supporting tissues:
Rest for the dentures porting tissues can be achieved by
Removal of the dentures from the mouth for an extended periodand /or the
use of temporary soft liners.
Soft tissue stimulation
Massage of the soft tissue two or three times a day using a soft toothbrush
or a damp washcloth will stimulate the blood supply and ald recovery.
(2) Occlusal correction of old prostheses
Resorptive changes in the edentulous jaws produce changes in the position of
the mandible in relation to the maxilla and hence changes in the occlusion of
dentures.
Acrylic resin may be added to the occlausal sufaces to correct an occlusal
error and improve the vertical dimension of occlusionand help. Toreestablish
the occlusion in the retruded position. Additions can be made over all the
posterior teeth or confined to the region of the premolars. These occlusal
pivots have the advantage of disoccludingthe molar teeth making it easier for
the mandible to assume its retruded position.
Temporary addition of acrylic resin to the posterior teeth produces a gap
between the anterior teeth. Most people accept this change once it has been
explained, but occasionally this is not acceptable. Backer et al (1983) have
described a method of increasing the height of the incisors at the chair side.
(3) Good nutrition.
A good nutritional program must be emphasized for each edentulous patient.
This is especially important for the geriatric patient whose metabolic and
masticators efficiency have decreased.
B) PRE-PROSTHETIC SURGICAL PREPARATION
Preprosthetic Surgery : is Procedures designed to optimize the retention,
support, stability and comfort of prostheses by the selective modification of
soft and hard tissues
The goal of pre-prosthetic surgery is to modify the oral environment to render
it free of disease and to make its form (and possibly its function) more
compatible with the requirements of complete denture wearing.
Surgical corrections should be made after altermate non-sugical approaches
have been considered and evaluated.
This ideal edentulous ridge should :
1- Provide adequate bony support.
2- Have bone covered be normal attached soft tissue.
3- Have no bony or soft tissue protuberances or
undercuts.
4- Have no sharp ridges.
5- Provide adequate buccal and lingual sulci.
6- Have no peripheral scar bands the prevent seating of a denture prosthesis.
7- Have no muscle fibers of frena that mobilize the prosthesis.
8- Posses no neoplastic lesions.
Objectives of surgical preparation of the edentulous mouth:
(1) To reduce or remove bony exostoses or undercut areas, e.g. torus palatines
or mandibularis.
(2) To smooth or remove sharp bony areas which may cause pain beneath a
denture e.g. mylohyoid rides, sharp knife-edged.
(3) To remove soft tissues witch may interfere with the success of the denture,
e.g excess fibrous tissue.
(4) To remove or alther high frenal attachments.
(5) To deepen shallow sulci to allowa greater area of denture coverage.
Pre-prosthetic Surgical Mouth Preparation
A.Conditions involving hard tissues :
1- Retained roots.
2- Unerupted teeth.
3- Sharp irregular residual ridges.
4- Sharp mylohoid ride.
5- Prominent maxillary tuberosities.
6- Undercut areas.
7- Tori and exostoses
a. Torus palatinus b. Torus mandibularis
c. Genial tubercles
8- Reduced residual ridge (R.R.R)
a. Ride augmentation. b .Implants
9- Discrepancies in jaw size
10- Pressure on the mental foramen
B. Conditions involving soft tissues
1. Hypermobile (flabby, fibrous) ridges.
2. prominent frena
3. Shallowsulci.
4. Pressureon the mental foramen.
5. denture stomatitis
6. Inflammatoryprpillary hyperplasia .
7. Epulis fissuratum.
8. Angular stomatitis
9. Oral cancer in denture wearers
Surgical procedures designed to enhance denture stability, function and comfort
include:
Alveolotomy or alveolectomy for immediate replacement dentures
Frenectomy for prominent frena
Removal of denturehyperplasia
Reduction of undercuts and enlarged tuberosities
Removal of bony prominences such as tori and mylohyoid ridges
Transposition of the mental nerve
Sulcus deepening
Ridge augmentation with bone or bone substitutes such as hydroxyapatite
Implants.
A] CONDITIONS INVOLVING HARD TISSUES:
1-Retaind roots
Most retained roots should beremovedbefore
prosthetic rehabilitation especially in the
presence of pathologic transformation.
Root tips that are covered by sound bone and
show no radiographic evidence of pathologic
change, especially if they have been covered by a denture in the past.
2- Unerupted teeth
The majority of uerupted teeth should be removed prophylactically,
especially in younger people to prevent possible transition to dentigerous
cysts and later differentiation into an ameloblastioma.
Unerupted teeth may be retained when the tooth has been a symptomatic
for years with no associated evidence of pathology. Radiographs should be
take at reasonable intervals to be sure no adverse changes occur.
3- Sharp irregular residual ridges or bony spicules
Rapid resorption on the labial and lingual side of the lower anterior ridge
leaves a knife edged ridge. the overlying soft tissue is often rolled with
mobile fibrous base The soft tissue is trapped between the hard denture
base and the sharp bony ridge.
Surgical procedures to recontour the sharp bony ridge left the patient with
less vertical tissue height and continued bone resorpion frequantly leading
to a recurrence of the knife edged ridge
Reason for the difficulty of knife-like lower ridge
Pain during mastication.
Treatment :
1- Relief
2- Resilient lining or
3- Alveoloplasty.
Alveoloplasty : isthe recontouring or reduction of a portion of the alveolar process
Goals of alveoloplasty:
Eliminate bony projections that result in
undercuts
Improve the path of insertion of the prosthesis
Eliminate bony sources of irritation.
Improve denture stability by removal of excess
tissue
Indications of alveoloplasty
1- Sharp spinous ridges.
2- Extreme irregularities of the alvreolar crest.
3- Exostoses.
4- Lacking of intermaxillary space, and
5- Esthetically unfavorable alveolar bone formations.
Types of Alveoloplasty
Simple alveoloplasty
Buccal or labial cortical reduction
Intraseptal alveolectomy and cortical plate in-fracture
Disadvantages of Alveoloplasty
Accelerates bone loss and Increased post-operative pain
Potential Complications:
Loss of sulcus depth in the hamular notch area
Oral-antral communication
Surgical techniques include:
surgical Excision
Cryosurgery
Electrosurgery
General surgical principles:
One of the most important principles is to be gentle with soft tissue,
particularly the periosteum. Excessive traumatizing of the soft tissue and periosteum
may produce hemorrhage, possible hematoma, necrosis extensive inflammation and
/or infection, all of which delay healing and result in more bone loss.
4- Sharp mylohyoid ridge
When the mylohyoid ridge is sharp and the mucose overlying it is painful to
pressue. Relocation of the mylohyoid muscle and osseous reduction or
smoothing of the mylohyoid ridge is indicated.
Care must be taken not to incise too far lingually because the lingual nerve
may transverse the retromolar pad region in 18% of patients.
Treatment
(1) Prosthetic treatment. Prosthetic measures to resolve the problem should be
attempted first. These include:
(a) A thorough re-appraisal of the dentures and correction of any design
faults.
(b) Reducing masticatory load on the denture-bearing tissues by reducing
the area of the occlusal table, for example, by reducing the width of the
posterior teeth so that they penetrate the bolus of food more easily.
(c) Localised relief of the impression surface of the denture in the region
of the bony projections.
(d) Smoothing the impression surface of the denture so that movement of
the denture does not traumatise the mucosa.
(e) Placing a soft lining.
(2) Surgical treatment. If prosthetic treatment of the condition is unsuccessful
surgical removal of the bony projections may be required.
5-Knife like lower ridge
It is the order number IV in the reduce resorption ridge.
Reason for the difficulty:
Pain during mastication.
Treatment:
Relief.
Resilient lining.
Alveoloplasty.
6- Prominent maxillary tuberosities:
An interfering tuberosity usually results from over erupted teeth
elongating the alveolar process. This occurs when there are no
opposing lower teeth. Following extraction of over erupted teeth, the
maxillary sinus frequently expands into tuberosities.
Maxillary tuberosities may be bulbous and have a definite undercut area above
them, If the bulbous portion is composed of soft tissue and so
close to the mandible (when in the rest position) satisfactory
denture cannot be made until some of the fibrous tissues have
been removed
A- Bony: They can be large bilaterally or
unilaterally.
When they are bilateral the rigid denture base cannot be inserted without
reducing the denture peripheries, with loss of peripheral seal.
Treatment:
a- Blocked out the undercuts on cast before processing. But this created
a space allowing to the ingress of air between the denture and tissues.
b- Shortens the flange only slightly into the undercut area this means
that close contact between denture and tissue is maintained, but since
the flange does not extend into full depth of the sulcus the peripheral
seal is reduced.
c- Carefully designed use of resilient lining material on the undercut
area has had a modicum of success. And the fitting surface may be
cut away until the denture can be inserted comfortably but the
periphery must not be reduced in height.
d- The reduction of the periphery of the denture on one side and a
path of insertion of the denture devised.
e- An alveoloplasty to reduce the undercut may be beneficial.
f- Flexible denture base
When they are unilateral : undercut side is inserted first and denture
swung into position on undercut side.
B- Fibrous
Treatment:
a- Two-part impression technique as with fibrous ridge to avoid the
distortionof it.
b- If they are so large as to intrude downwards into the inter-ridge
space then surgical reduction should be considered.
The technique of the operation is firstly to remove a V shaped wedge from the
centre of the tuberosity; the mucous membrance on either side of the area occupied by
the wedge is then undermined by the removal of the flbrous tissues. Finally, the flaps
of the mucous membrance so fromed are approximated by suture.
c- Bulbous maxillary tuberosities which affect interarch distance posteriorly:
Prosthetic treatment
(1) Re-assessment of the occlusal vertical dimension. This re-assessment
should be carried out routinely, because if the patient is able to accept a small
increase in occlusal vertical dimension sufficient inter-alveolar space might be
created to allow full extension of the denture bases.
(2) Accept posterior under-extension of both upper and lower dentures. This
might well be successful for the upper denture because the ridges are normally
well developed so the denture is well retained and stable as a result. However,
the approach is much more likely to compromise the lower denture and
therefore should not be adopted in this case.
(3) Use a thin denture base. It may be possible to extend the dentures fully if a
very thin metal base is used in the area of the reduced inter-alveolar space.
7 - Undercut areas
- In general, ridge undercuts are undesirable when they interfere with
the path of placement (insertion) of dentures and retention of the
denture.
- Undercuts only in the anterior labial region need not be reduced,
since a anterior path of insertion can usually be obtained. The anterior
residual ridge must be preserved whenever possible, since this area is
crucial for support and stability of the denture and tends to be a region
of rapid bone loss.
- Undercuts that interfere with the path of placement both in anterior
and posterior regions are usually detrimental to accurate tissue
adaptation.
- If both anterior and posterior interfercnces are present, reduction of
the posterior areas is preferred over reduction of the anterior region
with bilateral.
- Bony protuberances in tuberosity area, one side can usually be letft
intact and the opposite side surgically corrected. Alveolar bone can be
saved be changing the path of insertion and by use of soft liner.
7- Tori and exostoses
Tori are benign, slowly growing hyperexostoses common to both mandible
and maxilla they reach thrie maxmum growth by the age of 30, and are of
unknown etiology. Histologically, tori are composed almost entirely of
laminated cortical bone covered with a thin layer of mucosa.
Tori are considered to be interplayof genetic and environmental factors with a
familial occurrence suggesting autosomal dominant inheritance with reduced
penetrance.
The prevalence of torus mandibularis among whites and blacks ranges from
8% to 16% and shows no sex difference
The following criteria were used to classify different shapes of tori:
1. Flat Torus: Occurring as a slightly convex protuberance with a smooth surface
for mandibular tori. The same applies for palatal tori but extending
symmetrically on both side of the palate.
2. Lobular Torus: Present as a pedunculated or sessile lobular mass that can arise
from a single base. This applies for tori in both locations.
3. Nodular Torus: Occurring as a multiple protuberance each with individual
bases; these may coalesce forming grooves between them. This applies for tori
in both locations.
4. Spindle Torus: Present along the midline ridge along the palatal raphe area for
palatal tori and elongated tori bilaterally in the mandible for mandibular tori.
a- Torus palatinus :
Palatal exostoses occur in various sizes, locations,
and patterns. They appear to represent delayed
overgrowths of the medial margins of both palatine
proceses that expand at puberity and stop in the late
twenties.
The denture may rock across the midline and
eventually fracture.
Retention may be reduced, as an unrelieved torus prevents bedding into the soft
tissue.
The Fulcrum effect results from resorption of the alveolar process while the bone
of the exostoses remains unchanged. Resulting in an unstable denture base and
midline fracture of the denture. small tori can be retained and the denture
relieved to prevent a fulcrum effect
Treatment:
Adequate relief of the denture in the area of torus.
A metal plate will withstand strain fatigue better than an acrylic base.
Mucofunctional impression technique.
A denture in the form of a horseshoe is sometimes successful. Maximum
coverage of the palate must be used excluding the area of the torus but
extending posteriorly to the hamular notches. A carefully sited postdam is
essential on carefully selected compressible submucosal tissue. The
denture should be made on a model cast from an impression taken in a
accurately prepared special tray, with an compression impression
technique.
Surgical management.
A torus palatinus should be removed if
1- The exostoses are so large as to interfere with speech.
2- The exostoses extend posteriorly enough to adversely affect the
posterior palatal seal of the denture and
3- Denture stability becomes a persistent problem because of the fulcrm
effect of the torus on the denture.
4- The torus has traumatized overlying mucosa
5- Presence of deep undercuts
6- Interference with normal speech
7- The torus poses psychological problems (e.g., malignancy phobia)
b- Torus mandibularis
It is a bony prominence on the lingual surface, found usually bilaterally
within the first mandibular cuspid to first molar area.
Tori are composed of cancellous bone covered by compact bone, which
may be laminated. One or more tori may be present and arealways located
above the mylohyoid line but below the alveolar margin. Torus
mandibularis is rarely seen before the age of 10 years.
A number of studies have found that up to 10% of the general population
is affected.
Clinically, these tori vary in sizeand shape. Tori may be multi-lobulated
and have up to 14.0 mm in mesial distal width.
The tori usually present as well-rounded, smoothsurfaced,
hard, bony projections, covered with normal or blanched
mucosa.
The mucous membrane over the torus is generally thin and
susceptible to chroinic irritation from the denture base.
Mandibular tori often present obstacle to border seal of the denture in the
critical sublingual crescent areas..
Treatment :
1- A compression impression technique,
2- Adequate relief of thedenture in the area of torus.
3- A metal plate will withstand strain fatigue better then an acrylic denture base.
It is used if the mucosa is not easily traumatized.
4- A new mandibular complete denture Using Three Base Materials
incorporating a combination of soft acrylic flanges and liners . The denture
base was constructed with Ivocap injected-moulded acrylic resins for the
base and buccal flange, a thermoplastic material (BITEM) for the external
portion of the lingual flange and a resilient material (Molloplast) to line the
entire denture, including the lingual flange.
5- Surgical interference. Removal of mandibular lingual tori is usually indicated
because of the thin, easilytraumatized mucosa covering them and the inability
to perfect a lingual border seal of the mandibular denture
Thermoplastic material BITEM
It is relatively rigid at mouth temperature but tempers in hot water, softening
the material. It is adjusted by first chilling the denture and then polishing or
grinding.
Essentially, it is a methyl methacrylate, and therefore it bonds chemically to
the denture base and the resilient liner. The result is a semi-rigid flange that
slides easily over the mandibular tori.
Resilient liners such as Molloplast
They are widely used as a cushion on the fitting surface of dentures in the
management of traumatized oral mucosa, bony undercuts, bruxism, ridge
atrophy and congenital oral defects requiring obturation.
They providean even distribution of the functional load and avoid local stress
concentrations. There are 2 main types plasticized acrylics and silicone
elastomers the latter differing in the percentage of crosslinking agents,
catalysts and fillers and available in autopolymerizing and heat-curing forms.
Silicone-based polymers remain soft or rubbery at or below mouth
temperatures. J Can Dent Assoc 2000; 66:494-6
c- Genial tubercles
Genial tubercles are neither exostoses nor tori but are often
prominent following advanced alveolar ridge resorption in the
anterior lingual area of the mandible. They arecovered by thin
tissue, which will not bear the pressure of a denture flange
located in this area
Treatment
Relief and butterfly impression technique and If it is clinically necessary to
deepen the alveolingual sulcus in this area, the genioglossus muscle is sutured to the
geniohyoid muscle below it.
Complete removal of the genial tubercle should be avoided as lack of
attachment of the genioglossus and geniohyoid could lead to impaired tongue
function.
8 - Reduced residual ridges or flat ridge:
Reduced residual ridge presents a great problem for the patient and
prosthodontisit the condition of the type of ridges can be improved by ridge
augmentation or by the use of implant or by ridge distraction and
vestibuloplasty
Reason for the Difficulty : The shape of the ridge provides no resistance to
lateral movement of the denture, also, interference from adjacent musculature
is pronounced.
Treatment:
a- Careful peripheral adaptation
a- Balanced articulation.
b- Lowering the occlusal plane, if aesthetics permits and
c- Cuspless teeth.:
d- Mandibular ridge augmentation with block iliac crest onlay graft. Placement
of three iliac blocks contoured to fit superior surface of mandible. Segments
secured with wires. Cortical surfaces of grafts are placed superiorly.
e- ridge augmentation with hydroxyapatits
Hydroxyapatite has received much attention as a
material to augment resorbed alveolar ridges because
bony augmentation has failed to produce favorable long-
trem success in treating patients with anatomical
dehciencied of the denture bearing area.
The chemical structure of the dens, nonporous
frome of hydroxyapatite is slmilar to the minerals in
bone and therefore expected to unitechemically with bone without unlavorable side
effects.
Localize or generalized augmentation has been used to improve ridge contours
or significantly increase the anatomic foundation available for support, stablitity, and
retention of complete dentures.
9- Discrepancies in jaw size
Can be corrected by orthognathic surgery in sever cases
See management of jaw size Discrepancies
10- Pressure on the mental foramen
When the resorption of bone of the mandible has been extreme, the mental
foramen may open near or directly at the crest of the residual ridge.
Pressure will cause pain because the oral mucosa is punched between the
sharp bony ridge of the mental foramen and the denture.
Pressure on the mental foramen is relived by
- Relief at the painful area
- Increasing the opening of the mental foramen downward and
toward the inferior border of the body of the mandible which
permits the mental nerve to exit from the bone at a point lower than
it had previously.
CONDITIONS INVOLVING SOFT TISSUES ABNORMALITIES
Include removal of pathosescystic, traumatic, hyper-plastic, dysplastic tissues
1- Flabby Ridge (Abuse Tissues)
The condition results from resorption of the
alveolar bone under an ill-fitting denture from
constant unbalanced occlusal forces in a localized
area.
Hypermobile ridge tissue is commonly seen in
the anterior part of the edentulous ridge or overlying an atrophic knife-
edge mandibular ridgeit is usually the result of anterior hyper occlusion.
Excessive force in the anterior region result when a complete maxillary
dentureoccludes against mandibular natural teeth.
When porcelain anterior teeth are used in the same denture with acrylic
resin posterior teeth. The lower wear resistance of acrylic resin teeth
results in hyper occlusion of the anterior porcelain teeth.
Reason for the Difficulty : Flabby tissue compressed during mastication causas the
denture to be tilted and the seal thus broken
Treatment : the treatment plan may include any or all of the following :
1- the removal of old dentures from the mouth for few days before taking new
impressions to allow the inflammation to subside
2- Relining the old dentures with soft tissue conditioning materials to aid
recovery before constructing new dentures
3- Massage of the soft tissues two or three times a day to stimulate the blood
supply and aid recovery
4- Surgical removalof the flabby tissue
Causes
Excessive stress being applied to an edentulous ridge particularly in a lateral
direction Acommon example of this is the occlusion of six natural lower front teeth
against a full upper denture which frequently results in the re sorption of the alveolar
bone and hyperplasia of the gums .
Advanced periodontal disease results in resorption or the alveolar bone and
hyperplasia of the gum corium prior to the extraction of the teeth , leading to a thick
and frequently flabby mucosal covering of the resultant edentulous ridges
2 - Frenular attachments
The denture is more easily displaced when frena are attached near to the crest
of the ridge.
If the frenal notch is eased after the denture is fitted there is a danger that
the peripheral seal will be lost. Therefore it should be very carefully shaped
at the wax try appointment also the impression should be of the functional
depth of the sulcus in the area.
Excessive relief of the denture in the labial notch results in
awakened denture base that is proneto mid line fracture or
loss of border seal
If the frenumis close to crest of bony ridge, it may be
difficult to obtain the ideal extension and border of the flange of the denture.
The frenectomy can be carried out prior to initiating prosthetic treatment.
Division of frena surgically (frenctomy) before, or at time of insertion of
denture.
Indications for Correction
When speech is impaired
To improve denture seating and stability
To avoid trauma to the submandibular gland duct by the denture
Labial frenectomy
Simple labial frenectomy ( Diamond excision )
Z - plasty
V-Y plasty
V - Diamond plasty ( Modified V-Y plasty )
Simple labial frenectomy Z - plasty V - Y Plasty
3- Soft Tissue Interferences
These are best removed at the time of tooth extraction especially when the
soft tissue distal to the last molar approximates the retromolar pad.
Soft tissue that interferes with complete denture extension and
development of an adequate border seal should be removed
Soft-tissue projections need not be reduced if they are relatively firm and
do not interfere with stability or retention of the complete denture.
4- Vestibuloplasty of shallow sulci
Vestibuloplasty is a surgical procedure to
restore alveolar ridge height and/or width
by lowering muscle attachments and
unattached mucosa from the ridge crest of
the maxilla or mandible to a deeper
position. Vestibuloplasties can be grouped
into three basic techniques: Mucosal
advancement, secondary epithelialization,
and those using epithelial grafts.
Mucosal advancement involves dissection
and advancement of the subepithelial
connective tissue and placement by an
overextended surgical stent. It is used
mostly in the maxilla when there is
sufficient healthy mucosa in the vestibule
Secondary eoithelialization involves the
use of an epically repositioned flap sutured
to periosteum at the desired depth. the
exposed tissue is allowed to heal by granulation and secondary intention.
Epithelial graft vestibuloplasty is basically a secondary epithelialzation
procedure utilizing a skin or oral mucous membrane graft to cover the
exposed tissue.
It is used to increase support, stability and retention of a denture when
there is severe atrophy of the maxilla or mandible or when high muscle
attachments interfere with development of adequate border seal.
5 Palatal inflammatory papillary hyperplasia
Hyperplasic denture stomatitis
Papillary hyperplasia develops in the palatal vault as
multiple papillary projections of the epithelium;
usually it is bright red in colour. It is raspberry-
like in appearance and may involve the whole or
part of the palate.
Clinically, this condition manifests itself in several forms, from small isolated
projections to multiple papillary modular projections with fissures covering
most of the palate.
It is commonly in response to local irritation, poor oral hygiene, and low
grade infections such as Monilia.
May by associated with a relief chamber in the palatal vault area of the
denture. It appears that the pressure changes that occur within the relief
chamber cause a pumping motion.
This condition can also arise in response to tongue habits in individuals who
do not wear dentures.
Management:
Elimination of the mucosal inflammation
- Treatment of the inflammatory component of
this condition is the same as that described for
denture stomatitis. Antifungal agents have been reported to reduce the
inflammatory component but the hyperplasia remains
surgical management of the hyperplasia
- Small lesions may be removed surgically with sharp curettes or be
muco abrasionwith rotary instruments. Larger lesions can be removed
by split-thickness supraperiosteal excision following removal, the
patient'sdenture.
Prosthetic management of the hyperplasia
- If an acrylic denture is constructed without prior surgical removal of
the nodules, sharp spicules of acrylic resin will penetrate the fissures of
the lesion. As all dentures move to a certain extent during function,
these spicules have an abrasive effect on the mucosa and inflammation
will recur. To prevent this happening,
o The spicules should be lightly polished to reduce their
sharpness before fitting the denture.
o An alternative approach is to use a stainless steel denture base
After replacement or adjustment of the dentures, the inflammation and edema
may subside and produce some clinical improvement of the condition.
After surgical excision of the tissue and replacement of the denture, the lesions
are not likely to recur.
6-Epulis fissurata ( denture hyperplasia)
Denture irritation hyperplasia, Denture-induced hyperplasia
The lesions are the result of chronic injury by
unstable dentures or by thin, overextended denture
flanges. takes the form of single or multiple flaps of
fibrous tissue related to the border of a denture
The hyperplasia occurring around the border of the
denture may be fibrous growth referred to as epulis
fissuratum.
The condition is more commonly seen in the lower
jaw than in the upper.
It develops after a thin overextended denture
border ulcerates the oral mucous membrane and is not
treated i.e. the epulis develops as a result of chronic
irritation from ill fitting or overextended denture. Trauma from the denture
border may also occur if excessive tipping, dueto unbalanced occlusion, causing
the denture border to dig into sulcus tissue.
The lesions may be single or quite numerous and are composed of flaps of
hyperplasic connective tissue. Inflammation is variable; however, in the bottom
of deep fissures, severe inflammation and ulceration may occur.
Clinical examination reveals folds of hyperplastic tissue develop under the
denture and over the polished surface of the denture and the denture border fits
into the epulis
Treatment:
a- tissue rest
The hyperplastic tissue diminishes in size if the
denture is not worn for a period of time or if the
flange is cut away from the affected area
b-Eliminate denture trauma
The hyperplasic tissue diminishes in size if the
denture is not worn for a period of timeor if the flange is cut away from the
affected area. Other denture adjustments to reducethe level of trauma may be
indicated, such as applying a short-term soft lining material to improve the
fit and stability of the denture, or correcting occlusal imbalance.
b-Surgical treatment
If the size of the residual lesion is too large to allow adequate extension of the
denture surgerymay be unavoidable.
Surgery followed by suturing may decrease the depth of the vestibule once scar
contraction has occurred vestibuloplasty may be considered to increase sulcular
depth .
7- Denture stomatitis :
The most common pathologic finding in edentulous patient
who wears complete dentures is inflammation. most
commonly in the mucosa of the maxillary denture-bearing
area and does not extend beyond borders of denture
The prevalence of denture stomatitis is about 50% among complete denture
wearers. It may occur alone but is often seen with two associated conditions,
palatal inflammatory papillary hyperplasia and angular stomatitis.
Denture stomatitis occurs more frequently in females than in males, the ratio
being approximately 4:1 . Although the cause of this predisposition to denture
stomatitis in females is not known, possible explanations include endocrine
imbalance, iron deficiency anaemia, vaginal carriage of candida, a higher oral
carrier rate of candida and a greater inclination than males to wear dentures at
night.
Denture stomatitis is a inflammation of the denture bearing mucosa. It occurs
as a localized or generalized redness may vary from a patchy to a diffuse
inflammation of the oral mucous membrane covered by the denture.
In spite of the lesions rather angry appearance the patient rarely complains of
soreness, therefore the term denture sore mouth which was used to describe this
condition in the past is inappropriate.
A small number of patients complain of a burning or etching sensation that is
usually related to both the palatal and glossal mucosae. The condition tends to
occur more frequently in the maxillary arch beyond borders of the denture.
Denture stomatitis occurs more frequently in females than in males, the ratio
being approximately 4 : 1 Although the cause of this predisposition include
endocrine imbalance iron deficiency, anemia, vaginal carriage of candida and
a higher oral rate of candida.
Etiology
It is now widely accepted to be multifactorial in origin. It appears that
behavioral factors, such as poor denture hygiene and wearing the dentures
at night, are more important in the etiology of denture stomatitis than
biological factors.
Trauma from dentures e.g. unstable denture bases, unbalanced occlusion
and anterior hyperfunction, and the presence of fungus candida albicans.
Several reports in the literature have demonstrated the presence of candida
in over 90 percent of patients with denture stomatitis.
Local factors
(1) Candida albicans
This fungus is dimorphic, occurring both as yeast-like
blastospores and filamentous pseudohyphae. In denture
stomatitis, both forms are usually found in large numbers in
plaque on the impression surface of the denture.
Relatively few candida organisms are found on the mucosa and there is no
evidence that candidal invasion of the mucosa occurs.
(2) Bacteria
it has been suggested that a variety of bacteria may also play a part in the
condition.
(3) Poor denture hygiene
Inadequate cleaning of dentures allows the build up of denture plaque
containing candida and other micro-organisms.
In those cases where only a little plaque is seen, it should be realised that a
patient will sometimes have made an effort to clean the dentures in readiness
for the visit to the dentist
(4) Denture trauma
Dentures may traumatize the mucosa either because of the presence of faults
in the prostheses such as loss of fit or occlusal imbalance, or because the
patient exhibits parafunctional activity, such as bruxism, which overloads the
tissues.
Trauma could stimulate the turnover of the palatal epithelial cells, thereby
reducing the degree of keratinization and the barrier function of the
epitheliumhence, the penetration of fungal and bacterial antigens can take
place more easily.
(5) Wearing the dentures day and night
Wearing the dentures at night aggravates the effect of both denture plaque and
denture trauma by increasing the exposure of the palatal mucosa to both
etiological factors.
(6) Diet
Dentures with a reduced masticatory efficiency may encourage a patient to
adopt a relatively easily managed high carbohydrate diet, which favours the
growth of candida and increases the adhesion of the micro-organism to the
denture surface.
An increase in the amount and frequency of intake of relatively inexpensive
carbohydrate may also be encouraged by the patients economic
circumstances.
(7) Other, non-microbial, factors
Diffuse inflammation of the denture-bearing mucosa may occasionally be seen as
result of factors other than plaque or trauma. For example:
(a) Raised residual monomer
A faulty curing cycle when the dentures are processed can result in residual
monomer content highenough to produce mucosal inflammation.
If palatal inflammation and discomfort occur shortly after a new denture has
been fitted, or an existing denture repaired or relined, then a raised residual
monomer content might be suspected.
(b) Self-medication
Palatal inflammation is sometimes caused by patients using topical agents in
an inappropriate way. Certain mouthwashes, ointments or other substances
which are normally free of adverse effects can cause mucosal damage when
applied beneath adenturee.g. chlorhexidine gel, salicylate ointments
Systemic factors
(1) Immunological defi ciencies
(2) Hormonal imbalance, e.g. diabetes
(3) Defi ciencies of vitamin B complex, vitamin C and iron.
Classification: According to Newton's classification, three types of denture stomatitis
can be distinguished:
Type 1: A localized simple inflammation or pinpoint hyperemia.
Type II: An erythematous or generalized simple type presenting a more diffuse
erythema involving a part or the entire denture-covered mucosa.
Type III: A granular type (inflammatory papillary hyperplasia) commonly
involving the central part of the hard palate and the alveolar ridges. Type III
often is seen in association with type I or typeII.
Type I most often is trauma induced, whereas types II and III most often are
caused by the presence of microbial plaque accumulation (bacteria or yeasts) on the
fitting denture surface and the underlying mucosa.
Candida-associated denture stomatitis is relatively often associated with angular
cheilitis or glossitis, which indicates a spread of the infection from the denture-
covered mucosa to the angles of the mouth or the tongue, respectively.
Diagnosis:
From direct smear by the finding of mycelia or pseudohyphae and/or the isolation
of Candida species in high numbers from the lesions.
Treatment
Although denture stomatitis may be symptomless and the patient is often unaware of
its presence it should be treated before new dentures are constructed because:
(1) Swelling of the oral mucosa will have occurred as a result of the
inflammation. Producing a new denture from an impression of the mucosa in
this condition will compromise the fi t of the prosthesis.
(2) The mouth may be the source of candida organisms responsible for
infection in other parts of the body, such as nailbeds, the pharynx and the
larynx. In debilitated patients, systemic spread of candida from the mouth can
occur with fatal consequences.
a) Modification of the patients behavior to ensure proper denture hygiene is
essential for long-term success
Denture hygiene instruction
(1) Motivating and instructing the patient.
The need for meticulous cleaning must be explained to the patient
and the methods for carrying it out discussed, demonstrated and
subsequently monitored.
(2)Leaving the dentures out at night
All patients should be strongly advised to leave their dentures out
at night; in some instances, successful treatment will not be
possible unless the patient conforms to this advice.
(3) Denture and tissue hegine:
The patient should be removed the denture after the meal and
scrub it vigorously with soap before reinserting it.
The mucosa in contact with the denture should be kept clean and
massaged with a soft tooth brush.
(4)Laboratory cleaning and polishing of the dentures.
Where deposits are heavy and possibly partly calcified and where
the surface polishing of the denture has deteriorated.
(5) Disinfection of the dentures.
The dentures should be regularly immersed by the patient in a suitable
disinfectant. Disinfection of dentures by short exposure to microwave
irradiation has been shown
to be effective in vitro but overexposure to the irradiation could have
adverseeffects on the denture materials.
Two solutions have been shown to be effective in controlling denture
plaque: alkaline hypochlorite and aqueous chlorhexidine gluconate.
Either by
- Overnight immersion is necessary if either a hypochlorite solution
containing 0.08% available chlorine or 0.1% aqueous
chlorhexidine gluconate is used.
- When it is impossible to persuade a patient to leave the denture out
at night, immersion in a hypochlorite solution containing 0.16%
available chlorine for 20 minutes daily or in 2% aqueous
chlorhexidine gluconate for approximately 5 minutes daily are
alternatives.
The denture should be brushed thoroughly to remove most of the
plaque and then,
If chlorhexidine is to be used, rinsed carefully to remove any soap
which would otherwise inactivate the chlorhexidine. Patches of brown
staining usually appear on a denture that has been immersed in
chlorhexidine solution. As a rule, the staining is not severe and can be
removed by subsequent immersion in a hypochlorite cleaner.
The presence of a metal denture base complicates matters because
hypochlorite can cause corrosion of the base.
b- Correction of denture faults
(1) Occlusal faults. An unbalanced occlusion should be corrected by occlusal
adjustment or by the addition of cold-curing acrylic resin to the occlusal
surfaces of the dentures.
(2) Impression surface faults. Lack of fit in a denture can be corrected by
applying a short-term soft lining material to the impression surface.
c- Topical antifungal drugs
It could be used to remove C. albicans.
Local therapy with nystatin, or, miconazole, should be preferred to systemic
therapy with ketoconazole or fluconazole as resistance of Candida to the latter
drugs occurs regularly.
They are used topically as lozenges, mouthwashes or ointments applied to the
denture and to the lesion. Where problems with patient compliance are
anticipated some of these agents can be applied to the denture by the dentist as
a component of a tissue conditioner or as a lacquer
d) Systemic therapy
Systemic therapy is indicated in
1- If a cure is not achieved within 23 weeks, and persistent local factors
cannot be identified, systemic causes should be suspected and the
patient referred to a medical practitioner for further investigation.
2- In patients at an increased risk of systemic mycotic infections due to
debilitating diseases, drugs, or radiation therapy.
To reduce the risk of relapse:
1. Treatment with antifungal should continue for 4 weeks.
2. When lozenges are prescribed, the patient should be instructed to take out the den-
tures during sucking.
Surgical elimination of deep crypt formations in type III denture stomatitis usually
is a necessary prerequisite for effective mucosal hygiene. This could preferably be
achieved by cryosurgery.
8- Angular stomatitis (angular cheilitis)
It is an erythematous often erosive, non-vesicular skin
lesion radiating from the angle of the mouth.
it is usually bilateral frequently painful and is rarely seen e
except in denture wearer it is more commonly in female
Maceration results from the continuous bathing by saliva of the skin at the
corners of the mouth, which lowers the resistance of the skin to infection.
Maceration is encouraged by the presence of skin creases which draw saliva
from the mouth by capillary action and which may be due to inadequate lip
support being provided by the upper denture or to the presence of an excessive
freeway space.
Causes
a) It may attributed to reduction of vertical
dimension of occlusion .vitamin B & C deficiency or
candidal infection from contaminated saliva. The
presence of saliva on the skin at the corner of the
mouth may be due to:
a. The patient denture providing
inadequate lip support
b. Excessivefree way space
c. Loss of muscle tone associated with
aging
d. Reducedvertical dimension of occlusion
b) Microbial plaque
It has a role in angular stomatitis which is demonstrated by the observation
that if patients with angular stomatitis do not wear their dentures, a complete
cure usually results in 2 weeks even though all dental support to the lips has
been lost.
c) Causative organism:
Candida albicans is frequently isolated from the lesion of angular stomatitis
where denture stomatitis is also present. However, if angular stomatitis occurs
alone, Staphylococcus aureus is recovered from the lesion twice as often as
candida, in such cases, the nose may be the source of secondary infection with
carriage on the fingers being the method of transmission.
9-Oral cancer in denture wearers
An association between oral carcinoma and chronic irritation of the mucosa by
the dentures often has been claimed.
Case reports have detailed the development of oral carcinomas in patients
wearing ill-fitting dentures. The opinion is still valid that if a sore spot does
not heal following correction of the denture, malignancy should be suspected.
COMPLETE DENTURE THEORY AND PRACTICE Management of Problematic patients16
Management of Problematic Complete Denture Patient
1) V- Shaped palate
Retention is diminished as adhesion is effective if the palate of denture is
horizontal to a vertical displacing force. "V" shaped palate has sloping sides
there is very little of its area which is horizontal to a vertical displacing force
Acrylic denture bases tend to warp during curing the imperfect fit at sharp
angle of palate further reduces forces of adhesion.
Treatment: A cast metal palate may produce a more accurate fit.
2) Flat palate with shallow ridges
The denture may be displaced during mastication through lack of ridge support
and little resistance to lateral displacement.
the shallow sulci adversely influence peripheral seal,
Treatment: Careful peripheral adaptation , balanced articulation or useof cuspless teeth.
3) Tight lip
Lower denture Instability due to backward displacement caused by lip and
vertical lift occurring in premolar and canine region from modioli pressure.
Treatmen:.
Keep the occlusal plane low , thus reducing the contact area with the lip.
Adequate extension on the retromolar pads to counteract the lip pressure.
Keep the denture narrow across the premolar region.
Upper canineand premolars should be prominent to resist modioli pressure on
the lower denture.
4) Large tongue
Reason for difficulty:
If the tongue is cramped or the teeth set up so that they overhang it, the denture
will be moved during function.
Treatment:
Keep the occlusal plane low.
Provide tongue space by using narrow teeth or grinding away the lingual cusps.
Anterior teeth should be set up slightly forward to the ridge.
Peripherally trimmed impression technique.
5) Abnormal jaw relationships
A- Close bite
Reason for the difficult:
Lack of interalveolar space.
Treatment:
Use acrylic posterior teeth.
B- Superior protrusion
Narrow and retrusive lower arch in relation to a normal size upper arch.
Treatment:
Maintain the natural horizontal overlap, which will be large.
Periphery adapted impression technique.
C- Inferior protrusion
Large and wide lower arch in comparison to the upper arch, leading to an
unstable upper denture.
Treatment:
Peripherally adaptedimpression technique.
Metal plate.
Balanced articulation.
Posterior cross bite.
Anterior edge-to-edge bite.
6) Gross undercuts and large tuberosities
See: preparation of the mouth
7) Knife like lower ridge
See: preparation of the mouth
8) Large torus palatines area
See: preparation of the mouth .
9) Abnormal frena
See: preparation of the mouth .
10- Retching : [see Nausea & gagging]
Advanced resorption of residual alveolar ridge
(Residual ridge resorption RRR) Flat ridge
Definitions
it is a chronic, progressive , irreversible , multifactorial and cumulative disease of bone
reconstruction.
In a prosthetic sense, bone is considered to be the base which provides support for
dentures.
Ideal denture support
1. Adequate bone height and width.
2. Fixed Tissue under dentures.
3. Adequate ridge relationships.
4. Adequate space between ridges.
5. Adequate buccal and lingual sulci.
6. Absence of flabby tissue.
7. No obstructing frena or scar bands.
8. No displacing muscle attachments.
9. Adequate saliva.
The retromolar pad is one of the primary support areas. The pad contains glandular
tissue, loose areolar connective tissue, the lower margin of the pterygo mandibular raphe, fibers
of the buccinator, and superior constrictor and fibers of the temporal tendon. The bone beneath
does not resorb secondary to the pressure associated with denture use.
RESIDUAL RIDGE RESORPTION (RRR)
More rapid in Female >males
More rapid in first 6 months after extraction of teeth & slower pace till 12
months.
RRR precipitated by certain systemic disease so in an ideal situation the
systemic disease should be eliminated or controlled first.
The loss of alveolar bone is more pronounced in the mandible than in the
maxilla. Also common in maxillary dentures opposing natural teeth. The
different residual ridge resorption between the mandible and the maxilla
provide a smaller surface area for support.
During the first year after tooth extraction, the reduction of the residual
ridge height in the midsagittal plane is about 2 to 3 mm for the maxilla and 4
to 5 mm for the mandible.
Following healing of the residual ridge, the remodeling process will continue
but with decreased intensity. In the mandible, the annual rate of reduction in
height is about 0.1 to 0.2 mm and in general four times less in the edentulous
maxilla. However, the intraindividual variations are very important.
Most common residual ridge configurations:
Order I, preextraction;
Order II, post extraction;
Order III, high, well-rounded;
Order IV, knife edge;
Order V, low, well-rounded;
Order VI, depressed

Bones with the most severe RRR (Orders V and VI) may display the gross porosity of
medullary bone on the crest of the ridge and eventually may even display the uncovering of the
inferior alveolar canal on the mandible.
PATHOGENES1S OF RRR
Immediately following the extraction (Order II), any sharp edges remaining are rounded
off by external osteoclastic resorption, leaving a high, well-rounded residual ridge (Order III).
As resorption continues from the labial and lingual aspects (see arrows), the crest of the ridge
becomes increasingly narrow, ultimately becoming knife-edged (Order IV). As the process
continues, the knife edge becomes shorter and eventually disappears, leaving a low well-rounded
or flat ridge (Order V). Eventually, this too resorbs, leaving a depressed ridge (Order V1).
In maxilla the resorption occur evenly around the dental arch, but more on buccal and
labial side than on the palatal side ( in horizontal plane).
In mandible resorption proceeds more in labio-lingual and vertical directions
narrowing in maxilla and widening in mandible.
Determination of the amount of RRR
In clinical examination usually one can visually judge the residual ridge form. However,
sometimes a knife-edge ridge may be masked by redundant-or inflamed soft tissues.
One can more accurately determine the amount of underlying bone by palpation in the
mouth than by attempting to take measurements on stone casts.
Lateral cephalometric radiographs provide an accurate method for determining the
amount of residual ridge and the rate of RRR over a period of time.
absorptiometry,
quantitative computed tomography
neutron activation analysis
One of the simplest methods is intraoral micro densitometry, using a dental periapical or
panoramic radiograph.
Clinically, the soft tissues, overlying residual ridges that have undergone RRR may
range from normal to inflamed, edematous, ulcerated, indented, or otherwise abused tissue.
Etiology:
it is more often seen in the older age group. It is an irreversible process which may results from:
I- Anatomic factors:
1- Type of bone: cancellous bone is more prone to resorption than is cortical bone.
2- Size and shape of the ridge: thin narrow ridges will resorb more than well-formed
broad ridges, as the force received per unit area is less in the latter.
3- Facial skeletal morphology: Individuals with longer faces and obtuse gonial angle are
more likely to have atrophy of their ridges than those with short faces and right angle
gonial angle.
II- Biologic / metabolic factors:
1- Age: RRR generally increases with age.
2- Sex: RRR occurs more in females. This usually occurs during menopause, as a result
of hormonal disturbances.
3- Nutritional deficiency: calcium deficiency, decrease in vitamin C and/or protein
utilization and /or dysfunction of carbohydrate metabolism, are contributing factors.
4- Systemic health: RRR occurs more in cases such as:
a) Blood dyscrasis.
b) Uncontrolled diabetes and other debilitating disease that may cause tissue
destruction and reduce tissue resistance.
5- Treatment for certain diseases:
a) Radiation therapy reduces regeneration.
b) Hormonal drugs may have an adverse effect on the hard and soft tissues.
6- extraction of teeth as a result of periodontal contributes to more alveolar atrophy.
III- Metabolic Factors
It is further postulated that RRR varies directly with certain systemic or localized
bone resorptive factors and inversely with certain bone formation factors:
Local bone resorbing factors
The local biochemical factors in relation to periodontal disease could play an
important role in RRR.
- These factors include endotoxinsfrom dental plaque (plaque can occur
in edentulous mouths, especially in patients who do not properly clean
their dentures), osteoclast-activating factor (OAF) prostaglandins,
human gingival bone-resorption stimulating factor, and others.
Heparin, which is a cofactor in bone resorption, has been associated with
mast cells that have been observed in microscopic sections of residual ridges
close to the bone margin.
Trauma (especially under ill-fining dentures), which leads to increased or
decreased vascularity and changes in oxygen tension.
IV- Mechanical Factors
Bone that is "used," as by regular physical activity, will tend to strengthen within
certain limits, while bone that is in "disuse" will tend to atrophy.
The extraction of teeth in the adult is not a normal condition, but is carried out as
treatment for certain pathologic conditions.
Some postulate that RRR is an inevitable "disuse atrophy." Others postulate that
RRR is an "abuse" bone resorption due to excessive forces transmitted through
dentures. Perhaps there is truth in both hypotheses. The fact is that with or without
dentures some patients have little or no RRR and some have severe RRR.
There is a tendency for there to be more RRR in the mandible than in the maxilla.
The amount of force applied to the bone may be affected inversely by the
"damping effect," or energy absorption. The "damping effect" may take place in
the mucoperiosteum, which can be considered a viscoelastic material. In addition,
the "damping effect" of bone itself should be considered.
V- Functional/prosthodontic factors.
a. Functional factors: Habits with complete dentures such as bruxing, grinding and
tapping of teeth may cause advanced resorption of the ridges depending upon the
frequency, direction and amount of force to the remaining residual ridges.
b. Prosthodontic factors:
1- long-term wearing of dentures without serviceability.
2- Improperly constructed dentures with improper vertical dimension of occlusion,
centric relation, non-balanced occlusion and incomplete coverage of basal seat area.
3- Continuous wearing of the dentures without rest to the underlying tissues.
4- Porecelain teeth and/or anatomic teeth with high cusp angles transmit more forces to
the underlying ridge.
The shape of the ridge provides no resistance to lateral movement of the denture, also
interference from adjacent musculature is pronounced.
Consequences of residual ridge resorption:
1- Loss of sulcus width and depth.
2- Displacement of the muscle attachment closer to the crest of the residual ridge.
3- Loss of the vertical dimension of occlusion, reduction of the lower face height.
giving sadness appearance in frontal view .
4- Anterior rotation counterclockwise of the mandible and increase in relative
prognathia.
5- Changes in inter-alveolar ridge relationship following progression of the residual
ridge resorption, which is essentially centripetal in the maxilla and centrifugal in the
mandible.
6- Morphological changes of the alveolar bone such as sharp, spiny uneven residual
ridges and location of the mental foramina close to the top of the residual ridge.
7- Approximation of different structures to the crest of the ridge;
- Sensitive (mental, incisive nerves).
- Muscle and its attachments.
- Bone processes ( genial, mylohyoid,..
- sub mandibular salivary gland.
Management
Surgical management:
a) Vestibuloplasty: It is a surgical proceduredesigned to restorealveolar height
and / or width by detachment of buccal and/or labial and lingual tissues. These
tissues are positioned at a lower level to obtain maximum height of the
residual alveolar ridge.
This could be achieved by any of the following techniques:
i. Mucosa advancement: The subepithelial connective tissue and muscle
insertion are separated from the mucosa and periosteum through
supraperiosteal tunnels. The free mucosa is then advanced to its new
position by an over extended border of a carefully made surgical stent.
ii. Secondary epithelialization procedure: An apically repositioned flap is
sutured to the periosteum at a predetermined vestibular depth. A surgical
stent lined with tissue conditioning material is helpful in retaining the flap
in position and promoting rapid healing of the denuded tissues.
iii. Vestibuloplasty with epithelial grafts: This approach is similar to the
secondary epithelialization procedure except that the denuded tissue is
covered with a free epithelial graft (skin, buccal or palatal mucosa) and is
not left to heal by secondary intention.
b) Ridge augmentation: This procedure is used to increase the height and width
of the residual alveolar ridge. A variety of materials have been used for this
purpose.
a- Autogenous bone from the iliac crest or rib.
b- Non-autogenous bone.
c- Hydroxyapatite, (in the granular or block form) which is injected
through one or more subperiosteal tunnels to build up sufficient
height of the residual ridge.
Bony augmentation of the alveolar ridges often undergoes resorption in a short period of
time whereas the non-resorbable hydroxyapetite prevented this problem.
The block form of hydroxyapetite material avoids many of theproblems
accompanying the use of the granular form such as: Diffusion into adjacent areas resulting in
disfigurement of the patients face, Paresthesia and reduction in the planned height of the
alveolar ridge.
c) Contouring the genial tubercles: This is done to provide for an extension in
the sublingual flange of the mandibular denture.
d) Prominent mylohyoid ridge: It is sometimes trimmed to allow proper
extension of the lingual flange of the mandibular denture.
e) Distraction implants: Recently alveolar ridge distraction has been introduced
for augmentation of the atrophied mandible and maxilla by the help of
distraction implant which contain two mobile
endosteal parts which enable heightening of the
alveolar ridge up to 6 mm.
The prosthetic super structure is loaded 4 to 6
months after distraction. The advantage of
distraction is that there is no need for donor site, simultaneous lengthening of
the surrounding soft tissues as skin, muscles, blood vessels and nerves. The
disadvantages include a long treatment period, need for a suitable distracter
and danger of infection.
f) Osseo-integrated implants: For patients with atrophic edentulous mandible,
the placement of two or more implants anteriorly in the area between the two
mental foramina can be of value in improving horizontal stability and
retention of the constructed implant supported overdenture. These implants
can be used with or without ridge augmentation
Prosthetic management
A- Overdenture If some natural teeth are present in favorable position.
B- Implant overdenture. (The beast methods)
C- Conventional complete denture
Conventional complete denture
Preliminary impression: it is made to obtain a generally overextended registration.
Final Impression making: An ideal impression should provide:
1- Maximum extension without muscle impingement.
2- Intimate contact with the tissue area covered.
3- Proper form of the border including the posterior border of the maxillary denture.
4- Proper relief of hard and sensitive areas.
Different impression technique may be applied according to the condition of the
supporting tissues:
1- Muco- compressive impression technique:
Primary impressionis made with impression compound using a suitable sized
stock tray.
An achieved resin tray is made on the primary casts with occlusion rims on
both the upper and lower trays, being parallel to the ridges, meet each other
evenly and an acceptable occlusal vertical dimension.
Border molding of the periphery is carried out is in the usual manner using
green stick compound until a stable and retentive tray is obtained.
Final impression is made using zinc oxixe and eugenol impression paste while
the patient is closing on the occlusal rims (closed mouth technique.
2- Buitterfly impression technique:
it is indicated in case of advanced resorbed ridge with projecting sublingual glands.
1. A suitable metal tray is selected and the lingual border is made nearly flat to
cover the sublingual crescent area and a primary impression is made using
alginate.
2. On the resulting cast an acrylic resin special tray is fabricated with a butterfly
extension over the sublingual crescent area and an occlusion rim is added to
simulate the height and position of the anterior and posterior teeth.
3. The borders are adjusted so that the lingual flange and sublingual crescent
area are in harmony with the adjacent tissues during rest and function.
4. Three applications of tissue conditioning material are used for making this
impression for closed mouth technique.
5. Two application of a viscous tissue conditioning material. Each application is
allowed to remain in the mouth for 8-10 minutes. Pressure areas are corrected
after each application.
6. Then, third and final wash is made using either a soft tissue conditioning
material or a light bodied rubber base impression material.
7. The end result is an impression that has tissue placing effect, very thick and
confirming buccal borders, relatively thick lingual and sublingual crescent
areas and covering the maximum possible basal seat area within the functional
limits of the adjacent tissues.
3- Dynamic impression technique.
This technique is used to record the range of muscle action as well as spaces
into which the denture can be extended without displacement.
In this technique, complete utilization of the active and passive tissues is
obtained as the impression material is material is being shaped by the
function of the muscles and muscle attachments allowing properly formed
denture borders.
A special tray of activated acrylic resin is constructed on the primary cast.
Three stops of impression compound are added to the fitting surface of the
tray, one at anterior region and one at each side posteriorly in first molar
region to allow a room of two millimeters between tray and surface of cast.
Mandibular rests of impression compound are placed bilaterally on the
occlusal surface of the tray in the molar region.
Also a compound tongue rest is added in the anterior region to secure a correct
tongue position during impression making.
Final impression is made using a thin mix of alginate impression material.
The loaded tray is seated in the patient's mouth and pressed gently until the
stops are firmly seated on the residual ridge.
Then the patient is asked to close slowly until the Mandibular rests firmly
contact the maxillary arch and keep his tongue in contact with the tongue rest.
The patient is instructed to swallow 3-4 times and forcefully protrude the lips.
The resulting impression covers the maximum possible basal seat area and the
borders are in harmony with the adjacent moving tissues.
After making the final impression with any of the previously mentioned
impression techniques the complete denture construction is continued in the
usual manner, taking into consideration the following points.
J awrelation registration is carried out using check bite technique.
Occlusal plane is adjusted nearer to the flat ridge to decrease the lever arm.
A metal denture base is preferred to increase retention by inter facial surface tension.
Cross- linked cuspless acrylic teeth are used to decrease the lateral; component of force
and improve denture stability.
Setting up of teeth in the neutral zone would help to achieve denture stability.
the polished surfaces should harmonize with the musculature --> tongue, lips and
cheeks
Prosthetic factors to reduce the amount of force transmitted to the ridge
Broad-area coverage (to reduce the force per unit area).
Decreased number of dental units.
Decreased buccolingual width of teeth.
Improved tooth form (to decrease the amount of force required to penetrate a bolus of
food).
Avoidance of inclined planes (to minimize dislodgement of dentures and shear forces).
Centralization of occlusal contacts (to increase stability of dentures and to maximize
compressive forces);
Provision of adequate tongue room (to improve stability of denture in speech and
mastication);
Adequate interocclusal distance during rest jaw relation (to decrease the frequency and
duration of tooth contacts); and many more.)
Al veol ar r idge maint enance: see anatomy and physiology
Flabby ridge (Abused tissue)
Hyperplasia: It is the abnormal multiplication or increase in the number of normal cells in
normal arrangement in tissue.
Hypertrophy: It is the bulk of tissue beyond normal caused by an increase in size but not in
number of tissue elements.
Hypertrophy of the mucosa , which does not include fibrous hyperplasia, is usually reversible
and will resolve when the source of trauma is removed, whereas fibrous hyperplasia of the
mucosa is irreversible and necessitates surgical removal.
Flabby ridge tissues are commonly found at the maxillary anterior region and are
usually associated with a maxillary complete denture opposing natural mandibular anterior teeth
without posterior replacements. This also occurs if a mandibular partial denture is present but no
longer provides for posterior occlusal support due to tissue changes
flabby tissue may be localized or generalized over the entire ridge crest area. the most common
site is the upper anterior segment the lower anterior segment and the lower posterior segment.
Flabby tissue compressed during mastication causes the denture to be tilted and
the seal thus broken.
An excessive amount of flabby tissue will cause the denture to shift and move as
force is applied because the denture foundation itself is shifting and moving.
Forms of hyperplasia and Location of Flabby Tissue
- Single or multiple flaps or folds of fibrous tissue related to the border of a denture.
- The lesion may be localized, or generalized over the entire ridge crest.
- Most common: Anterior segment of maxillary and mandibular ridges.
- Posterior segment of mandibular ridge.
Etiology
1. Old loose dentures without serviceability, without relining or rebasing.
2. Anterior masticatory habits or anterior interference causes loadconcentration
on the anterior segment, this may also occur due to reduced vertical dimension
due to occlusal wear.
3. Rapid ridge resorption on lingual and labial on the lower alveolar ridge
frequently results in a narrow knife-edge ridge. The gingival tissue overlying
the bone becomes rolled and the soft tissue proliferates leaving a cordlike soft
tissue ridge crest. The same way occur when the denture is relieved over the
thin wiry crest, which causes a pump action and tissue proliferation. The cord
like ridge may be limited to the anterior region or may extend from one
retromolar pad to the other.
4. Complete maxillary denture opposing natural mandibular anterior teeth.
5. Badly constructed denture such as loose ill-fitting dentures as well as dentures
with wrong centric occluding relation, occlusal disharmony and traumatic
occlusion.
6. Dentures constructed with anterior porcelain and posterior resin teeth.
7. Over eruption of natural teeth against edentulous span.
8. Not removing the dentures during night to allow the basal seat mucosa to
regain its resting form
Treatment: The rehabilitation of abused oral tissue:
The rehabilitation of abused oral tissue is to allow the hypertrophic, traumatized and inflamed
tissues to regain its original form.
a) Remove old dentures from the mouth for few days before making new impressions to
allow the inflammation to subside. However, this may not be possible due to social
obligation of the patient.
b) Another line of treatment to treat each case by elimination of the cause and then, start
a recovery program to allow the tissues to regain its normal healthy.
1- Removeany pressure areas or sore spots using pressure- indicating paste.
2- Relining the old dentures with soft tissue conditioning materials to aid recovery
before constructing new dentures. The material has to be changed every 72 hours
as plasticizer will be leached out and the material will lose its conditioning effect.
3- Correction of occlusal disharmonies by clinical remounting.
4- Elimination of any contact between natural anterior teeth and opposing artificial
teeth.
5- Restoring the occlusal vertical dimension, this may be achieved by applying dough
of self cured acrylic resin on the palatal cusps of the second premolar and first
molar of the maxillary denture after Vaseline application to the oppsing
Mandibular teeth (sears and nelson occlusal pivots).
Initiate Tissue Recovery Program (Lytle):
Massage of the soft tissues two or three times a day to stimulate the blood supply.
Instruct the patient to dissolve one half teaspoon of table salt in a half glass of warm
water and rinse vigorously.
Remove the dentures out of the mouth for at least 8 hours every 24 hours.
Relieve pressure areas
Correct faulty occlusions and denture borders
Minimize stress bysoft diet and removal of denture at night
Use tissue conditioners
If the condition persists then the treatment may be either:
1- Surgical removal of the flabby tissue OR .
2- Prosthetic approach top the flabby tissue as follows:
In a situation with extreme atrophy of the maxillary alveolar ridge, flabby ridges should not be
totally removed because the vestibular area would be eliminated. Indeed the resilient ridge may
provide some retention for the denture.
Prosthetic management of flabby ridge
Primary impression is made in stock trays using low viscosity alginate to reduce tissue
displacement as much as possible.
The final impression is made applying the selective impression technique. This is done
either by providing sufficient relief and drilling holes opposite the flabby tissue OR
carrying out the sectional impression technique as follows:
Acrylic special tray are constructed having windows opposite the area of flabby
tissue.
Border moulding is carried out in usual manner and zinc oxide and
eugenol impression is made and excesspassing through the widow is
trimmed out.
The flabby area is recorded using plaster impression material applied
with a brush several times with the secondary impression in place. After the
impression plaster sets, an overall impression using a suitable stock tray loaded with
impression plaster is used to remove bothsections together.
The jaw relation is recorded using check bite technique (with the least
possible displacement of the supportingstructures).
Cross-linked cuspless acrylic teeth are used to decrease the lateral
component of force.
Teeth are placed in relation to the neutral zone and the bucco-lingual width should be
reduced.
After denture insertion, the patient is instructed for periodiccheck-up of the denture.
N.B.: - Final impression should be done according to the degree of mucosal
displacement.
- If the fibrous tissue is distorted during impression taking, by occlusal
pressure. Elastic recoil of displaced tissue forces the denture downwards
and eliminates retention (tissue rebound). In addition intermittent
occlusion cantraumatize the tissues.
- Minimal displacement could be achieved by taking aworking impression
in a spaced tray using an impression of low viscosity as impression plaster
or low viscosity siliconeimpression material
COMPLETE DENTURE THEORY AND PRACTICE CD FAILURE 17
Denture Failure
Criteria for Evaluating Denture Failures: An unsuccessful
denture is one which fails to fulfill any or all of the following
criteria:
1. Restore lost natural dentition and associated structures of the
maxillae or mandible.
2. maintain health of the tissues of the mouth.
3. help to restore function, phonetics, and esthetics.
4. be comfortable
Of greater importance are the failures of which the patient may
not be aware of, such as dentures which violate certain basic
principles of denture construction, which may permanently
damage the supporting oral structures. This article will discuss
some of the sources of error in denture construction and offer
certain suggestions.
I. Inadequate Patient Evaluation: The most frequent points of
failure.
- Failure to recognize the psychological limitations imposed
by the patient:
1. Many cannot accept the reality of dentures
2. They may have emotional problems which interfere with their
adaptive capabilities.
Examples are clenchers, grinders, gaggers, oversalivation, those
whose mouths become dry when they wear dentures.
- Failure to identify the physical limitations of the patient:
1. Structural abnormalities - resorbed alveolar ridges,
diminutive maxilla or mandible, tuberosities, tori
exostosis, a massive or hyperactive tongue, vibrating line
position may be more anterior and restrict denture space.
2. Systemic illness - is reflected in the tissues of the
mouth by poor tone, low pain threshold, slow healing,
sensitivities, and allergies.
3. Lack of neuromuscular coordination - makes many
steps of denture construction difficult, later these patients
find it difficult to adapt to dentures.
4. Postsurgical and radiation Sequelae - many have
swallowing and speaking difficulties which make it harder
to cope with dentures. Radiation of tissues causes pain ,
sloughing, and slow repair.
II. Failure of the dentist to understand his own limitations:
The two most common are :
A. interpersonal emotional conflicts
B. insufficient professional skill.
- Failure to prepare the patient for dentures: Preparation of the
patient for dentures is as important as construction of the
dentures themselves
1. Physical preparation of the patient - tuberosities,
bony overgrowths, sharp bony spicules
2. Emotional preparation of the patient - try to
determine what dentures mean to the patient, because the
mouth is one of the most emotionally charged areas of the
body.
3. Limiting the expectations of the patient - the most
universal anticipations are youthfulness and the ability to
use dentures like the teeth they once had.
III. Failure to obtain understanding and acceptance of the
treatment plan and fee - schedule an "explanation and
arrangements" session . Define the extent of services and the
time period. The fee and method of payment should be agreed
upon. A letter of confirmation addressing the above issues
should be sent if the spouse is not present. Place an outline in
the patients chart and have them sign it.
IV. Errors in denture construction: most frequent errors are
freeway space, occlusion, improper peripheral extension, poor
adaptation of denture base to tissues, poor esthetics.
V. Failure to seek consultation when indicated:
consultant should examine the patient in the office of the doctor
requesting the consult
consult should be returned in writing
patient may receive reassurance from a third party
VI. Lack of proper aftercare: it occasionally happens that
more time is spent with the patient after the dentures are
completed than during the construction. When such a
contingency is planned for, no problem occurs. Nothing should
be done that would alter the dentures in such a way as to make
them unacceptable from the standpoint of good denture
construction practices.
02-005. Koper, A. Why Dentures Fail. DCNA 8:721-734, 1964.
COMPLETE DENTURE THEORY AND PRACTICE Nausea & Gagging 18
Nausea & Gagging
Retching or gagging is commonly caused by stimulation of the soft palate, the posterior third of
the tongue and the fauces and most commonly occurs when impressions are taken.
Nausea is when the patient is unable to wear dentures without feeling sick. This can vary from
just a few minutes to a few hours. For more detail see impression making
CLASSIFICATION OF GAGGING
1. PSYCHOGENIC
anxiety, fear and apprehension
personality disorders
2. SOMATOGENIC (Kroz)
Due to local, physical or systemic stimuli during dental treatment, the gag reflex
is mostly induced by tactile stimuli to trigger zones
trigger zones sensitive area
- Tonsillar pillars
- Tongue
- Posterior pharyngeal wall
- Soft palate
- Hard palate
TREATMENT
PSYCHOGENIC GAGGING
1. BREATHING EXCERCISES WITH SPOON
2. DIRECTING PATIENTS ATTENTION AWAY FROM ORAL PROCEDURE
SOMATOGENIC GAGGING
No contact of potential trigger zones with instruments
Correction of technical faults of denture
POST DELIVERY GAGGING
1. IMMEDIATE :
- Tongue Interference With Lingual of Molars
- High Plane of Occlusion
- Retracted Tongue Position
2. DELAYED
- Incomplete border seal allowing seepage of saliva under denture
- Malocclusion loosening of dentures
Nausea during Impression Making
A disturbing factor experienced by some patients isthe sensitivity of the dorsum of the tongue to
foreign bodies; such conditions may produce retching and in rare instances actual vomiting. A
successful operation can be assured by adopting one or more of the following methods:
1- A firm sympathetic manner of self-confidence on the operator's part.
2- Assure the patient that no difficulty will be experienced if instructions are followed
and that the discomfort will be minimized as much as possible, being in any case, only
for a short time.
3- The patient should blow the nose to clear any nasal obstruction and then encouraged in
deep, nasal breathing.
4- Explain to the patient that, as soon as the impression is seated, the head may be brought
well forward over the lap and that a bowl will be provided to hold under the chin to
catch any saliva that may run out of the mouth.
5- Carry out the impression technique using as little material as possible. Avoid touching
the dorsum of the tongue with the back of the tray and seat the impression as quickly as
possible.
6- Desensitize the surface of the mucous membrane with:
a- Phenol mouth washes of one part phenol to eighty parts of cold water.
b- Sucking a tablet made for this purpose.
c-The application of a surface type of local anaesthetic either in the form of cream or
spray.
7- Progressive desensitization: As sensitive patients will experience the same difficulty
at each succeeding visit and as the wearing of the finished denture will be difficult, it is
advisable to construct a fitting base plate in acrylic on the first impression and give it
to the patient with instructions to practice wearing it for increasingly longer periods each
day until it can be worn for at least an hour without discomfort.
Patients dislike plaster of Paris more than any other material, even when it is flavoured, the
alginates are tolerated slightly better; composition is usually tolerated well, probably owing to its
putty-like consistency and its heat; zinc oxide paste seems to be disliked least of any but this may
be largely due to its only being used in a tray which already fits, though its flavour of cloves
undoubtly helps in some cases.
8- Exercise to extinguish the reflex by pressing the palate with a toothbrush over a period
of weeks. The brush is laid progressively further and further back until it can touch the
soft palate without causing distress.
Nausea during Denture insertion
The gag reflex is a normal, healthy defense mechanism, to prevent foreign bodies from entering
the trachea.
In sensitive patients, the gag reflex is easily released after placement of new dentures, but it
usually disappears in a few days as the patient adapts to the dentures. Persistent complaints of
gagging may be due to
1. An over or under-extended especially the posterior part of the maxillary denture and the
distolingual part of the mandibular denture).
2. Poor retention of the maxillary denture.
3. Inadequate tongue-space
4. The acrylic denture base too bulky.
5. Post-dam area of the denture too far posteriorly.
6. If the upper occlusal plane is too low causing the denture to be in contact with the
posterior surface of the tongue.
7. Excessive incisal contact on mandibular protrusion which causes the back edge of the
denture to move away from the tissue can cause the underlying mucosal glands to be
milked of their secretions which collect between the denture base and the mucosa can
make the patient feel sick.
8. Unstable occlusal conditions. The unbalanced or frequent occlusal contacts may
prevent adaptation and trigger gagging reflexes
9. If the denture is removed and the secretion wiped off and on replacing the reflex has
gone then this is diagnostic.
10. In cases where excessive bulk and large coverage of the denture is the cause specially
designed palate-shape to avoid the sensitive areas is sometimes successful if the
anatomy of the palate is favourable. It is often described as a horse-shoe shaped denture.
11. Increased vertical dimension of occlusion.
The cure is the correction of all or any of the design faults
Different techniques to manage gagging have been reported in the literature.
TheSaudi Dental J ournal, Vol. 2, No. 4, December 1990
Leslie adopted a surgical technique;
Singer placed five marbles in the mouth;
Landa, Krol, and Kovats1 mentioned psychological approaches.
Psychotherapy hypnosis was applied by Shaw and Weyanat.
Behavioral therapy was used by Appleby and Day.
Pharmacological agents have also been used. Peripherally acting drugs, i.e. topical
anaesthesia sprays, gels or lozenges, and injections, have been widely used in clinical
techniques.
Centrally acting drugs, i.e. antihistamines, sedatives, tranquilizers, and CNS
depressants, have also been used to treat the problem.
In wearers of old dentures, gagging may be a symptom of diseases or disorders of the
gastrointestinal tract, adenoids or catarrh in the upper respiratory passages, alcoholism, or severe
smoking.
COMPLETE DENTURE THEORY AND PRACTICE SINGLE COMPLETE DENTURE 19
SINGLE COMPLETE DENTURE
A single complete denture is a complete denture that occludes against some or all
of the natural teeth, a fixed restoration, or a previously constructed removable partial
denture or a complete denture.
A single complete denture may be constructed for either the maxillary ridge or the
mandibular ridge to oppose a dentulous arch or a partially edentulous arch.
Single Complete Maxillary Dentures VS
Natural dentition
Partial lower denture
Existing complete denture
Why we dont extract all teeth
In patients with discrepancies in jaw size who require a complete denture, it is advisable
to retain teeth in mandible.
In patients with inoperable cleft or perforated palates, it is advisable to retain teeth in
maxillary arch. This is because the convectional maxillary complete denture would be a
failure due to absence of peripheral seal.
I-Maxillary Single Dentures
maxillary single dentures is commonly encountered and better preferred compared
to lower single dentures due to the larger supporting area and due to the nature and form of
the supporting tissues.
Some problems difficulties are associated with the construction of maxillary single
dentures, these are:
1) Malposed, tipped, or supererupted teeth in the lower arch make it difficult to
achieve a harmonious balanced occlusion. This results in horizontal forces which
tend to move upper denture forwards causing soreness of the mucosa and enhancing
residual ridge resorption.
For this reason, grinding and correction of the offending teeth and adjustment of
the occlusal plane should be carried out before denture construction.
2) The fixed positions of the mandibular anterior teeth make the esthetic and phonetic
placement of the maxillary teeth difficult without introducing anterior
interferencesin eccentric functional movements.
3) Abrasion of the artificial teeth if acrylic resin is used or the abrasion of natural
teeth if porcelain is used.
4) The opposing natural teeth usually exert excessive forces that exceed the
physiologic tolerance of the tissues underlying the denture. This results in rapid
resorption of the residual ridge and the formation of flabby tissues.
For this reason, maximum extension of the denture base within physiologic and
functional limits is recommended in order to widely distribute the applied forces and
to reduce the pressure per unit area thus reducing the effect of the applied forces.
This requires a properly extended impression.
5) Excessive pressure exerted by the natural teeth also predisposes the denture to
Displacement
Fracture due to flexure
Severe residual ridge resorption.
For this reason, a strong metal base may be required to withstand the applied
forces.
6) The opposing lower anterior teeth are usually over erupted resulting in excessive
deep bite and a steeply inclined incisal angle.
For this reason, it may be necessary to either reduce the lower anterior teeth by
grinding or increase the horizontal overlap be placing the upper anterior teeth
forwards without adversely affecting esthetics and phonetics.
7) The presence of usually over erupted opposing lower anterior teeth hinders proper
adjustment of upper occlusion rim as the labio-lingual thickness of the wax rim
makes difficult for the lower anterior teeth to close behind the wax rim and the
incisal edges of teeth will contact the wax rim resulting in increased vertical
dimension .
For this reason, wax rim should be adjusted by removing wax palataly to free the
contact between the wax rim and anterior teeth.
8) Condition of the opposing arch. The most common condition is an irregular
occlusal plane. This often occurs due to a tilting and/or extrusion of teeth following
the extraction of a mandibular first molar or second premolar, or both. The second
and third molars exhibit an mesial inclination, and their distal halves supererupted.
This results in irregular occlusal plane and consequent unfavorable force
distribution.
9) Combination syndrome and associated changes (Kellys Syndrome)
Management of single complete denture problems:
I- General principles
Proper diagnosis and applying the principles of c.d construction
Maximum base extension within functional anatomical limits
(distributed forces over the largest possible area of supporting structures
and the force per unit area kept at minimum.)
Reduction of the forces to which the denture is subject
II-Occlusal problems
A. Tilting and supereruption of second and third molars:
B. Insufficient mandibular teeth are left to occlude with a complete maxillary
denture.
C. Irregular occlusal plane
III- Esthetics and phonetics
IV- occlusal materials for the single denture
V- Denture Fracture
I- OCCLUSAL PROBLEMS
A- Tilting and supereruption of second and third molars:
When missing lower first molars, or second premolars, or
both, the remaining molars are often severely inclined
mesially and their distal halves supererupted.
If this situation is left unaltered, there would be no
occlusion in protrusive and lateral excursions except for contact on the distal half of
the lower molars. These result in the maxillary denture being easily dislodged
during function movements.
Treatment:
If the molars are not severely tilted, they may be reshaped by selective
grinding of the distal half of the occlusal surfaces until become flat so denture
teeth set to occlude only with that area, leaving mesial cusps out of contact.
When more than a moderate amount of tooth reduction is found necessary,
the ideal treatment is to restore tilted molars with cast gold crowns, onlays,
or a fixed bridge if a large edentulous space exists mesial to the molars.
If a large space does exist mesial to the tilted molars, another alternative
treatment is to design a removable partial denture that would restore the
mesial half of the molars. By lowering the distal cusps and restoring the
mesial cusps using an onlay mesial rest, the occlusal surface may be restored
to an acceptable form.
Another possible treatment would involve the orthodontic repositioning of
the tilted molars.
Extraction
B- When insufficient mandibular teeth are left to occlude with a complete maxillary
denture.
The presence of a few anterior teeth places an excessive load on the maxillary
anterior alveolar ridge, which may lead to bone resorption along with hyperplasic
tissue changes.
Treatment:
When all the molars or more teeth are missing; a removable partial denture
is indicated.
If all teeth remain from first molar to first molar then a removable partial
denture is usually not indicated. The only exception to this rule would be
perhaps in a class II (retrognathic) jaw relationship, since the mandibular
premolars would be distributing the forces of mastication further posteriorly
than in a class I or class III jaw relationship.
C- Irregular occlusal plane:
The most common condition of the mandibular arch is an irregular occlusal
plane. This often occurs due to a tilting and/or extrusion of teeth following
the extraction of the maxillary teeth and one or more of the mandibular
teeth.
Treatment:
Modification of the mandibular occlusal palne is carried out by
selective grinding, if the irregularities are not severe.
Tooth Reduction Protocol.
Confirm pulpal maturity (X-rays, EPT)
No anesthesia
Begin with teeth requiring most reduction
Method of Modifications of Natural Teeth:
1) Swenson 1964.
Thelower natural teeth that interfere with the placement of the denture teethare
adjusted on the cast and the area is marked with a pencil.
Natural teeth are then modified using the marked diagnostic cast as a guide.
After the occlusal modifications have been completed, a new diagnostic cast of
the lower arch is made and mounted on the articulator. If more adjustment is
seemed necessary, the procedure is repeated.
Once the occlusal modification appears to be sufficient, the denture teeth are
reset and prepared for the try-in.
While this technique is simple, it can be time consuming if several impressions and
mountings must be made.
2) Yurkstas 1968 : use of U-shaped metal template
A metal U-shaped occlusal template that is slightly
convex on the lower surface is placed on the occlusal
surfaces of the remaining teeth; the cusps to be adjusted
are identified. E.g. Misch Occlusal Analyzer.
stone cast is modified to a more acceptable occlusal
relationship and areas reduced are identified by marking
with a pencil. cast is then used as a guide for modifying the natural teeth
3) Bruce 1971 : clear acrylic template
The lower diagnostic cast is mounted. The necessary
modifications are made on the stone cast occlusal
surfaces.
A clear acrylic resin template is fabricated over the modified stone cast.
The inner surface of the template is coated with pressure-indicating paste
and placed over the patient's natural teeth.
Interferences are noted through the template and
are removed by reshaping the occlusal anatomy. The
process is repeated until the template seats properly.
4) Boucher et al 1975 : use of maxillary porcelain teeth
First, the casts are mounted on a programmed articulator as with the other
techniques. The maxillary artificial teeth are arranged to obtain the best
possible occlusal balancing contacts.
If the mandibular natural teeth prevent this balancing, the interferences are
removed by movement of the maxillary porcelain teeth over the mandibular
stone teeth.
After the denture has been processed, a comparison of the natural teeth and
the altered stone cast is made and the areas to be reshaped are noted.
The natural teeth are ground at the areas marked on the stone cast. The
occlusion is refined using an arch-shaped layer of softened baseplate wax
over the lower teeth and guiding the patient to close in centric relation.
Prematurities are identified and removed by grinding the natural teeth. The
procedure is repeated for right and left lateral excursions until a harmonious
balanced occlusion is established.
Single Denture Occlusion
An occlusal scheme that employs a multiplicity of point contacts, rather than one
that utilizes broad-surfaced contacts on inclined planes is advocated.
John J. Shary
Occlusal requirements of the single complete denture
a. Maximum intercuspation of the teeth should be in the centric relation position, with
occlusal contacts as follows:
- Occlusal contacts are on teeth surfaces which transmit forces in a vertical
direction (seats the denture).
- Occlusal contacts are never on incline planes, since they generate horizontal
dislodging forces upon the denture.
- The anterior teeth are out of contact in centricrelation closure.
- The setting of the posterior teeth must ensure that the opposing inclined planes
do not contact as the jaw closes into CO. Only those surfaces of opposing teeth
should contact which transmit occlusal forces vertically.
- This arrangement can be provided with the use of both non-anatomic and
anatomic teeth.
o Non Anatomic Teeth are selected if the natural posterior teeth have
flat cusps due to attrition. Balanced occlusion may not be achievable
however, free articulation must be obtained.
o Anatomic Teeth are selected if the cuspal form of the natural teeth
has been retained. These should be arranged with good
intercuspation in CO (cusp-fossa relation).
- As the artificial teeth are usually smaller mesiodistally than the natural teeth,
small spaces may have to be left between them for proper intercuspation.
- Similarly, artificial teeth may need grinding of the cuspal inclines to
accommodate for the much larger bucco-lingual width of the natural teeth.
b. Balanced occlusion may not be achievable however, free articulation must be obtained.
After the occlusal plane has been levelled , what type of occlusion will we have? We
need Equal contacts in centric occlusion and no interferences in excursive movements
(commonly referred to as functional occlusion)
OR
c. However a cross bite molar relationship is required in the following:
When interdigitation of the posterior denture teeth with the opposing
natural teeth, results in the buccal surfaces of the denture teeth being set in the
buccal vestibule area. This wide occlusal position will create denture instability.
To prevent this problem, it is necessary to move the denture teeth lingually into a
cross bite molar relationship.
Anterior Tooth Arrangement
Lip support
Minimal vertical overlap (Overbite) [see esthetic ]
Protrusive balance
Posterior Tooth Arrangement
Shay Concept
No interdigitation (cusp to fossa)
Cusp to cusp
Maxillary Lingual VS mandibular Buccal
c.f. Lingualized
Avoid broad inclined planes
Why is bilateral balance so important?
Tipping of the denture and excessive lateral forces leadto resorption of
the edentulous arch
Premolar Occlusion
Indications
Short posterior edentulous span 2nd PMs
Adequate mastication Class II
Methods Used to Achieve Balanced Articulation
After adjustment of the occlusal plane of the natural mandibular teeth, a balanced
articulation for the maxillary complete denture is developed by one of the following
methods:
A. dynamically equilibrate the occlusion by the use of a functionally
generated path,
B. Statistically equilibrate the occlusion using an articulator programmed to
simulate the patient's jaw movement.
A-Functionally Generated Occlusal Pathways (Chew-In Technique):-
This technique provides the most accurate method of recording occlusal patterns.
Requirement:-
1) The record base should be stable.
2) The patient must have the neuromuscular control to perform the desired jaw
movements.
Technique:
A compound maxillary rim is trimmed buccally and lingually so that the
occlusion is free in lateral excursions.
Wax is added to the compound rim, and the patient is instructed to perform,
eccentric chewing movements.
The wax is slowly molded to functional movements, while the compound in
the central fossa acts as a guide to preserve the vertical dimension.
The generated occlusion rim is now removed from the mouth, and stone is
vibrated into the wax paths of the cusps.
The upper cast is again fastened to the articulator with the generated
occlusion rim and the stone cusp path record. Thestone cusp path record is
secured to the lower member of the articulator with plaster. Now we have
the upper cast mounted on the articulator and two lower casts. One is a
duplicate of the lower teeth and the other is a replica of the generated path.
The denture teeth are first set to the lower cast of the patient's teeth.
Try-in and check up of esthetics is carried out.
The lower cast is removed and the lower chew-in cast record is then secured
to the articulator. All interfering spots in the denture teeth with the chewin
cast are carefully ground until the incisal guide pin prevents further closure.
Other Techniques for Functional Chew-In
1) Stansbury In (1928)
He described the first functional chew in technique for an upper complete
denture opposing lower natural teeth. By using a compound maxillary rim
trimmed buccally and lingually so that the occlusion free in lateral
excursions.
Carding wax is added to the compound rim, and the patient instructed to
perform, eccentric chewing movements. The carding wax is slowly molded
to the functional movements, while the compound in the central fossa acts
as a guide to preserve the vertical dimension.
The generated occlusion rim is now removed from the mouth, and stone is
vibrated into wax paths of cusps. The upper cast is again fastened to the
articulator with the generated occlusion rim and the stone cusp path record.
The stone cusp path record is secured to the lower member of the articulator
with plaster. We now have the upper cast mounted on the articulator and
two lower casts. One is a duplicate of the lower teeth and the other is a
replica of the generated path. The denture teeth are first set to the lower cast
of the patient's teeth.
After the esthetics have been approved at the try-in, the lower cast is
removed and the lower chew-in cast record is then secured to the articulator.
All interfering spots are carefully ground until the incisal guide pin prevents
further closure. Thus. in centric and in eccentric movements maximum
bilateral balanced occlusion will have been established.
2) Vig In1964
He described a similar technique, by using of a fin of resin placed into the
central grooves of the lower posterior teeth, instead of using compound as
mentioned by Stansbury.
The resin fin maintains the vertical dimension and also helps to
diagnostically locate interfering lower cusp in eccentric movements the
lower cusp are ground until evencontact occurs between teeth and resin.
The fin is then built up using a soft wax, and a functional path is recorded.
3) Sharry In 1968
He mentions a simple technique of using a maxillary rim of softened wax.
Lateral and protrusive chewing movements are made so that the wax is
abraded, generating the functional paths of the lower cusps. This is
continued until the correct vertical dimension has been established.
4) Rudd In 1973
He used a compound maxillary rim as the same way. A thickness of
recording matrix, made up of three sheets of medium-hard pink baseplate
wax and two sheets of red counter wax, is added to the buccal and lingual
surfaces of the compound rim. He also using two maxillary bases, one for
recording the generated path and the other for setting the teeth. The
advantage of this is to reduce the number of appointments necessary for the
construction of the upper denture.
B- Articulator Equilibration Techniques:
If the denture bases lack stability or if the patient is physically unable to form a
chew-in record, the articulator equilibration method is preferred as follows:
The upper cast is mounted on an articulator using a face-bow. The lower cast
is related to the upper by a centric interocclusal record at an acceptable ver-
tical dimension and mounted on the articulator.
The buccolingual position of the lower teeth and their relation to the upper
arch is studied. A decision whether to articulate the central fossa of the
denture teeth to the lower buccal cusps or to the lower lingual cusps must be
made. Occasionally, because of tipped and inclined natural teeth, the buccal
cusps may be used in some and the lingual cusps in others.
If the denture teeth appear to be placed too far to the buccal when articulated with
the lower buccal cusps, they are reset to oppose the lower lingual cusps. If the denture teeth
appear to be placed too far, lingually when articulated with the lower lingual cusps, they
are reset to oppose the lower buccal cusps. Occasionally, because of tipped and inclined
natural teeth, the buccal cusps may be used on some and the lingual cusps on others.
Once the holding cusps (upper buccal or lingual) have been selected, the
inclines of the remaining cusps are reduced. This allows for a cusp-to-fossa
relationship between the upper and the lower teeth, simplifying the posterior
tooth setup and facilitating the task of balancing theocclusion.
If any of the natural teeth are supererupted or tipped, they are modified by
selective grinding or by restoring with a crown or onlay until an acceptable
occlusal plane is established. Therefore, in centric occlusion the only areas of
contact on the denture should be in centric fossae.
At the time of the wax try in, eccentric records are made and the condylar
inclinations are set on the articulator.
The upper posterior teeth are arranged to be as close to being balanced in
eccentric movement as possible.
After the denture has been processed, it is again related to the mounted lower
cast with a new centric interocclusal record (clinical remounting). The
condylar inclinations previously determined are reset on the articulator.
Selective grinding is performed to reestablish contact of the centric holding
cusps and eccentric balance is achieved. This is simply accomplished by
selectively grinding the interfering buccal and lingual cuspal inclines of the
upper teeth.
II-ESTHETICS (and anterior teeth occlusion)
In many cases the fixed positions of the mandibular teeth limit the ability to
esthetically position the maxillary anterior teeth and at the same time allow for
balancing the occlusion in eccentric movements. as esthetics requires a greater
vertical overlap, which will increase the incisal guidance (angle).
To achieve balanced occlusion with the presence of a greater vertical overlap, one
of the following alternatives is selected:
1- The use of steeper posterior teeth. This is a less desirable situation, since
steeper cusp angles reduce the stability of denture base.
2- Enough horizontal overlap can be created to decrease the incisal
guidance and allow freedom to balance in eccentric excursions and still
maintain esthetics.
3- Alteration of the clinical crowns of lower anterior teeth by selective
grinding or with restoration.
With a fixed vertical overlap (VO), as the
horizontal overlap (HO) increase the
incisal angle decrease.
Arrangement of Denture Teeth
a) Incisal angle: the flatter the angle the more stable the denture.
b) Reduce the amount of overlap by
1. raising the incisal edges of the denture teeth and making it
compatible with condylar guidance and the curve of Spee.
2. Reduce the length of the mandibular interiors.
3. A combination of both (1) and (2).
4. Do not set the upper teeth too far palatally use
the biometric guides.
5. Grind the labio-incisal surfaces of the lower teeth
and the palato-incisal surfaces of the upper teeth
to gain more OJ .
c) The incisal angle is manipulated to be compatible with angle of the second molar
to the occlusal plane by Use of 2nd molar as a balancing ramp.
d) The cuspal inclinations of the posterior maxillary denture teeth
are relatively flat and the compensating curve is 15 to 20
degrees. The incisal angle is compatible with the angle of the
compensating curve. During function tipping of the denture will be
minimized and therefore resorption minimized.
e) Natural anterior teeth must not contact the opposing complete denture in CR and
during Eccentric movements.
III- OCCLUSAL MATERIALS FOR THE SINGLE DENTURE
A- Porcelain Teeth
Porcelain teeth wear very slowly and therefore the occlusal vertical dimension is
maintained.
Disadvantages:
They are predisposed to fracture and chipping when opposed by natural teeth.
They are more difficult to equilibrate since their surfaces do not mark well with
articulating paper.
They cause rapid wear of opposing natural teeth
B- Acrylic Resin Teeth
Since acrylic resin teeth cause no wear of the opposing natural teeth and since they
are the easiest to equilibrate, they are the teeth of choice.
Disadvantage of resin teeth is their wear, which results in loss of vertical
dimension. However, wear of the occlusal surfaces is better than resorption of the
alveolar ridge. New dentures can always be made.
C- Acrylic Resin Teeth with Gold Occlusal surfaces
Gold occlusal surfaces are considered the best material to
oppose natural teeth.
Disadvantages: Their expense and the time involved in
their fabrication make them impractical for most patients.
D- Acrylic Resin with Amalgam Stops:
The amalgam inserts appear to reduce the occlusal wear,
and the technique is simple and much less time consuming
and less expensive than with the gold occlusal.
After the acrylic teeth have been balanced, occlusal preparations are made in the
acrylic teeth. Amalgam is condensed into the preparations and the articulator is
gently closed, going side to side and back and forth until the incisal guide pin is
again flush with the guide table.
E- IPN Resin
This material consists of an unfilled, highly cross-linked, interpenetrating polymer
network. The wear resistance of this material is higher than that of conventional
acrylic resin teeth.
F- Acrylic composite resin teeth
Non anatomic teeth are used if cusps of natural teeth exhibited wear or have been reduced
during occlusal adjustment. However, if natural cusps have been retained, anatomic teeth
are used.
IV- DENTURE FRACTURE:
This condition is common in cases with single complete denture, as the denture with
receive excessive load from the natural teeth;
Excessive anterior occlusal load.
Deep labial frenal notches.
High occlusal load due to excessive action of messeter.
PRECAUTIONS
Check the occlusion.
Maintain adequate thickness of the denture base.
Do not deepen the labial notch.
DIAGNOSIS AND TREATMENT PLANNING:
Unfavorable force distributions may then cause adverse tissue changes that
compromise optimum function. These changes include
1) Extensive morphological changes in denture foundation that can result in arch
relationship or occlusal plane discrepancies,
2) jaw relationship extremes,
3) Excessively displaceable denture-bearing tissue.
4) Routine morphological changes occur following tooth extraction and result in a
generally smaller maxilla when compared with the dentulous state. This creates a
cross bit anteriorly and posteriorly.
The best strategy for correcting this discrepancy posteriorly is to place the teeth in a
reverse horizontal overlap or crossbite arrangement. However, such a correction
procedure for the anterior discrepancy is not possible due to the esthetic impact on
the maxillary lip of such a tooth position. This also as in the situation with a Class
III skeletal relationship
5) Changes in the denture foundation also can occur due to longstanding
uncontrolled occlusal forces. As in {combination syndrome (Kelly syndrome)}.
CLINICAL AND LABORATORY PROCEDURES:
1) Final impression is made of the maxillary arch, and an opposing impression
is made of the mandibular arch.
2) Recording Intermaxillary Relations for Single Upper Denture: Removing
from the upper rim whatever quantity of wax is necessary to achieve the
required degree of jaw closer. The incisal level of the upper front teeth and the
occlusal plane can be determined later by reference to the lower natural teeth
2) Centric relation on record is made in wax. When stable centric stops are not
feasible because of a reduced mandibular dentition, a partial mandibular occlusion
rim must be employed for the CR record.
3) Face-bow registration is made, and the casts are mounted .
4) The condylar guidances on the articulator are set to either an average value or
to settings provided by protrusive records. The incisal guidance is set at the angle
considered necessary for the denture's occlusion. Horizontal settings will allow for
shallow inclines and a more stable denture during eccentric contact movements.
5) Teethselection: The morphology of natural teeth will determine the selection of
the artificial teeth. Eg,. The size and shade of artificial teeth should match the
natural teeth.
If mandibular teeth are attriated, 0 or cuspless teeth are preferred.
It mandibular teeth are not attriated, anatomicteeth are preferred.
Esthetics will influence the angle of the incisal guide because the vertical position
of the anterior teeth varies with the amount of vertical overlap used.
6) The teeth are arranged with the proper inclinations and vertical overlaps but
without following the exact occlusal plane of the opposing natural teeth when their
arrangement is not ideal.
7) The teeth placed in the hard baseplate-wax occlusion rim are then evaluated on
the articulator in eccentric positions.
8) Modifications to tooth position are made to provide stable cross arch balance
within a functional range of eccentric movement (2mm).
Difficulties found with maxillomandibular jaw relations for the single maxillary
denture:
A. The finalized maxillary wax occlusal rim
may not be parallel to the ala - tragus line,
since the opposing occlusal surfaces of the
mandibular natural teeth will dictate the
angulation of the occlusal plane.
b. The labiolingual thickness of the anterior
wax occlusal rim will interfere with
establishing the correct vertical dimension of
occlusion, if the future anterior teeth
arrangement will require vertical overlap. (fig.
A)
c. Occlusal rim occlusion: The anterior-lingual portion of the maxillary anterior
wax rim must be made thin, in order to allow the lower incisors to produce the
correct vertical overlap for establishing the correct vertical dimension of occlusion,
which will be less than the vertical dimension of rest.
Maxillary Denture Opposing a Distal Extension Removable Partial
Denture see combination syndrome
With some careful grinding of the canines we can produce a bilateral balanced occlusion
As a general rule, the closer the situation resembles a complete upper and lower denture
set-up, the better the chance for bilateral balanced occlusion .
If for economic reasons, periodontal concerns, sensitive teeth, etc. the patient wishes to
have no mandibular tooth replacement, what then?
- Patient education
- Metal palate in the maxillary denture
Single Complete Denture Opposing An Existing Denture
There are several factors that should be evaluated prior to the initiation of treatment
the teeth of the existing denture should be aligned with regards to the residual ridge
of its basal seat for mechanical stability and masticatory efficiency
the teeth of the existing denture should be has a properly aligned occlusal plane
the denture base is extended to utilize the available supporting tissues.
the denture base should have an esthetic contour and thickness
has good appearance, and
be stable and retentive
II-Mandibular Single Dentures
Very rarely the mandibular arch is the edentulous one. It usually happens due to
surgical or accidental trauma, i.e., radiation therapy of the jaw, fall, vehicle
accident or gunshot.
The denture bearing area for the lower denture is usually
limited and smaller in comparison to those underlying
maxillary dentures.
The supporting tissues are also less tolerable to occlusal
stresses transmitted by opposing natural teeth due to the porous cancellous nature
of the residual ridge which enhances the rate of lower ridge resorption.
For this reason, it was previously preferred to extract the opposing natural teeth and
avoid the construction of lower single dentures. However, this is against the recent
trends in conservative dentistry.
Difficulties:
a) Excessive load
b) Occlusal problems
c) Minimal denture foundation area
Three factors should be considered while treating such patients.
1. Preservation of Residual Ridge: Opposing natural teeth would apply greater
force and tongue activity can lead to denture movement hence rate of bone
resorption could be high.
2. Necessity for Retaining Maxillary teeth: These may be needed to retain
prosthesis, e.g., cleft palate, or these may be esthetically attractive and
periodontally healthy.
3. Mental Trauma: Loss of mandibular teeth is already traumatic to the patient and
advising the removal of remaining maxillary teeth will undoubtedly be traumatic
that may lead to depression.
Treatment modalities for lower edentulous ridges
Retention of key roots to provide additional
support and construction of lower overdentures; if
the patient presents with few remaining teeth that
are not candidates as partial denture abutments and
are rather indicated for extraction. It is preferred to
retain those teeth, reduce their contour and height to be used as overdenture
abutments.
Placement of implants and construction of implant supported overdentures.
Liningthe lower single denture with a resilient permanent soft liner.
There are two situations when a mandibular complete denture, opposing upper natural
teeth is accepted:
1. When the patient has a class III jaw relationship. This occur when the mandible is
larger than normal or the maxilla is smaller than normal.
2. When the patient has a cleft palate, either with the cleft partially open or closed.
The Favorable Situations
Occasionally, constructing a single mandibular complete denture is not potentially harmful,
e.g.,
1. When the maxillary arch has already been restored with a complete denture.
2. When all the maxillary posterior teeth are also missing and the patient needs a
bilateral distal extension maxillary RPD. The biting forces applied by the RPD will
be lass aremagnitude.
3. Very old and frail patient; the biting forces applied by the natural teeth would be
small, hence less damage to the mandible.
Complete denture theory and practice Combination syndrome 20
Combination syndrome
Anterior hyperfunction syndrome, Kelly disease.
Definition:
History
clinical changes
Mechanics, which produce the combination syndrome
Prevalence among denture patients
Pathogenesis
Histopathology;
prevention of combination syndrome
Treatment planning
Maintenance
Syndrome is a set of symptoms which occur together.
Definition:
Combination Syndrome is: the characteristic features that occur when an
edentulous maxilla is opposed by natural mandibular anterior teeth including;
loss of bone from the anterior portion of the maxillary ridge,
overgrowth of the tuberosities,
papillary hyperplasia of the hard palatal mucosa,
Extrusion of mandibular anterior teeth,
Loss of alveolar bone and ridge height beneath the mandibular
removable partial denture bases.
History
A- Ellsworth Kelly was the first person to use the term combination
syndrome. it was in 1972, as destructive changes in hard and soft
tissues of patients with complete maxillary denture opposing an
unstable bilateral free-end mandibular partial denture. The long-term
result is
Extrusion of the remaining mandibular anterior teeth and the alveolar
process surrounding them .
Lossof posterior mandibular bone.
The plane of occlusion becomes reversed.
Papillary hyperplasia of the hard palate develops.
The premaxilla becomes atrophic as a result of the force exerted on this
soft bone during occlusion.
The maxillary tuberosity develops hypertrophy, creating a limited
interarch space.
The groups of complications occurring in these patients are interlinked to one another
and collectively represent a syndrome. If not corrected, the unstable occlusion can
result in progressive posterior mandibular atrophy leading to greenstick fractures.
Combination Syndrome is an occlusal problem that slowly develops over time.
B- Tillman in 1961 described Problems associated with the provision of
complete lower denture opposed by an upper removable partial denture
(RPD), while Kelly described the oppositeScenario.
TheKelly condition is most likely to be the result of the usual pattern of tooth loss
in which maxillary teeth tend to be lost before mandibular teeth.
Clinical changes
Five signs or symptoms commonly occurred in this situation. They include:
1. Loss of bone from the anterior part of the maxillary ridge.
2. Overgrowth of the tuberosities.
3. Papillary hyperplasia in the hard palate.
4. Extrusion of the lower anterior teeth.
5. The loss of bone under the partial denture bases
Saunders et al later described six additional signs. They include:
1. Loss of vertical dimension of occlusion.
2. Occlusal plane discrepancy.
3. Anterior spatial repositioning of the mandible.
4. Poor adaptation of the prostheses.
5. Epulis fissuratum.
6. Periodontal changes
.
MECHANICS, WHICH PRODUCE THE COMBINATION SYNDROME
The maxillary denture moves up in the anterior region and down in the posterior
region in function.
The fulcrum of movement in this patient is in the cuspid and first
bicuspid region. patients show that at first the fulcrum is well to the
posterior, just anterior to the tuberosity.
With the posterior palatal seal, a negative pressure is produced
posterior to the fulcrum line. This negative pressure may account for
the enlarged tuberosities and the papillary hyperplasia.
Kellys theory suggests that
Negative pressure within the maxillary denture pulls the tuberosities down,
as the anterior ridge is driven upward by the anterior occlusion.
The functional load will then direct stress to the mandibular distal extension
and cause bony resorption of the posterior mandibular ridge.
The upward tipping movement of the anterior portion of the maxillary denture
and the simultaneous downward movement of the posterior portion, will
decrease antagonistic forces on the mandibular anterior teeth and lead to
their supraeruption.
Eventually an occlusal plane discrepancy will occur and the patient may
have a loss of vertical dimension of occlusion.
In addition, the chronic stress and movement of the denture will often result in
an ill-fitting prosthesis and contribute to the formation of palatal
papillary hyperplasia
PREVALENCE AMONG DENTURE PATIENTS
Shen and Gongloff in 1989, reviewed records of 150 maxillary edentulous
patients Among patients who had complete maxillary dentures and mandibular
anterior natural teeth, one in four demonstrated changes consistent with the
diagnosis of combination syndrome.
The changes associated with the syndrome are more likely to be found in patients
who stress the maxillary ridge, such as in angle class III jaw relationships and
parafunctional habits and in patients who have functioned mainly with mandibular
anterior teeth for long periods.
Pathogenesis
The Combination syndrome progresses in a sequential manner.
According to Kelly, the sequence of events is initiated by early loss of bone
from the anterior part of the maxillary jaw .
With the anterior loss of bone, flabby hyperplasic connective tissue
makes up the anterior part of the ridge.
This does not support the denture base and may fold
forward with the formation of epulis fissuratum in the
maxillary labial sulcus.
The posterior residual ridge becomes larger with the
development of enlarged fibrous tuberosities.
With these changes, the occlusal plane migrates up in the anterior
region and down in the back.
After a time, the natural lower anterior teeth migrate upward.
Excessive bony resorption under the lower removable partial denture
bases occurs to permit these changes and inflammatory papillary
hyperplasia often develops in the palate
Diagnostic mounting reveals occlusal plane discrepancy and need for
tuberosity reduction
Esthetically; anterior teeth on the complete denture disappear under the patients' lips
and both dentures migrate downward in the posterior region. The aesthetics are poor,
with the patient showing none of the upper anterior teeth and too much of the lower
anterior teeth and the occlusal plane drops down to expose the upper posterior teeth.
However, Saunders suggests that the sequence of events is initiated by the loss
of mandibular posterior support, resulting in gradual decrease of occlusal load
posteriorly and an increased occlusal load interiorly.
Eventually, this increased pressure results in resorption of the maxillary
anterior residual ridge.
The vertical overlap of the anterior teeth was excessive and with the
patient in the protrusive position there are no posterior contacts.
As a result the denture is tipped interiorly during function leading
eventually to severe resorption of the premaxilla (combination syndrome.
Histopathology;
The histopathology of the hyperplasic anterior ridge tissue and the fibrous
tissue which develops over the tuberosities is revealing.
Microscopic examination of these tissues shows that the anterior flabby
tissue and the posterior hard tissue over the tuberosities are
indistinguishable.
They are made up of mature, dense, fibrous connective tissue. This tissue in
both locations has dense bundles of collagen fibers, with relatively few cells,
with very few inflammatory cells. It is rather avascular with an overlying
epithelium that is almost normal, but shows some evidence of hyperplasia.
This is also the histopathology of a mature epulis fissuratum if we discount the
areaof ulceration caused by the denture border.
This similarity is surprising because the hyperplasic anterior tissue is freely
movable while the fibrous tissue over the tuberosity is hard. However, all three of
these conditions (the flabby anterior ridge, the fibrous tuberosity, and the epulis
fissuratum) are the result of prolonged trauma from the denture base. Therefore, the
fact that the tissue response is the same is logical.
The difference in consistency of fibrous tuberosities and flabby anterior
ridges must be explained on a mechanical basis.
The anterior bony ridge has virtually disappeared and the connective tissue
replacement is a narrow projection of tissue virtually unsupported on the labial
or lingual surface.
On the other hand the fibrous tissue over the tuberosity is supported by a broad
base of bone below.
PREVENTION OF COMBINATION SYNDROME
Preventing the changes produced by a maxillary complete denture opposed by a
class I mandibular RPD is by treatment planning to avoid this combination of
prostheses - causing combination syndrome. The options are,
1. Extraction of remaining anterior mandibular teeth CD/CD.
2. Retain the week posterior teeth as abutments by means of endodontic
treatment and periodontic recalls.
3. Overlay dentures in the mandible (overdenture).
4. Implants placed in the posterior region.
If no way from bilateral free end RPD construction
1. Maximum coverage of the distal extension ridges in RPD.
2. Application of basic prosthetic principles maximum area of coverage
proper OP orientation and balanced occlusion ensure preservation of
the alveolar bone.
3. An attempt to equalize the support gained from the teeth and the ridge by
altered cast impression will minimize denture rotation preservation of
the alveolar ridge.
4. Swing lock, flexible clasp arms, split cast major connector, mesially
repositioning rests, and overlay rests, labial bar major connector to prevent
protrusion of anterior teeth or lingual plate to prevent super eruption.
Two treatment approaches are suggested for patients with an edentulous maxilla
and some remaining anterior mandibular teeth.
A well-designed mandibular RPD is suggested for low-risk patients
An overdenture for high-risk patients.
The evaluation of the risk of developing the combination syndrome is based on
past dental history and the condition of the remaining mandibular anterior teeth.
When signs of the combination syndrome have not yet appeared, the status of the
remaining mandibular anterior teeth determine the prosthetic restoration of the
lower jaw.
Teeth that are relatively caries free with minimal restorations may, with a slight
alteration of contour, support an RPD with an occlusal plane conducive to a bilateral
balanced articulation.
Strategies for prevention of resorption
1- Correct occlusal discrepancies
a) Reshaping by grinding
b) Provide new restorations
c) Reshape with RPD framework
2- Retain root tips particularly in the premaxilla to facilitate support
3- Place osseointegrated implants to facilitate support
4- Minimizing Occlusal Forces on the Denture Foundation
5- Avoid excessive vertical overlap of the anterior denture teeth.
6- Salvage key roots, particularly in the premaxillary segment.
Why?
The anterior loads are borne by these roots thereby preventing inappropriate
compression of the periosteum during function. The retained roots can be
either covered with gold copings or their root canals can be filled with
amalgam. If gold copings are not used the root tips should be treated with
topical fluoride daily to prevent caries.

There are two reasons for the difficulty associated with the provision of a
successful complete denture for these patients.
1. The biting forces applied by the natural teeth are very high (198 lb by
natural molar tooth Vs 26 lbs by a CD).
2. Disrupted occlusal plane of the remaining natural teeth applies horizontally
directed forces to the opposing denture.
Solution
1. Maximum denture base extension and precise jaw relation records with
proper articulation of theteeth.
2. Reduce the magnitude of damaging forces by correcting the occlusal plane
orientation occlusal grinding, extraction and restoration of the tilted or over-
erupted teeth.
TREATMENT PLANNING
When planning treatment for patients with edentulous maxilla and a partially
edentulous mandible, the risk of development of the combination syndrome must be
recognized.
Systemic and dental considerations
Review medical, dental history.
Thorough clinical and radiographic evaluation of both hard and soft tissues
associated with prosthesis wear.
Resolution of any inflammation, if present.
Evaluation of patients caries susceptibility, periodontal status and oral
hygiene.
Factors to be considered in tooth to be used as abutment. (Tooth vitality,
morphologic changes, number of roots, bony support, mobility, crown- root
ratio, presence and position of existing restorations, position of teeth in the
arch, the availability of retention and guide planes.)
Treatment objective
Saunders et al in 1979 stated that
The basic treatment objective in treating these patients is to develop an
occlusal scheme that discourages excessive occlusal pressure on the maxillary
anterior region, in both centric and eccentric positions.
They also stated some specific treatment objectives:
The mandibular RPD should provide positive occlusal support from
the remaining natural teeth and have maximum coverage of the basal
seat beneath the distal extension bases.
The design should be rigid and should provide maximum stability
while minimizing excessive stress on remaining teeth.
The occlusal scheme should be at a proper vertical and centric
relation position.
Anterior teeth should be used for cosmetic and phonetic purpose
only.
Posterior teeth should be in balanced occlusion.
Patient education and frequent recall and maintenance care are
essential, if the development of this insidious syndrome is to be
avoided.
Perfecting the Occlusal Plane
Malposed, tilted or over-erupted teeth in the opposing arch are prone to
induce unfavorable occlusal contacts, which in turn may lead to
compromised denture stability. This may then cause discomfort, trauma
(which may result increased alveolar resorption) and social
embarrassments a result of movement of the prosthesis. These conditions
will result in an irregular occlusal plane that will result in unacceptable
occlusal function and esthetics.
the opposing dentition should be modified to give a more favorable
occlusal plane and geometry.
An irregular occlusal plane of the opposing natural / artificial teeth (picket
fence arrangement) is unacceptable; hence their irregularity must be
altered by,
- orthodontic means intrusion, extrusion, etc.
- placing restorations crowns, onlay prosthesis, etc.
- occlusal grinding to reshape the teeth and to create suitable
occlusal surface with low cusp height.
- by provision of a removable onlay appliance or alternatively more
extensive fixed restorations.
If this correction is not made, the finished prosthesis may have balanced contact
of teeth in centric relation position only and not in the eccentric occlusion hence
lack of stability will result.
Individual Tooth Modifications see single denture
- Sharp Unworn Cusps; Reduce cuspal inclination
- Heavily Abraded Teeth; Reduce Bu-Li width
-Tooth Reduction Protocol
Confirm pulpal maturity (X-rays, EPT electric pulp tester).
No anesthesia.
Begin with teeth requiring most reduction.
Arrangement of Denture Teeth
a) Incisal angle: the flatter the angle the more stable the denture.
b) Reduce theamount of overlap by
1. raising the incisal edges of the denture teeth and making it
compatible with condylar guidance and the curve of Spee.
2. Reduce the length of the mandibular interiors.
3. A combination of both (1) and (2).
c) The incisal angle is manipulated to be compatible with
angle of the second molar to the occlusal plane by Use of 2nd
molar as a balancing ramp.
f) The cuspal inclinations of the posterior maxillary denture
teeth are relatively flat and the compensating curve is 15
to 20 degrees. The incisal angle is compatible with the angle
of the compensating curve. During function tipping of the
denture will be minimized and therefore resorption
minimized.
g) Gold occlusal can be used to minimize wear of the occlusal surfaces or
amalgam stops can be inserted into the cusp tips of the acrylic resin denture teeth.
Seeocclusal materials for the single denture
Occlusal Adjustment
See: occlusal problems and method of modifications of natural teeth in single denture
Establishing the Vertical & Horizontal overlap;
See: esthetics (and anterior teeth occlusion) in single denture
Occlusal requirements
See: Occlusal requirements of the single complete denture
Treatment approaches
In 1985, Stephen M. Schmitt described a treatment approach that attempted to
minimize the destructive changes, by using the treatment objectives of Saunders et al.
The prosthesis is made in 2 stages.
Mandibular RPD is completed first.
Acrylic resin teeth are used to replace the maxillary anterior
teeth.
Cast gold occlusal surfaces for posterior denture teeth or using either alight
cured composite resin, or amalgam.
Mandibular overdenture provided better prognosis in patients who already had
combination syndrome and whose mandibular anterior teeth were structurally
or periodontally compromised.
Modalities of Treatment for the Combination Syndrome
1. Surgical treatment of gross changes
Kelly said that before proceeding with the prosthetic treatment, gross
changes that have already taken place should be surgically treated.
These include conditions like:
Flabby (hyperplastic) tissue
Papillary hyperplasia
Enlarged tuberosities
2. Supraerupted Teeth;
it requires alteration by shortening, crowning, or placing them under an
overdenture to obtain a harmonious occlusion.
If the incisal edges of the mandibular anterior teeth are
compared with the level of the resorbed posterior residual
ridges, the teeth may be mistakenly interpreted as being
extruded.
The level of the incisal edges of the mandibular anterior
teeth should be assessed in comparison to the proposed
posterior occlusal plane.
3- Alveolar ridge conservation:
The mandibular posterior alveolar ridge may also be conserved by leaving
teeth or roots.
At the same time, retained anterior maxillary roots will absorb occlusal forces
exerted by anterior mandibular teeth.
Long rooted maxillary canines strategically placed at the corners of the
maxillary arch are favored.
When labial undercuts are present and cannot be surgically corrected, the
peripheral seal of the denture may be compromised. The reduction in retention
can be compensated for by incorporating precision attachments into the roots
of the anterior teeth
4- The use of the mandibular RPD
The maxillary impression is made in a specially designed tray
using a combination of elastomeric impression material and
impression plaster without distorting the anterior residual ridge.
The mandibular RPD is supported interiorly by cingulum rests
on the canines with a lingual plate as the major connector.
The lingual plate delays the overeruption of the mandibular teeth,
preventing undesirable anterior pressure on the anterior part of the
maxillary denture. It also facilitates accurate positioning of the RPD during
relining procedures. Optimum fit of the denture base is achieved using the altered
cast technique.
Posteriorly, maximum support is obtained by extending the denture base
to cover the retromolar pad. The attachments of the buccinator, superior
constrictor, and temporalis muscles to the retromolar pad and the overlying
firmly bound masticatory mucosa provide a stress-bearing region that is
relatively resistant to resorptive change thereby maintaining posterior occlusal
contact.
Coverage of the horizontal buccal shelf with its superior
layer of cortical bone, submucous layer with glandular
connective tissue, and buccinators muscle fibers provides
primary- support for the denture base.
Maximum occlusal support posteriorly with no contact interiorly in centric
occlusion and a balanced articulation in eccentric movements further reduce
pressure on the anterior maxillary ridge.
Occlusal rests have been used to idealize the occlusal plane. The incisal
angle and the angle of the balancing ramp are compatible and bilateral
balance is maintained.
Limitations; Despite the lingual plate, the
mandibular anterior teeth may continue to erupt, in
the absence of anterior tooth contact, overloading of
the mandibular posterior ridge and consequent rapid
alveolar resorption may occur. Posterior occlusal
contact must be maintained by constant relining of the distal extension denture
base to compensate for its resorption.
5- The use of the teeth supported overdenture.
This more radical approach is also required when mandibular anterior teeth
have large structural defects or a weakened periodontium and are unable
to withstand normal occlusal loading.
An optimum anterior tooth relationship with minimum incisal guidance and no
contact in centric occlusion may be difficult to create when there is a step in
the occlusal plane because of the over eruption of the anterior dental complex.
The teeth are treated endodontically and reduced to the gingival level, and
an overdenture is supported and retained by roots of residual teeth.
All teeth in the mandibular jaw are, therefore, part of one restoration enabling
the occlusal load to be shared more evenly between the posterior edentulous
ridge and the remaining anterior roots.
The traumatizing edge-to-edge relationship of the incisal
teeth is replaced by a horizontal and vertical overlap, while
maintaining phonetics and esthetics.
Additional retention for the mandibular denture may be provided by stud
attachments cemented to the retained roots. Support is maintained posteriorly
by maximum tissue coverage
6- Mandibular implant-supported overdenture
Offers significant improvement in retention, stability, function.
7- Implant supported fixed prosthesis.
In 2001, Wennerberg et al reported excellent long term results with
mandibular implant supported fixed prostheses, opposing maxillary
complete dentures.
8- Augmentation of maxilla
Augmentation of maxilla with resorbable
hydroxyapatite in conjunction with a guided tissue
regeneration technique and vestibuloplasty.
Day after Surgery, the soft tissue takes on the created shape of the
inner surface of the denture. The denture must fit grafted tissue
loosely.
9- Reducing enlarged tuberosities
Kelly' who advises reducing enlarged tuberosities to allow the lower RPD
to extend over the retromolar pad. Even weak posterior teeth should be
retained as abutments with endodontic and periodontic techniques.
10- splinting the remaining mandibular anterior teeth
Saunders also advocates splinting the remaining mandibular anterior teeth
to provide the RPD with positive occlusal support, rigidity, and stability,
while minimizing excessive stress on the teeth.
11- implants beneath the distal extension base
Keltjens advocate placing implants beneath the distal extension base of
mandibular RPD to provide a stable posterior support.
Maintenance: 1
st
year most critical
1. Goal: Limit resorption and preserve remaining bone.
2. Recall: 24 h, 1w, 1m, 3m, 6m, 1y, and annually.
3. Verify VDO, VDR, CR=MI.
4. If CR does not coincide with MI, clinical remount, adjust occlusion.
5. Verify intimate contact in all primary stress bearing.
6. Reline if alveolar resorption has occurred.
7. Reinforce OH.
Explore other treatment modalities:
1. Preserve bone in anterior maxilla: preserve roots, implants, and overdenture.
2. Preserve posterior mandibular support tooth, root, implants.
3. Prevent excessive eruption of mandibular teeth and supporting bone
a. Swing lock RPD
b. Mandibular FPD
c. Mandibular splint bar supporting RPD
d. Mandibular overdenture (teeth or implant supported).
Combination syndrome does not meet the criteria to be accepted as a medical
syndrome
Sigvard Palmqvist et al in 2003, reviewed the literature on the
combination syndrome and related features such as alveolar bone loss,
bone resorption, maxillary tuberosities, denture stomatitis and maxillary
abnormalities, all combinedwith removable partial denture variables.
They concluded that combination syndrome does not meet the criteria to
be accepted as a medical syndrome. The single features associated with
the combination syndrome exist, but to what extent or in which
combination has not been clarified.
No epidemiologic study of combination syndrome. Compared with the
main feature," loss of bone from the anterior portion of the edentulous
maxilla, findings such as papillary hyperplasia of the hard palatal
mucosa seem to be rare. Enlarged tuberosities may also have other
causes than those described by Kelly as part of the combination
syndrome.
Enlarged tuberosities are often seen together with supraerupted maxillary
molars. In situations where mandibular molars have been lost, the
opposing maxillary molars may supraerupted together with the alveolar
process. The supraeruption may create enlarged tuberosities without
influence of a denture.
There seems to be no prospective study of the combination syndrome
in spite of the fact that many people have been provided with a complete
maxillary denture opposed by anterior mandibular teeth with or without
aclassI mandibular RPD. A long-term 21-year study of patients wearing
complete maxillary dentures provided no support for a systematic
development of the combination syndrome.
This does not mean that the observations made by Kelly were false. In the
title of his article, he emphasized the negative role of the mandibular
RPD. The same view was expressed by Keltjens etal, who found the
traditional treatment for an edentulous maxilla opposed by a partially
edentulous mandible with a complete denture and a Class I mandibular
RPD to be fundamentally inadequate. The authors also suggested use
of implants for distal support.
COMPLETE DENTURE THEORY AND PRACTICE COMPLETE OVERDENTURE21
COMPLETE OVERDENTURE
(Overlay denture, superimposed prosthesis, Hybrid Prosthesis, Telescopic Dentures)
Definition:
It is a complete or partial denture prosthesis constructed over existing teeth,
root structure, or implants for providing additional support, stability, and/or
retention. Or it is a removable prosthesis that is supported and could be
retained by natural teeth under its base.
It may be constructed of: acrylic resin, Gold, Chrome cobalt.
Objectives of overdenture prosthesis:
1. Retaining the abutments as part of the residual ridge to gain support and retention.
2. Preserving the remaining residual ridge by decreasing the rate of bone resorption.
3. preserving the response of proprioceptive exist in the periodontal membrane of the
abutment tooth.
Advantages:
1- Preservation of alveolar hone (less tissue trauma and bone resorption):
Alveolar bone exists as a support for teeth. If the teeth are removed, then the alveolar
process begins a rate of resorption consistent with the length of time the teeth have been
missing.
Vertical and lateral forces and excessive movement of the denture contribute to
resorption of bone and tissue in edentulous areas. An overdenture can help prevent the
loss of remaining oral structures. The retained natural teeth help to stabilize the
overdenture and dissipate the vertical forces, thereby decreasing the stress on the
edentulous areas. Also with the function of periodontal-membrane that transfers the
compressive forces to tensile forces will reduce the bone resorption.
2- Preservation of proprioceptive response:
With preservation of the teeth for an overdenture, there is
also the preservation of the periodontal membrane that
surrounds these teeth. This preserves the proprioceptive
impulses supplied by the periodontal membrane.
The existence of the periodontal membrane under the overdenture gives the patient a
sense that is not possible with conventional dentures. Also it will allow for easy record of
reproducible jaw relation and easy construction occlusion.
3- Support:
The patient has a denture that has far more support than any conventional appliance.
4- Stability:
In a case where four abutments are only present in the arch and in
strategically position (as two canines and two molars) excellent
stability for the base could be achieved due to creating support from
hard rather than soft tissues. Enhanced stability due to elimination
of ant. , post. , & lat. Slippage & sliding.
5- Retention:
Improved retention may be obtained by one of the several
attachment devices or by lining the overdenture with one of the
resilient denture liners to utilize available tooth undercuts.
6- A simple approach to the problem patient:
In the past, patients with congenital defects, such as cleft palate, partial anodontia,
microdontia, amelogenesis imperfecta, subject to a lengthy, and expensive course of
treatment. With the advent of the overdenture, a reasonably, relatively faster and
inexpensive mode of treatment become possible.
7- Patient acceptance:
Patients are most accept to and appreciative of this treatment because they experience a
striking improvement in function and esthetics while still maintaining some of their
own teeth.
8- Convertibility:
The overdenture concept is designed so that if for some reason overlaid teeth must be
extracted, the over denture can be converted to accept the alteration.
9- Transitional or training denture:
When few remaining teeth or roots are to be lost, the overdenture will provide
excellent period for training patients to receive later complete dentures.
10- Greater chewing efficiency:
Because of better stability and retention. Also in case where lower molars occlude
palatally, chewing is impossible. As well as Case where lateral movements of
mandible limited due to locking of mandible in centric occlusion.
11- Relieve trauma to TMJ & arthroses due to regression of condyle.
12- Preserve vertical dimension and facial support.
13- miscellaneous advantages
- Ease of maintenance - Open palate possible:
- Reasonable cost: - Ease in making measurement:
- Familiar procedures: - Ideal occlusion:
- Stabilization of existing structures: - Minimal adjustments.
- Possibility of using attachments or soft liners -Easy cleaning.
- Harmony of arch form
Disadvantages:
1- Caries susceptibility
The main problem with the overdentures is the carious
breakdown of the overlaid teeth. Accurate home care is stressed
as a cure for this occurrence with frequent recall to detect
incipient lesions.
2- Bony undercuts:
Because of the limited path of insertion of these appliances,
bony undercuts, especially those found adjacent to the overlaid
teeth (usually-buccally), have posed a problem in regard to the
close approximation of the denture flange to the underlying tissue.
(Due to limited path of insertion)
3- Encroachment of the interocclusal distance:
Sometimes, especially when internal attachments are used,
encroachment of the interocclusal distance may occur.
4- Esthetics:
A foreshortened flange that ends at the height of contour of
a bony undercut, a compensated occlusal plane in light of
space problem or an over bulked denture resulting from
insufficient space for attachment and replacement tooth do
little for esthetics and, if the problem is severe enough, may
indeed contraindicate an overdenture altogether.
5- Periodontal breakdown of the abutment teeth:
An overdenture not only prevents natural stimulation and cleaning
by the tongue and cheeks, it promotes accumulation of plaque as
well as being a potential source of irritation to the gingiva.
6- More bulky than fixed or removable partial dentures.
7- More expensive.
8- May cause attrition of teeth
9- Meticulous oral hygiene is required
10- Time consuming
11- Require special material & attach material
Indications:
1- Cases having few remaining badly worn teeth that are not suitable for fixed or removable
partial denture.
2- Patients having few remaining teeth, which are mobile due to an
unhealthy periodontal condition. The reduction in coronal portion
reduces drastically the mobility of these teeth and makes the good
abutments for overdentures.
3- Patients presenting with abnormal jaw sizes, large maxillary or
mandibular bony defects or with patients with Angle's II or III jaw
relationship.
4- Patients presenting with congenital defects as cleft palate,
microdontia, amelogenesis or dentinogenesis imperfecta or partial
anadontia. Patients presenting with acquired defects as those
having large maxillary or mandibular bone defects or those with
traumatic loss of many natural teeth.
5- It is an alternative line of treatment to single dentures opposing few natural teeth.
6- In younger patients: overdenture therapy with its maintenance of tooth and supporting bone
should always be considered over extraction of teeth for young patients.
7- Denture cripples: these are patients exhibiting flat ridges hence very little support, retention
and decreased patient's ability to manipulate dentures. Preventive prosthetic dentistry in the
form of overdenture is the best treatment for these patients.
8- In case which could provide poor prognosis for complete denture
as patient with high palatal vault (unstable complete denture), or
lower flat ridge or patients with retracted tongue.
9- When results with constructing overdenture are superior to the
other lines of treatment.
10- Attachment may be indicated in case of xerostomia and sialorrhoea.
Uses of the overdenture concept in other areas
o Partial overdenture: The use of an overlayed tooth that might otherwise be extracted
to give posterior support to a distal extension base or provide anterior support for a
large anterior supply on a partial denture renders obvious support advantage.
o Use of overlayed teeth in immediate and transitional (interim) dentures: The
technique employed is similar to that of an immediate or transitional denture. The only
difference is that teeth to be overlayed are contoured differently on the master cast than
teeth that are to be extracted. On the day of insertion, before the other teeth are
extracted, the overlayed teeth are reduced in the mouth to the desired height and
contour. This reduction is only an approximation. After a suitable interval when wound
healing is complete, the teeth are given their final contouring, copings fabricated if
indicated, and the appliance is either refitted or remade.
Contraindications:
1- In cases with poor oral hygiene.
2- Inadequate interarch distance to accept the denture and abutments.
3- Abutments exhibiting mobility, which exceeds grade II.
4- When other lines of treatment provide superior results, fixed or removable PD.
5- Absence of patient motivation, economic, presentation in appointment.
6- Patient with systemic disorders, radiotherapy.
7- Sufficient attached gingiva not present.
8- Where endo and perio treatment can not be performed satisfactorily.
Patient Selection
Only the patient who is strongly motivated to save his remaining teeth should be
considered for overdenture. Any indication that the patient will not cooperate in the oral hygiene
and regular office examinations also makes him a poor risk for time-consuming procedure.
Recall appointments for adjustment and modification of the overdenture are essential for
maintaining the remaining teeth and the supporting tissue structures in state of health.
Other factors influence overdenture constructions are:
1- Possibility of fixed or removable partial dentures: If the remaining natural teeth are
capable of supporting a fixed or removable appliance then this form of treatment must be
considered the primary one.
2- Endodontic therapy: Because of a tooth usually must be treated endodontically to allow
for sufficient reduction of the clinical crown, it must be ascertained that successful
endodontics can be performed.
3- Periodontal condition of the abutment teeth: Periodontal evaluation is a critical stage
in the construction of an overdenture. We must begin with optimum periodontal health to
ensure the longevity of teeth.
4- Supporting and underlying structures: Overdenture can be placed immediately if the
hard and soft tissues underlying them are in a reasonably state. The overdenture is to be
preferred to the lower complete denture for the patient with knife-edge ridge that will
provide inadequate support. The retained teeth for the overdenture will help to support
the restoration. From 5-6mm of bone support are required for each retained tooth. The
prognosis is poor if the crown /root relationship exceeds a 1:1 ratio.
5- Caries: If abutment teeth are caries prone, then we must question this mode of treatment.
6- Young patients: Overdenture therapy with its maintenance of tooth and supporting bone
should be considered over extraction of teeth for young patients.
7- Position and alignment of abutment teeth: Teeth are most useful in areas of maximum
occlusal force and ridge resorption potential. The anterior aspect of the residual ridge
especially that of the mandible, is very susceptible to change, cuspids and premolars are
valuable teeth to preserve in this area.
8- Economics: This approach can be very expensive to the patient.
Principles of the overdenture
Almost all techniques for overdentures have the following principles in common:
1- Reduction of the retained teeth to obtain a more favorable crown/root ratio.
2- Use of the retained teeth to minimize vertical movement of restoration.
3- Construction of the prosthodontic restoration so that it is at least partially tissue-borne
through out normal function.
4- Most retentive methods have some type of male-female devices that acts to minimize
lateral forces on the retained teeth and aids in retention of restoration.
The majority of overdenture techniques include most of the following procedures:
- Selection of the teeth to serve as abutments.
- Removal of hopeless teeth.
- Periodontal treatment of the abutments.
-Endodontic treatment of the abutments.
- Placement of immediate interim prosthesis.
- Preparation and cementation of cast copings or attachments on abutments.
- Construction of overdenture.
CLASSIFICATION OF OVERDENTURES
I- According to nature of support:
1- Tooth supported overdentures.
2- Implant supported overdenture.
3- Implant tooth supported overdenture.
I- Tooth Supported Overdentures:
1- According to time of placement:
Immediate overdenture. Transitional or intermediate overdenture.
Remote overdenture. Definitive overdenture.
2- According to the technique and design of abutment preparation:
A- For vital abutment teeth
Simple tooth modification and reduction:
Tooth modification and cast coping:
The telescopic overdenture:
B- For endodontically treated teeth:
Endodontic therapy and amalgam plug:
Endodontic therapy and cast coping:
Endodontic with cast copping utilizing form of attachment:
Submerged roots:
3- ACCORDING TO METHOD OF COPING;
NON COPING - with endodontic treatment,
- Without endodontic treatment.
COPING - with endodontic treatment,
- Without endodontic treatment.
COPING WITH ATTACHMENTS
4-According to the attachment design:
a- Rigid attachment: b- Resilient attachment:
According to the form:
Stud attachment:
Bar attachment: a- Bar unit. b- Bar joint.
Magnetic retention:
II- Implant Supported Overdentures:
Implant supported overdenture:
Implant and tissue supported overdenture:
III- Implant tooth supported overdenture.
According to nature of retention:
I- Tooth retained Overdentures:
II- Implant retained Overdentures:
III- Tooth - Implant retained Overdentures:
1. IMMEDIATE OVERDENTURE:
It is an overdenture that constructed for insertion immediately after the removal of natural
teeth. It is constructed for patient with a full complement of natural teeth most of which are to be
lost. The teeth chosen as abutments are reduced on the cast and the overdenture constructed and
placed on the day of extraction.
Procedures
Impression is made (as in immediate complete denture). Cast is poured. Occlusion blocks
are constructed. Jaw relations are made and mounting on articulator. Teeth are selected
and arranged as partial denture cases. Try in
Then hopeless teeth are cut off from the cast while the abutments of overdenture are only
cut off with 2-3 mm height.
The base is completed and also teeth arrangement and finally denture is processed.
At insertion the hopeless teeth are extracted and the other abutment teeth (previously
endodontically treated) are cut off. The fitting surface opposing the abutments is relieved.
Then by self-cure adaptation is obtained. By P.I.P pressure areas are detected and later
relieved.
Few weeks latter rebasing is required.
2- TRANSITIONAL OR INTERMEDIATE (INTERIM) OVERDENTURE:
Interim or transitional overdentures are used for patients in the transitional or
preparation phase when mouth preparation is performed and until the permanent
overdentures are constructed.
It is obtained by transferring an existing partial denture into an overdenture through
extending the denture base and adding new artificial teeth using self cure acrylic resin
until the permanent overdenture is constructed.
Advantages
- Less cost
- Patients experience with the old partial denture makes easy to accept the overdenture.
Disadvantages
- Border extension, esthetic, occlusion, support and stability of old partial denture are
inadequate which may affect the overdenture.
- Use of self-curing acrylic resin will result in weak overdenture. Therefore this denture
is considered as temporary or interim denture.
Construction procedures
Addition of the extracted hopeless teeth: An alginate overall impression is made with the
presence of the partial denture. A cast is poured and hopeless teeth are removed and
replaced by acrylic teeth. At insertion these hopeless teeth are extracted.
Changing the partial denture to a transitional overdenture (after endodontic treatment of
abutment teeth):
- The partial denture is inserted in the patients mouth and an overall alginate
impression is made.
- The positions of teeth in alginate impression are filled with tooth colored self-cure
acrylic resin (or the crown of the cut off abutments).
- After cutting off the clinical crown of abutments to the required height above
gingival margin the impression with the denture inside is reinserted and the
removed.
- A cast is poured and the flange is completed.
3- Remote overdentures:
A remote overdenture is an overdenture constructed for insertion at some time "remote"
from the removal of hopeless teeth.
It is placed over well-healed residual ridges, usually after a period of satisfactory
experience with an interim overdenture, which can be immediate or transitional
overdenture.
Remote overdentures can be constructed entirely of resin; metal bases are frequently used
to increase rigidity and strength.
Procedures:
Root canal treatment for the overdenture abutment.
Cut off the clinical crown of the abutments to a height of 2 mm above the gingival
margin.
The coronal portion is filled with amalgam. The abutment is prepared into dome shape.
Another forms of abutments:An impression is made for the abutments and cast metal
dome copings are made and cemented.
Also retentive means could be used as stud attachments (male and female) or bar
attachments (bar and sleeve) or magnets.
Then the conventional procedures for overdenture construction are following.
ACCORDING TO THE DESIGN AND TECHNIQUE OF ABUTMENT PREPARATION;
1- Simple tooth modification and reduction (non coping non endodontic):
This technique is often used in patients with severe abrasion of teeth. Minimum tooth
preparation is required because of the presence of a great deal of interocclusal distance.
The abutment teeth are reshaped to eliminate undercuts.
Tooth or prominent soft tissue undercuts should not be engaged with the overdenture.
Retention can be improved, if desired, by placing soft liners into tooth and some tissue
undercuts.
The tooth is modified by reducing the buccal surface 30 and lingual surface 15. The
mesial and the distal surface are modified to remove the undercuts.
This type is indicated:
- In case of good oral hygiene and low caries index.
- Attrition or abrasion of teeth with severe pulp recession.
- Adequate interarch space.
2- Tooth reduction and cast coping of vital abutment:
1-Thimble-shaped coping;
This is necessary because of sensitivity or as a caries control.
This approach is possible only when the teeth have an adequate bony support and a good
periodontal prognosis, because with this method there is only a minimum reduction in the
crown/root ratio.
Adequate interocclusal distance must exist or violation of VD is liable to occur with the
result being poor esthetics and eventual failure because of patient intolerance.
Copings may be placed on vital abutments. The technique requires preparations for full
crowns, preferably with shoulders, and the occlusal portion of the preparation is rounded
or parabolic in form. The thimble coping occupies considerable vertical and buccolingnal
space. It is mainly used in cases with partial anodontia and in cases exhibiting enough
inter-ridge space.
2-long coping nonendodontic:
Copings may be placed on vital abutments. The crown is reduced to the dome-shape and
wax pattern is made for cast coping.
3- Endodontic therapy and amalgam or composite plug:
In order to create enough space for the overdenture without increasing the
vertical dimension, the teeth must be drastically reduced, usually to the gingival
level 1-2mm above gingival margin, with endodontic therapy.
Even hypermobile teeth may be used because the drastic reduction in crown/root
ratio along with the periodontal therapy promises a very favorable prognosis.
This type is indicated in:
- Normal inter-arch distance.
- No loss of vertical dimension
- Normal crown height.
- Good oral hygiene.
- Pulp is not recessed.
The crown needs severe reduction so endodontic therapy is necessary; the reduced height is 1-2
mm above the gingival margin. The root canal is filled with gutta percha and the opening is
sealed with amalgam plug (Dome-shape appearance)
4- Endodontic therapy and cast coping (coping endodontic, short coping):
The procedure and indications are almost similar to the technique of endodontic
therapy and amalgam plug with the exception that a casting is placed on the
endodontically treated tooth instead of placing a simple amalgam restoration in
the root canal. The casting that is made is usually a shallow dome shape.
Retention is gained from a short post that is placed within the root canal.
Abutments are endodontically treated with root canal filling and sealed with cement.
The crown is reduced to the dome-shape and wax pattern is made for cast coping.
The metal coping takes its retention from a short post inserted in the root canal.
5- The Telescopic overdenture:
It is constructed to fit over the natural teeth like a sleeve. The supporting
abutments may be either vital or endodontically treated.
Retention is obtained through the frictional resistance produced between
the semi-parallel walls of the copings and the tissue side of the denture base.
6- Endodontic therapy with cast coping utilizing some forms of attachment:
This approach provides not only stability but when retention is desired by adding
means of retention. Because of the added time, cost, and risks, this procedure
should be reserved for patients with a favorable prognosis.
Overdentures retained by attachments offer the patient the idea of a fixed removable
bridge instead of a denture. The abutments are prepared as in short-coping but with long
intraradicular post to prevent root-coping dislodgment. Clinically, two attachments are
enough to retain a denture. A third attachment adds unnecessary complexity and weakens
the denture.
7- Root - Submergence Procedure:
The average reduction of the residual ridge after tooth loss has been estimated to average
0.5 mm per year.
Alveolar bone loss may result from lack of stimulation because of the absence of teeth.
Therefore the only known reliable way for prevention of alveolar bone loss and
maintenance of masticatory proprioception is by prevention of tooth loss.
Maintenance of alveolar bone is thought to be dependent on the tensile stimulation
provided by the periodontal ligament during masticatory activity.
The overdenture concept is an effort to preserve alveolar bone by retaining natural teeth
that may or may not be endodontically treated and constructing dentures directly over
them.
Unfortunately, periodontal disease, caries, and the expanse entailed have annoyed the
overdenture concept. It is because of these disadvantages that a simpler method of root
retention was sought, and the concept and practice of submerged root retention have
evolved.
The root of the tooth is served to 2 mm below the level of the alveolar bone, and the root
or roots are covered completely with gingival tissue flap.
Submerged vital roots
Submerged vital root as over denture abutment may be used.
This method is obviate the basic problems like caries, gingivitis, periodontitis,
need for endodontic therapy associated with conventional over denture abutments.
selected vital roots are selected and reduced to 2 mm. below the crestal bone and
then covered by mucoperiosteal flap
Major post operative problems are: development of dehiscences over retained roots
and pulpal pathologies
Advantages of root- submergence procedure:
1- Preservation of alveolar ridge.
2- Increased denture stability.
3- Maintenance of proprioceptive responses.
4- Inexpensive procedure.
5- No need for special home care.
Criteria for teeth selection:
No more than 1mm horizontal mobility.
No infra-bony pockets that could not be reduced at time of surgery.
Sufficient healthy muco-gingival tissue to enable final closure of the surgical
site.
Supporting alveolar bone equal to approximately one third of the length of the
total root length.
The teeth should have a small occlusal table.
Adjacent teeth should not be present.
Teeth should not have severe bony undercuts.
Adequate thickness of cortical buccal plate over the retained roots.
Techniques of root-submergence:
1- Preservation of the vitality of the pulp in the residual root.
2- Endodontic treatment of the residual root.
3- Endodontic treatment of the root which is intentionally extracted and reduced
and then replanted and submerged.
4- Pulpectomy is performed in the residual root and submerged without root canal
therapy.
Failure of submerged roots:
A- Surgical causes:
1- Insufficient reduction in root height.
2- Improper contouring of the retained roots. The effect is to produce a more
rounded ridge instead of the "boxy" one.
3- Incomplete removal of crevicular epithelium.
4- Insufficient tissue for perfect closure.
B- Prosthetic causes:
1- Abnormal denture pressure from ill-fitted denture bases.
2- Inadequate balanced denture occlusion.
Diagram for the possible forms of overdenture abutment preparations.
. I For vital abutment teeth: a- for a telescope crown. b-for a root coping. II- For endodontically treated teeth: c-
for support without root coping. D- for a dowel- coping. E- for directly mountable retentive elements.
NON COPING ABUTMENTS
Selected tooth abutments are reduced to a coronal height of 2 to 3
mm. and then contoured to a convex or dome shaped surface.
Most teeth required endodontic therapy and in final step are
prepared conservatively to receive an amalgam or composite type
restoration.
ABUTMENTS WITH COPINGS
Cast metal coping with a dome shaped surface and a chamber finish line at the gingival margin.
Types of copings: short coping - Long coping
SHORT CAST COPINGS (endodontic)
Short copings are 2-3 mm and normally require endodontic therapy
because the required coronal root reduction would expose the pulp.
Attached to cast coping is a post filled to the canal therefore canals
should be obturate with soft gutta-purcha like material rather than with metal points
LONG CAST COPING (nonendodontic)
Long cast copings are normally 5-8 mm long, conservative reduction of coronal tooth
structure is done. The end result is long ellipsoidal shaped coronal coping and a
larger cr\ root ratio.
Consequently, long cast coping require a greater level of osseous support.
ABUTMENT COPING WITH ATTACHMENTS;
Most attachments are secured to abutment by a cast coping.
Objective of attachment is to improve retention of denture base.
Drastic reduction in crown root ratio and where indicated periodontal and
endodontic therapy is required.
Treatment planning of the overdenture
Patient Selection
Only the patient who is strongly motivated to save his remaining teeth should be
considered for overdenture. Any indication that the patient will not cooperate in
the oral hygiene and regular office examinations also makes him a poor risk for
time-consuming procedure.
Recall appointments for adjustment and modification of the overdenture are
essential for maintaining the remaining teeth and the supporting tissue structures
in state of health.
The treatment plan starts first with the proper selection of the abutments which
will support the overdentures; one should consider root form, abutment location,
and amount of bone support, masticatory loads, space between abutments and the
opposing dentition.
I-Abutment Selection:
Position and number of abutment;.
At least one tooth per quadrant.
Retained teeth should preferable not be adjacent ones,
There should be several millimeters of space between the reduced tooth forms.
Canines and premolars are the best overdenture abutments to reduce adverse forces at
this site.
Periodontal evaluation;.
Minimal mobility
At least 6mm of bone support
Attached gingiva around the abutments
Good oral hygiene
Proper emergence profile to support the marginal gingiva
Endodontic evaluation;
Decay or previous restorations.
Inter-arch space:
There should be an adequate inter-arch space for the overdenture.
II- Preparatory Treatment
The following sequence of treatment can be used as a general guide, but it may not be
specifically applicable in all situations.
1. Construct an immediate treatment claspless denture and make a cast from an
irreversible hydrocolloid impression to replace the missing and the hopelessly involved
teeth for esthetic reasons and retain the jaw relations.
2- Remove the hopeless teeth and insert the removable prosthesis.
3- During the healing period institute the periodontic and endodontic treatment.
III- Preparation of the ABUTMENT Teeth
If the immediate treatment denture is to be retained in function until the complete
denture is ready for insertion, make a full arch irreversible hydrocolloid
impression with the prosthesis in place.
Then place the impression, with the prosthesis, in a humidor until the preparations
are completed.
TOOTH PREPARATION FOR MINIMAL RETENTION
- Crown reduction with or without endodontic treatment is usually required.
- Periodontal treatment including supragingival and sublingual scaling is
carried out to attain healthy gingival tissue.
1- Remove sufficient tooth structure to provide favorable root-crown
ratio to allow the insertion of the artificial replacement in an
acceptable esthetic position and in a favorable occlusal relation with
the teeth of the opposing arch.
2- Extend a chamfer type margin slightly beneath the free gingival
margin.
3- Taper the preparation in the occlusogingival direction. The finished tooth with
attached coping is the male member of the denture. The female member is a part of the
denture base.
4- The occlusal and/or incisal surface must be of a dimension suitable to provide an area
for the placing of a concavity in the coping to accommodate a cobalt chromium bearing.
The radius of the concavity is slightly more than the radius of curvature of the bearing.
The bearing is a hemispherical-shaped casting of a pattern taken from the inside of the
end of a #5 gelatin capsule.
IV- Primary impression:
Impression is made using stock tray and alginate impression material.
V- Second Impression
- Check the impression tray for accuracy. Reduce the borders. Refine the borders.
- Secondary impression is made using rubber base material and Box the impression and pour
immediately into stone.
- Wax patterns for the coping are made and cast in metal.
Coping fabrication
1. Make an accurate impression of the abutment and pour a die.
2. Carve the wax pattern. Place the concavity in the occlusal surface of the pattern, using
a wax tool.
3. Cast the coping, using a hard type of class III gold.
4. Cement the polished coping to the tooth.
5. Instruct the patient in home care of the abutment teeth.
VI- Final impression:
- Impression is made to obtain casts for the coping-covered abutments.
Other impression techniques may be used in overdenture construction:
Single tooth impression in a copper band
Single tooth-impression with injectable elastomer
Combined full-arch impression (two stages technique )
One stage technique with dowel coping
VII- Recording maxillomandibular relations;
Record bases and occlusion rims.
The only difference in the construction of the record bases for tooth-supported dentures and
conventional dentures is the incorporation of the metal bearing in the record base.
1. Apply one thickness of wax to the abutments, leaving the occlusal surface exposed.
2. Seat the bearing in the concavity and seal it to place with wax.
3. Eliminate any undercut areas with wax and construct a stable record base of activated
acrylic resin using the "sprinkle on" technique.
4. Attach wax occlusion rims to the record base.
A face-bow transfer is used to relate the maxillary cast to the articulator. The tentative records of
the vertical dimension of occlusion with the mandible in terminal relation to the maxillae are
made in the same manner as for conventional complete dentures.
- Mount the upper casts on semi-adjustable articulator by the help of face bow records.
- Centric occluding relation record used to mount the lower cast.
- Setting up of teeth is then carried out.
Tooth selection
1. The artificial teeth that are placed over the abutment teeth should be acrylic resin.
2. When the teeth in the opposing arch have gold occlusal surfaces, the occlusal surfaces
of the artificial teeth should be either gold or acrylic resin, preferably gold.
3. If the teeth in the opposing arch have porcelain occlusal surfaces, the artificial teeth
preferably should be porcelain.
4. If the teeth in the opposing arch are natural teeth not restored with gold or porcelain,
acrylic resin artificial teeth are preferred.
VIII- Setting the artificial teeth:-
To set the acrylic resin tooth over the abutment requires:-
(1) Removing the acrylic resin record base to expose the abutment,
(2) Retrieving the metal bearing from the record base and repositioning it in the
concavity by sealing the bearing to the abutment tooth, at the margins, with sticky wax,
(3) Hollowing the acrylic resin tooth with an acrylic bur until it is properly positioned and
the occlusion is adjusted,
(4) Sealing the bearing to the acrylic resin tooth with sticky wax,
(5) Arranging the remainder of the teeth in maximum occlusion, and (6) Contouring the
wax for the try-in appointment.
IX- TRYING IN THE TEETH. At this appointment, perform the following procedures:
Fitting surface of the trial dentures should be relieved over the abutments to ensure
proper denture seating.
Check of denture stability and support.
Check the vertical dimension.
Check the occlusion and the premature contact.
Verify the jaw relation records.
Make eccentric jaw relation records and adjust the articulator.
Assure esthetic acceptability by the patient.
Verify phonetic acceptability.
Laboratory Procedures
1. Contour the wax.
2. Flask the denture.
3. Eliminate the wax.
At this step, the metal bearings are retrieved from the acrylic resin tooth, cleaned with boiling
water, and dried. The cast is allowed to dry and the abutments, except the concavity, are painted
with tinfoil substitute. The metal bearing is seated in the concavity and a coping of activated
acrylic resin with cross-linked monomer is made, using the "sprinkle on" technique.
4. Prepare the acrylic resin. While the dough is soft, the coping, with bearing, is held securely in
place, and a small amount of the dough is pressed around the gingival surface of the coping.
5. When the dough is of proper consistency, the packing is completed in a manner similar to
packing a removable partial denture. The acrylic resin is placed in both sides of the flask. Trial
packing is possible when desired.
6- After the denture has been processed. Remount procedures for processing errors are
completed. The dentures are finished and polished.
X- Denture Insertion
At overdenture insertion the fitting surface should be relieved over the abutment to avoid
pressure on the gingival margin of the abutments.
1. Instruct the patient about the in denture use and home care of the abutment teeth &
denture.
2. Use pressure disclosing paste to locate contacts between the female member in the
denture base and the male abutments. There should be no contact except between the
convex surface of the metal bearing and the concave bearing surface of the coping.
3. Evaluate the tissue side of the denture base and the borders for pressure areas and
overextension.
4. Perfect the occlusion by remounting the dentures and selectively grinding the teeth.
5. Place the patient on a recall system. As a rule, after the initial adjustment phase, the
patients are seen once a month for the first six months and once every three months
thereafter. This frequency of visits may not be necessary with all patients. However, this
system has produced satisfactory results.
XI- Post insertion care:
- The patient should follow the oral hygiene instruction
- The patient should brush his denture after each meal.
- The denture should keep in tap water when not in use.
OVER DENTURE ATTACHMENTS
It is a mechanical device used for retention and stabilization of prosthesis.
It consists of two or more parts. One part is connected to a root, tooth or implant and the other
part to prosthesis.
Types
Various types of attachments are designed for retaining overdentures.
There are some attachments having one manufactured part and the other part is constructed by
the dentist or the dental technician.
I. Attachments fall into two categories: precision and semiprecision.
1- Precision attachments:
Precision attachments are just that "precision". Their components are machined in special
alloys under precise tolerances. Since the specific hardness of the alloys is controlled,
precision attachments offer the advantage of less wear on the abutments and standard
parts which allow the components to be interchangeable and usually easier to repair when
necessary.
2- Semi precision attachments:
A semi-precision attachment is fabricated by the direct casting of plastic, wax or
refractory patterns. They are considered: semi-precision" since in their fabrication they
are subjected to inconsistent water/ powder ratio, burn out temperature and other
variables.
Their main advantages are: economy, easy fabrication and ability to be cast in a wide
choice of alloys.
II. Classification of over denture attachments according to location:
a. Intracorornal.
b. Extracoronal.
c. Radicular/intraradicular stud type.
d. Bar type.
a. Intracoronal:
Intracoronal attachments are incorporated entirely
within the contour of the crown. The advantage of
an intracoronal attachment is that the occlusal
forces exerted upon the abutment tooth are applied
close to long axis of tooth.
A disadvantage arises when the abutment is over contoured by placing the intracoronal
attachment outside the crown contour, this often results from insufficient tooth reduction.
Since all intracoronal attachments are non-resilient it is indicated for fixed bridge
restorations, removable partial dentures and segmented bridge.
b. Extracoronal:
Extracoronal attachments are positioned entirely outside the
crown contour. The advantages of this type of attachments are
that the normal tooth contour can be maintained, minimal tooth
reduction is necessary and the possibility of devitalizing the tooth
is reduced.
Most extracoronal attachments have some type of resiliency.
It is however; more difficult to maintain hygiene with extracoronal attachments and
patients should be instructed to use dental floss and hygiene accessories.
c. Radicular / intraradicular stud type:
Radicular and intraradicular stud type attachments are connected to a root
preparation.
The stud attachment consists of male stud that snugly fits a female
housing.
The stud is usually attached to the metal coping cemented over the
prepared abutment, while the female housing is embedded in the fitting surface of the
acrylic overdenture exactly opposite to the abutment.
Some types are directly cemented into the prepared root without a cast coping e.g. new
direct O-ring. The female element of intraradicular stud type fit within the root frame
contour e.g. Zest attachment.
d. Bar type:
A bar attachment is in the form of a bar contoured to run parallel
and overlie the residual ridge connecting the abutments together.
The bar provides support and retention for the overdenture and
splinting of abutment teeth (Or implants).
The overdenture fits over the bar and is connected to it with one or more retention
sleeves, clips or plungers.
The advantages of bar attachments are that they splint questionable abutments together
for mutual support. Bar restorations, when properly related to the gingiva should not
cause food entrapment, blanching of the tissues, nor encourages tissue proliferation.
III. Classification of over denture attachments according to Function:
They could either be
- Rigid (ABUTMENT-TOOTH), not allow for movement of the denture base
providing adequate retention induce torque on the abutment.
- Resilient (ABUTMENT-TISSUE) allowing some controlled vertical movement,
induce less torque on the abutment teeth.
It is important to differentiate between resilient or non resilient type restorations.
Abutment/tooth supported restorations are considered non-resilient or solid, while
abutment and tissue supported restorations are considered resilient.
Resilient attachments reduce vertical and lateral forces on the abutments by distributing
more of the masticatory load to the tissues.
Resiliency is a special advantage when the denture base fits poorly due to alveolar
resorption. Resilient attachments are indicated with very weak abutment and when the
opposing is natural or non-resilient appliance.
Resilient attachments may range from vertical to universal resiliency. The vertically
resilient type attachment allows only movement in the vertical plane. The hinge type
resilient attachment allows movement around a given point, e.g. Mini Dalbo. The vertical
and hinge type resilient attachment allows movement in both the vertical plane and hinge
axis simultaneously e.g. Dalbo. The rotational and vertical type resilient attachment
allows both rotational and vertical resiliency e.g. anchors the Universal, Omni-planar
resilient type allows movement in any plane.
IV. Classification of over denture attachments according to retention mean:
It can be obtained by frictional, mechanical, frictional and mechanical, and magnets.
Magnets: One magnet pole is cemented in a prepared cavity in the endodontically
prepared tooth, while the other pole is attached to the denture base opposite to it.
Factors affecting Attachment selection:
1. Available inter-arch space.
2. Crown root ratio and alignment of the roots.
3. Type of coping.
4. Vertical space available.
5. Number of teeth present.
6. Amount of bone support.
7. Location of abutments.
8. Location of the strongest abutments.
9. Whether the overdenture is a tooth supported or tooth tissue- supported.
10. The type of the opposing dentition whether it is complete denture, overdenture, fixed
appliance or natural dentition.
11. The maintenance problems and the cost.
12. Clinical experience and personal preference.
Forms of complete overdenture attachment:-
1. Stud attachments.
2. Bar attachments.
3. Magnetic attachment.
1- Stud attachments:
Most of the stud attachments are simple in design, consisting of a male stud type that is
soldered to a base. The base is a coping covering the prepared tooth stump, usually
having a post extending into an endodontically treated root canal.
Fixation is achieved by a female housing that is either embedded in the acrylic of an
overdenture or soldered to a substructure in the overdenture. The female housing can be
rigidly attached to the male and classified as a non-resilient attachment.
It could also be designed with a spring load or some other engineered style to provide for
controlled movement and therefore be classified as a resilient attachment.
The male and the female parts of the retentive attachment may be held together by active
retention, which involves a spring loaded element engaging an undercut.
I- Gerber Attachment
Types: There are two types:
- The first type allows vertical movement.
- The rigid type: it is popular and widely used one. It consists of a male
post threaded onto a screw attached to a soldering base and a female
overall housing containing a retention spring and ring.
Retention is gained by the spring clip in the female housing engaging a groove in the
male section.
Advantages: Retention is adequate with this attachment and fabrication is relatively
simple. Disadvantages: The system is expensive and the attachment is capable of torque
on the tooth if the base has excessive movement due to poor adaptation or to an
inaccurate impression. In order for this type of attachment to be effective and non-
injurious to the abutment teeth, unsupported saddles must have minimum movement.
II- Dalbo Attachment
Components: male unit that is attached to the tooth and a female housing imbedded in the
denture base.
Types: There are three types of Dalbo attachments : rigid, resilient, and stress broken.
1. The rigid Dalbo attachment has a cylindrical male unit with a rounded head.
2. The resilient attachment, the smallest and most commonly used of the types,
allows vertical and rotational movement of the female around a sphere-shaped
male unit made possible because of a relief space between the units. This allows
for some vertical movement of the denture base before contact of male and female
occur.
3. The stress broken type is similar in design to the resilient type, with the exception
that the female housing is longer and incorporates a coil spring.
Retention with all three types is provided by the somewhat flexible arms of the female
unit fitting over the undercut head of the male unit.
III- Ceka Attachment
Components: male portion affixed to the tooth and has a rounded
shape wider at the top and splits vertically into 4 sections, that are
flexible and capable of being compressed. Over this fits a female
housing or ring.
The attachment also can be constructed with a different type of retaining male that has a
space between it and the female, allowing vertical play and some rotational movement of
the base.
IV- Zest anchor
Components: This attachment derives its retention from within the
root. A post preparation is made within the root and a female sleeve
is cemented to place.
The male portion is a nylon post and a ball head that is attached to
the overdenture as a chair-side procedure.
This post is placed into the sleeve and the overdenture is placed over this with cold cure
resin placed in a recess to accept the male.
Retention: to the tooth is gained by the ball head, snapping into the undercut in the
female sleeve.
Advantages:
o It overcomes any space problem because the attachment is within the root
structure.
o The leverage on the abutment tooth is negligible, since the point of attachment is
actually well below alveolar bone level.
o The attachment procedure is simple, can be performed quickly at chair-side, and
can be done without any casting, although the technique can be utilized with a
cast coping on and in the tooth root.
o If more than one tooth is used, parallelism is not necessary because of the
flexibility of the nylon male. This can be even further enhanced by reducing the
length of the sleeve and post if several teeth are utilized.
V- Rothermann Attachment
Types: 2 types, one allowing more movement than the other in a
vertical and rotational fashion.
It consists of a short stud with a groove deeper at one end than
at the other, and a retaining C-shaped ring, the ends of the ring, or clip, fitting into the
deepest part of the retaining groove.
Advantages:
- This attachment requires very little space for its utilization and is therefore
excellent for cases with little interocclusal space.
- Also, this attachment , because of its low height, need not be parallel if more than
one is being used.
- The male stud can easily be attached to a coping with free hand soldering and the
female clip is attached to the denture base with cold cure acrylic either as a
laboratory step or at the chair. However, it is difficult.
VI- Introfix attachment,
- This is a tall stud attachment composed of a solder base, an adjustable split male post,
and a female housing.
- Its providing a frictional retention between male and female. The male has a longitudinal
split, so it can be adjusted to gain more or less retention, and it is replaceable, since it is
screwed onto the solder base.
- Because of its length, it has much torque potential on the abutment tooth and therefore
should be used only on totally tooth supported over-dentures or on an overdenture, that
has an otherwise excellent support.
- The ancrofix system is a resilient type of attachment it can be allow for rotational
movement or become fixed by a simple adjust
VII- Schubiger attachment
This attachment is a permanent form of fixation using a screw system that
connects anchor teeth to bar joints and bar units.
It consists of a solder base with a screw that can retain, a ceramic metal
sleeve to which a bar unit may be soldered, and a lock nut with a screw
recess used to secure the sleeve.
This unit is indicated for a bar attachment on teeth with divergent roots.
VIII- Quinlivan attachment
This attachment consists of a prefabricated resin ball that is incorporated with the wax-up
of post and coping. The completed casting is then cemented into the endodontically
treated tooth.
A resin female housing is attached to the overdenture with cold-cure resin. Retention is
gained by an O rubber ring inside the female that is secured.
2- Bar attachment:-
The purposes of the bar attachments are splinting of the abutment teeth a retention and
support of the prosthetic appliance. Bar attachments are also indicated when the abutment
teeth are markedly nonparallel.
The bar follows the curve of the alveolar process and is seated 2-3 mm above the crest of
the ridge. Bar attachments are of two types, bar units and bar joints.
** Bar units have rigid fixation where there is no movement between the bar and
overlying sleeve and therefore can be classified as tooth borne as all stresses are
transmitted to the abutment teeth.
** Bar joints permit rotational movement between sleeve and bar, utilizing more
of the residual ridge for support.
I- Madder bar
This attachment can be either as a bar joint or a bar unit and can be used as a stud
attachment as well as a bar attachment.
The system consists of preformed plastic bars and clips. The plastic bar is attached to
the coping wax-up and is cast with the coping. The plastic clips can be imbedded in
the denture base to gain retention. If more retention is desired, the plastic clip can be
transformed into a metal clip. This is often necessary because the plastic clip loses
retention rapidly.
The bar and clip attachment is bulky and care must be exercised in its placement to
allow for space to set teeth.
The preformed bar can be adjusted to any length before casting or, can be used as a
short stud attachment on an individual tooth.
If more retention is needed, more clips may be added on a bar and the tension on a
metal clip may be increased.
II- Dolder bar
Types: This attachment is supplied as both a bar unit and a bar
joint.
The bar unit consists of a preformed bar that is soldered to copings
on the abutment teeth. The bar must remain in a straight line.
The shape of the bar has parallel sides with a rounded top. To this fits a sleeve that is
embedded in the acrylic overdenture. Retention is due to a frictional fit. Because of the
parallel side walls of the bar and the close adaptation of the sleeve, rotation of the
appliance around the bar is negligible; so this appliance can be looked upon as non-
resilient.
The unit is bulky for overdenture use, making esthetics, insofar as adequate space for
replacement teeth is concerned, very difficult.
The Dolder bar joint is also soldered to the copings of abutment teeth and also can use the
schubiger system if problems of parallelism arise.
The bar joint is egg shaped but it is still difficult to adapt to proper tissue contour. When
positioning the retentive sleeve of the appliance, a spacer is placed between the bar and
the sleeve. This will allow the sleeve to have vertical as well as rotational movement
around the egg-shaped bar, and thus become a resilient attachment. This attachment is
also bulky and difficult to use because of esthetic considerations in an overdenture case.
III- Baker clip
Components: This joint attachment consists of a small U-shaped clip designed to fit over
round wire.
There are two sizes available : 12 and 14 gauge to be used with either a preformed or cast
wire of the same gauge.
Advantage: simplicity and low cost. The clip simply is placed on the wire that has been
soldered to the post copings. It is then picked up into the denture with cold cure resin.
Means of attachment of the clip to the resin is not provided, so a retentive wire must be
soldered to the clip to gain retention in the acrylic. If the clip becomes worn or broken,
the involved clip can be ground out of the denture base and a new one inserted.
IV- Ackerman clip and C M. Clip
Components: Both of these bar joint attachments are similar in
design. They consist of a round bar soldered to the post copings
and a clip that fits over the bar similar to the Baker clip.
Their difference is in the fact that they come equipped with
retention wings on the clip for easy engagement into the acrylic of the overdenture.
They also supply a spacer so that the clip does not rest directly on the bar providing for
vertical and rotational movement. Because of their small size and ease of fixation, these
clips are excellent for overdenture retention when a bar joint system is indicated for use.
Resilient attachments; They allow a vertical movement to the overdenture so that under a
load more force can be carried by the residual ridge and less by abutment teeth.
Advantages and disadvantages
- Those that allow for more movement lessen the force on the abutment teeth by
increasing the load on the ridge but, at the same time, these types make accurate jaw
records and harmonious occlusion more difficult.
- Those that allow for little, if any, vertical movement place most of the stress on the
abutment teeth. This will allow for more accurate jaw records and more
proprioceptive response from the patient, but it also submits the abutment teeth to
more torsional forces and lateral stresses.
3- Magnetic retention
Small, strong mini magnets are successfully used to retain overdentures. One of the
magnet poles is cemented in a prepared cavity (KEEPER HOUSING) of the
endodontically treated abutment. The other pole is attached to the denture base.
Most of the attachments are subject to wear and may require adjustment or replacement
in service. The use of magnetism as a means of retention could solve these problems, but
until recently, permanent magnets could not be made small and strong enough.
Advances in technology have made available a new family of magnet alloys based on
cobalt and the rare earth metals. Permanent magnets made from these alloys are
sufficiently small and strong to be used for overdenture retention.
The magnetic retention unit is composed of detachable keeper element made of stainless
steel fixed to abutment done by;
- Cementing in performed keeper in tooth.
- screwed in performed keeper in tooth.
- Casting a root cap and dowel keeper and cementing to place.
The magnet protected by late to prevent wear, corrosion.
It gives retentive force about 250g.
No external magnetic field or residual. The metal composed of ferromagnetic material to
give strong magnet with small size.
Other Retentive Methods
Brill, who was one of the first to advocate the overdenture approach, referred to
the restoration as a hybrid-prosthesis because it was not a complete or removable
partial denture in the accepted form.
Retention is developed by special attachments (B and C anchors). After
endodontic treatment, the clinical crown is reduced.
A male knob is cemented onto each of the retained teeth. Passive springs placed
in the denture base engage the knobs when the prosthodontic restoration is moved
either laterally or vertically.
In a technique described by Dolder, a splint bar is attached to copings made for
the retained teeth. An open sided sleeve is embedded in the denture base. This
sleeve snaps over the splint bar when the denture is inserted.
The prosthodontic restoration can move vertically and horizontally within narrow
limits without engaging the bar.
Methods used to fabricate the non-retentive overdenture
An approach that has become popular in the past several years is to perform endodontic
therapy, drastically reduce the retained teeth, and construct the denture over the
unprotected teeth. This approach gives vertical support to the denture (the lateral surfaces
are reduced in the denture), maintains the alveolar bone around the teeth, and is less
expensive. The main disadvantage is that the teeth are more susceptible to caries.
However, if good hygiene is stressed and if fluoride is applied periodically, the prognosis
is good.
Miller uses a cast metal thimble in his technique for tooth supported overdenture. After
reduction of the retained teeth, cast coping are constructed and cemented. The master cast
is obtained, and a metal thimble embedded in the acrylic resin denture base acts as a
vertical stop during normal function of the denture.
Cozza, reduces the retained teeth and then places tapered cast copings. After the
copings have been placed, a conventional mandibular denture impression is made. Tinfoil
is placed on the lateral aspects of the stone reproductions of the copings before waxing
and setting up teeth. This allows for some lateral clearance between the coping and the
finished acrylic denture base during normal function of the prosthodontic restoration. The
coping acts as a vertical stop for the denture.
Morrow et al, are presently using a prefabricated chrome cobalt bearing between the
abutment and the denture base female depression. They first used gold copings with gold
bases inside the denture.
Lord and teel have described a method that is only slightly more complex and expensive.
They place short gold copings over radically reduced teeth. The ridge must be
reasonably mature. Endodontic therapy is performed when necessary prior to preparing
the retained teeth. The advantage of the gold coping over the unprotected tooth is obvious
it minimize susceptibility to caries.
COMPLETE DENTURE THEORY AND PRACTICE Implant 22
Treatment of patients using dental implants
I. Implant terminology
II. Historical development of implant biomaterial
III. Implant biomaterials
IV. Indication & contraindication
V. Classification of dental implants
VI. Component parts of root form implants:
VII. Diagnostic evaluation and treatment planning
VIII. Surgical technique for root form implant:
IX. Prosthodontic applications
Implant Biomechanics.
Impression techniques for implant
Attachments
X. Maxillofacial implant prosthesis
XI. Occlusion of implant overdenture
XII. Current Trends in Immediate Dental Implant
XIII. Osseointegration
XIV. Biological tissue response to dental implants
XV. Complications of dental implant.
XVI. Management of failing implant cases
Introduction
Depending on the degree of edentulism, several treatment options are available, including:
No replacement
Removable partial dentures
complete dentures
Conventional or adhesive bridgework
Implant-supported prostheses
Transplantation.
Dental implant is defined as A prosthetic device made of alloplastic biomaterial, surgically
implanted into the oral tissues beneath the mucosa, and/or periosteal layer, and/or within the
bone to provide retention and support for a fixed or removable prosthesis.
IMPLANT TERMINOLOGY
Abutment: A tooth, a portion of a tooth or that portion of dental implant that serve to
support and or retain prosthesis.
Fixed-detachable bridges: It is a prosthesis that may be removed by the dentist but not by
the patient. The method of fixation is by screws that attach the bridge to the implants.
Graft: A tissue or material used to repair a defect or deficiency.
Allograft: A graft of tissue between genetically dissimilar members of the species called
also allogenic graft and homograft.
Alloplastic graft: A graft using an inert material.
Autogenous graft: A graft taken from the patients own body called also autograft.
Isograft: A graft from one individual to another of the same genetic basis, as in twins- called
also isogenic grft, syngraft.
Homograft: A graft taken from one human and transplanted to another.
Heterograft: A graft taken from a donor of another species- called also xenograft.
Infrastructure : The implant substructure below the soft tissue
.Mesostructure: The part that couples the implant complex (Infrastructure) to the
superstructure.
Superstructure: The superior part of a multiple layer prosthesis that includes the
replacement teeth and associated structures.
Historical development of implant biomaterial
1. Ancient implants materials:
Replacing lost teeth with a bone-anchored device is not a new concept. During
the ancient Egyptians era, and in South America in the 18th century, Ancient
implant materials include the use of wood, carved stone and animal teeth.
2. Metallic implants:
A gold implant introduced in 1807 and a platinum post were used.
Lead coated platinumroot shaped rods in 1886.
Silver implantation around the end of the nineteenth century.
Vitallium implants were developed as an inert biocompatible material, which are
a castable alloy cobalt-chromium molybdenum.
Stainless steel and titanium were used in the fabrication of wire spiral implants.
Stainless steel alloy is stronger, cheaper and easier to machine, however, its
corrosion properties are inferior to titanium. For this reason, it has not been
approved as a dental implant material.
The wide use of implants can be attributed to the Branemark. In 1952, Professor
Per-Ingvar Branemark, a Swedish surgeon, discovered that when pure titanium
comes into direct contact with the living bone tissue, they form a permanent
biological adhesion. called "osseointegration".
He developed and tested a two- stage dental implant system utilizing pure titanium screws,
which he termed fixtures. The first fixtures were placed in patients in 1965,
IMPLANT BIOMATERIALS
METALS AND ALLOYS:
1-Titanium and its alloy; are frequently selected for endosteal implant because surface oxide
that forms spontaneously in air and in physiologic saline. Insertion techniques can alter the
surface layers and this reoxidation (passivation) is recognized as a significant advantage with
respect to minimizing biodegradation.
Pure titanium is somewhat weaker than its alloys, but does exhibit excellent ductility, which is
often a significant advantage for some implant devices.
2-Surgical stainless steel is subject to crevice and pitting corrosion in saline if the chromium-
rich oxide layer is removed. Therefore, passivation and protection of the oxide layer is critical
for this alloy system. Mechanical properties of stainless steel are excellent.
3-The casting alloy of cobalt is often used to make custom dental devices and although cobalt
alloy is somewhat less ductile, strength and surface properties are adequate for long term
implantation. Cobalt alloy is relatively inert in a passivated condition with the complex
chromium-oxide surface providing a significant reduction in corrosion phenomena
CERAMICS AND CARBONS:
Inert biomaterials include aluminum oxide (alumina and sapphire) ceramics, carbon and
carbon silicon compounds. Ceramic forms of hydroxyapatite (called hydroxylapatite to
represent ceramic form) have been introduced for bone augmentation and surface coating.
Selected silica-based glasses, such as invert soda-lime glass with additions of calcium
and phosphate, have been investigated for direct bonding to bone. To date, applications as
dental implants have been limited.
The general group of ceramics and carbons is different from metallic biomaterials in
physical, mechanical, chemical, and electrical properties. Inertness, conductivity,
modulus of elasticity, brittleness, and surface reactions for bonding are notable
differences. Properties should be carefully evaluated for each endosseous implant system.
This is especially critical with regard to handling and sterilization..
POLYMERS AND COMPOSITES:
A wide range of polymeric biomaterials used for other surgical and medical devices has
been investigated for use as dental implants and as surface coatings. In general, these
polymers have not found extensive use as major structural components of dental implants
owing to their relatively low strength and high ductilities.
Some surface coatings and abutment post applications continue. Primary concerns have
been low creep (cold flow) resistances under cyclic loading conditions.
Indication:
Patients who cannot wear partial or complete denture or who wear them with varying degrees of
difficulty are very frustrating, especially when it becomes clear that conventional denture therapy
is not the correct prescription. These patients are usually presented with one or more of the
following features:
1- Severe bone loss that significantly endanger denture retention, stability, support.
2- Poor oral muscular coordination.
3- Low tolerance of mucosal tissues.
4- Para-functional habits leading to recurrent soreness and denture instability.
5- Unrealistic prosthodontic expectation.
6- Active or hyper-active gag reflex precipitated by removable denture, roofless denture or
shorten flange can be used.
7- Psychological inability to wear denture, even with adequate one.
8- Massive bone and tissue loss following surgical removal of tumors.
9- Single tooth loss to avoid involving neighboring teeth as abutments by reduction.
10- in single denture when opposing natural or overdenture teeth or implant supported.
11- in maxillofacial rehabilitations as obturator, splinting, fixation.etc.
Contraindication to Oral Implant:
Absolute Contraindication to Oral Implant:
1. Uncontrolled diabetes mellitus.
2. Long term immunosuppressive drug therapy.
3. Diseases of connective tissue e.g. disseminated lupus erythematosis.
4. Blood dyscrasias e.g. leukemia and hemophilia
5. Regional malignancy.
6. Metastatic disease.
7. Previous radiation to the jaws.
8. Alcohol or drug addiction.
9. Severe psychological disorders.
Relative Contraindication:
1. Controlled diabetes.
2. Low dose irradiated jaws.
3. Osteoporosis.
4. Local pathology.
5. Other medical conditions that contraindicate the use of anesthesia or sedation.
6. Insufficient volume of bone for implant placement, poor bone quality,
7. Patients undergoing radiation treatment.
8. It is well documented that cigarette smoking have a deleterious effect on the long-term
success of dental implants.
9. Bruxism is another local factor that can compromise long-term success. Generally,
bruxism promotes micro-movement of the implant bone interface.
Conventional Dentures and Implant Overdentures
Implant overdentures generally offer the advantages of improved comfort, support,
retention, and stability. In addition, it has been shown that annual bone resorption is more
pronounced in patients who wear conventional complete dentures than in those who wear
implant overdentures.
Natural Tooth Overdentures and Implant Overdentures Compared
It has been stated that overdentures supported by implants have a higher probability of
success than mandibular overdentures upported by the roots of natural teeth (Mericske-
Stern, 1994)
On other hand , preservation of proprioceptive response is a major advantage with natural
tooth overdentures
Implant Fixed Complete Dentures and Implant Overdentures Compared
The implant overdentures have the following advantages:
1. A smaller number of implants are required and that decreases the cost.
2. It is possible to provide better support of the facial soft tissues.
3. There is improved phonetics for completely edentulous patients.
4. Patients have enhanced access for oral hygiene.
5. There is a better result when unfavorable jaw relationships are present.
6. When there is an opposing complete denture, it will be more stable.
7. It is easier to make modifications to the prosthesis base.
8. There is better access for inspection of the surgical site when surgically created oral
defects are present.
Components of a typical implant restoration:
The typical implant restoration is composed of:
The implant (fixture): it is the actual part that is inserted into the bone.
The abutment: it is the core area which is connected to the implant where the
prosthetic part is attached to it.
The prosthesis: it is either single crown, fixed partial denture, over denture or
any type of restoration connected to the implant and the abutment.
Classification of Dental Implants
Dental implant can be classified into two groups:
1- Tooth implants which include transplantation, reimplantation and endodontic
endosseous implants.
2- Non tooth implants which include subperiosteal, transosteal and endosteal blade and
root- form implants.
Classification depends on the anatomical relation of implant to surrounding tissue or
According to their anchorage component:
1. Endodontic stabilizer.
2. Mucosal insert. (in mucosal undercuts)
3. Subperiosteal implant. (on bone)
4. Transosseous implant(mandibular staples) (through bone)
5. Endosseous implant: (in bone)
a- Ramus blade or frame. ?
b - Blade vents implant.
c -Root form implant. May be
- Cylinders endosseous implants.
- Screws or spiral post endosseous implants.
I-Endodontic stabilizer
It is a Smooth or threaded metallic pin implant that extends through the root canal into
the periapical bone to stabilize the mobile tooth. This was first used by Cuswell and Senia
in 1983.
II-Mucosal inserts (Mucoperiosteal -implant interface, Button implant):
They are stainless steel or titanium inserts attached to the tissue
surface of a removable prosthesis that mechanically engage
undercuts in surgically prepared mucosal sites (crypt), or
mushroom shape titanium projection.
It is developed in early 1940 by Dahl from Sweden. Called also intramucosal insert,
mucosal implant, submucosal insert.
It is an effective and simple way to provide significant retention to a maxillary removable
prosthesis.
An insert of double head connected with a bar and called the Tandom Denserts concept
was also introduced in 1983.
These types of implants have the unique feature of penetrating through lining epithelium.
Establishment of an adequate CT seal around implant provides a barrier to the ingress of
oral toxins and bacteria. The maintenance of this seal is essential for providing the initial
peri implant tissue inflammation that can lead to destruction of the implant support.
Epithelial regeneration around well- integrated implants results in a structure similar to
the gingival tissues around natural tooth. The keratinized oral epithelium is continuous
with non keratinized sulcus epithelium.
Indicted in;
- Complete maxillary denture.
- Distal free end extension, maxilla, and mandible.
- Large bulb obturator.
III- Subperiosteal implants (eposteal implant):
it is an eposteal dental implant that is placed beneath the
periosteum & overlying the bony cortex.
It is a customized framework made of non-osseointegrated cobalt
chromium molybdenum based alloy resting on the alveolar bone
beneath periosteum, with abutment posts and intraoral bars to
attach prosthesis.
It is developed by Swedish dentist in United Stat, Dahl 1943& Gershkoff 1949.
Consists of major connectors (peripheral struts), and secondary struts and 4 abutment
head (2 canin, 2 molars) connect bar attachment.
May be maxillary or mandibular, used in severely atrophic ridge for fibroosseous
integration.
Contraindication;
- Patient with any type of metal in jaw.
- Knife edge ridge, firstly alveloectmy and delay implant for 6 months.
- If opposed natural teeth, cannot withstand force, only constructed with zero degree
acrylic teeth to avoid lateral stresses.
- If odontogenic disease.
Construction
Because there is often not enough bone in which to place an endosteal implant,
dentists turned to placing implants on and around bone. Silicon impression material
is used for this record.
The metal frame was casted with four abutments designed to perforate the covering
mucoperiostium to give support to a denture.
The shape of bone for frame construction is obtained through:
1. Direct bone impression (2 surgical exposures). In first surgery; incision and
reflection with direct bone impression with rubber base and centric relation record
with surgical bite rims. In second stage; after 6-8 weeks, currently done after 1
week the implant fixed in position.
2. Recently, CAD-CAM generated model (only one surgical exposure).
The second stage was performed for fixation of the casted metal frame to rest on bone
and to be covered by the mucoperiosteal tissues.
A three- dimensional replica of the mandible can be developed from computerized
tomography (CT) images, making it no longer mandatory to carry out extensive surgical
dissection for a direct bone impression. CT generated models, however, are not as precise
as those obtained from a direct bone impression, and many operators prefer the direct
technique.
Problems experienced included infection, exteriorization by the down growth of epithelium
and damage to the underlying bone. In some cases the subperiosteal implant would submerge
into the bone, making it extremely difficult to remove.
Complications of subperiosteal implant:
Inflammation, post insertion dysesthesia, swelling, pain, laceration of the mandibular nerve
or progressive bon resorbtion.
IV- Transmandibular (transosseous, mandibular staples staple boneplates:
The staple bone plate is used to rehabilitate the atrophic edentulous
mandible.
It is a transosteal threaded posts which penetrate the full thickness of
the mandible and pass into the oral cavity in the parasymphysial area.
Made of vitallium, titanium or gold alloy. Formed from metal plate (horizontal base)
fixed in inferior border of mandible by retentive pins (3-5 number) or by 5 cortical
screws. Transosteal threaded posts penetrate full thickness of mandible with 4 fasteners
and 2 locknut.
May be one piece as mandibular stable, or each posts can be removed individually if it
fall.
Indicated in;
Severe atrophic mandible,
irradiated mandible,
non union fracture of atrophic mandible,
cases of poor prognosis of augmentation.
V- Endosteal (Endosseous) implants:
The implant is placed into the alveolar bone and composed of anchorage component
(body) and a retentive component (abutment).
Endosseous implants are the most frequently used implants today for fixed, fixed
detachable prosthesis, overdenture and in cases of single tooth replacement.
Various implant designs emerged in the early 1960. The majorities are screw-shaped
but some are cylindrical, with or without vents and some have a fin- link extension. It has
to be noted that the era of placing root form implants into bone to support a tooth was
started very early with various degrees of success.
In 1978 Branemark presented his work, which done in Gothenburg, Sweden "the two-
stage titanium screw root- form implants with osseointegration concept"
The discovery of osseointegration has undoubtedly been one of the most significant
scientific breakthroughs in dentistry over the past 30 years.
Classification of endosseous implants according to their GEOMETRIC design:
a- Ramus blade or frame.
b - Blade vents implant.
c -Root form implant.
- Cylinders endosseous implants.
- Screws or spiral post endosseous implants.
a- Ramus blade and frame;
Ramus frame implant was designed to be placed in the ramus of the mandible.
Is one piece system made of iron chromium nickel based alloy.
Used in the posterior mandible when insufficient bone exists in the
body of the mandible.
Is a triple blade one piece device indicated when subperiosteal
implant is contraindicated.
In the form of blade or frame.
b- Blade-vent (Blade form) endosteal implant.
It is a wedge shaped, narrowed faiolingually implant composed of
head, neck and body with vents and recess in its shoulder which
develops fibro osseous integration with bone.
The blade implant is a mean of utilizing the narrow and/ or shallow
areas of remaining alveolar bone where dimensions do not permit
the use of root form implants.
The blade implant was restorable within a month of placement by
the superstructure.
The blade vent implant was designed to solve problem that existed in knife edge ridges.
May applied as one piece (body- abutment) in one stage surgery for fibrointegration, or
two pieces (body followed by abutment connection after healing in two stage surgery for
osseointegration.
advantages
- Better retention, lateral stability due to large area and flat design.
- Can be used in knife ridge.
- Easy inserted and adjusted.
- Vents allow bone groth, better anchorage.
- Used in low highet bone, above canal,below sinus.
Indications;
-Cases with bone less than optimal for implant.
-Abutment require more than 15 degree bend.
-When opposing arch is natural teeth.
-Cases with high vertical dimension.
Contraindications:
1) In single tooth replacement.
2) In recent extraction.
3) In patient with systemic diseases.
Disadvantages:
1- Poor flap design
2- Improper management of investing tissues.
3- Absence of osseous host site.
4- Improper osteotomy or implant placement.
The blade-vent implants is routinely utilized as one stag system with immediate loading
and two stage systems with total or semi submergence and delayed loading. The one stag implant
The two-stage configuration is indicated in the following:
1) Cases that have less than optimal bone for implant insertion.
2) Cases requiring more than 15-degree bend of the abutment.
3) Cases in which the opposing arch is natural dentition.
4) Cases with high vertical dimension.
5) The elderly.
c- Root form implants.
It is an endosteal implant shaped in the approximate form of teeth root.
may be;
may be Fixed, fixed-detachable, overdenture and single tooth.
Vary in length and diameter
Placed in one-stage or two-stage procedure
Requirement;
- More than 10mm vertical bone height,
- More than 6mm buccolingual width and
- More than 8mm mesiodistal bone length.
Advantages;
1- Better stress distribution over greater surface area.
2- Greater diameter at abutment root junction.
3- Greater bone density.
4- Better esthetic, better abutment design, greater retention and less fracture.
5- Less skill for its placement.
6- Better healing with respect to the crest of bone.
Mini implant
Reduced width; range from 1.8 to 2.4 mm width
Useful when conventional implants are not an option due to narrow ridges
immediate load. Used in temporary restoration or orthodontic treatmeny
Small diameter implants (SDIs) are the preferred treatment modality in cases of limited
anatomical geography.
These implants range from 2.75 mm to 3.3 mm in width and 8.0 mm to 15 mm in length.
SDIs are indicated for the replacement of teeth with small cervical diameters and in cases of
reduced interradicular bone. They also have been shown to be a viable alternative to bone
augmentation when poor alveolar ridge width is encountered and in cases of restricted
mesiodistal anatomy
Classification of Root Form Implants:
I-According to the design:
Threaded; screws or cylinder tapered screw (threaded or hollowed with fenestration).
None threaded; bullet shape (solid screw with external fins) or basket form (hollow).
Supplied in two forms, Cylinder and screw form
Cylinder form
Cylinder forms take its support mainly through shear force.
Cylinders have many forms such as tapered with external threads or basket type,
which is a perforated cylindrical implant. Its implant body designed in the form of
single, double and or triple contiguous cylinders
Screw shaped implant.
Any dental implant whose configuration resembles a screw:; it may be hollow or solid,
and usually consists of the dental implant abutment and the dental implant.
II-According to material:
a- Non metallic implants, this type of dental implants is made of either
- Ceramics.
- Polymers, or
- Carbons which decrease the induced stresses in bone, but it were found to be of lower
strength quality and thus it is not used any longer.
b- Metallic implants, this type of dental implants is made of high strength metals. It is one of the
most suitable types. Titanium and titanium alloys are the most widely used.
- A- Commercially pure titanium (C.P.Ti):
The oxide surface layer creates a chemically non-reactive surface to the surrounding
tissues, which gives (C.P.Ti) its high corrosion resistance advantage.
(C.P.Ti) was used which has poor wear resistance and its modulus of elasticity is five
times greater than that of bone. Its composed of 99.75% titanium with iron, oxygen,
nitrogen, carbon, and hydrogen so it's a low density metal .
Commercially pure titanium (C.P.Ti) and Ti alloy with radio-labeled lipoplysaccharide
(LPS) was used to decrease the affinity to Lps thus decreasing the possibility of
perimplant tissue response.
- B- Titanium-Aluminum-Vanadium alloy (Ti-6AL-4V):
It was stated that because of its high modulus of elasticity, it can be obtained in thin
sections without deformation.
- C-Aluminum, Titanium and Zirconium Oxides high ceramics:-
Due to its composition, it has better color, minimal conductivity and low modulus of
elasticity so it is used in bulk forms
III-According to surface character:
a- Sand blasted surface.
- Roughened titanium surface by sandblasting to increase bone contact than smooth
surface 50%-20%.
b- Acid etch surface
acid etching have also been used to increase the surface area and to alter its micro-topography or
texture
c- Titanium Plasma Sprayed surface (TPS),
- To increase the surface area and provide a more complex surface macro-topography it
has satisfactory results regarding the osseointegration
d- Titanium oxide surface (bioinert):
- Coating implants to make the inert metal a bioactive one. Titanium forms a tenacious
surface coating titanium oxide on it mineralized bone can be formed.
e- Hydroxyapetite coating (bioactive);
Its a calcium phosphate salt initiate bone growth from both surfaces of implant and the
cut bone. So, the osseointegration increase with time.
f- Polyactive coating
It is an elastomeric polyethylene oxide polybutylene-terephthalate (P.EO.PBT)
copolymer (polyactive) which exhibits bone-bonding characteristics. It has two types , dense
and porous type . the dense poyactive implant function adequately and had mobility resembling
natural teeth
g. Smooth, threaded, or vented.
IV-According the insertion manner:
Press fit: the implant sit is drilled slightly smaller than the actual size, where
implant is pressed depending on friction for primary stability. It is unthreaded
covered with hydroxyapetite or plasma spray coatings.
Self tapping: these are threaded implants. Threads are used to tap its site during
insertion.
Pre tapping: these are threaded implants, where their sits are previously tapped
using bone tap instruments before insertion in case of very dense bone.
V-According to surgical stages:
a- Single stage design (none submerged trans gingival):
The body of the implant is inserted into the bone with its abutment portion
penetrating through the mucoperiostium during the healing period.
b- Two stage design (submerged):
In this design the implant body is completely embedded in bone then exposed and
healing abutment is placed for soft tissue healing .
VI- according to reactivity of bone;
o Bioactive; Hydroxyapetite, ceramic.
o Bioinert; titanium, carbon, Vitallium.
VII- according to tissue response;
Fibrointegration.
Osseointegration.
Biointegration.
Ligamental integration.
Fibroosseous integration.
VIII According to the type of implant bone interface,:
a- Biointegration: anchorage may be achieved through a non mineralized zone, which is
claimed to be a pseudoperiodontium.
b- Ligamental integration: the presence of soft tissue layer surrounding the implant.
c- Fibrointegration: clinical success rating was not convincing with the presence of a
connective tissue layer surrounding the implant. it is doubtful to achieve a long-term
anchorage by means of connective tissue layer between the implant and the bone.
d- Osseointegration: it is a direct structural and functional connection between ordered
living bone and the surface of a load carrying implant. This type of connection is
considered the most desirable one by many authors.
IX- according to resiliency;
Resilient, to reduce the induced stresses. Distract implant have 2 movable endosteal can
elevate ridge to 6 mm.
Non resilient, rigid; the most available type.
X-According to time of placement:
a- Immediate implants,
They are placed into a prepared extraction socket following tooth extraction.
Placed 1-2 mm apical to tooth socket to engage inferior cortex. It was found
that osteocalastic activity increase 6-8 week after extraction so, to improve
used wit guided tissue regeneration.
b- Immediate delayed implants, they are placed within 2-12 weeks after the tooth loss
just after bone formation as the osteoblastic activity is very high and not followed by
osteoclastic activity.
c- Delayed implants, they are placed within 6-12 months after tooth extraction, when
complete healing and bone remodeling occur.
XI- Classification of endosseous implants according to time of prosthetic
loading: Int J Oral Maxillofac Implants. 2007 J ul-Aug;22(4):580-94
a- Immediately loaded implants, an acrylic resin prosthesis which is designed to be out
of occlusion is placed immediately after implant placement, specially in anterior
region for esthetic purposes.
b- early loading : patients received an overdenture [1 12] weeks after implant surgery
c- Delayed loading implant, delayed loading is done in maxillary implants after 4-6
months and in mandibular implants after 3-4 months to allow for better
osseointegration due to the difference of the investing bone composition.
XII - According to support
Implant supported overdenture designs are classified depending on the number and
location of implants, type of bone, opposing occlusion, into:
(1) Mainly Mucosa Supported Implant Overdenture:
It is a type of overdenture supported by the mucosa and it is attached to two implants by
means of resilient attachments or magnets. This type of attachment allows rotation and
translation of the overdenture.
Under vertical pressure the overdenture rests mainly on the mucosa and the attachments
ensure retention and stability during lateral and extrusive movements.
Mainly mucosa supported implant overdenture is indicated for patients suffering from
retention problems in the lower denture and then new dentures without implants will not
adequately solve the problem.
(2) Combined Mucosa Implant-Supported Overdenture:
The mucosa-implant supported overdenture is retained via a supra structure, consisting of
two implants interconnected by a bar, screwed onto the implants. This denture rests on
the mucosa in the dorsal areas and on the bar in the anterior region.
Combined mucosa implant-supported overdenture is indicated with severely resorbed
mandibular ridges when short implants are proposed., patients who are not able to receive
fixed implant-supported prosthesis, and for medically compromised patients. Also it may
be used in certain treatment considerations based on factors such as simplicity of this
method and lower cost, as a viable alternative to bone grafting.
The mainly mucosa-supported overdentures had less bone resorption distal to the implant
in comparison to the combined mucosa-implant -supported overdentures. Plaque index
score was significantly high in the group treated with magnet-retained overdentures.
After 18 months follow up, a group treated with combined mucosa-implant-supported
overdentures showed a significant increase in gingival inflammation when compared with
the other group.
The type of attachment or support may affect gingival inflammation or plaque
accumulation. Increased functional load may affect bone density and resorption.
(3) Mainly Implant-Supported Overdenture
The retention, stabilization and support are ensured by the implant system. Four to six
implants are usually required to provide support for this type of overdentures. A rigid bar,
with multiple clips for retention, is usually used to connect the implants in the anterior
region. Implant supported overdenture is usually used to achieve stress distribution
especially when the opposing arch has natural teeth. It is also indicated for patients with
sensitive mucosa and extreme gag reflex.
It is indicated in the presence of moderate ridge resorption, when an implant-supported
bridge cannot be acceptably placed.
The advantages
The overdenture being secured to the bar at three or four positions, thus giving at least
a tripod retention configuration.
The patient's hygiene maintenance is easier because the removal of the overdenture
allows greater access for cleaning.
In some cases the plate in the maxillary overdenture may be removed to enable the
patient to have a greater thermal sensitivity and increased taste sensation.
There are minimal tissue pressure, optimal access for hygiene and optimal esthetics
because the denture covers all metal frameworks.
COMPONENT PARTS OF ROOT FORM IMPLANTS:
1- Implant body There are two distinct parts of the implant body:
A-The implant crest module is the portion designed to retain the Prosthetic components
in two piece systems. It is smooth to prevent plaque retention crestal bone loss occurs.
B-The implant collar is located above the implant crest module in types coated with
hydroxyapatite (HA). It is not coated to prevent exposure of HA and the liability of
bacterial growth.
2- Prosthetic components:
A-First stage cover screw is placed into the top of the implant after the first stage surgery
to prevent bone, soft tissue, or debris from invading the abutment connection area during
healing.
B- Second stage permucosal extension (healing abutment), it extends the implant above
the soft tissue and results in the development of a permucosal seal around the implant.
C-The abutment, is the portion of the implant that supports and or retains a prosthesis or
implant superstructure.
The abutments are classified according to the method by which the prosthesis
or superstructure is retained into:
1) An abutment for screw retention uses a screw to retain the prosthesis or
superstructure.
2) An abutment for cement retention uses dental cement to retain the prosthesis or
superstructure.
3) An abutment for attachment uses attachment device to retain a removable
prosthesis.
Each of the three abutment types may be classified as straight or angled
abutments.
According to the internal core of the abutment which fit into the implant fixture
it is classified into:
1-Threaded.
2-Frictional, locking tapper (press fit, cold-welded).
3-Non threaded cementable with round or hex hole).
D- Hygiene cover screw is placed over the abutment for screw retention to prevent debris
and calculus from invading the internally threaded portion of the abutment between
prosthetic appointments.
E-Transfer coping is used to position an analog in an impression and is defined by the
portion of the implant it transfers to the master cast, either (the implant body transfer
coping or the abutment transfer coping.
According to the impression technique the transfer coping is classified into
1) An indirect transfer coping is screwed into the abutment or implant body and
remains in place when the set impression is removed from the mouth. It is
parallel-sided or slightly tapered to allow ease in removal of the impression and
often has flat sides or smooth undercuts to facilitate reorientation in the
impression after it is removed.
2) A direct transfer copings usually consists of a hollow transfer component,
often square, and a long central screw to secure it to the abutment or implant
body. After the impression material is set, the direct transfer coping screw is
unthreaded to allow removal of the impression from the mouth. Direct transfer
copings remains within the impress until the master cast is poured and separated.
F- An analog is something that is
analogous or similar to something else. An
implant analog is used in the fabrication of
the master cast replicate the retentive
portion of the implant body or abutment
(implant body analog, implant abutment
analog). After the master impression is
obtained corresponding analog (e.g.,
implant body, abutment for screw) is
attached the transfer coping and the
assembly is poured in stone to fabricate the
master cast.
G- A prosthetic coping is a thin covering,
usually designed to fit implant abutment
for screw retention and serve as the
connection between abutment and the
prosthesis or superstructure. A
prefabricated coping usually is a metal
component machined precisely to fit the abutment. A cast coping usually is a plastic
pattern cast in the same metal as the superstructure or prosthesis
H- A prosthetic screw secure the screw-retained prosthesis Superstructure to the implant
body.
Diagnostic Evaluation and Treatment Planning
Treatment planning
The restoration is influenced by the type, size, number and orientation of implants that can
be planned in relation to anatomical, surgical and prosthetic considerations. If implants are
to be placed in one jaw only, the prosthesis should be designed to take account of the
remaining and opposing dentition or prosthesis.
the following criteria will determine the treatment planning of the edentulous jaw:
the prosthetic design will depend on the distribution of the implants over the arch,
their location and their number;
the natural dentition or type of prosthesis in the opposing jaw will influence the
implant-prosthodontic design;
the intermaxillary relationship has to be considered;
the occlusal scheme is influenced by all these factors;
Esthetic considerations have to be involved.
The final treatment plan is based on a combination of:
patient assessment
radiological analysis
analysis of study models
Analysis of diagnostic wax-up/trial prosthesis.
Patients' preferences.
the treatment of the edentulous maxilla will require more elective procedures:
degree of atrophy of the residual jaw;
prospective location of the implants and inclination of the implant axis;
tissue volume dimensions;
facial morphology;
esthetics;
Function and phonetics.
Diagnostic Evaluation
Age
Implant placement is not recommended in young patients prior to completion of growth
as the implants may end up in infra occlusion. It is widely recommended to wait until the
patient is at least 17 to 18 years old. Completion of growth is usually earlier in females
than males.
There is no upper age limit to implant placement, as long as the patient is fit and able to
undergo the necessary surgery.
Smoking
Smoking is a well-established risk to general health and a factor in periodontitis.
Adverse effects of smoking include systemic vasoconstriction, reduced blood flow and
increased platelet aggregation.
Dental implants have approximately twice the failure rate in smokers compared to non-
smokers. All implant patients should be encouraged to stop smoking or to at least stop
smoking for several weeks before and after placement of implants.
Assessment of the patient
1- General assessment should include:
patient's complaint
medical assessment
psychological assessment
social history
Dental history.
At the initial consultation visit, a detailed medical and dental history is acquired.
Patients having a negative history for any systemic disease would be considered as acceptable
candidates for dental implant procedures. Patients having a history of slight or moderate
systemic disease that is well controlled and does not interfere to any significant extent with the
patient's normal physiologic function could also be considered acceptable for implants.
2- Clinical examination.
The extra-oral examination should include assessment of facial asymmetry, facial form
tooth display, jaw relations and jaw function
The intra-oral examination should include assessment of:
the oral mucosa and the saliva
the remaining dentition and periodontium
the original ridge form, related muscle and soft tissue attachments
The inter-occlusal and inter-ridge relations (vertical and horizontal).
Edentulous space requirement for implant : see Vertical and horizontal dimensions of
implant dentistry and number and position of implant
Interarch Space:
The distance from the occlusal plane to the edentulous mucosa at the crest of the ridge should
meet the following criteria:
There should be 10-12 millimeters of vertical space for fixed complete dentures or
overdentures.
The distance from the occlusal plane to the implant is important when planning fixed partial
dentures and single crowns.
- Prefabricated abutments range in height from 4-10 millimeters.When the available space is 3-4
millimeters, then custom fabricated abutments are required.
Assessment of soft tissue
The soft tissues of the arch should be firm, keratinized tissues. However, it has been documented
that when implants are placed in unkeratinized mucosal tissues, these tissues have responded
well provided that meticulous oral hygiene was maintained around the implants. Pendulous
tissues present in a potential implant site should be trimmed during the surgical placement of the
implant or prior to prosthodontic procedures.
Any high muscle attachment present in a potential implant site should be eliminated prior to
surgical placement of the implant.
Assessment of Inter-arch relationships & Inter-arch distance
Inter-arch skeletal relationships should be noted prior to surgical implantation.
Severe Angle Class II or III relationships could present problems, especially in
edentulous patients, owing to discrepancies between the centers of the denture-
bearing regions. These discrepancies could place unfavorable stress on the implants
as well as on the tissues of the opposing arch.
The possibility of orthognathic surgery should be considered to obtain a more normal Class I
arch relationship prior to implant therapy.
Inter-arch distance must be observed to be suite that the placement of implants does
not infringe on the inter-occlusal distance or the occlusal plane of the subsequent
prosthesis in its relation to both arches.
`
3. Radiographs (Imaging modalities for preoperative assessment in dental implant therapy)
Hong Kong Dent J 2010;7:23-30
A preoperative radiographic evaluation aims to
identify pathological lesions,
assess the quantity and quality of the alveolar bone,
identify critical structures at the potential implant sites,
Determine the orientation of the implants.
Bone quantity and quality will influence the choice of implants with respect to their
number, diameter, length and type. See later assessment of bone quantity and quality
Imaging objectives Journal of Oral Health Research, Volume 1, Issue 2, April 2010
Selection of imaging modality to use depends on the three phases.
1. Preprosthetic implant imaging (Phase 1): The objectives of this phase are to deter-mine the
quantity, quality, and angulation of bone; the relationship of critical structures to the prospective
implant sites; and the presence or absence of disease at the proposed surgery sites.
2. Surgical and Interventional implant imaging (Phase 2): The objectives of this phase are to
evaluate the surgery sites during and immediately after surgery, assist in the optimal position and
orientation of dental implants, evaluate the healing and integration phase of implant surgery, and
ensure abutment position and prosthesis fabrication are correct.
3. Post prosthetic implant imaging (Phase 3): It commences just after the prosthesis placement
and continues as long as implant remains in the jaws. The objectives of this phase are to evaluate
the long-term maintenance of implant rigid fixation and function, including the crestal bone
levels around each implant, and to evaluate the implant complex.
Standard diagnostic views including periapical, occlusal films, panoramic,
cephalometric , tomographic radiography, computed tomography (CT), interactive CT,
and magnetic resonance imaging (MRI)
1- Periapical radiography
Advantages
It provides high-resolution (more than 20 line pairs per mm)
and sharp images, which allow accurate measurements in the
horizontal direction, specifically measuring the proximity of
adjacent tooth roots.
These are well suited for documentation and assessment of possible peri-implant
bone resorption during follow-up and are considered superior to panoramic x ray.
With proper positioning techniques, periapical radiographs give minimum
magnification and distortion and the reproducibility of these radiographs is high.
Available alveolar bone in mesio-distal and vertical dimensions
Disadvantages
It provides only a lateral view of the selected potential implant site without cross-
sectional information,
The projections are not always perfect due to problems with film placement in
resorbed jaws. This can cause inaccurate measurements in intraoral
radiographs
Diameter of ball on radiograph \ Actual diameter of ball = Measurement of bone
on radiograph \ Actual bone measurement (X)
Digital periapical radiographs (digital subtraction)
Less radiation exposure
Standardization of exposure parameters/processing (films)
May depict bony changes (positive or negative) which cannot be
visualized.
Facial and lingual bone may be assessed.
Disadvantages
No cross-sectional information
Frequently not possible to place film apical enough to capture entire ridge
Possible foreshortening or elongation of ridge dimensions
With digital radiography, area imaged smaller
Occlusal Radiographs
Occlusal radiographs are used for the edentulous mandible/maxilla to obtain
information regarding bucco-lingual width and contour .
Applications: Individual implant sites and mapping for multidirectional
tomography.
2- Panoramic radiography
Advantages
It allows complete visualization of the relationship of the maxillofacial structures
within the focal trough, and provides information on the relative position of the
inferior alveolar canal and the maxillary sinuses in relation to the crest of the
alveolar ridge.
It provides an approximation of bone height and vital structures and any
pathological conditions that may be present.
panoramic radiographs may provide a useful overview and may be used in
conjunction with ridge mapping or other diagnostic tools,
Disadvantages
Unpredictable distortion of the visualized structures and a low level of
reproducibility.
Magnification in panoramic radiographs occurs in both vertical and horizontal
directions and varies considerably (1.1-1.7 times). Non-uniform magnification
may be up to 25%.
Accurate assessment of hard tissue morphology and density is impossible because
of the variable distortions occurring in different parts of the radiograph.
A panoramic image cannot provide clinicians with information about the
buccolingual cross-sectional dimension or the inclination of the alveolar ridge.
Assessments of mesiodistal distance can be very imprecise due to inappropriate
patient positioning and/or individual variations in jaw curvature.
the maxillary and mandibular anterior regions often appear blurred. Due to the use
of an intensifying screen to reduce the radiation dosage.
Lingually positioned structures projected more superiorly on the radiograph (e.g.
mandibular tori)
Zonography: Recently, a modification of the panoramic x-ray machine has been developed that
has the capability of making a cross-sectional image of the jaws.
3- Cephalometric radiography
Lateral cephalometric radiographs have been recommended for evaluating the
anterior maxilla and mandible for dental implant placement.
For overall assessment of position of maxilla and mandible
(relative to each other and cranial base)
No information regarding the dental arches
Advantages
It can accurately measure the height and width of the residual bone at the anterior
midline of both the maxilla and mandible.
It allows analysis of the quality of the bony host site (ratio of compact to cancellous
bone), particularly that in the anterior region of the mandible.
The soft tissue profile is also apparent on the radiographs and can be used to evaluate
profile alterations after prosthodontic rehabilitation.
If a patient is already wearing a denture, a recording should be made with the
denture in place in order to provide information about the preoperative relationships
between the maxilla and mandible.
Disadvantages
They are not useful when planning placement of implants lateral to mid-sagittal
plane. Moreover, due to the presence of genial tubercles, it may create overly
optimistic bone volume assessments.
With a fixed relationship between focus-film and film-object distance, there is a
uniform magnification of about 10% (7-12%).
Lateral oblique cephalometric radiography has been proposed by Poon et al. but it is difficult
to predict the amount of image magnification on these views.
4- Conventional Linear tomography
Recording of a cross-sectional image of the jaw through movement of
the x-ray source and receptor blurring of structures outside the
predetermined plane of interest
Advantages
Cross-sectional tomographs are more precise
than panoramic radiographs when measuring
distance between the alveolar crest and the
mandibular canal.
Several studies have shown that tomographic
images of the posterior mandible allow better visualization of the mandibular
canal than the other available radiographic techniques
Disadvantages
Teeth with large metallic restorations adjacent to the area of interest may obscure
the tomographic image.
using of an intensifying screen cassette, making the identification of anatomical
structures and assessment of bone topography more difficult.
They have a uniform magnification and the magnification factor depends on the
relationship between the focus-film and film-object distances.
Multi-directional tomography provides images superior in quality to linear tomography
because of more uniform blurring
5- Spiral tomography
Spiral tomography can be performed with the Scanora system which produces
buccolingual crosssectional tomograms.
This system uses a fixed projection angle to produce a series of four images, 4 mm in
thickness, centered 4 mm apart to include a 16-mm section of the jaw on one film 21.
It is possible to obtain four exposures per film using a field size of 7 cm 10.2 cm.
The Scanora has a constant magnification factor of 1.7.
This system uses a fixed projection angle to produce a series of four images, 4 mm in
thickness, centered 4 mm apart to include a 16-mm section of the jaw on one film 21.
It is possible to obtain four exposures per film using a field size of 7 cm 10.2 cm.
The Scanora has a constant magnification factor of 1.7
Advantages
lower radiation doses than does CT and their cost is approximately one-fifth of that of
a CT machine
6- Computed tomography
Advantages
It allows exact analysis of available bone volume and helps to determine the
appropriate position, angulation, number, and length of the planned implants,
It gives a high resolution, and soft tissues can be visualized to some degree.
The reformatted CT images provide axial, panoramic, and cross-sectional images,
allowing rapid correlation of the different views.
The most radiosensitive head and neck tissues, the corneas and the thyroid glands,
may be avoided by scanning the patient in the axial plane.
The scanning time is much reduced and the image quality much improved.
Computed tomography provides a much more accurate estimate of the position of the
mandibular canal than does periapical and panoramic radiography
The anterior mandibular buccal depression is more readily detected.
CT examinations with reformatted images are only effective means of evaluating the
bone volume present below the maxillary sinuses.
7- Cone-beam computed tomography
It employs a cone-shaped X-ray beam rather than the flat fan shaped beam used in
conventional CT.
It produces a 3-D image volume that can be reformatted using software for
customized visualization of the anatomy. It gives all the information of CT at 1/8th
the radiation dose and at a lower cost
Examples of such machines include 3D Accuitomo (J. Morita, Kyoto, Japan)
Advantages
Lower radiation dose , The overall effective dosage is equivalent to between two
and eight panoramic radiographs.
Greater resolution. Individual voxels are much smaller than conventional CT
voxels, resulting in greater resolution.
The 2-dimensional limitation has been overcome by lowdosage cone-beam
computed tomography (CBCT),
More user-friendly upright position used for scanning.
8- Magnetic resonance imaging
Metals can distort the magnetic field and compromise the images. Non-precious
ferromagnetic alloys (cobalt-chromium) produce large image deformations, whereas
precious alloys (Au, Ag, Ti, amalgam), which are mainly non-ferromagnetic, have no
effect.
MRI is contraindicated for patients with ferromagnetic metallic implants in their
bodies because of the potential risks associated with movement or dislodgment of
such objects
9- Interactive computer-guided implantology(Interactive diagnostic software)
Several different interactive software packages have been developed to allow
presurgical simulation of implant orientation and placement on a computer screen.
The software is available for both conventional tomography and reformatted
computed tomography. The softwares available for conventional tomography are
SURGPlan and for reformatted computed tomography are DentaScan and its
advanced version DentaScan Plus,
3-D Dental, ToothPix and SIM-Plant. These programs permit analysis of potential
implant sites for bone quantity, quality and morphology as well as simulating the
surgical placement of the implant in real time
SimPlant is interactive 3-dimensional CT software program has made it possible to
visualize the anatomical structures in a 3-dimensional mode on computer monitors
for interactive implant placement.
The CT scan data obtained from the SimPlant software can be used to produce
sterolithographic models for 3-dimensional visualization for planning complex
maxillofacial surgery.
There are two techniques available for making sterolithographic models.
The first technique applies laser technology in which a
sterolithographic model is built up, layer by layer, with resin
solution. A resin layer is solidified when its surface is struck
with the laser.
Another technique uses a computer-aided milling machine.
Surgical guides, and provisional and permanent restorations for implants,
can all be fabricated using sterolithographic models
Radiographic measurement template (Diagnostic templates or imaging stents) :
The use of presurgical measurement splints has been an accurate cost-effective means of
determining various bone dimensions.
A clear acrylic splint is fabricated to extend over the edentulous areas of the arch where
implant placement is anticipated. The intended implant site should be marked on the cast.
The intended implant sites are identified by markers made of radiopaque spheres or rods
(metal, composite resin, and gutta-percha) retained within an acrylic stent which the
patient wears during imaging procedure
Only nonmetallic radiopaque markers are (gutta-percha, composite resin) used in CT
imaging because metal markers produce image artifacts.
Once the ball bearing is secured, the entire splint is placed in the oral cavity and a
panoramic radiograph is obtained.
The ball bearing image on the radiograph is measured with a millimeter gauge to
determine the distortion factor of bone in a vertical fashion. If the 5-mm ball bearing now
measures 6 mm on the radiograph, a 20% distortion factor is present. Therefore, for each
multiple of 6 mm, or fraction thereof, three is only 5 mm of available bone for placement
of an implant.
In a similar fashion the splint can be maintained in the oral cavity and an occlusal film
may be exposed to obtain a guide as to the buccolingual or horizontal dimension of bone
in the area of the intended implant site.
In the totally edentulous mandible a straight lateral radiograph will also provide
knowledge of bony dimension at the midsymphyseal area.
Most imaging stents can be converted to surgical guides for use in the surgical phase of
implant treatment to orient the insertion angle of the guide bur and the angle of the implant.
Assessment of the jaw bone quantity (height and width) and quality
See Osseointegration
4- Study casts
It should be obtained from impressions of the patient's maxillary and mandibular arches and
mounted on a suitable articulator using a face-bow at an acceptable vertical dimension of
occlusion.
Study casts should:
where appropriate be mounted on an articulator, preferably using a face-bow,
indicate jaw and occlusal relationships, both vertically and horizontally, and
indicate the position and arrangement of any remaining natural teeth
help decide the possible position and number of implants and the orientation
of implants relativ e to the jaw bone and natural teeth.
They may also act as a guide when bone augmentation may be indicated.
Diagnostic wax-up/trial prosthesis
relates tooth position in the restored arch to:
the residual ridge
any remaining natural teeth
implant position
the opposing dentition or residual ridge
the necessity for a labial flange for optimal lip/cheek support.
Orientation of implants to allow a functional and aesthetic prosthesis to be
constructed.
5 - Placement of prosthetic teeth and a wax-in of this arrangement should be
performed with the patient to verify esthetics, phonetics, and occlusion. It also provides another
diagnostic tool for determining the placement of the implants. Once these determinations have
been verified, a clear surgical stint can be prepared from the articulated cast to aid in the exact
surgical placement of the implants.
SURGICAL TECHNIQUE FOR ROOT FORM IMPLANT:
General principles for surgical treatment
Surgical treatment should be conducted according to established protocol.
In particular, the surgical field should be suitably isolated and free from
contamination at the time of preparing canals in the bone and the positioning of
implant fixtures in the jaws.
Sterile implants, packed and prepared by the manufacturer should be used in
association with the recommended instrumentation.
The careful preparation of bone to avoid overheating is an essential feature of the
operation and for this copious irrigation, sharp instruments and low drill revolutions
are necessary
The positioning of implants should be carried out according to an established treatment
plan, avoiding vital structures (such as the inferior dental canal) and the roots of adjacent
teeth.
A surgical template, identifying the planned implant position and
likely position of the artificial tooth crowns of the future prosthesis, is
recommended for use in most cases.
Bone criteria: should be suitable for the implant system chosen .
Many systems recommend a two stage procedure in which the endosseous
component (fixture) remains isolated for several months within the jaw bone, in order to promote
integration with the healing bone. This is the preferred technique
In single-stage procedures it is advised that the implant should not be loaded immediately.
The Implant Placement Procedure
The Two-Stage Procedure
First Stage - Surgical placement (can be done with a local anesthetic)
Step 1 Step 2 Step 3 Step 4
Round bur 2 mm twist
1.Apical portion of twist
drills are conical, which
means that this portion of
the drill is deeper than the
actual implant length.
2. graduations on twist
drills represent height of the
fixture together with a
slotted cover screw.
3.Direction ,parallelism
should be checked and by
more than one person if
possible.
4.Use direction indicators
Pilot drill
1.Expands the entrance
of the osteotomy to 3
mm in preparation for
the 3 mm twist.
2.Limited reorientation
may be accomplished at
this step.
3.The cutting portion of
this drill are the sides.
3 mm twist drill
1.This is the terminal
twist drill for the
standard platform
fixtures.
2.In very dense bone,
a 3.15 mm twist drill
is recommended.
3.Reorientation may
be performed at this
stage.
Step 5 Step 6 Step 7
Countersink
1.Used to widen osteotomy
at coronal position so that
cover screw may be placed
at or below the level of the
bone.
2.Counersinking is NOT
typically performed.
Fixture
1.Come in a variety of
lengths and widths.
2.Typically, wider is better.
3.A variety of surfaces and
thread configurations are
available.
4.One-and two-stage
fixtures.
5.Type of fixture to be used
is often dictated by
restorative dentists
preference.
Cover screw
Second Stage - Uncovering of the implant
Step 1 Step 2 Step 3 Step 4
The implant is
screwed or tapped
into a surgically
prepared site. The
gum tissue is closed
over the implant
The implant remains
under the gum for 3 to
6 months. The patient
continues to wear their
denture during this
period.
3 to 6 months later. The
implant is exposed by
removing a small
amount of gum tissue.
An insert can be screwed
or cemented down into
the implant.
The secured insert can
accommodate various
attachments upon
which overdentures,
bars, crowns, or
bridges may attach.
The One - Stage Procedure
In step 2, the implant, which is placed, has an additional component that protrudes through
the gum tissue. This extension of the implant then does not become covered over during the
healing phase.
Soft tissue reflection:
1) The patient is premedicated and anaesthetized. Incision is made to the extent designed
in the treatment planning for each individual case.
2) Sharp periosteal elevator is used to reflect the periosteum and all fibrous tissues are
removed from the crest of the edentulous ridge.
3) Osteoplasty of the crest of the ridge is indicated to give an adequate width for implant
placement. It is done at low speed with excessive amount of saline until 5 mm width of
bone at the implant site is obtained.
Implant site preparation:
1) Pilot drill is used to map out all the implant sites before starting the implant
osteotomies. Drilling procedure is carried out with high torque handpiece at low speed
(800 to 2000 rpm) with internal and external saline irrigation to decrease heat generation.
2) Small diameter bone drill is used to begin the implant osteotomy. Direction, bone
density, and implant height are determined with the use of this initial drill. The surgical
guide template is used to locate the ideal angulation of the implant. Direction indicator
are placed in the osteotomies to evaluate angulation when the surgical guide is inserted.
3) Drills of gradual increase in diameter are used to prepare the implant site to the
required diameter. A slight modification in the angulation can be carried out.
4) Crestal counter sink drill is used when the crestal collar of the implant is greater than
the body and cortical bone is present on the crest or if cortical bone interfere with final
implant placement.
5) If threaded system is used a bone tap is used to thread the bone for more passive
implant body placement.
Implant placements
Implant body is threaded into position and a first stage cover screw is inserted. The
level of the implant body with crest is related to parafunction, bone density, and the
final prosthesis.
Soft tissue adaptation:
The soft tissue is replaced and sutured with continuous suture. Postoperative
medication and instructions are given. Sutures are removed 14 days. The denture is
recontoured so no contact is present on the implant body. Also the denture is lined by
sot tissue lining. If excessive from the soft tissue- bone prosthesis occurs, exposure of
the first stage cover screw may take place. However, if happens during healing it does
not require surgical correction.
The second stage surgery
A full thickness incision is made which bisect the attached gingiva and extends beyond
the location of the implant. Flap reflected to expose all the cover screw. First stage
cover screw removed and second stage permucosal extension is threaded. The buccal
and lingual tissues around the permucosal extension removed and the flap is sutured.
THE SURGICAL GUIDE STENT: It is used during the first stage surgery to aid in properly
positioning and angulating the guide drill, so that the fixture can be placed to insure optimum
esthetics for the prosthesis.: The study cast is marked for the implant sites and holes are drilled to
simulate ideal fixture angulation. Dowel pins and sleeves are placed on the prepared cast. Resin
material is adapted to 6-mm. height around plastic sleeves and to the entire ridge area. Then resin
is cured finished and polished.
Prosthodontic Applications
General principles for prosthodontic treatment:
Any temporary prosthesis should be designed to avoid pressure over implant sites.
A definitive prosthesis may be:
Supported entirely by implants and may be fixed or removable by the
patient depending on aesthetic, functional and maintenance considerations
Supported by implants and residual ridge.
Supported by implants and natural teeth.
Leverage should be kept to a minimum and the extent of any cantilever should
take into account the number, size and distribution of the implants and the rigidity
of the superstructure.
Selection of the appropriate occlusal scheme should be based on sound restorative
principles and take into account the type of opposing dentition/prosthesis.
An implant supported fixed prosthesis, used to restore the dentition of an
edentulous jaw, should be retained by implants of appropriate size and number: a
minimum of five in the mandible and six in the maxilla.
An over-denture prosthesis used to restore an edentulous jaw normally requires a
minimum of two implants in the mandible and four implants in the maxilla,
together with maximal coverage of the denture bearing area.
A partial, fixed prosthesis may be constructed on two or more implants. Due to
the different behavior of implant attachment and natural tooth to bone, it is
generally considered inappropriate to link implants and natural teeth with a
prosthesis unless a device allowing for differential movement is incorporated.
In the anterior maxilla, careful assessment and planning is needed to avoid
producing an unsatisfactory appearance.
Prosthodontic Applications
Single Tooth Replacement:
The single tooth implant may be an alternative when replacement of a single tooth would
involve preparation of un-restored teeth adjacent to the edentulous space.
The maintenance of a plaque-free dental implant and proper functional forces are the
paramount considerations in this situation. With equal pressure with the rest of the teeth.
Fixed Prostheses:
In the mandible for full arch fixed prosthesis, a minimum of five
properly spaced root form implants are inserted between the two mental
foramina. In the maxilla a full arch fixed prosthesis requires a minimum
of 6 root form implants due to the decrease in bone density.
The partially edentulous area may be restored utilizing a natural
tooth or teeth as an abutment in combination with an implant (composite
system), or the prosthesis may be completely supported by implants
(single system).
The abutment crown and pontic contours must be designed so the patient have easy
access to the interproximal and mucosal surfaces for the use of oral hygiene aide.
Fixed Removable Prosthesis - Fixed Detachable Bridge:
The fixed-removable prosthesis resembles a flangeless denture that is retained only by
several osseointegrated implants. This retention is obtained by the use of screws.
In most cases, the implants are present in the anterior region of the mandible or maxilla. The
anterior portion of the prosthesis is secured to the implant fixtures with screws. The posterior
portions of the prosthesis are cantilevered from the distal abutment implants. There is no
contact between the prosthesis and the tissues of the alveolar ridge.
The prosthesis consisted of a gold alloy framework attached to the copings of the implant.
Acrylic resin denture teeth were arranged on the framework and secured with acrylic resin.
Later modifications of this design incorporated changes in the structure of the framework as
well as the use of less expensive metal alloys with similar physical properties as the gold
alloys.
Since the implants are situated in the anterior region, the posterior sections of the framework
are cantilevered from the anterior portion of the framework.
The length, height, and width of the cantilever are crucial in minimizing the amount of
deformation of the prosthesis.
May need 4-8 implants depending on the amount and quality of
the bone present.
An option for those patients who don't want anything
removable in their mouth.
The teeth are built upon a metal base through which screws are inserted and, in turn, secure
the teeth into the implants.
The prosthesis consisted of a metallic framework attached to
the copings of the implant. Acrylic resin denture teeth are
arranged on the framework, and secured with acrylic resin.
There is no contact between the prosthesis and the tissues of
the alveolar ridge.
The metal base does not come into contact with the gums and sits, like a "platform" above
the gums. This "high water line" may be inconvenient for some cases, especially for upper
teeth replacements. If this is a concern, the use of crowns, which go over the implants, may
be a better, although more costly, option.
Implant Overdentures
The overdenture provides additional retention and stability over a conventional
denture. Three methods are used most commonly to provide retention for overdenture; ball and
socket attachment bar attachments and magnets.
The choice of fixed or removable prosthesis:
There are a variety of factors that will influence the indications for an overdenture, fixed
prosthesis, or a fixed-removable prosthesis. The selection of the overdenture for implant
prosthodontic reconstruction depends on several factors. One factor is the amount of bone
resorption that has occurred in the arch. The presence of minimal height and width of the
remaining bone, except in isolated areas, would prevent placement of a sufficient number of
implants to adequately retain a fixed prosthesis. However, the existence of isolated areas with
sufficient bone to allow for placement of one, two, or three implants would allow for the use of
an overdenture.
The lack of sufficient cortical bone in the maxilla as opposed to the mandible does not
allow the maxillary arch to be amenable to the full extension of the cantilever posteriorly for a
fixed-removable prosthesis, thereby limiting the extent of occlusion and masticatory efficiency.
This problem would be alleviated with the use of an overdenture. Severe resorption of the
maxillary arch anteriorly might create unfavorable cantilever forces with a fixed prosthesis in
order to provide adequate facial support, esthetics, and occlusion. An overdenture would be
indicated in this situation.
Overdentures may be used in situations where the arrangement of the implant fixtures
is unfavorable for retaining a fixed prosthesis. Fixtures that have been positioned with excessive
inclinations that may compromise esthetics or hygiene for a fixed prosthesis could be used with
an overdenture.
The use of a fixed prosthesis retained by implants in the maxillary arch may cause
difficulty during speech owing to an excessive escape of air through the spaces present between
the fixtures. This problem can be resolved with the use of an overdenture.
Implant-retained overdentures have been used in the oral rehabilitation of patients with
acquired or congenital defects of the maxilla and mandible. Other factors, such as cost and
patient acceptance, play a role in the selection process.
There are several factors that favor a fixed-removable prosthesis. There are instances
where severe resorption exists in the arch. Usually in the mandible, a minimal amount of
posterior residual ridge remains and the labial and buccal muscle attachments are continuous
with those of the floor of the mouth. In this situation, an overdenture may not be adequate
because of the lack of sufficient ridge and vestibular depth for retention, support, and stability.
Extensive surgical augmentation and vestibuloplasty would be required to improve the ridge
form before the placement of an overdenture. The existence of minimal height in the posterior
regions of the arch may preclude placing implants for a fixed prosthesis. However, anteriorly,
there usually exists sufficient remaining bone for the placement, of an adequate number of
implants to retain a fixed-removable prosthesis.
Other factors include the patient's ability to adapt to a removable prosthesis. Some
patients may not adapt psychologically to the wearing of a removable prosthesis while others
may not have the neuro-muscular coordination needed to retain a removable prosthesis. In these
patients, a fixed-removable prosthesis may be indicated.
Impl ant Biomechanics
Dental implants tolerate vertical forces well. Lateral forces increase the stress/strain
levels at the bone implant interface (exponentially) when compared with vertical loading.
Consequently, lateral (oblique/bending moments) forces should be minimized and/or avoided.
a) Implant width
b) Number of implants and choice of prosthesis.
c) Individual versus connected (splinted) implants.
d) Location of the Implants.
e) Implant Alignment.
f) Implant Component/Retentive Mechanism Height Above the Soft Tissue.
a) Implant Width:
oWider implants provide for increased bone-implant surface area and therefore
improved biomechanical advantage, however, in the anterior zone, wider implants may
compromise the mesial-distal restorative emergence profile. Consequently, regular
(average of 4-4.3 mm) and small (average of 3.5 mm) diameter implants are preferred.
oSelect an implant which is within 1-2 mm of the size of the restoration at the gingival
level.
Small diameter implants (3.3-3.5 mm): Maxillary laterals and Mandibular
incisors.
Once-piece 3.0 mm diameter implants: lateral incisors, when only 6 mm of
inter-root space is present and further orthodontic therapy is contraindicated.
Regular diameter implants (4.1-4.3 mm): Maxillary centrals, canines and
premolars.
Wide diameter implants (5.0-6.0 mm): Maxillary/Mandibular molars. Maxillary
canines in select cases (no greater than 5.0 mm diameter).
b) Number of implants and choice of prosthesis
The number and positioning of implants to be placed depends on:
Anatomic-morphologic conditions which determine to a certain degree the type
and design of prosthesis. Additionally, the size, curvature and shape of the ridges
determine the distribution of the implants over the arch.
The type of proposed restoration, and choice of prosthetic design
The quantity and quality of the available bone and
The loads to which the restoration will be subjected.
Anatomic-morphologic conditions affect implant selection
Vertical and horizontal dimensions of implant dentistry INSIDE DENTISTRY
J ULY/AUGUST 2009
a) cr own height space:
The key vertical parameter: Crown height space is the distance from the occlusal plane to
the crest of the alveolar ridge
Fixed Restorations
The cement-retained implant prosthesis requires a minimum of 8
mm of crown height space.
The ideal space, however, for a cement retained prosthesis is 9 mm to 10 mm in the
posterior and 10 mm to 12 mm in a maxillary central. The crown height space for a
cement-retained prosthesis has three main regions: the soft tissue, abutment, and occlusal
material.
The ideal vertical dimensions of each region are: 3 mm for the soft tissue;3 5 mm for the
abutment height;4 and 2 mm for the occlusal metal or porcelain
Removable Prostheses
An implant-retained removable prosthesis has two options in terms of connecting the
implant to the prosthesis. One option is a bar-retained prosthesis that needs at least 15
mm to 17 mm of crown height space (variance depends on the type of attachment). It is
comprised of the following: 3 mm, bone to soft tissue; 1 mm, soft tissue to bar; 3 mm to 5
mm, bar plus attachment.
The remaining vertical distance is made up of the denture teeth and supporting acrylic.
This is a height of > 8 mm from the bar/attachment to the incisal edge .
The second option is a low-profile independent attachment which has a lower vertical
space requirement. This space is measured from the alveolar crest to the inner aspect of
the lingual denture base, and the measurement is a minimum of 7 mm.
The current lowest vertical height of an attachment (abutment plus male) is 3.17 mm on
an externally hexed implant, and 2.5 mm on a non hexed implant.
When formulating a treatment plan involving implants, it is essential to be acutely aware of the
dimensions required for implant placement.
A minimum of 5 mm is required in terms of interocclusal space.
The minimum MD space for placement of a single tooth implant is approximately 6-7 mm.
For the replacement of some lower incisors and other such situations thin, narrow implants
exist. The strength of such implants, however, may be cause for concern.
EXCESSIVE CROWN HEIGHT SPACE
Excessive crown height space acts as a vertical cantilever. The greater the crown height
space, the greater the moment of force under lateral load.
For every 1 mm in crown height increase, the force increase may be 20%. Therefore, a
crown height increase of 10 mm to 20 mm may increase stress 200%.
To prevent this, there are different surgical approaches to help diminish available crown
height space, such as block onlay grafts, particulate bone grafts with mesh titanium or
barrier membranes, interpositional bone grafts, and distraction osteogenesis.
DIMINISHED CROWN HEIGHT SPACE
Diminished crown height space has several different solutions which depend on the
patients anatomical limitations as well as his or her perceived needs.
If the problem is the opposing arch, the solution may be fixed prosthodontics to level the
occlusal plane.
It may be intrusion of teeth with orthodontics or some combination of the two.
If there is too little crown height space and the patient is edentulous, the solution may be
to increase the vertical dimension of occlusion (VDO) with a removable prosthesis.
If the patient has a partial dentition, it may involve traditional fixed prosthodontics to
alter the VDO.
The patient may need a surgical approach, such as an osteoplasty, before implant
placement. .However, without an initial diagnosis, there is no way of formulating a
solution to an unknown problem.
b) Hor izont al COMPONENTS OF IMPLANT PLACEMENT
The horizontal aspect of implant spacing is critical to avoid bone loss on adjacent teeth
or implants. Single-tooth implants should be placed 1.5 mm to 2 mm from the adjacent
teeth, and implants should have at least 3 mm of space between them
.By keeping a minimum 1.5-mm distance from the adjacent tooth and a minimum
distance of 3 mm between adjacent implants, angular defects resulting from crestal
bone remodeling can be kept from becoming horizontal defects
c) ANTERIOR-POSTERIOR SPREAD
As a general rule, when five implants are placed in the anterior mandible between the
foramen, the cantilever should not exceed 2.5 times the anterior-posterior spread, with
all other force factors being low. The anterior-posterior distance is obtained by
connecting a line drawn from the distal aspect of the most posterior implants and a
parallel line drawn through the center of the most anterior implant.
The greater the anterior-posterior distance, the more favorable the situation for the
posterior cantilever.
There are two anatomical factors that will affect the amount of anterior-posterior
spread possible: the patients existing arch form and the arch form of the replacement
teeth. There are three types of arch forms: ovoid, tapering, and square. A square arch
form provides the shortest anterior-posterior spread because all of the implants are
basically in a straight line. Conversely, the tapering arch will result in the largest
anterior-posterior spread, and the ovoid will result in something in between.
By evaluating the arch form, the clinician will have an idea of the potential anterior-
posterior spread and the amount of cantilever possible to support the prosthesis.
Patient force factors will ultimately determine the amount of cantilever to be used for
the definitive prosthesis.
The type of proposed restoration, choice of prosthetic design:
Partial bridge - if three or more units are to be restored, and assuming that the units are
to be linked, it is desirable to distribute loads by arranging the implants in a tripod relationship to
each other. If this is achieved, it is not necessary to place one implant for each missing tooth.
Full maxillary fixed bridge - typically six implants may be used, but possibly more
when available bone is not ideal, or occlusal loads are expected to be high. The implants should
be placed at regular intervals and correspond to the correct tooth position for the proposed
restoration. Limited cantilevers may be considered.
Full mandibular fixed bridge - implants are typically placed anterior to the mental
foramina and, if required, distal to the formina, but clear of the inferior dental canal. Bone
quality in the mandible is normally better than that found in the maxilla. This may create an
opportunity to use fewer implants in the mandible than would be required in the maxilla.
Fixed prostheses in the mandible and maxilla
4 implants are necessary (6 to 8 implants);
one implant per one missing tooth is not necessary;
congruence of implant and prospective tooth position is necessary;
Bridgework with a segmented design can be fabricated.
Mandibular overdentures
The number of implants used with overdentures has included
one midline implant,
two individual implants
two implants connected by a bar
3 or more implants which may be connected by a bar
In the mandible, the use of 4 implants and a bar was compared with 2 implants and a bar.
No differences were noted in the clinical or radiographic parameters and the authors
suggest that 2 implants may be sufficient in the mandible. However, they did theorize that
4 implants might be beneficial for patients with sore, painful mandibular ridges since
more force would be supported by the implants and bar rather than the edentulous
mucosa.
Single attachments or bars can be mounted. If a bar is to be used, the implants should be
placed anteriorly so that a straight bar can be provided. This has the additional advantage
of the bar not encroaching on the lingual space.
If, due to advanced atrophy, the implant length becomes less than 8 mm, or if narrow,
thin ridges require a reduced implant diameter (3.3 mm), the use of three or four implants
is recommended.
In the presence of large or V-shaped anterior ridges, three to four implants will provide
for a more favorable design of the bar and the prosthesis.
The distribution of implants depends on the shape of the ridge.
- a) Bar connector would interfere with space for tongue. Ball anchors are suggested;
however, this will result in a hinging movement. Implants located in more anterior
position: this may result in inadequate length of the bar.
- b/c) Three or four implants with a connecting bar are in better harmony with the
shape of the ridge. Four implants allow for fixed prosthesis.
- d) Two anterior implants with a connecting bar of adequate length.
- e) U-shaped mandibular jaw with large curvature will allow for placement of four
implants and a connecting bar.
- f) This configuration is also favorable for mounting of a fixed screw-retained
cantilever prosthesis.
- g) Alignment of the implants in a rather straight line does not favor fixed prostheses.
The length of the bar segments should not be less than 15 mm, and can range from 15 to
25 mm. If four implants are placed they must be well spaced, or as an alternative a
cantilever-fixed prosthesis can be mounted.
2 implants for mandibular overdentures geriatric treatment conception;
3 or 4 intraforaminal implants: if reduced diameter or length of 6 mm;
3 or 4 intraforaminal implants: length of bar segments must be adequate;
4 intraforaminal implants: fixed cantileverprostheses may be recommended as an
alternative
Maxillary overdenture
In the maxilla most often bone quality and quantity are not favorable: i.e. according to the
criteria of Albrektsson et al. (1986), degree of atrophy corresponds to class C and D.
Four to six well-spaced implants, evenly distributed over the arch and connected by a bar,
will enhance the stability of the overdenture.
It has been proposed (Mericske-Stern, 1998 )that maxillary overdentures be supported by
at least 4 implants, evenly distributed around the arch and connected by a bar.
Distribution of maxillary implants for overdenture connection.
a) Use of two implants is not the standard procedure. In this situation only ball
anchors are suggested; a bar would interfere with the space of the tongue.
b) Four implants, well distributed, with a sufficient length of bar segments.
c) A bar cannot be recommended. It would result in a hinging movement.
d) Four implants, often located in an anterior position due to the extension of the
sinus.
e) Depending on the specific anatomic situation, the bar may be divided into
segments. An irregular number of implants can also be used.
f) In rare cases, more bone is available in the posterior part of the maxilla. Parallel
placement of two separate bars might be recommended.
The implants are mostly located in the anterior part of the upper jaw, between the first
premolars. Thus, additional surgery such as sinus floor elevation can be avoided in many
cases.
The implant length should preferably be 10 mm, and a standard diameter of 4.1 mm is
suggested. The literature provides evidence of an increased failure rate for short implants.
A connecting bar cannot be mounted to two implants in the maxilla, due to the anatomic-
morphologic conditions. Thus, the use of two maxillary implants for overdenture support
is rarely recommended. The use of two ball anchors results in a hinging movement of the
denture that may cause discomfort.
the minimum number of implants is preferably not less than four;
using two implants is not a standard procedure;
the implants should be evenly distributed over the arch;
implants of 6 mm length should be avoided;
implants with a reduced diameter (3.3 mm) have to be combined with
implants of standard diameter.
With all overdentures it is essential to have adequate interocclusal space for the
attachments. Implants may need to be placed deeper into the bone to obtain the space required.
Failure to provide adequate space results in overcontoured prostheses and thin acrylic, which is
prone to fracture.
The quantity and quality of the available bone
Number of Implants: Will depend on bone quality, biomechanical factors and
aesthetic considerations.
Upper Anterior zone (5-12 region - type III bone):
Implant-Pontic-Implant or Implant-Pontic-Pontic-Implant.
Avoid adjacent implants.
If 8 and 9 are missing, need to provide a minimum of 4-S mm of space
between the dental implants and also expect a reduced papillary height
compared with the original tooth-to-tooth papillary height (average of 1.S mm
papillary height loss following completion of restorations under optimal
treatment conditions). Patient expectations must be set/limitations accepted
and inter-implant distance available prior to considering this treatment option.
Lower Anterior zone (type I bone): Implant-Pontic-Implant or ImplantPontic-Pontic-
Implant.
Posterior mandible (type II bone): Implant-Pontic-Implant or Implant per tooth.
Posterior Maxilla (type IV bone): Implant per tooth.
Type 1/11 - Mandibular anterior and posterior sites. Require minimum of 1-2 mm of bone
surrounding the dental implant.
Type III/IV - Maxillary anterior and posterior sites. Require minimum of 1.5 to 2 mm of
surrounding the dental implant
c) Individual Versus Connected (Splinted) Implants
A study of photoelastic stress patterns indicated that individual implants with ball/o-ring
attachments transferred less stress to the implants than the design that used 2 implants connected
by a bar (Kenney, 1998).
Other studies indicate there were no biologic differences between the 2 designs but
greater prosthesis retention was attained when the implants were connected by a bar.
Mandibular overdenture
Since no clear biologic advantages have been associated with the number of
implants used in the mandible (individual or connected), the numerical decision
should be based on retention requirements.
For many patients, two individual implants with associated retentive
mechanisms provide good patient satisfaction and the treatment is less costly
than a bar overdenture.
For patients where retention is a primary requirement (as evidenced by active
oral musculature and functionally demanding eating expectations), the use of
3, 4, or more implants and interconnecting bars with multiple retentive
mechanisms is recommended.
Maxillary overdenture
There have been many studies found greater bone loss when individual implants
were used in the maxilla. the information suggests it may be prudent to connect
implants together in the maxilla until more definitive data becomes available.
d) Location of the Implants
The implants should be located so they are contained within the normal form of the
denture base. Their form and location should ideally not produce substantial changes in
the dimensions of the denture base. Posteriorly placed implants should be centered
beneath the prosthetic teeth.
The positions of the prosthetic teeth determine where the implants should be located.
Several factors determine the most appropriate prosthetic tooth positions and they include
(1) esthetics; (2) tooth-lip relationships; (3) phonetics; (4) anatomic landmarks; (5)
occlusal vertical dimension; and (6) muscular neutrality (neutral zone).
Mandibular implant site selection for overdenture: The greatest height of available bone
is located in the anterior region of the mandible between the mental foramina or anterior
loops of the mandibular canal. It was shown in many studies that the provision of two
implants in the anterior region of the mandible to stabilize the mandibular complete over
denture can result in significant improvements in nutritional and social aspects of
edentulism in affected patients
Anteriorly placed implant:
The canine areas often serve as appropriate locations for implants. Implant should be
centered beneath the prosthetic teeth or slightly lingual to the center of the prosthetic
teeth.
It is important to determine the location of the prosthetic teeth and the size and form of the
denture base prior to implant placement. These characteristics are identified through
development of a wax trial denture using conventional complete denture procedures.
Improperly placed implant
o When the implants are located Improperly placed, the denture base has to be enlarged
to encompass the implant and retentive mechanism. The enlarged base dimensions
prolong the time it takes for a patient to adapt to the new prosthesis and can make
the adaptation challenging.
o With malaligned implants, efforts are commonly made to reduce the amount of resin
base overcontouring and this process frequently leaves only thin areas of resin over
the retentive mechanisms. The thin resin is more prone to fracture.
e) Implant Alignment
Implants should be parallel to each other or have their long axes nearly aligned with
each other to facilitate the prosthodontic phase of treatment by allowing the use of
standardized components.
Malaligned implants with o-ring attachment, can make prosthesis placement
more difficult and the o-rings are pinched more often during placement and
removal, producing o-ring wear and earlier loss of retention.
When an implant is placed substantially out of alignment with other sources of
retention, the fabrication of custom components may be necessary.
To facilitate axial loading of the implants, it has been recommended that implants be
aligned so their long axes are perpendicular to the occlusal plane.
f) Implant Component/Retentive Mechanism Height Above the Soft Tissue
After development of the wax trial denture, it is important to assess base dimensions to
determine the amount of space available for implant components and retentive devices.
The height of implant components and retentive mechanisms above the soft tissue should be :
Reduced as much as possible since they weaken the prosthesis base.
Sufficient to allow bars to be fabricated in such a manner that some space is present
beneath the bar.
It is advantageous to have 2 or more millimeters of resin thickness surrounding the retentive
mechanism when possible
bar(s) /clip(s) attachment:
It is recommended that a 1-2 millimeter space be present between the underside of metal
bars and the edentulous ridge mucosa. It is felt that the potential for adverse soft tissue
responses is related to minimal spaces underneath a bar.
Bars and clips are frequently 2-4 millimeters occlusocervically and 2-3 millimeters
faciolingually. Bars that accept snap type attachments (Ceka) are about 1.5 millimeters in
height with a faciolingual dimension of 2-4 millimeters. The overlying attachment that
snaps into the recess in the bar is 1.5 to 2.5 millimeters in height for a total of up to 5
millimeters.
Ball /o-ring attachment
Ball attachments for o-rings can be as small as 2 millimeters in diameter or as large as
3.5 millimeters in diameter. The height of ball attachments (including the height of the
ball abutment and the overlying o-ring) is about 5-6 millimeters.
Same height is occupied by ball abutments and metal caps that snap over the ball.
All retentive mechanisms require an occlusocervical space of about 8 millimeters
(including retentive mechanism, overlying base material, and space under bars).
When there is not sufficient space available, a change in retentive mechanism may be
necessary or the base may have to be thickened.
For diagnostic purposes, the wax trial denture can be duplicated in clear acrylic resin and
used in conjunction with a wax pattern of the proposed retentive mechanism to assess
available space
Impression techniques for implant :See impression making
Attachments
Three attachment systems are used most commonly to provide retention for overdentures:
ball and socket attachment bar attachments and magnets. Telescopic attachment was described
by some authors
1-Ball and socket attachment (0-rings):
Ball attachments are stress-breaking components that retain and
laterally stabilize the tissue supported overdenture in either arch.
Each attachment consists of an implant retained titanium male ball
abutment, and a snap on female cap attachment socket that is
processed into the denture base.
2- Bar attachments
There are two groups of bar attachments: bar units and bar joints. Both
types provide retention for an overdenture while splinting the abutments.
The bar unit provides rigid fixation while the bar joint provides
rotational, resilient, or combined movement to the overdenture.
Both types could be used with implants. However, it appears that the more popular type
used with implant-retained overdentures is the bar joint system.
The bar joint systems traditionally used with natural teeth can be used with the various
implant systems. Some implant systems have their own bar joint components specifically
manufactured for use with that particular system.
In bar joint systems the overdenture is supported in part by the mucosal tissues of the
ridges. Thus, it is important that the borders of the overdenture be properly extended to
provide stability and retention present with conventional dentures in addition to the
retention and stability provided by the attachment system.
The principle of the bar joint system is to provide retention of the overdenture against
vertical dislodging forces. When the overdenture is functionally loaded during occlusion,
there is a shared distribution of the occlusal forces between the mucosa and the bar joint.
Rotational movements of the overdenture in the frontal and sagittal planes are permitted
by the rotation of the sleeve about the bar. However, these movements are guided by the
bar joint system eliminating any excessive, undesirable movements against the mucosal
tissues.
In most cases, the bar is placed in the anterior region. The bar should be placed directly
over or slightly lingual to the crest of the ridge in a straight, horizontal alignment.
In the anterior region, the bar should be perpendicular to a line bisecting the angle formed
by the posterior alveolar ridges.
While the arch form (V shaped arch) may limit the use of the bar joint. System depending
on the position of the remaining natural teeth, the flexibility in the placement of the
implant fixtures could allow for satisfactory alignment of the bar. Even so, there may be
situations where the bar cannot be aligned adequately, negating the use of a bar
attachment. In these cases, the use of individual abutments to retain an overdenture with
or without some other attachment system (magnets) would be feasible.
There should be at least 2 mm of space existing between the inferior surface of the bar
and the gingival tissues of the alveolar ridge. However, there is no disadvantage to
having the bar in direct pressure-free contact with the ridge as long as the patient
maintains regular oral hygiene.
Certain bar joint systems as the Dolder system, contain a prefabricated gold alloy bar
which is sectioned to the appropriate length and soldered to the abutment copings with
solder that is compatible with both the bar and the copings. However, the majority of the
bar joint systems presently available have plastic bar forms. They can be easily adjusted
to fulfill the desired form and can be waxed to the copings. The entire assembly can then
be cast as a single unit with a metal alloy designated by the manufacturer as being
compatible with the copings. The tedious technical aspects involved with soldering are
eliminated with this process.
Metal or nylon sleeves can be used with these bar joint systems. The flanges of the sleeve
flex over the bar when the overdenture is seated to provide the retention for the system.
The metal sleeves are adjustable to allow for flexibility in controlling the degree of
retention. However, they can be difficult to replace or repair. The nylon sleeves are not
adjustable but can be replaced easily.
3- Magnets
Magnetically retained overdentures have become very popular with the various implant
systems. Magnets have been used successfully for years with natural teeth to retain
overdentures.
Owing to their strong attractive force, they possess great resistance to vertical dislodging
forces. However, they have little resistance to lateral forces and can be easily moved in a
horizontal vector thus providing an inherently stress-relieved system as less lateral force
be transmitted to the abutments.
The majority of the force is directed apically along the long axis of the abutment. Owing
to the stress-breaking component inherent in this system, it can be used with implants,
natural teeth, or combinations of both abutments. In addition, the system is technically
easier to use and repair as compared to other attachment systems.
The system basically consists of a magnet and a keeper. Earlier types of magnets used
over the years included ferrite and alnico magnets. However, the samarium-cobalt and the
neodymiurn-iron-boron magnets have become the more popular magnets over the last 20
years.
Owing to their unique crystalline structure, the strength of the rare earth magnets are 20
to 50 times greater per unit volume than the strongest ferrite or alnico magnet. In
addition, they can be machined to small sizes without loss of the magnetic strength.
The magnetic strength ranges from 250 to 1000 Gs. They are available in either open-
field systems or closed-field systems. The closed- field system provides more efficient
use of the magnetic strength by using both poles of the magnet compared to the open-
field system, which uses only one pole of the magnet.
The magnetic system also contains a metal plate known as a keeper. This keeper is
usually attached to the abutment.
Various ferromagnetic alloys can be used such a palladium cobalt (containing more than
50 % palladium content) or stainless steel.
Magnets can be used with virtually any implant system. If the implant does not have a
prefabricated Keeper screw or coping for that system, a customized coping must be made
from a ferromagnetic alloy.
There are a number of implant systems that contain prefabricated keepers in the form of
copings or screws that attach directly to the implant fixture.
It is recommended that all keepers be cemented, even if there is an additional retentive
mechanism existing in the keeper (threads), to provide retention and as a barrier
between the two dissimilar metals of the implant and the keeper. This barrier will protect
the implant from any electro-galvanic reaction that might cause corrosion of the implant.
d) The telescopic attachments:
The attachment assembly is made up of a primary coping (patrix) attached to the implant
and a secondary coping (matrix) that is contained within the overdenture framework. The
attachment can be of rigid or resilient design depending on the degree of fit between the
two copings. The retention of a telescopic attachment system is also obtained through the
frictional contact between its components.
The advantages of telescopic or conical crowns include superior esthetics, firm retention,
prosthesis stability, and expansion possibilities.
Disadvantages include the needs for advanced laboratory skills in the fabrication process
and for more horizontal and vertical space in the tooth preparations.
Procedures for construction of implant retained over denture
1- Ball attachment restoration (O-ring)
A - Direct technique
The denture is constructed before the implant procedures, then modified intraorally to accept the
ball and socket attachment:
The healing collars are removed from the implants. Then the abutment ball
attachments are screwed in place..
The plastic caps (female parts) are snapped onto the ball component of the overdenture
abutment.
Using a round bur, a space is created in the fitting surface of the denture opposite each
of the plastic cap (female part)
The denture is checked in the mouth to be sure that there is no interference between
the attachment and denture.
The undercuts below the attachments are blocked out using a soft block out material
Auto-polymerizing acrylic resin is placed into the space created in the denture base
and a small amount of resin is injected intraorally on the dry attachment plastic
housing.
The denture is inserted into the patient's mouth and the patient is instructed to close
into occlusion, the housing will be picked up into the base of the denture.
When the acrylic has set, the denture is removed from the mouth, inspected, and any
voids around the attachment are filled with additional acrylic.
Excesses material is removed and the area is finished with a suitable bur.
B. Indirect Technique
Primary impression is made over the healing collars and edentulous areas, using
alginate impression material, in a stock tray. Then the impression is poured into
dental stone.
A custom impression tray is fabricated on this model, with a window designed in the
occlusal portion of the abutment to allow access to the guide pins and impression
copings. A spacer of one layer of base plate wax is used to provide a relief to the
special tray in the distal extension. Sufficient wax relief is achieved by a strip of
baseplate wax 8 mm wide and 6 mm high over the crest of the residual ridge and
over the abutment fixture area.
The custom tray is peripherally molded with low fusing compound.
The healing collars are removed from the patient's mouth and impression copings
with extension guide pins are attached to the implant orifices.
Impression is made with addition type silicon. After setting of the impression
material it is removed from the patient's mouth.
The impression pins are removed from the implant and seated in its place in the
impression.. Implant analogues are then screwed to the impression pins.
A cast is poured in an improved stone.
The impression copings are removed from the cast and the ball abutments or its
analogues are fixed to the imbedded implant analogue.
The plastic cups (female part) are snapped onto the ball component in the cast.
The laboratory will process the female attachment into the base of the patient's
existing denture with a reline impression.
When making a new denture, the laboratory will construct a record blocks with
incorporated female housing in its fitting surface.
The ball abutments are removed from the working cast, sterilized, and fixed to the
implant fixtures in the patient's mouth after removal of the healing collars. Then the
record blocks are inserted into the patient's mouth. The vertical dimension, centric
relation, eccentric relations and face -bow recordings are carried out.
The stabilized bases are mounted into semiadjustable articulator, then setting and
waxing up of the denture are carried out.
At the try - in appointment any necessary clinical adjustments to the stabilized
waxed up denture is carried out and. the patient approval for esthetic is obtained.
The denture processing and finishing are performed in the conventional manner. The
denture is delivered to the patient and follow up appointments are scheduled.
I1-BAR ATTACHEMENT PROSTHESES:
Primary impressions are made 2 weeks following second stage surgery. The old denture
is relieved in the area of the abutments and relined with tissue conditioning material to be
used by the patient between appointments.
Custom trays are fabricated with vestibular and palatal extension similar to a complete
denture. The open window design is used
All plaque is removed from the abutment and the impression copings are placed.
The custom tray is border molded and the impression is made. The guide pins are
loosened and the impression is removed. The laboratory analogues are placed and the
impression is poured in diestone.
When the bar is provided as a wax pattern, attachments (clips, gold cylinder or O-rings)
are screwed into the abutment and incorporated into the wax pattern design of the bar.
The wax pattern is sprued, invested cast and finished and polished in the usual manner.
If the bar is precast, the bar is positioned between the attachments (gold cylinders) and
the bar is cut to the required length. The bar is placed between the attachments and
secured in place with sticky wax. The guide pins are unscrewed and the bar assembly is
removed from the maser cast and positioned into a soldering investment. Soldering is
then performed. The bar is removed from the investment, cleaned, and polished.
The attachment bar is screwed in place to the abutment. The abutment- framework
interface is checked for accuracy. The bar is sectioned and soldered if inaccurate fit is
present.
The bar is placed on the master cast with gold screws. Laboratory clip analogues are
placed on the bar. Plaster is mixed and flowed over and below the bar leaving the clip
analogues exposed. Record block is constructed of acrylic base incorporating the clips
and wax rim. This base snaps into the attachment bar providing stability for interocclusal
records.
The attachment bar is positioned in the mouth. The record blocks are inserted and the
maxillomandibular relations are completed.
The baseplate is mounted on an articulator and tooth arrangement and waxing up of the
denture are done. The palatal portion of the maxillary denture can be removed if four or
more fixtures are used.
The bar is secured in the patient's mouth and the trial tooth arrangement is evaluated
The bar is placed on the master cast and held in position with screws. The retentive clips
are evenly spaced on the bar between the gold cylinders. The bar and gold cylinders are
blocked out with dental plaster. The overdenture wax-up is repositioned on the cast,
sealed and processed in the usual manner. A laboratory occlusal adjustment is performed.
The overdenture is finished and polished and, clip retention is verified on the master cast
and returned to the clinic for delivery.
The denture is snapped into the bar. Pressure indicating paste is used to adjust potential
denture soreness. Clinical remounting is made for final occlusal adjustment. Home care
instructions are given and follow up visits is arranged.
III- MAGNET RETAINED PROSTHESES
keepers are screwed into fixtures with perio-pack around the perimeter to aid in tissue
healing.
Impression pieces are secured to keepers. `Then impression is made. Keepers and implant
replica are placed into the impression and the impression is poured in dental stone
Black processing males are placed. Wax setup of the teeth is completed. Usually the teeth
in the area of the magnets are hollowed.
After the wax try-in has been verified, it is then flasked and boiled out in the usual
manner.
The o-ring spacer is seated down between the processing male at the top and the keeper
replica in the master cast. This metal spacer provides room for adjusting the position of
the magnet as needed. Then the restoration is packed with resin.
The processing males are removed from the denture fitting surface, and the magnets are
screwed in place.
Maxillofacial implant prosthesis
Osseointegrated implants are used for support of implant prostheses in-patients with
mandibular or maxillary resection. Also dental implants are used to retain extraoral restorations,
they are used to retain artificial ear, nose and eye. Different attachments are used in these cases
such as magnets and bars.
Clinical view of presenting implant-
supported prosthesis
Retentive bar connects 2 implants
positioned to support auricular
prosthesis.
Follow-up maintenance
Appropriate instruction in oral hygiene measures and care of the implants and prosthesis should
be given during treatment, and reinforced at follow-up visits.
Effective monitoring of the implants and the associated prosthesis is an essential part of
treatment. Following delivery of the prosthesis, the patient should be reviewed regularly to
ensure that they are maintaining a satisfactory standard of oral hygiene and that the prosthesis is
functioning as intended. In particular, the tightness of fixing should be checked after one month.
Regular inspection at yearly intervals is recommended after the first year.
Assessment at review appointments is by:
assessment of plaque and calculus deposits
clinical evaluation of the mucosal cuff around implants including:
visual assessment (gingival index, and, if indicated, bleeding on probing and
sulcus depth)
assessment of mobility of each implant by: percussion, application of rotational
forces to the implant and electronic mobility tester
radiological examination, preferably using a long cone periapical radiograph to
assess the level of marginal bone and to evaluate the implant bone interface.
Resilient connectors and other components should be replaced as necessary
according to the manufacturer's instructions.
Inspection of the superstructure/ prosthesis should be carried out to identify
cracks or fractures which may indicate an inexactness off it between the
prosthesis and implants. Marked occlusal wear facets may indicate imbalance in
the occlusion or parafunctional habits. Such damage should be corrected by a
modification of the prosthesis and/or the occlusion.

Occlusion of implant overdenture
Requirements of implant overdenture occlusion:
Centric relation position should coincide with centric contact, since the centric position is
the only repeatable one in completely edentulous patients.
In centric closure, bilateral posterior contact must be present simultaneously for ensuring
patient comfort. In addition to the potential for neuromuscular dysfunction that premature
contacts can create, occlusal force is increased when a high or premature contact is
present.
Smooth even lateral excursive movement with non-working interference.
Freedom from deflective contacts in intercuspal position.
Equal distribution of forces of occlusion.
Factors affecting selection of the occlusal scheme for implant supported overdenture:
1- The opposing arch condition:
It is recommended to establish a balanced occlusion for a patient with mandibular implant
supported overdenture opposing maxillary complete denture.
If the maxillary denture is also retained by implants, canine guidance over the implants is
recommended. Bilateral balance is developed only as an aid in stabilizing denture to prevent loss
of atmospheric seal.
2- Location of implants:
When the axis of the implant and the occluding antagonist are in a line, horizontal loading of
the implant can be reduced. The artificial teeth should be arranged in this vertical relationship
above the implants to minimize horizontal forces.
If this arrangement is not possible, horizontal forces should be avoided by choosing an occlusal
concept that reduces these forces as much as possible.
3- The occlusal force:
A primary goal of an occlusal scheme is to maintain the occlusal load that has been
transferred to the implant body within the physiologic limits of each patient. These limits
are not identical for all patients or restoration.
The force generated by patient is influenced by parafunctions, masticatory dynamics,
tongue size, implant arch position and location, and implant arch form and crown height.
These force factors could be best addressed by selecting the proper implant size, number and
position, using stress-relieving elements, increasing bone density by progressive loading, and
selecting the appropriate occlusal scheme.
4- Jaw relationships:
For class II patients some degree of vertical and horizontal overlap of the anterior
teeth with an increased bucco-lingual overlap of posterior teeth should be considered.
An occlusion free from lateral interference is necessary.
5-Appearance:
Maxillary posterior teeth with buccal cusp resembling natural teeth should be the
selection of choice to enhance esthetics.
Occlusal schemes for implant supported overdenture:
I- Bilateral balanced occlusion:
Balanced occlusion is defined as an occlusal scheme in which bilateral simultaneous
anterior and posterior occlusal contact of teeth occur in centric and eccentric jaw
position.
Advantages
The bilateral simultaneous contacts distribute the masticatory load evenly over the
implant fixture.
The freedom from interference during articular movements of the mandible enhance
the stability of the denture.
Reduced trauma to the supporting tissue.
Increase efficiency of mastication.
Patient comfort.
Normal esthetics.
Disadvantages
It is very difficult to achieve due to the resilience of the supporting tissues.
Several patient records are required to reproduce balanced occlusion.
The articulators can't reproduce the mandibular movement accurately.
The edentulous ridge undergoes negative changes, which leads to changes in occlusal
relations.
There are always excessive frictional wears of the teeth.
II- Group function:
Group function concept provides even contacts in intercuspal position on the
working side in the lateral excursions of the mandible with absence of non-working
side interference.
Advantages
It prevents the obliquely directed forces found in the non-working interference.
It maintains occlusion by saving the centric holding cusps from excessive wear.
III- Balanced lingualized occlusion:
In lingualized occlusion concept the lingual cusps of the anatomic maxillary posterior
teeth contact the shallow central fossae of the non-anatomic mandibular teeth. And a
balanced occlusion is created between these elements of the opposing teeth in protrusion
and lateral excursions, with freedom of movement (long centric) and clearance of anterior
teeth.
Advantages
It directs the forces of mastication vertically onto the ridge.
Mortar and pestle style of interdigitation provides for effective mastication of food.
The steep maxillary cuspal inclination decreases the need for unfavorable horizontal
movement in mastication.
The elimination of mandibular cusp tip function eliminates the potential for lateral
interference in excursive movement.
A shorter maxillary buccal cusps eliminates its interference in eccentric movements.
The limited number of occlusal contacts on each tooth makes the task of establishing
even distribution of forces easier and more attainable.
Cusp form maxillary teeth is more normal in appearance.
Disadvantages
lingualized occlusion is less natural in appearance than cusp tip to fossa occlusion.
There is a possible reduction in masticatory efficiency.
IV- Monoplane occlusion:
The monoplane occlusion utilizes zero degree posterior teeth. The upper and lower
anterior teeth are arranged without any vertical overlap. The posterior teeth are
arranged in a horizontal plane antro-posteriorly and medio-laterally. The occlusal
plane should be evenly divides the space between the upper and lower ridges,
parallels the mean foundation plane and end at the junction of the upper and middle
thirds of the retromolar bad.
Advantages
The zero degree posterior teeth offer these advantages:
More adaptable to unusual jaw relations as the class II and class III occlusion.
Used more easily in a cross-bite setup.
Impart to the patient a sense of freedom, because they don't lock the mandible in
one position only.
Eliminate horizontal forces that are more damaging than vertical forces.
They permit the use of simplified and less time consuming techniques.
Offer greater comfort and efficiency for a longer period.
They accommodate better to the inevitable negative changes in ridge height.
Disadvantages
Because of Christensen effect, heavy pressure is exerted in the anterior segment in
protrusion.
Poor esthetic in the premolar region.
Decreased masticatory efficiency.
More difficult to obtain balanced occlusion.
V- Mutually protected occlusion (Canine guidance):
The mutually protected occlusion embodying the concept of posterior contact only in
centric relation with immediate disocclusion on excursive motions. The anterior teeth
disocclude posterior teeth through all excursions. In addition to these trauma to the
anterior teeth during mastication must be prevented by not violating the envelope of
function.
Advantages
Esthetically, the arrangement most closely resembles the patient's natural
dentition.
Penetration of the bolus of food has been reported to be better therefor requiring
less occlusal forces.
Opposing inclines provide bucco-lingual stability, preventing tongue pressure
from tilting a tooth buccally.
Disadvantages
With the number of contact on each tooth, precise patient records are necessary to
transfer to the articulator.
Occlusal contacts on cuspal inclines during excursive movement are more apt to
occur. Adjusting of the inclines while maintaining even vertical force on all
posterior teeth is very challenging in clinical practice.
Because of the number of contacts on each posterior tooth, it is difficult to
evaluate bilateral simultaneous contact.
VI- Sequential Canine Guidance:
This concept is based on a combination of balanced occlusion and the mutually protected
occlusion. For the first 2mm of eccentric movements, the articulation is balanced, but
when this range of movement goes beyond this 2mm range, the balanced articulation is
replaced with a group function and finally a mutually protected occlusion. This concept is
suggested when mandibular implant prostheses oppose an excellent retained maxillary
complete denture.
VII- Implant - protective occlusion (medial lingualized occlusion):
Pound first introduced the term-lingualized occlusion. He stated that a line drawn from
the mesial aspect of the canine to each side of the retromolar pad was the region where
the mandibular lingual cusp should be placed. to stabilize the mandibular denture.
the implant overdenture does not require such tooth position to enhance stability and
natural tooth position is medial to the retromolar pad region. Therefore Mish suggested
that the mandibular posterior teeth be positioned on a line drawn from the tip of the
mandibular canine to the lingual aspect of the retromolar pad. The mandibular posterior
teeth are placed so that central fossa is over this line and lingual cusps extend medial to
the line. The occlusal centric contacts follow the guidelines of lingualized occlusion.
Only lingual cusps of the maxillary posterior teeth are in contact during centric relation.
Mediolateral and anteroposterior compensating curves achieve bilateral balance.
Advantages:
The mandibular overdenture teeth are in a position similar to that of the natural teeth.
The more medial the posterior denture teeth, the more vertical force over the maxillary
ridge, thus enhancing the maxillary denture stability.
Because the primary contact is lingual cusp of maxillary teeth, an additional stabilizing
factor for the maxillary denture is evidenced by directing forces closer to the ridge.
Narrower occlusal table is used, which increases masticatory efficiency.
Occlusal concept choice:
An outline of the implant prosthesis rehabilitation and the choice of occlusal concepts for the
different antagonistic situations is presented in the following table:
Maxillary
condition
Mandibular
condition
The suggested
occlusal concepts
Completely edentulous
restored by complete
denture
Completely edentulous restored by
mucosally supported or mucosa
implant supported overdenture.
Balanced occlusion.
Lingualised occlusion.
Monoplane occlusion.
Sequential canine guidance.
restored by complete
denture
fixed implant prosthesis
Balanced occlusion.
Mutually protected occlusion.
Group function.
restored by implant
overdenture
implant overdenture
- Mutually protected occlusion.
restored by implant
overdenture
Balanced occlusion.
Group function.
restored by fixed
implant prosthesis
Canine guidance.
Fully dentulous Completely edentulous restored by
Group function.
Mutually protected occlusion
restored by fixed
implant prosthesis
Fully dentulous - Canine guidance.
restored by fixed
implant prosthesis
Partially edentulous restored by
removable or fixed partial denture or
implant prosthesis.
- Canine guidance.
Kennedy class I
restored with
removable partial
mucosa implant supported or
Balanced occlusion.
denture implant supported overdenture.
Kennedy class I
restored with fixed
implant prosthesis
Group function.
Kennedy class II
restored by removable
partial denture
mucosa implant supported or
Group function or mutually
protected occlusion in dentulous
quadrant, and balanced occlusion
in edentulous side.
Kennedy class II
restored by fixed
implant prosthesis
Group function.
Kennedy class III and
IV restored with fixed
prosthesis or tooth
supported removable
partial denture.
Group function.
Current Trends in Immediate Dental Implant
Journal of Dental Education 2003 Volume 67, Number 8
Introduction:
Despite the high success rate of endosseous implant therapy, it has yet to achieve wide
public acceptance and utilization, the most frequently cited reasons for underutilization of
endosseous implant therapy are that treatment cost is perceived to be too high and
treatment takes too long (Branemarks original treatment protocols required one to two
years to complete treatment).
An obvious area of focus has been to decrease the amount of time necessary to complete
implant therapy. Three approaches to achieve this goal have dominated clinical research:
delayed/immediate implant loading,
improving implant surface technology (promotion of quicker healing and better
osseointegration),
and immediate placement of an endosseous implant after extraction of a natural
tooth
Advantages of Immediate dental implant
benefits include reduction of morbidity, reduction of alveolar bone resorption,
preservation of gingival tissues, preservation of the papilla in the esthetic
zone, and reduction of treatment cost and time (the healing phase is shorter in
general and there is a reduction in the number of procedures.
When a tooth is extracted, predictable bone resorption ensues for six months.
A typical defect of such resorption is a loss of crestal bone with a labial
concavity. Delayed implant placement may result in compromised esthetics
and function due to lingual placement of the implant . immediate implants will
provide for more ideal prosthetic placement and will optimize esthetics, all via
the preservation of bone.
Indication:
The vast majority of immediate implants are single tooth implant restorations
(predominantly incisors and premolars), which are site- and defect-specific.
Immediate dental implants may be the treatment of choice for
an endodontically infected tooth,
root fracture,
root resorption,
root perforation,
Unfavorable crown to- root-ratio (not due to periodontal loss).
Case Selection Criteria
Immediate dental implant selection criteria should reflect the following factors:
Achieving predictable osseointegration, :
o The bony height of the socket (from the apex of the alveolus to the crest of bone)
should demonstrate a minimum bone measurement of 7-10 mm. According to
some clinicians, 4-5 mm or 3-5 mm of sound bone beyond the apex is necessary.
This cushion of bone is an important guideline to prevent impingement of any
anatomical structures.
anatomical considerations:
o The extraction site must be large enough to accommodate an appropriately
selected commercial dental implant .
o The important aspects of residual extraction site morphology are axial inclinations
(slope), root curvature of the extracted tooth (dilacerations), root divergence,
presence of interseptal bone (amount and orientation) and location of the socket
apex.
Maximizing esthetic results and soft tissue maintenance :
o The success of immediate implants in the esthetic zone can be enhanced
further with the use of custom healing abutments (which serve to preserve
crestal soft tissue and interdental papillae).
Restoring function, Loading of immediate implant:
o Some authors consider that the immediate implants should not be loaded
immediately (delayed loading is a necessity). The rationale for delayed
loading is the immediate loading carries a great risk for fibrous encapsulation
of the bony defect, lack of osseointegration, apical epithelial migration onto
the implant surface, and lack of primary bone contact.
o However, others report high success (at six to eighteen months) after
placement of immediate implants with immediate loading. the criterion for
loading was primary stability.
the surgical technique and Experience of the dental surgeon :
o A traumatic extraction technique is very important for success of immediate
implants and facilitates maintenance of the maximum amount of bone
The patients Medical status, expectations, and level of compliance
Presence of Infection and Pathology :
o Immediate dental implant sites should be free of residual infection.
o some authors mentioned that presence of infection doesnt contraindicate
placement of immediate implant if there is no active suppuration and also
granulation tissue (associated with chronic infection) does not contraindicate
immediate implant therapy. As residual infection (without active suppuration)
have increased vascularity and cellular elements. Both vascular tissue and cellular
elements are supportive of osseointegration, regeneration, and repair. Hence, the
residual infection may provide a favorable environment
Implant Component Selection for Immediate Implants
Screw type implants have superior primary stability and long-term osseointegration as compared
to press-fit/machined surface implants.
Implants with enhanced surfaces (increased roughness) are also superior because they facilitate
better osseointegration
use of wide-diameter implants for immediate implants. Implants with a width less than 4 mm
have been associated with implant failure.
Anatomically shaped dental implants
The RE Implant System (Hagen, Germany) produces a computer-milled anatomic dental
implant that closely approximates the root morphology of the extracted tooth. Clinically
speaking, the tooth is extracted atraumatically and an impression of the extraction site is
obtained (captures socket morphology).
computer uses information gathered by impression to mill a chairside anatomical implant.
Advantages
Prevention of alveolar bone resorption, Improvement in soft tissues,
Prevention of epithelial down-growth, Elimination of barrier membranes,
Reduction in postoperative infection.
Disadvantages:
Milled implants unfortunately replicate undesirable anatomy, such as the mesial
concavity of the maxillary first premolar.
The impression technique adds to the trauma of the surgical procedure.
Immediate implants are placed within twenty minutes of tooth extraction, whereas
milled anatomic implant takes up to 2 hours to fabricate and place.
The cost for this type of procedure is considerably higher.
Osseointegration
Osseointegration is defined as an apparent direct attachment or connection of osseous tissue to an
inert, alloplastic material without intervening connective tissue, or The interface between
alloplastic materials and bone
In 1993, Misch defined it as the direct contact of living bone with the surface of an implant at the
light microscopic level of magnification, without intervening tissue.
Zarb classified the edentulous anterior jawbone into shape (quantity) and quality: see effect of
tooth loss
Worthington and Branemark classify bone as a guide;
Bone quantity;
A; good ridge without resorption
B; moderate ridge resorption.
C ; only basal bone remain.
D ; some basal bone resorption.
E ; extreme basal bone resorption.
Bone quality;
1. Mainly cortical plate compact bone
2. Thick compact bone with a dense trabecular core
3. Thin cortical plate with dense trabecular core
4. Thin cortical plate with low density trabecular core
Bone classification related to implant dentistry
Lekholm and zarb alveolar bone grading scale
According to this system alveolar bone has been divided into 4 classes:
1. Almost the entire jawbone is composed of homogenous compact bone.
2. Thick layer of compact bone surrounds a core of dense trabecular bone.
3. A thin layer of compact bone surrounds a core of dense trabecular bone of favourable
strength.
4. A thin layer of compact bone surrounds a core of low density trabecular bone.
The quality of the implant site in terms of relative proportion and density of cortical and
medullary bone had frequently been assessed using a grading scheme.
Lindh et al method of classification of alveolar bone
It is a recent method of classification based on periapical radiographs that grades the
medullary bone as
A) Dense
B) Sparse and
C) Alternating dense and sparse trabeculation.
Misch Bone Density Classification
Dl - Dense cortical bone,
D2 - Thick dense to porous cortical bone on crest and coarse trabecular bone within,
D3 - Thin porous cortical bone on crest and fine trabecular bone within,
D4 - Fine trabecular bone and
D5 - Immature, non-mineralized bone.
Radiographic bone density
Bone density may be more precisely determined by tomographic radiographs, especially
computerized tomograms.
Computerized tomography (CT) produces axial images of the patient's anatomy,
perpendicular to the axis of the body. The very soft bone observed after some bone grafts
may be 100 to 300 units.
The bone density may be different near the crest compared with the apical region where
the implant placement is planned. The most critical region of bone density is the crestal 7
to 10 mm of bone.
Therefore when the bone density varies from the most crestal to apical region around the
implant, the crestal 7 to 10 mm determines the treatment plan protocol
Assessment of the jaw bone quantity (height and width) and quality
Bone Quantity
The occlusocervical height of the residual ridge should be at least 7 millimeters,
since that is the shortest available implant length. short implants (7-10
millimeters) have a higher failure rate
Adequate height and width of the bone in the arch is needed for the placement
of the implants. A detailed assessment of the jaw bone dimensions of quantity and
quality can be assessed using:
radiographs with magnification markers (in conjunction with panoramic
tomography and cephalogram tomography
Ridge mapping techniques for assessing bone width multiplanar
computerized tomography.
Quantity: required for implant placement:
6 mm buccal-lingual width / sufficient tissue volume
8 mm interradicular bone width
10 mm alveolar bone above inferior alveolar canal or below maxillary
sinus (Implants should be placed at a minimum of 2mm from the inferior
alveolar canal or below the maxillary sinus)
If inadequate bone support, may need ridge or site augmentation:
Ramus or chin graft (autograft)
DFDBA (allograft)
Bio-Oss(xenograft)
Bone quantity was assessed as follows:-
Class A: Most of the alveolar ridge is present.
Class B: Moderate residual ridge resorption has occurred and only basal bone
remains.
Class C: Advanced residual ridge resorption has occurred and only basal bone
remains.
Class D: Some resorption of basal bone has begun.
Class E: Extreme resorption of the basal bone has taken place in the mandible.
Class F: Extreme resorption of the basal bone has taken place in the maxilla.
Bone Quality
The quality of the bone (as determined radiographically) is an important factor to
evaluate since implants that are placed into poor quality bone (Type IV bone) have
a higher failure rate.
Density of the bone should be suitable for the particular implant system chosen for
treatment. There should be an adequate ratio of cortical bone to cancellous bone to
provide initial stabilization of the implant at the time of placement as well as
excellent adaptation and final stabilization of the implant with the resultant
surrounding bone that regenerates during the brief healing period. A predominance
of one type of bone over the other will either compromise the initial stabilization of
the implant or delay the length of the healing period.
Best is thick compact cortical bone with core of dense trabecular cancellous bone.
Best region is mandibular symphysis; poorest in posterior regions.
Adequate height and width of the bone in the arch is needed for the placement of
the implants.
Bone quality (Types of bone structure) was assessed as follows:-
Class 1: Most of the jaw is homogenous compact bone (the best quality for
implant success).
Class 2: A thick layer of compact bone surrounds a small core of dense trabecular
bone.
Class 3: A thin layer of cortical bone surrounds a core of dense trabecualr bone of
favorable strength.
Class 4: A thin layer of cortical bone surrounds a core of low-density trabecular
bone.
Image processing software
By using the image processing software of the Digora, geometric (linear or angular) and
radiometric (densitometric) measurements can be performed.
The geometric data include distance measurement between recognizable features of the
teeth and periodontal structures found in the images, such as the measurements of bone
loss from the cemento-enamel junction to the deepest point of the pocket or from
cemento-enamel junction to the alveolar crest.
On the other hand a digital radiometric analysis employs statistical evaluations of gray
levels taken from digital images.
These values were used to determine the relative density and changes in density of
alveolar bone.
Mechanism of Osseointegration:
The healing process around dental implants is similar to primary bone healing,:
- A blood clot forms.
- Blood clot is transformed by phagocytic cells to procallus.
- Procallus becomes dense connective tissue and mesenchymal cells differentiate
into osteoblasts and fibroblasts.
- Formation of a fibrocartilaginous callus by the dense connective tissue.
- Penetration of new bone.
- Maturation of the new bone and increase in density and hardness.
Osteoconduction refers to directing of the bone forming activity to a particular site or
surface. Osteoconduction depends mainly on the migration of differentiating osteogenic
cells to the implant surface through a temporary connective tissue scaffold. It is the
function of the implant surface design to aid in the anchorage of this scaffold to the
implant surface. Some implant substrates are osteoconductive through their
hydroxyapatite coatings.
Osteogenesis refers to bone formation which occurs through stimulation of
osteoprogenitor cell proliferation, and enhancing of osteoblasts biosynthetic activity.
Osteogenesis results in a mineralized interfacial matrix, laid down on the implant surface.
The bonding of interfacial bone to the implant is affected by the implant surface
topography.
Osteoinduction refers to the activation of the mesenchymal cells to become osteoblasts.
it is denoted that bone remodeling is also a distinctive aspect of the bone formation
process around dental implants. Adequate remodeling is stimulated by forces transmitted
from a properly constructed superstructure
Factors affecting implant Osseointegration (Pre-Requests for Osseointegration):
There are a number of factors that may influence the degree of Osseointegration, relating to one
of three parameters:
implant design
Host site
Surgical technique.
I. impl ant design
a) Implant metal composition:
Implant must be fabricated from biocompatible material. Biocompatible material must
not be toxic, allergenic, carcinogenic, harmful to the surrounding tissues or disruptive to
the healing of the tissue. The implant should capable of withstanding the loads at the
implantation site and having great resistance to corrosion.
Most contemporary dental implants are made of commercially pure titanium, which has
been shown to have excellent biocompatibility.
b) Implant geometry
The implant surface must physically or chemically bond to the appropriate cells of the
recipient organ rather than become encapsulated and separated form the tissues by poorly
differentiated fibrous connective tissue. It is established that rough surfaced implants
allow a higher bone to implant contact.
Osseointegration is easily achieved with threaded implant, which is inserted so as to
create maximal contact between bone and implant.
Mechanical retention is based on undercut forms such as vents, screws, and dimples that
involve direct contact between the implant and bone.
While, bioactive retention is achieved with bioactive material such as HA which bond
directly to bone, similar to ankylosis of natural teeth.
Surface characteristics may be altered by several means including:
Machining - the surface is produced by precision milling with no subsequent
finishing.
Plasma-spraying - spraying with molten titanium modifies and increases the
effective surface area of the implant.
Machine grit-blasting - the implant surface is roughened by grit-blasting with
titanium oxide particles.
Acid-etching - the implant surface is chemically etched to increase the thickness
of the oxide layer.
Sand-blasting and acid-etching - sand-blasting followed by acid-etching to
substantially increase surface area.
Anodisation - surface is electrically treated to increase thickness of oxide layer.
Coating - the implant surface is coated with calcium phosphate hydroxyapatite to
produce a so-called bioactive surface to enhance bone-toimplant contact.
Increasing surface roughness increases the bone-to-implant contact area and, in
turn, osseointegration .
c) Implant Design
Implant Length: Shorter implants fail more often than longer implants. Implant length
varies from 6-20 mm. The most common lengths employed are between 8- 15 mm. It is
good practice to use the longest implant that can be safely placed.
Clearly, certain anatomical limitations exist, for example, in the posterior mandible
behind the mental foramen.
Implant Diameters : The diameter of most implants falls within the range of 3.3-6 mm.
Narrow diameter implants can be used in small spaces. Larger diameter implants may be
used, in particular in posterior areas of the mouth and where there is poor quality bone.
II. Host sit e
Adequate bone quality
For implants placed in type IV bone and in bone grafts, the reported failure rates are
higher as they have the weakest biomechanical strength and the lowest contact area to
dissipate the load at the implant/bone interface.
Sectional tomograms and computed tomography scans provide an indication of medullary
bone density.
From a clinical point of view, the quality of bone can be assessed during surgery, based
on subjective feel and by assessing cutting resistance during drilling, tapping and
placement of the implant.
The initial stability can be quantified using resonance frequency analysis (RFA), which is
a non-invasive method to evaluate implants stability.
III. Sur gical t echnique.
Surgical Experience : Clinical experience and surgical skill have been shown to have an
impact on implant success rates.
Operating Conditions
Implant surgery should be performed under highly controlled conditions. Contamination
of the implant surface during surgical placement should be avoided.
Possible sources of contamination Contact of non-titanium surgical instruments and the
patient's saliva
Incision Technique: A number of different incision types have been advocated, and these
will be considered in the chapter on surgical technique.
Drilling Technique
Frictional heat during any phase of the drilling procedure will cause a rise in temperature.
The critical time/temperature parameter for bone tissue necrosis is around 47C for one
minute. The generation of heat can be kept to a minimum by the use of sharp drills, slow
drill speeds, graduated drill sizes and copious water-cooling.
Atraumatic surgical technique:
The osseointegration is based on careful and gentile handling of the tissues with
minimal tissue damage in a clean and aseptic operating environment. Twist drill of
increasing size rotating at no more than 2000 rpm and cooled with copious external
and internal normal saline irrigation is used to prepare the bone.
Avoid excess heat generation during the preparation of the osteotomy. It was
suggested that the clinicians interrupt the drilling procedure at least every five
seconds for at least ten seconds while saline is applied to the bone, as the interruption
will dramatically decrease the time the bone temperature is elevated.
o Surgical flap design: reflect a little periosteum because elevated periosteum
loses its osteogenic potential. A mid crestal incision is recommended when
possible as it requires minimal reflection of mucoperiosteum.
o A bone tap rotating at no more than 15 rpm is used to tap threads in bone of
a density that is typically present in the anterior mandible. Self-tapping
implants are recommended in the maxilla and posterior mandible where the
bone usually has a loose trabecular pattern to prevent over-sizing of the
implant size during tapping process.
Loading Times
Moreover avoidance of over preparation can be done by using of drill with a narrower
diameter than that of the implant and this resulted in less damage to bone.
Implant placed in the mandible should remain unloaded for 3 to 4 months and
implants placed in the maxilla should remain unloaded for 6 to 9 months (two stage
surgical procedures).
IV. Pr imar y impl ant st abil it y INT J ORAL MAXILLOFAC IMPLANTS 2007;22:893904
Primary implant stability and lack of micro movement considered 2 of the main
factors necessary for the achievement of osseointegrated oral implants.
In the presence of movement, a soft tissue interface may encapsulate the implant, causing
its failure.
To minimize the risk of soft tissue encapsulation, it has been recommended that
implants be kept load-free during the healing period (3 to 4 months in mandibles
and 6 to 8 months in maxillae).
To decrease the risk of early failure with immediately loaded implants, various
clinical tricks have been suggested, such as
Under preparation of the implant site to achieve high primary stability,
use of non occluding temporary prostheses during the first 2 months,
Progressive loading of the prostheses.
The success of immediately loaded implants in mandible has been documented, but less
evidence is available for immediately loaded maxillary implants.
Criteria of osseointegrated implant success:-
Mobility:- Clinically, an individual unattached implant should be immobile .
Radiography:- An implant radiograph should be free from any evidence of peri-implant
radiolucancy. intraoral and panoramic radiography are most widely used for post surgical
assessment. The short- and long-term evaluation of crestal bone loss around implants is
best evaluated with Bite-wing radiographs.
Bone loss:- Vertical bone loss around an implant should not exceed 0.2 mm. per year
following the implant's first year service. Marginal bone loss of approximately 1.2 mm in
the first year and 0.1 mm is subsequent years is generally considered acceptable.
Signs and symptoms:- Absence of signs and symptoms such as pain, infectious parathesia
or violation of the mandibular canal, peri-implant pocket should not exceed 5 mm. at 2
successive appointments.
Minimum success rate:- At end of 5 year observation the success rate is 85% . and 80% at
the end of a ten year period is a minimum criterion for success.
Causes of Osseointegration failure:
Bad selection of patient.
Premature loading of the implant system, earlier than 3to6 months.
Placing the implant with too much pressure. It is advocated to make the implant site
slightly smaller than the implant so it can be tapped into place and that initial retention is
gained through a frictional fit.
Apical migration of junctional epithelium into the interface followed by connective tissue
element.
Overheating the bone during site preparation, bone will resorb if the temperature at the
periphery is above 47 degrees.
Implant not fitting the site exactly.
Infection.
Evaluation of peri-implant tissues
Peri-implant tissues can be evaluated clinically and radiographically.
Implants are evaluated clinically by certain parameters such as pain, probing depth, bleeding
index, plaque index, and mobility index.
1. Pain or infection :
It is reported that once the implant has achieved primary healing, absence of pain
under vertical or horizontal forces is an important clinical parameter to indicate
implant health. Percussion and forces up to 500 grams are clinically used to
evaluate implant pain or discomfort.
Usually, pain does not occur unless the implant is mobile and surrounded by
inflamed tissue or is immobile but impinges on a nerve. The presence of severe
pain may necessitate removal of the implant, even in the absence of mobility.
2. Peri-implant probing depth:
Probing depth around stable, rigid implant is not, in most cases, due to marginal bone
loss, but usually a reflection of the original soft tissue thickness of the area before
implant placement.
Some authors claim that the epithelial attachment surrounding an implant is not strong
and can be easily penetrated on probing and that nearly all implants can be probed to
within one or two millimeters of the bone level.
It is explained that the primary reason for the increased probing depth around implants is
due to the fact that the implant does not have a connective tissue attachment zone that
extends approximately 1mm above the bone as does a tooth.
Because the probe typically penetrates deeper next to an implant compared with a tooth,
care should always be taken not to contaminate the implant sulcus with bacteria from
a diseased periodontal site.
Probing not only measures pocket depth, but also reveals tissue consistency, bleeding,
and the presence of exudates.
It was also emphasized that only titanium or plastic instruments should be used to
probe the implant because stainless steel may lead to galvanic corrosion and surface
scratch that may develop marginal bone loss.
Probing depth does not matter; a change in probing depth is the matters
Use < 20g pressure
dipped in CHX, and reserved for implant only use to reduce cross contamination from
other pockets
Maintain as close to 0 degree angulation as possible.
Stable, rigid, fixated implants have been reported with pocket depths ranging from 2 to 6
mm. Sulcus depths greater than 6 mm around implants may have a greater incidence of
anaerobic bacteria and may require intervention in the presence of inflammation or
exudates (e.g., surgery, antibiotic regimens). IMPLANT DENTISTRY / VOLUME 17, NUMBER 1 2008
3. Bleeding index:
Modified bleeding index was introduced to assess sulcus bleeding.
Score 0: No bleeding when periodontal probe is passed along the gingival margin
adjacent to the implant.
Score 1: Isolated bleeding spots visible.
Score 2: Blood forms a confluent red line on margin.
Score 3: Heavy or profuse bleeding.
It was explained that a bleeding index is an indicator of sulcus health. Implant
success is not so related to gingival health as in the natural tooth. The
inflammation may be limited to above the bone, because there is less fibrous
tissue between the implant and bone interface.
When the sulcus depth is less than 5 mm and bleeding index increases
chlorhexidine is often indicated with other professional and home care methods.
However, if the sulcus depth is more than 5-6mm, reentry surgery is usually
required. Radiographic bone loss and increased pocket depth may be correlated
with bleeding.
4. Plaque index:
Modified plaque index was introduced to replace the original plaque index introduced by
Silness and Le (1964) to assess biofilm formation in the marginal area around implants,
plaque is assessed by modified plaque index at four areas; labial, lingual, mesial and
distal. Score of plaque index are as follows:.
Score 0: No plaque detected.
Score 1: Plaque recognized only by running a probe across a smooth marginal
surface of the implant.
Score 2: Plaque can be seen by the naked eye.
Score 3: Abundance of soft matter.
Increased plaque accumulation leads to subsequent inflammation resulting in increased
peri-implant probing depths similar to the process occurring around teeth.
There are vascular differences between periodontal and peri-implant tissues and the
significant difference is presence of fewer blood vessels in peri-implant mucosa. These
differences of lack of connective tissue fiber insertion and decreased vascular supply may
lead to a greater susceptibility to plaque-induced inflammation in peri-implant mucosa.
The process of teaching and motivating patients to control supragingival plaque is one of
the most important and challenging phases of periodontal therapy.
Chemical means such as chlorhexidine mouth rinses are sometimes used to control plaque.
The patient should apply chlorhexidine on brushes or cotton swabs to the tissue
surrounding the implant. Super floss or periofloss can also be used.
5. Mobility index:
Rigid fixation is a term that denotes the absence of observed clinical mobility of an
implant that was tested with vertical or horizontal forces under 500 grams.
Primary stability is achieved when the micro-movement of the implant-bone interface is
below the threshold at which fibrous encapsulation occurs.
Presence of mobility is an indication of future implant failure. Mobility may be due to

contamination of the implant surface, or to lack of primary stabilization.
A clinical implant mobility scale was proposed:
Zero : absence of clinical mobility with 500 grams in any direction.
1: Slight detectable horizontal movement.
2: Moderate visible horizontal mobility up to 0.5 mm.
3: Severe horizontal movement greater than 0.5 mm.
4: Visible moderate to severe horizontal and any visible direct movement.
Implants are tested by applying buccal and lingual pressure on the implant abutment with
the handle of 2 instruments.
Stability of implant can be better evaluated by means of electronic devices such as the Periotest
which provides an objective method to measure the degree of mobility. the specificity of the
Periotest is the highest of all tests.
The use of the Periotest should be limited to the verification of initial osseointegration at second
stage surgery and possibly to verify proper fixation of suprastructure components.
It was also stated for the Periotest to be reliable, bar, if used, must be disassembled. On other
hand other authors stated that it is of limited value in bar constructions and bridges.

6. Marginal bone loss (MBL)
During the first year after abutment connection, 1 mm of MBL is allowed followed by
0.2 mm per year. Today, these criteria are still frequently referred to as the gold
standard for implant success.
The most common method to assess the marginal bone loss is with a conventional
periapical radiograph. Although this only determines the mesial and distal bone loss, it is
a time-tested method. Computer-assisted image analysis and customized x-ray
positioning devices may be superior methods of measuring bone loss.
7. Soft tissue
Peri-implant mucositis: Reversible inflammatory reactions in the soft tissues
surrounding and implant exposed to the oral environment.
Peri-implantitis: The term peri-implantitis describes the bone loss from bacteria around
an implant. Peri-implantitis is defined as an inflammatory process affecting the tissue
around an implant in function that has resulted in loss of supporting bone.
Once the bone loss from stress or bacteria deepens the sulcular crevice and decreases the
oxygen tension, anaerobic bacteria may become the primary promoters of the continued
bone loss.
In other words, the bacteria involved in peri-implatitis may be secondary to one of the
prime causative factors, such as overloading the boneimplant interface.
Exudate or an abscess around an implant indicates exacerbation of the peri-implant
disease and possible accelerated bone loss. An exudate persisting for more than 1 to 2
weeks usually warrants surgical revision of the peri-implant
BIOLOGICAL TISSUE RESPONSE TO DENTAL IMPLANTS
PERI-IMPLANT GINGIVAL RESPONSE:
surgery procedures disrupt the gingival epithelium, both the attached gingiva and the
alveolar mucosa, when a flap is used to create the soft tissue opening to bone.
The surgically traumatized gingiva heals around the implant transmucosal post, as well as
reattaches to bone, and during healing a new anatomically free gingival margin complete
with gingival sulcus and free gingival groove is formed.
PERI-IMPLANT BONE RESPONSE:
Bone regenerates around the ridges and grooves of screw-type implants, into the pores of
porous root implants and through the pores of blades and hollow cylinder- type implants.
When bone is in direct apposition to an implant, the phenomenon is often referred to as
"osseointegration" or "osteointegration".
From the pathologic viewpoint, this is not ankylosis since the bone is not actually fused
to the biomaterials. Radiographically, a cortical bone interface appears as a unified
structure around the radicular aspect of an implant device.
PERI-IMPLANT CONNECTIVE TISSUE RESPONSE:
A direct bone interface is not always the result of implant placement . a large area of the
implant may be surrounded by connective tissue or collagen following healing. these
collagen bundles may run from bone to implant creating a peri-implant ligament around
the implant similar in morphology to that of a PDL.
When a radiograph reveals an endosteal implant with a thin radiolucent line around the
implant device, and yet clinically this implant is successful, it suggests that an organized
connective tissue interface between bone and implant can be a successful result, just as
much as a direct bone interface.
Complications of dental implant
Criteria for success
see: Criteria of osseointegrated implant success
- Intra-operative complications, of endosteal implants includes oversized osteotomy,
perforation of cortical plate, anteral penetration, in adequate soft tissue flaps for implant
coverage, broken bur, inoperative instrumentation, hemorrhage and poor angulations or position
of an implant.
- Short term complications (those that occurring during the first 6 months) postsurgery, during
healing includes: postoperative infection, paresthesia, wound breakdown, dehiscent implants,
radiolucencies, loss of healing screw, antral complications, mobile implants, implants of
improper angulations, broken prosthetic inserts, breakage of retention screws in fixed detachable
bridge, fabrication of implant-born temporary prosthesis and post surgical scar contracture.
- Long term complications include mobility of implant, saucerization (pericervical
radiolucency), fracture root form implants, stripped internal threads in implants and fractured
blade abutments.
Complications may classified as operative or inflammatory.
Operative complications occurred during or as a result of an operation and included
bleeding, nerve injury, displacement of the implant, fracture, or injury to adjacent teeth.
Inflammatory complications occurred at any stage of the implant treatment and included
infection, periimplantitis, periimplant mucositis, mucosal hyperplasia, and fistula formation.
Oper at ive compl icat ions
Bleeding and hematoma
Hematoma formation and bleeding after implant placement reportedly occurs in 0% to 29% of
cases. Bleeding is commonly controlled with local measures and is considered a minor
complication.
Hematoma formation after placement of dental implants usually resolves completely with
minimal sequelae. Life-threatening bleeding is rare, and only seven cases are reported in the
literature. Sublingual, submental, or submandibular swelling in conjunction with tongue
elevation was observed in all seven of these cases. Suggested risk factors for bleeding include
location, perforation of the lingual cortex, and implant length. All of the implants in the case
reports were placed in the canine or premolar region, perforation of the lingual cortex
intraoperatively was noted, and all implants were 18 mm or larger.
Careful preoperative preparation and intraoperative attention may reduce the risk of significant
bleeding. Preoperative CT imaging with coronal reconstruction promotes a better understanding
of the local anatomy and may reveal unanticipated concavities in the lingual cortex of the
mandible. A CT-guided prefabricated surgical splints guides the
osteotomy bur to its proper position while avoiding perforation of the lingual cortex, especially
in the presence of extensive sublingual fossae. During site preparation, the surgeon may note the
presence of small fragments of soft tissue on the bur, which suggests lingual perforation.
Intraoperative probing can be helpful for detection of bony perforations.
Using implants smaller than 16 mm also may reduce the risk of lingual perforation and reduce
the likelihood of this problem.
Nerve injury
The incidence of neurosensory disturbance after placement of dental implants ranges
from 0.6% to 36%. In general, research in the area of posttraumatic trigeminal nerve deficits is
compromised by the lack of uniform comparable data documenting nerve injury, absence of a
gold standard for neurosensory testing, and selection bias associated with censored data
caused by lack of follow-up. In implant research, these problems are compounded by the poor or
absent documentation of the injury, inconsistency in description and management of sensory
disturbances, and variable denominators (ie, patients or implants).
Inferior alveolar nerve injury during implant placement may result from direct
mechanical damage to the nerve, compression of the nerve and vessels, damage to vessels with
bleeding into the canal that results in a compartment-like syndrome, or the formation of a
traumatic neuroma. The risk factors for IAN injury during implant placement include the use of
nerve repositioning or lateralization procedures and implant placement in the severely atrophic
mandible.
Preoperative CT imaging of the atrophic posterior mandible may facilitate the prevention
of IAN injury associated with implant placement. Intraoperative periapical radiographs can be
helpful during site preparation to estimate apical position of the implant site in relation the IAN
before implant insertion. The diagnosis and documentation of nerve injury after implant
placement is crucial for management. It is useful to separate injuries according to whether they
have been complete or partial, as determined by detailed sequential neurosensory testing.
Effective treatment of nerve injuries depends on the clinicians capacity to assess.
the nature and severity of the injury and estimate the probability of spontaneous recovery.
Standardized, serial neurosensory examinations are critical to the decision-making process. Early
postoperative anesthesia suggests that direct, significant injury to the IAN and removing the
implant promotes early decompression of the nerve and may improve outcome.
Mandible fractures
Mandible fractures after implants placement are rare (reported frequency of 0.2%)
Etiologically, fractures may occur because implant site preparation creates an area of stress
concentration and weakness in the bone. Routine oral activities could result in pathologic
fracture.
The major risk factor for fracture is a severely atrophic mandible. Other risk factors
include lateralization of the IAN in association with implant placement, osteoporosis, and trauma
to the mandible after implant placement. To prevent fractures, the authors advocate imaging the
severely atrophic mandible to evaluate better the three-dimensional anatomy of the proposed site.
Avoidance of wide implants in cases of nerve lateralization also may decrease this risk.
In cases of severe resorption, bone grafting to increase mandibular volume and bulk may be
indicated.
Implant displacement
During implant placement or abutment connection, there is a risk for displacing the implant from
its site to adjacent anatomic structures (eg, the maxillary sinus, nasal floor, or mandibular canal).
The authors found no reports estimating the frequency of this complication. Risk factors for
implant displacement are placement of implants in soft (type IV) bone and in close proximity to
the maxillary sinus or mandibular canal. To avoid this complication, the authors advocate a
thorough preoperative evaluation of the bone quality, especially in posterior maxillary cases.
Evaluation of the implant site with a probe before insertion of the fixture is helpful to detect
bony perforations.
Early, unplanned implant exposure
Premature exposure of a staged dental implant because of wound breakdown occurs with a
reported frequency of 2% to 11%
Early exposure of two-stage dental implants may be associated with an increased risk for
inflammatory complications, including crestal bone loss and periimplant soft tissue
inflammation. Patients with early implant exposure have an almost fourfold increased risk for
bone loss when compared with cases in which wound integrity is maintained.
Dehiscence in esthetic areas may compromise the final esthetic outcome and necessitate soft
tissue grafting. Risk factors for premature implant exposure include immediate implant
placement after extraction or placement in association with reconstructive procedures, such as
bone grafts or membranes.
Mobile removable prostheses also may predispose to this problem. Denture adjustment to avoid
contact with the implant site is important. To avoid premature implant exposure, any pressure on
the wound must be eliminated. A meticulous closure of the wound without tension after
reconstructive procedures is valuable for avoiding this complication.
Damage to adjacent teeth
Injury to adjacent teeth associated with implant placement is a rare, but reported, complication.
The authors found no reports estimating the frequency of this complication. Injury to adjacent
teeth is caused by insufficient space between implants
and teeth or placing the implant at an improper angulation. Adequate preoperative imaging and
use of a prefabricated splint when placing implants help prevent inadvertent injury to adjacent
teeth.
Inf l ammat or y compl icat ions
Inflammatory complications can occur at any time during implant treatment. For the purpose of
this article, inflammatory complications are divided into acute and chronic categories.
a- Acute inflammatory conditions include perioperative infection, cellulitis,
and abscess formation.
b- Chronic inflammatory conditions include soft tissue periimplantitis (mucosal
erythema and edema) and hard tissue periimplantitis (progressive bone loss or
periimplant radiolucent lesions).
A- Acute inflammatory conditions
Perioperative infection after implant placement ranges from 1% to 3% and increases the risk for
implant failure. Among the risk factors for developing this complication is overheating of the
bone during site preparation. The use of aseptic technique and avoidance of implant placement
into previously infected sites may reduce the risk for infection. Prophylactic antibiotics
administered before implant placement reportedly decreased early failure rates twofold to
threefold.
Chlorhexidine rinses have been found to reduce infection during the initial healing period . When
preoperative antibiotics were given, there was no incremental benefit noted with the concomitant
administration of chlorhexidine. There are only sporadic case reports on serious infections after
placement of dental implants that required hospitalization.
B- Chronic inflammatory conditions
Chronic inflammatory complications occur with a reported frequency of 1% to 32%. For the
purposes of this article,
Chronic inflammatory complications are classified as
1-soft tissue periimplantitis
2-hard tissue periimplantitis.
1- Soft tissue periimplantitis
It is an inflammatory process that involves soft tissue surrounding an implant without
signs of bone loss. Soft tissue periimplantitis occurs most commonly in association with
implant-supported overdentures, with a reported frequency ranging from 11% to 32% .
Rates of soft tissue periimplantitis associated with implant-supported fixed prostheses
range from 7% to 20%.
Risk factors include unstable overdentures that result in mucosal ulceration and
hyperplasia, misaligned implants, implants that traverse nonattached gingival tissue,
poor oral hygiene, improper use of the abutment or healing caps, and presence of dead
space under the superstructures.
2- Hard tissue periimplantitis:
Fistula formation at the abutmentimplant interface may be one manifestation of hard tissue
periimplantitis. It was reported in the literature with an incidence of 0.02% to 25%.
Risk factors for developing chronic fistulas include poor oral hygiene and a gap between
the implant components that creates a nidus for infection.
The frequency of hard tissue periimplantitis and progressive bone loss is low, but its
occurrence is well documented in the literature. If unchecked, it may result in loss of
implant support and ultimate prosthesis loss.
Several studies have reported on the average marginal bone loss that occurs during the
first year after implant placement . Mean bone loss was 0.93 mm (range 0.4 mm 1.6
mm). The mean loss during subsequent years was 0.1 mm per year (range 0 mm0.2 mm.
Risk factors for hard tissue periimplantitis include early implant exposure and poor oral
hygiene.
Infection located at the apical area of the implant is another manifestation of hard tissue
periimplantitis and is often associated with implant failure.
The frequency of apical periimplantitis is approximately 0.3%. These lesions are often
found at the apical part of long implants placed into dense bone. Apical implant lesions
may be completely asymptomatic or present with tenderness, persistent pain or swelling,
and fistula formation.
The risk factors for apical periimplantitis include excessive heating of the bone during
insertion, residual bone cavities created by the placement of implants that are shorter than
the prepared surgical site, and bacterial
The complications associated with two stage implants are:
1- Poor implant placement or alignment:
Implants that are inclined too far buccally can compromise esthetics. Implants that are inclined
too far lingually can compromise tongue functions, sometimes this is unavoidable but the patient
must be evaluated pre-surgically to avoid this complication.
If implants are placed too close together, hygiene care and prosthetic restoration can be
compromised, the minimum recommended distance between implants is 6 mm from the center of
implants that are 3 to 4 mm in diameter, the implant should be placed in the centers of the
planned pontics to avoid being present in the embrasure area which can compromise the esthetic
results.
2- Implant mobility:
To avoid instability of the implant when placing it in the loose trabecular bone of the maxilla or
posterior mandible, self - tapping implants should be used and avoid counter sinking of the bone
below the superior cortical crest, the mobile implant should be removed and another implant can
be inserted after the bone has healed (9 to12 months).
3- Tissue dehiscence during initial healing phase:
As the results of pressure on the mucosa over the implant from a denture or because of
compromised blood supply to the flap from previous surgery or radiation therapy. In minimal
exposure, it is best to avoid elevating flaps to close the wound. Some bone loss may occur
around the superior aspect of the fixture, however, if the area is kept clean, the implant usually
heals successfully.
4- Tissue hyperplasia adjacent to the implant abutment:
Gingival hyperplasia as result of poor hygiene and improved oral hygiene will resolves the
problem. Occasionally gingival surgery is necessary when mobile tissue (alveolar mucosa)
surrounding abutment results in discomfort or persistent inflammation, vestibuloplasty with
mucosal grafting to create a non-mobile fixed tissue cuff around the implant is recommended.
5- Fracture of the abutment screws or screw attaching the prosthesis to the abutments:
Due to loosen of the screws and imperfect adaptation may cause screw to fracture because of
stress concentration along the screws. A narrow pointed instrument should be used to retrieve the
screw. A drill should not be used because it can rotate the screw deep into the implant and make
it impossible to remove. The reasons for screw loosening and fracture are:
- The conical screw design.
- Inadequate torque application.
- Cantilever extension.
- Inaccurate framework abutment interface.
- Fixture position and arch form.
- Occlusal discrepancy and jaw relationship.
Complications can be avoided or reduced by
1- proper patient selection and evaluation. A careful evaluation and understanding of the bone
anatomy and architecture, including the quantity and quality of available bone, are mandatory
before implant placement.
2- the physical and radiographic examination: the physical examination and plain
radiographs, CT imaging with the patient wearing a radioopaque lined stent yields valuable
information and aids in the planning process. A thorough clinical and radiographic examination
can be helpful in determining morphologic abnormalities and reducing the incidence of operative
complications, such as perforation of the lingual cortex, associated bleeding, and damage to
contiguous structures.
3- Careful implant procedures: Careful implant site selection, appropriate angulation, and soft
tissue handling may decrease mucosal inflammatory complications.
4- Longitudinal follow-up and assessment of bone and soft tissue health surrounding implants
should promote longevity and minimize these complications.
MANAGEMENT OF FAILING IMPLANT CASES
J Appl Oral Sci. 2008;16(3):171-5
The patient should be expected to question any symptoms, which may include pain, foul
taste, bleeding, drainage swelling, mobility, loss of function (mastication), and changes in
appearance. Any of these should initiate patient concern and the patient is advised to seek
knowledgeable professional evaluation.
Predictors for implant success and failure are generally divided into
patient-related factors (e.g., general patient health status, smoking habits, quantity and
quality of bone, oral hygiene maintenance, etc),
implant characteristics (e.g., dimensions, coating, loading, etc),
implant location,
clinician experience and
clinical technique .There are various causes related either to
o early failure (overheating, contamination and trauma during surgery, poor
bone quantity and/or quality, lack of primary stability, and incorrect
immediate load indication),
o late failure (periimplantitis, occlusal trauma, and overloading) failure
METHODS OF DIAGNOSIS
Methods of diagnosis include clinical observation, radiographic findings, microbiological testing,
and systemic considerations.
Clinical Observation
Tissue tone is most often an indicator of health or pathology present in the underlying tissues.
Localized tissue inflammation around the pergingival site, or within 5 mm of the abutments, is
not normal and often indicates loss of the biological seal or alveolar bone loss, or both.
Infection with its resultant symptoms may or may not be related to underlying loss of bone
support or loss of integration. Exudate from the pergingival site, or a nearby fistula, could
indicate an underlying pathologic condition.
Probing pocket depth, although helpful in diagnosis, may not be possible owing to the shape of
the implant or to the position of a fixed prosthesis. A deep gingival sulcus may also exist in a
healthy stable implant with proper rnaintenance. However, a deep probable area that bleeds
profusely when probed bears further investigation.
Stability, or loss of stability of the implant abutments and prosthesis, as intended, indicates the
state of health of the implant and the implant prosthesis. Cylindrical endosseous implants usually
commence function with zero mobility assuming osteointegration. The abutments on these
implants are either rigidly attached, or attached through a plastic device that allows slight
movement, thus attempting to simulate the movement that occurs naturally in the periodontal
membrane. Mobility in the abutment of an osteointegrated implant with rigid abutment design
could indicate a loosened abutment attachment, a change in the integration of the bone to fibro-
osteointegration, or loss of bone support for attachment of the implants, either full or partial.
Excess mobility of prosthesis supported by an osteointegrated implant with a mobile element
could indicate a loosening or wearing of the mobile element. It could also suggest a change in the
integration of the bone to fibro-osteointegration, loss of bone support, or failure of integration of
the implant either full or partial. It must be determined whether mobility is mechanical or
biological in origin, i.e., loose screw attachments, cement, or wear vs. loss of integration /
attachment.
Radiographic Findings
Various types of radiographs can be used, the most common being periapical radiographs.
Panoramic radiographs are also useful because they can extend the areas covered, which cannot
be achieved with periapical radiographs. Occlusal radiographs can reveal possible buccolingual
changes.
Computed tomography (CT) scans are currently used to determine the extent of osseous
breakdown in areas beyond those directly involved with the implant. The scans are generally
disrupted by the presence of metal dental implants.
In examining radiographs one should observe the extent of osseous changes as to whether or not
they partially surround the implant's perimeter and the extent they follow from the occlusal to the
apical end of the implant.
The presence of a fistula in the gingival area can be traced with either gutta - percha or silver
points, to determine if the source of origin is surrounding the, implant, or from existing teeth.
Infection or pain is often attributed to dental implants with their subsequent removal, when in
fact etiology is related not to the implant, but to natural teeth. A definite diagnosis should be
established prior to considering explant procedures.
Culturing
Culturing may be used to determine the type or source of infection present, if it is felt that
infection may be a problem involving the implant. if it is decided that the primary factor is
infection, the type of organism is identified with drug sensitivity tests and the patient is then put
on an appropriate medicinal regimen.
TREATMENT INTERVENTION
1- Mild forms of a marginal gingivitis can be treated with scaling and curettage, and by
improving home care with adequate plaque removal. Instruments used on the implants
should be of materials that will not disturb the implant surface.
2- Soft tissue problems often revolve around inadequate keratinized attached gingiva at the
perigingival sites. This lack of adequate tissue is more easily corrected prior to implant
insertion. However, if the problem exists, -it may be corrected with soft tissue grafts.
3- If the problems involve osseous tissues, a flap procedure may be indicated to expose the
implant and the surrounding bone. This may be followed by open curettage to eliminate
any soft tissue that has grown around the implant. One should also remove any hard
calcareous deposits which may be formed on the implant.
Various augmentation materials may be utilized to fill in the defect. These range from resorbable
hydroxyl-apatite, tri-calcium phosphate, freeze-dried demineralized bone, or collagen. One may
also utilize non-resorbable hydroxylapatite materials.
This region can be covered with a removable membrane or other barriers between the soft tissue
and bone layer. Currently placing a membrane, repositioning the flap, and then suturing the
tissue over the membrane obtain the most effective results. The membrane is allowed to remain
for approximately 6 to 8 weeks, after which it is removed.
4- If osseous breakdown occurs completely around the implant, and the implant has no
support from the surrounding tissues, an explant procedure should follow.
PROSTHESIS - OCCLUSION AND CONTOURS
In conjunction with the surgical approach, a view of the prosthesis has to be made to determine
that the occlusion is non-traumatic and that the mechanical portions of the prosthesis are
functioning adequately. Either may be primary etiologic factors and may have influenced the
degenerative changes that have occurred. If present, they must be corrected.
If an explant procedure has taken place and the site has been allowed to fill in with new bone,
then a new implant can be positioned, aligned in the previous site and with the existing
prosthesis. It then may be adapted to the existing prosthesis with a minimum of modification of
the prosthesis itself.
Often, owing to prosthesis utilizing connecting bars intraorally, there can be hypertrophy of
tissue beneath the bar and around the implant posts at the perigingival site. This may be trimmed
back to provide a healthier environment, using a scalpel.
Prosthetic considerations such as crown contours to provide for adequate plaque removal, and
narrow occlusal tables to minimize occlusal stresses, should be considered.
Implant replacement
it has been suggested that when an implant is lost, a flap should primarily cover the
entrance to the site and after 9-12 months, a new implant can be replaced at that site.
Some authors report immediately replacing 5 failed screw-type, commercially pure
titanium implants with larger-diameter, hydroxyapatitecoated implants in the same
sockets.
They suggest that a 1- year healing period may not be necessary provided
The socket can be prepared to eliminate thread grooves and invasive soft tissue;
Meticulous removal of granulation tissue on the failed implant site
the implant replacement is larger in diameter than the original implant;
sufficient available bone remains for the procedures
implants with improved surfaces such as TiUnite-surface implants
Other restorative options
Short arch
When planning implant rehabilitation or when facing implant failure, one should always refer to
the question: How many teeth are necessary for adequate function or what dentition assures oral
function? In some instances, the treated area can remain edentulous and this should be
considered as an option.
the World Health Organization (WHO) stated that throughout life, the retention of a functional,
esthetic, natural dentition of 20 teeth, without requiring prostheses, should be the treatment goal
for oral health. Therefore, 20 teeth have been used as an operative expression for a functional
natural dentition in epidemiological studies
Fixed partial denture
Removable denture
Complete denture theory and practice Geriatric edentulous patient 23
Geriatric Edentulous Patient
Gerodontology: It is the branch of dentistry that deals with the oral health
problems of the old people. one of the problems of aging is that some of
the bodily functions do not maintain their efficiency.
The provision and success of prosthodontic treatment for older patients
one commonly complicated by an array of dental as well as nondental
factors, which may or may not be unique to older patients.
Classification of elderly patients:-
The changes in geriatric patients can be classified as physiologic , psychologic and
pathologic
physiologic changes
1-The hardy elderly:-
Thosewho are well preserved physically and emotionally.
Many of our modem aged patients are in excellent physical and psychologic
condition. They are active in business and in community life and they display
maturity in everything they do. Most of the hardy elderly are aware of their
innocuous aging changes and quickly adapt to them.
2-The senile aged syndrome:-
Thosewho are really aged and chronically ill.
They are disadvantaged physically and emotionally and may be described as
handicapped, chronically ill, disabled, infirm, and truly aged. They resist
change, whether it be in their abode, clothing, food, or in any of the amenities
of routine living. It is become withdrawn, depressed, insecure, and dependent.
3-Between these Two extremes are many millions of elderly:-
They may have been hardy at one time or their impending illness is predict-
able. As a group, they exhibit every shade of health or illness.
psychological reaction to aging process,
1. realists: philosophic and exacting type
2. resenters: indifferent and hysterical type
3. resigned: vary in their emotional and systemic status. end treatment plan may be
palliative and definitive in nature.
The pathologic disorders most frequently encountered are
metabolic
skeletal
muscular
circulatory
neoplastic
psycologic
The principle cause of disability in persons of 65 years and above are
heart disease
hypertensive vascular disease
tuberculosis
disease of thebones, accidents, nephritis, diabetes, cancer and eye disease
The commonest cause of death after the age of 65 years are
Cerebral hemorrhage
Heart disease
Cancer
General arteriosclerosis
Accident
Prosthodontic treatment protocol for a geriatric dental patient
I. Sequalae of Aging
There are some factors which influence aging. Regarding this, two alternative views
on the nature of aging are prevalent.
1. First, it is the result of random damage.
2. Second is the result of some programmed enhancement and controlled,
degeneration of the organism.
Evidence exists that the elderly are at a special risk for developing malnutrition and
that vulnerability to nutrient deficiencies increases in the age.
II. Aging & Nutrition
A lack of essential nutrients can cause tissue friability and depress potential for
repair. The geriatric diet must include the proper amounts of protein, fats, and
carbohydrates, and sufficient vitamins and minerals.
Adequate nutrition plays a part in the health of the aging oral tissues, which in turn
influences the prognosis of any prosthetic treatment.
Factors contributing to nutritional problems in the elderly are
I. Oral
Changes in ability to chew food
Changes in taste and smell
Drug induced xerostomia
II. Physical
Changes in ability to absorb and utilize nutrients
Changes in ability to metabolize nutrients
Changes in energy requirements and activity
Effects of medication on appetite and nutrient absorption and utilization
Oral factors that affect diet and nutritional status
1. Xerostomia
Xerostomia affects almost one in five older adults. Xerostomia is
associated with difficulties in chewing and swallowing, all of which can
adversely affect food selection and contribute to poor nutritional status.
The use of drugs with hypo salivary side effects may have deleterious
influence on denture bearing tissues.
Deficient masticatory performance leads to consumption of more drugs,
than those with superior performance.
2. Sense of taste and smell
Age-related changes in taste and smell may alter food choice and decrease
diet quality in some people.
Factors contributing to this reported decreased function may include health
disorders, medications, oral hygiene, denture use and smoking. Sense of
smell decreases markedly with age, much more rapidly than the sense of
taste.
Diminished taste is the result of aging. Sensory changes may diminish the
appeal of foods (e.g., sensitivity to bitterness of cruciferous vegetables),
limiting their consumption and potential health benefits function.
3. Oral infectious conditions
Periodontal disease increases with age.
4. Dentate status
Poor oral health leads to impaired masticatory function. Whether MF plays
a role in food selection is still matter of debate, but impaired masticatory
function leads to inadequate food choice and alter nutrition intake.
The presence of natural teeth and well fitting dentures were associated
with higher and more varied nutrition intakes and greater dietary quality.
Effects of dentures on nutritional condition
Effects of dentures on taste and swallowing
A full upper denture can have an impact on taste and swallowing ability.
The hard palate contains taste buds, so taste sensitivity may be reduced when
an upper denture covers the hard palate. As a result, swallowing can be poorly
coordinated and dentures can become a major contributing factor to death
from choking.
Effects of dentures on chewing ability
As adults age, they tend to use more strokes and chew longer, to prepare food
for swallowing.
Masticatory efficiency in complete denture wearers is approximately 80%
lower than in people with intact natural dentition.
Effect of dentures on food choices, diet quality and general health
The effect of dentures on nutritional status varies greatly among individuals.
Some people compensate for decline in masticatory ability by choosing
processed or cooked foods rather than fresh food and by chewing longer
before swallowing.
Others may eliminate entire food groups from their diets. Dentate adults tend
to eat more fruits and vegetables than full-denture wearers.
Replacing ill-fitting dentures with new ones does not necessarily result in
significant improvements in dietary intake.
Similarly, exchanging optimal complete dentures for implant-supported
dentures, has not resulted in significant improvement in food selection or
nutrient intake.
III. Oral Aspect of Aging
LOSS OF TEETH
60% of men and 70% of women over 65 years of age are
edentulous
in old age chroma and hue of teeth will change as enamel is
abraded, exposing the underlying dentin to extrinsic stains.
chroma also deepens due to medication containing heavy metals
natural teeth take on a jagged brownish appearance of an aging
dentition when the incisal edges break and the exposed denture gather extrinsic
stains
Some patient in conflict with the esthetic sense of the dentist prefer to have
complete dentures with teeth that are smaller, straighter and whiter than natural
teeth.
Theloss of teeth and also some taste sense often leads to malnutrition.
Oral mucosa:-
The oral mucosa of the edentulous geriatric patient is
characterized by a reduction of the total number of component
cells with a resultant decrease in thickness of both the mucosa and
submucosa.
The result of this thinning and concurrent loss of resiliency is that
the oral mucosal lining becomes more susceptible to stress,
pressure, and disease.
stomatitis and other mild inflammations are the mucosal lesions encountered most
frequently in older edentulous mouths
Post menopausal woman : suffer from symptoms like ,dryness, burning sensation,
abnormal sensation.
In the presence of ill fitting dentures one will find inflammatory hyperplasia.
palatal inflammatory hyperplasia is also associated with ill fitting
dentures.
the thinning of the mucosa of the geriatric patient allows
Fordyce spots to become more apparent
Skin
As the skin ages, it may appear loose and wrinkled. The skin
loses its elasticity and the muscles, fat and connective tissues
all diminish in bulk. There is more skin than is needed to cover
them and so it dropsinto folds.
to eliminate wrinkles the patient frequently requests the dentist to place the
artificial teeth in undesirable relation to the support, to over intend or over contain
the borders, or to decrease the interocclusal distance.
Naso-labial groove deepens, which produce a sagging look to the
middle third of the face.
atrophy at subcutaneous end buccal pads of fat hollows the
cheeks
due to loss of fat support for the pre symphysial pad of fat
disappears and upper lip drops over maxillary teeth
changes are accentuated more dramatically when teeth are missing or when teeth
is lost at occlusal vertical dimension
Bone and maxilio-mandibular relation changes:
The quality of bone in all parts of the skelaton decrease
with age, this is added to alveolar resorption after teeth
extraction. this is more prominent in females
The peak bone mass attained at about 35 years old.
symptoms of osteoporosis : back pain, loss of bodyweight, facial height and
spontaneous fracture in advanced cases
The supporting bony tissues will also have undergone resorption to a greater or
lesser degree. The crest of the residual alveolar ridge is usually found to be
concave or flat and can terminate in "knife edge".
In some geriatric patients, extensive resorption of the mandibular alveolar ridge
may place the mental foramen at or near the crest.
In extreme cases, the layer of bone overlying the mandibular canal may have
resorbed completely, leaving a thin layer of oral epithelium as the only protection
for the contents of the exposed canal.
The geriatric mandible, because of senile atrophy, will exhibit a decrease in
surface area. The origins of the mentalis and buccinator muscles will migrate
inward toward the receding crest of the ridge. The origins of the mylohyoid and
buccinator muscles can actually be above the crest of the ridge when marked
senile atrophy has occurred.
The best treatment would be to try to replace the lost resilient mucosal tissue
covering the residual ridge with a layer of soft resin on the tissuesurface of the
denture.
The gradual hardening of soft denture liners over a moderate period of time occurs at a
slow rate that is barely perceptible to many geriatric patients. By the time the soft liner has
completely lost its resiliency, the patient may become used to the masticatory forces
transmitted by a hard base, and the oral mucosa and underlying bone may have become
more resistant to occlusal stress.
Dentures with a soft liner can be replaced at this time with a new complete denture, or the
liner can be removed and the prosthesis relined or rebased. At best, soft denture liners
should be considered only temporary and must be observed at regular intervals.
Tongue:
The size of tongue does not vary with age. However, tooth loss
can lead to wider tongue morphology by virtue of an
overdevelopment of some parts of the tongue's intrinsic
musculature.
Macroglosia may results from relaxation of the tongue
musculature. this occurs in disturbance of the endocrine glands
as hyperpituitarism. however the extraction of the mandibular posterior tooth
allows the musculature to relax and is preferably the most prevalent etiologic
factor
Constant and habitual attempts to keep a loose maxillary denture in place can
cause these changes. This may possibly be a result of transference of some of the
masticatory and phonetic function to the tongue. Unfortunately, this enlargement
has a negative effect on denture retention.
As the serous gland decrease in activity the saliva becomes more mucous and
soapy. When the salivary glands atrophy the reduction of the saliva flows result in
dry mouth.
Loss of taste:
Taste is perceived primarily in the tongue, with a lesser degree in the hard and soft
palates and pharynx. The tongue, particularly its anterior portion, is more sensitive
to sweat and salt than sour and bitter, whereas the palate is more sensitive to sour
and bitter and less sensitive to sweat and salt. The pharynx area is also sensitive to
a much lesser degree, to all four modalities of taste sensation.
With aging, the acuity of taste diminishes, particularly for salt, because of some
gradual nerve degeneration or hyperkeratinisation of the epithelium, which may
occlude the taste bud ducts and pores.
Xerostomia: see denture complaint
There is a decrease in salivary flow with ageing due to regressive changes in the
salivary glands. A decrease in salivary flow can also be the result of some
diseased, administration of certain medications, and other conditions.
A decrease in salivary flow will interfere with denture retention as well as make
mastication and deglutition difficult. The mechanical protection (lubrication) of
the denture supporting tissues by the saliva film will be lost predisposing them to
irritation.
The treatment of Xerostomia resulting from aging is generally unsuccessful. An
increased intake of water and frequent mouth rinses, particularly during meals,
may be helpful. Coating the tissue surface of dentures with petroleum, lubricating
jelly, silicone fluid, or one of the commercial dentures adhesive preparations can
temporarily increase denture retention and decrease irritation of the underlying
soft tissues.
Temporomandibular joint:
Overclosure over many years may affect the relations of the mandibular condyle
to the glenoid fossa. With age, the glenoid fossa can become shallower and the
head of the condyle flatter. Thus, it is possible for the meniscus or articular disc
between the condyle and fossa to be perforated or damaged by this change in the
temporomandibular relationships, causing pain and limitation of range of
movement of the jaws.
Facial muscles:
Falling-in of the lips may take place due to the loss of adequate support and
muscle tone. The facial musculature loses elasticity and resiliency with advancing
age and an increase in fibrous tissue. Wrinkling of the skin around the mouth may
also occur and will cause so- called "pressure-string". Often the oral orifice will
not be able to open as wide as to admit food.
Changes of the appearance
The effect of age on the nose: drooped tip and small hump develops on
the dorsum.
chin droop and folds of old age
concave lower profile of aged edentulous patient the "witch" profile
sunken look of old age - a patient wearing dentures giving very little
lip support
SENSES
Difficulty in hearing and diminishing vision can be offset by artificial aids
such as complete dentures hearing aids and eyeglasses. in many instances those who
will not wear a hearing aid or glasses will reject dentures
IV. Assessment of older adult:
The process of assessment of the older adult has been the keystone to operative
practice.
The dental assessment should also have a comprehensive base, but unfortunately,
both students and practitioners often neglect this important phase of the diagnostic
evaluation.
Steps involved are:
Identification data.
Information source.
Medical history and physical
evaluation.
Patient questionnaire.
Patient interview and summa
Dental history and evaluation.
Chief complaint.
Extra and intra oral examination.
Diagnostic aids.
Prosthesis
V. Prosthetic Diagnosis
The satisfied wearer of old dentures:
Some wearers of old dentures are satisfied with their old dentures in spite of
severe resorption of alveolar ridge, causing a lack of retention and stability as
well as a loss of VD and occlusal problems. They insist that they can chew
everything and dentures are as retentive as they were the day they were inserted.
It is an error to try to talk these patients into having new dentures constructed.
The prognosis of the new dentures is usually poor. They most certainly will
object to an increase in vertical dimension and a precise and uniform fit of the
tissue surfaces against the ridges.
The geriatric patient who does not want dentures:
An elderly person who has been without teeth for many years and has no desire
for complete denture is best left alone. If facial appearance is unimportant to
these patients and being without teeth does not alter their personalities, it is an
error to try to convince them to have complete dentures constructed. Some of
these patients get along well nutritionally without teeth, in fact much better than
some people with inadequate dentures.
The geriatric prosthetic patient:
Success in geriatric dentistry can be the result of building up the patient's
confidence in the dentist, regardless of the quality of the final prosthesis. The
important factor is to convince the patient to accept the dentures, to wear them,
and to use them. The patient must be educated to understand and accept the
reduced efficiency of the artificial dentition.
Older patients are often irritable and demanding. They tend to greatly
exaggerate their troubles and complaints. They must be treated with patience
and understanding. Visits should be carefully planned to be short, with a
maximum amount of work completed during scheduled time.. Working too
rapidly may give the geriatric patient the impression that the dentist is 'trying to
get rid of him.
VI. Esthetics:
Esthetics is important in fabricating dentures for the aged. An esthetic denture
may be the turning point in patient acceptance. Although we know that dentures
can do improve facial appearance,
If the patient expects too much, it should be clearly pointed out to the patient just
what to expect, always minimizing the results.
VII. Complete Denture Construction
Impressions:
Prior to making edentulous impressions for geriatric patients, the denture-bearing
tissues must be thoroughly examined. If they have been abused by ill-fitting
dentures, should be treated at first. Although, it is true that age tolerates change
badly and it is wise to avoid major changes, this does not mean that new dentures
should be under-extended, no matter how short the patient's old dentures were.
Our goal in impression making is maximum tissue coverage with no peripheral
displacement during functional movements.
Vertical Dimension
Certain acts must be taken into consideration during determining the vertical dimension.
The interocclusal distance increases with age. Excessive restoration of the
vertical dimension to achieve a more youthful appearance is contraindicated. It
will lead to destruction of the supporting tissues, severe discomfort, speech and
masticatory problems and possible TMJ dysfunction.
Anatomically constructed bite blocks to support the lips and improve the facial
appearance are necessary. They should not be overbuilt and must be able to worn
comfortably by the patient during the recording appointment.
An inter-occlusal distance of 5 to 10mm may be indicated because of physiologic
changes in the facial musculature, alveolar bone, skin, and sensory perception.
Esthetically, we do not want the aged patient to show a mouthful of teeth.
In severe cases of over-closure of patient's, old dentures in which the inter-
occlusal distance must be greatly corrected; it must be done over a period of
time. The vertical dimension should be opened no more than 5 mm at any one
time. After a period of a few years, the dentures can be remade and the inter-
occlusal distance increased another 3 to 4 mm.
If severe difficulty exists in the determination of vertical dimension, the patient's
old dentures, if available, can be used as a guide. The amount of resorption that
has taken place since their construction must be taken into consideration. Only
minor changes should be made.
In some elderly patients, even though the vertical dimension is carefully
determined, "clicking" of the dentures may still occur because of muscular in-
coordination or habit. In these cases it may be advantageous to use all resin
posterior teeth or porcelain uppers in opposition to resin lowers to minimize the
sound produced.
Centric Relation:-
The correct recording and duplication of centric relation is paramount to the success of
complete dentures.
A prognathic position of the mandible is often acquired by the geriatric patient.
This will prevent an immediate placement of the condyles into the most retruded
position in the glenoid fossae.
The patient must be seated in an upright position. The elderly patient must be
comfortable and relaxed during the recording of centric relation. Instructions
must be concise and precise. They should be constantly repeated.
The word "bite" should be avoided, and close with excessive pressure.
Premedication may be used as tranquilizers & muscle relaxants may be beneficial
in certain selected cases.
Mandibular exercises should be used to train the patient to relax the mandible.
The patient is instructed to protrude, retrude, and move the mandible from side to
side. Swallowing can also be used effectively to tire and relax the mandible.
Although, many prosthodontists recommend a Gothic arch for the determination
of centric relation of the elderly.
Other authors opposite to the Gothic arch tracing method. because some elderly
patients are unable to follow the movement instructions. The tracing device itself
may can't be used if there are abnormal ridge relationships or an excess of soft
tissue.
These others favor interocclusal wax check bites.
Posterior Tooth Selection:-
If anatomic teeth are used for an aged person, eccentric movements as well as
centric relation must be accurately recorded and transferred to an adjustable
articulator. Also, cusps must have freedom of movement in their respective
fossae.
Balance is necessary to ensure no interference with jaw movements to eccentric
positions.
Many prosthodontists recommend zero-degree posterior teeth for the edentulous
geriatric patient.
Other author used nonanatomic modifications of posterior tooth forms
constructed wholly or partially of chromium-cobalt alloy.
It is advantageous to patients with low closing pressure, where it is necessary to
reduce the force of the denture on the bearing surface during function.
The chromium-cobalt alloy, because of its strength, is said to be responsible for
increased efficiency of mastication.
Other author designed blocks of upper and lower acrylic posterior teeth in which
curved metal cutting blades are embedded. They are said to present the degree of
cutting efficiency required to cut fibrous foods and thereby diminish trauma to
the underlying tissues.
Adjustments
The occlusion should be perfected before the patient is permitted to wear the dentures. This
necessitates remounting on the articulator and selective grinding procedures prior to insertion.
The geriatric patient should be seen the day after insertion or, at the latest, the
second day.
If the patient is a new complete denture wearer, mastication should not be
attempted until the dentures can be worn comfortably and speech presents no
problems.
The lower denture can beremoved while eating during this period.
The patient should learn to eat soft vegetables first, then harder vegetables and
bread (not white bread, because it will become mushy and adhere to the teeth,
making learning difficult), and finally meats.
Food should be cut into small pieces and chewed slowly on both sides of the
mouth.
Bilateral chewing will provide maximum denture stability.
It usually takes several months before the geriatric patient will learn to eat well
with newly constructed complete dentures.
Relines:-
There are some situations related to advanced age in which relining is a valuable service.
Geriatric patients may have difficulty in coordination, or illness may impair their
ability to tolerate new dentures.
The construction of new dentures with the series of appointments can cause phy-
sical or mental stress.
New dentures obviously would be better, but it would not be practical to place
additional strain on the patients.
The use of a temporary resilient resin could also be considered, even though it
would be necessary to change the lining at frequent intervals.
When the dentist can not able to construct new complete dentures for any reason.
The existing jaw relations and the arrangement of the teeth must be satisfactory.
VIII. Burning Mouth Syndrome (BMS) and "Denture Sore Mouth"
See prepration of the mouth
IX. Implant prosthodontic treatment for the older patient:
The partial and completely edentulous patient may be unable to recover normal
function, esthetic comfort or a speech with traditional removable prosthesis.
Numerous studies have demonstrated impaired oral function for complete denture
wearers.
Improvement in oral function has been demonstrated after prosthetic rehabilitation
with implant-supported prosthesis due to enhanced stability and retention.
The increased need for implant related services among older adults results from the
combined effect of multiple factors including:
Loss of teeth
Anatomic condition of edentulous ridges
Inadequate performance of removable prosthesis
Psychological needs of the patient
Predictable long-term results of implant supported prosthesis.
Increased awareness of the benefits of implants by the profession and public.
To determine the efficacy and efficiency of implant supported prosthesis in geriatric
patients, the treatment outcome of elderly patients in ongoing clinical trials were
assessed. Hence following preliminary observations were made:
Being elderly is not a contraindication to long-term implant survival.
Successful osseointegration can be maintained irrespective of a patients oral
hygiene performance.
Diverse prosthesis designs appear feasible for elderly patients.
To date, our clinical studies support the conclusion that neither advance age itself or the
diminished level of oral hygiene are lone contraindication to a prescription for treatment with
implant supported prosthesis of various designs.
Complete denture theory and practice Duplication24
Duplication of Complete Dentures
Copy dentures, Template dentures, Replica dentures.
Definition
Duplicate denture: - a second denture intended to be a replica of the first one.
Aims
transfer of contours from old to new dentures for maintenance of neuromuscular control.
Any modifications done to the basic shape of the old denture should therefore be only
those necessary to correct the loss of fit i.e., (patients complaint) and those considered
essential by the operator, e.g., slight increase in the OVD and the replacement of the
worn denture teeth.
Indication
1. Elderly patients (geriatric) usually meet difficulty in adapting themselves to the
new dentures to the extent that it becomes essential to duplicate their old ones.
2. Provide replacement dentures (with improved fit) similar in most aspects to those
to which patients are already accustomed.
3. Sometimes duplication may also be essential to correct inaccuracies in the fitting
surface of the denture or the vertical dimension.
4. If we desire to renew old deteriorated and stained denture base material, the
duplicate denture will have the appearance of being completely new.
5. If it is desired by a patient to have a spare denture in case of accidentally fracture
or loss of the original denture. The patients often are concerned about being without
dentures during required repair or relining process.
6. If we need to experiment interchanging the occlusal relationship of the dentures
for clinical or research reasons. This could be carried out on the spare denture, without
changing the original one.
Advantages
It gives considerable advantages to both the patient and clinician because it save time and
money and usually ensure satisfactory results.
When to Duplicate a Denture
We are not going to duplicate a denture unless its examination reveals satisfactory
findings as regards to esthetic, physiologic, and psychologic needs of a patient.
The denture(s) should be evaluated for any previous fractures, craze lines, missing or
replaced teeth, esthetics, phonetics, accuracy of fit, and vertical & centric relations.
On the basis of this examination, the patient is then advised whether the existing denture
should be duplicated or remade.
Temporary Duplicate Dentures
Production of temporary duplicate dentures is sometimes carried out with the aim that
these can be progressively modified if the patients capacity to adapt is in doubt (e.g.,
gradual increase in occlusal vertical dimension) or if the cause of the patients complaints
is not clear (e.g., patient may be a denture collector).
These could be fabricated with low cost and with less clinical and laboratory time. Once a
satisfactory appliance has been achieved, it can then be copied to produce a definitive
denture.
Techniques
Many techniques have been proposed (Duthie et al. 1978; Davenport & Heath 1983;
Murray & Wolland 1986) for duplicating old dentures.
All of these techniques are based on the use of an elastic duplicating material. The elastic
duplicating material will allow the removal of the old dentures from the flask without
damage to either the duplicating material or the denture.
The duplicating materials suggested are silicone, polysulphide and reinforced alginate
impression materials.
All these techniques are similar except in the use of mould container and materials.
Some of these methods are:
1 - Duplicating flask method
2- Soap container method
3- Pour resin flask method
4- Silicon putty
5- Agar container method
6 - Sectional mold technique
7- CAD \ CAM method
8- Modified denture flask method
9- Cup flask method
Basically, a mould of the old denture is produced in an elastic material, such as alginate
or silicon putty supported in a rigid container.
The wax or auto-polymerizing resin template is fabricated from this mould. Any
necessary modifications to the old denture are performed on this template denture and
tried in the patients mouth before finishing the prosthesis.
In some of the techniques, autopolymerizing resin teeth are also fabricated instead of
using available ready-made moulds.
A-First Technique (duplicate flask method)
1. An impression to denture teeth poured in molten wax.
2. Wax teeth changed to acrylic resin. (personalized as in old denture
,custom mad teeth).
3. Undercuts present in the fitting surface of the old denture are blocked out using
plasticine or base plate wax. A separating medium is applied to the old
denture and a plaster cast is poured.
4. After setting of plaster, the cast is separated carefully from the
denture and the plasticine or modeling wax, used for blocking out the
undercuts, is removed.
5. Homogenous mix of rubber base or silicone impression material is poured in the fitting
surface of the denture. The plaster cast is covered with gauze, and inverted into the
fitting surface of the denture pressing on the setting duplicating material.
6. After setting of the duplicating material, the plaster cast is removed.
7. The denture will, then, have its fitting surface covered with a layer of elastic duplicating
material containing the gauze.
8. A mix of dental stone is poured into the fitting surface of the denture covered by the
duplicating material and the gauze is embedded in the setting stone. The stone replaces
the plaster cast to give strength to the layer of the elastic duplicating material.
9. The denture with the poured stone and the duplicating material in between is placed in
the lower portion of a flask, which has been partially filled with a mix of plaster.
10. After setting of the flasking plaster, the occlusal and polished
surfaces of the denture are covered with a layer of gauze-
contained mix of the duplicating material.
11. After setting of the duplicating material, the upper half of the flask
is filled with a mix of plaster, covered and seated under the press
for 30 minutes.
12. After thirty minutes, the flask is opened and the old denture is
removed.
13. Individually fabricated acrylic resin teeth, made from impression of the old denture, or
previously chosen ready-made teeth are fitted into their corresponding imprints in the
duplicating material.
14. Heat or cold cured acrylic resin can be used for fabricating the new denture.
Cases requiring correction of fit or vertical dimension:
The corrections are carried out as usual without replacing the tracing compound or the
impression material with acrylic resin. The corrected dentures are then duplicated as described
before.
B- Second technique (Soap Container method) (Heath &
Basker 1978)
- Denture borders are modified with green stick compound.
- The patient's denture is invested in alginate, which is supported in a
container such as a soapbox. A window is cut into its side to provide
an exit for sprues.
1. First mix of alginate to obtain an impression of polished and
occlusal surfaces. Adhesive is not applied to the walls of the container.
2. Alginate is trimmed at the level of the upper border of the box
and just below the denture periphery. Petroleum jelly is smeared on the
surface of the alginate to facilitate separation of the two halves of the mould.
3. Second mix of alginate to obtain a record of the impression surface.
4. Soapbox closed on to stops. Denture removed when alginate set. Sprue channels cut
with wax knife into heels of polished surface impression.
5. Wax poured to above level of gingival margin. Mould closed and held together with
rubber band.
6. Base poured in a fluid mix of cold-curing acrylic resin down one of
the holes with light vibrations, while air escapes from the other. Place the
container with the sprue holes upright in a pressure pot that contain water at
110F and process the resin under 15-30 psi pressure for 30 minutes.
7. After polymerization, the copy is removed from the mould and the sprues are cut off.
The resulting copy template has a rigid acrylic base together with wax teeth, which make the job
of the dental technician very much easier when setting up teeth on the trial dentures.
8. Centric relation record is obtained after adjusting the waxed teeth for the OVD.
9. The wax teeth on one of the dentures are then replaced with the identical mould of the
resin teeth. The opposing denture guides the set up in identical position to the original denture.
Advantage:
It has been shown that accurate copies can be constructed with this technique, the
maximum dimensional change being -2.12% (Heath & Basker 1978).
Diagrammatic summary for copy denture technique:
(1) First mix of alginate to obtain an impression of polished and occlusal surfaces. Adhesive is not applied to the
walls of the container.
(2) Alginate is trimmed at the level of the upper border of the box and just below the denture periphery. Petroleum
jelly is smeared on the surface of the alginate to facilitate separation of the two halves of the mould.
(3) Second mix of alginate to obtain a record of the impression surface.
(4) Soapbox closed on to stops. Denture removed when alginate set. Sprue channels cut with wax knife into heels of
polished surface impression.
(5) Wax poured to above level of gingival margin. Mould closed and held together with rubber band.
(6) Base poured in a fluid mix of cold-curing acrylic resin.
Variation of this method utilizes a specially designed aluminum flask (Murray & Wolland 1986).
C- Third technique (pour resin flask method)
It is suitable for patient had worn the dentures for a number of years. Tooth wear and
bone resorption have resulted in ovcrclosure and mandibular protrusion.
A new occlusal registration is taken, increasing the vertical dimension by the desired
amount. On the wax registration wafer is marked the level of the occlusal plane and the
centre line. Self curing resin replicas of the dentures are then made.
Procedure
1. Pieces of sticky wax are attached to the posterior aspects
of the dentures to form sprue-holes, keeping the wax clear
of the fitting surface.
2. The two dentures are then pushed into disposable plastic
impression trays which have been filled with alginate
impression material, so that the alginate reaches the peripheries of the dentures.
3. When the alginate is set, a second mix is used to form the reverse halves of the
moulds by 'sandwiching it between the two trays. No separating medium is
required as the mixes of alginate do not adhere to each other.
4. The mould is next dismantled and the dentures removed and returned to the
patient.
5. The portions of the mould are reassembled and held together with rubber
bands, localization of the portions being positive owing to the considerable area
of alginate in contact.
6. The rubber bands must not be too tight; otherwise the margins of the alginate may
separate causing leakage of the resin. The metal handle supplied with the
disposable trays. Suitably bent, forms a convenient foot on which the mould can
stand.
7. Cold cure acrylic resin is then mixed in the proportions of 16 ml. monomer to 21
g. polymer, this quantity; with few exceptions being sufficient. For both upper
and lower full dentures. Powder and liquid are mixed quickly and poured into the
two holes left by the sticky wax sprues. If two lips are formed on the edge of the
mixing vessel, the two dentures can be poured with one mix of resin.
8. The mould is kept upright during pouring and the liquid mix introduced as
quickly as possible before the viscosity increases and slows the flow.
9. When the resin is set the mould is opened and the replicas removed.
Owing to the close apposition of the halves of the mould there is very little flash on
the peripheries and finishing requires only cutting off the sprues and smoothing the
surfaces with sandpaper.
10. The two replica dentures are related by means of the wax registration and
mounted on a plane line articulator.
11. The upper replica is removed from the articulator, all the pink teeth ground off
and new anterior teeth set to the lines marked on the wax wafer, their mould
having been selected from the replica.
12. The indentations on the wax wafer indicate the buccolingual position of the
anterior teeth as well as their incisal length.
13. The posterior teeth are also set to the line and the whole occlusal plane thus
established. The pink teeth are similarly ground off the lower replica and stock
teeth set up against the uppers to give the desired incisor relationship and
posterior occlusion.
14. The completed set up on the acrylic bases is tried in the mouth and any errors
corrected.
15. Zinc oxide paste impressions are then taken inside the bases, any undercuts of
the fitting surfaces having first been removed. The upper impression is taken first
removed from the mouth and checked and reinserted. In order to avoid
introducing errors in the occlusion, the lower impression is then taken with the
teeth closed together.
In cases where the patient is aged or infirm and cannot be relied upon to maintain a
steady pressure on the dentures while the impression material is setting, it may be
more reliable to take the impressions separately, held in place by the operator.
16. The dentures can then be finished. After casting stone models into the zinc oxide
impressions, the wax can be cleaned excess impression material and then
flasking carried out in the usual way. The wax is washed away with boiling water,
the self-curing resin bases removed and discarded, and the dentures packed with
heat-cured resin.
Disadvantage:
1- The possibility of polymerization contraction of the cold cure acrylic replica,
resulting in problems at the impression stage;
2- The setting up procedure is time consuming for the technician since the resin
replica teeth have to be ground away and replaced with a wax base and new teeth.
3- Following flasking of the dentures for finishing, after the try-in stage, some
difficulty may be experienced in removing the residual part of the acrylic replica
from the flask.
D- Fourth technique (silicon putty)
This technique uses stock impression trays and silicone putty.
1. The occlusal and polished surfaces of the denture are embedded in a mix of
silicone putty held in an upper tray.
2. The impression surface is then invested in a
second mix of putty, which is supported on
the reverse surface of another tray. Once the
putty has set, the two impressions are
separated and the denture is removed.
3. Sprue holes are cut into the heels of the impression, and the copy template is
produced as described in third technique.
Procedure
1. The new required occlusion is recorded and the teeth selected. Before taking
impressions of the old dentures,( should the palate of the upper denture be thin,
and thus limit the space available in the mould for the replica, it is advisable to
increase the thickness by the addition of wax to the polished surface, in order to
create sufficient space to accommodate a subsequent shellac base plate).
2. Next, impressions of the dentures are taken in a manner similar to that described
above, using two large upper impression trays for each denture.
3. In place of alginate, however, silicone putty is employed. To increase working
time, the proportion of catalyst is reduced to approximately two-thirds of the
normal.
4. The putty is moulded to extend up to the denture periphery, and to provide a
complete rim or plateau around the denture.
5. When the putty has cured, Vaseline is applied as a separating medium and the
reverse half of the impression is token using the reverse of a disposable upper tray
coated with adhesive. This is achieved by packing the putty into the fit surface of
the denture, to eliminate air voids, the remainder being moulded to form even and
continuous contact with the rim of the first section of the impression.
6. Following separation of the two halves, the denture is removed, and returned to
the patient.
7. In-this technique the replica dentures are made of wax on shellac baseplates,
these ensuring sufficient stability and rigidity to allow impressions to be taken in
them at the next visit of the patient.
The formation of the shellac baseplates is a simple procedure; the silicone putty
impressions of the fitting surfaces are sufficiently rigid and heat resistant to permit
adaptation of shellac baseplate blanks.
8. These are trimmed to extend to within 1 mm. of the impression of the denture
peripheries.
9. Correct closure of the two halves of the mould is checked with the baseplate in
situ and the latter is fixed in position in the appropriate half. Pouring holes are cut
in the impression, one at each posterior border.
10. the two halves are closed together by rubber bands and baseplate wax at 100'C
is poured into the mould (the temperature is not critical, but l00'C is easily attained
with a water bath).
11. After cooling, the replica is removed, and the sprues cut off. The wax adheres
well to the shellac baseplate, but not to the silicone putty.
12. Using the record of occlusion, the putty impressions and their attached trays are
articulated; thus eliminating the need for production of plaster models.
13. The wax teeth of the replica dentures are removed one at a time, and replaced
with teeth of the selected mould and shade.
14. Any tooth position changes required are incorporated during the setting up and, on
completion; the replica dentures are ready for try-in.
15. After any necessary adjustments to peripheral extensions, wash impressions,
using zinc oxide paste, are taken in the shellac bases and the dentures returned to
the technician for final processing.
There is no need for the dentures to be removed from the models prior to flasking.
E- The fifth technique (Agar Agar method);
1- Dentures are suspended with a metal rod through the sticky wax
sprues.
2- Both Dentures are suspended in the agar container.
3- Molten Agar is being poured in the container.
4- Once Agar is set, the mold is sectioned through the sprue holes to retrieve the
dentures.
5- Auto-polymerized acrylic resin is then poured in the mold space
to produce template dentures for modifications.
F- Sectional mold technique J Prosthet Dent 2001;85:12-4.
It does not require the patient leave the denture with the clinician. A sectional
mold and dental stone are used to invest the denture, and heat-activated acrylic
resin is used to duplicate both the denture teeth and base.
For a denture to be considered for duplication, it must be physically and
esthetically acceptable and have a satisfactory jaw relation.
This technique allows the fabrication of a duplicate denture by using the superior
properties of heat activated acrylic resin. The exact size and shape of the patients
existing denture teeth are duplicated, and because a final impression is made, the
denture has more retention, stability, and support.
The only disadvantage of this technique is the risk of fracture of the master cast
when undercuts are present.
Procedures
1- Make a final impression with a thin layer of zinc oxide eugenol in the
original denture in centric occlusion to increase retention and reduce possible
changes in vertical dimension of occlusion in the duplicate denture. Remove
excess impression material extraorally from the borders.
2- Create a master cast by pouring the impression with stone. Apply a thin
layer of petroleum jelly to the outer surface of the denture. Remove any
excess jelly with a clean piece of cotton.
3- Flask the master cast and original denture in the lower half of a flask by
using dental stone as the investing material.
4- Use a brush to paint the outer surface of the denture with the stone
mixture. Use the remaining stone to invest the denture until only the tips of
the teeth remain.
5- Apply cold mold seal separating medium on the stone surface, and pour a
third layer of stone (the cap stone) to complete the flasking.
6- Complete the deflasking after immersing the flask in warm water at 70C
for 15 minutes for easier removal of the denture from the cast. Softening of
the impression material may prevent potential fracture of the cast. If fracture
does occur and the fracture line is clean, it can be easily fixed with the
appropriate adhesive material.
7- Remove the cover of the upper half of the flask, loosen the lateral screw,
and remove the stone with the denture from the upper half of the flask.
8- Separate the cap stone layer from the second layer by using a plaster knife.
9- Make 3 cuts with a minisaw in the heals and at the midline on the second
layer of stone.
10- With a plaster knife, separate the second layer from the denture.
11- Clean the denture, and return it to the patient. Gently reassemble the 4 stone
pieces to their original positions in the upper half of the flask. To get the
exact position of the parts, position the upper half with the lower half of the
flask under the press, and then tighten the lateral screw.
12- Separate the flask, and immerse the upper half in warm water for 5 minutes.
Melt hard modeling wax in a container, and then pour the molten wax into
the teeth mold.
13- After gradual cooling, immerse the upper half of the flask in cold water
(25C) for 15 minutes. Remove the cover of the upper half of the flask, and
loosen the lateral screw of the flask. Remove the stone and wax from the
flask gently. With a plaster knife, separate the cap stone layer from the
second layer. Then separate the parts of the second layer to get the arch wax
of the teeth intact.
14- Fix the arch wax of teeth with a stainless steel bur lingually to prevent
distortion of the arch wax during flasking.
15- Flask the arch wax in another flask. Then process the arch wax in Crown
and Bridge tooth-colored heat activated acrylic resin. Finish the arch teeth
gingivally and interdentally after deflasking.
16- Place the acrylic arch teeth in position on the cap stone with the other 3
pieces of the second layer, and place the upper half of the flask on it. Press
the lower half of the flask, and tighten the lateral screw. Finally, separate the
flask halves.
17- Apply cold mold seal separating medium on stone surface, and pack and
cure pink heat-activated denture base material (Quayle Dental). Finish and
polish the duplicate denture.
G- CAD \ CAM method
CAD \ CAM can be used for denture duplication
Denture Duplication Technique, Modifications / Further
applications
1. Addition of a labial flange to the open-face denture
2. Production of Temporary dentures
Teeth are fabricated with dentin colored self-cured acrylic resin before adding tissue
colored pink denture base resin.
Problem Areas in Fabrication & Solutions
1. Rigidity of the Box
The container used for fabricating the alginate mold must be rigid to avoid
distortion of the alginate and subsequently the self-cured acrylic resin template.
Precautions must be taken so as the rubber bands used to hold two halves of the
mold must not distort the soap container.
2. Distortion of the Alginate ridge
Immediately after pouring the wax to from template teeth, the mold should be
reassembled to check that the alginate impression of the ridge does not indent the
soft wax. Wax is removed if necessary to avoid any possible distortion of the
alginate ridge and production of a base plate without an intact all-acrylic resin
impression surface.
3. Impression & Jaw relation records
These steps should be performed with utmost care. Silicone impression material is
recommended for obtaining the reline impressions as the template dentures have to
be re-inserted in the mouth for recording the OVD and Centric Relation.
4. Tooth position and Tissue contours
Since the spatial positioning of the teeth and the resin contours of the polished
surfaces are important for neuromuscular control, the selection and placement of
the stock (readymade) teeth on the templates must be undertaken with great care.
Complete denture theory and practice Relining and rebasing25
Relining and rebasing
Definitions:-
Relining: It is a procedures used to resurface the tissue side of the denture with new base
material. Or Addition of Material to the tissue side of a denture to improve its
adaptation to the supporting mucosa.
Rebasing: It is the laboratory process of replacing the entire denture base material on an
existing dentureto improve its adaptation to the supporting mucosa.
INDICATIONS FOR RELINING OR REBASING
1. Immediate dentures at three to six months after their original construction.
2. Theresorbed residual alveolar ridges. See flat ridge
3. To decrease the cost of new dentures constructed.
4. To eliminate physical stress, for geriatric or chronically ill patients during series
appointments of the construction new dentures.
5- in case of
Loss of retention
Instability
Food under denture
Abused mucosa
Contraindications
The dentures should not be relined or rebased when:
1. When an excessive amount of resorption has taken place.
2. When abused soft tissues are present.
3. When the patient complains of temporomandibular joint problems. Until accurate diagnosis
and treatment of the problem has been accomplished, relining or rebasing is
contraindicated.
4. If the dentures have poor esthetics or unsatisfactory jaw relationships.
5. If the dentures create a major speech problem.
6. When severe osseous undercuts exist, until surgical removal and healing occurs.
7- Great vertical dimension loss
8- Severe occlusal wear
Clinical picture
Signs
- Loss of retention& stability.
- Loss of V.D.O.
-Loss of facial support
-Horizontal shift of denture
- Reorientation of occlusal plane.
Symptoms
Soreness
Looseness
Chewing inefficiently
Change in patient's appearance.
Minimal to moderate changes Relining
Moderate to maximal changes Rebasing
Relining or rebasing?
Diagnosing the problems isessential to determine the choice of treatment.
Thenature of tissue changes, their extent and locationshould be studied.
Tissue changes may be due to Incorrect or unbalanced occlusion: For such cases/
correction of occlusal disharmony issufficient.
If thevertical dimension is changed rebasing isrequired .
Other factors like amount of resorption, also determine the treatment requisite.
Change in the basal seat of the denture is revealed by looseness, general soreness,
inflammation and If the supporting tissues are traumatized.
Surgical correction (to eliminate the hyperplasia) may be needed before making the
reline impression.
The presence of all porcelain teeth greatly facilitates a rebasing procedure. If resin teeth
are present, relining is usually indicated, as it is difficult to rebase a denture with resin
teeth.
The denture is usually functionally relined prior to rebasing in order to establish (increase) a new
vertical dimension.
IMPRESSION MATERIALS USED FOR RELINING AND REBASING
1) ZOE paste.
2) Composition.
3) Elastomers.
4) Tissue conditioners.
5) Black gutta Purcha.
6) Cold cure acrylics.
Note: - Alginate is not suitable as an impression material because it is dimensionally unreliable
in thin section.
General Considerations
The following examination points should receive special consideration:
1. The occlusal VDshould be satisfactory. Check RVD and OVD
2. Centric occlusion should coincide with centric relation.
3. The denture appearance must be acceptable to the patient and dentist.
4. The oral tissue should be in optimum health.
5. The posterior limit and posterior palatal seal of the maxillary denture is correct.
6. Adequate denture base extensions. Assess lip support
7. denture base extensions permit distribution of forces over as large an area as possible.
8. The interocclusal distance is correct.
9. Speech is satisfactory with the existing tooth arrangement.
10. There are no existing hard or soft tissue conditions that would preclude the technique,
such as redundant tissue or severe osseous undercuts.
11. It should be understood that
The closed mouth impressions made for relining
- Do not record the tissues at rest position. Hence, relining may not give total relief
to the denture bearing area.
- The patient cannot determine the amount of pressure that is required to maintain
the denture in position. Hence the tissues might be displaced beyond acceptance.
In such cases, the prognosis of relining treatment will be poor.
- The record bases may move before the relining material sets. If there are
premature contacts at occlusion, the resultant impression may become inaccurate.
premature contacts must be eliminated prior to making closedmouth impression.
Remounting of denture in the articulator is necessary to reestablish an acceptable
inter-occlusal distance and harmonize the occlusion with jaw movements.
When both maxillary and mandibular dentures are to be relined or rebased, it is
better to handle maxillary denture first, make occlusal corrections, allow an
adjustment period and then proceed with mandibular denture. Nallaswamy
12. Principal Pitfalls : they must be avoided in any technique:
- Do not increase the occlusal vertical dimension.
- Do not permit the maxillary denture to move forward during impression.
- An equal thickness of final impression material should be used.
PRE TREATMENT PROCEDURE
a) Tissue Preparation
Patient is instructed to leave his denture out of his mouth at least 48 hrs to allow for
recovery of tissues and reduce irritation caused by ill-fitted denture.
With any relining or rebasing technique, any abused tissues should be treated
before make reline or rebase. See rehabilitation of abused oral tissue in flabby ridge
b) Denture Preparation
Relieved any pressure areas.
Corrected any occlusal disharmony.
Correct any small inadequate border.
Correct posterior palatal seal before the final impression.
Any undercuts are removed from the denture base.
Peripheral extensions are checked and adjusted.
Borders are reduced and squared to provide a definite edge for addition of new
resin material.
RELINING/REBASING PROCEDURES
(A)CLINICAL PROCEDURES
1. Static impression technique.
a) Openmouth b) closed mouth
2. Functional impression technique.
3. chair side impression technique
(B) LAB PROCEDURES
I. Articulator method
ii. J ig method
iii. Flask Method
I. Static impression (controlled pressure) Technique
a) OPEN MOUTH TECHNIQUE Boucher 1973
- It is the method for relining both maxillary & mandibular dentures at same appointment
- Existing C.O. not used.
- Dentures are used as a special tray for making the sec. impression.
- ZOE is the material of choice.
- Exactly 15 seconds after the denture has been placed in the mouth, the patient is asked to
pull the upper lip down and to open his mouth wide these actions mould the impression
material over the border of the denture. The lower impression is made after making the
upper impression. Nallaswamy
- After making both impression anew centric relation is recorded.
- Advantages
Selective trimming helps to make a selective pressure impression.
Making a separate inter-occlusal record will allow the operator to concentrate on
recording the jaw relation.
It is possible to verify the centric relation record if necessary.
The inter-occlusal record is reliable.
- Disadvantages
Difficult procedure.
It requires more clinical and laboratory time.
b) CLOSED MOUTH TECHNIQUE
- Both maxillary & mandibular relining/ rebasing should be done separately
- We prefer the closed mouth technique when we use the static impression tech.
Various Techniques
Technique -A New centric relation is recorded withmodelingwax or compound.
Technique - B
Technique - C Use the existing C.R.
Technique - D
Technique - E
Technique - A
C.R. - New C.R. is recordedis recorded using wax or
compound before making impression.
An interocclusal record and is used to guide dentures
in to position while making the reline impression.
Denture Preparation
All undercuts are relieved
Tissues surface of denture is relieved 1.5-2mm.
The centre portion of the palate can be removed (optional)
for visibility in positioning the maxillary denture during
impression making. Borders are reformed to their
functional contours using low fusing compound.
Clinical procedures
Low fusing modelling compound (Green stick)
ZOE is the impression material of choice. During impression making, patient is asked to
close lightly into the newly made inter-occlusal record
If palatal portion is cut than quick setting plaster is used as an impression material
Advantages
Palate relied for better visibility.
Pre made interocclusal record helps to position denture during impression.
. It also helps in orienting dentures in an articulator.
. It is a two-step procedure and it reduces the possibility of moving the maxillary
denture forward during final impression making. Hence, its more reliable
Disadvantages
The wax inter occlusal record is not an accurate & safe record because several
times, the patient can't close c out possibility of damaging the record.
This technique cannot be used to reline/ rebase both dentures at the same time.
Technique - B
No new centric relation record is made here.
Denture preparation
Same as technique- A
Clinical procedures
Border moulding is done using low fusing compound
Kerr's Impression wax (Iowa wax) is used as material of choice as it flows at
mouth temp.
Impression is made in two stages. In the first step all areas
except the labial flange and the alveolar crest in-between the
canines are recorded. The labial flange and alveolar crest
between canines are recorded in the second step
Advantages
It will reduce the possibility of extreme forward movement of the maxillary
denture.
Disadvantages
Wax impression materials are difficult to work with and can distort easily,
If the existing centric relation record is wrong then the impression becomes
inaccurate,
Technique - C
C.R.- Existing Centric relation is used
Denture preparation
Same as Technique A & B
Relief holes in labial & palatal flange decreasing the pressure inside the
denture there by preventing displacement of maxillary denture.
Clinical procedures
Border moulding is the same as in technique A
No specific Impression material
Advantages Same as Tech. A& B because This tech
Disadvantages is a combination of both A & B.
Technique- D
C.R.- existing C.R. is used to seat the denture
Denture Preparation
Same as in other techniques then Denture periphery should
be shortened to create a flat border.
A large opening should be proposed in the Palatal portion of
the maxillary denture.
Adhesive tape is attached over the buccal & labial surfaces
of both dentures. 2 mm above denture borders
Grooving in region b/w the reline impression & adhesive
tape & filling it with molten wax.
Clinical procedures
Border moulding is done using molten wax.
Impression:
- Dental plaster or ZnOE is suggested for recording most areas and plaster of Paris is
used to record the palatal portion.
- After impression making, a deep groove is cut into labial and buccal surfaces of the
dentures at the junction of the impression material and is filled with molten wax.
- The wax at the edge of the denture is used to record the sulcus.
Technique E
Centric relation The existing centric occlusion (intercuspation) is used.
Denture preparation Not specified.
Special suggestion Loss of vertical dimension is corrected by luting softened modeling
compound to the occlusal surfaces of the mandibular posterior teeth.
The patient is directed to repeatedly pronounce the letter "m." The record is
chilled, trimmed, and slightly heated before returning it to the patient's mouth.
The procedure is repeated until the occlusal vertical dimension is established.
Then a lower work impression should be made.
After pouring the impression and mounting the lower denture on an articulator,
the lower denture should be removed and cleaned.
Any excessive undercuts should be removed. The denture is luted to the maxillary
denture in maximum intercuspation.
Softened modeling compound is placed inside the mandibular denture and the
articulator closed against the lower cast to contact the incisal guide pin. With this
procedure, the amount of vertical dimension indicated by the thickness of the
compound on the surface of the mandibular teeth is transferred to the base of the
mandibular denture.
The mandibular denture at this stage is used as a tray for making the final
impression.
Impression zinc oxide-eugenol impression is suggested.
Advantages
(1) The loss of vertical dimension can be compensated for during the relining
procedures.
(2) The error in centric occlusion can be reduced during the laboratory stages.
Disadvantages
(1) This technique is very time consuming from the standpoint of clinical and
laboratory procedures.
(2) The procedure for establishment of occlusal vertical dimension is highly
questionable.
(II)FUNCTIONAL IMPRESSION TECHNIQUE
Suggested by Winkler.
- Here the patient need not be without dentures unlike previous techniques (e.g. the
dentures are not required for Lab. Producres).
- It is simple & practical method & is more popular.
- Fluid resins (Tissue conditioners) are used as an impression material.
Tissue conditioners are Temporary soft liners c the following characteristics
i) Easy to use
ii) Excellent for refilling complete denture.
iii) Capable of retaining for many weeks.
iv) Good in dimensional stability.
v) Good in bonding to resin denture bases.
Procedure
The patient is advised to avoid nightwear of dentures.
Occlusal errors in the dentures are corrected to obtain centric occlusion that coincides
with the centric relation.
Flange overextensions/under extensions and posterior palatal seal areas should be
corrected.
The tissue surface should be reduced to accommodate the tissue-conditioning material
The tissue surface of the denture is dried and tissue-conditioning material is placed. It
should flow evenly as a thin layer to cover the entire impression surface of the denture
and its borders.
Next, the denture is inserted and the patient's mandible is guided to centric relation in
order to stabilize the denture and the material is allowed to set.
Once it sets, the impression is removed and excess material is trimmed.
- Overextensions and voids are corrected.
- Unsupported areas in the dentures will show the overflow of the liner and poor recording
of the borders. This indicates the need for localized border moulding with green stick
compound.
- Depressed (Denuded) areas should be relieved.
The lining material will slump during setting if not adequately supported by the denture.
After making the corrections, the dentures are inserted with the material and the patient is
dismissed.
After 3 to 5 days, dentures are examined for denuded (depressed) areas, which should be
relieved.
Areas of under extension are corrected by adding more material.
The material should be renewed periodically (once a week) till the tissue healing is
complete.
Once the tissues are normal, impression is made with ZnOE or a light bodied
elastomer over the tissue conditioner material and a cast is poured immediately.
During one of the previous visits, an accurate orientation record of the maxillary denture
should be recorded using a face-bow.
- The tissue conditioner material undergoes somephysical changes during its use, which
help the dentist use it for different purposes.
- In its plastic and elastic stages it is used as tissue conditioner, whereas in itsfirm stage
it is used as reline impression material. Hence, for relining procedures, it should be left in
place for about 10 -14 days to allow them to become firm and then reline procedure is
carried out.
(III) CHAIR-SIDE IMPRESSION TECHNIQUE DIRECT RELINES (from Smith &
Bolender)
Acrylic is added to the denture & allowed to set in the mouth to produce instant relining or
rebasing.
Disadvantages
- Material produces a chemical burn in oral mucosa.
- Material is porous & develops a bad odour.
- Poor colour stability.
- Material is not easy to remove if not placed correctly.
Recently VLC (Visible light cure) resin has been developed which is similar to tissue
conditioners.
Both the static impression technique & functional impression techniques are well accepted
choice B/w the 2 methods is based on dentists & patient's convenience.
(B) LABORATORY PROCEDURES
I- Articulator method II J ig method III flash method
(I) ARTICULATOR METHOD
o Once the impression is received cast is poured
o Maxillary cast is mounted on an Semi adjustable articulator with the help of face
bow transfer
o Mandibular denture is mounted using an interocclusal record. (Procedure is common
for both relining & rebasing upto this stage)
For relining:
- The required amount of tissue surface of the existing denture is trimmed away
using an acrylic bur.
For rebasing
- If rebasing is to be done, the denturebase should be trimmed to just leave 2 mm
of acrylic around the existing teeth
- After trimming, the dentures are placed in the articulator and waxed up without
altering the vertical height.
(II) J IG METHOD
Here the impression is boxed and a cast is poured. A reline- jig is used in this method. Two
types of riling J ig are used
- Hooper's duplicatoi
- J ectron jig
About these jigs
They function to maintain the occlusomucosal relation. The
cast along with the impression is mounted on the upper
member of these instruments.
Hooper's duplicator is an instrument that has two triangular
parts connected by three pillars in each corner. Whereas,
J ectronjig uses onlytwo pillars.
A plaster index is made on the lower platformwith the denture
teeth penetrating the depth of about 2 mm. When the plaster
sets theindentations made by the denture teeth act asa key into
which the denture teeth can be repeatedly positioned to maintain a fixed distance and
relation between the cast and theocclusal surfaces.
When the key has set, the top and the bottommembers of the jig are separated. Denture is
removed from the cast.
All of the impression material is removed fromthe denture and the denture is prepared
(trimmed) according to the treatment selected(relining or rebasing).
If rebasing is selected, the entire denture base is removed from the teeth (if they are
porcelain), and all but a small connecting bridge of acrylic is removed (if the teeth are
plastic or acrylic).
The trimmed dentures are then set into the plaster key and the top of the instrument is
replaced. The denture is waxed to the cast, processed and finished as usual. The cured
denture should be repositioned on the jig tocorrect the occlusion prior to insertion.
If relining is opted, auto-polymerizing resin is used on the tissue surface of the denture
andthe upper member of the jig is closed.
Thedenture is cured in a pressure container of warm water at 15 psi for 30 minutes. Use
of auto-polymerizing resin is controversial dueto its irritation to the tissues but it avoids
theuse of excess heat (required for heat curingresins), which may warp the original base
material.
Problem Areas
The denture cannot be separated from the cast without breaking the cast or itself.
Occlusal errors may occur if the flask is not closed properly while curing.
Relined/Rebased denture may not beretentive.
Causes
Failure to remove denture undercuts beforeimpression making.
Denture teeth not seated properly into theindentations.
Wax shrinkage withdrew teeth from indentations, resulting in lack of occlusal contact.
Occlusion not properly maintained whilemaking the rebase impression.
Flask halves have a poor fit.
Posterior palatal seal not placed in cast. e Initial impression not adequate.
Solution
Remove undercuts using bur prior to makingthe rebase impression.
Seat the denture firmly.
Add chips of cooled wax to the space between tooth ridge laps and cast, in order to
minimizewax shrinkage.
Makerebase impression at proper occlusal relationship.
Use accurately fitting casts.. Scrape the posterior palatal seal in the cast prior to adding
resin.
. Inspect impression for any damage duringtransit to laboratorv.
(III) Fl ask Met hod
The poured impression alongwith denture isinvested into the base of a flask.
A silicone mould material is painted over thedenture prior to investing the body. This is
done to create a flexible mould. Flasking iscompleted as usual.
Coating silicone mould material sincesilicone provides a flexible mold, thedenture can
be removed carefully after opening the flask.
The denture base is trimmed as required (aportion of the tissue surface in relining andthe
entire denture base in rebasing) andplaced back into the mould.
Theinvested stone present in the base of the flask is the cast for the denture. If it is a
maxillary denture then the posterior palatal seal should be marked using a sharp
instrument on the invested stone.
Separating medium is painted over the mouldspace of the denture. The resin is packed,
cured, finished andpolished
The finished dentures are remounted to checkfor occlusal disharmony.
Problem Areas
Nodules on tissue surface of dentures.
Incorrect occlusion.
Causes
Air incorporated in silicone during mixing.
Flasks do not fit properly
Resin not trial packed adequately.
Initial impression not related to proper jawrelation.
Solutions
Do not whip air into mix during mixing resin.
Use accurately fitting flasks.
Eliminate all flash by triai closures.
Make sure that impression is related to proper occlusal position.
Examine impression for damage that mayoccur during transit.
Once the dentures are relined satisfactorily, they are inserted in the mouth with all the
necessary instructions.
PITFALLS
A. Problems Due to Improper Diagnosis
Relining when the lack of fit is not the only problem for example when the patient
presents all symptoms of a vertical dimension that is too great or the patient does not like
the appearance of the denture.
Attempting to increase the vertical dimension too much. It is difficult to control changes
when an attempt is made to compensate for too much resorption.
Relining for a loss of minor retention this occurs when patient becomes concerned
when the initial retention disappears. Patient must accept that even after the initial loss
of retention, the fit will usually remain stable for several years. Counsel patient that some
loss of retention can be expected and discourage indiscriminate relining.
B. Improper Preparation of the Soft Tissues
Relining over abused or inflamed tissue results in rapid loss of retention. Do not reline
until all the abused tissue has been recovered and returned to a more normal form.
C. Loss of Orientation
This may be due to failure to position the denture properly during the impression
procedure.
The patient may also complain that he/she shows much more anterior teeth before the
reline impression was made and the denture feels excessively thick in the palatal region.
This may be due to the impression being excessively thick in the anterior palatal region
and over a well-defined median palatine suture area.
D. Occlusal Discrepancies
This complaint is most often identified where no patient remount is carried out at the
delivery stage.
In some cases where definitive occlusal discrepancies exist at the impression stage it may
be necessary to take jaw relation records, remount and assess. The occlusion, the
technician may have to float the denture on mounted casts to improve the cuspal
relationships.
The reline impression will have to be repeated, if the antero-posterior discrepancy is
greater than one cusp. Selective grinding procedures may have to be carried out or even
artificial teeth reset.
E, Inadequate or Lack of Posterior Palatal Seal
Frequently posterior palatal seals are not established during the impression
procedure. You cannot expect the technician to incorporate an arbitrary seal in the
reline if no indication of where the seal area is to be established.
E. Displacement or Loss of Orientation
Using heavy biting pressure when making the impression may cause displacement
of the denture of major occlusal discrepancies have not been corrected.
Complete denture theory and practice CD Repair 26
Repair of Complete Dentures
Probably the most common denture fractures are those along the maxillary
and mandibular midline. However, other types of denture fractures may be
present.
Characteristically, however, a midline fracture is due to fatigueof the acrylic resin produced
by repeated flexing of the denture by forces too small to fracture it directly. Failure of the
denture base is due to the progressive growth of a crack originating from a point on the
surface where an abrupt change in the surface profile causes a localized concentration of
stress many times that applied to the bulk of the denture.
The crack often starts palatally to the upper central incisors
CAUSES OF FRACTURE
A- Constructional Faults:
1. When posterior teeth, particularly upper, are set outside the ridge, the ridge itself
becoming a fulcrum point. This will frequently results in a midline fracture.
2. Unbalanced articulation will result in abnormal stress being applied to the denture or
the teeth.
3. Inadequate relief of upper denture will cause the denture to flex over the hard areas of
the palate and fracture.
4. Excessive relief sometimes accounts for a broken denture by reducing in the midline
of the palate the thickness of the base beyond the limit of safety.
5. In accurate impression on which the denture was constructed, considerable stress will
be induced in the denture base during mastication owing to the unevenness of its support.
6. The use of incorrect dough consistency when packing, inadequate polymerization
times andtemperatures, and too rapid cooling after processing, will all result in a denture
base of reduced strength and dimensional inaccuracy.
7. Excessive grinding of either the ridge or the occlusal surface of porcelain teeth may
weaken it to extent that it will fracture after some period of use.
B- Causes in the Mouth:
1. Excessive force applied during mastication or by the patient clenching. This may
necessitate the replacement of acrylic resin by a metal base material. (Delayed fracture)
2. Alveolar resorption cause the denture to be unevenly supported in dentures which
have been worn for some considerable time, or which were made shortly after the
extraction of the teeth.
3. A labial frenum attached high on the ridge may necessitate a deep frenal notch in the
denture. Such a notch may be the site of the commencement of a denture crack (fracture).
4. Inadequate relief of an upper denture in midline of the palate, in patients showing
marked differences in mucosa thickness, may result in the denture flexing in the midline
during function. Fatigue fracture may follow. (Early fracture)
C- Causes Out of the Mouth:
1. Excessive pressure during cleaning.
2. Accidents such as dropping the denture on the floor or on to a washbowl.
D- Causes of Teeth Off, but not Broken:
1. Insufficient packing of acrylic resin.
2. A film of grease, separating medium or wax on resin teeth.
3. Packing acrylic resin when the dough is at too advanced a stage
there then being insufficient free monomer to unite with the acrylic resin teeth.
Classification of fractured dentures
I) According to location of fracture
Midline fracture Any part fracture
II) According to extent of fracture
Without broken or missing part &/or teeth
With broken or missing part &/or teeth
III) According to timing of fracture
Early fracture Delayed fracture
IV) According to cause of fracture
Operator Patient
Before undertaking any repair ,be sure that the denture can be returnedto the patient's mouth in a
satisfactory fitness.
In all cases as certain the causes of the fracture and, if possible, remedy this before repairing the
denture.
Repair of Fracture with no missing part
The broken edges of the denture arecleaned of food and material debris
and other interferences, so the two parts will fit together well.
The parts of the broken denture must be reassembled accurately and held
together by means of an old bur or match sticks which are luted to teeth
and the adjacent resin surfaces by sticky wax.
No wax is placed over the fracture, so that the tissue and palatal sides of the
fracture can be examined to see that they are in correct apposition.
Any undercut on the fitting surface is blocked out with wax or clay.
Undercutsthat are more than 6 mm. away from the fracture line.
Do not blockout immediately adjacent to the fracture line. Blockout
materials are as follows:
wet fiberglass investment liner
wet paper towel or kleenex
wet cotton rolls
softened red rope wax
thick pumice paste
clay
When the sticky wax has hardened, plaster is then gently vibrated onto
the palatal surface of the denture, avoiding air bubble formation, and the
remainder of the plaster is set on this to form the cast.
When the model has set the sticky wax should be removed and the
broken parts of the denture removed from the model.
Paint the tissue side of the plaster matrix with a coating of tinfoil
substitute.
Fractured edges are reduced, widened (8-10 mm) along the fracture line (at least Remove
1.5 mm. of acrylic on either side of the fracture line) and beveled towards the polished
surface to increase bonding surface area.
Dove tail cuts may be made to strengthen the repair joint.
In the case of complete upper dentures it is advisable to remove the entire palatal resin. The
reason for this is to minimize the warpage of the old acrylic resin during the polymerization of
new material. If heat is used for the repair internal strain in the old acrylic resin will be relieved
when processing and large areas such as palates will be distorted.
Although the warpage will be reduced if cold-cured material is used, it is still advisable to
remove the entire palate. It is possible to expose a greater area of old material for union with new
if this is done.
a) Repair using cold-curing resin:
Acrylic resin monomer is painted on the cut surfaces, and a cold-curing repair resin is
placed in the break.
The mixed monomer and polymer are carefully flowed into the space. The area should be
slightly overfilled to allow for finishing.
Deflasking, finishing and polishing are carried out as for a new denture.
The use of cold-cure acrylic resin is advised for all repairs in order to minimize the
warpage of the old material. The possible weakness with cold cure material is the area of
union of the old and new resin.
Owing to the rapid polymerization of cold cure material there may be insufficient time
for the monomer in the new resin to soften the surface of the old resin and thus ensure
chemical union between them.
For this reason it is helpful to paint the surface of the old resin that is to come in
contact with new material with a little monomer prior to packing. In addition it is
desirable to pack the new material at a somewhat earlier stage of dough formation than
is used for new dentures. This will enable the monomer to be available for softening the
old material for a slightly longer time.
An alternate method
Wax and contour the fracture line to desired form using base plate wax, followed by
flasking, wax elimination, packing with self cureand placing in flask under press for 2 h.
Deflasking, finishing and polishing is then done in the usual manner.
b) Repair using heat-curing acrylic resin:
The pieces of the broken denture are assembled (held together) and stabilized with
sticky wax and small wooden sticks.
A cast is poured after undercuts inside the denture are blocked out.
The denture is removed from the cast, free of sticky wax and sticks.
Preparation for repair beings by removing 2-3 mm of acrylic from the midline fracture of
the denture.
A long rounded bevel is made on each side of the opening about 5 mm wide along the
entire midline and onto the labial surface.
The plaster cast is painted with separating agent, and the two pieces of the denture are
placed back on the cast.
Waxing-up of the fractured area, flasking, boiling out of wax for eliminating it. Mixing
and packing of acrylic resin dough.
Using microwave for activating give cleaner and faster repair than polymerization with
the conventional hot water.
Cooling, Deflasking, finishing and polishing to complete the repair.
II- Fracture with missing or lost part
Procedures:
An impression is made with the denture placed in patient mouth.
After pouring the cast, either self cure A.R. is applied to replace the
missing part, or wax is added and carved to resemble the broken denture
part, followed by flasking, packing, curing, finishing & polishing.
III- Fracture with broken or missing teeth
If anterior teeth is loosened and capable of being replaced.
it should be waxed into its correct position and a plaster (index or
matrix ) overcast poured to register the position.
When the plaster of the overcast has set, the tooth can be removed by cutting away the
resin on the lingual or palatal side
a dovetail prepared for the new resin. This gives adequate access and provides
mechanical as well as chemical retention.
Usually the acrylic resin on the labial surface of the denture needsnot to be disturbed.
When the preparation is completed the tooth is repositioned with the aid of the plaster
index and waxed to the denture. If preferred the denture can now be flasked.
only the prepared area being exposed and boiling out, packing, and processing carried out
as described for the complete denture. This should be the method employed if several
teeth are being replaced.
When only one tooth is concerned it is not necessary to flask the denture. Another plaster index
(matrix ) can be poured to cover the waxed palatal or lingual area and the adjacent resin and this
is used to apply pressure to the cold cure resin after it has been placed in the dovetail.
A strip of tin foil can be placed between the resin and the plaster index. Pressure can be applied
by hand for the relatively short period that is required for this small amount of resin to
polymerize.
If a tooth or teeth have been broken or are missing from a complete denture,
Fractured teeth are cut away with burs.
On lingual side, enough acrylic is removed and dove tailed.
Teeth of same size, shape & shade are positioned in proper alignment
and waxed with base plate wax.
A plaster index is made to record & secure the position of waxed teeth.
Teeth to be repaired are removed together with all wax around them.
Teeth are then put back exactly in their original position aided by plaster key.
Self cure acrylic resin is added from the lingual side until repair area is over built. It is
then covered with tin foil.
After curing, the index is removed and the denture is finished and polished.
Similar principles are applied in replacing posterior teeth on complete
denture. Care must be taken to maintain correct occlusion by reference to the
opposing denture or model of opposing natural teeth.
Repair of lower denture
In a mandibular fracture the parts need to be placed in relation to each
other with great care. The margin of error is greater than with the
maxillary fracture, because the broken surfaces are limited in area.
Complete denture theory and practice Biomechanics of CD 27
Biomechanics of the Edentulous State
Support mechanism for natural teeth
The principal functions of the periodontium are support and positional
adjustment of teeth together with secondary and dependent function of
sensory perception.
PDL
Highly organizedand oriented.
Highly vascularized (three sources).
Highly innervated( touch, pain &pressure).
Contain elastic fibers.
Approximately uniform thickness.
Support mechanism for complete denture
Alveolar mucosa
Uneven thickness.
Uneven attachment &resiliency.
Less vasularization &innervations.
Diminished proprioceptive nerve endings.
Reduced elasticity.
Viscoelastic behavior of the alveolar mucosa
Oral mucosa is displaced under load about 10 times more than the periodontium.
mucosa has less elasticity than the PDL
Alveolar bone
Receive vertical, diagonal& horizontal loads.
Their quality differ according to location.
Undesirable and irreversible bone loss.
Factors influences mucosal support
Total surface area: 22.96 cm2 edentulous maxilla

12.25 cm
2
edentulous mandible
45 cm
2
PDL
Tolerance and adaptability: reduced by systemic and metabolic disease.
Masticatory loads: 44Ib(20 kg) natural teeth
13 to 16 Ib(6 to 8) complete denture.
Functional and parafunctional considerations
Functional: occlusion
mastication& swallowing
mandibular movements
Parafunctional: previously found
denture induced
RETENTION OF COMPLETE DENTURE
Definition:
It is a quality inherent in the prosthesis acting to resist the forces of dislodgement along
the path of placement. resistance of a denture to vertical movement away from the tissues
Factor involved in the retention of the denture
1. Physical factors
Interfacial surface tension force
Adhesion
Cohesion
Atmospheric pressure:
Gravity
Capillarity or Capillary attraction
2. Anatomic factors
Ridge form
Vault form
Arch form
Arch relation:
Interarch distance
Oral and facial musculature
Undercuts, rotational insertion paths,
and parallel walls
Maximum coverage of basal seat area
3. Mechanical factors
Balanced Occlusion
Contour of the polished surfaces
Position of the occlusal plane
Position of teeth in respect to the alveolar ridge
Inclination of the teeth labiolingualy at the incisal edge
4. Physiological factors
o Saliva o Neuromuscular control
5. biological factors
o Intimate tissue contact
o Peripheral seal. posterior
palatal seal
o Lingual flange area.
6. Psychological factors
o patient tolerance o Patient education.
7. Surgical factors
o Vestibuloplasty
o Zygomaticoplasty
o Tuberoplasty
o implant
8. Aids to retention
Factors involved in the retention of dentures:
I- physical f act or s
1- Adhesion
Definition: It is the physical attraction of unlike molecules for each other.
Adhesion of saliva to the mucous membrane and the denture base is achieved through
ionic forces between charged salivary glycoproteins and surface epithelium or acrylic
resin.
Another version of adhesion is observed between denture bases and the mucous
membranes themselves, which is the situation in patients with xerostomia.
The denture base materials seem to stick to the dry mucous membrane of the basal seat
and other oral surfaces. Such adhesion is not very effective for retaining dentures, and
predisposes to mucosal abrasions and ulcerations due to the lack of salivary lubrication.
Treatments of denture patient with xerostomia: see complaint.
The amount of retention provided by adhesion is proportionateto the area covered by the
denture. Therefore the adhesion in the mandibular denture is less than in maxillary
denture.
Darvell claimed that Adhesion ordinarily means some specific chemical interaction
across the interface of two solids .This has never been claimed for dentures, there
being no known mechanism for a direct acrylic-mucosa reaction that would achieve
this. Even so, the concept is frequently expressed in the denture retention field so
vaguely as to be useless. B D J , 189, NO. 5, SEP 9 2000
2- Cohesion
Definition: It is the physical attraction of like molecules for each other.
Normal saliva is not very cohesive, so that most of the retentive force of the denture-
mucosa interface comes from adhesive and interfacial factors unless the interposed saliva
is modified (as it can be with the use of denture adhesive).
It is effective in direct proportion to the area covered by the denture.
Darvell claimed that Cohesive failure means the separation of molecules within the
body against inter- or intramolecular forces. Such strengths are high. It has never been
claimed that a denture has failed to be retained because of such a breakdown. The
formation of bubbles in a saliva film would certainly cause loss of retention, but the
effect is caused by the ease of their flow, not the loss of cohesion.
The cohesive strength of saliva is much greater than the adhesion of mucosa to PMMA.
B D J , 189, NO. 5, SEP 9 2000
3- Interfacial surface tension force
Definition: it is the resistance to separation of two parallel surfaces that is imparted by a
film of liquid between them.
Interfacial force dependent on: the ability of the fluid to "wet" the rigid surrounding
material.
If the surrounding material has low surface tension, as oral mucosa does, fluid will
maximize its contact with the material, thereby wetting it readily and spreading out in a
thin film. If the material has high surface tension, fluid will minimize its contact with
the material, with the result that it will form beads on the material's surface.
Interfacial surface tension is dependent: on the existence of a liquid interface at the
terminus of the liquid/solid contact:
If the two plates with interposed fluid are immersed in the same fluid, there will be no
resistance to pulling them apart. In many patients, there is sufficient saliva to keep the
external borders of the mandibular denture awash in saliva, thereby eliminating the effect
of interfacial surface tension. This is not so in the maxilla.
Interfacial viscous tension refers to the force holding two parallel plates together that is
due to the viscosity of the interposed liquid.
Depends upon the wettability of two layers
If the material has low surface tension, like oral mucosa, fluid will maximize its
contact with the suface, thereby wetting it completely.
If the material has high surface tension, fluid will minimize its contact with the
material, resulting in formation of beads on the material surface.
Viscous tension is described by Stefan's law.
A two parallel circular plates of a radius r that
Separated by incompressible liquid of viscosity k and thickness h,
Its principle states that the force f necessary to pull the plates a part at a velocity v in a direction
perpendicular to the radius will be
F=Interfacial surface tension
k=Viscosity of the interposed liquid (saliva)
r =Circular plates of radius
h=thickness
V =Velocity
The viscous force varies directly with the viscosity of the interposed fluid.
The viscous force varies inversely with the distance between the plates (i.e., the thickness of the
interposed medium).
It is varies directly with the square of the area of the opposing surfaces.

When applied the equation to denture retention, we need that
1- Minimized the distance between denture and basal seat (h),
2- maximizing the surface area covered by the denture (r),
3-the theoretical improvement in retention made possible by increasing the viscosity of
the medium between the denture and its seat.
It also explains why a slow displacing action, a (small V) may encounter less resistance and,
therefore, be more effective at removing a denture than is a sharp attempt at displacement (large
V).
4- Atmospheric pressure:
Retention due to atmospheric pressure is directly proportionate to the area covered by
the denture base. it is referred to as emergency retentive force.
For atmospheric pressure to be effective, the denture must have a perfect seal around
its entire border. Proper border molding with physiological, selective pressure techniques
is essential for taking advantage of this retentive mechanism.
This resistance force has been called "suction" because it is a resistance to the removal of
dentures from their basal seat; but there is no suction, or negative pressure, except
when another force is applied suction alone applied to the soft tissues of the oral cavity
for even a short time would cause serious damage to the health of the soft tissues under
negative pressure.
Normal =14.7 b/sq inch.
Factor affects the atmospheric pressure,
- Perfect peripheral seal
- Proper border molding
- Selective pressure technique
Darvell claimed that It is not certain that a true seal of acrylic to mucosa can be
achieved. Under normal conditions, there is no pressure difference, no static retaining
force, and atmospheric pressure as such has no bearing on retention. B D J , 189, NO. 5, SEP 9
2000
5- Gravity
When a person is in an upright posture, gravity acts as a retentive force for the
mandibular denture and a dislodgment force for the maxillary denture.
The weight of a lower- denture. should not exceed 40 gm. In the upper jaw the lighter the
denture, the less the gravitational force moving it away from the tissues.
6- Capillarity or Capillary attraction
It is the quality or state arising due to surface tension causes elevation or depression of
the surface of a liquid that is in contact with a solid .
Capillarity causes a liquid to rise in a capillary tube because in this physical setting the
liquid will maximize its contact with the wall of the capillary tube.
When there is a close contact or adaptation between the denture base and mucosa , a thin
film of saliva tends to flow and increases its surface contact and thus increasing retention.
When the surface of the liquid is elevated when it is contact with a solid so any space
will filled like the action of the capillary tube and increase retention
Factors Aiding Capillary Action
Closeness of adaptation of denture base to soft tissue.
Greater surface of denture bearing area.
Thin film of saliva should be present
To obtain optimum physical retention
1- Area of impression surface
It has been shown the degree of physical retention is proportional to the area of the impression
surface. Therefore, the denture could cover the maximum area of mucosa with functional
muscular activity.
2) Accuracy of fit
Intimate tissue contact is the biologic ,,factor that refers to the close adaptation of the denture
bas to the underlying soft tissues,
3-Border seal is a biologic factor that involves intimate contact of the denture borders with the
surrounding soft tissue. In order to achieve and maintain the seal, the periphery of the denture
must exert a certain pressure on the mucosa.
II- Anat omical f act or s:
1- Ridge form:
A high ridge with flat crest give good support, retention and stability.
Very flat ridges may bear dentures that display strong resistance to displacement
perpendicular to the basal seat, due to interfacial and atmospheric forces. Yet these same
prostheses are very susceptible to movement parallel to the basal seat, analogous to
sliding a suction cup along a pane of glass, or sliding two glass pieces separated by fluid.
2- Vault form:
U shaped palatal vault is the most favorable for retention and stability of complete
denture as it resists vertical and horizontal forces. While the V shaped vault resists the
lateral force but the vertical displacing forces break the seal.
3- Arch form:
The square arch is more favorable for retention than the tapered and ovoid.
4- Arch relation:
In class II and III angle classification the small arch produce a problem with the retention
specially in class II which is less favorable because small surface area of mandible.
5- Interarch distance:
A small interarch distance increase the retention, because the tongue fills the oral cavity,
contacting the palate and lingual surface of the denture providing air tight seal.
6- Oral and facial musculature
The oral and facial musculature supply supplementary retentive forces, provided:
1- The teeth are positioned in the "neutral zone" between the cheeks and tongue.
2- The polished surfaces of the dentures are properly shaped.
Role of check & lips:
If the buccal flanges of the maxillary denture slope up and out from the occlusal
surfaces of the teeth, and the buccal flanges of the mandibular denture slope down
and out from the occlusal plane, the contraction of the buccinators will tend to
seat both dentures on their basal seats.
Roles of the tongue:
The tongue can rest on the occlusal surfaces of the teeth & stabilize the denture, if
placing the occlusal plane of the lower denture below the level of the tongue.
The lingual surfaces of the lower dentureshould slope toward the center of the mouth
so the tongue can fit against them and perfect the border seal on the lingual side of the
denture.
The base of the tongue also may serve as an emergency retentive force for some
patients. It rises up at the back and presses against the distal border of the maxillary
denture during incision of food by the anterior teeth.
7- Undercuts, rotational insertion paths, and parallel walls
The resiliency of the mucosa and submucosa overlying basal bone allows for the
existence of modest undercuts that can enhance retention.
For instance, in a patient who has undergone loss of normal anatomic contours due to
tumor resection or trauma, surgically created relative undercuts beneficial in success the
prosthesis.
8- Size Of denture bearing area.
The polished surface of the dentures is properly shaped For the oral & facial musculature
to be most effective in providing retention for complete denture.
The following condition must be met,
- The denture bases must be properly extended to cover the maximum area possible
without interfering in the health & function of the structure that surrounds the denture.
- The occlusal plane must be at the correct level.
- The arch form of the teeth must be in the neutral zone between the tongue & cheeks.
III Physiol ogical f act or
Saliva:
- Thick, high mucin saliva is more viscous than watery saliva.
- Thick secretion usually do not result in increased retention between watery, serous
saliva can be interposed in a thinner film than more cohesive mucin secretions.
Neuromuscular control
Neuromuscular control refers to the functional forces exerted by the musculature of the
patient that can affect denture retention. This is primarily a learned biologic phenomenon
Mechanical f act or s
Balanced Occlusion
Contour of the polished surfaces
Position of the occlusal plane
Position of teeth in respect to the alveolar ridge
Inclination of the teeth labiolingualy at the incisal edge
Biol ogical Fact or s
Peripheral seal
Peripheral seal is the area of contact between the peripheral
borders of denture and the resilient limiting structures.
This includesposterior palatal seal as well as all \labial, buccal and lingual vestibules.
Peripheral seal prevents entry of air between denture surface and soft tissue. Thus a
low pressure is maintained within the space between denture and soft tissue.
To achieve a good peripheral seal -
Denture borders should rest on soft and resilient tissues.
Retention produced by an atmospheric pressure is directly proportional to
denture base .
Intimate tissue contact
PSYCHOLOGIC FACTORS
- As patient tolerance
- Patient education.
AIDS OF RETENTION
1- DENTURE ADHESIVES
Denture adhesive is used to refer to a commercially available, nontoxic, soluble material
(powder, cream) that is applied to the tissue surface of the denture to enhance denture
retention, stability, and performance.
Denture adhesives are classified according to manufacturing type, i.e., powder, paste,
tape or cushion.
Soluble denture adhesives such as the powder and paste types do not damage the soft
tissues. Soluble denture adhesive cannot be abused to the extent of changing vertical
dimension, since they rapidly absorb water becoming gelatinousand spreading over the
denture through chewingstress.
denture adhesive contributes to reducing denture movement and therefore to improving
chewing function.
mechanism(s) of action
They enhance retention through optimizing interfacial forces by
Increasing the adhesive and cohesive properties and viscosity of the
mediumlying between the denture and its basal seat and
Eliminating voids between the denture base and its basal seat.
The hydrated material is formed when an adhesive comes into contact with saliva or
water.
Components
Denture adhesive materials in use prior to the early 1960s were based on vegetable gums
such as karaya, and acacia that display modest, nonionic adhesion to both denture and
mucosa, and possessed very little cohesive strength. The adhesive performance of the
vegetable gum based materials is short lived and relatively unsatisfactory.
Synthetic materials presently dominate the denture adhesive market.
1- The most popular and successful products consist of mixtures of the salts of short-acting
(carboxymethylcellulose, or CMC) and long-acting (i.e., less soluble) (poly [vinyl methyl
ether maleate], or "gantrez") polymers.
In the presence of water, CMC hydrates and displays quick-onset ionic adherence to both
dentures and mucous epithelium. The original fluid increases its viscosity and CMC increases in
volume, thereby eliminating voids between prosthesis and basal seat. These two actions
markedly enhance the interfacial forces acting on the denture.
2- Plyvinylpyrrolidone ("povidone") is another, less commonly used agent that behaves like
CMC. Over a more protracted time course than necessary for the onset of hydration of
CMC, gantrez salts hydrate and increase adherence and viscosity. Eventually, all the
polymers become fully solubilized and washed out by saliva; this elimination is hastened
by the presence of hot liquid.
Some objective and subjective responses to denture adhesive
Prior 1990, a few of denture adhesive contain very low levels of benzene, which is
regarded as a carcinogenic. Today's adhesives are either free of benzene or contain
trace amounts believed to be harmless.
Some patients object to the "grainy" or "gritty" texture of powder, or to the taste or
sensation of semi dissolved adhesive material that escapes from the posterior and
other peripheries often due to use of excessive quantity or use in an inadequate
prosthesis.
Others object to the difficulties encountered in removing adhesive from the denture
and the oral tissues, as well as to the cost of the material.
Indications and contraindications
Denture adhesives are indicated when well-made complete dentures do not satisfy
a patient's perceived retention and stability expectations.
Patients who suffer from xerostomia, the useof denture adhesive can compensate
for the retention that is lacking in the absence of healthy saliva, and can mitigate
the onset of oral ulcerations that result from frequent dislodgments.
Xerostomic patients must be moistened the adhesive bearing denture (e.g., with
water from the tap) before it is seated in the other-wise dry mouth to initiate the
actions of the material.
Some neurological diseases as Cerebrovascular accident (stroke) can complicate
the use of complete dentures, but adhesive may help to overcome the
impediments imposed. The stroke may lead to partially or wholly paralyze oral
musculature.
Patient, who has undergone loss of normal anatomic contours due to tumor
resection or trauma, may havesignificant difficulty in functioning with a tissue-
borne prosthesis unless denture adhesive is employed, even if rotational undercuts
have been surgically created to resist displacement of the prosthesis.
Contraindication
- Retention of improperly fabricated prosthesis
- Poorly fitting prosthesis
Patient education:-
- It is necessary for the dentist educate the patient with denture
about denture adhesive- They are use abuse, advantages,
disadvantages & choices.
- Choices between cream & powder largely subjective - Effect of
the powder formulation is not last as effect of cream formulation.
- Powder used in small quantity, it is to clean out denture& tissues.
- Powder cream products there is appro. 0.5 to 1.5 g per denture
unit material should be used.
- For powder sprayed denture should cleaned & then moistened lightly with water
being inserted...
- For cream two approaches are possible
- Patient must be instructed that daily removal of adhesive product from tissue
surface of the denture.
- Patient need to be educated about the limitations of denture adhesives.
- Pain& soreness signals a need for professional management.
- Denture patients need to be recalled annually for oral mucosal evaluation &
prosthesis assessment.
Comparison between cream and powder adhesive materials
POWDER CREAM
1-holding
2-time of action
3-quantity to be used
4- cleaning
5-initial holding
-Less than cream
-Less than cream
- Small quantity
- Easy clean
- Sooner than cream
-More than powder
-More than powder
- More quantity than powder
- More difficult
-Slower than powder
To obtaining the greatest advantage from the use of an adhesive product it should
be proper used as the following:
1- For powder and cream products, the least amount of material that is effective
should be used. This is approximately 0.5 to 1.5 g per denture unit.
2- For powders, the clean prosthesis should be moistened and then a thin, even
coating of the adhesive sprayed onto the tissue surface of the denture.
3- If the patient suffers from inadequate or absent saliva, the sprayed denture should
be moistened lightly with water before being inserted.
4- For creams, two approaches are possible.
a- Most manufacturers recommend placement of thin beads of the adhesive in
the depth of the dried denture in the incisor and molar regions, and, in the
maxillary unit, an anteroposterior bead along the midpalate.
b- However, more even distribution of the material can be achieved if small
spots of cream are placed at 5-mm intervals throughout the fitting surface
of the dried denture.
5- As with powders, use of denture adhesive cream by the xerostomia patient
requires that the adhesive material be moistened with water prior to inserting the
denture.
6- Patients must be instructed that daily removal of adhesive product from the tissue
surfaces of the denture.
Powder leads to faster retention and easily cleaning. Cream lead to more hold of the
denture to more longer time.
Removal of adhesive material
a-From the dentures: It is facilitated by letting the prosthesis soak in water or soaking
solution overnight, during which the product will be fully solubilized and can then be
readily rinsed off. If soaking is not possible before new adhesive material needs to be
placed, removal is facilitated by running hot water over the tissue surface of the denture
while scrubbing with a suitable hard-bristle denture brush.
b-From the mucosa: It is best removed by rinsing with warm or hot water, and then
firmly wiping the area with gauze or a washcloth saturated with hot water.
2- Vacuum devices:
A- Suction chamber:
It is like relief but it differs from it with its definitive border. When the denture is
inserted the patient created a partial vacuum in the chamber by sucking and
swallowing. This area of reduced pressure helps to keep the denture in place.
B- Rubber suction disc (sucker):
It consists of rubber disc which is buttoned on to a stud into the fitting surface of
the denture. It is unhygienic, and lead to pathological conditions like perforation
of the palate or malignancy.
C- Microvalve
It is created by provision of channel in impression surface of the denture. it need
efficient border seal .
Micro valves are designed so that the patient can suck saliva from between
denture and tissues and so reduce the film thickness.
the mucosa may proliferate into the suction channel.
D- Suction cup denture
A large number of small suction cups formed from a soft,
resilient silicone rubber are processed in an conventional denture
for enhancing the retention and stability of dentures.
They grip the oral tissue without causing any pathosis returns. The tissue tends to
temporarily assume the form of the cups, but then returns to normal when the
dentures are removed.
Indications
o Many patients have extremely resorbed ridges and cannot master the use
of dentures, let alone retain these prosthetic appliances in their mouths.
o This "Multi-Cup" technique (multiple suction cups) addresses their
problem, as well as knife-edge or flat ridges, and can be made with or
without palates.
Contraindications
o allergic reactions to the silicone liners.
o presence of moniliasis in the mouth. If possible, this organism should first
be eradicated, because the available silicone liners act as a propagating
media for fungal growth.
o physical tissue irritation may be caused by excessive suction cup height.
These sore spots are easily treated, by trimming off part of the offending
cup, using a modified nipper.
3- Springs:
It is a mechanical aid to push the denture toward the arch. Coil
spring can be attached to the denture at the premolar areas.
are made of coiled stainless steel, or gold plated base metal or
nylon. The springs are attached to the buccal flanges of upper and lower dentures in the
premolar regions.
4- Magnets:
Small magnets are imbedded beneath the molar and premolar teeth of the upper and lower
dentures and arranged with similar poles opposite each other.
5- Surgical interference:
a- Ridge augmentation
b- Deepening the sulcus
c- Using dental implant
d- Palatal Anchorage for the Retention of Interim Removable Prostheses
It is a technique that involves the use of palatal implants
to retain a maxillary interim prosthesis when extensive
bone graft procedures are performed.
The rationale is that some bone graft procedures require
the removal of the denture flanges for graft success.
Once the denture flanges are removed, the denture loses
all its retention capabilities, making this lengthy interim
phase difficult for the patient.
J ournal of Prosthodontics 18 (2009) 698702
STABILITY OF COMPLETE DENTURE
Stability is "The quality of prosthesis to be firm steady or constant, in order to resist
displacement by functional horizontal or rotational stresses".
Denture stability "is the resistance of a denture to movement on the denture foundation
area".
FACTORS AFFECTING STABILITY OF COMPLETE DENTURES:
I- Int r a-or al f act or s:
A number of intra-oral factors influence the quality of complete denture stability in relation to
the basal seat area these are:
1- Ridge form:
Residual ridges with flat crests and parallel or nearly parallel sides resist lateral forces
and enhance denture stability, while flat ridges offer minimal resistance to lateral stresses
reducing denture stability.
2- Arch form:
Square arch form provides the most favorable prognosis for denture stability; on the
contrary ovoid arch form is the least favorable condition.
3- Vault form:
The shape of the vault of the palate affects the stability of maxillary denture. The two
extremes, very flat, and very high V-shaped palatal vaults present difficulties in denture
stability, while a moderately high, broad palate offers better stability.
4- Vertical height of the residual ridge
A parallel well rounded vertical ridge form offers better stability than resorbed
ridge.
4- The mucosa supporting the prosthesis:
Mucosa of even, medium thickness (2-3 mm), composed of dense fibrous connective
tissue, and which is firmly attached to the underlying bone offers the most favorable
prognosis.
This nature of supporting mucosa prevents the denture and mucosa from moving together
in relation to the underlying supporting bone and serves as a cushion absorbing the forces
created by the denture.
If the oral mucosa is thin, ulcerations and sore spots are more likely to occur in the basal
seat area. On the other hand, thick flabby tissues, contribute to excessive vertical and
horizontal movements, reducing the stability of the denture. In such condition, it is
desirable to reduce these tissues surgically to gain a more stable denture bearing area.
5- Interarch distance:
A small interarch distance in contrast to large interarch distance, enhances stability as, the
occlusal surfaces of teeth are closer to the ridge, minimizing undesirable leverage action
and tongue forces.
6- The tongue:
The size, form and function of the tongue influence denture stability. Small narrow
tongue or extremely large tongue adversely affect denture stability, while broad thick
tongue enhances denture stability.
II- Mechanical f act or s:
A number of mechanical factors influence the quality of complete denture stability:
1- Position of posterior teeth: Posterior teeth are generally placed to enhance stability of
the mandibular denture.
i- Buccolingually, the teeth should be placed over or slightly lingual to the crest
of the mandibular ridge, however the lingual surface of the teeth should not
exceed the medial extension of the mylohyoid ridge, to provideenough space for
the tongue to move freely. Encroaching upon the tongue space, causes cramping
of the tongue, and lateral movement of the denture whenever the tongue moves.
ii- Anteroposteriorly, the teeth should never be positioned on the upward incline
of the mandible. Forces directed to an inclined plane are more dislodging than
forces directed at right angle to the supporting basal seat.
2- Lower occlusal plane:
i- Height of the lower occlusal plane should coincide with a line extending from
or slightly below the comers of mouth anteriorly and the center of retromolar pad
posteriorly. This position usually places the occlusal plane below the greatest
convexity of the tongue. This position allows the tongue to function in co-
ordination with the buccinator muscle to keep the food on the occlusal surface of
the teeth, and aid in lower denture stability.
ii- Direction of the occlusal plane: the plane of occlusion should be parallel to the
main direction of the denture foundation area, thus the masticatory biting forces
are perpendicular to the supporting basal seat, minimizing undesirable lateral
forces.
3- Shape of the denture polished surface: The denture polished surface should be
properly contoured so that, the tongue, cheek and lips seat rather than unseat the dentures.
4- Proper relief of the upper denture: The tissue covering the median palatine suture is
usually thin and non displaceable, acting as shifting fulcrum around which the upper
denture can rotate. Sufficient relief of the upper denture over the median palatine suture
to compensate for different degree of tissue displaceability, improve upper denture
stability.
5- Balanced occlusion: Balanced occlusion in dentures means even simultaneous contact
between upper and lower teeth in centric and eccentric position that is in harmony with
various mandibular movements. Occlusion is said to be balanced when there is at least
three widely separated points of occlusal contact in any lateral or protrusive position,
such contact stabilizes dentures on their basal seat. Uneven premature occlusal contact
adversely affects denture stability.
6- Quality of impression
An impression should be accurate& should duplicate all the details without any voids.
The impression should make of dimensionally stable materials & should poured
immediately
SUPPORT
Definition:
The resistance to vertical forces of mastication, occlusal forces & other forces applied in a
direction towards the denture bearing area.
- Maximum coverage provides the snowshoe effect which distributes applied forces over wide
an area as possible.
- Confining the occlusal forces to stress bearing areas & reliving the non stress bearing areas
will aid to improve support
Factors affecting stability & support
(1) Maximum coverage of the basal seat within the limit of the heath & functions of the
supporting &limiting tissues.
(2) Borders that are in harmony with anatomic & physiological limitations of the oral structures.
(3) A physiologic type of border moulding procedure
(4) Proper space ensured in tray for final impression material.
(5) Selective pressure technique for final impression.
(6) Ideal impression material to be used depending on clinical situation.
(7) A guiding mechanism for correct positioning of the impression tray in the mouth.
(8) The tray& final impression should be of dimensionally stable materials.
(9) The completed final impression form is similar to the external form of the completed denture.
(10) Accurately fitting final impression tray.
Pr obl ems of compl et e dent ur e r et ent ion, suppor t & st abil it y
See complaint
Complete denture theory and practice Concept of Neutral Zone28
Concept of Neutral Zone
Definition;
The neutral zone is that area in the potential denture space where the forces of tongue pressing
outward are neutralized by the forces of the cheeks and lips pressing inward; i.e. the potential
space between lips or cheeks and tongue. In this zone the natural
teeth lies, and the implants should be positioned.
Since these forces are developed through muscular
contraction during the various functions of chewing,
speaking, and swallowing, they vary in magnitude
and direction in different individuals.
Creation of neutral zone:
During childhood, the teeth erupt under the influence of muscular environment
created by forces exerted by tongue, cheeks and lips, in addition to the genetic factor.
These forces have a definite influence upon the position of the erupted teeth, the
resultant arch form, and the occlusion.
Generally, muscular activity and habits which develop during childhood continue
through life and after the loss of teeth, it is important that the artificial teeth beplaced
in the arch form compatible with these muscular forces.
Objectives: Positioning the artificial teeth in the neutral zone achieves two objectives. First, the
teeth will not interfere with the normal muscle function and second, the forces exerted by the
musculature against the denture are more favorable for stability and retention.
Uses of the neutral zone:
1- Setting up of teeth.
2- Contouring the polished surface.
3- Determination of the occlusal plane.
History:
Historically, different terminology has been loosely associated with this concept,
including dead zone, stable zone, zone of minimal conflict, zone of equilibrium, zone
of least interference, biometric denture space, denture space, and potential denture
space.
Sir Wilfred Fish first described the influence of the polished surfaces on retention and
stability in 1931. He also described how dentures should be constructed in the dead
space, which later became know as the neutral zone.
Since that time many techniques described to provide a molding of the neutral zone.
These involved the use of a soft, mouldable material (usually wax or compound) being
placed in the mouth with patients performing actions with their lips and tongues, the idea
being to capture in greater detail the actions of the lips, cheeks and tongue.
These actions determine the tooth position and the shape of the polished surfaces. The
aim is to produce a denture moulded by muscle function that is in harmony with its
surrounding structures and so enhancing stability and retention.
Importance of Neutral Zone
1- The aim of the neutral zone is to construct a denture in muscle balance. denture is in
harmony with its surroundings to provide optimum stability, retention and comfort.
2- As the area of the impression surface decreases (due to alveolar ridge resorption), less
influence it has on the denture retention and stability.
3- It is most effective for patient withatrophic ridge and a history of denture instability.
4- Used for patients who have had a partial glossectomy, mandibular resections or motor
nerve damage to the tongue which have led to either atypical movement or an
unfavorable denture bearing area.
5- For patient with an altered denture space caused by disease, trauma, or burns,
consideration should be given to a physiologic approach to obtain denture stability.
6- When retention and stability become more dependent on the correct positioning of the
teeth andcontours of external or polished surfaces of the dentures. forces applied by the
peridenture muscles should act to seat the denture.
Advantages:
Improved stability and retention
Posterior teeth will be correctly positioned allowing sufficient tongue space
Reduced food trapping adjacent to the molar teeth
Good aesthetics due to facial support.
Prevent lip, cheek biting.
The Neutral-Zone Philosophy
`The Neutral-Zone Philosophy is based upon the concept that:
For each individual, there exists within the denture space a specific area where the
function of the musculature will not unseat the denture & where forces generated
by the tongue are neutralized by the forces generated by lips and cheeks.
The artificial teeth should not be placed on the crest of the ridge or buccally or lingually
to it rather these should be placed as dictatedby the musculature.
The objectives achieved by this approach are,
a) The teeth will not interfere with the normal muscle function,
b) The forces generated by these muscles against the denture, especially for the
resorbed lower ridge, are more favorable for stability & retention.
The Potential Denture Space
The central thesis of the neutral zone approach to complete dentures is to locate that
area in the edentulous mouth where the teeth should be positioned so that the
forces exerted by the muscles will tend to stabilize the denture rather than unseat
it. The soft tissues that form the internal and external boundaries of the denture space
exert forces which generally influence the stability of the dentures.
Mechanism of action;
We are very familiar with the impression and the occlusal surfaces of the denture. The
third surface as termed by Fish, the polished surface is the rest of the denture.
The external or polished surface of the denture is in contact with the cheeks, lips, and
tongue. One can visualize that, per square unit of area, the polished surface can be as
large as or larger than impression and occlusal surfaces combined, depending on
anatomic structure. As the area of the impression surface decreases and the polished
surface area increases, tooth position and contour of the polished surface become more
critical.
With the neutral-zone concept, the impression surface is called the base and the polished
surface is called the body of the denture.
The forces exerted on the external surfaces of the teeth and the polished surfaces are
essentially horizontal. When the occlusal surfaces of the teeth are not in contact, the
stability of the denture is determined by
the fit of the impression surface and
Thedirection and magnitude of forces transmitted through the polished surfaces.
The influence of the lip on stability of the lower denture becomes more critical as
resorption of the ridge increases or as the patient ages. The force of the lower lip against
the anterior surface of the denture and the anterior teeth will cause the denture to rise
unless the teeth and flange are properly positioned and contoured. When the mouth is
closed, the denture may remain stable. However, as soon as the mouth opens, the lower
lip is like an elastic band pressing against the anterior flange and teeth. The wider the
mouth is opened, the tighter the band.
Lammie has shown that as the alveolar ridge resorbs, the ridge crest falls below the origin
of the mentalis muscle. As a result, the muscle attachment folds over the alveolar ridge
and come to rest on the superior surface of the ridge crest. The result is a posterior
positioning of the neutral zone and, with it, the need to place the lower anterior teeth
further lingually than had been the position of the natural teeth.
We all have had the experience of inserting a lower denture which moves upward as soon
as the patient opens his mouth or starts to speak. The first assumption is usually that the
denture is overextended so that the denture periphery may be reduced. However, no
matter how much the base is reduced, it still pops up. It is not the denture base that is the
cause for denture instability but, rather, the body of the denture that is, the tooth
position and the flange form which was erected on top of the denture base.
Muscles involved in the Neutral Zone
1. Those muscles which primarily dislocate the denture during activity (Dislocating
muscles),
2. Those muscles that fix the denture by muscular pressure on the polished surfaces
(Fixing muscles).
Each group can then be further divided according to their location on the vestibular (labial &
buccal) side or lingual side of the dentures.
Dislocating muscles
Vestibular: Masseter, Mentalis, Incisive Labii Infer.
Lingual: Medial Pterygoid, Palatoglossus, Styloglossus, Mylohyoid
Fixing muscles
Vestibular: Buccinators, Orbicularis oris
Lingual: Genioglossus, Lingual longitudinal, lingual vertical, lingual transverse
a: Lev. lab. sup. Alaeq. nasi b: Lev. labii superioris c: Orb. oculi
d: Zygomaticus minor e: Zygomaticus major f: Risorius
g: Platysma h: Dep. anguli oris i: Dep. lab. inf
j: Mentalis k: Orbicularis oris l: Incis. lab. inf
m: Masseter n: Buccinator o: Lev. ang
The main displacing forces acting on a lower complete denture are the tongue, the lower lip
and the modulus. If the denture is placed in the zone that balances these displacing forces, then
the denture will be retained more effectively during function.
Neutral Zone versus Biometrics
Neutral Zone concept for the placement of artificial teeth could not enjoy the universal approval,
as did the Biometric concept of tooth arrangement. The reasons for this limited success are
numerous, e.g.,
1. The viscosity of the material used for obtaining this impression is critical. More viscous
the material, more it will be difficult for the muscles to mold it and visa versa.
2. The geriatric patients could suffer difficulty during the procedure as their musculature may
have lost the tone.
3. The stability and retention of the bases on the soft denture support must be excellent as
well asthe comfort.
4. The resultant neutral zone is often narrow and more lingually placed - with the closed
mouth technique, the tongue could not perform all the functional movements, such as the
phonetics.
5. This technique does not offer any guidelines for the selection of the teeth.
6. The technique is troublesome for the patient and does not offer much advantage over the
biometric guides for the arrangement of teeth.
Stages of the neutral zone impression
Reversed sequence in denture construction
With the neutral-zone approach to complete dentures, the sequence in denture
construction is reversed. Individual trays are constructed first. These trays are
very carefully adjusted in the mouth to be sure that they are not overextended and
remain stable during opening, swallowing, and speaking. Next, modeling
compound is used to fabricate occlusion rims. These rims, which are molded by
muscle function, locate the patients neutral zone. After a tentative vertical
dimension and centric relation have been established, the final impressions are
made with a closed-mouth procedure.
1. Primary impressions
2. Secondary impressions
3. Assessing the base plates and recording the occlusion
4. Assessing upper wax try-in, the superstructure and OVD
5. Neutral zone impression
6. Wax try-ins
7. Finish and check record.
The primary impressions are taken in a stock tray with a mucodisplacive material such
as impression compound or a high viscosity alginate.
The lower secondary impression is taken in a close-fitting special tray with a low
viscosity mucostatic such as a zinc oxide eugenol.
The impression surface of the denture must be correctly extended to provide the maximum
support from the underlying structures. The borders must be moulded to represent muscle
activity, recordingthe functional depth and width of the sulcus.
The wax record rims are constructed on heat cured acrylic bases for increased stability,
and assessed for extension, comfort and stability. Once the base plates have been
assessed and modified, jaw registration can be carried out.
The upper rim should be carved to provide support for the musculature labially and
buccally. It is vitally important that the record rim is correctly trimmed to the full width
of the sulcus; otherwise the correct width of the lower arch cannot be developed.
After establishing the correct incisal level, occlusal planes and palatal contour, the
lower rim is adjusted to the correct occlusal vertical dimension (OVD). The rims can
now be registered in the retruded arc of closure.
The laboratory can now articulate the rims on an average value articulator and
construct the upper wax try in and lower base plate.
The wax is removed from the heat cured base plate and a superstructure is
constructed.
The superstructure has two functions: to provide even occlusal stops at the correct OVD and to
provide support for the NZ impression material. Numerous designs have been proposed and the
final decision is one of clinical preference.
Favored designs include self-cured pillars in the premolar regions with a short vertical fin
between them or a light cured vertical fin along the centre of the base plate. Whichever design is
used it must be assessed in order that the structure does not deflect the cheeks, lip or tongue and
that the desired OVD is maintained.
The stops and fins can be modified with self-cured acrylic or greenstick
tracing compound until the correct dimensions are produced.
Prior to taking the NZ impression the upper wax try-in is inserted.
This will support the facial muscles and allowthe tongue to be positioned on the teeth
and palatal contours during function.
The NZ impression see later. Setting the artificial teeth and once the wax try-in is
deemed satisfactory the dentures may be processed and finished
Instructions must be given to the technician to polish the denture lightly so that the contours
remain unaltered.
On final insertion the dentures are fully inspected and a check record performed to
eliminate any minor occlusal errors. The dentures should provide the patient with
improved facial appearance, stability and retention during function as they have been
constructed in harmony with their surroundings.
Base and body of t he dent ur e
It is important to understand the rationale behind the reversal of the usual steps in
complete denture construction. The premise is that we should separate the denture base
from the body of the denture.
With the neutral-zone concept, the impression surface is called the base and the
polished surface is called the body of the denture. In the past, we did not orient our
thinking in this direction, and as a result, we were less aware of the problems and their
solutions.
Different Neutral Zone techniques
Impression trays
Different designs of Impression trays. injecting the Alginate into the Denture
space Impression tray is stabilized by biting.
Material:
It is necessary to use material that can be moulded by the horizontal forces
from the tongue, lips, and cheeks. These materials are:
1- Modeling compound.
2- Soft or extra soft wax.
3- Medium body rubber base.
4- Alginate.
5- Tissue-conditioning material.
Techniques
Many techniques have been suggested using the previously described materials in
conjunction with movements including sucking, grinning and whistling, and pursing the
lips.
Articulation & Set-up of teeth Alginate impression acts as the index for tooth position
Replacing Impression material with Wax rim setting the teeth with a plaster index
First technique
The NZ impression requires a material that can be moulded by muscle activity. A high
viscous mix of Viscogel which is a tissue conditioner is advocated for the impression.
The mix is placed along the base plate and superstructure.
The volume of the material should be controlled and kept to a
minimum so that the sulci are not distorted. The material is
mixed so that it can be manipulated by hand and positioned as
an approximate rim on the lower base plate.
Before taking the impression the patient should be in a
comfortable, upright position with the head supported.
The plate is then rotated into the patients mouth and they are
asked to perform a series of actions designed to simulate
physiological functioning. These actions will need to be
rehearsed so that they are performed naturally and effectively.
Suggested actions include asking the patient to: smile, grin, pout/purse lips, count
from 60 to 70, talk aloud, pronounce the vowels, sip water, swallow, slightly
protrude the tongue and lick the lips.
These actions are repeated for 10 minutes until material has set.
The anterior labial surface shows proclination and the posterior part shows where
the tongue has rested and moulded the rim.
Laboratory procedure
Technicianwill replace NZ impression on master cast, cut locating
grooves and place plaster or a silicone putty index around impression.
Viscogel impression is then removed from e base plate and index
replaced. Indexwill have preserved the space of neutral zone.
Wax can then be poured into the space giving an exact
representation of the neutral zone. Teeth can then be set up exactly
following the index.
During the setting up of the teeth their position can be checked
by putting the index together around the wax try-in.
The posterior teeth invariably have to be trimmed lingually in
order that they are sufficiently narrow.
Once the wax try-in is deemed satisfactory the dentures may be
processed and finished.
Another Neutral Zone Impression Technique
Primary impressions of the upper and lower jaws are taken in impression compound or
impression plaster and the model are poured. On this model upper wax rims and a lower
special tray are constructed.
The special tray is a plate of acrylic adapted to the lower ridge, without
a handle, with spurs or fins projecting upwards towards the upper arch.
These help with retention of the impression material.
The upper wax rim is adjusted as in normal registration for a
complete denture.
The lower special tray is placed in the mouth.
Two occlusal pillars are then built up in self-cured acrylic (e.g. Total)
on opposite sides of the lower arch. These pillars are moulded and
adjusted to the correct height so as to give the usual 3 mm freeway
space. Occlusal pillars have been built up in green stick to the correct
occlusal height
Establishing the correct occlusal height
A thick mix of viscogel is then placed around the rest of the lower
special tray, distally and mesially to the occlusal pillars. The patient is
then asked to talk, swallow, drink some water etc.
After 5-10 minutes the set impression is removed from the mouth and
examined. The viscogel material will have been moulded by the patient's
musculature into a position of balance.
The viscogel rim being moulded within the mouth
A completed viscogel impression
Indices are then constructed in the lab, by surrounding the impression
with plaster.
When the viscogel and the tray is removed, a gutter corresponding to the neutral zone is left
behind. The teeth may then be placed into the neutral zone.
The resulting denture should feel more comfortable and be more stable and retentivebecause the
denture should not interfere with or be displaced by the functions of the lips, cheeks and tongues.
The swallowing/modeling plastic impression compound technique:
Because retention and stability of lower dentures are usually inferior to those of upper
dentures, the location of the neutral zone for the lower dentures only using modeling
compound is described.
This technique locate the neutral zone, using swallowing as the principle modeling
function. Considering that a person swallows up to 2400 times per day, and considering
also that during the entire swallowing sequence teeth come into contact for less than 1
second, it may be concluded that less than 40 minutes of tooth-to-tooth contact occurs per
day during function.
Impressions and jaw relationships are registered in the usual manner. Few
indices are made on the external surface of the tapered base of the lower
model. Another index is made on the tongue area of the lower model. The
lower model is then, lubricated before mounting to facilitate its removal
from the mounting plaster latter on.
1. After mounting, the lower record block is removed and a self curing
acrylic base is constructed over the lower model.
2. Stainless steel wire loops are attached to the acrylic base over the crest of
the ridge.
3. .Impression compound is softened and attached to the acrylic base to make
an occlusion rim. The acrylic base with the softened compound is then,
placed into the mouth and the patient is instructed to swallow, sip, smile,
raise and protrude the tongue and also to move it from right to left.
4. After hardening and removal from the mouth, excess compound is removed
and soft compound is added to the deficient parts. The procedure is
repeated until a good molded compound rim is obtained.
5. The lower acrylic base with the molded compound is returned to its place
on the mounted lower model. High interfering parts of the molded
compound are trimmed to allow the incisal pin to touch the incisal guide
table again.
Recorded neutral zone after adjustment of the vertical height.
The lower model with the acrylic base and the molded occlusion rim are
removal and lubricated. External and tongue matrices are built to the height
of the pre determined occlusal plane, using putty rubber base material .
Four circular holes on buccal surface and grooved cross indices on tongue area of lower
cast
Putty rubber base material used to make the external and tongue matrices.
The acrylic base and the compound occlusion rim are removed and the
neutral zone space is maintained by the rubber base matrices.
The neutral zone space was determined by the rubber base matrices.
A trial denture base and modeling wax occlusion rim are constructed on the
lower model. The matrices are then used for positioning the artificial teeth
in the neutral zone (Fig.10). For shaping the polished surfaces of the waxed dentures. Zinc oxide
and eugenol paste is applied over the polished surface of the trial denture base and inserted into
the patient's mouth. The patient is asked to make different expressional
muscular movements for molding procedure.
Teeth set up within the neutral zone space.
External impression of the polished surface of the trial denture.
N.B. Recording of neutral zone using other materials and techniques
are based on the same principles discussed before.

The phonetic technique
The molding of the phonetic neutral zone (PNZ) was developed progressively. One lateral
segment was molded first (right or left), then the other lateral segment; and, finally, the
anterior segment.
The custom tray was seated on the edentulous ridge, and 5mL of tissue- conditioning
material mixed in a 1:1 ratio were injected with a syringe on the right lateral segment of the
tray after the tongue was moved aside with a mirror.
The subject was asked to pronounce the phoneme SIS 5 times followed by the phoneme
SO once. Both sounds had to be pronounced clearly, loudly, and vigorously to induce
sufficient muscle contraction. This phonetic sequence was repeated until the material had
polymerized.
The tray was removed from the mouth, and excess tissue-conditioning material extending
anterior to the premolar area was removed with scissors.
The tray was reinserted intraorally, and the same procedure was repeated to mold the left
lateral segment of the PNZ. Then the right lateral segment that was molded initially was
removed from the tray and remolded because the first impression was not considered reliable
due to the fact that the first contact of the tongue with the soft material might be constrained,
as the tongue would try to avoid this initial contact.
Finally, the tray was reinserted and molding of the PNZ was completed by injecting material
in the anterior region and having the subject pronounce successively the phonemes DE, TE,
ME, PE, SE vigorously, until the polymerization of the material was complete.
The occlusal plane was then located according to the height of the lower lip at rest anteriorly,
the commissures laterally, and to a point located approximately two thirds of the height of the
retromolar pad posteriorly. Excess tissue-conditioning material was removed with scissors.
Using sandpaper, the occlusal surface of the resulting impression was leveled.
The buccal and lingual median lines were determined intraorally according to the sagittal
mid-face line and recorded first on the PNZ impression, and then on the subsequent cast.
The swallowing technique
Modeling plastic impression compound (Green Impression Compound
Type 1) was softened in a preheated water bath at 57C. Water
temperature was controlled with a thermometer. The soft material was
adapted to the tray and formed into the shape of an occlusion rim.
The modeling compound was reheated for 2 minutes in the water bath, and the tray was
carefully placed in the subjects mouth without distorting the rim.
The subjects were instructed to swallow and then purse the lips as in sucking, several times.
To make swallowing easier, 1 mL of warm water was injected intra-orally before each
swallow.
After the material cooled, the tray was removed from the mouth and excess compound forced
to an excessive height was trimmed away with a knife. The procedure was repeated as many
times as necessary to perfect the impression accordingto the swallowing neutral zone (SNZ)
technique. Impression was deemed satisfactory when 2 successive impressions produced
similar shapes.
The occlusal plane was then located as previously mentioned in PNZ impression. Using
sandpaper, the occlusal surfaceof the molded compound rim was leveled.
Recording Neutral Zone for a Single Complete Denture
Occlusal stops established intra-orally and retentive wire added to the special tray
Slow setting medium viscosity silicone impression material is coated on all the surfaces.
After inserting the tray, patient is advised to smile, swallow and to produce vowels, ooh,
ah, until the material is set.
Denture space Impression after removal from the mouth its appearance is totally un-
conventional.
Any evidence of large areas of air entrapment, insufficient or excessive volume of
impression material, or tray showing through necessitates re-taking the impression.
The Poured Denture space Impression Four matrices are required to record the buccal,
labial, lingual & ridge contours
The impression seated on the ridge matrix (with the buccal, labial and lingual matrices
removed) is mounted against the upper cast on the articulator.
Silicone impression is then removed; buccal and labial matrices (surfaces) are replaced.
Softened wax is then placed in the space for setting the lower teeth for wax try- in.
The Waxed Trial Denture the soft tissue contours are carefully developed without altering
the basic contours of the recorded impression.
The routine assessments are conducted at the trial insertion, with special emphasis on the
stability of the denture.
Using the neutral zone to obtain maxillomandibular relationship records for
complete denture patients
Correct determination of the OVDand the CR position is important..
The use of soft wax on the mandibular record base and stated that swallowing saliva is
the determinative factor in obtaining vertical dimension and centric relation. By
reducing the mandibular occlusion rim 3 mm and placing cones of soft wax, the vertical
dimension was established after the patient swallowed several times.
The technique described in this article uses a combination of functional and static
recording methods. The occlusal vertical dimension is obtained functionally after the
dentist has assisted closure into centric relation. The centric relation record is made with
the use of an anterior flat stop made during the determination of vertical dimension and
completed with the dentist assisting closure.
PROCEDURE
1. After final impressions have been made, fabricate record bases, and evaluate their stability.
Bases must be stable to proceed.
2. Contour the wax rim on the maxillary base as normal. The use of a Fox plane is mandatory
because the occlusal plane will be dictated by the contours of the maxillary rim.
3. Mark midline, distal of canines, and smile line on the maxillary rim.
4. Place sticky wax on the mandibular record base.
5. Uniformly soften red modeling plastic impression compound in a water bath at 132F to
137F, and place the modeling plastic on the mandibular record base.
6. Place the record base with the modeling plastic in the patients mouth.
7. Have the patient suck and swallow to mold the modeling plastic
impression compound into the area of the neutral zone. Remove the
record base and inspect it.
8. Place petroleum jelly on the maxillary wax rim, and place the maxillary record base in the
patients mouth.
9. Uniformly reheat the mandibular rim, and place the record base into
the patients mouth. Guide the patient into centric relation until the
rims lightly touch. Instruct the patient to swallow. An imprint of the
maxillary occlusal rim into the mandibular rim will result. The
tentative occlusal vertical dimension has been determined, and the
anterior stop has been created.
10. Trim all excess from the mandibular rim, and replace the rim in the
patients mouth. Evaluate the occlusal vertical dimension by
judging overall facial support, the vertical dimension of rest, and
the closest speaking space. Steps 9 and 10 should be repeated until
the appropriate vertical dimension of occlusion is determined.
11. Do not alter the anterior portions of the rims. Place v-shaped notches in the maxillary rim,
and lubricate the rim. Trim 1 mm of the rim in the posterior of the mandibular rim. Then
place vshaped notches and lubricate the mandibular rim.
12. Record the face-bow registration using the anatomic average hinge axis location of choice,
and set aside for articulation of the maxillary cast.
13. Place both record bases in the patients mouth, and practice guiding the patient into the
centric relation position.
14. Record the position by injecting a fast-setting vinyl polysiloxane material onto the
mandibular rim, and have the patient close into centric relation.
15. Verify repeatability, make a protrusive record, and articulate the cast.
16. Proceed with tooth selection and evaluation of the trial denture.
Further Applications of the Basic Technique
1- Determining the Fit of a completed denture to the Neutral Zone
Coat the polished surfaces of the denture with a low
viscosity silicone impression material. Ask the patient to
perform functional movements while the material sets.
Inspect the denture & adjust any heavy muscle contact.
2- Determining the optimal space for a segment of the denture
Remove the teeth and the base material from the segment of the denture that needs
modification. Apply adhesive and take the impression with moldable material. Check for
stability and undertake the laboratory procedures
External impressions
Usually, the contours of the external surfaces are arbitrarily determined by the dentist or
technician. With the neutral-zone procedure, the external contours are molded by muscle
function. The moldable material used to locate the neutral zone also determines the shape of the
arch and the angles and contours of the body of the denture. These three entities are determined
by the size and function of the tongue and action and tonus of the lips and cheeks.
J ust as a primary impression is the first step in developing the impression surface of the
denture, the compound rims which located the neutral zone can be considered the primary
impression or the first procedure in developing the polished surface of the denture.
External impressions, similar to secondary impressions of the ridge, capture in greater
detail the action of the lips, cheeks, and tongue and determine the thickness, contours,
and shape of the polished surface of the denture. By means of these external impressions,
a physiologic molding is done so that the external surfaces are functionally compatible
with muscle action.
Upon completion, wax trial dentures were placed and an additional impression procedure
was performed using either zinc oxide and eugenol paste or tissue-conditioning material.
This impression, an external impression, was made on the facial, lingual, and palatal
surfaces of the trial dentures between the cervical aspects of the denture teeth and
peripheral denture borders to record functional tissue interactions with these denture
surfaces.
The wax trial dentures carried impression material into the oral cavity and the patient was
instructed to close, purse the lips as in sucking, and then swallow. Once completed,
excess impression material was removed and the trial dentures were invested and
processed using conventional methods.
Complete denture theory and practice CD ESTHETICS29
COMPLETE DENTURE ESTHETICS
Int r oduct ion
Denture esthetics is defined as the cosmetic effect produced by a dental prosthesis which
affects the desirable beauty, attractiveness, character and dignityof the individual.
The subject of esthetics is not a totally scientific and objective discipline nor is it 100%
an art form . Esthetics is a combination of the art and the science of prosthodontics.
Hardy said it best when he wrote "make the teeth look like natural teeth. If adentist is to
make a denture, where in the teeth look they grew there, teeth must beset in an esthetic
and convincing arrangement that also meets the patients functional needs.
It appears that beauty really does lie in the eye of the beholder and moreoften is a matter
of genetic programming of course, there are individual as well as cultural variation. A
denture is usually perceived as esthetic when the teeth andbases are in harmony with the
facial musculature as well as size and shape of thehead. Pre extraction records, old casts,
photographs or Immediate dentures can beextremely helpful both for tooth selection and
arrangement.
The subj ect of est het ics shoul d be examined f r om3 point s of view -
Biological - physiological
It is necessary to have an understanding of facial musculature, normal facial appearance,
and the physiological limits within which esthetic compromises are to be made. A proper
impression procedure is necessary to provide the dentist with afinal maxillary cast that
has an accurate representation of the labial vestibule and all of the other remaining
structures.
1) The dentist should also have a visual concept of the cause and effect relationship. eg: -
If an edentulous patient has a tight, drawn & thin lips, proper support with a fully formed
occlusion rim and lip support by the labial 2/3 of the artificial maxillary anterior teeth,
should evert thevermillion border of lip. This would afford a more natural appearance.
2) As patients become older the natural lines of farce tend to deepen and to appear
accentuated and the elasticity of the facial musculature is lost. There is a tendency to
want to plump out the face with additional thickness of thedenture base material and the
musculature tends to loosen the denture or thefacial appearance, becomes strained.
3) Another approach to removing facial wrinkles is to Increase the VD. This approach is
fraught with the greatest of dangers and must be used withcaution. The actual process of
trial placement of the maxillary anterior teeth and the function of the maxillary and
mandibular anterior during theproduction of speech give one of the best guidelines for
creating andmaintaining an adequate inter occlusal distance.
The following principles should be followed in the placement of anterior teeth.
1) The lower anteriors should be placed lower in order to maintain an adequateinterarch
space. This will necessitate lowering of the occlusal planeposteriorly. This will have the
effect of placing the teeth closer to the mandibular ridge giving stability to the lower
denture.
2) The maxillary teeth should be moved slightly more anteriorly at the incisal edges.
Tilting the incisal edges of the mandibular incisors; lingually should be avoided.
According to Muysigmes for every lmm the incisal edges of themandibular anterior teeth
are posterior to their normal arrangement, the tongue is deprived of approximately
100cub mm of space in which tofunction.
Biomechanical
There are certain mechanical limitations in the placement of anterior teeth that must be
taken into account. The anterior teeth should be placed closely inrelation to the residual
ridge as were the original natural teeth. Fish says the proper position for the teeth is not
necessarily on the ridge, inside the ridge, or outside the ridge, but at a point where the
tongue and cheek pressures balance.
Psychological
Patient's self image is an important factor in esthetics. -:A patients perception of his or
her appearance may result in a broad simle (if it is a positiveself evaluation.) or a tight -
lipped, small, controlled smile, A patient with a poor self image may appear done,
unsure, questioning and introverted,. A patient with amore positive feeling tends to smile
more broadly.
Campers line may be thought of as a psychological plane of orientation. Ina person who
appears happy this line tends to rise and in a person who to depressed it may slant
downward.
The occlusal plane established by the dentist has an effect in determining theappearance
of a patients psychological state. eg: - by effecting a downward slant to the plane
posteriorly an observer may gain a negative impression of the patients emotional or
phychological state.
A- ANTERIOR TOOTH SELECTION
See: teeth selection
B- TEEt h Ar r angement
See: teeth arrangment
C- Dent ur e base shade sel ect ion and Char act er izat ion
See: teeth selection
D- Cor r ect pl acement of t he occl usal pl ane
It is important with respect to denture stability, function, and
esthetics. The location of the occlusal plane is critical to
achievement of a natural appearance.
The teeth should gradually rise along the occlusal plane toward the
back to follow the smile line and give an impression of distance.
Fact or s Inf l uencing t he Appear ance of Dent ur es
Patient factors:
1. Sex 2. Age
3. Personality
Tooth factors
1. Position 2. Colour
3. Size4. Form
Denture base factors
Tooth/Denture base factors
Final Decision for Esthetics depends upon
Maxillomandibular relationships
Patients appearance
Patients mental attitude
Functional requirements
Male Characteristics
- Larger teeth
- Square shapes
- Depressed and irregular positioning
- Rugged anatomy
Female Characteristics
-Smaller teeth
-Round shapes
-Rounded and pronounced positioning
-Softer labial anatomy
AGE
-Darker shades -Spacing and staining
-Irregular incisal edges -Pronounced gingival contours
Personality
-Key tooth position and shape
-Suitable smile and lip line
-Speaking line
-Contour of denture base
- following curve of lower lip
Factors to consider in tooth position
1. Relation to each other
2. Relation to opposing number
3. Spacing
4. Inclination
5. Relation to midline
6. Relation to incisive papilla
TOOTH / DENTURE BASE MODIFICATIONS
1. Spaces
2. Embrasures
3. Buccal Corridor
4. Gum Line
5. Interdental Papilla
DENTURE BASE FACTORS
1. Contour
2. Colour
DENTURE BASE ANATOMY
The gingival heights of the various teeth in the arch vary and
should never be waxed straight across. This a commonmistake
made in denture festooning.
The lateral is always shorter than the canine or central.
The canineis always longer than the premolar.
Benefits of properly contoured dentures
Improved tolerance and comfort
Facilitates stability and control.
Prevents chronic biting of the lip or cheek.
Correlation between function and esthetics
Good appearance is sorelated psychologically to comfort that the 2 cannot be separated.
Liefer had statistically significantly fewer adjustment appointments and a greater number
of pleased patients when all esthetic decisions were made by the patient. This implies that
when the esthetic result was successful, the dentures were more successful overall
VERIFY
shade
tooth arrangement
centric relation
incisal guidance
arch form
plane of occlusion
Est het ic concept s (J Prosthet Dent 2005;93:386-94.)
I. Early conceptstemperamental and typal
Temperamental theory of denture construction.
White introduced what is probably the first esthetic concept when he described his
theory of correspondence and harmony. White described this theory as a
correspondence between tooth form and color in harmony with age and gender.
It was based on the idea that a subjects temperament or bodily characteristics
matched the size, proportion, arrangement, and color of the teeth. Some
interesting ideas highlighted by this early esthetic concept included
(1) The relationship between age, gender, and appearance,
(2) The proper tooth-to-face-size proportion,
(3) Color harmony between face and teeth.
typal form concept
Hall was the first to describe what he believed was a correlation between face form
and tooth form. The argument for what became known as the typal form concept of
esthetics was based largely on Williams own anthropologic research.
He stated that 3 basic forms of teeth existed: square, tapering, and ovoid. These were
termed the typal forms of teeth.
The system succeeded due to its practicality and manufacturer support and not
because of any actual relationship. Past and current research has shown that no
significant correlation exists between facial form and tooth form.
Using the typal form concept clinically is complicated by facial form appearance
alterations due to age, hairstyle, eyewear, and body mass changes.
II. Dentogenic ( natural) concept of denture construction
Frush and Fischer establish the dentogenic concept of denture
construction.
These authors wrote that gender, personality, and age could be used as
guidelines for tooth selection, arrangement, and characterization to
enhance the natural appearance of the individual.
The success of the dentogenic concept coincided with great advances in denture
materials. As reliable acrylic resin became available, the ability to achieve esthetic results
improved considerably. Denture teeth, base material, and gingival tints could now
precisely match the form and color of the tissue being replaced
III. Modern conceptspatient involvement and preference (a patient-
centered approach , supernormal)
The assumption was that the denture is a work of art and should,
therefore, be held to the same standards of viewing as paintings or
sculptures. The primary guideline is to attempt dynamic unity, also
called unity with variety.
The entiredental composition should be complimentary to the faceand to itself. At the
same time, it should not be mechanicallystraight or without uniqueness.
If the patient is involved in esthetic decisions, patient preference for certain attributes
becomes important. If the dentist understands what the patient prefers, the chances for
miscommunication are likely to be decreased.
Thedifference between the 2 major esthetic concepts:
Dentogenics concept (natural) seek to match anatomic determinants of gender, age, and
personality ,
A patient-centered approach allows alterations from what may be normal to provide
patients withwhat they regard as beautiful.
IV. Denture look concept:
The third esthetic concept developed as a result of common errors
in fabrication and appearance for complete denture wearers. It has
been described asa denture look
a denture look is not acceptable, but elderly patients may be
accustomed to such an appearance. Likewise, if a denture look is
associated with elderly appearance, patients may expect and even
prefer to havesuch an appearance.
V. Golden proportion concept:
The concepts of the divine or golden proportion have also been described and provide useful
guidelines for the selection and positioning of anterior teeth.
COMPLETE DENTURE THEORY AND PRACTICE Speech30
Phonetics
Definitions
Phonetics is the study of sounds particularly those produced by human. It may
defined as the study of the medium of spoken language, that is, the production,
transmission and reception of the sounds of human speech.
Phonetics: the science of speech sounds (language independent.)
articulatory phonetics: study of how speech sounds are produced/articulated
acoustic phonetics: description of the physical properties of speech sounds:
voicing, aspiration, frication
auditory phonetics: deals with the perception of speech sounds
Phonology: the principles and patterns by which sounds are used in a language:
language dependent
Transcription: A standardized set of symbols for converting the continuous acoustic
stream into discrete, linguisticallyrelevant symbolic units.
Speech is a learned process that used the anatomic structures designed primarily for
respiration and deglutition. speech is a learned habitual neuromuscular pattern
depend on audio and orosensory feedback.
There are no organs special for speech per se. As a learned process, speech develops
over an extended period. Spoken language is produced by the movements of some
organs may be considered as organs helping in speech.
Organs helping in speech
The respiratory system, consisting of the lungs, the muscles of the chest, and the wind-
pipe (trachea)
The phonatory system, formed by the larynx
The articulatory system, consisting of the nose, the mouth (including the tongue, the
teeth, the roof of the mouth, and the lips)
5
Respiratory System Phonatory System Articulatory System
Lungs Muscles of
the chest
Trachea
Larynx
Pharynx Roof
of the
mouth
Teeth Lips
Organs of Speech
Tongue
Vocal
cords
Tip
Uvula
Hard
palate
Teeth
ridge
Soft
palate
Blade Front Back Rims
The larynx (voice box): phonatory system
The air from the lungs comes through the wind pipe or trachea, at the top of which is the
larynx.
In the larynx are two vocal cords, which are like a pair of lips placed horizontally from
front to back. They are joined in the front, but can be separated at the back, and the
opening between them is called the glottis.
The vocal folds are wide apart for normal breathing & voiceless consonants
Narrow closure: for a whispered vowel (/ahaha:)
Opening and closing: vibration for voiced sounds
Tightly closed for production of glottal stop
The State of the Glottis
When we breath in and out, the glottis is open. That is, the vocal
cords are drawn wide apart producing voiceless sounds.
If the vocal cords are held loosely together, the pressure of the air coming from the lungs
makes them vibrate; that is, they open and close regularly many times a second. Sounds
produced in this way are called voiced sounds.
13
Raised
Lowered
Nasal passage blocked
Oral sounds produced
Nasal passage open
State of the soft palate
Oral passage blocked Oral passage open
Nasal sounds produced
Nasalized sounds produced
The Articulators: articulatory system
The organs of speech above the glottis are the articulators involved in the production of
consonants:
Active articulator : the lower lip and the tongue
Passive articulator : the upper lip, the upper teeth, the roof of the
mouth and the back wall of the throat (or Pharynx).
The roof of the mouth
The roof of the mouth can be subdivided into four parts:
the teeth-ridge or the alveolar ridge, i.e., the hard convex surface just behind the
upper front teeth
the hard palate, i.e., the hard concave surface behind the teeth-ridge
the soft palate, i.e., the soft portion behind the hard palate
the uvula, i.e., a small fleshy structure at the end of the soft palate
In the production of a consonant, the active articulator is moved towards the passive
articulator.
PLACE
ACTI VE
ARTI CULATOR
PASSI VE
ARTI CULATOR
Bilabial Lower lip Upper lip
Labio-dental Lower lip Upper teeth
Dental Tip of tongue Upper teeth
Alveolar Blade of tongue Alveolar ridge
Retroflex Tip of tongue Hard palate
Palatal Front of tongue Hard palate
Velar Middle of tongue Velum (soft palate)
Uvular Back of tongue Uvula
2/10/2011 47
Sof t Pal at e and It s Impor t ance in Speech
The rapid and accurate positioning of the soft palate is essential for the production of the correct
sound. When speaking, (all sounds except for those of m, n and ngand vowels), the soft palate is
raised and form a competent velopharyngeal sphincter preventing all nasal escape of air which is
thus wholly directed through the mouth
Overextension of the maxillary denture in the post dam area: May cause irritation of the velum
and stiffness of its muscles
If the posterior border is overextended or does not make firm contact with the tissue at the
posterior palatal seal area : The K sound becomes altered toward the German Ch sound
Palato (velo) pharyngeal mechanism(Palato (Velo) Pharyngeal Sphincter)
The velopharyngeal mechanism is a coordinated valve formed by the muscles of the soft
palate and pharynx.
Muscles forming the velo-pharyngeal sphincter
Muscles forming the velo-pharyngeal region are, :
1-Muscles forming the palate, these are:
-Levator veli palatini muscle -Tensor veli palatini muscle
-Palato glossus muscle -Palato pharyngus muscle
-Uvula muscle, which is the intrinsic muscle of the velum
2-Muscles forming the pharynx, these are:
-Superior constrictor muscle -Salpingo pharynges muscle
-Palato pharyngus muscle which has two portions, the pharyngo palatal
portion and the thyro-palatal portion
The levator veli palatini muscle and the superior constrictor muscles play the dominant
role in velo-pharyngeal mechanism especially during closure of the nasal cavity. The levator
veli palatini muscle is a long muscle and provides a wide range of movement necessary in
moving the velum from the relaxed rest position to a fully elevated position
Palato (Velo) Pharyngeal mechanism
The velum acquires three positions to perform the valve action during swallowing and speech,
1-The relaxed position of the velum (uvula): Velopharyngeal opening:
This occurs during normal breathing and for pronunciation of vowels and
nasal consonants in a varying degrees. It is a relaxed position; the soft palate
drops downward to keep the oropharynx and nasopharynx opened.
2-Closure of the nasal cavity: It is required for swallowing and for production of
letters produced in the oral cavity. This mechanism is achieved as follows:
The middle third of the velum curves upwards and backwards in an attempt to contact the
posterior wall of the pharynx at or above the level of the plane of the palate at the level of
the atlas vertebra. This is done by the action of the levator veli palatini muscle. This is
aided by the contracted state of both the tensor veli palatine muscle and the uvulae
muscle that adds bulk to the nasal surface of the velum.
The pharynx shares in palato pharyngeal mechanism by:
*Movement of the posterior wall of the pharynx forwards. This is done by the
action of the superior constrictor muscle aided by the pharyngo palatalportion of
the palato pharyngus muscle.
*Movement of the lateral walls of the pharynx medially to close the last gap
between the lateral aspect of soft palate and lateral walls of pharynx. This is done
by the action of the salpingo pharynges muscle.
*The posterior pharyngeal muscles contracts strongly and produces a bunch-up
forming a prominent ridge or pad called Ridge of Passavant. This helps to
approximate the soft palate and pharynx,
Ridge of Passavant
The ridge of Passavant is a horizontal roll of muscles on the posterior wall of the pharynx
forming a bunching-up of the posterior pharyngeal wall. It is present at the level of the palate
which corresponds to the level of the atlas vertebra. It is usually more evident in patients with
soft palate defects as a compensating mechanism to aid in speech and swallowing. It also serves
as a guide for placement of soft palate prostheses
3-Closure of the oral cavity
This is required to permit exit of air through the nasal cavity during sucking and
pronunciation of sounds as M and Ng as in sing. This mechanism is achieved as follows:
-The thyro-palatal portion of the palato pharyngus muscle pulls the soft palate
downward towards the tongue.
-The tensor veli palatini muscle flattens the dome-shape of the soft palate.
-The tongue is forced upward and backward.
-The palato glossus muscle contracts and completes the palate tongue approximation.
Velopharyngeal insufficiency:
Palato pharyngeal insufficiency is a condition characterized by abnormal anatomy of the
palate in the form of absence, short length or cleft in the tissues of the soft
palate.
This could be congenital, or due to acquired causes as resection of soft
palate or lateral pharyngeal wall. This condition results in inability to
perform palato pharyngeal mechanism.
Prosthetic rehabilitation is achieved by palato-pharyngeal obturator
(speech bulb) or by meatle obturator. Nasal sounds
Velopharyngeal incompetence:
Palato pharyngeal incompetence is a condition characterized by normal
anatomy but ineffective or absent motor function (tissues are
functionally impaired).
It is diagnosed by easily lifting the soft palate by a tongue depressor, by
nasal endoscopy or byairflow pressure measurements. Oral sounds
Prosthetic rehabilitation is achieved by a palatal lift device.
Several conditions can cause failure of closure of the valve, resulting in what is
designated as "palatopharyngeal (velopharyngeal) incompetence (insufficiency)
Conditions that cause failure of closure of the valve
1. Neurologic disease : as poliomyelitis affecting oro-pharyngeal structures through affection
of any of the nerves of the pharyngeal plexus which includes fibers from the IX, X and
XI cranial nerves.
2. A congenital cleft of the palate .
3. A submucous cleft with inadequate bony structure and abnormal muscle fiber relationships
that impair closure,even if no palatal cleft is evident.
4. A variety of abnormalities of cavity relationships, e.g. short soft palate, excessively deep
pharynx;
5. Surgical resection of oral structures for treatment of cancer or traumatic injury .
6. Additional special cases : basilar skull deformities with associated congenital shortening
of the soft palate .
7. Congenital Iymphangioma with fixation of the soft palate
8. Diseases as multiple sclerosis or tumors, or due to traumatic head injuries.
Results
Palatopharyngeal incompetence leads to three primary speech consequences
1. Hypernasality,
2. Noise created by flow of air through nares during articulationnasal emission of air.
3. Impairment of palatopharyngeal valving that allows even minimal egress of air into the
nasal cavities would result in a distortion of articulation.
4. Reduced speech intelligibility
Components of speech: speech mechanism
Respiration :
During respiration, inhalation and exhalation are approximately equal in duration and the
airflow is regular and repetitive.
During speech, the inhalation is shortened and the exhalation phase is prolonged and is
not repetitive. Prolongation of exhalation is achieved by the valve mechanisms along the
laryngeal, pharyngeal andoral components of the respiratory truct. These valves impede
the expired air and help to create speech signals.
If the vital capacity of the lungs is compromised, as in emphysema, speech will be perceived
as breathy. The reduced volume and pressure of expired air cause poor projection of voice.
Phonation :
Speech requires a multitude of position, varying tensions, vibratory cycles, and intricate
coordination of the vocal folds with other structures.
If vocal folds are partially or completely closed, they impede the expired air. With proper
degree of tension and pressure, the vocal folds may vibrated and thus impart phonation.
The tension and position of vocal folds will determine the pitch of the phonated sound.
If the larynx is resected the patient must learn to use the esophagus or a substitute mechanical
device (electrolarynx) as an alternative phonating system.
Resonation:
The sounds produced at the level of the vocal folds are augmented and modified by the
chambers above the level of the glottis. The pharynx, the oral cavity, and the nasal cavity
are providing tonal quality and act as resonating chamber by amplifying voice.
If palatopharyngeal closure is compromised, or if the structural integrity or size of oral,
pharyngeal or nasal cavities has been altered, a compromised voice quality will occur.
Articulation:
The amplified, resonated sound is formulated into meaningful speech by the articulators,
i.e., by changing the special relationship of the tongue, the lips, the cheeks, the teeth and
the palate to each other.
The tongue is the single most important articulator of speech because of its ability to
changes in movement and shape.
Neural integration:
Speech in integrated by the central nervous system. At least 17000 different motor
patternsare required during speech.
A cerebrovascular accident may compromise the ability of patient to formulate
meaningful speech, evenall structures whichproduce speech are anatomically normal.
The ability to hear sounds (Audition) :
Hearing permits reception and interpretation of acoustic signals and allows the speaker to
monitor and control speech output.
Compromised hearing can preclude accurate feedback and affect speech.
Speech and Maxillofacial Prosthetics
Resonance and articulation are distorted by cleft lip and cleft palate.
A-Patients with cleft palate exhibit excessive nasal resonance because the inadequacy of the
velopharyngeal closure. This results in nasal sounds (hypernasality).
B- The sounds not affected by palatal clefts are the vowels (A,I, E,O and U) and nasal
consonants (M,N and NG).
C- The articulation of the other consonants is affected in varying degrees, depending on the
degree of oral pressure required for each sound. These sounds are deprived of their normal
explosive character (e.g. P and K) and give the voice a typical hollow nasal quality.
Airstream mechanisms :Production of anysound involves the movement of an airstream
pulmonic airstream mechanism
Inwhich the lungs and the respiratory muscles set the air-stream in motion.
Most sounds pulmonic egressive: by pushing air through the lungs, through the
mouth and sometimes also through the nose.
glottalic airstream mechanism
Inwhich the larynx, with the glottis firmly closed, is moved up or down to initiate
the air-stream.
Velaric airstream mechanism:
Velaric in which the back of the tongue in firm contact with the soft palate is
pushed forward or pulled back to initiate the air-stream
These air-streams can be:
Egressive, i.e., the air is pushed out
e.g., Sounds of Englishand Hindi are egressive pulmonic air-stream.
Inegresive, i.e., the air is pulled in
e.g., Sindhi has some sounds with an inegressive glottalic air-stream.
6 possible airstream mechanisms:
pulmonic egressive - used in all languages
pulmonic ingressive - not found
velaric egressive - not found
velaric ingressive - used in e.g. Zulu (South Africa)
glottalic egressive - used in e.g. Navajo (N. America)
glottalic ingressive - used in e.g. Sindhi (India)
Speech Sounds
In studying the physical properties of speech sounds we should understand:
- Manner of Articulation
- Place of Articulation
- Voicing
Manner of Articulation
concerns how the vocal tract restricts airflow
When producing obstruents, for example, articulators either:
- Totallystop the airflowthen release it (stops),
- create a partial closure leading to turbulence of the air particles (fricatives)
- combine these two types of closure (affricates).
Place of Articulation
refers to the location in the vocal tract
The number and variety of obstruents result directly from the fact that manners of
articulation can be exercised at various points in the vocal tract.
These point, places of articulation, are generally described in terms of where in the vocal
tract contact is made, rather than in terms of the identity of the active articulator involved.
Voicing
Each combination of manner and place of articulation may also be accompanied by vocal
cord (fold) vibration or voicing.
presence/absence of vocal fold vibration
Classification of sounds
1- Surds: are any voiceless sounds
2- Vowels (Sonants): are open voiced sounds relatively unimpeded by the oral valves
The tongue is the principle articulator for the vowels "A, E, I, O, U".
The active articulators: the front, the back, the centre of thetongue
The passive articulators: the hard palate, the soft palate, the meeting point of the
hard and soft palates.
The vowel sounds are formed by a continuous air flow escaped through the
mouth. The shape of which is altered for the various vowels by raising or
lowering the tongue and by altering the shape of the exit through the lips. The air
was escaped through the mouth in the form of a single chamber for the A , O , U
sounds and a duple chamber for the I and E sounds. The division occurring
throughthe dorsum of the tongue touching the anterior part of the soft palate.
3- Consonants: are articulated speech sound. Theymay classified
According to laryngeal action and manner of production
A- Stops (plosives):
Characterized by complete stoppage of the air stream by valves, building up of
pressure in oral cavity, and sudden release and explosion of the breath (e.g. P,B).
B -The fricatives:
Characterized by friction of the air stream, being forced through loosely closed
articulators or narrow passageway e.g. /S/, /f/, /z/.
C- The affricates: also called "affricatives" are combinations of two consonants
e.g. d3
D- Nasal: It is produced by complete oral closure, but in this case there is no
closure of nasal passage. soft palate is lowered and air passes through the nose.
E.g. N, M
E-The Glides: Involves relatively little impedance of air stream their distinctive
characteristic is that they vary acoustically physiologically during their duration
e.g. H, W, J , Hw.
F- Semi vowels: Involve the least impedance of breath stream, e.g. R, L.
according to the Place of Articulation :
This method of classification is probably most meaningful to the prosthodontist
since it highlights those consonants most affected by dental conditions
The place of articulation simply means the active and passive articulators
involved in the production of a particular consonant.
They are:
Bilabial : The two lips are the articulators. E.g., /p/, /b/, /m/
Labio-dental: The lower lip is the active articulator and the upper teeth are the
passive articulators. These sounds are produced by the air stream being stopped and
explosively released when the wet-dry line of the vermilion border of the lower lip
breaks contact with the incisal edge of the upper anterior teethE.g., /f/, /v/
Lingu- Dental: the tip of the tongue is the active articulator and the upper front
teeth are the passive articulators. This soundth(as in thin , then) is the result of
air flow restricted by the tongue against the incisal edge of upper and/or lower
incisors.
Lingu- Alveolar: Tongue and anterior portion of the hard palate (e.g. S, C
soft, Z, D, T, R, L).
The tip or blade of the tongue is the active articulator and the teeth-ridge is the
passive articulator.
With T and D, the tongue makes firm contact with the anterior part of the hard
palate, and suddenly drawn downwards, producing an explosive sound.
When producing the S , C soft, Z , R and L sounds, contact occurs between
the tongue and the most anterior part of the hard palate, including the lingual
surface of the upper and lower incisors, any thickening of the denture base in
this region may cause incorrect formation of these sounds.
The lower lip is brought into contact with the incisal edges
of the upper anterior teeth during production of the F, V
and Ph sounds.
Post-alveolar: The tip of the tongue is the active articulator and the back of the
teeth-ridge is the passive articulator.
Retroflex: the tip of the tongue is the active articulator, and it is curled back. The
back of the teeth-ridge or the hard palate is the passive articulator.
Palato-alveolar: The tip, blade, and front of the tongue are the active articulators
and the teeth-ridge and hard palate are the passive articulators.
Lingu-Palatal: Tongue and portion of the hard palate posterior to that of
above (e.g. J, CH, SH, L, R)
Faulty phonation of these consonants sounds may be results from thickening
of this part of the denture base covering the hard palate.
With the C soft, S, Z, CH and J sounds the teeth come very close together;
if the vertical dimension is excessive, a clicking teeth will results with these
sounds.
The front of the tongue is the active articulator and the hard palate is the
passive articulator.
Lingu- Velar: Tongue and soft palate (e.g. C hard, k, G, NG).
Difficulty in pronouncing these sounds results if the posterior border of the
upper denture is thick and does not merge into the soft tissues.
The back of the tongue is the active articulator and the soft palate is the
passive articulator. E.g. /k/, /g/
Uvular: The rear part of the back of the tongue is the active articulator and the uvula
is the passive articulator. There are no uvular sounds in English.
Glottal: Produced at the glottis. E.g., [h]
Nasal (e.g. M, N, NG).
In these consonants sounds the air stream is allowed to escape into the nasal cavity.
Speech Records
1- Subjective method.
2- Objective method.
1- Subjective method (auditory perceptual evaluation)
1- Through listening using a high quality stereo cassette recorder and a chrome bias
cassette.
2- Speech recordingswere carried out in a caustically treated room.
3- The subject is asked to counting from 1 -20, to pronounce specific speech sound, asked
about his name, age and his job, how the denture feels, how his speech sounds to him,
and which seem most difficult to pronounce.
4- Two different phoniatristsevaluated the speech samples.
5- Each audience evaluated the tapes for omissions, additions, substitutions or distortions
and marked any error on sheet containing transcriptions of speech materials.
6- Number and type of errors were recordedfor each subject.
2- Objective method (instrumental analysis):
This was done through:
Vocal 2 apparatus
Palatography ,ElectroPalatography
Cinefluorography
The sound spectrograph
(sonagraph,
spectrometer)
Computerized Speech Lab (CSL)
Techniques for Studying Speech Tests
Palatography is a technique for studying tongue contact with the
alveolar ridge and palate during the production of phonemes or
syllables
Cinefluorography does for the cephalometric roentgenogram; it
permits multiple measurements representative of continuous speech.
The sound spectrograph (sonagraph, spectrometer) It graphically portrays the regions of
energy concentration characteristic of the various phonemesspoken during 2.5 seconds of
continuous speech.
The f act or s in dent ur e const r uct ion af f ect ing phonat ion
1- Shape, , thickness, material and contours of a denture base
thick denture bases may cause :
loss of tonguespace - loss of toneand incorrect phonation.
2- Thickness and contour of its palatal portion:
- The thickness of the denture base covering the palate should not be thick.
- The artificial rugae should not be over-pronounced.
3- Extension and peripheral outline:
- The periphery of the denture must not be overextended. Prober thickness of the facial and
lingual flange
4- Vertical dimension
- Highvertical dimension cause clicking teeth with Ch and J sounds
5- The occlusal plane
If the occlusal plane is set too high the correct positioning of the lower lip may be
difficult. If the plane is too law, the lip will overlap the labial surfaces of the upper
anterior teeth and the F, V and Ph sounds might be affected.
6- The shape and size of teeth.
7- The anteroposterior postion of the incisors
The labiopalatal position of the upper anterior teeth is important for the correct formation
of the labiodental F,V and Ph and some palatolinguals S, C soft and Z, lisping with
result if the anterior teeth are placed too far palatally.
8- Relationship of the upper anterior to the lower anterior teeth
Consonants S, Ch, J , and Z requires near contact of upper and lower incisors so
that the air stream is allowed to escape through a slight opening between the teeth.
In abnormal protrusive and retrusive jaw relationships, some difficulty may be
experienced in the formation of these sounds, and the anteroposterior adjustment
of the upper and lower anterior teeth become necessary.
9- The post-dam area
Errors of construction in this region involve the vowels I and E and some palatolingual
consonants K,NG, G and C had.
If the denture base was made thick in the post-dam area, or the edge finished square
instead of tapering, the dorsum of the tongue will be irritated, impeding speech and
nausea may occurs.
Indirectly the post-dam seal influences phonation by increase the denture retention,
because in case of loss upper denture the patient tries to suck maxillary denture into
position, using tongue to hold it, hence, mouth does not open widely, speech becomes
muffeld.
10- Width of dental arch
The artificial teeth should be placed in the neutral zone.
If the arch form of the denture is too narrow the tongue will be cramped, thus affecting
the size and shape of the air channel and the lateral margins of the tongue make contact
with the palatal surface of the upper posterior teeth. These results in faulty phonation of
some consonants as T, D, S, M, N, K, G, and H.
11- Denture's retention and stability,
12- Patient adaptation in phonetics
People can learn to adapt their speaking habits to correct errors that may be caused by
faulty tooth placement in dentures.
Important of different sounds in denture construction:
Application of vowels (sonants) (A,E,O,I,U)
There will be little or no troubles with vowels sounds if the denture is phonetically
adjusted in consonant sounds (Rothman, 1961).
The tip of the tongue in all vowel sounds lies on the floor of the mouth either in contact
with or close to the lingual surfaces of the lower anterior teeth and gums.
The application of this in denture construction is that the lower anterior teeth should
not be set lingual to the alveolar ridge so that they do not impede the tongue positioning
for these sounds;.
Since the vowels E and I necessitate contact between the tongue and soft palate, the upper
denture base must be kept thin.
The posterior border should be tapered and merge into the soft tissue in order to avoid
irritating the dorsum of the tongue, which might occur if this surface of the denture was
allowed to remain thick and square-ended.
The vowel A , Ah as in Father is useful to locate the vibrating line, which is
helpful in determining the correct place of the post dam area.
For construction of speech aid prosthesis, in case of cleft palate and neuromuscular
deficient of the soft palate and pharynx.
Importance of labial sound(e.g. B, P, M).:
a- Orientation of the anterior teeth
b- Thickness of the labial flange.
Insufficient support of the lips by the teeth and denture base can cause these
sounds to be defective. Therefore the anteroposterior position of the anterior teeth
and thickness of the labial flanges of dentures can effect the labial sounds.
The anterior teeth and the denture flange must support the lips for these sounds.
C- A correct vertical dimension
It plays an important role in the normal formation of the labial sounds as by
increasing the vertical dimension patient can not close the lips comfortably to
form the air seal, and by decreasing the vertical dimension patients lips will
prematurely contact causing distortion of the labial sounds.
Effects of labiodental consonants (e.g. F, V, Ph)
1- Position of the maxillary and mandibular anterior teeth
a- Upper anterior teeth too long or too far posterior or too far anterior.
b. Lower teeth: Too far posterior, a space develops between the lip and the teeth
during pronunciation of words containing labiodental sounds.
c. Too far anterior; the lower lip crowds into the lower denture off the residual ridge
during pronunciation of labiodental sounds.
2- Vertical dimension: Increasing or decreasing of the V.D. affects the pronunciation of
the labio dental sounds.
3- These labiodental sounds serve as an excellent test or guideline for determining the
proper plane of occlusion and the placement of anterior
The Linguo-Dental (e.g. Th)
Effects of positioning of anterior teeth on the pronunciation of th.
If about 3mm of the tip of the tongue is not visible, the anterior teeth are probably too
far forward or there may be excessive vertical overlap and the th sound will be
more like d sound.
If these or those are pronounced as dese or dose, so, try to incline the
upper centrals lingually.
If more than 6 mm. of the tongue extends out between the teeth the teeth are
probably set too far lingually and the th will be pronounced t
Inadequate intra-occlusal distance or too much occlusal vertical dimension may
cause sensation of the tongue biting when the th sound is formed and also, the th
sound will be T or D sounds
Proper adjustment of the occlusal plane isnecessary for these sounds.
Linguo-alveolar consonants
A) T, D, and N sounds:-
a- Position of the anterior teeth:
If the teeth are set too far lingually, the T will sound more like a D.
If the anterior teeth are set too far anteriorly, the D sound will be more like a T sound.
b- Thickness of the palatal denture base:-
The palate of the denture base that is too thick in the rugae area : T will be more like a D and
the D, C, N sounds will be difficult to pronounce.
B) The Linguo-alveolar S, Z, and, C (soft), sounds: -
The upper and lower incisors should approach each other end-to-end, but they should not
touch that indicate a possible error in the amount of horizontal overlap of the anterior
teeth.
Always check on the total length of the upper and lower teeth (including their vertical
overlap)
Vertical length of anterior teeth during the pronunciation of sibilants. A, correct; B,
excessive vertical overlap; C, inadequate vertical overlap
Horizontal overlap of the anterior teeth during the pronunciation of sibilants. A. shows
correct amount of overlapping, B. showing excessive amount of overlapping, C. deficient
amount of overlapping.
These sounds are made with the tip of the tongue against the palate in the rugae area with
small space or slit like channel for the escape of air between the tongue and hard palate.
The size and shape of this small space or channel will determine the quality of the sound.
If this channel is too shallow (broad and thin) : Lisping Sh sound
if the depth of the channel is further decreased or obstructed: Lisping (th or etts)
If the channel formed between the hard palate and the tongue is too narrow and deep :
Whistling
The application of whistling
A cramped tongue space, especially in the premolar region, forces the dorsal
surface of the tongue to form too small, deep opening for the escape of air :
Setting of teeth over the ridge
If the upper anterior teeth are placed too far forward (labially) or the lower
anterior teeth are too far back (lingually) : the tongue will be forced to arch itself
up to a higher position, so that the airway would be too small (narrow and deep) a
whistle could result.
If the space formed between the anterior palatal denture base and the tongue is too
narrow and deep : thicken the center of the palate so that the tongue does not,
have to extend up so far into the narrow palatal vault
if the lingual flange of the lower denture is too thick in the anterior region : can be
corrected by placing the artificial teeth in the same position that the natural teeth
occupied and shaping the lingual flange of the lower denture, so that it does not
encroach upon the space needed by the tongue.
If the interincisal space is abnormal : thicken the center of the palate so that the
tongue does not, have to extend up so far into the narrow palatal vault
If the occlusal vertical dimension is too great the teeth will come together in
contact prematurely and they will "click" during connected speech while
pronouncing the "s" sound.
In case of S , C soft and Z sounds, a slit-like channel is formed between the
tongue and the palate through which the air hisses. If this channel is
obstructed by thickening the anterior part of the upper denture covering the
hard palate, by placing the anterior teeth too far back, or by lack of near
contact of the upper and lower incisors, a noticeable lisping may be produced.
However , if the channel is too narrow, due to cramped tongue, too narrow
dental arch, or placing the anterior teeth too far anteriorly whistling will result.
The procedurefor correcting whistling is to thicken the center of the palate so
that the tongue does not have to extend up, so far into the narrow palatal
vault. This allows the escape way, for air to be broad and thin.
A lisp with denture can be corrected by reversing the procedure and providing
a narrow concentrated airway for the S sound.
The correct positioning of the anterior teeth (antroposteriorly) important for
proper sounds of S, C (soft), Z, R, and L and for preventing both lisping and
whistling.
The application of lisping
1- The anterior part of the upper denture, covering the hard palate is thick.
2- The maxillary anterior teeth are placed too far back.
3- Lack of near contact of the upper and lower incisors
4- The level of the occlusal plane
a- In caseof too low occlusal plane the S sound will be developed as Sh
due to spreading of the tongue to cover the lower anterior teeth.
b-In case of too high occlusal plane the S sound will be developed as th
due to the protrusion of the tongue during pronunciation of S.
5- class II and class III jaw relationship hinder the production of S sound
somewhat difficult.
The following relationships are particularly important to the production of clear speech.
(1) Tip of the tongue to the palate.
Contact between the tip of the tongue and the palate is required in the production of /s/, /z/, /t/, /d/
and /n/. Consequently, a change in the shape or thickness of the denture contact surface resulting
from the fitting of new dentures will require a modification of tongue behaviour in order to
produce sounds which are the same as before. In the vast majority of cases, the necessary
modification occurs without any difficulty in a relatively short period of time.
The sound most commonly affected in this way is /s/, a sound which is generally produced with
the tongue tip behind the upper anterior teeth. A narrow channel remains in the centre of the
palate through which air hisses. If the palate is too thick at this point, or if the incisors are
positioned too far palatally, the /s/ may become a /th/. If the denture is shaped so that it is
difficult for the tongue to adapt itself closely to the palate, a channel narrow enough to produce
the /s/ sound will not be produced and a whistle or /sh/ sound may result. This is most likely to
be the consequence of excessive palatal thickening laterally in the canine region.
.(2) Lower lip to incisal edges of upper anterior teeth.
The lower lip makes contact with the incisal edges of the upper anterior teeth when the sounds /f/
and /v/ are produced. If the position of these teeth on a replacement denture is dramatically
different to that on the old denture there is likely to be a disturbance in speech.
(3) Lateral margin of the tongue to posterior teeth.
Contact between thelateral margins of the tongue and the posterior teeth is necessary to produce
the English consonants /th/, /t/, /d/, /n/, /s/, /z/, /sh/, /zh/ (as in measure), /ch/, /j/ and /r/ (as in
red). Air is directed forwards over the dorsum of the tongue and may be modified by movement
of the tongue against the teeth or anterior slope of the palate to produce the final sound. If the
contact can only be achieved with difficulty, movement of the tip of the tongue may be restricted
with consequent impairment of speech. This difficulty arises if the posterior contact surfaces are
too far from the resting position of the tongue as a result of the occlusal plane being too high, the
occlusal vertical dimension too great or the posterior teeth placed too far buccally.
In extreme cases, it may not be possible for the tongue to produce a complete lateral seal and so a
lateral sigmatism develops.
(4) The relationship of mandible to maxilla.
The mandible moves closest to the maxilla during speech when the sounds /s/, /z/, /ch/ and /j/ are
made. Normally, at this time, there will be a small space between the occlusal surfaces of the
teeth. However, if the occlusal vertical dimension of the dentures is too great, the teeth may
actually come into contact so that the patient complains that the teeth clatter.
Some phonatic complaints associated with prosthesis
1- Loss of tone and incorrect phonation
Causes: - Decrease of air volume and loss of tongue room resulting from too narrow
dental arch.
- Unduly thick denture bases (especially this part covering the palate).
- Overextended denture and periphery.
Treatment: - Broaden and widen arch form.
- Use narrow teeth.
- Reduce the thickness of the denture base.
- Adjust denture periphery.
2 -Drooling
Causes: - Arch form too constricted.
- Reduced vertical dimension.
- Poor muscle support.
Treatment: - Widen and boarden the arch form
- Restore proper vertical dimension.
- Teeth should be placed to support soft tissue more firmly.
3- Limited jaw mobility and low intensity of speech production:
Causes: Denture looseness; patient tries to suck maxillary denture into position, using
tongue to hold it, hence, mouth does not open widely, speechbecomes muffled,
and jaws move little.
Treatment:
- Check dentures for lack of adaptation, improper border extensions, insufficient
posterior palatal seal and deflective occlusal contacts. Then correct the defect.
4- Phonetic Sh instead of S
Treatment: - Have a slight vertical overlap.
- Increase vertical dimension.
-Set lower so incisal edges can approximate maxillary teeth to within 1
mm.
5-Clicking sound
causes: - High vertical dimension.
- Use of porcelain teeth.
- Poor retention of the denture.
Treatment:
- Decrease the vertical dimention.
- Use risen teeth.
- Treat the cause of poor retention.
6-Lisping and whistling: mensioned before.
Low front vowel: []
To pronounce a
sound, the dorsum of the
tongue arched with the
blade contacting the lower
alveolar ridge and the tip
resting behind the lower
incisors, the position
for E sound is
essentially the same,
except the dorsum is
arched a little higher, with
the blade in heavier contact
with the alveolar ridge and
the tip raised slightly.
To pronounce I
sound, the tongue
is pulled back with
the dorsum
flattened at the
beginning of the
sound, but raises to
the E position for
the completion.
High front vowel: [i]
To pronounce
U , the tongue
first assumes the
E position then
falls back with the
dorsum flattened
for the second part
of the sound.
High back vowel: [u]
For the O sound, the
tongue is in its flattest
and lowest position with
no palatal contact.
(For the consonantal
speech the tongue
contacts the front,
middle and back
portions of the hard
palate in pronouncing
many of them.)
A- The labial sounds P, B, and M: In case of the plosive (P
and B) the palatopharyngeal valve is closed. Lips are closed and then
opened suddenly with the expulsion of impounded air, while in case of
the nasal (M) sound, the pal atopharyngeal valve is opened, part of
this voiced air escape from the nose (resonating nasally)
1- The Labial Or Bilabial Consonants
In the production of the fricatives f, v, and ph sounds, forcing the breath
stream through contact made by the incisal edges of the max.
incisors and the lower lip. the lower lip is brought into contact with
the incisal edges of the maxillary anterior teeth. The lip may curt
over the labial surface of the maxillary teeth to a height of 1-2 mm.
2- Labio-dental Consonants:
b. Lower teeth: Too
far posterior, a space
develops between
the lip and the teeth
during pronunciation
of words containing
labiodental sounds.
c. Too far anterior; the
lower lip crowds into
the lower denture off
the residual ridge
during pronunciation
of labiodental
sounds.
Incorrect position of lower anterior teeth.
3- The Linguo-Dental Consonants:
The fricatives l inguodental sounds, as th in this, are
made with the tip of the tongue extending slightly between
the upper and lower anterior teethmaking incomplete
articulation to constrict the air stream. For the oral
emission on this pressure consonant the palatopharyngeal
valve is closed
3- The Linguo-Dental Consonants:
Effects of vertical positioning of anterior teeth on
the pronunciation of th. A. The tongue is prevented
from extending properly between the teeth.
B. The tongue extending between the teeth when they
are properly positioned
T, D, and N sounds
The Linguo-alveolar S, Z, and, C (soft), sounds
The fricatives (sh) and z (of measure)
The phonemes / tf (ch) / and /dz(dg)/
The consonant /L/
2/10/2011 28
The 10 lingua-alveolar consonants are divided into
five groups, each group having its distinctive place
and manner of production
4- Linguo-alveolar consonants:
The tip of the tongue contacts the alveolar ridge, with the sides of the tongue
in tight contact with the teeth and gingivae. In the case of plosive /t/ and
/d/, the palatopharyngeal valve is closed; impounded breath pressure
is suddenly exploded orally. In the case of nasel /n/ the
palatopharyngeal valve is open, and the voiced breath stream is
emitted nasally.
A) T, D, and N sounds:-
B) The Linguo-alveolar S, Z, and, C (soft), sounds: -
The S, Z and C sounds (sibil ants): the tongue and anterior part of the
palate formthe controlling valve. They result from the formation of a
narrow midline groove of the tongue through which air is directed against
the incisal edge of the teeth; the lateral margins of the tongue contact the
teeth and gingivae and the blade of the tongue nearly touches the alveolar
ridge. The palatopharyngeal valve is closed so that the air stream for
these continuants can be emitted orally
These sounds are
made with the tip of
the tongue against
the palate in the
rugae area with small
space or slit like
channel for the
escape of air between
the tongue and hard
palate. The size and
shape of this small
space or channel will
determine the quality
of the sound.
C) The fricatives (sh) and z (of measure)
fricatives / (sh) and z (of measure) are produced similarly to
/s/ and /z/ except that the tongue groove is broader than in /s/ and /z/.
While the lateral edges of the tongue contact teeth and gingivae, the tip
and blade of the tongue approximate the alveolar ridge The
palatopharyngeal valve is closed so that air can be directed
forcefully between the nearly closed teeth. The lips are often rounded
and protruded. The breath stream for production of / (sh) / is voiceless,
for / z (measure) / is voiced
D) The phonemes / tf (ch) / and /dz (dg)/
linguo-alveolar affricates. The palatopharyngeal
valve is closed in order to accomplish the pressure
required for the combination of a forceful plosive and a
prolonged fricative. The air stream in /t (ch) / is
voiceless, in / dz (dg)/ voiced
E) The consonant /L/
is a voiced semivowel. The tip of the tongue is in
contact with the alveolar ridge, The palatopharyngeal
valve is closed during its production. If the tip of the
tongue is positioned posteriorly with more palatal than
alveolar contact, varying degrees of so-called dark /L/
are produced.
6- The Linguopalatal Consonants:
Two consonants are produced by lingual
approximation to some portion of the palate
posterior to the alveolar ridge.
1. The consonant /r/ is a voiced semivowel
2. The consonant /j/ is a voiced linguapalatal glide
6- The Linguopalatal Consonants:
The consonant /j/ is a voiced linguapalatal glide. It
is initiated with the tongue raised toward the front of the
hard palate, The palatopharyngeal valve is closed
and the teeth are nearly approximated.
7-Linguovelar Consonants
Linguo palatal sounds formed by the dorsum
of the tongue and soft palate) so-called back-
consonants or gutturals, /k/, /g/, and /ng The
velar sounds (K,g and ng) have no effect on
dentures
7-Linguovelar Consonants
Linguo palatal sounds formed by the dorsum
of the tongue and soft palate) so-called back-
consonants or gutturals, /k/, /g/, and /ng The
velar sounds (K,g and ng) have no effect on
dentures
8- Glottal Consonants
Two consonants in which the
constriction is at the level of the
glottis (the space between the
vocal folds) are /h/ and /? /.
The /h/, is an unvoiced fricative
sound. The palatopharyngeal
valve is typically closed. Tongue
and lip positions do not
influence the character of the
phoneme.
The second consonant, /? /,
is a glottal plosive produced
by sudden impedance and release
of the breath stream at the glottis.
sounds. It is commonly
produced by infants.
COMPLETE DENTURE THEORY AND PRACTICE Stress Analysis
Stress Analysis
The effect of stresses on the dental structures with various prosthetic appliances is a
subject, which has been extensively studied. Most of these studies were in-vitro.
In-vivo versus in-vitro studies:-
It was stated that testing laboratory dentures are more accurate than those
clinically performed. This is attributed to the possible teeth mobility accommodated in
between impression making and due to difference in mucosal compressibility during
making impressions.
The ultimate test for any research conclusion is its application to patients and,
therefore, all dental researches should have, for its proving ground, the final evaluation in
the oral cavity
.
Any valid test in vivo should be repeated in the same mouth several times under
the same conditions of the supporting teeth and mucosa. This statement is based on the
following reasons: Histologic structures of the periodontal tissues vary from patient to
patient, the bone surrounding the roots varies in consistency, thickness, and height, and
the length and shape of roots are different. Due to these facts, it is obvious that there are
variances in the degree of mobility of the teeth from patient to patient.
These variances in teeth mobility fluctuate in the same mouth depending upon
prevailing conditions, such as, time of the day, general physical condition of the patient,
and physicochemical changes in the supporting structures from occlusal trauma.
Most biomechanical studies in dentistry are performed in vitro because of the
complex geometry and physiology of dental and oral structures.
Stress Analysis Techniques:-
Many stress analysis techniques were used in dental researches, these techniques
include:-
1- Brittle lacquer coating method:
It is a technique used to measure the strains existing in some bridge constructions.
The tested specimen is coated with a brittle lacquer, after dryness of the coating; the
specimen is subjected to load. The coated lacquer will crack. Then this cracked surface is
analyzed giving information about the surface strains. It was found that this method gives
only an overall picture of the direction and distribution of the strains at the outer surface
of the specimen.
This method allows the researchers to measure the direction and magnitude of the
principle strains on the surface of a three dimensional object. The disadvantages of this
method, is that, its insensitive and requires a good deal of skill in applying the coating.
2- Holographic interferrometry:-
Holographic interferrometry technique utilizes a fiberoptic laser system. The laser-
which is a temporarily coherent and monochromatic source of light, is splitted by means
of a beam splitter into two beams. One of the two beams is used as a reference and the
other is used to illuminate the object. The light reflected from the object interferes with
the reference beam forming lines called fringes. These fringes are registered on a
holographic film plate.
Holographic interferrometry registers on the film the fringes resulting from the
comparison of a deformed object with the non-deformed object used as a reference. This
fringe pattern is produced by a double exposure and because of the extremely high
sensitivity of the technique; continued reference to the undeformed state produces too
many fringes. Consequently, the reference exposure is taken at a given load, and an
increment of load is added to produce the fringe pattern.
Interpretation of the fringe patterns is based upon some basic observations. First,
the direction of the displacement is perpendicular to the fringes .Second the number of
the fringes is proportional to the magnitude of the displacement. Third, the fringes
become thinner and closer with increasing displacement. Although holographic
techniques reveal only surface deformations they are highly sensitive, being able to
register deformations in the order of the wavelength of the light used.
3- Streophotogrammetric analysis:-
The stereophotogrammetry is a means of recording and measuring contours of
landmasses. It is an optical system by which three-dimensional measurements to accuracy
of 11m "in vitro" and clinically to 25m can be obtained.
This technique was used for many applications including:-
Studying changes in the residual alveolar ridge form in cases of distal extension
partial dentures
20,21
. Also, it is used to study the abutment tooth movement in cases of
distal extension removable partial dentures clinically and in vitro.
It was mentioned that higher strains were distributed along the cervical region of the
supporting bone and the root surface this by strain gauges experiments, also by
photoelastic test it was that stress pattern decrease from the cervical to the apical region
of the root surface. These studies highlight the role of the periodontium in stress
distribution and bone remodeling.
4- Photoelasticity:-
Photoelsticity is a full field technique used in stress analysis testing. Initial
observations of a photo elastic pattern provides quick qualitative analysis of the overall
stress distribution and then an accurate quantitative data of any selected point is easily
obtained using straight forward measurement techniques and modern optical
instrumentation.
When a photoelastic resin is subjected to load these resins, alter the polarization of
light shining through them. Light is passed through a polarizing filter set at 90
0
to the
illuminating filter; light of different wavelengths rotates according to the level of stress in
the photo elastic resin. Stress liners are revealed as colored hands running across the
model. By determining the color shift, the pressure level of stress in the model can be
determined.
Photoelastic techniques are used with in vitro studies of dental structures and
embrace three broad categories:
a Photostress photoelastic coating:-
In which a specially formulated plastic coating is bonded to the actual test part or
structure, then as test or service loads are applied, the coating is illuminated by polarized
light. This technique was used to study different designs for distal extension removable
partial dentures.
b Two dimensional model analysis:-
In this technique, the design geometries and cross-sections are made from flat
sheets of photeolastic material and analyzed in a transmission polariscope.
The light transmitted by the transmission polariscope passes through the stressed
model. This leads to production of interference pattern, which could be recorded
photographically. Through studying this pattern the magnitude and direction of the
stresses can be determined. Many authors to study different designs for distal extension
removable partial denture used two-dimensional photoelasticity.
c Three dimensional model analysis:-
This technique provides a visual display of stress transmitted to the simulated teeth
and residual ridges and reveals stress concentration that is readable at any given point in
terms of direction and magnitude.
With this technique, a scaled three dimensional model is made from a specially
formulated epoxy plastic. The model is then placed in an oven and with force applied, it
is subjected to a careful prescribed heating-cooling cycle to freeze the deformations
resulting from stresses. After stress freezing, the model is sectioned to permit removal of
slices from various planes of interest. Slice examination takes place in a specially
configured transmission polariscope to reveal and measure the complete stress
distribution in the plane of the slice.
Photoelasticity was used to measure the biologic behavior of two implants retaining
different designs of cantilevered bar mandibular overdentures and to compare load
characteristics.
5- Finite element analysis:-
It is as a numerical method based on the principle of dividing a structure into a finite
number of small elements that are connected with each other at the corner points or
nodes. For each element, its mechanical behavior could be written as a function of the
displacement of the nodes. These nodes are submitted to certain loading conditions
resulting in a behavior of the model similar to the structure it represents.
Three dimensional finite element stress analysis of a cantilever fixed partial denture were
studied. The results showed that a cantilever pontic creates considerable compressive
stress on the abutment nearest to the pontic and produces tensile stress on the abutment
farthest from the pontic.
Two-dimensional finite element method was used to investigate the preferred design for a
cast circumferential clasp. The results suggested that the use of the performed clasp
pattern with a taper of 0.8 is preferable for reducing fatigue and or permanent
deformation of the clasp.
The finite element method is favorable to other methods because the dimensions and the
properties of composite materials can easily be simulated
34
.
It was stated that the information needed to calculate the stresses and displacements in
the model are:-
a) The total number of nodal points, and elements.
b) A numbering system for identifying each nodal point and element.
c) The elastic modulus and Poisson's ratio for the materials associated with each
element.
d) The co-ordinates of each nodal point.
e) The type of boundary constraints.
f) The evaluation of the forces applied to the external nodes.
Limitation of finite element:-
It was considered that, the limitation in creating an effective model is a disadvantage of
this method. The dental tissues have an anisotropic properties that is, they are different
depending on the orientation of the tissues. Furthermore, the boundaries between
different structures are very difficult to replicate.
Another limitation to finite element analysis is that it is not known at which
amount of stress biologic changes take place, as bone resorption and deposition, which
makes it difficult to drive definite conclusions.
Types of finite element analysis:-
Three-dimensional analysis: All the dental structure is highly irregular in shape
and relevant stress analyses may be carried out three dimensionally.
An axisymmetric solid was defined as a three dimensional body developed by the
rotation of a planar section about an axis. If the loads are axisymmetric, it may be
represented a two dimensional section.
The plane strain was defined as follows, which a solid can be subjected to a
constant condition of loading normal to its axis, and can be analyzed as infinite of two-
dimensional slices of unit thickness.
Application of finite element in dentistry:-
A three - dimensional finite element analysis was used to study the effect of prosthesis
height, angle of force application and implant offset on supporting bone.
A three- dimensional finite element analysis was used to study the biomechanical aspects
of marginal bone resorption around osseointegrated implants.
The influence of occlusal loading location on stresses transferred to implant supported
prostheses and supporting bone was investigated by 3- dimensional finite element
analysis.
A two-dimensional finite element analysis was used to determine the optimal thread
form configuration for an experimental stepped screw implant.
6- Strain gauge technology:-
Their use was recomended because of simplicity of installation, and adequate
response to fluctuating and static strain with an easily recorded output. They
recommended its use in vitro application because of the difficulties during in-vivo study,
e.g. presence of saliva, rapid temp changes movement of the patient resulting in
movement of the transmission wire, in addition to this, to its difficult and invasive
application in soft tissue. Another limitation of strain gauge that it can not be used at
locations out of reach.
Types of strain gauges:-
a- Vibrating wire gauges acoustic strain gauge
This method was described as a wire stretched between two posts attached to the
tested specimen, which vibrate at a particular frequency. The change in the distance
between the posts due to straining of the specimen leads to change in the tension of the
wire and its frequency, which is measured through a magnetic field.
b- DeLeiris pneumatic strain gauge:-
The principle of this device depends on the amount of air discharged from
constant pressure vessel through a discharge which is controlled by a small plate attached
to the tested specimen.
c- Dial gauges:-
Dial gauges were used for measuring small displacements of models subjected to
static loading. Its principle depends on the movement of a plunger in the form of spring
loaded to keep it in contact with the tested specimen. This movement is transmitted
through a rack and a pinion to a gear strain for its magnification and finally to a pointer
with a scale graduated in a division of 0.01 or 0.001 mm.
d- Mechanical stain gauges:-
They fall into two broad categories:-
1- Short gauge length with high magnification:
Its principle depends upon its holding against the tested specimen by a
spring pressure or a suitable clamp.
2- Long gauge length with low magnification:-
In these gauges the magnifying element is a twisted metal strip with an
attached long pointer, moving over a scale. The strip is fixed at one end and
attached to a moveable knife-edge on the other. The mechanical strain gauge
needs some experience in use.
e- The transducer:-
Transducers are devices used to convert one form of energy to another. There are
many types of transducer adopted in different methods.
Three types of transducers were reported ultrasonic methods depending on the
time taken for ultrasound pulse moving between two opposing transducers attached to the
tested specimen. Piezo-electric transducers types depend on the properties of certain
crystals and ceramics, which are electrically polarized when they are mechanically
strained. On the other hand the principle of the hydraulic pressure transducer is using a
fluid tube as a detector transducer and through the pressure of the fluid; a wave can be
recorded during mastication.
f- Electrical strain gauges:-
Some types of electrical variables commonly used were mentioned as electrical
capacitance strain gauges which were considered to be the simplest arrangement, and
composed of two condenser plates attached to the tested object by posts mounted a part
from each other, at some convenient distance. One plate is earthen and the other is
connected to a circuit. Consequently, the change in capacity can be measured for a
relative movement of the plates. It was added that the electrical inductance strain gauge
has an electrical circuit with a magnet, which can be altered by mechanical means, as
well as the electrical resistance strain gauge which are the widely used types of strain
gauges. He further divided it into two types; the bonded wire strain gauges which consists
of a fine wire sandwiched between two strips of paper or other backing material in a
zigzag manner. The ends of the two wires are welded to heavier lead wires and the metal
foil strain gauge which is similar to the above type but with a very fine foil instead of
wire. This type has greater heat dissipation.
Electrical resistance stain gauges have been used extensively in the stress analysis
studies with different prosthodontic appliances designs both in vitro and in vivo. This
technique is the most common method used for dental stress analysis and overcomes
many of the shortcomings of the application of other methods.
Theory of strain gauge:-
A metal element such as a wire, will change resistance when elongated. The strain
on an object can be measured by insulating a wire and cementing it to the object. The
change in resistance of the wire during loading is measured. This change in resistance can
be converted to strain measurements. This can be done by using the gauge factor of the
gauge with the following equation.

R/R R/R
G.F.= OR G.F.=
L/L
Where:-
G.F. is gauge factor.
R. is gauge resistance.
.R.is change in gauge resistance
L. is initial length of the gauge
AL. is the change in length of the gauge
. is the strain being measured.
The gauge should have a high gauge factor that they respond to small strains; they
also should display a high degree of thermal stability so as to minimize apparent strains
due to transient temperature fluctuations. It is important to protect the gauge from
humidity to obtain reliable readings.
A dummy gauge was used which is bonded to a similar material and in the same
environment as that, of the active gauge for this purpose. It was added that the dummy
gauge should have the same gauge factor as that of the active one.
Wheatstone Bridge:-
Strain gauge instrumentation utilizes the Wheatstone bridge as the primary circuit
used in stress-strain measurement. The bridge is extremely sensitive to small changes in
resistance and the output voltage of the bridge is proportional to the change in resistance
in the strain gauge
47
. The wheaststone bridge was described as shown in Fig.1
Where G= Galvanometer & R= Resistance
Fig. 1 Basic circuit of Wheatstone bridge.
For a balanced bridge, RA/RD=RB/RC also for maximum sensitivity RA=RB and RC=
RD. This technique is accurate, reliable, and it is possible to use small transducers that
can be installed in prosthetic appliances to measure occlusal forces during function.
Application of strain gauges in prosthodontic research:-
Strain gauges have been used to study the stresses induced in dental structures.
A cantilever beam of highly elastic spring steel loaded with two strain gauges was
used to study the effect of different removable partial denture clasp designs on abutment
tooth movement in distal extension cases. A diaphragm pressure transducer was used to
study the relationship between the width of the occlusal table and pressure under dentures
during function. The same technique was used to record forces transmitted to the
underlying tissue,. Electrical resistance strain gauges were also used in many studies
where the gauges were directly bonded to the surfaces at which strain was to be recorded.
The validity of diaphragm and cantilever strain gauges was compared in dental
research. The diaphragm assembly was found to be more sensitive. It was recommended
to place more than one diaphragm at strategic areas where quantitative accuracy is
required.
Electrical resistance strain gauges were used in the form of pressure transducers to
study the pressure distribution using tissue conditioners on simplified edentulous ridge
model and used to study the effect of occlusal scheme on the pressure distribution of
complete denture supporting tissues.
A non-linear finite element stress analysis was compared with in vitro strain gauge
measurements on strain in an implant-abutment complex. It was concluded that there is
compatibility between non-linear finite element stress analysis and in vitro strain gauge
analysis on the measurement of strains under the vertical loading. However, there are
differences between the methods in the quantification of strains on the collar of implants
under lateral loading.
Strain gauges were used to compare stress and strain magnitudes of butt-joint and
internal cone dental implants in a bone simulant and were used to measure the strain
magnitudes around endoosseous dental implants opposing natural teeth or implants.

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COMPLETEDENTURE

Terminating part of Alveolingual

Dislocating the denture

Presence of mobility is an indication of future implant failure. Mobility may be due to

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