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I didnt have the slides so it made it much more difficult to me forgive me for any mistakes

We will discuss two topics in this lecture : 1- Post dam in complete dentures 2 - Check records

Post dam complete dentures

This is a typical picture for an upper edentulous mouth. What you have being doing during your third year is learning how to construct a complete denture. In order to have a successful complete denture, it's important to achieve retention and stability in the final complete denture. Anteriorly we have the labial sulcus and posteriorly the buccal sulcus, in both these areas we can easily achieve a peripheral seal. But what is peripheral seal ? Peripheral seal is the area of contact between the mucosa and the peripheral polished surfaces of the denture base, thus preventing passage of air between the denture and tissues). It depends upon the proper extension of the denture borders, both in width and depth, to fill the mucobuccal space and contact the cheeks and lips without distorting them. achieved by having the peripheral borders and the polished surfaces of the complete denture in contact with the mucobuccal and the mucolabial fold (. This is ensured by proper border moulding) .This will help in preventing air from leaking beneath the denture surface. However, the problem is in the posterior area where no posterior vestibule is present So how can we achieve a posterior seal in this area?

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there is a unique tissue structure in the soft palate which allows us to apply some pressure but within a certain physiological limits. To compensate for the absence of the vestibule we need something that stays constantly in contact with the tissues of the soft palate that will help in preventing the air from leaking beneath the complete denture. . This is known as post dam This part in the patients mouth is called the posterior palatal seal area the opposing area which is part of the denture is called the post dam so they are two different parts. posterior palatal seal is part of the patients mouth .

post dam is part of the denture which is going to sit against the posterior palatal seal area. what are the anatomical landmarks to the posterior palatal seal area ?and how we are going to determine it in the patients mouth?

The Post Dam Area

The post dam is an elevated ridge of acrylic, so it is extra amount of acrylic is added on the posterior fitting surface of the denture, this will be in continuous contact with the posterior palatal seal in the patient's mouth. So the main aim is to achieve good peripheral seal both during rest and during function, we can achieve this by a proper border molding using the green stick.

So if we have achieved a successful peripheral seal we will achieve: 1- a good retention ( which is preventing the denture from falling downward) if we have a dislodging force acting perpendicular to the base of the denture.
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Cohesion (retentive forces between similar molecules, ex saliva) and adhesion (retentive forces acting between dissimilar surfaces, ex saliva between the denture fitting surface and underlying mucosa) and surface tension. All three help in retaining the denture when forces are applied 90 degrees to the denture base. 2- Lateral and horizontal dislodging forces are resisted by having complete peripheral seal. 3- Increasing stability of the denture and this is achieved by having an intimate contact between the soft tissues and the denture. So whenever denture moves; it will remain in contact with the underlying resilient tissues of the soft palate thus increasing the denture's stability.

advantages of post dam and posterior palatal

seal
1-It decreases: a) Gagging - which is usually stimulated by touching the posterior third of the mouth not by touching the soft palate, so if we have a denture which drops every second and continuously touching the posterior third of the mouth, that will stimulate the gag reflex. b) tongue discomfort - the post dam should blend with the tissues of the soft palate. It does not end as a butt joint c) food accumulation - there will be no separation between the denture base and soft tissues thus food accumulating beneath the denture.
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2-it compensate for shrinkage : When you process acrylic (PMMA); there will be polymerization shrinkage. Post dam will act as reservoir in order to compensate for the amount of shrinkage that might happen. 3-having a partial vacuum effect: Having continuous vacuum throughout when the denture is in the patients mouth is harmful, which usually ends by pathological tissue overgrowth. All what is needed is to only a partial effect. This is only activated when having horizontal lateral tipping forces which is not enough for to dislodge the upper denture, it will only slightly break the peripheral seal and this will lead to little amount of air leaking beneath the denture. Atmospheric air pressure is higher than the one beneath the denture and this pressure gradient will help to keep the denture in place.

anatomical landmarks:
1- pterygomaxillary notch ( hamular notch) its located posteriorly behind the tuberosity area and in front of the pterygoid process. This area has the capability of withstanding the physiological compression so we would like to extend the posterior border of the complete denture into this area. However, it's so important not to extend it over the pterygoid process because its only covered with a thin layer of mucosa . 2- fovea palatine which is the two ductal openings of the mucus glands which is found on either side of the midline. It helps in determining the vibrating line.

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3- midpalatal raphe a very thin layer of mucous membrane overlying the midpalatal suture, appears clinically as a tight cord, contains little or no submucosa and will tolerate little compression, may extend onto the soft palate. So when designing the postdam, it is important not to cause any pressure on it. 4-pterygomandibular raphe loose band of connective, extends from the pterygoid process to the retromolar pad area, mustnt be encroached upon by the denture. 5- posterior nasal spine which is the posterior part of the palatine bone, and that will affect the shape of the anterior vibrating line (see below) 6-vibrating lines We have anterior vibrating line and a posterior vibrating line. The anterior vibrating line is an imaginary line located between the well attached tissues which are overlying the hard palate and between the compressible ones over the soft palate. It is always on the soft palate and should NOT be confused with the junction between the hard and the soft palate (it's never in the hard palate because we need certain amount of compressibility). It is not a straight line due to the projection of the posterior nasal spine. The posterior vibrating line is an imaginary line, it represents the demarcation between that part of the soft palate that has limited or shallow movement and the remainder of the soft palate that is markedly displaced during function. Marks the most distal extension of the denture base. In the majority of patients (70- 80%) the posterior vibrating line is located anterior to the fovea palatine and t is found to be behind the fovea palatine in around 20% of patients.
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The area between the anterior and posterior vibrating lines can be compressed by the post dam in the upper denture because the area it covers from the soft palate contains glandular and adipose tissue, however you can notice here that there is minimal depth and width in the mid palatine part but why? Because this area does not contain glandular and adipose tissues and its covered by a thin layer of mucosa so we try to avoid having pressure over this area.

The posterior palatal seal area - anatomically

it's divided to two distinct anatomical parts: 1- the pterygomaxillary seal (A in the pic) 2- the postpalatal seal (B in the pic) Both of them constitute the posterior palatal seal area. Pterygomaxillary seal occupies the entire width of the hamular notch (extends from the distal surface of the tuberosity to the hamular process), continuing 34mm anterolaterally approximating the mucogingival fold.

(A) Pterygomaxillary seal extends through the pterygomqxillary notch (B)Post PS extends medially from 1 tuberosity to the other (C)posterior PS area lies btw the anterior & posterior V.L

Post palatal seal extends medially from one tuberosity to the other and it occupies the vibrating line.

classification of soft palate:

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Knowing the classifications of the soft palate will guide us in determining the outline of the post dam area. we have three classifications according to the angle which is formed between the soft palate (The more acute the angle the more muscle activity there is). 1- Class one : it's actually the most favorable because we have minimal muscular activity and its almost horizontal in shape, this will allow us to achieve the widest area (large distance between the AVL and PVL) of post dam however that will be the least in depth. 2- Class three : we have the maximum muscular activity (acute angle which is formed between the hard palate and the soft palate), which means that the soft palate will be more displaced compared to class 1 and class 2, this will lead to the narrowest post dam but the deepest. 3- Class two: lies between class 1 and 3 in its properties. Having mentioned that class 3 have the maximum displaceability and imagine we have a denture in place, so if the soft palate is going to be displaced downwards and forming an acute angle between the hard and soft palate, there will be a large gap between the fitting surface of the denture and the soft palate, so I need to increase the depth scrapped in the cast and therefore the thickness of the post dam area in order to preserve the intimate contact between the fitting surface and the soft tissues.
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Now in class 1 I have a minimal movement so there is a minimal space between the fitting surface and the soft palate so no need to increase the thickness of the post dam here, so its the widest however its the least in depth.

outline shape of the post dam

According to the classification of the soft palate I can outline the shape of the post dam area. There are three major types: 1- major and minor 2- cupid's bow or the butterfly shape ( which is the most used here) 3- single line In an average Class I soft palate the widest area of the butterflyshaped post dam is between 4 to 6 mm in width. However, it is 23mm in the modified butterfly. Picture represents the width and depth of the post dam in an Class I soft palate. The two mm in the hamular notch is almost average in the human beings however the area over the 4-6 mm may have slight variation between individuals and this will depend on the amount of displace ability and the activity of the muscle in the soft palate. Now the depth of the hamular notch is around 0.5 ml that will increase gradually to reach its maximum (in which we have the glandular and adipose tissues) and then will decrease gradually to reach 1ml towards the midline.

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 recording the posterior palatal seal (clinical part ) We can do it at any stage after the primary impression, however we usually do it at the try-in stage. We can do it in the master impression stage if we can anticipate that we are going to face problems in the retention of the record blocks at the jaw registration stage. The techniques in the clinic: 1- anatomical 2- functional 3- arbitrary - 'guess estimate' the least accurate

The anatomical technique: We start creating the post dam at the secondary impression by proper border moulding using green stick. We should check that the tray is well extended (2mm behind the fovea palatini) to prevent having an under extended post dam area at the final denture compromising the denture's retention. Green stick is a soft flowable material and it needs something rigid to support it. Thus, we should apply it over the posterior acrylic not the posterior edge. And to compress the soft tissues there should be enough thickness of the material. When it comes to the anatomy then we should determine: a) Pterygomaxillary seal b) Postpalatal seal (PVL, AVL) First. outline the pterygomaxillary seal by an indelible pencil line is placed through the hamular notch and extended 3-4mm anterolateral to the tuberosity, approximating the mucogingival junction.
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How to determine the posterior vibrating line? 1- asking the patient to say AHHH in short bursts 2- Valsalva maneuver: ask the patient to close their nose and to forcibly blow against the closed airway; noting the area between shallow and marked displacement) Determining the compressibility How to determine the anterior vibrating line ? AVL is determined by palpating the tissues anterior to the PVL using a T burnisher or mouth mirror to determine their compressibility and width. Valsalva maneuver or AH may be also used. Note the area in front of the posterior vibrating line until the compressibility of the tissues reaches its minimal or disappears, that will demarcate the anterior vibrating line. So we determine with an indelible pencil the lines in the patients mouth and either insert the record block, the trial denture, or the master impression (depending in which stage we are recording the posterior palatal seal area) in the patient's mouth. The aim is to copy the lines from the patient's mouth to the master cast to the correct depth and width that we have The anterior vibrating line has transferred to already talked about.
the master cast tissues using T burnisher

of

Disadvantages of the anatomical technique

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1)There is a chance to over compress the tissues beyond their physiological limits and 2) it needs accuracy in transferring these lines into the master cast.

The functional technique It is actually done in the master impression stage. All the steps in determining the posterior palatal seal are repeated just like the conventional way. After we finish border moulding and made the secondary impression using ZOE, we transfer the lines drawn intraorally to the master impression after it has set. After copying the post dam area onto the impression, we fill this area with a flowable wax which is designed to flow at mouth temperature. On the secondary impression, we melt the wax and place it over the determined posterior palatal seal area which was transferred to the impression. Wax is applied slightly in excess and allowed to cool below the The melted wax is painted onto the final impr mouth temperature to increase its within the outline of the posterior palatal seal consistency then held hold the tray under gentle pressure and leave it in patient's mouth for 5 minutes. Wax will flow at the patient's mouth temperature and will record the physiological displaceability of the soft tissues. The elevated part of wax will be replicated, when pouring the impression, as a negative depression in the master cast.

Advantages of functional stage

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1- over trimming the master cast is avoided 2- over compressing the tissues is avoided 3- it helps in achieving a better retentive record blocks at the jaw registration stage. 4- mechanical scraping of the cast is avoided Disadvantages: 1) more time is needed 2)difficulty handling the material.

Errors in recording of posterior palatal seal

1- under extension Which will have a short posterior border of the denture that will compromise our retention and stability of the denture. what might have lead to this under extension ? A) poor examination and poor determining of the posterior palatal seal area. B) it can be seen in patients who have severe gag reflex because during the primary or secondary impression you try not to push the material to the posterior part of the patient's mouth, so you will have an under extended master impression and therefore the final result will be an under extended complete denture. 2-over extension We sometimes try to overextend the upper posterior border thinking that we are maximizing the retention. However, the posterior edge will contact the active portion of the soft palate and will drop each time the soft palate in function compromising the retention. Overextension is due to wrong determining of the PVL. Patient will come complaining from painful swallowing and ulcers. Pain in the pterygoid process area which is covered by thin mucosa.
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We can overcome this over extension by cutting back the distal border.
3-shallow post dam

Can either be due to 1)mouth widely open and pterygomandibular fold becomes tense OR 2) under scrapping of the master cast. To overcome this problem we can further scrap the master cast and adapt the trial base if the conventional anatomical way is used or add more wax if the functional way was selected.

4-deep post dam: Due to over scrapping the master cast. Swallowing is painful and difficult, ulcers, nausea, loss of retention can all be expressed by the patient Correct it by selective trimming and polishing to the over convexities in the post dam.

Now we will talk about another topic which is:

Check records
At the insertion stage; you can end up by two scenarios - a successful polished surface, fitting surface and occlusal harmony or a denture full of errors and disharmony in occlusion. Now there are many causes that may lead to such a, less than ideal, final result, it can be due to lab error or clinical error.

Errors in occlusion can be due to: 1) incorrect registration of the centric relation.

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At the jaw relation record we have unstable record bases and there is a big chance they will move while recording the centric relation resulting in premature contact (unilateral, bilateral or in the incisor region) and leading to uneven compression of the underlying mucosa. You will end by having a premature contact on one side and a gap on the other side. This does not happen on cast, so this may pass unnoticed at the try-in stage. 2) poor mounting of the record blocks, you have achieved a good jaw relation record, you have sealed both upper and lower record blocks but you missed to check that the heels of the casts are not touching... so you will end up by incorrect jaw relation records . 3) irregular setting of the teeth by the technician, failing to achieve even contact in both centric relation and lateral excursions. Teeth are set in soft wax when cooling the wax will shrinks, so that may add to some of the inaccuracy at the insertion stage. the other cause is that at the try in stage the teeth are set in wax so you try to determine if you have a correct centric relation, however the patient can bite hard on one side than another, or if he has any premature contact there will be a slight movement of teeth under wax, or sliding of the base plates to achieve the maximum inter-cuspation between teeth. This is why problems can go unnoticed in the try in stage and that will only be noticed at the insertion stage. 4) Flasking errors

How can I adjust occlusion?

1-If I had minimal errors I can adjust them at the chair side. I insert the upper and lower denture, mark any premature contacts of high pots using articulating paper and adjust chair side. .
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2-Lab remount The main purpose is to achieve occlusal harmony (balanced occlusion and articulation) , re-establish the correct vertical dimension . I shouldnt over trim while adjusting teeth because otherwise I will lose the correctly determined vertical dimension. Ideally it should be done routinely after each de-flasking and before inserting the denture in the patient's mouth. Now this is the master cast and the processed denture still attached to it after deflasking. (Keep in mind that we still have the plaster mounting bases and the master cast at this stage). we re-attach the master cast into the plaster mounting and then get them back to the articulator because we need to know if we have done enough processing errors to either increase the vertical dimension due to processing or if I have any occlusal disharmony due to any tooth movement during flasking which was incorrectly repositioned. I shouldnt have the incisal pin raised more than 1 mm away from the incisal table. This would indicate that enough errors are done that merits the need to remake a new denture.

Summery -> LAB REMOUNT PROSEURE :

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Now after I have adjusted the dentures in the lab, and got rid of any lab errors. I send them to the clinic to insert them in the patients mouth. All what I may face of errors now are clinical ones, which may have happened during jaw registration stage. 3- clinical remount In the clinical remount I destroyed the master cast, in order to get the dentures out of them. I have nothing to remount the denture again back in the clinic, so how can I know the actual relationship between the upper and the lower once again ? We should first agree that the vertical dimension is correct at the insertion stage. Now, if I inserted the upper denture and the lower denture checked that(retention, stability, aesthetics are satisfactory) but there was a huge occlusal disharmony (ex anterior or posterior open bite, uneven contact etc...) that can't be corrected chair side I have to do something called clinical remount. Firstly, I have to remount the upper denture using either a facebow ( which is the most accurate) or arbitrary mounting jig that you have used in the lab. Now before remounting the upper denture you have to block out any undercuts in the fitting surface using tissue papers because we are going to pour the denture with plaster, so we are dealing with the denture as an impression, if we miss this stage the denture will be locked in the cast and will break upon removal.
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Now after mounting the upper denture on the articulator, you separate it from the plaster you insert it in the patient's mouth then you insert the lower denture as well. I now need to determine the relation between the upper and the lower, we have to re-record the centric relation once again. How can I record the relation between the upper and lower ? We have something called the ALUWAX or we can use the red modeling wax. Cover the maxillary teeth with 2-thicknesses of base-plate wax or ALUWAX but not beyond the buccal cusps (hinders visual assessment). Guide to RCP and stop just before teeth contact, teeth separation is about 0.5mm. Any area of thinned wax (uneven pressure) => repeat Accuracy is crucial Make sure that you have a stable lower denture. Remove both dentures together and mount lower denture after blocking the undercuts!. The relation between the upper and lower dentures are determined in the pre-centric position, which means that I will guide the patient to the centric relation where the condyles are in the most superior and anterior position, however I dont want the patient to go bite through the entire width of the wax (I dont let the teeth to touch each other), because if they do touch it will lead to displacement of dentures...repeating the same error that we have already done at the jaw relation stage. Any penetration or thinning in the wax will necessitate repeating the pre-centric record.

centric relation precentric

teeth are touching

avoid teeth touching

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To put things together, we mounted the upper after blocking out the undercuts=> take the pre-centric record=> mount the lower => remove the wax which was used to record the relation between the upper and lower dentures=> we will be left out by space which represents the thickness of wax=> we need to close the incisal pin in order to see where is the first premature contact I am facing.

adjusting the centric relation:

1-We can have a premature contact between a cusp and a fossa, but the question is: shall I deepen the fossa?or shall I trim the cusp ? or does it make any difference if I have a functional cusp or nonfunctional cusp ? Which one we try to avoid ? Answer: Avoid adjusting functional cusp as those are the ones which preserves the determined vertical dimension. The functional cusp in the upper The functional cusp in the lower palatal cusp buccal cusp

So imagine if we have premature contact between the upper palatal cusp (which is the functional cusp ) and opposing lower center fossa. Q- Do I have to adjust the palatal cusp or deepen the opposing fossa ? I can't determine now, I have to further ask the patient to do lateral excursions. if the cusp is high in both centric relation and lateral excursion, the problem is from the cusp, so I have to adjust the it. However, if the cusp which is already high at the centric relation is out of occlusion in lateral
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excursion, this means that the problem is coming from the fossa and we have to deepen it. Summary: so at centric relation it's difficult to determine whether I have to adjust the cusp or the fossa, so we will have to further ask the patient to move to lateral excursions and determine if the cusp is still in contact and needs adjustment. This picture is a premature contact between the functional cusp which is the buccal cusp in the lower, and the opposing fossa in the upper, so if this cusp is still high at lateral excursions, I need to adjust from the cusp, I adjust the slopes of the cusp(the mesial and the distal slopes) not cut the tip of the cusp.

adjusting the lateral contact:

Now I have achieved an even contact at the centric relation, so I won't touch the centric relation again, I have to go and adjust the lateral contact. Now in lateral we have a working side and a non working side contacts. what is the working side ? If I asked the patient to move to the left side, the direction in which the patient is moving is called the working side, and the right side will be the non working side . if I have both lower and upper buccal cusp touching, I adjust the upper because it's the non functional cusp . if I have both, the lower lingual cusp and upper palatal cusp touching I adjust the lower lingual cusp.
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so this rule is called the BULL rule, we adjust the buccal upper cusp and the lower lingual cusp, which are the non-functional cusps. Now what if we have a balancing interference (which is on the nonworking side) this happens with between both functional cusp between the upper palatal and the lower buccal cusp, so shall I trim the upper or the lower ? It is preferable to preserve the palatal cusp and rather adjust the lower. We try to adjust the slope of the cusps, by re-shaping the buccal-facing slope of the upper palatal cusp and the lingual-facing slope lower buccal cusp .

Adjusting the protruding contact:

By asking the patient to slight forward to an edge to edge contact. I may have anterior and/or posterior pre-mature contacts. - Grind the palatal surface of the upper anteriors and labial surface of lower incisorsthis does not reduce teeth length but sometimes I need to reduce slightly from the length of the lower incisors. -Anterior interferences are adjusted by preferably grinding the lower incisors because presumably the clinician has spent time to ensure correct aesthetics and phonetics. -Posterior interferences are adjusted by grinding the distal slopes of upper cusps and mesial slopes of lower cusps.

Now after adjusting everything you need re-polish the teeth to have a smooth surface, not ending by having rough surface after trimming the teeth. This can be done by applying some pumice to

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the occlusal surface of teeth and move them against each other, while they are still on the articulator. THE END

Wish you all the best of luck Life is too short, so smile while you still have teeth Diana : thank you for helping me ( bs mu kteer :P ) bel tafree3' o god bless our lovely friendship <3 Lana ( LOna :P ) ya a7la pharmacist bel denyeh And of course Ayah , Antibody and Fara7 ... ...

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