Complete Dentures

The Wax Try-InThe Wax Try-In

Introduction

Goals:Goals:•Evaluate and finalizeEvaluate and finalizethe anterior esthetics.the anterior esthetics.•Verify the vertical Verify the vertical dimension.dimension.•Evaluate and finalizeEvaluate and finalizethe occlusion. the occlusion.

The student/practitioner should:The student/practitioner should:

•Complete the wax-up/set-up.Complete the wax-up/set-up.•Evaluate all aspects of the set-up.Evaluate all aspects of the set-up.•Obtain patient approval.Obtain patient approval.

Armamentarium

•Mounted Casts/Wax Dentures.•Dental floss.•Fox plane. •Denture Adhesive.•Hand Mirror.•Cup of water.•Mold Chart.•Denture tooth shade guide.•Denture base shade guide.

Armamentarium

•Tongue blade.•Baseplate Wax.•Flexible Ruler.•Waxing Instruments.•Bunsen burner.•Alcohol torch.•Indelible transfer stick.•Red-handled knife and a sharp blade.•Green handled knife.

Prior to this appointment, the wax dentures are completed. All teeth are set properly and the wax-ups are festooned properly. Zero-degree, monoplane occlusions must have perfectly flat occlusal planes on both maxillary and mandibular dentures.

Flat planes should exist from the mid-buccal of the canines to the mesio-buccal of the first molars and from the mesio-buccal of the first molars to disto-buccal of the second molar on a plane turned approximately 20o toward the palate from the first plane so that the buccal surfaces of all molars are in a straight line. This rule applies to both anatomical teeth and zero-degree teeth.

Mandibular posterior teeth Mandibular posterior teeth must be set so that they are must be set so that they are over the crest of the ridge, over the crest of the ridge, with zero-degree teeth set with zero-degree teeth set so that the central fossas so that the central fossas lie directly over the crest lie directly over the crest and anatomic teeth set so and anatomic teeth set so that their buccal cusps are that their buccal cusps are over this line. With over this line. With severely resorbed ridges, severely resorbed ridges, lines are drawn from both lines are drawn from both sides of the retromolar pad sides of the retromolar pad and intersect at the canine. and intersect at the canine. The teeth would be set so The teeth would be set so they fall between these two they fall between these two lines.lines.

The anterior teeth should not be placed further forward than a line drawn perpendicular to the occlusal plane from the middle of the labial vestibule.

1. The buccal surfaces of the maxillary posterior teeth must not be placed any more buccally than a line perpendicular to the occlusal plane drawn from the depth of the buccal vestibule.

2. If ideal positioning of the mandibular posterior teeth dictates that maxillary posterior teeth must be set more buccal than this rule allows, the maxillary teeth must be set in crossbite.

1. Zero-degree teeth set in a monoplane occlusal scheme is desired for all crossbite situations in the pre-doctoral clinic.

2. Denture teeth should not be set on maxillary tuberosities.

3. Denture teeth should not be set on the retromolar pad as this would create forces that would dislodge the denture anteriorly.

A TrubyteR Millimeter Rule will aid in enhancing the curvature of the arch and impart a more balanced look to a denture.

Things to Check•Fit and Extension of Denture Bases.

•Labial Flange thicknesses in Frenum Areas.

•Posterior Palatal Seal Area.

•Posterior Tooth Positions:1. Relation of Plane to Retromolar

Pad.2. Relation of plane to Ala-Tragus

Line.3. Tongue Space.4. Ridge Relationship.

Things to Check

•VDO & VDRVDO & VDR•Centric relation (CR)Centric relation (CR)•ProtrusiveProtrusive•Esthetics and phoneticsEsthetics and phonetics•Posterior palatal sealPosterior palatal seal

•Physiologic rest position Physiologic rest position •Phonetics and esthetics Phonetics and esthetics •Ability to swallowAbility to swallow•Compare to old denture.Compare to old denture.

Things to Check•Positions of Anterior Teeth

1. Lip Support2. Length3. Relation to upper lip4. Interpupillary line5. Midline6. Phonetic exercise: “F” sounds (length of max. anteriors).

•Wax-up.1. Lip support.2. External form.

Things to Check•Vertical Dimension of Face. 1. Phonetic exercise: “S” sounds 2. Palatal contour 3. Swallowing •Esthetics

1. Picket fence or chicklets appearance2. Too much or too little of teeth show.3. Color (Shade)4. Size (mold, length & width)5. Too much base material is visible.

Things to Check•Positions of.Posterior Teeth

1. Is the occlusal plane parallel with ala-tragus line?2. Does the occlusal plane allow the patient to move in protrusive relation w/o the maxillary posterior teeth contacting the heels of the mandibular denture?3. Are posterior teeth set in an end to end relationship in occlusion? 4. Do premature occlusal contacts exist?

Things to Check

•Patient Instructions. 1. Dentures fit better than baseplates because the undercuts are blocked out.

2. The color of the denture base is selected to match the natural color of the patient’s gums.3. There are only a few tooth shades available for denture teeth.

Esthetic Set-Up

Factors:•Tooth Alignment•Golden Mean•Anatomic Contours

Tooth Alignment

•Midline is centered with the patient’s face.•Occlusal plane is parallel with the eyes.

This is a computer-generated picture and is not a picture of an actual patient.

Smile Line•Should

follow the contour of the lower lip.•Varies with

each patient.

Smile Line

Relaxed Positive Negative

EstheticsEsthetics

Closest speaking space (CSS) is used for Closest speaking space (CSS) is used for the final test to determine if the vertical the final test to determine if the vertical dimension is correct. Different amounts of dimension is correct. Different amounts of teeth are visible when the patient speaks teeth are visible when the patient speaks than when they smile.than when they smile.

• Use “s” soundsUse “s” sounds• Count from 60-70Count from 60-70

CSS

Plane ofOcclusion

•Anterior-PosteriorHorizontal Orientation.•Parallel With Patient’sEyes Anteriorly.

In many people, the width of the In many people, the width of the six anterior teeth and the width six anterior teeth and the width of the nose are approximately of the nose are approximately the same.the same.

This is a computer-generated picture and is not a picture of an actual patient.

Length of Maxillary Centrals•Should lie just above the resting lip.•Should contact the wet-dry line during speech (F,V sounds).

“F” and “V” sounds

Fricative sounds: Fricative sounds: Patients should be able to Patients should be able to make clear “f” and “v” make clear “f” and “v” sounds when the incisal sounds when the incisal edges of the maxillary edges of the maxillary central incisors contact central incisors contact the lower lip. the lower lip.

Maxillary anteriors are in harmony with lower lip.

Maxillary anteriors are over-long and collide with the lower lip.

During the production of the During the production of the Sibilants (“s” or “z”) Sibilants (“s” or “z”) sounds:sounds:

a) The anterior and posterior a) The anterior and posterior teeth should teeth should notnot collide (no collide (no clicking).clicking).

b)b) There should be no hissing or There should be no hissing or air loss (not sound like “th”). air loss (not sound like “th”).

c)c) The closest speaking space The closest speaking space should be 1.5 to 3 mm at the should be 1.5 to 3 mm at the second molar region.second molar region.

d)d) The patient will move the jaw The patient will move the jaw 2-3 mm forward during 2-3 mm forward during speaking.speaking.

Sibilant Sounds

The plane of occlusion of a complete denture The plane of occlusion of a complete denture with the second molar left off to match the with the second molar left off to match the mandibular posterior teeth where there was mandibular posterior teeth where there was insufficient room to set the mandibular molar insufficient room to set the mandibular molar without setting it on the rise to the mandible.without setting it on the rise to the mandible.

Verify Centric RelationVerify Centric Relation

Insert dentures and hold lower in position with Insert dentures and hold lower in position with your index fingers.your index fingers.

Retrude the mandible and close into centric Retrude the mandible and close into centric relation.relation.

Observe any shift in the upper denture.Observe any shift in the upper denture. Look for even contact of the posterior teeth Look for even contact of the posterior teeth

bilaterally.bilaterally.

Note the separation of the Note the separation of the posterior teeth in CR. This posterior teeth in CR. This patient’s centric relation patient’s centric relation is incorrect.is incorrect.

Note the separation of the posterior teeth in Note the separation of the posterior teeth in protrusive in this patient. This situation would not protrusive in this patient. This situation would not work because denture would impact constantly on work because denture would impact constantly on the anterior ridge, creating instability, and greatly the anterior ridge, creating instability, and greatly increasing the rate of resorption. The diastemas increasing the rate of resorption. The diastemas between the teeth are permitted at the patient’s between the teeth are permitted at the patient’s request or with their approval.request or with their approval.

• Soften a stick of compound over a Bunsen burner.• Place the compound onto the occlusal surfaces of

the mandibular posterior teeth.• Temper the compound in a water bath set at the

proper temperature (110o) and smooth it with your wet gloved finger. (140o if green stick compound is used.)

Verify Centric RelationVerify Centric Relation

• Remove and trim the record so that only the indentations from the cusp tips are present.

• Place the new record onto the master casts on the articulator.

• Make sure the articulator condyles are locked in centric position.

• Close the articulator.• If the maxillary teeth contact the indentations exactly

as they did in the mouth, you have proven that your original centric record was correct.

If the teeth do not contact the index exactly, remount the If the teeth do not contact the index exactly, remount the mandibular cast.mandibular cast.

• Loosen the condylar locks.• Set the teeth in the index.• Drop the pin so that it contacts the table. • Tighten the set screw.• Remove the mandibular cast.• Lock the articulator in centric.• Remount the mandibular cast to the new record.• Raise the pin so the teeth contact.• Tighten the set screw at that point.

FunctionFunction

•Evaluate:•Vertical dimension•Space available for tongue, lip-support, etc.

Esthetic Try-In

Use of a small amount of denture adhesive ishelpful in building patient’s confidence at the try-in stage.

Observe Maximum Intercuspation

Centric occlusion should correspond with articulator.

Denture provides lip support in B as compared to A, leading to recovery of patients natural appearance.

Lip Support Should Come From LabialSurfaces of Anterior Teeth.

A B

These pictures are computer-enhanced.

Proper contouring of dentures can significantly improve the physical appearance of the patient.

These are computer-enhanced pictures and not pictures of an actual patient.

Evaluate The Relation Of Mandibular Teeth In Relation To

Lower Lip.

Mandibular anterior teeth should bepositioned to contact lower lip.

Evaluate Cheek Contact.

Teeth Should Be in Muscular BalanceBetween Cheeks and Tongue (Neutral

Zone).

Evaluate Position of the Teeth Relative to the Tongue.

Difficult to evaluate

Golden ProportionMona LisaMona LisaNature is Nature is

asymmetric,asymmetric,but but

proportionateproportionate

ParthenonParthenon

Great PyramidsGreat Pyramids

Golden Proportion

When viewed from the front each tooth differs from its neighbor by a ratio of 1.618 to 1.

Selective grinding or rearranging of the teeth can provide a much more lively and more natural appearance. Teeth may need recontoured to permit a proper overlap or contact.

EstheticsPatient Approval/AcceptancePatient Approval/Acceptance

RecontorinRecontoringg

Get patient approval before you characterize anterior teeth.

Standard setting & Standard setting & contouringcontouring

Standard arrangementStandard arrangement DiastemaDiastema

A patient may desire to have a diastema placed in the same location that his natural teeth had a diastema.

OverlappingOverlapping Mesiolingual Mesiolingual rotationrotation

Crowding of the teeth may be desirable for the same reason.

• Anterior setup follows the lip line

• Pointed canines

• Large incisal embrasures

All these characterizations All these characterizations provide the patient with a youthful provide the patient with a youthful appearance.appearance.

TextureLook closely at the texture of the gingiva.

What do you see?

The denture wax-up is contoured to resemble natural tissue by festooning and stippling the wax.

Attached gingivae – orange peel textureAttached mucosa - smooth Orange Peel Orange Peel

Smooth Smooth

Check working (A) and balancing. (B)

AB

Should be finished and neat before seating the patient.

Wax-Up•Wax to ideal contour.•Do not over-polish.(minimal polish of areas around teeth)

Facial support affected by:• Position of the incisal edge• Thickness and contour of the labial

flange• Gingival contours

Without teethWithout teeth With teethWith teeth

Note the Note the contour of the contour of the

vermillion vermillion border region.border region.

These pictures are computer-These pictures are computer-enhanced. enhanced.

• Rotated right cuspid• Pointed right lateral

incisor• Distal incisal edge of

the right central has been recontoured

• Left cuspid is pointed

• Mesiofacial rotation of the left lateral

• Incisal edge of the left central has been flattened

What do you see in this setup?What do you see in this setup?

Posterior Nasal Spine

Velum

Glandular tissue

Posterior Palatal SealPosterior Palatal Seal

• Make points in the fovea palatina area and the hamular notch areas. Connect these points with a solid line.

• Place points in the glandular area 5-8 mm forward of this first line and about two mm anterior to the line at the mid palate.

• Draw a second line anterior to first in a butterfly pattern connecting these dots (looks like two mountains with a valley in between).

a)a) Carve the seal with a cleoid/disoid &/or #7 Carve the seal with a cleoid/disoid &/or #7 spatula or the back of a green-handled knife spatula or the back of a green-handled knife (best).(best).

b)b) It should be .5 mm deep in the middle of the It should be .5 mm deep in the middle of the posterior palate, 1 mm deep in the hamular notch posterior palate, 1 mm deep in the hamular notch area, and 1.5 mm deep in the glandular area area, and 1.5 mm deep in the glandular area between the hamular notch and the middle of the between the hamular notch and the middle of the posterior palate.posterior palate.

c)c) It should feather out to zero at the anterior line.It should feather out to zero at the anterior line.d)d) It should not extend onto the tuberosities or onto It should not extend onto the tuberosities or onto

a torus.a torus.

Check off list• Check vertical dimension of occlusion and vertical

dimension of rest.

• Prove centric relation record.

• Make protrusive record.

• Evaluate esthetics and phonetics.

• Mark the posterior palatal seal.

*These procedures must be performed in the sequence

listed above.