journal of prosthetic dentistry

7/29/2019 JOURNAL OF PROSTHETIC DENTISTRY

1/7

BERNARD A. SUSSMAN, D.D.S.New York, N. Y.

I) ENTISTS IN GENERAL PRACTICE depend upon techniques for complete dentureconstruction which have been found suitable to their skills, and supplementtheir techniques with new concepts offered by specialists. However, areas of dis-agreement may undermine the dentists ability to make successful dentures.This article is a resume of material pertaining to complete denture service.Too often, the efficient, painstaking efforts used in making complete dentures arenegated by the use of an incomplete technique for the delivery of dentures. Downs1commented . . . no one has a trouble-free prosthodontic practice. Martone said Itis possible for successful dentures to be denture failures simply because the neces-sary adjustments are not made. A technique for the delivery of dentures will bedescribed.

IMPRESSION PROCEDURESImpressions should be made of tissues that are free of irritation and free ofthick mucous saliva.3 The impressions should have contact pressure4 and shouldcover as much tissue as possible without encroaching on the surrounding tissues.The contact of the borders of the impression with the surrounding tissue is most

important. Before impressions are made, dentures should be left out of the mouth foras long a time as is necessary to permit the mouth to return to good health anduritil the tissues have recovered from damage and irritation resulting from previousdentures.5-7 Patients can leave dentures out of the mouth from Friday evening untilMonday morning (about 60 hours). This is a suggested recovery period.TISSUE CONDITIONING

Chase* outlined his technique to condition tissues with a soft reline resinwhich does not require the dentures to be left out of the mouth. This techniquenecessitates many appointments with the patient and a great amount of work. How-ever, in spite of all the time that goes into the making of a conditioning impression,there can be no guarantee that the complete denture will not need adjustments.Boucherg wrote, Why condition oral tissues and immediately place new dentureson them which uncondition the tissues as soon as they are inserted?IMPRESSION TECHNIQUES

Great interest can be aroused by any announcement that a new material as-sures the success of a complete denture because it produces an accurate impression4.51


2/7

452 STJSSMAN J. Pros. Den.May-June, 1966surface of the tissues to be covered or because it conditions tissues. TuckfieldlOsaid I think the impression surface has the least effect on the stability of thedenture. . . .

Hughesll summarized the impression problem when he noted There are manyopinions, but no facts.JAW RELATION PROCEDURES

Many articles describe the accuracy of techniques used to determine the physio-logic rest position,4 the free-way space (interocclusal distance), the vertical relationof occlusion, and centric relation. We, who accept the fact that the physiologic restposition has great significance, must realize that there is no scientific instrumentthat can accurately find this measurement.12~rsCENTRIC RELATION

No ingenuous adjustment technique can make dentures acceptable if the cen-tric relation is incorrect. A correct centric relation record is the most importantfactor in complete denture construction.i4Good fitting trial baseplates are essential to obtaining an accurate centricrelation record. TerreW5 wrote The accuracy of the registrations will be lost ifthe bases do not fit accurately. I use acrylic resin trial baseplates.An intraoral needle point tracer* can be used to locate the centric relation.Pleasure,la Porter,17 and Jones I8 describe the efficiency of this instrument. Some-times the setscrew of the instrument which is attached to the upper trial baseplatewill register a sharp pointed tracing on the graph plate which is attached to thelower baseplate. This apex indicates that the condyles are in their most retrudedposition. Sometimes the tracing is a blunt and rounded registration. This indicatesthat one or both of the condyles is anterior or medial to the most retruded position.Moyer-l9 said I. . . the greater the occlusal disharmony, the more likely centricrelation is to be found somewhere other than in the most retruded position. . . .I accept as centric relation the horizontal relation of the mandible to themaxillae when the mandible is in its most retruded position that is convenient forjaw movement and comfort. The medial occlusal position becomes a convenienceposition which is functional to the patient because of habit and use.HINGE AXIS

Is there a true hinge axis ? TrapozzanozO concluded that because of the in-ability of dentists to stabilize the denture bases with a sufficient degree of accuracy, . . . the accuracy attributed to the use of the hinge axis is more fancied than real.But McCollumzl said The hinge axis is a component of every masticatory move-ment of the mandible and, therefore, cannot be disregarded.Where is the hinge axis ? Grangerz2 reported that Anatomists seem to be inagreement that the center of rotation lies in the condyle and is not some imaginarypoint beyond it. Trapozzano and Lazzariz3 concluded These findings indicatethat, since multiple condylar hinge axis points were located, the high degree of

*Cable Denture Research Company, Inc., Raleigh, N. C.


3/7

Volume 16Number 3 COMPLETE DENTURE TREATMENT 4.53infallibility attributed to hinge axis points may be seriously questioned. Koskiz4is of the opinion that in many instances the axis could be found on the mastoidprocess of the temporal bone.

We must wait for further research to prove whether or not there is a truehinge axis, where it is located, and what controls its movements ; we also awaita less intricate technique for finding it.ARTICULATORS

Any sturdy articulator which retains the relationship of the mandible to themaxillae at the established vertical relation of occlusion and centric relation shouldsuffice for the placement of teeth. The final adjustments of the teeth can be madein the mouth on the completed dentures.Dentists who use the simple but sturdy inexpensive articulators should notfeel embarrassed because their offices are not geared to use highly adjustable in-struments. They can produce successful dentures without intricate articulators.Fleasurele said We rely on the articulator to do only what it can do well, i.e.,retain centric relation and vertical dimension ; and not to do what it can do poorly,i.e., imitate functional movements. Koskiz4 observed that The great variabilityof mandibular movements and the location of the axis can hardly be reproduced by aman-made mechanical device. Kaires*5 concluded The findings indicate that the

occlusal contacts established on the articulator did not coincide with the occlusalcontacts made during the functional movements in the mouth. These authors havestrengthened my belief about the choice of an articulator.ARTIFICIAL TEETH

I use posterior teeth that are nonanatomic* and teeth whose cusp height isreduced.+ The teeth retain sluiceways and grooves and are narrow, buccolingually,SD hey can be placed in the proper position in relation to the residual ridge. A widearch form should be maintained so that the tongue is given maximum space formovement and will not displace the denture. If possible, the occlusal height of thelower bicuspid teeth should be placed at the incisal height of the cuspid teeth.FINISHING AND PROCESSING THE DENTURES

Acrylic resins are used for denture bases and the laboratory is instructed tofollow the manufacturers directions in processing them. The discrepancies result-ing from processing procedures are kept at a minimum.The external form of the denture is very important to its retention. Thetlorders should be thickened to help maintain the denture against the dislodgingforces produced by masticatory and nonmasticatory movements.

DELIVERY OF THE COMPLETED DENTURESA proper technique for the delivery of dentures is essential and can eliminatesome of the errors that are not within the control of the dentist. Jones7 commented

*Frenchs Posteriors, Universal Dental Co., Philadelphia, Pa.tNic Poster iors, Universal Dental Co., Philadelphia, Pa.


4/7

454 SUSSMAN J. Pros. Den.May-June, 1966Our goal is to detect irritation soon after its inception and to make the necessarycorrections then, rather than waiting until the patient is suffering great discom-fort and has a lowered morale. Anthony and Peyton26 observed . . . a small amountof time spent adjusting both the accuracy of fit and the occlusal relationship whenthe dentures are inserted may be an important factor in the ultimate satisfaction. . . .

Our patients are people whose physiologic responses to the emotions of fear,love, hate, pride, illness, and anxiety are influenced by all other people with whomthey come into contact. Patients are often unable to give us the cooperation that wemust have. They may have an obvious or subconscious antagonism to dental care.These emotional antagonisms may be fortified by the fact that some relatives andfriends have had fewer dental disturbances. Such patients should be placed underlight sedation so they will be more amendable to our requests.The dentist must impress the patient with the fact that the use of moderntechniques eliminates pain-such as the pain that may have disturbed other people.

Patients are informed that they will feel comfortable when the treatments arecompleted. They are told that it usually takes one to two months to learn how tomanipulate foods of different textures with new dentures. They are advised to eatslowly, to break the food into small pieces, and to eat at home. Within the confinesof their homes, they can practice the manipulation of food without embarrassment.INSERTION OF DENTURES

The patient is asked to leave his old dentures out of the mouth from Fridayevening until Monday morning before the new dentures are inserted. This permitsthe new dentures to be inserted on tissues which have been given the opportunityto return to a near normal state of health.The new dentures are placed in the mouth and the patient is told to open andclose his mouth about ten times. By noting the position of the lips, the esthetics canbe observed. By noting the contact of the upper and lower teeth, an opinion of theaccuracy of the centric relation can be determined.ADAPTATION OF THE DENTURE BASES

I use a disclosing paste to adjust the external surfaces and borders of the den-ture bases to proper contact with the surrounding tissues, and to indicate pressureareas on the basal surfaces of dentures. 4,26The paste is placed on both sides of theborder of the upper denture in the tuberosity region. The denture is carefully placedin the mouth and the patient is instructed to use the same cheek and lip movementsthat were used when the impressions were made. The movements of the musclesagainst the external surface and border of the denture and the use of pressureagainst the tissue surface will disclose errors which may have been incorporatedinto the completed denture. The surfaces of the base material from which pastehas been displaced should be reduced. This treatment is continued until no denturebase material shows through a thin film of the paste.If the disclosing paste is thick or unmoved on the external surface of thedenture when it is removed from the mouth, it would indicate that there is a lackof contact between the external surface of the denture and the surrounding tissues.


5/7

Vclume 16Number 3 COMPLETE DENTURE TREATMENT 455Therefore, the facial muscles will not help retain the denture in position when it isaccidentally dislodged. If the paste is thick and unmoved on the tissue surface of thedenture, the impression was incorrectly made. All corrections can be made witha cold curing resin reline material after the denture has been adjusted to tissuecontact from tuberosity to tuberosity.

The buccal flange is adjusted after the adjustments on the tuberosity regionha.ve been completed. Full freedom of movement for the buccal frenum must beprovided in the same manner. Many dentures fail because of an incorrect contact ofthe denture base with the labial frenum.4The posterior palatal seal is not adjusted at this time. It is corrected at asubsequent visit should noticeable signs of irritation develop.The disclosing paste is used to adjust the lower denture in the same manneras was done on the upper denture. The procedure is begun at one posterior borderand continued around to the opposite side. Then the lingual surfaces of the dentureare corrected.The first visit for adjustment procedures is completed after the teeth have beenSpot ground to remove any obvious deflective occlusal contacts.INSTRUCTIONS TO THE PATIENT

The patient is instructed to wear the dentures at all times except for eating. Heis given an appointment to return in two days.At the next adjustment appointment, even though there should not be anycomplaints of pain, the disclosing paste procedure is used to locate incipient sitesof discomfort which may have been induced by the nonmasticatory functions ofyawning, talking, and swallowing. The occlusion is observed again for deflectiveocclusal contacts. The patient is instructed that he should not use the dentures foreating and that he is to return in three days.At the third adjustment appointment, the patient most likely will be pain free.He will not need extensive adjustment. However, the dentures receive the sametreatment that they received at the other visits.The three adjustment visits instill a sense of confidence and encouragement intE.e patient. He now knows that he is able to use the dentures with comfort forthe nonmasticatory functions. (All patients cheat and learn that they can usethe dentures for eating soft foods without pain.) These three adjustment visitsproduce a good psychologic effect and promote a feeling in the patient that all theensuing treatments will be successful.BALANCED OCCLUSION

After the patient has used the dentures for about a week to ten days, the oc-clusion must be corrected for function. I use a definite technique to grind the teethin.to balanced occlusion. The patient almost always volunteers the observation thatthe teeth feel much better.The occlusion should not confine mastication to a narrow limited tear dropdesign of mandibular movement. People eat differently. Some people eat slowly in agentle manner, with little protrusive or lateral mandibular movement. Other


6/7

4.56 SUSSMAN J. Pros. Den.May-June, 1966people eat with gusto in a violent manner, with large lateral and protrusive man-dibular movements.GRINDING THE TEETH

Teeth in dentures have been formed into the Monson (compensating) curveby grinding from the buccal cusps of the upper teeth and the lingual cusps of thelower teeth. However, stability can be added to the lower denture if the teeth areformed into the reverse occlusal curve by grinding from the lingual cusps of the up-per teeth and the buccal cusps of the lower teeth.4J4Js-1s,29I grind the teeth into the reverse occlusal pattern, except when the maxillaehave a poor form, and use the Coble Intra Oral Balancer* as a guide in grindingthe teeth.Caution must be exercised when the teeth are ground into the reverse curveof occlusion.27 If the upper residual ridge is small with a flat palate and with shortlateral walls, the Monson (compensating) curve should be developed in the oc-clusion. Upper complete dentures that rest on maxillae which are of unfavorable

form will lose stability if the teeth are ground into the reverse occlusal curve.BALANCING CONTACTS AND RAMPS

Schuyler2s wrote that A balancing contact of the posterior teeth in both theprotrusive position and on the balancing side are essential to the success of a fullprosthesis. Balancing contacts can be produced by: (1) a tooth-to-tooth con-tact 16~17,29,30r (2) by the use of ramps.4p31s32I use ramps to form balancing contacts .4 The ramps are added after the teethhave been ground into functional occlusion. The upper molar teeth, the denture basematerial in the region of the tuberosities, and the lower molar teeth are coated withpetroleum jelly. A mass of cold curing acrylic resin at a puttylike consistency isadded to both sides of the lower denture, distal to the lubricated area. The patientsteeth are guided into centric occlusion. When the resin has started to cure, thedentures are removed from the mouth. The lower denture is set aside to permitthe acrylic resin to complete its curing. The petroleum jelly and any resin that mayhave become attached to the upper denture are cleaned away. When the acrylicresin on the lower denture has completely cured, the dentures are replaced in themouth and adjusted into centric occlusion. Then the acrylic resin ramps are adjustedto provide protrusive and lateral balancing contacts.The ramps provide lateral and protrusive balancing contacts and prevent thetipping of the maxillary denture in protrusive and lateral positions.SUMMARY

A resume of a number of techniques for constructing complete dentures hasbeen presented. A technique for the insertion of dentures has been described. Thistechnique stresses the importance of the series of postinsertion visits.l C!oble Denture Research Company, Inc., Raleigh, N. C.


7/7

Volume 16Nnmber 3 COMPLETE DENTURE TREATMENT 457

REFERENCES1.il.14.i;.6.ii:9.

10.11.12.1.3.:!I16.17.18.19.20.21.22.23.24.25.26.27.28.29.30..ll.,32.

Downs, B. H.: A Discussion of Prosthodontic Research in Progress at the School ofAerospace Medicine, J. PROS. DENT. 13:70-71, 1963.Martone, A. L.: Clinical Applications of Concepts of Functional Anatomy and SpeechScience to Complete Denture Prosthodontics. Part VIII. The Final Phases ofDenture Construction, J. PROS. DENT. 13:204-228, 1%3.Ostlund, S. G. : Saliva and Denture Retention, J. PROS. DENT. 10:658-663, 1960.Sussm;;6t. A. : Procedures in Complete Denture Prosthesis, J. PROS. DENT. lO:lOll-1021,Lytle, R. B.: The Management of Abused Oral Tissues in Complete Denture Construction,1. PROS. DENT. 7:27-42. 1957.Lammte, G. A., and Storer, R.: A Preliminary Report on Resilient Denture Plastics, J.PROS. DENT. 8:411-424, 1958.Jones, P. hf.: Eleven Aids for Better Complete Dentures, J. PROS. DENT. 12:220-228, 1962.Chase, W. W.: Tissue Conditioninr Utilizina Dvnamic Adantive Stress. T. PROS. DENT.1 1:804-815, 1961. Y - , -Bouchel , C. 0.: Discussion of Sof t Tissue Displacement Beneath Removable Partial and

Complete Dentures, J. PROS. DENT. 12:~ 44-46, 1962.Tuckfield. W. T. : The Problem of the Mandibul ar Denture, J. PROS. DENT. 3:8-28, 1953.Hughes, G. A:: A Discussion of Present-Day Concepts in Complete Denture Service,J. PROS. DENT. 10:39-41,196O.Coulouriotes, A. : Free-way Space, J. PROS. DENT. 5:194-199, 1955.Willie, R. G.: Trends in Clinical Methods of Establishing an Ideal Interarch Relationship,J. PROS. DENT. 8:243-251, 1958.Kurth, L. E.: Balanced Occlusion, J. PROS. DENT. 4:150-167, 1954.Terrell, W. H.: Fundamentals Important to Good Complete Denture Construction, J.PROS. DENT. 8:740-752,1958.Pleasure, M. A.: Occlusion of Cuspless Teeth for Balance and Comfort, J. PROS. DENT.5:305-312, 1955.Porter, C. G.: The Cuspless Centralized Occlusal Pattern, J. PROS. DENT. 5:313-318, 1955.Jones, P. M.: A Realistic Approach to Complete Denture Construction, J. PROS. DENT.8:220-229. 1958.Moyers, R. E. : Some Pl tysiologic Considerations of Centric and Other Jaw Relations, J.PROS. DENT. (6:183-194, 1956.Trapozzano, V. R. : Occlusal Records, J. PROS. DENT. 5:325-332, 1955.McCollum. B. B.: The Mandibular Hinge Axis and a Method of Locating It. T. PROS.,

journal of prosthetic dentistry

Documents