CLINICAL AND LABORATORY PROCEDURES IN CONSTRUCTION OF COMPLETE DENTURES

Dr Ziad AL-Dwairi BDS, PhD(UK), FIADFE Associate Professor of Prosthodontics

Complete Denture
A dental prosthesis that replaces all of the natural dentition and associated structures of maxilla and mandible. It may be supported by mucosa or sometimes by dental implants.

Esthetic. Improve mastication. Improve speech. Function without interferences. Preservation of oral structures. Maintenance of health & comfort.

Clinical examination Tray selection Primary impression Primary cast Secondary impression Secondary cast Denture base fabrication and Occlusal rim

Setting of teeth Flasking ,dewaxing And curing Trimming and polishing

HISTORY AND EXAMINATION FOR EDENTULOUS PATIENTS

Objectives
Recognition of relevant anatomical, physiological and psychological conditions Understand significance of medical status Development of treatment plan (prescription of prosthesis) Assessment of existing dentures

Extra-oral examination The extra-oral examination should look for :

Temporo mandibular joint( TMJ): palpate externally and from inside the ear: pain, clicking, limitation of movement, extreme deviation The patients face height, Any facial asymmetry including The centre line;

Extra-oral examination
The lip line including the smile line as all these features will need to be transferred to the patients dentures. The degree of overclosure will also need to be assessed and this will help with deciding on how you want to make the denture

Extra-oral examination
The lip line including the smile line as all these features will need to be transferred to the patients dentures. The degree of overclosure will also need to be assessed and this will help with deciding on how you want to make the denture

Intra-oral Examination

Soft tissue Salivary flow Sulcus depth Ridge anatomy: height, depth and form (firm or flabby) Inter-ridge relationships If already wearing dentures: denture assessment fit, retention, stability and occlusion. Can you copy this if it is already satisfactory?

Maxillary arch

Mandibular Arch

IMPRESSIONS FOR COMPLETE DENTURES

IMPRESSIONS

Definition: A negative likeness of the tissues so that a model can be made from which a denture can be constructed. The impression material is held against the tissues and is supported by an impression tray. The material shows plastic flow in the initial stages and then hardens. A model is then formed using model stone or plaster. For maximum accuracy a 2 stage impression procedure is

IMPRESSIONS

Impression with a stock tray is first taken called a primary or preliminary impression

Preliminary Impressions

Impression compound (Modeling compound

Thermoplastic Material - Greatest pressure asserted to the center

of its mass Can be softened in wet heat for over- all adaptation, or it can be softened in small areas by dry heat for localized modifications
Softening not > 60 C

Preliminary Impressions

Impression compound (Modeling compound

Tray selection (cover anatomical landmarks) Kneading of compound to obtain a uniform consistency( rope or ball) Warming of tray Adaptation to tray with grooving to receive crest of ridge( the lingual aspect 3mm deeper than labial anteriorly and 6mm posteriorly)

Preliminary Impressions

Impression compound (Modeling compound

Can be added and re-adapted Used in combination with other materials Pouring of impression may be delayed Does nor reproduce fine surface details Should not be used in undercuts Re-softening-unhygienic

IMPRESSION TRAYS

Two types of impressions trays are used stock and special trays Properties: Must be clean and smooth Must be rigid and strong Should permit correct thickness of impression material to be used (3mm)

STOCK TRAYS

Box trays: RPD Trays for edentulous arches Combination trays: Distal extension base

STOCK TRAYS
Handle must be shaped and attached to the tray so that it doesnt displace the lip when the impression is taken Must hold the impression material in the correct position in the mouth and consequently must cover the whole area of the jaw required in the impression. Must prevent distortion of the impression material during setting

STOCK TRAYS

Variation in thickness of impression material Localised pressure on oral tissues Incomplete coverage of oral tissues Distortion of

Tray Selection

Primary Impression

Preliminary Impressions

Corrective alginate wash

To obtain greater surface details the initial compound impression is used as a tray to record a further impression in alginate Shake alginate tin to avoid condensing?? Powder or water first??

Preliminary Impressions

Alginate
Sodium alginate, calcium sulphate, trisodium phosphate Perforated trays, adhesive( polyamide in isoprpyl alcohol) Impression poured immediately( imbibition and syneresis): 30 minutes

Preliminary Impressions

Alginates
Record good surface detail with a minimum of tissue displacement Accuracy depends upon the accuracy of the tray Easily distorted

Preliminary Impressions

Alginates
Excellent surface details Elastic---undercuts Different viscosities Not flow in areas not supported by tray Cannot be added Liable to distortion at laboratory

Preliminary Impressions

Maxillary or mandibular impression first???

Increase salivation-----Maxillary Retching reflex---------Maxillary Chocking by impression----Maxillary

Preliminary Impressions

Common faults: (lower impression)

Edge of the tray showing:
Incorrect centring of the tray Use of too large or too small tray Forward thrust of tongue not been countered by backward pressure on the tray in the anterior region

Preliminary Impressions

Common faults: (lower impression)

Insufficient depth at lingual pouch:
Short flange Lack of compound Too little force applied Tongue trapped

Preliminary Impressions

Common faults: (Upper impression)

Deficiency in midline of palate
Insufficient compound Insufficient pressure Compound cold Trapped air

Lab forms

Special trays
Tray Material Amount of spacer and location of tissue stops Tray perforations Tray handle

DIAGNOSTIC CASTS

Analyse feasibility of various treatment measures Foundation for special trays Help the dentist to discuss possible treatment forms with patient or TECHNICIAN Analyse occlusion

CASTS MATERIAL

Compatible with all types of impression materials Reasonable setting and working time Reproduce surface details Exhibit surface hardness

EDENTULOUS CASTS

Posterior border of cast stops 8 mm from maxillary tuberosity or retromolar pad The outer surface of the cast is trimmed to about 3mm from the maximum convexity ( Land area)

Custom Trays

Conditioning the primary cast

Soak in water Draw the outline on the cast. Block out the undercuts using wax. Place the wax spacer on the cast.

SPECIAL TRAYS

The special tray can be either spaced or close fitting. Spaced trays are used with impression plaster and alginate. The mould is covered with a wax spacer and an acrylic sheet of at least 2mm thickness is then used to construct the tray. If the sheet is too thin, there will be no rigidity thus causing distortion of the impression. Close fitting trays are constructed with the undercuts blocked out on the cast.

record tissues in a state of anatomical rest. Stability during impression making. Relief the non stress bearing areas .

2 mm thick. modelling wax ,

SPECIAL TRAYS

Special tray is made such that in the mouth its periphery lies approximately 2 mm short of the reflection of the mucosa when the tissues are at rest. Upper tray is extended 1mm distal to the hamular notch and 2mm distal to the fovea palatini. The tray should

SPECIAL TRAYS

Lower tray is extended 1mm lateral to the external oblique ridge. The area overlying the mylohyoid muscle is coated with wax (2mm) so that it allows for contraction of the muscle during impression taking.

SPECIAL TRAYS

Materials used to construct the trays: Acrylic resins can be cold cured or heat cured. Tray handle position is important and depending on the impression material to be used a spacer is incorporated. In addition to the tray handle finger rests can be incorporated especially in the lower and should be 1cm long by 1cm high and 4mm wide. These are usually placed in the lower

SPECIAL TRAYS

To provide the space in the tray for the material, the model is covered first with 2 layers of wax and then the tray adapted to the surface. When alginate is used, holes can be drilled through the tray to provide mechanical retention.

SPECIAL TRAYS

Outlined on diagnostic cast with frenal relief Tissue stops to ensure even thickness of impression material Stubs to avoid interference with peripheries of impression

Border Molding

Border Molding

Secondary impressions

A more accurate working impression (called a working or secondary impression) is taken using special trays which is made for a particular

Secondary impressions

Impression plaster( with antiexpansion liquid) Zinc-oxide eugenol impression paste (most commonly used) Alginate Elastomers (Polysulphides and Silicons)

Secondary Impression

Secondary impressions

Zinc-oxide eugenol impression paste

Composition: Zinc-oxide, white powdered resin, eugenol, natural oils, fillers. Patient lips and nearby skin should be lightly covered with facer cream or petroleum jelly. Orange oil or chloroform to remove paste from patient or operator skin

Secondary impressions

Zinc-oxide eugenol impression paste

Excellent surface details Dimensionally stable Can be added and re-adapted Not used in undercuts Can only be used as wash material Require border moulding of the tray Eugenol sensetivity

Secondary impressions

Muscle trimming( border moulding). Aim: to record functional depth and

width of sulcus Using tracing compound-related to-impression compound???

Secondary impressions

Elastomers
Polysulphides :
base (polysulphide, titanium dioxide filler) and activator ( lead dioxide) Medium body viscosity is used for impression Hydrophobic material Prolonged setting time Strong odor of rubber

Secondary impressions
Silicones: condensation and additional
2 stage impression technique( putty and wash) Condensations are dimensionally unstable

IMPRESSION Techniques

Anatomic or arbitrary - Based on landmarks. Open or closed mouth - Based on the mouth position. Pressure - Pressure, nonpressure, negative pressure or selected pressure

IMPRESSION Techniques

Mucocompressive: Displace oral tissues because pressure is needed to seat the material Mucostatic: No displacement: good flow properties Functional: Taken during muscle contraction Special

Maintains the width and height of the sulcus Mainly preserves mucobuccal and mucolingual borders.

Materials used beading: utility wax boxing : boxing wax

Master Casts

Denture bases

Requirements
Easy to handle Capable of reproducing details from cast Should not distort at mouth temperature Capable of being modified at chairside

Made of: wax, shellac, acrylic resin and impression compound

Denture bases

Acrylic resin (heat cure, self-cured, light cured) bases have superior fit and stability Wax bases tend to distort if left in mouth or if subjected to heavy occlusal forces Shellac is more stable than wax but difficult to adjust at the chairside Compound bases may be used in cases where the rim is to be made of the same material

Record Blocks

Record base

Base of denture Support wax occlusal rims.

Requirements :

Well adapted to the final cast . Dimensionally stable. Retentive . 1mm thick on the crest and facial slope of the ridge . 2mm thick in the palatal and lingual flange.

Occlusal rims
Occluding surfaces built on temporary or permanent denture bases for the purpose of making maxillomandibular relation records and arranging teeth.
o o

Primarily serves as gingiva Done mainly to arrange teeth

Anatomical information: Maxilla

The labial surface of anterior teeth support the lips and is between 10 12mm labial to incisive papilla The centre of the last molar is nearly opposite the centre of the tuberosity and its buccal surface is 3-5mm buccal to centre of tuberosity On average, the distance from the functional sulcus to incisal edge of centrals is about 20mm and to the occlusal surface of first molar is about

22mm high from the depth of the sulcus. Ant region should be 8mm away from incisive papilla . 4 6 mm wide in ant region. Occlusal table should be 18mm high from the depth of sulcus. Occlusal table should be 8 12 mm wide posterior. Occlusal table should be 10 12 mm above the crest of alveolar ridge anteriorly.

Anatomical information: Mandible

The centre of the last molar is buccal to retromolar pad by 3mm The occlusal surface of posterior teeth corresponds with the centre of retromolar pad

Mandibular occlusal rim

6 -8mm high from the crest of the ridge anteriorly 18mm high from depth of the sulcus in the canine eminence region 3 6mm high from the crest of the ridge posteriorly The occlusal plate should extend to 2/3rd ht of the retromolar pad posteriorly Width anteriorly 4 6mm posteriorly 8 12mm

JAW RELATIONS AND ARRANGEMENT OF ARTIFICIAL TEETH FOR COMPLETE DENTURES

Jaw relations

A cast records details of natural dentition and alveolar ridges but we need to know the following information before denture construction so that the patient can get the maximum benefit from the complete denture:
Centric occlusion: Static tooth contacts in maximum intercuspation (termination of masticatory closure).

Jaw relations
Centric relation: most retruded position of mandible to maxilla from which lateral movement can be made at a given degree of jaw separation. Vertical dimension: the distance between alveolar process of maxilla and mandible in centric relation Occlusal plane: the position and angle of a plane to which the occlusal surfaces of teeth relate

Jaw relations

When teeth are missing, their positions are taken by record blocks and these information recorded on them The blocks are attached to a base constructed to accurately fit the mouth Registration blocks( base and wax rim)

Jaw relations

Orientation relation: relation to the cranium Vertical relation: amount of jaw separation Horizontal relation: antero-posterior and lateral relations These relations are transferred from patient to casts (replica of edentulous ridges) through the use of:
Face bow( Orientation relation) Record blocks( Vertical and Horizontal relations)

Jaw relations

The established recorded jaw relations are transferred to a mechanical instrument that represents TMJ and Jaws to which the maxillary and mandibular casts are attached. This is the articulator which aims to simulate some or all mandibular movements

The articulator

Jaw relations

Record blocks are used in recording jaw relations to:

Establish height and orientation of occlusal plane( anterior and anteroposterior) Establish maxillary and mandibular arch form( according to patterns of resorption0 Record horizontal and vertical jaw relations

Jaw relations
Assess lip support and notice vermillion border and naso-labial groove Check height and orientation of occlusal plane( anterior and antero-posterior): the lower border of the maxillary rim represents the level at which the incisive edge of the upper central incisors will be set and decides how much of the incisal edge will be seen below the margin of upper lip( 1mm average)

Jaw relations

Jaw relations

Maxillary rim
Check height and orientation of occlusal plane( anterior and anteroposterior the anterior occlusal plane is trimmed parallel to the inter-pupillary line while the patient is in rest The antero-posterior plane is parallel to Campers line( ala-tragus line)

Inter-pupillary line

Orientation of occlusal plane using Fox plane

Orientation of occlusal plane using Fox plane

Jaw relations

Maxillary rim
Check height and orientation of occlusal plane( anterior and anteroposterior :Mark centre line on labial surface of upper rim which should correspond to the centre line of the whole face and is not necessarily the centre of lips, nose , or any other individual facial structure

Jaw relations

Maxillary rim
Canine lines: better to indicate distal surfaces of canines High lip line:
indicates the position of maximum elevation of upper lip when smiling Assist in selecting length of upper anteriors

Jaw relations

Jaw relations

Jaw relations

Maxillary rim
Measure rest vertical dimension Patient seated upright with Frankfurt plane horizontal (lowest point in margin of orbit to highest margin of external auditory meatus). Ask patient to relax:
Swallow and relax Pronounce em and relax Moisten lips with tip of the tongue and relax

Jaw relations

Maxillary rim
Measure rest vertical dimension (VDR) The VDR is measured using

Willis gauge: separation between lower border of nasal septum and lower border of chin ( pressure applied and angulations of gauge may differ 2-dot technique: most common: tip of the nose and non-movable part of chin)

2-dot technique

Jaw relations

Measure Occlusal vertical dimension (VDO):

Insert lower base plate and wax rim Ensure even contact between wax rims At this stage, the heals of acrylic bases may touch, the interference may be trimmed but not to affect retention of bases Reduce lower occlusal rim so that the VDO( between 2-dots) is 2-4 mm less

Interocclusal space

Jaw relations

Arch form
Posterior height of lower wax rim should be 2/3 level up of retromolar pad There should be 8-10mm from centre of incisive papilla to labial surface of maxillary rim

Jaw relations

Record horizontal jaw relations Retruded contact position: jaw relationships in the horizontal plane at which the location of the occlusal rims will be registered

Jaw relations

Record horizontal jaw relations

when the condyles are in most retruded position in the fossa and the jaw muscles are relaxed, the mandible can be moved in a simple hinge like manner and the jaw must be in most retruded position Swallowing and closure Tip of the tongue against posterior border of upper base plate

Jaw relations

Measure Occlusal vertical dimension (VDO):

This space is interocclusal space existing between upper and lower teeth when mandible in physiologic rest position