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

IN GENERAL PRACTICE depend upon techniques for complete denture construction which have been found suitable to their skills, and supplement their techniques with new concepts offered by specialists. However, areas of disagreement 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 are negated by the use of an incomplete technique for the delivery of dentures. Downs1 commented . . . no one has a trouble-free prosthodontic practice. Martone said It is possible for successful dentures to be denture failures simply because the necessary adjustments are not made. A technique for the delivery of dentures will be described.

I)

ENTISTS

IMPRESSION

PROCEDURES

Impressions should be made of tissues that are free of irritation and free of thick mucous saliva.3 The impressions should have contact pressure4 and should cover 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 for as long a time as is necessary to permit the mouth to return to good health and uritil the tissues have recovered from damage and irritation resulting from previous dentures.5-7 Patients can leave dentures out of the mouth from Friday evening until Monday morning (about 60 hours). This is a suggested recovery period.
TISSUE CONDITIONING

Chase* outlined his technique to condition tissues with a soft reline resin which does not require the dentures to be left out of the mouth. This technique necessitates many appointments with the patient and a great amount of work. However, 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 dentures on 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 assures the success of a complete denture because it produces an accurate impression
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surface of the tissues to be covered or because it conditions tissues. TuckfieldlO said I think the impression surface has the least effect on the stability of the denture. . . . Hughesll summarized the impression problem when he noted There are many opinions, but no facts.
JAW RELATION PROCEDURES

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

No ingenuous adjustment technique can make dentures acceptable if the centric relation is incorrect. A correct centric relation record is the most important factor in complete denture construction.i4 Good fitting trial baseplates are essential to obtaining an accurate centric relation record. TerreW5 wrote The accuracy of the registrations will be lost if the 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. Sometimes the setscrew of the instrument which is attached to the upper trial baseplate will register a sharp pointed tracing on the graph plate which is attached to the lower baseplate. This apex indicates that the condyles are in their most retruded position. Sometimes the tracing is a blunt and rounded registration. This indicates that 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 centric relation is to be found somewhere other than in the most retruded position. . . . I accept as centric relation the horizontal relation of the mandible to the maxillae when the mandible is in its most retruded position that is convenient for jaw movement and comfort. The medial occlusal position becomes a convenience position 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 inability 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 movement of the mandible and, therefore, cannot be disregarded. Where is the hinge axis ? Grangerz2 reported that Anatomists seem to be in agreement that the center of rotation lies in the condyle and is not some imaginary point beyond it. Trapozzano and Lazzariz3 concluded These findings indicate that, since multiple condylar hinge axis points were located, the high degree of
*Cable Denture Research Company, Inc., Raleigh, N. C.

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infallibility attributed to hinge axis points may be seriously questioned. Koskiz4 is of the opinion that in many instances the axis could be found on the mastoid process of the temporal bone. We must wait for further research to prove whether or not there is a true hinge axis, where it is located, and what controls its movements ; we also await a less intricate technique for finding it.
ARTICULATORS

Any sturdy articulator which retains the relationship of the mandible to the maxillae at the established vertical relation of occlusion and centric relation should suffice for the placement of teeth. The final adjustments of the teeth can be made in the mouth on the completed dentures. Dentists who use the simple but sturdy inexpensive articulators should not feel embarrassed because their offices are not geared to use highly adjustable instruments. 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 variability of mandibular movements and the location of the axis can hardly be reproduced by a man-made mechanical device. Kaires*5 concluded The findings indicate that the occlusal contacts established on the articulator did not coincide with the occlusal contacts made during the functional movements in the mouth. These authors have strengthened my belief about the choice of an articulator.
ARTIFICIAL TEETH

I use posterior teeth that are nonanatomic* and teeth whose cusp height is reduced.+ The teeth retain sluiceways and grooves and are narrow, buccolingually, SDthey can be placed in the proper position in relation to the residual ridge. A wide arch form should be maintained so that the tongue is given maximum space for movement and will not displace the denture. If possible, the occlusal height of the lower 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 to follow the manufacturers directions in processing them. The discrepancies resulting from processing procedures are kept at a minimum. The external form of the denture is very important to its retention. The tlorders should be thickened to help maintain the denture against the dislodging forces produced by masticatory and nonmasticatory movements.
DELIVERY OF THE COMPLETED DENTURES

A proper technique for the delivery of dentures is essential and can eliminate some of the errors that are not within the control of the dentist. Jones7 commented
*Frenchs Posteriors, Universal tNic Posteriors, Universal Dental Dental Co., Co., Philadelphia, Philadelphia, Pa. Pa.

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Our goal is to detect irritation soon after its inception and to make the necessary corrections then, rather than waiting until the patient is suffering great discomfort and has a lowered morale. Anthony and Peyton26 observed . . . a small amount of time spent adjusting both the accuracy of fit and the occlusal relationship when the 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 whom they come into contact. Patients are often unable to give us the cooperation that we must have. They may have an obvious or subconscious antagonism to dental care. These emotional antagonisms may be fortified by the fact that some relatives and friends have had fewer dental disturbances. Such patients should be placed under light sedation so they will be more amendable to our requests. The dentist must impress the patient with the fact that the use of modern techniques eliminates pain-such as the pain that may have disturbed other people. Patients are informed that they will feel comfortable when the treatments are completed. They are told that it usually takes one to two months to learn how to manipulate foods of different textures with new dentures. They are advised to eat slowly, to break the food into small pieces, and to eat at home. Within the confines of 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 Friday evening until Monday morning before the new dentures are inserted. This permits the new dentures to be inserted on tissues which have been given the opportunity to return to a near normal state of health. The new dentures are placed in the mouth and the patient is told to open and close his mouth about ten times. By noting the position of the lips, the esthetics can be observed. By noting the contact of the upper and lower teeth, an opinion of the accuracy 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 denture bases to proper contact with the surrounding tissues, and to indicate pressure areas on the basal surfaces of dentures. 4,26The paste is placed on both sides of the border of the upper denture in the tuberosity region. The denture is carefully placed in the mouth and the patient is instructed to use the same cheek and lip movements that were used when the impressions were made. The movements of the muscles against the external surface and border of the denture and the use of pressure against the tissue surface will disclose errors which may have been incorporated into the completed denture. The surfaces of the base material from which paste has been displaced should be reduced. This treatment is continued until no denture base material shows through a thin film of the paste. If the disclosing paste is thick or unmoved on the external surface of the denture when it is removed from the mouth, it would indicate that there is a lack of contact between the external surface of the denture and the surrounding tissues.

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Therefore, the facial muscles will not help retain the denture in position when it is accidentally dislodged. If the paste is thick and unmoved on the tissue surface of the denture, the impression was incorrectly made. All corrections can be made with a cold curing resin reline material after the denture has been adjusted to tissue contact from tuberosity to tuberosity. The buccal flange is adjusted after the adjustments on the tuberosity region ha.ve been completed. Full freedom of movement for the buccal frenum must be provided in the same manner. Many dentures fail because of an incorrect contact of the denture base with the labial frenum.4 The posterior palatal seal is not adjusted at this time. It is corrected at a subsequent visit should noticeable signs of irritation develop. The disclosing paste is used to adjust the lower denture in the same manner as was done on the upper denture. The procedure is begun at one posterior border and continued around to the opposite side. Then the lingual surfaces of the denture are corrected. The first visit for adjustment procedures is completed after the teeth have been Spot 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. He is given an appointment to return in two days. At the next adjustment appointment, even though there should not be any complaints of pain, the disclosing paste procedure is used to locate incipient sites of discomfort which may have been induced by the nonmasticatory functions of yawning, talking, and swallowing. The occlusion is observed again for deflective occlusal contacts. The patient is instructed that he should not use the dentures for eating 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 same treatment that they received at the other visits. The three adjustment visits instill a sense of confidence and encouragement in tE.e patient. He now knows that he is able to use the dentures with comfort for the nonmasticatory functions. (All patients cheat and learn that they can use the dentures for eating soft foods without pain.) These three adjustment visits produce a good psychologic effect and promote a feeling in the patient that all the ensuing treatments will be successful.
BALANCED OCCLUSION

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

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people eat with gusto in a violent manner, with large lateral and protrusive dibular movements.
GRINDING THE TEETH

man-

Teeth in dentures have been formed into the Monson (compensating) curve by grinding from the buccal cusps of the upper teeth and the lingual cusps of the lower teeth. However, stability can be added to the lower denture if the teeth are formed into the reverse occlusal curve by grinding from the lingual cusps of the upper teeth and the buccal cusps of the lower teeth.4J4Js-1s,29 I grind the teeth into the reverse occlusal pattern, except when the maxillae have a poor form, and use the Coble Intra Oral Balancer* as a guide in grinding the teeth. Caution must be exercised when the teeth are ground into the reverse curve of occlusion.27 If the upper residual ridge is small with a flat palate and with short lateral walls, the Monson (compensating) curve should be developed in the occlusion. 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 the protrusive position and on the balancing side are essential to the success of a full prosthesis. Balancing contacts can be produced by: (1) a tooth-to-tooth contact 7 16~17,29,30 or (2) by the use of ramps.4p31s32 I use ramps to form balancing contacts .4 The ramps are added after the teeth have been ground into functional occlusion. The upper molar teeth, the denture base material in the region of the tuberosities, and the lower molar teeth are coated with petroleum jelly. A mass of cold curing acrylic resin at a puttylike consistency is added to both sides of the lower denture, distal to the lubricated area. The patients teeth are guided into centric occlusion. When the resin has started to cure, the dentures are removed from the mouth. The lower denture is set aside to permit the acrylic resin to complete its curing. The petroleum jelly and any resin that may have become attached to the upper denture are cleaned away. When the acrylic resin on the lower denture has completely cured, the dentures are replaced in the mouth and adjusted into centric occlusion. Then the acrylic resin ramps are adjusted to provide protrusive and lateral balancing contacts. The ramps provide lateral and protrusive balancing contacts and prevent the tipping of the maxillary denture in protrusive and lateral positions.
SUMMARY

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

Volume 16 Nnmber 3 REFERENCES

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A Discussion of Prosthodontic Research in Progress at the School of Aerospace Medicine, J. PROS. DENT. 13:70-71, 1963. il. Martone, A. L.: Clinical Applications of Concepts of Functional Anatomy and Speech Science to Complete Denture Prosthodontics. Part VIII. The Final Phases of Denture Construction, J. PROS. DENT. 13:204-228, 1%3. < 1. Ostlund, S. G. : Saliva and Denture Retention, J. PROS. DENT. 10:658-663, 1960. 4. Sussm;;6t. A. : Procedures in Complete Denture Prosthesis, J. PROS. DENT. lO:lOll-1021,
i;. Lytle, R. B.: The Management of Abused Oral Tissues in Complete Denture Construction, 1. PROS. DENT. 7:27-42. 1957. 6. Lammte, G. A., and Storer, R.: A Preliminary Report on Resilient Denture Plastics, J. ii: Chase, W. W.:

1. Downs, B. H.:

PROS. DENT. 8:411-424, 1958. Jones, P. hf.: Eleven Aids for Better Complete Dentures, J. PROS. DENT. 12:220-228, 1962. Tissue Conditioninr Utilizina Y Dvnamic Adantive Stress., T. PROS. DENT. 1.1:804-815, 1961. 9. Bouchelr, C. 0.: Discussion of Soft Tissue Displacement Beneath Removable Partial and Complete Dentures, J. PROS. DENT. 12:~ 44-46, 1962. 10. Tuckfield. W. T. : The Problem of the Mandibul ar Denture, J. PROS. DENT. 3:8-28, 1953. 11. Hughes, G. A:: A Discussion of Present-Day Concepts in Complete Denture Service, J. PROS. DENT. 10:39-41,196O. 12. Coulouriotes, A. : Free-way Space, J. PROS. DENT. 5:194-199, 1955. 1.3. 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. :!I Terrell, W. H.: Fundamentals Important to Good Complete Denture Construction, J. PROS. DENT.

8:740-752,1958.

16. Pleasure, M. A.: Occlusion of Cuspless Teeth for Balance and Comfort, J. PROS. DENT. 5:305-312, 1955. 17. Porter, C. G.: The Cuspless Centralized Occlusal Pattern, J. PROS. DENT. 5:313-318, 1955. 18. Jones, P. M.: A Realistic Approach to Complete Denture Construction, J. PROS. DENT.
8:220-229. 1958.

DENT. 10:428-435,196O. 22. Grangc2q2Ei9Fi: The Temporomandibular

19. Moyers, R. E. : Some Pl tysiologic Considerations of Centric and Other Jaw Relations, J. PROS. DENT. (6:183-194, 1956. 20. Trapozzano, V. R. : Occlusal Records, J. PROS. DENT. 5:325-332, 1955. 21. McCollum. B. B.: The Mandibular Hinge Axis and a Method of Locating- It.,< T. PROS. Joint in Prosthodontics, J.
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PROS.

23. Trapozzano, V: R., and Lazzari, J. B.: A Study of Hinge Axis

DEXT.

24. Koski, K.: Axis of the Opening Movement of the Mandible, J. PROS. DENT.

11:858-863,1961.

Determination,

1962. 25. Kairesi929.K. : Occlusal Surface Contacts During Mastication, J.

26. Anthony,

12:888-894,
9:952-961,

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D. H., and Peyton, F. A.: Dimensional Accuracy of Various Denture-Base Materials, J. PROS. DENT. 12:67-81, 1962. 27. Sussm!$6fl. A.: More Successful Complete Upper Dentures, J. PROS. DENT. 10:37-38,
28. Schuyler, C. H.: Factors of Occlusion Applicable to Restorative Dentistry, J. PROS. DENT. 3:772-782,1953. 29. Moses, C. H.: Biomechanics and Artificial Posterior Teeth, J. PROS. DENT. 4:782-804, 1954. 30. Sears, V. H. : Centric and Eccentric Occlusions, J. PROS. DENT. 10:1029-1036, 1960. :, .ll. Yurkstas, A. A:, and Emerson, W. H.: A Study of Tooth Contact Durtng Mastication

With Artificial Dentures, J. PROS. DENT. 4:168-174, 1954. 32. Beresin, V. E., and Beresin, M.: A Biomechanical Approach to the Problem of Prosthetic Occlusion, J. PROS. DENT. 6:472-487, 1956.
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