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Secrets of Successful Dentures

Dr. Bob Loney, DMD, MS Dr. Mark Vallee, DDS, MSc, FRCDC

Course Objectives
Identify patients who can be successfully rehabilitated Five-step method to diagnose & treat problems Select & use indicating media correctly Minimize problems with relines Denture esthetics & occlusion Implant overdentures & Locator attachments

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Google: Google: Removable Prosthodontics Dalhousie Welcome Select: CD CD Menu - Click on Secrets of ...Denture ...Denture

Successful Treatment
Selecting cases that can be successful !

Pick Your Patient!

Pick Your Patient!

Avoid: No ridge Ridge mucosa moves when tongue/cheek active Floor of mouth above mand. ridge LOOK during Function!

Avoid: Cheek or frena attach to top of ridge Vestibuloplasty (relative) LOOK during Function!

Pick Your Patient!

Pick Your Patient!

Caution: No saliva Poor nutrition Many sets in several years

Caution: Severe wear, loss OVD Severe undercuts/tori & don dont want surgery

Spend time Talking

Pick Your Patient!

When Not to Treat Partially Dentate!


Patient doesn doesnt want treatment
Comfortable Happy with appearance Function not a problem

Caution: No dentures for many years Patient who doesn doesnt want dentures Patient who doesn doesnt need dentures

Inform of consequences, costs, options Don Don t talk patient into treatment Shortened Dental Arch (SDA)

Treatment Option: No Replacement

Shortened Dental Arch (SDA)


Patients can function with as few as 20 occluding teeth No signicant difference in chewing discomfort
JCDA Sept 07, 73:593-4

No Replacement Shortened Dental Arch (SDA)


Require Anterior teeth + 4-6 occlusal units Opposing PM PMs = 1 occlusal unit Opposing Ms = 2 occlusal units Symmetric loss need 4 units Assymetric loss need 6 units

Patient Satisfaction

Patient Satisfaction
Difcult to quantify, unpredictable

More than good anatomy More than well constructed denture Includes expectations

Not directly correlated with quality Small percentage never satised Low quality results in lower satisfaction Patients more satised with dentures than eyeglasses and hearing aids

Satisfaction With various prosthesis

Patient Characteristics
Not correlated with satisfaction: Personality Age Attitude toward aging Reduced salivary ow & reduced ridge negatively correlated

Percentage of patients satised with prosthesis


Smedley TC, Friedrichsen SW, Cho MH: A comparison of self-assessed satisfaction among wearers of dentures, hearing aids, and eyeglasses. J Prosthet Dent. 1989; 62 : 654-661.

Fabrication Variables

Patient Expectations
High expectations if currently dissatised Unrealistic expectations negatively correlate with satisfaction Pre-treatment interview can help determine expectations

Related to satisfaction: clinical remounts accurate impressions & occlusal records patient involvement in denture esthetics

Matching Expectations

Iatrosedative Interview
1. Recognize & acknowledge problem

Critical for success If patient & dentist dont expect the same result - failure Helps determine need for referral

2. Explore & identify problem 3. Interpret & explain problem 4. Offer a solution

Iatrosedative Interview
1. Recognize & acknowledge problem
Patient: My problem is .... Id like.... Theyre too... Dentist: So your dentures feel..., I can see they are... That must be difcult ...

Iatrosedative Interview
2. Explore & identify problem
Dentist: History - You say the dentures loosen only when you are chewing on the left side? Exam - Visual intraoral check. Look for variations from normal in denture & tissue. Use indicating media. Have patient demonstrate the problem. Palpate.

Iatrosedative Interview
3. Interpret & explain problem
It appears that the denture teeth may be too far away from your bone. There is not much bone to support them. Look here in the mirror... The denture will always be looser than normal unless...

Iatrosedative Interview
4. Offer a solution
Dentist: So to review, you have 3 things you want changed.. You dont want these 2 things changed... I can change/improve ... but not....because... Do you understand...Do you have any questions What would you like to do?

Conclusions

5 Step Denture Troubleshooting


1. Differential Diagnosis 2. Look for Normal 3. Patient Demonstrates Problem 4. Never Adjust without Indicating Media ** 5. Patient Rates Improvement

Small percentage never satised, even with highest quality Comprehensive interview can help identify patients with high expectations Low clinical quality related to reduced patient satisfaction

Principal 1 Establish a Differential Diagnosis


Form a list of possible causes Try to prove problem is not caused by X by eliminating possible causes Expect resolution within 10-14 days If no resolution, eliminate something else

Principle 1: Differential Diagnosis

Prioritize from common to rare

Eliminate common etiologies rst, because:

Common things occur commonly Rare entities occur rarely

Differential Diagnosis: CD or RPD Pain


Occlusion Denture Base Vertical Dimension Infection Systemic Disease Allergy Remount, Articulating Paper, Adjust PIP, Adjust Time to Adapt, Reset Teeth Tests, Referrals, Medications Patch Tests, Referrals, Change Materials Attempt to eliminate problem. Re-evaluate results in 10-14 days

Principles of Diagnosis

Don Don t limit list too early in diagnosis Keep an open mind Revisit possible causes

Information Gathering

Gathering Information
Often inadequately investigated Spend more time talking to narrow possibilities

Chief Complaint

History of C.C.

Ask open ended questions:

History

How does that feel? feel?

Medical Dental

Not

Does that feel better? better?

Clinical Exam

History of Chief Complaint

Where?

History of Chief Complaint When?

Have patient point to problem Partially ignore patient patients position Dentist locate with stick, instrument or paste

Chewing only - Occlusion Gets worse throughout day - Occlusion When rst insert dentures Denture Base

History of Chief Complaint

Details

Principle 2: Identify Variations from Normal: Tissues & Dentures

How long?

...does it last? ...since it began?

Anything make it better/worse?

Identify Variations from Normal

Loose Denture: Prominent Midline Fissure, Soft


Palate

Dealing with Variations From Normal


If denture alone is not normal correct the denture If anatomy/patient not normal vary method to address variation

Principle 3: Patient Demonstrates Problem


Eliminate cause - resolve in 10-14 days

Principle 4: Always Use Indicating Media

Principle 5: Rate Improvement

100% Perfect Now

75% Feels a lot better

Never adjust without locating exact position of the problem

After adjustment

50% Better, but still not right

Use paste, indelible stick, or articulating paper

Ask patient to rate improvement

0%-100%
0% Still Same, Can Can t Tell

5 Step Denture Troubleshooting


1. Differential Diagnosis 2. Look for Normal 3. Patient Demonstrates Problem 4. Never Adjust without Indicating Media ** 5. Patient Rates Improvement

Use of Indicating Media


Loney & Knechtel,J Prosthet Dent 2009;101:137-141

Applying Pressure Indicating Paste


Dry denture Thin coat with stiff brush Leave streaks

More the colour of indicating medium than denture

Correct Amount with Streaks

Insufcient Amount

Too Much w/o Streaks

Prior to Placement
Ensure damp mucosa Spray surface of PIP with air/water

Seat Denture Firmly


Avoid lips/ridge when inserting Pressure over rst molars (not palate) Remove from oral cavity by breaking seal - nger pushing height of vestibule

Reading PIP
Burn-through (No paste left)

Read the Paste


No Contact Burn through Normal Contact

- Excessive pressure that should be relieved


Streaks remaining

No tissue contact Other areas need to be relieved

Paste remaining with no streaks

- Acceptable contact

Non-retentive Denture
What Whats Wrong?

Denture Base Adjustment


Relieve pressure spots - large acrylic burs Take care with undercuts

No palatal contact Short Flange in 1st quad

Looks like burn-through May not require adjustment

Use Care in Retentive Areas

Watch for Bony Impingements

Hamular Notch Tuberosity Undercuts Relieve

Check for Retention


Pull outward & upward on lingual of canines

Repeat Until Denture Fully Seats


Relatively uniform contact Minimal streaks No gross burn-through

Visually Check Peripheries


Seat denture & border mold Flanges should ll vestibule but not be dislodged by manipulation If denture dislodges, use PIP to adjust

Peripheries

Border mold Adjust Check again Adjust high spots or facets

Special Attention to Frenal Areas

Special Attention to Frenal Areas

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Use to Check Contours


Root prominences

Alter Phonetics

Thick peripheries More Info see: Website Resources Resources

Paste Removal
Gauze, cotton rolls, toothbrushes Alcohol for stubborn areas Cheap steamer Cement, debris

Secrets of Impressions

Polyvinyl Siloxanes
Dimensional Stability Detail Use for all procedures

Secrets of Impressions

Final Impressions
Load quickly - viscosity Material brought over periphery

Everything Dry

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Secrets of Impressions
Two Mirror Technique

Secrets of Impressions
Seat anterior of tray rst Cotton swabs on tray - remove excess posterior

- everything visible

Secrets of Impressions
Flange thickness

Secrets of Impressions
Tray not overextended

Secrets of Impressions
Why remake?

Relines
This denture needs a reline!

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Materials
Tissue Conditioners PVS Light Body Self/Light Cure? undercuts distortion porosity

Clean the Denture


Inspect when dry!

Position the Denture


OVD & Occlusion

Improperly Placed!

Longer Teeth! Lousy Occlusion!

Relieve Denture
Remove undercuts Shorten anges Create space for material

Relieve Denture

Vent holes for relief of hydraulic pressure

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Remove Excess Material

Mark Contacts Prior to/After Reline

Cotton Swabs on tray Better Contours

Red/Blue Should be close If not, don dont proceed

Posterior Palatal Seal


Needed for retention

Secrets of Jaw Relation Records


Record Bases stable & retentive Perfectly at contact between rims

Secrets of Jaw Relation Records


Ensure: Record bases don dont contact anything Casts don dont contact anything Only wax rim to wax rim contact

Secrets of Jaw Relation Records

Wax Rim Adjustment Video

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Secrets of Jaw Relation Records


Consider polyvinyl siloxane records Aluwax the most variable Elastomers least errors

Centric Record with PVS

Video Clip

Mullick et al. J Prosthet Dent 1981;46:304 Ockert-Eriksson et al, Int J Prosthodont 2000 Millstein & Hsu, J Prosthet Dent 1994 Breeding et al, J Prosthet Dent 1994

Partially Dentate Casts


If stable contacts (no rocking) Most accurate mounting - no medium

Secrets of Jaw Relation Records


Elastomers are extremely accurate Remove occlusal blebs from dentate casts Won Wont t into interproximals on some casts If cast doesn doesnt t into record, may need to adjust

Secrets of Jaw Relation Records


Stabilize casts when mounting Mean occlusal discrepancy of
1.6mm when hand held 0.25 mm sticks & sticky wax

Secrets of Denture Occlusion


All posteriors contact simultaneously

(Gunderson & Siegel, J Prosthodont 2002)

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Secrets of Denture Occlusion

Secrets of Denture Occlusion


Contacts buccal to the ridge destabilize - even monoplane
Browning, JPD 1986
M B

No contacts on inclines

Removable partial dentures B caused unseating Central loading better than distal loading

Secrets of Denture Occlusion


Excessive overbite will destabilize

Secrets of Denture Occlusion


Light rapid taps sound loud, mark widely Video Clip

Secrets of Denture Occlusion


No best occlusal scheme - use easiest possible monoplane, lingualized, fully balanced

Secrets of Denture Contours


No sharp contours Mildly convex lingual and buccal contours Use nger to feel for sharp contours

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Secrets of Denture Delivery

Secrets of Denture Delivery

Step 2 Denture peripheries with PIP One side at a time

Step 1

Check Denture base with PIP Moisten with air water syringe No peripheries

Avoid cheeks

Secrets of Denture Delivery

Laboratory Prescription
Fabricate: Remount index Remount casts Remount maxillary denture

Step 3 Occlusal Adjustment Remount with help

Record Centric Relation

Secrets of Denture Delivery

Step 3 Remount with help

Small amount of bite registration material Just cuspal indentations

Assistant remounts denture using centric record Stabilize casts

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Adjust Occlusion
Extraoral adjustment more efcient Eliminates continual removal & replacement of dentures Avoids reex avoidance

Secrets of Denture Delivery

Step 4 Chewing Test

Cotton roll No discomfort If discomfort now, worse after use

Secrets of Denture Delivery

Secrets of Denture Delivery

Step 5 Check Esthetics & Phonetics If large change, warn a head of time

Step 6 Polish Brasseler Denture Polishers

6 Step Delivery
Step 1 Adjust Denture base with PIP Step 2 Denture peripheries with PIP Step 3 Occlusal Adjustment Step 4 Chewing Test Step 5 Check Esthetics & Phonetics Step 6 Polish

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