CONTINUING EDUCATION

Volume 35 No. 3 Page 86

Successful and Predictable

Custom Complete Dentures
Authored by Tony Daher, DDS, MSEd; Mostafa El Sherif, DMD, MSCD, PhD;
William J. Davis, DDS, MS; William A. Lobel, DMD; Richard P. June, DDS;
Samuel M. Strong, DDS; Joseph P. Thornton, DDS; and Zarko J. Danilov, GMDT

Upon successful completion of this CE activity, 2 CE credit hours may be awarded

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does
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accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements.
 CONTINUING EDUCATION

Successful and Predictable Dr. Thornton graduated from Emory University School of Dentistry and has
completed the continuum series at the L. D. Pankey Institute. He can be reached
Custom Complete Dentures via email at jpt3dds@aol.com.

Disclosure: Dr. Thornton reports no disclosures.

Effective Date: 3/01/16 Expiration Date: 3/01/19 Mr. Danilov founded Danilov Dental in 1979. His lab is a synergistic force in
the research and development of new technology and materials in dentistry.
He can be reached toll-free at (800) 959-7033.

Disclosure: Mr. Danilov reports no disclosures.

About the Authors

Dr. Daher has been practicing dentistry since
1982 and currently maintains a private practice
limited to prosthodontics in LaVerne, Calif. He
has an MS degree in medical education from
the University of Southern California (USC), and
a postgraduate certificate in prosthodontics from
the University of California at Los Angeles (UCLA).
He can be reached at tonydaher@verizon.net.
Disclosure: Dr. Daher holds stock in Global Dental
Impression Trays.
Dr. El-Sherif graduated from Alexandria University College of Dentistry (Egypt),
then completed a master’s degree in restorative dentistry, and then earned a
PhD in fixed prosthodontics and dental materials with joint supervision by Okla-
homa University College of Dentistry and Tanta University. He can be reached
via email at drelsherif@comcast.net.
C
omplete denture service must be designed to main­tain
the stomatognathic system in a functionally healthy and
comfortable state. Patients who have lost all of their teeth
suffer from a chronic condition called oral disability, according
to the World Health Organization (WHO) criteria.1 One of
the popular treatments for this chronic condition is removable
complete dentures.2 Oral rehabilitation with complete dentures
can have tremendous patient im­pact and social implications.
Well-made re­movable complete dentures can restore a sense of
normalcy and self-esteem.3
Figure 1. EdentExam app
(Unique Dental Apps) for
iPad.

Disclosure: Dr. El-Sherif is a partner in Global Dental Impression Trays.

Dr. Davis graduated from Marquette University School of Dentistry and

earned his MS in prosthodontics from the University of Michigan School of
Dentistry. He can be reached via email at william.davis@utoledo.edu.
Figure 2. Removing
Disclosure: Dr. Davis reports no disclosures. denture adhesive with a
rotary brush in a bowl full
Dr. Lobel graduated from Tufts University School of Dental Medicine with a DMD of water.
degree. He can be reached at lobeldmd@aol.com.

Disclosure: Dr. Lobel maintains a financial interest in Global Dental Impression

Trays.

Dr. June is a graduate of the Loyola University of Chicago College of Dentistry

and of the General Practice Residency Programs at the Chicago West Side VA
Hospital, the University of Illinois Hospital, and Cook County Hospital. He can be
reached at rpjdds@yahoo.com. Figure 3. Sequence of the
making of the maxillary
Disclosure: Dr. June is a stockholder in Global Dental Impression Trays, a paid and mandibular final
instructor at the Massad Institute in Tulsa, and helps teach workshops presented impressions.
by Dr. Joseph Massad.

Dr. Strong received his DDS from Baylor College of Dentistry. He maintains
a private practice in Little Rock, Ark, with an emphasis on implant prosthet-
ics, aesthetic restorations, and sleep apnea. He can be reached via email at
strongdds@aol.com.

Disclosure: Dr. Strong is vice president of Global Dental Impression Trays.

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 CONTINUING EDUCATION

Successful and Predictable Custom Complete Dentures

There are many acceptable techniques a b
used in the construction of dentures in pri-
vate practice, and the complaint we hear
from practicing dentists is, “Denture treat-
ment is very frustrating. We have to deal
with so many adjustment visits!” and “We
have stopped treating denture patients
because we could not help them.”
However, because of the confusion that
exists in treating completely edentulous
patients, the purpose of this article is Figure 4. Caliper was used to select the width of the 6 maxillary anterior teeth by measuring the
width of the nose.
to present a successful and predictable
technique for fabricating removable a b b c
complete dentures. We have used and
finessed this system throughout the
years. It is worthy to mention that many
practitioners want to learn how to make
successful complete and/or presurgical
dentures that serve as blueprint templates
for the placement of dental implants. It
is important to know where the denture Figure 5. Massad Lip Ruler (Nobilium) was used to measure the upper and lower lips at rest.
teeth will be located prior to placement of
a b c
implants.

FIRST APPOINTMENT
Know Your Patient
The first consultation appointment is a
“get-acquainted appointment” with the
patient as it is very important to establish a
good rapport of kindness and understanding. Figure 6. (a) Esthetic Control Base is needed to make a proper lip support, and to mark proper lip
and position during laughing. (b) The anterior portion is leveled to the horizon for proper plane
The late L. D. Pankey stated that every clini- length
of occlusion and the midline is marked with a vertical line. (c) The portion of the wax rim distal to
cian must “know your patients.” They have a the canine will be made slanted to the lingual 45º to mark the buccal corridor.
dental problem and you want to help them.
At this meeting, you need to determine and understand exactly dentist to render the best possible service.”4
what the patient’s wants and expectations are. Of course you want If the fee for services is ac­cepted, signed informed consent—
to provide your patient with an exceptional aesthetic and func- which covers the benefits, risks, and alternatives of complete den-
tional denture. However, there may be other issues beyond your ture treatment—is obtained. Financial and refund policies are
control that by their nature make constructing a new denture diffi- clearly explained. A panoramic radiograph is taken and read.
cult or impossible. That is why the thoughtful interview and thor- Once the examination is completed, a printout summary of
ough clinical extraoral and intraoral examination is so important. the conditions will be handed to the patient. In this visit, oral
The use of the Dr. Massad Edentulous Exam (EdentExam [Unique hygiene instructions will be given on how to clean the prosthe-
Dental Apps; available from iTunes]) is recommended (Figure 1). ses and how to remove denture adhesive from the mouth and the
Before starting on the treatment, it is important to discuss your dentures (Figure 2).5
fair fee with your patient and establish solid financial arrange- We also make the following 2 requests from the patient prior
ments. Your patients must understand that you may or may not to the next appointment: (1) to remove the dentures for 24 hours
work directly with their dental insurance company. Pankey said, to get rested rebound oral tissues, the patient only using them
“A fair fee can be defined as that fee which the patient is willing to eat, and (2) to bring along a photo or a snapshot with a smile
to pay with gratitude and appreciation and which will enable the taken before natural teeth were lost, if possible.

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 CONTINUING EDUCATION

Successful and Predictable Custom Complete Dentures

a b c d

Figure 7. (a) Massad Jaw Recorders (Nobilium). (b) Striker plate and pin placed onto record bases. (c) Gothic arch tracing on the upper striking plate.
(d) Securing the tracers bases together with Futar D Fast (Kettenbach LP) bite registration Material.

a b c d e

Figure 8. (a) The neutral zone is an area where the forces of the cheek and lip muscles get neutralized by the forces of the tongue muscles. In this zone,
the lower denture teeth will be placed. (b) Neutral zone record molded in patient’s mouth. (c) Neutral zone record is trimmed at the black line at the level
of the rested lower lip. (d) The finalized neutral zone record placed in the patient’s mouth. (e) Silicone index is made and shows where the denture teeth
will be set. The black area is the playground of the tongue, the pink area is where the buccinators act, the green area is where the lips act, and the yellow
area is where the denture teeth are set.

SECOND APPOINTMENT a b Figure 9. Balanced artic-

ulation with anatomical
Collection of Records denture teeth setup (a) in
The following 4 objectives must be achieved in this visit: centric position, and (b)
1. The final impressions are made for the complete upper and in working and balancing
position. (c) Before and
lower dentures. During the procedures, it is advisable to educate c d (d) after images.
the patient about the importance of the impressions and what
they represent and why border movements are important.6
Multiple viscosities of vinyl polysiloxane (VPS) impression Before After
material in a low-temperature moldable edentulous tray to obtain
a co-lamination among the layers of material will be used. The tracers (Figure 7) and a neutral zone record for the mandibular
capture of an anatomically correct and detailed reproduction of all cast (Figure 8).
aspects of the edentulous arches is thereby enhanced (Figure 3).6
2. Measurement is taken of the width of the nose with THIRD APPOINTMENT
an Alameter (Ivoclar Vivadent) or a caliper (Figure 4) and 2 Collection of Records
measurements: one of the upper lip at rest and the second of the The following 6 objectives must be achieved in this appointment:
lower lip at rest with a Massad Lip Ruler (Figure 5). 1. Select a vertical dimension of occlusion (VDO) at a
3. If any labial, buccal, or lingual overextensions are present retruded contact jaw position using the Massad Jaw Recorders
on the impressions, it is advisable to mark the right extensions (Nobilium) or tracers7 with one set of the record bases. If linear
with a permanent marker. The maxillary vibrating line should be occlusion will be utilized, the recording is made at rest VDO.
transferred to the impression using an indelible marker. If lingualized occlusion is the occlusal scheme of choice, the
4. A laboratory prescription should be filled out with the rest VDO is closed 3.0 mm prior to making the tracers. Once
previously collected data, along with the request to fabricate recorded, a VPS material (Futar D Fast [Kettenbach LP] or Regisil
stone casts and 2 sets of record bases. One set is to be used to Bite Registration Material [DENTSPLY Caulk]) is used to secure
make a wax Esthetic Control Base (ECB) for the maxillary cast the bases together (Figure 7d).
(Figure 6); a second set is to be used to place the Massad disposable 2. The ECB is tried and adjusted for adequate upper lip support.

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 CONTINUING EDUCATION

Successful and Predictable Custom Complete Dentures

The anterior horizontal level of the wax is checked against the a b Figure 10. (a) Linear
articulation using maxillary
bi-pupil horizontal level for parallelism. The midline of the flat porcelain posterior
face, and the highest (laughing) lip-line are marked. The buccal teeth and mandibular
corridor is checked and sometimes adjusted (Figure 6). bladed form of porcelain
3. The neutral zone record8 is heated in a water bath of 140°F c d posterior denture teeth
in centric position. (Note:
then placed in the patient’s mouth. The patient will be asked to sip there is no vertical overlap
and swallow hot water 4 to 5 times, then cold water is used before of the anterior teeth.)
(b) Linear articulation in
removing the record out of the mouth. This neutral zone record protrusion. (c) Balancing
is a must when the lower ridge is very low to nonexisting. Use e f occlusion side view.
of the neutral zone method to identify and register the anatomy (d) Occlusal view of the
mandibular prosthetic
and physiology that impact prosthesis stability may result in teeth set up in linear
improved prosthodontic therapy for patients (Figure 8). occlusion. Note that the
4. The vibrating line is checked and the posterior border of the buccal cusps are shaped like a “blade.” (e) Smile with old dentures.
(f) Smile with new dentures.
record base is adjusted as required.
5. The shade and mold of the prosthetic teeth are selected a Figure 11. (a) External
with the patient input. Patient involvement in tooth shade, mold impressions made using
a light vinyl polysiloxane
selection, and tooth arrangement increases denture acceptance (VPS). (b) Finished
and results in fewer complaints and post-placements visits.9,10 dentures showing
6. A balanced articulation will be selected. Lingualized or linear the external anatomy
preserved.
occlusion will need to be determined and prescribed (Figures 9 b
and 10).11,12
During this appointment, it is advisable to explain and educate
the patient about the importance of these records. In addition,
the importance of bringing a spouse or close relative to the next
“rehearsal” appointment is also discussed.

FOURTH APPOINTMENT Table. Identification Consent Form

“Rehearsal” of the Wax Trial
Dentures
The following 6 objectives must be
achieved in this appointment:
1. The dentist checks first the wax
trial dentures for aesthetics, VDO,
plane of occlusion, buccal corridor,
centric, and phonetics.13
2. Then it is checked by the patient
standing in front of a big mirror; first
at 9 feet, then at 6 feet, then at 3 feet.
The patient will be asked for some
feedback about the fit and regarding
the look of these dentures in the
mouth. Never allow the patient to
use a hand mirror for viewing. Never
let the patient take the trial denture
home for family viewing.
3. Make an external impression
along all the cameo surfaces of the
trial denture using low viscosity
DENTURE IDENTIFICATION
(required by the State of ___)
Laboratory Fee $_______ per Denture
I wish to have my name or Social Security
Number placed in my denture(s).
________________________ _______
Patient Signature Date
I wish to waive the right to have
my name or Social Security Number placed
in my denture(s).
________________________ _______
Patient Signature Date
VPS in low residual ridges (Figure 11).
4. Sometimes it is important for
the patient to take ownership of this
appointment by signing an approval
paragraph placed in the patient chart.
5. It is prudent to ask the patient
for his or her consent or refusal for a
denture ID placement (Table).
6. If the VDO or centric occlusion
is off, a new tracing can be made
using the trial denture and the jaw
recorders. A remount and reset is then
achieved and the patient recalled for
verification.
FIFTH APPOINTMENT
Integration of the Finished
Complete Dentures
The following 4 objectives must be
achieved in this appointment:
1. The dentures are fitted using a
pressure indicating paste14 (Figure 12),

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 CONTINUING EDUCATION

Successful and Predictable Custom Complete Dentures

and sometimes a new Figure 13. Tracers used
centric record using to correct all procedure
occlusal errors of the
the Massad tracers is denture fabrication.
made to refine the occlu-
sion and balance the den-
tures (Figure 13). This
step is very important
for the patient’s com-
fort with the new den- a b Figure 14. (a) Titrating
steps with light VPS
tures. This step will to check border over-
not be necessary with extensions and (b)
linear occlusion since adjusting.
there are no inclined Figure 12. Pressure indicating paste
planes to adjust. to check the tissue fit of recently made
dentures.
2. The patient is
then given some grapes to chew to check for any sore spots
before dismissing him or her. Adjustments are made to relieve
any areas of discomfort.
3. Oral and written instructions are given as to how to care
for the new dentures and what the patient can expect. A good
practice-marketing tool is to give the patient a cleaning kit.
4. It is advisable for the office to keep the old dentures to
shorten the adjustment period of the new dentures. Old den-
tures will be given back when the patient is comfortable and no
further adjustments needed. Future adjustments will be made
until the patient is comfortable. It normally takes several weeks
to learn to eat efficiently with new dentures. It not unusual for
the dentures to feel too big if the VDO has been restored. The
musculature will adjust to the new height quickly.

SIXTH APPOINTMENT
Adjustment Phase: Adaptation to the New Dentures
The following 5 objectives must be achieved in this appointment:
1. The patient will be asked how he or she is getting along with
the new dentures. A troubleshooting procedure will be initiated to
solve any problems.15
2. Sometimes it is acceptable to say that some problems can-
not be solved due to the limitations of the patient’s condition.
3. Complete a visual inspection of the soft oral tissues for
any red lines or red ulcerations. Pressure-indicating paste (Lee-
Mark Pressure Disclosing Paste or LeeMark Sorefinder [Lee-
Mark Dental], or PIP or Mizzy [Keystone Dental]) could be used
to relieve the sore spots and the border overextensions can be
titrated with a light-body VPS (Panasil Light Bodied [Ketten-
bach] or AquasilUltra XLV Fast Set [DENTSPLY]) (Figure 14a).
4. Adjustments will be made (Figure 14b) until the patient is
comfortable and confident in wearing the new dentures. With
this described technique, one or 2 adjustment visits suffice for the Figure 15. Assessment form to be sent to patient after treatment is done.

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 CONTINUING EDUCATION
Successful and Predictable Custom Complete Dentures
successful integration of dentures. For medically compromised
patients whose muscle dysfunction cannot be corrected, it may
require implant stabilization. This must be discussed at the begin-
ning and at the end of treatment.
5. A denture assessment form (Figure 15) is to be mailed to the
patient after 2 weeks of the completion of the denture treatment.
This is an excellent form of feedback for the dental practice.
CLOSING COMMENTS
A summary of a predictable technique for the fabrication
of removable complete dentures has been presented. This
technique has been tested by many practitioners and has stood
up through the years.
The details of the technique are described in the referenced
articles, or you can view the technique videos at nobilium.
com/clinical-products, joemassad.com/nobiliumproducts, or
on youtube.com, search for Joseph Massad.F
References
1. World Health Organization. International Classification of Functioning,
Disability and Health. Geneva, Switzerland: World Health Organization;
2001.
2. Felton DA. Edentulism and comorbid factors. J Prosthodont.
2009;18:88-96.
3. Roumanas ED. The social solution—denture esthetics, phonetics, and
function. J Prosthodont. 2009;18:112-115.
4. Pankey LD, Davis WJ. A Philosophy of the Practice of Dentistry. Toledo, OH:
Medical College Press; 1985:158-159.
6
5. Cagna DR, Massad JJ, Daher T. Use of a powered toothbrush for hygiene
of edentulous implant-supported prostheses. Compend Contin Educ Dent.
2011;32:84-88.
6. Massad JJ, Cagna DR. Vinyl polysiloxane impression material in
removable prosthodontics. Part 1: edentulous impressions. Compend
Contin Educ Dent. 2007;28:452-459.
7. Daher T, Lobel WA, Massad J, et al. Predictable technique to register
retruded contact position (RCP) using a disposable jaw relation recording
device. Compend Contin Educ Dent. 2015;36:323-330.
8. Cagna DR, Massad JJ, Schiesser FJ. The neutral zone revisited:
from historical concepts to modern application. J Prosthet Dent.
2009;101:405-412.
9. Lefer L, Pleasure MA, Rosenthal L. A psychiatric approach to the denture
patient. J Psychosom Res. 1962;6:199-207.
10. Hirsch B, Levin B, Tiber N, et al. Effects of patient involvement
and esthetic preference on denture acceptance. J Prosthet Dent.
1972;28:127-132.
11. Jameson WS. Linear occlusion: an alternative tooth form and occlusal
concept as used in complete denture prosthodontics. Gen Dent.
2001;49:374-382.
12. Williamson RA, Williamson AE, Bowley J, et al. Maximizing mandibular
prosthesis stability utilizing linear occlusion, occlusal plane selection, and
centric recording. J Prosthodont. 2004;13:55-61.
13. Pithon MM, Alves LP, da Costa Prado M, et al. Perception of esthetic
impact of smile line in complete denture wearers by different age groups.
J Prosthodont. 2015 Sep 15. [Epub ahead of print]
14. Bookhan V, Owen CP. A comparison of the cost effectiveness of pressure-
indicating materials and their ability to detect pressure areas in complete
dentures. SADJ. 2001;56:228-232.
15. LaBarre E, Giusti L, Pitigoi-Aron G. Addressing problems in complete
dentures. Compend Contin Educ Dent. 2007;28:538-542.
 CONTINUING EDUCATION

Successful and Predictable Custom Complete Dentures

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POST EXAMINATION QUESTIONS

1. Well-made removable complete dentures, although proven 5. Sometimes, it is important for the patient to take ownership
to be helpful, very rarely restore a sense of normalcy and an of this appointment by signing an approval paragraph
acceptable self-esteem. placed in the patient chart.
a. True b. False a. True b. False

2. During the first consultation appointment, a “get-acquainted”
session with the patient is very important to establish good
rapport of kindness and understanding.
a. True b. False
6. It is never advisable for the office to keep the old dentures
to shorten the adjustment period of the new dentures.
a. True b. False

3. During the clinical procedures, it is advisable to educate
the patient about the importance of the impressions
and what they represent and why border movements are
important.
a. True b. False
4 A neutral zone record is a must when the lower ridge is very
low to nonexisting.
a. True b. False
7. It is never wise to say that some problems cannot be solved
due to the limitations of the patient condition.
a. True b. False
8. A denture assessment form can be used to gain some good
feedback for the dental practice.
a. True b. False

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 CONTINUING EDUCATION

Successful and Predictable Custom Complete Dentures

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