Tooth selection and setting of the teeth

Tooth selection and setting of the teeth

*Note: the reference for this lecture and the coming lectures that related to the setting of the teeth is chapter 16, 17 (286-328) Our lecture today is about tooth selection and setting of anterior teeth. Teeth setting is a multistage procedure, we set the anterior teeth first then we set the posterior, after we set the teeth we need to shape the gingiva.the wax rim is nice and smooth but after we set the teeth it becomes irregular because the wax melt on the teeth and it becomes messy. Now, we are in the third lab we did mounting and now setting we still haven't reach the 4th clinic which is wax try-in. What would we look like without teeth!! It isn't attractive, there are patients who born without teeth and if when we miss teeth we miss the alveolar bone which gives the facial support it's not just the teeth that gives this support (keep this in mind when we start talking about setting of the natural teeth). When we set the teeth in a different ways this will give different dentures and will affect the personality of the and change it because if you feel comfortable to the way you look socially you will interact with people in a different manner like for example when you dressed well and you are comfortable to the way you're dressed you will act differently when you're not dressed well." Teeth have a very significant effect on the way the person interact with the surrounding environment" When we select teeth we need to take a number of things into consideration, there're also guidelines for selecting the posterior teeth, in our country we usually don't select the posterior teeth we just select the anterior teeth and then we select the whole set of teeth, but it would be more correct to select both the anterior and the posterior teeth. Usually the company provides all the teeth together and there're many companies that allow you to select the posterior teeth or the anterior teeth individually according to the patient.

Tooth selection and setting of the teeth The artificial denture teeth can be made out of different materials the one that we are going to use it which is denture acrylic. The major requirement for selection and setting of the anterior teeth is esthetics it's also related to phonetics and function but the most important is esthetics to get a good appearance. Posteriorly function is the most important thing because we do most of our chewing on the posterior teeth. So, what kind of guidelines can we use to select the anterior teeth?
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There're a lot of types of records that we can use; 1- we can use for example an old photograph for the patient when he was smiling
2- diagnostic cast if you have patient that still has teeth and

you've been treating him for several years before he extract his teeth you can look at his previous teeth to see if they are attractive you can select similar 3- X-Rays 4- Old dentures 5- Patient's facial characteristics ,gender ,personality
6- Patient's age; the older the patient is the less teeth you expect

to see and the sharper the angles

7- The arch size and shape, if you have a very large mouth and

you put a very small teeth the setting won't look attractive. Ultimately you're not going to wear this denture youre making it for the patients to wear themselves so the patient's preferences "what they want in their mouth" is really important. You work as a guide you have information to narrow down the choices for the patient. There're a lot of reference marks that we learned about them in jaw relationship records we will talk about again during setting of the teeth
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Tooth selection and setting of the teeth and also during wax try-in because we need to go back and check them after setting which are the mid line position, the corners of the mouth, the high lip line, the low lip line specially the smile line. We even use anatomic references on the ridge which is the palate mid-line and also the incisive papilla because the position of it doesn't change during resorption so if we know the measurements between the natural teeth ( the labioincisal edge) and the incisive papilla so we can reproduce them we when we set the teeth and usually it's about 8-10 mm horizontally between the center of the incisive papilla and labio-incisal edge of the central incisors even if I set the labial fullness according to the nasio-labial angle I can also use the incisive papilla as a guide to check. We did all the measurements and at the end we went back and use alternative things to make sure that it's right. Then we have mandibular reference lines the basic one that we usually set the posterior teeth over the center of the ridge we draw a line from the retro-molar pad through the canine would be this gives the center of the ridge where we set the teeth on. The major problem that we have is that we try to communicate information to the technician that usually doesn't see the patient, you as a dentist can remember details about the patient because you have seen him but the technician can't, maybe you send a photograph with JRR because it's your job to communicate as much information as possible so the technician has something to work with. We mark the smile line, the canine line and the other things that we talked about them before using a Varity of things like ruler or dental floss we also have a flexible rulers which has gradations form 1-15 cm but at the right measurements for instance we end with E,F.G,H ; the letters are actually the name of the molds, for example a company make different shapes with different widths and name them according to this width the one with 40 mm width they name it A ,42mm =B , 44mm = C so all I have to do is just to take the ruler and see where it finishes, there's many different variations according to the company . the simplest way is to use a flexible ruler or a piece of dental floss from canine line to canine line on the arch "always measure across the curve not straight across the measurement is different.

Tooth selection and setting of the teeth

*the significant of the high smile line "high lip line": We said that usually "not in all patients" we expect to see 2/3 or 3/4 of the teeth so if I measure the high smile line at 9 mm so I expect the tooth to be at least 10-11 mm long and if the high smile line for example 6 mm the tooth should be 8-9 mm long when I select. Again you can use the line across the mid palatine raphe to be able to divide the tooth into right and left side, you can also use the incisive papilla on where to place the wax rim to where to set the teeth you can have a double check. The labial incisal edge of the central incisor is usually 8-10 mm in front and it varies with age, gender and size of arch.

The right place for the lower posterior teeth is lingual to the lower posterior arch anteriorly its labial, we set the teeth over the residual ridge not because it's a natural position but for bio-mechanical reasons. Even though you expect the lower anterior teeth to be more labial we try to keep the body of the tooth as close as possible to the ridge because if we keep them prominent this will create a rotational force which will cause a displacement to the denture.

So how we select the anterior teeth? You can choose any sequence
that you like but there's a logical sequence here if you follow it you will end up with an acceptable results. usually we start with the Size then we start thinking with other things and the technique we use based on previous records or if we don't have them we use the canine line after selecting the size we select the mold "what shape the teeth have" historically we used to used basic shapes; circular, square, triangular and so on this is a simplified form. Usually we tend to look at the facial form "the general shape of the patient's arch or face" and after that we select the length because we can have the same size and the same mold but the length maybe different. Finally we select the shade.

If there's an old denture, there's nothing more useful to use than it because it has a lot of information we can use it as a guide if the patient doesn't like the old denture then you will know what not to do but if the patient
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Tooth selection and setting of the teeth likes the old denture you just narrowed down your choices maybe from 100 to 1 because you know what to look for you have a very good guides in the old dentures. You can measure the old teeth using a vernier caliper. It's very useful to have an old photograph but the problem with photographs is that patients tend to have photograph without smiling or they are far away. You need a full face photograph with teeth which they are large enough to be able to see where the smile line was, to be able to see if there was a diastema , if there was a rotation in the teeth. We will describe how to set teeth ideally but you will see as a specialist that you don't set teeth in this way because that isn't the way real teeth are, most patients want ideal teeth but usually if you look at nature nothing is absolutely perfect because there is something which breaks perfection so they look more natural but if there is absolute perfection will look unnatural. You expect to see some slight aberration of perfection when you look at these teeth so as a dentist usually if I want to create a problem I will rotate one tooth very slightly to look more natural of course I will check this with patient first and it's nice to know if these aberration were present in the natural teeth, some patients want to reproduce what was in their natural teeth some patients come and say" I used to have a space between my central incisors so can you please make it in my new denture because people know me with this diastema " other come and say " I have a space so please close it to me" so it differs according to patient's preferences. As we said historically we used to use specific shapes for the teeth (square, triangular, round) but usually it's more logical to look at the facial form of the patient even though it's not that accurate it gives us a starting point, the studies say that there is no relation between the shape of the patient's arch or face with the shape of the teeth so to select the teeth we look at the patient's face and try to select what form actually fits the patient. This differs according to the age ( the older the patient the less teeth we expect to see and the sharper the angles) , the patient's personality, the gender (males tend to have sharper line angles, prominent canines and sharp angles on the centers but females tend to have softer curves on their teeth this is just a generalization it isn't that accurate, for artificial teeth this is a starting point for selection this doesn't mean you have to give male sharper angles and female softer angles we can mix two molds.
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Tooth selection and setting of the teeth

Most molds are calcified in the catalogue according to this classification: (upper or lower), (soft or rough), (small, medium or large) Usually there's a chair side catalogue which looks like a card, most companies have an average of approximately between 30-40 molds sometimes 50 and they divide them according to shape, size, and length. Some companies provide you samples of the exact teeth (a box that contain the molds which you can show them to patient) it's better than a picture but it's not always available. the selection of the teeth also depends on the preference of the patient and there's an information that guide the patient to choose which type of teeth would be appropriate for them **I can't put a very young teeth in a mouth of very old patient it won't look natural.

How should I choose shade?

There're a lot of thing that I can use to select the shade; we can use the shade guide which contains tapes we come to patient's mouth and start to compare what is suitable usually when we deal with patients with teeth when we select the shade we compare it with the teeth that are in their mouth for example if you want a restoration on an existing teeth, the dentist job is easier he just compare to the teeth that are there but what do you do when the patient has no teeth at all ?! you have to go by something which is present in the patient you can use the patient's complexion, the hair color, the eye color ( not just the iris you look also to the sclera) , the age also because older patients tend to have darker teeth, the personality of the patient( what the patient wants). It's also important to tell the patient not to choose the lightest teeth because most of our patients if you show them the whole shade guide immediately they will go to the lightest teeth but we know that the lightest teeth aren't always the most appropriate teeth. You will be taught that the color of the teeth is strongly related to the complexion or ethnicity of the patient (the patient with darker skin has a darker tooth and vice versa) and this is absolutely wrong because the shade is combined to different things; hue, chroma and value.

Tooth selection and setting of the teeth If there's anything that can gives you an idea what shade or hue to use you can use the complexion for example if the patient have a pinkish bright complexion maybe you would use shade similar to the hue of the patient's face, but the value almost has nothing to do with it. Melanin gives the pigment to the skin in the teeth there's no melanin so there is no relationship between the complexion and the shade of the teeth. The things that are really affect the eating habits, smoking and age because with age teeth tend to darken externally and internally (the dentine becomes yellower with time). Sometimes we check the shade of an existing denture if available. Metamerism the color of the subject. You need good lighting when you take the shade not under neon light or yellow light but under the dental light by the window to make sure that the color is normal.so based on all these information usually we narrow down about 2-3 shades and ask the patient to choose You also notice something else that color is also formed by contrast if I put a light color beside a dark color it would look different if I put it beside a color that is similar to it for example if your patient is wearing a bright red lipstick and you check the shade it's different when the patient remove this lipstick so it's preferable to take the shade without make-up. **always get the patient's approval, your job is to select the teeth, narrow down choices and then let the patient see because every person care about the way he look, usually when we do wax try-in we try to get relative or somebody close to the patient to get the reaction. So we have to give the patients full freedom to choose what they want and try to advice them not to choose something that isn't normal. There are different shade guides for different companies the most famous shade guide which we use in dentistry is called the veta shade system (veta is a company's name) it's a very old shade system and it's divided into A,B,C,D it's the veta classic system A= reddish brown B= reddish yellow C= grey D= reddish grey

Tooth selection and setting of the teeth The teeth which we are going to use in the lab are divided according to the shade classification, the teeth that we use in the clinic is a little bit different they have a slightly different shad system ( the major dense shade system . you will see that A is divided into A1,A2, A3, A3.5, A4 and so on . The veta shade system is not a hue and value it's hue and chroma ( )for example sometimes B4 is lighter than B3 doesn't mean that 1,2,3 is darker it means that the chroma is darker. In this system the letter is hue and the number is chroma. The major dense shade guide that we use in the clinics for artificial teeth is based on hue and value if you go form lower to higher it becomes lighter to darker not increase in color and the colors are white, pink, yellow, brown, grayish brown and grey. Historically most denture teeth are made out of porcelain, acrylic is a new material. The porcelain has advantages and disadvantages: porcelain is stronger than the acrylic it doesn't wear away fast (This point is both an advantage and disadvantage for porcelain why?) Because it doesn't wear away fast it has no soft pattern "no cushioning factor it transmits the force to the residual ridge very much and this result in an advance residual ridge resorption it becomes just a flabby ridge) the second problem with porcelain is that it doesn't bond chemically to acrylic there will be a small space around it, it needs mechanical retention this space will lead to leakage of the stain from the food around the tooth and they can separate from the denture much more easily.
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**the acrylic teeth are kinder to the gum the amount of force is less and the esthetics is almost as good as the porcelain because acrylic teeth now are not just one color they start to make them in layers (we have dentine,

Tooth selection and setting of the teeth enamel and translucent layers) so they look just as attractive as porcelain teeth. and they are more resilient they bond chemically to the base so they won't break easily and they wont stain easily either. porcelain teeth are like glass when the patient talk or eat they start to make sound like clicking sound but the acrylic are softer they don't produce this sound.
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porcelain teeth if there is a mistake in them it's very hard to trim because it might break but the acrylic teeth are easier to trim (much softer) .
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posterior teeth :

posterior teeth actually don't come in one mold shape and also we have sharp cusps and flat cusps and there are different degrees and it's one of the factors that we get balanced occlusion. Back to the mold catalogue "mold chart"; in this chart there's a key we have teeth with different shapes and sizes. Inside the patient's mouth we can use measurements to select the molds you will that different molds have a general range of size but they have different shapes (triangular, square, circular). If you look at individual molds you can find a numbers that indicates the width and the length of the tooth. The posterior teeth are similar they are usually measure one side not the entire posterior dentition (from the mesial of the first premolar to the destal of the second molar) we don't set the third molar ,the company always gives us 28 teeth not 32 teeth.

Many of our patients when they want to make a denture they bring us their gold tooth and ask us to put it in their new denture and this makes the denture to look so natural "when you put something like this in the denture it's very difficult to know either its real or not.

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Tooth selection and setting of the teeth You don't have only to put a gold tooth to make the denture looks real you can create a little grove on the central incisors if thee patients use to bite seeds so the denture looks real because it has an error. There are specific guidelines to set the teeth, each tooth has 4 criteria: Each tooth we have to know it's axis bucco-lingually, mesio-distally, it's relationship with the occlusal plane and it's axis on the arch of the jaw.

Done by: Lamees Nimri Best of luck all in your final examsstudy well Raya Hijazi , Raneem Rashdan: "To be depressed is to be lonely;
to have two lovely friends like you is to be happy..."

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