#10 Complete Dentures

#10 ‑ Complete Dentures

 

Initial F/F Exam

 

  1. Philosophy

 

By now you know how difficult dentures can be.  Did you see anything wrong with this statement?  Answer ‑ dentures aren’t difficult.  People adapting to dentures can be virtually impossible.  85% of the complaints in an average office are related to dentures.

 

Constructing a well fitting denture is only one half the battle.  The other half is overcoming the self doubts, fears, and negative feelings of the client.

 

The examination appointment has three goals.

  1. Establish a positive atmosphere for success.
  2. Evaluate the client’s physical ability to wear dentures
  3. Evaluate the client’s psychological ability to wear dentures

 

As we have discussed in earlier levels, your first four minutes with this client determines the success of the whole experience.

 

Greet them with a handshake in the reception room.  Assess them physically.

  1. Handshake ‑ firm or weak
  2. General appearance ‑ frail, healthy
  3. Walk ‑ strong, confident or weak, halting
  4. General greeting ‑ confident, skeptical, reserved
  5. Dress ‑ meticulous, casual, sloppy
  6. First conversation ‑
  7. About dentures, themselves, others
  8. Positive, negative

 

When your client is comfortably seated in a private office, begin your conversation.  Don’t be in any hurry.  This is the most important part of their entire experience with us.  Review the green sheet.  Begin by who referred them.  As always, we want to know who to thank, but equally important, the referrer may be a satisfied denture wearer (and, hopefully, we made the denture!).

 

While you’re reviewing the questions, expand on them.  Let your client talk.  Listen for:

  1. Recent emotional experiences
  2. History of problems with dentures
  3. History of problems with dentists
  4. Recent health problems
  5. Expectations of us and new dentures
  6. Look at body language
  7. Facial expressions
  8. Clenched hands
  9. Rigid, tense posture
  10. Intense gaze
  11. Lack of smile

 

 

Encourage your client to talk.  Get a clear picture of their expectations.  Be honest.  Give balanced examples ‑ some successes, some failures, of other cases we’ve had.  Use these points:

 

  1. People can only chew 25% as effectively with dentures as with their natural teeth.
  2. Even if they’ve worn dentures successfully for years, they will need several months to get used to their new dentures. The fit, feel, looks, and chewing ability will be new. It’s like starting all over again.
  3. Dentures aren’t a substitute for teeth. They are a substitute for no teeth.
  4. If their parents had dentures, expect your client to handle them with equal success (or problems).

 

What expectations does your client have?

Find out:

  1. Social and job requirements
  2. Wedding in 3 weeks, etc.
  3. Sings professionally
  4. Salesman
  5. Adaptability
  6. Trouble getting used to glasses or prescription change
  7. Wear rings, jewelry comfortably
  8. Worried about whether they can wear new dentures
  9. Motivation for new dentures strong
  10. Old ones unusable
  11. Spouse wants new look

 

Help your client feel that this is a unique opportunity for them to receive the care they deserve.

  1. The initial conference ‑ This is almost certainly a new ‑ and positive ‑ experience
  2. Ask for pictures of client when had their natural teeth
  3. Request spouse to come when working on esthetics.
  4. How we handle finances
  5. A recall system for seated denture clients

 

When you have finished reviewing the dental section, go over the past medical history.  Here are the significant factors to consider in the history:

 

 

 

DENTURE MEDICAL HISTORY

 

  1. Are you under the care of an M.D. ______________________________

 

  1. Age: (Over 65 will decrease ability to adapt to dentures)

(Does patient need extra understanding and sympathy)

 

  1. Diabetes: (Rapid bone loss, smaller teeth & food table, many adjustments)

 

  1. Arthritis: (Records difficult, periodic occlusal adjustments)

 

  1. Anemia: (Work with M.D., small food table, many adjustments)

 

  1. Tuberculosis: (Needs good diet, check dentures often)

 

  1. Radiation: (Make dentures when tissues return to normal)

 

  1. Hypertension, heart disease: BP ____/_____ (Beware of emergencies)

 

  1. Kidney problems: (Make tissues sensitive)

 

  1. Thyroid: (Alter mental & physical ability, can cause rapid bone loss, and low tissue tolerance)

 

  1. Menopause and endocrine disturbances: (Tissue changes, emotional problems)

 

  1. Epilepsy: (Work with M.D., quality of tissue a problem)

 

  1. How is your diet? _______________________________________________

 

_____________________________________________________________________

 

  1. Insomnia, depression, headaches, ulcers, colitis ‑ emotional problems

 

  1. People using walkers. All their muscles are effected.

 

  1. Pettechiae on skin. Expect some in month.

 

  1. Stomach upset. Check on prescriptions before hoping our new denture will correct.

 

  1. Smoking causes oral soft tissue problems.

 

  1. Are you taking any medication ___________________________________
  2. Cortisone: (Can cause painful mouth lesions)
  3. Estrogen: (Cause bone resorption)
  4. Smoking, excessive alcohol: (increase tissue sensitivity)
  5. Sedatives, sleeping pills, muscle relaxants, tranquilizers ‑ length of time on medication, size and frequency of dosage, emotional problems

 

Now escort your client to a dental chair.  Review the check list.  Here are some considerations:

 

  1. The tongue controls the lower denture.
  2. When the posterior teeth are lost, the tongue expands laterally.
  3. Dentures can make the tongue feel cramped

 

  1. When posterior teeth are lost, the ridge resorbs, but evenly.
  2. Upper ridge ‑ vestibular space decreases
  3. Lower ridge ‑ vestibular space increases

 

  1. Interarch space ‑ room to set teeth?

 

  1. Does the maxillary tuberosities touch lower ridge?

 

  1. Undercuts on the ridges

 

  1. Tori that would create sore spots

 

  1. As upper ridge resorbs, allows upper denture to sink up and back. Upper lip sinks in, wrinkles, and hides upper teeth. Chin looks more prominent.

 

  1. Do they gag easily during the exam? Is this often a problem for them?

 

Existing denture

  1. How long has it fit over its life?
  2. How does it look?
  3. What do you like about previous denture?

 

Description of old denture

  1. Appearance
  2. Good ‑ pleasant, natural appearance
  3. Fair ‑ generally pleasant but too regular
  4. Poor ‑1. teeth wrong size
  5. color
  6. position
  7. show too much
  8. show too little

 

  1. Retention (fit)
  2. Good ‑ seldom dislodge while eating or speaking
  3. Fair ‑ occasionally dislodge
  4. Poor ‑ often dislodge
  5. Ability to chew food
  6. Good ‑ able to eat most foods
  7. Fair ‑ must limit types of food
  8. Poor ‑ much difficulty or unable to eat with dentures
  9. Ability to taste food
  10. Good ‑ taste sensation is unchanged
  11. Fair ‑ some change, but not much of a problem
  12. Poor ‑ unable to taste much, don’t enjoy food anymore
  13. Speech
  14. Good ‑ Little or no change
  15. Fair ‑ Difficulty with a few words
  16. Poor ‑ Speech is greatly changed, difficult to understand, unable to make many sounds properly
  17. Comfort
  18. Good ‑ Rarely cause discomfort
  19. Fair ‑ some occasional soreness, but still able to wear dentures and eat with them
  20. Poor ‑ continuous soreness, unable to wear dentures

 

Posterior extension and seal processing, vertical centric, lateral, polish

 

Profile

  1. How much support for upper lip
  2. Relation of upper lip to lower
  3. Short active lip
  4. Long inactive lip
  5. Chin prominence

 

Ridges

  • Amount resorption
    1. Ridges
      1. upper flabby (usually lower anterior teeth still present)
      2. lower flabby (best to remove – warn client may need to be done later after new c/c seated)
    2. Position of inc. papilla
  • Size of bearing areas (gently stretch lips/cheeks to see amount of attached gingiva)
  • Undercuts
  • Are ridges nonparallel
  • Interridge distance – enough for false teeth
  • Relative size upper to lower
  • Size of mouth
    1. Broad arch can force teeth to be set facially and cause check abrasion
    2. Narrow arches lead to unstable tower dentures: hard to set teeth on ridges
  • U or V shape
  • Bony irregularities
  • Ridge length ‑ need to enlarge surgically?
  • Muscle attachments
  • Sharpness of lower
  • Tissue tone
    1. Normal‑firm, slightly resilient
    2. Non resilient ‑ associated with dry mouth
    3. Irritated
  • Tori and exostoses: may need to remove to avoid constant spot sore

 

Tissue Tone

  1. Skin
  2. Mucous membrane
  3. Musculature
  4. Inflammation
  5. Papillary hyperplasia
  6. Epulis
  7. Frenum attachments ‑ interfere with border seal?
  8. Stippling
  9. Burning in mouth

 

Tongue (no treatment, but make client aware of potential problems)

  1. Spread
  2. Control during impression
  3. Ability to handle lower denture
  4. Length
  5. Mobility
  6. Resting position

 

Bone

  1. Torus palatinus
  2. Torus mandibularis
  3. Tissue over tori: thin, thick, resilient, firm

 

Age Effect

  • General health of tissues
  • Pain threshhold
  • Fibrous material (lips, cheeks)
  • Coordination
    1. Open mouth 1/2 way ‑ tongue in right cheek
    2. Open all the way ‑ tongue in roof of mouth
  • Centric relation
  • IM joint
    1. Open wide
    2. Side to side
  • Saliva
    1. Amount
    2. Consistency
  • Lips ‑ vertical lines near border

 

Palate

  • Slope
    1. Class I
    2. Class II ‑ associated with high vault ‑ 45 degrees
    3. Class III ‑ 90 degrees ‑ associated with tapered faces, bilateral crossbite, Class III occlusion ‑ easiest to dislodge
  • Palatal seal width
  • Tendency to gag

 

Retromylohoid space ‑ size

 

Habits

  1. Bruxism
  2. Play with old denture
  3. Biting habit ‑ pipe, musical inst., etc.

 

Pictures of client when had natural teeth

 

Child with teeth that resemble patient’s X‑rays

  • fibrous material
  • Bony spicules
  • Cortical bone
  • Nutrient canals
  • Root tips
  • Mental foremen (any numbness when wear lower dentures)
  • Resorption

 

Patient’s Mental Attitude

  1. Philosophic ‑ rational, common sense, calm, dentures for health and appearance
  2. Exacting ‑ critical, accurate, likes explanations
  3. Emotional ‑ nervous, complaining, excited, ailments
  4. Indifferent ‑ little concern, not pay attention or follow instructions

 

Evaluation

  • Values and limitations of dentures
  • Supporting structures
  • Oral and general complications to wearing of dentures
  • How to use dentures
  • Problems of adjustment period
  • Need for tissue recovery periods
  • Cleaning dentures and supporting structures
  • Periodic examinations

 

Problem Cases

 

10‑15% of denture clients will have psychological problems that increase their problems wearing dentures.  Your task is to recognize these people.  Your dentist will take over these cases personally. There are four steps in this process.

  • Identify your client as a problem
  • Help them clarify the problem
  • Help client understand how you hope to solve problem

 

These questions will help

  • What kind of difficulties are you having?
  • What other problems are you having?
  • How old is your present denture?
  • What problems did you have during it’s construction?
  • For how long was it satisfactory (if at all)?
  • What did last dentist do to make it satisfactory?
  • How big a problem are your dentures in your life?
  • Did either of your parents have dentures?
    1. How well did they get along with them?

 

Now it’s time to make a major observation.  Is your client average or difficult.  We will add 20% onto the fee for a difficult client. Difficult has nothing to do with physical problems.  Difficult is the demanding person who will only be satisfied with perfection ‑ using their measures, not ours.  Look for these criteria:

 

  1. Average
  • are wearing dentures well now
  • have a pleasant adult conversation with you at the consultation visit
  • may know someone that you made a successful denture for
  • accepts responsibility for losing teeth (doesn’t blame)
  • smiles
  • expect adjustments after seating new dentures
  • have few or no problems wearing dentures
  • can eat anything

 

  1. Difficult
  • Complain how bad dentures are
  • Gag easily
  • Complain of looseness
  • Worried about wrinkles
  • Complain about previous dentist(s)
  • Don’t want to be bothered with understanding, just want me to get on with it

 

 

 

Take a Panoramic X‑ray

 

This will show:

  • Thickness of supporting bone
  • Any pathology in the jaws (roots, rumors, etc.)
  • Health of joints

 

Take a Photo

 

This photo will be helpful in our album of before and after photos. Take a full face and a smile close up.

 

Be sure to get a photo graphic release form signed if this photo is to be used in our album.

 

Dentist Consult

 

Now have your dentist come over.  Make the introductions.  Give a run down to your dentist on the conference, physical exam, x‑ray and color, shape of teeth.

 

The client will decide whether to have an economy or a characterized denture now.  When the client decides, escort them to the secretary for financial arrangements and appointments.

 

Be sure you have filled out the client Form.  Give them the original. Keep the carbon in the client’s record.

 

Finally, the point of this first appointment is the establishment of a winning relationship of trust.  We will do everything possible to make our client happy and satisfied.  Also, we will make the relationship a warm, caring, fun experience.

 

Special Situations

 

Occasionally, your doctor will be unsure if the client can be satisfied with new dentures.  In order to find out, your doctor will have you temporarily improve the existing dentures.

 

  1. 1. Make an alginate impression of the tooth surface, pour in plaster   (quick set)
  2. Use Impregum (no adhesive on the denture) to reline the dentures.
  3. Suck down a thin laminate over the tooth surface.
  4. Trim and adapt to the existing denture
  5. 5. Add quick care acrylic to the lower to increase vertical 1/2 of   ideal.
  6. Do the same to the upper, plus improve the esthetics.
  7. Allow the client to use this for 1‑2 days and let you know how it feels.  If they are satisfied, then we can make the new dentures.
  8. If your client has joint, muscle, or extreme psychological demands,  use Viscogel and let the client wear the changes for a month or so.

 

Immediate Dentures

 

This is a special situation.  We spend our professional lives helping people save their teeth.  Now you are faced by failure.  Our system and this client has become a dental cripple.  These people fall into two groups.

  1. The dentally hopeless
  2. Those that don’t want their teeth, but with care, have teeth that could last a lifetime.

 

We may choose not to treat this second group.  The first group requires some extra counseling.  Are they psychologically prepared to lose their natural teeth?  Loss of teeth has four symbolic significances

  1. Aging
  2. Sexuality
  3. Vitality
  4. Body degeneration

 

Use the following questionnaire to help discuss this very personal decision.

 

 

 

Immediate C/C

Interview

 

Before making an examination of your mouth, I would like to discuss some ideas about complete dentures with you.

 

  1. How do you feel about having your teeth extracted? _______________

 

______________________________________________________________________

 

  1. How do you feel about having complete dentures? __________________

 

______________________________________________________________________

 

  1. How do you think you’ll get along with dentures? _________________

 

______________________________________________________________________

 

  1. Do you know anyone that has complete dentures? ___________________

 

______________________________________________________________________

 

  1. How does he/she get along with them? _____________________________

 

______________________________________________________________________

 

  1. Do you expect to chew normally with these new dentures? __________

 

______________________________________________________________________

 

  1. Do you want to have your dentures ready to put in as soon as your teeth are removed or several months later?

 

______________________________________________________________________

 

  1. How long do you think it will take you to get used to your new dentures?

 

______________________________________________________________________

 

Advantages

  1. Less embarrassment (never toothless)
  2. No change in eating habits, tongue size
  3. Acts as bandage to help healing (less pain)
  4. Natural looking teeth are easier to select
  5. Position of jaws easier to maintain
  6. Less loss of bony ridge

 

Disadvantages

  1. Hard to get good molds of ridges over the teeth
  2. Initial good fit is lost in a few weeks usually
  3. Many treatment appointments are necessary to keep dentures comfortable as the ridges shrink and heal
  4. A permanent reline or new dentures is usually needed after a year
  5. Lips will look very full at first until muscles get used to plastic
  6. Lower immediate dentures are hard to get used to
  7. No way to try dentures in to see if you like them ‑ can only guess

 

Indications

  1. Pt. healthy
  2. Pt. must be around people
  3. Good attitude

 

Contraindications

  1. Poor health, age, heart, hemophilia
  2. Gums badly infected
  3. Nervous

 

 

 

  1. Wax Rim Construction

 

You will be working with your doctor for the first one half of this appointment and (when you’re ready) completing the appointment on your own.

  1. Set up operatory
  2. Edentulous trays
  3. Alginate
  4. Spatulas (3‑4)
  5. 3‑4 rubber bowls
  6. Water measurer
  7. Grey tooth selection manual
  8. Black tooth selection box
  9. Gray shade selection holder
  10. Swissedent booklet on esthetic dentures
  11. Pictures of esthetic set ups
  12. Blue wax (2 strips)
  13. Facebow fork heating in water bath
  14. Whipmix articulator ‑ cleaned with metal mounting plates attached

 

  1. Doctor will take upper impression ‑ coat client’s lips with baby oil

 

  1. Assistant will pour upper impression
  2. Pour in stone
  3. Place handle of tray in wood block to avoid pressure distortion

 

  1. Doctor will take lower impression

 

  1. Assistant will pour lower impression
  2. Doctor will make alginate tongue space
  3. Pour lower as upper was poured

 

  1. After 10 minutes, run your fingernail across the top of the model. As soon as you can only lightly dent the model, separate it and give it to your dentist to trim. It is easier to trim in this chalky stage than it will be 10 minutes later.
  2. You will make upper occlusion rim
  3. Wet the upper cast
  4. Heat 1/2 of a light pink sheet and adapt to the model (This wax is stiffer and supports the rim better).  Fold any excess onto the surface of the rim.
  5. Heat a second layer and adapt it onto the first in the same manner
  6. Make a pencil of the dark red wax
  7. Heat a 1/2″ wide strip across the short side of a wax sheet
  8. Bend this heated portion over onto itself
  9. Repeat these steps 4 times. Make sure the wax gets molten so it will fuse well
  10. Rip off this wax pencil.  Heat the bottom edge until the wax runs.
  11. Place the melted side on the light pink wax base
  12. Mold it into the position that teeth and gums would have in the upper arch
  13. Anterior teeth straight up and down from the flange edge
  14. Posterior teeth not too far out or in and no wider than teeth
  15. Remove the wax rim.  Heat a Bard Parker blade in the flame.  Cut away all excess wax around the flanges and posterior palatal area.
  16. Use the black torch flame to smooth the wax.
  17. This procedure should not take more than 5 minutes. Don’t make it perfect, only functional.
  18. Try in wax rim to make sure there are no rough edges that are uncomfortable.

 

 

 

  1. c. Facebow

 

  1. Set up
  2. Make sure facebow is clean
    1. Plastic earpieces sterilized
    2. Metal parts scrubbed clean ‑ don’t use knife to scrape plaster off ‑ the scratches will fill with plaster the next time and be impossible to clean out
  3. Make sure water bath on and facebow fork with thin layer of smooth red wax in bath
  4. Attach facebow to upper wax rim ‑ make sure fork in centered on rim. Fold over excess wax onto the occlusion rim for stability.
  5. Loosen all 3 screws and 2 toggles.
  6. Seat fork assembly in client’s mouth
  7. Ask client to “hold the bow and guide it into his/her ears.” Warn that the sounds will be loud.  Check to make sure both the ear pieces are firmly in the ears.  As the client guides these ear pieces into position fit the facebow shaft toggle over the facebow fork.  Tighten the center screw.  Then tighten the two side screws.  Ask your client to hold the facebow until the procedure is completed.
  8. Attach the nosepiece. Warn your client that s/he will feel pressure on the nose and in the ears.  Also know that we’re almost done.  Push the nose piece until it fits snugly and there is no wobble in the facebow.
  9. Use the hex wrench to tighten the toggle attached to the facebow fork. Support the facebow as you tighten the hex nut so it won’t rotate and hurt your client.  Use your free hand to support the wax rim and prevent it from moving.
  10. Tighten the remaining hex nut. This hooks the entire assembly together.  Now make sure the wax portion of the fork is still positioned comfortably in your client’s mouth and hasn’t moved.
  11. Loosen and remove the nosepiece.
  12. Loosen the 3 round screws.
  13. Have your client remove the facebow.
  14. Clean off the Whip mix articulator and attach 2 metal mounting rings.
  15. Make sure the condyle balls are tight on the lower member of the articulator. Use the large silver hex wrench to tighten it.
  16. Set the condyle guides at 30 degrees.
  17. Set the side shift guide at 15 (each line is 5)
  18. Put the upper model
  19. Attach the facebow to the upper member of the articulator. Push the one arm against your stomach.  Insert the other plastic earpiece onto the pin sticking out from the side of the flat metal surface.
  20. Tighten the center knob and then the two side knobs.
  21. The anterior end of the articulator must touch the facebow. If the upper model is in the way, carefully grind down the thickness of this model until the articulator and facebow can touch.
  22. Seat the upper member of the articulator onto the lower member. This supports the upper member while the plaster hardens.
  23. Mix quick set plaster in a green bowl.
  24. Place plaster on top of model and close down articulator onto the plaster. If the plaster is too thick, it will push the facebow fork down and distort your records.
  25. Add plaster between the cast and mounting plate until it is well covered.
  26. Run water in the green bowl. Support the articulator/facebow assembly with one hand and smooth the plaster with your fingers, wetting them periodically in the water.  Don’t allow plaster to get onto the tissue surface of the cast.
  27. Set the assembly aside for 5 minutes to allow the plaster to harden.

 

 

 

  1. Centric mounting

 

  1. Make the lower occlusion rim while the plaster is setting on the articulator/facebow assembly. Use light pink (harder).  Wet the cast to prevent the wax from sticking.  Middle 2/3’s of the way thru the wax.  Adapt the wax to the rim.  Roll the excess up onto the ridge.  Add the other half of the wax sheet.  Repeat this process.
  2. Carefully remove the facebow from the articulator. Be careful not to disturb the plaster.
  3. Remove the upper rim from the facebow using a Buffalo
  4. Seat both rims in your client’s mouth. Put the upper rim in first.    Seat the lower rim by rotating one side in at a time.  Check the vertical dimension (face height).  It is too great if:
    1. The client struggles to close the lips together
    2. Swallowing is difficult
  5. Vertical is too far closed if:
    1. Lower lip sticks out
    2. A free way space of 5 mm or more
    3. Looks prognathic (lower chin sticks forward)
  6. If the rims are too floppy in the client’s mouth, you can wet the rim and use denture adhesive.
  7. Another way to establish vertical is by using Swissedent’s plate and screw.
    1. Place upper plate on upper rim by heating the sides and pushing it into the wax. Add extra wax as needed.
    2. Add screw assembly to lower rim
    3. Adjust screw to apparent best vertical dimension.
    4. Adjust down 1 turn until client feels too far closed. Increase 1 turn at a time until client feels “propped open.”  Then reduce until feels “good.”
  8. A new method has been developed to determine vertical dimension. The craniometer works! See the video and try it on your next client (see article next page).
  9. Make sure your clients jaw is relaxed and closed in centric. This will be difficult for you to tell for several months.  Rest your client’s head firmly on the head rest.  Place your index finger below the chin and your thumb above the chin button.  Put a finger and thumb of your other hand between the upper and lower rims to stabilize them.  Have your client close using the words “close your back teeth together.”  Jiggle the jaw up and down as s/he closes.  This will help you feel if the jaw is loose and retruded correctly.  If the jaw is tight, your client will likely push the jaw forward.  This forward position will throw off the forward position will throw off the “feel” of vertical and confuse your reading of the lips at rest appearance.
  10. When the vertical and centric look correct and feel comfortable to your client, call your dentist over to verify. Remember, there is no “exact” vertical dimension.  Vertical dimension can even change with age.
  11. Next, place “V”‘s in the wax of the upper and lower rims.
  12. Seat the rims. Use your finger and thumb on the outside of the biting surface to support them.  Have your client practice closing in centric a couple times.
  13. Heat some Swissedent white wax (1/3 of a sheet). Form it into a cylinder.
  14. Push the cylinder over the lower rim. Have your client close into centric and squeeze.
  15. Using a finger and thumb of each hand to support the rims, have your client open and separate the rims.
  16. When client squeezes together, they often throw their lower jaws forward for more power. Check the bite by stabilizing the rims with your fingers and having your client gently close.  Make sure the white wax fits into the rim grooves exactly.
  17. Have your client open 1/2 way. Remove both dentures at the same time.
  18. Check the thickness of the white wax. Increase the vertical pin setting to offset the thickness of wax.  Turn the articulator upside down.  Make sure the pin touches the flat part of the incisal guide table.
  19. Try to seat the lower model in the lower rim. Usually the model will not seat completely.  Trim any non‑anatomical interfering stone.  If the model still won’t seat, have your doctor complete the rest of the model adjusting.
  20. Make sure the lower condyles fit against the back wall of the fossa of the upper member of the articulator. Attach the lower model to the lower member of the articulator using quick set plaster.     Smooth the plaster.  Sloppy mountings aren’t an indicator of a sloppy assistant – they are proof.
  21. After the plaster hardens, remove the wax rims and look at the upper and lower models. Usually they will be parallel.  Think about the size of molar teeth.  Would they have fit into the space between the models?  Did you take into account bone loss from the ridges?
  22. Separate the wax rims. Smooth them up.  Make new “V”‘s in the posterior of the lower rim.  Wet the lower rim to keep the rims from sticking together.  Recheck the vertical opening between the models.  Add new wax on the upper rim and squeeze the models together until the vertical pin touches the plate. Separate the wax rims.  Seat the rims (upper first) in your client’s mouth.  Close them carefully into centric.  Recheck your vertical opening.  If the centric mounting isn’t correct, the “V”‘s won’t match.  If this happens, repeat this procedure.
  23. Recheck of vertical. Use denture adhesive for upper.
    1. Lips shouldn’t strain to close together.
    2. With the lips at rest, have your client not move the lower jaw. Separate the lips.  There should be 2‑3 mm of space between the rims.  This is called the “freeway” space.
    3. Look at your client’s profile. Do the lips look puffed out and the chin too close to the nose?  Is your client struggling to keep the lips together?
    4. Use the Craniometric Device to check your vertical setting.

 

* Sloppy mountings are not an indication of a sloppy assistant. They are proof!

 

 

 

  1. Preliminary Esthetics

 

  1. Carve the upper rim so the wax has the same position that the teeth would have.
    1. Anterior rim should be straight down to support the upper lip
    2. Posterior “teeth” should be slightly inside the flange periphery.

 

  1. Place floss down the middle of the face from the nose to the chin. Use a blade to carefully mark this midline on the wax rim.

 

  1. Adjust the front edge of the upper rim to be even with the lip at rest.

 

  1. Use a tongue depressor as far back in the mouth as possible across the arch. Place a second tongue depressor across the client’s pupils.  The 2 depressors should be parallel.  Add or take away wax until they are parallel.  You can use the plastic mouth insert for this if you like.

 

  1. Have your client raise the upper lip in as big a smile as possible. Support the upper lip against the rim at this position.  Use the blade to carefully outline the smile line just below the lip on the wax rim.

 

  1. Use your 2 tongue depressors anterior ‑ posteriorly to establish the height of the posterior teeth. Have your client bite on the one depressor on either side.  The other depressor runs from the tragus of the ear to be ula of the nose.  Add or subtract wax until they are parallel.  Again you can use the plastic mouth insert if you choose.

 

  1. Did your client bring some old pictures that show teeth in a smile? Even an old picture that doesn’t show teeth, but shows the lips at rest and the correct vertical dimension will help.  The more you can get your client involved in the process, the better.

 

  1. Buccal corridor ‑ This is the space between the buccal of the upper posterior teeth and the inside of the cheek when a client smiles. Women have a wider space than men.

 

  1. Final checks for accuracy
    1. The upper wax rim will usually be 22mm long from its incisal edge to the deepest part of the cast just to the side of the anterior frenum. A small person could be as short as 18mm.
    2. The incisive papillae (small bump on the top of the upper ridge at the midline) is always between the 2 central incisors. Check your mid face measurement with this.

 

  1. Check the occlusal plane. It should not be above dorsum of the tongue.

 

  1. Show the client the Bioblend shades. Let the client choose the tooth color with your help.

 

  1. Watch out for lip drop. If one side of mouth drops, use white wax to fill out and improve appearance.  Be sure not to put white wax on the edge of the flange.  It would reduce retention.

 

Pick Shape of Teeth

 

  1. Use a Boley gauge to measure the length and width of the upper central on the existing denture. If

lower natural teeth present in upper central = 1.6 x width of lower central

  1. Use the gray looseleaf tooth selection manual
  2. Place the Trubyte Tooth Indicator on the client’s face. This indicator is designed to choose the

mould of the upper teeth based on the standard that the width and length of the teeth is equal to 1/16

of the width and length of the face.  Although this selection is based on averages, it works most of

the time.

  1. Write down the mm vertical and horizontal line numbers at the extend of the face.
  2. Compare these measurements to the size of the existing denture teeth.
  3. Use the Template to determine the shape of the face ‑ square, tapered, ovoid, or square tapering.

Square tapered looks good for most people.  Avoid ovoid shapes.

  1. If lower natural teeth are present, use the following average ratio: width of lower incisor X 1.62 =

width of upper incisor

  1. Bring the client mirror down and involve your client in this decision.
  2. Finally, compare the mould you have selected (pull it out of the black mould box) with the old

denture.  Is your client happy with the change?

  1. Lateral incisors not less than 2 mm smaller than centrals are very masculine (small laterals very feminine)

10.Ask the client to bring in 6-7 pictures of smiles (not full face, must smiles) that the client would be

happy with.

11.Women are usually much more discriminating than men.  Always ask a man if he would like his

wife to come along to our appointment.

  1. Take a smile picture of the old denture and with the mouth lose and lips together. These are fun

comparisons when we have the new dentures completed.

  1. Take a papilla meter reading to decide how long upper front teeth should be set ( lip at rest )

 

 

Selection of Color

 

Only three factors need to be considered when selecting shade.

  1. Age
  2. Complexion
  3. Client desires (and shade of old denture)

 

First, use the Trubyte guide to pick a range of possible shades given the age and hair texture/complexion of the client.

 

  1. Shade 100: yellow hair light complexion, blue eyes, avoid when possible, not enough color
  2. Shade 102‑104: better light shades
  3. Shade 104‑108: light brown hair medium complexion, young to medium age
  4. Shade 109‑112: medium brown hair, darker complexion older person
  5. Shade 113‑118: dark brown/black hair, older people

 

As we age, our teeth pick up more color.  Explain to your client that the color of teeth of a denture made 10‑20 years ago will be too light to day due to this aging process.

 

Next, hold two shade guides up to the clients cheeks and squint.  One of them will “disappear” first.  This one blends better with the complexion.  Bring the client mirror down and involve your client in the process.

 

Compare the shade you’ve selected with the shade of the old denture. Does your client like the new shade?  If you’re not sure, use the lighter shade.

On the back of the client’s treatment presentation sheet is the tooth order blank.  Refer to the gray Trubyte ring binder tooth selection guide.  Now that you’ve chosen the upper anterior, pick the lower anteriors that match them.  Now pick the 20 degree upper porcelain posterior teeth that match the upper anteriors.  Finally, pick the lower flat plane IPN ( much more wear resistant) posteriors that go with the upper anteriors.  Finally, match the posterior shade to the anterior shade you picked.  Here’s a good combination: centrals 106 laterals 108 and cuspids 109.

 

 

  1. Fill out Lab prescription

 

Use a carbon and a clipboard to position the papers.  Fill in the steps.

 

  1. Copy the tooth/shade selection from the client consult sheet.

 

  1. and 7. Note the esthetics you chose.

 

  1. Look at the horizontal rings on the incisal guide pin. The dark complete ring is at 0. Each notch above that is +1 mm.  Each notch below is ‑1 mm.

 

  1. Have your dentist establish these positions.

 

Extra Problems to Watch for

 

  1. The lower the occlusal plane, the easier to control the lower denture.
  2. Prognathic
    1. Tilt lower anteriors in
    2. Add an extra upper anterior tooth or some spacing
  3. The teeth don’t have to be over the ridge

 

 

 

  1. Esthetic try in

 

This is the most important appointment in making dentures.  Try to get your client (and spouse if s/he came along) involved.

 

Show your client the waxed up dentures.  Get out the picture that your client chose to have duplicated.  Show your client the similarities.

 

Give your client the “Your Personality Preview” sheet.

 

Don’t get so “hung up” in the technique that you ignore the person.  A denture has 3 functions

  1. Appearance
  2. Chewing
  3. Speech

 

Now’s the time to make sure our denture has accomplished 2 of the 3 functions.  We’ll only know about chewing after we’re finished.

 

  1. Rinse the dentures

 

  1. Try the upper in.  If it’s not retentive, use denture adhesive.    Reassure your client that the wax is distorted and this is the reason for the poor fit.  Also the shape of the wax won’t be the same as the final denture.  The wax color is not lifelike either.

 

  1. Seat the lower denture ‑ make sure the lower teeth are placed over the ridge.

 

  1. Recheck centric ‑ teeth should fit together the same on the model and in the mouth.

 

  1. Recheck vertical
  1. Too great
    1. Lips separated, tense
    2. Toothy click or talk with teeth together
  • Swallowing difficult
  1. No freeway space
  2. Ridges diverge anteriorly on cast mounting
  1. Too small
    1. Lower lip currels forward in profile
    2. Wet part of inside of lower lip shows
  • Teeth show very little
  1. More than 5 mm of freeway space
  2. Chin sticks out
  3. Lines around mouth
  • Ridges converge anteriorly on cast mounting

 

  1. Now it’s time to work on esthetics.  Your client should wear the wax try in for at least 10 minutes before starting this step.
  1. Get the picture or model of old denture.
  2. Show your client the dentures on the articulator.
  3. Show how the dentures match the picture/model.
  4. Get a large face mirror. Have your client hold the mirror about 2 feet away.  Explain they will want to move the mirror much closer, but this focuses on the teeth rather than the blend of the teeth and face.
  5. Give your client the hand out “Your Personality Preview.”

 

  1. Review each step from the preliminary esthetics you established in wax
  1. Upper anteriors not flared in or out and lip supported well
  2. Midline ‑ centrals parallel to midline, if not on it
  3. Incisal edges parallel to interpupillary line
  4. Correct incisal edge exposure
  5. Big smile doesn’t show wax above cervical of upper anteriors
  6. Plane of occlusion matches ala/tragus line
  7. Buccal corridor is attractive (space between the inside of the cheeks and the buccal surface of the upper teeth) Watch out for sunken cheeks. Involve client in this decision.  The trade off is occlusion versus appearance
  8. Occlusal of posterior teeth 2‑3 mm below dorsum of tongue
  9. Teeth not too big or small
  10. Tooth color correct
  11. Upper lip not too full under nose
  12. Lower anteriors set out to edge of labial flange
  13. Looking from the side (profile), the labial surface of the upper incisors are vertical to the floor
  14. Evaluate how much front teeth show
    1. too much
      1. great vertical dimension – reset all teeth
      2. occlusal plane too low – reset all teeth
      3. upper anterior teeth set out too far – remove 1st bicuspids and move in
      4. cupsids and laterals out too far
    2. too little – reverse all above

 

  1. Don’t just accept the esthetics the lab has given you.  Use the alcohol torch, dark red wax, and large metal spatula to move teeth around.  Here are some ideas.
  1. Look at your client. How vigorous or soft are the facial features.  Help the teeth match what you see.
  2. Never put a space between the centrals.
  3. Character of teeth
    1. Centrals express age (younger = longer = show more) space at distal of centrals = youth
      1. young woman ‑ up to 3mm below lip at rest
      2. young man ‑ up to 2mm below lip at rest
      3. mid‑age woman ‑ up to 1‑2mm below lip at rest
      4. mid‑age man ‑ up to 1mm below lip at rest
      5. older woman ‑ 1mm below lip at rest
      6. older man ‑ 0‑2mm short of lip at rest
    2. Laterals show sex
      1. Feminine ‑ rounded edges, rotate mesial out
      2. Masculine ‑ square
  • Cuspids show vigor
    1. Strong ‑ mesial turned in
    2. Soft ‑ mesial turned out
  1. First bicuspid is part of esthetics (chewing is secondary)
  2. First molar is main chewer
  3. Second molar balances the bite
  1. Feminine set up
    1. Rotate mesial of lateral and cuspid out
    2. Set right central in 1mm and angle in at mesial
  • Round laterals and have definite incisal embrasure
  1. masculine set up
    1. flatten incisals
    2. little or no incisal embrasure
  • Make teeth look smaller by widening papillae
  1. Upper first bicuspids should be set primarily for esthetics only secondarily for occlusion
  2. Custom shading of porcelain teeth
    1. Remove glaze, add color
    2. Start at 1200 degrees, increase temperature 50/min. to 1750 degrees
  • Cool to 1200 degrees, place overglaze
  1. Fire to 1800 degrees, 50/minute, cool
  1. A line drawn from the outer canthus of the eye to the chin point will pass through the point of the upper canines 85% of the time (or the point will be mesial to this line).

 

  1. Extra steps to verify correct position of teeth
  1. Lower anteriors
    1. Can be angled out if necessary
    2. The more prominent the chin, the more vertically they should be set
  • Make sure there is room for the tongue
  1. The labio‑mental fold (located above chin button) must be visible or the lower anterior is to full.
  2. Canines and first bicuspids at corner of mouth
  1. Vertical wrinkles in lower third of upper lip are caused by lack of support
  2. Cheek biting is caused by
    1. Too narrow an arch
    2. Reduced vertical dimension
  3. When your client swallows, the teeth should lightly touch
  4. Labial surfaces of the upper teeth should be parallel to the labial flange and visible when looking down from the top of the denture
  5. Generally the longer the lip, the less tooth shows when your client talks.
  6. Phonetics are an important step in verifying the correct placement of the teeth.
    1. Have your client read the poem “If”
    2. If “F” sounds like “V”, the uppers may be too long.
  • If “th” sounds like “d” the upper anteriors are too far lingual or the palate is too thick.
  1. If “s” sounds like “sh” the upper anteriors are too lingual or the vertical is closed.
  2. If “s” whistles, the space between the tongue and palate are too narrow. This happens if the bicuspids are too close to each other across the arch.  Sometimes you can compensate for this by thickening the palate.
  3. If the teeth touch during “s” sounds (s,sh,ch,,j) the vertical needs to be decreased. Your client needs a greater freeway space.
  • The incisal edge of the upper teeth should touch a couple mm inside the wet‑dry line of the lower lip on “f” and “v” sounds.
  • Some words that will help are: Victory, judge, fudge, chuck, Mississippi, counting from 50‑ 70, frivolous, sesame
  1. Try to avoid vertical overbite. The greater the overbite, the harder it will be to get the dentures to be stable when your client moves the lower jaw forward.  The lower teeth will hit the inside of the upper front teeth and “trip” the denture.  Allow at least 1mm of horizontal opening to provide a functional freeway space.
  2. Check the smile line. When your client smiles, the incisal edges of the upper incisors should just touch the lower lip.
  3. Occlusal plane ‑ parallel to interpupillary line, ending 1/2 ‑ 2/3 of the height of the retro molar pad.
  4. Step back and look at teh overall effect.

 

  1. Troubleshooting
    1. Lip sticks out
      1. Set teeth in or narrow arch
      2. Thin labial flange
    2. Lip falls in (reverse of #1)
    3. Severe anterior overbite
      1. Increase vertical
      2. Use shorter lower teeth
    4. Anterior teeth show too much
      1. Raise all upper teeth
      2. Narrow arch form
  • Decrease vertical dimension
  1. Use smaller anteriors and bigger posteriors
  1. Teeth need to match older person’s character
    1. Abrade incisal edges
    2. Stain teeth
  2. Denture base shows when smile
    1. Raise all upper teeth
    2. Change to longer teeth
  3. Dentures click
    1. Reduce vertical dimension
    2. Use lower plastic posterior teeth
  • Check for over extension of lower denture
  1. “s” sounds like “sh” ‑ increase vertical
  2. Uncontrollable slobbers at corner of mouth
    1. Widen arch form
    2. Increase vertical
  3. Lisping
    1. Reduce horizontal overlap
    2. Narrow arch form
  • Increase vertical
  1. Broaden and thicken palate
  2. Set teeth (anterior and posterior) lingually

 

  1. Locate vibrating line. The vibrating line determines the location of the back end of the denture.  It serves 2 functions:
    1. Keeps food from slipping under the denture
    2. Seals the denture to improve retention. Look for a color change between the hard and soft palate.  Have client pinch nose and blow.  The denture should end 1‑2 mm behind this line.  Dry the area with a gauze sponge.  Mark it with an indelible pencil all the way into the habmular notches.  Seat the denture.  Get a good transfer to the wax.  Now transfer to the denture.

 

  1. If someone has come with your client, ask for permission to have this person come to the operatory. Discuss the improvements you have achieved.  Ask for opinions.

 

  1. When you and your client are satisfied with the esthetics, ask him/her to take the wax try in home. It always looks different at home.  Have spouse, friends, etc. give their opinions.

 (see master manuals for pictures of set ups)

 

If your client is satisfied, we can have the dentures finished in one week.

 

If your client wants changes, schedule 1/2 hour with you and a lab man.  Continue these appointments until the client is completely satisfied.

 

  1. Lab Prescription

 

  1. Make sure doctor has marked on models
    1. Posterior extent of teeth
    2. Position of lingual cusps of lower teeth
    3. The number designation for the incisal guide pin
  2. Post palatal seal (from Earl Estepp)
    1. Flat palate
      1. Runs from hamular notch to hamular notch just behind fovea palatinus (2 small bumps at midline just behind hard palate)
      2. Make a second line curving forward so the combined lines look like this

5-6 mm

1-3mm

force

 

 

 

  • Scrape away 1 mm of stone inside these lines
  1. Average palate (not as flat)
    1. Run distal line through the fovea palatinue
    2. Mesial line is the same as for the flat palate
  • Cut 1 mm deep
  1. Deep palate
    1. Distal line is mesial to the fovea palatinae
    2. Mesial line is close to the distal line
  • Cut 1 mm deep
  1. Gaggers
    1. Distal line mesial to fovea palatinus and just short of hamular notches
    2. Cut 1mm deep on this line only
  2. Give the lab 2 working days to set the final occlusion ‑ when returned, have doctor check

 

 

 

 

 

 

  1. Lab Prescription

 

  1. Make sure doctor has marked on models
    1. Posterior extent of teeth
    2. Position of lingual cusps of lower teeth
    3. The number designation for the incisal guide pin
  2. Post palatal seal (from Earl Estepp)
    1. Flat palate
      1. Runs from hamular notch to hamular notch just behind fovea palatinus (2 small bumps at midline just behind hard palate)
      2. Make a second line curving forward so the combined lines look like this

5-6 mm

1-3mm

force

 

 

 

  • Scrape away 1 mm of stone inside these lines
  1. Average palate (not as flat)
    1. Run distal line through the fovea palatinue
    2. Mesial line is the same as for the flat palate
  • Cut 1 mm deep
  1. Deep palate
    1. Distal line is mesial to the fovea palatinae
    2. Mesial line is close to the distal line
  • Cut 1 mm deep
  1. Gaggers
    1. Distal line mesial to fovea palatinus and just short of hamular notches
    2. Cut 1mm deep on this line only
  2. Give the lab 2 working days to set the final occlusion ‑ when returned, have doctor check

 

 

 

  1. Lab Prescription (final check)

 

  1. Make sure
    1. Occlusion balanced
      1. Posterior teeth are inside the flange edges
      2. All markings on cast followed
  • At least 1 point of balancing contact has been developed for right, left working and protrusive
  1. Use articulating paper and check centric contacts
  1. Wax up is correct
    1. All wax contours complete
    2. Stippling completed
  2. Allow 3 working days to complete dentures

 

 

 

 

  1. Seating Dentures

 

  1. Remove dentures from sterile bag
  2. Run finger along inside of dentures to locate any sharp or rough area. Smooth
  3. Seat client
  4. Show the dentures
  5. Wet and seat the upper denture. Labial flange should be thin.
  6. Remove sore spots by marking with indelible stick and grinding.
  7. Make sure there is plenty of room for frenum. When denture feels okay, paint the inside with pressure indicating paste.  Grind areas that show through the paste.  Add more paste.  Repeat until there is a nice even coating of paste when you remove the denture from the client’s mouth.
  8. Seat in client’s mouth
  9. Repeat steps 6‑9 with lower denture
  10. Run your finger along your client’s cheek. If you bump into the buccal flange, cut it back.
  11. Show Doctor
  12. Cleanup dentures. If the occlusion looks good when the denture is initially seated, you can avoid the Coble Balancer

13.  Heat green stick compound over an alcohol torch.

14.  Spread the compound in a circle on the upper denture

15.  Seat the upper if bite is off, get Coble Balancer plate so dentist can place it in the midline of the denture centered on the second bicuspids and parallel to the occlusal plane.( see article in master manual.)

16.  Spread the green compound over the opposing area of the lower denture just below the cervical of the teeth.

17.  Seat the lower plate parallel to the occlusal plane.

18.  Seat the dentures.  Unscrew the central bearing pin until 1 tooth touches in centric.  Make sure the posterior flange doesn’t interfere.

19.  Adjust the interfering contacts, until the dentures hit solidly.

20.  Repeat until all interferences are removed

21.  Finally, your doctor will remove the balancer and check the protrusive guidance (See instructions on next page)

Occasionally, your doctor may cut channels in the lower posterior teeth and fill the channels with amalgam.  This adds improved function and longer life to the lower teeth.

 

If the balancer isn’t used, get a centric record in white Swiss wax, check the bite to make sure it’s accurate, and mount the models on the quick mount articulator with alginate and equilibrate the dentures using these rules:

 

  1. Centric Bull interferences ‑ adjust the buccal half of the maxillary teeth and the lingual half of the mandibular teeth.
  2. Heavy balancing side interferences ‑ lingual half of mazillary teeth.
  3. Eliminate any interferences in smooth movement laterally and improtrusive

 

If bite is off, give “ Care Package” to client

 

  1. Fixdent kit
  2. c/c client handouts
  3. eating
  4. maintenance

 

 

  1. F/F Post Seating Instructions

 

While you are waiting for your dentist, give your client:

  1. A denture cup
  2. “Denture Diet” sheet
  3. “Dentures” sheet

 

Review this information with your client, or, at least, ask them to read it.  Be available for questions.

Since almost denture wearers are over 50.

Here are some facts to remember:

  1. Prescription drugs can reduce saliva flow. This reduced lubrication leads to sores and inflammation.
  2. Older people eat more sugar to increase the taste of food.
  3. Arthritis can make even simple meal preparation a problem.
  4. Reduced
  5. “Sore tongue” is often caused by the client rubbing the tongue over the edge of a new denture.
  6. For many people dentures = old = loss = death
  7. Denture adhesive may be needed (although we’d like everyone to try for at least a week before they use) for:
  8. No ridge to support the denture
  9. Complete denture against natural teeth
  10. Client who never wants the denture to come loose

 

Here are some dietary ideas from an article in the Journal of Prosthetic Dentistry by Dr. Ken Wical.

These are the problems often faced by the elderly denture wearer.

  1. Reduced ability to chew
  2. Reduced appetite
  3. Lack of nutritional knowledge
  4. Hard to break old habits
  5. Limited money
  6. Often lives alone and hard to get around
  7. Hard to get to the grocery
  8. Health problems
  9. Food not digested well
  10. Drugs cause many side effects

 

Goals

  1. 4+ servings of vegetables and fruit
  2. 4 servings of whole grains
  3. 3 servings of milk
  4. 3 servings of meat or other proteins
  5. 1 teaspoon of vegetable oil
  6. 6 glasses of water
  7. Limit sugar, coffee, salt, fat

 

Hints

  1. Meat and vegetable soups
  2. Bread soften in soups or fruit
  3. Substitute yogurt for milk
  4. Add powdered milk to foods while cooking
  5. Calcium supplements for non-milk drinkers
  6. Adjust Dentures

 

  1. Listen closely. These first few adjustments are very important.  Is   it a sore spot ‑ or is our client unhappy with esthetics ‑ and just not saying it?

 

  1. When your client has finished describing the problems use your active listening skills.  Reflect back what you’re hearing “Mrs. Jones, I’m hearing you say that everything is ok, except for the sore area on your lower right ridge.”  Pin your client down to the exact problems.  Make notes as you’re talking in the record.

 

  1. Perform an oral exam using a mouth mirror
    1. Look for red sore areas
    2. Use pressure indicating paste if one side feels “sore.” Paint the paste on with long strokes. It doesn’t have to be too thick.  Grind the show through area and check bite.
    3. Use articulating paper if one side feels “high.” Adjust the lower denture only. You can also use the rectangular adhesive green wax strips.  This will allow you to support the dentures while your client closes up and down.  Use a felt pen to make the show through areas on the lower teeth for more accurate adjustment.

 

  1. Special Problems
    1. Lisping (when teeth are incorrect position, vertical of client has no poor speech habits)
      1. Many clients learning to use new dentures will lisp. Encourage them to read out loud and master the problem.  If the problem lasts more than two weeks, evaluate correcting the lisp by modifying the denture.
        • coat pressure indicating paste on the tongue side of the upper denture ‑ including the lingual surface of the teeth
        • ask your client to repeat troublesome words for one minute
        • carefully remove the denture
          1. area showing too heavy contact ‑ grind away 1mm at a time
          2. area showing no heavy contact ‑ add wax 1mm at a time
          3. repeat steps a and b until problem corrected
  1. Types of lisps
    • Sharp whistling sound ‑ palate too narrow
    • “sh” sounds like “se” ‑ palate too wide
  2. Place a 3‑4 mm bead of wax behind the incisive papilla (1‑2 mm high). This helps your client position the tongue for speech and swallowing.
  1. Burning upper anterior ridge ‑ relieve incisive area
  2. General soreness ‑ reduce vertical dimension
  3. Tongue, cheek biting ‑ reduce vertical dimension
  4. Upper denture loose
    1. Distobuccal flanges too thick
    2. Buccal flange too thick or high around notch
    3. Poor occlusion
    4. Falls when client opens wide – may need to thin poster of buccal flanged.
  5. Lower denture too loose
    1. Improper buccal ‑ lingual tooth position
    2. Retromylohyoid space not filled
    3. Poor occlusion
    4. Overextended borders
  6. Increased retention (upper denture)
    1. Usual problems
      • Inadequate extension into hamular notches (the area right behind the ridge). Use a mirror to see if this area is completely covered.
      • Poor extension posteriorly ‑ Mark the vibrating line in the mouth with an indelible pencil. Seat the denture.  Don’t extend past the vibrating line.
      • Poor post dam ‑ Add Visco Gel to the post dam. See if this improves retention.
    2. Gagging
      1. If posterior of denture correctly placed, then it’s primarily a psychological problem. Shortening the palate probably won’t help.  Look for four general causes of anxiety.
        • Wearing the dentures
        • Eating
        • Smoking
        • Talking
      2. Look for other causes
        • Loose fit
        • Poor occlusion
        • Too great vertical dimension
        • Posterior of denture more than 1 1/2‑2mm thick
      3. Meprobamate may help: reduce saliva for five days
      4. Increase thickness of post dam to stop “tickling” sensation
      5. Practice deep breathing when begins to panic
      6. Check the extension and thickness of the post palatal seal by painting the area with pressure indicating paste and asking the client to seat the denture and quickly swallow a small glass of water in several sips. Remove the denture.  Look for areas where the paste has been washed away.  Thin the tongue   side of the denture in these areas.  Repeat until the paste remains mostly intact.
      7. If the dentures are okay, then the problem is psychological.
        Try this approach to helping your client.

        • Use a cotton swab to coat the soft palate and base of the tongue with Chloroseptic or a similar anesthetic.
        • Check depth of anesthesia with a tongue blade. When you can touch the vibrating line without causing a gag, ask the client to seat the dentures and record the number of minutes until the gag occurs.
        • Repeat this procedure four times a day for four days.
        • Have your client return and report on the level of success.
      8. Denture borders over extended
        1. coat with white pressure indicating paste
        2. Support the denture lightly and pull the cheek or lip toward the teeth. The denture shouldn’t come loose.  If it does, remove it and grind about 1mm off the edge of the flange.
        3. Repeat until the denture is stable.
      9. Not enough stability due to short ridges ‑ will need to use denture adhesive ‑ client instructions
        1. clean and dry the inside of the denture
          • clean old adhesive out completely
          • don’t scratch inside of denture
        2. use paste, not powder ‑ more adhesive
        3. use a 1 inch length on each side in the crest of the bicuspid ‑ molar area
        4. seat denture firmly with hand pressure for 5‑10 seconds
        5. bite together a few times for correct bite
        6. wipe away excess with a tissue

 

  1. Desensitizing
    1. Client asked not to try wearing the dentures
    2. Client to lubricate finger with toothpaste and rub tongue, palate and cheeks for 2 minutes four times each day
    3. After seven days perform the same exercise with an ultrasoft toothbrush ‑ continue for 6 weeks
    4. Try in dentures ‑ wear during the day, if anxiety attack occurs, remove for 5 minute and try again.