denture esthetics -a forgotten...
TRANSCRIPT
denture esthetics-a forgotten art
K Jayadevan DDS, Shankar Iyer DDS
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dentures – the resistance
• not lucrative• time consuming• failures • not sexy• unappreciated• implants as alternatives
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dentures - Issues
• prevention - fewer dentures being made• decreasing emphasis on the curriculum• failures of implants • diagnostic wax-ups and stents • affording population• availability of time and compliance
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dentures – impact on esthetics
agenda: examination diagnosis treatment plan
techniques procedures results
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denture esthetics – the exam• meet the patient before meeting the mouth
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denture esthetics – the exam
• refer out for cosmetic improvements
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denture esthetics – the exam• establish rapport – communicate
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goals and desires• review of medical history
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goals and desires
• examine current dentures – how may sets?
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goals and desires• what is the chief complaint?
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goals and desires• “don’t try to be the genius to fix the patient’s
problems right away”
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when to jump in• verify fit, comfort, retention, stability, bite, “Patients most often may like existing
esthetics and only want increased fit”
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achieving esthetics -the first step
• esthetics starts with impressioning• examine the ridges and relate them to the face• combination syndrome
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Impression Concepts
• Healthy Tissues• Extension to include basal seat• Harmony - anatomical and physical
limitations• Removal without damage to tissues• Correct positioning of tray• Dimensionally stable tray and impression
material
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IMPRESSION OBJECTIVES
Support RetentionStabilityMaintain the health of oral tissuesFoundation for improved appearance
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Support
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Stability
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Retention• Resistance to removal in a direction
opposite that of insertion
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Factors involved in retention of dentures
1-Interfacial force : resistance to separation of two parallel surfaces that are imparted by a film of liquid between them
1- interfacial surface tension 2- interfacial viscous tension
2- Adhesion3- Cohesion4- Atmospheric pressure
5- Oral and facial musculature6- Undercut- Rotational path- Parallel walls7- Gravity
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Custom Tray
• 2 – 3mm thick• Stepped handle in the anterior region• Border 2mm short of depth of sulcus• Cover the hamular notches• 2mm posterior to vibrating line• VLC Resin – Triad
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Border Molding
• Modelling compound sticks• Added to tray in sections• Must be adequately softened• Preshaped to proper contour with fingers• Must be tempered in a water bath• Chilled after removal from mouth• Rounded contours
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Maxillary Border Molding
Anterior Region Lip - elevated & extended out, downward & inward
Buccal Frenum Region Cheek – elevated, pulled downward & inward, moved backward and forward
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Maxillary Border Molding
Posterior region Cheek – outward, downward and inward
Patient opens wide and moves mandible form side to side
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Mandibular Border Molding
Anterior Labial Region Lip – lifted outward, upward & inward
Buccal Frenum Region Cheek – lifted outward, upward & inward moved backward and forward
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Mandibular Border Molding
Posterior Buccal region Cheek – outward, upward and inward
Patient exerts a closing force while downward pressure exerted by dentist to activate masseter muscle
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Mandibular Border MoldingAnterior Lingual Region Tongue protruded - determines length of
lingual flange Tongue pushed against front part of palate –
determines thickness
Mid Lingual Region Tongue protruded – determines length and slope
of lingual flange Tongue touches cheek on both sides
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Mandibular Border MoldingPosterior Lingual Region Tongue protruded – activates the superior
constrictor muscle
Retromolar Pad Patient opens wide – determines length of
posteromedial border
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Impression Materials
Mucostatic e.g. Zinc Oxide eugenol paste More Fluid Minimal displacement of tissues
Mucodisplacive e.g. polyvinylsiloxane, polysulphide, More Viscous More displacement of tissues
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Tray Preparation
• Excess modeling compound removed
• Hole places in rugae area of maxillary tray
• Adhesive applied to tray
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Tray Preparation
• Excess modeling compound removed
• Hole places in rugae area of maxillary tray
• Adhesive applied to tray
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Impression Material
• Mixed according to manufacturer’s instructions
• Evenly distributed within tray
• Cover all borders
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Reasons for remaking impressions
• Incorrect positioning of the tray• Large voids or discrepancies• Incorrect consistency of impression
material• Movement of the tray before final set• Incorrect border molding procedures• Using too much or too little impression
material
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Boxing Impressions
• Preserves functional width of sulcus• Preserves functional depth of sulcus• Boxing wax strip attached 2-3mm below
border• Vertical wall extends 10-15mm above
impression• Seal wax with hot spatula
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POSTERIOR
PALATAL
SEAL
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Posterior Palatal Seal
• Pterygomaxillary (hamular) notches
• Vibrating Line – Junction of Moveable & non-moveable tissue
• Fovea Palatinae
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achieving esthetics -the first step
• special techniques for flabby ridges• dual impression techniques• the sulcus esthetics
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achieving esthetics -the rim factors• facial support
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achieving esthetics -the rim factors
• fox planes and arbitrary esthetic planes• campers line
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achieving esthetics -the rim factors• the true smile line
• the denture look vs. smile line dentures
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denture esthetics jr - vertical relationship• if it looks good it must be good
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denture esthetics jr at cr• are we opening or restoring vertical?• always register CR• verify with fricatives and smiles
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denture esthetics -selection of teeth
• facial form and tooth form• selection of mold, size and shape• color of teeth – shade guides• denture base colors – the Mehary guides
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denture esthetics• selection of articulators • balanced vs anterior guidance• types of arrangement
• do not correct skeletal discrepancies with teeth arrangement
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Development of Denture
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The Evolution
Teeth Forms
•1909 – Dentists Supply Company– 33 degree cusp (Gysi)
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The Evolution
Teeth Forms
•1932 – Pilkington and Turner (shallower 30 degree teeth– Tetrahedral forms
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The Evolution
Tooth Forms Anatomic forms:1927 – Gysi - modified “crossbite” posterior -maxillary lingual cusp only
against mandibular anatomic form - origin of ligualized occlusal
scheme?
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The Evolution
Tooth Forms Modified Anatomic forms:1922 – 1927 Victor Sears - “channel” tooth - mesiodistal channel in maxillary
posteriors against mandibular central ridge
- origin of controversy – “to balance or to reduce thrust?”
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The Evolution
Tooth Forms Modified Anatomic forms: 1930 – Avery brothers: - “scissor-bite technique” - opposite of Sears - not marketed commercially
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The Evolution
Tooth Forms Modified Anatomic forms: 1935 – French (similar to Sears) 1936 – McGrane “curved cusp” 1937 – Max Pleasure (Anti-Monson,
Flat and Monson) 1942 – John Vincent (resin with metal
vs. porcelain teeth)
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The Evolution
Tooth Forms Modified Anatomic forms: 1941 – S.H. Payne “lingualized occlusal
concept” - popularized by Pound and Murrell 1973 – Mehringer - FGP with metal inserts 1977 – Levin (functionally generated
occlusal forms(modification of Sosin 1961) – cast in gold
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The Evolution
Tooth Forms Nonanatomic or 0 degree cuspless forms: 1929 – Hall “inverted cusp tooth” 1929 - Myerson “True Kusp” FLX – freedom in lateral excursion - complete free gliding contact 1939 – Swenson “non-lock” 1946 – Hardy’s VO (Vitallium Occlusal) 1951 – Myerson “Shear-cusp” first cross-linked
teeth Sears –Myerson combination – Porcelain vs.
acrylic 1952 – Cook – “Coe masticators – Stainless steel
holes vs. porcelain teeth
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The Quest
Improved masticatory efficiency with control of vertical and horizontal
forces to minimize trauma to supporting tissues
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Balanced Occlusion
•Bilateral, simultaneous, anterior and posterior occlusal contact of teeth in centric and eccentric positions
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Factors Affecting Balanced Occlusion
•Condylar Guidance:Controversies:
– no definite condylar path. The Condyle can adjust to any occlusal scheme
– how closely does the condylar path have to match with that of patient’s?
– how much variance is tolerable?Kurth, Payne, Weinberg
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Factors Affecting Balanced Occlusion• Incisal Guidance- Esthetics- Phonetics- Arch Form- Ridge relationship
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Factors Affecting Balanced Occlusion
• The Plane of Occlusion– ½ - 2/3rds height of retromolar pad– Parallel to ala tragus line– Commissure of the mouth
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Factors Affecting Balanced
• The compensating curve– Christiansen’s phenomenon– Link between IG and CG
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Factors Affecting Balanced
• Cuspal angulation
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The balance beam
IG CG
CA
POCC
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- trial of the esthetics
• verify contours, phonetics, support, smile line • verify jr• get the patients approval• retry with old set – mix and match
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esthetics of interim immediates• the failing FPD• one step impression and master casts• the acrylic template and denture base• tryin and reline
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esthetics of immediates
• the decoronation procedure vs extraction• impressions• – the one day dentures – decoronation• - the one day dentures – extractions• - the one day smile make over
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denture esthetics
• transformations
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