secrets of successful dent 1

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Secrets of SuccessfulSecrets of SuccessfulDenturesDenturesDr. Bob Loney, DMD, MSDr. Bob Loney, DMD, MS

Dr. Mark Vallee, DDS, MSc, FRCDCDr. Mark Vallee, DDS, MSc, FRCDC

Course ObjectivesCourse Objectives

Identify patientsIdentify patients who can be successfully rehabilitated who can be successfully rehabilitated

Five-step methodFive-step method to diagnose & treat problems to diagnose & treat problems

Select & use Select & use indicating mediaindicating media correctly correctly

Minimize problems with Minimize problems with relinesrelines

Denture esthetics & occlusionDenture esthetics & occlusion

Implant overdenturesImplant overdentures & Locator attachments & Locator attachments

All Content OnlineAll Content Online

GoogleGoogle: Removable Prosthodontics Dalhousie: Removable Prosthodontics Dalhousie

WelcomeWelcome

Select:Select: ‘‘CDCD’’ Menu - Click on Menu - Click on ‘‘Secrets of ...DentureSecrets of ...Denture’’

Successful TreatmentSuccessful TreatmentSelecting cases that can be successful !Selecting cases that can be successful !

Pick Your Patient!Pick Your Patient!•• Avoid:Avoid:

No ridgeNo ridge

Ridge mucosa moves when tongue/cheek activeRidge mucosa moves when tongue/cheek active

Floor of mouth above mand. ridgeFloor of mouth above mand. ridge

LOOKLOOK during Function! during Function!

Pick Your Patient!Pick Your Patient!•• Avoid:Avoid:

Cheek or frena attach to top of ridgeCheek or frena attach to top of ridge

Vestibuloplasty (relative)Vestibuloplasty (relative)

LOOKLOOK during Function! during Function!

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Pick Your Patient!Pick Your Patient!

•• Caution:Caution:

No salivaNo saliva

Poor nutritionPoor nutrition

Many sets in several yearsMany sets in several years

••Spend time TalkingSpend time Talking


Severe wear, loss OVDSevere wear, loss OVD

Severe undercuts/tori &Severe undercuts/tori & don don’’t want surgeryt want surgery




No dentures for many yearsNo dentures for many years

Patient who doesnPatient who doesn’’t t wantwant dentures dentures

Patient who doesnPatient who doesn’’t t needneed dentures dentures

When Not to Treat PartiallyWhen Not to Treat PartiallyDentate!Dentate!

Patient doesnPatient doesn’’t want treatmentt want treatmentComfortableComfortableHappy with appearanceHappy with appearanceFunction not a problemFunction not a problem

Inform of consequences, costs, optionsInform of consequences, costs, options

DonDon’’t talk patient into treatmentt talk patient into treatment

Shortened Dental Arch (SDA)Shortened Dental Arch (SDA)

Treatment Option: No ReplacementTreatment Option: No ReplacementShortened Dental Arch (SDA)Shortened Dental Arch (SDA)

Patients can function withPatients can function withas few as 20 occludingas few as 20 occludingteethteeth

No significant difference inNo significant difference in

chewingchewing

discomfortdiscomfort

JCDA Sept 07, 73:593-4JCDA Sept 07, 73:593-4

No ReplacementNo ReplacementShortened Dental Arch (SDA)Shortened Dental Arch (SDA)

Require Anterior teeth + 4-6Require Anterior teeth + 4-6occlusal unitsocclusal units

Opposing Opposing PMPM’’ss = 1 occlusal unit = 1 occlusal unit

Opposing Opposing MM’’ss = 2 occlusal units = 2 occlusal units

SymmetricSymmetric loss need 4 units loss need 4 units

AssymetricAssymetric loss need 6 units loss need 6 units

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Patient SatisfactionPatient Satisfaction

More than good anatomyMore than good anatomy

More than well constructed dentureMore than well constructed denture

Includes expectationsIncludes expectations

Patient Satisfaction

• Difficult to quantify, unpredictable• Not directly correlated with quality• Small percentage never satisfied• Low quality results in lower satisfaction• Patients more satisfied with dentures

than eyeglasses and hearing aids

Satisfaction With variousprosthesis

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

Patient Characteristics

•Not correlated with satisfaction:• Personality• Age• Attitude toward aging

•Reduced salivary flow & reduced ridgenegatively correlated

Fabrication Variables

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

Patient Expectations

• High expectations if currentlydissatisfied

• Unrealistic expectations negativelycorrelate with satisfaction

• Pre-treatment interview can helpdetermine expectations

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Matching Expectations

• Critical for success• If patient & dentist don’t expect the

same result - failure• Helps determine need for referral

Iatrosedative Interview

• 1. Recognize & acknowledge problem• 2. Explore & identify problem• 3. Interpret & explain problem• 4. Offer a solution


• 1. Recognize & acknowledge problem•Patient: “My problem is .... I’d like.... They’retoo...”

•Dentist: “So your dentures feel..., I can see theyare... That must be difficult ...”


• 2. Explore & identify problem•Dentist:

•History - “You say the dentures loosen onlywhen you are chewing on the left side?”

•Exam - Visual intraoral check. Look forvariations from normal in denture & tissue. Useindicating media. Have patient demonstrate theproblem. Palpate.


• 3. Interpret & explain problem•“It appears that the denture teeth may be too faraway from your bone. There is not much bone tosupport them. Look here in the mirror... “

•“The denture will always be looser than normalunless...”


• 4. Offer a solution• Dentist:

• “So to review, you have 3 things you want changed..

• You don’t want these 2 things changed...

• I can change/improve ... but not....because...

• Do you understand...Do you have any questions

• What would you like to do? “

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Conclusions

• Small percentage never satisfied,even with highest quality

• Comprehensive interview can helpidentify patients with high expectations

• Low clinical quality related to reducedpatient satisfaction

5 Step Denture5 Step DentureTroubleshootingTroubleshooting

1.1. Differential Diagnosis Differential Diagnosis

2.2. Look for Normal Look for Normal

3.3. Patient Demonstrates Problem Patient Demonstrates Problem

4.4. Never Adjust without Indicating Media Never Adjust without Indicating Media ****

5.5. Patient Rates Improvement Patient Rates Improvement

Principal 1Principal 1Establish a Establish a Differential DiagnosisDifferential Diagnosis

•• Form a Form a listlist of possible causes of possible causes

•• Try to prove problem is not caused byTry to prove problem is not caused by““XX”” by eliminating possible causes by eliminating possible causes

•• Expect resolution within 10-14 daysExpect resolution within 10-14 days

•• If no resolution, eliminate somethingIf no resolution, eliminate somethingelseelse

Principle 1:Principle 1: Differential DiagnosisDifferential Diagnosis

•• PrioritizePrioritize from common to rare from common to rare

•• Eliminate common etiologies first,Eliminate common etiologies first,because:because:

Common thingsCommon thingsoccur commonlyoccur commonly

Rare entities occurRare entities occurrarelyrarely

Differential Diagnosis:Differential Diagnosis:CD or RPD PainCD or RPD Pain

Occlusion Remount, ArticulatingPaper, Adjust

Denture Base PIP, Adjust

Vertical Dimension Time to Adapt,Reset Teeth

InfectionSystemic Disease

Tests, Referrals,Medications

Allergy Patch Tests, Referrals,Change Materials

Attempt toeliminateproblem.

Re-evaluateresults in

10-14 days









10-14 days









10-14 days

Principles of DiagnosisPrinciples of Diagnosis

•• DonDon’’t limit list too early in diagnosist limit list too early in diagnosis

•• Keep an open mindKeep an open mind

•• Revisit possible causesRevisit possible causes

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Information GatheringInformation Gathering

•• Chief ComplaintChief Complaint

–– History of C.C. History of C.C.

•• HistoryHistory

–– Medical Medical

–– Dental Dental

•• Clinical ExamClinical Exam

Often inadequatelyOften inadequatelyinvestigatedinvestigated

Spend more timeSpend more timetalking to narrowtalking to narrowpossibilitiespossibilities

Gathering InformationGathering Information

••Ask open ended questions:Ask open ended questions:

••““How does that feel?How does that feel?””

••NotNot

••““Does that feel better?Does that feel better?””

History of Chief ComplaintHistory of Chief Complaint Where?Where?

•• Have patient point to problemHave patient point to problem

•• Partially ignore patientPartially ignore patient’’sspositionposition

•• Dentist locate with stick,Dentist locate with stick,instrument or pasteinstrument or paste

History of Chief ComplaintHistory of Chief Complaint When?When?

•• Chewing only - Chewing only - OcclusionOcclusion

•• Gets worse throughout dayGets worse throughout day- - OcclusionOcclusion

•• When first insert dentures -When first insert dentures -Denture BaseDenture Base

History of Chief ComplaintHistory of Chief Complaint DetailsDetails

•• How long?How long?

•• ...does it last? ...does it last?

•• ...since it began? ...since it began?

•• Anything make it better/worse?Anything make it better/worse?

Principle 2:Principle 2:Identify Variations from Normal:Identify Variations from Normal:Tissues & DenturesTissues & Dentures

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Identify Variations from NormalIdentify Variations from NormalLoose Denture:Loose Denture:Prominent Midline Fissure, SoftProminent Midline Fissure, Soft

PalatePalate

Dealing with Variations From NormalDealing with Variations From Normal

If denture alone is not normalIf denture alone is not normal

correct the denturecorrect the denture

If anatomy/patient not normalIf anatomy/patient not normal

vary method to address variationvary method to address variation

Principle 3:Principle 3:Patient Demonstrates ProblemPatient Demonstrates Problem

Eliminate cause - resolve in 10-14 daysEliminate cause - resolve in 10-14 days

Principle 4:Principle 4:Always Use Indicating MediaAlways Use Indicating Media

••Never adjust without locatingNever adjust without locatingexact position of the problemexact position of the problem

••Use paste, indelible stick, orUse paste, indelible stick, orarticulating paperarticulating paper

Principle 5:Principle 5:Rate ImprovementRate Improvement

••After adjustmentAfter adjustment

••Ask patient to rateAsk patient to rateimprovementimprovement

••0%-100%0%-100%

100% Perfect Now100% Perfect Now

0% Still Same, Can0% Still Same, Can’’t Tellt Tell

50% Better, but still not right 50% Better, but still not right

75% Feels a lot better75% Feels a lot better

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5 Step Denture5 Step DentureTroubleshootingTroubleshooting

1.1. Differential Diagnosis Differential Diagnosis

2.2. Look for Normal Look for Normal

3.3. Patient Demonstrates Problem Patient Demonstrates Problem

4.4. Never Adjust without Indicating Media Never Adjust without Indicating Media ****

5.5. Patient Rates Improvement Patient Rates Improvement

Use of Indicating MediaUse of Indicating MediaLoney & Knechtel,J Prosthet Dent 2009;101:137-141Loney & Knechtel,J Prosthet Dent 2009;101:137-141

Applying Pressure Indicating PasteApplying Pressure Indicating Paste

Dry dentureDry denture

Thin coat with stiff brushThin coat with stiff brush

Leave streaksLeave streaks

More the colour of indicating mediumMore the colour of indicating mediumthan denturethan denture

Correct AmountCorrect Amountwith Streakswith Streaks

InsufficientInsufficientAmountAmount

Too MuchToo Muchw/o Streaksw/o Streaks

Prior to PlacementPrior to Placement

Ensure damp mucosaEnsure damp mucosa

Spray surface of PIP with air/waterSpray surface of PIP with air/water

Seat Denture FirmlySeat Denture Firmly

Avoid lips/ridge whenAvoid lips/ridge wheninsertinginserting

Pressure over first molarsPressure over first molars(not palate)(not palate)

Remove from oral cavity byRemove from oral cavity bybreaking seal - fingerbreaking seal - fingerpushing height of vestibulepushing height of vestibule

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Reading PIPReading PIP

Burn-throughBurn-through (No paste left) (No paste left)

-- Excessive pressure that should be relievedExcessive pressure that should be relieved

StreaksStreaks remaining remaining

-- No tissue contact No tissue contact

-- Other areas need to be relieved Other areas need to be relieved

Paste remaining with Paste remaining with no streaksno streaks

-- Acceptable contactAcceptable contact

Burn throughBurn through Normal ContactNormal Contact

No ContactNo Contact

Read the PasteRead the Paste

Non-retentive DentureNon-retentive DentureWhatWhat’’s Wrong?s Wrong?

••No palatalNo palatalcontactcontact

••Short Flange inShort Flange in1st quad1st quad

Denture Base AdjustmentDenture Base Adjustment

Relieve pressure spots - large acrylic bursRelieve pressure spots - large acrylic burs

Take care with undercutsTake care with undercuts

Looks like burn-throughLooks like burn-through

May not require adjustmentMay not require adjustment

Use Care in Retentive AreasUse Care in Retentive Areas

Hamular NotchHamular Notch

Tuberosity UndercutsTuberosity Undercuts

Watch for Bony ImpingementsWatch for Bony Impingements

RelieveRelieve

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Check for RetentionCheck for RetentionPull outward & upward on lingual of caninesPull outward & upward on lingual of canines Repeat Until Denture Fully SeatsRepeat Until Denture Fully Seats

Relatively uniform contactRelatively uniform contact

Minimal streaksMinimal streaks

No gross burn-throughNo gross burn-through

Visually Check PeripheriesVisually Check Peripheries

Seat denture & border moldSeat denture & border mold

Flanges should fill vestibuleFlanges should fill vestibulebut not be dislodged bybut not be dislodged bymanipulationmanipulation

If denture dislodges, useIf denture dislodges, usePIP to adjustPIP to adjust

PeripheriesPeripheries Border moldBorder mold

AdjustAdjust

Check againCheck again

Adjust high spots or facetsAdjust high spots or facets

Special Attention to Frenal AreasSpecial Attention to Frenal Areas Special Attention to Frenal AreasSpecial Attention to Frenal Areas

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Root prominencesRoot prominences

Thick peripheriesThick peripheries

Use to Check ContoursUse to Check Contours Alter PhoneticsAlter Phonetics

More Info see: Website More Info see: Website ‘‘ResourcesResources’’

Paste RemovalPaste Removal

Gauze, cotton rolls, toothbrushesGauze, cotton rolls, toothbrushes

Alcohol for stubborn areasAlcohol for stubborn areas

Cheap steamerCheap steamer

Cement, debrisCement, debris

Secrets of ImpressionsSecrets of Impressions

•• Polyvinyl SiloxanesPolyvinyl Siloxanes

Dimensional StabilityDimensional Stability

DetailDetail

Use for all proceduresUse for all procedures


•• Everything DryEverything Dry

Final ImpressionsFinal Impressions

Load quickly - viscosityLoad quickly - viscosity

Material brought over peripheryMaterial brought over periphery

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Two Mirror TechniqueTwo Mirror Technique

-- everything visibleeverything visible

Secrets ofSecrets ofImpressionsImpressions


Seat anterior of traySeat anterior of trayfirstfirst

Cotton swabs onCotton swabs ontray - removetray - removeexcess posteriorexcess posterior


Flange thicknessFlange thickness


Tray not overextendedTray not overextended


Why remake?Why remake?

RelinesRelinesThis denture needs a reline!This denture needs a reline!

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MaterialsMaterials

Tissue ConditionersTissue Conditioners

PVS Light BodyPVS Light Body

Self/Light Cure?Self/Light Cure?

undercutsundercuts

distortiondistortion

porosityporosity Clean the DentureClean the DentureInspect when dry!Inspect when dry!

Position the DenturePosition the DentureOVD & OcclusionOVD & Occlusion

Improperly Placed!Improperly Placed!

Longer Teeth!Longer Teeth!

Lousy Occlusion!Lousy Occlusion!

Relieve DentureRelieve Denture

Remove undercutsRemove undercuts

Shorten flangesShorten flanges

Create space forCreate space formaterialmaterial

Relieve DentureRelieve Denture

Vent holes for relief ofVent holes for relief ofhydraulic pressurehydraulic pressure

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Remove Excess MaterialRemove Excess Material

Cotton Swabs on trayCotton Swabs on tray

Better ContoursBetter Contours

Mark Contacts Prior to/After RelineMark Contacts Prior to/After Reline

Red/BlueRed/Blue

Should be closeShould be close

If not, donIf not, don’’t proceedt proceed

Posterior Palatal SealPosterior Palatal Seal

Needed for retentionNeeded for retention

Secrets of Jaw Relation RecordsSecrets of Jaw Relation Records

Record Bases stable & retentiveRecord Bases stable & retentive

Perfectly flat contact between rimsPerfectly flat contact between rims


Ensure:Ensure:

Record bases donRecord bases don’’t contactt contactanythinganything

Casts donCasts don’’t contact anythingt contact anything

Only wax rim to wax rimOnly wax rim to wax rimcontactcontact


Wax Rim Adjustment VideoWax Rim Adjustment Video

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Consider polyvinyl siloxaneConsider polyvinyl siloxanerecordsrecords

Aluwax the most variableAluwax the most variable

Elastomers least errorsElastomers least errors

•• Mullick et al. J Prosthet Dent 1981;46:304Mullick et al. J Prosthet Dent 1981;46:304

•• Ockert-Eriksson et al, Int J Prosthodont 2000Ockert-Eriksson et al, Int J Prosthodont 2000

•• Millstein & Hsu, J Prosthet Dent 1994Millstein & Hsu, J Prosthet Dent 1994

•• Breeding et al, J Prosthet Dent 1994Breeding et al, J Prosthet Dent 1994

Centric Record with PVSCentric Record with PVS

Video ClipVideo Clip

Partially Dentate CastsPartially Dentate Casts

If stable contacts (no rocking)If stable contacts (no rocking)

Most accurate mounting - no mediumMost accurate mounting - no medium


Elastomers are extremelyElastomers are extremelyaccurateaccurate

Remove occlusal blebs fromRemove occlusal blebs fromdentate castsdentate casts

WonWon’’t fit into interproximalst fit into interproximalson some castson some casts

If cast doesnIf cast doesn’’t fit into record,t fit into record,may need to adjustmay need to adjust


Stabilize casts whenStabilize casts whenmountingmounting

Mean occlusal discrepancy ofMean occlusal discrepancy of

1.6mm1.6mm when hand held when hand held

0.250.25 mm sticks & sticky wax mm sticks & sticky wax

••

•• (Gunderson & Siegel, J Prosthodont 2002)(Gunderson & Siegel, J Prosthodont 2002)

Secrets of DentureSecrets of DentureOcclusionOcclusion

All posteriors contact simultaneouslyAll posteriors contact simultaneously

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No contacts on inclinesNo contacts on inclines

Secrets of Denture OcclusionSecrets of Denture Occlusion

•• Contacts buccal to the ridgeContacts buccal to the ridgedestabilize - even monoplanedestabilize - even monoplane

•• Browning, JPD 1986Browning, JPD 1986

Removable partialRemovable partialdenturesdentures

BB caused unseating caused unseating

CentralCentral loading better than loading better thandistal loadingdistal loading

MM

D D

L L BB

CC

Secrets of DentureSecrets of DentureOcclusionOcclusionExcessive overbite will destabilizeExcessive overbite will destabilize


Light rapid taps sound loud, mark widelyLight rapid taps sound loud, mark widely

Video ClipVideo Clip


No best occlusal scheme - use easiest possibleNo best occlusal scheme - use easiest possible

monoplane, lingualized, fully balancedmonoplane, lingualized, fully balanced

Secrets of Denture ContoursSecrets of Denture Contours

No sharp contoursNo sharp contours

Mildly convex lingual and buccal contoursMildly convex lingual and buccal contours

Use finger to feel for sharp contoursUse finger to feel for sharp contours

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Secrets of Denture DeliverySecrets of Denture Delivery

•• Step 1Step 1

•• Check Denture base with PIPCheck Denture base with PIP

•• Moisten with air water syringeMoisten with air water syringe

•• No peripheriesNo peripheries

Secrets of Denture DeliverySecrets of Denture Delivery•• Step 2Step 2

•• Denture peripheries with PIPDenture peripheries with PIP

•• One side at a timeOne side at a time

••Avoid cheeksAvoid cheeks


•• Step 3Step 3

•• Occlusal AdjustmentOcclusal Adjustment

•• Remount with helpRemount with help

Laboratory PrescriptionLaboratory PrescriptionFabricate:Fabricate:

Remount indexRemount index

Remount castsRemount casts

Remount maxillary dentureRemount maxillary denture

Record Centric RelationRecord Centric Relation

Small amount of biteSmall amount of biteregistration materialregistration material

Just cuspal indentationsJust cuspal indentations


•• Remount with helpRemount with help

•• Assistant remounts denture using centric recordAssistant remounts denture using centric record

•• Stabilize castsStabilize casts

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Adjust OcclusionAdjust Occlusion

Extraoral adjustment moreExtraoral adjustment moreefficientefficient

Eliminates continual removal &Eliminates continual removal &replacement of denturesreplacement of dentures

Avoids reflex avoidanceAvoids reflex avoidance


•• Step 4Step 4

•• Chewing TestChewing Test

•• Cotton roll Cotton roll

•• No discomfort No discomfort

•• If discomfort now, worse after use If discomfort now, worse after use


•• Check Esthetics & PhoneticsCheck Esthetics & Phonetics

•• If large change, warn a head of timeIf large change, warn a head of time


•• PolishPolish

•• Brasseler Denture PolishersBrasseler Denture Polishers

6 Step Delivery6 Step Delivery

Step 1Step 1 Adjust Denture base with PIP Adjust Denture base with PIP

Step 2Step 2 Denture peripheries with PIP Denture peripheries with PIP

Step 3Step 3 Occlusal Adjustment Occlusal Adjustment

Step 4Step 4 Chewing Test Chewing Test

Step 5Step 5 Check Esthetics & PhoneticsCheck Esthetics & Phonetics

Step 6Step 6 PolishPolish

secrets of successful dent 1

Documents

patient doesnpatient

units loss

occlusal unitopposing

loss ovdsevere wear

dentures dentureswhen

yearsno dentures

treat problemsselect

correctlyminimize problems