Written by Charles S. Barotz, DDS Friday, 01 March 2002 00:00
Full dentures are shunned by many practitioners. They are considered by many to be the poor cousins of implants and crown and bridge rehabilitation. Yet for many patients (for a number of reasons), this is their only treatment alternative.
Often, full dentures are shunned because the treating doctor has never taken the time to reflect on their true value. Cosmetic gurus talk daily about how a smile makeover (8 to 10 units of upper anterior crown and bridge) increases self-esteem and can be life changing to the patient. Full dentures done well provide all of this and more. They can greatly improve the cosmetics of the entire lower one third of the face, taking years off a patient’s appearance, while also relieving a patient from pain and greatly increasing their ability to function.
Despite this, most doctors with whom this author has spoken set their fees for a full cosmetic denture at little more than 20% to 25% of their fee for an 8- to 10-unit cosmetic smile makeover. In order for dentists to embrace this procedure again, they need to change their paradigm about what people will pay for it. If the doctor is not compensated at the same rate as for other cosmetic procedures, there is no incentive to incorporate this incredibly satisfying procedure back into their practice. In order to justify charging such a fee, however, the doctor must have a predictable, straightforward way to produce exquisite results.
Most denture patients who come into a prosthetic practice fit into three categories:
(1) The debilitated patient—this is a patient whose teeth are hopelessly involved and must be extracted.
(2) The dilapidated patient—this is a patient who has been wearing their existing dentures for many years, and the dentures are worn out or malpositioned because of ridge atrophy.
(3) The discouraged patient—this is a patient who has had poorly made dentures that are either extremely uncomfortable or cosmetically disfiguring.
|Figure 1. The patient was not satisfied with her existing denture because, "It's just not me."||Figure 2. Photo of the patient when she was younger reveals that she originally had an overbite, which she desired in her denture.|
Both the dilapidated and debilitated patient enter the office with valuable information for you, that being their old dentures. No matter how bad they are, they can be used as a diagnostic tool. The following technique uses the information provided by the old denture as a baseline for construction of the new prosthesis. The patient in this case did not have a bad denture to start with. In her words, “it’s just not me” (Figure 1). With the aid of the photos she brought in, it was determined that she originally had an overbite, and this was indeed the look she lacked and desired (Figure 2).
|Figures 3 and 4. The old dentures are duplicated using the Lang Denture Duplicator.|
Appointment 1. A thorough examination is accomplished, and the old dentures are duplicated in pink acrylic. This can easily be done in the office by an assistant with the use of a Lang Denture Duplicator (Figures 3 and 4). These duplicated dentures will serve as a custom tray with a built-in bite rim. The patient is sent home with instructions to rinse four to five times daily with salt water (1 tsp salt in 8 oz water) and leave the dentures out at least 6 hours daily. The patient is also asked to bring in photos of their smile before they lost their teeth (Figure 2).
|Figure 5. After trimming, the denture is border molded.||Figure 6. A face-bow is taken with the upper impression in place.|
|Figure 7. A centric relation record is taken.||Figure 8. After the models are boxed, poured, and mounted, bite rims are fabricated.|
Appointment 2. The borders of the duplicated dentures are trimmed 2 mm, then border molded with your favorite material. Kerr Green Stick Compound has been used in this case (Figure 5). Adhesive is applied and an impression is taken. A face-bow is taken with the upper impression in place (Figure 6). A centric relation record using the bilateral manipulation technique (as described by Dawson) is also taken (Figure 7). Models are boxed, poured, and mounted, and bite rims are fabricated (Figure 8).
Teeth are also selected at this appointment. To do this effectively, it is essential that you have tooth mould guides in the office. If adequate room is present, porcelain teeth are the choice of this author. If not, a composite tooth is the tooth of choice. The teeth used in this case were Vita Lumin porcelain teeth. Porcelain teeth are used whenever possible. They are chosen for durability, but mostly for their exquisite natural beauty. It is quite interesting that the cosmetic dentist rarely chooses composite veneers or a crown for a smile makeover, but will routinely choose a composite denture tooth.
With the aid of a DENTSPLY tooth selection guide, teeth are selected. The cuspid-to-cuspid width should be similar to the width of the nose and the shape of the face. The shades of the teeth should be bright (Vita Shades A1, A2, B1, B2, D2) in most cases. Once the teeth are selected they are ordered into the office along with the corresponding lower anterior and posterior teeth. The posterior tooth of choice for this technique is the Vita Syunoform Tooth. This is a 110 tooth that is very easy to equilibrate, yet has outstanding cosmetics. Remember, we are doing a cosmetic case.
Depending on your state law, this entire process could be done by an assistant. It is recommended, however, that the doctor at least do part of it for “perceived value” reasons.
THE SMILE DESIGN APPOINTMENT
Appointment 3. This is the fun appointment for the true cosmetic dentist. This is the appointment that separates this denture from the average denture. This is continuously stressed to the patient. At this appointment the dentist personally sets teeth Nos. 5 through 12. Once the cosmetics are determined, the function will follow.
|Figure 9. Teeth Nos. 8 and 9 are set using the position of the lips and basic guidelines for good cosmetics.||Figure 10. The midline position is verified.|
|Figure 11. Rest position is verified.||Figure 12. "E sound" position is verified.|
Teeth Nos. 8 and 9 (Figure 9) are the most challenging to set. They are set using the position of the lips and basic guidelines for good cosmetics. The midline position (Figure 10), rest position (Figure 11), and “E sound” position (Figure 12) are all verified. The rest is left to the practitioner’s artistic ability.
The full smile is viewed (Figure 13), and the patient’s preliminary cosmetic consent (Figure 14) is obtained. The case is then sent to the lab for the rest of the set-up, giving specific instructions for overjet and overbite, and insisting on a correct curve of Spee. Many lab techs are reluctant to trim the underside of teeth, and feel they must be set untouched. Persistence and insistence on the “correct curve of Spee” will eventually solve this problem.
|Figure 13. The full smile set-up is viewed.||Figure 14. The patient's preliminary cosmetic consent is obtained.|
|Figure 15. The patient views and approves the final set-up.|
|Figures 16 and 17. Post dam position is confirmed with the use of a transfer pencil and having the patient blow through the nose with the nostrils pinched.|
|Figure 18. The transfer pencil leaves a mark on the palate.|
Appointment 4. Wax try-in, bite verification, and establishment of post dam position are accomplished at this appointment. At this visit the patient is given the opportunity to view and approve the final set-up (Figure 15). Rarely are cosmetic concerns an issue, because they have been predetermined. Vertical dimension is confirmed by evaluating the freway space at rest position. The bite is confirmed by again taking a centric relation record and confirming it with the mounted case. If either the vertical or centric is in need of modification, the case is remounted and the patient reappointed for another try-in. The case is sent back to the lab for resetting of the teeth.
The post dam position is confirmed with the use of a transfer pencil (Figure 16) and having the patient attempt to blow through the nose with the nostrils pinched off (Figure 17). This will leave an imprint on the palate (Figure 18) and give you the information to mark your models accordingly.
|Figures 19 and 20. The completed case.|
Appointment 5. Delivery. This is the time to celebrate with your patient. After removal of pressure areas and equilibration of the bite, the case is complete (Figures 19 and 20).
TREATMENT OF THE DEBILITATED PATIENT
The technique described assumes the patient presents with a denture. In the patient with hopelessly involved teeth, an immediate denture using the least costly materials and process is fabricated. The patient is advised that this is a “diagnostic provisional denture” and will be replaced. It is stressed that the healing time is the patient’s opportunity to analyze what he likes and dislikes about this prosthesis. He is assured that the final result will be exquisite. Once healing has taken place, the technique as described in this article is used (using the provisional denture as your guideline).
After reading this article it is hoped that you will feel differently about the value of full dentures. The technique described is not a quick way to an excellent result, but it is uncomplicated and quite predictable. The major differences are: (1) the duplication of the original denture and its use as a custom tray and bite rim. This technique eliminates the tedious use of wax rims for jaw relations; and (2) the involvement of the dentist in setting the upper anterior teeth. This ensures an uncompromising cosmetic result. Most dentists have the skill to incorporate this technique into their practices without the need for significant investments in materials or complex instruments.
If a practitioner will embrace full dentures and reincorporate them back into his or her practice, they will be rewarded not only financially but with a level of professional satisfaction that is comparable to any other procedure they perform.
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