Week 9: Aesthetic Try-in and Problem Solving AND Delivery of Denture, Adjustment, and Review

Question 1

In the denture aesthetic try-in appointment, what is important and at stake (for the patients and dentist)?

Answer 1

• Patients self-esteem & confidence
• Patient’s health and well-being
• Patients review of clinical dental work

Question 2

What are three essential varibles in denture teeth selection?

Answer 2

• Composition (acrylic, composite, or porcelain)
• Colour (shade)
• Shape/Size (mold)

Question 3

How should denture teeth colour/shades be assesed and chosen?

Answer 3

• Check the shade against the patient’s face
• Dental manufacturers have a selection of denture teeth with different hues (mainly brown, yellow, grey, and reddish-grey) & values (brilliance)- prameters to describe colour were published in 1905 by Munsell
• Patients tend to choose lighters shades than natural shades or current denture teeth
• Younge patients should have more translucent/lighter teeth as compared to older patients more opaque/drakter teeth

Question 4

What is the process of anterior tooth selection?

Answer 4

• Predominantly invovles aesthetic considerations
• Replicate what was there previously or change what was there
• Tooth colour: same, lighter, darker?
• Tooth size: same, larger, smaller?
• Tooth shape: same, curved or straight, customized features?

Question 4

How can the shape and size/mould of teeth be determined?

Answer 4

• Determined by several factors such as age, sex, personality, face shape
• Study models fod edentulous arches also give cues or dictate what size as well as which occlusal schemes are followed
• Patients tend to choose a smaller mould to what really suits
• Popular way of choosing the mold is by using the general shape of the upside-down face as shown in the VITA brouchure

Question 5

Describe the psychology of acceptance

Answer 5

• Listen well for clues
• Makes notes- do not rely on memory
• Any old record of their smile is useful, whether liked or not (old dentures, photos with smile)
• Get the patient (decision-maker) heavily invovled in the decision making process
• They can “take ownership” of their decision and subsequently “sign-off” on it
• Take photographic record, a set of photos- at rest & smiling (Frontal; Oblique 45; Lateral)
• Have good communication & rapport with the Dental Technician (include photos with your lab request)

Question 6

What are the objectives of arrangement?

Answer 6

• Function
• Speech
• Aesthetics
• Don’t contribure to other problems (tongue/cheek biting)

Question 7

What is the process of teeth arrangement?

Answer 7

The bite registration information recorded on Wax Contour Rims enable the models to be mounted on an articulator. Apart from registering the relationship between the upper & lower jaws that is Centric Relation (CR) and Vertical Dimension, the following biometric markers on the wax contour rims are useful:
* Amount of upper lip support
- seen clinically as the naso-labial angle (plastic surgeouns aim for an idea of 90° in men and 95°-115° in women)
* Upper midline
- Based on external land marks such as the facial midline (eyes; ears; nose), philtrum etc.
* Canine position
-Dictated by the ala of the nose
* Smile lip line
- Patient to give the widest smile possible, cervical necks at or above line
* Occlusal plane
- The use of the Fox Plane guide will help with paralleling the occlusal plane with the ala-tragal line and the inter-pupillary line (eyes)
* Overjet
- Aim for 1-2mm horizontal overlap (in a classic Class I case)

Question 8

How is the occlusal plane in relation to the lower edentulous arch?

Answer 8

• Should intersect the middle of retromolar pads
• If the occlusal plane is too low- tongue biting
• If the occlusal plane is too high- strain as tongue struggle to replace the food bolus

Question 9

Fill in the blank:

Maxillary lingual cusps should be centered over the ____ to ensure ________ as this ________ during function.

Answer 9

(-) Center of the posterior ridge
(-)Denture stability
(-)Reduces fulcrum forces

Question 10

Fill in the blank:

Lower posterior teeth are set up ___ over the alveolar ridge

Answer 10

**DIRECTLY **

Question 11

True or False: Posterior and anterior teeth are always set up directly over the ridge

Answer 11

TRUE

Question 12

Lower denture teeth set up directly over the alveolar ridge should have

(A) Convex Surfaces
(B) Concave Surfaces

Answer 12

(B) Concave Surfaces

Question 13

How should wax dnetures by assessed at the try-in appointments?

Answer 13

Try wax dentures in one at a time. When satisfied with the result, put both in together.

Question 14

How to know if the dentures are over extened and how can this be fixed?

Answer 14

• Wax dentures should be passive when placed in the mouth (lower denture)
• When the wax denture does not stay in position and it ‘bounces’ up, it is over extened
• Investigate and reduce wax in overextened areas until the wax denture is passive
• Advise the technician of changes

Question 15

Describe patient consent in relation to wax partial denture try-in

Answer 15

Patient Consent
* Hand the patient mirror to the patient ONLY after you’ve done all the check and you are satisfied. Patient needs to be informed that clasps will be added to the final denture (so no suprises at the delievery appoinment). Patient consent should be obtained at this stage.

Question 16

How are phonetics checked in the wax try-in appointments

Answer 16

Count 50’s and 60’s

Question 17

True or false:

The VDO does not need to be re-checked in the wax try-in appointment

Answer 17

FALSE

Re-check VDO!

Question 18

If bite registration is incorrect in the wax try-in appointment how can this be fixed?

Answer 18

• Use red boxing wax (to re-record bie registration)
• Lab re-articualtes
• Lab/dental technician will fix overjet/overbite and occlusion

Question 19

What are the lab procedures of finished denture pre-delivery and optional patient instructions?

Answer 19

Lab procedure:
* The new set would be assessed for any surface errors with ungloved hands, to be able to check for sharp edges, tiny rough imperfections, projections and the flange, denture borders are rounded (Surface can be reassessed chairside as well).
* After assessment disinfect dentures
* Prior to the appointment, that patients can avoid wearing the old set for 12-24 hours in preparation for the new ones (optional)

Question 20

What results in errors in occlusion and can happen should these fail to be corrected?

Answer 20

Errors in occlusion can be a result of:
* Change in the state of the TMJ
* Inaccurate centric relation records
* Transfer error of centric relation to the articulator
* Ill-fitting eax rim bases
* Change of the vertical dimesion of occlusion on the articulator
* Incorrect arrangement of the posterior teeth

Failure to correct will lead to the destruction of the residual alveolar ridges.

Question 21

What is selective grinding/calibration?

Answer 21

• Selective grinding (SG) immediately after deflasking will eliminate most of the errors caused by processing changes
• It is important that labs use correct flasking and packing techniques (such as trial packing three times- if not will change vertical dimension of occlusion)
• SG will not eliminate errors produced by the impressions or jaw relation records and those which develop when the dentures are removed from the casts or are polished
• These errors are usually very minute and not obvious intra-orally
• Once the dentures are re-mounted the errors in occlusion are then easily removed by SG

Question 22

Discuss patient education and the delievery of denture, adjustment, and review appointment

Answer 22

Patient education
* Forewarn the patient that they will expereince a feeling of fullness and possibly excessive salivation, both of which will subside over the first few weeks
* Eating with new dentures is a skill that must be learned and may take 6-8 weeks to master, the food needs to be cut up small, placed bilaterally and chewed in an up and down motion in the beginning
* Phonetics: most will have some difficulty in speaking and reading out aloud. Pronouncing each word will help re-train the neuro-muscular balance associated with speech
* The tongue forward posture will help with the lowe denture stability and border seal
* Leave the dentures in water overnight to allow the oral mucosa to rest. This is optinal because not everyone is comfortable with the idea to have their denture teeth out.
* If oral thrush (candidiasis) is an occuring problem, then leave the dentures out to dry overnight. It is important to educate your patient on cleaning their dentures

Question 23

Discuss denture cleaning and maintenance

Answer 23

• An inexpensive denture soak is a bleach bath (1/2tsp household bleach to 120mls of water) but IS NOT suitable for Chrome-Cobalt (CoCr) dentures as tarnishing will occur as a result
• Metal based dentures will require denture cleaners specific for it
• Daily 30-minute denture soak is recommended
• Brushing thoroughly under running lukewarm water after soaking will remove the bleach & debris
• Brush dentures with a SOFT denture tooth brush
• Toothpaste SHOULD NOT BE USED to clean dentures because it will ruin the glossy shine. This will increase staining and plaque adhesion
• Household dishwashing liquid can be used provided that the denture gets a good rinse off afterwards
• Educate patients to stand over a bathroom sink on a mat incase the dentures fall and WILL chip if the bathroom has a hard surface floor (tiles). A plastic container in the sink is also a good idea to prevent the dentures from chipping if dropped in the sink
• The mucosa should be cleaned twice a day, using a soft tooth brush and toothpaste is okay to use

Question 24

What is after the delievery appointment? Describe the process

Answer 24

Post-delivery appointment is the review appointment.

• Review examination & adjustments
• Listen to the complaints and visually examine the problem areas (this is usually indicated by trauma spots)
• Look for erythema (trauma spots) which might not be sore
• Use Pressure Indicating Paste (PIP) to locate pressure areas and overextended borders
• Always check occlusion in line of the trauma spot (there is often a correlation)
• Check occlusion (should be balanced)
• Polish adjusted areas
• Sore spots- recommend to yout patients to rinse with lukewarm salty water (half tsp salt in a cup of water)

Question 25

What happens after the review appointment?

Answer 25

• Make appointments as required
• If there were adjustments made to areas with trauma spots previously, review the patient after 2 to 3 days and continue until the patient is comfortable
• Usually, a 12 month recall for complete dentures is adequate (this is a good time to assess denture retention and fit)
• Relines ideally should be done every 2 years depending on the fit of the denture and the problems the patient might be experiencing