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Exam 2
Chapter 1: The Edentulist Predicament
Edentulism is considered a serious emotional life issue. Patient responses and
perceptions are an integral part of the clinical decision making paradigm for complete
dentures. Many patients are considered to be maladaptive to dentures, and despite
many of the dentists best efforts, some patients just cant handle dentures. Patients
ability to adapt to new dentures depends on many different things, both biomechanical as
well as psychosocial. Patients mouths do change, both bones and other supporting
tissues, plus their neuromuscular control. A patients mindset is also a major factor.
Research has failed to take into account all these things to predict the best complete
denture service.
Implant Prosthodontics:
Involves endosseous anchorage in mandible
Research in 1982 led the way, before there were many failed efforts
o Greatly helps maladaptive denture wearers
As dentists, still very important to have knowledge of complete dentures without
implants. Implants are not always the best option
For complete dentures, implant-supported overdentures are the endorsed the most
Chapter 2: Biomechanics of the Edentulous State
It is inaccurate to state caries and periodontal disease as sole cause of edentulism
Edentulism due to combinations of: Cultural, Financial, Past Treatment, and
Dental Disease Determinants
In future, need for dentures will decline, partial tooth replacement increase
o Older old people will be needing dentures, though
o This means more difficult mounts for dentist
Patients look at edentulism as a handicap
Presents range of biomechanical problems for patient
Support Mechanisms for NATURAL DENTITION:
Masticatory system behaves quite differently from dentulous to edentulous
Teeth function properly only if adequately supported (periodontium)
PDL transmits forces to bone
Forces on teeth include mastication and deglutition (random biting)
o Others by tongue and circumoral musculature
o Lingual forces are greater than buccolabial forces
Sensory processes during mastication with natural teeth ensure no injury to soft
tissues (proprioception, etc.), therefore teeth must be placed along this same arch
to ensure functional balance of musculature and teeth (holding bolus in position
during chewing)
Proper mastication of food is important in digestion, denture patient will end up
chewing food less which will affect digestion of food
Tough food chewed in premolar region
Major differences between natural teeth and dentures:
o Mucosal mechanism of support, opposed to periodontium
o Movements of dentures during mastication
o Changes in maxillomandibular relations and eventual migration of denture
o Different physical stimuli to the sensor motor systems
During chewing, muscles flex, and soft tissues change shape, this changes
occlusal relationships of dentures
Parafunction (Not directly related to mastication) include more horizontal forces
as well as vertical forces
o
o
o
o
o
o with age: shorter chewing strokes, prolonged chewing time because they have
poor motor coordination and weak muscles
o sensitivity to taste declines with age (therefore more sugar and salt)
o old likely to have inadequate calories, calcium and absorb vitamins poorly
o wrinkles = sun causes melanocytes to enlarge, epidermis thickens, dermis thins
out, collagen and elastin dissolved and then wrinkles appear when fat is lost
o concavity of upper lip reduced, philtrum flattens, nasolabial grooves deepen,
buccal pads hallow the cheeks, upper lip droops
o teeth become brownish because of stains and dentin might be exposed
o older persons worry just as much if not more about their appearance
o the need for complete dentures in the western world will increase over the next
quarter of a century
o wounds heal more slowly and possibly less effectively in old people, this is bad if
ill-fitting dentures cause trauma
o new dentures are not accepted easily by older patients, so, whenever possible,
modify the dentures that are familiar to the patient rather than make new dentures
o if must make a new one, try to duplicate the general shape and tooth arrangement
o every denture should have the patients identity embedded visibly
To prevent:
Try to retain some teeth for overdenture abutments (tooth roots
in mandible is particularly important)
Regularly monitored to maintain acceptable fit and stable
occlusal condition
Possibly implants
o Pathological changes of oral mucosa
To prevent:
Patient must be monitored and come in on recall
Patient should abide by proper denture-wearing habits
Finally, it is important to remind and to explain to our patients that treatment with
complete dentures is not a definitive treatment and that their collaboration is
important to prevent the long-term risks associated with the consequences of wearing
complete dentures.
Chapter 15
Brought to you by Roy Krengel
Denture has 3 surfaces:
1) an impression surface
2) an occlusal surface
3) a polished surface
Impression Surface:
-rests on residual ridges and transmits forces directly to denture bearing tissues
Occlusal surface:
-consists of articulating surfaces of the prosthetic teeth that make contact during
functional and parafunctional activity
Polished surface:
-non articulating part of teeth (Buccal/Lingual surfaces) as well as buccal, labial, lingual,
and palatal parts of denture base
-design and orientation of surface are determined by its relationship to the functional role
of the tongue, lips, and cheeks
-position of equilibrium among these muscle groups called neutral zone
-get this neutral zone by making occlusion rims
Occlusion Rims:
-Records neutral zone first and then maxillomandibular relations
-also records level of occlusal plane
-most of these determinations cannot be made scientifically, more theoretical. However,
clinical experience proves to be successful
The preferred clinical sequence:
1) design the arch form on each wax occlusion rim
2) establish level/height of the occlusal place on mandibular rim
3) modify maxillary rim to meet the mandibular rim evenly at desired vertical
dimension of occlusion (VDO)
4) make a preliminary centric relation (CR) record
Arch Form:
- the width of occluding surfaces and the contour of the arch form of the occlusion
rims should be individually established for each patient
- when natural teeth are replaced by artificial teeth, it is logical to set the artificial
teeth in the same place where the natural teeth occupied
- the same forces stabilize the artificial teeth/dentures
- hard to do when patient is completely edentulous, clinical judgment needed
- the best guide for determining and designing the arch form is to consider the
pattern of bone resorption where the teeth are lost and the use of anatomical
landmarks that are stable in position
Mandibular Arch:
- in lower jaw, more bone loss on labial side of anterior residual ridge
- so, ridge is more lingually placed in anterior, but more buccally placed in
posterior
- corners of mouth used to determine position of canines
Maxillary Arch:
- no need to worry about tongue
- residual ridge usually moved palatal, therefore the maxillary teeth must be placed
labial and Buccal to the ridge to be in neutral zone
- Maxillary Central Incisor incisal edge 8-10mm anterior to incisive papilla
- Posterior teeth related to mandibular arch most of the time
- The longer the period of edentulism, the weaker the muscle tone of the face
Level of the Occlusal Plane:
- some dentists find the occlusal plane by shaping the maxillary occlusal rim so that
the incisal plane is parallel to the interpupillary line and is at a height that allows
for the length of the natural tooth plus the amount of tissue resorption that has
occurred
- can also use the upper lip as guide
- posteriorly, the occlusal plane is made parallel to the ala-tragus line on the basis
of the position of most natural occlusal planes
- for patients that this does not work, the dentist can establish the height of the
occlusion plane by marking the corners of the mouth (modiolus-where 8 muscles
meet pg. 263) on the rims to determine the height of the first premolars
Tests to determine (VDO):
1) Judgment of the overall facial support
2) Visual observation of the space b/w the rims when the jaws are at rest
3) Measurements b/w dots on the fae when the jaws are at rest and when the
occlusion rims are in contact
4) Observations when the s sound is enunciated accurately and repeatedly the
average speaking space (~1.5 -3 mm)
Interocclusal centric relation (CR) Records:
- interocclusal records are described as static, graphic, or functional
- static records are made with a soft material between two rims used to make a
checkbite record (preferred method)
- graphic records are made with intraoral or extraoral tracing devices
- functional records are made with pantographic tracing devices
List of how technique on bottom of page 265 if you guys really want to read it.
Waste of time is my guess!
Chapter 17 Part 1
Little things can be added to the denture to make it look more nature, i.e. wear or
restorations.
Posterior Tooth Selection
Goals:
1. properly fitted bases
2. correct jaw relation records that are transferred to an instrument
capable of accepting what is recorded
3. the arrangement of the teeth for the best stability and other functional
and nonfunctional activities
Over the years, anatomy has taken a back seat to function.
Buccolingual width of posterior teeth---less than the width of natural teeth replaced.
These narrower forms, especially in the lower denture, assist the cheeks and tongue in
maintaining the dentures on the residual ridge.
Mesiodistal length of posterior teeth---vary to accommodate needs of a patient, a line
from retromolar pad to canine on each side is made to assist placement on residual ridge.
No teeth are placed on incline of retromolar pad. The distance between canine and
beginning of incline determines if 3 or 4 teeth are used. Maxillary posterior teeth that
extend too close to the posterior border of the maxillary denture may cause the patient to
bite the cheek.
Vertical Height of the Facial Surfaces of Posterior Teeth---correspond to interarch space
and to the height of the anterior teeth. 1st premolar=canine (Maxillary, for esthetics), the
entire arch should mimick that of natural teeth.
Posterior teeth and materials---porcelain was the favorite because the rapid wear of
acrylic resin. With the tendency for porcelain to chip, acrylic gained popularity. In the
past two decades improved resin and composite resin teeth have been used because they
were more wear resistant.
Cusp inclines and posterior teeth---based on the type of occlusion to be developed, the
philosophy of occlusion to be fulfilled, and the accomplishment of both of these goals
with the least complicated approach. Blah Blah Blah
Arranging Teeth for Complete Denture Occlusion
Occlusion rim wax is used, helps determine the desired amount of lip support and the
technician arranges the teeth using the rims as a guide. These are adjusted at the try-in
appointment. Incisive Papilla is a valuable guide to anterior tooth placement because it
has a constant relationship to the natural central incisors, it positions the midline, it
should be noted that it works most of the time, not always. The labial surfaces of the
central incisors are usually 8 to 10 mm infront of the papillae.
The anterioposterior position of the dental arch should be governed chiefly by
consideration of the orbicularis oris muscle and its attaching muscles: the auadratus labii
superioris, caninus, zygomaticus, quadratus labii inferioris, risorius, triangularis, and
buccinator. (this my be to specific) The muscles are affected by the anteroposterior
position of teeth and denture base. Basically, too far forward or backward will be
baaaaad. So, if the residual ridge is resorbed, setting the teeth on it will lead to them
being to posterior and will give the patient an aged look. The wax occlusion rims, will be
the ultimate guide for the positioning of the teeth. A try-in of these rims will give the
dentist a good idea if the arch fits well with the space of the oral cavity and muscles. The
wax can be adjusted due to the try-in.
Arranging Anterior Teeth
Refer to the lab manual, this material seems different from what we have been taught in
lab. So, I will talk to the teacher on Monday about what we should follow.
Occlusal Schemes : 2nd Half of Ch. 17 (p314-328)
Key points:
nd
premolar is most often selected as it provides greater occlusal surface area for grinding.
Maxillary 1st premolar is typically selected for esthetic reasons
*2 compensating curves:
p. 319, 323
Anteroposterior compensating curve- developed to provide the needed tooth
structure for balancing contacts in Protrusive movement
Mediolateral compensating curve needed to provide the needed tooth
structure to achieve balanced articulation during lateral movements
*Posterior teeth are only set to the point at which the mandibular ridge begins to
curve upward toward the retromolar pad
- The vertical position of the upper canines is responsible for the shape of the
smiling line, if canines are placed to low this gives a reverse smiling
appearance (teeth look like they are frowning)
IV. Harmony of the opposing lines of the labial and buccal surfaces
- Asymmetry is the objective so that the dentures dont look fake
- Asymmetrical symmetry - dissimilarities in the inclination, rotation, and
position of the teeth on each side of the midline
- The teeth should have opposing equivalent angles away from a midline
V. Harmony of the teeth and profile line
- The Mx central incisors should parallel the face; ie: if the Mn is retracted the
cervical portion of the tooth should be out the furthest anterior and the incisal
portion posterior, whereas if the Mn is protracted the incisal portion of the
tooth should be the furthest anterior and the cervical portion posterior
VI. Harmony of the incisal wear and age
- The teeth in a denture should be ground down to simulate the wear surfaces
at the age of the patient; ie: older equals more wear
- Developing incisal wear on artificial teeth during balance and correcting of
occlusion is a logical approach to this phase of esthetics
- The artificial teeth of an older person should not have small ball point
interproximal contacts with large interproximal spaces because this would
be characteristic of a younger person
6. Refinement of individual tooth positions set with the appropriate inclinations
and rotations; this is why patients should have a preextraction record that helps
the dentist set the teeth in the right position
- A study of common irregularities to Mx teeth that should be added to a
denture
1. A slight lapping of the mesial surfaces of the lateral incisors over the
central incisors
2. A depressing of the lateral incisors lingually so the distal surface of the
central and the mesial serface of the canine are labial to the mesial and
distal surfaces of the lateral
3. A rotating of the mesial incisal corner of each lateral incisor lingual to
the distal surface of the central while the distal surface of the lateral
remains flush with the mesial surface of the canine
4. Placement of the incisal edge of each lateral higher than that of the
central incisor and canine
- Harmony of Spaces and Individual Tooth Position spaces can be used as
an irregularity between teeth to look more natural and to provide more
proper balance in the overall composition
7. The concept of harmony with sex, personality, and age of the patient
- Feminine: curved surfaces, roundness and softness in the form of the
dentition, and a prominent smiling line of the anterior teeth
- Masculine: boldness, vigor and squareness and a straightness to the incisal
line
- Size and position of the central incisors dominate the arrangement of the six
upper anterior teeth
- Smaller lateral incisors and rotation of these teeth give a softer more
feminine look
- Rotation of the distal central incisors gives a more vigor look
8. The correlation of esthetics and incisal guidance - no vertical overlap (overbite)
of anterior teeth while posterior teeth are in Centric Occlusion
- To compensate for this there needs to be overjet to make esthetically
pleasing
Patient Acceptance of the Arrangement of the Anterior Teeth
- Patients should be given opportunity to observe and approve the final arrangement of
the anterior teeth at the time of the appointment, the denture should not be completed
until approval is given
- Patient should not be able to observe trial dentures in their mouths until the dentist is
satisfied with the composition
- The patient should first observe how the teeth look in their mouth and second stand 3-4
feet back from a mirror and observe how they look in a normal conversation because
other people will be looking at them more than they will
- Patient should bring along the most critical family member or friend at the time of try
in
- The dentist should listen to all the concerns and comments of the patient and not
dismiss them as silly
- The dentist can make some changes, but other suggestions may not be advisable
because it is not anatomically feasible and may prevent the muscles in cheeks and lips
to properly move the face
- When everyone is in agreement, the dentist should have the patient sign a statement that
protects the dentist. This statement claims that the patient was given the opportunity to
view the teeth while arranged in wax or that requested changes were not done.