DELIVERY OF THE COMPLETED DENTURE

In the lab we are doing setting of teeth now after this "after finishing the setting of teeth" which is laboratory step then the technician will send the teeth in wax trial denture to the dentist. The dentist will do the try-in. After the try-in, the dentist will send back the trial denture to the technician . The technician will process them in to cure acrylic and send them back to the dentist. The dentist will insert them (or will deliver them) to the patient, so the delivery of the complete denture is the end result of the lab work and clinical work. Now we want to insert them in patient mouth Delivery stage is not important; it is just taking the dentures and insert them in the mouth. And that is WRONG. The delivery stage is very important stage clinically and very important also for the assessment of complete denture.

SLIDE (2) The first thing we do is what we called it Dentist Evaluations so you need to evaluate the complete denture ok? . So you have delivery visit and follow up visits. " the dentist evaluate is the success of the complete denture and the delivery visit and follow up visit"

Now, follow up visit is NOT optional is something compulsory because most of the time, most the complete denture they have complains at follow up visit.

So at the delivery visit you evaluated and you think these are successful dentures but some time or most of the time the patient comes back to you with complains like over extension, causing ulcer, inability to eat properly, problems with occlusion and a lot of things. So you have to do proper evaluation at delivery visit and at the follow up visit. We have Patient Evaluations You evaluate the denture in the term of scientific information about success of the denture like retention , stability, support, esthetic, for tic occlusion. Now the patient dose not know about these things, the patient evaluate the denture in term of aesthetic appearance "is the most important thing to the patient" and for tics . Sometimes he tries to chew or to bite and he will evaluate the bite but you can't assess function shear side although some patients bring some types of food to eat on shear side but it dose not evaluate. To evaluate the ability of chewing ,you need to send the pt home then he comes back after ONE week assessing the ability of chewing because he will not chew only one type of food, he will chew different types of food. Now we have Friend Evaluation Is very common for who wearing complete denture to have escort (moraf8) with them . The friends evaluations usually based on one thing which is esthetic appearance they tell them if the denture are esthetically acceptable or not, so the friends evaluation might be misleading to the patient , sometimes you find the patient satisfies to appearance but the escort or friends is not satisfy and they affect negatively to the satisfaction of the patient . At the end if the patient is not satisfied the treatment will be failure whatever you did "if you did the best denture in the world ,if the patient is not satisfied the end result is failure" So we need to have dentist evaluations ,patient evaluations and friends evaluations , and all of these at the end they satisfy the demands of the patient ,esthetically and functionally The patient should be able to eat , to speak properly, and the appearance is acceptable to the patient and to the people around. SLIDE(3) Now we will talk about Denture Insertion .

The first thing ,before inserting the dentures in the patient mouth the dentist u have to check for technical error Don't expect the technician or the technical work will be perfect ((in this year you do technical work and you can see how many mistakes you do in the technical work, the same thing for technician they are human being like you but they are with more training and experience but still they do mistakes or sometimes they don't know where the mistake is, for that we teach you how to do lab work to know the mistakes of technician so you have to check the technical errors)) The dentures come from the lab in bag filled of water the first thing you do, you open the bag and you remove the denture, you reins them (wash them )and with your finger, you check all the margins, all the border and the fitting surface and all-around of the denture with your finger WHY ? to check if there is any sharp margins >if there is sharp margin DON'T insert the denture inside the patient's mouth the first thing you have to relief or eliminate this sharp margin. this is the most important step . Number 2 with upper and the lower denture you check them together to see if the occlusion is good If the teeth don't interdigitated outside the patient mouth they will not interdigitated inside patient mouth. SO what you check outside the patient mouth, you should check the Finishing , Polishing , if there are any sharp margins and you check the occlusion of the dentures . It Is very common for the technician to leave stone (Jeps) between the teeth after the flasking procedure , so you have to check if there is any remaining between the teeth. If your patient is already denture wearer you have to tell him at[ try-in] stage to keep the old denture out of his mouth for at least 22 days before insertion WHY? the denture foundation area is covered by soft tissues and the soft tissues are compressible ,so if the patient wears the old denture, the denture foundation (soft tissue) takes the shape of fitting surface of the old denture , so the new denture might not fit properly and you ask the patient to take the old denture out of his mouth at least 22 days before insertion for recall of the soft tissues so that the new denture fit the soft tissues and it settle on the soft tissues and it change the shape of the soft tissues according to the new fitting surface .

SLIDE(4)

Now if you have basal surface errors =How many surface we have in the denture ? We have 3 surfaces 1-polished surface 2- occlusal surface 3- fitting or integrally surface So the Elimination of The Basal Surface Errors , The polished surface should be highly smooth, the polished surface consists of smooth part of the denture which is not in contact with denture bearing area plus the buccal and the lingual surface of teeth. NOTE: the buccal and lingual surface of the teeth are NOT part of the occlusal surface, they are Polished Surface. Now , the fitting surface It should has no Imperfections, ideally we DON"T touch the fitting surface Why? , because the fitting surface "the flex" is the anatomy of the denture bearing area, so the fitting area should not be touched except if we have sharp area or there are acrylic voids and you need to eliminate any imperfections exist on the fitting surface. You have checked the polished surface and fitting surface, now you have to insert the denture in the patient's mouth , you can't insert both of them(upper & lower) at the same time. The ideal way is to insert denture by denture , you can insert the upper or the lower first, but the ideal way is to insert the UPPER first, because the upper determines the esthetic outcome. So you insert the upper denture then you check the retention(retention means resistant to the dislodgment "moving") We have different type of retention to check;

>>The 1st thing the vertical dislodgment. In upper denture after you insert it you'll hold the denture with index and the thumb finger and you try to pulled it down. Now if you can do this easily , the retention is questionable , if you have resistant, this is good. >>The 2nd thing you put the thumb finger on the right side and you push if the left side dislodges this means the retention is questionable

>>The 3rd thing the thumb finger on the left side and you check the retention on the right side >>The 4th thing "is very important " to check the post dam area , the retention posteriorly by your thumb finger or index finger on the anterior teeth if it dislodges posteriorly easily this means the posterior palatal or the post dam is questionable . Keep in your mind this is insertion, still the dentures are not complete settle and the dentures bearing area are not designed exactly to the fitting surface, so what you see at the insertion will be better at follow up , because the denture will settle at follow up stage and the soft tissue are compressible ,so the retention at the follow up stage is BETTER than retention the insertion stage. If you think that your retention is not 100%. that's fine, [but not poor retention , when you put denture and it falls down by itself that's not good]. If you find that small force will dislodge your denture don't rush and say this is poor retention and we need to adjust the denture by relining or other procedures. no, you have to give it time for the follow up, in most cases they improve retention.

Now you have to check the stability (which is the resistance to lateral and rotational functional forces . ) We check with 2 thumbs one on right and other on the left if you press on the right you'll feel axial to the left this means poor stability and if you insert your index finger and thumb finger and rotate the denture and it rotates significantly this means poor stability .stability is the most important factor for the success of complete denture because stability is the resistant to the lateral and rotational forces during function and this is what the patient needs which is stable denture during function .if you have poor stability you might have to reline or remake the denture . Most of the time the cause of the poor stability is technician error. After we checked the retention and the stability of the upper denture we remove it and insert the lower denture . Again we check the retention, as the upper Upward forces , force on the right side , force on the left side and force anteriorly to check the retromolar pad area retention ,and we check the stability by moving the denture from side to side and you put pressure on the both side of the denture to see if there is any rock.

Note ; DONT misleading with a little movement of denture cuz the denture is fitting on soft tissues and soft tissues move a little bit and this is normal. We have minor degree of movement but not poor stability when you put your finger on one side the other side is rocks this is mean distortion in the acrylic . Now you check the flanges of the dentures. it should be rounded and have the proper thickness and extension and that was important in the 2nd impression in border molding. the aim was to register the functional depth and width of the sulcus,which is the thickness and the extension of the flanges .why we need to register that? to have good peripheral seal and so we'll have good retention and during function the muscle dont dislodge the denture because the edges of the flanges of the dentures are in the functional depth and in the width of the sulcus . How do we check if the flange is over extended or under extended ? When you insert the denture you'll flag the lips and cheeks and you'll see the functional sulcus if the flange is like this that means it is short and it need to be adjusted if it is pushing the sulcus, this means over extended and it needs to be adjusted also . Sometime the patient complains about sore areas or painful areas . Even if the patient dose not complain cuz the denture dose not completely settle at insertion. We have material called pressure indicating paste It Is a useful paste that used to check pressure area or high spot of fitting surface when you insert the denture you can't see the fitting surface you don't know where are the pressure areas on the soft tissues by this material you paint the fitting surface with a thin layer and then you insert it in the pt mouth. If there is any pressure areas the paste will be washed away and the acrylic will appear, and the other areas paste will stay on them. Where the paste has washed away, it should be relief .

SLIDE (5) Look at this upper and lower denture, look at the surface how it is polished, these are relieved areas of the frenum. look how the flanges is, and the margins how it's rounded, carving, finishing , polishing every things is fine .

SLIDE(6)

Now we need to check occlusion We need to check the upper and the lower when they occlude cuz this is important thing , when the pt functions it is related to occlusion It's common to have errors in occlusion Let's say every day(bel 3yadat) we have 5 to 10 insertions, at least 2 to 3 have major errors of the occlusion to a degree that you have to remake the denture. most of them have minor errors of the occlusion What are the causes of the errors in the occlusion?

When we try the denture at the stage of [Try-in] and the occlusion was good. The final denture is almost copy of the [try-in] denture ,,, so what happened here is change of TMGs . Changes of the TMGs don't happened in one week. over time, suppose the try-in has one period of time you might have errors in the occlusion or the pt has Diseases at TMG so that at try-in we have certain bite and at insertion we'll have different bite Inaccurate maxillomandibular relations When you do the registrations of the maxillomandibular relations ,and that registrations were not accurate, that lead to errors of the occlusion inaccurate mounting now we did what we call it ((jaw relation registration)) and you send the record block to the technician. When he do the mounting, he moves the relation. This kind of errors(inaccurate mounting) you can discover it at the try-in stage, but sometimes at try-in stage the teeth are fixed with wax and you can't check minor errors but at insertion because the teeth are fixed by heat cure acrylic. the minor errors can cause frank errors in occlusion. Change of the vertical dimensional occlusal on the articulator: At setting of the teeth, the pen of the articulator might be elevating form incisial table. in this case the vertical dimension has been changed (increased) Sometime the pen stays in touch, but we have spaces bt the teeth. The pt mouth will have decreased VDO

Movement of teeth at dewaxing When we do processing for the denture, we have step called dewaxing, when you eliminate the wax around the teeth but sometimes the teeth move. At the try in the teeth were perfect but during processing, the teeth moved. we would have errors at the insertion stage. At the processing we have something called flask if you don't complete the closure of the flask or you use too much pressure to close the flask this may lead to errors in occlusion. So flasking should be done properly to avoid mistakes in the occlusion,, flask consist of 2 parts if they don't close properly and we have space bt the 2 parts this will affect the occlusion Or when you use excessive pressure on the flask to close it ,this may lead to move the teeth and this lead to errors in the occlusion. We have Inherent property of acrylic which it is the shrinkage of acrylic, most of denture at try-in if you look at them carefully the occlusion is a little bit different WHY cuz the acrylic shrinks (polymerization shrinkage ) and when it shrinks the teeth would have minor movement We can't avoid the shrinkage but we can minimize it by the follow of the manufacturer's instructions in mixing and in processing to keep the shrinkage as small as possible and it doesn't affect the occlusion of the teeth. Over time the acrylic do what we call it water absorption and leads to expansion. even the property of acrylic when it's wet different from when it's dry ,,, over time may lead to occlusion errors cuz of water absorption Sometimes the technician finalizes the dentures and put it in the bag of water and he sends it to the doctor, the pt doesn't come for 2 or 3 months and the dentures still in water there might be water absorption and this causes expansion of the denture and leads to occlusion errors. All of these they can cause errors of occlusion.

SLIDE(7) How do we check the occlusion clinically ? We have paper called articulating paper This articulating paper for complete denture is like horse shoe shaped , for dentate it is straight.

Articulating Paper is a paper that marks when the pt bite from one side blue , and the other side red so that you can check the occlusion at centric, and you can check the occlusion at eccentric with different colors so that you can differentiated between contacts at centric occlusion and contacts at ex-curve movement or at eccentric occlusion. Now you do what we call it Selective Grinding You check with the articulating paper [Ideally the anterior teeth are out of the occlusion "out of contact"] Selective Grinding is ideally to see even contacts distributed in all posterior teeth, upper and lower Now with selective grinding when you insert the articulating paper you see for ex the lower 2nd premolar buccal cusp has a dark dot "bold dot" and the others have light dots, this means buccal cusp of the lower 5 needs to be grind. So here the selective grinding is needed. Now if you have minor mistakes, selective grinding in pt mouth might fix the problem but the selective grinding in the pt mouth is Not accurate for many reasons: >>The 1st one; Shifting of the denture. At insertion time, is the first time for pt to bite on this new denture so he isn't use to this bite "Mo mt3awed"or to this occlusion yet, so he might shift the denture or the denture bases. And when you start registering you think this is the true high spot so you keep grinding while it's not, cuz the denture had been shifted >>the 2nd one; Tissue Distortion The complete denture bites on the soft tissues, if we have an area with high spot "or premature contact" when the pt bites on the soft tissues, this area will have compression .so Tissue Distortion might misleads you to think the occlusion is good. At that time its high in this area but because of the distortion of the soft tissues happened. you think it's acceptable occlusion. >>the 3rd one; eccentric closure. You ask the pt to bite at centric and you think the pt was biting at centric but he deviated the mandible at this registration so you end up with multiple marks but they are not true marks they are false marks. >>the 4th one; saliva

The articulating paper it's a paper, with saliva it becomes wet and can be easily torn, and it doesn't mark with saliva so it's not easy for you to check these marks with articulating paper. All of this factors they make the selective grinding in pt mouth is not accurate procedure.

SLIDE(8) The solution of these factors is to do the selective grinding in the LAB. HOW? We do what we call it Clinical Remounting or Check Records or Pre Centric Check Record What's the main objective of clinical remounting?? To do the selective grinding on the articulator. Why?" For the reasons that I said for few minutes" Cuz the selective grinding in the pt mouth is not accurate enough for many reasons and the main reason is the Distortion of The Soft Tissues For ex: the pt have very minor high spot on the right side and he bites on the tissue. The tissue distorts and you can't check if this is high or not. While on the articulator the denture occludes on the cast and the articulator metal, so even microns you can check them by the articulating paper and you do remounting for the denture. ""Now quickly I will talk about it cuz the doctor sarah should give u something about occlusion and I don't know what she will talk about "" >>We have special type of wax called Aluwax This aluwax you enter between the upper denture and lower denture and you bring the aluwax and you place the aluwax on the mandibular posterior teeth >>Then you guide the pt to bites at centric relation or retruded contact position.(the two names are the same meaning ) Now when the pt bites you don't want the teeth to contact cuz when the teeth contact we will go back to the same idea of high spot that will cause the denture to move. We want the teeth to be very close to each other but without contact.

How can we check this ? when you remove the lower ,if you see any perforation in the wax, this means there was contact between the teeth and you have to repeat it. So ideally you see the indentation of the upper teeth in the lower wax without penetration "perforation" of the wax, for that we call it the pre centric check record. This relation is on the centric relation but becauce the teeth don't contact we call it pre centric check record >>After that we mount the upper and lower denture on the articulator using face bow ""I don't want to talk about the face bow cuz it is different topic"" Now we have the upper and the lower denture on the articulator with wax between them. >>We'll remove the wax and the incisal pin, so the teeth contact, if there is a high spot you can see it right away by using the articulating paper and you have to grind it. >>We have 4 types of adjustments: We have adjustment on the centric relation contact which it is Open & Close , this relation is between cusps and fossa and we do it when the incisal pin is not in contact with the incisal table. >>We have lateral movement (you can notice that the articulator can move right , left and posteriorly) So we have movements anterioposteriorly , right and left. we will do this movements with the incisal pin in contact with the incisal table. so that it guides you to these movement. In lateral movement we have [working side] and [non-working side or balancing side] The working side: is the side toward the mandible moves y3ny when you ask the pt to move to the right The right side will be >> the working side And the other side will be >> the non-working side or the balancing side

""Now I will talk about very important subject which you will asked about it in the next years ""

SLIDE (9) "plz refer to slides to see the pic " Let's take the 1st position which is (A) position when the articulator opens and close What is the possibility of interferences ? Which cusps are the function cusps? upper palatal & lower buccal

Now the possibility of the interferences is high in Palatal cusp of the upper with fossa of the lower or Buccal cusp the lower with fossa of the upper In this case if it is high, in this area we eliminate from the fossae WHY? Cuz these are the functional cusps if we grind them, the vertical dimension will be reduced cuz they are the one that determine the vertical dimension. >>>now in the case of centric if it was high and it was cusp to fossa relationship you have to eliminate the acrylic from the fossa

Now we will go to the working side when the pt moves to the right >>The possibility of interferences will be on the palatal slop of the upper buccal cusp and the buccal slop of the lower buccal cusp or the palatal slop of the upper palatal cusp and the buccal slop of the lower lingual cusp [ (B) position ] if we have high spot in this area we will eliminate from upper buccal cusp and lower lingual cusp cuz they are non-functional cusps this is what we call it Bull rule BUCCAL UPPER CUSP & LINGUAL LOWER CUSP to keep the vertical dimension of occlusion. So the rule of working side is the BULL rule we remove from buccal upper and lingual lower.

Now the non-working side, when the pt move to the right, the mandible will move to the left. >>In this case the interferences will be in Buccal slop of the upper palatal cusp with lingual slop of the lower buccal cusp [ (C) position ] In the case of non-working side we work on the Functional cusp In this case I have to grind from the functional cusps but I don't take from the height of cusps, I have to take it from the slop of the cusps so the vertical dimension occlusion retained as it is to the high degree. So in the non-working side we will grind from the slops of the functional cusps to avoid significant reduction of the vertical dimension of ccclusion These three (A,B,C) are very important and we call it selective grinding [to know how to remove from fossa or cusps , to remove from buccal or palatal cusps or buccal or lingual cusps, or to remove from the slops of the cusps. This's very important topic] Those are the movement that I was talked about slide 10,11. Notice how it moves, the interferences you have to remove it all. SLIDE (12) Now the mesiodistal when it moves anterioposteriorly The possibility of the interferences is in the distal slops for mesial upper cusps of the mesial slops for lower posterior cusps In this case we grind the slops of cusps. SLIDE(13) Notice here how it's look when you do selective grinding on the articulator and the marks distributed on the teeth. for ex: on this case you have to remove all of these marks cuz we're talking ideally we don't want marks on the anterior teeth on the complete denture.

SLIDE (14) Look here how is the occlusion in the pt mouth

The 1st pic is on the centric ,and the 2nd is on the eccentric .when the pt moves notice here how we get balanced occlusion. all cusps guide to the lower posteriorly

SLIDE (15) What do we aim in complete denture occlusion? ""as what doctor 3sam told us"" We aim for what we call it balanced occlusion or articulation What dose balanced occlusion means? Balanced occlusion by definition: bilateral simultaneous contacts at static and dynamic positions of the lower jaw That means in every position, the upper moves against lower and it should be at least 3 contacts right, left, anterior..WHY? Cuz complete denture is not natural teeth. when you have a contact on one side, dislodgment of the other side might happened. Now in the natural teeth we have (Christensen's Phenomenon.). If someone of you do protrusion anteriorly you will have separation of teeth posteriorly. what we call it Christensen's Phenomenon. the separation of teeth are dis occlusion posteriorly upon protrusion. In complete denture, we prefer Contact we DON'T want Christensen's phenomenon in complete denture, WHY? To avoid dislodgment during function and this what's we call it balanced occlusion in literature, do we really need balanced occlusion in complete denture ? the answer is yes and no, Don't think that the complete dentures that we did have balanced occlusion. most of them have not. How it will be successful? cuz the balanced occlusion is the movement like this!!!. Now during function are the teeth in contact?? NO cuz we will have bolus of food, so already we have separation of the teeth and usually the teeth don't contact during function only at the end of chewing cycle. Balanced occlusion is something theoretical more than practical. But still in the complete denture occlusion, we aim for balanced occlusion.(we try to do it)

WHY? Because it has advantage in stability during function, this will be on empty mouth but when the pt function with bolus of food it's not that important clinically. ""To this point we finished the insertion completely""

SILDE(16) ""Hala2 r7 nraw7 el pt"" We have very important instructions we must give it the pt These instructions are: 1- Individuallity of pt: every pt will behave or will accept the denture in his way ""Sometime I see pt, and the students do for him denture with mistakes and I wonder how he wears like this denture and the pt is happy with it. and some pt, the student do for him excellent denture and he is unhappy"" So there are big individualities for pts ""and in the 4th year I will tell you about complete denture, pt psychology and all of this issues"" You give instructions according to the pt. Some pts even if you tell him about instructions he don't understand those instruction, cuz he is not highly educated so when you give him instructions is wasting of time So you have to give instruction to his son or daughter Some pts are highly educated and they can speak English Those kind of pts , the instructions will be easy for them.

2- Apperance: you tell the pt this is the final appearance and usually it can't be change but it may has minor change according to the muscle. If the pt isn't happy from the appearance, that means failure of treatment.

3- mastication: you say to the pt look, these are denture teeth not natural teeth and don't accept that you can chew everything.

According to the study the deficiency of mastication is one tenth (1/10) of natural teeth specially if he was first time denture wearer, and you'll tell him this is the first time mastication for you and the chewing ability will become better over time, and at the beginning try small pieces of food, not sticky food, on the posterior teeth, avoid anterior teeth mastication until you get you used to the mastication. So, the ability of mastication will get better. Appearance is almost the same Soft food, small pieces on posterior teeth Avoid sticky and hard food So many pts try the denture on the nuts (moksarat) this is unfair and doesn't make sense cuz he can't chew nuts until he used to the denture Now, the Tongue>> it will help stabilize of the lower denture if the denture designed in proper way. Some of students will do setting of teeth in the lower, teeth will be lingualy tilted and the tongue will be destabilizing factor in this case. So the tongue will be stabilizing factor or destabilizing factor according to construction of the complete denture , the technics of clinical or technics of laboratory. Tongue with time will stabilize the lower denture and the upper denture. The posterior third of the tongue will stabilize the upper denture.

4- speech: if the pt has good speech at the insertion and over time the pt accommodates to the new dentures and he can speak better. if at the insertion the speech is not perfect that doesn't mean remake . No With time the pt will get used to it 5- Oral Hygiene: The pt should clean the dentures cuz the poor oral hygiene will cause denture stomatitis (elly a5dtoh bel oral patho ), inflammatory papillary hyperplasia, chronic candidosis, fungal infection, feltid order (bad smell) So the pt should have good oral hygiene By using soft brush after every meal under tap water to clean the denture

SLIDE(17) This pt with poor oral hygiene and has fungal infections Notice the white and red color And these are implants supported over the denture ( the denture will be over these implants ) SLIDE(18) 1- Rinse after meals 2- soft brush for both dentures and mucosa It's good to rub the mucosa with soft brush to avoid any black accumulation on the soft tissue if you clean the denture but there was black on the soft tissue it's the same idea ( it's useless"ma astafadna shi") 3- In the pharmacy they sells something called denture cleansing agent. it is tablet and the pt puts it with water. Usually you ask the pt in the first week to wear the denture at day and night to get used to the denture. After the first week we ask him to remove the denture at night for the soft tissues to relax and recoil back and keep the dentures in the [denture cleansing agent] 3- ask the pt to avoid abrasive pastes and it will cause abrasion for the denture avoid strong bleaching agent some pt puts colorix and the denture will turned to white in color 4- it's very common when you give the pt new dentures he may get trauma from it , sometime he even can't wear the denture. In this case You tell him to Remove the dentures, Put them in the denture cleansing agent with water And 1 to 2 days before coming back to me, Wear the denture. In this way I can see the place of trauma or ulcers in the recall visit

SLIDE(19)

Recall visit usually is after one week of the insertion and this is not optional it is compulsory You have to do review even if the denture excellent at the insertion. Most of dentures which are excellent at insertion have problems at review This means the recall visit is not optional it is compulsory very rare not having adjustment at recall 95% of dentures have adjustment at recall visit Again the same thing at recall you examine denture bearing area oral hygiene occlusion ulcers and hyperplasia and you ask the pt if there is any complains regarding the denture. adjustment The end. sorry for any mistakes I try my best >>>>>Done by Seba M.Basheer Hawass Hadeel abud el-razaq
.................................................................... . ................................................................................................ .......................................................................... ........................................................................ ................................................................. ................................................................... ....................................................................... ........................................................................... ..................................................................... ........................................................................ ...........................................................................
__ __ ___

Special thanks to Lilo and to ablah nazerah(Ranoon) and RawanOoo