Making Dentures --- Third Appointment

[Darya]

I'm making my first set of dentures and could use some tips! I'm trying to prepare as much as possible for the third appointment. The Rpros faculty:student ratio in our school is not great and I'm affraid I won't be getting much help in the clinic, therefore seeking help here.

I've been reading up my notes on adjusting the occlusal plane using the fox plane, determining the VDO, VDR and CR and facebow transfer and selecting teeth, but it would be great if I could get some advice.

In what order should these be done? What is the best and fastest way of doing them? How do you select the right teeth???? right shade??? Any tips that would make my life easier would be greatly appreciated 🙂

Pleaaaaaaaaase help!

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[Istr8nthem]

I'm making my first set of dentures and could use some tips! I'm trying to prepare as much as possible for the third appointment. The Rpros faculty:student ratio in our school is not great and I'm affraid I won't be getting much help in the clinic, therefore seeking help here.

I've been reading up my notes on adjusting the occlusal plane using the fox plane, determining the VDO, VDR and CR and facebow transfer and selecting teeth, but it would be great if I could get some advice.

In what order should these be done? What is the best and fastest way of doing them? How do you select the right teeth???? right shade??? Any tips that would make my life easier would be greatly appreciated 🙂

Pleaaaaaaaaase help!

When I was in dental school I always asked my patients to bring in an old photo of them smiling with natural teeth if they had a photo. You can then see what looks natural on the patient. Tooth shape, size, lip line, tooth show on smile, etc. I can't comment on tips for the actual facebow transfer, etc because I am an ortho not a prostho and I am going from what I know to be esthetically and functionally important and forget the step by step procedure I learned in D-school, but it was definitely nice to get the patients perspective of what they like/dislike based on a past photo or old dentures. The patients significant others can also be a help for helping with big decisions like these as they will be the one's staring at them all day everyday! Just my two cents.

 

[charlestweed]

At this point, you should have 2 master casts, upper and lower acrylic plates with pink occlusal wax rims.

Facebow record: use the upper acrylic plate with occlusal wax rim and the facebow to mount the upper cast to your articulator (make sure you make 3 V notches on the base of the master casts before you mount)

VDR determination:
1. mark 2 points on the pt’s face: one on tip of pt’s nose and one on the pt’s chin
2. Ask pt to relax, and measure the chin-nose distance
3. Adjust both upper and lower wax rims so when the patient bites down on these 2 wax rims, the chin-nose distance will be the same as step #2 above.

VDO determination: VDO should be approx 2mm less than VDR ( VDO= VDR - 2mm). There are other ways to obtain the VDO (ie closest speaking space) but I think this is the easiest way. Once you get the VDO, mount the lower cast to your articulator

Lastly, measure the inter-canine width and mark them on the facial of the upper wax rim. You can use pt’s old photos as Str8them pointed out.

If you are off on the VDO you can still readjust it during teeth try-in appointment and remount the lower cast.

By choosing the monoplane posterior teeth, you can get balanced occlusion easier.

Good luck

 

[platinumcaps]

At this point, you should have 2 master casts, upper and lower acrylic plates with pink occlusal wax rims.

Facebow record: use the upper acrylic plate with occlusal wax rim and the facebow to mount the upper cast to your articulator (make sure you make 3 V notches on the base of the master casts before you mount)

VDR determination:
1. mark 2 points on the pt’s face: one on tip of pt’s nose and one on the pt’s chin
2. Ask pt to relax, and measure the chin-nose distance
3. Adjust both upper and lower wax rims so when the patient bites down on these 2 wax rims, the chin-nose distance will be the same as step #2 above.

VDO determination: VDO should be approx 2mm less than VDR ( VDO= VDR - 2mm). There are other ways to obtain the VDO (ie closest speaking space) but I think this is the easiest way. Once you get the VDO, mount the lower cast to your articulator

Lastly, measure the inter-canine width and mark them on the facial of the upper wax rim. You can use pt’s old photos as Str8them pointed out.

If you are off on the VDO you can still readjust it during teeth try-in appointment and remount the lower cast.

By choosing the monoplane posterior teeth, you can get balanced occlusion easier.

Good luck

Wow. I would hate to remount. Is there a good way to get the rims to the right height to be ready for mounting the lower?

 

[HupHolland]

1) Adjust maxillary rim first. Try it in the patient's mouth, making sure that the rim is parallel to the interpupillary/frankfurt planes using the fox plane. Adjust as necessary. Next, adjust rim to obtain proper lip length. When saying f-sounds (ex: fifty five) the inferior border of the rim should just barely touch the wet-dry border of the lower lip. After adjusting length, examine the patient's profile ensuring that there is adequate upper lip support. Adjust as necessary. Mark midline using buffalo knife.
2) Record rest vertical dimension. Mark a dot on the nose, a dot on the chin. Have the patient say "Emma" a number of times, measuring the distance between the two dots--the lips should be barely touching or slightly open. Have the patient repeat saying Emma until you consistently get the same measurement.
3) Try in mandibular rim. Adjust the height of this rim so that when the pt occludes that distance between the 2 dots (on nose and chin) is 3mm less than rest vertical dimension. Verify mandibular rim height by having patient say s-sounds (ex: sixty six). The rims should just clear each other in the premolar region.
4) Take facebow record of maxillary rim.
5) Take CR record to record relationship of maxillary to mandibular rim.
6) Select teeth.
7) Mount case on articulator. If you have spare time, take a verification CR record to make sure your record is accurate.

Hope this helps...
Hup

PS: just realized that this thread is over a year old. Thanks, platinumcaps.

 

[mike3kgt]

1)
Hope this helps...
Hup

👍👍
Good resource. Only thing I would add is that ideally you should use a fox plane to orient the maxillary rim to Camper's plane (Ala/Tragus).

You should ALWAYS reconfirm CR/CO with teeth present because wax rims only get so close but cusps are much better for accuracy.

Monoplane teeth are ugly... stick with lingualized occlusion and you won't go wrong.

What I would do is go out and get a Boucher's or Rinn/Heartwell denture book and read it over.

 

[OceanDMD]

At this point, you should have 2 master casts, upper and lower acrylic plates with pink occlusal wax rims.

Facebow record: use the upper acrylic plate with occlusal wax rim and the facebow to mount the upper cast to your articulator (make sure you make 3 V notches on the base of the master casts before you mount)

VDR determination:
1. mark 2 points on the pt’s face: one on tip of pt’s nose and one on the pt’s chin
2. Ask pt to relax, and measure the chin-nose distance
3. Adjust both upper and lower wax rims so when the patient bites down on these 2 wax rims, the chin-nose distance will be the same as step #2 above.

VDO determination: VDO should be approx 2mm less than VDR ( VDO= VDR - 2mm). There are other ways to obtain the VDO (ie closest speaking space) but I think this is the easiest way. Once you get the VDO, mount the lower cast to your articulator

Lastly, measure the inter-canine width and mark them on the facial of the upper wax rim. You can use pt’s old photos as Str8them pointed out.

If you are off on the VDO you can still readjust it during teeth try-in appointment and remount the lower cast.

By choosing the monoplane posterior teeth, you can get balanced occlusion easier.

Good luck

This is the basic order, just a couple tips to add. When you make those marks, just take a tongue depressor, when the patient is relaxed, use the tongue depressor to record the marks. Now you have a tongue depressor with two marks, the distance between them being the VDR. Adjust to VDO accordingly. I personally like to get the planes perpendicular first (all with using a tongue depressor. Lay that thing flat against the wax rims, adjust until it parallels the interpupillary line. Then get your appropriate lip support, appropriate length (ie the younger they are, the more maxillary incisal edges they show. The older and the sex of the patient determines this as well). You also want the rim (the best you can) to follow the lower lip line. This gives you an idea about how much wax to remove from the posterior teeth (again all done with maxillary rim). Once you get the esthetics of the upper rim, you remove wax from the lower rim accordingly to get the correct VDO and position of mandibular teeth. All thats left is facebow (which I do not take in private practice) and bite reg. Dont forget to mark midlines and position of distal edge of canines.

 

[mamelons]

Another thing that helps if you are fortunate enough... is if your patient had some teeth before you started the dentures, take upper and lower alginates before the remaining teeth are extracted. Then use this as a "pre-extraction" record. This helps determine size, shape, etc when you are finally choosing denture teeth.

As far as monoplane vs. lingualized, it depends on the patient. Is the patient a first-time denture wearer? If so, having cusps on the teeth is better if their teeth have been recently extracted because it will be the closest thing to their real teeth. If the patient has existing dentures, you should not change the occlusal scheme because it is something they are used to. It would be very difficult for a patient to go from monoplane to lingualized and vis versa. We have been taught to not change the occlusal scheme. Other factors to consider... if the patient has difficulty reproducing CR, monoplane is the best. Also, if the patient has a history of TMD prior to losing all of their teeth, monoplane is recommended. One of my denture patients this year had bad TMD... jaw sometimes locked in place, extensive nighttime bruxism... the remaining teeth prior to extraction were worn down from grinding... I even had to post-pone my master impressions because my patient presented with a huge ulceration of the UR quadrant from grinding the gums together. Needless to say, the OVD was very short. TMJ inflammation caused difficulty in reproducing CR. Had to do two clinical remounts... so anyways, I obviously went with monoplane in this case. Fortunately my patient was asymptomatic (first time denture wearer) at the 24 hr and 1 week postplacement appts... did a phone consult last week (1 month post placement) still asymptomatic. I'd have to say it was a lucky outcome. Anyways, my point is (after all my rambling)... that even though lingualized teeth exhibit better esthetics, there are certain indications for using monoplane, no matter how much better the lingualized teeth may look. What I have also found, is that most denture patients are so happy to just have teeth, many of them wouldn't know the difference between lingualized and monoplane... they are happy to smile and eat again.

 

[mike3kgt]

Anyways, my point is (after all my rambling)... that even though lingualized teeth exhibit better esthetics, there are certain indications for using monoplane, no matter how much better the lingualized teeth may look. What I have also found, is that most denture patients are so happy to just have teeth, many of them wouldn't know the difference between lingualized and monoplane... they are happy to smile and eat again.

While removable is many times a "religious" discussion rather than one of hard science, I will do my best to back up my experience and understanding of literature with evidence.

Note: your justification of monoplane occlusion is spot on correct in your post, however, the two cases you listed are prime examples of when to use a non-anatomic occlusion (1. variable/non-repeatable centric position, 2. extreme parafunction). I do take a little issue with your last statement about patients just being happy with teeth. I find that MOST patients are esthetically and phonetically aware... in fact, I feel much more comfortable when a patient tells me up front that they would like their teeth to look a certain way, rather than "doc, just do your best because I don't care how they look or work."

Monoplane works just fine, but are darn ugly and are less efficient. For a good summary, see the pics I posted. Note: Neutrocentric = Monoplane

1st Table ref: Rhan AO, Heartwell CM. Textbook of Complete Dentures. 5th Ed, 1993.

2nd/3rd table ref: Becker CM, Swoope CC, Guckes AD. Lingualized occlusion for removable prosthodontics. J Prosthet Dent. 1977 Dec;38(6):601-8.

Further more:

A Contemporary article:
Sutton AF, McCord JF. A randomized clinical trial comparing anatomic, lingualized, and zero-degree posterior occlusal forms for complete dentures. J Prosthet Dent. 2007 May;97(5):292-8.

STATEMENT OF PROBLEM: There is a lack of evidence to recommend a particular type of posterior occlusal form for conventional complete dentures. PURPOSE: The purpose of this study was to compare subject satisfaction with 3 types of posterior occlusal forms for complete dentures in a randomized cross-over controlled trial. MATERIAL AND METHODS: For each participant (n=45), 3 sets of complete dentures were fabricated, each of which had a different posterior occlusal form (0-degree, anatomic, and lingualized). Each set was worn for 8 weeks in a randomized order. Subjective data were collected using the Oral Health Impact Profile 20-EDENT (OHIP-EDENT). The Wilcoxon statistical test was used to compare differences between the groups (alpha=.05). RESULTS: Lingualized posterior occlusal forms were perceived to be significantly superior in terms of painful aching in the mouth (P=.01), sore spots (P<.001), eating ability (P=.02), and meal interruptions (P=.008), compared with 0-degree posterior occlusal forms. Subjects with anatomic posterior occlusal forms had significantly fewer problems eating (P=.05) compared with 0-degree posterior occlusal forms. There was no significant difference found between the lingualized and anatomic posterior occlusal forms. CONCLUSIONS: Participants provided with complete dentures having lingualized or anatomic posterior occlusal forms exhibited significantly higher levels of self-perceived satisfaction compared to those with 0-degree posterior occlusal forms.

A Classic article:

Clough HE, Knodle JM, Leeper SH, Pudwill ML, Taylor DT. A comparison of lingualized occlusion and monoplane occlusion in complete dentures. J Prosthet Dent. 1983 Aug;50(2):176-9.

Summary: Two sets of dentures, one with lingualized occlusion and the other with monoplane occlusion, were made for each of 30 edentulous patients. Sixty-seven percent of those people preferred the lingualized occlusal scheme because of improved masticatory ability, comfort, and esthetics.

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According to Parr and Ivanhoe : Lingualized occlusion is "an occlusion for all reasons." (Parr GR, Ivanhoe JR. Lingualized occlusion. An occlusion for all reasons. Dent Clin North Am. 1996 Jan;40(1):103-12.)

I'd venture to say that it's an occlusion for most reasons... there are some cases that call for anatomical teeth and others that call for monoplane. Myself, however, I always go with lingualized at first and vary occlusion based upon presentation factors such as those listed in the tables.

 

[cuneatus2]

At this point, you should have 2 master casts, upper and lower acrylic plates with pink occlusal wax rims.

Facebow record: use the upper acrylic plate with occlusal wax rim and the facebow to mount the upper cast to your articulator (make sure you make 3 V notches on the base of the master casts before you mount)

VDR determination:
1. mark 2 points on the pt’s face: one on tip of pt’s nose and one on the pt’s chin
2. Ask pt to relax, and measure the chin-nose distance
3. Adjust both upper and lower wax rims so when the patient bites down on these 2 wax rims, the chin-nose distance will be the same as step #2 above.

VDO determination: VDO should be approx 2mm less than VDR ( VDO= VDR - 2mm). There are other ways to obtain the VDO (ie closest speaking space) but I think this is the easiest way. Once you get the VDO, mount the lower cast to your articulator

Lastly, measure the inter-canine width and mark them on the facial of the upper wax rim. You can use pt’s old photos as Str8them pointed out.

If you are off on the VDO you can still readjust it during teeth try-in appointment and remount the lower cast.

By choosing the monoplane posterior teeth, you can get balanced occlusion easier.

Good luck

I don't think Beumer could have said it any better himself!

 

[Dr. Dai Phan]

When I was in dental school I always asked my patients to bring in an old photo of them smiling with natural teeth if they had a photo. You can then see what looks natural on the patient. Tooth shape, size, lip line, tooth show on smile, etc. I can't comment on tips for the actual facebow transfer, etc because I am an ortho not a prostho and I am going from what I know to be esthetically and functionally important and forget the step by step procedure I learned in D-school, but it was definitely nice to get the patients perspective of what they like/dislike based on a past photo or old dentures. The patients significant others can also be a help for helping with big decisions like these as they will be the one's staring at them all day everyday! Just my two cents.

Greetings,

Unless patient INSISTS on bringing in the photo or so called "pre-extraction records", I would not even bring the subject up. Why? Because of these main reasons:

1. The positions of the teeth 10, 15, 20 years ago cannot be duplicated today because of the ridges resorption process. Therefore the artificial teeth position will have to different from the natural position. Trying to duplicate the position decades ago without regarding to ridges position will ensure the case to fail.

2. Facial profile changes as the person ages. The person may not be able to have that big smile today as she did 30 years ago. That is because the skin saggs downward as time go by and makes the maxillary teeth less apparent. Have you seen Jimmy Carter smile lately?

3. What patient had with their natural teeth may not be what is best for the patient. If the patient was born with big, long teeth that did not look good on her, then why do you want to duplicate that?

The best option is to ask patient if they have any special request but don't insist on them to bring in old photos. That will bring nothing but pure frustration. DP

 

[Dr. Dai Phan]

I'm making my first set of dentures and could use some tips! I'm trying to prepare as much as possible for the third appointment. The Rpros faculty:student ratio in our school is not great and I'm affraid I won't be getting much help in the clinic, therefore seeking help here.

I've been reading up my notes on adjusting the occlusal plane using the fox plane, determining the VDO, VDR and CR and facebow transfer and selecting teeth, but it would be great if I could get some advice.

In what order should these be done? What is the best and fastest way of doing them? How do you select the right teeth???? right shade??? Any tips that would make my life easier would be greatly appreciated 🙂

Pleaaaaaaaaase help!

Hello,

If you come here to get help because you do not get adequate supervision from your DS, then there is a SERIOUS flaw in your institution. You need to speak to your Department Chair on your concern or track down your professor and make him/her spent some time with you. That what your are paying for so make the school deliver that to you. DP

 

[OceanDMD]

Hello,

If you come here to get help because you do not get adequate supervision from your DS, then there is a SERIOUS flaw in your institution. You need to speak to your Department Chair on your concern or track down your professor and make him/her spent some time with you. That what your are paying for so make the school deliver that to you. DP

Nahhhh. Why not come here to get the shortcuts from some of the practicing dentists who post ideas?....😉