A PRECISION DENTURES

WILFRID

TECHNIQUE THAT FIT

THAT PRODUCES AND FUNCTION D.D.S.

TERRELL, Calif.

Pasadena,

HIS paper is not an analysis of various methods of denture construction, but is a presentation of a particular technique given in as much detail as space will allow. Though you have your own method of construction, it is always interesting to see how someone else does it, and I hope there may be a few points given which you can at least add to your own procedures to advantage. There are many good techniques.

There has been a gradual progress in the development of materials and instruments available for denture con$ruction, and also an increased understanding of the important factors necessary for consistent results. Exchange of ideas does much to stimulate progress. The dentures we make today should be better than those we made even five years ago. Let us see to it that progress never stops and that we never allow ourselves to reach the point where we feel there is no room for improvement and that we can learn nothing more. Thus, science, medicine, and It is important that we all have some dentistry will continue to progress rapidly. definite procedure for denture construction which we know will produce results tha.t are excellent and follow it consistently. Short cuts in construction are usually very expensive, for too much time will be used later in adjustments. The ideal It denture is one which fits the patient comfortably with a maximum of retention. should have perfect balance, with teeth that are sharp enough to cut food. There should be coordination of function with esthetics, with sufficient study given to each case to produce a natural effect that is not detectable as being artificial. The accuracy of our work will show up in the limited number of adjustments which will be Satisfied required. This means more return per hour and better satisfied patients. patients are our practice builders.
FIRST APPOINTMENT

Examination
This appointment is a most important one, for it is at this time that we decide whether or not we want the patient, and the patient is deciding whether or not we are to be his or her prosthodontist. First, a thorough examination of the mouth is made to determine the favorable and unfavorable factors of the case. These should be noted and brought to the patients attention. This should be followed by a consultation with the paiient in order to ascertain a complete case history. From this we will
Read at the Twelfth Australian Dental Congress at Sidney, Australia, Reprinted from the Dental Journal of Australia 22:484, 1950. Received for-publication March 22, 1951.
353

August,

1950.

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learn much. We will learn why previous work has not been satisfactory and whether it was the dentists fault, the patients fault, or the fault of the rnoutll. 1\!c should 1~ studying our patients during this consultation and decide whethel or not we want them. It is much easier to get undesirable patients than it is to get rid of them. To be a successful prosthodontist we must choose our patient5 This does not mean to take and take only those we are convinced we can satisfy. only the easy ones. There is a satisfaction that is much greater than average in satisfying difficult patients. Holrever, all patients must be analysed. Some arcseeking the impossible and they arc: tloomcd to disappointment if they cannot be educated to their limitation. trosthodontists are not miracle men. It is well to These should bc !ist on the patients charts the favorable and unfavorable factors. discussed with the patients, and no impossible promises should be made. WC should call to the patients attention the difficulties of their cases, and impress upon theln their limitations. After this discussion and examination ne should decide upon the fee WC \vill require to do the work. This necessarily must vary with all cases, and no fees can be set which will be fair to us or the patients until this appointment has been completed. If we accept the neurotic type we should make him pay for the grief lie will give us. The secret of success in prosthetics, aside from the ability of the operator, is a thorough analysis of patients. It is impossible to have a fixed fee for denture service that is fair. This must bc determined for each individual patient. We should have a minimum and a maximum fee and determine what we nlust have for each case after a thorough stud) of all factors. We should not overlook the psychologic factor, for this is probably the cause of far more failures than the inability to build a good set of dentures. If the fee is accepted, it is better to require half down when the work is started and the balance on completion. If our patients have an investment in what we are doing they will be much more cooperative, since dentures that are paid for arc always more satisfactory. Time payment is not very satisfactory in handling denture patients. Let them save up the money in advance if they want IIS to do the work. We then make a weekly schedule of appointments and we try, where I)ossible, if the patients so desire, to give them appointments at the same hour on the same days of each week.
SECOND APPOINTNENT

Primary

Impression

The subject of impressions requires more detailed discussion than some other parts of the technique, though it is only one link in the chain and no more important to success than any others. There is considerable confusion in the minds of many dentists as to what is the best impression procedure. There have always been two schools of thought, one believing in compression, if this is possihle, and the other in making impressions with the tissues at rest. Examples are the so-called mucostatic methods, or methods involving compression of tissue. Mucostatics is not new, for there have been

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many impression methods used by our preceptors which involved this same principle I cannot of making impressions of the tissues in a static or at rest condition. however, with the followers of the mucostatic technique, that peripheral agree, borders should be arbitrary in extension and knife-edge in thickness. Neither do I agree that metal bases are always indicated. I make both acrylic and metal bases, and I think each has its place. There is no remedy that will cure all ills, Neither is one particular metal only the and metal bases are not always desirable. Furthermore, mucostatics is not a guarantee answer where metal is indicated. Many other factors must enter in. I do agree with the of a successful denture. mucostatic principle of making an impression, providing it covers all the available stress-bearing area and has a peripheral border which has been formed by the tissues. Several years ago we found that in the cases we rebased we had practically no adjustments to make, the dentures were more comfortable, the retention was better and seemingly more permanent. We were taking these impressions with the tissues at rest, and there was no attempted compression which would give us distortion or displacement. Now, all our impressions are taken in this manner, and the results speak for themselves. The primary impressions can be made with various materials and trays. The material selected should be quite soft so as not to distort the tissues, but should have enough resistance to carry it slightly beyond the denture base area and get a good impression of all the pkripheral areas. We should use a material that we It is imcan handle well, and only one insertion of the tray should be required. portant that the proper tray be selected as to size and shape before this impression is made. Throughout this technique a choice of materials and equipment will be given, as it is more important how you use them than which one you use. I will mention the materials which I use, but this does not mean that you cannot use others and get good results. The physical properties of any other materials used should be similar to these. The materials that can be used for primary impressions are : (1) Muco-Seal, (2) alginates, (3) hydrocolloid, and (4) impression compound. Our primary impressions are taken with Muco-Seal in plastic trays which we made in the laboratory (Fig. 1). They are anatomic trays which cover the lateral throat form, the retromolar pad, and curve outward and up to get the external oblique ridges without cutting through the impression material. Alginates or hydrocolloids may be used in these trays, as they have rim lock borders for retaining the impression material. These trays can be made by reshaping and adding wax to standard S. S. UJhite aluminum trays to be used as patterns. It is important to have a tray that will carry the material to the desired areas. Muco-Seal is an acrylic resin which comes as a powder and liquid. When mixed, it is used in a very moldable or plastic form. It does not compress tissues, but it does get a beautiful impression of all denture base areas, and will spring otlt of the undercuts (Figs. 2 and 3). The detail is picked up in the final impression. Alginates or hydrocolloids may also be used. It is necessary to be careful that they flow up around the tuberosities, and that they do not trap air in vital spots along

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J. Pros. Den. July, 1951

the borders. Compound may be used if undercuts are not severe, and if it is softened sufficiently. Good primary impressions are just as important to the final results as good final impressions. At this same appointment, the molds and shades of teeth are selected. The plan for natural effects is made by mixing shades and molds, if desirable, and deciding upon a characteristic setup for the type of individual. The advisability of art work to be done on the porcelain teeth with stains and glazes should be studied and outlined. All of these may be varied as the case progresses, for esthetics is a very important part of denture work and one that is often neglected
OUTLINlNG BASES ON CAYi%

The upper cast is outlined just to the point where the check begins to reflect. If overextended, the final impression will he cut through to the tray in places along the border, and this will have to be corrected before the final impression is made.

Fig.

I.-Primary

trays

made

of plastic.

The lower must be very carefully outlined, not to be overextended on the border, and yet to cover all areas necessary for retention. The best final impression cannot he made by this method, if the base is not correct. Beginning at the distohuccal extremity, we follow forward on the external oblique ridge. This fades into the lateral surface of the mandible in the bicuspid region. As on the upper, the outline must follow close to the vertical surface of the mandible, the line where the reflection outward begins. Care must be taken to clear the attachment of the buccal and labial frenula. On the lingual, beginning at the distal, the outline crosses the distal of the retromolar pad and extends around in the arc of a small circle to the point where this intersects the distal end of the mylohyoid ridge (Fig. 4). There is no attempt made to utilize all the apparent area available here.

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The outline then extends down the mylohyoid ridge, extending not more than 2 mm. over it. This is the rule, but the exception will allow in some cases for These cases are those where there the extension to go to the floor of the mouth. The are no undercuts beneath the mylohyoid ridges, and the mouth is shallow. primary impression from which the lower cast was made gave an impression of

Fig.

2 .-Primary

upper

impression.

Fig.

3.-Primary

lower

impression.

the floor of the mouth at rest, covering that area which extends from the lowest point, which is in the bicuspid regions forward to the lingual frenum at the midline. This space is utilized for retention, adding much to the comfort and utility of the lower denture. The lower denture should be made thicker in this area (Fig. 5).

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Uen.

A great deal of care must he taken with the impressions and the outlining of the cases, or all value will be lost. There are two places to watch closely. One is the two papillae forming the opening For the sublingual glands; the other is the lingual frenum. These are the only places that are likely to develop soreness, and this can be very severe if not observed in time. All outlines on upper and lower casts nre scratched with a sharp instrument so the technician can see where t(J trinl the borders of the acrylic bases.
ACRYLIC BASES

The acrylic bases not onl; serve as our impression trays, but also are used ior ohtaining : ( 1) vertical opening, (2) approximate centric, (3) check bites to obtain the maxillomandibular relationship, and (4) bases on which to set up the teeth and try them in. They are waxed up on the casts with a full thickness of baseplate wax and then reinforced around the border and across the distal and

Fig. 4.-Lateral I____^.. ^l^-&__-^ ---^1-

ide view I_^ m-

of a typical -1. ____^1.1_

Fig. .?--&~...-

B.-Lingual

view

of a typical

lower

slightly to the lingual of the ridges (Fig. 6). They should be rigid when completed. They are made of denture acrylic and cured in the same manner. It is not necessary to give them a long slow cure as there is no bulk of material, and they are only for temporary use. They may also be made of the self-curing tray acrylic in about thirty minutes. After curing, the bases should be trimmed to the bead which has resulted from scratching the cast along the line which was drawn to determine the border outline. 1Vax rims are added, and they are then ready for the next appointment,

Vertical opening is not determined by any rule, but by judgment of the operator. Currently, there is much said about freeway space and the rest position of the mandible. The space between the wax rims, when the patient is speaking,

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It is well to observe the patient during should be approximately 2 millimeters. speech, and if the wax rims should contact on certain words, they should be reduced in height. If the space should be more than 2 mm., the rims should be lengthened.

Fig.

B.-Wax-up

for the plastic

impression

base.

Fig.

7.-Wax

bite blocks

for obtaining

the vertical

opening

and approximate

centric

relation.

Have the patient count from one to ten, first slowly, and then rapidly, and observe the space between the wax rims. Th e esthetics of the case when the patient has the rims in contact is an aid, but it should be remembered that there should be this freeway space allowed when the mouth is in repose. To build the wax rims so they contact at the desired esthetic vertical opening would be giving the patient

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too great a vertical opening (Fig. 7 ,I. The length of the teeth for esthetics can hc varied by the overjet and the overbite, but correct vertical opening has to do with comfort when the mouth is in repose. during speech, and when the dentures are in function. If the dentures are firmly in place, the teeth should never contact at an! time during speech. Some attempts have been made to determine vertical opening by finding that point at which the patient can produce the greatest amount of ljitittg pressure. There are other methods which attempt to establish the opening t)? dividing the face into thirds, establishing the lower third of the face equal to each of the other thirds. This, in some cases, will work, but in many patients these proportions would not be correct. From at: esthetic standpoint we cannot make our patients all fit a rule. By establishing a freeway space between the wax rinls

Fig. S.-Instruments used for obtaining vertical opening. Curved pooling instrument designed by Dr. M. M. House. Sorenson bite gauge measurements in obtaining the vertical opening.

hot used

plate anc~ wax for comparative

and observing the patient for a considerable time during speech, we can come very close to determining a vertical opening which will not only be comfortable but also The wax rims are reduced by means of incorporate the esthetic requirements. a curved hot plate (Fig. 8) until they contact at the desired height. This vertical opening which has been carefully established will be carriecl through to the finished case by means of the articulator used. Tt must have an incisal pin or a definite vertical stay in order to preserve this opening. The method used to obtain centric closure is to tilt the chair horizontally with the head well back. First, the patient is instructed to move the mandible forward and backward until a slight thud is felt or heard as the condyles hit the back of the glenoid fossae. This is practiced with the wax rims slightly separated as the mandible is moved forward and backward. After notching the upper rim and pooling the lower wax rim with a hot pooling instrument, the bases are placed in the patients mouth and the mandible moved forward and backward as before. By pressing very lightly on the tip of the chin you can feel the condyles reach the back of the glenoid fossae. Stop the patient

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at this point, instructing him to roll the tongue as far back in the roof of the mouth as possible and gently close. The soft wax in the center of the lower rim will key itself to the notches in the upper (Fig. 91, but do not let the patient decrease the

Fig. S.-Wax

rims

keyed

together

in approximate

centric

relation.

Fig.

lO.-Heater

for

impression

gel.

vertical opening by applying pressure to the rims. \Vhen cooled, have the patient close with a slight tapping motion, and it will be noted that closure is always at the same point. At this-time it is well to mark the median line on the wax rims before they are removed.
THE UPPER IMPRESSION

The upper impression is made by painting the tissue surface of the impression base with the material selected for the impression. There are several materials We which could be used as long as they have the essential physical properties.

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J. Pros. Den. July, 1951

become familiar with the use ot certain materials, and when we change to another it is often difficult to get a good result until we have had considerable practice with it. The material which we select fcJr this purpose should be one which will flow readily in the mouth, one which will not distort or displace tissues, and one which will accurately copy the surface detail of the tissues. Selection of the material should be determined by the accuracy with which it reproduces the surface anatomy of the tissues combined with the ease with which it can be used by the operator. Most of the zinc oxide eugenol impression pastes will serve this purpose very Lvell, though they are somewhat difficult to use. The material I am using at present is one which flows very readily. It is called Indicator Gel (Fig. 10). It softens when heated, and when it is chilled becomes quite firm. It will not stick or adhere to the tissues and can be removed easily from the base if the first insertion is not satisfactory. It is also possible to surface heat it with a spot heating torch or add to it. We use it not or$y for the final impressions, but also for relining and rebasing and for locating pressure spots under dentures. It is not foolproof, and requires some,skill in its use, but the results will justify the care required.

Fig.

Il.-Final

upper

and lower

impressions.

This material is brushed on the inSide of the acrylic impression base. A spot heating torch or jet of steam is then used to smooth the surface and eliminate bubbles. The impression is guided lightly to place, and the patient is instructed to open the mouth wide while the impression is steadied by the operator, All the muscle trimming that is done around the upper is just a gentle inward and downward pressure against the tissues ot the cheeks and lip: so that the borders are not thickened and the border tissues are not displaced. It is then chilled before removal (Fig. 11) . It is easy to correct any point which may have failed to obtain a good impression by heating it and then adding a cttle of the impression material. This is again heated and placed in the mouth. We have added a third step to our impression technique which completely eliminates the old trial-and-error method of building peripheral borders which With compound, no two impressions of the has been used for so many years. same mouth would be identical on the peripheral borders, but by this method of obtaining the peripheral border, a number of impressions of the same mouth will

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be the same. The final impression of the peripheral border is obtained by the use For the best retention of of Truplastic, soluble plaster or impression plaster. In addition to this, upper dentures, we must have perfect tissue adaptation. we must have an accurate peripheral border and a good seal across the posterior. This sounds obvious, but a careful analysis of dentures with which patients are reporting difficulty with retention will show that it is a failure in one of these three points. To have maximum retention, the peripheral border should include all of the space in the buccal and labial reflections, from tuberosity around to tuberosity. However, it must not be thick enough to interfere with muscle function. Dentures which require very little adjustment do not just happen, but are the result of a careful, accurate impression technique, coupled with a balanced occlusion.

Fig.

12.-Skull

showing

the

Hamular

notch.

The chair is now tilted horizontally with the head well back, and the impression is made of the periphery by applying a very small amount of the special impression plaster around the peripheral border by means of a cement spatula. Place wet cotton rolls between the wax rims and have the patient close firmly. The cheek is held out, and the Truplastic is placed high up in the buccal fold around the tuberosity area, coming forward to the cuspid area, across ihe anterior, and back to the tuberosity area on the opposite side. The chair is next placed in an upright position. The patient is instructed to bring the lips together firmly moving them forward and backward. With the patient relaxed, the thickness of the peripheral border is molded by gently pressing inward and downward. The border should be so perfectly molded that it will not be necessary to trim the finished denture. The post damming is not done on the impression, but always on the cast. If the impression of these tissues has been taken with them at rest, we can apply our seal across the posterior border by grooving the cast the desired depth,

TERRELL

J. Pros. Den. July, 1351

and we can control exactly the pressure to be applied. In order to have a gootl post darn, it is not necessary to cotupress this tissue to a maximum as is often done by the post damming techniques employing modeling compound. After the upper denture impression is completed we mark the hamular notches (Fig. 12 ) with an indelible pencil and connect these with a line which usually passes through the palatal foveae. We observe, by having the patient say ah and thus flexing the soft palate, just where the post dam should be placed. The compressibility of

Fig.

13.-Upper

casts showing

the post dam and palatal

seal.

Fig.

14.-Palatal

view

of a skull.

this tissue is then tested. The post dam should always be placed on the immovable compressible soft palate, but should not extend distally on to the flexible soft palate. A post dam accurately placed and carefully done should never require adjustments. Besides the post dam, we have added an additional sea1 which we term a palatal seal (Fig. 13). This has been used for several years now, giving considerable additional retention to the upper denture and with no detrimental effects. It extends forward, on either side from the posterior palatine area, in that soft tissue between the hard palate and the base of the ridge (Fig. 14). This tissue

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should be palpated with a large ball burnisher, and a line drawn with an indelible pencil along the area of greatest compressibility, stopping when it reaches the noncompressible tissue in the rugae area. This will add much to the retention of the upper denture. After having marked the post dam and palatal seal, we replace the upper impression, getting a transfer of the lines on the impression. With a sharp pointed instrument we scratch a line along the mark so that it will be transferred to the final cast that we may know exactly where these seals are to be placed. The depth of the seal which is placed on the cast with a No. 8 round bur should be between one-fourth and one-half the diameter of the bur. If it should he too deep it could be polished off in the finished denture, but a little practice will show the amount the average mouth will require, If done properly, there will be no soreness on the post dam or the palatal seal, and the retention will be greater than any you have ever known without the addition of this step (Fig. 15 )

Fig.

15.-Palatal

view

of gold

upper

denture.

Retention obtained in this way will remain much more permanent than retention obtained by increasing the pressure around the peripheral border. Soft flexible tissues do not change by the addition of slight pressure, but hard tissues will soon resorb and cause a loss of retention. Remember to place the seals in the correct places by transferring these lines from the mouth to the impression, and not arbitrarily placing them on the cast with no guide to follow.
THE LOWER IMPRESSION

The technique for the lower impression is exactly the same as for the upper. The inside of the impression base is coated with a thin coating of the impression material. It is seated in the mouth without pressure and held by the operator with the mouth open wide while the material sets or chills. Upon removal, if the impression is satisfactory, we are then ready to apply the peripheral border in the same manner we did in the upper impression. If there are any places that need correction this should be done first. The difference between the lower impression

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J. Pros. Den. July, 1951

and the upper is that the tongue is on the lingual border of the lower, and a certain. amount of movement must be allowed for. While making the lower impressioll. we instruct the patient to raise the tongue and move it around as if to clear the buccal and labial spaces of food. We limit the movements of the tongue to this amount, and it is not necessary for the patient to extend the tongue out of the mouth or move it to the extremes. If we allow the full range of movement of tht: tongue, we will lose the lingual-peripheral adaptation (Fig. 16), and a great deal of our chance for retention on the lower denture will be lost. The reason the patient is instructed to hold the mouth open wide while the impression sets is so that the muscle pull of opening the mouth to the extreme will not dislodge the finished lower denture. When this part of the denture is satisfactory the impression is completed the same as the upper, by first having the patient close on wet cotton rolls and then placing a very small amount of the special impression plaster around the peripheral border to complete the bucco-labial-peripheral seal. We then appl!

Fig.

16.-Lateral

occlusal

view

of a typical

lower

denture.

inward and upward pressure on the cheeks and lower lips to mold the excess material away so there is no overextension. The peripheral borders as finished in this manner will be the exact contour of the peripheral borders of the finished dentures. The impressions are then removed and the casts poured. It is not necessary to box the impressions, though there certainly is no objection to doing this. With an indelible pencil, mark a line around the entire peripheral border of both upper and lower impressions, about one-fourth inch down on the outside of the impressions. This gives a line to which the stone is trimmed, just before it sets, so the thickness of the entire peripheral border will be reproduced. A good mix of cast stone is important. Thoroughly mix the stone according to directions, and then place it under vacuum to remove the air from the mix. It is then taken out of the machine, placed in a towel, and some of the moisture absorbed. It is important to have a good vibrator so this stone, which is quite stiff in consistency, can be vibrated carefully into the impression. If metal split cast plates

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are used, the cast half of the plates is placed on the bench, and stone is built up on it (Fig. 17). The impression is then inverted on this stone and gently The stone is vibrated down to make the base of the cast as thin as possible. then molded up around the outside of the impression so that it covers the indelible line. Just before the stone has set, the excess around the peripheral border is cut back to the indelible line. This serves the same purpose as boxing the impression, if it is carefully done. But, in order to do it this way, the stone must not be thin. We pour our casts on some squares of plastic, and as soon as the stone begins to set, they are placed under water until the stone is set. This is the same principle that is used when a cement sidewalk is kept wet while the cement is setting. The special impression plaster or Truplastic which is used to take the impressions of the peripheral borders should be painted with a coat of sodium silicate, or water glass, before the cast is poured. This will facilitate separation

Fig.

17.-Split These

cast remounting make accurate

plates which were designed remounting of the cases after

by the author. curing.

and will keep the plaster from absorbing moisture from the stone around the periphery, in the initial set. If metal split cast plates have not been used, the bases of the casts should be grooved before mounting them on the articulator. This permits the casts to be removed from the articulator, and again replaced after the dentures are cured. This makes it possible to correct any changes that occur between the time when the cases are flasked, and the time when they are removed from the flasks. When the cases are remounted on the articulator, it will usualiy be found that the bite is open from one-half to one millimeter. By use of the injection method, or by use of spring clamps, this change can be kept to a minimum, and a few will come out demonstrating practically no change. A small amount of opening dogs no harm; in fact, it is an advantage as it allows us to do the occlusal correcting and milling, and still complete the case at the original vertical opening.

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FOURTH

TERRELL APPOINTMENT

J. Pros. Den. July, 195 I

Recording

Maxillomandibular

Relationships

Many otherwise good cases have been ruined because of an incorrect centric relation. There are many methods of recording centric jaw relation. Before checkbites can be taken, the casts should be mounted on the articulator that is to be used. They are mounted in an approximate centric relation by means of the wax rims. The impressions should not be removed from the casts until this step has been completed. Be sure that the in&al pin of the articulator is set when they are mounted, so the vertical opening will be preserved (Fig. 18). The impressions are then removed from the casts, and bases are cleaned up, and the wax rims are

Fig.

18.--P.elationship

recorder

mounted

at the previously

determined

vertical

opening.

removed. All undercuts on the casts should be blocked out with wax, and these The casts are then tinfoiled, and undercuts removed from the plastic bases. the impression bases are coated with zinc oxide eugenol paste, and seated to place on the tinfoiled casts. This gives an exact reproduction of the tissues as they were recorded by the final impressions (Fig. 19 j . The relationship which should be recorded depends upon the articulating instrument which is to be used for the case. The more fully adjustable the instrument, the more valuable complete records will be. If your instrument has then the important thing to record is an no condylar adjustments, accurate centric relation at the required vertical opening. Other check bites or records would be of no value and a waste of time. If your articulator has condylar adjustments, such as the Hanau articulator and others of this type, it is important

Volume 1 Number 4

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to take records of centric and protrusive positions. If you are using a fully adjustable articulator such as the Coordinator, the House, the Stansbery Tripod, or the Gysi Trubyte Articulator, then all four check bites, centric, protrusive, right and left lateral, should be taken, and will be of value. Three of the instruments just mentioned, have, beside condylar adjustments, a Gothic arch control which works against the incisal pin. Here lateral check bites are valuable, for the instrument can be set to follow the patients lateral Gothic arch path. Before decicling which records to take, classify your instrument-nonadjustable, partially adjustable, or fully adjustable. With nonadjustable instruments, take centric records. With the partially adjustable instruments, take centric and protrusive records. With the fully adjustable instruments, take centric, protrusive, and right and left lateral records. It is possible to build good dentures by usin g any of the articulating instruments. The mouth can even be used as an articulator. The articulator does not determine the dentures, but it is the skill of the dentist and his adaptation of his

Fig. 19.-Relationship

recorder

designed by the author is used for taking plaster check bites.

knowledge in the construction of those dentures which is most important. The articulator is a valuable aid in the construction of dentures. The more fully adjustable the instrument is, the more is the refinement which can be put into the occlusion. You probably all have read of at least two men who have discredited the use of articulators, and in my opinion their essays have contributed nothing to the advancement of prosthetic dentistry. In fact, I think they have done much harm. They can undoubtedly build dentures without an adjustable articulator, as I think most any of us can. But that is no reason to discredit the man who will work to finer detail and build more accuracy into his cases by properly using an adjustable articulating instrument. I have no doubt that they believe they are right, but that does not make all others wrong. There are many roads that lead to Rome, and many right ways of building dentures. Though I do not consider it the best way to build dentures, some dentists prefer to use the mouth as an articulator. I will describe one way that this can be done.

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Assuming that the casts have been mounted on a hinge with a vertical stop in correct centric relation (I would prefer a Gothic arch tracing with a plaster check bite to determine this), the teeth are set up on a flat plane. They are then tried in the mouth, and a wax check bite is taken in protrusive. This is examined to see whether the anterior teeth and posterior teeth are contacting at the same time. If only the incisors touch, the curve in the molar region is steepened and another wax check bite is taken. As long as the teeth do not contact in the posterior at the same time as they do in the anterior, it means that the occlusal curve is not steep enough to harmonize with the patients condyle path. Ii there is three-point contact in all positions the dentures will be stabilized, but any set of dentures that does not have at least a three-point balance in all positions will continually be subjecting the base tissues to trauma. This will cause soreness, resorption of the

Fig.

ZO.-Plaster check to reproduce

bites used for setting the maxillomandibular

the coordinator relations.

controls

can balance a set of If you ridges, and a gradual loosening of the dentures. dentures, you can use the mouth as an articulator, and the end result may be very good. For most men it is more difficult to get a good result by this method than to use an articulator which is at least adjustable to protrusive position. The tcleth may be balanced accordingly on the instrument. JVhile a partially adjustable articulator may not duplicate all details of movement, it does serve as a caliper to show us the steepness of the condyle paths, at least. It also indicates how we must set the teeth to coordinate them with the patients jaw movements. The use of a fully adjustable instrument is, of course, a still greater aid, due to the fact that the teeth will articulate in the mouth, just as they do on the articulator if it has been properly set. This applies, however, only to the fully adjustable instruments, Regardless of what kind of an articulator is used, I prefer to use plaster check bites in combination with a central-bearing Gothic arch tracing, to secure centric relation,

PRECISION

TECHNIQUE

FOR

PRODUCING

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371

and the other check bites, if they are required (Fig. 20). This eliminates all guess work in securing a balanced accurate centric relation, and it is a means of adjusting any articulator to the required relationships for that instrument. The more fully . adjustable the articulator used, the less grinding will be required at the chair to It is a means of giving our correct the occlusion after the dentures are finished. patients dentures with a maximum of efficiency and comfort, providing good impressions have been taken. Fully adjustable articulators accurately reproduce the jaw relationship records. A check with articulating paper will reveal multiple cusp contacts in all positions both on the working and balancing side, and ver! seldom is it ever necessary to grind the occlusal surfaces of the posterior teeth when the dentures are placed in the patients mouth.

Fig. Z.--The new T Mold and the accentuated

posterior carvings

tooth. which

Note the possible eliminate recarving

multiple cusp contacts after milling.

FIFTH

APPOINTMENT

Setup Anterior

Teeth

At this appointment the anterior teeth are set up for esthetics and phonetics. Here again there is no rule, but the results will lie with the judgment of the operator in cooperation with the ideas of the patient. If the esthetics of previous dentures has been good, this can be used as a base upon which to improve. Never be satisfied until the new dentures look much better than the previous ones. There is no such thing as perfection here, and all dentures could be improved. In fact, to most patients, esthetics means more than the details of balanced occlusion. Dont allow yourself to get the reputation for dentures that fit and function alone without coupling with this a reputation for making the most natural and best

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looking teeth. One is just as important as the other. If you have no previous record of the patient to go by, it is important to have the patient look up any photographs which he may have, that were taken at any age when the permanent teeth were in place. Hy the use of a magnifying glass it is possible to determine the tooth form and arrangement from photographs which may have been taken many years before. Also, the use of advice from other members of the family is valuable in getting a setup which is satisfactory to the patient, and which looks to them as it should. After the anterior teeth are set to satisfaction, the posteriors are set up. At this point, I would like to describe to you the new posterior teeth which I have recently carved (Fig. 21). They are known as the T Mold. I have no interest in this tooth, except that I think it is giving us something we never have had before in posterior teeth. I have been using this tooth for some time now, and find it is giving my patients better function than they have ever enjoyed with previous teeth. Since artificial teeth function on ridges covered with a sensitive membrane, it seems they should be made as sharp as possible. They have to chew food with approximately one-tenth the pressure that is exerted on natural teeth. Artificial teeth of all types, after adjustment for balance in the finished dentures, have poor excuses for cutting surfaces. We have tried to recarve these surfaces with stones and diamond points, but the result was rather crude and not very effective. The T Mold was carved and balanced on the Coordinator. The grooves have been deepenedand sluice gates opened; the cusps have been sharpened and multiplied by the addition of supplemental grooves. After the wax teeth were cast in metal they were again mounted on the Coordinator and spot-ground and milled. These were then recarved and repolished. Several sets of teeth were carved in development before these final ones were perfected. The molds from which the teeth are being made are from these last metal teeth, and they are available in three sizes: large, medium, and small. The anatomy is so accentuated that spot grinding, if the teeth have been properly balanced, will not eliminate the cutting surfaces, and they require very little recarving after milling. They are slightly narrower buccolingually than natural teeth, thus lessening the pressure on the ridges. They are wider at the neck than most posterior teeth, thus eliminating food pockets, or the show of acrylic between the teeth. Best of all, they are easy to set up and balance, and they are efficient when finished.
SIXTH APPOIKTMENT

Final Try-In This appointment should be repeated as many times as necessary, but the patient should understand that the arrangement arrived at is final. A little extra time given for a try-in may save a lot of trouble later on. Two or three extra appointments, if necessary, are quite important. If desirable, other members of the family or particular friends may be invited to come in and give their advice. This will often do much toward the satisfaction of the patient. These critical friends or relatives can ruin a perfectly good set of dentures for us. How many

Volume Number

1 4

PRECISION

TECHNIQUE

FOR

PRODUCING

DENTURES

373

times have we all had this happen ? I now ask them to bring their most severe critics, whether it is a member of their own family or one of their close friends, and I let them understand that it is possible at this time to make any changes whatsoever that they may desire, providing they do not violate any of the rules for balance and articulation of teeth. We can lengthen the teeth, or shorten the teeth, we can move them farther forward, we can move them farther back, we can set them straight, we can make them irregular, we can slant them out at the incisal edge, we can slant them in at the incisal edge, we can overlap them, space them, in fact, we can do anything they would like us to do, even to changing the molds and shades, but this is their last chance. These changes must be made This is the only time we can do this, and after while the teeth are still in wax. If the patients should change their minds the dentures are cured they are finished. after the dentures are finished, that is not our responsibility, and they should be told this. I sometimes set the teeth in hard wax, and allow the patients to take the trial dentures home. They are instructed to be careful to keep them chilled previous to trying them. They can then try them in at home and discuss them, and often times they are much happier after having done this. We do not go to these extremes with most patients, but occasionally it pays. A prosthodontist must understand psychology in order to satisfy his denture patients. We must continually be watching our patients mental reactions as the case progresses, and we cannot relax for one moment on this phase of the work. In most cases, I would say it is every bit as important as the technique we use. As Dr. House often says, It is easier with some patients to fit the mouth than it is to fit their minds. His mental classification of patients has been very valuable to me. He classifies his patients into four groups, philosophical, exacting, hysterical, and indifferent, or a combination of these. The philosophical type is the most valuable, and the one we enjoy the most. These people are intelligent; they understand what we are doing ; they do not expect us to perform miracles; they are cooperative, and if we do our part, we can rest assured the case will be a success. Would that they were all the philosophical type. The exacting type we can enjoy working for, if they have coupled with this a philosophical mind. It is a pleasure to work for exacting people, because they appreciate the fine detail that you put into their cases. However, there is in the exacting type the patient who carries a chip on his shoulder, and has very little confiThey are often dence in anyone. The patients in this category are very difficult. extremely intelligent and think they know everything, but they have some of the queerest ideas when it comes to dentures. The hysterical type includes those patients who are usually shallow mentally. They do not want to be hurt; they get terribly upset over very insignificant things, and you never know where you stand with them. They may be fine one day but the next they will be all off the beam. However, you eventually get their work completed. The indifferent type of patient doesnt care what you do, or how it is done, and doesnt show much appreciation for anything you do after youve done it.

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There is not much pleasure in working for the indifferent patient. Usually those in this group do not give too much trouble. We may have classified our patients at the first appointment, but by the time we have arrived at the final appointment. we know whether we were right or not, This is the time to lay the foundation for the next appointment which will be the patients first introduction to the new dentures. You know by now just what to expect, but this is your last chance. The next appointment, when they come in to get their dentures, should be one that is thrilling both to the patient and to the dentist. After all the hard work that has been put into the case, it is wonderful to have the patient pleased and happy. The determining factor of success is whether we have produced dentures that satisfy the requirements that are expected. During these earlier appointments is the time to educate the patient as to what to expect, and to the limitations of his particular case. If during this time we have gained his confidence, we should have no trouble at the completion of the work.
CURING THE DENTURES

The dentures are cured in injector flasks or spring clamps, but not in flask presses. They are cured for nine hours (overnight) in water at 165 F., then bench-cooled for an hour before cooling in water for at least fifteen minutes. Tf we do not have time for the overnight cure, we cure the dentures at 165 F. for one and one-half hours, and then boil them for thirty minutes. They are then bench-cooled for one hour and cooled in tap water for fifteen minutes. Regardless of the curing technique or the material used, it is an advantage to allow the case to set after it has been pressed for at least an hour, before the curing process is started. It gives the plastic a chance to harden, time for the monomer to be absorbed by the polymer, and it seems to make porosity less likely to develop.
SPOT GRINDING

When the dentures are removed from the flasks after curing, they are not immediately removed from the casts. The casts with the dentures still on them are reattached to the other half of the split casts on the articulator (Fig. 22 j, and Fastened in place, either mechanically or with plaster. Then, the points of interference in centric position are located with carbon paper, and are corrected with stones. Selective spot grinding is done in lateral and protrusive positions with small stones or diamonds. On the working side in lateral position, the lingual inclined plane of the buccal cusps of the upper and buccal inclined plane of lingual cusps of the lower are ground. That is, grinding is done on the buccal of the upper and lingual of the lower, BU-LL. On the balancing side, either the lingual cusps of the upper, or the buccal cusps of the lower are ground. The bite is checked in protrusive to see that the incisors and molars contact at the same time. In centric, the upper and lower anterior teeth should not contact. Most cases are open 5 to 1 mm. on the incisal pin after curing and remounting. The occlusion is corrected until the incisal pin of the articulator is touching in centric position, and the case runs freely into all positions with no cuspal interference.

Volume Number

1 4

PRECISION

TECHNIQUE

FOR MILLING

PRODUCING

DENTURES

375

The milling of the case is just a final refinement of contacting surfaces of the teeth. Abrasive paste is put on their occlusal surfaces. If the articulator has a milling device, it is put in motion, and the incisal pin is moved from side to The amount of milling and spot grinding that is side, and forward and backward. done on the articulator depends on the type of articulator that is used, and on the accuracy of the maxillomandibular relations that have been taken. If the records have been complete, and a fully adaptable instrument has been carefully adjusted, then the refinements of the articulation of the teeth may be completed on the instrument, and, when placed in the mouth, the results will be the same in the

Fig. 22.-Remounting of cases after curing in order to correct any cuspal interference by selective spot-grinding and milling.

Fig. 23.-The cision coordinator the author.

completed which

case on the prewas designed by

mouth as on the articulator. If a nonadjustable articulator is used, no adjusting of the occlusion should be done except in centric position, as this is the only record which has been taken, and everything else is arbitrary. However, all teeth should be touching equally in centric position. It is better to do the corrections for lateral and protrusive in the mouth, when a nonadjustable instrument is used. If you are using a semi-adjustable instrument, one which has condylar path adjustments, the case can be balanced in protrusive and centric positions, and a certain amount done in lateral, since the condylar paths of the instrument do approximately follow the patients condylar paths. ,4 case that has been spot-ground

376

TERRELL

.L

and milled on this type of instrument will require much less adjustment at the mouth than one which has been made on an arhitary nonadjustable instrument. lf you have used a fully adjustable instrument, and have taken accurate centric. protrusive, and right and left lateral check bites, and have set the Gothic arch controls of the instrument as well as the condylar guidances, the case can be spotground and milled completely on the instrument, and when it is placed in the

Fig.

24.-Lateral

view

of gold upper

denture.

Fig.

25.--Complete

upper

denture

with

gold palate.

In using the first two classes mouth, the patient will find no cuspal interference. of articulators, the final adjustment of the teeth should always be done in the mouth, but this does not mean that a good end result cannot be obtained. It does mean, however, that all this work that could be done. in the laboratory on the instrument must be done in the mouth. I cannot see how anyone who builds many dentures could say that an articulator is not valuable in the construction of dentures, and the more complete the articulator the more valuable its use. Selective spot grinding should be correctly done with the incisal pin in place. Then, when using the coordinator (Fig. 23)) set the grinder at 20. A&y milling paste and a little water to the occlusal surfaces of the teeth, and mill thrmgh all ranges of movement.

Volume Number

1
4

PRECISION

TECHNIQUE

FOR

PRODLCING

DENTL-RES

377

The milling merely smooths the contacting surfaces, and enables the teeth to glide smoothly through all positions without interference. This eliminates the soreness which is due to torque. The ground surfaces of the teeth are first polished with fine sandpaper discs, followed by pumice, and then porcelain polish on a hard felt wheel. Before polishing the teeth, the occlusal surfaces should be stones recarved with knife-edge diamond stones, or knife-edge Carborundum running in oil or water. Artificial teeth, when finished, should have sharp cutting edges, and not flat surfaces which can only mash food. If a patient cannot cut meat with a dull knife, how can he hope to chew it with flat smooth teeth7 Far too little attention has been given to sharp teeth, and their relation to chewing efficiency. Artificial dentures, at best, are poor chewing substitutes for natural teeth. Anything we can do to increase their efficiency is important. The amount of pressure which can be comfortably exerted on dentures is only from 15 to 30 pounds, while patients can exert anywhere from 100 to 300 pounds pressure on natural teeth. For this reason, artificial teeth should be much sharper than natural teeth, in order to give the patient a reasonable amount of chewing ability, Flat contacting surfaces will not do this.
SEVENTH APPOINTMENT

UclivPry

of the Finished Dmtwcs

The dentures are delivered and instructions given to the patient (Fig. 24). The patient will not experience any serious difficulties if he will refrain from heavy chewing during the first week, and there will be very little adjusting to do if these instructions are followed. An appointment should be made for the next day, and the mouth checked for any pressure spots. We use the material (Indicator Gel), which we used for our final impressions, to locate pressure spots, should there be any. It is well to give our patients a definite appointment each day or ever\ other day following the insertion of the dentures in order to check the mouth, and to get the patients reaction to the new dentures. Any misunderstanding which may be developing in their minds can be corrected then. Until they have gone through the adjustment period, our responsibility is not over. We should not release our patients until their mouths are perfectly comfortable, and they are happy with the results. Prosthetics is not easy, but it is, to me, the most interesting part of dentistry, and if it is well managed, can be the most remunerative (Fig. 2.5 ), In conclusion, I would like to state that the results of a precision technique will be Dentures That Fit and Function. Happy, satisfied patients refer more denture patients. 627 FIRST
PASADENA, TRUST BUILDING CALIF.