brewer a a treating complete dednture patients

7/29/2019 Brewer a a Treating Complete Dednture Patients

1/16

COMPLETE DENTURES

TREATING COMPLETE DENTURE PATIENTSALLEN A. BREWER,COLONEL, USAF (DC) *New York, N. Y.T HE TITLE SUGGESTS that we are concerned only with the treatment of completedenture patients. Many of the suggestions I have for accomplishing this areequally useful in treating patients requiring other types of dental service. I am usingcartoons and line drawings as they better emphasize the points that requireillustration.I have no panacea for all patient problems. I am not presenting a techniqueto which every patient can be fitted. I am not going to dwell on the mechanics in-volved in the various methods used in complete denture construction. These arebut steps necessary to the accomplishment of our real mission which is to treat thepatient.

I am going to show how I look at a patient and why and how I treat the pa-tient and why.FAILURES AND SUCCESS

Early in my practice I found it very disconcerting to have failures. This washard on my ego. These failures were most evident when complete dentures wereconstructed. Therefore, I set about learning all I could about complete dentures.I read every book and article on complete dentures that I could lay my hands on.I enrolled in many courses, and used every face-bow and hinge-bow I could ob-tain; worked with almost every articulator that had been produced; used manyimpression techniques and many different types of teeth. I even made hinge-bows,articulators, centric relation recording devices, and teeth of my own. I spent 5 yearsin dental research, much of it in trying to find out how teeth contacted in masticationand in other functions. My percentage of failures decreased. I found that once I hadrefined my mechanical skills I was able to construct successful dentures, regardless ofthe technique or instruments used. Frequently, this was in spite of the technique or

Read before the Academy of Denture Prosthetics in Milwaukee, Wis.This presentation represents the views of the author and does not necessarily reflect theofficial opinion of the Air Force Dental Service or of the Department of the Air Force.*Chief of Dental Services, 86th Tactical Hospital, AP012, New York.1015


2/16

instruments used. But, I still had failures. Today I have no failures. This was ac-complished in two ways. First, I rearranged my thinking-I no longer have failuresand I have varying degrees of success. Second, and more important, I treat the pa-tient instead of just constructing dentures for him. The two principal personalitiesconcerned in complete denture service, the dentist and the patient, are thus immedi-ately more comfortable.METHODS AND PLANNING

I am not deprecating the necessity for good sound methods, accuracy, andconstant striving for the optimum result. I am emphasizing other factors in patienttreatment that are of equal importance.In any endeavor we undertake, a smooth road to success is usually the resultof good planning. It is seldom luck. W e can compare our role with a consultingpatient to the role of an architect with a prospective home builder. The architectknows that his client could have gone to a builder and said, build me a house.The result would be a house commensurate with that builders ideas of what ahouse should be. Those of us who have been through this know that the servicesof a good architect are worth every penny we pay. The architect knows that hisclient has come to him for advice and help to obtain something that suits him. Thegood architect then proceeds to find out something of the personality of his client,his needs, desires, and aspirations. Is this to be a short-time residence or a life-time one ? Only after he has all the information possible does he start to plan andthen to build the house. He plans for utility, beauty, and ease of maintenance : andhe supervises every step of construction. He must keep abreast of the developmentof new materials and techniques in order to provide the optimum service for hisclient at minimum cost. Many of us are prone to assume the role of the builder.This may be because this is what we spend so much of our time doing-buildingand rebuilding. This is most true in this age of specialization when frequently wesee only within the confines of our own specialty. Unless we are willing to asslimeour role as architect and plan with our patients, we are going to send more andmore of them to the builder or illegal practitioner.EXAMIKlZTION, DIAGNOSIS, TREATMENT PLANNING

A reliable forecast can result only from adequate examination, diagnosis,and treatment planning assessed in the light of experience. Some wag has suggestedthat experience is the result of knowledge gained from mistakes. Many of thesemistakes may be avoided by the purchase of knowledge from formal courses, text-books, and journals. The examination should start with a gross appraisal of thepatient. This is the easiest way to start and the most fun. I suggest that the firstcontact with the patient nof be made at the dental chair. I prefer to greet thepatient as he walks in. This place of meeting should be a nice meeting place. Aconsultation room in which the patient and the dentist may become acquainted onthis first visit is the ideal. We all know that we always look for the nicest lookingrestaurant, mote l, and, even, service station. So this consultation room should beclean, neat, attractive and, above all, comfortable. As the patient walks in we areautomatically appraising physical characteristics, dress, carriage, poise, and ease.


3/16

Volume 14Number 6 TREATIKG COMPLETE DENTURE PATIENTS 1017UNDERSTANDING THE PATIENT

Just a few months ago I was treating a patient for whom complete dentureswere contemplated. This patient had given me a negative medical history. Becauseof his personality, a know-it-all type, I had placed him in Category III. I use theclassification system in which Category I is the easiest and IV the most difficult.Physically, this patient was Category I-but, psychically the situation was moredifficult. This, I attributed to his position and background. He is an old mastersergeant who knows better than anyone else everything about everything. Thiswas apparent from his stories about the mechanics who did not service his carcorrectly, the repairman who could not put his TV in order, and the tailor whomade such a mess of his uniforms. After our third session, I watched him crossthe parking lot. He had the typical slapping gait occurring with diseases of the pos-terior column in the spinal cord. I sent for his medical record. This patients medicalrecord revealed a diagnosis of cerebellar atrophy made 2 years previously. This isan irreversible and progressive condition. His physicians were treating him withreassurance. Fully aware of his condition, I was able to treat him with more toler-ance and understanding.

It really does help if we like our patients at first sight (Fig. 1). Which of thefigures in this instance would you prefer to work on ? And which of the figuresin Fig. 2 would you prefer to have work on you ? The first meeting with thepatient is the most important. Body types give us some indication as to the problemsinvolved. These are not hard and fast rules. During World War IT an attemptwas made to select aspirants to very hazardous tasks by this means. There weretoo many variables and the plan was dropped. I shall deal with these variables anduse this classification only as a guide. Fig. 3 shows a classification of body types.The thin chap is the ectomorph, characterized by a relative preponderance oflinearity and fragility with large surface area and thin muscles and connectivetissue. This is the patient with the thin inelastic mucosa that may have problems in

Fig. 1. Fig. 2.Fig. I.-Different body types.Fig. 2.-Appearance of dentists.


4/16

1018 J. Pros. Dnl.Nov..Dec., 1964

Fig. 3.-A classification of body types. Left, Ectomorph. Ccnlcr, Endomorph, Right, Mesomorph.

Fig. 4.-The handshake can reveal much about the emotional attitude of the patient. Left,The dead fish handshake may reveal a non-cooperative patient. Ri!~ltG, The viselike grip mayreveal an insecure patient.

wearing complete dentures. The endomorph has large digestive organs and apreponderance of fat. This patient is more likely to be impressed by the per-sonality of the dentist treating him than by the treatment. This man is going toeat, no matter what, so is probably the easiest of the three types to treat with com-plete dentures. The mesomorph in Fig. 3 has a relative preponderance of muscle,bone, and connective tissue, usually with a heavy hard physique. He has his goal in lifewell set and will put up with considerable discomfort to get a result, but he expectsresults and may complain bitterly at anything less than perfection.

Shaking hands with a patient is an informative process (Fig. 4). The deadfish handshake certainly might indicate a noncooperative patient without too muchinterest. The vicelike grip could be introducing a patient who is insecure and try-ing to impress us. This patient might try impressing us with how well he coulduse our dentures or might concentrate on trying to prove that we could not do ajob good enough for him. The patient offering a normal firm handshake wouldprobably be the easiest to get along with. There is other information to be gleaned


5/16

Volume 14Number 6 1019

Fig. L-Abnormal lip, mouth , or tongue habits are revealed if the patient is allowed to talk.

Fig. 6. Fig. 7.Fig. 6 .-A pipe will put a strain on the foundation under dentures, and is a potential causeof trouble.Fig. 7.-The lifes work of a patient is a factor in diagnosis.

from the handshake. I recall the visit I made to a physician some years ago. Heshook my hand five times in the space of a minute. I thought what a friendlyfellow until I realized he was trying to determine whether my hand was hot orsticky, cold and clammy, or dry. This could give him some lead as to my emotionalstatus and possibly as to my thyroid gland activity, whether hypo or hyper.Let the patient talk (Fig. 5). It is really amazing what we can learn fromlistening to the patient. In addition we can see any abnormal lip, mouth, or tonguehabits he might have. We can observe the degree of relaxation or, conversely,tension. Note playing with the teeth, sometimes aided by a pipe (Fig. 6), chew-ing gum, fingernail, or toothpick. We find out what a patient does for a living, andrealize that if he is a wind instrument player we might put him out of businessby removing his teeth (Fig. 7). We find out what the patient likes to do or expectsto do with his teeth. It is the ambition of some to he able to eat corn on the cob


6/16

1020 BREWER J. Pros. Den.Nov.-Dec.. 1964

Fig. X.-The patients expectations are important.

Fig. 9.-The aspirations of the patient can affect the choice of treatment.

Fig. lO.-The patients troubles are manifest by the dentures he brings with h im.


7/16

t-olume 13Number 6 TREATING COMPLETE DENTCRE PATIENTS 1021with dentures (Fig. S). We should be able to tell him if he will be able to do thiswith the dentures we can provide.\\e can learn at this time something of the aspirations of our patient (Fig. 9).Does he picture himself as an orator, a singer, a Thespian ? These people have dif-ferent requirements than do those who are not so concerned with projecting theirvoices. Ten years ago I was called in consultation by a dentist who was treatinga well-known actor. The question was, should his fekv remaining mandibular teethbe removed and a complete denture constructed or not. The patient had a fairlycomplete complement of maxillary teeth which had been covered with jacket crowns,and these teeth were in remarkably fine condition. Mechanically he had a wonder-ful foundation for a complete lower denture. On my recommendation, the remain-ing lower teeth were extracted and a complete mandibular denture was constructe(1.iz week later the dentist brought the patient to me complete with a lower dentureand a demonstration of what happened when he attempted to project his voice. Hisdenture went out with the sound. It was only then that I learned of the tremendousaction in the modiolus region when the voice was thrown. A loud ho-or-ha reallyactivates this musculature. Two dentures and 2 months later, this actor had hisrevenge. He sent me a pair of tickets for the opening of his new play. In attendancewere his physician, his psychiatrist, and his dentist. The payoff came with the re-vi,ews the next day. They stated that this actor had performed with his usual com-petence but he talked as though he had a mouthful of hot mush. I had learned.Three years later I was called in consultation about another actor. Even beforeseeing the patient I was able to make my diagnosis. This man was 60 years of ageand had a very successful play running in the east that was netting him about$3,500.00 per week. I said to the dentist who was treating him, whatever you do,save his teeth. If you remove them and anything happens to the show you have hadit. This was perfectly acceptable to the patient, the teeth were retained, and theshow went on.Sometimes the patient does not have to talk (Fig. 10). I n many instances theseare not problem denture patients, but rather patients who have gone to problemdentists. \Ve can and should tell a patient what we can provide for him beforeaccepting him for treatment.

Fig. Il.-The economic factor may determine the patients choice of treatment.


8/16

1022 BREWER Nov..Dec., 1964J. Pros. Den.

Fig. I%-The manner in which the patient opens his mouth is an indication of his attitudetoward dental treatment. Left, The show-off. Center, The cooperative patient. Right, The unin-terested and uncooperative patient.

Fig. 1X-General debilitation of the patient is a complicating factor in denture construction.

Do not ignore the socioeconomic factor (Fig. 11) .Many people in the lower income brackets expect to wear complete dentures ata relatively early age. Those in the higher income brackets often consider the meresuggestion that they have their teeth removed is an insult. With these patients Itry to work around to the point where they are requesting the complete denturesrather than my suggesting them. When I finally seat the patient in the dentalchair and make sure that we are both comfortable, I usually ask him to open hismouth (Fig. 12). Th e way he does this is an indication, as is the handshake, ofthe type of individual he is.COMPLICATING FACTORS IN THE CONSTRUCTION OF DENTURES

There are five factors that could complicate the construction of complete den-tures for a patient. The patient with only one of these undesirable conditions couldusually be treated successfully, but when two or more of the factors exist in the


9/16

Volume 14Number 6 TREATING COIVIII,ETE DENTURE PATIENTS 1023same patient, watch opt. The first of these factors is general debilitation (Fig. 13).The second is abnormal jaw function (Fig. 14). The third is abnormal jaw rela-tion (Fig. 1.5) with accompanying abnormal tooth relationships (Fig. 16). Thegreater the abnormality, the more difficult the problem, especially if the patient isedentulous and record casts are not available. If space is not provided betweenthe anterior teeth for the tongue thrust, the patient might dislodge his dentures con-stantly during mastication and speech. It is tantamount to malpractice to extracta patients teeth without first making adequate record casts. The fourth complicatingfactor is redundant tissue as illustrated in (Fig. 17). The tissues are depicted inFig. 18 would be mucl~ more desirable. Inadequate space for denture bases, as shownin Fig. 19, and bony protuberances and undesirable undercuts, as shown in Fig. 20,are also part of this complicating factor. I try to keep surgical intervention to aminimum, but I must have space for the denture bases. When undercuts are oppos-ing each other in the tuberosity region, we usually can reduce only one side andimprove the situation adequately. The fifth factor is the attitude of the patient, andeven though listed last, it is not the least important. In fact, the main body of thisarticle is concerned with assessing and influencing the attitude of the patient.KETENTION OF DENTURES

The degree of retention of a mandibular denture can be predicted. The drapingfloor of the mouth, as shown in Fig. 21, will not permit us to obtain the very positivetype of retention we can provide for the patient with the flat floor of the mouth,and well-defined sublingual fold space seen in Fig. 22. Fig. 23 shows the drapingfloor as we move further posteriorly. Fig. 24 shows the more desirable situationwhen the floor of the mouth is flat and a well-defined area is available betweenthe sublingual glands and the ridge.Contacting the patients physician can certainly guide us in how best to treathim (Fig. 25). The man who has had a coronary thrombosis, and for 2 years fol-lowing has not reported for a check-up by his physican is certainly not a goodcandidate for extensive periodontal therapy. The continuous maintenance and fre-quent visits to the dentist, necessary to the control of periodontal disease, wouldprobably not be observed by this patient. Likewise, the man who is careless abouthis financial obligations is probably careless about himself.

Fig. 14.-Abnormal jaw function.


10/16

1024 BREWER J. Pros. Den.Nov.-Dec.. 1964

f 15Fig. 15.-Abnormal jaw relations.Fig. 16.-Abnormal tooth relationships.

Fig. 17.-The excess soft tissues on the ridges supply poor support for dentures.Fig. 18.-A reasonable thickness of soft tissues on the ridges is desirable.

Fig. W.-Inadequate space for denture bases.Fig. PO.-Excessive bony protuberances and undercuts can c,ause difficulties for the dentistand discomfort to the patient.


11/16

Volume 14Number 6 TREATING COMPLETE DENTURE PATIENTS 1025

Fig. Zl.-The draping tissues lingual to the anterior part of the ridge are unfavorable toretention.Fig. 22.-The character of these tissues on the lingual side of the ridge are more favorableto retention.

Fig. 23.-The draping tissues lingual to the ridge in the molar ridge are unfavorable toretention.Fig. 24.-The well-defined space between the sublingual fold and the residual ridge is favor-able to retention.

WHICH IS THE BETTER PATIENT?Now let us take another look at the 2 patients we started to consider. The littledoll (Fig. 26) we all thought would be such fun to work on looks a bit different

now. I would hesitate to remove all of her teeth. She could then blame me for toomany of her other problems. Our other patient (Fig. 27) is well adjusted and busyenough not to be thinking constantly of herself. Psychologically she is the idealdenture patient.TREATMENT OF PATIENTS WHO HAVE DIFFICULT PROBLEMS

How then do we treat patients who we recognize as extremely difficult to treat.We cannot send all of them to someone else. We cannot treat them by joiningthem with this bottle (Fig. 28). It cannot be done by too close a personal relation-ship (Fig. 29). The cost of treatment would far exceed the fee. Kowtowing to thepatient (Fig. 30) is certainly not the key to successful patient treatment.THE GOLDEN RULE

Use the golden rule. Treat the patient as you would like to be treated: withkindness and consideration and a real attempt to establish rapport (Fig. 31). Oneof the best plans for getting the patient off the defensive is not to insist that thepatient pay for his dentures when he receives them. The dentist could insist that thepatient wait until he was happy and pleased with the dentures. One dentist who hasused this plan lost only one fee but he made a great many pleased denture wearersand many, many friends.


12/16

1026 BREIZER

PHYSICIAN

DITtEAU

Fig. XL-Consultation with the patients physician and a check on his credit is essential.

Fig. 26.-This patient would look for every opportunity to blame someone else for her troubles.

Fig. 27.-This patient is well-adjusted and would accept her responsibilities.


13/16

Volume 14Number 6 TREATING COMPLETE DENTURE PATIENTS 1027

Fig. 28.-This sharing will not solve the patients problems.

Fig. 29.-Too close a personal relationship can only add to the problems.

Get all the help possible (Fig. 32). Since learning more of periodontal therapy,I save many teeth that I formerly replaced. I am able to advise the periodontistas to the prognosis for complete dentures. If favorable, the patient is saved manyhours of trauma in sometimes hopeless causes. When upon examination I see anarea that does not appear normal, I enlist the aid of a specialist in oral medicineor a pathologist. We do not observe the area in a vague manner. The patientreceives a definite appointment for observation, and if he does not report he is calledin. The orthodonist is of great help with many patients. Moving individual teethprior to the construction of fixed or removable partial dentures is sometimes a rela-tively simple process that pays good dividends. I have stressed the importance ofconsultation with the internist as to the patients general health. The internists, inturn, consult us occasionally for help in confirmation of systemic diseases. Oralmanifestations sometimes corroborate their diagnosis. Close association with theoral surgeon is a real blessing. We seldom do alveolectomies in the posterior regionat the time of multiple extractions, By waiting for healing to occur, we find thatwe can save much very useful bone.


14/16

1028 BREWER Nov.Dec., 1964J. Pros. Den.

Fig. 30.-Kowtowing to the patient will not solve his or the dentists problems.

Fig. 31 -Mutual trust and confidence will lead to successful treatment.

ORAL SURGEON

Fig. 32.-Consultation with other specialties is indicated for many patients.


15/16

Volume 14Sumber 6 TREATING COMPLETE DENTURE PATIENTS 1029IMMEDIATE DENTURES

In the maxillary region we provide immediate replacement for the six anteriorteeth whenever possible. By removing the bare minimum of bone and by takingas much care with the immediate denture as with the subsequent denture we havemade many that did not require alteration for years. We do not make lower imme-diate dentures. Instead, we make a temporary mandibular denture immediately afterextraction, and frequently we use the patients extracted teeth in the denture. Thesetemporary dentures can be made while the patient waits and are worn until heal-ing is complete. We then make the maxillary immediate denture to oppose a secondmandibular denture that can be stabilized on healed ridges. This method avoidsmuch discomfort for the patient and saves time and money for both the patient anddentist.OTHER GUIDES

We always enlist the aid of the patients family when it is available. If the pa-tient is edentulous but has children, we can usually pick out the child who lookslike the patient and observe his teeth as a guide. We ask for photographsmade before the loss of his teeth. It is usually the patient who states he does notcare how he looks who heads immediately for the mirror when his new denturesare inserted. We never let the patient look into a small mirror. We have them usea large wall mirror while standing well back away from it. I talk to the patientshusband or wife and show him or her how we are changing the teeth and why.I also caution him against remarks, such as where did you get the horse teeth?A few years ago I had cautioned, in this manner, the husband of a patient I wastreating. The day following insertion of the new dentures she returned much upset.Her husband had said the night before; "you sure look nice but why do you lisp?I had this patient read a magazine first with her old dentures then with her newdentures while I recorded what she said. Then I played the recordings back forher. She could not tell any difference in the two recordings. I next asked our speechtherapist to listen to the recordings. He told her she talked better with the newdentures than with the old. The patients confidence was restored.DECiTURE ADJUSTMENTS

I would like to make a plea at this time for denture adjustments. It is true thatwe make many dentures which do not require adjustment. It is equally true thatwe make many dentures which do require adjustment and sometimes many adjust-ments. Denture adjustment is just as important in patient treatment as is theconstruction of the dentures. If we are offended or show displeasure with thepatient who requires denture adjustments, we are quitting our responsibility. Somepatients enjoy adjustments and frequently they are only seeking reassurance. Whenwe have a patient who shows extreme anxiety or a conversion reaction, we insiston appointments for adjustment. We do this the first thing in the morning so hedoes not spend a part of the day building up resentment. Frequently, when a patientmakes a big thing of some minor symptom, his real complaint is not the physicalailment but an emotional problem. Time, personality, attention, and confidence


16/16

1030 BREWER J. Pros. Den.Nov.-Dec., 1964that the same care will be available again on another visit is a real help to thistype of patient.ESTIIETICS

I would like to re-emphasize the importance of esthetics. I still spend moretime on this than on any other phase of complete denture construction. FArI Pomtfand Roland Fisher have done yeoman service to the dental profession by the workthey have presented and published on this aspect of complete denture service.Remember that no matter how well the dentures function, unless the patient thinksthey look well he will be unhappy.CONCLUSIONS

I have given you no scientific facts. But how many scientific facts do we havein dentistry ? Until such time (and I hope it never comes) as we have reducedpatient treatment to a scientific mathematical formula, I respectfully suggest thatwe treat the patient instead of just treating his teeth. Our patients will be happier,and we will receive immeasurably greater pleasure from our work.I am pleased to acknowledge the assistance of Mr. Doyle, Chief of Training hids, School of

Aerospace Medicine, Brooks AFB, Texas, for his preparation of the illustrations for this article.86~~ TACTICAL HOSPITALAPO 12, NEW YORK, N. Y.

brewer a a treating complete dednture patients

Documents