complete dentures - · pdf file1.identify reasons for the need for complete denture...

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Complete Dentures:A Review for the

Dental Professional

By

Jeffrey L. Tarlow, DDS

P.O. Box 1930Brockton, MA 02303800-438-8888

Dental Planner: Karen Hallisey, DMDThe planner has disclosed that she has no significant financial or other conflicts of interest pertaining to this course book.

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ii

ABOUT THE AUTHORJeffrey L. Tarlow, DDS, earned his doctorate in dental surgery from Case Western Reserve University School of Dentistry in Cleveland, Ohio, before pursuing a Clinical Fellowship in Prosthetic Dentistry at Harvard University School of Dental Medicine and a residency in fixed and removable prosthodontics at the Veterans Administration Outpatient Clinic in Boston. He served as a dentist for the U.S. Department of Veterans Affairs for more than 40 years, serving 34 of those years as a staff prosthodontist. Dr. Tarlow was director of the General Practice Residency Program at the Manhattan campus of the Department of Veterans Affairs New York Harbor Healthcare System from 1985 to 2016. Dr. Tarlow was a peer reviewer for The International Journal of Prosthodontics for 5 years and a principal investigator for two major dental implant clinical research studies; he has had 13 articles published in peer-reviewed jour-nals. Dr. Tarlow has lectured extensively on restorative and implant treatment for the geriatric patient.

Jeffrey L. Tarlow has disclosed that he has no significant financial or other conflicts of interest pertaining to this course book.

ABOUT THE PEER REVIEWERJoanne M. Falzone, DMD, FICD, FACD has been teaching at Tufts University for the past 21 years in the pre-clinical arena and she is the course Director for Dental Anatomy and Cranio-facial Function. She also teaches Fixed Prosthetics, Complete Dentures, Partial Dentures, Implant Prosthetics, and Operative Dentistry. She lectures annually to the Esthetic residents and is a Faculty Mentor for The American Student Dental Association at Tufts, and a frequent contributing writer for SMILE and the ASDA Journal. She has authored many teaching tools for Dental Anatomy, Tooth Development, and was awarded the Dean’s Award for Outstanding Teaching for many years.

Joanne M. Falzone has disclosed that she has no significant financial or other conflicts of inter-est pertaining to this course book.

FS0118WS

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WESTERN SCHOOLScourse evaluation

COMPLETE DENTURES: A REVIEW FOR THE DENTAL PROFESSIONAL

INSTRUCTIONS: Using the scale below, please respond to the following evaluation statements. All responses should be recorded in the lower right-hand corner of the FasTrax answer sheet, in the section marked “Evaluation.” Be sure to fill in each corresponding answer circle completely using blue or black ink. Leave any remaining answer circles blank.

A B C D

Agree Agree Disagree Disagree Strongly Somewhat Somewhat Strongly

OBJECTIVES: After completing this course, I am able to: 1. Identify reasons for the need for complete denture treatment.

2. Discuss the consequences of edentulism and the comorbidities involved.

3. Describe the maxillary and mandibular anatomy essential for complete denture support and the impression procedures necessary to obtain accurate preliminary and final impressions.

4. Select anterior teeth for complete dentures based on current research recommendations.

5. Develop an evidence-based philosophy of complete denture occlusion.

6. Describe the key elements involved in the digital denture technique.

7. Explain key factors in patient satisfaction with complete denture treatment.

COURSE CONTENT 8. The course content was presented in a well-organized and clearly written manner.

9. The course content was presented in a fair, unbiased, and balanced manner.

10. The course content presented current developments in the field.

11. The course was relevant to my professional practice or interests.

12. The final examination was at an appropriate level for the content of the course.

13. The course expanded my knowledge and enhanced my skills related to the subject matter.

14. I intend to apply the knowledge and skills I’ve learned to my practice.

A. Yes B. Unsure C. No D. Not Applicable

CUSTOMER SERVICEThe following section addresses your experience in interacting with Western Schools. Use the scale below to respond to the statements in this section.

A. Yes B. No C. Not Applicable 15. Western Schools staff was responsive to my request for disability accommodations. 16. The Western Schools website was informative and easy to navigate. 17. The process of ordering was easy and efficient. 18. Western Schools staff was knowledgeable and helpful in addressing my questions or problems.

vcontinued on next page

Course Evaluation— vi Complete Dentures:A Review for the Dental Professional

ATTESTATION

19. I certify that I have read the course materials and personally completed the final examination based on the material presented. Mark “A” for Agree and “B” for Disagree.

COURSE RATING

20. My overall rating for this course is

A. Poor B. Below Average C. Average D. Good E. Excellent

COURSE SELECTION

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A. 1-2 hours B. 3-5 hours C. 6-9 hours D. 10 or more hours

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A. Conducted an online search B. Redirected from the ADI or GSC website C. Received a Western Schools catalog in the mail D. Received a Western Schools email E. Heard about Western Schools from a friend/colleague

You may be contacted within 3 to 6 months of completing this course to participate in a brief survey to evaluate the impact of this course on your clinical practice and patient/client outcomes.

Note: To provide additional feedback regarding this course and Western Schools services, or to suggest new course topics, use the space provided on the Important Information form found on the back of the FasTrax instruction sheet included with your course.

C O N T E N T SCourse Evaluation ....................................................................................................................................................vFigures and Tables ..................................................................................................................................ixIntroduction .............................................................................................................................................xi

Course Objectives .........................................................................................................................xiComplete Dentures: A Review for the Dental Professional .................................................................1

Is There a Need for Complete Dentures? .......................................................................................1

Denture Demographics ............................................................................................................1

Complete Dentures for Implant Treatment Planning ...............................................................1

Consequences of Edentulism: Comorbidity ...................................................................................2

Medical Conditions ..................................................................................................................2

Nutrition/Malnutrition........................................................................................................2

Obesity ...............................................................................................................................3

Cardiovascular Diseases ....................................................................................................3

Diabetes ..............................................................................................................................3

Respiratory Diseases ..........................................................................................................4

Cancer ................................................................................................................................5

Cognitive Disorders (Dementia) ........................................................................................6

Mortality ............................................................................................................................6

Psychosocial/Quality of Life Consequences ............................................................................7

Consequences of Edentulism: The Bottom Line .....................................................................7

Complete Denture Impressions ......................................................................................................7

Complete Denture Impression Techniques ..............................................................................7

Edentulous Anatomy ................................................................................................................7

Denture Impression Controversies ...........................................................................................9

Impression Techniques ..........................................................................................................10

Preliminary Impression Technique (Wax-Alginate) ........................................................11

The “House” Technique for Elastomeric Final Impressions ...........................................14

Complete Denture Impressions: The Bottom Line ................................................................28

Anterior Tooth Selection ..............................................................................................................28

Relationship Between Sex and Tooth Size and Shape ...........................................................29

Relationship Between Face or Arch Shape and Tooth Shape ................................................30

Face Shape and “The Law of Harmony” .........................................................................30

Arch Shape .......................................................................................................................31

Relationship Between Face Size or Anatomy and Tooth Size ..............................................31

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Contents— viii Complete Dentures:A Review for the Dental Professional

Face Size ..........................................................................................................................31

Facial or Intraoral Anatomy .............................................................................................32

Clinical Application of Anterior Tooth Research ............................................................34

Patient Preferences for Tooth Selection and Arrangement ....................................................34

Anterior Tooth Selection: The Bottom Line ..........................................................................36

Complete Denture Occlusion .......................................................................................................39

Types of Occlusions ...............................................................................................................39

Monoplane Occlusion ......................................................................................................39

Anatomic Occlusion .........................................................................................................39

Lingualized Occlusion .....................................................................................................39

Effect of Denture Occlusion on Masticatory Efficiency and Patient Satisfaction .................41

Complete Denture Occlusion: The Bottom Line ...................................................................45

Digital Dentures ...........................................................................................................................45

Overview of the Digital Denture Technique ..........................................................................45

Case Reports ..........................................................................................................................46

Clinical Trials .........................................................................................................................47

Systematic Reviews ...............................................................................................................48

Expedited Non-Digital Denture Fabrication Techniques ......................................................48

Simplified Edentulous Treatment Technique ........................................................................49

Digital Dentures: The Bottom Line .......................................................................................49

Patient Satisfaction With Complete Dentures ..............................................................................49

Edentulous Anatomy ..............................................................................................................49

Psychological Makeup (Personality) .....................................................................................51

Other Patient or Dentist Variables .........................................................................................52

Patient Mucosal Sensitivity and Neuromuscular Control ................................................52

Patient-Dentist Relationship ............................................................................................53

Clinical Outcome (Denture Quality) ......................................................................................53

Clinical Protocol/Technique ..................................................................................................55

Is There Any Reliable Way to Predict Patient Satisfaction With Complete Dentures? ........56

Patient Satisfaction: The Bottom Line ...................................................................................57

Summary ......................................................................................................................................58Exam Questions ......................................................................................................................................59Resources ................................................................................................................................................65References ...............................................................................................................................................67

F I G U R E S A N D T A B L E S

Figure 1: Chronic Atrophic Candidiasis (Denture Stomatitis) ..................................................................5

Figure 2: Maxillary Support Areas ............................................................................................................8

Figure 3: Mandibular Support Areas .........................................................................................................9

Figure 4: Maxillary Dentulous Tray, Pink Base Plate Wax .....................................................................11

Figure 5: Maxillary Tray “Customized” With Base Plate Wax ...............................................................12

Figure 6: Maxillary Alginate Impression .................................................................................................13

Figure 7: Maxillary Preliminary Plaster Cast ..........................................................................................13

Figure 8: Mandibular Preliminary Impression and Preliminary Plaster Cast ..........................................14

Figure 9: Preliminary Cast Is Marked for Vestibular Depth, Custom Tray Border,

and Relief Over Rugae .............................................................................................................15

Figure 10: Maxillary Custom Tray (Triad Trutray) .................................................................................15

Figure 11: Maxillary Custom Tray Tried in Mouth, Assuring That It Is Two Millimeters

Short of the Mucobuccal Fold ................................................................................................16

Figure 12: Maxillary Custom Tray With Polysulfide Adhesive Applied, on Table of Triad Oven ........17

Figure 13: Regular Body Polysulfide ......................................................................................................17

Figure 14: First (Three Millimeters Wide) Application of Polysulfide ...................................................18

Figure 15: First Application of Polysulfide, Inside Entire Periphery ......................................................18

Figure 16: First Application of Polysulfide Has Set ................................................................................19

Figure 17: Border Molding Maxillary Tray With Regular Body Polysulfide .........................................19

Figure 18: Border Molding Polysulfide Has Set ......................................................................................20

Figure 19: Depth of Polysulfide on Periphery Is Tested, Should Be About 2 Millimeters .....................20

Figure 20: Lathe Wheel Is Employed to Remove Areas of Tray Overextension ....................................21

Figure 21: Maxillary Tray Reduced in Areas of Overextension ..............................................................21

Figure 22: Regular Body Polysulfide Is Added to These Areas ..............................................................22

Figure 23: Maxillary Border Molded Custom Tray .................................................................................23

Figure 24: Light Body Polysulfide (For Wash) .......................................................................................23

Figure 25: Maxillary Final Impression ....................................................................................................24

Figure 26: Maxillary Yellow Stone Master Cast .....................................................................................24

Figure 27: Maxillary Custom Tray With Heavy Body Reprosil ..............................................................25

Figure 28: Wash Done With Medium Body Reprosil, Impression Boxed (Plaster and Pumice),

Maxillary Master Cast ............................................................................................................25

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Figures and Tables— x Complete Dentures:A Review for the Dental Professional

Figure 29: Preliminary Impression (Wax-Alginate) And Preliminary Plaster Cast,

Final Impression (VPS) and Stone Master Cast ....................................................................26

Figure 30: Mandibular Cast Showing Posterior Extent of Mandibular Denture .....................................26

Figure 31: Intra-Orally Delineating Junction of Pear-Shaped and Retromolar Pads ...............................27

Figure 32: Mandibular Polysulfide Final Impression ..............................................................................28

Figure 33: Denture Esthetics – Normal, Supernormal, and Denture Look ..............................................34

Figure 34: Complete Denture Esthetics – Restoration of Vertical Dimension ........................................36

Figure 35: Complete Denture Esthetics – Restoration of Vertical Dimension ........................................36

Figure 36: Complete Denture Esthetics – Correction of Uneven Smile ..................................................37

Figure 37: Complete Denture Esthetics – Change in Maxillary Anterior Tooth Size .............................37

Figure 38: Complete Denture Esthetics – Change In Maxillary Anterior Tooth Size .............................37

Figure 39: Complete Denture Esthetics – Correction of Excessive Gingival Display ............................38

Figure 40: Complete Denture Esthetics – Natural Versus Prominent Tooth Display .............................38

Figure 41: Monoplane Occlusion .............................................................................................................39

Figure 42: Semi-Anatomic (20°) Occlusion ............................................................................................40

Figure 43: Lingualized Occlusion ............................................................................................................40

xi

I N T R O D U C T I O N

COURSE OBJECTIVESAfter completing this course, the learner will be able to:

1. Identify reasons for the need for complete denture treatment.

2. Discuss the consequences of edentulism and the comorbidities involved.

3. Describe the maxillary and mandibular anatomy essential for complete denture support and the impression procedures necessary to obtain accurate preliminary and final impressions.

4. Select anterior teeth for complete dentures based on current research recommendations.

5. Develop an evidence-based philosophy of complete denture occlusion.

6. Describe the key elements involved in the digital denture technique.

7. Explain key factors in patient satisfaction with complete denture treatment.

The continued need for complete denture treatment in the United States means that many of the con-cepts and procedures taught in dental school curriculums remain relevant. However, recent research

has shed new light on some long-standing concepts in denture treatment. In addition, the fabrication of complete dentures utilizing digital technology is likely to be more common in the near future. Current practitioners may not have been exposed to some of these newer concepts while receiving their training.

This intermediate-level course is intended to serve as both a review and an introduction to some of the more recent information and developments in complete denture fabrication. After completing this course, the practitioner will be better equipped to provide quality denture care in a less stressful and more cost-effective manner for both clinician and patient.

C O M P L E T E D E N T U R E S :A R E V I E W F O R T H E

D E N T A L P R O F E S S I O N A L

IS THERE A NEED FOR COMPLETE DENTURES?

Denture DemographicsIn 2002, Douglass, Shih, and Ostry pub-

lished a landmark paper that predicted that the 10% decline in edentulism seen each decade for the past 30 years would be offset by the 79% increase in the adult population older than age 55. Their research led these authors to estimate that 37.9 million people in the United States would need a complete denture (for one or both arches) by 2020. However, the actual number of edentulous individuals, although substantial, has not increased to the level predicted by Douglass and colleagues. According to Slade, Akinkugbe, and Sanders (2014), across a five-decade obser-vation period, edentulism prevalence (age ≥ 15) declined from 18.9% in 1957-1958 to 4.9% in 2009-2012. These researchers have reported that the decline in edentulism is only partially offset by growth in the aging population. The U.S. Census Bureau (2016) reported a 2012 U.S. population (age ≥ 15) of 247,696,000, making the 4.9% edentulous population 12,137,104. Slade and colleagues have pre-dicted that the prevalence of edentulism (age ≥ 15) will be 4.6% in 2020. The U.S. Census Bureau (2016) estimates that this population (age ≥ 15) will be 270,167,000 in 2020, which would mean approximately 12,400,000 edentu-lous individuals.

Edentulism statistics are higher for persons age 65 and older. Nearly 19% of U.S. adults age 65 and over were edentulous in 2012 (Dye, Thornton-Evans, Li, & Iafolla, 2015). The U.S. population age 65 and over was 41,507,000 in 2012 (U.S. Census Bureau, 2016), which means that approximately 7,886,330 edentulous individuals age 65 and over were living in the United States at that time.

Commenting on the demographic data rel-ative to tooth loss, Felton (2016) noted that although dentistry has made an observable impact in the decline of tooth loss and complete edentulism in the United States, complete eden-tulism is still prevalent and a need for complete denture education still exists.

Complete Dentures for Implant Treatment Planning

Knowledge of complete denture fabrication is a prerequisite for more extensive treatment, for example, with implants. A properly made com-plete denture serves a variety of diagnostic func-tions in implant treatment planning, including:

1. helping to establish acceptable tooth posi-tion for esthetics, phonetics, and occlusion. A radiographic template (for a cone beam study) made using the fabricated denture allows assessment of bone availability rela-tive to the desired tooth position.

2. helping to assess the need for a maxillary labial flange for facial support, by removing

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2 Complete Dentures:A Review for the Dental Professional

the labial flange of a complete denture or duplicated denture. Performing this proce-dure facilitates the decision to provide a conventional fixed type of restoration, or one with a flange (e.g., hybrid or overdenture).

3. helping to assess the existing restorative space and the possible need to remove excess bone or, conversely, to replace lost tissues with either a graft or prosthesis.

4. functioning as a fixed provisional (conver-sion) prosthesis to evaluate clinical param-eters and patient acceptance.

(Barzilay, Habsha, Strauss, & Tamblyn, 2003; Cooper, Limmer, & Gates, 2012; Geminiani, 2016).

Furthermore, implant overdentures must in-corporate the principles of conventional complete denture design and fabrication (Vogel, 2007).

CONSEQUENCES OF EDENTULISM:

COMORBIDITY

Regardless of varying prevalence estimates, edentulism is associated with numerous

adverse findings. These findings include medi-cal, psychosocial, and quality-of-life condi-tions that exist together with edentulism (i.e., comorbid findings). It is important to note that comorbidity does not necessarily imply a direct cause-effect relationship. Rather, comorbid-ity means that disorders are observed to exist together in an individual.

Medical ConditionsNutrition/Malnutrition

Most research has shown that a reduction in the number of teeth is associated with a poorer diet quality.

A 2008 study by De Marchi, Hugo, Hilgert, and Padhila found that completely edentulous

individuals, using only one denture, were 3.26 times more likely to exhibit malnutrition than a partially dentate cohort. In this random sample of 471 people older than age 60 living in south-ern Brazil, those with compromised oral status had a higher risk of malnutrition. Retaining up to eight natural teeth increased the maintenance of adequate nutritional status. Better nutritional status was also associated with complete den-ture (maxillary and mandibular) use in com-pletely edentulous subjects.

A study of Finnish “service housing” (simi-lar to nursing homes) residents assessed mal-nutrition with the Mini Nutritional Assessment (Saarela et al., 2014). Nutritional status was sig-nificantly associated with dentition status. Of the participants in Group 1 (edentulous with no den-tures), 23% were malnourished, 63% were at risk of malnutrition, and 14% were well nourished. The respective figures for Group 2 (edentulous, wearing dentures), were 12%, 64%, and 24%. In Group 3 (all or some natural teeth remaining, with or without removable dentures), 12% of the participants were malnourished, 65% were at risk of malnutrition, and 22% were well nourished.

Other research has shown that providing complete dentures, while improving nutritional intake, does not ensure an optimal diet. Han and Kim (2014) reported that, of 1,168 edentulous South Korean older adults, the risk of malnour-ishment was 1.89 times higher in non-denture wearers than in those wearing dentures. Even so, 12.8% of the denture-wearing cohort were still malnourished.

Shinkai and colleagues (2002) found that the majority of the patients they studied who wore dentures had deficient diets regardless of the tech-nical quality of their dentures, objective mastica-tory performance, or subjective chewing ability.

Similarly, Hamada and colleagues (2001) found that the replacement of old dentures with new dentures (either a conventional mandibular

Complete Dentures:A Review for the Dental Professional 3

denture or a mandibular implant-supported over-denture) did not result in significant improvement in intake of essential nutrients. The authors of this study concluded that ongoing nutritional counsel-ing is an important part of denture treatment.

Goel and colleagues (2016) assessed dietary and nutritional changes among elderly patients following different types of prosthetic treat-ments. Significant improvement in body weight; body mass index; and intake of proteins, carbo-hydrates, calories, calcium, iron, and vitamins B and C were seen in completely edentulous patients provided with dentures compared with partially edentulous patients treated with either removable or fixed prostheses. The authors commented that an improvement in patients’ diet might also be ascribed to their participation in the research project.

However, Liljestrand and colleagues (2015) observed in their research no significant dif-ferences in nutritional intake among groups of patients with varying degrees of missing teeth.

Obesity

A higher risk for obesity was found for individuals with fewer than eight natural teeth remaining (De Marchi et al., 2012) and in eden-tulous individuals (Österberg et al., 2010). Obesity is linked to a variety of medical condi-tions (e.g., cardiovascular disease, type 2 dia-betes) and is a major risk factor for obstructive sleep apnea (Dempsey, Veasey, Morgan, & O’Donnell, 2010).

Cardiovascular Diseases

A systematic review by Polzer and col-leagues (2012) investigated any association between circulatory mortality (death due to cardiovascular causes) and tooth loss. Of the 23 studies referenced, three high-quality studies found an increase in circulatory mortality with increasing tooth loss, whereas one moderate-quality study did not. Criteria for study quality

are detailed in the article (Polzer et al., 2012). The effect of denture use on circulatory mortal-ity remains to be established, according to this systematic review.

In a prospective cohort study of a national sample of Scottish adults, poorer dental status (edentulism in particular), was shown to be an independent predictor of cardiovascular disease mortality (Watt, Tsakos, de Oliveira, & Hamer, 2012). Edentulous subjects had a nearly three times greater risk for stroke-related mortality.

Schwahn and colleagues (2013) found a 1.88 times greater risk of death from cardiovascular disease in people with nine or more non-replaced missing teeth (not including third molars).

In a recently published study of 8,446 sub-jects in Finland, the number of missing teeth was used to predict the incidence of cardiovascular diseases (Liljestrand et al., 2015). It was found that having five or more teeth missing was asso-ciated with a 60% to 140% increased hazard for coronary heart disease events (p < 0.020) and acute myocardial infarction (p < 0.010). No association with stroke was observed. The researchers suggested that the number of miss-ing teeth might be a useful indicator of the need for further medical evaluation. According to the authors, patients in the study missing from nine to 31 teeth were likely suffering from chronic periodontitis, which could plausibly increase systemic inflammatory burden.

Diabetes

Patel, Kumar, and Moss (2013) analyzed data from a Centers for Disease Control and Prevention National Health and Nutrition Exam-ination Survey (2003-2004) and found that the prevalence of edentulism was 28% for the dia-betic population, compared with 14% for people without diabetes. In the study by Liljestrand and colleagues (2015), diabetes was associated with nine or more missing teeth (p < 0.040).


Respiratory Diseases

A statistically significant association was found between oral health status and chronic obstructive pulmonary disease (COPD)-related events, after adjusting for hypertension, smoking, and diabetes. Edentulous individuals diagnosed with COPD had a higher incidence of COPD-related events (hospitalization and death) than individuals with natural teeth and those with good periodontal health (Barros, Suruki, Loewy, Beck, & Offenbacher, 2013). In this study, more than 97% of the edentulous participants had com-plete dentures. The biofilm forming on dentures contains bacteria, yeasts, and fungi that cause an inflammatory response in oral tissues. This situa-tion, according to the authors, is why edentulism is predictive of COPD-related events.

In a recent analysis of the complete den-tures of 130 people, 64.6% were colonized by known respiratory pathogens (O’Donnell et al., 2016). Six species in particular were identi-fied: Streptococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, Haemophilus influenzae B, Streptococcus pyogenes, and Moraxella catarrhalis. The authors concluded that dentures can act as a reservoir for potential respiratory pathogens in the oral cavity, thus increasing the theoretical risk of developing aspiration pneumonia. Routine denture hygiene practices were recommended to help reduce the risk of respiratory infection among the elderly population.

Aspiration pneumonia has, in fact, been shown to be associated with wearing dentures during sleep (Iinuma et al., 2015). Japanese researchers found a 2.38-fold higher risk for pneumonia with overnight denture wear. They concluded that empirical evidence exists for the association of denture wearing during sleep with oral inflammatory and microbial burden and also with incident pneumonia. They also highlighted

the importance of oral hygiene programs for pneumonia prevention in the community.

Candida is a commonly occurring, indig-enous oral fungus, and is known to be a cause of pneumonia (Kuyama, Sun, & Yamamoto, 2010).

Denture stomatitis is one of the most prev-alent denture-related oral conditions. Also known as “chronic atrophic candidiasis,” “ denture-induced candidiasis,” “oral thrush,” and “denture sore mouth,” it presents as inflamed palatal mucosa beneath a maxillary complete denture (see Figure 1). The etiologic factors for denture stomatitis include denture trauma, allergy, poor oral and denture hygiene, immune system compromise, and infection with Candida species of fungus (Bansal, Sharma, Bhanot, & Chahal, 2013).

Several species of Candida may be detected in oral mucosa lesions and the intaglio (tissue) surface of dentures: Candida albicans, Candida glabrata, Candida tropicalis, and Candida parapsilosis. Candida albicans has been found to be the most common fungal species, being detected in 54% of oral lesions and nearly 40% of denture tissue surfaces (Koba, Koga, Cho, & Kusukawa, 2013).

In a study of 48 complete denture wear-ers and 43 controls (non-denture wearers), Bianchi and colleagues (2016) found a statisti-cally significant association between the use of removable dental prostheses and the presence of oral candidiasis. Elderly individuals who wore removable dental prostheses showed a 6.9-fold higher chance of developing oral candidiasis compared with elderly non-wearers.

Treatment of chronic atrophic candidiasis must include:

1. removal of dentures at night;

2. improvement in oral hygiene and denture hygiene;


3. evaluation of both denture fit and intaglio surface and reline or remake of the prosthe-sis as needed; and

4. treatment of acute mucosal symptoms with antifungal medication, including nystatin, amphotericin B, or miconazole (Bansal et al., 2013). Warm salt water rinses are also help-ful in soothing and healing the oral tissues.

It is clear that denture hygiene is critical in the prevention of denture-related adverse health events (e.g., aspiration pneumonia, den-ture stomatitis). Research has also shown that patients are often unaware of the risks asso-ciated with improper denture care and how to avoid them (de Castellucci et al., 2008). Evidence-based recommendations for denture hygiene, developed by an American College of

Prosthodontists task force, have been published (Felton et al., 2011). These recommendations are an excellent source of patient education material. However, there is still a significant need to compare denture cleansing methods, especially with regard to antimicrobial effects on denture materials (Axe, Varghese, Bosma, Kitson, & Bradshaw, 2016).

Cancer

In a meta-analysis of 10 studies, Zeng and colleagues (2013) found a direct association between tooth loss and cancer of the head and neck region. Loss of 20 or more teeth resulted in a 1.89 times greater risk of acquiring head and neck cancer. The authors concluded that tooth loss is probably a significant risk factor for head and neck cancer. This risk escalates

FIGURE 1: CHRONIC ATROPHIC CANDIDIASIS (DENTURE STOMATITIS)

Note. From Western Schools, 2018.


with increasing tooth loss (after six teeth have been lost). However, the authors also note that “the association of tooth loss with [head and neck cancer] might or might not be causal” (p. 7).

A meta-analysis by Wang, Hu, Gu, Hu, and Wei (2013) also showed that tooth loss is asso-ciated with an increased risk of head and neck cancer. On the other hand, dental status was not significantly associated with cancer mortality in the study by Watt and colleagues (2012) men-tioned previously.

In a meta-analysis done to determine the relationship between dentures and the develop-ment of oral cancer, Manoharan, Nagaraja, and Eslick (2014) found that the use of dentures is associated with an increased risk of developing oral cancer (odds ratio = 1.42, meaning 1.42 times greater risk). Furthermore, ill-fitting den-tures appear to substantially increase the risk of oral cancer (odds ratio = 3.90).

Cognitive Disorders (Dementia)

Okamoto and colleagues (2015) conducted a 5-year prospective cohort study of 2,335 indi-viduals to investigate the effect of tooth loss on the development of mild memory impairment (MMI) among older adults, assessed using the Mini-Mental State Examination (MMSE). A significant association was found between tooth loss and cognitive dysfunction. There was a 2.39 times greater risk of decline in cognitive function (odds ratio = 2.39) in the edentulous patients than in the dentate cohort. The study authors presented biological expla-nations for the relationship between tooth loss and memory disorder, including genetic risk factors related to both periodontal disease and MMI and the inflammatory burden of perio-dontal disease.

Another large-scale (11,140 patients) study examined the association of oral disease with

dementia/cognitive decline in a type 2 diabetic population (Batty et al., 2013). The main find-ing was that, relative to the group with the most teeth (>22), being edentulous was associated with the highest risk of developing dementia and cognitive decline.

Mortality

In the systematic review of 23 studies by Polzer and colleagues (2012) mentioned above, only one high-quality study (meeting defined criteria) found a relationship between the num-ber of teeth and all-cause mortality. No treat-ment recommendations were made, given the inconsistent results of moderate- and high- quality studies. No studies were found that in-vestigated whether replacement of missing teeth is protective against mortality.

Watt and colleagues (2012) found that, after adjusting for demographic, socio-economic, behavioral, and health status, edentulous sub-jects had significantly higher risk of all-cause mortality compared with subjects with natu-ral teeth. As mentioned previously, this study found that edentulous individuals were almost three times more likely to die of a stroke than were people with some remaining natural teeth.

In a study of 1,803 patients over a 10-year period, Schwahn and colleagues (2013) found an increased risk of death in people with nine or more non-replaced teeth. After adjusting for smoking, alcohol consumption, physical activ-ity, obesity, hypertension, diabetes, and dys-lipidemia, the risk was 1.43 times greater for all-cause mortality.

Liljestrand and colleagues (2015) also found that having nine or more missing teeth increased the risk of death from any cause and that the risk was greater for completely edentulous sub-jects (1.68 times the risk of those with no miss-ing teeth or only one missing tooth).


Psychosocial/Quality of Life Consequences

Edentulism has been shown to adversely affect the quality of life of elderly people, partic-ularly regarding social participation (Rodrigues, Oliveira, Vargas, Moreira, & Ferreira, 2012). A study of 94 residents of long-term care homes in Germany found that oral health-related quality of life was low but showed improvement with better oral health (Zenthöfer, Rammelsberg, Cabrera, Schröder, & Hassel, 2014).

One study noted significant improvement in patients’ oral health-related quality of life (OHRQoL) after treatment of edentulous patients with complete dentures (Sivakumar, Sajjan, Ramaraju, & Rao, 2015). Assessment of 56 patients who had not previously worn dentures (mean age 60.5 years) was done 1 month and 6 months after denture delivery. The oral health impact profile for assessing the levels of dysfunction, discomfort, and dis-ability associated with edentulism on an indi-vidual’s quality of life (OHIP-EDENT) was significantly improved at 1 month and further improved at 6 months. Interestingly, female patients had appreciably greater improvement in OHRQoL after 6 months of denture wear than male patients.

It has been found that a mandibular 2 implant overdenture results in a substantially greater quality of life improvement than is achieved with a conventional complete denture (Cardoso et al., 2016). However, this treat-ment option is obviously more costly, involves surgery, and is not feasible for edentulous indi-viduals with limited economic means (Carlsson & Omar, 2010).

Consequences of Edentulism: The Bottom Line• Edentulism coexists with a variety of adverse

medical and psychosocial conditions.

• However, the exact relationship between tooth loss and disease remains unclear (Emami, de Souza, Kabawat, & Feine, 2013).

• Future research will undoubtedly elucidate the interactions among edentulism, complete denture rehabilitation, and overall health and mortality.

• What has been established thus far is that providing complete dentures to edentulous patients results in a significant improvement in quality of life.

For further reading on the consequences of edentulism, please refer to the Resources sec-tion of this course.

COMPLETE DENTURE IMPRESSIONS

Complete Denture Impression Techniques

The prosthodontic literature recommends a variety of techniques and materials for com-plete denture impressions (Rao, Chowdhary, & Mahoorkar, 2010). However, a paucity of scien-tific evidence exists establishing the superiority of any particular impression technique. For example, according to a review by Carlsson, Örtorp, and Omar (2013), no support exists for the frequent textbook statement that a two-step impression procedure (preliminary and final) is necessary and superior to a one-step method. Even so, the traditional two-step impression procedure is almost universally taught in dental schools in the United States (Petrie, Walker, & Williams, 2005).

Edentulous AnatomyRegardless of the impression technique

used, knowledge of edentulous anatomy is essential for a successful result. Complete denture support is the resistance to vertical movement of the denture base toward the ridge.


Impressions for complete dentures must capture the anatomic areas that provide support for the prosthesis. These stress-bearing areas (in both maxilla and mandible) are made up of corti-cal bone, covered by firmly bound keratinized masticatory mucosa (Jacobson & Krol, 1983). In the maxilla, the primary support areas are the horizontal antero- and posterolateral hard pal-ate. The maxillary ridge crest functions as a sec-ondary support area. The rugae area and midline suture usually require slight relief, while the denture border does not contribute to maxillary denture support (see Figure 2).

The primary support areas in the mandible are the buccal shelf and the pearshaped pad. The pear-shaped pad (first named by Craddock in his 1951 textbook Prosthetic Dentistry) can be defined as “the most distal extension of attached keratinized mucosa overlying the mandibular ridge crest formed by the scar-ring pattern after extraction of the most poste-rior molar” (Glossary of Prosthodontic Terms, 2005, p. 60). The pear-shaped pad should be differentiated from the freely movable retro-molar pad that the Glossary of Prosthodontic Terms defines as “a mass of tissue comprised of

FIGURE 2: MAXILLARY SUPPORT AREAS

Primary: Horizontal antero- and postero-lateral hard palate

Secondary: Ridge crest

Relief (R): Rugae, midline palatal suture

Non-contributing (NC): Denture border



nonkeratinized mucosa located posterior to the retromolar papilla and overlying loose glandu-lar connective tissue. This freely movable area should be differentiated from the pear-shaped pad” (p. 69). The widely held belief that a man-dibular denture must (or should) cover the retro-molar pad makes little anatomic or functional sense. It may be that clinicians are really refer-ring to the keratinized pear-shaped pad anterior to the retromolar pad. The posterior extent of a mandibular denture should be at the junction of the pear-shaped and retromolar pads (Jacobson & Krol, 1983). This junction is located by intra-oral examination (see Figure 3). The second-ary support areas in the mandible are the ridge

crest and area of the genial tubercles. Lingual and labial ridge inclines are either relieved or noncontributing.

For further reading on edentulous anatomy, please refer to the Resources section of this course.

Denture Impression ControversiesTwo studies illustrate the conflicting infor-

mation regarding the optimal technique for complete denture impressions. At the University of Connecticut School of Dental Medicine, an abbreviated impression technique for com-plete dentures is taught at the undergraduate level. This simplified technique involves heat- processed acrylic resin denture bases fabricated

FIGURE 3: MANDIBULAR SUPPORT AREAS

Primary: Buccal shelf and pear-shaped pad

Secondary: Ridge crest and area of genial tubercles

Relief (R) or non-contributing (NC): Lingual and labial ridge inclines



directly on casts obtained from overextended irreversible hydrocolloid (alginate) impres-sions made in stock trays. Border extensions are determined by marking the cast at the point where the alveolar process begins to turn into the vestibule. Researchers Duncan and Taylor (2001) conducted a retrospective study to investigate this technique. Predoctoral (under-graduate) dental students fabricated complete dentures for 80 completely edentulous patients. Of the patients, 40 were treated with traditional impression techniques and 40 were treated with the abbreviated technique. The results showed that the simplified impression technique signifi-cantly decreased the number of visits required to fabricate complete dentures. In addition, a statistically significant reduction in the number of post-insertion visits during the first 3 months was required with the abbreviated impression technique, with no increase in the number of reline procedures. It should be noted that the total amount of denture adjustment time was not reported in the study.

Other studies have produced results in agreement with the Duncan and Taylor study, indicating that a simplified complete denture impression technique produces results equiva-lent to the conventional (traditional) technique. For example, Regis and colleagues (2013) com-pared a simplified method for complete denture fabrication to the conventional protocol in terms of oral health-related quality of life (OHRQoL) in 42 edentulous patients. Methods employed with the simplified (S) group differed from those used with the conventional (C) group in several respects, including the impression tech-nique. In the S group, final casts were made from an alginate impression in stock trays, whereas in the C group, casts were obtained from compound border-molded custom trays and zinc oxide-eugenol paste secondary impres-sions. Three months after denture insertion,

there was no difference in denture quality as assessed by a prosthodontist. At 6 months after insertion of the dentures, there were no sig-nificant differences in patient satisfaction or OHRQoL. Similar findings were reported in an earlier study by Kawai and colleagues (2005).

However, a study conducted by Jo and col-leagues (2015) reported differing results. This study was a crossover randomized controlled trial on 24 mandibular complete dentures fab-ricated using two different impression meth-ods. The conventional method used a custom tray border molded with compound and a sili-cone final impression. The simplified method used a stock tray and an alginate impression. Participants were randomly divided into two groups. The C-S group was treated using the conventional method first, followed by the sim-plified method. The S-C group was treated in the reverse order. For both groups, the maxillary impression was made with silicone in a border-molded custom tray. Adjustment was performed four times. A “wash out period” was set for 1 month, during which time the participants were instructed to use their old dentures. The primary outcome was general patient satisfac-tion, measured using visual analogue scales, and the secondary outcome was oral health-related quality of life, measured using the Japanese version of the Oral Health Impact Profile for edentulous people (OHIP-EDENT-J) question-naire scores. With regard to general patient satisfaction, the study showed that the conven-tional mandibular impression method was sig-nificantly more successful than the simplified method. However, no significant differences were observed between the two methods in the quality-of-life measures.

Impression TechniquesThere is a variety of impression tech-

niques and materials that can provide excel-lent clinical results for the edentulous patient.


Border molding (for final impressions) with compound and a mercaptan rubber base, zinc oxide eugenol, or an elastomeric material (e.g., vinyl polysiloxane or polyether) has tradition-ally been taught for decades (Rao et al., 2010). Alternative techniques, such as employing elas-tomeric border molding (without the use of compound; Massad & Cagna, 2007) produce excellent impressions. Salinas (2009) also dem-onstrated successful final impressions using a variety of materials.

The technique for elastomeric final impres-sions, presented in this section, was developed in the late 1960s by Dr. James E. House at the University of Indiana. Although not described in the dental literature, the “House” technique was taught both at the undergraduate level and in postgraduate prosthodontics residency

programs for many years. This technique has received positive feedback from many clinicians who have been delighted with its efficiency and the results obtained. Once the custom tray is properly adjusted, as described below, the impression procedure is quite rapid, which contributes to a reduced overhead expense. Moreover, the results of border molding can be objectively tested. Patients have also given posi-tive feedback on the speed and comfort of this impression procedure.

Preliminary Impression Technique (Wax-Alginate)

A dentulous stock tray is used (e.g., COE Spacer tray from GC America or Waterpik Tray-Tens impression trays from Water Pik, Inc.; see Figure 4).

FIGURE 4: MAXILLARY DENTULOUS TRAY, PINK BASE PLATE WAX



In general, a slightly larger-size tray works better than a smaller one. The tray is “customized” by placing pink base plate wax (e.g., Hygenic from Coltene or Truwax from DENTSPLY Prosthetics), warmed using a Bunsen burner, in the tray and using the wax as an impres-sion material. After a series of additions and “impressions,” the stock tray is customized with the base plate wax (see Figure 5).

After a little practice, the correct tempera-ture and amount of wax (more ridge resorption requires more wax) can be ascertained more quickly, and the procedure takes very little time. Additionally, the overhead cost of the wax is quite low. This step of the procedure is often described to patients as being “like getting a warm wax spa treatment.”

As shown in Figure 5, the wax produces an “impression” that is purposefully overextended.

Next, alginate adhesive is placed on the wax, and an alginate irreversible hydrocolloid mate-rial (for example, Jeltrate from DENTSPLY Caulk or Supergel from Bosworth) is used to take a wash impression (see Figure 6).

The hydrocolloid material should be kept in a humid environment (a plastic bag with a wet paper towel works well) and then poured within an hour in white plaster (see Figure 7).

A plaster preliminary cast is easier to trim and adjust than a stone cast. If this impression is to be used as the final (secondary) impres-sion, then it is poured in yellow stone. The same wax-alginate technique is used for the mandibu-lar impression (see Figure 8).

The cast obtained from the preliminary impression technique described above can be used as a final impression if the dentist prefers. However, the technique produces an impression

FIGURE 5: MAXILLARY TRAY “CUSTOMIZED” WITH BASE PLATE WAX



FIGURE 6: MAXILLARY ALGINATE IMPRESSION


FIGURE 7: MAXILLARY PRELIMINARY PLASTER CAST



that is intentionally overextended in the border areas. The proper extension of the record base must be indicated on the cast, as described in the study by Duncan and Taylor (2001).

The “House” Technique for Elastomeric Final Impressions

Maxillary Impression

The practitioner uses a custom tray mate-rial such as Triad TruTray from DENTSPLY Prosthetics (a light-cured urethane dimethacry-late) or Fastray from Bosworth (a self-curing acrylic) to fabricate a custom tray. First, the extent of the tray and an area of relief (one layer of wax) over the rugae area are marked on the preliminary cast (see Figure 9).

No other relief for the tray is needed. After the tray is made and adjusted to the line indicated on the preliminary cast as seen in Figure 10, it

is placed in the mouth and adjusted so that it is 2 mm short of the mucobuccal fold, defined by the Glossary of Prosthodontic Terms (2005) as “the line of flexure of the mucous membrane as it passes to the cheek” (p. 53). The mucobuccal fold is also referred to as the peripheral turn, or vestibule, and is the area where the denture bor-der ends (see Figure 11).

This is a critical step. If the tray is over-extended, the impression procedure takes con-siderably longer. Mercaptan polysulfide “rubber base” (e.g. Permlastic from Kerr Restoratives or COE-FLEX from GC America) is the material of choice for this technique. Vinyl polysiloxane (VPS) impression materials (e.g., Reprosil from DENTSPLY Caulk or Imprint from 3M) also work well, although they are generally more expensive. Vinyl polysiloxane materials are more palatable to patients, however, and can be

FIGURE 8: MANDIBULAR PRELIMINARY IMPRESSION AND PRELIMINARY PLASTER CAST



FIGURE 9: PRELIMINARY CAST IS MARKED FOR VESTIBULAR DEPTH, CUSTOM TRAY BORDER, AND RELIEF OVER RUGAE


FIGURE 10: MAXILLARY CUSTOM TRAY (TRIAD TRUTRAY)



used with convenient cartridge systems. They are also more dimensionally stable than the mercaptan materials.

Coat the entire tray, including the labial and buccal borders, with polysulfide adhesive. If a Triad oven is available, placing the tray inside for about 45 seconds will set up the adhesive (see Figure 12). The first material applied is regular body polysulfide (see Figure 13).

The regular body polysulfide is placed inside the tray, as a 3-mm-wide application, around the entire inside border (including the posterior palatal seal area on the maxillary tray). The material is not placed on the peripheral turn, as this is not the border-molding step. The purpose of this first application is to lightly compress and seal the movable mucosa against the alveolar bone. This task can be accom-plished in one entire application of material (see Figures 14, 15, and 16).

Significant retention is gained from this application of material to seal the movable mucosa. After this step is completed, border molding is accomplished by again applying regular body polysulfide onto the tray periph-ery and gently manipulating the tissues. For the maxilla, stand behind the patient and use both index fingers to hold the impression tray firmly against the palate. The clinician should have the patient move his or her jaw from side to side. This will move the coronoid processes and mold the material in the posterior. This step should be practiced with the patient prior to placing the tray intraorally. Next, the dentist’s palms are used to press the patient’s cheeks against the tray, molding the material from the tuberosity to the cuspid, bilaterally. Finally, the thumbs are used to mold the patient’s upper lip against the anterior part of the impression tray. (The clinician should push the upper lip in and

FIGURE 11: MAXILLARY CUSTOM TRAY TRIED IN MOUTH, ASSURING THAT IT IS TWO MILLIMETERS SHORT OF THE MUCOBUCCAL FOLD



up.) Alternatively, the patient can suck in on the dentist’s index finger or a straw. The border molding can be done in one step or via multiple applications of material (see Figures 17 and 18).

After completion of the border molding, the borders are objectively tested. This testing is done using either a periodontal probe or the dentist’s thumbnail (see Figure 19).

The goal is ideally to have a depth of 2 mm of polysulfide around the entire periphery. A depth up to 4 mm is acceptable, but beyond

that the border is subject to distortion. Contact with the tray border before 2 mm of material is probed means that the tray was overextended. In this case, the polysulfide material is removed from the overextended area and the tray is shortened. A large green lathe wheel works very well for this purpose. The tray is lightly held against the wheel and the polysulfide comes off easily (see Figures 20 and 21).

After these corrections are made, more of the medium-body polysulfide is applied to the

FIGURE 12: MAXILLARY CUSTOM TRAY WITH POLYSULFIDE ADHESIVE APPLIED, ON TABLE OF TRIAD OVEN


FIGURE 13: REGULAR BODY POLYSULFIDE


continued on page 22


FIGURE 14: FIRST (THREE MILLIMETERS WIDE) APPLICATION OF POLYSULFIDE


FIGURE 15: FIRST APPLICATION OF POLYSULFIDE, INSIDE ENTIRE PERIPHERY



FIGURE 16: FIRST APPLICATION OF POLYSULFIDE HAS SET


FIGURE 17: BORDER MOLDING MAXILLARY TRAY WITH REGULAR BODY POLYSULFIDE



FIGURE 18: BORDER MOLDING POLYSULFIDE HAS SET


FIGURE 19: DEPTH OF POLYSULFIDE ON PERIPHERY IS TESTED, SHOULD BE ABOUT 2 MILLIMETERS



FIGURE 20: LATHE WHEEL IS EMPLOYED TO REMOVE AREAS OF TRAY OVEREXTENSION


FIGURE 21: MAXILLARY TRAY REDUCED IN AREAS OF OVEREXTENSION



adjusted areas of the tray and the border mold-ing procedure is repeated for those areas (see Figure 22).

The peripheral border is again tested as before. If measurement confirms at least 2 mm of polysulfide, the border-molding step is con-sidered complete (see Figure 23).

Next, a long-shank (laboratory) No. 8 round bur is used to make a vent hole in the rugae area. Light body polysulfide is applied as a thin “buttery” layer (or “wash”) to complete the impression (see Figure 24).

The same border-molding procedure (as described above) is done while the wash mate-rial sets. This completes the maxillary impres-sion (see Figure 25).

Any small defects or voids in the impression can be corrected with sticky wax or boxing wax. If the dentist chooses to place a posterior palatal seal at this stage, it can also be done with either

sticky wax or boxing wax. Some practitioners prefer to carve in the post dam on the master cast. The final impression is boxed and poured in yellow stone (see Figure 26).

As mentioned above, vinyl polysiloxane impression material can also be used in this technique. In Figure 27, heavy-body Reprosil is used for sealing the mucosa and border mold-ing. Medium-body Reprosil is used for the wash (see Figure 28). Other brands of VPS material can also be used. Figure 29 shows the prelimi-nary impression (wax-alginate), plaster cast, final impression (vinyl polysiloxane [VPS]), and cast.

Mandibular Impression

The mandibular custom tray is made using the same materials as the maxillary tray. There is no relief/spacer incorporated into the lower tray. As explained previously, the posterior extent of the denture, and therefore the custom

FIGURE 22: REGULAR BODY POLYSULFIDE IS ADDED TO THESE AREAS



tray, should be at the junction of the keratinized pear-shaped pad and the non-keratinized retro-molar pad (see Figure 30). A mouth mirror can be used to depress the tissue over the posterior ridge crest. A marked increase in depressability

of the tissue usually demarcates the anterior border of the retromolar pad (see Figure 31).

For the mandibular impression, the sequence of application of material is the same as in the maxilla.

FIGURE 23: MAXILLARY BORDER MOLDED CUSTOM TRAY


FIGURE 24: LIGHT BODY POLYSULFIDE (FOR WASH)




FIGURE 25: MAXILLARY FINAL IMPRESSION


FIGURE 26: MAXILLARY YELLOW STONE MASTER CAST



FIGURE 28: WASH DONE WITH MEDIUM BODY REPROSIL, IMPRESSION BOXED (PLASTER AND PUMICE), MAXILLARY MASTER CAST


FIGURE 27: MAXILLARY CUSTOM TRAY WITH HEAVY BODY REPROSIL

A. Custom tray, 2 mm short of peripheral turn

B. Areas of tray show through are relieved

C. Heavy body first applied inside tray periphery

D. Heavy body applied to periphery



FIGURE 29: PRELIMINARY IMPRESSION (WAX-ALGINATE) AND PRELIMINARY PLASTER CAST, FINAL IMPRESSION (VPS) AND STONE MASTER CAST


FIGURE 30: MANDIBULAR CAST SHOWING POSTERIOR EXTENT OF MANDIBULAR DENTURE



The border molding procedure for the man-dible is as follows:

1. Pressure is applied to the patient’s cheeks with the dentist’s palms; this forms the bor-der from molar area to cuspid.

2. Both thumbs are placed across the patient’s lower lip (at about the cervical level of the denture teeth), pushing inward and down-ward; alternatively, the patient can suck on the dentist’s index finger or a straw to mold the anterior border.

3. Both thumbs are placed anteriorly (at the mandibular central incisor area) about 1 inch outside the mouth. The patient is instructed to move the tip of the tongue

forward and to push (as hard a possible) against the dentist’s thumbs. This border molds the lingual areas, bilaterally. A final impression is thereby obtained that is not overextended posteriorly (see Figure 32).

Vinyl polysiloxane can also be used for the mandibular final impression, in a fashion simi-lar to that for the maxillary impression.

In summary, there are a variety of complete denture impression techniques and materials that, when properly employed, can produce clinically excellent results. The key is to record the relevant edentulous anatomy of the mouth and to make the impressions when the tissues are in optimal health. In addition, pre-prosthetic surgery, for

FIGURE 31: INTRA-ORALLY DELINEATING JUNCTION OF PEAR-SHAPED AND RETROMOLAR PADS


Retromolar pad is outlined

Denture ends at junction of pear-shaped and retromolar pads


example, to reduce or eliminate bony under-cuts, exostoses, and unfavorable frenum/ muscle attachments is important for clinical success (Costello, Betts, Barber, & Fonseca, 1996).

Complete Denture Impressions: The Bottom Line• A variety of impression techniques are

available that can produce excellent clinical results.

• Knowledge of relevant edentulous anatomy is essential for the clinician.

• Impressions should be made with the tissues in health. Tissue conditioning and treatment of any existing Candida infection should be done prior to the final impression.

• Pre-prosthetic surgery, when indicated, is important for a successful outcome.

ANTERIOR TOOTH SELECTION

Prosthodontic research is replete with rec-ommendations on the selection of anterior

teeth for complete dentures (Sellen, Jagger, & Harrison, 1999; Ibrahimagić, Jerolimov, & Čelebić, 2001; Kumar, Ahila, & Devi, 2011). Young (1954) reported on 21 techniques for selecting the anterior tooth mold, which were published between 1872 and 1951. Many of these suggestions, however, lack any appreciable valid research or scientific basis. For example, in

FIGURE 32: MANDIBULAR POLYSULFIDE FINAL IMPRESSION


Step 1: Regular body inside turn

Step 2: Regular body border molding

Movable mucosa is sealed

Step 3: Light body wash


1884, J. W. White described the “temperamental technique,” in which tooth molds are classified as “sanguine” (optimistic), “phlegmatic” (sluggish), “choleric” (bad-tempered), or “melancholic” (sad). In 1913, Cigrande described the “finger-nail technique,” in which the outline form of the finge rnail was used to select the outline form of the maxillary central incisor (Young, 1954).

In this section, four basic questions will be investigated relative to anterior tooth selection:

1. Is there a relationship between sex and tooth size or shape?

2. Is there a relationship between face shape and tooth shape?

3. Is there a relationship between face size or facial/intraoral landmarks (anatomy) and tooth size?

4. Do patients have a preference for a particu-lar tooth selection or arrangement?

As would be expected, there is controversy surrounding some of these issues. Varying research methodologies studying diverse patient populations (e.g., ethnicities) often make reaching a unified conclusion problematic. Nevertheless, some of the older and more recent publications will be reviewed with the intent of shedding light on this topic.

Relationship Between Sex and Tooth Size and Shape

Male teeth are generally larger than those of females (Adeyemi & Isiekwe, 2003; Ellakwa et al., 2011; Gillen, Schwartz, Hilton, & Evans, 1994; Sterrett et al., 1999). However, a per-son’s sex cannot be determined by examin-ing only the shape or size of the anterior teeth (Burchett & Christensen, 1988). In Burchett and Christensen’s classic study, the anterior teeth of 16 dental patients having no or minimal ante-rior restorations were photographed. Then 48 dentists, 67 dental laboratory technicians, and

27 dental auxiliaries attempted to determine the age and sex of each patient. The percentages of correct determinations for age were dentists 36%, laboratory technicians 36%, and auxilia-ries 35%. The percentages of correct determi-nations for sex were dentists 55%, laboratory technicians 53%, and auxiliaries 51%. (The percentages of correct sex determination were higher because there were only two choices for sex and three age groups.) The authors concluded that determining the age and sex of patients by observing only their anterior teeth was “difficult” (p. 179).

In a study published in 2002, Berksun, Hasanreisoğlu, and Gökdeniz asked 13 prostho-dontists to identify the sex of 60 dental students based on digital photographic records of full face, dental arch, and anterior tooth images. The results showed that these experts were unsuc-cessful in distinguishing the subject’s sex by visual assessment of just the anterior teeth.

Wolfart, Menzel, and Kern (2004) similarly concluded that the 10 dentists participating in their study were not capable of determining a subject’s gender from only intraoral photo-graphs of the anterior teeth. No significant cor-relation was found between tooth shape and sex.

A more recent study (Jassé et al., 2012) had 15 judges (three orthodontists, three restorative dentists, three prosthodontists, three recently graduated general practitioners, and three lay-persons) analyze digital photographs of 40 den-tal students (20 men, 20 women). The digital images exposed only the labial surfaces of the occluded anterior teeth; lips were not visible in the photographs. The photographs of men and women were correctly selected 58.8% and 57.6% of the time, respectively. There was no statistical difference in correct responses between the groups of professionals and the laypersons. The conclusion reached was that


differentiating sex by viewing photographs of anterior teeth was not possible.

The concept, or philosophy, of “dentogen-ics” (Frush & Fisher, 1956) proposed that ante-rior teeth can be made to look feminine by using oval, rounded shapes; conversely, mas-culinity can be exemplified by square shapes. Although this differentiation does not actu-ally occur in nature, as seen in the study by Brunetto, Becker, and Volpato (2011), people (laypersons) have demonstrated a preference for ovoid teeth in women and square teeth in men (Marunick, Chamberlain, & Robinson, 1983). However, as discussed in the next section, there is considerable variability in patients’ esthetic desires and choices.

Relationship Between Face or Arch Shape and Tooth ShapeFace Shape and “The Law of Harmony”

The subject of facial esthetics has been debated for more than a century. In 1906 Frederick H. Berry stated: “After years of careful comparison I find, that almost without exception, the shape of the face turned upside down is the edge shape of the upper central inci-sor which belongs to that face” (p. 407). Berry termed this observation “the laws of Harmony” (p. 406) and described this as the correct way to select the maxillary central incisors for denture patients. However, no research was provided by Berry to substantiate this concept.

J. Leon Williams (1914) conducted exten-sive studies of human and animal skulls while at the Royal College of Surgeons in London. Based on his observations, Williams found that teeth can be classified into three basic shapes: square, tapering, and ovoid. Williams similarly classi-fied faces into four basic forms: square, taper-ing, oval, and ovoid (a more rounded shape than oval). These classifications have been shown to be valid, with some variation (Ibrahimagić,

Jerolimov, Čelebić, Carek, et al., 2001). Many dental companies continue to use this shape clas-sification as the basis for tooth manufacturing (e.g., Trubyte teeth from DENTSPLY, Kenson teeth from Myerson).

Williams also discovered that, paradoxically, the shape of the skulls and the maxillary anterior teeth most often were dissimilar. Williams thus proposed his own “Law of Harmony” theory, by which the maxillary central incisors should be selected to match the perceived face form, using square, tapering, or ovoid shapes. The inten-tion was to improve on Nature’s “imperfection” (Williams, 1914, p. 28) by matching face and inverted central incisor tooth form, even though this matching does not generally occur naturally. Williams’s recommendation appears to have been purely subjective, since, as with Berry, Williams presented no research in his 1914 work to substantiate his “Law of Harmony.” However, this system of tooth selection based on facial harmony was quite popular, and is still taught and in use today.

Numerous studies have since been published attempting to clarify the relationship between face and anterior tooth shape. In a 2015 study, Shaweesh, Al-Dwairi, and Shamkhey, using Fourier analysis, found that in Jordanian adults, the face and maxillary central incisor shapes were significantly and quantitatively related. Fourier analysis is a mathematical method that quantitatively analyzes shapes and forms. Shaweesh and colleagues claimed that the face form could be used to select anterior tooth form for complete dentures or complex anterior resto-rations. The authors suggested that differences in research methodologies may partly explain their disagreement with other studies.

Conversely, other researchers have reported an insignificant relationship between the face shape and inverted maxillary central incisor tooth form (Ibrahimagić, Jerolimov, Čelebić, Carek,


et al., 2001; Koralakunte, & Budihal, 2012; Mavroskoufis & Ritchie, 1980; Varjão, Nogueira, Russi, & Arioli Filho, 2006; Wolfart et al., 2004).

Ibrahimagić, Jerolimov, Čelebić, Carek, and colleagues (2001) conducted one of the most extensive studies on the correspondence between the face and the tooth form. Two thou-sand individuals from the city of Zenica, in the nation of Bosnia and Herzegovina, were mea-sured for three horizontal distances on both the face and the central incisors. Three basic face forms were identified: oval (83.3%), square-tapered (9.2%), and tapered (7%), and three basic central incisor forms were identified: tapered-square (53%), oval (30%), and tapered (16%). Tooth and face forms matched in only 30% of the population studied. The most com-mon combination was the oval face and the tapered-square incisor.

Varjão and colleagues (2006) studied 160 subjects (40 whites, 40 blacks, 40 mixed white and black, 40 Asians) aged from 18 to 33 years. Photographs were taken of the face and max-illary right central incisor, and then outline tracings were made using computer software. Three prosthodontists were asked to determine if any correspondence could be found between tooth and face form. Results indicated a cor-relation in only 23.75% of the subjects. The authors concluded that no “highly defined cor-relation” exists between tooth and face form in the racial groups studied (Varjão et al., 2006, p. 771). Additional evidence of the lack of face and tooth shape correlation can be seen in studies by Koralakunte and Budihal (2012), Mavroskoufis and Ritchie (1980), and Wolfart and colleagues (2004).

It is possible that an ethnic component to the face-tooth shape relationship exists. In certain populations, as in the Shaweesh study (2015), there is a correlation between the shape of the face and the central incisor. That said, the

preponderance of dental literature does not sup-port this relationship.

The dentist and patient together should select the most appropriate denture teeth. Some clini-cians believe that the size of the anterior teeth, especially the central incisors, and their arrange-ment are of more importance to the esthetic out-come than the actual shape of the teeth. These issues are further discussed below. It has also been shown that the shape of the denture tooth is often obscured by the gingival (pink) component of the denture base (Seluk, Brodbelt, & Walker, 1987), which may minimize the importance of the actual denture tooth shape.

Arch Shape

Sellen and colleagues (1999) found an insig-nificant correlation between the shape of the maxillary arch and the shape of the maxillary central incisors. This finding was corroborated by Shaweesh and colleagues (2015), who found no relationship between tooth and maxillary arch outlines or between face and maxillary arch outlines.

Relationship Between Face Size or Anatomy and Tooth SizeFace Size

Many dentists have attempted to relate tooth size to face size. One of the first to pub-lish numerical data was J. A. Wavrin, in 1920. Wavrin reported a 16:1 ratio for face width to maxillary central incisor width and a 20:1 ratio for face length to maxillary central incisor length. These findings were later validated by M. M House (1939). House took bizygomatic mea-surements and mandibular symphysis-to-hairline measurements in 555 individuals. The ratio of these measurements to maxillary central inci-sor width and length, respectively, ranged from 19:1 to 13:1. However, a ratio of 16:1 was found to be a good reference for selecting tooth size. Bizygomatic width divided by 16 was equivalent


to the central incisor width; symphysis-to- hairline length divided by 16 was equivalent to the central incisor length. House termed this relationship the “bio-metric ratio of tooth size to face size” (p. 16). LaVere, Marcroft, Smith and Sarka (1992) describe a denture tooth selection device based on this 16:1 ratio. Although F. H. Berry (1906) is often cited in reference to the origination of the “bio-metric ratio” and might have lectured on this subject, no mention of this measurement is made anywhere in Berry’s paper.

Numerous researchers have tested the “bio-metric ratio” for its dependability as a tool in selecting anterior denture teeth. In 1967, Kern measured 509 skulls with intact dentitions and failed to find a high consistency in the ratio between the bizygomatic measurements (of the skulls) and the widths of the crowns of the maxillary central incisors. Scandrett, Kerber, and Umrigar (1982) found that, although a 16:1 ratio was confirmed, the correlation was not of sufficient magnitude to justify the use of the 16:1 ratio for an individual edentulous patient. Similarly, Radia, Sherriff, McDonald, and Naini (2016) found a bizygomatic maxillary central incisor width ratio of 15.56:1. However, the standard deviation (slightly over 1), the 95% confidence intervals, and gender differences caused the authors to suggest caution in the use of the 16:1 ratio and recommend its use only as a guide rather than an absolute.

Facial or Intraoral Anatomy

Intercommissural Width

Intercommissural width is the distance between the junction of the upper and lower lip lateral to the angle of the mouth. In 2001, Ibrahimagić, Čelebić, and colleagues compiled anatomic measurements made directly on two thousand individuals. A ratio of 1.23:1 was found between the intercommissural distance and max-illary cuspid-to-cuspid width (distal surfaces).

Interalar Distance

Interalar distance (IA), or nasal width, is the distance between the most lateral aspects of the alae nasi.

Kern’s 1967 study of 509 skulls found that nasal width and maxillary incisor (centrals plus laterals) width were equal to or within 0.5 mm in 93% of samples. Conversely, Mavros-koufis and Ritchie (1981) measured nasal width on live subjects and found no relation-ship between the nasal width and the width of the maxillary incisors. However, the study did demonstrate an almost equivalent distance between the intercanine distance (straight dis-tance between the cuspid tips) and the nasal width. According to the authors, the arc width of the cuspids (in the skeletal Class I edentu-lous patient) can be derived by adding 7 mm to the nasal width.

Hoffman, Bomberg, and Hatch (1986), found that multiplying the IA by 1.31 can pro-vide a good estimate of the combined width of the circumferential arc distance between the dis-tal surfaces of the maxillary cuspids.

Of various anatomic landmarks studied, Ibrahimagić, Čelebić, and colleagues (2001) found the dimension with the highest correla-tion to be the straight-line width between the tips of the maxillary cuspids (measured directly on the patient) and the IA. This ratio was 1:1.04.

Gomes, Gonçalves, Costa, and De Lima Lucas (2009) analyzed whether there is a con-sistent relationship between the IA and the combined mesiodistal width of the six maxil-lary anterior teeth. In a study of 81 dentate Brazilian subjects, it was found that, when increased by 31%, the IA could suggest the circumferential distance of the six maxillary anterior teeth as measured between the distal surfaces of the maxillary canines. The authors concluded that the width of the nose, when


measured in digital photographs, can be utilized as a reliable guide for the selection of the max-illary anterior teeth width.

Conversely, Qamar, Hussain, and Naeem (2012) found no correlation between the IA and the combined mesiodistal width of max-illary anterior teeth in their study of edentu-lous patients in the Pakistani population. The researchers concluded that the IA was not a reli-able predictor for the selection of the width of maxillary anterior teeth.

Interpupillary Distance

Interpupillary distance (IPD) is the distance between the center of the pupils of the two eyes.

Cesario and Latta (1984) studied 100 indi-viduals (25 black men, 25 white men, 25 black women, and 25 white women). The ratios between the IPD and the mesiodistal width of the maxillary central incisor were 6.5:1 for white men and black women, 6.6:1 for white women, and 7:1 for black men. The authors concluded that the IPD can be used reli-ably in selecting maxillary anterior teeth for prosthodontics.

Isa, Tawfiq, Noor, Shamsudheen, and Rijal (2010) used image analyzing software to deter-mine the IPD, inner canthal distance (ICD), and IA of 60 dentate Malaysian adults. Widths of the six maxillary anterior teeth were measured directly from casts of the subjects, using digital calipers. Regression models were employed to predict the widths of the anterior teeth using a combination of the facial dimensions studied. It was found that the width of maxillary central incisor equals 4.22 plus 0.07 times IPD.

Al-Kaisy and Garib (2016) found that in a Kurdish population the proportion between the IPD and the central incisor width was 6.93. They concluded that the IPD can be used to pre-dict the width of anterior teeth in both sexes.

Inner Canthal Distance

Inner canthal distance (ICD) is the distance between the medial angles of the palpebral fissures of the eyes (the opening between the eyelids).

Tandale, Dange, and Khalikar (2007) mea-sured the ICD and the intraoral maxillary cen-tral incisor widths in 210 patients. The ICD multiplied by 0.271 gave an accurate estimate of the central incisor width.

George and Bhat (2010) found a relation-ship, termed the “golden proportion,” between the ICD and maxillary central incisor width, in subjects living in southern India. In geometry, the “golden proportion” is a ratio of 1.618:1 and its reciprocal 0.618. As measured in 300 indi-viduals, the ICD, when multiplied by 0.618 and divided by 2, was a reliable predictor of maxil-lary central incisor width. This finding was pre-viously reported by Abdullah (2002) in a Saudi Arabian population.

Multiple Variables

Scandrett and colleagues (1982) found that multiple metrics were required to predict the width of the maxillary anterior teeth and central incisors because no single predictor was accu-rate enough for clinical application.

Ellakwa and colleagues (2011) found that maxillary arch width and length and IA were the most highly validated indicators of anterior tooth size, and that combining these measures improved the strength of the correlation.

Maxillary Cast Measurements

Baker, Morris, Lefebvre, Price, and Looney (2010) studied various measurements on eden-tulous casts to see if any could be useful in the selection of maxillary anterior teeth. The dis-tance from left to right mid-hamular notches, plus 10 mm, was the best (of 6 measurements) in estimating the cuspid-to-cuspid width, correctly classifying more than 50% of both the medium


and large casts. The canine-to-canine distance was derived by measuring a contoured maxillary wax rim from each relaxed commissure.

Clinical Application of Anterior Tooth Research

It is evident that some tooth-size measure-ment techniques may be difficult to apply clini-cally. However, by selecting a larger tooth for a larger face size and a smaller tooth for a smaller face size, a favorable esthetic result can be obtained. The tooth shape and face shape do not need to coincide. A square or ovoid tooth shape will work well for most patients. Often, using two different shapes (tooth moulds) for the right and left maxillary lateral incisors can create a more natural-looking smile. It is important to note that patient input into tooth selection is an essential element contributing to patient satis-faction with the esthetic outcome of complete dentures (Hirsch, Levin, & Tiber, 1972). A low-pressure and unhurried setup try-in appointment is important for patient satisfaction with denture esthetics. Modification of the anterior setup, if needed, can be done chairside or via detailed instructions to the laboratory technician. It is also recommended that the clinician have the patient look at the setup using a large (full face,

at least) wall mirror, at arm’s length. This is the “social distance” and will allow the patient a more realistic assessment of the esthetics.

Patient Preferences for Tooth Selection and Arrangement

In an excellent review of complete den-ture esthetics, Waliszewski (2005) illustrated and described three basic esthetic types: “natu-ral,” “supernormal,” and “denture look” (see Figure 33). Interestingly, in a subsequent study, 147 edentulous patients (88 female, 59 male) viewed full face photos of six test subjects for whom each of the three denture esthetic types were created (Walszewski, Shor, Brudvik, & Raigrodski, 2006). The “natural” setup used anterior teeth that two clinicians had chosen based on anatomic averages for the patients’ size, age, and sex. The “supernormal” anterior tooth arrangement used teeth 1.5 mm longer and 1.0 mm wider than the “natural” arrangement. The “denture look” setup used anteriors 1.5 mm shorter and 1 mm narrower than the “natu-ral” anteriors. All three tooth selections were the same shade, based on the subjects’ age. It was found that 55% of respondents preferred the “natural” setups, while 19% preferred the

FIGURE 33: DENTURE ESTHETICS – NORMAL, SUPERNORMAL, AND DENTURE LOOK

A. “Normal” appearance B. “Supernormal” appearance C. “Denture look” appearance

Note. From Waliszewski, M. (2005). Restoring dentate appearance: A literature review for modern complete denture esthetics. Journal of Prosthetic Dentistry, 93(4), 386-394.


“supernormal,” and 26% preferred the “denture look.” Thus, 45% of the respondents preferred appearances that were not anatomically average (Waliszewski, 2005). The author concluded that there was no clear preference in esthetics, and that time spent with the patient was necessary in order to ensure patient approval of his or her “denture look” (Waliszewki, 2005).

As described by Shor, Shor, and Goto (2005), a patient’s “body image” (the percep-tions, thoughts, and feelings about one’s body and bodily experience) can have significant effects upon certain patients’ satisfaction with denture (and dental) esthetics. Esthetic results that may be perfectly acceptable to the clinician may not be acceptable to these individuals if they are not in alignment with their body image. These researchers also emphasized the impor-tance of proper communication between the dental team and the patient.

In a 1980 study, Brisman showed drawings and photographs of different shapes, symme-tries, and proportions of maxillary central inci-sors to 112 dentists, 215 dental students, 399 male patients, and 695 female patients. No facial photos were included. Brisman found that most dentists disliked the “piano key” or “picket fence” compositions, but that many patients preferred this anterior tooth arrangement. A significant difference was found between the evaluations of patients and dentists, and the preferences of dental students fell between those of patients and den-tists. Male and female patients had similar opin-ions. It is important to note that a vital element in esthetic outcome is how patients see their smiles.

In a 2016 study by Pithon and colleagues, evaluators (150 laypersons) of various age groups were asked to evaluate photographs of smiling denture patients. Image manipulation software was employed to alter the amount of the maxillary anterior teeth that showed. Gingival margins of the maxillary anterior teeth

and exposure of the mandibular teeth were not altered. The correlations between the ratings of the three age groups (15 to 19 years, 35 to 44 years, and 65 to 74 years) were significant and strong (r > 0.9). Complete dentures showing smiles in which the lower border of the upper lip coincided with the cervical margins of the maxillary anterior teeth were rated the most acceptable. Less exposure of the maxillary teeth corresponded with reduced attractiveness.

Limited research exists on patient prefer-ences relative to the coincidence of face shape and tooth shape. Mavroskoufis and Ritchie (1980) reported that more esthetically pleasing appearances were noted when there was dis-similarity of face and tooth shapes. However, it is not clear who was making this assessment, and there were no quantitative data presented. Marunick and colleagues (1983) investigated whether laypersons preferred tooth shape and face shape to be similar. The researchers asked 110 people (none of whom were dental pro-fessionals) to view photographs of six eden-tulous people (3 males and 3 females), who had distinctly square, tapering, or ovoid faces. The individuals in the photographs were shown smiling, with a maxillary denture displaying square, tapering, or ovoid teeth. A statistically significant preference was found only for square teeth with square facial form. As mentioned pre-viously, ovoid teeth were preferred for females, and square teeth were preferred for males.

The importance of patient involvement in complete denture esthetics has been recognized for many years. In a 1964 study, Rosenthal, Pleasure, and Lefer found that patients who were given significant control over their denture esthetics had greater postinsertion satisfaction and fewer postinsertion adjustments compared with a control group for whom the esthetic deci-sions were made mostly by the dentist.


See the Resources section of this course for further reading on denture esthetics. Examples of common complete denture esthetic problems and solutions are shown in Figures 34 to 40.

Anterior Tooth Selection: The Bottom Line• Men have slightly larger maxillary anterior

teeth than women. However, a person’s sex cannot be determined by examining the max-illary anterior teeth.

• Teeth in specifically “masculine” or “femi-nine” shapes do not exist naturally. However, a maxillary denture may be made to appear more masculine or feminine by employing more square- or ovoid-shaped maxillary ante-rior teeth, respectively.

• Three basic maxillary anterior tooth and face shapes are observed in people: square, ovoid, and tapering. Most research does not show that the tooth and face shape of an individual

FIGURE 34: COMPLETE DENTURE ESTHETICS – RESTORATION OF VERTICAL DIMENSION

A. Patient with existing dentures in maximum intercuspation: Marked loss of occlusal vertical dimension (VDO).


B. Existing dentures: Loss of vertical dimension and pseudoprognathism.

FIGURE 35: COMPLETE DENTURE ESTHETICS – RESTORATION OF VERTICAL DIMENSION

A. New complete dentures restoring vertical dimension and smile.


B. New dentures: bilateral posterior crossbite and anterior Class 3 occlusion.



FIGURE 36: COMPLETE DENTURE ESTHETICS – CORRECTION OF UNEVEN SMILE

A. Existing denture: uneven smile; poor esthetics.


B. New denture: improved esthetics.

FIGURE 37: COMPLETE DENTURE ESTHETICS – CHANGE IN MAXILLARY ANTERIOR TOOTH SIZE

A. No maxillary anterior teeth are visible during normal smile.


B. Patient must force lip up to display anterior teeth which are small (relative to face size), and positioned too superiorly.

FIGURE 38: COMPLETE DENTURE ESTHETICS – CHANGE IN MAXILLARY ANTERIOR TOOTH SIZE

A. More esthetic smile.


B. New denture: esthetics improved with larger maxillary anterior teeth.


match. In other words, the upside-down shape of a person’s maxillary central incisor is not usually the same shape as that person’s face. However, there is some research that does show this relationship. This difference in research results could be due to ethnic variations in the populations studied, but this has not been confirmed.

• Many anatomic parameters have been exam-ined in the search for a method of selecting an appropriate tooth size for an edentulous

patient. In the absence of pre-extraction records, these measurements do not dis-play foolproof accuracy but can serve as a guideline.

• Patients’ preferences for denture esthetics frequently differ from those of the dentist. Involving patients in the decision-making process regarding their denture esthetics has been shown to increase patient satisfaction. The setup try-in appointment can be a criti-cal step in achieving a satisfactory outcome.

FIGURE 39: COMPLETE DENTURE ESTHETICS – CORRECTION OF EXCESSIVE GINGIVAL DISPLAY

A. Teeth are positioned too inferiorly, resulting in excessive gingival display.Note. From Western Schools, 2018.

B. New denture has teeth positioned more superiorly.

FIGURE 40: COMPLETE DENTURE ESTHETICS – NATURAL VERSUS PROMINENT TOOTH DISPLAY

A. Some patients prefer a more natural denture appearance.Note. From Western Schools, 2018.

B. Some patients prefer a more prominent tooth display.


COMPLETE DENTURE OCCLUSION

Types of OcclusionsThree basic types of complete denture

occlusion/tooth forms are typically used:

1. monoplane,

2. anatomic or semi-anatomic, and

3. lingualized.

(Parr & Loft, 1982)

Monoplane Occlusion

Monoplane occlusion uses monoplane (also known as flat plane, 0°, rational, non-cusp, and nonanatomic) posterior teeth. I. R. Hardy (1942) first introduced nonanatomic teeth with flat occlusal surfaces set to a flat occlusal plane (see Figure 41). Another early proponent was M. M. DeVan (1954), who incorporated monoplane occlusion into his neutrocentric occlusion con-cept. This occlusal scheme uses 0° teeth set on a flat plane, with no compensating curve poste-riorly and no incisal guidance anteriorly (i.e., no balancing contacts in excursive movements).

Monoplane occlusion has been proposed for patients with resorbed (flat) mandibular ridges, presumably because this occlusion transmits less occlusal stress to the ridge (Jones, 1972). However, research by Woelfel, Winter, and Igarashi in 1976 did not validate this belief.

Anatomic Occlusion

Anatomic artificial teeth duplicate the forms of natural teeth and have cusp angulations of 30° to 45°. Modified occlusal forms are those with a 20° cusp incline or less. These forms are also called anatomical teeth (Glossary of Prosthodontic Terms, 2005). Another name for modified occlusal forms is semianatomic teeth (see Figure 42). Anatomic denture occlusion was first introduced by Gysi in 1910. Improved masticatory efficiency (Hickey & Woelfel, 1963) and esthetics (Parr & Loft, 1982) are advantages of anatomic occlusion.

Lingualized Occlusion

Lingualized occlusion was proposed by Gysi in 1927 and further developed by Payne in 1941. Most commonly in lingualized occlusion,

FIGURE 41: MONOPLANE OCCLUSION



only the maxillary lingual posterior cusps (ana-tomic or semi-anatomic) contact the central groove area of the mandibular (non-anatomic or flat plane) posterior teeth; mandibular buccal cusps do not contact maxillary teeth in centric or in excursive movements (Becker, Swoope, & Guckes, 1977; Phoenix & Engelmeier, 2010; see Figure 43). The relative simplicity of setting up a lingualized occlusion is a positive feature of this concept, according to Lang (1996).

Any of the above occlusal schemes can be either balanced or nonbalanced. A balanced

occlusion (balanced articulation) is defined as “the bilateral, simultaneous, anterior, and pos-terior occlusal contact of teeth in centric and eccentric positions” (Glossary of Prosthodontic Terms, 2005, p. 17). A complete denture setup can be balanced either with protrusive/lateral eccentric records; by intraoral adjustment (usu-ally of the lower second molars or the most pos-terior denture teeth); or by the use of balancing ramps in a monoplane setup (Teledyne Hanau, 1996; Sharry, 1974; Nimmo & Kratochvil, 1985). Anatomic occlusion usually incorporates

FIGURE 42: SEMI-ANATOMIC (20°) OCCLUSION


FIGURE 43: LINGUALIZED OCCLUSION

A. Maxillary lingual cusps contact mandibular central groove.


B. No contact of maxillary buccal cusps.


bilateral balance (Parr & Loft, 1982). Balanced versus nonbalanced occlusion is further dis-cussed below.

Effect of Denture Occlusion on Masticatory Efficiency and Patient Satisfaction

Many studies have involved objective tests of chewing function with different posterior tooth forms and occlusions. The correlation between denture occlusion and patient satisfaction has also been the subject of numerous studies. However, differing research protocols and occlusal schemes make direct comparisons difficult. There are few randomized, controlled clinical trials involv-ing complete denture occlusion. Furthermore, research projects involving balanced occlusion rarely describe precisely how this balance was obtained. Keeping this situation in mind, the fol-lowing is a chronological summary of several relevant articles on denture occlusion.

In a study published by Trapozzano in 1960, dentures with removable inserts were made for 12 patients. The inserts allowed changing poste-rior setups on the same denture base. Balanced occlusion was done with a protrusive record (for horizontal articulator condylar setting, H) and Hanau’s formula, H/8 + 12 = L (for lateral condylar settings). Chewing tests (objectively measured by the amount of chewed test food passing through a mesh screen) and patient pref-erences were recorded. Seven patients had no preference for either balanced or nonbalanced occlusion, three patients preferred the nonbal-anced occlusion, and two patients preferred the balanced occlusion. Neither type of occlusion demonstrated greater overall chewing efficiency.

In a 1965 study by Kapur and Soman, vari-ous occlusal patterns were made in posterior denture teeth. Masticatory performance was assessed by having patients chew peanuts and raw carrots. The chewed food was collected

and sieves of different sizes were employed to measure the resultant particle size. In all, 2,040 masticatory tests were performed on 16 patients to evaluate the effectiveness of 15 different occlusal patterns. Results of the study showed that the presence of a longitudinal groove on the occlusal surfaces of mandibular posterior teeth, opposed by teeth with transverse or oblique grooves, significantly improved masticatory performance (of raw carrots only). Based on these findings, re-establishing occlusal anat-omy in posterior teeth, following equilibration, would appear to be indicated.

In a study conducted by Brewer, Reibel, and Nassif in 1967, two sets of dentures were made for 25 patients; one set had 0° porcelain teeth and a second set had anatomic porcelain teeth. Anatomic teeth were set in balanced occlu-sion, using a protrusive record and Hanau’s formula. Zero-degree teeth were set on a flat plane with no compensating curve. Patients were unaware that two sets of dentures with two different occlusions were made for them. The dentures were switched at intervals ranging from 1 day to 6 months, and changed thereafter at daily, weekly, or monthly intervals, without the patients being informed. Only two of the 25 patients noticed the change and realized they had been given a different set of dentures. Twenty-three patients were questioned after the study regarding their preference. Two patients preferred anatomic teeth, 11 preferred the 0° teeth, and 10 had no preference.

In 1975, Kelly conducted a thorough review of the available literature and patient surveys. He concluded that “as yet we have not found a relationship between the type of tooth form [anatomic versus nonanatomic] and occlusal arrangement and the ability to chew” (p. 133).

A crossover trial was published in 1983 by Clough, Knodle, Leeper, Pudwill, and Taylor. A crossover trial is a type of study in which


participants receive each treatment in random order. With this type of trial, each patient serves as his or her own control. Two sets of com-plete dentures were made for 30 patients. One set used nonanatomic (0°) posterior teeth; the other had maxillary anatomic (30°) teeth and mandibular nonanatomic teeth set in lingualized occlusion. In their report, the researchers did not specifically state whether the setups were bilaterally balanced. (Both occlusal schemes were described as being “noninterfering,” but this term was not defined.) One of the two sets of dentures was chosen at random and inserted for the patient. After three weeks, the dentures were switched. Of the 30 patients included in the trial, 20 expressed a preference for the den-ture with lingualized occlusion. Five patients preferred the monoplane occlusion; five had no preference. Improved chewing ability and bet-ter esthetics were reported as the reasons for patients’ preference for lingualized occlusion.

In 1990, Motwani and Sidhaye published a study comparing the masticatory performance of 30 patients with complete dentures having balancing contacts in centric relation only with 30 patients with complete dentures having bal-ancing contact in centric and eccentric relations. Although the specifics of obtaining balancing eccentric contacts were not described (other than remounting and selective grinding), and the masticatory test was not detailed, the authors concluded that no significant difference in mas-ticatory performance was observed between the two groups.

Noting that conventional complete denture base movement can have an effect on the results of denture occlusion studies, Khamis, Zaki, and Rudy (1998) tested various occlusal forms in mandibular dentures retained with Hader bars on four symphyseal implants. Maxillary and mandibular dentures with interchangeable pos-terior segments were made for eight patients

(a relatively small sample size). Three occlu-sal forms were tested: 0°, 30°, and lingualized. The researchers’ published report does not state whether the occlusion was balanced or nonbal-anced. Patients used each occlusal form for 6 months, during which time three chewing tests were performed every 2 months. Chewing effi-ciency (objective) and patient preference (subjec-tive) were both evaluated. Chewing efficiency was assessed by measuring the number of chew-ing strokes until the mouth was free of food, along with other similar measurements. Tests with a variety of foods showed that 30° and lin-gualized occlusal forms provided better chewing efficiency than 0° occlusal forms. Patients pre-ferred either 30° or lingualized occlusal forms. None preferred 0° occlusal forms.

Peroz, Leuenberg, Haustein, and Lange (2003), in a randomized clinical trial of 22 patients, compared two different occlusal concepts: canine guidance and anatomic bal-anced occlusion. Subjective patient opinion was obtained using a visual analogue scale. Patients assessed canine-guided dentures to be significantly more satisfying in esthetic appear-ance, mandibular denture retention, and chew-ing ability.

In an attempt to elucidate the relationship between denture occlusion and patient satisfac-tion, Sutton, Glenny, and McCord (2005) con-ducted a Cochrane Systematic Review. Inclusion criteria for this review were randomized or quasi-randomized controlled clinical trials. After reviewing 1,076 titles and abstracts dealing with this subject, only one study fully met the review’s inclusion criteria. This was the study by Clough and colleagues (1983) mentioned previously.

In 2006, Kimoto and colleagues compared complete dentures with lingualized occlusion (LO; balancing contact of only the maxillary 20° lingual cusps in lateral and protrusive move-ments) to dentures with bilaterally balanced


occlusion (BBO; both buccal and lingual cusps of 20° semi-anatomic teeth in contact in excur-sive movements). The first 14 patients were given LO; the next 14 participants were pro-vided with BBO. The study, therefore, was not randomized. The procedure for obtaining the two occlusional schemes was not described. Masticatory performance was assessed by mea-suring the amount of chewed peanuts remain-ing on a sieve. Subjective ratings for general assessment, ability to chew, and denture retention and stability were done with a 100 mm visual analogue scale (VAS). Researchers found no difference in objective measures of masticatory performance between the lingualized occlusion and the bilateral balanced group. In terms of sub-jective assessment, the type of occlusal scheme did not exhibit any significant effects on the patients’ general satisfaction with their dentures, denture stability, or ability to masticate. Patients with lingualized occlusion had a statistically sig-nificant more positive opinion regarding denture retention. However, the large confidence interval (degree of uncertainty) meant that the authors could not conclusively determine whether LO had a meaningful clinical effect.

Noting the paucity of scientific evidence in recommending one type of posterior occlusal form over another in complete denture fabrica-tion, Sutton and McCord (2007) conducted a randomized clinical crossover trial comparing anatomic, lingualized, and 0° posterior occlu-sal forms for complete dentures. Three sets of dentures, with each occlusal scheme, were made for 45 patients. The patients used each prosthesis for 8 weeks, after which time they completed the Oral Health Impact Profile-20 EDENT. A significant subjective preference for anatomic or lingualized occlusion versus mono-plane occlusion was noted, with patients report-ing fewer problems with eating, sore spots, and meal interruptions with these two occlusions.

Heydecke and colleagues (2007) conducted a study of 20 edentulous patients. Each patient received two sets of complete dentures: one with semi-anatomic teeth and lingualized occlu-sion (LOD) and the other with anatomic teeth and a first premolar/canine-guided occlusion (CGD). The LOD was done with an intraoral tracing of centric relation and a facebow trans-fer. The CGD was made using a simplified procedure: jaw records were fashioned with wax rims and without a facebow transfer. The dentures were delivered in randomized order and worn for 3 months before switching to the other set. Patients used visual analogue scales to rate their ability to chew. Patients rated CGD significantly higher than LOD.

Farias Neto, Mestriner Junior, and Carreiro (2010) conducted a double-blinded controlled crossover clinical trial to compare the mastica-tory efficiency of complete-denture patients with either bilateral balanced occlusion (BBO) or canine guidance (CG). Twenty-four patients wore complete dentures with one occlusal con-cept for 3 months and then switched to the other occlusal scheme. Occlusion was changed from BBO to CG by the addition of composite resin to the lower canines to obtain 2 mm of molar disclusion in eccentric movements. The resin was removed to change occlusion from CG to BBO. Objective chewing data were obtained by having patients chew specially designed beads containing fuchsine dye. Subjective data were obtained by having patients rate their chewing function. The researchers collected data at 3 and 6 months after denture insertion. No statistically significant difference was found for masticatory efficiency between the two occlusal concepts studied. Furthermore, no significant relationship was found between (objective) masticatory effi-ciency and patients’ subjective rating of chew-ing ability or in overall patient satisfaction.


Two of the authors of this study subsequently published the results of an extensive literature search for randomized controlled clinical trials comparing complete dentures with BBO and canine-guided occlusion (Farias Neto & Carreiro, 2013). They concluded that no scientific evi-dence existed for BBO being the preferred occlu-sal concept for conventional complete dentures. In fact, little support exists to show that the occlusal concept has any significant influence on clinical outcomes and patient satisfaction (Farias Neto & Carreiro, 2013).

Abduo (2013), in a systematic review of occlusal schemes for complete dentures, con-cluded that “in general anatomical teeth are preferred over flat teeth in both subjective and objective assessments” (p. 29). Anatomic or lin-gualized occlusions have greater patient accep-tance than monoplane occlusion because of the enhanced esthetics and better masticatory func-tion of anatomical teeth.

In another systematic review of complete denture occlusion, Zhao, Mai, Wang, Yang, and Zhao (2013) reported that there was no conclu-sive evidence supporting any occlusal design as the most appropriate for complete dentures. Furthermore, the belief that complete dentures require a balanced occlusion was not supported by the reviewed literature.

A 2014 study by Niwatcharoenchaikul, Tumrasvin, and Arksornnukit found no signifi-cant differences in masticatory performance or maximum occlusal force between complete den-tures with bilateral balanced occlusion and com-plete dentures with neutrocentric (monoplane) occlusion. Ten patients (a small sample size) were provided with dentures with interchange-able posterior teeth. This study measured occlu-sal force with pressure-sensitive film.

A randomized clinical crossover trial con-ducted in 2014 by Shirani, Mosharraf, and Shirany compared patient satisfaction with

complete dentures that employed different occlu-sal schemes. Fifteen patients received three sets of dentures, using fully bilateral balanced occlu-sion (FBBO), lingualized occlusion (LO), and buccalized occlusion (BO). BO (the reverse of LO) has anatomic buccal posterior cusps contact-ing the central groove area of maxillary flat-plane posteriors. According to the study, all three set-ups were completely balanced. Patients reported a more pleasant eating experience with LO den-tures than with the FBBO dentures. Patients also had a greater tendency to avoid certain foods with the FBBO dentures than with the LO and BO dentures.

Kawai and colleagues (2017) found that patients with extensive ridge resorption (less than 20 mm of mandibular alveolar ridge height) provided more favorable subjective ratings of lingualized occlusion than fully bilat-erally balanced occlusion.

It is evident that, when considering complete denture occlusion, a consensus in published research findings does not exist. Nevertheless, it can be seen from the outlined studies that patients generally have a greater preference for dentures with posterior cusped teeth than for dentures with monoplane posteriors. Better esthetics and subjective chewing ability are the reasons most often given for this preference. Balancing denture occlusion does not appear to be advantageous for chewing function.

Given this lack of research consensus, den-tists are advised to employ a combination of literature evaluation, clinical experience, and judgment when deciding on the appropriate treatment. Working in this way is the essence of evidence-based practice (Ismail & Bader, 2004).

It should be mentioned that, regardless of the type of occlusion, complete dentures pro-vide much less masticatory efficiency than the natural dentition. According to a classic study by Kapur and Soman (1964), “the chewing


efficiency of the denture wearer is less than one-sixth that of the subject with a [natural] dentition” (p. 411). Although beyond the scope of this course, it is important to note that man-dibular complete dentures retained by two implants significantly improve masticatory effi-ciency compared with conventional dentures (Cardoso et al., 2016).

Complete Denture Occlusion: The Bottom Line• There is no universally accepted, evidence-

based occlusal scheme for complete dentures.

• Patients usually prefer posterior denture teeth with cusps.

• Bilateral balance does not improve mastica-tory efficiency when compared with nonbal-anced occlusion.

• Subjective results (patient preferences) do not necessarily correlate with objective mea-sures (masticatory ability).

DIGITAL DENTURES

The most significant advance in complete denture treatment within the past 30 years

has undoubtedly been the application of endos-seous root-form implants for implant overden-tures (Feine & Carlsson, 2003). More recently, the application of digital (CAD/CAM) technol-ogy has the potential to become another para-digm shift in complete denture treatment.

The use of computer-aided technology to fabricate complete dentures was first intro-duced by Maeda, Minoura, Tsutsumi, Okada, and Nokubi in 1994. This group of Japanese researchers fabricated complete dentures from photopolymerized composite resin material with rapid prototyping (RP) technology. Laser scan-ning of maxillary and mandibular impressions obtained edentulous ridge and surrounding tis-sue anatomy. Technological advancements were

reported by several investigators in subsequent publications (Bidra, Taylor, & Agar, 2013). These developments included digital tooth arrangements, cone beam computed tomogra-phy (CBCT), scanning and fabricating complete dentures through computerized numerical con-trol (CNC) milling, and developments in rapid prototyping (RP).

Companies marketing digital dentures in the U.S. include:

• AvaDent (Global Dental Sciences, LLC; http://www.avadent.com),

• Pala (Heraeus Kulzer; http://www.paladigitaldentures.com),

• Dentca (http://dentca.com),

• 3Shape (https://www.3shape.com),

• Amann Girrbach (https:www.amanngirrbach.com),

• Ivoclar Vivadent/Wieland Dental (http://www.ivoclarvivadent.com), and

• Arfona (https://www.arfona.com).

(Brown, 2016)

Overview of the Digital Denture Technique

Two different basic fabrication techniques are employed for digital dentures, depending on the company:

• Additive: 3-D printing or rapid prototyping (e.g., Pala or Arfona), or

• Subtractive: Computer numerical control (CNC) milling (e.g., AvaDent or Ivoclar).

Modifications of these approaches are also employed by various dental laboratories that have their own proprietary digital denture ser-vices. Each company has software and clinical armamentaria for their particular digital denture protocol. Dental professionals should review the information available for each digital denture manufacturer, much of which is available online.


All digital denture protocols require the den-tist to make impressions. In order to obtain a final impression during the first appointment, some digital systems provide special trays, which are used with an elastomeric impression material (usually vinyl polysiloxane). These impressions are then scanned by the laboratory, or poured conventionally, and the casts scanned. Dentists can also use traditional impression pro-cedures using conventional trays.

Depending on the digital system employed, all patient records (e.g., vertical dimension, centric bite registration, anterior tooth posi-tion) are either created at the first visit (together with impressions) or at a subsequent visit, with record bases. These record bases can be made digitally (3-D printed or milled). The clinician selects the tooth (mold and shade), using tradi-tional guidelines. The two-visit digital denture protocol does not allow for a try-in appoint-ment. However, the try-in step may be included at an additional (third) appointment. A setup try-in can be done either with a 3-D-printed polymethyl methacrylate or photopolymer (PMMA) prototype or, with a record base, with the teeth secured by wax. The denture can be processed, as mentioned above, via 3-D printing (additive) or milling (subtractive).

Journal articles by Schmitt and Schmitt (2013) and Hayes (2017) describe the basics of digital denture fabrication. In 2013, Kattadiyil, Goodacre, and Baba published a comprehensive review of two commercial digital denture fabri-cation systems (AvaDent and Dentca).

According to Bidra and colleagues (2013), the advantages of CAD/CAM dentures are

• reduced number of clinical appointments,

• superior strength and fit,

• reduced microbial contamination (due to a decrease in porosity of the resin),

• reduced costs,

• easily duplicated dentures (due to storage of digital data),

• research application, and

• quality control.

Case ReportsInfante, Yilmaz, McGlumphy, and Finger

(2014) described the AvaDent digital tech-nique used to fabricate a complete denture in two appointments. Final impressions and jaw registrations were done at the first appoint-ment. These results were subsequently scanned and the dentures milled to the specifications obtained. No conventional stone models, flask-ing, or processing were required. The dentures were delivered at the second appointment. The authors reported that, although initial results were promising, use of the central bearing tracing device was a challenging method of obtaining a centric relation bite record. (They did not elaborate.) These researchers suggested that long-term clinical trials be done to validate this digital technique.

In a clinical study, McLaughlin and Ramos (2015) reported that the use of CAD/CAM (AvaDent) record bases can provide an improved denture fit with fewer post-processing occlusal errors. The procedures described in this case report, with the exception of final impression scanning and digitally controlled milling of the record base, were conventional (traditional) clini-cal techniques.

A 2016 clinical report by Neumeier and Neumeier described the use of the AvaDent sys-tem to provide digital immediate dentures for two patients. According to the authors, the digi-tal denture process can be effective and time-efficient for clinicians, with enhanced patient satisfaction. They suggest the need for a con-trolled clinical study of the digital denture pro-cess for immediate dentures.


The Amann Girrbach system has been described by Wimmer, Gallus, Eichberger, and Stawarczyk (2016). Clinical and laboratory research is necessary to validate these proce-dures, according to the authors.

AlHelal, AlRumaih, Kattadiyil, Baba, and Goodacre (2017) found significantly increased retention of milled (AvaDent) denture bases compared with conventional (heat- polymerized) denture bases. The absence of polymerization shrinkage of milled denture bases, resulting in improved fit, was the likely reason for better retention.

Clinical TrialsThere have been few clinical trials of digi-

tal dentures published to date. A prospective clinical study of clinical outcomes, patient sat-isfaction, and undergraduate dental student preference for either digitally (AvaDent) or conventionally processed complete dentures was published by Kattadiyil, Jekki, Goodacre, and Baba in 2015. Fifteen patients received a set of both AvaDent (two-appointment protocol) and conventional (five-appointment protocol) dentures. Treatment was provided by third- and fourth-year dental students, with faculty supervision. Each patient wore one set of com-plete dentures for one week, and then wore the other set for one week. The digitally pro-duced dentures were rated significantly higher in patient satisfaction, faculty evaluation, and student preference. However, an anterior open bite caused one patient (6.66%) to require a digital denture remake.

Saponaro, Yilmaz, Heshmati, and Mc- Glumphy (2016) evaluated the two-visit AvaDent protocol in a dental school retrospective study. Ninety prostheses were digitally fabricated for 48 patients; 17 of these patients required three clinical appointments to fabricate and insert the dentures. The mean number of postinsertion

adjustment visits was 2.08. Clinical complica-tions required remaking the denture for five patients (10.41%). Patients were generally satis-fied with their overall treatment outcomes and experiences, as measured with a post-treatment survey. This study did not include a control group of patients who received conventionally made dentures. The authors stated that further research is needed to substantiate the digital technique.

Saponaro, Yilmaz, Johnston, Heshmati, and McGlumphy (2016) reported results of a retro-spective survey (using a questionnaire) to assess patient preferences and satisfaction with digi-tally fabricated (AvaDent) dentures. Out of 50 patients, 19 (a 38% response rate) answered the survey. The median number of months of den-ture wear prior to answering the survey was 20. In all categories evaluated, patients gave posi-tive responses regarding their digital complete dentures. In the subset of 14 experienced denture wearers (defined as patients who had worn con-ventional dentures previously), 11 agreed that their new prostheses were better than their pre-vious conventional complete dentures. Among the limitations of this study, acknowledged by the authors, were the low survey response rate, the absence of a control group receiving conven-tional (non-digital) dentures, potential patient recall bias when introduced to an “innovative” method of denture fabrication that reduced the number of clinical appointments, and the struc-ture of the survey itself.

Bidra and colleagues (2016) tested a two-visit digital denture protocol involving the fabrication of monolithic CAD/CAM com-plete dentures for 20 patients (Global Dental Science). This study did not include a control group of conventional denture patients. Three patients (15%) withdrew from the study shortly after denture delivery because of dissatisfaction with the prostheses (with respect to esthetics, occlusion, and comfort) and were considered


treatment failures. At the 1-year recall, 79% of the remaining patients were satisfied with their digital dentures overall. However, only about 50% of these patients rated the dentures (using a visual analogue scale) as “good” or “excel-lent” for “tightness” (retention), “absence of rocking” (stability), or “absence of food under-neath the denture” (adaptation of the denture bases). Another 50% of these patients rated their dentures as “fair.” Two prosthodontists also evaluated the dentures. Overall assess-ment of clinical outcomes was rated “good” or “excellent” in 50% of the cases by the first prosthodontist judge and in 69% of the cases by the second judge. The study authors felt that all treatment failures and complications could have been avoided if a denture try-in appointment had been included in the protocol. In addition, the extra time involved in fabricating a clear duplicate denture (for use as a custom tray in this study protocol), plus the time required to communicate and approve the digital previews with the laboratory, made the actual overall time spent comparable to time spent for the con-ventional four-to-five-visit treatment procedure.

Systematic ReviewsIn a recent systematic review of “computer-

engineered” dentures (digital, CAD/CAM), Kattadiyil and AlHelal (2017) identified only four articles that met their inclusion criteria for patient population (minimum of five par-ticipants). A significantly reduced number of appointments and amount of clinical time, improved retention, and digital achievability were the main advantages cited in the clinical studies reviewed. The authors noted a positive trend in outcomes for computer-engineered den-tures, but stated that long-term clinical studies are still needed before definitive conclusions can be reached.

Another systematic review (five studies) of clinical complications and quality assessments

with computer-engineered complete dentures was recently published by Kattadiyil, AlHelal, and Goodacre (2017). The conclusions, based on limited data, were as follows:

1. The most common complications were over-all patient dissatisfaction, inadequate reten-tion, and esthetic discrepancies.

2. Complications related to esthetics, vertical dimension, and centric relation might have been a result of the absence of a clinical try-in prior to fabrication.

3. Difficulty in evaluating a digital preview is an issue unique to the digital denture process.

Fernandez, Nimmo, and Behar-Horenstein (2015) reported on a survey of the prevalence of digital denture technology taught or used in U.S. pre- and postdoctoral prosthodontic pro-grams. The survey was sent out in January of 2015 and the data analyzed in June of that same year. Only 10% or fewer of cases involving complete dentures were processed using CAD/CAM technology, at either the pre- or postdoc-toral levels.

Expedited Non-Digital Denture Fabrication Techniques

It is worth noting that expedited denture fabrication techniques, not necessarily using digital technology, have been published. In 1984, Javid, Colaizzi, and Jaggers detailed a procedure in which preliminary compound impressions were made at the first appoint-ment. Maxillary and mandibular wax occlusion rims were then added to those impressions, which were subsequently border-molded. Vertical and centric jaw relation records were recorded, and the preliminary impressions were then used for final impressions. Tooth selec-tion was also completed at this visit. Trial den-ture try-in was conducted during the second


appointment; denture delivery took place at the third appointment.

Simplified Edentulous Treatment Technique

In 2017, the Simplified Edentulous Treatment (SET) technique, a three-appointment technique, was evaluated by Ceruti and colleagues. The SET procedure uses a multilayer impression tray (Major Dental) to produce a final impression onto which a maxillary rim made of light-polymerizing resin is added – a concept similar to that of Javid and colleagues (1984).

In addition to the Major Dental Company products used by Ceruti and colleagues (2017), products and protocols are available from other companies for an expedited denture technique. For example, the Good Fit Company (https://goodfit.com) markets a product that combines a thermoplastic tray (used for final impres-sions) and a basic setup. This tray and setup can be modified to change the vertical dimen-sion and marked to indicate tooth position changes. A conventional denture setup and processing can then be accomplished using this impression-setup device as a guide (Ginsburg & Cavalier, 2002).

Other simplified conventional methods of complete denture fabrication are discussed in Patient Satisfaction with Complete Dentures.

Digital Dentures: The Bottom Line• Clinical research on computer-engineered

(digital) dentures thus far indicates that a three-visit protocol (i.e., incorporating a setup try-in appointment) may be the pre-ferred approach.

• There are numerous significant advan-tages to computer-engineered prostheses in addition to the reduction in the number of patient appointments.

• Digital denture fabrication will likely be more widely employed as clinicians become increasingly familiar with this paradigm shift and as the technology becomes further refined.

• Adherence to fundamental principles of complete denture prosthodontics remains essential to the success of any denture pro-tocol, whether digital, conventional, or an amalgam of both.

PATIENT SATISFACTION WITH COMPLETE

DENTURES

According to the prosthodontics literature, patient satisfaction with complete denture

treatment is influenced by a variety of factors. There is, not surprisingly, a lack of consensus concerning the effect these factors actually have on patient satisfaction. Some areas that have been investigated for their effects on patient sat-isfaction with dentures are

• the patient’s edentulous anatomy,

• the patient’s psychological makeup (personality),

• other patient or dentist variables (e.g., neu-romuscular control, mucosal sensitivity, patient-dentist relationship),

• the clinical outcome (denture quality), and

• the clinical protocol/technique.

A final area of investigation concerns whether any reliable way to predict patient satisfaction with complete dentures exists.

Edentulous AnatomyVarious aspects of the edentulous mouth

have been cited in the literature as affecting complete denture function and patient satisfac-tion. These aspects include size and shape of the residual ridges, mucosal sensitivity, soft tis-sue composition (keratinization) and resilience,


location of muscle attachments, vestibular depth, size and shape of the tongue, muscle tonus (McCartney, 1981), and amount and com-position of the saliva (Wolff, Gadre, Begleiter, Moskona, & Cardash, 2003). However, the rela-tive importance of any of these anatomic vari-ables has been debated. Selected articles dealing with this issue over the last three decades of research are described below.

In 1990, 130 patients who received new complete dentures at the Dental School of the University of Utrecht (Netherlands) were evalu-ated for pretreatment edentulous anatomy (van Waas, 1990a). Three prosthodontists indepen-dently evaluated lateral cephalograms, edentu-lous casts, and intraoral anatomy. The anatomical characteristics that were assessed included the

• height of the mandible in the anterior region (via lateral cephalogram),

• quality of residual ridges (via casts),

• basal seat (intraoral),

• inter-ridge form (intraoral),

• borders (intraoral),

• abnormalities (intraoral), and

• total assessment.

Patient satisfaction was determined by a questionnaire sent about 3 months postinsertion. No correlation was found between patient sat-isfaction and any of the variables related to the physical characteristics of the mouth.

Similar findings were reported by Diehl, Foerster, Sposetti, and Dolan (1996) in a study of 60 dental school patients. Maxillary and mandibular anatomy was not significantly associated with denture success (assessed with a patient questionnaire at 1, 6, and 18 months postinsertion). Similarly, in a study by Heydecke, Klemetti, Awad, Lund, & Feine (2003), clinical assessment of ridge height and quality of the denture-supporting tissues showed

no correlation with patients’ assessment of their existing dentures.

Pan and colleagues (2010) conducted a study to determine whether mandibular bone height affected patients’ rating of satisfaction and func-tion with conventional complete dentures (CDs) or mandibular two-implant overdentures (IODs). The 214 patients who participated rated their sat-isfaction with their prostheses at 6 months post-insertion using the McGill Denture Satisfaction survey. Mandibular bone height had no effect on patients’ ratings of general satisfaction, stability, comfort, esthetics, or ability to speak or chew. Patients who received mandibular IODs rated them significantly higher for all mandibular bone height categories.

Närhi, Ettinger, and Lam (1997) evaluated the relationship between alveolar bone resorp-tion, the location of the mental foramina, and denture-related complaints in 96 patients. No significant differences were shown in denture complaints (e.g., “sore gums” or poor-fair chew-ing ability) among patients with varying degrees of ridge resorption. The amount of alveolar bone above the mental foramen also did not affect the amount of denture-related complaints.

In a study published in 2003 of 222 den-ture patients, Čelebić and colleagues found that comfort of wearing maxillary dentures was higher in patients with good denture- bearing areas (better retention and stability). Paradoxically, the comfort of wearing man-dibular complete dentures was lower in those patients with better edentulous ridge anatomy (less resorption). Patients whose mandibular denture-bearing area was assessed as excellent or very good gave the lowest ratings to overall satisfaction, chewing quality, retention, and comfort of the mandibular denture. The authors speculated that patients with more resorbed mandibular ridges had a longer time period


wearing a mandibular denture, and more time to establish neuromuscular adaptation.

The correlation between patient satisfaction with complete dentures and various anatomic factors, salivary flow rate, and denture quality was studied in 50 subjects by Wolff and col-leagues in 2003. A low salivary flow rate was significantly correlated with lower patient sat-isfaction. The comfort of the mandibular den-ture was related to the mandibular ridge shape. Oral musculature affected subjective maxillary denture retention. Other anatomic or denture-quality-related parameters had no influence on patient satisfaction. Conversely, a study by Diehl and colleagues published in 1996 found that the amount of mouth moisture was not sig-nificantly associated with patient satisfaction. For patients presenting with a dry mouth, artifi-cial saliva products (available over the counter) may be helpful.

In their study comparing lingualized occlu-sion to bilateral balanced occlusion, Kimoto and colleagues (2006) reported that patients with a higher alveolar ridge displayed greater mas-ticatory performance (objectively measured). However, the condition of the mandibular alve-olar ridge did not exhibit any statistically sig-nificant correlation with patients’ subjective chewing satisfaction.

Fenlon, Sherriff, and Walter (2008), using complex statistical analysis (structural equation modeling), demonstrated a strong relationship between favorable mandibular ridge anatomy and patient satisfaction. The authors suggested that this phenomenon resulted from the increased accuracy of recording jaw relationships in patients with better ridges. These researchers suggested that inappropriate statistical method-ology used by other researchers can explain the discrepancies in various study results.

Both the size (large) and position (retracted or retruded) of the tongue have an effect on

mandibular denture stability, which (as dis-cussed below) can affect patient satisfaction. In a study by Jiang (2001), 148 out of 157 patients were able to successfully use the complete den-tures provided. Of the nine patients who had unsatisfactory results, three had a hypertrophic tongue, two had macroglossia, and two had a habitually retruded tongue. Research by Lee and colleagues (2009) showed that a habitually retruded or elevated tongue adversely affected mandibular denture stability. These authors measured mandibular denture retention using an electrical dynamometer connected to the central incisors, with the tongue in two differ-ent positions: either retracted or with the tip of the tongue contacting a horizontal groove made in the anterior lingual flange (ideal resting posi-tion). When participants held their tongues in the ideal resting position, mandibular denture retention increased by an average of 57.73%.

In 2012, Bhupindera and colleagues pub-lished a review of the importance of the tongue in mandibular denture success.

Ridge resorption often leads to a relative superior positioning of the mentalis muscle near the crest of the mandibular ridge. Both mentalis muscle pull and the tendency to set mandibular anterior teeth too far lingually are causes of denture instability (Zarb, Hobkirk, Eckert, & Jacob, 2013).

Consensus on the importance of patient anatomy to subjective outcome (patient satisfac-tion) clearly does not exist. However, anatomic factors affecting mandibular denture stability (e.g., tongue size and position) appear to be the most significant factors.

Psychological Makeup (Personality)Attempts to classify patients by personality

type and to correlate this classification with the outcome of complete denture treatment were initially published by E. Neil, and expanded


upon and popularized by M. M House (Winkler, 2005). Other patient personality classification systems appear in the literature (Gaikwad et al., 2015; Koper, 1988). However, scientific valida-tion for these classifications relative to complete denture success is inconsistent.

In 1967, Carlsson, Otterland, and Wennström conducted a study of 182 denture patients and found no strong correlation between “social adaptation” (e.g., happiness with work, relation-ships with family) and patient’s appreciation of (satisfaction with) his or her dentures.

In 1976, Smith published a condensed ver-sion of her master of science thesis on patient personality traits and their relation to patient satisfaction with complete dentures. Prior to treatment, 70 patients were given a shortened version of the Minnesota Multiphasic Personality Inventory (MMPI). The traits assessed were hypochondriasis, depression, hysteria, and mani-fest anxiety. Smith found no relation between these personality traits and the degree of the patient’s general level of satisfaction at the 95% confidence level (p = 0.05).

Berg, Johnsen, and Ingebretsen (1986) were also unable to demonstrate an association be-tween psychological variables and denture acceptance in 74 patients. Similarly, van Waas (1990b) found no relationship between dissatis-faction with new dentures and neurotic lability (measured by two psychological questionnaires) in 130 subjects. Patients who had positive pre-treatment expectations regarding the outcome of treatment were more often satisfied.

Conversely, when Guckes, Smith, and Swoope (1978) had 81 complete denture patients fill out extensive psychological questionnaires prior to receiving treatment at a dental school, they found that patients who scored higher for potential neurosis issues (“neuroticism-stability” traits on the Eysenck Personality Inventory) were significantly less satisfied with the outcome of

treatment than patients who scored lower (p = 0.05). As described by Eysenck and Eysenck (1991), a person with a high neuroticism score is an anxious, worrying individual who is moody and frequently depressed, and who is overtly emotional and reacts too strongly to all sorts of stimuli.

Psychological factors also significantly influenced denture satisfaction in studies by Bolender, Swoope, and Smith (1969); Moltzer, Van der Meulen, and Verheij (1996); Al Quran, Clifford, Cooper, and Lamey (2001); and Fenlon, Sherriff, and Newton, (2007). Diehl and colleagues (1996) also found that psychological and interpersonal factors were more important determinants of denture satisfaction than ana-tomic or clinical factors.

Clearly, variability exists in the impact of a patient’s psychological makeup on satisfac-tion with denture treatment. Moreover, a patient may experience life events or a change in health status during the course of treatment that render initial assessment of personality less significant. Clinicians should be attuned to the concerns or anxieties expressed by denture patients and per-haps increase the amount of pretreatment coun-seling provided to more anxiety-prone patients. Dentists should make certain that all complete denture patients have realistic expectations of treatment outcome while keeping a positive, optimistic attitude.

Other Patient or Dentist VariablesPatient Mucosal Sensitivity and Neuromuscular Control

S. Howard Payne, in 1960, wrote, “It is always quite obvious that the innate adaptability and neuromuscular coordination of the patient are factors of extreme significance” (p. 489). Payne’s was a statement based on clinical exper-tise and experience, rather than on research data.


According to Kelly (1975), mucosal sensi-tivity and neuromuscular control are important factors in chewing ability. However, Kelly did not investigate patient satisfaction per se.

Patient-Dentist Relationship

The importance of patient involvement in complete denture esthetics has been recognized for many years. A 1964 study by Rosenthal, Pleasure, and Lefer found that patients who were given significant control over their den-ture esthetics had greater postinsertion satis-faction and fewer postinsertion adjustments compared with a control group in which the esthetic decisions were made mostly by the den-tist. Similarly, Hirsch, Levin, and Tiber (1973) found that patients treated by “high-authori-tarian” dentists (as assessed by a personality questionnaire, the California F Scale) were less satisfied with their dentures than were patients treated by “low-authoritarian” dentists.

According to Friedman, Landesman, and Wexler (1988), the dentist’s behavior is the most significant influence in minimizing the response of a maladaptive patient. These authors rec-ommend an “iatrosedative” model of behav-ior for the dentist (“iatro” meaning doctor, and “sedative” meaning the act of making calm). This model is a method of chairside interac-tion used to reduce or eliminate dental fears encountered in practice (Friedman, 1983). For maladaptive patients, feelings about the dentist play an important role in accepting a denture. Clinicians should realize that the problem for these patients is not the denture itself, but rather their feelings or emotional response toward the prosthesis. For example, these feelings may have an origin in traumatic memories of a parent who struggled with dentures. Furthermore, according to the authors, a small subset of patients will not adapt to dentures because maintenance of symp-toms serves other psychological needs, such

as rationalizing other problems, manipulating others, or obtaining sympathy.

Diehl and colleagues (1996) also found that the interpersonal relationship with the treat-ing dentist was an important variable affecting patient satisfaction.

Clinical Outcome (Denture Quality)It might seem intuitive that patient satisfac-

tion with dentures would be closely correlated with prosthesis quality. However, this has not always been shown to be the case. Moreover, results of research are not always in agreement as to which areas of denture quality are most important relative to patient satisfaction.

Cerutti-Kopplin and colleagues (2017) stud-ied 117 denture patients in southern Brazil. General satisfaction with the dentures was signif-icantly associated with maxillary and mandibular denture stability, chewing ability, and a lower denture 5 years old or older. A statistically sig-nificant association was also found between the Functional Assessment of Dentures (FAD) score obtained by an expert examiner (prosthodontist) and patients’ overall denture satisfaction.

In a 2014 study by Alfadda, three dentists used a standardized set of criteria to evalu-ate the complete dentures of 33 patients. Most patients were rated between “reasonably satis-fied” and “very satisfied” with their prosthe-ses. Significant positive correlations existed between overall denture satisfaction and stabil-ity and retention of the mandibular denture. However, esthetic lip support, lower lip line, occlusion, and maxillary denture stability and retention were not correlated with participants’ overall satisfaction level.

Čelebić and colleagues (2003) found that the variable having the strongest correlation with patient satisfaction was the dentist’s assessment of denture quality. In addition, patients who were more satisfied with their own well-being


(quality of life) were generally satisfied with their dentures and chewing ability.

In an examination of 182 patients (Carlsson et al., 1967), the three factors most associated with patients’ appreciation of their dentures were their opinion of the esthetic result, reten-tion of the maxillary denture, and feeling of security regarding the maxillary denture. These factors were highly associated with the total denture assessment made by the dentist.

Chewing ability and eating enjoyment were highly correlated with chewing comfort and overall patient satisfaction in a study by Garrett, Kapur, and Perez (1996). After existing dentures were modified to improve the fit and occlusion, patients perceived an improvement in chew-ing ability, despite a lack of improvement in objective masticatory ability or masseter mus-cle activity. According to the authors, chewing ability was viewed in terms of comfort by the patients, rather than how well food was actually chewed (swallowing threshold).

A study by van Waas (1990b) found only a moderately positive correlation (r = 0.36) between satisfaction of the patient and quality of the dentures.

Fenlon and Sherriff (2004) found no signifi-cant associations between aspects of new den-ture quality and patient satisfaction 2 years after insertion. This finding differed from the results 3 months after denture delivery, when signifi-cant relationships were reported between reten-tion and stability of the mandibular dentures and patient satisfaction (Fenlon & Sherriff, 2008).

Wolff and colleagues (2003) found that den-ture satisfaction was not affected by factors related to denture quality.

Yoshizumi (1964) reported results of a study of 239 denture patients. Standardized criteria were employed to evaluate denture qual-ity (including occlusion, vertical dimension,

adaptation of the denture base, and border extension). Patients were given a questionnaire regarding aspects of their comfort with the den-tures and their ability to chew. The study found a positive correlation between denture quality and patient comfort and between denture quality and the ability to masticate. However, the study also found that among the patients who had poor quality dentures, 46.5% reported that they were comfortable and 57.7% were able to mas-ticate well. Overall, the factor of comfort played a dominant role in determining the ability of patients to masticate.

De Lucena, Gomes, Da Silva, and Del Bel Cury (2011) evaluated the correlation between patient and dentist assessment of dentures and how this correlation related to objective mea-sures of masticatory function. Researchers asked 28 subjects to rate their dentures (on a visual analogue scale) for general satisfaction and satis-faction with maxillary and mandibular dentures independently for esthetics, comfort, stability, and chewing and speaking ability. One dentist (who was unaware of the patient ratings) evalu-ated the dentures for freeway space, occlusion, retention, and stability. Participants chewed a test material in objective tests of chewing func-tion (masticatory performance and swallowing threshold). Particle size of the chewed material was assessed with a sieve. The subjects’ subjec-tive rating of chewing ability was significantly correlated with their satisfaction of upper and lower denture stability and comfort. However, no significant correlation was found between objective masticatory function and patient satis-faction. Furthermore, no correlation was noted between the dentist’s assessment of the func-tional quality of the denture and either patient satisfaction or objectively measured chewing ability. One of the conclusions reached was that patients evaluate oral function not based on the particle size of food after chewing, but on


comfort and prosthesis stability during function. This finding is similar to the results obtained by Garrett and colleagues (1996).

Fifty years prior to De Lucena and col-leagues’ 2011 research, Langer, Michman, and Seifert (1961) conducted a study of denture sat-isfaction among 127 geriatric patients living in four nursing homes. The clinical fit of the den-tures (as assessed by dentist evaluators) showed a weak correlation to patient satisfaction. Also, almost no correlation existed between the patient’s appraisal of the prosthesis and the dentist examiner’s appraisal. The study found that, “apparently, the patients could manage their dentures whether or not stability, retention and other factors involved in denture construc-tion were present” (p. 1025). In research pub-lished in 1976, discussed earlier, Smith found no significant relationship between the technical quality of the dentures and the degree of patient satisfaction with the same dentures.

A 2006 study by Anastassiadou and Heath reported that pain, discomfort, and diffi-culty chewing in 119 denture patients failed to show any association with quality indica-tors. Similarly, in 2009, Akeel found that some patients were satisfied with prostheses judged by dentists to be of unacceptable quality, sug-gesting that factors other than prosthesis quality affected clinical outcome.

The quality of complete dentures has not consistently been shown to have a strong cor-relation with patient satisfaction. This finding does not mean that adherence to careful clinical technique is not important. Rather, it implies that other factors are also important in achieving positive patient acceptance for their prostheses.

Clinical Protocol/TechniqueTraditional denture fabrication incorporates

a number of clinical procedures into a five-visit protocol. Although highly successful prostheses

have been made for countless patients with this approach, various aspects lack firm evidence. Several research studies have evaluated modi-fications to this conventional approach and the ways in which clinical outcome and patient sat-isfaction are affected.

Two different complete denture fabrication protocols were evaluated in a multipart 1984 study conducted at the University of Kentucky. The “complex” technique (32 patients) involved hinge axis location, facebow transfer, centric relation and eccentric records, balanced occlu-sion, and post-processing occlusal correction on an articulator with a new centric record. The “standard” (simplified) technique (32 patients) featured arbitrary mounting of maxillary cast (no facebow), no eccentric records (only cen-tric), no attempt to balance occlusion, and post-processing occlusal correction on an articu-lator with no new centric record. In Part III of this study (Ellinger, Somes, Nicol, Unger, & Wesley, 1979), the dentures were evaluated by several prosthodontists using defined cri teria. No significant difference between dentures made with either technique could be detected by subjective examination. Once again, in Part VI of the study, researchers found no difference in objective masticatory performance (mea-sured by percentage of chewed test food pass-ing through a mesh screen) between dentures made with either the “complex” or “standard” technique (Wesley, Ellinger, & Somes, 1984). Patient satisfaction, per se, was not evaluated in this multipart study.

Kawai and colleagues (2005) compared two different denture fabrication techniques: “tradi-tional” and “simplified.” Several steps generally taught in denture curricula (e.g., border mold-ing a custom tray and secondary impression, facebow transfer, remount) were omitted from the simplified protocol. No significant differ-ences were found in patient satisfaction (n = 122)


between the two techniques. In addition, prostho-dontists serving as evaluators could detect no sig-nificant differences between dentures made with either protocol.

Similarly, Heydecke, Vogeler, Wolkewitz, Türp, and Strub (2008), in a randomized crossover trial, found no difference in patient satisfaction between simplified versus compre-hensive fabrication of complete dentures.

Regis and colleagues (2013) conducted a randomized trial of a simplified versus conven-tional protocol for complete denture fabrica-tion and concluded that the simplified method was capable of delivering dentures of a qual-ity comparable to those produced by the con-ventional method. No significant difference was seen in oral health-related quality of life (OHRQoL) or patient satisfaction. Simplified protocols generally involve one impression (using hydrocolloid), no facebow transfer, and a less adjustable articulator.

As described in the Digital Dentures sec-tion of this course, the Simplified Edentulous Treatment (SET) resulted in a comparable level of patient satisfaction, as did the conventional protocol (Ceruti et al., 2017). In a 2015 sys-tematic review, Paulino, Alves, Gurgel, and Calderon found no difference in patient satisfac-tion between dentures made with traditional or simplified techniques. Moreover, no differences in masticatory variables or quality assessment were evident between the techniques.

Previously, Carlsson (2006) found no evi-dence that a more complex fabrication tech-nique resulted in a better clinical outcome. Carlsson also found that variations in materials and technique appeared to have only a minor influence (if any) on the clinical result. Carlsson concluded that psychosocial factors, especially a good dentist-patient relationship, were more important to a positive outcome of complete denture treatment.

Is There Any Reliable Way to Predict Patient Satisfaction With Complete Dentures?

A pre-operative method to establish a prog-nosis for complete denture treatment would benefit both clinician and patient. However, no reliable method exists. For example, as described above, no consistent relationship between the patient’s edentulous anatomy and post-treatment success has been found. It therefore would be misguided for dentists to routinely lower the expectations of patients with less than favorable anatomy. Patient satisfaction with complete den-tures is multifactoral.

Bolender and colleagues (1969) reported that the Cornell Medical Index was a reliable method of identifying patients with psycho-logical issues that could potentially result in dissatisfaction with denture treatment. These individuals, according to the authors, would benefit from additional counseling regarding denture treatment and use. In contrast, Berg and colleagues (1986) found that a “focused interview” containing 21 psychological vari-ables given prior to new denture insertion was ineffective in predicting patient acceptance of the prosthesis.

Wolff and colleagues (2003) proposed that an evaluation of salivary flow rate may be used as a predictor of future denture satisfaction. This was based on their finding, discussed pre-viously, that low submandibular/sublingual salivary flow rate was directly related to low satisfaction with dentures.

Evaluating tongue position and tightness of the mentalis muscle has been useful in predict-ing mandibular denture stability, which may be associated with denture satisfaction in some patients. Patients who automatically position their tongues upward and back in an unfavor-able position upon opening the mouth can be trained to change to a more favorable position


(flat, with tip of tongue against mandibular anterior lingual surfaces). A small (2 mm) acrylic bead is placed just below the gingival margins of the mandibular central incisors. The patient is instructed to practice keeping the tip of the tongue touching this bead. Alternatively, a shallow groove can be placed in this area (Lee and colleagues, 2009). A very tight and active mental muscle can contribute to mandibular denture instability. Patients presenting with this situation are advised to avoid, as much as pos-sible, tightening the lower lip. Severe mentalis muscle problems can be addressed with surgical procedures to release or reposition the muscle. However, numerous adverse sequelae are asso-ciated with these procedures (Zarb et al., 2013).

In a review of the literature from the 1960s through 2010, Critchlow and Ellis (2010) found the following positive indicators for complete denture success: “construction of technically correct dentures” (p. 2), a well-formed mandib-ular ridge, and accurate jaw-relation records. Negative indicators are poorly formed man-dibular ridge and a patient with a neurotic per-sonality. In addition, a minority of patients are unable to adapt to a complete denture, particu-larly the mandibular. Further research is sug-gested for this subset of patients (Critchlow & Ellis, 2010).

It is clear that no consensus exists relative to the positive indicators listed above by Critchlow and Ellis and that other factors have been noted in the literature, as described in this section. Furthermore, in a comment on the article by Critchlow and Ellis (2010), Al-Ansari (2010) stated that “… this review showed that after decades of providing patients with conventional complete dentures, the dental profession still lacks good quality studies to show what factors can really lead to a satisfied conventional den-ture patient” (p. 47).

It should be emphasized that the majority of patients surveyed in published research were satisfied with (or at least able to adapt to) their complete dentures, regardless of the reason (Carlsson, 2006).

Patient Satisfaction: The Bottom Line

It is clear that there is no consensus in the literature regarding what factors are essential to patient satisfaction with complete denture treat-ment. Heterogeneity of clinical studies (e.g., patient populations, research methodology, and statistical analysis) makes (meta) analysis problematic. However several key points are worth noting:

• The majority of patients are satisfied with their complete dentures.

• Chewing comfort and mandibular denture stability are related and important to patient satisfaction. However, most studies do not support a close association between denture quality and patient satisfaction.

• Many patients function to an acceptable level with dentures that are clinically suboptimal.

• Patients’ assessments of their dentures often do not agree with the clinical assessment by dentists.

• Several procedures that are part of most complete denture curricula are not essen-tial for denture success. These procedures include the use of secondary impressions (with custom trays), employment of a face-bow transfer, recording of eccentric records, and establishment of balanced occlusion.

• Patient involvement in treatment (e.g., tooth selection, try-in approval) contributes to patient satisfaction.

• Psychological issues are likely to be more prevalent in patients who are dissatisfied with complete denture treatment.


SUMMARY

The need for complete dentures will con-tinue for the foreseeable future. Traditional

clinical and laboratory techniques have provided excellent health and quality-of-life improvement for millions of patients. However, various aspects of the “classical” denture protocol do not meet current evidence-based standards. Familiarity with recent research and concepts is essential.

The modern denture clinician should be knowledgeable in edentulous anatomy and phys-iology, methods of registering vertical dimen-sion and maxillomandibular relations, anterior esthetics, posterior occlusion, insertion and adjustment procedures, and denture-related pathology. (Several of these areas have not been covered in the present course.) Digital technol-ogy should be of benefit to both clinician and patient. Dentists may choose to use computer engineering for all or part of their denture fabri-cation protocol. Awareness of patient psychol-ogy and establishment of doctor-patient rapport are possibly the most important aspects of suc-cessful denture treatment.

E X A M Q U E S T I O N SCOMPLETE DENTURES:

A REVIEW FOR THE DENTAL PROFESSIONALQuestions 1–32

Note: Choose the one option that BEST answers each question.

1. Which statement most accurately describes the demographics of the edentulous population in the United States?

a. The prevalence of edentulism (ages 15 and older) is predicted to be 4.6% in 2020 (approximately 12,400,000).

b. The continuing major decline in edentulism will likely eliminate the need for complete denture treatment by 2050.

c. The growth in the elderly population will more than offset the decline in edentulism in this group.

d. Accurate data are impossible to obtain because people are reluctant to provide this type of information.

2. A properly made complete denture serves a variety of diagnostic functions in implant treatment planning, including the

a. ability of the patient to sit through long dental procedures.

b. need for a maxillary labial flange for facial support.

c. ability of the patient to maintain a complex fixed restoration.

d. financial commitment of the patient.

3. Which of the following statements is true regarding comorbidity and edentulism?

a. Edentulism can cause a variety of medical conditions.

b. Treating edentulism can cure a variety of medical conditions.

c. Edentulism will make many existing medical conditions worse.

d. Edentulism and other medical conditions can exist together in the same individual.

4. A study by Shinkai and colleagues on denture quality and patient diets found that

a. dentures result in significant dietary improvement regardless of the quality of the dentures.

b. dentures result in significant dietary improvement only if high clinical standards are met.

c. patients may continue to have deficient diets despite being provided with clinically acceptable dentures.

d. the adequacy of the patient’s diet actually declines when dentures are used.

59 continued on next page


5. A recent study by Liljestrand and colleagues in Finland found that having five or more missing teeth was associated with an increased hazard for coronary heart disease events and acute myocardial infarction of

a. 10% to 50%.

b. 40% to 75%.

c. 60% to 140%.

d. 80% to 170%.

6. Researchers have found that edentulism is predictive of COPD-related events because

a. edentulous patients are more likely to smoke cigarettes than those with natural teeth.

b. the biofilm on complete dentures results in inflammatory responses that may exacerbate COPD.

c. edentulous patients are less likely to seek medical treatment for COPD.

d. COPD patients with natural teeth are more compliant with medical advice regarding diet and exercise.

7. Antifungal medications used to treat the acute mucosal symptoms of chronic atrophic candidiasis include nystatin, amphotericin B, and

a. amoxicillin.

b. acyclovir.

c. miconazole.

d. meclizine.

8. What is the effect of complete denture treatment on the oral health-related quality of life (OHRQoL) of edentulous individuals?

a. The improvement is significant.

b. Improvement depends on the material used to make the dentures.

c. The OHRQoL improves only for male patients.

d. Dentures have no effect on OHRQoL.

9. What statement is correct regarding the traditional two-step complete denture final impression technique?

a. Little evidence in the dental literature supports it.

b. It has been shown to be superior in nearly all published clinical studies.

c. It is the most cost-effective method of obtaining an accurate final impression.

d. It is the only method compatible with the digital denture protocol.

10. The primary support areas for a mandibular complete denture in the mandible are the buccal shelf and the

a. pear-shaped pad.

b. ridge crest.

c. genial tubercles.

d. labial ridge inclines.

11. The posterior extent of a mandibular complete denture is

a. two-thirds of the way up the retromolar pad.

b. at the junction of the pear-shaped pad and the retromolar pad.

c. at the distal end of the retromolar pad.

d. at the location that is most comfortable for the patient with respect to swallowing.

12. What is a major advantage of vinyl polysiloxane impression materials over mercaptan polysulfide materials?

a. They are less expensive.

b. They have a longer working time.

c. They are available in a variety of colors.

d. They are more dimensionally stable.


13. One of the main indications for pre-prosthetic surgery for clinical success for a complete denture patient is to

a. correct the existing occlusal relationship.

b. decrease the available denture supporting area.

c. eliminate bony undercuts, exostoses, and unfavorable frenum/muscle attachments.

d. establish a more acceptable interarch distance.

14. Can a person’s sex be determined by examining only the maxillary anterior teeth?

a. Yes, but only dentists can do this.

b. Yes, and both dentists and laypersons can do this.

c. Yes, but only experienced dental technicians can do this.

d. It is not possible to determine this.

15. Which of the following statements is correct regarding the use of the “bio-metric ratio” of 16:1 (face size:maxillary central incisor size) to select anterior teeth for the edentulous patient?

a. It is reliable in almost 100% of edentulous patients.

b. It is accurate in only about 10% of patients.

c. It is useful only in extremely large individuals.

d. It is a helpful initial reference for selecting tooth size.

16. The term used for the nasal width or the distance between the most lateral aspects of the alae nasi is the

a. interalar distance.

b. innercanthal distance.

c. interpupillary width.

d. intercommissural width.

17. A 2016 study by Pithon and colleagues found that the dentures rated as the “most acceptable” were the ones providing smiles

a. that exhibited less exposure of the maxillary teeth.

b. that exhibited more exposure of the mandibular teeth.

c. in which the lower border of the upper lip coincided with the cervical margins of the maxillary anterior teeth.

d. in which the upper border of the lower lip coincided with the incisal edges of the mandibular anterior teeth.

18. The three basic maxillary anterior tooth and face shapes observed in people are square, ovoid, and

a. round.

b. tapering.

c. triangular.

d. trapezoidal.

19. Anatomic artificial teeth duplicate the forms of natural teeth and have cusp angulations of

a. 0°.

b. 10° to 25°.

c. 30° to 45°.

d. 50° to 65°.

20. The term for the type of occlusion that most commonly has only the maxillary lingual posterior cusps contacting the central groove areas of the mandibular posterior teeth is

a. balanced occlusion.

b. unilateral occlusion.

c. eccentric occlusion.

d. lingualized occlusion.


21. A 2010 study by Farias Neto and colleagues that compared the masticatory efficiency of complete denture patients with either bilateral balanced occlusion or canine guidance found that

a. no significant relationship existed between (objective) masticatory efficiency and patients’ subjective rating of chewing ability.

b. occlusion with bilateral balance exhibited significantly higher masticatory efficiency than canine-guided occlusion.

c. patients were unable to chew the test food, making conclusions about occlusion impossible.

d. masticatory efficiency was markedly improved if a facebow transfer was used.

22. Which of the following statements is correct regarding complete denture occlusion?

a. A bilaterally balanced occlusion has been shown to improve the chewing function of complete denture wearers.

b. There is no universally accepted, evidence-based occlusal scheme for complete dentures.

c. Patients usually prefer posterior denture teeth without cusps.

d. Dentures with canine-guided occlusion provide much more masticatory efficiency compared with the natural dentition.

23. What are the two main methods of fabricating a complete denture digitally?

a. Injection molding and flasking

b. Computer engineering (disking) and Copyplast (copying)

c. Additive (3-D printing) and subtractive (milling)

d. Sintering and laser-copying

24. What is a significant disadvantage of the two-visit digital protocol?

a. It is more expensive than conventional methods.

b. It requires more postinsertion adjustments.

c. It is suitable only for patients with favorable ridge anatomy.

d. It does not allow for a setup try-in appointment.

25. Which of the following is an advantage of digitally fabricated CAD/CAM dentures?

a. Superior esthetics

b. Greater occlusal accuracy

c. Increased insurance reimbursement

d. Reduced microbial contamination

26. A 2015 survey of digital denture technology utilization by U.S. pre- and postdoctoral prosthodontic programs by Fernandez, Nimmo, and Behar-Horenstein found that

a. 10% or fewer of complete denture cases were processed using CAD/CAM technology, at either the pre- or postdoctoral levels.

b. most pre- and postdoctoral programs are currently employing this technology.

c. only postdoctoral programs currently employ this technology.

d. The survey response rate was inadequate to make any conclusions.

27. Which of the following statements is true regarding the Simplified Edentulous Treatment (SET) technique?

a. It was first described by Bidra and colleagues in 2000.

b. It is a two-appointment technique.

c. It uses a multilayer impression tray.

d. It uses a maxillary record base made of baseplate wax.


28. Which statement most accurately describes the relationship between edentulous anatomy and patient satisfaction with complete dentures?

a. A lack of consensus exists in the literature on the importance of patient intraoral anatomy to subjective outcome (patient satisfaction).

b. A direct correlation exists between favorable ridge anatomy and patient satisfaction with dentures.

c. No correlation exists between intraoral anatomy and patient satisfaction with dentures.

d. Intraoral anatomy has significance only for first-time denture wearers.

29. What aspects of tongue anatomy and position are most likely to adversely affect mandibular denture stability and subsequent patient satisfaction?

a. Small size and a habitually protruded position

b. Large size and a habitually protruded position

c. Small size and a habitually retruded postion

d. Large size and a habitually retruded position

30. A person with a high neuroticism score is often

a. egotistical and narcissistic.

b. obsessive-compulsive.

c. anxious and overreacts to stimuli.

d. controlling and extremely aggressive.

31. According to a 2014 study published by Alfadda, the most important determinant of overall satisfaction with complete dentures is

a. clinician-patient rapport.

b. ultimate cost of the denture.

c. clinical stability of the mandibular denture.

d. overall esthetics of the denture.

32. Which of the following procedures for complete denture fabrication is considered essential for denture success?

a. Balanced occlusion

b. Facebow transfer

c. Impressions that capture the relevant edentulous anatomy

d. Secondary impressions employing custom trays

This concludes the final examination.Please answer the evaluation questions found on page v of this course book.

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Murrell, G. A. (1988). Esthetics and the edentulous patient. Journal of the American Dental Association, 117(4), 57E-63E.

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