successful and predictable custom complete dentures · disclosure: dr. strong is vice president of...

CONTINUING EDUCATION

Successful and Predictable Custom Complete Dentures

Volume 35 No. 3 Page 86

Authored by Tony Daher, DDS, MSEd; Mostafa El Sherif, DMD, MSCD, PhD; William J. Davis, DDS, MS; William A. Lobel, DMD; Richard P. June, DDS; Samuel M. Strong, DDS; Joseph P. Thornton, DDS; and Zarko J. Danilov, GMDT

Upon successful completion of this CE activity, 2 CE credit hours may be awarded

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of specific product names does

not infer endorsement by Dentistry Today. Information contained in CE articles and courses is not a substitute for sound clinical judgment and

accepted standards of care. Participants are urged to contact their state dental boards for continuing education requirements.


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Dr. Thornton graduated from Emory University School of Dentistry and has completed the continuum series at the L. D. Pankey Institute. He can be reached via email at [email protected].

Disclosure: Dr. Thornton reports no disclosures.

Mr. Danilov founded Danilov Dental in 1979. His lab is a synergistic force in the research and development of new technology and materials in dentistry. He can be reached toll-free at (800) 959-7033.

Disclosure: Mr. Danilov reports no disclosures.

Complete denture service must be designed to main tain the stomatognathic system in a functionally healthy and comfortable state. Patients who have lost all of their teeth

suffer from a chronic condition called oral disability, according to the World Health Organization (WHO) criteria.1 One of the popular treatments for this chronic condition is removable complete dentures.2 Oral rehabilitation with complete dentures can have tremendous patient im pact and social implications. Well-made re movable complete dentures can restore a sense of normalcy and self-esteem.3


Effective Date: 3/01/16 Expiration Date: 3/01/19

Dr. Daher has been practicing dentistry since 1982 and currently maintains a private practice limited to prosthodontics in LaVerne, Calif. He has an MS degree in medical education from the University of Southern California (USC), and a postgraduate certificate in prosthodontics from the University of California at Los Angeles (UCLA). He can be reached at [email protected].

Disclosure: Dr. Daher holds stock in Global Dental Impression Trays.

Dr. El-Sherif graduated from Alexandria University College of Dentistry (Egypt), then completed a master’s degree in restorative dentistry, and then earned a PhD in fixed prosthodontics and dental materials with joint supervision by Okla-homa University College of Dentistry and Tanta University. He can be reached via email at [email protected].

Disclosure: Dr. El-Sherif is a partner in Global Dental Impression Trays.

Dr. Davis graduated from Marquette University School of Dentistry and earned his MS in prosthodontics from the University of Michigan School of Dentistry. He can be reached via email at [email protected].

Disclosure: Dr. Davis reports no disclosures.

Dr. Lobel graduated from Tufts University School of Dental Medicine with a DMD degree. He can be reached at [email protected].

Disclosure: Dr. Lobel maintains a financial interest in Global Dental Impression Trays.

Dr. June is a graduate of the Loyola University of Chicago College of Dentistry and of the General Practice Residency Programs at the Chicago West Side VA Hospital, the University of Illinois Hospital, and Cook County Hospital. He can be reached at [email protected].

Disclosure: Dr. June is a stockholder in Global Dental Impression Trays, a paid instructor at the Massad Institute in Tulsa, and helps teach workshops presented by Dr. Joseph Massad.

Dr. Strong received his DDS from Baylor College of Dentistry. He maintains a private practice in Little Rock, Ark, with an emphasis on implant prosthet-ics, aesthetic restorations, and sleep apnea. He can be reached via email at [email protected].

Disclosure: Dr. Strong is vice president of Global Dental Impression Trays.

About the Authors

Figure 1. EdentExam app (Unique Dental Apps) for iPad.

Figure 2. Removing denture adhesive with a rotary brush in a bowl full of water.

Figure 3. Sequence of the making of the maxillary and mandibular final impressions.


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There are many acceptable techniques used in the construction of dentures in pri-vate practice, and the complaint we hear from practicing dentists is, “Denture treat-ment is very frustrating. We have to deal with so many adjustment visits!” and “We have stopped treating denture patients because we could not help them.”

However, because of the confusion that exists in treating completely edentulous patients, the purpose of this article is to present a successful and predictable technique for fabricating removable complete dentures. We have used and finessed this system throughout the years. It is worthy to mention that many practitioners want to learn how to make successful complete and/or presurgical dentures that serve as blueprint templates for the placement of dental implants. It is important to know where the denture teeth will be located prior to placement of implants.

FIRST APPOINTMENT Know Your Patient

The first consultation appointment is a “get-acquainted appointment” with the patient as it is very important to establish a good rapport of kindness and understanding. The late L. D. Pankey stated that every clini-cian must “know your patients.” They have a dental problem and you want to help them. At this meeting, you need to determine and understand exactly what the patient’s wants and expectations are. Of course you want to provide your patient with an exceptional aesthetic and func-tional denture. However, there may be other issues beyond your control that by their nature make constructing a new denture diffi-cult or impossible. That is why the thoughtful interview and thor-ough clinical extraoral and intraoral examination is so important. The use of the Dr. Massad Edentulous Exam (EdentExam [Unique Dental Apps; available from iTunes]) is recommended (Figure 1).

Before starting on the treatment, it is important to discuss your fair fee with your patient and establish solid financial arrange-ments. Your patients must understand that you may or may not work directly with their dental insurance company. Pankey said, “A fair fee can be defined as that fee which the patient is willing to pay with gratitude and appreciation and which will enable the

dentist to render the best possible service.”4

If the fee for services is ac cepted, signed informed consent—which covers the benefits, risks, and alternatives of complete den-ture treatment—is obtained. Financial and refund policies are clearly explained. A panoramic radiograph is taken and read.

Once the examination is completed, a printout summary of the conditions will be handed to the patient. In this visit, oral hygiene instructions will be given on how to clean the prosthe-ses and how to remove denture adhesive from the mouth and the dentures (Figure 2).5

We also make the following 2 requests from the patient prior to the next appointment: (1) to remove the dentures for 24 hours to get rested rebound oral tissues, the patient only using them to eat, and (2) to bring along a photo or a snapshot with a smile taken before natural teeth were lost, if possible.


Figure 4. Caliper was used to select the width of the 6 maxillary anterior teeth by measuring the width of the nose.

ba

b ca b

ca b

Figure 5. Massad Lip Ruler (Nobilium) was used to measure the upper and lower lips at rest.

Figure 6. (a) Esthetic Control Base is needed to make a proper lip support, and to mark proper lip length and position during laughing. (b) The anterior portion is leveled to the horizon for proper plane of occlusion and the midline is marked with a vertical line. (c) The portion of the wax rim distal to the canine will be made slanted to the lingual 45º to mark the buccal corridor.


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SECOND APPOINTMENT Collection of Records

The following 4 objectives must be achieved in this visit:1. The final impressions are made for the complete upper and

lower dentures. During the procedures, it is advisable to educate the patient about the importance of the impressions and what they represent and why border movements are important.6 Multiple viscosities of vinyl polysiloxane (VPS) impression material in a low-temperature moldable edentulous tray to obtain a co-lamination among the layers of material will be used. The capture of an anatomically correct and detailed reproduction of all aspects of the edentulous arches is thereby enhanced (Figure 3).6

2. Measurement is taken of the width of the nose with an Alameter (Ivoclar Vivadent) or a caliper (Figure 4) and 2 measurements: one of the upper lip at rest and the second of the lower lip at rest with a Massad Lip Ruler (Figure 5).

3. If any labial, buccal, or lingual overextensions are present on the impressions, it is advisable to mark the right extensions with a permanent marker. The maxillary vibrating line should be transferred to the impression using an indelible marker.

4. A laboratory prescription should be filled out with the previously collected data, along with the request to fabricate stone casts and 2 sets of record bases. One set is to be used to make a wax Esthetic Control Base (ECB) for the maxillary cast (Figure 6); a second set is to be used to place the Massad disposable

tracers (Figure 7) and a neutral zone record for the mandibular cast (Figure 8).

THIRD APPOINTMENT Collection of Records

The following 6 objectives must be achieved in this appointment:1. Select a vertical dimension of occlusion (VDO) at a

retruded contact jaw position using the Massad Jaw Recorders (Nobilium) or tracers7 with one set of the record bases. If linear occlusion will be utilized, the recording is made at rest VDO. If lingualized occlusion is the occlusal scheme of choice, the rest VDO is closed 3.0 mm prior to making the tracers. Once recorded, a VPS material (Futar D Fast [Kettenbach LP] or Regisil Bite Registration Material [DENTSPLY Caulk]) is used to secure the bases together (Figure 7d).

2. The ECB is tried and adjusted for adequate upper lip support.


a b c d

Figure 7. (a) Massad Jaw Recorders (Nobilium). (b) Striker plate and pin placed onto record bases. (c) Gothic arch tracing on the upper striking plate. (d) Securing the tracers bases together with Futar D Fast (Kettenbach LP) bite registration Material.

a b c d e

Figure 8. (a) The neutral zone is an area where the forces of the cheek and lip muscles get neutralized by the forces of the tongue muscles. In this zone, the lower denture teeth will be placed. (b) Neutral zone record molded in patient’s mouth. (c) Neutral zone record is trimmed at the black line at the level of the rested lower lip. (d) The finalized neutral zone record placed in the patient’s mouth. (e) Silicone index is made and shows where the denture teeth will be set. The black area is the playground of the tongue, the pink area is where the buccinators act, the green area is where the lips act, and the yellow area is where the denture teeth are set.

b

d

Before After

Figure 9. Balanced artic-ulation with anatomical denture teeth setup (a) in centric position, and (b) in working and balancing position. (c) Before and (d) after images.

a

c


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The anterior horizontal level of the wax is checked against the bi-pupil horizontal level for parallelism. The midline of the face, and the highest (laughing) lip-line are marked. The buccal corridor is checked and sometimes adjusted (Figure 6).

3. The neutral zone record8 is heated in a water bath of 140°F then placed in the patient’s mouth. The patient will be asked to sip and swallow hot water 4 to 5 times, then cold water is used before removing the record out of the mouth. This neutral zone record is a must when the lower ridge is very low to nonexisting. Use of the neutral zone method to identify and register the anatomy and physiology that impact prosthesis stability may result in improved prosthodontic therapy for patients (Figure 8).

4. The vibrating line is checked and the posterior border of the record base is adjusted as required.

5. The shade and mold of the prosthetic teeth are selected with the patient input. Patient involvement in tooth shade, mold selection, and tooth arrangement increases denture acceptance and results in fewer complaints and post-placements visits.9,10

6. A balanced articulation will be selected. Lingualized or linear occlusion will need to be determined and prescribed (Figures 9 and 10).11,12

During this appointment, it is advisable to explain and educate the patient about the importance of these records. In addition, the importance of bringing a spouse or close relative to the next “rehearsal” appointment is also discussed.

FOURTH APPOINTMENT“Rehearsal” of the Wax Trial

DenturesThe following 6 objectives must be achieved in this appointment:

1. The dentist checks first the wax trial dentures for aesthetics, VDO, plane of occlusion, buccal corridor, centric, and phonetics.13

2. Then it is checked by the patient standing in front of a big mirror; first at 9 feet, then at 6 feet, then at 3 feet. The patient will be asked for some feedback about the fit and regarding the look of these dentures in the mouth. Never allow the patient to use a hand mirror for viewing. Never let the patient take the trial denture home for family viewing.

3. Make an external impression along all the cameo surfaces of the trial denture using low viscosity

VPS in low residual ridges (Figure 11). 4. Sometimes it is important for

the patient to take ownership of this appointment by signing an approval paragraph placed in the patient chart.

5. It is prudent to ask the patient for his or her consent or refusal for a denture ID placement (Table).

6. If the VDO or centric occlusion is off, a new tracing can be made using the trial denture and the jaw recorders. A remount and reset is then achieved and the patient recalled for verification.

FIFTH APPOINTMENT Integration of the Finished

Complete DenturesThe following 4 objectives must be achieved in this appointment:

1. The dentures are fitted using a pressure indicating paste14 (Figure 12),


Figure 10. (a) Linear articulation using maxillary flat porcelain posterior teeth and mandibular bladed form of porcelain posterior denture teeth in centric position. (Note: there is no vertical overlap of the anterior teeth.) (b) Linear articulation in protrusion. (c) Balancing occlusion side view. (d) Occlusal view of the mandibular prosthetic teeth set up in linear occlusion. Note that the

buccal cusps are shaped like a “blade.” (e) Smile with old dentures. (f) Smile with new dentures.

a b

c d

e f

a

b

Figure 11. (a) External impressions made using a light vinyl polysiloxane (VPS). (b) Finished dentures showing the external anatomy preserved.

DENTURE IDENTIFICATION (required by the State of ___)

Laboratory Fee $_______ per Denture

I wish to have my name or Social Security Number placed in my denture(s).

________________________ _______Patient Signature Date

I wish to waive the right to have my name or Social Security Number placed in my denture(s).

________________________ _______Patient Signature Date

Table. Identification Consent Form


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and sometimes a new centric record using the Massad tracers is made to refine the occlu-sion and balance the den-tures (Figure 13). This step is very important for the patient’s com-fort with the new den-tures. This step will not be necessary with linear occlusion since there are no inclined planes to adjust.

2. The patient is then given some grapes to chew to check for any sore spots before dismissing him or her. Adjustments are made to relieve any areas of discomfort.

3. Oral and written instructions are given as to how to care for the new dentures and what the patient can expect. A good practice-marketing tool is to give the patient a cleaning kit.

4. It is advisable for the office to keep the old dentures to shorten the adjustment period of the new dentures. Old den-tures will be given back when the patient is comfortable and no further adjustments needed. Future adjustments will be made until the patient is comfortable. It normally takes several weeks to learn to eat efficiently with new dentures. It not unusual for the dentures to feel too big if the VDO has been restored. The musculature will adjust to the new height quickly.

SIXTH APPOINTMENT Adjustment Phase: Adaptation to the New Dentures

The following 5 objectives must be achieved in this appointment:1. The patient will be asked how he or she is getting along with

the new dentures. A troubleshooting procedure will be initiated to solve any problems.15

2. Sometimes it is acceptable to say that some problems can-not be solved due to the limitations of the patient’s condition.

3. Complete a visual inspection of the soft oral tissues for any red lines or red ulcerations. Pressure-indicating paste (Lee-Mark Pressure Disclosing Paste or LeeMark Sorefinder [Lee-Mark Dental], or PIP or Mizzy [Keystone Dental]) could be used to relieve the sore spots and the border overextensions can be titrated with a light-body VPS (Panasil Light Bodied [Ketten-bach] or AquasilUltra XLV Fast Set [DENTSPLY]) (Figure 14a).

4. Adjustments will be made (Figure 14b) until the patient is comfortable and confident in wearing the new dentures. With this described technique, one or 2 adjustment visits suffice for the

Figure 13. Tracers used to correct all procedure occlusal errors of the denture fabrication.

Figure 12. Pressure indicating paste to check the tissue fit of recently made dentures.

Figure 14. (a) Titrating steps with light VPS to check border over-extensions and (b) adjusting.

a b

Figure 15. Assessment form to be sent to patient after treatment is done.


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successful integration of dentures. For medically compromised patients whose muscle dysfunction cannot be corrected, it may require implant stabilization. This must be discussed at the begin-ning and at the end of treatment.

5. A denture assessment form (Figure 15) is to be mailed to the patient after 2 weeks of the completion of the denture treatment. This is an excellent form of feedback for the dental practice.

CLOSING COMMENTSA summary of a predictable technique for the fabrication of removable complete dentures has been presented. This technique has been tested by many practitioners and has stood up through the years.

The details of the technique are described in the referenced articles, or you can view the technique videos at nobilium.com/clinical-products, joemassad.com/nobiliumproducts, or on youtube.com, search for Joseph Massad.F

References1. World Health Organization. International Classification of Functioning,

Disability and Health. Geneva, Switzerland: World Health Organization; 2001.

2. Felton DA. Edentulism and comorbid factors. J Prosthodont. 2009;18:88-96.

3. Roumanas ED. The social solution—denture esthetics, phonetics, and function. J Prosthodont. 2009;18:112-115.

4. Pankey LD, Davis WJ. A Philosophy of the Practice of Dentistry. Toledo, OH: Medical College Press; 1985:158-159.

5. Cagna DR, Massad JJ, Daher T. Use of a powered toothbrush for hygiene of edentulous implant-supported prostheses. Compend Contin Educ Dent. 2011;32:84-88.

6. Massad JJ, Cagna DR. Vinyl polysiloxane impression material in removable prosthodontics. Part 1: edentulous impressions. Compend Contin Educ Dent. 2007;28:452-459.

7. Daher T, Lobel WA, Massad J, et al. Predictable technique to register retruded contact position (RCP) using a disposable jaw relation recording device. Compend Contin Educ Dent. 2015;36:323-330.

8. Cagna DR, Massad JJ, Schiesser FJ. The neutral zone revisited: from historical concepts to modern application. J Prosthet Dent. 2009;101:405-412.

9. Lefer L, Pleasure MA, Rosenthal L. A psychiatric approach to the denture patient. J Psychosom Res. 1962;6:199-207.

10. Hirsch B, Levin B, Tiber N, et al. Effects of patient involvement and esthetic preference on denture acceptance. J Prosthet Dent. 1972;28:127-132.

11. Jameson WS. Linear occlusion: an alternative tooth form and occlusal concept as used in complete denture prosthodontics. Gen Dent. 2001;49:374-382.

12. Williamson RA, Williamson AE, Bowley J, et al. Maximizing mandibular prosthesis stability utilizing linear occlusion, occlusal plane selection, and centric recording. J Prosthodont. 2004;13:55-61.

13. Pithon MM, Alves LP, da Costa Prado M, et al. Perception of esthetic impact of smile line in complete denture wearers by different age groups. J Prosthodont. 2015 Sep 15. [Epub ahead of print]

14. Bookhan V, Owen CP. A comparison of the cost effectiveness of pressure-indicating materials and their ability to detect pressure areas in complete dentures. SADJ. 2001;56:228-232.

15. LaBarre E, Giusti L, Pitigoi-Aron G. Addressing problems in complete dentures. Compend Contin Educ Dent. 2007;28:538-542.


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1. Well-made removable complete dentures, although proven to be helpful, very rarely restore a sense of normalcy and an acceptable self-esteem.

a. True b. False

2. During the first consultation appointment, a “get-acquainted” session with the patient is very important to establish good rapport of kindness and understanding.

a. True b. False

3. During the clinical procedures, it is advisable to educate the patient about the importance of the impressions and what they represent and why border movements are important.

a. True b. False

4 A neutral zone record is a must when the lower ridge is very low to nonexisting.

a. True b. False

5. Sometimes, it is important for the patient to take ownership of this appointment by signing an approval paragraph placed in the patient chart.

a. True b. False

6. It is never advisable for the office to keep the old dentures to shorten the adjustment period of the new dentures.

a. True b. False

7. It is never wise to say that some problems cannot be solved due to the limitations of the patient condition.

a. True b. False

8. A denture assessment form can be used to gain some good feedback for the dental practice.

a. True b. False

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ANSWER FORM: VOLUME 35 NO. 3 PAGE 86Please check the correct box for each question below.

1. o a. True. o b. False








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