2

Fabrication of complete & Partial denture

Ibraheem
Farah Shakhtour & Bayan Qawabeh

15 7 2015
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Clinical steps in the fabrication of complete denture

And partial denture All the slides
are included
Notes:-

-it is a review lecture about clinical steps of fabrication complete denture and
we will talk about partial denture briefly.
-this lecture represents as a guide line for you next year in the clinic so you
have to read it carefully :")
-please try your best to bear this number of pages
-& now let's start step by step:-

Assessment of patient (before doing anything ):-

It has 2 part:-1)physical assessment (ridge formetc) and 2)mental
assessment for the patient, it is very important in the first visit after
examining the patient and determine what is the prognosis of the case to tell
the patient how the denture is going to be at the end and if they there is any
problem and not to delay it to the day of delivery because the patient takes it
as an excuse to consider anything as an error you've done during the
treatment.
After patient assessment you are going to start the procedures (primary
impression, secondary impression, jaw registration, try in, delivery and
recall)

Primary impression

Tray selection:-
If you have a solid tray, you are going to use an
adhesive material because we dont need any
features of retention and
the perforated tray for non-adhesive material in
nature like alginate (for the primary impression we
use an alginate and compound material).
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Retention Features for alginate is:

1) Perforated tray
2) Adhesive material in order to retain the impression material inside the tray
Why do we have to make sure that the impression material is retained
inside the tray?
-In order not to make a distortion in the impression, while removing it from
the patient mouth and get error in the impression

3) Rim-lock tray

The ridges of the sides are inverted inside

(protruded margins inside the tray and at
the periphery of the tray), so the impression
material will get stuck inside these
inversions, which are around the outer side
and the inner side of the tray.

How to differentiate between edentulous and dentate trays?

By cross section, edentulous trays are rounded while dentate trays are square
shaped.
The tray adhesive is usually used when the impression material is not-
adhesive in nature like alginate and silicon material like PVS (ply vinyl
siloxan), addition silicon, condensation silicon and other rubber material.
Each material has different adhesive.

This one for alginate material

and we use another one
specially for silicon material
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Stock tray
In the primary impression you have to choose stock
tray, when we mix the alginate firstly it become runny
material (liquid) so it doesn't have a body to support
itself at the beginning so you have to make sure that the
impression material is well extended in the patient
mouth because we need the primary impression to be
fully extended in the sulcus so if the tray is short you
can apply utility wax to extend the border of the tray.

The other thing in the stock tray is to be an adequate

size because we need an enough space of the material to
be accurate.

You have to have an enough space on between the tray margins and the
ridge so the alginate will be in adequate thickness to support itself and to be

accurate otherwise it will be distorted easily, so 3-4 mm is the minimum

thickness of alginate.
In the primary impression in complete
Denture we have two important things:
Bad news
About the property for the compound and
alginate material the Dr said that you
should have to go back and study it.

1) We have to record all the landmarks, for example in the maxilla, the
impression should record from anterior premaxillary ridge to the hamular
notch, and in the mandible it should record the anterior ridge to retro molar
pad
2) The optimal depth of the sulcus, the reason why we make primary
impression is to make a special tray (should be 2mm shorter of the sulcus, if
it was shorter than 2mm, the impression compound that we use and the
border molding won't support itself and it can break easily.) ** 2mm is optimal
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We have two techniques in order to take a primary impression

for complete dentures:-
1) Conventional (by stock tray we take the primary impression)
1) Template:
if the patient already has a denture, we will make a copy for the fitting by
alginate material or condensation silicon, the cast is usually made from
stone in case of conventional technique but here we get a cast made from
impression material (silicon)

the advantage for this technique is:

If the old denture is well extended then you will have an exact and perfect
extension for the special tray and we dont need to do any trimming for it in
the clinic so you can save your time and the patient time.

Special tray
1) It should be 2-3 mm shorter than the sulcus where we can put the green
stick to record the full depth and width of the sulcus.

2) Cover the whole bearing areas

3) It shouldnt be perforated because when you are dealing with complete
dentures you should have a suction in order to do border molding later with
the green stick and if its perforated; air will get in and you will never be able
to know if you have achieved retention or not, so if you make a special tray
even if we use alginate material you have to have a solid tray to start with
until you do border molding then we will check the retention and then you do
the perforation.

It has to be non-perforated whatever the

impression material to be use
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Spacer:-
Sometimes we use a spacer and sometime we dont use it. So
when we need to use spacers?
There are 2 general indications to use spacers:-
1) To provide space for impression materials.
- For Example - Alginate spacer (which is wax) needs to have 3mm
minimum thickness in order to be accurate, so you have to ask the lab to
provide you with a spacer that is 3 mm in thickness.
- Now most of times in the dental clinics we are going to take the final-
master impression with ZnO, Its minimum thickness is 0.5 mm, and if
theres no other indication to use a spacer we use a close fit tray .

- If the patient has undercut and we want an accurate impression material we

should use elastomeric impression material like PVS which is condensation
silicone and for this material we use a 1.5mm spacer.

We can divide the spacer in to two types:

a) Full spacer (used to support the impression material)

b) Segmented spacer: we use it when we have an area in the tissue that should
be relieved such as incisive papilla (because it is a prominent area that
contains nerve and blood vessels) and mid palatine raphe thats covered by a
thin mucosa, so if you have any compression over it, it will become
traumatized thats why, you have to provide relief under impression material
if the impression is close fitting surface.

2) Selective pressure technique

When we cover certain areas to relief them such as support area (crest of the
ridge, tuberosity, and flat part of the hard palate) and relief areas that are
covered by thin mucosa or contain bloods vessels and nerves.
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Segmented spacer in the maxilla

becomes either like I-shaped or if
the anterior ridge needs to be
relived again by wax in T-shaped
spacer.

Here there are relief areas in the maxilla and the mandible

Border molding:
After receiving the special tray from the lab you have to check the
extension if there is any over extension then you have to trim it to achieve
2mm space between the edge of the tray and the sulcus to support the green
stick wax.

Wax spacer remains in place during border molding procedure in order to

keep the fit surface of the tray accurate inside the patient mouth during border
molding it maintain complete adaptation to the tissue and to prevent rocking
to happen.
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We flam the green stick on the Bunsen burner until it becomes runny then
apply it to the edge of the tray and then temper it in a warm water.
Why we temper the green stick in a warm water??
Tempering: dripping the
To avoid burning the patient mouth tray with green wax on it
in warm water in order to
To make Sure that it will stay soft inside the oral lose fluidity of the wax.
cavity, and this will able you to do border molding
for long period of time; Because green stick hardens quickly.

(The temperature of the water should be 140 F, which is equally to 60

degrees)

after finishing the border molding it should

be smooth and it should represent the sulcus.
you can see the frenum and the sulcus around
the tuberosity so it should look like something
anatmoical not rough.

check the rentention in the maxilla by pulling the tray dawnward to check
the retention in the buccal and labial flanges
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and if you want to check the rentention in the post dam area you try to tip
the tray from the palatal aspect of the hamular and if there is any error you
should adjust it.
Border molding for the lower tray is a bit more difficult (upper is
straight forward, we dont have a lot of movable tissue)

In the mandible, buccal and labial sides are easier to mold than the
lingual side , because you can't see the lingual side clearly in addition to
that , the floor of the mouth is moving , which means the position between
the resting position and active position is a quit big difference.

When the patient is in a resting position the floor of the mouth will be at
zero level but when the patient moves his tongue and the floor of the mouth,
the difference between zero level and the new position is about 5 mm, which
is big difference!!!

when you do the border molding on the functional position the tray will
be short by 4-5 mm and when we do it at the resting . And if you border
mold on the resting position, it will be over extended and the muscles wont
be free to move (it may interfere with the function of the muscles and this
will displace the denture)
secondary impression,

After finishing the border molding the tray will be ready for the secondary
impression, the primary purpose from the secondary impression is to
record the fine details (in the primary impression we have to record the full
extension and the full depth of the sulcus) and we use:-
1- zinc oxide eugenol to get an accurate impression because it is very good
in recording the fine details
2- alginate (irreversible hydrocolloid)
3- irreversible hydrocolloid (reversible like agar) but this technique is very
rare because it is sensitive and need a special preparation.
4- silicon rubber material like addition silicon (PVS)
5- Admixed technique can use to make a secondary
impression
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Admix technique:-
A mixture between impression compound + tracing compound (green stick).
Has special proportion (according to the dentist who invited it):-
If we divide the material used to 10 parts= 7 parts green stick + 3 parts of
impression compound.
to make a secondary impression specially for pt with atrophic mandible.
why?
As when the dentist wants to make an impression for a pt who has an atrophy in
his mandible , he needs material that provides:-
1-body for the impression(impression compound does this)
2- moldability :-ability to record accurate details for the tissues folding on top of the
crest of ridge after bone resorption by spreading them (greenstick does this)
Why not using zinc oxide euginol ?
As it's a running material that won't give us a body to spread the tissues .
What about light/medium bodies of PVS ?
The same thing as it's quite light & runny that won't give us body to spread these tissues.

This is addition silicon material :-

- The most used material
-Records all fine details that
can't be recognized by green stick
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Jaw registration:-

3 basic things we must do :-

1- Creating and outlining the form of the upper denture.
2- The relation between the maxilla & mandible.
3- Select the shape & shade of teeth .
Creating and outlining the form of the upper denture:-
To determine teeth position by using wax rim after the master cast.

Labial fullness:
- wax is added to the base plate to achieve lip support after the edentulous pt had
ridge resorption especially in labial part .
How to know if the lip support adequate or not?
By looking laterally to the pt & noticing:-
Nasolabial angle:- the angle between the base of the nose & the philtrum, it
shoud be around 90 if fullness is good
Appropriate lip support should restore
the vermilion border and the philtrum
(if u can see them it's sufficient)

Visibility :-
It increases with age as tissue will be relaxed by age leading to longer upper lip, so u
check the appearance at rest & smiling, then according to age +lip length u decide:
#Age :-
Older patients: 0-1 mm under resting lip
Younger patients; up to 3 mm under resting lip
#lip length :-
long :-reduce visibility to get adequate inter arch space (as if the pt has long lip & we
give him high visibility reduce lower arch space )
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Occlusal arch plan:-

By using fox plane which should be :-

Medio-laterally parallel to interpupillary line

Anterio-posteriorly parallel to alla-tragus line

(camper's line )
Mid of the tragus

Base of ala

Buccal corridor:-
the space you see when the pt smiles between the teeth & the cheek (the corner of the
mouth )

3-5 from canine tips

it's unpleasant not to get a buccal corridor

10-15% of full smile (if u measure it from commissure to another, it will be 10-15% of
the space, but dentists at clinics don't do this they decide just by looking at the pt )

Lines:-
Midline :- pass a floss on the midline of the face (through tip of the nose ,mid of the
philtrum put a mark on the wax rim decide the position of the central incisors )

Canine line :- it's drawn to know the inter canine space(distal-distal)to help the dentist in
teeth selection as the mold chart depend on this space in teeth sizes:-
pass a line on the inner cantus of the eye & the ala of the noseput a mark on the wax,
this will present the tip of the canine
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Ask the pt to rest without smiling put a point on his resting commissuresgive
us the distal aspect of the canine

Commissure point

Now we measure the distance between the commissur point & the canine tip it
may be roughly 3-4 mm or around

The distance between commissure & canine

tip = distal aspect of the canine which
represents the position of the canine as its
width 8-10 mm.

Finally when you want to select anterior teeth(from canine to canine) you need the
whole distance between canines (inter-canine space not from tip to tip) so you will
add :-
The distance between tips + the distance between left canine tip & left commissar +
the distance between right canine & commissure.
Smile line:- to give us the height of central incisors
Mold chart :-

It has 3 numbers :- inter-canine distance , central incisors width ,central incisors

height & The lines are drown to find these 3 numbers choose the suitable teeth.
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When we start jaw registration, either we start with the upper finish it and adjust
the lower accordingly or vice versa, but the common technique is to start with the
upper, why?!
Because the upper is showed more than the lower so it more important than the lower
from an esthetics points of view

How to adjust the lower?

Based on the relation of the mandible to maxilla and it includes three dimensions
which are called the Intermaxillary Relations
Vertical
Antero-posterior
Lateral; mdeio lateral of the mandible in relation to the maxilla.

Vertical dimension
we can deviled it into two dimensions:
vertical dimension at rest (VDR); when we are relaxing our teeth wont be
touching.
* This measurement is fixed and we cant control it
vertical dimension at occlusion (VDO); when we bite, the mandible will
move up and the teeth will achieve contact.

The difference between occlusion at rest and at occlusion is called free way
space and usually it 2-4 mm.

Our function when we do the VD is to record the free way space by:
Firstly we insert the upper wax block alone then we measure the VDR,
Then, we insert the lower wax block and ask the patient to bite, that will give
you the initial vertical dimension of occlusion.
Our Vertical Dimension of Occlusion (VDO) should be = Vertical
Dimension at Rest (VDR) (2-4) m
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Lets say our VDR is 80 so the VDO should be 78-76 but if it was more the 78
or 80 we have to adjust the lower by trimming the wax to reduce the height,
and if it was less, we put another layer of wax

what are the techniques we use to check the vertical dimension :

Facial measurements
Profile
Phonetics

Facial measurement
marking two dots on the patients face
one on the
nose and the other on the chin then let the patient
relax and u measure the VDR
we insert lower
Our vertical and measure
dimension the be
will never VDO,accurate because these tissue that we
we measure the difference between them
depend on are movable not bony structures epically the chin, so when the
and you adjust accordingly if it needs to be
patient bite,
increased or even without
or decreased to the biting
achieve thefree
oral muscles or the facial muscles can
movespace
way moving them these tissues, and thats why we use different
withrequirement
2-4mm
techniques in measuring the vertical dimension.

Profile
you look at the patient from a lateral view

Sometimes the dentate patient if he is putting a piece if food u will know

because the tissue will be stretched or if he is opening his jaw inside his
mouth the lower facial height will be stretched.
So to know if the patient for example is over closing you look at his profile
laterally by that can decide if the patient is normally closing, over closing or
stretching the lower facial height
1- the picture on the right we have
increased VDO, the patient is over biting, there is
nothing to support the VD
2- on the left is the normal one
3- look at the vermilion border, imagine that the
patient doesnt not have the upper wax rim in his
mouth then the vermilion border wont be visible
because it will be intruded.
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Phonetics
we have something called the closing speaking space: the space between the
upper and the lower when u pronounce the letter (S) usually its 0.5 mm.

How do you check it in the denture?

U ask the patient to tell some words that have letter (S) in it , and u see the
space between the upper and the lower wax rims.
If you have 4mm for example , it if there is no space and the upper and
means that VDO is decreased lower wax rims are hitting each other
because the space is increased when pronouncing the s sound it
and the free way is increased so means that the VDO is increased u
you should add a wax layer of have to trim the lower to achieve
adequate free way space for the
wax to the lower rim.
patient.

NOW lets get more into details.....

VDR:
Upper rim in.
you put the upper without the lower because if u also put the lower the patient
will automatically bite

Head upright.
Balance between elevator and depressor muscles of the mandible.
Make sure the head in the upright position.
The patient's head should be in an upright position because the VDR is
dependent on the balance the muscles tone of the mandible and the gravity
if the patients head is retroclined posteriorly the elevator muscles will be
stronger and push the mandible up-word so your measurement of the VDR
will be shorter
if the chin is down, the gravity will affect the position of the mandible and
again u will get wrong VD
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Anterioposterior dimension:
- is how we are going to records the centric relation to set teeth later
accordingly.
Centric relation: bone to bone relation, centric relation when we describe the
position of the TMJ in the condyle, the most anterior superior position of the
condyle in the glenoid fossa.

Why do we record the centric relation why not to ask the patient just bite and
record this bite?!
The unique thing about centric relation is that is reproducible every time.
In centric relation its reproducible and u can manipulate the mandible to put it
every time in the same position.

Even if the patient had never bit on the centric relation, he can learn it
with time when we provide the patient the denture, the maximum
intercuspation is in the centric relation and the patient will get used to it and
will always bite in the centric relation.

lets assume that the patient had bit randomly and recorded his bite, its
impossible to let the patient do it again on the same bite, meaning that this
bite cant be done twice , it not reproducible.

the dentate patient have intercuspul position ( maximum intercuspation) and centric
relation position, these are different from each in about 1-2 mm

and the reason is that because every time we bite we will have a memory the brain will
remember the position of the jaw based on the intercuspation ,when u lose teeth there
is no intercuspal position and there is nothing for the brain to remember so u have to
provide the patient with something that already exists in his mouth and does not
change which is the centric relation .

Help the patient

After we have finished the VD, now we want to teach the patient how to bite
in the centric relation because many edentulous patients dont know how to
bite in the centric relation.
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To guide the patients, we have techniques on how to put the mandible in

the centric relation:
Guide a relaxed mandible
Tongue technique

Guide a relaxed mandible

first you ask the patient to open and close many in order to tiered the muscles
of the jaw then relax the mandible, after doing so, u will be able to guide the
mandible smoothly in the CR.

Tongue technique
we use the tip of the tongue. if u try to put the tip of the tongue at the
posterior aspect of the palate and then bite , the jaw will go to the CR position

In the clinic if u told the patient to put your tongue on the back of your palate
he wont know where to put it exactly
so we have to help the patient so we place a dot of wax on the posterior part
of the upper base plate (on the palate) and show it to the patient u can also
give the patient a mirror to see it inside his mouth then ask the patient to feel
it with the tip of the tongue , this will automatically push the tongue
posteriorly and the patient will find it easily.

NOTES:
1- if you try to put the mandible in the CR position, the patient will push the mandible
away, he wont let you.

2- Naturally if you swallow upon eating or chewing your mandible will go to CR and if
you chew or eat, so you can ask the patient to swallow and the patient will go to CR
automatically.

CR: Centric relation,

RCP: retruded contact position
RAP: retruded axis position
*they all have the same meaning

At the end u have to be sure and confident that u have accurately determined
the CR.
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when we are confident that we have found the CR position and the patient is
cooperative, you do the following:
Ask the patient to bite in the centric relation position or what we think is
the CR position and
extend theses lines on the lower ( canine line and the centric line so we
will have like a tripod ( three lines at different places)
ask the patient to open again manipulate the mandible and ask him to
close ( you can use any of the techniques that was mentioned )
see if these line coincide with each other or not

if they dont coincide this means the that the original recording of the CR
is not actually the CR its a haphazard position that is not reproducible

if these lines coincide every time the patients closes then this is the centric
relation

You dont seal the upper with the lower, until you are sure that the patient is biting in the CR position

How to seal the upper and lower with each other

we can use hot spatula pass it between the upper and lower base plate (
dont forget to protect the lip) remove them from his mouth as one piece
and then we do further sealing

we can make V notches in the upper bring wax or any thing for sealing
(in the clinic we have what we call oclofast its a bite registration material)
squeeze some of it on the upper ask the patient to bite in the CR position
u will get impression for the notches of the upper on the lower ,
* Using this way, you can put them in the right position even if they arent
sealed with each other inside the patients mouth.
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Lateral dimension
it will be registered automatically, when u achieve the centric relation your
mandible will be centered at the middle of the mediolatrela in relation to
maxilla.
Finding the VDO, CR and then sealing the upper and lower is the end of the jaw
registration

The last clinical step is: teeth selection

We have two aspects:
Shade mould

Tooth mould.
Post-extraction methods:
Inner canthus-ala line , smile line, Canine tips and measurements that we
took in the jaw registration

Pre extraction records:

Photographs
Some patients bring pictures and asks u to make the new teeth like his old
ones
A patient came to DR Ibrahim she had crowding in her teeth and she
wanted her denture to be the same.
Cast
in some countries, patients take impression when they are youn and make
casts out of them cuz they know that later on they will lose their teeth and
have to make a denture , so they keep the cast and bring it to the dentist to
arrange the dentures teeth according to his pre-teeth :P

some people thinks that these patients are needy, actually they are not needy
nor demandy, they are helpful.
Sometimes u do the setting and the patient didnt tell u how he wants it, after
u do the setting, at the delivery stage they dont like it.
( if the patient asks for something and u did it for them he will be happy)
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Anterior teeth mould

Comprises three values:
Inter-canine distance (distal aspect in the mould)
Height of central incisor (based on smile line)
Width of central incisor
firstly, we use a flexible ruler or a floss and measure
from the two canine line then put the floss on the
ruler to its length to measure the intercanine distance
secondly, we go to chart and select the closest numbers
to our measures.

Select mould that is within 1 mm of the inter-canine

distance because most of the time u wont find the
exact measures
For middle aged patients, when the patient smile,
Highest point on labial surface of central incisor should
be 1 above the high smile line
When we measure the smile line we chose the central incisor height 1m
higher than the smile line so that we will have part of the central is hidden
under the patient lip
The patient will show almost 95% of the central, 1mm wont be shown
this is a pleasant smile

Tooth Shade
We have the shade guide to select the shade with the patient.
In edentulous patients, the shade guide is not demanding because we dont
have any teeth, so we are not matching the color with existing natural teeth ,
we give the patient new set of teeth with different shades.

The most important thing that the patient likes the color

There are some criteria we can use to help the patient and advice the patient
that not all the time the white teeth are nice
Age teeth get darker
Patients preference u advice him but eventually u let him decide.
Skin color
we can use like the lip shade or the color of the face
For example if the patient has a dark skin color, its better to chose dark color of
teeth to look more natural.
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this shade is usually used for porcelain teeth (vita shade)

for acrylic there is a different shade guide

When we finish jaw registration, we send the jaw registration box to the lab where
they set the teeth according to the jaw registration

then we will have the try-in clinic where we check everything we did in the
jaw registration so we do all the steps with the same sequence as we did in
the jaw registration
We check on articulator:
Fit
Setting (angles, occlusal plane, curves, etc.)
VDO

we look at the articulator, the central fossa of the lower teeth should be
on the crest of the ridge to achieve the best stability
if its buccal the denture may flip every time the patient bite because its
outside the fulcrum
if the lower are too far lingual they will interfere with the space of the
tongue and the tongue will displace the lower denture every time it moves.

The central fossa has to be in the crest of the ridge and the palatal cusps of
the upper oppose the central fossa so the palatal cusps of the upper should
be biting on the lower crest of the ridge
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Inside patients mouth:

Esthetics phonetics
Occlusal planes Occlusion
if we started with the maxilla, well start checking with the maxilla; we
check lip fullness, visibility, occlusal planes, buccal corridor, mid
line, canine lines.
Notes regarding phonetics:

- We dont trust phonetics at the jaw registration stage because the wax rim is thick
and the patient wont be able to move the tongue easily, while at the try-in teeth are
present and there is no excess wax, so the patient will be able to speak easily and will
be more accurately in registering the phonetics.

We use these techniques to assess phonetic:

Closest speaking space (Mississippi) we mentioned it earlier:
Contact between teeth: increased OVD
Whistling: reduced OVD
V,f assess anterior-posterior and superior inferior positioning of incisors
Too far lingual
then or too
well put short incisors:
the lower V check
denture and will sound like f dimension with the
the vertical
To far labial or too
measurements we long incisors:
talked F will
about them butsound like v
its easier with phonetics

then we try to manipulate the mandible in the same way we did in the jaw
registration, the most important step in the try-in is to check the centric
relation position; when we tell the patient to bite in the centric relation.

We have to set teeth in the centric relation, so if you guide the patients
mandible in the centric relation we should be able to achieve maximum
intercuspation in the centric relation position .

IMPORTANT: The minimum occlusal requirements in the complete

denture is that the maximum intercuspation should happen in the centric
relation position , in other words the maximum intercuspation should equal
the centric relation , or centric occlusion should equal centric relation!
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So when you guide the patients mandible into the centric relation the teeth
should come smoothly into maximum intercuspation (maximum digitation)
what if this didnt happen !!
What are the reasons for that?!
Maybe the bite registration was incorrect
the position of the upper and lower jaws was changed in the lab
maybe they were moved or the position of the articulator was changed.

What are the Consequences?!

We will have errors in the centric relation; maximum intercuspation will not
coincide with the centric relation inside the patients mouth.
What happens actually is once we guide the mandible into the centric
relation the teeth will not come into maximum interdigitation,
so there will be a premature contact, either cusp to cusp contact or teeth are
far away from the maximum intercuspation.

If we have error in the centric relation we will see it in the try-in, so you have to
look for errors.
Always think that centric relation or the try-in is wrong! Always assume that the
try-in is wrong!! Because in the clinic well see that the setting with the crowding of
students will give many errors.
Even if you done the jaw registration perfectly with no errors you should expect to
have errors in the centric relation on the try-in; as a lot of mistakes happen in the lab!
Always assume that the centric relation is wrong and you have to do another try-in

What is the most common error?!

The most common error we will have with the centric relation at the try-in
stage is that when you ask the patient to bite in the centric relation one of the
teeth cusp will hit with the opposing and then the patient will slide into the
maximum intercuspation;
so we have a slide between the centric relation and centric occlusion, the
amount of this slide determines what are we going to do
 Page 24 of 29

Lets assume that we go the try-in and we found that the maximum
intercuspation doesnt coincide the centric relation what should we do?
Should we redo the centric relation or just proceed?
If it was within 1mm (or 0.5 or less) this means that its adjustable at the
delivery stage, you can adjust the cusps of the teeth so we will have smooth
biting into the maximum intercuspation in the centric relation.
If it was more than 1mm you cant adjust because you will lose the hole
cusp all the cusp width is about 1mm, in this case you are risking losing
the anatomy of the teeth, so u have to register the centric relation, but how?!

we dont remove hole teeth in the upper and lower as we did in the jaw
registration, we keep everything in the upper if everything was correct in the
upper and we keep the lower anterior teeth, we just remove the lower
posterior teeth (premolars & molars) and we replace them with wax, then we
register the bite again (the centric relation again)

Why do we keep the lower anterior teeth?! because we need to hold

the vertical dimension (we dont need to measure the vertical dimension
again) so lower teeth with upper will hold the correct vertical dimension so
we keep them and dont remove the lower anterior teeth just we remove
lower posterior teeth, replace them by wax and then we take the bite again.

The steps are the following :

We remove the premolars and molars we replace them with wax.

Put them in the patients mouth and then we manipulate the patients
mouth in order to record the centric relation so we will get the indentations of
 Page 25 of 29

the upper teeth.

No need to do sealing or notches, the indentations of the upper will
appear on the lower and we can position the upper and lower accurately.
After that we put them on the articulator where we have the upper and
lower mounted, we keep the upper but re-mount the lower on the new bite,,
this is done if we have a big difference in the centric relation and maximum
intercuspation.
The last thing we do on the try-in stage is to determine where the peripheral seal
is; we determine the posterior aspect of the upper denture which is the post dam
area

The land marks of the post dam area (the butterfly shape):
The junction between the hard palate and the
soft palate determines the anterior border of the butterfly
shape
*it is determined by asking the patient to blow against his
closed nose , the soft palate will become bulgy and u will be
able to differentiate between the hard palate and the soft palate this way is
called valsava maneuver.

The posterior border of the butterfly is determined by the vibrating line:

which is the junction between the movable and non-movable parts of the soft
palate)
*it is determined by asking the patient to say AH (AH line).

The lateral aspects we have the hamular notches (which are a depression
posterior to the tuberosity) if you hold a burnisher once you drop behind the
turberosity this is the hamular notch

On the middle, our land mark is the fovea palatine which is openings for
minor salivary glands, usually the vibration is 2m anterior to the fovea
2mm
Page 26 of 29

How to mark the vibrating line?

we can make the vibrating line arbitrary on the cast, if the hamular notch
and the fovea palatine are clearly demarcated, we can draw the vibrating line
2mm anterior to the fovea palatine then extend it until it reaches the hamular
notch on each side.

If u want to be more accurate, not always the fovea palatine is an accurate

guide, sometimes its anterior, others its posterior, or it can be on the vibrating
line itself, for more accurate u go to the patient in the try in stage ask him
to say AH see were the vibrating line is mark it in the patient then copy it
on the base plate or on the impression then we carve it on the cast by and
finally it will appear on the CD as a protrusion to prevent air from coming in .
Look at the end of the page for better understanding

Functions of PPS the

Aids in compensating for dimensional changes in curing
Prevents food from getting under the denture base
Firm contact with the tissue of the soft palate reduces the tendency to gag
The thickened area provides added strength across the denture
To provide retention, Because it will complete the seal post;
The peripheral seal on margins is done by border molding
posteriorly u can achieve the peripheral seal by carving the post dam
area.
It will prevent air from getting underneath the denture to achieve the
negative pressure that will make the retention of the complete retention
better.

Denture insertion
Systematic approach to inspect all surfaces.
You check everything you have done in the try in:
Check occlusion on articulator and inside pts mouth
Freeway space Retention Extension
Page 27 of 29

Partial denture
- the Dr read few slides and told us to read the rest, all the slides are included.
Page 28 of 29

Notes:
The trays are different in shape from the ones in complete denture.
In complete denture the patient loses all teeth and they lose any reference
for occlusion.
In dentate patients the occlusion reference is maximum intcrcuspation
In most dentate patients the centric relation doesnt coincide with the
centric occlusion( maximum intercuspation ) only in 3% of patients and
usually centric occlusion is 2mm anterior to the centric relation
If we try to put the tip of the tongue posteriorly and bite slowly , u will
feel that we have interference then your mandible will slide forward

Reorganizing approach :
we reorganize the occlusion and we give him a new occlusion.
Reorganizing is done for patients that have extensive tooth loss free end
saddles or patients that are completely edentulous.
If we want to do reorganize approach we record the centric relation

Here the patient doesnt have posterior teeth, he lost all the
posterior teeth in lower, they dont have any occlusal pairs
the we can do mounting on in this case even if they have
natural teeth u have to reorganize the occlusal approach u
give them a new occlusal approach different from the one
they had when they were completely dentate.

Conformative approach
We conform the occlusion that already exists.
In case if we have dentate patient (when we have single crown or free rete
bridge) or partly edentulous patient who have teeth to mount casts on.
When conformative approach we record the centric occlusion
If we can achieve maximum intercuspation even if we have two premolars
alone and you we can put them together in maximum intercuspation then
you have to conform this approach .
Page 29 of 29

here we want to make for this patient a partial denture,

we have molars and premolars and both have
intercuspation ,also we have occlusal position we can refer to,
so no need for reorganization of occlusion and it wrong
because u have to restore every single tooth if we want to reorganize.

This slide has nothing to do

with the planet, the Dr told
us to read it.

The end ..

If there is any
mistake , forgive
us & just post it
on our FB group
.