MATERIALS & METHODS

Materials & Methods

Table of Contents
A. Patient Examination ................................................................................................................ 52
i. Medical History ........................................................................................................................ 52
ii. Dental History .......................................................................................................................... 52
iii. Intra Oral Examination ....................................................................................................... 52
B. Complete Denture Construction .............................................................................................. 53
C. Patients Grouping .................................................................................................................... 56
Group I (Control Group) ................................................................................................................ 57
Group II (Test Group) ..................................................................................................................... 60
System components and technique .................................................................................................. 60
D. Patient’s Instructions ............................................................................................................... 66
E. Determination of the geographic center of the lower denture: ............................................... 67
F. Clinical evaluation of mandibular complete denture retention .............................................. 68
G. Digital evaluation of mandibular complete denture................................................................ 69
H. Patient satisfaction evaluation of mandibular complete denture............................................ 71

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 Materials & Methods

Materials and Methods

Case-control study introduced within this study in which retentive appliance
was used in lower complete dentures as study group and compared plain lower
dentures as a control group.

In order to study clinical, digital and patient satisfaction, mandibular

complete denture was constructed on completely edentulous mandibular ridge. Ten
completely edentulous co-operative patients were selected from the Out-patient
Clinic, Removable Prosthodontics Department, Faculty of Dentistry-Boys, Azhar
University according to the following criteria:

Inclusion criteria

1. Patients were non-smokers and had no previous denture experience.

2. The residual alveolar ridges covered with firm mucoperiosteum with no

signs of inflammation, ulceration or hyperplasia and with adequate height
and width.

3. Age of the selected male patients ranged between 45-60 years.

4. Patients exhibited Angle`s class I maxilla-mandibular relationship and

adequate inter arch space.

5. They had a normal tongue size.

Exclusion criteria

1. Patients with any signs or symptoms of oral pathological disease.

2. Patients with history of recent chemotherapy or radiotherapy.

3. Patients with bad oral habits as clenching and bruxism.

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4. The residual alveolar ridges with bony exostosis or, undercuts.

5. Patients with any systemic diseases or hormonal disorders or taking systemic

drugs.

6. Patients with excessive salivation or thick ropy saliva.

A. Patient Examination

Full medical and dental histories were taken from each patient followed by
intra-oral examinations to fulfill the selection criteria.

i. Medical History

Patients were investigated for their medical histories to exclude patients

having systemic disorders as diabetes, thyroid or parathyroid hormonal diseases.
Patients who were having blood diseases, lowered immunity or who were chronic
drug users affecting the condition of oral tissues were excluded. Furthermore,
patients who had history of recent administration of cancer therapy were not
selected.

ii. Dental History

Patients were asked about both the date of last extraction and the cause of
extraction whether it was due to dental caries or periodontal disease. Moreover,
they were asked about having any previous experience with oral prosthetic
restorations.

iii. Intra Oral Examination

Visual and digital examinations were thoroughly carried out to assess the intra-
oral condition to fulfill the pre-mentioned criteria:

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 Materials & Methods

1. Maxillary and mandibular ridges were examined for the presence of

any bony undercuts, sharp residual alveolar ridges, tori or any soft
and hard tissue abnormality. Furthermore, this examination was
essential to evaluate the interocclusal distance and ridge relationship.
Only patients with adequate interocclusal distance and normal ridge
relation were included in this study.
2. Salivary secretion was examined to avoid thick ropy saliva and dry
mouth.
3. Mucosa of the edentulous area was examined to detect any signs of
inflammation, pathology or tissue flabbiness.

B. Complete Denture Construction

Upper and lower preliminary impressions were made using alginate

impression material iaccording to the manufacturer’s instructions, figure (1).

The preliminary impressions were poured immediately by hard dental stone ii

to obtain diagnostic casts. Self-cured acrylic resin special trays iii were constructed
on the diagnostic casts; the borders of the special tray were trimmed 2-3mm shorter
than the tissue reflection area. Special trays were checked intra-orally for correct
border extension and adaptation.

i
Cavex Dental- Holland.
ii
Elite Rock Stone- Zhermack Clinical- Italy.
iii
Acrostone- Acrylic resin cold cure- Egypt

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Figure 1: Primary impressions

The tray was painted with adhesive for silicone material. Border tracing was
performed using heavy bodied condensation silicone i . The material was mixed
following the manufacture`s instruction., applied to the borders of the tray and
seated properly in the patient`s mouth. The impression was held in place and
border molding was done by asking the patient to perform physiological functional
movements as pursing the lips and cheeks, swallowing and sucking. The tray was
held without pressure in position till the material has set for three minutes.

The secondary impressions were taken using medium consistency rubber

base material ii with light finger pressure. The tray was held in position till the
material has set for three and half minutes. The tray was removed and inspected for
the evidence of tissue contact and accurate recording of the supporting anatomical
structures of the maxillary and mandibular arches, figure (2). The secondary
impressions were poured using extra hard stone iii to obtain the master casts.

i
Heavy body Condensation Silicine- Zhermack Clinical- Italy.
ii
Regular body Condensation Silicine- Zhermack Clinical- Italy.
iii
Elite Rock Stone- Zhermack Clinical- Italy.

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Figure 2: Secondary impressions

Occlusion blocks were constructed on the master casts. The upper occlusion
block was adjusted to developed proper lip support and properly orient its occlusal
plane. A face bow record was made to mount the maxillary cast on a semi-
adjustable articulatori then transferred to the articulator. Centric occluding relation
was recorded at the predetermined vertical dimension of occlusion following inter-
occlusal wax technique to mount the lower cast with protrusive record, figure (3).

Figure 3: Mounting using face-bow record

i
Bioart Dental- Brazil.

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 Materials & Methods

Suitable size maxillary and mandibular artificial cross-linked acrylic teeth i

were set up to conform the principles of facial esthetics and phonetics. In addition,
the posterior teeth were arranged following the guide lines of a suitable occlusion
theory to reduce trauma on the underlying tissues.

The waxed up denture was tried in the patient's mouth to ensure proper
facial contour, esthetic, even contact between all the posterior teeth and harmony
between centric occlusion and centric relation at the predetermined vertical
dimension of occlusion, figure (4).

Figure 4: Try- in stage

C. Patients Grouping

The selected cases were divided randomly according to the method of

acrylic resin denture base retention into two groups. There was no vulnerable
group as each patient received newly formed denture with proper extensions,
vertical dimensions, retention and support.

i
Acrostone Dental Plus- Egypt.

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Group I (Control Group)

Each patient within the control group received a plain conventional complete
denture cured by long cycle heat cured acrylic resin.

Patients in this group were rehabilitated with complete dentures constructed

from water- bath heat-cured (short cycle 72 °C for 0.5 h and 92 °C for 1.5 h)
acrylic resin polymethylmethacrylate (PMMA) denture base material in the
following manner:

The waxed trial denture bases were flasked in a metallic dental flask with
dental stone using two pour technique.

The base of the flask was painted with vaseline and filled with dental stone.
The cast with the waxed up denture base was immersed into the plaster filled base
at the center of the flask.

Once the base was invested, a separating medium was applied and the
second pour was done. The flask was left for 30-60 minutes undisturbed till the
investing stone reach its final setting time.

Wax elimination was done by placing the flask in boiling water for 15
minutes. After 15 minutes, the flask was taken out of the water bath. The base and
the body were carefully separated and the softened wax was flushed out using hot
water stream, figure (5).

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Figure 5: Wax Elimination

The powder and the liquid of the heat cured acrylic resin were mixed
following the manufacturer's instructions and packed into the mold when the mix
reached the dough stage. Pressure was applied on the flask after the first packing
within 100- 150 Bar using calibrated compressor, figure (6).

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Figure 6: Packing of acrylic resin inside dental flask

After the final closure of the flask, it was kept at room temperature for 30-60
minutes for bench curing, and then the flask was heated in water bath following the
short curing cycle (72 °C for 0.5 h and 92 °C for 1.5 h). The flask was cooled
slowly and deflasking was done carefully to avoid cast fracture.

After deflasking, laboratory remounting was carried out to refine occlusion

and correct the processing occlusal errors. Dentures were decasted, finished and
polished. Dentures were stored in tap water for 24 hours before delivery.

The finished dentures were delivered to the patient after performing the
needed occlusal adjustment, figure (7).

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Figure 7: Denture Delivery

Group II (Test Group)

Each patient within the test group received a lower complete denture cured
by short cycle heat cured acrylic resin retained by ultra suction devicei.

System components and technique

1. Spacer bar used to create retention chamber, made of malleable metal, the
bar was designed to sit intimately against the ridge.
2. Two unidirectional valves designed to expel the air beneath the lower
dentures. The central hole in the valve body was described as the inlet and
the valve cover as the exhaust.

i
Impexbo - Impexbo SARL, Route de Lausanne 3, CH - 1041 Bottens.

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3. Processing caps were fitted onto the valves bodies before installation process
to protect the valves. They removed only after the polishing phase.
4. Two diaphragm and two spares came with the system kit. These tiny plastic
discs seal the inlet under negative atmospheric pressure and release the
pressure under resting conditions.
5. Service key had two extremities. The upper part was used to grip, close and
open both the valve covers and the processing caps. The lowest part was
slightly larger replica of the valve and might be used as a gauge for depth
and diameter, figure (8).

Figure 8: Ultra suction system Kit

Extra hard stone was used to pour the casts from the impression and after
setting, the cast models were trimmed. On the ridge, the location of the spacer was
marked, making sure that the bar stopped at least1 cm short of the end of the
denture, figure (9).
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Acrylic base plates were prepared on the top of the spacer bars followed by
bite blocks. After jaw relation record, the casts were mounted on an articulator and
teeth set up for try in was carried.

Each cast was packed in three part flask, the spacer bar remained on the
model and any undercuts were blocked out.

Figure 9: Marking the crest of the ridge for spacer location

After polymerization and deflasking, the bars were removed from the
dentures by digging prudently to prevent damage to walls of the retention chamber.
The dentures were trimmed and polished.

At the chosen lingual side, the location of the valves was drawn with a felt
marker between first and second premolar, with the center of the valve preferably
1-1.5 mm above the highest point of retention chamber, figure (10).

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Figure 10: Denture preparation of valve location

The cavities for the valves were prepared with a round bur intermittently
using the gauge side of the service key for guidance i.e. depth and diameter.
Processing caps were then placed in the valves to protect the core from being filled
with self cure acrylic resin and then tried in, figure (11).

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Figure 11: Processing caps

The valves were installed with cold cure acrylic. Soft rubber cylinder points
were used to remove excess material and to polish around the valves. The dentures
were given a final sheen, figure (12).

Figure 12: Valve installation

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The processing caps removed and the valve body inspected. Using 1mm
fissure, a communication channel was created between the valve and the high point
of the retention chamber. For the dentures with significant thickness of acrylic
between valves and the retention chamber, drilling was done on an obtuse angle,
figure (13).

Figure 13: Valve installation

Each valve was rinsed and dried thoroughly to ensure a smooth placement of
the diaphragm into its housing. The perforated cover was fitted and tied up using
the service key, figure (14).

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Figure 14: Valve installation

D. Patient’s Instructions
Patients were instructed to perform oral and denture hygiene as follow:

• Cleaning the dentures after every meal under running water only.
• Not to use any type of denture cleansers, tooth paste and solutions
containing phenol. Also, denture adhesives should be avoided.
• Removing the prosthesis at night for tissue rest and immersing it in a cup of
tap water.

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E. Determination of the geographic center of the lower

denture:
When both sets were finished the dentures were prepared for the retention
tests. It has been documented by several authors that the measurement of complete
denture was best attempted by pulling the denture from its geographic center.
Hence, it was essential to locate this center for both sets of the dentures.

By the using of digital digimizer software i , figure (15), three lines were
drawn on the cast and extended to the cast base to aid in determining the
geographic center of the mandibular denture. Line (1) connecting two points at the
apices of the retro molar pads of both sides of the arch, line (2) passing through the
crest of the anterior ridge and parallel to line (1), line (3) passing through the mid
line of the crest and perpendicular to both lines (1) and (2), point (A) the midpoint
between line (1) and (2) drawn on line (3), line (4) passing though point (A) and
running parallel to lines (1) and (2). The denture was then placed on the cast and
prepared for the retention test.

Figure 15: Determination of geographic center using Digimizer software

i
MedCalc Software- USA

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F. Clinical evaluation of mandibular complete denture

retention
Three orthodontic brackets were attached to the lingual aspect of the
denture, one at midline and two posteriorly where line (4) passing through them.
Three metallic wires 0.9 mm diameter were engaged by the three lingual brackets
and extended upwards to meet in the geographic center of the denture. A metal
loop was then used to join the three wires on the top of the denture.

Mandibular complete denture retention was measured using digital force

meteri, figure (16). Forty-five days follow up period was maintained for retention
measurement as retention was measured at time of delivery, after two weeks and
after forty-five days.

Figure 16: Determination of geographic center using Digimizer software

i
Eagle Scale- India

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When complete dentures were finished, the dentures were prepared for
retention tests. The measurement of mandibular complete denture was measured by
pulling the denture from its geographic center.

The retention was measured by digital force-meter which can apply forces in
upward and downward directions. The pull off procedure was repeated 10 times to
obtain 10 records for each, the mean of which was calculated, figure (17).

Figure 17: Retention Measurement

G. Digital evaluation of mandibular complete denture

Prior to employing T-Scan occlusal analyzer to assess the occlusion on the
complete denture, complete denture was seated and checked for fitness, stability,
pressure areas with pressure indicating paste and border evaluation and extension.
The peripheral seal should be evident so that the denture-maintained suction
against maxillary tissues. Upon completion of these fit and stability assessments,
the occlusion could then be addressed.

The method considered for the occlusal analysis was a computerized system i.
The system was composed of a computer with a specific board and software
i
Tekscan Corp, Boston, Massachuttes, USA.

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capable of converting information recorded by the sensor to visual and numerical

information on tooth contact. For Tekscan system to function properly, computer
system must meet or exceed specified system requirements.

The Tekscan USB handle, figure (18), does not require an additional interface
card or parallel box in order to be connected to computer. When inserted into
computer, the computer`s operating system will automatically detect and configure
the hardware for use. The T-Scan sensor was an ultra-thin (.004”, 0.1 mm), flexible
printed circuit that detected the patient`s occlusal parameters.

Figure 18: Tekscan USB Handle

The recordings were taken by placing the sensor in the patient`s mouth, with
the sensor support pointer between the two central incisors and keeping the
scanning handle as parallel to the occlusal plane as possible. Having the patient

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bite down normally on the sensor, the first tooth contact would cause the system to
begin recording, figure (19). While recording was in progress, the Real-time Status
Bar showed the frame count progress.

Figure 19: Tekscan Recordings

H. Patient satisfaction evaluation of mandibular complete

denture
Convenient sampling used to administer the questionnaires to the patients on
review visits after having their complete denture delivered at Removable
Prosthodontics Department Clinics, Faculty of Dentistry-Boys, Azhar University.

Sampling data collection performed through closed-ended questionnaires

divided randomly through both studied groups using (14) simple yes/no questions
fulfilled by the operator, figure (20).

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Figure 20: Patient Questionnaire

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