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Inside Dental Technology

April 2011, Volume 2, Issue 4
Published by AEGIS Communications


Exceeding Esthetic Expectations

Proven prosthodontic techniques to restore natural esthetics and function in a complete denture patient.

By Robert Kreyer, CDT

An esthetic smile powerfully affects a person’s self-confidence at work or in daily life. The goal in prosthodontics is to exceed patient expectations by providing a prosthesis that contributes to a happy, positive state of mind.

The middle-aged female patient in this case works with the public, and her smile is very critical to her success. The original prosthesis (Figure 1 and Figure 2) was only a few years old, but impaired the patient’s ability and desire to express herself freely with an esthetic smile.

Anterior esthetics is a critical factor when trying to understand a patient’s expectations and desired results. Denture tooth forms should be selected according to facial features, such as the nose (ala to ala measurement) and the lips (incisive papilla measurement), in order to create harmony when the patient is smiling, speaking, and laughing.1,2

The previous prosthetic occlusion was set in severe Class II relationship with an extreme horizontal and vertical overlap. The vertical overlap, combined with the selection of a maxillary anterior tooth that was too short, created a noticeable gingival display extending from teeth Nos. 6 through 11. To eliminate the “gummy” gingival display, a papillameter was used to determine the exact negative space from incisive papilla to maxillary lip at rest and high smile line.

To determine the proper horizontal or labial position of the maxillary anteriors, an intraoral tracing was made to establish a physiological centric relationship and to determine the proper amount of horizontal overlap (Figure 3 and Figure 4 ).

The impressions were then separated, boxed in alginate, and poured to create proper working master casts and then mounted on a Stratos® 100 articulator (Ivoclar Vivadent, www.ivoclarvivadent.com) (Figure 5 and Figure 6 ). A cast analysis determined the residual ridge relationship and delineated proper tooth placement.

Phonares™ denture teeth (Ivoclar Vivadent) were then arranged for a try-in, verified, and the final gingival contours were waxed for flasking (Figure 7, Figure 8, Figure 9 and Figure 10). The dentures were then invested for the Ivocap continuous press injection system (Ivoclar Vivadent) and prepared for gingival characterization (Figure 11).

The Preci Clix attachment (Preat Coporation, www.preat.com) was placed on the model analog and blocked out before injection to prevent acrylic resin from being pressed into the matrix (Figure 12 and Figure 13). Characterization of the gingival base can be accomplished either with an intrinsic (inside the mold or negative process) or extrinsic (outside the mold or positive process) technique. For this case, the intrinsic technique was used for the gingival base. The colors were applied with a brush in stages, starting with the interdental papilla and extending toward the peripheral border or mucosal tissue where the color would be more vascular or reddish (Figure 14, Figure 15, Figure 16 and Figure 17).

After polymerization, the molds were cooled for 30 minutes then deflasked. After deflasking, the processed acrylic-resin dentures were left on the master casts and placed back on the Stratos 100 articulator to evaluate occlusal contacts and correct any processing errors (Figure 18, Figure 19 and Figure 20).

A very important advantage of the Ivocap continuous press injection system is that the closed flask process prevents any increase in vertical dimension. This can be verified by placing articulating ribbon between the incisal pin and the table. A red contact mark is evident where the incisal pin touches the table (Figure 21 and Figure 22).

After carefully removing the processing stone casts from the acrylic resin dentures, the intaglio surface was inspected. The denture surface should be very clean with no voids or stone in the resin, often caused by improper application of separator after wax elimination (Figure 23 and Figure 24).

The dentures were then finished and polished, achieving a natural appearance within the biofunctional denture space of the oral environment (Figure 25).

Conclusion

The first thing patients want to see is how the new prosthesis looks and how it changes their personal appearance. The patient wanted a softer, more youthful esthetic smile in harmony with her face. The flat facial surface and even incisal edges of the previous prosthesis gave the patient an aged appearance compared to the open incisal embrasures of the new prosthesis, which provide the youthful appearance the patient desired (Figure 26).

When comparing the high smile line between the two prostheses, the previous prosthesis displayed excessive gingival tissue and interdental papillae when the patient smiled. In comparison, the new prosthesis displays an esthetic gingival margin when the maxillary lip is at full smile (high lip line), showing teeth not tissue (Figure 27).

It also is always preferable to use various shades of denture teeth to provide a more natural look. The previous prosthesis had a monochromatic appearance compared to the new prosthesis in which shade A1 was used for the centrals, A2 for the laterals, and A3 for the canines. The pre-molars were shade A2 with a slight stain on the occlusal third. The molars were shade A3 to break up the color. The cervicals of the canines and the laterals have a slight ocher stain to add to the illusion. What truly makes a difference is exposing the full mesial aspect of the canines so the patient shows this full-body tooth during an esthetic smile.

The goal in prosthodontics is to restore function, enhance esthetics, and preserve health. Laboratory professionals can consistently exceed esthetic expectations by applying these principles in their prosthetic techniques.

References

1. Pound E. Lost—Fine arts in the fallacy of the ridges. J Prosthet Dent. 1954;4(1):6-16.

2. Pound E. Personalized denture procedures: dentist’s manual. Anaheim, CA: Denar Corp; 1973.

About the Author

Robert Kreyer, CDT
Director of Removable Prosthodontics
Microdental/DTI
Dublin, California


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Image Gallery

Figure 1  The existing smile with maxillary complete and mandibular implant-retained overdenture. Note the Class II relationship.

Figure 1

Figure 2  The existing smile with maxillary complete and mandibular implant-retained overdenture. Note the Class II relationship.

Figure 2

Figure 3  To verify relationship and record centric relation/vertical dimension of occlusion, a central bearing device (Gnathometer-M, Ivoclar Vivadent) was set up with closed-mouth wash impression.

Figure 3

Figure 4 To verify relationship and record centric relation/vertical dimension of occlusion, a central bearing device (Gnathometer-M, Ivoclar Vivadent) was set up with closed-mouth wash impression.

Figure 4

Figure 5  After boxing and pouring impressions, master casts were mounted on a Stratos 100 average value articulator.

Figure 5

Figure 6  After boxing and pouring impressions, master casts were mounted on a Stratos 100 average value articulator.

Figure 6

Figure 7  After clinical esthetic wax try-in, verification denture waxing was completed and prepared for investing.

Figure 7

Figure 8  After clinical esthetic wax try-in, verification denture waxing was completed and prepared for investing.

Figure 8

Figure 9: Occlusal view of completed maxillary and mandibular waxed dentures. Maxillary has a custom palate that duplicates the patient’s natural rugae.

Figure 9

Figure 10  Occlusal view of completed maxillary and mandibular waxed dentures. Maxillary has a custom palate that duplicates the patient’s natural rugae.

Figure 10

Figure 11   Dentures have been invested and the wax eliminated to prepare for intrinsic colorizing of gingival base.

Figure 11

Figure 12  Mandibular implant analogs with Preci-Clix attachments.

Figure 12

Figure 13  Preci-Clix attachments blocked out with Panasil x-light body VPS impression material (Kettenbach LP, <a href=www.kettenbach.com).">

Figure 13

Figure 14  Maxillary denture mold with five-color gingival characterization. A layer of color 55 was placed in the labial unattached tissue of the positive mold, where there are more vascular colors.

Figure 14

Figure 15  Maxillary denture mold with five-color gingival characterization. A layer of color 55 was placed in the labial unattached tissue of the positive mold, where there are more vascular colors.

Figure 15

Figure 16  Mandibular denture molds with five-color gingival characterization. As in the maxillary, a layer of color 55 was placed in the area of the labial sulcus unattached tissue.

Figure 16

Figure 17  Mandibular denture molds with five-color gingival characterization. As in the maxillary, a layer of color 55 was placed in the area of the labial sulcus unattached tissue.

Figure 17

Figure 18  After processing and deflasking, the dentures were re-mounted with casts on the Stratos 100 articulator to verify occlusal contacts.

Figure 18

Figure 19  Using articulating ribbon, occlusal contacts were verified for lingual contact occlusion.

Figure 19

Figure 20  Using articulating ribbon, occlusal contacts were verified for lingual contact occlusion.

Figure 20

Figure 21  The incisal contact can be verified by placing articulating ribbon between the incisalpin and the table.

Figure 21

Figure 22  A red contact mark is evident where the incisal pin touches the table.

Figure 22

Figure 23  The Ivocap Injection processed dentures were deflasked and the intaglio surface was checked. Block-out around the Preci-Clix attachments would be removed during finishing.

Figure 23

Figure 24  The Ivocap Injection processed dentures were deflasked and the intaglio surface was checked. Block-out around the Preci-Clix attachments would be removed during finishing.

Figure 24

Figure 25  Finished and polished maxillary and mandibular complete-denture prosthetics in the oral environment.

Figure 25

Figure 26  Facial view of new smile line with improved anterior esthetics.

Figure 26

Figure 27  Right facial view of the smile line and anterior esthetics.

Figure 27