Clinical protocol - Conventional Complete Denture Clinical Guide Flashcards
compete denture clinical protocol basic steps?
A) pt assessment, tx plan and informed consent
B) primary impressions
C) secondary impressions
D) recording the jaw relationship
E) wax denture try-in
F) fit of complete denture
G) complete denture review
A) Assessment, Treatment Plan and Consent
pt assessment steps?
1) History
[complaint, history of presenting complaint, medical, dental (denture use) history, social and family history]
2) Extra-oral examination
– Angular Cheitis, lower facial height (OVD, FWS), labial and buccal tissue support, teeth show and smile line
3) Intra-oral examination
- Assess for soft tissue lesions, extent of ridge resorption, soft tissue undercuts and overgrowth, tuberosity, mylohyoid ridge, flabby ridge, frenal attachments
4) Examination of existing dentures
– Stability, retention, extensions, prosthetic teeth wear, tissue fitting surfaces and shaping of polished surface
what is used to assess OVD, RVD and FWS?
Willis gauge at initial app
extra-oral examination?
Angular Cheitis
lower facial height (OVD, FWS)
labial and buccal tissue support
teeth show
smile line
A) Assessment, Treatment Plan and Consent
How to Diagnosis and formulate a treatment plan?
1) ‘conventional new dentures’ or ‘replica dentures’)
** If you opt for replica technique, please see separate Protocol for Replica Dentures and do not forget to enter the reasoning in patients clinical notes
2) Plan your clinical and laboratory stages and appointments (paying attention to latest information on technical laboratory timings and allowing for Public Holidays.) You are required to book all your appointments and laboratory sessions on the first visit
- Discuss the arrangement with the patient.
- Gain informed consent
what appointment do you book all future app?
at the first app
lab and clinical app
B) primary imps
1) Modify extensions and borders
- of edentulous poly stock trays with putty or greenstick or trimming with an acrylic/ tri-cutter bur. If the opposing arch is dentate, select and modify a dentate poly tray or choose a metal tray if extensions are adequate.
2) Make impression
- ensuring good reproduction of oral anatomy. Alginate impression material is most commonly used here, but you may choose silicone or impression compound if the ridge is severely resorbed.
Discuss with your clinical supervisor and seek to understand the rationale.
3) Complete a Student Clinical Prescription Card
- for a non-perforated, custom tray in light cured acrylic, extending to the marked border*, with tissue stops and stepped or stub/rim handle as appropriate.
- Please prescribe adequate spacer according to material preference for working impression -discuss with your clinical supervisor
–> If a flabby ridge is present, double the spacer/ perforate the tray in the area of the flabby tissue. For more severe cases, a windowtray with lid may be required for a selective pressure impression
What to write on lab prescription after primary imps?
COMPLETE A PRESCRIPTION CARD FOR…
for a non-perforated, custom tray in light cured acrylic, extending to the marked border*
with tissue stops and stepped or stub/rim handle as appropriate.
Please prescribe adequate spacer according to material preference for working impression -
discuss with your clinical supervisor
If a flabby ridge is present, double the spacer/ perforate the tray in the area of the flabby tissue.
For more severe cases, a windowtray with lid may be required for a selective pressure impression
B) Primary imps
once disinfected, what should you do?
Once disinfected, mark the required extensions of the special tray on the impressions. This mark should be 2mm below the mucobuccal fold.
B) primary imps
if pt has flabby ridge, what do you do?
If a flabby ridge is present, double the spacer/ perforate the tray in the area of the flabby tissue.
For more severe cases, a windowtray with lid may be required for a selective pressure impression
C) secondary imps
steps in taking secondary imp
1) Assess the custom tray on the cast prior to insertion in the patient’s mouth.
- Ensure smooth borders.
- Check extensions in the mouth and trim if necessary.
2) Use green stick compound or silicone putty to border mould the peripheral extensions of the trays. (A non-perforated tray will allow confirmation of the peripheral seal at this early stage.)
3) Make impressions in med-bodied silicone or alginate. (pre-determined at the previous appointment in order to prescribe the correct spacer dimensions)
material for secondary imps?
med-bodied silicone or alginate.
C) secondary imps
steps in taking secondary imp with window tray?
If an window tray is used…
medium body silicone should be used over firm tissues
light body silicone impression material applied through the window of the tray over the flabby ridge area.
Immediately replacing the lid over the window to contain the setting material.
C) secondary imps
what do you wrote on the prescription card?
Complete the Student Clinic Prescription Card for…
working casts to be poured up and duplicated for providing, light cured acrylic denture bases supporting wax occlusal registration rims to average dimensions.
D ) recording jaw relationship
steps to record jaw relationship
1) Check bases on model and in mouth for extensions, stability and retention.
2) Shape the labial & buccal surfaces of the maxillary rim to provide correct soft tissue support and teeth show.
3) Adjust the palatal slopes of the maxillary occlusal rim to ensure tongue space.
4) Check and adjust the maxillary rim using a Fox’s occlusal plane indicator (parallel to the ala-tragal line posteriorly and inter-pupillary line anteriorly).
what should the fox’s occlusal plane align with?
parallel to the ala-tragal line posteriorly and inter-pupillary line anteriorly
D) recording jaw relationship
What is being checked here and what is the purpose?
1) Adjust mandibular rim to fit the maxillary rim and provide adequate Free Way Space (FWS).
2) Use a Willis Gauge, or measure the distance between a point on the tip of the nose and another on the chin to establish adequate FWS.
- Phonetics may also be used to detect the closest speaking space and confirm adequate FWS.
- Always use more than one technique.
FWS = RVD – OVD. (must be a minimum of 2 mm.)
3) Ensure the heel of the mandibular rim is not interfering with the posterior areas of the maxillary rim and base.
4) Ensure occlusal plane of the mandibular rim is below the dorsum of the tongue and level with the retromolar pads at the posterior ends.
5) Ensure adequate tongue space, labial and buccal overjet.
how to measure FWS?
This can be done using the Willis Gauge or dividers and ruler as shown on the image
D) recording jaw relationship
How to check FWS, what 5 basic points should you check?
1) Stability
2) Consistent horizontal jaw relationship
3) Adequate freeway space
4) Even occlusal rim contact
5) Soft tissue support
Mark additional information on the maxillary rim with the centre, canine, low and high smile lines
D) recording jaw relationship
How to record the the wax rim relationship in to mouth to send to lab
1) Make locating cones or notches on both the maxillary and mandibular wax rims
2) Educate the patient to position the jaw in retruded relation. Ask the patient to curl the tongue towards the soft palate and close the mouth. You may need to use more than one technique to establish the true, retruded position. Please refer to the prescribed textbook for other techniques.
3) Once the patient is comfortable to close in the retruded position and you are confident about the reproducibility, you may register the jaw relationship with bite registration material.
D) recording jaw relationship
after you have taken the relationship between the wax rims, what is left to do?
1) Study any existing dentures for information regarding the selection of prosthetic teeth and their set up, as well as choice of occlusal scheme. If you want to copy the mould or tooth position from previous prostheses, it may be useful to make an impression of the denture in alginate and have a model poured for the technician to use as reference
2) Discuss the prosthetic teeth characteristics (shape, size, shade) with the patient. Engage the dental nurse in this discussion. Please check the Prosthetic Teeth Mould Guide (available on clinic). Once confirmed, prescribe the prosthetic teeth shade and mould details on the Student Clinic Prescription Card.
(*translucentpink-veined acrylic will bethedefault,butclearor differentgingivalshadescanbediscussedifrequired)
3) Add any extra information re patients gender or age and relevant set-up information, and any characterisation required e.g. addition of diastemas
Piezograph tray?
record the true neutral zone of the mandibular arch. Discuss with clinical supervisor and add to prescription
D) recording jaw relationship
Piezograph tray?
At this stage, consider the need for a Piezograph tray to record the true neutral zone of the mandibular arch. Discuss with clinical supervisor and add to prescription
Requiring a Piezograph (Neutral Zone impression) will require light cured acrylic based wax bite rim for the opposing maxillary, and a carefully extended light cured acrylic base with blocks in premolar region and embedded wire loops for retention of the recording material.
Please check with your clinical supervisor.
E) Wax denture try-in
first steps?
1) Ensure your prescription for shade, mould and set-up was followed.
2) Assess each trial denture separately in the mouth to determine stability, retention, base extensions, teeth set up, midline, lip support, appropriate tooth show and neutral zone.
3) Check tooth positions in relation to the residual ridge anatomy. Ensure the trial dentures have smooth borders.
4) Assess the teeth set up, shade and position out of the mouth in static and dynamic occlusion
(*do not leave the wax trial dentures in the patients mouth for excessive periods; have cold water at hand to cool wax to avoid any distortion.)
E) wax denture try-in
trying both dentures in together, what are you assessing?
1) Try in both maxillary and mandibular trial dentures together and check:
- occlusion
- OVD
- freeway space
- appearance
- speech (ask patient to say the days of the week or count from 60 to 70).
Confirm availability of closest speaking space.
E) wax denture try-in
how to check occlusal plane, what are you looking out for?
- Check the occlusal plane in relation to the reference planes. Ensure the mandibular occlusal plane is below the dorsum of the tongue, and posteriorly in line with the retromolar pads.
- If indicated, make any adjustments to anterior teeth to patient’s satisfaction.
- Adjust by heating a wax knife and repositioning the teeth as required. Avoid trimming the occlusal surfaces to adjust occlusal interferences at this stage.
E) wax denture try-in
what to do if occlusal interferences are destabilising the denture?
1) Either adjust individual teeth by trimming the base of the prosthetic tooth and replacing it on the wax rim to the correct occlusion.
or
2) Remove teeth, add rolled up wax and re-record the jaw relationship.
Ask the laboratory to rearticulate and re-set teeth for a re-try, ensuring that you have given them as much information as possible about required changes.
(Then at subsequent re-try appointment proceed as for ‘wax try-in’ in slide E.1 and E.2.)
E) wax denture try-in
what lab prescription if you need to:
Remove teeth, add rolled up wax and re-record the jaw relationship?
Ask the laboratory to rearticulate and re-set teeth for a re-try, ensuring that you have given them as much information as possible about required changes.
(Then at subsequent re-try appointment proceed as for ‘wax try-in’ in slide E.1 and E.2.)
E) wax denture try-in
When can you proceed to fit stage?
ONLY when the patient,family members, clinical supervisor and yourself are satisfied with the trial prostheses
E) wax denture try-in
at the end of this stage, hat is the lab prescription?
Complete Student Clinic Prescription Card:
- To flask, pack and finish the dentures for fit in heat cured acrylic resin(discuss acrylic colour now if not already done so at bite stage)
- To label the dentures with the patient’s name.
- To return the denture on articulated support casts if possible.
F) fitting dentures
10 steps in this stage
1) Check the fitting surfaces of the maxillary and mandibular dentures for any irregularities, blebs of acrylic etc.
2) Assess each denture separately in the mouth to check for any discomfort - use pressure indicating paste to identify areas that may need adjustment. Confirm physical retention, stability, base extension and neutral zone.
3) If changes were made at try-in, check these have been followed and re-assess shade, mould, tooth size, position etc. as required
4) Confirm OVD and FWS.
5) Check occlusion with articulating paper and modify tooth surfaces if necessary to ensure reproduction of the desired occlusal scheme.
6) Confirm patient satisfaction regarding appearance and comfort.
7) Give patient advice on denture use, care and hygiene.
8) Inform patient regarding the importance of annual check ups of general oral health as well as check up of the dentures.
9) Inform patient that the dentures may need periodic relining to improve fit with continuing ridge resorption, and replacement every five years.
10) Give the patient the copy of the MHRA patient statement card.
G) complete denture review
- Review patient after one week.
- Check health of denture bearing areas.
- Carry out any refinements to the occlusion and fitting surfaces as necessary.
- Arrange further reviews as required.
- Inform patients to return to GDP for routine continued check-up and care.
