A technique for fabricating mandibular treatment dentures Robert G. Tupac, D.D.S.* University of California, School of Dentistry, Los Angeles, Calif.
With most difficult-to-treat denture patients problems center on the m a n d i b u l a r denture. T h e m a n d i b u l a r provisional or treatment denture facilitates patient education and the transition to complete dentures. For the patient with difficulties it is a reliable treatment modality. A m a n d i b u l a r treatment denture is a provisional complete denture that is constructed on a cured acrylic resin base made from a border-molded impression. It generally includes anterior teeth, to satisfy the esthetic and phonetic needs of the patient, and flat chewing platforms instead of posterior teeth. T h e platforms contact the opposing posterior teeth evenly when the mandible is in centric relation, and they are in bilateral balanced occlusion for eccentric movements. T h e chief advantage of the treatment denture lies in its adaptability. By relatively simple means the vertical dimension of occlusion can be increased or decreased, borders m a y be extended or reduced, and conditioning materials can be employed. T h u s a variety of remedies may be a t t e m p t e d to achieve comfort and function for the patient. This article describes the use of a treatment denture and proposes a technique for its fabrication.
3. significant changes in the vertical dimension of occlusion must be made; 4. significant changes in border extension must be made; 5. the m a n d i b u l a r basal seat must be conditioned; 6. there is d o u b t whether a new denture will restore comfort, function, or retention; 7. a conventional denture must be attempted before alternative treatment is considered (preprosthetic surgery, implants, etc.); 8. adaptability is temporarily compromised due to physical problems, as with menopausal women; or
9. the patient demonstrates lack of adequate muscular coordination or tissue tolerance. CONTRAINDICATIONS Contraindications include: (1) an existing maxillary denture with an improperly oriented anteropost e n o r plane; (2) a reverse occlusal plane that makes it impossible to achieve eccentric bilateral balanced occlusion; and (3) a space between the m a n d i b u l a r residual ridge and the maxillary teeth that ~s inadequate to provide proper interocclusal clearance for the treatment denture.
INDICATIONS If new dentures are necessary to correct existing deficiencies, and if patient expectations can thereby be fulfilled, a m a n d i b u l a r treatment denture is indicated when: 1. the patient's psychological adaptability is in question; 2. the patient has never before tolerated a m a n dibular denture; *Lecturer. Division of Hospital Dentistry, Department of Maxillofacial Prosthetics.
110
TECHNIQUE A m a n d i b u l a r treatment denture m a y be fabricated in three appointments.
First appointment-Impressions 1. Make an irreversible hydrocolloid impression of the occlusal side of the existing maxillary denture and pour the cast (Figs. 1 and 2). 2. Make a border-molded m a n d i b u l a r final impression and pour the cast (Figs. 3 and 4).
JANUARY 1978
VOLUME39
NUMBER 1
FABRICATINGMANDIBULARTREATMENTDENTURES
,(
\ Fig. I. The irreversible hydrocolloid impression of the maxillary denture.
Fig. 2. The maxillary cast.
Fig. 3. The mandibular final impression.
Fig. 4. The mandibular cast.
Second appointment-Tooth setup and interocclusal jaw relation records 1. Fabricate a m a n d i b u l a r baseplate with posterior wax occlusion rims. 2. A d d m a n d i b u l a r anterior teeth and first premolars of appropriate shape and shade and try in the m o u t h (Fig. 5). 3. W h e n esthetic and phonetic requirements are satisfied, record centric relation at the tentative vertical dimension of occlusion (Fig. 6). 4. M o u n t the maxillary and m a n d i b u l a r casts with the interocclusal record on a simple hinge articulator (Fig. 7). 5. W a x the treatment denture to proper contour with the chewing platforms in point contact with the maxillary lingual cusps (Fig. 8). T h e platforms must
THE JOURNALOF PROSTHETICDENTISTRY
Fig. 5. Eight lower anterior teeth are arranged for esthetics and phonetics.
111
TUPAC
Fig. 6. The centric relation is recorded.
Fig. 7. The maxillary and mandibular casts are mounted on the articulator.
Fig. 9. The posterior chewing platforms are waxed to the width of a first molar.
Fig. 10. The treatment denture is processed. Toothcolored acrylic resin is used for the occlusion rims. be wide e n o u g h to provide contact in eccentric movements (Fig. 9). 6. Process the denture as usual, using toothcolored acrylic resin for the posterior occlusal blocks (Fig. I0). 7. R e m o u n t the denture and equilibrate t h e occlusion, then trim a n d polish.
Third appointment-placement of the treatment denture
Fig. 8. Posterior chewing platforms are waxed to point contact with the maxillary linqual cusps.
112
1. Locate and relieve pressure spots using indicator paste (Fig. 11). 2. A d d a d o u g h y mixture of tooth-colored coldcure acrylic resin to the posterior resin blocks (Fig. 12). 3. Place the treatment denture in the m o u t h a n d
JANUARY1978 VOLUME39
NUMBER1
FABRICATING MANDIBULAR TREATMENT DENTURES
Fig. 11. The pressure spots are located and relieved.
Fig. 12. A doughy mixture of tooth-colored acrylic resin is applied to the chewing platforms.
Fig. 13. Fully balanced occlusal pathways are generated.
Fig. 14. Tissue-conditioning material is added.
assist the patient in generating fully balanced occlusal pathways as the resin sets (Fig. 13). 4. T r i m the excess resin and polish. 5. Add tissue-conditioning material to the tissue surface of the denture (Fig. 14). 6. Place the completed m a n d i b u l a r treatment denture in the m o u t h for use by the patient (Fig. 15). POSTINSERTION CARE T h e patient is evaluated the next day. I f any parts of the base show t h r o u g h the tissue-conditioning material, they are relieved and a thin mix of a new conditioning material is flowed into these regions. T h e tissue-conditioning material is totally replaced at weekly intervals or more often if break-
THE JOURNALOF PROSTHETICDENTISTRY
Fig. 15. The mandibular treatment denture is cornpleted.
113
TUPAC
d o w n of the m a t e r i a l is i n d i c a t e d b y a g r a n u l a r a p p e a r a n c e or if it has s e p a r a t e d from the base. Borders m a y be e x t e n d e d or r e d u c e d u n t i l t h e y are functional. T h e vertical d i m e n s i o n of occlusion m a y be c h a n g e d b y the a d d i t i o n or r e m o v a l of acrylic resin from the c h e w i n g platforms. T h e p a t i e n t ' s progress is e v a l u a t e d d u r i n g these sessions. T h e p a t i e n t wears the t r e a t m e n t d e n t u r e u n t i l a decision to m a k e new d e n t u r e s or d i s c o n t i n u e treatm e n t is m a d e b y the dentist. In most instances p a t i e n t comfort a n d a c c e p t a n c e can be achieved in 2 to 8 weeks. T h e t r e a t m e n t d e n t u r e m a y be relined with acrylic resin to serve as a spare d e n t u r e after new dentures are constructed.
SUMMARY F o r most difficult-to-treat d e n t u r e patients, p r o b lems are c e n t e r e d on the m a n d i b u l a r d e n t u r e . T h e m a n d i b u l a r t r e a t m e n t d e n t u r e is a v a l u a b l e diagnostic a n d t r e a t m e n t device t h a t can be used with success in t r e a t i n g these patients. T h e a d v a n t a g e s , indications, a n d c o n t r a i n d i c a t i o n s for the m a n d i b ular t r e a t m e n t d e n t u r e have been described. Reprint requests to: DR. ROBERT G. TUFAC UNIVERSITYOF CALIFORNIA
SCHOOLOF DENTISTRY Los ANGELES,CALIF.90024
ARTICLES TO APPEAR IN FUTURE ISSUES
A method of fabricating a hollow obturator Aaron Schneider
Air flow and intelligibility of speech of normal speakers and speakers with a prosthodontically repaired cleft palate Carl R. Schneiderman, Ph.D., and Mary B. Mann, Ph.D.
Pin-retained composites for splinting lower anterior teeth Harold E. Schnepper, D.M.D., M.S.D.
Delivering surface irradiation to persistent unresectable squamous cell carcinomas: A prosthodontic solution Alan B. Sheiner, D.D.S., and Phyllis J. Ager, M.D.
Retention of endodontic dowels: Effects of cement and dowel length, diameter, and design J. P. Standlee, D.D.S., A. A. Caputo, Ph.D., and E. C. Hanson, D.D.S.
114
JANUARY1978
VOLUME39
NUMBER1
With most difficult-to-treat denture patients problems center on the m a n d i b u l a r denture. T h e m a n d i b u l a r provisional or treatment denture facilitates patient education and the transition to complete dentures. For the patient with difficulties it is a reliable treatment modality. A m a n d i b u l a r treatment denture is a provisional complete denture that is constructed on a cured acrylic resin base made from a border-molded impression. It generally includes anterior teeth, to satisfy the esthetic and phonetic needs of the patient, and flat chewing platforms instead of posterior teeth. T h e platforms contact the opposing posterior teeth evenly when the mandible is in centric relation, and they are in bilateral balanced occlusion for eccentric movements. T h e chief advantage of the treatment denture lies in its adaptability. By relatively simple means the vertical dimension of occlusion can be increased or decreased, borders m a y be extended or reduced, and conditioning materials can be employed. T h u s a variety of remedies may be a t t e m p t e d to achieve comfort and function for the patient. This article describes the use of a treatment denture and proposes a technique for its fabrication.
3. significant changes in the vertical dimension of occlusion must be made; 4. significant changes in border extension must be made; 5. the m a n d i b u l a r basal seat must be conditioned; 6. there is d o u b t whether a new denture will restore comfort, function, or retention; 7. a conventional denture must be attempted before alternative treatment is considered (preprosthetic surgery, implants, etc.); 8. adaptability is temporarily compromised due to physical problems, as with menopausal women; or
9. the patient demonstrates lack of adequate muscular coordination or tissue tolerance. CONTRAINDICATIONS Contraindications include: (1) an existing maxillary denture with an improperly oriented anteropost e n o r plane; (2) a reverse occlusal plane that makes it impossible to achieve eccentric bilateral balanced occlusion; and (3) a space between the m a n d i b u l a r residual ridge and the maxillary teeth that ~s inadequate to provide proper interocclusal clearance for the treatment denture.
INDICATIONS If new dentures are necessary to correct existing deficiencies, and if patient expectations can thereby be fulfilled, a m a n d i b u l a r treatment denture is indicated when: 1. the patient's psychological adaptability is in question; 2. the patient has never before tolerated a m a n dibular denture; *Lecturer. Division of Hospital Dentistry, Department of Maxillofacial Prosthetics.
110
TECHNIQUE A m a n d i b u l a r treatment denture m a y be fabricated in three appointments.
First appointment-Impressions 1. Make an irreversible hydrocolloid impression of the occlusal side of the existing maxillary denture and pour the cast (Figs. 1 and 2). 2. Make a border-molded m a n d i b u l a r final impression and pour the cast (Figs. 3 and 4).
JANUARY 1978
VOLUME39
NUMBER 1
FABRICATINGMANDIBULARTREATMENTDENTURES
,(
\ Fig. I. The irreversible hydrocolloid impression of the maxillary denture.
Fig. 2. The maxillary cast.
Fig. 3. The mandibular final impression.
Fig. 4. The mandibular cast.
Second appointment-Tooth setup and interocclusal jaw relation records 1. Fabricate a m a n d i b u l a r baseplate with posterior wax occlusion rims. 2. A d d m a n d i b u l a r anterior teeth and first premolars of appropriate shape and shade and try in the m o u t h (Fig. 5). 3. W h e n esthetic and phonetic requirements are satisfied, record centric relation at the tentative vertical dimension of occlusion (Fig. 6). 4. M o u n t the maxillary and m a n d i b u l a r casts with the interocclusal record on a simple hinge articulator (Fig. 7). 5. W a x the treatment denture to proper contour with the chewing platforms in point contact with the maxillary lingual cusps (Fig. 8). T h e platforms must
THE JOURNALOF PROSTHETICDENTISTRY
Fig. 5. Eight lower anterior teeth are arranged for esthetics and phonetics.
111
TUPAC
Fig. 6. The centric relation is recorded.
Fig. 7. The maxillary and mandibular casts are mounted on the articulator.
Fig. 9. The posterior chewing platforms are waxed to the width of a first molar.
Fig. 10. The treatment denture is processed. Toothcolored acrylic resin is used for the occlusion rims. be wide e n o u g h to provide contact in eccentric movements (Fig. 9). 6. Process the denture as usual, using toothcolored acrylic resin for the posterior occlusal blocks (Fig. I0). 7. R e m o u n t the denture and equilibrate t h e occlusion, then trim a n d polish.
Third appointment-placement of the treatment denture
Fig. 8. Posterior chewing platforms are waxed to point contact with the maxillary linqual cusps.
112
1. Locate and relieve pressure spots using indicator paste (Fig. 11). 2. A d d a d o u g h y mixture of tooth-colored coldcure acrylic resin to the posterior resin blocks (Fig. 12). 3. Place the treatment denture in the m o u t h a n d
JANUARY1978 VOLUME39
NUMBER1
FABRICATING MANDIBULAR TREATMENT DENTURES
Fig. 11. The pressure spots are located and relieved.
Fig. 12. A doughy mixture of tooth-colored acrylic resin is applied to the chewing platforms.
Fig. 13. Fully balanced occlusal pathways are generated.
Fig. 14. Tissue-conditioning material is added.
assist the patient in generating fully balanced occlusal pathways as the resin sets (Fig. 13). 4. T r i m the excess resin and polish. 5. Add tissue-conditioning material to the tissue surface of the denture (Fig. 14). 6. Place the completed m a n d i b u l a r treatment denture in the m o u t h for use by the patient (Fig. 15). POSTINSERTION CARE T h e patient is evaluated the next day. I f any parts of the base show t h r o u g h the tissue-conditioning material, they are relieved and a thin mix of a new conditioning material is flowed into these regions. T h e tissue-conditioning material is totally replaced at weekly intervals or more often if break-
THE JOURNALOF PROSTHETICDENTISTRY
Fig. 15. The mandibular treatment denture is cornpleted.
113
TUPAC
d o w n of the m a t e r i a l is i n d i c a t e d b y a g r a n u l a r a p p e a r a n c e or if it has s e p a r a t e d from the base. Borders m a y be e x t e n d e d or r e d u c e d u n t i l t h e y are functional. T h e vertical d i m e n s i o n of occlusion m a y be c h a n g e d b y the a d d i t i o n or r e m o v a l of acrylic resin from the c h e w i n g platforms. T h e p a t i e n t ' s progress is e v a l u a t e d d u r i n g these sessions. T h e p a t i e n t wears the t r e a t m e n t d e n t u r e u n t i l a decision to m a k e new d e n t u r e s or d i s c o n t i n u e treatm e n t is m a d e b y the dentist. In most instances p a t i e n t comfort a n d a c c e p t a n c e can be achieved in 2 to 8 weeks. T h e t r e a t m e n t d e n t u r e m a y be relined with acrylic resin to serve as a spare d e n t u r e after new dentures are constructed.
SUMMARY F o r most difficult-to-treat d e n t u r e patients, p r o b lems are c e n t e r e d on the m a n d i b u l a r d e n t u r e . T h e m a n d i b u l a r t r e a t m e n t d e n t u r e is a v a l u a b l e diagnostic a n d t r e a t m e n t device t h a t can be used with success in t r e a t i n g these patients. T h e a d v a n t a g e s , indications, a n d c o n t r a i n d i c a t i o n s for the m a n d i b ular t r e a t m e n t d e n t u r e have been described. Reprint requests to: DR. ROBERT G. TUFAC UNIVERSITYOF CALIFORNIA
SCHOOLOF DENTISTRY Los ANGELES,CALIF.90024
ARTICLES TO APPEAR IN FUTURE ISSUES
A method of fabricating a hollow obturator Aaron Schneider
Air flow and intelligibility of speech of normal speakers and speakers with a prosthodontically repaired cleft palate Carl R. Schneiderman, Ph.D., and Mary B. Mann, Ph.D.
Pin-retained composites for splinting lower anterior teeth Harold E. Schnepper, D.M.D., M.S.D.
Delivering surface irradiation to persistent unresectable squamous cell carcinomas: A prosthodontic solution Alan B. Sheiner, D.D.S., and Phyllis J. Ager, M.D.
Retention of endodontic dowels: Effects of cement and dowel length, diameter, and design J. P. Standlee, D.D.S., A. A. Caputo, Ph.D., and E. C. Hanson, D.D.S.
114
JANUARY1978
VOLUME39
NUMBER1
