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Minimal Visit Complete Denture

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Minimal Visit Complete Denture

Currently, complete dentures are mainly designed and fabricated using conventional methods, which involve a broad series of clinical and laboratory procedures.
Dentists may want to consider using an update of a unique complete denture technique that saves total chair time and, therefore, decreases cost.
It is possible to fabricate a complete denture with different techniques in minimal visit. These techniques has positive benefits saving a lot of time and materials for both the patient and the clinician.

Currently, complete dentures are mainly designed and fabricated using conventional methods, which involve a broad series of clinical and laboratory procedures.
Dentists may want to consider using an update of a unique complete denture technique that saves total chair time and, therefore, decreases cost.
It is possible to fabricate a complete denture with different techniques in minimal visit. These techniques has positive benefits saving a lot of time and materials for both the patient and the clinician.

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Minimal Visit Complete Denture

  1. 1. MINIMAL VISIT COMPLETE DENTURE DIFFERENT TECHNIQUE OF FABRICATING COMPLETE DENTURE IN SHORTEST CLINICAL TIME PRESENTED BY: Dr. Anshul Sahu MDS Final Year
  2. 2. CONTENTS: • INTRODUCTION • REVIEW OF LITERATURE • DIFFERENT TECHNIQUES • THREE-VISIT, COMPLETE-DENTURE TECHNIQUE UTIIIZING VISIBLE IGHT-CURED RESIN FOR TRAY AND BASE PIATE CONSTRUCTION • 3D CD - THREE DAYS COMPLETE DENTURE TECHNIQUE FOR COMPROMISED GERIATRIC PATIENTS • CAD/CAM TECHNOLOGY: APPLICATION TO COMPLETE DENTURE • SUMMERY & CONCLUSION • REFERENCES
  3. 3. INTRODUCTION: • Edentulism has been a serious public health problem in industrialized countries due to population aging and in developing countries due to poor oral care. • Complete dentures are 1 mainstay choice for edentulous patients. The demand for complete dentures will continuously increase in the next decades. • Currently, complete dentures are mainly designed and fabricated using conventional methods, which involve a broad series of clinical and laboratory procedures.
  4. 4. • To obtain complete dentures, edentulous patients typically have to make 5 visits to the dental clinics, including preliminary impressions, final impressions, recording jaw relations, trial placement of wax denture, and placement/insertion of complete dentures. • Dentists may want to consider using an update of a unique complete denture technique that saves total chair time and, therefore, decreases cost. • Various attempts have been made to reduce complete- denture procedures to four visits, three visits or less.
  5. 5. REVIEW OF LITERATURE • In 1953, Swenson reported using four appointments instead of the usual five to construct complete maxillary and mandibular dentures. Swenson MG. Complete Dentures, ed 3. St Louis: Mosby, 1953:384-395,
  6. 6. • In 1992, Harvey and Brada improved on Swenson's technique by combining the impression and jaw-relation appointments into one appointment and using triad visible light-cured resin (VLC, Dentsply International). Update of a one-appointment master impression and jaw relation record technique. Quintessence Int 1992;23:547- 550
  7. 7. • In 1994, Maeda et al developed a computer-aided system including a work station for determining artificial tooth arrangements, occlusion, the outline of polished surface, and denture border location using a knowledge data base. • A complete denture was fabricated from photopolymerized resin composite material using a 3D laser lithography machine via printing, but this complete denture had poor mechanical properties such as the strength, thus being unusable in patients. "A CAD/CAM system for removable denture. Part I: Fabrication of complete dentures." international Journal of Prosthodontics 7.1 (1994).
  8. 8. • In 2001, Duncan JP and Taylor TD compared the conventional method and shortened method for complete denture fabrication and concluded that stock tray impressions made in alginate significantly reduced the visits. The corrective procedures required in conventional and abbreviated technique showed no significant difference in a 3 month follow-up period. Teaching an abbreviated impression technique for complete dentures in an undergraduate dental curriculum. The Journal of prosthetic dentistry. 2001 Feb 28;85(2):121- 5.
  9. 9. • In 2005, Kawai Y et al in a randomized control trial showed there to be no major difference in conventional and simplified technique in relation to the satisfaction of the patient or the objective denture quality. Do traditional techniques produce better conventional complete dentures than simplified techniques. Journal of dentistry. 2005 Sep 30;33(8):659-68.
  10. 10. • In 2017, Owen CP and MacEntee MI have described a technique CD3 to provide dentures in three clinical appointments. This technique is based on abbreviated technique involving three clinical sessions. • There were no significant differences in masticatory performance or chewing ability after 6 months between complete dentures made by a conventional or an abbreviated technique. "A Randomized Controlled Trial of Mastication with Complete Dentures Made by a Conventional or an Abbreviated Technique." International Journal of Prosthodontics 30.5 (2017).
  11. 11. A three-visit, complete-denture technique utilizing visible light-cured resin for tray and base plate construction • This article presents a system for making maxillary and mandibular complete dentures in three appointments without omitting any procedure used in the traditional five-visit method of construction. • It retains the use of modem, highly developed, popular, proven cross-linked heat-cured polymethylmethacrylate as the denture base material for the completed dentures. This technique also eliminates the need for laboratory procedures associated with the first three visits of the traditional method for complete-denture construction. Ling, Booi-Cie. "A three-visit, complete-denture technique utilizing visible light--cured resin for tray and base plate construction." Quintessence international 35.4 (2004)
  12. 12. • METHOD & MATERIALS  First Appointment:  Primary Impression  Incorporation of Biometric wax occlusal rim  Final Impression  Maxillomandibular relation record  Second Appointment:  Try in  Third Appointment:  Denture Insertion
  13. 13. MATERIAL REQUIRED: • Visible light-cured resin (VLC, Dentsply International) • Anatomic Tray such as Carboxylate Tray, Xantalgin (Bayer Dental) • Biometric wax occlusion rim
  14. 14. FIRST APPOINMENT • This is made possible by using Visible light-cured resin (VLC, Dentsply International) material as the preliminary impression material. The resulting light-cured impression is then used as the tray, as well as the base material, for the occlusion rim to be used in a combined closed- mouth final impression and maxillomandibular relation record.
  15. 15. PRIMARY IMPRESSION: VLC material spread in Carboxylate tray Impression is made, uncured removed from Mouth Excess VLC material Deficient VLC material Cut off with sharp knife New material added After removal from the mouth, the tray is then put in a light box to cure the VLC material for 3 to 5 minutes. The cured VLC-resin impression is then removed from the tray
  16. 16. Mandibular poly-carboxylate tray with an impression of the mandibular edentulous ridge made with visible light-cured base/tray material
  17. 17. Light-poiymerized impression, separated from the Xantaigin tray
  18. 18. WHAT IF WE DON’T HAVE ANATOMIC TRAY??? • Alternatively, metal stock tray can be used in following manner: Primary impression is made with elastomeric putty/impression compound/ alginate 1.5 to 2 mm of the material is then cut off from the labial, buccal frenum; the labial and buccal sulcus extension of the impression; as well as any undercut areas A sheet of the VLC material is then laid over the initial preliminary impression, and an impression is made with the VLC material, uncured The tray is removed from the mouth, and excess VLC resin is removed. The tray is then reinserted into the mouth and border molded Placed in a light box for 3 to 5 minutes to cure the VLC material Cured VLC tray is then removed from the stock tray
  19. 19. Mandibular metal stock tray with the initial preliminary impression made in impression compound. The VLC base/tray cured and separated from the initial compound impression.
  20. 20. Maxillary stock tray containing the initial preliminary impression in irreversible hydrocolloid, and the final impression tray made with VLC material cured and separated
  21. 21. Preliminary VLC impressions trimmed, ready for incorporation of the biometric wax occlusion rim to form the base plate for making the closed-mouth final impression and maxillomandibular relation record.
  22. 22. INCORPORATION OF BIOMETRIC WAX OCCLUSION RIM: Biometric wax occlusion rim is soaked in a bowl of warm water (45'C to 55'C) for approximately 5 minutes Now is blow dried with compressed air; its fitting surface heated over the Bunsen flame or blow torch; and is adapted onto the VLC tray VD at rest is measured, Desired OVD achieved. Necessary correction done (i.e lip fullness, Incisal visbility)
  23. 23. FINAL IMPRESSION: • The impression trays/ base plates are now ready for a closed-mouth impression technique. • Border molding done using green stick or putty. • The patient is instructed to leisurely perform the normal functional movements viz. swallowing, speaking, smiling, yawning, whistling, pursing and wetting the lips. • An impression is then made of the maxillary and mandibular edentulous ridges with a metallic oxide eugenol or an elastomeric impression material. • Both maxillary and mandibular impressions can be done simultaneously using a closed-mouth impression technique.
  24. 24. • Alternatively, the maxillary impression can be made first, using an open-mouth impression technique, followed by the mandibular impression using a closed-mouth technique, with the mandibular record base and rim occluding with the maxillary in centric relation.
  25. 25. MAXILLOMANDIBULAR RECORD: • Patient is guided into the desired centric-relation jaw position • Maxillomandibular relationships are recorded using metallic oxide eugenol-based bite registration paste or elastomeric bite registration paste. • The various reference lines such as lip line, canine lines and middle line are marked on the occlusal rims.
  26. 26. SECOND APPOINMENT • Trial denture. This visit is the same as the fourth visit for the conventional five-appointment method of denture construction. • During this visit, assessment of the trial denture by the clinician and patient is made for accuracy of the centric relation position, the interocclusal clearance, phonetics, and the esthetic quality of the trial denture • Any correction should be done at this stage before processing the denture.
  27. 27. THIRD APPOINMENT • Denture insertion. During this stage, dentures are delivered to the patient. Fit, phonetics, occlusion, and patient satisfaction are verified. The patient is given instructions on the use and care of the new prostheses.
  28. 28. ADVANTAGES:  All clinical steps is included  Easy to applied DISADVANTAGES: × Little Bit expensive × Requires additional curing unit
  29. 29. 3D CD - Three Days Complete Denture Technique for Compromised Geriatric Patients • This article presents a case in which a completely edentulous patient was treated with a rapid method of treatment 3D CD (Three day complete dentures) technique, in which the treatment was completed in three appointments instead of conventional five appointments. The impression procedures were carried out in a single appointment along with ANTAG (Anterior teeth arrangement guide) fabrication followed by jaw relations recording along with maxillary anterior try-in and ultimately insertion of complete dentures. Lodha M, Patil SB, Bhat S, Chaudhari N, Kant A.3D CD - Three Days Complete Denture Technique for Compromised Geriatric Patients. Int J Oral Health Med Res 2016;3(1):126-130
  30. 30. • METHOD & MATERIALS  First Appointment:  Primary Impression  Final Impression  Second Appointment:  Maxillomandibular relation record  Maxillary anterior Try in  Third Appointment:  Denture Insertion
  31. 31. FIRST APPOINMENT • On this appointment, maxillary and mandibular impressions were made, and ANTAG (Anterior Teeth Arrangement Guide) is fabricated.
  32. 32. • PRIMARY IMPRESSION: Perforated stock metal trays for edentulous arches is selected The wax is adapted on the tissue side of the trays in the canine and first molar areas and sufficiently softened, and trays is placed in the patient's mouth such that the borders of the trays were away from the sulcus areas in function The trays were removed and immersed in chilled water for the wax strips to harden. These wax strips acted as tissue stops
  33. 33. Impressions is made for the maxillary and mandibular arches subsequently with putty consistency addition silicone elastomeric impression material
  34. 34. • SECONDARY IMPRESSION: The borders of primary impressions is reduced using a sharp knife 2 mm short of the sulcus in both the maxillary and mandibular impressions Notches is made on the borders about 1mm deep and wide such that they created an undercut for retention of the border molding material to be added This impression acted as a custom tray for border molding and wash impression Same putty consistency material is mixed added to the borders of the impressions. The trays were placed in the mouth, and functional movements are carried out
  35. 35. The impressions are retrieved and checked for any discrepancies The borders were then trimmed by another 0.5mm and wash impressions are made using light bodied consistency addition silicone material
  36. 36. • ANTAG FABRICATION Modeling wax and sticky wax are mixed in a ratio of approximately 4:1 by volume in a hot water bath When the mixture was sufficiently soft, it is tempered and adapted to the patient's anterior maxillary ridge with tin foil on the tissue side. After it is sufficiently hardened it is removed The wax is added subsequently on the labial and incisal aspect of the ANTAG and placed in the mouth so as to give adequate fullness for the maxillary lip
  37. 37. Its incisal plane was so adjusted to be parallel to the interpupillary line with adequate visibility. This ANTAG guided the arrangement of the maxillary anterior teeth.
  38. 38. • FIRST LABORATORY STEP The impressions are beaded and boxed, and casts are poured in type III gypsum product or the dental stone Retrieval of the casts from the impressions ANTAG is adapted to the maxillary cast Separating medium is applied to the tissue surface of the remaining maxillary cast Temporary record base is made for the posterior maxillary residual ridge using auto polymerising acrylic denture base resin
  39. 39. A full arch mandibular temporary denture base is made using auto polymerising acrylic denture base The conventional maxillary occlusal rim is made for the posterior aspect, and a mandibular occlusal rim is made for the full arch. Maxillary anterior teeth arranged using the selected teeth set for the patient.
  40. 40. SECOND APPOINMENT • In this clinical appointment, jaw relations are recorded along with maxillary anterior try-in. • VD at rest is measured, Desired OVD achieved. Necessary correction done. • Patient is guided into the desired centric-relation jaw position • Maxillomandibular relationships are recorded using zinc oxide eugenol paste or elastomeric bite registration paste.
  41. 41. • SECOND LABORATORY STEP The sealed occlusal rims are placed on their respective casts Mounted on a mean value articulator in the recorded relation. Teeth Arrangement Denture Fabrication
  42. 42. THIRD APPOINTMENT • Denture insertion. During this stage, dentures are delivered to the patient. Fit, phonetics, occlusion, and patient satisfaction are verified. The patient is given instructions on the use and care of the new prostheses.
  43. 43. ADVANTAGES:  Economic  Easy to applied DISADVANTAGES: × Only maxillary anterior try in is possible
  44. 44. CAD CAM FABRICATED COMPLETE DENTURE • Computer-aided design and computer-aided manufacturing (CAD/CAM) has emerged as a new approach for the design and fabrication of complete dentures. • Several commercial CAD software systems, including 3Shape Dental System and AvaDent digital dentures, have recently become available for designing complete dentures. • With this CAD/CAM technology, only 2 appointments are needed for patients to get their complete dentures.
  45. 45. • All impressions, jaw relations, occlusal plane orientation, tooth mold and shade selection, and maxillary anterior tooth positioning could be finished in 1 patient visit for the fabrication of complete dentures.
  46. 46. CONVENTIONAL METHOD OF DENTURE FABRICATION  ADVANTAGES  Ability to customize tooth arrangements and to confirm all preceding steps before the trial placement stage  Clinically predictable outcomes
  47. 47.  DISADVANTAGES × The need for a minimum of 4 to 5 patient visits × Varying laboratory expenses and time × Lack of intimate fit of the denture bases with underlying tissues due to polymerization shrinkage × Inability to easily create an optimal duplicate denture
  48. 48. • The CAM technology could be classified into 2 types:  Additive Manufacturing  Subtractive Manufacturing • In Prosthodontics subtractive manufacturing CAD/CAM technology has been extensively used to fabricate Inlays, Onlays, Crowns, Fixed and Removable Partial Denture, Implant Abutments, Maxillofacial Prostheses.
  49. 49. • Additive Manufacturing Any process by which 3D objects are constructed by successively depositing material in layers such that it becomes a predesigned shape. • Subtractive Manufacturing Any process by which 3D objects are constructed by successively cutting/milling extra material away from a solid block of material according to the digital model.
  50. 50. CAD/CAM Technology : Application to Complete Dentures • In this article the AvaDent™ softwere system is discussed. The AvaDent™ digital denture process is designed to capture the necessary information for the fabrication of complete dentures in one appointment without compromising prosthesis quality. • The entire digital CAD/CAM process consists of the following appointments: 1. Impressions, jaw relation records, occlusal plane orientation, tooth mold and shade selection, and maxillary anterior tooth positioning record 2. Placement of dentures Kattadiyil, M. T., and C. J. Goodacre. "CAD/CAM technology: application to complete dentures." Loma Linda University Dentistry 23 (2012): 16-23.
  51. 51. Flowchart for Designing and Fabricating Complete Dentures via CAD/CAM Technology
  52. 52. AvaDent™ Kit
  53. 53. APPOINTMENT 1 Customizing Stock Trays • If old denture is available: Putty cast created by adaptation to the old maxillary denture
  54. 54. • Thermoplastic tray selection based on the arch size for the maxillary and mandibular cast. Stock tray being tried on maxillary & mandibular putty cast
  55. 55. • The tray is softened by immersion in a water bath set at 80 C for approximately one minute and adapted to the putty cast by pressing the material into contact with the cast Customized maxillary stock tray
  56. 56. Making Maxillary and Mandibular Final Impressions • Apply an appropriate adhesive and add tissue stops (AvaDent™ registration or a fast setting interocclusal record material is applied as four dabs to distributed areas on the maxillary tray and three areas of the mandibular tray). • The AvaDent™ border molding impression material, or a medium body poly (vinyl siloxane) impression material, is then used to border mold the maxillary and mandibular trays.
  57. 57. • Final impressions of the maxillary and mandibular arches are made using either the AvaDent™ impression material or a light-body poly (vinyl siloxane) impression material.
  58. 58. JAW RELATION RECORD • The AvaDent denture technique uses an Anatomical Measuring Device (AMD) that can be adjusted to the desired occlusal vertical dimension. • The AMD consists of a maxillary tray with a centrally located adjustable stylus and an adjustable lip support flange and a mandibular tray with a flat occlusal tracing plate.
  59. 59. • This AMD maintains this dimension while centric relation is recorded using the incorporated gothic arch tracing plate and stylus. • The AMD is also used to determine the correct amount of upper lip support, the position of the maxillary six anterior teeth, and the desired mesio lateral orientation of the occlusal plane.
  60. 60. • In addition, there is an occlusal plane orientation ruler that can be inserted into the maxillary AMD and used to record the alignment of the maxillary AMD with the interpupillary line to make it possible for the computer program to align the maxillary teeth with the interpupillary line.
  61. 61. STEPS FOR RECORDING JAW REALTION • The maxillary AMD is filled with AvaDent™ registration material and seated to record the ridge morphology of the maxillary arch. • The mandibular tray with the recording plate is then filled with the recording material and used to stabilize the tray in the patient’s mouth.
  62. 62. • Maxillary and mandibular AMDs are positioned to be fairly parallel to each other. • Maxillary stylus is located over the anterior aspect of the mandibular AMD tracing plate.
  63. 63. • Confirming occlusal vertical dimension • Occlusal vertical dimension being adjusted by turning screw • Gothic arch recording
  64. 64. • A recess is then made in the tracing plate that approximates the tip diameter of the stylus at the apex of the gothic arch arrowpoint using round bur or acrylic resin bur.
  65. 65. Occlusal Plane Orientation, Maxillary Anterior Mold and Shade Selection, and Maxillary Anterior Tooth Positioning • AvaDent™ ruler attached to the Maxillary AMD • Determining the appropriate occlusal plane with AvaDent™ orientation ruler
  66. 66. • The midline on the lip support flange as well as the smile line are marked. • The size of the maxillary anterior teeth is selected from the three available tooth size templates that matches the patient’s desired tooth size. • AvaDent registration material is injected into the space between the maxillary and mandibular arches, with the jaw stabilized in centric relation.
  67. 67. • To serve as a guide during denture fabrication, flowable composite resin is applied to the inside of the selected tooth mold template.
  68. 68. Jaw relation record with mold tab
  69. 69. • After disinfection, the final impressions and all the interocclusal records are scanned. • Virtual casts are created and articulated. • Teeth are arranged and bases are virtually formed.
  70. 70. THE DENTURE FABRICATION • The denture base is milled from a block of pink denture base resin with recesses that accurately fit each denture tooth, and the teeth are bonded with special adhesives with higher adhesive properties. Determining (virtually) the borders of the maxillary Milled CAD/CAM denture base
  71. 71. MILLING AND GLUING STAGES • The artificial teeth need high abrasion resistance. • It is difficult to cut the artificial teeth from a single property block. Thus, only the denture base is fabricated by cutting . • Then commercially available artificial teeth are adhered to the denture base. Special adhesives with higher adhesive properties are being developed.
  72. 72. CAD/CAM DENTURES ADVANTAGES:  Reduced number of patient visits  Superior strength and fit  Reduced microbial colonization  Reproducibility  Standardization for clinical research  Better quality control
  73. 73. CAD/CAM DENTURES DISADVANTAGES: × Absence of a clinical try-in procedure. × Technique sensitive × Feasibility × The denture base is fabricated by cutting. Teeth fabrication is not possible. Thus commercially available artificial teeth are adhered to the denture base.
  74. 74. CONCLUSION • It is usually seen in edentulous patients that they are enthusiastic about the replacement of missing teeth with dentures at the beginning but due to the prolonged time and an excessive number of appointments, they, especially the very old, become fatigued and irritated. This can have an effect on the success of the treatment. Patients who are institutionalized or bed-ridden and who are dependent on someone else for locomotion need a rapid but appropriate treatment regime . • If the number of appointments can be reduced, it will be of great help in successful treatment.
  75. 75. • It is possible to fabricate a complete denture with different techniques in minimal visit. These techniques has positive benefits saving a lot of time and materials for both the patient and the clinician. • However the final result depends on the skill and knowledge of materials, anatomy, occlusion, function and ability to determining the proper esthetic parameters.
  76. 76. REFERENCES • Swenson MG. Complete Dentures, ed 3. St Louis: Mosby, 1953:384-395 • Update of a one-appointment master impression and jaw relation record technique. Quintessence Int 1992;23:547-550 • "A CAD/CAM system for removable denture. Part I: Fabrication of complete dentures." international Journal of Prosthodontics 7.1 (1994). • Ling, Booi-Cie. "A three-visit, complete-denture technique utilizing visible light--cured resin for tray and base plate construction." Quintessence international 35.4 (2004) • Lodha M, Patil SB, Bhat S, Chaudhari N, Kant A.3D CD - Three Days Complete Denture Technique for Compromised Geriatric Patients. Int J Oral Health Med Res 2016;3(1):126-130
  77. 77. • Do traditional techniques produce better conventional complete dentures than simplified techniques. Journal of dentistry. 2005 Sep 30;33(8):659-68. • "A Randomized Controlled Trial of Mastication with Complete Dentures Made by a Conventional or an Abbreviated Technique." International Journal of Prosthodontics 30.5 (2017). • Kattadiyil, M. T., and C. J. Goodacre. "CAD/CAM technology: application to complete dentures." Loma Linda University Dentistry 23 (2012): 16-23. • Han, Weili, Yanfeng Li, and Yue Zhang. "Design and fabrication of complete dentures using CAD/CAM technology." Medicine 96.1 (2017).
  78. 78. THANK YOU

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