2 Treating The Complete Denture Patient

Treating the
Complete Denture Patient

Treating the Complete Denture Patient
Edited by
William Glen Golden, DDS
Associate Clinical Professor (retired)
The Ohio State University College of Dentistry, Columbus, OH, USA
assisted by
Carl F. Driscoll, DMD

Professor
School of Dentistry, University of Maryland, Baltimore, MD, USA;
Private Practice, Bethesda, MD, USA
This edition first published 2020
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Library of Congress Cataloging‐in‐Publication Data

Names: Driscoll, Carl F., editor. | Golden, William Glen, 1947- editor.
Title: Treating the complete denture patient / edited by Carl F. Driscoll, William Glen Golden.
Description: Hoboken, NJ : Wiley-Blackwell, 2020. | Includes bibliographical references and index.
Identifiers: LCCN 2019039403 (print) | LCCN 2019039404 (ebook) | ISBN 9781119569589 (hardback) |
ISBN 9781119569572 (adobe pdf) | ISBN 9781119569565 (epub)
Subjects: MESH: Denture, Complete
Classification: LCC RK656 (print) | LCC RK656 (ebook) | NLM WU 530 | DDC 617.6/92–dc23
LC record available at https://lccn.loc.gov/2019039403
LC ebook record available at https://lccn.loc.gov/2019039404
Cover Design: Wiley
Cover Image: © hoozone/Getty Images
Set in 9.5/12.5pt STIXTwoText by SPi Global, Pondicherry, India
10 9 8 7 6 5 4 3 2 1
v
Contents
Foreword vii
Acknowledgements ix
About the Companion Website xi
1 The Diagnostic Appointment 1
2 Preliminary Impressions 5
3 Custom Trays: The Key to a Great Final Impression 17
4 Using Custom Trays to Make Final Impressions 25
5 The Final Impression 41
6 Boxing and Pouring a Final Impression 47
7 Base Plates and Occlusion Rims 51
8 Adjusting Wax Rims to Fit the Patient 57
9 Using the Denar Facebow 59
10 Mounting Maxillary Casts on an Articulator 63
11 Centric Relation Records 67
12 Selecting Proper Denture Teeth 73
13 Setting Anterior Denture Teeth 81
14 Setting Posterior Anatomic Teeth in Bilaterally Balanced Occlusion 85
15 Setting Zero‐Degree Posterior Teeth in Monoplane Occlusion 93
16 Overview of Lingualized Occlusion 99
17 Setting Teeth in a Lingualized Occlusion 105
18 The Anterior Esthetic Wax Try-In 111
19 The Complete Denture Wax-Up 115

vi Contents
20 Sealing Complete Dentures to the Cast 121
21 The Wax Try-in of Teeth 123
22 Making an Arbitrary Posterior Palatal Seal in the Lab 135
23 Interacting with Dental Labs 137
24 Flasking, Packing, and Processing Complete Dentures 139
25 Completing a Laboratory Remount 151
26 Making a Remount Index 155
27 Remove Complete Denture from the Cast and Finish 159
28 Quality Standards in Appearance 165
29 Inserting Complete Dentures in the Mouth 169
30 Performing a Clinical Remount 175
31 Equilibrating Dentures Set in Lingualized Occlusion 187
32 Equilibrating Fully Anatomic (30°) Set‐Ups 191
33 Equilibrating Complete Dentures Set in a Monoplane Occlusion 197
34 Troubleshooting Complete Denture Problems 199
35 Replacing Teeth on a Complete Denture 215
36 Repairing a Broken Complete Denture 219
37 Using Implants to Stabilize a Complete Denture 229
38 Immediate Complete Dentures 239
39 Tissue Conditioners 253
40 The Fabrication of Digital Complete Dentures 263
List of Captions 271

Index 293
vii
Foreword
William Glen Golden began his dental training with years until he retired from actively practicing dentistry in
nine years enlisted service as a dental prosthetic laboratory June 2014.
technician in the US Navy, achieving the rank of Dental
Technician Chief. Carl F. Driscoll is an acclaimed educator, researcher,
He completed dental technician A&C schools in San and clinician. He currently serves as a Professor at the
Diego and Field Medical Service School at Camp University of Maryland Dental School, where he previ-
Pendleton, California. He served as a dental prosthetic ously served as Director of the Prosthodontic Residency for
technician and dental clinic supervisor before entering 21 years. That assignment followed a 20‐year career with
dental school in 1976 at West Virginia University on the the US Army culminating with being the Prosthodontic
Navy version of the Armed Forces Health Professions Program Director at Walter Reed Army Medical Center for
Scholarship. Graduating in 1980, he was sent to the Naval three years. Dr Driscoll has served as President of the
Dental Clinic in Yokosuka, Japan, where he served for American Academy of Fixed Prosthodontics, President of
four years, part of that time on the USS Blue Ridge the American Board of Prosthodontics, and President of
(LCC‐19), the flagship of the Seventh Fleet. the American College of Prosthodontists. He has been
He completed a postdoctoral Fellowship in Prosthodontics awarded both the Garver‐Staffanou Award (for outstand-
at the Naval Dental Clinic, Great Lakes, Illinois, in 1985 ing service as a program director) and the Moulton Award
and a Residency in Prosthodontics at the US Navy Dental (for outstanding contributions to fixed prosthodontics)
Postgraduate School in Bethesda, Maryland, in 1988 with a from the American Academy of Fixed Prosthodontics. In
certificate in Prosthodontics. addition, he recently was awarded the Educator of the Year
Following graduation, he served aboard the USS Award from the American College of Prosthodontists. Dr
Nimitz (CVN 68), at the US Naval Academy in Annapolis, Driscoll has given over 450 presentations nationally and
Maryland, as Head of the Prosthodontics Department, internationally and has authored over 75 publications.
as a prosthodontist at the Washington Navy Yard, and as Besides teaching in the PG Pros program at Maryland, he
the Director of the Area Dental Prosthetic Laboratory at also maintains a private practice in Bethesda, Maryland,
Naval Dental Clinic, Great Lakes, until his retirement with his wife, Dr Sarit Kaplan.
in 1995.
After retiring from the US Navy, Dr Golden worked for Nadim Z. Baba received his DMD degree from the
two years as a restorative dentist and prosthodontist for a University of Montreal in 1996. He completed a Certificate
managed‐care dental practice in Green Bay, Wisconsin, in Advanced Graduate Studies in Prosthodontics and a
then as Clinical Assistant Professor and Prosthodontist at Masters degree in Restorative Sciences in Prosthodontics
the Ohio State University (OSU) College of Dentistry in from Boston University School of Dentistry in 1999. Dr
November 1997. He directed three undergraduate com- Baba is a Professor in the Advanced Education program in
plete denture courses and was promoted to Clinical Prosthodontics at Loma Linda University School of
Associate Professor. He was serving as the Director of Dentistry, an Adjunct Professor at the University of
Removable Prosthodontics and Director of the Complete Texas Health Science Center School of Dentistry in the
Denture Clinic at OSU when he retired at the end of Comprehensive Dentistry Department, and maintains a
December in 2010. part‐time private practice in Glendale, CA. He is currently
Following his retirement from OSU, Dr Golden accepted the President of the American College of Prosthodontists
a part‐time position as a Clinical Associate Professor at and an active member of various professional organiza-
West Virginia University School of Dentistry in November tions, a Diplomate of the American Board of Prosthodontics,
2011. He became Course Director of a six credit‐hour pre- and a Fellow of the American College of Prosthodontists
doctoral complete denture course and served for two and the Academy of Prosthodontics.
ix
Acknowledgements
To Susan G. Kestner, who guided me in the right direction USN, and CAPT Alexander Sanderson, DC, USN who rec-
in organizing my thoughts and putting them down in print. ognized my competence as a Dental Prosthetic Technician
To Dr. Charles Goodacre, Dr. Timothy Saunders, and Dr. and greatly encouraged me to become a dentist, then sup-
Alejandro Peregrina who encouraged me to write this ported me greatly to be selected for the Armed Forces
book, reviewed its content, and made suggestions in how to Health Professions Scholarship Program.
improve it. To Dr. Carl F. Driscoll, who agreed to be co-author and
To Anthony Buffamonte, whose lab expertise, encour- advisor and help me get this book published.
agement, and friendship I have treasured. To Dr. Nadim Z. Baba who agreed to write the chapter on
To Dr. Stephen Ancowitz, whose praise and support were digital complete dentures.
always greatly appreciated. And finally, to my wife, Louise Teets Golden, who put up
To CAPT Robert Slater, DC, USN, CAPT Charles R. with the long hours it took me to complete this textbook
Linkenbach, DC, USN, RADM George A. Besbekos, DC, and kept my schedule organized.
xi
About the Companion Website
Don’t forget to visit the companion website for this book.
www.wiley.com/go/driscoll/denture
There you will find valuable video material designed to enhance your learning.
Scan this QR code to visit the companion website
1
The Diagnostic Appointment
Our goal is to teach students what to look for when diag- patients with complete dentures are about 5–6 times less
nosing conditions that impact upon the use and prognosis than patients with natural or restored teeth.
of a complete denture, so that they may be better able to Some conditions will require preprosthetic surgery and a
provide a complete denture service to their patients. First, healing period prior to the final impression being made for
certain anatomical features will be evaluated, and a judg- complete dentures.
ment rendered as to their possible effects on the prognosis Many complete dentures are made in mandibles with
and success of a complete denture. We will identify typical impacted wisdom teeth and the patient may experience no
landmarks that we should be able to find in all patients. trouble; however, the patient needs to be informed about
During a clinical examination, anatomical landmarks the risks involved with leaving an impacted tooth in place.
that are present in nearly every patient need to be evalu- As the ridges resorb, the bone overlying a tooth remnant or
ated to determine if there is any distortion, abnormality, or impacted tooth will resorb away, and this area will eventu-
missing landmarks due to severe alveolar bone resorption, ally only be protected from the denture by a thin layer of
disease processes, previous surgical alterations, or natural mucosa. When this happens, an infection or traumatic
physical variation that would indicate a problem area. ulcer may develop. Retained mandibular third molars com-
In the maxillary arch, we should be able to identify the monly dehisce. Have them removed!
incisive papilla, labial and buccal vestibules, rugae, resid- A torus is a benign outgrowth of bony tissue covered by a
ual ridge, maxillary tuberosity, hamular notch, palatine thin layer of mucosa. Some maxillary tori can be left as
fovea, buccal and labial frenula, midpalatine suture, and they are, and a denture placed over them if they are not too
glandular area. We should then be able to determine the large and do not adversely affect the retention or function
vibrating line that is so important to maxillary complete of the maxillary complete denture. This may be possible
denture retention. because a maxillary complete denture has a broad denture‐
In the mandibular arch, we should be able to identify the bearing area for support in the palate. Often this is man-
tongue, pterygomandibular raphe, residual ridge, buccal aged by placing a palatal relief chamber over the torus as
and labial vestibules, buccal, lingual, and labial frenula, papillary hyperplasia will not form over these tissues, and
buccal shelf, retromolar pad, retromylohyoid fossa, alveo- if these areas become traumatized, they will be slow to heal
lolingual sulcus, lingual tubercle, and submaxillary due to the limited vascularity in that area.
caruncles. Mandibular tori are sometimes left in place for a tooth‐
Once these landmarks have been identified, we must borne removable partial denture (RPD). When the patient
assess how their size, shape, location, presence or absence loses posterior teeth and a distal extension of the flange of
may affect treatment and prognosis. Patients must be the denture becomes necessary, they may fail to see the
informed of any situation that may affect their ability to need for surgical reduction, but if these are left in place, the
comfortably wear their complete dentures. denture base will erode the overlying soft tissues severely,
The denture‐bearing area is that part of the attached and causing intense pain. A tissue conditioner may help tempo-
unattached mucosa of the edentulous ridges upon which rarily, but it will not be a long‐term fix. When immediate
the dentures will rest. This area becomes progressively insertion dentures are placed over tori, patients often must
smaller as residual ridges resorb. Maximal biting forces in suffer until the tissues heal. A second surgery may not be
Treating the Complete Denture Patient, First Edition. Edited by Carl F. Driscoll and William Glen Golden.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/driscoll/denture
2 Treating the Complete Denture Patient
recommended while the tissue is thus inflamed or not r esorption occurs. It is not a good support area for a den-
completely intact. ture. This condition most often develops in the maxillary
Exostoses are bony outgrowths on the alveolar ridge. They anterior region because the tongue protects the lower
also pose a considerable problem for a complete denture anterior teeth from decay. A mandibular RPD is much
patient. The tissue is stretched tightly over them and the more stable than a mandibular complete denture (CD), so
undercuts they have would prevent a peripheral seal for a the lower anterior teeth are retained to provide retention
denture from being evenly remotely possible. Food debris for a mandibular RPD. This results in Kelly syndrome,
generally will collect in the overhangs they provide, and den- otherwise known as combination syndrome.
ture movements will denude the soft tissue overlying them. Combination syndrome or Kelly syndrome defines a sit-
Tori and exostoses often show signs of trauma because of uation that develops when a steep anterior guidance angle
their thin epithelium and prominent profile. This is par- allows minimal or no posterior contacts in working, bal-
ticularly true after eating a hard‐crusted food such as pizza. ancing or protrusive relationships when the patient goes
Healing will take place slowly in these areas because of the through the chewing cycle. This results from the denture
lack of adequate vascularization. Infection will have easy tipping anteriorly during the chewing cycle, compressing
access to the underlying tissues. the mucoperiosteum of the premaxilla, leading to resorp-
Inflammatory fibrous hyperplasia begins as a traumatic tion of the bone of the premaxillary area. The negative
ulcer secondary to an ill‐fitting denture flange and devel- pressure in the posterior can lead to a maxillary tuberosity
ops into a callous‐like fibroma called an epulis fissuratum. protuberance.
These need to be removed and the existing denture relined Resorption can be so severe as to require augmenta-
with tissue conditioner to promote healing. Healing must tion with bone grafts in order to prevent idiopathic frac-
be completed before making a final impression for a com- ture of the mandible. There are cases on record where a
plete denture. patient has suffered a fracture from simply falling asleep
Inflammatory papillary hyperplasia can also occur under with their hand on their chin. A mandibular CD is very
a denture. It can arise with or without the presence of seldom made opposing the maxillary restored arch due
Candida albicans and is caused by an ill‐fitting denture, to the almost impossible task of achieving bilateral bal-
wearing the denture at night, and/or poor oral hygiene. It ance of the denture teeth against the restored teeth and
appears as flattened or grape‐like clusters, dependent upon the increased forces that a patient can generate while
the pressure of a denture over the area. This often occurs chewing against the natural or restored teeth. This can
under a palatal relief chamber that was placed to increase lead to rapid resorption of the mandibular alveolar
suction under a maxillary complete denture. ridge.
As resorption progresses, the maxilla shrinks upward The retromolar pad is a cushioned mass of tissue, fre-
and inward, while the mandible shrinks downward and quently pear‐shaped, located on the alveolar process of
outward, leading to more and more of a posterior crossbite. the mandible behind the area of the last natural molar
As the bone resorbs, the area involved becomes less able to tooth. It is composed of nonkeratinized loose alveolar tis-
tolerate the presence of a denture overlying it, due to the sue covering glandular tissue, fibers of the buccinator
decreased surface area and a resulting increased instability. muscle, the superior constrictor muscles, and the ptery-
In a severely resorbed mandible, the inferior alveolar nerve gomandibular raphe, and the terminal part of the tendon
may lie on top of the residual ridge. Any pressure on this of the temporalis muscle. Since there were no teeth
area will be painful. beneath this area, it is usually the most stable area of the
A sharp mylohyoid ridge will press against the overly- mandibular edentulous ridge and should be covered by
ing tissue and make it very tender to any pressure of even the denture flange. Trauma from ill‐fitting mandibular
a well‐fitting denture. Trauma to this area can be mini- complete dentures or the patient failing to wear a lower
mized or prevented altogether if the patient inserts the complete denture when chewing can also lead to this area
mandibular complete denture in the posterior first, then being soft and loose. The alveolar process, on the other
slides the denture forward and down over the anterior hand, has had teeth which have been removed and
ridge. This is an important area, as it provides an under- although these areas have filled in with reparative bone, it
cut that will improve retention of the mandibular com- is not as resistant to resorption.
plete denture. Some severely resorbed ridges will manifest as knife‐
A flabby residual ridge is simply soft tissue that becomes edged bone under a ridge of soft tissue that feels firm. The
soft and flabby over the knife‐edged bone of the alveolar bone under these ridges is so small that it resembles a knife
residual ridges when an advanced residual ridge in a sheath. It is very susceptible to spontaneous fracture
The Diagnostic Appointment 3
and will require augmentation with a synthetic material, with a Class III palate will have the hardest time of the three
cadaver bone or autogenous bone graft. in tolerating a maxillary complete denture.
House classified the posterior palate by the shape of Neil classified the lateral throat form by measuring the
the soft palate according to how it drapes down posteriorly, height of the lingual vestibule in the retromylohyoid region. A
relevant to developing the posterior palatal seal in a maxil- patient with a Neil Class I lateral throat form will have over
lary complete denture. In his classification system, a patient ½ in. of depth provided and is very favorable for mandibular
with a Class I palate will be able to tolerate a complete den- denture retention and stability. A Neil Class II lateral throat
ture easily because this palate offers the broadest range of form falls between Class I and Class III and is less than ½ in.
area (5–10 mm) in which to place the posterior palatal seal, in depth. A Class III lateral throat form has no vestibular
but it is also the hardest to locate the exact area because of its depth and would have an unfavorable prognosis. Generally,
flat curvature. A Class II posterior palate is the most com- around three‐quarters of patients will have Neil Class I lateral
mon in the Caucasian population, with a range of 3–5 mm. It throat form, about one‐fifth will be Class II, and only 5–6%
falls between the limitations of the Class I and the Class III will be Class III. The lateral throat form is bounded anteriorly
palate. A Class III posterior palate has a vibrating line that is by the mylohyoid muscle, laterally by the pear‐shaped pad,
easiest to locate as it drops down suddenly, but it offers only posterolaterally by the superior constrictor, posteromedially
1–3 mm of area to place the posterior palatal seal. A patient by the palatoglossus, and medially by the tongue.
5
Preliminary Impressions
A preliminary impression is a negative likeness made for or the efficacy of the material will be greatly reduced.
the purpose of diagnosis, treatment planning, or the fabri- Room temperature water (70 °F) should be used for best
cation of a tray. It is made in a stock tray that is selected results.
from an assortment. These trays are made to fit the major- There are three types of impression trays used for con-
ity of patients, but really do not fit anyone well. They sim- taining the impression material: Styrofoam, plastic, and
ply provide a vehicle to carry the impression material to the metal. A Styrofoam tray is not rigid, is bulky, and does not
patient’s mouth for that first impression as a starting point. retain the impression material well. Some plastic trays are
This is the first impression of the patient’s mouth that is disposable and are not very rigid. They require adhesive to
made for diagnosis, treatment planning, and then for mak- retain the impression material. Reusable plastic trays are
ing the custom trays. rigid and retain the material by retention holes and rim
There are primarily two types of materials used for pre- locks. Metal trays are rigid. Some are perforated and retain
liminary impressions: modeling compound and hydrocol- the impression material with retention holes. Others are
loid. Modeling compound is used almost exclusively for solid and very rigid and retain impression material with
edentulous patients. It is a thermoplastic material that is rim lock retention. Some metal trays can be minimally
color coded for working temperature. Thermoplastic means adapted by bending if the tray is not made of stainless steel.
that it is softened when heat is added and becomes firm Stainless trays are not adaptable.
when it cools. It comes in cake and stick forms, with the Regardless of the tray selected, a suitable tray for a pre-
stick form most commonly used for border‐molding a tray. liminary impression must conform to the general shape and
Green compound has a working temperature above 123 °F size of the ridge. The flanges of the tray are contoured to
and red compound has a working temperature above 132 °F. follow the depth of the peripheral roll, best with a periphery
Compound must be tempered in a water bath to obtain the wax made specifically for that purpose, although red rope
correct temperature and not burn the patient. The hot water wax is often substituted. The tray should allow for 3–5 mm
tempering bath is set at 140 °F for green compound to allow of impression material thickness between tray and edentu-
for enough plasticity to be transferred from the bath to the lous tissues. If a tray is not easily adaptable, use a smaller
mouth and the compound be formed to the desired shape. tray and use compound to extend and modify the tray.
The second material used for preliminary impressions is With metal trays that can be adapted, use pliers or bend
an irreversible hydrocolloid (alginate). It is a hydrophilic them with fingers. Shorten the border areas so that adapta-
gel made from seaweed, calcium sulfate, and water. tion can start with the palate. Smooth and polish the modi-
Hydrophilic means that it mixes completely with water and fied areas with the pumice‐impregnated rubber wheel.
it provides a very good impression in the moisture of the A preliminary impression should have the following
mouth. The setting time for alginate impressions is varied characteristics. It should show good borders and com-
by the addition of sodium phosphate (a retarder). Fillers of pletely fill the peripheral roll. It should be centered in the
diatomaceous earth and silicate powders determine the tray and be of uniform thickness. It should show good tis-
hardness of the alginate. sue adaptation and be free of bubbles and voids. It should
The dentist must hold the tray still the entire time until extend posteriorly to record the pterygomaxillary notch
the alginate is set or distortion will result. A patient should and the vibrating area in the maxilla. It should extend pos-
never be asked to hold the tray themselves. The tempera- teriorly to record the retromolar pads and the lateral throat
ture and amount of water should be measured accurately, form of the mandible.
Impression materials for preliminary impressions should lary notches and 3–4 mm in facial and 4–5 mm in posterior
be economically priced. Prepackaged impression materials sections. The peripheral roll is 2–3 mm in depth from the
are always more expensive than bulk packaged materials. land area. The facial outline form of the land area should
Bulk packaged materials should be kept in air‐tight and follow the outline form of the peripheral roll. The sides of
moisture‐tight containers in a cool area. They should be the cast are perpendicular to the base. The cast surface is
kept in a relatively small container so that the material can free of voids and no nodules of stone are present. The cast
be used in a fairly short period of time. is free of foreign material and debris.
When a preliminary impression is poured, a double‐
pour technique is used. An alginate impression should be
separated from the cast about 45 minutes after pouring to 2.1 Making the Preliminary
prevent damage to the cast as leaving stone in alginate Impression
overnight will result in extreme shrinkage and binding of
the impression material to stone models. When com- Preliminary impressions are made in stock trays which are
pound is used for the preliminary impression, remove all not capable of making an accurate impression of the vesti-
compound from the cast before proceeding. Use a boil out bules. The vestibules will always be overextended on an
tank or a hot water bath to remove wax from the cast. You impression made in a stock tray. The best you can do is to
must temper the cast for five minutes in warm water pick a tray that will fit over the arch and confine the impres-
before a boil out tank is used, or the hot water will frac- sion material to that area.
ture the cold cast. An appropriate tray is selected to fit the patient as accu-
Before using the model trimmer, trim the land area of the rately as possible. Remember that a stock tray is not meant
cast with the laboratory knife. Never use a red handle knife to be a perfect fit. A main concern is that the tray must be
or a scalpel for this as the blade can break and severely cut able to be placed in the mouth while loaded with alginate
your hand. Remove all foreign material (alginate, com- and removed easily as a unit without damaging the impres-
pound, impression material, and wax) before using the sion or the patient. The trays are made specifically for
model trimmer. Always have the water turned on while edentulous mouths. A tray made for patients with teeth
operating the model trimmer. Light pressure should be should not be used to make impressions of an edentulous
used to push the cast against the model trimmer wheel, so mouth.
you do not lug the motor down. Slowly move the cast back If the patient has an existing denture, it can be used to
and forth to achieve maximum efficiency. Brace your fin- determine the best size tray to be used for the impression.
gers against the table and keep hand instruments away It is placed in an edentulous tray to determine the appro-
from the model trimmer to prevent damage from the rotat- priate size tray to use for the impression (Figure 2.1). There
ing wheel. Moisten the cast under running water prior to should be adequate clearance between the denture and the
grinding on the trimmer to prevent the gypsum/water tray to allow the tray to fully seat in the patient’s mouth
spray from adhering to the cast like concrete. without impinging upon the tissue surfaces when it is
Preliminary casts should be trimmed to certain dimen- loaded. If the patient does not have an existing denture, the
sions. Trim the edentulous cast to an outline form that is dentist can spread the index finger and the second finger
flat in the posterior and arched on the facial. Always trim apart and use them to measure the width of the arches then
the surface of the land areas first to visualize the width of place them in the tray to determine the best fit.
the land area. Establish the 2–3 mm depth to the land area. It is very important that the tray will support the alginate
(You may find it helpful to use a pencil to outline the width in the two most critical areas: the retromolar pad area of
of the land areas before going to the model trimmer.) Trim the mandible and the hamular notch (pterygomaxillary
the base of the cast to make the residual ridge parallel to notch) of the maxillary. These areas must be captured in
the base and the bench top. Also make the cast 12–13 mm the impression because they are the most stable areas of
thick to a flat plain occlusion table and a flat bench top. the residual ridges. The tray should correspond to denture‐
Make the posterior side of the cast flat. Finalize the sides of bearing surfaces. Select a tray that is at least 3–4 mm larger
the cast and the land area width. Rinse the slurry water and than the residual ridge. The retromylohyoid space must
debris off the cast immediately. Do not use a heavy scrub also be captured, because these areas have such a profound
brush to clean the cast or it may be damaged. effect on the retention and stability of the mandibular den-
All edentulous casts must meet the same criteria. The ture by providing a distal undercut that will resist the den-
median foundation plane is horizontal and parallel to the ture dislodging posteriorly when the patient bites on
base of the cast when the cast is on the bench top. The cast something anteriorly.
is 12–13 mm thick in its thinnest portion. The land area is Flange areas and the palate can be modified for a more
1 mm above the tissue surface between the pterygomaxil- comfortable and uniform fit. Periphery wax is the best
Preliminary Impressions 7
Figure 2.1 Place a denture in an edentulous tray to determine

the appropriate size tray to use for the impression.
material used to modify and support the tray in these criti-

cal areas, but the main objective of placing the tray in the
mouth and removing it without distorting the impression
must not be compromised. This blue periphery wax is a
mouth‐temperature wax and will mold to fit the anatomy
of the mouth. Red rope wax is often used instead of periph-
ery wax but is a poor substitute as it does not have the same
properties as utility wax. The impression tray is more com-
fortable for the patient when a strip of periphery wax is
placed around the entire flange of the tray.
Border‐molded trays should be comfortable and accu-
rately cover the extensions of the arch. Blue periphery wax
is applied to the complete circumference of the border of
the tray (Figures 2.2 and 2.3). This wax can be modified to Figures 2.2 and 2.3 Apply blue periphery wax to the tray
fit the mouth more accurately because it will become softer border for patient comfort.
at mouth temperature and will allow a certain amount of
border molding. The frenulum areas require special atten-
tion so that the metal of the tray does not show through.
After the periphery wax is placed on the tray, it is warmed
in a warm water bath (Figure 2.4). This will soften it so that
it easily molds to record the vestibular extensions in the
patient’s mouth. The warmed periphery wax is muscle-
trimmed in the mouth to border mold the tray. When the
border molding is complete, the tray is soaked in cool water
to set (harden) the wax. A tray must be cool when loaded
with alginate impression material before it is inserted in
the mouth because the alginate will set quicker in a warm
tray, which will prevent it from making a good
impression.
A mouth mirror is used to pull the cheek away from the
tray (Figure 2.5) to allow it to be eased into the mouth. This
can sometimes be very difficult to do because some Figure 2.4 Warm the tray in a warm water bath.
Figure 2.5 Use a mouth mirror to pull the cheek away from
Figure 2.7 Coat a stock tray with an alginate adhesive aerosol
the tray.
spray.
memory to return to the arch form relatively quickly.

Alginate is inexpensive when compared to most other
impression materials. Major drawbacks are that the impres-
sion must be poured within 30 minutes to be accurate and
the impression tray must be supported by its handle while
the stone is setting.
Figure 2.6 shows a typical set‐up of the materials used to
make a preliminary alginate impression.
An alginate tray adhesive is applied to the inside of the
border‐molded tray. A thin layer of adhesive is sprayed or
painted over the tissue surface of a tray. An aerosol spray
can be used to coat the stock tray with alginate adhesive
(Figure 2.7). The key to applying the spray adhesive is to
use a thin coat. If too thick a coat is applied, it will take too
long to get tacky. If alginate is placed in a tray that has wet
Figure 2.6 Materials used to make a preliminary alginate adhesive, the alginate impression will separate from the
impression. tray when the impression is removed from the mouth. An
impression will be distorted if it separates from the tray and
patients’ lips may have become stiff with old age. The side is pressed back into place.
of the tray that is away from the mirror is inserted first, and The correct amount of room temperature (70 °F) water is
used to push the cheek over to that side of the mouth while poured into a vial supplied by the manufacturer of the algi-
the fingers or a mouth mirror pull the cheek away from the nate and filled to the designated line marked on the vial.
other side of the tray as that side is rotated in. The measured water is poured into a rubber mixing bowl.
Sodium alginate is by far the most popular material used The powder is poured into the water for the best results and
to make preliminary impressions. Alginate impression stirred to incorporate it into a homogenous mixture using a
material is also called irreversible hydrocolloid because it is round‐edged flexible spatula in a vigorous manner
a one‐time use item. It is a very suitable impression mate- (Figure 2.8). Sweeping strokes are used to press the mixture
rial for this purpose, because it has enough body when it is against the walls of the mixing bowl to force out any air
placed in the mouth to not run excessively from the tray bubbles and form a thicker mix. The mix will appear dry at
and sets rather quickly. It is also capable of making accu- first but do not add additional water. After several strokes,
rate impressions in various thicknesses of material in ill‐ the mix will become smooth and creamy (Figure 2.9). It is
fitting trays. Alginate impressions will pull from undercuts recommended to use slightly less water to achieve a thicker
with a lower risk of tearing and have a very good elastic mix when making the maxillary impression on a gagging
Figure 2.8 Use a round-edged flexible spatula to vigorously Figure 2.10 Make sure that the impression material fills the
mix gypsum powder with water to incorporate it into a tray completely.
homogenous mixture.
Figure 2.9 Use sweeping strokes make a smooth and creamy

mix.
Figure 2.11 Use fingers to spread the lips and center the tray
patient. This is done rather than using warmer water as the in the mouth.
warmer mix will set before the tray is inserted. Vacuum
spatulas and other mechanical mixers are very useful and andle straight out from the midline (Figure 2.11). The
h
do the job very well but are not necessary once a person frenula and lips are manipulated in a procedure called
becomes skilled at mixing the material in a rubber bowl. muscle trimming while the tray is gently pressed down
As you hold the mandibular tray by the handle in one (Figure 2.12).
hand, load the alginate from the back on one side of the Have the patient raise the tongue as the tray is inserted
tray and distribute it around the tray, pushing all air ahead and push it out over the handle while you press down gen-
of the mix. Make sure that the tray is filled completely tly, then move it to the right and left. This must be done
(Figure 2.10). several times while the alginate is setting, or the patient
Mandibular impressions are made by placing the loaded will relax and place their tongue fully back into the mouth
tray in the mouth while standing in front and to one side of and under the tray. The patient may worry that they will
the patient. The fingers of both hands are used to spread drool over themselves during this procedure, so be pre-
the lips and the tray is centered in the mouth with the pared to use a small suction tip and have paper towels
Figure 2.12 Manipulate the frenula and lips by muscle

trimming.
Figure 2.13 Landmarks of a mandibular impression.
available close by. The lower impression should be done

first because it is less likely to cause the patient to gag and
they may be less anxious about making the maxillary
impression.
Check the finished impression for voids and look for
areas where the tray may have pressed through the algi-
nate. This may lock the tray onto the cast and make it very
difficult to remove. Be aware that alginate impressions
always overextend the vestibules unless the tongue relaxes
and gets under the tray in the lingual vestibule. Remake the
impression if this has happened or you will not be able to
make a suitable custom tray on the cast.
There should be an S‐shaped curve in the lingual vestib-
ular area on both sides of the impression. Look for the
mandibular landmarks in your impression. The labial
notch, labial flange, buccal notch, buccal flange, alveolar Figure 2.14 Massage the lips and cheeks to border mold the tray.
groove, and retromolar fossa should all be very identifiable
in the impression. Likewise, the pterygomandibular notch,
retromylohyoid eminence, lingual flange, premylohyoid
eminence, lingual notch, and lingual tubercular fossa
should also be easy to see (Figure 2.13).
When you “border-mold” the tray with periphery wax for
a maxillary alginate impression, simply push the lips and
cheeks in as you massage them (Figure 2.14). This will
result in overextended vestibules which will enable you to
better make a custom tray. Since the wax is very soft at this
point, the tray must be removed very carefully to avoid dis-
torting the wax (Figure 2.15). The tray is then chilled in
cold water to harden the wax and slow down the setting
time of the alginate.
Mix the powder and water to a thick, creamy consistency
according to the manufacturer’s directions. The procedures
for mixing alginate for the maxillary impression are the Figure 2.15 Remove the tray carefully to avoid distorting the
same as outlined for the mandibular impression. Load the periphery wax.
Figure 2.18 Seat maxillary trays while standing behind the

patient.
Figure 2.16 Load alginate mix into the tray and push air ahead
of the mix.
Figure 2.19 Rotate the tray evenly into position over the ridge.
Figure 2.17 Use moist fingers to distribute and smooth

impression material in the tray.
alginate into the tray so that the air is pushed ahead of the
mix, starting at one side in the back of the tray and loading
the entire tray (Figure 2.16). Distribute and smooth the
material in the tray using moist fingers (Figure 2.17).
The maxillary tray is seated by the dentist from behind
the patient (11 o’clock position if the right hand is used). It
is placed in the mouth with one hand holding the tray han-
dle while using the fingers of both hands to spread the lips
(Figure 2.18). The tray is rotated into position, making sure
that the handle comes straight out from the midline and
that the tray is situated evenly over the ridge (Figure 2.19).
The anterior portion is seated first so that the air is forced
out the back as the tray is seated (Figure 2.20). Any excess Figure 2.20 Seat the anterior portion of the tray first to force
impression material that is forced out the back is quickly air out the back as the tray is seated.
removed with a mouth mirror and the impression is gently Check the impression for any voids that may make it nec-
border molded to form the borders of the vestibules. essary to remake the impression. Small bubbles (less than
If the patient does feel nauseous, have them lean forward 5 mm in diameter) can be flicked off the stone cast but if
to minimize the gagging and raise the napkin to catch any they are larger than that, the impression should be remade.
drooling (Figures 2.21). Use the mouth mirror to pull for- Show‐through of the periphery wax does not mean that a
ward any excess alginate that is running out the back of the new impression needs to be made (Figure 2.25).
tray (Figure 2.22). Have the patient tense the stomach mus- Evaluate the impression to ensure that all the maxillary
cles by raising their legs while you hold the tray firmly in landmarks are captured (Figures 2.26 and 2.27). The
place for the entire time (Figure 2.23). Although the patient labial flange, labial notch, alveolar groove, buccal notch,
will feel discomfort for a short period of time, it will help to median palatal groove, buccal flange, and coronoid contour
avoid having to make a second impression. should all be very visible in the impression. Likewise, the
To break the seal under the denture, grasp the handle of incisive fossa, rugae, tubercular fossa, fovea palatinae,
the tray firmly, raise the cheek on one side, and remove the
impression in one quick but controlled motion (Figure 2.24).
You do not want to damage the patient or the impression by
being too aggressive.
Figure 2.23 Have the patient raise their legs to fight nausea by
tensing their stomach muscles.
Figure 2.21 Ask nauseous patients to lean forward to minimize

gagging and raise the napkin to catch any drooling.
Figure 2.24 Grasp the tray handle firmly and raise the cheek
Figure 2.22 Use a mouth mirror to pull forward any excess on one side to break the seal and remove the impression tray in
alginate from the back of the tray. one quick, controlled motion.
terygomaxillary seal, and posterior palatal seal area

p Hamular notch, posterior palatal seal, etc. Note the pres-
should all be easily seen in the maxillary impression. sure spot over the incisal papilla.
Completed preliminary impressions should have no Immediately after the impression is made, it must be
major pressure spots or voids. They should capture all sprayed with disinfectant before it is sent to the lab.
peripheral extensions. Do not expect a perfect impression
but avoid the expression: “Oh, it’s just a diagnostic impres-
sion!” Remember that you are basing your entire diagnosis
2.2 Pouring the Preliminary
on the casts made from these impressions. Note the cap- Impression
ture of the retromolar pad and the peripheral extensions in
the impression (Figure 2.28). The maxillary impression Thoroughly rinse the impression before pouring the stone,
(Figure 2.29) captures all of the anatomical landmarks – the then mix water and powder according to the manufacturer’s
instructions using a vacuum mixer to ensure a dense mix.
Figure 2.25 A show-through in the periphery wax does not Figure 2.28 Capture the retromolar pads and the peripheral
necessarily mean an impression needs to be remade. extensions in the mandibular impression.
Figures 2.26 and 2.27 Capture all maxillary landmarks in the maxillary impression.
Figure 2.29 Capture the hamular notches, posterior palatal seal,

and all the anatomical landmarks in the maxillary impression.
Figure 2.31 Place the tray handle in a drying rack and allow
the stone in a poured impression to set for 30 minutes.
Improve the mechanical retention of the first pour to

the base by adding several small mounds of stone to the
poured impression. Place the poured impression in a dry-
ing rack (Figure 2.31) or a groove in the bench so that it is
supported by the tray handle while the stone sets for
30 minutes. This takes the weight off the impression except
for the weight of the stone and avoids undue distortion
that would result if the impression were to be resting in
contact with the bench top.
An accurate diagnostic cast will include all anatomical
landmarks that should be covered by a denture base and
allow a custom tray to be made that will permit a very
accurate final impression to be made. The tongue area of
a lower cast should always be filled in and flattened so
that it strengthens the lower cast and allows no restriction
Figure 2.30 Rinse the impression thoroughly and mix water of access to these areas (Figure 2.32). The bases of the
and powder according to manufacturer’s instructions in a
vacuum mixer to ensure a dense mix. casts should be about 13 mm thick and the land areas
should be 3–4 mm wide all the way around the casts
(Figures 2.32 and 2.33).
Start the pour by placing the mix in the center of the palate Land area is any part on the face of the cast that was not
on the maxillary (Figure 2.30) or the distal on one side in the captured in the impression. Since the land area is not
mandibular and pushing it around the tray to displace any recorded by the impression, it is not a landmark. It will
air. Vibrate the impression on medium vibration and tilt the serve to protect the areas recorded by the impression and
impression on the vibrator until the stone has flowed over represented in the cast. It should not limit visual or work-
the entire tissue surface, and then allow the stone to run out ing access to the vestibular area of the cast.
of the impression. This will leave a thin layer of stone over If a cast shows some deficiencies from those aspects
the entire tissue surface, breaking the surface tension of the previously mentioned, a new impression needs to be
stone against the impression, and allow any bubbles to flow made. If a denture does not extend back over the retro-
out of the impression. Vibrate more stone into the impres- molar pad area, a significant amount of support will be
sion following the same sequencing as was established by lost and ridge resorption will be hastened. Land area pro-
the first pour. tects the borders of the impression and the cast and
Figures 2.34 and 2.35 Ensure that a 3–4 mm wide land area
exists to protect the borders of the impression and the cast.
Figures 2.32 and 2.33 Ensure that bases of casts are over
13 mm thick.
should be 3–4 mm wide all the way around the cast when the cast is duplicated. Technique casts used in the
(Figures 2.34 and 2.35). Any voids, particularly in the lab show excellent land area and should be used as an
lingual land area, could tear an impression of the cast example of how a cast should look.
17
Custom Trays
The Key to a Great Final Impression
Custom trays are made on preliminary casts and are con- tray material is placed onto the wax and pressed down in
structed prior to the final impression appointment. They the palatal area by moving the thumb toward the periphery
are used when making a final impression because they can to avoid entrapping air under the wax (Figure 3.8).
produce a much more accurate impression than a stock tray Trim the Triad in the same manner as the wax by press-
can provide. Stock trays are universal – they are not made to ing it along the edge of the cast and cutting it off (Figure 3.9).
fit a specific patient’s mouth. They are difficult, if not impos- Using the thumbnail, press the Triad into the relief area
sible, to adjust to fit a patient’s mouth. The most accurate where the cut was made in the wax border (Figure 3.10).
impressions are those made with a thin layer of impression Do this around the entire border of the cast.
material of even thickness. Custom trays require a mini- Mold a handle onto the tray that rises from the crest of
mum amount of impression material and allow a uniform the anterior ridge of the tray at a 45° angle to the crest of
thickness. Obviously, if there are undercuts that would lock the ridge and is long enough to accommodate the width of
the tray onto the preliminary casts, these will have to be the thumb (Figures 3.11 and 3.12). This allows enough
blocked out before the custom tray is made. access for the border molding to be accomplished in this
area and provides enough surface area for the tray to be
securely held during placement and removal. Cure the tray
3.1 Fabricating Custom Trays on the cast in a curing unit for three minutes (Figure 3.13).
Remove it from the cast and place it in the curing unit with
An outline is drawn on the master cast with a dark pencil the waxed side up for an additional two minutes.
about 2 mm short of the periphery in the labial and buccal Place the thumb on the handle to determine if there is
vestibular areas (Figure 3.1). The line is made long in the enough thickness and length to allow adequate grasp for
posterior palate. All undercuts are blocked out with wax the tray to be placed and removed during the impression
because it will not stick to the tray material (Figure 3.2). One procedure (Figure 3.14). Allow the wax to cool, and then
layer of base plate wax is heated over a Bunsen burner or in trim the tray material back to the level of the wax spacer. A
a hot water bath and draped over the cast (Figure 3.3). It is lathe will speed up the process and a handpiece can be
pressed into place with thumb and finger pressure. A pencil used to refine the cutback. Be careful when using acrylic
eraser can be used to press the wax into hard‐to‐reach areas. burs in the electric laboratory handpiece (Figure 3.15). A
Excess soft wax is trimmed by pressing it with a thumb bench lathe is another option, where available, and is very
against the sharp external edge of the land area of the cast stable. If the speed is too great, the shank can bend and
(Figure 3.4). The dark line scribed on the cast should be break the Triad tray or damage a hand or finger. A rein-
visible through the wax and serves as a guide to cut back forced lab diamond is specially made for this purpose and
the wax in the posterior palate (Figure 3.5) and 2 mm from should be used instead.
the depth of the vestibule (Figure 3.6). After the tray borders have been reduced and the tray has
The wax is left a little long in the posterior palate area to been finished, place it back on the cast to evaluate the cut-
allow the tray to be constructed long in this area, per- back (Figure 3.16). If the cutback is correct, remove an addi-
mitting the posterior palate to be recorded where the pala- tional 2 mm of wax from the inside of the tray to allow the
tal seal will be formed. A layer of 0.001 in. thick tin foil border molding material to overlap the edge of the tray and
(Figure 3.7) can be placed over the wax to prevent wax from form a U‐shaped joint (Figures 3.17 and 3.18). This joint will
impregnating the Triad® material. One thickness of Triad be strong enough to firmly retain the compound on the tray.
Figure 3.1 Draw an outline about 2 mm short of the periphery Figure 3.4 Trim off excess soft wax by pressing it against the
in the labial and buccal vestibular areas on the master cast. sharp external edge of the land area.
Figure 3.2 Block out all undercuts with wax, as it will not stick Figure 3.5 See the dark line through the wax on the cast
to the tray material. which serves as the guide for a cutback.
Figure 3.6 Use a sharp scalpel to trim the wax 2 mm short of
Figure 3.3 Heat one layer of base plate wax over a Bunsen the depth of the vestibule.
burner or in a hot water bath.
Figure 3.9 Trim off any excess wax by pressing it along the
edge of the cast.
Figure 3.7 Leave the wax a little long in the posterior palate area.
Figure 3.10 Use a thumbnail to press the Triad into the relief
cut made in the wax border.
Figure 3.8 Press one thickness of Triad tray material into the
palatal area to avoid entrapping air under the wax.
Figures 3.11 and 3.12 Make a tray handle at 45° to the crest of the anterior ridge that is long enough to accommodate the width
of the thumb.
Figure 3.16 After trimming the tray, place it back on the cast to
evaluate the cutback.
Compound
I O
n u
n t
Figure 3.13 Cure the tray on the cast for three minutes in a e e
Triad curing unit. r r
s s
u u
r r
f Tray f
a a
c c
e e
Wax
Figure 3.14 Check the width of the handle with a thumb.
Figures 3.17 and 3.18 Form a U-shaped joint in the inside of

the tray by removing an additional 2 mm of wax to allow the
Figure 3.15 Use a lathe or a handpiece for cutback of the tray. border molding material to overlap the edge of the tray.
Custom Trays: The Key to a Great Final Impression 21
Remove an additional few millimeters of wax from the the line long in the retromolar pad areas and block out any
posterior palatal area (Figure 3.19) to allow for the palatal undercuts with base plate wax (Figures 3.21 and 3.22).
seal area to be developed in the final impression. Press the wax into the lingual area first (Figure 3.23) and
Make the mandibular tray in much the same manner as then the buccal and labial areas. Cut it by pressing the wax
the maxillary tray. There are a few differences between the against the outer border of the land area. Trim it to the
maxillary and mandibular trays due to differences in the dark pencil line with the red‐handled knife (Figures 3.24
anatomy and the need to accommodate the tongue, but the and 3.25).
same basic procedures apply. Begin by drawing an outline Leave the wax spacer in place to provide relief for an
with a dark pencil 2 mm short of the periphery in the labial, even thickness of impression material when the impres-
buccal, and lingual vestibular areas (Figure 3.20). Leave sion is made. Place a piece of Triad over the wax spacer.
Press it into the lingual area first to prevent air pockets
from forming (Figure 3.26), and then press it over the ridge
and buccal areas. Pinch it off at the edge of the land area.
Cut along the edge of the lingual vestibule with a red‐han-
dled knife and remove this section (Figure 3.27).
Make a handle for the lower tray that is longer than the
one for the upper tray to allow for positioning of the tray in
the mouth from an anterior approach (Figure 3.28). It
needs to be narrower to allow the tongue to be extruded
Figure 3.19 Remove an additional few millimeters of wax from

the posterior palatal seal area.
Figure 3.20 Draw an outline on the mandibular cast with a

dark pencil 2 mm short of the periphery in the labial, buccal, and Figures 3.21 and 3.22 Leave the line long in the retromolar
lingual vestibular areas. pad areas and block out any undercuts with base plate wax.
Figure 3.23 Press the wax into the lingual area first.
Figure 3.26 Press the Triad into the lingual area first to
prevent air pockets from forming.
Figure 3.24 Press the wax into the buccal and labial areas, and Figure 3.27 Cut along the edge of the lingual vestibule with a
trim it with a sharp instrument. red-handled knife and remove this section.
Figure 3.25 The wax is trimmed 2 mm. short of the vestibule. Figure 3.28 Make a handle for the lower tray that is longer
than the one for the upper tray.
Custom Trays: The Key to a Great Final Impression 23
Figures 3.29 and 3.30 Make finger rests on the posterior ridge crest.
forward and to the sides during border molding of the lin-

gual flange areas. Make finger rests on the posterior ridge
crest that are narrower than the width of the tray to prevent
the width of the dentist’s finger being recorded when bor-
der molding is done (Figures 3.29 and 3.30). Be sure to
allow enough distance between these and the anterior han-
dle for the tongue to pass through. These are not necessary
if the patient’s residual ridge is wider than the dentist’s
finger.
Cut back the tray to the wax that has been made 2 mm
short of the vestibule to allow for enough bulk of the bor-
der molding compound (Figure 3.31). Leave the wax spacer
in place but cut it back about another 2 mm (Figures 3.32
and 3.33) to allow for the compound border molding to be
shaped so that it forms a U‐shaped joint with the edge of
Figure 3.31 Cut back the tray to the wax that has been made the tray to provide enough strength to the compound so
2 mm short of the vestibule. that it does not fracture off during the impression phase.
Figures 3.32 and 3.33 Leave the wax spacer in place but cut it back about another 2 mm so the compound will form a U-joint.
25
Using Custom Trays to Make Final Impressions
After the trays have been made and reduced to the proper down to the bench before the patient is seated. If an auto-
dimensions, they will be border molded. Border molding is matic mixer/dispenser is to be used, it should also be pre-
defined as the shaping of an impression material by the sent with its refills and mixing tips.
manipulation or action of tissues adjacent to the borders of
an impression tray. This is done to determine the contours,
height, and width of the borders of the complete denture. 4.1 Adapting Custom Trays to Fit
The material of choice for border molding a custom tray is the Arches
green stick compound. This will be applied liberally to the
vestibular extension areas and then placed into a hot water It is very important to get a tray adequately reduced so that
bath to temper it before placing the tray back into the it is 2 mm short of the vestibule. This is especially true with
patient’s mouth for border molding. The compound is then the lower tray because when the patient relaxes the tongue
adapted to the tray extensions by pulling the lips and or the person making the impression tires, gravity will
cheeks over the tray or hyperextending the tongue. cause the thin impression material to flow to fill the area
All the following items must be available at chair side for that is supplied by the relaxed muscles. This is not so much
the border molding of the final impression to allow the pro- a problem with the upper arch because gravity will work in
cedure to go smoothly: favor of the dentist, but care must be taken with the maxil-
lary impression to prevent the impression material from
●● border molding materials
running down the patient’s throat.
●● final impression materials
Trays are placed in the mouth and reduced 2 mm short of
●● Bunsen burner or Blazer torch
the vestibule when the lips and cheeks are pulled up (max-
●● Hanau torch (filled with denatured alcohol)
illary) or down (mandibular) over the border. Special con-
●● hot water bath set at 140 °F (slightly above the fusion
sideration should be given to important areas such as the
temperature of the compound) with a sterilized tub filled
lingual frenum area of the lower and incisal frenum area of
three‐quarters full of clean water
the upper, which are likely to be underrecorded in the
●● bowl of ice water
impression. Although the trays were reduced when made
●● red‐handled knife with a new blade
on the preliminary cast, these casts represent overexten-
●● wax spatula for removing the wax spacer
sion of the borders, so they are not as accurate, especially
●● acrylic trimming burs for the straight handpiece
in frenular areas.
●● matches or a lighter
Overextension of the borders of the impression leads to
●● custom trays.
overextended flanges which translate into sore spots
It is better to have more available than is necessary rather caused by denture wearing. With the lower impression
than having to go searching for something that is not there. tray in place, the patient is asked to raise the tongue
The ice water should already be in the bowl that is two‐ (Figure 4.1) and forcefully extend it forward over the tray
thirds full of ice and water and the hot water bath should handle (Figure 4.2) to determine if the tray is overex-
be already heated to 140 °F with water at a level of at least tended in the floor of the mouth. An indelible transfer
two‐thirds full. The blade should be on the red‐handled stick is a very useful tool to determine the extent of the
knife and the paper mixing pad should already be taped vestibule.
Figure 4.1 Ask the patient to raise the tongue when the lower
impression is placed in the mouth.
Figure 4.3 After the tray is adjusted, have the patient again
raise his tongue and force it straight forward to border mold the
lingual section of the tray.
Figure 4.2 Have the patient forcefully extend his tongue

forward over the tray handle to determine if the tray is
overextended.
Figure 4.4 Have the patient move his tongue to the right.
When the mandibular tray is adequately reduced, the robably due to the lingual flange impinging upon the
p
patient is asked to raise his tongue, force it straight for- lingual frenum.
ward (Figure 4.3), and then move it to the right (Figure 4.4) The labial frenum is a common area that gets under-
and to the left (Figure 4.5) to border mold the lingual sec- represented in the border‐molding process and conse-
tion of the tray. This will make one registration as the quently also in the final impression. These areas are
tongue widens the initial notch made in the border mold- marked with an indelible transfer stick (Figure 4.6) and
ing. This is the reason the tray handle must not be so large the tray is placed in the mouth (Figure 4.7) to transfer the
or over extended that it prevents the tongue from coming mark to the exact area to be reduced on the tray. The
straight forward, otherwise there would be two or more flange is reduced just enough to provide a 2 mm space
registrations made. This should show any overextension between the frenum and the tray border when the lip is
of the tray in the lingual area. If the tray rises, it is pulled up.
Using Custom Trays to Make Final Impressions 27
Figure 4.5 Have the patient move his tongue to the left.
Figure 4.8 Smooth all rough areas and overextensions with

an acrylic bur.
Figure 4.6 Mark both sides of the labial alveolus where the
frenum attaches.
Figure 4.9 Stretch the lips with a finger and the side of the
tray to provide access.
When adjusting the maxillary tray, the tray must be

carefully inspected to ensure that there are no rough
edges before placing it in the mouth. Rough areas and
overextensions are removed with a lab acrylic bur in a
straight handpiece (Figure 4.8). The tray is placed in the
mouth by using the tray on one side and a finger on the
opposite side to stretch the lips and cheeks to provide
Figure 4.7 Place the tray in the mouth to transfer the mark to access to insert the tray as it is gently rolled into position
the tray. (Figure 4.9). The tray handle should be at roughly 45°,
Figure 4.10 Mark each side of the frenula attachment on the

buccal alveolus.
coming off the crest of the anterior ridge. This will allow Figure 4.11 Record these marks on the inside of the tray.
the tongue and lip to move around the tray and permit
accurate border molding. The handle needs only to be
about the width of the thumb, as the handle should only This raises the soft palate (Figures 4.20–4.22) and the area
be used as a convenience in placing the tray in the mouth. can be visually assessed to determine that the tray has been
The leverage afforded by a longer handle can only be reduced adequately. This determination can also be made
destructive as the tray is removed from the mouth, so by having the patient blow his nose when the nostrils have
forceful removal must never be attempted. been pinched closed.
The frenula are marked on each side of their attach-
ment to the buccal alveolus (Figure 4.10). This will
allow their exact location to be recorded on the inside of 4.2 Border Molding
the tray (Figure 4.11) and indicate where the tray needs an Impression Tray
to be relieved to allow an accurate recording in the
impression. The method of border molding and making an impression
The tray is reduced in this area with an acrylic bur as described in the following procedures is called the selec-
(Figure 4.12) and tried in the mouth to ensure that enough tive pressure technique. In this technique, the tissues are
relief has been created (Figures 4.13 and 4.14). The tray is synthetically manipulated to get them extended into the
relieved 2 mm short of all frenula and vestibular depths vestibular areas to reflect maximum extent of normal
around the entire tray. movement before the denture is engaged and displaced.
The posterior palatal seal area is marked by placing dots Dental compound is the preferred material to be used to
in the midline of the posterior palate at a point where the border mold custom trays, because of its ability to be sof-
muscles of the posterior palate are attached and bilaterally tened by heat and manipulated any number of times to
in the hamular notch area (Figures 4.15–4.17). This area achieve the desired shape. Although there are several types
designates the border of the vibrating line. of compound, the type most commonly used for this pur-
The dots are connected (Figures 4.18) and the tray is pose is green stick compound.
placed in the mouth. After a couple of seconds, the tray is The compound is dipped in hot water immediately after
removed, and the position of the vibrating line can be eas- heating it with the alcohol torch, just before inserting the
ily seen on the distal surface of the palatal side of the tray tray into the mouth. Any delay in moving the tray from the
(Figure 4.19). hot water tempering bath to the mouth will allow the com-
The tray is reduced in this area and replaced in the pound to cool and it will become too hard to allow proper
mouth. The patient is asked to say “Ahhh” and to swallow. border molding. The temperature of the tempering bath
Figures 4.12–4.14 Relieve the tray 2 mm short of all frenula and vestibular depths.
varies with the type of stick compound used (green, gray, or It is generally a good idea to border mold the lower tray
red) but is always a few degrees (140 °F for green) above the first, because there is less chance of gagging the patient
fusion temperature of that compound. This assures that than with the upper tray. As the patient goes through the
the compound is still plastic when the tray is placed in the process of border molding the mandibular tray, they learn
mouth. The temperature of the water bath should be peri- about the procedure and become more comfortable with it.
odically checked for accuracy to prevent it from being hot- The patient will then be less apprehensive and more likely
ter or cooler than the setting on the heating element. to follow instructions.
Always remember to temper the compound in a water bath The secret to border molding a tray is to get the com-
for 3–5 seconds before placing it in the mouth to avoid seri- pound on the tray quickly, and to mold the compound in
ous burns. the mouth by manipulating the tissues through massage
Figures 4.15–4.17 Mark the posterior palatal seal area by making dots with an indelible transfer stick.
Figure 4.18 Connect the dots to show where the posterior Figure 4.19 View the vibrating line on the distal surface of the
palatal seal is to be located. palatal side of the tray.
Figures 4.20–4.22 Have the patient raise the soft palate and assess the area.
and lightly pulling with a forefinger, then reheating it and allow it to sag into place. Dip the fingers in the water
tempering it in a hot water bath prior to inserting it in the bath and press the compound into shape on the flange
mouth. Usually the mandibular tray will be border molded of the tray between the thumb and forefinger
first. The following sequence shows how this is done. (Figure 4.24). If the hot compound is touched with a
dry finger, the compound will stick to the finger and
4.2.1 Border Molding the Mandibular Tray pull away from the tray.
2) Temper the compound. Heat the compound again
1) Heat the compound. Heat a single stick of green (Figure 4.25) after shaping it on the tray so that it is an
compound uniformly over a broad area (Figure 4.23). even temperature throughout. Temper the heated com-
Pass it through a Bunsen burner flame as you rotate the pound in a hot water bath to cool it and establish a
stick and move it back and forth through the flame. lower uniform temperature before placing it in the
The compound stick will begin to look very smooth and mouth (Figure 4.26). Immerse the tray in the hot water
the end of the stick will become blunt just before it completely. Remove it and place it quickly in the mouth
starts to sag. At this point, hold it over the tray and (Figure 4.27). This prevents the compound from
Figure 4.25 Reheat the compound.
Figure 4.23 Uniformly heat a single stick of green compound

over a broad area with a torch.
Figure 4.26 Temper the compound in hot water.
Figure 4.24 Press the compound into place and shape it with a
wet finger and thumb.
ardening before it is placed in the mouth and while still

h
at a temperature that is not uncomfortable to the patient.
3) Border mold the frenula areas. Border mold the
frenula areas first since they are the hardest to develop
a good registration in the compound. Place compound
on the lingual flange area of the mandibular tray and
mold it to fit the tray. Have the patient raise the tongue
and push it over the tray handle to record the lingual
frenum, and then move it to the right and to the left.
4) Border mold the rest of the tray. The tray must be
held down firmly on the ridge with one hand while
stretching the lip and cheek over the area being border Figure 4.27 Place the tray in the mouth to mold the compound.
Figures 4.28 and 4.29 Raise the lip and mold the compound with the fingers.
molded with the other hand (Figures 4.28 and 4.29). when the compound was applied. If a tray is not dried
Small mounds placed as finger rests on the crest of the off sufficiently before the compound is applied, it will
ridges can improve the ability to hold the tray in place not bond well enough to stay in place. In areas where
and prevent the width of the finger from being a decid- the compound is too thick or overextended (see arrows
ing factor in the width of the border‐molded area. on Figure 4.30), reduce it. It is then reheated with the
5) Inspect the border‐molded areas. The border mold- alcohol torch and the tray is replaced in the mouth to
ing must be inspected to see if there is any show‐through refine the border molding.
of the tray. The compound should be of adequate thick- 6) Chill and trim the compound. The compound must
ness and be tightly attached to the tray. For any areas be firm before trimming, so it is chilled in ice water
where the edge of the tray shows through, the com- (Figure 4.31). It is then trimmed with a sharp scalpel
pound is used as a reduction guide to reduce the tray in
that area. If some flash extends over the wax spacer
(Figure 4.30), this is removed with a sharp scalpel blade
when the border molding is completed. It is very impor-
tant that the border‐molding compound is not left too
thick or the impression will also be too thick in this area.
If a section of compound has pulled away from the
flanges, this is most likely due to the tray being moist
Figure 4.30 Flash is seen extending over the wax spacer. Figure 4.31 Chill the compound in ice water before trimming.
very carefully and with the cutting stroke directed

toward the tray to avoid fracturing the compound from
the tray (Figure 4.32).
7) Finish the surface of the compound. Once the com-
pound has been trimmed to the desired size, it is heated
again with the alcohol torch (Figure 4.33) and tempered
in hot water (Figure 4.34). It is inserted in the mouth,
then chilled (Figure 4.35) and dried. The border of the
tray that has been border molded with compound should
now resemble the flanges of a complete denture.
4.2.2 Border Molding the Maxillary Tray
1) Heat the compound and apply it to the tray. A

piece of compound is heated along a broad area until it
is uniformly softened and sufficiently long to cover a
broad area of the tray (Figure 4.36). Allow it to sag
onto the tray as it is moved along the border, thus Figure 4.34 Retemper the compound in hot water.
Figure 4.35 Insert the tray in the mouth, remove it, then chill
and dry it.
Figure 4.32 Trim off excess compound with a sharp scalpel.
Figure 4.33 Heat the compound again with the alcohol torch. Figure 4.36 Uniformly heat a broad area of compound to soften it.
Figures 4.37 and 4.38 Adapt the compound to a maxillary tray as was done with the mandibular tray.
Figure 4.40 Place compound on the tray borders sequentially,

until all borders are covered.
Figure 4.39 This compound is too hot and is runny.
ensuring an even distribution of heat (Figure 4.37) and

adapt it to the tray, as was done with the mandibular
tray (Figure 4.38).
2) Avoid overheating. The compound should not be
so hot that it is runny, as in Figure 4.39. If it is runny,
it becomes unmanageable and can burn the fingers
and stick to anything it touches. It is placed on the
tray borders sequentially, until all borders are cov-
ered (Figure 4.40). The hot compound is then tem-
pered by dipping it briefly in a hot water bath that is
set slightly above the fusion temperature of the com-
pound (Figure 4.41).
3) Insert the tray. The tray is inserted in the mouth by
using the tray to displace tissue on one side and a finger
on the opposite side to stretch the lips and cheeks to
provide access and gently roll the tray into position Figure 4.41 Temper the hot compound in water set slightly
(Figure 4.42). The lip is pulled outward and downward above its fusion temperature.
Figure 4.44 View the labial notch area to make sure it is

clearly visible.
Figure 4.42 Stretch the lips and cheeks and insert the tray.
Figure 4.45 Chill the compound in ice water.
Figure 4.43 Border mold the labial flange and frenum areas by
pulling the lip outward and downward. 5) Reheat if necessary. Where there are obvious areas of
compound overlap (Figure 4.47), the area is heated and
the tray returned to the mouth to refine the area and
to border mold the labial flange and particularly the make it fit accurately (Figure 4.48). Areas such as these
labial frenum area (Figure 4.43). notches should show up where there are frenula located
4) Inspect and chill the tray. The labial notch created by (Figure 4.49).
the labial frenum is clearly visible in the compound 6) Impress the rest of the tray and refine the border.
(Figure 4.44). The compound is chilled in ice water until The compound is placed around the rest of the tray and
it becomes very brittle (Figure 4.45), and then trimmed the posterior palatal seal is refined last (Figure 4.50).
with a sharp knife (Figure 4.46), cutting toward the tray The vacuum provided by this additional compound
and away from the edge to avoid chipping the compound should be immediately obvious and the tray should
away from the areas that are desired in the recording. resist removal from the mouth. It is better to leave the
Figure 4.46 Trim the compound by cutting toward the tray

with a sharp knife.
Figure 4.48 Reheat the area, temper, and return the tray to the
mouth to refine it.
Figure 4.47 Look for areas of overlap of the compound.

Figure 4.49 Observe notches where there are frenula located.
wax spacer in place until the border molding is done as

this will preserve the space for the impression material. (Figure 4.51). Any excess compound is carefully
It is removed just prior to making the impression. trimmed off, the compound is reheated with the Hanau
Excess compound is trimmed from around the tray and torch, and the entire tray is border molded again.
the compound is reheated with the Hanau torch. It is 7) Remove the wax spacer. When there is no excess com-
tempered for a couple of seconds in the water bath and pound showing up as flash, the wax spacer will be ready to
the tray is reinserted in the mouth. After it is checked be removed. A cut is made in the wax spacer across the
for any changes and modified to obtain an ideal fit, if tissue surface of the palate (Figures 4.52 and 4.53). The
necessary, more compound is added to the posterior broad end of a #7 wax spatula is used to carefully scrape
palatal seal area and the tray is reinserted in the mouth and remove the wax completely (Figure 4.54). The same
Figure 4.50 Place compound around the rest of the tray.
Figures 4.52 and 4.53 Bevel the area of the posterior palatal
seal toward the palate with a sharp scalpel.
Figure 4.51 Add more compound to the posterior palate,

temper, and reinsert the tray.
procedure is done with the lower tray. The space for the
impression material will now be maintained by the border
molding. The compound is tapered toward the inside of
the tray so it will not irritate the mouth. If a piece of com-
pound breaks off at this point, more compound must be
applied and border molded in that area. The compound Figure 4.54 Carefully scrape the tray to completely remove
that is left on the tray should provide space to do this. all wax.
4.3 Prepare the Surface of

the Impression Tray for the Final
Impression
Ensure that the impression material will bond securely

with a custom tray by applying a thin coat of adhesive to
the inner surface of the tray. Adhesives are particularly for-
mulated to match a specific impression material and are
not to be substituted for a different impression material.
1) Manage the adhesive properly. Although the tray
adhesive bottle has a brush attached to the lid, pour a
small amount of tray adhesive (about a teaspoonful)
into a paper cup to avoid contaminating any that is left
in the bottle. This can be further poured in small
Figure 4.55 Pour a small amount of adhesive into the
amounts into the impression tray to facilitate its appli- impression tray.
cation (Figure 4.55). Immediately replace the cap on the
bottle to prevent the adhesive from drying up.
2) Use a disposable brush. Use a disposable brush to
paint the adhesive on all internal surfaces and the exter-
nal surface just below the tray border (Figure 4.56). A
benda-brush can be used for this purpose but a pressure
indicator paste (PIP) brush will do the job in less time.
Paint a thin coat of adhesive on the tray so that it will
dry in a short period of time. Paint on enough to cover
the area where the wax spacer was removed and the
surrounding compound.
3) Allow the adhesive to dry. This may take several min-
utes. The adhesive must be totally dry and thin before
the impression is made. If it is not dry, or too thick, the
impression will separate from the tray when it is
removed from the mouth. The impression cannot just
be pressed back into the tray with the hope that it will
still be accurate. The adhesive must also be over the bor- Figure 4.56 Spread adhesive with a small disposable brush
der of the tray by about 5 mm so that the impression to all internal surfaces and to external surfaces just below the
material will bond to it in this area. tray border.
41
The Final Impression
5.1 Different Types of Impression set up on the mixing tube interface of the container or a
Materials and Their Useage lubricant was placed by the manufacturer (see the dark
spot surrounding the dark green). Once this is done, lock
There are many different types of impression materials the mixing tube in place on the mixing gun.
that are used to make final impressions for completely Squirt the impression material into the tray (Figure 5.2).
edentulous arches. All have their redeeming qualities but Continue to do this by adding to the existing material a lit-
they also have their limitations. We will discuss the two tle at a time until the tray is filled. If you remove the point
most popular materials in use currently. of the mixing tube from the tray and move to another spot,
One material commonly used for complete denture start by placing the tip into an area that is covered by the
impressions is medium‐viscosity, auto‐mix polyvinylsilox- impression material to prevent incorporating air into the
ane. This material comes in various colors, depending on mix. Use the tip of the mixing tube or a tongue blade to
the manufacturer, and is also very popular for making spread the mixed impression material or (Figure 5.3) so it
impressions for fixed prostheses. The reasons why many lightly covers the entire inner surface of the tray and
dentists use this impression material include its long work- includes the area over the borders of the tray.
ing time (2–4.5 minutes), short setting time (3–7 minutes), Another option, especially for the budget‐conscious den-
and its simple auto‐mix system. It has good tear strength, tist, is a polyvinylsiloxane impression material that comes
flow, and reproduction of surface detail, and is highly elas- in two tubes of different sizes. This is also marked injection
tic for easier removal around undercuts with negligible dis- type on the tube, but it requires a separate injection syringe
tortion. It can be repoured if a resilient border molding is to be used in this manner and this is not necessary when
used for up to one week. making complete denture impressions. Equal lengths of
As with any other dental material, this one has a few polyvinylsiloxane impression material are expressed onto a
negative qualities, including its inherent hydrophobic mixing pad and mixed by hand (Figure 5.4) and loaded into
nature, although recent advances have developed more the tray (Figure 5.5).
hydrophilic products. This hydrophobic quality requires a Another impression material that is very popular, espe-
wetting solution to be used when pouring casts because its cially with older, more seasoned dentists, is light‐bodied,
surface tension qualities will inhibit the flow of the liquid low‐viscosity, polysulfide rubber base material. This is only
stone over its surface and this tends to create bubbles. It is available in two tubes of different sizes. It is mixed on a
moderately more expensive in auto‐mix cartridges than mixing pad as described in the previous section. The rea-
hand‐mix types, although hand‐mix tubes are also availa- sons for its popularity include its long working time (4–7
ble for the economy‐conscious dentist. It can be very runny, minutes), good tear resistance, easy flow, and ability to pre-
especially if the low‐viscosity product is used, and will tend cisely reproduce surface detail. It also has high flexibility
to flow out of the tray into the patient’s mouth, especially that allows it to be easily removed from undercuts, is low
when the maxillary impression is being made. cost, and can be repoured if a resilient border‐molding
If an auto‐mix system is used, assemble the components material is used. Some of its disadvantages are that it is
of the auto‐mixer by first placing the cartridge containing very messy, and clothing touched by it will be permanently
the impression material on the auto‐mixer gun. Squirt out stained. It also can cause an allergic reaction in certain
a small amount onto the pad (Figure 5.1). This is important latex‐sensitive patients. This is the main reason for the
as there is always a small amount of the material that has decline in its popularity in recent years.
Whichever impression material is used, one must weigh its have some excess left over after the tray is loaded. These are
advantages against its disadvantages. Even if a certain impres- placed on a mixing pad that has been secured to the bench
sion can be poured over an extended period or for several top with masking tape. Three tongue blades are used to mix
pours, this does not excuse the dentist from doing everything the impression material (one to start the mix, one to finish
possible to make sure the first pour is accurate and well the mix, and one to load the tray). The catalyst is picked up
condensed. with the tongue blade first.
When using a hand‐mixed impression material, use Blend the catalyst with the base material, using a swirling
enough base and catalyst (three lengths about 6 in. each) to motion with the tongue blade. Tongue blades are used
because they are disposable and there is no cleaning up after
using them. Use a second blade to blend the mix using just
the tip of the tongue blade to mix the material. Use only a
small part of the tongue blade to mix the material and throw
it out after the impression material is heaped in a pile.
To prevent air bubbles, use only a small amount of impres-
sion material at a time to fill the tray, starting from the distal
of the tray and filling the tray progressively from that point until
you reach the distal of the other side. Add each application to
an area that has already been filled, and then push it forward to
cover more of the tray. This will prevent incorporation of air
into the mix (bubbles). Load the tray in this manner so that
all areas that will be part of the impression are covered
completely or they will not be included in the impression.
5.2 Making the Mandibular

Impression for a Complete Denture
The tray is placed in the mouth by engaging one side of the

Figure 5.1 Squirt out a small amount of impression material mouth with the tray, pulling the cheek on the opposite side
onto a mixing pad before loading the tray. of the mouth to provide access, and then rotating the tray
Figures 5.2 and 5.3 Squirt impression material into the tray to completely fill it.
The Final Impression 43
the gap. Hold the impression in place for 6–8 minutes with
the fingers while the lip and cheek are lifted or until it is
fully set.
The impression should be an accurate representation of the
mouth, with the vestibules not too wide and without pressure
spots over critical areas. The pressure spots seen in the impres-
sion in Figure 5.6 would require relieving the denture in these
areas or they would result in sore spots in the mouth.
A good mandibular impression will be bubble free, have
narrow borders, and have impression material of even thick-
ness throughout (Figure 5.7). It will cover the retromolar
Figure 5.4 As an alternate method, express equal lengths of

polyvinylsiloxane impression material onto a mixing pad and
mix it by hand.
Figure 5.6 Inspect the impression for show-through spots

which would require relieving the tray and remaking the
impression.
Figure 5.5 Use a tongue blade or broad, flat spatula to load

the tray with impression material.
into place. For the lower impression, stand to the side and
front of the patient while inserting the tray. This allows the
use of the fingers to manipulate the soft tissue while hold-
ing the tray in place. The tray must be held firmly in place
during the entire impression‐making procedure, otherwise
folds and/or thin areas of flash will occur in the impres-
sion. Never rely on the patient to hold the tray!
Muscle trim the lingual area by having the patient extend
their tongue forward over the handle, then to the left, and
finally to the right. The straight‐forward position is done
Figure 5.7 Inspect the mandibular impression to ensure that it
first to establish a single recording of the frenum, and then is bubblefree, with narrow borders, and even thickness of
any movement to the left and right positions just widens impression material throughout.
pad and retromylohyoid areas with good registration of all

frenula and will accurately record but will not be overex-
tended in the labial flange or lingual frenum areas.
5.3 Making the Maxillary

Impression for a Complete Denture
With the patient is seated in the upright position, approach

the patient from the 11 o’clock position if you are right‐
handed or from the 1 o’clock position if you are left‐handed.
This allows the tray to be seated with the fingers pointed
up, which makes it easier to grasp the lip and cheek to
effect muscle trimming of the impression (Figure 5.8).
When seating the tray in the mouth, it is wise to have a
mouth mirror handy to assist in pulling out any impression
material that is expressed from the rear of the tray. While
seating the tray first in the rear may lessen the amount of
impression material that goes toward the back of the tray, it
also increases the chance of entrapping air in the palate, Figure 5.9 Pull the lip and cheek down to mold the impression
material over the flange areas.
particularly in the case of a highly arched palate.
The lip and cheek are pulled down to mold the impres-
sion material over the flange areas and tightly adapt it to
the compound during the entire impression process
(Figure 5.9). The patient can be asked to assist by pursing
their upper lip. Light pressure is kept on the tray the entire
time the tray is in the mouth (Figure 5.10). The patient
should not be expected to hold the tray in place as they will
not be able to hold it in the correct position.
Figure 5.10 Have the patient purse their upper lip to assist in
border molding the anterior facial area of the impression.
If an impression shows a labial flange area that is too thick

or there is show‐through of border molding on the buccal
flange, this area is noncritical to the success of the dentures.
If an impression shows a buccal flange area that is slightly
Figure 5.8 Seat the maxillary tray with the fingers pointed up, too thick or the only show‐through is in the posterior palate,
so the lip and cheek can be manipulated to effect muscle these are also noncritical areas. Areas of the maxillary
trimming of the impression. impression that would be considered compromised and
The Final Impression 45
Figure 5.11 View the maxillary impression immediately after

Figure 5.13 Paint a suitable adhesive on the posterior palatal
removal from the mouth to determine its accuracy.
area and add a small amount of higher viscosity impression
material to form a functional posterior palatal seal.
Figure 5.12 Trim any excess impression material from the Figure 5.14 Reinsert the impression in the mouth and repeat
posterior palatal area. the process until a neat and effective seal is produced.
would require another impression to be made, are the midpalatal area in a butterfly pattern, then inserting the impres-
dle of the palate (especially if there is a palatal torus present) sion back in the mouth. This can also be done by painting a
and the maxillary tuberosity areas. The posterior palate is suitable adhesive in the posterior palatal area (Figure 5.13)
not a critical area if a show‐through occurs, because that and adding a thicker viscosity impression material in only
area will be covered by a functionally generated posterior this area. The impression is held in place for a few minutes
palatal seal. Figures 5.11 and 5.12 show a more ideal maxil- and the patient is asked to say “Ahhh” a few times. Successful
lary impression immediately after removal from the mouth establishment of an effective seal will become apparent as
(Figure 5.11) and after the excess impression material is the impression becomes difficult to remove from the mouth.
trimmed from the posterior palatal area (Figure 5.12). The palatal seal area is inspected, and any overextensions
Once the maxillary impression has been approved and are removed with a sharp knife, then the impression is rein-
trimmed, a functional posterior palatal seal can be easily serted in the mouth and the process is repeated until there is
made by applying mouth temperature wax to the posterior a neat and effective seal (Figure 5.14).
47
Boxing and Pouring a Final Impression
A final impression is boxed and poured to contain the stone (Figure 6.4). This will form the land area of the cast,
and allow it to set with the tissue surface down toward the which should be established at about 4 mm width
impression. This will form a denser, more accurate cast on and about 3 mm height below the border to allow for
the tissue surface as any air bubbles in the mix will rise trimming. If an area is deficient, soft wax can be
toward the surface that is the base of the cast. This method added and shaped to fill the defect after the gypsum
also requires only one pour. A master cast should never be has set (Figure 6.5).
poured by the two‐pour method or it would be weak and 7) After the plaster/pumice mix has set, it is removed
fracture during the packing procedure required to process from the plastic sheet and trimmed to the desired size
a complete denture. (about 4 mm from the edge of the tray) on the model
The following series of pictures outlines the correct pro- trimmer. The acrylic handle will be trimmed down
cedures for boxing and pouring a master cast. also, allowing an even reduction of the base.
8) If there are any defects in the plaster/pumice base,
1) A band of sticky wax is placed around the entire
they are corrected with a thin mix of plaster/pumice.
periphery of the impression (Figure 6.1).
The plaster/pumice mixture is painted with petrola-
2) Enough rope wax is affixed to the sticky wax to serve as
tum or filled in with wax (Figures 6.6 and 6.7) and
a guide to position the plaster/pumice mix or putty the
secured to a rigid plastic or metal plate with sticky
correct height on the impression (Figure 6.2).
wax.
3) A 50/50 mixture of plaster/pumice mix is placed on a
9) A hot waxing instrument and/or a Hanau torch is used
rigid plastic sheet.
to smooth the wax (Figure 6.8).
4) The tray is set down in the plaster/pumice mix with
10) A box of boxing wax is formed around the impression
the impression side up (Figure 6.3). The plaster/pum-
and its plaster/pumice base (Figure 6.9).
ice mix extends up around the tray and is smoothed to
The boxing wax is sealed together and to the plastic
be even with the rope wax. This will support the
sheet with sticky wax and utility (rope) wax
impression when it is boxed and poured and prevent
(Figure 6.10). The wax rim is extended to be at least
the stone from leaking out. Flowing hot wax around
13 mm above the impression to allow enough thickness
the edge of the bead and wall of the boxed area solidi-
for the base of the cast.
fies the seal.
11) The boxed impression is filled with yellow stone
5) The plaster/pumice mixture is smoothed, especially in
(Figure 6.11), since the processed denture must be
the lingual area of the mandibular impression where
removed by sectioning the cast from the acrylic den-
the tongue area is filled in and flattened.
ture base. Pink stone is too hard, increasing the risk of
6) The wax is shaped and smoothed around the periph-
breaking the denture.
ery of the impression with a hot #7 wax spatula
Figure 6.1 Place a band of sticky wax around the entire
periphery of the impression.
Figure 6.4 Shape and smooth the wax around the periphery of
the impression.
Figure 6.5 Add soft wax and shape it to fill a defect after the
gypsum has set.
Figure 6.2 Affix enough rope wax to the sticky wax to serve as
a guide to position the plaster/pumice mix or putty the correct
height on the impression.
Figures 6.6 and 6.7 Paint the plaster/pumice mixture with

Figure 6.3 Place the tray in a plaster/pumice mix with the petrolatum or fill it in with wax and secure it to a rigid plastic or
impression side up. metal plate with sticky wax.
Figures 6.6 and 6.7 (Continued) Figure 6.10 Seal the boxing wax together and to the plastic
sheet with sticky wax and utility (rope) wax.
Figure 6.8 Use a hot waxing instrument and/or a Hanau torch

to smooth the wax.
Figure 6.11 Fill the boxed impression in with yellow stone.
Figure 6.9 Form a box of boxing wax around the impression

and its plaster/pumice base. Figure 6.12 Peel off the boxing wax after the stone sets.
12) After the stone sets, the boxing wax is peeled off
(Figure 6.12) and the cast is soaked with the impres-
sion and base in hot water (Figure 6.13)
13) The land area of the master cast is finished by
reducing its height to 2 mm from the depth of the
vestibule all around the border. Do not use the red‐
handled compound knife or a scalpel for this but
use a sharp knife with a stiff blade that will not
break.
14) The cast is trimmed on the model trimmer set to cut at
a 90o angle so that the land area is 4 mm in width.
15) The base of the cast is reduced on the model trimmer
until it is 13 mm thick at its narrowest point.
Figure 6.13 Soak the cast, the impression, and base in hot water.
51
Base Plates and Occlusion Rims
The base plate is made by a method similar to making a (Figure 7.7) and cured for three minutes in the Triad
custom tray. The main differences are that the cast must conditioning unit (Figure 7.8).
have all undercuts blocked out that would prevent the 4) The record base is removed from the cast and placed
base plate from being easily removed and replaced on in the curing unit with the intaglio side up for an
the master cast without causing any damage to the cast. additional two minutes (Figure 7.9). A quick look
If the cast were to be damaged, a new impression would will show where the Triad material extends onto the
have to be made. Base plate wax is used conservatively to land area (Figure 7.10).
block out the undercuts. A surveyor is a useful tool in 5) A cut is made in the mandibular base plate in the
placing the proper amount of wax in the right places. If tongue area (Figure 7.11). Triad is adapted to the
too much wax is used to block out the undercuts, the master cast as was done with the maxillary base plate,
base plate will be overcontoured, and its retention but a section is removed from the tongue area after
reduced in the mouth. the Triad is adapted to the ridges (Figure 7.12). The
same steps are followed in processing the mandibular
base plate as were used with the maxillary base plate.
6) The wax used to block out the undercuts is removed.
7.1 Fabricating Base Plates 7) The accuracy of the fit is checked. When the base
and Occlusion Rims plate is placed back on the cast, there is always a lit-
tle bit of distortion. This is most noticeable in the
1) Any deep undercuts are blocked out with wax palate, manifesting as a slight opening between the
(Figure 7.1). Excess wax is trimmed off. The model is cast and the base plate in the middle of the palate
painted with tinfoil substitute, petroleum jelly (Figure 7.13). This is known as “processing error”
(Vaseline®), or Triad® Model Release Agent (Figure 7.2). and is anticipated.
2) Triad base plate material comes as a soft, pliable 8) The Triad is washed to remove the air barrier coating
sheet in a sealed plastic pouch (Figure 7.3). One and all flash is trimmed off.
thickness is adapted to fit the cast by pressing it down 9) Any excess thickness is removed, and all borders are
in the palate first, then, while holding the thumb in smoothed.
the palate, the Triad is molded down over the vesti- 10) To make an occlusion rim, a piece of base plate wax is
bules (Figure 7.4). Any excess is trimmed off by press- formed into a tightly compressed wafer about 10 mm
ing against the sharp border of the land area with a wide and 6 in. long (Figure 7.14). A sheet of base
thumb (Figure 7.5). plate wax is heated in a water bath or over a Bunsen
3) Care is taken to not thin the Triad in the palate of the burner and folded several times while it is pressed
upper and the lingual of the mandible where it is together. Preformed wax rims should not be used as
being held in place by the thumb (Figure 7.6). The they are softer and will easily distort when recording
base plate should fill the vestibules and is not trimmed the jaw relationship.
back as was done with the tray. When it has the cor- 11) An occlusion rim is formed by bending the wax to fit
rect form, it is painted with Triad air barrier coating the base plate (Figures 7.15–7.17).
Figure 7.1 Any deep undercuts are blocked out with wax.
Figure 7.4 One thickness of wax is adapted to fit the cast by

pressing it down in the palate and molding it over the vestibules.
Figure 7.2 The model is painted with tinfoil substitute,

petroleum jelly (Vaseline), or Triad Model Release Agent.
Figure 7.5 Any excess is trimmed off by pressing it against the

sharp border of the land area.
Figure 7.6 Care is taken to not thin the Triad in the palate of
Figure 7.3 Triad base plate material comes as a soft, pliable the upper and the lingual of the mandible where it is being held
sheet in a sealed plastic pouch. in place by the thumb.
Base Plates and Occlusion Rims 53
Figure 7.10 Triad material extends onto the land area.
Figure 7.7 When it has the correct form, it is painted with Triad
air barrier coating.
Figure 7.11 A cut is made in the mandibular base plate in the

tongue area.
Figure 7.8 The Triad is cured for three minutes in the Triad

conditioning unit.
Figure 7.9 The record base is removed from the cast and
placed in the curing unit with the intaglio side up for an Figure 7.12 Triad is adapted to the master cast and a section is
additional two minutes. removed from the tongue area.
Figure 7.13 Curing distortion is most noticeable in the palate,
manifesting as a slight opening between the cast and the base
plate in the middle of the palate.
Figure 7.14 Mold a piece of base plate wax into a tightly compressed Figures 7.15–7.17 (Continued)
wafer about 10 mm wide and 6 in. long to make an occlusion rim.
Figure 7.18 A glass eyedropper can be used to apply melted

wax to seal the occlusion rim to the base plate.
12) A thin layer of sticky wax is flowed over the area of the
base plate overlying the crest of the ridge. The rim is
luted to the base plate with a hot instrument. Wax is
added to lute the rim to the base plate. A glass eyedrop-
per can be used to apply melted wax to seal the occlu-
sion rim to the base plate (Figure 7.18). A broad spatula
is heated with the Bunsen burner and used to contour
the facial and lateral surfaces of the occlusion rim
(Figure 7.19). This same instrument is used to flatten
the occlusal surfaces of the wax rims (Figure 7.20).
13) The excess wax is cut off from the ends of the rim. The
rest of the wax rim is trimmed to the proper width. In
the lab, the widths of the maxillary and mandibular
occlusion rims are adjusted to equal 10 mm posteriorly
and 8 mm anteriorly. This would provide enough wax
to allow the rims to be modified to conform to the
patient’s facial contours as dictated by the relationship
of the labial and buccal surfaces of the wax rim to the
Figures 7.15–7.17 An occlusion rim is formed by bending the patient’s lips and cheeks. The distal ends of the maxil-
wax to fit the base plate. lary rim are trimmed to a point about 6 mm short of
Base Plates and Occlusion Rims 55
the distal border of the base plate and at about a 45°

angle (Figure 7.21). The mandibular rim will end at a
point two‐thirds of the way up the retromolar pad. A
line is marked on the occlusal surface of the wax to
indicate the crest of the ridge from the canine emi-
nence to the retromolar pad (Figure 7.22).
14) The height of the maxillary rim is 22 mm in the ante-
rior (A) and 18 mm in the posterior (B) (Figure 7.23).
The height of the mandibular rim is at a point two‐
thirds up the retromolar pad posteriorly (C) and
18 mm from the depth of the vestibule anteriorly (D)
(Figure 7.24). Note that these dimensions are totally
arbitrary, and the rims must be adjusted in the
patient’s mouth to fit the arches.
Figure 7.21 The distal ends of the maxillary rim are trimmed
to a point about 6 mm short of the distal border of the base
plate and at about a 45° angle.
Figure 7.19 A broad spatula is heated with the Bunsen burner

and used to contour the facial and lateral surfaces of the
occlusion rim.
Figure 7.22 A line is marked on the occlusal surface of the wax

rim on the mandible to indicate the crest of the ridge from the
canine eminence to the retromolar pad.
Figure 7.20 A broad spatula is used to flatten the occlusal Figure 7.23 The height of the maxillary rim is 22 mm in the
surfaces of the wax rims. anterior and 18 mm in the posterior.
Clinically, the labial surfaces of both the maxillary and

mandibular occlusion rims are adjusted to fit the patient’s
mouth and provide the desired support for the lips and
cheeks, and the anterior height is determined by having
the patient make fricative sounds.
Once the buccal and labial contours are established in
the patient’s mouth, the midline, the cuspid lines, and
the high lip line are recorded on the maxillary occlusion
rim to facilitate orientation of the teeth. In the lab, this is
done by using the point that is the center of the vesti-
bules at the midline. Record this point onto the land area
by laying a tongue blade on the cast over this mark on the
land area and marking where the tongue blade crosses
the land area on both sides. With the tongue blade in
Figure 7.24 The height of the mandibular rim is at a point place, the labial surface of the wax rim is reduced to this
two-thirds up the retromolar pad posteriorly and 18 mm from point.
the depth of the vestibule anteriorly.
57
Adjusting Wax Rims to Fit the Patient
Before mounting a mandibular cast for a clinical patient, d) The wax rim is adjusted so that it is parallel to the
we must first adjust the wax rims to fit the patient. A cen- ala–tragus line.
tric relation record must be made to mount the mandibular e) A tongue blade running from the ala of the nose to
cast as explained in the following procedures. the tragus of the ear is used to verify that the Fox
occlusal plane analyzer is parallel to that line
1) Establish the anterior height of the maxillary rim.
(Figure 8.2).
a) The maxillary rim is adjusted by establishing the
2) Once the height and configuration of the maxillary rim
contours that support the labial and buccal face form.
are established, the mandibular wax rim can be
b) The anterior height of the maxillary rim is estab-
adjusted. No other adjustments are made to the maxil-
lished so that it is 1–2 mm below the resting lip. This
lary wax rim when adjustments are being made to the
height is confirmed by having the patient pronounce
mandibular wax rim. A light dusting of adhesive pow-
words that have fricative sounds (55, any words with
der sprinkled on the intaglio surface will help hold the
F and V sounds). Have the patient count from 50 to
base plate in place during the record‐making proce-
60 and watch closely when they say 55.
dures (Figure 8.3).
c) The wax rim is adjusted so that it is parallel to the
interpupillary line (Figure 8.1).
Figure 8.3 Sprinkle a light dusting of adhesive powder on the

intaglio surface of the base plate to help hold it in place during
the record-making procedures.
Figure 8.1 Adjust the wax rim so that it is parallel to the

interpupillary line.
Figure 8.2 Use a tongue blade to verify that a Fox occlusal

plane analyzer is parallel to a line from the ala of the nose to
the tragus of the ear.
59
Using the Denar Facebow
Several brands of facebows can be used for making an 2) A well‐fitting base plate and accurate cast.
accurate facebow registration. Each will have its own limi- a) The base plate must fit the cast.
tations, degree of difficulty or ease of usage, and other b) The base plate must fit the patient.
advantages or disadvantages. The Denar® Slidematic face-
bow can make an accurate recording of the relationship of
the maxilla to the external ear canal. This facebow is 9.1 Steps in Making a Facebow
classed as an arbitrary‐type facebow because it uses the
Transfer
ears instead of the actual hinge axis as two points of refer-
ence and the ala of the nose as a third point of reference.
1) Attaching the record base to the bite fork
An adapter platform is provided (marked with an H) to
(Figure 9.1).
mount the facebow record on the Hanau™ Wide‐Vue artic-
a) The patient is seated in an upright position.
ulator. This gives the dentist or dental laboratory techni-
b) The patient’s midline is recorded on the anterior of
cian the ability to position the teeth of complete dentures
the maxillary wax rim.
with acceptable accuracy to provide acceptable esthetics
c) The bite fork is heated over the Bunsen burner.
and function. Several conditions must be met if this record-
d) The bite fork is embedded in the wax rim so that the
ing is to be accurately transferred to the articulator.
notch on the bite fork is in line with the midline
The accuracy of a facebow transfer is predicated upon
recorded on the wax rim.
the following factors.
e) The wax is cooled under cool running water. The
1) An accurate facebow registration, which depends upon bite fork will then be firmly attached to the wax rim.
the following aspects. f) If a perforated bite fork is used, an index is cut in the
a) The steps of making the facebow record and the bite posterior regions of the wax rim and polyvinysilox-
registration should not be combined as one. ane (PVS) or another recording medium is used
b) The facebow record should be transferred to the between the wax rim and the bite fork. Since the
articulator before the wax rims are altered and the dimensions of the wax rim have no bearing on the
bite registration is made. facebow transfer, the wax rim does not have to be
c) The record must allow easy and accurate placement adjusted in the mouth until after the maxillary cast
and removal from the mouth. The orientation of the is mounted.
wax rim has no bearing on the accuracy of the face- 2) Positioning the facebow on the patient (Figures 9.2
bow record and serves only as a means of attaching and 9.3).
the bite fork to the base plate. a) The set‐screw is loosened on the facebow itself to the
d) All set‐screws are tightened to the point that they point that the parts of the facebow slide easily and
prevent movement of the record during transfer allow it to be comfortably positioned in the patient’s
from the mouth to the articulator. ears.
e) The base plate is securely fastened to the bite fork. b) The ear pieces of the facebow are placed in the ears
f) A third point of reference is established (in this case, bilaterally (a) and the set‐screw tightened (b).
the ala of the nose). c) The patient holds the facebow in his ears.
g) The pointer of the facebow (f) is positioned so that it

points at the ala of the nose and the set‐screw (g) is
tightened.
h) The thumbscrew in the retainer marked #1 (h) is
tightened.
i) The thumbscrew marked #2 (i) is tightened to lock
the elements in place.
3) Removing the facebow from the patient.
a) The entire assembly is removed from the patient’s
mouth.
b) The screw fixing the facebow fork to the facebow is
loosened and the bite fork is removed (Figure 9.4).
4) Placing the mounting jig on the articulator.
a) The Hanau mounting adaptor (marked with an H) is
mounted on the lower member of the articulator
(Figure 9.5).
b) The facebow transfer is placed into the mounting jig
Figure 9.1 Attach a maxillary bite fork to the base plate. and the set‐screw is tightened to fix it in place
(Figure 9.6). Depending upon the mounting jig used
b for the transfer, the fork will dogleg left or right
based on the arm of the jig, otherwise there may be
some interference when mounting.
5) Preparing the cast.
a) An “X” is cut in the base of both casts about ¼ inch
deep (Figures 9.7 and 9.8).
d
a
c
f h
i
Figures 9.2 and 9.3 Position a facebow on the patient.
d) The transfer assembly is held so that the numbers

are facing the dentist and are right side up.
e) The loop marked #2 on the transfer jig (c) is loosely
positioned over the shaft of the facebow fork and the
base plate is put in place in the mouth.
f) The vertical shaft of the transfer jig is inserted in the
Figure 9.4 After all thumbnuts are thoroughly tightened,
slotted hole in the facebow (d) and the set‐screw is remove the entire transfer assembly from the patient’s mouth
tightened (e). and from the facebow.
Using the Denar Facebow 61
b) A small bit of Vaseline is placed in this “X” b) A little bit of mounting plaster is placed in the “X” in
(Figure 9.9) and around the border (about ¼ inch the base of the cast and a little bit is placed on the
thick) and the casts are then soaked in water. mounting plate (Figure 9.10).
6) Mounting the maxillary cast. c) The articulator is closed (Figure 9.11).
a) The maxillary cast is mounted to a mounting plate
on the upper member of the articulator.
Figure 9.5 Mount the Hanau mounting adaptor (marked with Figure 9.6 Place the facebow transfer into the mounting jig
an H) on the lower member of the articulator. and tighten the set screw to lock it in place.
Figures 9.7 and 9.8 Cut an “X” in the base of both casts about ¼ in. deep.
Figure 9.9 Place a small bit of Vaseline in this “X.”

Figure 9.11 Close the articulator and gently tap the upper
member to close it completely until the pin touches the guide
table firmly.
Figure 9.10 Place a little bit of mounting plaster in the “X” of

the cast and a little bit on the mounting plate.
Figure 9.12 Once the plaster has set, trim off the excess and
smooth the mounting.
d) The upper member of the articulator is gently tapped
to close the articulator until it seats firmly against f) More mounting plaster is added to give the mount-
the incisal guide table. ing some form.
e) A rubber band is placed between the upper and g) The mounting plaster is allowed time to set and the
lower members of the articulator, passing around excess mounting plaster is trimmed off and the
the front of the guide table and the set‐screw on mounting is smoothed (Figure 9.12).
the upper member. A “T” support or other device h) The maxillary base plate is removed from the bite
should be used to support the maxillary cast dur- fork and an interocclusal record is made in the
ing mounting. The rubber band is used to reduce mouth.
distortion caused by extreme expansion of the
mounting plaster.
63
10
Mounting Maxillary Casts on an Articulator
10.1 Adjusting the Articulator guide table. If the pin is set on zero and contacts this
for Mounting the Transfer horizontal line, the guide table can be moved to any
position without affecting the vertical dimension.
First, the orbitale third point of reference plane indicator d) The lateral wings of the guide table are set at zero
that is just behind the guide pin on the upper member of and left at this setting (C) (Figure 10.4).
the articulator is removed (Figure 10.1). This indicator is e) The lateral condylar guidance is set by loosening the
not used with this facebow. knob on top of the articulator and setting the guide
at 15o (D) (Figure 10.5). The lock nut at the back of
the horizontal condylar guide is loosened and the
10.1.1 Setting the Incisal Guide Pin guidance angle is set at 30o for anatomical teeth by
of the Articulator at Zero tightening the lock nut (E) (Figure 10.6). These arbi-
trary settings are universal for all patients. For
Always leave the incisal guide pin set at zero. The nut in
greater accuracy, for a clinical patient, these settings
front of the upper member of the articulator is loosened,
will be determined by recording them on the patient.
the pin is slid so that the dark line is positioned at the top
f) The mounting plate is attached to the upper member
of this member, and the nut is tightened securely.
of the articulator. There must be no wobble of the
plate when the set‐screw is completely tightened.
10.1.2 Locking the Articulator Condyles
in Centric Relation
10.2 Mounting the Transfer Jig
The set‐screw on the condylar element is loosened, the
on the Articulator
condylar ball is pushed back flush with the rear wall of the
condylar fossa, and it is locked in centric relation position
1) The set‐screw is loosened on the transfer jig.
by tightening the set‐screw (Figure 10.2).
2) The vertical portion of the transfer assembly is placed in
1) Setting the incisal guide table so it is parallel with the the slot at the front of the transfer jig with all the num-
lower member of the articulator. bers facing toward the front (Figure 10.7).
a) The mark that is directly under the lateral guide set‐ 3) The set‐screw is tightened securely.
screw is placed at the zero mark on the base of the 4) The mounting jack is attached to the lower member of
incisal guide platform (A) so that the guide table is the articulator (Figure 10.8). The mounting screw is
parallel with the lower member of the articulator tightened securely.
(Figure 10.3). 5) The horizontal bar (that is on top of the jack stand) is
b) The guide table is positioned at the point where the positioned under the bite fork. The set‐screw is securely
guide pin hits on the horizontal line in the center of tightened on the jack stand.
its flat surface (B) (Figure 10.4). 6) The indexed wax rim of the base plate is placed in the
c) The lock screw under the lower member of the articu- index of the registration material on the facebow fork
lator is set. This line marks the axis of rotation of the (Figure 10.9).
Figure 10.1 Remove the orbitale third point of reference plane

indicator. Figure 10.3 Set the guide table set‐screw at the zero mark on
the base of the incisal guide platform (A).
Figure 10.2 Loosen the set‐screw on the condylar element,

push the condylar ball back flush with the rear wall of the
condylar fossa, and tighten the set‐screw.
Figure 10.4 (B) Position the guide table at the point where the
7) An “X” is cut in the base of the maxillary master cast guide pin hits on the horizontal line in the center of its flat
and it is placed in the mounted base plate (Figure 10.10). surface. (C) Set the lateral wings of the guide table at zero.
10.3 Mounting the Maxillary Cast 3) The guide pin is checked to ensure that it is set on zero
and the condylar ball is locked completely in the most
1) A mounting plate is attached to the upper member of posterior position of the condylar guide.
the articulator. The mounting screws are tightened 4) The index grooves in the base of the cast are lubricated
with finger pressure until there is no movement of the with petroleum jelly.
plate in that area. 5) A paper towel is soaked in water and placed in the con-
2) A piece of wide masking tape is placed around the base of tainment barrier to soak the cast and ensure a good
the dry cast to make a containment wall that surrounds bond between the plaster and the stone cast.
the border of the cast and allows a neat and easy mount- 6) Enough mounting plaster is placed in the containment
ing (Figure 10.11). At least 1 inch of the tape should barrier to make a pillar on top of the cast that covers
extend over the sides of the cast to ensure a good bond. the indices cut into the base of the cast.
Mounting Maxillary Casts on an Articulator 65
Figure 10.5 Set the lateral condylar guidance at 15o (D).
Figure 10.8 Tighten the mounting jack attached to the lower

member of the articulator.
Figure 10.6 Tightening the lock nut (E) to set the horizontal
condylar guidance angle at 30o (F).
Figure 10.9 Place the indexed wax rim in the index of the
registration material on the facebow fork.
Figure 10.7 Place the vertical portion of the transfer assembly
in the slot at the front of the transfer jig with all the numbers
facing toward the front.
Figure 10.12 Place enough mounting plaster in the

containment barrier to make a pillar on top of the cast.
7) The retention index grooves on the mounting plate are

filled with plaster.
8) The articulator is closed together and inspected to
ensure that there is enough mounting plaster between
Figure 10.10 Cut an “X” in the base of the maxillary master
the mounting plate and the cast.
cast and place it in the mounted base plate.
9) The top of the upper member of the articulator is gen-
tly tapped to ensure that the pin touches the guide
table.
10) Additional plaster is added if needed (Figure 10.12).
11) The mounting plaster is permitted to set until it
becomes hot to the touch. This verifies that it is suffi-
ciently hard to allow removal of the base plate and
occlusion rim from the maxillary cast. The jaw rela-
tions can now be recorded on the patient in centric
relation so that the mandibular cast can be mounted
on the articulator.
12) After this plaster has set, the bite registration phase is
ready to begin. The mounting is refined after the
patient leaves and the mandibular cast is mounted.
Figure 10.11 Place a piece of wide masking tape around the
base of the dry cast to make a containment wall.
67
11
Centric Relation Records
11.1 Objectives 11.3 Adjusting the Wax Rims to Fit

the Patient
1) To record centric relation.
2) To transfer that recording to the articulator. To make the bite registration and mount the mandibular
3) To mount the mandibular cast at the proper articulator casts, the following items must be available: the casts, the base
settings. plates with occlusion rims (which have been adjusted to fit
together accurately at the proper vertical dimension in centric
relation in the patient’s mouth), a bite registration material,
11.2 Definition
sticky wax, a splinting material (plastic or metal are best), and
of course the articulator with the mounted maxillary cast. The
Centric relation is the most retruded relation of the mandible
procedure for recording the jaw relationship is as follows.
to the maxilla when the condyles are in their most posterior
unstrained position in the glenoid fossa from which lateral
movement can be made, at any degree of jaw separation. 1) The mandibular rim is reduced bilaterally in the poste-
When a centric relation record is made. there are several rior regions so that there is adequate space for a bite reg-
requirements that must always be fulfilled. istration material (approximately 2 mm) (Figure 11.1).
2) Both rims are scored with a sharp knife to make V‐shaped
1) The mandible must be positioned in its correct horizon- cuts about 2 mm deep that cross in the middle of the cast
tal relationship to the maxilla. (Figures 11.1 and 11.2). These will ensure that registra-
2) Equal bilateral vertical contacts must exist between the tion of the bite will be stable in a lateral direction.
occlusion rims and the opposing recording surfaces. 3) A piece of Aluwax is softened over a flame and/or in hot
3) The ideal recording medium is a free‐flowing material water and placed on mandibular platforms by mounding
that will allow equalized pressure bilaterally. it up to a level of at least 3 mm above the occlusal plane.
4) The ideal registration material should be rigid and sta- 4) The patient is asked to place his tongue to the roof of
ble upon setting. Three such acceptable media are: his mouth and as far posterior as possible.
a) plaster (must be quick‐setting). 5) The patient is gently assisted to close in the centric
b) ZnOE Bite Registration Paste relation position and hold this position long enough to
c) Aluwax™. allow the Aluwax to harden.
5) Elastomeric recording media such as Take 1™, Regisil®, 6) The Aluwax should completely fill the maxillary
Blu‐Mousse®, etc. are not rigid enough to transfer the grooves (Figure 11.3).
measurements without allowing some distortion, 7) After the wax is completely hard, any excess wax is
although they are widely used because of their conveni- trimmed away from the registration area with a sharp
ence. Registrations made with these must be at least knife.
2 mm thick to have any chance of being accurate. 8) If Blu‐Mousse or Regisil or other elastomeric bite reg-
Whatever the recording medium used, the relation istration materials are used instead, the wax rims are
record must be capable of being separated and rechecked prepared in the same manner as described for Aluwax.
in the mouth and must be stable and recognizably accurate 9) A thickness of the registration material is placed higher
in the horizontal, vertical, and sagittal planes. than the wax plane on the mandibular cut‐out area.
10) Both record bases are removed (as a unit if possible).
Figure 11.1 Reduce the mandibular rim to accommodate the

Figure 11.3 Completely fill the maxillary grooves with Aluwax.
bite registration material.
Figure 11.4 Another option is to make an interocclusal

registration with Blu-Mousse.
Figure 11.2 Index both occlusion rims with a sharp knife to enough clearance for the mounting plaster. If the heels
make V-shaped cuts about 2 mm deep that cross in the middle are in contact between the casts, the land areas must
of the cast.
be reduced to the point that they are not in contact
with the opposing casts.
11) The maxillary base plate is placed on the maxillary 17) Figure 11.4 shows the interocclusal registration made
cast, which was previously mounted on the articulator with Blu‐Mousse. When using an elastomeric registra-
using a facebow transfer. tion material, the procedure is very much like that
12) The mandibular master cast is placed into the man- described previously for Aluwax. Adequate reduction
dibular base plate. of the mandibular rim is made so that there is enough
13) Sticky wax and pieces of plastic or tongue blade are space for a bite registration material (approximately
used to splint the two casts together. 2 mm). This is more critical when this elastomeric
14) The articulator is inverted. material is used than when using Aluwax. Note that if
15) The mandibular cast is gently placed into the mandib- the wax rims are not in intimate contact, the relation-
ular base plate. ship is not stable. If this is the case, the rims must be
16) The relationship is checked to see that it is stable, that adjusted so that they contact intimately, and a new reg-
the heels of the casts do not touch, and that there is istration must be recorded intraorally.
Centric Relation Records 69
18) The upper cast and its mounting are removed from the
articulator.
19) The bite registration is placed between the occlusion rims
and the two base plates are placed on their respective casts.
20) Fixation splints are affixed to the casts to secure the
bite registration in place. The registration index must
be completely stable before the casts are mounted to
insure accuracy.
21) A minimum of three splints are used to fix the casts
and the base plates in place securely. These can be
made with pieces of tongue depressor, although metal
or plastic strips are much better as they will not warp
when wet (Figure 11.5).
22) The maxillary cast with the attached registration index
including the mandibular cast is placed on the inverted
articulator and the mounting screw tightened securely
into the mounting plate.
23) The articulator is opened to allow enough access to
place the mounting stone.
24) The relationship of the retromolar pad or the hamular Figure 11.6 Close the articulator and inspect to insure that there
notch areas is checked to insure that there is no com- is no binding of the mounting plate with the containment wall
promise between them. If the heels of the casts touch, then fill this area with mounting stone.
the mounting is considered inaccurate and they will
need to be reduced.
25) The base of the mandibular cast is inspected to insure
that it is properly indexed and properly lubricated.
26) A piece of masking tape is placed around the cast to
form a containment barrier for the mounting stone.
Figure 11.7 Fill the containment barrier with a thin mix of

mounting stone.
The articulator is closed to insure that there is no bind-

ing of the containment wall with the lower member of
the articulator upon closing (Figure 11.6).
27) The containment barrier is filled with a thin mix of
mounting stone.
28) The stone is permitted to set fully.
29) The mounting is removed from the articulator.
30) The masking tape that forms the containment barrier
and keeps the cast clean is removed (Figure 11.8).
31) The wax and the fixation splints are detached, and the
casts are cleaned.
32) Excess mounting stone is trimmed off with a green‐
handled knife or a Buffalo knife. A red‐handled com-
Figure 11.5 Make splints to hold the parts of the interocclusal pound knife is not used for this as the blade can slip
registration together. and cause a serious cut to a finger or hand (Figure 11.9).
Figure 11.10 Use wet/dry sandpaper to smooth the cast under

running water.
Figure 11.8 After the stone sets, remove the masking tape
forming the containment barrier.
Figure 11.11 Inspect the casts and mountings to insure that

they are neat and clean.
Figure 11.9 Never use a red-handled compound knife or

scalpel to trim gypsum as a blade can break and cause an injury. surface of the stone should be very smooth and profes-
sional in appearance.
33) The mounting is checked, and any voids are filled with 38) The juncture between the cast and the mounting plas-
wet mounting stone. ter should be as close to 90° as possible (Figure 11.12),
34) The surface smoothness is further refined by using as this will enable the cast to be removed from its
wet/dry sandpaper to smooth it under running water mounting more easily and allow for a future remount
(Figure 11.10). after the complete dentures are processed.
35) The surface of the cast and mounting is inspected for 39) The articulator is cleaned, and the mounted casts
smoothness. replaced on the articulator.
36) There should be a definite demarcation line between 40) The articulator and the mounted casts are checked
the mounting and the cast. again to insure that they are free of any excess stone,
37) The casts and their mountings are inspected to insure that the pin is set on zero, and that the condyles are
that they are very neat and clean (Figure 11.11). The locked back in centric relation (Figure 11.13).
Centric Relation Records 71
41) If the pin and condyles were not set properly when the
casts were mounted, the lower cast must be removed,
the articulator reset, and the lower cast remounted.
42) The wax is replaced on the wax rims where it was
removed preparatory to making the bite registration
index (Figure 11.14). Accurate wax rims are a must
before teeth can be set.
Figure 11.12 Make sure the juncture between the cast and the
mounting plaster is as close to 90° as possible.
Figure 11.14 Replace the wax on the rims where it was

removed preparatory to making the bite registration index.
Figure 11.13 Set the guide pin on zero and lock the condyles
in centric relation to check and make sure the index seats
correctly between the wax rims, thereby proving the accuracy of
the mounting.
73
12
Selecting Proper Denture Teeth
Selecting teeth should not be a big mystery. While the patient members of their family had dentures and they came to
is in the chair, you have several things to work with. You have expect that this was a natural consequence of the aging
the shape of the face, the width of the nose, the height of the process. Maybe they expect the teeth in their new dentures
smile, the corners of the eyes, and the midline of the face. to look exactly like their natural teeth did when they were
These measurements must be recorded on the wax rim. With a young adult. Maybe they are a Class II skeletal relation-
these recordings, you have that information at your disposal ship and they always wanted to look like they were Class I.
when the patient is not in the chair and can set the denture Certainly, these are things that you need to know and
teeth to reflect the ideal positions for the patient. You should address prior to working with your patients and providing
also have their casts correctly mounted on the articulator. them with a new set of dentures.
Recording this information will become second nature to Check the wear patterns on existing dentures and check
easily select the right teeth for patients. Dentists must edu- for repair sites and relines (Figure 12.1). Ask the patient if
cate their patients and guide them to select the teeth most this was an immediate denture. It is obvious that the den-
suited to their situation, and then the patients must stand ture in Figure 12.2 was made as a temporary denture but it
by their decision. If a patient brings in a friend, relative, or may not always be this clear.
spouse, they all must receive the training. That way, the It is important to note that even if the patient claims to
patient, the patient’s friends and family, and the dentist can be satisfied with the denture that they are currently wear-
all be happy with the result. ing, they came in for some reason. A patient usually is not
The patient’s current set of dentures can provide a wealth aware that problems of instability and lack of retention are
of information. The wear patterns can indicate how the often related directly to the positions of the teeth in rela-
patient chews. They can indicate how well a patient is able tion to each other and to the positions and conditions of
to accept dentures, whether they gag easily, whether they the denture supporting structures.
are bruxers, the current tooth mold and shade, the color of The bottom line in setting teeth on dentures is that den-
the current denture base, how the denture teeth relate to ture teeth cannot be set to the same occlusion as natural
the teeth in the opposing arch, and in general provide a teeth, because anterior guidance is not acceptable in den-
good idea as to what success can be expected for the tures and is desirable in natural teeth or in arches restored
patients while wearing their new dentures. with fixed dental prostheses. It is generally a good idea to
Some of the first questions you should ask patients are explain to the patient that their natural teeth were lost
“How do you like your old dentures?,” “What changes would because the positions of the teeth and other conditions
you like to see in your new dentures?,” “Do you like the size, were not ideal and that dentures made with teeth in the
shape, shade, and position of the teeth in your old denture?,” same position as the natural teeth would not be expected to
and “How well do you expect to eat with your new den- be as successful as the natural teeth.
tures?” Their answers may astound you. These are only a Begin by measuring the width of the six maxillary ante-
start. If a patient seems very dissatisfied with their current rior teeth (the distance from distal of #6 to distal of #11),
dentures or brings in several other dentures, anticipate that measured on the curve (Figure 12.3). Measure the distance
the patient’s expectations for their dentures may be too high. from the mesial of the most forward premolar to the distal
It is important to uncover any unrealistic expectations of the most distal molar and compare this with the teeth on
that a patient may have regarding wearing dentures, and a card (Figure 12.4), then measure the height and width of
their philosophy toward having dentures. Perhaps many the maxillary central (Figures 12.5 and 12.6). This will give
Figure 12.4 Measure the width of the posterior teeth and

compare them to the width of posterior teeth on a tooth card.
Figure 12.1 Check existing dentures for wear patterns and for
repair sites and relines.
Figure 12.5 Measure the height of the maxillary central.
Figure 12.2 Some temporary dentures are obvious but others

can look like a final complete denture.
Figure 12.6 Measure the width of the maxillary central.
you an idea as to how well these teeth fit within the meas-
urements that you recorded on the wax rim while the
patient was in the chair. These measurements were the
high lip line and the canine lines. They are available in a
mold chart of the denture teeth and can be compared to the
marks recorded on the wax rims. Dental supply companies
will provide you with useful flexible rulers to enable you to
measure these distances.
Use the proper shade guide to go with the available
Figure 12.3 Measure the combined width of the six maxillary teeth. It is recommended that this shade guide be disin-
anterior teeth. fected with an appropriate cold sterilizing solution
Selecting Proper Denture Teeth 75
Figures 12.7 and 12.8 Compare the shade of the teeth in the old dentures to the shade tabs in the shade guide.
according to the manufacturer’s instructions. Caution:

chloride or iodophors, e.g. bleaches or solutions contain-
ing iodine, will damage the color of the shade guide and
should not be used to clean or disinfect it.
Compare the shade of the teeth in the old dentures to the
shade tabs in the shade guide (Figures 12.7 and 12.8). Ask
the patient if they like the color of the teeth in the old den- Width
ture. Most will want a lighter shade. The current trend
toward bleaching natural teeth has made unnaturally
white teeth appealing to many patients.
Choose a mold of teeth that complements the patient’s
face form. Tooth shapes are generally based on four forms,
square, triangular, tapering, and ovoid, and can be a combi-
nation of these forms as in square tapering, tapering ovoid,
triangular ovoid or square ovoid. The molds we have avail-
able are limited, so we must choose the one that is the best
match with the patient. Other variations of teeth may be
available from another manufacturer, but the cost of the Length
denture must be increased to reflect the difficulty of pur- Figure 12.9 The Trubyte Tooth Indicator helps determine the
chasing and resetting denture teeth to cover the increased correct mold of tooth based on facial form and size.
cost of the teeth and the loss of chair time and the lab bill.
Denture teeth manufacturers will supply you with picto- While the indicator is still on the face, observe the rela-
graphs (mold chart) and other helpful aids to make it easier tive straightness or curvature of the profile. Check three
for you and the patient to make the selection. points: the forehead, the base of the nose, and the point of
The Trubyte® Tooth Indicator (Figure 12.9) is a handy the chin. If these points are in line, the profile is straight. If
device to help determine the correct mold of tooth to fit the the point of the forehead and chin are recessive, the profile
patient based on facial form and size. Simply place the indi- is curved.
cator on the patient’s face, allowing the nose to come You should have one complete set of teeth in an anterior
through the center triangle. Center the pupils of the eye in mold guide and one complete set in a posterior mold guide
the eye slots and hold the indicator with its center line available for use in the clinic. These should never leave the
coinciding with the median line. Slide the side indicator clinic and should be kept in the sterilization/issue area.
bar until it touches the face and read the width of the upper Use the tooth selection chart and mold display to select the
central incisor in millimeters. Slide the bottom indicator teeth for your patient. Begin with the maxillary anterior
bar up until it touches the face immediately underneath teeth.
the chin with the lips at rest and read the indicated length A mold chart will have several suggested teeth that will
of the upper central incisor in millimeters. complement the maxillary anterior teeth you select. Once
the mold of anterior teeth has been selected, consult the use zero‐degree posterior teeth set in a monoplane set‐up
chart of selected articulations and mold combinations. for all Class II and crossbite dentures.
Determine the mold of mandibular anterior teeth and pos- Denture teeth come mounted in wax on a plastic or metal
terior teeth that are recommended to go along with the card (Figure 12.10). The maxillary anterior teeth have the
maxillary anterior teeth that you have selected. Be aware mold and shade listed on the front of the card as well as the
that this recommendation was based upon a patient with a brand of tooth. The teeth are arranged in the proper order,
skeletal Class I jaw relationship. A Class II patient would so do not remove the teeth from the card until you are set-
possibly require a smaller mold of mandibular anterior ting them on the base plate. The anterior teeth that are
teeth. most often switched by the student are the canines in the
Look at a organizational chart of representative molds. maxillary and the central and lateral incisors in the lower
These are provided usually at no charge from various anterior set‐up. Sometimes the maxillary posterior teeth
dental supply companies. There are also conversion are switched to the opposite side of the arch by inexperi-
charts available to advise the dentist of a close match to enced dental students. A thorough knowledge of basic
another company’s products. The organizational chart tooth anatomy is invaluable in preventing this error when
will indicate the height and width of a central incisor and setting teeth.
the combined width of the six maxillary anterior teeth Use the mold compatibility chart to pick all posterior
for a specific mold. These are displayed in real‐life dimen- teeth and the mandibular anterior teeth (Figure 12.11).
sions for your convenience and are listed by mold num- The mold of tooth is stamped in gold ink on the left side of
ber. It will also indicate the suggested mandibular mold the card in the Trubyte Bioform IPN teeth and the shade of
of tooth that goes with that maxillary teeth selection. The the tooth is stamped on the right side of the card in green.
width of the group of six anterior teeth is listed when the An easy way to verify the selection of the maxillary teeth
teeth are set flat and when they are set on a curve, as is to mark the midline and the canine lines on the ridge
would be expected with a patient. and transfer them to the land area of the maxillary master
There are different charts available from different manu- cast, then put a piece of soft rope wax or Triad® on the ante-
facturers. They all give you roughly the same information, rior ridge area of the cast and set the teeth in place
but the mold numbers are different. Make sure you consult (Figures 12.12 and 12.13). To avoid ruining the display in
the proper chart for the lab you are using. Compatibility the mold chart, use only the teeth from your on‐hand sup-
charts are useful but can only offer a certain degree of com- ply for this purpose. They will need to be thoroughly disin-
promise in the selection of teeth. fected before returning them to their card and placing
Whatever mold you are using, select the maxillary ante- them back in the cabinet.
rior teeth that best match the patient’s mold (old CD or Measure the width of the four mandibular posterior teeth,
natural teeth if available). Use the manufacturer’s chart to then measure the length available for setting the mandibular
determine the mandibular anterior teeth and all posterior posterior teeth from the distal of the canine back to the rise of
teeth that will be in harmony with those teeth. It is wise to the mandible at the start of the retromolar pad (Figure 12.14).
Teeth should never be set on the rise of the mandible as this
would cause instability of the lower denture.
Compare the mesiodistal width of the four teeth with the
Shade length of the mandibular posterior ridge (Figures 12.15–12.17).
MOLD Number
BioForm® IPN®
F B66
230M B66
Right Right Right Left Left Left
Canine Lateral Central Cantral Lateral Canine
230M B66
Figure 12.10 Denture teeth come mounted in wax on a plastic Figure 12.11 Pick the posterior teeth and the mandibular
or metal card. anterior teeth by consulting a mold compatibility chart.
Figure 12.15 Set the four mandibular teeth in soft rope wax to
determine if there is enough room for four teeth.
Figure 12.12 Put a piece of Triad on the anterior ridge area of

the cast and set the teeth in place.
Figure 12.16 Set two molars and one premolar and evaluate
the available room.
Figure 12.13 Evaluate the six anterior teeth from the facial
view.
Figure 12.17 Set one molar and two premolars and evaluate
the available room.
to be established in anatomical teeth and the second pre-

Figure 12.14 Measure the width of the four mandibular molar has more occlusal surface area than a first premolar.
posterior teeth. Teeth that are set on the rise of the mandible will create a
problem which allows the pressure on a tooth set on this
It is easy to see that the width of the four teeth is too wide for rise to displace the denture down the slope and move it
this area, so we will choose three to set in this area. Which anteriorly, so this practice is not recommended. It is a good
three will fit best and give the best posterior occlusion? idea to explain the reason for this to the patient who may
The second premolar and two molars are chosen because become concerned that they are not getting all the teeth
the molars are necessary for a proper compensating curve they are paying for.
Also remember to select a denture base acrylic that will If the posterior teeth come off the card, they have identi-
match the patient’s natural coloring as closely as possible fying dots on the mesial of the ridgelap areas of the teeth
(Figure 12.18). The COE‐LOR shades are usually reserved (Figure 12.19). One dot indicates the first molar or first
for African‐Americans but can be used if the patient bicuspid, two dots indicate the second molar (Figure 12.20,
requests this color. Any such request should be recorded in
the patient’s notes and the entry stating the reason for the
request must be signed by the patient to avoid future
problems.
Figure 12.18 Use a shade guide made for that purpose to

select a denture base acrylic shade that will match the patient’s
natural coloring as closely as possible.
Figure 12.19 Denture teeth have identifying dots on the

mesial of the ridgelap areas.
1 dot = 1st molar or bicuspid.

2 dots = 2nd molar or bicuspid.
Figure 12.20 One dot indicates the first molar or first bicuspid, Figures 12.21–12.23 Here are three different approaches to
two dots indicate the second bicuspid or the second molar. providing a denture on the same patient.
arrows) or second bicuspid. Of course, if the teeth must be they look. When the teeth are set for a wax try‐in of anterior
ground in the ridgelap area, this identifier is lost. teeth, all posterior teeth should also be set, and the dentures
Here are three different approaches to providing a denture festooned to their ideal form so that you can visualize the
on the same patient (Figures 12.21–12.23). Note the differ- esthetic value of the dentures and verify the vertical dimen-
ences in the setting of the teeth and the festooning. The same sion of occlusion. The patient will then sign an entry in the
mold of teeth was used in each case but note how different chart approving the anterior arrangement of teeth.
81
13
Setting Anterior Denture Teeth
1) When viewed facially, all maxillary anterior teeth are the base plate. Make a similar cut just distal to the
tilted mesially, with the lateral incisor inclined the canine point. Remove this section of wax in its entirety
most and raised about 1–2 mm above the plane (Figures 13.7 and 13.8).
(Figure 13.1). When viewed laterally, the incisors are 6) Reduce the anterior ridge of the maxillary base plate to
depressed at the cervical, with the lateral incisor being provide a little extra space for the teeth, but reduce the
the most depressed, and the canine being straight with teeth, if necessary, to fit properly.
the long axis perpendicular to the occlusal plane 7) Use a flat plate resting flush with the occlusion rim to
(Figure 13.2). position the central incisor so that it contacts the
2) When viewed facially, all the mandibular anterior occlusal plane (Figure 13.9).
teeth except the central incisors are tilted mesially, 8) Use a flexible plastic ruler to verify that the incisal por-
with the canine inclined the most (Figure 13.3). When tion of the tooth’s labial surface is properly located and
viewed laterally, the central incisors are depressed at in contact with the anterior curvature of the occlusion
the cervical, with the lateral incisor being straight, and rim (Figure 13.10).
the canine being inclined lingual to the long axis 9) Set the rest of the anterior teeth on the right side
(Figure 13.4). according to the curve defined by the plastic ruler
3) The anterior teeth should not be positioned any fur- (Figure 13.11). The labioincisal line angle of the inci-
ther forward than the depth of the labial vestibule, sors should touch the ruler, as well as the midbuccal
determined by a line drawn from the depth of the ves- surface of the canine (Figure 13.12).
tibule and perpendicular to a line drawn parallel to the 10) Set the rest of the anterior teeth according to the curve
occlusal plane (Figure 13.5). The depth of the vestibule defined by the plastic ruler and the plane defined by a
is the fulcrum point and the further forward a tooth flat plate (Figure 13.13). An anterior view of the maxil-
extends beyond this point, the greater are the forces lary anterior teeth shows that only the lateral incisors
that tend to dislodge the denture. do not touch the occlusal plane as recorded by the
4) Mark the midline of the patient’s face by placing a dot mandibular wax rim. With the maxillary anterior teeth
on the incisive papilla and marking this midline on the set, record the patient’s midline and set the mandibu-
maxillary anterior land area, extending down the front lar anterior teeth. Again, check to see that the labioin-
of the cast (Figure 13.6). cisal line angles of the incisors touch the ruler, as well
5) Make a cut with a heated, sharp knife, at the midline as the midbuccal surface of the canines (Figure 13.14).
in the maxillary anterior wax rim. Cut all the way to
Figure 13.1 All maxillary anterior teeth are inclined mesially.
Figure 13.5 Do not position any anterior teeth further forward

than the depth of the labial vestibule.
Figure 13.2 When viewed laterally, the maxillary incisors are

depressed at the cervical, with the canine being straight with
the long axis perpendicular to the occlusal plane.
Figure 13.6 Mark the midline of the patient’s face by placing a

dot on the incisive papilla and marking this midline on the
maxillary anterior land area.
Figure 13.3 All the mandibular anterior teeth are inclined

mesially except the central incisors.
Figure 13.4 When viewed laterally, the mandibular central Figures 13.7 and 13.8 Make a cut all the way to the base plate
incisors are depressed at the cervical, the lateral incisor is at the midline in the maxillary anterior wax rim and one distal
straight, and the canine is inclined lingual to the long axis. to the canine point and remove this section entirely.
Setting Anterior Denture Teeth 83
Figures 13.7 and 13.8 (Continued)
Figure 13.10 Use a flexible plastic ruler to verify that the

incisal portion of a tooth’s labial surface is properly located and
in contact with the anterior curvature of the occlusion rim.
Figure 13.11 Set the rest of the anterior teeth on the right
side according to the curve defined by the plastic ruler.
Figure 13.9 Use a flat plate resting flush with the occlusion
rim to position the maxillary central incisor.
Figure 13.12 Set the maxillary incisors so their labioincisal

line angles touch the ruler, as well as the midbuccal surface of
the canine. Figure 13.14 Position the labioincisal line angles of the
maxillary incisors and the midbuccal surface of the maxillary
canines touch the ruler.
Figure 13.13 Set the rest of the maxillary anterior teeth

according to the curve defined by the plastic ruler and the plane
defined by a flat plate.
85
14
Setting Posterior Anatomic Teeth in Bilaterally Balanced Occlusion
1) Remove a section of wax from one side of the maxil- by turning the distobuccal cusp of the first molar 20°
lary base plate between the canine and the second toward the palate (Figure 14.7).
molar position (Figure 14.1). Leave a posterior pillar of 5) Set the teeth on the opposite side of the arch in the
wax in the second molar area to preserve the occlusal same manner as these teeth, and then use a tongue
plane in this area and facilitate the setting of the first blade to depress the distobuccal cusp of the first molar
premolar and first molar on this plane. Leave the rim so that it lies ½ mm above the occlusal plane provided
intact on the opposite side to maintain the location of by the mandibular occlusion rim (Figure 14.8). Depress
the occlusal plane. the buccal cusps of the second molar so that they lie
2) There should be plenty of space to set the teeth with along this same plane (Figure 14.9), so that the
little or no reduction. If not, reduce the base plate and/ mesiobuccal cusp is 1 mm above the occlusal plane
or reduce the ridgelap area of the teeth. Set the first and the distobuccal cusp is 1.5 mm above the plane
premolar (Figure 14.2) and second premolar (if there (Figure 14.10). The lingual cusps should still be left
is mesiodistal room), Set the first molar (Figure 14.3) extending down toward this occlusal plane, so that
in the proper buccolingual position and flat to the when viewed distally, they will form a visible arc called
occlusal plane and with the central grooves aligned the compensating curve. Set the maxillary teeth on the
over the mark on the center of the mandibular ridge. left side, making sure that the compensating curve is
Turn the distal of the first molar so that its distobuccal there too (Figure 14.11).
cusp lies 20° toward the palate from the buccal plane 6) Ideally, this curve is developed by raising the distobuc-
established by the mesiobuccal cusp of the first molar, cal cusp of the maxillary first molar to 0.5 mm above
the buccal surface of the premolar, and the midlabial the occlusal plane, the mesiobuccal cusp of the maxil-
bulge of the canine. lary second molar 1 mm above the plane, and the dis-
3) Once these two teeth are set, remove the wax pillar on tobuccal cusp of the maxillary second molar 1.5 mm
that side and set the second molar (Figure 14.4) to the above the plane. Check the occlusal plane before
plane that is preserved by these teeth and the wax rim beginning to set the mandibular teeth to see that it is
on the opposite side. Set the second molar flat with the uniform on both sides. If it is not, you will not be able
occlusal plane and along the same plane buccally that to develop the proper bilateral balance in the set‐up.
was established with the position of the first molar. A 7) With the compensating curve established, remove
tongue blade is used to ensure that the second molar enough wax from the posterior section of the rim to
lies along this buccal plane. A view from the distal con- accommodate the posterior teeth on one side
firms that the central groove of the second molar is (Figure 14.12). The first mandibular tooth that is set is
directly over the line marked on the lower wax rim the mandibular first molar (Figure 14.13), the “key to
(Figure 14.5). occlusion.” The positions of all the other mandibular
4) Use a tongue blade to verify that the buccal cusp of the teeth depend upon the position of this tooth. The teeth
maxillary premolar(s) and the mesiobuccal cusp of the must be positioned without hindrance to their place-
first molar lie along a plane with the middle of the ment and are first set into position on pillars of wax
facial surface of the canine (Figure 14.6), then use the (Figure 14.14).
tongue blade to verify that the buccal cusps of the first 8) When these teeth are in the right position, melt the
and second molars lie along the plane that is defined wax pillars and allow the wax to cool so that the teeth
Figure 14.4 Remove the wax pillar on that side and set the
maxillary second molar.
Figure 14.1 Remove a section of wax from one side of the
maxillary base plate between the canine and the second molar
position.
Figure 14.5 Position the central groove of the maxillary second

molar directly over the line marked on the lower wax rim.
Figure 14.2 Set the maxillary first premolar.
Figure 14.6 Position the buccal cusp of the maxillary premolar

and the mesiobuccal cusp of the first molar along a plane with
Figure 14.3 Set the maxillary first molar.
the middle of the facial surface of the canine.
Figure 14.10 Position the maxillary second molar so that its
mesiobuccal cusp is 1 mm above the occlusal plane and its
distobuccal cusp is 1.5 mm above the occlusal plane.
Figure 14.7 Position the buccal cusps of the maxillary first and
second molars to lie along the plane defined by turning the
distobuccal cusp of the first molar 20° toward the palate.
Figure 14.8 Depress the distobuccal cusp of the maxillary first Figure 14.11 Set the maxillary teeth on the left side, making
molar so that it lies 0.5 mm above the occlusal plane provided sure that the compensating curve is there, too.
by the mandibular occlusion rim.
Figure 14.9 Depress the buccal cusps of the maxillary second

molar so that they lie along a plane defined by the buccal cusps Figure 14.12 Remove enough wax from the posterior section of
of the first molar. the mandibular rim to accommodate the posterior teeth on one side.
Figure 14.15 Melt the wax pillars supporting the teeth and allow
Figure 14.13 Set the mandibular first molar first, because it is this wax to cool so that the teeth become firmly fixed in position.
regarded as the mandibular tooth that is the “key to occlusion.”
Figure 14.14 The positions of all other mandibular posterior

teeth depend upon the position of the first molar.
are firmly set in position (Figure 14.15). Since wax will

shrink slightly as it cools, several adjustments may be
necessary. Check the position of the teeth in centric
occlusion, working and balancing relationships,
including views from the buccal and from the lingual
(Figures 14.16 and 14.17). After these teeth are stable,
set the teeth on the opposite side in the same way.
9) You are now ready to set the mandibular anterior teeth
in the same manner (Figures 14.18). Set the mandibu- Figures 14.16 and 14.17 Check the positions of the teeth in
lar canines first, then the lateral incisors, and finally centric and lateral relationships from the buccal and lingual views.
Setting Posterior Anatomic Teeth in Bilaterally Balanced Occlusion 89
Figure 14.18 With the mandibular posterior teeth set in proper

positions, the mandibular anterior teeth can now be set.
the central incisors (Figures 14.19–14.21). Since the

posterior teeth were all set in proximal contact with
each other, the central incisors should contact at the
midline. Clinically, if the incisors must be set further
forward than the middle of the anterior vestibule, they
must be replaced with a smaller mold of teeth that will
allow the teeth to be set in the proper positions.
10) A view from the back of the articulator should show
that the centric holding cusps are all in their proper
places (Figure 14.22). If not, the teeth are “tweaked”
slightly (Figure 14.23) so that the mesiolingual cusps
of the maxillary molars are centered in the central fos-
sae of the mandibular molars. The lower posterior
teeth will have a lingual tilt to match the buccal tilt of
the upper posterior teeth.
11) Here, the right second mandibular molar
(Figure 14.24), is set with the buccal cusp too far to the
buccal of the maxillary second molar’s central fossa.
The tip of a wax spatula is used to reposition it
(Figure 14.25), so the cusps of the mandibular poste-
rior teeth fit properly into the central fossa of the max-
illary posterior teeth.
12) These views of the teeth set on a compensating curve
demonstrate the overlap of the anterior teeth in centric
occlusion (Figures 14.26 and 14.27). The vertical com-
ponent is directly related to the combination of the
cusp angle, horizontal overlap, and compensating
curve. The teeth must be bilaterally balanced in centric
occlusion.
13) Lateral movement must be independent of the anterior
teeth, with bilateral balance only on the posterior teeth
and the anterior teeth never coming in contact during
the lateral movements (Figures 14.28 and 14.29). This Figures 14.19–14.21 Set the mandibular canines first, then
creates a problem as the posterior teeth wear down, as the lateral incisors, and finally the central incisors.
Figure 14.22 Make sure centric holding cusps are all in their
proper positions.
Figure 14.25 Use the tip of a wax spatula to reposition the

mandibular second molar.
Figure 14.23 “Tweak” the teeth slightly to improve their

relationships.
Figure 14.26 Teeth set on a compensating curve allow overlap

of the anterior teeth in centric occlusion.
Figure 14.24 Here, the second mandibular molar on the right

is set with the buccal cusp too far to the buccal of the maxillary
second molar’s central fossa. Figure 14.27 The vertical component is directly related to the
combination of the cusp angle, horizontal overlap, and
compensating curve.
Setting Posterior Anatomic Teeth in Bilaterally Balanced Occlusion 91
Figure 14.28 Lateral movement is independent of the anterior

teeth.
Figure 14.29 When the posterior teeth wear down, the anterior
teeth may then begin to contact prematurely.
the anterior teeth may then begin to contact prema-

turely. This is the main reason why porcelain anterior
teeth are not set with plastic posterior teeth.
14) The anterior teeth are set so that they contact the max-
illary anterior teeth when the incisal edges are in an
end‐to‐end protrusive relationship (Figures 14.30–
14.32), where they will also contact simultaneously
Figures 14.30–14.32 Simultaneous contact of anterior and
with the posterior teeth. posterior teeth occurs in protrusive relationship.
15) The dentures are checked again to ensure that the teeth
still contact properly in working (Figures 14.33 and
should be multiple posterior contacts on the working
14.36) and balancing (Figures 14.34 and 14.35) relation-
side when the teeth contact on the balancing side.
ships. Although there is only one contact of the poste-
rior teeth necessary on the balancing side, the more Since fully anatomic teeth are made based upon a per-
teeth that are in simultaneous contact, the better. There fect Class I occlusion, it should be obvious that setting
Figures 14.33 and 14.36 After finishing procedures are Figures 14.34 and 14.35 After finishing procedures are
complete, the teeth still contact properly in working relationship. complete, the teeth still contact properly in balancing
relationship.
the teeth in a bilaterally balanced fully anatomic set‐up up or a lingualized occlusal scheme with appropriate
may not the best choice for a patient with a Class II maloc- a natomic maxillary teeth may be more appropriate. These
clusion or a posterior crossbite. With these interocclusal occlusal set‐ups will be described in the following
relationships, a zero‐degree tooth set in a monoplane set‐ chapters.
93
15
Setting Zero-Degree Posterior Teeth in Monoplane Occlusion
1) With monoplane set‐ups, the mandibular posterior the maxillary posterior teeth should have plenty of
teeth are set before the maxillary posterior teeth, since space to be set with little or no reduction. The rim is left
there are no cusps to interfere on the posterior teeth. intact on the opposite side because this will help you to
Remove enough wax on one side of the mandibular maintain the location of the occlusal plane.
denture base to allow setting most of the posterior teeth 6) Set the teeth on the maxillary right side so that all teeth
and thin the base plate to allow for their positioning are in contact mesiodistally and the posterior teeth
(Figure 15.1). Leave a small segment of the wax rim overlap the mandibular teeth about 2 mm buccally. Set
intact in the posterior and clearly mark the midline to the teeth so that the buccal surfaces of the premolar(s)
facilitate the setting of the teeth anterior to it. After and mesial cusp of the first molar line up with the
these teeth are set, remove it to allow the last tooth to be midbuccal surface of the canine (Figure 15.12). The
set, and those teeth anterior to it will indicate the center distobuccal cusp of the first molar should deviate
of the ridge (Figures 15.2 and 15.3). approximately 20° from this plane and the second molar
2) Check the position of the teeth to the center of the ridge will fall along this plane (Figure 15.13).
with a tongue blade used as a straight edge (Figure 15.4). 7) Check to see that occlusal surfaces of these teeth all lie
Once you have verified this relationship is correct flat to the surface of the flat metal plane, then check to
(Figure 15.5), you may begin setting the teeth on the see that the buccal surfaces are properly oriented
other side, using the same steps for setting, sequencing, (Figures 15.14 and 15.15).
and verification that were used on the first side 8) Check to see that occlusal surfaces of all teeth contact
(Figure 15.6). their opposing counterparts properly (Figure 15.16).
3) With all the mandibular teeth set, check the occlusal Note: There is no vertical overlap of the anterior teeth
plane with a flat metal plate to verify that all the teeth (Figure 15.17).
contact the flat surface evenly (Figure 15.7). Expect 9) The mandibular teeth should contact the maxillary
some changes because of the shrinkage of the wax, teeth on a perfectly flat occlusal plane with the incisal
which will shift the teeth slightly (Figure 15.8). Check guide pin set on zero (Figure 15.18) and touching the
the harmony of the curve from central incisor to molar mark on the guide table (Figure 15.19). This plane
teeth using the midline of the clear millimeter ruler cen- should be parallel with the ala–tragus line and the inter-
tered on the midline between the mandibular central pupillary lines. All teeth are in contact with this plane,
incisors (Figure 15.9). Correct any discrepancies before except for the maxillary lateral incisors. The horizontal
moving on to setting the maxillary posterior teeth. condylar guidance and the anteroposterior inclination
4) With all the mandibular teeth set, check to see that all of the guide table should be set in harmony with the
the teeth contact the flat surface of the maxillary wax plane of occlusion with the lateral wings set on zero
rim evenly. If they do, begin setting the maxillary poste- (Figure 15.20). There should be simultaneous bilateral
rior teeth. contact of the posterior teeth in centric, lateral and pro-
5) Remove the wax on one side of the maxillary base plate trusive movements with no vertical overlap of the ante-
(Figures 15.10 and 15.11). A quick look will verify that rior teeth (Figure 15.21).
Figure 15.1 Remove wax and thin the base plate on one side
to allow setting of the posterior teeth. Leave a small segment of
the wax rim intact in the posterior.
Figure 15.4 Check the position of the teeth with a straight edge.
Figure 15.2 This wax pillar clearly marks the midline to

Figure 15.5 Once you have verified this relationship is correct,
facilitate the setting of the teeth anterior to it.
you may begin setting the teeth on the other side.
Figure 15.3 Remove the pillar and set the last molar, as the Figure 15.6 Set the teeth on the other side using the same
middle of the ridge is recorded by the teeth anterior to it. procedures.
Setting Zero-Degree Posterior Teeth in Monoplane Occlusion 95
Figure 15.7 Use a flat metal plate to verify that all the teeth Figure 15.10 Remove the entire wax pillar on one side of the
contact the flat surface evenly. maxillary base plate.
Figure 15.11 Leave the rim intact on the opposite side to

maintain the location of the occlusal plane.
Figure 15.8 Expect some changes because shrinkage of the

wax will shift the teeth slightly.
Figure 15.12 The buccal surfaces of the premolar(s) and

Figure 15.9 Check the harmony of the curve from central mesial cusp of the first molar line up with the midbuccal surface
incisor to molar teeth using a clear millimeter ruler. of the canine.
Figure 15.13 The distobuccal cusp of the first molar should

deviate approximately 20° from this plane established by the
buccal of the canine to the mesiobuccal of the maxillary first molar.
Figure 15.16 Check to see that occlusal surfaces of all teeth

properly contact their opposing counterparts.
Figure 15.17 Verify that there is no vertical overlap of the

anterior teeth.
Figures 15.14 and 15.15 Check to see that occlusal surfaces of

these teeth all lie flat and contact the surface of a flat metal plate. Figure 15.18 Set the incisal guide pin at zero (the wide black mark).
Setting Zero-Degree Posterior Teeth in Monoplane Occlusion 97
Figure 15.21 Ensure that the maxillary and mandibular posterior

Figure 15.19 Ensure that the incisal guide pin touches the teeth contact simultaneously in centric, lateral, and protrusive
mark on the guide table when set on zero. movements with no vertical overlap of the anterior teeth.
Figure 15.20 Check that the horizontal condylar guidance and

the anteroposterior inclination of the guide table are in
harmony with the plane of occlusion and with the lateral wings
of the guide table set on zero.
99
16
Overview of Lingualized Occlusion
As the residual ridges resorb to the point that there is little inclines developed buccal to the central fossa contact
or no ridge, a discrepancy may develop between the size of points ground in for centric relation.
the narrowing and receding upper ridge compared with the 4) When in protrusive relation, the incisors are edge to
widening and receding lower jaw. Lingualized occlusion is edge, and the posterior contact is between the maxillary
a set‐up technique developed to enhance denture stability lingual cusps and a trough cut into the mandibular pos-
in such patients. It is also indicated for patients with terior teeth anterior to the centric contact point.
implant‐supported overdentures to eliminate the stresses
Advantages of lingualized occlusion include the following.
of lateral forces rocking abutment implants loose over
time, to reduce stress on distal extensions, and to avoid 1) There is maximized cutting efficiency with minimized
breakage of intracoronal attachments. lateral forces (denture base slide).
In conventional denture set‐ups, both the buccal and lin- 2) There is improved esthetics over purely zero‐degree
gual cusps of the upper and lower denture come into con- posterior teeth arrangements.
tact on the working side during lateral jaw movement. This 3) Maxillary cusped teeth break up food better than zero‐
achieves balance and distributes the bite force over the degree posterior teeth.
widest area of the jaw. In a lingualized occlusion scheme, 4) Lingualized occlusion has a limited amount of lateral
buccal cusp contacts are eliminated to alleviate lateral forces due to the small area of contact between the max-
stresses or lateral dislodging forces. In lingualized occlu- illary lingual cusp and the zero‐degree mandibular
sion, the lingual cusps of the upper posteriors make con- teeth during lateral excursions.
tact in the central fossae of the lower posteriors in centric 5) This occlusion can be used for a wide variety of residual
relation and are in simultaneous contact with the mandib- ridge conditions.
ular teeth in working and balancing movements, thus cre-
Lingualized occlusion is a compromise between using
ating stability.
anatomic and nonanatomic posterior tooth forms. In a
Most molds of posterior teeth can be modified to suit a
nonbalanced set‐up, the dentures may still tip in contact
lingualized occlusal scheme and some manufacturers have
positions other than centric occlusion due to the lack of
developed molds of posterior teeth designed specifically for
balancing contacts. For this reason, the bilateral occlusal
lingualized occlusion. These seem to work well but in the
contacts are developed in the following manner.
authors’ experience setting maxillary cusped teeth against
lower zero‐degree teeth ground to match the maxillary
teeth set in a suitable curve seems to work equally well. 16.1 Setting Teeth in Lingualized
Tooth contact characteristics of lingualized occlusion for
Occlusion
this set‐up include the following.
1) Anterior teeth contact in protrusive only. A simple way of setting posterior teeth in lingualized occlu-
2) On the working side, the lingual cusps of the maxillary sion is to use fully anatomic maxillary teeth set against
teeth contact the opposing mandibular teeth on inclines mandibular zero‐degree teeth (Figure 16.1). Since only
developed lingual to the central fossa contact points the mandibular teeth are adjusted for occlusal contacts,
ground in for centric relation. it makes little sense to use a mandibular fully anatomic pos-
3) On the balancing side, the lingual cusps of the maxil- terior tooth mold. Although this may seem like a duplication
lary teeth contact the opposing mandibular teeth on of effort or possibly even wasted effort, it offers the advantage
Figure 16.1 Set the posterior teeth in lingualized occlusion by

using fully anatomic maxillary teeth set against mandibular
zero-degree teeth.
Figure 16.3 With the pin lowered, approximately a 1 mm gap

exists between the upper and lower teeth.
Figure 16.2 Lower the incisal guide pin down one mark in
relation to the top of the upper member of the articulator.
of easily establishing an occlusal plane with the teeth set

over the ridges that will stand up to deformation when the
maxillary teeth are set. Mandibular wax rims will simply
deteriorate as the maxillary posterior teeth are set. This
method will also enable the dental professional to determine Figure 16.4 Remove the maxillary posterior teeth one at a
if a lingualized occlusion set‐up will be suitable for a patient. time from the zero-degree set-up.
Obviously, lingualized occlusion will not work with a poste-
rior crossbite relationship. A Hanau™ Wide‐Vue semi‐
2) Remove the maxillary posterior teeth one at a time
adjustable articulator is described in the following example.
from the zero‐degree set‐up. Start with the right first
1) Lower the incisal guide pin down one mark in relation premolar (Figure 16.4). This will allow you to set the
to the top of the upper member of the articulator maxillary 33° teeth in the correct position over the
(Figure 16.2). (In other words, open the bite 1 mm.) mandibular ridge.
Note that this will leave approximately a 1 mm gap 3) Set each tooth in the proper position and allow the
between the upper and lower teeth (Figure 16.3). Use wax to harden before moving on to set the next tooth
33° maxillary posterior teeth that are of a compatible (Figure 16.5).
mesiodistal width to the mandibular teeth to facilitate 4) Set the 33° maxillary first premolar so that its lingual
harmonious cusp alignment when lateral excursive cusp touches the opposing mandibular premolar
movements are made. (Figure 16.6), keeping its buccal surface in line with
Overview of Lingualized Occlusion 101
Figure 16.5 Set each tooth in its proper position and allow the
wax to harden before moving on to set the next tooth. Figure 16.7 Set the 33° maxillary second premolar so that its
lingual cusp touches the opposing mandibular premolar.
Figure 16.6 Set the 33° maxillary first premolar so that its
lingual cusp touches the opposing mandibular premolar.
Figure 16.8 Keep the buccal surface of the maxillary first

the anteroposterior curve established by the positions molar in line with the anteroposterior plane established by the
of the zero‐degree set‐up, but with its buccal cusp positions of the zero-degree set-up.
raised 1 mm above the mandibular occlusal plane.
5) Remove the maxillary right second premolar and set
the 33° maxillary second premolar so that its lingual
cusp touches the opposing mandibular premolar 7) Remove the maxillary right first molar and set the 33°
(Figure 16.7). maxillary first molar so that its mesiolingual cusp
6) Keep its buccal surface in line with the anteroposterior touches the opposing mandibular molar. Its mesiobuc-
plane established by the positions of the zero‐degree cal cusp is raised 2 mm above the lower occlusal plane
set‐up, but with its buccal cusp raised 1 mm above the and its distolingual cusp is raised approximately
lower occlusal plane (Figure 16.8). 0.5 mm above the plane (Figure 16.9).
Figure 16.11 Turn the distobuccal cusp of the maxillary first

molar so that the buccal surface of the tooth falls in line with
the plane that extends from the mesiobuccal of the maxillary
Figure 16.9 Set the 33° maxillary first molar so its first molar to the distobuccal of the maxillary second molar.
mesiolingual cusp touches the opposing mandibular molar, its
mesiobuccal cusp is raised 2 mm above the lower occlusal plane,
and its distolingual cusp is raised approximately 0.5 mm above
the plane of the mandibular teeth.
Figure 16.12 Position the 33° maxillary second molar so that

its cusps touch the plane that is established by the cusps of the
maxillary first molar.
Figure 16.10 Position the buccal surface of the maxillary first
molar in line with the anteroposterior plane established by the
positions of the zero-degree set-up.
molar. This plane is known as the curve of Spee
(Figure 16.12).
8) The buccal surface of the maxillary first molar is posi- 11) This positioning should leave the lingual cusp tip
tioned in line with the anteroposterior plane estab- approximately 1 mm above the plane of occlusion of
lished by the positions of the zero‐degree set‐up the mandibular molars. The mesiobuccal cusp will be
(Figure 16.10). approximately 1.5 mm above that plane. The distobuc-
9) The distobuccal cusp of the maxillary first molar will cal cusp should be approximately 2 mm above that
be turned so that the buccal surface of the tooth falls in plane (Figure 16.13).
line with a second plane that extends from the 12) The buccal surface of the maxillary second molar should
mesiobuccal of the maxillary first molar to the disto- also be in line with the anteroposterior plane established
buccal of the maxillary second molar (Figure 16.11). by the positions of the buccal cusps of the maxillary first
10) Remove the maxillary right second molar and set the molar (Figure 16.14), placing it in‐board from the plane
33° maxillary second molar so that its cusps touch the that runs from the canine to the mesiobuccal cusp of the
plane established by the cusps of the maxillary first maxillary first molar (Figure 16.15).
Overview of Lingualized Occlusion 103
Figure 16.15 The maxillary second molar lies in-board from

the plane that runs from the canine to the mesiobuccal cusp of
the maxillary first molar.
Figure 16.13 Ensure that the lingual cusp tip of the maxillary
second molar is approximately 1 mm above the plane of occlusion,
the mesiobuccal cusp is approximately 1.5 mm above that plane,
and the distobuccal cusp is approximately 2 mm above that plane.
Figure 16.16 Make sure that the mandibular first and second
molars contact the lingual cusps of the maxillary molars.
Figure 16.14 Be sure that the buccal surface of the maxillary

second molar is in line with the anteroposterior plane established
by the positions of the buccal cusps of the maxillary first molar.
13) Raise the mandibular first and second molars so that

they contact the lingual cusps of the maxillary molars
(Figure 16.16). This will provide the curve of Spee
(compensating curve) necessary to allow for the ante-
rior teeth to contact in protrusive as the maxillary lin-
gual cusps contact their individual fossae and allow a Figure 16.17 A curve of Spee (compensating curve) allows the
anterior teeth to contact in protrusive as the maxillary posterior
slight amount of anterior overlap for enhanced esthet- lingual cusps contact their individual fossae and allow a slight
ics (Figure 16.17). amount of anterior overlap for enhanced esthetics.
Figures 16.18–16.20 Set up the upper and lower posterior teeth on the opposite side.
14) Repeat the same steps to set up the upper and mandibular teeth to contact the maxillary posterior teeth
lower posterior teeth on the opposite side do not apply. The teeth will simply be set to contact the
(Figures 16.18–16.20). maxillary teeth with the incisal guide pin opened to 1 mm
to allow for occlusal adjustment of the lower teeth which
If the teeth are set in lingualized occlusion against a
will bring the guide pin back to zero.
mandibular wax rim with the lower anterior teeth already
set, obviously the steps regarding raising the zero‐degree
105
17
Setting Teeth in a Lingualized Occlusion
When dentures set in lingualized occlusion are returned mandibular teeth during the clinical remount. Loosen
from the lab, a lab remount is not necessary. Instead, a clin- the condylar lock screw, freeing the balls in their
ical remount is done as described below. guides, and raise the setting until all teeth are in exact
contact with the registration.
1) Make a facebow transfer and bite registration 6) Mark the contacts with AccuFilm® articulating film
(Figure 17.1). These measurements can be made much (Figures 17.9 and 17.10). Form a mortar (pothole) on
more accurately than those made with a base plate the mandibular posterior teeth in each area where
with teeth set in wax. there is contact with a maxillary lingual cusp
2) Also make a bite registration in protrusive relation. (Figure 17.11). This will be done using the round end
This will be used to set the horizontal guidance of the of an acrylic bur in a straight handpiece. Do not use a
articulator in harmony with the patient’s condylar round bur or diamond bur in a latch grip or high‐speed
inclination (Figure 17.2) and their range of jaw move- handpiece!
ment during mastication. 7) Carefully deepen each pothole (Figure 17.12) until the
3) Mount a remount cast with the maxillary denture in guide pin again contacts the guide table in centric rela-
place on the upper member of the articulator with the tion (Figure 17.13).
pin set on zero (Figure 17.3) and the condyles locked 8) Broaden the pothole by reducing cuspal inclines in
in centric relation (Figure 17.4). protrusive. Use the black side of the articulating film
4) Lower the incisal guide pin 2 mm (Figure 17.5) to com- to mark the points in centric (Figure 17.14). Use the
pensate for the setting of the pin when the teeth were red side of the film to mark the contacts in protrusive
set and the anticipated increase due to processing (Figure 17.15).
error. Make a lower remount cast and mount it with 9) Check to see that the anterior teeth contact simultane-
the denture in place on the lower member of the artic- ously with the posterior teeth as you make protrusive
ulator (Figure 17.6). Make sure the incisal guide pin is movements (Figure 17.16). They will not contact dur-
at zero (the wide mark). Note that the pin will be off ing lateral movements. Use a piece of the paper that
the table more than 1 mm due to the opening at which separates the AccuFilm in its pack to determine if
the teeth were set and the increase due to processing there is contact (Figure 17.17).
error. 10) Broaden the fossa buccolingually to establish continu-
5) When the mounting plaster has set, set the lateral con- ous contact throughout lateral movements (Figures 17.18
dylar guidance by loosening the large black nut on top and 17.19). At this point, each cusp should be making a
of the articulator. Move the condylar element to 15 reverse crowfoot pattern in its respective contacting
(Figure 17.7) and tighten the lock nut. Set the horizon- fossa, when combined with the straight anterior–poste-
tal condylar guidance (Figure 17.8). Adjust only the rior protrusive movement.
Figure 17.1 Make a bite registration in centric relation with a

semi-rigid to rigid impression material like this compound
registration material. Figure 17.4 Lock the condyles in centric relation.
Figure 17.5 Lower the incisal guide pin 2 mm.

Figure 17.2 Also make a bite registration in protrusive relation.
Figure 17.3 Mount a remount cast with the maxillary denture

in place on the upper member of the articulator with the pin set Figure 17.6 Mount a lower remount cast with the denture in
on zero. place on the lower member of the articulator.
Setting Teeth in a Lingualized Occlusion 107
Figure 17.7 Set the lateral condylar guidance.
Figure 17.10 The mandibular posterior teeth in each marked

area are in contact with a maxillary lingual cusp.
Figure 17.8 Set the horizontal condylar guidance.

Figure 17.11 Form a mortar (pothole) on the mandibular
posterior teeth in each area where there is contact with a
maxillary lingual cusp.
Figure 17.9 Mark the mandibular occlusal contacts with Figure 17.12 Deepen each mandibular contact, creating a
AccuFilm articulating film. shallow pothole.
Figure 17.16 The anterior teeth contact simultaneously with

the posterior teeth in protrusive movements but will not contact
during lateral movements.
Figure 17.13 Stop the grinding to increase the depth when the
guide pin again contacts the guide table in centric relation.
Figure 17.17 Use a piece of the paper that separates the

AccuFilm in its pack to determine if there is contact between the
opposing teeth.
Figure 17.14 Use the black side of the articulating film to mark
the points in centric relation on the mandible.
11) In Figure 17.20, the vectors of movement during lat-

eral and protrusive movements are represented on the
teeth in red. The centric contact is represented as a
black dot. The contacts will look more like the picture
in Figure 17.21 as the articulating paper will smear as
the movements are made.
12) The reality of setting teeth in lingualized occlusion is
that it is not easy the first time around. Choose a lab
very carefully, assuring that the laboratory technician
who works on your denture has the experience and
technical ability to do it correctly. The more precise
the lab work, the less time you will have to spend
adjusting at the chair.
Figure 17.15 Use the red side of the film to mark the contacts
in protrusive relation where the potholes are broadened by
reducing cuspal inclines.
Setting Teeth in a Lingualized Occlusion 109
Figures 17.18 and 17.19 Broaden the fossa buccolingually to establish continuous contact throughout lateral movements.
Figure 17.20 Red marks on the teeth simulate the vectors of Figure 17.21 Centric contacts are represented as a black dot,
movement during lateral and protrusive movements. which will look more like a smear, as the articulating paper will
smear as the movements are made.
111
18
The Anterior Esthetic Wax Try-In
18.1 Wax and Its Manipulation the load acting as a lever. A load placed anterior to the
middle of the vestibule will have the same destabilizing
1) Mark certain landmarks on the occlusion rims as an aid effect on the lower denture as a person will have while
in setting the teeth and refining the wax‐up. These are seated on a seesaw. As biting pressure is applied anteri-
the locations of the cuspids, the high lip line, and orly, the body of the denture will rise, and the anterior
midline. ridge suffers the abuse.
2) Adjust the occlusal surface on the maxillary occlusion A patient may insist on the enhanced esthetics of a verti-
rim so that the plane is parallel to both the interpupil- cal overlap of the anterior teeth. They may even bring in a
lary line and the ala–tragus line. picture of their natural teeth when they were younger
3) Make wax rims in the lab 22 mm high on the maxillary (Figure 18.1). You must inform the patient of the pitfalls of
rim and 18 mm high on the mandibular rim. This corre- this relationship, (unstable lower denture, sore spots, epu-
sponds to the vertical dimension in the average patient. lis formation, increased ridge resorption) caused by disoc-
4) Configure the mandibular wax rim in the lab to be two‐ clusion of the posterior teeth. In order to allow for even a
thirds of the way up the retromolar pad. On most small degree of anterior vertical overlap and still achieve
patients the occlusal plane will cross this region. bilateral balance of the posterior teeth, you would have to
5) Contour the occlusal rims to hold the lips in their proper drop one of the maxillary posterior teeth and “ramp” the
positions. Set the teeth in their proper positions in wax most distal mandibular posterior tooth. In other words,
to maintain the desired labial fullness. Teeth set too far horizontal and vertical overlap of anterior teeth must be
labially will give the lips a “punched‐out” appearance. matched with the guidance angle of the posterior teeth for
Teeth set too far lingually give the lips a “dished‐in” bilateral balance to occur.
appearance.
●● A curved plane (20°, 30°) or a flat plane can be used to
Skeletal relationships cannot be corrected without sur- facilitate setting teeth.
gery. Only so much can be done to improve the appearance ●● Axial inclination of the mandibular anterior teeth in the
of patients with a Class II or Class III interocclusal relation- “basic” arrangement includes the following.
ship. Proper contouring of dentures can greatly improve the a) Maxillary (labial view): converging toward incisal.
patient’s physical appearance. Dentures provide lip support, i) central incisor: long axis slightly inclined toward
leading to recovery of a patient’s natural appearance. midline.
If the teeth are placed forward of the mandibular ridge, ii) lateral incisor: long axis more inclined toward
instability leading to increased resorption of the man- midline.
dibular ridge (Kelly syndrome) is likely to result. This is iii) cuspid: long axis only slightly inclined toward
especially important for stability of the mandibular den- midline, less than central incisors.
ture. The further a tooth is placed anterior to this line, b) Maxillary (proximal view).
the less the amount of force required to displace the den- i) central incisor: slightly depressed at cervical,
ture. Displacement force effect increases exponentially inclined labially.
as this distance increases. This is because the middle of ii) lateral incisor: slightly more depressed at cervical
the anterior vestibule is where the flange of the denture than central, inclined labially.
contacts and it acts as a fulcrum, with the denture and iii) cuspid: straight with long axis.
maxillary teeth are set with the buccal cusps contacting

the central fossa of the lower teeth. To achieve the best
results, the maxillary and mandibular molars are fre-
quently switched so that the right maxillary teeth are set
on the mandibular left arch, the left mandibular molars
are set on the maxillary right arch, etc.
●● When viewed from the proximal, the buccal–lingual
relationship of cusped posterior teeth in centric relation
will show a gradual rise of the buccal cusps from a flat
plane beginning at the distobuccal cusp of the first molar
(curve of Wilson mediolaterally and curve of Spee anter-
oposteriorly). The distobuccal cusp of the first molar will
be 0.5 mm above the flat plane, the mesiobuccal cusp of
the second molar is 1 mm above the plane, and the disto-
Figure 18.1 A patient may insist on the enhanced esthetics of buccal cusp is 1.5 mm above the plane.
a vertical overlap of the anterior teeth as seen in a picture of ●● Bilateral balance is necessary for complete denture sta-
their natural teeth when they were younger. bility. This occurs when teeth on one side are in contact
in working relationship and the teeth on the other side
c) Mandibular (labial view). contact simultaneously.
i) central incisor: straight with long axis. ●● Two buccal planes are used to align the maxillary poste-
ii) lateral incisor: long axis slightly inclined toward rior teeth. The first involves the midbuccal surface of the
midline. canine (crest of curvature), the buccal cusps of the pre-
iii) cuspid: long axis slightly more inclined toward molars, and the mesiobuccal cusp of the first molar. The
midline than lateral incisor. distal of the first molar is turned toward the palate so the
d) Mandibular (proximal view). buccal cusps align with a plane at an angle of about 20°
i) central incisor: slightly depressed at cervical, from this first plane. The second molar is set so that its
inclined labially. buccal cusps lie along this second plane.
ii) lateral incisor: straight. ●● A concave configuration of the buccal and lingual flanges
iii) cuspid: slightly inclined lingually. can help hold the denture in place. These flanges define
●● The ideal position for setting the posterior teeth is with the boundaries of the “neutral zone” where the force
the buccal cusp of the mandibular tooth directly over the from the tongue equals the forces from the cheeks and
middle of the mandibular ridge. The determination as to lips respectively. When the patient tightens the lips and
whether to set the maxillary teeth in crossbite or in nor- presses against the denture with the tongue, the man-
mal arrangement is then made based on the relationship dibular denture stays in place over the ridge.
of the maxillary ridge to the mandibular teeth. ●● A carver is held at about a 45° angle to the long axis of a
●● If the mandibular posterior teeth are set lingual to the tooth when the gingival wax is carved to give the correct
ridge, this tends to stabilize the lower denture but effect of the gingiva. The wax is trimmed to the line rep-
restricts the area allowed for the tongue. If the mandibu- resenting the cemento‐enamel junction or approximately
lar posterior teeth are set buccal to the ridge, this tends to 1.5 mm from the bottom of an untrimmed tooth.
destabilize the lower denture but allows more room for ●● The wax is trimmed from the midbuccal of a tooth to
the tongue. This should be avoided whenever possible. the interproximal area. This procedure is repeated for
Advise the patient that his tongue will adapt with time to each tooth. In this way, the interdental papilla is prop-
the space it is allocated. erly formed. The interdental papilla is always convex in
●● If the mandibular posterior teeth must be set buccal to form, never flat or concave, and does not extend up to
the ridge, zero‐degree teeth are used, as these eliminate the contact area.
some of the lateral shear stresses experienced by cusped ●● Festooning is done to give natural anatomic form to den-
teeth. Again, this is a rare situation and should be avoided ture flanges. Although lingual and palatal festooning is
wherever possible. done, the labial and buccal festooning are most prominent.
●● The ideal position of cusped posterior teeth where the Since this is an esthetic effect, the maxillary labial festoon-
ridges are aligned in a crossbite relationship is to set the ing is the most prominent since it is most often noticed.
molar teeth with the mandibular teeth positioned with the ●● Stippling helps to break up the glossy texture of the
buccal cusp over the crest of the mandibular ridge. The smooth reflective surface of the labial and buccal surfaces
The Anterior Esthetic Wax Try-In 113
and provides a more natural orange peel appearance. This this should be a simple process of raising or lowering
surface reflects light in a more normal way than a smooth the mandibular teeth. The incisal edges of the maxil-
surface. Compare this with the natural tissue. lary central incisors should contact all mandibular
●● The canine eminence represents the path of the root incisors while at least one posterior tooth on each side
under the bone and the tissue surface will appear tightly is contacting.
stretched in that area, therefore the stippling disappears ●● Dentures should be waxed up completely for the wax try‐
in that area. The canine eminences of both the maxillary in, with all areas smooth and rounded.
and mandibular canines extend all the way to the vesti- ●● During the wax try‐in, the dentures are evaluated to
bule, and the maxillary lateral incisors have the shortest ensure:
and shallowest festooning. There is a gingival collar –– the occlusal plane lines up parallel to the ala–tragus
around each tooth, but it is very thin around the canines. and interpupillary lines
●● The vestibular borders of the denture are rounded, espe- –– the vertical dimension is correct
cially in the area of the frenula notches. –– there is enough available tongue space, lip support, etc.
●● On the articulator, set the teeth in centric occlusion. The mandibular anterior teeth should be positioned to
Adjust the teeth for lateral excursions by locking the contact the lower lip. All mandibular teeth should be in
working side condyle in centric relation and loosening muscular balance between cheeks and tongue. Lip sup-
the screw on the balancing side just enough for the work- port should come from labial surfaces of anterior teeth,
ing side teeth to line up. The maxillary and mandibular especially the area of the vermilion border
buccal cusp tips of the teeth on the working side should –– centric occlusion in the mouth corresponds with the
be in a straight line, and tracking through the embra- articulator
sures of the opposing teeth. –– the vertical axis of anterior teeth is correct relative to
●● The balancing side is then adjusted so that at least one the base of the denture.
maxillary posterior lingual cusp simultaneously contacts ●● Nature is asymmetrical but proportionate. Most peo-
an opposing mandibular tooth when all the working side ple’s faces are not bilaterally symmetrical. Their nose
buccal cusps are in occlusion. The canines and other ante- may be to one side and their ears may be different
rior teeth should not touch at any time unless there are shapes, sizes or positions. Their eyes may be two differ-
posterior teeth simultaneously contacting on both sides. ent colors. Their midline may be off. Our job is to pro-
●● Adjust the teeth in protrusive relationship last. If the vide dentures that complement the positive features of a
posterior teeth are set properly in lateral excursion, patient the most.
115
19
The Complete Denture Wax-Up
19.1 Objective 5) Ambient light should be deflected off the denture. This

can be accomplished by stippling in the wax‐up or on
To simulate natural gingival contours on a complete den- the processed acrylic denture.
ture by waxing or festooning the gingival portion. 6) The denture must replace lost bony structure; therefore,
the canine eminence (at the corner of the mouth) and
the gingival bulge (on the buccal surface) are very
19.2 Materials and Supplies important.
7) The denture base must be uniform in outer thickness.
1) Completed denture set‐up Lumps and bumps are very uncomfortable, draw attrac-
2) #7 wax spatula tion to their presence, and provide a site for debris
3) Slow‐speed handpiece accumulation.
4) Acrylic burs and diamond Triad® bur 8) The waxed denture is exactly duplicated in the final
5) Die saw denture. Care must be taken to wax the denture exactly
6) Bunsen burner as you wish the final denture to appear.
7) Hanau™ torch 9) The posterior palatal seal helps retain the denture and
8) Pink base plate wax must be cut into the cast before the denture is sealed
9) Hot water bath down and processed.
10) Roach carver (or other carving instrument capable of
getting to the wax in the interdental papilla area)
19.4 Before Beginning
19.3 Special Considerations
All wax must be removed from the clinical crowns of den-
ture teeth, otherwise it will be replaced by pink acrylic and/
1) The palate of the maxillary denture should be of even
or teeth could dislodge during packing. All other remain-
thickness throughout, should provide room for the
ing wax should be smooth and refined.
tongue, and not interfere with speech in any way. The
palate may be completely smooth or have rugae in the
anterior portion (if the patient has successfully used a
denture with a smooth palate, do not put rugae in the
19.5 Procedure
new denture).
19.5.1 Maxillary
2) The denture must be self‐cleansing. Holes or rough
areas provide food traps. Interdental papillae must be Ideally, the palate of the base plate is removed and replaced
smooth and flat or slightly convex. with two thicknesses of base plate wax to provide for uni-
3) The lingual flange of the mandibular denture should be form thinness of the palate of the denture. For our lab den-
slightly concave but not so much as to cause dislodg- ture, we will not remove the palate but will add one
ment of the denture by the tongue. thickness of wax over the Triad base plate. This is done
4) The denture should appear natural. Natural teeth do because in working with students, we have found that they
not have grooves between them, nor should denture tend to stretch the layers of base plate wax as they press
teeth. them into place and thereby make the palate too thin.
1) Remove palatal wax. Remove the maxillary mounted thumb to cut it off at the linguo‐occlusal line angle of
cast, with the base plate and set teeth attached, from the the posterior teeth and the linguo‐incisal line angle of
articulator. Make a line in the wax of the palate with a the anterior teeth (Figure 19.2). Keep this layer as uni-
sharp instrument that runs approximately 8 mm palatal form in thickness as possible. Seal and smooth the wax
to the teeth. Trim the wax palatal to this line down to with a spatula and/or torch. Extend the sheet of base
the base plate and then taper the wax from the teeth plate wax beyond the posterior border of the posterior
down to the line where the wax was removed. palatal seal. Apply a gentle flame to smooth the palatal
2) Place the wax in the palate. Cut a piece of base plate surface with a Hanau torch (Figure 19.3).
wax in half and heat it in a hot water bath or by care- 3) Carve the palatal surface. Use the knife end of a
fully passing it through the flame of a Bunsen burner Roach carver to carve wax on the palatal side of the pos-
until it is uniformly soft and pliable. Press this sheet of terior teeth 20° below the horizontal palatal plane
wax into place in the palate (Figure 19.1) and use your (Figure 19.4). The angle will be greater on the side of
Figure 19.3 Smooth the palatal surface by passing a gentle

flame over the surface with a Hanau torch.
Figure 19.1 Press a sheet of base plate wax into place in the
palate.
Figure 19.2 Use a thumb to trim off excess wax at the Figure 19.4 Use the knife end of a Roach carver to carve the
linguo-occlusal line angle of the posterior teeth and the wax on the palatal side of the posterior teeth 20° below the
linguo-incisal line angle of the anterior teeth. horizontal palatal plane.
The Complete Denture Wax-Up 117
anterior teeth. Remove all wax from the lingual of the wax (Figure 19.9). Contour the wax to form fullness or
teeth above the collar or finish line. Smooth the wax convexity above the anterior teeth to simulate attached
with a Hanau torch (Figure 19.5). Use a sharp instru- gingiva, and contour a prominent canine root eminence
ment to remove any remaining wax around the gingival (Figure 19.10) that stops short of the border.
margin of each tooth (Figure 19.6). Contour the root prominences over the maxillary cen-
4) Contour facial and buccal surfaces. Use a Hanau tral incisors (not as prominent as canines) (Figure 19.11).
torch to soften and flow a thin layer of wax onto the base Form a slight depression over the maxillary lateral
plate and around the necks of the teeth (Figure 19.7). incisors. This will enhance the canine eminence
Adapt a softened piece of wax along the facial surface of (Figure 19.12) which is formed by the prominent root of
the base plate. Be certain to provide a full extension of the canine in a natural dentition. A “gingival bulge”
the borders. Use a sharp instrument to adapt the wax begins over the second bicuspid (if there is one) and
between the teeth (Figure 19.8) and trim away any excess widens as it travels to the distal of the second molar.
Make a slight depression in the first premolar area
(Figure 19.13). This is the canine fossa and is important
Figure 19.5 Remove all wax from the lingual of the teeth
above the collar or finish line and smooth it with a Hanau torch.
Figure 19.7 Use a Hanau torch to soften and flow a thin layer
of wax onto the base plate and around the necks of the teeth.
Figure 19.6 Use a sharp instrument to remove any remaining Figure 19.8 Use a sharp instrument to adapt the wax between
wax from around the gingival margin of each tooth. the teeth.
Figure 19.11 Contour the root prominences over the maxillary

central incisors.
Figure 19.9 Use a sharp instrument to trim away any excess wax.
Figure 19.12 Make a slight depression in the first premolar

area to create a “gingival bulge.”
Figure 19.10 Contour the wax to form a fullness or convexity

above the anterior teeth to simulate attached gingiva and to
produce a prominent canine root eminence.
if normal facial expression is to be obtained. Make a

slight concavity in the buccal surface between the gingi-
val bulge and the peripheral roll.
5) Carve the gingival wax in the buccal and facial
areas of teeth. Seal the wax with a hot spatula around
the necks of the teeth so that it will not separate, flake or
chip when it is carved. Trim around the necks of the
Figure 19.13 Continue the gingival bulge over the second
teeth with a Roach carver at the junction of the collar bicuspid (if there is one) and widen as it travels to the distal
and crown. Remove all remaining wax from the teeth. of the second molar.
The Complete Denture Wax-Up 119
Carve interdental papillae to produce a convex surface.

Apply a flame gently with a Hanau torch to produce a
smooth gingival margin (Figure 19.14). After flaming,
use a small sharp instrument to remove any wax around
gingival margins of each tooth.
19.5.2 Mandibular
1) Lingual. Flow wax on the lingual surfaces of the
teeth and carve the gingival margins to an angle of up
to 20° below the posterior teeth and 45° on anterior
teeth. Contour the posterior lingual flanges from the
teeth to the peripheral roll, producing an inclined
plane that slopes toward the tongue and is not convex.
It should be slightly concave but not so much as to
cause the tongue to dislodge the denture (Figures 19.15
and 19.16).
Contour and wax the distolingual area of the flange so
that it blends into the retromylohyoid space. The periph-
eral roll should be rounded and completely fill the
mucolingual sulcus of the cast. Flame the wax to smooth
it with a torch.
2) Labial and buccal. Form a small gingival bulge just
below the gingival margins of the four incisors (like the
bulge on the maxillary) (Figure 19.17). Form the canine
eminences (not as prominent as on the maxillary) by
carving the wax from below the first premolar to form a
slight concavity (Figure 19.18). Establish a posterior
gingival bulge that is convex with no root prominence.
Produce a concavity between the gingival bulge and the
Figures 19.15 and 19.16 Contour the posterior lingual flanges

from the teeth to the peripheral roll to form a slight concavity,
but not so much as to cause the tongue to dislodge the denture.
Figure 19.14 Carve the interdental papillae to produce a

convex surface and gently apply a flame with a Hanau torch to Figure 19.17 Form a small gingival bulge just below the
produce a smooth gingival margin. gingival margins of the four incisors.
Figure 19.18 Enhance the canine eminences by carving the

wax from below the first premolar to form a slight concavity.
Figures 19.20 and 19.21 Contour the interdental papilla and

smooth it with a torch.
Figure 19.19 Form a concavity between the gingival bulge and

the peripheral roll of the posterior teeth.
function. Contour the gingival margins and remove all
excess wax from the teeth. Contour the interdental
peripheral roll (Figure 19.19). This concavity will ena- papillae and smooth them with a torch (Figures 19.20
ble the cheek to fill the area and enhance the retention and 19.21). Use a sharp instrument to remove any wax
of the lower denture on the mandibular ridge during around the gingival margins of each tooth.
121
20
Sealing Complete Dentures to the Cast
Use a softened narrow roll of base plate wax to add a very First molar – has a prominent gingival bulge and a concav-
thin line of wax around the entire periphery of each den- ity above the bulge to the peripheral roll.
ture. Use a hot spatula to seal and smooth the wax. Make Second molar – has a gingival bulge that is 5–6 mm wide
sure to blend this additional wax into portions already and blends into the distal of tooth.
waxed and take care not to distort or ruin any work already
done.
●● Place mounted casts back on the articulator. 20.2 Mandibular Contours
●● Check occlusion and tooth alignment.
●● Adjust occlusion and rewax if necessary. 1) Anteriors.
Central incisors – have a slight gingival bulge.
(Figures 20.1–20.3) Lateral incisors – have a slight gingival bulge.
Canines – have a canine eminence that stops short of
the peripheral roll but is not as large as the maxillary
20.1 Maxillary Contours
eminence.
1) Interiors. 2) Posteriors.
Central incisors – have a slight root eminence, a gingi- First bicuspid – has a slight gingival bulge.
val bulge, and a depression above the bulge. Second bicuspid – has a slight gingival bulge.
Lateral incisors – have a slight gingival bulge and a First molar – has a gingival bulge, and a depression
slight depression above the bulge. below the bulge rolling into the peripheral roll.
Canines – have an eminence which stops short of the Second molar – has a gingival bulge that rolls to the distal.
peripheral roll.
3) Lingual.
2) Posteriors. Anterior – is smooth and sloped to the peripheral roll.
First bicuspid – has a hint of a gingival bulge, and the Posterior – is smooth and sloped to the peripheral roll,
canine eminence rolls into the area of the first bicus- has a slight depression in the molar region, and a
pid to create the canine fossa. distolingual flange that blends into the retromylo-
Second bicuspid – has the start of a gingival bulge. hyoid space.
Figure 20.1 Evaluate the right buccal contours of the complete Figure 20.3 Evaluate the left buccal contours of the complete
dentures. dentures.
Figure 20.2 Evaluate the labial contours of the complete

denture and seal them to the casts.
123
21
The Wax Try-in of Teeth
The goal of the wax try‐in appointment is to evaluate and It is important that all the teeth be set properly, and the
finalize the anterior esthetics of the complete denture set‐ wax properly contoured for the wax try‐in appointment,
up, to verify that the vertical dimension is correct, and to because the shape of the denture base area as related to the
evaluate and finalize the occlusion based on sound pros teeth will have a considerable bearing on the esthetic prop
thodontic principles. erties of the denture. The patient will be signing a state
Prior to this appointment, the student should have com ment in the record that they approve of the anterior
pleted the wax‐up/set‐up. During this appointment, they esthetics, but the student dentist must be able to evaluate
will evaluate all aspects of the set‐up and make modifica the denture wax‐up for the vertical dimension of occlusion
tions as necessary, then obtain patient acceptance of the (VDO), phonetics, parallelism of the occlusal plane to ana
anterior esthetic arrangement of teeth. Obviously, they tomic landmarks, and prematurities in the occlusion. If
should appear knowledgeable and comfortable in perform this is not done at this appointment, the patient should be
ing the procedure. reappointed for another evaluation of these areas of
The student should bring to the clinic or obtain from the responsibility. Zero‐degree, monoplane occlusions must
side lab or the dispensing area all the instruments and have perfectly flat occlusal planes on both maxillary and
materials necessary to reset the teeth during a wax try‐in mandibular dentures.
appointment. It is always better to be overprepared than If the buccal surfaces of the bicuspid teeth do not fall on
underprepared for any eventuality and thereby avoid a the line from the midbuccal of the canine to the mesiobuc
delay in treatment. cal of the maxillary first molar, the denture will have a
The basic equipment for this appointment would be as characteristic “Cheshire cat” look, or toothy smile. The
follows. patient may return with complaints that their friends
thought that dentures were unesthetic and want them
1) Mounted casts/wax dentures remade, even though they signed that they liked the look of
2) Dental floss the dentures initially. Flat planes should exist from the
3) Fox plane midbuccal of the canines to the mesiobuccal of the first
4) Denture adhesive molars (Figure 21.1) and from the mesiobuccal of the first
5) Hand mirror molars to the distobuccal of the second molar on a plane
6) Cup of water turned approximately 20° toward the palate from the first
7) Mold chart plane (Figure 21.2) so that the buccal surfaces of all molars
8) Denture tooth shade guide are in a straight line. This rule applies to both anatomic
9) Denture base shade guide teeth and zero‐degree teeth.
10) Tongue blade Mandibular posterior teeth must be set so that they are
11) Base plate wax over the crest of the ridge, with zero‐degree teeth set so
12) Flexible ruler that the central fossae lie directly over the crest and ana
13) Waxing instruments tomic teeth set so that their buccal cusps are over this line.
14) Blazer torch With severely resorbed ridges, the crest of the ridge is
15) Alcohol torch almost impossible to determine and is broader based,
16) Indelible transfer stick therefore there is more flexibility in setting the posterior
17) Acrylic finishing burs teeth. With severely resorbed ridges, lines are drawn from
18) Green‐handled knife both sides of the retromolar pad and intersect at the canine
Figure 21.3 With severely resorbed ridges, draw lines from

both sides of the retromolar pad that intersect at the canine and
set the teeth between these lines.
Figure 21.1 Establish flat planes from the midbuccal of the

canines to the mesiobuccal of the first molars.
Figure 21.4 Do not place the mandibular anterior teeth further

forward than a line drawn perpendicular to the occlusal plane
from the middle of the labial vestibule.
(Figure 21.4). To do so would place the mandibular ante

rior teeth ahead of the axis of rotation and contribute to
instability of the mandibular denture.
The buccal surfaces of the maxillary posterior teeth must
not be placed any more buccally than a line perpendicular
Figure 21.2 Establish flat planes from the mesiobuccal of the to the occlusal plane drawn from the depth of the buccal
first molars to the distobuccal of the second molar on a plane vestibule. If ideal positioning of the mandibular posterior
turned approximately 20° toward the palate from the first plane. teeth dictates that maxillary posterior teeth must be set
more buccal than this rule allows, the maxillary teeth must
(Figure 21.3). The teeth would be set so they fall between be set in crossbite.
these two lines. This is not done with well‐developed Cusped teeth are designed to be set in a certain way and
ridges, however. they will not line up properly when set in crossbite. Denture
The mandibular anterior teeth should not be placed fur teeth should not be set on maxillary tuberosities or on the
ther forward than a line drawn perpendicular to the retromolar pad as well, as this would create forces that
occlusal plane from the middle of the labial vestibule would dislodge the denture as the forces generated in the
The Wax Try-in of Teeth 125
back of the mouth are very strong and will press the den These dimensions must be a consideration because the
ture down this incline and move it forward. patient has adapted to the old denture and will need to rea
While nobody is perfectly bilaterally symmetrical, it is dapt to new dentures. The patient must be made aware of
commonly accepted that the closer someone is to being this factor and be willing to devote the time and effort it
bilaterally symmetrical, the more esthetically pleasing is takes to adjust to the new dentures.
their appearance. A plastic ruler is a valuable tool to enable Other things to check include the following.
the technician to design dentures that are very close to
being bilaterally symmetrical. This has broader implica Positions of Anterior Teeth
tions than esthetics. It is much easier to establish bilateral
1) Lip support
balance in all excursive movements in a set of complete
2) Length
dentures that are bilaterally symmetrical in their tooth
3) Relation to upper lip
arrangement than it is in a set that is not symmetrical.
4) Interpupillary line
Sadly, it is impossible to establish this harmony in many
5) Midline
patients, and this is where the zero‐degree, monoplane set‐
6) Phonetic exercise: “f” sounds (length of max. anterior
up is very useful.
teeth). To make a distinct “f” sound, patients must be
One of the most common areas of the lower denture that
able to place the wet/dry line of their lower lip against
is overextended is the labial flange. This is checked with
the incisal edge of the maxillary incisors. Also, if the
the denture out of the mouth and the lower lip is pulled up
maxillary incisors are inclined toward the palate, there
and out to reveal the areas of attachment of the muscles.
will not be proper support rendered by the teeth to the
This depth can be measured using a periodontal probe and
upper lip. This is sometimes seen when the technician
then transferred to the flange. The flange is then reduced to
attempts to minimize the horizontal overlap of a skele
this height and the denture is inserted in the mouth. When
tal Class II patient. When this is done, the patient will
the lip is pulled up and out, the denture is observed to see
often complain that the labial flange of the maxillary
if it is displaced. Another area commonly overcontoured is
denture is too long or too thick.
the lingual flange in the area of the lingual frenum. The
patient is advised to raise their tongue and touch the roof
of the posterior palate. Again, this height can be measured
with a periodontal probe and this measurement is trans
ferred to the denture. The denture is then reduced in this
area, replaced in the mouth, and observed to see if it is dis
placed when the tongue is raised. Since the posterior pala
tal seal area is arbitrarily placed, it will generally require
some adjustments and is tapered on the polished side so Point
on
that the tongue will pass over it unimpeded. nose
Aspects to check include the following.
1) VDO and vertical dimension at rest (VDR)
2) Centric relation (CR)
3) Protrusive
4) Esthetics and phonetics
5) Posterior palatal seal
6) Physiological rest position
7) Phonetics and esthetics
8) Ability to swallow
9) Compare to old denture VDO
One of the main things we must consider when we look VDR
at old dentures for comparison to our own measurements
is that the old dentures may never have really been the
proper vertical dimension or that the vertical dimension
Figure 21.5 Use marks on a tongue blade to record the
has changed over the years of wear. Use a tongue blade to
distances between a point on the nose and a point on the chin
record the distances between a point on the nose and a when determining the vertical dimension of occlusion (VDO)
point on the chin to record the VDO and VDR (Figure 21.5). and vertical dimension at rest (VDR).
Wax-up This requires that the plane of occlusion must intersect the
posterior rise of the mandible at a point at least two‐thirds
1) Lip support
of the way up the retromolar pad. Any amount less than
2) External form
this will restrict the patient’s ability to move in a normal
range of motion as the most distal maxillary tooth will con
Vertical Dimension of Face
tact the heel of the lower denture. Also, teeth that contact
If a denture increases the patient’s VDO, it will be difficult
in an end‐to‐end relationship tend to cause the patient to
for the patient to swallow. The posterior teeth may also
bite their cheek or lips, because they do not position the
click together when the patient talks. If the vertical dimen
lips or cheek away from the point of contact when the
sion is decreased, the patient may drool at the corners of
patient chews.
the mouth, and “s” and “x” sounds may sound like a “th”
sound.
Patient Instructions
1) Phonetic exercise: “s” sounds
1) Dentures fit better than base plates because the under
2) Palatal contour
cuts are blocked out.
3) Swallowing
2) The color of the denture base is selected to match the
natural color of the patient’s gums.
Esthetics
3) There are only a few tooth shades available for denture
1) Picket fence or chicklets appearance teeth.
2) Too much or too little of teeth show
One thing that must always be assumed when dealing
3) Color (shade)
with a complete denture patient is that they very likely
4) Size (mold, length, and width)
have little knowledge about dentures, have been misin
5) Too much base material is visible
formed about the limitations of dentures, or otherwise
Every effort must be made to provide the patient with a have some unreal expectations. Regardless of how many
set of dentures that provide a natural appearance. For this years a patient has been wearing dentures, they will still
reason, it is a good idea to look at preextraction casts and need to be provided with instructions, both orally and in
photographs. Ask the patient if they want their teeth to be writing. If they don’t accept your instructions or otherwise
overlapped or twisted, or if diastemata between the natural claim to know more than you do about dentures, you may
teeth are to be duplicated in the dentures. Such changes want to consider not treating them.
can be provided if the rule of bilateral balance in the occlu
sion is not violated. The size, shape, and color of the teeth We have already discussed how tooth arrangement affects
must be accepted by the patient prior to processing the the perception of esthetics. The Golden Mean (or Golden
dentures, and they must sign a statement in the record Proportion) was established when it was noticed that the
indicating their approval. interrelationship between the width of the anterior teeth
has a considerable effect on esthetics. It was found that the
Positions of Posterior Teeth maxillary anterior teeth are more esthetic when viewed
The patient must be able to occlude their teeth properly in from the facial profile at the central incisor region if each
eccentric movements. tooth differs in the width of tooth visible from its more
anterior neighbor by a ratio of 1 to 0.618. Also, the shapes
1) Is the occlusal plane parallel with the ala–tragus line?
of the teeth are related to the shape of the face for striking
2) Does the occlusal plane allow the patient to move in
a balance between the individual teeth and a patient’s
protrusive relation without the maxillary posterior teeth
facial features for improved esthetics.
contacting the heels of the mandibular denture?
Two of the most important evaluations you will need to
3) Are posterior teeth set in an end‐to‐end relationship in
make are that the midline of the dentures lines up with the
occlusion?
middle of the patient’s face and that the anterior occlusal
4) Do premature occlusal contacts exist?
plane lies parallel to their interpupillary line (Figure 21.6).
Parallelism of the occlusal plane with the ala–tragus line The most important aspects of this plane are that it lies par
is of secondary importance. It is easier to set the posterior allel to the interpupillary line and is located at the proper
teeth if they are positioned so that the plane of occlusion vertical dimension for esthetics and phonetics (normally
divides the interarch distance by half. The patient’s ability 1–2 mm below the resting lip). This is the component of the
to move their jaw in lateral and protrusive movements occlusal plane that everyone sees. Other people seldom
must be unobstructed within a normal range of motion. notice the occlusal plane in the posterior area. A patient
Figure 21.7 Use the nose as a guide to the placement and size
of teeth. The inner canthus of the eyes and the ala of the nose
should line up with the canines, unless there has been surgery
or deformity to these areas.
It is important to remember that anatomic landmarks

such as the nose are guides to the placement and size of
Figure 21.6 Make sure the midlines of the dentures line up
teeth, not ironclad rules. Ideally, the inner canthus of the
with the middle of the patient’s face and the anterior occlusal eyes and the ala of the nose should line up with the canines
plane lies parallel to the interpupillary line. (Figure 21.7), but a patient could have had a rhinoplasty
(nose job) done and the size and shape of the nose may not
will notice these two things in a mirror and their friends represent a relationship to the size and shape of the teeth.
may comment on them. The arch form is more of an indicator as to where the teeth
Two things that patients and their friends will also notice should be set and even then, the width of the patient’s nat
are related to how attractive their smile appears. For the ural teeth may have been compromised by overlapping or
best esthetics in a smile, the curvature of the maxillary have a diastema and the arch form will not indicate the size
anterior teeth should match the curvature of the lower lip or shape of the teeth. For this reason, I always select the
and the patient should not show any denture base above size and shape of the teeth without the patient being pre
the coronal portion of the teeth. sent and get their approval at the wax try‐in appointment.
The main thing that you do not want to happen is to An often overlooked factor at the insertion appointment
cause the patient to show too much gum when they is that the labial flange of the lower denture is overex
smile. To avoid this, the high lip line is marked on the tended. If this is the case, the lower lip will not be able to
wax rim and the mold of teeth to be set is selected accord touch the incisal edges of the maxillary anterior teeth with
ingly. This is one of the steps that are closely checked out raising the lower denture (Figure 21.8). This is proba
during the wax try‐in appointment. When the patient bly the most often overlooked aspect of complete dentures
signs the record indicating their acceptance of the ante during the insertion phase. If this deficiency is not cor
rior esthetics of the teeth, this is one area that they will rected prior to the clinical remount, the remount will be
be looking at, therefore it is important that all the poste incorrect and any occlusal adjustment made during the
rior teeth are set and a proper festooning is completed remount will likewise be inaccurate. The patient will usu
prior to this appointment. Closest speaking space (CSS) ally not complain if the flange is slightly overextended at
is used for the final test to determine if the vertical the insertion appointment, but at the 24‐hour check there
dimension is correct. Different amounts of teeth are vis will usually be a visible ulcer in this area and the patient
ible when the patient speaks than when they smile. Have will complain that it is too long. This results because when
the patient say words with “s” sounds or have them count the denture rises and settles during normal function, the
from 60 to 70. denture pinches the tissue.
The sounds made when the patient’s lower lip touches If the VDO is increased, the teeth will contact prematurely
the maxillary incisors are the “f” and “v” sounds. A good and give a clicking sound. Instruct the patient to count from
way to assess this is to have the patient count from 50 to 60 60 to 70 to assess the vertical dimension, and carefully listen
and watch carefully as the patient says “fifty‐five.” If the to the sounds that are made when the patient says “sixty‐
“v” sound doesn’t come out clearly (usually sounds like a six.” This may come out as a clicking sound if the increase is
“b” sound), then the lower lip is not touching the teeth cor slight, sixty‐six if the VDO is more open, or a “th” sound
rectly and a change must be made to correct this deficiency (sikthy‐sikth) if the vertical dimension is decreased and the
during the anterior wax try‐in appointment. tongue is placed between the teeth to fill the gap. The CSS
If the maxillary anterior teeth are set in a position that is should be 1.5–3 mm at the second molar region. The patient
too low (Figure 21.9), the patient will struggle to position will move the jaw 2–3 mm forward during speaking.
the lip correctly, but it will contact the teeth prematurely. Sometimes a tooth must be left out to accommodate the
This will create a “f” sound instead of a “v” sound when patient’s anatomic configuration or to allow the patient to
the patient says “fifty‐five” and it will sound like “fifty‐fife” move the lower jaw into eccentric positions. This can be
and the “f” sounds will be somewhat “airy” as the air is due to a steep rise of the ramus or a severe Class II skeletal
forced unnaturally over the teeth. The patient will also gen relationship. The posterior teeth should not be set on the
erally spew saliva when speaking if the maxillary anterior slope of the ramus nor should the maxillary molar contact
teeth are too long. the lower denture base when the patient moves into pro
trusive or lateral positions. Also, there must be enough
room to accommodate all the mandibular anterior teeth,
without having to remove one of them. Either a molar
(Figure 21.10) or a premolar (Figure 21.11) may be left out
of the set‐up, depending on the size of the area necessary to
allow adequate movement or space to set the anterior teeth.
Figure 21.8 Overextension of the labial flange of the lower

denture will not allow the lower lip to touch the incisal edges of
the maxillary anterior teeth without raising the lower denture.
Figure 21.10 Consider leaving out a molar if the mesiodistal

length of the mandibular residual ridge is too short to
accommodate four teeth.
Figure 21.9 If the maxillary anterior teeth are set too low, the
patient will struggle to position the lip and it will contact the Figure 21.11 If the mesiodistal length of the residual ridge is
teeth prematurely. too short for four teeth, consider leaving out a premolar.
The posterior teeth must be set to compensate for any Such minor discrepancies must be resolved during the
vertical overlap of the maxillary anterior teeth over the clinical remount. Verify centric relation by inserting the
mandibular anterior teeth. This can be easily evaluated by dentures and lower them into position with your index fin
placing a flat plane on the occlusal surface of the maxillary gers. Retrude the mandible and close into centric relation.
denture (Figure 21.12). The anterior teeth must not contact Observe any shift in the upper denture. Look for even con
in all excursions except between the incisal edges in pro tact of the posterior teeth bilaterally.
trusive relation. Posterior teeth must not be set buccal to It is important to note that if the anterior denture teeth
the crest of either the maxillary (Figure 21.13) or mandibu contact prematurely, the lack of contact in the posterior
lar ridges (Figure 21.14) or instability will result. Patients teeth will cause the lower denture to tip forward until the
must be advised that they need new dentures to resolve any posterior teeth come in contact. This creates a phenome
problem caused by this. A reline will not correct the prob non called the combination syndrome or Kelly syndrome.
lems caused by this poor relationship of teeth to ridge, and This out‐of‐balance relationship will create undue pressure
instability and resorption would cause the dentures to fail. on the maxillary anterior ridge and increase the rate of
It is difficult to fully evaluate the occlusion during the bone resorption. This condition is particularly common in
wax try‐in phase. Be aware that each phase of complete patients with a Class II musculoskeletal relationship and
denture construction is only as accurate as the steps com occurs when the posterior teeth wear down more rapidly
pleted prior to that phase allow it to be. A base plate is not than the anterior teeth because of the more frequent con
as accurate as a denture base. Teeth set in wax will shift in tacting of those teeth during the mastication process. This
the patient’s mouth. Base plates will allow movement so is the main reason why porcelain anterior teeth are not
that the teeth appear to be in ideal contact, even though used with plastic posterior teeth. Such a condition will
they are not (Figure 21.15). Note the separation of the pos
terior teeth in centric relation. The centric relation of the
patient shown in Figure 21.15 is incorrect.
Figure 21.14 Do not set posterior teeth buccal to the crest of

the mandibular ridge.
Figure 21.12 Compensate any vertical overlap of the maxillary

anterior teeth by ramping the positions of the posterior teeth
and evaluate this by placing a flat plane on the occlusal of the
maxillary denture.
Figure 21.15 Because base plates are not very stable, they will
Figure 21.13 Do not set posterior teeth buccal to the crest of allow movement which makes the teeth appear to be in ideal
the maxillary ridge. contact, even though they are not.
need to be corrected prior to the relining of the dentures or contact the indentations exactly as they did in the
the instability that exists will not be corrected by the relin mouth, you have proven that your original centric
ing procedure because of the separation of the posterior record was correct.
teeth in protrusive excursions. This situation would not It is vital to the accuracy of the bite registration that the
work because the denture would impact constantly on the teeth must seat fully into this index. In order that this can
anterior ridge, creating instability and greatly increasing be visually assured, any excess material is removed from
the rate of resorption. The diastemata between the teeth the index, leaving only the cusp tips in the record. This will
are permitted at the patient’s request or with their approval. allow enough visual access so that the teeth can be placed
Obviously, working with the base plate is not going to be entirely in the index with confidence. When making such
as accurate as a processed denture base. Often, however, an index, it is also a good idea to record the anterior teeth.
there will be an obvious discrepancy in occlusion of the This will provide an improved stability to the cast in the
wax dentures intraorally. This is an easy way to determine index during the remounting. Once the teeth are reset, the
the correct centric relation. The green stick compound we wax denture can be tried in the patient’s mouth to assess
normally use when border molding would be very suitable the accuracy. The patient is then asked to sign a statement
for this purpose as it is very accurate and stable, but in the indicating that they accept the positions and the esthetics
dental office polyvinylsiloxane bite registration material of the anterior teeth and they are then taken to the cashier
will normally be used. In some cases, the teeth can be left to pay at least one half of the cost before the dentures are
as they are and the indexing material placed between them. processed.
Often, if the vertical dimension will not support this altera If the teeth do not contact the index exactly, remount the
tion, the mandibular posterior teeth will need to be mandibular cast. Loosen the condylar locks. Set the teeth
removed. The patient is then gently guided into occlusion in the index. Drop the pin so that it contacts the table.
and the registration material can harden before removal Tighten the set‐screw. Remove the mandibular cast. Lock
from the mouth. Immediately after removal, a quick check the articulator in centric. Remount the mandibular cast to
is done to determine if the heels of the lower denture are the new record. Raise the pin so the teeth contact. Tighten
contacting the denture base of the upper denture. the set‐screw at that point.
When you do this bite registration, you must ensure that Give the patient a mirror and have them evaluate for
the patient is giving you a true centric relation. It is often themselves the vertical dimension, space available for the
more difficult to achieve an accurate record with Class II tongue, lip support, etc. (Figure 21.17). They will do this as
patients because they traditionally tend to posture forward they talk and look into the mirror and it is a good way of
of this position. The true centric relation record must be showing that you value their concerns. You can then
obtained to mount the cast correctly on the articulator, answer any questions that may arise. Evaluate the patient’s
because although the patient may not normally bite down vertical dimension, space available for the tongue, lip sup
in centric relation, he will most certainly go to that position port, etc.
on the rotating condyle during lateral movements. The
entire process of making a bite registration must be
explained to the patient and a few dry runs completed in
order to get a good bite registration. Once this is done, the
cast and the lower denture can be remounted on the articu
lator and the teeth adjusted to fit this new position. It is
very helpful if this repositioning of the teeth is done while
the patient is still seated in the chair.
To make a centric relation record, recline the chair
back, which will help retrude the mandible. Stabilize
the mandibular base with your index fingers with the
thumbs under the mandible (bimanual technique).
Rehearse closing with the patient. Have the patient gen
tly close into the compound just short of tooth contact
(Figure 21.16). Remove and trim the record so that only
the indentations from the cusp tips are present. Place
the new record onto the master casts on the articulator.
Figure 21.16 To achieve an accurate centric relation record,
Make sure the articulator condyles are locked in centric rehearse closing movements with the patient to have them
position. Close the articulator. If the maxillary teeth close gently into the compound just short of tooth contact.
A denture adhesive will often be necessary to retain the Centric occlusion in the mouth should look exactly as it
base plate in the mouth at the try‐in appointment does on the articulator. If it does not correspond com
(Figure 21.18). A powder adhesive works better than a pletely, the mounting is wrong, and a new centric relation
paste as it is easier to clean up. Powdered adhesive needs to record needs to be made and the mandibular cast
be put in the base plate or denture after wetting the inside remounted. Also observe the relationship of the teeth in
and then the powder is spread by holding the denture over maximum intercuspation.
the sink and shaking it briskly side to side. The powder is Evaluate the relation of the mandibular teeth in relation
made into a paste by dabbing it with a wet finger and the to the lower lip. It is very important that a denture be in
denture/base plate is inserted in the wet mouth and held in harmony with the lower lip. If the teeth are not set properly
place for a few seconds. A paste adhesive is placed in a dry or the labial flange is too long, the lower lip will raise the
denture and a dry mouth as the paste will not adhere to a denture during eating and speaking. This is the main rea
wet surface. Using a small amount of denture adhesive is son that we do not flare the mandibular teeth forward to
helpful in building the patient’s confidence at the try‐in improve the anterior occlusion in a Class II patient.
stage. The labial support of the teeth also pertains to the flange.
A patient will not be used to having a flange and the added
bulk will give the patient a profile that will seem strange.
For this reason, a patient may request that the flange be
removed or thinned to the point that it is extremely fragile
(Figure 21.19). This increase in the patient’s profile must be
explained before the denture is made and reinforced dur
ing the wax try‐in and insertion phases. The teeth must not
be set back on the ridge or the flange will become more
noticeable (Figure 21.20). This becomes a particularly
grievous problem when the maxillary ridge extends out in
front of the labial vestibule and especially with a skeletal
Class II patient.
The flip side of the coin is that when a patient has lost a
considerable amount of the supporting bone of the ridges
Figure 21.17 Give the patient a mirror and have them evaluate
for themselves the vertical dimension, space available for the
tongue, lip support, etc.
Figure 21.19 Do not yield to a patient’s request that the flange

Figure 21.18 It is often necessary to use a denture adhesive to be removed or thinned to the point that it becomes extremely
retain the base plate in the mouth at the try-in appointment. fragile.
If the internal forces are greater than the external

forces, the tongue may rise above the occlusal surfaces of
the teeth. This will make it very prone to getting in the
way when the patient takes a bite of something. Through
diligent practice, the patient will develop a new aware
ness as to where the tongue is in relation to the denture.
The tongue will shrink back to fill this space, but it took
a long while to overdevelop so the patient should be cau
tioned to allow enough time for it to shrink to fit the
space.
Things occurring in nature are seldom bilaterally sym
metrical, but the more symmetrical an object appears, the
more esthetically pleasing it is to the observer. Also, things
in nature are more esthetic if their parts are in proportion
to one another. Architects, artists, and engineers have used
this premise for centuries when they design their work.
Following this line of reasoning, the maxillary anterior
teeth are esthetically related to one another by a ratio of
1.618 to 1. In other words, as we view the teeth from ante
rior to posterior, the amount of tooth that is visible becomes
Figure 21.20 Do not set the anterior teeth back on the ridge or
progressively smaller in width by a ratio of 1.618 to 1
the flange will become more noticeable.
(Figure 21.21) and can be shown by an accordion caliper
that is set to these dimensions. This can also be used to
measure this relationship and will demonstrate that this
through trauma or resorption, normal facial contours can same relationship exists between the height of the tooth
be restored by the denture flange, giving the patient a more above the crest of the interdental papilla as related to the
youthful appearance because certain wrinkles associated amount below the crest.
with the aging process will seem to disappear. This is antic Selective grinding or rearranging of the teeth can provide
ipated and often looked forward to by a patient who has a much livelier and more natural appearance. Compare the
had dentures for several years. noncontoured teeth in the picture in Figure 21.22 to the
Likewise, the teeth of the lower denture must be in har contoured teeth in the picture in Figure 21.23. Teeth may
mony with the cheeks and the tongue. This area is called need recontouring to permit a proper overlap or contact.
the “neutral zone” because this is where the external forces Always get patient approval before you characterize ante
from the lips and cheek balance the internal forces from rior teeth.
the tongue. If the mandibular posterior teeth have been
missing for some time, the tongue will have grown to a very
large size to fill the space it was afforded. The patient will
have formed a bad habit of pressing the food against the
palate, so along with its increased size, the tongue has also
gotten stronger. The teeth need to be set over the ridge for
improved stability, but the tongue will have become such
an overpowering muscle that the cheeks and lips have been
crowded and the neutral zone has shifted to a more buccal
position.
When a new denture is placed, the patient will feel that
the tongue is crowded and may well never wear the lower
denture. The patient needs to be assured that the tongue
will shrink in size given a proper amount of time, and to
Figure 21.21 The maxillary anterior teeth are esthetically
expect a few episodes of the teeth biting the tongue. The key
related to one another by a ratio of 1.618 to 1, so from anterior
to the success of a lower denture in a patient such as this is to posterior the amount of tooth that is visible becomes
persistent practice and a strong emphasis on esthetics. progressively smaller in width by a ratio of 1.618 to 1.
Figure 21.25 Provide lip support by contouring the gingiva

appropriately.
Figures 21.22 and 21.23 Compare the noncontoured teeth in

the picture in Figure 21.22 to the contoured teeth in the bottom
picture. Teeth may need to be recontoured to permit a proper
overlap or contact.
Figure 21.26 Note the unsupported upper lip in this picture,

and the undercontouring in the lip that results from it.
A patient may want to have a diastema placed in the

same location that their natural teeth had a diastema. One
problem inherent to a diastema is that food debris tends to
collect between the teeth so the patient must floss the den
tures to get it out. This must be explained to the patient at
the wax try‐in appointment.
If we crowd or overlap the teeth, the problems of keep
ing the teeth cleaned are increased, as calculus will tend to
Figure 21.24 Stipple a denture to provide a surface texture
that will break up the ambient light as it reflects from the form on dentures much as it does on natural teeth.
mouth. Overlapping the teeth can also create problems in
e stablishing a bilaterally balanced occlusion. This must also plane of occlusion, the midline, the color and mold of the
be explained to the patient in detail and a signed statement teeth, and the horizontal overlapping of the posterior
must be placed in the record stating that the patient has teeth as the patient functions. If only the anterior teeth are
been encouraged not to get overlapping teeth due to the set, phonetics and function cannot be evaluated, and the
difficulty in keeping them clean. patient will have to be recalled for another appointment to
Stippling of the denture provides a surface texture that evaluate these aspects.
will break up the ambient light as it reflects from the The position of the teeth and the flange also provides
mouth (Figure 21.24). This will have an orange peel facial support, so it is necessary to evaluate these aspects as
appearance and can be done prior to the denture being well. Lip support is also provided by the contours of the
processed or can be applied to the denture after it is pol gingiva, which is established by the festooning of the den
ished. Laboratory technicians tend to prefer applying ture in Figure 21.25, compared to the unsupported lip in
this stippling after the denture is polished as stippling Figure 21.26. Particularly note the relationship of the ver
on a denture wax‐up tends to collect stone debris during milion border of the lower lip to the upper lip.
processing or will be eliminated in the final polish Before you seat the patient for the anterior esthetic eval
procedure. uation, you should make a checklist of the necessary steps.
Since the wax try‐in of a denture involves the patient’s This will include but is not necessarily limited to checking
approval of the esthetics, the denture should be fully the vertical dimensions of occlusion and rest, proving the
waxed up with all the teeth set, including the posterior accuracy of the centric relation record, making a protrusive
teeth. This also allows the occlusion to be evaluated and record, evaluating esthetics and phonetics, and evaluating
the vertical dimension to be assessed. Also, evaluate the the posterior palatal seal.
135
22
Making an Arbitrary Posterior Palatal Seal in the Lab
To make a posterior palatal seal in a denture when a patient Carve the seal with a cleoid/discoid carver (Figure 22.3),
is not available, begin by marking points in the palatine a #7 wax spatula or, better yet, the back of a green‐handled
fovea area and the hamular notch areas (Figure 22.1). knife (Figure 22.4). It should be 0.5 mm deep in the middle
Connect these points with a solid line. Place points in the of the posterior palate, 1 mm deep in the hamular notch
glandular area 5–8 mm forward of this first line and about area, and 1.5 mm deep in the glandular area between the
2 mm anterior to the line at the midpalate (Figure 22.2). hamular notch and the middle of the posterior palate
Draw a second line anterior to the first in a butterfly pat- (Figure 22.5). It should feather out to zero at the anterior
tern, connecting these dots to create a pattern which looks line. It should not extend onto the tuberosities or onto a
like two mountains with a valley in between. torus.
Figure 22.1 Mark points in the palatine fovea and the hamular
notch areas and connect them together with a line. Figure 22.4 Carve the seal with the back of a green‐handled
knife blade.
Figure 22.5 Carve the posterior palatal seal to be 0.5 mm deep

Figure 22.2 Place points in the glandular area 5–8 mm in the middle of the posterior palate, 1 mm deep in the hamular
forward of this first line and about 2 mm anterior to the line at notch area, and 1.5 mm deep in the glandular area between the
the midpalate. hamular notch and the middle of the posterior palate.
Figure 22.3 Carve the seal with a cleoid/discoid carver.

137
23
Interacting with Dental Labs
One of the most important and sometimes most aggravat- stand up in court if it is completely and properly filled out.
ing processes encountered when providing complete den- If it is not filled out with complete instructions, you may
ture service is dealing with a dental lab. When dentists have to accept the dental lab person’s best guess as to the
interact for the first time with a dental laboratory, they proper design or set‐up for the prosthesis you ordered. This
evaluate the lab and the lab evaluates them in return. This could cost you a lot of money for prostheses that simply
is a very professional interaction, and one which if not won’t be acceptable for your patients.
done properly will cause a lot of heartburn on both sides. Some of the important things that need to be expressed
Dental labs generally have several technicians in their on a laboratory prescription for a complete denture include
employ. Some are more experienced and generally provide the following.
better work than others. Often, dental labs will have tech-
nicians who are in training or have just finished dental lab 1) Business address
school. These people need to be kept busy and the lab 2) Business phone
supervisor will assign them to those cases that are consid- 3) Patient’s name
ered easy to do. This judgment may be made on the basis 4) Patient’s age
that certain doctors will make just about anything they are 5) Dentist’s name (printed or stamped)
sent go into the patient’s mouth and out the door. Don’t 6) Dental license number
allow this to happen to your practice. Write detailed 7) Date signed
descriptions for the work you want done and send the pros- 8) Date sent
theses back if they aren’t suitable. Soon, only the better lab 9) Due date
technicians will be doing your work and there won’t be so 10) Mold and shade of teeth
many compromises on quality that you will have to make. 11) Type of teeth (porcelain, acrylic, 0, 10, 20, 30 or 33°,
Most of the areas that the dental laboratory considers etc.)
important are designated in block form on the lab request. 12) Type of occlusal scheme (lingualized, monoplane,
This makes it easy to fill out the form but be aware that this bilaterally balanced, crossbite, anterior end‐to‐end,
usually is not all that you should provide. Always view this curved occlusal plane, etc.)
request as a laboratory prescription. Even if a lab owner/ 13) Design and location for placement of a posterior pala-
operator tells you that you don’t need to write a detailed tal seal if this was not provided in the cast
description of what work you want performed, do it any- 14) Type of denture base resin
way. This lab prescription is a legal document and will 15) Instructions
Try in Finish 23.1 Preparing Casts and Wax

RxINSTRUCTIONS Dentures for the Lab
Please flask, pack and process maxillary and mandibular
completed dentures using LRP characterized Lucitone
resin. Please place patient name on inside of dentures.
●● Carefully separate the casts with the wax dentures prop-
Return on casts so that a lab remount can be done.
erly sealed to them from their plaster mountings. Do not
damage either the casts or the mountings.
●● Set these mountings aside in a safe place so that they are
Thank you.
not lost or damaged in any way.
139
24
Flasking, Packing, and Processing Complete Dentures
Dentists should understand the process of fabricating com- flask. Position the cast in the plaster (Figure 24.10), allow-
plete dentures so that they can effectively convey their ing excess plaster to squeeze upward around the periphery
desires to the laboratory technician and turn in their wax (Figure 24.11). Trim off excess plaster so that it is flush
dentures ready to be processed. This should reduce the with the land area of the cast and clear of the flask lip
number of complete denture remakes. (Figure 24.12). The depth to which the cast is placed into
To understand the process of making complete dentures, the plaster is determined by the height of the teeth in rela-
a dentist or technician must first be knowledgeable about tion to the top of the flask. It is advisable to place the upper
the materials, instruments, and processes involved. half of the flask, without the lid, onto the lower half of the
Most processing flasks contain a lid (Figure 24.1), an upper flask to make this determination. No difficulty will be expe-
(Figure 24.2) and lower component (Figure 24.3) (shaped rienced if the cast thickness is correct as described in the
appropriately according to whether it is used for the upper or procedure for pouring and trimming the master cast.
lower denture) and a bottom knockout disc (Figure 24.4). If a double‐pour method was used to pour the cast, and
The lid and the two main sections have an ID number. the base was too thin, the cast can fracture during process-
Always match up the ID numbers of the sections when ing and compromise the results. The cast may be further
assembling a flask and place the upper and lower sections pressed into the plaster until the correct height is achieved.
of the flask together and ensure that they fit flush with one This must be accomplished while the plaster is still soft,
another (Figure 24.5) (so that there is no gap between the and all excess plaster should be removed after each manip-
two sections that will allow the stone to leak out). ulation. Allow the plaster to set for a minimum of 20 min-
Place the casts in their respective flasks (Figure 24.6) (the utes. Trim and smooth all plaster surfaces. Remove excess
maxillary flask rim will be parallel with the base and the plaster around the edges of the flask so that the two halves
mandibular flask rim will be inclined from back to front). can be placed together without leaving a gap between the
The distance between the teeth of a denture wax‐up and two sections.
the top of the flask should not be closer than 3 mm or 1/8 Apply separating medium into the exposed plaster and
inch. The better option is to allow a one‐half inch clearance stone surfaces (Figure 24.13). This can be petroleum jelly or
from the top of the flask (Figure 24.7). a tinfoil substitute. Tinfoil substitute is painted on with a
If there is too short a distance between the top of the flask brush until a shiny surface is attained and allowed to dry.
and the teeth, this could cause teeth to shift during the Vaseline is rubbed on with the fingers or a brush and the
packing procedure. The base of the cast must be reduced if second pour can be done immediately. Apply a small amount
it is too thick. This destroys the mounting index, preventing of stone over the teeth with the fingers to ward off any bub-
a laboratory remount, so processing error is not corrected. bles that are formed during the second pour (Figure 24.14).
Lubricate the denture casts on all exposed surfaces with Place the upper half of the flask over the lower flask without
Vaseline®. A piece of tinfoil can be adapted to the base to the lid. Make a mix of plaster (or a 50/50 stone/plaster mix-
allow easy separation when deflasking the processed denture) and vibrate it into the flask to a point just over the
ture (Figure 24.8). Prepare the appropriate flask by lubricat- occlusal surfaces of the teeth (Figure 24.15). The amount of
ing all internal surfaces with petroleum jelly (Figure 24.9). plaster needed depends upon the size of the denture.
This will also facilitate the deflasking process. Smooth the plaster down to the occlusal surfaces of the
Each denture is first invested in the lower half of the teeth (Figure 24.16) with a wet finger. Allow the plaster to
respective flask. Make a mix of plaster and place it into the dry until it is hard to the touch and paint it with Vaseline or
Figure 24.3 The lower section of a flask.

Figure 24.1 The lid of a flask.
Figure 24.2 The upper section of a flask. Figure 24.4 The bottom knockout disk.
tinfoil substitute. Allow the tinfoil substitute to dry if it is will better resist pressures against teeth during packing.
used. Clean off the edge of the flask so that it will fit flush Allow the stone to set for 45 minutes.
with the surface. Prepare a mix of stone, enough for one After the investing stone has completely sat, immerse the
model, and carefully apply it to the occlusal portions of the flask in boiling water for five minutes to soften the wax
teeth. Vibrate additional stone into the flask to slightly (Figure 24.19). Remove the flask from the water and care-
overfill it (Figure 24.17). Replace the lid on top of the upper fully pry open the flask halves. Peel away the base plate and
section of the flask and press it completely into place, unmelted portions of the wax (Figure 24.20). Note that if
allowing the excess to squeeze out of the lid holes Triad® was used as a base plate, it will not soften under heat
(Figure 24.18). Clear away excess stone and place the flask and will need to be carefully lifted off the casts to avoid
in a press under light pressure. Artificial stone is used over marring the casts’ surface. Rinse both sections of the flask
the teeth because it has greater strength than plaster and with hot water (Figure 24.21). If the cast is altered in any
Flasking, Packing, and Processing Complete Dentures 141
Figure 24.8 Adapt a piece of tinfoil to the base of the cast to

allow easy separation when deflasking the processed denture.
Figure 24.5 Make sure that the pieces fit together flush with
one another.
Figure 24.9 Lubricate all internal surfaces of the flask with

Figure 24.6 Place the casts in their respective flasks. petroleum jelly.
way, the denture will not fit the mouth and will cause a
sore spot that will require relief. Even though care is taken,
the surface of the mold is often scored, and the resulting
defect will have to be polished out of the denture.
The teeth are generally retained in the upper half of the
flask. The two halves of the flask are separated and placed
in a boil‐out tank in a perforated tray. A detergent may be
used to clean out the mold (Figure 24.22), but all traces of
detergent must be flushed away before applying the sepa-
rating medium. Any excess investment flash should be
scraped from the rim of the flask at this time. Clear all
Figure 24.7 Maintain a distance of not less than 3 mm or 1/8 inch traces of wax and detergent from all investment, cast sur-
between the teeth of a denture wax-up and the top of the flask. faces, and teeth by flushing it repeatedly with clean boiling
Figure 24.10 Position the cast in the plaster in the lower half Figure 24.12 Trim off excess plaster flush with the land area
of the flask. of the cast and clear of the flask lip.
Figure 24.13 Apply separating medium to the exposed plaster

and stone surfaces.
Figure 24.11 Allow excess plaster to squeeze upward around

the periphery of the cast.
water (Figure 24.23). Allow the flasks to cool to room tem-

perature and paint all surfaces with tinfoil substitute,
except the teeth, until they appear shiny (Figure 24.24).
Allow the tinfoil substitute to fully dry before beginning
the packing process (Figure 24.25). It is common practice Figure 24.14 Paint a small amount of stone over the teeth
to paint all surfaces with the tinfoil substitute as an easy with the fingers.
Figure 24.15 Vibrate a 50/50 stone/plaster mixture just over

the occlusal surfaces of the teeth.
Figure 24.17 Vibrate additional stone into the flask to slightly

overfill it.
Figure 24.16 Smooth the plaster down to the occlusal surfaces

of the teeth with a wet finger.
way to apply the separator, but this is not a good idea

because it can inhibit a chemical bond from forming
between teeth and acrylic denture base.
When applying the acrylic to the molds, care should be
exercised so that the teeth are not lifted or removed. The
packing pressure should be moderate and applied gradu-
ally as the excess acrylic escapes. Great pressure can be
directed at the teeth during the closure and this can dis-
place or press them down into the investing material.
Figure 24.18 Press the lid on top of the upper section of the
Therefore, it is critically important to have removed all the flask completely into place and squeeze out excess stone from
excess wax from the teeth prior to investing the denture. the lid holes.
Figure 24.19 After the investing stone has completely set,

immerse the flask in boiling water for five minutes to soften the
wax.
Figure 24.21 Rinse both sections of the flask with hot water.
Figure 24.20 Peel away the base plate and unmelted portions
of the wax. Also remove any excess stone residue that is present.
Prepare a mix of acrylic resin enough for a denture

(30 gm. polymer to 10 ml. monomer is enough for the aver-
age case). In any case, follow the manufacturer’s directions
for proper mixing and packing consistency. Generally, the
mixture is placed in a covered jar and allowed to reach a
doughy consistency before being packed into the mold
(Figure 24.26). For the trial closure, acrylic is placed into
each half of the flask with a slight amount of excess and
two sheets of plastic are placed between the two halves
before closure (Figures 24.27 and 24.28). If there is mini- Figure 24.22 Use a detergent to clean out the mold.
mal undercut on the cast, the single‐pack method can be
used but the double‐pack method is mandatory for situa- press illustrated is a pneumatic press, but hydraulic and hand
tions where the acrylic must pull from deep undercuts presses are also suitable. The flask is opened carefully to pre-
when the flask is separated. vent the possibility of pieces of investing plaster or other
To ensure maximum density of the packed acrylic, the debris from getting into the acrylic. If the expressed acrylic
flask is slowly compressed in a press, allowing excess acrylic totally covers the flasked denture and investment surfaces, it
to squeeze out between the flask halves (Figure 24.29). The is a good pack (Figure 24.30). Evidence of underpacking
Figure 24.25 Allow the tinfoil substitute to fully dry before

beginning the packing process. Note the small piece of plaster flash
overlying the land area on the left side of the cast . This should be
removed prior to the application of the separating medium.
Figure 24.23 Flush the flask repeatedly with clean boiling

water.
Figure 24.26 Place the acrylic mixture in a covered jar and

allow it to reach a doughy consistency before being packed into
the mold.
appears as minute microbubbles in the soft acrylic and lack

of flash around the complete border of the flask. If a mold is
underpacked, more acrylic can be added and the packing
process repeated until the flash is seen expressed around the
entire border of the flask (Figure 24.31). This denotes a com-
plete and even fill.
The flash is carefully removed (Figures 24.32 and 24.33),
and the process is repeated at least twice more with one
Figure 24.24 Paint all surfaces, except the teeth, with tinfoil layer of plastic between the two halves (Figure 24.34) until
substitute until they appear shiny. no flash is seen.
Figures 24.27 and 24.28 For the

trial closure, place a small amount of
excess acrylic into the half of the
flasks containing the teeth with two
sheets of plastic placed between the
two halves before closure.
Figure 24.30 Make sure that the expressed acrylic totally

Figure 24.29 Slowly compress the flask in a press, allowing covers the flasked denture and investment surfaces to ensure
excess acrylic to slowly squeeze out between the flask halves. that it is a good pack.
Figure 24.31 If a mold is underpacked, add more acrylic and

repeat the packing process until the flash is expressed around Figure 24.34 Repeat the process at least twice more with one
the entire border of the flask. layer of plastic between the two halves until no flash is seen.
Figure 24.35 To ensure that the acrylic is sufficiently dense,

press it until it feels rubbery to the touch, and remove all flash.
When the acrylic is sufficiently dense, feels rubbery to

the touch, and all flash is removed (Figure 24.35), the cast
side of the flask is again painted with tinfoil substitute and
the final closures made (Figure 24.36).
The last thing that is done before closing the flask is to
place the patient’s name on the tissue side of the denture.
An easy way to do this is to reverse a carbon paper in a
conventional typewriter and type the patient’s name on a
piece of packing plastic placed over the carbon paper. This
makes a mirror image of the patient’s identification. The
Figures 24.32 and 24.33 Carefully remove all flash. intaglio surface of the denture is moistened with monomer
Figure 24.36 Paint the cast side of the flask with tinfoil Figure 24.38 Cure the acrylic resins in water in a curing tank
substitute again, and then make the final closure. at 160 °F for one hour.
Figure 24.39 Gradually cool the flask in a deflected stream of

cool water that is spread out so that it bathes the entire surface
of the flask.
curing. If two dentures are to be cured, they may be trans-

Figure 24.37 Pack the flasks under moderate pressure and
avoid compressing the spring in the bottom of the pressure flask ferred to a double processing pressure flask. The manufac-
until the pressure plate contacts the bottom of the flask. turer’s directions should be followed for curing. Most acrylic
resins are cured in water in a curing tank (Figure 24.38) at
160 °F for one hour, followed by another hour at boiling.
and the plastic is pressed into place with the carbon Another method is to cure them at 160 °F for 10 hours.
embossed side toward the denture before the final closure. Cool water is used to cool the flask, but the stream must
The final closure will not contain a plastic sheet, except for be deflected and spread out so that it bathes the entire sur-
this small piece. face of the flask and allows it to gradually cool uniformly
The packed dentures should be placed in a processing (Figure 24.39). The flasks are removed and allowed to
press that is screwed down until the flasks are under moder- bench cool (Figure 24.40). Bench cooling is important, as
ate pressure (Figure 24.37), or “C” clamps can be used. The separating the denture while it is too hot may cause frac-
flasks should remain under pressure for at least 15 minutes ture and/or distortion. Also, too rapid cooling can cause
before being placed in the curing tank. This is known as stress to be incorporated within the denture base that can
bench curing and allows acrylic to equalize its flow before lead to a spontaneous fracture.
Figure 24.40 Remove the flasks and allow them to bench cool.
Figure 24.41 Remove the flask lid by wedging an instrument

such as a Buffalo knife or chisel in the notch.
After the flask is sufficiently cool to the touch, the flask

lid is removed by wedging an instrument such as a Buffalo
knife or chisel in the notch (Figure 24.41) that is provided
on the flat end of the flask. The working of this chisel up
and down in this notch will quickly free the lid.
Use a mallet to tap the insert disc at the bottom of the flask
Figures 24.42–24.44 Use a mallet or hammer to dislodge the
until the investment is dislodged from the flask. A metal ham- invested denture from the upper part of the flask and to tap the
mer can be used and works well in experienced hands insert disc at the bottom of the flask until the investment is
(Figures 24.42–24.44), but great care must be taken when dislodged from the flask.
Figure 24.47 If the denture detaches from the cast, clean the
cast and the mounting carefully and allow them to dry.
plaster should be removed in small increments so that

none of the acrylic, cast or teeth are fractured. The pro-
cessed denture base containing the teeth should be recov-
ered intact and still attached to the stone master cast. If the
denture detaches from the cast (Figure 24.47), the cast and
the mounting must be carefully cleaned and allowed to dry.
The denture is placed in a bowl of water while the cast and
Figures 24.45 and 24.46 Use a plaster saw or chisel to remove mounting dry. When the plaster mounting and cast are
all plaster until the denture is exposed. thoroughly dry, the denture is removed from the water,
toweled dry and replaced on the cast. The denture is
using a hammer because it can beat up the flask. Use the secured to the cast with sticky wax.
broad, flat surface of the mallet to remove the invested den- The flasking, packing, and processing of a complete den-
ture from the flask. If the flask was properly lubricated prior to ture can produce some distortion from the original waxed‐
the investing, removal should not be a problem as the invested up form. The most common fault is an increase in vertical
denture should come out clean (Figure 24.44). An air chisel, dimension which leaves the incisal guide pin open or not
plastic shears, and/or nippers can be used to chip the plaster touching the incisal guide table due to the slight excess of
from around the periphery of the stone cast until the base is acrylic in the flask. This is called “processing error” and is
exposed. Care must be taken when using these tools, however, anticipated and desired. This is increased if the flash has
because they can do serious damage to the denture. not been sufficiently removed during trial closure. An
Use a plaster saw or chisel (Figure 24.45) to remove all occlusal error of up to 0.75 mm is acceptable and can be
plaster until the denture is exposed (Figure 24.46). The corrected by occlusal alteration of the teeth.
151
25
Completing a Laboratory Remount
Before seeing the patient for the insertion appointment, proximal surfaces of both the casts and their plaster
the processed dentures must be retrieved from the lab and mountings (Figure 25.6). Remount the complete den-
the maxillary cast must be remounted on the articulator, tures by adding sticky wax around the entire periphery
using the original plaster mount. of the mounting and cast (Figure 25.7).
25.1 Steps to Be Completed 25.3 Adjusting the Occlusion
1) The complete denture (CD) is fully processed. 1) Check the guide pin for an increase of vertical dimen-
2) The CD is remounted on the articulator. sion, which is expected and is termed “processing error”
3) Do not use superglue. (Figure 25.8). This will have to be corrected during a
4) The processing error is corrected. laboratory remount procedure. It shows up as a gap
5) A remount index is made (preserves facebow record). between the guide pin and the incisal guide table. No
cusps are reduced in the process. This is the only correc-
tion done during the lab remount. Since there are no
cusps on zero‐degree teeth, the only occlusal reduction
25.2 The Laboratory Remount Procedure made on a denture with zero‐degree teeth is that the
occlusal surfaces of the maxillary denture teeth are
1) Set the incisal guide pin at the level where the wide
made flat using a flat piece of sand paper resting on a
mark on the pin is even with the top member of the
flat surface. A sanding sponge must not be used for this
articulator (Figure 25.1). Make sure that the incisal
procedure because it is soft and incapable of developing
guide pin touches the guide table (Figure 25.2). Lock
a flat surface on the denture teeth.
the maxillary member in its most forward position
2) Ensure the greatest accuracy in marking the articular
using the condylar thumbscrews (Figure 25.3).
surfaces of the teeth by using one thickness of double‐
2) Set the lateral guidance at 15° using the large set‐screw
sided articulating tape (AccuFilm®) (Figure 25.9). Do
on top (Figure 25.4). Adjust and set the horizontal con-
not use heavier articulating paper because it will record
dylar guidance on both sides of the articulator at 30° for
areas that are not in intimate contact. This would result
anatomic teeth (Figure 25.5).
in unnecessary and undesirable reduction of surfaces
3) The casts are returned from the lab on the casts and are
that will need to be preserved. It is important to note
ready to be remounted on their original mountings.
that during the lab remount procedure, processing error
Clean the bases of the casts and the surfaces they con-
is the only correction that is made.
tact on the plaster mountings by brushing them with a
soft toothbrush to ensure they are clean prior to mount- With the condyles locked in centric relation, deepen the
ing the casts on the articulator. Very well‐defined marks in the fossae with the end of a laboratory acrylic bur
grooves which have been cut in the bases of the casts (Figures 25.10 and 25.11). Do not reduce any cusp tips! No
before their initial mounting will ensure that there is an eccentric adjustments are made to the occlusion prior to the
accurate and stable fit between the casts and their clinic remount, as it is impossible to obtain totally accurate
mountings. Since the casts are moist and sticky wax will records of jaw relationships with base plates and wax rims
not stick to wet casts, retention cuts are made on the or teeth set in wax. Once the pin touches the guide table
Figure 25.3 Lock the maxillary member in its most forward

position using the condylar thumbscrews.
Figure 25.1 Set the incisal guide pin so that the wide mark on
the pin is even with the top member of the articulator.
Figure 25.4 Set the lateral guidance at 15°.
in a laboratory remount to correct the changes in vertical

dimension of occlusion due to processing error.
Figure 25.2 Make sure that the incisal guide pin touches the If it is a zero‐degree monoplane denture, the occlusion of
guide table when it is set at the wide mark. the maxillary denture’s occlusal plane is flat‐surfaced with
a piece of sandpaper on a flat surface (Figure 25.13).
(preferably it was set at zero when the case was submitted to A sanding block cannot be used for this purpose. A remount
the lab) (Figure 25.12), no further adjustments are made index is then made to preserve the facebow record; other-
until the dentures are fitted in the mouth and new interoc- wise a new facebow record must be done during the inser-
clusal records are made in the clinical remount procedure. tion appointment. The dentures are then returned to the
Therefore, only the occlusion is adjusted in centric relation lab for removal from the cast and final finishing.
Figure 25.8 Check the guide pin for evidence of processing error.
Figure 25.5 Set the horizontal condylar guidance on both

sides of the articulator at 30° for anatomic teeth.
Figure 25.9 Use one thickness of double-sided articulating

tape to mark the articular surfaces of the teeth.
Figure 25.6 Make retention cuts on the proximal surfaces of

both the casts and their plaster mountings.
Figure 25.10 Use a laboratory acrylic bur to deepen the marks

Figure 25.7 Remount the complete dentures by adding sticky wax. in the fossae of the teeth.
Figure 25.13 With a monoplane denture set in zero-degree

teeth, flat-surface the maxillary denture’s occlusal plane with a
piece of sandpaper resting on a flat surface.
Figure 25.11 Avoid reducing any cusp tips.
Figure 25.12 Once the pin touches the guide table, make no
further adjustments during the lab remount.
155
26
Making a Remount Index
1) After locking the condyles in centric and setting the the upper member of the articulator to hold the guide
incisal guide pin at zero, attach the remount table to the pin tightly against the guide table. Allow the plaster to
lower member of the articulator (Figure 26.1). Lubricate harden. Remove all rubber bands and tape from the
the teeth with petroleum jelly (Figure 26.2). Wrap a plaster index (Figure 26.5).
piece of masking tape around the occlusal index table 3) Remove the index from the remount platform and
(Figure 26.3). reduce it on the model trimmer until the depressions of
2) Close the articulator so that the tape covers about 2 mm the teeth are less than 1 mm deep (Figure 26.6). The
up on the teeth (Figure 26.4). Fold the tape under the remount platform has two or three distinct depressions
occlusal index platform to achieve a good seal with the on its surface which produce an index on the reverse
platform. Pour mounting plaster and flatten it down. side of the remount index so that it can be easily repo-
Close the articulator and seat the upper teeth into the sitioned on the platform (Figure 26.7). Print the
plaster by gently tapping on the upper member of the patient’s name on the index with a permanent marker
articulator until the guide pin touches the table. You to identify it and store it in a safe place for future use
may use rubber bands or place a heavy weight on top of (Figure 26.8).
Figure 26.1 Attach the remount table to the lower member of
the articulator.
Figure 26.4 Close the articulator so that the tape covers about
2 mm up on the teeth.
Figure 26.2 Lubricate the teeth with petroleum jelly. Figure 26.5 Remove all rubber bands and tape from the
plaster index.
Figure 26.3 Wrap a piece of masking tape around the occlusal Figure 26.6 Reduce the remount index on the model trimmer
index table to form a containment barrier. until the depressions of the teeth are less than 1 mm deep.
Making a Remount Index 157
Figure 26.7 The remount platform has two or three distinct

depressions on its surface which produce an index.
Figure 26.8 Print the patient’s name on the index with a

permanent marker.
159
27
Remove Complete Denture from the Cast and Finish
The dentures are very carefully removed from the casts to bubbles between the teeth may be easily removed by the
avoid breaking or otherwise damaging them. This is done point of a green‐handled knife (Figure 27.7).
by making grooves in the base of the cast and carefully
1) Inspect the tissue side of the dentures for small blebs
fracturing small sections of the cast one piece at a time
due to voids in the casts. Remove these with burs and/or
(Figure 27.1). Trim off all flash from the peripheral borders
a denture scraper (Figure 27.8). A piece of 2 × 2 gauze
of the dentures with a laboratory acrylic bur (Figure 27.2)
rubbed lightly over the tissue surface will pull a thread
or an arbor band (Figure 27.3).
if there are any small blebs (Figure 27.9).
2) Check for flash on the teeth. Remove this carefully with
a discoid or other small instrument and a mounted rub-
27.1 Finish and Polish the Dentures ber point (Figure 27.10) but do not overpolish acrylic
denture teeth.
Instruments and supplies needed are as follows. 3) Finish the external surface and peripheral fold with
rubber points to remove gross defects and impart the
●● Plaster saw
final contour. Use light pressure on the restoration
●● Buffalo knife
when using a lathe or handpiece.
●● Acrylic trimmers – burs and stones
4) Use wet rag wheels (Figure 27.11) and wet felt cones
●● Rag wheel
(Figure 27.12) mounted on a lathe to polish the external
●● Felt wheel
surfaces up to the peripheral fold. Use coarse abrasives
●● Felt cone
and burs first, if needed for gross reduction. Use finer
●● Pumice
abrasives to finish. Start with medium pumice followed
●● Hi‐Shine polishing agent
by fine flour of pumice until all scratches are removed. It
Care must be taken not to overpolish the denture in the is advisable to use the low speed on the lathe and copious
following areas. amounts of pumice in order to better control the amount
of polish. Maneuver the denture so that the depressed or
●● Buccal, facial, and lingual fold contour (remember you
concave areas are polished (Figures 27.13 and 27.14).
should have established these areas by border molding
Maintain the surface contour during this procedure.
and muscle trimming!) (Figure 27.4)
5) Finally, impart a high shine on the same areas using a felt
●● Postdam area
wheel and Hi‐Shine (Figure 27.15). Note that the basal seat
●● Gingival festooning around the teeth (Figures 27.5 and
surfaces are not altered or shined. A piece of masking tape
27.6)
can be placed over the teeth to prevent inadvertent abrad-
●● Surface contour and root eminences
ing of their surfaces (Figure 27.16). Finish the gingival
Minor alteration of these areas may be made with acrylic embrasures and other hard‐to‐reach areas with Hi‐Shine
burs, small burs, and stones (Figures 27.7–27.9). Small and soft bristle brush wheels (Figures 27.17–27.18).
Figure 27.1 Remove the cast from the denture in small Figure 27.3 Use an arbor band to quickly remove large
sections one piece at a time. amounts of flash.
Figure 27.2 Trim off all flash from the peripheral borders of
the dentures with a laboratory acrylic bur.
Figure 27.4 Take care not to overreduce buccal, facial, and
lingual fold contours.
Figures 27.5 and 27.6 Take care not to reduce or overpolish gingival festooning around the teeth.
Remove Complete Denture from the Cast and Finish 161
Figure 27.7 Remove small bubbles easily from between the Figure 27.9 Rub a piece of 2 × 2 gauze lightly over the tissue
teeth with the point of a green‐handled knife. surface, which will pull a thread if there are any small blebs.
Figure 27.10 Remove small blebs carefully with a discoid

Figure 27.8 Remove small blebs on the tissue side of the carver, other small instruments, and/or a mounted rubber point.
dentures with acrylic burs, rubber points, and/or a denture scraper.
Figure 27.11 Use wet rag wheels mounted on a lathe to polish

the external surfaces up to the peripheral fold.
Figures 27.13 and 27.14 Maneuver the denture so that

depressed or concave areas are polished.
Figure 27.12 Use wet felt cones on a lathe to polish the

external surfaces up to the peripheral fold.
Remove Complete Denture from the Cast and Finish 163
Figure 27.15 Use a felt wheel revolving at slow speed and

Hi‐Shine polishing agent to impart a high gloss on concave
external surfaces of the denture.
Figures 27.17 and 27.18 Finish gingival embrasures and other

hard‐to‐reach areas at low speed with Hi‐Shine and soft bristle
brush wheels.
Figure 27.16 Place a piece of masking tape over the teeth to

prevent inadvertent abrading of their surfaces.
165
28
Quality Standards in Appearance
28.1 Acrylic Appearance 4) The denture base is burned or discolored from heavy
pressure or extended polishing with a lathe and/or
1) The denture base is clean without traces of investment handpiece.
or polishing media present on its surface (Figure 28.1). 5) Sharp denture borders or sharp areas on the tissue sur-
2) Lingual contours (Figure 28.2) and gingival contours face are still present after polishing.
(Figure 28.3) mimic nature and follow the desired crite- 6) Teeth are broken during cast retrieval or polishing.
ria of the restoring dentist and the patient. 7) Frenular notches are overrelieved.
3) All edges are rounded and smooth, but not overpolished. 8) Teeth were overpolished, and surfaces were abraded
4) Stippling and festooning are subtle and follow accepted away by careless use of polishing cones (Figure 28.5) or
criteria for appearance and contour. wheels (Figure 28.6) and heavy abrasives or pressures.
5) Hard‐to‐clean areas must be well scrubbed under run- 9) Dentures are insufficiently polished by using only
ning water with a denture brush and soap (Figure 28.4). mounted rubber points (Figure 28.7). The denture
6) The tissue‐bearing surface of the denture base must be must be polished to a high shine, otherwise plaque will
free of sharp edges and positive or negative defects adhere to the surface and calculus will form.
(bubbles and voids). 10) Seal the dentures in a plastic bag containing water to
keep them moist in order to prevent distortion due to
warpage casued by a denture base drying out and
28.2 Quality Standards in Occlusion being rehydrated in the mouth. For the same reason,
the patient should place the dentures in a water bath
1) There should be minimal pin opening on the articulator whenever they are removed from the mouth.
when the restorations are remounted. Prior to placing the denture in the patient’s mouth, care-
2) The appliance should have even contact on all occlusal fully check the internal surface of the denture for any
surfaces. rough spots that would cause irritation to the underlying
3) Premature tooth contacts are removed carefully with soft tissue. Rub a piece of 2 × 2 gauze gently over the intag-
selective grinding procedures; care must be taken to lio surface to easily find a rough spot. If a thread pulls from
maintain an esthetic appearance of the teeth. the gauze, this indicates an area that is sufficiently rough to
4) Labial, buccal, and lingual surfaces of denture teeth cause irritation to the underlying soft tissue.
should not require polishing. Remove any undercuts in the internal surfaces of the
denture that may prevent a denture from seating or cause
damage to the underlying soft tissue during its seating. If
28.3 Quality Failures these areas are overlying displaceable soft tissue, they
should be highly polished. If a maxillary denture is difficult
1) The denture was broken when the investment was to seat because of the path of insertion created by a strong
removed. labial prominence of the maxillary anterior ridge, the rugae
2) Tooth surfaces are overpolished and show loss of labial, area can be reduced and the denture smoothed to facilitate
buccal, and lingual anatomy. its placement. This will prevent undue reduction of the
3) The tissue surface of the denture base has been inad- internal labial surface of the flange which would negatively
vertently polished, creating loss of retention and fit. affect a proper seal and lead to poor retention.
Figure 28.4 Scrub hard-to-clean areas very well under running

water with a denture brush and soap.
Figure 28.1 Check the denture base surface to ensure that it is
clean with no traces of investment or polishing media present.
Figure 28.2 Follow the desired criteria of the restoring dentist

and the patient to produce lingual contours that mimic nature.
Figure 28.5 Careless use of polishing cones and heavy

abrasives or heavy pressures will overpolish and abrade away
surface detail.
Figure 28.3 Follow the desired criteria of the restoring dentist

and the patient to produce gingival contours that mimic nature.
Quality Standards in Appearance 167
Figure 28.6 Using a cone or wheel that is too large will

overpolish and abrade away the lingual surfaces of these teeth.
Figure 28.7 Using mounted rubber points alone will
insufficiently polish a denture.
169
29
Inserting Complete Dentures in the Mouth
Before the patient is seated in the chair, the fee for the fin- 9) Equilibrate the teeth in lateral excursions until a maxi-
ished dentures must be paid in full and the dentures mum number of posterior teeth contact on the work-
retrieved from the lab. Other instruments and accessories ing side and continuous contacts exist on the balancing
needed are as follows: side. There should be no contact of the anterior teeth
during these movements.
●● the articulator
10) Adjust the teeth in protrusive until the anterior teeth
●● a remount index and jig
are in uniform contact simultaneously with the poste-
●● a Buffalo knife or green‐handled knife
rior teeth bilaterally.
●● acrylic burs
11) Polish and insert the dentures.
●● a straight handpiece
12) Instruct the patient in the techniques of proper home
●● articulating paper
care of the dentures and what to expect from their
●● shim stock
dentures.
●● pressure indicator paste (PIP)
13) Do a 24‐hour follow‐up and make corrections as needed.
●● a bristle brush for applying the PIP
14) Do a 72‐hour follow‐up and make corrections as needed.
●● an exam pack
●● two tongue blades These procedures should be performed in the sequence
●● a mixing bowl and spatula listed. They should all be performed for all complete den-
●● disclosing wax. tures with anatomic posterior teeth. Steps 6 and 8 are omit-
ted for dentures with zero‐degree teeth and step 9 is done
Lab items which must also be available include mount-
after the horizontal condylar guidance is set to correspond
ing plaster and room‐temperature water.
with the angle of the occlusal plane and after the maxillary
denture is flat‐surfaced. Patients should be given follow‐up
appointments at the sequences indicated.
29.1 Insertion Sequence
1) Paint the internal surfaces with PIP and place the den-
ture in the patient’s mouth. 29.2 Relationship between
2) Adjust the intaglio surface of the bases anywhere there Adaption and Occlusion
is premature contact.
3) Adjust the denture borders where overextensions are The interrelationship between base adaptation and
obvious. occlusion cannot be precisely duplicated outside the
4) Test the dentures for comfort and retention. mouth, both because of minor distortions in the fabrica-
5) Make a protrusive record. tion process and because the oral tissues are dynamic.
6) Make an interocclusal relationship record in centric Casts of the edentulous arches only represent the oral
relation (CR). contours at the time the impressions were made and
7) Remount the dentures on the articulator in centric reflect the accuracy of the tray. Articulators can only rep-
relation. resent mandibular movements, they cannot duplicate
8) Adjust centric contacts until there are simultaneous them. Wet the dentures. Seat the dentures firmly in the
contacts on all posterior teeth. mouth. Have the patient close together.
Each step involved in the fabrication of complete den- that should be highly polished. The retention of the lower
tures must be completed as accurately as possible for that denture is assessed by gently pushing posteriorly against
step. The most accurate interocclusal record cannot be the facial surfaces of the mandibular incisors. The denture
made until the complete dentures are processed and a sta- should not become dislodged.
ble denture base with teeth bonded to acrylic is established.
For this reason, a patient remount is imperative for a set of
dentures to fit and function properly. Intraoral adjustments 29.5 Pressure Indicator Paste
are not reliable for achieving bilateral balance in dentures.
Pressure indicator paste (Figure 29.1) should be used to
recheck the adaptation to the denture‐bearing tissues of
29.3 Common Causes of Lack both upper and lower prostheses, even if retention seems
of Retention acceptable. Small areas of excess pressure can disrupt
occlusal harmony or lead to ulceration that erodes patient
Most problems that cause insufficient retention of a maxil- acceptance of the prosthesis.
lary complete denture result from a lack of intimate con- A handy brush is used to wipe on the paste. A disposable
tact between the maxilla and the intaglio surface of the syringe will make application easier. PIP spray or mouth-
denture. This may result from several conditions, the most wash is used in xerostomia patients to prevent the PIP from
common of which is the failure to provide an adequately sticking to the mucosa. Mouthwash can also be used as a
prepared posterior palatal seal. Frequently, the denture solvent to remove the PIP from the internal surface of a
high‐centers on the hard tissue of the palate and prevents denture. A cotton roll or cotton‐tipped applicator should
the posterior palatal seal area from contacting the soft pal- not be used to apply the PIP, as it is important to see brush
ate. This situation should be obvious if PIP is used properly. marks as a diagnostic tool.
This is most often the case where there is a palatal torus
●● Paint a thin, even coat of PIP on a dry denture surface
present, even one that is very small and would not other-
with a bristle brush.
wise interfere with the retention of a maxillary complete
●● Any visible brush marks will indicate areas that are not
denture. The area in the tissue surface of the maxillary
in contact.
denture should be liberally reduced over the palatal torus
●● Areas where there were brush marks made but the marks
to prevent any contact whatsoever with the torus. An over-
are not visible indicate areas where the tissue is within
growth of soft tissue will not occur over a torus and the
subsequent resorption of the ridge will invariably lead to
this high‐centering effect.
After you evaluate the retention, have the patient try to
remove the dentures. Then instruct the patient to slip a fin-
ger along the buccal corridor and break the air seal so they
can be removed.
29.4 Common Causes of Instability
Probably the most common cause of instability in a man-

dibular denture is the failure to set the teeth over the crest
of the ridge, particularly the anterior teeth. The more buc-
cal or labial the mandibular teeth are set, the more prone
the denture is to dislodge due to a teeter‐totter effect. If a
mandibular denture can engage undercuts in the retro-
mylohyoid region, and this is tolerated by the patient, a
resistance to displacement by an anterior occlusal force is
provided. The more labially the mandibular anterior teeth
are set, the more pressure that will be brought to bear on
this area, which decreases the chances that the patient will
be able to tolerate it. To improve patient comfort, this is Figure 29.1 Use pressure indicator paste to recheck the
probably the only area of the intaglio surface of a denture adaptation to the denture-bearing tissues.
Inserting Complete Dentures in the Mouth 171
half a bristle of the brush of being in contact. It is not nec-

essary that the denture base be adjusted to allow contact
in all areas where the brush marks have been obliterated.
●● Smudged areas indicate contact with the underlying
tissues.
●● Smudged areas over undercuts in displaceable soft tissue
are not reduced as they would likely break the seal.
●● Smudged areas where you can see the pink denture base
showing through indicate contact with the underlying
tissues.
●● Smudged areas over undercuts in displaceable soft tissue
are not reduced as they would likely break the seal.
Adjust pressure areas, wipe off, add more, adjust, etc.
Adjust sparingly, as the impression is expected to have
been very accurate (Figure 29.2). Do this until the pressure
is evenly distributed over the entire tissue surface of the
Figure 29.3 Pay particular attention to any tori of a maxillary
denture. Expect to see contact spots in the palatal seal area. denture.
These are desired and should not be adjusted unless they
are excessively heavy.
When the adjustment is completed, the brush marks are
mostly absent, and the posterior palatal seal bead will be
showing. Particular attention must be paid to the mylohy-
oid ridge area of the lower denture and any tori of a maxil-
lary denture (Figure 29.3) and these contacts must be
relieved (Figure 29.4). These are particularly vulnerable
trouble spots. If a maxillary torus is prominent, the maxil-
lary complete denture will invariably fracture right down
the middle of the palate.
Areas that often require relief on the maxillary complete
denture (Figure 29.5) are the retrozygomatic prominence,
the midpalatal suture groove, the buccal notch, the incisive
Figure 29.4 Relieve the area of any tori of a maxillary denture.
fossa, and the labial notch. Generally, high spots result

because the impression material displaces soft tissue in
these areas while setting. The denture provides constant
pressure bearing on these areas and the soft tissue displaces
the thin impression paste which results in spots where the
intaglio surface of the denture shows through.
Because the maxillary anterior is frequently undercut,
pressure spots appearing in this area are not routinely
removed. Unless and until the patient feels uncomfortable,
this area is not relieved. If the patient feels discomfort in
this area, the denture is relieved only enough for the patient
to be able to insert and remove it comfortably. Alternatively,
and more desirably, the denture can be relieved slightly in
Figure 29.2 Adjust pressure areas sparingly, wipe off the
abrasive, inspect the area, use more abrasive if necessary, make the rugae area to allow some freedom during insertion and
more adjustments, etc. removal. The denture should be repainted, reinserted, and
mandibular dentures, the flanges can be reduced consider-

ably without damaging the fit.
29.6 Disclosing Wax
Overextended denture flanges are adjusted using disclos-

ing wax (Figure 29.7) to show these areas after the den-
ture is fitted in the mouth. In this example, disclosing wax
has been placed in a disposable syringe to ease its place-
ment on the denture borders. It is not the same as PIP and
is much stiffer. For this reason, the wax in the syringe is
tempered in a warm water bath to make it more flowable.
It is simply squirted on the dried denture border and the
denture is inserted in the mouth to mold the borders of
the selected areas.
Place the disclosing wax on the flange with an instru-
ment. Make sure there is adequate thickness. Start with
maxillary anterior. Place the denture in the mouth and pull
Figure 29.5 Other areas that will often require relief on the
maxillary complete denture are the retrozygomatic prominence, the lip down firmly, then remove the denture and adjust
the midpalatal suture groove, the buccal notch, the incisive the area that is highlighted. Be careful not to overadjust as
fossa, and the labial notch. the vacuum seal could be compromised, causing the den-
ture to be unstable. Adjust the area that is highlighted.
Continue with other areas and reapply until all overex-
tensions are eliminated. When one area is adjusted, move
to another area and reapply the wax and continue the pro-
cess until all overextensions are eliminated. Do not forget
the buccal surfaces of flanges, particularly where the coro-
noid process contacts the distobuccal flange (Figure 29.8)
when the patient moves their jaw laterally.
Continue with the lower denture. In particular, check
the lingual frenum area (Figure 29.9) which is the most
common problem area on a lower denture. Also, the retro-
mylohyoid flange area (Figure 29.10) and the labial
notch (Figure 29.11) frequently require adjustment. The
bulk of the labial flange can be removed prior to placing
Figure 29.6 Areas that will often require relief on the

mandibular complete denture are the retromylohyoid flange, the
buccal flange, the lingual notch, labial flange, and labial notch.
relieved repeatedly until there are no pressure spots and/or

the patient is comfortable.
Areas that will often require relief on the mandibular
complete denture are the retromylohyoid flange, the buccal
flange, the lingual notch, labial flange, and the labial notch
(Figure 29.6). Again, these are caused because the impres-
sion material will fill the vestibule if the pressure is relaxed
because gravity will pull it down. This flange overextension
is more common in the mandible than in the maxilla. Figure 29.7 Adjust overextended denture flanges using
Since there is no concern about breaking a vacuum seal on disclosing wax.
Inserting Complete Dentures in the Mouth 173
Figure 29.8 Do not forget to check the buccal surfaces of Figure 29.10 The retromylohyoid flange area frequently
flanges, particularly where the coronoid process contacts the requires adjustment.
distobuccal flange.
Figure 29.11 The labial notch frequently requires adjustment.
Figure 29.9 In particular, check the lingual frenum area of the the denture can be marked with an indelible transfer stick
lower denture. to show where reduction is needed. Disclosing wax is
meant to do the fine tuning, not bulk reducing. The lingual
the disclosing wax by pulling the lip up and out and observ- frenum area can be adjusted in the same way by measuring
ing the height before placing the denture in the mouth. the height of the floor of the mouth when the patient raises
This height can be measured with a periodontal probe and their tongue to the roof of the mouth.
175
30
Performing a Clinical Remount
30.1 Clinical Remount of Complete the flanges of a denture to hold the dentures firmly in
Dentures Set in the Three Different place. The palate of a maxillary denture should also
touch. Any undercuts are minimally blocked out before a
Occlusal Schemes
rigid cast is poured into the denture. A block‐out material
must be able to be easily removed from the denture with-
Typically, the casts have been removed by the dental lab
out leaving a residue. If the block‐out material interferes
and the dentures are finished before they are returned to
with removing and replacing the cast accurately on the
the dental office. They are polished and ready to insert. If
remount cast, it must be removed. The drawback of hav-
this is the case, a remount index will not be provided and a
ing such a minimal amount of registration of the denture
new facebow record will need to be made. The following
base is that the denture must be fixed in place with sticky
pictures illustrate how this is done.
wax or with compound. They must be kept clean. Use a
1) First, make a facebow transfer record since the relation- toothbrush to remove any accumulated debris.
ship of the original record was not preserved when the 6) Make sure that the casts are clean of debris before they
lab removed the upper denture from the cast (Figure 30.1). are mounted on the articulator, otherwise the dentures
2) After adjusting the dentures in the patient’s mouth using will be unnecessarily harmed during the occlusal equili-
pressure indicator paste (PIP), make a bite registration in bration that follows. Remount casts must hold the den-
protrusive and centric relations You will be able to record tures accurately and firmly in place. To do this, they must
these measurements much more accurately than you could be kept clean. Use a toothbrush to remove any debris that
expect from a base plate with teeth set in wax. These records accumulates in the teeth imprints of the remount index
will be made with the recording medium covering the and on the tissue surface of the remount casts.
occlusal and incisal surfaces of all teeth, be intact as a single
unit, and be in a horseshoe shape.
3) Since the centric record will be used first in the mounting
of the mandibular cast, make a protrusive record first
30.2 Making a Maxillary Remount Cast
(Figure 30.2). The protrusive record will be used to set the
The denture remount cast does not require a land area, so
horizontal condylar guidance on the articulator to match
after it is mounted, the plaster can be trimmed flush with the
the patient’s condylar guidance. When recording the pro-
denture with a green‐handled knife or Buffalo knife
trusive relation, the teeth need only to be in an end‐to‐end
(Figure 30.4). The mounting can then be smoothed under
relationship. This may not be obtainable in some severe
running water with a piece of wet/dry sandpaper (Figure 30.5).
Class II patients and cannot be recorded on the articula-
A better way of making a maxillary remount cast is
tor. A special articulator with an extended condylar path
described in the following instructions.
can be used, if available, but this is usually unnecessary as
the patient will perform all the normal movements of 1) Record the denture flange. Place a strip of rope (utility)
masticatory function posterior to the incisal contact point. wax around the external part of the denture flange and
4) Set the protrusive relation record aside and use the cen- lute it in place with sticky wax and a hot instrument
tric relation record (Figure 30.3) to mount the lower (Figure 30.6).
denture on a remount cast. 2) Block out undercuts in the maxillary denture. The
5) Remount casts must be accurate and stable. All that is area over the palate should be left uncovered. Clay,
necessary in a remount cast is about 2 mm depth around putty, or wet pumice can be used as a block‐out
Figure 30.1 Make a facebow transfer record since the relationship of the original record was not preserved.
Figure 30.2 Make a bite registration in protrusive relation.
Figure 30.4 The plaster of the denture remount cast can be

trimmed flush with the denture.
material (Figure 30.7). Wax should not be used to

block out the undercuts as it is hard to remove from
the tissue surface of a denture. (There should be a
2 mm minimum depth on flanges and the palate
should be recorded.)
3) Box and pour the cast in quick‐set plaster. Boxing is the
best way to make a remount cast (Figure 30.8) because
you get a nice dense cast. Although this is not entirely
Figure 30.3 Make a bite registration in centric relation and use necessary for an accurate remount cast, it looks much
it to mount the lower denture on a remount cast. more professional to the patient (Figure 30.9).
Performing a Clinical Remount 177
Figure 30.5 Smooth the mounting under running water with a

piece of wet/dry sandpaper
Figure 30.7 Use clay, putty, wet paper towel, or wet pumice as a
block-out material.
Figure 30.8 Boxing is the best way to make a remount cast.

Figure 30.6 Place a strip of rope (utility) wax around the
external part of the denture flange and lute it in place with
sticky wax and a hot instrument.
30.3 Mounting a Maxillary
Remount Cast
4) After the plaster has set, remove the boxing wax and
●● Place the maxillary remount cast and the maxillary com-
beading wax (Figure 30.10).
plete denture on the remount index (Figure 30.14). Be
5) Clean off all residues (Figure 30.11).
sure to index the base of the cast and soak it in cool water
6) Remove the denture from the remount cast. Then
so the plaster will stick to it!
remove the wet paper towel from the cast (Figure 30.12).
7) Trim down the land area so that it is smooth and only Mount the maxillary denture with its remount cast on
about 1 mm in depth. the articulator. With the pin set on zero, lock the condyle in
8) Replace the denture on the remount cast and make sure the centric relation position with the incisal guide pin
the fit is accurate (Figure 30.13). touching the incisal guide table (Figure 30.15). Since the
Figure 30.11 Clean the cast of all residues.

Figure 30.9 A dense cast made by boxing and pouring an
impression looks much more professional to the patient.
Figure 30.12 Remove the denture from the remount cast and
remove the wet paper towel.
Figure 30.10 After the plaster has set, remove the boxing wax
and beading wax.
patient does not see this procedure being done, usually a

mix of wet plaster is placed between the mounting plate
and the base of the wet cast and the upper member is
closed. A rubber band is usually placed between the upper
and lower members of the articulator to hold the pin down Figure 30.13 Replace the denture on the remount cast and
on the guide table. make sure the fit is accurate.
nylsiloxane putty (Figure 30.16.). A patty of plaster is made

on a plastic sheet and the mandibular denture is set onto it
(Figure 30.17). After the plaster sets, it is trimmed down so
that it is esthetically pleasing (Figure 30.18).
The following instructions describe a better method of
making accurate and stable remount casts that works very
well in inexperienced hands.
1) Place a narrow band of sticky wax around the entire
flange area of the denture. This should be located
Figure 30.14 Place the maxillary remount cast and the

maxillary complete denture on the remount index.
Figure 30.16 A mandibular remount cast can be made without

a containment barrier by placing mounting plaster over the
retentive pins and polyvinylsiloxane putty.
Figure 30.15 With the pin set on 0, lock the condyle in centric
relation position with the incisal guide pin touching the incisal
guide table.
30.4 Making a Mandibular Remount Cast
If there is a problem with availability of time, a mandibular

remount cast can be made without a containment barrier Figure 30.17 Set the mandibular denture onto a patty of
by placing mounting plaster over retentive pins in polyvi- plaster on a plastic sheet.
about 2 mm from its border on the polished surface

(Figures 30.19 and 30.20). The wax covers the heel of
the lower denture all the way to the edge.
2) Place one thickness of utility (rope) wax on the area
covered by the sticky wax. Be sure to lute it to the sticky
wax with a hot instrument on the polished side of the
denture (Figures 30.21 and 30.22).
3) For the mandibular denture, place a small triangular
piece of boxing wax in the tongue area. Lute it in place
with sticky wax.
4) Surround the denture with boxing wax. Lute it to the
utility wax band with a hot spatula. Notice the double
thickness of wax in the area of the joint (Figures 30.23
and 30.24).
5) Place the entire apparatus on a piece of stiff plastic or
porcelain tile. Lute it in place with sticky wax.
6) Block out the internal ridge fossa area of the lower
denture. Soak a paper napkin or paper towel in water
until it begins to break down, then tear off pieces and
Figure 30.18 Trim the plaster after it sets to improve esthetics
of the cast. pack them in the denture with the broad end of a #7
Figures 30.19 and 30.20 Place a narrow band of sticky wax around the entire flange area of the denture.
Figures 30.21 and 30.22 Place one thickness of utility (rope) wax on the area covered by the sticky wax.
Figures 30.23 and 30.24 Surround the denture with boxing wax and lute it to the utility wax band with a hot spatula.
Figure 30.25 Block out the internal ridge fossa area of the
lower denture with a piece of paper napkin or paper towel. Figure 30.26 Fill the containment area with a wet mix of
quick-set plaster and use a spatula to level it off.
wax spatula to block out the undercut, being careful to

allow at least 2 mm distance from the wet paper to the
denture border (Figure 30.25).
7) Fill the containment area with a wet mix of quick‐set
plaster. Use a spatula to level it off (Figure 30.26). If
there are no serious undercuts present, the dentures do
not have to be blocked out and the plaster can fill the
entire tissue surface of the denture. Do not use mount-
ing stone for this as it will be extremely hard to remove
from the dentures if there is even the slightest amount
of undercut, which may result in breaking the denture.
8) Remove the wax containment barrier. Allow the plas-
ter to dry completely before removing the wax barrier
(Figure 30.27). A look at the other side of the barrier
shows no plaster coming through, proving that there
were no leaks in the containment barrier (Figure 30.28).
9) Remove the denture from the remount cast Figure 30.27 Allow the plaster to dry completely before
(Figure 30.29). removing the wax containment barrier.
Figure 30.28 Check to make sure that there were no leaks in Figure 30.30 Remove the wet paper towel from the cast.
the containment barrier.
Figure 30.31 Trim down the land area so that it is smooth and
Figure 30.29 Remove the denture from the remount cast. only about 1 mm in depth. The denture should fit snugly back
into place on the cast.
10) Remove the wet paper towel from the cast Figure 30.30).
11) Trim down the land area so that it is smooth and only 30.5 Mounting a Mandibular
about 1 mm in depth. The denture should fit snugly Remount Cast
back into place on the cast (Figure 30.31).
12) Use the jaw relationship records in centric relation and It is important to note that the mandibular cast cannot be
protrusive to set the articulator. The protrusive record mounted when the dentures are returned from the lab. The
must have been recorded with the anterior teeth in an lower cast will be mounted after a new bite registration is
end‐to‐end relationship. made with the new dentures inserted. This is necessary
13) For lingualized occlusion only, lower the incisal guide because the denture base must be processed and adjusted
pin 2 mm to compensate for the setting of the pin when to fit the ridges by using PIP. Only then can jaw relation-
the teeth were set plus the anticipated increase due to ships be accurately recorded, with the denture teeth firmly
processing error (Figure 30.32). For full‐anatomic and anchored in stable plastic denture bases. The mandibular
zero‐degree set‐ups, leave the guide pin set at zero. cast can be mounted once a new centric relation record is
14) Make a lower remount cast (Figure 30.33). made (Figure 30.34).
Figure 30.34 The mandibular cast can be mounted once a new

centric relation record is made.
Figure 30.32 For lingualized occlusion only, lower the incisal

guide pin 2 mm to compensate for the setting of the pin when the
teeth were set plus the anticipated increase due to processing error.
Figure 30.35 Ideally, a remount index has been provided by

the lab.
2) Set the horizontal guidance on the articulator. This is

done by raising the guide pin so it is not in contact with
the guide table, and adjusting the horizontal condylar
Figure 30.33 Make a lower remount cast.
elements by moving them up and down so that the
teeth of the mounted dentures fit precisely in the pro-
Ideally, a remount index has been provided by the lab
trusive index when the mandible is placed forward in
(Figure 30.35). If you have the index that was made before
the condylar element. If the dentures were mounted in
the maxillary denture was removed from its cast, the pol-
the true centric relation position, this position will not
ished denture is placed on the remount cast and the teeth
be changed when the condyle is moved to match the
are placed in the plaster index and mounted on the articu-
protrusive record.
lator before the patient arrives (Figure 30.36).
3) Establish a bilateral balanced occlusion. The horizon-
1) Use a protrusive record. Once the casts are mounted in tal guidance of the articulator now matches the
centric relation, a protrusive record, generated by the patient’s condylar inclination in centric relation and
patient, is used to set the horizontal condylar element. in protrusive relation when the anterior teeth are in
cast (Figure 30.37) comes loose from its mounting, it

can be easily replaced back into position. Mount the
cast on the lower member of the articulator by placing
the teeth of the lower denture in the centric relation
record that was made on the patient in the clinic
(Figure 30.38).
7) Allow the plaster mounting to set completely.
8) Raise the incisal guide pin to zero (the wide mark)
(Figure 30.39). Note that the pin will be off the table
more than 1 mm due to the opening at which the teeth
were set plus the increase due to processing error.
Figure 30.36 If an index was made before the maxillary

denture was removed from its cast, the polished denture is
placed on the remount cast and mounted on the articulator
before the patient arrives.
contact with their opposing counterparts. With these

two relationships accurately established as endpoint
boundaries, all eccentric movements that the patient
makes during mastication can be made on the articu-
lator with enough accuracy to allow clinically accept-
able bilateral balancing of the denture occlusions. Do
Figure 30.37 Mount the lower cast on the lower member of
not reduce centric holding contacts on the cusps or the articulator.
opposing fossae. This is fine‐tuned to provide the
degree of bilateral balance to the occlusion that is nec-
essary to assure stability and retention of the lower
complete denture.
4) Place this facebow record on the transfer platform. The
platform to be used has been marked with an H for
Hanau to designate that it is an adapter for the face-
bow record recorded with a Denar® Slidematic facebow
so that it will fit the Hanau™ Wide‐Vue articulator. It
is important that an articulator be used with a record
made with a compatible facebow.
5) Place this platform on the lower member of the articu-
lator. Secure it in place by tightening the lower mount-
ing screw securely.
6) Mount the lower cast on the lower member of the
articulator. Invert the articulator and place the centric
relation record on the maxillary teeth, then articulate
Figure 30.38 Mount the mandibular cast on the lower member
the lower denture and remount cast with it. Note that of the articulator by placing the teeth of the lower denture in the
an index was made in the base of the cast so that if the centric relation record that was made on the patient in the clinic.
11) Set the horizontal condylar guidance. Loosen the con-

dylar lock screw (Figure 30.41). Free the balls in their
guides. Raise or lower the setting until all teeth are in
exact contact with the registration (Figure 30.42).
12) Set the lateral guidance at 15 using the large set‐screw
on top. The horizontal condylar guidance is set at the
positions dictated by the jaw relationship record
obtained from the patient’s actual horizontal condylar
inclination as recorded clinically.
13) Set the horizontal condylar guidance, using the pro-
trusive index of the patient. Loosen the centric lock
screw on both sides of the articulator to free up the
upper member of the articulator so that it can be
moved back and forth. Loosen the horizontal condylar
lock screws on both sides of the articulator to allow the
horizontal condylar element to be set to the relationship
Figure 30.39 Raise the incisal guide pin to 0.
Figure 30.41 Set the horizontal condylar guidance by

loosening the condylar lock screw.
Figure 30.40 Move the lateral condylar element to 15 and

tighten the lock nut.
9) Set the lateral condylar guidance. Loosen the large

black nut on top of the articulator.
10) Move the condylar element to 15 (Figure 30.40). Figure 30.42 Raise or lower the setting until all teeth are in
Tighten the lock nut. exact contact with the registration.
recorded by the protrusive index. To do this, remove and vice versa. Lateral movements are more accurately
the incisal guide pin, loosen the condylar lock screw, described as laterotrusive movements.
and move the condylar element up and down while 15) Once the horizontal condylar element of the articula-
holding down firmly on the upper member of the tor is properly adjusted to fit the relationships dictated
articulator. You can feel the solid contact when the by the protrusive index, you are ready to adjust the
teeth fit firmly into the index. mandibular teeth to establish bilateral balance. Mark
14) Move the condylar elements individually until the teeth the contacts with AccuFilm® articulating film.
fit precisely into the index, then tighten them securely.
You will then have the patient’s centric relation position The procedures used in balancing dentures depend upon
and protrusive position recorded on the articulator. Any the teeth and occlusal schemes that are used in the den-
lateral movement should be accurate, since the condyle tures. These variances in procedure are discussed in detail
will rotate on one side while the other side translates in the following chapters.
187
31
Equilibrating Dentures Set in Lingualized Occlusion
When doing the equilibration on a denture set in lingual- and loosen the previously locked screw on the other side
ized occlusion, form a mortar (pothole) on the mandibular (Figure 31.11). Adjust as you move the lower member of
posterior teeth (Figure 31.1) in each area where there is the articulator on that side.
contact with a maxillary lingual cusp (Figure 31.2). This Next, broaden the fossa buccal‐lingually to establish con-
will be done using the round end of an acrylic bur in a tinuous contact throughout lateral movements. (At this
straight handpiece (Figure 31.3). Do not use a round bur or point, each cusp should be making a reverse crowfoot pat-
diamond bur in a latch grip or high‐speed handpiece as tern in its respective contacting fossa, when combined with
these can remove too much plastic from the teeth and the straight anterior–posterior movement protrusive.)
destroy them quickly as you cannot easily control them. In Figure 31.12, the vectors of movement during lateral
Carefully deepen each pothole until the guide pin again and protrusive movements are represented on the teeth in
contacts the guide table in centric relation (Figure 31.4). red. The centric contact is represented as a black dot. The
Check for contacts on the heels of the mandibular denture contacts will look more like the picture in Figure 31.13, as
(Figure 31.5). These must be eliminated on the mandibular the articulating paper will smear as the movements are
denture! Do not adjust any cusp tips! made.
Broaden the pothole by reducing these inclined sur- It is important that you make the adjustments very care-
faces in protrusive (Figure 31.6). Use the black side of the fully and in the proper order and that you reduce only a
articulating film to mark the points in centric minor amount as you equilibrate in the various excursions.
(Figure 31.7). Use the red side of the film to mark the Always begin by establishing the depth of the fossae in cen-
contacts in protrusive. tric relation first. Next, lengthen the fossae as necessary to
Check to see that the anterior teeth contact simultane- correctly establish the correct depth in protrusive. Then
ously with the posterior teeth as you make protrusive broaden the fossae by deepening them as you move the
movements (Figure 31.8). (They will not contact during lower member of the articulator laterally. Always check the
lateral movements.) Use a piece of the paper that separates contacts made in the other excursions as you complete
the AccuFilm® in its pack to determine if there is contact each adjustment, and make any necessary adjustments to
(Figure 31.9). You probably will have to raise the pin a lit- establish the amount of harmony required to make the
tle more to compensate for the processing error that was movement smooth and not binding.
created during the packing and curing phases of the den- Once you have made the adjustments to the fossae in the
ture processing procedures. Reset the pin to the point lower denture in all excursions, loosen the set‐screws on
where you have contact with the anterior teeth in protru- both sides so that the lower member of the articulator can
sive relation. move freely through all excursions, and “fine‐tune” your
To equilibrate the dentures in lateral excursions, you will equilibration as you randomly move the lower member of
first lock the condyle in centric relation on one side so that the articulator and carefully make minute adjustments to
you get a purely rotational movement on that side and any discluding contacts.
open the set‐screw on the other side so that a purely trans- The contacts do look more like those seen in Figures 31.14
lational movement can be made on that side (Figure 31.10). and 31.15, with the articulating paper marking the centric
Move the lower member of the articulator back and forth occlusion contacts smeared by the various movements in
on this side. When you are satisfied with the adjustments eccentric relations. Nevertheless, the movements are
made to the teeth on this side, lock the condyle on this side smooth and unencumbered by discluding cusps.
Figure 31.4 Carefully deepen each pothole until the guide pin
again contacts the guide table in centric relation.
Figure 31.1 Form a mortar (pothole) on the mandibular

posterior teeth.
Figure 31.5 Check the heels of the mandibular denture contact

marks.
Figure 31.2 Evaluate the marks made in each area where the
maxillary lingual cusps contact with the lower teeth.
Figure 31.3 Use the round end of an acrylic bur in a straight Figure 31.6 Broaden these potholes by reducing the inclined
handpiece to enlarge a pothole. surfaces in protrusive.
Equilibrating Dentures Set in Lingualized Occlusion 189
Figure 31.10 Lock the condyle in centric relation on one side so

that you get a purely rotational movement on that side and open the
Figure 31.7 Use the black side of the articulating film to mark set-screw on the other side so that a purely translational movement
points of contact in centric relation. is possible to equilibrate the dentures in lateral excursions.
Figure 31.8 The anterior teeth should contact simultaneously Figure 31.11 Move the lower member of the articulator back
with the posterior teeth in protrusive movements. and forth on the translational side and make adjustments, then
repeat the process on the other side.
Figure 31.9 Use a piece of the paper that separates the

AccuFilm in its pack to determine the strength of a contact Figure 31.12 View the vectors of movement during lateral and
between opposing teeth. protrusive movements which are represented on the teeth in red.
Figures 31.13–31.15 The contacts in centric occlusion are points, the contacts made by the various movements in eccentric
relations are smeared.
191
32
Equilibrating Fully Anatomic (30˚) Set-Ups
To ensure the retention and stability of a denture with fully The dentures in Figure 32.5 are shown after occlusal
anatomic teeth, any occlusal disharmonies must be cor- equilibration in centric relation. Centric occlusion does not
rected before a patient can wear the denture home. look too bad with these dentures. The right side looks best
but the left side shows the mandible positioned slightly
more mesial than the original recording (Figure 32.6).
32.1 Instruments and Materials Required When viewed facially (Figure 32.7), the amount of horizon-
tal overlap of the posterior teeth is obvious. There is mini-
1) Mouth mirror mal horizontal overlap with anatomic teeth. This is largely
2) Handpiece and suitable stones and bits because the working cusps of the teeth must be set so they
3) Maxillary “remount cast” on articulator contact the fossae and grooves of the opposing teeth.
4) Mandibular “remount cast” Figures 32.8 and 32.9 show the same set of dentures before
5) Articulating paper occlusal equilibration and Figures 32.10 and 32.11 show the
6) Aluwax™ same dentures after equilibration. Before equilibration, only
7) Pressure indicator paste (PIP) with brush or Q‐tips a few contact points are visible. After equilibration, there are
8) Thompson’s indicator sticks (have a blue indelible ink several points of contact.
blotch on one end) Although there is only one solid contact necessary on the
balancing side to provide a bilateral balance, there should
be several on the working side that are in contact. This rela-
32.2 Procedure tionship will establish a tripod effect which is a very stable
geometric relationship. If there was only one contact pre-
Use thin articulating film to record the contacts sent on each side, an axis of rotation would be established
(Figure 32.1) and the end of a large lab acrylic bur to adjust which is very unstable. The following pictures show a work-
(Figure 32.2). A smaller bur will make potholes in the ing relationship on the left (Figure 32.12) and balancing
occlusal surfaces. A thicker articulating paper will make relationships on the middle and right (Figures 32.13 and
multiple contacts and it would be hard to determine just 32.14) and the posterior teeth should contact simultane-
which contacts needed adjusting. A piece of the onion skin ously on both sides in working, balancing, and protrusive
paper from between the pieces of articulating film can be relationships. The anterior teeth should not contact except
used to evaluate the contacts. in protrusive relationship and then simultaneously with the
After mounting the dentures in centric relation on their posterior teeth. The tip of an acrylic bur is used to adjust the
original casts, a lab remount is done. The pin is set on zero cusps to equilibrate the teeth (Figure 32.15).
as it was when the dentures were sent to the lab. There will Adjust the dentures in lateral working movements using
be a certain amount of pin opening in relation to the incisal the mnemonic BULL, adjusting only the buccal cusp tips
guide table, caused by “processing error.” The fossae of the on the upper denture and the lingual cusp tips on the lower
opposing teeth are deepened until the pin touches the guide denture on the working side in lateral excursions.
table (Figure 32.3). These cusps that are in contact are When adjusting the teeth on the nonworking or bal-
known as “centric holding cusps” (Figure 32.4) and as such ancing side during lateral excursions, the rule of BULL
should never be reduced, even when the teeth are adjusted means grinding the buccal inclines of the upper palatal
when the jaws are in a lateral or protrusive relationship. teeth and lingual inclines of the lower buccal cusps. In
Figure 32.1 Use thin articulating film to record the contacts in

Figure 32.4 Cusps that are in contact are known as “centric
all relationships.
holding cusps.”
Figure 32.5 Centric occlusion on the right side does not look
Figure 32.2 Use the end of a large lab acrylic bur to adjust the too bad with these dentures.
contacts in the denture.
Figure 32.6 Centric occlusion on the left side shows the

Figure 32.3 Deepen the fossae of the opposing teeth until the mandible is positioned slightly more mesial than the original
pin touches the guide table. recording.
Equilibrating Fully Anatomic (30°) Set-Ups 193
Figure 32.7 When viewed facially, the amount of horizontal

overlap of the posterior teeth is obvious.
Figures 32.10 and 32.11 Here is the same set of dentures after
occlusal equilibration in centric relation.
Figures 32.8 and 32.9 Here is a set of dentures before occlusal Figure 32.12 View a working relationship in the picture on
equilibration is done in centric relation. the left.
Figure 32.15 Use the tip of an acrylic bur to adjust the cusps
to equilibrate the teeth.
Figures 32.16 and 32.17 show the contacts of the teeth in

left lateral movement of the mandible in its relationship to
the maxilla after occlusal refinement. Figures 32.18 and
Figures 32.13 and 32.14 View a balancing relationship on the 32.19 show the contacts of the teeth in right lateral move-
middle and right pictures. ment of the mandible in its relationship to the maxilla after
occlusal refinement is completed.
other words, on the balancing side, the point of contact Adjust the teeth as necessary to achieve bilateral balance
opposing the centric holding cusps will be the inclines of in protrusive relation (Figures 32.20–32.22), being careful
the upper lingual cusps and the lingual inclines of the to avoid reducing the contact areas that were previously
mandibular buccal cusps. Cusp tips are not reduced on established in centric occlusion or lateral excursions. After
the balancing side. In order to achieve balance on the a good bilaterally balanced occlusion is established in pro-
balancing side, only one point of contact is necessary trusive relation, go back and check the contacts in centric
throughout the movement (a gliding contact) as the and lateral relationships.
mandible moves toward the working side; however, more The dentures are adjusted in all excursions and checked
points of contact are desirable, if possible. with onion skin paper to see if the desired contacts are
It is important to note that when adjusting a denture in a there bilaterally. After the protrusive contacts are finalized,
lateral excursion, the condylar element on the rotating (work- the denture is again checked to see if the contacts are still
ing) side is locked back in centric. The condylar element on there in all other excursions.
the translating (balancing) side is opened only enough to It is important to note that when adjusting a denture in a
allow the buccal cusps of the maxillary first molar to line up protrusive relationship, the condylar elements are opened
with the buccal cusps of the mandibular first molar. only enough to allow the maxillary central incisors to line
A balanced occlusion is achieved when the cusps of the up end to end with the mandibular central incisors when
working side posterior teeth contact simultaneously when the midlines of the maxillary and mandibular dentures
the cusp tips of the posterior teeth on the balancing side are line up. Balanced occlusion is achieved when the incisors
in contact. The anterior teeth should never contact during contact simultaneously when the posterior teeth contact
lateral excursions. on both sides.
Equilibrating Fully Anatomic (30°) Set-Ups 195
Figures 32.18 and 32.19 View the contacts of the teeth in

right lateral movement of the mandible after occlusal
refinement is completed.
Figures 32.16 and 32.17 View the contacts of the teeth in left
lateral movement of the mandible after occlusal refinement is
completed.
6) The working side lingual cusp tips were reduced on the
maxillary teeth.
7) The working side buccal cusp tips were reduced on the
32.3 Problems and Errors mandibular teeth.
8) The lingual inclines of the lingual cusps were reduced
1) Teeth were not set in balanced occlusion during the on the balancing side on the maxillary teeth.
waxing up process. 9) The buccal inclines of the buccal cusps were reduced
2) Teeth shifted considerably during packing (usually due on the balancing side of the mandibular teeth.
to a soft investing stone). 10) There is no continuous contact of any posterior teeth
3) Improper or excessive grinding has obliterated the on the balancing side when the teeth are in contact on
occlusal anatomy and adversely affected the occlusal the working side.
plane, vertical dimension, compensating curve, and 11) The teeth were adjusted in protrusive relationship
efficiency of the teeth. before the lateral adjustments were completed.
4) The teeth were not properly reduced in centric relation 12) The anterior teeth do not contact end to end in protru-
until the pin touched the guide table. sive relation simultaneously with the posterior teeth.
5) Teeth were adjusted for lateral excursions before the 13) The anterior teeth interfere with posterior occlusion in
centric adjustment was completed. lateral or protrusive excursions.
Figures 32.20–32.22 Adjust the teeth as necessary to achieve bilateral balance in protrusive, but not at the expense of contact
areas that were previously established in centric occlusion or lateral excursions.
197
33
Equilibrating Complete Dentures Set in a Monoplane Occlusion
When adjusting the teeth in a zero‐degree, monoplane set‐ process known as “stripping.” In this process, the pin is
up, the maxillary denture is flat‐surfaced by using wet/dry removed and wet/dry sandpaper is placed between the
sandpaper that is placed on a stable, flat desktop (Figure 33.1). two dentures with the grit side toward the lower teeth
Any further occlusal adjustments are made only to the lower (Figure 33.3). The upper member of the articulator is
denture. It is important to note that there is no rise in the closed and pressed firmly with the heel of the hand. The
posterior teeth in a monoplane occlusion. This creates a sandpaper is pulled out once or twice, taking care to
problem when adjusting the dentures to fit the patient’s con- avoid too much stripping which would overreduce the
dylar inclination. This problem is minimized by ensuring teeth and reduce the esthetic and functional capabilities
that the flat occlusal plane is established at a point where the of the denture.
teeth are set so that this plane intersects the cast at a point Figure 33.3 shows the “stripping” being done. Figure 33.4
two‐thirds of the way up the retromolar pad area. shows the mandibular denture prior to the stripping and
A close look will show that the occlusal surfaces of the Figure 33.5 shows the contacts after “stripping” was com-
teeth are ground flat. This can be verified by placing the pleted. The teeth in the denture in Figure 33.5 have more
denture on a flat surface. One downside to a monoplane uniform contact.
set‐up is that the denture teeth do not really look natural, Although dentures which are set in a monoplane
and if the anterior teeth were not set on the plane, they occlusion are not really set in “balance,” the flat sur-
may be unesthetic. faces are in harmonious contact and patients tend to get
All adjustments made to the lower denture teeth in a along very well with them. These are especially desira-
zero‐degree, monoplane set‐up are done with the flat edge ble when patients have a retrognathic mandible with a
of a large acrylic bur. The bur in Figure 33.2 is a cylinder strong Class II orthognathic jaw relationship. In par-
shape and is the best one to use for this. A large blunt‐ ticular, the results are better if the occlusal plane inter-
nosed bur can also be accurately used if care is taken. sects the lower ridge at a point no lower than two‐thirds
After the mandibular posterior teeth are ground flat of the way up the retromolar pad and the horizontal
and are in good contact with the maxillary teeth in condylar elements are set to a plane parallel to the
centric occlusion, the occlusion is further refined by a occlusal plane.
Figure 33.3 Place a flat dry piece of wet/dry sandpaper

between the two dentures with the grit side toward the lower
teeth and pull it forward with the articulator locked and closed
Figure 33.1 Flat-surface the maxillary denture set in a
in centric relation.
monoplane set-up by using wet/dry sandpaper placed on a
stable, flat desktop.
Figure 33.4 View the mandibular denture prior to the stripping.
Figure 33.2 Use the flat edge of a large cylinder-shaped

acrylic bur to make all adjustments to the lower denture teeth
in a zero-degree, monoplane set-up.
Figure 33.5 View the mandibular denture after the stripping.

199
34
Troubleshooting Complete Denture Problems
There are several shortcomings that are commonly Some factors are totally related to the patient. Retention
associated with ill‐fitting and poorly functioning com- and stability may be compromised by moderate to severe
plete dentures. resorption, unfavorable floor of mouth posture, retruded
tongue position, reduced salivary flow, and poor neuro-
1) Unstable lower dentures muscular control. These factors are beyond the control of
2) Unstable maxillary dentures the dentist! We nevertheless must deal with these issues.
3) Cheek biting Patient education is the main key to preparing the patient
4) Midline fractures to understand the level of function and esthetics that they
5) Fractured teeth and flanges should rightfully expect from their dentures.
6) Poor esthetic value There are several possible solutions to patient‐related
7) Epulis fissuratum problems and several things we can do to assure a better
8) Papillary hyperplasia chance of success with complete dentures. Possible solu-
9) Combination (Kelly) syndrome tions include placing osseointegrated implants, using den-
10) Poor chewing ability ture adhesives, placing permanent hard or soft liners, or
11) Unclear speaking ability repairing, adjusting, or remaking the dentures.
12) Gagging Let’s consider some causes and effects of ill‐fitting com-
Some of the main causes of these problems include the plete dentures. How are these related?
following. Wearing dentures creates a never‐ending cycle of
destruction of the underlying tissues of the denture sup-
1) Teeth not set over the ridge port area (Figure 34.1), in which the pressure on the den-
2) Flanges too long ture causes resorption of the ridges. This in turn causes the
3) Flanges too short denture to be dysfunctional, which further causes uneven
4) Teeth set too far forward pressure on the ridges and so the cycle continues with even
5) Teeth angled back more destruction and resorption.
6) Teeth angled forward The lower complete denture is almost always the most
7) Incorrect VDO unstable of a set of complete dentures. Stability can be
8) Teeth not set in bilaterally balanced occlusion improved if the teeth are in bilaterally balanced occlusion
9) Teeth not set on casts mounted in centric relation and positioned over the crest of the residual ridge. This is
10) Too much vertical overlap in anterior teeth accomplished by carefully positioning the teeth before pro-
11) Clinical patient remount not done cessing and performing a clinical remount of the dentures
12) Teeth not equilibrated properly during the insertion appointment. When a patient com-
13) Class II orthognathic patients with fully anatomic teeth plains of an unstable lower denture, this could be caused
14) Teeth set to match positions of natural dentition by a flange that is too long or too short, or improper posi-
15) No or poor posterior palatal seal tioning of the teeth. Teeth may be positioned with too
16) Existing tori not reduced much vertical overlap, they may be set too far beyond the
17) Patient demands ridge, there may be occlusal interferences, or the teeth
18) Insurance company’ demands may be angled facially or lingually. If the teeth are set in the
correct positions, the problem should be corrected easily by the second molar area and in the first premolar area, then
doing a clinical remount and an occlusal equilibration of transferring the marks to the heel and the anterior land
the dentures. area of the cast, using a tongue blade as a straight edge
Anatomic posterior teeth are set in a compensating curve (Figure 34.5). You can then mark the center of the ridge
equal to the vertical overlap of the anterior teeth onto the wax occlusion rim using a ballpoint pen
(Figure 34.2). (Figure 34.6) and set the maxillary teeth accordingly. The
Mandibular anterior teeth should never be set further mandibular buccal cusps of the anatomic posterior teeth
forward than the labioincisal edge to the middle of the should then line up over the crest of the ridge (Figure 34.7).
labial vestibule. The mandibular posterior teeth should
always be set over the middle of the ridge crest. With fully
anatomic teeth, this means the working cusps of the man-
dibular posterior teeth are positioned over the crest of the
mandibular ridge (Figure 34.3). With a zero‐degree tooth,
the central fossae of the mandibular posterior teeth are
positioned over the crest of the mandibular ridge. The fur-
ther off the ridge the teeth are, the more the mechanical
advantage that can be used to dislodge the denture and the
denture will tip toward that side, as happens with a man on
a seesaw (Figure 34.4).
Setting the maxillary posterior teeth over the ridge is as
simple as marking the middle of the mandibular ridge in
Dysfuction
Pressure
Denture
Resorption
Figure 34.3 The working cusps of the mandibular posterior
Figure 34.1 Wearing dentures creates a never-ending cycle of anatomic teeth are positioned over the crest of the
destruction of the underlying tissues of the denture support area. mandibular ridge.
Condylar Inclination
Compensating Curve
Incisal Guidance –
Cuspal Inclination Not in dentures.
Occulusal Plane
Inclination
Cuspal inclination
+ Occulusal Plane Inclination
Condylar inclination &
Compensating Curve
Figure 34.2 Set anatomic posterior teeth in a compensating curve equal to the vertical overlap of the anterior teeth.
Troubleshooting Complete Denture Problems 201
Figure 34.6 Mark the center of the ridge onto the wax occlusion
Figure 34.4 The further off the ridge the teeth are, the more rim using a ballpoint pen and set the maxillary teeth accordingly.
the mechanical advantage a force places on the denture to
dislodge it.
Figure 34.5 Mark the middle of the mandibular ridge in the

second molar area and in the first premolar area, then use a
tongue blade as a straight edge to transfer the mark to the heel Figure 34.7 The mandibular buccal cusps of the anatomic
and anterior land areas of the cast. posterior teeth should then line up over the crest of the ridge.
If a flange is too long, disclose premature contacts on Implants require a certain amount of bulk to be retained in
the flange using mouth temperature wax and reduce the the denture base (Figure 34.8), and this will weaken the
length of the flange. If a flange is too short, you may either resistance of the denture to fracture. Mini‐implants require
reline or rebase the current denture or make a new one. If less supporting surface area of the denture base than regu-
teeth are set so that they have too much vertical overlap, lar osseointegrated implants but the increased amount of
are set off the ridge, have occlusal disparities, or are angled force that a patient can place on an implant‐supported den-
forward or lingual to the ridge, you may want to remove ture can lead to an increased tendency to fracture of the
and reset teeth or remake the denture. If it is simply that teeth or denture base.
the teeth have minor premature contacts, a clinical Functioning of the orthognathic complex during mastica-
remount and occlusal equilibration of the teeth may be all tion when there are no teeth to contain the tongue in posi-
that is required. tion and the patient has to mash their food against the palate
Implants can be a very good means of providing addi- leads to a condition called macroglossia where the tongue
tional retention to dentures, but the basic rules of setting can reach gargantuan proportions. If a patient has mac-
the teeth in balanced occlusion should not be violated. roglossia, this is usually because the tongue has enlarged
Figure 34.8 Implants require a certain amount of bulk to be

retained in the denture base, and this will weaken the resistance
of the denture to fracture.
Figure 34.9 At the insertion appointment, inform the patient

who has been without teeth for a while that they will need to
allow time for the tongue to shrink to fit the space provided by
the mandibular denture.
due to the lack of containment of the teeth. The tongue will

adapt in time to fit the space provided but this will take sev-
eral weeks to occur and requires a large amount of patient
compliance and commitment. The patient needs to be
informed at the insertion appointment to expect this and
Figures 34.10–34.12 If a lingual flange appears too long,
told that they need to allow time for the tongue to shrink to evaluate and check the stability of the lower denture by having
fit the space the mandibular denture provides (Figure 34.9). the patient raise their tongue and forcefully extend it.
To evaluate a lower denture if a flange appears too long,
have the patient raise their tongue and extend it Undercut areas in the retromylohyoid spaces
(Figures 34.10–34.12) to check the stability of their lower (Figures 34.13 and 34.14) can be very useful in retaining
denture. Often, the lingual frenum needs more relief to the lower denture if the patient can tolerate them. This can
reduce instability. be most beneficial if the patient has minimal height of the
Figure 34.16 Ridge resorption is the most common cause of

an unstable upper denture.
Figures 34.13 and 34.14 Undercut areas in the retromylohyoid

spaces can be very useful in retaining the lower denture.
Figure 34.17 The ridge fills the denture when the denture is
inserted.
Figure 34.15 The shape of the flange under the tongue can
either enhance or inhibit retention.
anterior residual ridge. The shape of the flange under the

tongue can also enhance retention (Figure 34.15). When
being placed in the mouth, the denture is placed posteri-
orly and slid forward to seat the anterior portion. The
undercut provided by a lingual groove will allow the tongue
to function within the parameters it establishes, and this
will prevent the tongue from sliding to a position under the
denture’s lingual flange.
If the patient complains of an unstable upper denture, Figure 34.18 When a ridge resorbs, the hard palate does not
this is usually the result of ridge resorption (Figure 34.16), resorb, and the denture “high-centers.”
an undercontoured posterior palatal seal, a poor relation-
ship of teeth to the ridge, an inaccurate repair, a flange that ridge resorbs, the hard palate does not resorb, and the den-
is too long or too short, or an underreduced or unaltered ture “high‐centers” (Figure 34.18).
palatal torus. The residual ridge should fill the denture These problems are usually addressed or corrected by
when the denture was inserted (Figure 34.17). When a relining, rebasing, or remaking the denture if the problem
is caused by ridge resorption. If the problem is an inade-

quate posterior palatal seal, the denture is relined or
repaired by adding a posterior palatal seal with repair
acrylic. If the relationship of teeth to ridge is wrong,
remove and reset the teeth. If the instability is the result
of an inaccurate repair, then make a new denture. If the
flanges are too long, reduce the flanges. Use disclosing
wax on that flange area. Place the denture in the mouth
for a few seconds then remove the denture and check for
a show‐through. Reduce the area with an acrylic bur or
denture scraper.
An overextended flange is easily seen by the skilled Figure 34.21 The intaglio surface of the denture will reflect if the
observer (Figures 34.19 and 34.20); however, dentists often patient has a very shallow vestibule or a highly attached frenum.
overlook what should be obvious. This condition can lead
to many problems with phonetics, esthetics, and trauma.
If the patient has a very shallow vestibule or a frenum
that is attached high to the ridge (Figure 34.21), the intag-
lio surface of the denture must reflect this. Too often, a
custom tray is not used for the final impression or is not
Figure 34.22 Have the patient push their tongue as far

forward as they can.
properly border molded to fit the ridge and the borders are
left overextended.
Overextension can be prevented by carefully assessing
the length of the flanges. Have the patient push their
tongue as far forward as they can (Figure 34.22). Pull the
lips to the side with two fingers close together on each side
so all the denture can be seen. Have the patient move their
tongue far to the left (Figure 34.23) and then far to the right
(Figure 34.24). If the muscles are bound by the denture
borders, an ulcer will result along the area of the binding if
the dentures are worn for even a short time. If there is suc-
tion on the mandibular complete denture, the flanges are
likely overextended.
Disclosing wax is used to check the length of the denture
borders (Figure 34.25). In this example, it has been placed
in a disposable syringe and squirted onto the peripheral
edge of the denture flange while it is held in the hand.
Figures 34.19 and 34.20 An overextended flange is easily Disclosing wax is not the same as pressure indcator paste
identified by the skilled observer. (PIP) and is much thicker.
Some other examples of areas of complete dentures

c ommonly overcontoured or undercontoured that can be
determined with disclosing wax include the following.
1) If flanges are too short, reline the denture.
2) If there is an interfering palatal torus, surgically reduce
or remove the torus, reline or remake the denture.
3) If a maxillary complete denture does not have enough
suction to be retentive when it is first placed in the
mouth, most likely the posterior palatal seal is not doing
its job. If the patient does not suffer from xerostomia,
then there should be suction. To correct this problem,
reline the denture and place a new seal in the denture,
either by the arbitrary method or the physiologic
method.
Figure 34.23 Have the patient move their tongue far to the left.
4) If the posterior palatal seal is insufficient, this area can
be cut out (Figure 34.26), and an alginate impression is
made of the denture in the mouth. A cast is poured
into the denture in the impression in type II stone, and
an arbitrary posterior palatal seal cut into the stone
cast (Figure 34.27). Another method is to form a func-
tional seal by adding compound or mouth temperature
disclosing wax to the denture (Figure 34.28). Both
methods then involve flasking, packing, and process-
ing the palatal seal onto the denture, usually with self‐
curing resin.
If a patient complains after the date of insertion of sore
spots internally, have them point to the sore spot. Mark the
sore spot in the mouth with an indelible transfer stick.
Place the denture in the mouth for a few seconds. Remove
Figure 34.24 Have the patient move their tongue far to the right.
Figure 34.26 If the posterior palatal seal is insufficient, cut

Figure 34.25 Use disclosing wax to check the length of the out this area and make an alginate impression of the denture
denture borders. in the mouth.
Figure 34.29 A small palatal torus may not need to be

Figure 34.27 Pour a cast of type II stone into the denture in removed or reduced.
the impression and cut an arbitrary posterior palatal seal into
the stone cast.
Figure 34.30 Biting of the tongue or cheek is generally caused

by insufficient horizontal overlap of the posterior teeth.
Tongue or cheek biting is generally caused by insuffi-

cient horizontal overlap of the posterior teeth (Figure 34.30).
It is most commonly seen in a patient with a Class II
orthognathic relationship who has excessive protrusive
movement. If there is end‐to‐end occlusion of the most dis-
tal teeth in the arch, there is a good chance that the patient
Figure 34.28 A functional seal can be formed in a cast by
will experience cheek or tongue biting. Teeth may need to
adding a posterior palatal seal of compound or mouth
temperature disclosing wax to the denture, inserting it in the be set in a crossbite relationship to avoid cheek biting
mouth, then pouring the cast. (Figure 34.31).
When a mandible moves forward from centric relation
(Figure 34.32) into protrusive relation, the teeth have a more
the denture and check the highlighted area. Reduce the end‐to‐end relationship as seen in Figure 34.33. The more
area with an acrylic bur or a denture scraper. forward the mandible must move for the patient to achieve
A palatal torus, such as the one illustrated in Figure 34.29, protrusive, the more likely the patient is to experience cheek
may not need to be removed or reduced and may not be a biting or tongue biting. Class II patients naturally tend to
problem until the ridges resorb. Then, there must be an posture forward, so this effect needs to be anticipated and
adjustment of the intaglio surface of the denture, which compensated for when setting teeth. Although the mandibu-
may leave the palate very thin in this area and prone to lar teeth appear to be different in Figures 34.32 and 34.33,
fracture. Since the tissue is very thin in this area and papil- they are the same and only the positions relative to the max-
lary hyperplasia is not prone to develop over a torus, this illary teeth have changed. I suggest using a zero‐degree
area can be reduced enough to be in relief. monoplane occlusal scheme for such patients.
To correct an insufficient horizontal overlap, grind the

buccal surface of the tooth that is most lingual, usually the
most distal tooth. In the case of a Class II orthognathic
relationship with excessive protrusive movement, you may
need to reset zero‐degree mandibular teeth in crossbite.
Macroglossia (Figure 34.34) usually results from lack of
containment of the tongue, usually involving the mandibu-
lar teeth where the patient has gone without dentures for
years and mashes their food against the maxillary denture or
restored arch. Management of this abnormality is usually
accomplished by patient education and compliance. Once
the patient develops ingrams (awareness) of where the teeth
Figure 34.31 Teeth may need to be set in a crossbite lie in relation to the tongue or cheek and the tongue shrinks
relationship to avoid cheek biting. to fit the allotted space, this is no longer a problem, unless
the patient does not wear their mandibular appliance.
Every fracture has a cause, which must be determined
and eliminated or corrected before a repair can be success-
ful (Figure 34.35). Before attempting to repair fractured
teeth or fractured flanges, evaluate all factors that could be
leading to the fracture.
Figure 34.32 This graphic shows the relationship of a

mandible to the maxilla in centric relation. Figure 34.34 Macroglossia usually results from lack of
containment of the tongue.
Figure 34.33 This graphic shows the relationship of a Figure 34.35 Every fracture has a cause which must be
mandible to the maxilla in protrusive relation. eliminated or corrected before a repair can be successful.
Immediate complete dentures have thin acrylic over the denture or remaking the denture, but the patient must be
areas of the extraction sites and thin flanges because the educated not to place too much pressure on the denture
ridges are expected to resorb, and the denture is corrected when chewing. Implant‐retained complete dentures can be
by a reline when the healing is completed, usually after repaired by thickening the acrylic overlying the retentive
six months. components of the implant at the cost of reduced esthetic
To correct the problem leading to a midline fracture, value, or a new denture can be made.
reline or remake a denture. Fractures typically happen Dentures should be expected to be dropped or otherwise
with immediate complete dentures. This is due to the broken by accident (Figures 34.36 and 34.37), so they will
resorption of the residual ridges with the hard palate not always need to be carefully handled. Dentures that are
resorbing, leading to a “high centering” where the palatal dropped or otherwise broken by accident can be simply
section has very little or no support from the residual repaired by fitting the parts together accurately. If the
ridges. The denture rocks back and forth as the patient pieces cannot be repositioned accurately, attempting to
chews. The chance of fracture can be lessened by applying repair the denture is generally a waste of time. Broken or
several regular replacements of tissue conditioners during missing teeth should be replaced with teeth of the same
the entire healing period for about six months and instruct- mold and shade whenever possible. Porcelain teeth gener-
ing the patient to not bite down excessively hard. For this ally weaken the denture base and if patients place too
reason, it is best to refer to an immediate denture as a much pressure on the denture, the teeth or the denture
“temporary denture” that will need to be replaced with a base will fracture. The patient will need to be educated
“permanent” denture after a least six months of postsurgi- about the cause of the fracture and approve of replace-
cal healing. Patients must be instructed in how to protect ments before plastic teeth are used.
their dentures and how to care for them and use them
properly. If an immediate complete denture is broken, it is
best to make a new denture, as repairing a thin area usually
will not resolve the problem and better esthetics can be
gained by showing more length of the teeth.
To correct a repaired denture, make a new denture. If a pala-
tal torus is the cause, repair the denture and add more acrylic
over the torus or remove or reduce the torus then repair and
reline the denture or make a new complete denture.
Midline fractures of the maxillary denture are usually
the result of ridge resorption and the resulting “high cen-
tering” of the denture on the palate with inadequate sup-
port from the ridges. Sometimes, these result from the
design of the denture itself, when the posterior teeth are
placed too buccal to the ridge. If the relationship of teeth to
the ridge is the reason for the fracture, reset the posterior
teeth in a crossbite relationship and make a new denture.
These fractures can also result if the parts of a fractured
denture were improperly aligned when a repair was done.
If a palatal torus is present, the overlying acrylic is very
thin and this can lead to fracture.
Implant‐retained complete dentures have thin acrylic
overlying the retentive components of the implant. When
implants are placed to stabilize the denture, the patient can
place too much stress on the denture. This, combined with
the thin acrylic shell surrounding the retentive compo-
nents, weakens the denture base and can lead to a fracture.
These areas are susceptible to fracture, so they need to be
protected during the lifespan of the denture. Some implant‐
retained complete dentures can possibly be made less sus-
ceptible to fracture by changing the type of abutments Figures 34.36 and 34.37 A patient should anticipate that they
and repairing the denture, including adding acrylic to the may drop their dentures or otherwise break them by accident.
The esthetics of a set of dentures may be compromised

when the anterior teeth were set too far anteriorly or angled
too far posteriorly, or too large a mold of teeth was used.
Possibly too short a tooth was used, or the shade of teeth
does not match the patient’s desires.
If too much tooth is shown, this could be due to excessive
flange length. Immediate complete dentures usually have
short teeth set due to lack of space.
To correct problems of unesthetic anterior teeth, teeth
should be removed and selected teeth set in the proper
positions, then processed to the original denture base, or
a new denture is made. If too much tooth is shown, this
could be due to excessive flange length. If this is the
case, the lip cannot close sufficiently to cover the teeth.
Reduce the length of the flange. If this corrects the prob-
lem, then the patient should be able to easily close their
lips together.
Immediate complete dentures often have short teeth set
due to lack of space allowed by unresorbed ridges. Patients
should have been advised at the time they accepted the
treatment plan for an immediate complete denture that
they would need to have new dentures made after six
months to allow time for healing.
Epulis fissuratum is an irritation fibroma that develops
over a long period of time due to an ill‐fitting denture
(Figures 34.38 and 34.39). These can be very large and firm.
Figures 34.38 and 34.39 Epulis fissuratum is an irritation
Successful treatment involves surgical removal of the epu-
fibroma that has developed over a long period of time due to an
lis and lining the denture with tissue conditioner. Allow six ill-fitting denture.
weeks for the area to heal, then evaluate the site and reline
the denture or make a new one.
Papillary hyperplasia is an overgrowth of tissue caused t ypically when the patient does not wear the mandibular
by an ill‐fitting denture (Figures 34.40 and 34.41). It RPD. It manifests as a flabby maxillary anterior ridge and is
usually occurs in the anterior palate and is often associ- often associated with distended maxillary tuberosities. This
ated with a vacuum chamber that was placed to improve is best treated by augmenting the maxillary anterior ridge,
retention of the maxillary complete denture. It can occur surgically reducing the tuberosities, and making new den-
with or without the presence of Candida albicans and is tures. The existing denture should be relined with tissue
caused by an ill‐fitting denture, wearing the denture at conditioner until total healing has occurred. If the denture
night, and poor oral hygiene. This is treated by surgically is in good condition, it could be relined with a hard labora-
removing the excess tissue and relining the denture with tory reline. The patient must be informed that they should
tissue conditioner. Six weeks of postsurgical healing not use their anterior teeth to chew their food, a habit that
should occur, then the site is evaluated to determine if has usually led to this condition.
enough healing has occurred to reline the denture. Most If the patient complains that they cannot chew their
often appearing as grape‐like clusters, this tissue is often food adequately, check the dentures and the patient very
removed by abrasion with a large cherry stone or lab dia- carefully. It may be that their teeth do not line up prop-
mond. The tissue conditioner‐lined denture serves as an erly, or that the teeth have not been properly equilibrated.
effective compression bandage until healing occurs. The dentures may be unstable for a variety of reasons.
This tissue conditioner should be replaced every three Possibly the occlusal scheme does not fit the patient’s
weeks or less, until healing has occurred and the tissue needs, or the patient has poor neuromuscular control. If
appears healthy. the patient has a severely atrophied mandible, they
Combination (Kelly) syndrome generally results when a may not be able to bring adequate force to bear on the
maxillary complete denture is opposed by a mandibular dentures to masticate their food properly. Certainly,
distal extension removable partial denture (RPD) and the patient must be questioned to determine if their
due to an open or closed vertical dimension of occlusion

(VDO), an incorrect positioning of maxillary anterior teeth,
or the crossarch positions of the posterior teeth do not
allow the tongue space to function properly. If the anterior
palate of the maxillary denture is very smooth or thick, the
tongue is positioned in an unnatural position for the patient
to get a good seal. The tongue may collide with the denture
when the patient attempts to speak. If sibilant sounds are
the only part of the speech that is affected, the VDO may be
opened and the mandibular teeth do not provide a proper
seal with the palate or upper teeth.
If too much teeth show, and the patient does not seem
to have trouble swallowing, consider the possibility that
the flanges are overextended. Simply remove the den-
tures and pull the upper lip down and the lower lip up to
check the vestibular depth. A good rule of thumb on the
lower denture is that if there seems to be suction present,
there is a good chance that the vestibule is overextended.
This may or may not be the case, however, as in some
older patients, the soft tissue becomes more flaccid and
the patient is not able to raise their lips in the buccal and
labial vestibules to the point that enough pressure is
brought to bear on the denture flanges to dislodge the
lower denture. Reduce the frenula attachment areas first,
and then proceed with the rest of the flange where it
appears overextended. If the teeth do not follow the
curve of the lower lip, remove the teeth and reset them in
proper position on the denture base, then process them
Figures 34.40 and 34.41 Papillary hyperplasia is an
or remake the dentures entirely. This case probably also
overgrowth of tissue caused by an ill-fitting denture. involves excessive flange length which should have been
caught in the wax try‐in phase. The teeth should be set so
that they follow “Pleasure’s curve,” in other words, the
expectations of success with dentures are realistic. This contour of the lower lip.
often is the case with immediate complete dentures, If the established VDO is too open, the patient will
where a patient expects to be able to use their prostheses have trouble swallowing and the denture teeth will click.
to correct all the problems they had with their natural If the VDO is closed, the patient will lisp as they say “S”
dentition. This is what is euphemistically known as a and “X” sounds. These problems are corrected by estab-
“facelift by complete dentures.” lishing a proper VDO. A palate that is too smooth will
Many of these problems could be avoided if the dentist also cause a lisp, but sometimes patients will object if
manages the process of designing dentures properly. If a rugae are duplicated and placed in the anterior palate of
patient is orthognathic Class II or has a posterior cross- their denture. A denture palate that is too thick may col-
bite or poor neuromuscular control, a zero‐degree mon- lide with the tongue and cause the patient to gag. The
oplane set‐up will avoid a lot of problems. Setting the patient will also be unable to make proper “ch” and “th”
teeth on casts mounted in centric relation and complet- sounds. If the occlusal plane is too high, the mandibular
ing a patient remount and equilibration will also avoid lip will not contact with it when the patient says “F”
many problems. Sometimes, ridge augmentation and/or sounds. All these things can be evaluated and corrected
dental implants can correct problems caused by man- at the wax try‐in. If the patient is a new denture wearer,
dibular deficiency. they may adapt to this situation in time as they become
If the problem is that the patient cannot speak clearly, more used to their dentures.
have the patient go through a phonetic exercise and observe Some other common patient complaints, manifestations,
them speaking sibilant and fricative sounds. This may be and their solutions are listed in the following chart.
Problem Solution
Trapped movable tissue Reline or rebase

(pinch)
Sore throat: too much Reduce and polish
posterior palatal seal
Sore throat: overextended Reduce and polish
lingual flange
Excessive opening (open Reset the teeth to a closed VDO
VDO)
Clicking teeth 1. Grind the teeth to reduce the
VDO
2. Reset the teeth
3. Rebase the denture
Denture looseness 1. Grind to reduce vertical
2. Reset teeth
3. Rebase
4. Educate the patient
Tongue feels cramped 1. Reset teeth and rebase
2. Educate patient
Rough surfaces on denture 1. Smooth and polish Figure 34.42 Pressure indicator paste is painted in the area of
a sore spot and the denture is replaced in the mouth.
2. Repair
Cheek biting 1. Conservatively grind
mandibular buccal contours
2. Reset upper teeth to overlap
lowers more and rebase
Food adherence 1. Recontour and polish
2. Educate patient
Collapsed appearance 1. Reset teeth
2. Expand arch
3. Remake denture
Checked or broken teeth 1.Correct occlusion
2. Repair and replace teeth
3. Reeducate the patient
Face too full 1. Reset teeth and rebase
2. Educate patient
Lip wrinkles 1. This is anatomic and has no
treatment
2. Educate patient
Sore spot Mark with indelible transfer stick
and reduce
A sore spot should be easily located. It may be red (early)

Figure 34.43 A prominent sore spot will make a mark in the PIP.
or white (late). Areas that are not seen as a sore spot should
not be corrected. The patient may notice them after the chief
complaint has been corrected, then they are corrected. for the soreness to resolve. You are relieving the cause but
Paint PIP paste in the area (Figure 34.42) and replace it not the soreness.
in the mouth. If it is prominent, it will make a mark An overextended flange caused the lesions shown in
(Figure 34.43). Usually, it will not make a mark until Figure 34.44 in the labial frenum in the anterior mandibular
after a callus is formed. Reduce the mark and replace the area. They correspond to the premature contacts indicated
denture. Inform the patient that it may take a few hours in the PIP pattern in this area. Note the posterior palatal seal
Figure 34.44 An overextended flange caused these lesions in

the labial frenum in the anterior mandibular area. Figure 34.46 This lesion will mark in PIP paste on the denture
flange and can then be reduced with an acrylic bur.
Figure 34.45 A mature ulcer has formed along the denture

border overlying the canine eminence.
area of this denture: the arbitrary bead is too deep and too
sharp. This caused an ulcer to form at the midline.
In Figure 34.45, a mature ulcer has formed along the
denture border overlying the canine eminence and will
mark in PIP paste (Figure 34.46) the area on the denture
flange which can then be reduced with an acrylic bur. This
area represents a bony spicule just beneath the mucosa. If
this is mobile, it should be removed. Unless the denture is
properly adjusted in this area, the irritation will progress to
ulceration and infection.
Inspect the frenum areas. The anterior maxillary frenum
is shown in Figure 34.47. It is the most common frenum to
become irritated from denture overextension (Figure 34.48).
With the aid of disclosing wax, the frenum area is adjusted
Figures 34.47 and 34.48 The anterior maxillary frenum is the
with the small‐diameter acrylic bur using a slow‐speed most common frenum to become irritated from denture
handpiece (Figure 34.49). overextension.
Figure 34.51 Poor neuromuscular control may be the single

Figure 34.49 With the aid of disclosing wax, the frenum area is most significant factor in the successful manipulation of
adjusted with the small-diameter acrylic bur using a slow-speed complete dentures under function.
handpiece.
Figure 34.50 In patients with severe resorption of the

mandibular alveolar ridge, a portion of the inferior alveolar
nerve may be exposed on the surface of the mandible.
Beware of the inferior alveolar nerve! In patients with

severe resorption of the alveolar ridge, a portion of the
inferior alveolar nerve may be exposed (Figure 34.50).
Pressure in these areas may cause significant pain.
Neuromuscular control may be the single most significant Figure 34.52 Denture adhesive powder is sprinkled on the
damp intaglio surface of a denture.
factor in the successful manipulation of complete dentures
under function (Figure 34.51). Tongue function and denture‐
wearing experience are important prognostic indicators. Permanent soft liners (silicone elastomers) may be indi-
Denture adhesives come in at least three different forms: cated and are usually limited to mandibular dentures for
powder, cream, and pads. We generally discourage the rou- the treatment of chronic soreness, bruxism, and in the case
tine use of denture adhesives. In very few cases for short where no attached gingiva exists (Figure 34.54). They are
periods of time, adhesive may help keep new dentures in contraindicated, however, in patients with poor oral
place. Denture retention, particularly in the mandible, is a hygiene or xerostomia. They must be replaced more fre-
matter of neuromuscular control which is gained by prac- quently than a hard reline. One such silicone elastomer is
tice and time. Sprinkle powder adhesive on the damp Molloplast® B. Special burs are required for adjustment of
intaglio surface of a denture (Figure 34.52). Gently wet it silicone elastomers. These are especially good where there
under a small stream of water (Figure 34.53). is poor ridge height or lack of attached mucosa.
Figure 34.54 Permanent soft liners (silicone elastomers) may

be indicated and are usually limited to mandibular dentures for
the treatment of chronic soreness, bruxism, and in the case
where no attached gingiva exists.
Figure 34.53 The denture adhesive powder is gently wetted
under a small stream of water.
215
35
Replacing Teeth on a Complete Denture
Occasionally, teeth are knocked off a complete denture by to show the area repaired. The denture and cast are
a traumatic blow, or because the denture tooth was not immersed in warm water (115 °F) in a pressure pot for
bonded adequately to the base. In Figure 35.1, tooth #9 was 10 minutes. After the resin is totally cured, the matrix is
fractured when the denture base fractured. In any case removed from the denture, all excess acrylic is removed,
involving a broken tooth on a broken denture, the denture and it is polished to a high shine. Care must be taken to not
base is repaired first, and then the tooth replacement is polish the plastic teeth.
done to preserve the relationship of the denture base If several teeth have fractured (Figure 35.9), the broken
pieces. In the following pictures, red Duralay® resin is used teeth are carefully removed (Figure 35.10) and the denture
to make the repairs for the purpose of showing the repair areas palatal to or lingual to the debonded or fractured
site. In the real situation, a denture repair resin would be teeth are reduced. Again, the labial or buccal areas of the
used that closely resembles the color of the denture base denture are not reduced, if possible. Teeth of the same
being repaired. shade, shape, and size as the original teeth are carefully
To replace a broken tooth, a notch is cut into the denture selected and fixed in place with sticky wax (Figure 35.11)
base acrylic palatal to or lingual to the tooth (Figure 35.2). and checked against a cast of the opposing dentition or the
Sticky wax is placed on the lingual (palatal) surface of the opposing denture to ensure they do not interfere with the
tooth to hold it in place (Figure 35.3). occlusion. Triad® (uncured), clay, or Play‐Doh® can be used
The labial margin of the tooth is not disturbed. The sur- to help hold the teeth in place.
faces of the tooth and parts of the denture that will be cov- A matrix of quick‐setting plaster (best) (Figure 35.12) or
ered by the matrix are lightly lubricated. A plaster matrix is polyvinylsiloxane putty (Figure 35.13) is made. It is removed
made on the labial or buccal side of the tooth being replaced from the denture after it sets, the teeth are cleaned, and a
(Figure 35.4). This should cover an area of about two teeth diatoric is cut in the lingual of each tooth (Figure 35.14).
on either side of the missing tooth (Figure 35.5). The The teeth are attached to the plaster matrix with sticky wax
replacement tooth for the missing tooth is placed in the in such a way that they do not interfere with the placement
matrix and secured in place with sticky wax (Figure 35.6). of the matrix back on the denture. If a putty matrix is used,
The matrix containing the tooth is placed into position extreme care must be taken to not flex the matrix, or the
on the denture (Figure 35.7) and can be held there with sticky wax will break and the teeth will come loose.
sticky wax. The tooth should fit perfectly into the undis- Resin is applied by the brush‐bead method (Figure 35.15)
turbed labial area. Diatoric interlocks can be cut into the to slightly overfill the prepared area (Figure 35.16). Red
tooth to provide additional mechanical retention (see repair resin is used here on this technique denture. Repair
arrow). The matrix is luted back into place and “tacked” to resin that is closest in color to the denture base would be
both proximal areas with sticky wax. If three teeth are used with a real-life patient. The repair cast and uncured
missing, the teeth adjacent to solid teeth are repaired first, denture resin are placed in a pressure pot half‐filled with
and then the one in the middle is repaired. warm water (115 °F) for 10 minutes to cure (Figure 35.17).
The prepared areas of the denture are overfilled with The brush is cleaned by dipping it in monomer and drying
autopolymerizing repair resin (Figure 35.8). Pink acrylic it thoroughly on a paper towel to remove any residual
repair resin is used here to contrast to the red Duralay resin acrylic which would harden and ruin the brush.
Figure 35.1 Tooth #9 was fractured when the denture base

fractured.
Figure 35.4 Make a plaster matrix on the labial or buccal side
of the tooth being replaced.
Figure 35.2 To replace a broken tooth, cut a notch into the

denture base acrylic palatal to or lingual to the tooth being Figure 35.5 Cover an area of about two teeth on either side of
replaced. the missing tooth with a plaster matrix.
Figure 35.6 Place the replacement tooth in the matrix and

Figure 35.3 Add sticky wax on the lingual (palatal) surface of secure it in place with sticky wax.
the tooth to hold it in place.
Replacing Teeth on a Complete Denture 217
Figure 35.7 Place the matrix containing the replacement tooth

into position on the denture.
Figure 35.11 Select replacement teeth and fix them in place

with sticky wax. Note the Triad being used to help hold the teeth
in place to make the teeth more stable when the matrix is made.
Figure 35.8 Overfill the prepared areas of the denture with

autopolymerizing repair resin.
Figure 35.12 Make a matrix of quick-setting plaster.
Figure 35.9 Several teeth in this denture have fractured.
Figure 35.10 Carefully remove the broken teeth. Figure 35.13 A matrix is made of polyvinylsiloxane putty.
Figure 35.14 Cut a diatoric in the lingual of each tooth and

attach the teeth to the plaster matrix with sticky wax.
Figure 35.17 Cure the repair in a pressure pot half-filled with

warm water (115 °F) for 10 minutes. The repair can then be
shaped and polished to finalize the repair.
Figure 35.15 Apply resin to the repair site by the brush-bead

method.
Figure 35.16 Slightly overfill resin in the prepared area.

219
36
Repairing a Broken Complete Denture
36.1 Repairing Fracture their current denture. It is also not uncommon for a patient
of Complete Dentures to present with someone else’s denture, either innocently
believing it is their own or as an elaborate scheme to get a
The midline fracture of the maxillary complete denture is new denture without paying for it.
the fracture most often seen in dentures (Figure 36.1). This When a midline fracture of a maxillary complete denture
is largely because as the ridges resorb and remodel, the occurs, the cause must be determined. As with any fracture,
palatal bone does not. This leads to “high‐centering” of the this must be corrected if the repair is to be successful. First,
denture, where the denture contacts primarily in the hard the pieces are assembled and tried against a cast of the
palate and secondarily contacts the residual ridge. This opposing dentition. The parts of the fractured denture are
leads to a constant rocking effect which accelerates bone aligned and splinted into position using long shank dental
loss of the residual ridge and causes a steady loss of stabil- burs, coat hanger wires (Figure 36.2), plastic sticks, or large
ity of the denture, in time leading to a stress fracture of the paper clips. These are “tacked” to the teeth with sticky wax
denture base. (Figure 36.3). Wooden sticks or toothpicks are not recom-
The second most common fracture of a complete den- mended for this as these can absorb water and warp.
ture is the mandibular fracture. This usually is the result of All undesirable undercuts that are more than 10 mm
an accidental drop, although it can occur during function. from the fracture site are blocked out with wet tissue paper,
When function is the cause, it usually involves a thin den- putty, or wet pumice. About 2 mm of the denture flange
ture base, as is common in an immediate complete denture borders are left uncovered and a base of quick‐setting plas-
and invariably is associated with a poor adaptation to the ter or stone is poured. The easiest method of blocking out
ridge as is often seen following resorption during healing. the ridge area away from the fracture site is to use polyvi-
Often, patients will resort to not wearing the lower com- nylsiloxane putty. The quick‐setting plaster will not bond
plete denture due to the lack of support that is common with this material and will need to have some sort of
with lower complete dentures. They may place it in a mechanical retention provided. Pieces of paper clip cut and
drawer and allow the denture base to dry out, so that it bent into a loop will do nicely (Figure 36.4). They must be
becomes distorted. This not only makes it fit more poorly, it placed into the putty before it sets, and the loop section
also makes it more brittle and prone to fracture. Soaking needs to extend into the area that will be filled by the plas-
it in water will not ensure that it returns it to its original ter. A generous area (about 8–10 mm) close to the fracture
state, either. site is left free of putty coverage (Figure 36.5).
When a patient shows up with a fractured denture, the After the plaster has set, the bracing rods and sticky wax
first thing the dentist should do is determine whether the are carefully removed. All denture pieces are removed
denture is truly the patient’s own denture. Always fit the from the stone matrix (Figure 36.6). These pieces and the
pieces of the denture together with sticky wax and place it matrix are cleaned and reassembled on the cast to ensure
against the opposing denture or a cast of the opposing teeth that they can be accurately positioned (Figure 36.7). The
to ensure that the denture is correct for the patient. It may approximating surfaces are beveled so that there is a 3 mm
be a mate to a second set of dentures that a patient owns gap on the polished surface and a 2 mm gap on the cast side
but never wears. The patient may have worn out, lost, or (Figure 36.8). This allows visual access to see that the
broken the mate to the one they are wearing and hope that acrylic is filling the entire area. The pieces are replaced in
the one they provide to the dentist can be adapted to fit position on the cast and checked for accuracy.
Figure 36.4 Cut pieces of paper clip and bend them into a loop
Figure 36.1 The most common fracture of a complete denture to make good retainers for the repair cast.
is the midline fracture of the maxillary complete denture.
Figure 36.5 Block out the ridge area away from the fracture
Figure 36.2 Align the parts of the fractured denture and splint site with polyvinylsiloxane putty. Leave a generous area (about
them into position with coat hanger wires. 8–10 mm) close to the fracture site free of putty coverage.
Remove enough acrylic from the polished surface side of

the denture to allow a gap of 8–10 mm cut halfway through
the denture (Figure 36.9). This process is called “rabbet-
ing” and provides an increased surface area that affords a
stronger joint between the old and new acrylic. The rabbet-
ing thins the proximal surfaces of the dentures about half-
way through the polished side and adds about 3 mm more
width to the gap on each piece, totaling about 8 mm on the
polished surface side between the pieces. Any small pieces
are left out and replaced entirely with repair acrylic.
Separating medium is painted on the cast at least 10 mm
to either side of the fracture line (Figure 36.10). The parts
are “tacked” with sticky wax into position on the cast base.
The “brush‐bead” method is used to overfill the repair
Figure 36.3 “Tack” the wires to the teeth with sticky wax. area with repair acrylic (Figure 36.11). For demonstration
Repairing a Broken Complete Denture 221
Figure 36.6 Remove all denture pieces from the stone matrix.
Figure 36.8 Bevel the approximating surfaces so that there is a

3 mm gap on the polished surface and a 2 mm gap on the cast side.
Figure 36.7 The pieces and the matrix are cleaned and
reassembled on the cast to ensure that they can be accurately
positioned.
urposes only, red Duralay® resin is used here so that the

p Figure 36.9 Remove enough acrylic from the polished surface
juncture can be easily seen. If this were done on a patient’s side of the denture to allow a gap of 8–10 mm cut halfway
denture, a repair acrylic matching the denture’s original through the denture.
acrylic would be used.
The entire assembly is placed in warm water in a pressure tissue side is checked for irregularities and these are repaired
pot and allowed to cure for about 10 minutes at a pressure of or smoothed. Inspection of the denture should show a
20 pounds/square inch. After the acrylic has set for 10 min- smooth line at the junction of the denture base acrylic and
utes, the repaired denture is removed from the stone matrix the repair acrylic (Figure 36.14). In this example, the repair
(Figure 36.12) and finished with successively finer abra- acrylic has permeated the crack in the denture tooth. This
sives until a high shine is achieved (Figure 36.13). The tooth will be replaced in a subsequent procedure.
Figure 36.10 Paint separating medium on the cast at least

10 mm to either side of the fracture line.
Figure 36.13 Finish the repaired denture with successively

finer abrasives until a high shine is achieved.
Figure 36.11 Use the “brush‐bead” method to overfill the

Figure 36.14 An inspection of the denture should show a
repair area with repair acrylic.
smooth line at the junction of the denture base acrylic and the
repair acrylic.
The following pictures demonstrate how a fracture of a

mandibular compete denture is successfully repaired. Red
Duralay resin is used so that the juncture can be easily
seen. If this were done on a patient’s denture, a repair
acrylic matching the denture’s original acrylic would be
chosen. First, the broken pieces (Figure 36.15) are approxi-
mated and fixed in position with a nonabsorbing splinting
material (Figure 36.16) (wire, plastic, etc.). Sticky wax is
used to lute these braces to the denture base. The tissue
surface must be checked to make sure that the pieces are in
close contact and that there is no wax or other debris on
that surface (Figure 36.17).
Polyvinylsiloxane putty is used to block out the area away
from the fracture site. About 10 mm of the surface is left
uncovered on the tissue side kept bare of any putty
Figure 36.12 Remove the repaired denture from the stone matrix. (Figure 36.18). Pieces of paper clip are pressed into the
Figure 36.18 Keep about 10 mm of the surface on the tissue

side bare of any putty.
Figure 36.15 Approximating the broken pieces of a

mandibular denture.
Figure 36.16 Fix the broken pieces in position with a

nonabsorbing splinting material.
Figure 36.19 Remove the splinting material and all the sticky
wax from the denture surface and the repair cast.
site is inspected for any defects. The denture pieces are

replaced on the cast and examined to ensure that they fit
precisely back into place (Figure 36.20).
Approximately 1.5 mm of acrylic is removed from the
proximal surfaces of the fracture line on the polished sur-
face and 1 mm on the tissue side, forming a gap of 2 mm on
the tissue surface and 3 mm on the polished surface
(Figures 36.21 and 36.22). The pieces are placed back on
the cast and these dimensions are verified. It is necessary
that this amount of gap be present to allow enough visual
Figure 36.17 The denture pieces are in close contact and there
and working access, so the repair acrylic can be placed and
is no wax or other debris on that surface. fill the entire repair site. Enough acrylic is removed from
the polished surface side of the denture to allow a gap of
putty while it is soft to provide retention of the putty to the 8–10 mm (Figures 36.23 and 36.24). This process is called
plaster base of the repair cast. A mounting plaster base is “rabbeting” and provides an increased surface area that
poured to complete the repair cast. The splinting material affords a stronger joint between the old and new acrylic
and all the sticky wax from the denture surface and the (Figure 36.24).
repair cast are removed (Figure 36.19). The denture pieces Al‐Cote®, a tinfoil substitute, is painted on the area under
are removed from the cast and the area under the fracture the site to be repaired (Figure 36.25). The denture parts are
BEVEL
CAST
Figure 36.20 Fit the denture pieces precisely back into place
on the cast.
replaced and luted in place with sticky wax (Figure 36.26).

Rabbeting and beveling noticeably increase the amount of
visual and working access provided.
The method used to apply repair acrylic to the denture in
this exercise is called the “brush‐bead” method. Dappen®
dishes containing monomer and polymer are arranged
close to the denture. The brush is first “wetted” in the liq-
uid monomer, then it is dipped in the polymer powder.
This will cause a small bead to form on the wetted end of
the brush (Figure 36.27). These beads are placed in the
repair site to make the repair. Additional acrylic is added
until the entire site is slightly overfilled.
The brush is dipped in monomer and dried thoroughly
on a paper towel to remove any residual acrylic to prevent
Figures 36.21 and 36.22 Remove approximately 1.5 mm of
ruining the brush. If this step is forgotten, the acrylic will acrylic from the proximal surfaces of the fracture line on the
harden and the brush will be ruined (Figure 36.28). Extra polished surface and 1 mm on the tissue side, forming a gap of
acrylic is added to overbuild the repair site area to assure 2 mm on the tissue surface and 3 mm on the polished surface.
that there is enough thickness of high‐quality acrylic.
Moisture from the water bath in the pressure pot can
cause a rough surface to form, which must be removed set. After ensuring that the dentures fit together properly,
after the denture is cured. The repair cast and denture are the excess acrylic is removed with a denture bur and abra-
placed in a warm water bath to cure (Figure 36.29). The sives and polishing agents are used to polish the repaired
denture is removed from the cast and checked to make area, taking care to not overpolish the area or the teeth. An
sure that the acrylic is of good quality and covering all the unused, clean polishing wheel must be used for each abra-
desired areas (Figure 36.30). sive. If a repair is done properly with the correct acrylic, it
The dentures are fitted together to ensure that they is almost impossible to tell where the denture has been
occlude properly (Figure 36.31). If the occlusion is off, then repaired. One must look closely to discern the repair site
the repair is not accurate. It is essential that the dentures because the repair acrylic blends together so precisely with
are inspected to ensure that they fit together before making the original acrylic (Figure 36.32). This is how a repair
the repair cast. The patient may be giving you a mismatched should look!
Figure 36.23 Remove enough acrylic from the polished surface Figure 36.26 The denture parts are replaced and luted in
side of the denture to allow a gap of 8–10 mm. place with sticky wax.
RABBET
CAST
Figure 36.24 “Rabbeting” provides an increased surface area Figure 36.27 Use a disposable brush dipped in the polymer
that affords a stronger joint between the old and new acrylic. powder to form a small bead on the wetted end of the brush.
Figure 36.28 Dip the brush in monomer and dry it thoroughly

on a paper towel to remove any residual acrylic and prevent
ruining the brush.
Figure 36.25 Paint Al‐Cote, a tinfoil substitute, on the area
under the site to be repaired.
Figure 36.29 Place the repair cast with the denture in a pressure pot water bath to cure.
Figure 36.31 Fit the dentures together to ensure that they

occlude properly.
Figure 36.30 Check to see that the acrylic is of good quality
and covers all the desired areas.
to build up in the denture base as well as increasing the
resorption rate of the supporting bone. These stresses are
36.2 Summary released in the form of a fracture, and most frequently these
appear first as a midline fracture of the maxillary denture.
Fractures occur on dentures most frequently when the Occasionally, teeth are knocked off a denture by a trau-
residual ridge resorbs to the point where the denture is matic blow, or because the denture tooth was not bonded
unstable. The resultant rocking of the denture causes stress adequately to the base. This can occur with plastic teeth as
well as porcelain teeth, and fractures through the teeth

themselves can occur in both porcelain and acrylic teeth,
although more often in porcelain teeth.
In any case involving a broken denture or debonded
tooth, the parts are reassembled by hand, held together
temporarily with a sticky wax, and stone is poured into the
base to make a cast so that the fracture can be repaired with
an autopolymerizing resin. When the repair is complete,
the cause of the fracture should be explored and eliminated
if possible. Most frequently, the fractured denture needs a
new liner to compensate for the resorption of the residual
ridge, thus eliminating the most common cause of the
fracture.
Figure 36.32 The repair site acrylic should blend together so

precisely with the original acrylic as to make the repair almost
invisible.
229
37
Using Implants to Stabilize a Complete Denture
37.1 Overdentures and Implants Implants also have improved retention and allow for a
variety of implant abutment types. The ball or reverse
There are several advantages of overdentures compared to cone‐shaped abutments are the most popular (Figure 37.5)
conventional complete dentures: improved stability, because they allow for appliance movement. Ball abut-
improved retention, no need for denture adhesives, can be ments are made to fit any type of osseointegrated implant,
used where there is minimal bone height, reduced stress on and some are also made to be cemented into endodonti-
residual ridge, reduced resorption, increased ability to cally treated teeth. They offer the advantage of allowing
masticate food, increased confidence level in patients, less freedom of movement in several directions.
length of flange required, improved phonetics, and longer Some abutments are designed to screw into an implant.
time between relines. Others are made for cementation into an endodontically
Even with all these advantages, there are still some draw- treated tooth. The screw‐in type will have a hexagonal hole
backs with complete overdentures: weakened denture in the top of the ball, which is engaged by a special hex
base, may make it too hard to remove denture, increased wrench provided for that purpose. Other systems will have a
ability of patient to bite hard enough to break the denture screw hole in the top of the ball and a screw that is placed in
or to break off teeth, may cause loss of opposing teeth that the hole to attach it to the implant. This can be a simple hex
are periodontally involved, the metallic components may wrench that the dentist will use to hand‐tighten the screw
corrode, it is more difficult to get an impression, it may based on their own judgment and experience, but better sys-
increase speech difficulties due to added bulk in palate, tems are designed to be tightened by a torque wrench.
and it makes it harder to reline a denture. These abutment components are attached to the implants
Overdenture abutments can be placed in healthy teeth, and tightened with a torque wrench which will not allow
in endodontically treated teeth, and can be retained by the abutment to be overtightened. It is very important not
implants. to torque the implant by overtightening. Components
A simple overdenture abutment can be made with cast could be fractured or their threads stripped, or the implants
nonprecious metal dowel copings (Figure 37.1). These could fail to augment to the bone.
resemble upholstery tacks and are cemented into endodon- In the following example, yellow cap attachment trans-
tically treated teeth. fers are snapped onto the ball abutments (Figure 37.6). Cap
Amalgam also is sometimes used to make overdenture abut- attachments with stainless steel housings are pressed over
ments (Figure 37.2) and usually is placed in endodontically the transfers (Figure 37.7). The transfer and housing
treated teeth. Note the common problem of corrosion with assemblies are rotated to create a connection path of draw
amalgam. Glass ionomer and composite restorations have con- and block‐out undercuts. The assembled housings and
siderable wear and therefore are seldom recommended. transfers are rotated up to 28° to create relative parallelism
Rare earth magnets are an interesting alternative to more for a path of draw. The undercuts are blocked out beneath
conventional overdenture abutments and are embedded in the assemblies with silicone or wax (Figure 37.8).
the denture. A magnetic metal stud is placed in the endo- An implant impression is best done with a custom tray
dontically treated tooth abutment (Figure 37.3) or the mag- fabricated on a working cast. A spacer is made to accom-
nets can be cast to a metal stud (Figure 37.4). These modate the ball abutment transfer. The existing denture is
magnets corrode very easily and are placed in the overden- modified to be worn while laboratory work is done so that
ture itself to allow for easy removal. the implants are not stressed.
Figure 37.4 Magnets can be cast to a metal stud.
Figure 37.1 Make simple overdenture abutments with cast

nonprecious metal dowel copings.
Figure 37.5 Ball or reverse cone-shaped abutments are the

most popular overdenture abutments.
Figure 37.2 Amalgam also is sometimes used to make
overdenture abutments.
Figure 37.3 Place a magnetic metal stud in the endodontically Figure 37.6 Snap yellow cap attachment transfers onto ball
treated tooth abutment. abutments.
Using Implants to Stabilize a Complete Denture 231
Figure 37.7 Press cap attachments with stainless steel

housings over the transfers.
Figure 37.9 An open-faced custom tray.
Figure 37.8 Block out undercuts beneath the assemblies with

silicone or wax.
There are basically two different types of custom trays

used to make impressions of implant abutments: open‐
faced (Figure 37.9) and closed‐face (Figure 37.10), to be
used with two different types of transfer copings. The Figure 37.10 A closed-face custom tray.
transfer copings n Figure 37.9 have a flat surface on one
side and are screwed onto the abutment. When the impres- implants – 30 Ncm; one‐piece, one‐stage complete
sion is removed from the mouth, the screws are removed implants – 20 Ncm.
and the entire coping is removed with the impression. With Ball implant systems consist of the abutment and a metal
the teeth in Figure 37.10, the transfer copings also have a “keeper” that is embedded in the denture and holds a nylon
flat surface on one side and a ring‐shaped undercut around or plastic “grommet” which can be replaced when worn.
the circumference of the shaft. When the impression is Ball attachment transfers are press‐fitted onto the tops
made in this situation, the transfer copings remain in place of the ball abutments. A stiff elastomeric impression is
in the mouth. They are removed and snap into the elasto- recommended for this purpose. Light‐bodied impression
meric impression, and then the impression is poured to material is placed around the abutments. Heavy‐bodied
make the cast. impression material is loaded into the tray. The impres-
Healing collars are removed with special hex tools. The sion must set completely before it is removed from the
appropriate ball components are screwed into the implants mouth. The attachment transfers and housings are assem-
with a torque wrench with a 1.25 mm hex tool: two‐piece, bled onto the attachment replicas in the working cast.
two‐stage implants – 30 Ncm; two‐piece, one‐stage The impression is removed from the cast and the ball
abutment transfers are removed from the impression. Cap

attachment transfers are press‐fitted onto the ball abut-
ment replicas (Figure 37.11), and cap attachment hous-
ings are placed onto the cap attachment transfers.
One system utilizes a simple ball abutment that a nylon
retentive unit fits over. This is placed over the abutment in
the mouth. This is contained in the denture by a soft nylon
expansion bushing that is placed over the nylon bushing in
the mouth and encapsulates it while it is in the denture. It
will allow the first part to expand within a can‐like metal
container, which is pushed into place over the nylon bush-
ing. This system allows for easy replacement of the first
nylon bushing, which wears down before the other compo-
nents of the system. The second part can also be replaced
when it no longer will retain the first part, leaving the long‐
wearing metal canister unharmed.
After the implants are placed, they need to be covered
Figure 37.12 Retain rubber rings with metal “keepers” that
to protect them during the augmentation process. This is encircle the ring and protect it.
done by relieving the existing denture and reconstruct-
ing it such that it does not place undue stress on the
implants. A relief chamber is cut in a maxillary com-
plete denture that has been modified to fit over newly
placed implants (Figure 37.11). This chamber is filled
with repair acrylic and cut back to provide relief and
filled with tissue conditioner to protect the implants. It
will be used for about six months, or until the implants
are fully osseointegrated.
The rubber rings are retained by metal “keepers” that
encircle the ring and protect it (Figure 37.12). The weak
part of the system is the ring which will require frequent
replacing.
While implants are being augmented, the tissue surface
of the denture is relieved and a tissue conditioner is added
Figure 37.13 Add a tissue conditioner to the relieved area.
to the relieved area (Figure 37.13). The denture is then

seated in the mouth and a tissue conditioner “impression”
is made of the implants (Figure 37.14). Figure 37.15 shows
another example of tissue conditioner being used to line a
relief chamber cut into the base of the denture to prevent
loading the implants until after fusion with the surround-
ing bone.
A bar system can be used as overdenture abutments.
Figure 37.11 Cut a relief chamber in a maxillary complete Plastic or metal clips can be used to hold the denture to the
denture that has been modified to fit over newly placed implants. bar. If the bar extends anteriorly and posteriorly from the
Figure 37.14 Make a tissue conditioner “impression” of the

implants. Figures 37.16 and 37.17 This bar must be in a straight line to
allow for this movement.
attachment that fits over the bar. The bar must be in a

straight line to allow for this movement.
Before they are loaded, the implant abutments are left
in a passive state for about six months until they have
achieved fusion (augmented) with the bone. On the
working cast, a plastic form is bonded between the two
abutment analogs with sticky wax or Duralay® resin,
removed from the analogs, invested, and cast in a suit-
able metal.
The metal bar is tried in the mouth to assure a perfect fit.
If the fit is not perfect, the bar is sectioned close to one end
and soldered. The fit must be precise to avoid causing
stresses that would cause the abutments to fail. A perfectly
fitting bar is secured in place on the working cast with
abutment screws. The access holes are sealed with gutta‐
percha, polyvinylsiloxane putty, or any other substance
that will not bond to acrylic and can be easily removed after
Figure 37.15 Use a tissue conditioner to line a relief chamber processing. A machined metal sleeve is cut to a length that
cut into the base of the denture. fits and is pressed into place over the bar. A denture is
made or adapted to fit over the sleeve by using autopolym-
abutments, it is not designed to allow for movement of the erizing resin (Figure 37.18).
appliance, so a stress relief system must be used. The bar in Figure 37.19a does not allow rotation and
Examples of bar systems that can be used as overdenture must not be placed in a mandibular distal extension situa-
abutments are shown in Figures 37.16 and 37.17. This bar tion. The bar in Figure 37.19b allows rotation. Sleeves that
is designed to allow for rotation of the appliance about a fit these bars often have wings that engage the investing
single axis and uses a machined sleeve semi‐precision acrylic of the denture base.
A B C
Figure 37.18 Cut a machined metal sleeve to a length that fits

and press it into place over the bar.
Figure 37.20 Three different types of implant transfer
abutments and transfer analogs.
(a) (b)
in the impression and the abutment screw is completely
enclosed in the transfer abutment so as not to interfere
with the replacement in the impression. Other examples of
transfer copings that are made to be screwed intraorally
onto the abutment are shown on the right (B, C). Using
these systems, when the impression is removed from the
mouth, the copings are left in place in the impression and
the long screws are removed so the impression can be
removed from the mouth. An analog is then screwed in
place and the working cast is made.
Ball abutment transfers are placed over the ball abut-
ment replicas and they are inserted into the impression
Figure 37.19 (a) The bar on the left does not allow rotation holes. The ball abutment transfers are removed and placed
and must not be placed in a mandibular distal extension
situation. (b) The bar on the right allows rotation. onto the ball abutment replicas. They are then reinserted
back into the impression holes. An opposing impression is
made. All impressions and materials are then sent to a lab
37.2 Transfer Analogs for final fabrication of the abutment.
The metal housings are processed into the base plate
There are several different types of analogs made to go with (Figure 37.21). A ball of Triad® is placed over the metal
the many different implant systems. Three of these types of housing and cured. A sheet of Triad is placed over the
implant transfer abutments and transfer analogs are shown entire cast and cured. A wax rim is secured to the base plate.
in Figure 37.20. A bite registration is made on the stabilized base plate
The one on the left (A) can be used with either an open‐sided and occlusion rim. Yellow cap attachment transfers are
tray or a closed tray. It can be repositioned back in the impres- snapped onto the ball abutments in the patient’s mouth.
sion after it is removed from the mouth. The two to the right (B, The base plate is placed over the cap attachments.
C) would require an open‐sided tray because the transfer abut- The set‐up is completed and the wax denture is tried in.
ment is made to be retained by the impression and not removed The setting of teeth and waxing of the denture are com-
until after the cast is poured, so the screw must be removed pleted. The yellow cap attachment transfers are snapped
before the impression is removed from the mouth. onto the ball attachments. The denture base plate is placed
The flat surfaces ensure that the transfer coping on the over the transfer assembly. Esthetics and phonetics are
left (A) is to be placed in the proper orientation when it is evaluated. Centric relation, vertical dimension of occlu-
placed back into the impression. The circumferential rings sion, and vertical dimension at rest are verified. The patient
around the copings ensure that the copings are fully seated signs the chart for approval.
Figure 37.21 Process the metal housings into the base plate.
Figure 37.22 To determine where to place the mini-implant
The denture is processed in the normal way except that abutments, evaluate the cast and the existing denture, then
mark these locations on the ridge with an indelible pencil and
the cap attachment transfers and their housings are placed
transfer these marks to the denture.
onto the ball attachment replicas before packing the
denture.
The final prosthesis is prepared and tried in. The ball
components are retightened with the torque wrench and
hex tool. The nylon liners are placed in metal housings on
the denture base with the insertion tool from the cap
attachment instruments kit. Only one liner is inserted and
adjusted at a time. The denture is snapped on and retention
is checked. The final prosthesis is delivered. The denture is
inserted and final adjustments are made. The patient is
cautioned not to use bleach and instructed to insert and
remove the denture in a vertical direction. The patient
needs to return for a recall appointment to get liners
replaced. Gray liners are made for stronger attachments.
37.3 Mini-Implants
Figure 37.23 Make pilot holes which are simple to place and
There is also a mini‐implant system which is cheaper, and
can be done with or without a placement stent.
the implants are smaller in diameter (SDI) than conven-
tional implant system components. These implants do not
require a special tap to place threads into the bone. As critical as with a conventional implant. A special twist tool
such, they can be placed into a narrower ridge than stand- facilitates placement.
ard osseointegrated implants. Radiographs are made to
verify their positioning.
The first phase is to determine where to place the mini‐ 37.4 Abutments in Natural Teeth
implant abutments for the best result, bearing in mind the
location of the inferior alveolar nerve. This is done by eval- Endodontic therapy of the abutment teeth must be com-
uating the cast and the existing denture, then marking pleted if the teeth are to be used as overdenture abutments.
these locations on the ridge and transferring these marks to The teeth are left long until the endodontic therapy is com-
the denture via an indelible transfer (Figure 37.22). pleted so that rubber dam isolation is completed
The pilot holes are simple to place and can be done with (Figure 37.24). The abutment teeth are prepared for cop-
or without a placement stent (Figure 37.23). An effort is ings by reducing them down to the level of the crest of the
made to place them as parallel as possible, but this is not as ridge (Figure 37.25).
Figure 37.24 Leave the teeth long until the endodontic therapy
is completed.
Figure 37.26 Cement magnetic faceplates into endodontically
treated teeth and adjust them with burs to fit the profile of the
teeth abutments.
Figure 37.25 Prepare the abutment teeth for copings.
37.5 Adapting an Existing Denture Figure 37.27 Locate the implants with an impression of the
to Fit Implants or Endodontically arch or use PIP in the denture.
Retained Teeth Abutments
same for making all types of abutment fit an existing com-
The procedure for adapting an overdenture to fit teeth plete denture whether they are in endodontically restored
abutments is basically the same as for fitting an existing teeth or implants.
denture to fit implants. First, the abutments must be Once the abutments are located (Figure 37.27), those
located. This can be done by making an impression in the areas overlying them are removed with an acrylic bur.
conventional way with a custom tray, then making a mas- The housings are processed into the denture base. The
ter cast. Another method is to use the existing denture as a denture is seated in the mouth to determine the locations
tray to make an impression or use pressure indicator paste of the implants. The top of the housing is marked with an
(PIP) to locate the abutments. This will show the exact indelible tracer. PIP paste is painted into the denture. The
location of the abutments and eliminate several steps in denture is removed, and the marked areas relieved with an
the adaptation and save chair and lab time. acrylic bur (Figure 37.28) until the denture can be seated in
In the following pictures, rare earth magnets are being the mouth without contacting the magnet. Rare earth mag-
placed in an existing mandibular complete denture. nets are placed on the magnetic sensitive plates of the abut-
Magnetic faceplates are cemented into the endodontically ments and the denture is placed over them to assure
treated teeth and adjusted with burs to fit the profile of the enough resin has been removed to prevent moving the
teeth abutments (Figure 37.26). The procedures are the magnets (Figure 37.29).
Figure 37.28 Relieve marked areas with an acrylic bur until the
denture can be seated in the mouth.
Figure 37.30 Place a small amount of autopolymerizing acrylic

into the dry relief areas of the denture.
Figure 37.29 Place the denture over the abutments to assure

enough resin has been removed to prevent moving the magnets.
Figure 37.31 Remove the denture after the acrylic sets.
A small amount of autopolymerizing acrylic is placed

into the dry relief areas of the denture (Figure 37.30). patient is instructed to close in centric. The denture is
A small amount of acrylic is also placed on the top of the removed after the acrylic sets (Figure 37.31). Any addi-
magnets. The denture is placed over the housings and the tional voids are filled with autopolymerizing resin.
239
38
Immediate Complete Dentures
Immediate complete dentures are those dentures inserted After six months, the dentist may offer a hard reline as an
immediately after the teeth are extracted and should be alternative to new dentures, but only after the patient has
considered temporary prostheses. Patients often ask for been examined by the dentist, who has made the decision
immediate dentures because they are reluctant to be seen that relining is an acceptable alternative. The patient
in public without teeth. Usually, their expectations are should anticipate that they will need a new denture made,
higher than is realistically possible. For this reason, any so it is best to not even mention that option at an earlier
patient contemplating an immediate denture must be appointment. It is so much easier to explain to a patient
thoroughly informed of the compromises that are being that you may be able to save them some expense by relining
made and be willing to accept the consequences of their their current denture after you have made the diagnosis at
decision to have immediate complete dentures made prior the six months evaluation than to tell them that they will
to any changes being made in their mouth or any prosthe- have to pay for a new denture because their current “imme-
sis being fabricated. diate” denture is unsuitable for relining.
First, the dentist should emphasize that immediate den- Patients often want their dentures to resemble their nat-
tures are more expensive than conventional complete den- ural teeth. They must be informed that dentures must have
tures. It is better to refer to the denture as a “temporary a balanced occlusion to be properly retentive and stable,
denture.” It should also be emphasized that this denture and that this may not be possible if their denture teeth are
will need several relines with tissue conditioner, which will set in the same relationship as their natural teeth. A patient
be paid for by the patient and which will drive up the cost. will usually be more receptive to this idea when the dentist
One of the big complaints patients often have with explains that commonly, natural teeth are lost due to peri-
immediate dentures is that the flanges are too thick or that odontal disease, and that some of the factors that led to
the teeth are too short. Explain that dentures must have a their loss were undoubtedly caused by premature contacts
certain thickness of acrylic to be resistant to fracture under of natural teeth. When patients realize that their dentures
the forces of mastication and that they must have a flange would not be satisfactory if they are made to look like their
to provide the seal necessary for a vacuum that will resist natural teeth, they generally will accept the dentist’s pro-
dislodgment of the dentures and prevent food from collect- fessional advice in having their dentures made according to
ing under them. Explain that as the tissues resorb and his or her guidelines.
recontour over time, more room will become available to As a default, if a patient will not make a reasonable
set the teeth and allow the flange to be better contoured. concession, it is better to refuse the treatment than to
The patient must understand that during this period, deal with the aftereffects. If the dentist compromises and
immediate complete dentures will loosen and feel overcon- has dentures fabricated that they know are not in the
toured, and cannot be considerably thinned in the labial patient’s best interest, they would have a tough legal bat-
flange area. Explain that, for these reasons, the patient tle in a courtroom.
should anticipate the need for another denture after at least When immediate complete dentures are chosen, the
a six months healing period, for which they must pay the patient must understand that they must leave them in for
cost of a new denture because most dental insurance com- three days after insertion without removing them. Explain
panies will not cover the cost of two dentures. It is wise to that the dentures are simply a compression bandage with
have the patient sign a statement in their record that they teeth on them for this period. Also explain that the patient
understand these conditions before any treatment is begun. will experience swelling and some discoloration of their
skin. This is normal after surgery and should be expected. applied to cover the bruising, but her honeymoon was a
Although it may seem ridiculous, some patients have been disaster, as would be anticipated. She, of course, blamed
known to schedule a large dinner after their surgery to cel- the dentist for ruining the whole process and tried to
ebrate and show off their new dentures or to even book a refuse payment and threatened a lawsuit. Her aunt was a
photography session to capture their new look. city councilwoman and tried to use her influence to
A “refractory patient” is one who has had several den- “make things right.” The case never went to court, but the
tures made and has had what they felt were negative patient and her family tried to get my practice “black-
results. They do not accept responsibility for the reasons balled” by the community. The truth is, she never once
why they had to have their dentures made. These patients advised us of her plans and had made up the schedule
will attempt to get a “guarantee” from the dentist that their because her aunt was paying for the dentures as a wed-
new dentures will fit, or they will not have to pay the bill. It ding gift and other family members and friends were pay-
can sometimes be very difficult to determine if a perspec- ing for the photographs, wedding, and honeymoon.
tive denture patient will develop into one of these. Usually, Probably the main reason she didn’t let us know was that
if a patient demands compromises or promises from the she knew we wouldn’t provide the treatment if we were
dentist, there is a good chance that they have the tendency aware of her plans.
to become a “refractory patient.” My best suggestion is that The bottom line is this: a good diagnostic work‐up is as
these patients be referred by the general dentist to a pros- crucial as any other phase of treatment. If something
thodontist, who will have more experience in dealing with doesn’t seem right, don’t work on the patient!
this type of patient.
You must make it clear to the patient that they must go
with your treatment plan exclusively before you begin the 38.1 Immediate Dentures
process. I have had patients come in after having all their
teeth extracted by another dentist who offered them extrac- Patients who are missing several teeth and who are unsure
tions at a lower cost and want their immediate dentures of the prognosis of the remaining teeth will have several
inserted that day. My advice is to have the dentures returned questions for the dentist. The dentist must be able to
from the lab prior to the date of insertion and inspect them explain all their options and educate them as to the best
carefully to determine their suitability. It has happened course of action for them. The dentist must deal with their
that the immediate dentures I received were not the ones frustrations and sometimes the sense of hopelessness that
made for that patient. Imagine the challenge to your repu- is characteristic of these patients. Although the pattern of
tation if you extracted all a patient’s teeth and discovered progression from fully functional, healthy, and esthetic
that you had the wrong denture to insert. A malpractice natural dentition to total breakdown and unhealthy teeth is
lawyer would have a field day! To avoid this mistake, retain very familiar to the dentist, this may come as a complete
a diagnostic cast of the patient to compare it to the denture surprise to the patient. Often, this comes about because of
when it is returned, then call the patient to affirm that all is the patient’s financial situation, which has led them to
ready for their appointment. think that they only need to visit the dentist when they feel
Be aware that you cannot do extractions on the last day discomfort or notice dark spots or missing teeth which
of the year and insert an immediate denture on New Year’s affect their appearance in the public eye. What they are
Day. This constitutes fraud and will get you jail time and really seeking is reassurance that the dentist can make eve-
loss of your dental license. rything right after years of dental neglect.
With over 35 years of dental practice and another nine For those patients who want an immediate denture
as a dental laboratory technician who has made a consid- because they fear being seen in public without teeth, this
erable number of complete dentures, I have encountered may be the single most important factor in their treatment.
several cases of unrealistic expectations on the part of The dentist must be able to guide them in making the best
patients and their families. The most bizarre instance decision for their situation through honest and compas-
involved a patient who insisted that she needed to have sionate explanation of the problems as well as the attrib-
her immediate dentures by a certain day and was willing utes of immediate complete dentures. Some of the guiding
to pay a fee to get it done. She had her teeth extracted and principles of immediate complete dentures in the follow-
her immediate complete dentures inserted in the morn- ing discussion may help clear up questions a patient might
ing of the day that she had scheduled to have her prenup- have regarding this type of prosthesis.
tial photographs taken in the afternoon. She was to be Suppose a patient has the maxillary anterior teeth and
married and depart on her honeymoon the next day! the maxillary second molar teeth remaining. All the teeth
Everything went according to plan, with a lot of make‐up have moderate bone loss and Class 1 or 2 mobility, and the
Immediate Complete Dentures 241
molars have a Class 2 furcation involvement. If a conven- since the patient is never without teeth, but there are issues
tional denture were to be made, all teeth would be extracted, which cannot be disregarded. One consideration is that the
and the ridges allowed to heal for at least two months deterioration of the periodontal health undoubtedly had
before the final impression for a denture could be made. an adverse effect on the relationship of the teeth and this
Considering the several steps involved in making a conven- relationship in turn led to further deterioration of the sup-
tional complete denture, this process could take several porting periodontium. If the natural teeth were lost due to
weeks or even months, while the patient would be without an unstable ridge relationship and unbalanced teeth posi-
any teeth. This would lead to the patient learning several tions, what effect would teeth set in similar positions have
bad habits while eating without teeth, including develop- on the chances of success of a complete denture?
ing an enlarged tongue, traumatizing the opposing ridge High‐quality diagnostic casts mounted on a semi‐
with the remaining lower teeth, etc. Good‐quality pretreat- adjustable articulator are also a must as they are invalua-
ment photographs are essential (Figures 38.1–38.3), as well ble in educating the patient and demonstrating the need
as a complete write‐up of the patient’s oral, physical, and for surgical correction before permanent dentures can be
emotional health. Patients may soon forget the overall made (Figures 38.4–38.6). As with all complete dentures,
health conditions they presented with before the teeth certain esthetic compromises may have to be made, and
were extracted. the same is also true with immediate dentures. The fact
This traumatic sequence of events can be avoided if an that there is no wax try‐in of all the teeth for an immedi-
immediate denture is made. Impressions of a patient’s ate denture leads to some compromise in esthetics and
mouth are made while the teeth are still present. A denture function. Also, it is necessary for a complete denture to
is made at the vertical dimension that the patient presents contact simultaneously on the posterior teeth on both
with and is inserted at the time of extraction. On the sur- sides of the arch, a condition not mandatory with natural
face, this seems like a great way to address the problem teeth. Then, too, the amount of vertical overlap that a
Figures 38.1–38.3 Good-quality pretreatment photographs are essential.

Figures 38.4–38.6 High-quality diagnostic casts mounted on a semi-adjustable articulator are extremely important.
patient had with their natural teeth may not be possible immediate complete dentures for what they are, namely a
with a complete denture. This vertical overlap may even temporary prosthesis.
have played a significant role in the early loss of the natu- Since immediate dentures are inserted immediately after
ral teeth. A patient must understand that it may not be the extraction of all remaining teeth, a patient must antici-
possible to duplicate the dentition seen in high school pate that there will be some swelling. The effect of this
pictures or casts of the original teeth. swelling can be minimized by placing a denture immedi-
Considerable time must be spent with some patients to ately. The patient should be advised to expect swelling and
psychologically prepare them to accept an immediate den- to leave the dentures in place for 72 hours before taking
ture if a satisfactory result is to be obtained. For instance, them out for any length of time. Most patients can get a
a patient may think that getting a denture may solve all the clearer picture of what they are to experience if they are
problems of esthetics and function caused by compro- told that an immediate complete denture is nothing more
mised maxillomandibular relationships such as Angle’s than a compression bandage with teeth for the first three
Class II or Class III and crossbite relationships. They may days after they are inserted. If the denture is not inserted
also anticipate a successful experience with dentures immediately, or is taken out because it is uncomfortable,
because a close friend or relative experienced no problems the swelling that occurs might not allow the patient to
and was very happy with their dentures. Usually, these wear the denture until the swelling has subsided.
problems can be successfully addressed prior to the teeth Since there will be considerable resorption and remode-
being extracted and the patient is “conditioned” to accept ling of the residual ridges for approximately six months
after extraction with the average patient, a patient must be

conditioned to expect that a new denture will necessarily
be constructed at that time. At the end of the six‐month
period, the dentist must carefully examine the denture and
determine if it is suitable for a reline. The patient is not
advised prior to this appointment that a reline may be an
option until it is determined by the dentist; otherwise, they
may not desire a new denture when the immediate denture
is not satisfactory for relining. It is far easier to convince a
patient that a reline is a viable option at that six‐month pos-
tinsertion appointment if they anticipate a new denture
than it is to convince them that they need a new denture
when they expect a reline.
They must also anticipate the need for several tissue con-
ditioner relines during that six‐month healing phase. They
need to be made aware that these changes are normal,
anticipated, and that they are not the fault of the dentist.
The patient must anticipate the additional charges for the
tissue conditioner relines. While waiving a fee for a tissue
conditioner reline may seem like a good idea, some patients
Figure 38.7 Mark a line with a colored pencil approximately
may view it as an attempt by their dentist to make up for 2 mm short of the depth of the vestibule on a preliminary cast.
their inability to make the denture to fit at the insertion
appointment. Nevertheless, immediate denture patients
must spend more time in the dental chair for adjustments
than conventional denture patients. Immediate dentures
are more expensive than conventional dentures; therefore,
delaying making dentures after extraction is an advantage.
A patient must also understand that when a new com-
plete denture is to be made, any desired esthetic and pho-
netic changes must fall within the limits of proper denture
prosthodontics. Even though the immediate denture is
retained by the patient after a new denture is made, it
should only be used as a spare (emergency) denture and
never as a primary denture, otherwise the tissues will
adapt to the configuration which made it unsuitable for
relining. Patients must be told that the immediate com-
plete denture does not match up with the permanent den-
tures and should never be used interchangeably with the
permanent denture.
38.2 The Custom Tray

Figure 38.8 In the single tray technique, place a thickness of
Some of the techniques that may be used to make immedi- base plate wax over the remaining teeth on the diagnostic cast
ate complete denture impressions are described in the fol- and trim it so that it covers only the teeth.
lowing discussion. There are two basic types of impressions:
one where only one tray is used and another where two or the remaining teeth on the diagnostic cast and trimmed so
more trays are used. that it covers only the teeth (Figure 38.8). Another thick-
In both impression techniques, a line is marked with a ness of wax is placed over the entire intaglio surface of the
colored pencil approximately 2 mm short of the depth of the cast including the area over the remaining teeth
vestibule on a preliminary cast (Figure 38.7). In the single (Figure 38.9). Cuts for tissue stops are made over the teeth
tray technique, a thickness of base plate wax is placed over to provide an even thickness of the impression material and
Figure 38.9 Place another thickness of wax over the entire

intaglio surface of the cast, including the area over the remaining
teeth. This wax will be retained in the cured tray when it is
removed from the cast. Trim this back to allow for border molding.
the borders of the wax are removed back to the line marking
the periphery on the cast. A single piece of tray material is
adapted over the wax shim. When anterior teeth remain, as Figure 38.10 Place three dome-shaped mounds of Triad on the
in this example, a tray handle is usually unnecessary. first tray in a triangular fashion.
Triad® tray material is cured in the curing oven for two
minutes. The tray is carefully removed from the cast, leav-
ing the wax shim in place. The flash is trimmed down to the
wax everywhere except the posterior palatal area, where the
tray is purposely left longer to allow for capturing the poste-
rior palatal seal area in the impression. The wax is further
trimmed back to 2 mm from the edge of the tray except the
posterior palatal area where a section extending well for-
ward of the vibrating line is removed to allow border mold-
ing to achieve a posterior palatal seal in that area. The tray
is border molded with compound and an impression is
made with a low‐viscosity polysulfide impression material
in the same way a conventional complete denture is made.
The second method involves two trays and is used when
the remaining teeth are so compromised that if a single
tray method were used, the teeth might well be extracted
by the impression itself. In this method, the cast is pre-
pared as in the single tray method, except a custom tray is
made just over the palatal part where there are no teeth
present. Three dome‐shaped mounds of Triad are placed
on the tray in a triangular fashion (Figure 38.10). These Figure 38.11 Place the first tray on the cast and adapt one
domes will be very useful when the final, second‐stage thickness of tray material to cover the first tray and the anterior
impression is made. The tray is trimmed so the borders are teeth portion to make the second custom tray.
smooth. Tinfoil is adapted to the outside of the first tray.
The first tray is placed on the cast and one thickness of tray The vestibular and posterior palatal seal area of the first
material is adapted to cover the first tray and the anterior tray is border molded with dental compound. The second
teeth portion to make the second custom tray (Figure 38.11). tray is tried for fit over the first tray and any necessary
The ends of the mounds of the second tray are cut off so that adjustments are made to assure a good fit. The anterior
they fit around the mounds on the first tray. The second tray flange area of the second tray is border molded with green
is adjusted to fit 2 mm short of the vestibule and the trays are stick compound and the second tray is tried again over
assembled and tried for fit on the cast (Figure 38.12). the first tray and adjustments are made as necessary.
Use the two‐tray method with polysulfide in the first tray

and alginate in the second tray for impressions for an
immediate complete denture. Box the impression and pour
it in yellow (Type III) stone. This stone is used because pink
stone is too hard to be removed from the denture and might
cause the denture to crack during its removal.
Make an interocclusal record in centric relation with the
mouth slightly open and the teeth not touching. Any neces-
sary equilibrations to the teeth should be made prior to
making the impression. A sheet of wax can be used to make
a wax record but wax rims on a partial base plate are better.
An anterior acrylic jig called a Lucia jig can also be used to
ensure that the patient closes into the desired position.
Take 1™ bite registration material can be used to record
centric relation. An immediate denture bite registration in
centric relation is done as for conventional complete den-
tures, but the base plates and occlusion rims are modified
to allow room for the remaining teeth.
As with a conventional complete denture, a well‐
Figure 38.12 Adjust the second tray to fit 2 mm short of the adapted base plate is mandatory if a good facebow trans-
vestibule and assemble the trays and fit them on the cast.
fer, bite registration and accurate mounting on an
articulator are to be made. A base plate must be made on
The internal surface of the first tray is painted with the a master cast (Figure 38.13) that was made from the final
appropriate adhesive, and an impression of the edentu- impression that is to be mounted on the articulator and
lous area is made with low‐viscosity polysulfide impres- the denture processed. A base plate made on a prelimi-
sion material. Remove any flash (impression material) nary cast cannot be used to record the jaw relationships
from the outside of the tray and try the second tray in over on the master cast. A base plate must be relieved around
the first tray and adjust as necessary. Both the external all existing teeth, so it will fit in the mouth (Figure 38.14).
surface of first tray and the internal surface of the second The rims can then be adjusted in the mouth to the correct
tray are painted with the appropriate adhesive for the sec- height for the patient and be made parallel to the interpu-
ond over‐tray impression (usually alginate). The first pillary line and ala–tragus line.
impression is placed in the mouth and the second impres-
sion tray is loaded with alginate and placed over the first
tray in the mouth. Excess alginate is expressed from the
access holes to allow the second tray to seat into a proper
position. The tray and their impressions are then removed
as a single impression and are boxed and poured in yellow
(Type III) stone.
A modification to the two‐tray method is sometimes
used where the first tray and the impression are made as
described in the previous example. The difference is that a
conventional stock tray is then loaded with alginate and
placed over the first impression in the mouth. Tray adhe-
sive is not used between the first tray and the second
impression with this technique because the stock tray will
overextend the borders of the impression captured by the
first impression. After removal from the mouth, the first
impression is removed from the second impression, the
area of the alginate impression is removed, and the algi-
nate that extends beyond the border is removed. The two
impressions are again placed together, and the impression
is boxed and poured in Type III stone. Figure 38.13 Make a base plate on a master cast.
Only plastic teeth are used for an immediate complete

denture. Begin by selecting the mold and shade of the
teeth. The selection of anterior teeth is based on the size
and shape of the patient’s natural teeth if present
(Figure 38.15). The type of posterior teeth is limited to
fully anatomic and zero‐degree. If a patient is a skeletal
Class I, you may select a fully anatomic posterior tooth.
Sizes of artificial posterior teeth are limited. You will want
to select the size and type that most closely match the
opposing restored arch (Figure 38.16), but if all the teeth
are to be extracted, the occlusion of previous dentition is
not a factor. If a patient is a Class II skeletal relationship,
has a posterior crossbite, or has very little mandibular
ridge remaining, you must select a zero‐degree tooth.
Figure 38.14 Relieve a base plate around all existing teeth.
38.3 Replacing Missing Teeth
Small areas such as a missing tooth do not need to be filled

in. You only need enough to get a stable and accurate bite
registration. Again, make sure the base plate does not
touch the opposing cast before mounting the casts.
Although the positions of the natural teeth are often not
consistent with the midline of the patient’s face, it is still
necessary to record the midline of the face on the maxillary
cast for an immediate denture registration, but the patient
should be advised if their natural teeth are off‐center. They
may want to preserve the “natural” look. The same thing is Figure 38.15 Select anterior teeth for an immediate complete
true for the parallel alignment of teeth with the interpupil- denture based on size and shape of their natural teeth.
lary line.
The high lip line is also recorded and marked on the cast.
When this is done, explain the necessity for bilateral bal-
ance in complete dentures and discuss with the patient
that the length of the maxillary central incisors, the amount
of horizontal overlap, and the amount of vertical overlap of
the natural teeth may not be duplicated in the denture.
Also discuss diastema, rotated teeth, worn teeth, etc. that
may exist in the natural dentition.
You will want to discuss with the patient the impact that
their skeletal relationship (Angle’s classification) has on
the placement of teeth for dentures. Explain that dentures
must have bilateral balance to be successful. This is not
necessary with natural teeth. Also discuss the type of
occlusal scheme that they will receive in their dentures,
such as crossbite, monoplane occlusion, etc. In short, tell
them up front that you probably will not be able to dupli- Figure 38.16 Select the size and type of plastic tooth that
cate the set‐up of their natural teeth. most closely matches the opposing restored arch.
You may elect to do a wax try‐in of teeth, but only if the

situation permits. Usually, the remaining teeth are in such
disarray that very little can be gained by a wax try‐in other
than to verify vertical dimension of occlusion (VDO).
Usually, in areas where there is not enough room to set a
single tooth, the area is not filled at the wax try‐in phase.
You will want to evaluate and mark certain “esthetic
indicators” on the casts such as the midline, the canine
line, high lip line, and the pocket depth around the exist-
ing teeth. Complete the laboratory procedures, including
the completed wax‐up and processing of the dentures.
Complete the second surgical phase by extracting the
remaining anterior teeth. Deliver the prosthesis, bearing
in mind that the occlusion is not adjusted during the
extraction appointment. Explain to the patient that the
denture is a compression bandage and must be kept in
place to contain the swelling.
The amount of cast alteration depends on depth of the
alveolar pockets surrounding the teeth. Minimal pocket
Figure 38.18 The denture teeth replacing #8 and #10 are
depths are depths less than 1 mm where hardly any stone is
much more uniform to the arch than the natural teeth.
removed from the ridge area of the cast. A deep pocket
depth will require that more stone must be removed if
appropriate alterations are made. Final reductions are usu- most off the desired plane of occlusion and replacing it
ally made in the flask just prior to the impression for a sur- with one of a similar mold and color. The correct height is
gical stent. Always provide a surgical stent to the oral determined intraorally by observing the patient speaking
surgeon prior to the removal of the teeth to limit the neces- naturally.
sity of a follow‐up appointment to remove additional bone. The first tooth is set in the desired position and will act as
Generally, the teeth are set for an immediate denture by a guide in setting the remaining teeth. In this case, the
first removing the maxillary central incisor that is most tooth is set somewhat shorter than the natural tooth beside
out of the desired curvature of the arch (Figure 38.17) or it. This position was determined by evaluating the patient’s
pronunciation of fricative sounds. Always line up the
mesial surface of the central incisor with the middle of the
patient’s face.
Remove every other tooth one at a time and reduce the
cast to the gum line to avoid losing the proper orientation.
Set plastic teeth to replace the missing teeth in an ideal
position, not necessarily the same position as the original
(Figure 38.18). Choose as guides teeth that are in the more
ideal positions. Replace any teeth that have migrated or
otherwise are out of position first. When the teeth are set,
make sure that they are over the ridges and that the den-
tures have bilateral balance to ensure the best chance of
creating stability (Figure 38.19).
In Figures 38.17–38.18, notice how much more uniform
to the arch the denture teeth replacing #8 and #10 are than
the natural teeth. A main goal in making complete imme-
diate dentures is to improve the appearance and function-
ality over the patient’s existing condition. This is one way
we can assure that this goal is met.
Wax the flanges directly onto the cast (Figures 38.20–
Figure 38.17 Set plastic teeth to replace the missing teeth in 38.22). The wax is not festooned or stippled for an immedi-
an ideal position. ate complete denture. Seal the dentures to the cast and
send them to the lab for processing. Remember to ask for a

surgical stent to be made of the cast and for the dentures to
be returned on the cast so that a lab remount can be done
to correct any processing error. A patient remount is not
done on the day of insertion.
The patient is informed that this is a temporary denture
and will need several relines with tissue conditioner as it is
expected to become loose in a short period of time. The
patient is informed that a new set of dentures will need to
be made in six months.
The main problem with this method of making an imme-
diate complete denture is that rarely are the teeth in good
relationships to the ridges or to each other in their natural
state. Age, wear, and periodontal disease are just some of the
conditions that lead to a collapsing of the arches. Maximum
intercuspation is not the same as a more open centric rela-
Figure 38.19 Set teeth over the ridges and ensure bilateral tion. Complete dentures must be set in centric relation.
balance to have the best chance of creating stability.
Figures 38.20–38.22 Wax the flanges directly onto the cast.

Figures 38.23–38.25 The relationship of the arches indicates that the vertical dimension has probably closed due to collapsing
of the arch.
Figures 38.23–38.25 show the relationship of the arches

as the patient presents and indicate that the vertical dimen-
sion has probably closed due to collapsing of the arch.
Obviously, the patient must be evaluated to determine if
they can tolerate dentures set at a more open relationship
and vertical dimension.
38.4 The Surgical Stent
A surgical stent (Figure 38.26) must be fabricated to ensure

that the denture‐bearing area is reduced to fit the denture.
This is made by the laboratory technician by making a dupli-
cate of the cast in the flask after the wax denture has been
“boiled out” and cooled. A cast is poured in this impression
and two thicknesses of base plate wax are placed on this cast Figure 38.26 Use a surgical stent to ensure that the denture-
and it is invested and processed in clear acrylic resin bearing area fits the denture.
A detailed explanation of the process of making a surgi- may cause them to flare out and result in combination syn-
cal stent is as follows. The wax denture is boiled out and drome in the maxilla.
the halves of the flask are separated. The master cast is Rapid resorption of bone will take place for about six
trimmed in the flask. An alginate impression is made of weeks in the average patient. Long‐term recontouring will
the altered cast and poured in yellow stone. Two thick- take place over another five months. Patients with compro-
nesses of base plate wax are adapted to the cast and it is mised immunity to infections and diabetes could take
flasked in the same manner as the wax dentures. The longer and suffer more bone loss. A major advantage of
stent is fabricated by flasking, packing, and processing in this method is that the denture fits better and has better
clear acrylic in the same way as for a denture. The non- esthetics.
tissue surface is polished to a high shine; the stent is You will need to provide the patient with both oral and
cleaned with soap and running water and placed in disin- written instructions. These instructions must be brief and
fectant in a plastic bag. to the point and include informing the patient to leave the
After teeth are extracted, place the surgical stent over dentures in for three days except for those times when they
the ridges and reduce any blanched tissue of the ridges to are cleaning them and stipulating that they must return for
fit the stent. Remove the stent and seat the denture. 24‐hour and 72‐hour checks and adjustments, and tissue
Adjust the borders and intaglio surface of the denture conditioner relines. Oral tissue care instructions should
and provide the patient with written and oral include information on removing the dentures five times/
instructions. day to rinse with a warm saline solution made by stirring
half a teaspoon of table salt in a cup of warm water. The
denture foundation area, other than the extraction sites,
38.5 Alternate Method Allowing should be brushed with a soft bristle toothbrush to pro-
a Six-Week Waiting Period mote healing. Healing should be obvious 7–10 days after
surgery.
An alternate way of making an immediate complete den- You will also need to inform the patient that they have
ture is to extract the posterior teeth and allow six weeks had sutures placed which will resorb and fall out or must
healing before starting the process of making the immedi- be removed at a return visit. Advise the patient to eat a soft
ate complete denture. If this method is used, a definitive diet until they can chew coarser foods. They must also be
clinical contact, usually a premolar, is left to maintain the informed that they need to brush the dentures with a soft
VDO. This method avoids unnecessary recontouring of bristle toothbrush, which has been dipped in salt water.
ridges. They should periodically soak them in a denture cleaner
Necessary surgeries are done for large tori, enlarged overnight, and always place them in water when they are
maxillary tuberosities, severe bony undercuts, sharp ridges, removed for any length of time. They should be told to
etc. Often, the patient want a interim prosthesis to be fabri- expect the ridges to shrink down with time which will
cated at extra cost which will be worn while the extraction adversely affect stability and retention.
sites heal. When delivering the interim prosthesis, adjust borders
There are certain advantages to this method. The patient and intaglio surface only. Occlusal adjustments should be
has the esthetic and phonetic values of the anterior teeth deferred until at least three days after the 72‐hour check
and will feel more confident out in public. This method and adjustment appointment when a tissue conditioner
also allows time for surgical sites to heal and provides a has been placed (Figure 38.27). This will allow the tissue
better support base for dentures because there are fewer conditioner to harden sufficiently so it will not be distorted
surgical sites at the time of immediate complete denture during the procedure. Pressure indicator paste (PIP) can be
insertion. The patient will experience fewer sore spots and used at the insertion appointment, but only gross adjust-
infections are given time to clear up before proceeding with ments should be made to the denture at this time.
the denture‐making process. During the insertion appointment, tissue conditioner is
Problems with this method include the fact that at least usually not placed unless the prosthesis is totally not reten-
two surgeries are required. Also, the patient’s tongue tive. Swelling will occur immediately after the denture is
becomes enlarged and will feel crowded by the teeth. It will inserted, which will conform the ridges to the shape of the
conform in time, but many patients tend to leave out lower denture and retain the denture as a compression bandage.
complete dentures rather than train themselves to accept Tell the patient to not remove the prosthesis until the next
the situation. This causes the patient to learn bad habits day and then only for a very brief time to clean it otherwise
such as chewing with the anterior teeth and nibbling on swelling will prevent the prosthesis from fitting if it is left
things. This creates undue forces on anterior teeth which out overnight or for other long periods of time.
the tissue conditioner becomes hard and absorbs bacteria

and food debris.
38.6 Recommended Recalls After

Extractions
The following chart indicates the timetable for procedures

relating to immediate complete dentures and should be
closely followed if the patient is to have the best chance of
success with their new dentures.
Day of extraction Reline? Minimal adjustments
+1 day post surgery (24 hour) Reline? Adjust sore spots

Figure 38.27 Achieve a better-fitting and more esthetic
+2 days post surgery (72 hour) Reline? Adjust sore spots
denture by allowing a six-week healing period.
+1‐week post surgery Soft reline
+2 weeks post surgery Soft reline
To maintain the retention and fit of the interim pros- +2 weeks post surgery Soft reline
thesis as the tissue heals, “mouth‐cured” tissue condi- +3–4 weeks post surgery Soft reline
tioner soft relines are placed. They are left in place for 2–3 +3–4 weeks post surgery Hard chair‐side reline
weeks and should provide the patient with increased
+3–4 weeks post surgery Evaluate – soft reline only
comfort and denture stability. Often, a patient will leave when necessary
these in place for a long time to avoid paying for consecu- Five months post surgery Make preliminary impression
tive relines; however, their ability to promote healing and
Six months post surgery Start prosthesis fabrication
good tissue health declines quickly after three weeks as
253
39
Tissue Conditioners
39.1 Clinical Application of Tissue Place the tissue conditioner mixture into the lower
Conditioners enture, starting on the distal on one side and moving
d
around the rest of the denture to minimize the incorpora-
When making a tissue conditioner reline, the first step is to tion of air (Figures 39.12–39.14). Make an impression using
assess the denture in the mouth to see if it has proper the denture as a tray. The only difference between this and
flange length to make an effective seal with the soft tissues. any other complete denture impression (besides the mate-
The denture pictured in Figure 39.1 has been marked 2 mm rial used) is that the patient bites together into a proper
shy of the length of the flange and reduced. This allows occlusion while the impression is made.
adequate space for the tissue conditioner to be border On the mandibular denture, in order to border mold the
molded to fit the mouth. If the flanges are too short and do lingual portion appropriately, the patient will have to move
not make a good seal, do not reduce the denture borders to their tongue forward and then laterally while you hold the
this extent in these areas. The tissue conditioner kit comes denture in place with your thumbs or fingers (Figures 39.15–
with a mineral oil lubricant (Figure 39.2). This is painted 39.18). The tongue is always thrust straight forward first,
on the dentures in the areas where the tissue conditioner otherwise you’ll get possibly up to three different registra-
should not adhere, such as around teeth, in the palate, etc. tions of this frenum in the lingual of the denture.
(Figures 39.3 and 39.4) After the patient does the tongue exercises, have them
Lynal® is a tissue conditioner relining material which close against the opposing arch, then you will lift the lips
will provide a denture with a soft temporary liner. This and cheek to border mold the impression by moving them
liner will soothe the abused tissues and allow them to heal up and down (Figures 39.18 and 39.19). If the upper and
to a healthier state. Although the kit comes with a mixing lower dentures both need to be relined, the lower denture
spatula and a little mixing cup, it is wise to use a tongue is usually done first as it is the more unstable of the two.
blade as a spatula and a paper cup. This is because it is very Usually, both dentures are not relined at the same appoint-
difficult to clean the Lynal from the spatula and the mixing ment. This is done to lessen the chance of making a mis-
cup. The average complete denture will require 10 mL of take with both dentures at the same time. This ensures that
powder and 2 mL of liquid (Figures 39.5–39.8). It is best to one denture is available that has been unchanged to aid in
pour the liquid into the cup first and dump the powder in balancing the occlusion.
on top of that, then use the tongue blade to mix the ingre- For the maxillary denture, the high‐viscosity tissue con-
dients together (Figure 39.9). Stir the mixture just long ditioner is placed in the tissue surface and roughly config-
enough to assure that all the powder and liquid are mixed ured to fit the denture using a tongue blade, as shown in
together. The mix will appear somewhat dry and has been Figures 39.20 and 39.21. The mixture is spread evenly
compared to the appearance of molasses on a cold day. across the palate of the denture as seen in Figure 39.22.
Apply the Lynal to the denture by removing a small The dentures are then placed in the mouth and the
amount of the mixed acrylic from the paper cup with a patient asked to close together so that the relined denture
tongue blade and placing it in the denture in the way will be in proper occlusion with the opposing dentition.
impression material is placed into a tray (Figures 39.9– While the patient holds the teeth firmly together, the lips
39.11). This will minimize the chances of incorporating air and cheeks are grasped firmly and pulled down and to the
bubbles into the mix. side (Figure 39.23). The patient is also asked to say “Ah”
Figure 39.1 Mark and reduce the denture 2 mm shy of the
length of the flange.
Figures 39.3 and 39.4 Paint lubricant on the dentures in the

areas where the tissue conditioner should not adhere.
Figure 39.2 The tissue conditioner kit comes with a mineral oil
lubricant.
several times to bring the soft palate down and configure

the posterior palatal seal area.
In Figures 39.24–39.26, the cheeks are manipulated by
pulling them down away from the borders of the denture
toward the teeth. Using a combination of pulling down and
pressing with the fingers against the side of the face, the Figures 39.5–39.8 The average complete denture will require
liner can be configured to the proper shape. It is critical 10 mL of powder and 2 mL of liquid resin.
Tissue Conditioners 255
Figures 39.5–39.8 (Continued)
that the patient keeps the mouth closed while this procedure
is being done.
The denture in Figure 39.27 is shown with the tissue
conditioner in place immediately after removal from the
mouth. It shows the flash that is present around the bor-
ders of the denture immediately after its removal from the
mouth.
Immediately after removal of the tissue conditioner Figures 39.9–39.11 Use a tongue blade to mix the ingredients
relined denture from the mouth, you will notice that there together.
is considerable flash over the entire external border of the
denture as shown in Figures 39.28 and 39.29. If the exter- An easy way to remove flash is to use a tongue blade in a
nal surface of denture was lubricated, the adhering tissue scissors action against the borders of the denture as shown
conditioner should be easy to remove and yield a suitable in Figures 39.31–39.33. Simply move the sharp edge of the
result as seen in Figure 39.30. tongue blade down against the surfaces of the flange
Figures 39.12–39.14 Apply Lynal to the denture with a tongue blade, loading the lower denture with tissue conditioner mixture
from the distal on one side and moving around the rest of the denture.
Figures 39.15–39.17 Have the patient move their tongue forward and then laterally while you hold the denture in place with your
thumbs or fingers.
Figure 39.15–39.17 (Continued)
Figures 39.20 and 39.21 Place high-viscosity tissue

conditioner in the tissue surface and shape it to fit with a
tongue blade.
toward the teeth and peel off any flash that is loosened. A
knife is not used for this because the blade will drag against
the tissue conditioner and cause it to distort. A pair of
curved‐beak iris scissors can also be used for this without
causing distortion. Obviously, this procedure should be
done with the hands gloved.
Figures 39.34–39.36 show other examples of trimming
off the flash from a tissue conditioner border‐molded den-
ture. The secret of doing a good job is to trim the flash off
Figures 39.18 and 39.19 Lift the lips and cheek to border by making the cutting strokes with the tongue blade toward
mold the impression by moving them up and down. the denture flange.
Figure 39.23 Manipulate the lips and cheeks while the patient
holds the teeth firmly together.
Figure 39.22 Spread the mixture evenly across the palate of

the denture.
Figures 39.24–39.26 Manipulate the cheeks, moving them up and down while pressing them against the teeth.
Figure 39.27 View a tissue conditioner in place immediately

after removal from the mouth.
Figures 39.28 and 39.29 Considerable flash is seen over the

entire external border of the denture.
Figure 39.30 The external surface of a denture has been

lubricated to allow easy removal of any adhering tissue
conditioner.
Figures 39.31–39.36 Use a tongue blade in a scissors action against the borders of the denture to remove flash.
Figure 39.31–39.36 (Continued)
Figure 39.37 View the appearance of the tissue conditioner Figure 39.38 View the appearance of the tissue conditioner
immediately after trimming. after three days in the mouth.
Figures 39.39–39.41 Examples of Coe-Comfort tissue conditioner relines.
The denture in Figure 39.37 shows the appearance of the generated impression using the denture as a tray. After the
tissue conditioner immediately after trimming. The den- tissue conditioner has cured for 1–3 days and is inspected
ture in Figure 39.38 shows the appearance of the tissue and found to be suitable, it can be sent to the lab and be
conditioner after three days in the mouth. This tissue con- converted to a hard laboratory reline.
ditioner will take approximately seven hours to set to the The tissue conditioner relines in Figures 39.39–39.41 are
point that it will not be molded in the mouth. During this of a different brand called Coe‐Comfort™. This tissue con-
time, any rough areas that are left on the flange extensions ditioner is white in color but otherwise has very similar
will be smoothed by the oral tissues functioning against properties to the Lynal brand and will provide equally good
them because the patient essentially forms a functionally results.
263
40
The Fabrication of Digital Complete Dentures

Nadim Z. Baba
The success of computer‐aided design (CAD) and com- bases with maxillary and mandibular teeth set in wax
puter‐aided manufacturing (CAM), used extensively in rims following conventional and fundamental princi-
other disciplines in dentistry [1–4], along with a shortage ples recognized in CD prosthodontics. The EZ guides
of qualified dental laboratory technicians [5], encouraged will be trial placed and adjusted as required and a CR
both the clinician and the dental technician to consider record made (Figure 40.4a–d).
using CAD/CAM technology for the fabrication of digital 4) Using the provided records, the laboratory utilizes the
complete and partial dentures. CAD process to virtually design the future CD and print
Seven systems are currently available for the fabrication or mill try‐in dentures from polymethylmethacrylate
of digital dentures: AvaDent®/DentsplySirona, Ivoclar (PMMA) (Figure 40.5).
Vivadent®, Dentca™, Amann Girrbach, Vita Vionic®, Pala®, 5) The try‐in dentures are trial placed to assess phonetics,
and Baltic Denture System [6,7]. This chapter will high- esthetics, and function at this appointment. Following the
light the step‐by‐step procedures followed to fabricate digi- try‐in evaluation, any desired modifications should be com-
tal dentures of the three most commonly used systems in municated to the laboratory to implement them for the
North America. future CDs prior to the milling of the definitive CDs. Two
types of fully milled one‐piece monolithic CDs can be
ordered: XCL‐1 (extreme cross‐linked technology) with
40.1 AvaDent/DentsplySirona monochromatic teeth or XCL‐2+ with polychromatic teeth.
6) Once received, the definitive digital dentures are placed
1) Several methods can be used to obtain the clinical exactly like conventional CDs, followed by occlusal con-
records before sending them to the laboratory. Traditional tact adjustments (Figure 40.6).
definitive impressions using prefabricated or custom
fabricated trays can be adjusted and used to make a
definitive impression with the use of polyvinylsiloxane 40.2 Ivoclar Vivadent
(Figure 40.1a–c).
2) The clinician can also use conventional wax rims or 1) Heat‐moldable disposable trays (Accudent XD,
duplicates of the patient’s existing complete dentures Ivoclar Vivadent, Amherst, NY) are adjusted, modi-
(CD) (Figures 40.2 and 40.3). The wax rims or duplicates fied, and used to make definitive impressions with
are adjusted at the appropriate vertical dimension of the use of light‐body and heavy‐body polyvinylsilox-
occlusion border molded with heavy‐body polyvinylsi- ane (Figure 40.7). Stone casts are obtained from the
loxane or a similar material, and washed with a light‐ definitive impressions and conventional wax rims fab-
body polyvinylsiloxane and joined together with a centric ricated. The maxillary wax rim is adjusted to be paral-
relation record (CR). Another method would be to make lel to Camper’s line and the interpupillary line, the
a digital impression of the edentulous jaws using an appropriate vertical dimension of occlusion is obtained
intraoral scanner and provide the Standard Tessellation and a CR record made (Figure 40.8). Another tech-
Language (STL) file (.STL file) to the laboratory. nique to obtain clinical records is to duplicate the
3) Using the provided information, the manufacturer will patient’s existing CD. The duplicates are adjusted at
mill a Wagner EZ guide tray that consists of record the appropriate vertical dimension of occlusion, if
(a) (b) (c)
Figure 40.1 (a) Maxillary and mandibular AvaDent prefabricated trays. (b) Maxillary definitive impression. (c) Mandibular definitive
impression.
Figure 40.2 Duplicates of patient’s existing dentures used to Figure 40.3 Conventional wax rims used to establish VDO,
make a definitive impression, establish Vertical dimension of determine lip support, and make a CR record.
occlusion (VDO), determine lip support, and make a CR record.
(a) (b)
(c) (d)
Figure 40.4 (a) Maxillary milled Wagner EZ guide tray. (b) Mandibular Wagner EZ guide tray. (c) Maxillary and mandibular Wagner EZ
guide trays trial placed and adjusted as required. (d) Centric relation record made with the Wagner EZ guide trays.
The Fabrication of Digital Complete Dentures 265
(a) (b)
Figure 40.5 (a) Computer-aided design design of digital dentures. (b) Milled trial maxillary and mandibular dentures as proposed by
the CAD design and approved by the clinician. Source: Photo (b) courtesy of Dr Charles J. Goodacre.
necessary, and then border molded with heavy‐body

polyvinyl siloxane and washed with a light‐body poly-
vinylsiloxane and joined together with a CR record
(Figure 40.9).
2) The papillameter is used at repose to measure the
length of the maxillary lip and the position of the
incisal edge. The same measurements are taken at
smile to establish the length of the teeth (Figure 40.10).
3) An Ivoclar facial meter is used to measure the inter‐ala
measurement to determine the size of the anterior
mold and a SR Vivodent S DCL shade guide is used to
determine the desired shade (Figure 40.11).
4) The wax rims in CR, papillameter, and inter‐ala read-
Figure 40.6 Definitive digital denture in the patient mouth. ings are sent to the laboratory to be scanned. Following
(a) (b)
Figure 40.7 (a) Definitive maxillary impression made with PVS using Ivoclar moldable disposable trays. (b) Definitive mandibular
impression made with PVS using Ivoclar moldable disposable trays.
Figure 40.8 Conventional wax rims used to establish VDO,

determine lip support, and make a CR record.
Figure 40.10 Papillameter used with lips at repose.
Figure 40.9 Duplicates of patient’s existing dentures used to

make a definitive impression, establish VDO, determine lip
support, and make a CR record.
the CAD design, the laboratory will communicate with

the clinician to obtain final approval of the design prior
to printing or milling the try‐in dentures (Figure 40.12).
5) The milled try‐in dentures are milled from a block of
white PMMA (ProArt CAD try‐in) in a five‐axis mill-
ing machine (Figure 40.13).
6) The try‐in dentures are printed using a 3D printer. The
denture teeth are printed out of PMMA in the desired
patient shade and the base is printed out of pink
PMMA. Following the printing and cleaning, the den-
ture teeth are bonded to the base with a light‐cure pink
PMMA (Figure 40.14).
7) The try‐in CDs are trial placed to assess the fit, occlu-
sion, and border extensions. This can even be given to
the patient, if needed, to take home to evaluate esthet-
ics, or show them to their family members if unde-
cided about the esthetics of their future CDs.
8) If for any reason the intaglio surfaces, vertical dimen-
sion of occlusion, flanges, teeth or occlusal surfaces Figure 40.11 Facial meter used to measure inter-ala distance.
(a) (b)
Figure 40.12 (a) Duplicates of dentures with CR record used to mount the impression on the virtual articulator and create virtual
casts. (b) CAD of digital dentures.
have been altered, a light‐body polyvinylsiloxane wash

and CR records must be made and sent to the labora-
tory for rescan and adjustment of the CAD‐designed
CDs prior to milling the definitive ones.
9) Using a five‐axis milling machine, the laboratory will
oversize mill the bases of the definitive dentures from
a homogenous PMMA disc and the denture teeth from
a double crosslinked material with the desired teeth
shade. The teeth are then bonded to the base using a
light‐cure pink PMMA and inserted in the milling
machine for final milling (Figure 40.15).
10) Once received, the definitive digital dentures are
placed exactly like conventional CDs, followed by
Figure 40.13 Trial placement of milled CD out of white ProArt occlusal contacts adjustments (Figure 40.16).
CAD PMMA.
40.3 Dentca
1) A heavy‐body and light‐body polyvinylsiloxane are used

to border mold and make the definitive impressions
using two‐piece maxillary and mandibular impression
trays supplied by the manufacturer (Figure 40.17).
2) A #15C surgical blade is used to separate the posterior
area of the maxillary and mandibular impression trays.
The anterior sections of the trays are placed in the
mouth and the central pin of the gothic arch tracing
device is adjusted to obtain the appropriate vertical
dimension of occlusion (VDO) (Figure 40.18).
3) Centric relation position is recorded by injecting bite
registration material between the mandibular and max-
Figure 40.14 Trial placement of milled CD. illary trays (Figure 40.19).
(a) (b) (c)
(d) (e)
Figure 40.15 (a) Oversize mill of the denture base out of pink Ivobase CAD. (b) Oversize mill of denture teeth out of color shaded SR
Vivodent CAD. (c) The milled teeth bonded to the base and inserted in the milling machine for final milling. (d) Definitive CD after
final milling. (e) Definitive CD after polishing.
Figure 40.16 Definitive digital denture in the

patient’s mouth.
(a) (b) (c)
(d) (e)
Figure 40.17 (a) Dentca two-piece impression trays. (b) Maxillary Dentca impression tray showing the detachable posterior section
of the tray. (c) Mandibular Dentca impression tray showing the detachable posterior sections of the tray and the stylus used to record
CR. (d) Maxillary definitive impression. (e) Mandibular definitive impression. Source: Photos (d) and (e) courtesy of Dr Ewa Parciak.
(a) (b) (c)
Figure 40.18 (a) #15 C surgical blade used to separate the posterior area of the maxillary impression tray. (b) Maxillary impression
tray after separation of the posterior section of the tray. (c) Mandibular impression tray after separation of the posterior sections of the
tray. Source: Courtesy of Dr Ewa Parciak.
(a) (b)
Figure 40.19 (a) Determination of the VDO and registration of the CR record. (b) Impression trays with CR record. Source: Courtesy of
Dr Ewa Parciak.
Figure 40.20 Papillameter used with lips at repose. Source: Figure 40.21 CAD of digital dentures.
Courtesy of Dr. Ewa Parciak.
6) The definitive dentures are printed using a 3D printer.
4) The papillameter is used at repose to measure the length of
The denture teeth are printed out of PMMA in the
the maxillary lip and the position of the incisal edge and at
desired patient shade and the base is printed out of pink
smile to measure the length of the teeth (Figure 40.20).
PMMA (Figure 40.23). Following the printing and
5) The dentures will be virtually designed and presented to
cleaning, the denture teeth are bonded to the base with
the clinician for evaluation and approval (Figure 40.21).
a light‐cure pink PMMA and the denture is polished.
Once the design is approved, trial dentures are printed
7) Once received, the definitive digital dentures are placed
and sent to assess esthetics, function, and phonetics
exactly like conventional CDs, followed by occlusal con-
(Figure 40.22).
tacts adjustments (Figure 40.24).
Figure 40.22 Printed maxillary and mandibular try-in dentures. Figure 40.24 Definitive placement of printed dentures.
Figure 40.23 Printed definitive dentures.
R
eferences
1 Rekow, D. (1987). Computer‐aided design and 5 Ettinger, R.L., Beck, J.D., and Jakobsen, J. (1984).
manufacturing in dentistry: a review of the state of the art. Removable prosthodontic treatment needs: a survey.
J. Prosthet. Dent. 58 (4): 512–516. J. Prosthet. Dent. 51 (3): 419–427.
2 Al Mardini, M., Ercoli, C., and Graser, G.N. (2005). A 6 Baba, N.Z. (2016). Materials and processes for CAD/CAM
technique to produce a mirror‐image wax pattern of an ear complete denture fabrication. Curr. Oral Health Rep. 3 (3):
using rapid prototyping technology. J. Prosthet. Dent. 94 (2): 203–208.
195–198. 7 Baba, N.Z., AlRumaih, H.S., Goodacre, B.J., and Goodacre,
3 Sarment, D.P., Sukovic, P., and Clinthorne, N. (2003). C.J. (2016). Current techniques in CAD/CAM denture
Accuracy of implant placement with stereolithographic fabrication. Gen. Dent. 64 (6): 23–28.
surgical guide. Int. J. Oral Maxillofac. Implants 18 (4):
571–577.
4 Mörmann, W.H. (2004). The origin of the Cerec method:
a personal review of the first 5 years. Int. J. Comput. Dent.
7 (1): 11–24.
271
List of Captions
Figure 2.1 Place a denture in an edentulous tray to determine the appropriate size tray to
use for the impression. 7
Figures 2.2 and 2.3 Apply blue periphery wax to the tray border for patient comfort. 7
Figure 2.4 Warm the tray in a warm water bath. 7
Figure 2.5 Use a mouth mirror to pull the cheek away from the tray. 8
Figure 2.6 Materials used to make a preliminary alginate impression. 8
Figure 2.7 Coat a stock tray with an alginate adhesive aerosol spray. 8
Figure 2.8 Use a round-edged flexible spatula to vigorously mix gypsum powder with
water to incorporate it into a homogenous mixture. 9
Figure 2.9 Use sweeping strokes make a smooth and creamy mix. 9
Figure 2.10 Make sure that the impression material fills the tray completely. 9
Figure 2.11 Use fingers to spread the lips and center the tray in the mouth. 9
Figure 2.12 Manipulate the frenula and lips by muscle trimming. 10
Figure 2.13 Landmarks of a mandibular impression. 10
Figure 2.14 Massage the lips and cheeks to border mold the tray. 10
Figure 2.15 Remove the tray carefully to avoid distorting the periphery wax. 10
Figure 2.16 Load alginate mix into the tray and push air ahead of the mix. 11
Figure 2.17 Use moist fingers to distribute and smooth impression material in the tray. 11
Figure 2.18 Seat maxillary trays while standing behind the patient. 11
Figure 2.19 Rotate the tray evenly into position over the ridge. 11
Figure 2.20 Seat the anterior portion of the tray first to force air out the back as the tray is seated. 11
Figure 2.21 Ask nauseous patients to lean forward to minimize gagging and raise the napkin
to catch any drooling. 12
Figure 2.22 Use a mouth mirror to pull forward any excess alginate from the back of the tray. 12
Figure 2.23 Have the patient raise their legs to fight nausea by tensing their stomach muscles. 12
Figure 2.24 Grasp the tray handle firmly and raise the cheek on one side to break the seal
and remove the impression tray in one quick, controlled motion. 12
Figure 2.25 A show-through in the periphery wax does not necessarily mean an impression
needs to be remade. 13
Figures 2.26 and 2.27 Capture all maxillary landmarks in the maxillary impression. 13
Figure 2.28 Capture the retromolar pads and the peripheral extensions in the mandibular impression. 13
Figure 2.29 Capture the hamular notches, posterior palatal seal, and all the anatomical
landmarks in the maxillary impression. 14
Figure 2.30 Rinse the impression thoroughly and mix water and powder according to manufacturer’s
instructions in a vacuum mixer to ensure a dense mix. 14
Figure 2.31 Place the tray handle in a drying rack and allow the stone in a poured impression to
set for 30 minutes. 14
Figures 2.32 and 2.33 Ensure that bases of casts are over 13 mm thick. 15
Figures 2.34 and 2.35 Ensure that a 3–4 mm wide land area exists to protect the borders of the impression
and the cast. 15
272 List of Captions
Figure 3.1 Draw an outline about 2 mm short of the periphery in the labial and buccal
vestibular areas on the master cast. 18
Figure 3.2 Block out all undercuts with wax, as it will not stick to the tray material. 18
Figure 3.3 Heat one layer of base plate wax over a Bunsen burner or in a hot water bath. 18
Figure 3.4 Trim off excess soft wax by pressing it against the sharp external edge of the land area. 18
Figure 3.5 See the dark line through the wax on the cast which serves as the guide for a cutback. 18
Figure 3.6 Use a sharp scalpel to trim the wax 2 mm short of the depth of the vestibule. 18
Figure 3.7 Leave the wax a little long in the posterior palate area. 19
Figure 3.8 Press one thickness of Triad tray material into the palatal area to avoid entrapping
air under the wax. 19
Figure 3.9 Trim off any excess wax by pressing it along the edge of the cast. 19
Figure 3.10 Use a thumbnail to press the Triad into the relief cut made in the wax border. 19
Figures 3.11 and 3.12 Make a tray handle at 45° to the crest of the anterior ridge that is long enough to
accommodate the width of the thumb. 19
Figure 3.13 Cure the tray on the cast for three minutes in a Triad curing unit. 20
Figure 3.14 Check the width of the handle with a thumb. 20
Figure 3.15 Use a lathe or a handpiece for cutback of the tray. 20
Figure 3.16 After trimming the tray, place it back on the cast to evaluate the cutback. 20
Figures 3.17 and 3.18 Form a U‐shaped joint in the inside of the tray by removing an additional 2 mm of
wax to allow the border molding material to overlap the edge of the tray. 20
Figure 3.19 Remove an additional few millimeters of wax from the posterior palatal seal area. 21
Figure 3.20 Draw an outline on the mandibular cast with a dark pencil 2 mm short of the
periphery in the labial, buccal, and lingual vestibular areas. 21
Figures 3.21 and 3.22 Leave the line long in the retromolar pad areas and block out any undercuts with
base plate wax. 21
Figure 3.23 Press the wax into the lingual area first. 22
Figure 3.24 Press the wax into the buccal and labial areas, and trim it with a sharp instrument. 22
Figure 3.25 Trim the wax by pressing it against the outer border of the land area. 22
Figure 3.26 Press the Triad into the lingual area first to prevent air pockets from forming. 22
Figure 3.27 Cut along the edge of the lingual vestibule with a red-handled knife and
remove this section. 22
Figure 3.28 Make a handle for the lower tray that is longer than the one for the upper tray. 22
Figures 3.29 and 3.30 Make finger rests on the posterior ridge crest. 23
Figure 3.31 Cut back the tray to the wax that has been made 2 mm short of the vestibule. 23
Figures 3.32 and 3.33 Leave the wax spacer in place but cut it back about another 2 mm so the compound
will form a U‐joint. 23
Figure 4.1 Ask the patient to raise the tongue when the lower impression is placed in the mouth. 26
Figure 4.2 Have the patient forcefully extend his tongue forward over the tray handle to
determine if the tray is overextended. 26
Figure 4.3 After the tray is adjusted, have the patient again raise his tongue and force it straight
forward to border mold the lingual section of the tray. 26
Figure 4.4 Have the patient move his tongue to the right. 26
Figure 4.5 Have the patient move his tongue to the left. 27
Figure 4.6 Mark both sides of the labial alveolus where the frenum attaches. 27
Figure 4.7 Place the tray in the mouth to transfer the mark to the tray. 27
Figure 4.8 Smooth all rough areas and overextensions with an acrylic bur. 27
Figure 4.9 Stretch the lips with a finger and the side of the tray to provide access. 27
Figure 4.10 Mark each side of the frenula attachment on the buccal alveolus. 28
Figure 4.11 Record these marks on the inside of the tray. 28
Figures 4.12–4.14 Relieve the tray 2 mm short of all frenula and vestibular depths. 29
Figures 4.15–4.17 Mark the posterior palatal seal area by making dots with an indelible transfer stick. 30
Figure 4.18 Connect the dots to show where the posterior palatal seal is to be located. 30
Figure 4.19 View the vibrating line on the distal surface of the palatal side of the tray. 30
Figures 4.20–4.22 Have the patient raise the soft palate and assess the area. 31
Figure 4.23 Uniformly heat a single stick of green compound over a broad area with a torch. 32
Figure 4.24 Press the compound into place and shape it with a wet finger and thumb. 32
Figure 4.25 Reheat the compound. 32
Figure 4.26 Temper the compound in hot water. 32
Figure 4.27 Place the tray in the mouth to mold the compound. 32
Figures 4.28 and 4.29 Raise the lip and mold the compound with the fingers. 33
Figure 4.30 Flash is seen extending over the wax spacer. 33
Figure 4.31 Chill the compound in ice water before trimming. 33
Figure 4.32 Trim off excess compound with a sharp scalpel. 34
Figure 4.33 Heat the compound again with the alcohol torch. 34
Figure 4.34 Retemper the compound in hot water. 34
Figure 4.35 Insert the tray in the mouth, remove it, then chill and dry it. 34
Figure 4.36 Uniformly heat a broad area of compound to soften it. 34
Figures 4.37 and 4.38 Adapt the compound to a maxillary tray as was done with the mandibular tray. 35
Figure 4.39 This compound is too hot and is runny. 35
Figure 4.40 Place compound on the tray borders sequentially, until all borders are covered. 35
Figure 4.41 Temper the hot compound in water set slightly above its fusion temperature. 35
Figure 4.42 Stretch the lips and cheeks and insert the tray. 36
Figure 4.43 Border mold the labial flange and frenum areas by pulling the lip outward
and downward. 36
Figure 4.44 View the labial notch area to make sure it is clearly visible. 36
Figure 4.45 Chill the compound in ice water. 36
Figure 4.46 Trim the compound by cutting toward the tray with a sharp knife. 37
Figure 4.47 Look for areas of overlap of the compound. 37
Figure 4.48 Reheat the area, temper, and return the tray to the mouth to refine it. 37
Figure 4.49 Observe notches where there are frenula located. 37
Figure 4.50 Place compound around the rest of the tray. 38
Figure 4.51 Add more compound to the posterior palate, temper, and reinsert the tray. 38
Figures 4.52 and 4.53 Bevel the area of the posterior palatal seal toward the palate with a sharp scalpel. 38
Figure 4.54 Carefully scrape the tray to completely remove all wax. 38
Figure 4.55 Pour a small amount of adhesive into the impression tray. 39
Figure 4.56 Spread adhesive with a small disposable brush to all internal surfaces and to
external surfaces just below the tray border. 39
Figure 5.1 Squirt out a small amount of impression material onto a mixing pad before loading the tray. 42
Figures 5.2 and 5.3 Squirt impression material into the tray to completely fill it. 42
Figure 5.4 As an alternate method, express equal lengths of polyvinylsiloxane impression
material onto a mixing pad and mix it by hand. 43
Figure 5.5 Use a tongue blade or broad, flat spatula to load the tray with impression material. 43
Figure 5.6 Inspect the impression for show‐through spots which would require relieving the
tray and remaking the impression. 43
Figure 5.7 Inspect the mandibular impression to ensure that it is bubble free, with narrow
borders, and even thickness of impression material throughout. 43
Figure 5.8 Seat the maxillary tray with the fingers pointed up, so the lip and cheek can be
manipulated to effect muscle trimming of the impression. 44
Figure 5.9 Pull the lip and cheek down to mold the impression material over the flange areas. 44
Figure 5.10 Have the patient purse their upper lip to assist in border molding the anterior facial
area of the impression. 44
Figure 5.11 View the maxillary impression immediately after removal from the mouth to
determine its accuracy. 45
Figure 5.12 Trim any excess impression material from the posterior palatal area. 45
Figure 5.13 Paint a suitable adhesive on the posterior palatal area and add a small amount of higher
viscosity impression material to form a functional posterior palatal seal. 45
Figure 5.14 Reinsert the impression in the mouth and repeat the process until a neat and effective
seal is produced. 45
Figure 6.1 Place a band of sticky wax around the entire periphery of the impression. 48
Figure 6.2 Affix enough rope wax to the sticky wax to serve as a guide to position the plaster/pumice
mix or putty the correct height on the impression. 48
Figure 6.3 Place the tray in a plaster/pumice mix with the impression side up. 48
Figure 6.4 Shape and smooth the wax around the periphery of the impression. 48
Figure 6.5 Add soft wax and shape it to fill a defect after the gypsum has set. 48
Figures 6.6 and 6.7 Paint the plaster/pumice mixture with petrolatum or fill it in with wax and secure
it to a rigid plastic or metal plate with sticky wax. 48
Figure 6.8 Use a hot waxing instrument and/or a Hanau torch to smooth the wax. 49
Figure 6.9 Form a box of boxing wax around the impression and its plaster/pumice base. 49
Figure 6.10 Seal the boxing wax together and to the plastic sheet with sticky wax and utility (rope) wax. 49
Figure 6.11 Fill the boxed impression in with yellow stone. 49
Figure 6.12 Peel off the boxing wax after the stone sets. 49
Figure 6.13 Soak the cast, the impression, and base in hot water. 50
Figure 7.1 Any deep undercuts are blocked out with wax. 52
Figure 7.2 The model is painted with tinfoil substitute, petroleum jelly (Vaseline), or Triad Model
Release Agent. 52
Figure 7.3 Triad base plate material comes as a soft, pliable sheet in a sealed plastic pouch. 52
Figure 7.4 One thickness of wax is adapted to fit the cast by pressing it down in the palate
and molding it over the vestibules. 52
Figure 7.5 Any excess is trimmed off by pressing it against the sharp border of the land area. 52
Figure 7.6 Care is taken to not thin the Triad in the palate of the upper and the lingual of the
mandible where it is being held in place by the thumb. 52
Figure 7.7 When it has the correct form, it is painted with Triad air barrier coating. 53
Figure 7.8 The Triad is cured for three minutes in the Triad conditioning unit. 53
Figure 7.9 The record base is removed from the cast and placed in the curing unit with the
intaglio side up for an additional two minutes. 53
Figure 7.10 Triad material extends onto the land area. 53
Figure 7.11 A cut is made in the mandibular base plate in the tongue area. 53
Figure 7.12 Triad is adapted to the master cast and a section is removed from the tongue area. 53
Figure 7.13 Curing distortion is most noticeable in the palate, manifesting as a slight opening between
the cast and the base plate in the middle of the palate. 54
Figure 7.14 Mold a piece of base plate wax into a tightly compressed wafer about 10 mm wide
and 6 in. long to make an occlusion rim. 54
Figures 7.15–7.17 An occlusion rim is formed by bending the wax to fit the base plate. 54
Figure 7.18 A glass eyedropper can be used to apply melted wax to seal the occlusion rim to the
base plate. 54
Figure 7.19 A broad spatula is heated with the Bunsen burner and used to contour the facial
and lateral surfaces of the occlusion rim. 55
Figure 7.20 A broad spatula is used to flatten the occlusal surfaces of the wax rims. 55
Figure 7.21 The distal ends of the maxillary rim are trimmed to a point about 6 mm short of
the distal border of the base plate and at about a 45° angle. 55
Figure 7.22 A line is marked on the occlusal surface of the wax rim on the mandible to indicate
the crest of the ridge from the canine eminence to the retromolar pad. 55
Figure 7.23 The height of the maxillary rim is 22 mm in the anterior and 18 mm in the posterior. 55
Figure 7.24 The height of the mandibular rim is at a point two‐thirds up the retromolar pad posteriorly
and 18 mm from the depth of the vestibule anteriorly. 56
Figure 8.1 Adjust the wax rim so that it is parallel to the interpupillary line. 58
Figure 8.2 Use a tongue blade to verify that a Fox occlusal plane analyzer is parallel to a line
from the ala of the nose to the tragus of the ear. 58
Figure 8.3 Sprinkle a light dusting of adhesive powder on the intaglio surface of the base
plate to help hold it in place during the record‐making procedures. 58
Figure 9.1 Attach a maxillary bite fork to the base plate. 60
Figures 9.2 and 9.3 Position a facebow on the patient. 60
Figure 9.4 After all thumbnuts are thoroughly tightened, remove the entire transfer assembly
from the patient’s mouth and from the facebow. 60
Figure 9.5 Mount the Hanau mounting adaptor (marked with an H) on the lower member of the
articulator. 61
Figure 9.6 Place the facebow transfer into the mounting jig and tighten the set screw to lock it in place. 61
Figures 9.7 and 9.8 Cut an “X” in the base of both casts about ¼ in. deep. 61
Figure 9.9 Place a small bit of Vaseline in this “X.” 62
Figure 9.10 Place a little bit of mounting plaster in the “X” of the cast and a little bit on the mounting
plate. 62
Figure 9.11 Close the articulator. 62
Figure 9.12 Gently tap the upper member of the articulator to close it completely. 62
Figure 10.1 Remove the orbitale third point of reference plane indicator. 64
Figure 10.2 Loosen the set‐screw on the condylar element, push the condylar ball back flush with
the rear wall of the condylar fossa, and tighten the set‐screw. 64
Figure 10.3 Set the guide table set‐screw at the zero mark on the base of the incisal guide platform (A). 64
Figure 10.4 (B) Position the guide table at the point where the guide pin hits on the horizontal line
in the center of its flat surface. (C) Set the lateral wings of the guide table at zero. 64
Figure 10.5 Set the lateral condylar guidance at 15o (D). 65
Figure 10.6 Tightening the lock nut (E) to set the horizontal condylar guidance angle at 30o (F). 65
Figure 10.7 Place the vertical portion of the transfer assembly in the slot at the front of the transfer
jig with all the numbers facing toward the front. 65
Figure 10.8 Tighten the mounting jack attached to the lower member of the articulator. 65
Figure 10.9 Place the indexed wax rim in the index of the registration material on the facebow fork. 65
Figure 10.10 Cut an “X” in the base of the maxillary master cast and place it in the mounted base plate. 66
Figure 10.11 Place a piece of wide masking tape around the base of the dry cast to make a
containment wall. 66
Figure 10.12 Place enough mounting plaster in the containment barrier to make a pillar on top of the cast. 66
Figure 11.1 Reduce the mandibular rim to accommodate the bite registration material. 68
Figure 11.2 Index both occlusion rims with a sharp knife to make V‐shaped cuts about 2 mm deep
that cross in the middle of the cast. 68
Figure 11.3 Completely fill the maxillary grooves with Aluwax. 68
Figure 11.4 Another option is to make an interocclusal registration with Blu‐Mousse. 68
Figure 11.5 Make splints to hold the parts of the interocclusal registration together. 69
Figure 11.6 Close the articulator and inspect to insure that there is no binding of the mounting
plate with the containment wall. 69
Figure 11.7 Fill the containment barrier with a thin mix of mounting stone. 69
Figure 11.8 After the stone sets, remove the masking tape forming the containment barrier. 70
Figure 11.9 Never use a red‐handled compound knife or scalpel to trim gypsum as a blade can
break and cause an injury. 70
Figure 11.10 Use wet/dry sandpaper to smooth the cast under running water. 70
Figure 11.11 Inspect the casts and mountings to insure that they are neat and clean. 70
Figure 11.12 Make sure the juncture between the cast and the mounting plaster is as close to 90° as
possible. 71
Figure 11.13 Set the guide pin on zero and lock the condyles in centric relation to check and make
sure the index seats correctly between the wax rims, thereby proving the accuracy of
the mounting. 71
Figure 11.14 Replace the wax on the rims where it was removed preparatory to making the bite
registration index. 71
Figure 12.1 Check existing dentures for wear patterns and for repair sites and relines. 74
Figure 12.2 Some temporary dentures are obvious but others can look like a final complete denture. 74
Figure 12.3 Measure the combined width of the six maxillary anterior teeth. 74
Figure 12.4 Measure the width of the posterior teeth and compare them to the width of posterior
teeth on a tooth card. 74
Figure 12.5 Measure the height of the maxillary central. 74
Figure 12.6 Measure the width of the maxillary central. 74
Figures 12.7 and 12.8 Compare the shade of the teeth in the old dentures to the shade tabs in the shade guide. 75
Figure 12.9 The Trubyte Tooth Indicator helps determine the correct mold of tooth based on facial
form and size. 75
Figure 12.10 Denture teeth come mounted in wax on a plastic or metal card. 76
Figure 12.11 Pick the posterior teeth and the mandibular anterior teeth by consulting a mold
compatibility chart. 76
Figure 12.12 Put a piece of Triad on the anterior ridge area of the cast and set the teeth in place. 77
Figure 12.13 Evaluate the six anterior teeth from the facial view. 77
Figure 12.14 Measure the width of the four mandibular posterior teeth. 77
Figure 12.15 Set the four mandibular teeth in soft rope wax to determine if there is enough room
for four teeth. 77
Figure 12.16 Set two molars and one premolar and evaluate the available room. 77
Figure 12.17 Set one molar and two premolars and evaluate the available room. 77
Figure 12.18 Use a shade guide to select a denture base acrylic shade that will match the patient’s
natural coloring as closely as possible. 78
Figure 12.19 Denture teeth have identifying dots on the mesial of the ridgelap areas. 78
Figure 12.20 One dot indicates the first molar or first bicuspid, two dots indicate the second bicuspid
or the second molar. 78
Figures 12.21–12.23 Here are three different approaches to providing a denture on the same patient. 78
Figure 13.1 All maxillary anterior teeth are inclined mesially. 82
Figure 13.2 When viewed laterally, the maxillary incisors are depressed at the cervical, with the
canine being straight with the long axis perpendicular to the occlusal plane. 82
Figure 13.3 All the mandibular anterior teeth are inclined mesially except the central incisors. 82
Figure 13.4 When viewed laterally, the mandibular central incisors are depressed at the cervical, the
lateral incisor is straight, and the canine is inclined lingual to the long axis. 82
Figure 13.5 Do not position any anterior teeth further forward than the depth of the
labial vestibule. 82
Figure 13.6 Mark the midline of the patient’s face by placing a dot on the incisive papilla and marking
this midline on the maxillary anterior land area. 82
Figures 13.7 and 13.8 Make a cut all the way to the base plate at the midline in the maxillary anterior wax rim
and one distal to the canine point and remove this section entirely. 82
Figure 13.9 Use a flat plate resting flush with the occlusion rim to position the maxillary central incisor. 83
Figure 13.10 Use a flexible plastic ruler to verify that the incisal portion of the tooth’s labial surface is
properly located and in contact with the anterior curvature of the occlusion rim. 83
Figure 13.11 Set the rest of the anterior teeth on the right side according to the curve defined by the
plastic ruler. 83
Figure 13.12 Set the maxillary incisors so their labioincisal line angles touch the ruler, as well as the
midbuccal surface of the canine. 84
Figure 13.13 Set the rest of the maxillary anterior teeth according to the curve defined by the plastic
ruler and the plane defined by a flat plate. 84
Figure 13.14 Position the labioincisal line angles of the maxillary incisors and the midbuccal
surface of the maxillary canines touch the ruler. 84
Figure 14.1 Remove a section of wax from one side of the maxillary base plate between the
canine and the second molar position. 86
Figure 14.2 Set the maxillary first premolar. 86

Figure 14.3 Set the maxillary first molar. 86
Figure 14.4 Remove the wax pillar on that side and set the maxillary second molar. 86
Figure 14.5 Position the central groove of the maxillary second molar directly over the line
marked on the lower wax rim. 86
Figure 14.6 Position the buccal cusp of the maxillary premolar and the mesiobuccal cusp of the
first molar along a plane with the middle of the facial surface of the canine. 86
Figure 14.7 Position the buccal cusps of the maxillary first and second molars to lie along the plane
defined by turning the distobuccal cusp of the first molar 20° toward the palate. 87
Figure 14.8 Depress the distobuccal cusp of the maxillary first molar so that it lies 0.5 mm above
the occlusal plane provided by the mandibular occlusion rim. 87
Figure 14.9 Depress the buccal cusps of the maxillary second molar so that they lie along a plane
defined by the buccal cusps of the first molar. 87
Figure 14.10 Position the maxillary second molar so that its mesiobuccal cusp is 1 mm above
the occlusal plane and its distobuccal cusp is 1.5 mm above the occlusal plane. 87
Figure 14.11 Set the maxillary teeth on the left side, making sure that the compensating curve
is there, too. 87
Figure 14.12 Remove enough wax from the posterior section of the mandibular rim to
accommodate the posterior teeth on one side. 87
Figure 14.13 Set the mandibular first molar first, because it is regarded as the mandibular tooth
that is the “key to occlusion.” 88
Figure 14.14 The positions of all other mandibular posterior teeth depend upon the position of the
first molar. 88
Figure 14.15 Melt the wax pillars supporting the teeth and allow this wax to cool so that the teeth
become firmly fixed in position. 88
Figures 14.16 and 14.17 Check the positions of the teeth in centric and lateral relationships from the buccal and
lingual views. 88
Figure 14.18 With the mandibular posterior teeth set in proper positions, the mandibular anterior
teeth can now be set. 89
Figures 14.19–14.21 Set the mandibular canines first, then the lateral incisors, and finally the central incisors. 89
Figure 14.22 Make sure centric holding cusps are all in their proper positions. 90
Figure 14.23 “Tweak” the teeth slightly to improve their relationships. 90
Figure 14.24 Here, the second mandibular molar on the left is set with the buccal cusp too far to the
buccal of the maxillary second molar’s central fossa. 90
Figure 14.25 Use the tip of a wax spatula to reposition the mandibular second molar. 90
Figure 14.26 Teeth set on a compensating curve allow vertical overlap of the anterior teeth in centric
occlusion. 90
Figure 14.27 The vertical component is directly related to the combination of the cusp angle,
horizontal overlap, and compensating curve. 90
Figure 14.28 Lateral movement is independent of the anterior teeth. 91
Figure 14.29 When the posterior teeth wear down, the anterior teeth may then begin to contact
prematurely. 91
Figures 14.30–14.32 Simultaneous contact of anterior and posterior teeth occurs in protrusive relationship. 91
Figures 14.33 and 14.36 After finishing procedures are complete, the teeth still contact properly in working
relationship. 92
Figures 14.34 and 14.35 After finishing procedures are complete, the teeth still contact properly in balancing
relationship. 92
Figure 15.1 Remove wax and thin the base plate on one side to allow setting of the posterior teeth.
Leave a small segment of the wax rim intact in the posterior. 94
Figure 15.2 This wax pillar clearly marks the midline to facilitate the setting of the teeth anterior to it. 94
Figure 15.3 Remove the pillar and set the last molar, as the middle of the ridge is recorded by
the teeth anterior to it. 94
Figure 15.4 Check the position of the teeth with a straight edge. 94
Figure 15.5 Once you have verified this relationship is correct, you may begin setting the teeth
on the other side. 94
Figure 15.6 Set the teeth on the other side using the same procedures. 94
Figure 15.7 Use a flat metal plate to verify that all the teeth contact the flat surface evenly. 95
Figure 15.8 Expect some changes because shrinkage of the wax will shift the teeth slightly. 95
Figure 15.9 Check the harmony of the curve from central incisor to molar teeth using a clear
millimeter ruler. 95
Figure 15.10 Remove the entire wax pillar on one side of the maxillary base plate. 95
Figure 15.11 Leave the rim intact on the opposite side to maintain the location of the occlusal plane. 95
Figure 15.12 The buccal surfaces of the premolar(s) and mesial cusp of the first molar line up with the
midbuccal surface of the canine. 95
Figure 15.13 The distobuccal cusp of the first molar should deviate approximately 20° from this plane
established by the buccal of the canine to the mesiobuccal of the maxillary first molar. 96
Figures 15.14 and 15.15 Check to see that occlusal surfaces of these teeth all lie flat and contact the surface of a
flat metal plate. 96
Figure 15.16 Check to see that occlusal surfaces of all teeth properly contact their opposing counterparts. 96
Figure 15.17 Verify that there is no vertical overlap of the anterior teeth. 96
Figure 15.18 Set the incisal guide pin at zero (the wide black mark). 96
Figure 15.19 Ensure that the incisal guide pin touches the mark on the guide table when set on zero. 97
Figure 15.20 Check that the horizontal condylar guidance and the anteroposterior inclination of
the guide table are in harmony with the plane of occlusion and with the lateral wings
of the guide table set on zero. 97
Figure 15.21 Ensure that the maxillary and mandibular posterior teeth contact simultaneously in
centric, lateral, and protrusive movements with no vertical overlap of the anterior teeth. 97
Figure 16.1 Set the posterior teeth in lingualized occlusion by using fully anatomic maxillary
teeth set against mandibular zero‐degree teeth. 100
Figure 16.2 Lower the incisal guide pin down one mark in relation to the top of the upper
member of the articulator. 100
Figure 16.3 With the pin lowered, approximately a 1 mm gap exists between the upper and lower teeth. 100
Figure 16.4 Remove the maxillary posterior teeth one at a time from the zero‐degree set‐up. 100
Figure 16.5 Set each tooth in its proper position and allow the wax to harden before moving on
to set the next tooth. 101
Figure 16.6 Set the 33° maxillary first premolar so that its lingual cusp touches the opposing
mandibular premolar. 101
Figure 16.7 Set the 33° maxillary second premolar so that its lingual cusp touches the opposing
mandibular premolar. 101
Figure 16.8 Keep the buccal surface of the maxillary first molar in line with the anteroposterior
plane established by the positions of the zero‐degree set‐up. 101
Figure 16.9 Set the 33° maxillary first molar so its mesiolingual cusp touches the opposing
mandibular molar, its mesiobuccal cusp is raised 2 mm above the lower occlusal
plane, and its distolingual cusp is raised approximately 0.5 mm above the plane of the
mandibular teeth. 102
Figure 16.10 Position the buccal surface of the maxillary first molar in line with the anteroposterior
plane established by the positions of the zero‐degree set‐up. 102
Figure 16.11 Turn the distobuccal cusp of the maxillary first molar so that the buccal surface of the
tooth falls in line with the plane that extends from the mesiobuccal of the maxillary first
molar to the distobuccal of the maxillary second molar. 102
Figure 16.12 Position the 33° maxillary second molar so that its cusps touch the plane that is
established by the cusps of the maxillary first molar. 102
Figure 16.13 Ensure that the lingual cusp tip of the maxillary second molar is approximately 1 mm
above the plane of occlusion, the mesiobuccal cusp is approximately 1.5 mm above that
plane, and the distobuccal cusp is approximately 2 mm above that plane. 103
Figure 16.14 Be sure that the buccal surface of the maxillary second molar is in line with the
anteroposterior plane established by the positions of the buccal cusps of the
maxillary first molar. 103
Figure 16.15 The maxillary second molar lies in‐board from the plane that runs from the
canine to the mesiobuccal cusp of the maxillary first molar. 103
Figure 16.16 Make sure that the mandibular first and second molars contact the lingual cusps of the
maxillary molars. 103
Figure 16.17 A curve of Spee (compensating curve) allows the anterior teeth to contact in
protrusive as the maxillary posterior lingual cusps contact their individual fossae
and allow a slight amount of anterior overlap for enhanced esthetics. 103
Figures 16.18–16.20 Set up the upper and lower posterior teeth on the opposite side. 104
Figure 17.1 Make a bite registration in centric relation with a semi‐rigid to rigid impression
material like this compound registration material. 106
Figure 17.2 Also make a bite registration in protrusive relation. 106
Figure 17.3 Mount a remount cast with the maxillary denture in place on the upper member
of the articulator with the pin set on zero. 106
Figure 17.4 Lock the condyles in centric relation. 106
Figure 17.5 Lower the incisal guide pin 2 mm. 106
Figure 17.6 Mount a lower remount cast with the denture in place on the lower member of the
articulator. 106
Figure 17.7 Set the lateral condylar guidance. 107
Figure 17.8 Set the horizontal condylar guidance. 107
Figure 17.9 Mark the mandibular occlusal contacts with AccuFilm articulating film. 107
Figure 17.10 The mandibular posterior teeth in each marked area are in contact with a maxillary
lingual cusp. 107
Figure 17.11 Form a mortar (pothole) on the mandibular posterior teeth in each area where
there is contact with a maxillary lingual cusp. 107
Figure 17.12 Deepen each mandibular contact, creating a shallow pothole. 107
Figure 17.13 Stop the grinding to increase the depth when the guide pin again contacts the guide
table in centric relation. 108
Figure 17.14 Use the black side of the articulating film to mark the points in centric relation on the
mandible. 108
Figure 17.15 Use the red side of the film to mark the contacts in protrusive relation where the
potholes are broadened by reducing cuspal inclines. 108
Figure 17.16 The anterior teeth contact simultaneously with the posterior teeth in protrusive
movements but will not contact during lateral movements. 108
Figure 17.17 Use a piece of the paper that separates the AccuFilm in its pack to determine if there is
contact between the opposing teeth. 108
Figures 17.18 and 17.19 Broaden the fossa buccolingually to establish continuous contact throughout lateral
movements. 109
Figure 17.20 Red marks on the teeth indicate the vectors of movement during lateral and protrusive
movements. 109
Figure 17.21 Centric contacts are represented as a black dot, which will look more like a smear,
as the articulating paper will smear as the movements are made. 109
Figure 18.1 A patient may insist on the enhanced esthetics of a vertical overlap of the anterior
teeth as seen in a picture of their natural teeth when they were younger. 112
Figure 19.1 Press a sheet of base plate wax into place in the palate. 116
Figure 19.2 Use a thumb to trim off excess wax at the linguo‐occlusal line angle of the posterior
teeth and the linguo‐incisal line angle of the anterior teeth. 116
Figure 19.3 Smooth the palatal surface by passing a gentle flame over the surface with a Hanau torch. 116
Figure 19.4 Use the knife end of a Roach carver to carve the wax on the palatal side of the
posterior teeth 20° below the horizontal palatal plane. 116
Figure 19.5 Remove all wax from the lingual of the teeth above the collar or finish line and smooth
it with a Hanau torch. 117
Figure 19.6 Use a sharp instrument to remove any remaining wax from around the gingival
margin of each tooth. 117
Figure 19.7 Use a Hanau torch to soften the wax and flow a thin layer of wax onto the base plate
and around the necks of the teeth. 117
Figure 19.8 Use a sharp instrument to adapt the wax between the teeth. 117
Figure 19.9 Use a sharp instrument to trim away any excess wax. 118
Figure 19.10 Contour the wax to form a fullness or convexity above the anterior teeth to simulate
attached gingiva and to produce a prominent canine root eminence. 118
Figure 19.11 Contour the root prominences over the maxillary central incisors. 118
Figure 19.12 Make a slight depression in the first premolar area to create a “gingival bulge.” 118
Figure 19.13 Continue the gingival bulge over the second bicuspid (if there is one) and widen it
as it travels to the distal of the second molar. 118
Figure 19.14 Carve the interdental papillae to produce a convex surface and gently apply a flame
with a Hanau torch to produce a smooth gingival margin. 119
Figures 19.15 and 19.16 Contour the posterior lingual flanges from the teeth to the peripheral roll to form a
slight concavity, but not so much as to cause the tongue to dislodge the denture. 119
Figure 19.17 Form a small gingival bulge just below the gingival margins of the four incisors. 119
Figure 19.18 Enhance the canine eminences by carving the wax from below the first premolar
to form a slight concavity. 120
Figure 19.19 Form a concavity between the gingival bulge and the peripheral roll. 120
Figures 19.20 and 19.21 Contour the interdental papilla and smooth it with a torch. 120
Figure 20.1 Evaluate the right buccal contours of the complete dentures. 122
Figure 20.2 Evaluate the labial contours of the complete denture and seal them to the casts. 122
Figure 20.3 Evaluate the left buccal contours of the complete dentures. 122
Figure 21.1 Establish flat planes from the midbuccal of the canines to the mesiobuccal of the first molars. 124
Figure 21.2 Establish flat planes from the mesiobuccal of the first molars to the distobuccal of the
second molar on a plane turned approximately 20° toward the palate from the first plane. 124
Figure 21.3 With severely resorbed ridges, draw lines from both sides of the retromolar pad that
intersect at the canine and set the teeth between these lines. 124
Figure 21.4 Do not place the mandibular anterior teeth further forward than a line drawn
perpendicular to the occlusal plane from the middle of the labial vestibule. 124
Figure 21.5 Use marks on a tongue blade to record the distances between a point on the nose and
a point on the chin when determining the vertical dimension of occlusion (VDO) and
vertical dimension at rest (VDR). 125
Figure 21.6 Make sure the midlines of the dentures line up with the middle of the patient’s face
and the anterior occlusal plane lies parallel to the interpupillary line. 127
Figure 21.7 Use the nose as a guide to the placement and size of teeth. The inner canthus of the
eyes and the ala of the nose should line up with the canines, unless there has been
surgery or deformity to these areas. 127
Figure 21.8 Overextension of the labial flange of the lower denture will not allow the lower lip
to touch the incisal edges of the maxillary anterior teeth without raising the lower denture. 128
Figure 21.9 If the maxillary anterior teeth are set too low, the patient will struggle to position the
lip and it will contact the teeth prematurely. 128
Figure 21.10 Consider leaving out a molar if the mesiodistal length of the mandibular residual
ridge is too short to accommodate four teeth. 128
Figure 21.11 If the mesiodistal length of the residual ridge is too short for four teeth, consider
leaving out a premolar. 128
Figure 21.12 Compensate any vertical overlap of the maxillary anterior teeth by ramping the
positions of the posterior teeth and evaluate this by placing a flat plane on the
occlusal of the maxillary denture. 129
Figure 21.13 Do not set posterior teeth buccal to the crest of the maxillary ridge. 129
Figure 21.14 Do not set posterior teeth buccal to the crest of the mandibular ridge. 129
Figure 21.15 Because base plates are not very stable, they will allow movement which makes
the teeth appear to be in ideal contact, even though they are not. 129
Figure 21.16 To achieve an accurate centric relation record, rehearse closing movements with the
patient to have them close gently into the compound just short of tooth contact. 130
Figure 21.17 Give the patient a mirror and have them evaluate for themselves the vertical dimension,
space available for the tongue, lip support, etc. 131
Figure 21.18 It is often necessary to use a denture adhesive to retain the base plate in the mouth at
the try‐in appointment. 131
Figure 21.19 Do not yield to a patient’s request that the flange be removed or thinned to the point
that it becomes extremely fragile. 131
Figure 21.20 Do not set the anterior teeth back on the ridge or the flange will become more noticeable. 132
Figure 21.21 The maxillary anterior teeth are esthetically related to one another by a ratio of
1.618 to 1, so from anterior to posterior the amount of tooth that is visible becomes
progressively smaller in width by a ratio of 1.618 to 1. 132
Figures 21.22 and 21.23 Compare the noncontoured teeth in the picture on the left to the contoured teeth in the
bottom picture. Teeth may need to be recontoured to permit a proper overlap or
contact. 133
Figure 21.24 Stipple a denture to provide a surface texture that will break up the ambient light as
it reflects from the mouth. 133
Figure 21.25 Provide lip support by contouring the gingiva appropriately. 133
Figure 21.26 Note the unsupported upper lip in this picture, and the undercontouring in the lip that
results from it. 133
Figure 22.1 Mark points in the palatine fovea and the hamular notch areas and connect them
together with a line. 136
Figure 22.2 Place points in the glandular area 5–8 mm forward of this first line and about 2 mm
anterior to the line at the midpalate. 136
Figure 22.3 Carve the seal with a cleoid/discoid carver. 136
Figure 22.4 Carve the seal with the back of a green‐handled knife blade. 136
Figure 22.5 Carve the posterior palatal seal to be 0.5 mm deep in the middle of the posterior
palate, 1 mm deep in the hamular notch area, and 1.5 mm deep in the glandular
area between the hamular notch and the middle of the posterior palate. 136
Figure 24.1 The lid of a flask. 140
Figure 24.2 The upper section of a flask. 140
Figure 24.3 The lower section of a flask. 140
Figure 24.4 The bottom knockout disk. 140
Figure 24.5 Make sure that the pieces fit together flush with one another. 141
Figure 24.6 Place the casts in their respective flasks. 141
Figure 24.7 Maintain a distance of not less than 3 mm or 1/8 inch between the teeth of a
denture wax‐up and the top of the flask. 141
Figure 24.8 Adapt a piece of tinfoil to the base of the cast to allow easy separation when
deflasking the processed denture. 141
Figure 24.9 Lubricate all internal surfaces of the flask with petroleum jelly. 141
Figure 24.10 Position the cast in the plaster in the lower half of the flask. 142
Figure 24.11 Allow excess plaster to squeeze upward around the periphery of the cast. 142
Figure 24.12 Trim off excess plaster flush with the land area of the cast and clear of the flask lip. 142
Figure 24.13 Apply separating medium to the exposed plaster and stone surfaces. 142
Figure 24.14 Paint a small amount of stone over the teeth with the fingers. 142
Figure 24.15 Vibrate a 50/50 stone/plaster mixture just over the occlusal surfaces of the teeth. 143
Figure 24.16 Smooth the plaster down to the occlusal surfaces of the teeth with a wet finger. 143
Figure 24.17 Vibrate additional stone into the flask to slightly overfill it. 143
Figure 24.18 Press the lid on top of the upper section of the flask completely into place and squeeze out
excess stone from the lid holes. 143
Figure 24.19 After the investing stone has completely set, immerse the flask in boiling water for five
minutes to soften the wax. 144
Figure 24.20 Peel away the base plate and unmelted portions of the wax. 144
Figure 24.21 Rinse both sections of the flask with hot water. 144
Figure 24.22 Use a detergent to clean out the mold. 144
Figure 24.23 Flush the flask repeatedly with clean boiling water. 145
Figure 24.24 Paint all surfaces, except the teeth, with tinfoil substitute until they appear shiny. 145
Figure 24.25 Allow the tinfoil substitute to fully dry before beginning the packing process. 145
Figure 24.26 Place the acrylic mixture in a covered jar and allow it to reach a doughy consistency
before being packed into the mold. 145
Figures 24.27 and 24.28 For the trial closure, place a small amount of excess acrylic into each half of the
flasks with two sheets of plastic placed between the two halves before closure. 146
Figure 24.29 Slowly compress the flask in a press, allowing excess acrylic to slowly squeeze out
between the flask halves. 146
Figure 24.30 Make sure that the expressed acrylic totally covers the flasked denture and investment
surfaces to ensure that it is a good pack. 146
Figure 24.31 If a mold is underpacked, add more acrylic and repeat the packing process until the
flash is expressed around the entire border of the flask. 147
Figures 24.32 and 24.33 Carefully remove all flash. 147
Figure 24.34 Repeat the process at least twice more with one layer of plastic between the two
halves until no flash is seen. 147
Figure 24.35 To ensure that the acrylic is sufficiently dense, press it until it feels rubbery to the
touch, and remove all flash. 147
Figure 24.36 Paint the cast side of the flask with tinfoil substitute again, and then make the final
closure. 148
Figure 24.37 Pack the flasks under moderate pressure. 148
Figure 24.38 Cure the acrylic resins in water in a curing tank at 160 °F for one hour. 148
Figure 24.39 Gradually cool the flask in a deflected stream of cool water that is spread out so
that it bathes the entire surface of the flask. 148
Figure 24.40 Remove the flasks and allow them to bench cool. 149
Figure 24.41 Remove the flask lid by wedging an instrument such as a Buffalo knife or chisel
in the notch. 149
Figures 24.42–24.44 Use a mallet or hammer to tap the insert disc at the bottom of the flask until the
investment is dislodged from the flask. 149
Figures 24.45 and 24.46 Use a plaster saw or chisel to remove all plaster until the denture is exposed. 150
Figure 24.47 If the denture detaches from the cast, clean the cast and the mounting carefully
and allow them to dry. 150
Figure 25.1 Set the incisal guide pin so that the wide mark on the pin is even with the top
member of the articulator. 152
Figure 25.2 Make sure that the incisal guide pin touches the guide table when it is set at the wide mark. 152
Figure 25.3 Lock the maxillary member in its most forward position using the condylar thumbscrews. 152
Figure 25.4 Set the lateral guidance at 15°. 152
Figure 25.5 Set the horizontal condylar guidance on both sides of the articulator at 30° for anatomic teeth. 153
Figure 25.6 Make retention cuts on the proximal surfaces of both the casts and their plaster mountings. 153
Figure 25.7 Remount the complete dentures by adding sticky wax. 153
Figure 25.8 Check the guide pin for evidence of processing error. 153
Figure 25.9 Use one thickness of double‐sided articulating tape to mark the articular surfaces of
the teeth. 153
Figure 25.10 Use a laboratory acrylic bur to deepen the marks in the fossae of the teeth. 153
Figure 25.11 Avoid reducing any cusp tips. 154
Figure 25.12 Once the pin touches the guide table, make no further adjustments during the lab remount. 154
Figure 25.13 With a monoplane denture set in zero‐degree teeth, flat‐surface the maxillary denture’s
occlusal plane with a piece of sandpaper resting on a flat surface. 154
Figure 26.1 Attach the remount table to the lower member of the articulator. 156
Figure 26.2 Lubricate the teeth with petroleum jelly. 156
Figure 26.3 Wrap a piece of masking tape around the occlusal index table to form a containment barrier. 156
Figure 26.4 Close the articulator so that the tape covers about 2 mm up on the teeth. 156
Figure 26.5 Remove all rubber bands and tape from the plaster index. 156
Figure 26.6 Reduce the remount index on the model trimmer until the depressions of the teeth
are less than 1 mm deep. 156
Figure 26.7 The remount platform has two or three distinct depressions on its surface which
produce an index. 157
Figure 26.8 Print the patient’s name on the index with a permanent marker. 157
Figure 27.1 Remove the cast from the denture in small sections one piece at a time. 160
Figure 27.2 Trim off all flash from the peripheral borders of the dentures with a laboratory acrylic bur. 160
Figure 27.3 Use an arbor band to quickly remove large amounts of flash. 160
Figure 27.4 Take care not to overreduce buccal, facial, and lingual fold contours. 160
Figures 27.5 and 27.6 Take care not to reduce or overpolish gingival festooning around the teeth. 160
Figure 27.7 Remove small bubbles easily from between the teeth with the point of a
green‐handled knife. 161
Figure 27.8 Remove small blebs on the tissue side of the dentures with acrylic burs, rubber
points, and/or a denture scraper. 161
Figure 27.9 Rub a piece of 2 × 2 gauze lightly over the tissue surface, which will pull a thread if
there are any small blebs. 161
Figure 27.10 Remove small blebs carefully with a discoid carver, other small instruments, and/or a
mounted rubber point. 161
Figure 27.11 Use wet rag wheels mounted on a lathe to polish the external surfaces up to the
peripheral fold. 162
Figure 27.12 Use wet felt cones on a lathe to polish the external surfaces up to the peripheral fold. 162
Figures 27.13 and 27.14 Maneuver the denture so that depressed or concave areas are polished. 162
Figure 27.15 Use a felt wheel revolving at slow speed and Hi‐Shine polishing agent to impart a
high gloss on concave external surfaces of the denture. 163
Figure 27.16 Place a piece of masking tape over the teeth to prevent inadvertent abrading of their surfaces. 163
Figures 27.17 and 27.18 Finish gingival embrasures and other hard‐to‐reach areas at low speed with Hi‐Shine
and soft bristle brush wheels. 163
Figure 28.1 Check the denture base surface to ensure that it is clean with no traces of investment
or polishing media present. 166
Figure 28.2 Follow the desired criteria of the restoring dentist and the patient to produce
lingual contours that mimic nature. 166
Figure 28.3 Follow the desired criteria of the restoring dentist and the patient to produce gingival
contours that mimic nature. 166
Figure 28.4 Scrub hard‐to‐clean areas very well under running water with a denture brush and soap. 166
Figure 28.5 Careless use of polishing cones and heavy abrasives or heavy pressures will overpolish
and abrade away surface detail. 166
Figure 28.6 Using a cone or wheel that is too large will overpolish and abrade away the lingual
surfaces of these teeth. 167
Figure 28.7 Using mounted rubber points alone will insufficiently polish a denture. 167
Figure 29.1 Use pressure indicator paste to recheck the adaptation to the denture‐bearing tissues. 170
Figure 29.2 Adjust pressure areas sparingly, wipe off the abrasive, inspect the area, use more
abrasive if necessary, make more adjustments, etc. 171
Figure 29.3 Pay particular attention to the mylohyoid ridge area of the lower denture and any
tori of a maxillary denture. 171
Figure 29.4 Relieve the area of any tori of a maxillary denture. 171
Figure 29.5 Other areas that will often require relief on the maxillary complete denture are the
retrozygomatic prominence, the midpalatal suture groove, the buccal notch,
the incisive fossa, and the labial notch. 172
Figure 29.6 Areas that will often require relief on the mandibular complete denture are the
retromylohyoid flange, the buccal flange, the lingual notch, labial flange, and labial notch. 172
Figure 29.7 Adjust overextended denture flanges using disclosing wax. 172
Figure 29.8 Do not forget to check the buccal surfaces of flanges, particularly where the
coronoid process contacts the distobuccal flange. 173
Figure 29.9 In particular, check the lingual frenum area of the lower denture. 173
Figure 29.10 The retromylohyoid flange area frequently requires adjustment. 173
Figure 29.11 The labial notch frequently requires adjustment. 173
Figure 30.1 Make a facebow transfer record since the relationship of the original record was not preserved. 176
Figure 30.2 Make a bite registration in protrusive relation. 176
Figure 30.3 Make a bite registration in centric relation and use it to mount the lower denture on a
remount cast. 176
Figure 30.4 The plaster of the denture remount cast can be trimmed flush with the denture. 176
Figure 30.5 Smooth the mounting under running water with a piece of wet/dry sandpaper 177
Figure 30.6 Place a strip of rope (utility) wax around the external part of the denture flange and
lute it in place with sticky wax and a hot instrument. 177
Figure 30.7 Use clay, putty, or wet pumice as a block‐out material. 177
Figure 30.8 Boxing is the best way to make a remount cast. 177
Figure 30.9 A dense cast made by boxing and pouring an impression looks much more
professional to the patient than a cast made without boxing. 178
Figure 30.10 After the plaster has set, remove the boxing wax and beading wax. 178
Figure 30.11 Clean the cast of all residues. 178
Figure 30.12 Remove the denture from the remount cast and remove the wet paper towel. 178
Figure 30.13 Replace the denture on the remount cast and make sure the fit is accurate. 178
Figure 30.14 Place the maxillary remount cast and the maxillary complete denture on the remount index. 179
Figure 30.15 With the pin set on 0, lock the condyle in centric relation position with the incisal
guide pin touching the incisal guide table. 179
Figure 30.16 A mandibular remount cast can be made without a containment barrier by placing
mounting plaster over the retentive pins and polyvinylsiloxane putty. 179
Figure 30.17 Set the mandibular denture onto a patty of plaster on a plastic sheet. 179
Figure 30.18 Trim the plaster after it sets to improve esthetics of the cast. 180
Figures 30.19 and 30.20 Place a narrow band of sticky wax around the entire flange area of the denture. 180
Figures 30.21 and 30.22 Place one thickness of utility (rope) wax on the area covered by the sticky wax. 180
Figures 30.23 and 30.24 Surround the denture with boxing wax and lute it to the utility wax band with a
hot spatula. 181
Figure 30.25 Block out the internal ridge fossa area of the lower denture with a piece of paper
napkin or paper towel. 181
Figure 30.26 Fill the containment area with a wet mix of quick‐set plaster and use a spatula to level it off. 181
Figure 30.27 Allow the plaster to dry completely before removing the wax containment barrier. 181
Figure 30.28 Check to make sure that there were no leaks in the containment barrier. 182
Figure 30.29 Remove the denture from the remount cast. 182
Figure 30.30 Remove the wet paper towel from the cast. 182
Figure 30.31 Trim down the land area so that it is smooth and only about 1 mm in depth.
The denture should fit snugly back into place on the cast. 182
Figure 30.32 For lingualized occlusion only, lower the incisal guide pin 2 mm to compensate for
the setting of the pin when the teeth were set plus the anticipated increase due to
processing error. 183
Figure 30.33 Make a lower remount cast. 183

Figure 30.34 The mandibular cast can be mounted once a new centric relation record is made. 183
Figure 30.35 Ideally, a remount index has been provided by the lab. 183
Figure 30.36 If an index was made before the maxillary denture was removed from its cast, the
polished denture is placed on the remount cast and mounted on the articulator before
the patient arrives. 184
Figure 30.37 Mount the lower cast on the lower member of the articulator. 184
Figure 30.38 Mount the mandibular cast on the lower member of the articulator by placing the
teeth of the lower denture in the centric relation record that was made on the
patient in the clinic. 184
Figure 30.39 Raise the incisal guide pin to 0. 185
Figure 30.40 Move the lateral condylar element to 15 and tighten the lock nut. 185
Figure 30.41 Set the horizontal condylar guidance by loosening the condylar lock screw. 185
Figure 30.42 Raise or lower the setting until all teeth are in exact contact with the registration. 185
Figure 31.1 Form a mortar (pothole) on the mandibular posterior teeth. 188
Figure 31.2 Evaluate the marks made in each area where the maxillary lingual cusps contact
with the lower teeth. 188
Figure 31.3 Use the round end of an acrylic bur in a straight handpiece to enlarge a pothole. 188
Figure 31.4 Carefully deepen each pothole until the guide pin again contacts the guide table in
centric relation. 188
Figure 31.5 Check the heels of the mandibular denture contact marks. 188
Figure 31.6 Broaden these potholes by reducing the inclined surfaces in protrusive. 188
Figure 31.7 Use the black side of the articulating film to mark points of contact in centric relation. 189
Figure 31.8 The anterior teeth should contact simultaneously with the posterior teeth in protrusive
movements. 189
Figure 31.9 Use a piece of the paper that separates the AccuFilm in its pack to determine the
strength of a contact between opposing teeth. 189
Figure 31.10 Lock the condyle in centric relation on one side so that you get a purely rotational
movement on that side and open the set‐screw on the other side so that a purely
translational movement is possible to equilibrate the dentures in lateral excursions. 189
Figure 31.11 Move the lower member of the articulator back and forth on the translational side
and make adjustments, then repeat the process on the other side. 189
Figure 31.12 View the vectors of movement during lateral and protrusive movements which are
represented on the teeth in red. 189
Figures 31.13–31.15 The contacts in centric occlusion are points, the contacts made by the various
movements in eccentric relations are smeared. 190
Figure 32.1 Use thin articulating film to record the contacts in all relationships. 192
Figure 32.2 Use the end of a large lab acrylic bur to adjust the contacts in the denture. 192
Figure 32.3 Deepen the fossae of the opposing teeth until the pin touches the guide table. 192
Figure 32.4 Cusps that are in contact are known as “centric holding cusps.” 192
Figure 32.5 Centric occlusion on the right side does not look too bad with these dentures. 192
Figure 32.6 Centric occlusion on the left side shows the mandible is positioned slightly more
distal than the original recording. 192
Figure 32.7 When viewed facially, the amount of horizontal overlap of the posterior teeth is obvious. 193
Figures 32.8 and 32.9 Here is a set of dentures before occlusal equilibration is done in centric relation. 193
Figures 32.10 and 32.11 Here is the same set of dentures after occlusal equilibration in centric relation. 193
Figure 32.12 View a working relationship in the picture on the left. 193
Figures 32.13 and 32.14 View a balancing relationship on the middle and right pictures. 194
Figure 32.15 Use the tip of an acrylic bur to adjust the cusps to equilibrate the teeth. 194
Figures 32.16 and 32.17 View the contacts of the teeth in left lateral movement of the mandible after occlusal
refinement is completed. 195
Figures 32.18 and 32.19 View the contacts of the teeth in right lateral movement of the mandible after occlusal
refinement is completed. 195
Figures 32.20–32.22 Adjust the teeth as necessary to achieve bilateral balance in protrusive, but not at
the expense of contact areas that were previously established in centric occlusion
or lateral excursions. 196
Figure 33.1 Flat‐surface the maxillary denture set in a monoplane set‐up by using wet/dry
sandpaper placed on a stable, flat desktop. 198
Figure 33.2 Use the flat edge of a large cylinder‐shaped acrylic bur to make all adjustments
to the lower denture teeth in a zero‐degree, monoplane set‐up. 198
Figure 33.3 Place a flat dry piece of wet/dry sandpaper between the two dentures with the grit
side toward the lower teeth and pull it forward with the articulator locked and closed
in centric relation. 198
Figure 33.4 View the mandibular denture prior to the stripping. 198
Figure 33.5 View the mandibular denture after the stripping. 198
Figure 34.1 Wearing dentures creates a never‐ending cycle of destruction of the underlying
tissues of the denture support area. 200
Figure 34.2 Set anatomic posterior teeth in a compensating curve equal to the vertical overlap of
the anterior teeth. 200
Figure 34.3 The working cusps of the mandibular posterior anatomic teeth are positioned over
the crest of the mandibular ridge. 200
Figure 34.4 The further off the ridge the teeth are, the more the mechanical advantage a force
places on the denture to dislodge it. 201
Figure 34.5 Mark the middle of the mandibular ridge in the second molar area and in the first
premolar area, then use a tongue blade as a straight edge to transfer the mark to the
heel and anterior land areas of the cast. 201
Figure 34.6 Mark the center of the ridge onto the wax occlusion rim using a ballpoint pen and
set the maxillary teeth accordingly. 201
Figure 34.7 The mandibular buccal cusps of the anatomic posterior teeth should then line up
over the crest of the ridge. 201
Figure 34.8 Implants require a certain amount of bulk to be retained in the denture base, and
this will weaken the resistance of the denture to fracture. 202
Figure 34.9 At the insertion appointment, inform the patient who has been without teeth for a
while that they will need to allow time for the tongue to shrink to fit the space
provided by the mandibular denture. 202
Figures 34.10–34.12 If a lingual flange appears too long, evaluate and check the stability of the lower
denture by having the patient raise their tongue and forcefully extend it. 202
Figures 34.13 and 34.14 Undercut areas in the retromylohyoid spaces can be very useful in retaining the lower
denture. 203
Figure 34.15 The shape of the flange under the tongue can either enhance or inhibit retention. 203
Figure 34.16 Ridge resorption is the most common cause of an unstable upper denture. 203
Figure 34.17 The ridge fills the denture when the denture is inserted. 203
Figure 34.18 When a ridge resorbs, the hard palate does not resorb, and the denture “high-centers.” 203
Figures 34.19 and 34.20 An overextended flange is easily identified by the skilled observer. 204
Figure 34.21 The intaglio surface of the denture will reflect if the patient has a very shallow
vestibule or a highly attached frenum. 204
Figure 34.22 Have the patient push their tongue as far forward as they can. 204
Figure 34.23 Have the patient move their tongue far to the left. 205
Figure 34.24 Have the patient move their tongue far to the right. 205
Figure 34.25 Use disclosing wax to check the length of the denture borders. 205
Figure 34.26 If the posterior palatal seal is insufficient, cut out this area and make an alginate
impression of the denture in the mouth. 205
Figure 34.27 Pour a cast of type II stone into the denture in the impression and cut an arbitrary
posterior palatal seal into the stone cast. 206
Figure 34.28 A functional seal can be formed in a cast by adding a posterior palatal seal of
compound or mouth temperature disclosing wax to the denture, inserting it in the
mouth, then pouring the cast. 206
Figure 34.29 A small palatal torus may not need to be removed or reduced. 206
Figure 34.30 Biting of the tongue or cheek is generally caused by insufficient horizontal overlap
of the posterior teeth. 206
Figure 34.31 Teeth may need to be set in a crossbite relationship to avoid cheek biting. 207
Figure 34.32 This graphic shows the relationship of a mandible to the maxilla in centric relation. 207
Figure 34.33 This graphic shows the relationship of a mandible to the maxilla in protrusive relation. 207
Figure 34.34 Macroglossia usually results from lack of containment of the tongue. 207
Figure 34.35 Every fracture has a cause which must be eliminated or corrected before a repair can
be successful. 207
Figures 34.36 and 34.37 A patient should anticipate that they may drop their dentures or otherwise break
them by accident. 208
Figures 34.38 and 34.39 Epulis fissuratum is an irritation fibroma that has developed over a long period of
time due to an ill‐fitting denture. 209
Figures 34.40 and 34.41 Papillary hyperplasia is an overgrowth of tissue caused by an ill‐fitting denture. 210
Figure 34.42 Pressure indicator paste (PIP) is painted in the area of a sore spot and the denture is
replaced in the mouth. 211
Figure 34.43 A prominent sore spot will make a mark in the PIP. 211
Figure 34.44 An overextended flange caused these lesions in the labial frenum in the anterior
mandibular area. 212
Figure 34.45 A mature ulcer has formed along the denture border overlying the canine eminence. 212
Figure 34.46 This lesion will mark in PIP paste on the denture flange and can then be reduced
with an acrylic bur. 212
Figures 34.47 and 34.48 The anterior maxillary frenum is the most common frenum to become irritated from
denture overextension. 212
Figure 34.49 With the aid of disclosing wax, the frenum area is adjusted with the small‐diameter
acrylic bur using a slow‐speed handpiece. 213
Figure 34.50 In patients with severe resorption of the mandibular alveolar ridge, a portion of the
inferior alveolar nerve may be exposed on the surface of the mandible. 213
Figure 34.51 Poor neuromuscular control may be the single most significant factor in the successful
manipulation of complete dentures under function. 213
Figure 34.52 Denture adhesive powder is sprinkled on the damp intaglio surface of a denture. 213
Figure 34.53 The denture adhesive powder is gently wetted under a small stream of water. 214
Figure 34.54 Permanent soft liners (silicone elastomers) may be indicated and are usually limited to
mandibular dentures for the treatment of chronic soreness, bruxism, and in the case
where no attached gingiva exists. 214
Figure 35.1 Tooth #9 was fractured when the denture base fractured. 216
Figure 35.2 To replace a broken tooth, cut a notch into the denture base acrylic palatal to or
lingual to the tooth being replaced. 216
Figure 35.3 Add sticky wax on the lingual (palatal) surface of the tooth to hold it in place. 216
Figure 35.4 Make a plaster matrix on the labial or buccal side of the tooth being replaced. 216
Figure 35.5 Cover an area of about two teeth on either side of the missing tooth with a plaster matrix. 216
Figure 35.6 Place the replacement tooth in the matrix and secure it in place with sticky wax. 216
Figure 35.7 Place the matrix containing the replacement tooth into position on the denture. 217
Figure 35.8 Overfill the prepared areas of the denture with autopolymerizing repair resin. 217
Figure 35.9 Several teeth in this denture have fractured. 217
Figure 35.10 Carefully remove the broken teeth. 217
Figure 35.11 Select replacement teeth and fix them in place with sticky wax. 217
Figure 35.12 Make a matrix of quick‐setting plaster. 217
Figure 35.13 A matrix is made of polyvinylsiloxane putty. 217
Figure 35.14 Cut a diatoric in the lingual of each tooth and attach the teeth to the plaster matrix
with sticky wax. 218
Figure 35.15 Apply resin to the repair site by the brush‐bead method. 218
Figure 35.16 Slightly overfill resin in the prepared area. 218
Figure 35.17 Cure the repair in a pressure pot half‐filled with warm water (115 °F) for 10 minutes. 218
Figure 36.1 The most common fracture of a complete denture is the midline fracture of the maxillary
complete denture. 220
Figure 36.2 Align the parts of the fractured denture and splint them into position with coat
hanger wires. 220
Figure 36.3 “Tack” the wires to the teeth with sticky wax. 220
Figure 36.4 Cut pieces of paper clip and bend them into a loop to make good retentive loops. 220
Figure 36.5 Block out the ridge area away from the fracture site with polyvinylsiloxane putty.
Leave a generous area (about 8–10 mm) close to the fracture site free of putty coverage. 220
Figure 36.6 Remove all denture pieces from the stone matrix. 221
Figure 36.7 The pieces and the matrix are cleaned and reassembled on the cast to ensure that
they can be accurately positioned. 221
Figure 36.8 Bevel the approximating surfaces so that there is a 3 mm gap on the polished
surface and a 2 mm gap on the cast side. 221
Figure 36.9 Remove enough acrylic from the polished surface side of the denture to allow a gap of
8–10 mm cut halfway through the denture. 221
Figure 36.10 Paint separating medium on the cast at least 10 mm to either side of the fracture line. 222
Figure 36.11 Use the “brush‐bead” method to overfill the repair area with repair acrylic. 222
Figure 36.12 Remove the repaired denture from the stone matrix. 222
Figure 36.13 Finish the repaired denture with successively finer abrasives until a high shine is achieved. 222
Figure 36.14 An inspection of the denture should show a smooth line at the junction of the
denture base acrylic and the repair acrylic. 222
Figure 36.15 Approximating the broken pieces of a mandibular denture. 223
Figure 36.16 Fix the broken pieces in position with a nonabsorbing splinting material. 223
Figure 36.17 The denture pieces are in close contact and there is no wax or other debris on
that surface. 223
Figure 36.18 Keep about 10 mm of the surface on the tissue side bare of any putty. 223
Figure 36.19 Remove the splinting material and all the sticky wax from the denture surface
and the repair cast. 223
Figure 36.20 Fit the denture pieces precisely back into place on the cast. 224
Figures 36.21 and 36.22 Remove approximately 1.5 mm of acrylic from the proximal surfaces of the fracture
line on the polished surface and 1 mm on the tissue side, forming a gap of 2 mm
on the tissue surface and 3 mm on the polished surface. 224
Figure 36.23 Remove enough acrylic from the polished surface side of the denture to allow a gap of
8–10 mm. 225
Figure 36.24 “Rabbeting” provides an increased surface area that affords a stronger joint between
the old and new acrylic. 225
Figure 36.25 Paint Al‐Cote, a tinfoil substitute, on the area under the site to be repaired. 225
Figure 36.26 The denture parts are replaced and luted in place with sticky wax. 225
Figure 36.27 Use a disposable brush dipped in the polymer powder to form a small bead on the
wetted end of the brush. 225
Figure 36.28 Dip the brush in monomer and dry it thoroughly on a paper towel to remove any
residual acrylic and prevent ruining the brush. 225
Figure 36.29 Place the repair cast with the denture in a pressure pot water bath to cure. 226
Figure 36.30 Check to see that the acrylic is of good quality and covers all the desired areas. 226
Figure 36.31 Fit the dentures together to ensure that they occlude properly. 226
Figure 36.32 The repair site acrylic should blend together so precisely with the original acrylic
as to make the repair almost invisible. 227
Figure 37.1 Make simple overdenture abutments with cast nonprecious metal dowel copings. 230
Figure 37.2 Amalgam also is sometimes used to make overdenture abutments. 230
Figure 37.3 Place a magnetic metal stud in the endodontically treated tooth abutment. 230
Figure 37.4 Magnets can be cast to a metal stud. 230
Figure 37.5 Ball or reverse cone‐shaped abutments are the most popular overdenture abutments. 230
Figure 37.6 Snap yellow cap attachment transfers onto ball abutments. 230
Figure 37.7 Press cap attachments with stainless steel housings over the transfers. 231
Figure 37.8 Block out undercuts beneath the assemblies with silicone or wax. 231
Figure 37.9 An open‐faced custom tray. 231
Figure 37.10 A closed‐face custom tray. 231
Figure 37.11 Cut a relief chamber in a maxillary complete denture that has been modified to
fit over newly placed implants. 232
Figure 37.12 Retain rubber rings with metal “keepers” that encircle the ring and protect it. 232
Figure 37.13 Add a tissue conditioner to the relieved area. 232
Figure 37.14 Make a tissue conditioner “impression” of the implants. 233
Figure 37.15 Use a tissue conditioner to line a relief chamber cut into the base of the denture. 233
Figures 37.16 and 37.17 This bar must be in a straight line to allow for this movement. 233
Figure 37.18 Cut a machined metal sleeve to a length that fits and press it into place over the bar. 234
Figure 37.19 (a) The bar on the left does not allow rotation and must not be placed in a
mandibular distal extension situation. (b) The bar on the right allows rotation. 234
Figure 37.20 Three different types of implant transfer abutments and transfer analogs. 234
Figure 37.21 Process the metal housings into the base plate. 235
Figure 37.22 To determine where to place the mini‐implant abutments, evaluate the cast and
the existing denture, then mark these locations on the ridge with an indelible pencil
and transfer these marks to the denture. 235
Figure 37.23 Make pilot holes which are simple to place and can be done with or without a
placement stent. 235
Figure 37.24 Leave the teeth long until the endodontic therapy is completed. 236
Figure 37.25 Prepare the abutment teeth for copings. 236
Figure 37.26 Cement magnetic faceplates into endodontically treated teeth and adjust them
with burs to fit the profile of the teeth abutments. 236
Figure 37.27 Locate the implants with an impression of the arch or use PIP in the denture. 236
Figure 37.28 Relieve marked areas with an acrylic bur until the denture can be seated in the mouth. 237
Figure 37.29 Place the denture over the abutments to assure enough resin has been removed to
prevent moving the magnets. 237
Figure 37.30 Place a small amount of autopolymerizing acrylic into the dry relief areas of the denture. 237
Figure 37.31 Remove the denture after the acrylic sets. 237
Figures 38.1–38.3 Good‐quality pretreatment photographs are essential. 241
Figures 38.4–38.6 High‐quality diagnostic casts mounted on a semi‐adjustable articulator are extremely
important. 242
Figure 38.7 Mark a line with a colored pencil approximately 2 mm short of the depth of the
vestibule on a preliminary cast. 243
Figure 38.8 In the single tray technique, place a thickness of base plate wax over the remaining
teeth on the diagnostic cast and trim it so that it covers only the teeth. 243
Figure 38.9 Place another thickness of wax over the entire intaglio surface of the cast, including
the area over the remaining teeth. 244
Figure 38.10 Place three dome‐shaped mounds of Triad on the first tray in a triangular fashion. 244
Figure 38.11 Place the first tray on the cast and adapt one thickness of tray material to cover the
first tray and the anterior teeth portion to make the second custom tray. 244
Figure 38.12 Adjust the second tray to fit 2 mm short of the vestibule and assemble the trays and
fit them on the cast. 245
Figure 38.13 Make a base plate on a master cast. 245
Figure 38.14 Relieve a base plate around all existing teeth. 246
Figure 38.15 Select anterior teeth for an immediate complete denture based on size and shape of their
natural teeth. 246
Figure 38.16 Select the size and type of plastic tooth that most closely matches the opposing
restored arch. 246
Figure 38.17 Set plastic teeth to replace the missing teeth in an ideal position. 247
Figure 38.18 The denture teeth replacing #8 and #10 are much more uniform to the arch than
the natural teeth. 247
Figure 38.19 Set teeth over the ridges and ensure bilateral balance to have the best chance of
creating stability. 248
Figures 38.20–38.22 Wax the flanges directly onto the cast. 248
Figures 38.23–38.25 The relationship of the arches indicates that the vertical dimension has probably
closed due to collapsing
of the arch. 249
Figure 38.26 Use a surgical stent to ensure that the denture‐bearing area fits the denture. 249
Figure 38.27 Achieve a better‐fitting and more esthetic denture by allowing a six‐week healing period. 251
Figure 39.1 Mark and reduce the denture 2 mm shy of the length of the flange. 254
Figure 39.2 The tissue conditioner kit comes with a mineral oil lubricant. 254
Figures 39.3 and 39.4 Paint lubricant on the dentures in the areas where the tissue conditioner should not adhere. 254
Figures 39.5–39.8 The average complete denture will require 10 mL of powder and 2 mL of liquid resin. 254
Figures 39.9–39.11 Use a tongue blade to mix the ingredients together. 255
Figures 39.12–39.14 Apply Lynal to the denture with a tongue blade, loading the lower denture with tissue
conditioner mixture from the distal on one side and moving around the rest of the denture. 256
Figures 39.15–39.17 Have the patient move their tongue forward and then laterally while you hold the
denture in place with your thumbs or fingers. 256
Figures 39.18 and 39.19 Lift the lips and cheek to border mold the impression by moving them up and down. 257
Figures 39.20 and 39.21 Place high‐viscosity tissue conditioner in the tissue surface and shape it to fit with a
tongue blade. 257
Figure 39.22 Spread the mixture evenly across the palate of the denture. 258
Figure 39.23 Manipulate the lips and cheeks while the patient holds the teeth firmly together. 258
Figures 39.24–39.26 Manipulate the cheeks, moving them up and down while pressing them against the teeth. 258
Figure 39.27 View a tissue conditioner in place immediately after removal from the mouth. 259
Figures 39.28 and 39.29 Considerable flash is seen over the entire external border of the denture. 259
Figure 39.30 Lubricate the external surface of a denture to allow easy removal of any adhering
tissue conditioner. 259
Figures 39.31–39.36 Use a tongue blade in a scissors-like action against the borders of the denture to
remove flash. 259
Figure 39.37 View the appearance of the tissue conditioner immediately after trimming. 260
Figure 39.38 View the appearance of the tissue conditioner after three days in the mouth. 260
Figures 39.39–39.41 Examples of Coe‐Comfort tissue conditioner relines. 261
Figure 40.1 (a) Maxillary and mandibular AvaDent prefabricated trays. (b) Maxillary definitive
impression. (c) Mandibular definitive impression. 264
Figure 40.2 Duplicates of patient’s existing dentures used to make a definitive impression,
establish VDO, determine lip support, and make a CR record. 264
Figure 40.3 Conventional wax rims used to establish VDO, determine lip support, and
make a CR record. 264
Figure 40.4 (a) Maxillary Wagner EZ guide tray. (b) Mandibular Wagner EZ guide tray.
(c) Maxillary and mandibular Wagner EZ guide trays trial placed and adjusted
as required. (d) Centric relation record made with the Wagner EZ guide trays. 264
Figure 40.5 (a) Computer‐aided design design of digital dentures. (b) Printed trial maxillary
and mandibular dentures as proposed by the CAD design and approved by the clinician.
Source: Photo (b) courtesy of Dr Charles J. Goodacre. 265
Figure 40.6 Definitive digital denture in the patient mouth. 265

Figure 40.7 (a) Definitive maxillary impression made with PVS using Ivoclar moldable
disposable trays. (b) Definitive mandibular impression made with PVS using
Ivoclar moldable disposable trays. 265
Figure 40.8 Conventional wax rims used to establish VDO, determine lip support, and make
a CR record. 266
Figure 40.9 Duplicates of patient’s existing dentures used to make a definitive impression,
establish VDO, determine lip support, and make a CR record. 266
Figure 40.10 Papillameter used with lips at repose. 266
Figure 40.11 Facial meter used to measure inter‐ala distance. 266
Figure 40.12 (a) Duplicates of dentures with CR record used to mount the impression on the virtual
articulator and create virtual casts. (b) CAD of digital dentures. 267
Figure 40.13 Trial placement of milled CD out of white ProArt CAD PMMA. 267
Figure 40.14 Trial placement of milled CD. 267
Figure 40.15 (a) Oversize mill of the denture base out of pink Ivobase CAD. (b) Oversize mill of
denture teeth out of color shaded SR Vivodent CAD. (c) The milled teeth bonded to
the base and inserted in the milling machine for final milling. (d) Definitive CD after
final milling. (e) Definitive CD after polishing. 268
Figure 40.16 Definitive digital denture in the patient’s mouth. 268
Figure 40.17 (a) Dentca two‐piece impression trays. (b) Maxillary Dentca impression tray
showing the detachable posterior section of the tray. (c) Mandibular Dentca
impression tray showing the detachable posterior sections of the tray and the
stylus used to record CR. (d) Maxillary definitive impression. (e) Mandibular definitive
impression. Source: Photos (d) and (e) courtesy of Dr Ewa Parciak. 268
Figure 40.18 (a) #15 C surgical blade used to separate the posterior area of the maxillary
impression tray. (b) Maxillary impression tray after separation of the posterior
section of the tray. (c) Mandibular impression tray after separation of the posterior
sections of the tray. Source: Courtesy of Dr Ewa Parciak. 269
Figure 40.19 (a) Determination of the VDO and registration of the CR record. (b) Impression
trays with CR record. Source: Courtesy of Dr Ewa Parciak. 269
Figure 40.20 Papillameter used with lips at repose. Source: Courtesy of Dr. Ewa Parciak. 269
Figure 40.21 CAD of digital dentures. 269
Figure 40.22 Printed maxillary and mandibular dentures. 270
Figure 40.23 Printed definitive dentures. 270
Figure 40.24 Definitive placement of printed dentures. 270
293
Index
a ball abutment 229–232, 234 centric relation, centric relation records

AccuFilm® II Double‐Sided Articulating ball abutment replicas 232, 234 63, 66–71, 99, 105, 106, 108, 112, 113,
Film 105, 151, 186 ball abutment transfers 229, 234 125, 129–131, 134, 151, 152, 169,
adhesives 5, 8, 39, 45, 57, 58, 131, 199, ball attachment transfers 231 175–177, 179, 182–184, 186–191, 193,
213, 214, 229, 245 bar system 232, 233 195, 198, 199, 206, 207, 210, 234, 245,
air barrier coating 51, 53 bench lathe 17 248, 263, 264, 267
ala–tragus line 93, 111, 126, 245 “bimanual technique” 130 cheek biting 199, 206, 207, 211
Al‐Cote®, a tin‐foil substitute bilaterally balanced occlusion 85–92, clinical remount 105, 127, 129, 152,
223–225 134, 194, 199 175–186, 199, 200, 201
alginate 5–12, 205, 245, 250 bite fork 59, 60, 63 COE‐Comfort™ Self‐Cure Chairside
Aluwax™ Bite and Impression Waxes bite registration 59, 66–69, 71, 105, Edentulous Tissue Conditioner 261
67, 68 106, 130, 175, 176, 182, 234, 245, combination syndrome 2, 129, 250
alveolar groove 10, 12 246, 267 combination tooth forms: (tapering
alveolar process 2 Blu‐Mousse® 67, 68, 130 ovoid, triangular ovoid or square
Angle’s classification system 246 boil out tank 6, 141 ovoid) 2, 129, 250
anterior guidance 2, 73 border molding 5, 7, 17, 20, complete dentures 1–3, 25, 34,
articulating paper 108, 109, 151, 23, 25, 26, 28–38, 41, 44, 130, 41–45, 47, 59, 71, 74, 112, 115–123,
187, 191 159, 244 125–127, 129, 130, 137, 139–151,
articulators 59–69, 71, 73, 89, 100, boxing an impression 47–50 159–163, 169–173, 175, 177, 179,
105, 106, 113, 116, 121, 130, 131, Breaking the seal 184, 197–227, 229–237, 239–251,
151–153, 155, 156, 165, 169, 175, 177, “brush‐bead” method 215, 218, 220, 253, 254, 263–270
178, 182–187, 189, 197, 198, 241, 242, 222, 224 conditioning unit 51, 53
245, 267 buccal flange 10, 12, 44, 172 containment barrier 64, 66, 69, 70,
augmentation 2, 3, 210, 232 buccal notch 10, 12, 171, 172 156, 179, 181, 182
autogenous bone graft 3 buccinator muscle 2 coronoid contour 12
auto‐mix impression system 41 bulk‐packaged impression material 6 curing oven, curing unit 17, 20, 51,
auto‐mixing instruments 41 Bunsen burner 17, 18, 25, 31, 51, 54, 53, 244
55, 59, 116 cusped teeth 99, 112, 124
b butterfly pattern 45, 135
base plates 17, 18, 21, 51–60, 62–64, d
66–69, 76, 81, 82, 85, 86, 93–95, 105, c Deflasking 139, 141
115–117, 121, 123, 126, 129–131, 140, Candida Albicans 2, 209 Denar® Slidematic facebow 59, 184
144, 151, 175, 234, 235, 243, 245, 246, cap attachment transfers 229, 230, 232, dental compound 28, 244
249, 250 234, 235 dental stone
basic tooth forms: (square, triangular, Care & maintenance denture adhesive (paste, powder) 123,
square tapering, or ovoid) 76, 215 Ceka Attachment System 131, 199, 213, 214, 229
294 Index
denture‐bearing area 1, 249 g interocclusal registration, interocclusal

denture repairs 215 gagging patient 8, 12, 29, 199 record 62, 68, 69, 152, 170, 245
diagnosis 5, 13, 239 “Golden Mean” (or “Golden interpupillary line 57, 58, 111, 113,
diagnostic casts 14, 240–243 Proportion”) 126 125–127, 245, 246, 263
dimensions 6, 25, 55, 59, 63, 76, 79, green stick compound 25, 28, 130, 244 irreversible hydrocolloid 5, 8
111, 113, 123, 125–128, 130–132, 134, grinding 6, 108, 132, 165, 195
150–152, 195, 210, 223, 234, 241, 247, gypsum 6, 9, 47, 48, 70 j
249, 263, 266, 267 jaw relationship records (JRR) 182, 185
disclosing wax 169, 172–173, 204–206, h
212, 213 Hamular notch (pterygomaxillary k
“dished‐in” appearance 111 notch) 1, 6, 13, 14, 28, 69, 135, 136 Kelly syndrome (Plummer‐Vinson or
disinfectant, disinfecting an impression “Hanau’s Quint” Paterson‐Kelly syndrome) 2, 111,
13, 250 Hanau™ Wide‐Vue articulator 59, 129, 199, 209
distortion 1, 5, 14, 41, 51, 54, 62, 148, 100, 184 “key to occlusion” 85, 88
150, 169, 257 healing collar 231 knife, buffalo, green handled 70, 123,
double‐pour technique 139 “high‐centering” 170, 208, 219 135, 136, 149, 159, 169, 175
drying rack 14 high lip line 56, 74, 111, 127, 246, 247
DuraLay Inlay pattern resin 215 horizontal condylar guide 63 l
house classification of complete denture labial flange 10, 12, 36, 44, 125, 127,
e patients 3 128, 131, 172, 239
elastomeric bite registration labial notch 10, 12, 36, 171–173
materials 67 i laboratory handpiece 17
Epulis fissuratum 2, 199, 209 identifying dots 78 lab remount 105, 151, 154, 191, 248
equilibration 175, 187, 191, 193, 200, immediate complete dentures land area 6, 14, 15, 17, 18, 21, 22, 47,
201, 210, 245 208–210, 219, 239–251 50–53, 56, 68, 76, 81, 82, 139, 142, 175,
esthetics, “esthetic indicators” 59, 79, impacted teeth 1 177, 182, 200, 201
99, 103, 111–113, 123, 125–127, 130, implants 99, 199, 201, 202, 208, 210, landmarks 1, 10, 12–14, 111, 123, 127
132, 134, 180, 204, 208, 209, 234, 241, 229–237 lateral condylar guide 63, 64
242, 247, 250, 263, 266, 269 implant transfer abutments 234 lateral throat form 3, 5
exostoses 2 impression materials 5–9, 11, 17, 21, light‐cured resins 244
25, 37–39, 41–45, 106, 171, 172, 231, light‐curing machines 233
f 243–245, 253 lingualized occlusion 99–109, 182,
facebow, facebow registration 59–63, impressions 1, 2, 5–15, 17, 21, 23, 183, 187–190
65, 68, 105, 151, 152, 175, 184, 245 25–39, 41–45, 47–51, 106, 169, 171, lingual tubercular fossa 10
facebow transfer 59–62, 68, 105, 175, 172, 178, 204, 205, 206, 229, 231–234, Lucia jig 245
176, 245 236, 241, 243–245, 247, 249–251, 253, Lynal® tissue conditioner and temporary
festooning 79, 112, 113, 115, 127, 134, 257, 261, 263–269 reliner 253, 256, 261
159, 160, 165 incisal guide table 62, 63, 150, 151,
facial esthetics 126 177, 179, 191 m
final impressions 1, 2, 14, 17–23, incisive fossa, incisive papilla 1, 12, 81, Macroglossia 201, 207
25–39, 41–45, 47–50, 204, 241, 245 82, 171, 172 master casts 17, 18, 47, 50, 51, 53, 64,
finishing 92, 123, 152 indelible transfer stick 25, 26, 30, 123, 68, 76, 130, 139, 150, 236, 245, 250
flabby residual ridge 2 173, 205, 211 maximal biting forces 1
flasking 139–150, 205, 250 indexing a cast 130 median palatal groove 12
flasks 139–150, 247, 249, 250 inflammatory fibrous hyperplasia 2 midline fractures 199, 208, 219,
flat‐plane teeth 111, 112, 123, inflammatory papillary hyperplasia 2 220, 226
124, 129 insertion appointment 127, 151, 152, mini‐implant system 235
fovea palatinae 12–13 199, 202, 243, 250 modeling compound 5
Fox occlusal plane analyzer 58 instability 2, 73, 76, 111, 124, 129, 130, Model Release Agent 51, 52
frenulum, frenula 1, 7, 9, 10, 25, 28, 170, 202, 204 mold chart 74–76, 123
29, 32, 36, 37, 44, 113, 165, 210 intaglio surface of the denture 147, monoplane occlusion 93–97, 123,
fricative sounds 56, 57, 210, 247 170, 171, 204, 206, 250 197, 246
Index 295
mounting casts 61–66, 69–71, 138, posterior palatal seal (arbitrary, reverse crowfoot pattern 105, 187
150, 151, 175, 177–179, 182–186, functionally‐generated) 3, 13, 14, 21, rugae 1, 12, 115, 165, 171, 210
191, 223, 246 28, 30, 36–38, 45, 115, 116, 125, rule of BULL 191
muscle‐trimming 9, 10, 44, 59 134–136, 170, 171, 199, 203–206, 211, ruler, flexible plastic 81, 83
mylohyoid ridge 2, 171 244, 254
pouring a final impression 47–50 s
n pouring time 6, 8, 14 sandpaper, wet/dry 70, 175, 177,
Neil’s classification of lateral throat preliminary casts 6, 17, 25, 243, 245 197, 198
form 3 preliminary impressions 5–15 seating the tray 44
neuromuscular control 199, 209, premylohyoid eminence 10 selecting teeth 73
210, 213 processing error 51, 139, 150–153, selective grinding for esthetics 132
“neutral zone” 112, 132 182–184, 187, 191, 248 selective pressure technique 28
pterygomaxillary seal 1, 2, 5, 6, 10, 13 semiadjustable articulator 100,
o prepackaged impression material 6 241, 242
occlusal equilibration 175, 191, 193, preprosthetic surgery 1 separating impressions from casts
200, 201 presses 112, 144 220, 222
occlusion rims 51–56, 66–69, 81, 83, pressure indicator paste (PIP) 39, 169, separating medium 139, 141, 142,
85, 87, 111, 200, 201, 234, 245 170–172, 175, 191, 211, 236, 250 220, 222
“orange peel appearance” 113, 134 processing setting articulators 63, 67
organizational chart of representative “processing error” 51, 139, 150–153, setting teeth 73, 76, 99–109, 111, 206
molds 76 182–184, 187, 191, 248 setting time 5, 10, 41
overdentures, advantages, protrusive relation record 175 S‐shaped curve 10
disadvantages 229 pterygomandibular raphe 1, 2, 10 stippling 112, 113, 115, 134, 165
pterygomaxillary notch 5, 6 stock trays 5, 6, 8, 17, 245
p pumice 5, 159, 175, 177, 219 superior constrictor muscle 2
packing 47, 115, 139–150, 187, 195, “punched‐out” appearance 111 surgical stent 247–250
205, 235, 250 styrofoam tray 5
palatal relief chamber 1, 2 r
palatal seal 3, 13, 14, 17, 21, 28, 30, “rabbeting” 220, 223–225 t
36–38, 45, 115, 116, 125, 134, rare earth magnets 229, 236 Take 1TM bite registration material
135–136, 170, 171, 199, 203–206, red rope wax 5, 7 67, 245
211, 244, 254 “refractory patient” 240 tempering bath 5, 28
palatal torus 45, 170, 203, 205, Regisil® 67 tempering thermoplastic materials 5
206, 208 registration index 69, 71 temporalis muscle 2
papillary hyperplasia 1, 2, 199, 206, relief chamber 1, 2, 232, 233 thermoplastic materials 5
209, 210 remount casts 105, 106, 175–186, 191 third point of reference 59, 63, 64
patient remount 170, 199, 210, 248 remount index 151, 152, 155–157, 169, tissue conditioner relines 243, 250,
periphery wax 5–7, 10, 12, 13 175, 177, 179, 183 253, 255, 261
permanent soft liners (silicone remounting casts 130 tongue exercises 253
elastomers) 213, 214 repairs 73, 74, 199, 203, 204, 207, 208, tooth repairs 73, 74, 199, 203, 204, 207,
planes: horizontal, sagittal and 211, 215, 217–227, 232 208, 211, 215
vertical 6, 67 Reprosil® 50ml cartridges torus, tori 1, 2, 45, 135, 170, 171, 199,
plaster/pumice mix 47–49 resorption 1, 2, 14, 111, 129, 130, 132, 203, 205, 206, 208, 250
Playdough (Play‐Doh) 215 170, 199, 203, 204, 208, 213, 226, 227, transfer analog 234
polishing 159, 163, 165, 166, 224, 268 229, 242, 250 trays 5–8, 11, 17–23, 25–39, 231,
polishing lathe 159, 162 retarder 5 243–245, 263–265, 267–269
polishing materials 5, 223 retromolar pad 1, 2, 5, 6, 13, 14, 21, 55, treatment planning 5
polyether 56, 69, 76, 111, 123, 124, 126, 197 Triad® TruTray™ VLC Custom Tray
polymethylmethacrylate 263 retromylohyoid eminence, Material, Dentsply Triad Denture
polysulfide rubber base 41 retromylohyoid space 6, 10, 119, Base Material 17, 19–22, 51–53, 76,
polyvinylsiloxane 41, 43, 179, 215, 217, 202, 203 77, 115, 140, 215, 234, 244
219, 220, 222, 233, 263, 265, 267 reusable plastic trays 5 trimming casts 6, 47, 50, 139, 142
296 Index
trimming flash 257 vertical dimension at rest (VDR) 125, 234 wax try‐in 79, 111–113, 123–134, 210,
trimming impressions 44 vertical dimension of occlusion (VDO) 241, 247
troubleshooting 199–214 79, 123, 125, 152, 210, 234, 247, 263,
Trubyte® Tooth Indicator‐Dentsply 266, 267 z
International 75, 76 vestibule, vestibular depth 1, 3, 6, 10, zero‐degree teeth 76, 92, 93–97,
tubercular fossa 10, 12 12, 17, 18, 21–23, 25, 28, 29, 43, 50–52, 99–102, 104, 112, 123, 125, 151, 152,
two‐tray impressions, two‐tray method 55, 56, 81, 82, 89, 111, 113, 124, 131, 154, 169, 182, 197, 198, 200, 206, 207,
244, 245 172, 200, 204, 210, 243–245 210, 246
vibrate the impression 14 ZEST Anchors, Inc., LOCATOR®
v Attachment System
vacuum spatulas 9 w ZnOE Bite Registration Paste 67
vermillion border waxing instruments 47, 49, 123

2 Treating The Complete Denture Patient

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2 Treating The Complete Denture Patient

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Treating the

Complete Denture Patient

Carl F. Driscoll, DMD

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Library of Congress Cataloging‐in‐Publication Data

Set in 9.5/12.5pt STIXTwoText by SPi Global, Pondicherry, India

1 The Diagnostic Appointment 1

3 Custom Trays: The Key to a Great Final Impression 17

4 Using Custom Trays to Make Final Impressions 25

5 The Final Impression 41

6 Boxing and Pouring a Final Impression 47

7 Base Plates and Occlusion Rims 51

8 Adjusting Wax Rims to Fit the Patient 57

9 Using the Denar Facebow 59

10 Mounting Maxillary Casts on an Articulator 63

11 Centric Relation Records 67

12 Selecting Proper Denture Teeth 73

13 Setting Anterior Denture Teeth 81

14 Setting Posterior Anatomic Teeth in Bilaterally Balanced Occlusion 85

15 Setting Zero‐Degree Posterior Teeth in Monoplane Occlusion 93

16 Overview of Lingualized Occlusion 99

17 Setting Teeth in a Lingualized Occlusion 105

18 The Anterior Esthetic Wax Try-In 111

19 The Complete Denture Wax-Up 115

20 Sealing Complete Dentures to the Cast 121

21 The Wax Try-in of Teeth 123

22 Making an Arbitrary Posterior Palatal Seal in the Lab 135

23 Interacting with Dental Labs 137

24 Flasking, Packing, and Processing Complete Dentures 139

25 Completing a Laboratory Remount 151

26 Making a Remount Index 155

27 Remove Complete Denture from the Cast and Finish 159

28 Quality Standards in Appearance 165

29 Inserting Complete Dentures in the Mouth 169

30 Performing a Clinical Remount 175

31 Equilibrating Dentures Set in Lingualized Occlusion 187

32 Equilibrating Fully Anatomic (30°) Set‐Ups 191

33 Equilibrating Complete Dentures Set in a Monoplane Occlusion 197

34 Troubleshooting Complete Denture Problems 199

35 Replacing Teeth on a Complete Denture 215

36 Repairing a Broken Complete Denture 219

37 Using Implants to Stabilize a Complete Denture 229

38 Immediate Complete Dentures 239

39 Tissue Conditioners 253

40 The Fabrication of Digital Complete Dentures 263

List of Captions 271

­About the Companion Website

Don’t forget to visit the companion website for this book.

The Diagnostic Appointment

Figure 2.1 Place a denture in an edentulous tray to determine

material used to modify and support the tray in these criti-

memory to return to the arch form relatively quickly.

Figure 2.9 Use sweeping strokes make a smooth and creamy

Figure 2.12 Manipulate the frenula and lips by muscle

available close by. The lower impression should be done

Figure 2.18 Seat maxillary trays while standing behind the

Figure 2.17 Use moist fingers to distribute and smooth

Figure 2.21 Ask nauseous patients to lean forward to minimize

­ terygomaxillary seal, and posterior palatal seal area

About the Companion Website

terygomaxillary seal, and posterior palatal seal area

ardening before it is placed in the mouth and while still

4.3 Prepare the Surface of

5.2 Making the Mandibular

5.3 Making the Maxillary