CD Lec 8 - Try-In, FB, RX, Processing, Insert, Adj 2023 PDF

10/4/2023 Try-in, Processing Polishing, Insertion and Adjustment, Laboratory and Clinical Remount Troubleshooting Roxana Hashemian, DDS, MPH RS522 ~ 10/4/23 10/4/2023 Sequence of Patient and Lab Visits α Preliminary Impressions Custom trays α Final Impressions Record bases & Occlusion rims...

10/4/2023 Try-in, Processing Polishing, Insertion and Adjustment, Laboratory and Clinical Remount Troubleshooting Roxana Hashemian, DDS, MPH RS522 ~ 10/4/23 10/4/2023 Sequence of Patient and Lab Visits α Preliminary Impressions Custom trays α Final Impressions Record bases & Occlusion rims α Intermaxillary Records Tooth Set-up α Trial Denture Processing & Laboratory Remount α Insertion Clinical Remount = 10/4/2023 Analog Try-in ? ESTHETICS PHONETICS Does the PATIENT like the way it looks and sounds? Does it LOOK and SOUND the way it should? THE TRIAL DENTURE CR VDO Does it WORK the way it should? 10/4/2023 Digital Try-in ? ESTHETICS PHONETICS FIT Does it FIT the way it should? Does it LOOK & SOUND the way it should? Does the PATIENT like the way it looks & sounds? THE TRIAL DENTURE VDO CR Does it WORK the way it should? 10/4/2023 TRIAL DENTURE (Tooth Try-in Visit) INTEROCCLUSAL RECORDS • OCCLUSAL PLANE recording • OCCLUSAL PLANE confirmation • VERTICAL DIMENSION recording • VERTICAL DIMENSION confirmation • FACEBOW REGISTRATION recording • FACEBOW REGISTRATION preservation (lab) • CENTRIC RELATION recording • CENTRIC RELATION confirmation • TOOTH SELECTION recording • ESTHETICS / PHONETICS confirmation FIT Final Impression if digital • 10/4/2023 Trial denture check list: • • • • • • VDO? CR? Phonetics? Esthetics? Digital Denture: FIT? Patient Approval Signature? (EDR) 10/4/2023 VDO Evaluation Freeway space (“M”) Closest speaking space (“S” ) • • • • • • The Freeway Space is the space between the teeth when the mandible is at rest (VDR) VDO occurs during swallowing VDR occurs at the end of swallowing The mandible moves upward from VDR to VDO traveling a distance of about 2-3 mm • • The Closest Speaking Space is the smallest space between the occlusal surfaces of opposing teeth during speaking pronouncing sibilant sounds Opposing teeth should not contact or click during sibilant “S” sounds. If teeth touching => occlusion is excessive, If A & C correct => Adjust areas B & D If A & C incorrect => correct them and adjust B & D accordingly Engage the patient in conversation so they are relaxed and not self-conscious Space of Donders (SOD) Inter-ridge space • • • • • • Space of Donders: the space between hard palate & dorsum of tongue at rest. ↑VDO (teeth too tall) → ↑Space of Donders Cantor Curtis JPD 1971 Overextension can impair manipulation of food, initiation of deglutition, and speech ↓VDO (teeth too short) or too thick denture base→ ↓Space of Donders Underextension leaves little space for the tongue and can create difficulty in swallowing When natural teeth are in occlusion, anterior ridge crests are a minimum of 12mm apart and posterior teeth are a minimum of 1-2mm apart 10/4/2023 VDO? Confirmed by Top •swallow •esthetics •phonetics Increased vertical will result in a Stretched appearance Decreased vertical will result in Overclosed appearance VDO VDR 10/4/2023 Correction of VDO •First evaluate and assess the problem(s), Is VDO excessive or insufficient? •Confirm that CR intraorally = CR on Articulator •Then correct VDO chairside •Extensive correction may require an additional trial denture visit or a new interocclusal record •If CR is not correct, retake CR and remount •If neither VDO nor CR are correct you need to remove teeth, place wax rims, create proper VDO and retake the interocclusal record 10/4/2023 10/4/2023 Set-up Evaluation on Articulator 2/3 RMP Anterior Reference Esthetic Zone Max Incisal Edges Posterior Reference Occlusal Plane of Mand Teeth 10/4/2023 Continuing on with Trial denture check list: • • • • • • VDO? CR? CO? PHONETICS? ESTHETICS? PATIENT SIGNATURE? 10/4/2023 Why make dentures in Centric Relation? Independent of tooth contact Clinically discernable Clinically reproducible 10/4/2023 CR? Initial CR taken with Aluwax without rims touching Confirmed by intra-oral check-bite with Aluwax; teeth must not touch Comparison made w/ articulator 10/4/2023 Rules of Denture Occlusion Verify CR in patient’s mouth AND articulator • • • • No anterior contact in CO No incisal guidance in Protrusion No canine guidance in Lateral CO (MIP) = CR 10/4/2023 What if there is a discrepancy between the CR on the articulator and in the patient’s mouth ? • • • • • Look for even space in the posterior teeth bilaterally Look for a shift in the record bases when approaching CR This patient’s CR is incorrect How did this happen? What should we do next? 10/4/2023 How to correct CR Place Aluwax on lower denture and take new CR intraorally. Upper denture is already mounted with FB. CORRECT CR MOUNTING NEEDED FOR PROCESSING Invert articulator. Key lower denture/Aluwax into upper at slightly increased vertical. Since teeth do not touch. Lower cast has already been cleaved from its original incorrect mounting. Stabilize lower cast and trial denture. Remount lower trial denture Aluwax removed and pin adjusted to correct VDO. 10/4/2023 Edge-to-edge Acceptable? Y/N? Cross-bite Acceptable? Y/N? 10/4/2023 Check for movement Check for Heel Interference Majority of problematic dentures, at tooth try-in or insertion, involve anterior open bites If there is a heel interference in the patient mouth relieve it, retake the CR, and remount the lower cast 10/4/2023 Trial denture check list: • • • • • VDO? CR? PHONETICS? ESTHETICS? PATIENT SIGNATURE? 10/4/2023 Phonetics • Labial Sounds (“B”, “P”, “M”) – Eval A/P position of anteriors – Eval labial flange thickness • Labio-dental Sounds (“F”, “V” – Fricative Sounds) – Eval A/P position of anteriors – Eval occluso-gingival position of anteriors • If too high, then F≈V • If too low, then V≈F “F” 10/4/2023 Phonetics • Dento-alveolar (“Th”, “T”, “S”, “D”, “N”, “Z”) – Th – Eval tongue position between incisal edges • If incisors >3mm visible; teeth too labial or too long • If incisors <3mm visible; teeth too lingual or too short – T, D – Eval A/P position of anteriors – If too lingual, then T ≈ D • If too labial, then D ≈ T – S – Eval length & overlap of anteriors • If Anterior or Posterior teeth touch… excessive VDO • If whistling – Anterior overlap or Posterior width too narrow • If lisping – Anterior open bite (or insufficient overlap) or Posterior width too wide “S” “Th” 10/4/2023 Phonetics • Palatal (e.g. “onion”, have little influence) • Velar (“K”, “G”, “NG”, teeth have no influence, but posterior palatal thickness does) • Lisp: “show” instead of “so” – maxillary posteriors set too wide • Whistle – maxillary posteriors set too narrow 10/4/2023 Trial denture check list: • • • • • VDO? CR? PHONETICS? ESTHETICS? PATIENT SIGNATURE? 10/4/2023 Esthetic Evaluation • Add diastemata, overlap, restorations, wear facets as needed • Compare with photographs if available • Invite other opinions, such as spouse or close relative or friend before processing 10/4/2023 How accurate are we? 10/4/2023 Compare? 10/4/2023 Trial denture check list: • • • • • • • VDO? CR? CO? PHONETICS? ESTHETICS? FIT? – If digital try-in PATIENT SIGNATURE? 10/4/2023 Trial denture check list: • • • • • • VDO? CR? CO? PHONETICS? ESTHETICS? PATIENT SIGNATURE? 10/4/2023 1. 2. 3. 4. Yellow Card Consent Esthetic Approval 2 Sigs 10/4/2023 Set –up & Wax-up completed Your set –up is completed, with perhaps some refinements. Wax up, facebow preservation, and lab rx will be done today in SLC Reminder: Final project due November 1 10/4/2023 Facebow Registration Facebow Preservation 10/4/2023 Facebow Registration Relates the maxilla to the condyle Facebow record 10/4/2023 Facebow Preservation relates the upper denture to the condyle by preserving the facebow registration position on the articulator Facebow record 10/4/2023 Facebow preservation relates the upper denture to the condyle by preserving the facebow registration position on the articulator Upper tooth impression preserves relation of upper arch to condyles Minimal indentation will prevent locking 10/4/2023 ? REGISTRATION PRESERVATION CLINICAL REMOUNT WHERE? Patient Articulator Articulator HOW? Bite fork & Blu-mousse Paper cup & Plaster Face Bow Preservation WHY? Relate Maxillary Record Base to TMJ Relate Maxillary Set-up to TMJ Relate Maxillary Denture to TMJ 10/4/2023 Facebow Preservation • Preserves relationship of maxilla to articulator after maxillary cast is lost during processing • Permits mounting of maxillary denture without a new Facebow Registration • Saves chairside time. 10/4/2023 Preparation for Processing And what we would like your final project (due Nov 1) to look like 10/4/2023 The occlusion should be checked after the wax-up is complete because the teeth can shift during wax up or FB preservation 10/4/2023 The exposed crowns must be free of wax 10/4/2023 The Incisal Pin must contact the guide table at the proper VDO. The pin setting must be sent to the lab. 10/4/2023 Bases must be sealed/luted to casts around entire border 10/4/2023 1 2+3 4 8 Required items for a legal work authorization: 1. 2. 3. 4. 5. 6. 7. 8. Date Lab Name Lab Address Patient Name Dr’s Name Dr’s License Number Dr’s Signature Instructions 8. Instructions We will write in class today 5+6 7 10/4/2023 Complete Denture Processing - Analog The “Lost Wax” Technique or “Pack & Press” 10/4/2023 Steps in Traditional Denture Processing Flasking: wax-up is placed in flask filled with plaster investment to make a mold Boil out: wax-up & record base are softened to permit removal from mold Packing: mold is filled with acrylic & closed under pressure Curing: mold is slowly heated in water tank to160° for 9 hrs, then slowly cooled De-flasking: cured denture & its cast are removed from the investment Lab remount: denture on cast is returned to articulator to √ for processing errors De-casting: denture separated from cast by sacrificing cast to prevent fracture of denture 10/4/2023 Flasking Flasking Flasking Flasking Boil-out Curing Boil-out Boil-out Boil-out Packing 10/4/2023 De-flasking De-flasking Lab Remount De-flasking 10/4/2023 LAB REMOUNT • Dentures are keyed into their notches and replaced on their original mountings 10/4/2023 Key in the v notches on the master cast to the mounting plaster 10/4/2023 Processing errors may occur which can change VDO (VDO may increase as much as 1-2mm raising the pin) Dentures are adjusted during the Laboratory Remount only until pin touches table at original pin setting 10/4/2023 Laboratory remount During lab remount, we attempt to restore the VDO to what we had before processing, as long as VDO does not change more than 3mm during processing Look for heel Interference Most common Where do you grind? 10/4/2023 Grinding upper may result in perforation and loss of suction Contacts generally occur in posterior… 53 10/4/2023 Selective grinding stops when pin hits table VDO is restored 54 10/4/2023 Lab Remount Summary • After processing & deflasking, while dentures still on cast. • Must request on RX. • Corrects for processing errors, expansion and tooth drifting ONLY until original VDO is reestablished 55 10/4/2023 DECASTING Casts are strategically cut away from the dentures to prevent their fracture 10/4/2023 Recovered denture Select a bur based on the desired contour Finishing 10/4/2023 √ X Removing flash, smoothing borders Your view of the borders is important Do not over trim Border must remain full thickness √ X 10/4/2023 Polishing High speed Wet rag wheel Do not linger Do not use coarse pumice Wet flour pumice Do not press hard Do not polish the teeth Slow speed Low shine Pumice 10/4/2023 Polishing Rouge Luster shine Dry wheel Dry material Dry denture High speed High speed High shine material 10/4/2023 NEVER Polish the intaglio surface 10/4/2023 Insertion 10/4/2023 Insertion Insertion is a three-step visit Adjust the intaglio surface of the denture Adjust the occlusion through clinical remount Re-Adjust the intaglio surface of the denture, (if needed), further 10/4/2023 Insertion Sequence • Adjustment of the intaglio- upper alone • Adjustment of the intaglio- lower alone • Insert U/L w/o occluding • CR verification – rehearse / record • Mount lower • Clinical Remount- refine occlusion • Re-polish • Review home care instructions • Reappoint for 1st post-insertion adjustment 64 10/4/2023 Insertion Sequence • Adjustment of the intaglio- upper alone • Adjustment of the intaglio- lower alone • Insert U/L w/o occluding • CR verification – rehearse / record 65 10/4/2023 Insertion Adjusting the intaglio surface Pressure Indicatin g Paste Sorensen’s paste (PIP) (Disclosin g Wax) For the intaglio For the borders 10/4/2023 Insertion Evaluating and Adjusting the borders and flanges for overextension with Sorenson’s Paste Applied thickly to borders w/ a tongue blade Note “show through” in border paste due to overextension 10/4/2023 Insertion Adjusting the borders with Sorenson’s Paste Sorensen’s applied to lower border & border molded intra-orally 10/4/2023 Insertion Adjusting the intaglio surface 10/4/2023 Insertion Adjusting the intaglio surface Areas that touch tissue Areas that did not touch tissue (can still see brush marks) Areas of show-thru (over-compressed) 10/4/2023 Insertion Adjusting the intaglio surface 10/4/2023 Insertion Adjusting the intaglio surface 10/4/2023 Insertion Adjusting the occlusion Why?… Processing errors Isn’t the lab remount enough?… CR record 10/4/2023 Insertion Adjusting the occlusion The most accurate CR record is the one made on the insertion appointment 10/4/2023 Insertion Adjusting the occlusion In the mouth…? …on the articulator? Occlusion affects retention, stability, and fit of the denture, as well as the health of the underlying tissue 10/4/2023 Insertion Adjusting the occlusion In the mouth… …on the articulator Intaglio brushed with PIP Courtesy of Drs. Wayne Harris and Steven Morgano 1970 10/4/2023 Insertion Adjusting the occlusion Each arch tried in separately. Show thru’s noted and adjusted Courtesy of Drs. Wayne Harris and Steven Morgano 1970 10/4/2023 Insertion Adjusting the occlusion Dentures then recoated and pt asked to occlude Courtesy of Drs. Wayne Harris and Steven Morgano 1970 10/4/2023 Insertion Adjusting the occlusion New show thru’s (in different locations due to occlusion and unstable denture bases Courtesy of Drs. Wayne Harris and Steven Morgano 1970 10/4/2023 Insertion Adjusting the occlusion Comparison of results: Without Occluding Not in occlusion In Occlusion In occlusion Courtesy of Drs. Wayne Harris and Steven Morgano 1970 10/4/2023 Insertion Adjusting the occlusion Without Occluding Not in occlusion In Occlusion In occlusion In Courtesy of Drs. Wayne Harris and Steven Morgano 1970 10/4/2023 Insertion Adjusting the occlusion …on the articulator Clinical remount 10/4/2023 Insertion Adjusting the occlusion Clinical remount 15 clinical remount 1 had sore spots 30 patients 15 no clinical remount All had sore spots 10/4/2023 Clinical Remount 10/4/2023 Before clinical appointment: 1. Remount casts are made Common undercut areas Bockout with Mortite 2. The maxillary denture is mounted using the face bow preservation index 10/4/2023 DECASTING Remember that there is no cast, for clinical remount you must make new casts using the intaglio of the dentures 10/4/2023 The maxillary denture is mounted using the face bow preservation index – before the clinical appointment This saves: Your time Chair time Patient time 10/4/2023 Clinical Remount @ Patient Appointment… CR Record 10/4/2023 Clinical Remount Mount the lower denture 10/4/2023 Insertion Before you Adjust the occlusion Double-check that the articulator = the patient “Measure twice… cut once!” 10/4/2023 Insertion Adjusting the occlusion Adjust the Bullseyes only, not the Smudges 10/4/2023 Clinical Remount – when? Conventional Denture Immediate/Interim Denture • @ insertion • @ subsequent adjustments • NOT @ insertion • @ subsequent adjustments – If occlusion caused sore spot/s – If occlusion is the cause of patient CC – – – – When tissue no longer swollen And then again: If occlusion caused sore spot If occlusion the cause of pt CC 10/4/2023 Post Insertion Adjustments – when? Conventional Denture Immediate/Interim Denture • 48 hours • 1 week • • • • • • PRN (as needed) 24 hours 72 hours 1 week 1 month Monthly for 6 months until ready for definitive tx 10/4/2023 Post Insertion Adjustments – how? 1. Listen to and carefully record patients chief concerns 2. Ask pertinent questions about how the denture has been worn, what the diet has been and look for clues to the problem 3. Carefully inspect the denture and the mouth for more clues 4. Make your diagnoses and use pastes, Dr. Thompson indelible pencil etc. to confirm and adjust 10/4/2023 Post Insertion Adjustments Armamentarium • Sorenson’s Paste- peripheral seal & borders (use after denture is seated, unless there is trouble seating it) • Pressure Indicating Paste (PIP)- cohesion • Indelible pencil- Post Dam marking pencil - small area checks. If you can see the sore spot, mark it and adjust it. • Articulating paper- occlusion and heel interference • Your skill and patient’s input 95 10/4/2023 Post-insertion adjustment Sore spots Indelible pencil Thompson’s stick Sorenson’s Paste 10/4/2023 Post-insertion adjustment Sore spots PIP Paste Pterygomandibular Raphe 10/4/2023 Insertion & Adjustment Checklist Before Insertion During Insertion Lab remount Polish Prepare U/L remount casts Mount upper w/ FB Preservation Adjust upper Adjust lower Rehearse CR Record CR Clinical Remount Polish & clean Review Home care Reappoint for 1st adjustment After Insertion Listen to patient Evaluate occlusion Evaluate tissue Evaluate retention Evaluate home care 10/4/2023 Home Care Instructions 3 page document On On Blackboard RS522 RS532 RS642 RS522 10/4/2023 Troubleshooting 10/4/2023 Diagnosis of Post-insertion Problems  Sore Spots  Burning Sensation  Tongue and Cheek biting  Tissue Redness  TMJ Pain  Instability  Interferences  Esthetics  Phonetics 10/4/2023 10/4/2023 Almost all complaints have an Occlusal component Clinical Remount helps minimize occlusal complaints 10/4/2023