TOOTH SELECTION.pdf

Good morning. My goodness. Good morning. And how is everyone today? So I'm in a quandary. I've seen a very disconcerting trend of people coming in and taking attendance and then turning around and walking out. So at some point in time today, I'm going to be taking a second attendance. I just want to...

Good morning. My goodness. Good morning. And how is everyone today? So I'm in a quandary. I've seen a very disconcerting trend of people coming in and taking attendance and then turning around and walking out. So at some point in time today, I'm going to be taking a second attendance. I just want to see how many what the difference is between first attendance and second attendance. I mean, if you don't want to be here. Why go to dental school? Right. Okay. Today we're going to be talking about to selection esthetics arrangement. And we have a two part discussion on denture occlusion. We'll start with denture occlusion, meaning how we manage anterior teeth that will begin to play a role in our posterior denture occlusion. So as we always do. If this is this too bright for you, I'm going to tone down the lights a little bit. It's kind of blinding for me. Okay. So as we always do. We're going to show you where we are in the scheme of things. We're still in into maxillary records. There's a lot to do in inter occlusal records. I use the term inter maxillary inter occlusal records interchangeably. The prosthetic gods would like me to actually change over to the term inter occlusal records. And so I, I there's a place here where I neglected to change this to inter occlusal records. But wherever you see that term, inter occlusal inter maxillary is interchangeable. And the, the term inter occlusal is the preferred term. So we're at tooth setup. Of course, then we do the trial denture process or mill or print lab remount and then insert. We've adjusted our rims for video at Inter Occlusal records, Facebook registration centric relation, record tooth and denture based selection patient photos. So this is all that takes place at Inter Occlusal records, and we're at tooth and denture base selection today. So goals for a successful venture. We talked about what made a successful venture in terms of the recognition of the anatomy, the musculature, managing occlusion and managing esthetics. And so here we are in the esthetics and occlusion portion comfort function and esthetics. So occlusion is in function and of course esthetics comes into play. So how we achieve these goals. It takes a village. It really does take a village of information, patient information, accurate patient records, clinical records, clinical exam, what we know and what we're going to collect from our data, our clinical requirements and patient expectations. There is an expression. Expectation minus reality. Equals. Disappointment or excitement and and you know a successful denture. So really there's we have to balance expectation and reality and communication is the key between expectation and reality because that's what balances the two pieces of information. So patient information. So we'll go through all of those steps. There's lots of things that we need to gather, lots of things that we use. We may not be able to use everything because it might not be there, but we and we can piece together. It's sort of like a mystery sometimes, especially if patients come in with no teeth and no denture. And so we need to read the anatomy. We need to read the landmarks. We're looking at things like face shape. We certainly can get a lot of information from the hi smile line, canine distance, the appearance of an individual, whether you're going to be setting teeth in a very rugged manner or a very soft manner, the patient's complexion. So their skin tone, their eye color will lend itself as we're choosing shades for our teeth and choosing not only shades for the teeth, but denture based shades. Again, if the patient has all dentures, we're going to use those old dentures to give us information, useful information, whether or not the patient likes their old dentures. So if they like the old denture, then that's great. We can potentially use that old denture. We're going to learn the term reference denture technique where you can literally use that exact denture, making impressions, using that, that denture taking a bite, using that denture and copying that denture, of course improving or tweaking whatever we need to do, but we can utilize that denture as the framework to build the next denture. But then again, you can also use that denture what not to do for the next denture. So it's important that we learn from what the patient has and we use it or we don't use it. Old photos. And when you ask a patient to to bring in old photos, you know, they're like, well, I don't know if I have old photos, but then when you say, Well, how about a graduation photo? How about a wedding photo? So those momentous occasions, they typically do have old photos, old radiographs. If the patient has been a patient of yours or the practices for a long time and we can see whether or not the patient had diastolic data, what classification the patient is. And so we can use that information to help us when we do set up old casts. And again, if a patient has a significant other that does provide information or does give a lot of feedback to that patient, then perhaps you would want that significant other. Or you can ask the patient if they want that significant other when it comes time to selecting teeth, but not only selecting teeth but doing the tooth trying because the last thing you want is the patient to go home with a brand new set of dentures. And then the first thing you know they hear is, Oh my God, what happened to you? You know, or something like that. So, you know, you don't want the first time for for anyone to see these teeth and then have a very strong opinion. So significant other may play an important role in that patient's opinion of their selection. Things like. So now you're going to look at the clinical examination. Things like the condition of the ridge is going to play an important role in our selection of our teeth, particularly the posterior teeth resorption. And we're going to go we're going to see exact examples. So I'm just giving you a list at this point. Resorption of the bone. So how much how much resorption has taken place on the ridge? The quality of the bone, the shape of the ridge will tell us where we're going to put the teeth and the vertical height of the ridge, the health of the tissue. Certainly we're not going to embark on a denture until the tissue is healthy. Otherwise, if we have any tissue changes, you know, the fit of the denture is paramount patient neuromuscular health. So if a patient is. Not doing well neuromuscular and we have a difficult time in capturing centric relation or the patient has had some severe periodontal breakdown and we have difficult time capturing centric. We may not necessarily want to select perhaps a fully anatomical posterior tooth because that locks a patient into a certain occlusal scheme and that might be very limiting for that patient, for example, if a patient has Parkinson's. So you might want to give that patient a little bit more freedom in terms of movement, where when you are restoring their dentition movement of the tongue and renal attachment. So that we addressed when we talked about final impressions, capturing the movement of the tongue and final attachments so that it doesn't interfere with the seating and the passive seating of the denture itself. Saliva, certainly saliva as we talked. Plays an important role in not only the retention of the denture, but the comfort of the denture. So if a patient is zero stomach and and their tissues are burning, they are going to have a dreadful time holding dentures in their mouth because they're they're uncomfortable to begin with and then sitting a denture on top of that. And patients of functional habits usually have play a role in the denture dislodging. Clinical requirements. We first have to have well fitting record bases and occlusion rims. If we don't, our records are not going to be correct if if the record bases are uncomfortable for the patient, if they're overextended. Do you think that we are going to be able to capture a centric relation that is accurate? If the patient is uncomfortable and the patient is not relaxed in in in terms of when you're trying to capture centric, do you think the patient is going to be able to perform and be able to put their tongue to the roof of their mouth? If you put your tongue to the roof of your mouth and slide it back again, this is a neuromuscular position, okay? If the record base is overextended and you ask a patient to put their tongue to the roof of the mouth and it's overextended on the lingual, what do you think is going to happen with the record base? It might lift and if it lifts and you're trying to capture centric, what do you think is going to happen? It might wind up in an inaccurate position. So. Well, fitting record bases, correct video if your video is off. In other words, if you if you have excessive video, maybe even excessive to the extent that you have three millimeters excessive and you're trying to capture centric relation with excessive video, do you think that centric relation will be accurate? No, because what will happen? Will the patient be in centric relation? Will the patient be in rotation? No. So there's a chance that if the patient is in excessive video, the patient might actually be starting to translate a bit. So we have to be very careful that we are within the range of vertical dimension that we we need to be in order to capture centric relation. Okay. Now we do have a second chance to verify vertical and to verify centric, and that's going to be our trial denture our tooth trying so that if we aren't 100% accurate, we can verify and make corrections. But who wants to not be accurate? Okay, So we have that opportunity. But it would be nice to be as close as possible to 100% accurate as we can when we're capturing it for the first time. Right. Canine lines and midline. We're going to drop them down. Those are going to be our key witnesses to the position of our centric relation. We may even add, remember another pair of lines, our centric lines. So we'll have five sets of lines that when we rehearse the patient, those five lines are going to line up so that when we add our looks and place it in the patient's mouth, dead, soft, sparkling, the patient closes down, those five lines are going to line up again. And then we know that the patient has rehearsed it. They've done it at least a half a dozen times. You know, where it's supposed to be. And those lines are going to line up again. And so you're pretty accurate that the only way at this point that centric is going to be off is that something has happened between the time that you've recorded centric and you've mounted it on the articulator. Maybe something happened during the mounting, and that's a possibility, too. Okay. So. Um, other things we're going to look at. Hi, smile line inter pupillary line today. Okay, so let's start by looking at the midline. This is a patient who has had a denture in her mouth for a number of years and. Take a look at the midline. Initially, the patient did not like the appearance of her existing denture, with the midline appearing skewed. To one side of her face to the right side of her face. So we went ahead and this is at Tooth Tryon. We went ahead and straightened up the midline. And she looked at herself and she said, Oh, that's so weird. Right, she said, because the midline is actually appropriate to her face. But she wasn't used to her appearance. Interesting. We say the mid-line comes from the face, but we also obviously want feedback from the patient. So it took her a couple of tries to decide whether or not she wanted that midline center to her face. And what really threw her was the lower anterior teeth were natural. And so originally, if you can see her midline, which was matching her lower anterior teeth, which we usually don't do because the lower anterior mid lines are usually not accurate, Lower anterior teeth have a tendency to rotate and shift, and they're typically not indicative of the facial midline or incisive papilla or anything like that. Okay. So now what happens is we shift her midline over to the face and now it's off between her lower natural teeth. And that's what really threw her. So the important thing is when we do when we do these corrections, obviously it's not unilateral. It's a conversation between yourself and the patient. Okay. So make sure you have a thorough discussion with your patient. If they don't care. And believe it or not, some patients don't. Most patients do, but some don't. And then you use your best judgment. And my suggestion is it comes from the face. It doesn't come from any intra oral landmark. Here is another patient who went from natural dentition to denture. And with this patient, her midline natural midline was skewed to the left and she wanted it corrected to her face. And she was happy with this correction. Okay. She went with of course, this was an immediate denture and so it wasn't like she had the opportunity to do a try in. Fortunately the immediate denture and we'll talk about immediate dentures in a number of weeks from now but the the immediate denture, interestingly enough, the setup brought the teeth back to where the incisive papilla was so her natural teeth had shifted from that. So it's not a reliable, always a reliable intraoral landmark. We go by the face always and patient conversation. Patient discussion. Okay. So that's her whole face. Canine lines in many, the width of the six anterior teeth and the width of the nose are about the same and maybe as wide, however, as the inter pupillary line. So it depends on the shape of the arch and the shape of the bone. Okay, so here we have the basically the height of contour of the canines and pretty much the width of the width of the nose or the alias of the nose. Okay. But it can be as wide as the inter pupillary line here. You can see in profile all the way back. So when you're looking at a patient, you're you're basically making your decision based on the height of the canines. This line is a little skewed, sorry, based basically on the height of the canines, not on the distal of the canines. And that's going to play a role in how you measure. Okay. Another way of determining how wide your canines are is if you have canine eminences remaining on your cast, if you can see them, you can record them and transfer those lines onto the land. After you transfer the line onto the land, you can then move those lines back onto your wax. Okay? And it's those lines that can be measured for the actual canine to canine distance, okay? Because you can't measure it on the cast because you have to certainly add for how much lip support the wax is going to provide. But again, what you're doing is you're basically measuring the height of contour and then adding a couple of millimeters to go from distal of canine to distal of canine. Okay. Patients do love to provide you with photos with them in big smile, especially if they kind of miss their teeth and want to go back to how they look. Especially, you know, if they have unusual tooth setups, as these individuals did have. And of course, these were small photos that they kind of sent to me. And so showing these to you, which they've given me permission for, is a, it's hard to blow them up without them pixelated. But, you know, we have a tendency to we want to try to do these types of setups for these patients so that they're they feel very, very comfortable with their new teeth. But again, patient expectations, if you give them this perfect little setup it, you know, they have a denture smile and not their own smile. And what they're looking for is their own smiles back again. The nice part about having digitally fabricated dentures now is that we can take these photos, superimpose them on the teeth and bio copy, even a photo like this to get them the setup that they're looking for. So we can we can certainly copy what they've had in the past and it's certainly easier to give them what they've had in the past because that's what bone they have remaining versus trying to give them something unnatural like taking a class three or a class two patient and making them a class one. Which a lot of times you're asked to do and it's almost impossible to do. So this is a setup that, again, we've superimposed on top of someone's previously positioned natural teeth and we can kind of tweak and morph and resize and reshape and give them exactly the tooth setup that they've had. And you'll have the opportunity to do exactly just this in the middle third of the course when we do our digital component. Incisal edge contour, incisal edge contour is going to be pretty important, especially not only for esthetics but also for phonetics. It's our fricative sounds and we want the incisal edges long enough so that it mimics the lower lip. Here's a patient, a young woman, who came in with an older denture and she noticed that her teeth were appearing shorter. And she also had kind of what we call a reverse smile line. So our canines now were longer than her incisors, and it gave her kind of a denture smile. We call these the reverse smile line. And so we just did a very subtle change. In her appearance and obviously new teeth. Doesn't doesn't it helps but we took the centrals and laterals and brought them down to follow the contour of the lower lip and brought the the canines up. Now, if you actually measured this on a plane, on an occlusal plane, you'll find that it is probably flat against the occlusal plane. But just the just the idea of how the setup is. And it follows her lower lip. It gives her that smile that she's looking for, and it also restores her phonetics. So we study smiles a lot. We study natural smiles a lot because our dentures should represent what the patient has because there's no reason why it shouldn't. We talked about hi smile lines and for the most part we smile to the C J's, we smile to the J. Sometimes we have unnaturally lower smiles and sometimes we have much higher smiles. And those are these are the easiest ones to restore because you hardly see the anterior teeth and these are the hardest ones to restore. So. But what you need to be calm is a student of esthetics and looking and learning as much as you can about natural tooth setups, looking at the teeth on how they relate to the lower lip, how the smiles and what fills the frame and what fills the smile. Many denture programs scanners now allow you to scan the smile so that you can then incorporate it into the virtual tooth setup program and then combine the two for for your tooth setup. So our two selection criteria. In the anterior. We need to know the shape, the size and the shade. And we're going to cover that in just a minute. In the posterior, we have to decide the cusp height, the length of the tooth and the width of the tooth, the material. We have to decide whether it's going to be plastic, IPN or porcelain. And for the most part, we don't use plastic or porcelain anymore. So the decision is pretty much done for you. For a denture, it's going to be IPN, which is basically it is a Pmma product, but it's a much harder Pmma product and it combines the the best of both of plastic. It combines the nondestructive properties of plastic with the beauty of porcelain. And other factors as we talked about earlier, with form, face form, arch form, tooth form, occlusion, rim and shades. Okay, so record bases and occlusion rim, your rim is your prescription after. Now, you didn't really do a whole lot of adjusting on your occlusion rim in terms of contour. You did for vertical dimension, but not necessarily for contour, meaning lip support and lip support is very important. Lip support not only changes the esthetics, but it can change phonetics as well. But primarily it is the number one reason why patients feel that their dentures are either too bulky or not supportive enough either why patients feel like they see too much teeth or they don't see teeth at all. It is. It is what is behind the drape of your lips. So as I mentioned, I think it was last week, pretend I'm on a stage with a curtain in front of me. Okay. And I the curtain right now is not touching me, but the curtain reaches the floor. If I step forward on that curtain, what I'm going to do is shorten that curtain and my shoes are going to peek out from the bottom of the curtain. Okay, So I'm going to make that curtain a lot fuller and you're going to see the bottom of my shoes or the bottom of me. Okay. And the same thing will happen with occlusion, rims and with teeth. The more bulky your occlusion rims are, the more facial your occlusion rims are. The higher your lip comes and the more teeth, the more incisal edge you're going to see at when your lips are at rest. So it kind of gives you kind of a very full appearance. Either cotton rolls under the lip or just sort of Bucky appearance. Okay. And a lot of patients don't appreciate that. On the other hand, patients who have lost a lot of bone, who have lost a lot of lip support, sometimes we add a lot of wax in this area to give them that support. Okay. Patients that have perhaps a lot of extra skin or tissue and have a lot of wrinkles want to have a little bit more support here so that, you know, the wrinkles smooth out just a bit. So that's how we utilize this wax and we adjust the wax until the contours are appropriate for our patients face before we send the wax either for to set up or before we scan the wax for a virtual two setup. Conversely, if I'm standing all the way back to the curtain and I'm not touching the curtain at all without any contact whatsoever, you might not see teeth at all. And patients may not like that either. So you have to find a balance. But when your rim is done and when you've taken centric and when these are either ready to be sent for analog setup or scan for digital setup, the rim is the final product. It is exactly where you're going to be setting your teeth. It's it's a prescription. That's exactly where the teeth are going to be. This is how you communicate with your laboratory, whether it's whether it's analog or whether it's virtual. Okay. So what are some of the things that we need to see on the rim? We need to see the midline. We need to see canine lines. We need to drop the midline and the canine lines down to the mandibular rim. Because when you if you're the one to do the mounting, your laboratory needs to make sure that these lines line up. Because if they don't line up and you're sending them something with the line skewed, how confident is your technician going to be that your mounting is correct? Okay. So that's what I said. You've got to have those three or even five sets of lines. I don't know if you can see it, but there's another set of lines here. So your five sets of lines have to line up coming out of your patient's mouth and on your articulator or on your scan. If they don't line up, it doesn't leave the building or it doesn't leave your office. Okay. Because if your technician gets it, they're going to be, hey, you know, I'm not setting teeth on this because I'm not confident that your centric is correct. So we've got a high smile line. You're going to ask the patient to smile big. And if the patient doesn't smile big, you're just going to ask the patient to lift their lip as high as it goes. Because at some point in time, when they leave your office, that lip is going to come up and you want to see how high they raise their lip so that you're going to be able to measure how high that is so that you'll be able to select the appropriate tooth for that area. Okay. These are your centric lines. And so here is your patient with all of these lines inside. The midline, as we said, comes from the face. The smile line will give us the length of the centrals and the canine lines, either one half the ala to medius this line right here or the mid pupillary line. And you can decide really what looks the best. Or the canine eminence on the cast. So any one of these three ways you're looking at your patient and you as you look at your patient, you're going to say, hm, where where do the canines look best within the frame of your patient's face, just like you're deciding where the midline is. You're going to say, Where do my canines look? The bit, the height of contour of the canines, Where do they look the best in terms of the patient's face? So you want to consider each side separately? Right. And then when that happens, the line that you've drawn. Let me back this up for a second. The lines that you've drawn for those canine lines are going to fall at the height of contour of the canines. Okay. Because when you look at someone, it's really the height of contour of their canines. Okay. Then what you're going to have to do. Is you're going to wind up adding a couple, three millimeters on either side to get the actual distal of the canine to the distal of the canine distance. So how do we do this? So now we have all of our measurements. So some of this is subjective, right? Some of this is once we get the subjective onto the wax rim, then we take out our ruler and measure. Okay, so we have our lines. The height of our hi smile line. Is on this case is approximately 10.5mm. Okay? The range of the teeth that are available is generally between 9 and 12mm. But the average person will have approximately a ten millimeter central incisor on average, ten, 10.5, 9.5, somewhere around there. Okay. But the teeth that we're using run anywhere from 9 to 12mm. As far as the canines go, we usually measure from the midline to one side and add that couple three millimeters and then the midline to the other side and add the couple three millimeters. Okay. Now, when we do that, you have your ruler. So this is this is the ruler that we've given you. When you see the ruler, you're going to see a couple. You're going to see a couple of things on the ruler, but there's going to be a range on the ruler from about 42mm to about 58mm. And there's going to be an alphabet. They're starting from the letter B to the letter J, and that represents the molds that are available proximately the smallest mold that's available is 42mm from canine to canine. And the largest mold that's available is approximately 58mm from canine to canine. Okay. Represented by letter B, So 2222 B is the smallest mold and 42 J is the largest mold. And those are they're not exactly arbitrarily assigned in terms of those numbers. Those numbers actually mean stuff. And you're going to be receiving a portfolio of a tooth, our tooth mold portfolio today where you're going to see all of the molds that are available. I'm going to have some slides of it on here now to show you how to use it. So once we have this, we're going to measure hi smile line on this patient is ten millimeters and then we're going to measure one side to the canine and then the other side from midline to canine. Usually they're a little bit different, maybe a millimeter off on that side, and then we double it. So one side is 25mm. We double it as 50. The other side is 26mm. We double it. That's 52. And the reason why we do it is because we want to have a range for when we're actually opening up the mold guide and we're picking some teeth. So we have ten millimeter length of centrals, 50 to 52mm on a curve. Now, what do we do with this information? If we take a look at our studies, there's been studies upon studies looking at face shapes and tooth shapes and arch form shapes. The shape of a patient's face is commonly used as a reference to select teeth, whereas the shape of the central incisor is approximately suggested to be similar to the patient's face only turned upside down and loosely related to the arch form. The validity of this has not been absolutely proven in studies, but there have been a number of studies that have embarked on doing so. So what this basically tells us is that people over the years have been seeing this correlation of face shape to tooth shape to arch form. And so that's what we go by now. We're not just square and square tapering and tapering and ovoid, but those are the four basic face shapes. In addition to that, we've also kind of subcategories people to much more so that, you know, if you read any kind of magazines and you're looking at things like selecting glasses or selecting haircuts, you know, they're going to talk about all these different kinds of face shapes which might be conducive to selecting one pair of frames or a certain haircut over another. But basically this helps us narrow down our choices. Again, if you're starting from scratch and you don't have a preexisting denture that the patient loves, bless you. Or if you have a denture that the patient hates, and yet you look at the denture and it looks like a tooth that would absolutely not match a patient's face. And all of a sudden you say, I know how I'm going to fix this. So, for example, if the if the patient is a very tall individual with a very long ovoid face and there's a small square little tooth in the denture, you might say, huh, maybe I can suggest a better, you know, a different tooth that will kind of go with the face and go with the person's size a lot better. So we open up our mold guide. So this is a mold guide. This is the book of teeth, and then this is the mold chart. And this chart matches what's what's in the guide itself. So our mold guide has a complimentary shade guide to go with it. This is a dense ply sirona tooth and so this is a dense plaster to mold guide and shade guide. And then this is the book of teeth or the mold chart that goes with it. And as you may be able to read, we have this divided into face shapes. So we have the first five is square, then we have square tapering, square, ovoid tapering, tapering, ovoid, ovoid and then square tapering ovoid. And you can we have from here down and then across here, these are all our lower anteriores and then these are posteriors. Okay. So if you open the book, this is what it looks like. Here we have. I've just selected two molds. And these two molds. Why did I select the two molds? Because, remember, we're working on a case right now that has a ten millimeter length of central with canine to canine of approximately 50 to 52 ish millimeters on a curve. And so what I did was I selected two molds. The patient's face is square ish to square tapering. And so I kind of went into this book and I well, I looked at the patient. I mean, there are certain molds that I like to use. I mean, after a period of time, you know, you just kind of get to know the molds after a while. So there's some favorite molds that I like. But basically I picked two molds with similar numbers, but one in the square and one in the square. Tapering. So I have more of a square tooth and one with a square bottom, but the neck is a little bit more tapering. Okay. Now how can I tell? So here this gives me my information. So all of these numbers mean something. My first number gives me the length of the central. My second number gives me the width of the central. My third number gives me the canine to canine distance. One is flat on a piece of paper or on the card. And the second number is on a curve. And that's what we're looking for. We're looking for the canine to canine on a curve. Okay, because they're never flat. So I'm looking at these numbers and that's how I picked this mold and this mold. 12 G and 22 G. And notice that the G's are similar. Why? Because the G means it falls on the scale or it falls on the ruler in the 51 52 millimeter width. Right. So these GS represent the width. This is 51. This is 53. Again, this is blown up just a little bit. So here's the mold. Here's an E mold. This is a 9.3. Length 8.1 width. And then this is the canine to canine distance on a curve or flat. So first, what I'm going to do is I'm going to compare the two molds, especially where know if I'm not sure one or the other, I can put it on my wax so I can look at my two mold choices and I could look at the guidelines on the occlusion rims and see if it works. Okay. So I could just pluck them right out of the guide and see if it works, if it works. And I still am kind of undecided. And also I like to offer my patient choices is we have a what they call a rim selector kit, or you can just simply use some wax is I'll set up both molds on my kit. Right here. I'll put one mold on one side, the three teeth and one on the other side. And without the occlusion rim in the patient's mouth, I'll slip it under the lip. And I'll get a feel for what it might look like under the patient's lip. So you notice that the square is very square, and I don't see much into dental papilla. In other words, it doesn't taper quite as much as the square tapering. So I will be seeing more inter dental papilla on on this side. Plus, this tooth is a little bit longer than this one. So, you know, again, you obviously have to do a lot more than just one set to say, aha, you know, I'm going to be really quick on this and make this decision. But, you know, I see sometimes students will take the mold guide from the dispensary and say to the patient, open up the mold guide and put it on their lap and say, okay, which one do you want? And that's a little bit daunting, you know, because I can't imagine, you know, and all they focus on is the color of the teeth that's in there. And they're like, Oh, I don't like this color. And of course, the the color of or the shade of the teeth and the mold guide is, I think like C one or C two. So patients kind of freak out. So you want to help the patient and kind of guide them to what you think. Kind of similar to selecting a shade. Yes. Question. I don't know. Yeah, then that's fine then. Then you can select what you like better and let them know why you selected it. Absolutely. But the thing is, when you're communicating with the patient and you're letting them know why you're selecting it, then the patient feels like they're involved and then they're part of the process and they will accept it better, especially if this is their first venture or one of their first. You know, this is a real hard pill to swallow, you know? And so keeping getting them part of the process is really important. I see a hand? Okay. I saw it on here. It's so hard. I'm so blinded by this. Yeah. They need to be modified or trimmed down or. Yes, yes. So digitally we can modify it easily. Virtually. Okay. If you want to make modifications on an analog setup, you take a handpiece and make modifications. Here in the SSC. When we do our setup, we're going to make no modifications whatsoever. Okay. So lower a.s how do we pick those? Well, that's easy. We just go by what is suggested on the chart. So when we go back to the chart, okay, for example, we picked 11 G and then you see this block, this dark block right underneath 11 G where it says R, So that's your lower mold. And if the patient is a class one, then we go with because all the lower anterior we'll see that in a second. All the lower interiors pretty much look the same. Some are longer, some are shorter. But on average, if the patient's a class one, we're going to go with what the what the chart recommends us to go with. Okay. Now here. 12 G. I don't know why. On some molds they have one suggestion, some molds. They have two suggestions and some molds. They have three suggestions. Sometimes they suggest it because some individuals may have no resorption, a moderate amount of resorption, a tremendous amount of resorption. So if that's the case, then if a patient has a lot of resorption, then you might pick a longer mold. So that when it goes into the denture, you see a longer tooth because if you pick a tiny little tooth and then you have all of this denture base, it might look like baby teeth. And then some patients don't like that, especially when their natural teeth were very long. Okay. So again, you can have that conversation with the patient or if you think it's appropriate to select the longer tooth and that's what you do. But this is most of the time you go with the average tooth that is recommended on the chart. Okay. Now, the only time that you so seriously, these all look the same to me. Small, short, medium and long. The only time that you go with a different width of. So this is narrow, medium and wide. Also because it's going to match the maxillary anterior teeth. The only time you might go off chart. Is if a patient is a class two or a class three. A class two. Meaning if the patient's mandible is smaller than the maxillary arch or if the patient's mandible is wider or larger than the maxillary arch, Why? Because you need to fit more. You need to fit the same amount of teeth in order for it for the cusp to line up at some point in time. So if the patient's a class two, you'll select a smaller mold. And if the patient's a class three, you'll select a larger mold so that the posterior teeth start in the same position. Okay. Makes sense. Okay. Posteriors. Let's see. Posterior. Let me see where we are. All right. Two more slides and then we'll take three more slides and we'll take a break. Posterior teeth come in different cusp heights. Okay, so we have zero, ten, 20, 22, 30, 33 and 40. When do we pick those teeth? Well, I'll tell you in just a minute. The teeth themselves, when they come from the lab, the anterior teeth come in cards of six. So the anterior teeth sit on wax and plastic cards of six. Some of the anterior teeth, some of the really, really high end anterior teeth come in cards of two. So especially if you're restoring a partial denture and all you need are 1 or 2 teeth. Okay. The posterior teeth come in cards of eight. So today you're going to receive a full set of teeth. You're going to get two of the anterior one maxillary, anterior, one mandibular anterior, and then an upper and lower set of posterior teeth. Yes. Yeah, it's more expensive. Much more expensive. Yeah. So the usually a full set of high end teeth that we would be putting in the the teeth that we use in our treatment center is approximately 150, $175 for an arch. For an arch. The teeth that we're utilizing in the sslc are just like about $10 for the full set. So we love you, but it's not going in anyone's mouth. Okay. All right. So how does this work? So this is the back page of your this is the back page of your your chart and first column right here. These are your upper molds. So right here is your 12 G, right? The next column is your lower molds. Lower anterior molds. Right. So again, if you're picking 12 G, this is the the lower anterior mold. You can pick G, R or V or anyone that's there, but this is the recommended lower. Sorry. No. Okay, then from here, all the way over. These are all columns of the posterior teeth. So starting with non anatomical, semi anatomical and anatomical, depending on what posterior tooth we choose, you can just read down the column and you literally pluck it off. There's no conversation. So if you want to zero degree tooth and you're doing a 12 G, we're going to pick a 634 If you want a fully anatomical tooth and you're doing a 12 G, you just pick a 34. And, you know, it kind of depends because it's all proportional to what the maxillary anterior teeth do. So the rule of thumb for posterior teeth is. This this upper series of pictures, this, this and this represent the lower ridge, the flatter the ridge. The bottom represents tooth cusps, the flatter the tooth. So if the patient has a robust ridge, they are an acceptable candidate for a cusp tooth. They are an acceptable candidate for a for a cuff to patient has severe, severe resorption. We're going to go with a flatter cusp or no cusp whatsoever. And we're going to have lots of conversations about that. But this is just rule of thumb. So I'm kind of giving you the the universal rule before we talk about why and how and all of that so flatter the ridge, the flatter the tooth. Okay, let's take a break. Come back in ten. So it's five of five of nine. Come back at 9:05. Hi. Good. How are you? Okay, let's get started. Ready posteriors. So as I alluded to earlier, residual ridge is an important key component of what we are. What will help us decide on on a posterior occlusal scheme? The flatter the ridge, the flatter the tooth. Arch relationships also play an important role. Class one twos and threes, cross bites, bruxism power, functional habits. These are all. Key elements that one will one will utilize in order to decide whether we're going with a fully anatomical tooth, a semi anatomical tooth or a neuroscientific or monoplane or flat plane tooth, Patients. Health. Neuromuscular coordination. Patients experiences with old dentures. So if a patient had a fully anatomical. Dentition in their old denture and was very successful in wearing it, we typically give them back the same occlusal scheme. If a patient has an anterior overbite, so managing over bites are challenging. And that's why we say we're looking at what the anterior teeth are going to look like in terms of how we manage those because we don't want something like incisal guidance in a denture occlusion because just incisal guidance without balance in the posterior, we're going to learn something new. We can't have a natural occlusion, a natural occlusal scheme in a denture. So whereas in natural dentition we're looking for Incisal guidance, we're looking for canine guidance, we're looking for mutually protected occlusion. Those terms don't exist in denture occlusion at all. Okay, we are. And in natural occlusion we have, you know, we do have centric relations sometimes, but for the most part we have MIP. And so but in denture occlusion we do not. So we have to kind of rethink what we know and compartmentalize denture occlusion very differently. So let's take a look at the classifications of complete denture occlusion. On one hand, we have an anatomic occlusion where the teeth interdigital much like a natural dentition. On the other hand, we have a non anatomic occlusion, which is a flat tooth against a flat tooth on a flat plane going from one spectrum to the other. We have kind of a a dentition in the middle that sort of meets all the criteria of what we're looking for with a nice compromise. We have intercourse fading and we have non intercourse fading. Obviously the flat plane on a on a flat and a flat on a curve and even to a certain extent a semi anatomic legalized which is non intercourse just fading is not really non interfering with a patient who has severe resorption. The nice part about the semi anatomic lingual occlusion, however, is that it is opposing an arch that has a semi anatomic tooth which contributes the esthetic component to the setup. So we have a monoplane tooth upper and lower here, flat against flat, but we have a flat tooth against a semi anatomic tooth up here on our lingual ised option and the semi anatomic tooth contributes to the esthetic component. Of of the setup. There we go. The esthetic component of the setup. Okay. So what we're going to be doing is we're going to be doing a setup. We're going to be learning about three. We're going to be learning about all this, all these setups, but we're going to be doing a setup beginning today that is going to look very much like this, a 20 degree tooth on the maxillary arch opposing a monoplane tooth on the mandibular arch. Then when we get to the digital setups, we're going to be spending a lot of time on a lingual eye setup that will have a 20 on the maxillary arch with a ten degree on the mandibular arch. And we'll also spend a lot of time with anatomic occlusions so that we get to learn occlusion. Now, the reason why we're doing at least one setup analog is not so that you can become lab technicians. The reason why we're doing this is because when you get out there in practice and you are doing a denture if you so choose and you do have a setup. To work with and you have to make small changes to your teeth. You're not afraid to take a hot smoking spatula and make those changes. Okay. You also will be able to get a setup back from your laboratory and evaluate it and understand what you're looking at and be able to make those assessments and have that dialog with your technician. Because at no time you ever want to be able to or you ever want your technician to really know more than you, you and your technician are partners in providing providing this restoration to your patient. And then when we get into the virtual environment, you're going to be able to learn more about occlusion. When we're working with the lingual eyes set up with a ten degree lower and then a fully anatomic setup, we're going to see what it means to have what we call bilateral balance. Okay, We're probably not going to be able to get bilateral balance with the setup that we're having today. But what we're going to have is we're not going to have guidance and we're going to show you how to create that. Yes? Question. I don't know. What does it mean? Lower jaw, then lower teeth will. What does. When I. Stay tuned. Next slide. Okay. Lingual eyes occlusion. What does that mean? The concept is very simple. You can basically you can take any anatomical denture tooth. Okay. And lingual eyes, the setup. Okay. Basically, what a lingual occlusion means is that the maxillary arch has more of an anatomical tooth or semi anatomical tooth. The mandibular arch is flatter to no cusp at all. Okay. So what you have is. You can take if this started off as anatomical, what you have is a flatter mandibular tooth so you can flatten out this lower tooth. Then you take your buckle cusp and rotate it upwards. Now we're not asking you to do it because there are teeth that are manufactured just for this purpose. So if you want to do a lingual eyes setup, what you would do is you would procure a maxillary tooth that had a steeper cusp and a mandibular tooth that had a shallower cusp. When you set it up, the maxillary tooth's buccal cusp would then be turned upward so that the buckle cusp is non interfering. So as you can see, here's an example of a 20 on the upper, a ten on the lower. Here's an example of a 20 on the upper and a zero on the lower. And the only thing that's in contact is the lingual cusp. Hence lingual occlusion. So only the lingual cusp is in contact, not the buckle cusp. The lingual cusp becomes the main functional cusp that when you chew food, it's twitchy like a mortar and pestle. Okay, so only one cusp is contacting as opposed to an anatomical occlusion where everything is locked into place so that when the patient moves side to side, there are lateral shear forces involved. And if the if the setup isn't perfect, you can start putting too many forces on the ridge, moving that denture and banging into the ridge. And if there is no ridge, then the denture moves off the ridge. The nice part about lingual occlusion is that with only one contact without the buckle cusp in contact, there's more freedom of movement so that it doesn't push that denture side to side and off the ridge. Okay, so there's more flexibility with from centric to eccentric. Okay, so the buckle cusp is a non interfering cusp. So lingual ized occlusion works when the options are you have a steeper cusp on the maxillary arch and a shallower cusp on the mandibular arch. The most common combinations are ten and 20 on the maxillary arch and zero and ten on the mandibular arch. We're working, we're going to be starting to work with 20 on the maxilla and zero on the mandible. Okay. So now in terms of going back to selecting. Our teeth and when and where? The flat or the ridge. The flat or the tooth. So monoplane or zero. All of these terms are interchangeable. Monoplane zero rational resort bridges versus excellent ridges, class twos or class threes. We typically go with a monoplane tooth, though if you're using a lingual eyes concept like we are, you can use a monoplane tooth like we are and satisfy the patient who's a class two or a class three. So every time I talk about monoplane, you can also substitute monoplane slash lingual ized if you're using a zero degree lower tooth. Okay. So that, you know, satisfies both components. It satisfies the need for substituting the zero degree tooth because of some of these problems, cross bites and bruxism and debilitation. But it also provides the esthetic component that a semi anatomical tooth will contribute on the maxillary arch. I have here. When in doubt And when might you be in doubt is when a patient is transitioning from teeth to no teeth and you're trying to capture a centric relation by on a patient who has severe periodontal disease and tooth lost and tooth loss and you're trying to fabricate an interim or an immediate denture for this patient. We'll see some of those examples when we have that lecture on immediate and interims. On the other hand, anatomical might be used in addition to the excellent reJ if a patient has natural opposing teeth. So you're restoring one arch, but the opposing arch has natural dentition when you're looking for bilateral balance. And we'll talk about that next week. Yeah, next week. Severe over bites when we can't reconcile again bilateral balance, improved esthetics. I'm not so sure anymore. Only because of what we can do with lingual ized occlusion these days and previous denture experience chewing efficiency. Again, many studies have set out to prove that chewing efficiency is better with cusp teeth. But you know when with patient satisfaction studies. So, you know, they've they've been doing in vitro studies for chewing efficiency. But then when you ask patients to do to to chew little packets of gauze and peanuts and you provide them with monoplane versus lingual eyes versus anatomical, there's very little difference between lingual and anatomical in terms of chewing efficiency. Okay. Any questions before we move on? Yeah. Yes. Yeah. Asked about. Well, I. And using our dentures, correct? Yep. What about. I. We can't get into that now. Maybe next next semester, Next year, when we do third year. You know, the next course. Okay. Available with. So again, in the in the posterior, I just go off the charts. But as I mentioned, the numbers in the charts do have some meaning to it. So, for example, as I mentioned, if you were going to pick that 12 G mold and you were going to pick an anatomical tooth, the tooth to select is 34. And what that means is basically the measurement between the distal of the canine all the way back to where you're going to stop setting a tooth. And generally, the averages just work. But what I wanted to show you was where they got those numbers from, basically. So there's your measurement from measured from the distal of the cusp to the rise of the ramus of the mandible, which is basically where you're going to stop setting teeth. On the other hand, the M stands for medium, meaning an average amount of resorption versus L, meaning a longer tooth or s meaning a shorter tooth. And that just has to do with the the the length of the tooth and how much tooth is going to be exposed from the occlusal plane down to the residual ridge. Okay. Denture tooth material. As I mentioned, the the the material of choice is IPN and IPN basically stands for inter penetrating network. It's a really fancy term for a really good Pmma or poly methyl methacrylate. And it just shows you just the comparison between the old Pmma, the acrylic and porcelain. Some of these some companies are starting to make denture teeth not only from IPN or high end Pmma, but also composite, and that's totally fine as well. So we basically go with what the the high end tooth selection tooth molds that are being offered to us today. But porcelain is really being phased out for are just straight on dentures, the removable dentures, nothing that's implant supported, no hybrids and, you know, things like that. Okay. So these are just removable dentures with with no implants. With nothing. The teeth in terms of retention devices in a denture based acrylic. A number of years ago until fairly recently, until we began to print and mill our dentures, denture teeth popping out of dentures was very, very common. Okay, so some companies, especially those that produce porcelain teeth, devised ways to keep teeth in dentures. And so the porcelain teeth had pins coming out of their teeth, the anterior teeth. And still to this day is far as the posterior teeth go. They have little pockets or holes in on the bases or the ridge lap. This area of the denture tooth is called a ridge lap. The holes are called dietary fix. And that would add not only to the mechanical retention because a tooth is retained in a denture base via chemical retention because the denture tooth is also, like I mentioned, the IPN is Pmma. Now if the denture tooth is made out of the composite resin, as I mentioned, it would definitely need to have a dietary and some technicians would go right before processing and create those holes with the undercuts in them in order to create increase mechanical retention for that tooth so that there would be additional help and bonding to the denture base acrylic denture tooth opposing combinations. So again, we used to need to worry much more than we do today because the iPads and the composites are a little bit stronger, but combinations within the denture again years ago because the the plastic teeth were began to become unsightly very quickly. They would stain many technicians would place porcelain on the anterior for esthetics and plastic on the posterior, which was the worst combination you possibly could do because porcelain and plastic would obviously wear at different rates. And so what would happen is if you had porcelain on the anterior plastic on the posterior, especially in this situation, let's say, where the patient's lower interiors were enamel, the the plastic and the posterior would wear, the anterior would not. And what would happen is all that extra pressure would transfer to the underlying bone and you would get increased pressure, increased movement and resorption of the underlying bone. So we have to think about the combinations and the long term effect of poorly chosen combination ones. Okay, This is a moving denture out of porcelain and these are the patient's lower anterior teeth. The problem with having porcelain teeth in a denture in addition to having porcelain against porcelain but porcelain against enamel. And you'd have to make an adjustment in occlusal adjustment is that you cannot polish porcelain in a denture. You just can't. Even with porcelain polishing pastes. ET cetera. If you break the glaze on a porcelain denture tooth, you really can't ever get back the glaze initial the initial glaze that comes out of the card of tooth. And so over time, we attempt not to have occlusion in the anterior, but things happen. You know, we fabricate a lower partial for a patient and then the patient just doesn't wear their lower partial. So we have to protect the underlying bone. And that's why we've just with with the replacement of plastic teeth, with IPN and high end composites, we've stopped using porcelain teeth for those reasons. All right. Shades, tooth and denture based shades. The denture based shades come in, multiple shading, depending on if you're going analog or if you're going digital. It. It does have compatible shades. It even has customized shades if you want to have pigmentation in the denture bases as well. So photographs work wonders in order to transfer that information to the technician. Shade guides should match the mold guides that you're using. So when it comes time for you to start getting your first patients, we will show you what we have in shade guides and guides, where to find them and what you're going to be selecting in terms of what you're going to be doing. Most of your shades are going to be coming out of your dense ply portrait shade guides. You'll be probably getting these as a gift from dense ply sirona If they continue doing this every year, which so far they've been doing. But all of this is available at the dispensary and you'll have your mole charts and your mole guides and your shade guides to boot. Again, when you're picking shades, very similar to when you're picking molds. I like to use a skin tone, the eye color, and I like to pick 2 or 3 shades that I think might be appropriate to the patient and then show it to the patient. Again, I don't I wouldn't necessarily give this whole shade guide to the patient on their lap. Patients usually run for this and then, you know, you do the trying and it just, you know, sometimes it just doesn't work out. But if a patient wants Spider white, then the patient gets covered or white. Look, it's their teeth, right? So. Okay. There will be an order form that will need to be completed and we'll show you how to complete the order form. But basically, you're ordering cards of six on the maxillary arch and cards of eight on the mandibular arch. Just a little heads up. We we circle the teeth that we're ordering, the denture base shade, the cusp height. So all of this information goes in to the order form. Arrangement of the teeth. The sequence is a little bit different if you're setting up a monoplane or our lingual ized with monoplane lowers, then if you're setting up an anatomical setup. But. Comparing both sequences. We always start with the maxillary anteriores because that's our. That's, that's the money set up. That's the esthetics. That's phonetics, right. It sets the arch form for us. And what I'd like to do is point out to you and this is going to be in your portfolios today, what I want you to do is learn how to read the bone. And basically you shouldn't be reading the bone at this stage. You should be reading the bone before you create your occlusion Rim because your occlusion rim should mimic the shape of the underlying bone and then you follow through with your tooth setup. So your bone, your tooth setup should follow the occlusion rim, which should have followed the the underlying bone. This is an example of an arch form that is square. So as we mentioned, we've got arch forms that are square, square tapering just like we have teeth and they should be fairly consistent, square tapering and ovoid. Notice the difference. This is much more rounded. The Centrals are typically a little bit more ovoid in setup and a much more tapered arch form. Look at the difference between these two Centrals and let's say your square centrals. So your square, your centrals and laterals come straight across your square tapering, your laterals begin to turn your tapering, it starts to taper right at the Centrals. So your Edentulous Eddy is a square tapering setup. So your square, your centrals are going to be square, but your laterals will already take the curve. Okay. So follow the bone and this is what we're going to follow. Square tapering. Again, the rim is your prescription. You can either do one of two things. I know the video that you watched. I'm going to show you both ways. The video that you watched set the two centrals first, then the two laterals and then the two canines. I like to establish my midline first. This is going to show you setting one side first, but we're going to see both ways. Okay. So you've already seen two Centrals, two laterals, two canines. This is. Setting one side at a time. You can remove your wax. You don't have to remove all the wax. Let's go back for one second. You. This removes all the wax down to the record base. I would leave a little bed of wax as you begin to remove. You can do that with your two centrals or again one side, but leave a little bit of wax in which to