- Email: [email protected]
Combination syndrome: A treatment approach
KLEIN
DISCUSSION The ideal impression can best be accomplished by using zinc oxide-eugenol paste in a tray that is produced from a tissue-placement preliminary impression with proper physiologic borders. The effects of tissue placement and possible distortion should be eliminated from the formed impression tray. A heat-processed clear acrylic resin tray undergoes less warpage than the autopolymerizing materials and permits visual observation of ischemia caused by excessive loading. The use of holes provides venting to minimize displacement by the final impression material. The quality of the secondary impression will depend on the incorporation of these features into the secondary impression tray. The secondary impression material cannot be expected to compensate for inadequacies in the tray. The advantages of this technique are: 1. Reduction of the amount of time necessary to complete a satisfactory impression because border molding is unnecessary 2. Elimination of potential pressure spots before the impression material is inserted 3. Close approximation to physiologic and anatomic ideals 4. Preservation of residual ridge because of reduction of excessive displacement. Roberts” stated, “The making of impressions for full dentures is an important step in denture construction because good impressions contribute to retention, stability, and comfort of finished appliances. They are the foundations on which we build our dentures and, as such, merit our best effort.”
SUMMARY A technique has been described with which a physiologic and anatomic registration of the attached and unattached tissue of the denture-bearing areas can be attained. Clear acrylic resin trays aid in eliminating excessive displacement at the secondary impression phase. Inadequacies of the mucostatic concept include:
Combination
syndrome:
AND
BRONER
1. Failure to register the tissues, which are important for retention and stability 2. Certain metal bases that are part of this procedure can be implemented by only a small number of technicians 3. Increased cost There are two shortcomings of the tissue-loading technique for complete denture impressions. 1. Resulting retention and stability lasts only for a short period of time. 2. Unwanted ridge resorption and tissue changes occur. REFERENCES 1. Picton DCS, Wills DS: Viscoelastic properties of the periodontal ligament and mucous membrane. J PROSTHET DENT 40:263, 1978. 2. Fournet SC, Tuller CS: A revolutionary mechanical principle utilized to produce full lower dentures surpassing in stability the best modern upper dentures. J Am Dent Assoc 23:1028, 1936. 3. Boucher CO, Hickey JC, Zarb GA: Prosthodontic Treatment for Edentulous Patients, ed 7. St. Louis, 1975, The CV Mosby Co, pp 133-158, 184-213. 4. Sharry JH: Complete Denture Prosthodontics, ed 3. New York 1974, McGraw-Hill Book Co, pp 191-211. 5. Heartwell CM, Rahn AO: Syllabus of Complete Dentures, ed 2. Philadelphia, 1974, Lea & Febiger, pp 157-178. 6. Montieth BD: Management of loading forces on mandibular distal-extension prosthesis. J PROSTHET DENT 52:673, 1984. 7. Page HL: Mucostatics-A capsule explanation. Chronicle of the Omaha District Dental Society, April 1951, p 195. 8. Addison PI: Application of mucostatic principles to full denture construction. NY J Dent 17:135, 1974. 9. Applegate OC: The partial denture base. J PROSTHET DENT 5~636, 1955. 10. Klein IE, Goldstein BM: Physiologic determinants of primary impressions for complete dentures. J PROSTHET DENT 51:611, 1984.
11. Roberts AL: Principles of full denture impression making and their application in practice. J PROSTHET DENT 1:213, 1951. Ke,twint requests to: DR. IRA E. KLEIN 19 WEST 44~~ ST. NEW YORK, NY 10036
A treatment
approach
Stephen M. Schmitt, D.D.S., M.S.* USAF
Medical
Center,
Keesler Air Force Base, Miss.
The views and opinions expressed herein are those of the author and do not necessarily reflect the views of the U.S. Air Force or Department of Defense. *Major, USAF (DC); Assistant Chairman, Department of Prosthodontics.
664
T
reating patients with edentulous maxillae and a partially edentulous mandible is a common occurrence. Many times only mandibular anterior teeth remain (Fig. 1) and specific degenerative changes are often seen. NOVEMBER
1985
VOLUME
54
NUMBER
5
COMBINATION
SYNDROME
Fig. 1. Patient with edentulous maxillae and remaining mandibular anterior teeth. Fig. 2. Fit of framework is corrected in mouth with disclosing wax. Fig. 3. Corrected master cast. Fig. 4. Casts are mounted on articulator with interocclusal centric relation record. Fig. 5. Record base with artificial teeth in mouth. Fig. 6. Record base with modeling plastic and cusp-sulci ridge.
Kelly’ noted five destructive changes that occur in these patients: (1) loss of bone from the anterior part of the maxillary ridge, (2) overgrowth of the tuberosities, (3) papillary hyperplasia in the hard palate, (4) extrusion of the lower anterior teeth, and (5) loss of bone under the removable partial denture bases. He called these changes the combination syndrome. THE JOURNAL
OF PROSTHETIC
DENTISTRY
Saunders et al.2 described six changes that may also occur. They are ( 1) loss of vertical dimension of occlusion, (2) occlusal plane discrepancy, (3) anterior spatial repositioning of the mandible, (4) poor adaptation of the prosthesis, (5) epulis fissurata, and (4) periodontal changes. They felt that the basic objective in treating these patients was to develop an occlusal scheme that would 665
SCHMITT
Fig. 7. Frontal view of cusp-sulci ridge and mandibular setup. A, Cusp-sulci ridge and mandibular teeth in centric relation position. B, Right lateral position. C, Left lateral position. D, Adjustment of mandibular right denture tooth.
discourage excessive occlusal pressure on the maxillary anterior region in both centric and eccentric positions. Saunders et a1.2 also stated some specific treatment objectives. (1) The mandibular removable partial denture should provide positive occlusal support from remaining natural teeth and have maximum coverage of the basal seat beneath the distal-extension bases. (2) The design should be rigid and provide maximum stability while minimizing excessive stress on remaining teeth. (3) The occlusal scheme should be at the proper vertical and centric relation position. (4) Anterior teeth should be used for cosmetic and phonetic purposes only. (5) Posterior teeth should be in balanced occlusion. This article describes a treatment approach that attempts to minimize the destructive changes noted by using the treatment objectives of Saunders et a1.2This approach is indicated for patients who are aware of their present dental condition and want to reduce the inevitable resulting destructive syndrome. 666
RATIONALE The prosthesis is made in two stages using a modification of the complete denture construction technique described by Meyer.3-6 The mandibular removable partial denture is completed first. The tooth position, cusp height, sulcus depth, and marginal ridge position of the mandibular teeth will be determined using a cusp-sulci analysis. The completed mandibular removable partial denture is then used to construct a generated wax occlusal path. This path will be used to create the occlusal surfaces of the maxillary teeth. The maxillary denture is completed and delivered to the patient. Acrylic resin teeth are used to replace the maxillary anterior teeth because they abrade more rapidly than porcelain and tend to reduce stress concentration on the maxillary anterior ridge. Cast gold occlusal surfaces are made for the posterior denture teeth. Gold is used because it does not abrade readily, can be accurately cast to a multitude of tooth forms, and can be modified easily. NOVEMBER
1985
VOLUME
54
NUMBER
5
COMBINATION
SYNDROME
Fig. 8. Duplicated mandibular teeth with cast metal occlusal surface. Fig. 9. Completed mandibular removable partial denture.
TECHNIQUE Accurate casts are made and evaluated. It may be necessary to mount them in an articulator to diagnose the need for preprosthetic surgery or treatment of malpositioned teeth. The mandibular cast is then surveyed and the framework design carefully drawn on the cast. This serves as a guide for clinical tooth preparation as well as laboratory fabrication of the framework. If only six anterior teeth are present, incisal rests are usually required on the canine teeth. Cingulum rests are generally not used because the enamel is thin over the cingulum of mandibular teeth. If cingulum rests are required for esthetic purposes, then cast restorations are indicated. The completed framework is fitted in the mouth with disclosing wax (Kerr Manufacturing Co., Romulus, Mich.) and imperfections in the casting are corrected (Fig. 2). Acrylic resin bases are added to the framework, border molded with modeling plastic, and an impression of the residual ridge is made with zinc oxide and eugenol or a light bodied rubber-base impression material. A corrected master cast is then made and recovered (Fig. 3). A suitable technique is used to make the maxillary impression, maxillary cast, and two record bases. One record base will be used to make jaw relation records and set the teeth (Figs. 4 and 5). The second base will be used to analyze the occlusal surface of the mandibular teeth and record the movement of the restored mandibular arch in wax. After the casts have been mounted in the proper vertical and centric relation position, the mandibular acrylic resin denture teeth can be positioned in wax. Their position can be determined either anatomically or with a mechanical guide such as the Broadrick occlusal plane analyzer (Teledyne Hanau, Buffalo, N.Y.). The maxillary teeth can be positioned against the already-set mandibular teeth. The waxed setup is carried to the mouth and evaluated. Anterior teeth should be carefully THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 10. Cuspal path wax and cusp-sulci ridge in centric relation position.
checked for proper esthetic and phonetic placement. The centric and vertical position of the setup should be checked, and, most important, the movement of the mandibular teeth against opposing maxillary teeth should be tested in all eccentric positions. To evaluate proper tooth position, it is important for the dentist to understand how the compensating curve, plane of orientation, condylar guidance, incisal guidance, and relative cusp height can create a balanced occlusion.’ If the setup is considered acceptable, then a more careful analysis of the mandibular teeth can be made.
CUSP AND SULCI ANALYSIS Black modeling plastic (Impression Compound, Type I, Kerr Mfg. Co.) is added to the maxillary record base in a manner similar to that described by Meyer.6 While the modeling plastic is still warm, the upper cast and record base are closed in the articulator against the mandibular setup. The anatomy of the occlusal surface of the mandibular teeth should be recorded accurately in 667
Figs. 11 through 668
18. For 1egends, see opposite
page.
NOVEMBER
1985
VOLUME
54
NUMBER
5
COMBINATION
SYNDROME
the modeling plastic (Fig. 6). The maxillary record base is chilled and trimmed so that only a small ridge of material remains in the central sulcus of the mandibular teeth (Fig. 7, A). This ridge will be used to evaluate the position and anatomy of the mandibular teeth. As the dentist guides the patient’s teeth against this ridge, an analysis can be made of (1) the initial position of the teeth, (2) the steepness of compensating curve, (3) the buccolingual tilt of the teeth, and (4) the potential for protrusive balance with the required vertical and horizontal overlap of the anterior teeth. If correction in tooth position is required, it should be made at this time, and the modeling plastic ridge should be readapted to the new tooth positions. A more precise analysis of the occlusal tooth form can then be made. The patient is guided into centric relation and then to a right lateral position with articulating paper over the posterior teeth. Surfaces that contact first can be noted by marks on the inclines of the denture teeth. One possible contacting relationship is noted in Figure 7, B, where the upper ridge on the right side contacts the mandibular right molar tooth on the buccal incline of the lingual cusp. Simultaneous contact on the opposite side is not possible because of the steepness of the right lingual cusp. This problem can be corrected by: (1) grinding the buccal incline of the mandibular right lingual cusp until simultaneous contact occurs on the opposite side, or (2) making the fossae of the mandibular right molar more shallow by adding inlay wax in the fossa and readapting the upper ridge to the new fossa depth. To determine which should be done, a left lateral movement is made (Fig. 7, C). If it is noted that the upper ridge has simultaneous contact on both sides, then the fossa depth of the right molar is correct and the right lingual cusp should be reduced (Fig. 7, 0): If, on the other hand, there is contact only on the right side, then the fossa is too deep and must be made more shallow. This analysis is continued in right, left, and protrusive positions until simultaneous contact is developed between the upper sulci ridge and opposing mandibular teeth. The occlusal surface of the denture teeth is duplicated in gold using a technique described by Engelmeier (Fig. 8).B At the same time a stone core is made of the
mandibular setup so that each quadrant of denture teeth can be repositioned in the mandibular waxup in the same position as the original teeth. The mandibular removable partial denture is then processed and adjusted in the mouth (Fig. 9) before the maxillary denture is made. Two benefits that result are: (1) the mandibular arch can be treated as an intact arch, and (2) the amount of processing error (change) is reduced because the mandibular removable partial denture has been completed. GENERATED
OCCLUSAL
PATH
The maxillary setup and cusp-sulci ridge are checked in the mouth against the restored mandibular arch for proper vertical and centric position. If errors are noted, the modeling plastic ridge is readapted to the mandibular teeth. It is then possible to record the movement of the mandibular arch in wax. This cuspal wax path is made by melting medium hard baseplate wax with red counter wax in a l/3 ratio by volume.’ The wax can be made softer by increasing the amount of red counter wax. This wax is then added to the ridge record base (Fig. 10). This step can be done in the mouth or, more easily, with the record base mounted against a stone cast in an articulator. The wax is heated in a water bath (122” F) and carried to the mouth. The patient is instructed to close in centric relation and the wax is cooled. The wax is reheated; and right, left, and protrusive movements are carefully made against the wax until a smooth record of the movement of the mandibular teeth is recorded (Fig. 11). If there are areas where cuspal paths are not generated, additional wax is added and the movements are repeated. This generated occlusal path is boxed (Fig. 12) and poured in improved dental stone. The stone cast is then mounted in an articulator at a specific pin setting, which is noted. The stone path and recorded movement of mandibular teeth (red arrows working, blue arrows protrusive and balancing) are shown in Fig. 13. COMPLETION DENTURE
OF MAXILLARY
TEETH AND
The occlusal and lingual surfaces of the maxillary posterior denture teeth are ground away and retentive
Fig. 11. Recording movement of mandibular teeth against cusp-sulci ridge and cuspal path wax. Fig. 12. Generated occlusal path is boxed and poured in dental stone. Fig. 13. Stone path and recorded movement of mandibular teeth. Red arrows indicate working movement, blue arrows in c#!cate protrusive and balancing. Fig. 14. Reduced surface of maxillary denture teeth. Fig. 15. Maxillary teeth waxed to stone path. Fig. 16. Completed waxup and duplicated teeth. Fig. 17. Teeth positioned against stone path with sticky wax. Fig. 18. Stone path sprayed with red marking medium. THE JOURNAL
OF PROSTHETIC
DENTISTRY
669
SCHMITT
Fig. 19. Processing Fig. 20. Completed result.
errors noted in red on denture teeth. prosthesis. A, Display of metal. B, Balanced occlusion.
grooves are placed in them (Fig. 14). Inlay wax is added to the teeth and the articulator closed against the stone path (Fig. 15). Care is taken to achieve intimate contact with the stone path at the noted pin setting. Supplemental grooves are placed in the waxup, and the occlusal surface is duplicated in gold (Fig. 16). Each quadrant of teeth can then be held against the stone path with sticky wax and the maxillary waxup completed (Fig. 17). After the denture is processed, it is recovered and remounted. Processing errors can be detected using Occlude (Pascal, Bellevue, Wash.) on the stone path (Fig. 18). Premature contacts can be located and removed from the occlusal surfaces of the denture teeth (Fig. 19). The completed denture is cleaned, polished, and delivered to the patient. The completed prosthesis, its balanced occlusion, and esthetic appearance are illustrated in Fig. 20.
described. This technique attempts to minimize the destructive changes seen in these patients by carefully distributing occlusal stress over the hard and soft tissues and by developing an occlusal relationship that is stable and balanced. REFERENCES 1. Kelley E: Changes caused by a mandibular removable partial denture opposing a maxillary complete denture. J PROSTHET DENT 27~140, 1972.
2.
Saunders TR, Gillis Jr RE, Desjardins RP: Maxillary complete denture opposing mandibular bilateral distal extension partial denture: Treatment considerations. J PR~THET DENT 41:124,
3.
Meyer FS: A new, simple and accurate technique for obtaining balanced and functional occlusion. J Am Dent Assoc 21:195, 1934. Meyer FS: Balanced and functional occlusion in relation to denture work. J Am Dent Assoc 221157, 1935. Meyer FS: Something new in cusps and sulci analysis: Balanced and functional occlusion and stress-breakers. J Am Dent Assoc 23~1204, 1936. Meyer FS: The generated path technique in reconstructive
1979.
4.
SUMMARY A method of treating patients who require a complete maxillary denture opposing a mandibular bilateral distal-extension removable partial denture has been
670
C, Esthetic
5.
6.
NOVEMBER
1985
VOLUME
54
NUMBER
5
COMBINATION
SYNDROME
dentistry. Part I: Complete dentures. J PROSTHET DENT 9:354, 1959. 7. Hanau RL: Articulation defined, analyzed and formulated. J Am Dent Assoc 13~1694, 1926. 8. Engelmeier RL: Fabricating denture teeth with custom anatomic and nonanatomic metal occlusal surfaces. J PROSTHET DENT 43:X2, 0.
1980.
Rudd KU,
Morrows KM:
The Generated Functional
Path
Concept in Complete Denture Prosthesis. Handout No. 3, Department of Prosthodontics, Wilford Hal USAF Medical Center, Lackland AFB, Texas.
Re~mll ?zquest., lo: DR. STEPHEN M. SCHMITT USAF MEDICAL CENTER/SGD KEESLER AFB, MS 39534
Diagnostically restoring a reduced occlusal vertical dimension without permanently altering the existing dentures Carl A. Han&en, D.D.S.* University
of Nebraska, College of Dentistry, Lincoln, Neb.
0
ccasionally a patient with complete dentures will display an obviously reduced vertical dimension of occlusion. When faced with the challenge of making new dentures in this situation, it is desirable for the dentist to reestablish the patient’s optimum vertical dimension of occlusion. Pound,’ and Pound and Murrell,2 accomplish this procedure by making preparatory or diagfiostic dentures and adding or subtracting resin to mandibular posterior dcclusal forms until a suitable vertical dimension of occlusion is reached. This approach is useful and offers valuable diagnostic information. Unfortunately, it also demands additional time and a higher fee. Another approach is to alter the patient’s present dentures by adding autopolymerizing resin to the mandibular posterior teeth and adjusting jaw separation until an optimum vertical relationship is achieved. This is more economical, but it permanently alters the occlusal surfaces of the denture. This article describes an alternative technique that uses a mandibular removable onlay splint to diagnostically restore the vertical dimension of occlusion of a complete denture. The occlusal surface of the denture is not permanently changed.
PROCEDURE Clinical phase No. 1 1. Inspect the polished surfaces of the lingual flange regions immediately inferior to the mandibular second
*Assistant Professor, Department of Adult Restorative Dentistry
THE JOURNAL
OF PROSTHETIC
DENTISTRY
molars bilaterally. They should be slightly undercut in relation to each other. If they are not, recontour and polish them to provide minimal opposing undercuts. 2. Make irreversible hydrocolloid impressions of the maxillary and mandibular complete dentures. Pour with improved stone. 3. Obtain a face-bow record with the maxillary denture in place. 4. Use a silicone putty (Optisil 2, Unitec Corp., Monrovia, Calif.) to record the maxillary-to-mandibular jaw relationship with the mandible in, the terminal hinge position at a vertical dimension of occlusion that appears appropriate. A central bearing device can be used to control jaw separation if desired (Fig. 1). 5. Record the shade of the patient’s denture teeth.
Laboratory procedures 1. Fabricate a thin plastic shell matrix on the cast of the mandibular denture with O.OZinch thermoplastic temporary splint material (5 x 5 inch, B&&lo Dental Mfg. Co., Brooklyn, N.Y.) and a vacuum apparatus (Acra Vat, Howmedica, Inc., Chicago, Ill.). Carefully cut and remove the splint from the cast, and fill the anterior portion with the appropriate shade of toothcolored autopolymerizing resin (Fig. 2). The polymerized resin will not adhere to the thin matrix material. 2. On the same mandibular cast, fabricate a heavier splint with thermoplastic resin (Clear 0.0%inch, 5 X 5 inch splint material, Buffalo Dental Mfg. Co.) as described by McNeill.3 3. Cut the heavy resin splint material with a large
671
DISCUSSION The ideal impression can best be accomplished by using zinc oxide-eugenol paste in a tray that is produced from a tissue-placement preliminary impression with proper physiologic borders. The effects of tissue placement and possible distortion should be eliminated from the formed impression tray. A heat-processed clear acrylic resin tray undergoes less warpage than the autopolymerizing materials and permits visual observation of ischemia caused by excessive loading. The use of holes provides venting to minimize displacement by the final impression material. The quality of the secondary impression will depend on the incorporation of these features into the secondary impression tray. The secondary impression material cannot be expected to compensate for inadequacies in the tray. The advantages of this technique are: 1. Reduction of the amount of time necessary to complete a satisfactory impression because border molding is unnecessary 2. Elimination of potential pressure spots before the impression material is inserted 3. Close approximation to physiologic and anatomic ideals 4. Preservation of residual ridge because of reduction of excessive displacement. Roberts” stated, “The making of impressions for full dentures is an important step in denture construction because good impressions contribute to retention, stability, and comfort of finished appliances. They are the foundations on which we build our dentures and, as such, merit our best effort.”
SUMMARY A technique has been described with which a physiologic and anatomic registration of the attached and unattached tissue of the denture-bearing areas can be attained. Clear acrylic resin trays aid in eliminating excessive displacement at the secondary impression phase. Inadequacies of the mucostatic concept include:
Combination
syndrome:
AND
BRONER
1. Failure to register the tissues, which are important for retention and stability 2. Certain metal bases that are part of this procedure can be implemented by only a small number of technicians 3. Increased cost There are two shortcomings of the tissue-loading technique for complete denture impressions. 1. Resulting retention and stability lasts only for a short period of time. 2. Unwanted ridge resorption and tissue changes occur. REFERENCES 1. Picton DCS, Wills DS: Viscoelastic properties of the periodontal ligament and mucous membrane. J PROSTHET DENT 40:263, 1978. 2. Fournet SC, Tuller CS: A revolutionary mechanical principle utilized to produce full lower dentures surpassing in stability the best modern upper dentures. J Am Dent Assoc 23:1028, 1936. 3. Boucher CO, Hickey JC, Zarb GA: Prosthodontic Treatment for Edentulous Patients, ed 7. St. Louis, 1975, The CV Mosby Co, pp 133-158, 184-213. 4. Sharry JH: Complete Denture Prosthodontics, ed 3. New York 1974, McGraw-Hill Book Co, pp 191-211. 5. Heartwell CM, Rahn AO: Syllabus of Complete Dentures, ed 2. Philadelphia, 1974, Lea & Febiger, pp 157-178. 6. Montieth BD: Management of loading forces on mandibular distal-extension prosthesis. J PROSTHET DENT 52:673, 1984. 7. Page HL: Mucostatics-A capsule explanation. Chronicle of the Omaha District Dental Society, April 1951, p 195. 8. Addison PI: Application of mucostatic principles to full denture construction. NY J Dent 17:135, 1974. 9. Applegate OC: The partial denture base. J PROSTHET DENT 5~636, 1955. 10. Klein IE, Goldstein BM: Physiologic determinants of primary impressions for complete dentures. J PROSTHET DENT 51:611, 1984.
11. Roberts AL: Principles of full denture impression making and their application in practice. J PROSTHET DENT 1:213, 1951. Ke,twint requests to: DR. IRA E. KLEIN 19 WEST 44~~ ST. NEW YORK, NY 10036
A treatment
approach
Stephen M. Schmitt, D.D.S., M.S.* USAF
Medical
Center,
Keesler Air Force Base, Miss.
The views and opinions expressed herein are those of the author and do not necessarily reflect the views of the U.S. Air Force or Department of Defense. *Major, USAF (DC); Assistant Chairman, Department of Prosthodontics.
664
T
reating patients with edentulous maxillae and a partially edentulous mandible is a common occurrence. Many times only mandibular anterior teeth remain (Fig. 1) and specific degenerative changes are often seen. NOVEMBER
1985
VOLUME
54
NUMBER
5
COMBINATION
SYNDROME
Fig. 1. Patient with edentulous maxillae and remaining mandibular anterior teeth. Fig. 2. Fit of framework is corrected in mouth with disclosing wax. Fig. 3. Corrected master cast. Fig. 4. Casts are mounted on articulator with interocclusal centric relation record. Fig. 5. Record base with artificial teeth in mouth. Fig. 6. Record base with modeling plastic and cusp-sulci ridge.
Kelly’ noted five destructive changes that occur in these patients: (1) loss of bone from the anterior part of the maxillary ridge, (2) overgrowth of the tuberosities, (3) papillary hyperplasia in the hard palate, (4) extrusion of the lower anterior teeth, and (5) loss of bone under the removable partial denture bases. He called these changes the combination syndrome. THE JOURNAL
OF PROSTHETIC
DENTISTRY
Saunders et al.2 described six changes that may also occur. They are ( 1) loss of vertical dimension of occlusion, (2) occlusal plane discrepancy, (3) anterior spatial repositioning of the mandible, (4) poor adaptation of the prosthesis, (5) epulis fissurata, and (4) periodontal changes. They felt that the basic objective in treating these patients was to develop an occlusal scheme that would 665
SCHMITT
Fig. 7. Frontal view of cusp-sulci ridge and mandibular setup. A, Cusp-sulci ridge and mandibular teeth in centric relation position. B, Right lateral position. C, Left lateral position. D, Adjustment of mandibular right denture tooth.
discourage excessive occlusal pressure on the maxillary anterior region in both centric and eccentric positions. Saunders et a1.2 also stated some specific treatment objectives. (1) The mandibular removable partial denture should provide positive occlusal support from remaining natural teeth and have maximum coverage of the basal seat beneath the distal-extension bases. (2) The design should be rigid and provide maximum stability while minimizing excessive stress on remaining teeth. (3) The occlusal scheme should be at the proper vertical and centric relation position. (4) Anterior teeth should be used for cosmetic and phonetic purposes only. (5) Posterior teeth should be in balanced occlusion. This article describes a treatment approach that attempts to minimize the destructive changes noted by using the treatment objectives of Saunders et a1.2This approach is indicated for patients who are aware of their present dental condition and want to reduce the inevitable resulting destructive syndrome. 666
RATIONALE The prosthesis is made in two stages using a modification of the complete denture construction technique described by Meyer.3-6 The mandibular removable partial denture is completed first. The tooth position, cusp height, sulcus depth, and marginal ridge position of the mandibular teeth will be determined using a cusp-sulci analysis. The completed mandibular removable partial denture is then used to construct a generated wax occlusal path. This path will be used to create the occlusal surfaces of the maxillary teeth. The maxillary denture is completed and delivered to the patient. Acrylic resin teeth are used to replace the maxillary anterior teeth because they abrade more rapidly than porcelain and tend to reduce stress concentration on the maxillary anterior ridge. Cast gold occlusal surfaces are made for the posterior denture teeth. Gold is used because it does not abrade readily, can be accurately cast to a multitude of tooth forms, and can be modified easily. NOVEMBER
1985
VOLUME
54
NUMBER
5
COMBINATION
SYNDROME
Fig. 8. Duplicated mandibular teeth with cast metal occlusal surface. Fig. 9. Completed mandibular removable partial denture.
TECHNIQUE Accurate casts are made and evaluated. It may be necessary to mount them in an articulator to diagnose the need for preprosthetic surgery or treatment of malpositioned teeth. The mandibular cast is then surveyed and the framework design carefully drawn on the cast. This serves as a guide for clinical tooth preparation as well as laboratory fabrication of the framework. If only six anterior teeth are present, incisal rests are usually required on the canine teeth. Cingulum rests are generally not used because the enamel is thin over the cingulum of mandibular teeth. If cingulum rests are required for esthetic purposes, then cast restorations are indicated. The completed framework is fitted in the mouth with disclosing wax (Kerr Manufacturing Co., Romulus, Mich.) and imperfections in the casting are corrected (Fig. 2). Acrylic resin bases are added to the framework, border molded with modeling plastic, and an impression of the residual ridge is made with zinc oxide and eugenol or a light bodied rubber-base impression material. A corrected master cast is then made and recovered (Fig. 3). A suitable technique is used to make the maxillary impression, maxillary cast, and two record bases. One record base will be used to make jaw relation records and set the teeth (Figs. 4 and 5). The second base will be used to analyze the occlusal surface of the mandibular teeth and record the movement of the restored mandibular arch in wax. After the casts have been mounted in the proper vertical and centric relation position, the mandibular acrylic resin denture teeth can be positioned in wax. Their position can be determined either anatomically or with a mechanical guide such as the Broadrick occlusal plane analyzer (Teledyne Hanau, Buffalo, N.Y.). The maxillary teeth can be positioned against the already-set mandibular teeth. The waxed setup is carried to the mouth and evaluated. Anterior teeth should be carefully THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 10. Cuspal path wax and cusp-sulci ridge in centric relation position.
checked for proper esthetic and phonetic placement. The centric and vertical position of the setup should be checked, and, most important, the movement of the mandibular teeth against opposing maxillary teeth should be tested in all eccentric positions. To evaluate proper tooth position, it is important for the dentist to understand how the compensating curve, plane of orientation, condylar guidance, incisal guidance, and relative cusp height can create a balanced occlusion.’ If the setup is considered acceptable, then a more careful analysis of the mandibular teeth can be made.
CUSP AND SULCI ANALYSIS Black modeling plastic (Impression Compound, Type I, Kerr Mfg. Co.) is added to the maxillary record base in a manner similar to that described by Meyer.6 While the modeling plastic is still warm, the upper cast and record base are closed in the articulator against the mandibular setup. The anatomy of the occlusal surface of the mandibular teeth should be recorded accurately in 667
Figs. 11 through 668
18. For 1egends, see opposite
page.
NOVEMBER
1985
VOLUME
54
NUMBER
5
COMBINATION
SYNDROME
the modeling plastic (Fig. 6). The maxillary record base is chilled and trimmed so that only a small ridge of material remains in the central sulcus of the mandibular teeth (Fig. 7, A). This ridge will be used to evaluate the position and anatomy of the mandibular teeth. As the dentist guides the patient’s teeth against this ridge, an analysis can be made of (1) the initial position of the teeth, (2) the steepness of compensating curve, (3) the buccolingual tilt of the teeth, and (4) the potential for protrusive balance with the required vertical and horizontal overlap of the anterior teeth. If correction in tooth position is required, it should be made at this time, and the modeling plastic ridge should be readapted to the new tooth positions. A more precise analysis of the occlusal tooth form can then be made. The patient is guided into centric relation and then to a right lateral position with articulating paper over the posterior teeth. Surfaces that contact first can be noted by marks on the inclines of the denture teeth. One possible contacting relationship is noted in Figure 7, B, where the upper ridge on the right side contacts the mandibular right molar tooth on the buccal incline of the lingual cusp. Simultaneous contact on the opposite side is not possible because of the steepness of the right lingual cusp. This problem can be corrected by: (1) grinding the buccal incline of the mandibular right lingual cusp until simultaneous contact occurs on the opposite side, or (2) making the fossae of the mandibular right molar more shallow by adding inlay wax in the fossa and readapting the upper ridge to the new fossa depth. To determine which should be done, a left lateral movement is made (Fig. 7, C). If it is noted that the upper ridge has simultaneous contact on both sides, then the fossa depth of the right molar is correct and the right lingual cusp should be reduced (Fig. 7, 0): If, on the other hand, there is contact only on the right side, then the fossa is too deep and must be made more shallow. This analysis is continued in right, left, and protrusive positions until simultaneous contact is developed between the upper sulci ridge and opposing mandibular teeth. The occlusal surface of the denture teeth is duplicated in gold using a technique described by Engelmeier (Fig. 8).B At the same time a stone core is made of the
mandibular setup so that each quadrant of denture teeth can be repositioned in the mandibular waxup in the same position as the original teeth. The mandibular removable partial denture is then processed and adjusted in the mouth (Fig. 9) before the maxillary denture is made. Two benefits that result are: (1) the mandibular arch can be treated as an intact arch, and (2) the amount of processing error (change) is reduced because the mandibular removable partial denture has been completed. GENERATED
OCCLUSAL
PATH
The maxillary setup and cusp-sulci ridge are checked in the mouth against the restored mandibular arch for proper vertical and centric position. If errors are noted, the modeling plastic ridge is readapted to the mandibular teeth. It is then possible to record the movement of the mandibular arch in wax. This cuspal wax path is made by melting medium hard baseplate wax with red counter wax in a l/3 ratio by volume.’ The wax can be made softer by increasing the amount of red counter wax. This wax is then added to the ridge record base (Fig. 10). This step can be done in the mouth or, more easily, with the record base mounted against a stone cast in an articulator. The wax is heated in a water bath (122” F) and carried to the mouth. The patient is instructed to close in centric relation and the wax is cooled. The wax is reheated; and right, left, and protrusive movements are carefully made against the wax until a smooth record of the movement of the mandibular teeth is recorded (Fig. 11). If there are areas where cuspal paths are not generated, additional wax is added and the movements are repeated. This generated occlusal path is boxed (Fig. 12) and poured in improved dental stone. The stone cast is then mounted in an articulator at a specific pin setting, which is noted. The stone path and recorded movement of mandibular teeth (red arrows working, blue arrows protrusive and balancing) are shown in Fig. 13. COMPLETION DENTURE
OF MAXILLARY
TEETH AND
The occlusal and lingual surfaces of the maxillary posterior denture teeth are ground away and retentive
Fig. 11. Recording movement of mandibular teeth against cusp-sulci ridge and cuspal path wax. Fig. 12. Generated occlusal path is boxed and poured in dental stone. Fig. 13. Stone path and recorded movement of mandibular teeth. Red arrows indicate working movement, blue arrows in c#!cate protrusive and balancing. Fig. 14. Reduced surface of maxillary denture teeth. Fig. 15. Maxillary teeth waxed to stone path. Fig. 16. Completed waxup and duplicated teeth. Fig. 17. Teeth positioned against stone path with sticky wax. Fig. 18. Stone path sprayed with red marking medium. THE JOURNAL
OF PROSTHETIC
DENTISTRY
669
SCHMITT
Fig. 19. Processing Fig. 20. Completed result.
errors noted in red on denture teeth. prosthesis. A, Display of metal. B, Balanced occlusion.
grooves are placed in them (Fig. 14). Inlay wax is added to the teeth and the articulator closed against the stone path (Fig. 15). Care is taken to achieve intimate contact with the stone path at the noted pin setting. Supplemental grooves are placed in the waxup, and the occlusal surface is duplicated in gold (Fig. 16). Each quadrant of teeth can then be held against the stone path with sticky wax and the maxillary waxup completed (Fig. 17). After the denture is processed, it is recovered and remounted. Processing errors can be detected using Occlude (Pascal, Bellevue, Wash.) on the stone path (Fig. 18). Premature contacts can be located and removed from the occlusal surfaces of the denture teeth (Fig. 19). The completed denture is cleaned, polished, and delivered to the patient. The completed prosthesis, its balanced occlusion, and esthetic appearance are illustrated in Fig. 20.
described. This technique attempts to minimize the destructive changes seen in these patients by carefully distributing occlusal stress over the hard and soft tissues and by developing an occlusal relationship that is stable and balanced. REFERENCES 1. Kelley E: Changes caused by a mandibular removable partial denture opposing a maxillary complete denture. J PROSTHET DENT 27~140, 1972.
2.
Saunders TR, Gillis Jr RE, Desjardins RP: Maxillary complete denture opposing mandibular bilateral distal extension partial denture: Treatment considerations. J PR~THET DENT 41:124,
3.
Meyer FS: A new, simple and accurate technique for obtaining balanced and functional occlusion. J Am Dent Assoc 21:195, 1934. Meyer FS: Balanced and functional occlusion in relation to denture work. J Am Dent Assoc 221157, 1935. Meyer FS: Something new in cusps and sulci analysis: Balanced and functional occlusion and stress-breakers. J Am Dent Assoc 23~1204, 1936. Meyer FS: The generated path technique in reconstructive
1979.
4.
SUMMARY A method of treating patients who require a complete maxillary denture opposing a mandibular bilateral distal-extension removable partial denture has been
670
C, Esthetic
5.
6.
NOVEMBER
1985
VOLUME
54
NUMBER
5
COMBINATION
SYNDROME
dentistry. Part I: Complete dentures. J PROSTHET DENT 9:354, 1959. 7. Hanau RL: Articulation defined, analyzed and formulated. J Am Dent Assoc 13~1694, 1926. 8. Engelmeier RL: Fabricating denture teeth with custom anatomic and nonanatomic metal occlusal surfaces. J PROSTHET DENT 43:X2, 0.
1980.
Rudd KU,
Morrows KM:
The Generated Functional
Path
Concept in Complete Denture Prosthesis. Handout No. 3, Department of Prosthodontics, Wilford Hal USAF Medical Center, Lackland AFB, Texas.
Re~mll ?zquest., lo: DR. STEPHEN M. SCHMITT USAF MEDICAL CENTER/SGD KEESLER AFB, MS 39534
Diagnostically restoring a reduced occlusal vertical dimension without permanently altering the existing dentures Carl A. Han&en, D.D.S.* University
of Nebraska, College of Dentistry, Lincoln, Neb.
0
ccasionally a patient with complete dentures will display an obviously reduced vertical dimension of occlusion. When faced with the challenge of making new dentures in this situation, it is desirable for the dentist to reestablish the patient’s optimum vertical dimension of occlusion. Pound,’ and Pound and Murrell,2 accomplish this procedure by making preparatory or diagfiostic dentures and adding or subtracting resin to mandibular posterior dcclusal forms until a suitable vertical dimension of occlusion is reached. This approach is useful and offers valuable diagnostic information. Unfortunately, it also demands additional time and a higher fee. Another approach is to alter the patient’s present dentures by adding autopolymerizing resin to the mandibular posterior teeth and adjusting jaw separation until an optimum vertical relationship is achieved. This is more economical, but it permanently alters the occlusal surfaces of the denture. This article describes an alternative technique that uses a mandibular removable onlay splint to diagnostically restore the vertical dimension of occlusion of a complete denture. The occlusal surface of the denture is not permanently changed.
PROCEDURE Clinical phase No. 1 1. Inspect the polished surfaces of the lingual flange regions immediately inferior to the mandibular second
*Assistant Professor, Department of Adult Restorative Dentistry
THE JOURNAL
OF PROSTHETIC
DENTISTRY
molars bilaterally. They should be slightly undercut in relation to each other. If they are not, recontour and polish them to provide minimal opposing undercuts. 2. Make irreversible hydrocolloid impressions of the maxillary and mandibular complete dentures. Pour with improved stone. 3. Obtain a face-bow record with the maxillary denture in place. 4. Use a silicone putty (Optisil 2, Unitec Corp., Monrovia, Calif.) to record the maxillary-to-mandibular jaw relationship with the mandible in, the terminal hinge position at a vertical dimension of occlusion that appears appropriate. A central bearing device can be used to control jaw separation if desired (Fig. 1). 5. Record the shade of the patient’s denture teeth.
Laboratory procedures 1. Fabricate a thin plastic shell matrix on the cast of the mandibular denture with O.OZinch thermoplastic temporary splint material (5 x 5 inch, B&&lo Dental Mfg. Co., Brooklyn, N.Y.) and a vacuum apparatus (Acra Vat, Howmedica, Inc., Chicago, Ill.). Carefully cut and remove the splint from the cast, and fill the anterior portion with the appropriate shade of toothcolored autopolymerizing resin (Fig. 2). The polymerized resin will not adhere to the thin matrix material. 2. On the same mandibular cast, fabricate a heavier splint with thermoplastic resin (Clear 0.0%inch, 5 X 5 inch splint material, Buffalo Dental Mfg. Co.) as described by McNeill.3 3. Cut the heavy resin splint material with a large
671