Predictions exist that by the year 2020 we will have 38 million edentulous adults with 61 million edentulous arches in the United States (Douglass, et. al.). Chances are they will be looking for a dentist at some point to help determine restorative dental treatment options. Socioeconomic data provide insights where if a patient is 65 or older, without a high school degree, “poor” and a smoker, then this patient is completely edentulous. 

Dentures

What are the options for complete dentures?

  1. Dental implant-related restorations: fixed or removable, one arch or both
  2. Conventional complete removable denture prostheses
  3. Refer to another office

What if you are in a position where the only option is #2 - complete dentures?

Check this out - in a study published by Walton & MacEntee in 2002, 36 percent of older edentulous participants refused FREE mandibular dental implants. While socioeconomic factors likely played a role, there is apparently a segment of the population with either a fear of the procedure involved or a general lack of belief that dental implants will work for them. Certainly, a patient might have a contraindication relative to the healing potential required for dental implants to integrate, resulting in the decision for a complete denture.

Are there factors in the technique that make a difference in your office?

  1. Patient Selection - This is probably the most important “technique.” This is specific to each dentist and may be different at various points along the course of a career. The key is to work with a patient that has the potential to adapt to something new and different. There exists a group of people that fit in the category of “mal-adaptive” denture patients. It is important to identify challenging patients as soon as possible. One of the classic articles by Dr. Koper classifies patients into categories that add a little humor into what can be a tough situation. The categories related to difficult denture birds include: Karate Hawk, Myway Magpie, Minewere Mallard (aka: I Usta Duck), the Forever Flicker and the Tipsy Pipit, Rummy Robin, Martini Meadowlarck, etc. Recommendations or suggestions pertaining to the topic of patient selection describe the relationship with the patient as being more important than the technical expertise applied to making a well-crafted prosthesis.
  1. Impressions - This is always a great topic of discussion. The traditional technique involves a two-stage approach with a primary impression and a secondary or final impression making use of a custom tray and border molding. A technique involving irreversible hydrocolloid as a final impression has been published as a technique used with dental students where the key is an opportunity to check the impression using a processed acrylic denture base. Another technique is a layered impression made of vinyl-polysiloxane (VPS) to allow for the opportunity to evaluate and refine the retention and stability over time. All of the techniques work. It’s really the attention to detail that makes a difference, although it’s nice to have a few options when working with our patients. How do you make a decision on technique?
  1. Denture occlusion - This is typically a hot topic related to complete denture technique. Would you incorporate canine guidance into your occlusal design? The technique often associated with denture occlusion relates to “balanced” contacts in eccentric positions. Anterior balance, cross-arch balance and cross-tooth cross-arch balance all fit in the category, with much more precision with each option, at least on the articulator. Cusp height comes in as a decision: flat plane, 15 degree, 30 degree or any variation depending on the manufacturer. Tooth position and denture occlusion really begins with the position of the two maxillary central incisors. Facially generated treatment planning applies as much here as in any restorative dental treatment plan. What types of decisions here influence your strategy?

Strategy: Enhancing your esthetic practice through denture patients

Every patient thinking about a new denture is looking for an “esthetic” result ... something that at least doesn’t have the look of a denture. Think about all of the detail involved with tooth position (incisal edge length, incisal edge position, vertical midline, tooth proportion AND gingival levels, occlusal plane, etc.) that we can “practice” with teeth set in wax to optimize the final result. It's facially generated treatment planning where the restorative dentist can influence the variables related to the appearance of our patient's smile.

Beyond the technical aspects of denture construction, the interpersonal skills involved in patient selection and relationship-building are skills that transfer to the patient looking for an esthetic enhancement of their existing smile, whether with veneers or full-coverage restorations. This is true for not only the restorative dentist, but also for the staff associated with the dental practice. And ... there is an opportunity for dental implants to become a higher priority for your complete denture patients at some point in the future. That is a great opportunity for a growing practice!

What is your complete denture strategy?

References

Douglass, et. al. Will there be a need for complete dentures in the United States in 2020? Journal of Prosthetic Dentistry. 2002;87:5-8. Koper, A. Difficult Denture Birds. Journal of Prosthetic Dentistry 1967;17:532-539.

Walton J, MacEntee MI. Choosing or Refusing Oral Implants: A Prospective Study of Edentulous Volunteer for a Clinical Trial. International Journal of Prosthodontics 2005;18:483-488.  

Douglas G. Benting, DDS, MS, FACP, Spear Visiting Faculty and Contributing Author. www.drbenting.com


Comments

Roxanna Jean Esguerra
April 8th, 2015
I read Koper's article during my prosthodontic residency in San Antonio. It is a must-read for ANYONE who fabricates complete dentures, regardless of whether they are implant-retained or conventional. For myself, however, it made me feel a bit over confident. I assumed that all patients who are functioning happily with their old dentures will easily adapt to new dentures. I recently was proven wrong on this point. My patient, an older woman who had just started IV bisphophonates, but complained of a "loose lower denture" presented to my clinic. Obviously, she falls into category 2 mentioned above. After some discussion of the options, we agree to make a new denture for reasons other than improving stability or function. At the end of treatment, she told me "I cannot eat with my new dentures, even soft bread, so I've been wearing my old dentures." Upon some further investigation, I realized her old dentures did not have balance, and the balanced occlusion that I created in the new dentures was not compatible with her habitual chewing cycle. So,old dentures are still a bit like an old pair of shoes. Every aspect must be evaluated carefully, in order to decide what "technique" will be used to fabricate the new dentures.
Doug Benting
April 13th, 2015
Interesting point … there are certainly patients that present with more challenging situations. I have several patients that have worn their dentures for many decades and are referred or find my office after the previous attempt (or more) has not been successful. Most of the time the issue relates to the patients ability to adapt to a new prosthesis and I have been successful at either relining or rebasing the existing dentures. There are many articles out there that talk about a poor correlation between denture quality and overall patient satisfaction. Also important is that it has been shown that bite force and chewing efficiency decrease for a relatively long time period following the delivery of complete removable dentures. A study by Fenlon & Sherriff discusses this point and may explain why patients may complain about what appears to be a high quality denture. So … is there any hope? It is my understanding that the treating dentists relationship with the patient is more important than the technical quality of a complete denture. Tell the patient what is going to happen, what to expect in the process, and how to handle some of the issues that arise in order to show them that you care and that we can hear and understand what the patient is sharing with us about a very personal challenge. This skill is as important in treatment related to complete denture as it is to patients with high esthetic demands for a crown & bridge or veneer case.
Emily B.
December 31st, 2015
Doug - This is a great read and hopefully anyone that treats edentulous patients has read it. I still refer to Koper's articles routinely and I have come up with a few more "bird" categories of my own. I send out a quarterly newsletter to my referring community and I selected this topic a little over a year ago. http://www.pickledental.com/blog/the-batson-byte/ Telling the edentulous patient or soon to be edentulous patient that dentures are like artificial limbs has helped me communicate that the process takes time to be done well, and no one - either dentist or patient - should feel bad if there are a few bumps in the road. But, not expecting the bumps is what many doctors and patients have expressed in their frustration. Thanks for sharing your knowledge and experience.