If removable prosthetics are part of your practice, do you make prostheses or plates?

If you’re like the majority of dentists, you simply allow the laboratory technician to choose the moulds and brand based on their preference and corresponding “as close as possible” to a shade that you give them. The denture tooth quality and type is, therefore, dependent on the experience that the technician has with favored brands, which often are the same as the manufacturer of their favorite acrylics. Since removable technicians seldom have the photographic information and detailed treatment planning information that Spear dentists provide for complex esthetic cases, they are left to choose anterior teeth based on the shape of the palate and some landmark on the model or lines that we draw on the wax rim, if that step has not been omitted.

While there are many techniques for determining tooth size from arch form to even measuring the index fingers of the patient1, the fact of the matter is that the laboratory technician simply does not have the patient in front of him and cannot possibly grasp the physical and anatomical needs of the patient. The difference between a plate and a prosthesis is the diagnosis!

Selection

There are many brands of denture teeth on the market, and most of us who routinely set our own denture teeth tend to favor one brand or another; however, we recognize that there are times when using an atypical denture tooth is beneficial to the patient. Each brand of denture tooth has its pros and cons. For example, there is one particular brand that I have used that actually makes what I believe is the prettiest tooth on the market with the best optical characteristics that I have found, but it comes in only a few anterior moulds, most of which do not fit my population of patients. My favorite brand has nice esthetics and is very durable, but it comes is a wide variety of moulds: short, fat, long, ovoid, square ovoid, square tapering ovoid, etc. In my opinion, the teeth should be chosen to fit the patient’s desired esthetics and facial form in preference over the palatal form – after all, I have yet to find a person who shows off their palate when they smile, but they do show off their teeth, whether they want to or not!

assorted denture teeth

When prescribing denture teeth, we first need to determine the distance on a curve between the distal surfaces of the canines. Dr. Doug Benting discusses how to do this in a wonderful digital course on setting teeth for edentulous patients. Incisal edge position is determined using the facially generated treatment planning sequence and principals. Once we clearly establish these parameters and have an adequate and retentive wax rim, we can begin to set the maxillary teeth.

(Click this link to learn more about facially generated treatment planning.)

Waxing

While many dentists find setting anterior denture teeth to be ominous, waxing can be relaxing! There are a few pearls to simplify the process.

1. Start with setting the maxillary two centrals intraorally to establish horizontal and vertical inclination.

2. Then draw a line on the land area of the master cast with the repositioned record base as a reference in case the teeth move while waxing the others in the laboratory.

3. Make sure that the middle-third of the maxillary centrals is most prominent.

4.Set the lateral incisors so that the incisal, facial, and lingual embrasures are symmetrical and make the incisal edge more facial than the rest of the tooth but in line with the incisal edge mesial-distally of the centrals; for a youthful look, set approximately .5 mm apical to the central incisal edge. 

5. Set the canine tooth again using the ebrasure form as a guide and then make the gingival-third the most prominent section of the tooth. Be sure to “turn the corner” angling the distal cusp arm directly down the crest of the posterior ridge. 

If you are making a mandibular denture, set the mandibular anterior teeth in the same sequence only make the central incisal-third more prominent than the middle-third of the lateral incisor. Then make sure the gingival-third of the canine is the most prominent aspect of that tooth. I like to remember the phrase “MIG over IMG” when I set anterior denture teeth to remember which third of each tooth should be most prominent. 

dentures esthetic tooth position

When setting the mandibular teeth, remember to move the articulator through excursive movements that have been set from your bite records

(Click this link for more articles by Dr. Kevin Huff.)

Kevin D. Huff, DDS, Spear Moderator and Contributing Author - www.doctorhuff.net

References

1. Ahila SC, Vaishnavi P, Muthu KB. Comparative evaluation of maxillary and mandibular anterior teeth width with the length of index and little finger. Journal of Indian Prosthdontic Society 2014;14(3):215–218.


Comments

Doug B.
May 4th, 2016
Hey Kevin, great article! The picture of your patient shows your artistry ... can you describe more on what you are doing with the denture base to create the color variation and the look of keratinized tissue? I assume this patient has an active/mobile upper lip where the gingival esthetics become more important than the typical gingival display.
Kevin H.
May 4th, 2016
Thank you, Dr. Benting for your compliment. I can take little credit for the tissue shading except to say that I request Enigma tissue shading from my laboratory (http://enigmacosmeticdentures.com) for final processing. I will refrain from citing a particular lab because there have been several excellent labs that I've used over the years. I also don't follow the protocol because I like to use Portrait IPN (Dentsply) for denture teeth rather than Enigma teeth simply as a mattee of artististic preference. I also use custom acrylic shading with standard acrylic for many cases, which can rival Enigma. Excellent acrylic technicians can make any system work well esthetically, I have found. I also have had my lab make me some tissue shade guide tabs that I will sometimes use for reference, as I would with teeth. I believe one key is that I request a clear palate that extends to 1mm from the vestibular border. This usualy requires a cut-back of the first pressing of the pink denture base acrylic and then repacking with clear acrylic. This does two things. It blends the vestibular flange so it appears translucent and also somewhat on the intaglio surfaceof the facial flange. I believe this creates "vitality" by allow some show-through of the underlying tissue color. It also allows darkness to shadow through from the palate when the patient.smiles and speaks. Pink palates tend to create an opaqing effect, to borrow a phrase from fixed prosthetics, in my opinion. An extra benefit is that it makes visualization of pressure areas a snap during seating because they blanch and can be seen through the clear acrylic. I hope this helps to answer your question. Kevin
Doug B.
May 5th, 2016
Thank you for sharing your thoughts -- the details you share add up to a great, highly esthetic result for patients that are in a highly vulnerable state.
Sam C.
July 28th, 2016
Kevin, thank you for the informative article. I am looking for a good full denture lab. I would appreciate knowing those that you have had success with in the past. Sincerely, Sam