Finlay and Rowans Complete Denture Construction Manual PDF
Finlay and Rowans Complete Denture Construction Manual PDF
Finlay and Rowans Complete Denture Construction Manual PDF
This complete denture construction protocol is based on the guides published by the British Society of
Prosthodontics in 1996. These are as relevant today as when they were first published. The guides can be
obtained at: http://www.bsspd.org/About/BSSPD+guidelines.aspx. It is relevant to refer to these Guides
to Standards in Prosthetic Dentistry as well as these instructions. We attempt to give the patient
“prosthodontic privacy”. A phrase created by Dr John Besford, whereby only the patient and treating
prosthodontic team know that the patient has prosthetic teeth.
My nurse translates what I say so that the patient fully understands the true nature of wearing dentures.
In addition, the patients can be truly honest with the dental nurse regarding the aesthetics of the
dentures.
There are no quick fixes or easy way, it takes effort, focus and time
Lowers – thin anteriorly and widening out posteriorly. Supporting a lower denture appropriately is very
important. Primary support is gained from the buccal shelves and retromolar pads. The remaining ridge
is secondary support and the lingual part of the ridge offers no support. Lingually the denture terminates
at the insertion of the mylohyoid muscle, apart from distal to the 6 into retromylohyoid area where it is 2-
3 mm overextended. The denture posteriorly extends completely over the retromolar pad. This is
important to get stability and potentially suction from the lower denture.
Photographs
My most important piece of kit – the camera
My camera is the most important piece of equipment I use. I use it constantly for all of my patients. It
helps with the following things and more:
1. Diagnosis and treatment planning – particularly helpful for looking at high smile line and aesthetic
problems
2. Checking the quality of my work – particularly when I am doing the end of treatment letters
3. Communication with the dental technician
4. When trying to mimic old dentate photographs for a person requiring full or almost full dentures
5. Patient education – showing them evidence of what I can do
6. Teaching colleagues and dental students
7. Commination with referring colleagues
8. A picture tells a thousand words
I use standardised orthodontic views. In addition, I use a few other extra oral views too which help
aesthetically.
I use a Canon 5D MkIII and lens with twin flash.
Examination
Extra oral, lip support, tooth show and OVD check.
Check occlusion RCP=ICP or is not coincident. High levels of occlusal wear may indicate excursive
movements. Thinking balanced articulation if gross occlusal wear case.
Check extensions of dentures paying particular attention to retro molar pads and upper post dam.
Check retention support and stability
Important - If it is stated something can’t be resolved now (before treatment) – this is a diagnosis, if it is
stated after the treatment, this is an excuse. This is where the “you should be aware of” part of the letter
is very important.
Consent letter – containing all factors a patient should be aware of before treatment
All of my patients receive a treatment plan letter before proceeding with treatment.
There is a part of the letter which explains everything that a patient should be aware of before embarking
on treatment and what to expect. This list gets bigger and bigger over time with treating patients as new
things that patients experience get added to this list. If these factors are discussed with the patient prior
to starting, they are a diagnosis, if they are discussed once the problem arises after denture provision they
are often thought of as “an excuse”, by the patient, meaning we are then on the back foot.
Rowan, the team and I do our absolute best to ensure that all treatment we deliver is successful. Replacing
missing teeth (Prosthodontics) is challenging due to the two demands of function (chewing and eating)
and aesthetics. The following list contains items that I feel you should be aware of before you decide to
have treatment. It covers aspects of this type of treatment, which I feel are important and has been
developed over the past 25 years following treating patients with similar requirements to you;
• The new upper denture will extend slightly further back in the mouth compared to your current
denture. The extra extension is important in producing good suction (peripheral seal). I feel it is
important for you to be aware of this prior to commencing treatment and I am confident that you will
accommodate to this.
Impression making
Small lip retractors for impression making are very helpful
My dental nurse helps me when I’m impression making by holding the patients lips forward and out with
small lip retractors. These help me to visualise the ridge and see more clearly where I need to position the
tray. They help with accurate tray positioning.
We have cut down and polished two photographic retractors to do this. This video shows how they are
used.
Figure 4 Lip retractors fashioned from photographic retractors are very useful for correct position of
the impression tray in the mouth
Primary impressions
I look in the mouth before taking a primary impression. I look at the depth and width of the sulcus. I
rehearse the process of taking the impression and imagine the material filling this space in a smooth roll.
Visualising the denture space helps me produce better primary impressions enabling the production of
correctly extended special trays.
Primary impressions are always over-extended so that correctly extended special trays can be made on
the primary casts.
Figure 7 The upper special tray is made to 2 mm short of the sulcus depth – avoiding the frenum
Lower special tray is not spaced – for use with zinc oxide or impregum.
Figure 9 The lower special tray is made to the following extensions 1.Draw round the left
6. Draw a line from the retromolar pad fully
middle of the retromolar
pad vertically down to 2.Avoid the Someya
the edge of the sinew
mylohyoid line and
forward anteriorly to the
divergence point 3. Buccal shelf 2 mm
short of the buccal
edge of the
mandible
7. Draw a second line 2-
3mm behind line 6 and
join up at the divergence 4. Avoid midline and
point buccal frena
The dental technician must know exactly the requirements of the special tray design.
Greenstick is then applied to the borders of the tray from the 4s back to the tuberosities - this enhances
suction/retention. Care is taken to keep the labial border of the impression very thin without a border
moulding material, corresponding with the minimal bone loss which occurs at the top of the labial sulcus
region after the anterior teeth have been extracted. This thinness will allow the upper lip to assume its
pre-extraction form when the new dentures are worn. This is placed in the patient’s mouth with muscle
trimming and the patient is instructed to moved the jaws fully, from right to left “waggle the jaws”. The
cheeks are muscle trimmed.
A very thin mix of alginate (avoiding over filling the tray) is applied and glazed with water. The same
trimming and movements are performed as with greenstick application, with the addition of sucking
firmly for 1 second. Keep the periphery thin in the upper anterior region.
Figure 13 Greenstick application on special tray areas for mandibular definitive impression – fitting
surface
Vaseline is placed on the lips. Zinc oxide, SS White http://www.sswhite.com/home.asp (or use Medium
viscosity Impregum) is used to finalise the impression – avoiding overfilling the tray. The tray is placed
over the ridge and pushed down firmly. The patient is instructed to perform movements 1, 2 and 3 above
in the same manner and more exaggerated as for the greenstick application.
If the patient can’t find a dentate photograph with their natural teeth visible, it is still useful to have a
photograph of their face, when they had their natural teeth without smiling. These photographs are still
an excellent reference giving me lots of information about lip support, lower face height and indirectly
their natural teeth positions.
It is much more useful than having no photograph at all.
Post dam position for maxillary complete dentures – the fovea palatini getting a good posterior seal
The posterior border of a maxillary complete denture is positioned at or around the position of the fovea
palatini, by cutting a “cupids bow shaped” groove onto the master cast. The post dam groove extends
from the right to the left hamular notches, enclosing the tuberosites passing across the midline of the
palate within 1 mm of the fovea palatini. I cut a post dam onto on the definitive maxillary cast at the
beginning of the registration appointment. The posterior border of the wax rim is warmed and pushed
into the post dam on the definitive cast. This ensures that the upper rim has good retention when assessing
the aesthetics of the lip support, incisal plane, occlusal plane, centre line and buccal corridors. Without
the post dam on the upper rim, the rim can have a tendency to drop down, making assessing the aesthetics
impossible to judge with accuracy.
95% of complete dentures I make extend to just in front of the vibrating line. This position is generally
within 1 mm of the fovea palatini and produces the best suction. Before treatment I demonstrate this on
a denture example and explain it with photos in the treatment plan consent letter.
Sometimes the patient cannot tolerate this extension as it makes them heave or feel sick. This will normally
occur at the registration rim stage or denture try in stage. I explain to the patient that this normally
resolves itself once the denture is finished and worn. Adaptation to the extension normally occurs.
Occasionally though, this does not happen. In these cases I bring the posterior border forward by
approximately 10mm at the midline keeping the extension around the tubersoities into the hamular
notches. A post dam is added along this border to form a posterior seal.
The retention is often not quite as good as a fully extended posterior border, but it generally is sufficient
for the patient to manage well with the new denture. It is particularly important that the other denture
parameters are correct, such as sulci extension, tooth positions and the occlusion.
The rim is carved in the following way, the order being very important:
1. The desired lip support is created
2. The incisal plane is carved – usually parallel with the interpupillary line.
3. The occlusal plane is carved parallel with the ala- tragus line.
4. The buccal corridors are carved.
The lower rim with pivots is tried in. The correct OVD is created. This is a purely visual thing. If the OVD
looks right, it is right.
Figure 16 Pivots on the lower registration rim – help greatly with registration:
This is where a central bearing point is fixed to one arch and a plate is fixed parallel to the opposing arch.
The only point of contact between the upper and lower arches is the central bearing point. The patient
scribes a mark on the plate by moving the mandible forwards and backwards and side to side. The scribed
mark often looks like an arrow (gothic arch), the tip of which is centric relation. This position is recorded
by fixing the upper and lower plates together using an occlusal registration material.
Figure 18 Gothic arch tracing/central bearing apparatus for difficult to find RCP
The occlusal vertical dimension is established properly before the central bearing procedure is
performed. The screw is turned to increase or decrease the OVD.
Figure 19 Gothic arch tracing on the upper tray. The head of the arrow indicates RCP
A facebow transfer is routinely used for mounting the maxillary cast in the correct relationship in the
articulator.
Photographs of the patient smiling and at rest with the shaped wax rims in place are extremely helpful
for the technician. I take the following 10 photographs with the patient smiling and at rest:
1. The right and left profile
2. The right and left three quarter view
3. Portrait view
Photographs of the patient smiling with the shaped wax rims in situ – send to the technician:
Along with dentate photographs of the patient, if these are available, the above photographs are of great
assistance for setting the teeth. Corrections to the prescribed tooth positions of the wax rim can be made
by the dental technician with reference to these photographs, adding another check in the system.
Trial insertion
If a full frontal dentate photograph of the patient is available then Dr John Besfords tooth size calculation
formula can be used to calculate the size of the prosthetic teeth:
True width of (UR1 + UL1) = Photographic width of (UR1 + UL1) x Actual interpupillary distance
Photographic interpupillary distance
The mould and size can be taken from the Engima tooth chart:
http://www.enigmacosmeticdentures.com/index.php
The teeth are arranged as per the photograph or other specified parameters. The posterior teeth are
mainly arranged into balance articulation, unless aesthetics dictate that an alternative occlusion is
necessary. A very important aesthetic factor in, making the dentures life-like is to place darker canines,
compared to the incisors. This is how natural teeth are.
In general, the best place to position denture teeth are in the same positions as their natural predecessors.
Not only does this make the dentures look like natural teeth with correct lip support, it leads to stable
dentures as the artificial teeth sit within the neutral zone.
Be brave with your tooth positioning
To make the denture tooth positioning natural it essential that the clinician and technician are brave.
Setting up denture teeth unevenly and wonky in the laboratory, on the bench, does not look as obvious
when tried in the mouth.
Exaggerating the teeth imbrication, irregularly and gaps on the model/cast is necessary for it to be visible
in the mouth.
The following parameters are checked at try in before the patient looks at the teeth:
1. Occlusion must be the same on the articulator as in the patients mouth
2. The aesthetics.
The patient is photographed extra- orally with the trial set up in place and a short video taken. The
photographs are placed on a screen and can be inspected by the patient and dental nurse, without the
dentist being present. The teeth are adjusted or a new try-in carried out until the patient is completely
happy. The patient can take this home to assess if they wish. It is essential that there is no pressure placed
on the patient to accept the denture aesthetically until they are completely happy.
Wax try in – gaining patient acceptance of their new dentures using video
The patient sees a much more realistic appearance of themselves if they observe a video (with the sound
turned down) of themselves talking, smiling and communicating with the denture try in – in place.
I have found the use of video to be very helpful in gaining patient acceptance. Since using video at the try
in from 2013 onwards. Since this time just one patient has required a remake owing to not being happy
with the aesthetic outcome.
This has the further advantage that in some cases the patient may be able to settle for very good
removable dentures and save the considerable effort and expense of implants, etc.
At the fitting appointment of new dentures I check the comfort of the denture fitting surface (intaglio) by
first asking the patient - “Is it sore?” when I push down on it in the mouth. If it is sore I ask – “please point
to the area “. I then place light bodied silicone impression material on the fitting surface and refit the
denture in the mouth and wait for it to set. If the denture fitting surface pushes through the impression
material in a place the patient has identified as being sore I use a china graph pencil on this, peel off the
silicone and grind down the pencil mark. I repeat this until it is comfortable.
This method reduced the number of postoperative adjustments at the review visit by 50%.
The occlusion is checked, by asking the patient if one side contacts before the other when closing together
in retracted contacted position/habitual biting position. Miller’s forceps holding articulating paper are
used to mark up the contacts. The contacts adjusted are the ones on the side the patient feels is contacting
earlier. This is carried out until the patient feels that the bite is even when closing together.
At the fitting appointment, I ensure that the new dentures are comfortable by the time the patient leaves,
as any degree of soreness will gradually worsen as the dentures are worn.
As the dentures are removable mechanical substitutes for missing living tissues and as such exhibit
movement when chewing food, talking and when the tongue and muscles of the mouth move. This
improves with time with adaptation. This normally takes between 6 weeks to 12 months.
Occasionally, during the week the patient may find the new dentures too sore to wear. In these
circumstances, I advise the patient to leave them out and revert to their previous set of dentures. I instruct
them to wear the new dentures for the two consecutive days before their review appointment, wearing
them for the same length of time they would normally wear their dentures. This allows me to see exactly
where the dentures are rubbing, thus enabling precisely accurate adjustment of the denture at the review.
New memory patterns through neuromuscular control require time to be established in order for the
muscles of the tongue, cheeks and lips to keep the dentures in position.
The occlusion on the dentures are designed like this on purpose to encourage the patent to bite using the
premolars rather than the incisors which reduces tipping forces on the dentures.
Review
The dentures are reviewed 5-7 days after insertion. Pressure sores are relieved using mizzy paste, placed
on ulcers and picking up inside the denture. The dentures are adjusted until it is more comfortable. The
occlusion is checked as at the fit stage.
Figure 27 Molloplast B soft lining for patients with denture bearing support problems
Spare dentures
At the end of treatment some patients request a spare denture in case of emergency.
I discuss the process of fabricating the spare with Rowan (dental technician) looking at the laboratory work
(casts) we have of the patient. We plan the treatment and number of visits carefully so that an accurate
quotation can be made.
Making a well-fitting spare denture often involves 4 visits and I am mindful to concentrate on this as much
as the original denture made.
Dr Finlay Sutton
BDS, DGDP (UK), MSc, MFDS RCS Ed, MRD RCS Ed, PhD, FDS (Rest Dent) RCS Ed
Registered Specialist in Restorative Dentistry, Prosthodontics, Endodontics and Periodontics
Mr Rowan Garstang
BSc, Hons, HNC, OND
Registered Dental Technician
Finlay qualified as a dentist in Sheffield in 1993 and worked in General Dental Practice for 6 years. He has
always had a desire to provide the best possible treatment for his patients and has continued to develop
professionally through specialist training leading to; MSc in fixed and removable prosthodontics, PhD and
two Specialist qualifications (MRD and FDS). He has previously been a Senior Clinical Teaching Fellow and
Consultant in Restorative Dentistry at the University Dental Hospital of Manchester at Liverpool University
Dental Hospital.
Rowan was previously the Chief Dental Technician in Prosthodontics at the University Dental Hospital of
Manchester for ten years, having started working there in 1987. He trained Dental technicians at the
University of Manchester for over 15 years. Rowan and Finlay have worked together since 1999 and have,
over the years, satisfied the dental needs of many people throughout the North West of England. In
addition, Rowan provided all of the invaluable technical work for Finlay’s PhD.