Complete and Partial Dentures
The way complete dentures are taught in all the dental schools has not changed in 100 years. Impressions are made of the ridges and a bite relation is secured. A try-in of the waxed-up dentures is shown to the patient. The patient looks at the dentures while in wax and hopefully they give their approval. At this point the dentures are processed, which takes several days or even several weeks and then given to the patient. It is only after the dentures are totally finished that the patient and dentist find out if they will be acceptable.
In all dental treatment where there is a change in the cosmetics or bite of a patient, a temporary restoration is first constructed. For example, if a person is having their front teeth crowned because of unsightly old fillings or crooked and ugly teeth, the patient will wear temporary crowns while the final crowns are being prepared. The patient is able to see a mock-up of how their final crowns will look and function. If the patient is not happy with the temporary crowns, the dentist will alter and change the temporary crowns before the final crowns are placed. In other words, the temporary crowns are a mock-up of the final crowns. If the patient does not like the cosmetics and comfort of the temporary crowns, they will not like the final crowns.
We do not think it was fair and certainly not too smart that the first time the patient got to wear and to take their new dentures on a “test drive”, so to speak, was after they were totally finished.
Constructing a complete denture for a patient is probably the most unpredictable treatment in all of dentistry. Dr. Ange’s mentor, Dr. Jack Turbyfill, developed the Branching Denture Technique that allows the patient to wear and accept the denture while it is in a temporary form prior to making the final denture.
Dr. Turbyfill perfected a technique that he taught Dr. Ange that allows the denture patient to wear their new denture, in a temporary form, to gain their acceptance before we construct their final dentures. There are never two patients who are exactly alike and no two mouths that are exactly alike.
The success or failure of complete denture treatment depends on many things—things that patients should know!! These are all factors that we take into consideration while designing dentures for our patients.
There are basically two kinds of bone. There is cancellous bone and cortical (or basal) bone. Cortical bone is like the bone in the lower part of your leg. You can feel the cortical bone on the front of your lower leg where the skin is thin and it is hard as a rock. Cancellous bone is soft and sort of like a sponge. When our natural teeth grow into the mouth they grow in cancellous (soft) bone. When the teeth are lost, some of the cancellous (soft) bone stays in place. When dentures are constructed and rest on this type of bone they are usually very comfortable. Most times when a patient gets their first denture it is very comfortable but this will not last. It is sad to say, but this cancellous (soft) bone will not last for a lifetime. As the years go by this bone recedes and now as the patient ages the dentures are resting on this basal (hard) bone. Many patients are never totally comfortable when the bone degenerates to this state. The retention of the dentures is adversely affected by the amount of bone. With the loss of bone, the dentures will not have the suction to keep them secure. The companies that make denture adhesive powders and creams are making billions of dollars selling their product due to this process.
There are cases when there is too much bone to make a satisfactory denture. This happens when the teeth are extracted because of decayed and broken teeth. The patient has no bone disease and the bone is healthy, but the teeth are unrestorable. Each of these type cases must be treatment planned according to patient needs and desires.
One thing that we see very often is the total deconstruction of the bone in the upper jaw. Although it can happen for many reasons the most common reason is loss of all upper teeth while saving the lower teeth. The lower front teeth biting too hard against the upper front denture teeth cause this. This heavy bite is caused by the use of plastic teeth, which is accepted as standard treatment by the academic as well as practicing dentures. The only way this bone can be brought back is by surgical placement of bone grafts. There are ways to prevent this or at least keep it from getting any worse.
As a person ages the tissues get softer and I hate to use the word, but the tissues get FLABBIER. These aging tissues do not have the cushioning effect as they once had. A younger person who wears dentures has no problem with retention or comfort because their dentures are resting on cancellous (soft) bone and the tissue over the bone is firm and thick. As the patient ages, the cancellous (soft) bone goes away and the tissues thin and denture comfort may never be achieved. Dentists have available many types and brands of soft, spongy denture liners to help with comfort. Many times these soft liners are a “God send” to the patient with basal (hard) bone and thinning tissues. Most soft liners will not last the life of the denture and require replacement from time to time.
To understand why denture comfort with basal (hard) bone and thin tissues is hard to achieve, it should be pointed out that bone has no sensory nerves and it is nerves in the tissue that makes the denture-bearing areas hurt. With time and thinning of these tissues, the discomfort increases. As we age it becomes easier to bite the inside of the cheek while eating. This happens whether an individual wears dentures or has natural teeth.
3. Patient Adaptability
As we grow older, our ability to adapt and accept changes becomes more difficult. There are people who cannot accept changes. We become set in our ways. A young person can accept and wear a set of bricks in their mouths, but as we age it becomes more difficult to accept changes.
Dentures in a younger person actually become a part of them, but as we age the dentures are like uncomfortable shoes—something that you wear because you have to and can’t wait until you get home and take them off. These are people who can’t stand tight clothes, can’t stand to get sand in their shoes on the beach and things like putting lotion on their face or arms. Many people like this have claustrophobia and can’t stand tight or enclosed places.
4. The Esthetics (Cosmetics) of Dentures
Most times the dentist can position the artificial teeth in a position that is pleasing to the patient. The manufacturers of artificial teeth are now making teeth that are very white to make even the most critical patient happy. Tooth bleaching is becoming very popular. When a person is twenty years of age and their lips are relaxed and slightly open, they will show about 1/3 of an inch of their upper front teeth. All the person has to do is to live to age sixty and with the same lip relaxation they show none of their upper front teeth. As we age the lips get longer due to tissue flab and the mobility of the lips is more restricted. One mistake that some denture patients make is to ask the dentist for teeth that are far too white and youthful for their age. When one who is 80 years old with teeth that look like a 20 year old, it always looks artificial. The looks of the teeth can be any way that makes the patient happy.
5. Chewing Efficiency
The ability to chew foods is the one thing that is such an individual thing that is difficult for a dentist to determine who will do well and who will have problems. Some patients eat anything and whatever they desire. Other patients prepare foods and order foods in restaurants that are easy to chew. If a person gets artificial legs they don’t expect to run a marathon or get an artificial eye and expect to receive vision. Dentures are supposed to do and look like the teeth that God created. Dentistry has come close to matching the looks and function of natural teeth, but they still have shortcomings. Every person knows a person that has dentures and they can eat anything and can bite an apple. It must be understood that functions like biting an apple is a function that the patient learns to perform. Not every person will learn to bite an apple with his or her dentures.
At this point, we need to understand that people do not need teeth to live a healthy life. People have been told that with no teeth they will not chew food well and will have stomach problems and may develop stomach cancer. This is not true. God designed our bodies that if we could swallow a chicken whole, our bodies would digest the chicken. Stomach gas might be a problem for a while, but the chicken will be digested.
6. The Tongue
If a person goes for a long period not wearing any dentures, the tongue will expand to fill the space that nature meant for the teeth to occupy. Now when dentures are introduced, tongue biting might be a problem. In time the tongue will live in harmony with the teeth.
Believe it or not, the way a person holds the tongue when the mouth is opened will affect the stability of the dentures. When opening, if the tip of the tongue stays down and touches the back of the lower front teeth, the dentures will stay down. If; however, the tongue rolls up into the back of the mouth when opening wide, like to take a bite, the denture will lift up. In time most denture patients will learn to open properly.
When a person gets new dentures the speech will always be affected. In time this problem is self-correcting. I think that the reason for this is that the patient is trying too hard not to have the new dentures affect speech. I once had a patient who complained that they could not whistle with the new dentures. No two dentures can be constructed to be exactly alike. If a person has learned to whistle with their old dentures then they will soon learn to whistle with their new dentures.
8. The Jaw Joints
The temporomandibular joints are the most complex joints in the human body. A person has two elbow joints and each side can be moved without moving the other side. The jaw joint cannot be moved without both sides moving. God, in his wisdom, made mans’ jaw actually come unhinged. This unhinging is generally very smooth because the disk that keeps the bone from rubbing together slides along with the jaw joint as it opens and closes.
The complexity of the TMJ is a problem that is much too complicated to discuss in detail in this paper.
I will say that the position, the comfort of this jaw joint is extremely important if the patient is to be functional and comfortable with their dentures.
I often joke that the complexity of the temporomandibular joints is the reason most dentists are bald and grey.
9. About Denture Adhesives and Pastes
Many patients wear denture adhesives and if they wear them long enough, they can become addicted to these products. Even when new dentures are constructed and adhesive is not needed, the patient never feels secure enough not to use these products. I don’t think there are any healthy concerns from using adhesives. Just use a very small amount and keep trying until just the smallest amount will do the job.
10. Cheek Biting
As a person ages and as the inside of the cheeks get a little spongy and softer, it becomes easy to bite the cheeks while eating. People with natural teeth have the same problem. This sometimes can be corrected by changing the shape of some of the teeth.
11. The Palate
People with natural teeth do not have the roof of their mouth covered with plastic. God put rugae on our palate for a reason. Rugae are the little ridges behind the upper front teeth. They are there for clarity of speech and keep a person from spitting when they talk rapidly. If these ridges bother the person they can be polished off, but it is best to keep them. I never saw a person that did not get to the point that they did not know they are there.
Some people have very sensitive palates and touching the roof of the mouth with a finger, taking impressions or wearing a denture can cause gagging. Some can’t brush the inside of their upper teeth in the morning.
When this serious problem is discovered, alternate plans can be made to use, for example, implants. Dental implants are a Godsend for people who have this problem.
The use if implants do not have to be extensive. One patient who has a severe gagging problem had their problem solved with four small implants. This treatment changed the patient’s life. Now she can go out and have dinner with friends. These four small implants gave enough retention to the upper denture that the palate of the denture was removed and the denture still stayed in place.
Many denture patients, especially with their first dentures will say that they can’t taste the food like they did. First there are no taste buds in the roof of the mouth. All taste buds are on the topside of the tongue. I think the reason for this is that with the roof of the mouth covered with the denture base, the texture of the food can’t be felt. I have never seen a patient who did not say a little later “I got my taste back”. This problem is self-limiting.
I would like to recap what happens with a patient who wears dentures for a long time:
If a person loses all their teeth at, say…age thirty, their first denture will be a wonderful success at this time in their life. There is a lot of cancellous bone, the tissues are firm with lots of cushioning effect, lip mobility and firmness is great and with all that, the ability of the young person to adapt to something new is wonderful. I often say that a young person is so adaptable that they could wear a set of bricks in their mouths.
Now let’s follow this 30 year-old patient through their life wearing dentures. Say they have new dentures constructed every six or seven years until they are about 86 years old. Every time that new dentures are constructed, the process becomes more difficult and the results never as satisfactory.
Development of Dental Implants
Dental implants have literally changed the lives of many denture patients. We have the technology in our office to take three-dimensional cat-scans of the jaws. This imaging cat-scan x-ray machine is made especially for the dental patient. At one time the entire body had to be scanned to see the jawbones, but no more. The radiation is only a fraction of a body scan. The treatment dentures are ideal x-ray guides to look at where teeth need to be and the position of the available bone. The jaws are scanned with the treatment dentures in the mouth. The treatment dentures are scanned out of the mouth and the software can put the two together and precise placement of implants can be determined.
Implants can be placed with the use of local anesthetic—no hospital stay is necessary. Patients can be sedated if the thought of the minor surgery is negative.
Most patients who have implants placed rarely even have to take any pain medicine.
The possibility of dental implants can be assessed as the patient wears the treatment dentures, the treatment dentures make great x-ray guides for the cat-scan imaging.