Medical knowledge | Dentistry » Gunnar-Carlsson - Facts and fallacies, An evidence base for complete dentures

0ROSTHODONTICS UNNAR % #ARLSSON &ACTS AND &ALLACIES !N %VIDENCE "ASE FOR #OMPLETE $ENTURES !BSTRACT 4HE RATE OF EDENTULISM IS FALLING BUT MANY EDENTULOUS PEOPLE STILL NEED COMPLETE DENTURES 4HERE IS POOR CORRELATION BETWEEN THE QUALITY OF DENTURES AND PATIENT SATISFACTION 4HERE IS NO EVIDENCE THAT A MORE COMPLEX FABRICATION TECHNIQUE INCLUDING FACE BOW REGISTRATION RESULTS IN A BETTER CLINICAL OUTCOME "ALANCED OCCLUSIONARTICULATION IS NOT NECESSARY FOR SUCCESSFUL COMPLETE DENTURE FUNCTION 6ARIATIONS IN MATERIALS AND TECHNIQUES APPEAR TO HAVE ONLY MINOR INFLUENCE IF ANY ON THE CLINICAL END RESULT 0SYCHOSOCIAL FACTORS ESPECIALLY A GOOD RELATIONSHIP BETWEEN DENTIST AND PATIENT ARE MORE IMPORTANT THAN PROSTHODONTIC FACTORS FOR A POSITIVE OUTCOME #LINICAL 2ELEVANCE #REATING A GOOD RELATIONSHIP BETWEEN THE DENTIST AND THE PATIENT IS EXTREMELY IMPORTANT FOR A SUCCESSFUL OUTCOME OF A COMPLETE DENTURE TREATMENT $ENT 5PDATE     4HE POSSIBILITY OF

PROVIDING EDENTULOUS PATIENTS WITH A TREATMENT OPTION OTHER THAN COMPLETE DENTURES HAS ONLY BEEN AVAILABLE FOR ABOUT  YEARS !LTHOUGH THE INTEREST IN IMPLANT DENTISTRY HAS GROWN QUICKLY DURING THE LAST TWO DECADES THE GREAT MAJORITY OF THE WORLDS EDENTULOUS PATIENTS STILL HAVE TO ACCEPT COMPLETE DENTURES BECAUSE ECONOMICAL AND OTHER CONSIDERATIONS PRECLUDE ANY IMPLANT RELATED TREATMENT OPTION )N MANY COUNTRIES ORAL HEALTH IS IMPROVING AND THE RATE OF EDENTULISM IS FALLING WHICH WILL LEAD TO A DECREASING NEED FOR COMPLETE DENTURES (OWEVER IN THE 53! IT HAS BEEN ESTIMATED THAT IN SPITE OF THE FALLING RATE OF EDENTULISM THE NUMBER OF EDENTULOUS JAWS WILL INCREASE UP TO YEAR  BECAUSE OF THE GROWTH OF THE ELDERLY POPULATION 7HEN DISCUSSING THE IMPLICATIONS OF THIS PARADOX FOR THE DENTAL COMMUNITY ONLY COMPLETE DENTURES WERE CONSIDERED IMPLANTS WERE NOT EVEN MENTIONED AS A TREATMENT OPTION 4HE REASON IS OF COURSE THAT THE EDENTULOUS UNNAR % #ARLSSON ,$3 /DONT $R 0H$ $R /DONT

HC $R $ENT HC &$3 2#3 0ROFESSOR %MERITUS &ACULTY OF /DONTOLOGY ÚTEBORG 5NIVERSITY "OX  3%   ÚTEBORG 3WEDEN  $ENTAL5PDATE PATIENTS BELONG TO THE POOREST SECTOR OF THE POPULATION AND ARE NOT EXPECTED TO ASK FOR IMPLANT TREATMENT &ROM THE RAPIDLY INCREASING PART THAT IMPLANTS TAKE IN MANY DENTAL CONFERENCES ESPECIALLY THOSE IN PROSTHODONTICS PERIODONTOLOGY AND ORAL SURGERY THE IMPRESSION THAT THE MAIN PART OF A DENTISTS WORK TODAY CONSISTS OF IMPLANT RELATED TREATMENT MAY BE &IGURE  .UMBER OF ARTICLES IN FOUR AREAS OF PROSTHODONTICS LISTED IN -EDLINE PER DECADE FROM  TO  &OR #OMPLETE $ENTURES #$ 2EMOVABLE 0ARTIAL $ENTURES 20$ AND &IXED 0ARTIAL $ENTURES &0$ THE SEARCH EXCLUDED IMPLANTS &OR IMPLANTS THE SEARCH INCLUDED DENTAL IMPLANTS AND PROSTHESIS )MPL 0ROS  !PRIL  0ROSTHODONTICS GIVEN 4HE DEVELOPMENT OF THE LITERATURE IN PROSTHODONTICS WITH AN EXTREMELY RAPID INCREASE OF ARTICLES ON IMPLANTS AND A

DIMINISHING PROPORTION OF TEXTS ON CONVENTIONAL PROSTHODONTICS GIVES A SIMILAR FEELING &IGURE   (OWEVER THE FACT IS THAT THE MAJORITY OF THE DAILY PROSTHODONTIC WORK OF GENERAL DENTAL PRACTITIONERS CONSISTS OF CROWNS SMALL BRIDGES AND REMOVABLE DENTURES %PIDEMIOLOGICAL STUDIES ON THE PREVALENCE OF DENTAL IMPLANTS ARE RARE BUT A ROUGH ESTIMATION AT THE END OF THE S INDICATED THAT ON A GLOBAL LEVEL AT MOST  OF TOTALLY AND PARTIALLY EDENTULOUS PATIENTS HAD BENEFITED FROM TREATMENT WITH IMPLANT SUPPORTED PROSTHESES !CCORDING TO THE LATEST PUBLISHED DATA FROM 3WEDEN  OF THE EDENTULOUS SUBJECTS HAD RECEIVED DENTAL IMPLANTS !T LEAST A FEW YEARS AGO IT WAS STATED THAT 3WEDEN HAD THE HIGHEST PENETRATION RATE OF IMPLANT TREATMENT IN THE WORLD  IMPLANTS PER   PEOPLE COMPARED TO  IN THE 53! AND EVEN LOWER IN THE 5NITED +INGDOM  ! RECENT ESTIMATION IN THE 53! REPORTED THAT ONLY  OF TEETH BEING REPLACED ARE BEING REPLACED WITH IMPLANTS 4HE OTHER  ARE

STILL BEING REPLACED WITH TRADITIONAL PROSTHODONTIC METHODS OF TREATMENT %VEN IF AVAILABLE EPIDEMIOLOGICAL DATA ARE LIMITED IT IS EVIDENT THAT FOR MANY YEARS TO COME COMPLETE DENTURES WILL CONTINUE TO BE THE MOST COMMON TREATMENT ALTERNATIVE FOR EDENTULOUS PATIENTS NOT ONLY IN THE 53! BUT ALL OVER THE WORLD 4HIS DESERVES CONTINUING CONSIDERATION BY THE DENTAL COMMUNITY AND SOCIETY .EVERTHELESS THE COMPLETE DENTURE MARKET WILL DIMINISH OVER THE NEXT  YEARS IN SOME COUNTRIES INCLUDING THE 5+ UP TO n 4HIS WILL UNDOUBTEDLY AFFECT DENTAL EDUCATION AND DENTAL CARE PROVIDERS   &ABRICATION OF COMPLETE DENTURES HAS HAD A LONG AND SUCCESSFUL HISTORY #OMPLETE DENTURES HAVE BENEFITED EDENTULOUS PATIENTS BY GIVING MOST OF THEM AN AESTHETIC FUNCTIONAL AND SOCIALLY ACCEPTABLE REPLACEMENT FOR THEIR LOST TEETH -ALADAPTIVE DENTURE WEARERS HAVE BEEN RELATIVELY FEW AND BEFORE THE ERA OF OSSEOINTEGRATED IMPLANTS THEY HAD TO BE TREATED WITH VARIOUS MODIFICATIONS OF CONVENTIONAL

TECHNIQUES 7HEN THESE ALSO FAILED THEY WERE OFTEN DISMISSED AS LONG TERM COMPLAINERS -ANY DENTISTS HAVE REGARDED MALADAPTIVE DENTURE WEARING AS A RESULT OF ANATOMICAL AND PHYSIOLOGICAL !PRIL  CAUSES WHEREAS CURRENT KNOWLEDGE EMPHASIZES PSYCHOSOCIAL FACTORS MORE )T IS THE PURPOSE OF THIS PAPER TO REVIEW CURRENT EVIDENCE FOR SELECTED PROCEDURES IN COMPLETE DENTURE FABRICATION BASED ON A SCRUTINY OF THE PROSTHODONTIC LITERATURE FEW YEARS WILL BE LISTED PRINICIPALLY BUT THEY INCLUDE A GREAT NUMBER OF REFERENCES TO EARLIER PUBLICATIONS 0ATIENT SATISFACTION $ENTURE QUALITY ,ITERATURE ON COMPLETE DENTURES 4HERE ARE NUMEROUS ARTICLES AND A GREAT NUMBER OF TEXTBOOKS ON COMPLETE DENTURES IN THE DENTAL LITERATURE )N &EBRUARY  -EDLINE0UB-ED LISTED  PAPERS IN A SEARCH OF COMPLETE DENTURES EXCLUDING DENTAL IMPLANTS 4HERE IS A MARKED DECREASE DURING THE LAST DECADE ESPECIALLY IN COMPARISON WITH THE EXPLOSIVE INCREASE OF ARTICLES ON IMPLANT SUPPORTED PROSTHESES DURING THE

LAST TWO DECADES &IGURE   (OWEVER THE NUMBER OF ARTICLES ON COMPLETE DENTURES IS LARGE AND PRACTICALLY IMPOSSIBLE TO REVIEW FOR A SINGLE PERSON ! SELECTION MUST THEREFORE BE DONE EG BASED ON THE QUALITY OF THE PAPERS !CCORDING TO THE PRINCIPLES OF @EVIDENCE BASED DENTISTRY IT IS AGREED THAT A RANDOMIZED CONTROLLED TRIAL 2#4 IS THE MOST SCIENTIFICALLY SOUND METHOD TO ESTABLISH RELIABLE CONCLUSIONS ABOUT THE EFFECTIVENESS OF THERAPEUTIC ALTERNATIVES 4HUS TO GET A FIRM EVIDENCE BASE FOR A SCRUTINY OF THE COMPLETE DENTURE LITERATURE WE SHOULD LOOK FOR 2#4S 4HE PROPORTION OF 2#4S IN THE PROSTHODONTIC LITERATURE IS HOWEVER VERY SMALL ,ESS THAN  OF ARTICLES PUBLISHED IN THREE 53 PROSTHODONTIC JOURNALS DURING THES WERE 2#4S )N AN EXTENSIVE REVIEW OF THE PROSTHODONTIC LITERATURE  2#4S WERE IDENTIFIED UP TO THE END OF YEAR  AND ONLY A FEW OF THEM WERE RELATED TO COMPLETE DENTURE FABRICATION 4HE HARSH CONCLUSION OF THE EVALUATION OF THE 2#4S WAS THAT ONLY FEW

STUDIES WERE REPORTED IN ACCORDANCE WITH CONTEMPORARY GUIDELINES FOR ADEQUATE REPORTING OF TRIALS 4HERE ARE THUS OBVIOUS LIMITATIONS WHEN ONE TRIES TO FIND STRONG EVIDENCE FOR BEST METHODS IN COMPLETE DENTURE FABRICATION )T MAY BE COMFORTING TO SEE THAT THERE ARE SIMILAR DIFFICULTIES IN OTHER SEGMENTS OF DENTISTRY AND IN MEDICINE !CKNOWLEDGING THESE LIMITATIONS AN ATTEMPT WILL BE MADE TO ASSESS THE AVAILABLE EVIDENCE CONCERNING SOME OFTEN DISCUSSED ISSUES IN COMPLETE DENTURE FABRICATION !RTICLES FROM THE LAST 4EXTBOOKS AND UNDERGRADUATE TEACHING HAVE STRONGLY EMPHASIZED THAT THE BEST WAY TO ACHIEVE A SUCCESSFUL OUTCOME OF TREATMENT WITH COMPLETE DENTURES IS TO FOLLOW THE TRADITIONAL PROSTHODONTIC RULES FOR OPTIMAL QUALITY (OWEVER SEVERAL STUDIES HAVE DEMONSTRATED THAT THERE IS OFTEN POOR CORRELATION BETWEEN A DENTISTS ASSESSMENT OF DENTURE QUALITY AND A PATIENTS SATISFACTION WITH THE TREATMENT 4HE MAJORITY OF COMPLETE DENTURE WEARERS ARE SATISFIED WITH THEIR DENTURES

IRRESPECTIVE OF THE QUALITY OF THE DENTURES AND SOME ´ ARE DISSATISFIED EVEN IF THE DENTURES ARE CONSTRUCTED ACCORDING TO ALL PROSTHODONTIC RULES 4HIS FINDING MAY EXPLAIN WHY A PATIENT COMPLAINS ABOUT THE DENTURES WHEN THE QUALITY IS ASSESSED AS EXCELLENT 4HE OPPOSITE ALSO EXISTS )N A STUDY OF  COMPLETE DENTURE WEARERS A CLOSE CORRELATION WAS FOUND BETWEEN DENTIST AND PATIENT APPRECIATION WHEN THE DENTURES WERE RATED AS POOR BUT LITTLE OR NO CORRELATION WHEN DENTISTS OR PATIENTS RATED THE DENTURES HIGHLY 4O BE ABLE TO STUDY THE RELATIONSHIP BETWEEN PATIENT SATISFACTION AND PROFESSIONALLY ESTIMATED CONDITIONS FOR COMPLETE DENTURE FABRICATION A CONCEPT WAS CREATED CALLED @PROSTHETIC CONDITION WHICH COMBINES THE QUALITY OF THE DENTURES AND RESIDUAL RIDGES 4HE RESULTS DEMONSTRATED THAT NO VARIABLE OF THE @PROSTHETIC CONDITION WAS SIGNIFICANTLY CORRELATED WITH DENTURE SATISFACTION $ENTISTS RELINE OR REPLACE POORLY FITTING DENTURES TO IMPROVE DENTURE QUALITY AND

PATIENT SATISFACTION )T IS COMFORTING FOR DENTISTS TO SEE THAT THE MAJORITY OF THE PATIENTS ARE SATISFIED WITH THE MODIFIED OR NEW DENTURES BUT DISTURBING THAT NOT ALL ARE PLEASED 4HIS UNDERLINES THE OFTEN POOR CORRELATION BETWEEN DENTURE QUALITY AND PATIENT SATISFACTION  )T ALSO DESERVES ATTENTION THAT BITE FORCE AND MASTICATORY PERFORMANCE TEND TO DIMINISH RATHER THAN IMPROVE FOR A SUBSTANTIAL TIME PERIOD AFTER DELIVERY OF NEW DENTURES  4HERE IS ALSO NO EVIDENCE THAT MAKING BETTER DENTURES WILL CHANGE DIETARY SELECTION OR IMPROVE THE $ENTAL5PDATE  0ROSTHODONTICS A B /RIENTATION &IGURE  4WO EXAMPLES OF @DIFFICULT DENTURE BIRDS ACCORDING TO ! +OPER WITH PERMISSION  QUALITY OF DIET IN EDENTULOUS SUBJECTS  4HESE DISCOURAGING RESULTS REGARDING THE IMPORTANCE OF DENTURE QUALITY SHOULD OF COURSE NOT BE TAKEN AS AN INVITATION TO IGNORE ALL ATTEMPTS TO MAKE THE DENTURES AS GOOD AS POSSIBLE
3TATE OF ORAL TISSUES )T IS USUALLY EXPECTED THAT THE

PROGNOSIS OF A DENTURE TREATMENT IS CLOSELY RELATED TO THE STATE OF THE DENTURE SUPPORTING TISSUES -ANY STUDIES HAVE FAILED TO VERIFY THIS BELIEF  /NE STUDY COMPARED CLINICIANS RATINGS OF THE STATE OF ORAL TISSUES AND THEIR SATISFACTION WITH TREATMENT OF EDENTULOUS MANDIBLES TO PATIENTS RATINGS OF TREATMENT SUCCESS .ONE OF THE CLINICAL VARIABLES EXAMINED WAS SIGNIFICANTLY CORRELATED WITH PATIENT SATISFACTION EITHER BEFORE OR AFTER TREATMENT )T WAS CONCLUDED THAT CLINICIANS ASSESSMENTS OF THE QUALITY OF DENTURE SUPPORTING TISSUES ARE POOR PREDICTORS OF PATIENT SATISFACTION WITH MANDIBULAR PROSTHESES 0SYCHOLOGICAL FACTORS )T HAS LONG BEEN ACKNOWLEDGED THAT A PATIENTS PERSONALITY AND PSYCHOLOGICAL FACTORS ARE INVOLVED IN THE OUTCOME OF TREATMENT WITH COMPLETE DENTURES ! HUMOROUS ATTEMPT TO DESCRIBE THE OFTEN PAINFUL INSIGHT WHICH DENTISTS  $ENTAL5PDATE HAVE ACQUIRED OF PROBLEMATICAL DENTURE PATIENTS IS A SERIES OF ARTICLES ABOUT @DIFFICULT DENTURE BIRDS &IGURE

  4HERE ARE ALSO SEVERAL STUDIES ON THIS TOPIC /NE SUCH STUDY FOUND THAT ONE GROUP CONSISTENTLY COMPLAINED ABOUT THEIR DENTURES AND THAT AMONG PERSONALITY FACTORS NEUROTICISM HAD A SIGNIFICANT RELATIONSHIP WITH DENTURE DISSATISFACTION ! RECENT STUDY CORROBORATED PREVIOUS FINDINGS THAT DENTISTS AND PATIENTS INTERPERSONAL APPRAISALS OF EACH OTHER WERE MOST SIGNIFICANT FACTORS ACCOUNTING FOR PATIENTS EVALUATION OF TREATMENT OUTCOME !LSO EARLIER REVIEWS OF THE LITERATURE SUGGESTED THAT THE CREATION OF A GOOD RELATIONSHIP WITH THE PATIENT IS MORE IMPORTANT THAN A TECHNICALLY PERFECT DENTURE CONSTRUCTION FOR ACHIEVING PATIENT SATISFACTION  *AW RELATION RECORDS !MONG THE PROCEDURES INCLUDED IN COMPLETE DENTURE FABRICATION THOSE RELATED TO RECORDING THE MAXILLOMANDIBULAR RELATIONSHIP PROBABLY CONTAIN MOST CONTROVERSIES *AW RELATIONS CAN BE CLASSIFIED INTO THREE GROUPS „ /RIENTATION „ 6ERTICAL RELATION „ (ORIZONTAL RELATION /RIENTATION RELATION ESTABLISHES THE

REFERENCES IN THE CRANIUM AND ORIENTING THE CASTS OF THE EDENTULOUS JAWS TO THE ARTICULATOR USUALLY BY USING SOME TYPE OF A FACE BOW RECORD 6ARYING WITH THE CLINICIANS BELIEF OF THE IMPORTANCE OF SIMULATING THE PATIENTS JAW MOVEMENTS ON THE ARTICULATOR A GREAT VARIETY OF REGISTRATION METHODS AND INSTRUMENTS ARE USED )T IS GENERALLY SUGGESTED THAT THE MORE SOPHISTICATED THE METHODS THAT ARE USED THE BETTER THE RESULTS THAT WILL BE ACHIEVED ! CLASSICAL SERIES OF 2#4S INITIATED IN  REFUTED THAT BELIEF LONG AGO 4HIS STUDY COMPARED  EDENTULOUS PATIENTS RANDOMLY ALLOCATED TO TWO TREATMENT GROUPS ONE COMPLEX TECHNIQUE INVOLVING HINGE AXIS LOCATION FOR A FACE BOW TRANSFER TO THE ARTICULATOR THE OTHER USING A SIMPLE TECHNIQUE WITHOUT FACE BOW AND WITH AN ARBITRARY MOUNTING 4HE PATIENTS WERE FOLLOWED OVER  YEARS WITH EXTENSIVE CLINICAL AND RADIOGRAPHIC EXAMINATIONS 4HE RESULTS HAVE BEEN PRESENTED IN NINE ARTICLES ONLY TWO OF THE FOLLOW UPS ARE LISTED   .O SIGNIFICANT

DIFFERENCE IN OUTCOME BETWEEN THE DENTURES CONSTRUCTED BY THE TWO TECHNIQUES WAS FOUND EITHER IN THE SHORT OR LONG TERM ASSESSMENTS 4HIS WAS TRUE FOR BOTH PROFESSIONAL AND PATIENT EVALUATIONS )NTERESTINGLY ABOUT THREE QUARTERS OF THE PATIENTS IN BOTH GROUPS EVALUATED AT  YEARS WERE WEARING THE ORIGINAL UNMODIFIED DENTURES )N SPITE OF THE STRONG EVIDENCE DEMONSTRATED BY THIS WELL DESIGNED AND WELL CONDUCTED SERIES OF STUDIES PRACTICALLY ALL PROSTHODONTIC TEXTBOOKS UP TO NOW HAVE CONTINUED TO RECOMMEND THE USE OF FACE BOW RECORDS AND  OF 53 DENTAL SCHOOLS STILL INCLUDE IT IN THEIR PRECLINICAL CURRICULUM ! MORE CRITICAL VIEW ON THE VALUE OF THE FACE BOW IS DEVELOPING AS MORE RESEARCH ON THIS SUBJECT IS BEING PUBLISHED 4WO RECENT STUDIES HAVE CORROBORATED THAT MOUNTING IN THE ARTICULATOR WITH OR WITHOUT FACE BOW GIVES SIMILAR CLINICAL RESULTS  !MONG GENERAL PRACTITIONERS THE VALUE OF THE FACE BOW HAS BEEN QUESTIONED AND AT ANY RATE IN 3CANDINAVIA THE USE OF FACE BOWS HAVE

BEEN ABANDONED LONG AGO NOT ONLY FOR COMPLETE DENTURE FABRICATION BUT ALSO IN OTHER TYPES OF PROSTHODONTIC WORK 4HE REASON SUPPORTED BY THE 3CANDINAVIAN 3OCIETY FOR 0ROSTHETIC $ENTISTRY IS THAT THERE IS NO PUBLISHED EVIDENCE SHOWING THAT THE !PRIL  0ROSTHODONTICS A  7ITH DENTURES SOUNDING @M  B -EAN POSTURAL FACE HEIGHT . N MM 7ITH DENTURES RELAXATION 7ITHOUT DENTURES SOUNDING @M  7ITHOUT DENTURES RELAXATION /CCLUSION    )NSERTION  DAYS ! 0 %XAM ) %XAM ))  DAYS %XAM ))) &IGURE  6ARIATION IN POSTURAL REST POSITION AND FACE HEIGHT DURING A  DAY CEPHALOMETRIC FOLLOW UP STUDY IN  EDENTULOUS PATIENTS 4HE REST POSITION WAS DETERMINED WITH EITHER A PHONETIC METHOD SOUNDING @M OR BY RELAXATION AND WITH OR WITHOUT DENTURES IN THE MOUTH !  OLD 0  NEW COMPLETE DENTURES -ODIFIED AFTER #ARLSSON AND %RICSON  WITH PERMISSION  &IGURE  #ASTS WITH OCCLUSAL RIMS MOUNTED ON A SEMI ADJUSTABLE ARTICULATOR ACCORDING TO AN

AVER AGE VALUE TECHNIQUE A LATERAL VIEW B ANTERIOR VIEW USE OF A FACE BOW WILL LEAD TO BETTER CLINICAL END RESULTS THAN WHEN NOT USING A FACE BOW !VERAGE MOUNTING IN THE ARTICULATOR IS EASY TO PERFORM &IGURE   4HOSE WHO THINK THAT FACE BOW REGISTRATION WORKS WELL CAN OF COURSE CONTINUE USING IT BUT THEY SHOULD NOT MAINTAIN THAT IT IS A SCIENTIFICALLY BASED METHOD 6ERTICAL RELATION 4HERE ARE SEVERAL DIFFERENT METHODS FOR ESTABLISHING THE VERTICAL MAXILLOMANDIBULAR RELATIONSHIP IN COMPLETE DENTURE FABRICATION .O SYSTEMATIC COMPARATIVE STUDIES OF SUCH METHODS ARE AVAILABLE SO THERE IS NO SCIENTIFIC BASIS FOR DETERMINING A CORRECT VERTICAL DIMENSION OF OCCLUSION 6$/  -ANY OF THE METHODS  $ENTAL5PDATE INCLUDE THE USE OF THE POSTURAL REST POSITION AND THE SO CALLED FREEWAY SPACE IE THE SEPARATION BETWEEN THE TEETH OR OCCLUSION RIMS WHEN THE MANDIBLE IS RELAXED ! COMMON RECOMMENDATION IS TO HAVE A FREEWAY SPACE OF  TO  MM "ESIDES THE QUESTIONABLE USE OF MEAN

VALUES WHEN INDIVIDUAL VARIATION IS GREAT BOTH INTRA ORAL AND GENERAL FACTORS CAN SUBSTANTIALLY INFLUENCE THE POSTURAL POSITION OF THE MANDIBLE 4HE METHODS USED FOR DETERMINING THE POSTURAL POSITION EG RELAXATION SWALLOWING OR PHONETICS AS WELL AS THE PRESENCE OR ABSENCE OF DENTURES OR OCCLUSION RIMS AND THE HEIGHT OF THESE CAN AFFECT THE REST POSITION %VEN THOUGH THIS WAS DEMONSTRATED LONG AGO &IGURE   MANY TEXTS STILL RECOMMEND THE FREEWAY SPACE METHOD 4HE METHOD WITH AN AVERAGE FREEWAY SPACE IN DETERMINING THE 6$/ IS NOT RELIABLE AND SHOULD BE COMBINED WITH AN ASSESSMENT OF PATIENT COMFORT AESTHETIC AND FUNCTIONAL CONSIDERATIONS (ORIZONTAL RELATION )T IS ALMOST UNIVERSALLY PRESUMED THAT THE CENTRIC RELATION #2 IS THE MANDIBULAR POSITION OF CHOICE WHEN RECORDING THE HORIZONTAL POSITION OF THE OCCLUSION ! COMPLICATION IS THAT THERE IS NO CONSENSUS HOW TO DEFINE #2 4HE CURRENT !CADEMY OF 0ROSTHODONTICS LOSSARY OF 0ROSTHODONTIC 4ERMS GIVES SEVEN DEFINITIONS

!LTHOUGH THE DEFINITIONS ARE SOMEWHAT DIFFERENT THEY ALL AGREE THAT #2 IS DETERMINED BY THE 4-* STRUCTURES AND NOT BY THE DENTITION WHICH IS GOOD WHEN TREATING EDENTULOUS SUBJECTS  4HERE IS ALSO DISAGREEMENT OF HOW BEST TO DETERMINE #2 CLINICALLY 4HE CONFLICTING IDEAS HAVE EVOKED STRONG EMOTIONS OVER MANY YEARS AND THEY STILL EXIST -OST PROBABLY THE SMALL DEVIATIONS IN LOCATION OF MANDIBULAR POSITIONS RESULTING FROM THE VARIATION OF METHODS USED ARE OF MINOR CLINICAL IMPORTANCE IN COMPLETE DENTURE FABRICATION %VEN IF IT IS ALMOST A CONSENSUS THAT #2 IS PREFERABLE WHEN RECORDING THE HORIZONTAL JAW RELATION THERE IS A LESS !PRIL  0ROSTHODONTICS UNANIMOUS OPINION ABOUT THE LOCATION OF THE MAXIMUM INTERCUSPATION 4HE CURRENT TERMINOLOGY DEFINES CENTRIC OCCLUSION #/ AS THE OCCLUSION OF OPPOSING TEETH WHEN THE MANDIBLE IS IN #2 IE #2 AND #/ COINCIDE 4HE MOST COMMON CONCEPT IN TEXTS ON COMPLETE DENTURE FABRICATION IS TO HAVE MAXIMUM INTERCUSPATION IN #2 3INCE IT IS KNOWN

THAT THE GREAT MAJORITY OF PEOPLE WITH A NATURAL DENTITION HAVE THEIR MAXIMUM INTERCUSPATION SLIGHTLY ´ UP TO  MM n ANTERIOR TO THE #2 SOME CLINICIANS ARGUE IN FAVOUR OF A @LONG CENTRIC OR @FREEDOM IN CENTRIC ALSO IN COMPLETE DENTURES )N THE CLINICAL SITUATION THIS IS EASILY SOLVED WITHOUT SPECIFIC MEASURES BY NOT USING TOO STEEP CUSP INCLINES ON THE DENTURE TEETH 4HERE IS NO EVIDENCE TO SUPPORT THE VALUE OF ECCENTRIC RELATION RECORDS FOR DETERMINING THE SAGITTAL AND LATERAL CONDYLE PATH INCLINATION .EVERTHELESS TWO THIRDS OF THE UNDERGRADUATE PROGRAMMES IN 53 DENTAL SCHOOLS TEACH THE USE OF PROTRUSIVE RECORD TO SET THE ARTICULATOR !VERAGE SETTING OF THE ARTICULATOR APPEARS TO BE ADEQUATE EG  DEGREES FOR THE SAGITTAL AND  DEGREES FOR THE LATERAL CONDYLE PATH INCLINATION /CCLUSION &ACTORS RELATED TO OCCLUSAL PATTERNS TOOTH FORM AND ARRANGEMENT FOR COMPLETE DENTURES HAVE BEEN THE FOCUS OF HEATED DISCUSSIONS DURING MANY DECADES .UMEROUS OPINION PAPERS HAVE BEEN

PUBLISHED ON THESE TOPICS BUT SYSTEMATIC STUDIES REGARDING THE OVERALL EFFECT ON FUNCTION AESTHETICS LONG TERM MAINTENANCE OF THE SUPPORTING TISSUES AND PATIENT SATISFACTION ARE SCARCE ! RECENT #OCHRANE 2EVIEW ON OCCLUSAL SCHEMES FOUND  TITLES BUT ONLY ONE STUDY THAT FULLY MET THE REVIEWS INCLUSION CRITERIA !MONG THE  PATIENTS IN A CROSS OVER TRIAL COMPARING LINGUALIZED TEETH AND ZERO DEGREE TEETH  PREFERRED THE LINGUALIZED AND FIVE THE ZERO DEGREE DENTURE WHEREAS FIVE HAD NO PREFERENCE !S THE DIFFERENCE WAS STATISTICALLY SIGNIFICANT THE REVIEWERS CONCLUDED THAT THERE IS WEAK EVIDENCE THAT IT MAY BE ADVANTAGEOUS WHEN PROVIDING COMPLETE DENTURES TO PRESCRIBE POSTERIOR TEETH WITH CUSPS TO IMPROVE PATIENT SATISFACTION COMPARED TO PROVIDING CUSPLESS TEETH (OWEVER THEY ADDED THAT THIS !PRIL  CONCLUSION IS ONLY TENTATIVE UNTIL FURTHER WELL CONDUCTED TRIALS ARE UNDERTAKEN 3INCE STRONG EVIDENCE IS LACKING MUCH OF COMPLETE DENTURE OCCLUSION CONTINUES TO BE AN EMPIRICAL

PROCEDURE ! FEW ASPECTS SUPPORTED BY 2#4S WILL BE TAKEN UP #ONCEPTS OF OCCLUSION OR ARTICULATION 4HE MAJOR CONCEPTS HAVE BEEN CATEGORIZED AS „ BALANCED OCCLUSION AND „ NON BALANCED OCCLUSION !S LINGUALIZED OCCLUSION IS ALSO CONSIDERED TO BELONG TO THE FIRST CATEGORY BALANCED OCCLUSION HAS BEEN THE MOST COMMON RECOMMENDATION )T HAS GENERALLY BEEN STATED THAT THE BALANCED OCCLUSION INCREASES THE STABILITY OF THE DENTURES (OWEVER THIS STATEMENT HAS BEEN QUESTIONED SINCE THE BALANCE IS OFTEN LOST DURING CHEWING 3TUDIES HAVE ALSO DEMONSTRATED THAT THE BALANCED OCCLUSION EXISTING AT DELIVERY OF THE DENTURES IS OFTEN LOST WITHIN A RELATIVELY SHORT PERIOD OF TIME WITHOUT PATIENTS COMPLAINING ABOUT IT  ! RECENT 2#4 COMPARED BALANCED OCCLUSION AND CANINE GUIDANCE FOR COMPLETE DENTURES 0ATIENTS ASSESSED CANINE GUIDED DENTURES TO BE SIGNIFICANTLY MORE SATISFYING IN AESTHETIC APPEARANCE MANDIBULAR DENTURE RETENTION AND CHEWING ABILITY !VAILABLE EVIDENCE THUS INDICATES THAT

COMPLETE DENTURES CAN FUNCTION SUCCESSFULLY WITHOUT A BALANCED OCCLUSIONARTICULATION !N EXTENSIVE REVIEW OF THE LITERATURE ON COMPLETE DENTURE OCCLUSION CONCLUDED @$ESPITE ITS BIOMECHANICAL IMPORTANCE OCCLUSION AS WELL AS THE TECHNICAL QUALITY OF THE DENTURE PLAYS ONLY A MINOR ROLE IN DETERMINING SUCCESS OR FAILURE OF A DENTURE TREATMENT ! NUMBER OF PSYCHOSOCIAL FACTORS ARE LIKELY TO BE MORE IMPORTANT THAN PROSTHODONTIC FACTORS FOR A POSITIVE OUTCOME )MPRESSIONS -OST TEXTBOOKS ADVOCATE A TWO STAGE PROCEDURE „ 0RELIMINARY IMPRESSION OFTEN WITH AN IRREVERSIBLE HYDROCOLLOID ALGINATE IN A STOCK TRAY AND „ &INAL IMPRESSION IN A CUSTOM TRAY USUALLY MADE OF ACRYLIC RESIN 4HERE ARE MANY MATERIALS FOR THE FINAL IMPRESSION SUCH AS GYPSUM ZINC OXIDE AND EUGENOL :/% PASTE POLYSULPHIDE RUBBER POLYETHER POLYVINYL SILOXANE AND ALGINATE ! VARIETY OF TECHNIQUES HAVE BEEN DESCRIBED FOR EXAMPLE AS MUCOSTATIC MUCODISPLACIVE OR COMBINATIONS OF THESE AFTER THE AMOUNT OF DISPLACEMENT OF

THE DENTURE SUPPORTING TISSUES 0REFERENCES VARY MUCH AMONG DENTISTS (OWEVER THERE IS NO EVIDENCE THAT ONE TECHNIQUE OR MATERIAL PRODUCES BETTER LONG TERM RESULTS THAN ANOTHER !MONG HUNDREDS OF ARTICLES ON IMPRESSION MATERIALS AND METHODS ONLY ONE 2#4 WAS FOUND ! COMPARISON BETWEEN FLUID WAX OR POLYSULPHIDE RUBBER FOR MANDIBULAR COMPLETE DENTURE IMPRESSION DEMONSTRATED THAT THERE WAS NO DIFFERENCE IN ADJUSTMENT OF THE DENTURES UP TO ONE YEAR AFTER DELIVERY !LTHOUGH IMPRESSION MATERIALS DIFFER IN MANY ASPECTS AND THERE IS A VARIETY OF TECHNIQUES IN TAKING THE IMPRESSIONS IT IS NOT PROBABLE THAT COMPARISONS BETWEEN DENTURES MADE WITH VARYING MATERIALS AND METHODS WOULD LEAD TO SIGNIFICANT DIFFERENCES IN CLINICAL LONG TERM RESULTS 7ITHOUT STRONG EVIDENCE FOR RECOMMENDING A SPECIFIC IMPRESSION MATERIAL AND TECHNIQUE IT IS OF INTEREST TO KNOW THE NORMAL PRACTICE FOR COMPLETE DENTURES AMONG GENERAL PRACTITIONERS ! SURVEY IN A REGION IN THE 5+ REVEALED THAT PRACTICALLY ALL RESPONDING

DENTISTS USED ALGINATES FOR PRIMARY IMPRESSIONS !LSO FOR THE SECONDARY IMPRESSION IRREVERSIBLE HYDROCOLLOID WAS MENTIONED AS AN OPTION BY  :/% PASTE BY  AND POLYVINYL SILOXANE BY  ,ABORATORY SPECIAL TRAYS WERE USED BY  FOR THE FINAL IMPRESSION /THER ASPECTS RELATED TO THE IMPRESSION PROCEDURES EXHIBITED A GREATER RANGE OF CLINICAL PREFERENCES IN COMPARISON TO THE DOMINANT ROLE OF IRREVERSIBLE HYDROCOLLOIDS 4HE USE OF IRREVERSIBLE HYDROCOLLOID FOR PRELIMINARY IMPRESSIONS WAS ALSO DOMINANT  IN .ORTH !MERICAN DENTAL SCHOOLS WHEREAS THE MATERIALS FOR THE FINAL IMPRESSION DIFFERED MARKEDLY FROM 5+ GENERAL PRACTICE  USED ONLY POLYSULPHIDE RUBBER AND  ONLY POLYETHER ! MORE RECENT SURVEY OF 53 DENTAL SCHOOLS FOUND THAT  USED CUSTOM TRAYS WITH BORDER MOULDING FOR FINAL IMPRESSIONS OF WHICH  WERE PERFORMED WITH THE SELECTIVE PRESSURE TECHNIQUE AS DESCRIBED IN MANY TEXTBOOKS )T WAS CONCLUDED THAT EVEN IF THE TEACHING AGREED ON MANY ASPECTS OF IMPRESSION

MAKING $ENTAL5PDATE  0ROSTHODONTICS THERE WERE VARIATIONS REGARDING IMPRESSION PHILOSOPHY AND THE MATERIALS USED "ORDER MOULDING ! STEP IN IMPRESSION MAKING DESCRIBED IN MOST COMPLETE DENTURE TEXTS IS BORDER MOULDING 4HE PURPOSE IS TO MODIFY THE PERIPHERY OF THE TRAY TO ACCOMMODATE THE ACTION OF MUSCLES -ATERIALS RECOMMENDED ARE STICK IMPRESSION COMPOUND POLYETHERS AND ADDITION SILICONES )N   OF 53 DENTAL SCHOOLS USED IMPRESSION COMPOUND FOR BOLDER MOULDING THE FINAL IMPRESSION TRAY .O 2#4S HAVE BEEN PUBLISHED TO ASSESS THE VALUE OF THE BORDER MOULDING METHODS BUT TWO STUDIES CAN BE MENTIONED &OUR PROSTHODONTISTS EACH MADE FIVE IMPRESSIONS WITH BOLDER MOULDING USING EITHER IMPRESSION COMPOUND OR POLYETHER MATERIAL ON ONE EDENTULOUS SUBJECT 4HE POLYETHER MATERIAL WAS REPORTED TO BE EASIER TO HANDLE AND GAVE A MORE CONSISTENT RESULT THAN THE VESTIBULAR IMPRESSION ! RETROSPECTIVE COMPARISON WAS MADE IN A LARGE NUMBER OF PATIENTS WHOSE DENTURES WERE

FABRICATED FROM IMPRESSIONS WITH BORDER MOULDING USING EITHER IMPRESSION COMPOUND OR HEAVY BODY VINYL POLYSILOXANE IMPRESSION MATERIAL 4HE MEAN NUMBER OF POSTINSERTION ADJUSTMENT VISITS OVER ONE YEAR WAS EXACTLY THE SAME  FOR BOTH GROUPS /F THESE TWO STUDIES IT IS CLEAR THAT THE LAST ONE HAS MORE CREDIBILITY REGARDING CLINICAL OUTCOME 4HERE IS THUS WEAK EVIDENCE THAT THE MATERIAL USED FOR BORDER MOULDING DOES NOT INFLUENCE THE DENTURE FUNCTION AND IT IS UP TO THE DENTIST TO CHOOSE A METHOD ON THE BASIS OF HISHER OWN EXPERIENCE AND PERHAPS COST OF MATERIALS  ! DETAIL IN BOLDER MOULDING IS IDENTIFICATION OF THE VIBRATING LINE AND ENHANCING THE POSTERIOR PALATAL SEAL USUALLY BY CARVING A ´ MM DEEP 6 SHAPED GROOVE AT OR SLIGHTLY IN FRONT OF THE VIBRATING LINE 3UCH A CARVING OF THE MAXILLARY MASTER CAST IS TAUGHT BY  OF 53 DENTAL SCHOOLS !GAIN THERE IS NO STUDY THAT HAS EVALUATED THE VALUE OF THIS TECHNIQUE ´ ALL TEXTS SEEM CONVINCED THAT IT IS NECESSARY FOR AN

IMPROVED CLINICAL END RESULT (OWEVER AN INTERESTING STUDY REPORTED INSIGNIFICANT ALTERATION OF RETENTION OF MAXILLARY COMPLETE DENTURES AFTER EXTENSIVE REDUCTION OF THE PALATAL COVERAGE ´ IN FACT ALL THE PALATAL PLATE WAS REDUCED TO  $ENTAL5PDATE A 5 SHAPED BORDER SITUATED APPROXIMATELY  MM FROM THE DENTAL ARCH 4HESE REMARKABLE RESULTS SHOULD WARRANT MORE RESEARCH ON THE VALUE OF ENHANCING THE POSTERIOR PALATAL SEAL IN MAXILLARY COMPLETE DENTURES )N SUMMARY THERE IS A LACK OF SOUND EVIDENCE ON A NUMBER OF COMMON PROCEDURES IN FABRICATION OF COMPLETE DENTURES 3INCE MANY PEOPLE WILL NEED COMPLETE DENTURES FOR MANY MORE YEARS RESEARCH IN THIS FIELD OF PROSTHODONTICS MUST CONTINUE WITH MORE RESEARCHERS USING WELL DESIGNED SYSTEMATIC STUDIES TO HELP ANSWER REMAINING QUESTIONS THAN IN THE PAST     #ONCLUSIONS 4HE NUMBER OF PAPERS THAT CAN PROVIDE STRONG EVIDENCE SUCH AS SYSTEMATIC REVIEWS AND RANDOMIZED CLINICAL TRIALS ARE RARE IN THE FIELD OF COMPLETE DENTURES

!CKNOWLEDGING THESE LIMITATIONS THE FOLLOWING CONCLUSIONS MAY BE DRAWN „ 4HE PREVALENCE OF EDENTULISM IS FALLING BUT THERE ARE STILL NUMEROUS PEOPLE WITHOUT TEETH MOST OF WHOM HAVE TO BE TREATED WITH COMPLETE DENTURES „ 4HE GREAT MAJORITY OF EDENTULOUS PEOPLE SEEM TO BE ABLE TO ADAPT TO COMPLETE DENTURES BUT AN UNKNOWN AND PROBABLY GROWING NUMBER EXPERIENCE DISSATISFACTION „ 4HERE IS POOR CORRELATION BETWEEN THE QUALITY OF THE DENTURES AND PATIENT SATISFACTION „ 4HERE IS NO EVIDENCE THAT A MORE COMPLEX FABRICATION TECHNIQUE INCLUDING THE USE OF FACE BOW REGISTRATION RESULTS IN A BETTER CLINICAL OUTCOME OF COMPLETE DENTURE TREATMENT „ "ALANCED OCCLUSIONARTICULATION IS NOT NECESSARY FOR SUCCESSFUL COMPLETE DENTURE FUNCTION „ 6ARIATIONS IN MATERIALS AND TECHNIQUES APPEAR TO HAVE ONLY MINOR INFLUENCE IF ANY ON THE CLINICAL END RESULT OF COMPLETE DENTURE TREATMENT „ 0SYCHOSOCIAL FACTORS ESPECIALLY A GOOD RELATIONSHIP BETWEEN DENTIST AND PATIENT ARE MORE IMPORTANT THAN

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