**Complete Dentures** Preclinical **An Overview**     Edentulism • Debilitating and irreversible condition • Final marker of disease burden for oral health • Prevalence has declined over the last few decades • Remains a major disease worldwide (especially among older adults) • Prevalence varies both intra-country and inter-country. • Contributing factors may be: ✓ Economic circumstances ✓ Education ✓ Lifestyle ✓ Oral health knowledge & beliefs ✓ Access and attitudes to dental care ✓ Age ✓ Insurance coverage **Edentulism can lead directly to impairment, functional limitation, physical, psychological, and social disability**  **Edentulism** Edentulism can lead directly to impairment, functional limitation, physical, psychological, and social disability Oral rehabilitation with complete dentures can restore chewing, phonetics, aesthetics, self-esteem and dignity of the patient **Oral rehabilitation with complete dentures** can restore chewing, phonetics, aesthetics, self-esteem and dignity of the patient  Epidemiology of Tooth Loss Edentulism **Causes of Tooth Loss** • Dental Caries (63%) • Periodontal Disease (20%) • Dental Trauma • Congenital Disorders • Parafunction • Smoking Epidemiology of Tooth Loss No simple association between edentulism and socio-economic and socio-demographic indicators. Marked ethnic disparities in edentulism and tooth loss have been demonstrated in various parts of the world. e.g. in New Zealand: Maori women **5 times** more likely to be edentulous than Caucasian women. In studies from the 1990’s rates of edentulism were estimated to be between 7% and 69% of the adult population internationally. The loss of teeth is associated with compromised oral function and loss of social status as well as diminished self-esteem. Carlsson, G. E., 2010  **Left Chart: Edentulous Rate vs. GDP per Capita** - X-axis: GDP per capita (US$) - Y-axis: Edentulous rate (%) - Countries plotted: - Low GDP, Low Edentulous: Gambia, Kenya - Low GDP, Moderate Edentulous: Uzbekistan, Sri Lanka, Kyrgyzstan - Middle GDP, High Edentulous: Malaysia, Iceland, Netherlands - High GDP, Low Edentulous: Hong Kong, Sweden, United States **Right Chart: Edentulous Rate vs. Dentists per 10,000 Inhabitants** - X-axis: Dentists per 10,000 inhabitants - Y-axis: Edentulous rate (%) - Highlighted: - Iceland: High dentist density, highest edentulous rate - Kenya & Nigeria: Low dentist density, very low edentulous rate - Other countries: - Moderate Edentulous and Dentist Rates: Finland, Ireland, Saudi Arabia, Spain - Low Edentulous and Higher Dentist Rates: Sweden, Hong Kong, Belarus Trend lines and disparities suggest complex relationships.  Impact of Edentulism on Patient’s Health **Oral Health** General Health Quality of life    Impact of Edentulism on Oral Health **Oral Health** 1. **Tooth loss:** modifier of normal physiology • Alveolar bone loss follows tooth loss • Height of residual ridge and size of denture bearing area are both reduced • Face height and facial appearance 2. **Tooth loss:** risk factor for impaired mastication • Oral function and health related to number of functional tooth units • Reduced bite strength and masticatory force (by 1/5 to 1/4) • Complete denture wearers require seven times more chewing strokes than dentate individuals • Muscular atrophy associated with edentulism 3. **Tooth loss:** determinant of oral health • Edentulism associated with functional and sensory deficiencies of oral mucosa, musculature and sensory glands • Decreased tissue regeneration and decreased tissue resistance lowers protective function of oral mucosa • Increased rate of mucosal disorders (angular cheilitis, denture stomatitis, candidiasis or traumatic ulcers) • May induce oral dyskinesia Emami et al, 2013 Impact of Edentulism on Oral Health **1. Tooth loss:** modifier of normal physiology • Alveolar bone loss follows tooth loss  Impact of Edentulism on Oral Health 1. Tooth loss: modifier of normal physiology - Alveolar bone loss follows tooth loss - Height of residual ridge and size of denture bearing area are both reduced High AB = AC > BC Normal AB = AC = BC Low AB = AC < BC Size of Denture Bearing Area - periodontium / arch 45 cm² - edentulous maxilla 23 cm² - edentulous mandible 12 cm²       Impact of Edentulism on Oral Health 1. Tooth loss: modifier of normal physiology • Alveolar bone loss follows tooth loss • Height of residual ridge and size of denture bearing area are both reduced • **Face height and facial appearance**  Impact of Edentulism on Oral Health 1. Tooth loss: modifier of normal physiology • Alveolar bone loss follows tooth loss • Height of residual ridge and size of denture bearing area are both reduced • Face height and facial appearance 2. Tooth loss: **risk factor for impaired mastication** • Oral function and health related to number of functional tooth units • Reduced bite strength and masticatory force (by 1/5 to 1/4 ) • Complete denture wearers require seven times more chewing strokes than dentate individuals • Muscular atrophy associated with edentulism **Elders with poorer mastication had:** • Significantly lower cognitive function. • A steeper cognitive decline. • Associations with dementia cross-sectionally • An increased risk for incidence of dementia longitudinally. Impact of Edentulism on Oral Health 1. Tooth loss: modifier of normal physiology • Alveolar bone loss follows tooth loss • Height of residual ridge and size of denture bearing area are both reduced • Face height and facial appearance 2. Tooth loss: risk factor for impaired mastication • Oral function and health related to number of functional tooth units • Reduced bite strength and masticatory force (by 1/5 to 1/4) • Complete denture wearers require seven times more chewing strokes than dentate individuals • Muscular atrophy associated with edentulism 3. Tooth loss: determinant of oral health • Edentulism associated with functional and sensory deficiencies of oral mucosa, musculature and sensory glands • Decreased tissue regeneration and decreased tissue resistance lowers protective function of oral mucosa • Increased rate of mucosal disorders (angular cheilitis, denture stomatitis, candidiasis or traumatic ulcers) • May induce oral dyskinesia  Impact of Edentulism on General Health **General Health** • **Dietary changes** • Lower intake of fruits, vegetables, fibre and carotene • Increased cholesterol and saturated fats • Higher prevalence of obesity • **Alterations to the GI tract** • Chronic inflammatory changes of the gastric mucosa • Upper gastrointestinal and pancreatic cancer • Higher rates of peptic or duodenal ulcers • **Increased risk of non-insulin dependent diabetes mellitus** • Excessive intake of highly processed high-fat and high-carbohydrate foods • **Increased risk of cardiac issues** • Hypertension • Heart failure • Ischaemic heart disease • Stroke • Aortic valve stenosis • **Increased risk of chronic kidney disease** • **Association between edentulism and sleep-disordered breathing** Tooth loss in edentulous individuals was found to be associated with the onset of disability and mortality, even after adjusting for confounding factors such as socioeconomic and health behaviour factors. Emami et al 2013 Impact of Edentulism on Quality of Life **Quality of Life** - is defined as an individual’s perception of his or her position in life, in the context of the culture and value systems in which they live, and in relation to their goals, expectations, and concerns. Perception of **QoL** - varies among individuals and fluctuates over time for the same person as a result of changes in any of its component parts Patient’s perceptions of **QoL** - are important in evaluating efficacy of oral health care and are influenced by: • Aesthetic concerns • Speech issues • Impaired mastication • Dental trauma • Social life • Decreased self esteem • Altered taste Clinical measures of treatment efficacy - provide little insight into psychosocial aspects of health **Factors Affecting Denture Satisfaction** **drugs** salivary flow denture retention **systemic factors** **neurological disorders** e.g. Parkinson disease denture retention and neuromuscular control **oral manifestations** of systemic illnesses **e.g. Sjögren's syndrome** denture retention and comfort **psychological factor** personality **neuroticism** denture dissatisfaction **Complete Denture Overview** It is **important** to remember that: Complete dentures are not a substitute for the natural dentition. They are an alternative to edentulism    **Edentulism** *Evolution of Complete Dentures* THE UNIVERSITY OF WESTERN AUSTRALIA Oral Health Centre of Western Australia            **Complete Denture Overview** Stages of Conventional Denture Fabrication Anatomical impression → Anatomical models * **Dentist** * Upper model * Pouring the impression and completing the anatomical models       Complete Denture Overview **Stages of Conventional Denture Fabrication** Anatomical impression Anatomical models Functional impression tray Functional impression Functional models Pouring the impression and completing the anatomical models Fabrication of the functional impression tray made of self curing acrylic Mimetic movement (muscle trimming) Marking the functional borders on the functional impression Trim model up to the marking Complete Denture Overview **Stages of Conventional Denture Fabrication** Anatomical impression Anatomical models Functional impression tray Functional impression Functional models Bite rims Pouring the impression and completing the anatomical models Fabrication of the functional impression tray made of self curing acrylic Mimetic movement (muscle trimming) Marking the functional borders on the functional impression Trim model up to the marking Fabrication of the bite rims on the functional models Complete Denture Overview **Stages of Conventional Denture Fabrication** Anatomical impression Anatomical models Functional impression tray Functional impression Functional models Bite rims Bite recording Dentist Pouring the impression and completing the anatomical models Fabrication of the functional impression tray made of self curing acrylic Mimetic movement (muscle trimming) Trim model up to the marking Fabrication of the bite rims on the functional models Over (UJ) Complete Denture Overview **Stages of Conventional Denture Fabrication** Anatomical impression Anatomical models Functional impression tray Functional impression Functional models Bite rims Pouring the impression and completing the anatomical models Fabrication of the functional impression tray made of self curing acrylic Mimetic movement (muscle trimming) Trim model up to the marking Fabrication of the bite rims on the functional models Bite recording Mounting on the articulator Complete Denture Overview Stages of Conventional Denture Fabrication Anatomical impression Anatomical models Functional impression tray Functional impression Functional models Bite rims Pouring the impression and completing the anatomical models Fabrication of the functional impression tray made of self curing acrylic Mimetic movement (muscle trimming) Marking the functional borders on the functional impression Trim model up to the marking Fabrication of the bite rims on the functional models Bite recording Mounting on the articulator Tooth selection Setup of the teeth A. in the posterior area B. in the anterior area Male Female THE UNIVERSITY OF WESTERN AUSTRALIA Oral Health Centre of Western Australia Complete Denture Overview **Stages of Conventional Denture Fabrication** 1. **Anatomical impression:** Dentist pouring the impression and completing the anatomical models. 2. **Anatomical models:** Upper model. 3. Functional impression tray: Fabrication of the functional impression tray made of self-curing acrylic. 4. **Functional impression:** Dentist mimetic movement (muscle trimming). 5. Functional models: Marking the functional borders on the functional impression. Trim model up to the marking. 6. Bite rims: Fabrication of the bite rims on the functional models. 7. **Bite recording:** Dentist recording the occlusal plane. 8. Mounting on the articulator. 9. **Tooth selection:** Dentist selecting teeth for male and female. 10. Setup of the teeth. A. in the posterior area B. in the anterior area 11. Waxing - Try-in by dentist Complete Denture Overview Stages of Conventional Denture Fabrication **Anatomical impression** Pouring the impression and completing the anatomical models Anatomical models **Functional impression tray** Fabrication of the functional impression tray made of self curing acrylic **Functional Impression** Mimetic movement (muscle trimming) **Functional models** Marking the functional borders on the functional impression Trim model up to the marking **Bite rims** Fabrication of the bite rims on the functional models **Bite recording** **Mounting on the articulator** **Tooth selection** According to sex, type, jaw shape and colour **Setup of the teeth** **Waxing** A. in the posterior area B. in the anterior area **Investing** **Packing and pressing** **Try-in by dentist** **Polym**erization **Finishing** **Final check** Issue of the dentures Dentist Oral Health Centre of Western Australia Complete Denture Overview **Treatment Alternatives** Do Nothing Ov**erdenture** All-on-Four Digital Workflows for Immediately-placed <b>Implant-Supported Prostheses</b>       **Treatment Planning** Poor planning can have unanticipated consequences **George Stathakis** A 46 year old bachelor and chef decided to go over the Niagara Falls in July, 1930 in a massive self-made barrel. His intention was to generate revenue to publish a book on his metaphysical experiences. The barrel, which was 5 ft in diameter, ten feet long and weighed a ton, survived the 170 ft plunge but became trapped behind the falls for twenty hours. Sadly, when the barrel was recovered George had died from suffocation but his 150 year old pet turtle survived. **Proper Planning Prevents Poor Performance** Proper Planning Prevents Poor Performance  Complete Denture Overview **Treatment Schedule** | Visit | Operator | Procedure | |---|---|---| | Visit 1 | Clinician<br>**Laboratory** | Patient evaluation & primary impressions<br>Diagnostic casts & special trays | | Visit 2 | Clinician<br>**Laboratory** | Secondary impressions<br>Bead & box, master casts, base & rims | | Visit 3 | Clinician<br>**Laboratory** | Contour rims, OVD, MMR, shade & mould selection<br>Articulation & tooth setting | | Visit 4 | Clinician<br>**Laboratory** | Wax try-in<br>Finalisation & processing | | Visit 5 | Clinician | Assessment & issue<br>Instructions for care | | Visit 6 | Clinician | Post operative review, post insertion instructions |