Digital Meets Aesthetics by Ioulianos Moustakis

The patient

The patient is a 67-year-old female who has been wearing full dentures for many years. She was tired of having constant problems with ill-fitting dentures. She had 5 implants placed in the upper arch and 4 in the lower arch. She has good oral hygiene so a compromise between fixed and removable was decided for this patient.

Implant bars

The upper dental implant bar is a Diamart^TM bar with a PEKKTON superstructure
The lower is a Dolder Bar

Aesthetics

Patient has requested a natural looking appearance

Upper structure

Lower structure

Preparations

The original models will be duplicated in order to make the working models, in which it will be done the case. Important: We must be careful in preparing the models so that we have 100% accuracy in copying them and the right result.

The original model was prepared with wax to enlarge the dimension of it, to later trim the functional edge not to be violated.
For the silicone double process at the Maxilla temporary titan abutments were used.

For the silicone double process at the Mandibular it were used narrow transfer caps (Multi Unit) and all the caps were blocked with Pattern Resin between them. The Mandibular and Maxilla duplicated working models are done and the final sanding is made. With a higher extension on the base of plaster models they are high enough to parallel them more accurate.

Setting in the articulator

The Articulator is the device that simulates the movements of the chew, such as opening and closing movements of the mouth, the lateral and protrusion movements as well as the retrusion movements. IMPORTANT: Model analysis can only be done on articulated models.

Articulate the Mandibular model.

After the parallel of the models is made in relation to the bite registration. They are ready to be placed in the articulator. For its positioning: It is important that the occlusal plane is aligned with the rubber band to later place the incisal pointer on the plaster wall to the incisal point.

For its arrangement in the articulator: First, the Mandibular model have to be placed on hard silicone and then with plaster stone on the Maxilla model to fix it, to finally articulate the Mandibular model.

Control the vertical dimension and occlusal plane

Views of the interfacial space conditions of the models after articulating.

Model Analysis

A correct model analysis is an essential part of every setup concept. For this reason, it should be carried out with great care and to the best of our knowledge and belief. It is largely carried out by the user himself. It includes highlighting anatomical features of the upper and lower jaw and automatically merging them into orientation points and planes. (An incorrect model analysis can lead to an incorrect tooth set-up and possibly to a sway of the denture base during chewing movements).

Mandibular: Draw in the two retromolar tubercles and the highest elevation of the alveolar ridge with the pen. The center of the retromolar pads and the position of the tongue band are marked. The retromolar pads are halved. The distance between the center points of the trigons is halved and marked on the model and a connection between the points should be made in the sagittal direction to get the anatomical model center. Incidentally, this is not always the case Face center of the patient, that will define the largest chewing unit of the lower jaw.

The outline of the alveolar ridge is marked with a compass on the model base carried out. The profile circle is positioned at a 90 ° angle to the course of the alveolar ridge. This is followed by drawing the tangent, a parallel line to the Camper plane (occlusal plane), which touches the deepest point of the sagittal ridge.

Markings of the functional area of the Maxilla and Mandibular on the articulate.

Markings of the functional zone on the Mandibular model in situ with plaster pre-wall.

Teeth set up

Lingualized Occlusion has been defined as “a form of denture occlusion that articulates the maxillary lingual cusps with the mandibular occlusal surfaces in centric, working and non-working mandibular positions”. An inter-alveolar relationship in the transverse direction, which does not clearly indicate a cross bite, sometimes leads us to a lingualized list. The fossa of the second premolar and the first molar is moved lingually by grinding so that the palatal cusp of the first premolar and the first molar come into contact with the fossa.

Anterior Tooth selection criteria

Morphology (Mold): 1. Gender: male – rugged with square teeth & bold central incisors. female – pronounced curvatures, rounded point angles 2. Personality: vigorous or delicate “Personality tooth” The maxillary lateral incisors vary more in size, form and position than any other tooth 3. Age: Young: Tapered, ovoid, rounded teeth. Old: Square, sharp corners

Size: 1. Must harmonize with face and arch size. 2. Any disproportion in arch size influences the length, width and position of the teeth. 3. Vertical distance between the ridges – use a tooth long enough to minimize the display of the denture base. 4. Mark high lip line and canine lines on the occlusion rim at the time the jaw relations are recorded. These guide lines provide information about the gingival-incisal length and total mesiodistal width of the maxillary six anterior teeth. 5. Shape and contour the wax rim so that it mimics the shape and contours of the finished denture with the anterior teeth. 6. The wax rim should extend 1-2 mm below the lip line. 7. Mark the canine line at the corner of the lips and measure the distance with a flexible ruler.

Color: Guides 1. Complexion 2. Hair color 3. Eye color 4. Age 5. Personality & activity 6. Patient desires 7. Need to educate patients

Tooth Placement: Positioned in the same general area on the natural teeth. This position was tentatively established during the clinical refinement of the maxillary occlusal rim to provide adequate lip support and proper phonetics. Used to its maximum potential when accomplished at chairside. The arrangement has to fulfill certain biomechanical needs as well as esthetic ones.

Factors: 1.Midline 2.Lip support 3. Vermilion border 4.Phonetics- f, v, s sounds 5. Buccal corridor 6. Canine eminance- arch type, square, tapered, ovoid 7. Incisal papilla- to labial of central incisor 8-10 mm 8. Vertical and horizontal overlap- 1.5 mm. 9. Generally, 1-2 mm of the incisal portion of the maxillary central incisor is visible below the relaxed lip. 10. Smile line- follow contour of lower lip. 11. Occlusal Plane.

Measurements

Basic measurements that the Dentist should do on marking: Midline, middle of face, Canine line, Smile line, Occlusal plane. The length of the 6 anterior of the upper jaw with the help of an elastic ruler at the edge of the bite. Also the height of the Central.

Posterior Tooth selection criteria

Morphology (Mold) 1. Gender: male – rugged with square teeth & bold central incisors. female – pronounced curvatures, rounded point angles 2. Personality: vigorous or delicate “Personality tooth” The maxillary lateral incisors vary more in size, form and position than any other tooth 3. Age: Young: Tapered, ovoid, rounded teeth. Old: Square, sharp corners

Size: 1. Must harmonize with face and arch size. 2. Any disproportion in arch size influences the length, width and position of the teeth. 3. Vertical distance between the ridges- use a tooth long enough to minimize the display of the denture base. 4. Mark high lip line and canine lines on the occlusion rim at the time the jaw relations are recorded. These guide lines provide information about the gingival-incisal length and total mesiodistal width of the maxillary six anterior teeth. 5. Shape and contour the wax rim so that it mimics the shape and contours of the finished denture with the anterior teeth. 6. The wax rim should extend 1-2 mm below the lip line. 7. Mark the canine line at the corner of the lips and measure the distance with a flexible ruler.

Color: Guides 1. Complexion 2. Hair color 3. Eye color 4. Age 5. Personality & activity 6. Patient desires 7. Need to educate patients

Tooth Placement: Positioned in the same general area on the natural teeth. This position was tentatively established during the clinical refinement of the maxillary occlusal rim to provide adequate lip support and proper phonetics. Used to its maximum potential when accomplished at chairside. The arrangement has to fulfill certain biomechanical needs as well as esthetic ones.

Factors: 1.Midline 2.Lip support 3. Vermilion border 4.Phonetics- f, v, s sounds 5. Buccal corridor 6. Canine eminance- arch type, square, tapered, ovoid 7. Incisal papilla- to labial of central incisor 8-10 mm 8. Vertical and horizontal overlap- 1.5 mm. 9. Generally, 1-2 mm of the incisal portion of the maxillary central incisor is visible below the relaxed lip. 10. Smile line- follow contour of lower lip. 11. Occlusal Plane.

Set-up

The Setup starts from maxillary anterior teeth using an incisal pointer, which is pointed out to us the plaster wall. Anterior Slope from upper teeth and lower teeth.

In the 2nd graphic is described the average antero-posterior distance from the center of the incisive papilla to the labial surface of the centrals. The term overbite, refers to the sagittal anterior overbite, horizontally of up to 2 mm aprox.

Upper Anterior teeth setup, based on the horizontal plane. Review with plaster wall and the incisal pin. First molar is raised distally so that the distobuccal cusp reaches the level of the canine (i.e. it is situated approx. 1 mm above the occlusal plane). Lingual inclination of the molars 6°.

Tooth-to-tooth relationship

The setup follows an imaginary line which runs from the canine distal facet through the central fissures of the premolars and molars. Set up of the first molar, like the premolars, is made with a tooth-to-tooth relationship.

Lingual occlusion principles.

The completed setup up, shows the connection between clear duplicable function and esthetic harmony. Also, the excellent (high-precision) palatal contact relationship is guaranteed through the consistent application of the lingual occlusion principles.

Teeth customization

The Mandibular and Maxilla front teeth from VITA Excell were individualized in shape and color. After selecting the teeth based on the measurements from the registration splint, they come with specific features as manufactured by the company. So, customization for each patient is done handmade.

First step: After teeth setup it is important to cover up with transparent silicone, so it can be polymerized with light.

Second step: Sandblast the inner part of the teeth and the framework, then wipe them with the adhesive and finally polymerize it with light. (Shade A3)

Third step: To cut back the teeth more on incisal and less on cervical. Then, start layering teeth internally with translucent and other color modifiers.

Then the form of the teeth is completed with enamel material. Tooth extension is milled with a little yellow cervical material in the search of a natural look. The same technique is used on the palatal surface.

Micro and macro surface treatment is always based on the morphology of the teeth. Finally, a light polish with different rubber shapes is handmade.

The same personalization technique is used for teeth of the Mandibular.

Tooth characterization and staining

For the color characterization of teeth, there were used materials from the company Shofu (Ceramage, Ceramage-Up, LiteArt). As you can see in the color map picture it was removed the enamel of the prefabricated teeth and it was layered a combination of different transparent materials; either pure or a mix of different stain shades.

Choice Teeth color

The choice of teeth color in a total recovery is related to patient’s gender and age. This selection was made between the colors A2 and A3. At the end, A3 was chosen because, in his experience, Ioulianos believes it is a universal color.

Completion

At Mandibular:
The completion will be done in the traditional way with a silicone key, the only difference being that the surface area of the artificial gums shrinks by about 50% with acrylic material (PMMA). So that, it can be completed the rest of the anatomical surface of the gums and it can be personalized the color with composite material.

At the Maxilla:
It will only be completed with composite material gum color, because the surface of the gums is, as high as, the height of the milled bar and free space is needed between the bar and the gums for the patient to clean it easily.

Acrylic Mandibular

Next to the completion with acrylic Mandibular. Good preparation with wax on all the points that could be difficult to release after polymerization. Check the silicone keys close to the teeth so that they fit and do not touch the Dolder Bar.

Polymerization & cementing

After the completion and polymerization of the acrylic material (color 34 opaque from Briegel Dental). Confirm the fit on the surface of the Mandibular. The next step will involve cementing the 4 titanium bases with the superstructure made of PEKKTON Diamart.

Good preparation with wax on all the points that could be difficult to release after polymerization. This is followed by the process of sealing the bridge onto the bar, to prevent any microbial infiltration between the bar and the bridge. (Implantlink semi-DETAX). After the completion to fix the 4 Ti bases and the sealing the PEKKTON superstructure, it will be ready for the completion of the gingiva with Composite (VITA VM LC). The surface area of the denture base is reduced by 50%, to personalize after with the intense gum colors.

Gum characterization & staining

Here is a color map of the reconstruction. The materials used are from the company VITA VM (LC Gingiva) paste as a base and flow composite with intense colors SHOFU (CeramageUp) in combination with stains (LiteArt).

Selective grinding technique for final balancing of occlusion in complete dentures

The ideal moment to adjust the occlusion is after the dentures have been transferred from wax to acrylic. The purpose of this arrangement of teeth is to provide stabilizing forces to the denture base on their basal seat, when teeth make contact and the jaws are in centric or eccentric relation. All this to maintain stabilizing forces as the mandible moves the teeth to and from centric to eccentric occlusion. Micro and macro surface treatment is always based on the morphology of the teeth. Finally, a light polish with different rubber shapes is handmade.

Final result

Thank you, Iouliaons Moustakis, DT

Materials and settings

Articulator:	Artex CR (Amann Girrbach)
Upper Teeth:	Vitapan Excell (VITA)
Lower Teeth:	Vitapan Lingoform (VITA)
Gum characterization and staining:	VITA VM (LC Gingiva) SHOFU (CeramageUp) in combination with stains (LiteArt).
Condyle Settings:	Left and right condyles was set at 30°
Incisal Guidance:	Incisal guidance was set at 0°