Patient Visit 4 - Patient Approval

The final step in checking the trial denture is patient approval.  Careful and thorough checking of the various factors at the trial stage is important.  The patient should be encouraged to express his or her opinions and careful answers should be given.  Often, slight changes can be made in the arrangement at the suggestion of the patient without detracting in any manner from the functional requirements of the dentures.  It is useful to have another member of the family present at this time.  This person should be the most critical family member, a fact which you can determine in conversation with the patient.  

Complete the Checklist for Wax Trial Insertion Appointment
Review and initial each category first.  Ask your supervising clinical faculty member to review the form independently and discuss your findings.  Discuss the trial dentures with the patient also.  Make any changes necessary to satisfy yourself, the faculty member supervising your treatment, and the patient.  When you, the faculty member, and the patient are all satisfied with the results of the checklist have the patient sign the checklist on the signature line. 
The dentures should not be processed until the patient is satisfied with the trial denture.  Disinfect the wax trial dentures and seal in a Ziplock bag for at least 10 minutes.

The Trial Insertion Appointment

This appointment is perhaps the most critical in the series of appointments for denture construction.  This is your last opportunity to correct errors before the dentures are processed. 

The following steps should be checked at the trial insertion.

1. Midline - Should be centered to the philtrum of the upper lip when the patient is smiling.  Mandibular midline should correspond with maxillary if a complete mandibular denture is being constructed.  A discrepancy usually indicates an incorrect centric relationship.

2. Centric Relation - The posterior teeth must all contact simultaneously when the patient closes lightly to their perceived "first contact" in centric relation.  If a prematurity exists the mandibular cast must be remounted and the teeth rearranged to provide even and simultaneous contact.  This must be verified again in the mouth.  Never ignore an erroneous relationship.  It will be worse after the dentures are processed. 

3. Occlusal Vertical Dimension - The patient should look normal.  Excessive display of maxillary and mandibular teeth simultaneously should usually not be evident unless a deep vertical overlap exists.  During sibilant sound production one or two millimeters of space should exist between the maxillary and mandibular first premolars.  Patient should feel comfortable with the degree of jaw separation their trial dentures provide.  Develop the ability to look at the patient and form an opinion as the whether their OVD contributes to a normal appearance.  Make nose to chin measurements at rest position.  This should be 2-3 mm greater than the OVD.  Teeth should not contact during speech sounds, especially the sibilant sounds. 

4. Lip Support/Waxed to Full Contour - Observe the lip support when the prosthesis(es) is/are in place.  The labial flange(s) must be waxed to proper contour.  The patient's lip should have proper support and a natural appearance.

5. Tooth Position - Mandibular posterior teeth are set over the crest of the lower ridge.  Maxillary anterior teeth are set to provide natural lip support and position that is agreeable to the patient.  The inclination of the maxillary six anterior teeth must be correct.  Refer to denture technique handouts.  Mandibular anterior teeth should be set slightly anterior to the crest of the ridge and non-interfering in protrusive position, especially for the first 2 - 3 mm of protrusive movement.  Check the inclination of these 6 teeth carefully.  A crossbite relationship may need to be established if the maxillary posterior teeth tend to be positioned too far buccally.  The posterior teeth must have approximately 1.5 mm of horizontal overlap to avoid cheek biting.  Zero degree teeth must be set flat - perfectly flat - antero-posteriorly and medio-laterially.  A compensating curve may be developed later, after a protrusive record is made. 
When the six maxillary and mandibular anterior teeth have been set correctly and the posterior teeth meet the requirements for their correct position, observe the relationship of the maxillary canine to the first premolar.  The first premolar should by slightly wider in arch position than the canine.  Adjust the canine and premolar as necessary.  All of the maxillary posterior teeth should have nearly the same inclination to their facial surfaces as the canine to create a harmonious appearance. 

6. Buccal Corridor - The buccal corridor is the space between the buccal surfaces of the posterior teeth and the cheeks.  This space should be neither excessive (maxillary teeth constricted) nor diminished (maxillary teeth set too far toward buccal). 

7. Occlusal Plane - The occlusal should be parallel with the pupils of the eyes when viewed from in front of the patient.  The occlusal plane should not drop as it progresses posteriorly.  The mandibular second molar distal occlusal surface should be 1/2 to 2/3's up the retromolar pad.  Ascertain that the maxillary anterior teeth are not at a higher level than the posterior teeth.

8. Phonetics (C.S.S. and Sibilant Clarity) - Ask the patient to count from sixty to seventy.  Observe how close the teeth approach each other.  They should not contact during speech.  If they touch, the occlusal vertical dimension is too great and will need to be reduced.  Also listen for sibilant distortions such as a whistle or central lisp.  Review your clinical manual on how to correct sibilant distortions.

9. Overall Appearance (Size, Position, Form, and Arrangement) - Stand back away from the patient.  Ask him/her to smile and speak.  The dentures should appear natural looking.
 
10. Maxillary Posterior Extension - Using an indelible transfer applicator, mark each pterygomaxillary notch and the vibrating line.  Evaluate the extension of the trial denture to verify that it ends on the line and in the pterygomaxillary notches.  You must palpate the notches to locate them.

11. Patient Approval - The wax trial dentures should be clean and neatly festooned.  All excess wax on the teeth should be removed so the patient can visualize the final appearance.  Wax caught between the teeth, incisal to the contact level should be removed carefully with unwaxed dental floss.  The patient may then be provided with a mirror to view the arrangement.  Ask for comments and objections.  Do not "bully" the patient to accept the dentures.  Correct objections immediately, where possible.  Try to have a family member present at this time.  Criticism is better at this time than when the patient goes home with the completed prosthesis(es).  Some especially particular patients may require an additional trial insertion appointment before they are satisfied.  Accept this as a learning opportunity and a chance to provide a superior service. Obtain written approval by having the patient sign the approval statement on the checklist.

Your grade for this procedure will be determined by how you observe these guidelines and perform the suggested procedures.  You will not be graded low for remounting when indicated but you will be for not recognizing the need or objecting to having to perform the procedure when it is indicated.