COMPLETE

DENTURES

TREATING

COMPLETE

DENTURE

PATIENTS

ALLEN A. BREWER,COLONEL, USAF (DC) *

New York, N. Y.
HE TITLE SUGGESTS that we are concerned only with the treatment of complete denture patients. Many of the suggestions I have for accomplishing this are equally useful in treating patients requiring other types of dental service. I am using cartoons and line drawings as they better emphasize the points that require illustration. I have no panacea for all patient problems. I am not presenting a technique to which every patient can be fitted. I am not going to dwell on the mechanics involved in the various methods used in complete denture construction. These are but steps necessary to the accomplishment of our real mission which is to treat the patient. I am going to show how I look at a patient and why and how I treat the patient and why. FAILURES AND SUCCESS

Early in my practice I found it very disconcerting to have failures. This was hard on my ego. These failures were most evident when complete dentures were constructed. Therefore, I set about learning all I could about complete dentures. I read every book and article on complete dentures that I could lay my hands on. I enrolled in many courses, and used every face-bow and hinge-bow I could obtain; worked with almost every articulator that had been produced; used many impression techniques and many different types of teeth. I even made hinge-bows, articulators, centric relation recording devices, and teeth of my own. I spent 5 years in dental research, much of it in trying to find out how teeth contacted in mastication and in other functions. My percentage of failures decreased. I found that once I had refined my mechanical skills I was able to construct successful dentures, regardless of the technique or instruments used. Frequently, this was in spite of the technique or
Read before the Academy of Denture Prosthetics in Milwaukee, Wis. This presentation represents the views of the author and does not necessarily reflect official opinion of the Air Force Dental Service or of the Department of the Air Force. *Chief of Dental Services, 86th Tactical Hospital, AP012, New York. 1015 the

instruments used. But, I still had failures. Today I have no failures. This was accomplished in two ways. First, I rearranged my thinking-I no longer have failures and I have varying degrees of success. Second, and more important, I treat the patient instead of just constructing dentures for him. The two principal personalities concerned in complete denture service, the dentist and the patient, are thus immediately more comfortable.
METHODS AND PLANNING

I am not deprecating the necessity for good sound methods, accuracy, and constant striving for the optimum result. I am emphasizing other factors in patient treatment that are of equal importance. In any endeavor we undertake, a smooth road to success is usually the result of good planning. It is seldom luck. We can compare our role with a consulting patient to the role of an architect with a prospective home builder. The architect knows that his client could have gone to a builder and said, build me a house. The result would be a house commensurate with that builders ideas of what a house should be. Those of us who have been through this know that the services of a good architect are worth every penny we pay. The architect knows that his client has come to him for advice and help to obtain something that suits him. The good architect then proceeds to find out something of the personality of his client, his needs, desires, and aspirations. Is this to be a short-time residence or a lifetime one ? Only after he has all the information possible does he start to plan and then to build the house. He plans for utility, beauty, and ease of maintenance : and he supervises every step of construction. He must keep abreast of the development of new materials and techniques in order to provide the optimum service for his client at minimum cost. Many of us are prone to assume the role of the builder. This may be because this is what we spend so much of our time doing-building and rebuilding. This is most true in this age of specialization when frequently we see only within the confines of our own specialty. Unless we are willing to asslime our role as architect and plan with our patients, we are going to send more and more of them to the builder or illegal practitioner.
EXAMIKlZTION, DIAGNOSIS, TREATMENT PLANNING

A reliable forecast can result only from adequate examination, diagnosis, and treatment planning assessed in the light of experience. Some wag has suggested that experience is the result of knowledge gained from mistakes. Many of these mistakes may be avoided by the purchase of knowledge from formal courses, textbooks, and journals. The examination should start with a gross appraisal of the patient. This is the easiest way to start and the most fun. I suggest that the first contact with the patient nof be made at the dental chair. I prefer to greet the patient as he walks in. This place of meeting should be a nice meeting place. A consultation room in which the patient and the dentist may become acquainted on this first visit is the ideal. We all know that we always look for the nicest looking restaurant, motel, and, even, service station. So this consultation room should be clean, neat, attractive and, above all, comfortable. As the patient walks in we are automatically appraising physical characteristics, dress, carriage, poise, and ease.

Volume
Number

14
6

TREATIKG

COMPLETE

DENTURE

PATIENTS

1017

UNDERSTANDING

THE

PATIENT

Just a few months ago I was treating a patient for whom complete dentures were contemplated. This patient had given me a negative medical history. Because of his personality, a know-it-all type, I had placed him in Category III. I use the classification system in which Category I is the easiest and IV the most difficult. Physically, this patient was Category I-but, psychically the situation was more difficult. This, I attributed to his position and background. He is an old master sergeant who knows better than anyone else everything about everything. This was apparent from his stories about the mechanics who did not service his car correctly, the repairman who could not put his TV in order, and the tailor who made such a mess of his uniforms. After our third session, I watched him cross the parking lot. He had the typical slapping gait occurring with diseases of the posterior column in the spinal cord. I sent for his medical record. This patients medical record revealed a diagnosis of cerebellar atrophy made 2 years previously. This is an irreversible and progressive condition. His physicians were treating him with reassurance. Fully aware of his condition, I was able to treat him with more tolerance and understanding. It really does help if we like our patients at first sight (Fig. 1). Which of the figures in this instance would you prefer to work on ? And which of the figures in Fig. 2 would you prefer to have work on you ? The first meeting with the patient is the most important. Body types give us some indication as to the problems involved. These are not hard and fast rules. During World War IT an attempt was made to select aspirants to very hazardous tasks by this means. There were too many variables and the plan was dropped. I shall deal with these variables and use this classification only as a guide. Fig. 3 shows a classification of body types. The thin chap is the ectomorph, characterized by a relative preponderance of linearity and fragility with large surface area and thin muscles and connective tissue. This is the patient with the thin inelastic mucosa that may have problems in

Fig.

1. Fig. I.-Different Fig. 2.-Appearance body types. of dentists.

Fig.

2.

1018

J. Pros. Dnl. Nov..Dec., 1964

Fig. 3.-A

classification

of body types. Left, Ectomorph.

Ccnlcr,

Endomorph,

Right,

Mesomorph.

Fig. 4.-The handshake can reveal much about the emotional attitude of the patient. Left, The dead fish handshake may reveal a non-cooperative patient. Ri!~ltG, The viselike grip may reveal an insecure patient.

wearing

complete dentures. The endomorph has large digestive organs and a preponderance of fat. This patient is more likely to be impressed by the personality of the dentist treating him than by the treatment. This man is going to eat, no matter what, so is probably the easiest of the three types to treat with complete dentures. The mesomorph in Fig. 3 has a relative preponderance of muscle, bone, and connective tissue, usually with a heavy hard physique. He has his goal in life well set and will put up with considerable discomfort to get a result, but he expects results and may complain bitterly at anything less than perfection. Shaking hands with a patient is an informative process (Fig. 4). The dead fish handshake certainly might indicate a noncooperative patient without too much interest. The vicelike grip could be introducing a patient who is insecure and trying to impress us. This patient might try impressing us with how well he could use our dentures or might concentrate on trying to prove that we could not do a job good enough for him. The patient offering a normal firm handshake would probably be the easiest to get along with. There is other information to be gleaned

Volume 14 Number 6

1019

Fig. L-Abnormal

lip, mouth, or tongue habits are revealed

if the patient

is allowed

to talk.

Fig. 6. Fig. 6.-A pipe will put a strain on the foundation under dentures, of trouble. Fig. 7.-The lifes work of a patient is a factor in diagnosis.

Fig. 7. and is a potential

cause

from the handshake. I recall the visit I made to a physician some years ago. He shook my hand five times in the space of a minute. I thought what a friendly fellow until I realized he was trying to determine whether my hand was hot or sticky, cold and clammy, or dry. This could give him some lead as to my emotional status and possibly as to my thyroid gland activity, whether hypo or hyper. Let the patient talk (Fig. 5). It is really amazing what we can learn from listening to the patient. In addition we can see any abnormal lip, mouth, or tongue habits he might have. We can observe the degree of relaxation or, conversely, tension. Note playing with the teeth, sometimes aided by a pipe (Fig. 6), chewing gum, fingernail, or toothpick. We find out what a patient does for a living, and realize that if he is a wind instrument player we might put him out of business by removing his teeth (Fig. 7). We find out what the patient likes to do or expects to do with his teeth. It is the ambition of some to he able to eat corn on the cob

1020

BREWER

J. Pros. Den. Nov.-Dec.. 1964

Fig. X.-The

patients

expectations

are important.

Fig. 9.-The

aspirations

of the patient

can affect the choice of treatment.

Fig. lO.-The

patients

troubles

are manifest

by the dentures

he brings

with

him.

t-olume 13 Number 6

TREATING

COMPLETE

DENTCRE

PATIENTS

1021

with dentures (Fig. S). We should be able to tell him if he will be able to do this with the dentures we can provide. \\e can learn at this time something of the aspirations of our patient (Fig. 9). Does he picture himself as an orator, a singer, a Thespian ? These people have different requirements than do those who are not so concerned with projecting their voices. Ten years ago I was called in consultation by a dentist who was treating a well-known actor. The question was, should his fekv remaining mandibular teeth be removed and a complete denture constructed or not. The patient had a fairly complete complement of maxillary teeth which had been covered with jacket crowns, and these teeth were in remarkably fine condition. Mechanically he had a wonderful foundation for a complete lower denture. On my recommendation, the remaining lower teeth were extracted and a complete mandibular denture was constructe(1. iz week later the dentist brought the patient to me complete with a lower denture and a demonstration of what happened when he attempted to project his voice. His denture went out with the sound. It was only then that I learned of the tremendous action in the modiolus region when the voice was thrown. A loud ho-or-ha really activates this musculature. Two dentures and 2 months later, this actor had his revenge. He sent me a pair of tickets for the opening of his new play. In attendance were his physician, his psychiatrist, and his dentist. The payoff came with the revi,ews the next day. They stated that this actor had performed with his usual competence but he talked as though he had a mouthful of hot mush. I had learned. Three years later I was called in consultation about another actor. Even before seeing the patient I was able to make my diagnosis. This man was 60 years of age and had a very successful play running in the east that was netting him about $3,500.00 per week. I said to the dentist who was treating him, whatever you do, save his teeth. If you remove them and anything happens to the show you have had it. This was perfectly acceptable to the patient, the teeth were retained, and the show went on. Sometimes the patient does not have to talk (Fig. 10). I n many instances these are not problem denture patients, but rather patients who have gone to problem dentists. \Ve can and should tell a patient what we can provide for him before accepting him for treatment.

Fig. Il.-The

economic factor may determine

the patients

choice of treatment.

1022

BREWER

Nov..Dec., 1964 J. Pros. Den.

Fig. I%-The manner in which the patient opens his mouth is an indication of his attitude toward dental treatment. Left, The show-off. Center, The cooperative patient. Right, The uninterested and uncooperative patient.

Fig. 1X-General

debilitation

of the patient

is a complicating

factor

in denture

construction.

Do not ignore the socioeconomic factor (Fig. 11) . Many people in the lower income brackets expect to wear complete dentures at a relatively early age. Those in the higher income brackets often consider the mere suggestion that they have their teeth removed is an insult. With these patients I try to work around to the point where they are requesting the complete dentures rather than my suggesting them. When I finally seat the patient in the dental chair and make sure that we are both comfortable, I usually ask him to open his mouth (Fig. 12). Th e way he does this is an indication, as is the handshake, of the type of individual he is.
COMPLICATING FACTORS IN THE CONSTRUCTION OF DENTURES

There are five factors that could complicate the construction of complete dentures for a patient. The patient with only one of these undesirable conditions could usually be treated successfully, but when two or more of the factors exist in the

Volume Number

14 6

TREATING

COIVIII,ETE

DENTURE

PATIENTS

1023

same patient, watch opt. The first of these factors is general debilitation (Fig. 13). The second is abnormal jaw function (Fig. 14). The third is abnormal jaw relation (Fig. 1.5) with accompanying abnormal tooth relationships (Fig. 16). The greater the abnormality, the more difficult the problem, especially if the patient is edentulous and record casts are not available. If space is not provided between the anterior teeth for the tongue thrust, the patient might dislodge his dentures constantly during mastication and speech. It is tantamount to malpractice to extract a patients teeth without first making adequate record casts. The fourth complicating factor is redundant tissue as illustrated in (Fig. 17). The tissues are depicted in Fig. 18 would be mucl~ more desirable. Inadequate space for denture bases, as shown in Fig. 19, and bony protuberances and undesirable undercuts, as shown in Fig. 20, are also part of this complicating factor. I try to keep surgical intervention to a minimum, but I must have space for the denture bases. When undercuts are opposing each other in the tuberosity region, we usually can reduce only one side and improve the situation adequately. The fifth factor is the attitude of the patient, and even though listed last, it is not the least important. In fact, the main body of this article is concerned with assessing and influencing the attitude of the patient.
KETENTION OF DENTURES

The degree of retention of a mandibular denture can be predicted. The draping floor of the mouth, as shown in Fig. 21, will not permit us to obtain the very positive type of retention we can provide for the patient with the flat floor of the mouth, and well-defined sublingual fold space seen in Fig. 22. Fig. 23 shows the draping floor as we move further posteriorly. Fig. 24 shows the more desirable situation when the floor of the mouth is flat and a well-defined area is available between the sublingual glands and the ridge. Contacting the patients physician can certainly guide us in how best to treat him (Fig. 25). The man who has had a coronary thrombosis, and for 2 years following has not reported for a check-up by his physican is certainly not a good candidate for extensive periodontal therapy. The continuous maintenance and frequent visits to the dentist, necessary to the control of periodontal disease, would probably not be observed by this patient. Likewise, the man who is careless about his financial obligations is probably careless about himself.

Fig.

14.-Abnormal

jaw

function.

1024

BREWER

J. Pros. Den. Nov.-Dec.. 1964

f 15
Fig. Fig. 15.-Abnormal 16.-Abnormal jaw relations. tooth relationships.

Fig. Fig.

17.-The 18.-A

excess soft tissues reasonable thickness

on the ridges supply poor support for dentures. of soft tissues on the ridges is desirable.

Fig. W.-Inadequate space for denture Fig. PO.-Excessive bony protuberances and discomfort to the patient.

bases. and undercuts

can

c,ause difficulties

for

the

dentist

Volume 14 Number 6

TREATING

COMPLETE

DENTURE

PATIENTS

1025

Fig. Zl.-The retention. Fig. 22.-The to retention.

draping character

tissues lingual

to the anterior

part of the ridge

are unfavorable

to

of these tissues on the lingual

side of the ridge are more favorable

Fig. 23.-The retention. Fig. 24.-The able to retention.

draping

tissues lingual

to the ridge

in the molar

ridge

are unfavorable

to

well-defined

space between

the sublingual

fold and the residual

ridge is favor-

WHICH

IS THE BETTER PATIENT?

Now let us take another look at the 2 patients we started to consider. The little doll (Fig. 26) we all thought would be such fun to work on looks a bit different now. I would hesitate to remove all of her teeth. She could then blame me for too many of her other problems. Our other patient (Fig. 27) is well adjusted and busy enough not to be thinking constantly of herself. Psychologically she is the ideal denture patient.
TREATMENT OF PATIENTS WHO HAVE DIFFICULT PROBLEMS

How then do we treat patients who we recognize as extremely difficult to treat. We cannot send all of them to someone else. We cannot treat them by joining them with this bottle (Fig. 28). It cannot be done by too close a personal relationship (Fig. 29). The cost of treatment would far exceed the fee. Kowtowing to the patient (Fig. 30) is certainly not the key to successful patient treatment.
THE GOLDEN RULE

Use the golden rule. Treat the patient as you would like to be treated: with kindness and consideration and a real attempt to establish rapport (Fig. 31). One of the best plans for getting the patient off the defensive is not to insist that the patient pay for his dentures when he receives them. The dentist could insist that the patient wait until he was happy and pleased with the dentures. One dentist who has used this plan lost only one fee but he made a great many pleased denture wearers and many, many friends.

1026

BREIZER

PHYSICIAN

DIT tEAU
Fig. XL-Consultation with the patients physician and a check on his credit is essential.

Fig. 26.-This

patient

would look for every opportunity

to blame someone

else for her troubles.

Fig. 27.-This

patient is well-adjusted

and would accept her responsibilities.

Volume 14 Number 6

TREATING

COMPLETE

DENTURE

PATIENTS

1027

Fig.

28.-This

sharing

will

not solve

the patients

problems.

Fig.

29.-Too

close a personal

relationship

can only

add to the problems.

Get all the help possible (Fig. 32). Since learning more of periodontal therapy, I save many teeth that I formerly replaced. I am able to advise the periodontist as to the prognosis for complete dentures. If favorable, the patient is saved many hours of trauma in sometimes hopeless causes. When upon examination I see an area that does not appear normal, I enlist the aid of a specialist in oral medicine or a pathologist. We do not observe the area in a vague manner. The patient receives a definite appointment for observation, and if he does not report he is called in. The orthodonist is of great help with many patients. Moving individual teeth prior to the construction of fixed or removable partial dentures is sometimes a relatively simple process that pays good dividends. I have stressed the importance of consultation with the internist as to the patients general health. The internists, in turn, consult us occasionally for help in confirmation of systemic diseases. Oral manifestations sometimes corroborate their diagnosis. Close association with the oral surgeon is a real blessing. We seldom do alveolectomies in the posterior region at the time of multiple extractions, By waiting for healing to occur, we find that we can save much very useful bone.

1028

BREWER

Nov.Dec., 1964 J. Pros. Den.

Fig. 30.-Kowtowing

to the patient will not solve his or the dentists problems.

Fig. 31 .-Mutual

trust and confidence will lead to successful treatment.

ORAL

SURGEON

Fig. 32.-Consultation

with other specialties

is indicated

for many patients.

Volume Sumber

14 6 DENTURES

TREATING

COMPLETE

DENTURE

PATIENTS

1029

IMMEDIATE

In the maxillary region we provide immediate replacement for the six anterior teeth whenever possible. By removing the bare minimum of bone and by taking as much care with the immediate denture as with the subsequent denture we have made many that did not require alteration for years. We do not make lower immediate dentures. Instead, we make a temporary mandibular denture immediately after extraction, and frequently we use the patients extracted teeth in the denture. These temporary dentures can be made while the patient waits and are worn until healing is complete. We then make the maxillary immediate denture to oppose a second mandibular denture that can be stabilized on healed ridges. This method avoids much discomfort for the patient and saves time and money for both the patient and dentist.
OTHER GUIDES

We always enlist the aid of the patients family when it is available. If the patient is edentulous but has children, we can usually pick out the child who looks like the patient and observe his teeth as a guide. We ask for photographs made before the loss of his teeth. It is usually the patient who states he does not care how he looks who heads immediately for the mirror when his new dentures are inserted. We never let the patient look into a small mirror. We have them use a large wall mirror while standing well back away from it. I talk to the patients husband or wife and show him or her how we are changing the teeth and why. I also caution him against remarks, such as where did you get the horse teeth? A few years ago I had cautioned, in this manner, the husband of a patient I was treating. The day following insertion of the new dentures she returned much upset. sure look nice but why do you lisp? Her husband had said the night before; "you I had this patient read a magazine first with her old dentures then with her new dentures while I recorded what she said. Then I played the recordings back for her. She could not tell any difference in the two recordings. I next asked our speech therapist to listen to the recordings. He told her she talked better with the new dentures than with the old. The patients confidence was restored.
DECiTURE ADJUSTMENTS

I would like to make a plea at this time for denture adjustments. It is true that we make many dentures which do not require adjustment. It is equally true that we make many dentures which do require adjustment and sometimes many adjustments. Denture adjustment is just as important in patient treatment as is the construction of the dentures. If we are offended or show displeasure with the patient who requires denture adjustments, we are quitting our responsibility. Some patients enjoy adjustments and frequently they are only seeking reassurance. When we have a patient who shows extreme anxiety or a conversion reaction, we insist on appointments for adjustment. We do this the first thing in the morning so he does not spend a part of the day building up resentment. Frequently, when a patient makes a big thing of some minor symptom, his real complaint is not the physical ailment but an emotional problem. Time, personality, attention, and confidence

1030

BREWER

J. Pros. Den. Nov.-Dec., 1964

that the same care will be available again on another visit is a real help to this type of patient.
ESTIIETICS

I would like to re-emphasize the importance of esthetics. I still spend more time on this than on any other phase of complete denture construction. FArI Pomtf and Roland Fisher have done yeoman service to the dental profession by the work they have presented and published on this aspect of complete denture service. Remember that no matter how well the dentures function, unless the patient thinks they look well he will be unhappy.
CONCLUSIONS

I have given you no scientific facts. But how many scientific facts do we have in dentistry ? Until such time (and I hope it never comes) as we have reduced patient treatment to a scientific mathematical formula, I respectfully suggest that we treat the patient instead of just treating his teeth. Our patients will be happier, and we will receive immeasurably greater pleasure from our work.
I am pleased to acknowledge the assistance of Mr. Doyle, Chief of Training Aerospace Medicine, Brooks AFB, Texas, for his preparation of the illustrations
86~~

hids, School of for this article.

APO

TACTICAL 12, NEW

HOSPITAL YORK, N. Y.