Finlay's Case Presentation

Welcome to my December 2020 Newsletter Case Presentation

This newsletter describes in step by step detail Anne's transition from an immediate complete upper denture to a definitive complete upper denture.

This 73 year old woman was referred to me by her general dental practiioner for treatment.

Dental concerns

  • “Upper teeth/crowns/bridges all loose”
  • “Dentures seem the only option”
  • “Bottom teeth are not good but still functional”

Medical History

  • Anxiety - medication Citalopram and Propanolol

Social history

Retired civil servant

Dental wish list

  • “Advise on upper denture”
  • “Provide a working denture”
  • “Provide a good looking denture”

Diagnoses

  1. The remaining natural upper natural teeth and lower back molars were heavily restored having generalised periodontitis stage 4 Grade C. Some of the teeth exhibited caries. The prognosis for these teeth ranged from dubious to hopeless.
  2. The lower teeth (apart from the lower back molars) had better progniosis and were to be managed by the referring general dental practitioner.
  3. The upper and lower acrylic based partial dentures exhibited suboptimal extension of the flanges and saddles. They had poor retention, support, stability and tissue fit.
  4. The patient had a high smile line showing 5mm or more alveolar soft tissue above the upper front teeth during social interaction.

Treatment options discussed for the upper arch

  1. Do nothing
  2. Complete denture
  3. Retain some of the teeth and provide a removable partial denture
  4. Implant supported complete denture
  5. Implant supported fixed teeth

The clinical situation and treatment process is shown in detail below with photographs. In addition, threre is a link to the a 45 minute webinar I gave explaing this case. I provided the clinical work and Rowan Garstang provided the technical work.

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Figure 1 Pre - treatment. High smile line and failing upper teeth.
Figure 1 Pre - treatment. High smile line and failing upper teeth.
Figure 2 Pre - treatment. High smile line and failing upper teeth.
Figure 2 Pre - treatment. High smile line and failing upper teeth.
Figure 3 Pre - treatment. Failing upper teeth
Figure 3 Pre - treatment. Failing upper teeth
Figure 4 Pre - treatment. Failing upper teeth
Figure 4 Pre - treatment. Failing upper teeth
Figure 5 Pre - treatment. Failing upper teeth
Figure 5 Pre - treatment. Failing upper teeth
Figure 6 Pre - treatment. Failing upper teeth
Figure 6 Pre - treatment. Failing upper teeth
Figure 7 OPG radiograph supplied by the referring GDP showing reduced bone levels and planned extractions
Figure 7 OPG radiograph supplied by the referring GDP showing reduced bone levels and planned extractions
Figure 8 treatment planning card containing sequenced treatment plan and quotation. This is how I plan all of my patients treatments
Figure 8 treatment planning card containing sequenced treatment plan and quotation. This is how I plan all of my patients treatments
Figure 9 Treatment plan letter for the patient
Figure 9 Treatment plan letter for the patient
Figure 10 Discussing the treatment plan prior to commencing for consent (Pre-Covid in 2018)
Figure 10 Discussing the treatment plan prior to commencing for consent (Pre-Covid in 2018)
Figure 11 Primary impression taking
Figure 11 Primary impression taking
Figure 12 Upper primary impression made in two stages using Zhermack alginate. This allows full extension to record the sulcus
Figure 12 Upper primary impression made in two stages using Zhermack alginate. This allows full extension to record the sulcus
Figure 13 Lower primary impression with Dentsply Blueprint
Figure 13 Lower primary impression with Dentsply Blueprint
Figure 14 Custom trays for the definitive impression, allowing impression making without the teeth "getting in the way". The under tray is for the edentulous parts. The over tray records the teeth.
Figure 14 Custom trays for the definitive impression, allowing impression making without the teeth "getting in the way". The under tray is for the edentulous parts. The over tray records the teeth.
Figure 15 Trying in the under tray - checking the extension - making sure the tray periphery is 2mm short of the depth of the sulcus
Figure 15 Trying in the under tray - checking the extension - making sure the tray periphery is 2mm short of the depth of the sulcus
Figure 16 Definitive impression - border moulding with greenstick compound
Figure 16 Definitive impression - border moulding with greenstick compound
Figure 17 Definitive impression - zinc oxide and eugenol. Left - prior to cleaning window with blade - right after cleaning window with blade
Figure 17 Definitive impression - zinc oxide and eugenol. Left - prior to cleaning window with blade - right after cleaning window with blade
Figure 18 Definitive impression placed back into the mouth
Figure 18 Definitive impression placed back into the mouth
Figure 19 Over impression in alginate to record the teeth using over tray
Figure 19 Over impression in alginate to record the teeth using over tray
Figure 20 Left completed 2 part impression - right working cast for Mk 1 denture
Figure 20 Left completed 2 part impression - right working cast for Mk 1 denture
Figure 21 Registration visit with wax rim - teeth in maximum intercuspation
Figure 21 Registration visit with wax rim - teeth in maximum intercuspation
Figure 22 Registration visit with wax rim - teeth in maximum intercuspation - recorded with Futar D
Figure 22 Registration visit with wax rim - teeth in maximum intercuspation - recorded with Futar D
Figure 23 Mounted working cast for Mk 1 immediate denture. Teeth removed from cast - minimal preparation of the cast to reduce adjustments at fit
Figure 23 Mounted working cast for Mk 1 immediate denture. Teeth removed from cast - minimal preparation of the cast to reduce adjustments at fit
Figure 24 Mounted working with Mk 1 immediate denture.
Figure 24 Mounted working with Mk 1 immediate denture.
Figure 25 Mk 1 Immediate denture with thin flange
Figure 25 Mk 1 Immediate denture with thin flange
Figure 26 Planning the incisal plane of the immediate denture - lifting the occlusal plane. The patient wanted something similar to the dentate photograph supplied - "but finer"
Figure 26 Planning the incisal plane of the immediate denture - lifting the occlusal plane. The patient wanted something similar to the dentate photograph supplied - "but finer"
Figure 27 Ideal incisal plane translated to the mounted cast
Figure 27 Ideal incisal plane translated to the mounted cast
Figure 28 Ideal incisal plane translated to the mounted cast
Figure 28 Ideal incisal plane translated to the mounted cast
Figure 29 Mk 1 immediate denture - incisal plane lifted by 2.5 mm
Figure 29 Mk 1 immediate denture - incisal plane lifted by 2.5 mm
Figure 30 Finished upper immediate denture. Optimal extension of flanges via the 2 part impression process - figures 14 - 20
Figure 30 Finished upper immediate denture. Optimal extension of flanges via the 2 part impression process - figures 14 - 20
Figure 31 Extraction of the upper teeth
Figure 31 Extraction of the upper teeth
Figure 32 Extracted teeth
Figure 32 Extracted teeth
Figure 33 Upper teeth removed
Figure 33 Upper teeth removed
Figure 34 Checking the fit with light bodied silicone
Figure 34 Checking the fit with light bodied silicone
Figure 35 The light bodied silicone shows potential support problems where the acrylic pushes through
Figure 35 The light bodied silicone shows potential support problems where the acrylic pushes through
Figure 36 A pencil mark shows the areas that push through - often this is the labial flange. This is adjusted with a tungsten carbide bur
Figure 36 A pencil mark shows the areas that push through - often this is the labial flange. This is adjusted with a tungsten carbide bur
Figure 37 Immediate denture fitted straight after extracting the teeth
Figure 37 Immediate denture fitted straight after extracting the teeth
Figure 37 Mk 1 denture fitted immediately after extracting the teeth. Occlusion checked - even contact when patient closed together
Figure 37 Mk 1 denture fitted immediately after extracting the teeth. Occlusion checked - even contact when patient closed together
Figure 38 One week review after extractions - room for improvement aesthetically. the Immediate denture makes a good diagnostic appliance
Figure 38 One week review after extractions - room for improvement aesthetically. the Immediate denture makes a good diagnostic appliance
Figure 39 Alveolar resorption has occurred - chairside reline indicated
Figure 39 Alveolar resorption has occurred - chairside reline indicated
Figure 40 A sheet of wax (1.5mm) is placed on the labial aspect of the upper denture - with 1mm of peripheral roll exposed to allow the reline material to adhere
Figure 40 A sheet of wax (1.5mm) is placed on the labial aspect of the upper denture - with 1mm of peripheral roll exposed to allow the reline material to adhere
Figure 42 Adhesive applied to the fitting surface
Figure 42 Adhesive applied to the fitting surface
Figure 43 Ufi Gel hard reline material used - placed in the mouth and bordered moulded
Figure 43 Ufi Gel hard reline material used - placed in the mouth and bordered moulded
Figure 44 The denture is seated firmly onto the palate to keep the reline as thin as possible. There is no change to the vault of the palate - this is a stable support
Figure 44 The denture is seated firmly onto the palate to keep the reline as thin as possible. There is no change to the vault of the palate - this is a stable support
Figure 45 The reline material flows over the labial aspect of the teeth. The wax on the labial surface of the teeth speeds up cleaning because it prevents the material from running into the embrasures. This image shows the reline when removed from the mou
Figure 45 The reline material flows over the labial aspect of the teeth. The wax on the labial surface of the teeth speeds up cleaning because it prevents the material from running into the embrasures. This image shows the reline when removed from the mou
Figure 46 The wax has been removed and the reline can now be trimmed.
Figure 46 The wax has been removed and the reline can now be trimmed.
Figure 47 Trimming the periphery of the reline
Figure 47 Trimming the periphery of the reline
Figure 48 Immediate denture with chairside reline
Figure 48 Immediate denture with chairside reline
Figure 49 Resorption of the upper ridge at 4 months - laboratory reline indicated
Figure 49 Resorption of the upper ridge at 4 months - laboratory reline indicated
Figure 50 Preparation of the fitting surface and periphery for laboratory reline
Figure 50 Preparation of the fitting surface and periphery for laboratory reline
Figure 51 Light bodied silicone impression material used for the reline. This is placed firmly in the mouth seating fully in the palate and border moulded as per a definitive impression. The impression is made without the patient occluding. I find I have
Figure 51 Light bodied silicone impression material used for the reline. This is placed firmly in the mouth seating fully in the palate and border moulded as per a definitive impression. The impression is made without the patient occluding. I find I have
Figure 52 Laboratory reline in light bodied silicone impression material. This is placed firmly in the mouth seating fully in the palate and border moulded as per a definitive impression
Figure 52 Laboratory reline in light bodied silicone impression material. This is placed firmly in the mouth seating fully in the palate and border moulded as per a definitive impression
Figure 53 Reline cast and relined denture. The occlusal key in white plaster maintains the vertical dimension
Figure 53 Reline cast and relined denture. The occlusal key in white plaster maintains the vertical dimension
Figure 54 Thinned labial flange of reline - giving improved lip support
Figure 54 Thinned labial flange of reline - giving improved lip support
Figure 55 Laboratory relined Mk 1fitted - note the periphery
Figure 55 Laboratory relined Mk 1fitted - note the periphery
Figure 56 The patient is in a stable holding position for the next 8 months whilst further resorption occurs
Figure 56 The patient is in a stable holding position for the next 8 months whilst further resorption occurs
Figure 57 The start of the definitive upper denture (Mk 2). Primary impressions. Upper in 2 part Zhermack alginate lower Dentsply Blueprint creme alginate
Figure 57 The start of the definitive upper denture (Mk 2). Primary impressions. Upper in 2 part Zhermack alginate lower Dentsply Blueprint creme alginate
Figure 58 Primary cast and custom tray
Figure 58 Primary cast and custom tray
Figure 59 Custom tray border moulded with greenstick compound, ensuring a peripheral seal is obtained
Figure 59 Custom tray border moulded with greenstick compound, ensuring a peripheral seal is obtained
Figure 60 Upper custom tray prepared with alginate adhesive
Figure 60 Upper custom tray prepared with alginate adhesive
Figure 61 Definitive impression made in alginate (Blueprint)
Figure 61 Definitive impression made in alginate (Blueprint)
Figure 62 Definitive impression made in alginate (Blueprint) with resultant definitive cast
Figure 62 Definitive impression made in alginate (Blueprint) with resultant definitive cast
Figure 63 Registration visit with wax rim for tooth position/OVD recording and central bearing apparatus for CR recording
Figure 63 Registration visit with wax rim for tooth position/OVD recording and central bearing apparatus for CR recording
Figure 64 The upper rim is carved with repeated reference to the dentate photograph - figure 65
Figure 64 The upper rim is carved with repeated reference to the dentate photograph - figure 65
Figure 65 The patient wanted her new denture to look like this "but finer". This was the photograph used when carving the wax rim
Figure 65 The patient wanted her new denture to look like this "but finer". This was the photograph used when carving the wax rim
Figure 66 The upper rim is prescribed in this order
Figure 66 The upper rim is prescribed in this order
Figure 67 Lip support is prescribed
Figure 67 Lip support is prescribed
Figure 68 Lip support is prescribed by carving the rim with a wax knife
Figure 68 Lip support is prescribed by carving the rim with a wax knife
Figure 69 The incsial plane is generally carved parallel to the inter-pupillary plane
Figure 69 The incsial plane is generally carved parallel to the inter-pupillary plane
Figure 70 The incisal plane and occlusal plane are trimmed with a heated "wall paper" scraper
Figure 70 The incisal plane and occlusal plane are trimmed with a heated "wall paper" scraper
Figure 71 From the side view the occlusal plane is carved parallel with the ala-tragal line (Camper’s plane) as this is approximately parallel with the occlusal plane in fully dentate people
Figure 71 From the side view the occlusal plane is carved parallel with the ala-tragal line (Camper’s plane) as this is approximately parallel with the occlusal plane in fully dentate people
Figure 72 The buccal corridors created by carving back the buccal walls of the rim with reference to the dentate photographs. The centre line is scribed clearly on the rim
Figure 72 The buccal corridors created by carving back the buccal walls of the rim with reference to the dentate photographs. The centre line is scribed clearly on the rim
Figure 73 The occluding vertical dimension is prescribed. "If the patient looks right - they are right"
Figure 73 The occluding vertical dimension is prescribed. "If the patient looks right - they are right"
Figure 74 Comparison of Mk 1 denture and Mk 2 rim
Figure 74 Comparison of Mk 1 denture and Mk 2 rim
Figure 75 Comparison of Mk 1 denture and Mk 2 rim - improved lip support
Figure 75 Comparison of Mk 1 denture and Mk 2 rim - improved lip support
Figure 76 Comparison of Mk 1 denture and Mk 2 rim - improved lip support
Figure 76 Comparison of Mk 1 denture and Mk 2 rim - improved lip support
Figure 77 The technician must receive both of these photographs to allow arrangement of the artificial teeth in the same positions as the natural ones
Figure 77 The technician must receive both of these photographs to allow arrangement of the artificial teeth in the same positions as the natural ones
Figure 78 Gothic arch plate on light cure base - before chinagraph pencil application
Figure 78 Gothic arch plate on light cure base - before chinagraph pencil application
Figure 79 Chinagraph pencil application to allow tracing to scribe CR
Figure 79 Chinagraph pencil application to allow tracing to scribe CR
Figure 80 Central bearing apparatus to record centric relation accurately. The mandibular pin is the only point of contact between the maxilla and mandible. The patient performs excursive movements - forwards, backwards and all over
Figure 80 Central bearing apparatus to record centric relation accurately. The mandibular pin is the only point of contact between the maxilla and mandible. The patient performs excursive movements - forwards, backwards and all over
Figure 81 Central bearing apparatus to record centric relation accurately - maxillary plate. The patient has scribed an arrow shape - the apex is centric relation
Figure 81 Central bearing apparatus to record centric relation accurately - maxillary plate. The patient has scribed an arrow shape - the apex is centric relation
Figure 82 A plastic countersink hole is placed and fitted over the apex.
Figure 82 A plastic countersink hole is placed and fitted over the apex.
Figure 83 A plastic countersink hole is placed and fitted over the apex.
Figure 83 A plastic countersink hole is placed and fitted over the apex.
Figure 84 Central bearing apparatus guided into a countersink hole on the maxillary plate.
Figure 84 Central bearing apparatus guided into a countersink hole on the maxillary plate.
Figure 85 Central bearing apparatus fixed together with Futar D.
Figure 85 Central bearing apparatus fixed together with Futar D.
Figure 86 Central bearing apparatus fixed together with Futar D taken out of the mouth showing pin in countersink hole over apex of the arrow
Figure 86 Central bearing apparatus fixed together with Futar D taken out of the mouth showing pin in countersink hole over apex of the arrow
Figure 87 Facebow bite-fork fitted with Futar D to the upper rim
Figure 87 Facebow bite-fork fitted with Futar D to the upper rim
Figure 88 Facebow and CR record (central bearing apparatus) are using to mount the definitive casts on the articulator
Figure 88 Facebow and CR record (central bearing apparatus) are using to mount the definitive casts on the articulator
Figure 89 Facebow and CR record (central bearing apparatus) are using to mount the definitive casts on the articulator (Denar Mk 2)
Figure 89 Facebow and CR record (central bearing apparatus) are using to mount the definitive casts on the articulator (Denar Mk 2)
Figure 90 Mk 2 teeth wax try in with Schottlander Enigmalife teeth in centric relation position determined by central bearing apparatus.
Figure 90 Mk 2 teeth wax try in with Schottlander Enigmalife teeth in centric relation position determined by central bearing apparatus.
Figure 91 Mk 2 teeth wax try in with Schottlander Enigmalife teeth in mouth in centric relation position
Figure 91 Mk 2 teeth wax try in with Schottlander Enigmalife teeth in mouth in centric relation position
Figure 92 Mk 2 mock up try in
Figure 92 Mk 2 mock up try in
Figure 93 Video recording of the patient with Mk 2 try in - sipping cold water to minimise movement of teeth in wax
Figure 93 Video recording of the patient with Mk 2 try in - sipping cold water to minimise movement of teeth in wax
Figure 94 Patient verified mock up, using video trial insertion, still photographs and mirror
Figure 94 Patient verified mock up, using video trial insertion, still photographs and mirror
Figure 95 Patient verified mock up, using video trial insertion, still photographs and mirror - along with partner and Claire (dental nurse)
Figure 95 Patient verified mock up, using video trial insertion, still photographs and mirror - along with partner and Claire (dental nurse)
Figure 96 Mk 2 definitive denture finished - 12.5 mm overjet
Figure 96 Mk 2 definitive denture finished - 12.5 mm overjet
Figure 97 Mk 2 definitive denture finished - with characterisation
Figure 97 Mk 2 definitive denture finished - with characterisation
Figure 98 Mk 2 definitive denture finished - with characterisation
Figure 98 Mk 2 definitive denture finished - with characterisation
Figure 99 Mk 2 definitive denture finished - with super thin flange under the base of the nose for optimal lip support
Figure 99 Mk 2 definitive denture finished - with super thin flange under the base of the nose for optimal lip support
Figure 100 Ridge - resorption 12 months after extraction of teeth
Figure 100 Ridge - resorption 12 months after extraction of teeth
Figure 101 Mk 2 fitted definitive denture - Schottlander Enigmalife teeth
Figure 101 Mk 2 fitted definitive denture - Schottlander Enigmalife teeth
Figure 102 Mk 2 fitted definitive denture - Schottlander Enigmalife teeth teeth together - occlusion in CR
Figure 102 Mk 2 fitted definitive denture - Schottlander Enigmalife teeth teeth together - occlusion in CR
Figure 103 Before treatment and after treatment with definitive Mk 2 complete denture
Figure 103 Before treatment and after treatment with definitive Mk 2 complete denture
Figure 104 Comparison of natural teeth and Mk 2 complete upper denture
Figure 104 Comparison of natural teeth and Mk 2 complete upper denture
Figure 105 Comparison of natural teeth and Mk 2 complete upper denture
Figure 105 Comparison of natural teeth and Mk 2 complete upper denture
Figure 106 From the side view the occlusal plane is carved parallel with the ala-tragal line (Camper’s plane) as this is approximately parallel with the occlusal plane in fully dentate people
Figure 106 From the side view the occlusal plane is carved parallel with the ala-tragal line (Camper’s plane) as this is approximately parallel with the occlusal plane in fully dentate people
Figure 107 Testimonial 1
Figure 107 Testimonial 1
Figure 108 Testimonial 1
Figure 108 Testimonial 1
Figure 109 If I was to treat Anne again I would provide the definitive denture (Mk 2) with metal reinforcement as per this image - because if the denture breaks - "A fractured denture is much easier to repair than the patient's broken confidence" - Quote
Figure 109 If I was to treat Anne again I would provide the definitive denture (Mk 2) with metal reinforcement as per this image - because if the denture breaks - "A fractured denture is much easier to repair than the patient's broken confidence" - Quote
Figure 110 Thank you, as always, to my mentor Dr B!
Figure 110 Thank you, as always, to my mentor Dr B!
This is my lecture/webinar explaining in detail this case for my full membership presentation to the British Academy of Aesthetic Dentistry in October 2020 - https://youtu.be/LoxEQAaqf5c
This is my lecture/webinar explaining in detail this case for my full membership presentation to the British Academy of Aesthetic Dentistry in October 2020 - https://youtu.be/LoxEQAaqf5c
LECTURES AND LIVE DEMONSTRATION ON A PATIENT BY FINLAY - please click on the link if you are interested in doing this course.
LECTURES AND LIVE DEMONSTRATION ON A PATIENT BY FINLAY - please click on the link if you are interested in doing this course.

Reference material

Full access PDF to my published scientific papers which explain my philosophy and clinical techniques. Please click on the link below and scoll down this page to find lots of useful clinical techniques, reference material and previous lectures:

https://www.finlaysutton.co.uk/speaking

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