# Creating Dentures for Edentulous Patients
## Introduction
[0] I'm really excited to talk to you about this very common scenario of a patient coming into your office with absolutely no teeth. Now, this sweet patient came to me with a situation where she had gotten some teeth taken out roughly about fourteen days ago on the mandible, and she's completely edentulous now. [11] And her upper denture, she hates it so bad. She said that she would refuse to bring it to me for me to use it as a reference point. It's kinda funny because I could have saved a little bit of time if I had that old denture even if it was really bad. We could use it still for our records.
## Starting from Scratch
[32] But so what do you do in the scenario when you have nothing and you're starting from ground zero and you're short for time and you need to make your records for either a same day or a next day denture? Well, we do have the mod denture record system for that. The mod denture record system is essentially a putty mush bite, but it's taken into two different stages. [54] First, you do the maxillary index with the mod, fox plane that you snap in, to the denture record system and you wanna take the maxillary index with some soft putty. And you're gonna do it, using the interpupillary line, the midline, and the FOX plane as a reference.
## Creating the Maxillary Index
[79] There's also a standard setup of cuspid to cuspid, teeth in the tray to give you kind of a reference point of lip support and where you want the lip to go anterior posteriorly for the incisal edge position. And that is a lot to do with just doing the maxilla. [96] Then you get the maxillary index out, you take the tray off and then you reline the putty with some light body polyvinyl siloxane and reseat it. At that point it stays in the mouth, after you realign it cause it's gonna have ultimate suction and retention and it's not gonna move anywhere.
## Creating the Mandibular Index
[116] What you then do is you mix up some dead soft putty. I like to use Ivoclar's Fast Set Polyvinyl Sloxane putty. And you're gonna put it on the tray and then manipulate the patient in sensor relation at the vertical and close down their mandibular index or their arch into the putty at the proper vertical. [135] So you need a decent amount of putty, dead soft putty so that you get the ridges. And then what you could do is you could realign that with light body as well.
## Using the 3D Printed Video Gauge
[145] Now that's essentially a triple tray almost if you will for a dentulous arches. One of my mentors did this with plaster back in the fifties and sixties and sometimes you get that plaster locked in the mouth which was always a bad day. [157] Now how do we turn the vertical? Well, I like to use this three d printed video gauge. Again, all these are downloadable on our website. And you basically look patient's lip at rest. You make sure they're just relaxed and completely in a neutral head posture. They're sitting upright, and they're fully relaxed, lips together.
## Measuring and Adjusting
[178] And you measure interpupillary to mid commissure with this gauge. And then you subtract four to six millimeters for freeway space to get your vertical dimension of occlusion. [191] So you'll roll these little knobs and there's little notches on here. You'll slide it four to six millimeters smaller because we established vertical dimension of rest and now we need vertical dimension of occlusion. And then what you do is chin to subnasally is gonna be the VDL.
## Scanning and Aligning
[205] And so when you have the putty on the tray and you have them closed you could use this as a guide. And as soon as the knob hits the nose, the patient knows that that's the hard stop and then you hold them in on that position. [220] You could do chin point bimanual manipulation, tongue to the back and roof of your mouth in order to get that CR at the proper vertical. Then you have the whole entire complex that you scan in and let me show you what scanning looks like on the Shining Elite here.
## Scanning the Edentulous Arches
[242] And this is gonna be sped up for the sake of time. It's five times speed. So we start scanning the edentulous maxilla, and we get the maxilla in all of our attached tissues, and then we get hamular notch to midline. [261] And then typically I now need to get the contralateral hamular notch to midline. So I'm gonna erase some areas that I have some extraneous data and I'm gonna focus on the contralateral hamular notch to midline with my retractors.
## Completing the Scans
[274] And I'm gonna scan that in starting from a reference point and get that, movable tissues in a stretched state because I like to see the muscle fibers and the folds and the pleats of the muscle fibers as they attach to the ridge of the edentulous arch, which helps me determine my borders from a digital impression. [294] Next, we move on to the mandible. We start on the midline. We go all the way up to the retromolar pad into the retromylohyoid fossa back to midline.
## Aligning the Scans
[302] We then erase any extraneous data that we have that might interfere with the next scan, and we go back to the midline and go to the contralateral retromylohyoid fossa and then back down. And we should now have a complete maxillary scan and mandibular scan with no jaw reference. [321] And this is where we then take our record system tray and scan that whole entire complex into the software. Now in the shining elite, we call it a record based workflow because when you call it a record based workflow, it's gonna ask you to scan what it thinks is a record base.
## Finalizing the Denture Design
[332] And this is essentially treated like a record base because the upper and lower edentulous arch scans are gonna actually be automatically pinned to the tray scan like you see here. And we have some beautiful scans with good borders now with our proper vertical all aligned to our tray system. [359] Now this is kind of the magic sauce here is how do we get this now and align it to the patient's face? And so we do a quick face scan both retracted and smile with the pros with this tray in place.
## Aligning with the Face Scan
[374] And from that data, we're able to actually align a retracted face scan with the tray in place to the complex here, the upper and lower arch and tray merge part that we got from our intraoral scanner using Exocad's align mesh feature. [392] Here, I'm painting the areas and inverting it so that it only focuses on the tray for that initial alignment from the retracted to the tray, and then I now bring in a smile photo.
## Merging and Final Adjustments
[403] It's a, it's a best guess estimate of the patient's smile with the tray in place. And then I merge the smile face scan to the retracted face scan using the forehead, nose, eyes, and the tip of the tray. [416] And then I erase the lips from the face scan so I could bring in my jaw scans. And from here now, I'm gonna accept my path of insertion. I'm gonna set the allowable block out in ExoCAD.
## Designing the Denture
[432] When you do intraoral scans like this, it it's a little bit of experience of how much block out you want and how much you don't want. I'm gonna give you some guides for that, in some other videos. But then we go ahead and align, a preset up arch of upper and lower teeth into that, vertical. [451] And we could position that to our liking for the patient. And we have perfect occlusion here because it's already been waxed up and comes in together with both arches.
## Finalizing the Design
[461] And we could show you a tip on how to do that. You could watch one of our exocad denture lessons where you could see how you could wax dual arches really fast using this technique. Now we pick our borders looking at our muscle attachments, our frenum, fovea palatini, and other landmarks to determine exactly where that border needs to be on that upper denture. [484] And from here then, we create the tissues and do a little digital fast tuning.
## Conclusion
[490] It's really, easy to do when the software gives you all the tools to be able to create some phenomenal fast tuning. Check out some videos for our exocad level three course on how to design dentures. It is an advanced concept. [504] If you're uncomfortable designing, it's really good to partner with a lab that has a lot of experience with digital design because the fit of the dentures is determined mostly by the design. Very minimally by your scan. You need good borders with your scan. You need to get in the retromelohive fossas up the retromolar pads and your hamular notches on the maxilla and you need complete borders.
[525] But then it's up to the design to determine how we add retention to the prosthesis. What is our selective pressure that we're putting back into the prosthesis because this is a mucostatic impression. We need to then go back and add strategic pressure areas to engage tissue undercuts, at a certain micron density. [548] And, I'll show you guys what I mean by that in a minute here. So here we're just, festooning. Now the patient had just received extractions on the on the mandible, so we have very little rooms is essentially almost an immediate, denture here.
[560] One thing that I think is really cool about the way that this software lets you operate is you have complete freedom of everything. Where the teeth go. You have the digital twin of the patients. You have their face, their smile, their retracted image. You already have a good occlusal setup here. You see the Russian roller pads. You have your vertical planes all set in path, and you could do fast tuning or minimum fast tuning. [582] It's really creativity up to you, what you wanna do.
[591] For me, I love, adding anatomy to the tissues to make it look a little bit more realistic but not too intense so it's hard to clean. And there's a fine line between that. So once we get the final kinda denture part, we tell the software to make pockets in the tissue for the teeth to fit in so that we could three d print the base out of a pink material and the teeth out of a tooth material and then bond them together using liquid base resin is usually what I use. [616] Liquid print base resin. And you just kind of squeeze the teeth in there and cure it with a a light.
[623] I will say this that the fit that you'll get from a printed denture should actually be better than anything else. You should have an exact replica of your design. But they will only fit good if number one, you know how to nest on your printer. [631] If two, you know how to post process without warping everything. And three, the digital design has the proper retentive elements in it. So here we can see we we have the digital twin of the patient.
[648] Now let's check out how this delivery went and what the patient thinks about these dentures when she received them because it's really telling the before and the after from this individual who came in again with no teeth to see me. And and literally the whole entire records appointment was roughly about thirty minutes long. [669] Then we go into design, and you could do a same day denture or a next day denture using this technique where we have all the control to do these in house. It's really not that complicated.
[678] Armed with just a video gauge and basically a putty triple tray centric tray. We have everything that we need to be able to fabricate because we could combine it with the face scan.
