Case reports that convince – VITA PHYSIODENS in action

The implant prosthesis wearer also shows the same stereotypic chewing movements as every person with full dentition. He also needs no bilateral balancing, no unilateral balancing and no canine alignment, but his lower jaw is also neuromuscularly guided by the central nervous system, cortically conscious or subcortically unconscious. For a harmonious integration of an implant prosthesis in the stomatognathic system, he therefore needs denture replacement teeth in the same form and position in his jaw where he once had his natural teeth. And these original teeth certainly had no maximum tripodized contacts, no consistent ABC contacts, no lingualized occlusion and no long centric.

As long as there is solid food between the teeth, it is simply not possible to have a tooth alignment. Only when the food is chewed into a bolus can contact occur. However, this contact only takes place in a three-dimensional functional space of about 1 mm, which features physiological chewing curves. Implant-supported prostheses should also be balanced in this centric functional space. This only works if the new teeth match the shape, size and placement of the original teeth. The Spee and Wilson curves, as well as the helicoid twist curve, are not compensation curves for the balancing of prostheses. This anatomical structure has been evolutionarily optimized in its function in order to work economically with the least amount of force. The tooth axes in the upper and lower jaws are in line with the force vectors of the closing masticatory muscles. The concept of the physiological occlusion is logical. It makes clear statements on the position of the lower to upper jaw in anterior-posterior, lateral and vertical position and on the movement patterns. The occlusal relief of the posterior teeth and the anatomical shape of the anterior teeth follow this function and the centric positional relationship in their shape. 

Because of its reproducibility, the Bio-Logical concept, which copies the pattern of nature, can be universally implemented in combination therapies prosthetically, conservatively and orthodontically. It is not an artificially induced theory, but rather a documented deduction from observation and consideration of natural conditions. In 20 years of practice, the concept of nature has proven to be very successful in all prosthetic disciplines. The positive reactions of patients to the esthetics and chewing comfort speak for themselves. All integrated prostheses, whether implant-supported or not, all combination work in various designs, were produced by me without balancing, without canine alignment, without anterior tooth alignment and without group alignment. Not a single patient has missed these unphysiological tooth tracking movements in his new restoration.

More and more full dentures are integrated today as implant-supported. A huge step towards greater quality of life for edentulous patients. Many superstructures are possible, but the most appropriate solution must be individually tailored to the patient. Age and motor skills are the essential criteria for providing the patient with problem-free handling of his dentures in the long term. No variants of implant-supported restorations, however, allow us to abandon the basic rules of total prosthetics in physiological occlusion. The neuromuscular system with all its involved structures, requires a biological rather than a mechanical-static way of thinking. And don't patients have a right to be cared for according to the laws of nature? Are static, mathematical/geometric concepts really the better choice? Then the question arises: Should the dentures be anterior tooth-aligned or canine-aligned, or both, and when should the alignment take place? Is it better to set things up bilaterally balanced or unilaterally balanced? Should posterior teeth with reduced chewing surface be used? Large or rather small teeth? We could continue on and on with the list of confusing issues. None of this helps the dentist, the dental technician and especially the patient.

In the following case, a patient is treated with a full denture in the upper jaw (Fig. 1) and with an implant-supported removable piece in the lower jaw, in accordance with the Bio-Logical principle. For the stable anchoring of the lower jaw prosthesis, four implants were inserted in regions 32, 33, 42, and 43 (Fig. 2). Appearance, esthetics and speech, along with phonetics, are of the utmost importance for most patients, along with the chewing function. The dental technician usually has no contact with the patient, so it is very important that the practitioner gives the dental technician accurate information regarding tooth position. The information must be three-dimensional. The incisal length of the anterior teeth, the labial/oral position and the information on parallelism to the bipupillary plane of the entire upper jaw front must be determined. The facial center, smile line and canine line are also essential landmarks for the dental technician. The practitioner transfers the three-dimensional information via the wax rim on a bite template, or better still, on the tray of the precisely fitting functional impression. The upper jaw wax rim is heated in warm water and can then be moved in the labial or oral direction until the lip profile is right. Now the speech and phonetics can also be inspected. 

A perfect impression and precise model fabrication of the jaws (Figs. 3 and 4) as well as an optimal bite registration are the basic conditions for a well functioning denture. It is also recommended that the centric be registered with wax rims on the individual trays in the case of edentulous jaws. After functional impression and master model fabrication, extended edges of the impression should be shortened to obtain perfectly fitting bite templates (Figs. 5 and 6). This method guarantees a very precise transfer from the mouth to the master model or vice versa.

About three months after the extraction of his remaining telescopic abutment teeth in the lower jaw, a 61-year-old patient presented in the practice for advice. The prosthesis was no longer viable without the anchoring in the lower jaw. Due to the bone resorption, the patient was presented with relining as a possible therapy. In general, however, the patient was dissatisfied with the esthetics of both prostheses. He thought the denture teeth were too dark. He complained about insufficient hold and disturbed phonetics (Fig. 1). During the clinical inspection, it was evident that the current setup did not line up with the center of the face. In the first quadrant, the teeth were exposed too far in the caudal direction, so that the laugh line appeared out of alignment (Fig. 2). The tooth axes of the maxillary incisors did not harmonize with the actual midline. In addition, the incisal edge progression between the middle and lateral incisors was too uniform, so the natural play of different sizing was lacking. The incisal edges in the lower jaw were highly rounded and did not correspond to the anatomy of functioning teeth (Fig. 3). The papillae were too long and too pointed, and the gingival anatomy was, in general, not simulated on the vestibular lip shield. For this reason, the patient felt uncomfortable when laughing. 

Based on the existing case documentation, the patient was shown the individual options currently offered by full dentures in the consultation. This allowed the individual details to be fully explained. The difference between a standard restoration and a personally tailored restoration with a customized lip shield, age-appropriate tooth morphology and characteristic staining quickly became clear. Informed and inspired by the presented patient cases, he decided on a completely new prosthetic restoration for the upper and lower jaw, where the individuality of an age-appropriate restoration could be attained. The patient specifically desired a lifelike reproduction of the vestibular gingival parts and an age-appropriate individualization of the teeth. The removable dentures should by more seamless and integrated. In general, the patient rejected a permanent restoration with implants. Based on the advice and visual impressions, the patient was able to make his own decision as to how he envisioned his new restoration. The more individual the dentures are required to be, the more important it is to respond in detail to specific patient wishes. 

Alginate impressions were used to make anatomical models for producing individual trays. From these, the mucodynamic impressions were carried out and the master models were produced. Registration templates were produced on the master models from light-curing plate material. The wax rims could then be positioned using the model analyses. As part of the jaw relation determination, the wax rims were optimized intraorally so that they provided an accurate orientation when set up in wax. The Camper’s plane was then registered with a face bow. Finally, the two registration templates were encoded. After the corresponding articulation of the master models, the setup in wax could be started (Fig. 4).

To do a setup according to BLP (Bio-Logic Prosthetic according to Dr. End), premium denture teeth from VITA PHYSIODENS were used. Especially when individual esthetics are required, the VITA PHYSIODENS Anteriors offer the advantage that the set is handmade. The three-dimensional anatomical layering with root, dentin and enamel materials repeatedly shows an individual character and a nuance-rich play of color and light. Each tooth is one of a kind. The anterior teeth provided a suitable basis to meet the patient’s need for individuality. In texture and morphology, the developers of the set of teeth based the design on real teeth, which is why the tooth axes, angular characteristics and length-width ratio automatically comply with the natural rules of dentition. Abrasion surfaces were incorporated as part of the setup in order to create an age-appropriate character. With this more or less pronounced modification, the anterior tooth set can reflect the entire age spectrum as needed. A slightly nested setup also provided authenticity. The true-to-life morphology of the VITA PHYSIODENS Posteriors made efficient placement in the posterior region possible, as the interlocking approximal surfaces ensured uncomplicated and rapid positioning. The anatomical occlusal surfaces – according to the physiological occlusion – led automatically to the simultaneous and uniform, point-like occlusal contacts. In this case, the setup of the second molars was omitted for reasons of space, which is normally an integral part of the BIO-Logical setup. 

The imitation of the mucogingival anatomy was meticulously taken into account, even during the wax try-in. At this stage, the patient should have an accurate idea of what the final result will be. The palatal ridges of the patient were also imitated for optimal phonetics and functional support when chewing food. The palatine ridges on the master model were molded with kneading silicone for this purpose and a key was made. With this silicone stamp, the palatal ridges could be transferred to the heated wax and then refined and smoothed. During the wax try-in, the patient was satisfied with the intermediate result achieved. On the basis of the setup, the possible individualizations and characterizations of the denture teeth were discussed once more with the patient, and his wishes recorded. Finally, images were made with the wax-up so that the patient and his immediate family and friends could privately compare the current restorations with the new situation in wax. After a brief time of reflection, he finally gave his approval for the implementation in acrylic. The two wax setups were reduced on the master models, and the situation fixed with a position-stable silicone key. The teeth were then removed and buffed and blasted on the composite surfaces to create a microretentive surface. The teeth were then repositioned in the silicone key and the composite surfaces chemically conditioned with VITACOLL adhesive. The bases were converted into polymer using a cold polymer, and then processed with an acrylic bur. The vestibular surfaces of the denture bases and the prefabricated teeth were then blasted with aluminum oxide (Fig. 5). In the upper jaw, the mesial and distal flanks of the middle incisors and the mesial flanks of the two lateral incisors were also reduced with an acrylic bur (Fig. 6, 7).