MAX denture en-US

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P ers önlic h P DF for J ens Deuts c her, Acc ount ID 1052353, ers tellt am 04.03.2022 C opyrig
ht 2022, Quintess enz Verlag s -G mbH
EXPERIENCE REPORT
Lineup according to Professor Gerber

today
Current status of the method for the edentulous patient
MAX BOSSHART
242 QUINTESSENCE DENTAL TECHNOLOGY | Volume 48 - Issue 3 - March
2022
BOSSHART
Introduction ◼ For intraoral centric registration

using the arrow angle, the patient
Current and future persons responsible must be in an upright position (Fig.
for programming e-prosthetics must be 1).
familiar with the mode of action of the
artificial tooth occlusion so that the If you would like to know more about
molar teeth can be positioned in a way this and the following topics, you will
that is suitable for the mandibular ridge. find detailed information in the book
An important topic is the model "Function and esthetic rehabilitation of
analysis, which includes the upper jaw the edentulous using the original
in addition to the sagittal course of the Gerber method "1 published by
mandibular ridge and analyzes the Quintessenz. The book is also available
mutual interaction of the masticatory in Polish and Russian. According to Heinze8
,
forces. Action is required here with the arrow angle registration, whether
regard to the previous interpretation performed analogously or digitally, is
before errors are cemented in the probably the most reliable method for
programs for digital prosthetics. determining a physiological centric
relation. It was used very early by McCrane9
Impression taking and centric and even earlier by Gysi7. Dental
registration technicians are directly dependent on
the centric registration from the
The belief that the denture is chewing practice, because every error causes
stable for a long time thanks to a good major corrections to the tooth structure.
impression and the suction power technical work.
achieved remains a belief. After months,
up to one or two years later, this may be
true, but then the suction power has
dropped to 50 percent or less in many
cases. Then relining is done, so every
two to three years, until the prosthesis
has become a lump. In this case,
checking the occlusion would very
often be more helpful.
Impression taking has improved
Summary greatly in recent decades. There is little
The paper shows the physical- point in writing on this subject. On the
geometrical, science-based effect of
masticatory forces during unilateral other hand, based on the feedback from
mastication. Mastication requires customers and colleagues, the
force, a physical quantity to which determination of the physiological cen-
force vectors. Removable total
dentures thus follow a logical trical registration is sometimes still a
consequence. It is important that this problem. Two basic points should be
analog knowledge finds its way into
noted:
the digital set-up programs.
◼ Pre-treatment is highly
Indexes recommended before replacing old
Complete denture, edentulous patient, prostheses. This relieves muscle
centric registration, force vector, model
analysis tension and incorrect positioning of
Fig. 1 Whether sitting or standing,
the articular disc. an upright head and body posture is
important for registration.
QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022 243

P ers önlic h P DF for J ens Deuts c her, Acc ount ID 1052353, ers tellt am 04.03.2022
C opyrig ht 2022, Quintess enz Verlag s -G mbH
EXPERIENCE REPORT
2 3 4
5 6 7
They later form the basis for all further

work. The esthetic parameters are
included, ideally also the tongue space
and, very importantly, the contact with
the cheek muscles.
When fabricating in the laboratory,
the sagittal alignment can be realized
precisely and easily with the wax wall
8 former (Fig. 2), as can the horizontal
from the front view (Fig. 3). The incisal
Fig. 2 A wax wall former placed behind the maxillary tuberosity a u t o m a t i c a l l y
produces the desired occlusal plane when the wax melts to the specified anterior line must be angular, which facilitates
height (20-22 mm). Fig. 3 In frontal view, the incisal edge is often amazingly correct. control in the mouth and later during
Figs. 4 and 5 Exactly shaped wax walls with angular incisal areas. Figs. 6 and 7
Anterior wax wall only approx. 3 to 4 millimeters wide, posterior wax wall 6 to 9
set-up in the laboratory (Fig. 4-8).
millimeters wide, depending on the size of the model. Fig. 8 Central incisor aligned
exactly with the wax rim.
Man chews on one side
The process of learning to chew food

begins in infancy and leads to unilateral
The wax walls deficits still exist in the work from the mastication. This remains the case for
laboratory. At present, models and wax the rest of the child's life until tooth loss
Correctly shaped and with a good base, walls are often scanned, so the most or poor dentures lead to adaptation of
wax walls make work in practice much important points will be explained the masticatory muscle. Therefore,
easier. Here are again here. removable dentures must be
unilaterally stable.
244 QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022

BOSSHART
Statics This was proven by Schuhmann's 1986 Tooth size selection

dissertation.12 In ridge-oriented
By static we mean the position of a occlusion, a pronounced surface Current programs automatically
tooth, thanks to which the denture contact of the palatal cusp to the recognize the static tooth position
remains stable under chewing pressure. balance facet of the buccal cusp results during digital model analysis. The
It neither tilts nor shifts. The occlusal in a redirection of the force vector in the technician or the program decides
form plays an important role here. This direction of the alveolar ridges (Fig. 11). which teeth are used based on the
should be recalled here once again. distance between the canine and the
With which teeth do we chew? stop line. The buccal-palatal width is
The occlusal shape of artificial rarely taken into account.
teeth and resulting force vectors In the 1988 video entitled "Chewing
dynamic functions that must work", How wide should the first upper
Classical occlusal tooth shapes with A- published by Quintessenz Verlag Berlin5 , it molar be?
B-C contacts result in a force vector is easy to see that the chewing action
acting upward-outward when chewing takes place mainly between the molars On the one hand, teeth must not restrict
pressure is applied to solid food (Fig. 9). and to a lesser extent between the the tongue space, on the other hand,
Lingua- lized occlusion with reduced second premolars. The first premolar there should be as good a contact as
buccal cusps results in a force vector serves to hold the chewing material in possible with the wall musculature:
acting upward-outward under chewing place when feeding the near- molar. ◼ The cheek contact helps to stabilize
pressure on solid foods such as meat or the prosthesis.
bread.
9 10 11
Fig. 9 Unstatic situation due to the upward-outward force vector. Fig. 10 By leaving a gap of at least two millimeters between the buccal
cusps, an almost vertical force vector remains. Fig. 11 The large contact surfaces (green) cause force vectors directed toward the respective
ridges.

EXPERIENCE REPORT
◼ The cheek contact counteracts the with that of over a million years ago, for Inclination as the jaw ridge should stand.
Zun- g pressure. which our teeth developed at that time. Then the force vector will hit the lower
◼ The chewing material remains on the jaw ridge at a right angle. This theory
occlusal table and does not slide Method for analyzing the has already been incorporated into the
buccally into the fold. forces software of some providers. In this way,
one more tooth can often be placed
For structural reasons, the palatal Professor Gerber's method consists in and the method appears simple. Simple
cusp of the first molar analyzing the forces generated during and fast is always a good selling point.
(Condyloform, Candulor, Rielasingen- mastication, their effect on the However, it should not be to the
Worblingen) must not be outside the supporting structures, their control and patient's disadvantage.
center of the alveolar ridge. The buccal neutralization to protect the natural
part can reach up to the fold, at most tissues. The basis comes from physics. The chewing pressure affects both
slightly above it (Fig. 12). In this way, the prostheses
tooth size of the molars can be Problem of not thought through
determined. The teeth selected by the model analysis Due to the distal-upward inclination of
laboratory are often too small. both molars, a downward-rearward
Instead of more but too narrow Determination of the stop line: The force vector is created when chewing
teeth, it is better to make sure that the sagittal view with a 22.5° or 25° inclined pressure is applied to solid food, but an
molars are wide enough and, if line, marked distally from the lowest upward-front force vector is created for
necessary, to do without a tooth. point, is widely used (Fig. 13). The the upper molar (Fig. 14). The upper
Clinical experience shows that patients theory in this case is that the last molar denture slides forward under chewing
chew just as well with only three molars should be parallel, with the same pressure on the inclined base
per side as with four teeth. Our current (proglissement). The result is a sloppy
chewing gum is soft, compared ridge and ridge resorption.
12 13
Fig. 12 The distance from the center of the alveolar ridge to the fold results in the desired tooth width. Fig. 13 From the deepest point, a line
with 22.5° is drawn distal-upward. The stop line ends at the intersection point (distal yellow arrow). Theoretically, this is the usable area for the
last tooth. Decades ago, Stuck distanced himself from the determination of the stop line by tangential contact to the course of the alveolar
ridge (mesial yellow arrow).

BOSSHART
14 15 16
Fig. 14 Between the molars (white squares), a direction of force (force vector) still upward and at the same time forward is created under
chewing pressure. Fig. 15 The beginning of the ascending branch of the mandible determines the stop line. The course of the upper jaw ridge
is neutral.
Fig. 16 In the upper jaw, the ridge running strongly backwards and downwards is clearly visible. From here on, there is no parallelism with the
m a n d i b l e , which is why a stop line is drawn here.
It is wrong to think that upper Upper and lower jaw must be parallel to this is displaced. Thus, the last tooth -
prostheses are prevented from the lowest point. From the place where without counterbite - functions like a
proglissement by the anterior alveolar the parallelism ends, no teeth can be set guard rail (Fig. 18).
ridge. There is a rotational movement. up. The software should recognize this, The last tooth, be it a seven or a four
This is shown by the fact that the center but it must also be programmed to do of the opposite side, allows an
line shifts laterally during the wading so. additional protrusion contact. This helps
roll test. This means that the model In the case of Fig. 15, the stop line is to reduce sagittal rocking movements,
analysis must include the downward at the beginning of the ascending especially in the case of a sloppy ridge.
and upward force vectors. This can be branch of the mandible. In the case of Without the last tooth, a hole
programmed in the software. Fig. 16, a stop line is drawn at the top remains behind the first molar (Fig. 20).
and bottom. In each case, it is the place The chewing material gets stuck there.
The model analysis from which there is no parallelism Even with "tongue acrobatics", the food
between the upper and lower jaws. A stubbornly sticks now and then. Finally,
Here you can see two model analyses, second molar cannot be set up. In this only the finger can help. If the denture
which include the upper and lower jaw. case, the tooth row is shortened by one wearer is in company, the only option is
The horizontal functional zone or lowest tooth. to go to the bathroom or the toilet of the
point for the first lower molar and for restaurant.
the upper molar, respectively, is How important is the bottom
important (Fig. 15, blue-green area). The seven? Double shortened dentition
denture does not shift under chewing
pressure. It is intended for the largest The last tooth, if it can be positioned (a As an example, two cases, one with a
masticatory unit. The stop line is molar or a quad from the opposite side), double shortened row of teeth and one
determined with respect to the forces prevents the tongue from moving into with a triple shortened row of teeth. In
occurring between the two ridges, so- the free space behind the last tooth both cases, the current software is
called interdependence. The usable (Fig. 17). It may then happen that the probably overloaded due to the lack of
area for the tooth set-up in the tongue, when moving forward, will not programming. Manual intervention is
reach the pro- therefore

EXPERIENCE REPORT
19
17 18 20
necessary, if this is possible. In the case

of Figure 21, it is clear that the distally
already very far anteriorly sloping upper
ridge is the problem. The canine was
replaced by a first premolar in order to
obtain another sagittally stabilizing unit.
Triple shortened tooth row
Here, a very unfavorable situation with

strongly resorbed alveolar ridges and
extensive anterior maxillary sclerotic
21 ridge can be seen. Both canines had to
Fig. 17 Due to the missing septum, an indentation is created into which the tongue give way to the first premolars. Thus, at
expands. There is a risk that the tongue will push the denture forward. Fig. 18 The last
tooth provides guidance for the tongue. Fig. 19 The last tooth, in the figure the least two masticatory units are available
seventh, allows a sagittal stabilizing contact. If the mucosa is rather soft and the ridge per side. The molars served solely for
is floppy, this helps to stabilize the prosthesis.
cheek support and esthetics (Figs. 22
Fig. 20 A hole remains behind the molars. Food debris gets stuck there and is not
always easy to get out with the tongue. Fig. 21 Stop line lying very far anteriorly. Two and 23).
tooth units are missing. To compensate, a first premolar is in antagonistic contact with The anxious question was whether
the lower canine instead of the canine. Due to lack of space, no further tooth was set
up distally. the patient could chew and eat with it.
Short-term follow-up checks were
carried out several times. Result: The
patient was able to eat with it, but
certainly not as well as with a
"normal" prosthesis, but far best-

BOSSHART
ser than with the previous tooth Occlusion adequate to the of the two ridges ran parallel to each
replacement with 28 teeth. Implants alveolar ridge other (Fig. 24). In Professor Gerber's
were not possible because of the poor writings and lectures, he always referred
bone supply, but also financially. In the following case, the prostheses to the "ridge-adequate" set-up. In the
were to be replaced in an existing lower case shown here, the so-called Speek
Dento-(implanto)-mucosal bar work. The roots of the teeth were curve must be ori- entated parallel to
prosthesis firm and undiscovered and the alveolar the two alveolar ridges. The course of
ridge situation was good, even though the occlusion is shown in red-yellow.
Natural tooth roots cannot withstand the upper jaw was heavily resorbed. The position of the last molar is also
horizontal thrusts for long. Therefore, However, the sagittal ridge at the top drawn. It is parallel to the alveolar ridge,
the same rules apply as for complete and bottom was tilted obliquely inclined distal-lower (Fig. 25).
dentures. backwards and downwards. This could
be unfavorable for the upper denture.
But it was not, since a large area
22 23
24 25
Figs. 22 and 23 Very unfavorable conditions on both sides. Only two molars were stable during the cotton roll test. Fig. 24 The situation with
bar and posterior-lower inclined ridges. Fig. 25 Drawn prosthetic occlusal plane (yellow-red) with drawn lower molar.

EXPERIENCE REPORT
Partial prosthesis Statics and implants as a model. The analysis in Figure 28

shows the resulting force vector outside
Thrust and traction forces are the Combined implant- and gingiva- the implant. A destructive lever is
enemy of the remaining tooth roots of supported removable dentures are created.
partial dentures. As Figure 26 shows, subject to the same laws as described Due to the buccal reduction of the
proglissement not only causes forward above. Here, horizontal thrusts damage upper buccal cusp, the center of force
thrust. At the same time, an upward the superstructure. This is often shifts palatally (Fig. 29). In addition, there
movement occurs at this lower triad. manifested by repeatedly loosened is a large-surface contact between the
The work in Figure 27 is ready for screws. balance facets. This causes the force
try-in in wax. The tooth row is Whether single crowns or in a vector to be redirected upwards and
shortened by one element. The gap composite of several elements, axial inwards, axially to the implant.
between the canine and the first loading of the implants is important to
premolar is provided for the clasp guide. prevent damage to the superstructure Unimaxillary denture
This also allows a hygienic design of the (for example, loose or broken screws).
space between the teeth. The buccal relief according to the Retro pul- sion facets continue to be
Gerber method serves here again little known. As far as the author is
aware
26 27
Fig. 26 Model analysis on the lower and upper

model. Teeth set on crooked distal r i d g e s
cause damaging horizontal forces under
masticatory pressure.
Fig. 27 The situation in wax, ready for try-in.
Fig. 28 The buccal contact causes
unfavorable loading of the implant. Fig. 29
Thanks to the buccal relief of the buccal
cusps, the center of force shifts lingually.
Note the contact zone of the palatal c u s p
and the inclined force vector.
28 29

BOSSHART
30 31
32 33 34
Figs. 30 and 31 The distal surround of the lower tooth causes a stabilizing pressure in the distal direction. However, the retral movement must
not be impeded. Fig. 32 The areas of the buccinator muscle are only slightly concave. No grooves are present. Fig. 33 The buccal margin shows
the continuation of the envelope fold; no grooves in which food debris is caught. Fig. 34 Denture wearers often have a strong and thick
orbicularis muscle. They need free space because otherwise they push the prosthesis backwards when opening the mouth.
This very effective occlusal form is not The denture margin is round and counterproductive. The tongue will
included in any software. The facet, connects seamlessly to the denture grow in and then lift the prosthesis with
which is adapted distally to the natural tooth (Fig. 33). It is important to every movement.
tooth, has a pronounced stabilizing maintain a high model margin. The
effect on the pro- thesis (Figs. 30 and denture body follows the curve and is Cheek frenulum passages
31). A disadvantage is the anterior only slightly concave.
pressure on the natural tooth. The anterior lip shield should be The ligament runs from the mandibular
pronounced, concave, but without bone under the edge of the denture to
Muscle grip modeling grooves (Fig. 34). The purpose is to the outside and merges in a spindle
leave space for the orbicularis oris shape with the fibers of the buccinator
Unfortunately, the word "grippy" is muscle so that it does not push the pro- muscle. The passage under the denture
often misinterpreted. Grooves above the thesis backwards. can be reduced from the outside to
crease are of no use. On the contrary, they approximately 1.5 millimeters in order
promote deposits of all kinds. Only the Lingual no cavities to leave room for the ligament and to
passage of the cheek frenulum is grooved adapt to the denture from the outside.
and immediately changes to a soft, Lingually, care should also be taken to The apex of the prosthesis margin must
slightly concave shape (Fig. 32). ensure a smooth transition from the not be ground, because otherwise saliva
teeth to the prosthetic margin (Fig. 35). and air will penetrate under the
Hollowing out in order to give the prosthesis. Sharp edges
tongue more space is
EXPERIENCE REPORT
35 36
37a 37b 38
Fig. 35 Smooth, concave and grooveless progression of the lingual denture areas, shown by the yellow lines. Fig. 36 View of the lower denture
from below. The cheek band passages can be seen on both sides. Fig. 37 Sections of the buccal frenulum passages. a The limit to which
grinding back is possible. b Representation of the buccal frenulum with the transition into the buccinator muscle.
Fig. 38 Unilateral cotton roll test during try-in.
must be avoided at all costs. In case of Conclusion reality, because at last prostheses do
doubt, it is better to process too little. not necessarily have to be fitted with 28
Figure 36 shows a lower pro- thesis In digital total and hybrid pro- thetics, teeth, the shortened row of teeth will be
after injection and lifted from the the analog processes serve as a "presentable."
model. The cheek band areas are visible template for programming. This is Digitization is making the less
on both sides. Figure 37 shows enlarged normal, no one wants to reinvent the popular total prosthetics more
cheek band areas (see also Fig. 32). The wheel. There is a great opportunity to attractive. This gives rise to hopes of
objective of the work can be seen in clean up old habits. In one case, this is better results. But there are still
Figure 38. already construction sites that need to be
considered now, so-

BOSSHART
long the process of transition to di- Literature 11. Preti G et al. Riabilitazione protesica.
Turin: Unione tipografico-editrice
gitalization has been underway.
1. Bosshart M. Function & Esthetics. Tori- nese, 2003.
This article is intended to recall the Rehabi- litation of the edentulous 12. Schuhmann R, Palla S. Investigation of
basics of the method according to according to the Origi- nal Gerber the influence of occlusal design on
Method. Berlin: Quintessenz Verlag, the direction of occlusal forces during
Professor Gerber, because it is one of the mastication in total pro- tics. Schweiz
2014.
best, if not the best, method. 2. Gerber A. Contributions to total pro- Monatsschr Zahnmed 1986;96:935-
Unfortunately, many technicians found thesis (II). Chewable prostheses for 945.
edentulous maxillae. The
it too complicated and difficult until
Quintessence 1973;5:59-64.
now. But now the computer should and 3. Gerber A. Contributions to total
can do much of this work for us without prosthodontics (V). Functional
dynamics determine the set-up
much additional effort. technique. Quintessence 1973;7:
55-60.
4. Gerber A. The articular function and
Discussion mucosal loading during mastication of
dentures. Bern: University of Bern,
Providers of digital processes for the 1946.
5. Gerber A. Kaudynamic functions that
manufacture of total dental prostheses
must work, part II. video. Ber- lin:
must choose one of the methods that are Quintessenz Verlag, 1989.
available in abundance in the analog 6. Gerber A. Occlusion and articulation in
prosthodontics. Zurich: Condylator
range. They vary from country to country. Service, 1960.
The question arises as to what is the best 7. Gysi A. The setting up of a complete
choice, since the new software programs prosthesis. Schw Vierteljahresschr
1915; 1/2:1-103.
are to be available to customers 8. Heinze NA. Inaugural - Dissertation.
worldwide. There are static and dynamic Investigation of the precision of the
basics that apply to all methods. Every intraoral support pin registration in
d e t e r m i n i n g t h e centric jaw
programmer should know them before relation compared with the maximum
the algorithm is available to customers. intercuspidation position of functionally
healthy subjects. Münscher: Medical
Unfortunately, the analog models
Faculty of the Westphalian Willhelms Max Bosshart
contain inconsistencies or errors that are University, 2006. Max Bosshart Dental Prosthetics
now being eliminated. 9. McGrane HF. Five basic principles of the Zurichstrasse 5
McGrane full denture procedure. Florida 8840 Einsiedeln
can. State Dent J 1949;20:5-9. Switzerland
10. Payne SH. A posterior set-up to meet E-mail: bossdent@hotmail.com
individual requirements. Dent Digest
1941;47:20-22.
NACERA®
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THE AESTHETIC EVOLUTION OF ZIRCONIA
• Carefree handling - uncritical positioning during

nesting possible anywhere in the disc
• Developed for all indications - from monolithic single
crowns to complex superstructures for the anterior and
posterior region
• Highly translucent multi-layer zirconia -
≥ 1,000 MPa in the incisal area
• Naturally smooth color and translucency transitions -
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QUINTESSENCE DENTAL TECHNIQUES | Year - Issue 3 - Mä 48rz 2022 253
C opyrig ht 2022,
DOCERAM MedicalQuintess enz Verlag s -G mbH
Ceramics GmbH
EXPERIENCE REPORT
www.nacera-medical.com | info@nacera-medical.com

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Lineup according to Professor Gerber

Introduction ◼ For intraoral centric registration

QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022 243

They later form the basis for all further

The process of learning to chew food

244 QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022

Statics This was proven by Schuhmann's 1986 Tooth size selection

QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022 245

246 QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022

QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022 247

necessary, if this is possible. In the case

Triple shortened tooth row

Here, a very unfavorable situation with

248 QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022

QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022 249

Partial prosthesis Statics and implants as a model. The analysis in Figure 28

Fig. 26 Model analysis on the lower and upper

250 QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022

252 QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022

• Carefree handling - uncritical positioning during

254 QUINTESSENCE DENTISTRY | Volume 48 - Issue 3 - March 2022

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