REMOVABLE PROSTHODONTICS

LOUIS BLATTERFEIN, ROBERT M. MORROW, S. HOWARD PAYNE, Section editors

Let /S/ be your guide

Earl Pound, D.D.S.

Westlake Village, CaZif.

T
1 t is likely no subject in removable prosthodontics has been researched more thor-
oughly than that of restoring the vertical dimension of occlusion. The search still
goes on for the valid controls that are necessary to cope with the tremendous varia-
tions in usable denture spaces, the many types of occlusion, and the tongue thrusters.
It is said that research is seeing what everyone else has seen but thinking what
no one else has thought. The following technique is apropos of this saying because
the controls used are necessary to develop clarity of speech in patients who wear
dentures. These controls also can be used to develop a dependable vertical dimen-
sion of occlusion for most patients and to help the dentist know the maximal and
minimal limits for the most difficult treatment situations.

PRINCIPLES INVOLVED
Several principles for developing clear speech are involved. One is that the most-
forward, most-closed position of the mandible during speech is assumed when /S/
sounds are enunciated at conversational speed (Fig. 1). Another is that no teeth or
denture parts should ever make contact during speech. It should be understood that
the /S/ sound is a subtle whistle which is created when air is forced through a 1 to
1.5 mm. space between the incisal edges of the lower central incisors and the coronal
surfaces of the upper central incisors. If the tongue intervenes between these surfaces
the /S/ sound becomes mushy and lacks c1arity.l

POSITION OF MANDIBULAR CONTROL

After more than 10 years of group study utilizing these principles,2 a very infor-
mative mandibular control has emerged; that is, the mandible, whether or not it
contains teeth, is consistently carried forward and upward to this same precise /S/
Read before the Academy of Denture Prosthetics,San Antonio, Texas.
This article is being published simultaneously in THE JOURNAL OF PROSTHETICDENTISTRY
and the California Dental Association Journal by special arrangement between the Editors.
482
 Let /S/ be your guide 403

Fig. 1. The incisal edges of the upper and lower anterior teeth are at the normal /S/ position.
The average posterior speaking space for a Class I occlusion is between 1.5 and 3 mm.
Fig. 2. The white ball indicates the most-closed and most-forward /S/ position of the ridge
to which the teeth must be set. Greater ridge resorption has no affect on mandibular position;
it means only that more space occurs between the lower ridge and the upper central incisors.

Fig. 3. Diagram showing action of the mandible as it moves from /S/ to “verti-centric” relation.
The mandible should be retruded to a physiologic hinge position and then closed into contact.

position or level (Fig. 2). Therefore this position can be recorded as a three-dimen-
sional anterior stopping point.
The salient fact is that this position can be established for any edentulous indi-
vidual and it is just as definitive and recordable as the terminal hinge position of the
condyles. At this /S/ position the condyles are usually, but not always, anterior to
terminal hinge position, and because of this semiprotrusive position it is possible to
obtain a definitive horizontal recording of the body of the mandible at its most
closed position during speech. After the upper and lower anterior control teeth have
been adjusted to their /S/ clearance, the vertical and centric relation positions can
be recorded by simply retruding the mandible to a comfortable hinge position and
then closing until the lower anterior teeth make contact with the upper teeth (Fig.
484 Pound J. Prosthet. Dent.
November, 1977

3). If the degree of retrusion results in a palatal contact an acceptable vertical

dimension of occlusion can be attained by a study of the posterior speaking space.
This is the space that exists between the posterior teeth and/or the edentulous ridges
when the mandible assumes its /S/ position while functioning at conversational
speed (Fig. 1).
It is the simplicity of this approach that is unbelievable. Previously the only
definitive controls considered for edentulous individuals were the temporomandibular
joints since anterior stops were lost, and these joints together with occlusion rims have
supplied the usual means of developing jaw relations and tooth positions.
It is important to remember that during speech mandibular movements, which
developed during the patient’s formative years, carry the lower anterior teeth to this
specific but spatial /S/ clearance of 1 to 1.5 mm. The fact that the teeth were re-
moved does not affect the muscles per se; therefore when the edentulous patient
speaks these muscles continue to place the mandible at the previously determined
vertical and horizontal levels, but at this point clear enunciation without teeth is
impossible.

EXPLORING CONTROLS
It is one’s right to question the validity of these statements and the consistency
of these controls. However, condemnation before investigation is unfair and for this
reason the following investigation for open minds is suggested.
Checking the consistency of the /S/ clearance. Place teeth or wax upon an upper
base; this should restore the approximate position of the upper anterior teeth. Do
the same on the lower base and adjust the incisal portions so that a measureable
space occurs between them when the patient attempts /S/ sounds at conversational
speed. Lips are always apart at such times and the repeatability of the clearance
will be apparent (Fig. 4).
Checking the consistency of the vertical /S/ level of the mandible with or without
teeth. The subject should have dentures that assume a normal /S/ position. Place a
dot on the upper lip under the nose and one on a prominent part of the chin.
Calibrate the distance between them during enunciation of /S/ sounds with the
dentures in place. Remove the dentures, ask the patient to make the same sounds at
the same speed, and judge the results.
Slow speech creates a larger incisal space during /S/ sounds. Therefore the
speech patterns that create the closest contact should be used when adjusting the
/S/ clearance. These patterns occur during rapid conversation when several words
involving an /S/ followed immediately by a vowel are closely related to one another.
On the other hand adjusting an /S/ clearance to slow speech will create tooth con-
tacts during rapid speech. During speech tests the patient should never know that /S/
is being studied since unconscious speech patterns are necessary.

ACCEPTABLE VARIATIONS
The upper control teeth are the central incisors. Setting incisal edges of these
teeth precisely to their original positions, while ideal, is not always necessary because
no two dentists will set them to the same position. This variance from natural posi-
 Let /S/ be your guide 485

Fig. 4. Beeswax is used to demonstrate the classic /S/ clearance. Repeatability of this clearance
can be demonstrated.
Fig. 5. The posterior speaking space necessary for a patient with an extreme Class II occlusion
and a classic /S/ position.

tions will create a corresponding variation in the pitch and length of the lower
replacements. The development of unusable replacements would indicate the possi-
bility of an error in the placement of the upper teeth which the dentist may be able
to correct. If correction is not possible an atypical /S/ position probably exists, and
it should be developed. An Analytical Control Chart has been designed showing the
procedure to be described.’
The length, pitch (angulation) , and lingual anatomy of the upper central incisors
can cause a variation in the degree of closure after retrusion and therefore a cor-
responding variation in the vertical dimension of occlusion. Theoretically, this varia-
tion will be slight if the teeth are carefully selected for size and form and arranged
according to principles of lip support, tooth display, and anatomic harmony. Such
an anterior variation would measure only a millimeter or so in the molar region and
is therefore of no great consequence. Contrary to past assumptions extensive experi-
mentation with diagnostic dentures strongly indicates that the vertical dimension
of occlusion is quite flexible. This is especially true of patients with Class II occlu-
sions.“, 3

THE POSTERIOR SPEAKING SPACE

There are two types of spaces that can be studied when patients make /S/ sounds,
those existing between posterior teeth and those existing between edentulous ridges
and their opposing surfaces.
After the vertical dimension of occlusion has been established the first type will
produce a posterior speaking space which is controlled by the vertical and horizontal
overlaps of the anterior teeth. Class III occlusions exhibit very little, if any, over-
lapping and have less than 2 mm. of /S/ clearance anteriorly so that the posterior
space is only 1 to 1.5 mm. Class I jaw relations have vertical overlaps of the incisor
teeth that vary from 1.5 to 3 mm. and the posterior speaking spaces have a cor-
respondingly smaller range (Fig. 1). Class II occlusions may have as much as 10 mm.
of posterior speaking space (Fig. 5)) especially where the classic /S/ exists. Those
486 Pound J. Pmsthet. Dent.
November. 1977

Fig. 6. In patients with extreme Class II occlusions, the lower incisors either contact the palate
or make no contact at all when the jaws are in “verti-centric” occlusion. This condition is
usually caused by tongue interferences during speech and when it occurs the anterior teeth
cannot be used as a control for establishing verti-centric. The posterior speaking space becomes
the most meaningful subject for study.

patients who are tongue thrusters and those with extreme Class II occlusions are the
most difficult to treat. Their /S/ positions are usually atypical and cannot be used
for accurate determination of the vertical dimension of occlusion (Fig. 6).
The patients in Classes I and II who have practically no forward jaw movement
in speech place limitations on the dentist that are difficult to overcome. The posterior
speaking space diminishes with the lack of forward movement.
The second type of patients are those suspected of having inadequate interridge
space. A diagnosis can be made at the setup stage by slight manipulation of the lips
during speech to see how closely the ridges relate during the /S/ sounds. If the ridges
cannot be seen place one or more fingers on the anterior ridge during conversation
and the space will manifest itself by the slight initial pressure on the fingers as the
mandible moves into its /S/ position.
All patients have an /S/ position. Whether or not they have clear /S/ sounds
is beside the point because the mandible will assume its own /S/ level, wherever
it may be. The type of /S/ space that existed previously cannot be ascertained in
this manner, but locating the available interridge space will indicate the limits within
which the dentist must work.

THE FINAL GUIDE

It is best to use the dentist’s choice of method for establishing the vertical dimen-
sion of occlusion and then mount the casts on an articulator. All but the lower
posterior teeth are set at this time and a hard wax rim is used in their place to
occlude against sharp upper cusps. A try-in is done and the posterior speaking space
is analyzed. The vertical level of the wax rim may be adjusted between the most-
closed and the most-open guidelines until a practical speaking space is determined
(Fig. 7).
Even though the musculature may have changed through the years these princi-
ples will still apply because muscle activity established at the time the dentures are
 Let /S/ be your guide 487

Fig. 7. This adjustable lower wax occlusion rim is used to evaluate the posterior speaking
space during speech. Any change needed to obtain a more functional vertical dimension of
occlusion can easily be made by adjusting the level of the wax rim.
Fig. 8. The protrusive jaw record is used to seat the upper posterior teeth solidly in order to
record the angles of the eminences.

being made is what has to be utilized; how and where the muscles performed before
dentures were acquired are of no great consequence.

THE PROTRUSIVE REGISTRATION

After the position of the anterior teeth has been refined to esthetic and phonetic:
standards and after the vertical dimension of occlusion has been established on an
articulator, the incisal guide angle, which is controlled by the horizontal and vertical
overlaps of the anterior teeth, can be set. It is then possible to make a protrusive
registration of the incising position of the anterior teeth. This method of registration
is more accurate than that in which occlusion rims are used where no incisal guide
control can be established. The procedure is very simple.

TECHNIQUE
For the best results a face-bow mounting should have been made and the con-
dylar controls temporarily set at 45 degrees. The registration controls are then pre-
pared in the articulator.
Warm baseplate wax is adapted around the incisal portions of the four lower
anterior teeth and the articulator is closed into an edge-to-edge, midline incisal
position so that the upper teeth make a good imprint in the wax. The imprint is
refined, the excess trimmed, and the record secured with sticky wax. A block of softer
wax, 1 cm. square, is sealed with sticky wax on each side of the lower rim in the
region opposing the upper second molars. The articulator is again closed into the
incisal control, creating imprints of the upper molar surfaces in the soft wax.
To make the jaw registration warm the posterior wax in water at about 110’ F.,
place the base in the mouth, and guide the patient into the preformed incisal control
using slight pressure. A new imprint will be created in the softened posterior wax.
Remove the lower occlusion rim, trim the wax, and chill the rim in ice water.
Dry it and spread a mix of zinc-oxide paste between the controls. Place the rim in
488 Pound J. Prosthet. Dent.
November, 1977

Fig. 9. Lingualized occlusion is a method of centralizing the power of chewing by utilizing sharp
upper cusps that operate in the open central fossae of the lower teeth. Lateral stress is reduced
appreciably by eliminating the contact of the lower buccal cusps.

the patient’s mouth and again direct him to close and hold in the three firm controls
until the paste sets. Separate and remove the trial dentures. Secure the record with
sticky wax and re-place the dentures in the articulator (Fig. 8) . Loosen and rotate
the condylar controls on each side of the articulator until the upper teeth make
solid anteroposterior contacts on both sides. Record and use the resultant protrusive-
angle readings.
There is no need to make protrusive registrations for patients with Class III edge-
to-edge occlusions because all of their speaking and masticating movements are in
a vertical and lateral direction. However, even those patients in Classes I and II who
function in this same manner and have a minimal speaking space do protrude the
mandible while incising and so they would benefit from a protrusive registration.
Making lateral registrations is usually unnecessary when using lingualized occlusion
(Fig. 9)) which is strongly advocated in denture construction.3 In such occlusions
sharp upper cusps operate in open central fossae of the lower teeth and the lateral
contacts are minimal, being made only within the range of the chewing cycle, not
into boundary movements.

SUMMARY AND CONCLUSIONS

New guidelines for establishing the vertical dimension of occlusion have been
reviewed. They are based upon the fact that the body of the mandible assumes an
easily recordable, repetitive horizontal and vertical position when the patient is at
the /S/ position during speech.
This controlled method of developing vertical dimension correlates the posterior
speaking space with the placement of the upper and lower anterior teeth when set to
a phonetic standard. This permits the development of a dependable vertical dimension
of occlusion for most patients and also serves as a guide for the more difficult to treat
Class II and tongue-thrusting patients. A method of obtaining a protrusive registra-
Volume 38 Let /S/ be your guide 489
Number 5

tion is also presented; it coordinates the angle of the eminences with the actual
incisal guide angle of the patient.
In all techniques there should be a final try-in after the setup of the teeth is com-
plete. The guidelines presented in this article for controlling speech and “verti-
centriCa can also be used to verify and/or alter that which has been established by
any technique.

References
1. Pound, E.: Controlling Anomalies of Vertical Dimension and Speech, J. PROSTHET. DENT.
36: 124-135, 1976.
2. Foundation for Denture Research, Manhattan Beach, Calif.
3. Pound, E., and Murrell, G. A.: An Introduction to Denture Simplification, Phase II, J.
PROSTHET. DENT. 29: 598-607, 1973.
4. Pound, E.: Personalized Denture Procedures Dentists’ Manual, Anaheim, 1973, Denar
Corporation, p. 10.

32144 AGOURA RD., STE. 204

WESTLAKE VILLAGE, CALIF. 91361

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