COMPLETE DENTURES

FLANGE TECHNIQUE: AN ANATOMIC AND PHYSIOLOGIC APPROACH

TO INCREASED RETENTION, FUNCTION, COMFORT, AND
APPEARANCE OF DENTURES

FRANK LOTT, C.B.E., D.D.S., M.Sc.D., PH.D.,* AND BERNARD LEVIN, D.D.S.“”
University of Southern California, School of Dentistry,
Los Angeles, Calif.

to be described in this article will give substantial im-

T provement
HE DENTURE TECHNIQUE
in stability, function, comfort, and appearance of complete dentures
over other techniques.
The basic thought is simple. Much attention is given to impressions in order to
make efficient bases for dentures. Much emphasis is placed on occlusion. The
facial, tongue, and palatal surfaces of dentures, however, have been comparatively
ignored. These surfaces are usually carved into an “ideal” form without sufficient
consideration for the position and function of cheeks, tongue, and lips which are
always in contact with dentures.
If a denture must be closely adapted to the structures on which it rests, and
if its occlusion with the opposing denture must be accurate, it is equally important
that it be intimately adapted to the cheeks, tongue, and lips with which it is con-
stantly in close contact and with which it must function in harmony.
The reasoning in this concept is not new. Fauchard stated in 1746, ‘(We must
consider the form and the curvature that the outside and the inside surfaces must
have to avoid discomfort of the tongue, the gingivae, and the inside of both cheeks.“l
Fish2v3 described this feature of denture construction in 1932. Lott’s4 first
application of these principles was to improve the stability and function of completed
dentures, principally mandibular dentures, that were otherwise satisfactory. The
intervening years have brought extension of its field of usefulness through changes
in method, improved materials, and consultation with other men, notably Dr. Rus-
sell Tenth. The technique has been simplified until it is rapid and easy to apply,
and the improvement in retention, mastication efficiency, and other features has
been quite apparent.

THE PHYSICAL FORCES INVOLVED

A few familiar experiments in elementary mechanics will recall the physical

forces underlying retention (Fig. 1). The pressure at the point (F) in the tube is

Read before the Academy of Denture Prosthetics in Milwaukee, Wis.

*Professor and Chairman, Department of Prosthodontics.
**Post-graduate Student. Presently Assistant Professor and Chairman, Department of Pros-
thodontics.
394
 FLAiYGE TECHNIQUE 395

the same as at any other point on the same level (B) or atmospheric pressure, be-
cause the water is in hydrostatic equilibrium.
The surface of the water in the tube is also acted upon by atmospheric pressure,
but the value of this pressure is reduced by the surface tension and adhesion. This
pressure difference between the two levels was reduced to a formula by Stanita :;
2C
Pressure difference = ~
R
where C is the surface tension coefficient and R the internal radius of the tube.
Thus, the height to which the water will rise in the tube or, in other words, the
capillary forces depends inversely on the bore of the tube.
Let us now develop this reasoning a little further (Fig. 2).
The internal diameter of the tube in Fig. 1 has now become the distance apart
of’ the plates (K) and the Stanitz formula changes to

I<
Thus it follows that the thinner the intervening film, the greater will be the capil-
lary force and, in other words, the greater will be the force required to separate
th.em.
Cox6 related this information more closely to denture construction (Fig. 3 ) .
The reasoning is basically the same as before. The film forms a meniscus
around the periphery and the surface tension and adhesion sustain the pressure
difference across the space (K)
A force such as exerted by the weight (W) will not cause separation until it

-K- I I

L M
II
Fig. 2

=.-=--- --_
7-
-- --rz-
-------- __----- -L-z---
~q&EJz-ZL-- ZT-
-------_ ------ -- -
_z
- - -I- - - ---
------- --- - - -----ILL= _
--- - - _ -_ -z-L-= - - ------_
------ - ---- --
---- 35 = =- --
---- ----ITT-
:---= E Q---L ---y--z

Fig. l.-Let (A) be a glass tube suspended vertically in water, the surface of which shows
at (B). Adhesion causes the surface of the water in the tube to rise to a height (H) above the
surface of the water in the container. Surface tension assists by distributing the adhesion effect
across the upper surface of the column. The column will rise until the weight of the water
equals the resultant of the two forces.
Fig. 2.-The two glass plates (L) and (M) are suspended vertically in water, a distance (K)
apart. (B) The water level. The water column will rise between them (H) just at it did in the
tube and the surface will form the same meniscus.
396 LOTT AND LEVIN J. Pros. Den.
May-June, 1966

Fig. 3.-A smooth, flat glass disk (L) was suspended horizontally from a support. A similar
disk (M) was assembled with it by a drop of water (E) between them. (K) The thickness of
the water. (W) A weight. The disks were still together forty-eight hours later.

equals the pressure difference multiplied by the area of the surfaces in contact.
Thus, the Stanitz formula must be elaborated to
2C
-xA
K
where A is the area of the surfaces in contact.
All of this now means that, in denture construction, the closer the adaptation
of denture to basal structures, the more accurate the periphery to establish and
maintain a strong meniscus and the greater the area covered by the denture, the
greater will be the retention. Various authors r -l2 have verified this conclusion in
one way or another.
Dentistry has done well regarding the close adaptation of the denture base to
basal structures, but there is another important point for consideration regarding
the area customarily covered by dentures.
It is recognized procedure to locate the border of the impression and, subse-
quently, the border of the denture just beyond the line of tightly attached structures
and yet not sufficiently over on them to interfere with their physiologic activities.
This limits the area of the denture to a minimum and locates the denture border
on the very “threshold of instability” because any abnormal movement may disturb
the thin line of the salivary seal and, perhaps, break it and cause a loss of retention.
Likewise, such procedures as arbitrary waxing, alteration of the denture border in
trimming and finishing a denture, and postinsertion reduction of the borders may
cause a loss of retention.
The technique to be described will increase the area of intimate contact of the
denture with the oral structures and the intervening film. It will maintain the vital
seal by moving the meniscus appreciably away from the above-mentioned “thres-
hold of instability” which is close to the line of tightly attached tissues. At the same
time, it will contour the facial-tongue-palatal surfaces of the denture bases to the
physiologic and esthetic requirements.

THE FLANGE PROPOSAL

The technique involves making impressions of the soft structures of the mouth
adjacent to the buccal, labial, lingual, and palatal surfaces of dentures and incorpor-
Volume 16 FLANGE TECHNIQUE
Number 3

Fig. 4.-A schematic drawing of the buccinator muscle.

ating the resulting extensions into the denture construction. The extensions will be
described as flanges or flange modifications. They will be related to the anatomy
and physiology in each region.

hfAXILLARY AND MANDIBULAR BUCCAL REGIONS

The buccinator is the principal muscle of the cheek. It originates in three sets
oi fibers : the middle, upper, and lower as shown in Fig. 4.
The middle fibers arise posteriorly on the pterygomandibular raphe with those
of the opposing constrictor pharyngis superior. They are joined in the molar regions
by the upper fibers from above the maxillary molars and the lower fibers from
below the mandibular molars and all three sets of fibers converge as they proceed
to the angle of the mouth. The middle fibers of the middle group probably end here
at the angle of the mouth. The upper middle fibers cross over the lower middle
fibers to continue on forward into the lower lip. The lower middle fibers cross
beneath the former into the upper lip. This area of convergence and crossing forms
part of a muscular knot, or modiolus, at the angle of the mouth that is of consider-
able importance in our technique.
The upper and lower fibers of the buccinator muscle pass forward through
o:r near the modiolus for insertion into their respective lips.
 LOTT AND LEVIN J. Pros. Den.
398 May-June, 1966

Fig. 5.-The altered relationships of the buccinator muscle to the teeth and tissue are
seen in a cross-section through the maxillary and mandibular molar regions. The buccinator
muscle is represented by the dotted lines at the left. (A) The muscle lies against the buccal
side of the alveolar ridges and the buccal surfaces of the natural teeth. (El The bucclnator
muscle is not in contact with the buccal surfaces of dentures with arbitrarily carved buccal
surfaces from (d) to (e). The dotted lines on the lingual side represent the contours of the
natural teeth and tissues. (C) The flanges of the denture are molded to restore the size and
shape of the natural tissues and to increase the size of the denture surface. Note that the
vertical lines indicate the same relative position in each drawing.

The loss of the natural teeth alters the relation and functions of the buccinator
as it faces the resorbed ridge (Fig. 5).
When natural posterior teeth are in the mouth, the buccinator muscle lies in
close apposition to their buccal surfaces as shown by the dotted line in Fig. 5,A.
After the loss of the natural teeth, resorption and denture construction (Fig. 53))
the now flaccid muscle and other cheek tissues are shown in their former position
to demonstrate the space that is left by an arbitrarily carved denture. This space
exists even when the artificial posterior teeth are placed in the same buccolingual
positions as the natural teeth they replace. When the artificial posterior teeth are
moved lingually to follow the crest of the ridge in a badly resorbed mouth, the
space between the teeth and the cheek tissues is even greater.
This increased space has some deleterious results. The middle fibers of the
buccinator muscle tense anteroposteriorly during mastication to move a bolus of
food inward between the opposing posterior teeth and then to press against their
buecal surfaces to hold it there as the jaws close in mastication. This action leaves
the upper and lower fibers of the buccinator more or less flaccid to form a collapsed
space opposite the maxillary and mandibular ridges. This tends to permit food to
collect there, to the embarrassment of the patient. Also, the “falling in” of the
cheeks often derogatively alters the appearance of the patient. Finally, it establishes
the border of each denture at or very close to the junction of the movable cheek
tissues with the tightly attached covering of the ridges (Fig. 5,B at d and e) . This
very important point regarding the retention of dentures deserves further explana-
tion.
When a suitable impression material is inserted into these spaces between the
cheeks and the buccal flanges on trial dentures or finished dentures, the buccinator
muscle (especially its middle fibers) will mold the impression material against the
flanges and restore the oral structures more or less to the dimensions of natural
ridges and teeth. Then, several advantages will result.
The new buccal borders will not be located at the limit of the tightly attached
tissues, as in Fig 5,B at d and e. Instead, they will be located as far over on the
buccal surfaces of the flanges as there is intimate contact of denture base to the
cheek (Fig. 5,C at f and g). The salivary meniscus will extend laterally to this
‘Volume 16
Number 3 FLANGE TECHNIQUE 399

new border and perfect the border seal. These new effective borders will vary with
cheek movements but they will be unlikely to be the same as the usual border
line at or near to the margin of the tightly attached tissues They will extend beyond
the border line that is the “threshold of instability.”
The effective area of the basal seat of the dentures in close contact with adja-
cent tissues will be greatly increased to directly increase the retention. On the lower
denture (Fig. 5) the effective area will extend from g to PErather than from h to fi.
The cheeks will be supported to automatically improve the appearance and
often to draw voluntary favorable comment from patients regarding greater com-
fort because of the noticeable support for the cheek structures and cheek biting will
probably be avoided.
The flanges formed in this manner will act in conjunction with the tongue to
determine the neutral space to be occupied by the row of posterior teeth.
The posterior border of the maxillary buccal flanges can be easily determined.
The medial margin of the anterior surface of the ramus is considerably pos-
terior to its lateral margin. This causes the anterior surface of the ramus and the
overlying temporalis muscle to have a width of a centimeter or more that is parallel
to the lateral surface of the tuberosity.
When the maxillary tuberosity is prominent, there is but little space for the
buccinator muscle to pass between the denture base and the tuberosity. A closing
movement will squeeze an impression material against the tuberosity and often mold
the posterior border of the buccal flange to a more or less sharp edge. This is in-
teresting and important because many dentures have been shaped with too thick a
distobuccal margin and a swing of the mandible to the opposite side has caused pain
or dislodgment of the denture or both.

ANTERIOR MARGINS OF BCCCAL FLANGES

The insertion of the buccinator muscle into and through the modiolus permits
this muscle to move the angle of the mouth backward with the middle fibers, upward
with the upper fibers, and downward with the lower fibers.
The levator anguli oris or caninus muscle arises below the infraorbital foramen
and proceeds downward through the modiolus into the lower lip almost to the
median line (Fig. 6). Alone, it draws the angle upward ; with its fellow levator,
it lifts the lower lip and helps to close the mouth ; with its depressor opponent, the
triangularis muscle, it pulls the angle of the mouth forward, as in sucking or pursing
t’he lips.
The zygomaticus major muscle arises from the zygomatic bone and extends
downward, forward, and medially into the modiolus. It draws the angle of the
mouth upward, backward, and laterally, as in laughing.
The depressor anguli oris, or triangularis muscle, arises from the external ob-
lique line of the mandible below the bicuspids to converge into the modiolus where
its fibers cross those of the levator muscle and proceed into the upper lip extending
almost to the median line. Acting alone, it draws the angle of the mouth down;
with its opposite fellow, it draws the angle forward, as in sucking.
The combined actions of these muscles of facial expression should be kept
c’learly in mind. The convergence of all of them into the modiolus makes it a muscu-
400 LOTT AND LEVIN J. Pros. Den.
May-June, 1966

Fig. G.-The muscles of the facial expression about the mouth illustrating the modiolus
at the angle of the mouth.

Fig. ‘I.-The flange contours have been molded by the modiolus. Note the irregular surface
and deep buccal notch.

lar knot of considerable strength with a wide versatility of movement up, down, for-
ward, and back. Situated as it is at the angle of the mouth, it is in a strategic position
to unseat mandibular dentures and, sometimes, maxillary dentures as well. This
may occur if the arch form of teeth and the flange are too wide and restrict the
freedom of movement of the modiohrs.
‘volume 16
Number 3
FLANGE TECHNIQUE 401

When a soft impression material is applied on a suitably prepared occlusion

rim, the modiolus will mold it to establish the buccal limit to which the position
of the bicuspids must be restricted. On a trial denture, the modiolus will narrow
and terminate the anterior margin of the buccal flange in the soft impression ma-
terial, provide for its own complete freedom of movement, and assist in restoring
the natural appearance of the mouth. Also, it will increase the effective area of
l.he denture base and maintain the border seal for greater retention. The extent to
which this molding by the modiolus can occur is shown in Fig. 7.

LABIAL FLANGES

The region of the labial flanges of maxillary or mandibular dentures is that part
of the flanges covered by the lips and bounded laterally by the modiolus at each
angle of the mouth. The muscles of expression not previously mentioned are in-
volved in this region. The muscles of the maxillary region include the quadratus
:labii inferioris and the risorius.
The quadratus labii superioris muscle originates in three heads. The angular
head arises from the frontal process, the infraorbital head arises from above the
infraorbital foramen, and the zygomatic head arises from the malar process. All
three heads proceed downward to the upper lip, extending from attachments near
1:he median line as far back as the modiolus. Their common action is to raise the
upper lip.
The risorius muscle arises from the fascia over the masseter muscle, and comes
horizontally forward for insertion into the skin at the angle of the mouth. It can
draw the angle of the mouth posteriorly, as in a grin.
In the mandibular region, the quadratus labii inferioris or depressor labii in-
:rerioris muscle arises on the oblique ridge of the mandible below the cuspid but at
a higher level than the triangularis muscle. It passes upward, almost vertically and
medially, and inserts into the modiolus. Its main action is to draw down the angle
of the mouth. Acting with the levator anguli oris muscle, it draws the angle of the
mouth forward, as in sucking. This action thus pulls the modiolus forward and
1:ensesthe middle fibers of the buccinator muscle.
The mentalis muscle originates in the incisive fossa below the lateral incisor.
:Some of its fibers enter the skin of the chin, others proceed upward to join the
orbicularis oris muscle. Its action is to raise the lower lip and to protrude it.
It is not necessary to remember the details concerning the individual members
Iof this labial assembly of muscles. It is important to know that they also contribute
to the size and strength of the modioli, and that their versatile, collective movements
up, down, forward, and back must not be restricted by dentures. Further, these
muscles and the modioli will mold a soft impression material on an occlusion rim to
correctly establish the shape and anteroposterior position of the arch form of the
anterior part of the dental arch. Similarly, these muscles can mold an impression
material on trial dentures to extend the intimate contact of the denture base to the
Ilips. This will extend the important border seal to the new denture borders. This
will increase the size of the effective area of the denture base and increase the re-
1:ention in the same ratio. The lips will be supported to restore or improve the ap-
pearance of the patient.
 J. Pros. Den.
402 LOTT AND LEVIN May-June, 1966

THE PALATAL AREA

The palatal area of the basal seat is bounded posteriorly by the soft palate, by
the residual alveolar ridge at the sides and anteriorly, and by the tongue below. The
soft palate consists mainly of its muscle groups attached by an aponeurosis to the
posterior border of the palatine bone.
The posterior border of the denture should extend onto the resilient tissue of
the soft palate sufficiently to maintain a seal regardless of palatal movements. This
area may be very narrow, however, and it often makes the establishment of the
posterior border of a denture a very critical step.
Flanges can not be used in this region, although a slight line of soft impression
material will often improve the posterior border of dentures.
The size and position of the arch form of the posterior teeth on a denture have
a direct bearing on the comfort and function of the tongue, on the width and curva-
ture of the anterior part of the arch form of the anterior teeth, and on speech. The
usual contours of dentures in these areas are shaped to average curves without ac-
curate information regarding individual deviations and requirements. A soft impres-
sion material placed over the palatal surface of a trial denture can develop a form of
the palate that would contribute much to the comfort and function of the finished
maxillary denture.

THE MANDIBULAR LINGUAL REGION

Two assumptions are made in the following discussion of the mandibular region
with relation to flanges : (1) that an acceptable border has been established, and (2)
that the occlusal plane has been correctly located. Errors in these particulars will
reduce the value of the added retention of mandibular dentures and the comfort
provided to the patient by addition of flanges. The explanation then limits itself to
the tongue and a few other structures.

THE TONGUE

The tongue and its activities are often given insufficient thought and attention
in denture construction. However, the tongue contacts the natural ridges, palate,
and teeth, and it is important for retention, comfort, and phonation to establish a
similar relationship of the tongue to the lingual surfaces of the denture bases and
artificial teeth. This will increase the area of contact and maintain the seal of man-
dibular dentures. Further, the tongue is a powerful assembly of muscles that can
easily hoist an ill-designed mandibular denture out of position. Its wide range of
movements can often break the usual seal just beyond the junction of the tightly
attached membrane of the residual ridge. Because of its almost constant movement
it can cause injury to itself if it is crowded by the denture base or teeth. The many
positions the tongue assumes for phonation can be hampered by an incorrectly con-
structed denture.
The tongue is a complex bilateral organ consisting of two groups of muscles.
The intrinsic group alters the shape of the tongue. It has a pair of superior and
inferior longitudinalis muscles that can shorten the tongue and turn the tip and
Volume 16 FLANGE TECHNIQUE
Number 3 403

sides up or down, a transverse pair of muscles that can narrow and elongate it, and
a verticalis pair of muscles that can flatten and broaden it.
These tongue movements have mainly to do with speech. The identification of
specific muscle actions for the various speech sounds will not be made in this article.
However, talking or reading aloud are used in the process of molding the lingual
and palatal surfaces of dentures by the flange technique.
The extrinsic group of muscles of the tongue changes the position of the
tongue, and thus assists in molding the borders of mandibular dentures.
The glossopalatine muscles, descending from the soft palate as the anterior
pillars of the fauces, can draw the root of the tongue upward and constrict the
pillars in deglutition.
The styloglossus muscle arising from the styloid process above and posterior
‘to the tongue can pull the tongue upward and backward (Fig. 8).
The hyoglossus muscle, arising from the hyoid bone below, can depress the
tongue and draw down its sides.
The genioglossus muscle, arising from the superior mental spine, can draw
the root of the tongue forward and protrude its apex with its posterior fibers, or
retract it with its anterior fibers. The two genioglossus muscles acting together
can draw the tongue down along the center to make a longitudinal groove in the
tongue that appears in the act of swallowing or sucking.
Note that the collective actions of the muscles of the tongue produce upward,
downward, forward, and backward movements that are recognized in the flange
technique.
A normal tongue fills the floor of the mouth. The apex rests on the lingual
s,urfaces of the mandibular anterior teeth and the sides rest against the lingual
surfaces of the posterior teeth and extend slightly over their occlusal surfaces, but
not sufficiently to make contact with the maxillary posterior teeth. When the mouth
is opened, the tongue can rest on the mandibular teeth and stabilize a mandibular
denture if the occlusal plane has been correctly located. During mastication, the
sides of the tongue press food outward over the posterior teeth in opposition to
the inward pressure of the middle fibers of the buccinator muscle. During degluti-
tion, they also press firmly against the posterior teeth while the middle fibers of
the buccinator muscle tense. The anterior part of the tongue, in the meantime, first
presses against the lingual surfaces of the maxillary anterior teeth, then against

Fig. S.-The extrinsic muscles of the tongue.

 LOTT AND LEVIN J. Pros. Den.
404 May-June, 1966

the anterior part of the palate and, finally, progressively backward to force food
posteriorly into the pharynx.

THE ANTERIOR PART OF THE FLOOR OF THE MOUTH

The mylohyoid muscle is a sheet of muscle fibers originating along the entire
length of the mylohyoid line from the symphysis to the last molar region on each
side. The middle and anterior fibers of the myloyoid muscle are inserted into a
median raphe with those of the opposite mylohyoid muscle. The posterior fibers
attach to the front part of the hyoid bone. The two mylohyoid muscles form the
base for the floor of the mouth. Their action in deglutition is to raise the floor of the
mouth and press the tongue against the palate.

THE SUBLINGUAL GLAND

The sublingual gland rests on top of the mylohyoid muscle on each side of the
tongue in the space extending from the molar region posteriorly to the midline
anteriorly. It provides a soft region between the muscle and tongue that is normally
squeezed between them during mastication to literally pump saliva into the mouth.
The border of a denture is usually critical in this entire region. The problem
is made more difficult by variations in the amount of tongue retraction. However,
if a soft impression material is applied to the entire lingual surface of a mandibular
denture and the patient is required to talk rapidly, to swallow frequently, to suck
forcibly, to protrude the tongue, and to move it from side to side, several advan-
tages will result. There will appear. varying degrees of extensions over the sub-
lingual gland on each side that might be mistakenly regarded as impingement.
However, these extensions will be found to be tolerated and appreciated by the
patient. The increased area of contact of the denture base with the tongue and
glands means greater effective area of the base and greater retention regardless of
minor degrees of tongue retraction. There will be comfortable clearance everywhere
for the tongue at rest and in all of its positions and movements, Better phonation
will result.

End view

Fig. 9.-A keel developed for use in this technique. A set of four is required to maintain
the occlusal vertical relation.
Volume 16
Number 3
FLANGE TECHNIQUE 405

FLANGE TECHNIQUE

The successful application of the flange technique will depend upon the familiar-
ity of the dentist with the basic information already given and his willingness and
capability to apply it with care and discretion.
The flange technique is not a completely new method of denture construction.
It consists of a few additions to any acceptable complete denture technique.
It can be used (1) to determine the physiologic alignment of the arch form of
the anterior and posterior teeth on the occlusion rims, (2) to secure an accurate
impression of the structures surrounding the trial dentures and thus determine
the form of the polished surfaces of both dentures, and (3) to improve the retention,
appearance, and speech on otherwise acceptable finished dentures.

TO DETERMINE A PHYSIOLOGIC ALIGNMEKT OF THE TEETH

The usual procedures of denture construction have been carried out to the
point where the casts are mounted on the articulator, centric relation has been
verified, the articulator guidances have been adjusted, and the teeth have been
selected.
It is logical and mandatory that the functions of tongue and cheeks in the
posterior part of the mouth, and of the tongue and lips in the anterior region should
continue as they matured with the natural teeth in place. It follows, then, that
the positions of the artificial teeth should be coordinated with such physiologic
activities as talking, swallowing, etc., by each individual patient.

THE TECHNIQ.UE

The occlusal plane and the occlusal vertical dimension must be accurately
maintained after the casts are mounted and the articulator is adjusted.
Prepare for the patient by sealing a small metal keel into each occlusal surface
ol’ both occlusion rims. A keel* developed for this technique is a small, elongated
metal ellipse one inch long and three sixteenths of an inch wide, with a similar
ellipse in the center lengthwise on the underside of the first, and at right angles to
it. Its similarity to a keel on a sailing vessel prompted the name (Fig. 9).
Imbed each keel flush with the occlusal surface of the occlusion rim and in the
center of it, both anteroposteriorly and transversely, and, as nearly as possible,
exactly opposite the one in the opposing occlusion rim.
Narrow both occlusion rims buccolingually to the width of the keels, and to
n-lore or less of a knife-edge in the anterior region (Fig 10).
An alternative method is to construct extra plastic bases and mount the keels
on vertical columns of plastic in the same relations as just described. This method
ta.kes additional time but it may be preferred, expecially for the anterior molding or
where a permanent record is desired (Fig. 11).
Use of soft flange wax+ to build the occlusion rims back to slightly greater bulk
than that of the resorbed structures (Fig. 12). Cut some flange wax into strips

‘Harmony Dental Products Corp., South Pasadena, Calif.

tSurgident, Ltd., Los Angeles, Calif.
406 LOTT AND LEVIN

Fig. 10

Fig. 11

Fig. lO.-The keels in place in the occlusion rims which are narrowed in preparation for
the next step.
Fig. Il.-The keels may be mounted on plastic bases.

12

Fig. 13

Fig. 12.-The occlusion rims are built back with soft flange wax to slightly greater bulk
than that of the lost and resorbed structures.
Fig. 13,The occlusion rims after the molding of the soft flange wax has been completed.

one half inch wide and place them in water at about 110” F. for five minutes to
thoroughly soften them.

THE BUCCAL AND LABIAL SURFACES

Form a roll of the wax long enough to extend from the tuberosity to the cuspid
region and large enough in diameter to restore the estimated resorption. Remember
that the ultimate object, in addition to increasing retention, is to restore the position
and function of the cheek muscles by occupying, with the denture base, as much of
the collapsed space above and below as did the former ridge and teeth. A roll that
is slightly too large is necessary for molding purposes but an excessively large
Volume 16
Number 3
FLANGE TECHNIQUE 407

one will result in distention of the cheek, loss of time in reducing it, and extra in-
sertions to finally trim it for comfort and function.
Rub a roll of the softened wax into place on each buccal surface of both oc-
c’lusion rims.
Cover the labial surface of each occlusion rim to a contour that is slightly
fuller than that of the original occlusion rim.

THE PALATAL AND LINGUAL SURFACES

Add softened wax to the palate of the maxillary occlusion rim in the posterior
region on each side in the position of the former ridge, and in the anterior region
add softened wax over the rugae area, particularly at the junction of the residual
ridge and the occlusion rim.
Add a sufficient layer of softened wax on the surfaces of the mandibular lingual
surfaces to give them a fuller contour than probably will be required by the finished
denture.

MOLDING THE SOFT FLANGE WAX

If the keels were imbedded in the wax occlusion rims, soften the overlying
flange wax with a bench torch to avoid softening the hard baseplate wax that sup-
ports the keels.
If the keels were mounted to plastic (as in Fig. 11)) place the occlusion rims
in warm water at about 110” F. for five minutes to throughly soften the flange
wax.
Coat the occlusal surfaces with a little petroleum jelly and insert the occlusion
rims in the mouth.
Direct the patient to read aloud and rapidly on some interesting subject. Read-
ing aloud requires more strenuous muscular movement than reading quietly, and
reading rapidly produces more saliva and causes more numerous swallowing actions.
An interesting subject tends to draw attention away from the occlusion rims and
what is being done so the movements of the tongue, lips, and cheeks will be more
natural.
A good alternative is to engage the patient in an animated conversation on a
subject of mutual interest.
Direct the patient to forcefully grin and purse the lips as a final requirement.
These actions will cause the natural function of most, if not all, of the muscles in-
volved.

ACTIONS PRODUCED BY THESE EXERCISES

The sides of the tongue press outward against the posterior lingual surfaces of
the occlusion rim, especially in the act of swallowing. The middle fibers of the
buccinator muscles constrict simultaneously to press inward against the buccal
surfaces of the occlusion rims, and these opposing actions force the soft flange wax
into the neutral space between them that was formerly occupied by the natural
teeth.
 J. Pros. Den.
408 LOTT AND LEVIN
May-June, 1966

The modiolus tenses into a stabilizing knot and moves in various directions to
aid in locating the neutral tooth zone in the buccal bicuspid regions.
The tip of the tongue presses strongly against the lingual surfaces of the
occlusion rims during the first part of the act of swallowing, and molds the soft
wax to a contour that establishes the arch form of the teeth in the anterior lingual
region.
The lips do not strongly antagonize the tongue in the act of swallowing but
they are particularly active in facial expression. They will mold the soft wax on
the labial surfaces of the occlusion rims to appreciably assist in determining an
acceptable arch form for the teeth.
In subsequent stages of swallowing, the tip of the tongue presses against the
rugae area first, then the body of the tongue presses against the palate and the
lingual surfaces of the maxillary occlusion rim in a movement that progresses
posteriorly during the act of forcing a bolus of food posteriorly into the pharynx.
This action completes the molding of the soft wax in the palate.
Remove the occlusion rims and trim off any excess wax that may have been
molded over the occlusal or incisal surfaces. Then resoften the flange wax and repeat
the entire procedure until wax no longer flows toward the occlusal and incisal sur-
faces of the occlusion rims. Then direct the patient to rinse the mouth with cold
water, and remove the occlusion rims carefully to avoid distorting the wax (Fig. 13).

LABORATORY PROCEDURES

The occlusion rims may now be used in either of two ways to lay out the posi-
tion of the teeth. The first is to place them on their casts and draw pencil guide
lines on the casts.
The second method is more accurate and should be used for patients with
unfavorable situations.
Remove the casts from the articulator and place the perfected occlusion rims
on them. Surround each cast and occlusion rim with a wax boxing and pour in
it a plaster matrix (Fig. 14). When the plaster has partly set, cut a deep groove
in it in the anterior region so it can be fractured there later to make two sections
which are easily removed.
Remove the flange wax and keels from the occlusion rims and arrange the teeth
using the plaster matrix as the guide to-tooth position. If the flange wax has been
formed on plastic bases with the keels on them, simply replace them with the orig-
inal wax occlusion rims, and set the teeth according to the guide formed by the
plastic matrix (Fig. 15). The tooth positions can be checked at any time by
assembling the matrix around the cast and the trial denture.

TO DETERMINE THE FORM OF THE POLISHED SURFACES

The second and most valuable use of this technique is to determine the form
of the polished surfaces of dentures after the accuracy of the various jaw and tooth
relations has been determined.
Remove all excess baseplate wax from the buccal, labial, and lingual surfaces
of both trial dentures. Retain only enough of the wax to hold the teeth in position
(Fig. 16), and add softened flange wax over the remaining baseplate wax.
Volume 16
Numbrr 3 FLANGE TECHNIQUE 409

Fig. 14.-The completed plaster matrix after the wax boxing has been removed.

Fig. 15.--The plaster matrix is reassembled on the trial denture and cast to determine the
s ccuracy of the tooth alignment.

Fig. 16.-Trial dentures prepared for the addition of flange wax. All excess baseplate wax
has been removed except that required to hold the teeth in position.

Add sufficient flange wax to the buccal surfaces of the maxillary trial denture
to slightly exceed the size and shape of the contours previously molded on the
occlusion rims
Add a slight excess of soft flange wax on the labial surface to be reduced by
lip function and facial expression.
Add enough soft flange wax on the palatal surface completely around the arch
to enable the tongue to re-establish the lingual form of the ridges in the posterior
,region and the anterior curvature of the dental arch in the anterior region (Fig.
17).
410

Fig. 17.-The flange wax has been added to the trial dentures.

Soften the flange wax that has thus been added to the maxillary trial denture
slowly and evenly with a bench torch, taking care not to soften the baseplate wax
supporting the teeth.
Temper the soft wax quickly in water at 110” F., insert the trial denture in
the mouth, and have the patient wear it while the mandibular denture is being
prepared.
Remove the baseplate wax from the mandibular trial denture to make space
for the flange wax in the same manner as the maxillary trial denture was prepared.
Add flange wax on the buccal and labial surfaces by the same procedures and in
comparable amounts as on the maxillary trial denture.
Add an appreciable excess of flange wax beyond the usual arbitrary carving
on the posterior part of the lingual surfaces of the lingual flanges. This will permit
the tongue to displace the excess and shape it to accommodate all requirements
of tongue positions and movements.
Add a somewhat larger amount of excess of flange wax to the anterior part
of the lingual surface of the lingual flange (from bicuspid to bicuspid). This is a
most important surface because patients often tolerate surprisingly large extensions
over the sublingual glands with comfort. These extensions can provide definite
tongue rests (Fig. 17).
Carefully soften the flange wax on the mandibular trial denture and insert it
in the patient’s mouth
Have the patient swallow forcibly, grin broadly, pucker the lips, read aloud
for a few minutes, and make other movements of the mouth.
Remove the mandibular denture, resoften the flange wax on it, reinsert it,
and have the patient repeat the oral and lip movements. Then hold the denture down
with a finger on a molar on each side, and have the patient protrude the tongue
strongly to each side, and lick his upper lip from angle to angle while his mouth is
wide open. This will free the attachments of the genioglussus muscles.
The excess flange wax tends to move toward the occlusal and incisal surfaces of
the teeth. If it moves toward the denture borders, it indicates that the original
impressions were underextended. If the extension of the flange wax in any place
around the border is small, the cast can be carefully relieved with probable success.
If the extension of wax is large, a new master cast should be made. The trial den-
tures should now feel natural and comfortable to the patient.
Chill the trial dentures in the mouth and remove them (Fig. 18). The in-
creased size of the flanges is often surprising and yet satisfactory to the patient
(Figs. 19 and 20).
Volume lb FLANGE TECHNIQUE
Number 3 411

Fig. l&-The flange wax has been molded on the trial dentures by the patient.

19 Fig. 20

Fig. 19.-A cross-section of a pair of unsatisfactory dentures.

Fig. 20.-A similar cross-section of duplicates of the satisfactory replacement dentures made
1~ this technique. Note the greatly increased size of the flanges.

Reset any teeth that may have moved while the flange wax was being molded.
Prepare the dentures for flasking by removing the flange wax from around the
reeth. Process the dentures in such a way as to preserve the general contour estab-
‘lished by the flange wax. Minor changes in the contour of the bases may be made
iaround the teeth for esthetics provided the general contours are unchanged.

ADVANTAGES OF THE TECHNIQUE

The area of intimate contact of the denture bases with the underlying and
adjacent structures is considerably increased by the flanges, and the retention is
increased.
The location of the dental arches is changed from the status of “a rule of
thumb” location that is dependent upon the skill and judgment of the dentist or
the estimate of the technician to a physiologically located position. Reliance is
placed upon the patient for the necessary shaping of the borders and flanges.
The tongue position may be established with confidence.
The appearance of patients who have worn dentures for long years is improved
and it is maintained for patients recently treated. The buccal and labial flanges
provide complete support to the facial structures without limiting their function.
The patient’s speech may be more natural because the width of the dentures in
 J. Pros. Den.
412 LOTT AND LEVIN May-June, 1966

the bicuspid regions is determined by the accurate placement of the teeth in the
dental arch. The anterior arch form of the teeth and the shape of the anterior
part of the palate are correctly located by the molding action of the tongue. These
factors may be the determining factors in the maintenance or re-establishment of
correct phonation.

IMPROVEMENT OF UNSATISFACTORY DENTURES

The flange technique can be used to improve the retention of unsatisfactory

dentures, or to locate the dental arches in their most favorable positions.
Where only the retention is at fault, grind away the denture base material
of the flanges to make space for the flange wax.
Add the flange wax in the same manner as was described for adding it to a
trial denture. Make a zinc oxide and eugenol reline impression. Have the patient
mold the wax on the flanges as described for trial dentures. Pour a cast in the
denture.
Flask the denture in the bottom section of the flask.
Cover the denture with a one-eighth to one-quarter inch layer of silicone release
material,* and complete the flasking.
Pry the flask open after the stone has set. This is possible because of the
elasticity of the layer of silicone.
Remove the teeth from the denture and place them in their respective depres-
sions in the silicone.
Pack the mold with new denture base material, and process and finish the
denture. Do the packing of the material in the flask with care to avoid increasing
the occlusal vertical dimension of the denture.

CONCLUSION

The reasoning behind the use of flanges molded by the patient on the facial,
buccal, lingual, and palatal surfaces of dentures to the individual requirements of
each patient is sound theoretically and physiologically. The results of the use of the
flange technique are superior to the results of the discretionary methods of deter-
mining the tooth and tongue positions and the arbitrary carving of the facial, tongue,
and palatal surfaces.

REFERENCES

1. Fauchard, P.: Le Chirurgien Dentiste ou Traite des Dents, Paris, 1746, chez Pierre-Jean
Mariette, 2 :425.
2. Fish, E. W.: An Analysis of the Stabilizing Factors in Full Denture Construction, Brit.
D. J. 52:1-12, 1931.
3. Fish, E. W.: Principles of Full Denture Prosthesis, London, 1933, John Bale, Sons and
Danielsson, Ltd., p. 100.
4. Lott,. F. M. : A Stablhzation Technique for Lower Dentures, Oral Health 24:22-29, 1934.
5. Stamtz, J. D.: An Analysis of the Part Played by the Fluid Film in Denture Retention,
J.A.D.A. 37:168-172, 1948.
6. Cox, A. M.: A Consideration of the Fundamental Physical Principles Involved in the
Retention of Artificial Dentures, Brit. D. J. 47:1058-1070, 1926.
Wlastic No. 338 Denture Release Material with Catalyst, Dow Corning Corp., Medical and
Pharmaceutical Products Div., Midland, Mich.
Volume 16 FLANGE TECHNIQUE 413
Number 3

:7. Campbell, R. L.: Some Clinical Observations Regarding the Role of the Fluid Film in
the Retention of Dentures, J.A.D.A. 48:58-63, 1954.
:3. Ostlund, S. G. : Saliva and Denture Retention, J. PROS. DENT. 10:658-663,1960.
‘3. Craig, R. G., Berry, G. C., and Peyton, F. A.: Physical Factors Related to Denture Re-
tention, J. PROS. DENT. 10:459-467,1960.
10. Snyder, F. C., Kimball, H. D., Bunch, W. B., and Beaton, J. H.: The Effect of Reduced
Atmospheric Pressure Upon Retention of Dentures, J.A.D.A. 32:445-450, 1945.
11. Skinner, E. W., Campbell, R. L., and Chung, P. : A Clinical Study of the Forces Required
to Dislodge Maxillary Denture Bases of Various Designs, J.A.D.A. 47:671-680,
1953.
l.!. Skinner, E. W., and Chung, P.: The Effect of Surface Contact in the Retention of a
Denture, J. PROS. DENT. 1:229-235,1951.
925 WEST 34~~ ST.
1.0s ANGELES, CALIF. 90007