Aesthetic Perception of Patients and Dentists on Conventional and Characterized Complete Dentures.

Objective: The objective of the study was to compare the perception of patients and dentists regarding the esthetics achieved with conventional and characterized complete dentures. Materials and
Methods: Twenty completely edentulous participants were selected and given both conventional and characterized complete dentures. Participants including patients wearing the dentures and dentists subsequently evaluated both types of dentures by giving scores using 0-10 cm Visual Analog Scale on denture esthetics. The esthetic scores were statistically analyzed using paired t-test (P = 0.05 as significant).
Results: Patients' satisfaction with conventional and characterized complete dentures were statistically similar except for the fact that patients were more satisfied with ideal arrangement of teeth in conventional denture (standard deviation [SD]-7.0 ± 2,0) compared to the characterized (SD-4.8 ± 2.7) arrangement of the teeth (P = 0.038). Conclusions: Aesthetic satisfaction with complete dentures was influenced by the patients' socioeconomic status. Patients could not see any significant difference between conventional and characterized complete denture. Copyright:

INTRODUCTION

Edentulism is defined as the state of being edentulous; without natural teeth.[1] Complete dentures have been extensively used and are a satisfying option for the oral rehabilitation of edentulous patients.[2] Natural appearances of the patient are further enhanced by the characterization of the denture base by incorporating stippling, creating scalloped margins and gingival staining. This gives a psychological boost to the patient and also helps in easy acceptance of the patient using dentures in the society.[3] Various studies have shown that characterized complete denture increases the acceptance and confidence level of the patient. However, there are only a few studies on comparing aesthetics between conventional and characterized denture. Moreover, data is scanty with patients' and dentists' perceptions of aesthetics on complete dentures. Null hypothesis to be tested was that there is no difference in aesthetics between conventional and characterized complete denture.

MATERIALS AND METHODS

The ethical approval for the study was obtained from the ethics committee (1248/IEC/2017). Edentulous subjects (n = 20 Males: 11, Females: 9) aged between 30 and 70 years of age, requesting for complete dentures with high esthetic expectations. Both characterized and conventional complete dentures were fabricated for each patient and inserted. On the day of denture insertion, a questionnaire containing five questions was given to each patient to evaluate the aesthetics of both the complete dentures on the basis of visual analog scale (VAS) (0–10 cm). This was followed by evaluation of both the complete dentures by the dental specialists and undergraduate interns on the basis of VAS (0–10 cm).

All the complete dentures were fabricated within 1 year (study duration) in a postgraduate dental clinic, under the supervision of dental professors having experience of more than 12 years, using a standardized technique.

Guidelines for teeth setting in characterized complete denture

The anterior teeth selection was done by using the measurement taken from the width of the nose[4]

Lighter shades of teeth were selected for younger patients and darker shades of teeth were selected for aged patients[5]

The anterior teeth were arranged with overlapping of lateral incisors and mild rotations of canine to avoid an ideal symmetry followed in a conventional denture[6] [Figure 1a]

Figure 1

Wax trial dentures (a) Characterized (b) Conventional

Wax up and root prominences were created as usual. Stippling and frenum were added to mimic the natural appearance as close as possible. The flasking was done in a manner similar to the conventional denture, but before the second pour, Zetalabor lab putty and indurent gel were mixed and adapted on the tooth and waxed up surfaces without incorporation of air to preserve the carving and festooning of the denture. Acrylic stains (DENTURE ART, Lot no: DD 3900, Dreve Dentamid Gmbh, Made in Germany) were added on the replica of the waxed up surface according to the photographs which were taken during the try-in procedure. Basic stains in the kit are Castdon Margin white, Castdon gingival red, Castdon blue. The other Castdon intense stains come in yellow, brown, red, and white. Castdon veins are also available in red and blue

The first layer of mild pink color with autopolymerizing monomer was added initially in all the regions. Second, marginal blue and red were mixed together to mimic purple pigmentation in the interdental papilla regions. Brown Stains were added ranging from fair to dark melanin pigmentation according to the patients intraoral appearance. The amount of pigmentation may vary from individual to individual from mild-to-severe pigmentation. Red stains were added on the frenum areas and above the attached gingiva region. The remaining areas were occupied by the traditional pale pink heat cure acrylic resin

Intense colors were used in the areas wherever necessary for the particular patient

After the staining procedure, heat cure acrylic resin was packed immediately to avoid porosity on the stained surface

Then, it was then subjected to short processing cycle and cured, finished, and polished [Figure 2a].

Figure 2

(a) Characterized complete denture (b) Conventional complete denture

Guidelines for arrangement of teeth in conventional complete denture

Same size, shape, and color of the teeth were selected that as used for characterized denture set for each subject

The arrangement of teeth was done according to the principles given by Fenn.[7] [Figure 1b]

Conventional denture was fabricated as usual[8] [Figure 2b].

Insertion of characterized and conventional complete denture

Both characterized and conventional complete dentures were inserted into the patients' mouth and checked for occlusal discrepancies, overextensions, aesthetics, phonetics, vertical and centric relations were checked [Figure 3a and b].

Figure 3

(a) Characterized denture insertion (b) Conventional denture insertion

Aesthetic evaluation of dentures by the patients, panel of five undergraduate interns and specialists

Questionnaire containing five questions on aesthetics was given to the participants. This questionnaire was used in previous studies.[6910] For validation, the questionnaire was tested on ten random complete denture wearers as a pilot testing before use in the current study. After validation, the participants of the study were asked to give their score on both the dentures through VAS (0–10) on the same day of insertion. Questionnaire was modified for the patients in the regional language (Tamil) along with the inclusion of their socioeconomic status (Education, Employment and income level), and responses were recorded based on:

Opinion on appearance of the denture base?

Opinion on arrangement of the teeth?

Opinion on facial harmony with the denture?

Do you consider the denture aesthetically appealing?

Do you consider the denture natural?

Statistical analysis

The data thus obtained were tabulated and analyzed using statistical analysis.

The Normality tests Kolmogorov–Smirnov and Shapiro–Wilks tests results revealed that the variables follow normal distribution. Therefore, to analye the data parametric methods (Paired t-test) were applied to compare mean values between characterized and conventional dentures. Paired t-test was applied between Patient, undergraduate interns, and Specialists. To analyze the data SPSS (IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY: IBM Corp. Released 2017) was used. Significance level was fixed as 5% (χ =0.05).

RESULTS

Mean values of response to each question given by patients, undergraduate interns, and specialists were calculated, and comparison was done between conventional and characterized complete dentures. Paired sample t-test was used to compare mean values of conventional and characterized dentures in each group, and comparison between the groups were also done to provide the P value, which helped in analyzing the significance of the study. Paired t-test showed no significance (P > 0.05) difference was found between conventional and characterized complete dentures which were evaluated by the patients.

The first question about denture base appearance reveals that patients had no significant differences between conventional pink dentures and characterized dentures. However, the acceptance of conventional dentures (mean score 6.4) was marginally higher than the characterized dentures (mean score 5.5), which was found to be statistically insignificant (p-0.364) [Table 1]. On the other side, both undergraduate interns and specialists were highly satisfied with the characterized denture (Mean scores 7.6 and 7.7) rather than conventional denture (Mean score 4.0 and 4.6), which is statistically significant (P < 0.001) [Tables 2 and 3]. The second question of the present study was about the arrangement of teeth; it was found that the patient was satisfied with the ideal arrangement of teeth in conventional denture (mean score: 7.0) than the characterized denture (mean score: 4.9) in which mild rotation and overlapping was done which was found to be statistically significant (P < 0.038). In contrast, undergraduate interns and specialists were more satisfied with the characterized denture (mean score 7.6 and 7.8) than the conventional denture (Mean score 4.5 and 4.9) which was found to be statistically significant.

Table 1

Paired t-test to compare mean values between conventional (n=20) and characterised (n=20) dentures among patients

Question number	Patient	Mean±SD	P
1	Conventional	6.4±2.2	0.364
	Characterized	5.5±2.7
2	Conventional	7.0±2.0	0.038
	Characterized	4.8±2.7
3	Conventional	6.8±1.9	0.164
	Characterized	5.4±2.5
4	Conventional	6.3±2.1	0.248
	Characterized	5.2±2.3
5	Conventional	6.6±2.0	0.320
	Characterized	5.6±2.7

SD: Standard deviation

Table 2

Paired t-test to compare mean values between conventional (n=20) and characterised (n=20) dentures among undergraduates

Question number	Undergraduates	Mean±SD	P
1	Conventional	4.0±0.5	<0.001
	Characterized	7.6±0.3
2	Conventional	4.5±0.6	<0.001
	Characterized	7.6±0.5
3	Conventional	4.5±0.5	<0.001
	Characterized	7.5±0.5
4	Conventional	4.2±0.6	<0.001
	Characterized	7.5±0.4
5	Conventional	4.0±0.7	<0.001
	Characterized	7.7±0.5

SD: Standard deviation

Table 3

Paired t-test to compare mean values between conventional (n=20) and characterised (n=20) dentures among specialists

Question number	Specialist	Mean±SD	P
1	Conventional	4.6±0.4	<0.001
	Characterized	7.7±0.5
2	Conventional	4.9±0.4	<0.001
	Characterized	7.8±0.3
3	Conventional	4.7±0.4	<0.001
	Characterized	7.8±0.4
4	Conventional	4.7±0.5	<0.001
	Characterized	7.7±0.3
5	Conventional	4.5±0.5	<0.001
	Characterized	7.8±0.3

SD: Standard deviation

The third question about facial appearance in the present study found that the patient was satisfied with a conventional denture (mean score: 6.8) than characterized denture (mean score: 5.4), which was statistically insignificant (P = 0.164). In contrast, undergraduate interns and specialists found characterized dentures (mean scores 7.5 and 7.8) more satisfying than conventional dentures (mean scores: 4.5 and 4.7), which was statistically significant (P < 0.05). The other questions in the present study based on denture attractiveness and natural appearance, patients found no significant difference between conventional and characterized dentures while undergraduate interns and specialists were more satisfied with characterized dentures which were found to be statistically significant (P < 0.05).

DISCUSSION

In this study, we focused on determining the various aesthetic quality measures that may have been correlated with patients' satisfaction with their complete dentures. Selecting a random sample is the preferred way to avoid having a biased or unrepresentative sample.[11] In this study, we avoided exclusion biases and underrepresentation and overrepresentation biases by selecting a simple random sample in which all units of the same size had an equal chance of being selected.

In most of the previous studies, the questionnaire was given to the participants and the satisfaction level was calculated by the response given based on the pictures shown to the patients. No studies had compared the conventional and characterized complete denture from the patients' point of view. The present study was conducted by actually delivering both the conventional and characterized dentures to the participants and received the response by the patients' experience on the denture. Although standardized protocols had been followed for the fabrication of the complete dentures, human errors are unavoidable. Therefore, evaluation was carried out the same day to ensure other factors such as comfort, mastication, retention, and stability does not affect the patients perception of esthetic part of the complete denture prosthesis. Then, the data were subjected to statistical analysis. Various studies showed that characterized dentures increase the confidence and satisfaction of the patients. On the contrary, most of the participants in this study were in favor of the conventional dentures than the characterized dentures. This result was greatly influenced by the socioeconomic status of the participants involved in this study. In order to characterize the dentures, different stains were incorporated in various areas to mimic the natural appearance, but it was found that the patients considered melanin pigmentation that was added as unusual in the characterized denture. Inspite of these characterizations incorporated in the denture, patients were highly satisfied with the pink polished dentures. Only few patients who participated in this study could appreciate the characterization. These patients were found to be comparatively more educated.

Similar to the results of the present study, Celebić et al.[12] in 2003, found that patients with less education and socioeconomic status had higher level of satisfaction with conventional complete denture compared to patients with good socioeconomic status. They also found that those patients' who are educated were more demanding and showed lesser satisfaction towards conventional complete dentures.

Most of the studies advocate characterized denture to increase the acceptance of the patients. In the present study, it was seen that patients are very much satisfied with the ideal arrangement of teeth and conventional denture base. This was influenced by the education level of the patients. Illiterate patients were found to have a myth that the ideal arrangement of teeth and pink denture increases their confidence level, which totally contradicts the concepts of natural appearance and characterization of the denture. This was in accordance with Stockheimer and Waliszewski[6] in 2012 did a survey on dentulous and edentulous patients' preference among different denture esthetic concepts. It was concluded that respondents considered supernormal and denture look arrangements were more satisfying than the natural look arrangements. These results were similar to the present study, where patients had more satisfaction towards the ideal arrangement of the teeth rather than characterized arrangement of the teeth.

The questionnaire study which was conducted previously had a hitch wherein the survey was taken by showing the pictures of characterization to the patients due to which they didn't have the opportunity to decide upon the requirement of the denture. In the present study, patients were given the opportunity to evaluate both the types of denture and give their response. On the contrary, Matsuda et al.[9] in 2015 conducted a survey in Osaka University Dental Clinic on denture characterization where the questions were asked after briefing on denture characterization by showing pictures and explaining the costs involved. It was concluded that 65% of participants cared about their denture appearance, and over 50% of participants were particular about the denture gum appearance. As many as 70% of participants were concerned about the denture base characterization. Females and subjects <75 years of age were more interested in characterization. Khurshid and Sarvar.[13] in 2017 did a case report on characterization of a single lower complete denture and an opposing partial denture. It was reported that the patients were very satisfied with the results on insertion. The authors of this study urge practitioners to meet the expectations of patients by denture characterization.

On the other hand, Shenoy.[10] in 2018 did a questionnaire study on 100 removable denture wearers on denture aesthetics and denture base characterization where she found 68% of the patients were concerned about denture gum appearance among which 52.9% were lot concerned, and the remaining patients were not concerned. She also found that 91% of the patient considered characterization as a very important objective while 84% of patients wanted characterization to be applied in the denture, and 95% of the patients felt that denture base characterization improves their confidence while conversation.

The limitations of the study are

Errors could have crept in during the clinical and laboratory procedures

The control over the application of acrylic stains was difficult

Stains could have dispersed from the specific region while packing.

Further research can be done with gingival shade composite resin which has more esthetic qualities, and operator can have adequate working time for customization of the denture. Furthermore, a larger sample size can be evaluated and studied with similar parameters to get significant results. However, the results obtained from this study depicts patients didn't find any significant difference between conventional and characterized complete denture.

CONCLUSIONS

Within the limitations of this in vivo study, it can be concluded that,

The characterized denture does not have any significant influence, whereas patients are marginally more satisfied with their conventional dentures. Education and socioeconomic status play an important role in the acceptance and satisfaction of conventional dentures over the characterized dentures

Undergraduate interns and specialists found characterized dentures more aesthetically appealing than the conventional dentures

Even though, specialist and undergraduate interns found characterized dentures more aesthetic, the patient preference should be given more importance, and dentures should be fabricated accordingly.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.