She had trained herself not to smile

Breakthrough Clinical’s Editorial Director Dr. Stacey L. Gividen discusses a “routine” denture case that, after six try-ins, resulted in three thought-provoking takeaways for her future cases.

Gritted Teeth Smile Dreamstime Cropped
ID 54556972 © Steven Day |

DENTURES are something I really don’t enjoy doing because of their inherent problems, especially with regard to patients who expect those pieces of plastic to function like their natural teeth. There really is only so much I can do, and the rest is truly up to the patients’ mind-set and how they manage their prosthesis. I always encourage the utilization of implants; however, for a multitude of reasons, implants are not always possible.

When I started this particular denture case, which was a replacement of an existing full/partial, I didn’t expect to run into any issues. I have done thousands of denture prosthetics, and this one, in my mind, was no different. The patient’s chief complaint was: “I want to smile.”

Impressions, framework/wax rim, vertical dimension, midline, etc., were easy. The patient brought in pictures of her natural teeth for reference, and she was smiling in each of the pictures.

Try-in No. 1: A no-go. The midline needed to shift to the right.

Try-in No. 2: "Too much teeth are showing.”

Try-in No. 3: "Not enough teeth are showing.”

Try-in No. 4: “Can you change the shape and shade of the teeth?”

Try-in No. 5: "I like the other teeth better, and not enough teeth are showing. Can we switch back and try this?”

During these visits, the patient would take pictures and FaceTime her family members to get their thoughts and opinions.

By this time, I was getting a tad frustrated. The patient’s demands were being met, but progress was not being made. We seemed to be spinning our wheels. What’s more, the patient kept comparing everything to her old dentures, which, as we all know, is a no-no.

I decided it was time to do something different.

Try-in No. 6: I thought for sure that this would be the final one. I put the denture in place and didn’t hand the patient a mirror this time. I told her to smile. She smiled, but she didn’t show any teeth. I said, “No, smile and show your teeth.” She smiled, but again she didn’t show any teeth. I asked her: “Do you think you are showing teeth when you smile?” She said she thought she was.

Right then and there I knew what the problem was. Over the course of her denture-wearing years, this patient had trained herself not to smile. It was a self-taught reflex that impacted what was supposed to be an easy denture case and turned it into a very challenging one. Whenever the patient had the mirror, she “fake smiled it,” and it wasn’t what she wanted to see. She wanted a natural-looking smile, but that natural smile was nonexistent.

I explained to the patient what the underlying issue was and encouraged her to try to retrain herself to smile again. This was difficult because all she had was her old denture to go off of, and she didn’t like her smile with that prosthesis. We weren’t going anywhere with her new denture, so, in essence, we were at a crossroad with nowhere to go. By this time, the patient and her husband were going away for the winter, so we ended up stopping the process altogether.

What’s the take-home? A few things, actually:

1. Just because someone has had dentures for a long time doesn’t mean the case is a slam dunk. These cases can actually be harder, because everything you do (or don’t do) is compared to the old dentures. Chuck those things in the trash!

2. Perception is everything. Beauty is in the eye of the beholder. What you think looks good (or bad) may be the opposite for the patient. We’ve all been here.

3. In this case, the patient had stopped believing in the process and my capacity as a dentist to deliver what I had promised. In retrospect, perhaps I was too confident that I could make her smile again. Was that my fault or hers? This point could be debated, for sure.

Dentures, or any removable prosthesis for that matter, are some of the easiest yet most difficult things that we as dentists have to manage. As a rule of thumb, especially for new denture wearers, I always give worst-case scenarios as to what their experiences will be like so the patients’ expectations can be somewhat rooted in reality. In this situation, I missed the nail completely. But in the end, I learned something that I can apply to my future denture cases. If you are a cup-half-full person, it’s a win.

Carry on, my friends, and cheers to the things in dentistry that keep it real each and every day...

Stacey L. Gividen, DDS

Editorial Director, Breakthrough Clinical

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Editor's note: This article originally appeared in Breakthrough Clinical, a clinical specialties newsletter from Dental Economics and DentistryIQ.

Stacey Gividen DdsStacey L. Gividen, DDS, a graduate of Marquette University School of Dentistry, is in private practice in Hamilton, Montana. She is a guest lecturer at the University of Montana in the Anatomy and Physiology Department. Dr. Gividen is the editorial director of Endeavor Business Media’s clinical dental specialties e-newsletter, Breakthrough Clinical, and a contributing author for DentistryIQPerio-Implant Advisory, and Dental Economics. She also serves on the Dental Economics editorial advisory board. You may contact her at        

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