54556972 © Steven Day | Dreamstime.com
Gritted Teeth Smile Dreamstime Cropped 5cdf27c848a95

She had trained herself not to smile

July 27, 2023
This “routine” denture case resulted in three thought-provoking takeaways—after six try-ins.

Editor's note: Published May 17, 2019. Updated July 2023.

I really don’t enjoy doing dentures because of their inherent problems, especially in patients who expect those pieces of plastic to function like their natural teeth. There's only so much you can do, and the rest is truly up to the patient's mindset and how they manage their prosthesis. I always encourage implants, but for a multitude of reasons, implants are not always possible.

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

Denture try-in times six

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

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 on the case. 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, “Now, 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.

You may also be interested ... 5 things dentists wish patients knew about caring for their teeth

An aha moment

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. This was difficult because all she had to go off of was her old denture, and she didn’t like her smile with that prosthesis. 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.

My takeaways

  • 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 the patient tends to compare everything you do (or don’t do) to the old dentures. Chuck those things in the trash!
  • 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. 
  • 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.

Dentures, or any removable prostheses for that matter, are some of the easiest yet most difficult things that we have to manage. As a rule of thumb—especially for new denture wearers—I always give patients worst-case scenarios as to what their experiences will be like so their expectations can be more closely 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.

You may also be interested in ... 4 postpandemic dental industry trends: Here to stay?