Dental care at eye level

A 68-year-old male patient had been provided with temporary dentures. After a year had passed, he wanted a fixed, light and palateless implant-retained restoration. The two temporary dentures could be used as the basis for the new implant-retained dentures, as the patient was able to function properly with them. Only the functional margins and the covered palate bothered him. For the purposes of DVT, the temporary restorations were modified to act as X-ray templates. During backward planning using this 3D diagnostic tool, it was possible to position the implants virtually in the bone and create a drill template on this basis. Once the implants had been inserted and healing was complete, fixation impressions were taken and master models fabricated that were articulated appropriately for the patient using the registered temporary dentures.

In consultation with the patient, the appropriate VITAPAN EXCELL mould was selected in the shade A2. Morphology that follows esthetic guidelines, a natural surface texture and anatomical layering provide these denture teeth with a lifelike appearance. For the posterior region, VITA PHYSIODENS was selected in A2 in order to quickly achieve unique centric occlusion. The patient wanted custom anterior positioning instead of straight positioning. Final verification of occlusion, phonetics and esthetics could then be performed during clinical try-in.

The optimized setup and the master models were then scanned individually and in articulation (IScan D104i, Imetric, Courgenay, Switzerland). In the CAD software (Exocad, Darmstadt, Germany), full virtual shrinkage of the setups was performed as part of a first step in order to achieve an anatomically supported, dimensionally accurate structure from which the substructure could gradually be constructed. The substructure was fabricated from a non-precious metal blank using CAD/CAM technology (Millhouse, Wallau, Germany). Using a silicone key, it was possible to transfer the denture teeth in wax to the substructures. During wax modelling, the teeth were extended morphologically in the cervical area and the alveolar process was shaped. The situation was duplicated using dental putty.

Following wax extraction, cleaning and conditioning, the denture teeth were fixed in the duplicating key using superglue, and VITACOLL bonding agent was applied in the basal-cervical area. The silicone matrix was then repositioned on the master model. It was then possible to inject the tooth-colored cold-curing polymer resin VITA VM CC A2 via a posterior opening. Following removal of the key, the shade fidelity could be seen between the homogeneously shaped cold-curing polymer resin and the denture teeth. Once finishing had been completed, the gingival appearance of the patient was replicated in the vestibular area using the flowable light-curing veneering composite VITA VM LC flow. Finishing was performed using a fine diamond instrument and fine pumice, followed by diamond polishing paste

Following wax extraction, cleaning and conditioning, the denture teeth were fixed in the duplicating key using superglue, and VITACOLL bonding agent was applied in the basal-cervical area. The silicone matrix was then repositioned on the master model. It was then possible to inject the tooth-colored cold-curing polymer resin VITA VM CC A2 via a posterior opening. Following removal of the key, the shade fidelity could be seen between the homogeneously shaped cold-curing polymer resin and the denture teeth. Once finishing had been completed, the gingival appearance of the patient was replicated in the vestibular area using the flowable light-curing veneering composite VITA VM LC flow. Finishing was performed using a fine diamond instrument and fine pumice, followed by diamond polishing paste

A 73-year-old patient presented at our practice because he was unhappy with the stability of his full denture restoration. He wanted to be able to chew properly and with confidence again. During the intraoral examination, it became apparent that the upper denture provided insufficient retention. The lower denture showed proclination, meaning there was forward movement of the lower denture under load. Due to this malocclusion, with premature contacts in the posterior region, impacting forces were being transmitted in the anterior direction. The occlusal plane was well aligned, but the length-to-width ratio of the teeth and the denture base did not suit the anatomical features and facial shape. During extraoral evaluation of both dentures, it was evident that they had been extended and modified multiple times.

After anatomical and subsequent mucodynamic impressions were taken, it was possible to create master models, and on these, to fabricate bite templates with wax rims. For correct wax rim alignment, their length and soft tissue support were first checked intraorally. The palatal and lingual parts of the front of the wax rim were then reduced to provide more space for the tongue and make it easier for the patient to speak. During determination of the jaw relation, it became apparent that the orbicularis oris had strong muscle tone, which could limit denture retention. For this reason, the muscle was allowed to rest against the surfaces of the registration rims without causing destabilization. This was intended to ensure effective retention of the final denture. To finish, the wax rims were registered with each other via retentive notches.

The models were aligned to Camper's plane during articulation. Model analysis was carried out based on Prof. A. Gerber's method. In doing so, all the information was transferred to the model. In the lower jaw, the center of the alveolar ridge was measured and marked to facilitate ridge-stable setup, as was the stop line to prevent proclination. The model analysis not only indicated where the teeth should be positioned for functional reasons, but also provided guidance regarding tooth selection in terms of mesiodistal and vertical dimensioning. Additionally, an old photo of the patient showing their natural dentition was used in the laboratory to select the appropriate anterior tooth shape. In the articulator, the teeth were gradually set up based on the wax rim that was aligned to suit the patient. For the anterior wax try-in, the premolars were also positioned because the anterior setup alone would not have provided the patient with sufficient reference points. After the practitioner and the patient were satisfied with the interim result, setup was completed using the remaining teeth in the VITAPAN LINGOFORM tooth sets.

Following implementation in resin, the occlusion was verified, and finishing carried out on the denture base. The cut-back technique was then used to begin individualization of the labial shield. Prior to that, the shape of the labial shield was registered using silicone. Controlled reduction of the labial areas was then performed to replicate the shade variation of the mucogingival anatomy in these areas using light-curing VITA AKZENT LC composite stains. In the next step, the teeth were also characterized using VITA AKZENT LC. To finish, the silicone key was used to shape the initial morphology with transparent PMMA. After final finishing and polishing, both full dentures were ready to be sent to the dental practice for final integration.

Before final integration, the completed dentures were checked again for sharp edges and areas with excessive undercuts. In the end, verification of the length of the margins was the first step that was performed intraorally. The next step was to check the suction effect and soft tissue adaptation. Due to the subsequent soft tissue adaptation, static and dynamic occlusion were evaluated last, since only obvious premature occlusal contacts were initially removed The first follow up took place after one day, and the second after one week, during which some modifications were made to tooth 11 and 21, due to unbalanced lower lip movement. This custom rehabilitation restored the desired personality and function for the patient. Thanks to teamwork between the dental practice and dental laboratory, it was possible to achieve a custom restoration for the patient using VITAPAN EXCELL and VITAPAN LINGOFORM. As a result, teeth were integrated in the end, not dentures.

A 54-year-old patient presented at our facility because she was unhappy with the esthetic appearance of her full denture restoration. The overly small, lifeless appearance of the teeth in the esthetic zone had bothered her right from the start. Over time, they also showed significant discoloration. Severe abrasion had led to loss of bite height, as shown by the sunken lip and cheek areas. Despite these esthetic deficits, the patient had been comfortable with the function offered by her old full denture restoration for over ten years. As a result, the decision was taken to use it as a reference for the planned new restoration, in order to minimize the adaptation period as much as possible. 

While the Copy Denture technique would have previously required complex analog work with duplicating materials and cold-curing resins, today's laboratories can use sophisticated laboratory scanners and 3D printing systems. In this case, the old upper and lower dentures were first reproduced additively. This was then also followed, in the virtual data set of the lower denture, by design and additive fabrication of a flat surface for incisal pin registration (lingual side) and of a sensor adapter protruding from the mouth (labial side) for digital determination of the jaw relation using the JMA Optic system (zebris Medical, Isny, Germany). These three components formed the basis for comprehensive registration and were also to provide successive orientation during subsequent manual setup in the articulator.

To begin with, mucodynamic impressions were taken using the old dentures, and used as a basis for creating master models. This was followed by initial analysis with the patient using the two additively fabricated denture duplicates. The nasal width and midline were marked and the bipupillary line and Camper's plane verified using the occlusion determination device. The lower denture duplicate was then separated, and the fenestrated bite fork of the JMA Optic system secured on the dental arch with silicone. The situation was scanned, and the face bow attached and secured to the bite fork. The second expanded duplicate version, with the flat registration surface on the lingual side and the sensor adapter, was incorporated in the lower jaw. The adapter provided a precise connection to the lower jaw sensor of the digital system. This allowed real movement data to be registered, centric occlusion to be determined and integrated support pin registration to be registered using silicone. 

Using the mechanical transfer stand, the upper jaw model was gypsum-mounted into the SAM articulator, following the digitally registered spatial positioning of the upper jaw. This was followed by articulation of the opposing jaw using the recorded support pin registration. The SAM articulator allowed the real movement data that had been determined digitally for the temporomandibular joint to be adjusted in terms of tilt and angle to suit the patient. Model analysis was then carried out based on TiF to gather all the necessary reference points for optimal positioning of the denture teeth. The patient's face, the models and the potential anterior denture teeth were scanned, and all the data sets matched with the old dentures that had previously been digitized. This allowed the correct anterior teeth to be chosen together with the patient in the desired shade (A2) and in a relaxed atmosphere in front of the screen. The square VITAPAN EXCELL S46 anterior tooth range was selected for the upper jaw with L37 in the lower jaw. The patient liked the shape and texture, and at the same time, these anterior teeth also met the requirements for vertical dimension and space on the alveolar ridges. The more delicate VITAPAN LINGOFORM 21L was chosen for the posterior area so as to provide sufficient space for the tongue and to establish the jaw relation without the need for significant occlusal milling. 

The duplicates of the old dentures provided the orientation as planned during the wax setup. The teeth were successively removed and replaced with new denture teeth. After a wax try-in of the anterior teeth, the posterior teeth were also set up, and the mucogingival and palatal anatomy shaped. A silicone key of the setup was fabricated to allow for repositioning of the denture teeth at any time. Once the setups had been scanned, the wax was boiled out. The teeth that had been repositioned in the silicone key were then scanned at the base so that the basal areas of the teeth could be cut out in the CAD software during design. To prevent polymerization shrinkage, CAD/CAM technology was then used to fabricate the bases from VITA VIONIC Base discs (Light Pink). After the bases had been finished, the teeth were integrated in a stable position into the alveoli using a silicone key and cold polymerization.

The labial shields were roughened using instruments and the alveolar processes highlighted, beginning with a balanced mixture of VITA AKZENT LC composite stains in white and orange. This was followed by uneven application of a mixture of pink (2/3) and cream (1/3). Fine vascular structures were created using dark-red. A uniform gloss was established across the entire labial shield by applying VITA AKZENT LC GLAZE and UV curing at a wavelength below 430 nm. Final surface finishing was carried out using a clean linen polishing buff without polish at a speed of 5000 rpm.  

Digital technology, analog craftsmanship and the Copy Denture technique, along with the right tooth selection, resulted in a highly esthetic full denture outcome. The three-dimensional, anatomical layering of the robust composite formulation VITA MRP (Microfiller Reinforced Polymer matrix) combined with the lifelike surface texture of the VITAPAN EXCELL anterior tooth range provided a perfectly natural-looking result. The patient literally beamed with joy during integration. 

The 70-year-old patient presented to the dental practice because he was dissatisfied with his now 50-year-old full denture. Both prostheses had been repaired, expanded and relined several times over the course of the period they had been worn. The teeth had massive abrasions, which is why the bite height had dropped sharply, resulting in rhagades and sunken lips and cheeks. The denture teeth were highly stained and were of varying shades. Overall, the restorations appeared lifeless. The clinical examination revealed atrophy in both the upper and lower jaw and a pronounced, flabby alveolar ridge. Since the patient refused implants, we decided to produce a new, mucosa-supported full denture. In doing so, the bite was to be raised by 5 mm in favor of the mandible.

After the functional impression was taken with individually manufactured trays and the master model was made, the jaw relation was determined. For this purpose, the old dentures were duplicated in wax and keyed with aluminum wax in accordance with the planned bite elevation in the posterior area. This was followed by the patient-specific articulation of the master models with the registration. In the next step, the model analysis was carried out according to TiF, in order to know where the prefabricated teeth had to be set up from a functional and esthetic point of view, and which tooth dimensions were possible due to the space available. Together with the patient, the right anterior set in terms of shape and shade were now to be selected from the VITAPAN EXCELL range. Since the patient was fundamentally satisfied with the old denture teeth in the front of the upper jaw, these were used for orientation. 

The teeth should not look too youthful, but should appear age-appropriate in terms of morphology and texture. The triangular VITAPAN EXCELL T48 upper anterior teeth, with a width of 48.1 millimeters, matched the model analysis, harmonized with the masculine appearance, and the patient approved of the look. The moderate tooth length matched the vertical space available. The VITAPAN EXCELL L39 was selected for the lower jaw to match the model analysis, the vertical dimension, and the shape of the front of the upper jaw. The 9.8 millimeter long set of teeth were intended to occupy the space of the vertical bite elevation. The multifunctional VITAPAN LINGOFORM L22 was selected for the posterior area based on the determined support zone. At the patient's request, all tooth sets were to have the shade A3.

Since VITAPAN EXCELL fundamentally corresponds to the esthetic rules in terms of morphology, the anterior region was set up quickly and intuitively. For anatomical reasons, and at the patient's request, care was taken to fill in the upper lip and not to let the upper anterior teeth protrude too far labially. In the idealized position, the upper incisors pointed into the lower labial arch and the lip was well supported. In the posterior region, the occlusal surface design, based on the gear wheel principle, helped the antagonists of the VITAPAN LINGOFORM to automatically find each other centrally with the articulator connection. For the setup in the posterior region, care was taken to make the compensation curve steeper. As planned, the raising of the bite was only carried out in the lower jaw, so as not to change the patient's appearance too much when laughing and when opening the mouth. 

When modeling the denture bases, care was taken to fill the labial arch as much as possible in order to ensure a stable seat of the denture, especially with regard to the flabby alveolar ridge. After embedding, wax extraction and repositioning and conditioning of the prefabricated teeth, denture resins of various shades were placed directly into the wall for individualization in order to have an effect from the inside out. The alveoli became darker and redder, and the alveolar hillocks lighter than the base resin. The remainder of the denture base was stuffed with veined resin. After hardening, the resin was finalized with various milling attachments, shaped and polished. After integration, the patient's smile immediately appeared healthier and friendlier. The compensation curve was significantly improved, and significantly less of the denture base was visible when smiling. Thanks to the right tooth selection in terms of shape and shade, and a well-planned setup, the patient felt comfortable and was able to laugh again. 

An edentulous 70-year-old patient was referred to the dental department of Phunphin hospital (Surat Thani, Thailand). Due to her lack of teeth, she had difficulty chewing her food and speaking and was unhappy with her appearance, which was impacting her mental health. The patient wanted large, square teeth that would give her a broad smile. She was generally healthy and was not taking any medication. After an initial examination it was apparent that a full denture restoration was possible. The upper and lower alveolar ridges were well-developed. Extraorally, only a loss of vertical dimension, due to the lack of teeth was visible.

As a basis for full denture restoration, impressions were taken of the upper and lower jaw using alginate. This was used as a basis for situation models and custom impression trays were created. These were used to take mucodynamic impressions in multiple steps. In doing so, a green compound material was used on the margins. The rest of the impression was taken in one step using Light Body silicone. Using the impressions as a basis, master models were created on which it was then possible to fabricate bite templates for determining jaw relation. 

When aligning the wax rims, attention was first paid to sufficient lip support. The incisal plane was then established parallel to the interpupillary line. In a third step, the occlusal plane was established parallel to the ala-tragus line as a connecting line between the lower edge of the nostrils and the center point of the tragus. This was followed by correct dimensioning of the buccal corridor. To finish, the horizontal jaw relation was determined between the upper and lower jaw using the bilateral manipulation technique and registered using aluminum wax. A facebow was placed to facilitate transfer of the spatial alignment of the upper jaw in relation to the base of the skull to the partially adjustable articulator, and to establish balanced, patient-appropriate occlusion.

An age-appropriate tooth shade A3 was chosen that matched the patient's skin tone. The anterior tooth sets VITAPAN EXCELL T48 and L37 were chosen to meet the patient's wishes and the need for a square facial shape. In addition, the relation between a tooth facet length of 10.5 cm in the upper jaw and 9.9 cm in the lower jaw harmonized with the vertical relation of the alveolar ridges. In the posterior area, VITAPAN LINGOFORM 22L was selected to facilitate balanced, bilateral occlusion. Thanks to the design of the tooth surface, and based on a gear wheel principle, the posterior teeth are automatically in centric occlusion with each other when the articulator is closed, allowing them to be set up quickly and reliably. Both VITAPAN EXCELL and VITAPAN LINGOFORM are pressed from a single mould using VITA MRP, a composite made of a Microfiller Reinforced Polymer matrix with a highly cross-linked formulation. As a result, high abrasion stability can be expected.

The teeth were set up using the pink modeling wax Cavex Set Up Regular (Cavex, Haarlem, The Netherlands). The mucogingival anatomy was reproduced using red plate wax (dental wax, Prominent dental, Thailand). The wax surface was stippled to minimize light reflections on the denture base, and to simulate the natural gingiva. A result that was indistinguishable from natural dentition was achieved by combining stippling and individualized shading. As the patient was wearing dentures for the first time, the palatal ridges were also replicated. In combination with the tongue, these facilitate faster or even immediate phonetic adaptation. Esthetics, jaw relation, phonetics and fit were verified during clinical try-in. The patient was already pleasantly surprised at this stage by the lifelike brilliance of VITAPAN EXCELL that was facilitated by the three-dimensional anatomical layering comprising enamel, cervical and dentine material in combination with the pronounced surface structure.

After successful clinical try-in, it was possible to implement both restorations in resin using a PMMA heat-curing polymer resin. Finishing was performed using acrylic burs and rubber polishers. Final polishing was carried out using a pumice stone, polishing paste and a polishing buff. The occlusion was verified in the articulator, minimally milled and repolished at selected locations on the processed surfaces. During final placement, the patient was delighted with the esthetic and functional results. Occlusal testing was carried out in two additional sessions to prevent occlusal interference following the extended period of edentulism, and to eliminate any pressure points.

Intraorally, the VITAPAN EXCELL anterior tooth set facilitated a brilliant play of shade and light that made the patient look considerably younger. In the posterior area, VITAPAN LINGOFORM enabled balanced bilateral occlusion that provided the basis for sufficient chewing. In the long-term, the even distribution of force also means less resorption of the alveolar ridges. The mucogingival anatomy around the teeth was already carefully reproduced in wax so that the red esthetics and patient-appropriate support of the lips and cheeks could be modelled in the resin in a controlled manner. Simulation of the palatal ridges allowed the patient to get used to the phonetics very quickly. At a follow-up appointment after three months, the patient was delighted with her new appearance and with the secure fit of the new restoration.

The 60-year-old patient presented in the dental practice because he had lost all of his natural teeth over time. He now wanted to have a full denture fitted for the first time. During the examination, it was found that the alveolar ridges were sufficiently developed to provide a safe, mucosa-supported bed for the planned full dentures, despite severe atrophy in the posterior region of the mandible. In the first step, models were created on the basis of anatomical impressions on which individual trays for the functional impressions could be manufactured. The mucodynamic impression was used to create the master model, which was the basis for the production of a support pin registration, where the centric condyle position was registered, based on the movement paths during laterotrusion and protrusion. This made the centric position visible in the form of the tip of an arrow angle on the registration.

The master models were articulated using the keyed support pin registration, revealing a significantly sunken vertical dimension. In the registration, the patient did not want to allow for a raised bite; otherwise, he would feel "locked" and uncomfortable. During the production of the bite templates, it became clear that the vertical height of the prefabricated teeth was limited. During the final alignment of the wax rims, the occlusal plane was aligned parallel to the bipupillary line, and the occlusal plane parallel to Camper's plane. The resting position was checked again and the center line, canine line and smile line were scratched in. After keying the determination of the jaw relation, it was removed and used for the final articulation, where the new teeth were to be set up. 

The right selection of the anterior teeth in the upper jaw is key to the rapid acceptance of a new restoration. In this case, the rectangular VITAPAN EXCELL R45 was selected in collaboration with the patient to fit the small vertical dimension, the smile line, and at the same time, the width of the nose and the delicate facial features. The graceful, short VITAPAN EXCELL L33 was selected for the anterior of the lower jaw to match. For the posterior region, the appropriate universal partner for all setup concepts, VITAPAN LINGOFORM 21L, with a delicate height and mesio-distal dimensioning, was selected. After the anterior teeth had been set up, the posterior set could be efficiently set up with the automatic centric finding, based on the gear wheel principle when the articulator was closed. After the mucogingival anatomy had been worked out, the clinical wax try-in could be done. 

An age-appropriate tooth shade A3 was chosen that matched the patient's skin tone. The anterior tooth sets VITAPAN EXCELL T48 and L37 were chosen to meet the patient's wishes and the need for a square facial shape. In addition, the relation between a tooth facet length of 10.5 cm in the upper jaw and 9.9 cm in the lower jaw harmonized with the vertical relation of the alveolar ridges. In the posterior area, VITAPAN LINGOFORM 22L was selected to facilitate balanced, bilateral occlusion. Thanks to the design of the tooth surface, and based on a gear wheel principle, the posterior teeth are automatically in centric occlusion with each other when the articulator is closed, allowing them to be set up quickly and reliably. Both VITAPAN EXCELL and VITAPAN LINGOFORM are pressed from a single mould using VITA MRP, a composite made of a Microfiller Reinforced Polymer matrix with a highly cross-linked formulation. As a result, high abrasion stability can be expected.

After embedding the teeth in cuvettes and wax extraction, they were repositioned and conditioned. Then whitish, crimson, light orange, blue and pink characterizations were made on the labial shield. The base was then inlayed with denture acrylics in shades of orange-red, dark red, light red, pink and dark pink, and all the heat-curing resins were pressed from a single mould. After being stored in the pressure pot, the finished dentures were divested, finished and polished. The three-dimensional anatomically layered VITAPAN EXCELL of enamel, neck and dentin material appeared absolutely natural in the reproduced mucogingival anatomy of the denture base. Thanks to the successful esthetic effect, the patient was able to quickly get used to his new dentures. After a short adaptation phase and minimal corrections in the biodynamic environment, his first full denture fitting went very well and he was completely satisfied. 

A 74-year-old patient visited the practice, as she was dissatisfied with the function and esthetics of her current full denture. The restorations were the result of original partial dentures that had been successively expanded, since tooth 16 and the anterior of the lower jaw had been preserved for a long time. The patient did not want the new restoration to change her facial features in any way. Only the curvature of the philtrum was to be slightly reduced to harmonize better with the dental support of the soft tissue in the lower jaw. The wear on the current denture teeth suggested an approximate increase in bite of 1 -2 mm. However, due to the patient's cardiovascular disease, it was decided to maintain the current occlusal height. The centric position was unstable and could not be identically reproduced.

Trays for the mucodynamic impressions were developed on the basis of anatomical impressions, and in turn, were used to fabricate the master model. Based on this, a support pin registration followed in order to determine the maxillo-mandibular relationship. Since clear deviations to the left and right were repeatedly noted during laterotrusion, the support pin registration was carried out using a number of superimposed trajectories. Since the diurnal centric could only be registered diffusely in a larger area that extended far in the distal direction, it was decided to code the centric position 0.5 mm in front of the anterior area of the support pin marks. The denture teeth in the posterior region should be given more space to compensate for the existing class II angle. In the old dentures, the prefabricated teeth were severely abraded and the front teeth were in contact. Based on our observations, this protrusive tendency is generally more pronounced in Japanese patients.

The master models were articulated based on the determination of the maxillo-mandibular relationship in order to provide the basis for the fabrication of the new full denture work. The denture teeth VITAPAN EXCELL (anterior) and VITAPAN LINGOFORM (posterior) were selected for the new restoration, as these are based on the highly cross-linked composite formulation VITA MRP (Microfiller Reinforced Polymer), which means that a high level of wear resistance can be expected over the clinical course. When choosing the anterior tooth set, the decision was made against the T-shape in order to prevent the lip from sagging too much in the upper jaw. The O- and the R-shape proved to be closer choices. We selected VITAPAN EXCELL O45 in the upper jaw and L35 in the lower jaw, due to the patient's gender and the shape of her head. In the posterior region, VITAPAN LINGOFORM L21, which has small mesio-distal dimensions, was to be used in order to have room to dentally compensate for the distal occlusal position. Upon request, a lighter shade of A2 was selected as the tooth shade. 

Since VITAPAN EXCELL corresponds to the esthetic rules, the anterior teeth were set up intuitively. Thanks to the multifunctional occlusal relief of the VITAPAN LINGOFORM, stable dentition with the closing of the articulator could be produced quickly in the posterior teeth. This was followed by the clinical wax try-in, with final corrections and the transfer of the dentures to resin. When finishing and polishing, care was taken not to reduce the surface texture of the VITAPAN EXCELL too much in order to obtain an age-appropriate effect. Upon integration, the patient was satisfied with her new appearance, which was the fundamental requirement for acceptance of the new restoration. VITAPAN EXCELL had given her the tooth shape and shade that met her expectations, while also suiting her personality and appearance.