S ER I ES
GUID E
A CLINICAL GUIDE
TO REMOVABLE
PARTIAL
DENTURES
Contents
Preface
Acknowledgements
Part I - P a t i e nt
assessment
2
3
Working impressions
Recording the jaw relationship
Trial insertion of the metal framework
Altered cast technique
Trial insertion of waxed -up dentures
Insertion of the completed denture
Review
Further reading
Index
v
VI
3
5
1
5
21
2
5
39
33
4
7
53
57
5
9
69
7
1
7
5
8
7
9
7
91
81
99
10
7
111
115
12
3
13
12
3
9
13
7
Part
P
1atient assessment
art 1 of this book opens by making the important distinction between the need
and an account of the various management options for the partially dentate patient
(chapter
Theforincreasingly
pertinent
subject
of RPDs
and the
elderly is con
and3)thefollow.
demand
removable partial
denture
(RPD)
treatment.
A discussion
of
sidered next (chapter 4), followed by a reminder of the relevant aspects of intra-oral
anatomy,
jaw andand
occlusal
relationships
(chapters
5 andfitting
6). an RPD (chapter 2),
the and
advantages
disadvantages
that can
result from
By applying this knowledge during the history taking and examination of the patient,
information is obtained to develop a diagnosis and a provisional treatment plan (chap
ter 7). However, before the latter can be finalised, it is necessary to examine study casts
obtained from preliminary impressions of the patient's mouth (chapter 8). These casts
may need to be mounted on an articulator (chapter 9).
Availability of treatment.
Acceptability of treatment.
Accessibility of treatment.
Availability
Availability refers to numbers of dentists, their particular skills,
their accessibility to the public and the economic realities of the
community in which they practise.
Acceptability
Acceptability describes the attitudes of people to different forms
of treatment. These attitudes are influenced by such matters as
education, personal finance, and cultural background.
Accessibility
Accessibility highlights important differences between people. For
example, a particular form of prosthetic treatment may be equally
available to young and old patients, but the latter may find that
the effort needed to seek out that treatment is just too great.
Recognizing the difference between need and demand prompts
the question, 'How many teeth must be lost before a patient seeks
prosthetic replacement?' Experience suggests that the answer can
vary greatly. On the one hand, the loss of one anterior tooth is
usually a powerful motivator for the patient, whereas another
patient may have had many posterior teeth extracted before they
seek the advice and help of a dentist.
Although the restoration of appearance can be a
powerful motivating factor, not every patient will seek
treatment follow
ing the loss of an anterior tooth. A study of elderly men living in
an area where dental treatment was readily available and afford
able showed that one in five had at least one unrestored space
towards the front of the mouth. In another study, dentists rated
the dental appearance of a group of elderly people as less attrac
tive than did the subjects themselves. The dentist must therefore
avoid preconceptions and consider the thoughts and wishes of
the individual patient before recommending the provision of a
denture. The time, effort and understanding taken to make this
judgement are likely to prevent unnecessary treatment.
There can thus be a large difference between the perception of
need and demand for a prosthesis as an aid to chewing efficiency.
Nutritional status is affected by psychological, sociological and
economic factors as well as by the effectiveness of the
dentition.
Figure 1.1
Whether or not a removable partial denture (RPD) is worn by the
patient is dependent upon self-motivation. In a UK survey people were
asked , 'If you had several missing teeth at the back would you prefer
to have an RPD or manage without? ' The chart shows that most
people would prefer to manage without and that the preference grows
stronger with increasing age. It is almost as if the longer the person
has managed to avoid dentures the stronger is the wish to do without
them.
100%
90%
80%
.!!
r::
l
.
.
a..
60%
50%
40%
30%
20%
10%
16-24
25-34
35-44
45-54
Age (Yrs)
Have RPD (%)
55-64
65 and
over
100%
In the same study people were asked , 'Do you find the thought of
having a partial denture to replace some of your teeth very upsetting,
a little upsetting or not at all upsetting?' Overall, only 40% found the
idea of having dentures not at all upsetting. A breakdown of the
answers by
age is shown in the chart. Again , there is a suggestion that older
people tend to find the thought of an RPO more upsetting than do the
young.
90%
80%
70%
60%
!!!
c
50%
GI
:;:;
a
O
.
.I
30%
10%
0%
16-24 25-34
65 and
Very upsetting
upsetting
35-44
45-54
D A little upsetting
55-64
over
Age (Yrs)
Figure 1.3
The SDA concept (see Chapter 3) is based on the following
observations: older people can usually function adequately with a
significantly reduced number of teeth; the provision of a distal
extension RPO tends not to contribute any significant functional
benefits; the replacement of missing posterior teeth should be
driven by demand and not by need.
Figure 1.4
90
For how many people is the SDA concept a viable proposition? The
percentage of the UK adult population that possessed four 'good'
quadrants was found to be 54%. The relationship to age is shown in
the chart. The number of people who might have a functional SDA falls
dramatically with age. Nevertheless , there is a risk that a considerable
number of older people could well be provided with RPDs on the
advice of a dentist and yet fail to need them or even wear them.
80
Ill
70
<(
"
s =
Ill ..40
....
c
30
GI
.a'.
:;:; 20
O
.
50
16-24
25-34
35-44
45-54
55-64
65 and
over
Age (Yrs)
In chapter two there is an account of the real benefits that can providing an RPD for any patient.
accrue from wearing RPDs, as well as illustration of the tissue "Does the patient really want an RPD?' (the patient's assess
damage which can occur. This 'biological price' is particularly ment).
likely to be exacted if RPDs are not maintained adequately even 'Are the benefits likely to outweigh the possible damage that
if they are well-designed and constructed. I t is therefore may occur?' (the dentist's assessment ) .
prudent for the dentist to consider the following
questions before
Benefits of RPDs
The potential benefits of RPDs which will be considered in this
section are their contribution to the following.
Appearance.
Speech.
Mastication .
Maintaining the health of the masticator y system:
- preventing undesirable tooth movement ;
- improving distribution of occlusal load.
Preparation for complete dentures.
Figure 2. 1 - Appearance
The restoration of the missing 12, 11 and 21 undeniably benefit this
patient , an 18 year-old girl, and the motivation to wear the denture is
understandably strong . Particular attention has been paid to the
appearance of the denture by the careful choice of artificial teeth and
design of the flange. A natural appearance has been created by
using a 'veined' acrylic, by reproducing the pre-extraction form of
alveolar ridge and by making the distal margin of the flange thin and
irregular, thus masking the transition from flange to adjacent mucosa .
Appearance
Not only may an RPO help to restore appearance but it may actually improve it.
(a) This patient's maxillary lateral incisors had never developed and she
was concerned about the spacing of the anterior teeth .
(b) The combination of orthodontic movement of the central incisors and the provision of RPOs
improved the appearance.
Figure 2.4 -
Speech
Figure 2. 5 - Mastication
With modern foods and methods of preparation it is unlikely that a
patient will suffer from malnutrition even though a large number of teeth
are missing. However, the gaps that arise through the loss of posterior
teeth reduce the efficiency of mastication: the bolus of food is allowed
to slip into the edentulous areas and thus escape the crushing and
shearing action of the remaining teeth . An RPO will prevent this
escape of the bolus and thus contribute to efficient mastication .
Figure 2. 7 -
Figure 2.9 -
rw
Over-eruption of a tooth may place it in such a position that it bears the brunt of the load on initial contact or in excursive movements of the
mandible and therefore it may well be subjected to excessive force. In addition , where over-eruption of a tooth has created an occlusal
interference (*), the patient may modify the habitual movement patterns of the mandible in order to avoid the interfering contact. Although such
a modification may reduce the load applied to the tooth , the changed pattern in activity of the mandibular musculature may subsequently
produce muscular dysfunction .
Figure 2. 12 -
Figure 2. 14 -
Direct trauma
from components
Abrasion and
fracture of
teeth or
restorations
tissues
Progression to
underlying structures
Inflammation of gingival
tissues
Progression to
underlying structures
Transmission of
excessive
functional forces
(a)Tooth mobility
(b)Aggravation of existing
periodontal disease
Occlusal error
(c)Tooth mobility
(d)Aggravation of existing
periodontal disease
Edentulous areas
mastication
Muscles of
Inflammation of
mucous membrane
Localised inflammation
of mucous membrane
.
Dentureinduced
hyperplasia
Inflammation of
mucous membrane
Resorption of bone
Inflammation of mucous
dysfunction membrane
Resorption of bone
Muscle
The areas that tend to collect most plaque are the proximal surfaces of abutment teeth adjacent to
the saddle .
(a) These surfaces are difficult to clean when using a conventional toothbrush.
(b) An interdental brush cleans the proximal surfaces more effectively.
The design of the denture may have a significant effect on plaque accumulation. For example , it has
been shown that more plaque collects under a lingual plate than under a lingual bar.
(a) The lingual plate is well supported on the natural teeth and fits well against tooth surfaces.
(b) However, gingival inflammation has been caused by the increased accumulation of plaque.
Figure 2. 17 -
10
Figure 2. 19 -
There is no evidence for the contention that a clasp arm may wear away the enamel surface to a degree
that is significant clinically. However, the movement of a clasp arm may wear the surface of restorative
materials.
11
If the forces transmitted to the mucosa and bone of the edentulous area are excessive, the mucosa will
become inflamed and the bone will resorb. The obvious consequence of bone resorption is an
irreversible loss of part of the denture foundation. . .
(a) In this example the denture is supported only on the tissues of the edentulous. area. It has caused
resorption of the bone to such an extent that the lingual bar connector has been pushed down
towards the floor of the mouth.
(b) The amount of bone that has been destroyed is apparent when the denture is removed.
'
Figure 2.23 -
Occlusal error
If the occlusal surface of the RPO is not designed correctly, normal jaw closure may be prevented by
a premature occlusal contact. There are three possible sequelae.
(1) If the premature contact is on a natural tooth , damage to the tooth or its periodontal ligament may
occur.
(2) If the saddle bears the brunt of the force of closure , there will be localised mucosaI inflammation
and resorption of the underlying bone.
(3) If the patient attempts to steer the mandible around the premature contact until a more comfortable
occlusal position is found , this abnormal closing pattern throws increased demands on certain muscles
of mastication , which may result in the patient complaining of facial pain.
12
The primary responsibility of the dentist and the clinical team is to ensure that the remaining teeth and
supporting tissues are restored to a healthy state and that the patient is effectively motivated and
instructed in how to maintain this state.
(a) This mouth is not in a fit state to receive an RPO. There is chronic periodontal disease and
accumulation of plaque.
(b) This patient has responded well to instruction in oral hygiene and the periodontal tissues are healthy.
The
dangers of wearing the RPDs are thus minimised.
Figure 2. 25 -
13
-v
Figure 2.27a and b -
In this mouth the reasons for providing dentures are not overwhelming . There are sufficient teeth at the
front of the mouth to satisfy the demands of appearance and speech. There are certainly enough teeth to
allow a varied diet to be eaten. Most of the teeth have antagonists in the opposing arch .
If the mouth is well cared for and the patient requests dentures , the RPO equation is favourably balanced .
However, if plaque control is suspect , there is a strong argument for advising against dentures , at least for
a few months until the long-term response to oral hygiene advice is ascertained.
14
Management
options for the
partially dentate
patient
0
No prosthetic treatment
This would be the best choice when the harmful consequences
of provid ing a prosthesis could outweigh the possible benefits.
This would be the case, for example, if the perceived benefits
of
a prosthesis were marginal and the patient was unable to main
tain an acceptable level of plaque control.
Fortunate patients may not require prosthetic _treatment
because they possess a functioning dentition in the form
of a 'shortened dental arch'.
The shortened dental arch concept
The shortened dental arch (SDA) concept is related to the World
Health Organization 's goal for oral health , which is, 'the reten
tion throughout life of a functional, aesthetic, natural dentition
of not less than 20 teeth and not requiring a prosthesis'. The
SDA concept is that adequate oral function can be maintained
with a reduced dentition, consisting of 9 or 10 occluding pairs
of teeth.
Prosthetic treatment
Selection of fixed or removable options
When the desirability for prosthetic intervention has been estab
lished by systematic evaluation of the information obtained from
the history and examination , a decision as to the most suitable
type of prosthesis, ie fixed or removable, has to be made. In gen
eral, the following aspects should be considered when making
this decision.
General factors
Figure 3. 1 -
Psychological faCtors
15
Figure 3.3 -
Aesthetic factors
One of the limiting factors for fixed restorations , however, is the extent
of alveolar resorption in the edentulous area . For patients where a
significant amount of resorption has occurred , there is often an
advantage in utilizing an RPO because the missing alveolar bone can
be readily replaced by the denture base - in this case by the addition
of a labial flange .
'
16
17
Macro-attachments
Macro-attachments include various types of telescopic crown. They have a circumferential grip on the
abutment teeth and include individual circumferential frameworks . In Figure 3.7 gold thimbles have been
placed on the prepared upper anterior teeth to support an RPO. An example of such a prosthesis incorporating
telescopic crowns is shown in Figure 3.8.
Figure 3.9 -
Micro-attachments
18
Micro-attachments
Implants
of
Figure 3. 13 - Implants
In recent years Osseo-integrated implant-supported prostheses have
been introduced as alternatives to conventional FPs and RPDs for the
replacement of teeth in partially dentate subjects . However, surgery is
always required for the placement of implants and may be complicated
by the proximity of the neuro-vascular bundle or maxillary sinus . Also ,
lack of alveolar bone volume is particularly disadvantageous . In
addition , implants are expensive and there is a range of medical
contraindications to this form of treatment , including heavy smoking.
For these reasons it is unlikely that implants will significantly reduce
the need for RPDs in the foreseeable future .
older age groups were more negatively inclined towards the wear
ing of RPDs than younger individuals. It was as if the longer a
person had managed to function adequately without an RPD, the
greater the reluctance to resort to such a device. This potential
barrier to the elderly accepting prosthetic treatment, together
with the following specific problems, suggests that very careful
thought is required before advising prosthetic treatment for the
older population.
Tooth wear
21
Tooth wear
Figure 4.3 -
Patient assessment
General health status
Age by itself is an imprecise guideline in the assessment of older patient's recovery from severe illness is being hampered by an
patients. Of much greater importance is the effect that illness may inadequate dentition. Unless patient s themselves wish to have
have had on the ageing process. For this reason a detailed med RPDs and unless a high standard of plaque control can
ical history is essential and should include a full list of any pre be achieved either by the patients themselves or by the carers,
treat ment is unlikely to be successful.
scribed medications .
The state of health is an important factor to be considered
when deciding whether or not to advise the provision of RPDs. Domestic circumstances
Progressive infirmity or debility can have an adverse effect on the Social factors should also be considered. For example, the
capacity to adapt and may explain the difficulty that some absence of support from carers may pose difficulties for
patients have in coming to terms with dentures, particularly if patients in
they have had no previous denture wearing experience. It is thus attending for treatment or in complying with the necessary main
very important to determine what, if any, improvement in the tenance procedures .
state of health can be expected. The effect that health factors may Assessment of existing RPDs
have on the ability of patients to attend for treatment and sub The assessment of existing RPDs and an understanding of pre
sequent maintenance must also be considered .
vious denture wearing experience should follow precisely the for
The wearing of even the best designed RPD is likely to mat described in chapter 7.
be accompanied by an increase in plaque accumulation.
I f there is evidence of the patient having difficulty in
undertaking mainte nance procedures , the potential for
damage may outweigh the likely benefits of the prosthesis in
terms of function and aesthet
ics. For example, a patient may have difficulty in cleaning nat
ural and artificial teeth because of failing eyesight. Alternatively,
a drug-induced dry mouth with its associated reduction in the
buffering capacity and volume of saliva can result in a dramatic
increase in caries and periodontal disease.
Desire and motivation
As mentioned earlier, it is important to assess the degree to which
patients are motivated to wearing RPDs. I t is not uncommon to
find that the request for prosthetic treatment comes from carers
or members of the family, particularly if they feel that
the
22
harm to the mouth may well be more critical than for a younger
patient.
Treatment options
If a shortened dental arch exists particular attention must be given to the possibility of simply maintaining
the status quo rather than providing an RPO.
Figure 4.5 -
Treatment options
Figure 4.6 -
Treatment options
Where there has been extensive tooth loss, one of the most
important decisions is whether or not to retain a selection of teeth to
assist with
the wearing of an RPO. Even if it appears that such an arrangement
may have a limited life it is usually far preferable to extractions and
the
provision of complete dentures. In this example the remaining natural
teeth helped to stabilise maxillary and mandibular RPOs. After a short
time two of the maxillary teeth and both mandibular teeth were
converted to overdenture abutments and continued to serve the
patient faithfully for many years. Thus an effective 'pre-edentulous '
state was preserved.
Even if the eventual extraction of the remaining teeth is inevitable , their
retention in the short term to stabilise an RPO can make a significant
contribution to a successful transition of a patient to complete
dentures.
23
Anatomy of the
denture-bearing
areas
Incisive
papilla
Labial
frenum
Residual
ridg
e
Buccal frenum
Zygomatic
buttress
Rugae
_ _ .::.:
Palatine
_, _ " ' \ _
torus
Hamular
notch
Palatine
fovea
Labial
sulcus
Buccal
sulcus
Incisive papilla
This soft pad of tissue overlies the incisive canal through which pass
he nerves and vessels supplying the anterior part of the palatal
mucosa. The labial surfaces of the natural central incisors lie
approximately 1Omm anterior to the centre of the papilla, a
relationship that should be borne in mind when positioning the artificial
replacements.
25
Rugae
Figure 5.5
1. Palatine raphe
This is a mucosal ridge lying sagittally in the midline of the palate.
2. Palatine Torus
This developmental bony prominence is sometimes seen in the
centre of the palate. This structure is often covered by relatively
incompressible mucoperiosteum. A mucosally-supported denture may
need to be relieved over the torus to prevent the denture rocking and
flexing about the midline.
Figure 5. 6 -
Vibrating line
This is the junction between the movable mucosa of the soft palate
and the static mucosa of the hard palate. If a decision has been taken
to obtain maximum posterior extension of the major connector, the
posterior border of the connector should be positioned on the
compressible tissue just anterior to the vibrating line.
Figure 5.7
1. Palatine fovea
v
1
26
2. Hamular Notch
This mucosal depression is located posterior to the maxillary tuberosity.
The notch overlies the gap between the pterygoid hamulus and the
maxillary tuberosity and marks the posterior limit of extension of a
maxillary saddle where there is no distal abutment tooth.
of
Js
ed
e
Palatine submucosa
Mucoperiosteum
Mucosa
Submucosa
Bone
e
ay
Pear
shaped
pad
Retromylohyoid area
(lingual pouch)
Retromolar
pad
Buccal
shelf
nd
Lingual
frenum
Buccal
sulcus
Buccal
shelf
Buccal
frenum
Buccal
sulcus
Labial
sulcus
Labial
frenum
Buccal
frenum
Labial frenum
Figures 5. 9 and 5. 10 -
mandible Figure 5. 11 -
Bucca/ shelf
This lies between the crest of the residual ridge and the external
oblique ridge of the mandible. Its relatively broad horizontal surface
covered with smooth cortical bone makes it a valuable support area for
a mandibular prosthesis and of particular importance in the support of
a distal extension saddle.
ity.
27
The pear-shaped pad (1) lies anteriorly to the retromolar pad (2) and
is the most distal extension of the attached keratinised mucosa
overlying the mandibular ridge. It is formed by the scarring pattern
following extraction of the most posterior molar. It is firm and fibrous
and forms an important part of the denture-bearing area. It offers
support to the denture and helps to resist posterior displacement.
The retromolar pad is a freely movable mass of tissue consisting
of non-keratinised mucosa overlying loose glandular connective
tissue. It falls outside the denture-bearing area.
In the absence of maxillary and mandibular posterior teeth , a
point between the pear-shaped and retromolar pads may be
used to determine the level of the occlusal plane of the denture teeth
posteriorly.
Figure 5. 13 -
My/ohyoid ridge
Mylohyoid ridge
and muscle
Figure 5. 14 -
This area is the part of the lingual sulcus lying below the mylohyoid
ridge posteriorly. Whenever the functional movements of the sulcus
permit, the lingual flange of a distal extension saddle should be
extended into this area to provide optimum stability.
28
1
g
Sulcus
The sulcus is the mucosal trough * lying between the ridge on the
one hand and the cheeks , lips or tongue on the other. An accurate
impression of the functional depth and width of the sulci is necessary
because , in the majority of cases , the denture flanges will need to fill
the dimensions of the sulci so recorded. It is particularly important to
obtain an accurate recording of the form of the lingual sulcus
because this will determine the design and positioning of lingual
major connectors .
Figure 5. 17 - Frenum
s
Figure 5. 18 -
Zygomatic
process of
the maxilla
le
Genioglossus m .
Sub-lingual
salivary gland
29
LAO
ZM
IS
DAO
II
II
DAO
Figure 5.23 -
Menta/is muscle
Contraction of the mentalis muscle raises the soft tissues of the chin,
thus reducing the depth and width of the labial sulcus. If there has
been marked resorption of the underlying bone, this muscle can exert
considerable pressure on the labial flange of an RPO resulting in its
posterior and upward displacement. Care may therefore be needed in
contour ing and thinning the flange to minimise this pressure.
30
Sub-lingual folds
When the tongue is elevated , the sublingual folds are raised and
may greatly reduce the depth and width of the lingual sulcus . This
phenomenon is most marked when advanced resorption of the ridge
has occurred.
Figure 5.25 -
Coronoid process
31
Jaw relationships
Figure 6. 1 -
Non-contact relationships
The teeth are apart and the mandible moves entirely under the
influence of the muscles of mastication and the articular
surfaces of the temporomandibular joints (posterior guidance).
Non-contact relationships
33
I.
Non-contact relationships
Figure 6.4 -
Contact relationships
Contact between the teeth of the opposing dental arches has a
moderating influence on the basic pattern of movement of the
mandible (anterior guidance).
F
i
g
u
r
e
6
.
5
l
n
t
Figure
6. 6 - Retruded contact position
e
r is a contact relationship in which the mandible is located 1 -1.5
This
mm
c distal to the intercuspal position. There are generally fewer tooth
contacts
present than in ICP and there is a slightly greater vertical
u
separation of mandible from maxilla as the contact is on the slopes
s
of the cusps. Ideally, movement from retruded contact to intercuspal
p
position should be a forward slide with no lateral deviation.
a
l
34
p
o
s
i
t
i
o
Jaw
relationships
Figure 6. 7 - Protrusive relationship
ormally, protrusion of the mandible will lead initially to contact of the
abial surfaces or incisal edges of the mandibular anterior teeth against
the palatal aspect of the maxillary incisors and eventually to an edge
to-edge incisal contact.
Thus in this early stage of protrusion, the direction of
mandibular movement is determined by the palatal slope of the
maxillary incisors ; this is known as incisal guidance . Commonly
this
movement
is associated with separation of the posterior
occlusal surfaces. Where the ncisors commence in an edge-toedge relationship or where the mandibular incisors are in advance
of the maxillary incisors, protrusive 'llovement will carry the
mandibular incisors forward of the maxillary teeth, often with quite
widespread contact of the posterior occlusal surfaces .
'"
''' '' '
'
''
\
\\
'I I
'\
'
' ,
\ ............
..
Figure 6.8 e
e
is
lly
Lateral excursion
',
'
'
'
'
Figure 6.9 -
\
\
Lateral excursion
In
ct
o
ar
0
of
35
Lateral excursion
:
I
I
'I
\
\
KE
Y
= Freeway space
FWS
0 = Maximum opening
L = Maximum lateral excursion
-
Contact movements
Non-contact movements
Envelope of movement
A so-called 'envelope of movement' traced by the mandibular mid-incisal point and described originally by
Posselt , can represent the total range of mandibular movement. This envelope is shown in the sagittal
plane (6.13, left) , in the coronal plane (6.14 , middle) and in the horizontal plane (6.15, right) .
36
Jaw
relationships
Figure 6. 16 -
Figure 6. 17 -
ck
Figure 6. 18 -
Problems can also arise when tooth loss and occlusal wear are
superimposed on an underlying malocclusion. Here, the initial
contact takes place in the anterior region and the occlusal surfaces
of the posterior teeth are separated by at least 2mm.
Figure 6. 19 -
37
Information
gathering: history,
examination,
diagnosis and
treatment planning
I'
Denture history
The patient's opinion of any current denture should be sought.
If an RPD has been worn with reasonable satisfaction, it might
be advisable to reproduce those aspects of the design thought to
have contributed to this success. Conversely, an RPD that has
never been satisfactory might have an inappropriate design that
should be positively avoided in any new prosthesis.
The timing of a patient's denture problems is often illuminat
ing. For example, when problems have existed since the denture
was first fitted it suggests the possibility of fundamental flaws
in the design or construction of the RPD, or of
unfavourable
Poor
treatment
result
Poor dentist
motivation
Poor patient
motivation
39
Denture history
Movement of the RPO during function , particularly when incising (a) can be a troublesome limitation of large
prostheses. The necessity for tongue control must be explained to the patient. Techniques can be
demonstrated , for example, by asking the patient to 'hump up the back of the tongue' to support the
posterior border of a maxillary denture during incision {b). A small bead of wax or impression compound
placed at the posterior edge of the denture can act as a 'target' to help the patient locate the correct spot.
The patient is informed that such deliberate control will initially be a conscious activity but eventually
becomes automatic. The time taken for such habituation to occur will vary. If the process is expected to be
prolonged because of advanced age or chronic illness, the patient should be warned accordingly and
encouraged to persevere.
This preparation of the patient is particularly important for the novice denture-wearer , or for patients
who have a history of denture problems of this type.
Dental history
The previous dental history can significantly influence the
patient's attitude to dental treatment . For example, failed treat
ment in the past, especially if associated with pain, may give rise
to a reluctance to undergo relatively prolonged, expensive
restorative work and a desire to progress towards the perceived
'simpler' option of complete dentures. Conversely, satisfaction
with previous treatment may create a positive attitude towards
more advanced restorative procedures. Successful dental treat
ment received by friends or relatives can also engender a similar
outlook towards dentistry in the patient.
Recent dental extractions may indicate the presence of active
caries or periodontal disease that needs to be addressed by pre
vent ive aspects of the treatment plan. The timing of extrac
tions is also relevant because the most rapid phase of
bone resorption occurs during the few months following the
tooth loss. Dentures constructed around the time of the
extractions
40
Figure 7.3 -
1-
1-
Medical history
Figure 7.4 -
Medical history
any factors reduce the ability of the oral mucosa to resist microbial,
mechanical, chemical or thermal attack. For example, smoking ;
mmuno-suppression; mucosal disorders such as pemphigus (as
shown here) and lichen planus; hyposalivation whether produced as a
side-effect of a number of drugs or by glandular disease such as
Sji:igren's syndrome. Erosion and softening of hard tooth tissue can
result from frequent vomiting produced by gastro-intestinal disease ,
regular dietary indiscretions or psychological disorders such as
anorexia nervosa or bulimia. The rate of resorption of alveolar bone
can be increased in osteoporosis which is common in females after
the menopause who are not receiving hormone replacement therapy,
and 1n males over 60.
IS
41
Figure 7. 7 -
Intra-oral
Figure 7.9 -
Intra-oral
42
,. a
Intra-oral
e
of
'Tl
!O
ry
Figure 7.11 -
Intra-oral
The form of the residual ridges and the compressibility of the investing
soft tissues in the edentulous areas should be assessed visually and
by palpation. Included in this examination is the hard palate since
ncompressible areas may have to be avoided by denture margins.
led
tute
a
' ber
Figure 7. 12 -
Intra-oral
Figure 7. 13 -
Intra-oral
iation
'l e
hich
43
Figure 7. 14 -
Intra-oral
Figure 7. 15 -
Intra-oral
The mandible has now been guided forward into a postural position in
which there is substantial contact between the opposing dentitions in
the anterior and posterior regions.
Uli\lill!Jib.&i
ii &
11
44
Intra-oral
Occlusal indicator wax , articulating paper or tape , and thin metal foil
(shimstock) may be helpful in a clinical assessment of the occlusion .
It is also helpful to mount study casts on an articulator .
Figure 7. 17 -
Intra-oral
Any drifting or tilting of teeth that may have been noted when the
individual dental arches were examined should be reassessed in
relation to the opposing arch. The abnormal position may contribute to
occlusal faults or to problems when designing a denture in the other
jaw. Over-erupted teeth, such as 14, 15 and 47, should also be noted
as remedial treatment in the form of occlusal equilibration , reduction in
height and restoration by means of crowns , or even extraction may be
required.
Figure 7. 18 -
Intra-oral
Figure 7. 19 - Intra-oral
The degree to which the denture restores occlusal contact should be
assessed. Here, alveolar resorption and occlusal wear of the artificial
teeth have resulted in lack of posterior tooth contact , causing
increased loading on the anterior teeth.
ent
hed
. It
45
Treatment plan
46
Preliminary
1mpress1 ons
P
e
the
Figure 8.1
Stock trays are available in a variety of sizes and shapes. They may
be perforated or unperforated, metal or plastic, of simple box design or
shaped to fit bilateral distal extension saddles.
Figure 8.2
A size of tray is selected so that the teeth sit centrally within the
trough of the tray. If possible there should be a space of about 4mm
between the flange of the tray and the buccal and labial surfaces of
the teeth.
47
Because the range of stock trays is limited it will commonly be found that an ideal size and shape of stock tray
is not available. In this example, the maxillary stock tray does not cover the labial surfaces of the teeth
sufficiently, neither does it include the most posterior teeth .
48
(;
Preliminary
impressions
Figure 8. 13
Compound that has contacted the teeth should be cut away as it
may prevent accurate re-insertion of the impression tray and will
eliminate space around the teeth necessary for a sufficient thickness
of the alginate used to complete the preliminary impression.
Figure 8.14
Under-extension in the labial region can be corrected by the addition of
impression compound to the deficient areas of the tray to form a
slightly over-extended flange.
49
Figure 8.16
When a water bath is not available for softening the
impression compound , alternative materials, such as silicone
putty or pink modelling wax , may be used to modify the tray.
dry before the tray is loaded with alginate. The tray is then
seated in the mouth and the impression material bordermoulded.
Figures 8. 17 and 8. 18
The completed impression is assessed by considering three aspects.
1 Those sulcus areas which will be related to the denture borders.
2 The edentulous areas.
3 The teeth.
The impression on the left is satisfactory, the one on the right shows a number of faults: the tray has been
positioned too far to the patient's right; the borders of the alginate are unsupported ; the impression is
under extended in the post-dam region.
I f on inspection the impression is found to be satisfactory, it fected. The impression should be shaken to remove any excess is
rinsed thoroughly to remove all traces of saliva and is disin moisture.
so
Preliminary
impressions
Figure 8.19
rid
Figure 8.20
W hile the impression is waiting to be cast the tray should be
supported so that its own weight is not applied to the borders of the
impression . If this is not done, permanent deformation of the
impression will occur.
The impression must be cast as soon as possible to avoid
inaccuracies developing as a result of the dimensional instability
of alginate.
Sl
Articulators
Types of articulator
Figure 9. 1 - Hinge articulator
This simple articulator holds the casts in a prescribed relationship,
usually the intercuspal position, and allows separation and approximation
of the casts. The hinge is in no way related to the hinge axis of the
mandible and there is no attempt to reproduce mandibular movement.
Thus with this type of articulator it is possible to produce even occlusal
contact only in the recorded static jaw relationship. The limitations of this
device have long been recognised.
If this instrument is used at all it must be in circumstances where the
occlusion is to be restored to an existing stable intercuspal relationship
and where the excursive guidances of the remaining natural teeth will
ensure separation of those teeth replaced by the RPO.
It will also be necessary to identify and eliminate occlusal
discrepancies when the restoration is inserted in the
mouth.
Figure 9.2 -
53
Semi-adjustable articulators
In order to reproduce the mandibular movements of individual
patients with any degree of accuracy, articulators need to
be adjustable to conform to those anatomical features, such as
incisal guidance and condylar guidance, which influence those
move ments. They should also take account of the bodily
shift of
Figure 9.4 -
Articulators of the arcon type, such as the Whipmix and Denar series
, have a condylar element on the lower member which is able to slide
against an adjustable plane on the maxillary component of the
articulator. A Denar instrument is illustrated here.
54
Articulators
Occlusal records
If the intercuspal relationship is comfortable and well-defined it
should be accepted, particularly if excursive guidances are estab
lished by the natural dentition. If all the remaining posterior teeth
occlude very precisely it may be possible to locate the casts in the
Figure 9. 7 -
Occlusa/ records
Figure 9.8 -
Occlusal records
55
Occlusal records
56
Part
P
2reparation of
the mouth
he chapters in Part 2 describe procedures for creating the best possible oral envi
ronment for the provision of an RPD and are arranged in the sequence most com
monly appropriate to clinical practice. However, it should be remembered that there
will be occasions when several of the procedures are undertaken concurrently, or when it
is necessary to alter the sequence.
An example of a typical course of treatment might be as follows.
Impressions for study casts are obtained and a provisional design produced at the out
set because the design of the proposed appliance may well influence, or be influenced by,
subsequent treatment such as extractions, orthodontics and the design of tooth restora
tions. Any treatment required to stabilise the patient's oral condition will also need to be
undertaken at the earliest opportunity.
The following items of treatment, if required, should be carried out at an early stage for
the reasons indicated.
1. Initial prosthetic treatment - to overcome any current denture problems.
2. Surgery - to allow the longest possible healing period before new dentures
are provided.
3. Periodontal treatment - so that the patient's ability to maintain a high standard of
plaque control can be monitored for an adequate period before final decisions are taken
concerning the type of denture, if any, to provide. Also, changes in gingival contour
following periodontal treatment should be complete before working impressions are
obtained.
4. Orthodontic treatment - so that any required improvement in the position of the
teeth can be achieved without delaying the prosthetic treatment unduly.
Once the preparatory treatment outlined above has been completed the following items
may be required.
5. Conservation treatment and root canal therapy - to ensure that the remaining teeth
are in a good state of repair and that their contours are unlikely to be altered once an
RPD has been constructed.
6. Tooth preparation - so that the crown shape of the remaining teeth is improved to
receive rests, retentive clasp arms, bracing and reciprocating elements.
These last two aspects of preparatory treatment are closely linked as conservation treat
ment may be required to achieve the desired crown shape.
57
10
I
Initial prosthetic
treatment
Figure 10.1 -
Figure 10.2 -
59
Teeth
If a tooth has become detached from the denture but is still available,
a rapid chairside repair can usually be effected using cold-curing
acrylic resin. It is advisable to cut some form of mechanical retention
in order to reinforce the chemical bond.
Teeth
The attachment of teeth to metal connectors can be achieved by the creation of mechanical retention such
as perforations or soldered wire loops. Alternatively, acrylic can be bonded to cobalt-chromium using meta
adhesives.
Figure 10.5 -
Connectors
60
Connectors
The addition or extension of a flange may be achieved using a nonpoly methyl methacrylate resin, such as butyl methacrylate resin, which
is adaptable directly in the mouth. However, as the colour stability of
these resins is relatively poor, the technique is not ideal if the flange
is visible and the denture is to be worn for more than a few weeks.
For the laboratory addition of a flange, an alginate impression in
a stock tray is obtained of the denture in situ. The tray will usually need
to be extended in the area where the flange is to be added using a
suitable border-moulding material.
ly
Temporary relining
The acrylic base of an RPB may be relined temporarily where
loss of fit has resulted in instability or mucosal injury.
Temporary relining is carried out in the mouth using either
soft or hard materials. When mucosal inflammation is present,
the cushioning effect of the short-term soft materials
(tissue
61
Temporary relining
Figure 10.10 -
Temporary relining
Figure 10. 11 -
Temporary relining
Figure 10. 12 -
Temporary relining
62
Initial prosthetic
treatment
Figure 10. 13 d
Figure 10. 14 a
to
1e
N-
sity
Temporary relining
Temporary relining
Figure 10.15 -
Temporary relining
Temporary relining
Once the denture has been relined , any excess material must be
removed from the polished surfaces and teeth. If the relining material
is a hard resin the borders are trimmed and polished (maxillary
denture) .
Excess short-term soft lining material is trimmed on the
polished surface of the denture so that the denture border consists
of a smooth roll of the material (mandibular denture) .
63
Temporary relining
A patient who has had a denture relined with a short-term soft lining
material should be given specific instructions on how to clean the
lining. Some of these materials are damaged by the use of alkaline
perborate denture cleansers and others by alkaline hypochlorites.
Unless the patient is warned of these incompatibilities rapid
deterioration of the lining will occur.
Occlusal adjustment
Figure 10.18 -
Occ/usa/ adjustment
Figure 10.19 -
Occlusal adjustment
Interim prostheses
An interim prosthesis may be constructed before the definitive
denture for the following reasons.
Space maintenance and aesthetics.
64
Space
Figure 10.21 -
65
66
mucos
a
I
I
---
mucosa!
thini;tiw,and
I . , . :. .
.; f ijD)Pref!
-.,
petl'l)<illilY..
denture{
plaque
dentur{
base
/\
salivary
/
anti-candidal I
antibody
/
Figure 10.28 -
sucrose-rich diet - _
_ .J
'
candida
trauma
system
ic factors
Figure 10.29 -
67
Figure 10.31 -
7
Figure 10.32 -
68
If the lesion does not respond to these local measures the inves
tigation of possible systemic factors should be undertaken. In
such refractory cases, oral antifungal agents such as Ampho
tericin B, Nystatin or Miconazole may be beneficial. It should
be noted, however, that these antifungal agents by themselves are
of very limited value and unless the underlying cause of the
den ture stomatitis is eradicated the condition will recur when
the antifungal agents are withdrawn.
Surgery
Figure 11.1
This radiograph reveals that an unerupted second premolar has
influenced the alignment of the first premolar, which is tilted distally and
is unsuitable for use as an abutment. If it is decided that an RPO
should be provided it will be necessary to consider removal of both
teeth.
Figure 11.2
A third molar erupting at such an unfavourable angle will not
provide acceptable support for an RPO and will prevent full
extension of the distal extension saddle. It should be removed prior
to denture construction .
69
Figure 11.4
Bulbous and mobile tuberosities provide poor support for RPO
saddles and may also create problems in the orientation of the
occlusal plane. Surgical reduction will improve the contour and
consistency of the soft tissues .
Figure 11.5
The prolonged wearing of an unsatisfactory denture has caused this
localised area of soft tissue hyperplasia . The tissue must be
removed before a new denture is constructed . The excised piece of
soft tissue should be sent for histopathological examination.
Surgery is clearly indicated in this instance. Where a lesion is
associated with the flange of a denture , the flange should be
cut back to allow resolution of the inflammation before the need
for surgery is assessed.
70
12
N
Periodontal treatment
Figure 12. 1
Even in a superficially clean mouth the wearing of an RPO is often
associated with some degree of gingival and mucosa! inflammation .
Localised inflammatory changes of this type will usually resolve if
the level of plaque control and denture hygiene can be improved.
Figure 12.2
This acrylic RPO, which replaces two maxillary incisors , 12 and 11,
has extensive and unnecessary coverage of palatal gingival margins.
71
Figure 12.4
In contrast to the patient in Figure 12.3, there has been so much
inflammation and soft tissue damage in this mouth that improvement
in oral and denture hygiene is unlikely to achieve resolution . The
gingival tissues will need to be recontoured surgically prior to the
construction of a replacement RPO.
Figure 12.5
Here the inflammatory changes affecting the palatal gingival
tissues under a succession of mucosa-borne RPOs have produced
some degree of hypertrophy with pocketing and an unfavourable
tissue morphology.
Figure 12.6
A gingivectomy has been undertaken to improve the soft tissue
contours , the standard of oral hygiene has been greatly improved and
a tooth-supported cobalt chromium RPO, incorporating generous
clearance of the gingival margins, has been provided .
72
Periodontal treatment
Figure 12.la
Figure 12.l b
Figure 12.8
Hypertrophy of the gingival tissues , however, has led to coverage of
most of the palatal aspect of the crown of 27 and if this tooth is to
serve as an abutment for an improved design of RPO, it will be
necessary to undertake gingivectomy to expose the anatomical crown.
The defective restoration in 24 will, of course , also require to be
replaced.
Figure 12.9
This patient has worn a mucosa-borne RPO in the mandible with
acrylic distal extension saddles and a stainless steel lingual bar
connector.
This inadequate prosthesis has caused considerable damage to the
gingival tissues around 45 and 34, stripping them away from the
distal and lingual aspects of these abutment teeth. Deposits of supraand subgingival calculus are present and 45 shows increased
mobility.
It is important to evaluate whether or not the gingival tissues can
be restored to a condition of health and whether these teeth now
have sufficient investing bone to contribute to the support of an RPO
framework.
73
13
0
Orthodontic treatment
Figure 13.1
In this instance, absence of the permanent maxillary lateral incisors,
together with early loss of 21, has allowed the remaining central incisor
to drift across the midline. Prosthetic treatment has not achieved a
satisfactory aesthetic result.
Figure 13.2
The retained deciduous canine has been extracted and a
removable orthodontic appliance has been used to retract 11 and
bring it into a more acceptable alignment.
75
Figure 13.4
Lack of a prosthetic replacement for missing posterior teeth has
allowed this mandibular molar to tilt mesially. In this position it not only
offers less than adequate support for an RPO but also creates
problems in the maintenance of an adequate standard of oral
hygiene.
Figure 13.5
Orthodontic treatment has re-established space by uprighting
the tooth. It has also produced an abutment tooth that is
favourably positioned to provide effective support and retention
for an RPO framework.
76
14
Conservative
Figure 14.1
It is particularly important that teeth which are to serve as abutments
for an RPO should be carefully evaluated. Here, 16 has advanced
caries
of the crown structure. It is important to ascertain whether or not it is
vital and , if non-vital, to assess whether it has been , or can be,
adequately root-treated. It is also critical to ensure that the coronal
structure can be soundly restored. If the long-term prognosis is
doubtful it may be wiser to consider extraction and incorporation within
the RPO.
Figure 14.2
Where the need for extensive restoration 1of a tooth justifies the fitting
of a full veneer crown, the opportunity should be taken to incorporate
(1) guide surfaces, (2) retentive undercuts and (3) rest seats into the
crown. These modifications will usually be carried out at the waxing-up
stage of crown construction and will be produced by careful shaping of
the wax pattern on the surveyor . However, it must be remembered
when preparing the tooth that sufficient tooth structure must be
removed to allow these features to be included within the bulk of the
restoration.
77
Figure 14.4
The completed restoration incorporates a seat for an occlusal rest
that will provide support for an RPD.
Figure 14.5
Full veneer crowns have been used to reduce the degree of
undercut on the buccal aspect of these two maxillary molars, and to
provide a more favourable survey line for clasping .
Figure 14.6
In the mandible, the need is more frequently to modify lingual
contours . Here a crown has been used to reduce an excessive lingual
undercut and thus produce a more favourable shape for clasping .
A similar procedure may on occasion be necessary on
lingually tilted molars or premolars , which would otherwise
prevent the insertion of a lingual connector.
78
Conservative treatment
Figure 14.7
A mandibular premolar with an unsatisfactory survey line has been
restored with a full veneer crown that provides an acceptable degree
of undercut for a gingivally approaching 'I' bar clasp.
Guide surfaces have also been established to determine the
path
of insertion and removal of the RPO framework and to
provide reciprocation for the retentive clasp arm.
79
15
p
Tooth preparation
Figure 15.1 -
Rest seats
Rest seats may need to be prepared to:
produce a favourable tooth surface for support (Figure 15.1);
prevent interference with the occlusion (Figure 15.2);
reduce the prominence of a rest (Figure 15.3).
Rest seats
A rest placed on an inclined surface will tend to slide down the tooth
under the influence of occlusal loads (1). The resulting horizontal
force may cause a limited labial migration of the tooth with further loss
of support for the denture.
The provision of a rest seat (2) will result in a vertical loading of
the tooth, more efficient support and absence of tooth movement.
3
81
Figure 15.3 -
Rest seats
Figure 15.4 -
Figure 15.6 -
82
Tooth
preparation
Where a clasp is to extend buccally from an occlusal rest and there is no space occlusally for it to do so, the
preparation must be extended as a channel on to the buccal surface of the tooth . In some circumstances it
may also be necessary to reduce and recontour the cusp of the tooth in the opposing arch.
83
Figure 15. 11 -
Figure 15.12 -
Guide surfaces
Figure 15.13 -
Guide surfaces
Guide surfaces (*) are two or more parallel axial surfaces on abutment
teeth , which limit the path of insertion of a denture. Guide surfaces
may occur naturally or, as is more often the case, may need to be
prepared.
Increased stability.
Reciprocation.
Prevention of clasp deformation.
Improved appearance.
Figure 15. 14 -
Increased stability
84
Tooth
preparation
Figure 15. 15 - Reciprocation
A guide surface* allows a reciprocating component to maintain
continuous contact with a tooth as the denture is displaced occlusally.
The retentive arm of the clasp is thus forced to flex as it moves up the
tooth. It is this elastic deformation of the clasp that creates the
retentive force (Chapter 7, A Clinical Guide to Removable Partial
Denture Design).
Figure 15.17 -
A
I
1
A
,,
I
Improved appearance
SS
Figure 15.19 -
Figure 15.20 -
86
Tooth
preparation
Figure 15.23 -
(1)A high survey line may also result in deformation of the clasp
because , on insertion , the clasp is prevented from moving down the
tooth by contact with the occlusal surface . If the patient persists in
trying to seat the denture, the clasp is bent upwards rather than
flexed outwards.
(2)Shaping the enamel to lower the survey line will allow the clasp to
be positioned further gingivally and it also provides a 'lead-in' during
insertion, causing the clasp to flex outwards over the survey line as
planned .
Y
'
Retentive areas
Figure 15.24 - Retentive areas
Retentive areas can be created by grinding enamel. However, the
enamel is relatively thin in the gingival third of the crown where the
retentive tip of the clasp would normally be placed, so the amount of
undercut that can be achieved by these means without penetrating the
enamel is strictly limited. It is usually better to establish improved
contours for retention by restorative methods as outlined in Chapter
14.
Figure 15.25 -
Retentive areas
87
Part
3
Prosthetic treatment
n this part we consider the clinical procedures involved in the construction of remov
expenence.
able partial dentures. The various chapters offer only a basic guide to these procedures
as we believe that the details of technique can be learnt only by clinical tuition and
89
Working impressions
Figure 16.1 -
Individual tray
The production of a working cast sufficiently accurate for the
construction of an RPD frequently necessitates the use of an indi
vidual tray. Such a tray enables an accurate impression to be
made of the functional depth and width of the sulci in those
areas that will be related to the denture border and to
component s such as gingivally approaching clasps, connecting
bars and plates.
Individual tray
Figure 16.2 -
Individual tray
91
Individual tray
Figure 16.5 -
Figure 16.6 -
92
Working impressions
For optimum effectiveness the stops must be carefully positioned to ensure three-point location of the tray.
Suitable locations for stops include those areas related to the incisal or occlusal surfaces of the teeth, the
palatal vault and posterior border, and the retromolar pads. They should not be placed over teeth that are to be
covered by denture components as the shape of these teeth should be recorded by an optimum thickness of
impression material. Any stops that include more than the incisal edges or cusp tips should be reduced as the
excess material may hinder reseating of the tray.
Figure 16.8 -
Once the stops have been pre d , the tray is re-inserted into the
mouth. Gentle retraction of the lips and cheeks will indicate labial or
buccal over- or under-extension. Any areas of over-extension should
be reduced, as here where space has been created for the buccal
fraenum. Any areas of underextension should be made good by the
addition of a border-moulding material such as tracing compound. For
distal extension saddles the tray should cover the retromolar pads or
enclose the tuberosities.
Figure 16.9 -
Figure 16.10 -
F
i
g
u
r
e
1
6
.
1
1
The appropriate adhesive for the chosen material must
be applied to the tray in a uniformly thin layer. It is most
important
C
that the adhesive film be allowed to dry before the impression
h
material is brought into contact with it.
o
i
cPreparation of the mouth
eFigure 16.12 - Preparation of the mouth
The layer of saliva that would otherwise hinder the flow of impression
o
material into direct contact with the teeth should be removed using a
fwarm air syringe . This is particularly indicated when there are
94
the working time of an elastomer has been reached, since the vis
cosity of these materials begins to increase immediately after mix
ing has commenced . Thus the working time as stated by the
manufacturer of the material must be observed.
Working
impressions
Figure 16.14 -
Figure 16.16 -
Care must be taken to preserve the functional depth and width of the
sulci recorded with the impression. It is difficult to attach wax beading
to alginate and elastomer impression materials; however, an indelible
pencil can be used to draw a line on the outside of the impression 3
mm away from the border.
Figure 16.17 -
Trimming of the cast should be stopped once the pencil mark on the
stone is reached. An adequate area of 'land' (1) is thus created on
the cast.
95
Common faults
Common faults
Common faults are under-extension of the tray borders or incomplete seating of the tray on its stops.
Both faults lead to inadequate support for the impression material. The correct depth and width of the
sulci are unlikely to have been recorded and the impression material is almost certain to be distorted
when pouring the cast.
Figure 16.21 -
Common faults
Figure 16.22 -
Common faults
If the border of the tray was over-extended the true functional form of
the sulci may not have been recorded. Such over-extension should
be reduced and the impression retaken.
96
Working
impressions
If the impression needs to be retaken, all the set impression
material must be removed from the tray, the tray modified as
required, and another thin layer of adhesive applied and allowed
to dry before the new attempt is made . Multiple retakes may
result in a thick layer of adhesive on the tray. Such a layer exhibits
poor adhesive properties; it must therefore be removed before a
new thin layer is applied.
97
98
17
Recording the ja
relationship
mounted on an articulator. This will permit correct positioning
of the artificial teeth.
Figure 17.1 -
General objective
Figure 17.2 -
Figure 17.3 -
Occlusal stop
99
Figure 17.6 -
Occ/usal rims
100
101
102
The patient must close into the retruded jaw relationship and
maintain that position while the recording medium sets under
minimal pressure .
103
Any recording medium that has flowed beyond the tips of the
opposing cusps or edge of the opposing rims is carefully trimmed so
that only shallow indentations remain. This aids direct visual
assessment of the accuracy of the record in the mouth.
Figure 17.20 -
The casts are now placed in occlusion using the occlusal rims .
Trimming of the casts may be necessary to permit their accurate
location in the registration. The heels of the casts may touch each
other, as shown here, or portions of the opposing rim or baseplate
and thus prevent the casts from seating fully in the occlusal record .
..
It is important to remember that it is the clinician's responsibility to ensure that the desired jaw relationship has
been transferred accurately from the mouth to the casts . The relationship of the natural teeth to each other
must thus be inspected ; if they are further apart on the casts (a) than they are in the mouth (b}, compression of
the wax or mucosa must be suspected.
104
Metal backings
Metal backings are likely to be required for artificial maxillary anterior teeth when opposing natural teeth
are virtually contacting the mucosa of the edentulous area.
105
18
place at once, the presence of wax hinders the search for inter
ferences and additionally, if the casting needs adjustment with
work should initially be undertaken without the addition of
Figure
- Trial
of the
metal
any wax
rims or18.1
artificial
teeth.insertion
If the casting
does
not framework
fit into
The framework is first examined on the cast to ensure that the
prescribed design has been followed. Any wrought clasps should have
been included and attached to the cast-metal framework by solder or
cold-curing acrylic resin. All components should be checked to ensure
that the fit is accurate, that they are of adequate dimensions and are
correctly positioned.
These components are not correctly positioned, being too close to the gingival margins or failing to cross
the margins at an angle of at least 90.
10 7
Figure 18.8 -
108
Figure 18.10 -
Figure 18.11 -
109
110
19
Al.tered cast
technique
Figure 19. 1
When a distal extension saddle is constructed on a cast poured from a
mucostatic impression, the differential in the support offered by the
abutment tooth in its relatively incompressible periodontal ligament
and the more displaceable denture-bearing mucosa is greatest. As a
result, the tendency for the distal extension saddle to sink under
occlusal load and pivot about the rest on the abutment tooth is
increased.
Figure 19.2
The objective of the altered cast technique is to reduce the support
differential for a distal extension saddle by obtaining a compressive
impression of the edentulous area under conditions which mimic
functional loading. The distribution of load from the denture to the
residual ridge is thus improved and the denture is more stable.
Figure 19.3
Acrylic resin tray material is added to the framework to form a base
that covers the relevant edentulous area . It must be of sufficient
thickness
to be rigid. At the chairside the periphery of the base is inspected for
under- or over-extension and adjusted accordingly. Any undercuts in
the impression surface are removed . This surface is dried and zinc
oxide impression paste or medium-viscosity silicone impression
material applied .
111
Figure 19.5
When the impression material has set, the framework is removed
from the mouth and the impression inspected. Any errors must be
corrected by appropriate modification or by retaking the impression .
Figure 19.6
Once a satisfactory impression has been obtained the need for an
extra clinical stage to record the jaw relationship can be avoided by
adding wax rims to the framework at the chairside and proceeding with
the recording at the same appointment.
112
Altered cast
technique
Figure 19.7
When the completed impression has been conveyed to the laboratory,
the relevant edentulous areas are cut from the original master cast.
The framework is carefully and accurately seated on the teeth.
Figure 19.8
Finally, a new composite cast is produced by pouring artificial stone
into the saddle impression.
When the acrylic tray is removed from the framework it will
usually be seen that the metal 'foot' attached to the spaced mesh
(Figure 18.8) has lost contact with the underlying ridge. If this is
the case a small portion of cold-curing acrylic resin should be
added to the mesh at this point to re-establish the contact and to
support the framework on the cast.
Figure 19.9
A disadvantage of this method is that it will usually disrupt the
evenness of occlusal contact in the saddle area by creating
premature contacts posteriorly. The occlusal correction required can
be quite considerable.
20
Trial insertion of
waxed-up
dentures
Figure 20. 1 -
The arrangement of the anterior teeth should be pleasing to the eye and conform to any requests on the
laboratory card. The labial surfaces and incisal edges should harmonise with the abutment teeth . If incisal
wear is present on the natural teeth it should be simulated on the denture .
The appearance of the incisors in (a) is less acceptable than that in (b). The appearance may need to
be modified after both the patient and the dentist have had the opportunity to view the denture in the
mouth .
11
Figure 20.4 -
A common error, which creates a poor appearance, is to place the gum margin of the artificial maxillary
premolars at a lower level than that of the adjacent natural teeth (a). This may be overcome by careful
waxing up and by the selection of an artificial tooth of appropriate crown length (b).
116
Figure 20. 7 -
If the chosen path of insertion and withdrawal for the denture does
not eliminate undercuts on the labial or buccal sides of the ridge, the
flanges should be thinned as they pass over the survey line and end
approximately 1mm beyond it.
The dentures are now seated in the mouth along their planned
path of insertion so that the fit, positioning of all components
and flange extension can be checked by visual inspection. Func
tional movements of the lips, cheeks and tongue should not dis
place the denture . The relationship of the artificial teeth to the
soft tissues should be assessed to determine whether the pre
scription supplied by the occlusal rims has been followed. The
Figure 20. 8 -
The patient must maintain only the lightest possible occlusal contact
while the occlusion is being checked, otherwise any premature
occlusal contact may be masked by distortion of the denture base,
by displacement of the mucosa or, as shown here, by movement of
the trial denture away from the tissues.
Correction of significant occlusal errors will require the
replacement of the artificial teeth with wax rims so that the jaw
relationship can be re-recorded.
117
Figure 20. 10 -
Figure 20.11 -
Figure 20. 12 -
118
Figure 20. 14 -
Figure 20. 15 -
119
Figure 20. 17 -
Figure 20. 18 -
120
Figure 20. 20 -
Figure 20.21 -
121
21
Figure 21.1 -
Insertion of the
completed denture
Figure 21.2 -
If acrylic resin has entered the gingival sulcus adjacent to the natural
teeth (left), the resultant sharp ridge of acrylic resin should be
eliminated (right) . Care must be taken not to remove excess material,
since the soft tissues are liable to proliferate into the space so
created.
If the denture has been returned from the laboratory on dupli of insertion and withdrawal. If it does not seat, it is likely to be
cate casts, the latter should be examined for signs of abrasion due to acrylic resin having entered undercuts related to the nat
produced by forcing rigid portions of the denture into place . ural teeth or the alveolar ridges. The area of acrylic resin involved
Such abraded areas indicate parts of the denture that may require may be detected by visual inspection or by the use of disclosing
media as described in Figure 18.10.
adjustment.
The denture is now seated in the mouth along the planned
path
123
Figure 21.4 -
Once the denture is seated and is comfortable the fit of all its
components is checked.
There is evidence that even apparently well-fitting rests might
not accurately contact the surface of the rest seat. I f this
is thought to be significant in a particular case, an effective,
though perhaps underused, 'retro-fitting' of the rests can be
carried out. This involves adding a small amount of composite
to the pre pared surface of the rest seat, seating the
framework fully, removing any excess composite from around
the rest, light-cur-
Figure 21.5 -
124
Figure 21.8 -
Figure 21.9 -
125
Figure 21.11 -
Figure 21.12 -
Area of
interferenc
e
Area
of
suppor
t
126
12 7
22
Review
First review
The first review will usually be undertaken about one week after
denture insertion. The patient is asked for comments on this ini
tial period of denture-wearing and a history is taken of any com
plaint. The most common complaints are of pain or looseness,
or both .
Even if the patient expresses complete satisfaction with the den
tures, a careful examination of the mouth is essential. This is
because tissue damage caused by the denture may occur (even
extensive ulceration) in spite of the patient having reported that
the dentures are entirely comfortable. Reasons for this apparent
discrepancy may be that the patient possesses a high pain thresh
old, or is reluctant to risk offending the dentist.
Since the ulcer in the left lower buccal sulcus is related to the
denture border, the cause is most likely to be over-extension. Where
visibility is good the offending area of over-extension can usually be
easily identified and corrected. However, visibility may be poor in the
posterior region of the mouth so that pressure-sensitive disclosing
media may be needed to ensure accurate location of the area of flange
requiring adjustment.
129
I
I
I
130
Review
Figure 22. 5 - Denture control
Dentures whose retention depends primarily on control by the
patient's musculature may be reported as being loose if the patient
has not yet developed the necessary skills. Further advice and
encouragement may have to be given at this stage.
Subsequent reviews
I f anything more than very minor tissue damage is noted at the
first review an additional appointment may be required to ensure
that healing has taken place.
I f the patient is slow to acquire the neuromuscular skills nec
essary for retention, it may be possible to modify the denture to
increase physical retention .
Direct retention can sometimes be improved by adding
a wrought clasp, and/or by modifying tooth contour by acidetch composite additions (Figure 15.25).
Denture maintenance
Once problems arising directly after insertion of a denture have
been resolved, regular inspection and maintenance of the den
ture is undertaken as part of the patient's routine dental care.
Unless there are regular inspections the denture can cause con
siderable damage which, at least in the early stages, may be symp
tomless; therefore the patient would not necessarily be aware that
treatment is required. I t is thus essential that when the dentures
have been fitted the need for regular recall appointments
is emphasised to the patient.
Continued alveolar resorption, usually most marked under
mandibular distal extension saddles, progressively reduces
mucosal support for dentures. When the effect of this on oral
health and function is judged to be clinically significant, a rebase
to correct the lack of fit is indicated. The clinical procedure fol
lows the principles laid down in chapter 19.
Maintenance may also, from time to time, involve repairs and
additions to the dentures as described in chapter 10.
131
Denture maintenance
Postscript
Two contrasting clinical situations are offered at the end of this
final chapter.
F
i
g
u
r
e
2
2
.
9
P
o
s
t
s
c
r
i
p
t
No one would deny that the long-term treatment of this patient has
failed entirely. Many teeth have been damaged as a result of
wearing an RPD that replaced just one tooth : a high biological price
has been paid.
Postscript
132
Postscript
T H ECL I N ICA L
S ER I ES
G UI DE
Lavishly illustrated and taken in conjunction with the companion volume by the same
authors, A Clinical Guide to Removable Partial Denture Design, the book serves to guide
the reader through every aspect of partial dentures. It does this in a practical way that
ensures all aspects of the subject are covered, from the initial examination and history
through to the review appointment after fitting the finished prosthesis.
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