Preventive prosthodontics

T.Sudhakar Reddy
III yr pg

CONTENTS

Introduction
Preventive measures in
Fixed partial dentures
Removable partial dentures
Tooth supported overdentures
Implants
Complete dentures
Conclusion
References

Introduction

PROSTHODONTISTS OF TODAY are vitally concerned with the practice of

preventive dentistry because they are more conscious of the after effects of the
loss of a single tooth. It is a recognized fact that after all other dental procedures
have been accomplished, it is up to the prosthodontist to regain the normal
atmosphere and function of the stomatognathic system. Many times the
prosthodontist is consulted too late in the treatment phase to be of much help;
whereas had he been consulted earlier, the prognosis would 'have been more
positive and the results more gratifying. The primary goal is to esthetically
restore the masticatory function and the missing parts of the oral cavity and to
improve the health of the patient. However, the ultimate goal is to preserve what
is present in the oral cavity.
It is perpetual preservation of what already exists and not the meticulous
replacement of what is missing-M.M deavn.
A Preventive prosthodontics emphasizes the importance of any procedure that
can delay or eliminate future prosthodontics problems.
FIXED PARTIAL DENTURE:
Planning for fixed partial dentures should include: adequate extension for
prevention. We can Prefer partial veneer crowns instead of full veneer crowns
since they requires less tooth reduction. Facial surface is left intact for superior
esthetics. Used when minimal retention is sufficient and when abutment tooth is
healthy.
Resin bonded retainers
They Require minimal tooth reduction. Have a small metallic extension which are
designed to be bonded directly onto the lingual surface of the abutment tooth
using resin cement. These partial dentures do not accept heavy loads. Indicated
for anterior teeth.
Supra-gingival finish line
As early as 1941, Orban proposed supragingival margins for improved
periodontal health. Studies have supported the use of supra-gingival or equigingival finish lines rather than sub-gingival finish line whenever possible to
ensure periodontal health. Biological width violation depends more on margin
placement rather than on margin design. Supra gingival finish liners are Easier
to prepare accurately without trauma to the soft tissues. Restorations are are
more easily kept clean.
Pontic design
In addition to properly designing the undersurface of pontics, it is imperative to
open embrasure spaces adjacent to abutments to allow room for interproximal
tissue and access for oral hygiene.
OCCLUSAL FORCES Can be reduced by : Reducing the buccolingual width of the
pontic by as much as 30%
Veneers:
Dental veneers are custom made shells made from tooth colored materials that
facilitate covering the front surface of the tooth and these are alternately known
as dental laminates. A uniform 0.5mm intraenamel reduction is sufficient.

Preparations are extended to the gingival crest and into the interproximals
without breaking contact.
Three ways to manage incisal edge coverage.No incisal edge coverage .Cover
incisal edge Wrap around incisal edge.
Lumeneers:
Lumineers are a revolutionary type of veneer. They are so thin, they mimic the
natural surface of a tooth. Traditional veneers are generally thicker, and they
require irreversible removal of healthy tooth structure. But with Lumineers, the
veneer can be made so thin that this step is often unnecessary. In fact, the
procedure is so smooth that it's often called "no-prep" veneering technique.
Snap-On Smile is a multi-purpose restorative appliance that requires no
preparation or altering of tooth structure, no injections, and no adhesives. These
are comfortable, removable appliance fits directly over existing dentition and
attains its retention utilizing the anatomy of each existing tooth. The Snap-On
Smile appliance is made from crystallized acetyl resin. This material is very
durable and has a slight flexibility.
Removable partial denture:
Guiding planes:While designing rpd all guidelines close to the incisal or occlusal
line angles should be reduced to place the guideline closer towards the gingival
areas. This will create guiding planes for insertion and removal of the prosthesis
without forcing teeth to move each time the prosthesis is inserted.
Retentive clasp arm
Placing the clasp terminals nearer the gingival one-third of the tooth will aid in
reduction of torque on the periodontal fibers.
Combination clasps (wrought wire retentive terminal and cast clasp reciprocal
terminal) will aid in tooth preservation by decreasing the rigidity of cast clasps.
Stress-breaking features are inherent in this type of a clasp. Incorporation of
stress breakers in to rpd by means of attachments or split major connector will
distribute forces equally on abutment teeth and residual ridges.
Overdenture: a removable partial or complete denture that covers and rests on
one or more remaining natural teeth, roots, and/or on dental implants; also
called as overlay denture, overlay prosthesis, superimposed prosthesis.
According Atwood & Tallgren CD wearers suffered irreversible bone loss
especially in the first year. Tallgren observed that the average reduction of
anterior mandibular ridge height was 9 mm to 10 mm over a 25- year denturewearing period. And maxillary ridge 2.5 mm to 3 mm. mandible resorbs four
times than maxilla.
Alveolar bone resorption is dependent upon three variables which are: 1) the
character of the bone, 2) the health of the individual, 3) and the amount of
trauma to which the structures are subjected.
Crum and rooney demonstrated less alveolar bone reduction in patients with
complete maxillary and mandibular overdentures compared to patients with

maxillary and mandibular complete dentures. 16 men aged 46-67 were studied
for 5 years.
Morrrow discussed the usefulness of utilizing abutment teeth in the support of
complete dentures. By maintaining teeth the alveolar ridge is less likely to
resorb.
Highlights:

Soft tissue of residual ridge receives less abuse since abutment teeth
provide support.
More horizontal stability.
Increased vertical stability.
Excellent patient acceptance.
Natural teeth unacceptable for conventional dental use are acceptable for
tooth supported dentures.

Thayer said that Preserving the teeth or the roots preserves the periodontal
ligament
Periodontal ligament

Supports the tooth

Provides proprioception in directional sensitivity
Dimensional discrimination
Tactile sensitivity to load
Canine response

1942 Bevelander studied the histological tissue reactions to experimental root

fracture in dogs
In 1947 Glickman and associates histologically described the healing of
postextraction wound with the presence of retained root remnants in rats.
1959 Simpson examined a number of retained roots in humans and suggested
that root fragments, which were originally unaffected, could be safely left in
position.
1960 Helsham reported on a clinical supply of 2000 patients referred for removal
of retained roots
small percentage of retained roots caused symptoms and demonstrable
pathologic changes.
In 1973 Herd reported on 228 retained roots removed from 171 patients. He
found 163 of these roots to have vital pulp tissue with no inflammation. In 1974
Whitaker and Shankle found higher success rate in the vital roots (12 of 19) than
in the endodontically treated roots (3 of 17). The successfully submerged
endodontically treated roots were associated with mild pericoronal inflammatory
response. This reaction was totally absent in all the successful vital submersions.
1976 plata reported on a histologic study of the regeneration of alveolar bone
over submerged vital roots in the dog.

Eight of the 12 roots there was complete bone coverage after 12 weeks with the
pulp retaining its vitality in all roots.
1978 welker and associates reported on 12 roots submerged in six patients.Eight
were vital and four nonvital. Dentures had been worn over the roots for periods
up to 51months. All patients had been termed clinically successful.
Over denture Advantages

Soft tissues of residual ridges are spared abuse.

The denture- horizontal stability.
Vertical stability during functional loading -masticatory performance.
Natural teeth which are unacceptable as abutments for conventional
restorations are worth retaining for use as supporting elements to
complete dentures.
Patient acceptance of tooth-supported dentures is excellent.

DISADVANTAGES

Caries and periodontal disease

Bony undercuts
Encroachment of interocclusal distance

Types of tooth supported overdenture

According to method of abutment preparation:
1. NON COPING

a) with endodontic treatment

b) Without endodontic treatment

2. COPING

a) with endodontic treatment

b) Without endodontic treatment

3. ATTACHMENTS

Implants in preventive prosthodontics

RP4
Definition
Removable prostheses that are supported completely by the implants
Indications
Enough alveolar bone to hold (Mand. 4-6 & Max. 6-8) implants
Contraindications
Inability to place enough implants
Overdenture attachments usually connect the removable prosthesis to a lowprofile tissue bar or superstructure that splints the implant abutments .usauallly
5 or 6 implants in the mandible 6 to 8 implants in the maxilla are required

RP5
Definition: Removable prostheses that are supported by both the implants and
the alveolar ridge
Indications: Inability to place enough implants for the implant supported denture
Contraindications: Young patients due to high bone resorption
The primary advantage of an RP-5 restoration is the reduced cost.. RP-5
prosthesis need minimum 2 implants in canine region. Relines and occlusal
adjustments every few years are common.
Indicated to resolve

Lack of retention,stability
Decrease in function
Speech difficulties
Sensitive tissues and abrasions

Associated with conventional dentures- Specially the mandibular

Implant Overdenture Advantages
After extraction of mandibular teeth an average of 4mm vertical bone loss occur
during first year after treatment. This experience for next 25 years with mandible
experiencing a fourfold greater vertical bone loss than maxilla. The bone under
overdenture may resorb as little as 0.6 mm vertically y over 5 years

Minimum anterior bone loss prevents bone loss

Improved esthetics
Improved stability (reduces or eliminates prosthesis movement)
Improved occlusion
Decrease in soft tissue abrasions
Increased chewing efficiency and force
Improved speech
Reduction in the size of the prosthesis.

Implant overdenture disadvantages

Psychological (need for no removable teeth)

Long term maintenance
- attachments(change)
- -relines(RP-5)
Continued posterior bone loss
Food lodgement
Movements (RP-5)

Dostalova at al evaluated two different types of overdenture treatment. The first

group (17 patients) was treated by overdenture supported by teeth and the
second group included 18 patients was treated by osseointegrated implants.
They wore their dentures from 1 to 5 years. Evaluated overdenture stability and
retention and denture complications. complications appeared in 13 cases of
tooth supported and those are necessity of the repair of the broken denture,
matrices changing, post recementation, the need of root resection.
Immediate Implants And Socket Preservation
Its well documented that following teeth extraction and the subsequent
restoration with removable dentures, the size of the alveolar ridge will become
markedly reduced, not only in horizontal but also in vertical dimension and the
arch will be shortened. Resorption more pronounced at the buccal than the
lingual/palatal aspects of the ridge.
25% decrease in the width of the alveolar bone during the first year
Average 4 mm decrease in height during the first year. (Carlson 1967, Misch
2000)
Tatum and Misch have observed a 40%-60% decrease in alveolar bone width
after the first 2 to 3 years post extraction.
Rationale for immediate implants

Reduced number of visits in the dental office

Preservation of bone at the site of implantation
Optimal soft tissue esthetics
Enhanced patient acceptance

Disadvantages

Site morphology may complicate optimal Placement and anchorage.

Adjunctive surgical procedures may be required.
Technique sensitive procedures.
Thin tissue biotype may compromise optimal outcome.

Esthetic Complications with Immediate Implants

Observed complications with immediate implants in early 2000.

Increased risk for facial bone resorption and consequent soft tissue
recession.

Keys of success in Esthetic Zone

Preservation of adequate amount of facial bone.

Surgical procedures which encourage healing capable of maintaining at
least 2 mm of facial bone dimension.
Appropriate bone dimension (horizontal bulk in addition to vertical height)
helps to maintain bone and soft tissue over the longer term.

Where to place implants in extraction socket.

in maxillary anterior region. One should engage palatal wall since resorption
more on buccal side than palatal.
For multi rooted teeth better to engage inter radicular septa.
Jordi Ortega-Martnez conducted a study to review the current state of immediate
implants, with their pros and cons, and the clinical indications and
contraindications. An exhaustive literature search has been carried out in the
COCHRANE library and MEDLINE electronic databases from 2004 to November
2009. Twenty studies out of 135 articles from the initial search were finally
included which summed up a total of 1139 immediate implants with at least a
12-month follow-up.
Conclusions:

Survival rates - similar to delayed placement

Interproximal bone level and soft tissue recession- similar
Treatment of the gap between implant and bone wall- inconclusive
Presence of periapical infection
Chronic periapical infection is a risk factor but not an absolute
contraindication
Primary implant stability- similar

Chrcanovic BR , Martins MD, Wennerberg A.conducted a studyto review the

literature regarding treatment outcomes of immediate implant placement into
sites exhibiting pathology after clinical procedures to perform the
decontamination of the implant's site. An electronic search in PubMed was
undertaken in March 2013. 32 studies were identified within the selection criteria
Conclusions
The high survival rate obtained in several studies .Implants may be successfully
osseointegrated when placed immediately after extraction of teeth presenting
endodontic and periodontal lesions, provided that appropriate clinical procedures
are performed before the implant surgical procedure such as

meticulous cleaning
socket curettage/debridement
chlorhexidine 0.12% rinse

Preventive prosthodontics-complete dentures

In the case of the completely edentulous patient in the impression stage, we
should cover as much available area of Support as possible ending our
perpheries on compact bone, and provide functioning borders where muscle
attachments exist and restoration of the vertical dimension of occlusion requires
strict attention in order not to encroach on the interocclusal distance (free-way
space) since this will lead to bone resorption.
Conclusion
A review of some of the cogent principles of prosthodontics have been discussed
with the ultimate goal of preventing further loss of vital oral tissues which cannot
be easily replaced once they have been lost through negligent thinking and
practices.
A planned treatment with judicious approach can bring paradigm shift in
longevity and outcome of an already handicapped patient.

References:
1. Devan MM. Basic principles in impression making. JProsthet Dent 1952;
2:26-35.
2. Morrow RM, Feldmann EE, Rudd KD, Trovillion HM. Toothsupported
complete denture, an approach to preventive prosthodontics. J Prosthet
Dent 1969; 21 : 322.
3. Crum RJ, Rooney GE Jr. Alveolar bone loss in overdenture a five year study.
J Prosthet Dent 1978; 40 : 610-13.
4. Thayer, H. H. Overdentures and the periodontium. DCNA 24:369-377, 1980
5. Casey, D, M. and Lauciello, F. R. A review of the submerged root concept. J
Prosthet Dent 43:128-132, 1980.
6. Dostlov T, Radina P, Seydlov M, Zvrov J, Valenta Z.Overdenture implants versus teeth - quality of life and objective therapy
evaluation.Prague Med Rep. 2009;110(4):332-42.
7. Jordi Ortega-Martnez.Immediate implants following tooth extraction. A
systematic review Med Oral Patol Oral Cir Bucal. 2012 Mar 1;17
8. Chrcanovic BR , Martins MD, Wennerberg A. Immediate Placement of
Implants into Infected Sites: A Systematic Review. Clin Implant Dent Relat
Res. 2013 Jul 2
9. Contemporary implant dentistry , 3rd edition , Misch
10.Internet.