RFE310 Advanced Removable Prosthodontics 2011

Ting-Ling Chang, DDS

Clinical Professor
Division of Advanced Prosthodontics
UCLA School of Dentistry
Treatment Options for
Replacement of Missing Teeth
No treatment
Implant supported restoration
Fixed partial denture (bridge)
Removable partial denture (RPD)

*A fixed replacement is usually the preferred treatment

of choice.
Treatment Options for
Replacement of Missing Teeth
No treatment
Implant supported restoration
Fixed partial denture (bridge)
Removable partial denture (RPD)
 Treatment Options for
Replacement of Missing Teeth
No treatment*
Implant supported restoration
Fixed partial denture (bridge)
Removable partial denture (RPD)
1. Long edentulous spans
2. Absence of adequate periodontal support
3. Structurally and anatomically compromised abutments
4. Need for cross-arch stabilization
5. Distal extension
6. Need to restore soft and hard tissue contours
7. Age and health
8. Attitude and desires of pt.
9. Ease of plaque removal
RPD Treatment Planning (ATP work-up)
Required Diagnostic Information
Caries diagnosis-
high caries rate or not, contributing factors

Periodontal probing depths, mobility, bone level, level

of keratinized attached tissue (especially for RPD
abutment teeth )

Pulp vitality, status of previous endodontic treatment,

periapical pathosis, presence and state of foundation
restorations(build-ups, cast post and cores, etc)
 RPD Treatment Planning (ATP Work-up)
Occlusal Analysis

Occlusal relationship must be evaluated with mounted

diagnostic casts to study the following:
Vertical Dimension of Occlusion (existing VDO assessment)
Occlusal plane
Amount of interocclusal space
Horizontal and vertical relationship of anterior teeth
Centric occlusal contacts
Occlusal eccentric schemes (anterior guidance, group function)

The above factors play a critical role in designing a

removable partial denture.
Mouth Prep for RPD framework
(modify the contours of teeth selected to serve as RPD
abutments)

Four Objectives:
Prepare the RPD abutment teeth
to obtain parallel guiding surfaces-develop the path of
insertion/promote stability and (frictional)retention
to achieve positive rests-promote support/comfort
to remove excessive undercut/lower the height of
contour-improve esthetics
to create desired undercut for retention-promote
retention
 Objectives of Modifying
RPD Abutment Tooth Contours

retention support

stability
retention
 Example of Promoting Esthetics by modifying the
Contour of RPD Abutment

Height of Contour

Paralleled-sided bur

Reprint from McCracken’s

Removable Partial Prosthodontics 11th edition
When Does One Choose to Fabricate a Crown to Serve as a
Removable Partial Denture Abutment?

When correction of
unacceptable tooth
contours cannot be
achieved through
enamel modification
alone leading to
significant dentine
exposure.
Dentine exposure can
cause sensitivity and
caries
When does one choose to fabricate a surveyed
crown, -- Continued
To restore a badly broken
down clinical crown

To reestablish a proper

occlusal plane (i.e. supra-
erupted teeth

To provide proper rests,

particularly with anterior
teeth, and adequate
retentive undercuts for
direct retainers (I-bar, C-
clasp) when inadequate
contours exist.
 Combining Fixed Restorations and Removable
prostheses--Treatment Sequence
Diagnosis Determine that a surveyed crown is needed

Design RPD design is based on support, stability,

and retention

Fixed Restorations

Removable
Prostheses
Map out the final RPD design first
Occlusion consideration
Full Arch Impression
Pindex cast and soft tissue cast
Communication with fixed lab
Wax pattern and final crown check
Highlight the role of the surveyed crown as the RPD
Abutment
(rest? Proximal plate? Retainer? I-bar or C-clasp?
Active or Passive? )
Trouble Shooting
Case Report—Combination Case
Maxillary Complete Denture vs. 4 surveyed PFM crowns and a distal
extension removable partial denture
 Surveyed crowns are to be fabricated because of:
 Root caries on facial , lingual, and interproximal surfaces
 Teeth proclined facially resulting in a difficult path of

insertion for the RPD

 Canines with flat cingulums making it difficult to develop

positive rests
Maxillary denture and mandibular survey crowns (#21, 22, 27, 28)+ mandibular cast RPD
Map out the final RPD design:
Maxillary denture and mandibular survey crowns (#21, 22, 27, 28)+ mandibular cast RPD
Map out the final RPD design:

Occlusion design and consideration:

Anterior guidance vs. Canine Guidance vs. Fully balanced vs. Group function
Occlusion Consideration
Establish the occlusal plane and develop the occlusal
scheme
Fully balanced occlusion is
desirable for this case.
Proceed with upper CD treatment
first up to the maxillary wax denture
try-in stage.
Diagnostic wax up of the surveyed
crowns and set up mandibular
denture teeth against the maxillary
wax denture to ensure fully balanced
occlusion is developed

Then fabricate the vacuum formed clear matrix

1. Prepare teeth. Use the vacuum formed matrix to ensure
proper tooth preparation
2. Make a FULL ARCH final impression capturing edentulous
areas bilaterally.
3. Fabricate a provisional restoration using your vacuum formed
matrix. If applicable, adjust provisional and treatment partial
prior to cementation.

Final FULL ARCH

impression
4. Send the PVS impression to fixed laboratory to pour twice,
1st pour- pindex cast, separate from base.
Ask laboratory not to section between preps, or trim your dies
and return your master cast for record base fabrication and
mounting of the case.
2nd pour- soft tissue cast (solid cast) – for surveying the
crowns during wax pattern and final crown stages

pindex cast
Final FULL ARCH impression Base
 Record base fabricated on
mandibular master cast

Wax-rim added

Determine VDO, occlusal plane, proper anterior tooth display

and lip support clinically.
Complete mounting of the mandibular cast with a centric relation record
against maxillary wax denture

-Set teeth (md edentulous area)

-Confirm vertical dimension
-Determine proper tooth position,
-Verify mounting
-Begin surveyed crown fabrication
Occlusion:
Fully balanced occlusion is developed with the denture teeth and surveyed crowns
Esthetics:
Optimal esthetics is achieved with coordination between fixed and removable

Communication
with
the fixed lab
by sending in
all these critical
workup
1st pour: Pindex Cast

During the die trimming, all soft tissue

contour will be removed below the crown
margin.
These peri-abutment soft tissue contour
are critical information for infrabulge retainer
design such as I-bar or ½T-bar

1st pour: Pindex Cast

 The 2nd pour from the same
PVS final impression generates
the soft tissue cast (Solid cast)
No trimming on this cast and all
soft tissue contour is preserved
for surveying.

2nd pour: Soft Tissue Cast(Solid Cast)

Communication with the fixed lab:
Tripod the MAP on the soft tissue
cast
 Wax Pattern and Final Crown Check
Highlight the role of the surveyed crown as the
RPD Abutment

#21 and 28:

Mesial rest
Distal guiding plane
Facial 0.01” I-bar
#22 and 27:
Cingulum rest
Mesial guiding plane

Receive the full contoured wax-up. Place on surveyor at the designed MAP based on
Tripod, carve rest seats, guiding planes, facial/and lingual heights of contour for direct
retainers (I-bars, C-Clasps) and reciprocating arms or elements (i.e. minor connectors,
proximal plates, partial lingual plates.)
 Survey the soft tissue
cast to determine the
MAP and tripod

Perform a full contoured wax-up according to your MAP, determine

occlusion (set adjacent and opposing teeth)
Guiding planes and rests should
be in metal
Positive cingulum rest

Maximize guiding plane

height and width to Survey for tissue undercuts on
optimize stability a solid model to aid in retainer
design
Cut back wax-up for PFM fabrication. Maximize height and width of
guiding planes to enhance RPD stability, make sure rests are positive.
 Final check of final crowns on
the soft tissue cast

Trouble shooting
Rest not positive
Guiding plane too bulky
Height of contour too high

Height of contour too low (lack of

desirable retention)

Use calipers to measure during

adjustment, metal thickness no less
than 0.5 mm
 Surveyed Crown Fabrication Porcelain Bisque Try-in
Use carbides or stones to adjust metal, diamonds to adjust
porcelain. Polish all adjustments with silicone carbide wheels.

Long, wide guide planes maximize

Note the perfect location for I-bar. 0.01” stability, and minimize tissue
undercut at the cervical 1/3 of crown hypertrophy under RPD frame.
Surveyed Crown Fabrication
Final Delivery
After all adjustments are
completed:
Glaze Porcelain
Polish Metal
Cement Crowns
If treatment partials
present, plan for their
adjustment to fit around
new crowns
Make final RPD impression
in alginate capturing all soft
tissue (denture bearing
surfaces) detail.
 RPD Framework Fabrication
Alginate impression for RPD framework must capture
all tissue detail

The retromolar pads and

the retromylohyoid area
have been captured well in
the alginate impression

Once happy with the

RPD’s path of insertion,
tripodize cast
Long, parallel guide
plane
RPD Design Cast
Follow proper design sequence
Final Result