Removable

Prosthodontics
at a Glance

James Field
Claire Storey
Removable
Prosthodontics
at a Glance
Dr James Field
BSc(Hons) BDS PhD MFGDP RCSEng MFDS MPros
FDTFEd RCSEd CertClinEd MA(Ed) FAcadMEd PFHEA
Senior Specialist Clinical Teacher in Restorative
Dentistry & Consultant in Prosthodontics
National Teaching Fellow and Principal Fellow, HEA

Miss Claire Storey

BDS MSc MRes CertEd MFDS FDS RCSEng
Consultant and Specialist in Restorative Dentistry
This edition first published 2020
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Library of Congress Cataloging-in-Publication Data
Names: Field, James, 1979- author. | Storey, Claire, author.
Title: Removable prosthodontics at a glance / James Field, Claire Storey.
Description: Hoboken, NJ : Wiley-Blackwell, 2020. | Includes
bibliographical references and index.
Identifiers: LCCN 2019056770 (print) | LCCN 2019056771 (ebook) | ISBN
9781119510741 (paperback) | ISBN 9781119510710 (adobe pdf) | ISBN
9781119510697 (epub)
Subjects: LCSH: Dentures. | Prosthodontics.
Classification: LCC RK656 .F495 2020 (print) | LCC RK656 (ebook) | DDC
617.6/92—dc23
LC record available at https://lccn.loc.gov/2019056770
LC ebook record available at https://lccn.loc.gov/2019056771
Cover Design: Wiley
Cover Image: Courtesy of James Field
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Set in Minion Pro 9.5/11.5 by Aptara Inc., New Delhi, India
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Contents

About the companion website  viii

1 Introduction  2
James Field
2 The function of removable prostheses  4
James Field
3 Stability and retention  6
James Field
4 Patient assessment for complete dentures  8
James Field
5 Edentulous ridge presentations  10
James Field
6 Patient assessment for partial dentures  12
James Field
7 Factors complicating success  14
James Field
8 Accessibility and operator position  16
James Field
9 Pre-prosthetic treatment  18
Claire Storey and James Field
10 Revisiting the anatomy  20
James Field
11 Making a primary impression – complete dentures  22
James Field
12 Making a primary impression – partial dentures  24
James Field
13 Special trays  26
James Field
14 Compound and putty materials – handling and manipulation  28
James Field
15 Recording an upper functional impression  30
James Field
16 Recording a lower functional impression  32
James Field
17 Managing fibrous ridges  34
James Field
18 Denture bases  36
James Field
19 Recording the maxillo-mandibular relationship  38
James Field

v
 20 Prescribing the upper wax contour  40
James Field
21 Prescribing the lower wax contour  42
James Field
22 Tooth selection and arrangement  44
James Field
23 Occlusal dimensions and occlusal schemes  46
James Field
24 Respecting the neutral zone  48
James Field
25 Assessing trial prostheses  50
James Field
26 Fitting and reviewing finished prostheses  52
James Field
27 Copying features from existing prostheses  54
James Field
28 Classifying partial prostheses and material choices  56
James Field
29 Designing partial prostheses  58
James Field
30 Saddles, rests and clasps  60
James Field
31 Connectors and bracing  62
James Field
32 Surveying and preparing guide planes  64
James Field
33 Designing frameworks – case examples  66
James Field
34 Precision attachments – the fixed–removable interface  68
James Field
35 Dealing with frameworks and substructures  70
James Field
36 The altered cast technique and the RPI system  72
James Field
37 Swing-lock prostheses  74
James Field
38 Gingival veneers  76
James Field
39 Immediate and training prostheses  78
Claire Storey and James Field
40 Occlusal splints  80
James Field
41 Implant-supported mandibular overdentures  82
Claire Storey and James Field
42 Principles of restoring maxillary defects  84
James Field
43 Tissue conditioners, liners and re-basing  86
Claire Storey and James Field
44 Maintaining adequate oral hygiene  88
Claire Storey and James Field
45 Troubleshooting loose or painful dentures  90
James Field

vi
46 Gagging, other difficulties and making a referral  92
James Field
47 Summary of procedural stages  94
James Field

Appendices  97
Recommended and supplementary reading  106
Index  110

vii
 2

1 Introduction
Chapter 1 Introduction

Figure 1.1 Assessment processes

• Social reasons • Mechanical and

for failure technical reasons
for failure
• Noticeable pain
• Visible pathology Often objective
Often subjective

Integration
Shared understanding
and
decision-making

Exchange of information Shared

both ways decision-making

All discussions should be

recorded in the notes

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
R
emovable prosthodontics is often described as a ‘black This incredibly important part of the process is investigative. 3
art’ – the Marmite of dentistry; practitioners tend to either It should determine the choice of treatment that will follow. If
love it or hate it. Fortunately, we love it – and with some simple the patient has an existing prosthesis, ensure that you ask what

Chapter 1 Introduction
guidance, hopefully you will too. Like most operative interventions, they think might change with a new one? What would they like
success depends on: to change?
• The skill of the dentist It is at this early stage that you can begin to modify your
• The technical difficulty of the case patient’s expectations if you feel that they are unrealistic. It is
• The patient’s perceptions, ideas and expectations always better to begin this way, than back-tracking later and
Providing prostheses that are satisfactory to the patient trying to reduce high expectations at the try-in or the fitting
is a challenge – and there are many reasons why patients can stages.
be dissatisfied with the finished result. Many relate to social It is also a good opportunity to provide your honest thoughts
aspects of patients’ lives – how they are able to interact with on the likely outcome. We would caution against promising
others, particularly when eating and speaking. Common reasons patients that their new prosthesis will be any better than the
include: one that is being replaced, even if you can identify significant
• Unacceptable aesthetics technical flaws. Instead, it is beneficial to ensure that you:
• Inability to chew food properly • Reiterate why you think the patient would like a new prosthesis
• Inability to enjoy the same foods as before • Describe any technical features that you believe you can
• Problems with speech improve upon
• Discomfort or persistent pain • Estimate how many visits, including retries and review
• Disagreements over time and cost appointments, you expect may be needed
Despite the diversity of complaints, there is often a common • Explain the fact that when the new prosthesis is fitted, even if
thread running through them all – lack of information exchange it is technically better, it will still take a period of acclimatisation
and an inappropriate level of patient expectation. We would (up to 6 months, and longer in some cases) before the patient is
therefore argue that the most important skill when making able to function optimally
satisfactory removable prostheses is that of communication. • Generate an understanding that during this time, the patient
will need to adapt slowly to their new prosthesis, even if it appears
to function comfortably – and this is particularly important in
Communication and expectations relation to complete denture patients
Effective communication takes time. As clinicians we often start
looking for mechanical reasons to explain why patients might
be having difficulties with their existing prostheses – excessive The clinical process
movement, trauma or ulceration, poor retention, or design of Communication aside, the process of making removable pros-
coverage. On that basis, we often agree to make a new prosthesis. theses is more manageable than it may seem at first. There are
In reality, patient tolerance relates to very much more than just often simple approaches that can yield excellent results, without
mechanics and physical function. It is crucial that the treatment expensive materials or equipment. In the main, technical success
you provide is driven by patient-perceived need. This means that is about attention to detail and knowing which materials work
patients need to understand and buy into the clinical rationale, best in your hands.
including risks and benefits, of the proposed treatment. Simi- The aim of this at-a-glance guide is to provide advice on
larly, we need to understand the patient’s rationale for wanting how to achieve optimal outcomes at each clinical stage of
a prosthesis. Given enough time, it is highly likely that these the process. Our opinions are based on decades of combined
requirements can be met. experience teaching at undergraduate and postgraduate level,
Often, the process of making removable prostheses begins and routinely treating a wide range of cases. We have provided
with a primary impression. Try and break that habit, and recommended reading for each chapter in case you wish to
implement these simple steps first: read more about the technical stages, or to understand better
1 Set aside at least 5 minutes to talk to your patient the theory and evidence base that underpins the fabrication of
2 Sit in front of your patient – do not stand in front of your removable prostheses.
patient with a stock tray in your hand! Educationally, we use the term ‘bricolage’ (tinkering) when
3 Invite your patient to explain why they would like you to make we are teaching our students about new materials in the clinics.
a denture – what are they hoping it will provide? If it has been a while since you have used some of the materials in
Crucially, your patient needs to feel that they can talk freely this book, then get hold of some of them, and have a play!
and comfortably about their tooth loss. This will not happen if
they feel rushed, or feel that you are not actively listening to them.
 4

2 The function of removable prostheses

Chapter 2 The function of removable prostheses

Figure 2.1 The function of removable prostheses

Improved quality
of life

Replace multiple
short endentulous saddles

Avoid preparing natural

teeth for extra coronal
restoration

Soft tissue support

Provide and aesthetics
posterior
support
Mastication Speech

Preventing unwanted
tooth movement
Replace long
edentulous
saddles

Avoid cantilevering fixed

bridgework from root-treated teeth

Improved transition to edentulism

• Partial prostheses can help to acclimatise the patient in

anticipation of wearing more extensive or complete prostheses

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
Function Finally, but by no means least, our patients may well request
removable prostheses in order to:
5
It is often assumed that the function of a prosthesis relates only to
• Improve aesthetics

Chapter 2 The function of removable prostheses

‘mastication’ – but there are many other functions that removable
• Restore social confidence
prostheses can serve. As clinicians, we are often good at recognis-
• Improve their eating experience
ing technical reasons why dentures should be constructed – but
often the social aspects from the patient’s perspective are
overlooked.
Be mindful that the prosthesis must serve a function as
Restoring vs improving
Notice that most of the clinical rationale is based around restor-
perceived by the patient. If we are constructing a prosthesis that
ing or rehabilitating, whilst patient requests often centre around
has a clear clinical rationale, but the reasons are less obvious to
improving. This important subtlety can easily be lost when nego-
the patient, then we must spend time explaining how we intend
tiating informed consent. Correcting technical deficiencies and
the prosthesis to help. Unless the patient understands and
restoring clinical function does not necessarily result in a patient-
believes the rationale for their construction, they are unlikely to
perceived improvement. Again, moderating patient expectations
wear them regularly.
is critical at each stage of treatment.
That said, it is remarkable what patients will tolerate in order
to achieve a desired outcome. For example, a patient might wear
their prostheses whilst they are out of the house in order to Quality of life
facilitate a more normal social life – even if it is painful – but it One of the most profound moments as an undergraduate was
is likely that they will take them out once they enter the house when Professor Janice Ellis (Newcastle) asked us whether we
again – especially if they live alone. This is probably not dissimilar would rather lose a leg, and have a prosthetic replacement, or
to us kicking off a pair of shoes that have been rubbing – but lose all of our teeth and wear a denture? At the time this seemed
made us look good. Many patients living alone also take their like a ridiculous comparison to make – but actually as clinicians
dentures out in order to eat – so do not always think that the we do become desensitised to seeing edentulous patients or par-
primary function of your lovingly constructed dentures is to help tially dentate patients. The bottom line is whether we really sym-
your patient to chew! pathise with our patients or not. By working on a daily basis with
It is important to remember that replacement of all of the edentulous patients who are struggling to cope, it is relatively
patient’s missing teeth is often unnecessary. That said, it is still easy to sympathise with the condition – even if we are unable to
critically important that denture bases are extended into the fully empathise. However, if we converse with denture-wearers
full denture-bearing area in order to maximise stability and less frequently, then there is a chance that we forget about what
retention – and this will be discussed further in the following Professor Ellis termed the ‘edentulous plight’. This reiterates why
chapters. it is important that we take the time to listen to what our patients
Removable prostheses are indicated primarily for the want, and that they feel comfortable enough to tell us.
following clinical reasons (Figure 2.1):
• Restoring masticatory function
• Restoring appearance Risks of removable prostheses
• Restoring speech One of the most significantly overlooked aspects of denture provi-
• Restoring soft tissue bulk and providing soft tissue support sion is the potential negative impact on the hard and soft tissues. Pri-
• Acclimatisation during the transition to becoming edentulous marily this relates more to the provision of partial prostheses – and
Removable prostheses are often indicated for the following patients should be made aware as part of the planning process
technical reasons: (through informed consent) of the risks and benefits of receiving
• Restoring long edentulous saddles dentures. Do not assume that because your patient is already wear-
• Restoring multiple short edentulous saddles ing dentures that there is no need to reiterate the potential risks.
• Providing posterior stability and improving occlusal load Whilst the jury is probably out in terms of the impact on
distribution periodontal disease, there is clear evidence of an increased risk
• Preventing undesirable tooth movements of plaque accumulation, gingivitis and root caries for patients
• Rehabilitating to an increased vertical dimension wearing partial prostheses. Many well-conducted studies show
• Facilitating functional anterior guidance that the key to minimising soft and hard tissue damage whilst
• In order to prescribe diastemata between prosthetic teeth wearing dentures is to maintain an optimal level of oral hygiene,
• To avoid preparing abutment teeth for fixed prostheses and to attend regular review and maintenance appointments;
• To avoid cantilevering from root-treated teeth this is very much a shared responsibility between clinician and
• To aid planning and diagnosis, especially prior to implant patient. The patient must understand this, and the discussion
placement should be well documented in the case notes.
 6

3 Stability and retention

Chapter 3 Stability and retention

Figure 3.1 Stability and retention

Stability Retention

• Resistance to horizontal displacement • Resistance to displacement in an axial

or rotation when fully seated direction from the fully-seated position

Stability is enhanced by: Retention is enhanced by:

• Covering the full denture bearing area • Covering the full denture bearing area
• Respecting the neutral zone • Developing a border seal (completes)
• Engaging the full functional sulcal depth • Employing clasps (partials)
• Employing hard and soft tissue support • Employing precision attachments

Base extensions

• Engaging the full denture bearing area improves bracing against the bony anatomy and improves stability

Poor extension Optimised extension

A lower surface
contact area
reduces the effects
of cohesion and
adhesion and
compromises Posterior extension
retention on the lower
significantly improves
antero-posterior
stability

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
S
tability and retention are fundamental principles for the demonstrates both stability and retention. The key here is that 7
construction of removable prostheses  – consequently, the prosthesis covers the full denture bearing area – and accom-
problems with retention and stability often underpin the modates functional movements within the periphery – the func-

Chapter 3 Stability and retention

patient’s perception of the prostheses. tional sulcus.
We will revisit the full anatomy of the maxillary and
mandibular denture bearing areas (DBA) later  – but some
Stability important anatomical and functional considerations for stability
This can be defined as the resistance to horizontal displacement include:
or rotation – in complete dentures, or around large saddles, this • The form of the edentulous ridge and palate
is often determined by the underlying anatomy and ridge form; • The degree of support offered by the ridges
this is primarily assessed in terms of the cross-sectional profile • The position of the polished surfaces in relation to the neutral
of the ridge, and how much support the ridge is able to provide zone (Chapter 24)
before it distorts or displaces. • The degree to which the maxillary tuberosities are fully
From time to time you will notice ridges that present with captured
fibrous aspects, which have a tendency to displace on palpation • The degree to which the disto-lingual anatomy is captured
and loading. You may notice these presentations being referred Patients tend to learn how to improve the stability of dentures
to as flabby ridges, but this expression is not so well received by improving muscle tone, tongue control and chewing habits.
with patients! Fibrous elements can affect the whole aspect of the Whilst edentulous patients often have a habit of improving
ridge, or just the crestal tissues. The impact this has on denture retention by holding dentures up with the posterior dorsum of
stability will be determined by which anatomical features are the tongue, this appears to be a very patient-specific skill.
affected and is discussed further in Chapter 17. Important anatomical aspects for retention include:
When considering shorter or bounded saddles, elements • Full coverage of the DBA
of stability will be derived from the way in which the denture • Developing an adequate border seal
base contacts the hard tissues (either acrylic or cobalt chrome) ■■ Fully capture the maxillary tuberosities
and engages undercuts. This is largely determined by the ‘path ■■ Fully capture the lingual anatomy
of insertion’ (POI) and is discussed further in Chapter 32. To ■■ Accounting for the insertion of buccinators into the retro-
a degree, the stability of the prosthesis is therefore dependent molar pad
on how effectively the neighbouring teeth can support lateral • Ensuring that the denture is adequately extended, but not
loading. This is known as ‘bracing’. If there is inadequate overextended, in function
bony support for the abutment teeth then they will also move Whilst the DBA and its extensions are very important, the
pathologically, and cause denture instability. This will cause position of the teeth is also critical, particularly in relation to the
further damage, possibly resulting in secondary occlusal trauma. labio-lingual position of incisors on a lower complete denture.
These aspects will be discussed further, later in the book, in The concept of the neutral zone is very important and this will
relation to partial denture planning. also be discussed later in Chapter 24. As well as the neutral
zone, and impressions to record it, there are other prosthodontic
techniques that can be employed to overcome challenges with
Retention fibrous ridges – such as:
This can be defined as the ability of the prosthesis to withstand • The RPI design principle
removal in an axial direction – with complete dentures or areas • The Altered Cast technique
over large saddles, this is often determined by the degree of • Various mucostatic or mucocompressive impression tech-
coverage (employing cohesive and adhesive contact forces) niques
and whether a border seal can be achieved. It is also important These will be discussed further later in the book.
to consider the extensions of the prosthesis when assessing
retention – whilst the prosthesis might be stable when fully
seated, overextension may cause a lack of retention in func- The gag reflex
tion, as the functional sulcus shortens and displaces the denture This is discussed in more detail in Chapter 46 – however, it is
base. When considering partial dentures and implant-supported worth mentioning at this early stage that the vast majority of
overdentures (ISOD), retention becomes a much more active patients presenting with a gag reflex are anticipating movement
concept, through the use of direct clasps and retentive abutments. or loss of retention of their prosthesis. It may be that their cur-
ISODs are considered further in Chapter 41. rent prosthesis is stable and retentive – however, most often I
find that this is not the case. It is important to take the time to
explain to patients that the best outcome is achieved if a stable
Stability vs retention and retentive denture is created first, which can then be used as
I am often asked whether a denture can be stable yet unreten- a predictable tool for overcoming a gag reflex. Even in patients
tive – and vice versa. The simple answer is yes – to both. The where counselling is required in order to overcome psychosocial
technical challenge comes in ensuring that the prosthesis triggers, a well-fitting prosthesis is necessarily the starting point.
 Patient assessment for complete
8

4
Chapter 4 Patient assessment for complete dentures

dentures
Figure 4.1 Assessing the edentulous patient

Presence of
retained roots
or pathology

Assessing the
intra-oral access
Signs of
temporomandibular Presence of
joint dysfunction angular cheilitis
or candidosis

Lateral tongue
spread and
Gag reflex when Signs of a activity
the denture bearing dry mouth
area or posterior
tongue are palpated

Why not visit the example complete denture assessment sheet in Appendix 1?

Assessing edentulous ridges

Here, the maxillary

arch is used as an
example

Immediately Well-rounded Knife-edge Flat Depressed

post extraction ridge form ridge form ridge form ridge form,
with some
basalar
loss evident

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
A
rguably one of the most important elements of your patient • Tori or significantly undercut ridges – If present will these inter- 9
assessment, is about taking the time to understand what the fere with the denture extensions or path of insertion?
patient wants and why. It is also about making a judgement • Retained roots  – Could these be retained as overdenture

Chapter 4 Patient assessment for complete dentures

about how likely you are to succeed with your endeavours – there abutments?
are a number of risk factors that can alter your chances of suc- • Any suspicious lesions, particularly for at-risk patients, that
cess and these should be discussed and recorded before the should be investigated or monitored alongside treatment?
active elements of treatment begin. The majority of these factors
are outlined below, largely as bullet point questions, but please
do visit the recommended reading section for details of other Ridge assessment
academic texts which explore some of these concepts in further Manual palpation is very important in order to assess the ridges
detail. Please also see the sample Complete Denture Assessment adequately. This includes the ridge form (Figure 4.1) (well-
Proforma in Appendix 1. formed, atrophic, rounded, flat, knife-edge, fibrous, undercut)
and the proximity of the frenal attachments to the crest of the
ridges.
The patient and the rationale for
treatment
• Why does the patient want new or improved dentures? Assessment of existing prostheses
• Is there any difficulty chewing or speaking? The stability (resistance to horizontal or rotational displace-
• Do the dentures cause pain or nausea? ment when fully seated) and retention (resistance to vertical
• Do the dentures cause gagging, and if so, is it immediate? displacement) of each prosthesis should be assessed in turn. It
• Are the dentures of a satisfactory appearance? is easier to do this individually rather than having both pros-
• Have any of these problems got worse recently? theses in at the same time. The upper should be seated from in
front of the patient, and whilst holding the molar units, should
be rotated in a horizontal plane. It can then be displaced verti-
Prosthodontic history cally, ensuring that the patient is not holding the denture in
• What type of denture is the patient currently wearing? place with their tongue, to assess retention. The lower should
• How old is the prosthesis and where was it/they made? also be seated from in front of the patient, ideally with the
• For how many years has the patient been edentulous? patient in a seated position. Stability can be assessed as above,
• How many prostheses has the patient received before? but also in an antero-posterior direction by pinching the lower
• Is the patient willing to attend for the necessary appointments, incisors between thumb and forefinger and moving the den-
including review appointments? ture lingually and labially.
The denture extensions should then be considered – labial,
buccal and posterior aspects – but also coverage of the tuberosi-
Clinical examination ties on the upper and disto-lingual extension on the lower. The
Before considering removable complete prostheses, it is impor- anatomy of the denture-bearing area is considered in Chapter 10.
tant to carry out a full and comprehensive extra- and intraoral It is important to assess the extensions systematically to look
assessment. The following aspects can then be considered for under- or overextension. Direct vision is possible for the
(Figure 4.1). lower but it can be more challenging on the upper. Retracting
• Intraoral access – Can the full denture-bearing anatomy be pal- the sulcus with your index finger parallel to the arch means
pated easily, and can the existing prostheses be easily inserted that as you seat the denture, you can feel whether the sulcus is
and removed from the mouth? ‘pulled in’ towards the prosthesis. If this is the case, the denture
• Tongue – Does this occupy a normal space, or does it exhibit is overextended in this area. It is also possible to take a wash
lateral spread? Is there a habit of using the tongue to retain the impression in silicone or alginate to assess the denture exten-
upper denture posteriorly? sions at this stage.
• Gag reflex – Can the full denture-bearing area be palpated In terms of aesthetics – lip support, incisal plane and buccal
without eliciting a gag reflex? If not, where are the trigger zones? space should be noted. These are considered further in Chapter 20.
These are most often the dorsum of the tongue, or the posterior Finally, in relation to the occlusion, it is important to note
palate. whether the intercuspal position is stable and whether there
• Ulceration – Are there any existing signs of ulceration, and do are any heavy contacts. Is the intercuspal position coincident
they correspond to the extensions of a prosthesis? with the retruded arc of closure – and if not, what are the char-
• Temporomandibular disorder (TMD) – Are there currently acteristics of the slide? Finally, assessment should be made of
any signs of muscle pain or temporomandibular joint (TMJ) the freeway space between the dentures – although at this stage
derangement? an estimate can be made by listening to the ‘speaking space’
• Candidosis and angular cheilitis – How old are the prosthe- available – sibilant sounds will sound sharp and whistle-like if the
ses and what is the patient’s current hygiene regime? Does the freeway space is restricted, and hollow or absent, if it is excessive.
patient seem to be over-closed? Is there a high carbohydrate At this point, a diagnosis can be made with a suitable prog-
intake throughout the day, nutritional deficiency or a dry mouth? nosis (and justification), and your patient’s expectations can be
• Dry mouth – Does the patient complain of a dry mouth? Is this discussed in an informed way. A treatment plan can be devised
medication-induced? You can grade a dry mouth using the Chal- relating to the fitting surface, the occlusal surface and aesthetics
lacombe scale (see recommended reading). (polished surfaces).
 10

5 Edentulous ridge presentations

Chapter 5 Edentulous ridge presentations

Figure 5.1 Edentulous ridge presentations

1 2

3 4

5 6

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
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T
he photographs opposite show a range of edentulous ridge existing denture, which is short by at least 15 mm. It is also pos- 11
presentations. Whilst the range shown is by no means exhaus- sible to see the limited degree to which the denture base wraps
tive, each photograph presents a number of interesting points around the tuberosities. Both of these features will significantly

Chapter 5 Edentulous ridge presentations

for consideration when planning a removable prosthesis. compromise the stability and retention, and perpetuate the gag
reflex. A thin band of tissue exists along the crest of the ridge
from incisor to premolar on the patient’s right-hand side, and
Upper edentulous ridges this should be accounted for in the working impression; in order
to avoid the denture ‘nipping’ the tissues, the impression should
Photograph 1 be taken in zinc oxide eugenol, and the borders of the thin tissue
Intraoral access here is good and the full denture-bearing area ridge should be filleted away with a scalpel. Once again, the labial
(DBA) can be palpated without any pain or gagging. The mucosa portion of the anterior ridge presents with a significant under-
looks moist and there are no signs clinically of a dry mouth. The cut and it is worth considering at the assessment stage whether a
ridge is well formed with high and rounded ridges – and this defined path of insertion is possible, or whether the permanent
would be classified as Class III (Cawood and Howell). A retained base should be modified with permanent soft liner to allow the
root has recently been extracted from the UL5 and this presents ridge to be atraumatically engaged.
as a crestal defect. The prominent incisive papilla is erythema-
tous and this is a sign that it may need a degree of relief in order
to prevent recurrent trauma. There is a slight buccal defect to Lower edentulous ridges
the ridge on the left-hand side and the muscle attachment here
inserts into the base of the sulcus. Paradoxically it can be easier Photograph 4
to account for high muscle insertions than lower ones – and so The full DBA can be palpated without any pain, although con-
this area would receive particular attention during the working tact with the posterior lateral borders of the tongue elicits a
impression. It is possible to see the posterior extent of the exist- gag reflex. The ridge is atrophic with a knife edge presenta-
ing denture, which is short of the fovea palatini by at least 10 mm. tion (Class IV). A thin fibrous band of tissue runs along the
It is also possible to see the limited degree to which the denture entire crest of the ridge – and this should be accounted for in
base wraps around the tuberosity on the right-hand side – and the working impression; in order to avoid the denture ‘nip-
this can be improved during the working impression with a bor- ping’ the tissues, the impression should be taken in zinc oxide
der moulding material to ensure that its full anatomy is captured. eugenol, and the borders of the thin tissue ridge should be
filleted away with a scalpel. Muscle attachments are low and
Photograph 2 there is only a moderate sulcal depth anteriorly when the lip
Intraoral access here is slightly restricted. The full DBA can be is retracted. The tray will need to be carefully adjusted here to
palpated without pain or gagging. The mucosa looks shiny and ensure it is not overextended.
dry, and clinically there are signs of a dry mouth; the mirrors
stick to the mucosa, and food debris accumulates at the denture Photograph 5
borders. It may be necessary for the patient to consider a saliva The full DBA can be palpated here without eliciting pain or a
substitute in order to promote effective adhesion and cohesion, gag reflex. The tissues are fibrous anteriorly, and it is possible to
and a border seal. The ridge is well defined and rounded (Class see the folds of tissue in the photograph. The ridge is atrophic
III), but the sulcal depth reduces significantly towards the poste- (Class V) but presents with an identifiable fibrous crest. This
rior aspects. The palate is relatively shallow and broad – shallow is thicker than in photograph 4, and so is unlikely to fold over
ridges and a shallow palate mean that the denture may have a when the denture is seated. No special interventions are required
compromised stability. The muscle attachments insert onto the in that regard. There is little identifiable sulcus anteriorly and so
crest of the ridge – this is the other extreme of how attachments the tray will need to be carefully adjusted here – and it may even
may present. The challenge here is ensuring they are accom- be the case that a purposefully mucostatic or mucocompressive
modated for, without compromising the border seal. The labial impression (depending on the assessment) is taken to account
portion of the anterior ridge presents with a significant under- for the anterior fibrous tissue. Ulceration is visible in the buccal
cut and it is worth considering at the assessment stage whether a and labial sulci, and it is important to ensure that this is resolved
defined path of insertion is possible, or whether the permanent prior to working impressions.
base should be modified with permanent soft liner to allow the
ridge to be atraumatically engaged. Photograph 6
The full DBA can be palpated without pain or gagging. The ridge
Photograph 3 is firm, well formed and generally rounded at the crest – although
Intraoral access here is excellent. Palpation of the DBA in the there are undercut aspects around the buccal aspect. This would
palate beyond the posterior border of the existing prosthesis be graded as Class IV. Muscle attachments are relatively low and
results in a gag reflex. There is no pain on palpation. The ridge there appears to be a reasonable depth to the labial sulcus. Avoid
is well formed (Class III) but lacks some definition in the pre- thinking that these cases are straightforward to treat – it is some-
molar regions, where it presents with a knife edge (Class IV). times the case with well-formed ridges that they pose problems
Once again, muscle attachments are situated near the base of in terms of ridge pain after fitting of the dentures.
the sulcus, so attention to detail during the working impression
will be important. It is possible to see the posterior extent of the
 Patient assessment for partial
12

6
Chapter 6 Patient assessment for partial dentures

dentures
Figure 6.1 Patient assessment for partial dentures

Patient history

Primary impressions
• Accurate, well extended
• Material supported by the tray
• Full sulcal recording
• Free from air blows, drags or tears

Articulated casts
• Accurate articulation either in
intercuspal position or at an
increased occlusal vertical
Assessment process

dimension

• For notes on accurate

preliminary registration
see chapters 19 and 29

Periodontal assessment

Basic periodontal Radiographic

examination (BPE) assessment of: • Bony support for abutment teeth • Look out for crestal
or 6 point pocket chart funnelling, indicative
• Root angulation of abutment teeth
+ mobility scores of occlusive trauma
• Pathology around abutment teeth

Preliminary restorative work Consider:

• Additions to worn teeth
• Provision or replacement of
extra coronal restoration
• Extractions of roots
Preliminary designs

Marking teeth that are unable

to support axial loads, can help
you to design the partial denture
more efficiently

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
A
n assessment for a partial prosthesis begins in much the • Temporomandibular disorder – Are there currently any signs of 13
same way as for a complete denture – why does the patient muscle pain or temporomandibular joint derangement?
want the treatment, and what are the risk factors that can • Dry mouth – Does the patient complain of a dry mouth? Is this

Chapter 6 Patient assessment for partial dentures

alter your chances of success? The main obvious difference, how- medication-induced? A dry mouth will significantly increase the
ever, is the presence of standing natural teeth. The health and risk of root caries and gingivitis when wearing a partial denture.
prognosis for these teeth must be adequately assessed in order • Retained roots  – 
Could these be retained as overdenture
to plan the treatment effectively for removable partial prosthe- abutments and what is the space between root surface and
ses – and whilst the method of partial denture design will be cov- opposing tooth? Do not forget that healthy retained roots
ered later, the necessary clinical information and indices will be will prevent alveolar resorption, improve proprioception and
mentioned here as part of the initial assessment stage. chewing ability. Further, there is a large psychological benefit to
retaining natural teeth and tooth roots.
• Worn or compromised teeth – Could worn teeth be restored
The patient and the rationale for treatment directly or indirectly prior to the provision of removable
• Why does the patient want new or improved dentures? prostheses? Could the removable prosthesis overlay the worn
• Do the current dentures cause pain? teeth to restore their form and function? Can an extra coronal
• Is there any difficulty chewing or speaking? restoration be placed with elements that will facilitate partial
• Are the dentures of a satisfactory appearance? denture stability and retention, such as milled shoulders,
rest seats and guide planes. These are questions that are often
overlooked when planning removable partial prostheses and will
Prosthodontic history be discussed further later in the book.
• What type of denture is the patient currently wearing?
• How old is the prosthesis and where was it/they made?
• For how many years has the patient been wearing partial Ridge assessment
dentures? Ridge form may be less critical with removable partial dentures,
• How many prostheses has the patient received before? particularly if there are bounded saddles – but atrophic ridges
• Is the patient willing to attend for the necessary appointments, and thin fibrous bands of tissues should still be noted, because
including review appointments? these can cause problems, especially with free-end saddle
presentations.

Clinical examination
Before considering removable partial prostheses, it is important Partial denture classification
to carry out a full and comprehensive extra- and intraoral assess- In relation to ridge and saddle configuration, it is important to
ment. The following aspects can then be considered. be able to communicate the type of partial denture effectively
• Intraoral access – Can the denture-bearing anatomy be pal- to colleagues and the wider dental team. Chapter 28 describes
pated easily, and can any existing prostheses be easily inserted the Kennedy partial denture classification system, which is
and removed from the mouth? probably the most ubiquitous. It is also very important to decide
• Plaque control – Wearing removable partial dentures in the whether you will maintain the natural tooth contacts in the
presence of poor plaque control poses a significant risk to the current intercuspal position, or whether you will be changing
dentition, for the progression of root caries and soft tissue dis- (or reorganising) the occlusion. It will not be possible to plan
ease. If the basic periodontal examination (BPE) codes are any- or design a partial denture effectively without deciding this first.
thing but 0, you should be carrying out at least a plaque score and This is covered further in Chapter 23.
providing tailored oral hygiene instruction.
• Tooth mobility and periodontal pocket depths – Whether teeth
are pathologically mobile or present with deep bleeding pock- Assessment of existing prostheses
ets is often overlooked during a partial denture assessment. It is Partial dentures should be assessed in the same way as for
often assumed that the expected future loss of teeth warrants an complete dentures in relation to retention and stability. It is,
acrylic partial denture – in reality, it is important to determine however, also important to appraise the connector design, and
which teeth might be capable of helping to support a removable the path of insertion, even if the dentures are made totally in
partial denture down their long axis, and use them accordingly. acrylic. Material choice and connectors are discussed later in
Teeth may also present with mobility because of occlusal trauma, Chapters 28 and 31.
especially if there is a lack of posterior support. This is unlikely
to improve without the provision of a removable prosthesis to
replace posterior units. Radiographic assessment
• Gag reflex – Can the denture-bearing area and connector sites As well as a thorough periodontal and restorative assessment, it
be palpated without eliciting a gag reflex? If not, where are the is important to assess potential abutment teeth radiographically
trigger zones? These are most often the dorsum of the tongue, or for any potential periapical pathology and to assess the bony sup-
the posterior palate. port available. It is also important to assess the angulation of the
• Ulceration – Are there any existing signs of ulceration, and do long axis of the tooth. Non-axially loading a tooth can exacerbate
they correspond to the extensions of a prosthesis? occlusal trauma and bony loss.
 14

7 Factors complicating success

Chapter 7 Factors complicating success

Figure 7.1 Factors complicating success

Prognosis and justification

Diagnosis and treatment options Patient choice with informed consent
Risk factors for removable
for success prostheses

Patient factors Clinical factors Technical factors

? Confusion or uncertainty Restricted intra oral access Ask/Listen Poor communication

Perceived pain over the full

denture bearing area, or Dry mouth Suboptimal clinical
persistent pain or technical work

! Immediate intolerance
Hyperactive tongue
or lateral spread
Damage to work
in transit

Multiple consecutive sets Gag reflex

Lack of experience wearing Ulceration (especially if medication-induced)

removable prostheses

Ψ
History of non perseverance, Superficial nerves due to advanced resorption
anxiety or depression

Poor neuromuscular control Atypical facial pain

or dexterity

Tori impeding extensions or path of insertion

Large discrepancy between intercuspal position

and retruded arc of closure

Ability of the patient to sit upright in the dental chair

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
Prognosis and justification must be informed that the acclimatisation process will necessar-
ily be longer. It also makes prescribing the tooth positions and
15
Each diagnosis and treatment plan should be qualified with
the vertical dimension more challenging.

Chapter 7 Factors complicating success

a prognosis – an indication of the likely outcome of the condi-
• History of non-perseverance – If patients are unable or unwill-
tion, or the proposed treatment. Without this information, the
patient is unable to make an informed choice about which treat- ing to persevere in order to overcome minor problems with their
ment modality to pursue – and so it is important to remember prostheses, then it is likely that the prognosis will be significantly
to discuss this and record the discussions within the patient affected.
• Poor neuromuscular control or dexterity – If the patient has suf-
notes. Just as important as the prognosis is the justification for
how this decision is reached. A comprehensive and thoroughly fered a stroke, or has been diagnosed with Parkinson’s disease or
recorded assessment will facilitate this process. The factors below other neuromuscular disorders, then the prognosis will be sig-
are considered to be risk factors when constructing removable nificantly affected.
prostheses (Figure 7.2).
Clinical factors
The following clinical factors can significantly compromise the
Risk factors outcome of denture provision:
• Restricted intraoral access
Patient factors • Dry mouth
• Patient confusion or uncertainty – If patients are unsure about • Widespread or significant ulceration (especially if the patient
why they are receiving a prosthesis, or they feel that there is lit- is taking nicorandil)
tle need, then they are less likely to wear the finished product. • A gag reflex when the DBA is palpated
You must be clear about what your treatment aims are, and this • Obvious hyperactivity of the tongue or lateral tongue spread
should be checked and reinforced at each patient appointment. • Superficial mental nerves causing pain on palpation
• Pain over the full denture-bearing area (DBA) – An ache or a • Significant tori that will impede extension or full seating of a
burning sensation over the entire DBA (on either arch) can be prosthesis
difficult to diagnose accurately and manage. This may happen • A large discrepancy between the current intercuspal position
if the occlusal vertical dimension is excessive, meaning that the and the retruded arc of closure
denture bearing area is perpetually overloaded. Leaving one or • Problems or difficulties with the patient’s ability to sit upright
both dentures out can help to confirm the diagnosis. This type in a dental chair
of pain can also present if there is an allergy or an intolerance
to materials in the denture base. If this is suspected, it will be Ridge anatomy
important to send the patient for patch testing for sensitivity to It is generally accepted that an atrophic ridge means that the
denture-base materials. prognosis will be affected, especially on the lower arch. In these
• Immediate intolerance –  It is always a concern when the patient
cases, more attention needs to be paid to accurate extensions,
is unable to retain a prosthesis in the mouth for any time at all. functional border moulding and tooth position. However, it is
Occasionally this may be because of acute trauma from the pros- often assumed that high and rounded ridges means a high chance
theses, making fully seating them painful. However, it is often of ‘success’ – but be careful – patients with ridges of this type
the case that patients are reluctant to insert their prostheses – and often present with pain on the crest of the ridge. Ridges should
begin to reject them before they are even fully inserted into the also be inspected for the height of the muscle attachments – are
mouth. This rejection may also be accompanied with a gag reflex, they near the crest of the ridge (which means you need to be
which is discussed further below. There are often psychosocial very careful to accommodate them in function) or are they low
problems that will complicate the acceptance of a removable or absent? Also look for significant ridge undercuts, which may
prosthesis and it is important that the patient feels comfortable mean that you need to consider a specific path of insertion, or
enough to highlight any concerns. You must also be sensitive even pre-prosthetic surgery.
to the fact that some patients may have experienced traumatic
events in the past that have manifested as oral intolerances. Be
prepared on some occasions to refer patients, via their general
Technical factors
Poor communication with the laboratory means that technical
practitioner, for counselling.
• Received multiple consecutive sets – Patients that present with aspects may be suboptimal. Make it clear on your communica-
tions to the laboratory why you are making the prostheses and
a bag full of previous dentures should be assessed very carefully.
ask the technician to contact you if they encounter any problems
The previously failed prostheses are usually a warning sign that
or suboptimal clinical work.
risk factors have been missed – it is also often the case that patient
Ultimately, success is compromised by poor communication
expectations have been mismanaged. In this case, just assess the
between operator, patient and technician – be honest about your
set of dentures that the patient prefers or wears most frequently.
• Lack of recent prosthetic experience – Patients presenting with- likelihood of success and document the discussions carefully in
the patient notes.
out any dentures, or who have not been wearing any recently,
 16

8 Accessibility and operator position

Chapter 8 Accessibility and operator position

Figure 8.1 Accessibility and operator position

Upper arch

• Straight back behind the patient

• Allows stability of posture

• Allows support for the patient’s head

• Allows control of the mandible and

peri-oral area

• Allows correct manipulation and

seating of the trays

Tray handles

• Control

• Orientation

• Allow material
to fully engage
relevant holes
and grooves

Lower arch

• Sitting or standing in front of the patient

• Straight back

• Allows correct manipulation and seating

of the trays

• Allows optimal field of direct vision

• Improves inter-arch visibility, especially

posteriorly

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Companion Website: www.wiley.com/go/field/removable
S
uccessful clinical stages during prosthetic treatment are not • Allows you to palpate and inspect the full upper denture-bearing 17
just dependent on your technical ability. The previous chap- area
ter talked about how limited intraoral access, or the inability • Facilitates the correct manipulation and seating of trays

Chapter 8 Accessibility and operator position

of the patient to sit in your dental chair, are risk factors for fail- because of a greater range of wrist movements (trying to fully
ure. However, it is equally as important to consider your posture seat an upper tray, posterior aspect first, from in front of the
and operating position. patient is incredibly difficult)

Posture and operating position Lower arches

It is easy to forget your posture when you are concentrating on a In most cases we would recommend making impressions of the
clinical stage. Some types of saddle seat, or wearing loupes, can lower arch from in front of the patient, with the patient sitting
help to reinforce a good posture – however, with the exception upright (Figure 8.2). Most dental chairs become narrower half-
of tooth preparations, we would recommend carrying out each way down, and this is a good place to position yourself. Ensure
prosthodontic clinic stage in a standing position. you have a straight back, rather than allowing yourself to bend
Maintaining a dynamic position around the patient means over forwards. One of the aspects of lower special trays that is
that you are less likely to strain your neck or back, and more likely most poorly extended and adapted is the labial extension. This
to move into an appropriate position. This will ensure that your is often because operators are sitting behind the patient when
back and neck will remain healthy, and your operative dental assessing this area, which results in inappropriate manipula-
career will be more sustainable! Aside from your own health, it tion of the lower lip. Once again, your arms should not be
is also more comfortable for patients to have impressions taken raised – instead, they should adopt a similar position to that
when they are sitting upright rather than in the supine position. described for an upper arch position. Dental chairs tend to need
to be lowered considerably to achieve this position. However, it
is also useful for the following reasons:
Move yourself, and the patient • Facilitates the correct manipulation and seating of trays
A dynamic operating position means that you are able to move because of a greater range of wrist movements
yourself around the patient, but that you are also moving the • Field of view is not blocked by the facial anatomy, which causes
patient into an appropriate position. Typically as dentists we operators behind the patient to lean forwards
are good at neither, often staying around the 12 o’clock operator • Encourages a straight back
position. It is very important to make sure that you are comfort- • Improves interarch visibility for assessing occlusal relation-
able first, before considering how you can then move the patient ships, facial aesthetics and speech
to optimise your field of view or operative control. This may
mean moving the patient up or down in the chair, retroclining
the patient or simply turning their head to either side. Ensure Control of the prostheses and trays
that wherever possible you maintain a straight back, straight It is very important that you take control of inserting and remov-
neck and direct vision of the operative area. ing impression trays, and the patient’s prostheses. When you
insert and remove prostheses, you are able to look closely at the
way in which the extensions and fitting surface engage with the
Upper arches tissues, and check paths of insertion. You are also able to apply
Typically we would recommend operating from behind the appropriate pressure to certain areas in order to check stability
patient when working on impressions for the upper arch or painful trigger points. If the patient continually removes and
(Figure 8.1). You should stand with the top of the patient’s head inserts their prostheses, then they often take the opportunity to
at the level of your non-dominant elbow. Do not stand immedi- displace them in fairly imaginative ways – and it is these par-
ately behind the patient – instead, imagine that you are holding afunctional habits that you will spend much of your time coun-
the patient’s head like a rugby ball, or that you are getting them selling them against. Further, in relation to impressions – never
into a ‘head lock’ – so slightly to the side. When your hands meet leave an impression in the patient’s mouth without being in
in front of the patient’s mouth, your hands should be lower than full control. This means not letting go and performing another
your elbows. Imagine water running down your arms, and off task – and handles are critically important in ensuring control,
your little fingertips – the ‘first position’ in ballet. This position tray orientation and efficient and effective removal.
serves a multitude of functions:
• Ensures that you are able to stand with a straight back
• Ensures stability of posture so that you can manipulate the Other considerations
patient confidently and securely Restricted access might mean that you need to use a syringe to
• Allows you to support the patient’s head with your non-dom- deliver material onto the denture-bearing anatomy and then
inant arm insert the tray as the carrier. When rotating trays into the mouth,
• Gives you control of the mandibular lower border, should you it is useful to ask the patient to ‘half close’ – and applying Vaseline
need to encourage the patient into a particular position to the corners of the mouth can avoid trauma to friable tissues.
• Gives you control of the perioral area (which is especially
useful if the patient has a habit of raising their hands to reach for
their mouth)
 18

9 Pre-prosthetic treatment
Chapter 9 Pre-prosthetic treatment

Figure 9.1 Pre-prosthetic treatment

Initial assessment

Management of
acute pain or sepsis
Pre-prosthetic planning and treatment

Periodontal and caries screening

Stabilise • Oral hygiene instruction
oral disease • Caries management
• Periodontal therapy
• Maintenance

• +/- surgical modification

Interim prostheses
• +/- implant planning of hard and soft tissues
if required

• +/- prosthesis design • +/- provision of precision

attachments or indirect
restorations that complement
a prosthesis design

Implant placement +/- tooth extraction

and integration and healing

Definitive prosthesis design, construction and delivery

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
W
hen embarking upon the provision of removable pros- should be instigated and suitably demonstrated by the clinician. 19
theses, it is important to assess the patient’s oral environ- If a code 4 persists (pocketing above 5.5 mm after plaque con-
ment comprehensively. Achieving a stable foundation is trol has been optimised and superficial inflammation resolved),

Chapter 9 Pre-prosthetic treatment

the bedrock upon which successful rehabilitation will be built. then full mouth 6-point pocket charting should be completed.
Castles cannot be built on sand. Pre-prosthetic treatment involves For persistent deep and bleeding pockets, a course of non-
the care that is delivered prior to the planning and delivery of surgical management should be undertaken, supported by regu-
prostheses (Figure 9.1). This may involve: lar full mouth disclosed plaque and bleeding scores. Subgingival
• Management of acute pain/sepsis instrumentation should utilise local anaesthesia to comfortably
• Stabilisation of any active oral disease including periodontal treat deeper and inflamed periodontal pockets, or where tooth
disease, caries, soft tissue conditions and neoplasia sensitivity causes patient distress. Ultrasonic debridement is rec-
• Surgical modification of hard and soft tissues to facilitate ommended for this as an effective and efficient method, whilst
retention and/or stability of the prosthesis preventing excessive cementum removal. The 6-point pocket
charting should be reassessed 2–3 months following treatment.
Generally, periodontal health may be assumed when bleeding
Extraoral assessment is at fewer than 10% of sites and pocket probing depths are no
A careful extraoral assessment can reveal the following features, greater than 4 mm, with no bleeding at the 4 mm deep sites.
which may impact on how and when you provide prosthetic During periodontal stabilisation treatment, the patient
rehabilitation: may need to have teeth extracted that are deemed of hopeless
• Facial asymmetries prognosis, especially if they present as lone standing and
• Skeletal class grade III mobile, have bone loss progressing towards the tooth
• Restrictions or trismus apex (or a true perio-endo lesion), or have been unresponsive
• Hypertrophy of muscles of mastication to periodontal treatment. During this stabilisation phase a
• Degree of mobility and dexterity temporary acrylic denture may need to be provided to restore
aesthetics and masticatory function, and to reduce occlusal
trauma on remaining tooth units. The prosthesis is likely to be
Edentulous patients entirely mucosa borne, and so care should be taken with the
Where the fully edentulous patient is concerned, the condition design to ensure that trauma at the gingival margins because of
of the soft tissues should be assessed and the architecture of the denture displacement is avoided. The contact points between the
bony hard and overlying soft tissues noted. This was discussed saddles and abutment teeth should be cleansable, and the patient
in Chapter 4 – however, it is important to note that significant should be counselled with respect to plaque control on the
undercuts, tori, or fibrous tissue may benefit from pre-prosthetic denture and on the abutment teeth. Even a well-polished acrylic
surgery. It may also be the case that muscle attachments may denture acts as a bacterial reservoir and it is for this reason that
need repositioning, vestibules surgically deepened, sharp ridges in short span rehabilitations, resin-bonded bridgework should
smoothed, keratinised tissues augmented and previous surgical be considered as an alternative in order to minimise plaque
sites debulked. The latter are often carried out in conjunction retention; this clearly depends on the quality of the abutment
with oral surgeons – and any pre-prosthetic surgery will need to teeth.
be consented and planned appropriately, with a suitable period Appropriate prevention with diet counselling, hygiene and
of healing prior to provision of the definitive prosthesis. Con- fluoride therapy should be instigated where the caries risk is
sideration should be given for how the patient will manage in raised. Where conservation work is required, this can also allow
the interim, either without a prosthesis in place, or by making for construction of restorations which aid the support and
modifications to existing ones. retention of the final removable partial denture. Restorations
(both direct and indirect) can be fabricated with rest seats,
guide planes, adequate bulbosities and precision elements to
Partially dentate patients aid the success of the denture. Accurate primary impressions
Where the partially dentate patient is concerned, additional and mounted study models are essential planning aids for
observations must be made around the condition of the remain- the prosthetic rehabilitation. Aesthetics can also be assessed
ing dentition including: and addressed at this stage, considering modifications such as
• Active dental disease (plaque control, caries and periodontal composite augmentation to correct tooth dimensions and paths
health) of insertion for minimising dead spaces.
• Type of occlusion including any evidence of bruxism or
parafunction
• Limitations caused by drifted, overerupted and tilted teeth Implants
• Endodontic status of teeth Implants may well form part of definitive pre-prosthodontic
• Status of any existing direct or indirect restorations treatment. Restoratively driven assessment, case selection and
planning are essential in order to maximise success. Following
the stabilisation of existing oral disease, an optimised prosthesis
Periodontal disease and caries should be constructed in order to assess aesthetic and functional
Where teeth have been lost because of periodontal disease, a acceptability and define the ideal prosthetic envelope. This
thorough assessment of periodontal health including a basic can help to plan the implant positions and trajectories. The
periodontal examination (BPE) should be carried out. When restoration of two mandibular parasymphyseal implants with
a code 3 or 4 presents, a personalised prevention programme overdenture abutments is discussed in Chapter 41.
 20

10 Revisiting the anatomy

Chapter 10 Revisiting the anatomy

Figure 10.1 Revisiting the anatomy

Denture bearing areas Muscular anatomy

Labial frenum
Retromolar
Temporalis pad

Masseter
Buccal
frenum Buccinator
Vibrating line
– posterior
border of Superior
denture constrictor

Medial
! pterygoid

Restricted sulcus
width resulting Glandular triangle
Fovea Palatini from movement Mylohyoid (no muscle – relates to
of the coronoid retromylohyoid fossa)

! Hamular notch process Overextension into the lingual

sulcus will cause displacement
– but over-extension into the
glandular triangle will cause
pain too

Labial frenum

!
Constriction Buccal Medial
due to Masseter pterygoid
frenum
modiolus
Mylohyoid
Lingual ridge
External frenum
Superior
oblique constrictor
ridge Pear-shaped
pad

!
!
Mylohyoid Mylohyoid
contraction area

!
Retromylohyoid
Retromolar
pad Buccinator

fossa

! Often poorly recorded

anatomical site

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I
t is very easy to forget the denture-bearing anatomy. In the end, • Potential lingual undercuts or mandibular tori 21
we tend to focus only on the ridge form, noting whether it is • The action of several relatively deep and complex muscles,
rounded, or flat and atrophic. Perhaps attention may also be which cannot be activated independently

Chapter 10 Revisiting the anatomy

paid to whether there are any fibrous (or flabby) aspects of the It is very important before you pick up a stock tray, or indeed
ridge (Chapter 17). a special tray, to remind yourself of the obvious limiting anatomy
In actual fact, there is a need to recall the full denture-bearing of the lower arch. Asking the patient to lift their tongue, gives an
and limiting anatomy – not least so the current status quo can immediate idea of tongue spread, frenal attachments and lingual
be accurately assessed – but clearly a working knowledge of sulcal depth. Asking the patient to relax the lower lip as you gently
the anatomy is important for obtaining accurate functional lift it upward to reveal the true functional sulcus depth is also
impressions. For this reason it is also important to be aware a very useful exercise. Often on atrophic ridges, virtually no
of muscle movements which allow the limiting anatomy to be functional sulcus remains. You should be mindful of this, when
accurately recorded – and these will be discussed further, below adjusting the special trays and taking the working impression.
(Figure 10.1). Gently reflecting the buccal mucosa around the entire arch can
give you a good visual representation of the ridge anatomy and
help to identify the external oblique ridge, which represents the
Upper arch main bearing area of the lower denture. Palpating this area can
The upper arch is probably the simplest in terms of identifiable help too. Other limiting anatomy that is commonly unaccounted
anatomic structures – and yet many dentures that are constructed for is discussed below.
fail to respect much of the anatomy. Whilst most of us will cor-
rectly identify frenal attachments, it is important to consider Anterior limiting anatomy
whether these have a relatively high or a low attachment to the Aside from the labial sulcus discussed above, Modiolus is a
edentulous ridge. This will indicate how carefully you will need complex confluence of perioral muscles (buccinator, orbicularis
to adjust the special trays, and how significantly the finished den- oris, levator and depressor muscles, risorius, platysma and
ture base will deviate from the general sulcal depth in that area. zygomaticus major) that meet slightly lateral to the corner of the
Overextension around frenal attachments is still, however, very mouth. If activation of these muscles is not accounted for, then the
common. lower denture base can become perpetually antero-posteriorly
The fovea palatini sit, most frequently, around 3–4 mm and superficially displaced during speech, mastication and facial
posterior to the vibrating line (the junction between the hard and expression. It is an extremely variable piece of anatomy and so
soft palate). It is important to identify this junction, because this asking patients to employ certain movements is the best way to
marks the optimal posterior border of the upper denture. We will record this limiting anatomy. This will be discussed further in
discuss later the technical importance of the vibrating line and Chapter 16.
how it aids in developing a border seal.
Two pieces of anatomy that are very frequently neglected are: Posterior limiting anatomy
1 The restrictions created by the coronoid process when man- In order for a border seal to be established on the lower arch,
dibular excursions occur. Try placing your index finger in your it is necessary to account for the insertions of buccinators dis-
upper buccal sulcus and extend it along to the second molar. Try tally. Stock trays can indiscriminately overextend the special tray
moving your jaw left and right! It is necessary to encourage lateral buccally and so careful tray adjustment is advised. The lower
mandibular movements during the working impression in order denture should sit over the keratinised pear-shaped pad (repre-
to accurately record these restrictions, otherwise the patient will senting the scar tissue from the last standing molar) and up onto
experience pain, or dislodgement of the denture. the retromolar pad. Full coverage of the retromolar pad is not
2 The hamular notches, which represent the posterior border of
advised – primarily, because this tissue is only para-keratinised
the tuberosity joining the medial and lateral plates of the ptery- and glandular (and so it does not contribute significantly to den-
goid process. This is primarily because of the fact that materials ture stability) – but also because extension in this area can com-
chosen for working impressions are not supported sufficiently plicate later stages with heel clash of the denture bases.
by a well-extended tray. It is also necessary to encourage and
manipulate impression materials around the tuberosities and the
hamular notches in order to develop a strong border seal. This
Medial limiting anatomy
The lingual sulcus is notoriously difficult to respect  – 
and
will be covered later in Chapter 15.
extreme tongue movements can help to activate this anatomy.
In particular, palatoglossus is the only muscle that will elevate
Lower arch the posterior tongue and maintain the palatoglossal arch (which
retains saliva in the mouth) – this, and mylohyoid (which defines
The lower arch is often complicated by several factors:
• The tongue and its lateral spread and possible hyperactivity and reinforces the floor of the mouth), can only be activated by
• The challenge of defining the limited anatomy on an atrophic swallowing and speaking. Tongue movements that record the
ridge full limiting anatomy will be discussed in Chapter 16.
 Making a primary
22

11
Chapter 11 Making a primary impression – complete dentures

impression – complete dentures

Figure 11.1 Making a primary impression for partial dentures

Primary impression

Operator position Tray selection Impression material

(see chapter 8) and modification (see chapter 14)

Correct underextension

&

Reduce overextension

Original tray Trimmed tray

Impression materials

Alginate Putty Compound

Self-supporting
away from the tray
Thin unsupported On atrophic ridges, peak
Operator fingers material will up the material to prevent
have prevented distort when the tray periphery defining
engagement of poured up the border
material with
Overextension
retention holes
– tray showing
through

Retention with holes

and adhesive

Alginate and putty Compound

Mark the centre of the sulcus to help
• No specific equipment required • Requires a water bath for your technician design the trays
• Quick safe use

• Must record anatomy during the • Can be remoulded

setting time

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
T
he assumption is often made that primary impressions for some of these apparent problems. An initial impression is taken, 23
complete dentures do not really need to ‘do that much’. I which is then cut back at the periphery. A final wash impression
often hear people saying, ‘I’ll get a proper impression once is then taken, which allows the alginate to more reliably record

Chapter 11 Making a primary impression – complete dentures

my special tray comes back’. In fact, the primary impressions are distant anatomy. Whilst this is often true, there still tends to be a
one of the most critical stages of complete denture construction poor record of the full aspects of the tuberosities and the hamu-
and underpin the remainder of the clinical and technical stages. lar notches.
Primary impressions for complete dentures should: 2 Impression compound has been considered the gold standard
• Record the full denture-bearing area within teaching hospitals for many years, because it is thought
• Capture the functional sulcus depth to give the most predictable and stable impression and can be
• Ideally account for any limiting anatomy reliably disinfected. This material must be heated to 56 °C in
• Show no voids, drags or air blows order for it to reach its glass transition temperature. At this point
• Show no tears or detachment from the tray it is mouldable, but importantly it will also support itself inde-
• Be central in the tray with an even thickness of material pendently from the tray. It is possible to rewarm and remould
This will allow an accurate special tray to be made that requires compound several times and so this can be an excellent mate-
minimal adjustment and will record the anatomy in function. rial of choice for difficult cases. The drawback is that ideally a
Making the effort at this stage pays dividends later both in terms water-bath should be used in order to temper the material to
of accuracy and time. A good primary impression is influenced the correct temperature and to prevent it cooling down. Once a
by (i) operator position (already discussed in Chapter 8), (ii) the relatively thick amount of compound has cooled, it takes a dis-
tray and (iii) the impression material proportionately long time to warm it up again. The viscosity of
compound (in contrast to alginate) also means that it is common
to over-record relatively shallow sulci, such as the lower labial
Choice of tray segment. In this case, it is possible, after disinfection, to demar-
Most edentulous stock trays on the upper arch are a reasonable cate the sulcal anatomy so that the technician knows where to
starting point for primary impressions. Use the patient’s exist- extend the special trays (see Figure 11.1).
ing dentures as a guide in order to help select the correct size of 3 Silicone putty provides a happy medium, in my opinion (not
tray. The lower arch tends to be more problematic and using the laboratory putty, which is not licensed for intraoral use). Quick
existing denture as a guide (especially if they are underextended and easy to manipulate, clinical putty offers benefits common to
distally) will lead to inaccuracies. Atrophic ridges can further both compound and alginate. However, there is a defined work-
complicate using a lower stock tray – so do not be afraid to trim ing time, and once the material has set, it cannot easily be modi-
the trays before you begin (see Figure 11.1). Otherwise, the spe- fied. It does, however, provide a resilient and robust primary
cial trays will often come back very overextended in the labial impression, which can be poured-up with accuracy. Putty has a
and lingual sulcus and require significant adjustment. tendency to drag, and so it is important to encourage the putty
back up against the tray in areas where this is likely to happen,
such as around the tuberosities or the distal extensions of the
Material lower arch.
There is a lot of debate about which material provides the best
outcomes for primary impressions. If you are confident about
handling the material, and you have reasonably adapted trays, Lower arches
then it probably makes little difference – however, it is important Both compound and silicone putty allow the material to be ‘built-
to understand the limitations of the different available materials up’ in the tray prior to taking the impression (see Figure 11.1)
and to choose one that works best in your hands. The three main which can help to record the ridge and sulcal anatomy without
choices of material are discussed below. having to fully seat the tray. This means that the tray exten-
1 Alginate is a cheap and quick material to use. However, it is sions are less likely to over-record the limiting anatomy. It is
unable to support itself in thin section and is therefore poor at also tempting to ‘pinch’ the lower tray against the lower border
recording anatomy that is more than a few millimetres from of the mandible, between thumb and forefinger. However, you
the tray periphery. Typically, this means that distal aspects on should just use the tray handle to hold the tray in place, other-
the upper, and disto-lingual aspects on the lower, are poorly wise the material fails to engage the retentive slots or holes (see
recorded. Alginate is also easily displaced from the tray border, Figure 11.1); this approach also prevents the trays from digging
meaning that the material is more likely to begin to lift or peel into the lateral aspects of the ridges.
away from the tray. Finally, alginate is not stiff and is unable to If the arch is not central in the tray, or the ridges are too close
resist distortion when it is poured with plaster (which is heavy). to the tray edges, then you will feel resistance and assume that
Alginate that is not supported by a tray will distort, and you will the tray is fully seated, when it is not.
be none the wiser. If you have ever had a special tray that seems Finally, once the impression has been checked and disinfected,
to adapt to the ridge anteriorly, but has a larger discrepancy pos- you must inform the technician of your choice of wash material
teriorly, then that is most probably why. Some clinicians advocate so that the correct thickness of spacer is employed. This is
a two-stage alginate primary impression in order to overcome discussed further in Chapter 13.
 Making a primary impression – partial
24

12
Chapter 12 Making a primary impression – partial dentures

dentures

Figure 12.1 Making a primary impression for partial prostheses

Operator position (see chapter 8)

Primary impression Tray selection and modification

Impression material (see chapter 14)

Dentate trays Correct underextension

Support over edentulous saddles

to prevent tipping and help carry
impression material

Tray collapses Underextended

onto hard tissues
and edentulous
ridges

Tray extension
moves away
from sulcus

Putty or compound
in saddle areas then
seat the tray in the
mouth

Remove, trim back excess from the teeth,

apply adhesive and take wash impression

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
A
s described in Chapter 13, primary impressions underpin Whichever material is used to record the teeth, it is almost always 25
the remainder of the clinical and technical stages. A well- the case, especially with free-end saddles, or saddles greater than
made primary impression will ensure that the special tray about 2 cm, that a supportive material is required to effectively

Chapter 12 Making a primary impression – partial dentures

is well extended and that the prosthesis covers the full denture- stabilise the tray and carry wash material to the distant anatomy.
bearing area (DBA). This concept is often overlooked when tak- The main choices of supportive and impression material are dis-
ing impressions of partially dentate arches. This is especially the cussed below.
case when elements of direct retention are also employed, such as
denture clasps, implants and extracoronal attachments. In reality, Supportive materials
utilising the full DBA is equally as important in order to ensure Both impression compound and clinical putty provide excel-
that support is truly mucosa- and toothborne – and to avoid rely- lent support over edentulous saddles in partially dentate arches.
ing too heavily on mechanical elements, which will otherwise They also act effectively to extend the tray in free-end saddles
undoubtedly perish sooner. or around maxillary tuberosities, ensuring that the impression
Primary impressions for partially dentate arches should: material is not unsupported. The merits and drawbacks of each
• Record the full remaining dentition and DBA material are described in Chapter 14. Given that these materials
• Capture the functional sulcus depth act only to support a less viscous material, clinical putty tends
• Ideally account for any limiting anatomy to be the most practical solution. A small amount of putty is
• Show no voids, drags or air blows mixed and placed into the dentate tray over the edentulous areas
• Show no tears or detachment from the tray (Figure 12.1). The tray is seated for a moment whilst the putty
• Be central in the tray with an even thickness of material firms, taking care not to allow the tray bottom to touch the
occlusal or incisal surfaces. The tray is removed and putty that
has been in contact with the hard tissues is removed with a wax
Choice of tray knife or a scalpel. Once set, this can be retried in the mouth in
The recording of edentulous ridges in partially dentate patients order to practise fully seating the tray. The actual impression can
is complicated by the fact that we are forced to use dentate trays. then be taken over the top in order to record the dentate areas
There is significant potential with free-end saddles for trays to tip accurately.
onto the edentulous ridges if they are not supported – as the tray
rotates it complicates accurate recording of the lingual or labial Impression materials
sulcus. Further, dentate trays do not often reach the full DBA (see A number of materials can be used to take the definitive impres-
Figure 12.1). sion. These are outlined below. Regardless, a suitable adhesive
Conversely, dentate trays may occasionally need significant should be used to ensure that the impression material binds to
adjustment in order to account for displaced teeth, or particularly the supportive material and the exposed tray. At this point, it
shallow sulci. Take the time to ensure that the tray fits the arch is vital to ensure that the impression material is not overloaded
form. onto the tray. It is common for this to happen, but it means that
Sometimes a smaller tray is an adequate length, but just you will often fail to fully seat the tray – and in this circumstance
needs to be slightly wider. A larger tray is either difficult to you are essentially using an unmodified stock tray once again.
insert or extends too far posteriorly. In this case, it is possible to Remember that the impression material should be elastic, oth-
modify most commercial plastic/acrylic trays by heating in the erwise you will be unable to remove the impression from the
midline with a flame or hot air burner. Once warmed, the tray undercuts around the teeth. Zinc oxide eugenol is therefore con-
can be expanded before being cooled and retried in the mouth. traindicated in this situation.
Some commercial primary trays are designed to be heated and Alginate is a cheap, quick and effective material to use for this
modified, although this feature often attracts a premium price. purpose. If you notice large undercuts or multiple embrasure
Finally, inserting a loaded dentate tray into the mouth can spaces, then alginate will tend to tear. In these circumstances it is
be particularly challenging. They are inevitably deeper than the worth considering a more resilient material like silicone.
equivalent edentulous trays, and it is important to check that Silicones (light- or medium-bodied) are more expensive but
you are in a suitable operator position. The patient should be are more accurately applied to the impression tray. The working
relaxed and ‘half-close’ whilst you rotate the impression tray time is slightly longer, allowing you to ensure that the tray is fully
into the mouth. One hand should retract the soft tissue of the seated, and that you have time to carry out some basic functional
cheek whilst the other hand rotates the tray into the mouth on border moulding.
the opposite side. Do not begin to seat the tray until you are sure As always, once the impression has been checked and
that the antero-posterior position is correct. Seat the heels first, disinfected, you must prescribe your intended wash material
to ensure that excess material is displaced anteriorly along the for the working impression to the technician. This way, they can
sulcus, and keep the lip retracted until the tray is fully seated. employ the correct thickness of spacer when constructing the
special tray. This is discussed further in Chapter 13.
Material
The presence of teeth, and associated undercuts, limits the
choice of impression materials available for partial impressions.
26

13 Special trays
Chapter 13 Special trays

Figure 13.1 Special trays

Special trays • Should have the amount of spacer prescribed, with or without tissue stops

Tissue stops, particularly Close fit Classic spaced

useful in palate vault and
tuberosity
Zinc Oxide Eugenol (ZnOE) 0.8 mm
(for complete dentures only)

Light bodied silicone 1.0 mm

Spacer size
Medium bodied silicone (with
or without perforations) 2–3 mm

Alginate or polyether
• Appropriate thickness (with perforations) 3 mm
• Even thickness
• Supported by the tray

Extensions Handles

• Accuracy depends on the primary impressions • Stubbed, fins, or rests

• May require trimming
• Check in the mouth not on the casts

• Fin – easy to hold

but can interfere
with tissue moulding
2–3 mm
from
functional
sulcus

• Stub
• Vertical stubs are preferred in order
to prevent tissue restrictions during
border moulding

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Companion Website: www.wiley.com/go/field/removable
C
onstruction of a special (or custom) tray is often a cru- are fabricating them at the chairside, I would recommend 27
cial stage of the denture-making process. The special tray a relatively rigid material such as greenstick, impression
should allow relatively close adaptation to the full denture- compound or clinical putty. These should be fashioned by gently

Chapter 13 Special trays

bearing area, so that an accurate and functional impression can seating the tray in the mouth to the intended depth and then
be obtained. Of course, the extensions of the special tray are trimming back any excess material from the stops. Aim to place
dependent on the anatomy picked up in the primary impres- them in supportive areas, such as over ridges and in the palate.
sion; there is little point asking for a special tray to be made if
it will require significant modification at the chairside. The less
accurate the primary impression, the less ‘special or custom’ the Handles
subsequent tray can be. Tray handles should be designed and positioned so that you can
Ideally the special tray will allow an impression to be made adequately control the tray, whilst at the same time allowing free
which is sympathetic to the impression material, allowing a movement of the local soft tissues. A small, vertical handle, sit-
suitable and uniform thickness of material between the tray ting over the crest of the edentulous ridge, is often the best type.
and the denture-bearing anatomy. Tray extensions should sit Larger, broader handles can interfere with border moulding.
2–3 mm from the base of the functional sulcus – the methods to Sometimes auxiliary handles or handles in alternative
determine this will be discussed in Chapters 15 and 16. However, positions are added – this might be to allow pick-up impressions
tray extensions should not be assessed by sitting the tray on for implants, to allow windowing of a tray, or simply to provide
the primary cast. Regardless of how the tray is constructed or more even load distribution over the entire ridge. It is a good idea
adjusted, it should have smooth and rounded peripheries. A to inform the laboratory where you would like the handles to be
carbide acrylic bur (shaped like a gherkin) should be used to placed – especially if it deviates from your normal requirements.
adjust the periphery of trays (Figure 13.1).

Material retention and support

Materials As mentioned previously, it is incredibly important that pri-
Most special trays are constructed with sheets of light-cured resin mary and working impressions are fully supported by the tray,
or shellac, a thermoplastic material. Light-cured resin trays often otherwise the impression is likely to distort when poured with
present with an uncured surface layer (the oxygen-inhibited gypsum products, which are heavy. It is very difficult to deter-
layer), which should be removed by the laboratory prior to tray mine whether this has happened or not. That said, it is equally as
use. This uncured layer should not come into contact with soft important to ensure that impression materials do no peel away or
tissues. For this reason, it is also very important to wear gloves detach from the impression tray – otherwise pouring the models
when handling light-cured acrylic trays. When adjusting the will also create an invisible distortion. There are two main meth-
trays at the chairside, it is important to remember that acrylic ods to ensure that this detachment is minimised – (i) the use of
dust should be suctioned away immediately with a high-volume adhesives, and (ii) mechanical tray features (such as perforation
aspirator to ensure that it is not inhaled by those nearby – this is holes, slots or rim locks).
to avoid the risk of silicosis. Trimmed trays should also be rinsed • Adhesives – Often tray adhesives contain hazardous chemi-
in order to avoid the transfer of resin dust or unpolymerised resin cals such as xylenes, siloxanes and benzene – accordingly, trays
to the soft tissues. Whilst shellac does not create dust particulate, should be tried in the mouth, and adjusted, prior to adhesives
it often melts with the heat of the straight hand piece bur, which being applied. A thin and uniform coat should be applied, which
can be uncomfortable if it comes into near contact with skin. is then air-dried prior to application of the impression material.
It is important to ensure that the adhesive reaches the full periph-
ery of the tray, including sulcal extensions. A paper sheet under-
Tray spacers and tissue stops neath the tray can help to contain stray aerosol or drips from
Depending on your choice of impression material, the laboratory brush-based products. Cross-infection control is paramount.
may introduce a tray spacer between the cast and your special For brush-based products, these should be first dispensed into a
tray. This is routinely prescribed for relatively viscous materi- Dappen dish prior to application onto the tray.
als, and it ensures that hydrostatic pressure is minimised, whilst • Perforations – Perforations are often used for less close-fitting
allowing the material to flow across the full anatomical area. The trays, with materials such as alginate and medium or heavy-
following spacers are often prescribed: bodied silicones. This reduces further the hydrostatic pressure
• Zinc oxide eugenol (ZnOE) – 0.8 mm and facilitates full seating of the tray.
• Alginate – 3 mm
• Light-bodied silicone – 1 mm
• Medium-bodied silicone – 2–3 mm Full seating
Some laboratories leave no spacer at all for ZnOE. In this case, Regardless of the material used for the impression, it is impera-
it can be very useful to employ tissue stops. Tissue stops help to tive that special trays are not overloaded. You must ensure that
ensure an even thickness of impression material, by preventing they can be fully seated in order to achieve the required impres-
over-seating of the tray in any particular area (Figure 13.1). Tissue sion thickness, otherwise they fail to act as special trays, and they
stops can be fabricated by the laboratory, or at the chairside. It is are probably no better than a good primary impression.
easiest to ask the laboratory to create these for you, but if you
 Compound and putty
28

14
Chapter 14 Compound and putty materials – handling and manipulation

materials – handling and manipulation

Figure 14.1 Compound materials – handling and manipulation

Glass transition materials Compound + Greenstick

Waterbath Hot air blower Bunsen burner Hemmel torch

– necessary if warmed materials – useful for re-warming
are to be applied directly to localised areas of material
the mouth

• Greenstick can also be

• Warm gently and evenly until tacky and shiny. used to extend trays
At this point the material will stick posteriorly. No water bath
is required in this situation

• Warm further until softening begins.

Keep rotating the material
to ensure even heating

• Apply the material onto the tray border

in full thickness

• Once removed there is around

• Temper in the water bath 56°C 10-15 seconds of working time
for the mould in the mouth before
it cools

1 – Approach in sections 2 – Mould the distolingual of 3 – Encourage back around the 4 – Cut back excess from the
the lower tray with a swallow tuberosities on the upper arch fitting surface

Apply full thickness of greenstick

into tray borders Rewarm and repeat as necessary

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
I
t is important that you understand the full range of materials to warm the material first in water – it should be warmed in air 29
at your disposal, their strengths and limitations, and how to or a flame until it becomes shiny and tacky. Warm the material
employ them properly. Afford yourself the opportunity – both slowly until it starts to begin to flop (Figure 14.1). At this point

Chapter 14 Compound and putty materials – handling and manipulation

at dental school and thereafter – to play purposefully with a range it can be applied directly to the dry tray at its full thickness. It
of materials. Removable prosthodontics offers a unique oppor- should then be tempered briefly before moulding in the mouth.
tunity in this respect, given that most procedures involving the There is no need for greenstick to be heated so much that it bub-
manipulation of materials are non-invasive and reversible. bles, like pizza cheese, or drips onto the bench. Once tempered,
You will find that you are able to control some materials better there is a window of around 10–15 seconds before it becomes
than others. It may also be the case that specific situations dictate too cool to mould effectively. Look for active material displace-
the material of choice. The remainder of this chapter considers ment, which will reassure you that the material is recording a
important aspects of handling and manipulation of compound, functional sulcus. I often see greenstick being ‘traced’ onto the
greenstick and putty. Alginate is discussed in Chapter 11. tray in small volumes. This is unproductive as the material cools
too quickly and is never presented in sufficient volume to be
moulded away from the functional sulcus. For border mould-
Compound and greenstick ing complete arches, it is useful to approach sections of the arch
These materials have a glass transition temperature of around in turn (Figure 14.1). Greenstick can be used to place a palatal
56 °C and so they need to be heated either with a flame, a hot air stop, which reduces voids during the working impression. It is
burner, or a water bath. On any occasion that you are moulding then helpful to record the buccal and labial sulcus on each side,
material in the mouth, you must ensure that it is tempered to no then the tuberosities, and finally to communicate with a small
more than 60 °C. The most predictable way to do this is to use a addition of material across the post-dam. This final increment
water bath. If you are confident, you can also use running warm should sit onto the palatal aspect of the trimmed tray – not distal
water. At the point when the water feels hot to touch, it is usually to it. Do not proceed to the wash impression until you are happy
still a safe temperature in the mouth. If in doubt, take a sip of the that the borders are moulded correctly. Trim excess material that
running water from a cup to test it. has extended onto the fitting surface. If you are developing a bor-
If the material is being used to form a tray extension, then the der seal, a ‘squelching’ sensation indicates that the border seal
material will have cooled before using it in the patient’s mouth; is compromised, typically around the tuberosities or post-dam.
in this case a water bath is not needed.
When applying the material, the tray needs to be dry in Difficult areas
order for the material to adhere effectively. At this point it can An excellent method of ensuring full recording of the tuberosi-
be reliably reheated and remoulded without it lifting from the ties and post-dam is to place greenstick into the fit surface of
tray. The ability to reheat and remould makes these materials the tray and encourage excess material, which escapes distally,
an excellent choice for difficult cases. However, once a relatively back up and against the required anatomy (Figure 14.1). If using
thick amount of compound or greenstick has cooled, it takes a alginate or silicone, it is possible to pre-load into this area with a
disproportionately long time to warm it up again – so bear this is syringe to help record them fully, but the material will quickly
mind when using large volumes. slump and flow away. On the lower arch, greenstick can also be
placed into the tray over the pear-shaped and retromolar pads,
Compound and then excess can be encouraged back against the tray and into
Compound is most often available as ‘cakes’, either trapezoid or the disto-lingual sulcus (whilst also including border moulding
round in shape. If warming in water, try to sit the cake within with a swallow, and buccal moulding, to account for buccinator’s
an alginate mixing bowl to avoid the material sticking to the attachment).
sink or the water bath walls. Once the material is unable to sup-
port itself, it is ready to apply to the tray. Compound is relatively
viscous and so it will tend to easily displace the soft tissues and Putty
overextend sulci. However, it is excellent at supporting itself as it Clinical putty is available as a catalyst and base putty which need
cools, and so it records distal aspects of anatomy like tuberosities to be mixed together. The most efficient way to do this is on the
and retromolar pads effectively. Unlike alginate or silicone, it will bench top, akin to needing dough. This ensures a homogene-
withstand distortion when the impression is poured up. Where ous mix and keeps the material cool, maximising your working
large amounts are used across the arch, it is possible to rewarm time. The material provides a quicker alternative to warming
localised areas with a hot air burner or a pin flame. Again, this and moulding compound – although it cannot be modified once
should be tempered before re-seating in the mouth. it has set. Putty also needs to be encouraged back up to the anat-
omy around edentulous areas, because it has a tendency to drag.
Greenstick Adhesive should also be applied to the tray before using putty in
Greenstick has a bad name for itself because its use is rather large edentulous areas or free-end saddles. Putties and heavy-
technique-sensitive – but it is an incredibly useful and diagnostic bodied silicones can also be used to carry out border moulding
material. Whilst it can be used for support in small edentulous on trays – but again, the tray must be dry and adhesive must be
areas, it is most useful for extending trays and border mould- applied beneath. Once the putty is placed onto the periphery, it
ing. The sticks are purposefully designed with a particular is helpful to wet the border under the tap before moulding in
thickness – and they are most effective when used in this way the mouth. This results in a much more accurate and smooth
(Figure 14.1). As a border moulding material, it is important not border.
 Recording an upper functional
30

15
Chapter 15 Recording an upper functional impression

impression
Figure 15.1 Recording an upper functional impression

A systematic approach to border moulding Tray extensions

• Approach sections on the special tray in turn – typically the • Buccal and labial
anterior segments first, then buccal, and then finally the
tuberosities and the post dam • Posterior
• Active tissue moulding by the clinician, with the patient relaxed

• Ask the patient to carry out exaggerated movements such as

saying ‘ooo’ and ‘eee’ A watercolour pencil being used to trace
the vibrating line intra orally
• Record the restrictions of the coronoid process by asking the
patient to move their jaw left and right This can then be picked up on the special
tray (image below) in order to help define
the posterior border
Most common faults

• Inadequate capturing of the

tuberosities
• Overloaded trays
• Trays not being fully seated
• Inadequate border moulding

Border moulding

Buccal and labial Tuberosities and post dam (encourage Creating your own post dam
greenstick back up and around the with greenstick
tuberosities and across the post dam)

Wash impression (do not overload the A clear prescription at the posterior border Scribing your own post dam
tray, and ensure it is fully seated with – note the even thickness of wash material on the master cast
plenty of functional moulding)

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T
he vast majority of patients who are struggling to retain their cast, taking into account the degree of tissue compressibility 31
upper dentures are suffering from significant denture over- across the posterior palatal arch. This creates an artificial ‘peak’
or underextension. The stage at which the extensions are on the posterior denture border, which sits into the soft tissues

Chapter 15 Recording an upper functional impression

most easily and accurately recorded is during the functional (or and facilitates the maintenance of a border seal. If the posterior
working, major) impression. At this stage, effective tray extension border is not defined, then the technician will assume its posi-
and border moulding will dictate the limiting anatomy and tion, its contour and its depth. Some clinicians request their
result in a stable prosthesis. Making adjustments at a later stage working cast to be returned so that they can carve the post-dam
is troublesome – not only in terms of identifying exactly where a themselves. It is also possible, using a self-supporting material
denture is overextended – but by how much. In my opinion, time like greenstick, to create your own post-dam during the actual
spent at this stage is time very well spent. working impression (Figure 15.1). The advantage here is that you
are able to make an immediate assessment about how stable and
retentive the denture base is likely to be. Furthermore, the con-
Checking the special tray tour and depth of the post-dam are defined by the patient’s actual
At this stage the tray must be checked for adaptation and exten- anatomy.
sion. This can only reliably be achieved if tried in the patient’s It is quite possible to obtain all of the functional information
mouth. Trying trays on the casts, especially in the absence of in alginate, or silicone, in one go. However, I prefer, certainly in
tissue stops, can result in inappropriate tray alterations. The difficult cases, and when teaching this to students for the first
tray border should sit 2–3 mm clear of any limiting anatomy. time, to split this process into two stages.
It will act as a carrier so that the actual border anatomy can be
recorded with a mouldable material such as greenstick, or dur- Developing the peripheral extensions
ing the wash impression. The posterior sulcal extensions can be This involves using greenstick or putty peripherally first, to
assessed by holding the tray lightly in the mouth whilst reflect- ensure accurate functional border moulding. Areas of under- or
ing the sulcus outwards and downwards. The patient needs to overextension can be identified and rectified without the compli-
be relaxed, with the mouth ‘half-closed’, for this approach to be cations of a wash material. The degree of displacement and (for
successful. If you can feel the tissues pulling the tray down, then complete dentures) the border seal, can then be assessed prior
it is still overextended. It is also possible to carry out a diag- to commencing the wash. See Chapter 14 for details on material
nostic ‘wash’ impression with light-bodied silicone, or alginate, behaviour and border moulding.
which will show areas of over- or underextension. The posterior
border can be marked intraorally using an indelible autoclav- The wash impression
able pencil; if it is located correctly, when the patient’s soft palate Adhesive should be applied to the tray when using silicone or
resonates during speech (typically saying ‘ahhh’) only the dis- alginate. It is critical not to overload the tray with material, oth-
tal aspect of the line will move. Full posterior movement of the erwise it loses its function as a close-fitting special tray. Remind
line indicates that it should be placed mesially. Once it is located yourself of the spacing that you requested; loading a tray with
correctly, seating the tray in the mouth should record any over- zinc oxide eugenol, for example, is akin to icing a cake’s surface,
extension onto the tray itself (which can be trimmed back) – or rather than ‘filling up’ the void within the tray. Ensure coverage
failing that, a tray deficit should be noticeable either directly or of the full tray surface including up and over the tray extensions.
using a mirror. For complete dentures, failing to cover the entire periphery often
means that a border seal is achieved upon seating, but excess
material is then unable to flow peripherally and escape. The
Important functional anatomy impression should be seated slowly to avoid unnecessary hydro-
It is important to extend the impression into the entire functional
static pressure. Ensure that the tray is fully and evenly seated and
sulcus. Flangeless or socket-fit complete dentures will not read-
continue the border moulding process in cycles until the mate-
ily develop a border seal, and patients should be warned of this
rial has set. Remind the patient to remain calm and relaxed dur-
explicitly if they request or require such designs. The impression
ing this stage to ensure adequate border moulding. Impressions
should also fully capture the tuberosities where necessary – not
should be removed by breaking the border seal around one of
just in the horizontal plane, but extending up and around the
the tuberosities, rather than ‘wiggling’ the impression free. This
hamular notch (Figure 15.1). Finally, the palate must be ade-
approach is less likely to cause distortions. Working impressions
quately captured, without voids, extending back to the vibrating
for complete dentures should be rinsed and tried back in, in
line. This anatomical boundary is usually bordered on the distal
order to assess retention and stability.
aspect by the fovea palatini. Capturing this junction between the
hard and soft palate for complete dentures means that a border
seal can be maintained between the tuberosities. The special tray
should be adjusted to meet these anatomical requirements.
Partial dentures
It is still important to ensure that partially dentate special trays
are appropriately extended. This is still often forgotten with par-
tial dentures. Free-end saddles should be treated with the same
Posterior border respect as for complete dentures. Overextension and displace-
Ideally, the posterior border of the denture should be clearly
ment can still cause significant problems with partial dentures,
defined within the impression – either by a clear boundary on
more so if they are actively retained – in this case, overextension
the impression itself (Figure 15.1) or by marking the vibrating
will often cause ulceration rather than displacement (or even
line onto the impression. The related technical stage traditionally
both).
involves carving a ‘cupid’s bow’ or ‘post-dam’ into the working
 Recording a lower functional
32

16
Chapter 16 Recording a lower functional impression

impression
Figure 16.1 Recording a lower functional impression

Tray extensions

• Upright handle to avoid displacing the tissues

• Reflect the labial sulcus and visually inspect

(no sulcus means no tray extension!)
• Retract the buccal tissues
• Ask the patient to lift and protrude the tongue

• Buccal and labial aspects should be recorded • Record the distolingual extensions with a swallow
first – functional border moulding including • Record the lingual sulcus by pushing on the handle
‘ooo’ and ‘eee’ sounds to account for modiolus with the tongue and lifting the tongue

Partial functional impression

• Check stability in the mouth prior

to a wash impression

• The same principles apply for partial

lower functional impressions, except
you should use alginate or silicone
for the wash impression

• An alginate syringe can help to deliver wash

material distolingually and posteriorly but • If using Zinc Oxide Eugenol, fillet away ridge
the alginate must be supported by the tray, detail to prevent the denture base nipping
or its extensions the tissues

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Companion Website: www.wiley.com/go/field/removable
T
he vast majority of patients who are struggling to retain there are advantages to spending some time developing the pos- 33
their lower dentures are suffering from significant over- or terior extensions prior to taking a wash impression.
underextension – but also placement of the lower anterior

Chapter 16 Recording a lower functional impression

teeth outside the neutral zone. The latter is discussed further in Developing the peripheral extensions
Chapter 24. This involves using greenstick or putty peripherally first, to ensure
accurate functional border moulding. The material should be
applied to sections of the tray in turn, and the border moulding
Checking the special tray procedures repeated each time. These can be based on soft tissue
As discussed in the previous chapter, the tray border should sit manipulation, patient movements, or both. On the lower there
2–3 mm clear of any limiting anatomy. The anterior and poste- may be a need for more patient involvement because of the pres-
rior sulcal extensions can be assessed by holding the tray lightly ence of the tongue. It can be helpful to ask patients to say ‘oooo’
in the mouth whilst reflecting the sulcus outwards and upwards. and ‘eeee’. Most of the time there is little point border moulding
The patient needs to be relaxed, with the mouth ‘half-closed’, for the periphery buccal to any standing teeth – the denture will not
this approach to be successful. Unlike the upper arch, it is much be extended into this area. However, it is equally as important
easier to see tray extensions directly on the lower. If the tray to ensure that trays are not overextended in this area, otherwise
reaches the full depth of the functional sulcus then it must be they can affect the seating of the tray and its relationship to the
trimmed back. If you can feel the tissues pulling the tray up, then denture-bearing area elsewhere in the arch.
it is still overextended. The patient should also be asked to raise When reaching the posterior aspect, it is useful to place
the tongue to the roof of the mouth, and to protrude it laterally a small amount of border moulding material onto the pear-
and anteriorly. It also useful for the patient to push against the shaped and retromolar area. When the tray is seated and the
anterior tray handle with their tongue, which activates genioglos- excess material escapes peripherally, this should be encouraged
sus. Swallowing will activate palatoglossus, although this is quite back up against the tray in order to begin to record finer muscle
difficult to carry out without stabilising the tray – as a result, tray attachments and subtly engage undercuts lingual to the ridge.
displacements are missed. It is better to ask the patient to swal- The same movements that were used to check the tray should be
low when you are ready to record border movements actively. repeated in order to record the functional border.
Finally, it is also possible to carry out a diagnostic ‘wash’ impres- It is much less common to achieve a border seal in the lower
sion with light-bodied silicone, or alginate, which will show areas arch, although this is possible with careful adaptation to the
of over- or underextension. pear-shaped and retromolar pads, and the disto-lingual sulcus.

The wash impression

Important functional anatomy Adhesive should be applied to the tray when using silicone or
On lower arch arches presenting with free-end saddles, the alginate. Overloading of the tray tends to be less critical on the
impression should fully capture the pear-shaped pads (which lower edentulous ridge, but can still be a problem with multiple
represent the scar tissue from the last standing molar) and par- bounded saddles. Once again, the impression should be seated
tially cover the retromolar pads. It is also important to account slowly to avoid unnecessary hydrostatic pressure. Ensure that the
for the insertion of the buccinator into the retromolar pad and tray is fully and evenly seated and continue the border moulding
the confluence of modiolus. These anatomical features are dis- process in cycles until the material has set. This includes raising
cussed further in Chapter 10. The special tray should be adjusted the tongue to the roof of the mouth, and protruding it laterally
to meet these anatomical requirements. and anteriorly. Also ask the patient to push against the anterior
tray handle with their tongue and to half-close to encourage a
swallow. Remind the patient to remain calm and relaxed during
Labial sulcus this stage to ensure adequate border moulding. Working impres-
With severely atrophic lower ridges, it is common for stock trays sions for complete dentures should be rinsed and tried back in,
to exaggerate the labial sulcus. Without due attention, this then in order to assess stability. Often, atrophic lower edentulous
results in special trays which are also overextended. Special ridges present with a thin fin of tissue along the crest of the ridge.
attention should be paid to the tray extension in this area. Do not It can be useful to dissect this away with a scalpel in order to
be afraid to adjust the tray until it is stable in function. No sulcus prevent the denture ‘nipping’ (Figure 16.1). This technique will
means there should be no tray extension. The tray handle may be discussed further later.
restrict border moulding in this area and you may feel that you
also need to trim this back to facilitate the process.
Partial dentures
Elastic impression materials are required for partial dentures
Posterior and disto-lingual anatomy (silicone or alginate). Do not forget that free-end saddles should
The antero-posterior and rotational stability of a denture sitting be treated with the same respect as for complete dentures – over-
on a severely atrophic ridge will be largely determined by the extension and displacement can still cause significant problems.
distal and disto-lingual extensions. If your special tray happens An alginate syringe can be a useful adjunct for delivering alginate
to fall short of the retromolar pad, then it must be extended ade- disto-lingually, but do not forget that if the alginate is not sup-
quately prior to the wash impression. The posterior and disto- ported by the tray, then it is likely to distort when the impression
lingual anatomy is particularly tricky to record properly and is poured up.
 34

17 Managing fibrous ridges

Chapter 17 Managing fibrous ridges

Figure 17.1 Managing fibrous ridges

Consider Is the current

denture stable?

Would you make

more than one
denture for Would it be stable
different if it were correctly Yes
functions? extended?
Managing Correct
a fibrous extensions
ridge
and
No

tooth
Yes placement
When is the Is it unstable in
patient having the the neutral zone
most problems? at rest?

No
In At rest or
function when speaking

Mucostatic
(or minimally displacive)
technique

Mucocompressive or ‘selective pressure’

Adapt the greenstick to a damp primary cast Adapt the tray and pick up the greenstick Selectively warm the periphery
and the denture bearing area,
avoiding the re-moulding material
overlying the fibrous tissues

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Companion Website: www.wiley.com/go/field/removable
O
ccasionally you may notice that edentulous ridges are Clearly there are situations where the patient would benefit 35
mobile, or ‘fibrous’. This is most common in the upper from both a mucostatic and a mucocompressed tissue – and
anterior region, the tuberosities and the lower retromolar so communication with the patient is very important. The

Chapter 17 Managing fibrous ridges

region. Occasionally it can affect the arch more generally. Whilst patient should understand that it may not be possible to create
there is little evidence for the cause, upper anterior fibrous ridges a conventional denture that is stable all of the time. In some rare
are often attributed to the combination of lower natural anterior cases we have made patients two or even three dentures for use at
teeth, opposing the upper edentulous ridge. You may hear the different times – exact replicas, apart from the way in which they
term ‘flabby’ ridge – although we tend not to use this term in interact with the fibrous tissue. We will now consider techniques
front of patients, because it can seem rather discourteous in the to record tissue mucostatically and mucocompressively.
absence of any other explanation!
Fibrous ridges are nothing to be worried about – but they do
have the potential to cause denture instability. During the denture Mucostatic
assessment it is important to investigate the boundaries of the Mucostatic impressions are sometimes referred to as ‘minimally
mobile tissue – and in which directions it appears to displace displacive’ – it must be understood that it is quite hard to con-
when loaded. It is also important to bring this relevant anatomy to struct a denture that will not load the fibrous tissue at all. In this
your patient’s attention and describe the potential problems that case, we should use materials for our primary impression that
they may encounter – even if they are not currently reporting any minimally distort the fibrous tissue, such as alginate or silicone,
issues. If the patient has a current denture, then make sure that rather than compound or putty. This will mean that the special
you spend some time assessing its fit and its stability, so that you tray is already somewhat respectful of the tissue’s normal resting
can appreciate how much of an impact the fibrous tissue might anatomy. The technique requires the use of a ‘window’ within
have. Whilst fibrous ridges might impact on denture stability, the working impression tray to allow the tissue to be recorded
they should not really affect the degree of retention. Sometimes without being compressed. It is possible to ask the laboratory to
it is useful to reassure patients that although they might feel the pre-cut a window into the tray – and in order for this to be accu-
denture moving slightly in function, if well made, it will not rate, you must communicate (either by drawing on the primary
displace from the denture-bearing area. impression or drawing a diagram) where the window should
So what can be done to try to minimise the effects of the be. The impression is developed as normal and after taking the
mobile tissue? Whilst for severe cases, localised surgery may wash impression, material is cut away from the window and the
provide an effective solution, most of the time we can cater for impression is re-seated. A mucostatic material such as light-
the mobile tissue within our working impression. It is, however, bodied silicone is then introduced around the fibrous tissue to
important to understand the following: restore the impression (Figure 17.1). If using a two-stage tech-
• Is the current denture stable? – If the current denture is stable nique, and first establishing the border extensions, it is useful to
at rest and in function, then there is little need to be concerned cut the window yourself after you have finished the peripheral
about the fibrous tissue during denture construction border moulding; otherwise the window will prevent you from
• If not, is the instability because of poor extensions? – When establishing a border seal.
patients have a fibrous ridge, it is common to attribute denture
instability to the fibrous ridge itself. Make sure that the problem
is not compounded by over- or underextension into the sulci, or Mucocompressive
across the denture-bearing area. This will allow you to make a Many classic texts consider a ‘selective pressure’ technique. Here,
more informed judgement about the likely impact of the fibrous a primary impression is taken in a mucocompressive material
tissue such as compound. The special tray is then adapted with green-
• Is the denture sitting outside the neutral zone at rest? – The neu- stick against the primary cast. Ensure that the cast is soaked first
tral zone will be considered in Chapter 24, but whether the den- to prevent the greenstick adhering. After cooling, the technique
ture’s polished surfaces are correctly placed or not will impact on then requires the greenstick to be heated and moulded selec-
denture stability, similar to considering the extensions. Ensure tively in all but the fibrous areas. The borders are then moulded
that this is not compounding the problem. normally, with or without a wash impression. In reality, this is a
Ultimately, if the fibrous ridge is affecting denture stability, very technique-sensitive method. In my experience it is sufficient
then it is equally as important to understand when your patient is to record a primary impression in a mucocompressive material
having the most problems. This key question should allow you to (compound) and then request a special tray to be constructed
determine which approach will be most effective in managing the with no perforations and no spacer over the fibrous area. A rel-
fibrous ridge. If the patient is having difficulty at rest or during atively mucocompressive material should then be used for the
speech, then the tissue is likely recoiling against the denture base wash impression. In this case, zinc oxide eugenol will behave
and causing displacement. In this case, the area of fibrous tissue mucocompressively because of the lack of spacer.
should be respected and recorded mucostatically (Figure 17.1). In any case, requesting a permanent base for the jaw relation
If the patient is having most problems during mastication, then stage means that you can judge the outcome of your chosen
the tissue is allowing itself to be compressed during function technique sooner, and ensure a more accurate prescription.
and causing displacement. In this case, the area of fibrous
tissue should be compressed during the working impression
(Figure 17.1).
36

18 Denture bases
Chapter 18 Denture bases

Figure 18.1 Denture bases Broad Sulcal

sulcal width definition

Primary cast (left) in comparison to

a working cast (right) for a complete
denture – note the differences in
sulcal width, depth and definition

Minimal posterior anatomy Posterior definition

Advantages of a permanent base Advantages of a temporary base

• Able to definitively check comfort, stability and retention • Avoids the problem of heel clash
• Able to make definitive permanent changes • Able to scribe your own post-dam on the master cast
• More stability and accuracy when recording jaw relations • Greater flexibility when inter-arch space is limited
• Able to remove wax down to the base without distortion or collapse

Alternative denture bases

Take care with excess
other than cobalt chrome
wax at the periphery

A flexible nylon
denture

• Excess wax on a permanent base should be

trimmed away to prevent displacement and
incorrect tissue support

Trimming the
excess wax at
the periphery.
Sometimes this
can be significant!
A PEEK
(polyetheretherketone)
denture

• On temporary bases, excess wax that is removed

at the extensions will re-appear at the finish stage
when the denture is processed!

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Companion Website: www.wiley.com/go/field/removable
T
he finished fitting surface of your prosthesis will be derived permanent acrylic base beneath the wax. On occasions it may 37
from your master (or working) impression. Although it is also be necessary to augment or further extend the denture
possible in some cases to obtain a very detailed and func- base – and this might happen if you notice a discrepancy or an

Chapter 18 Denture bases

tional impression with a well-adjusted stock tray, it should underextension. Permanent bases are relatively easy to augment
normally be the case that the degree of functional anatomy using compound or greenstick, without the base perishing.
recorded for the master cast is significantly more detailed than Temporary bases are notoriously difficult, if not impossible,
that recorded for the primary (Figure 18.1; note the differences to extend reliably. In any case, if a modification to the base
in sulcal definition, depth and width). This discrepancy becomes was needed, a final wash impression to pick up the fine detail
significant if you are in the habit of requesting record blocks would be saved until the dentures had been tried in and were
alongside your special trays; in the interests of time, we often found to be satisfactory. At this point, any undercuts should be
see registration stages and major impressions being carried out removed from the fitting surface and a wash impression taken
at the same appointment. The problem here is that the record using a closed mouth technique (with the patient closing into
blocks, which have been constructed on the primary casts, are their intercuspal position against the opposing arch). When
then seated onto the working casts in order to articulate the utilising permanent bases for registration and try-in stages, it
models. Most laboratory technicians will tell you that they dislike may be necessary to ask the patient to remove their old denture
this approach, because they find it almost impossible to accu- half an hour or so before the appointment to allow the tissues to
rately seat the blocks. In the interests of accuracy and longer term recoil. If you know that you made a retentive impression but at
expedience, I would recommend using registration blocks con- first insertion the permanent base seems to have lost retention,
structed on working casts. For cobalt chrome partial dentures, do not panic. Be patient, calm and reassuring before moving on
this is never really a concern, because the working impression to troubleshoot other factors.
must be taken first in order for the framework to be waxed-up
and cast. Once it has been tried in, the metal framework will then Temporary bases
have wax record blocks attached to its edentulous areas ready for Temporary bases can be formed entirely from wax, sometimes
the registration process. reinforced with a stainless-steel arch wire. This is quite typical for
partial registration blocks. Alternatively, the temporary base may
be constructed from shellac or light-cured acrylic, with wax rims
Types of denture base attached. In any case, it is often when we are adjusting temporary
For partial denture construction it is most convenient to pro- bases that distortions occur. If you need to alter a record block on
ceed through the registration and try-in stages using temporary a temporary base, be sure to firstly place it back onto the working
denture bases. However, for complete dentures you can consider cast, so that it can be supported whilst you modify it.
requesting that the record blocks are constructed on permanent Advantages of using temporary complete denture bases
bases. The merits of each approach are discussed below. include:
• The possible avoidance, or facilitation of the management, of
Permanent acrylic bases heel clash during registration
In this case, the record blocks are constructed on the actual fin- • The ability to scribe your own post-dam onto the master cast at
ished denture bases. It is common for the working cast to break the chair side before the base is definitively processed
or fracture during unflasking because of the rigid nature of the • Greater flexibility when interarch space is limited
acrylic – and so expect to see defects on the returned working The main drawbacks of temporary bases include compromised
cast. Now that the base has been processed, the remaining cast is retention and the inability to modify the base definitively without
of little consequence, other than it is used to reliably and stably going back a stage and taking a new working impression.
seat the block for articulation purposes.
Advantages of using permanent complete denture bases
include: Alternative denture base materials
• Provide a more stable block and therefore a more accurate Alternatives to acrylic resin and cobalt chrome seem to come and
recording of the jaw relationship go – and we will see more of these innovations with further devel-
• Offer an opportunity to check definitively the comfort, adapta- opments in 3D printing and laser sintering. Flexible dentures
tion, stability and retention of your finished denture base prior made from Nylon have been available for some time – although
to fit for partial dentures we should exercise caution. This is primarily
• Permit the removal of wax completely without the risk of the because a flexible denture base fails to gain support from across
block collapsing the full arch from the hard and soft tissues. By its very nature, it
• Permanent base changes are retained throughout the remain- flexes – which means that it can be loaded differentially and even
der of the construction process place excessive torqueing forces onto abutment teeth. Rests and
• You have less need to protect your working casts as they clasps do not behave in the same way and yet we use traditional
accompany the laboratory work back and forth cobalt chrome design principles to construct frameworks. Poly-
It is always worth checking how wax has been added to etheretherketone and polyketoneketone bases show a degree of
the denture base – the lip support should be derived from the promise although they are still up to 10 times more flexible than
crowns of the teeth only. Extending large volumes of wax up cobalt chrome and cannot be utilised in thin section. At the time
to the denture border is unnecessary and will undoubtedly of writing, I advise caution with these materials until further
compromise the sulcal adaptation and border seal. This excess clinical evidence of their effectiveness and support for oral health
wax should be trimmed away prior to the bases being placed into is available.
the mouth (Figure 18.1). This is much easier to manage with a
 Recording the maxillo-mandibular
38

19
Chapter 19 Recording the maxillo-mandibular relationship

relationship
Figure 19.1 Recording the maxilla-mandibular relationship

Partially dentate Edentulous

Maintain existing Alter the No existing

tooth contacts intercuspal tooth contacts
position

• Adjust the blocks so that they • Adjust the blocks so that

don’t interfere with intended they meet evenly at the
tooth contacts required vertical dimension.
Where possible, cut
notches in the record
Cut deep opposing notches
blocks that oppose natural
into the registration blocks
teeth

• Adjust the blocks so that they • Cut deep opposing notches Encourage the patient to close in the
don’t interfere with intended retruded arc of closure until the first
tooth contacts contact occurs. Then register together
passively with silicone paste

Mark up any potential heel clash

• Register passively with with Millers forceps and articulating
silicone paste paper in order to allow appropriate
adjustments to be made

Millers forceps

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T
he term ‘registration’ is often used to encompass both the such, the registration matrices have a tendency to ‘bounce’ when 39
recording of the relationship between the upper and the lower the casts are mounted together. To overcome this, the fine fis-
arches and the prescription for the placement of the denture sures recorded in the silicone registration matrices can be sliced

Chapter 19 Recording the maxillo-mandibular relationship

teeth. In fact, these are two very different processes, which away with a scalpel. It is also possible to smudge carding wax
should be carried out independently of one another. Placement into the occlusal fissures of the natural teeth prior to taking the
of the upper and lower teeth is considered in Chapters 20–22 registration. In this way, the fine detail is not replicated in the
respectively. The remainder of this chapter will consider the silicone – only the cusp tips are important here.
fundamental aspects of actually recording the relationship It is not reliable to heat or roughen the occlusal wax and ask
between the upper and lower blocks. the patient to ‘bite’ together. This results in a relationship that
is often irreproducible. Furthermore, warming the wax surface
can alter the occlusal relationship and distort the prescription for
The denture bases where the technician should place the teeth.
The merits of employing a permanent denture base for the regis-
tration stage of complete dentures were discussed in Chapter 18.
The more stable the registration base, the more accurate and reli- A passive process
able the registration process is going to be. This is also an oppor- The more passive the registration process, the more accurate
tunity to make any necessary changes to the denture base in order the result. Patients should be completely relaxed and reclined
to improve the comfort, fit or the extensions. Changes made to to around 45 degrees. Encourage your patient to relax their
temporary bases will be lost, unless a new working impression is shoulders by applying some light pressure on them, and ask
taken. Partial denture registration blocks are almost always pro- them to feel their jaw dropping backwards as they relax. Try this
vided as temporary bases. You may find that it is useful to employ yourself – close in and out of intercuspal position whilst looking
some denture adhesive in order to stabilise the bases if you have forwards – and then slowly tilt your head backwards. Feel your
problems with retention. jaw retruding, and slowly close – the majority of people who
are dentate will feel an early contact in the retruded arc of clo-
sure. Whilst we often use bi-manual manipulation to encourage
Natural tooth contacts in partially patients into this arc, often this really is not necessary and can,
dentate patients in fact, cause inaccuracies. If you take the time to explain what
you want to achieve, patients can actually be extremely helpful
At this stage, the occlusal vertical dimension should have also
been prescribed, and this is discussed further in Chapter 23. in obtaining an accurate registration. The problem is that many
However, it is important to reinforce that for partially dentate dentists refer to this process as a ‘bite’ stage, which gives the
patients, if you are working to existing tooth contacts, then it patient the wrong idea about what they should be doing. Patients
makes the process of recording the relationship between the should slowly close until they feel something touch – and then
upper and lower dentition simpler – and much easier to verify. stop. That might be the intended contact(s) – but it might also be
Each block should be adjusted independently in the mouth to an aberrant contact or heel clash of the denture bases. This can be
ensure that the natural contact(s) are maintained. Record blocks an extremely diagnostic process if your patient is understanding
should act as carriers for a more accurate registration medium and cooperative.
like silicone; patients should not be biting into wax with their
natural teeth. The only noticeable contact should be between
the natural teeth. The patient should be relaxed and the process The process
should be passive. This will ensure that you obtain accurate and When you are ready, and the patient is clear about the process,
reproducible results. The process of accurately recording the prepare the registration paste. Seat the block(s) and slowly
relationship is described below. encourage your patient to passively close until they feel contact.
Check this is reproducible and in the intended position. Upon
contact with the block(s), syringe the registration paste into the
The registration material voids in the blocks so that it records the opposing surface. Record
all sections concurrently. It is important to manage the patient’s
As mentioned earlier, the registration blocks should act as ‘car-
riers’ for a registration medium, such as a silicone paste. By cut- mandibular position during the setting time – do not leave the
ting deep and retentive notches into the registration blocks, the patient to attend to other matters.
paste can be introduced passively into the void, and record the
detail of the opposing surface(s). This arrangement should then
be disassembled for disinfection, and readily reassembled. It is Checking the registration
a good idea to test the disassembly and reassembly before dis- Apart from being able to disassemble and reconstruct the regis-
infection, and before the patient has left the chair, in case you tration, you should also inspect the relationship of the bases for
find that it cannot be relocated easily – and should therefore be heel clash – between bases if they are opposing – or heel clash on
repeated. There is no need to create a thin layer of registration the master casts. The latter can usually be adjusted, but heel clash
paste around the entire arch – this will interfere with the interoc- between a denture base should be corrected (usually by adjust-
clusal relationship and can promote a slide. Instead, three or ing the base or increasing the occlusal vertical dimension) and
four points around the arch should be chosen, ensuring that the re-recorded. If you suspect heel clash, either insert some GHM
casts have at least tripod stability when reassembled, reducing articulating paper between the bases and ask the patient to close
the risk of rocking. One limitation of silicone which should be or carry out the same procedure with a small amount of registra-
noted is that it often picks up more detail on an opposing natu- tion or pressure relief paste. Contact of the bases will be visible
ral dentition than is replicated by an alginate impression and as and can then be adjusted (Figure 19.1).
 40

20 Prescribing the upper wax contour

Chapter 20 Prescribing the upper wax contour

Figure 20.1 Prescribing the upper wax contour

Midline

Interpupillary line

Incisal plane

Incisal level and

lip support Buccal corridor

Canine line

Thinned upper
anterior block to
create tongue
space and a more
realistic palatal
Upper lip support contour

The alar tragal plane being

demarcated on a patient’s face
(between alar of nose and tragus
of ear)

Alma
gauge Wax hot plate
A fox’s plane guide

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A Incisal level and the alar–tragal plane
t this stage it is very important to revisit the treatment plan 41
that you originally devised. Unless the presence of natural A fox’s plane guide can be used to assess the incisal plane and
teeth dictates your prosthetic tooth positions, you have a

Chapter 20 Prescribing the upper wax contour

the alar–tragal plane (with which the occlusal surface should be
degree of artistic licence; you should clearly note the specific parallel). It might seem straightforward to prescribe an incisal
aesthetic and occlusal features that you wish to prescribe. It is plane, but sometimes asymmetrical facial anatomy can make this
imperative that the registration block is tried in, and is comfort- challenging. Most often we tend to prescribe the incisal plane
able and stable, prior to proceeding with this clinical stage. All parallel to the interpupillary line. However, the lips themselves,
modifications to the block should be made with care and preci- the nose or even the ears can be used as reference points. If in
sion. Rough wax work will make it hard for the technician to doubt, assess which plane the existing denture incisors are paral-
read your prescription – and it will also affect the relationship lel to and take it from there. It is easiest to adjust the block using
with the upper lip. Often at try-in dentists find that they seem a hot plate, which provides a flat surface. The amount of inci-
to have prescribed an incisal level that is too high (resulting in sor showing changes with age and typically we would expect the
inadequate exposure of the incisors). This is often because the lip incisor tips to contact the lower lip during labiodental fricatives
rests further down on the refined waxwork and smooth denture (such as ‘F’).
teeth than it did on the rough block. It is a good idea to check the alar–tragal plane (the antero-
There are several features that should be prescribed on the posterior plane) early on in the process so that you already have
upper block, and these are shown in Figure 20.1 and described an appreciation of how you might need to alter the wax block.
below. As a rule of thumb, it is usually a good idea to prescribe the For example, if you are about to raise the incisal level, it would
upper tooth positions based on aesthetics. be useful to know if you also need to remove wax anteriorly
in order to correct the alar–tragal plane. The two can then be
Using the previous denture as a guide altered concurrently. Without this consideration, you may have
to remove wax along the entire block, only to need to replace
An Alma gauge is an invaluable piece of equipment that can
it again in one specific area. Adding wax in this way is much
save a lot of chairside time. The gauge allows you, using the inci-
more difficult to achieve than levelling the occlusal plane with
sive papilla as a consistent landmark, to measure the amount
a hot plate. If in doubt, simply correct the occlusal plane first,
of lip support (horizontal reading) and the incisal level (verti-
and then address the incisal level. At least with this approach you
cal reading) provided by an upper denture. It is possible to use
are removing or adding wax across the entire block in an equal
the existing denture’s measurement to help inform your decision
thickness.
at the prescription stage and also to inform the technician how
much lip support and what incisal level you would like on your
registration block. This can save a lot of clinical time which is Buccal corridors
otherwise spent adding or removing wax and is discussed further Prescribing buccal corridors is often forgotten – and as a con-
in Chapter 27. sequence the upper teeth can sometimes look falsely ‘full’ in
the mouth. Whilst the upper block should prescribe teeth that
sit over the edentulous ridge in order to maximise stability,
Lip support upper teeth do not naturally contact the buccal mucosa in func-
Pay close attention to the wax rim and ensure that wax does not tion. Ask someone to give you a big cheesy smile and you will
extend right up to the denture border. This is unnecessary – it notice a void between the buccal surfaces of the teeth and the
will compromise your border seal (for complete dentures) and buccal mucosa – these are known as buccal corridors. Failing to
will provide an incorrect soft tissue support for the upper lip, respect them can lead to speech problems and cheek biting. As
resulting in a rolled appearance of the infranasal tissues. This can a rule of thumb, prescribe the teeth over the edentulous ridge; at
also happen if the denture base extensions are too thick. If this this point, if buccal corridors are missing, then hold the block
is the case, a permanent base can be adjusted before proceeding. obliquely onto the hot plate and bevel the edge of the block. This
Be careful with a temporary base, because these adjustments will tuck the buccal surfaces in medially and begin to allocate
will be lost prior to processing, and will result in an altered lip some buccal space.
support at the fit stage. The lip support should be derived from
the crowns of the teeth only – and it is useful to remember this
if you find yourself adding more wax, or indeed, taking it away. Other useful markers
Only a strip of wax, around 1 cm high, needs to be added to or Once you have finishing making changes to your planes of refer-
removed from the incisal aspect of the block. Patients can usu- ence, it is important to clearly mark the midline and the high
ally articulate whether they feel they would like the degree of smile line with a wax knife. It is also useful to mark the intended
lip support to be changed – and normally we would expect the canine positions, but this is discussed further in Chapter 22.
angle formed between the upper lip and the base of the nose
to be around 90 degrees – this is usually a good starting point
(Figure 20.1). However, it is always worth reminding the patient
Tongue space and assessing speech
Once you have prescribed your lip support, it is useful to pare
that there is a sensitive interplay between aesthetics, stability
out the palatal aspect of the block to replicate the expected tooth
and speech. Increasing the lip support significantly may result
contour (Figure 20.1). A 1 cm thick wax rim will severely restrict
in a denture that is unstable in function, as it loses a direct
the tongue, causing displacement, and makes assessment of
relationship to the upper edentulous ridge upon which is should
speech very difficult.
gain support.
 42

21 Prescribing the lower wax contour

Chapter 21 Prescribing the lower wax contour

Figure 21.1 Prescribing the lower wax contour

Soft tissue
support

The lower lip

is usually deep
to the upper
Typical buccal relationship
of the blocks

Speech and
Stability
mastication

Check base extensions

The wax can also be thinned,
or pared out, lingually in order
to make space for the tongue.
This can help to check speech
Reduce excess wax posteriorly
and to identify the neutral zone
in order to more accurately
represent the occlusal plane,
facilitate visibility and
reduce posterior This is easily carried out
early contact by removing a posterior
triangle of wax down to
the base

Asking your technician to avoid placing second molar

teeth, and instead, flattening the waxwork to provide
a lingual shelf, can help the patient’s muscular control
of the denture

Prescribe the correct buccal relationship. Tracing the

existing upper block position onto the lower using a
wax knife intra orally can help you to make accurate
adjustments outside of the mouth

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T Lip support
he previous chapter described how the upper block should 43
be primarily prescribed based on aesthetics and facial Once again, only a strip of wax, around 1 cm high, needs to be
support – but a depleted lower dentition, or an edentulous

Chapter 21 Prescribing the lower wax contour

added to or removed from the incisal aspect of the block. In
arch, will often dictate that stability and zones of neutrality are the a class I skeletal base we would normally expect the lower lip
main drivers for prescription of the lower block. Once again, the to sit deep to the upper lip (Figure 21.1). Paying close attention to
patient should be reminded at this stage of the interplay between the stability of the lower block in an antero-posterior direction
soft tissue support, stability and speech. It is therefore particu- may mean you need to reduce the lip support significantly in
larly important on the lower arch, especially labially, to check for order to account for the activity of the lower lip and mentalis
base overextension prior to proceeding with the prescription. muscles.
When standing in front of the patient, the labial tissues can be
fully reflected to inspect the extensions directly.
It is common for lower complete registration blocks to be
fabricated with discrepant occlusal planes; typically too high
Incisal level and plane
Once the lower block is stable antero-posteriorly, it is necessary
posteriorly, because the most superior aspect of the distal base to ensure that the block meets the upper with bilateral simultane-
extension is used as a reference. More often than not this plane ous contact upon closure. Do not worry about the final occlusal
is incorrect, and so removing the posterior triangle of wax vertical dimension at this point – just ensure that you have even
can help – this keeps the posterior aspect, and its relationship contacts. Maintaining flat occlusal planes on each block by using
to the upper block, visible. It also increases the efficiency of a hot plate will ensure that this process is straightforward. Also,
modification to the block. look very carefully for a slide – it is critically important to notice
For complete dentures it is worth considering the use of when this is happening, and to make necessary adjustments.
permanent bases – not only to ensure maximum stability – but Recording the relationship of the blocks after a slide is point-
also in case there is a need to permanently alter the bases to less and inaccurate. Your patient should be encouraged to close
correct overextension, heel clash, or to remove segments of wax slowly and passively until they feel something touch. The aim is
to execute a neutral zone impression (described in Chapter 22). for even contact of the blocks – but if they stop short then you
If you are intending to carry out a neutral zone impression at have identified an early contact – either between the heels of the
the registration stage, then wax rims which are already missing denture bases, or between an uneven wax surface on one or both
the lower anterior portion can be requested. These are known of the blocks.
as ‘Manchester’ rims – whilst they might seem easier to adjust,
be careful not to fall into the habit of using these without
prescribing the lower anterior tooth position. For partially Buccal relationship
dentate arches, especially on the lower anterior sextant, you may The most stable masticatory position for the lower teeth is
find that small saddle areas distort or detach easily from the main over the ridge. However, it is also important to consider the
block. Do not worry too much about this – the adjacent teeth relationship to the upper teeth; normally we would expect the
will give information about intended tooth positions, and it is upper teeth to sit buccally to the lower teeth, in order to support
unlikely that small bounded saddles will help with the accuracy the soft tissues effectively and prevent cheek biting. It is useful
of recording jaw relations. Similar to the upper arch, the presence to transpose the upper buccal contour onto the lower block with
of natural lower teeth might dictate your prescription in terms of a wax knife intraorally, in order to help you make the necessary
arch-form and occlusal plane. With natural anterior lower teeth adjustments.
that are opposing an upper edentulous ridge, it is often important
to revisit the upper block and pare out the wax palatally in order
to accommodate the lower anteriors (prescribing an overbite). Vertical dimensions, tongue space and
This is necessary in order to allow an appropriate occlusal
vertical dimension and incisor relationship to be accounted for speech
simultaneously. The final vertical dimension is a function of the upper block
incisal level, the upper posterior occlusal plane, and the height
of the complementary lower block. On the lower, typically we
The tongue would expect the incisor tips to be just visible during speech,
Aside from sulcular extensions and the neutral zone, the other and the tongue to sit slightly superior to the lower occlusal plane
factor that will impact significantly on lower denture stability at rest. The vertical dimensions are discussed in more detail in
is the tongue. This is made significantly more troublesome for Chapter 23.
patients who are not in the habit of wearing an existing lower Once you have largely prescribed the lower block, it is useful
prosthesis. As a muscle, the tongue can lose tone and become to pare out the lingual aspect, to replicate the expected tooth
particularly unruly when allowed to passively occupy extra space. contour. A 1 cm thick wax rim will severely restrict the tongue,
When prescribing the positions of the lower teeth, especially for causing displacement, and making assessment of speech very
complete dentures, it pays dividends to be mindful of how the difficult. At this point, both the upper and the lower blocks
tongue can be re-trained to help control the lower prosthesis. should be anatomically similar to the intended tooth dimensions.
This requires a degree of perseverance by the patient – but also This is the best opportunity to test the function of the blocks in
consider flattening the lingual aspect of the waxwork distally terms of speech, paying particular attention to sibilant (s) sounds
in order to provide a shelf upon which the tongue can rest and and fricatives (f). Whistling sounds indicate that the speaking
help to stabilise the denture. Also consider leaving off the lower space is restricted – whilst hollow ‘s’ sounds indicate an excess of
second molars, which further increases the space available for freeway space.
the tongue to help stabilise the denture base.
 44

22 Tooth selection and arrangement

Chapter 22 Tooth selection and arrangement

Figure 22.1 Tooth selection and arrangement

Centre line

Upper
smile
line

Inter-canine
lines

Compare width measurement with tooth guide

The relationship with the lower
block should be based on
‘aesthetics’, ‘stability’ and ‘speech’

Mold Relationship

Ovoid
Class 1 – the lower incisor
tips sit just palatal to the
upper incisor tips

Squared

Class 2,1 – the upper incisors

sit forwards and out of contact
with the lower incisor tips

Tapered

Class 2,2 - the upper incisors

are retroclined pointing slightly
inwards towards the lower
incisors

Class 3 – the lower incisors

sit forwards of the upper
incisor tips
Partial dentures must account for existing
natural tooth positions

Always consider your incisal relationship, and communicate this requirement to your technician.
Consider prescribing the upper block for aesthetics, and the lower block for stability. Generally,
this results in an incisal relationship that is similar to the patient’s previous dentate incisal relationship

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
T
he previous chapters have largely considered prescription of teeth initially. It is even possible to ask for a particular mould of 45
the upper and lower blocks based on soft tissue support and tooth to be returned with your registration blocks in case you
stability. Whilst both of these attributes can be prescribed by want to spend some time setting these up at the chairside. Whilst

Chapter 22 Tooth selection and arrangement

the wax blocks alone, it is also important to remember that the this takes a little longer, it can save an extra visit, especially if
outer surface of the wax blocks is essentially your prescription the patient decides they do not like the mould you have cho-
for the placement of the denture teeth. This chapter therefore sen. Having something to work from will usually prompt more
considers the choices surrounding tooth selection, and how you useful thoughts or suggestions from your patient. Of course, if
might define intended tooth arrangements. the patient is happy with their existing arrangements then you
An assessment should have been made prior to the can use a stock tray to take an alginate impression of the current
commencement of treatment about the patient’s aesthetic denture for the technician to copy. Whatever happens it is use-
demands and requirements. It is therefore important at this stage ful to give some indication to the technician that will help them
to carefully revisit the treatment plan. It is not uncommon for to select a suitable tooth mould. Technicians often tell me that
patients to be unable, or find it difficult, to communicate their they are asked to set up teeth for a try-in where they are not even
aesthetic concerns. Take the time to explore tooth arrangement aware of the patient’s sex. Clearly, the more information that you
and set-up at the planning stage. Does the patient want their can provide, the better.
prosthetic teeth to replicate their previous natural tooth
arrangement? If so, do they have any photos that they can share?
Prompt patients to ask whether they would like any ‘gaps’ between Tooth sizes
the teeth, or for teeth to ‘overlap’ (in relation to the overbite, Whilst there are a number of shape styles available for denture
overjet and imbrications). Clearly where natural teeth still exist, teeth, most manufacturer tooth charts will allow even more
especially in multiple bounded saddles, the prescription will specificity – this largely relates to the sizes of the denture teeth.
largely be determined by the existing tooth positions, shape and It is helpful to the technician if you can at least estimate the
shade. intended tooth size. Most often this is conveyed on tooth charts
In the absence of any other useful information, it is possible as a distance around the arch between the distal surfaces of the
to use biological guides as a starting point for planning tooth canine teeth (Figure 22.1). Once the canine lines have been
arrangements. A smooth and well-defined block (Figure 22.1) estimated, this can be measured with a flexible ruler. It is often
will facilitate this process, ensuring that your reference lines are said that the width of the central incisor should correspond
clear to the technician. to the width of the philtrum. Again, this is a rather sweeping
generalisation – and in fact a lot of these measurements become
futile if you are also asking the technician to set up teeth that
Biological markers are crowded or spaced. The main factor here is that you have
The diagram in Chapter 20 shows the main biological guides to prescribed the necessary anatomical lines onto the blocks.
tooth arrangement. These include:
• The midline (which should correspond to the centre of the
philtrum of the lip, or the nose) Tooth shade and characterisation
• The high smile line (which is used to determine the cervical Once again the patient should be directly involved in decisions
margin placement of the denture teeth) about tooth shade. This process is somewhat easier for complete
• The canine centre lines (which should sit along a plane that dentures, or where large anterior saddles exist, because this
passes through the inner canthus of the eye and the alar of the allows a degree of uniformity in relation to the apparent shade.
nose). This can be determined using a piece of dental floss. The process is complicated by multiple saddles bounded by
A number of other anatomic features are purported to relate teeth with a disparate appearance. There really is no limit to the
to ideal tooth positions, although there is little clinical evidence degree of characterisation that can be designed into a removable
for this to be the case. If you are interested, I refer you to the prosthesis – and given the time and technical skill, it is possible to
recommended further reading to explore these concepts further. create prostheses with a significant degree of camouflage.
The overriding principle once again, is the interplay between
aesthetics, stability and speech.
Other considerations
Another aesthetic component that changes with age is the incisal
Tooth shapes level – the amount of incisor showing at rest and during speech.
A huge variety of moulds are available for denture teeth and these Typically this reduces as we age, and our facial tone reduces, with
largely centre around four main shapes – rectangular, tapered, the incisors becoming increasingly ‘hidden’ behind the upper lip.
ovoid and square. It is suggested that the category of tooth shape For complete dentures, or large anterior saddles, paring
should largely conform to the patient’s facial profile although in out the record blocks palatally and lingually will allow you to
my experience there is often little correlation. It is important to appreciate the incisor relationship that you are prescribing. It
consider the patient’s wishes and expectations. The relationship makes open bites and overjets more apparent. Ensure, however,
of the blocks may also help you to suggest a particular tooth that you explain to the lab which incisal relationship you wish
shape. I tend to find that an incisal Class 2,1 looks quite natural them to set up, otherwise it is not uncommon for teeth to be
with tapered teeth and that ovoid teeth suit Class 2,2 relation- returned for try-in with a Class 1 incisal relationship.
ships. If you cannot decide, try just setting the upper anterior
 Occlusal dimensions and occlusal
46

23
Chapter 23 Occlusal dimensions and occlusal schemes

schemes
Figure 23.1 Occlusal dimensions and occlusal schemes

Natural tooth contacts in Is the occlusal vertical

intercuspal position (ICP)? dimension acceptable?

Plan a new occlusal vertical Natural tooth contacts in Is there room for planned
dimension +/– study models retruded arc of closure (RAC)? restorations or partial
and wax-ups in RAC denture elements?

Are these suitable for the

basis of a new ICP?

Reorganise Conform to ICP

Is there room for planned

restorations or partial
denture elements?

Confirm new occlusal vertical Ensure that natural tooth

dimension at registration contacts are maintained
stage Conform to RAC at registration stage and
communicated to
the laboratory

Retruded arc of
closure - most
superior position Retruded
in the glenoid fossa contact

RVD OVD OVD

(Resting in in
vertical RCP ICP
dimension)

RVD – OVD = FWS

Interocclusal space

A retruded contact point (RCP) may result in

increased interocclusal space, compared to
full closure in the intercuspal position (ICP)

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable
T
his chapter aims to highlight several important aspects of as an excursion (lateral or protrusive) is made, the anterior teeth 47
occlusion relating to removable prostheses. The occlusal take up the guidance. The posterior teeth disclude, which pre-
vertical dimension (OVD) for complete dentures is rela- vents them from being loaded non-axially. As such, the anterior

Chapter 23 Occlusal dimensions and occlusal schemes

tively straightforward to understand (Figure 23.1) – at rest, your and posterior teeth mutually protect each other.
patient should have a certain amount of ‘freeway space’ (FWS) When our patients have lost their posterior stability, you
between the teeth. This is usually expected to be around 2–3 mm should consider how to replace this – the anteriors should be able
but this is very much a guide. Your patient’s existing FWS can to support the prosthesis and also allow guidance movements
be measured using a Willis gauge which sits beneath the nose that cause posterior disclusion. Conversely, the opposite is true;
and the chin. It is determined using the formula shown in Figure with loss of anterior units, the posterior teeth should help to
23.1 – by subtracting the OVD from the resting vertical dimen- support a prosthesis, and the anterior units should be left out
sion (RVD). Callipers can also be used by taking measurements of full function in the ICP and yet able to provide guidance in
between a point marked onto the tip of the nose and the chin. excursions. Most of the time these occlusal features are overseen
Many factors can influence the results that you obtain (not least by your technician – however, it is important to be aware of these
whether the patient has a big beard!) and so remember that this important principles when planning removable prostheses.
process is really just a guide. Determining that there is suffi- Anterior guidance is often divided into two schemes – canine
cient ‘speaking space’ is another useful process – and this relies guidance and group function (where more than one tooth is
on a qualitative assessment of the sounds that patients are able involved in guidance on any given side). In reality we rarely
to reproduce, rather than a quantitative assessment of their face see unrestored patients with isolated canine guidance. That
height. Wherever possible I prefer to use both methods. said, when we are designing a new occlusal scheme, guidance
centred around existing healthy canine teeth usually provides a
predictable and stable solution.
Conform or reorganise? Where prostheses replace guidance teeth, it is important to
Upon completion of your dental assessment for a partially den- consider which guidance pattern you wish to prescribe. Think
tate patient, your treatment plan will necessarily involve a deci- about sharing guidance between natural and prosthetic teeth,
sion about whether to alter the existing occlusal relationship (to and whether a prosthesis will benefit from any support around its
reorganise), or to maintain it (to conform). The flow diagram guidance teeth to prevent them fracturing or wearing excessively.
(Figure 23.1) should help you to negotiate this decision-making Cobalt chrome frameworks acting as backings to guidance teeth
process. Largely it will be determined by whether your patient can be very useful.
has existing natural tooth contacts, and whether they occlude at
a suitable OVD or not. If no natural tooth contacts exist, either
in the intercuspal position (ICP) or the retruded arc of closure Complete denture occlusal schemes
(RAC), then the process is actually quite straightforward, and Traditionally it was thought that balanced occlusion was
involves prescribing the OVD at the registration stage. This can, necessary to optimise the stability of complete dentures – canine
of course, also be planned using a diagnostic wax-up on mounted guidance was avoided because it was felt that this caused insta-
study casts. On occasions, despite having stable natural tooth bility and displacement. However, a number of comprehensive
contacts, there may still be a need to increase the OVD – this may systematic reviews have concluded that the type of guidance
be required in order to: prescribed for complete dentures has little effect on the patient’s
• Augment the teeth with direct or indirect restorations quality of life, or masticatory performance. If you anticipate that
• Make room for partial denture elements such as rests or if an the patient will have a high degree of muscle activity, or there
onlay design is to be used are severely resorbed ridges or fibrous tissues, then you might
• Restore the OVD to treat problems with overclosure such as consider prescribing a lingualised occlusion. In this type of bal-
temporomandibular joint disorders or angular cheilitis anced articulation, prominent maxillary palatal cusps contact
In these cases, a new, reorganised OVD should be planned. the mandibular central fossae, which acts to reduce interferences
This may become complicated if it is not immediately apparent in excursion and more favourably distributes stress during
how you might restore the existing natural teeth whose contact parafunction.
will be lost when the new prosthesis is fitted. Here, we rely
heavily on the concept of the Dahl effect. It is not within the
scope of this book to discuss this (or methods of recording the Facebows
RAC further). The further reading section provides some links I am often asked whether a facebow transfer is needed. The
to useful articles and you will easily find information about the facebow allows prescription of:
process in mainstream restorative texts. • The maxillary plane in relation to the temporomandibular
joint hinge axis
• The distance of the maxillary teeth from the hinge axis
Occlusal schemes • The intercondylar width
Our natural dentition is most often based on a ‘mutually protected These factors will all affect the excursive movements of the
occlusion’. In the ICP the posterior teeth are loaded axially, whilst semiadjustable articulator, and are considered important if you
the contact on the anterior teeth is maintained only slightly. The intend to represent your patient’s movements accurately and
stable posterior contacts prevent the anterior teeth from becom- alter the OVD.
ing overloaded, resulting in wear, mobility and drifting. As soon
 48

24 Respecting the neutral zone

Chapter 24 Respecting the neutral zone

Figure 24.1 Respecting the neutral zone

The neutral zone is a zone
of passivity between the • Trialling alterations to
tongue and the lips or labio lingual tooth
cheeks positions at try-in by
moving the teeth, or
using carding wax to
There is often a discrepancy mimic new tooth
between the natural tooth The neutral zone can be respected by: positions (see image)
position and the zone of
• Paying close attention at the registration
neutrality
stage to labio lingual tooth positions in
terms of stability and speech

• Recording the neutral zone

formally using impression
Recording the neutral zone material

If a permanent base has been used,

this lower block can be cut away,
Use of a neutral zone tray, and the neutral zone recorded as part
constructed at the intended of the registration process
OVD after the registration stage

Notches cut ready

to record the jaw
relations

Try-in

It is also possible to use a permanent

base without any retentive features.
Adhesive should be applied to the base,
and a medium bodied silicone should
be injected into the space between the
lips, cheeks and tongue

Note the overjet which is frequently Placement of an anterior bite plane to account
prescribed as a consequence of for the resulting overjet, can help maintain
respecting the neutral zone speech and masticatory function

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Companion Website: www.wiley.com/go/field/removable
A
nother extremely common reason that lower dentures having to spend lots of time adding and removing with hot wax. 49
are unstable is because the denture is not sitting pas- It is also possible to request that the blocks are returned without
sively between the lower lip and the tongue. This area also the anterior sextant waxed up in order for you to choose how you

Chapter 24 Respecting the neutral zone

involves the buccinator muscle of the cheeks and the orbicularis wish to record this zone. These are known as ‘Manchester’ rims,
oris muscle anteriorly, particularly when patients are yawning or although you should be careful not to completely forget to pre-
opening wide. We describe this passive area as the neutral zone. scribe the positions of the anterior teeth. Carding wax can also
As described previously, denture instability can also be caused by be used additively in order to help diagnose incorrect tooth posi-
base over- or underextension. It is very important to check that tions or soft tissue support – both at try-in and when assessing
displacement is not exacerbated by these errors, before moving existing dentures (Figure 24.1). When you are unsure, this saves
on to consider the neutral zone proper. removing teeth and spending time with hot wax; it can simply be
removed again after testing.

Diagnosis
With the lower denture in place, and the patient relaxed, the soft The formal neutral zone impression
tissues of the lips and cheeks should be carefully retracted. If the Ultimately, it may be necessary to use an impression material
lower denture still shows poor stability, lifts with tongue move- to record the neutral zone. This is often the case in particularly
ments, or ‘bounces’ when fully seated, then it is likely that there challenging cases, where the neutral zone is not created by a
are errors with the denture extensions. If the denture only dis- simple antero-posterior interplay between tissues. Examples of
places, particularly antero-posteriorly, when the soft tissues are this include patients who have suffered a stroke, have a degree of
allowed to rest back against the polished surface, then it is likely paralysis, or have undergone surgery or laser treatment, and dem-
that the anterior teeth are not within the neutral zone. onstrate restrictions because of scar tissue. The classic literature
recommends the use of dedicated neutral zone trays (Figure 24.1)
which are constructed after the casts have been articulated, and
Managing the neutral zone which sit against an upper try-in with occlusal stops. The trays
Many classic texts and papers describe a specific impression tech- can employ the use of wires or acrylic fins to help to support and
nique to record the neutral zone, in order that the technician can retain the neutral zone impression material, but either way it is
place the denture teeth and polished surfaces in the most stable important to ensure that these features do not restrict free soft
position. However, it is not always necessary to include a dedi- tissue movement, and affect the recording of the neutral zone. I
cated impression in order to account for the neutral zone. The tend to find that it is more accurate to leave a total void anteriorly
following techniques can often be used in order to accommodate (Figure 24.1). In fact, as a matter of routine, it is helpful to carry
for the neutral zone without formally recording an impression. out the impression when you have finished prescribing the upper
and lower record blocks. For this to be successful, you should
Pay close attention at registration stage or ensure that you are working with permanent bases so that you
can trim the wax entirely away from the anterior region without
try-in the block collapsing or distorting (Figure 24.1).
When prescribing the lower block, pay attention to how stable it
It is possible to use tissue conditioners as the impression
is in situ. Remove from the block labially if the block is displac-
material, but these are rather technique-sensitive and take a
ing in a posterior direction (or remove lingually if it is displacing
relatively long time to set. They also tend to slump and flow down
anteriorly). Note that if the block outline does not follow the con-
around the tray extensions, which can be difficult to manage. I
tour of the arch, then this can also cause displacement from the
prefer using a medium-bodied silicone, which has a reasonable
neutral zone. This is particularly common around the premolar
setting time, and can be easily trimmed back to the occlusal
area buccally, where the modiolus is active. Aside from any cor-
plane with a scalpel. Adhesive should be applied to the base, and
rections at the prescription stage, make sure that you pay close
this should then be placed in situ prior to syringing the material
attention at the try-in. At this stage, it is not too late to alter the
up the level of the occlusal plane. Do not worry, the material will
inclination of the lower anterior teeth, or to remove the lower
be contained within the neutral zone. All functional movements
anterior teeth and formally record the position of the neutral
including sipping water (early on to wet the mucosal surfaces)
zone with an impression. The advantage here is that (assuming
and swallowing, should be recorded. It is also helpful to ask the
there are no overextensions and that the articulation is accu-
patient to say ‘oo’ and ‘ee’ in order to activate the modiolus.
rate) the patient is more able to carry out speech and swallow-
The technician will make a putty matrix against the neutral
ing functions than with the record blocks in situ. Furthermore,
zone impression before peeling it away and using the matrix to
the material used for the neutral zone impression adheres more
set the teeth. You can make this at the chairside instead if you
effectively to the roughened wax following removal of the teeth
wish.
than it does to a smooth denture base.

Consider prescribing the anterior segment in Effects of respecting the neutral zone
carding wax You should once again be mindful of the interplay between aes-
If you feel that you want to play around with some different tooth thetics, stability and speech. If the lower anterior teeth are sig-
positions in order to find a zone of neutrality, then consider nificantly distalised, it may be useful to prescribe a bite plane to
removing the anterior portion of wax from the lower block and facilitate sibilant and post-alveolar sounds. This can be waxed in
replace with a thin piece of carding wax. This will allow you to by the laboratory for a try-in or by yourself using some carding
make subtle changes antero-posteriorly to the wax work without wax (Figure 24.1).
 50

25 Assessing trial prostheses

Chapter 25 Assessing trial prostheses

Figure 25.1 Assessing trial prostheses

Checks prior to trying in:

• Check the prescription in terms • Check for full base coverage

of mould, shape and size

• Check the incisor relationship, • Check for correct occlusal contacts

including overjet and anterior and functional cusps (palatal upper,
contacts buccal lower)

For partial dentures, also check:

• Intended natural tooth contacts • Look for unintended dead spaces

have been maintained

• Look for interferences from • Remind yourself of the path

frameworks of insertion

In the mouth How to manage an incorrect

maxilla-mandibular relationship

Or
• Check insertion and removal

• Check for pain on seating/loading Alter tooth positions Re-record the relationship
at try-in

• Check stability and retention Or

• Check extensions in function In intercuspal position At the point of early

after removing the or first contact
• Check the centre lines, canine lines and smile lines interfering teeth

• Check buccal corridors

• Check occlusal contacts (static and dynamic) Dependent on intended

occlusal vertical dimension
(OVD)

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T Features to check in the mouth
rying in prostheses should be a relatively uneventful stage, 51
assuming that you have: • Check that the prosthesis can be fully seated easily without
• Listened carefully to your patient’s requests restrictions.

Chapter 25 Assessing trial prostheses

• Correctly prescribed the intended tooth positions • Check that the occlusal relationships are correct. Once again
• Considered the interrelationship between stability, aesthetics this includes intercuspal and excursive contacts.
and speech • With partial dentures that conform to existing natural tooth
• Tested the function of your record blocks at the registration contacts, ensure that these contacts are maintained when the
stage prostheses are in situ; try-in each arch independently first in
• Accurately recorded the relationship between the upper and order to more easily identify discrepancies.
lower blocks • Check the extensions of the prostheses using functional border
• Checked for the absence of heel clash (between casts or bases) moulding and/or patient expressions, speech and swallowing.
• Prescribed a registration record that can be reliably disman- • Load the prosthetic teeth axially in order to check for stability.
tled, disinfected and reassembled without ambiguity Ideally you will have prescribed the teeth over the edentulous
• Communicated effectively with your technician ridges where possible.
You may be daunted by this list – but be reassured that in all • Check soft tissue support, including the presence of buccal
but very experienced hands, it is common for something to need corridors, where necessary.
at least minor adjustment – even if this relates to a minor heavy • Allow the patient to check the aesthetic outcome.
contact somewhere in the arch. Often, if you are struggling with It is wise to allow the patient to wear the try-in prostheses
the prescription stage, it is helpful to proceed to try-in. Errors for at least 10 minutes in order to be able to provide some
are often more visible at this stage and are also often more easily meaningful feedback.
corrected because the waxwork is less bulky, and existing teeth
that can be moved or removed, as required. As mentioned
previously, both the accuracy and success of the prescription and Managing occlusal discrepancies
the try-in stage will be improved by using permanent bases. You may notice a discrepancy when the prosthesis is in the
mouth. This most commonly relates to an inaccurate registra-
tion, resulting in an early contact. This may result in a slide into
What should be checked at try-in? an intercuspal position (ICP), a persistent open bite somewhere
The short answer is: everything. All of the features and dimen- in the arch, or tipping of the prosthesis. Remember that in order
sions that you prescribed during your prescription and registra- to check for this, the patient should be relaxed, and you should
tion stage should be checked. Once again, the treatment plan assist them to close slowly until they feel something touch
should be revisited and discussed with the patient prior to trying together. You should be in front of the patient to assess this and
the new prostheses. It is helpful to remind your patient about why watch very closely as the arches close together. There should be
they wanted new prostheses and the discussions you had about no lateral or antero-posterior slide into the ICP. If a discrepancy
expectations, so that they can make a suitable comparison and is noted, you must decide whether you can correct it at the chair-
judgement about whether they are happy to proceed to finish. side or whether it is necessary to record the registration again
Take your time and make it clear that beyond this stage there is and ask for a re-articulation and a re-try.
little or no useful adjustment that can be made to the prostheses. Heavy occlusal contacts that do not result in a slide or an
open bite should be noted and adjusted at the fit stage – in my
Features to check on the bench experience there tends to be a subtle degree of denture-base
• Try the prostheses on the articulated casts – check that the base flexure and tooth movement during flasking and curing that
extends across the full denture-bearing area and that the occlusal often means the same discrepancies become elusive and are
relationships are correct. This includes intercuspal and excursive replaced by other minor discrepancies.
contacts. On marking up, the functional cusps should be palatal If the occlusal relationship has gross inaccuracies in the ICP,
on the upper and buccal on the lower (PUBL). if the occlusal vertical dimension is incorrect, or there is a large
• For partial dentures, check that any expected natural contacts slide into the ICP, then the try-in prostheses should be adjusted.
have been maintained and that the path of insertion conforms to This can be done three ways (Figure 25.1):
your intended design, particularly in relation to guide planes and 1 Tooth movement at the chairside.
dead spaces. Pay close attention to teeth that have fractured off 2 Removing the interfering teeth, closing passively into the ICP
and have been glued back into place – these are risky areas where and re-registering the try-in blocks together with registration
bounded saddles are concerned. paste.
• For frameworks, check for unintended interferences such as 3 Re-registering the try-in blocks at the point of an early contact
excess wax around clasp arms or on the fitting surface. (prior to a slide). This is technically more challenging and will
• Check that the technician has followed your prescription for undoubtedly result in a larger occlusal vertical dimension than
tooth position, incisor relationship, mould and shade. was originally intended.
 Fitting and reviewing finished
52

26
Chapter 26 Fitting and reviewing finished prostheses

prostheses
Figure 26.1 Fitting and reviewing finished prostheses

Fitting Start

PATIENT JOURNEY

• Check with gloved fingers, for lumps, bumps, or rough and sharp areas on the fitting surface,
removing these with a bur where necessary

• Once again check the fit, retention, stability, aesthetics, speech, occlusal contacts

• Offer advice on denture hygiene and reiterate the risks of wearing partial dentures

• Offer eating advice, especially where large edentulous areas or complete dentures are involved

• Offer the patient the medical devices sheet or receipts for the lab work

• Reassure the patient regarding acclimatisation to the new prostheses and once again check
expectations with respect to retention, stability and control

Pressure relief paste is applied to the fitting surface and the A soft pencil is used to mark thinned areas before
patient is encouraged to close into their intercuspal position the material is peeled off. Areas for adjustment
are clearly visible
Review

Mark up the occlusion

2 Check for rough areas 3 and look for heavy
of the denture base(s) contacts

1 week

Pain on the
fitting surface

Check for pain on For frank ulceration, make any

the ridge using minor necessary adjustments
1 direct palpation and encourage the patient to
without the leave the denture out until the
denture in situ ulceration has resolved

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Companion Website: www.wiley.com/go/field/removable
A Checking the fitting surface
ssuming that the prescribed features of the prostheses were 53
correct at the most recent try-in appointment, then there If you are using permanent bases for complete dentures, then
should be little of concern when fitting them. Nonethe-

Chapter 26 Fitting and reviewing finished prostheses

you may have carried this out at the prescription and registra-
less it is important to check the same features as you did during tion stage. However, the fitting surface should be checked again,
the try-in stage. This will include the fit, retention and stability, because it is always possible that lumps, bumps and sharp ridges
aesthetics and speech. It should not simply be assumed that the of excess acrylic remain after processing. Prior to inserting in
prosthesis will be satisfactory and it should always be fitted in the the mouth, spend a few moments running your gloved fingers
chair – never send it out in the post. and thumbs over the fitting surface. If any area seems sharp, then
The fitting stage is an incredibly important event, not just this should be adjusted with an acrylic bur. The surface should
because it is the culmination of the clinical and technical work, generally appear smooth without abrupt changes in contour.
but because the patient is at the point where they will leave Small localised adjustments will not significantly affect the fit
your surgery with the prosthesis in place. They should feel and stability of the prostheses. It is also possible to prophylac-
comfortable inserting and removing it and keeping it clean. tically investigate areas where the prosthesis is putting excess
They should also understand the risks to the oral structures if pressure onto the soft tissues – this can be done for complete or
they do not maintain the prosthesis properly (this is discussed partial dentures and should be carried out using a closed-mouth
further in Chapter 44). technique. Pressure relief paste is rather technique-sensitive
Note that we do not expect all patients to feel completely and messy to use, and so a silicone (light bodied or a specific
comfortable with the prosthesis in place – whilst for many this pressure-indicator silicone) is recommended. A light wash
will be the case, it is the fitting stage where you should afford extra should be applied to areas of concern, and the prosthesis seated
time and support to anxious patients, those who are wearing a fully prior to the patient closing into the intercuspal position.
prosthesis for the first time, or those who had experienced Areas of heavier contact can be noted and adjusted (Figure 26.1)
significant difficulties in the past. The more difficulties that with an acrylic bur prior to polishing.
you can anticipate and discuss with the patient in advance, the
more favourably they will encounter them. They will also feel
more comfortable with your advice and guidance, and also your
reassurance. Sending patients away with unaddressed problems
Checking occlusal contacts
Once inserted into the mouth, you should re-check the occlusal
will damage your care relationship and may well result in patients contacts with thin articulating paper. Remember that the pala-
seeking care elsewhere. If you do not see patients again, do not tal cusps are functional on the upper, and buccal on the lower.
always assume you have been successful in your prosthodontic Do not assume that this will be acceptable just because it was
endeavours! checked at try-in. Subtle changes during processing mean than
Some technical aspects will help you to anticipate and identify small occlusal discrepancies often appear. Particularly heavy
errors that need adjustment, and these are described below. contacts will appear as a dark contact area surrounded by a
lighter ‘halo’ – and these should be reduced slightly.

Returning on casts
It is a good habit to ask for finished prostheses to be returned on Reviewing the prostheses
master casts (or if necessary, duplicated master casts). This can I would recommend a review no longer than a week after fitting.
help you to identify errors that may have been introduced since Patients should be counselled that it is normal for some areas to
the try-in stage, during processing. Before trying in the partial feel a little sore. However, if the area becomes too painful or ulcer-
prosthesis you should remind yourself of your chosen path of ated and the prosthesis cannot be worn, then the patient should
insertion – this will help you to remove it from the casts, but also leave it out until the day before they come for review. Usually,
to insert and remove it confidently and effectively in the mouth. sore areas on the fitting surface are because of a heavy contact.
On the casts, pay particular attention to areas of teeth that are Marking up the contacts should be the first investigation that you
worn, typically around bounded saddles. This can help you to make. Adjusting the fitting surface should be the last interven-
identify areas that might be troublesome during fitting. It is then tion that you make. All too often these are carried out in reverse!
useful to place one sheet of thin (around 40 microns) articulating It is worth reminding patients that, paradoxically, successfully
paper over areas of the dentition (either on the cast or in the improving denture stability and retention has the potential to
mouth) before seating the prosthesis, to help you identify cause pain, as patients begin to use them more – the tissues will
specific areas that may be binding. This is preferred to trimming not be accustomed to being loaded so heavily or frequently, and
away acrylic indiscriminately, leaving large embrasure spaces so the greater the improvement, often the greater the expectation
and defects, which attract food and plaque, and compromise that there will be sore areas. Patients should be counselled about
retention and stability. If you have not prescribed a particular this and take it slowly – soft and small food items for a couple
path of insertion for the partial prosthesis, then the technician of weeks, and chewing at the back of the mouth. Patients need
will often process acrylic into a number of undercuts, expecting to understand that, in the same way that they would not run a
that you will make adjustments at the chairside. In this case it marathon in new trainers, they need to build up their experience
cannot be returned on a cast – ensure that adjustments are in of wearing their new prostheses. A number of review appoint-
relation to a single path of insertion only. It is much easier (and ments are normal, and patients should be reassured of this; it is
actually your own responsibility) to prescribe a path of insertion not a sign of a failed construction process, or the inability of the
as part of your denture design. patient to wear or tolerate them effectively.
 Copying features from existing
54

27
Chapter 27 Copying features from existing prostheses

prostheses
Figure 27.1 Copying features from existing prostheses

Copying denture extensions Copying denture features

• Existing dentures have • Photos
been modified with the • Visiting the technician
addition of greenstick • Own measurements
material prior to copying

Alginate
impression

1 2 3

The extended denture fitting The impression is trimmed A special tray is constructed
surface is copied in putty so that the sulcular extensions (with the required spacer)
are visible directly onto the putty index

Modified copy process

1. A copy box metal tray is filled with alginate 2. One set, the alginate is trimmed and Vaseline is applied to the
and the occlusal aspect of the denture is exposed denture surface. The remaining half of the box is loaded
seated into the material with alginate, and closed tightly until set

3. The box is opened, excess alginate 4. The technician uses acrylic Registration
is removed and the denture is lifted out and wax to replicate the denture

Acrylic At try-in the following should be noted:

• Once try-in is complete, a wash impression is taken
• It is necessary to remove all undercuts
• One arch should be completed at a time
• A closed mouth impression technique should
be used
Wax teeth
Fit

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Companion Website: www.wiley.com/go/field/removable
I
t is important to know how you might copy certain existing You are essentially carrying out the recording of the jaw relation- 55
features of a prosthesis and this chapter considers various ship next.
methods for doing so.

Chapter 27 Copying features from existing prostheses

Registration
The wax teeth should be altered in order to obtain suitable tooth
Tooth arrangements positions – if these were ideal in the copied dentures then there
One of the most common reasons for copying features is to is little to do. The occlusal vertical dimension should be checked
communicate tooth arrangements to the technician  – tooth anyway, along with the occlusal planes and the incisal level and
mould, size, arch position and other characteristic features. The lip support. Because of the minimal amount of wax, this pro-
method involves taking an impression of the relevant denture cess is easier than with traditional blocks. The only drawback is
teeth (usually the upper anteriors) within a stock tray. There is no that the copy bases are usually rather rough (they have been cre-
need for a high degree of accuracy, and dimensional stability is ated from alginate impressions) and unretentive. Patients should
unimportant, so alginate is the material of choice. Of course, it is be reassured that this is normal. Once you are happy, the copy
also possible to take and send photos, or even communicate your blocks can be registered together in the usual way. Often they can
own measurements – however, I find that an alginate impression be hand articulated, but it is better to verify that this is the case in
is, in most cases, sufficient. the mouth first rather than making an assumption; just because
the teeth interdigitate when hand articulated does not mean that
this is an accurate representation of the jaw relationship in the
Fitting surface mouth. Do not forget to prescribe a shade – and a mould too if
If the current complete denture is largely correct, or you can eas- you have altered the anterior waxwork so that the teeth are no
ily make some reversible modifications, it is possible to copy the longer visible. Often, when technicians copy dentures, they will
fitting surface in silicone putty. This can then be trimmed and also create a plaster cast of the tooth set-up so that they have a
used to make a special tray directly, which saves taking and cast- reference.
ing a primary impression. The technique is especially useful if
you are unable to access your usual impression materials – such
Try-in
as on domiciliary or other visits within a non-clinical setting. It
The next stage is try-in – and this is essentially carried out in the
is also dimensionally stable, which is important if the impression
same way as for conventional dentures (see Chapter 25). How-
is going to be stored while you are out and about. Your technician
ever, the main difference here is that once the try-in is correct,
should be instructed to construct a special tray in the usual way,
there is a need to carry out a wash impression (the major or
2–3 mm from the full sulcal border.
working impression) in order to modify the relatively crudely
copied bases. It is incredibly challenging to address the border
Full denture contour extensions separately when they are constructed in wax; it is
therefore very important to modify the denture, where possible,
Complete dentures can be copied in their entirety using copy
before copying. Crucial to the process is that undercuts should
boxes (Figure 27.1) which replicate the fitting, occlusal and pol-
be removed from the internal aspect of the denture base. Inspect
ished surfaces. More often than not, however, we use copy boxes
the base carefully and use an acrylic bur where necessary to trim
to create wax and acrylic replicas of the dentures, which are then
back the base. If undercuts remain, then when the impression is
modified clinically.
cast, the denture becomes locked into place. The wash impres-
sions are carried out using a closed-mouth technique. Each pros-
Modifying prostheses prior to copying thesis should be loaded with impression material in the same
way as a special tray – a thin icing of material (silicone or zinc
If dentures can be modified prior to copying their features,
oxide eugenol) in the internal fitting surface rather than being
then it means there is less work to do at the subsequent stages.
filled up. This ensures that the bases are seated fully. It also pre-
More often than not this involves additions to a denture that
vents a large inadvertent increase in occlusal vertical dimension,
can be reliably carried out with greenstick or compound. This is
which is an unintended consequence of a closed-mouth impres-
removed once the impression has been taken. Waxes are a poor
sion technique when copying dentures. Each arch is taken in
substitute because they tend to distort easily. Subtractive changes
turn, and once loaded, the base is fully seated and the patient is
to existing dentures are less desirable and may be an indication
encouraged into their intercuspal position. It is imperative that
to construct the new denture conventionally.
you continue to functionally border mould during the working
impression – this is something that is often omitted, resulting in a
How to create modified copy dentures copy denture which is overextended around the periphery. Once
the impression material has set, the denture is left in situ, and the
Robust and rigid copy boxes should be used. Within each box,
same procedure is carried out (as a closed-mouth impression)
the occlusal and polished surface of the denture is seated firstly
with the opposing arch.
into alginate. Once set, the exposed denture and alginate are
coated with Vaseline prior to the remainder being recorded.
Once the denture is removed, and the box closed, this results in a Fit
void within which the copy template can be poured by the tech- The technician will process the try-in with the wash impression(s)
nician. Communication with the technician about which aspects for fitting at the next visit. The fit appointment is treated in
you are intending to copy is critical to the success of the copy exactly the same way as for conventionally constructed dentures
denture process. After copying, the dentures will be returned (Chapter 26).
either completely in wax, or with acrylic bases and wax teeth.
 Classifying partial prostheses and
56

28
Chapter 28 Classifying partial prostheses and material choices

material choices
Figure 28.1 Classifying partial prosthesis and material choice

Kennedy classification of partially dentate arches

• Determined by the distal-most saddle

• Class 4 cannot be modified, otherwise

1 2 3 4 it becomes reclassified to 1, 2 or 3

2,1 3,2

Challenges

• Obtaining indirect • Obtaining sufficient • Least difficult but • Obtaining sufficient

retention bracing potential problems indirect retention
with bracing
• Torquing forces on • Choosing suitable • Avoiding overextension
abutment teeth teeth across the • Eliminating dead anteriorly
arch for stability spaces effectively
and retention

Material choice

• Avoid loading teeth with <50 % • Prosthesis should gain support from
horizontal bony support, hard and soft tissues where possible
pathological mobility or active Acrylic Cobalt
periodontal disease chrome • Acrylic should not be the default
starting point

Or both?
Cast rests and clasps are more accurate and predictable than stainless steel clasps without occlusal rests

Cast element embedded into acrylic base

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C
lassification systems for partial prostheses are taught within • Class 3 – bounded saddles – these cases tend to be the least 57
most undergraduate curricula – however, I find that for challenging to restore. However, whilst there are often useful
many, this knowledge is lost to the ether soon after gradu- guide planes that can be engaged, it can sometimes be difficult

Chapter 28 Classifying partial prostheses and material choices

ation. This is probably because of a lack of engagement with the to obtain adequate bracing, and to choose a suitable path of
classification process in everyday clinical practice. It could be insertion that eliminates dead spaces effectively. This class is,
argued that knowing how to classify partial prostheses is largely however, potentially the healthiest in terms of hard and soft
an academic exercise – however, I would propose that it is useful tissue support.
to retain this knowledge for two main reasons: • Class 4 – unilateral saddle crossing the midline – in these cases
1 In order to communicate with colleagues and make referrals the biggest challenge, certainly in larger saddles that extend to
appropriately the premolars or beyond, is obtaining sufficient indirect reten-
2 In order to identify some of the specific clinical and technical tion to prevent the anterior saddle dropping. It requires extreme
challenges that are associated with each classification care when prescribing the anterior borders to ensure that these
are not overextended. It is also important to identify undercut on
the anterior ridge, in order to decide to what extent a heels-down
Kennedy Classification tilt for the path of insertion will provide an extra degree of direct
This is perhaps the most ubiquitous classification. Prostheses retention.
are classified into four main classes, determined by the distal-
most saddle. Figure 28.1 shows examples of each. A class can
be modified by any number of extra, bounded saddles. Class Material choice
4 (a single bounded saddle that crosses the midline) cannot be A partial prosthesis should, where possible, gain support from
modified – an extra more-distal saddle, in this case, would result both the hard and soft tissues. This is considered to be the gold
in a different classification (with the anterior saddle becoming a standard approach. A denture that employs a rigid substructure,
modification of the new class). such as cobalt chrome, allows this. The important caveat here is
that hard and soft tissue support should be employed where pos-
sible. There are occasions where a completely acrylic denture is
Applegate Classification indicated, such as allergy to the metalwork, inappropriate/inad-
This modification sees the introduction of two extra classes to equate support from remaining teeth, or if the denture is to be
the Kennedy system. provided as an immediate denture.
• Class 5 – this is the same as a Kennedy Class 3. However, it rec-
ognises that the anterior teeth are incapable of providing axial Periodontally involved teeth
support for the prosthesis. As a rule of thumb, teeth that exhibit pathological mobility, over
• Class 6 – this class suggests that the complete occlusal load 50% horizontal bony loss, or active periodontal disease (deep,
can be entirely toothborne and supports the use of unilateral bleeding pockets) should be avoided when looking for tooth sup-
prostheses in some situations. I am not overly supportive of the port. All teeth in the arch should be assessed in terms of their
concept of unilateral prostheses; these tend to be rather fiddly ability to provide support – and where possible, they should
to seat into place and can suffer from a high degree of rotational be considered. To provide a purely mucosa-borne denture (all
forces when in situ because of the lack of bracing that they can acrylic) just because the patient has active periodontal disease is
obtain. inappropriate.
If you do not wish to employ a full rigid framework, then it
is possible to embed cast cobalt chrome elements into the acrylic
Potential difficulties with each class base (Figure 28.1). Although this design is weaker than a full
• Class 1 – bilateral free-end saddles – in these cases the biggest framework, you will achieve much better fitting and appropriately
challenge is obtaining sufficient indirect retention to prevent engaging rests and clasps than if wrought stainless steel is used.
the prosthesis lifting posteriorly. This means that the posterior Stainless steel clasps often fail to engage tooth structure properly
denture extensions, the choice of connector and the clasping and are not accompanied by a rest. They distort easily and act
axis are critical. There is also potential to place a high degree with an abrasive action axially along the tooth (and potentially
of torqueing forces on the abutment teeth if the rest, clasp and the soft tissues) as the denture is loaded.
connector assembly are not designed carefully. These concepts
are all discussed further in subsequent chapters.
• Class 2 – unilateral free-end saddles – in these cases the biggest
Cost of rigid substructures
Cost is often stated as the main reason for not providing patients
challenge is obtaining sufficient bracing to resist displacement
with cobalt chrome dentures within primary care. However,
in function. Once again, the posterior denture extensions are
qualitative evidence shows that it is also a lack of confidence in
critical – and, in the absence of any other saddles, choosing
terms of prescribing and planning for cobalt chrome dentures
suitable and accessible natural teeth in the remainder of the arch
that prohibits their use. The following chapters will therefore aim
to receive rests and clasps can be a challenge. There is potential
to provide some clear guidance on tooth and mucosa-borne den-
with this class for the overeruption of opposing teeth to be more
ture design.
extreme than for Class 1; temporomandibular disorder is also
more frequent than in Class 1.
 58

29 Designing partial prostheses

Chapter 29 Designing partial prostheses

Figure 29.1 Designing partial prostheses

• Wax blocks used as carriers only
Preliminary registration
• Maintain natural tooth contacts passively

• Record the relationship of the block to the

opposing surface using a silicone paste

• Fissures should be filleted out to prevent

the casts bouncing on the highly accurate
silicone record

• Record the coronal condition, periodontal status,

bone levels and mobility scores of potential abutment
teeth. It can be helpful to mark on the cast which teeth
• Send details of natural tooth are suitable for providing axial support, or which to
contacts to the technician avoid as part of your design

Design process

Step 1 – Eyeball the casts Step 2 – A system of optimal design Step 3 – Surveying at the path of
• Classification natural displacement (POND) and
confirming a new path of insertion
• Expected difficulties (POI) if required (chapter 32)
• Dead space Saddles

• Undercuts
• Tooth arrangements Simplification Rests

Something really
Major
complicated is Clasps
and minor
connectors best resolved
in many stages!

Indirect
Reciprocation
retention

Bracing

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T
he decision to provide partial prostheses should be derived as Initially, it is useful to spend some time studying the 59
part of a wider and holistic treatment strategy, with the risks casts – considering (without definite measurement) the
and benefits being explicitly discussed with the patient and classification of the prosthesis and any expected difficulties or

Chapter 29 Designing partial prostheses

recorded in the notes. This will necessarily entail a full restorative challenges. I find it particularly useful to draw on the primary
assessment – followed by a diagnosis, risk assessment and staged cast with a marker (Figure 29.1) in order to label or question
treatment plan. A template for this is provided in Appendix 2. the suitability of individual teeth to provide support or direct
retention, or to highlight teeth that may benefit from further
restorative intervention, such as new or replacement restorations,
Preliminary registration or restoration of tooth surface loss. Remember that individual
Once accurate primary impressions have been obtained, periodontally involved teeth (those with active periodontal
preliminary registration blocks (either on wax or temporary disease or pathologically mobile teeth) may be omitted from a
acrylic bases) should be constructed to allow you to record design, whilst allowing other stable teeth to provide support.
the intended relationship between the arches. More often than It does not have to be an all-or-nothing approach. The casts
not, this involves recording (and maintaining) natural tooth should ideally be mounted on a rigid articulator and be
contacts – but it may be necessary, even in the absence of tooth detachable – either by split-cast mounting or by using magnetic
contacts, to assess the space between natural teeth and the baseplates.
opposing edentulous ridge. Other features that you should note at this stage include:
This record is then articulated and will be used to inform • Undercuts around teeth and edentulous ridges
your design process. This is arguably the least well executed • Severely tipped, tilted or rotated teeth
aspect of partial denture planning and therefore you should • Obvious dead spaces adjacent to saddles
check this articulation carefully – both at the chair side, before • Embrasure spaces, particularly in patients with recession
you send it to the technician, and when it is returned. It is useful • A lack of interarch space
to send details to the technician of the tooth contacts you have
recorded in the intercuspal position so that they can verify the
articulation. As described previously, the wax blocks should only A system of design
act as carriers for a registration paste – and the process should be At this stage it is useful to sit down with a design template
passive. Natural teeth should not be biting into wax blocks – you (Appendix 4) to work through a system of design.
should hear the sound of natural teeth tapping together when At this point, many conventional texts will tell you to survey
the blocks are in place, nor should silicone be syringed around the casts. In the absence of any proposed design, this is a rather
the entire arch. Cut definite and purposeful notches that will inefficient and laborious process. Practically, there is no need
oppose natural cusp tips, and when the patient has closed into to survey every tooth surface in the arch – and trying to juggle
intercuspal position, syringe the material into the individual all of the information yielded by this process can be extremely
voids. Reassemble this at the chairside on the primary casts, confusing. Instead, it is useful to come up with what you would
checking for the intended contacts and also for interferences consider to be an ‘ideal’ design, based on your initial examination
such as heel clash. It is useful to fillet out the fissures from the of the cast(s) and the information listed above. This does make
silicone registration with a scalpel to prevent this ‘bouncing’ on the assumption that you have adequate undercuts to clasp teeth
the less accurate primary casts. Alternatively, smear carding wax and that guide planes or undercuts are favourable – but you can
over the occlusal surfaces before taking the interocclusal record; easily check this later. I find that this approach makes designing
the only detail you need to record is that of the cusp tips. much more accessible and understandable for students. It also
makes you quicker and more efficient.
I have devised a mnemonic to facilitate the design process. It
Other necessary information ensures that you follow a logical, reproducible and comprehensive
In order to design an appropriate prosthesis that optimises hard sequence. It is also a useful way of communicating a denture
and soft tissue support, it is necessary to consider some other design, during an exam for example. Each aspect of design listed
factors: below should be considered, in turn, and drawn onto your design
• Recent periodontal indices (within the last 3 months ide- sheet. The following chapters will cover each in more detail,
ally) to include pocket depths, clinical attachment loss, mobility along with some specific case examples that highlight certain
scores and the patient’s oral hygiene capabilities important principles.
• Recent radiographic assessment of potential abutment teeth
(this can be obtained retrospectively when confirming the suit- Something Really Complicated Is Best Resolved (in) Many
ability of teeth to act as abutments if you prefer) in order to Stages
exclude any periapical pathology or root angulation that is not
able to provide effective axial support This stands for: Saddles, Rests, Clasps, Indirect Retention,
• Details of any coronal restorations for each tooth, including Bracing, Reciprocation, Major and Minor Connectors. The last
types of crown or inlay/onlay, details of direct restorative mate- stage is to consider whether your design is as simple as possible.
rials, pontic placement and support, and any planned replace-
ments, refurbishments or de novo restorations.
 60

30 Saddles, rests and clasps

Chapter 30 Saddles, rests and clasps

Figure 30.1 Saddles, rests and clasps

• Ensure coverage of the full denture bearing area

Saddles
• Maximise bracing and support

• Rounded
• Provide hard tissue support to complement • Bevelled edge
Rests
the saddles • Test with a round-ended probe
• Deflect food and debris away from the down the long axis
saddle-abutment junction

Ensure rests are acting down the

long axis of the tooth, and adequate
space is present occlusally

Clasp types
• Purposeful and deliberate Ring
Clasps
• Initially use 2 clasps to set up
a clasping axis of rotation
Clasp axis Indirect
retention
3-arm

C-clasp

Indirect
retention

• Place indirect retainers (rests or

Indirect retention
saddles) as far away as possible
from the clasping axis Example
• Often an asymmetrical and design
anteroposteriorly discrepant axis
is the most useful

• Prescribe saddles (blue), rests (orange) and clasps (red)

clearly on your design
• Identify your clasping axis and elements of indirect retention

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Saddles provide palatal or lingual shoulders, guide planes and undercuts
for clasps. If you do choose to have crowns milled to a partial
61
The first design features that should be prescribed are the
denture design, ensure that your technician leaves enough space

Chapter 30 Saddles, rests and clasps

saddles. This is where the prosthesis will derive its soft tissue
support – and so it is important to consider covering the full for connectors rather than just milling guide planes and prepar-
denture-bearing area, particularly any distal extensions. How- ing rest seats in isolation.
ever, prescribing a saddle for support does not always mean
prescribing the replacement of missing teeth. A large saddle will
usually provide a large amount of support and bracing, especially
Direct retention – clasps
At this point the directly retentive elements of your design
if you are able to engage the palatal vault and tuberosities on the
should be considered. Primarily this will be derived from clasps,
upper or the disto-lingual and retromolar aspects on the lower.
but also by engaging ridge undercuts – the latter is discussed in
Do not forget that your ability to extend into these areas depends
Chapter 32.
on how well extended your impressions were. Make sure that
It is important to be deliberate in your prescription for clasps.
the saddles are drawn clearly, including the intended extensions
Clasping excessive numbers of teeth will complicate the design,
(Figure 30.1)
increase the difficulty with which the prosthesis is seated and
removed, and result in greater amounts of food debris and plaque
Rests accumulating. As a rule of thumb, only two clasps are required.
This is explained further, along with indirect retention, below.
Rests should then be considered. These serve three main
functions: Clasps will only be effective where the tooth surface is
• Complement the support offered by saddles, by resting on undercut in relation to both the path of insertion and the occlusal
dental hard tissues plane (path of natural displacement). This can be checked later on
• Transmit occlusal loads from the denture down the long axis the surveyor. Clasps should always be supported by an occlusal
of the supporting teeth rest – they are relatively fragile components and they should be
• Deflect food away from the saddle-abutment junction passive when the denture is fully seated. The clasp tips should
Most often, rests engage various aspects of the crowns of begin to engage at the point the denture displaces in an occlusal
teeth – either small mesial and distal elements, larger shoulders direction. Prescribing clasps without a rest means that the clasp
or even onlay elements that restore large proportions of coronal arm can move up and down the tooth surface, causing distortion
structure. This support can also be obtained from sound retained and trauma. Clasp arms need to be ‘reciprocated’ (balanced) to
roots, with an overdenture for example. As a rule of thumb, rests prevent displacement or jiggling forces on the abutment teeth.
tend to be placed on either side of a saddle – but it may be the This can be achieved by the clasp encircling the tooth (ring
case, for short one- or two-tooth saddles, that only one rest is clasp), another clasp arm on the opposite tooth surface (3-arm
useful or, indeed, possible. clasp), or the major connector itself (c-clasp) (Figure 30.1). At
the surveying stage you should measure the depth of undercut to
ensure that it is sufficient for the clasp to engage and to allow you
Rest preparations to prescribe an appropriate material (cobalt-chrome 0.25 mm,
You should check the articulation carefully to assess the relation-
gold 0.5 mm), or make modifications to the clasping teeth or
ship of the opposing surface to the intended rest position. Even if
your design. Generally, to avoid weakening the structure, gold
there is ample interocclusal space, a rest seat should still be posi-
clasps need to be embedded in acrylic rather than soldered to the
tively prepared in order to ensure that it transmits forces down
cobalt-chrome framework.
the long axis of the tooth, and that there is a seamless emergence
of the framework from the tooth surface. Preparations should
be rounded to allow movement in function. I recommend a
large round diamond bur (1.5–2 mm diameter) seated to just
Indirect retention
Generally, two clasps will enable a ‘clasp axis’ to be set up. It is
over half its depth in the mesial or distal pit of the natural tooth about this axis that you should expect the prosthesis to rotate or
(or equivalent place in an existing restoration). The bur should tip. The clasp axis is akin to the centre point of a see-saw. In the
be carefully dragged down over the proximal surface in order same way that placing boxes under the end of the see-saw will
to bevel this surface and remove any sharp line angles, and to stop it from tipping, rests, connectors and saddles prevent the
make room for the framework to flow up and into the rest seat prosthesis from tipping about its clasping axis (Figure 30.1). It
(Figure 30.1). Without this reduction the framework can end up is important to consider the elements that will provide the best
bulky in this area, and at an increased risk of fracture because of indirect retention, on both sides of the axis. The further away
sharp line angles. Check your preparation with a round-ended from the clasping axis, the better the indirect retention. It is often
probe. The probe tip should be supported when loaded down the best to opt for an asymmetrical and antero-posteriorly discrep-
long axis. If it slips off, it is insufficient – the framework of the ant clasping axis, because this increases the likelihood that one
denture will suffer the same shearing action and fail to load the of the indirect retainers is already in a useful position. Obtaining
tooth axially. It is worth remembering that sometimes it is not sufficient indirect retention is often a challenge with free-end
appropriate to prepare a rest – the removal of sound tooth tissue saddles (especially bilaterally); ultimately the type of major con-
or creating damage to an existing restoration outweighs the ben- nector, and whether rest elements can be placed onto any of the
efit of having a rest in that area. Your clinical judgement should anterior teeth, become more significant considerations than in
be used in each case. That said, I would always consider whether other Kennedy presentations.
existing restorations would benefit from replacement as part of
the process. Porcelain-fused-to-metal crowns can be milled to
 62

31 Connectors and bracing

Chapter 31 Connectors and bracing

Figure 31.1 Connectors and bracing

Bracing • Resistance to horizontal displacement

when the prosthesis is fully seated

Where does bracing come from?

S

• Palatal vault
GE
RID

• Good sulcular extension on free end saddles

Connectors • Guide planes and precision or milled surfaces

against hard
tissues, or milled • NOT from clasp arms
precision attachments

Connectors

Major Minor

• A design principle, considering: • Framework elements in close proximity

– How the denture engages the hard and soft tissues to the hard tissues
– Indirect retention, bracing, rigidity, hygiene and
patient tolerance • Connects smaller elements to the main
substructure

Upper Lower

• Lingual bar – hygienic;

well tolerated
• Solid – rigid; good
cohesion and adhesion Think

• Sublingual bar – hygienic;

well tolerated; rigid; requires
adequate sulcus depth • How do my framework elements
• Ring – reduced palatal connect together?
coverage; less bracing;
less rigid • How will the major connector
‘reach’ the rests or clasps?
• Dental bar – hygienic;
good indirect retention • Is it a robust connection?

• Strap – minimal palatal

coverage; less rigid
• Lingual plate – rigid;
good indirect retention;
mucosal coverage

• Horseshoe – no palatal
coverage; good tolerance;
poor bracing; poor rigidity • Labial bar – good indirect
retention; useful to help
avoid lingual tori

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O
nce you have identified the hard and soft tissue support, and extending the framework up into the proximal spaces will 63
the retentive elements, you must then consider how to con- increase the risk of gingival inflammation and root caries in the
nect the components together. Even if you are unable to uti- absence of meticulous plaque control; however, this approach

Chapter 31 Connectors and bracing

lise teeth for hard tissue support, you may still wish to prescribe a can also offer a degree of indirect retention and bracing.
cobalt-chrome substructure in order to reduce gingival coverage
or to ensure greater rigidity and strength. Major connectors
When considering how to connect the prosthesis across the arch,
it is important to take into account the following factors:
Bracing • Tooth spacing – Any major connector sitting lingual or palatal
At this stage it is worth considering your connector design and to the crowns of the teeth will be readily visible if diastemata exist
your bracing elements together; often the two go hand-in-hand. or the patient has experienced gingival recession.
Bracing affords the prosthesis the ability to resist horizontal dis- • Local soft tissue anatomy – The presence of tori or shallow sulci
placement when it is fully seated. This includes both lateral and may limit your choice of connector.
rotational movement. Primarily, bracing will be obtained from • Clinical crown height and angulation – Short or near-vertical
base extension across the full denture-bearing area, and the palatal and lingual crown surfaces may offer little indirect reten-
ability to extend over ridges and into the palatal vault. Some tion or support.
degree of bracing can be obtained from minor connectors and • Prognosis of the remaining teeth – Anticipating future tooth
rest elements, especially if they contain features that engage tall loss in the short- to medium-term means that you may choose to
and broad vertical surfaces (such as a milled shoulder or a guide bring a major connector closer to specific teeth.
plane) (Figure 31.1); that said, it is best not to rely solely on these • Patient preference for mucosal coverage – Patients who have
when considering how to optimise stability. Clasp arms do not previously worn a prosthesis may express a preference for
afford any bracing, because the clasp tips should be passive when gingival coverage. They may also demonstrate a strong gag
the denture is fully seated. reflex, which limits your choice of mucosal coverage. Where
the posterior palate is causing a gag reflex, you may consider
a horseshoe design – however, do not choose this route lightly.
Major and minor connectors Gag reflexes are often exacerbated by poorly retentive and unsta-
Often, a source of confusion with rigid substructures is where a ble dentures – plenty of reassurance and full coverage may be
major connector ‘ends’ and a minor connector ‘begins’. Actually, required. Nearly all patients will acclimatise successfully with
it is better to think of a minor connector as a design ‘element’ this approach.
in proximity to the hard tissues which connects the finer or • Patient oral hygiene capabilities – The more complex the major
smaller elements, such as rests or free-end saddle meshwork, to connector, the less cleansable it will be and the more difficult it
the remaining substructure. As such, despite being called minor will be to keep debris and plaque-free.
connectors, they still need to be robust enough to transmit load • The need for indirect retention, bracing and rigidity – Extending
to both the underlying tissues and to the remaining substruc- a major connector onto specific anatomical areas such as the pal-
ture. Major connection, however, should be considered more atal vault or the lingual surfaces of the lower incisors may offer
as a design ‘principle’, which considers how the substructure a degree of indirect retention and bracing, whilst also increasing
should generally engage the hard and soft tissues, taking into the rigidity of the design.
account indirect retention, bracing, rigidity, hygiene and patient • The need to maximise cohesive and adhesive forces – Increasing
tolerance. mucosal coverage across more of the full denture-bearing
area will optimise cohesive and adhesive forces. This may be
Minor connectors critical in difficult cases, such as Kennedy Class I and Class IV
When considering how clasps will be reciprocated, you should presentations.
consider the mechanism for how the occlusal rest and clasp The major connector choices are shown in Figure 31.1. Upper
assembly flow from the major connector. When drawing your major connectors can take the form of solid connectors, ring-
design onto the design sheet, make sure that you are explicit style connectors, strap connectors or horse-shoe connectors.
about how you wish each component to connect. Imagine the Lower major connectors can take the form of lingual plates,
technician waxing up or designing your framework – is your lingual bars, sublingual bars, dental bars, labial bars, or labial
design clear? Have you considered how a cobalt-chrome sub- and lingual bars concurrently. In my experience dental bars are
structure will ‘reach’ each of your design elements whilst remain- significantly underutilised and provide a very suitable solution
ing robust? It is generally not a good idea to connect rests to for patients who have embrasure spaces with a concurrent need
other minor connectors such as saddle meshwork – ring clasps for indirect retention in the lower anterior region.
adjacent to saddles, for example, are probably best avoided. Ultimately, the final choice relies on patient preference and
Generally, frameworks should be at least 3 mm away from the your clinical experience – but do consider the full range of
gingival margins. Less than this, and the relatively small space options on each occasion rather than defaulting to a habitual
encourages food-trapping and reduces cleansability. Conversely, design or expecting your technician to choose.
 64

32 Surveying and preparing guide planes

Chapter 32 Surveying and preparing guide planes

Figure 32.1 Surveying and preparing guide planes

The provision of new PFM crowns

with a clear path of insertion defined
for the technician means that guide
planes can be usefully employed –
eliminating the need for clasps in
this case

Marking a survey line on the cast

Assessing for guide planes

Surveyor arm Surveyor arm

and stylus
The metal sheath of the
surveyor arm protects
the lead from snapping
whilst surveying. The
opposite side of the metal
sheath can also be used
for assessing dead spaces
and guide planes
Occlusal table
Pencil lead

Protective metal
sheath Leads and
gauges

Altering the path of insertion, where necessary,

particularly in relation to engaging anterior
saddle undercut

Dead A method for communicating the

space chosen path of insertion to the
technician. Three vertical marks
are drawn onto the cast (bucally,
mesially and lingually) in order to
help re-orientation in the lab

Altered path of
insertion reduces
dead space

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S
urveying is a critical part of the partial denture design pro- or to engage specific guide planes that may exist. In the case of 65
cess. As mentioned earlier, it is not always necessary to for- engaging anterior undercuts, your technician should only extend
mally survey the casts prior to working through a design – in the denture to around 1 mm beyond the maximum undercut of

Chapter 32 Surveying and preparing guide planes

fact, for those becoming accustomed to the process, accounting a ridge. This may mean that, in relation to the path of natural
for all of the information that an indiscriminate surveying pro- displacement, the denture extensions are relatively short in
cess yields can often overcomplicate the design process and result this area, which will likely affect bracing, aesthetics, and food
in elements being missed or poorly considered. In my experi- retention; therefore, engaging as much anterior ridge undercut
ence it also means that clinicians are less likely to consider other as possible is recommended. It may also be necessary to alter the
necessary tooth modifications such as restoring tooth form with POI in order to negotiate tilted or rotated teeth.
composite or altering/replacing/providing indirect restorations Importantly, once you have chosen a new POI, the relevant
with features that will complement the design such as shoulders, surface should be surveyed again at the new path. For undercut
guide planes and relevant undercuts. Examining the casts before to be useful, it must be common to both the new POI and the
you begin, as discussed in Chapter 29, is still an important part path of natural displacement. You then need to convey the new
of the process. intended POI to the technician. Practically, a general description
will often suffice (for example, a heels-down and slight left-
hand tilt in order to reduce dead spaces and engage the anterior
Should I survey for acrylic dentures? ridge – and to eliminate dead space on the left posterior bounded
Partial denture design is still very important even if you are pre- saddle). If the POI is more complex, then the new plane can be
scribing an all-acrylic prosthesis. Base extension, gingival relief/ marked onto the casts using three tripod marks – bilaterally and
contour and path of insertion (POI) should still be specifically anteriorly – to allow the technician to find the intended POI. It is
prescribed. If you fail to prescribe a POI, then your technician still a good idea to explain both the altered POI and the rationale
may well process the acrylic denture into multiple undercuts, for your choice.
expecting you to make a decision and adjust the denture accord-
ingly at the chairside. Unfortunately, to both you and the patient,
it appears that the denture does not fit at all – and in an attempt Guide planes
to make it seat fully, you will often inadvertently remove acrylic Employing two or more guiding surfaces can result in a prosthesis
from multiple paths of insertion – the denture will seat eventu- that is very retentive. In many cases, engaging multiple guide
ally, but it will be less retentive and stable, and with more dead planes means that you can eliminate the need to prescribe clasps.
spaces than if you had prescribed a single POI to the technician. Ensuring that guide planes are prepared appropriately is techni-
For rigid substructures, once you have an ‘optimal design’ it cally challenging. Guide planes should be at least 3 mm in height
is time to survey the casts to check the feasibility. The following for them to be effective – it is therefore important to make sure
aspects should be considered. the bur you are using is tall enough to cut the guide plane, and
for you to make a judgement about the long axis of the bur at the
same time. A long parallel-sided diamond fissure bur is a good
Path of natural displacement choice – and at around 8 mm in length, you are able to assess
This is the direction in which the prosthesis will be inclined to the guide plane angulation relatively accurately. The more guide
displace in function – and is usually perpendicular to the occlusal planes you decide to engage, the more technically challenging it
plane. Surfaces of interest include teeth that you are intending is to directly prepare the surface to a single POI. One of the best
to clasp (to check for suitable undercut), tooth surfaces adjacent ways to employ guide planes is to have them built into indirect
to saddles (to check for dead space) and anterior edentulous restorations – the technician will be able to use a surveyor when
ridges (to check for useful undercut to engage). The cast should waxing up the restorations (or use CAD software) to ensure that
be placed onto the surveyor table and adjusted until the occlusal guide planes conform to a single POI.
plane is parallel to the bench top. A lead can be inserted into
the surveyor arm – the lead is supported down one side by an
extension of the arm, to prevent the lead from snapping whilst Modifying the dentition
surveying. The lead should not extend beyond the metal support Once you have surveyed the cast(s) at the path of natural dis-
(Figure 32.1). The path of natural displacement can be traced lat- placement and (if different) the POI, you are able to make a
erally around the relevant teeth and ridges. The opposite, rigid judgement about whether your optimal design will be possible.
side of the surveyor arm can be used to assess for dead spaces It may be that on occasions, a tooth you would like to clasp has
(Figure 32.1). little undercut. Here you have a choice – you can consider alter-
ing the clasping axis or consider altering the tooth itself. A tooth
with little undercut can often be augmented with flowable com-
Path of insertion posite (even crowns can be augmented if sandblasted and silane
You may wish to alter the POI from the path of natural dis- coupled first). You can also consider replacing crowns, and these
placement. This could be for a number of reasons, but primar- should be replaced as porcelain-fused-to-metal designs with
ily includes the desire to eliminate anterior dead spaces (often milled shoulders and guide planes where possible. The techni-
by tilting the heels of the cast away from the occlusal plane). cian will need to know your intended design in order to make
On the upper arch this is known as a heels-down tilt. You may the new crowns first, and these should be fitted prior to taking
also wish to engage a greater degree of anterior ridge undercut, the working impressions.
 66

33 Designing frameworks – case examples

Chapter 33 Designing frameworks – case examples

Figure 33.1 Designing frameworks – case examples

1 2

3 4

5 6

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T Example 3 – Upper Kennedy Class III,
he aim of this chapter is to identify and justify a number 67
of design features by considering a selection of real frame-
works at the try-in stage. These cases have been chosen modification I

Chapter 33 Designing frameworks – case examples

because they raise useful discussion points, so feel free to discuss In this case, the major clasping axis has once again been set asym-
them further with colleagues and technicians. It is important to metrically although the antero-posterior discrepancy is limited by
remember that there is unlikely to be one single ideal design – 10 a requirement to avoid an unaesthetic clasp on the lateral incisor.
dentists in a room will probably end up giving you 11 different This case is interesting because of the palatal torus, which prevented
framework designs. What is more important is that you are able full palatal coverage from being prescribed. Indirect retention has
to justify your design choices, ideally (in time) based on your been obtained as far as possible from the clasping axis, on the upper
clinical experience. left molar and the upper right premolar. The C-clasps have been
reciprocated with the major connector to ensure rigidity and aid
bracing, given that the palatal vault is not engaged. The upper lat-
Example 1 – Upper Kennedy Class I, eral was already crowned, and so a rest was taken up towards the
modification I distal aspect to afford the saddle some extra support, without hav-
ing to prepare into the crown retainer. Another option would be to
In this case, the clasping axis has been set asymmetrically and
replace the crown with a porcelain-fused-to-metal (PFM) crown
is antero-posteriorly discrepant in order to maximise the effects
and to prescribe a tall palatal shoulder for axial support.
of indirect retentive elements, which should sit as far from the
clasping axis as possible to maximise the mechanical benefit.
This is an interesting case because of the large diastema between Example 4 – Upper Kennedy Class III,
the centrals. If you are not careful and do not communicate
the design properly, then your technician may be mistaken for
modification I
This case is interesting because a removable solution was being
assuming that you wish the small anterior saddle to be restored. sought to address a loss of occlusal vertical dimension. The ante-
The way the cast has been trimmed posteriorly is also slightly rior teeth were restored with composite, but the premolar teeth
deceiving. The C-clasps on the premolar and the molar are failed to re-establish occlusal contact – the decision was made not
accompanied by occlusal rests placed in accessible areas, and to replace the existing indirect restorations. Instead, the frame-
are reciprocated by the major connector in order to reduce the work was designed to allow onlay elements over the premolars.
chances of clasp deformation. Indirect retention is obtained The patient’s desire not to receive clasps on the canines, and the
from the rests on the palatal aspects of the upper right lateral fact that the posterior restorations were not to be replaced, meant
and canine, and the full extension across the ridge and around that the clasping axis, and the subsequent indirect retention, were
the tuberosity on the left. The rest elements anteriorly were also compromised. The incisor teeth were of a dubious prognosis and
bolstered palatally to accommodate a relatively intrusive contact so that anterior aspect of the major connector was perforated to
from the lower canine. The patient expressed a preference for a allow future additions. You may wish to consider the benefits and
horseshoe connector design although it was possible to extend risks of extending the framework posteriorly and up to the pala-
this slightly into the palatal vault to offer more bracing and tal aspects of the second premolars and first molars.
rigidity. This meant, however, that it was not possible to relieve
the framework from the gingival margins without compromis-
ing the rigidity. Extending up to the palatal aspects will improve Example 5 – Upper Kennedy Class III,
the bracing element, although the patient must be aware of the modification I
increased risk of root caries and plaque accumulation if this is This case received new anterior crowns as part of the denture plan-
not kept clean. ning and design process. The PFM crowns had palatal shoulders
to allow the framework to sit in close adaptation and be loaded
down their long axis. The distal of the left lateral also had a guide
Example 2 – Lower Kennedy Class III, plane prescribed, which corresponded to the medial of the premo-
modification I lar on the same side. The major clasping axis has once again been
In this case, the major clasping axis has once again been set asym- set asymmetrically and is antero-posteriorly discrepant in order
metrically and is antero-posteriorly discrepant in order to max- to maximise the effects of indirect retentive elements. The patient
imise the effects of indirect retentive elements. Indirect retention expressed a preference for a horseshoe connector design although
was considered on the lower left premolar and the lower right it was possible to extend this slightly into the palatal vault to offer
molar. The molar was periodontally compromised and unable to more bracing and rigidity. The major connector was used in order
be utilised for hard tissue support and so as well as an occlusal to reciprocate the clasps, and there was little need to prepare a rest
rest for indirect retention, an extra direct retainer was placed on seat distally on the upper right canine because of the presence of a
the lower left premolar. Ordinarily it is not a good idea to con- retained root, acting as an overdenture abutment. Indirect reten-
nect a clasp to another minor connector (the saddle meshwork tion is obtained from the rest on the mesial aspect of the left molar
on the left). However, in this case the undercut lingual to the and the palatal shoulders of the anterior PFM crowns.
molar was too significant to block out for a major connector and
so a ring clasp was used to ensure reciprocation was present. This
area of the framework will be particularly weak and it is impor-
Example 6 – Lower Kennedy Class II
In this case, the saddles have been restored using the RPI system
tant that the patient does not use the clasp arm to try and remove (mesial rest, distal plate, i-bar) to reduce torqueing forces on the
the denture. The direct retainer on the canine (i-bar) was recip- premolar teeth. Indirect retention has been optimised by placing
rocated with a cingulum plate, which will also help with bracing. a dental bar (which is further away from the clasping axis than a
A lingual bar was prescribed because of imbrications of the lower lingual bar would be). The advantages over a lingual plate are the
incisors and the short clinical crowns. reduced gingival coverage and improved cleansability.
 Precision attachments – the
68

34
Chapter 34 Precision attachments – the fixed–removable interface

fixed–removable interface
Figure 34.1 Precision attachments – the fixed-removable interface

Abutment Prosthesis

• Interlocking
• Improves retention and stability
Intra coronal Extra coronal

• Within the crown • External to the crown

• Friction fit • Greater resilience

• Ensure adequate
space during
preparation
Ball joints

Semi precision rests

Bar joints

• Often milled crowns

• Tall guide planes
• Deep shoulders
• Good bracing

Locator™
abutments

Auxiliary
• Ensure that rest seat
elements and shoulders
are fabricated in metal

Telescopic
copings

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A
precision attachment can be defined as an interlocking allow a greater degree of movement, or ‘resilience’. The attach- 69
device – one component is attached to an abutment, and the ments most often take the form of ball joints, which project
other is part of a removable prosthesis. The primary aim of laterally from the crown. However, the attachments can also be

Chapter 34 Precision attachments – the fixed–removable interface

a precision attachment is to improve retention and stability of studs (such as the Locator® systems), bars or magnets – and these
the prosthesis. tend to project occlusally. It is therefore important to ensure that
Employing precision attachments has, in the past, remained there is sufficient space within the housing of the prosthesis (and
a relatively niche modality, requiring an able technician and within the anticipated occlusal vertical dimension) to accommo-
a knowledgeable clinician who communicate well with one date these types.
another. However, the art of intra- and extracoronal precision The Locator® system is very popular as it offers a degree
attachments is becoming increasingly accessible in relation of resilience without the prosthesis completely detaching
to implant restorations, and with more manufacturers and from the abutments. This is discussed further in Chapter
technicians employing CAD-CAM, 3D printing, and laser 41, Implant-supported mandibular overdentures. Magnets
sintering. Many mainstream companies such as Cendres + are also still popular, especially on the faces of retained root
Métaux, Zest Dental Solutions and Nobel Biocare now offer a abutments – however, resilience is poor and a small degree of
large range of precision attachment choices. Some of the most occlusal instability can disassociate the magnet and its keeper. It
ubiquitous relate to mechanisms for improving the retention can also be technically challenging to process the magnet keeper
of removable partial dentures (RPD). Often these attachments into the denture base accurately, so that it functions optimally.
consist of two matched precious metal components, although Therefore, magnet keepers are often ‘picked-up’ at the chairside
we are increasingly seeing resilient plastic components. One once the prosthesis is completed, using cold-cure acrylic.
component is associated with the crown of the abutment tooth Cobalt-samarium magnets are resistant to corrosion and can be
and the other is housed in the framework of the prosthesis. processed up to 300 °C. Neodymium magnets are twice as strong
and are very thin, but they must be coated to prevent corrosion
Potential advantages of using precision and they will only tolerate temperatures of up to 150 °C.
attachments with a RPD
• Increased retention and stability Auxiliary attachments
• Improved aesthetics (no visible clasping assemblies) The telescopic coping (or telescopic crown) is classed as
• Retention is unaffected by external coronal contour an auxiliary attachment  – 
because it is neither intra- nor
• Reduced framework bulk extracoronal – it is the coronal aspect of the tooth (Figure 34.1). A
• Elimination of debris accumulation around clasps assemblies thin metal coping of gold, cobalt-chromium or nickel-chromium
is used to provide a durable outer coating to the preparation,
Potential disadvantages of using precision which has an optimal total occlusal convergence angle. The pros-
thesis can be processed around the coping (either in acrylic or
attachments with a RPD
• Often requires more extensive preparation of abutment teeth cobalt-chrome), or a sleeve can be manufactured which is picked
• Technique sensitive (clinical and technical) and is more time up and embedded into the acrylic. The latter tends to be more
durable.
consuming
• Higher cost when utilising precision attachments A range of alternative attachments are also available,
• Requires a minimum crown height (often >4 mm) which cater for less common clinical presentations. In some
circumstances, it is not possible to fit a removable prosthesis
along one single and common path of insertion. In this case, it
Classifying precision attachments is possible to employ screw precision attachments to lock several
pieces of the prosthesis together once fully seated. A similar and
Precision attachments are most often classified by the attachment
position. more accessible arrangement can be developed with bolts – a
derivative of which is the swing-lock denture, described in
Chapter 37. The advantage here is that with hinged flanges, it is
Intracoronal attachments possible to engage undercuts which would otherwise be blocked
Intracoronal attachments have the connection located within
out, which improves the aesthetics, retention and stability, and
the crown of the abutment tooth. Generally, they provide a rigid
reduces the incidence of food packing.
connection between the abutment tooth and the prosthesis.
Often this exists by way of a friction-fit mechanical lock. The
degree of mechanical advantage this offers is related to the height
of the clinical crown (and therefore the possible height of the
Semi-precision rests
Originating as the CSP (channel, shoulder, pin) system in the late
intracoronal attachment). When employing intracoronal attach- 1950s, this approach – which required the fitting of a metal-based
ments, failure to prepare the abutment tooth with adequate space crown with guide planes, deep and tall shoulders and occlusal
will result in a bulbous projection in the crown. Clearly this has pin slots, upon which the framework would seat – became known
implications for pulpal health and ideally should only be con- as the ‘milled crown’. More recent derivatives do not include the
sidered for teeth where large proximal restorations already exist. pin slots, but the guide planes and deep, tall shoulders provide
remarkable bracing. These crowns should be porcelain-fused-
Extracoronal attachments to-metal-based, or all-metal, so that the seating framework can
As you would expect, extracoronal attachments have the connec- be afforded a degree of resilience without the risk of fracture of
tion (or part of the connection) located external to the crown veneering material, or worse, fracture of the crown itself.
of the abutment tooth. This means that the assembly tends to
 Dealing with frameworks and
70

35
Chapter 35 Dealing with frameworks and substructures

substructures
Figure 35.1 Dealing with frameworks and substructures

Cast rests and clasps Alloy teeth

• More robust than stainless steel clasps without a rest • Cobalt chrome or preformed stainless steel crowns
• More accurate fit • Onlay elements to increase the occlusal vertical
• Must prescribe a path of insertion for the technician dimension or in bruxist cases to reduce accelerated
denture wear

Accounting for additions

• If you are anticipating further tooth loss in the

foreseeable future, plan for additions by asking
for a perforated framework Try-in of the framework

• Check that your design has been followed

• Check your path of insertion
• Check for visible rubbing or wear on the casts
• Seat in the mouth, using the rest elements only
• Check the adaptation to the tissues
• Mark the fit surface with GHM articulating paper
to identify binding areas
• Check the occlusion for interferences and aesthetics

Onlay dentures

• When designing onlay dentures, request bobbled frameworks in order to help retain acrylic or composite

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P
roblems with rigid frameworks can cause a lot of frustra- allow the teeth to be embedded within the acrylic, or as men- 71
tion, primarily because they are relatively expensive, but tioned earlier, as part of the substructure itself. Consider what
also because problems with frameworks can delay treat- material the denture teeth are opposing and whether the patient

Chapter 35 Dealing with frameworks and substructures

ment significantly because of turnaround times for re-makes. has bruxist tendencies or a particularly heavy bite.

Try-in of the framework Accounting for additions

You may notice that the framework does not fit accurately. It As part of the denture design process, you should be considering
is worth considering whether the working impression has dis- teeth of short- to medium-term prognosis, that is, teeth that
torted. This is most likely to happen if some impression material might be lost during the functional life of the prosthesis. In this
was not supported by the tray, the material has torn or peeled case, it is worth designing frameworks that allow future additions
from the tray or there has been a dimensional change. These (Figure 35.1), which may involve extending frameworks into
risks are reduced by using a silicone material. You may also have areas that you might otherwise have left clear – and considering
recorded distortions in tooth position if teeth were mobile or perforating the framework so that acrylic additions can be made
there was pressure on the teeth from the tray during the impres- easily.
sion. Finally, air blows can be a source of error, so I advise pre-
loading rest seats for a better result, either with silicone from a
fine tip or with a smear of alginate. Do not assume that air blows Protecting small anterior saddles
can be ‘flicked off ’ by your technician – just because they flick On the upper arch it is common for single teeth or entire small
off, it does not mean that the area underneath corresponds accu- saddles to fracture off the substructure. This is exacerbated in
rately to the tooth surface. patients with deep overbites or parafunctional habits. It is worth
• Check your design has been followed. considering in these cases whether you will extend the frame-
• Remind yourself of the path of insertion so that you can work up onto the palatal aspects in order to protect these teeth in
remove and place the framework back onto the cast and in the function. If there is no room to place a full prosthetic tooth onto
mouth without causing distortion or wedging. the labial aspect, then it will most likely be trimmed down so
• Check the cast for visible areas of rubbing, wear or fracture that it veneers the framework in this area. If you can identify the
repair, because this will usually correspond to tight areas in the need for this approach early, it will help you to design an appro-
mouth. priate framework and to check for occlusal interferences. This is
• Attempt to seat in the mouth. If you feel resistance, seat thin where a preliminary registration is particularly helpful – and the
GHM paper under the framework to mark-up tight areas. Look technician may even want to send an anterior tooth try-in prior
around rests and plates at the saddle junctions, especially around to framework construction, so that they can determine the ideal
small bounded saddles. Make a decision about whether you can prosthetic envelope. This will help to inform your framework
make any necessary adjustments or not. If not, you will need to design – clearly in cases like this, it is of benefit to have an open
retake the working impression, but do communicate the prob- dialogue with your technician.
lems to the laboratory and send back the old framework as a ref-
erence. If seated fully, check that it is comfortable and that the
patient does not feel any significant pressure on the dentition. Altering clasps
• Seat the framework using the rest elements only – avoid load- It is common for technicians to ‘deactivate’ clasps to facilitate
ing saddle areas, which will cause the framework to pivot. seating and removal from the casts. This may lead you to think
• Check the occlusion – with accurate preliminary registration that the framework is unretentive or poorly fitting – and so it
then this is seldom an issue, but if you have interferences, mark is important to inspect the framework on the casts in the first
up with articulating paper in the intercuspal position and in instance. The clasp tip should be sitting on the surface of the
excursions. If rests are becoming thin, then consider removing tooth, not away from it. You can ask your technician to ‘reacti-
entirely or reconsidering a new design – thin rests will fracture vate’ the clasp prior to finishing – but from time to time you may
and can remain very sharp. need to do this yourself – it is also necessary to adjust clasps over
Onlay dentures – Ask for bobbling so that acrylic or composite time as they distort, in order to re-engage with the tooth surface.
can be added, avoiding the need for labial flanges (Figure 35.1). Clasps should be adjusted with Adams pliers, and in my opinion
If onlaying posterior teeth, you can prescribe cobalt-chrome if it is much easier and more predictable to adjust a C-clasp that is
the patient has bruxist tendencies, or the acrylic is too thin to be reciprocated with the major connector, than a ring or a 3-arm
retained effectively. clasp. Clasp arms tend to deform at their junction from the sub-
Cast rests and clasps – Using cast rests and claps rather than structure, not within the clasp arms themselves. To avoid this,
stainless steel can be a cost effective alternative to a full cobalt- the tips of the Adams pliers should hold the clasp arm just prior
chrome framework, especially where just one or two clasps are to its junction with the occlusal rest – the clasp tip itself should
required. The advantage here is that a rest can be included as not be adjusted. Do not grip too tightly otherwise the flat sur-
a necessary adjunct and the rigid assembly works much more face of the pliers will begin to flatten and distort the clasp arm.
appropriately than a stainless steel wire, which is unsupported in Instead, apply some gentle inward pressure. When you think you
function. In my experience these fit extremely well, but you still have seen the clasp tip move, that is enough!
need to consider a path of insertion, dead spaces and undercuts.

Alloy teeth
These can be cobalt-chrome or stainless steel pre-formed crowns
(Figure 35.1) – cobalt-chrome can be cast with engaging fins to
 The altered cast technique and the
72

36
Chapter 36 The altered cast technique and the RPI system

RPI system
Figure 36.1 Altered cast technique and RPI system

Correct extension Placement of teeth

within the neutral zone
(chapter 24)

Stability

Accounting for
fibrous ridges

Mucocompressive and
mucostatic impression
Altered cast technique techniques – Chapter 17 RPI system of design

• Mesial rest
• Distal plate
• I-bar

Try-in of the framework

An RPI system of design ensures that,

particularly on a mucocompressive distal
saddle, all minor connectors, clasps and
rests, move away from the hard tissues.
This reduces the torquing forces on the
Framework plus non-spaced acrylic tray. abutment teeth
This requires careful border moulding
in the mouth

The new section is now recorded

mucocompressively and the
prosthesis is less likely to displace
in function

The cast is sectioned The cast is repoured to form

the ‘altered cast’

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P
reviously, we discussed strategies for optimising stability of mucocompressive, yet overextended. One clinical problem is 73
a prosthesis. These included: then replaced with another. Do not forget to check the acrylic fin
• Correct extension, both into the functional sulcus, and extensions, or to border mould adequately during the altered cast

Chapter 36 The altered cast technique and the RPI system

across the full denture-bearing area impression.
• Placement of the teeth within the neutral zone It is also very important to ensure that you seat the framework
• Accounting for fibrous ridges by its toothborne elements only, otherwise the framework will tip
In relation to fibrous ridges, there are several approaches when you load the free-end saddle(s). This is most likely with a
that can help to accommodate differential movement beneath Kennedy Class I presentation. If tipping occurs, it will result in a
the denture base. Respecting or compressing the tissues during distorted cast when the impression is re-seated onto the working
a working impression was discussed in Chapter 17. This was cast in the laboratory.
largely discussed in relation to completely edentulous ridges.
Whilst these techniques can be used in partially dentate patients,
there are two other formally recognised techniques that can be The RPI system
employed. These are discussed below. The RPI (rest, plate, I-bar clasp) system can also be used where
the tissues overlying a free-end saddle are likely to cause down-
ward displacement and rotation of the denture base in function.
The altered cast technique Instead of attempting to re-record the tissues compressively with
The altered cast technique can be used where the tissues overlying an altered cast technique, the RPI system relates to a specific
a free-end saddle are likely to cause downward displacement framework design that is thought to reduce the impact of den-
and rotation of the denture base in function. Accommodat- ture base rotation on the abutment teeth.
ing for this displacement can reduce the torqueing effects of RPI describes the following components, which specifically
the framework on the abutment teeth. There is little evidence relate to the abutment teeth adjacent to the free-end saddle:
that this approach makes any perceived clinical difference – and • Mesial rest (instead of a rest immediately adjacent to the
using a relatively mucocompressive material during the primary saddle)
impression can negate the need for any further special interven- • Long distal plate (which engages from the marginal ridge
tions. Regardless, if you decide to employ an altered cast tech- down onto the attached gingival tissues)
nique to formally account for a compressive free-end saddle, this • Gingivally approaching I-bar (which moves passively towards
is usually carried out after the framework try-in stage. An extra the embrasure space as the prosthesis rotates)
appointment is therefore required. The aim of the technique is This clasping and resting combination is thought to reduce
to ‘re-record’ the free-end saddle mucosa with a greater degree the torsional forces placed onto the abutment tooth. Ordinarily,
of compressibility. with displacement over the ridge, a distal rest would place a non-
Once the framework accuracy is confirmed, the framework is favourable torqueing load onto the tooth, whilst a C-clasp tip
adapted by the technician with an acrylic fin, which recreates the would also engage towards the tooth surface rather than in an
special tray extensions around the free-end saddle. No spacer is axial direction. Instead, a mesial rest and a gingivally approaching
used by the technician when adding the fin; this means that when I-bar would move away passively from the tooth surface as the
the framework is fully seated, and the acrylic fin is loaded with saddle is depressed (Figure 36.1). The distal plate should engage
impression material, the impression becomes mucocompressive. as a tall guide plane, which means that the distal aspect of the
Because the tray is not perforated, it is best to use zinc oxide abutment should be prepared in line with the intended path of
eugenol, or a heavy-bodied silicone (with appropriate adhesive) insertion. The long distal plate requires more meticulous oral
to record the free-end saddle. Ensure, as normal, that the tray hygiene because of its close contact with the tissues – however, it
is adequately trimmed, and if necessary, border moulded with serves to stabilise the prosthesis further and to protect the tooth–
greenstick or putty. tissue junction by preventing food impaction as the denture
Once the altered cast impression is received by the technician, moves in function.
the corner of the cast representing the free-end saddle(s) is cut Often the RPI approach is only partially implemented – usually
away, and the framework is re-seated onto the model. The aspect by way of a mesial rest and an I-bar. Once again there is limited
of the model that is missing is then re-poured, to represent evidence that the approach makes any clinical difference. I would
the compressed free-end saddle mucosa. In theory, the final certainly counsel against automatically prescribing this design
prosthesis is less likely to ‘bounce’ in function and will reduce for every free-end saddle that you come across. Pay attention to
the torqueing forces on the abutment teeth. whether the free-end saddles seem to more be mucocompressive
A very common clinical mistake (and probably the reason than normal. More importantly, you should consider where
that there is little reliable evidence for its use) is that the border the occlusal rests can be usefully placed and employed, both in
extensions of the acrylic fin are neglected. Far too often the terms of any potential existing restorations, and in relation to
fin is simply loaded with material and the impression taken, the opposing occlusal contact(s). Blindly placing a rest mesially
without careful checking of the extensions or attention to because of a free-end saddle is likely to cause more serious
border moulding. This results in a free-end saddle which is problems than a potential bouncing saddle!
 74

37 Swing-lock prostheses
Chapter 37 Swing-lock prostheses

Figure 37.1 Swing-lock prostheses

Indications
and contra-
indications of
swing lock
prostheses
• Engage a short
• Poor manual dexterity for
dentate span
latching and unlatching

• 5mm+ of • Unrealistic aesthetic

sulcal depth requirements

• Engaging hard • High frenal attachments

tissue undercut interfering with locking
arm position

• Avoiding the • Traumatic occlusion interfering

need for clasps with substructure elements

• Periodontally • Lack of undercuts

stable dentition

A typical design for a swing-lock assembly

Embedded
clasp assembly

Alternative clasp assemblies –

multiple I-bars instead of
embrasure acrylic. This design
is less aesthetic but more
cleansable

• Accessible rather than

embedded clasp assembly

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S Assessing the periodontal condition
wing-lock dentures tend to be labelled as specialist-level 75
treatment. However, there is little reason why a swing-lock Some clinicians maintain that a swing-lock design can be
design should not be considered when planning treatment.

Chapter 37 Swing-lock prostheses

useful for splinting periodontally involved teeth, especially
With considered design features and good communication because patients are transitioning towards edentulism. It is very
with a confident technician, they can be provided as part of the important to counsel patients about the inherent risks of this
standard prosthodontic armamentarium. approach – and whilst engaging the teeth may indeed help them
to acclimatise to a removable prosthesis, it may also perpetuate
What is a swing-lock prosthesis? or accelerate the deterioration of the engaged teeth. On balance, I
would suggest that a swing-lock design is best employed around
A swing-lock prosthesis consists of a preformed labial or buccal
periodontally stable teeth (with no active periodontal disease);
hinge, which attaches to a precision attachment, housed on the
ideally with little mobility and at least 50% horizontal bony sup-
major connector. Traditionally, the swing-lock framework is cast
port. This is an arbitrary figure – and it is worth noting that in the
as a single unit, although advances in polymer technology mean
absence of occlusal rests, and the presence of lingual plates, the
that ‘replaceable inserts’ are now available that can be embedded
axis of rotation is nearer the gingival margin. As such, there is
into keepers within the framework. Typically, a swing-lock
minimal torqueing effect on the distal abutments.
prosthesis is inserted from the lingual or palatal aspect before
the retentive bar closes across the labial surfaces. The retentive
bar can engage undercuts provided by the teeth and/or the eden-
tulous ridges, and is normally reciprocated by a lingual or palatal
The latch assembly
The latch assembly should sit in the recessive element of the
plate. labial ridge (Figure 37.1). You must ensure that the functional
impression is accurate in this area – and this means careful exten-
Indications sion of the special tray. I would recommend formally recording
the border with a mouldable material such as putty or greenstick.
Some situations where you might consider a swing-lock design
Prior to the wash impression, any large embrasure spaces can be
include:
blocked out from the palatal/lingual surface, leaving some degree
• To engage short dentate spans, where at least 5 mm of
of embrasure engagement from the labial surface. This prevents
functional sulcal depth exists labially
tearing of the interproximal impression material and ensures
• A lack of support and retention for the prosthesis, such as hard
good adaptation of the acrylic where required.
tissue undercuts
• To avoid the need for prescribing or replacing crowns, or other
extracoronal recontouring procedures
• To avoid the need for unaesthetic clasps or occlusal rests
Retentive elements
The latch arm will be directly retentive as it swings closed and
• Where multiple embrasure spaces exist
engages the ridge undercut. As described previously, it may also
• Where the prosthesis will gain support from a periodontally
engage the embrasure spaces with acrylic (Figure 37.1). It is also
stable dentition possible to employ single I-bar type clasps (known as struts) or
multiple struts (Figure 37.1). Acrylic veneering results in a much
Contraindications closer adaptation to the tooth surfaces, which results in better
aesthetics (especially in cases with large embrasure spaces or
• Poor manual dexterity – Assessing the manual dexterity of your
recession) and less food packing.
patient is incredibly important when considering a swing-lock
In order to maximise bracing, lingual and palatal plates are
design. This relates to their ability to insert the framework along
taken up onto the lingual and palatal surfaces of the natural teeth,
a prescribed path of insertion, their ability to lock and unlock
stopping short of the incisal surfaces. You may also consider
the latch assembly, and their ability to maintain meticulous
occlusal rests on mesial and distal surfaces, and on multiple teeth.
oral hygiene around the abutment teeth. Swing-lock prostheses
To optimise bracing further, porcelain-fused-to-metal crowns
maximise their stability by covering the full lingual and palatal
with guide planes and milled shoulders can be considered.
surfaces of the teeth – and so there is a significant risk of food
stagnation, plaque accumulation and caries.
• Aesthetic demands – From an aesthetic perspective, it is also
important to consider the height of the patient’s smile line or
Connector design
Rigid connectors for swing-lock dentures can follow traditional
position of the lower lip line. This will help you to determine connector designs, provided the lingual or palatal plate is present
whether any clasping or framework elements will be visible. to act as bracing and reciprocation for multiple labial elements.
• Frenal attachments – Relatively high frenal attachments in the
In the maxillary arch, a strap, horseshoe, open palate or full cov-
area of the framework should be viewed with caution. Adequate erage design can be successfully employed – although remember
relief for these may compromise your design or completely that a significant degree of bracing and rigidity will be obtained
inhibit extension of the framework into the length of the sulcus. from engaging the palatal vault.
• Traumatic occlusions – Akerly Class 2, 3 and 4 traumatic over-
bites, or deep overbites, may prevent extension of the framework
onto the full lingual or palatal surfaces of the natural teeth.
• Lack of undercut – A lack of undercut provided by the remain-
ing dentition or alveolar ridges would mean that a swing-lock
would fail to obtain any useful retention.
76

38 Gingival veneers
Chapter 38 Gingival veneers

Figure 38.1 Gingival veneers

Gingival
veneer

• Replace soft
• Deliver topical medicines
tissue bulk
and dressings
• Restore ideal soft • Avoid periodontal
tissue contour • Cover and protect plastic surgery
recession defects

Contraindications
• Poor oral hygiene • Active periodontal disease • Allergy to acrylic or silicone materials
• High caries risk • Poor manual dexterity • Prominent frenal attachments

Addition of a tray handle, and the adaptation of the tray

periphery anteriorly to engage the full sulcus contour

Accurate primary impressions, accounting

1
for the full recording of labial surfaces and
sulcus. It may be necessary to modify your
primary impression tray, especially where
more significant undercuts exist

A special tray should be constructed that Stops

2
rotates around the canine tips, which will act
as stops. Prior to taking the impression,
palatal embrasure spaces should be blocked
out to prevent through-and-through
engagement of the silicone and subsequent
tearing

Shade recording using

3
a gingival shade guide
– this can also be
determined digitally

The final veneer presented

on the working cast

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A Indirect technique
gingival veneer (sometimes called a gingival prosthesis) is a 77
removable device that is provided, most often in the ante- A working impression is required that captures an accurate
rior maxilla, in order to:

Chapter 38 Gingival veneers

functional sulcus on the labial aspect. This may require the mod-
• Replace soft tissue bulk
ification of stock trays and dedicated border moulding of special
• Restore ideal soft tissue contour
trays. It is important to block embrasure spaces (from the palatal
• Cover and protect recession defects
aspect only) using carding wax, to prevent the impression mate-
• Avoid periodontal plastic surgery
rial from locking into place and tearing on removal. A special
• Delivery topical medications and dressings to the periodontal
tray should be constructed that sits on the incisal edges of the
and dental hard tissues lateral and canine teeth, using them as stops. Light bodied sili-
For most patients, the gingival veneer will address most, if not cone can be applied interproximally. The tray is then loaded with
all, of these functions (Figure 38.1). Gingival recession can cause medium or heavy bodied material and rotated into place, which
concerns over aesthetics, marked dentine sensitivity because of ensures a degree of sustained lateral pressure from the material
exposed root surfaces and problems with speech because of air into the interdental spaces. I would recommend avoiding putty,
escape through embrasure spaces. Some patients will also suffer because this tends to drag when not completely confined by a
from significant food accumulation and stagnation in larger closed tray. Removal should be linear, in a labial direction.
embrasure spaces.
Regardless of the function(s) of the gingival veneer, there is
no doubt that the patient’s oral hygiene must be excellent. Such a
close-fitting device will otherwise promote significant soft tissue
Retention
Retention for acrylic veneers is obtained by engaging the dis-
inflammation and dental caries in the covered hard tissues. Many tal aspects of the canine or premolar teeth. A degree of flexion
patients wearing a gingival veneer already present with exposed offered by the acrylic means that the prosthesis will ‘snap’ into
root dentine, which puts them at high risk of developing root place because it engages undercuts provided by the hard tissues.
caries, especially if the veneer is worn for long periods or if Once in place, the extensions into the embrasures (which replace
plaque and cariogenic substances have accumulated. Once the the papillary form) will offer a degree of bracing and retention.
prosthesis is fitted, it is important to emphasise to the patient the A small degree of cohesive and adhesive forces from contact
need for regular review. with the attached gingival tissues will aid in improving reten-
tion and stability. In more advanced cases it is possible to use
precision attachments to connect gingival veneers to other fixed
Contraindications or removable prostheses in the mouth.
• Patients who are unable to maintain excellent oral hygiene effec-
tively should be counselled against the use of a gingival veneer.
• I would also advise against the use of a gingival veneer, in all
but the most temporary of applications, for patients with active
Silicone vs acrylic
Silicone veneers are becoming more popular, particularly as the
periodontal disease or who have been assessed as having a high degree of gingival characterisation improves. Whilst they are
caries risk. not as robust as acrylic, they can look more natural. Nearly all
• Gingival veneers are relatively small prostheses that can be
dead space is eliminated because the silicone can be withdrawn
quite fiddly to fit and remove. Patients with poor manual dexter- from undercuts. With silicone it is also possible to engage almost
ity may therefore struggle to manipulate the prosthesis – and, in the full labio-palatal depth of the embrasure space. As a result,
my experience, I tend to find that removal is the most difficult apart from helping with retention, silicone is useful for patients
aspect. with crowded teeth, short dentate spans and for those with short
• If patients report or demonstrate an allergy to acrylic or any
bounded saddles. Silicone materials adapt more closely to the
other denture-base materials. soft tissues in function – they obtain a significant degree of their
• Prominent frenal attachments may weaken acrylic veneers,
retention from cohesive and adhesive forces. Patients who pre-
although this specific problem can be avoided by prescribing a sent with a dry mouth, and in the absence of any suitable saliva
silicone veneer. These present their own challenges and are dis- substitutes, may therefore struggle to manage a silicone veneer
cussed further below. effectively. Furthermore, whilst silicone veneers show a good
degree of adaptation and comfort because of their flexibility and
close soft tissue contact, some patients report that they dislodge
Veneering materials during eating more frequently than acrylic veneers.
Provisional or temporary gingival veneers can be fabricated
directly in the mouth, or at the chairside, using silicones or light-
cured sheet acrylic. This can be useful in order to provide the
patient with an idea of the coverage that can be expected, or to
Shade taking
Good communication with your technician is necessary from
provide an immediate solution. However, the aesthetic result the planning stages onwards. Clinical photographs (including
using these approaches is likely to be unsatisfactory, and there gingival shade tabs), diagrams and digital scans can help to
are inherent risks of placing and curing acrylic material directly communicate the architecture of the tissues, including the
in the patient’s mouth, both biologically and mechanically. mucogingival line, stippling and vascularisation.
Definitive gingival veneers are most often made indirectly and
are constructed from heat-cured acrylic or silicone.
 78

39 Immediate and training prostheses

Chapter 39 Immediate and training prostheses

Figure 39.1 Immediate and training prostheses

• Time-limited – should
be replaced definitively
Immediate prosthesis Interim prosthesis

• Primarily due to • Provide occlusal stability

tooth extraction • Prevent unwanted tooth movement
• Test a new occlusal vertical dimension
• Develop aesthetics
Process
• Prescribe an ideal prosthetic envelope

Primary impression Additional stages

Recording interocclusal relationship • To support large or multiple saddles

Extractions + / – record blocks • To ensure stable and accurate articulation

FIT Try-in If possible, to check occlusion and aesthetics

especially if large saddles already exist

24 h
• Protect healing sockets (+/- sutures)
• Reduce trauma
Leave in situ
• Reduce swelling
• Maintain an accurate fit

• Eating advice
4–6 weeks See chapter 43
• Hygiene advice Tissue conditioners,
REVIEW 3–7 days • As before, plus
• Reassurance liners and re-basing
• Local reline if required
• Advice about denture adhesives

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Companion Website: www.wiley.com/go/field/removable
T
he Glossary of Prosthodontic Terms (published by the Jour- stability, confidence and adaption to the removeable prosthesis. 79
nal of Prosthetic Dentistry) defines an immediate denture as Dependent on the number of teeth removed and the acceptability
one which is ‘placed immediately following the removal of a of the prosthesis to the patient, a hard chairside lining material

Chapter 39 Immediate and training prostheses

natural tooth/teeth’. It may be a partial or a complete prosthesis. may be considered if retaining it as a definitive prosthesis or a
On occasions, a prosthesis also may be constructed with a tem- conventional remake of a complete prosthesis can be undertaken,
porary function, in order to provide occlusal stability, prevent correcting any features that have been unacceptable to the patient.
unwanted tooth movements, test a new occlusal vertical dimen-
sion, or develop aesthetics; this is known as an ‘interim’ pros-
thesis. The interim prosthesis may also be immediate in nature. Partial immediate dentures
In any case, at some point both an immediate and an interim Where partial immediate dentures are to be provided following
prosthesis should be replaced definitively. The process is outlined tooth extraction, wrought stainless steel clasps or Adam’s cribs
in Figure 39.1 may be considered to aid retention because the prosthesis is usu-
ally entirely mucosa-borne – inaccuracies of immediate dentures
at the fit stage normally precludes the prescription of rigid frame-
Complete immediate dentures works, unless the edentulous saddle in question is very small.
Complete immediate dentures are commonly fabricated when a A pre-extraction impression is disinfected and sent to the
decision is made to extract remaining teeth in a terminal denti- laboratory, with a prescription clearly indicating which teeth
tion affected by caries or periodontal disease, or where trauma are to be extracted, along with a shade – often the technician’s
has rendered the dentition unrestorable. They are usually con- judgement is used to match the shape of the natural teeth. An
structed straight from a primary impression (Chapter 12), which interocclusal record is required if there are no tripod tooth
might be challenging especially if the teeth to be extracted are contacts remaining once the teeth have been extracted. You may
pathologically mobile or painful. require preliminary registration blocks to achieve this accurately.
The technician removes the remaining dentition on the
stone models prior to fabricating the denture; as such, they
make assumptions about how the alveolus will be modelled Training prostheses
immediately after the extractions. It is not often possible or A training prosthesis can be provided to help patients to over-
useful to have a try-in stage prior to final fabrication, because come barriers in adapting to a prosthesis. Most commonly this
of the presence of the remaining natural dentition. It is for relates to hypersensitive gag reflexes, but it can also be very help-
these reasons that the prosthesis may require some chairside ful when developing psychological acceptance of a removable
modifications (usually by relining), or some denture adhesive in prosthesis.
order to improve stability or retention. Aesthetics may also need Training prosthesis are most commonly used on the upper
to be modified anteriorly, both in terms of tooth position/mould arch, and usually consist of the baseplate component of a
and shade. To improve the fit, conveying the periodontal pocket complete denture only. Sometimes several post dams are carved
depths of the teeth to be extracted can help the technician to onto the prosthesis, allowing the clinician to sequentially
estimate how much soft tissue collapse is expected. nudge the posterior border more anteriorly with minimal loss
At the fitting appointment, the patient must be prepared to of peripheral seal. In our opinion, it is more helpful to ensure
acclimatise to the new immediate prosthesis – including leaving the full denture-bearing area is covered, and for the patient
it in situ for approximately 24 hours post-extraction wherever to feel reassured and in control of the baseplate when it is in
possible to maintain stable blood clots in the sockets and to situ. In some respects, if necessary, it is better to work towards
guard against swelling post-removal. If the prosthesis is left out, full palatal extension, rather than away from it. In any case,
the patient may be unable to reinsert it or suffer considerable the baseplate should always be manufactured with a handle to
pain and distress doing so; it is worse if a large number of teeth ensure good patient control.
are extracted or there are surgical extractions. If the patient is able to tolerate mucosal coverage, anterior
Denture hygiene instructions should be issued and advice teeth (commonly canine to canine) may be added to the
regarding a softer, lighter, non-sticky diet avoiding overly chewy prosthesis, which may motivate the patient to persevere with the
or crunchy foods. This is especially important whilst the person adaption process and restore some aesthetic aspects and social
develops muscular control and is learning to function with their function. It is less common to offer a training plate on the lower
new prosthesis. Denture adhesive is useful in this learning phase. arch – primarily because the main trigger zones for gagging are
Three well-placed pea-sized blobs on the fit surface is usually the posterior tongue and the palate.
sufficient, with instructions on how to remove the adhesive The provision of a training plate will undoubtedly lengthen
effectively from the prosthesis and the oral tissues. Patients are the treatment process  – although it can prove to be an
expected to adapt within 2–6 weeks but may need frequent invaluable step in the rehabilitation of the patient. As with any
adjustments and hard/soft relines during the healing phase. acclimatisation process, the patient should be reviewed regularly,
A soft liner applied chairside can be useful to reline the with plenty of positive praise as they develop their tolerance. It
denture during the healing phase. As the ridge continues to is not uncommon to see patients’ personalities and presentations
heal and remodel over approximately 6 months, multiple relines change dramatically as they overcome personal and psychosocial
may have to be undertaken chairside to increase retention, barriers to tolerating prostheses.
80

40 Occlusal splints
Chapter 40 Occlusal splints

Figure 40.1 Occlusal splints

Preventing a traumatic overbite Reducing bruxist sequelae

Protecting restorations or rehabilitations Occlusal splints Testing increases in occlusal vertical dimension

Managing temporomandibular joint Permanent Providing idealised occlusal contacts

disorder symptoms

1. Accurate full-arch impressions, 2. An accurate retruded

which are well-supported axis record, at the
by the tray intended occlusal
vertical dimension

Wax should be
thinned across
the expected
occlusal contacts

3. Mounted casts should be checked for accuracy and the intended occlusal vertical dimension should be verified or prescribed

or

Maintain intercuspal position Increase occlusal vertical dimension

4. Prepare materials and equipment for splint fit

• Millers forceps and GHM paper
• Shim stock and mosquito forceps
• Acrylic bur and high volume aspiration

5. The splint should seat fully without rocking or clicking into place
• Mark up tight contacts with GHM and make small adjustments
until fit. Splints are typically tight interproximally and on the
labial and buccal aspects

• Mark up retruded contacts, making adjustments until there

are full arch simultaneous contacts

• Maintain a flat occlusal surface – do not create divots with

the bur

• Mark up lateral and protrusive excursions and ensure

there are no interferences
• Polish the splint prior to final fit
Adjustments are made with the • Ensure the patient can insert and remove
lateral aspect of the bur to ensure
• Arrange a review for no more than one week later
maintenance of a flat occlusal table

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A
n occlusal splint is a removable appliance that is fitted to and rock. This prevents the device from stabilising the occlusion 81
the occlusal surfaces of the maxillary or mandibular teeth in effectively.
order to aid diagnosis or as a treatment intervention.

Chapter 40 Occlusal splints

An occlusal splint may be fitted in order to:
• Reduce the impact of deflective or early contacts Occlusal coverage
• Provide idealised occlusal contacts It is extremely important to ensure that soft splints and stabili-
• Test increases in occlusal vertical dimension sation splints provide full occlusal coverage in order to prevent
• Reduce the physical impact of bruxist habits unwanted tooth movement and overeruption. This advice also
• Manage the symptoms of temporomandibular disorder extends to any other occlusal coverage device that remains in the
(especially if they exist prior to extensive or invasive plans for mouth overnight or for long periods of time on a regular basis,
rehabilitation) such as bleaching trays. There are many instances where partial-
• Reduce the effects of a traumatic overbite coverage splints and trays have resulted in posterior overerup-
• Protect restorations both during and after treatment tion and significant occlusal discrepancies, which can be quite
A splint can therefore be considered as a treatment platform. complicated to manage. The best way to ensure full occlusal cov-
erage is to extend the trays to capture the full arch. Remember to
make sure that the impression material is fully supported, other-
Splint types wise when poured up, the model will be inaccurate and the splint
The vast majority of splints made within primary care are soft will rock antero-posteriorly.
splints. Typically, these are made from vinyl acetate, and are rela-
tively easy to construct and fit. Most commonly they are made
to fit the lower arch and are simply used to interrupt occlusal Records for construction
contact of the natural teeth. Soft splints are unable to be bal- Soft splints are often constructed using a single impression of
anced because of their flexible nature – and adjusting them can the relevant arch. For rigid splints, accurate upper and lower
be troublesome. It is therefore recommended that these are worn impressions are a necessary starting point. They will then need
for defined periods only – such as during sport, during periods in to be articulated. It may be, especially if you have large or multi-
the day when bruxist tendencies are likely, or overnight, in order ple edentulous saddles, that registration blocks are a necessity in
to reduce the impact of sleep bruxism. It is important to note that order to help stabilise the interocclusal records. The interocclusal
soft splints may actually exacerbate bruxist tendencies and so, as relationship should be recorded in the retruded arc of closure. The
with any removable device, arranging a review soon after fitting most predictable way to do this is to use beauty hard wax. This
is advised. wax can be warmed and folded twice into a wafer. This should
The other main group of splints are rigid – these are primarily sit across the upper arch from canine to molar (Figure 40.1).
used as stabilisation devices in patients with unstable occlusal Avoiding the incisor teeth reduces the risk of aberrant mandibu-
schemes, traumatic overbites or myofascial pain. These should lar deviations on closing. The patient is encouraged to close into
provide firm and stable contacts in the intercuspal position, with the retruded arc until the intended vertical dimension is reached.
canine guidance ramps for anterior guidance only. The occlusal The wax is then cooled using the air syringe and removed care-
surface should be as flat as possible to prevent intercuspation fully from the mouth. The wax is brittle when cooled, meaning
and encourage relaxation of the muscles of mastication. It is that it is unlikely to distort without a noticeable fracture. If you
recommended that these splints are constructed in the retruded have identified early contacts in the retruded arc of closure, these
arc of closure. Typically, these are made from acrylic and are should be identifiable as the thinnest areas on the wax record
technically more demanding to construct, fit and adjust than soft (Figure 40.1). The cooled wax can be tried back into the mouth;
splints. Stabilisation splints fitted to the upper arch are sometimes the lower arch should close directly into the record, with a dull
referred to as Michigan splints – and those fitted to the lower ‘tapping’ sound. Absence of this sound indicates the presence of
are also known as Tanner appliances. A review no later than a a slide. In this case the record should be retaken.
week after fitting is advised, because the majority of patients will You will need to choose a vertical dimension at which to
distalise once their old intercuspal position is interrupted and construct the splint – this is often driven by the minimum
further muscle relaxation occurs. It is therefore nearly always amount of space that is required posteriorly (around 2 mm).
necessary to make minor readjustments at review. Other types of Less than this and the splint is likely to fracture in function.
rigid splint include anterior repositioning splints that encourage There are two ways to prescribe the intended vertical dimension.
the mandible into a protrusive position. This can be particularly The first way, with models mounted using a facebow on a
helpful in patients with temporomandibular joint pain, joint semiadjustable articulator, is to increase the height of the incisal
noises or crepitus. A hybrid type of splint also exists with a rigid pin. My preferred method, however, is to record the intended
occlusal surface and a softer fitting surface. These are known as vertical dimension directly intraorally as part of the wax record
bilaminar splints and are purported to be easier to manufacture stage. This can then be mounted on an average value articulator
and fit. In my experience, however, this type of splint should be without the need for a facebow record (unless further changes to
avoided where occlusal stabilisation is needed. This is primarily vertical dimension are anticipated).
because although the splint may have a rigid occlusal surface, its The clinical stages of record-taking and splint fitting are
softer fitting surface acts as a ‘cushion’ and allows the splint to tip shown in Figure 40.1.
 Implant-supported mandibular
82

41
Chapter 41 Implant-supported mandibular overdentures

overdentures
Figure 41.1 Implant supported over-dentures

The relative merits of

each ISOD system

Bar Ball Locator R-T Magnet

Hygiene
Tolerance with
the denture out
Resilience
Maintenance

Longevity

Locator insertion and removal tool

Locator components

Blue inserts being

placed into the
female housing

Locator abutments with the pickup rings in situ

Pickup impression

Analogues inserted
into an impression
Closed tray impression copings in situ, ready to be picked up
in the working impression

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Companion Website: www.wiley.com/go/field/removable
I
t is widely believed that implant-supported overdentures from the clinical notes – if not, it may be necessary to remove 83
(ISOD) should be the first choice of rehabilitation in the eden- them and measure them directly.
tulous mandible. A substantial body of evidence demonstrates Polyether impression material is the most accurate and stable

Chapter 41 Implant-supported mandibular overdentures

that this is the case, both in terms of the patient’s quality of life impression material for picking up ISOD abutments, although
and from a cost–benefit perspective. Whilst you may not plan it is very rigid when set. With bars and divergent abutments,
and place implants yourself, it is still important that you discuss take care that the impression does not get locked into place. This
ISODs with your patients as a potential treatment option. It is can cause distress for both you and the patient when attempting
also important that you are at least aware of the stages required removal. Undercuts should be blocked out with carding wax
to plan, construct and maintain such prostheses. prior to taking the impression.
The special tray should be adjusted and border moulded with
the ISOD abutments in situ. The same principles apply as for
Planning conventional dentures (Chapter 16). Once complete, laboratory
Treatment planning should be prosthodontically driven. There- analogues should be seated into the impression copings at the
fore, the starting point is an optimal conventional lower denture chairside to ensure that they are adequately and accurately seated
which defines the intended prosthetic envelope (the zone within (Figure 41.1). Requesting a permanent base for recording the jaw
which the teeth are to be placed, in order to satisfy functional relations and subsequent try-in stage means that you are able to
and aesthetic requirements). At this stage, the optimised pros- maximise the retention of the denture base during these critical
thesis can be copied in a radiopaque acrylic and worn by the stages and improve accuracy.
patient whilst a cone beam computed tomography (CBCT) scan When fitting the prosthesis, the female retentive component
is obtained. This will allow the planning clinician to take into may require activation. The manufacturer’s instructions should
account important anatomical structures such as mental nerve be followed and appropriate tools used. Where Locator®
position, blood vessels and the quality and quantity of bone, in abutments are employed, care should be taken when seating to
order to determine the optimal implant dimensions and angula- ensure that the peripheral plastic does not fold over and prevent
tions. It is not within the scope of this chapter to discuss further full engagement. You may consider using Locator R-Tx inserts,
the stages involved in implant placement. which not only account for implants diverging by up to 60
At the planning stages, it is important to choose and order degrees, but also reduce distortion of the insert. Always begin
the components for the attachment system that will retain the with the lightest retention force insert (blue), otherwise it can be
denture. Important factors for consideration include: difficult to remove dentures easily, even when they are retained
• Hygiene and cleansability by only two abutments.
• Patient tolerance when the denture is removed Occasionally, patients may complain of tissue trapping. In
• Resilience (ability to withstand displacement prior to loss of this case, you must assess whether this is because of the denture
attachment) extension or inadequate height of the ISOD abutment. Whilst
• Technical aspects of maintenance problems may be similar to those of conventional complete
• Longevity dentures (Chapters 45 and 46), looseness may be because of
If you require the attachments to be processed into the inadequate torqueing of the abutment or inadequate retention
denture base by the laboratory (rather than picking them up at from the female component.
the chairside at fit), you will also require an abutment analogue,
along with impression copings for the working impression stage.
For ball and Locator® abutments, closed-tray impression copings Maintenance
are available – this keeps the working impression stage relatively Following rehabilitation, a maintenance programme is key to
straightforward. long-term success. Allowing the tissues to breathe by leaving
prostheses out overnight, or for several hours during the day, is
recommended.
Construction ISOD abutments should be cleaned with conventional and
Following well-extended primary impressions, a closed special interdental brushes, and the prostheses themselves should be
tray should be requested with full coverage of the denture-bear- cleansed in alloy-safe solutions (such as those suitable for cobalt-
ing area, spaced for silicone and non-perforated. Space should chrome partial dentures).
also be provided above the healing caps for the abutment and At each patient review, in relation to the implants, you should
impression copings to be attached. monitor pocket depths. If pockets are bleeding and deepening,
The appropriate abutment height depends on the implant despite efforts to improve oral hygiene and remove calculus, then
system and abutment system employed, and so you should follow this is indicative of peri-implantitis. This can be confirmed with
the specific clinical guide provided. Locator® abutments should evidence of crestal bone loss on radiographs. At this stage, it is
sit at least 1.5 mm clear of the gingival tissues. Knowing the acceptable to refer the patient to (or recommend that the patient
height of the healing abutments is helpful in determining what sees) a specialist for treatment of the peri-implantitis.
size Locator® abutments to order. This can often be determined
 Principles of restoring maxillary
84

42
Chapter 42 Principles of restoring maxillary defects

defects
Figure 42.1 Principles of restoring maxillary defects

Aramany classification

Class I Class II Class III Class IV Class V Class IV

Primary impression of the defect in putty

Class II defect requiring rehabilitation

Gauze is then placed across the defect prior to an alginate wash

Special tray for alginate, perforated on the fitting surface

Careful border moulding around the defect and denture

Final wash impression, allowing some engagement of
periphery
tissue undercut

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F
rom time to time, you may encounter patients with maxillary necessarily differ. There is little doubt in these cases that a rigid 85
defects. These may be minor, or extensive, developmental or and full coverage major connector is most useful.
acquired – often the palate, ridges and the teeth are involved, We will discuss a number of design considerations for the

Chapter 42 Principles of restoring maxillary defects

either in isolation or in combination. This chapter aims to various defect configurations (Figure 42.1) below:
describe some of the clinical and design approaches that you • Class I – Full unilateral defect to the midline. Consider placing
may wish to consider when constructing an upper prosthesis occlusal rests on the most medial and distal surfaces. Placing
for patients with varying Aramany classifications. The prosthe- double rests can prevent wedging forces because of the large
sis would be referred to as an obturator, because it is closing a torqueing effect of the poorly supported saddle. Extending up to
congenital or an acquired tissue opening. the palatal surfaces can maximise bracing and stability. With full
coverage designs, ensuring adequate oral hygiene is paramount.
• Class II – A single unilateral defect not involving the premaxilla.
Primary impressions Indirect retention is important here and this can be obtained by
Taking impressions for patients with maxillary defects can be resting on the canine that is furthest away from the defect. A tri-
daunting. Primarily, this is because of the appearance of the tis- pod design with double rests on the posterior teeth and engage-
sues involved with the defect. Secondarily, you will want to avoid ment of the palatal surfaces will maximise bracing and stability.
losing impression material into the defect – especially if it is deep Consider smaller occlusal tables with fewer posterior teeth.
or inaccessible. It is well worth taking the time to explore the sur- • Class III – A midline defect of the hard palate. Aside from the
rounding anatomy. Palpate the peripheral walls, noting whether absence of prosthetic saddles, the design approach is largely
the tissue is firm or fibrous. Make a note of the sensation the similar to many Kennedy Class III presentations. A quadratic
patient feels when you palpate – and consider whether the tissues clasping approach is recommended in the absence of any palatal
can provide support for the prosthesis or aid in retention. It is support.
not necessary to record the full height of the defect. However, • Class IV – A single unilateral posterior and premaxillary defect.
recording the full peripheral anatomy is important to ensure an This presentation is challenging because of the presence of a sin-
adequate oral seal. It is possible to ask the technician to engage a gle line of teeth. Ensuring correct extensions is critical. Consider
certain amount of undercut within the defect by utilising perma- using multiple clasps with mesial and distal rests or placing indi-
nent soft lining material. In the case in Figure 42.1, resistance and rect restorations with milled shoulders, guide planes and even
retention was gained from the medial, mesial and distal aspects channels or pins. Once again, a reduced occlusal table will be
of the defect (palatine bone and anterior nasal spine). Care was helpful.
taken to avoid heavily engaging the lateral aspect (the alveolar • Class V – A bilateral posterior defect. Again, indirect retention
recess of the maxillary sinus) because of its respiratory epithelial is important here, given the forced symmetry of the clasping axis.
lining, which was tender to palpate. In other cases you can look This may involve coverage of the palatal surfaces. An RPI (rest,
out for bands of scar tissue, which often flex, to allow insertion plate, I-bar clasp) approach can be considered to reduce torque
and improved retention. on the abutment teeth. For both this and class IV presentations,
Initially, putty is a very useful material to use in a tray. It will you might consider a swing lock design if the abutment teeth
largely record the defect and once set it will then help to carry an were periodontally sound, well-supported and there was suffi-
alginate or silicone wash. It is a good idea to apply gauze across cient sulcus depth.
the defect prior to taking a wash impression, to prevent excess • Class VI – A single anterior bilateral defect. This is quite a rare
material becoming retained. presentation and usually presents because of trauma or congeni-
tal conditions. This is essentially managed as a Kennedy Class
IV design, maximising indirect retention. In this case, a lack of
Major impressions anterior soft tissue support also means that a quadratic clasping
As always, the extensions of the special tray are critical in obtain- design is preferred.
ing a truly functional impression. Communicate with the techni-
cian about where you would like the tray to engage around the
defect and how closely. Ensure that the tray is extended prop- Obturator bungs
erly; we would advise recording the borders of the periphery and The bung is the portion of the obturator that engages the defect.
critical areas of the defect initially, using greenstick. The wash Two main types exist. Extended hollow bulbs engage more of the
impression is most often taken in alginate, because this material defect and are therefore better supported. Rigidity means that
is most easily removed from undercuts and defects. Remember problems with leakage are common, although the hollow nature
that only a thin wash is necessary – and leave the impression in of the bulb improves speech resonance and reduces the weight.
situ until it has fully set in order to facilitate complete removal. The alternative is an open top with a flexible bung – this design is
able to atraumatically engage undercuts and provide an excellent
seal. The drawback of this design is the fact that the permanent
Framework designs soft liner material will perish more quickly and adjustments to
Whilst it is a good idea to remember the standard design the fitting surface can be difficult.
principles for partial prostheses, there are some principles that
 Tissue conditioners, liners
86

43
Chapter 43 Tissue conditioners, liners and re-basing

and re-basing

Figure 43.1 Tissue conditioners, liners and rebasing

Chairside Laboratory
placement placement

Perish sooner More resilient

Soft liners Better finish

Quicker Months to years, Can process against

depending on application features on a rigid cast

Poor margins Slower

Hard liners Better finish

Technically challenging Permanent Requires a wash impression

if undercuts present to be sent to the laboratory

Best result is with a full rebase

Soft tissue healing
from a wash impression
Tissue conditioners Functional impression Rebase Variable results chairside +
risk of engaging undercuts
2–4 weeks Neutral zone impression Permanent
Will invariably alter the occlusal
vertical dimension unless the
base is adjusted first

An example of a laboratory placed soft liner. Often a well extended lower complete impression will engage minor undercuts
around the lingual shelf. Engaging with a soft liner rather than under-extending or adjusting the base can help to maintain a
border seal and reduce lingual trauma

Permanent soft
liner around
undercut areas

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F
rom time to time, it may be necessary for you to adjust and comfortably; this may have been trialled first with a tissue con- 87
augment a finished denture base significantly. This may be ditioner. Soft liners can also distribute loads more comfortably
for the following reasons: over localised painful areas, although we would urge against

Chapter 43 Tissue conditioners, liners and re-basing

• Changes in ridge anatomy prescribing a full-coverage soft liner where the patient claims
• Over- or underextension into the functional sulcus it makes the denture(s) more comfortable. This seems a logical
• Relief over an area of trauma, surgery or a superficial nerve thing to do, but practically this prevents occlusal forces being
• Alterations to the occlusal vertical dimension distributed evenly across the full denture-bearing area. Paradoxi-
• Alterations to avoid fabrication of a totally new prosthesis cally, this causes rocking, tipping, aberrant occlusal contacts and
When augmenting the denture base, the materials and areas of localised pain.
methods that you use will be dependent on a number of factors Soft liners placed at the chairside may require trimming and
(outlined in Figure 43.1). These include: finishing to make the interface with the acrylic as seamless as
• Junctions and marginal finish possible. Specific silicone burs should be used for this purpose.
• Accuracy Where a longer term need for the soft liner exists such as in
• Material availability, technique and chairside time oncology or cleft defects, then a more resilient, laboratory-
• Expected resilience and longevity of the addition provided soft liner should be considered at the time of prosthesis
• Laboratory requirements fabrication.
The most significant challenge when relining or rebasing,
regardless of where the processing will occur (at the chairside
or in the laboratory), is the ability to control the denture during Degradation
the moulding stage. Polished denture surfaces and the absence of Over the relatively short life of the tissue conditioner, plasticiser
a handle make it difficult to ensure stability and correct seating will leach from the material leading to a loss of surface integrity
prior to tissue manipulation. The only exception to this is the use and a rough surface. This can inflame the denture-bearing area
of a tissue conditioner. and encourage a reservoir of bacteria and fungi to reside against
the tissues. Chairside soft liner materials are more resilient than
tissue conditioners, but will ultimately suffer the same fate. Anti-
Tissue conditioners fungal and bacterial agents may be present in the materials to
Tissue conditioners can remain in situ for 2–4 weeks, depending counteract the growing microbial reservoir, but by the time this
on the specific product – and because of the high volume of plas- becomes a problem, the prosthesis should have been definitively
ticiser present in the material, the tissue conditioner continues modified or replaced. Surface degradation can also cause these
to be moulded in function whilst the patient uses the prosthesis. materials to peel away from the underlying prosthesis; this can
This is useful for obtaining functional border extensions in dif- also happen if the material becomes degraded or if vigorous
ficult cases, such as in patients being rehabilitated after oncology hygiene techniques are used. Cleaning is recommended with a
treatment or after suffering a stroke. Tissue conditioners are also soft brush, sponge or the patient’s fingertips under lukewarm
extremely useful for temporary re-lines around areas of trauma water with liquid soap.
or recent surgery, or for neutral zone impressions. Tissue con-
ditioners tend to be coloured white as a reminder of their tem-
porary nature. However, some soft lining systems allow you to Re-basing
alter the mixing ratio to determine how resilient and how tempo- Re-basing is the term given to replacing the entire intaglio den-
rary you would like the material to be. In these cases, the colour ture surface and borders in hard acrylic whilst preserving the
is consistent regardless of the application. Tissue conditioners tooth arrangement and other polished surfaces. A chairside
are typically mixed from a polymer powder (usually polyethyl re-base should be avoided because autopolymerising acrylic is
methacrylate, or PEMA) and a plasticiser and monomer liquid. not as stable in the longer term and carries with it a risk of cur-
Regardless of the product used, the prosthesis should be physi- ing into undercuts at the chairside. It is difficult to handle, is
cally and chemically cleaned prior to application. Most soft liner exothermic in large quantities and carries with it considerable
products include an ‘adhesive’ that actually just cleans the surface room for errors. Hard re-line of partial dentures should also be
prior to application – this tends to be a ketone-based solvent. approached with considerable caution, especially where multiple
short spans are present, with drifted and tilted teeth, and bony
undercuts. Instead, a silicone impression and laboratory re-base
Soft liners is recommended.
Soft liners (sometimes known as resilient liners) can be semi- For any hard re-line or re-base procedure at the chairside,
permanent or permanent. Chairside applied liners tend to be undercuts should be blocked out using wax, temporary inlay
semipermanent in nature and may last months or even years material or silicone. The prosthesis should be removed and
depending on their mode of use and area of application. They reinserted as it goes through its exothermic reaction to ensure
can be categorised as silicone elastomers or plasticised acrylic it is able to be removed and reinserted with ease along a single
resins. The silicone-based materials are more resistant to leach- path of insertion. Excess should be removed chairside with an
ing their plasticisers. They are commonly used where undercuts acrylic bur and the prosthesis polished to ensure it is cleansable
(either occurring naturally or post-surgery) need to be engaged and comfortable.
 88

44 Maintaining adequate oral hygiene

Chapter 44 Maintaining adequate oral hygiene

Figure 44.1 Maintaining adequate oral hygiene

Mechanical Chemical

Abrasives

Triclosan
Enzymes
Salts
Cationic surfactants

QAC
Phenols SLS

s
let
tab
ing
ns
Mo
lea
uth ec
ntur
w
a sh De

Discuss rationale
for improving
oral hygiene Informed patient
preventative plan

Patient factors
• Dexterity
• Motivation
• Goals

Plaque score
and distribution

Plaque accumulation around a

natural and prosthetic dentition

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M
aintaining adequate oral hygiene is a shared responsibility surface imperfections begin to develop. Acrylic resin is already 89
between clinician and patient. As dental professionals we a relatively porous material on a microscopic level, which is why
are expected (either individually or as a team) to inform storing the prosthesis in a solution is such an important part

Chapter 44 Maintaining adequate oral hygiene

the patient of: of the hygiene protocol. Cobalt-chrome materials and ceram-
• The rationale for good oral hygiene ics are much more resistant to plaque accumulation, although
• Their current level of oral hygiene the design of major connectors will impact significantly on oral
• Patient-specific optimal methods hygiene, and these are discussed in Chapter 31.
• Individual progress in maintaining adequate oral hygiene Patient factors that may increase the risk of plaque
Instigating and maintaining behaviour change can be time accumulation and caries further include:
consuming – and it is important for the patient to understand • Poor manual dexterity
that they have very much an active role. If the patient does not • Lack of suitable oral hygiene equipment
believe, or understand, the need for adequate plaque control then • Poor understanding of hygiene procedures
they are unlikely to build suitable habits into their daily routines. • Dietary risk factors
We can help the patient on their journey by removing calculus • Xerostomia
and charting the location of plaque. A full mouth prophylaxis • Systemic disease states such as diabetes
can also help to motivate the patient. • Nicotine use and smoking
The patient should be made aware of these risks, when
present, and suitable preventive measures put into place.
The impact of partial prostheses This may include liaising with the patient’s general medical
Patients must understand the extra burden that removable pros- practitioner, certainly in relation to diabetic control, xerostomia
theses place on maintaining adequate plaque control. It is for because of polypharmacy and smoking cessation. In the dentate
this reason that adequate oral hygiene efforts should be demon- patient, oral hygiene should be undertaken on a bi-daily basis
strated by the patient before a prosthesis is provided. Once the including mechanical and chemical plaque control. It is not
prosthesis is in place, the patient will face the challenge of greater within the scope of this chapter to discuss this further but Figure
food debris accumulation, greater plaque accumulation and the 44.1 highlights the important techniques and materials.
need to satisfactorily clean the dental tissues and the prosthesis
itself. This is no small task, and once a partial prosthesis is fitted,
part of the review process should include an assessment of the Cleaning partial and complete prostheses
patient’s ability to keep it clean. Even a highly polished acrylic denture is plaque retentive and so
The patient should also understand that there are significant this should first be cleaned mechanically with liquid soap over a
risks to wearing a prothesis continually. The main risk is that water-filled sink. This ensures that the prosthesis does not frac-
of root caries, as plaque and other food debris are held against ture if dropped. Toothpastes are effective in removing bacteria
exposed root surfaces for long periods of time. Without adequate but not fungal colonisation, and abrasive toothpastes (such as
and timely management, a biofilm will develop and mature, whitening pastes) should be avoided on acrylic because this will
encouraging an anaerobic environment and promoting bacterial create a more plaque-retentive surface. If there is no metal base
growth that is more resistant to removal by conventional means on the denture then up to 6% hypochlorite may be used for 20
and that is increasingly pathogenic. minutes prior to storage in water. This gives excellent antimicro-
Patients should be encouraged to leave their prosthesis out bial results. Care must be taken with cobalt-chrome-based den-
overnight – failing this, for several hours during the day. This tures, because hypochlorite will cause corrosion and pitting, and
allows intraoral surfaces to be cleansed by saliva and the tongue, certain acidic cleansers will cause a black oxide layer to form on
and for the prosthesis to be mechanically cleaned, followed by the prosthesis. Recent reviews have shown that specialist denture
immersion in a suitable cleaning solution. cleanser tablets give a good combination of microbial efficacy
and reasonable material compatibility.

Complicating factors
It is important for us to be able to identify elements of prosthetic Fixed prostheses
design that, combined with the patient’s social and medi- Communication with the laboratory is essential to produce a
cal history, may increase the risks of plaque accumulation and fixed prosthesis that favours patient self-care and maintenance.
caries. There is little doubt that ensuring a prosthesis sits at Providing your technician with an interdental brush can help
least 3 mm from the gingival margins is a useful approach to to create adequate embrasure spaces for cleansing and to design
reduce food and plaque accumulation against the hard tissues; contact against abutment teeth that will prevent food impaction,
however, acrylic resin will deteriorate over time, especially as gum stripping and abutment disease.
 Troubleshooting loose or painful
90

45
Chapter 45 Troubleshooting loose or painful dentures

dentures
Figure 45.1 Potential causes of loose or painful dentures

Denture problems

Movement Pain

Loss of Increased Base Problems Other

retention displacement irregularities with occlusion

- Xerostomia - Lack of ridge - Sharp or - Excessive occlusal - Existing pathology

support due to unfinished vertical dimension
- Changes in tissues remodelling or parts of the (OVD) (pain on the - Tissue trapping
fibrous ridges fitting ridges)
- Poor/altered neuro- surface - Nutritional
muscular control - Overextension - Excessive freeway deficiencies
- Fracture space (FWS) (pain
- Poor engagement - Deep post dam in the temporo- - Superficial nerves
or loss of undercuts mandibular joint
(in partial dentures) - Teeth not in the (TMJ) and - Psychosomatic
neutral zone angular cheilitis
- Post dam too deep - Normalised use of
- Teeth not placed - Heavy occlusal dentures on friable
- Home alterations over the ridges contacts ridges
by the patient
- Displacing occlusal
contacts

- Intolerance of the
retruded arc of
closure

- Steep guidance
surfaces

- Parafunctional
habits

Delivering advice, with or without adjunctive therapies

Adjustment Regular review • In any case a trouble shooting

visit should be followed-up with
a review appointment either to
Remake or significant modification check modifications or to schedule
alterations or remakes

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R
egardless of the stages of denture construction or review, it • An excessively deep post dam 91
is important to be able to troubleshoot the causes of insta- • Failure to place teeth within the neutral zone
bility and pain. We most commonly see these problems • Failure to place teeth directly over the ridges

Chapter 45 Troubleshooting loose or painful dentures

either soon after dentures are fitted or when patients present to • Displacing occlusal contacts
us wanting new dentures to be made – but they can also present • An intolerance of a shift to a more retruded arc of closure
during construction. There are a number of ways to pre-empt • Lack of freedom in intercuspal position (steep guiding
these problems and reduce the number of complications. At all surfaces)
stages, ensure that your patient is forewarned about potential • Lack of support from the edentulous ridge(s)
complications, including pain under the dentures and instabil- • Pain avoidance mechanisms and parafunctional habits
ity. Forewarned is forearmed – and if you have already discussed
potential problems with your patient, then they are less likely to
be surprised when they occur. This helps to maintain a trusting Pain underneath denture bases
relationship and shows that you are mindful of complications, When we hear patients reporting pain from the fitting surface
and that you are in control of managing them. However, it can of a denture, often the first instinct is to pick up a hand piece
also be incredibly frustrating when you are unable to find a direct and make some adjustments. I would suggest that this course of
cause, or indeed a suitable solution, to denture pain. I find that action should be one of the last things that you do – there is no
following a logical and systematic approach means that you are going back from this intervention and it sets up a futile cycle
unlikely to miss out any less-obvious causes. The flow diagrams of adjustments. However, minor adjustments to surface finish
in Figure 45.1 can help to guide you through this troubleshooting will not affect the fit and adaptation of the denture – as soon as
process. you receive the permanent base back from the technician, it is a
good idea to run your gloved fingers over the fitting surface and
remove any obviously sharp lips, bumps and rough areas with a
Loss of retention and displacement polishing bur.
Looseness or mobility of dentures is caused, primarily, by both a By far the most common cause for pain over the ridges is
loss of retention and an increase in displacement forces. incorrect, premature or heavy occlusal contacts. Checking
contacts in the intercuspal position with articulating paper
Loss of retention should form a routine part of your troubleshooting process, even
One of the benefits of employing a permanent base for the jaw if you have identified another obvious case. If frank ulceration
relation stage and beyond is that you are able to test the actual is present, then I would recommend that the patient leaves their
retention and stability of the prosthesis prior to fitting. Other- denture out until this has resolved. It is possible to make some
wise, it can always be quite tense at the fit stage, when you have adjustments at the same appointment but be wary of adjusting
been working, thus far, with a temporary base – border exten- the denture base so much that the pain no longer presents – it is
sion inaccuracies may not be apparent during construction. likely in this case that you have overadjusted the denture base,
Some clinicians tell patients at the fit stage that they will need which may result in instability, food trapping, or pain elsewhere
to wait for their dentures to ‘bed in’. This is by no means a pana- on the ridge. In the absence of any pathology, it is a good idea to
cea for ill-fitting dentures, although there is some truth in this palpate the ridge with a gloved finger. Sometimes patients report
instruction – often, when old dentures are removed and new pain over the ridge when there is no obvious cause – and this can
ones fitted straight away, a degree of soft tissue recoil is required be a frustrating presentation. Paradoxically, patients who have
in order to allow close adaptation of the new denture base. This not been wearing dentures for a while (or who have been coping
is especially true if the working impression has taken a rela- with ill-fitting dentures) often report pain when they begin to
tively long time to make. Normally, tissue recoil happens within use dentures effectively again, especially if they are more stable.
10–20 minutes – and as mentioned above, it is always helpful to It is important to reassure this group of patients and to pre-empt
pre-empt these particular nuances with the patient. the problem by offering eating advice – softer and smaller food
Other possible causes of lack of retention and instability choices for the first few weeks, and chewing at the back of the
include: mouth, on both sides. Occasionally during denture assessment,
• Xerostomia patients present with pain on the ridge even with gentle
• Changes in tissue fluid (in patients who take steroids periodi- loading – in these cases, it may be necessary to consider relief
cally) over the crest of the ridge at the construction stage. Ultimately,
• A lack of appreciation of the need for muscular control you may wish to refer these patients for a specialist opinion.
• For partial dentures, lack of a defined path of insertion (mean-
ing that multiple adjustments have likely been made in order to
fit the prosthesis, with resulting dead spaces and poor adaptation Other causes of pain
to abutment teeth) Other common causes of pain include:
• Heel clash of the denture bases causing tissue trapping (check
Increased displacement with articulating paper between the heels)
• Nutritional deficiencies (B12, folate) that predispose to ulcera-
An increase in displacement can be observed in the following
cases: tion or symptoms of oral dysaesthesia
• Ridge changes because of remodelling following extractions
• Overextension in sulcal depth and width
 Gagging, other difficulties and
92

46
Chapter 46 Gagging, other difficulties and making a referral

making a referral
Figure 46.1 Gagging, and speech

Gagging
• Explore with the patient the history of their gag reflex

• Palpate the full denture bearing area in order to better

understand the potential trigger zones and what the
patient currently tolerates
• Psychosomatic

• Palate

• Tongue

• Posterior
ridges

Consider a training impression or plate – but counsel

the patient on how to use it effectively (see text)

• Can take up to 9 months to acclimatise

Speech 9/12 • Especially if tooth positions have changed
• Read aloud each day in order to improve control

Palatal tongue contact patterns

Contact area
Consider patterns of tongue contact if particular phonetics are challenging for the patient

T/D/N Z/S Sh K/G L

sounds sounds sounds sounds sounds Non-contact
area

Consider freeway space if ‘s’ sounds are whistling or hollow

• Very hollow suggests excessive freeway space (FWS)
• Whistling or sharp ‘s’ sounds suggests restricted FWS

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F
rom time to time you may encounter particularly challenging only applies to a minority of patients. The vast majority should be 93
presentations. This chapter considers how to deal with a severe reassured in a calm and confident manner, and given the space
gag reflex, hyperactive tongue and lips, and speech problems. and opportunity to acclimatise themselves to wearing a full-

Chapter 46 Gagging, other difficulties and making a referral

Aspects of the referral process are covered in Appendix 3. coverage prosthesis.

Managing the gagging patient Tongue spread and lip activity

I would consider a severe gag reflex to be one of the most chal- Lateral spread or hyperactivity of the tongue or lower lip can be
lenging situations facing prosthodontists. It is recognised that incredibly frustrating to manage. In these cases, it is important
the acceptance of dentures in gagging patients will improve with to explain to the patient what is happening and how they can
continued and persistent use. However, the aetiology is consid- try and help. Like any muscle, the tongue will lose tone if it is
ered to be multifactorial, and many psychologists recognise that not in continual use. Patients who do not currently wear lower
the gag reflex is classically conditioned. This means that patients prostheses routinely will need to re-acclimatise – and this often
can present with significant and deeply embedded fear-related involves a bit of homework. It is possible to give patients a series
components. In its milder forms of presentation, the gag reflex of simple exercises that can allow them to regain some muscular
can simply be an anxious response to denture instability. Con- awareness and control. These are described below and should be
structing a properly extended and stable prosthesis is often all demonstrated to the patient first, with the recommendation that
that is needed – and the patient should be reassured as such. they are carried out in front of a mirror:
Occasionally a more structured approach is needed and this is • Slide the thumb along the upper ridge from tuberosity to
described below. tuberosity whilst keeping the tongue relaxed, without allowing
the tongue to touch the thumb, especially posteriorly
Functional analysis and patient control • Slide the index finger along the lower ridge whilst the tongue
Functional analysis is a well-established approach for supporting slides as far back as possible and away from the index finger
patients through difficult treatments. This comprises: • Consciously relax the lower lip to allow palpation of the ante-
• Building a trusting and relaxed relationship rior crest of the ridge with an index finger
• A careful history of specific trigger factors • Look carefully at the tongue in a mirror and do not let it escape
• Investigation of the patient’s concerns and stressors the mouth or cross over the vermillion border of the lower lip
• A direct observation of the problem whilst resting
• Continual clinical observation during procedures
One of overarching principles for the treatment of patients
who gag is allowing the patient to feel that they are in control. This Speech problems
does not mean, however, that dentures should be removed from Most patients will adapt quickly to speaking with their new pros-
the mouth as soon as a gag reflex is elicited. On the contrary, thesis, assuming that there have not been significant changes to
immediate removal is a behaviour which will perpetuate the gag the incisal relationship or palatal contour. Nonetheless this can
reflex, regardless of how hard patients try and persevere. The take up to 9 months, or even longer in some cases. Alteration
principle is to give the patient the tools to overcome any anxieties to speech can be a cause of great concern to your patients – and
they might hold about wearing a prosthesis. once again this needs a sympathetic and systematic approach. I
A simple primary impression in compound (which is robust tend to find that prescribing adequate speaking space at the pre-
and cleansable) can be taken home and used as an acclimatisation scription stage (see Chapter 23) avoids subsequent problems.
tray. It must have a handle and be fully extended (Figure 46.1). The evidence suggests that, in the first instance, patients should
Patients should spend regular time each day in a calm and stress- be encouraged to read out loud for at least an hour each day. This
free environment. They should attempt to retain the impression can improve both speech and masticatory function.
as long as possible, with careful and controlled breathing. When However, sometimes patients are more concerned about
they begin to gag, they should sit calmly and focus on their subtle alterations to their speech. Often this will relate to how the
breathing – the impression should not be removed each time tongue is interacting with the denture base palatally – this can be
the urge arrives – yet the patient themselves must be in control. checked with a dusting of pressure relief cream onto the polished
With this approach, even before completion of new dentures, the surface palatally. Tongue contact will be directly visible – this
patient is often able to tolerate the necessary clinical stages. A should appear largely in line with the patterns in Figure 46.1. It is
similar approach can be adopted with an acrylic training plate, or possible to add carding wax diagnostically onto existing dentures
a series of training plates – however, in my experience, it is easier in order to alter the relationship to the tongue. This contour can
and more effective to simply provide a full arch impression that then be copied by the technician.
comprehensively covers the denture-bearing area and the full
depth of the sulci.
On occasion, we are unable to overcome patients’ pathological Referral process
reflexes and it may be necessary to consider adjuncts such as Appendix 3 details what information should be included in a
acupuncture or referring the patient (via their general medical referral letter.
practitioner) to a clinical psychologist. In my experience, this
 94

47 Summary of procedural stages

Chapter 47 Summary of procedural stages

Prescribing the placement of teeth and • Obtain accurate study models

■■ Well-extended trays
recording jaw relations ■■ Pre-loading of difficult areas
• Check the prescription blocks ■■ Ensure material is supported by the tray
■■ Retention and fit • Accurately articulate
■■ This is often easier with permanent bases ■■ Employ registration blocks where tripod contacts are not
■■ Any changes you make to temporary bases will be lost dur- possible
ing final processing ■■ Detail expected tooth contacts to laboratory
• Modify lip support and incisal level on the upper rim • Study each cast making notes of:
■■ Alma gauge to compare with the previous denture ■■ Ridge undercuts
■■ Fox’s plane guide to assess incisal plane and alar–tragal plane ■■ Dead spaces
■■ Pare out waxwork palatally to make room for tongue ■■ Guide planes
• Mark centre lines, canine lines and smile line ■■ Teeth unable to support a prosthesis
■■ Decide on reference point for centre line ■■ Teeth of poor prognosis and anticipated loss
■■ Canine tips in line with alar of nose and inner canthus of eye • Prescribe saddles
• Check buccal corridors ■■ Ensure full ridge coverage
■■ 2–3 mm of buccal space with a wide smile ■■ Saddles do not necessarily indicate the replacement of
■■ Bevel the wax block on a hot plate to create space teeth
• Adjust lower rim to occlude evenly with upper • Rests
■■ Don’t worry about occlusal vertical dimension yet ■■ Occlusal support at each saddle junction
■■ Achieve even contact first ■■ Consider if tooth can support a rest axially
■■ Use a wax plate to ensure flat occlusal planes ■■ Tooth preparation often needed
• Modify lower rim to maximise stability and speech ■■ Check articulation for occlusal space
■■ Consider neutral zone ■■ Rounded to allow movement in function
■■ Pare out excess wax lingually to create tongue space ■■ Consider onlay or shoulder elements
■■ Check speaking space • Clasps
• Adjust occlusal vertical dimension ■■ Direct retentive elements
■■ Based on speaking space and appearance ■■ Must be accompanied by a rest
■■ Whistling sounds suggest restricted space ■■ Consider an asymmetrical and anterioposteriorly discrepant
■■ Hollow sounds suggest excessive space clasping axis
• Re-confirm even contact in retruded arc of closure ■■ Consider how the clasp assembly connects to the major
■■ Take care to identify and avoid heel clash connector, and the robustness of the design
• Mark with buccal check marks and cut opposing notches bilaterally • Indirect retention
■■ Deep square notches down to the denture base ■■ Consider rest or saddle elements far away from the clasping
• Close passively and register with silicone axis, that will prevent tipping
■■ Gently hold the patient in the intended intercuspal position • Bracing
whilst syringing silicone registration paste into the opposing ■■ Consider major connector extension over ridges and into
notches palate
• Check for heel clash ■■ Consider proximal plates
■■ If present, adjust and re-register • Reciprocation
• Check for reproducibility after disassembly ■■ Reciprocate clasp arms with a reciprocating arm, a ring
■■ Disassemble and reassemble prior to disinfection clasp, or the major connector itself
• Select mould and shade ■■ Consider how elements connect together
• Copy old tooth set-up or arrangement, in alginate, if needed ■■ Consider the robustness of the design
• Write laboratory prescription and package disinfected records • Major connector
carefully ■■ Consider rigidity, cleansability, mucosal coverage, bracing,
cohesion/adhesion
Partial denture design ■■ Ensure connectors and the design are as simple as possible
• Survey
• Ensure accurate and contemporaneous periodontal assessment
■■ Mark survey lines for the path of natural displacement and
■■ 6-point pocket chart or Basic Periodontal Examination as a
the intended path of insertion (if different)
minimum
■■ Tilt the casts to reduce dead spaces and engage guide planes
■■ Plaque and bleeding scores
■■ Consider augmenting teeth with flowable composite if
■■ Mobility scores
undercut is required
■■ Radiographs of potential abutment teeth

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 ■■ Consider replacing existing crowns if rest seats or other ■ Do not overfill the tray 95
supportive elements need to be prepared ■ Ensure fully seated with functional border moulding
• Clearly communicate the design, including intended paths of • Recording jaw relations and prescribing tooth positions

Chapter 47 Summary of procedural stages

insertion, to the laboratory ■ Upper block for aesthetics
■ Lower block for stability
■ Record the relationship passively
Partial denture provision ■ Check for heel clash
• Patient assessment (see Appendix 2) ■ Record shade and mould
■■ Including discussion of patient expectations • Try-in
• Obtain accurate study models ■ Check fit and stability
■■ Well-extended trays ■ Check occlusion
■■ Pre-loading of difficult areas ■ Check aesthetics and speech
■■ Ensure material is supported by the tray • Fit
• Accurately articulate • Review
■■ Employ registration blocks where tripod contacts are not
possible
• Denture design Modified copy denture provision
■■ Still important for acrylic dentures • Patient assessment (see Appendix 1)
■■ Define a path of insertion ■ Discuss patient expectations
■■ Prescribe cast elements where necessary ■ Confirm denture extensions are largely correct
• Obtain special trays • Obtain accurate copies of the denture(s)
■■ Define impression material to be used ■ Use metal copy boxes
■■ Request tissue stops if needed ■ Ensure copies are free from large voids and other defects
• Tooth modifications • Recording jaw relations and prescribing tooth positions
■■ Where necessary ■ Replica dentures should be largely correct
■■ Rest seats ■ Check upper block for aesthetics
■■ Guide planes ■ Check lower block for stability
■■ Place or replace extra-coronal restorations ■ Record the relationship passively
• Functional impressions ■ Check for heel clash
■■ Ensure adequate tray adjustment ■ Record shade
■■ Do not overfill the tray • Try-in
■■ Ensure fully seated with functional border moulding ■ Check fit and stability
• Framework try-in ■ Check occlusion
■■ Check design ■ Check aesthetics and speech
■■ Check path of insertion ■ Remove undercuts from fitting surface of acrylic base
■■ Seat using rest elements only ■ Functional impression – closed mouth, one arch at a time
■■ Check occlusion ■ Do not overfill the tray
• Recording jaw relations and prescribing tooth positions ■ Functional border moulding
■■ Maintain existing natural tooth contacts or • Fit
■■ Choose a new occlusal vertical dimension • Review
■■ Record the relationship passively
■■ Record shade and mould
• Try-in Implant-supported mandibular
■■ Check fit and stability overdenture provision
■■ Check occlusion • Patient assessment (see Appendix 1)
■■ Check aesthetics and speech ■ Discuss patient expectations
• Fit ■ Determine attachment system
• Review ■ Determine abutment heights
■ Order necessary components
• Obtain accurate primary impressions
Complete denture provision ■ Ensure full coverage of the denture- bearing area
• Patient assessment (see Appendix 1) • Obtain special trays
■■ Including discussion of patient expectations ■ Specify open or closed tray
• Obtain accurate primary impressions ■ If closed tray, ensure laboratory prescribe relief over the
■■ Ensure full coverage of the denture-bearing area intended implant abutments
■■ Consider copying dentures in putty if largely correct or ■ Define impression material to be used
easily extended ■ Request tissue stops if needed
• Obtain special trays • Functional impressions
■■ Define impression material to be used ■ Ensure adequate tray adjustment
■■ Request tissue stops if needed ■ Attach abutments and impression copings
• Functional impressions ■ Use an accurate silicone or polyether material
■■ Ensure adequate tray adjustment ■ Ensure fully seated with functional border moulding
 96 ■■ Attach laboratory analogues into the impression copings • Try-in
within the impression ■■ Check fit and stability
■■ Request a permanent base ■■ Check occlusion
Chapter 47 Summary of procedural stages

• Recording jaw relations and prescribing tooth positions ■■ Check aesthetics and speech
■■ Upper block for aesthetics • Fit
■■ Lower block for stability (less so if retained well on the ■■ Activate implant attachment system if necessary
permanent base) ■■ Ensure patient can insert and remove
■■ Record the relationship passively ■■ Discuss implant health and maintenance
■■ Check for heel clash • Review
■■ Record shade and mould
Appendices

Appendix 1: Complete denture assessment proforma  98

Appendix 2: Restorative assessment proforma  100
Appendix 3: Referral letters  104
Appendix 4: Partial denture design sheet  105
Recommended and supplementary reading  106

97
Appendix 1: Complete denture
assessment proforma

Appendix 1
Department of Restorative Dentistry
Complete Denture Assessment Clinic

Clinician Date Place patient label

Medical History checked complicated here
Gender Age

Why does the patient want new dentures?

Loose upper denture at rest when eating

Loose lower denture at rest when eating

Denture pain upper lower Other details

Difficulty chewing worse recently Acrylic

Difficulty speaking worse recently Co-Cr
Nausea at rest eating speaking Age of denture (years)
Intolerance immediate (within 5 seconds) Total years edentulous
Worn denture(s) local generalised Total number of sets
Poor appearance

Extra-oral examination Left (L) Right (R) or Bilateral (B) No positive findings

TMJ Click Pain Lock Crepitus

Palpable nodes
Muscle pain Masseter Temporalis SCM Other

Glands Currently suffering from known systemic illness

Clinical examination

Intra-oral access good restricted

Tongue normal lateral spread hyperactive

Gag reflex tongue palate

Ulceration
Candidosis
Angular cheilitis
Dry mouth
Tori palate lower lingual other

Retained roots sound carious

Suspicious lesion

Other information

Tongue FOM
Sulcus Palate

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98
Appendix 1b
Ridge assessment

Upper ridge well-formed atrophic rounded flat knife-edge fibrous undercut

Lower ridge well-formed atrophic rounded flat knife-edge fibrous

Upper frenae low/absent high

Lower frenae low/absent high

Upper stability and retention: Lower stability and retention:

Stability good fair poor Stability good fair poor

Retention good fair poor Retention good fair poor

Upper denture extensions: Lower denture extensions:

Labial correct under over Labial correct under over

Buccal correct under over Buccal correct under over

Posterior correct under over Posterior correct under over

Tuberosities correct under over Lingual correct under over

Aesthetics: Occlusion:

Acceptable yes no Heavy contacts no yes __________

Lip support good high low Stable ICP yes no

Incisal plane correct incorrect ICP=RAC yes no

Buccal space present absent FWS mm

Mould/shade accept change Speaking space sufficient restricted

Special investigations and other information:

Diagnosis: Communication:

Explained plan

Patient expectations reasonable high

Prognosis for success guarded good

Treatment plan in relation to: Techniques suggested:

Impression surface: Neutral zone

Muco-compressive

Occlusal surface: Muco-static

Aesthetics:

Signed: Date:

99
Appendix 2: Restorative
assessment proforma
Appendix 2

Department of Restorative Dentistry

Adult Assessment Form

Clinician Date

Medical History checked Gender M:F Age

Place patient label
here
Relevant medical history

Dental history
Last attendance: Sporadic

Regular attender Previous bad experience

Nervous/anxious Currently in pain

Principal presenting complaint(s), relevant history and pain history (SOCRATES):

Secondary complaint(s) and relevant history

Patient expectations of treatment and outcome:

Other relevant dental history:

Social history
Occupation
Barriers to attendance Work Dependents Other

Smoker Previous Current No/day SCA given Referral offered

Consumes alcohol Units/week and type

Recreational drug use

Current preventive regime

Brushing Manual Electric Ultrasonic Times per day

Interdental Floss Brushes Sticks Other Regularly

Mouthwash Fluoride CHX Other

Toothpaste Fluoride Sensitive Whitening

Scaling Regular Supra Deep, with local anaesthetic

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Appendix 2b

Diet (record frequencies per day where possible)

Hot drinks Tea/coffee Milk Sugar Other information:

Cold drinks Juice Energy/Sports Fizzy

Sweets/mints Sugar Sugar-free

Snacks Fruit Carbohydrate

Positive findings on extra-oral examination: Left(L) Right(R) or Bilateral(B) No positive findings

TMJ Click Pain Lock Crepitus

Palpable nodes

Muscle pain Masseter Temporalis SCM Other ______________________________

Glands Currently suffering from known systemic illness

Positive findings on intra-oral examination No positive findings

Palate
Relevant information from intra/extra oral examination:
Sulci

FOM

Tongue

Lips

Fauces
Oral hygiene suboptimal
Gingivae

Initial Tooth, Periodontal and Gingival Examination

Mobility

TSL (S&K)

Upper

UR8 UL8
7 6 5 4 3 2 1 1 2 3 4 5 6 7
LR8 LL8

Lower

TSL (S&K)

Mobility

Charting Key:
C Crown V Veneer Restoration PE Partially erupted

R Retainer # Fracture Cavity FS Fissure sealed

P Pontic – Missing Recurrent caries

Basic Periodontal Examination:

Other information:

101
 Appendix 2c

Basic occlusal assessment

ICP Stable Unstable If RCP ≠ ICP, please note CRCP contacts:

OVD Normal Reduced

TSL Normal Pathological Sensitivity present Dietary and behaviour analysis required

Bruxism Facets Ridging/scalloping Fracture lines

P/- Acrylic Co-Cr Unretentive/unstable Worn Unhygienic ______ Age (years)

-/P Acrylic Co-Cr Unretentive/unstable Worn Unhygienic ______ Age (years)

Further assessment of prostheses required

Special test and investigations

Radiographic assessment

Please provide a radiographic summary. If necessary, report further in the medical notes __/__/__

Views taken and grade: RF Root canal filling

PAR Peri-apical radiolucency
Date of last bitewings: W Widened periodontal membrane space

Peri-radicular findings
and root canal fillings
Bone levels (%)

UR8 7 6 5 4 3 2 UR1 UL1 2 3 4 5 6 7 UL8

Coronal
radiolucencies
LR8 7 6 5 4 3 2 LR1 LL1 2 3 4 5 6 7 LL8

Bone levels (%)

Peri-radicular findings
and root canal fillings

Description of findings:

Results of other special tests:

Further notes:

102 
Appendix 2d

Diagnoses: Prognosis Justification

Risk assessment:

Caries High Moderate Low

E.g. Active symptoms, poor diet, poor plaque control, no history of caries

Periodontal High Moderate Low

E.g. Deep pockets with bleeding, bone loss, poor plaque control, smoker, poorly controlled diabetes, no history

TSL High Moderate Low

E.g. >1/3 crown height, symptoms, <1/3 crown height, poor diet, parafunction, reflux, no loss of contour

Soft tissues High Moderate Low

E.g. Lesion requiring referral, monitoring lesion, tobacco use, high alcohol intake, no lesions

Endodontic High Moderate Low

E.g. Symptomatic lesion, sclerosed canals, asymptomatic lesion, simple canals, no lesions

Treatment plan

Prevention and Stabilisation: OHI +/- gross scale required prior to finalising plan

See supplementary 6-point pocket chart, plaque score and bleeding

Operative interventions:

Rehabilitation options:

Maintenance plan: Risks and benefits explained to the patient for each strategy

Patient involvement discussed

Any other details including recall strategy:

Plan explained to patient

Treatment plan summary provided

Name: ________________________________________________ Date: _________________________________

Signed: ________________________________________________

103
Appendix 3: Referral letters
The Restorative Dentistry Departments in most hospitals will receive • Detail if this is for treatment planning, an opinion only, or also
hundreds of referral letters each week. Many of these are suitably for the provision of treatment
written, but it is a good idea to ensure that you follow the suggestions • Provide enough supporting information so that the grading
below so that your referral letter can be graded appropriately. consultant can make a decision. Usually this will be:
It is worth noting that it is considered good practice to grade ■■ Pictoral charting
and sort referral letters using a team approach. This is already ■■ Basic periodontal examination as a minimum
happening in some larger centres, where resources allow. Poorly ■■ Other relevant indices such as mobility scores, plaque scores,
written referrals, or those that do not follow the local protocols results of special tests
or guidelines, will often be returned to you for modifications, or ■■ Relevant diagnostic radiographs
even rejected. ■■ Details of treatment provided to date and the outcome
• For complete or partial dentures, give details of denture design,
materials used for construction, and materials used to take
• Ensure that you are using an up-to-date referral template or impressions
letter • If patients report problems after provision of treatment, be spe-
• Ensure that you have completed all aspects of the template cific about what they are, and how you have investigated them in
legibly the first instance
• Detail the specific reason why you are making a referral, and • Ensure that your patient clearly understand the reason for refer-
why the treatment does not fit within primary care dentistry ral and the time frames involved

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Appendix 4: Partial denture
design sheet
Appendix 4 Partial denture design sheet

Partial denture design sheet Design component checklist

Saddle
Patient name
Rests

DoB Clasps

Indirect retention
Signature of
Clinician Bracing

Date Reciprocation

Connector design

Maxillary denture design details

Mandibular denture design details

Notes regarding design and discussions with the laboratory

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105
Recommended and supplementary
reading

When compared with other disciplines within Dentistry and and methods. Settle on materials and techniques that work well in
wider medical professions, removable prosthodontic tech- your own hands in order to ensure optimal results.
niques suffer from a relatively poor evidence base – this is The recommended and supplementary reading below is
largely because the majority of clinical stages involve manipu- provided so that you can read around each topic in order to develop
lation and application of materials, communication with the your understanding. It is by no means exhaustive. Furthermore,
patient and the wider team, and the use of specialist equip- this book is not a reference text – and so it is important for you
ment; these are very operator-specific skills and as such, the to engage with and explore the supporting literature further.
clinician becomes arguably the most critical and uncontrolla- Many of the classic prosthodontic texts for partial and complete
ble confounding factor. prosthetics are over 50 years old, and very hard to obtain. For
My advice would be to ensure that you are well informed about this reason, and having reviewed these texts comprehensively, I
possible prosthodontic tools and techniques – and afford yourself have mostly chosen journal articles that offer sound practical and
adequate opportunity to test out and play with a range of materials clinical advice and are relatively accessible.

General reading Allen, PF & McCarthy, S (2003) Complete Dentures – From Planning to Problem Solving, New Malden:
Quintessence.
Allen, PF (2002) Teeth for Life for Older Adults, New Malden: Quintessence.
Basker, RM, Davenport, JC & Thomason JM (2011) Prosthetic Treatment of the Edentulous Patient, 5th
edn, Oxford: Wiley-Blackwell.
Carlsson, GE (2006) Facts and fallacies: an evidence base for complete dentures, Dental Update 33(3):
134–142. doi: 10.12968/denu.2006.33.3.134
Critchlow, SB, Ellis, JS & Field JC (2012) Reducing the risk of failure in complete denture patients, Dental
Update 39(6): 427–436. doi: 10.12968/denu.2012.39.6.427
Davenport, JC, Basker, RM, Heath, JR, Ralph, JP & Glantz, PO (2000) A Clinical Guide to Removable
Partial Dentures, London: British Dental Journal Books.
Davenport, JC, Basker, RM, Heath, JR, Ralph, JP, Glantz, PO & Hammond P (2000) A Clinical Guide to
Removable Partial Denture Design, London: British Dental Journal Books.
Jepson, NJA (2004) Removable Partial Dentures, New Malden: Quintessence.
Lynch, CD (2019) Successful removeable partial dentures, Dental Update 39(2): 118. https://www.dental-
update.co.uk/articleMatchListArticle.asp?aKey=943
McCord, JF & Grant, AA (2000) A Clinical Guide to Complete Denture Prosthetics, London: British
Dental Journal Books.
Accessibility Breslin, M & Cook, S (2015) No turning back: posture in dental practice, BDJ Team 2: 15164. doi:
and operator position 10.1038/bdjteam.2015.164.
Pîrvu, C, Pătraşcu, I, Pîrvu, D & Ionescu, C. (2014) The dentist's operating posture – ergonomic aspects,
Journal of Medicine and Life 7(2):177–182.

Removable Prosthodontics at a Glance, First Edition. James Field and Claire Storey. © 2020 James Field and Claire Storey. Published 2020 by John Wiley & Sons Ltd.
Companion Website: www.wiley.com/go/field/removable

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Pre-prosthetic Cawood, JI & Howell, RA (1988) A classification of the edentulous jaws, International Journal of Oral
assessment and and Maxillofacial Surgery17(4): 232–236. doi: 10.1016/s0901-5027(88)80047-x.
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Chapple, ILC & Gilbert, AD (2003) Understanding Periodontal Diseases: Assessment and Diagnostic
Procedures in Practice, New Malden: Quintessence.
Devlin, H (2001) Integrating posterior crowns with partial dentures, British Dental Journal 191: 120–123.
doi: 10.1038/sj.bdj.4801115a.
Heasman, PA, Preshaw, PM & Robertson, P (2004) Successful periodontal therapy: a non-surgical
approach, New Malden: Quintessence.
Ismail, AI, Sohn, W, Tellez, M, Amaya, A, Sen, A, Hasson, H & Pitts, NB (2007) The International
Caries Detection and Assessment System (ICDAS): an integrated system for measuring dental caries,
Community Dentistry and Oral Epidemiololgy 35(3): 170–178. doi: 10.1111/j.1600-0528.2007.00347.x.
International Caries Classification and Management System (ICCMS).https://www.iccms-web.com/
McGarry, TJ, Nimmo A, Skiba, JF Ahlstrom, RH, Smith, CR & Koumjian, JH (1999) Classification
system for complete edentulism, Journal of Prosthodontics 8(1): 27–39. doi: 10.1111/j.1532-849X.1999.
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Impression taking Besford, JN & Sutton, AF (2018) Aesthetic possibilities in removable prosthodontics. Part 2: start with
the face not the teeth when rehearsing lip support and tooth positions, British Dental Journal 224:
141–148. doi: 10.1038/sj.bdj.2018.76.
Field, JC (2016) First impressions count: how to take a primary impression, Dental Nursing (12)3. doi:
10.12968/denn.2016.12.2.72.
McCullagh, A, Sweet, C & Ashley, M (2005) Making a good impression, Dental Update 32(3): 169–170.
doi: 10.12968/denu.2005.32.3.169.
Turner, JW, Moazzez, R & Banerjee, A (2012) First impressions count, Dental Update 39(7): 455–458.
doi: 10.12968/denu.2012.39.7.455.
Managing fibrous ridges Allen, PF (2005) Management of the flabby ridge in complete denture construction, Dental Update 32(9):
and the neutral zone 524–526. doi: 10.12968/denu.2005.32.9.524.
Clarke, P (2016) Managing the unstable mandibular complete denture – tooth placement and the
polished surface, Dental Update 43(7): 660–662. doi: 10.12968/denu.2016.43.7.660.
Imran, H (2018) Five steps to flabby ridge success, British Dental Journal 225: 597–599. doi: 10.1038/
sj.bdj.2018.812
Lynch, CD & Allen, PF (2006) Management of the flabby ridge: using contemporary materials to solve an
old problem, British Dental Journal 200: 258–261. doi: 10.1038/sj.bdj.4813306.
Lynch, CD & Allen, PF (2006) Overcoming the unstable mandibular complete denture: the neutral zone
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time and improve accuracy, Dental Update 42(3): 275–278. 10.12968/denu.2015.42.3.275.
McCord, JF & Grant, AA (2000) Registration: Stage III – intermaxillary relations. British Dental Journal,
188(11): 601–606. doi: 10.1038/sj.bdj.4800549.
Copying features from Beddis, HP & Morrow, LE (2013) Technique tips – greenstick modification of dentures prior to the
existing prostheses replica technique, Dental Update 40(8): 688. doi: 10.12968/denu.2013.40.8.688.
Jablonski, RY, Patel, J & Morrow, LA (2018) Complete dentures: an update on clinical assessment and
management: part 2, Brtish Dental Journal 225: 933–939. doi: 10.1038/sj.bdj.2018.1023.
Soo, S & Cheng AC (2014) Complete denture copy technique – a practical application, Singapore Dental
Journal 35(12): 65–70. doi: 10.1016/j.sdj.2013.12.001.
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 Designing partial Bhola, S, Hellyer, PH & Radford, DR (2018) The importance of communication in the construction of
prostheses partial dentures, British Dental Journal 224: 853–856. doi: 10.1038/sj.bdj.2018.431.
McCord, J, Grey, NJA, Winstanley, RB & Johnson A (2002) A clinical overview of removable
prostheses: 3. Principles for removable partial dentures, Dental Update 29(10): 474–481. doi: 10.12968/
denu.2002.29.10.474.
Stilwell, C (2010) Revisiting the principles of partial denture design, Dental Update 37(10):682–684. doi:
10.12968/denu.2010.37.10.682
Walmsley, AD (2003) Acrylic partial dentures, Dental Update 30(8): 424–429. doi: 10.12968/
denu.2003.30.8.424
Precision attachments: Thomas, MBM, Williams, G & Addy, LD (2014) Precision attachments in partial removable
the fixed–removable prosthodontics: an update for the practitioner Part 2, Dental Update 41(9): 785.
interface
Williams, G, Thomas, MBM & Addy, LD (2014) Precision attachments in partial removable
prosthodontics: an update for the practitioner Part 1, Dental Update 41(8): 725.
RPI system of denture Krol, AJ (1973) RPI (REST, Proximal Plate, I Bar) clasp retainer and its modifications, Dental Clinical of
design North America 17(4): 631–649.
Sayed, M & Jain, S (2019) Comparison between altered cast impression and conventional single-
impression techniques for distal extension removable dental prostheses: a systematic review,
International Journal of Prosthodontics 32(3): 265–271. doi: 10.11607/ijp.6198
Shifman, A & Ben-Ur, Z (2000) The mandibular first premolar as an abutment for distal-extension
removable partial dentures: a modified clasp assembly design, British Dental Journal 188: 246–248. doi:
10.1038/sj.bdj.4800443.
Swing-lock prostheses Alani, A, Maglad, A & Nohl, F (2010) The prosthetic management of gingival aesthetics, British Dental
Journal 210(2): 63–69. https://www.nature.com/articles/sj.bdj.2011.2
Lynch, CD & Allen, PF (2004) The swing-lock denture: its use in conventional removable partial denture
prosthodontics, Dental Update 31(9): 506–508. doi: 10.12968/denu.2004.31.9.506.
Gingival veneers Alani, A, Maglad, A & Nohl, F (2010) The prosthetic management of gingival aesthetics, British Dental
Journal 210(2): 63–69. https://www.nature.com/articles/sj.bdj.2011.2
Hickey, B & Jauhar, S (2009) Gingival veneers, Dental Update 36(7): 422–424. doi: 10.12968/
denu.2009.36.7.422.
Immediate and training Ali, R, Altaie, A & Morrow, L (2015) Prosthetic rehabilitation of the gagging patient using acrylic
prostheses training plates, Dental Update 42(1): 52–58. doi: 10.12968/denu.2015.42.1.52.
Jogezai, U, Laverty, D & Walmsley AD (2018) Immediate dentures Part 1: assessment and treatment
planning, Dental Update 45(7): 617.Jogezai, U, Laverty, D & Walmsley AD (2018) Immediate dentures
Part 2: denture construction, Dental Update 45(8): 720.
Occlusal splints Adel Moufti, M, Lilico, JT & Wassell, RW (2007) How to make a well-fitting stabilization splint, Dental
Update 34(7): 398–408. doi: 10.12968/denu.2007.34.7.398.
Longridge, NN & Milosevic, A (2017) The bilaminar (dual-laminate) protective night guard, Dental
Update 44(7): 648–654.
Wassell, RW, Verhees, L, Lawrence, K, Davies, S & Lobbezoo, F (2014) Over-the-counter (OTC) bruxism
splints available on the Internet, British Dental Journal 216: E24. doi: 10.1038/sj.bdj.2014.452.
Implants and implant Laverty, D, Green, D, Marrison, D, Addy, L & Thomas, MBM (2017) Implant retention systems for
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Vere, J, Bhakta, S & Patel, R (2012) Implant-retained overdentures: a review, Dental Update 39(5):
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Principles of restoring Ali, R, Altaie, A & Nattress, B (2015) Rehabilitation of oncology patients with hard palate defects Part 2:
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Maintaining adequate Laing, E, Ashley, P, Gill, D & Naini, F (2008) An update on oral hygiene products and techniques, Dental
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Newton JT & Asimakopoulou K. (2015) Managing oral hygiene as a risk factor for periodontal disease:
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Ower, P (2018) Improving uptake of oral hygiene instructions, Dental Update 45(9): 893.
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vertical dimension Australian Dental Journal 57(1), 2–10. doi: 10.1111/j.1834-7819.2011.01640.x.
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Jagger, R (2016) Occlusion and removable prosthodontics. In: Functional Occlusion in Restorative
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techniques, British Dental Journal 196(7): 395–402. doi: 10.1038/sj.bdj.4811130.

 109
Index

abutments buccal corridors, 41, 94 embrasure spaces, blocking for gingival veneers, 77
fixed–removable interface, 68–69 buccinator, 20, 21, 33 examination, 9, 13
implant-supported overdentures, 83 bungs, obturators, 85 proforma, 101–102
retained roots as, 13 existing prostheses, assessment, 9
teeth, radiography, 12, 59 c-clasps, 60, 61 expectations, 3
access, 15–16 candidosis, 9 extensions, 6, 7
examination of, 9 canine guidance, 47 assessment, 9
restricted, 17 canine line, 44, see also upper smile line copying, 54
acclimatisation, 3 carding wax, 39, 49, 93 denture bases, 37
acrylic cast rests, 71 disto-lingual, 33
gingival veneers, 77 casts, 36–37, see also altered cast technique fibrous ridges vs, 35
hygiene, 89 partial denture design, 59 peripheral, lower functional impressions, 33
acrylic bases, 37 clasp axis, 60, 61 special trays, 26, 27
acrylic dentures, 19 clasps, 57, 60–61, 95 tray extensions, 32, 33
partial, 56, 57 for casts, 70 upper functional impressions, 30, 31
surveying for, 65 deactivation, 71 external oblique ridge, 20
Adams pliers, clasp adjustment, 71 stainless steel, 57 extracoronal attachments, 68, 69
additions to dentures, 70, 71 swing-lock dentures, 74, 75 extractions, 19
adhesives, 27, 29 cleaning, 89 immediate prostheses after, 79
immediate prostheses, 79 cobalt chrome, see also alloy teeth extraoral assessment, 19
aesthetics, assessment, 9, 45 cleaning, 89
alar–tragal plane, 40, 41 partial dentures, 56, 57 facebows, function, 47
alginate, 22, 23, 25 communication, 3, 5 fibrous ridges, 7, 11, 34–35
alloy teeth, 70, 71, see also cobalt chrome on fibrous ridges, 35 finished prostheses, 52–53
Alma gauge, 40, 41, 94 with laboratory, 15 fitting stage, 53
altered cast technique, 72–73 complete dentures, 95 fitting surfaces, 37, 53
angular cheilitis, 9 assessment for, 8–9 copying, 55
anterior guidance, 47 proforma, 98–99 fixed–removable interface, 68–69, see also
anterior repositioning splints, 81 immediate, 79 implant-supported overdentures
antero-posterior (alar–tragal) plane, 40, 41 primary impressions, 22–23 flabby ridges (fibrous), 7, 11, 34–35
Applegate classification, 57 compound materials, 22, 23, 28–29 flangeless dentures, 31
Aramany classification, 84 connectors, 62–63 flat ridge form, 8
arc of closure, retruded, 39, 46, 81 swing-lock dentures, 75 flexible denture bases, 37
articulations contact points, 53, see also early contacts; tooth fovea palatini, 20, 21
balanced, 47 contacts Fox’s plane guide, 40, 41, 94
registration blocks, partial dentures, 59 retruded, 46 fracture, saddles, 71
assessment troubleshooting, 91 frameworks, 70–71
aesthetics, 9, 45 copy boxes, 54, 55 altered cast technique, 73
for complete dentures, 8–9 copying, 54–55, 95 design, 66–67
proforma, 98–99 coronoid process, 21 maxillary defect restoration, 85
for partial dentures, 12–13, 94 crowns, 61, 65 rest preparation, 61
pre-prosthetic, 18–19 milled, 69 try-ins, 70, 71, 95
tongue, 21 stainless steel, 70 free-end saddles, 57
atrophy, ridges, 15 custom trays see special trays compressive, 73
auxiliary attachments, 69 impressions, 33
auxiliary handles, 27 dentate trays, 24, 25 tray tipping, 25, 73
denture bases, 36–37, 41 freeway space, 47
balanced articulations, 47 re-basing, 86–87 functional analysis, 93
ball joints, 68, 82 denture-bearing area, coverage, 25 functional impressions
bar joints, 68, 82 depressed ridge form, 8 lower, 32–33
bases see denture bases dexterity of patient upper, 30–31
beauty hard wax, 81 gingival veneers, 77 functional sulcus, 21
bilaminar splints, 81 swing-lock dentures, 75 funnelling, crestal, 12
biological markers, tooth arrangement, 45 diet, proforma, 101
blocks see registration blocks; wax blocks disto-lingual extensions, 33 gagging, 7, 63, 92–93
bolts, precision attachments, 69 dry mouth, 9, 11, 13, 77 training prostheses, 79
border moulding, 30, 33 dynamic operator position, 16 trigger zones, 9, 13
bracing, 7, 62–63 gingival veneers, 76–77
bricolage, 3 early contacts, 43, 51, 81, 91 glandular triangle, 20
bruxism, 81 edentulous patient, pre-prosthetic treatment, 19 glass transition temperature, 23, 29

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gold clasps, 61 maxilla peri-implantitis, 83
greenstick compound, 28, 30 defects, restoration, 84–85 periodontal disease
mucocompressive impressions, 35 relationship with mandible, 38–39, 50–51 partial dentures, 57, 59
guidance patterns, 47 tuberosities, 31 pocket depth, 13
guide planes, 64–65, see also anterior guidance medial pterygoid muscle, 20 implant-supported overdentures, 83
Michigan splints, 81 pre-prosthetic treatment, 19
habits, parafunctional, 17 milled crown, 69 swing-lock dentures, 75
hamular notches, 20, 21 Millers forceps, 38, 80 permanent bases, 36, 37, 41, 43
handles, 15–16 minor connectors, 62, 63 acrylic, 37
lower impression trays, 32 mnemonic, partial denture design, 59 neutral zone, 48
special trays, 26, 27 mobile ridges (fibrous), 7, 11, 34–35 plaque control, 13, 88–89
heating see warming mobility of teeth, 13 polyetheretherketone, 37
heavy contacts, 53, 91 mosquito forceps, 80 polyketoneketone, 37
heel clash, 38, 39 motivation, 15 position of operator, 15–16
heels-down tilt, 65 mucocompressive impressions, 35 arms of operator, 17
Hemmel torch, 28 mucosal coverage, 63 position of patient, registration, 39
high smile line, 44, 45 mucostatic impressions, 35 post-dams, 30, 31
history-taking, 9 multiple consecutive sets, 15 posterior extensions, 33
hot plate, for wax, 40 muscle insertions, 11, 15 posterior stability, 47
hygiene, 5, see also oral hygiene muscles, 20 posture of operator, 15–16
mutually protected occlusion, 47 pre-prosthetic treatment, 18–19
I-bars, 73 precision attachments, 68–69
swing-lock dentures, 74, 75 neutral zone, 48–49 prescription, 41, 43, 45
immediate intolerance, 15 denture outside, 35 facebows, 47
immediate prostheses, 78–79 notches, registration blocks, 38, 39, 48, 59 partial immediate dentures, 79
implant-supported overdentures, 82–83, 95–96, nylon, dentures, 37 pressure relief paste, 52, 53, 93
see also fixed–removable interface primary casts, 36
implants, pre-prosthetic, 19 obturators, 85 primary impressions
impressions, see also primary impressions bungs, 85 complete dentures, 22–23
for copying, 55 occlusal dimensions, 46–47 partial dentures, 24–25
distortion, 71 vertical (OVD), 47 prognosis, 15
fibrous ridges, 34–35 occlusal plane, 41, 43 putty, 22, 23, 29
gag reflex treatment, 93 occlusal schemes, 46–47 handling, 28–29
for gingival veneers, 76, 77 occlusal splints, 80–81 maxillary defect impressions, 85
implant-supported overdentures, 83 occlusion, 46–47 as supportive material, 25
lower functional, 32–33 assessment, 9
maxillary defect restoration, 84, 85 onlay dentures, 70, 71 quality of life, 5
neutral zone, 49 operator position, 15–16
for occlusal splints, 80, 81 arms of operator, 17 radiography, 12, 13
operator position, 16 oral hygiene, 13, 88–89 for partial dentures, 59
upper functional, 30–31 gingival veneers, 77 proforma, 102
incisal level, 41, 43, 45 overdentures, implant-supported, 82–83, 95–96, re-basing, 86–87
incisal plane, 40, 43 see also fixed–removable interface reactivation, clasps, 71
incisive papilla, 11, 41 overextension, 7, 9, 20, 21, 22 recession, gingival, 76
incisors (artificial), 44 lower dentures, 33 reciprocation, 61, 67, 94
indelible pencil, 31 upper dentures, 31 record blocks, 37, 39, see also registration blocks
intercuspal position, 9, 46, 51 overjet, 48 referral letters, 104
interface, fixed–removable, 68–69, see also registration
implant-supported overdentures pain, 5 (term), 39
interim prostheses, 78, see also temporary dentures assessment at fitting, 52, 53 copying, 55
interocclusal space, 46 troubleshooting, 90–91 partial dentures, 58, 59
interpupillary line, 40 whole denture-bearing area, 15 registration blocks, 37, 41
intracoronal attachments, 68, 69 palatal stops, 29 maxillo-mandibular relationship,
parafunctional habits, 17 38, 39
Kennedy classification, 56, 57, 67 partial dentures, 94–95 notches, 38, 39, 48, 59
knife-edge ridge form, 8, 11 assessment for, 12–13, 94 for occlusal splints, 81
classification, 13, 56–57 partial dentures, 59
labial sulcus, at lower functional impressions, 33 cleaning, 89 stability, 49
laboratory, communication with, 15 design, 58–59 registration paste, 39
latch assemblies, swing-lock dentures, 75 design sheet, 105 reheating, 29
light-cured resin, trays, 27 extensions, 31 relaxation, registration, 39
liners, 86–87 immediate, 79 relining, immediate prostheses, 79
lingual frenum, 20 lower functional impressions for, 32, 33 resilience, precision attachments, 69
lingual sulcus, 21 occlusal schemes, 47 resting vertical dimension, 46, 47
lip hyperactivity, 93 primary impressions, 24–25 restoration
lip support, 40, 41, 43, 94 trial prostheses, 50, 51 improvement vs, 5
Locator™ system, 68, 69, 83 partially dentate patients maxillary defects, 84–85
looseness, 90–91 maxillo-mandibular relationship, 38 restoration of teeth
lower functional impressions, 32–33 pre-prosthetic treatment, 19 preliminary, 12, 19
lower teeth, relationship with upper teeth, 43 path of insertion, 64, 65 previous
lower wax contour, 42–43 path of natural displacement, 65 partial denture design, 59
patient-perceived need, 3 rest preparation, 61
magnets, 69, 82 pear-shaped pads, 20, 21, 33 proforma, 100–103
major connectors, 62, 63 pencil, indelible, 31 restricted access, 17
Manchester rims, 43, 49 perceptions, 5, see also patient-perceived need rests, 60–61, 68, 95, see also cast rests
mandible, relationship with maxilla, 38–39, 50–51 perforated frameworks, 70 mesial, 73
masseter, 20 perforations, 27 semi-precision rests, 68, 69

Index 111
retention, 6–7 stability, 6–7, 33, 72–73 troubleshooting, 90–93
assessment, 9 assessment, 9 try-ins, 41, 50–51
gingival veneers, 77 fibrous ridges and, 34, 35 copied dentures, 55
loss, 90–91 lower wax contour and, 43 frameworks, 70, 71, 95
retromolar pads, 20, 21, 33 posterior, 47 tuberosities, maxillary, 31
retruded arc of closure, 39, 46, 81 registration blocks, 49 two-stage impressions, 23
retruded contact points, 46 troubleshooting, 90–91
review appointments, 53 stainless steel ulceration, 52
ridges, 20 clasps, 57 ultrasonic debridement, 19
assessment, 8, 9 crowns, 70 undercuts, 11, 15, 65
fibrous, 7, 11, 34–35 stock trays clasps and, 61
partial dentures and, 13 choosing, 23, 25 swing-lock dentures, 75
presentations, 10–11 for gingival veneers, 76 underextension, 24, 31
risk factors, 15 for neutral zone, 49 unflasking, working casts, 37
stability and, 7 stubs (handles), 26 unilateral prostheses, 57
ring clasps, 60, 61 supportive materials, partial denture impressions, 25 upper functional impressions, 30–31
risks, 5, 15 surgery, pre-prosthetic, 19 upper smile line, 44, 45
roots, retained, 11, 13 surveying, 59, 64–65, 94–95 upper teeth, relationship with lower teeth, 43
RPI system, 72–73 swallowing, lower functional impressions, 33 upper wax contour, 40–41
swing-lock dentures, 69, 74–75
‘s’ sound, 43 veneers, gingival, 76–77
saddles, 60–61 Tanner appliances, 81 vertical dimensions, 94
classification of partial dentures, 57 teeth (artificial), 44–45 lower wax contour, 43
fracture, 71 shapes, sizes, shades, 45 occlusal (OVD), 47
tray choice, 25 telescopic copings, 68, 69 occlusal splints, 81
screws, precision attachments, 69 temperature resting, 46, 47
selective pressure technique, 35 compounds, 23 vibrating line, 20, 21, 31
semi-precision rests, 68, 69 waterbaths, 29
shade temporalis muscle, 20 warming
artificial teeth, 45 temporary bases, 36, 37, 41 compounds, 23, 29
recording for gingival veneers, 76, 77 temporary dentures, 19, see also interim prostheses stock trays, 25
shallowness, ridges and palate, 11 3-arm clasps, 60, 61 wash impressions
shellac, 27 tinkering (bricolage), 3 copied dentures, 55
sibilants, 43 tissue conditioners, 49, 86–87 lower, 33
silicone, gingival veneers, 77 tissue recoil, 35, 37, 91 maxillary defects, 85
silicone putty, 23, 25 tissue stops, 27 upper, 31
slides, 43, 51, 81 special trays, 26 waterbaths, 28, 29
socket-fit dentures, 31 tissue trapping, implant-supported overdentures, 83 wax
soft liners, 87 tongue beauty hard wax, 81
soft splints, 81 assessment, 21 on denture bases, 37
soft tissues, pressure on, 53 lower functional impressions, 33 temporary bases, 37
spacers, trays, 27 lower wax contour and, 43 wax blocks
speaking space, assessment, 9 space for, 41, 43 lower contour, 42–43
special trays, 26–27 speech, 92–93 partial dentures, 58, 59
checking, 31 tongue spread, 93 upper contour, 40–41
for gingival veneers, 76, 77 tooth contacts, 39 whistling, speech, 43
maxillary defect restoration, 84 toothpastes, 89 windows, impression trays, 35
speech, 9, 43, 92–93, 94 training prostheses, 79, 93 working casts, 36, 37
splints, occlusal, 80–81 tray extensions, 32, 33 worn teeth, 13
squelching sensation, 29 trays, see also special trays; stock trays
stabilisation dentate trays, 24, 25 zinc oxide eugenol, 25
periodontal, 19 trial prostheses, 50–51 lower functional impressions, 32
splints for, 81 trimming, denture bases, 36 mucocompressive impressions, 35

112  Index
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