Edentulousness

• Adult Dental Health Survey 2009 • 3 million edentulous

Successful partial dentures Plus

1978 1988 1998 2009 • A further 5 million need
tooth replacement
Rob Jagger Edentulous 30 21 13 6 • More extensive partial
% dentures
• Older patients
1 March 2017 • More challenging?

Options for replacement Shortened dental arch concept

A spectrum of satisfaction - dissatisfaction Options
Kayser
Older people can have adequate function and
– Bridge
• Many denture patients have problems related aesthetics, without adverse effect, with ten pairs of
– Denture occluding teeth (SDA)
to denture wearing
– Implants
• There may be significant distress – Orthodontics
Extremely shortened dental arch (ESDA)
– Nothing

Each option has advantages and disadvantages

Informed consent

Removable partial dentures Aims – morning session Objectives

To describe treatment planning and denture • Treatment planning

Three phases of prosthetic dentistry
design
• Component parts of a denture
– Treatment plan - Denture design
To give you the opportunity to discuss any
– Denture construction aspect of partial denture treatment planning • Denture design process
– Denture maintenance
• Hands on

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 Outcomes Denture design 1. Treatment planning
Rules and exceptions
• Improved confidence and ability in designing • To discuss exceptions you need to know the A structured approach
removable partial dentures rules
• Many if not all cases are exceptions
...... A few important points
Options
• Advantages Disadvantages

Informed consent

Each person is unique Personalities Personalities

Sum of Each person / patient is an unique individual
Personality (genetic)
Sum of personality (genetic) and experience
Experience (acquired)
(acquired)

• Transference – Opinions, attitudes, expectations, prejudices

• Counter-transference – Motivation
– Adaptation / habituation Mood disorders - Neuroses Depression
Importance of the patient dentist relationship – Transference Counter-transference Psychoses
Carlsson G. Critical review of some dogma in prosthodontics Personality disorders
Journal of Prosthodontic Research 2009 53 3-10 Other disorders

Illness Ageing Treatment plan

Ageing of systems • History

Oral symptoms affect prognosis
• Exam
Age related illness • Special investigations
There are other illnesses without oral symptoms • Diagnosis
that can have a profound effect on prognosis
Mobility
Dexterity
Other? Adaptation Habituation Treatment plan
Communication
Prognosis

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 History Examination
C/O List of current complaints • Extra oral Overall
PDH • Denture assessment
Dental • Intra oral
Denture 1. Mucosa Fit surface / Clasp units
History of most recent denture(s) 2. TP
Polished surface
Have you ever has a satisfactory denture? Perio OH BPE mobility
If so which and where where is it? Teeth caries/deficient restorations/tooth wear Teeth (selection position)
PMH Conditions relevant to pros treatment?* 3. Occlusion Occlusion
SH Access 4. Denture*
Attitude
Ageing* Special investigations*

Special investigations
• ICP record • CJR record
• Radiographs
• Vitality Hand articulate When
Wax wafer
• Articulated surveyed study models? (Wax wafer / silicone) Wax rims

Wax rims

Surveying Surveying Treatment plan

• Detects hard and soft tissue undercut • Provisional

• Survey for design Dentist - technician

– Path of insertion • Definitive

• Survey for construction

– Usable undercut
• Contingency planning?
– Guide planes

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 Treatment plan 2. Component parts Component parts
Removable treatment options? 1. Saddle
2. Teeth
• Nothing 3. Rests
• Refurbish 4. Clasps
• New 5. Bracing
– Standard technique new 6. Connectors
– Special technique(s) new 1. Major
2. Minor

1. Saddle Flange 2. Teeth

. Acrylic
(Porcelain)

• Anterior

• Posterior

Saddles

3. Rests 4. Clasps
Provide support Occlusal rest Cingulum rest

There are three types Provides resistance to movement away from the
tissues (retention)

occlusal rest
cingulum rest They are flexible and act by engaging undercut
incisal rest

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 Occlusally approaching clasps Gingivally approaching clasps

There are two main types of clasp: A gingivally approaching clasp

Only the terminal one third contacts the tooth surface only
of an occlusally approaching at its tip.
clasp arm should engage the
 occlusally approaching clasp undercut.
The rest of this clasp does not
touch the mucosa or the
 gingivally approaching clasp This is the retentive portion gingival margin.
of the clasp arm. The length of this clasp usually
makes it more flexible than an
occlusally approaching clasp.

Clasps
Clasps may have different shapes
Materials used to construct a clasp are:

• I • Cobalt Chrome - cast  MINIMUM LENGTH of a CoCr clasp to

• T - wrought
allow adequate flexibility is 13mm
• Stainless steel - wrought
• Y • Gold
• S • Acetal resin
• C • Nylon

Which clasp do you choose?

5. Bracing / Reciprocation 6. Connectors

This is a component of a denture

The choice of clasp on an individual tooth that resists lateral movement. The major connector links up the saddles
depends on (and joins up all the structures of the
1. Position of undercut Enables clasp function by keeping denture)
clasp opposed to the tooth
2. Amount of bone support Minor connectors join all other parts (to
Each clasp must have reciprocation
3. Length of clasp the major connector)

4. Appearance

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 Major connectors Major connectors Major connectors for the
maxilla
An important requirement of a major
connector is that it is rigid
The choice of connector depends on
• Palatal plate Avoid gingival margins
CoCr  Anatomy (as much as possible)
– Anterior
Acrylic  Hygiene
– Mid
 Occlusion
Sufficiently thick  Patient preference – Posterior
• Ring connector

Ring Connector
Palatal plate Major connectors for the
mandible
i. Lingual bar
ii. Lingual plate
iii. Dental bar
iv. Kennedy bar
v. Sublingual bar
vi. Labial bar

Lingual Bar Lingual Plate Dental Bar

• Avoids damage to the
periodontium
• 3mm gingival clearance
• Patients do not
• Encourages plaque tolerate it well.
formation
≥ 7mm needed

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 Kennedy Bar Sublingual bar Sublingual bar
• NOT the same as the lingual bar.
• Continuous clasp.
• Its dimensions are determined by the master
impression and it represents the functional depth
and width of the sulcus.
• This is rarely well •
tolerated • The technician waxes up the connector as
determined by the impression.

• Difficult to construct
Sublingual bar

Labial bar Minor connectors 3. Denture design

May be useful if teeth

are severely lingually
inclined

Rarely used

Types of partial dentures! i. By denture base material ii. By missing teeth

i. By material Acrylic resin

ii. By distribution of missing teeth
iii. By support Cobalt chrome

Vinyl resin
Confusion relating to describing dentures
Polyamide

Titanium Kennedy I Kennedy II Kennedy III Kennedy IV

Other

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 iii. By support Design
STEP 1*****
Mucosa • To design a denture you must first decide
the type of denture by support - because
If it’s ‘not broken’ – don’t ‘mend’ it the design process for each type is
Tooth
different
• Adaptation! Mucosa
Tooth and mucosa • Habituation!!!!! Tooth
• Modifications are ok Tooth and mucosa

Stability is a composite of STEP 2. 1. MUCOSA BORNE DENTURES

Support resistance towards tissues • DECIDE TYPE by SUPPORT

Retention resistance away
Bracing resistance laterally
– Mucosa borne
– Tooth borne
All prostheses benefit from optimum stability – Tooth and mucosa borne

Mucosa borne dentures Mucosa borne dentures Mucosa borne dentures

• May be made from any of the denture base
• A mucosa borne denture is a denture that • Very common > 95% materials
derives its support entirely from the soft tissues ... usually acrylic resin
• Little is written about them in textbooks or but also
journals
– Acrylic co-polymer (high impact)
– Cobalt chrome
• There is a general lack of knowledge and many – Nylon
misconceptions –
–
Titanium
Gold
– Stainless steel
– Vulcanite

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 Mucosa borne dentures Mucosa borne dentures Mucosa borne dentures

Why so common? Why so common? Why so common? • Disadvantages

Easy to design Easy to design Soft tissue support

Easy to make Easy to make
Easy to adjust Easy to adjust Lack retention
Easy to add/repair Easy to add/repair
Cheap Cheap Potential for damage
…….. but?

Mucosa borne dentures Mucosa borne dentures

design process Mucosa borne dentures

Potential for damage

Recommended designs
Decide material - maxilla
• Alveolar bone
Wide support
• Mucosa
Gingival free
• Teeth
Retention - Avoid clasps if possible
• Gingival tissues

Mucosa borne dentures Mucosa borne dentures Mucosa borne dentures

Recommended designs • 3 exceptions
- mandible Additional retention
• Temporary (relatively quick)
In general NO design is recommended in the • Wrought clasps
mandible – Stainless steel
• Transitional
– Gold
(Gradual extractions and additions) – CoCr Wrought (Wiptam)
Mucosa borne mandibular partial – Acetyl resin
• Replacing success – Nylon
= Gum stripper

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 Mucosa borne dentures Mucosa borne dentures

Good technical support is needed! • Wide support

• Avoid gingival margins
Technicians need to • Avoid clasps if possible

– develop a path of insertion – survey and blocking out

hard and soft tissue undercut • Avoid mandibular denture if possible
– relieve gingival margins
– Use duplicate casts

2. Tooth borne dentures Tooth borne dentures

Support from teeth Support from teeth

2. TOOTH BORNE DENTURES
Rests either side of Better support
the saddles Better retention

No support from Cf. mucosa borne denture

the connector

Tooth borne dentures Tooth and mucosa borne dentures

A system for design: Very similar design process to tooth borne
3. TOOTH AND MUCOSA BORNE
• Outline saddles but
DENTURES you must deal with the additional problems caused
• Support by the free-end saddle
• Retention
• Bracing 1. Support
• Connectors 2. Stability
3. Retention
• Review design
4. Damage to abutments

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 Tooth and mucosa borne dentures Tooth and mucosa borne dentures Tooth and mucosa borne dentures
3. Retention
1. Support 2. Stability
• Direct Retention – abutment tooth
Optimum Extend into the Clasps
Extension retromylohyoid
space
• Indirect retention –
(Muco displacive
Impression) support opposing rotation is obtained anterior
to the rotational axis

4. Minimise forces (torque/rotational force)

on the abutment tooth

i. Mesial rest placement

ii. Gingivally approaching clasp

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 i. Mesial rest placement ii. Gingivally approaching clasp

RPI system - good practice

Additional
• Managing the free end saddle • Designing for the cast • Rules and exceptions
remember the occlusion
1. Support
• To discuss exceptions to the rules you
2. Bracing • Designing for the cast v the mouth need to know the rules
3. Retention
4. Damage to abutments
• Each case is an exception with potential
options

Hands on
Three cases

For each case please design

– Mucosa borne for the maxilla

– Tooth borne or tooth and mucosa borne
for the mandible

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