Beruflich Dokumente
Kultur Dokumente
Removable Prosthodontics
Two hours of CDE credit
This article provides information regarding the many ways that removable partial den- flanges will be visible (Fig. 2). Dentists
tures (RPDs) may be used to solve restorative problems in the esthetic zone without must pay attention to flange design (that
displaying metal components or conspicuous acrylic resin flanges. The esthetic zone is is, contours) in such cases; custom color
defined and described, as are methods for recording it. Six dental categories are characterization also may be necessary
presented that assist the dentist in choosing a variety of RPD design concepts that may for optimal esthetics. Finally, the study
be used to avoid metal display while still satisfying basic principles of RPDs. New noted that 6.0% of all patients displayed
materials that may be utilized for optimal esthetics are presented and techniques for only the maxillary anterior teeth from ca-
contouring acrylic resin bases and tinting denture bases are described. nine to canine when smiling and may dis-
play only part of those teeth and no at-
Received: March 4, 2004 Accepted: April 19, 2004 tached gingiva (Fig. 3). Dentists can offer
these patients a wide array of RPD design
concepts that do not compromise the es-
Esthetic dentistry is associated most often how it relates to the six partially edentu- thetic zone.
with anterior restorative dental care. Es- lous dental categories that determine Mandibular anterior teeth must be ob-
thetic dentistry describes the efforts RPD treatment options. served and described in the treatment
made to restore teeth or prostheses with- plan.6 Most patients display only 50% of
out drawing attention to those changes. The esthetic zone the mandibular anterior teeth and 50% or
Esthetic dentistry also may enhance one’s The term esthetic zone is used here to de- less of the buccal surfaces of the premo-
appearance by improving contours of scribe the teeth and gingiva as they are lars in the esthetic zone, while all occlusal
teeth and gingival architecture or by pro- observed when a patient emits a hearty surfaces of the premolars usually are visu-
viding a brighter and more noticeable laugh; this laugh should be described, alized. Dentists can conceal distracting
look. Removable partial dentures drawn in the treatment plan, or displayed RPD components in these patients but
(RPDs) are one aspect of esthetic restora- in a photograph. This practice will allow planning is more complicated for the
tive dental care that often is neglected. dentists to avoid including unwarranted
Due to the emphasis placed on esthetic displays of clasps and other metal com-
dentistry in the media and the advances ponents in the treatment plan (Fig. 1).
made in this area during the past 15 According to Preston, the esthetic zone is
years, patients have come to demand wherever the patient thinks it is.4 Even
prostheses that not only are comfortable though the patient may not display metal
but also are less noticeable or more natu- while laughing, he or she still may believe
ral in appearance. Many of the materials, that it can be observed. Dentists should
techniques, and designs that may en- always communicate to patients when Fig. 1. A patient’s esthetic zone. Note the
hance esthetics often are not taught to un- metal is to be used on the facial surfaces visible clasps.
dergraduate dental students.1,2 Most den- of teeth, even when the metal will not be
tal schools are reducing the curriculum visible in the esthetic zone. Patients
hours devoted to the clinical teaching of should have the opportunity to select al-
removable prosthodontics at a time when ternative designs.
the need for RPDs is increasing.3 In 1984, Tjan et al demonstrated that
Implant dentistry may be used to re- 87% of all patients had what was referred
place RPDs for some patients; however, to as the average smile, in which the cervi-
financial, anatomic, psychological, or cal to incisal length of all maxillary ante-
medical considerations still require den- rior teeth was displayed to either the first Fig. 2. A patient whose maxillary teeth and
tists to understand how to create a treat- or second premolar.5 In light of this find- attached gingiva are visible upon smiling.
ment plan, design, and treat patients for ing, dentists must be vigilant to eliminate
removable prostheses. Fabricating in- clasps, metal proximal plates, spaces, or
conspicuous implant restorations in the any obstruction in the esthetic zone for
esthetic zone is challenging and often can the majority of individuals in their prac-
be performed more satisfactorily by uti- tice. In that same study, 4.0% of the pa-
lizing RPDs. RPDs also offer a less com- tients displayed all of their maxillary an-
plicated, less expensive, and time-saving terior and posterior teeth and their
alternative to implant treatment. attached gingiva. These patients are the
This article describes the esthetic most difficult to satisfy since all frame- Fig. 3. A patient showing 50% of the anteri-
zone, how it should be evaluated, and work components and acrylic resin or teeth from canine to canine.
Fig. 4. A PA rotational path of insertion RPD. Fig. 5. Framework with bracing component
on disto-facial of abutment teeth.
Fig. 7. A PA rotational path RPD with Fig. 8. Saddle-Lock RPD with retainer arm Fig. 9. Saddle-Lock RPD retainer beneath
lingual retention. beneath the proximal plate. the proximal plate in disto-facial undercut.
many patients who don’t fall into this cat- placed in the gingival third of a tooth and tained practically without milling a cast
egory. Patients display more mandibular the approach arm should not traverse restoration. Bracing is a term used to de-
teeth and gingiva as they age.7 soft tissue undercuts. scribe what has been known convention-
Wrought wire and cast circumferen- ally as a reciprocating clasp. The bracing
Categories of partial tial clasps are alternative designs for sur- clasp is used to prevent horizontal move-
edentulism veyed casts and appropriately recon- ment after the clasping assembly is seated
This article is divided into six categories toured abutment teeth. The approach completely. Together with the retentive
of partial edentulism that are used to de- arm of these clasps should emanate from clasp and rest of a clasping assembly, the
termine RPD treatment options. the middle third of an abutment tooth bracing clasp satisfies a basic principle of
and the retentive tip of the clasp should clasp design by encircling the abutment
Esthetic zone is not a concern be in the gingival third of the abutment tooth by more than 180 degrees.12
and no need exists for abutment tooth. The proximal section of circum- Using lingual retention to hide a re-
retainers ferential clasps should not emanate from tentive clasp often is an excellent option.
Most prosthodontists agree that a less- the occlusal third of the tooth.10 If the abutment tooth has the appropriate
complicated approach to RPD treatment When tooth-supported RPDs are pos- contour, a lingual undercut can be uti-
is best.8 Any conventional clasping sible, a posterior anterior rotational path lized for the retentive clasp that is not vis-
arrangement can be used, provided abut- RPD also should be considered. This ible. To satisfy the basic principle of en-
ment teeth are not restored and the es- RPD will allow conservation of tooth circlement, bracing can be utilized on the
thetic zone does not display an RPD’s structure on posterior abutments while distofacial aspect of the abutment
components. The patient must be in- avoiding facial and lingual clasps that can teeth—together with rests, minor con-
formed that clasps will be placed on the irritate the tongue and facial attached nectors, and tooth contacts (Fig. 5 and
facial surfaces of teeth. These clasps will gingival tissues (Fig. 4). The rotational 6)—without the unsightly display of a
not be visible when the patient smiles or path RPD design will be described in de- buccal clasp arm.13 The lingual retention
emits a hearty laugh; however, they may tail later in this article. option can be utilized for tooth-support-
be visible if the lips are displaced forcibly. ed and tooth-and-tissue-supported res-
The patient should consent to this prior Esthetic zone is a concern and no torations.
to treatment rather than after a frame- need exists for abutment retainers When abutment tooth contours are
work has been constructed. When the facial surfaces of abutment favorable, the posterior anterior rotation-
Infrabulge clasps are the most esthetic teeth are visible in the esthetic zone, den- al path RPD can be designed for lingual
of the conventional retentive clasps, of- tists should consider other locations for retention of the conventional clasping as-
fering dentists the best opportunity for retentive and/or bracing clasps. It is im- sembly (Fig. 7).
placing metal in less-conspicuous loca- portant to distinguish between bracing A Saddle-Lock RPD (Boos Dental
tions.9 The foot of the infrabulge clasp and reciprocating clasps as part of a Laboratories, Minneapolis, MN; 800.
often can be reduced for optimal place- clasping assembly.11 Reciprocating a 333.2667) avoids visible clasps by utilizing
ment. Ideally, these clasps should be force from a retentive clasp cannot be at- a distal facial undercut and a mesial rest.
Fig. 13. Initial path of insertion on distal of Fig. 14. Initial path of insertion on distal of Fig. 15. Lateral path of insertion framework
first premolar, left side. first premolar, right side. with diagonal rotation.
This design is particularly suited for are out of the esthetic zone (Fig. 10 and
tooth-supported situations. One should 11). The author has used this concept to
be cautious when using it for tooth-and- replace first premolars and all maxillary
tissue-supported partial dentures, as this anterior teeth successfully.
design makes it difficult to establish guid- When a limited space (for example,
ing planes on abutment teeth and it may two central incisors) must be replaced,
compromise retention and stability of the dentists should use a dental surveyor to
prosthesis (Fig. 8 and 9). ensure that rests and rigid proximal Fig. 16. Lateral path of insertion RPD re-
The Rotational Path of Insertion con- plates are not prevented from seating on placing teeth No. 6 and 7.
cept is one of the most appropriate de- natural teeth during the initial path of
signs for this category.14,15 By rotating an placement. Additional modification
RPD into position, dentists can avoid us- spaces also may be replaced using this rotational path RPD that is rotated in a
ing the standard number of clasps that concept but the design is more complex more diagonal direction. When conven-
normally are required. It must be re- and proper blockout procedures must be tional clasping is utilized, the initial path
membered that this design concept is performed to avoid interferences when is located more anteriorly and the con-
used primarily for tooth-supported rotation occurs around abutment teeth tralateral side is rotated and positioned
RPDs, although there are a variety of ways (Fig. 12). more posteriorly (Fig. 15 and 16).
to utilize this concept: posterior anterior Although it is not always considered, a Flexite (Dentsply International, York,
(PA), anterior posterior (AP), and lateral Kennedy Class III with a modification PA, 800.877.0020) is a translucent mate-
paths of placement. The first letter indi- space on the other side of the arch (bilat- rial that can be used to avoid metal dis-
cates the initial path of placement (utiliz- eral tooth-supported partially edentulous play; it also can be attached to metal
ing a rigid proximal component); the sec- spaces) is another method for utilizing frameworks, resulting in cross-arch stabi-
ond letter indicates the segment of the the AP rotational path RPD, precluding lization and clasp encirclement. In recent
prosthesis after rotation has occurred. the need for a visible clasp on a first or years, the author has experienced excel-
This segment has a conventional clasping second premolar. A distal undercut on lent clinical success using this material
system. premolars is used for the initial path of with cast frameworks (Fig. 17–19). Due
The AP design used in Kennedy Class placement and the RPD is rotated with a to Flexite’s lack of tensile strength, it must
IV situations (that is, partially edentulous conventional clasping system on the mo- be designed with greater vertical height
spaces that cross the midline) is the most lars (Fig. 13 and 14). and thickness than metal, which results
popular rotational path design. This de- Conceptually, the lateral path of RPD in broader coverage of the abutment
sign eliminates clasps on the facial sur- insertion is not different from the AP, ex- tooth. The author designs Flexite clasps
faces of anterior teeth. Conventional cept that a Kennedy Class III partially from the height of contour of the abut-
clasping can be utilized on both maxil- edentulous space (that is, one that does ment tooth to the tooth gingival junction;
lary and mandibular posterior teeth that not cross the midline) is replaced with a most are 3.0–4.0 mm high and 1.5 mm
thick. Flexite is a relatively new material more amenable to repair than intracoro- cure the relationship between the attach-
and there is concern regarding its clasp nal attachments. Extracoronal attach- ment and the crown. This brass dowel
strength and stability in the mouth over ments also minimize tooth reduction and prevents damage during divesting by al-
time; as a result, this design would be the satisfy stress-releasing or stress-direction lowing the laboratory technician to re-
last choice for achieving an optimal es- principles that are required for tooth- move the metal ceramic crowns from the
thetic result in this category. and-tissue-supported RPDs (Fig. 20).16 master cast prior to investing; it also main-
Based on experience, the author prefers tains the exact relationship of the RPD
Esthetic zone is a concern and the the ASC-52 anterior protect system framework and the crown (Fig. 22). De-
need exists for abutment retainers (Medesco Attachment/Implant Company, livery of the RPD is accomplished without
All of the above concepts can be utilized Laguna Hills, CA; 800.633.3726) and the difficulty and the need to correct an ill-fit-
when metal ceramic crowns are needed ERA-RV attachment (Sterngold Attach- ting attachment with an auto-cured resin
to restore abutment teeth in tooth-sup- ments, Attleboro, MA; 800.243.8942).17 pick-up at delivery is reduced.
ported situations. This section focuses The ASC-52 attachment is a universal The ERA attachment has a plastic re-
on tooth-and-tissue-supported RPDs. joint resilient extracoronal attachment, ceptacle that is connected to the wax-up
Precision attachments are needed for this containing an iridium platinum receptacle for the metal ceramic crown. For the ERA
situation to avoid clasps in the esthetic that is cast with the abutment crown (Fig. attachment to fit accurately into the recep-
zone. While there are numerous preci- 21). The receptacle is resistant to wear and tacle, an excellent casting process is re-
sion attachments on the market, it would avoids food retention due to its open de- quired. Because the receptacle is made
be desirable for a dental practice to limit sign. The ASC-52 is a spring-loaded dow- from the same metal as the crown, a met-
the available attachments to two or three. el that can be replaced easily. As a univer- al of sufficient hardness must be used to
Limiting the available choices will reduce sal joint, this attachment is unique because limit wear. The manufacturer recom-
the number of necessary components it does not require parallelism to function, mends a Vickers hardness of 200 and a
and result in greater efficiency and re- it does not torque the abutment teeth, and minimum of 85,000 psi ultimate tensile
duced cost. it can be used with a single abutment sup- strength. Dentists must be aware of this
As stated previously, most prostho- port when good cross-arch stability is metal requirement and communicate this
dontists agree that a less-complicated ap- achieved.18 to the technician, although metal recepta-
proach to RPD treatment is best. Howev- One major advantage the ASC-52 sys- cles will wear as a result of the plastic at-
er, dentists must be prepared to place tem offers is the accuracy between the at- tachment regardless of the metal that is
precision attachments on unrestored tachment and the metal ceramic crown used.
abutment teeth when the esthetic de- that is maintained during the processing Sterngold provides ERA attachments
mand is high. In these situations, the au- of the acrylic resin. A brass processing in a variety of sizes. The increased cir-
thor prefers to use extracoronal attach- dowel is used during the investing process cumference provides more retention in
ments, which are easier to fabricate and (in place of the attachment ferrule) to se- the receptacle attached to the abutment
Fig. 31. A patient wearing the Flexite pros- Fig. 32. Locator stud attachments placed on Fig. 33. RPD with plastic locator attach-
thesis from Fig. 30. teeth No. 12 and 15 for RPD retention. ments.