Introduction to removable partial denture (RPD) course Treatment options for partially edentulous patients

:Slide 2: Definition of RPD RPD it is any prosthesis that replaces one or more, but not all missing teeth. Or we can say some teeth in partially edentulous .arch. It can be removed from the mouth and replaced at well Note: fixed partial denture (FPD) can be called "bridge"and it .can't be removed :Slide 3: Types of RPD :We classify RPD according to support mainly into two types .mucosally supported OR tissue supported -1 This type of RPD is mainly composed of acrylic. But, it is important to know that they aren't supported by the tissue/mucosa one hundred percent. Example: *some of mucosally supported RPDs achieve their support by the teeth also and not only from tissues. (Mainly from the edentulous area).*another example: some clasps that we use for acrylic partial denture designed in a way that transfer the load to the abutment teeth (the remaining teeth).so, again they aren't .mucosally supported 100% Most of acrylic RPDs is mainly mucosally supported. They don't achieve much support from teeth. They are called gummo strippers (because they compress on gum).and these type of RPDs sink during function. Acrylic RPD can be used as a final definitive prosthesis. Since, type of material that we use doesn't indicate if your prosthesis is provisional or definitive. But, most .(of the time acrylic RPDs are provisional (temporary

Acrylic RPDs can have a dual support (i.e. from the tooth** .(and the tissue .Tooth supported OR tooth-mucosally supported -2 .This type of RPD is mainly composed of metal Just to refresh your memory Retention, stability & support all are applied for both complete denture . and partial denture

Definition Complete denture Partial denture Support- it is a Always from the Can be increased by characteristic of the tissue the remaining teeth supporting tissue to (abutment) & not withstand the .only from the tissue functional forces .during mastication Retention- it is the Same as the Clasps also provide ability of the definition additional retention prosthesis to resist dislodgment Stability-it is the Same as the Same as the ability of the definition definition prosthesis to resist rotational movements during function In conclusion: The concepts of all these 3 terms are the same in .both complete denture and partial denture

For slides (4 to 7): please refer to your slides .& see the pictures :Slide 4 Acrylic base Everything is made of acrylic. The base, the artificial teeth & the junction between the artificial teeth & the base plate all are .acrylic except the clasps are made of metal

Metal base Denture base (called also metal framework) is made of metal except the artificial teeth & the junction between the artificial .teeth & the metal are made of acrylic :Slide 5 .This is metal base removable partial denture in maxillary arch :Slide 6 .This is also another example Slide 7: Components of RPD Each component will be given in a separate lecture. (Refer tothe slides: these components of metal framework -cobalt .(chromium- RPD

Slide 8: Indications What do we mean by indications? It means when do we prescribe RPD for patients, instead of No treatment or instead of fixed ????partial denture or implant *.Long span edentulous area For example: missing 3, 4, 5, 6, & 7. In this case, if we want to fabricate RPD it will be extended from 8 to the lateral incisor. But, lateral it is not a good abutment. As a result of that the RPD should be extended to the central incisor. By this you will end up with a very long bridge & high chance of complications or may be failure. So, patients can't afford implant therapy. Here RPD is highly indicated for long span edentulous areas, especially when we have multiple edentulous areas. And instead of having 3 bridges, partial denture will replace all these missing teeth. And you have noticed that artificial teeth can be on the right side, left .side & anteriorly .No abutment tooth posterior to the edentulous area * For example: if somebody has 6, 7 and 8 are extracted. Can we construct a bridge? No. So, don't do fixed partial denture with distal extension except if you have very short distal extension and good abutment. In this case we have free and saddle. Therefore the option of fixed RPD is dropped, and the only options that we have are RPD or implant. For some cases the .implant is not an option. So, we have RPD or no treatment Hint: some dentists do extension to the bridge for 6 and 7 areas. After a few months or may be one year, if you hold the 7 area you can move the bridge 1 cm buccally and 1 cm lingually. And you can take out the abutment tooth by your hand without need to the forceps. (I know it's not clear enough but, this is what the .(!!!!!!!!!dr. said .reduced periodontal support for remaining teeth * i.e.: if you have mobile teeth due to periodontal disease. So, how can you decide which one to extract? According to "Grade of mobility". Grade 1 & grade 2 aren't indicated for extraction.
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Grade 3(severe mobility) is indicated for extraction. Furthermore if the tooth can't be retained in good health and the patient can't do proper brushing around this tooth, then extraction is indicated. But, if the patient can clean the tooth properly extraction isn't .indicated Do you think a mobile tooth is a good abutment to construct abridge? When you want to fabricate a 3 unit bridge(example:6, 7 are missing) already the periodontal membrane is reduced for the teeth. The 5 and 8 gain the forces of the missing teeth in addition to the forces that applied to them. So, what does this mean? RPD might be indicated in this case. Especially, acrylic RPD. If it is metal it might be tooth/tissue supported. And if it is only tooth supported you can distribute the load on more than 2 teeth by applying rests on all remaining teeth. By this in RPD you can .transmit the forces to more teeth .need for cross arch stabilization * In RPD you can do cross arch stabilization, while bridge is only .on one side .Excessive bone loss within the residual ridge * In case of excessive bone loss Implant is not an option. But, only when we do bone grafting implant is accepted. Sometimes the patient can't afford for this treatment or even for medical reasons he can't have it. So; what's the option? RPD. Why?? Because we .have acrylic flange that replaces the missing bone .Physical or emotional problems exhibited by patients * For example: if somebody has missing teeth from canine to canine, so what's the treatment option? Do we choose implants as a treatment for this patient? Of coarse no. this patient can't physically (i.e. ability to eat & to speak) and psychologically withstand for a period of time without teeth (it is not acceptable). Therefore RPD is the treatment option & within 3 weeks to 1 .month the patient can have teeth and function .Esthetics *
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Some people think that implants or even veneers provide best esthetics. Actually, in some cases they provide the worst esthetics. So, don't think that implants give the best esthetics. It might give the least esthetic outcome, while using RPD can give .the best esthetic outcome. That depends on case selection Dr. said: I remember a 30 years old woman that had 8 implants and a fixed prosthesis on them. She spends thousands of money for those implants. After came again to the clinic and complained that she doesn't like the prosthesis. Unfortunately, we can't solve the problem now and do a complete denture to her as a better .esthetic option. So, it depends on case selection .Immediate replacement of teeth that need extraction * We can't construct a partial denture before extraction of teeth. So, you extract the teeth and immediately insert them. Especially that the big psychological trauma for patients is accompanied .with missing or extracted teeth .Patient's desire * Sometimes, we let our patient decide which treatment option he prefers. Especially if we have an old patient (in his 60s or 70s) the most favorable treatment is to have quick & cheap teeth (RPD). Or sometimes if you tell your patient about the complexity of other modalities of treatment, then he will say to .you please do the simplest one .Unfavorable maxillomandibular relationships * For example: if someone has severe class 2 or class 3, implant dentistry or even fixed prosthodontics is not the straight forward procedure for those patients. But, removable prosthesis is much easier than fixed & implant prosthesis.(besoholeh mnet3ada el discrepancy).i.e. if the patient has class 3, what do we need to do?! Just to retrocline the lower anteriors a little pit and to procline the upper anteriors a little pit. By this we transfer from class 3 to edge to edge. Can I do this in implants? No. why?? Because, if we want to do it by putting implant we should direct them labially. And unfortunately there is no enough bone and .may be we cause sever recession of the gum
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Slide 9 + slide 10: Advantages of RPD it restores function and esthetics. And this is what we want most.of the time it improves speech and occlusal stability. This point fulfills thecriteria of a dental prosthesis which is function (includes .mastication and speech), esthetics and stability replaces one or more missing teeth in one side or both sides of the upper or lower jaw. So, one .prosthesis replaces many missing teeth more affordable than fixed. Because it is very cheap. Forinstance; acrylic partial denture costs 50 J.D and one implant 650 .J.D Some students, who have relative dentists that say to them that RPD is a part of history, don't believe them. It is still wherever you go in the worldin the United States in Australia in Canada& in Europe; there are cases that must be treated only by RPD. For example: postmenopausal woman is highly exposed to osteoporosis and they can't have implants. So, osteoporosis contraindicates the use of implants. And according to this the option is RPD. Furthermore, no way to plan the implant case without starting with RPD. Because, we dont know the final outcome. To conclude, you must have to start with complete denture for edentulous patients and with RPD for partially .edentulous arches .replaces missing soft tissue and bone as well less accurate techniques than fixed prosthesis and easy occlusal .adjustments In RPD occlusal adjustments is only for 5 minutes, but in bridges for 0.5mm we need have an hour (in order to remove the .(ceramic
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.easy to clean because it's removable .(may provide as an interim prosthesis. (Something provisionalquite easy to adjust and add more teeth if later loss occurs. (We.(will talk about it in provisional restorations By the way any prosthesis has advantages and disadvantages. If you have done RPD and the patient doesn't like, he can get rid of it.. But in case of implant there is prescription and installation. So, you can't remove it easily. So, you must remove part of the .bone If you construct a bridge can you do this (remove it)? Another bridge means that cut the bridge, refine preparation again and take a new impression (because already teeth are prepared and the bridge is cemented).in abroad, bridges cost 5000 dollars and .even in Jordan 4 unit bridge costs 800 J.D Don't think by implant dentistry you can get rid off traditional prosthodontics. It is still indicated in many cases. Especially, in .our countries Slide 11 -15: Disadvantages of RPD Can cause caries for adjacent teeth depending on the design of the RPD, age of the patient, and the oral hygiene efficiency. Some patients have bad oral hygiene and this indicates caries. Such criterion is not limited only for RPD. It is also suitable for fixed partial denture in which they will have more serious .carious cases Can damage the supporting tissues if poorly designed and cause tooth loosening and mucosal ulceration. Especially if it is tissue .supported can cause trauma Unsuitable for many patients who don't like removable prosthesis. I.e. a lot of patients they are reluctant especially young patients. They don't like to remove their prosthesis and .(then retain it. (It is not acceptable socially
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The RPD rotates during function especially the mucosally or dually-supported one which reduces efficiency and increases trauma. So, RPD during function rotates not as fixed partial .denture Its construction involves some preparation and adjustment of the remaining dentition. We need to do adjustment on teeth especially in metal framework in which we have rests and so on The acrylic teeth wear and require later replacement. Whenacrylic opposes teeth the wear is more than in acrylic teeth in complete denture. That's regarding to the hardness number of enamel which is more than acrylic. (For enamel it is 350, and for acrylic it is 30).but, it is not a big problem. We can replace the .distorted teeth by other new acrylic teeth The clasps may be unaesthetic if placed anteriorly. This is reallya big disadvantage. For example: if the patient with missing canine (3) or (4), you need a clasp for retention on the canine. .And this is not esthetic May stimulate candidal infection of the mucosa underneath especially if not cleaned frequently and after meals. Candidal infection for those patients is very common for two reasons: 1) poor oral hygiene. 2) Or if the denture is ill-fitting. And most of the time combined (both of them).we can notice this infection on .the hard palate

.The acrylic has low impact strength and may fracture Bone resorption if mucosally or dually-supported and frequent relining may be required. After bone resorption there will be a space between the denture and the bone leading to more
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movement and more damage. The best solution is to reline in .which we add acrylic on the fitting surface of the prosthesis Bulky if compared with fixed prosthesis, and so uncomfortable for new wearers. As we noticed in RPD we fulfill the hard palate to replace missing lateral. In contrast, in fixed prosthesis it is .very tiny Some patients complain of reduced thermal sensation with upper RPD covering the palate. When you eat a piece of cake .thermal and taste expansion will be reduced Better to be removed at night for tissue re-adaptation. Most offungal infections occur in patients that wear their RPD 24 hours .(^_^)

Slide 16: Treatment options for partially edentulous patients What are the treatment options for partially edentulous patients? .There are 4 options NO treatment (1 RPD (2 FPD (3 .(implant-supported prosthesis (fixed, removable (4

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.Hint: implant doesn't mean fixed prosthesis only

Each one of these 4 options is suitable. So, it is not necessary to follow this sequence. For example: if we have two patients and both of them with missing laterals. As a treatment option for the first patient we decide to do RPD. And for the other we decide to do a bridge depending on many factors that we will talk about .them later Slide 17: **veeeeeeeeeeeeeeeery important slide What are the steps involved in construction of removable partial .(dentures? (Metal-acrylic and acrylic only -.Metal-acrylic which is metal framework .Acrylic only which is acrylic RPD

Now we will talk about acrylic RPD only, and metal acrylic we .will talk about it later
Mount casts on articulator analysis of diagnostic casts 11

Data from history and oral *examination

Dr. mentioned: after that)* We take *Treatment plan a primary .impression So, what Designing RPD type of material ?should we use Only alginate. Keep in your mind that impression compound can't be .(used for edentulous patients
Metal acrylic RPD Tooth modifications *(Final impressions *Acrylic only RPD

final impressions jaw relations (if needed

*Try-in metal framework

try-in of RPD

Jaw relations Try-in of RPD

insertion of RPD

Insertion of RPD Review

:Dr. explained according to treatment plan ) *

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This sequence may be changed. Sometimes you need treatment planning for mounted models & sometimes you can do treatment planning without mounted model. Example: patient with missing lateral doesn't need mounted model in comparison to patient with multiple missing teeth & supra eruption of some teeth, we can't plan the case in patient's mouth because we might need more than two hours. Also we can't see from behind the teeth. So, we mount the model. Then do treatment plan & decide is it acrylic ). RPD or metal RPD

Dr. explained according to acrylic RPD: in some cases we need special)* tray and final impression. in other cases final impression is enough. For .(instance: if the patient with missing lateral, primary impression is enough Dr. explained according to jaw relations: in some cases you can)* articulate the models without need for the record block because we have .(remaining teeth and it is not as in complete denture Dr. explained according to try-in of RPD: also it depends on the case. if)* the patient with missing lateral no need for try-in. but, if all anterior teeth .(are missing in this patient you need to do try-in

Slide 18: Provisional/temporary RPDs :We have 3 types of PROVISIONAL RPDs Interim RPD (1 Transitional RPD (2 Treatment RPD (3
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Does interim RPD means acrylic partial denture? No, it can be* .metal not only acrylic Slide 19: Interim RPD .Indications* What does interim mean? Interim means provisional prosthesis that can be replaced by another definitive prosthesis. Example: if somebody has missing lateral and supposes that he is 17 years old. As a first treatment option we put RPD- for 2-3 years- until he becomes 20 years old. After that implant therapy will replace it. In this case we use RPD as a temporary solution to be replaced by another definitive prosthesis. By the way definitive treatment .can be another partial denture not necessarily implant Materials. (Cold-cure acrylic/ heat-cure acrylic/acrylic &* .metal). Most of the time, we use heat-cure acrylic Clinical procedures. Exactly the same as I just mentioned* above. But, in cold cure or metal the steps are different from that .applied to the heat cured :Laboratory procedures. Include many steps* .Step 1: Classification of the models Step 2: Do survey to determine the desirable and undesirable .undercuts .Step 3: Block out the undesirable undercuts .Step 4: Wire binding and preparing the clasps .Step 5: Setting of teeth .Step 6: Denture base .Or you can do the two last steps (5&6) together After that you do processing (includes flasking, dewaxing, .(packing, curing, deflasking, finishing and polishing .Slide 20-22: -Refer to your slides to see the pictures Take this case for example: this is 21 years old female. She had anterior bridge (fixed partial denture) when she was 16 years. As
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you see in the picture there is a fracture in the ceramic. The patient didn't like the color of her teeth and their level. So, the bridge is defective, In addition to the endodontic problems that she had. If we want to correct the deficiency we cut the bridge and get rid off it. We can't leave our patient without teeth!!!!!. Since, we need a provisional treatment (i.e. we need RPD as an interim prosthesis that will be replaced by definitive one). So, this is an interim RPD and after this she had two implants and a bridge on these implant. (Here one tooth is added and another one is extracted).This example is introduced to show you that RPD is part of prosthodontic treatment, not considered as a part .of history Slide 23: Transitional RPD .Indications* It means that the patient is in the process of being edentulous. There are a lot of possibilities for patients that have transitional RPD like: neglected mouth, poor oral hygiene, decayed teeth and mobile teeth. To avoid the big psychological trauma/impact of your patient you don't take all teeth out, although you know the fate of these teeth is extraction. But, you do the process slowly to reduce the psychological trauma. For example: if your patient has extracted molars and the remaining teeth are from 5 to 5. Then you construct an acrylic denture and start to extract the worst teeth that your patient complains about. And then add a tooth every month until the patient has a complete denture base. .Finally you construct a new complete denture .(Materials (heat-cure acrylic/acrylic & metal* .Clinical procedures* .Laboratory procedures* You should know how to add a tooth. (These procedures .(described in chapter 19 in your book Slide 24: Treatment RPD

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.Indications* .(Materials (acrylic & tissue conditioner* Tissue conditioner is a very soft material & it still soft only for one week. We put it on the fitting surface of the denture, In order .(to recover the lesion (that caused by traumal infections These RPD called "treatment RPD", because we use it for .treatment purposes Just to know: soft acrylic considered as another material that can .be used .Clinical procedures* Laboratory procedures. The only difference is that you need* space for tissue conditioner. So, before you do the acrylic base you add spacer. Same procedure that we do in the special tray in which we use wax spacer and acrylic. When you remove the wax spacer there will be a space for the impression material. Here is the same concept; you add wax spacer and construct the acrylic partial denture (can be cold-cure acrylic). After construction you will remove the spacer. So, you will end up with space in the partial denture and then add the tissue conditioner and place it in .patient's mouth
Tooth-mucosa supported RPD

Wish you all the best& forgive me for any mistake

Done by: Fatina akel

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