*Prosthodontic course II *Removable partial denture *The second lecture, but the first one to be scripted since the

first one is an introduction.. Today we will continue talking about removable partial denture, as we talked in the last lecture (which has not been scripted) we talked about the different divisions of partial denture and we initially talked about the classifications, we will discuss them in more details and recognize some other classifications, which we already talked about them in the lab. These are the divisions of prosthodontic in general:

Now we all know what a prosthesis is. Simply a partial denture is a prosthesis that replaces one or more missing teeth. A partial denture is distinguished from complete denture in that ; partial denture replaces teeth in a partially edentulous mouth, but the number of teeth is quite variable, we can have one missing tooth, or we can have one remaining tooth ,so that can vary from 1-15 missing teeth and its still called partial denture, now this creates a challenge in terms of design ,in complete denture its straight forward we have 2 edentulous arches, and we have 2 prostheses a maxillary and a mandibular complete dentures. In partial denture because there is such a variability there are actually 10000 combinations if you calculate them for different types of designs ,its actually difficult to figure out what the design look like for the

patient. To simplify that, different classification systems were designed, and these were done in North America. The classification system that you have already been familiar with is Kennedys classification with Applegates modification. Now Dr Kennedy proposed this classification 90 years ago, Kennedys classification has some deficiencies and thats why Mr. Applegate came along and made some modifications. There are newer classifications which are more biological, Kennedys classifications is more mechanical. Im not going to talk about them (The DR) but the Dr will be giving us a handout for assigned video to look at it (Ta ta36ena elslides awal ya DR ba3deen mnebla$ bel vedio ;)) we dont use these classification here in the university. The more modern classification from American dental association you should be familiar with to see these different types of classes that they have been described. We talked about the different divisions, we talked about the indication for making partial denture in the lab, now when we replace missing teeth we have many choices to consider; 1-your first choice is not replacement what so ever; if the occlusion is stable and there are no esthetic concerns, and there are enough teeth in the arch so that the patient can function normally, no intervention by the dentist is indicated sometimes. You know that the dental arches in such away that each positioned teeth except for the upper third molar, has to opposite teeth, so if one molar is missing in the arch and there is adequate interdigitation between the arches ,and the interdigitation prevents supra eruption and mesial tipping and keep the teeth in the same place ,and if the patient doesnt desire for psychological reasons, there is actually no reasons to replace teeth functionally, so you give the patient the option that you dont have to replace the teeth . Every time you insert a tooth, you introduce something new to the patients mouth, and the surfaces will never be the same before you actually made the prosthesis, you can never make the mouth exactly as it was when you born with it, you have to remember when youll learn about something called differential diagnosis and treatment planning your first choice should always be; can the patient manage without a tooth??, and can I offer this option to the patient. the patient may not financially need the tooth now, may be he wanted later, so this always should be in your mind. There is another concept in dentistry called, the shortened dental arch ,there is a dentist in north Europe his name is kisa (not sure) his idea was when you have an elderly patients (40-50 or over) and they have missing posterior teeth ,he did a lot of study to see how much function we have with or without these teeth he tried to reduce the number of teeth until the minimal number in away they can still function normally like this (16 upper_16 lower, 15 upper -15 lower, 14 upper-14 lower..and so on ) actually he tried to figure out, if the patient has the teeth until the second premolar in the upper and lower can they still function normally??, do

they need partial denture in the back or not?? ,he did a lot of study and he found that (The patient can function with only 20 teeth from second premolar to second in both arch if the arches is curve not (straight or square) in Shape, that means if the patient has a missing molar he can still function just fine thats what shortened dental arches mean( ( . Like this picture..

Second premolar

Second premolar

Shortened dental arch So you can offer the patient not to replace ,if you make sure that he doesnt face any problem and the teeth are stable, because since the upper posterior are missing and the lower are missing the only objective becomes psychological ,and functional. And in terms of function you learned that each molar only provides a certain amount of percentage of function and you can get 60-70% of function just from premolar occlusion. Partial denture replaces one or more missing teeth, now there is a student who asked the DR once, when do I choose to make Removable partial and when do I Choose to make Fixed partial denture?? .it usually Pours in a number of things. We usually talk about 3 things, phonetic, aesthetic, and function, how much function can they get from the teeth ,a simple basic rule the more the teeth you have ,the greater the probability of replacing a removable prosthesis ,why??? With fixed partial denture we take our support directly from the adjacent teeth. Now in term of terminology the tooth which supports the prosthesis whether its fixed or removable its called abutment. Like the picture.

Abutments (teeth) supporting the prosthesis

So the teeth around the edentulous spaces are called abutments, so if my abutments are a canine and a third molar, how many missing teeth do I have?? 4,5,6,7 so they are 4 missing teeth being carried by a canine and a third molar. If we did a fixed bridge we have to prepare the canine trim it down, prepare the third molar trim it down we put a retainer on the canine and the molar, and in between we have essentially 4 missing teeth we called them pontics in Latin pon means abridge so we have 4 bridging teeth. Now if you think about this we have six teeth (a six unite bridge) 3,4,5,6,7,8 ,but only 2 teeth are carrying the load ,there is something you will learn in the future called Antes law and Antes is a dentist, who said that( if the bridge is too long you have to make sure that the bridge cant be too long or the teeth cant carried the weight ),but now we dont actually follow it but the idea becomes logical, the longer the bridge the more impractical to place a fix prosthesis ,so generally the more the missing teeth ,the more directed we are to removable prosthesis).Now you can still place a fixed prosthesis over along bridge ,but there is a certain design principle that you will learn in the 4th year. So the first factor is 1* the area of the missing teeth., the other factors are 2* aesthetic, and psychological ones, some patients dont want to take prosthesis inside there mouth, most patients dont like to take the denture during the night, the doctor had a patient that even his family doesnt know that he wears a removable prosthesis he told him that he has never taken his prosthesis out, so in these cases you start thinking about fixed prosthesis or implant. So generally removable prosthesis are for long partially edentulous patients, fixed prosthesis for short partially edentulous patients, now implants can replace any of these cases. now the other factor is 3* how much tissue is missing, if the tissue which is missing is just teeth, that means the residual ridge is not very resorbed we can usually replace it with a fixed prosthesis, or an implant, like this case.. .so for a single missing front tooth Its recommended to choose fixed prosthesis.

However, if a lot of bone is resorbed that means the patient comes about 30 years after extraction, you have natural teeth on either side and in between there are missing teeth , the residual ridge will be very far from the occlusal plane ,the residual ridge will be very far from where the cervical margin should be, if I made normal looking missing teeth for a fixed bridge, there probably will be a space between the cervical margin of those teeth and residual ridge, when the patients smile, they have a big space, now actually I can fix this, we actually have fixed bridge with a pink thing surrounding them to make up this space, but its still very difficult to clean and when the patient talks he actually has problems with saliva escaping. So sometimes for aesthetic reasons, its better to have removable prosthesis than fixed ones. Like this picture..

*Indications for RPD's (Excessive alveolar bone loss (esthetic problem)

Now why is that??? Because with removable prosthesis I can make a flange that goes to the depth of the sulcus which hides any deficiency in the residual ridge, now you might say why I dont make a flange in fixed prosthesis?? because as you will learn in the future in a fixed prosthesis you have to clean underneath the bridge with a special devices and if you have a flange its very difficult to do this , you cant clean underneath the flange and go in and out ,so the tissues become unhealthy so if there is a difference between where the bone is and where the teeth should be, a removable prosthesis with a flange is better aesthetically to the patient, some patients are rich and come to you as a dentist and said I want an implant and I said as a dentist no it will not look as good as removable ,if he insist I will at least explain to him. So for a single missing front tooth what you think you should do to the patient????

Its a commonsense what your choice should be?? Is it a removable partial denture covering most of the palate just to replace one missing tooth?? Your choice will be a fixed partial denture bridge, which is resin bounded, and your other choice is a single tooth implant. The larger the bridge the harder it is to control this cases. A four unit fixed partial denture is usually acceptable, when we talk about five unit bridge the 2 retainers and 3 ones hanging in between it become more complicated, you will learn that there are more factors related to occlusion . so when the extension of the edentulous patient area is so long fixed partial denture no longer becomes practical, you have one of 2 choices *Removable prosthesis, or an implant supports or retains the prosthesis .like this picture..

Now what do you think you should do to Indications for RPD's(Edentulous area
too long for fixed prosthesis Longer than 4 units is more complex

the patient above , now extraction is our last option, but in this case we make removable partial denture, because the Edentulous area too long for fixed prosthesis. Now for those who took the lab its a tooth-tissue supported prosthesis, kenedy class IV. Dont worry we will talk about them in detail in this lecture. Look at this picture which Ive already put it

We have missing teeth from canine to canine ,you can see these acrylic teeth and you can see the labial flange there is so much missing bone here and if I did it with a fixed bridge ,it would be very difficult to clean ,and it may over load the adjacent premolar, so in such a case a removable partial denture is indicated ,for hygiene reasons ,for aesthetic reasons and for functional reasons. If the patient has a lot of ridge resorption some times you try to retain as much of remaining teeth as possible to delay extraction. This is an extreme case where the bone is negative due to extreme resorption there is a hole where the bone should be look at the picture..

The Dr skipped some slides. Now in the next lecture we will be talking about provisional partial denture. Now I told you that we have 2 divisions within RPD, one is called transitional or provisional partial denture, the other is metal frame work partial denture, see the pictures below please, which we call it definitive. The first one is made of acrylic and stainless steel wire mainly, the other one is made out of 2 materials mainly a metal base frame work which is usually cobalt chromium and the gingiva and the teeth made of acrylic. The second one is more definitive, and this the one that will take the bulk of the semester. The acrylic partial denture we have to learn about it because we use it for a variety of purposes.

Interim (transitional)

Definitive (permanent

Usually we use provisional partial denture for only short period of time ,we will talk about this next week enshaalah .now we said in the lab that the partial denture obtains its retention in a method different from complete denture ,we can get

mechanical retention from the undercut area near the cervical margin of natural teeth and to get this mechanical retention we have an extension from partial denture into the undercut area in the form of wire ,or clasps ,we will learn much about transitional and partial denture next week there is a lecture about the components of metal frame work partial denture it has more components than the acrylic partial denture. If we go back and take a look where we have this acrylic partial denture and this metal framework see the pictures above please ,acrylic partial denture looks like complete denture minus some teeth with some wires ,in some cases we dont even use wires we just have acrylic . In metal framework partial denture, if you look at the base or whats called the major connector as we will learn, its look different and its thinner than the acrylic base, it has a special extension, you can see the extension on the occlusal surface you can see the triangle here on the occlusal surfaces of the teeth, its a finger like projection sets on the top of the tooth look at the picture below please..

The retainer prevents the denture from going further down

The patient bites and moves the denture in this direction

So if I have a missing teeth there will be an extension on the occlusal surfaces of the abutments on either side as the picture above (the arrow and the dark black line),so when the patient bite down on the teeth in the middle this rests prevent the denture from going further down, I cant do this to acrylic partial denture ,99% of acrylic partial denture is too week ,if I had a small piece on the occlusal surface when the patient bites down it will break and fall away, so acrylic is not strong enough .Now with copal chromium ,nickel chromium, titanium its strong enough to 1 mm thick on the occlusal surface not to break .when the patient bites down he bites on acrylic teeth in acrylic partial denture the acrylic will move the forces to the denture base, the denture base will bite down on soft tissue like complete denture . In metal frame work partial denture, we have a component called rest as the picture above that can go on the occlusal surface so when the patient bites down instead of the force going down to the tissue directly it goes to the teeth first, I also have extensions which I might not have in acrylic partial denture on the lingual surfaces

and the facial surfaces, the one on the facial surface you already see it in acrylic, its called clasps or retentive arm ,another one from the lingual called Reciprocal arm

And this is how they do look on the teeth .

'Clasp' or 'clasp unit' composed of:

Rest Retentive arm Reciprocal arm

We said in orthodontics the wire in the acrylic or the retainer is like a spring its used to move teeth ,in partial denture I dont want to move teeth , so what happens when the patient wears this prosthesis , I have a wire in the outside for retention when I put it outside the patient mouth, first of all it has to stretch a little bit because the teeth are pulpous , it has to push the tooth a little pit before going in the undercut ,so we have to put something inside the tooth to prevent the movement, ,now these components have its own lecture. Now we will talk about the classifications of partial dentures. We have 2 different classification and we have a third one from American dental association, the first one is:

1-Kennedy Classification we will talk about design principle according to classification, so when I told the technician to make class I, they need to see the picture of the patients dental arch, they also imagine the design that should be placed to the patient, you will learn in the future to draw a design, there is a specific design option that you must put. Quick review for Kennedy Classification, we have 4 Kennedy classification, another gentleman called Applegate came and said that those classifications is not detailed enough, so I have to make modifications. Now in Kennedy classifications you must remember that the order is essential so in Kennedy Classification the number is important, but in Applegates modification number is not important. 1- Kennedy Class I. Bilateral edentulous areas located posterior to all remaining teeth.

2- Kennedy Class II.

Unilateral edentulous area located posterior to all

remaining teeth

3- Kennedy Class III.

Unilateral edentulous area bounded by anterior &

posterior natural teeth.

4-Kennedy Class IV .. Single, but bilateral (crossing the midline) edentulous area located anterior to remaining teeth

Remember this: Class I . 2 edentulous areas Class II.1 edentulous area. In class III I have one edentulous space there is a mistake in the slides its not uni or bilateral its just unilateral (one edentulous area, it can be 2 but it has different name, now if this space crosses the midline it becomes class IV ,some times there is other missing spaces not the typical form that Kennedy talked about, now if I have tooth

missing here below (the star ) what should I call it there is an Applegates rule says that I always choose the most posterior edentulous part ,the one that is the most posterior is the distal extension ,which is Kennedy class II, what should I call the other space (here its the star )Applegate said that if I have an additional edentulous area I dont care to the number of teeth, it could be one or 2 ,now each additional missing space ,is called modification space, not according to the number of missing teeth but according to the bounded spaces so this a class II mod I.

The other problem with Kennedy classes is, here I have class IV what if I have teeth missing, here the stars below>>>

I take the most posterior edentulous area and the anterior space becomes a modificationeven though it crosses the midline which is another rule of Applegate (There is no modification space in Class IV)class I,II,III can have a modification ,its

commonsense if I have class IV modification I (which cant happen) it should be class III any way ,here is my explanation any edentulous area other than the one in class IV it will be for sure in posterior part because class IV should cross the midline which means that its anterior to any edentulous areas and as Applegate said that we choose the most posterior, so if I have any additional edentulous area with class IV it will transform to a modification instead of a class by it self. Sometimes there are teeth in the mouth that I dont use them in my design. What if I tell you that this upper 3rd molar has no lower 3rd molar so usually in Applegate modification you will see that if the third molar is not included in my design ,its not included in the classification so if Im not using 3rd molar ,this becomes a unilateral extension of edentulous area ,Kennedy class II

If I delete this molar it becomes class II

Now this true for 3rd and 2nd molar, unless I give you specific information then you have to take specific default, now again lets go to Applegates rules. 1- Classification should follow rather than precede extraction If a patient come to you and has a periodontal disease extract the teeth then make the classification, or imagine the patient without that tooth or teeth. 2- If 3rd molar is missing & not to be replaced, it is not considered in the classification. 3- If the 3rd molar is present and to be used as an abutment, it is considered in the classification 4- If the second molar is missing and not to be replaced, it is not considered in the classification 5- The most posterior edentulous area determines the classification 6- Edentulous areas other than those determining classification are called modification spaces 7- The extent of the modification is not considered, only the number 8- There is no modification space in Class IV. Now lets move to the second type of classification, this is more simple to talk about, where do I get my support from, where dose the denture set, does it set on tissue ,or does it take support from teeth . in an acrylic partial denture and a complete denture

usually when the patient bites down the forces goes directly to the tissue of residual ridge or the palate, so complete denture and most not all partial denture are called tissue supported prosthesis or tissue borne, however a metal framework partial denture because I have rests they are usually either, tooth supported or tooth-tissue supported, now which of Kennedy classification are tissue supported and which are tooth tissue supported. Now Kennedy class III bounded areas and small Kennedy class IV they are called tooth supported prosthesis and its important to the design. How about Kennedy class I,I have a rest in the front but no rest in the back ,so tissues in the back ,tooth in the front, so its tooth-tissue supported, so class III ,class IV(Short span) are tooth supported, class I and II are tooth tissue supported, in some cases if we have lots of missing teeth ,,very rare class III ,but more commonly class II it can be tooth tissue ,why is that ???do you remember this case below if you put a rest on abutments it will give support ,but not that much that you cannot count on it, you need additional support from tissues .

Now lets move to the steps in the lab 1-Making the Impression (with Irreversible Hydrocolloid Alginate) we can modify stock tray using utility wax, or green stick impression compound if necessary. 2- Mix the material in special rubber bowel for alginate and the other for the stone one Measure to: one Measure for small impression and 1.5 Measure for larger ones We mix for a min or half, we have a minute to put it in the tray and in the moth it takes 3-4 min , you have to put it from posterior to anterior, and remove it with a snap motion. Remember that the material is a water based ,so we need to be careful in maintaining .so the impression must be put in humid environment and enclosed in a sulfane sheet. (Not sure) .,, No-large voids in the impression must be, you need to make sure there is a room between the tray and the mouth from 3-6 mm ,for dentate moth like partial denture the tray has across section of a square ,for edentulous its semicircular ,then we disinfected for 10 min and send it to the lab. * Preliminary impressions for partial edentulous patient done with these trays:

Now how we pour the impression?? either we use a vacuum mixer ,to have less voids using stone ,we only use a plaster for primary edentulous impression ,and for mounting cast on the articulator ,and for the first and part of the second layer in flasking , plaster is not strong enough that if have one or 2 teeth in a dentate cast they might break , when Im separating the impression . So in partial denture my primary and secondary casts are made from dental stone type 3 the opposite of complete denture, now flow the material on the vibrator and then reverse it on a base. We are going to end up with a cast which we trim; it has to be at least a 1 Cm and a half in thickness in the narrowest area. Now we are going to take a secondary impression what are our choices we can use alginate, we can use any of the silicon, either additional, condensation, poly either or polysulfide .we can use light cure or cooled cure to make the custom tray. The differences between this tray and complete denture custom tray are 2 things. 1-the spacer is thicker around the teeth we need two layers of spacer around the teeth, because I need at least about 3-6 mm of space around the tray and the material because I have more undercuts, on the edentulous area I only use one spacer ,on complete denture I use only one spacer every where. So there will be different spaces between edentulous area and the tooth area. The tray should have perforations, as my material is an elastomer I need a mechanical retention so I make holes on the tray in the edentulous area I leave 2 mm distance from the sulcus like complete dentures, I can place a separating agent (tinfoil substitute). I can either make the holes before it sets, or I wait for it to become hard and take a drill to make 15 holes, but its better to make the holes before it sets, now in case of self cure its cured about 3-4 min, I barely have enough time to adapt it, with light cure its much easier there is also stoppers that prevent the tray from going down to maintain the space. And these are the pictures for all the above steps..

1-Selection of a Stock Tray

2-modifying stock tray if necessary

3-prepare alginate 1:1

4-mixing

5- Fill Tray

6- Making the Impression

7- Removal wth snap motion

8- No-large voids in the impression

9-

Mixing Stone for primary impression

10- Pour stone into impression

11- Invert impression with set first pour onto base stone

12- Trimming Casts Cast should be minimum of 10-12mm (.5 inch) in thinnest part

1 0 -1 2 mm

Then we start with the secondary impression on the diagnostic cast.. .

Miur a ba n l d

Mlr al y xa i

Thats it .. Sorry for any mistake I did my best I tried to put as much pictures as possible to make every thing easier to understand and to enjoy studying .

Done by : Bayan Mohammad Mrayan