Prosthodontics.

The complete guide to not losing your head while crafting dentures for the partially edentulous.
The first step is to get your hands on a patient, which you can do so from the outdoor unit in Room No.2 where theres usually a different house officer every day. Tell them you want patients suitable for a removable partial denture. Or alternatively, make friends with the guy called Aamir who handles all the patients at the outdoor. Or, ask the Maam sitting in the middle of the room for suitable patients (but she usually only has patients to hand out on Tuesday, that is the impression day for the hospital side of the department.) A word about the quota. Each man for his own here. You have to complete 12 credits in all, with tooth/prosthesis in any one quadrant being equal to 0.5 credits, making a patient with a tooth missing in each quadrant, a 2 credit one, which also boasts of being the theoretical maximum. (Some lucky people do get simple 2 credit patients with all their central incisors missing, usually from trauma.) Its better to stick to at least one credit patients from the start, because frankly, its too much effort for the half credit patients, unless of course, you know a guy who knows a guy who knows how the magical pseudos work in this department.

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Initial Examination Allotment, paperwork Impression Study models, articulation Wax-up, clasps, tooth setup Trial (only for complicated cases like free end saddles, or for anterior teeth) Flasking, de-waxing, curing Denture finishing, polishing Insertion Patient Instructions Quota book signatures

Initial Examination
Once youve gotten hold of a patient, just quickly go through this initial exam, wherever you can, as soon as you can, to see if theyre indeed suitable for an RPD. - there must be no grossly carious teeth - mobile abutment teeth, BDRs have to be extracted first - most patients require scaling first, adherent tartar, plaque, calculus deposits. - fillings to be placed, crown-bridge work - assure that the patient wants and requires a removable prosthesis, and NOT a fixed one!

- enough edentulous space for a replacement - be wary of free end saddles (too much effort things, all over again) - be wary of high risk patients, HCV, HBV, HIV etc. - patients who come from distant areas and might not be able to comply with multiple visits. - children, less than 10-12 years old.

Allotment, paperwork
Now that you have a patient, you have to get yourself assigned a supervisor, for which you need to call your patient over to the college side of the department, get them approved by any demonstrator there (bring a mirror) and get yourself assigned a supervisor. Then take the patients history (especially their mobile number) and tell them to go and submit the money for the denture. Once you have the fee receipt, fill in the details on your quota book and then get it stamped from the room where they make the parchi, then take that stamped book to Mr. Boota (crucial personality this, find out who he is) wholl enter your name in a register and give you a number. And now, youre finally ready to get started! Supervisor. Mirror. Gloves. Boota. Amir. Stamp. Patients complete history

Impression
Things youll need: Alginate, gloves, napkins, bowl, spatula, impression trays, impression compound, nurses, border moulding. Explain to the patient what youre going to do. First, you have to select an impression tray by placing it into the patients mouth and checking that its stable and doesnt rock or anything, theres adequate space around all the teeth that its covering all the tissues you want to reproduce. Then have one of the nurses mix the alginate and load it into an impression tray for you. Youll only need the impression compound for large span edentulous areas, free end saddles or a very high palate. For Maxillary impressions: Lower the chair. Patients mouth at level with the operators elbow. Operator stands behind on right side. Patient seated upright Theres a simple technique to this procedure thats best explained by doing . Retract the patients left cheek with a mirror or your finger, and the right cheek with the impression tray that is now loaded, such that the tray is initially at a right angle to the final position that it will be in, and then twist it around as you move it in. Seat the post. Part first so the excess flows towards the front and not towards the throat. Next is what you call the border moulding. Which is basically a combination of movements that ensures that the impression material has flowed to all the important areas. Attend the demo for this, I cant be bothered to explain.

For Mandibular impressions: Raise the chair Patients mouth at level with the operators shoulder. Operator stands in front on the right. The technique here is similar to that for the maxillary impression, except that you withdraw the left cheek with the side of the loaded, inverted tray now and vice versa. For tricky impressions, take some alginate on your gloved finger and pack over deep areas in the arch, just before inserting the tray. Setting time varies according to the consistency of the mix, and its usually given on the pack that youre using but an approximate guess is 90-120 secs. Break the seal a little first, then remove with a snap. Then go show it to your supervisor, and if they say its okay then you may proceed to the next step.

Study models, articulation

Hard plaster, making a base, model trimmer, draw wax pattern, block undercuts, Articulation. Once you have the impressions, its time to pour them using hard plaster, which you can get from the tech. school building (second floor) just behind the department. Once the plaster has hardened sufficiently, you have to make a base of soft plaster. Just pile some up on the counter and invert the tray containing the impression and the hard plaster model onto it. Now once the base has hardened too, you have to remove the tray and the alginate impression from the final model including the soft plaster base using the wax knife. Be careful though, perfect impressions can be useless if you fracture the model at this stage. Fill up any defects or bubbles with more plaster. You can block the undercuts now too. Trim the bases of the models with this machine here. Now take the models and an indelible pencil to your supervisor wholl draw a wax pattern for the prosthesis on the model and tell you what clasps or retainers youre going to be adding, and finally mark the occlusion on both the models so you can mount them on your articulator. Also, get your quota book signed now for the impression that youve taken and for the teeth, wax and wire youll be needing in the next steps too.

Wax-up, Clasps, tooth setup

You can get the wax, teeth and wire from the tech. school again. Make the clasps first and secure them on the models with a bit of wax, before you start with the wax-up, which is easy enough if you paid attention in junior prostho in 2nd year. Remember to block the undercuts otherwise they can be a real nuisance during the insertion. Clasps shouldnt be adapted too closely to the tooth surface except on the buccal/labial side. The tooth setup can be a bit tricky, but the key word here is aesthetics. Just match the

teeth youre replacing with the natural dentition of the patient and keep things symmetrical and neat. Youll need a round bur for grinding the teeth into size.

Trial insertion, occlusion

This is only for complicated cases like free end saddles, or for anterior teeth. I only had to call back two or three of my patients for this.

Flasking, de-waxing, curing

Once your supervisor has approved the wax-up, give it to Rehmat for curing, which he works on after hospital hours and usually gives you the denture by the next day.

Denture finishing, polishing

Trim the excess away using the big stone bur thats mounted on a motor. Use firm pressure for removing bulk in excess. Move the denture over the bur when youre going for the initial finish. Use a sand paper for a while to get a good finish. Now shift to the hand held motor and the small stone bur which is to be used at low speeds only. Clear the excess from the margins and from around the clasps and the interdental areas with the round or the fissure bur. Now finish the denture by polishing it first with the pumice bur and then the cake, and finally with just this buff thing. Pop the denture in a bowl of water and call your patient in the next day.

Insertion
If youve been meticulous in your work, this part shouldnt be much of a problem. However, clasps and undercuts have a way of kinda growing overnight. Focus on seating the prosthesis properly in the patients mouth first. Mostly the undercuts are to blame or the clasps need a bit of adjusting. Once the prosthesis is seated, take an articulation paper (from Aamir at the hospital side or Boota) and check for and remove high spots using a round bur. Once everythings in order, give the denture a final polish. Check that the patient can speak, smile and chew properly. Show them a mirror so they can admire their brand new teeth! Give the patient instructions on how to care for their denture and basic oral hygiene. Bring your supervisor around now so they can do a last check and get the final signatures on the quota book too. Good luck, and Godspeed!