Treatment plan Aims - afternoon session

Removable treatment options • Describe the clinical stages of partial denture

prosthetics
Partial dentures
• Refurbish • Describe alternative techniques and materials
Clinical techniques • Describe problem solving techniques
• New denture Standard technique
Rob Jagger
An opportunity to discuss any aspect of partial
• New denture Special technique(s) denture prosthetics
1 March 2017

A word about materials....... Waxes Impression materials

• Modelling wax
• Soft wax
• Waxes – Accurate
• Sticky wax
• Impression materials – Good surface detail
• Occlusal registration wax
• Denture base materials – Dimensionally stable

Options?

Classification of impression materials.

Impression materials Impression materials
Impression materials

• Elastic • Hydrocolloids
• Non-elastic
– (Reversible/ Agar)
• Compound
– Irreversible / Alginate
Non-elastic Synthetic elastomers Hydrocolloids
• ZnO eugenol
(5 day Hydrogum)

Polysulfides Reversible • Elastomers

Plaster
Polyethers
Irreversible
– (Polysulfides)
Compound

Silicones
– Polyethers
ZnO/eugenol
Condensation – Silicones
Waxes Addition
• condensation
• addition

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 Clinical stages Impressions Impressions

• Impressions It is recognised good practice to take • Applied anatomy

• Jaw relations
• Primary – Optimum surface area
• Try Including free end saddles
• Secondary
• Fit
• Review
Why?
Always?

Primary Impression Primary Impression

Tray selection? Tray modification?

Modify the tray using

Wax
Compound
Silicone

Adhesive

Primary Impression Primary Impression Final Impression

Freeend saddle

Acrylic Alginate Spaced* Perforated

CoCr Silicone Spaced Non perforated

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 Final Impression Primary Impression
Free end saddle impression
alginate silicone
technique
• Tray modification

• Blocking out
undercuts
Buccal shelf

Retromolar pad

• Adhesive Retromylohyoid

Secondary impression Secondary impression Secondary impression

Greenstick free end saddles

Enables a mucodisplacive impression
c.f. altered cast technique
Trim the trays

Ridge
Retromolar pad
Buccal shelf
Retromylohyoid
Silicone impression in a special tray

Summary
Handling impressions
Dealing with the FES
• Support
– Rest Metal try in
– Wide saddle coverage / palatal plate
– Disinfection – Clinical muco-displacive impression
– Transport • Stability
– Casting – Retromylohyoid extension
• Retention
– Indirect
• Abutment damage
– Mesial rest
– Flexible clasp

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 Metal Framework Metal Framework
• Fit -
Does it fit the cast?
Does it seat correctly in the mouth? CJR stage
Adjust now

• Occlusion -
Is it interfering with the occlusion?
Adjust now

• If two frameworks –
adjust each separately then
both together

Jaw relationships
The purpose of the CJR stage is to collect the
following information for the technician Tooth contact is stable?
- Hand articulate Tooth position

• Record of CJR The technician uses anatomical landmarks

Tooth contact but is not stable
• Tooth position - Wax rims for jaw relations
• Tooth selection Retain intercuspal contacts ICP If any information is missing (extensive tooth
loss), the principles are the same as for
complete dentures
If there is no intercuspal position use
Retruded arc / OVD principles as for complete
dentures

Lip support Lip support

How?
ICP if possible
Or  Naso labial angle
Trim upper
Trim lower
Record CJR - AP and Vertical
Select teeth
Alma gauge

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 Occlusal plane
Inter-pupillary line • Ala-tragus line

Posterior occlusal
Anterior occlusal plane
plane

! Lip line Smile line

How to determine OVD Changing OVD Aesthetics

1. RVD • Need to increase OVD? • OVD
• Major tooth position
2. OVD previously satisfactory dentures • The greater the change the greater • Minor tooth position
adaptation needed • Tooth selection
3. Appearance • Tooth modification
• Try testing an increase? • Gingival modification
– Acrylic • Path of insertion
Decide!
– Splint • Clasps
Too much FWS causes fewer problems than too
little

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 Tooth selection Tooth selection
Tooth selection
Mould and shade Mould and shade

Facial shape Facial shape

I. Material – Square – Square
– Ovoid – Ovoid
– Tapering – Tapering
II. Mould
Previous dentures Previous dentures
III. Shade
Photos Photos

Restoring the occlusion

Recording CJR Recording CJR - dental articulators

Posselt’s space
How?
envelope 1. Simple
hinge
2. Average
value
Border movements Base stability
Horizontal and vertical control
Recording RCP
Locate
3. Semi
adjustable
4. Fully
adjustable

EBD - facebows for prosthodontics Occlusion

• Occlusion and partial dentures TRY IN
Partial denture teeth should not interfere with
natural teeth contact in ICP or lateral
excursions

Farias-Neto A, Dias AHM, de Miranda BFS, de Oliveira AR 2013

If a new occlusion is provided principles are as
Face-bow transfer in prosthodontics: a systematic review of the
literature. for complete dentures
Journal of Oral Rehabilitation 40:686-692

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 Try in Fit
N.B.
• Base • Fit
• Occlusion Process partial dentures on duplicate • Occlusion
• Tooth position models • Appearance
• Appearance

Fit Fit Fit

• Look
• Listen
• Feel
• Ask patient

• Artic paper back up

Fit Fit Instructions

• Occlusion • If correction would be

excessive - remove teeth
What to expect
– ICP RCP Cusp fossa
– Balance BULL
What to do

Cleanser
Adhesive

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 Adhesives Cleansers Review
• History
• Examination
• Treatment plan

Adjustments without identifying the cause

can lead to multiple adjustments and the
possible need to remake.

Refurbishment Reline materials Problem Solving

Relines Hard
– Lab acrylic
– Chairside acrylic copolymer
Repairs
local Takuso Rebase

Additions
Soft
- Chairside Viscogel
etc.

Problem Solving Problem Solving Problem Solving

• Assessment
Systematic approach! • History
• Exam
Use a standardised format in order to
• Assessment • Special investigations detect-
• Diagnosis • Diagnosis
Patient factors
Treatment plan Denture factors
Prognosis

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 Problem Solving Problem Solving Problem Solving
• Patient factors • Patient factors • Patient factors

Anatomy Psychology Normal Psychology abnormal

Pathology Neuroses
Physiology - function Personality Psychoses
Psychology Personality disorders
Other

Problem Solving Problem Solving Problem Solving

• Denture factors • Assessment • Looseness
• Diagnosis • Fracture
Fit surface Options • Appearance
Clasp units Nothing • Allergy
Polished surface Adjust /correct • Impaction
Replace
Teeth (selection position) • Other
Standard technique
Occlusion Special technique

• Loose • Patient factors • Denture factors

Support Anatomy Fit surface / clasps

Stability Saliva Polished surface
Retention Ability Tooth selection position
Expectations Occlusion
All can be controlled to a degree – partial
dentures may be loose

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 Special materials
Problem Solving Problem Solving
/ Special techniques
• Assessment Systematic approch can be applied to -
• Diagnosis
Options • Looseness
Nothing • Fracture
Adjust /correct • Appearance
Replace
• Allergy
Standard technique
Special technique • Impaction
• Other

Implant retained prosthesis Advantages Disadvantages Bar clips

• Stability • Surgery

Mr L • Function • Failure /complications Ball O ring

• Psychological • Maintenance

• Cost

Benefit v Harm
Magnets
Informed consent

Controlling aesthetics Controlling aesthetics Factors that control aesthetics

1. Perfect - BSD
2. Imperfect anonymous
3. Imperfect and personal

• Complex argument regarding what should be

done in clinical practice
Build on success
Informed consent

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 Factors that control aesthetics CAD CAM CAD CAM
Scanning
• OVD
• Major tooth position CAD
• Minor tooth position
• Tooth selection Printing
• Tooth modification
Template for
• Gingival modification Conventional
casting
Additive Subtractive

Spark erosion Milling

CAD CAM a. CAM - template b. CAM CoCr sinter

Valplast Valplast Valplast

• Mucosa borne
• Thermoplastic nylon • Flexible base

• Flexible • Adjustable?
• Added to
• Aesthetic a CoCr tooth borne or • Reline?
tooth and mucosa borne
framework • Repair?

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Swinglock dentures Two part dentures
• Sectional dentures Locked by -

Two parts with different • Bolt

paths of insertion
• Split pin

Two part dentures

Unilateral partial dentures

• Two part

• Cobalt chrome

• Valplast

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 Goodall W et al. Brit Dent J. 2017; 222:79 - 84
Impaction
Swallowed Inhaled
• Goodall W et al. Brit Dent J. 2017; 222:79 - 84
• Symptoms
– Early
– Medium
– Late
• Risk factors
• Diagnosis /Treatment
• Prevention

Allergy Allergy Allergy

Allergy

Diagnosis?
Allergy to what?
Potential Adverse
Reactions

• Infection
Allergic/ MMA
• Irritation
Hypersensitivity reactions Non- Allergic reactions
(Immunological)

Pigments
Type I Anaphylactic,
antibody-mediated
Type II Cytolytic or
cytotoxic reactions
Type III
Immune complex reaction
Type IV Delayed-type Chemical Irritation Psychological Impact • True allergy Metals

Allergy Retching Retching

• The retch reflex

Testing Normal v abnormal – Normal
– Abnormal
Mechanical
Olfactory
Alternative materials
Auditory
Luxene Vinyl resin Anticipatory
Valplast Nylon

Assessment - Patient factors / Denture factors

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 Retching Retching Retching

Structured assessment • Patient factors • Denture factors

Patient factors Anatomy Fit surface

Pathology Polished surface
Denture factors Physiology Tooth position
Psychology Occlusion

Retching Prominent retch reflex Prominent retch reflex

- Making a denture
Mechanical
Tolerating the denture Options
• During dental treatment, retching can be Good technique • Reducing mechanical stimuli
managed by Psychologic Thin / small denture
Anti anxiety IROD
– Reducing mechanical stimuli Distraction
• Psychological
– Psychological Pharmacologic
Errorless learning
Anti anxiety
– Pharmacology Systematic desensitisation
Relative analgesia
– Alternative measures Alternative
Hypnosis

Prominent retch reflex Implant retained prosthesis

Management - Tolerating the denture

Denture design –

Thin
Mr L

Reduced extension

Palateless

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 Prominent retch reflex Prominent retch reflex
Management - Tolerating the denture
• Mechanical
Combined physical
Denture design
and psychological Palateless
treatment IROD
• Psychological
Anti anxiety
(Errorless learning)
Systematic desensitisation
and finally........
Success in prosthetic dentistry Success in prosthetic dentistry
• Good basic technique • Good basic prosthetic techniques
• Knowledge of special techniques
• Knowledge of special techniques
• Sympathetic manner
– Good communication
• Sympathetic manner
– Good treatment planning
Prominent retch reflex
Desensitisation
• Maxillary impression warm
alginate or compound
• Training plate 2/3 post dams
• Progressive increase in
wearing
• Add teeth
• New denture ? copy
technique
Laboratory
Aims and objectives
To describe clinical prosthetic dentistry
- Describe clinical stages partial denture
prosthetics
- Describe problem solving techniques
To give you the opportunity to discuss any
aspect of partial denture prosthetics
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