Concise Prosthodontics

SECOND EDITION

Vijay Prakash BDS, MDS, FPFA,

FICD
PROFESSOR, Department of Prosthodontics and Implantology, Divya Jyoti
College of Dental Sciences and Research, Modinagar (UP), INDIA

Ruchi Gupta BDS, MDS, FPFA, FICD

PROFESSOR, Department of Conservative Dentistry and Endodontics,
Divya Jyoti College of Dental Sciences and Research, Modinagar (UP),
INDIA
Table of Contents

Cover image

Title page

Copyright

Dedication

Preface to the second edition

Preface to the first edition

Acknowledgements

SECTION I. Complete Dentures

1. Introduction to edentulous state

Introduction

Parts of complete denture

Residual ridge resorption

 Importance of temporomandibular joint in complete dentures

Role of TMJ in biomechanical phase of the prosthetic rehabilitation

Importance of patient motivation and patient education

Patient motivation and education

2. Diagnosis and treatment planning for edentulous patients

Introduction

Mental attitude of the patient

House classification

Extraoral examination

Neuromuscular examination

Intraoral examination

Ageing

Gag reflex

Role of saliva

Pre-extraction records and their importance

Radiographic evaluation

Nutritional requirement of edentulous patients

Role of nutrition in prosthodontics

3. Mouth preparation of complete denture patients

Introduction

Nonsurgical methods

Preprosthetic surgery
 Resilient liners

Role of tissue conditioners

4. Impressions in complete dentures

Introduction

Impressions

Retention

Stability

Support

Impression techniques

Biological consideration in maxillary impressions

Relief areas

Postpalatal seal

Biological considerations in mandibular impressions

Relief areas

Primary impression

Primary cast

Custom tray

Border moulding

Secondary impression or wash impression

Impression materials

5. Articulators and facebows

Introduction
 Mandibular movements

Envelope of motion of the mandible

Facebow

Importance of anterior and posterior reference point

Hinge axis

Articulators

Split cast method and its importance

Bennett movement

6. Maxillomandibular relationship
Introduction

Record bases

Occlusal rims and their importance

Physiological rest position

Vertical jaw relation

Freeway space or interocclusal rest space

Silverman’s closest speaking space

Effects of altered vertical dimension

Horizontal jaw relation

Eccentric jaw relations

7. Selection and arrangement of teeth

Introduction

Denture aesthetics
 Pre-extraction records

Evolution of anterior teeth selection

Posterior teeth selection

Arrangement of the anterior teeth

Arrangement of the posterior teeth

Principles of arranging teeth

Modiolus

Phonetics

8. Concept of occlusion
Introduction

Evolution of anatomic and semi-anatomic teeth

Evolution of nonanatomic teeth

Complete denture occlusion

Lingualized occlusion concept

Neutrocentric occlusion or monoplane occlusal scheme

Spherical occlusion

Balanced occlusion

Types of teeth (table 8.2)

9. Wax try-in and laboratory procedures

Introduction

Wax try-in

Flasking procedure
 Wax elimination

Packing

Processing of denture

Deflasking of the denture

Laboratory remount procedure

Finishing and polishing of complete dentures

10. Insertion and troubleshooting in complete denture prosthesis

Introduction

Denture insertion

Clinical remount procedure

Selective grinding

Intraoral methods to correct occlusal disharmony

11. Relining and rebasing

Introduction

Rationale for relining complete dentures

Problems associated with relining procedures

Preparation of the tissues

Preparation of dentures

Techniques of relining

Rebasing

12. Single complete dentures and immediate dentures

 Introduction

Immediate dentures

Combination syndrome

Single complete dentures

Techniques to modify natural teeth

13. Overdentures
Introduction

Overlay dentures or overdentures

Preventive prosthodontics

Attachments in overdenture design

Maintenance of overdentures

SECTION II. Removable Partial Dentures

14. Introduction to removable partial dentures

Introduction

Classification

Indications and contraindications of RPD

Classification of partially edentulous arches

15. Diagnosis and treatment planning

Introduction

Objectives of prosthodontic treatment for a partially edentulous patient

Importance of medical condition of patient before oral examination

 Diagnostic cast and its importance

Importance of radiographs in removable prosthodontics

Splinting and its role in prosthodontics

16. Components of removable partial denture

Introduction

Internal and external finish lines in relation to minor connectors

Rests and rest seat

Direct retainers and intracoronal retainers

Clasp assembly

Circumferential clasp

Gingivally approaching clasp

RPI and RPA concept

Indirect retainers and their importance in distal extension cases

Denture base and functions of distal extension partial denture base

17. Principles of RPD design

Introduction

Surveyor and surveying

Methods of stress control in RPD

Shortened dental arch concept

18. Mouth preparation in RPD

Introduction
 Objectives of mouth preparation and preprosthetic phase of mouth preparation
in partially edentulous patients

Prosthetic phase of mouth preparation in partially edentulous patients

Preparation of the guiding planes

19. Impression making in removable partial denture

Introduction

Impression making in tooth-supported partial denture cases

20. Laboratory procedures, occlusal relationship and postinsertion of

removable partial denture
Introduction

Steps involved in the fabrication of cast partial denture

Methods of establishing occlusal relationship for partial dentures

Aesthetic try-in in removable partial dentures

21. Insertion, relining and rebasing

Introduction

Troubleshooting during metal try-in and fitting of the framework in patient’s

mouth

Postinsertion instructions to the partial denture patient

Insertion and postinsertion problems and their management in relation to RPD

Relining of RPD

Special removable partial dentures

SECTION III. Fixed Partial Dentures

22. Introduction to fixed prosthodontics
Introduction

Fixed dental prosthesis

23. Diagnosis and treatment planning in fixed partial denture

Introduction

24. Design of fixed partial denture

Introduction

Different designs in fixed prosthodontics

Laminate veneer

Rationale of restoring an endodontically treated tooth and ideal requirements

of post

Ferrule

Resin-bonded bridge

25. Clinical crown preparation in fixed prosthodontics

Introduction

Finish lines

Porcelain jacket crown

Preparation of full cast crown

Preparation for partial veneer crown

Preparation for PFM crown

26. Impressions in fixed partial denture

 Introduction

27. Provisional restoration

Introduction

28. Occlusion relationship

Introduction

Different concepts of occlusion in fixed prosthodontics

Bilateral balanced occlusion

Unilateral balanced occlusion or group function

Canine-guided occlusion or mutually protected occlusion or organic occlusion

Functionally generated pathway

Pros and cons of semi-adjustable articulators in fixed partial denture

Fully adjustable articulators and their utility in FPD with multiple abutments

Pathological occlusion

Splints

Myofascial pain dysfunction syndrome

Occlusal therapy in fixed prosthodontics

29. Laboratory procedures in fixed prosthodontics

Introduction

Dies and various materials used for making dies

Alloy and historical perspective of dental casting alloy

Shade selection for the patient requiring FPD

 Dentist–technician inter-relationship—important key to success in fixed partial
denture

30. Finishing and cementation

Introduction

Commonly used abrasives and polishing agents

Biocompatibility of various dental cements used in fixed prosthodontics

Failures in fixed partial denture (FPD)

SECTION IV. Maxillofacial Prosthodontics

31. Introduction and materials

Introduction

Effect of radiation on the oral cavity

Evolution of maxillofacial prosthesis

Materials used in prosthetic restoration of the facial defects

Stents and splints used in maxillofacial prosthesis

32. Maxillofacial defects and prosthesis

Introduction

Cleft lip and palate

Mandibular defects

Extraoral prosthesis

Retention aids in maxillofacial prosthesis

SECTION V. Implant Dentistry

33. Diagnosis and treatment planning
Introduction

Dental implant and its scope and limitations

34. Osseointegration and materials

Introduction

Osseointegration

Healing process in dental implants

35. Surgical and prosthetic phase

Introduction

Implant abutment

Implant failures and their management

Immediate loading of implants

Question bank

Suggested readings

Index
Copyright

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Concise Prosthodontics, 2e, Vijay Prakash & Ruchi Gupta

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Dedication
With Blessings of Lord Ganesha

Dedicated to

my late father Shri CP Gupta

&

to our two angels Dhaanvi and Keshav

Preface to the second edition
Vijay Prakash, Ruchi Gupta

It gives us great pleasure and at the same time significant

responsibility to bring the second edition of our book on
Prosthodontics. Through our teaching experience and interaction with
undergraduates, postgraduates and fellow practitioners, we found
that understanding of Prosthodontics is often complex and
challenging. We believe that it is one subject which should be taught,
read and understood three dimensionally. We have attempted to
demystify the subject and have written in easy-to-understand format.
In this edition, the book is redone to shape into concise textbook form
that have plenty of flowcharts, illustrations, line diagrams and tables.
Another distinctive feature is that the book is in full colored version
that includes updated text and diagrams for better understanding of
the subject. The coloured line diagrams will aid in having better visual
impact and clarity to the students.
This book is divided into five sections, each section is dedicated to
each branch of Prosthodontics. These five sections include: Complete
Denture, Removable Partial Denture, Fixed Partial Denture,
Maxillofacial Prosthodontics, and Implantology. Each section is
written in such a format that it covers the entire syllabus laid down by
the Dental Council of India (DCI). Within the scope of the book, latest
topics such as CAD– CAM in dentistry, porcelain laminates and
immediate loading implants have been covered. At the end of each
chapter, Key Facts provided which will help the students preparing
for the entrance examinations and viva-voce. At the end of Section V,
Question Bank is given as Appendix. This question bank will expose
students to variety of questions usually asked in various university
examinations at both undergraduate and postgraduate level.
Finally we consider our privilege to share our knowledge and
experience over the years with the budding dentists. We sincerely
hope newer generation of dentists will continue to inspire and
innovate methods to improve patient care and take our profession to
newer heights.
You can refer the front inner cover of the book to explore online
additional reading material. Besides these, you will get access to the
complimentary e-book also.
Preface to the first edition
Vijay Prakash, Ruchi Gupta

It gives us a sense of immense pleasure and pride to bring out the

Prosthodontics: Exam Preparatory Manual for Undergraduates. The
understanding of prosthodontics with its variations can be complex
and challenging especially considering the rapid advancements in the
technology and newer materials. Students often complain about the
lack of understanding in one or more areas of this subject.
This book is divided into five sections and each section is dedicated
to an individual branch of prosthodontics. It is delibrately written in
the question–answer format so that the students can understand,
remember and reproduce it in the examination. The answers are
accompanied by line diagrams for better understanding and
reproducibility. In the entire book only line diagrams are given so that
the students can easily grasp and redraw in the examination. Attempt
has been made to keep the answers as simple, comprehensive and at
the same time complete. We have referred to a number of textbooks
and journals to comprehensively provide relevant answers to the
questions. We have included Key Facts in every chapter and have also
provided a Question Bank at the end of the book for the complete
preparation for the examination.
Although we have made all attempts to cover almost all the
syllabus laid down by the Dental Council of India but still we
recommend the students to read the standard textbook along with this
manual. This book is not meant to replace but to complement the
standard textbook.
Finally, we sincerely hope all the readers will benefit from this
book. We wish the students all success in life and sincerely advice
them with this success mantra—
“Life’s battles don’t always go to the stronger and the faster man,
But sooner or later the man who wins is the man who thinks he
can”.
Acknowledgements
We wish to express our gratitude to the Almighty for bestowing his
grace on us to accomplice this book. Accomplishment of any work
requires the efforts of number of people and this is no exception.
Writing a book on Prosthodontics was always one of our dreams and
with blessings of God, parents, teachers and wishes of colleagues and
students it seems to be fulfilled.
First we would like to extend our sincere and heartfelt gratitude to
our teachers who have been instrumental in shaping our thoughts at
various points of our career. Our sincere gratitude to all our teachers
during graduation and postgraduation, especially to our guides Dr
Mariette D’souza (Manipal) and Dr Sanjay Tewari (Rohtak). We are
grateful to our friends and colleagues whose support over the years
have encouraged and influenced our thinking.
We wish to express our love, gratitude and respect to our parents
who have always been pillars of strength and have motivated us
throughout our lives. A special hug to our children who have made
our life journey joyful.
A special measure of appreciation to our students over the years
who have inspired us to excel and make teaching fun filled and
exciting.
Finally, our sincere thanks to excellent editorial team of ELSEVIER
India, especially to Ms Nimisha Goswami, Mr Anand K Jha, Dr
Nabajyoti Kar for the expertise and enthusiasm shown towards this
project. We wish to also acknowledge the efforts of artist Mr R K
Majumdar.
SECTION I
Complete Dentures
OUTLINE

1. Introduction to edentulous state

2. Diagnosis and treatment planning for edentulous

patients

3. Mouth preparation of complete denture patients

4. Impressions in complete dentures

5. Articulators and facebows

6. Maxillomandibular relationship

7. Selection and arrangement of teeth

8. Concept of occlusion

9. Wax try-in and laboratory procedures

10. Insertion and troubleshooting in complete

denture prosthesis
11. Relining and rebasing

12. Single complete dentures and immediate

dentures

13. Overdentures
CHAPTER 1
Introduction to edentulous state

CHAPTER OUTLINE
Introduction, 2
Parts of Complete Denture, 3
Denture Surfaces, 3
Component Parts of Complete Denture, 3
Residual Ridge Resorption, 6
Pathology of RRR, 6
Pathogenesis, 6
Aetiology, 7
Treatment and Prevention, 7
Importance of Temporomandibular Joint in Complete Dentures, 7
Role of TMJ in Biomechanical Phase of the Prosthetic
Rehabilitation, 8
Importance of Patient Motivation and Patient Education, 9
Patient Motivation and Education, 9
Physiological Rest Position and its
Importance, 10
Morphological Changes Associated with
Edentulous State, 10
Soft Tissue Changes in Denture Patients, 11
Introduction
Loss of teeth in a patient results in psychological, aesthetic and
functional impairment. There is a need to restore and replace the
missing teeth and adjacent structures with artificial substitutes to
allow the patient to lead a normal life. Replacement of teeth and
adjacent structures is covered under specialized branch of complete
denture prosthodontics.
Definitions:
Complete denture prosthodontics is defined as ‘that body of
knowledge and skills pertaining to the restoration of the edentulous arch with
a removable dental prosthesis’. (GPT 8th Ed)
Complete denture prosthetics is defined as ‘the replacement of the
natural teeth in the arch and their associated parts by artificial substitutes’.
(GPT 8th Ed)
Complete denture is defined as ‘a removable dental prosthesis that
replaces the entire dentition and associated structures of the maxillae or
mandible’. (GPT 8th Ed)
Objectives of complete denture prosthetic care are as follows:

• To enable the patients to masticate food so as to get adequate

nutrition.

• To restore the aesthetics by preserving the normal appearance.

• To restore speech as distinctly as the breathing factors permit.

• To provide oral comfort and improve the patients’ sense of well-

being.

• To educate the patients about the changes to be expected in the

supporting tissues.

• To convince them about the need for regular check-ups and

subsequent treatment.
Parts of complete denture
A complete denture has three surfaces and four component parts.

Denture surfaces (fig. 1-1)

Impression surface
This surface is in direct contact with the basal seat tissues and limiting
structures. It is a negative replica of the tissue surface of the jaw.

FIGURE 1-1 Denture surfaces: Impression surface (1),

polished surface (2), occlusal surface (3).

It is defined as ‘the portion of the denture surface that has its contour
determined by the impression’. (GPT 4th Ed)

Polished surface
This surface includes the external surface of the denture, i.e. the labial,
buccal, lingual and the palatal surfaces of the denture. This surface is
desired to be highly polished to facilitate plaque control.
It is defined as ‘that portion of the surface of the denture that extends in
an occlusal direction from the border of the denture and includes the palatal
surfaces. It is that part of the denture base that is usually polished, and it
includes the buccal and lingual surfaces of the teeth’. (GPT 4th Ed)

Occlusal surface
This surface consists of denture teeth which simulate the natural teeth
and cusps and act as sluiceways to aid in eating.
It is defined as ‘a surface of a posterior tooth or occlusal rim that is
intended to make contact with an opposing occlusal surface’. (GPT 1st Ed)

Component parts of complete denture (fig. 1-2)

Denture base
It is that part of the denture which rests directly over the oral tissues
and to which teeth are attached and which helps in mastication and
restoring natural appearance.

FIGURE 1-2 Parts of denture: Denture base (1), denture

flange (2), denture border (3), denture teeth (4).
 It is defined as ‘that part of a denture that rests on the foundation tissues
and to which teeth are attached’. (GPT 8th Ed)

Purpose

• To transmit the forces acting on the denture to the basal seat tissues.
Wider the denture base, more is the retention and lesser are the
forces on the underlying tissues.

• Forms the foundation of the denture.

• Can be characterized to enhance aesthetics.

Denture base is commonly made of acrylic resin. However, metals

can also be used for constructing denture bases. Some of the
commonly used metals are gold and gold alloys (type IV), cobalt–
chromium and nickel–chromium.

Acrylic denture base

• It is the commonly used material to construct denture bases.

• It is supplied as monomer and polymer.

Advantages

• It is easy to fabricate and is economical.

• It is easily relined or rebased.

• It can be characterized to enhance aesthetics.

• It has adequate rigidity to resist functional forces.

Disadvantages

• It cannot be used in thin sections.

• Wear is faster as compared with metal base.

• Thermal conductivity is less.

• There are chances of acrylic warpage.

Metallic denture base

Metallic denture base is defined as ‘the metallic portion of a denture base
forming a part or the entire basal surface of the denture. It serves as a base for
the attachment of the resin portion of the denture base and the teeth’. (GPT
8th Ed)
Commonly used metals for denture base are type IV gold alloys,
cast chrome-based alloys and aluminium-based alloys (Fig. 1-3).

FIGURE 1-3 Metal base dentures.

Advantages

• High strength

• Increased accuracy

• Less chances of tissue change under the metal base

• Lesser porosity and, therefore, easy to clean

• Better thermal conductivity

• Less chances of deformation under function

Disadvantages

• High cost

• Difficult to reline or rebase

• Fabrication is time consuming and technique sensitive

Denture flange
It is defined as ‘that part of the denture base that extends from the cervical
ends of the teeth to the denture border’. (GPT 8th Ed)
In the upper denture, the denture flange includes the labial and the
buccal flanges, whereas in the lower denture, the denture flange
includes the labial, buccal and the lingual flanges, which is the vertical
extension along the lingual side of the alveololingual sulcus.
The labial flange provides the lip support, fullness and aesthetics. If
the labial flange is thick, it gives an artificial denture look to the
patient.
The buccal flange provides support to the cheeks and occupies the
buccal vestibule of the mouth. In the lower denture, it also transfers
the occlusal forces to the buccal shelf region, which is the primary
stress-bearing area in the mandible.
Lingual flange occupies the space adjacent to the tongue. It contacts
the floor of the mouth and provides the peripheral seal to aid in
retention of the denture. Overextended lingual flange may result in
loss of retention of the denture.

Denture border
It is defined as ‘the margin of the denture base at the junction of the
polished surface and the impression surface’. (GPT 8th Ed)
It is the peripheral border of the denture base at the facial, lingual
and the posterior portion. This part of the denture provides the
peripheral seal which aids in the retention and stability for the
denture. Overextended and underextended dentures result in the loss
of retention. Denture border should be smooth and well polished; any
sharp margins may irritate and injure the underlying soft tissues.

Denture teeth
Denture teeth form the occlusal surface of the denture; these provide
aesthetics, enable the patient to chew and aid in speech. These are
usually made of acrylic resin or porcelain.
Classification
On the basis of tooth morphology, denture teeth can be classified as
follows (Fig. 1-4):

• Nonanatomic teeth

• Semi-anatomic teeth

• Anatomic teeth

On the basis of type of the material used, these can be classified as

follows:

• Acrylic teeth

• Porcelain teeth

• Gold occlusal

• Acrylic resin with amalgam stops

• Acrylic teeth with metal inserts

• Interpenetrating polymer network (IPN) resin teeth

FIGURE 1-4 (A) Anatomic tooth. (B) Semi-anatomic tooth.
(C) Nonanatomic tooth.
Residual ridge resorption
Residual ridge resorption (RRR) is defined as ‘a term used for
diminishing quantity and quality of the residual ridge after the teeth are
removed’. (GPT 8th Ed)
RRR is considered as the chronic, progressive, irreversible and
cumulative oral disease. It is described under the following headings.

Pathology of RRR
Basically, the ridge resorbs and decreases in size under the
mucoperiosteum.

• Although there is primary localized loss of bone, sometimes this loss

may be accompanied by redundant tissues.

• Maxilla resorbs vertically and palatally in the anterior region and

vertically and medially in the posterior region.The maxillary ridge
becomes progressively smaller and the incisive foramen comes
nearer to the crest of the ridge as the resorption progresses.

• Mandible resorbs vertically and lingually in the anterior region and

vertically and laterally in the posterior region. Mandibular ridge
appears progressively wider on resorption. Progressive resorption
of the maxillary and mandibular ridges makes the maxilla narrower
and the mandible wider.

Atwood’s classification of the form of residual ridge (1963) (Fig. 1-5):

• Order I: Pre-extraction

• Order II: Postextraction

• Order III: High, well rounded

• Order IV: Knife edge

• Order V: Low, well rounded

• Order VI: Depressed

FIGURE 1-5 Atwood’s classification of residual ridge: Order

(I): pre-extraction; order (II): postextraction; order (III): high,
well rounded; order (IV): knife edge; order (V): low, well
rounded; order (VI): depressed.

Pathogenesis
• After the extraction of the teeth, the empty sockets are filled with
blood to form blood clot. During healing, a new bone is laid down.
The residual ridge changes in shape and size at varying rates in
different individuals and in same individual at different times. RRR
progresses slowly over a longer period of time resulting in reduced
residual ridge.

• A. Tallgren (1972), D.A. Atwood and W.A. Coy (1971) found that the
mean ratio of the anterior maxillary RRR to the anterior mandibular
RRR was 1:4.

Aetiology
RRR is a multifactorial biomechanical disease resulting from the
following factors:

Anatomical factors:
RRR varies with the quantity and quality of the bone
of the residual ridge.

• RRR α-anatomic factors: More the bone, more are

the chances for resorption, but the rate at which it
may resorb may vary.
Metabolic factors:

• RRR is a localized loss of bone on the crest of

residual ridge and certain local and systemic factors
may influence the rate of resorption.

• Local factors are endotoxin, osteoclast activating

factor, prostaglandins, heparin, trauma, etc.

• Systemic factors may influence the balance between

the bone formation and bone resorption.

Mechanical factors:

• Remodelling of the bone is influenced by the force

 factor.

• The amount, frequency, duration, direction, area

and the damping effect of the underlying tissue
influence ridge resorption.

• RRR α-force:

• RRR may increase in a patient with parafunctional

habits such as clenching and grinding of teeth.

• The amount of force applied may be affected

inversely by the damping effect or energy
absorption.

• Damping effect takes place in the mucoperiosteum

which is viscoelastic in nature.

• Energy absorbing quality may influence the rate of

RRR.

• Maxillary residual ridge is broader, flatter and has

increased cancellous bone than mandible and,
therefore, has greater damping effect.
Treatment and prevention
The goal is to reduce the amount of force on the ridge and, therefore,
to reduce the RRR. It can be accomplished by the following:

• Broad area coverage

• Reduced number of teeth

• Reduced buccolingual width of the teeth

• Use of anatomic teeth

• Centralization of occlusal contact

• Avoidance of inclined planes

• Provision of adequate tongue space

• Adequate interocclusal space

Importance of temporomandibular joint
in complete dentures
Temporomandibular joint (TMJ) is a complex synovial joint in which
mandible articulates bilaterally to the cranium. It is a
ginglymoarthrodial joint which is capable of making hinge and
gliding movement (Fig. 1-6).

FIGURE 1-6 Anatomic components of temporomandibular

joint (TMJ): Head of condyle (1), articular disc (2), articular
eminence (3), superior joint cavity (4), inferior joint cavity (5),
retrodiscal (6), superior lateral pterygoid muscle (7), inferior
lateral pterygoid muscle (8).

TMJ is formed by the mandibular condyle fitting into the

mandibular fossa of the temporal bone. Separating these two bones
from direct articulation is the articular disc. This disc serves as the
nonossified bone that permits the complex movement of the joints. In
the sagittal plane, the disc is divided into three regions (intermediate,
anterior and posterior zones) according to the thickness. The hinge
movement occurs between the condyle and the articular disc and the
gliding movement occurs between the disc and the articular eminence
of the temporal bone.
Each of the joints can simultaneously act separately but not
completely without the influence of the other joint. Unlike the other
joints, TMJ is not composed of the hyaline cartilage. The articular
surfaces and the middle or intermediate portion of the articular disc
are made of nonvascular, nerve-free, dense fibrous connective tissues.
The intermediate portion of the articular disc is the load-bearing area.
The articular disc is thicker both anterior and posterior to the
intermediate zone.
Role of TMJ in biomechanical phase of
the prosthetic rehabilitation
Studies show that the condyles are stress-bearing structures, and the
continuous positioning of the disc on the articular surface throughout
the normal movements suggests that the intermediate zone of the disc
must assume pressure during function. In the normal position, the
articular surface of the condyle is located on the intermediate zone of
the disc, bordered by the thicker anterior and posterior regions. As
mentioned earlier, the intermediate zone of the disc is the load-
bearing area. The innervated posterior band protects the joint by
sensory feedback and provides a biomechanically stable relationship.
As the articular eminence is an inclined plane, the condyle disc
assembly should be stabilized on this slope by the muscular activity
unless it is in the position of biomechanical equilibrium. The lateral
pterygoid muscle plays an important role in determining the position
of the condyle disc assembly on the eminence at any given movement.
The fibres of the TM ligaments are oriented in appropriate directions
to limit posterior movement of the mandible. A posterior force tends
to pivot the condyle superoanteriorly because of the restriction by this
ligament.
In a dentulous patient, the physiological relation between the
condyles, disc and their glenoid fossa is maintained during maximal
occlusal contacts and movements guided by the occlusal elements.
This occurs in the centric relation position.

• Centric relation is the most superior position of the mandibular

condyles with the intermediate zone of the disc in contact with the
articular surface of the condyle and the articular eminence. This
position is consistent with the functional bearing capacity of the
posterior slope of the eminence, the adaptation of the intermediate
zone of the disc and the biomechanical stability of the joint resulting
 from the shape of its components.

• In an edentulous patient, the pathological or adaptive changes of

TMJ occur over a period of time. Centric relation position coincides
with the reproducible posterior hinge position of the mandible and
should be recorded with accuracy in the edentulous patient.

• Centric relation is considered as an essential relationship in any

prosthodontic rehabilitation.

• The occlusion of the complete denture patient should harmonize

with the primitive unconditioned reflex of the patient swallowing.

• It is observed that unconscious swallowing occurs when the

mandible is at or near the centric relation position.

• If the occlusion in a complete denture patient does not coincide with

the centric relation, morphological changes can occur in TMJ.
Continuous loading beyond the adaptive capacity of the joint can
lead to degenerative joint disease. In the absence of prosthetic
rehabilitation, a complete edentulous patient is susceptible to
degenerative joint disease.
Importance of patient motivation and
patient education
The success of complete denture prosthesis is determined not only by
proper diagnosis and treatment planning but also by communicating
with the patient. Patient motivation and education are one of the most
important factors which influence the success of the complete denture.
There has to be a good communication between the patient and the
dentist in order to build a mutual trust and a good rapport.
Patient motivation and education
Patients should be informed about their oral condition after complete
digital and visual examination and radiographic investigation. It is
best to dictate the observation made during examination to the
chairside assistant.
It has two desirable effects:

• Firstly, it informs the patients about the conditions existing in their

mouth. It educates the patients about their oral condition and the
need for a specific treatment.

• Secondly, it informs the patients in a formal and dignified manner

about their oral health.

Most of the time, it is quite possible that the patients may not know
the significance of the observations dictated to the assistant. Any
query from the patients should be addressed with proper knowledge
about the existing condition, e.g. knife-edged lower ridge with the
anterior redundant tissues. Patients are educated about the existing
condition and the problems that may be encountered during the
treatment. Additional time may be required to treat some patients
than others depending on the conditions.
It is always best to avoid discussions about the existing dentures.
Even if the patients insist a discussion on the existing dentures, they
should be told that a new diagnosis is to be made after making clinical
observations. Patients’ reactions to this will give a good indication
about their mental attitude.
Patients should be clearly informed about the proposed treatment
in details in the language which they understand so as to avoid any
misunderstanding. Patients are educated about the procedures
necessary to do mouth preparation before impression making. The
number of appointments expected and the time required to handle the
case in the best way should be considered.
Construction procedures such as the impression material, jaw
relation records, teeth and denture base material should be dictated to
the assistant in the presence of the patient. Any procedure requiring
extra time should be specified during the treatment planning itself.
Some decisions are based on the choice of the patient such as the type
of denture base (acrylic or metal) or the shade of the teeth or choice of
characterization.
Patients are motivated and educated to make the best choices,
suiting their conditions. A summary of the proposed treatment plan is
explained to the patients and the possibilities and limitations of the
treatment are underlined. Patients are educated about the proposed
treatment plan, so that the patients do not have unrealistic
expectations. The instructions and suggestions are given to the patient
preferably in the patient’s own language.
Patients should be informed about the estimated cost of the
treatment and the payment process. Fees of the treatment should be
based on the existing conditions, time required to treat and on the
aesthetic demands and mental attitude of the patient. Uniform fee for
all the patients is unjustified.
Patients are educated and motivated to maintain oral hygiene and
to use the oral hygiene aids. They are advised and motivated to follow
proper nutritional programmes. They should be educated on the
importance of having a balanced diet. Instructions on maintaining oral
hygiene should be given right from the first appointment. It is
important to understand the value of patient education and
motivation in the success of complete denture prosthetics.

Physiological rest position and its importance

Physiological rest position is defined as ‘the postural position of the
mandible when an individual is resting comfortably in an upright position
and the associated muscles are in the state of minimal contractual activity’.
(GPT 8th Ed)
The physiological rest position is the position of the passive
equilibrium governed by gravity and the elasticity of the tissues and
muscles attached to the mandible.
J.A. McNamara (1974) believed that this position is maintained by
the tonic activity of the elevator muscles opposing the gravitational
forces. The neurological basis of this position is influenced by the
muscle spindles in the elevator muscles which when stretched result
in the monosynaptic jaw closure or development of myotatic (stretch)
reflex.
The gamma efferent system influences the firing threshold of the
muscle spindles and can alter the sensitivity of the feedback system
through myotatic reflex. When the mandible tends to depress due to
the gravitational force, the myotatic reflex activates a number of motor
units in the elevating muscles resulting in the elevation of the
mandibular position in the original position. This unconscious activity
maintains the mandible in the physiological rest position.
The response threshold of the muscle spindle is influenced by the
activity of the gamma efferent system. Gamma efferent system is
excited by the reticular formation in the central nervous system, thus
establishing the connection between the brain, brainstem activity,
muscle spindle and the muscle tonus or contraction. This connection
explains the clinical observation that muscle tonus increases with the
emotional stress or psychic tension.
Increase in the tonus of the mandibular elevators decreases the
vertical dimension at rest and also the interocclusal distance or
freeway space. Thus, emotional or psychological state of the patient
has a positive influence on the physiological rest position.
Some researchers believe that tongue–palate relationship acts as a
sensory mechanism to determine the postural rest position. Factors
influencing the postural rest position are age, physical and mental
health, history of bruxism, sequence and duration of the tooth loss,
alveolar ridge height, respiratory and postural changes.
Head and body postures have strong influence on the rest position
of the mandible. Therefore, during recording of the jaw relation, the
patient is asked to sit or stand in the upright position and gazing
straight ahead.
Morphological changes associated with
edentulous state
Loss of teeth adversely affects the normal appearance of the patient to
a large extent. It is important to understand the morphological
changes occurring in an edentulous patient and identify the means to
rectify them during the treatment.
The following morphological changes are associated with
edentulous state:

• Loss of the labiodental angle

• Deepening of the nasolabial groove

• Decrease in the horizontal labial angle

• Narrowing of the lips

• Prognathic appearance of the patient

• Increase in the columella–philtral angle

Soft tissue changes in denture patients

It is common to observe changes under the complete denture in both
hard and soft tissues. These begin as soon as the dentures are inserted
in the patient’s mouth. Oral mucosa shows low tolerance to injury or
irritation and is normally not suited to the load-bearing role of the
complete dentures. It shows little or no response to this altered
function. Continuous wearing of denture shows soft tissues changes
such as the papillary hyperplasia and pseudoepitheliomatous
hyperplasia (Table 1-1).

TABLE 1-1
SOFT TISSUE CHANGES IN DENTURE PATIENTS
FIGURE 1-7 Papillary hyperplasia developed in palatal vault.
 FIGURE 1-8 Epulis fissuratum developed due to chronic
irritation of ill-fitting maxillary denture border.

Key Facts
• Complete denture prosthodontics deals with replacement of all the
natural teeth with artificial substitutes.

• Somatoprosthetics is the art and science of prosthetic replacement

of the external parts of the body that are missing or deformed.

• Myotatic reflex is the mechanism that mediates the jaw-closing

reflex and the jaw-jerk reflex.

• Chewing cycle in a dentulous patient when viewed in the frontal

plane demonstrates the jaw motion in the shape of tear drop.

• Cyclic jaw movements are controlled by the chewing centre in the

brainstem.

• Direction of resorption of the maxillary ridge is upwards and

lingual.

• Direction of resorption of the mandibular ridge is downwards and

outwards.
• Translatory movements of the condyle and the disc are controlled
by the capsular ligament and the superior head of the lateral
pterygoid muscle.
CHAPTER 2
Diagnosis and treatment
planning for edentulous patients

CHAPTER OUTLINE
Introduction, 14
Mental Attitude of the Patient, 15
House Classification, 16
Extraoral Examination, 16
Facial Examination, 16
Neuromuscular Examination, 18
Speech, 18
Neuromuscular Coordination, 19
Mandibular Movements, 19
Muscle Tone, 19
Intraoral Examination, 19
Oral Mucosa, 19
Maxillary Basal Seat, 20
Mandibular Basal Seat, 20
Residual Alveolar Ridge, 20
Hard Palate, 23
Soft Palate, 23
 Fibrous Cord-like Ridge, 24
Tongue, 24
Frenal Attachments, 26
Floor of the Mouth, 26
Saliva, 26
Bony Undercuts, 26
Palatal Throat Form, 27
Lateral Throat Form (Postmylohyoid Space), 27
Ageing, 27
Characteristics of Ageing, 28
Effects of Ageing, 28
Gag Reflex, 29
Aetiology, 29
Pavlovian Conditioned Reflex, 29
Role of Saliva, 30
Pre-extraction Records and Their Importance, 31
Radiographic Evaluation, 32
Nutritional Requirement of Edentulous Patients, 32
Proteins, 33
Carbohydrates, 33
Fat, 33
Vitamins, 33
Minerals, 33
Water, 34
Role of Nutrition in Prosthodontics, 34
Introduction
Success of complete denture treatment depends on thorough
diagnosis and proper treatment planning, which will satisfy the need
of the patient.
Definitions:
Diagnosis is defined as ‘determination of the nature of the disease’.
(GPT 8th Ed)
Treatment planning is defined as ‘the sequence of procedures planned
for the treatment of a patient after diagnosis’. (GPT 8th Ed)
Factors necessary to be evaluated for proper diagnosis and
treatment planning prior to fabrication of dentures are as follows:

(i) General information about the patient:

• Name, age, sex, occupation, address

• Chief complaints
(ii) Medical and dental history:

• Medical history

• Dental history

• Period of edentulousness

• Pretreatment records

• Diagnostic casts
• Previous denture
(iii) Observation of the patient:

• Speech

• General appearance
(iv) Clinical examination:

• Extraoral examination:

• Facial examination

• Facial profile

• Face form

• Complexion

• Temporomandibular joint (TMJ) examination

• Neuromuscular examination

• Lip examination

• Intraoral examination:

• Hard tissue examination

• Soft tissue examination

• Saliva

• Gag reflex
(v) Radiographic examination

(vi) Examination of existing prosthesis

Treatment Planning
• Tissue conditioning: Prescription of medication, finger massage, type
of tissue treatment material

• Preprosthetic surgery: List of any preprosthetic procedures required

• Articulator:

(i) Type of articulator

(ii) Control settings on the articulator

• Tooth selection: Shade, mould, material of the anterior and posterior
teeth

• Denture base material: Type of material to be used

• Anatomic palate: Yes or no

• Characterization: Type of stains, location, etc.

• List of changes to improve the new denture

Mental attitude of the patient
Mental attitude of the patients largely determines their ability to
adjust and accept the new prosthesis.
The mental attitude of the patient can be classified as follows:
Class 1: Patients are in good health, well adjusted to life and in need
of dental service.

• Have no experience with dentures and do not anticipate special

difficulties with new prosthesis

• If denture wearer, then worn the dentures satisfactorily

Class 2: Such patients are exacting and concerned with appearance

and efficiency of complete dentures.

• Reluctant to accept complete dentures

• Doubts whether anybody can satisfy their needs and may insist a
guarantee

Class 3: Hysterical and nervous patient with long, neglected oral

status.

• Will accept complete dentures as the last resort

• Have met failures during previous attempts to wear dentures

House classification
Dr Milus House proposed the following classification of patient’s
mental attitudes on the basis of extensive clinical experiences:

Class I: Philosophic
• Best mental attitude

• Well motivated

• Cooperate with the dentist and learn to adjust

• Rational, sensible, calm and composed even in difficult situations

• Have ideal attitude for successful treatment and have excellent

prognosis

Class II: Indifferent

• Have little concern for their teeth or oral health

• They are apathetic, unmotivated and not interested in the treatment

• Have little appreciation for the efforts of their dentists

• Require more time for their instruction on the value and use of
denture

• Their attitude can be very discouraging to the dentist

• Have questionable and unfavourable prognosis

Class III: Critical

• Find faults with everything that is done for them
• Never happy with their previous dentist because the previous
dentist did not follow their instruction

• Firm control of these patients is essential

• They are methodical, precise and very demanding

• Can be traumatic in a dental practice, if not controlled properly

• Medical consultation is always advisable for such patients

Class IV: Sceptical

• Had past bad experience

• Often they will have a recent series of personal tragedies such as

loss of a spouse, business problems or other things not directly
related to their denture problems

• Doubt the ability of anyone to help them

• They need kind and sympathetic approach

• Usually require more time to build confidence in the dentist

• Can be excellent patients, if handled carefully

Extraoral examination
Extraoral examination of the patient starts as soon as the patient enters
the operatory.
It is based on visualization and palpatory methods.

• Patient’s head and neck region should be first examined in general

for the presence of any pathological conditions relating to a
nondental or systemic condition.

• Nodules, naevi or ulcerations are noted.

Facial examination
It includes the evaluation of facial form and facial profile. There
should always be harmony between the facial form, facial profile and
the artificial teeth selected.

Facial form
M M House and Loop, JP Frush and RD Fisher, and Leon Williams
classified facial form on the basis of the outline of the face (Fig. 2-1) as
follows:

• Square

• Square tapering

• Tapering

• Ovoid
 FIGURE 2-1 Facial form: (A) square; (B) tapering; (C) square
tapering; (D) ovoid.

Facial profile
• Examination of the facial profile is very important because it helps
in determining the jaw relation and occlusion.

• The profile is obtained by joining two reference lines. One line joins
the forehead and deepest point in curvature of the upper lip and the
second line joins the deepest curvature of the upper lip and the
most prominent portion of the chin.

• E. Angle classified facial profile as follows (Fig. 2-2):

FIGURE 2-2 Facial profile: (A) straight; (B) convex; (C)

concave.
Class I: Normal or straight profile.
Class II: Retrognathic profile or convex profile —occlusion has class II
disharmony in the centric position.
Class III: Prognathic profile or concave profile —occlusion has class III
disharmony in the centric position.

Facial height
• This can be evaluated by examining the face when the patient bites
on the existing dentures. If the face appears collapsed with wrinkles
around the face, then it suggests a decreased vertical dimension.
Lesions such as angular cheilitis may also be present in these
patients.

• If the face appears strained and taut, then it suggests an increased

vertical dimension.

Facial complexion
• Colour of the skin, eyes and hair along with patient’s age helps in
shade selection for the anterior and posterior teeth.

• Skin colour, texture and lesions may also indicate the systemic
condition of the patient, e.g. bronzed skin occurs in Addison disease
and lemon yellow complexion may indicate jaundice.

• Such patients may require prolonged adjustment with the dentures.

Lip examination
Lip should be examined for the following characteristics:
Lip • Lack of adequate lip support results in a collapsed appearance
support • Adequate lip support is important for the success of complete denture
• Wrinkles around the mouth can be corrected to some extent with proper lip support;
however, excessive wrinkles due to age or medical condition cannot be corrected even with
adequate lip support
Lip • Thin lips are very sensitive to small changes in the positions of anterior teeth and any change
thickness in faciolingual position of the tooth can alter its fullness and support
• Thick lip gives the dentist more flexibility in positioning the anterior teeth
Lip • Length of the lip will affect the exposure of the tooth while in function
length • Short lips may show more of the teeth and even the denture base when the patient smiles or
talks
• Long lips would hide the denture base and most of the teeth during facial expression
Lip • The amount of lip fullness is proportional to the support it gets from the mucosa or the
fullness thickness of the denture
• Thickened labial flange of the denture makes the lip appear too full
• Arrangement of teeth in the anterior region is very crucial as it directly determines the
amount of lip fullness

TMJ examination
Digital examination of the joint area is made by placing the middle
fingers bilaterally just anterior to the auricular tragi and asking the
patient to open and close the jaws slowly.
Auricular palpation indicates any clicking in the joints or
asynchronous movements in the joints.

• The TMJ should be evaluated for the following symptoms:

• Pain and tenderness in the muscles of mastication

• If the joint indicates excessive increase or decrease

in the vertical dimension of occlusion

• Crepitus or clicking sounds during condylar

movements

• Limitations of mandibular movements

• A patient suffering from one or more of the above symptoms is
considered to be suffering from a TMJ disorder.

• For patients associated with TMJ disorder, the following treatment

strategies are recommended:
• Symptomatic treatment

• Control or reduction of contributory factors

• Treatment of pathological sequelae

• Due to difficulty in opening and closing of mouth,

recording of the jaw relation is difficult
• Postinsertion occlusal discrepancies and vertical dimension should
be checked.

• Health of the TMJ is a key factor in the assessment of the ability of

patients to cooperate with the dentist when jaw relation records are
being made.
Neuromuscular examination
Speech
Speech of a patient can be classified on the basis of his/her ability to
coordinate and articulate it.
Class I (normal): Such patients can produce articulated speech with
their existing dentures. They usually learn to articulate distinctly with
the new dentures.
Class II (affected): Such patients have impaired speech articulation
with existing dentures. They require special attention during teeth
arrangement, palatal designs, etc.

Neuromuscular coordination
• Physical abilities and motor skills of the patients should be observed
as soon as they enter the clinic.

• The gait, level of coordination and steadiness of the patients reflect

on their neuromuscular coordination.

• Recording of jaw relations becomes difficult in patients with poor

neuromuscular coordination. These patients usually face problems
in handling the new dentures.

Mandibular movements
• Coordinated mandibular movements are essential for stable
complete denture prosthesis.

• Jaw movements are observed as the patients open or close their

mouth. Any deviation to particular side should be noted.

• Some patients can make lateral movements and protrusive

 movements with ease, whereas others are comfortable in
performing hinge movements only.

• Bilateral balanced occlusion is indicated in patients who can

perform all eccentric movements with ease, whereas prosthetic
approach should be altered in patients with limited or excessive
movements.

Muscle tone
Class I: Tissues are normal in tone and function. Completely
edentulous patients mostly do not have class I musculature as some
amount of degenerative changes occur in all such patients except in
patients with immediate dentures.
Class II: Patients wearing efficient dentures with correct vertical
height present with almost normal tone and function of the muscles.
Class III: Subnormal muscle tone and function because of wearing ill-
fitting dentures.
Intraoral examination
Systemic intraoral examination and proper interpretation determine
the correct procedures for the mechanical phase of complete denture
fabrication.

Oral mucosa
• Colour of the mucosa reveals about its health.

• Normal mucosa is coral pink coloured.

• Redness of the mucosa refers to inflammation of the tissues to

varying degrees.

• Treatment will vary because of differences in the causes of

inflammation and the length of time the tissues have been irritated.

• The inflammation caused by irritation can be:

(i) Mechanical

(ii) Chemical

(iii) Bacteriological
• Common prosthetic causes of irritation are as follows:

(i) Overextension of the denture borders

(ii) Ill-fitting dentures, etc.

• Some tissues recover with simple rest (i.e. keeping the denture out
 of the mouth). Some require relieving overextended borders or sore
spots and use of tissue conditioning resins inside existing or
repairing of denture; others will require surgery to make them as
healthy as possible.

• Oral tissue must be healthy before impression for new dentures is

made.

• White lesions on the mucosa are potentially dangerous and so the

patient should be sent to an oral pathologist for examination.

• Some white lesions on the mucosa are as follows:

(i) Oral submucous fibrosis

(ii) Lichen planus

(iii) Leukoplakia
Oral mucosa can be classified on the basis of their thickness as
follows:
Class 1: Firmly bound mucosa of uniform thickness which forms ideal
cushion for the basal seat of the denture.
Class 2:

(i) Soft tissues which are covered by thin, friable mucosa and are
susceptible to injuries.

(ii) Soft tissues which have mucous membrane twice the normal
thickness and may or may not be mobile.

Class 3: Excessively thick mucosa containing mostly redundant

tissues; tissues should be treated surgically or nonsurgically.

Oral mucosa can also be classified according to its oral appearance

as follows:

Class I: Healthy

Class II: Irritated

Class III: Pathological

Maxillary basal seat

• Basal seat should be having a uniform layer of soft tissue over the
bone.

• Ideal tissue will be quite firm and slightly resilient.

• Thin tissue covering can easily be damaged by the pressure from the
denture and too thick tissues will be too soft and may displace the
denture.

• Maxillary tuberosities are often enlarged with the movable fibrous

tissue, which affects the support for denture.

• Large tuberosities should be removed, if they are movable.

• Hyperplastic or flabby maxillary ridges also affect the stability and

support for the denture.

• Best treatment is to remove it by surgery.

Mandibular basal seat

• Crest of the residual mandibular ridge is palpated for loose or firmly
bound tissues.

• Soft tissues include the retromolar pad which is both soft and easily
displaceable.
• Pad does not support the denture but must be covered by the
denture, if a border seal is to be maintained.

Residual alveolar ridge

Height of the residual ridge

Amount of remaining alveolar bone provides the height of the ridge
support of the denture (Fig. 2-3).

FIGURE 2-3 Height of residual alveolar ridge: (A) Class I –

adequate height; (B) Class II – moderate ridge; (C) Class III –
highly resorbed ridge.

Class I: Adequate height of the ridge is present which provides good

denture support and best resists the lateral movement of the denture
base.
Class II: Slight to moderate amount of resorption of the bone has
occurred but still adequately resists the lateral movement of the
denture base.
Class III: Residual ridge has undergone almost complete resorption
and provides little or no resistance to the lateral movement of the
denture base.

Shape of the residual ridge

Class I: U-shaped ridge.

• Best form to prevent rotational movements

Class II: V-shaped ridge provides some vertical support for the
dentures.
Class III: Knife-edged ridge provides little or no vertical denture
support.

Arch form
Classification based on the shape of the arch form given by House
(Fig. 2-4) is as follows:

FIGURE 2-4 Shape of the arch: (A) square-shaped arch

form; (B) tapered arch form; (C) ovoid arch form.

Class I: Square

• Best form to prevent rotational movements

• Has more surface area

• Most favourable shape and provides best stability

Class II: Tapered

• Offers lesser resistance to rotational movements

• Usually associated with a high-arched palate

• Comparatively less retention and stability due to less surface area

• Provides reduced surface area which lies perpendicular to the

vertical displacing forces

Class III: Ovoid

• Because of its rounded shape, it provides little or no support to

rotational movements

Arch relationship
Relationship between the upper and lower arches is examined as
shown in Fig. 2-5.

FIGURE 2-5 Ridge relationship: (A) Class I ridge relationship;

(B) Class II ridge relationship; (C) Class III ridge relationship.

Classification of anterior arch relationship:

Class I: Normal anterior horizontal overjet of around 2–4 mm
Class II: Excessive horizontal overjet of more than 8 mm

• Mandible is less developed than the maxilla.

• Smaller jaws offer less support and retention.

Class III: Edge-to-edge incisal relationship

• It is due to overdevelopment of the mandible.

• Sometimes there is pseudo-class III relation which is habitual.

• It is often seen in a patient who has been without teeth for a period
of time and has a habit of chewing by using anterior part of the
ridges.

Classification of posterior arch relationship:

Class I: Normal functional and nonfunctional cusp relationship
Class II: Associated with underdeveloped mandible
Class III: Associated with a large mandible or an underdeveloped
maxilla or both

Interarch space
Amount of space available between the upper and lower ridges
determines the amount of space available to set the artificial teeth.
Based on the space in cross-section (Fig. 2-6), the interarch is
classified as follows:

FIGURE 2-6 Interarch space: (A) Class I – interarch space;

(B) Class II – excessive interarch space; (C) Class III – limited
interarch space.

Class 1: Adequate interarch space to accommodate dentures.

Class 2: Excessive interarch space; distance between the teeth and the
supporting bone is excessive which decreases denture stability and
retention due to increased leverage.
Class 3: Interarch space is limited or less; difficult to accommodate
teeth during arrangement.

Ridge parallelism
When teeth are lost gradually, there are chances that the ridges will
diverge (nonparallel) from each other. When ridges are not parallel to
each other, the dentures tend to slide over the basal seat when
occlusal forces are applied to them.
Class I: Both upper and lower ridges are parallel to each other;
provide best denture stability.
Class II: Either upper or lower ridge is divergent anteriorly. Either of
the dentures tends to slide forward.
Class III: Both upper and lower ridges are divergent anteriorly and,
therefore, tend to slide forward.

Hard palate
Vertical support and retention of the maxillary denture are partially
determined by the shape of the hard palate.
Classification of the hard palate based on shape (Fig. 2-7):
Class I:

• Broad, flat with U-shaped palate; offers best vertical support

• Most favourable for retention and stability

Class II:

• V-shaped palate

• Gives lesser denture support and retention

Class III:

• Flat palate
• Offers little vertical denture support and retention

• Not very favourable

• Poor resistance to lateral forces

FIGURE 2-7 Shape of hard palate: (A) Class I – U-shaped

palate; (B) Class II – V-shaped palate; (C) Class III – flat
palate.

Soft palate
Soft palate determines the extent of additional area available for
retention as well as the width of the posterior palatal seal area.
Classification: Based on the angulations between the hard and the soft palate
( Fig. 2-8):
Class I

• Soft palate is almost horizontal, curving gently downwards.

• This is most favourable, as it provides maximum tissue coverage for

palatal seal.

• Muscular activity is minimal.

Class II

• Soft palate turns downwards at about 45° from the hard palate.

• Palatal coverage is less than that of class I.

Class III

• Palate turns downwards sharply at about 70° to the hard palate.

• Usually seen along with a deep V-shaped palate.

• This is least favourable, as the available space for the palatal seal is
minimum.

FIGURE 2-8 Classification of soft palate: (A) Class I – soft

palate; (B) Class II – soft palate; (C) Class III – soft palate.

Sensitivity of the palate

Denture construction is difficult in patients with sensitive palate, as
they have a tendency to gag.
Class 1: No response to palpation; normal palate.
Class 2: Minimal response to palpation indicating the patient’s
sensitivity.
Class 3: Hypersensitive palate which has violent response to
palpation.

Tori
• These are the bony enlargements usually found at the midline of the
hard palate or lingual to premolar region of the mandible.

• Small tori normally do not present any problems in the denture

construction.

• The denture should always be relieved in this region so as to avoid

 excess pressure over the thin mucosa covering the tori.

• Generally, surgery is avoided, but if the torus is so large that it

extends beyond the vibrating line and over part of the soft palate
then it should be removed or reduced in size, as it may interfere
with the development of the posterior palatal seal.

• Usually mandibular tori are removed surgically whenever feasible

(Fig. 2-9).

FIGURE 2-9 Frequent location of tori: (A) Class III – palatal

torus; (B) Class III – mandibular tori.

• Class 1: Tori are absent or small and do not interfere with the use of
dentures.

• Class 2: Ridges have tori that offer mild difficulty for adaptation of
dentures. Surgery may be optional.

• Class 3: Tori are excessively large, present undercuts. Surgical

intervention is mandatory.

Fibrous cord-like ridge

• In some patients, the severely resorbed mandible has a cord-like soft
tissue ridge crest.

• These are easily displaceable labially, buccally and lingually.

• These do not provide stability and support for the dentures.

• These are painful when dentures are worn.

• These can be treated surgically.

Tongue
• Favourable tongue is average sized, moves freely and covered by
healthy mucosa.

• Tongue contributes in denture stability by controlling the denture

during functions such as speech, mastication and swallowing.

• During examination, tongue size and position are observed.

Tongue size
Classification
Class 1: Size of the tongue is adequate to fill the floor of the mouth
and there is adequate space for the lower denture.
Class 2: Tongue slightly overfills the floor of the mouth.
Class 3: Excessively large tongue.

Problems with enlarged tongue

• Enlarged tongue makes denture construction difficult.

• Impression making is difficult.

• Tongue biting can occur.

• Denture stability becomes a major issue, as any movement of the
denture tends to destabilize the denture.

Management in patient with large tongue

• Occlusal plane may be lowered.

• Use narrower teeth.

• Increase intermolar distance.

• Grind the lingual cusps.

• Avoid setting of the second molar.

Tongue position
If the tongue does not maintain the correct position, it is difficult to
attain the lingual seal in the lower denture.
Wright’s Classification (Fig. 2-10)
Class I:

• Tongue lies in the floor of the mouth in the correct position.

• Tip of the tongue is relaxed and rests slightly below the incisal edge
of mandibular anterior teeth.

• The lateral surface of the tongue contacts the lingual surfaces of the
posterior teeth and the denture base.

Class II:

• Tip of the tongue turns either up or down.

• The lateral borders of the tongue are in correct position.

Class III:
• Tongue is depressed into the floor of the mouth and is in retracted
position.

• Tip does not touch the lower denture or ridge.

• Lateral border rests above the mandibular occlusal plane.

• Floor of the mouth will be raised and tensed.

FIGURE 2-10 Various tongue positions: (A) Class I; (B) Class

II; (C) Class III.

Malignant and premalignant changes

• Side and undersurface of the tongue are common locations for
carcinogenic lesion.

• Biopsy is mandatory to confirm diagnosis.

• Surgical removal of the affected parts is usually the treatment of

choice after diagnosis.

Frenal attachments
• Frenal attachments are traditionally classified as high and low in
 relation to the crest of the ridge.

• Unfortunately, this creates confusion; therefore, an alternative

classification is proposed.

Class I: Muscle or frenal attachment is close to the vestibule and

considered as low.
Class II: Muscle and frenal attachments are higher and closer to crest
of the ridge.
Class III: Muscle or frenal attachment is too high. The attachment is at
or close to the crest of the ridge, which is unfavourable. Denture seal
is difficult and may interfere with retention of the denture. In such
cases, surgical intervention may be necessary.

Floor of the mouth

• It can affect the prognosis of the mandibular denture.

• If the floor of the mouth is at or near the level of the ridge crest, the
retention and stability of the denture are less.

• Sometimes sublingual glands and mylohyoid regions spill on to the

ridge due to excessive ridge resorption.

Saliva
Saliva can be classified on the basis of its quality and quantity.
Class 1: Normal quality and quantity of the saliva; ideal cohesive and
adhesive properties.
Class 2: Excessive saliva, more mucus or watery; difficulty in making
impression; also may cause gagging.
Class 3: Xerostomia; denture retention is a problem; more chances of
denture soreness.

• Saliva is an important factor in denture retention.

• The amount and consistency of the saliva are noted.

Consistency of Saliva
• Thin: Favourable for denture retention.

• Thick: Ropy consistency tends to displace the denture.

Amount of Saliva
• Normal: Ideal for denture.

• Excessive: Makes denture construction difficult and messy.

• Reduced: Reduced flow results in reduced retention of the denture.

• Soreness can occur.

• Salivary substitutes or oral moisturizers may be

prescribed.

Bony undercuts
Severe bony undercuts usually require surgical intervention, as these
tend to destabilize the dentures. However, unnecessary bone
reduction should be avoided such as in cases of mild undercuts.
Surveying of the diagnostic cast is essential in determining the depth
of undercut.
Class I: Bony undercuts are absent.
Class II: Small or unilateral mild undercuts, wherein the denture can
be placed by altering the path of insertion or relieving the pressure
areas on the denture.
Class III: Severe bilateral undercuts that are mostly corrected by
surgical intervention.
Palatal throat form
House classified palatal throat form as (Fig. 2-11) follows:

FIGURE 2-11 Palatal throat form: (A) Class I; (B) Class II; (C)
Class III.

Class I: Large size and normal in form. This form consists of relatively
immovable band of resilient tissue 5–12 mm distal to the distal edge
of the maxillary tuberosity.
Class II: Medium size and normal in form. It is a relatively immovable
band of resilient tissue which lies 3–5 mm distal to the distal edge of
the tuberosities.
Class III: Usually seen in small maxilla. The curtain of the soft tissue
turns down abruptly 3–5 mm anterior to a line drawn across the
palate to the distal edge of the tuberosities.

Lateral throat form (postmylohyoid space)

This area is observed when the patients retrude their tongue (Fig. 2-
12).

FIGURE 2-12 Lateral throat form: (A) Class I; (B) Class II; (C)
Class III.
Class 1: Approximately 0.5 inch of space exists between the
mylohyoid ridge and the floor of the mouth. This is most favourable
for retention of the lower denture.
Class 2: Less than 0.5 inch of space exists between the mylohyoid
ridge and the floor of the mouth. It is less favourable for retention of
the lower denture.
Class 3: The mylohyoid fold is at the same level as the mylohyoid
ridge. Retention of the lower denture is almost impossible.
Ageing
Geriatrics is defined as ‘the branch of medicine that treats all problems
peculiar to the ageing patient, including the clinical problems of senescence
and senility’. (GPT 8th Ed)

Characteristics of ageing

Physiopathological conditions of ageing

Ageing is a normal physiological process and not an illness. A number
of gradual changes occur as age increases, such as:

• Increased desiccation of tissues

• Slowing of cell division, growth and tissue repair

• Decreased metabolic rate

• Cellular atrophy

• Increased cell pigmentation

• Fatty infiltration of cells

• Decreased velocity and magnitude of neuromuscular function

• Increased breakdown of central nervous system (CNS)

Psychosocial changes
A person’s values and attitudes change as his/her age advances. These
changes are:

Motivational changes: Enthusiasm is less and often requires great

support, incentive and encouragement.
Physical performance and endurance: More tendencies to get fatigued;
muscle tone and coordination are inadequate for skilful
management of the prosthesis.

Family position: It plays an important part in the adjustment of older

person.

Effects of ageing

Oral changes
• Oral mucosa and skin changes

• Residual bone and maxillomandibular relation changes

• Tongue and taste changes

• Salivary flow changes and nutritional impairment

Oral mucosa and skin changes

• Secretory cells in the skin become dry and less elastic.

• Edentulous mucosa is thin and tightly stretched, gets easily

traumatized.

• Reduction in oestrogen output (menopause) has atrophic effect on

epithelial surfaces.

• Reduction in surface area affects oral mucosa and skin.

• Skin appears loose and wrinkled.

• Patients have compromised mucosal support and may require

frequent application of soft liners.
Residual bone and maxillomandibular relation
changes
Gross reduction of maxillary and mandibular residual ridges often
results in long-term denture wearing.

Disuse atrophy
Several dentists attribute ridge reduction to disuse atrophy. However,
this is not established yet.

Changes in size of the basal seat

• Edentulous maxilla resorbs upwards and inwards. Thus, it becomes
smaller in all dimensions and the denture-bearing surfaces
decrease.

• The mandible resorbs lingually and inferiorly in the anterior region

and buccally in the posterior region.

• This can affect the denture support and stability.

Maxillomandibular relations
Changes occur in the vertical maxillomandibular relations with time
because of the residual ridge resorption and muscle changes.

Tongue and taste

• Tongue may become smooth and glossy, or red or inflamed.

• Vitamin B deficiency may result in sore or burning tongue.

• Tongue thrusting because of nervous tension can lead to sore

tongue.

• Taste bud atrophy can lead to loss of appetite.

Salivary flow and nutritional impairment
• Skin dryness may indicate concomitant decrease of function of the
salivary glands.

• Xerostomia may result from atrophy of salivary glands.

• Dry mouth offers little or no lubrication for the denture bases.

• It also decreases the retentive characteristics that are afforded to the

dentures by the hydrostatic nature of the saliva.
Gag reflex
Gag reflex is a normal healthy defence mechanism which prevents
foreign bodies from entering the trachea. It is present since birth.
It is defined as ‘an involuntary contraction of the muscles of the soft
palate or pharynx that results in retching’. (GPT 8th Ed)

Aetiology
Classifications of causes include the following:

Systemic disorders
Chronic conditions such as a deviated septum, nasal polyps or
sinusitis and blocked nasal passages increase the likelihood of gag
reflex.
Gastrointestinal tract problems such as chronic gastritis, carcinoma
of stomach, peptic ulcer and cholecystitis may increase irritability,
lower the threshold for excitation of the oral cavity and cause nausea
and gagging.

Psychological factors
• In some patients, an abnormal gag reflex may be due to past
experiences.

• Gagging as psychosomatic reaction may be active or passive and

can be modified by fear, anxiety and apprehension.

Physiological factors
Visual, auditory and olfactory stimuli are extraoral factors that can
elicit the gag reflex, while dental prostheses and performance of
dental procedure represent intraoral stimuli.
Extraoral stimuli: Mere sight of a mouth mirror or impression tray or
an acoustic stimulus can initiate the gag reflex.

Intraoral stimuli: Certain regions in the oral cavity are extremely

sensitive to the tactile stimulus.

Social causes
Heavy smoking, coughing and excessive consumption of alcohol are
some social causes of gag reflex.

Pavlovian conditioned reflex

Patient who gags repeatedly with denture becomes so intimately
associated with the denture that any procedure involving the denture
or in the oral cavity triggers the reflex.

Management
• Clinical technique

• Prosthodontic management

• Pharmacological measures

• Psychological intervention

Clinical techniques

• Marble technique: A method for treating the ‘hopeless gagger’ for

complete dentures.

• An impression technique with modified custom tray for mild

gagging edentulous patients.

• Acupuncture technique: Using pressure point on Neikuan point and

L-14 point (Fig. 2-13).
• Appleby and Day’s finger massage technique.

• Controlled breathing method.

FIGURE 2-13 Acupuncture technique.

Radiographic technique

• Use fast speed films.

• Preset the timer.

• Moisten the film pack.

• Have the patient rinse the mouth with cool water.

• When all such attempts fail, extraoral radiograph should be taken.

Prosthodontic management
Excessive thickness, overextension or inadequate postdam should be
corrected.

• Local anaesthetic is added to irreversible hydrocolloid material.

• Modified edentulous maxillary custom tray.

• Palateless or roofless denture (Fig. 2-14).

• Using elastomeric impression material for making impression.

 FIGURE 2-14 Palateless denture.

Pharmacological measures
Peripherally acting drugs: These are topical local anaesthetics. These are
applied in the form of sprays, gels or lozenges or by injection.
Centrally acting drugs: These are categorized as antihistamines,
sedatives and tranquillizers, parasympatholytics and CNS
depressants.

Psychological intervention
Hypnosis: Principles of this treatment are using relaxation, anxiety
control, conditioning/desensitization and confidence-boasting
technique.
 Diversion techniques:

• Engage the patient in interesting conversation.

• Ask the patient to count rapidly.

• Ask the patient to breath audibly.

• Ask the patient to tap the foot rhythmically.

• Ask the patient to raise the leg and hold it in air.

Role of saliva
Saliva plays an important role in providing stability and retention to
complete dentures. The amount and consistency of the saliva
primarily affects these properties and provides comfort to the wearer.
Normally, there should be serous type of saliva with moderate flow,
which provides excellent retention and stability to the dentures.
Saliva can be classified on basis of amount and consistency as
follows:
Class 1: Normal quantity and quality of saliva.

• It should be serous type of saliva with moderate flow which

provides ideal cohesive and adhesive properties.

• Provides excellent retention and stability.

Class 2: Excessive saliva; more mucous type.

• Thick and ropy-type saliva; complicates impression making because

of heavy secretion of mucus formed from the palatal glands, under
the maxillary denture.

• Results in loss of retention and stability.

• Can also cause gag reflex while making the impression.

Class 3: Xerostomia; lack of saliva.

• Lacks in retention.

• Absence of saliva causes the cheeks and lips to stick to the denture
base. Solution: Petrolatum jelly can be applied on the surface of the
denture.

• Saliva provides the physical factors of retention such as adhesion,

cohesion, capillary action and interfacial surface tension. (See
Chapter 4 on retention.)
Pre-extraction records and their
importance
• Pre-extraction records serve as guides in the proper fabrication of
dentures.

• These provide vital information regarding shape, form, colour and

position of the natural teeth, vertical dimension of occlusion,
support of lips and relationships of the teeth to lips.

• These include previous photographs, diagnostic casts, tattooing of

intraoral structures, measurements of extraoral structures, charts of
remaining teeth and radiographs.
Pre-extraction Importance
records
1. Photographs • Photographs showing natural teeth provide information regarding tooth size, shape,
position and display during facial expression
• Extremely effective tools in achieving patient aesthetics and satisfaction
2. Diagnostic • These serve as guide to place artificial teeth
casts • These give an indication about the vertical dimension of occlusion
3. Tattooing • Records of the vertical dimension of occlusion can be made by tattooing the attached
gingiva prior to extraction
• Distance between the tattoos is measured
• A window is placed in the record base in the area of the tattoo while establishing the
vertical dimension of occlusion
4. Extraoral • Permanent landmarks on the face such as scars, moles or warts can serve as guide for
measurements establishing the correct vertical dimension of occlusion
• Acrylic mask can be made on the cast made after making impression of the face when
teeth are in occlusion
• After extraction of the teeth, the face is repositioned into the mask
5. Old dentures • If old dentures of the patient are available, the vertical dimension of occlusion can be
approximated by measuring the dentures
• The aesthetics and phonetics can be checked with old dentures
6. Charts of • Charts can be made of remaining teeth. A sketch can show colour, stains, cracks,
teeth existing restorations and incisal edges
7. Radiographs • Preoperative radiographs can provide useful information about size and form of the
teeth
• Image magnification and shortening should be taken into consideration
Radiographic evaluation
Radiographs are important diagnostic aids in evaluating the
submucosal conditions in the patients seeking prosthodontic
treatment.

• Radiographic examination should be advised to rule out any bony

conditions that could affect the treatment.

• A panoramic radiograph can reveal many conditions that affect the

treatment plan and prognosis of the case.

• The radiograph is useful in the following instances:

• Bone pathosis

• Retained tooth roots

• Unerupted teeth

• Cysts

• Tumours

• Bony fractures

• Soft tissue thickness

• Extent of bone resorption

• Determine thickness of the body of mandible

• To plan surgeries

• To see remaining bone density and quality

• To keep as treatment records

• For patient education

Classification is based on radiographic interpretation of the osseous
structures which provide support for the prosthesis.
Class 1: Dense bone provides optimum foundation for the dentures.

• Trabeculae are compact and medullary spaces are few.

• Cortex is solid and well defined. These structures show little or slow
resorption.

Class 2: Cancellated bone gives adequate support, if occlusal loading

is within physiological limit.

• The trabeculae and medullary spaces are evenly balanced.

• Cortex is defined but lighter in contrast.

Class 3: Noncortical bone is radiolucent and poor in organic salts.

• No definite cortex, margins are feathery, thin and often apiculated.

• Offers poor bone support for denture.

• Higher rate of resorption and discomfort.

Extraoral radiographs are useful in providing an overview of

patient’s denture foundation and surrounding structures.
Presently, charged couple device and complementary metal oxide
semiconductor image sensing systems are becoming popular because
of less radiation exposure to the patient.
Nutritional requirement of edentulous
patients
Nutrition is defined as ‘the science of food, the nutrients and other
substances their actions, interaction and balance in relation to health
and disease and the processes by which the organism ingests, digests,
absorbs, transports, utilizes and excretes food substances’.
Adequate nutrition with proper quantity of proteins, carbohydrates,
fats, vitamins and minerals is important to maintain the health of oral
tissues of edentulous patients.
Goals of Nutrition
• To provide adequate energy (calories) in young adults, growing
children and elderly.

• The amount, proportion and type of macronutrients and

micronutrients should be correct.

• To establish a balanced diet; this is consistent with the physical,

social, psychological and economical background of the individual.

Proteins
• As the patient becomes older, the amount of protein required per
kilogram of the body weight is increased.

• About 1.4 g/kg body weight is optimum.

• Too much protein never damages the health of the elderly person.

• Milk is an ideal source of protein for this age group.

• Best sources of proteins are meat and fish.

• Protein deficiency can decrease salivary flow and enlarges the
parotid glands.

Carbohydrates

Fibres
• Promote normal bowel activity.

• Lower glycaemic response.

• Reduce serum cholesterol.

• Prevent diverticular diseases.

Fat
• Because of the evidences of the link between dietary intake of
saturated fat, cholesterol and occurrence of heart diseases and
obesity, adults are advised to reduce fat intake to 30% of the total
calories.

• Saturated fat (animal fat): 8–10% of total calories.

• Unsaturated fat (vegetable oil): 10–15%.

Vitamins
Vitamin intake should be increased for the following reasons:

• Provides nervous stability.

• Provides resistance to bacterial infections.

• Improves digestive efficiency by aiding in the use of carbohydrates

and utilization of mineral elements.
• Intake of mainly vitamins A, B-complex, C and D should be
increased.

• Deficiency of vitamin B-complex can result in angular cheilitis,

angular stomatitis and glossitis.

Minerals
• Minerals are of considerable importance to the aged persons.

• Calcium loss contributes to bone fragility.

• The patients often experience a rapid and excessive ridge resorption

under complete dentures, which may be related to negative calcium
balance. Calcium deficiency is one of the prime causes of
osteoporosis.

• Poor nutrition has been linked to an increased risk of many diseases,

including heart disease and diabetes.

• Human body requires both macronutrients, which are the main

source of calories, and micronutrients (approximately 40 essential
minerals, vitamins and other biochemicals), which are required for
virtually all metabolic and developmental processes.

Water
• Comprises about 60% of the body weight

• Chief component of blood plasma

• Aids in temperature regulation

• Lubricates joints

• Shock absorber in eyes, spinal cord and amniotic sac (during

 pregnancy)

• Active participant in many chemical reactions

• Helps in excretion
Role of nutrition in prosthodontics
• A denture is a mechanical object intended to function in a biological
environment that is vital and constantly changing.

• The functional demands of the prosthesis must be kept within the

metabolic ability of the tissues which supports the prosthesis.

• The success of complete denture prosthesis depends on the health

and integrity of the denture-bearing tissues. The realization of these
factors forms the entire basis for the essential role of nutrition in
prosthodontics.

Key Facts
• Posterior palatal seal area is used to complete the peripheral valve
seal across the distal border of the denture.

• Abfraction is the pathologic loss of hard tooth substance caused by

biomechanical loading forces.

• Angular cheilitis is the inflammation of the angles of the mouth

causing redness and the production of the fissures. It is also called
perleche.

• Class I type of soft palate is the most favourable to the complete

denture retention, as it allows more tissue coverage for the palatal
seal.

• Snow shoe principle enhances the support of complete denture by

using the maximal coverage within the normal functional limits.

• Mean foundation plane is the mean of the various irregularities in

form and inclination of the basal seat.
• V-shaped palatal vault is associated with class III soft palate.

• Flat palatal vault is associated with class I and class II soft palate.

• Palpation of the temporal muscle is used to check the retrusion of

the mandible.

• The posterior palatal seal is around 1–1.5 mm high and 1.5 mm

wide.

• The stability of the lower denture is enhanced when the tongue

rests on the occlusal surfaces of the lower teeth at rest.

• Masseteric notch in the distobuccal corner of the mandibular

denture is due to action of the masseter on the buccinator.

• Mean denture-bearing area of the maxilla is 22.96 cm2.

• Mean denture-bearing area of the mandible is 12.25 cm2.

• Engrams are the setting of the memorized pattern of the muscle

activity due to repeated proprioceptive signals of the teeth.
CHAPTER 3
Mouth preparation of complete
denture patients

CHAPTER OUTLINE
Introduction, 35
Nonsurgical Methods, 35
Pre-Prosthetic Surgery, 36
Minor Pre-prosthetic Surgical Procedures, 36
Resilient Liners, 42
Ideal Requirements of Resilient Liners, 43
Composition, 43
Role in Edentulous Patient, 43
Drawbacks, 43
Role of Tissue Conditioners, 44
Uses, 44
Composition and Characteristics, 44
Causes of Abused Tissues, 44
Treatment of Abused Tissues, 44
Introduction
Before undergoing a complete denture prosthesis, it is always
necessary to examine the mouth of the patient to identify the potential
problem areas. These problem areas can be corrected by various
nonsurgical and surgical methods.
The following methods are commonly used to prepare the mouth to
receive complete dentures:

(i) Nonsurgical method

(ii) Surgical method or preprosthetic surgery

Objectives of Mouth Preparation

• Improves denture foundation

• Improves the ridge relations

• Enhances support

• Restoration of form and function of the stomatognathic system

• Improves aesthetics
Nonsurgical methods
Nonsurgical methods of preparing mouth for complete dentures are
shown in Table 3.1.

TABLE 3-1
NONSURGICAL METHODS
Preprosthetic surgery
Preprosthetic surgery is defined as ‘surgical procedures designed to
facilitate fabrication of prosthesis or to improve the prognosis of
prosthodontic care’. (GPT 8th Ed)

• Pre-prosthetic surgery attempts to create an environment that can

support the complete dentures and enhances its longevity and
patient satisfaction.

• It is aimed to prepare the edentulous jaw to accept the best possible

complete denture prosthesis.

• The edentulous jaw is aimed to provide an ideal shape and form.

Minor preprosthetic surgical procedures

Alveoloplasties
• Least bone resorption takes place, if the sockets are digitally
compressed after simple extraction.

• Surgical technique of alveoplasty is to reflect the mucoperiosteal

flap and reduce the bone with rongeurs or a rotary bur.

• When there is adequate ridge height but bony undercut occurs on

the buccal aspect of the jaw, intraseptal alveoloplasty with cortical
bone repositioning is indicated.

Frenectomy
• It is defined as surgical excision of the frenum.

• Frenectomy or frenotomy is indicated when a band of fibrous tissue

 attaches near the crest of residual ridge or the thick frenum
continuously displaces the denture during function.

• Hypertrophic maxillary labial frenum most commonly interferes

with denture function followed by lingual frenum and maxillary
buccal frenum.

• Different techniques for frenectomy include diamond excision, Z-

plasty technique and V–Y advancement technique.

• Diamond excision is the most common technique used to release

maxillary and mandibular labial frena.

• Z-plasty technique is used when frenum is broad and short (Fig. 3-

1).

• V–Y advancement technique is used when concomitant decrease in

nasal base width is desired.

• During mandibular frenectomy, it is advisable to give tongue

traction suture in order to improve visibility and control of tongue.

• Broad frena in the maxillary bicuspid molar region are best treated
by localized vestibuloplasty.

FIGURE 3-1 Z-plasty technique used in frenectomy: (A) ‘Z’-

shaped incision; (B) reflection and detachment of frenum from
alveolar process; (C) sutures closing the wound.

Excision of redundant soft tissues, papillary

hyperplasia or epulis fissuratum
• Surgical excision may be required to remove excess
noninflammatory tissues caused due to long-term wearing of a
poorly fitting prosthesis.

• Care should be taken that there is minimal trauma to the remaining

tissues.

• Epulis fissuratum is surgically removed by sharp excision,

electrocautery, cryosurgery and laser excision.

• Laser excision offers better haemostasis and reduced postoperative

pain.

• Cryosurgery may require several appointments.

• Palatal papillary hyperplasia is caused by poorly fitting complete

denture and sometimes by candidal infection.

• Attempt should be made to reduce the size of the lesion

preoperatively by providing relief of the denture and using tissue
conditioners and antifungal agents.

• Soft tissue removal can be accomplished by surgical excision,

curettage, electrosurgery and reduction using large rotary bur or
laser ablation.

Maxillary tuberosity reduction and exostosis

removal
• Excess tissue in the region of maxillary tuberosity commonly
interferes with the construction of denture.

• This excess tissue may be soft redundant tissue or a bony undercut.

• Articulated casts are valuable to plan the amount and location of
tissue removal.

• The excessive soft tissue is surgically excised and sutured to obtain

primary closure.

• To remove excessive bony undercut, an ellipsoid incision is made

and the mucoperiosteum is reflected and rongeur or rotary bur is
used to remove the bone.

Tori removal
Tori can be palatal or lingual.

Palatal tori
• These are usually located at the centre of the palate and are more
common in the females.

• These are composed of entirely cortical bone and occasionally may

have cancellous components.

Removal of palatal tori is indicated when the following

characteristics are noticed:

• Extremely large torus fills the palatal vault (Fig. 3-2).

• Torus extending beyond the posterior dam area.

• Mucosa is traumatized over the torus.

• Deep bony undercut.

• Interferes with functions such as speech, swallowing.

• Psychological reasons (fear of malignancy).

• Smaller torus does not require removal and relief in the denture is
sufficient.

• However, large torus requires surgical removal.

FIGURE 3-2 Large maxillary torus in the centre of the palate.

Technique

• Anteroposterior incision is made over the middle of the torus with a

Y-shaped releasing incision at each end.

• Full thickness mucoperiosteal flap is raised carefully and the torus is

sectioned with a bur.

• Sectioned torus is removed in pieces with chisel.

• A large rotary bur may also be used to grind the torus away.

• Mucosal tissues are approximated and sutured to achieve primary

closure.
• A stent or denture is used to support the palatal tissues to avoid
haematoma formation.

• Possible complications: Nasal perforation, oronasal or antral fistula

formation, palatal tissue necrosis and haematoma.

Mandibular tori (fig. 3-3)

• These can be single, multiple or lobulated.

• These are commonly located on the lingual aspect of the premolar

region.

• Osteotome is used to remove the torus by creating a groove in the

lingual cortex with a fissure bur.

• Alternatively large rotary bur can also be used.

• Bone is smoothened with bone file and the primary closure is

obtained.

• Possible complications: Haemorrhage of the floor of the mouth, and

infection.

FIGURE 3-3 Removal of lingual torus: (A) lingual torus; (B)

grooving and removal of torus; (C) sutures placed.
Mylohyoid ridge reduction
• Vertical bone resorption of the bone in the posterior mandible
results in prominent ridge.

• It limits the extension of the lingual flange of the lower denture.

• Incision is made in the posterior aspect of the mandible on the crest

of the ridge.

• Mucoperiosteal flap is reflected and a rotary bur or bone file is used

to reduce the prominence of the ridge.

• Primary closure is achieved after suturing and a stent or modified

denture is immediately placed to position the muscle inferiorly.

Ridge augmentation
Augmentation is defined as ‘to increase in size beyond the existing size. In
alveolar ridge augmentation, bone grafts or alloplastic materials are used to
increase the size of an atrophic alveolar ridge’. (GPT 8th Ed)

Rationale of ridge augmentation

Rationale of ridge augmentation is to recreate an edentulous ridge
having features compatible with the requirements of denture wearing.

Factors affecting ridge augmentation success

• Type of augmentation material, i.e. autografts, allograft or alloplast

• Augmentation site

• Surgical and prosthodontic design

• Willingness of the patient

• Prosthodontic follow-up

• Physical and mental condition of the patient

• Skill of the surgeon and prosthodontist

Diagnosis and treatment planning

• Through medical and dental history.

• Complete radiographic evaluation.

• Frontal and profile photographs.

• Radiographs and photographs are obtained after satisfactory jaw

relations.

• Properly mounted casts.

• Mock surgery performed on the cast to determine the surgical

approach to be used and the level of desired correction.

• Minimum of 16–18 mm of interarch space is required to construct

complete dentures.

The techniques commonly used for ridge augmentation are as

follows:

Visor osteotomy
• In this technique, the buccolingual dimension of the mandible is
split and the lingual cortical bone is repositioned superiorly.

• Some authors have suggested decreased postoperative bone

resorption and good vertical bone augmentation.

• Incidence of paraesthesia of the mandibular nerve is high.

• Postoperative ridge form following this technique is poor.

Onlay bone grafting

Indications
• When bony support in the maxilla and mandible is inadequate.

• When the residual vertical bone height between the mental foramen
is less than 7 mm.

• In this technique, autogenous bone from the iliac crest has been used
to augment the atrophic maxilla or mandible.

• Drawback is high rate of resorption of the onlay graft.

• Secondly, another surgery is performed to increase the depth of the

vestibule.

Interpositional bone grafts

• In this technique, an osteotomy is performed by splitting the
superior–inferior dimension of the residual jaw and the bone is
grafted within this osteotomy.

• In the maxilla, Le Fort osteotomy is performed with interpositional

grafting. The advantage of this technique is that it shows less
resorption in comparison to the onlay grafting procedure.

• After grafting, secondary soft tissue procedure to increase the

vestibular depth is usually necessary.

• Horizontal sandwich technique is used to augment the anterior

mandible. Advantage is that it shows less incidence of nerve
paraesthesia when compared to visor osteotomy.

• Allogenic bone graft can be used instead of autogenous graft.

• This is the procedure of choice for mandibular ridge augmentation,
as it includes a combination of osteotomy techniques (horizontal or
vertical). This procedure involves the movement of the pedicle of
the bone along with blood supply.

Inferior bone grafts ( fig. 3-4)

• This was first described by R.E. Marx and T.R. Saunders (1986) for
reconstruction of the mandible following resection.

• It was modified by P.D. Quinn, K. Kent, I.I. MacAfee and A.

Kenneth (1991).

Indications
• Severely atrophic mandible.

• Mandible has 5–8 mm of bone and there are chances of pathological

fracture.

Procedure
• A supralaryngeal incision is made from the mastoid process to the
mastoid process on the other side.

• Subsequently, the inferior border of the mandible is dissected.

• A freeze-dried allogenic mandible is hollowed out and is used as a

tray to hold the autogenous cancellous graft harvested from the iliac
crest.

• If needed, hydroxyapatite or allogenic particulate bone is used as

graft expander.

• Graft is secured in place using sutures or wires.

• The freeze-dried allogenic bone crib is replaced by a process called

 creeping substitution over a period of several months.

• Implants can be placed into the graft 4 months postsurgery.

• Advantages of this technique are consistent; 11–17 mm of bone

augmentation is achieved with a resorption rate of only 5%.

FIGURE 3-4 Inferior border bone grafting technique.

Vestibuloplasty
Vestibuloplasty is defined as ‘a surgical procedure designed to restore
alveolar ridge height by lowering muscles attachment to the buccal, labial and
lingual aspects of the jaws’. (GPT 8th Ed)

Indications

• When other conservative procedures fail

• A healthy patient who is highly motivated

• A cooperative patient

Contraindications

• A medically unfit patient

• An undermotivated patient

• A geriatric patient who is debilitated or medically compromised

• When vertical ridge height is inadequate

• A severely prognathic patient

• A patient who cannot bear the cost and time of the treatment

Techniques

Mucosal advancement

• This was first described by R.B. McIntosh and H.L. Obwegeser

(1967).

• It is indicated when maxillary denture is unstable due to shallow

vestibular depth or high muscle attachment, but there should be
sufficient healthy mucosa in the vestibule.

• Mouth mirror test is used to assess the amount of mucosa.

• Mouth mirror is used to reflect the soft tissue to the desired

 vestibular depth; if abnormal shortening of the lip is not noticed,
then sufficient mucosa exists to do the procedure.

• A subperiosteal tunnel is created by dissecting any underlying

submucosal connective tissue away from the periosteum.

• The intervening submucosal tissues are then excised or repositioned

anteriorly.

• An overextended surgical stent or overextended denture is placed to

the new vestibular area.

• Stent is removed after complete healing.

• New denture is then fabricated to a new maxillary form and

vestibular depth.

Secondary epithelialization (fig. 3-5)

• This involves the use of apically repositioned flap sutured to the

periosteum to the desired sulcus depth.

• Exposed tissues are allowed to heal by granulation and secondary

intention.

• This can be used when hypermobile and hyperplastic ridges are

present and can be reduced while the ridge is extended.

• Overcorrection is advised beyond the desired sulcus depth, as

chances of relapse are very high.
 FIGURE 3-5 Secondary epithelialization procedure: (A)
incision of the ridge; (B) supraperiosteal reflection; (C)
suturing of flap at new sulcus depth and placement of splint.

Epithelial graft vestibuloplasty

• It is a secondary epithelization procedure which uses skin or

mucous membrane graft to cover the exposed tissues.

• It was first described by J.F. Esser (1917) and later developed by

H.L. Obwegeser (1967).

• It is used to enhance retention, stability and support of a denture in

highly resorbed maxilla or mandible.

• It is used when there is high muscle attachment that interferes with

the development of adequate border seal.

• Adequate vertical height of the bone is required to allow relocation

of the vestibule.

• This technique is the most preferred and predictable of all the

vestibular procedures.

Lip switch procedures (transitional flap vestibuloplasty) (fig. 3-6)

• It was first described by V.H. Kazanjian (1935).

• Indicated for patients with insufficient vestibular depth owing to

mandibular atrophy and high muscle and soft tissue attachments.
• This technique effectively increases the vestibular depth in the
patients having bone height more than 15 mm.

• If the bone height is less than 15 mm, then the prosthetic results are
compromised and other procedures such as ridge augmentation are
advised.

• A submucosal dissection is made from the inner lower lip to the

mucogingival junction.

• Then supraperiosteal dissection is done to remove the muscle and

connective tissue attachments inferiorly to the desired vestibular
depth.

• Periosteal flap is dissected from the bone and sutured to the raw lip
bed.

• Raised mucosal flap is adapted to the exposed bone to the depth of

the new vestibule and is fixed with sutures or stent.

• Possible complications: Pain, oedema and/or transient mental nerve

paraesthesia.

FIGURE 3-6 Lip switch technique of vestibuloplasty: (A)

incision made in labial mucosa or periosteal flap; (B) flap is
reflected to the depth of vestibule; (C) flap sutured.
Resilient liners
Resilient liners (Fig. 3-7) are elastomeric polymers which are used to
prevent chronic soreness from complete dentures and to preserve the
supporting structures.

FIGURE 3-7 Resilient liner. Source: (Reprinted by permission of GC

India Dental Pvt Ltd.)

Types of resilient liners on the basis of their composition are as

follows:

(i) Velum rubber

(ii) Vinyl or acrylic resin

(iii) Silicones

(iv) Polyurethane
(v) Ethyl methacrylate elastomers

Ideal requirements of resilient liners

• Material should be durable.

• Material should have adequate hardness and strength and its

hardness should not change with time.

• Material should adhere well to the denture base.

• Material should recover well from deformation.

• Material should be easily cleaned and adjusted.

• Material should not be affected by the microorganisms and their

metabolites.

• Material should be colour stable, odourless, tasteless, nonirritating

and nontoxic.

• Material should be dimensionally stable and accurate.

• Material should not distort the denture base.

• Material should have good surface wettability.

Composition
• Vinyl and acrylic polymers are made resilient by adding oily or
alcohol type of plasticizer.

• Hydrophilic polymer is a mixture of polyethylene glycol

methacrylate with diacetins.

• Once hardened, the material can be polished by conventional

means.
• It becomes flexible when placed in water or in moist environment of
the oral cavity.

Role in edentulous patient

• Resilient liners are used in case of resorbed or atrophied edentulous
ridges which require protection (e.g. in knife-edged ridges, mental
foramen region, dehiscent mandibular canal or surgically excised soft or
bony tissues). Resilient liners provide excellent protection to
underlying soft tissues.

• These are used when surgical correction of bony undercuts is

contraindicated. Resilient liners are useful in patients who cannot
afford or undergo surgery for correction of the bilateral undercuts.
These materials owing to their flexibility facilitate insertion and
removal without compromising retention.

• These are used in the patients with parafunctional habit such as

bruxism. The constant grinding of the occlusal surfaces of the
denture teeth transmit intermittent shear stress to the basal seat
which results in mucosal irritation and subsequent bone resorption.
Resilient liners protect the supporting tissues from excessive stress.

• These are used in the relief area such as mid-palatal raphe or

anterior nasal spine. The soft flexible material provides relief to
these regions.

• These are used when congenital or acquired oral defects are to be

restored. Resilient liners are valuable in fabricating prosthesis such
as obturator to restore congenital or acquired oral defects.

• It can be indicated in xerostomic patients. However, it should be

avoided in severe xerostomic patients, as they too can cause
mucosal irritation.

• These are used in cases where the edentulous arch opposes the
 natural dentition.

• Resilient liners prevent the problems of chronic soreness from

complete dentures and thus help in preserving the supporting
tissues.

Drawbacks
• Plasticizer leaches out over the period of time making it hard and
discoloured.

• Silicone elastomers do not adhere well with the acrylic resin denture
base and thus are prone to get discoloured, difficult to finish and
polish, dimensionally unstable and affected by the metabolites of
Candida albicans.

• Polyurethanes are ultra-soft and comfortable but are difficult to

processes.

• Ethyl methacrylates can be processed by compression moulding

technique and can be easily finished and polished by conventional
means.
Role of tissue conditioners
Tissue conditioners (Fig. 3-8) are used to treat abused and
compromised tissues due to congenital or acquired abnormalities,
parafunctional habits, systemic deficiencies or faulty dentures. The
softness and flexibility of these materials help in protecting the
supporting tissues from functional and parafunctional occlusal
stresses.

FIGURE 3-8 Tissue conditioners. Source: (Reprinted by permission of

GC India Dental Pvt Ltd.)

Uses
• For temporary reline of dentures following oral surgery

• For conditioning the denture-bearing areas to healthy state

• As an aid in the treatment of chronic soreness from dentures

• As an impression material to reline complete dentures

• As a final impression material for new complete dentures

• For temporary relining of loose immediate dentures

• For temporary obturation and protection of surgical areas

• As a stabilizer for baseplates or surgical stents

Composition and characteristics

• Tissue conditioners are composed of polyethyl methacrylate and an
aromatic ester ethyl alcohol mixture.

• When these materials are mixed, they form a cohesive, resilient gel.

• The material does not adhere to the wet mucosa but readily adhere
to dry acrylic resin, to skin or to old tissue-conditioning material.

• Flow of the material can be improved by adding plasticizing liquid.

• These continue to flow under pressure for several days.

• To obtain good results, the material should be changed after every

72 h.

• The material usually remains plastic but will become grainy and
discoloured, if in contact with denture for more than 2 weeks.

Causes of abused tissues

• Hyperaemic or traumatized oral mucosa because of ill-fitting
dentures
• Poor occlusion

• Bruxism

• Papillary hyperplasia

• Depressed area with suction cups

• Nutritional disorders

• General debilitating patients

Treatment of abused tissues

• For patients who cannot do without dentures over an extended
period of time, tissue conditioners are used.

• Before the fabrication of new dentures, the hypertrophic, irritated,

hyperaemic and abused oral tissues should be conditioned to a
healthy state.

• Self-curing, slowly polymerizing material provides an excellent

medium to aid in conditioning of the abused tissues.

• After occlusal adjustments and correction of the underextended or

overextended borders, tissue conditioning material is applied.

• Tissue side of the denture and the borders are reduced by

approximately 2 mm.

• Posterior palatal seal and the buccal shelf region are not reduced, as
they act as posterior stops.

• Also, anterior stops are provided by reducing a small area of 3 × 3

mm in the cuspid region during initial relief.

• Anterior and posterior stops are necessary to correctly orient the

 dentures to the ridges during placement of the material and to
maintain a correct vertical dimension.

• Material is mixed following the manufacturer’s instructions.

• Material is spread evenly on the tissue surface and border areas of

the denture.

• Dentures are placed in the mouth and the patient is instructed to tap
the dentures lightly together.

• The dentures are left in the mouth for several minutes for setting.

• Any excess material is trimmed using a sharp BP blade.

• Pressure spots are relieved using acrylic trimmer or vulcanite bur.

• Dentures are placed back on the ridges, appearance is checked and

the vertical dimension is verified.

• The centric relation position should coincide with the centric

occlusion.

• The patient is recalled after 72 h and he/she is instructed not to

brush the tissue surface of the denture.

• The denture should be cleaned with lukewarm water.

• When the patient returns, the dentures and the tissues are examined
and necessary corrections are made.

• Once the tissues return to normal health, preliminary impressions

are made.

Key Facts
• Epulis fissuratum is caused due to overextension of the labial
 flanges.

• Generalized soreness of the denture-bearing area in a new denture

wearer is due to increased vertical dimension.

• Mandibular tori are most commonly located lingual to the premolar

region.

• Maxillary tori are most commonly located in the mid-palatal region.

CHAPTER 4
Impressions in complete dentures

CHAPTER OUTLINE
Introduction, 47
Impressions, 47
Definitions, 47
Retention, 48
Biological Factors, 48
Mechanical Factors, 49
Physical Factors, 50
Psychological Factors, 50
Surgical Factors, 50
Stability, 51
Definition, 51
Biological Factors, 51
Mechanical Factors, 53
Physical Factors, 54
Support, 55
Definition, 55
Factors Responsible for Effective Support of the
Prosthesis, 55
Impression Techniques, 56
Mucostatic Impression Technique, 56
Mucocompressive Impression Technique, 57
Selective Pressure Technique, 57
Biological Consideration in Maxillary Impressions, 57
Hard Palate, 58
Residual Ridge, 58
Rugae, 59
Maxillary Tuberosity, 59
Alveolar Tubercle, 59
Limiting Structures, 59
Relief Areas, 60
Incisive Papilla, 60
Mid-palatine Raphe, 60
Fovea Palatini, 60
Postpalatal Seal, 61
Anterior Vibrating Line, 61
Methods to Locate Anterior Vibrating Line, 61
Posterior Vibrating Line, 62
Biological Considerations in Mandibular Impressions, 62
Buccal Shelf Area, 62
Pear-shaped Pad, 64
Residual Alveolar Ridge, 64
Limiting Structures, 64
 Anterior Region, 66
Middle Region, 66
Posterior Region, 66
Retromolar Pad, 66
Relief Areas, 66
Mylohyoid Ridge, 66
Mental Foramen, 67
Torus Mandibularis, 67
Primary Impression, 67
Definition, 67
Ideal Requirement of Impression Trays, 67
Points to Consider during Tray Selection, 67
Functions of the Tray, 68
Primary Cast, 68
Requirements of a Primary Cast, 68
Uses of Primary Cast, 68
Custom Tray, 68
Ideal Requirements of a Custom Tray, 69
Materials Used for Fabrication, 69
Adapting Relief Wax, 69
Spacer Thickness and Design, 69
Method of Fabrication, 69
Sprinkle-on Method, 69
Border Moulding, 70
 Multistep or Incremental or Sectional Border
Moulding, 70
Single Step or Simultaneous Border
Moulding, 71
Secondary Impression or Wash Impression, 72
Impression Materials, 72
Impression Plaster, 72
Impression Compound, 73
Zinc Oxide Eugenol Paste, 73
Reversible Hydrocolloid, 74
Irreversible Hydrocolloid, 74
Rubber Base Impression Material, 74
Impression Waxes, 75
Introduction
Impression making is one of the most important steps in the
construction of dentures. Primary objective of the impression
procedure is to accurately record the entire denture-bearing areas to
construct stable, precise fit and retentive dentures. The clinician
should be well versed with the anatomy of the edentulous arches and
according to the existing condition should be able to select an
appropriate impression technique.
Impressions
Definitions
An impression is defined as ‘the negative likeness or copy in reverse of the
surface of an object; an imprint of the teeth and adjacent structures for use in
dentistry’. (GPT 8th Ed)
‘An impression is the negative form of the teeth and/or other tissues of the
oral cavity, recorded at the moment of crystallization of the impression
material’. (Heartwell)
Objectives of Impression Making
There are five primary objectives of impression making. These are as
follows:

(i) Preservation of remaining structures

(ii) Support

(iii) Stability

(iv) Aesthetics

(v) Retention

Impression can be made in dentulous, partially dentulous or

completely edentulous patients and also in the patients with
congenital or acquired defects.
DeVan Dictum
The famous dictum, proposed by Muller DeVan (1952), states that
‘...our task is not to try to maintain function, in scope, degree and
direction as it had been prior to the mutilation, but rather to preserve
what remains of the oral mechanism’.
 It is widely accepted that with the loss of natural teeth the
remaining alveolar ridge resorbs. Although there is individual
variation on the rate of resorption, certain local factors may enhance
or slow its rate. Apart from the factors such as occlusion, interocclusal
distance and centric relation coinciding with the centric occlusion, the
type of impression technique plays an important role in the overall
health of the soft and hard tissues. For example, application of
pressure in the impression technique will reflect as pressure in the
denture base and will result in increased rate of resorption and soft
tissue damage.
Retention
It is defined as ‘that quality inherent in the dental prosthesis acting to resist
the forces of dislodgement along the path of placement’. (GPT 8th Ed)
Retention can also be defined as the ability of the prosthesis to
withstand displacement against its path of opening.
Factors Affecting Retention
(i) Biological factors

• Anatomical factors

• Physiological factors

• Muscular factors
(ii) Mechanical factors

(iii) Physical factors

(iv) Psychological factors

(v) Surgical factors

Biological factors

Anatomical factors
Size of denture-bearing area: Retention increases with an increase of
denture-bearing area. More is the denture-bearing area, more is the
surface area available and, therefore, more is the retention. Size of the
maxillary denture-bearing area is 22.96 cm2, whereas the size of
mandibular denture area is 12.25 cm2; therefore, maxillary dentures
have more retention than the mandibular dentures.
Quality of denture-bearing area: Firm, keratinized tissues provide best
support and do not move easily and, therefore, provide maximum
retention in comparison to tissues that get easily displaced during
function.

Physiological factors
Quantity and quality of saliva: Quality of the saliva determines
retention. Thick and ropy saliva gets accumulated between the
tissue surfaces of the denture and the mucosa leading to loss of
retention. Likewise, thin and watery saliva also leads to reduced
retention.

Condition of mucosa and submucosa: Maximum coverage without undue

displacement of the tissues during impression making determines
retention in the complete denture.

Neuromuscular control: It refers to the functional forces exerted by the

musculature of the patient that can affect retention. This is primarily
a learned biological phenomenon. Individuals appear to differ in
their ability to develop the motor coordination and coordinated
reflexes necessary to manipulate dentures.

Ridge characteristics: An ideal ridge is parallel or nearly parallel with

adequate vertical height and flat crest. This type of ridge provides
maximum amount of support and stability and retention.

Ridge relationship: There should be an adequate inter-ridge distance

between the upper and the lower ridges. Excessive inter-ridge
distance results in poor stability and retention because of the
increased leverage. A small inter-ridge distance will lead to
difficulty in arranging the teeth and maintaining a proper freeway
space.

Muscular factors
Orofacial muscles provide supplementary retentive force, if the
following are noticed:

• Teeth are arranged in neutral zone between the cheeks and the
tongue.

• Polished surfaces of the dentures are properly shaped.

• Base of the tongue serves as an emergency retentive force (Fig. 4-1).

• Occlusal plane should be at the correct level.

• Denture bases should be extended over the maximum area possible.

• Muscle control and patient tolerance often play a vital role in

retention of the complete denture prosthesis. It is the muscle control
that enables the patient to function with dentures which rest on the
basal tissues that have undergone the resorptive changes.

FIGURE 4-1 Base of the tongue acts on emergency retentive

force.

Mechanical factors
Undercuts: Mild undercuts help in providing retention. Also, unilateral
undercuts may aid in retention but severe bilateral undercuts will
mostly require surgical intervention before denture fabrication.

Retentive springs: Mode of retention which is not in use currently.

Magnets: Intramucosal magnets aid in improving the retention of

highly resorbed ridges.

Denture adhesives: These are nontoxic soluble materials, which are

supplied as powder, cream or liquid and are applied to the tissue
side of the denture to improve denture retention and stability.

Suction chambers: These were used in practice in the past to aid in

retention of the maxillary denture. These act by creating negative
pressure and increasing retention. These have the potential to create
palatal hyperplasia and even palatal perforation in extreme cases.

Contour of denture base: The polished surface of the denture base

should be properly placed. Proper contour and design of the
polished surface should harmonize with the function of the tongue,
lips and cheeks to effect seating of the denture.

Parallel buccal and lingual walls: These provide significant retention by

increasing the surface area between the denture base and mucosa.
This enhances the retention by increasing the interfacial surface
tension and atmospheric forces.

Physical factors (fig. 4-2)

Adhesion: It is defined as ‘the physical attraction of unlike molecules to
one another’. Adhesion of saliva to the mucous membrane and the
denture base is achieved through ionic forces between charged
salivary glycoproteins and surface epithelium or acrylic resin. A
thin film of saliva formed between the denture and the tissue
surface helps to hold the denture to the mucosa. Retention by
 adhesion is proportional to the amount of denture-bearing area.

Cohesion: It is the physical attraction of like molecules to each other.

This occurs between the denture base and the mucosa and works to
maintain the integrity of the interposed fluid. Watery serous saliva
can form thinner film and is more cohesive than the thick mucus
saliva.

Interfacial surface tension: It is the resistance to separation of two

parallel surfaces that is imparted by a film of saliva between them.
The thin film of saliva tends to resist the displacing force which
tends to separate the denture from the tissues.

Atmospheric pressure: It acts to resist the dislodging forces applied to

the dentures, provided they have effective peripheral seal. This
peripheral seal prevents the entry of air between the denture
surface and the soft tissue. When displacing forces act on the
denture, a partial vacuum is produced between the denture and the
soft tissues, which aids in retention. Retention due to atmospheric
pressure is directly proportional to the area covered by the denture
base. Atmospheric pressure is also referred to as emergency retentive
force or temporary restraining force.

Capillarity action: When there is a close adaptation between the

denture and the mucosa, thin film of saliva tends to flow and
increase its surface contact thereby increasing the retention.

Gravity: When a person is in upright posture, gravity acts as a

retentive force for the mandibular denture and a displasive force for
the maxillary denture.
 FIGURE 4-2 Thin film of saliva between the denture base
and the tissue surface aids in retention by adhesion,
cohesion, interfacial surface tension and atmospheric
pressure.

Psychological factors
• Intelligence

• Expectation

• Apprehension or fear of embarrassment

• Gagging

Surgical factors
Implant dentures: Retention is definitely enhanced in implant-retained
prosthesis.

Ridge extension: It increases retention by increasing the surface area.

E.W. Fish (1948) gave three principal factors that affect the retention
of complete dentures, which are as follows:

(i) Denture-bearing surface

(ii) A balanced harmonious occlusion

(iii) Properly formed polished surface

S. Friedman (1957) advocated three basic goals for achieving

retention, which are as follows:

(i) Maximal coverage without undue displacement of tissues

(ii) Development of good border seal

(iii) Adequate provision for resistance areas

Stability
Definition
It is defined as ‘the quality of a denture to be firm, steady or constant, to
resist displacement by functional horizontal or rotational stresses’.
It is the resistance to horizontal or rotational forces. Stability ensures
physiological comfort to the patient, whereas retention contributes to
psychological comfort.
Factors affecting stability can be categorized as biological, mechanical
and physical factors.

(i) Biological factors:

• Residual ridge anatomy

• Residual ridge relationships

• Nature of soft tissues covering the ridges

• Importance of modiolus and associated structures

• Mandibular lingual flange

• Influence of orofacial musculature.

• Neuromuscular control and education of the patient

(ii) Mechanical factors:

• Tooth position and teeth arrangement

• Relationship of the polished surfaces of the denture
base to the surrounding orofacial musculature

• Relationship of opposing occlusal surfaces

• Occlusal plane

• Contour of polished surface of denture

(iii) Physical factors:

• Quality of impression

• Occlusal rims

• Base adaptation

Biological factors

Residual ridge anatomy

The development of stability is limited by the anatomical variations of
the patient that determines the residual ridge height and
conformation.
Large, square and broad ridges offer a greater resistance to the lateral
forces than small, narrow and tapered ridges.

Vertical ridge height. 

The residual ridges with sufficient vertical height provide better
stability than the resorbed ridges.

Arch form. 
Square or tapered arches tend to resist rotation of the prosthesis better
than the ovoid arches.

Palatal vault. 
The shape of the palatal vault also contributes to the stability of the
prosthesis.
A broad, flat palatal vault may enhance the stability by providing a
greater surface area of contact and long inclines approaching a right
angle to the direction of the force. The V-shaped palate provides least
vertical support and retention.

Residual ridge relationships

Normal dental relationships of the artificial teeth set on ridges
enhance the stability of the denture.
Stability in prognathic and retrognathic patients is compromised
because of offset ridge relations.

Nature of soft tissues covering the ridges

The presence of keratinized, firmly bound mucosa to the residual ridge
permits the tissues to resist stress favourably and enhance stability.
Hyperplastic or flabby tissues with excessive submucosa provide poor
stability.

Importance of modiolus and associated structures

• Modiolus or tendinous node is an anatomical landmark near the corner

of the mouth. It is formed by the intersection of several muscles of
the cheeks and lips (Fig. 4-3).

• A total of eight muscles form the modiolus. These are zygomaticus,

quadratus labii superioris, quadratus labii inferioris, caninus,
triangularis, risorius, buccinator and mentalis.

• The denture base must be contoured to permit the modiolus to

function freely as one muscle can influence all the other muscles.
• The superior fibres of the buccinator act to seat the denture, the
middle fibres control the bolus of the food and the inferior fibres
contribute to the mandibular denture stability.

FIGURE 4-3 Muscles comprising modiolus.

Mandibular lingual flange

The lingual slope of the mandible approaches 90° to the occlusal plane
which enables it to effectively resist horizontal forces and provide
stability.
The lingual flange of the lower denture should incline medially to
allow for contraction of the mylohyoid muscle which lies beneath the
mucosa covering the lingual slope of residual ridge.

Influence of orofacial musculature

• The orofacial musculature plays an important role in enhancing the
stability of the denture.

• The basic geometric design of denture bases should be triangular. In

the frontal section, the upper and lower dentures should appear as
two triangles whose apexes correspond to the occlusal surface (Fig.
4-4).

• The maxillary buccal flange should incline laterally and superiorly.

The mandibular buccal flange should incline laterally and inferiorly,
and the lingual flange should incline medially and inferiorly. Such
inclinations provide favourable vertical component to any
horizontally directed forces.

• The tongue should rest against a lingual flange inclined medially

away from the mandible and somewhat concave to direct the
seating action on the mandibular denture.
 FIGURE 4-4 Basic denture design of upper and lower
dentures.

Neuromuscular control and education of the

patient
• The tongue plays an important role in the neuromuscular control. In
a completely edentulous patient, all the periodontal receptors are
lost and the sensory stimuli from the oral mucosa are used to learn a
new act with the dentures.

• Tongue works primarily by the touch and pressure system in

contrast to skeletal muscle which function by kinaesthesis.

• Normal tongue position enhances the stability of the dentures, as it

completely fills the floor of the mouth. Its lateral borders rest over
 the ridge, whereas its tip or apex rests on or just lingual to the lower
anterior ridge.

• Patient education regarding denture use and maintenance is

important for the stability of dentures.

Mechanical factors

Tooth position and teeth arrangement

• Anterior and posterior teeth should be arranged as close as possible
to the position once occupied by the natural teeth.

• The teeth in the denture should be arranged in the neutral zone or in

the zone of minimal conflict.

• Neutral zone is defined as ‘the potential space between the lips and
cheeks on one side and the tongue on the other side’.

Or

• ‘That area or position where the forces between the tongue and
cheeks or lips are equal’.

• Natural or artificial teeth in this zone are subjected

to equal and opposite forces from the surrounding
musculatures (Fig. 4-5).
 FIGURE 4-5 Teeth arranged in neutral zone.

Relationship of the polished surfaces of the

denture base to the surrounding orofacial
musculature
• Action of the musculature on the denture base generally results in
lateral and vertical dislodging forces. Such muscles should be
identified and their actions should be permitted without any
interference.

• The denture border must be extended to contact the movable

tissues. Optimal extension enhances the denture stability.

• The external surface should be developed to harmonize with the

associated functioning musculature of the tongue, lips and cheeks.

• E.W. Fish (1933) believed that the contours of the polished surface
provide the principal factor governing the complete denture
 stability.

Relationship of opposing occlusal surfaces

• Harmony between the opposing occlusal surfaces contributes to
denture stability.

• The dentures should be free of any interference within the

functional range of movement of the patient, regardless of the type
of posterior teeth form used.

• Balanced occlusion enhances the denture’s stability.

Occlusal plane
• The occlusal plane should be oriented parallel to the residual ridge.
If the occlusal plane is inclined, then the sliding forces may act on
the denture and reduce its stability.

• If the occlusal plane is tipped, then there will be a shunting effect and
loss of stability.

• If the mandibular occlusal plane is too high, then it can result in

reduced stability.

• Raised occlusal plane prevents the tongue from reaching over the
food table into the vestibule. This compromises the stability of the
denture.

Contour of polished surface of denture

• The polished surface of the denture should be in harmony with the
oral structures.

• These should not interfere with the action of the oral musculature.
• The proper contour of the denture flanges permits the horizontally
directed forces that occur during contraction of muscles to be
transmitted as vertical forces tending to seat the prosthesis.

Physical factors

Quality of impression
• Impression should be accurate and should duplicate all the details of
the tissues.

• Impression should not distort upon removal and should be

dimensionally stable. The cast should be poured as soon as possible.

Occlusal rims
• The occlusal rims should be parallel to the ridge. The occlusal plane
should equally divide the interarch space.

• If the occlusal plane is inclined, then the sliding forces may

destabilize the dentures.

Base adaptation
Stable denture bases enhance the stability of the dentures.
Support
Definition
Support is defined as ‘the resistance to vertical forces of mastication,
occlusal forces and other forces applied in a direction towards the denture-
bearing areas’.
It counteracts the forces directed towards the ridge at right angles to
the occlusal forces. It involves the relationship between the intaglio
surface of the denture base and the underlying tissue surface under
varying degrees and types of function so as to maintain an established
occlusal relationship and to promote optimal function with minimum
tissue-ward movement and base settling.
Types of Support
(i) Initial denture support: This support is achieved by impression
procedures that provide optimal extension and functional loading
of the supporting structures.

(ii) Long-term support: This support is achieved by directing the

occlusal forces towards the tissues resistant to remodelling and
resorptive changes.

Factors responsible for effective support of the

prosthesis
• Denture is extended to cover the maximal surface area without
impinging on movable tissues.

• Tissues capable of resisting resorption are selectively loaded.

• The tissues capable of resisting vertical displacement are allowed to

make firm contact with the denture base during function.
• Compensation is made for varying tissue resiliency to provide
uniform denture base movement under function.

• Soft tissues, firmly bound to the underlying cortical bone and

covered by the keratinized mucosa, minimize the base movement,
decrease the soft tissue trauma and reduce the long-term resorptive
changes.

Snowshoe Principle
This principle is based on maximal extension of the denture to make a
positive contact with the soft, yielding peripheral tissues as limited by
muscle function or bony anatomical structures.
It states that under given constant occlusal force, a broader
denture-bearing area decreases the stress per unit area under the
denture base, thereby decreasing the tissue displacement and
reducing the denture base movement.
Maximal border extension during impression procedure is,
therefore, essential in providing adequate denture support (Fig. 4-6).

FIGURE 4-6 Snowshoe principle.

Impression techniques
Impression techniques can be classified on the following basis:

(i) On the basis of pressure used during impression making:

• Mucocompressive technique

• Mucostatic technique

• Selective pressure technique

(ii) On the basis of tray selection:

• Stock tray impression

• Custom tray impression

(iii) On the basis of type of impression:

• Diagnostic impression

• Primary impression

• Secondary impression
(iv) On the basis of material used:

• Reversible or irreversible hydrocolloids

• Impression compound

• Impression plaster

• Impression waxes

• Silicone impression
(v) On the basis of mouth opening:

• Open mouth technique

• Closed mouth technique

(vi) On the basis of hand-manipulated functional movements:

• Dynamic functional movements

• Passive functional movements

Mucostatic impression technique

• This technique was first proposed by J.A. Richardson and later
popularized by Henry Page.

• Failures in pressure technique lead to the popularization of

nonpressure techniques.

• Supporters of this technique describe interfacial surface tension as

the only significant way of retaining complete dentures.

• Impression should, therefore, cover only the area of the oral cavity,
where the mucous membrane is firmly attached to the underlying
 bony structure.

• The main point of the mucostatic principle was concerned with

Pascal’s law which states that pressure applied on a confined liquid
will be transmitted throughout the liquid in all directions.

• According to this concept, mucosa being more than 80% water will
react as liquid in a closed vessel. However, this is not true as the
tissue fluids can escape under the border of the denture. Also, the
mucosa is not a closed vessel.

• Impression is made with an oversized tray with oral mucosa and

jaws in a normal and relaxed manner.

• It requires minimal pressure to be applied to the oral tissues during

seating of the impression tray and set of the impression material
and requires a material of high fluidity.

• This technique seeks to eliminate all distortion of the oral tissues

and thus create a denture base that models the unloaded tissues.

• Retention is entirely dependent on surface forces of adhesion,

cohesion and interfacial surface tension.

• For this, thin film of saliva is necessary.

• Border moulding is not done in this technique.

• Impression material of choice is impression plaster.

• It results in denture which is closely adapted to the mucosa of the

denture-bearing area but has poor peripheral seal.

• Tissue health and denture retention is compromised.

Mucocompressive impression technique

• This technique was popularized by Carole Jones. It records the
tissues in a functional and displaced form. The materials used for
this technique are impression compound, waxes and soft liners. It
appeared logical to make impression that would press the tissues in
the same manner as chewing forces.

• G. Tryde, K. Olsson, S.A. Jenson, R. Cantor, J.J. Tarsetano and N.

Brill (1965) advocated closed mouth technique so that the patient
could exert his/her own masticatory force during impression
making.

• Proponents of this technique presume that the occlusal loading

during impression making is comparable with the occlusal loading
during function.

• The oral soft tissues are resilient in nature.

• As the tissues are recorded with pressure method in this technique,

the soft tissues tend to rebound as soon as the forces are relieved.

• Dentures made by this technique tend to get displaced due to tissue

rebound at rest.

• Due to continuous pressure on the tissues during function, there is

compromised blood supply to the tissues leading to increased ridge
resorption.

Disadvantages
• Dentures made from such impressions did not fit well at rest.

• Due to continuous pressure, the tissue will undergo resorption.

• Closed mouth technique does not permit border moulding.

Selective pressure technique

• This technique was advocated by C.O. Bouchers and combines the
principles of pressure and minimal pressure techniques.

• The philosophy of this technique is that certain areas of the maxilla

and the mandible are by nature better adapted for withstanding the
additional forces of mastication.

• Here, the impression is extended over as much denture-bearing

areas as possible without interfering with the limiting structures at
function and rest.

• This is achieved by the design of the custom tray in which the

nonstress-bearing areas are recorded in a state of rest, whereas the
stress-bearing areas are recorded under pressure.

• Relief is given using wax in the custom tray, which should be

removed before making the final impression.

• The relief wax is applied on the primary cast before custom tray
fabrication.

• In this way, pressure is being directly applied to the primary stress-

bearing areas which are biologically and biomechanically more
capable of supporting and distributing the loads.

• This technique seeks to create a denture base that selectively loads

the oral tissues during functioning of the prosthesis, thereby
optimizing the stability and retention of the prosthesis.

• Opponents of this technique are of the opinion that it is impossible

to record certain areas with different pressure from that applied to
the other area.
Biological consideration in maxillary
impressions
The foundation for dentures is made up of bones covered by the
mucous membranes (mucosa and submucosa).

• Mucosa can be of three types, namely, masticatory, lining and

specialized mucosa depending on the location in the oral cavity.

• The submucosa varies in thickness and consistency and is

responsible for supporting the denture. When thin, it gets easily
traumatized and when loosely attached, it gets inflamed or
edematous.

• Ultimate support for the maxillary denture is the bone of two

maxillae and the palatine bone.

• The anatomical landmarks in maxilla are as follows (Fig. 4-7):

FIGURE 4-7 Anatomic landmarks of maxillary arch.

Supporting Structures
(i) Primary stress-bearing areas:

• Hard palate

• Posterolateral slopes of residual alveolar ridge

(ii) Secondary stress-bearing areas:

• Rugae

• Maxillary tuberosity, alveolar tubercle

Hard palate
The cortical bone in the hard palate, composed of the palatine processes
of the maxillae and the horizontal processes of the palatine bones, has been
shown to resist resorptive changes.

• A cross-section of the hard palate shows that it is covered by tissues

of varying depths.

• Therefore, it is important to employ an impression technique that

equalizes the pressure distribution.

• The submucosa in the mid-palatine suture is extremely thin and,

therefore, relief should be provided in the part of the denture
covering area.

• The horizontal portion of the hard palate lateral to the midline acts
as the primary stress-bearing area, as it resists resorption and is
covered by keratinized mucosa. The trabecular pattern in the bone
is perpendicular to the direction of force, making it capable of
 withstanding any amount of force without marked resorption.

Residual ridge
• It is defined as ‘the portion of the alveolar ridge and its soft tissue
covering which remains following the removal of teeth’. (GPT 8th Ed)

• It resorbs rapidly following extractions and continues at reduced

rate throughout life.

• The submucosa over the ridge has adequate resiliency to support the
denture.

• The crest of the ridge may act as a secondary stress-bearing area.

• The posterolateral portion of the residual ridge is a primary stress-

bearing area.

• The remaining facial slopes of the maxillary residual ridge are not
essential in denture support.

Rugae
• These are the thick fibrous bands of tissues located in the anterior
segment of the palate.

• The rugae area acts as the secondary stress-bearing area because it is

set at an angle to the occlusion plane of the residual ridges and is
rather thinly covered by the soft tissues.

• Also, the rugae resist anterior displacement of the denture.

• Folds of the mucosa play an important role in speech.

Maxillary tuberosity
It is the bulbous extension of the residual ridge in the second and
third molar regions.

• It terminates at the hamular notch.

• The rough prominence behind the position of the last tooth is the
alveolar tubercle.

• It is considered as the secondary supporting structure.

• The posterior part of the ridge and the tuberosity are considered as
one of the most important areas of support, as these are least likely
to resorb.

Alveolar tubercle
The medial and lateral wall resists horizontal and torquing forces,
whereas the lateral wall resists the anterior movement of the denture.

Limiting structures
Labial frenum: It is a fold of mucous membrane at the median line. It is a
passive frenum, as it contains no muscle. This frenum is fan-shaped
and it converges as it inserts onto the labial aspect of the ridge. The
labial notch in the denture should not only be narrow but also be
wide enough to accommodate the labial frenum without
interference.

Labial vestibule: It extends from the buccal frenum on one side to the
other and is divided into two compartments by the labial frenum. It
is covered by the lining mucosa. This space is easily distorted
because of the presence of submucosa and, therefore, should be
completely filled to provide retention.

Orbicularis oris: It is the main muscle lying in this region. Its tone
depends on the support received from the thickness of the labial
flange and positioning of the artificial teeth. Because its fibres run
horizontally and anastomoses with fibres of buccinator, it has an
 indirect effect on the extent of the denture base.

Buccal frenum: It lies between the labial and the buccal vestibule. It
requires more clearance than the labial frenum and the buccal notch
should be broad enough to allow its movement. Three muscles are
associated with it, namely, orbicularis oris (pulls the frenum
forward), caninus or levator anguli oris (attaches beneath the frenum
and affects its position) and buccinator (pulls it backward).

The borders of the denture should be moulded in

such a way that the depth and width of the frenum
are exactly recorded (Fig. 4-8).
Buccal vestibule: It extends from the buccal frenum anteriorly to
hamular notch or pterygomaxillary notch posteriorly. The size of
the vestibule is controlled by the following:

• The contraction of the buccinator muscle

• Position of the mandible

• The malar process of zygomatic arch

• Amount of bone lost from the maxilla

The ramus and coronoid process of the mandible and

the masseter determine the width of the buccal
vestibule. The lateral movement of the mandible alters
the shape and size of the posterior part of the
vestibule. The distal end of the flange of the
denture should be adjusted so as to avoid
 interference to the coronoid process during
function.

The distobuccal border is influenced by the masseter

muscle which acts outside the buccinator muscle
during contraction and by the coronoid process
during lateral movements.
Hamular notch: It is situated distally to the tuberosity of the maxilla
and mesially to the hamulus of the medial pterygoid plate. It serves
as an anatomic guide for the distal extension of the impression in
this area.

The denture border should extend to the hamular

notch beyond tuberosity. The posterior palatal seal
(PPS) should extend through the centre of the deep
part of the hamular notch as it does not contain any
muscle attachments (Fig. 4-8). They are always
located in the soft plate and guide the location of
the posterior border of the denture.
FIGURE 4-8 Location of labial vestibule, buccal frenum and
buccal vestibule.
Relief areas
Relief areas are divided into three categories which are as follows:

(i) Tissues susceptible to resorption should not be loaded (e.g. some

maxillary and most mandibular ridge crests)

(ii) Areas that have thin mucosa over hard cortical bone (e.g. mid-
palatine raphe, tori, exostosis and lingual surface of mandible)

(iii) Areas of mucosa overlying neurovascular bundles (e.g. incisive

papilla, in some cases mental foramen)

Incisive papilla
• It is a pad of fibrous connective tissues overlying the orifice of the
nasopalatine canal.

• It is located on the line immediately behind and between the central

incisors.

• It covers incisive foramen carrying the nasopalatine nerves and

vessels.

• It may lie on the crest of the alveolar ridge and its position can vary.

• It should be relieved in every denture.

• Position of the papilla indicates the amount of bone loss (Fig. 4-7).

Mid-palatine raphe
• It extends from the incisive papilla to the distal end of the hard
palate.
• The mucosa is thin and unyielding.

• The underlying bony union is very dense.

• It is here that the palatal torus, if present, is located.

• It should be relieved to avoid tissue impingement between the

denture base and bone (Fig. 4-7).

Fovea palatini
• These are formed by coalescence of mucous glands and are located near
the midline of the palate.

• These are usually two in number and are present one on each side of
the midline, slightly posterior to the junction of the hard palate and
the soft palate.

• These are always located in the soft palate and guide the location of
the posterior border of the denture (Fig. 4-7).
Postpalatal seal
It is defined as ‘the seal area at the posterior border of a maxillary removable
dental prosthesis’.
Postpalatal seal area is defined as ‘the soft tissues area at or beyond the
junction of the hard and soft palates on which pressure, within physiological
limits, can be applied by a complete denture to aid in its retention’.
It lies in the area of the soft palate and provides the peripheral seal
to the denture. The seal prevents air between the denture and the
tissues and helps in resisting the horizontal and torquing forces.
The histological content of this area consists of a thick submucosa,
containing glandular tissues, which allows displacement of the tissues
without impairment.
Functions of PPS
• Aids in retention

• Reduces gag reflex

• Reduces food accumulation between the posterior aspects of the

denture

• Reduces patient discomfort

• Compensates for polymerization shrinkage

PPS can be divided into two separate areas on the basis of

anatomical boundaries, which are as follows:

(i) Postpalatal seal: This extends medially from one tuberosity to

another.

(ii) Pterygomaxillary seal: This extends laterally from one hamular

notch to another and 3–4 mm anterolaterally approximating the
mucogingival junction.
 The PPS lies between the anterior and posterior vibrating lines (Fig.
4-9).

FIGURE 4-9 Posterior palatal seal.

Anterior vibrating line

It is an imaginary line located at the junction of the attached tissues
overlying the hard palate and the movable tissues of the immediately
adjacent soft palate. The anterior vibrating line is cupid bow shaped
due to the projection of the posterior nasal spine.

Methods to locate anterior vibrating line

The Valsalva manoeuvre: In this method, both the nostrils of the patient
are held firmly and the patient is asked to gently blow through the
nose. This positions the soft palate inferiorly at its junction with the
hard palate.
Visualization method: This can also be located by asking the patient to
say ‘ah’ in a short vigorous burst and visualizing the area.

Posterior vibrating line

This is an imaginary line at the junction of the aponeurosis of the
tensor veli palatine muscle and the muscular portion of the soft palate.
Posterior vibration line is visualized by asking the patient to say ‘ah’
in a short burst in normal, unexaggerated fashion. It marks the distal
most extension of the denture base.
Techniques to Record PPS
(i) Conventional approach

(ii) Fluid wax technique

(iii) Arbitrary scraping of master cast

Conventional approach
• ‘T’ burnisher is used to locate the hamular notch.

• An indelible pencil is used to extend a line from hamular notch on

one side to the other.

• The patient is instructed to say ‘ah’ in short burst.

• The mark is placed at the junction of movable and nonmovable soft

palate.

• This mark is transferred to master cast.

• The cast is scraped to a depth of 1–1.5 mm in resilient areas and 0.5–

1 mm in less resilient area.

• The scraping should taper progressively.

Fluid wax technique
• The procedure followed is similar as described above, except that
special waxes, such as Iowa wax or Korecta wax, are used.

• After secondary impression, these fluid waxes are applied in the

posterior seal region.

• Various head and tongue movements are made to record posterior

palatal seal.

Arbitrary scraping of master cast

• It is the least accurate method and should not be followed.

• Cast is arbitrarily scraped by the dentist.

Biological considerations in
mandibular impressions
The available denture-bearing area for the edentulous mandible is
only 14 cm2, whereas that of the maxilla is around 24 cm2.
The basal seat of the mandible is different from the maxilla in terms
of size and form.
The anatomical landmarks in mandible can be studied as follows
(Fig. 4-10):

FIGURE 4-10 Anatomic landmarks of the mandibular arch.

Supporting Structures
(i) Primary stress-bearing area

• Buccal shelf area

• Pear-shaped pad
(ii) Secondary stress-bearing area

• Residual alveolar ridge

Buccal shelf area

• It extends between the mandibular buccal frenum and the anterior
border of the masseter muscle (Figs 4-10 and 4-11).

• Its boundaries are as follows:

• Medially by the crest of residual ridge

• Anteriorly by the buccal frenum

• Laterally by the external oblique ridge

• Distally by the retromolar pad

• It is covered by a layer of cortical bone and lies at right angles to the
vertical occlusal forces

• It is covered by mucosa with submucosal layer containing

buccinator fibres and glandular fibres.

• Buccinator fibres run along the buccal shelf in anteroposterior

direction and portion of the denture base lies directly on the muscle
without displacement.

• Width of the buccal shelf area:

• 4–6 mm
• 2–3 mm (in case of narrow mandible)
• As it lies at right angles to the occlusal forces, it serves as primary
stress-bearing area.

FIGURE 4-11 Location of buccal shelf region.

Pear-shaped pad
• It is the distal most extent of keratinized masticatory mucosa of the
mandibular ridge.

• It is formed by scarring pattern after third molar extraction.

• The term was coined by F.W. Craddock.

• The retromolar pad lies distally to the pear-shaped pad.

• Distal border of the mandibular impression should extend to the

junction of retromolar pad and pear-shaped pad.

• Buccinator, superior constrictor and temporal muscles are attached

to it.

• Muscle attachment and overlying keratinized mucosa provide

stress-bearing region that is relatively resistant to resorption.

• It is considered as the primary stress-bearing area (T.R. Jacobson

and A.J. Kroll).

Residual alveolar ridge

• The crest of the ridge is covered by fibrous connective tissue.

• The underlying bone is mostly cancellous without any muscle

attachments.

• The submucosa, if loosely attached, makes the soft tissue movable,

thereby making the denture construction difficult; however, if
firmly attached it provides good support.

• Ridge crests are considered as secondary support areas (Fig. 4-10).

Limiting structures

Labial frenum
• It contains a band of fibrous connective tissue which attaches the
orbicularis oris muscle (Fig. 4-12).
• Frenum is active and quite sensitive.

• It should be carefully relieved to avoid soreness and provide

adequate seal.

FIGURE 4-12 Location of labial and buccal vestibule.

Labial vestibule
• This extends from the labial frenum to the buccal frenum on each
side (Fig. 4-12).

• Related muscles are orbicularis oris and mentalis.

• The depth of the flange is determined by the mucolabial fold.

• The extent of the flange in this area is limited because the muscles
are inserted close to the ridge crest.

• If the flange is thick and the mouth is wide opened, the orbicularis
oris narrows the sulcus which in turn displaces the denture.
Buccal frenum
• It is a fold or folds of mucous membrane extending from the buccal
mucosa to the slope or the crest of the residual ridge (Fig. 4-12).

• It may be single or double, broad U-shaped or sharp V-shaped.

• It overlies the depressor anguli oris.

• Relief must be provided in the denture base to avoid dislodgement

of the denture.

Buccal vestibule
• It extends from the buccal frenum to the retromolar pad area (Fig. 4-
12).

• It is bounded by the residual alveolar ridge on one side and the

buccinator muscle on the other.

• The extent of the vestibule is influenced by the buccinator muscle

and the distobuccal border at the end of the buccal vestibule is
influenced by the action of masseter on the buccinator.

• Buccinator muscle extends from the modiolus to the

pterygomandibular raphe and attaches to the buccal shelf region.

• Because its fibres run horizontally, it has seating effect on the

denture Fig. 4.3.

• Contraction of the masseter alters the shape and size of the

distobuccal end of the lower buccal vestibule.

• Masseter pull is recorded by asking the patient to exert the closing

force, in which the operator applies the force in opposite direction.
Lingual frenum
• It is a fibrous band of tissue that overlies the centre of the
genioglossus muscle (Fig. 4-12).

• It is an extremely resistant and active frenum.

• It is usually a narrow single band of tissue but may be broad.

• Relief is needed in this area of the impression as well as in the

finished denture because inadequate clearance may result in pain or
displacement of the denture.

• A high lingual frenum is called a tongue-tie and should be

corrected, as it affects the stability of the denture.

Alveololingual sulcus
• It is the space between the residual ridge and the tongue and
extends from the lingual frenum to the retromylohyoid curtain (Fig.
4-13).
 FIGURE 4-13 Alveololingual sulcus.

• It is divided into the following three areas:

(i) Anterior vestibule referred to as the sublingual

crescent area or the anterior lingual fold

(ii) Middle vestibule referred to as the mylohyoid area

(iii) Posterior vestibule or the distolingual sulcus

Anterior region
• It extends from the lingual frenum to the premylohyoid fossa, where the
mylohyoid ridge curves below the sulcus.
• Length and width of the border are important in maintaining the
seal of the lower denture.

• Position of the tongue is important in maintaining this seal.

• It is influenced indirectly by the mylohyoid muscle.

• The lingual border of the impression in the anterior region should

extend down to make contact with the mucosa of the floor of the
mouth when the tip of tongue touches the upper anteriors.

• The anterior lingual flange will be shorter than the posterior lingual
flange.

Middle region
• It extends from the premylohyoid fossa to the distal end of mylohyoid
ridge, curving medially from the body of the mandible.

• This curvature is caused by the prominence of the mylohyoid ridge

and the action of the mylohyoid muscle.

• The length and width of the flange are determined by the

membranous attachment of the tongue to the mylohyoid ridge.

• The lingual borders are formed when the mylohyoid muscle is

functional.

• The middle of lingual flange should slope medially towards the

tongue, which helps in three ways as follows:

• The tongue rests over the flange, thereby stabilizing

the denture.

• This provides space for raising the floor of the

 mouth without displacing the denture.

• The peripheral seal is maintained during the

function.

Posterior region
• This is the distolingual vestibule, also referred to as lateral throat form
or retromylohyoid fossa.

• Posterior lingual flange usually extends more inferiorly than the

anterior lingual flange.

• The border of the lingual flange in this region assumes the typical ‘S’
shape because of the projection of mylohyoid ridge towards the
tongue and the existence of retromylohyoid fossa at the distal end
of the sulcus.

• The distal end of the lingual flange is called the retromylohyoid

eminence and its contour lies below the level of retromolar pad.

Retromolar pad
• It is an important structure which forms the posterior seal of the
mandibular denture (Fig. 4-10).

• The denture should include the retromolar region.

• It aids in stability by adding another plane to resist the movement of

the denture base.

• It is a triangular soft pad of tissue at the distal end of lower ridge.

• It consists of pterygomandibular raphe, fibres of superior constrictor

and buccinator muscle, fibres of temporalis tendon and some
glandular tissues.
Relief areas
Mylohyoid ridge
• It extends along the lingual surface of the mandible.

• Anteriorly, the ridge lies close to the inferior border of the mandible,
whereas posteriorly it flushes with the superior surface of the
residual ridge.

• Thin mucosa over the ridge should be relieved to avoid trauma.

• The lingual flange should be properly shaped and extended during

the impression making to ensure proper border seal.

Mental foramen
• It lies between the first and second premolar region.

• Severe resorption of the bone may result in mental foramen lying at

the crest of the ridge.

• Relief should be provided to avoid paraesthesia of the lip.

Torus mandibularis
• It is a bony prominence usually found at the first and second
premolar region.

• It is covered by a thin mucosa and should be relieved to avoid

soreness of denture.

• It is surgically removed if large and interferes with the denture

retention and stability.
Primary impression
Definition
Primary or preliminary impression is defined as ‘a negative likeness
made for the purpose of diagnosis, treatment planning or the fabrication of a
tray’.
This is the first step in fabricating complete denture prosthesis for a
patient.
For this purpose, an impression tray is used.
Impression tray: It is defined as ‘a device that is used to carry, confine
and control impression material while making an impression’ or ‘a receptacle
into which suitable impression material is placed to make a negative likeness’.
Classification (Lavere and Treda [1976])
Impression trays are of two types: (i) stock trays and (ii) custom trays

(i) Stock trays are further classified as follows:

Type A: Disposable and nondisposable

Type B: Metallic and nonmetallic

Type C: Perforated and nonperforated

• Rim lock trays: Thickened flange edges for

mechanical retention.

Rim lock trays can be of two types on the basis of type

of dental arch:

(a) Edentulous
(b) Dentulous
(ii) Custom trays are also called special trays or final impression trays or
individualized trays.

Ideal requirement of impression trays

• Tray should be rigid.

• It should be dimensionally stable.

• It should be smooth to avoid injury to mucosa.

• It should provide uniform space for impression material.

• It should not distort the vestibular area.

Points to consider during tray selection

• Stock tray should have 5–6 mm of space between the ridge and the
tray.

• Tray is placed in mouth by centring the labial notch of the tray over
the labial frenum.

• Once the tray is anteriorly positioned, it is observed posteriorly for

extension.

• A slightly oversized tray is always selected.

• The tray should not be too large or too small.

Functions of the tray

• To support the impression material in planned contact with oral
tissues
• To allow the placement of additional stress in selected regions of the
residual ridge while recording other regions in an undisplaced state

• To support the impression material when removed from the mouth

so that a cast can be poured

Principles of Impression Making

• Impression should extend to cover all the basal seat area.

• Borders should be in harmony with the anatomical and

physiological limitations of oral tissues.

• Border moulding should be performed.

• Selective pressure should be applied on the basal seat during

impression making.

• Proper space should be provided for the impression material.

• Guiding mechanism should be provided for correct positioning of

the tray.

• Tray and final impression should be made of dimensionally stable

material.

• External shape of the final impression should match the external

surface of denture.

• Oral tissues should be in healthy state.

• Impression when removed from the mouth should not damage the
soft tissues.

• Sufficient space should be available for the impression material in

the impression tray.
Primary cast
Primary cast is defined as ‘a positive likeness of a part or parts of the oral
cavity for the purpose of diagnosis and treatment planning’.

Requirements of a primary cast

• The surface should be smooth, dense and free of voids.

• It should cover all the area which provides denture support.

• Wall of the cast should be parallel or diverging outwards but should

never be converging inwards.

• Tongue space should be smooth.

• Occlusal table should be parallel to the floor.

Uses of primary cast

• To measure the depth and extent of undercut

• To evaluate the size and contour of the arch

• To determine the path of insertion of the denture

• To perform a mock surgery

• To educate the patient

• To determine the requirements for preprosthetic surgery

Custom tray
A custom tray or special tray is defined as ‘an individualized
impression tray made from a cast recovered from a preliminary
impression. It is used in making a final impression’.

Ideal requirements of a custom tray

• It should be dimensionally stable on the cast and in the mouth.

• It should have an excellent fit.

• The tissue surface should be free of voids or projections.

• It should be rigid in thin sections, especially in the palatal or lingual

flange region.

• It should not warp or flow.

• It should be easy to remove and should not react with the

impression material.

• It should be 2 mm short from the sulcus to provide space for the

green stick compound.

Materials used for fabrication

• Self-cure resin

• Shellac

• Vacuum-formed thermoplastic resin

• Vacuum-formed polystyrene
• Type II impression compound

Adapting relief wax

• Relief wax is adapted over relief areas in the maxillary and
mandibular casts.

• Relief is provided to prevent any excessive pressure on the

nonstress-bearing areas.

• It is 2 mm in thickness and can vary depending on the quality of the

tissues.

Spacer thickness and design

• A wax spacer is then placed within the outlined border to provide
space for the impression material in the tray.

• It also ensures that the loaded tray is not too bulky and allows the
ease of placement in the mouth.

• A planned relief is designed to carry out the impression procedure

best suited for the patient.

• This depends on the tissue tonicity and on the difference in the

displaceability of tissues in every patient and in different buccal
areas of the same patient.

• In addition, the special circumstances that sometimes occur in a

given clinical situation may indicate the use of different shaped
spacers.

• The technique by A.R. Halperin suggests that peripheral relief

provided by the spacer so that a uniform space for border moulding
material and correct positioning of tray are achieved.
• Some areas that are routinely relieved in selective pressure
technique are incisive papilla, mid-palatine raphe in the maxilla and
the crest of the ridge in the mandible.

• Baseplate wax, approximately 1 mm thick, is placed on the cast

within the outlines to provide space in the tray for the final
impression material.

• The PPS area is not covered with the wax spacer and in the lower
area the buccal shelf area is left uncovered.

• In addition to this, tissue stops can also be placed in the wax spacer.

Method of fabrication
• Eliminate undercuts with a thin coat of wax and paint the cast with
tin foil substitute and allow it to dry.

• The acrylic resin can be adapted on the cast by sprinkle-on method

or by dough method.

Sprinkle-on method
• In this method, the powdered polymer is shifted on the cast and is
saturated with the liquid monomer until a uniformly thick tray is
formed.

• The tray might be too thick or too flexible.

• It might be too thin over the ridges and too thick over the palates.

• It is important that the tray is 2–3 mm thick.

• Remove the tray only after complete polymerization has taken

place.
• Afterwards, the handle is placed on the tray, which could be a
stepped handle or an angulated handle.
Border moulding
Border moulding is defined as ‘the shaping of the border areas of an
impression material by functional or manual manipulation of the soft
tissue adjacent to the borders to duplicate the contour and size of the
vestibule’.
Secondary or final impression can be defined as ‘the impression that
represents the completion of the registration of the surface or object’.
Border moulding can be done by using the following two
techniques:

(i) Multistep or incremental or sectional border moulding

(ii) Single step or simultaneous border moulding

Multistep or incremental or sectional border

moulding

Refining of maxillary impression trays

• Green stick compound is added in sections to the shortened borders
of the custom tray. The compound is then heated with the flame
from an alcohol torch, tempered and moulded in the mouth.

• The tray is carefully removed from the mouth, and the modelling
compound is chilled in ice water.

• The border moulding is accomplished in the anterior region when

the upper lip is elevated and extended outwards, downwards and
inwards.

• In the region of the buccal frenum, the cheek is elevated and then
pulled outwards, downwards and inwards and moved backwards and
forwards to simulate movement of the buccal frenum.
• Posteriorly, the buccal flange is border moulded when the cheek is
extended outwards, downwards and inwards.

• The PPS is formed through both hamular (pterygomandibular)

notches and across the palate over the vibrating line.

• Should the tray be underextended, the length is corrected by the

addition of modelling compound.

• A strip of low-fusing modelling compound is placed over the

vibrating line and through the hamular notches.

• After the border moulding procedure is completed, the spacer wax

is removed from the inside of the final impression tray.

• Holes are placed in the palate of the impression tray with a No. 6
round bur to provide escape ways for the final impression material.

Refining the tissue-bearing areas of the final

upper impression
• The final impression material is mixed according to the
manufacturer’s instructions and uniformly distributed within the
final impression tray.

• All the borders must be covered.

• The tray is positioned in the patient’s mouth.

• The border moulding procedures are performed first in the

posterior regions on both sides and then in the anterior region.

• When the impression material is completely set, the dentist removes

the impression from the mouth by grasping the handle of the tray
downwards and forwards in the direction of the labial inclination of
residual ridge.
• The impression is inspected for acceptability.

Refining of mandibular impression trays

• Green stick compound is added to the borders of the resin tray in
sections, beginning with the labial flange, then the buccal flanges
and finally the lingual flanges.

• Each section of the modelling compound is heated and border

moulded before the next section is added.

• For the border moulding of the labial flange, the lower lip is lifted
outwards, upwards and inwards.

• In the buccal frenum region, the cheek is lifted outwards, inwards,

backwards and forwards to simulate the movement of the lower
buccal frenum.

• Posteriorly, the buccal flange is moulded when the cheek is moved

outwards, upwards, and inwards.

• The distobuccal sulcus is recorded by asking the patient to close the

mouth against resistance. The masseter muscle acting on the
buccinator muscle forms a notch in the impression called the
masseteric notch.

Border moulding of the lingual flanges

• The tray is placed in the patient’s mouth and the patient is
instructed to protrude the tongue.

• This movement creates the functional activity of the anterior part of

the floor of the mouth, including the lingual frenum and determines
the length of the lingual flange of the tray in this region.

• The tray is placed in the mouth and the patient is asked to push the
 tongue forcefully against the front part of the palate.

• This action causes the base of the tongue to spread out and develops
the thickness of the anterior part of the lingual flange.

• The compound is then added to the area of the tray between the
premylohyoid and the postmylohyoid eminences on both the sides.

• The heated and tempered compound is placed in the patient’s

mouth and the patient is asked to protrude the tongue.

• This develops the slope of the lingual flange in the molar region to
allow for the action of the mylohyoid muscle.

• The action of the mylohyoid muscle, which raises the floor of the
mouth during this movement, determines the length of the flange in
the molar region.

• The distal end of lingual flange should extend about 1 cm distal to

the end of mylohyoid ridge.

• The flange should be shaped so as it turns laterally towards the

ramus below the level of retromolar pad and mylohyoid ridge.

• Compound on the distal end of flange is heated and the tray is

placed in the mouth.

• The patient is instructed to protrude his/her tongue to activate the

superior constrictor.

• With the lower final impression tray in place in the mouth, the
patient should be able to wipe the tip of his/her tongue across the
vermillion border of the upper lip without noticeable displacement
of the lower tray.

• The compound forming posterior part of the retromolar fossa is

heated, the tray is placed in the mouth and the patient is asked to
 open the mouth wide.

• If the tray is too long, a notch will be formed at the posteromedial

border of the retromolar fossa, indicating tray encroachment on the
pterygomandibular raphe.

• The tray is adjusted accordingly.

• The final tray should be so formed that it can support the cheeks
and lips in the same manner as the finished denture would do.

• The wax spacer is removed.

• Holes are cut in the centre of the alveolar groove of the tray.

Refining of the tissue-bearing areas of the final

lower impression
• The final impression material is mixed in proper quantities and
evenly distributed over within the tray, covering all the borders.

• The tray is positioned in the patient’s mouth and the borders are
moulded.

• Once the material is set, the impression is removed from the mouth
and inspected for acceptability.

Single step or simultaneous border moulding

• A material that will allow simultaneous moulding of all borders has
two general advantages:

• The number of insertions of the trays for maxillary

and mandibular border moulding is reduced to
two.
• Development of all borders simultaneously avoids
propagation of errors caused by a mistake in one
section affecting the border contours in another
section.
• The procedure followed is a technique that utilizes polyether
impression materials for border moulding.

• It significantly reduces the time required for making impressions.

Secondary impression or wash
impression
• This is a clinical procedure in complete denture fabrication done to
prepare a master cast.

• This is done after the upper and lower border moulding are
completed.

• Its primary objective is to record the denture-bearing area in great

detail and it also records the muscular peripheral tissues in
function.

• This method makes use of a custom tray or special tray, prepared

from the primary cast.

• The borders of the tray should be 2 mm short from the peripheral

structures.

• The tray can be prepared from autopolymerizing resin or shellac

baseplate.

• Once the tray is ready, the peripheral structures are recorded by a

procedure called border moulding or peripheral tracing.

• Tracing compound or elastomers can be used.

• The impression material chosen for the secondary impression

should be of low viscosity to record the structures accurately.

• The materials of choice for the secondary impression are zinc oxide
eugenol impression paste and medium-bodied elastomeric
impression material.

• The final impression material is mixed according to the

 manufacturer’s instructions and uniformly loaded over the tray.

• All borders should be covered before placing the tray in the

patient’s mouth.

• This impression is called wash impression because between the

properly moulded borders and the peripheral tissues, only a thin
film of material will exist.

• Once the material is set, the tray is removed from the mouth of the
patient and inspected for acceptability.
Impression materials
The choice of impression material depends on the following:

• Character and position of the tissues to be reproduced

• Purpose of the impression

• Technique used for making the impression

• Type of submucosa and the relationship of the supporting bone to

the denture base

• Dimensional stability of the material after setting

Various materials commonly used for impression making in complete

dentures are as follows:

• Impression plaster

• Zinc oxide eugenol paste

• Modelling plastic or impression compound

• Reversible hydrocolloid

• Irreversible hydrocolloid

• Rubber base impression material

• Impression waxes

Impression plaster
• Certain modifiers are added to the impression plaster to regulate the
setting time and control the setting expansion.
• Flavouring agents are used.

• These plasters are not commonly used.

Advantages
• Minimal tissue distortion

• Quick flow

• Absorption of palatal secretions during setting

• Accurate record of tissue detail

• Easy manipulation and handling

Disadvantages
• Possibility of warpage

• Subject to breakage due to brittleness

• Messy to use; separation of cast from the impression is tedious

• Pores in impression should be filled before pouring cast

• Undercuts cannot be recorded

Impression compound
• Impression compound is a reversible thermoplastic material, which
is used for making preliminary impressions.

• It is softened in a water bath at 64°C and kneaded until a uniform

mass is obtained.

• The impression is made using a stock tray.

• It has a good dimensional stability but excessive water
incorporation can cause dimensional change.

Advantages
• Surface can be corrected.

• Impression can be reinserted for evaluation of fit.

• Surface does not have to be treated before pouring the stone cast.

• Material can be beaded and boxed for pouring of cast.

Disadvantages
• Due to its viscosity, it can displace the tissue surface and also it does
not record the surface details very accurately.

• Thermal conductivity of modelling compound is low, outer surface

of the impression softens first, whereas the inside sets the last.

• It is subjected to distortion during and after removal from the

mouth.

• Higher is the temperature of compound during impression, more

are the chances of linear thermal expansion.

Zinc oxide eugenol paste

• Its basic composition is zinc oxide and eugenol.

• Plasticizers, fillers and other additives are added to alter certain

properties such as smoothness of the mix, adhesiveness and
hardness.

Advantages
• Tissue details are accurately recorded as a result of fluidity.

• The paste shows minimal distortion, if it is allowed to flow under

minimal pressure.

• It has a good flow and ease of handling.

• It is easy to bead and box for pouring of the cast.

• It is dimensionally stable on setting.

Disadvantages
• Setting time is not easily controlled.

• Temperature and humidity influence the setting time.

• It is difficult to control at the borders.

• It may distort when removed from the undercuts.

Reversible hydrocolloid
• This impression makes use of agar (a reversible hydrocolloid) as the
impression material.

• Hydrocolloid sols change property to gels under certain conditions.

• The agar is taken from the tempering section, which is at 46°C and
loaded on to a water-cooled rim lock tray.

• It requires heat for sol–gel transformation.

Advantages
• It is an elastic material and, therefore, can be used to record
 undercuts.

• It shows an excellent surface detail reproduction (up to 25 microns).

• It can be reused.

Disadvantages
• It has a poor dimensional stability due to syneresis and imbibition.

• It is capable of displacing soft tissues.

• It has a tendency to get easily distorted during the gelation period.

• It requires special water-cooled trays and equipment.

• It is not easy to manipulate.

• The tray should be held rapidly during gelation.

• It should be poured immediately.

Irreversible hydrocolloid
• Alginate is the hydrocolloid used for this type of impression.

• Sol–gel transformation occurs by chemical reaction.

• Water/powder ratio is 2:1.

Advantages
• Better peripheral seal than other impressions

• Ease of manipulation

• Less patient discomfort

• Short chairside time

• Accurate reproduction of undercut areas

• Minimal equipment needed

Disadvantages
• It has poor dimensional stability due to syneresis and imbibition.

• It should be poured immediately.

• It deteriorates rapidly at elevated temperatures.

Rubber base impression material

Advantages
• It is dimensionally stable.

• It has an accurate reproduction of detail.

• It does not affect hardness of the stone surface.

• It is easy to manipulate and handle.

• It can record undercuts accurately.

Disadvantages
• Proper mixing is essential.

• If the mass is not homogenous, distortion occurs.

• Ratio of material is critical.

Impression waxes
• Low-fusing impression waxes are not accurate for impression
making.

• These are only used as a corrective material to refine the borders.

Key Facts
• Sublingual crescent is the crescent-shaped area on the anterior floor
of the mouth formed by the lingual wall of the mandible and the
adjacent sublingual fold. It is the area of the anterior alveololingual
sulcus.

• Retromolar pad consists of glandular tissues and the fibres of

temporalis posteriorly, buccinator laterally and pterygomandibular
raphe and superior constrictor medially. It should be covered in the
denture to aid in posterior seal of the lower denture.

• Peripheral seal is the contact of the denture border with the limiting
structures to prevent the passage of air or food.

• Distobuccal border of the maxillary denture is limited by the

coronoid process, ramus of the mandible and the masseter muscle.

• The purpose of boxing the impression is to give definite shape to

the base of the cast and preserve the width of the border after
border moulding.

• Aesthetics of the denture begins during the impression stage itself.

• Mucostatic impression is the negative replica of the oral tissues on

the state of rest.

• Recording jaw relation is difficult in denture construction of patient

with neuromuscular disorders.
• In the upper denture, the accurate adaptation of the labial flange
and the positioning of the teeth influence the aesthetics.

• Neutral zone concept was first proposed by Wilfred Fish.

CHAPTER 5
Articulators and facebows

CHAPTER OUTLINE
Introduction, 77
Mandibular Movements, 77
Influence of Opposing Tooth Contacts, 78
Anatomy and Physiology of TMJ, 78
Axis around which the Mandible Rotates, 78
Actions of Muscles and Ligaments, 78
Neuromuscular Control, 79
Envelope of Motion of the Mandible, 79
Definition, 79
Envelope of Motion in the Sagittal Plane, 79
Envelope of Motion in the Frontal Plane, 81
Envelope of Motion in the Horizontal Plane, 81
Facebow, 82
Definition, 82
Evolution of Facebow, 82
Parts of Facebow, 82
Indications, 83
Contraindications, 83
 Types of Facebow, 83
Method of Use, 84
Importance of Anterior and Posterior Reference Point, 85
Definition, 85
Anterior Reference Point, 86
Posterior Reference Point, 86
Hinge Axis, 87
Definition, 87
Concepts of Hinge Axis, 87
Schools of Thought Regarding the Transverse
Axis, 88
Articulators, 88
Definition, 88
Uses, 88
Advantages of Articulators, 88
Limitations, 89
Evolution of Articulators, 89
Classification of Articulators, 90
Fully Adjustable Articulators, 94
Split Cast Method and Its Importance, 94
Definition, 94
Uses, 95
Benefits, 95
Split Cast Methods, 95
 Technique Employed, 95
Bennett Movement, 96
Definition, 96
Importance, 96
Introduction
The mouth of the patient is considered as the best articulator, but it is
not possible to arrange prosthetic teeth in the patient’s mouth or to do
any intraoral procedure which is needed for construction of dentures.
Therefore, it is necessary to use a mechanical device which can
simulate jaw movements and transfer the relationship of the jaws to
this device. These devices are called articulator and facebow which are
described in this chapter.
Mandibular movements
Mandibular movements occur primarily around the
temporomandibular joint (TMJ) which is capable of making complex
movements. Condyles articulate with the temporal bone which is
located in the glenoid fossa in which they travel forward, from side-
to-side and in some instances slightly backwards. Condyle moves
along the posterior slope of the articular eminence and extends as far
forward as its crest. Movement of the mandible is related to three
planes of the skull, namely, the horizontal, frontal and sagittal planes.
Types of Mandibular Movements
Based on TMJ movement

(i) Rotational movement can occur around three reference planes:

• Rotation around the horizontal axis

• Rotation around the vertical axis

• Rotation around the sagittal axis

(ii) Translational movement

Based on the types of movement

(i) Hinge movement

(ii) Retrusive movement

(iii) Protrusive movement

(iv) Lateral excursive movement

(v) Medial excursive movement

Based on the extent of the movement

(i) Border movement

• Border movements around the horizontal plane

• Border movements around the sagittal plane

• Border movements around the frontal plane

(ii) Intraborder movement

• Functional movements

• Chewing

• Speech

• Swallowing

• Parafunctional movements

• Bruxism

• Clenching
• Any habitual movement

Four movements of prime importance to complete denture service

are as follows:

(i) Hinge-like movement is used in opening and closing the mouth.

(ii) Protrusive movement is used in grasping and incising the food.

(iii) Right or left lateral movements are used in reduction of food.

(iv) Bennett movement is the bodily shift of the mandible which is

recorded in the region of rotating condyle on the working side.

Factors regulating movements of the mandible are as follows:

• Opposing tooth contacts

• Anatomy and physiology of the TMJ

• Axis, around which the mandible rotates

• Actions of muscles and ligaments

• Neuromuscular control

Influence of opposing tooth contacts

• One of the many factors which influence the jaw movements is
occlusion of the opposing teeth.
• Relationship of the occlusal surfaces is not only confined to teeth but
also to the muscles, TMJ and neurophysiological components.

• In complete dentures, the occlusal surfaces on teeth should contact

bilaterally and simultaneously to enhance the stability (balanced
occlusion).

• The inclined planes of the denture teeth should be positioned in

such a way that they are in harmony with the other factors that
regulate jaw movement.

Anatomy and physiology of TMJ

• TMJ is divided into two compartments by the articular disc.

• Movement in the upper compartment is primarily translatory, whereas

movement in the lower compartment is primarily rotational.

• Mandibular movements can be translatory or rotational or

combination of both.

Axes around which the mandible rotate

• Mandible can rotate around three reference axes, namely,
horizontal, sagittal and vertical.

• Horizontal axis of rotation: Mandibular movement around this axis is

a hinge movement, i.e. opening and closing movement (Fig. 5-1).

• This axis is used to properly orient the maxillary cast on the

articulator.

• In lateral movements, the mandible rotates around the vertical axis

passing through the condyle on the working side because the
condyle on the balancing side moves forward and medially (Fig. 5-
2).
• Mandibular movement around the sagittal axis occurs during lateral
movement, as the balancing side condyle moves not only forwards
and medially but also downwards because of the slope of the
articular eminence (Fig. 5-3).

FIGURE 5-1 Mandibular movements around horizontal axis.

FIGURE 5-2 Mandibular movement around vertical axis.
 FIGURE 5-3 Mandibular movement around sagittal axis.

Actions of muscles and ligaments

• Muscles responsible for mandibular movements show increased
activity during any jaw movement.

• The activity and interaction of various muscles for series of jaw

movements can be determined using electromyography.

• Temporal and inframandibular muscles retrude the mandible and

maintain it in this most posterior position.

• Lateral pterygoid muscle moves the mandible and the condyle

forward during uncontrolled opening movements.

• It is also responsible for making lateral and protrusive movement of

 the mandible which is necessary to make eccentric interocclusal
records or pantographic tracings.

Neuromuscular control
• Muscular control of all the movement of the mandible is governed
by impulses from the central nervous system.

• Loss of teeth eliminates the source of receptors that are located in

the periodontium. These receptors help in controlling the position
of the mandible.

• Such a loss is compensated by construction of dentures with centric

relation (CR) coinciding with the centric position.
Envelope of motion of the mandible
Definition
Envelope of motion is defined as ‘the three-dimensional space
circumscribed by the mandibular border movements within which all
unstrained mandibular movement occurs’. (GPT 8th Ed)
Envelope of motion or maximum border movements can occur
around three planes, namely, the sagittal, horizontal and frontal plane.

Envelope of motion in the sagittal plane (fig. 5-4)

• Tracing is made when a pathway of the bead attached to the lower
central incisor is plotted.

• The tracing starts at point P, which represents the most protruded

position of the mandible with both upper and lower anterior teeth
in contact.

• As the patient moves the mandible posteriorly, it reaches the centric

occlusion (CO) position which is the position of maximum
intercuspation of the posterior teeth.

• When the mandible is further retruded, it attains the most posterior

relation to the maxilla which is represented by the point CR.

• Single restorations are usually constructed at the CO position.

• Multiple restorations and complete dentures are fabricated with

their occlusion in harmony with CR.

• As a patient opens the jaws, there is a separation of the teeth and the
mandible moves in its most retruded position to the position of
maximum hinge opening (MHO).
• Till the position of MHO, the condyles rotate without translation
movement.

• Opening of the jaws beyond MHO will force the condyles to translate,
i.e. to move forward and downward from their most posterior
position.

• Translatory movement of the condyles continue till the maximum

opening (MO) of the jaws.

• At the point MO, the condyles are in their most anterior position in
relation to the mandibular fossa.

• The line joining CR–MHO represents the posterior terminal hinge

movement.

• This movement is clinically used to locate the transverse hinge axis

(THA) for mounting the cast on the articulators.

• The line joining MO–point P represents the pathway of the

mandible, as it moves from its most open position to the most
protruded position.

• The masticatory cycle can be viewed in the sagittal plane and can be
superimposed on the envelope of motion.

• The masticatory cycle begins from CO and then extends downwards

and then upwards to end again at this point.

• In complete dentures, the CR and CO positions should coincide

with each other and, therefore, the masticatory cycle terminates at
this point.

• The mandibular rest position occurs somewhere downwards and

slightly forwards from the point CR as indicated by REST(R).

• This rest position is the habitual postural position of the mandible

 when the patient is at ease in the upright position.

• The rest position is one of the most important reference positions to

record the vertical jaw relations.

FIGURE 5-4 Envelope of motion in the sagittal plane.

Envelope of motion in the frontal plane (fig. 5-5)

• The envelope of motion seen in the frontal plane resembles a shield.

• The tracing begins at the CO position.

• As the mandible moves to the right with the opposing teeth making
contact, the dip in the upper line is created when the upper and
lower canines pass edge-to-edge.
• Movement of the mandible is continued further till the maximum
right lateral position.

• From this position, the opening movement is started and continued

with the mandible in the extreme right lateral position until the
maximum opening occurs at the point MO.

• From MO, the mandible is moved to the extreme left lateral position
till the opposing teeth contacts.

• Again, there is dip in the left side representing the edge-to-edge

contact of the upper and the lower canines.

• Finally, the mandible moves back to the CO position.

• The masticatory cycle starts in the centre of the graph in the position
of CO representing the teeth penetrating the food bolus.

• The masticatory cycle moves downwards and then upwards to end

at CO.

• In the frontal plane, the rest position lies slightly downwards from
CO.
 FIGURE 5-5 Envelope of motion in the frontal plane.

Envelope of motion in the horizontal plane (fig. 5-

6)
• The Gothic arch tracers are used to record the envelope of motion in
the horizontal plane.

• It consists of the recording plate attached to the maxillary arch and

the recording stylus attached to the mandibular arch.

• As the mandible moves, the border movements are recorded on the

plate with ease.

• Condyles are in the CR position and the mandible moves to the left
 lateral position.

• When the mandible reaches the maximum left lateral position, it is

continued to the protrusive movement.

• This protrusion continues till both the upper and lower teeth are in
maximum protrusion.

• At this time, the jaw is opened and is closed in the CR position.

• The mandible then moves to the right lateral position.

• This movement continues to the maximum right lateral position and

then to the protrusive movement.

• Gothic arch tracing is the graphic method used to record the centric
position.

FIGURE 5-6 Envelope of motion in the horizontal plane.

Facebow
Definition
Facebow is defined as ‘caliper-like instrument used to record the spatial
relationship of the maxillary arch to some anatomic reference point or points
and then transfer this relationship to an articulator; it orients the dental cast
in the same relationship to the opening axis of the articulator’. (GPT 8th Ed)

Evolution of facebow
• In 1860, W.G.A. Bonwill concluded that the distance from the centre
of the condyle to the median incisal point of the lower teeth is 10
cm.

• In 1866, F.E. Balkwill demonstrated an apparatus to measure the

angle formed by the occlusal plane of lower teeth and the plane
passing through the condyles and incisal plane of lower teeth.

• In 1880, R.A. Hayes constructed an apparatus called caliper with

median incisal point localized in relation to the two condyles.

• In 1890, W.E. Walker invented clinometer that is used to obtain the

relative position of the lower cast in relation to the condylar
mechanism.

• At about a turn of the nineteenth century, A. Gysi constructed an

instrument for registering the condylar path which is also used as
facebow.

• In 1899, George B. Snow constructed a simple instrument which has

become the prototype for all the facebows constructed in present
days.
Parts of facebow (fig. 5-7)

U-shaped frame
• It is a metallic U-shaped bar which forms the main form of the
frame.

• The remaining components are attached to the frame by clamps.

• It is large enough to extend from the region of TMJ or external

acoustic meatus to a distance of 2–3 inches in front of the face.

• Wide enough to avoid contact with the side of the face.

 FIGURE 5-7 Diagrammatic representation of facebow and its
parts.

Condylar rods
• These are placed on a line extending from the outer canthus of the
eye to the top of the tragus of ear and are 13 mm in front of the
external auditory meatus.

• This placement generally locates the rods within 5 mm of the true

centre of the opening hinge axis of the jaw.

Bite forks
• These consist of a stem and prongs.

• These are attached to the maxillary occlusal rims.

• In a kinematic facebow, it is attached to the mandibular rims.

Locking device
It helps to attach the bite fork to the U-shaped frame.

Orbital pointer with clamp

• It is used to make contact with the infraorbital notch which serves as
the third point of reference.

• Clamp secures the orbital pointer in position.

Ear plugs
• These are placed in the external auditory meatus.

• On the articulator, the location of these rods compensates for the

position of the meatuses which are posterior to the transverse
opening axis of the mandible.

Bite clamp
It allows sliding of the bite fork.

Indications
• When cusp form teeth are used.

• Definite cusp–fossa relationship is desired.

• Interocclusal check record is used to verify jaw position.

• When vertical dimension of occlusion (VDO) is subject to change.

• Balanced occlusion in eccentric position is desired.

Contraindications
• When nonanatomic teeth are used.

• When interocclusal check records are not used.

• When there is no alteration of occluding surfaces of the teeth that

would necessitate changes in VDO originally recorded.

• When articulator is not designed to accept facebow transfer.

Types of facebow (Table 5-1)

Facebows are usually of the following two types:

(i) Arbitrary facebow

• Earpiece type

• Fascia type
(ii) Kinematic facebow

TABLE 5-1
TYPES OF FACEBOW

Kinematic Facebow Arbitrary Facebow

Opening axis is located physiologically Axis is located using anatomical landmarks
Rotational points located by attaching clutches to mandible Centres of rotation are located 13 mm
as the patient opens and closes his mouth; a stylus is anterior to external auditory meatus on line
adjusted until true hinge axis is located towards outer canthus of eye
Locates the true hinge axis with exceptional accuracy Locates the rods within 5 mm of true hinge
axis
Requires complex equipment and is time consuming Simple to use and faster
Used in full mouth rehabilitation, occlusal equilibration and Used in fabrication of complete dentures
gnathological studies
Expensive Comparatively cheaper

Arbitrary facebow
• In this type, the axis is located using anatomical landmarks.

• Condyle rods of the facebow are placed over the arbitrarily marked
centres of hinge axis.

• It is the most commonly used facebow in complete denture

prosthodontics.

Fascia type

• This type of facebow utilizes an arbitrary point on the skin over the
TMJ as the posterior reference point.

• These points are located by measuring from certain anatomical

landmarks on the face.

Earpiece type

• Earpiece type of facebow uses external auditory meatus as the

posterior reference point.

• The external auditory meatuses are assumed to have a fixed

relationship to the hinge axis.

• An average distance from the external auditory meatus to an

arbitrary hinge axis is built into the facebow design.

• Special condylar compensators are provided on the facebow, which

help the articulator to compensate for this by placing the condylar
inserts at a certain distance behind the rotational axis of the
articulator.
 Earpiece type of facebow is more popular because of the following
reasons:

• It is easy to use.

• It does not require measurements or markings on the face.

• It is as accurate as other arbitrary types of facebow.

Kinematic facebow
• It is used to determine and locate true hinge axis.

• It locates the opening axis physiologically with exceptional

accuracy.

• A facebow with adjustable calliper ends is used to locate the

transverse horizontal axis of the mandible.

• It is a more complex instrument which requires fabrication of

clutches which are attached to the lower jaws.

• It requires the use of articulator with extendable condylar shafts

which must be extended to meet stylus of the facebow.

• The stylus should not be extended; otherwise, the true hinge axis
will be lost.

• It is indicated for full mouth rehabilitation, occlusal equilibration

and the gnathological studies.

Method of use
• The facebow is attached to the lower jaw by clutch.

• A graph or grid paper is placed near TMJ to detect the stylus

movement.
• Patient is instructed to open and close the mandible to centric
position.

• Initially, the movement of the stylus may be in the shape of arc.

• The stylus is adjusted until the tip rotates instead of arching.

• This point is the true hinge axis and is marked on the skin.

Types of facebows used with commonly used

articulators
(i) Hanau facebows

For Hanau H2 series

• Fascia facebow

• Earpiece facebow

• The twirl-bow (modified earpiece)

• Kinematic facebow

Note: Commonly used ones are fascia, earpiece and

twirl.

For Hanau Arcon H2

• Spring bow

• Fascia facebow
• Earpiece facebow

• Twirl-bow
(ii) Whip-Mix

• Quick mount/earpiece facebow

• Kinematic/adjustable axis facebow

(iii) Denar

• Earpiece facebow

• Fascia facebow

• Slidematic facebow

• Kinematic facebow
(iv) Dentatus

• Similar to Whip-Mix

Significance of Facebow
• Transverse hinge axis (THA) can be located with the aid of facebow.

• Records the position of maxilla in three planes with one anterior

reference point and two posterior reference points.

• To relate the maxillary casts to the transverse axis of the articulator.

• Mandibular hinge axis coincides and relates to the maxilla by CR
record.

• It aids in securing the anteroposterior cast position in relation to the

condyles of the mandible.

• It registers the horizontal relationship of the casts accurately so as to

assist in incisal plane location.

• It helps in restoring vertical height in the articulator.

• Failure to use facebow can lead to error in occlusion of denture.

• Facebow transfer allows more accurate arc of closure on the

articulator when the interocclusal records are used.
Importance of anterior and posterior
reference point
Definition
Anterior reference point is defined as ‘any point located on the midface
that, together with two posterior reference points, establishes a reference
plane’. (GPT 8th Ed)
Posterior reference point is defined as ‘two points, located one on each
side of the face in the area of the transverse horizontal axis, which, together
with an anterior reference point, establishes the horizontal reference plane’.
(GPT 8th Ed)

Anterior reference point

• The selection of anterior point of reference determines which plane
in the prosthesis becomes the plane of reference.

• The objective of the natural appearance in the form and position of

the teeth is achieved by mounting the maxillary cast relative to the
Frankfurt horizontal plane (FH plane).

• The objective of the natural appearance in the occlusal plane is

achieved by mounting the cast relative to the Camper’s plane.

• To establish a standard line for comparison between the patient’s

FH plane, anterior reference point is frequently used.

Commonly used anterior reference points are as follows:

• Orbitale: It is the lowest point on the infraorbital rim and along with
the two posterior points. It forms axis–orbitale plane (Fig. 5-8).

• Orbitale minus 7 mm.

• Nasion minus 23 mm.

• Incisal edge plus articulator midpoint to articulator axis: Niles Guichet

emphasized that a logical position of casts in the articulator would
be one which would position the plane of occlusion near the mid-
horizontal plane of the articulator.

• Alae of the nose: In complete dentures, the tentative occlusal plane is

made parallel with the horizontal plane (Camper’s plane).

FIGURE 5-8 Orbitale used as anterior third point of

reference.

Posterior reference point

• The position of the terminal hinge axis on either side of the face is
generally taken as posterior reference point.
• Prior to aligning the facebow on the face, the posterior reference
points must be located and marked. They are located by either of
these two methods:

(i) Arbitrary method

(ii) Kinematic method

Commonly used posterior reference points are as follows:

• Bergstrom point: A point 10 mm anterior to the centre of the spherical

insert for the external auditory meatus and 7 mm below the FH
plane. H.O. Beck stated that it lies closest to the hinge axis. It is
considered to be the most accurate reference point and is located
closest to the hinge axis.

• Beyron’s point: A point 13 mm anterior to the posterior margin of the

tragus of ear on a line from the centre of the tragus to the outer
canthus of the eye. This point is the second most accurate (Fig. 5-9).

• Denar reference point: A point 12 mm anterior to posterior border of

tragus and 5 mm inferior to the line extending from the superior
border of tragus to outer canthus of the eye.

• Teteruck and Lundeen’s point: A point located 13 mm anterior to the

tragus on a line from the base of the tragus to the outer canthus of
the eye.

• A.G. Lauritzen and G.H. Bodner point: A point 12 mm anterior to

centre of external auditory meatus and 2 mm inferior to porion–
canthus line.

• Whip-Mix: According to their design of their ear bow, in

anteroposterior direction at anterior wall of external auditory
meatus and in superior–inferior direction approximately at level of
most prominent point of posterior border of tragus.
• Brandrup-Wognsen: About 12 mm anterior to the most prominent
point of posterior border of tragus on line from it to the outer
canthus of the eye.

• Weinberg’s Point: A point 11–13 mm anterior on a reference line

drawn from the middle and posterior border of tragus of the ear to
the corner of the eye.

• Gysi: About 13 mm anterior to anterior margin of external auditory

meatus on line from superior margin of external auditory meatus
and the outer canthus of the eye.

FIGURE 5-9 Beyron’s point (P).

Hinge axis
Definition
Hinge axis or transverse horizontal axis is defined as ‘an imaginary line
around which the mandible may rotate within the sagittal axis’. (GPT 8th
Ed)
Hinge axis is also called horizontal axis, intercondylar axis, terminal
hinge axis, transverse horizontal axis.

Concepts of hinge axis

Transverse horizontal axis (THA)

Authors who advocated that THA exists are B.B. McCollum, C.E.
Stuart, R.B. Sloane, H. Sicher and Allil.

• The THA is the most retruded hinge position and is significant

because it is learnable, repeatable and recordable and coincides with
CR. The limits of the hinge movement in this position are about 12–
15° at condyles or 19–21 mm in the incisal region.

• The THA plus one other anterior point serves to locate the maxillae in
space and to record the static starting point for functional
mandibular movements.

• The recording and reproduction of the opening axis of the mandible

enables a given occlusal relation to be reproduced on the articulator at any
vertical height without the necessity of making a new interocclusal
(IO)–centric relation (CR) record at new VDO.

Gnathology
The proponents (McCollum, Stuart, Sloane, Allil) of gnathology claim
that there is one THA common to both condyles.
• The condyles are in a definite position in the fossa during the
rotation.

• Snow recognized the importance of this axis and to transfer this axis
to the articulator led to the development of facebow. In 1921,
McCollum, Stuart and others reported the first method of
transferring this axis.

Transographics
The proponents (Page, Trapozzanno, Lazzari) of transographics claim
that each condyle has a different THA.

H. Page (1957):

• He was the first one to state the theory of split

hinge axis. He also stated that:

• There were at least 12 hinge axes in every head.

• Three in each TMJ

• Three in each mandibular angle

• These, he said, were responsible for movements in

all three planes.
V.R. Tropazzono and J.B. Lazzari (1957):

• They found the presence of multiple hinge axes.

• Relaxation of the patient, during the making of THA

recordings is essential.
Because of the presence of multiple hinge axes points, increase or
decrease of the VD on the articulator is contraindicated unless a new
interocclusal record is made on the patient at the desired VDO.

L.A. Weinberg (1958):

• He refuted the transographic concept.

• He said that because it was mechanically impossible

for a solid object to have two axial centres of
rotation in the same plane for one direction of
movement.

Schools of thought regarding the transverse axis

• Absolute location of the axis: The absolute location of the hinge axis school,
as practised by V. Lucia (1953), B.B. McCollum (1939, 1943), E.R.
Granger (1952, 1954).

• Arbitrary location of the axis: The arbitrary axis school as practised by

Craddock and Symmons (1952).

• Nonbelievers in the transverse axis location: Nonbelievers such as H.A.

Collett (1955), R. Levao (1955), L.E. Kurlh and I.K. Feitistein (1951),
F.W. Craddock and H.F. Symmons (1952) and H.O. Beck (1959)
expressed doubts about the presence of THA.

• They thought that the axis is theoretically possible

but not practically acceptable.
• Split axis rotation: Page, V.R. Trapozzanno, J.B. Lazzari, F.R. Slavens
(1961) believed in the transographic theory.
• They believe in the split axis with which each
condyle rotates independently of the other, as the
mandible is not bilaterally symmetrical.

• There must be two axes parallel to each other with

both axes at right angles to the opening and closing
movement of the mandible.
Articulators
Definition
Articulator is defined as ‘a mechanical instrument that represents the
temporomandibular joints and jaws, to which maxillary and mandibular
casts may be attached to simulate some or all mandibular movements’. (GPT
8th Ed)

Uses
• To diagnose the state of occlusion in both the natural and artificial
dentitions.

• To plan dental procedures based on the relationship between

opposing natural and artificial teeth.

• To aid in the fabrication of restorations and prosthodontics

replacements.

• To correct and modify completed restorations.

• To arrange artificial teeth.

Requirements of an Articulator
Minimal requirements

• It should hold cast in correct horizontal and vertical relationship.

• The cast should be easily removable and re-attachable.

• It should provide a positive anterior vertical stop (incisal pin).

• It should accept facebow transfer record using an anterior reference

point.
• It should open and close in a hinge movement.

• It should be made of noncorrosive and rigid materials that resist

wear and tear.

• It should not be bulky or heavy.

• There should be adequate space present between the upper and

lower members.

• The moving parts should move freely without any friction.

• The nonmoving parts should be of rigid construction.

Additional requirements are as follows:

• The condylar guides should allow protrusive and lateral jaw

motions.

• The condylar guides should be adjustable to accept and alter the

Bennett movement.

• The incisal guide table should be customizable.

• It should have adjustable intercondylar distance.

Advantages of articulators
• These allow the operator to visualize the patient’s occlusion,
especially from the lingual aspect.

• Patient’s cooperation is not a factor when using an articulator once

the appropriate interocclusal records are obtained from the patient.

• The refinement of complete denture occlusion in the mouth is

difficult. This is eliminated by the use of articulators.
• These reduce the chairside time.

• The patient’s saliva, tongue and cheeks do not interfere when using
articulators.

Limitations
• An articulator can simulate but not duplicate jaw movements.

• Articulators made of metal may show error due to tooling or error

resulting from metal fatigue and wear.

• The articulator may not exactly simulate the intraborder and

functional movements of the mandible.

• Thus, the mouth would be the best place to complete the occlusion,
but using the jaws as an articulator also has limitations:

• Inability of humans to visually detect the finer

changes in the motion

• Making accurate marks in the presence of saliva

• Exact location of the condyles

• The resiliency of the supporting structures

• The dentures are movable on slippery base

Evolution of articulators
Articulators have evolved from simple hinge axis device to more
sophisticated instruments simulating the movements of the jaws
accurately. The objective of evolution was to reproduce the occlusal
relationships extraorally.

1756: Plaster articulator was first described by Phillip Pfaff. It is also

called slab articulator.

1805: First mechanical articulator described by JB Gariot.

1800s: Barn door hinge articulators.

1800s: Adaptable barn door hinge was capable of opening and closing
only in a hinge movement. It has anterior vertical stop between the
upper and lower members. It is also known as Dayton Dunbar
Campbell instrument.

1840: J. Cameron and T.W. Evans made attempt to device plane line
articulator.

1858: W.G.A. Bonwill developed an articulator based on the theory of

equilateral triangle (Bonwill triangle). It was the first of the kind of
articulator that imitated the movements of mandible in eccentric
movements.

1896: P.M. Walker devised a clinometer which had provision for Gothic
arch tracings.

1902: M.M. Kerr articulator developed by Kerr brothers had fixed

protrusive and lateral movements. Hinge was located at
approximately the same place as the occlusal plane of the mounted
cast.

1906: New century articulator developed by George B. Snow.

1910: Acme articulator was also developed by George B Snow. It had

three models of different widths with three ranges of intercondylar
width.

1910: Gysi’s adaptable articulator developed by Gysi.

1914: Gysi simplex articulator was introduced. Condylar guidance of
this articulator was fixed at 33° and was shaped like ‘ogee path’.
This path is an S-shaped curve in profile.

1918: Maxillomandibular instrument developed by George Monson.

This articulator was based on the spherical theory of occlusion.

1923: Rudolph L. Hanau developed Hanau model M Kinescope

articulator. This articulator has two condylar posts on each side.
Bennett angle was adjusted here.

1923: Homer Relator was introduced by Joseph Homer. Plastic

material was used to preserve the articulator positions.

1927: Hanau model H110 modified introduced incisal guide table.

1929: Stansberry tripod instrument was developed without hinge to

reproduce any functional relationship.

1938: Phillips occlusoscope did not use facebow. The articulator was
adjusted by either intraoral or extraoral records.

1950s: Coble articulator maintained CR and vertical dimension (VD)

but did not allow functional movements.

1955: Pankey–Mann articulator was developed by L.D. Pankey and

A.W. Mann.

1956: Stuart articulator was developed by Charles E. Stuart. It is a fully

adjustable arcon-type articulator.

1963: Hanau model H2 Series. It had increased distance between the

upper and lower members from 95 to 110 mm.

1958: Dentatus ARL articulator. It is a semi-adjustable articulator with

straight condylar path and fixed intercondylar distance.
1960: Verticulator developed by William Windish.

1962: Ney articulator is an arcon-type articulator with no locking

device between the upper and lower members in CR.

1964: Whip-Mix articulator was developed by Charles E. Stuart. It is a

semi-adjustable articulator which has three intercondylar
adjustments (Fig. 5-10).

1968: Denar D4A articulator developed by Niles Guichet. It is a fully

adjustable articulator which is programmed by tracings made with
pneumatically controlled pantographs.

1971: Simulator evolved from Granger Gnathoscope. It is a fully

adjustable articulator that is set from pantographic tracings,
positional records and other tracings.

1975: Denar Mark II by S. Hobo and F.V. Celanza.

1978: Penadent articulator – based on the work of Robert Lee.

1981: Panahoby articulator – Arcon-type semi-adjustable articulator

devised by S. Hobo. It had provisions of adjustment of sagittal
inclination of condylar path between 0° and 60°, immediate
mandibular lateral translation between 0 and 4 mm, progressive
lateral translation between 0° and 25°.

1982: Cyberhoby articulator – Fully adjustable articulator devised by

S. Hobo.
 FIGURE 5-10 Whip-Mix articulator.

The articulators have evolved over the period of time and the
present generation of articulators such as KaVo Protar, Denar Mark II,
Panadent, Hanau radial shift incorporate the Bennett movement in
order to simulate the mandibular movements as closely as possible.

Classification of articulators
• Based on instrument functions

• Based on the ability to simulate jaw movements

• Based on the adjustability of the articulator

• Based on the theories of occlusion

• Based on the type of interocclusal record used

Based on instrument functions

According to the International Prosthodontic Workshop on Complete
Denture Occlusion at University of Michigan in 1972, articulators are
classified as follows:

Class I

• Simple holding instruments capable of accepting a

single static registration.

• The first articulators were known as ‘slab

articulators’. Plaster indices extended from the
posterior portion of the casts and were keyed to
each other by means of these indices (e.g. JB
Gariot’s hinge articulator [1805]).
Class II

Instruments that permit horizontal as well as vertical

motion but do not orient the motion to TMJ with
facebow transfer.
Class IIA

• It permits eccentric motion based on average or

arbitrary values.

• In this type, the condyles are on the lower member

and their paths are inclined at 15°. Casts are
mounted to this articulator according to Bonwill’s
theory (e.g. Gritmann articulator [1899]).
Gysi simplex articulator (1914) has the condylar path
inclined at 30° and the incisal fixed at 60°.
Class IIB

• Permits eccentric motion based on arbitrary theories

of motion (e.g. maxillomandibular instrument
designed by Monson in 1918 based on his spherical
theory of occlusion).
Class IIC

• Permits eccentric motion based on engraved records

obtained from the patient and does not accept a
facebow transfer (e.g. House articulator designed
by MM House in 1927).
Class III

• Instruments that simulate condylar pathways by

average or mechanical equivalents for all or part of
the motion and allow for joint orientation of the
casts with a facebow transfer.
Class IIIA

• Accepts facebow transfer and a protrusive

interocclusal record (e.g. Hanau model H designed
by Rudolph Hanau in 1923, Dentatus articulator
 [1944]).
Class IIIB

• Accepts facebow transfer, protrusive interocclusal

records and some lateral interocclusal records.

• For example, A. Gysi (1926) introduced the Trubyte

articulator. It is a nonarcon instrument with a fixed
intercondylar distance. The horizontal condylar
inclinations are individually adjustable and the
individual Bennett adjustments are located near the
centre of the intercondylar axis. The incisal guide
table is adjustable.
Class IV

• Instrument accepts three-dimensional dynamic

registrations and utilizes a facebow transfer.
Class IVA

• The condylar pathways are formed by registrations

engraved by the patient (e.g. TMJ instruments
designed by Kenneth Swanson in 1965).
Class IVB

• Condylar pathways are selectively angled and

customized.
For example, gnathoscope designed by Charles Stuart
in 1955, Niles Guichet in 1968 designed the Denar
(D4A) fully adjustable articulator. The latest
instrument in Denar series is D5A which has the
plastic condylar inserts. This has provision for both
immediate and progressive side shift Bennett
adjustment.

Based on the ability to simulate jaw movements

Class I

• These are instruments that receive and reproduce

stereograms (pantograms). These articulators can
be adjusted to permit individual condylar
movement in each of the three planes. These are
capable of reproducing the timing of the side shift
of the orbiting (balancing) side and its direction on
the rotating (working) side.
Class II

• Instruments that will not receive stereograms. Some

of the instruments have fixed controls whereas
others are adjustable, but usually in no more than
two planes. Most are set to anatomical averages or
with some type of positional records.

• This class is divided into four types:

Type 1 (hinge): This type is capable of opening and
closing in a hinge movement. A few permit limited
nonadjustable excursive-like movements.

Type 2 (arbitrary): This is designed to adapt to specific

theories of occlusion or is oriented to a specific
technique.

Type 3 (average): This type is designed to provide

condylar element guidance by means of averages,
positional records or mini-recorder systems. Most
permit adjustments of both horizontal and lateral
guidance surfaces. Some types of facebow can be
used in maxillary cast orientation.

Type 4 (special): This type is designed and used

primarily for complete dentures.
Class II (Type 2)

• Monson

• Handy II

• The correlator

• Transograph

• The gnathic relator

• Verticulator
Class II (Type 3)

• House

• Dentatus

• Hanau (several models)

• Whip-Mix (several models)

• Denar: Mark II and Omni model

• TMJ: Mechanical fossa and moulded fossa models

• Panadent

Based on the adjustability of the articulator

• Nonadjustable

• Semi-adjustable

• Fully adjustable

Based on the types of records used for their

adjustment
Interocclusal record adjustment

• Most articulators used for fabrication of complete dentures are

 adjusted by some kind of interocclusal records.

• These records are made in wax, plaster of Paris, zinc oxide eugenol
paste or cold curing acrylic resin.

Graphic record adjustment

• Articulators designed for the use with graphic records are generally
more complicated than those designed for interocclusal records.

• As graphic records consist of records of extreme border positions of

the mandibular movements, the articulator must be capable of
producing at least the equivalent of curved movements.

Based on the theories of occlusion

Bonwill theory articulators

• One of the early instruments that reproduced eccentric movement

was the Bonwill articulator.

• Although Bonwill invented his articulator in 1858, it was marketed

only in late 1880s.

• According to the Bonwill’s theory of occlusion, the teeth move in

relation to each other as guided by the condylar and the incisal
guidances.

• Bonwill’s theory is also known as the theory of equilateral triangle

according to which the distance between the condyles is equal to
the distance between the condyles and the midpoint of the
mandibular incisors (incisal point).

• An equilateral triangle is formed between the two condyles and the

incisal point. Theoretically, the dimension of the equilateral triangle
is 4 inches.
• Bonwill articulators allow lateral movement and permit the
movement of the mechanism (joint) only in the horizontal plane
(Fig. 5-11).

FIGURE 5-11 Diagrammatic representation of Bonwill

triangle.

Conical theory articulators (proposed by R. E. Hall). 

The conical theory of occlusion proposed that the lower teeth move
over the surfaces of the upper teeth as over the surface of a cone,
generating an angle of 45° with the central axis of the cone tipped 45°
to the occlusal plane (Fig. 5-12).
 FIGURE 5-12 Diagrammatic representation of the conical
theory of occlusion.

Spherical theory articulators

• The articulator devised by G.S. Monson in 1918 operated on the

spherical theory of occlusion.

• The spherical theory of occlusion proposed that lower teeth move

over the surface of upper teeth as over a surface of sphere with a
diameter of 8 inches.

• The centre of sphere was located in the region of glabella.

Semi-adjustable articulators. 
These have adjustable horizontal condylar paths, adjustable lateral
condylar paths, adjustable incisal guide tables and adjustable
intercondylar distances. The degree and ease of these adjustments
differ.
 There are two types of semi-adjustable articulators:

(i) Arcon articulators

(ii) Nonarcon articulators

Features

• These articulators are used to simulate the patient’s condylar path

by using mechanical equivalents which has capacity to simulate all
or part of its motion.

• Casts mounted in this articulator have approximately the same

spatial relationship as the condyle to the teeth, thus discrepancies in
the difference in the radius of arc of closure is minimized.

• Therefore, the occlusal discrepancies in the finished restoration are

minimal.

• Facebow transfer is necessary to use semi-adjustable articulators.

• It is useful in diagnostic evaluation of the study cast, occlusal

analysis, occlusion correction and rehabilitation.

• It is ideal to use a semi-adjustable articulator with facebow for

complete denture fabrication with minimal occlusal errors.

• It is the more preferred articulator for complete denture construction to

fully adjustable as it is comparatively easy to use and requires less
time and is cheaper.

• It is the articulator of choice for denture remount procedures.

• Semi-adjustable articulator can accept centric, lateral and protrusive

records.

• It can be arcon or nonarcon depending on the location of the

condylar guides and condylar elements.
Arcon and nonarcon articulators. 
The term arcon was given by G. Bergstorm. ‘Ar’ means articulator and
‘con’ means condyle. The differences between arcon and nonarcon
articulators are given in Table 5-2.

TABLE 5-2
DIFFERENCES BETWEEN ARCON AND NONARCON
ARTICULATORS

Arcon Articulator Nonarcon Articulator

The condylar element is attached to the lower member Condylar guidance is attached to the lower
of the articulator and the condylar guidance is attached member and the condylar elements are attached
to the upper member to the upper member
Simulates TMJ Does not simulate TMJ
The facebow transfer, occlusal plane and the Angulation between the condylar inclination and
relationship of the opposing casts are preserved when the occlusal plane changes when the articulator is
the articulator is opened and closed opened and closed
Upper member is rigid and the lower member is Upper member is movable and lower member is
movable as in the patient rigid
Examples are Hanau Wide Vu and Whip-Mix Examples are Hanau H series, Dentatus and Gysi

Fully adjustable articulators

• A fully adjustable articulator is an instrument that will accept three-
dimensional ‘dynamic’ registrations.

• These are capable of being adjusted to follow the mandibular

movement in all directions.

• By virtue of numerous adjustments available on it, the articulator is

capable of repeating most of the precise condylar movements
depicted in any individual patient. The adjustments include the
following:

• Adjustable horizontal condylar guidance

• Adjustable lateral condylar guidance

• Adjustable incisal guide table
Adjustable intercondylar distance, i.e. the fully adjustable
articulator can accept the following records:

• Centric

• Protrusive

• Lateral

• Facebow transfer

• Intercondylar distance

Stuart instrument gnathoscope is an example of fully adjustable

articulators.

Advantages
• Most accurate instrument to reproduce restorations that precisely fit
the occlusal requirements of the patient.

Disadvantages
• Expensive

• Demands high degree of skill

• Time consuming

Indications
• Primarily for extensive treatment requiring the reconstruction of an
entire occlusion.
Split cast method and its importance
Definition
Split cast method is defined as ‘method of mounting casts wherein the
dental cast’s base is sharply grooved and keyed to the mounting ring’s base.
The procedure allows verifying the accuracy of the mounting, ease of removal
and replacement of the casts’. (GPT 8th Ed)

• This technique was first introduced by A.G. Lauritzen.

Uses
• It is an useful method of relating upper and lower cast to each other
in the articulator for the purpose of occlusal rehabilitation.

• It is used to compare the interocclusal records.

• It is used in mounting casts for multiple restorations or full mouth

rehabilitation.

Benefits
• To verify plaster records in centric and to adjust the horizontal
condylar inclination in the articulator.

• To verify centric records during full mouth rehabilitation.

• To check the accuracy of hinge axis transfer.

• To observe processing errors during clinical remount procedure.

• To simplify waxing and carving procedure, as the master cast can be

easily removed from the articulator and replaced back.
Split cast methods
• Custom cut notches (Lauritzen)

• Custom-made grooves

• Split cast formers – diagonal grooves

• Magnetic split cast

Technique employed

Preparation of the primary cast

• Impression is poured with stone conventionally.

• Sides and base of the cast is trimmed to form a primary cast.

Preparation of the secondary cast

• V-shaped notches are made on the base of the cast with cylindrical
stone.

• Two notches are made in the area of lateral incisor, two at the buccal
border and one at the posterior border of the cast.

• Box the cast after applying separating medium around the cast.

• Stone is poured in the boxed cast with different colour to form the
secondary cast.

Separation of the split cast

• Secondary cast is separated from the primary cast and its fit into the
grooves is verified.
• The separated secondary cast is assembled back on the primary cast.

• Split cast consists of a primary cast with five notches and a

secondary cast with five ridges corresponding to the notches.

Articulation of the split cast

• Split cast is mounted on the articulator with the help of facebow
transfer.

• Split cast technique allows separation of the primary cast from the
secondary cast which is mounted on the upper member of the
articulator.

Mounting lower cast to articulator with centric

record
Centric interocclusal record is used to mount the lower cast with the
upper cast.

Verification of several interocclusal centric

records with split cast
• After mounting, the interocclusal record is removed and the second
record is placed in its position over the lower cast.

• Upper split cast is removed from the mounting and positioned over
the interocclusal record.

• The upper member of the articulator which has the secondary cast is
lowered into the base of the upper primary cast until the notches
engage its counterpart.

• If the notches engage accurately, the interocclusal centric record is

correct.
• If the notches do not engage accurately, another interocclusal record
is made.

• At least two interocclusal centric records should fit the cast

accurately in order to verify the record.

• This shows consistency and accuracy of the interocclusal centric

record.

• Only then it is accepted as the true centric record.

Bennett movement
Definition
Bennett movement or laterotrusion is defined as ‘condylar movement on
the working side in the horizontal plane. This term may be used in
combination with terms describing condylar movement in other planes, for
example, laterodetrusion, lateroprotrusion, lateroretrusion and
laterosurtrusion’. (GPT 8th Ed)
Or
‘the direct lateral side shift of the mandible that occurs simultaneously with a
lateral mandibular excursion’. (Bouchers)
The term Bennett movement is obsolete and is referred to as
lateroretrusion.
Bennett angle is defined as ‘the angle formed between the sagittal plane
and the average path of the advancing condyle as viewed in the horizontal
plane during lateral mandibular movements’. (GPT 8th Ed)

Importance
• For the articulators to simulate the jaw movements, the location of
the axis of rotation, establishment of the horizontal and lateral
condylar guidances and the provision for the Bennett shift should
be incorporated.

• Bennett movement was first described by Dr Norman Bennett in 1908

(Fig. 5-13).

• He showed that the working side condyle moved outwards (bodily

shift) during the lateral movement of the mandible in the frontal
plane.

• The amount of the medial movement of the balancing condyle

during the lateral excursion governs the magnitude of the direct
 lateral slide of the mandible.

• Bennett shift is the bodily shift of the entire mandible when the
patient moves the mandible from its centric position into its pure
laterotrusive position.

• Bennett side shift has two components, namely, the immediate side
shift and the progressive side shift (Table 5-3).

• Immediate side shift is defined as ‘the translatory portion of the lateral

movement in which the nonworking condyle moves essentially straight
and medially as it leaves the centric relation position’. (GPT 8th Ed)

• Immediate side shift occurs when the nonworking condyle moves

from CR straight medially (1.0 mm). It varies according to the shape
of the glenoid fossa.

• Progressive side shift occurs at a rate which is directly proportional

to the forward movement of the balancing condyle on the opposite
side.

• Immediate side sift occurs in the early stages of the horizontal

lateral movement. When the mandible moves laterally,
simultaneously the mandible translates first an average of 0.4 mm
towards the working side and then shifts to the lateral rotational
movement.

• The amount of immediate side shift varies between individuals from

0 to 2.6 mm with a mean of 0.42 (S. Hobo, 1982).

• During balancing of occlusion, if the immediate side shift is

reflected on the cuspal morphology, a centric slide is created by
grinding the slopes of the opposing teeth so that the cusp tips move
by the immediate side shift towards the working side.

• Beyond the immediate side shift, the condyles move forward,

downwards and inwards. N.F. Guichet referred this movement as
 the progressive side shift.

• Progressive mandibular lateral translation ‘this is the translatory

portion of the lateral movement that occurs at a rate or amount which is
directly proportional to the forward movement of the orbiting condyle’.
The value of the progressive lateral translation is about 7.5° (H.C.
Lundeen).

• The horizontal condylar path on the nonworking side or balancing

side is composed of the immediate and progressive side shift (Fig.
5-14).

• Bennett angle is the angle formed by the orbital path (horizontal

lateral condylar path) and the sagittal plane. It varies between 2°
and 44° with a mean of 16° (S. Hobo and H. Takayama, 1993).

• Bennett angle is adjusted in the articulator (semi- and fully

adjustable). It is the angle between the condylar tract of the
articulator and the midsagittal plane.

• The Bennett angle on the nonworking side controls the amount of

lateral movement of the working side on the articulator.

• Bennett shift is governed by the shape of the glenoid fossa,

looseness of the capsular ligaments and the contraction of the lateral
pterygoids in a normal subject.

• The timings of the Bennett movement occur at the rate or amount of

descent of the contralateral condyle and the rotation and lateral
shift of the ipsilateral condyle.
 FIGURE 5-13 Diagrammatic representation of Bennett
movement of mandible. The working condyle (W) moves
laterally (outwards) towards right and the balancing condyle
(B) moves medially (inwards).

FIGURE 5-14 Horizontal lateral condylar path. ISS,

immediate side shift; PSS, progressive side shift; BA, Bennett
angle.
TABLE 5-3
DIFFERENCES BETWEEN IMMEDIATE SIDE SHIFT AND
PROGRESSIVE SIDE SHIFT

Immediate Side Shift Progressive Side Shift

Takes place before rotation of the condyles Accompanies rotation of the condyles
It is an instantaneous side shift Gradual side shift
It is measured at the horizontal plane Measured at the sagittal plane
Measured in millimetres, usually less than 2 mm Measured in degrees, value usually less than 20°
The balancing condyle moves straight and Occurs at a rate which is proportional to the forward
medially from the centric position movement of the balancing condyle

Key Facts
• Arcon articulators contain the condylar guidance within the upper
member and the condylar elements within the lower member.

• Functional articulation is the occlusal contact of the maxillary and

mandibular teeth during mastication and deglutition.

• Bennett angle is formed between the sagittal plane and the orbital
path (horizontal lateral condylar path). Average Bennett angle is
between 7.5º and 12.8º.

• Bonwill triangle is a 4-inch equilateral triangle bounded by lines

connecting the contact points of the incisal edges of mandibular
central incisors to each condyle and from one condyle to the other.

• Frankfurt horizontal plane (FH plane) is a horizontal plane which

is established by joining the line between the lowest point on the
margin of the orbit to the highest point on the margin of the
auditory meatus.

• Bonwill triangle was first given by W.G.A. Bonwill in 1858.

• Fischer’s angle is the angle formed between the sagittal protrusive

condylar path and the sagittal lateral condylar path. Its average
value is 5º.
• Pantographic tracing is the graphic record of the jaw movements
recorded in all the three planes, i.e. horizontal, sagittal and frontal
with the help of styli on the recording tables of the pantograph or
by means of electronic sensors.

• The articulation of natural dentures in the patient mouth is called

anatomical articulation.

• Dummy dentures used for preliminary work in denture

construction are called occlusal rims.

• Pure hinge movement occurs at the terminal hinge position.

• Bennett shift of the mandible is the direct lateral shift of the condyle
during lateral movements.

• Kinematic facebow is attached to the lower rim.

• Balkwill’s angle is the angle formed between the occlusal plane and
the Bonwill’s triangle.

• Average progressive Bennett shift is 7.5º.

• Average immediate Bennett shift is between 0 and 2.5 mm.

• The intercondylar distance in Whip-Mix articulator can vary

between 88 and 112 mm.

• RUM position (rearmost, uppermost, midmost condylar position) of

the condyles was proposed by C.E. Stuart (1969). It was considered
a physiologic condylar position, harmonious with the centric
occlusion.
CHAPTER 6
Maxillomandibular relationship

CHAPTER OUTLINE
Introduction, 99
Record Bases, 100
Definition, 100
Criteria for Selecting Record Bases, 100
Materials for Record Bases, 100
Stabilization of Record Bases, 101
Occlusal Rims and Their Importance, 101
Factors Affecting Fabrication of Rims, 102
Physiological Rest Position, 104
Definition, 104
Factors Influencing the Physiological Rest
Position, 104
Niswonger’s Method of Recording Rest
Position, 105
Vertical Jaw Relation, 105
Vertical Dimension, 105
Mechanical Methods, 106
Physiologic Methods, 108
Freeway Space or Interocclusal Rest Space, 109
Silverman’s Closest Speaking Space, 110
Method to Record Closest Speaking
Space, 110
Effects of Altered Vertical Dimension, 111
Effects of Excessively Increased Vertical
Dimension, 111
Effects of Excessively Decreased Vertical
Dimension, 111
Horizontal Jaw Relation, 111
Centric Relation, 111
Methods of Retruding Mandible in Centric
Relation Position, 112
Factors Affecting Centric Relation Records, 113
Concepts of Centric Relation Records, 113
Graphic Method of Recording Centric
Relation, 114
Functional Methods, 117
Physiologic Method, 118
Tentative Jaw Relation, 119
Pressureless Method, 120
Staple Pin Method, 120
Swallowing Method, 120
Pressure Method, 120
Eccentric Jaw Relations, 120
Procedure, 121
Introduction
In an edentulous patient, removal of all the teeth leaves a space
between the two residual ridges which was previously occupied by
teeth and supporting structures. The record bases and occlusal rims
replace these structures and the teeth while establishing the
preliminary jaw relations.
One of the primary requirements to establish the correct jaw
relation is to fabricate an accurate record base.
Record bases
Definition
– ‘A temporary form representing the base of a denture which is used for
making maxillomandibular (jaw) relation records and for arrangement of
teeth’. (GPT 8th Ed)
It is a working matrix for recording the jaw relation registrations
and for setting the teeth. These are not just static devices but an
important means of communication between the dentist and the
patient and between the dentist and the laboratory technician.

Criteria for selecting record bases

• Record bases should be dimensionally stable both in the mouth and
cast.

• These should be well adapted and accurately formed on the cast.

• These should be free of voids or sharp projections on the impression

surface.

• Extent and shape of the borders should resemble the finished

dentures.

• These should provide enough space for teeth arrangement.

• These should be fabricated from materials which are dimensionally

stable.

• These should be easily removed from the cast and from the mouth.

Materials for record bases

There are several materials used for fabricating the record bases.
There are two types of record bases:

• Temporary

• Permanent

Materials used for temporary record bases:

• Shellac

• Cold-cure acrylic

• Vacuum-formed vinyl or polystyrene

• Baseplate wax

Materials used for permanent record bases:

• Heat-cure acrylic

• Gold

• CoCr alloy

• NiCr alloy

Ideal requirements for materials

The materials should fulfil certain criteria for their selection as
follows:

• These should be rigid even in thin sections.

• These should readily adapt to the required shape and contour.

• These should not distort during fabrication.

• These should not exhibit flow at mouth temperature.

• These should be biocompatible and nonreactive to the tissues.

Stabilization of record bases

Additional stability can be provided to the record bases by using:

• Zinc oxide eugenol paste

• Light-bodied rubber base impression material

• Soft liner denture resins

Occlusal rims and their importance
Occlusal rims are defined as ‘occluding surfaces fabricated on interim or
final denture bases for the purpose of making maxillomandibular relation
records and arranging teeth’. (GPT 8th Ed)
Occlusal rims are usually made of wax which are used to establish
an accurate maxillomandibular relationship and for arranging teeth
on temporary denture base to form trial dentures (Fig. 6-1).

FIGURE 6-1 Well-adapted record base with occlusal rims.

Functions of Occlusal Rims

• Help in determining the length and width of artificial teeth

• Provide proper lip support

• Midline of the arch used as a guideline to arrange maxillary central

 incisors accurately

• Provide proper cuspid eminence

• Provide space for teeth arrangement

Factors affecting fabrication of rims

The following four factors are important during fabrication of occlusal
rims:

(i) Relationship of natural teeth to alveolar bone

(ii) Relationship of occlusal rims to residual alveolar ridge

(iii) Fabrication techniques

(iv) Clinical guidelines for occlusal rims

Relationship of natural teeth to alveolar bone

Artificial teeth should be placed in the same position as occupied by
the natural teeth.

Anterior teeth

• Maxillary anterior teeth are inclined labially and provide support to

the upper lip and the corners of the mouth.

• Incisal edge of the upper anterior teeth approximates the vermillion

border of the lower lip.

• Mandibular incisors are inclined labially and support the lower lip.

• Incisal edge of the lower anteriors is 1–2 mm behind the lingual

surfaces of the maxillary incisors.

Posterior teeth
• Maxillary posterior teeth are buccally inclined, whereas the
mandibular posterior teeth are inclined lingually.

• Maxillary buccal cusps usually project 2–3 mm beyond the buccal

cusps of the mandibular teeth in occlusion.

Relationship of occlusal rims to residual alveolar

ridge
• Occlusal rims reproduce the location and dimensions of the natural
teeth and their relationship to the anatomic structures.

• Artificial teeth should be arranged in position occupied by the

natural teeth (Fig. 6-2).

• Occlusal rims are used to determine the original vertical dimension

even in a resorbed ridge case.
 FIGURE 6-2 Position of occlusal rims should be similar to
that of natural teeth: (A) position of natural teeth; (B) position
of occlusal rims.

Clinical guidelines for occlusal rims

• Proper contour of the occlusal rims is determined by carefully
observing the nasolabial sulcus, mentolabial sulcus, the philtrum
and the corner of the mouth.

• If the occlusal rims do not provide proper lip support, there will be
deepening of the nasolabial and mentolabial sulci.

• Anterior length of maxillary rim is adjusted 1–2 mm below the

lower edge of the lip. This lip position is called the low lip line.

• Maxillary posterior plane is adjusted such that the height in the first
molar region is one quarter inch below the Stenson’s duct.
• Upper anterior plane should be parallel to the interpupillary line.

• Upper posterior plane should be parallel to the Camper’s line (line

projected from the ala of the nose to the superior edge of the tragus
of the ear) (Fig. 6-3).

• Cuspid eminences are marked by placing lines at the corners of the

mouth which represents the approximate location of the distal
surface of the canines.

• Posterior part of the lower occlusal rim extends to two-thirds the

height of the retromolar pad.

• Posterior to the cuspid area, the lower rims should be located over
the centre of the crest of the ridge.

FIGURE 6-3 Relationship between interpupillary line,

 Camper’s plane and the occlusal plane (anterior occlusal
plane should be parallel to interpupillary line; posterior
occlusal plane should be parallel to Camper’s plane).

Dimensions of occlusal rims

Maxillary occlusal rims

• Vertical height of the maxillary rim in the anterior is approximately

22 mm from the reflection of the cast.

• Width of the rim in anterior region is 5 mm and in posterior region

is 8–10 mm.

• Occlusal rim in the posterior region measures approximately 18 mm

from the depth of the sulcus.

• Anterior rim is labially inclined and the anterior edge of the rim in
the midline is approximately 8–10 mm from the incisive papilla
(Figs 6-4 and 6-5).
 FIGURE 6-4 Dimension of maxillary and mandibular rims.

FIGURE 6-5 Width of the maxillary and mandibular rims.

Mandibular occlusal rims

• Anterior vertical height is 6–8 mm when measured from crest of the

 ridge and 18 mm when measured from the depth of the sulcus in
canine region.

• Width of the rim in anterior region is approximately 5 mm and in

posterior region is 8–10 mm.

• The occlusal plane in the posterior region should flush with two-
thirds the height of the retromolar pad.

Fabrication techniques
Rolled wax technique:

• This is a commonly used method.

• A sheet of wax is softened over the flame and is

rolled to a width of 4 mm.

• Care is taken to avoid trapping of air bubbles

during rolling.

• The rolled wax is shaped in the form of cylinder.

• This cylinder of wax is placed on the record base

and is adapted and contoured to the shape of the
arch.
Preformed occlusal rims:

• Preformed occlusal rims of varied consistency, i.e.

soft and hard, are available.
• These are preformed rims which are placed on the
record bases and contoured according to the shape
of the arch.

• Alternately, metal occlusal rim formers can be used

to fabricate occlusal rims from base plate wax or
scrap wax.
Physiological rest position
Definition
Physiological rest position is defined as ‘the habitual postural position of
the mandible when the patient is sitting comfortably in the upright position
and the condyles are in a neutral unstrained position in the glenoid fossae’.
It is also called the rest position or postural position of the mandible or
the vertical dimension of rest. This is the position of the mandible in
relation to the maxilla when the maxillofacial musculatures are in a
state of tonic equilibrium. This position is influenced by the muscles of
mastication and muscles involved in speech, swallowing and
respiration.
There are two main hypotheses about the postural position of the
mandible. One involves an active mechanism and other involves a
passive mechanism.

• According to the active mechanism, this position is assumed when the

muscles that close the jaws and that open the jaws are in a state of
minimal contraction to maintain the posture of the mandible.

• The second hypothesis which is the passive mechanism states that the
elastic elements of the jaw musculature, and not any muscle
activity, balance the influence of gravity.

Significance of the Physiological Rest

Position
• It is bone–bone relation in vertical direction.

• In absence of the pathosis, the relation is fairly constant throughout

the life.

• It is measurable and repeatable position within acceptable limits.

• It determines vertical dimension of occlusion.

• It is essential for health of the basal tissues.

• It gives rest to muscles and safeguards against fatigue.

• It prevents soreness and helps in minimizing residual ridge

resorption.

Factors influencing the physiological rest position

• Anatomical factors

• Physiological factors

• Pathological factors

Anatomical factors
• Role of periodontal ligament

• Tongue

• Teeth: Space between teeth is essential when mandible is at rest. If no

space is available between teeth in dentures, the patient will
complain of discomfort, pain and generalized hyperaemia.

• Muscles of facial expression

Physiological factors
• Gravity: Position of the mandible is influenced by gravity.

• Postural position: The patient should sit upright with the head erect,
looking straight ahead when jaw relations are recorded.
• Psychic factor: Rest position is relaxed position of the mandible.
Values of measurements obtained are questionable when patient is
tensed, nervous, tired or irritable.

Pathological factors
• Pathology of bone or joint

• Effect of anaesthetic drug

• Neuromuscular disorder: It is difficult to determine

maxillomandibular relations with such patients. The dentist should
have patience and be considerate to such patients.

Niswonger’s method of recording rest position

• This method was given by M.E. Niswonger and M.J. Thompson in
1934.

• The patient is asked to sit upright with head unsupported in relaxed

state.

• Two arbitrary points are marked with indelible pencil, one at the
base of the nose and another at the chin.

• Upper and lower rims are inserted and the patient is asked to look
straight and repeatedly swallow and relax.

• The distance between the two points is measured and the procedure
is repeated till two measured values coincide.

• After relaxation is obvious, the lips are carefully parted to evaluate

the amount of space between the rims.

• This space in the rest state is between 2 and 4 mm when viewed in

the premolar region. It is called the freeway space.
• The interarch space and rest position are measured by using
indelible dots or adhesive tape on the face.

• Vertical dimension at rest (VDR) is determined by using a formula:

VDR = VDO + freeway space.

• If freeway space is more than 4 mm, the vertical dimension in

occlusion (VDO) is considered too small and if the space is less than
2 mm, the VDO is considered too large.

• It is important to record adequate interocclusal space when the

mandible is in rest position.

• Although it is not an accurate method but when used with other

methods, it will aid in recording proper maxillomandibular relation.
Vertical jaw relation
It is defined as ‘a registration of any positional relationship of the mandible
relative to the maxillae, made at any vertical orientation’.

Vertical dimension
The distance between two selected anatomic or marked points
(usually one on tip of the nose and the other upon the chin), one on a
fixed and one on a movable member.

• Vertical jaw relation can also be defined as the amount of separation

between the maxilla and mandible in a frontal plane.

• This record provides the optimal separation between the maxilla

and mandible.

• If this record is not measured accurately, the joint will be strained

(overextended or underextended).

• The vertical separation between the maxilla and the mandible

depends on the TMJ and the muscles of mastication.

• If the vertical dimension is altered, there will be severe discomfort in

both the TMJ and muscles of mastication.

• This relation is the easiest to record but is very critical, as errors in

vertical dimension are the first to produce discomfort and strain.

Objectives of recording optimal vertical

dimension
• To maintain aesthetic harmony of the face

• For proper speech

• To satisfy functional requirements

• To provide comfort to the TMJ, masticatory muscles and residual

ridge

• To preserve residual ridge

Methods of Determining Vertical Relations

Mechanical methods
(i) Ridge relation

• Distance of incisive papilla from mandibular

incisors

• Parallelism of the ridges

(ii) Measurements of the former dentures

(iii) Pre-extraction records

• Profile radiographs

• Articulated casts

• Facial measurements

• Profile silhouettes

• Profile photographs
• Wright’s method

• Willis method

• Face mask

Physiologic methods
(i) Physiologic rest position

(ii) Phonetics and aesthetics as guides

(iii) Swallowing threshold

(iv) Tactile sense or neuromuscular perception

(v) Patient-perceived comfort

(vi) Occlusion rims

(vii) Bimeter

Mechanical methods

Ridge relations
Distance from incisive papilla from mandibular incisors

• Incisive papilla is a stable landmark that does not change a lot with
the resorption of the alveolar ridges (Fig. 6-6).

• The distance between the incisive papilla and the lower incisors will
be approximately 4 mm.

• The incisal edges of the maxillary central incisors are usually 8–10
 mm anterior to the centre of the incisive papilla.

• The average vertical overlap between the upper and lower incisors
is, therefore, 2 mm (overbite).

FIGURE 6-6 Incisive papilla is a stable landmark on the

palate.

Ridge parallelism

• The residual ridges are parallel to each other during occlusion in

natural teeth.

• This factor can be used to determine the vertical dimension at

occlusion.

• Both the alveolar ridges when parallel to each other at vertical

dimension of occlusion enhance the stability of the denture.

• The mandible of the patient is adjusted parallel to the maxilla.

• The position associated with a 5° opening of the jaw in the posterior

 region usually gives a correct amount of jaw separation (Sears).

• This method is not reliable in patients who have lost their teeth at
different times.

Measurements of former dentures

• Patients’ existing dentures are valuable aid in determining the
amount of change required.

• Boley’s gauge is used to measure the distance between the borders of

the maxillary and mandibular dentures when in occlusion.

• If the distance is less, the corresponding change is made in the new

dentures.

Pre-extraction records
Profile radiographs

• Profile radiographs of face may be used to determine vertical

dimension of rest position.

• Inaccuracies of techniques and magnification factor limit the use of

this method.

Articulated casts

• Dentulous patient’s casts are mounted onto the articulator using

facebow transfer.

• Occlusal record with the jaws in correct centric relation (CR) is used
to mount the mandibular casts.

• After extraction of the teeth, the edentulous casts are mounted onto
the articulator and the interarch distance is compared.
• Usually the edentulous ridges are parallel to each other at the
correct vertical dimension of occlusion.

• This method is valuable in the patients where residual ridges are not
sacrificed during teeth removal.

Facial measurements.
The distance between the base of the nose and the undersurface of the
chin is measured by means of pair of calipers or divider before the
teeth are extracted (Fig. 6-7).

FIGURE 6-7 Facial measurements made with calipers.

Profile silhouettes
• An accurate reproduction of the profile can be cut out in cardboard
or contoured in wire from patient’s photograph.

• This silhouette acts as a template.

• It can be repositioned to the face after the vertical dimension has

been established at the initial recording and when the artificial teeth
are tried.

Profile photographs

• The profile photographs with teeth in maximum intercuspation are

enlarged to life size.

• Measurements of the anatomic landmarks on the photographs are

compared with those on the face during wax try-in and when
interocclusal records are made.

Wright’s method

• A recent full face photograph of the patient is obtained when patient

had natural teeth.

• According to W.H. Wright, a ratio exists between the interpupillary

distance and brow to chin distance in natural teeth.

• It is not a reliable method.

Willis method

• Willis observed that the distance from the base of the nose to the
 lower edge of the mandible is equal to the distance between the
pupil of the eye and rima oris.

• These facial distances are measured with the help of Willis gauge.

• It is also called eye-lip-nose-chin method.

• The vertical dimension is acceptable, if both these facial distances

are equal.

Limitations

• It is difficult to generalize the anthropometric measurements.

• Soft tissue landmarks can vary among individuals.

Face mask

• Prior to extraction of the teeth, face mask is made with acrylic resin
after making impression of the face with alginate.

• This transparent mask is placed over the face of the patient at the
time of determining the vertical dimension in edentulous jaws.

• The patient’s face will accurately fit in the mask when correct
vertical dimension is obtained.

Physiologic methods

Physiologic rest position

It has already been described earlier in the chapter.

Phonetics and aesthetics as guide

Phonetics
• This method involves the observation of movements of the oral
tissues and analysing speech of the patient.

• It is a widely used method to determine the proper vertical

dimension of occlusion.

• The production of ‘ch’, ‘s’ and ‘j’ sounds bring the upper and lower
teeth very close to each other (Fig. 6-8).

• This small amount of space between the upper and lower teeth in
the anterior region is called Silverman’s closest speaking space.

• If this space is too large, the VDO is too small and if this space is too
small, the VDO is too great.

• Phonetics can also be used as a guide by observing the anterior teeth

relation when patient makes ‘F’ or ‘V’ and ‘S’ sounds.

• The position of the upper anterior teeth is determined by the

position of the maxillae when the patient says the words beginning
with ‘F’ or ‘V’.

• The position of the lower anterior teeth is determined by the

position of mandible when the patient says the words beginning
with ‘S’.
 FIGURE 6-8 Position of upper and lower teeth during ‘S’
sound production.

Aesthetics

• It is affected by the vertical relation of the mandible to the maxillae.

• Aesthetics can be used as a guide to determine correct vertical

dimension by selecting teeth of the same size as the natural teeth
and also by correctly assessing the residual ridge resorption.

Swallowing threshold
• The position of the lower jaw at the beginning of swallowing is used
as a guide to establish the vertical dimension of rest and occlusion.

• This method is based on the theory that when a person swallows,

the teeth come together with a very light contact at the beginning of
the swallowing cycle.
• Upper and lower record bases are inserted in the patient’s mouth.

• Soft wax cones are added to the lower occlusal rim and the patient is
given a candy to stimulate salivation.

• On repeated swallowing, the wax cones get flattened and allow the
mandible to reach the correct vertical dimension of occlusion.

• Softness of wax and the length of time this action is continued can
affect the results.

Tactile sense method

• Patient’s tactile sense can also be used as a guide to establish vertical
dimension of occlusion.

• Here, central bearing plate is attached to the lower rim and central
bearing screw is attached to the upper rim.

• The bearing screw is opened to increase the vertical dimension and

then it is slowly closed till the patient is comfortable at a particular
height.

• This height, where the patient is comfortable, determines the correct

vertical dimension.

• Limitation: The patient may not be comfortable with the presence of

foreign objects on the palate and tongue space.

Patient’s perceived comfort

Here, excessively long occlusal rims are inserted in the patient’s
mouth and the rims are reduced stepwise till the patient perceives the
height to be comfortable.

Occlusal rims
• Wax occlusal rims can be used to establish both the tentative vertical
dimension of occlusion and the tentative CR.

• After the casts are articulated, a tracing device is attached to the

occlusal rims for use in graphic tracing.

• Facial expression and aesthetics are used for final evaluation, after
teeth are arranged for trial dentures.

Bimeter
• This method is based on the theory that muscles are capable of
exerting maximum force from the position of the mandible, when
the teeth first contact in centric occlusion.

• The bimeter measures biting forces from which the vertical

dimension of occlusion can be determined.

• This method was suggested by R.H. Boos (1940).

• Metal plate is attached to accurately fitting maxillary record base to

provide a central bearing point.

• Vertical distance is adjusted by turning the cap.

• Patient is asked to bite on the record bases at different degrees of

jaw separation.

• When maximum reading (power point) is indicated, plaster

registrations are made and casts are transferred to the articulator.

• Pain experienced by patient during this method influences the

reading and limits its use.
Freeway space or interocclusal rest
space
The distance between the vertical dimension of rest and vertical
dimension while in occlusion is called the freeway space.

• In the natural dentition when the mandible assumes its

physiological rest position, there exists a space between the upper
and lower teeth.

• This interocclusal space observed in the premolar region is around

2–4 mm and is called the freeway space.

• It is used to establish the proper vertical dimension when the

muscles are in physiologic tonus and the mandible is in rest
position.

• It is a static position.

• VDO is established by using this formula.

VDO = VDR – freeway space

• Freeway space as given by various authors are as follows:

• M.J. Thompson: 2–3 mm.

• H. Sicher: 2–5 mm.

• M.E. Niswonger: 3 mm.

• M.A. Pleasure: 3 mm.
Silverman’s closest speaking space
• It is defined as ‘the closest relationship of the occlusal surfaces and incisal
edges of the mandibular teeth to the maxillary teeth during function and
rapid speech’.

• Meyer Silverman (1953) suggested the use of closest speaking

method to record vertical dimension.

• This method can be used as follows:

• As pre-extraction record

• To determine vertical dimension during jaw

relation procedure

• To verify the available interocclusal space during

wax try-in

Method to record closest speaking space

• The patient is seated in upright position with head unsupported and
made to close in centric occlusion.

• A line is drawn on the lower anterior teeth at the horizontal level of

the incisal edges of the opposing upper anterior teeth.

• This line is called centric occlusion line.

• The patient is asked to pronounce words such as Mississippi or to

count numbers 60 onwards (s sounds).

• During pronunciation of these words, the upper anterior teeth come

 close to the lower teeth.

• This is the closest speaking relation of the mandible to the maxilla

(Fig. 6-9).

• Again a horizontal line is drawn on the lower anterior teeth at the

horizontal level of corresponding upper teeth.

• This line is called closest speaking line.

• The distance between the centric occlusion line and the closest
speaking line is called the closest speaking space between the upper
and lower teeth.

• This space is usually 1–2 mm.

• A decrease in closest speaking space indicates increased vertical

dimension and vice versa.

• The closest speaking space measures vertical dimension when the

mandible and muscles involved are in physiologic function of
speech.

• It is considered as dynamic or functional position.

FIGURE 6-9 Silverman’s closest speaking space.
Effects of altered vertical dimension
Effects of excessively increased vertical
dimension (fig. 6-10)
• Increased lower facial height

• Difficulty in swallowing and speech

• Muscular fatigue

• Trauma caused by constant pressure on mucosa

• Loss of freeway space

• Clicking of complete dentures

• Patient discomfort

• Stretching of facial muscles produces expression of strain

• Excessive trauma to the lower denture-bearing area

 FIGURE 6-10 Altered vertical dimension.

Effects of excessively decreased vertical

dimension
• Decreased lower facial height

• Angular cheilitis due to folding of corners of mouth

• Difficulty in swallowing

• Pain, clicking and discomfort of TMJ may result in TMJ pain

dysfunction syndrome

• Cheek biting

• Loss of lip fullness

• Loss of muscle tone

• Drooping of corners of the mouth

• Thinning of vermilion borders of the lip

• Obstruction of Eustachian tube due to elevation of the soft palate
due to elevation of tongue and mandible

• Increased trauma to denture-bearing area

Horizontal jaw relation
Centric relation

Definition
‘The maxillomandibular relationship in which the condyles articulate with
the thinnest avascular portion of their respective discs with the complex in
the anterosuperior position against the slopes of articular eminences. This
position is independent of tooth contact. This position is clinically discernible
when the mandible is directed superiorly and anteriorly. It is restricted to a
purely rotary movement about the transverse horizontal axis’. (GPT 8th Ed)
‘The most retruded physiologic relation of the mandible to the maxillae to
and from which the individual can make lateral movements. It is a condition
that can exist at various degrees of jaw separation. It occurs around the
terminal hinge axis’. (GPT 5th Ed)
‘The most retruded relation of the mandible to the maxillae when the
condyles are in the most posterior unstrained position in the glenoid fossae
from which lateral movement can be made at any given degree of jaw
separation’. (GPT 1st Ed)

Theories of centric relation

Generally, there are four accepted theories to explain the centric
relation (CR):

(i) Muscle theory

(ii) Ligament theory

(iii) Osteofibre theory

(iv) Meniscus theory

Muscle theory.
This theory considers CR to be a product of a dense reflex which
causes the external pterygoid muscles to contract and thus to halt the
jaw every time the condyles or the interarticular disc approach the
posterosuperior depth of the glenoid fossae.

Disadvantage.
It does not explain the following:

• CR is same at any vertical level

• The sharpness of Gothic arch

• Posterior hinge movement

Ligament theory.
This theory was advocated by A. Ferrein.

• Ligament joins the elements of articulation, limits their movements

and is capable of determining terminal border positions.

• It provides acceptable physiologic explanation.

Limitations

• It does not explain the lateral border movements.

• It does not explain the satisfactory location of hinge axis.

Osteofibre theory

• This theory was proved by M.L. Meyers.

• It involves a retrusive terminal stop formed by the soft tissues of the

posterior part of the roof of the glenoid fossa.

• This fibrous stop acts as a buffer and was found to be loose, fibrous
and functionally differentiated.
• Zenker called this structure as ‘retroarticular cushion’.

Meniscus theory

• This theory was given by P. Saizer.

• The CR position is myologically active position.

• In order to attain this position and maintain it, a patient should

retain the predominance of the retropulsive and elevating muscle
structures.

Significance of Centric Relation

• It is a bone–bone relationship.

• It is repeatable, recordable and learnable position which remains

constant throughout the life.

• The patient can voluntarily and reflexly return to this position.

• CR is a horizontal reference position in recording

maxillomandibular relations and a starting point for developing
occlusion. It is a point of return.

• This position is verifiable.

• The CR and centric occlusion of the artificial dentures should

coincide, otherwise the stability of dentures will be jeopardized.

• The casts should be mounted in CR because it is a point from which

all movements can be simulated on the articulator.

• CR should be accurately recorded and transferred onto the

articulator to permit proper adjustments of the condylar guidance.

• Edentulous patients use CR position for chewing and swallowing.

• The muscles, bones, ligaments, teeth and all related structures grow
into this muscle centre. Stability of natural teeth is jeopardized when
mandible loses its centric position.

Methods of retruding mandible in centric relation

position
• The mandible should be in its most posterior position while
recording CR.

• Some patients may show difficulties in retruding the mandible due

to certain biological, psychological and mechanical difficulties.

Method of retruding the mandible

• Relax the patient. Make him/her feel comfortable.

• The patient is asked to try to bring his/her upper jaw forward while
occluding on the posterior teeth.

• The patient should be instructed to touch the posterior border of the

upper record base with his/her tongue.

• The mandible occlusal rim should be tapped gently with a finger.

This would automatically make the patient to retrude his/her
mandible.

• The temporalis and the masseter are palpated to relax them.

Difficulties in retruding mandible

Difficulties in retruding the mandible can be classified as follows:

• Biological

• Physiological
• Mechanical

Biological causes

• Lack of coordination between groups of opposing muscles when the

patient is requested to close in the retruded position.

• Habitual eccentric jaw relation.

Physiological causes

• Inability of the patient to follow the dentist’s instructions is one of

the major psycho-physiological factors, which produce difficulty in
retruding the mandible.

• This is overcome by instituting stretch–relax exercises, training the

patient to open and close his/her mouth. Central bearing devices
can also be used to retrude the mandible in these patients.

Mechanical causes.
Poorly fitting base plates produce difficulty in retruding the mandible.
The base plates should be checked using a mouth mirror for proper
adaptation.

Factors affecting centric relation records

Factors influencing the CR records are:

• Resiliency of the supporting tissues

• Accurate fit of the denture bases will ensure adequate retention and
stability of the CR record

• TMJ and its associated neuromuscular mechanism – any deviation

from the normal will affect the records

• Technique used in making the records and the accuracy of the

 recording devices used

• Skill and the knowledge of the clinician

• Cooperation and physical and mental well-being of the patient

• Correct maxillomandibular relationship

• Posture of the patient

• Size and form of the residual alveolar ridge

• Quality and quantity of the saliva

• Size and position of the tongue

• Psychic or emotional stress to the patient

• Protective relax action caused by the faulty occlusal contacts

• Materials and equipment used for making the records

• Accuracy of the articulators

• Use of articulators which do not adjust to all interocclusal check

records

Concepts of centric relation records

There are two basic differences in concepts and objectives of the CR
records as they relate to occlusion.

First concept
• The CR record should be made with minimal closing pressure so that
the tissues supporting the bases will not be displaced while the
record is made.
• The objective behind this is to achieve a uniform contact of the teeth
touching simultaneously at the very first contact. The uniform
contact of the teeth will not stimulate the patient to clench and relax
the closing muscles in periods between the meals.

Second concept
• The CR records should be made under heavy closing pressure, so
that the tissues under the recording bases are displaced while the
record is made.

• The objective of this concept is to simulate the same displacement of

the soft tissues as it would exist when the heavy closing pressure is
applied on the dentures. Therefore, the occlusal forces would be
distributed over the supporting residual ridges when the heavy
closing pressure is applied to the dentures.

• If the distribution of the soft tissues is uneven, the teeth will contact
unevenly on their first contact.

• This uneven contact can stimulate the nervous patient to clench and
relax the closing muscles of the jaws which can result in changes in
the residual ridges.

Both the concepts can be used to make CR records, but the clinician
should decide which method is best for individual patients. For most
of the patients, the first technique will provide best results.
Methods of Recording Horizontal Jaw
Relation
Classification of methods for recording CR:
According to C.O. Bouchers

(i) Static methods: In this, the mandible is caused to assume CR

position and the rims are locked into this position. Advantage is that it
causes minimal displacement of the recording bases in relation to the
supporting base.

(ii) Functional methods: Records are made when the mandible is in

function. The disadvantage of this method is causing lateral
displacement and anteroposterior displacement of the recording
bases.

A. Gysi and R.H. Kingery Classification

• Direct recording

• Graphic recording

• Functional recording

• Cephalometric method

Patient-guided methods of recording CR

• Schuyler technique

• Physiological technique

• Gothic arch (arrow point tracing)

• Myo-monitor technique

Operator-guided methods

• Chin point guidance methods

• Three finger chin point guidance methods

• Bimanual manipulation method

• Anterior guidance with Lucia jig

• Anterior guidance by a leaf gauge

• Anterior guidance by OSU Woelfel gauge

• Power centric registration method

Graphic method of recording centric relation

Definitions
Gothic arch tracing is defined as ‘the pattern obtained on the horizontal
plate used with a central bearing tracing device’. (GPT 8th Ed)

Gothic arch tracer is defined as ‘the device that produces a tracing that
resembles an arrowhead or a gothic arch. The device is attached to the
opposing arches. The shape of the tracing depends on the relative location of
the marking point and the tracing table. The apex of a properly made tracing
is considered to indicate the most retruded, unstrained relation of the
mandible to the maxillae, i.e. centric relation’. (GPT 8th Ed)

Graphic method records the tracing of the mandibular movements in

one plane. Graphic method can be accomplished either intraorally or
extraorally depending on the placement of the recording device (Table
6-1).

Table 6-1
DIFFERENCES BETWEEN EXTRAORAL AND INTRAORAL
TRACERS

Extraoral Tracers Intraoral Tracers

Placed outside the oral cavity Placed in the oral cavity
Visible Not visible
Tracings are larger Tracings are smaller
Apex is more discernible Difficult to locate true apex
No hole is required Tracer should seat in the hole for accuracy
Patient is guided and directed more easily Difficult to guide and direct the patient
Tracings made away from the centre of rotation Tracings made closer to the centre of rotation
Examples: Gysi, Hight and Stansberry tracers Examples: Seidel, Ballard and Masserman tracers
Evolution of graphic records
• Earliest graphic recordings based on the studies of mandibular
movements were given by F.E. Balkwill (1866).

• First ‘needle point tracing’ was done by F. Hesse (1897).

• A. Gysi (1910) improved and popularized graphic method of

recording CR position.

• Gysi used an extraoral tracer which had tracing plate attached to the
lower rim and the needle point attached to the upper rim.

• V.H. Sears (1926) placed the tracing plate in the upper rim and
needle point tracer in the lower rim.

• R. Hanau (1929) described the role of ‘Realeff’ which means ‘resilient

and like effect’ and argued that records made in wax had source of
errors due to this. He advocated equalization of pressure when
recording horizontal relationship.

• G.P. Phillips (1934) developed the ‘central bearing point’ based on

the concept that this device will produce equalization of pressure on
the supporting tissues.

• Phillips tracers indicate the path of the condyle and direction and position
of the mandible.

• Intraoral tracing devices are referred to as the combination of the

central bearing point with the needle point tracings, e.g. Seidel,
Ballard and Masserman tracers.

• M.M. Silvermann (1957) obtained the CR by incorporating a ‘biting

point’ on an intraoral central bearing device by means of tattooing
the alveolar ridges. Biting point was obtained by hard biting. He
believed with this the closing musculature placed the mandible in
the most retruded functional position.
• A. Obrez and C.S. Stohler (1996) stated that muscle pain had a
bearing on the static and dynamic occlusal contact relationship.

• Principles of the Gothic arch tracing were revisited in the BPS

system (biofunctional prosthetic system).

• Y Watanabe (1999) used personalized computer to analyse and

evaluate the horizontal mandibular position with the edentulous
positions.

Factors considered during graphic methods

• Stability of the record bases.

• Occlusal rims offer more resistance to horizontal movements than

central bearing point.

• Difficult to locate the centre of arches in excessively protruded or

retruded jaw relations.

• Difficult to stabilize record bases on the flabby or hyperplastic

tissues.

• Difficult to stabilize record bases on residual ridges with insufficient

height.

• Recording devices may not be compatible with normal physiologic

mandibular movements.

• Tracing with only sharp apex is considered acceptable.

• Double tracings indicate that the jaw movements were not

coordinated or recordings were made at different vertical
dimension.

• It is important to perform graphic tracing at the predetermined

vertical dimension of occlusion.
• Graphic methods can record the eccentric relations of the mandible
to the maxilla.

• These records are the most accurate visual means of recording CR.

Procedure of gothic arch tracing (graphic

methods)
• Vertical dimension of occlusion is predetermined.

• Tracing devices are attached to the occlusal rims and the rims are
placed in the mouth (Figs 6-11 and 6-12).

• Patient is instructed to open and close the mouth number of times

and the relationship of the stylus to the table which is coated with
black wax or soot is evaluated.

• It is made sure that pin is the only point of contact between the
mandible and the maxilla.

• First the patient is instructed to make the maximum anteroposterior

movement of the mandible to establish the protrusive range.

• The patient then moves the mandible backwards in a retruded

position.

• From the retruded position, the patient is instructed to move the jaw
laterally either to the right or left and to stop.

• The stylus is elevated and the patient is instructed to bring the

mandible back to the retruded position.

• Then the patient moves the jaw to the opposite side (either left or
right).

• The relationship at the initial point of contact to the apex of the

tracing is observed.
• The procedure may be repeated until a sharp well-defined tracing is
achieved.

• Ney’s mandibular excursion guide can be used to train the patient to

make appropriate mandibular movements.

FIGURE 6-11 Tracing devices attached to occlusal rims: (A)

central bearing pin; (B) central bearing plate.
 FIGURE 6-12 Tracing devices placed in patient’s mouth.

Importance of Gothic arch or needle point or arrowhead tracings or

stylus tracings:

• Needle point tracing is basically a single representation of the

position of the mandible and its movement in the horizontal plane.

• Dull or rounded apex of the needle point tracing is not indicative of

an exact CR.

• Sharp apex indicates the retruded position of the mandible, i.e. the
condyles are properly located in their glenoid fossae (Fig. 6-13).

• If the condyles do not pivot or do not have centres from which

lateral movements are made, a faulty tracing will be obtained.
 FIGURE 6-13 Gothic arch tracing should have sharp apex.

Drawbacks of the needle point tracings

• It is relatively time consuming.

• It requires well-defined, nondisplaceable upper and lower alveolar

ridges to allow stable and retentive acrylic bases.

• Large tongue can cause movement of the base during tracing.

• True excursive movements are difficult for the patient to repeat.

• Too much cooperation from the patient is required.

• Tracing restricts the available tongue space which may produce

recording errors.

Functional methods
Functional chew-in record is defined as ‘a record of the movements of the
mandible made on the occluding surfaces of the opposing occlusal rim by
teeth or scribing studs and produced by simulated chewing movements’.
(GPT 4th Ed)
Functional methods utilize the functional movements of the jaws to
record the horizontal jaw relation. The patient is instructed to move
the jaw in protrusion, retrusion, right and left lateral position until
most retruded position is identified.
Types of functional chew-in methods:

• Patterson method

• Needle–House method

Factors common to both the functional methods are:

• Both require a tentative interocclusal wax record of CR at the

tentative vertical dimension of occlusion.

• Occlusal rims are reduced in excess of the predetermined vertical

dimension of occlusion.

• Record bases should be accurately fitting and stable.

• Patient should have good neuromuscular control.

• Movable basal seat and lack of equalized pressure exerted on the

record base during eccentric movements can result in inaccurate
recording of the CR.

Patterson method
• M.F. Patterson (1923) used wax occlusal rims.

• A trough was made in the mandibular rim and was filled with a
mixture of plaster and corborundum paste (1:1 ratio) (Fig. 6-14).

• The patient was asked to move his/her mandible and continue the
motion until a curvature is formed on the rims.

• This is said to equalize pressure and provide uniform contacts in all

excursive movements.
• The movements of the mandible generated compensating curves in
the plaster and the corborundum.

• When this paste is reduced to the predetermined vertical dimension

of occlusion, the patient is instructed to retrude the mandible in this
position.

• This retruded position determines the horizontal jaw relationship

and both the rims are joined by means of staples.

FIGURE 6-14 Occlusal rims made with plaster and pumice

mix in Patterson method.

Needle–house method
• It is the more commonly used functional method.

• In this method, the occlusal rims are made of compound.

• Four triangular-shaped studs with cutting edges are place in the

maxillary rim in the premolar and molar regions (Fig. 6-15).

• The rims are inserted into the patient’s mouth and the patient is
instructed to make mandibular functional movements.
• During these movements, the studs engrave four separate Gothic arch
recordings into the block of compound.

• These tracings relate to movements in three planes and are called

the ‘chew-in’ recordings.

• These records are placed on an appropriate articulator, and the

condylar elements are adjusted accordingly.

FIGURE 6-15 Needle–House method: (A) Triangular-shaped

studs; (B) Gothic arch tracings in the lower rim.

Physiologic method
• It is also called static recording method.

• Phillip Pfaff (1756) first described this technique of ‘taking a bite’.

• This type of record made with wax or compound was called ‘mush’
or ‘biscuit’ or ‘squash’ bite.

• G.J. Christensen (1905) used the impression wax to record centric

relation.
• Jacob Greene (1910) used impression compound along with plaster
wash to record CR.

• To get accurate results from this method, the proprioceptors and

tactile sensation of the patient should be in normal range.

• W.H. Wright (1939) believed that accuracy of records was influenced

by resiliency of the tissues, saliva films, fit of the bases and the
pressure applied.

• W.B. Akerly (1979) described a direct tripodal method of recording

CR, which was a minimum pressure technique that could be
quickly and accurately verified.

Types of Physiologic Methods

• Tactile or interocclusal check record methods

• Pressureless method

• Pressure method

Tactile or interocclusal check records

• The normal functioning of the patient’s proprioception and tactile
sense is important in making an accurate record.

• These records are made by asking the patient to retrude the

mandible. This gives the tentative CR. This relation is verified by
using interocclusal records and errors, if any are corrected.

Factors influencing the interocclusal direct records are:

• Stability of the record base

• Number of reference points used to make the records

• Amount of pressure exerted on the displaceable tissues in the joints

• Amount and equalization of pressure depends on uniform

consistency of the recording material

Indications
• Abnormal skeletal jaw relation

• Large tongue

• Excessively displaceable tissues

• Abnormal mandibular movements

Commonly used materials

• Waxes

• Impression compound

• Dental plaster

• Zinc oxide eugenol paste

Waxes

• These are low-fusing materials.

• These offer little resistance to jaw closure when soft and these stiffen
quickly.

Advantages

• These can be used in a patient with poor muscular control.

• These require less time and equipment.

Disadvantages

• These can easily distort.

• These harden on the surface first then inside.

• These are technique-sensitive and do not provide uniform resistance

to pressure.

Compound, plaster and zinc oxide eugenol

• These should remain in contact until these harden.

• These normally break before distortion.

• Setting and hardening time can be controlled in case of plaster and

to less extent in zinc oxide paste but cannot be controlled in case of
compound.

• These records require longer time to set.

• These can be used when nonanatomic posterior teeth are used.

Tactile or interocclusal record can be made in following two steps:

• Tentative CR is recorded using wax rims attached to stable bases.

• Interocclusal check record is made during try-in stage.

Tentative jaw relation

• Maxillary rim is inserted in patient’s mouth and facebow transfer is
made.

• Maxillary cast is mounted on articulator.

• Vertical dimension at rest is established and the mandibular rims

are reduced to allow excess interocclusal distance.
• Recording material is placed in between and the tentative CR record
is made.

• The mandibular rim is mounted using this record and teeth are
arranged in this relation.

Interocclusal check record during wax try-in:

• Both maxillary and mandibular trial record bases are inserted in the
patient’s mouth.

• Patient is prevented from occluding by using cotton rolls on both

sides.

• Recording material such as Aluwax is placed on the mandibular rim

in the premolar and molar regions and the patient is allowed to
slowly close and stop just short of making tooth contact.

• Once the record is set, the maxillary and mandibular trial dentures
are placed on the articulator and the record is seated on the
maxillary cast.

• If the tentative relation is correct, then the condylar elements will

rest against the centric stops in the same position as the cast were
originally mounted.

• If not, then the record is incorrect and is to be repeated.

• Occlusal indicator wax can also be used instead of the Aluwax as

interocclusal check record, especially when nonanatomic posterior
teeth are used.

Pressureless method
• Nick and notch method.

• V-shaped notch is made on the maxillary occlusal rim.

• Nick is made anterior to the notch on the maxillary rim.

• A trough is created on the mandibular rim from premolar region to

the distal most region.

• Petroleum jelly is applied in the nick and notch areas.

• Aluwax or zinc oxide paste is placed in the trough in the

mandibular rim and the patient is guided into centric position.

• Allow the material to set.

• Occlusal rims along with the recording material are removed.

• Any excess material is trimmed and casts are mounted on

articulator using this record.

Staple pin method

• Occlusal rims are sealed with staple pins in centric position.

• This method should not be used, as the CR record cannot be

verified.

Swallowing method
• T.E.J. Shanahan (1955) used physiologic approach to record CR
position. He advocated cones of soft wax to be placed on the
mandibular occlusal rims and the patient was asked to repeatedly
swallow. According to him, during swallowing, the tongue forced
the mandible to be in CR position (Fig. 6-16).
 FIGURE 6-16 Shanahan swallowing method.

Pressure method
• Jacob W. Greene described ‘pressometer’ to check equalization of
pressure in recording CR. It consisted of two celluloid strips which
were placed between the maxillary and the mandibular bite rims
bilaterally. If the pressures were unequal, the rims would hold one
strip while the other could be removed.
Eccentric jaw relations
Eccentric jaw relation is defined as ‘any relationship between the jaws
other than the centric relation’. (GPT 4th Ed)
Eccentric records should include the protrusive and the right and
left lateral records. The purpose of the eccentric relation record is to
adjust the horizontal and lateral condylar inclinations on the
articulator. These adjustments are necessary to achieve balanced
occlusion in the complete dentures. These records can be made by
functional, graphic or tactile methods within the functional range. The
methods of recording eccentric records are similar to the methods
used to record the CR position.
Extraoral tracing with a central bearing device has several
advantages over other techniques, if the recording devices are
attached to stable bases.

Procedure
• Once the mandibular cast is mounted on the articulator in CR, the
recording devices are placed back in the patient’s mouth.

• Distance of 5–6 mm is measured from the apex of the tracing on the

protrusive path and is marked.

• Patient is instructed to protrude the jaw till the stylus rests on the
marked point.

• Quick setting plaster is injected in between the rims and is allowed

to harden.

• Hardened cast is removed from the mouth.

• Horizontal condylar adjustments are freed on the articulator by

releasing the locknuts.
• The incisal guide pin is raised about ½ inch from the incisal guide
table.

• The record bases are seated on the cast, and hardened cast is placed
in between the rims.

• Accurate seating of both the condyles is ensured and locknuts are

tightened.

• The right and left calibrations of the horizontal condylar guidance

are adjusted accordingly.

• For the lateral records, two additional records are made, one on the
right lateral and the other on the left lateral position in similar
manner as described above for protrusive.

• The articulator is adjusted to each of this lateral record.

• Also, the protrusive relation record can be made by using layers of

soft wax.

• During the wax try-in, the patient is instructed to protrude the

lower jaw approximately 5–6 mm.

• Once the patient has learned this position, layers of soft wax are
placed on the posterior and anterior teeth of the lower trial denture.

• Patient is asked to protrude the jaw to a distance of 5–6 mm with the

wax and then close the jaw.

• Wax is allowed to harden and then removed.

• Wax record is inspected for even contact.

• This record is used to adjust the horizontal condylar guidance on

the articulator.

Important consideration during eccentric jaw relations are as follows:

• Condylar path cannot be controlled or altered by the clinician.

• Condyles always follow the contour of the bony fossae and never
travel in straight line path.

• Articulators having straight slot for condylar elements travel are not
suitable for eccentric records.

• Articulators should accept the lateral records which provide other

points of reference.

• Articulators which can record the individual condylar path using

pantographic tracings provide information in three planes.

Key Facts
• Camper’s line is the line joining the inferior border of the ala of the
nose to the superior border of the tragus. Ideally, the Camper’s
plane is considered to be parallel to the occlusal plane.

• Christensen’s phenomenon is the space that occurs between the

occlusal surfaces during mandibular protrusion.

• Central bearing device was first described by Alfred Gysi in 1910.

• Interocclusal distance or freeway space is 2–4 mm which is

observed in the premolar region in class I cases. In class II, it is
greater than 4 mm and in class III, it is less than or equal to 1 mm.

• Gothic arch tracing is a device which produces a tracing resembling

the arrowhead or Gothic arch during the mandibular movements.

• Increased vertical dimension leads to trauma to the tissues, pain in

the TMJ, clicking sound of the dentures, increased facial height,
tense facial muscles and difficulty in speech.

• Reduced vertical dimension results in reduced function of the

 muscles with loss of muscle tone, creases at the corner of the mouth,
trauma to the TMJ, decreased facial height, lax facial muscles with
ageing appearance.

• Vertical dimension influences the aesthetics and mechanics of the

denture and if incorrect may produce possible disturbances in the
TMJ.

• M.E. Niswonger (1934) called the rest position as neutral position and
estimated it to be 3 mm.
CHAPTER 7
Selection and arrangement of
teeth

CHAPTER OUTLINE
Introduction, 123
Denture Aesthetics, 123
Definition, 123
Biological, 123
Mechanical, 123
Psychological, 123
Pre-Extraction Records, 124
Pre-Extraction Guides, 124
Evolution of Anterior Teeth Selection, 124
Selection of Anterior Teeth, 125
Size of the Teeth, 125
Size of the Maxillary Arch, 126
Distance between the Canine Eminences, 127
Jaw Relations, 127
Contour of Residual Ridge, 127
Vertical Distance between the Ridges, 127
 Lip Support, 127
Form of the Teeth, 128
Composition of Material of Anterior Teeth, 130
Posterior Teeth Selection, 133
Size of the Posterior Teeth, 134
Form of the Posterior Teeth, 135
Colour of the Posterior Teeth, 136
Material of the Posterior Teeth, 136
Arrangement of the Anterior Teeth, 136
Relationship of Anterior Teeth with the Incisive
Papilla, 137
Relationship of Anterior Teeth with the Soft
Tissue Reflection, 137
Horizontal Relation with Residual Ridges, 137
Vertical Positions of the Maxillary Anterior
Teeth, 137
Arrangement of the Posterior Teeth, 138
Horizontal Positioning of the Posterior
Teeth, 139
Vertical Positioning of the Posterior Teeth, 139
Buccolingual Positioning of the Posterior
Teeth, 140
Principles of Arranging Teeth, 140
Maxillary Anterior Teeth, 140
Mandibular Anterior teeth, 141
 Maxillary Posterior Teeth, 141
Mandibular Posterior Teeth, 142
Modiolus, 142
Definition, 142
Importance of Modiolus, 143
Phonetics, 143
Components of Speech, 144
Role of Phonetics in Complete Denture
Patient, 144
Prosthetic Considerations, 146
Introduction
Optimum aesthetics in complete denture construction is achieved by
arranging teeth in their natural position and according to the patient’s
aesthetic and functional requirement. Complete dentures are
aesthetically pleasing when teeth and denture bases are in harmony
with the facial musculature, facial profile and colour of eyes, and skin.
Denture aesthetics
Definition
Denture aesthetics is defined as ‘the effect produced by a dental prosthesis
that affects the beauty and attractiveness of the person’. (GPT 8th Ed)
According to S. Winkler, aesthetics in complete denture
prosthodontics is affected by the following three factors:

(i) Biological

(ii) Mechanical

(iii) Psychological

Biological
• The clinician should have proper knowledge of the anatomical
structures, facial musculature and normal facial appearance.

• The clinician should understand the cause and effect relationship.

• If the labial flange is made too bulbous, it will push the lips
outwards giving them an artificial appearance or vice versa.

• Facial wrinkles tend to reduce by increasing the vertical dimension

of occlusion.

• But excessive increase in vertical dimension leads to patient

discomfort, clicking sound during function and compromised
health of residual ridges.

• Also, the placement of maxillary and mandibular teeth affects

speech which is dependent on the interocclusal distance.
Mechanical
• The artificial teeth should be arranged at the position which was
once occupied by the natural teeth.

• The teeth should be placed such that forces from the cheeks and lips
are balanced by the forces from the tongue. This area where forces
are balanced is called the neutral zone.

• Placing the teeth in neutral zone will enhance the stability of the
denture.

Psychological
• A patient’s perception of his/her appearance plays an important role
in dental aesthetics.

• A patient with a positive self-image will have a broad smile,

whereas a patient with a poor self-image will have a tight-lipped
introverted smile.

• Camper’s plane is often considered as the psychological plane of

orientation.

• Higher plane of orientation is seen in patients with positive self-

image, whereas the plane tends to depress downwards in patients
with poor self-image.

• Therefore, plane of orientation established by the clinician

determines the psychological state of the patient to some extent.
Pre-extraction records
Pre-extraction guides
Pre-extraction guides are an important aid in selecting teeth,
especially the anterior teeth. Various pre-extraction guides used are as
follows:

Diagnostic casts
It is defined as ‘life size reproduction of a part or parts of the oral cavity
and/or facial structures for the purpose of study and treatment planning’.
(GPT 8th Ed)

• It is the most reliable aid in selecting and arranging anterior teeth.

• Anterior teeth can be selected by determining the form and size of

the teeth on the cast.

• Usually, the patient accepts the shape and form of the teeth similar
to the natural teeth.

Photographs
• Past photograph which shows the anterior teeth or at least the
incisal edges of the teeth.

• It is a valuable aid in determining width, length and outline form of

the artificial teeth.

• It can also establish the algebraic proportion of the anterior teeth.

• Close-up photographs can give the interpupillary distance which

can be compared to the patient without teeth.
• Interpupillary distance helps in establishing the horizontal width of
the upper six anterior teeth.

Formula for calculating horizontal width is

Radiographs
Intraoral radiographs of natural teeth can provide information about
the size and form of the teeth to be replaced, despite the fact that
radiographs are slightly enlarged and distorted due to divergence of
the X-rays.

Extracted teeth
• Sometimes patients preserve the extracted teeth with them.

• Extracted teeth help in determining the shape, size and form of the
artificial teeth.

• However, colour cannot be determined with the extracted teeth.

Observing teeth of a close relative

• Close observation of the teeth of a close relative will give an idea
about the shade, shape and size of the teeth.

• Size, colour and arrangement of teeth of children can be effectively

used in selecting and arranging artificial teeth for their parents.
Evolution of anterior teeth selection
Selection of teeth is as old as dentistry itself. It involves the choices of
size, shade and outline form of the artificial teeth. The evolution of
various techniques used for anterior teeth selection is briefly
mentioned as follows:

Ivory age and early porcelain period: Teeth were selected mostly by the
dimensional measurement with slight consideration given to the
face form or other features.

J.W. White (1872): He gave the concept of correspondence and harmony.

He asserted the association of tooth form and colour with the
patient’s temperament.

W.R. Hall (1887): He gave the concept of typal form. Major basis of this
concept was the tooth labial surface curvatures, outline form and
neck width of the teeth. Minor basis was the relationship of the
labiolingual inclinations of the upper incisors with the facial profile.

Berry biometer ratio method (1906): This method is based on the concept
that the outline form of the inverted upper central incisor
approximated the outline form of the face. Berry found a correlation
between the tooth form and the face form. According to him, the
width of the central incisor is one-sixteenth of the width of the face
and one-twentieth of the length of the face.

Clapp’s tabular dimension table method (1912): This method is based on

selecting size of all the six anterior teeth arranged on the Bonwill
circle and the available interarch space.

Valderrama’s molar tooth basis (1913): According to this method, varying

measurement between combination of the cusp points indicated the
size of individual and overall tooth measurements.
B.J. Cigrande (1913): He used the outline of the fingernail to select the
outline form of upper central incisor.

Leon Williams typal form method (1914): This was interpreted by the
geometric pattern created by the outline form of the bony face
frame. He classified the teeth as square, square tapering, tapering
and ovoid forms. The upper central incisor was considered as the
model tooth form of the arch.

A. Nelson (1920): He gave the maxillary arch outline form technique

which assumed that the arch outline form was a valid method, as it
relates to the individual’s anatomy.

Wright’s photometric method (1936): It was based on using a photograph

of the patient with natural teeth and establishing the ratio by
comparative computation of the measurement of like areas of the
face and the photographs.

R.L. Myerson (1937): He gave a ‘multiple choice method’ which was

based on a need for characterization of teeth by time, wear, etc. and
varying the shade of teeth.

M.M. House (1939): He proposed the ‘House instrumental method’ of

projecting typal outline and profile silhouettes onto the face by
means of a telescopic projector instrument and silhouettes form
plates.

V.H. Sears (1941): He advocated the anthropometric cephalic index

method. This method was used to determine the width of the upper
central incisor by either dividing the transverse circumference of the
head by 13 or the bizygomatic width by 3.3. Also, the tooth length
should be in proportion to the face length.

Dentists’ Supply Company (1950): It gave the Bioform technique based on

geometric outline form of the face and the teeth, typal forms and the
3D harmony of the tooth and face forms. It is associated with the
tubular systems and the mould guide system.
Austenal Company (1951): It proposed ‘automatic instant selector guide’
which correlates form, size and appearance in such a manner that a
single reading is required to select an appropriate tooth mould
based on the dimension of the denture space and harmony of the
face and tooth form.

Selection of anterior teeth

Complete denture is considered aesthetic when the teeth and the
denture base are in harmony with the surrounding facial structures.
Lack of harmony gives an unaesthetic look which may be due to
selection of incorrect size, shape or colour of the teeth or even
improper orientation of the occlusal plane. Therefore, selection of
artificial teeth requires thorough knowledge and skills.
Selection of anterior teeth is primarily based on satisfying the
aesthetic need of the patient. The three important factors on which the
anterior teeth selection is usually based are as follows:

(i) Size of the teeth

(ii) Form of the teeth

(iii) Colour of the teeth

Size of the teeth

The size of the teeth selected for a particular patient should be in
accordance to the size of his/her face and head. Usually, larger people
have larger teeth and vice versa but there can be variations where
larger people may have smaller teeth and smaller ones may have
larger. There are a number of methods, as discussed below, by which
sizes of anterior teeth are selected.

Based on size of the face

 The facebow is used to measure the bizygomatic width of the face.

Sears anthropometric cephalic index

The mesiodistal width of the maxillary central incisor is measured by
measuring the circumference of the head and dividing by 13.

Berry biometric index

The length of the face is measured by taking two arbitrary points, one
at the hairline and the other at lower edge of the most prominent part
of the chin.
Pound’s formula

The same values were also observed by M.M. House and J.L. Loop.
Trubyte tooth indicator is also used to determine the size of the
maxillary central incisors.

Golden proportion
B. Levin advocated that the perceived mesiodistal width of the
maxillary anterior teeth lies in the golden proportion of 1.681:1 when
viewed from the front (i.e. central incisors are 1.681 times broader
than the lateral incisor). He suggested the use of this proportion to
select and arrange anterior teeth to achieve maximum aesthetics (Fig.
7-1).
 FIGURE 7-1 Existence of golden proportion between the
elements of anterior maxillary teeth.

Size of the maxillary arch

The distance measured between the crest of the incisive papilla and
the hamular notch on one side and between the two hamular notches
gives the approximate width of all anterior and posterior teeth (Fig. 7-
2).
 FIGURE 7-2 Measurement between incisive papilla and
hamular notch.

The measurements may not be always correct because factors such

as amount of bone loss, spacing and tooth rotation may influence the
size of anterior teeth.

Distance between the canine eminences

The distance between distal of one canine eminence to the other
eminence is measured with the help of flexible plastic ruler which
indicates the combined mesiodistal width of maxillary anterior teeth.
The measurement is always done labial to anterior border of the
incisive papilla.
Alternately, a well-contoured maxillary rim is placed in the
patient’s mouth and the corners of the mouth are marked on the rim.
Distance between these two markings gives the approximate width of
maxillary anterior teeth.

Jaw relations
The available interarch space greatly influences the height, width and
position of the anterior teeth selected. When the available space is
more, longer teeth will be more aesthetically acceptable than smaller
ones.

Contour of residual ridge

• Artificial teeth should be placed along the contour of the residual
ridge that existed when the natural teeth were present.

• Knowledge of the resorption pattern of both maxilla and mandible

will aid in accurate visualization of the original contour.

• Resorption of the maxillae in the anterior segment is in the vertical

and palatal direction and posteriorly it is in the vertical and medial
direction.

• Resorption of the mandible in the anterior segment is in the vertical

and lingual direction and posteriorly it is in the vertical and slightly
lingual direction.

• As resorption occurs, the maxillary arch becomes smaller and the

mandibular arch becomes larger.

Vertical distance between the ridges

• The length of teeth is determined by the amount of available interarch
space.

• Longer teeth are used, if adequate space is available to eliminate the

visualization of the denture base.

• Teeth are more attractive in appearance than the denture base.

• Denture base can be characterized or personalized to give more

natural appearance.
Lip support
• When lips are relaxed and apart, the labial surface of the maxillary
anterior teeth supports the upper lips.

• Usually, the incisal edges extend inferior to or slightly below the lip
margins.

• When teeth are in occlusion and the lips are together, the labial
incisal one-third of the maxillary anterior teeth supports the
superior border of the lower lip.

• When patient says ‘fifty-five’, the incisal edges of the maxillary

anterior teeth contact the lower lip at the junction of the moist and
dry surfaces of the vermillion border (Fig. 7-3).

• Properly contoured maxillary rim will aid in determining the length

of the teeth.
 FIGURE 7-3 Incisal edges of upper anterior teeth contact
lower lip as the patient speaks ‘fifty-five’.

Form of the teeth

On the basis of facial form

The anterior teeth selected should harmonize with the facial form, i.e.
the frame in which the selected teeth has to be placed. J. Leon Williams
(1914) classified maxillary anterior teeth on the basis of typal form. He
classified the facial form as follows:

(i) Square

(ii) Tapering

(iii) Square tapering

(iv) Ovoid

Later, House and Loop classified teeth considering the mesiodistal,

incisogingival and facial outline form of the tooth. They classified
three pure typal forms and their five possible combinations (Fig. 7-4).

(i) Square

(ii) Tapering

(iii) Ovoid
 FIGURE 7-4 Form of teeth selected on the basis of facial
form: (A) square; (B) ovoid; (C) tapering.

The combinations were square–tapering, reverse–tapering, ovoid–

square, ovoid–tapering and ovoid–reverse–tapering.

On the basis of facial profile

The labial surface of the teeth selected should harmonize not only
with the facial form but also with the facial profile of the patient. The
general facial profiles are as follows (Fig. 7-5):

(i) Convex

(ii) Concave

(iii) Straight
 FIGURE 7-5 Teeth selected on the basis of facial profile.

The frontal surface of the teeth should appear flat or convex

depending on the profile of the patient when viewed from the side.

On the basis of colour or shade of the anterior

teeth
• The colours recognized by the human eye are the effect of certain
wavelength of light on the retina.

• During shade selection, it is observed that yellow is more dominant

in the gingival third and grey is more dominant in the incisal third.

• Colour has four qualities, namely, hue, chroma, value and

transparency.

• Hue: It is the basic colour of the spectrum.

• Chroma (saturation): It is the amount of colour per

unit area of an object. It is synonymous with the
intensity of the basic colour.

• Value (brilliance): It refers to lightness and darkness

of an object.

• Transparency: It is the property of an object that

permits the passage of light through it.
• E.B. Clarke (1933) established that shade possesses three dimensions,
namely, cervical, incisal and transitional shade in the middle third
of the tooth.
• Generally, cervical area has more chroma and incisal area is more
translucent in the anterior teeth.

• Also, there is transition of shade from the central incisors to the

canines.

• The canines are less translucent, more opaque and have more
chroma than the central incisors.

• Shade selection also depends on sex, personality and age (SPA).

• Factors influencing shade selection with age are secondary dentin,

abrasion and stains.

• Colour of the face is the basic guide to the colour of the teeth.

While selecting the shade or colour, observations are made in the

following three positions:

(i) Outside the mouth along the side of the nose

(ii) Under the lips with only the incisal edges exposed

(iii) Under the lips with the cervical end exposed when the patient
opens mouth widely

Prerequisites for Shade Selection

• Shade tabs should be moistened.

• North (white) light is ideal for shade selection.

• Light should not be focused for more than few seconds.

• Blue-coloured object is viewed in between.

• Shade is also confirmed at the distance of 6–8 feet.

• The dentist should position himself/herself such that the teeth to be
viewed should be in a plane perpendicular to the plane of his/her
vision and the patient should be in upright position.

• Teeth are always viewed from different angles so that shadows do

not influence the shade.

• There should be harmony between the colour of the teeth and colour
of skin, hair and eyes.

Composition of material of anterior teeth

• Artificial teeth are made of either porcelain or acrylic resin.

• Porcelain teeth are usually vacuum fired and are denser.

• Porcelain teeth are difficult to wear but retain their polish.

• Porcelain is attached to the acrylic denture base by mechanical

means (usually by gold pins) (Fig. 7-6).

• Acrylic teeth have less strength than porcelain teeth.

• Acrylic teeth wear faster than porcelain teeth.

• Acrylic teeth bond to the acrylic denture base by chemical means.

• Acrylic teeth can be easily grinded as compared with porcelain

teeth.
 FIGURE 7-6 Porcelain teeth attached to acrylic resin by pins
or diatoric holes: (A) Pins embedded in porcelain teeth; (B)
diatoric hole.

Porcelain teeth versus acrylic resin teeth

Posterior tooth form can be made of a variety of materials. Porcelain
and acrylic resin teeth are most commonly used for manufacturing
denture teeth. Differences between porcelain teeth and acrylic resin
teeth are given in Table 7-1.

Table 7-1
DIFFERENCES BETWEEN PORCELAIN AND ACRYLIC RESIN
TEETH

Porcelain Teeth Acrylic Resin Teeth

More aesthetic than acrylic resin teeth Less aesthetic
More resistant to wear Least resistant to wear which is
clinically significant
Retained on the denture base by mechanical interlocking; diatoric Chemically adhere to the denture
holes can be placed into teeth into which the denture base resin flows base
Teeth are brittle and clicking sound is produced on contact with the Have softer impact sound
opposing teeth
Resistant to staining but may show marginal staining Tend to stain more rapidly
Require greater interarch distance because they cannot be grounded as They can be grounded to thin
thin in the ridge lap area as acrylic teeth without destroying the sections and polished and also can
diatoric channels which are the only means of retention to the denture be placed in decreased interarch
base distance
Shape and form are maintained during trimming Shape and form cannot be
 maintained during trimming
Ground porcelain surface should be highly polished to reduce friction Self-adjusting and self-polishing
and prevent chipping
Wear does not cause much change in the vertical dimension Wear results in loss of vertical
dimension
Only type of denture teeth that allows the denture to be rebased This is not possible in case of
because they can be grounded and polished and can maintain shape acrylic resin teeth
for years
Can cause abrasion to opposing gold crowns and the natural teeth Causes less abrasion to the
opposing gold crowns and the
natural teeth

Squint test
Squint test is useful in evaluating the shade of the teeth with the
complexion of the face. In this method, the clinician partially closes
the eyelids to reduce the amount of light. The clinician then compares
the prospective colours of the artificial teeth held along the face of the
patient. The colour that fades first from the view is the one that is least
conspicuous in comparison with the colour of the face. Such a colour
is selected for artificial teeth of a complete denture patient.

Dentogenic concept
It is defined as the art, practice and technique of creating an illusion of
natural teeth in artificial dentures and is based on the elementary
factors suggested by the sex, personality, age (SPA) of the patient.
Dentogenic restoration is designed to enhance the natural
appearance of the individual.
J.P. Frush and D.R. Fisher (1956) proposed the dentogenic concept in
selecting artificial teeth based on SPA. Their concept was based on the
work of William Zech, a Swiss sculptor, who applied ‘sculpture’ in
denture and helped to achieve the effect of sex identity. They
advocated that in order to achieve complete harmony in an individual
patient, the influence of the above-mentioned factors along with the
cosmetic factor should be considered. The arrangement of the teeth is
influenced by the following factors:

• Age
• Sex

• Personality

• Cosmetic factor

• Artistic reflection

Sex
Sex of the individual influences the arrangement of the artificial teeth.
The individual contours and arrangement of the teeth are different for
men and women.
Tooth form varies with the sex of the individual (Figs 7-7 and 7-8).
Male Female
Squareness of arch denotes masculine Roundness of the arch form denotes feminine dentition
dentition
Masculine tooth forms are generally square Feminine tooth forms are usually ovoid
In men, the incisal edges are more angular The incisal edges of the anterior teeth are more rounded
Incisal edges of maxillary anterior teeth are Incisal edges of the maxillary anterior teeth in women
parallel to the lips follow the curve of lower lip
Distal surface of central incisors is usually not Distal surface of the central incisors is usually rotated in
rotated posterior direction
Lateral incisors are almost at the same level as Lateral incisors are narrower and shorter than central
central incisors and impart quality of hardness incisors and impart quality of softness
The mesial surface of the lateral incisors is The mesial surface of the lateral incisors is often in anterior
posterior to the distolabial surface of the relation to the distolabial surface of the central incisors in
central incisors women
Cuspids are more visible and prominent The distal surface of the cuspids is rotated posteriorly
Maxillary bicuspids are less visible than in Maxillary bicuspids are more visible during expressive
females smile in women
FIGURE 7-7 Feminine smile characterized by curvature of
incisal line coinciding with the lower lip.

FIGURE 7-8 Masculine smile characterized by straighter

incisal line.
Third dimension depth grinding
• Denture look is mostly due to the flat appearance of the artificial
teeth.

• Depth grinding is required to impart natural appearance.

• Depth grinding is moderately done for men and women and should
be increased or decreased depending on the individual
interpretation of SPA.

• Depth grinding depends on the following features:

• Flat, thin, narrow tooth indicated for delicate

women: Little depth grinding is required.

• Thick, bony, big-sized tooth heavily indicated for

men: Severe depth grinding may be required.

• For an average patient, healthy women or less

vigorous men: Average depth grinding is required.

Personality
Soft, delicate personality is associated with women, whereas bold and
vigorous personality is associated with men.
Factors influencing the personality of patients are (i) personal
grooming, (ii) cleanliness, (iii) occupation, (iv) physical appearance
and (v) aggressive/regressive behaviour pattern.
Divisions of personality spectrum are as follows:

(i) Delicate: Fragile, frail.

(ii) Medium pleasing: Normal, moderately robust, healthy and

intelligent appearance.
(iii) Vigorous: Hard, aggressive, muscular type, almost primitive, ugly.

• An intelligent manipulation of the size, shape and

form of the teeth, and supporting structures can
successfully satisfy the objective and subjective
personality.
Based on their experience, J.P. Frush and D.R. Fisher described the
patients according to personality as follows:

(i) Vigorous men: 15%

(ii) Delicate or soft women: 5%

(iii) Medium or average both men and women: 85%

• By overaccentuating the upper central incisor, strength and

boldness are depicted in the smile.

• Arranging the central and lateral incisors that are of nearly same
size gives masculine feature.

• Arranging lateral incisor shorter than the central incisor tends to

portray feminine feature.

Age
The objective of age factor is to maintain high degree of conformity
between the restorations and patient’s physiological age structure.

Features
• Selection of appropriate shade is important in denture construction.
Lighter shades are selected for young and darker shades for old
patients.
• Ageing is depicted in the denture by mould refinement. Wear
pattern, attrition can be included in the denture teeth.

• In young patients, mamelons are present at the incisal edge of the

central and lateral incisors. The cuspids present a pointed tip which
is very sharp in appearance.

• Teeth abrade with age. Central and lateral incisors abrade in straight
line and cuspids abrade in a curve. Abrasion of the incisal edges of the
anterior teeth flattens the arch.

• Interincisal distance increases with age, i.e. visibility of the mandibular

teeth increases with age. Increased visibility is due to loss of muscle
tonus, allowing the lower lip to sag and the upper lip to drop.

• Wearing away for the natural teeth at the contact point creates
spaces between the teeth.

• Smile line is sharp in young patient and less sharp in the old.

• Gingival tissues recede with age. This recession can be reproduced by

selecting a long tooth, contouring the wax and proper positioning of
the teeth.

• Effects of erosion in the artificial teeth can be imparted by carefully

grinding and polishing the teeth.

Cosmetic factor
• It involves personal grooming.

• Dentist should strive for refinement in the arrangement of the

artificial teeth in a well-groomed and dressed person.

• Similarly, refinement should also be done in shabbily dressed bushy

person. However, this gives an artificial look.
• Modification of the natural appearance is helpful in improving the
patient’s appearance.

Artistic reflection
• Artistic ability of the dentist is tested to achieve a composition of
teeth that harmonizes with the surrounding features and is also
acceptable to the patient.

• Patient desires are always given due considerations after the

physiological requirements are satisfied.
Posterior teeth selection
Posterior teeth should be selected for an edentulous patient on the
basis of colour, size, form and material. The selected teeth should be in
accordance with the size and contour of the mandibular residual
ridge. Selection of the posterior teeth should satisfy not only the
masticatory efficiency but also aesthetics, comfort and preserve the
underlying tissues.
Factors influencing selection of posterior teeth for moderate ridges
are:

• Size

• Form

• Colour

• Material

Size of the posterior teeth

The following factors are considered during size selection of the
posterior teeth:

(i) Buccolingual width

(ii) Mesiodistal length

(iii) Occlusogingival height

Buccolingual width
• Buccolingual width should be greatly reduced than the width of the
natural teeth to be replaced.
• Narrow buccolingual width of the posterior teeth aids in development
of the correct form of the polished surface of the denture by
allowing the buccal and lingual denture flanges to slope away from
the occlusal surfaces (Fig. 7-9).

• This helps to maintain the denture in position over the residual

ridge.

• Narrow occlusal table reduces the degree of stress on the supporting

tissues of the basal seat on mastication.

• Although narrow occlusal table is desired, it should have adequate

width in order to hold the food during mastication.

FIGURE 7-9 Narrow buccolingual width of the posterior teeth.

Mesiodistal length
• The mesiodistal length of the mandibular ridge from the distal
position of canine to the anterior border of the retromolar pad is available
for posterior teeth arrangement (Fig. 7-10).

• If the residual ridge anterior to it slopes upward, smaller or fewer

 teeth should be used.

• Smaller number of teeth prevent the lower denture from sliding

forward when pressure is applied in the molar region.

• The total mesiodistal width of all the four posterior teeth is

indicated as a mould number.

• The posterior teeth should not extend too close to the posterior
border of the maxillary denture, as there are chances of cheek
biting.

• The posterior teeth should not be placed on the slope of the residual
ridge, as this will displace the denture. Forces directed to the
inclined plane are more displacing than the vertically directing
forces.

• These teeth are never arranged over the retromolar pad because the
pad is too soft and is easily displaced allowing the denture to tip
easily during mastication.

FIGURE 7-10 Mesiodistal length of the edentulous ridge.

Occlusogingival height
• Posterior teeth are selected on the basis of the available interarch space
and the length of the anterior teeth (Fig. 7-11).
• Artificial teeth are available in varying occlusogingival height.

• Length of the maxillary first premolar should be comparable to the

maxillary canine in order to give a proper aesthetic effect. Failure to
do this results in unaesthetic visibility of the denture base.

• Form of the dental arch should simulate the arch form of the natural
teeth.

FIGURE 7-11 Height of the posterior teeth selected on the

basis of available interarch space.

Form of the posterior teeth

Form of the posterior teeth is selected on the basis of the occlusal
surfaces desired. The occlusal surface depends on the type of
occlusion planned for a particular patient.
Factors that control the selection of the form of posterior teeth are:

(i) Condylar inclination

(ii) Shape and height of the residual ridge

(iii) Incisal guidance

(iv) Plane of occlusion

(v) Ridge relationship

(vi) Height of occlusal plane

(vii) Compensating curve

Types of posterior teeth form are:

(i) Cusp form:

• Anatomic teeth

• Semi-anatomic teeth
(ii) Cuspless:

• Nonanatomic teeth
• If teeth are arranged in balanced occlusion in centric and eccentric
positions, anatomic teeth are desired.

• If posterior teeth are desired to disocclude in the eccentric jaw

movement and occlude in centric position, anatomic or nonanatomic
teeth can be used.

• If the posterior teeth are arranged on a flat plane and are desired to
be balanced only in the centric position, nonanatomic teeth are used.

• If a nearly horizontal incisal guidance is selected, shallow posterior

tooth inclines should be selected.

• Try-in of all the anterior teeth aids in the selection of the sizes and
inclines of the posterior teeth.
• Commonly used posterior teeth have cuspal inclines of 33°, 20° or
0°.

• The cuspal inclination is measured as the angle formed by the incline of

the mesiobuccal cusp of the lower first molar with the horizontal plane.

• Nonanatomic teeth are used when it is difficult to record jaw relation

or if the patient has abnormal jaw relationships (Table 7-2).

Table 7-2
COMPARISON BETWEEN CUSPED AND NONCUSPED TEETH

Colour of the posterior teeth

• It should harmonize with the colour of the anterior teeth.

• Maxillary premolars are more often used for aesthetic purpose than
the functional one.

• Their shade is lighter than other posterior teeth; however, their

shade should never be lighter than that of the anterior teeth.

Material of the posterior teeth

• Artificial posterior teeth can be of various types such as air-fired or
vacuum-fired porcelain, acrylic resin, all-metal or metal occlusal
 surfaces.

• Commonly used posterior teeth are the acrylic resin and porcelain
teeth.
Arrangement of the anterior teeth
• The carved occlusal rims provide a reliable guide for placement of
the anterior teeth in the arch.

• The occlusal rims indicate the anteroposterior and vertical position

of the incisor teeth on the basis of support they provide to the lips
and the mandible.

• Period of edentulism is in direct relation with the amount of

resorption which is to be expected.

• As a general rule, in well-rounded ridges, the teeth are placed closer

to the ridge and in highly resorbed ridge the teeth are arranged
farther away from the ridge (Fig. 7-12).

• This is done in order to place the occlusal plane of the teeth in the
same position it occupied when the natural teeth were present.
 FIGURE 7-12 Arrangement of tooth in normal and resorbed
ridge.

Relationship of anterior teeth with the incisive

papilla
• Incisive papilla has a constant relationship with the upper central
incisors. It is found in the lingual embrasure between the incisors. It
is used as a guide to position the midline of the upper dental arch.

• It is used as a guide to the anteroposterior position of the teeth.

Relationship of anterior teeth with the soft tissue

reflection
• Relationship of the labial surfaces of the anterior teeth with the
reflection of the soft tissues can be used as a guide to place two
 central incisors.

• Labial surface of the ridge acts as a guide to determine the

inclination of the anterior teeth.

• Accuracy of this guide decreases as the resorption of the ridge

increases.

Factors influencing the positions of the artificial teeth are:

• Functions of surrounding tissues

• Quality of the basal seat tissues

• Anatomical limits

• Mechanical factors

Factors that guide the positioning of the teeth in complete dentures

are:

• Horizontal relation with the residual ridges

• Vertical positions of the occlusal surfaces and the incisal edges

between the residual ridges

• Aesthetic requirements

• Inclinations for occlusion

Horizontal relation with residual ridges

• Anteroposterior relations of the maxillary and the mandibular
ridges influence the amount of overjet between the maxillary and
mandibular anterior teeth.

• The cervical end of the maxillary anterior teeth is placed anterior to

 the incisive papilla.

• The necks of the mandibular anterior teeth are placed to direct the
vertical force towards the crest of the ridge.

• Arch form is used as a guide for the initial teeth arrangement.

• In tapered arches, the central incisors are arranged further forward

than the canines.

• In square-shaped arches, central incisors are arranged nearly

horizontal than the canines.

• In ovoid arches, the anterior teeth are arranged in a gentle curve.

• If anterior teeth are placed too far posteriorly, there is insufficient

support of the lips which will result in drooping down of the
corners of the mouth, deepening of the nasolabial sulcus, wrinkles
above the vermilion border of the upper lip and reduction in the
prominence of the upper lip.

• If the anterior teeth are placed too far anteriorly, there is excessive
support of the lips resulting in stretched or tight appearance of the
lips, tendency of lips to dislodge the denture during function,
distortion of philtrum, and elimination of the normal contours of
the lips.

• Past photographs of the patient can be useful during arrangement of

the teeth in correct position.

Positioning of the teeth anteroposteriorly and mediolaterally helps in:

• Providing adequate stability

• Directing forces to the most favourable areas for support

• Providing adequate support to lips and cheeks for aesthetics

• Harmonizing with function of the surrounding tissues

Vertical positions of the maxillary anterior teeth

• Aesthetics and phonetics are used as a guide in arranging the
maxillary anterior teeth.

• When the patient says ‘fifty-five’ the incisal edges of the maxillary
central incisor should contact the vermilion border of the lower lip
at the junction of the moist and dry mucosa.

• The amount of visibility of the upper anterior teeth during speech

and facial expression depends on the length and the movement of
the upper lip in relation to the vertical length of the dental arch.

• If upper lip is long, the visibility of the upper teeth is very less or
negligible.

• In cases of relatively short upper lip, full crown may be visible (Fig. 7-
13).

• In some cases, the entire crown and the mucous membrane may be
visible while smiling (gummy smile).

• With age, the visibility of the mandibular incisors increases and the
tendency is more in men than in women.

• Lower lip is a better guide for orientation of the anterior teeth than
the upper lip.

• In most cases, the tip of the lower canine and the first premolar are
located at the level of the lower lip at the corner of the mouth when
the mouth is slightly opened.

• If the lower teeth lie above the corner of the mouth, one or more of
the following conditions may exist:
• Plane of occlusion may be too high.

• Vertical overlap of the anterior teeth may be

excessive.

• Vertical space between the jaws may be excessive.

FIGURE 7-13 Diagram showing visibility of teeth in different

lip lines: (A) high lip line; (B) medium lip line; (C) low lip line.
Arrangement of the posterior teeth
• Arrangement of the posterior teeth is greatly influenced by
occlusion.

• Setting of the posterior teeth depends on the following factors:

• Orientation of the occlusal plane

• Shape and position of the arch

• Inclination and rotation of teeth for aesthetics

• Mechanics to obtain proper tooth inclination for

balanced occlusion

Anatomical landmarks which aid in relocating the centre of the

mandibular alveolar ridges are:

Retromolar fossa
• These are triangles formed by the external oblique lines and the
mylohyoid lines.

• This area corresponds to the middle of the retromolar pad in the

medial lateral direction.

Retromolar papilla
• It is a small pear-shaped tissue which lies at the base of the
retromolar pad and is almost at the centre of the residual ridge.
Retromolar pad
• It is a triangular or pear-shaped pad that is located at the distal end of
the mandibular ridge.

• It consists of glandular tissues, fibres of superior constrictor,

buccinator and the temporalis muscle.

• The pterygomandibular raphe enters the pad at the superior medial

corner.

• Vertical distance between the base of the pad to the superior border
is the usable guide on the cast.

Mandibular canine
• It is the cornerstone of the arch.

• Distal surface of the canine is usually rotated in a posterior direction

in line with the centre of the ridge.

• Position of the distal surface of the canine is located by passing a

line parallel to the pupil of the eye and intraorally at the corner of
the mouth.

• These two points are recorded bilaterally on the occlusal rim and
transferred on the lower cast.

With these points, the crest of the alveolar ridge is located and
guide lines are placed on the cast for arrangement of the teeth.

Horizontal positioning of the posterior teeth

• The mandibular arch determines the posterior limit for placing
occluding posterior teeth.
• Stress-bearing mucosa in the mandible terminates at the retromolar
papilla.

• No posterior teeth should be placed distal to the retromolar region.

• The stress-bearing mucosa of the mandibular arch lies anterior to

that of the maxilla.

• If the mandible has steep ascent, the distal most posterior teeth
should be placed anterior to this ascent.

• Posterior teeth should never be placed on the incline, as this will

cause dislodgement of the denture.

• The medial limit of mandibular posterior teeth placement is

determined by the medial extension of the mylohyoid ridge.

• If the teeth are placed more lingually, they will encroach into the
tongue space.

• The actions of the tongue, cheeks and aesthetics determine the

lateral limit of arranging the mandibular posterior teeth.

• Maxillary premolar teeth arranged in proper position enhance the

aesthetics.

• Buccal surfaces of the maxillary premolar are placed continuous

with the arch of the anterior teeth.

• Mandibular premolars are placed in harmony with the anterior

teeth in the arch.

• Posterior teeth arranged with the proper horizontal overlap support

the cheek and prevent cheek biting.

Vertical positioning of the posterior teeth

When teeth are placed in the correct vertical position, they:
• Provide stability to the denture

• Provide favourable forces

• Provide adequate support for the lips and the cheeks

• Enhance compatibility with the activities of the lips, cheek and

tongue

Anatomical guides used to establish vertical position of the

posterior teeth are:
Orifice of the duct of parotid gland (Stensen’s duct): The occlusal surface
of the maxillary first molar is measured around quarter inch below
the orifice of the Stensen’s duct.
Retromolar pad: A mark is placed on top of the retromolar pad on
the cast and is extended on the lateral border of the cast to be used as
a guide.
This is used as a guide to arrange the mandibular posterior teeth; the
occlusal surfaces of the posterior teeth should lie at the centre of this
mark.

• Vertical position of the posterior teeth determines the height of the

occlusal plane.

• The height of the occlusal plane extends from the incisal edge of the
canine to the anterior two-thirds of the retromolar pad. The lingual
cusps of the upper should conform to this line on the mandibular
occlusal rim.

If occlusal plane is too high, the following are witnessed:

• It causes additional tipping of the mandibular denture.

• It leads to the chances of angular cheilitis because of excessive

pooling of saliva in the lower buccal vestibule.

• It becomes difficult for the tongue and cheeks to maintain food

 bolus on the occlusal table.

If the occlusal plane is too low, the following are witnessed:

• Aesthetics is compromised.

• Greater chances of tipping of the maxillary denture as upper teeth

will be located at a greater distance from the ridge.

Buccolingual positioning of the posterior teeth

Correct buccolingual placement of the posterior teeth aids in
developing the correct contour of the buccal and lingual borders of the
denture. This aids in denture retention and stability.
Guides used to locate the buccolingual position of the posterior teeth
are:

• Teeth should be placed in the neutral zone (Fig. 7-14).

• Buccal cusp should always be placed over the buccal turning point
of the crest of the lower ridge.

• Lingual cusp should be located within the triangle formed by the

line drawn bilaterally from the mesioincisal angle of the lower
canine to the lingual corner of the retromolar pad.

• Posterior teeth when placed too far buccally tend to dislodge the
denture when vertical forces are applied.

• Posterior teeth when placed too far lingually tend to encroach into
the tongue space and there is a tendency of the denture to be
displaced during normal tongue activity.
FIGURE 7-14 Teeth should be arranged in neutral zone.
Principles of arranging teeth
Maxillary anterior teeth (fig. 7-15)

Maxillary central incisor

• The long axis of the tooth should lie parallel to the vertical axis
when viewed from the front.

• The long axis of the tooth slopes labially when viewed from the side.

• Incisal edge of the tooth should contact the glass plate.

FIGURE 7-15 Arrangement of maxillary anterior teeth: (A)

frontal view; (B) side view.

Maxillary lateral incisor

• Long axis of the tooth slopes labially such that the distal surface is
turned lingually at the considerable angle when viewed from the
side.

• This tooth is inclined distally at the cervical end than any other
anterior tooth.
• Incisal edge is 2 mm above the horizontal plane.

Maxillary canine
• Long axis tilts slightly towards the midline when viewed from the
front.

• This tooth is inclined towards the distal end at the cervical end more
than the central incisor and less than the lateral incisor.

• It is rotated in such a way that the distal half of the labial surface
points in the direction of posterior arch form.

• The cervical third of the canine is more prominent than the incisal
third.

• Cusp tip contacts the glass plate (horizontal plane).

Mandibular anterior teeth (fig. 7-16)

Mandibular central incisor

• Long axis of the tooth is parallel to the vertical axis when viewed
from the front.

• Long axis of the tooth slightly tilts labially when viewed from the
side.

• Incisal edge of the tooth is 2 mm above the plane of occlusion.

 FIGURE 7-16 Arrangement of mandibular anterior teeth.

Mandibular lateral incisor

• Long axis of the tooth is parallel to the vertical axis when viewed
from front.

• Long axis of the tooth tilts labially less than the central incisor,
appears almost perpendicular when viewed from side.

• Incisal edge is 2 mm above the plane of occlusion.

Mandibular canine
• Long axis of the tooth tilts slightly lingually when viewed from
front.

• Long axis of the tooth tilts slightly mesially when viewed from side.

• Canine tip is 2 mm above the plane of occlusion.

Maxillary posterior teeth (fig. 7-17)

Maxillary first premolar

• Long axis is parallel to the vertical axis when viewed from the front
and side.

• Buccal cusp contacts the occlusal plane and the palatal cusp is 1 mm
short than the plane.

FIGURE 7-17 Transverse view of arrangement of maxillary

posterior teeth.

Maxillary second premolar

• Long axis of the tooth is parallel to the vertical axis when viewed
from the front and side.

• Both buccal and palatal cusps are in contact with the horizontal
plane.

Maxillary first molar

• Long axis tilts buccally when viewed from the front.

• Long axis is tilted distally when viewed from the side.

• Only the mesiopalatal cusp contacts the horizontal plane.

Maxillary second molar

• Long axis tilts buccally more steeply than the first molar when
viewed from the front.

• Long axis tilts distally more steeply than the first molar when
viewed from the side.

• All the four cusps are short from the horizontal plane but the
mesiopalatal cusp is more close to it.

Mandibular posterior teeth (fig. 7-18)

Mandibular first premolar

• Long axis tilts slightly lingually when viewed from the front.

• Long axis is parallel to the vertical axis when viewed from the front.

• Lingual cusp is closer to the horizontal plane than the buccal cusp
which is 2 mm above the plane.

FIGURE 7-18 Arrangement of the mandibular posterior teeth

in relation to the maxillary teeth.
Mandibular second premolar
• Long axis tilts slightly lingually when viewed from the front.

• Long axis is parallel to the vertical plane when viewed from the
side.

• Both buccal and lingual cusps are 2 mm above the horizontal plane.

Mandibular first molar

• Long axis tilts slightly lingually when viewed from the front.

• Long axis tilts slightly mesially when viewed from the side.

• All the four cusps are above the horizontal plane with the buccal
and distal cusps being higher than the mesial and lingual cusps.

Mandibular second molar

• Long axis of the tooth tilts lingually, slightly more than the first
molar when viewed from the front.

• Long axis of the tooth tilts mesially, slightly more than the first
molar when viewed from the side.

• All the cusps are above the horizontal plane and higher than the
first molar; also, the buccal and distal cusps are higher than the
mesial and lingual cusps.
Modiolus
Definition
Modiolus is defined as ‘the area near the corner of the mouth where eight
muscles converge that functionally separates the labial vestibule from the
buccal vestibule’. (GPT 8th Ed)
Modiolus is the meeting place of eight muscles, which forms a
distinct conical prominence at the corner of the mouth. The word
modiolus is derived from Latin and means ‘hub of wheel’ (Fig. 7-19).

FIGURE 7-19 Modiolus is a muscular knot which is formed

by eight muscles.
 Following are the muscles meeting at the modiolus:

(i) Zygomaticus

(ii) Quadratus labii superioris

(iii) Caninus (levator anguli oris)

(iv) Mentalis

(v) Quadratus labii inferioris

(vi) Triangularis (depressor anguli oris)

(vii) Buccinator

(viii) Risorius

All these muscles merge into the orbicularis oris which determines
their functioning.

Importance of modiolus
• Modiolus becomes fixed when the buccinators contract while
chewing.

• Contraction of the modiolus presses the corner of the mouth against

the premolars such that the occlusal table is closed in the front.

• Because of this action, food cannot escape out of the mouth when
crushed by the premolars and the molars.

• It contributes to denture stability.

Phonetics
Phonetics is defined as ‘the movement and placement during speech of the
organs that serve to interrupt or modify the voiced or unvoiced air stream
into meaningful sounds’ or ‘the study of speech sounds, their production,
combination and their representation by written symbols’.

Components of speech
Speech is divided into six components as follows:

Respiration: During speech, the inhalation phase is shortened and the

exhalation phase is prolonged.

Phonation: Speech requires multitude of positions, varying tension,

vibratory cycles and intricate coordination of the vocal folds with
other structures.

Resonation: The pharynx, the oral cavity and the nasal cavity act as
resonating chamber by amplifying some frequencies and muting
others, thus refining tonal quality.

Articulation: The velopharyngeal mechanism proportions the sound

and/or air stream between the oral and nasal cavities and influences
voice quality (or the basic sound) that is perceived by the listener.

• Amplified, resonated sound is formulated into

meaningful speech by the articulators, namely, the
lips, tongue, cheeks, teeth and palate.
Neurological integration: Speech is integrated by the central nervous
system both at the peripheral and central levels.

Audition or the ability to receive acoustic signals is

 vital for normal speech.

• The successful performance of these functions is

necessary for the production of acceptable speech.

• All speech sounds are made by controlling air.

Classification of Speech Sounds

(i) Labial sounds (e.g. b, p, m)

(ii) Labiodental sounds (e.g. f and v)

(iii) Dental and alveolar sounds (e.g. th, t, d, n, s, and z)

(iv) Palatal sounds (e.g. year, vision, onion)

(v) Velar (posterior sounds, e.g. k, g, ng)

Role of phonetics in complete denture patient

Denture thickness and peripheral Outline

• Unduly thick denture bases cause incorrect phonation and loss of tone
due to decrease of air volume and loss of tongue room in the oral
cavity.

• The production of the palatolingual group of sounds involves contact

between the tongue, and the palate, the alveolar process or the
teeth.

• With the consonants ‘T’ and ‘D’, the tongue makes firm contact with
the anterior part of the hard palate, and is suddenly drawn
downwards, producing an explosive sound; any thickening of the
 denture base in this region may cause incorrect formation of these
sounds.

• When producing the ‘S’, ‘G’ (soft), ‘Z’, ‘R’ and ‘L’ consonants sounds,
contact occurs between the tongue and the most anterior part of the
hard palate, including the lingual surfaces of the upper and lower
incisors to a slight degree.

• In case of the ‘S’, ‘C’ (soft) and ‘Z’ sounds, a slit-like channel is formed
between the tongue and palate through which the air hisses.

• If the artificial rugae are overpronounced, or the denture base is too

thick in this area, the air channel will be obstructed and a noticeable
lisp may occur as a result.

• To produce the ‘Ch’ as in church and ‘J’ as in judge sounds, the

tongue is pressed against a larger area of the hard palate, and in
addition makes contact with the upper alveolar process, bringing
about the explosive effect by rapidly breaking the seal thus formed.

• The ‘Sh’ sound is similar in formation, but the air is allowed to

escape between the tongue and palate without any explosive effect,
and if the palate is too thick in the rugae region, it may impair the
production of these consonants.

Vertical dimension
• The formation of the labial sounds such as ‘P’, ‘B’ and ‘M’ are made
at the lips.

• With ‘P’ and ‘B’ sounds, the air pressure is built behind the lips and
released with or without voice sounds, whereas in ‘M’ sound, lip
contact is passive.

• For this reason, ‘M’ sound can be used as an aid in obtaining the
correct vertical dimension because a strained appearance during lip
 contact, or the inability to make contact, indicates that the bite
blocks are occluding prematurely.

• With the production of ‘Ch’ (soft), ‘S’ and ‘J’ sounds, the teeth come
very close together, if the vertical dimension is excessive, the
dentures will actually make contact as these consonants are formed,
and the patient will most likely complain of ‘clicking teeth’.

• If the distance is too large, then the vertical dimension established is

too small.

Occlusal plane
• The labiodentals, ‘F’ and ‘V’, are made between the upper incisors
and the labiolingual centre to the posterior one-third of the lower
lip.

• If the occlusal plane is set too high, the ‘v’ sound will be more like
an ‘f’ sound.

• If on the other hand, the plane is too low, the ‘f’ sound will be more
like a ‘v’ sound.

• The incisal edges of the central incisors contact the lower lips in a
proper position as the patient says ‘fifty-five’.

Anteroposterior position of the incisors

• Anteroposterior positioning of the teeth is very critical in the
production of some sounds.

• Anteroposterior position of the anterior teeth and thickness of the

labial flange can affect the sounds of ‘b’ and ‘p’.

• In setting the upper anterior teeth, consideration of their labiopalatal

positions is necessary for the correct formation of the labiodental
 sounds such as ‘F’, ‘V’ and ‘Ph’.

• If they are placed too far palatally, they will contact the lingual side
of the lower lip when ‘f’ and ‘v’ sounds are made.

• During making of dental sounds such as ‘th’, ‘this’, ‘that’, if 3 mm of

the tip of the tongue between the upper and lower incisors is not
visible, then anterior teeth are placed too far forward.

• Alveolar sounds such as ‘t’, ‘d’, ‘n’, ‘s’ and ‘z’ are produced when
the tip of the tongue contacts the anterior part of the palate or the
lingual side of the anterior teeth.

• If teeth are placed too far lingually, ‘t’ will sound as ‘d’.

• Similarly, if the anterior teeth are set too far anteriorly, ‘d’ will
sound as ‘t’.

• ‘S’ sound is made when the tip of the tongue contacts the alveolus in
the area of the rugae with the small space for the escape of air
between the tongue and the alveolus.

• The size and shape of this small space determine the sound quality.

• If the space is broad and thin, the ‘s’ sound will develop as ‘sh’.

• If the space is too small, a kind of whistle will result.

Postdam area
• Errors of construction in this region involve the vowels ‘I’ and ‘E’
and the palatolingual consonants ‘K’, ‘NG’, ‘G’ and ‘C’ (hard).

• In the latter group, the air blast is checked by the base of the tongue
being raised upward and backward to make contact with the soft
palate.
• A denture which has a thick base in the postdam area, or that edge
is finished square instead of tapering, will probably irritate the
dorsum of the tongue, impeding speech.

• Indirectly the postdam seal influences phonation, for if it is

inadequate the denture may become unseated during the formation
of those sounds having an explosive effect, requiring the sudden
repositioning of the tongue to control and stabilize the denture.

Width of dental arch

• If the teeth are set to an arch which is too narrow, the tongue will be
cramped, thereby, affecting the size and shape of the air channel.

• This results in faulty phonation of consonants such as ‘T’, ‘D’, ‘S’,

‘M’, ‘N’, ‘K’, ‘C’ and ‘H’, where the lateral margins of the tongue
make contact with the palatal surfaces of the upper posterior teeth.

• Therefore, it is important to place the lingual and palatal surfaces of

the artificial teeth in the position previously occupied by the natural
dentition.

Prosthetic considerations
• Speech problems are usually identified immediately after prosthetic
treatment.

• Speech adaptation to new complete dentures normally takes place

within 2–4 weeks after insertion.

• If maladaptation persists, special measures should be taken by the

dentist or by a speech pathologist.

• When new prostheses are to be made for these patients, certain

difficulties in learning new motor acts may delay and obstruct the
adaptation.
• Consequently, a virtual duplication of the previous denture’s arch
form and polished surfaces, especially the palate of the maxillary
denture, will ensure a minimal period of postinsertion speech
adaptation.

• Old dentures may be of guidance when designing new ones and, if

necessary, a virtual copy of the denture could be made.

• This procedure will frequently solve problems that may arise due to
speech and adaptation difficulties.

Characterization of denture
Characterization is defined as ‘to alter by application of unique markings,
indentations, colouration and similar custom means of delineation on a tooth
or dental prosthesis thus enhancing natural appearance’. (GPT 8th Ed)

Characterization of teeth
• R.E. Lombardi (1973) stated that arrangement of central incisors
reflected the patient’s age, lateral incisor reflected the patient’s sex
and the canine’s reflected the patient’s vigour or personality.

• Frush JP and Fischer RD (1958) advocated that dentogenics

influences tooth arrangement, shade and teeth selection.

• Teeth can be characterized to enhance aesthetics by crowding or

tilting the mandibular anterior teeth.

• The best guide to characterize denture is an old photograph or old

cast of the patient with natural teeth.

Characterization of the denture base

• Aesthetics of the denture base has direct influence on the facial
aesthetics.
• Frush and Fisher (1957) recommended convex, round and shortened
papilla in the elderly.

• They also advocated exposure of more of the cervical root portions

of the denture teeth in older patients.

• Finer stippling along the lighter base shade was recommended for
women, whereas heavy stippling with rougher base shade was
recommended for men.

• Interdental papilla and the muscle attachment areas are preferred

with deeper shades of red to enhance aesthetics.

• To characterize the denture base correct festooning, careful stippling

and custom staining are recommended.

• Various shade guides for denture base materials are available or can
be made.

• E. Pound and S.C. Choudhary suggested the use of diagram to map

out areas to be stained with different shades of colour.

• R.M. Morrow (1986) recommended use of five shades in different

areas of denture base:

(i) Basic pink is used over hard tissue such as attached

gingiva.

(ii) Light red is used for papilla and muscle

attachments.

(iii) Medium red is used sparingly.

(iv) Purple is used sparingly in heavily pigmented

 gingiva.

(v) Brown is used for heavily pigmented gingiva.

Key Facts
• Space of Donders is the space that lies above the dorsum of the
tongue and below the hard and soft palates when the mandible and
tongue are in the rest position.

• Silverman’s speaking space is the space that occurs between the

incisal and/or occlusal surfaces of the maxillary and mandibular
teeth during speech.

• For most of the patients, the average speaking space is 1.5–3 mm.

• Patients with class II occlusion have larger speaking space, i.e. 3–6
mm.

• Patients with class III occlusion have reduced speaking space, i.e.
about 1 mm.

• Palatogram is the graphic record of the area of the palate contacted

by the tongue during speech.

• Size of the artificial teeth is determined by the size of the face,

interarch space, length of lips, skeletal jaw relation, amount of
resorption and size of the anterior arch from cuspid-to-cuspid.
CHAPTER 8
Concept of occlusion

CHAPTER OUTLINE
Introduction, 148
Definitions, 149
Evolution of Anatomic and Semi-Anatomic Teeth, 149
Evolution in the Development of Anatomic and
Semi-Anatomic Teeth, 149
Evolution of Nonanatomic Teeth, 150
Evolution in the Development of Nonanatomic
Teeth or Cuspless Teeth, 150
Complete Denture Occlusion, 151
Basic Requirements for Complete Denture
Occlusion, 152
Lingualized Occlusion Concept, 152
Definition, 152
Indications, 153
Advantages, 153
Disadvantages, 154
Neutrocentric Occlusion or Monoplane Occlusal Scheme, 154
Advantages, 155
Disadvantages, 155
Spherical Occlusion, 155
Definition, 155
Limitations, 155
Balanced Occlusion, 155
Definition, 155
Requirements for Balanced Occlusion, 156
Advantages, 156
Unilateral Occlusal Balance, 156
Bilateral Occlusal Balance, 156
Protrusive Occlusal Balance, 157
Lateral Occlusal Balance, 157
Concepts of Balanced Occlusion, 157
Condylar Inclination, 159
Definition, 159
Incisal Guidance, 160
Plane of Orientation, 161
Cuspal Inclination, 161
Compensating Curve, 162
Types of Teeth, 164
Anatomic Teeth, 164
Nonanatomic teeth, 164
Introduction
Occlusion in complete dentures involves the contact between the
occlusal surfaces of the teeth in both static and functional movements.
These contacts have definitive role in the stability, chewing efficiency,
comfort and aesthetics of the dentures.

Definitions
Occlusion is defined as ‘the static relationship between the incising or
masticating surfaces of the maxillary or mandibular teeth or tooth analogues’.
(GPT 8th Ed)
Articulation is defined as ‘the static and dynamic contact relationship
between the occlusal surfaces of the teeth during function’. (GPT 8th Ed)
Balanced articulation is defined as ‘a continuous sliding contact of
upper and lower cusps all around the dental arches during all closed grinding
movements of the mandible’. (GPT 8th Ed)
The differences between natural and artificial occlusions are given
in Table 8-1.

TABLE 8-1
DIFFERENCES BETWEEN NATURAL OCCLUSION AND
ARTIFICIAL OCCLUSION

Natural Occlusion Artificial Occlusion

Natural teeth function independently of each other and each Artificial teeth function as a unit and occlusal
tooth disperses the occlusal load load is dispersed over the entire unit
Nonvertical forces are well tolerated and affect only the teeth Lateral or nonvertical forces affect all the
that are involved teeth on the base and can traumatize the
underlying tissues
Incising with anterior teeth will not affect the posterior teeth Incising with the anterior teeth can destabilize
the denture posteriorly
Second molar is the favoured area for heavy mastication for Heavy mastication over the second molar can
better leverage and power shift or tilt the denture base, if they are on
inclined plane
Bilateral balance is not necessary and may cause hindrance in Bilateral balance is necessary, as it increases
proper function the stability of the denture
Malocclusion can be uneventful for a long time Malocclusion poses immediate problems
involving all the teeth and the base
Proprioceptive impulses give a feedback mechanism to No such mechanism exists in denture patient;
avoid the occlusal prematurities; it can help the patient to any occlusal prematurity can destabilize the
attain habitual centric denture
Natural teeth are retained by the periodontal ligaments which The denture rests on the moist and slippery
are uniquely innervated and structured mucosa
Evolution of anatomic and semi-
anatomic teeth
Evolution in the development of anatomic and
semi-anatomic teeth
1914: Dr Alfred Gysi is credited for designing the first anatomic
porcelain tooth with 33° cusp angle. These teeth were called
‘trubyte’, which had transverse ridges for providing occlusion with
tight interdigitation.

1922: Victor Sears designed a ‘channel tooth’. In this, deep channels

were created in the maxillary occlusal surface mesiodistally which
ran through the entire length of all the four posterior teeth. The
lower posterior teeth were reduced to almost half the buccolingual
width of the anatomic tooth. The teeth were almost a single central
ridge which contacted the maxillary channel teeth to provide an
unlimited protrusive glide (Fig. 8-1).

1927: Gysi introduced a modified ‘crossbite’ posterior teeth. In his

modification, the maxillary buccal cusp was almost eliminated
resulting in a prominent lingual cusp occluding into the lower
anatomic tooth. He described the modification as ‘mortar and pestle’
action of this occlusal scheme.

1930: Avery Brothers introduced ‘scissor-bite tooth’. The posterior teeth

were modified anteroposteriorly by grinding steps on the surface of
the teeth. The angle of these steps was modified by the condylar
inclination. The modified occlusal surfaces were meant to shear the
food in lateral excursions (Fig. 8-2).

1932: Pilkington and Turner developed anatomic posterior tooth with

slightly shallower cusp angle of 30°. Their tooth was called
 Pilkington–Turner tooth.

1935: F.H. French and Universal Dental Company developed a modified

posterior tooth. The maxillary tooth had a central groove running
mesiodistally with shallow buccolingual inclines to reduce the
lateral thrust.

1936: H.F. McGrane marketed ‘curved cusp posterior tooth’. These teeth
were designed to lock anteroposteriorly and be free laterally. These
were intended to shear food in harmony with the lateral condylar
guidance determined by Bennett angle.

1937: Max Pleasure proposed the occlusal scheme which modified the
position of the lower posterior teeth more buccally. This enables the
forces to be directed lingually, favouring the stability of the lower
denture.

1941: Sir Howard Payne introduced the concept of lingualized occlusion.

1942: John Vincent used metal inserts in the resin posterior teeth. The
metal inserts protruded from the middle third of the posterior
occlusal surfaces with shallow buccal and lingual cusps protruding
beyond the metal inserts. These teeth opposed the French
mandibular posteriors. With wear of the teeth, the heaviest chewing
forces were concentrated in the centre of the denture to minimize
the tipping of the denture.

1957: Myerson FLX ‘freedom in lateral excursion’ posteriors when

properly arranged resulted in balanced occlusal contacts.

1961: M.B. Sosin replaced the maxillary second bicuspid and first and
second molars with cleat-shaped vitallium forms called cross blades.
The patient was made to chew wax in the lower. The indentation
was converted into gold and was cured with the denture (Fig. 8-3).

1977: B. Levin modified cross blade teeth in the upper row by reducing
their size.
FIGURE 8-1 Sear’s channel type posterior teeth.

FIGURE 8-2 Avery Brother’s scissor-bite teeth.

FIGURE 8-3 Sosin’s cross blade posterior teeth.

Evolution of nonanatomic teeth
Evolution in the development of nonanatomic
teeth or cuspless teeth
1929: R.Hall was the first to introduce nonanatomic teeth. He called it as
‘inverted cusp tooth’. This design has flat occlusal surface with sharp
concentric ridges which provided efficient shredding of the food.
The only drawback was that the food was clogged into the
depressions as no escape ways were provided.

1929: R.L. Myerson designed a cuspless tooth and called it ‘true cusp’. It
has series of transverse buccal lingual ridges with sluiceways
between them.

1934: Nelson designed nonanatomic teeth and called them ‘chopping

block’. The ridges on the mandibular teeth ran transversely and on
the maxillary teeth ran mesiodistally. This provided an efficient
chopping and shredding of food (Fig. 8-4).

1939: M.G. Swenson designed posterior tooth called ‘nonlock’. These

were flat teeth with sluiceways for efficient shredding and clearing
of food from the occlusal table.

1946: I.R. Hardy developed nonanatomic teeth with metal inserts in

upper and lower teeth with vitallium occlusal. Narrow zigzag
vitallium ribbon was inserted on the occlusal surfaces running
mesiodistally. This established a narrow, flat, convoluted metal
surface that was slightly higher than the encapsulating resin. This
metal-to-metal contact provided efficient cutting ability (Fig. 8-5).

1951: Myerson Tooth Corporation introduced the first cross-linked

acrylic tooth in a flat occlusal scheme and called it ‘shear–cusp tooth’.
These teeth were of higher wear-resistant quality.
1952: W.A. Cook introduced Coe masticators. In this, the second
premolar and the first molar had flat stainless steel casting with the
holes on the occlusal surfaces that opened to a port on the buccal
surface. However, food used to clog these ports and was very
difficult for the wearer to clean it.

1957: W. Bader designed a ‘cutter bar’ scheme. In this scheme, the upper
porcelain cuspless teeth were opposed by metal cutting bar
replacing second premolar, first molar and second molar.

1967: J.P. Frush advocated a scheme called ‘linear occlusal concept’. The
flat maxillary ridge opposed the flat lower ridge with a single
mesiodistal ridge.

FIGURE 8-4 Nelson’s chopping blocks.

FIGURE 8-5 Hardy’s vitallium occlusal teeth.

Complete denture occlusion
The term occlusion is referred to describe static contacts of the teeth
that exist after the jaw movement has stopped and the tooth contacts
are identified.
V.H. Sears (1952) has laid down the following guidelines to plan
complete denture occlusion:

• Smaller the occlusal surface, lesser will be the force transmitted to

the supporting structures.

• Vertical forces applied to the inclined occlusal plane result in

nonvertical forces on the denture base.

• Vertical forces applied to the inclined supporting tissues result in

nonvertical forces on the denture base.

• Vertical forces placed outside the crest of the ridge cause tipping of
the denture.

• Vertical forces on the denture base resting on the flabby tissues

produce leverage forces resulting in instability of the denture.

Basic requirements for complete denture

occlusion
• It should provide stability of occlusion in the centric and eccentric
positions.

• It should provide bilateral balanced occlusal contact in all eccentric

movements.

• It should provide freedom in movement of the cusp mesiodistally to

allow for gradual settling of denture on ridge resorption.
• Buccolingual cuspal height should be decreased to reduce the
horizontal forces on the dentures.

• It should have efficient cutting, penetrating and shearing occlusal

surfaces.

• It should provide functional lever balance.

• It should have sharp ridges or cusps and sluiceways for increased

masticatory efficiency.

• It should provide anterior incisal clearance during posterior contact

functions such as mastication and bruxism.

These basic requirements can be fulfilled, if any occlusal scheme is

divided into the following units:

(i) Incisal

(ii) Working

(iii) Balancing

Requirements for incising units

• Incising units should be sharp to enhance the cutting efficiency.

• These should be out of contact during mastication.

• These should have as shallow or flat incisal guidance as possible for

better aesthetics and speech.

• These should have adequate overjet to permit denture base settling.

• These should contact during protrusion.

Requirements for working units

• Working units should enhance the cutting and grinding efficiency.

• These should have reduced buccolingual width to decrease the

forces transmitted to the supporting tissues.

• These should contact simultaneously during chewing and eccentric

movements.

• These should be positioned over the crest of the ridge for better
lever balance.

• These should transmit the forces vertically to the supporting

structures.

• These should centre the occlusal load to the anteroposterior centre

of the denture.

• These should have occlusal plane parallel to the mean foundation

plane as closely as possible.

Requirements for balancing units

• Balancing units should contact the second molar during protrusion.

• These should contact along with the working side at the end of the
chewing cycle.

• These should provide smooth gliding contacts during lateral and

protrusive excursions.

Concepts in Occlusion
Different occlusal concepts in complete dentures are:

• Bilateral balanced occlusion

• Monoplane/neutrocentric occlusion
• Lingualized occlusion

• Spherical occlusion

• Organic occlusion

• Physiologically generated occlusion

Lingualized occlusion concept
Definition
This is defined as ‘this form of denture occlusion articulates the maxillary
lingual cusps with the mandibular occlusion surfaces in centric working and
nonworking mandibular positions’. (GPT 8th Ed)

• A. Gysi was the first to report the biomechanical advantages of

lingualized tooth forms in 1927.

• Gysi designed and patented ‘crossbite posterior teeth’ in 1927.

• Lingualized occlusion concept was first described by Sir Howard Payne

in 1941.

• E. Pound and G.R. Murrell (1973) also advocated this concept of

occlusion.

• Earl Pound coined the term lingualized occlusion (1970).

• It is an attempt to maintain the aesthetic and food penetration

advantages of the anatomic form while maintaining the mechanical
freedom of the nonanatomic form.

• This concept utilizes anatomic teeth for the maxillary denture and
modified nonanatomic or semi-anatomic teeth for the mandibular
denture.

• Anatomic posterior teeth with prominent lingual cusp are used for
maxillary denture.

• Nonanatomic or semi-anatomic teeth are used for mandibular

posterior teeth denture.
• Narrow occlusal table.

• Maxillary lingual cusps should only contact in centric position (Fig.

8-6).

• Maxillary buccal cusp was not allowed to contact the mandibular

teeth in centric or eccentric positions.

• Balancing and working contacts only at upper lingual cusps (Fig. 8-

7).

FIGURE 8-6 Lingualized occlusion in centric position.

 FIGURE 8-7 Lingualized occlusion with balancing and
working side contacts.

Indications
• It is helpful when the patient places high priority on aesthetics but a
nonanatomic occlusal scheme is indicated by severe alveolar
resorption.

• It is indicated for class II jaw relationship or displaceable supporting

tissue.

• It is indicated in the cases where complete denture opposes a

removable partial denture.

• It is indicated for patients with flabby ridge coverings.

Advantages
• It provides cross-arch balance.

• It improves denture stability.

• It decreases lateral contact because maxillary lingual cusps provide

 sole contact with mandibular posterior teeth.

• It minimizes the damaging lateral forces.

• It is a simpler technique.

• Bilateral balance can be obtained.

• Adjustments can be done easily.

• It can be used in class II and class III jaw relationships.

• Upper teeth maintain aesthetics.

• Vertical forces are centralized on the mandibular teeth, resulting in

increased stability of the denture and maintenance of the
supporting hard and soft tissues.

Disadvantages
• It is less natural than the cusp tip to fossa occlusion.

• It results in decreased masticatory efficiency as maxillary buccal

cusp does not contact the mandibular teeth.
Neutrocentric occlusion or monoplane
occlusal scheme
• This concept maintains that the ‘anteroposterior plane of occlusion
should be parallel with the plane of the denture foundation and not dictated
by the horizontal condylar guidances’.

• M.M. DeVan gave the concept of neutrocentric occlusion in 1955.

• This concept of occlusion eliminates any anteroposterior or

mediolateral inclines of the teeth and directs the forces of occlusion
to the posterior teeth (Fig. 8-8).

• When teeth are arranged on the plane, these are not inclined to form
compensatory curves.

• In the mediolateral direction, the tooth is set flat with no medial or

lateral inclination.

• Thus, this concept of occlusion eliminates any anteroposterior or

mediolateral inclines of the teeth and directs the forces of occlusion
to the posterior teeth.

• The patient is instructed not to bite with the anterior teeth.

• Monoplane or cuspless posterior teeth are used in this type of

occlusion.

• Because of this, there is no projection above or below the occlusal

plane.

• The horizontal and lateral condylar guidances of the articulator are

programmed to ‘zero’.

• To direct force towards the centre of the support and to reduce the
 functional forces, the buccolingual width of the teeth and the
number of teeth are also reduced.

FIGURE 8-8 Teeth arranged in neutrocentric occlusion.

Factors influencing neutrocentric occlusion are:

• Skeletal relationship of the jaws.

• Influence of somatic nervous system to control muscle movement

and proprioception.

• Accuracy of the denture bases.

• Stable position of the condyles in the glenoid fossa.

Advantages
• It is more adaptable to unusual jaw relation such as class II and class
III jaw relationships.

• It can be used with crossbite relations.

• It provides freedom in occlusion.

• It is useful in cases of poor ridges.

• It is a simplified and less time-taking technique.

Disadvantages
• It results in poor aesthetics.

• It results in decreased masticatory efficiency.

• It results in decreased denture stability during eccentric movements.

• It is difficult to obtain balanced occlusion.

Spherical occlusion
Definition
Spherical occlusion is defined as ‘an arrangement of teeth that places their
occlusal surfaces on the surface of an imaginary sphere (usually 8 inches in
diameter) with its centre above the level of the teeth’. (GPT 4th Ed)

• Spherical theory of occlusion was introduced by G.S. Monson (1918).

• This concept of occlusion was based on observations of the natural

teeth by German anatomist von Spee.

• Hagman balancer and one phase of the Pankey–Mann occlusal

reconstruction technique were based on the spherical theory of
occlusion.

• According to this concept, the anteroposterior and mesiodistal

inclines of the artificial teeth should be arranged in harmony with a
spherical surface.

• The spherical theory of occlusion proposed that lower teeth move

over the surface of upper teeth as over a surface of sphere with a
diameter of 8 inches.

• The centre of sphere was located in the region of glabella.

• The surface of the sphere passed through the glenoid fossa and
along with the articulating eminences.

Limitations
• Articulators based on this theory do not have provisions for
variations in inclinations for condylar paths.
• It cannot be used in all patients due to variation in the paths of jaw
movements.
Balanced occlusion
Definition
Balanced occlusion is defined as ‘the bilateral, simultaneous, anterior, and
posterior occlusal contact of teeth in centric and eccentric positions’. (GPT
8th Ed)
Or
‘Stable simultaneous contact of the opposing upper and lower teeth in
centric relation position and a continuous smooth bilateral gliding from this
position to any eccentric position within the normal range of mandibular
function’. (Winkler)

Goals of balanced occlusion

• Maximal bilateral, simultaneous contact in centric positions.

• Working contacts are present all along the working side from the
canine posteriorly.

• Balancing contact in protrusive position in the molar region. Slight

variation in angulation can result in this contact.

• Balancing in the molar region in lateral position.

• Occlusal plane of the completed set up parallel to the maxillary and

mandibular residual ridges.

Factors which aid in achieving balanced occlusion are described as

follows:

Factors of protrusive balance

• The inclination of the condylar path.
• Angle of the incisal guidance chosen for the patient.

• Inclination of the plane of occlusion.

• The compensating curves chosen for orientation with the condylar

path and incisal guidance.

• Cuspal height and inclination of the posterior teeth.

Factors of lateral balance

• Inclination of the condylar path on the nonworking side.

• Inclination of the incisal guidance and cuspid lift.

• Inclination of the plane of occlusion on the balancing or nonworking

and the working side.

• Compensating curve on the balancing and the working side.

• The buccal cusp heights or inclination of teeth on the balancing side.

• The lingual cusp heights or inclination of teeth on the working side.

• The Bennett side shift on the working side.

Requirements for balanced occlusion

• All the teeth of the working side (canine to second molar) should
glide evenly against the opposing teeth.

• No single tooth should produce any interference or dislocation of

other teeth.

• There should be contact in the balancing side, but they should not
interfere with the smooth gliding movements of the working side.
• There should be simultaneous contact during protrusion.

Advantages
• Balanced occlusion is one of the most important factors that affect
the denture stability. Absence of occlusal balance will result in
leverage forces which destabilize the denture during mandibular
movement.

• Bilateral balanced occlusion provides contact during the terminal

arc of closure to help seat the denture in a stable position during
chewing.

• Balanced occlusion aids during swallowing as it allows even

bilateral contact.

• It helps in preventing the destructive lateral forces generated during

parafunctional habits such as bruxism to be transmitted to the
supporting tissues.

• It provides stability, retention and comfort.

• Dentures which are not balanced tend to move during function, this
movement or shifting of the denture base tends to abuse the
supporting tissues.

Types of Balanced Occlusion

(i) Unilateral occlusal balance

(ii) Bilateral occlusal balance

(iii) Protrusive occlusal balance

(iv) Lateral occlusal balance

Unilateral occlusal balance
• This type of occlusion has all the teeth contacting on the working
side and with no contact on the balancing side.

• This type of occlusion is not advised in complete denture fabrication

but can be used in fixed partial dentures.

Bilateral occlusal balance

• This occurs when there is bilateral simultaneous contact of the teeth in
centric and eccentric movements.

• In this, minimum of three contacts are needed to establish a plane of

equilibrium.

• This type of balance is dependent on the interaction of condylar

inclination, incisal guidance, plane of occlusion, height of the cusp
and teeth angulation.

• This type of occlusion is the most desired one in complete denture

fabrication.

• It enhances the denture stability in centric and eccentric movements.

Protrusive occlusal balance

• During protrusion of the mandible, there is simultaneous and
bilateral contact in the posterior and anterior teeth.

• It requires a minimum of three contacts, one on each side on the

posterior teeth and one on the anterior teeth.

• This type of balance also depends on the interaction of factors

similar to the bilateral balance (Fig. 8-9).
 FIGURE 8-9 Teeth contact during protrusive balance.

Lateral occlusal balance

• There is a simultaneous contact on the working and balancing side
on lateral movements.

• Minimum three-point contact is needed.

• Greater the number of teeth contacting, greater will be the balance.

• It is desirable in complete dentures to enhance stability.

Concepts of balanced occlusion

Gysi’s concept (1914)

• A. Gysi first proposed the concept of balanced occlusion in 1914.

• He suggested that 33° anatomic teeth can be arranged under various

movements of the articulator to enhance the stability of the denture.

French’s concept (1954)

• F.H. French (1954) used modified French teeth to obtain balanced
occlusion.

• He suggested lowering of the lower occlusal plane to enhance

stability of the dentures along with balanced occlusion.

• He arranged the upper first premolars with 5° angulation, upper

second premolars with 10° angulation and upper molars with 15°
angulation.

Sear’s concept (1949)

• He introduced the balanced occlusion for nonanatomic teeth using
posterior balancing ramps or an occlusal plane which curves
anteroposteriorly and laterally.

Pleasure concept (1937)

• M.A. Pleasure introduced a Pleasure curve or the posterior reverse
lateral curve to align and arrange the posterior teeth in order to
increase the stability of the denture.

• He used reverse curve in the first premolar, flat occlusal surface on

the first molar and Monson curve at the second molar to achieve
balance.

• The reverse curve helped in directing the forces of occlusion

lingually to enhance the stability of the lower denture.

Frush’s concept
• He advocated arranging teeth in a one-dimensional contact
relationship, which could be reshaped during the wax try-in to
obtain balanced occlusion.
Hanau’s quint (1929)
• Rudolph L. Hanau proposed that five factors were important in
achieving balanced occlusion, which are as follows:

(i) Condylar guidance

(ii) Incisal guidance

(iii) Compensating curves

(iv) Relative cusp height

(v) Plane of orientation of the occlusal plane

Trapozzano’s concept
• It is also called ‘triad of occlusion’.

• Reviewed factors of Hanau’s Quint and came to the conclusion that

only three factors were important to achieve balanced occlusion.

• He eliminated the plane of occlusion as he believed that its location

is highly variable and depends on the available interarch space.

• He suggested that occlusal plane should be located at various

heights to favour a weaker ridge.

• The other factor which he considered unimportant was the

compensating curve.

• When the cuspal angulation that will produce balanced occlusion is

determined, the concavity or convexity of the curve can easily be
evaluated.
Lott’s concept (fig. 8-10)
• F. Lott studied Hanau’s work and clarified the laws of occlusion by
relating them to the posterior separation that is the resultant of the
guiding factors.

FIGURE 8-10 Lott’s chart.

Lott’s Laws of Occlusion are:

• Greater the angle of the condylar path, greater will be the posterior
separation during protrusive movement.

• Greater the vertical overlap, greater is the separation in the anterior

region and the posterior region regardless of the angle of the
condylar path.

• Greater the separation of the posterior teeth, greater or higher will

be the compensating curve.
• Posterior separation beyond the balancing ability of the
compensating curve requires the introduction of the plane of
orientation.

• Greater the separation of the teeth, greater must be the height of the
cusps in the posterior teeth.

Boucher’s concept
• C.O. Boucher confronted V.R. Trapozzano’s concept and proposed
the following three factors for balanced occlusion.

(i) According to him, there are three fixed factors,

namely, orientation of the occlusal plane, incisal
guidance and the condylar guidance.

(ii) Angulation of the cusp is more important than

the height of the cusp.

(iii) The compensating curve enables one to

increase the effective height of the cusps without
changing the form of the teeth.

Levin’s concept
• This concept was similar to the Lott’s concept except here the plane
of orientation factor is eliminated.

• According to him, the plane of occlusion can be slightly altered by

1–2 mm in order to improve stability of the denture.

• He named other four factors as QUAD.

• The condylar guidance is fixed and given by the patient. The
balancing condylar guidance includes the Bennett shift of the
working condyle. This may or may not affect the lateral balance.

• Incisal guidance is obtained from the patient’s aesthetic and

phonetic requirements. However, it can be modified (e.g. in cases of
resorbed residual ridges, the incisal guidance can be reduced).

• Compensating curve is the most important factor for obtaining

balance. Monoplane or low cusp teeth should employ the use of
compensating curve.

• Cusp teeth or anatomic teeth have the inclines necessary for

obtaining the balanced occlusion but are used mostly with the
compensating curve.

Factors influencing balanced occlusion

Rudolph L. Hanau proposed nine factors that govern the articulation
of the artificial teeth, which are:

(i) Horizontal condylar guidance

(ii) Compensating curves

(iii) Protrusive incisal guidance

(iv) Plane of orientation

(v) Buccolingual inclination of tooth axis

(vi) Sagittal condylar pathway

(vii) Sagittal incisal guidance

(viii) Tooth alignment

(ix) Relative cusp height

These nine factors were called the laws of balanced articulation.

Hanau later condensed these nine factors and formulated five factors,
which are commonly known as Hanau’s Quint.

(i) Condylar guidance

(ii) Incisal guidance

(iii) Compensating curves

(iv) Relative cusp height

(v) Plane of orientation of the occlusal plane

Condylar inclination (fig. 8-11)

FIGURE 8-11 Diagram showing condylar inclination which is

the only factor given by the patient.

Definition
Condylar inclination is defined as ‘the direction of the lateral condylar
path’. (GPT 4th Ed)

• It is the only factor which is given by the patient.

• The inclination of the condylar path is determined by the protrusive

record.

• This factor is fixed by the patient and cannot be altered by the dentist.

• The articulator is programmed using the protrusive record of the

patient.

• The occlusion set on the articulator should be in harmony with the

patient’s temporomandibular joint.

Incisal guidance (fig. 8-12)

Definition
Incisal guidance is defined as ‘the influence of the contacting surface of the
mandibular and maxillary anterior teeth on mandibular movements’. (GPT
8th Ed)

• It is called the second factor of occlusion.

• It is determined by the dentist and altered depending on the individual

case.

• It can be set depending upon the desired overjet and overbite planned
for the patient.

• It is the anterior controlling factor.

• If the overjet is increased, the inclination of the incisal guidance is

decreased.
• If the overbite is increased, the inclination of the incisal guidance
increases.

• The incisal guidance has greater influence on the posterior teeth

than the condylar guidance.

• This is because the posterior teeth are closer to the action of incisal
inclination than the action of the condylar guidance.

• During protrusive movements, the incisal edge of the mandibular

anterior teeth move in a downward and forward path
corresponding to palatal surface of the upper incisors.

• This is known as the protrusive incisal path or incisal guidance.

• The angle formed by this protrusive path to the horizontal plane is

called protrusive incisal path inclination or the incisal guide angle.

• This influences the shape of the posterior teeth.

• If the incisal guidance is steep, the compensating curve is needed to

produce balanced occlusion.

• In a complete denture, the incisal guide angle should be as flat

(more acute) as the aesthetics and phonetics permit.

• Therefore, while arranging the anterior teeth, for aesthetics, a

suitable vertical overlap and a horizontal overlap should be chosen
to achieve balanced occlusion.

• Also, once the aesthetics is established, this factor becomes fixed.

• If the incisal guidance is steep, then to achieve balanced occlusion

steep cusps, steep occlusal plane or compensating curve is used.

• The location of the incisors is governed by various factors such as

aesthetics, function and phonetics.
 FIGURE 8-12 Schematic diagram showing incisal guidance:
(A) anterior teeth; (B) incisal guide table.

Determinants of the incisal guidance are:

• Phonetics

• Aesthetics

• Ridge relationship

• Arch shape

• Ridge fullness

• Inter-ridge space

Plane of orientation (fig. 8-13)

Definition
Plane of orientation is defined as ‘the average plane established by the
incisal and occlusal surfaces of the teeth. Generally, it is not a plane but
represents the planar mean of the curvature of these surfaces’. (GPT 8th Ed)
• The plane of orientation should be established exactly as it was
when the natural teeth were present.

• It is established anteriorly by the height of the lower canine, which

nearly coincides with the commissures of the mouth and posteriorly
ends at the anterior two-thirds of the retromolar pad.

• It is essentially parallel to the ala–tragus line or the Camper’s line.

• It can be slightly altered and its role is not as important as other

factors.

• Tilting the plane of occlusion beyond 10° is not advisable.

• Research shows that when the occlusal plane is parallel to the ala–
tragus line, the closing force during maximum clenching is greater
than when it is altered ±5°.

FIGURE 8-13 Diagram showing height of occlusal plane.

Cuspal inclination
Definition
Cusp angle is defined as ‘the angle made by the average slope of the cusp
with the cusp plane measured mesiodistally or buccolingually’. (GPT 8th Ed)

• The cusps on the teeth or the inclination of cuspless teeth are

important factors that modify the effect of plane of occlusion and
the compensating curves.

• The mesiodistal cusps lock the occlusion, such that repositioning of

teeth does not occur due to settling of base.

• In order to prevent the locking of occlusion, all the mesiodistal

cusps are eliminated during occlusal reshaping.

• In the absence of mesiodistal cusps, only the buccolingual cusps

were considered as a factor for balanced occlusion.

• In cases with a shallow overbite, the cuspal angle should be reduced

to balance the incisal guidance.

• This is done because the jaw separation will be less in cases with
decreased overbite.

• In cases with deep bite (steep incisal guidance), the jaw separation is
more during protrusion.

• Teeth with high cuspal inclines are required in these cases to

produce posterior contact during protrusion.

• Commonly used posterior teeth are those with cuspal inclination of

33°, 20° and 0°.

• Although the effective final height of the cusp depends on

inclination of the teeth, incisal guidance, condylar guidance, height
of the occlusal plane and the compensating curve, 33° posterior
teeth are best suited for balanced occlusion.
Compensating curve
• It is a valuable factor as it allows the dentist to alter the cusp height
without changing the form of the teeth.

• The height of the cusp can be varied by inclining the long axis of the
teeth.

• In cases of cuspless teeth, compensating curve can be used to

produce the equivalent of the cusp.

• Compensating curve is determined by the inclination of the

posterior teeth and their vertical relationship to the occlusal plane.

• Steeper condylar path requires a steeper compensating curve to

achieve balanced occlusion.

Definition
Compensating curve is defined as ‘the anteroposterior curving (in the
median plane) and the mediolateral curving (in the frontal plane) within the
alignment of the occluding surfaces and the incisal edges of the artificial teeth
that is used to develop balanced occlusion’. (GPT 8th Ed)
Or,
‘The anteroposterior and the lateral curvature in the alignment of the
occluding surfaces and incisal edges of the artificial teeth that is used to
develop balanced articulation’.

Purpose of compensating curve

• To provide balancing occlusal contacts for the protrusive
mandibular positions

• To aid in compensating for steep condylar inclination

Types of Compensating Curves

(i) Anteroposterior curves

• Curve of Spee
(ii) Lateral curves

• Curve of Wilson

• Curve of Monson

• Pleasure curve
The curve of Spee, the curve of Wilson and the curve of Monson are
associated with the natural dentition. These curves are incorporated in
the complete dentures in order to produce balanced occlusion.

Anteroposterior curve
Curve of spee. 
It is defined as ‘the anatomic curvature established by the occlusal
alignment of the teeth, as projected onto the median plane, beginning with the
cusp tip of the mandibular canine and following the buccal cusp tips of the
premolar and the molar teeth, continuing through the anterior border of the
mandibular ramus, ending with the anterior most portion of the mandibular
condyle’.

• This curve was first described by Ferdinand Graf Spee in 1890.

• It is found in natural dentition and is reproduced in complete

dentures to enhance stability (Fig. 8-14).

• There will be contact of the posterior teeth during protrusion.

• If this curve is not followed, there will be disocclusion of the

 posterior teeth during protrusion (Christensen’s phenomenon).

FIGURE 8-14 Anteroposterior curve – curve of Spee.

Lateral curves
Curve of monson (fig. 8-15). 
It is defined as ‘the curve of occlusion in which each cusp and incisal edge
touches or conforms to a segment of the surface of a sphere 8 inches in
diameter with its centre in the region of the glabella’. (GPT 8th Ed)

• It was first described by George S. Monson (1869–1933).

• It involves molar teeth.

• The curve usually does not exceed 5–10° from the horizontal plane
of orientation when viewed from the frontal plane.

• It has concavity facing upwards.

• The curve touches the palatal and buccal cusp of the maxillary
molars.

• During lateral movement, on the working side, the mandibular

lingual cusp slides along the inner inclines of the maxillary buccal
cusp and on the balancing side, the mandibular buccal cusp would
contact the maxillary palatal cusp to provide lateral balance.

FIGURE 8-15 Curve of Monson.

Curve of wilson (fig. 8-16)

• It is defined as ‘the curvature in the lower arch affected by the equal

lingual inclination of the right and left molars so that the tip points of the
corresponding cross-aligned cusps can be placed into the circumference of
the circle. The curve in the lower arch being concave and the one in the
upper arch being convex’.

• It was first described by G.H. Wilson (1911).

• First premolars are arranged according to this curve such that they do
not produce interference during lateral movements.

FIGURE 8-16 Curve of Wilson.

Curve of pleasure (fig. 8-17)

• It is also called frequency curve, probability curve, reverse curve or

anti-Monson curve.

• It is defined as ‘a helicoid curve of occlusion that, when viewed in the

frontal plane, conforms to a curve that is convex from the superior view,
except for the last molars which reverse that pattern’.

• It was first described by Max Pleasure (1937).

• He modified the occlusal surfaces of the lower posterior teeth to a

reverse curve by tilting the tooth buccally.

• This did not provide balancing contact in either protrusive or lateral

movements.

• Later this scheme was modified to provide the balancing contacts.

• The reverse curve was set in the premolars, flat occlusal surface on the
first molar, and a Monson curve at the second molar was arranged to
provide balanced contacts in lateral excursions.

• The distal of the second molar is elevated to produce the

 compensating curve for the protrusive balance.

• The reverse curve, i.e. tilting of the occlusal surfaces buccally is done
in order to direct the forces of occlusion lingually to favour the
stability of the lower denture.

• C.H. Moses (1954) suggested that Pleasure curve was desirable in all
the patients except in those where the maxillary denture is insecure
because of the size or character of the basal seat.

FIGURE 8-17 Pleasure curve.

Types of teeth (table 8.2)
Anatomic teeth
Anatomic teeth are defined as ‘teeth that have prominent cusps on the
masticating surfaces and that are designed to articulate with the teeth of the
opposing natural or prosthetic dentition’. (GPT 8th Ed)
Anatomic teeth have 33° cusp angle. Cusp angle is measured as the
angle formed by the incline of the mesiobuccal cusp of the lower first
molar with the horizontal plane.

TABLE 8-2
TYPES OF TEETH
 FIGURE 8-18 Anatomic teeth.

FIGURE 8-19 Cuspless or nonanatomic teeth.

Nonanatomic teeth
Nonanatomic teeth or cuspless teeth are defined as ‘artificial teeth with
occlusal surfaces that are not anatomically formed’. (GPT 8th Ed)
Zero-degree teeth are defined as ‘posterior denture teeth having 0°
cuspal angles in relation to the plane established by the horizontal occlusal
surface of the tooth’. (GPT 8th Ed)
Key Facts
• Farrar appliance is a type of occlusal device which is used to
position the mandible anteriorly to treat temporomandibular joint
(TMJ) disk disorders.

• Condylar guidance of the patient is determined by a protrusive

record.

• ‘S’ shaped path of the glenoid fossa determines the path of

movement of the condyle and determines the condylar guidance.

• In the natural dentition, the centric occlusion is usually 0.5–1 mm

anterior to the centric relation.

• Concept of lingualized occlusion was proposed by Gysi in 1927, in

which the maxillary lingual cusp was used as the dominant element
which occluded against the corresponding position of the
mandibular teeth.

• Reverse articulation is the occlusal relationship in which the

maxillary buccal cusps are placed in the central fossae of the
mandibular teeth.

• Steep inclines are undesirable in complete dentures, as they

decrease the stability of the denture by increasing the inclined
planes.

• In resorbed ridges, the occlusal plane is placed closer to the ridge in

order to reduce leverage forces on the denture.

• Surfaces of the dentures that affect stability of the dentures are the
occlusal, impression and polished surfaces of the denture.
• Flat or zero incisal guidance provides maximum denture stability.

• Two end factors controlling protrusive movement in the complete

denture patients are incisal guidance and the condylar guidance.

• In long centric, there is freedom of movement up to 1 mm in the

sagittal and horizontal direction.

• Mutually protected occlusion is an occlusal scheme in which the

posterior teeth prevent excessive contact of the anterior teeth in
maximum intercuspation and the anterior teeth disengages the
posterior teeth in all mandibular excursive movements.
CHAPTER 9
Wax try-in and laboratory
procedures

CHAPTER OUTLINE
Introduction, 167
Definition, 167
Requirements of Wax-Up, 167
Waxing Procedure for Maxillary Trial
Denture, 168
Wax-Up Procedure for Mandibular Trial
Denture, 168
Wax Try-In, 169
Procedures Followed During the Try-In
Stage, 169
Flasking Procedure, 170
Definition, 170
Procedure, 171
Wax Elimination, 171
Procedure, 171
Packing, 172
Packing Procedure, 172
Processing of Denture, 172
Deflasking of the Denture, 173
Laboratory Remount Procedure, 173
Procedure, 173
Rules for Selective Grinding, 173
Finishing and Polishing of Complete Dentures, 174
Procedure, 174
Introduction
Definition
Waxing is defined as ‘the contouring of a wax pattern or the wax base of a
trial denture into desired form’. (GPT 1st Ed)
Waxing-up is defined as ‘the contouring of a pattern in wax generally
applied to the shaping in wax of the contours of a trial denture’. (GPT 1st
Ed)

Requirements of wax-up
• Wax-up should duplicate the soft tissues as closely as possible.

• Contours of the denture flanges should be compatible with the

shape of the cheeks and lips.

• Contours of the lingual flange should be compatible with the

tongue. It should have least possible amount of bulk, except at the
border.

• Palatal section of the maxillary denture should accurately reproduce

the patient’s palate.

• Notches should be provided to accommodate the frenum in both

size and direction.

• Borders, both labial and lingual, should fill the vestibule.

Methods of Waxing-Up the Trial Dentures

(i) Free hand or conventional method

(ii) Physiological or flange method

Waxing procedure for maxillary trial denture
• The thickness of the denture flanges and the borders are reduced or
built-up to desired dimension dictated by the final impression.

• Wax is contoured just above the cervical end of the tooth to produce
the gingival bulge or fullness simulating the attached gingiva.

• Wax is contoured around the cervical margin of the tooth at 30–40°

angulation with the long axis of the crown for anterior teeth and 45°
angulation for the posterior teeth.

• Wax is contoured above the canine to simulate the canine eminence.

• Root portion of the anterior teeth is carved in a triangular manner

with the canine root being the longest followed by the central
incisor and the lateral incisor.

• The contour of the anterior trial denture should have slight convex
effect overall.

• Gingival bulge area is almost nonexistent in the first premolar region

and progressively becomes more prominent in the second premolar
and molar regions.

• Long and pointed interdental papillae are carved for the young
patient, whereas short and blunt papillae are carved for old.

• Stippling can be accomplished using a modified bristle brush in the

region of attached gingiva (Fig. 9-1).

• Stippling contributes to the natural appearance by reducing even

light refraction and by blending contours.

• Palatal surface is waxed to restore contours present before the loss

of teeth and supporting structures.
• Thickness of the palate should not be less than 1.5–2.0 mm in any
area. Any added thickness can alter the proper formation of speech
sounds.

• The lingual contours of the upper central incisors are re-established

in the waxing procedures. This contour aids in phonetics and
provides natural feel to the patient’s tongue.

• Vault form of the denture depends on the vault form of the maxillae.
It is modified by the absorption of the bone and tissue as the result
of loss of teeth and supporting structures.

• Lingual festooning can be accomplished by restoring part of the

lingual surface of the tooth that is not supplied in the artificial teeth.

FIGURE 9-1 Stippling is accomplished using modified brush.

Wax-up procedure for mandibular trial denture

• The shape of the polished surface of the mandibular denture is
extremely critical in promoting stability of the denture.

• Buccal and lingual surfaces of the external denture surface should

 slope towards the teeth to allow the tongue and cheeks to lie in rest
position and aid in retention of the denture (Fig. 9-2).

• The lingual flanges of the mandibular denture are waxed from the
posterior teeth to the peripheral roll to produce an inclined plane
that slopes towards the tongue.

• The lingual flange should have least amount of bulk, except at the
border which is made thicker.

• This thickness is below the narrower portion of the tongue and it

greatly enhances the seal of the denture.

• The free gingival margin, gingival bulge and the interproximal

papilla are contoured similarly to the maxillary trial denture.

• The buccal surface of the mandibular dentures in the first premolar

region should be carefully shaped so that it does not interfere with
the action of modiolus.

• Softened and tempered wax on the lingual flange can be moulded

by instructing the patient to swallow forcibly, grin broadly, pucker
the lips, read aloud for a few minutes and doing other oral and lip
movements.

• Interproximal area should be full bodied and convex, mesiodistally

and incisogingivally.

• Carving of the wax is followed by polishing. Before polishing, it

should be ensured that any excess wax is removed, especially over
the tooth surface. Wax is smoothened by gently flaming using
alcohol torch, followed by cooling in chilled water.
FIGURE 9-2 Buccal and lingual surfaces should slope
towards the teeth for better stability.
Wax try-in
Wax try-in is defined as ‘the process of placing a trial denture in the
patient mouth for evaluation’. (GPT 8th Ed)
Rationale for Try-In

• Rationale for wax try-in is to compare the general tooth and arch
position with that which might have been present during the
natural teeth.

• Relationship of the mandibular and maxillary teeth is checked with

the edentulous ridge.

• The interocclusal distance is verified.

• Fit and extension of the denture are checked.

• Underextension and overextension are checked.

• Stability of the trial denture should be checked during this stage.

• Occlusal plane is checked.

• Jaw relation records are verified.

• Aesthetics and phonetics are verified.

Procedures followed during the try-in stage

Verification of jaw relation records

• Both the recording bases should accurately fit into the patient’s
mouth.

• These should be stable.

• First the mandibular denture should be inserted followed by the
maxillary denture.

• The patient is instructed to close the mouth lightly.

• If the denture border causes binding of the frenum, the labial notch
is deepened.

• The vertical dimension at rest and occlusion is assessed.

• Discrepancy in the occlusion, if any, is observed.

• New centric relation record is made and the lower denture is

mounted with the new interocclusal record.

Centric relation can be verified by the following methods:

(i) Intraoral observation of the intercuspation: If the teeth slide over each
other or if some tooth/teeth prevent others to intercuspate during first
contact, then discrepancy exists in centric relation position and new
record is advised.

(ii) Intraoral intraocclusal records: Posterior teeth are removed from the
lower denture. The lower occlusal rim is placed in the patient’s mouth
and he/she is instructed to close in the interocclusal record. This
record is verified on the articulator.

(iii) Extraoral articulator method: Centric relation is checked and verified

on the articulator rather than in the mouth. The centric relation record
is made by placing soft wax between the opposing teeth. This record
is placed in mouth to verify its accuracy. The purpose is to determine
whether the position of the teeth on the articulator is same as that in
the patient’s mouth.

Checking facial measurements

• When the trial dentures are placed in mouth, the vertical dimension of
 face is assessed.

• Appearance of the patient’s face (whether relaxed or strained)

suggests whether there are any alterations in the vertical dimension.

• Lip fullness and visibility of the teeth are assessed as the patient
smiles.

• The deepening of nasolabial sulcus, mentolabial sulcus and shape of the

philtrum are assessed.

• Positioning of the teeth is assessed by instructing the patient to

speak different words.

Orientation of the occlusal plane

• Plane of occlusion is checked for proper orientation.

• It should be parallel to the ala–tragus line.

• Position of the anterior teeth and the retromolar pad is used as

anterior and posterior landmarks, respectively, to assess the plane
of occlusion.

Changes in tooth colour and translucency

• Characterization of the teeth according to the patient’s age, sex and
personality is assessed at this stage.

• The tooth colour, wearing, etc. are assessed for harmony between
the teeth and the patient’s face.

Establishing posterior palatal seal

• Posterior border of the denture is determined in the mouth and its
location is transferred on the cast.
• A T-burnisher or mouth mirror is used to locate the hamular
notches on either side.

• The location of the right and left hamular notches is marked using
indelible pencil.

• As the patient says ‘ah’, the vibrating line is marked with the pencil.

• This marking is transferred on the trial denture base when the same
is inserted in patient’s mouth and the excess of base plate is
trimmed.

• The trial denture base is placed on the cast and bead on the cast is
scribed using sharp scraper.

• Groove on the cast is 1 mm high and 1 mm wide and sharp at its

apex which will be transferred as bead on the denture.
Flasking procedure
Definition
Flasking is defined as ‘the process of investing a cast and a wax replica of
the desired form in a flask preparatory to mould the restorative material into
the desired product’. (GPT 8th Ed)
Flasking is a laboratory procedure for making a two-sectional
mould by investing the cast with a waxed denture in a flask. This two-
sectional mould is used to form an acrylic denture base.
This procedure applies to both maxillary and mandibular dentures.

Procedure

Preparation of cast before flasking

• The bottom of the cast is lubricated with petrolatum jelly. This is to
ensure that the cast is accurately repositioned during the remount
procedure.

• Cast and the waxed denture are soaked in water for few minutes
and then painted with gypsum separating medium.

Flasking procedure
• The lower half of the flask is invested first.

• The cast is centred into the flask.

• Use mixture of dental plaster for investment.

• Any undercuts should be removed in the investment, as they will

prevent the separation of the upper and lower flask after wax
elimination procedure.
• Investment is allowed to set.

• Separating medium is applied on the investment in the lower half of

the flask.

• The ring portion of the flask is positioned over the lower flask.

• Second pour of dental plaster and stone are mixed.

• The mix is carefully poured over the teeth such that occlusal
surfaces and the incisal edges of the teeth are exposed.

• Investment is allowed to set.

• Once again the separating medium is applied to the ring portion of

the investment.

• Third pour of dental plaster and stone are mixed.

• This is poured over the ring and the top of the flask is positioned
and secured in place.
Wax elimination
Wax elimination or boil out is defined as ‘removal of wax from a mould,
usually by heat’. (GPT 8th Ed)

Procedure
• Once the stone and plaster mix used in flasking are completely set
(approximately 45 min), the wax elimination procedure is initiated.

• The flask is placed in clean boiling water on a flask holder for 5 min
to soften the wax adequately.

• Remove the flask from the water and gently open it.

• Insert an instrument between the upper and lower halves and

gently separate them.

• The softened wax and temporary denture base are removed

carefully.

• The teeth should remain in the top half of the flask; any loose tooth
is removed and kept aside.

• Flush out all the remaining wax with clean boiling water.

• Saturate a piece of cotton with wax solvent and apply it around the
teeth to remove any wax.

• Detergent can be added to remove any wax residue not removed by

the wax solvent.

• The mould is flushed again with boiling water to remove traces of

detergent.

• It should be ensured that all the wax residues are removed, as

 acrylic resin will not adhere to the surface coated with wax.

• The loose tooth is washed with boiling water and cemented into
correct position using cement.

• If palatal relief is indicated, tinfoil can be used to fit the outline of

the palatal relief.

• The mould surface is painted with liquid-separating medium to

prevent the surface from absorbing the liquid resin monomer.

• When the mould is still warm, the separating medium is painted.

• Allow the first coat to dry and then second coat is applied.

• This should result in a smooth, shiny mould surface.

• Allow the flasks to cool to room temperature.

Packing
Packing is defined as ‘the act of filling a mould’.
Denture resin packing is defined as ‘filling and pressing a denture base
material into a mould within a refractory flask’. (GPT 8th Ed)

Packing procedure
• Monomer and polymer are mixed according to the manufacturer’s
instructions.

• Polymer-to-monomer ratio is approximately 3:1 by volume and 2:1 by

weight.

• For an average-sized denture, usually 30 g polymer and 10 mL

monomer are sufficient.

• When the mix is in the dough stage, it is packed into the mould.

• The solubility of polymer into monomer and the size of the polymer
particles influence the dough forming time.

• The mixed dough is packed in the upper half of the flask in one
direction to avoid trapping of air into the mould.

• Enough material is packed to ensure overpacking on the first

closure.

• Wet plastic sheet is placed over the acrylic resin.

• The lower half of the flask is secured in position using hand

pressure.

• Flask is placed in a bench press and closed slowly to ensure

complete flow of excess acrylic resin.
• Flask is removed from the press and carefully opened.

• Excess resin is removed.

• Trial closure is done till all the excess materials are removed.

• In the final opening, the lower part of the mould is coated with
separating medium.

• The two halves of the flask are secured in position, such that there is
complete contact of the two metal edges of the flask.

• The closed flask is placed under pressure for 30 min before curing.
Processing of denture
Processing of the denture is defined as ‘the means by which the denture
base materials are polymerized to form a denture’. (GPT 8th Ed)

• Polymerization of resins can be done in three ways: (i) external heat,

(ii) light-curing and (iii) autopolymerization or self-curing.

• External heat polymerization is most popular.

• Microwave processing can also be done for

polymerizing resins. It requires a microwave oven,
special resin and nonmetal flasks.
• The amount of heat should be controlled when processing acrylic
resin as the reaction is exothermic and the process becomes very
rapid between 140°F and 160°F.

• The temperature of the water should be maintained at or below

160°F for at least 1.5 h.

• Time required for the temperature of resin to drop to that of water

bath depends on the type and size of flask, quantity of the resin in
mould and temperature of flask when packed.

• Usually, two processing methods are employed for polymerizing

acrylic resin – slow curing and rapid curing.

Slow Processing (Long-Curing Cycle)

• Adequate time is given for the monomer to be incorporated into the

polymer.

• After packing, the flask is placed in cold water for 30 min.

• Temperature of the control unit is set at 165°F.

• The resin is then cured for 9 h.

• If boiling is also desired in curing, the temperature is held at 160°F

for 9 h and then raised to 212°F for 30 min.

Rapid Processing (Short-Curing Cycle)

• The flasks are placed in the water bath at room temperature.

• Water is slowly heated to 165°F and maintained at this temperature

for 1.5 h.

• The water is then heated to 212°F and temperature is held for 30

min.
Deflasking of the denture
• After the acrylic dentures are processed, the flasks are slowly cooled
to room temperature.

• Deflasking includes the procedure of removal of the mould from the

flask and separation of the mould from the denture and the cast.

• The flask once cooled is placed in cool water for 15 min before
deflasking.

• Place the flask into the flask ejector and remove the flask from the
artificial stone surrounding the denture.

• Remove the top pour of plaster and stone by placing plaster knife
between the second and third pour.

• The occlusal surface of the denture teeth is now exposed.

• With the dental saw, a cut is made at each corner and the middle of
the stone.

• Laboratory knife is placed into these cuts and the stone is removed.

• Only the cast denture and stone in the tongue space region remains.

• Again using the laboratory knife, a cut is made in the tongue space
region and the stone is slowly removed.

• During deflasking, it is very important to preserve the cast and the

dentures should not be removed or lifted from the cast.

• Casts and exposed denture surface are cleaned and scrubbed before
laboratory remount procedure.
Laboratory remount procedure
Remount procedure is defined as ‘any method used to relate restorations
to an articulator for analysis and/or assist in development of a plan for
occlusal equilibration or reshaping’. (GPT 8th Ed)

Procedure
• Casts with the processed dentures are replaced over the original
plaster mountings.

• Attach the mounting to the articulator with sticky wax and close the
articulator.

• If the incisal pin does not contact the incisal guide table, the vertical
dimension is altered during processing and should be re-
established.

• Articulating paper or carbon paper is used to detect the interceptive

occlusal contacts.

• Selective grinding procedure is initiated for occlusal corrections.

• Refine and equalize the centric occlusion.

• Working and balancing side contacts are perfected.

• Correct the protrusive occlusion.

• The process is continued till the vertical dimension is re-established

and the incisal pin touches the incisal guide table.

• The final refinement of eccentric occlusion is done during clinical

remount procedure.
Rules for selective grinding
• Cuspal tip is never grinded unless it contacts prematurely in all
excursive movements of the mandible. Always the opposing fossa is
deepened.

• BULL (buccal, upper and lingual lower) rule is utilized for

perfecting working occlusion. Buccal cusp of upper and lingual cusp of
lower are grinded.

• To perfect the balanced occlusion, never grind the interfering cusp

tips but grind the cusp inclines.

• For correcting the protrusive interferences in the anterior teeth, labial

surface of the incisal edges of the lower teeth and the lingual surface
of the upper teeth are grinded.

• To correct interferences in the posterior teeth, upper buccal cusp slopes

and the lower lingual cusp slopes are reduced.
Finishing and polishing of complete
dentures
Finishing of complete dentures refers to perfecting the final form of the
dentures by removing any excess acrylic resin at the denture border, any
excess resin or stone remaining around the teeth.
Polishing of the complete dentures involves making the dentures
smooth and glossy without changing their contours.

Procedure
• Any gross excess resin is removed with large acrylic bur on the
lathe.

• With tapered acrylic bur, small amount of excess resin is removed.

• Remove the stone and sharp ledges around the teeth with sharp BP
blade.

• Stone burs, if required, may be used for finishing the denture.

• The dentures can then be smoothened with sand papers of different

grades.

• Smoothen the labial, buccal, lingual and palatal external surfaces of

the dentures with wet pumice on a rag wheel at slow speed.

• Keep plenty of pumice on the surface of denture and keep moving

the denture over the polishing buff at all times.

• Polish the resin around the teeth with pumice and brush wheel with
slow speed.

• If stippling was not done during wax-up procedure, but is desired,

it can be accomplished with thin round bur between the second
 premolars on both sides.

• Apply polishing compound and polish the dentures to a high lustre

at slow speed.

• Store the polished dentures in water until they are inserted in the
patient’s mouth.

Key Facts
• Shim stock is a thin strip of 8–12 microns used to identify the
presence or absence of occlusal or proximal contact.

• Errors in mounting casts on the articulator are detected when the

centric relation is used as a horizontal reference position.

• Mandibular equilibration is the condition in which all the forces

acting on the mandible are neutralized.

• Stippling is done on the surface of the artificial gingiva with minute

pits to simulate the natural appearance of the gingiva.

• Laboratory remount procedure is important, as it helps in correction

of the errors during processing, correcting other errors during bite
registrations and mounting.
CHAPTER
10
Insertion and troubleshooting in
complete denture prosthesis

CHAPTER OUTLINE
Introduction, 175
Denture Insertion, 175
Procedure before Patient Appointment, 176
Procedures Followed during Insertion of the
Dentures, 176
Clinical Remount Procedure, 177
Advantages, 177
Procedure, 177
Selective Grinding, 178
Procedures in Selective Grinding, 178
Intraoral Methods to Correct Occlusal Disharmony, 181
Articulating Paper, 181
Central Bearing Device, 181
Occlusal Wax, 182
Abrasive Paste, 182
Postinsertion Instructions to Denture
Patients, 182
Troubleshooting in Complete Denture
Prosthesis and its Management, 183
Denture Cleansing Agents, 187
Introduction
Insertion of complete dentures is the final step in the construction of
dentures. The primary goal is to deliver prosthesis which will enhance
comfort, function and aesthetics. Proper fitting dentures are ensured
to achieve this goal.
Denture insertion
Denture placement or insertion is defined as ‘the process of directing a
prosthesis to the desired location’. (GPT 8th Ed)
Objectives of the Placement of Dentures

• To identify and correct potential areas of denture base that will

cause soreness or discomfort to the patient

• To identify and correct any portion of the denture that interferes

with the retention and stability of dentures

• To identify and correct any part of the dentures that is aesthetically

unpleasing

• To refine the occlusion

• To deliver the dentures to the patient

Procedure before patient appointment

Once the dentist receives the dentures, he/she should evaluate the
dentures for the following:

• Polished surfaces should be smooth and well contoured.

• Denture borders are rounded and fully extended.

• All imperfections on the tissue surface have been removed.

• Maxillary and mandibular remount casts have been properly made.

• The maxillary remount cast has been accurately mounted on the

articulator.

Procedures followed during insertion of the

dentures

Evaluation of accuracy of tissue surface

• Dentures are placed separately in the patient’s mouth and evaluated
for comfort and stability.

• If tissue undercuts are present, pressure indicating paste is used for

detection.

• Any interference is removed by carbide acrylic bur at slow speed.

• The denture is removed and placed two or three times to ascertain

that the areas are adjusted.

• Procedure is repeated until adequate relief is obtained.

Evaluation of the border extensions

• Denture borders are carefully evaluated to check the extensions.

• Denture border should completely fill the vestibular areas within

the anatomical limits.

• The labial and buccal notches should allow adequate freedom to the
muscular frenum.

• Hamular notch areas of the maxillary denture should not be

overextended.

• Distal end of the maxillary denture and the posterior palatal seal
should be properly located.

• The borders of the maxillary denture under the zygomatic arches

should not be overextended.
• The lingual flange of the mandibular denture should allow freedom
for the mylohyoid muscle.

• Dentures should be stable during speech and swallowing.

• Border extensions are examined visually and by using pressure-

sensitive paste or mouth temperature waxes.

• The patient is instructed to make functional movements when

dentures are inserted in mouth.

• Any discrepancy at the denture border is detected and removed.

Evaluation of retention and stability

• Dentures are assessed for adequate retention and stability, once the
tissue adaptations and border extensions are evaluated.

• The dentures should be retentive and stable when they are not in
occlusion.

Evaluation of aesthetics and facial contours

• Dentures are critically evaluated for aesthetics and facial contours.

• They should provide proper facial support.

• Proper facial support and natural appearance are accomplished by

proper positioning of the teeth and by contouring the denture
flanges to correct height, thickness and shape of the surface.

• Any obvious alterations should be corrected before the final denture

polishing.

Centric relation interocclusal records

• The final step is to make and verify the centric interocclusal record.

• To correct the occlusal errors, clinical remount procedure is

necessary.

Occlusal disharmony can occur due to the following:

• An incorrect centric relation record at the time of wax try-in

• Errors in mounting the cast on the articulator

• Tissue fit of the processed denture that is different from the tissue fit
of the trial occlusal rims

• Changes which may have occurred in the soft tissues since the final
impressions

• Dimensional changes in the base material from processing

• Dimensional changes from polishing procedures

Clinical remount procedure
Clinical remount procedure is defined as ‘any method used to relate
restorations to an articulator for analysis and/or assist in development of a
plan for occlusal equilibration or reshaping’. (GPT 8th Ed)
Rationale for Clinical Remount Procedure

• Difficult to see occlusal discrepancies intraorally

• Resiliency and displaceability of the supporting tissues to varying

degrees tend to disguise premature occlusal contacts

• Visual inspection of dentist cannot be relied on to checking the

occlusal discrepancies

• The dentist cannot depend on the patient to diagnose occlusal

problems

This is the procedure to remount the patient dentures on the

articulator by means of interocclusal records made in the patient’s
mouth.

Advantages
• This procedure reduces chairside time.

• This permits the dentist to see the occlusion better.

• This provides a stable working foundation and the bases are not
resting on resilient tissues.

• Marks of articulating paper are more accurate in the absence of

saliva.

• Correction needs not be made in front of the patient.

Procedure
• Both the dentures are placed in the patient’s mouth and the
relationship of centric occlusion to centric relation is verified.

• When closing, the patient should stop at the point of first contact
between the opposing dentures, so that any possible occlusal
contact is observed.

• This procedure is repeated until the closure into centric position is

assured.

• Centric interocclusal record is made as close to the vertical dimension

of occlusion (VDO) as possible without denture contact.

• Small amount of fast setting impression plaster is mixed and laid

over the mandibular posterior teeth.

• A wax or modelling compound can also be used.

• The patient is then instructed to close into the centric relation

position which was practiced.

• Allow the interocclusal record to set.

• Place the interocclusal record and mandibular denture on the lower

mounting cast. The maxillary denture is positioned over the cast
attached to the articulator. Maxillary denture is secured over the
mandibular denture using the interocclusal record in between them.

• Make sure that there is no contact between the two dentures.

• Seal the opposing dentures to the interocclusal record by means of

sticky wax.

• The incisal pin is lengthened.

• The lower cast is mounted on the articulator using plaster.

• Once the plaster is set, the interocclusal record is removed and the
first contact between the dentures on the articulator and in the
mouth is same or altered.

• Any alteration points to discrepancy in the mounting and the

procedure needs to be repeated.

• Adjust the condylar guidances to the original settings or new eccentric

records are made.

• Ensure that the teeth are dry before using articulating paper.

• Articulating paper is used over the occlusal surfaces of the

mandibular posterior teeth.

• Tap the articulator in centric relation position.

• Any coloured marks with white centres that are transferred to the teeth
will indicate the areas of heaviest tooth contact.

• Selective grinding procedure is undertaken to refine the occlusion.

Selective grinding
Selective grinding is defined as ‘the intentional alteration of the occlusal
surfaces of teeth to change their form’. (GPT 8th Ed)
Objectives of Selective Grinding

• To correct occlusal discrepancy in centric and eccentric positions

• To develop contacts bilaterally when anatomic teeth are used and

balanced occlusion is desired

• To alter cuspal inclines to develop maximum intercuspation in

centric relations.

• To obtain balanced occlusion.

Procedures in selective grinding

Selective grinding of anatomic teeth

• The anatomic teeth are altered by selective grinding to obtain
balanced occlusion in centric relation position.

• Once both upper and lower dentures are mounted on the articulator
with the interocclusal record, a protrusive record is made in the
patient’s mouth.

• Both the horizontal and condylar settings are adjusted using the
protrusive record.

• Evaluate the areas of centric and eccentric contacts.

• Articulating paper of minimum thickness is used to mark the actual

contact of the teeth.
• High marks are observed on the mandibular and maxillary teeth.

• Grinding is accomplished using Chayes stones No. 16, 11 and 5.

Grinding is done only in the fossa and not on the cusps.

• While grinding, the incisal pin is relieved from the contact on the
incisal guidance table to allow for slight reduction of the vertical
dimension.

• Once the centric deflective occlusal contacts are removed, the incisal
pin is placed in contact with the incisal guidance table.

• Then again the articulating paper is placed between the teeth on

both sides and the articulator is moved laterally to one side, the
paper marks contact on both the sides for the same lateral
movements.

• Any interfering contact is grinded with appropriate stone.

• Grinding to correct occlusal errors in lateral movements is limited to

altering the lingual inclines of the upper buccal cusps and buccal inclines
of the lower lingual cusps on the working side and to alter the lingual
inclines of the lower buccal cusps on the balancing side.

• Selective grinding to remove occlusal errors for anatomic teeth is

described below.

Types of occlusal errors and their corrections.

Occlusal errors can occur in three positions:

1. Centric occlusion Table 10.1

2. Working side Table 10.2

3. Balancing side Table 10.3

TABLE 10-1
OCCLUSAL ERRORS IN CENTRIC OCCLUSION AND THEIR
CORRECTION

Types of Occlusal Error Correction

1. Any pair of opposing teeth, one too long • To correct this error, the fossa of the teeth is deepened by
keeps the other tooth out of contact (Fig. 10- grinding and bringing both teeth in contact
1) • Cusp is not shortened
2. Upper and lower teeth are nearly end-to- • Inclines of the cusp are grinded in such a way that upper
end (Fig. 10-2) cusp inclines buccally and the lingual cusp inclines lingually
• Central fossae are broadened
• Cusps are not shortened
3. Upper teeth can be too far buccally in • To correct this error, the lingual cusp of the upper tooth is
relation to lower teeth (Fig. 10-3) made more narrow by broadening of the central fossa
• Buccal cusp of the lower tooth is moved buccally by
broadening of the central fossa
• Cusps are not shortened

FIGURE 10-1 Teeth too long prevent proper tooth contact.

FIGURE 10-2 Upper and lower teeth nearly end-to-end.
 FIGURE 10-3 Upper teeth are too far buccally placed.

TABLE 10-2
OCCLUSAL ERRORS ON WORKING SIDE AND THEIR
CORRECTION

Types of Occlusal Error Correction

1. Both upper buccal cusp • Upper buccal cusp and the lower lingual cusp are reduced by grinding, so
and lower lingual cusp are that the other teeth will touch in that position
too long Fig. 10.4 • Central fossa is not deepened
2. Buccal cusp contacts but • To correct this error, the buccal cusp is reduced and the lingual incline of the
lingual cusp does not cusp is changed so that it becomes less steep
(buccal cusp is too long)
(Fig. 10-5)
3. Lingual cusp contacts but • To correct this error, the lower lingual cusp is shortened by grinding the
buccal cusp does not buccal inclines of lower lingual cusp so that it is not that steep
 (lingual cusp is too long)
(Fig. 10-6)
4. Upper buccal or lingual • To correct this error, selective grinding is done, so that the mesial inclines of
cusp is mesial to their the upper buccal cusp move distally when the cusps are narrowed and the
intercuspating positions distal inclines of the lower lingual cusp are reduced to move them forward
(Fig. 10-7)
5. Upper buccal or lingual • To correct this error, selective grinding is done on the distal inclines of the
cusp is distal to their upper cusp and mesial inclines of the lower cusp
intercuspating positions
(Fig. 10-8)
6. Teeth on the working side • May be caused due to excessive contact on the balancing side
do not contact at all (Fig.
10-9)

FIGURE 10-4 Upper buccal and lower lingual cusps are too
long.
FIGURE 10-5 Buccal cusp is too long.
FIGURE 10-6 Lingual cusp is too long.
FIGURE 10-7 Upper buccal or lingual cusps are mesial to
their intercuspating position.
FIGURE 10-8 Upper buccal or lingual cusps are distal to their
intercuspating position.
 FIGURE 10-9 No contact occurs on working side.

TABLE 10-3
OCCLUSAL ERRORS ON THE BALANCING SIDE AND THEIR
CORRECTION

Occlusal Errors on Balancing Side Correction

1. Heavy balancing side contacts leave • To correct this error, the lingual inclines of the lower buccal cusp
the working side teeth out of contact are reduced as paths on the balancing side so that contact on the
(Fig. 10-10) working side is established
• As far as possible, each interfering cusp is preserved
• Grinding of the lower lingual cusp is avoided
2. No balancing contact on the • To correct this error, the upper buccal cusp and the lower lingual
balancing side cusp on the working side are reduced
• By doing this, the lingual inclines of the upper buccal cusp and the
buccal inclines of the lower lingual cusp are made less steep
• Grinding of the central fossa is avoided
 FIGURE 10-10 Heavy contact on balancing side.

Selective grinding procedure of nonanatomic

teeth
• Gross premature contact in centric relation is removed by using an
articulating paper.

• Occlusal interferences are detected in the lateral and protrusive

movements.

• Selective grinding is done on the occlusal surfaces of the teeth that

have been tipped or elongated during processing.
• In eccentric position, grinding is not done on the distobuccal portion of
the lower second molar.

• On the balancing side, all grinding is done on the lingual portion of

the occlusal surface of the upper second molar.

• Abrasive paste can be placed on the teeth on the articulator and the
lateral and protrusive movements are initiated.

• The abrasive paste mills the interfering contact and the procedure is
continued till smooth gliding movements of teeth are achieved in all
excursions.

• Spot grinding may be required to eliminate small discrepancies in

centric relation after grinding with abrasive paste.

• Small discrepancies are identified using articulating paper or tabulator

ribbon and selectively grinded.
Intraoral methods to correct occlusal
disharmony
Some of the commonly used methods are described below.

Articulating paper
• Using the articulating paper alone does not give accurate indication
of the premature contact.

• Resiliency of the tissues sometimes allows the dentures to shift

which may produce false result with the articulating paper.

• When the articulating paper is placed on one side, the patient can
shift the jaw close to or away from the side.

• Placing articulating paper on both sides of arch simultaneously may

sometimes be difficult.

Central bearing device

• Correlator which is a type of central bearing device with a spring is
used to detect occlusal prematurities.

• Pin attached in the mandibular mounting contacts with the metal

plate attached in the vault of the maxillary denture.

• The interceptive occlusal contacts are located with articulating

ribbon.

• Patient cooperation is very important.

• Coble device without the spring can also be used.

Occlusal wax
• Adhesive green wax is placed over the mandibular denture and the
patient is instructed to close in centric position.

• Points of penetration on the wax that occurs upon closure of the

jaws are detected and marked with lead pencil and relieved.

• Interferences can also be located in functional movements.

• However, chances of false markings are high during functional

movements as shifting of the dentures can take place over the
resilient tissues.

• This is an excellent method to detect occlusal prematurity in centric

position only.

Abrasive paste
• Abrasive paste when used over the occlusal surfaces of the teeth
mills the cuspal inclines to remove the premature contact.

• Shifting of the base as a result of premature contact results in

altering the occlusion.

• Cusps that maintain the occlusal vertical dimension may be

destroyed.

• This type of paste is not selective.

Postinsertion instructions to denture patients

Patient education regarding the limitations of the denture as artificial
prosthesis simulating natural tissues is started from the first
appointment. Still at the time of denture insertion, many instructions
are given to the patient.
Appearance with new dentures
• Patient must be educated that appearance with the new dentures
will become more natural with time.

• Initially, the dentures may feel bulky and give a feeling of the
fullness in the lips and the cheeks.

• With the passage of time, the lips and cheeks will adapt to the
fullness of the dentures.

• Muscle tension will improve after the patient becomes more relaxed
and self-confident.

• The patient is instructed not to compare his/her denture with others.

• Also, they should be advised to avoid exhibiting their dentures to

curious friends until they are confident.

Mastication with new dentures

• It will take at least 6–8 weeks for the new denture patient to chew
satisfactorily.

• Time is required for the establishment of new memory patterns for

both the facial muscles and muscles of mastication.

• The muscles of the tongue, cheeks and the lips must be trained to
keep the denture in place over the ridges during mastication.

• Initially, there will be excessive salivation with new dentures.

• Within few days, the salivary glands accommodate to the presence

of the dentures and the production of saliva.

• The patient is instructed to chew soft food from both sides of the
mouth.
• Hard food should be avoided till the time the patient adjusts with
the new dentures.

• The patient should be discouraged to incise the food between the

anterior teeth in front of the mouth.

• He/she is instructed to put the food towards the corner of the

mouth.

• The patient is informed about the role of tongue in the stability of

lower denture during mastication.

Speech with new dentures

• Speaking normally with new dentures requires practice.

• The patient is encouraged to read loud and repeat words or phrases

that are difficult to pronounce.

• They are encouraged to read newspaper aloud in front of the mirror

to master speech.

Oral hygiene instructions

• The patient is educated on the importance of maintaining good oral
hygiene.

• The patient is instructed to brush dentures at least twice daily and

rinse dentures after every meal, whenever possible.

• Dentures are cleaned with a soft brush using liquid soap or

toothpaste with low abrasion.

• Dentures should be brushed over the washbasin which is partially

filled with water or covered with wet cloth to prevent breakage of
denture on accidental dropping.
• Denture cleansers can be advised to remove stains from the
dentures.

• The mucosal surface of the residual ridges and the dorsum of the
tongue should be brushed daily with a soft brush.

Preserving residual ridges

• The patients are discouraged to wear the dentures during the night.

• They are educated on the importance of rest to the tissues.

• The patients are instructed to keep the dentures in a container filled

with water to prevent drying and possible dimensional changes of
the denture base materials.

• The dentures should be removed to provide rest to the tissues

during night-time.

• The patients should also be discouraged on the continuous use of

denture adhesives and home reliners.

• The patients are educated on the need for periodic recalls.

Educating materials for patients

• The patients should be given written instructions about the
dentures, preferably in the patient’s language.

• The patients should be advised to read book or pamphlet regarding

the care of dentures.

Troubleshooting in complete denture prosthesis

and its management
Troubleshooting in complete denture prosthesis can be caused by
either of the following factors:

• Adverse intraoral anatomical factors (e.g. atrophic mucosa)

• Clinical factors (e.g. poor denture stability)

• Technical factors (e.g. failure to preserve the land area on the master
cast)

• Patient adaptational factors

All of the above-mentioned factors are important but by far the

patient adaptational factor is the most critical. Some patients are
positive with the treatment and some find it difficult to adapt to the
new prosthesis physically and psychologically. It is important to take
proper history and accurately diagnose the problem individually.
Troubleshooting in complete dentures usually arises after insertion of
the new dentures.
Troubleshooting can be broadly divided into the following categories:

(i) Discomfort or pain with the dentures

• Discomfort related to impression surface of

dentures (Table 10-4)

• Discomfort related to the occlusal and polished

surfaces of dentures (Table 10-5)

• Discomfort related to possible systemic factors

(Table 10-6)
(ii) Looseness of the denture

• Due to decreased retentive factors (Table 10-7)

• Due to increased displacive factors (Table 10-8)
(iii) Inability to adapt to dentures (Table 10-9)

TABLE 10-4
DISCOMFORT WITH DENTURES RELATED TO IMPRESSION
SURFACE OF DENTURES

Symptom(s) Cause(s) Treatment

Discrete painful areas Pearls or sharp ridges of acrylic on Use disclosing
impression surface material and relieve
Pain on insertion and removal Denture is not relieved in the region of Use disclosing
undercuts material and adjust
in the region of ‘wipe
off’
Areas painful to pressure Faulty impression, damage to master cast, Use disclosing
warpage of denture base, lack of relief to material to
active frena, nondisplaceable mucosa over accurately locate area
the bony prominence to be relieved
Pain on swallowing Overextended lower denture Determine extent
and location of
overextension and
relieve accordingly
Generalized pain over the denture- Underextended denture base due to Extend denture to
bearing areas overadjustment to the periphery optimal available
denture support area
Lack of relief for frenum, muscle Peripheral overextension resulting from the Relieve with aid of
attachments, pinching of tissues impression stage and design error disclosing material
between the denture base and
retromolar pad or tuberosity
Sore throat, difficulty in swallowing Posterior palatal area is too deep Removal of existing
seal and replacement
with new material is
required

TABLE 10-5
DISCOMFORT RELATED TO THE OCCLUSAL AND POLISHED
SURFACES OF DENTURES

Symptom(s) Cause(s) Treatment

Pain on eating, in Anterior or posterior premature Detect occlusal prematurity and adjust by
the presence of contacts, lack of balanced occlusion selective grinding; if the error is severe, take
occlusal imbalance new interocclusal record and remount
Pain lingual to the If no overextension is present, look for Detect deflective occlusal inclines of posterior
lower anterior ridge protrusive slide from the centric teeth and adjust by selective grinding
 relation to centric occlusion
Pain or Lack of overjet Reduce the overbite; if appearance is
inflammation of disturbed, rearrange the incisor
labial aspect of
lower ridge
Pain in the VDO is more If VDO is less than 1.5 mm, adjust by
periphery of selective grinding; if more than 1.5 mm,
dentures rearrange teeth at proper VDO
Cheek and/or lip For cheeks: The functional width of the For cheeks: Restore functional width of
biting sulcus was not restoredFor lips: Poor sulcusFor lips: Grind lower incisor to alter the
lip support/inadequate overjet incisal guidance
Tongue biting Teeth placed in the tongue space more Remove lower lingual sulcus or reset teeth
lingually
Pain at the Distobuccal border of the upper Use disclosing material to accurately define
posterior region of denture is too thick and constraining area involved; relieve and polish
upper denture on the coronoid process
opening

TABLE 10-6
DISCOMFORT DUE TO POSSIBLE SYSTEMIC FACTORS

Symptom(s) Cause(s) Treatment

Burning sensation over the upper Burning mouth Correction of any denture faults, may require
denture-bearing areas syndrome seen in multivitamin drugs, nutrition and medical
middle age or elderly advice
patient
Beefy red tongue Vitamin B12/folate Seek medical advice
deficiency
Frictional lesions related to Xerostomia, side Advise citrus lozenges or artificial saliva
dentures, complain of dry mouth effect of prescribed
drugs
Tongue thrusting; empty mouth Neurological or Difficult to manage; seek medical advice
chewing seen in elderly psychological aspect;
can be drug related
Presence of herpetiform ulcers in Herpes simplex or Suggest preventive remedy (e.g. acyclovir) but
the mouth herpes zoster virus with medical advice
Clicking of the TMJ on opening TMJ pain dysfunction Careful correction of vertical dimension of the
and/or closing mouth with or syndrome may be dentures
without tenderness related to rapid
change of VDO
Painless erythema of mucosa Denture-related Rest to tissue; correct denture problem using
related to the support of upper stomatitis, ill-fitting tissue conditioners and occlusal pivots; for
denture may be accompanied with denture with candidal angular cheilitis advice antifungal and
angular cheilitis infection antibacterial agents

Note: TMJ = temporomandibular joint.

TABLE 10-7
LOOSENESS OF DENTURE RELATED TO DECREASED
RETENTION FORCES

Symptom(s) Cause(s) Treatment

Lack of peripheral seal Underextended borders in depth and Relining of the dentures
width
Inelasticity of the cheek Consequences of ageing process, Border moulding is done in
tissues scleroderma, mucous fibrosis increments using softened tracing
compound
Xerostomia – reduces Side effects of drugs, patient on Dentures designed to maximize
ability to form adequate radiotherapy, salivary gland disease retention and minimize displacing
seal forces; artificial saliva can be
prescribed
Speech and eating Lower posterior placed lingually, occlusal Correct design faults, denture
difficulties plane too high, upper posterior placed too adhesives may be prescribed
far buccally, lingual flange of lower
convex, reduced neuromuscular control
Denture rocking, gap Deficient impression, damaged master Reline if design is satisfactory,
between the periphery of cast, warped denture, overadjustment of ensure areas of heavy contact
flange and ridge, occlusal impression surface, residual ridge between the denture and tissues
errors subsequent to resorption, excessive relief are relieved before impression
warpage making

TABLE 10-8
LOOSENESS OF DENTURE RELATED TO INCREASED
DISPLACING FORCES

Symptom(s) Cause(s) Treatment

Overextended denture borders Thickened lingual flange causes tongue to Relieve the overextensions;
in depth and width, slow rise of lift the denture, thick upper and lower check borders of the record
lower denture when the mouth labial flanges may produce displacement rims and trial dentures at
is half-open, line of during muscle activity the appropriate stages
inflammation at reflection of the
sulcus tissues, deep postdam on
upper denture base
Poor fit to supporting tissues Poor impression Reline if design is
satisfactory
Denture not in optimal space Molars on lower denture are placed Remove lingual cusp and
lingually, posterior occlusal table too broad lingual surface and
causes tongue biting, thick lingual flanges repolish or reset or remake
encroaching in tongue space, excessive lip the dentures, reshape
pressure to lower anterior aspect, excessive lingual polished surface,
pressure from upper lip to the denture in thin lower labial flange or
anterior aspect remake the dentures
Occlusal errors Uneven tooth contacts causing tilting of the Adjust occlusion until even
dentures initial contact in centric
Centric relation and centric occlusion does not position is
coincide obtainedOcclusion
Lack of freedom in centric adjusted to coincide centric
occlusion with centric
position
Remount dentures on
 articulator and adjust area
of occlusal contact, allow
freedom of movement
from the centric position,
use nonanatomic teeth, if
required
Ulceration labial to lower ridge Excessive overbite, lack or balance and Reduce height of lower
lower anterior tooth contact cause tilting anteriorsRemove the
and soreness of lower ridgeLast molar is posterior teeth from
placed too far over the retromolar pad dentures and reset
Occlusal plane is not oriented appropriately Usually requires teeth to be
and masticatory forces tend to move reset or dentures remade
dentures over the supporting tissues
Bony prominence covered by Denture rocks over the prominence which Use disclosing paste and
thin mucosa may be covered with inflamed tissues relieve the denture
accordingly
Fibrous displaceable tissue Masticatory forces tend to cause the denture Reline using low viscosity
to sink and tilt into the supporting tissues material and provide many
vents, maximize posterior
border seal

TABLE 10-9
INABILITY OF PATIENT TO ADAPT TO DENTURES

Symptom(s) Cause(s) Treatment

Clicking of dentures Excessive VDO, occlusal Patient education, relieve occlusal interference,
interference, may lack skill with adjust vertical or remake the denture
new denture, loose dentures
Difficulty in eating, Unstable dentures Construct new denture
denture moves on
supporting tissues
Jaws close too far Decreased VDO May increase up to 1.5 mm by relining or else
remake
Speech problems, Excessive VDO Can remove up to 1.5 mm or else remake
cannot open mouth
widely, facial pain
over masseter
Speech problems Cause may not be obvious Check the vertical dimension, check positioning
of the teeth, excessive palatal contour
Gagging Loose dentures, thick distal border Construct new dentures
of upper denture, low occlusal
plane, palatal placement of upper
posterior teeth
Too much visibility Level of occlusal plane Reset teeth or remake
of teeth unacceptable, poor lip support
Creases at the VDO decreased, labial fullness and Adjust correct tooth position, re-register jaw
corners of the mouth anterior tooth position inaccurate relation
Colour of denture Denture base not characterized to Rebase with suitable material
base unnatural individual needs
Appearance not Patient failed to comment during Accurate assessment of the patient’s aesthetic
satisfied try-in, change from old denture to requirements, ample time with the patient
new is sudden, influenced by during try-in, use available evidence such as
 relatives photographs to assist

Denture cleansing agents

Denture cleansers are aids used in maintaining complete denture
hygiene. It is important for the patient to practise denture hygiene
regularly for better success of complete denture treatment.
Denture cleansers can be divided into the following categories.

Chemical cleaning agents

• Safe and effective denture cleansing agent should be used by the
patient.

• Many denture cleansers have strong bleaching agent in them and if

used regularly for long, can cause discolouration of the denture
base and teeth.

• Inexpensive, safe and effective denture cleansing solution has been

suggested by Buffalo School of Dental Medicine, New York.

• This solution consists of 1 teaspoon of sodium hypochlorite, 1 teaspoon of

calgon and 4 ounces of water.

• Sodium hypochlorite provides bleaching action to remove stains from

the dentures and is also an effective germicidal agent.

• Calgon is a water softener, which by its detergent action loosens food

deposits on the denture.

• The patients are instructed to wash the denture with soft brush
under running water after chemical soaking.

• White vinegar can also be used overnight to remove calculus deposits

over the surface of denture.

• Acetic acid present in white vinegar helps in decalcifying the

 calculus deposits on denture.

Mechanical cleaning agents

• Soft denture brush, soap or denture cleansing paste and water are used
effectively to clean dentures.

• Hard denture brush should be avoided, as it abrades the teeth and

the denture.

• Gentle brushing with nonabrasive detergent or paste is

recommended for effective denture cleansing.

Sonic cleaners
• These are new denture accessories.

• Sonic cleaners employ vibratory energy and not ultrasonic energy to

clean the dentures.

• Sonic cleaners effectively remove calculus from the dentures.

• It is also observed that sonic cleaner when used with sodium

hypochlorite is more effective than when sodium hypochlorite was
used alone.

Key Facts
• An occlusal pivot is an elevation placed on the occlusal surface of
the molars to limit the mandibular closure by acting as a fulcrum.

• The occlusion of the complete denture should be checked after 24 h.

• Burning sensation of the anterior palate in a new denture wearer is

due to insufficient relief of the incisive papilla.
• Midline fracture of the dentures is mainly because of thick frenum
not relieved in the denture, wide deep notch in the midline, teeth
set too far buccally and excessive resorption.
CHAPTER
11
Relining and rebasing

CHAPTER OUTLINE
Introduction, 189
Definition, 189
Rationale for Relining Complete Dentures, 190
Problems Associated with Relining
Procedures, 190
Preparation of the Tissues, 190
Preparation of Dentures, 190
Techniques of Relining, 190
Open Mouth Relining Technique, 190
Closed Mouth Relining Technique, 191
Rebasing, 194
Procedure, 194
Advantages of Rebasing Over Relining, 195
Disadvantages, 195
Introduction
Residual alveolar ridges tend to resorb with time at variable rate in
different individuals. The rate of ridge resorption is higher in females
than in males. With resorption, the adaptation of the denture with the
tissues is altered and hence it requires continuous maintenance.
Relining and rebasing are two techniques which are used to maintain
adaptation of the dentures to the tissues.

Definition
Relining is defined as ‘the procedures used to resurface the tissue side of a
removable dental prosthesis with new base material, thus producing an
accurate adaptation to the denture foundation’. (GPT 8th Ed)
Rebasing is defined as ‘the laboratory process of replacing the entire
denture base material on an existing prosthesis’. (GPT 8th Ed)

Indications for relining or rebasing

• Immediate dentures which were made 3–6 months before

• Poor fit of the denture base to the ridges because of resorption

• The patient cannot afford remaking of the dentures

• When mental or physical health of the patient does not permit

fabrication of new dentures

Contraindications
• If ridges are excessively resorbed

• If the soft tissues are highly abused

• Patients with temporomandibular joint problems

• Major alteration in speech

• Poor aesthetics

• Severe bony undercuts

• Unsatisfactory jaw relationship

Advantages

• Reduced patient visits

• Economical for patient

• Fit of the prosthesis is improved

• Soft liner can be used, if needed

Disadvantages

• Not used in case of excessive resorption

• Chances of altered jaw relationship during the process

• Cannot correct occlusal arrangement

• Cannot alter aesthetics or jaw relations

Rationale for relining complete
dentures
• To re-establish the correct relation of the denture to the basal tissues

• To restore the lost occlusal and maxillomandibular relationships

• To restore retention and stability of the denture

Problems associated with relining
procedures
• Denture base almost always becomes thicker after relining.

• Maxillary denture is displaced anteriorly and, therefore,

oversupports the lips after relining.

• Plane of occlusion may be altered.

• It may result in colour difference between the original denture base

and the new relining material.

Relining is the procedure of adding additional acrylic resin to the

tissue surface of the original denture base to replace the lost oral
tissues.
Preparation of the tissues
• Excessive hyperplastic tissues should be surgically removed.

• Any irritating cause to oral mucosa is removed.

• Adequate rest to the supporting tissues.

• Dentures are left out of mouth for at least 2–3 days before making
final impressions.

• Daily massage of soft tissues is recommended.

Preparation of dentures
• Pressure areas in the denture should be relieved.

• Minor occlusal prematurities are removed by selective grinding

procedure.

• Correct posterior palatal seal should be established.

• Minor border inadequacies, if any, are corrected.

Techniques of relining
Open mouth relining technique

Carl O. Boucher’s Reline method (1973)

• Existing dentures are used as recording bases.

• Jaw relation is recorded after making maxillary and mandibular

final impressions.

• In the maxillary denture, posterior palatal seal is recorded with

modelling plastic.

• About 1 mm of space is provided in the tissue surface of the

denture.

• The denture borders are reduced by 1 mm to allow space for impression

material to form a new border.

• Similarly, the denture borders and the tissue surfaces of the lower
denture are reduced by 1 mm.

• Modelling plastic handle is made over the anterior teeth to facilitate

handling.

• Adhesive tape is applied over the polished surface of the denture.

• Border can be moulded with modelling plastic.

• After this, zinc oxide eugenol impression paste is loaded over the tissue
surface of the dentures and placed in the mouth.

• The patient is instructed to pull his/her lip down and open his/her
mouth widely.
• These actions help the impression to be moulded over the border of
the denture.

Advantages

• Impression is made with selective pressure technique.

• It is possible to verify the centric relation record.

• Interocclusal record made with plaster is reliable.

Disadvantages

• This technique requires more clinical and laboratory time.

• This technique is difficult to master.

Closed mouth relining technique

1. F.W. Shaffer’s technique (1971)

• Centric relation is recorded before the impression is

made using modelling compound or wax.

• Denture is relieved in large undercut areas and 1.5–

2 mm from the tissue surface.

• Denture borders are reduced by 1–2 mm, except the

posterior border of the maxillary dentures.

• A large part of palatal portion of the maxillary denture is

removed to improve visibility of the maxillary
denture during impression making (Fig. 11-1).
• Border moulding is done using modelling plastic.

• Zinc oxide eugenol impression paste is used for

impression making.

• During border moulding and impression making,

the patient closes his/her mouth lightly into the
interocclusal record that was previously made.

• The impression of the exposed palatal portion of the

upper denture is made by quick-setting plaster.

Advantages

• Opening of the palatal portion of the maxillary

denture allows better seating.

• Premade interocclusal record helps in orienting the

dentures during impression making and mounting.

• Two-step impression procedure reduces the chances

of anterior shifting of the maxillary dentures.

Disadvantages

• Possibility of forward movement of maxillary

denture is there.

• Wax interocclusal record is not reliable.

• It is difficult to reline both dentures at the same
time.
2. N.J. Hansen’s technique (1964)

• Existing centric occlusion and intercuspation are

used as means to seat the dentures.

• Denture borders are prepared as in the above-

described technique.

• Even in this technique, palatal portion of the

maxillary denture is removed.

• The palatal portion is outlined and reduced to half

the thickness of the denture base.

• Holes are drilled at 5–6 mm interval inside this

groove and slowly the portion is removed (Fig. 11-
2).

• Green stick compound is used for border moulding.

• Impression is made with Kerr’s impression wax.

• Impression is made in two steps and the impression

of the labial flange and crest of ridge is made in the
second step.
Advantage

• Two-step impression technique reduces the chances

of extreme forward movement of the maxillary
denture.

Disadvantages

• It is difficult to manipulate the impression wax.

• Errors of existing centric occlusion can lead to

inaccurate impression.
3. J.F. Bowman’s technique (1977)

• Existing centric relation is used to seat the dentures.

• Denture is prepared as in the above-described

techniques.

• Labial and palatal flanges of the dentures are perforated.

• Perforation is made to decrease the pressure during

impression making.

• No specific impression material is recommended.

4. L.G. Jordon’s technique (1971)

• Existing centric occlusion is used to seat the

 maxillary denture.

• Denture is prepared as in the above-described

techniques.

• Denture periphery is reduced to create flat border.

• A large opening is made in the palatal portion of the

maxillary denture.

• Adhesive tape is attached over the buccal and labial

surfaces of both dentures, 2 mm short of the denture
borders (Fig. 11-3).

• Using a knife-edged stone, deep grooves are cut

into the labial and buccal surfaces of the dentures at
the junction of the impression material and filled
with molten baseplate wax.

• Impression plaster or zinc oxide eugenol paste is used

for impression making for the first step.

• Impression plaster is used to make impression for the

second step.

Advantage

• Same as Shaffer’s technique.

Disadvantage

• Existing errors of centric occlusion can result in

faulty impression.
5. N.S. Javid et al. technique (1985)

• This technique is based on the use of tissue

conditioning material.

• The patient is instructed not to wear the dentures

overnight.

• Centric occlusion in the old denture is carefully

examined and if any error is detected, it is
corrected.

• The centric relation should coincide with the centric

occlusion.

• The denture borders and the tissue surface of the

denture are adequately reduced for tissue
conditioning material (Fig. 11-4).

• The surface is dried before impression material is

placed.

• Minimum thickness of tissue conditioning material

is placed over the tissue surface of the denture and
 then inserted in the patient’s mouth.

• Once the material sets, the denture is removed from

the mouth and the excess material is trimmed using
sharp BP blade.

• The patient is instructed regarding care of the

relining material before dismissing him/her.

• When the patient returns after 3–5 days, the denture

is re-examined for denuded areas.

• Any denuded area is marked with indelible pencil

and the pressure areas are relieved before next
application of the tissue conditioners.

• The material is changed periodically within 1 week.

• This is done till the tissues return to clinically healthy

condition.

• At this time, the patient is scheduled for final

impression.

• All the tissue conditioning materials on the tissue

side are replaced by new ones.

• Zinc oxide paste or light body polysilicones can also be

used.
• Once the impression is satisfactory, it is poured
immediately.

• The maxillary cast is mounted on the semi-

adjustable articulator using facebow record.

• The mandibular cast is mounted using interocclusal

record.

• The relined dentures are replaced by the new

material.

• Dentures are finished and polished in conventional

manner.

• Dentures are inserted in the patient’s mouth and

occlusal interference, if any, is detected and
corrected by selective grinding.
FIGURE 11-1 Large parts of palatal portion are removed for
visibility.

FIGURE 11-2 Preparation of denture borders and palatal

portion of denture: (A) denture borders reduced by 2 mm; (B)
perforation in the palate.
FIGURE 11-3 Denture borders trimmed flat and adhesive
tape is used.
FIGURE 11-4 Tissue conditioners applied over the
impression surface of the denture.
Rebasing
Rebasing is defined as ‘the laboratory procedure of replacing the entire
denture base material on an existing prosthesis’. (GPT 8th Ed)
Indication and contraindication of rebasing are similar to relining.
Rebasing refers to the procedure of replacing all the denture base
materials with new ones.

Procedure
1. Jig Method (Fig. 11-5)

• Impressions are made and the cast is poured in the

denture.

• The cast with the denture is mounted on an

instrument such as Hooper duplicator.

• This instrument maintains the relationship of the

teeth to the cast.

• The original denture base is removed.

• The original teeth mounted in the duplicator are

rewaxed in their previous positions on the cast.

• Denture is then processed in the laboratory in

conventional manner.
2. Flask Method (Fig. 11-6)
• Impressions are made and the cast is poured in the
denture.

• Cast is not separated from the denture.

• The cast is placed into the lower half of the flask.

• The silicone mould material is painted over the

denture before investing. This creates a flexible
mould.

• Flasking is completed in conventional manner.

• The flask is opened, once investing is completed.

• Because of the silicone mould, it is easier to separate

the two parts of flask.

• Denture base is trimmed completely and the teeth

are replaced into the indentation.

• Separating medium is applied over the cast and the

mixed resin is packed into the space.

• Denture is cured, finished and polished in

conventional manner.

• Finished dentures are remounted to check for any

occlusal prematurities.
3. Articulator Method (Fig. 11-7)

• Impression is poured immediately.

• Maxillary cast is mounted on articulator using

facebow transfer.

• The mandibular cast is mounted using interocclusal

record.

• If occlusal discrepancy exists, it is identified and

corrected.

• The complete denture base is reduced leaving 2 mm

of acrylic around the teeth.

• The trimmed teeth are placed back on the

articulator and waxed without altering the vertical
dimension.

• The denture is then processed in conventional

manner.
FIGURE 11-5 Denture is indexed into Hooper duplicator.
FIGURE 11-6 Flask method.
 FIGURE 11-7 Articulator method.

Advantages of rebasing over relining

• There is no colour difference between the old and new resin.

• Problem of release of strain from processing an old base is avoided.

• Thickness of the base is better controlled.

Disadvantages
• It has an additional laboratory step.

• There are chances of displacement of teeth during waxing-up.

Key Facts
• Tissue conditioners are used in functional reline technique.

• The major drawback of rebasing complete dentures is chances of

alteration in the centric relation.
CHAPTER
12
Single complete dentures and
immediate dentures

CHAPTER OUTLINE
Introduction, 196
Immediate Dentures, 196
Definition, 196
Requirements of Immediate Denture, 196
Indications of Immediate Denture, 197
Contraindications of Immediate Denture, 197
Advantages of Immediate Dentures, 197
Disadvantages of Immediate Dentures, 197
Diagnosis and Treatment Planning of Immediate
Denture Patients, 197
Fabrication of Immediate Denture, 198
Insertion, 200
Postinsertion Care, 201
Combination Syndrome, 202
Pathophysiology in Combination
Syndrome, 203
Single Complete Dentures, 203
 Objectives, 203
Indications for Single Complete Denture, 203
Materials of Tooth Form Opposing Natural
Occlusion, 205
Techniques to Modify Natural Teeth, 206
Introduction
Immediate dentures and single complete dentures are fabricated
depending on the type of clinical situation. In immediate dentures, the
prosthesis is inserted immediately after extraction of remaining teeth,
whereas in case of single complete dentures, the position, size and
location of the remaining natural teeth determine the type, tooth form
and occlusion of the dentures.
Immediate dentures
Definition
Immediate denture is defined as ‘any removable dental prosthesis
fabricated for placement immediately following the removal of a natural
tooth/teeth’. (GPT 8th Ed)

Requirements of immediate denture

• It should be biocompatible.

• It should restore masticatory efficiency within limits.

• It should preserve aesthetics.

• It should preserve the remaining tissues.

• It should harmonize with functions of speech, deglutition and

respiration.

Indications of immediate denture

• It is indicated in any healthy dentulous or partially edentulous
patient whose remaining natural teeth need to be extracted due to
caries, periodontal reasons or trauma.

• It is indicated in a cooperative patient with good dexterity and

sound mental health.

Contraindications of immediate denture

• A patient with poor surgical risks, such as cardiac disorders,
glandular disorders or blood dyscrasias
• A patient with mental illness

• A patient with limited dexterity

• An uncooperative patient

Advantages of immediate dentures

• Maintenance of the vertical dimension – if the posterior teeth are
present, it is likely that the vertical dimension is correct.

• Natural teeth serve as an excellent guide during teeth selection and

arrangement.

• It avoids the embarrassing edentulous period.

• Postoperative pain is less because the extraction site is protected.

• There are less chances of residual ridge resorption.

• The patient’s function of speech, deglutition and mastication are not

affected to a great extent.

• It acts as a bandage or splint to control bleeding and food lodgement

in extraction sockets.

• It aids in rapid healing of surgical site.

• It results in increased patient acceptance due to the presence of teeth at

all times.

Disadvantages of immediate dentures

• There is no scope of anterior try-in.

• It is expensive, because the immediate dentures will require frequent

relining to meet the rapid changes in the tissues.
• Potentially, it gives less retention because of arbitrary scrapping of
the cast to fabricate the prosthesis.

• Need to reline is frequent as the resorption of the bone and the

shrinkage of the tissues are faster and greater.

• Do not replace the stimulation provided by the natural teeth to the

bone.

Types of Immediate Dentures

There are two types of immediate dentures, which are:

(i) Conventional immediate denture: After healing, the immediate

denture is either refitted or relined to serve as a long-term
prosthesis.

(ii) Interim immediate denture: It is worn by the patient only during the
healing period. It is then replaced by a new prosthesis.

Diagnosis and treatment planning of immediate

denture patients
Diagnosis is defined as the determination of the nature, location and cause
of the disease.
Diagnostic procedure starts by reviewing the medical and dental
history of the patient, intraoral and extraoral examinations of the soft
and hard tissues, evaluation of the patient’s mental attitude and
his/her expectations.
Medical history and past dental history of the patient are of utmost
importance in evaluating the prognosis for the immediate dentures.
Some of the systemic conditions which can affect the basal seat are:

• Uncontrolled diabetics

• Cardiovascular and cerebrovascular diseases – these present a

problem of poor clotting mechanism
• Mucosal disorders such as desquamative stomatitis

• Keratosis, hyperkeratosis and dyskeratosis can result from

deficiency of vitamins A and B

• Dermatological disease, such as psoriasis, pemphigus or erosive

lichen planus

• Collagen disorders such as lupus erythematosus

• Osteoporosis resulting from bone matrix defect

During the extraoral examination, facial form, facial symmetry,

facial profile and temporomandibular joint (TMJ) are evaluated. It is
followed by complete clinical examination of the hard and soft tissues,
which also includes assessing the periodontal condition of the
remaining teeth. It is supplemented by full mouth radiographic series
(IOPA and bitewing) which are helpful in evaluating the extent of the
bone loss due to periodontal disease.
Local factors which are of significance in complete immediate
denture treatment:

• Periodontal status of the remaining teeth to be extracted

• Location of the teeth in the arch

• Presence and severity of soft and hard tissue undercuts

• Presence of bony exostosis

• Condition of the bone adjacent to the remaining teeth

• Lack of muscular coordination

Mounted diagnostic casts are an important aid in evaluating the

position of the teeth, jaw relationship and any occlusal plane
discrepancies. These also help in analysing the tissue undercuts.
Position of the lip line and amount of tooth exposure in function are
clinically evaluated. Location of the posterior limit should be
tentatively marked on the cast. Any requirements of occlusal
corrections on the opposing teeth are planned on the cast during this
stage.
A patient’s psychological status and mental attitude should be
assessed during the diagnosis and treatment planning phase. The
patient’s expectations are discussed and the patient should be
educated from the first visit to the completion of the treatment.
A treatment plan is formulated based on the diagnostic information
of the patient. When a treatment plan is made for immediate complete
dentures, either both the maxillary and mandibular arches are
restored together or either of the arches is restored. It should be
preferred to restore the single arch with immediate complete denture
and after its stabilization, the opposing arch should be treated.

Fabrication of immediate denture

The procedure for fabrication of immediate dentures is discussed
under the following headings.

Mouth preparation
• Mouth preparation for immediate complete dentures starts at least 6
weeks before making the final impression.

• It is recommended to remove all the posterior teeth except unilateral

or bilateral bicuspids to maintain the vertical height.

• Removal of posterior teeth should be 4–6 weeks before the final

impression to ensure establishment of posterior borders for the
finished dentures.

• A single stage in which all the teeth are removed in one visit and
immediate dentures inserted in the same visit is recommended for
patients having very depleted oral condition.
Clinical procedures
Impression making

• Primary impression is made with irreversible hydrocolloid using a

stock tray.

• Impression is poured with stone to form a diagnostic cast.

• Diagnostic casts are used to fabricate custom trays.

• Custom trays are fabricated using autopolymerizing resin.

• The remaining teeth are covered with two thickness of baseplate

wax. The wax acts as a spacer.

• Any undercut area is blocked with wax before custom tray

fabrication.

• There are two techniques of making final impression, which are as

follows:

1. In the first technique (single impression

technique), a single custom tray is fabricated by
covering the entire denture border area.

• Border moulding is done using green stick

compound.

• Custom tray is perforated to ensure flow of excess

material and increase the retention of the material
within the tray.

• Tray adhesive is applied over the impression surface.

• The final impression is made preferably with light-
bodied polysulphide rubber, as it records both the soft
and hard tissues with accuracy and facilitates
removal because of its elasticity.

2. In the second technique (dual impression

technique), custom tray extends onto the
edentulous area only.

• The tray is moulded with a green stick compound.

• Impression is made of the edentulous area using

zinc oxide eugenol impression paste.

• Impression is removed and inspected.

• Impression is replaced and an irreversible

hydrocolloid-loaded tray is placed in the mouth.

• Once the impression material sets, the stock tray is

removed along with the custom tray which is
embedded in the impression.

• Impression is poured with vacuum-mixed dental

stone to obtain the master cast.
Jaw relations

• Recording base with wax occlusal rims is fabricated in the

conventional manner.
• A facebow record is made to orient the cast on the articulator.

• A tentative occlusal vertical dimension is obtained.

• Centric relation record is made at a slightly increased vertical

dimension using free-flowing medium on the occlusal rim such as
zinc oxide eugenol impression paste.

• Lower cast is mounted using this record.

Teeth selection and arrangement of teeth

• Shape, size and shade of the teeth are selected using the existing
dentition of the patient.

• Appropriate teeth are selected and arranged so as to provide

bilateral posterior contacts in centric relation.

Posterior try-in

• Posterior try-in is done to verify the centric relation and the vertical
dimension of occlusion (Fig. 12-1).

• Position of the posterior palatal seal is verified and scribed on the

cast.
 FIGURE 12-1 Posterior try-in.

Arrangement of anterior teeth

• The anterior teeth are arranged once the satisfactory posterior try-in
is accomplished.

• The anterior teeth are trimmed one at a time from the master cast.

• Each tooth is trimmed to the level of gingival margin using a sharp BP

blade or rotary instrument.

• Denture tooth is positioned in this space.

• In the first method, alternate teeth are removed from the cast and the
denture tooth is positioned.

• This procedure is repeated for arranging all the anterior teeth.

• This method ensures accurate positioning of the teeth and
maintaining natural appearance.

• In the second method, teeth on the cast are trimmed to a line

corresponding to the depth of the gingival sulcus and are broken off
the cast at their cervical aspect.

• One segment of the cast is trimmed and the teeth are arranged
taking the other segment as a guide.

• Similarly, the other segment is removed and the denture teeth are
arranged.

• The advantage of this method is that the clinician can ensure that the
complete cast preparation is carried out correctly.

Laboratory procedures
• Wax-up of the denture is done to provide adequate thickness and
proper contour of the denture base.

• After the de-waxing procedure, the cast can be trimmed, if needed

to smoothen the ridge contour.

• The denture is processed using conventional techniques.

• The finished denture is stored in a disinfectant solution and is

thoroughly cleaned before insertion.

Insertion
• The remaining teeth are removed after adequately anaesthetizing
the surgical site.

• Bony spicules or sharp edges are removed with minimal trauma.

• Surgical template is used to evaluate the prepared site.

• After the surgical procedure, the dentures are carefully seated and
positioned into place.

• Denture is checked for any overextension.

• Gross occlusal premature contacts are relieved.

• Tissue conditioners can be used, if the impression surface is

trimmed.

• The patient is instructed not to remove the denture for first 24 h.

• The patient is advised proper medication to control pain.

Surgical template
Surgical template is defined as ‘a thin, transparent form duplicating the
tissue surface of a dental prosthesis and used as a guide for surgically
shaping the alveolar process’. (GPT 8th Ed)
Surgical template is used as a guide for shaping the ridge while the
teeth are removed and immediate dentures are inserted.

Advantages
• This reveals the amount of bone to be removed during surgical
procedures.

• This is useful when large amount of bone recontouring is essential.

• This is used as a necessary adjunct during contouring of any

amount of bone.

• This is useful in removing sharp bony spicules.

Disadvantages
• If a small amount of bone needs to be recontoured, the denture can
be relieved using pressure-indicating paste rather than bone
trimming.

• It has an additional cost.

Fabrication procedure
• After the wax elimination procedure and cleansing, the ridge area of
the cast is trimmed to the desired form.

• Impression is made of the trimmed cast with irreversible

hydrocolloid.

• Impression is poured with dental stone.

• A duplicate cast is formed.

• An accurately fitting clear resin template is formed over the

duplicate cast using following methods:

(i) Vacuum form method: Clear resin sheet is adapted over the duplicate
cast and a template is formed by means of a vacuum-formed
technique.

(ii) Sprinkle-on technique using clear acrylic resin.

(iii) Process a template in clear acrylic resin by making wax pattern for
the template of thickness 2 mm over the cast, flasking and heat
curing in conventional way.

Once the surgical template is fabricated, it is used at the time of

surgical procedure of teeth removal. The template is made to seat over
the surgical site uniformly and completely. In case of any interference
due to bony or soft tissues, it is trimmed.

Postinsertion care
Postinsertion care for immediate denture patient is described below.

After 24 h
• The patient is recalled after 24 h of denture wearing.

• Occlusion is checked with articulating paper before removing the

denture. Any premature contact is relieved.

• The dentures are removed and the soft tissue is carefully inspected.

• Any sore spots or overextension is relieved.

• Tissue surface is cleaned.

• The patient is instructed to rinse mouth gently with a mouthwash.

• Removal and insertion should be done as minimally as possible.

• Liquid diet is prescribed for the patient.

• The patient is recalled after 48 h.

After 48 h
• Steps followed during the first appointment are repeated.

• The patient is instructed to practice warm saline rinses.

• The patient is instructed to wear the denture throughout the night

for first 3 days.

• Soft diet is prescribed for the patient.

• The patient is recalled after a week.

After 1 week
• Suture removal, if any, is done.

• Occlusion is again checked for any premature contact.

• Tissue surface of the denture is checked using pressure-indicating

paste.

• Soft tissues are examined thoroughly for any soreness.

• Tissue conditioners, if used, are replaced.

• The patient is recalled after 3–4 weeks.

After 3–4 weeks

• Any specific complaint by the patient is addressed.

• Clinical remounting can be done at this stage to refine the occlusion

on the articulator.

• Tissue conditioners, if used, are replaced.

• Number of recall appointments will depend on factors, such as age,

medical health, patient psychology, emotional health and tissue sensitivity.

• The patient is recalled after 4–6 weeks.

After 4–6 weeks

• Complete healing of the sockets will take around 6 months.

• The patient is evaluated for fit of the denture.

• If denture is loose, it is relined.

• After 6 months, the denture is either relined or remade.

Combination syndrome
Combination syndrome occurs when an edentulous maxilla is
opposed by natural mandibular anterior teeth. It is also called anterior
hyperfunction syndrome.
The term combination syndrome was coined by E. Kelly in 1972.
Features of Combination Syndrome (Fig. 12-
2)
• Loss of bone from the anterior portion of the maxillary ridge

• Downward growth of the maxillary tuberosities

• Papillary hyperplasia of the mucosa of the hard palate

• Extrusion of the lower anterior teeth

• Loss of alveolar bone and ridge height, beneath the mandibular

removable partial denture bases

There are six associated changes observed in combination syndrome

as follows:

(i) Loss of vertical dimension of occlusion

(ii) Occlusal plane discrepancy

(iii) Development of epulis fissuratum

(iv) Anterior spatial repositioning of the mandible

(v) Poor adaptation of the prosthesis

(vi) Periodontal changes

 FIGURE 12-2 Schematic diagram showing features of
combination syndrome.

Pathophysiology in combination syndrome

When the remaining mandibular natural anterior teeth oppose the
maxillary denture, the patient tends to function in protrusive
relationship to masticate. As the anterior portion of the maxillary
ridge is composed primarily of the cancellous bones, it is subjected to
rapid resorption. As the ridge resorps and progresses, the bony ridge
is replaced by the redundant soft tissues, initiating the combination
syndrome and the associated changes.

• With resorption of the maxillary anterior ridge, the denture tends to

tip upward anteriorly and downward posteriorly.

• The labial flange of the denture produces chronic irritation from

overextended labial flange of denture resulting in epulis fissuratum.

• Posterior downward tipping of the maxillary denture results in the

overgrowth of the fibrous tissues covering the maxillary
 tuberosities.

• The retention and stability of the denture are compromised because of

the changes in the supporting tissues.

• Because of ridge resorption, the angulation of the occlusal plane

changes. The mandible tends to assume more anterior position.

• Supraeruption of the lower anterior teeth takes place because of the

changes mentioned earlier.

• Loss of posterior support in the mandible results in an increased

anterior occlusal function and a decreased posterior occlusal
function.
Single complete dentures
Single complete dentures are the making of a maxillary or mandibular
denture as distinguished from a set of complete dentures.

Objectives
• To achieve an acceptable interocclusal distance

• To achieve a stable jaw relationship with bilateral tooth contacts in

retruded closure

• To achieve stable tooth quadrant relationships providing axially

directed forces

• To achieve multidirectional freedom of tooth contacts throughout a

small range of mandibular movements

Indications for single complete denture

Single complete denture is desirable when it opposes any one of the
following:

• Natural dentition only

• Combination of fixed restorations and the natural teeth

• A removable partial denture and the natural teeth

• An existing complete denture

Types of Single Complete Dentures

The following are the types of single complete dentures:

• Mandibular denture to oppose natural maxillary teeth

• Single complete maxillary denture opposing natural mandibular
teeth

• Complete maxillary denture to oppose a partially edentulous

mandibular arch with fixed prosthesis

• Complete maxillary denture opposing a partially edentulous lower

arch and a removable partial denture

• Single complete denture opposing the existing complete denture

1. Mandibular denture to oppose natural maxillary teeth.

• Completely edentulous mandibular arch usually

occurs because of surgical or accidental trauma.

• Three factors are considered in such patients,

namely, preservation of residual alveolar ridge,
necessity of retaining maxillary teeth and mental
trauma.
2. Single complete maxillary denture opposing natural mandibular
teeth (Fig. 12-3)

• It is more common than the mandibular denture.

• The periodontal status of remaining teeth, adequate

freeway space and oral hygiene of the patient are
evaluated during diagnosis and treatment planning
phase.

• Whenever possible, balanced occlusion should be

 provided in order to enhance the retention and
stability of the denture.

• Occlusal form of the natural teeth usually

determines the selection of the occlusal form of the
artificial teeth.

• Because of the angulation of the natural lower teeth,

the upper teeth may not be arranged in the
aesthetically acceptable positions. In order to
encounter this problem, the natural teeth can be
orthodontically repositioned or the clinical crown
of the teeth can be altered by grinding or with
restorations.
3. Complete maxillary denture to oppose a partially edentulous
mandibular arch with fixed prosthesis

• When maxillary denture opposes a partially

edentulous mandibular arch, in which the missing
teeth are replaced with fixed restoration.

• The occlusal surface material determines the choice of

material for the artificial denture teeth. If the fixed
restorations are made of porcelain, the choice of
material for the denture teeth should be porcelain.

• If the gold restorations are given in the lower arch,

the occlusal surface of the artificial teeth should be
 made up of gold or acrylic resin.
4. Complete maxillary denture opposing a partially edentulous lower
arch and a removable partial denture (Fig. 12-4)

• This is one of the most frequently encountered

situations.

• The existing partial denture should be critically

evaluated to check the occlusal plane, aesthetics,
arrangement of teeth and the material.

• The condition of the remaining teeth is evaluated.

• If the removable denture is found unsuitable, both

the dentures are simultaneously fabricated.
5. Single complete denture opposing the existing complete denture

• It is important to determine the time at which the

patient is wearing the denture.
FIGURE 12-3 Maxillary complete denture opposing natural
mandibular teeth.

FIGURE 12-4 Single complete maxillary denture opposing

mandibular removable partial denture.
 The following queries also need to be considered:

• Whether the existing denture is satisfactory or it needs to be remade

with the opposing denture?

• Was the existing denture inserted immediately after teeth

extraction?

• Few existing dentures fulfil the ideal requirement of the dentures,

and most of them require either relining or rebasing or remaking of
the denture.

Materials of tooth form opposing natural

occlusion
Various tooth form materials that are used to oppose the natural
dentition in single complete denture cases are available. Some of the
commonly used materials are described in Table 12-1.

TABLE 12-1
TYPES OF TOOTH MATERIAL OPPOSING NATURAL TEETH
FIGURE 12-5 Diagram showing denture teeth with gold
occlusals.
Techniques to modify natural teeth
Various techniques used to modify the natural teeth prior to the
denture fabrication are reported in literature, some of which are as
follows:

1. M.G. Swenson technique (1964)

• Maxillary and mandibular casts are mounted on an

articulator at an acceptable vertical dimension using a
provisional centric relation record.

• On the complete denture cast, the denture base is

fabricated and the teeth are arranged.

• The cast is made to occlude the opposing natural

teeth.

• If the natural teeth interfere with the denture teeth,

they are marked on the cast with a pencil.

• The natural teeth are then modified using the marked

diagnostic cast as a guide.

• After this modification, new diagnostic cast is made

and mounted.

• If more adjustments are required, the procedure is

repeated.
• Once the occlusal adjustments are sufficient, the
denture teeth are rearranged and are prepared for
try-in.
Advantage

• It is a simple technique.
Disadvantage

• It may require multiple impression and diagnostic

mountings.
2. A.A. Yurkstas technique (1968)

• A U-shaped metal occlusal template which is convex

on the lower surface is used.

• This template is placed on the natural teeth on the

cast and the cusps to be modified are identified and
marked on the cast.

• The stone cast is adjusted to a more acceptable

occlusal relationship and the areas are identified by
marking with a pencil.

• The cast is then used as a guide to modify the

natural teeth.
3. R.W. Bruce technique (1971)
• The lower cast is mounted on the articulator as
described earlier.

• Any occlusal adjustments needed are made on the

cast.

• A clear resin template is fabricated over the modified

stone cast (Fig. 12-6).

• The inner surface of the template is coated with

pressure-indicating paste and the template is seated
over the natural teeth.

• The interferences are readily identified on the teeth

and are accordingly modified.

• The process is repeated until the clear resin

template seats properly.
4. C.O. Boucher et al. technique (1975)

• After the upper and lower casts are mounted on the

programmed articulator, the maxillary artificial
teeth are arranged to obtain the best possible
occlusal balancing contacts.

• If the opposing lower natural teeth interfere in the

balanced occlusal contact, the interfering contact is
identified and is modified on the cast.
• Altered diagnostic cast is used to modify the natural
teeth.

• Balanced denture is processed.

• The occlusion is refined using an arch-shaped layer

of the softened baseplate wax.

• Any premature contact is identified and the natural

teeth are modified.

• The procedure is repeated until a harmonious

balanced occlusion is obtained.

FIGURE 12-6 Clear resin template fabricated over modified

cast.

Key Facts
• Continuous gum denture is an artificial denture consisting of the
porcelain teeth and tinted porcelain denture base material fused to a
platinum base.

• Immediate dentures should be removed by the dentist after 24 h of

wearing.

• Thickness of the palatal surface of the maxillary denture should not

be more than 2 mm.
CHAPTER
13
Overdentures

CHAPTER OUTLINE
Introduction, 208
Overlay Dentures or Overdentures, 208
Requirements of the Overdenture, 209
Advantages, 209
Disadvantages, 210
Indications, 210
Contraindications, 210
Preventive Prosthodontics, 210
Rationale of Retaining Teeth for
Overdentures, 210
Patient Selection, 212
Bare Tooth Overdenture (Noncoping
Abutments), 213
Telescopic Overdenture (Abutments with
Copings), 213
Types of Primary Copings, 213
Attachment Fixation Overdenture (Abutments
with Attachments), 214
 Factors Considered during Attachment
Selection, 215
Attachments in Overdenture Design, 215
Gerber Attachments, 215
Resilient Gerber Attachment, 216
Ceka Attachments, 216
Zest Anchor, 216
Rothermann Attachment, 217
Introfix Attachment, 218
Magnets, 218
Bar Attachments, 219
Maintenance of Overdentures, 220
Maintenance after Insertion, 220
Introduction
Overdenture concept emphasizes on the preventive aspect in
prosthodontics in which denture is fabricated over the remaining
natural tooth or root. Preservation of teeth has definite benefits in
reducing rate of resorption, preserving bone and proprioception
among others.
Overlay dentures or overdentures
Overlay dentures or overdenture is defined as ‘any removable dental
prosthesis that covers and rests on one or more remaining natural teeth, the
roots of natural teeth, and/or dental implants’. (GPT 8th Ed)
This is also called biologic denture, telescopic denture, onlay denture,
hybrid denture, root-supported denture and superimposed denture.
Principles of Overdenture
• It maintains the teeth as part of the residual ridge. The denture rests
over the remaining teeth or root and minimizes its vertical movement.

• It decreases the rate of resorption. Various studies show that

overdenture preserves the alveolar bone and decreases the rate of
resorption.

• There is preservation of the periodontium along with the teeth. This

increases the manipulative skills of the patient in handling the
denture.

• Reduction of the retained teeth to establish a favourable crown–root

ratio.

Requirements of the overdenture

• Reduction of the crown–root ratio decreases the mobility of the
tooth by decreasing the length of the lever arm and thus reducing
torquing forces on the mobile tooth.

• The basal seat tissues should be well healed and firmly bound to the
underlying bone in order to resist and distribute the functional load
over the wider surface.

• The denture should be relatively simple to fabricate and maintain.

• The teeth or root utilized for the overdenture should have sound
periodontal health.

• The denture should be easily manipulated by the patient.

Classification of Overdentures
• On the basis of method of abutment preparation:

• Noncoping

• Coping

• Attachments
• On the basis of method of retention:

• Copings

• Attachments

• Sleeve coping prosthesis

• Submucosal vital root retention

• Implant supported
• On the basis of time of fabrication:

• Immediate overdenture
• Transitional overdenture

• Training overdenture
• On the basis of type of tooth-supported overdentures:

• Tooth-supported conventional complete

overdenture

• Tooth-supported immediate complete overdenture

• On the basis of type of design:

• Bare root

• Telescopic

• Attachment fixation overdenture

Advantages
• Overdentures help in preserving the alveolar bone.

• These help in preserving the proprioceptive response by retaining the

neutral teeth and the periodontium.

• These provide a static stable base and greatly improve the stability
and support of the denture, which is not possible with the
conventional denture.

• These provide enhanced retention of the prosthesis.

• It is an useful, inexpensive approach to restore function, aesthetics

 and comfort in the patients with congenital defects, such as cleft
palate, partial anodontia, microdontia and amelogenesis imperfecta.

• These have excellent patient acceptance.

• It is easy to maintain the optimum health of the periodontium.

• These can be converted easily to conventional complete denture in

case of extraction of the retained tooth/teeth.

• These are of reasonable cost.

• Horizontal and torquing forces are minimized.

• These may require minimum postinsertion appointments.

• Roofless denture or open palate is possible.

Disadvantages
• Retained teeth are susceptible to caries.

• Bony undercuts may limit the path of placement of the denture.

• Presence of undercuts may result in denture which may be

overcontoured or undercontoured.

• Increased interocclusal distance is required to accommodate internal

attachments.

• Aesthetics may be compromised in case of overcontoured or

undercontoured denture.

• The retained teeth are susceptible to periodontal breakdown.

Indications
• In a patient with few remaining teeth

• Younger the patient, greater the indication

• In a patient with congenital defects such as cleft lip and palate

• In a patient with high vault palate and sloping ridges

• In a patient with a poorly defined sublingual fold

• In cases when complete denture opposes natural teeth

• In cases where there is extensive bone around the teeth which are to
be retained

• In a cooperative and motivated patient

Contraindications
• In case of physically and mentally handicapped patients

• In case of uncooperative and undermotivated patients

• In case of decreased interarch space and severe tissue undercuts

• In a patient with teeth with class III mobility

• In case of soft tissue and bony defects which cannot be corrected by

surgery

• In case of vertical fracture or retained root or tooth

• In case of mechanical perforation of the tooth

• In case of horizontal fracture of the root below the bony crest

• In case of broken instrument in the root canal

Preventive prosthodontics
Preventive prosthodontics emphasizes the importance of any
procedure that can delay or eliminate future prosthodontic problems.
The concept of preventive prosthodontics is highlighted in the
treatment of overdentures.

Rationale of retaining teeth for overdentures

Retention of teeth for overdentures offer several advantages both
functionally and biologically. Overdentures should always be
considered in case of loss of alveolar bone support and subsequent
development of unfavourable crown–root ratio. These should be
considered as an alternative to extraction of all the natural teeth.
Sequelae of extracting all the natural teeth are:

• Loss of discrete proprioception

• Progressive loss of alveolar bone

• Transfer of all occlusal forces from the teeth to the oral mucosa

It is logical to preserve the natural tooth or root, as they provide not

only periodontal ligament to support the teeth but also tactile
sensitivity to load, dimensional discrimination, directional sensitivity
and canine response.
Rationale of retaining teeth can be described under three headings:

• Preservation of proprioception

• Alveolar bone preservation

• Occlusal forces in overdentures

Preservation of proprioception
Proprioception is defined as ‘information provided about the position and
movements of the body and its parts by receptors’. (Ramfjord and Ash
[1971])
The periodontal ligament is richly innervated by these receptors
and the tooth is surrounded by large number of receptors which can
receive mechanical stimulation. Receptors may also be located in the
supporting bone, adjacent periosteum and the mucosa. Retention of
the tooth root preserves the integral component of the sensory feedback
system that programmes the masticatory system throughout the
patient’s life. The neuromuscular function of the masticatory system
depends on the harmony of the sensory feedback and the motor
neuron response at the reflex level.
Retention of the tooth for an overdenture preserves the periodontal
proprioceptors. The afferent input from the periodontal ligament
receptors contains information about the magnitude and direction of the
occlusal forces and the size and the consistency of the food bolus. The
periodontal receptor also protects the teeth against occlusal
overloading.

Alveolar bone preservation

R.J. Crum and G.E. Rooney (1975) in their 4-year study compared
alveolar bone loss in patient with mandibular overdenture with
conventional mandibular dentures. It was observed that when
mandibular canines were used for overdentures, the rate of resorption
of bone surrounding the teeth reduced by eight times. The
overdenture patient also exhibited reduced bone loss in the area
immediately posterior to it. This study clearly showed that the use of
overdenture preserved the bone between the canines in both height
and width.
With the preservation of bone, the overdenture patient showed
better masticatory efficiency and reduced loss of overall face height. Several
studies have shown alveolar bone loss after extraction of the natural
teeth and replacement with the conventional complete dentures. Also,
it is shown that the alveolar bone of the anterior mandible resorbs
faster than the anterior maxilla. The use of overdentures clearly
indicates the preservation of the alveolar bone, especially in the area
where the teeth are retained.

Occlusal forces in overdentures

F.J. Pacer (1971) found that the overdenture patients could
discriminate measured occlusal forces better at higher levels than the
patient with the conventional dentures. This discrimination was due
to the greater sensory input from the periodontal receptors.
A.H. Fenton (1973) compared the ability of the patient to perceive
thin objects between the occlusal surfaces of the natural dentition,
conventional dentures and overdentures. He found that an
overdenture patient had less occlusal thickness perception than a
patient with the conventional dentures. The natural tooth/root,
therefore, provides better vertical support than the conventional
dentures.

Patient selection
The factors which are critical in patient selection for overdentures are:

• Periodontal status of the abutment teeth:

• Optimum periodontal health is important for the

longevity of the overdenture treatment.

• Inflammation, periodontal pocket, intrabony defects

or loss of attached gingiva should be eliminated
before beginning the treatment.

• Usually, the overdenture abutment teeth have poor

zone of attached gingiva. This can be corrected by
periodontal surgery using a free gingival graft or
 apically repositioned split thickness flap.
• Caries

• The patient’s caries index should be critically

evaluated before selecting the abutment teeth for
overdenture treatment.

• Healthy clinical crown which is caries-free is desired

for overdenture treatment.

• If the tooth is having carious lesion, the extent and

location is evaluated. If the carious tooth can be
restored and an environment can be created so that
the caries incidence is reduced, the particular tooth
can be used as an abutment.

• If the patient has high caries index, the overdenture

treatment should be chosen with caution.

• The abutment tooth should be properly prepared,

restored and polished to facilitate plaque control
measures.

• The caries-prone tooth can be treated with low

concentration of stannous fluoride or 0.5% acidulated
phosphate fluoride (APF) gel to ensure any further
breakdown.
• The patient should be educated and instructed to
follow home care programme carefully to reduce
the incidence of caries.
• Endodontic therapy

• Usually, the teeth selected as abutment for the

overdenture treatment require endodontic therapy
so that sufficient reduction of the clinical crown is
possible.

• It should be ensured that the single-rooted or

multirooted teeth are adequately treated
endodontically.

• After endodontic treatment, the tooth should be

observed for 2–4 weeks to rule out any endodontic
complication.
• Possibility of fixed or removable partial denture

• If the remaining teeth are capable of supporting the

fixed or removable partial denture, they should be
preferred to the overdenture treatment.
• Age of the patient

• Age factor is very critical in selecting patient for

overdenture treatment.
• For a young patient with poorly prognosed teeth,
overdenture treatment should be preferred over
extraction of the teeth.

• Proper tooth preparation and home care

programme become more critical in such patients.
• Location of the abutment teeth

• Location of the remaining teeth is important to

determine the support of the overdenture and the
preservation of the bone.

• Whenever possible, teeth on both the sides of the

arch should be preserved because this will ensure
better support, better preservation of bone and
maintenance of occlusal vertical dimension.

• Even if single tooth can be preserved, it should be

used as an abutment for overdenture.

• Preservation of teeth become more critical, if the

arch is opposed by natural dentition.
• Cost

• Sometimes, the cost of the treatment becomes

critical.
• It is important to determine the prognosis of the
treatment carefully against the cost of the
treatment.

Types of Overdenture Designs

The basic overdenture designs:

• Bare root overdenture

• Telescopic overdenture

• Attachment fixation overdenture

Bare tooth overdenture (noncoping abutments)

These overdentures are directly placed over the crownless,
endodontically treated roots, either as an interim step in fabrication or
as a final prosthesis (Fig. 13-1).

FIGURE 13-1 Diagram showing bare tooth overdenture.

Indications
• Roots used for support and preserve bone
• Elderly patient

• A patient with poor health

• Low caries index

• Root caries free

Disadvantages
• It provides only stability without retention.

• Roots are not connected to rigid prosthesis and thus are not
splinted.

• Exposed dentin is susceptible to caries.

Telescopic overdenture (abutments with copings)

Roots are restored with a cast restorations (primary coping) such that
the prosthesis contacts directly with the denture acrylic or with metal
coping (secondary coping) (Fig. 13-2).
 FIGURE 13-2 Diagram showing telescopic overdenture.

Types of primary copings

• Long coping

• Medium coping

• Short coping

Advantages
• This overdenture retains roots and conserves bone.

• Abutments teeth provide support (often retention) for more stable

prosthesis.

• It preserves proprioception.

• It has greater patient acceptance.

• It allows easy modification.

• Auxiliary retention devices can be added later on.

• It is easy to fabricate.

• It is cheaper than the attachment fixation overdenture.

Disadvantages
• Retention is fixed and not variable.

• Overdenture can be bulky and less aesthetic than attachment

overdenture design.

• Short copings provide minimal retention.

• Long or medium copings may provide inadequate retention.

• Retention is dependant on friction alone, which is not reliable.

• Long or medium copings cannot be used when the interocclusal

space is limited.

Attachment fixation overdenture (abutments with

attachments)
This type of overdenture may connect to the copings with studs or
other form of attachment such as bar and rider systems. The patient
experiences increased comfort, function and aesthetics as the results
closely approximate that obtained with fixed partial denture or
precision partial denture prosthetics (Fig. 13-3).
 FIGURE 13-3 Diagram showing attachment fixation
overdenture.

Advantages
• Retained roots preserve alveolar bone.

• Coping coverage is indicated for caries control.

• Weaker abutments may be splinted.

• Retention can be adjusted and controlled.

• Better patient acceptance and comfort.

• Improved aesthetics.

• Better distribution of forces between the abutment and the tissues.

Disadvantages
• Attachment fixation overdenture is costly in comparison to
conventional telescopic overdenture.

• It is difficult to fabricate.
• It is difficult to maintain.

• Some attachments are bulky and may cause aesthetic and occlusal
space problems.

• It is difficult to use in a patient with limited dexterity.

Types of Overdenture Attachments

Classification of overdenture attachments on the basis of shape,
design and primary area of their use:

Coronal

A) Intracoronal – radicular attachments such as Zest, Ginta, etc.

B) Extracoronal

Extracoronal

A) Telescope stud attachments

B) Bar attachments – joints, units

C) Auxiliary attachments:

(i) Screw units

(ii) Pawl connectors

(iii) Bolts

(iv) Stabilizers/balancers

(v) Interlocks
(vi) Pins/screw

(vii) Rests

Factors considered during attachment selection

• Desired crown–root ratio

• Type of coping

• Interocclusal space

• Number of teeth present

• Amount of bone support

• Location of abutments

• Location of stronger abutment

• Cost

• Maintenance problems

• Type, i.e. either tooth-supported or tooth-tissue supported

Attachments in overdenture design
There are wide variety of attachments which are used for overdenture
prosthesis. Most of these attachments are named after the inventor,
e.g. Dalla Bona, Zest, Gerber and Dolder. Most of these attachments
are either resilient or nonresilient. A resilient attachment reduces the
vertical and lateral forces on the abutments by distributing the
masticatory load mostly to the tissues. This is accomplished by
creating a gap of 0.5–1 mm between the overdenture and the metal
substructure. Resilient attachments are indicated for tooth-tissue
supported cases. A nonresilient attachment does not permit any vertical
movement during function. If the prosthesis is totally tooth supported,
the abutment teeth should bear the entire load. Attachments can be
extracoronal or intracoronal.

1. Extracoronal attachment is defined as ‘any prefabricated attachment

for support and retention of a removable dental prosthesis. The male and
female components are positioned outside the normal contour of the abutment
tooth’. (GPT 8th Ed)

For example: Studs (Gerber, Dalla Bona, Rotherman,

etc.), bar, auxiliary attachments
2. Intracoronal attachment is defined as ‘any prefabricated attachment
for support and retention of a removable dental prothesis. The male and
female components are positioned within the normal contour of the abutment
tooth’. (GPT 8th Ed)

For example: Zest, Ginta, etc.

Some of the commonly used attachments are described below.

Gerber attachments
• These attachments are of two types – resilient and nonresilient.

• The nonresilient Gerber attachments are the most common and widely
used attachments.

• They consist of male post-threaded into the soldering base and the
female portion consists of female housing consisting of the retention
spring and the ring.

Advantages
• All components are interchangeable and replaceable.

• Retention is adequate and fabrication is simple.

• Maintenance is easy.

Disadvantages
• Gerber stud is expensive.

• Attachment can torque the tooth, if the denture base has excessive
movement due to poor adaptation.

• A mandrel is needed to parallel the attachments when more than

one is used.

Resilient gerber attachment

• It is also known as Puffer and is a spring loaded, vertically resilient
attachment.

• It allows vertical movement and imparts less torquing forces on the

abutment teeth.

• It is complex in fabrication and design.

• It has nine parts and is one of the most sophisticated and expensive
stud attachments.

Advantages
• Rebasing is simple.

• Soldering base is interchangeable.

• Spring-loaded resilience allows the base to adapt under function.

Disadvantages
• It is expensive.

• Attachment is bulky.

• Design is complex.

• Torque factor can be considered, if the base is not adapted

adequately.

Ceka attachments
• It consists of a soldered base with a removable male stud that is
conical in shape and has a rounded top with an increased diameter
for retention (Fig. 13-4).

• It splits vertically into four sections.

• These four sections are flexible and are engaged into undersized
female housing.

• Use of processing spacer allows the attachment to provide vertical

and horizontal movements.
• Overall height of the attachment is 4.5 mm.

FIGURE 13-4 Ceka attachment.

Advantages
• Attachment allows for either solid or resilient fixation.
• It has higher durability.

• Its components are replaceable.

Disadvantages
• It requires complex torque-producing intraoral adjustments.

• Nonresilient Ceka can produce excessive torque on the teeth.

Zest anchor
• This was originally developed by Carl Axel Gross in 1954 in
Sweden.

• It was introduced in America by Max Zuest in 1973.

• This attachment derives its retention within the root.

• A post preparation is made within the root and the female sleeve is
cemented in place.

• Male portion is a nylon post which is placed in the sleeve and is picked
up in the denture resin as a chairside procedure (Fig. 13-5).

• Retention is achieved by the ball head snapping into the undercut of

the female sleeve.
 FIGURE 13-5 Zest anchor attachment.

Advantages
• It has negligible torque or leverage on the abutment tooth.

• It can be used in reduced interocclusal space.

• It is simple to use and inexpensive.

• Attachment can be used without the dowel or coping.

• It provides slight vertical and rotational movement.

• It can be used on divergent teeth.

Disadvantages
• It is susceptible to caries.

• Sleeve requires meticulous oral hygiene maintenance.

• Nylon studs can absorb water and can bend, break or prevent entry
of attachment.

• Studs may be replaced quite frequently.

Rothermann attachment
• This type of attachment can be either resilient or nonresilient (Fig. 13-
6).

• It consists of male stud with a solder core for freehand soldering to a

coping and a female clip consisting of a perforated retention beam
with a split C ring extension.

• Difference in resilient and nonresilient attachment is in the height of

the male portion, i.e. in resilient it is 1.7 mm and in nonresilient it is
1.1 mm.
 FIGURE 13-6 Rothermann attachment.

Advantages
• Attachment is low in height, it is shortest attachment available.

• It does not require mandrel for alignment and is inexpensive.

• Torque is an absolute minimum.

• Minimal retention can be obtained by spreading the retention ring.

Disadvantages
• It has no provision for ‘C’ ring activation.

• Rebasing is difficult.

• There is lingual bulk in the orientation of the attachment.

Indications
• When space is limited

• Teeth are divergent

• When vertical as well as rotational movement is desired (resilient)

Introfix attachment
• It is a solid cylinder attachment that can be used for fixed removable
bridge work and for overdentures.

• It consists of three parts, namely a solder base, a replaceable and

adjustable male friction part and a female cylindrical housing.

• The male post can be split longitudinally to allow adjustment of the

retention.

Advantages
• It is simple to use.

• Its components are replaceable.

• Retention is good.

• It can be used in combination with resilient attachments.

• Service life is indefinite.

• It is ideal for rigid overlay denture.

Disadvantages
• It requires mandrel for alignment with additional attachments.

• It is processed in a laboratory.

• Torque potential is maximum, if the denture base is not adapted

adequately.

Magnets
• A magnet consists of detachable keeper elements made of stainless
steel; it is fixed to the abutment tooth.

• Denture retention elements have paired cylindrical, cobalt–

samarium magnets, axially magnetized and arranged with their
opposite poles.

• Flat magnet faces are covered by magnet keeper and on the other end
by thin stainless steel plates.

• These plates protect the magnets against wear and corrosion and
provide excellent retention.

Bar attachments
Bar attachments are one of the most widely used attachment, if
adequate vertical space is available. These provide rigid splinting of the
abutment teeth, enhance retention, stability and support and can be
used with all coping sizes. Bar attachments are of two types:

(a) Bar units: These act as a fixed unit. These provide rigid fixation
with frictional retention. It is indicated in totally tooth-supported design.
(b) Bar joints: These have a curved contour and allow the prosthesis to
rotate around the bar slightly. These permit rotational movement
between the bar and the sleeve and allow some of the load to be borne
by the residual ridge.

Some of the commonly used bar attachments are as follows:

1. Hader bar (Fig. 13-7)

• It can be used as bar unit or as bar joint and as stud

attachments.

• It consists of prefabricated plastic bars and clips

• The plastic bars are attached to the coping wax-up

and is casted along with the coping.

• The plastic clips are embedded in the denture to aid

in retention or can be casted in metal.

• If additional retention is required, more clips may

be added on a bar and tension on the metal clip
may be increased.

Advantages:

• Preformed plastic bars allow fabrication in any

alloy.

• Retention can be controlled.

• It has capability to follow anteroposterior gingival
contours.

• Assembly technique is simple.

Disadvantages:

• Bar and clip assembly is bulky.

• Retention may be lost rapidly due to wear of plastic

or metal clip.
2. Dolder bar (Fig. 13-8)

• It can be used as bar unit and bar joint.

Bar unit consists of preformed bar which is soldered

to the coping on the abutment tooth:

• Shape of the bar has parallel sides with a rounded top.

• Sleeve which is embedded with the resin in the

denture rests over the bar to provide retention with
frictional means.

• Movement is negligible and assembly is rigid.

• Bar unit is bulky and it is difficult to achieve

aesthetics.
FIGURE 13-7 Hader bar.
 FIGURE 13-8 Egg-shaped Dolder bar joint.

Dolder bar joint is an egg-shaped bar with a brass spacer to provide

resilience:

• The spacer allows the sleeve to have a vertical and rotational

movement.

• Assembly is bulky, which hinders in achieving good aesthetics.

• It is expensive and requires exceptional skill for its use.

3. Baker clip
• It is a type of bar joint which consists of a small U-
shaped clip designed to fit over the round wire.

• It is available in 11 and 14 gauges.

Advantages:

• It is adjustable for retention and provides rotational

movements.

• It is readily available.

Disadvantages:

• Retention for the clip is not provided.

• It provides joint movement only.

4. Andrews bar

• It consists of a series of curved austenitic friction bars

of different radii with corresponding retentive
sleeve.

Advantage:

• None

Disadvantages:
• It requires complicated mechanical joining and
soldering of a nonprecious metal bar to a coping.

• It is excessively bulky.
5. Ackerman clip and CM clip

• Both the bar joint attachments are similar in design.

• These consist of the round bar soldered to the post

copings and a clip that fits over the bar.

• These supply a spacer to aid in vertical and

rotational movement.

• These are small in size and can be easily fixed.

• These provide excellent retention.

Maintenance of overdentures
Success or failure of the overdenture treatment depends entirely on its
maintenance. There are certain problems associated with the
overdenture treatment, e.g.

• Recurrence of dental caries

• Recurrence of periodontal disease

• Loss or breakage of attachment components

• Breakage of overdenture prosthesis

• Poor retention and stability

• Poor aesthetics

• Loosening of the coping

• Loss of abutment tooth

Most of the problems can be prevented by proper diagnosis and

treatment planning. During planning on the type of attachment, the
patient’s manual dexterity should be considered. Properly planned
and fabricated overdenture will last for a longer period of time than
otherwise.

Maintenance after insertion

• The patient is educated and trained on path of placement and removal
of the prosthesis.

• The patient is instructed not to bite the prosthesis into position but
to feel it into position.
• Initially patient may complain of bulky prosthesis and problem in
speech.

• The patient is instructed to read aloud until he/she becomes

accustomed to the bulk of the prosthesis.

• The patient is instructed to take small bites, chew slowly and chew on
both the sides of his/her mouth.

• Proper home care instructions are given to the patient.

• The patient is taught proper technique for brushing and cleaning the
prosthesis.

• Oral hygiene maintenance aids are suggested to the patient such as

dentrifice, toothbrush, floss, toothpick, stimulating devices,
disclosing solution and water irrigation devices.

• Soft, multitufted nylon brush with bristles are recommended. The brush
is held at 45° angulation to the gingiva, coping and bar. The brush is
moved in short circular motion.

• Unwaxed dental floss is recommended.

• The dental floss should be wrapped around the abutment and is

moved up and down to remove the plaque. Care should be taken
not to injure the gingiva.

• Interproximal brush can be prescribed in cases of more open

interproximal areas. It is gently moved back and forth from the
facial and then to the lingual direction.

Key Facts
• Overdenture primarily preserves bone, preserves proprioception
and enhances patient’s manipulative skills.
• Application of low concentration stannous fluoride or 0.5% APF gel
is recommended on abutment teeth to reduce caries rate.

• Overdenture treatment is highly useful in the patients with

congenital anomalies such as cleft palate, microdontia,
amelogenesis imperfecta and dentinogenesis imperfecta.

• In immediate overdenture concept, certain poorly prognosed teeth

are removed and denture is inserted over the remaining teeth until
complete healing of the extraction site occurs.

• Immediate overdenture concept was popularized by J.L. Lord and S.

Teel (1969).
SECTION II
Removable Partial Dentures
OUTLINE

14. Introduction to removable partial dentures

15. Diagnosis and treatment planning

16. Components of removable partial denture

17. Principles of RPD design

18. Mouth preparation in RPD

19. Impression making in removable partial denture

20. Laboratory procedures, occlusal relationship

and postinsertion of removable partial denture

21. Insertion, relining and rebasing

CHAPTER
14
Introduction to removable partial
dentures

CHAPTER OUTLINE
Introduction, 224
Definition, 224
Classification, 224
On the Basis of Type of Attachment of the
Denture to the Natural Teeth, 225
On the Basis of Type of Support, 225
On the Basis of Type of Material, 225
Indications and Contraindications of RPD, 225
Benefits of RPD, 225
Indications, 225
Contraindications, 226
Classification of Partially Edentulous Arches, 226
Kennedy’s Classification and Applegate’s
Modification, 226
Commonly Used Classification for Partially
Edentulous Arches, 228
Sequential Phases in Treating a Partially
Edentulous Patient with Removable
Prosthesis, 230
Introduction
Replacement of teeth in partially edentulous individuals using
removable partial dentures (RPDs) demands preserving health of
remaining hard and soft tissues, restoration of oral comfort, function,
speech and aesthetics.

Definition
Removable prosthodontics is defined as ‘the branch of prosthodontics
concerned with the replacement of teeth and contiguous structures for
edentulous or partially edentulous patients by artificial substitutes that are
readily removable from the mouth’. (GPT 8th Ed)
Classification
Removable prosthodontics can be broadly classified as follows:

(i) Removable complete prosthodontics: This refers to the replacement of

teeth and adjacent structures in completely edentulous patients
with complete dentures.

(ii) Removable partial prosthodontics: This refers to the replacement of

teeth and adjacent structures in partially edentulous patients with
partial dentures. It is of two types: extracoronal and intracoronal.

On the basis of type of attachment of the denture

to the natural teeth
On this basis, it can be classified as:

(i) Extracoronal retainers

(ii) Intracoronal retainers

Extracoronal retainers: This is defined as ‘that part of a fixed dental

prosthesis uniting the abutment to the other elements of the prosthesis that
surrounds all or part of the prepared crown’. (GPT 8th Ed)

The commonly used extracoronal retainers are in the form of clasps.

The clasp assembly consists of the retentive arm which is located in
the undercut area of the tooth and the reciprocal or bracing or
stabilizing arm which lies above the undercut area on the opposite
side of the tooth.

Intracoronal retainers: These retainers are located within the tooth and
the retention of the denture depends on the exact parallelism of the
two retentive units. Intracoronal attachments are used in this type
of retainers.
Intracoronal attachment is defined as ‘any
prefabricated attachment for support and retention of a
removable dental prosthesis. The male and female
components are positioned within the normal contours of
the abutment tooth’. (GPT 8th Ed)

On the basis of type of support

On the basis of type of support, RPD is classified as follows:

(i) Tooth supported: When RPD derives its support from the abutment
tooth entirely.

(ii) Tooth and tissue supported: When RPD derives support from both
the abutment tooth and the edentulous ridge.

On the basis of type of material

On the basis of the type of material used, RPD is classified as follows:

(i) Complete acrylic: RPD is conventionally made up of acrylic (e.g.

cross-linked heat-cure acrylic resin).

(ii) Metal based: RPD framework is made of metal (e.g. type III or IV
gold alloys, base metal alloys and titanium alloys).
Indications and contraindications of
RPD
All forms of prosthodontic treatment should give due consideration to
DeVan’s dictum given by Muller DeVan (1952), which states that ‘the
preservation of that which remains and not the meticulous replacement of
that which has been lost’.

Benefits of RPD
• Improved appearance

• Maintaining or improving phonetics

• Establishing masticatory efficiency

• Maintaining the health of the masticatory system by preventing

undesirable tooth movement and by evenly distributing the occlusal
load

Indications
• Length of the edentulous span: Longer edentulous span should be
restored with RPDs, as it is stabilized and supported by the teeth
present on the opposite side of the arch and by the residual ridge.
This cross-arch stabilization considerably reduces the harmful
leverage and torquing forces onto the abutment tooth/teeth.

• No distal abutment

• Cross-arch stabilization: In cases where the remaining teeth are

periodontally compromised, bilateral cross-arch stabilization is
required to resist harmful torquing and lateral forces.
• Questionable periodontal status of the remaining teeth

• Excessively resorbed residual ridges

• Immediate replacement after extraction: Soon after extraction, it is

best to replace with a provisional RPD which can be relined over a
period of time as resorption occurs.

• Aesthetic reason: In cases of multiple missing anterior teeth, it is

better to replace with RPD to provide better aesthetics. The denture
teeth can provide life-like natural appearance in comparison to the
pontics of fixed denture which appears flat and dull. Moreover, the
denture base can be characterized for an individual patient to
enhance aesthetics.

• Patient’s preference: Sometimes patients prefer and insist on

removable prosthesis. This is due to the following reasons:

• The patients want to avoid preparation of the sound

healthy tooth

• Cost involved
• Patient’s physical or emotional condition: The patients with
physical or emotional problems find it difficult to undergo lengthy
procedures involved in fixed treatment and, therefore, prefer RPD
which can be completed in much shorter time.

• Age of the patient: Fixed prosthodontic treatment is avoided in a

young patient because of the large pulp horns and lack of clinical
crown height. In a very old patient, reduced life expectancy
contraindicates fixed treatment.

Contraindications
• Patient’s mental health: It is avoided in mentally retarded patient
with reduced dexterity.

• Poor oral hygiene: Success of any prosthodontic treatment will be

questionable in such patients.

• Large tongue: Displacement tendency of removable denture is high.

• Medical condition: RPD should be given with caution to patient

prone to epileptic attack.
Classification of partially edentulous
arches
There is a definite need to classify partially edentulous arches so as to
aid in proper diagnosis and treatment planning.
The classification should be used because of the following reasons:

• It helps in proper diagnosis and treatment planning.

• It helps to communicate with the technician or professional.

• It helps to anticipate complexity of the treatment.

• It helps to formulate the best treatment for the patient according to

the given individual condition.
Requirements for an acceptable classification are as follows:

• It should be universally acceptable.

• It should allow visualization of the type of partially edentulous

arch.

• It should permit differentiation between the tooth-supported or

tooth tissue-supported cases.

• It should provide guidance on the type of design to be used.

Kennedy’s classification and Applegate’s

modification

Kennedy’s classification
• This is the most commonly used classification.
• It was originally proposed by Dr Edward Kennedy in 1925.

• The original classification consists of four classes and applies to

most of the partially edentulous arches.

• It is simple, logical and the widely accepted classification.

• However, it cannot quantify the amount of support for the tooth-borne

or tooth tissue-borne cases.

• Edentulous areas, other than those determining the classification,

are described as modification spaces.

Kennedy’s classification has following four classes:

Class I: Bilateral edentulous areas located posterior to the remaining
natural teeth (Fig. 14-1)
Class II: Unilateral edentulous area located posterior to the
remaining natural teeth (Fig. 14-2)
Class III: Unilateral edentulous area with natural teeth located both
anterior and posterior to it (Fig. 14-3)
Class IV: Single, bilateral edentulous area located anterior to the
remaining natural teeth such that it crosses the midline (Fig. 14-4)
Any additional edentulous area is referred to as modification space.
FIGURE 14-1 Kennedy class I.

FIGURE 14-2 Kennedy class II.

FIGURE 14-3 Kennedy class III.
 FIGURE 14-4 Kennedy class IV.

Applegate’s modifications
• Dr O.C. Applegate modified Kennedy’s classification by adding two
more classes to it.

• However, acceptance of this modification has not been universal.

Class V: Edentulous area bounded by natural teeth both anterior and

posterior to it but the anterior abutment is not suitable for support
(Fig. 14-5)
Class VI: Teeth adjacent to the edentulous space are capable of
providing complete support to the prosthesis
 FIGURE 14-5 Kennedy Applegate’s class V.

Applegate’s rules for applying Kennedy’s classification

Rule 1: Classification should follow rather than precede the extraction of

teeth that might alter the original classification.

Rule 2: If the third molar is missing and is not to be replaced, it is not

considered in the classification.

Rule 3: If the third molar is present and is to be used as abutment, it is

considered in the classification.

Rule 4: If the second molar is missing and is not to be replaced because

of the missing opposing tooth, it is not considered in the
classification.
Rule 5: The most posterior edentulous area or areas always determine the
classification.

Rule 6: Edentulous areas, other than those determining the

classification, are referred to as modification spaces and are
designated by their number.

Rule 7: Extent of modification is not considered, but only the number of

additional edentulous area is considered.

Rule 8: Class IV does not have any modification areas.

Commonly used classification for partially

edentulous arches
Apart from the Kennedy’s classification, some of the most commonly
used classifications are given below.

W. Cummer’s classification
• This classification was proposed in 1920 and is the first to be
recognized.

• This is a classification based on the position of the direct retainers.

Class I: Diagonal, two direct retainers are diagonally opposite to each

other (Fig. 14-6)
Class II: Diametric
Class III: Unilateral, two direct retainers are present on the same side
Class IV: Bilateral, three direct retainers in triangular configuration or
four direct retainers in quadrilateral configuration (Fig. 14-7)
FIGURE 14-6 Cummer’s class I: two direct retainers
diagonally opposite.
 FIGURE 14-7 Cummer’s class IV: three direct retainers
present bilaterally.

M. Bailyn’s classification (1928)

This classification is based on the type of support. Bailyn called the
edentulous area saddle area.
Anterior restorations had saddle areas anterior to the first premolar
and posterior restorations had saddle area posterior to the canine.
Class I: Bounded saddle (less than three teeth missing)
Class II: Free-end saddle (edentulous posterior spaces)
Class III: Bounded saddle (more than three teeth missing)

F. Neurohr’s classification (1939)

It is a complex classification which is not currently used.
E. Mauk’s classification (1942)
This classification is based on the following characteristics:

• Number, length and location of the edentulous spaces

• Number and position of the remaining teeth

Class I: Bilateral posterior edentulous spaces

Class II: Bilateral edentulous spaces with teeth/tooth present
posterior to one of the spaces
Class III: Bilateral edentulous spaces with teeth/tooth present
posterior to both the spaces
Class IV: Unilateral edentulous space without any tooth posterior to
it
Class V: Anterior edentulous space with unbroken posterior arches
on both sides
Class VI: Irregular edentulous spaces in the arch

R.J. Godfrey’s classification (1951)

This classification is based on the location and extent of the edentulous
spaces in the arch.
Class I: Tooth-supported denture base in the anterior part of the
mouth (e.g. broken five-tooth space or unbroken four-tooth space)
Class II: Tissue-supported denture base in the anterior region (e.g.
unbroken six-tooth space)
Class III: Tooth-supported denture base in the posterior region (e.g.
unbroken three-tooth space)
Class IV: Tissue-supported denture base in the posterior region (e.g.
unbroken four-tooth space)

J. Friedman’s classification (1953)

This classification is based on the boundaries of the spaces.

A: Anterior tooth-bound space

B: Bounded posterior space

C: Cantilever or posterior free end

L.S. Beckett’s and J.H. Wilson’s classification

(1957)
This classification is based on Bailyn’s classification and considers the
amount of support provided by the teeth and the tissue.
Class I: Tooth-borne saddle
Class II: Tooth- and tissue-borne saddle and totally tissue-borne
saddle
Class III: Inadequate tooth support and inadequate tissue support for
the saddle

F.W. Craddock’s classification (1954)

Class I: Saddles supported on both the sides with adequate number
of abutment teeth
Class II: Mucosa supported
Class III: Tooth supported only at one end of the saddle

Sequential phases in treating a partially

edentulous patient with removable prosthesis
When treating a partially edentulous patient with a removable
prosthesis, the treatment should be carried out sequentially in five
phases. These phases are:

Phase 1 (educating the patient): The patient should be educated about

the benefits and limitations of the treatment with removable
prosthesis. Patient education is essential and should start at the first
contact and should continue throughout the treatment. It is
important to educate the patient about the maintenance of oral
hygiene and care of the prosthesis.
Phase 2 (diagnosis, treatment planning, design considerations and
mouth preparation): With the help of medical and dental history of
the patient, complete oral examination including clinical and
radiographic evaluation is done. Mounted cast is helpful in
diagnosis and treatment planning. Surveying of the diagnostic cast
is absolutely essential in treatment planning. Once the type of the
prosthesis is planned, mouth preparation is performed.

Phase 3 (obtaining support for distal extension cases): The soft tissue
is recorded in functional form. To obtain adequate support,
corrected impression techniques and fabrication of the altered cast
may be necessary.

Phase 4 (establishments and verification of the occlusal relations

and teeth arrangement): Jaw relation is recorded after successfully
verifying the fit of the cast partial framework in the mouth. Proper
occlusal relationship and teeth arrangements are important steps in
construction of the partial dentures.

Phase 5 (initial placement procedures): Occlusal harmony is ensured,

minor processing errors are corrected. Functional reline of the
denture base is done in cases of distal extension bases. Postinsertion
instructions are given to the patients.

Key Facts
• Maxillary first molar is the most commonly missing tooth in
permanent dentition.

• The primary objective of the partial dentures is to preserve those

tissues that remain in a state of health.

• Removable partial denture is best suited for patient with high caries
index and having poor oral hygiene.

• Displaceability of mucoperiosteum is 2.0 mm and that of

periodontal ligament is 0.25 ± 0.1 mm.
CHAPTER
15
Diagnosis and treatment
planning

CHAPTER OUTLINE
Introduction, 232
Objectives of Prosthodontic Treatment for a Partially Edentulous
Patient, 233
Importance of Medical Condition of Patient before Oral
Examination, 233
Diagnostic Cast and Its Importance, 233
Mounted Diagnostic Casts as Fundamental
Diagnostic Aids in Dentistry, 234
Importance of Radiographs in Removable Prosthodontics, 235
Radiographic Evaluation of the Abutment
Tooth, 235
Bone Index Area, 235
Periodontal Evaluation of Partially Edentulous
Patients, 236
Splinting and Its Role in Prosthodontics, 237
Definition, 237
Removable Splinting, 237
Fixed Splinting, 237
Indications, 237
Contraindication, 238
Requirements of Splints, 238
Objectives of Splinting, 238
Advantages of Splinting, 238
Disadvantages of Splinting, 238
Removable Permanent Splints, 239
Introduction
Thorough diagnosis and sequential treatment plan are essential for
successful removable partial denture treatment. Diagnostic
information is obtained after considering patient information, clinical
examination, radiographic analysis, diagnostic models and
preliminary survey of the casts. On the basis of these key elements of
diagnosis, partial denture design is established and treatment
planning is done.
Clinical diagnostic procedure for partially edentulous patient is
similar to that of completely edentulous patients, which is already
discussed in Chapter 2. In this chapter, we have focussed on
additional diagnostic and treatment options and their importance.
Objectives of prosthodontic treatment
for a partially edentulous patient
The objectives of prosthodontic treatment for a partially edentulous
patient:

• To eliminate the disease

• To preserve the remaining teeth and oral tissues in a healthy state

• To improve or establish the masticatory efficiency

• To develop and restore aesthetics

• To maintain or improve the phonetics

Importance of medical condition of
patient before oral examination
It is very important to assess the general health of the patient before
performing the oral examinations. The patient should be asked to
complete the health questionnaire. Any positive response should be
thoroughly investigated during the interaction with the patient. Vital
stats, such as the measurement of blood pressure, pulse and
respiratory rate should be examined. The symptoms, manifestations
and prognosis of the disease should be evaluated. It is important to
determine the effect such diseases will have on the prosthodontic
treatment. If in doubt, the patient’s physician should be consulted.
Some of the systemic conditions that may have significant effects on
the prosthodontic treatment are:

1. Diabetes: Those who are suffering from uncontrolled diabetes may

have high sugar levels with multiple oral abscesses and poor tissue
tone. In these cases:

• The patients are more prone to infection.

• The patients have reduced salivary flow which may

reduce their ability to tolerate the removable
prosthesis.

Caution: Uncontrolled diabetes should be brought

under control before prosthodontic treatment.
2. Arthritis: Patients with arthritis may show changes in the
temporomandibular joint (TMJ). In these cases, it would be difficult to
record proper jaw relation.
3. Parkinson disease: The disease is characterized by rhythmic
contractions of the musculature, including muscles of mastication. In
such cases:

• The patient has excess salivation and poor dexterity.

• It is difficult to make impressions and record jaw

relation.
4. Pemphigus vulgaris: This disease is characterized by the formation
of bullae in the oral cavity. The disease results in dryness of the mouth
and painful ulcers in the oral cavity. As a result, it is difficult for the
patient to tolerate the prosthesis.

Treatment: The disorder can be controlled with

medication and the prosthesis should be highly
polished with smooth contours of partial denture.
5. Epilepsy: In case of epilepsy, fabrication of partial dentures is
contraindicated, if the patient reveals a history of frequent seizures.

• If epilepsy is controlled, then prosthesis can be

given but with caution.

• The prosthesis should be made of radio-opaque

material.

• Medical consultation is a must before starting

treatment.
6. Cardiovascular disease: Medical consultation is a must and a
written approval should be obtained.

Caution:

• Prophylactic antibiotics are recommended before

starting any treatment.

• If such patients are not handled with caution, there

can be a medical emergency.
Diagnostic cast and its importance
Diagnostic cast is defined as ‘a life size reproduction of a part or parts of
the oral cavity and/or facial structures for the purpose of study and treatment
planning’. (GPT 8th Ed)
A diagnostic cast is an accurate reproduction of teeth and adjacent
structures, which aids in proper diagnosis. It is made up of dental
stone and usually an alginate impression is made to record the details
in the oral cavity. It plays an important role in proper diagnosis and
treatment planning of partially edentulous patient.
Importance of Diagnostic Cast (Figs 15-1 and
15-2)
• It permits analysis of soft tissue and hard tissue contours in the
mouth.

• It permits visualization of the occlusal contact from both the buccal

and the lingual aspects.

• It helps to determine the type of restoration to be placed.

• It helps to identify and locate the deflective occlusal contact.

• It helps to determine the need for surgical correction of bony

exostosis, high frenal attachment, bulbous tuberosity and severe
undercuts.

• It can be surveyed and the proposed design of the prosthesis can be

drawn on the cast.

• It is helpful in the patient education.

• Interarch space can be evaluated on the mounted casts on the

articulator.
• It helps in visualization of the occlusal plane and tooth migration
that may require correction before fabrication of the prosthesis.

FIGURE 15-1 Section of maxillary diagnostic cast.

FIGURE 15-2 Section of mandibular diagnostic cast.

Mounted diagnostic casts as fundamental

diagnostic aids in dentistry
Mounted diagnostic casts are indeed an important aid for proper
diagnosis and treatment planning of partially edentulous patients.
The casts accurately mounted on the articulator help in proper
visualization of the occlusion, location and position of the remaining teeth
(Fig. 15-3).
 FIGURE 15-3 Mounted diagnostic casts.

Objective of diagnostic mounting

The objective of diagnostic mounting is to position the cast on the
articulator in the same relationship as the mandible to maxilla in the
patient’s skull.
Importance of Diagnostic Mounting
• To analyse and visualize the occlusion of the patient from all
possible directions

• To study the position, location of the teeth, interarch space and any
deflective occlusal contact

• To analyse the soft tissue and hard tissue undercut

• To help in educating the patient about the treatment plan

• To provide permanent record of the oral condition before treatment

Importance of radiographs in
removable prosthodontics
Radiographic examination should always be used with the clinical
findings to determine the existence of pathology in the oral cavity
with special attention to the abutment tooth and the residual ridge. It
is one of the most important diagnostic tools.
Rationale of Radiographic Examinations
• To determine the presence and the extent of caries, and the relation of
carious lesions to the pulp and the periodontal ligament

• To evaluate the quality and quantity of the alveolar bone

• To locate the area of infection and other pathosis that may be present

• To evaluate the existing restorations for recurrent caries, marginal

leakage and overhanging restorations

• To evaluate the alveolar support of the abutment teeth, their number,

crown-to-root ratio and morphology of the roots

• To determine the presence of root fragments, bony spicules and irregular

residual ridge formations

• To evaluate the alveolar support of the prospective abutment

• To permit an evaluation of periodontal conditions and to establish

the need and possibility for treatment

Radiographic evaluation of the abutment tooth

• Multirooted teeth with long divergent roots are more favourable
abutment teeth than single-rooted teeth.
• Crown-to-root ratio can be determined with radiographs by using
long cone paralleling technique.

• Changes in the lamina dura reveal the prognosis of the abutment

teeth.

• Absence of lamina dura indicates periodontitis.

• Thinning of the dural space indicates periodontal disease.

• Uninterrupted lamina dura indicates a good prognosis of the

abutment teeth.

• Thickening of the lamina dura indicates tooth mobility, occlusal

trauma and heavy function.

Bone index area

Bone index areas are those areas on the alveolar bone that are
subjected to greater force than normal.

• Positive bone factor: Alveolar bone which can favourably react to

additional stress. Responses in favour of the positive bone factor are
dense lamina dura, dense cortical bone, normal bone height, normal
periodontal ligament space and supportive trabecular pattern (Fig.
15-4).

• Negative bone factor: This is characterized by bones that respond to

stress unfavourably, prone to resorb rapidly under occlusal force
and such abutment teeth provide poor bone support (Fig. 15-5).
 FIGURE 15-4 Schematic diagram showing positive bone
factor.

FIGURE 15-5 Schematic diagram showing negative bone

factor.

Periodontal evaluation of partially edentulous

patients
Most of the partially edentulous patients have evidence of gingivitis
and periodontal disease. Such periodontal disease needs treatment
before a prosthodontic restoration can be done. The health of the
periodontium of the remaining teeth should be thoroughly and
systematically evaluated. This can be done as follows:

• By observing the colour, texture and architecture of the gingiva

• The presence of periodontal pocket is detected by using a calibrated

probe

• By observing the presence of cervicular exudates using digital

pressure or probing techniques

• By determining the width of the attached gingiva

• By observing any tension placed on the attached gingiva by the

muscle or frenal attachment

• By complete radiographic examinations

Signs and symptoms of periodontal disease

• Periodontal pocket depth greater than 3 mm

• Furcation involvement

• Change in colour and contour of gingiva

• Presence of cervical marginal exudates

• Tension of the attached gingiva by muscle or frenum

• Width of the attached gingiva less than 2 mm

Any sign of the presence of periodontal disease will require

treatment before prosthodontic intervention. If the abutment tooth is
periodontally weak, it should be critically evaluated. The causative
factors should be eliminated and the progression of the disease should
be reversed to consider a tooth a ‘prospective abutment’. Several
treatment options are available to restore the abutment tooth to
optimum health. Some of the available treatment options are:

• Root scaling and root planning

• Gingivectomy

• Periodontal flap procedures

• Free gingival graft to provide adequate width to the attached

gingiva
Splinting and its role in prosthodontics
Definition
Splinting is defined as ‘the joining of two or more teeth into a rigid unit by
means of fixed or removable restorations or device’. (GPT 8th Ed)
Splint is defined as ‘a rigid or flexible device that maintains in position a
displaced or movable part’. (GPT 8th Ed)
There are two types of splinting, namely, removable splinting and
fixed splinting.

Removable splinting
• It is helpful in stabilizing the periodontally compromised teeth by
removable means.

• Mobility of the teeth with removable splinting is either decreased or

remains the same.

• The philosophy behind removable splinting is broad stress

distribution.

• It consists of rigid major and minor connectors with multiple clasps and
rests.

• Lateral movement of the weakened teeth is minimized by

appropriate reciprocation.

• Periodontally compromised teeth are rigidly supported not only

during the functioning of prosthesis but also during the removal of
prosthesis.

• Splinting using clasps is done when no other approach is feasible. It

is done by clasping one or more teeth in the arch by multiple rests
and guiding the planes for stabilization of the prosthesis and the
 teeth.

• The main advantage of removable splinting is to provide cross-arch

stabilization.

• Swing-lock partial dentures can be used effectively to splint remaining

teeth.

Fixed splinting
• It is accomplished by giving full veneer crowns splinted together
with the adjacent teeth.

• Pin-ledge restorations can also be used for splinting.

• Splinting of two or more teeth increases the periodontal ligament

area and thus helps to distribute the stresses over the wider surface
area.

• Splinting using crowns helps in stabilizing the abutment teeth in the

anteroposterior direction and not in the buccolingual direction.

• For a splint to stabilize in the buccolingual direction, it should

extend around the curve of the arch.

• To resist the lateral forces, cross-arch stabilization is required, which

can be provided by a rigid major connector.

Indications
• In cases where there is loss of attachment due to periodontitis.

• In case of short or tapered single-rooted tooth which is a proposed

abutment tooth, splinting with the adjacent tooth can in effect
produce a multirooted abutment tooth.
• In cases of pier abutment, where usually the bicuspid is splinted to
the stronger anterior tooth such as canine by fixed partial denture.

Contraindication
Extremely weak abutment tooth should not be splinted with strong
tooth. This will actually weaken the stronger tooth.
Types of Splints
According to Ross, A. Weisgold and A. Wright, splints are classified
on the basis of the duration of use.

(i) Temporary stabilization

• Removable extracoronal splints

• Fixed extracoronal splints

• Intracoronal splints

• Etched metal resin-bonded splints

(ii) Provisional stabilization

• Acrylic splints

• Metal band and acrylic splints

(iii) Long-term stabilization

• Removable splints

• Fixed splints
• Combination of removable and fixed splints

Requirements of splints
• These should be simple and cost-effective.

• These should be stable and efficient.

• These should be nonirritating and hygienic.

• These should not interfere with the treatment.

• These should be aesthetically acceptable.

• These should not require any excessive tooth cutting or preparation.

• These should not interfere with speech and function.

• These should be less bulky.

Objectives of splinting
• To reduce mobility and distribution of forces to number of teeth

• To prevent tooth migration, food impaction and supraeruption

• To improve masticatory function and aesthetics

• To eliminate pain and discomfort

• To stabilize the proximal contact

• To improve the appearance

• To provide a favourable environment for healing of the tissues

Advantages of splinting
• Immobilization with splinting permits undisturbed healing.

• Functional forces are redistributed to number of teeth.

• Splinting redirects the forces more axially over all the teeth included
in the splint.

• It restores integrity of the arch by restoring the proximal contact of

the teeth.

• It restores the functional stability.

• It ensures psychological well-being.

Disadvantages of splinting
• It is difficult to do any extensive restorative procedure.

• It is difficult to achieve marginal adaptation, good contour or

functional occlusion.

• To have a common path of insertion, additional tooth reduction may

be required.

• It poses difficulty in plaque removal.

Classification of Permanent Splints

According to D.A. Grant, J.B. Stern and M.A. Listgarten, permanent
splints are classified as follows:

(i) Removable (external)

Continuous clasp devices

Swing-lock devices
Overdentures (full or partial)
(ii) Fixed (internal)

Full coverage, three-fourths coverage crowns and

inlays

Posts in root canals

Horizontal pin splints

(iii) Cast metal resin-bonded fixed partial denture (Maryland splints)

(iv) Combined

Partial dentures and splinted abutments

Removable fixed splints

Full or partial dentures on splinted roots

Fixed bridges incorporated in partial dentures seated

on posts or copings

Removable permanent splints

Continuous clasp devices

• Removable permanent devices incorporate continuous clasps and
fingers that brace loose teeth.

• These usually provide support from the lingual surface and may
 incorporate additional support from the labial surface or using
intracoronal rests.

• Palatal bars may be added to provide cross-arch splinting effect.

• Some may use pins that fit into the grooves or holes in inlays.

Swing-lock devices
• Cosmetic disadvantages of labial continuous clasping can be
overcome by the use of swing-lock appliances which tend to hide
the metal of the splint and avoiding torque on the teeth.

• These are used in situations where the fixed splinting is not possible
or desirable.

• These are indicated when remaining teeth are too mobile to be used
as abutment or their position is not favourable for the conventional
design.

Overdentures
• When there are few teeth with questionable prognosis, overdenture
may be indicated.

• Few remaining teeth that may be periodontally weak can still be

used as abutment for overdenture, if they are strategically located in
the arch.

• Retaining the teeth preserves bone and preserves proprioception.

• This also improves the function and the patient acceptability.

Key Facts
• Stability is the most important quality of the partial denture.
• Kennedy class IV has no modification spaces.

• Contingency design of partial denture refers to a transitional

denture. If a tooth with questionable prosthesis is removed, that
tooth is added in the existing denture.
CHAPTER
16
Components of removable partial
denture

CHAPTER OUTLINE
Introduction, 241
Components of Removable Partial
Denture, 241
Major Connectors, 241
Minor Connectors, 250
Internal and External Finish Lines in Relation to Minor
Connectors, 251
Internal Finish Line, 251
External Finish Line, 252
Rests and Rest Seat, 252
Definition, 252
Functions of Rests, 252
Types of Rests Used in Partial Dentures, 253
Direct Retainers and Intracoronal Retainers, 254
Definition, 254
Intracoronal Retainers, 254
Clasp Assembly, 254
 Definition, 254
Requirements of the Clasp Assembly, 255
Circumferential Clasp, 255
Definition, 255
Types of Circumferential Clasp, 257
Gingivally Approaching Clasp, 260
Definition, 260
Design Features, 260
‘T’ Clasp, 261
Modified ‘T’ Clasp, 262
‘Y’ Clasp, 262
‘I’ Clasp, 262
‘I’ Bar, 262
RPI and RPA Concept, 262
RPI Concept, 262
RPA Concept, 263
Indirect Retainers and Their Importance in Distal Extension
Cases, 264
Definitions, 264
Rationale, 264
Indirect Retainers in Distal Extension
Cases, 265
Factors Influencing the Effectiveness of the
Indirect Retainers, 265
 Types of Indirect Retainers, 265
Denture Base and Functions of Distal Extension Partial Denture
Base, 266
Definition, 266
Purpose of Denture Base, 266
Requirements of Ideal Denture Base, 266
Functions of Distal Extension Partial Denture
Design, 266
Metal Denture Base, 267
Anterior Teeth Replacement, 267
Posterior Teeth Replacement, 267
Introduction
Components of removable partial denture
Removable partial dentures (RPDs) consist of the following parts:

• Major connectors

• Minor connectors

• Rests

• Direct retainers

• Indirect retainers

• Denture base

Major connectors

Definition
Major connector is defined as ‘a part of removable partial denture which
connects the components on one side of the arch to the components on the
opposite side of the arch’. (GPT 8th Ed)
All the remaining components of the partial denture should join the
major connectors directly or indirectly. All major connectors should
fulfil certain requirements, which are described below.

Ideal requirements of major connectors

• Major connectors should be rigid, as it allows the functional stresses
to be effectively distributed over the supporting areas and the
abutment teeth.
• These should vertically support and protect the soft tissues.

• These should provide means for attaching indirect retainers whenever

required.

• These should be comfortable to the patient.

• These should be easily cleanable and should not lodge food

accumulation.

Desirable features of major connectors

• Major connectors should never terminate on the highly vascular gingival
tissues, as they are susceptible to trauma from pressure.

• In the maxillary arch, the border of the major connectors should be

at least 6 mm from the gingival margin of the teeth.

• In the mandibular arch, the border of the major connectors should

be at least 3 mm from the gingival margin of the teeth.

• The border of the major connectors should be round and parallel to

the gingival margin.

• If the gingival margin needs to be crossed, it should cross at right

angle to produce least contact with the soft tissues.

• Adequate rests are provided so that the major connectors are

prevented from transmitting harmful horizontal or lateral forces.

• Anterior border of the maxillary major connectors should always

end in the valleys of the rugae and not on the crest of the rugae.

• Metal extensions from major connectors should lie in the embrasure

space in order to disguise the metal thickness.

• These should be made symmetrical and should cross the palate in a

 straight line whenever possible.

• These should be designed in such a way that its margins do not cross
the bony prominences such as tori or soft tissue prominences.

• These should have support from other components of the framework

to minimize rotation of the prosthesis during function.

• These should be made of the alloy which is biocompatible.

• These should not interfere with the patient’s speech.

Beading of maxillary cast

Beading of the maxillary cast means to scribe or indent a shallow groove
on the maxillary cast before duplication.
Rationale
It is done to:

• Provide an excellent visible finish line.

• Provide intimate tissue contact and prevent collection of food particles

below the framework.

• Provide scope to the technician to reduce metal thickness on the

polished side in this area without compromising on the strength.

• Transfer major connector design to the investment cast.

The beading of the cast is accomplished with a spoon excavator and

has depth and width of 0.5–1.0 mm each. Depth of the beading varies
where the mucosal covering is thin such as over the midpalatal raphe
or the torus region. Beading should be 6 mm (minimum) away from the
gingival margin. When the denture is removed from the mouth, the
outline of the beading should be visible on the palatal tissue but there
should be no sign of inflammation. The intimate contact of the metal
major connector and the palatal tissue enhances the retention and
stability of the prosthesis.

Designing of maxillary major connector

L. Blatterfein (1953) described five steps which should be followed
while designing maxillary major connectors. Primary impression is
made to form diagnostic casts and the displaceability of the palatal
tissues is thoroughly assessed.
Steps in designing are as follows:

Step 1: Outline primary bearing areas on the diagnostic cast. The

primary bearing areas are those that are covered by the denture
base.

Step 2: Outline nonbearing areas on the cast. Nonbearing areas include

lingual gingival tissues within 5–6 mm of the teeth, midpalatal
raphe, palatal torus, tissues posterior to the posterior vibrating line.

Step 3: Outline the connector area.

Step 4: This step involves selection of the type of major connectors. The
selection depends on four factors namely rigidity, area of denture
base, indirect retention and patient’s comfort. Connectors should be
rigid so as to distribute functional stresses and should have
minimum bulk. Need for indirect retention influences the outline of
the major connectors.

Step 5: Unification – joining of the denture base and the connectors.

Types of maxillary major connectors

(i) Single posterior palatal bar

(ii) Single palatal strap

(iii) Anteroposterior or double palatal bar

(iv) Horseshoe- or U-shaped connectors

(v) Closed horseshoe or anteroposterior palatal strap

(vi) Complete palate

Single posterior palatal bar (fig. 16-1)

• It is a narrow and half oval-shaped bar which is thickest in the centre.

• The bar is gently curved and its width is less than 8 mm.

• Sharp angles are best avoided at the junction of the palatal bar and
the denture base.

FIGURE 16-1 Single palatal bar.

Indications
• It is used to fabricate interim partial denture.

• It is used to replace one or two teeth on either side of the arch.

Disadvantages

• It is not adequately rigid because of narrow width.

• It derives little vertical support from the hard palate.

• It can interfere with tongue function.

• It is not used in distal extension cases and for replacing anterior

teeth.

Single palatal strap (fig. 16-2)

• Its width is more than 8 mm.

• It consists of thin wide band of metal.

• The width is increased as the edentulous span is increased.

• Sufficient rigidity is obtained using a 22-gauge plastic pattern.

 FIGURE 16-2 Palatal strap.

Indications

• Bilateral or unilateral tooth-supported edentulous span (class III

cases).

• Sometimes, wide palatal strap can be used for unilateral distal

extension partial denture (class II).

Advantages

• It has good rigidity and it resists torquing and bending stresses.

• It can be kept in thin sections without compromising rigidity.

• It results in enhanced patient comfort.

• It distributes stresses over a wide surface area.

Disadvantages

• Soft tissue reaction may lead to papillary hyperplasia.

• Some patients may complain of excessive palatal coverage.

Anteroposterior or double palatal bar (fig. 16-3)

• It has an excellent rigidity due to strong L-beam effect (two bars

which lie in two different planes produce structurally strong L-
beam effect).

• Anterior strap is flat, located just posterior to the rugae region and is
narrower than the posterior strap.

• Posterior strap is thin and is at least 8 mm wide, located on the hard

palate.

• Lateral straps or bars are narrow. These are often 7–8 mm wide.

• This type of connector is used when the periodontal support of the

remaining teeth is good.
 FIGURE 16-3 Anteroposterior major connector.

Indications

• In class I and class II situations with healthy abutment and good

ridge support.

• Connector of choice in cases of large midpalatal maxillary tori.

• It can be used in most of the partial denture situations.

Advantages

• It has an excellent rigidity.

• It is a patient’s preference, as it has less palatal coverage.

Disadvantages

• It derives less vertical support because of limited palatal coverage.

• It cannot be used in cases where the remaining teeth are
periodontally compromised.

• It should not be used in cases of high narrow vault, as the anterior

bar interferes with speech.

• The patient may complain of discomfort in the anterior region.

Horseshoe-shaped or U-shaped connectors (fig. 16-4)

• These consist of a thin band of metal extending along the lingual

slope of the posterior teeth onto the palatal tissues.

• The metal covers the cingula of the teeth and extends onto the palate
to entirely cover the rugae region.

• Borders of the connectors should be either 6 mm from the gingival

margin or extend onto the lingual surface of the teeth.

• All borders should be curved and well rounded.

 FIGURE 16-4 Horseshoe-shaped or U-shaped major
connector.

Indications

• In case of class IV situations

• In cases on inoperable tori extending onto the soft palate

• In cases of hard median suture

Advantages

• These can derive little vertical support.

• In patients with large overbite, this connector can be suitable to

support the replacement teeth even in thin sections.

Disadvantages

• The connector has a tendency to spread apart when vertical force is

applied.

• These are not used in distal extension cases.

• The patient may complain about speech problems.

Closed horseshoe or anteroposterior palatal strap (fig. 16-5)

• It is rigid and has adequate strength.

• It can be used in most of the partial denture situations.

• It is mostly used when there are large maxillary tori with more
number of teeth missing.

• Border of the connector is kept 6 mm from the free gingival margin.

• It should be ensured that the borders are made smooth and
polished.

FIGURE 16-5 Closed horseshoe-shaped major connector.

Advantages

• It is rigid and derives good vertical support from bony palate.

• It resists torquing and bending stresses better, as it provides L-beam

effect.

Disadvantages
• Interference with speech

• Patient’s discomfort

Complete palate (fig. 16-6)

• This provides excellent support, rigidity and retention.

• The anterior border is kept 6 mm away from the gingival margin or

should cover the cingula of all anterior teeth.

• There are three designs for this type of connector, which are as
follows:

(i) All acrylic resins: Connectors are made entirely

of acrylic.

(ii) Combination of cast metal and acrylic resin:

Anterior portion of the denture is made up of
metal and the posterior portion of the denture is
constructed of acrylic resin.

(iii) All cast metal: Entire palate is covered with

thin metal casting.
 FIGURE 16-6 Complete palate.

Indications

• In class I and class II situations

• In cases of missing anterior as well as bilateral edentulous spaces

• In cases of poor ridge support or flabby tissues

• Long edentulous span

• When opposing all mandibular teeth are present

• Cleft palate cases with a high-arched palate

Advantages

• Excellent rigidity and support

• In cases of metal base, better perception of temperature changes

Disadvantages

• Speech interference

• Chances of papillary hyperplasia

Mandibular major connectors

Mandibular major connectors are one of the essential components of
mandibular partial denture. Unlike the maxillary major connectors,
mandibular connectors have limitation of space due to height of the
floor of the mouth, vestibular depth, location of the lingual frenum or
presence of tori.

Desirable features of mandibular major connectors

• Rigidity of the major connector is the most important requirement.

• Relief is routinely required between the mandibular major

connectors and the mucosa.

• Amount of relief required is determined by the type of RPD and the

lingual slope of the residual ridge.

• Minimum relief is given in tooth-supported partial denture,

whereas considerable relief is given in distal extension cases.

• If the lingual slope of residual ridge is almost vertical, minimum

relief is provided and if it slopes towards the tongue horizontally,
greater relief is required.

• In mandibular major connectors, beading is never given.

Mandibular major connectors

There are commonly five types of mandibular major connectors,
which are as follows:

(i) Lingual bar

(ii) Sublingual bar

(iii) Lingual plate

(iv) Kennedy’s bar or double lingual bar or continuous bar

(v) Labial bar

Lingual bar (fig. 16-7)

• This is the most commonly used mandibular major connector.

• It is half pear-shaped in cross-section with the bulkiest portion placed

at the inferior border of the bar whereas the superior border is
tapered to the soft tissues.

• Thickness of the bar is 6 gauge half pear-shaped wax or plastic

pattern to ensure adequate rigidity.

• A minimum of 8 mm vertical space (space between the gingival

margin of the tooth and the active tissues of the floor of the mouth)
is required for the fabrication of lingual bar.

• The minimum thickness of lingual bar is 5 mm and the remaining 3

mm of space is essential to be left between the gingival margin and
superior border of the bar.

• Active vertical space is best determined using a periodontal probe

when the patient is asked to protrude the tongue and make
functional movements.

• Lingual bar should be fabricated as inferior as the patient can

 tolerate, as this increases the amount of space available for the
lingual bar.

FIGURE 16-7 Lingual bar.

Indication

• For all partial denture designs, if adequate vertical space is

available.

Advantages

• As there is no contact with the teeth, no decalcification of tooth

surface takes place.

• It is the simplest design with ease of fabrication.

• It results in minimal tissue contact.

Disadvantages

• It is not used in cases with mandibular tori.

• It cannot be used where the vestibular depth is less.

• Insufficient available space can result in fabrication of flexible

lingual bar.
Sublingual bar

• It is a modification of the lingual bar, as it is located more inferiorly

and is horizontally placed over the anterior floor of the mouth.

• Specialized impression is needed to record the depth and width of

the sulcus.

Indications

• It can be used along with lingual plate in the presence of anterior

lingual undercut.

• In cases where the lingual sulcus is shallow or the available vertical

space is less than 6 mm.

Contraindications

• In case of tori

• High lingual frenum

• Severe lingual tilt of remaining anterior teeth

• Decreased active vertical space

Lingual plate (fig. 16-8)

• It has same basic design as the pear-shaped lingual bar with an

added feature of thin metal plate extending onto the lingual surface
of the anterior teeth.

• Adequate relief is provided for soft tissue and bony undercuts.

• Also, the free gingival margin and the sulcus area should be
adequately relieved.

• Lingual plate has a scalloped design with the metal margin covering
 the entire embrasure space extending up to the contact area.

• Chrome metal is the most preferred material for this type of

connector, as it can be used in thin sections.

• In cases of diastema between anterior teeth, cut backs or step back is

given in the design so as to hide the metal covering the cingula.

FIGURE 16-8 Lingual plate.

Indications

• In class I situation when there is excessive resorption of the residual

ridges

• When remaining teeth are periodontally compromised and require

splinting
• When there is insufficient space for the lingual bar

• Presence of mandibular tori

• When additional indirect retention is required

• Future replacement of one or more anterior teeth

Advantages

• This is the most rigid mandibular major connector.

• It provides maximum support and stabilization.

• It helps in stabilizing periodontally compromised dentition.

• It prevents overeruption of mandibular anterior teeth.

• It has a better patient acceptability.

Disadvantage
Chances of decalcification of tooth surface due to extensive coverage
of the teeth and soft tissues are there.

Double lingual bar or Kennedy’s Bar or ccontinuous Bar (fig. 16-

9)

• It differs from the lingual plate in that there is no metal extension

below the superior margin of the plate and the lingual bar, thereby
exposing the lingual surface of the teeth and the interproximal soft
tissues.

• It consists of a pear-shaped lingual bar attached to the thin metal bar

which is half oval in cross-section and is 2–3 mm high and 1 mm
thick at the greatest diameter.

• In case of diastema between anterior teeth, step back design is given

so as to avoid metal visibility.
• It is supported by rests on the either side of the connector on the
primary abutments.

FIGURE 16-9 Double lingual bar.

Indications

• When there are large interproximal embrasure spaces

• When some degree of indirect retention is required

Advantages

• It provides horizontal stabilization of the prosthesis.

• It provides indirect retention.

• It provides natural stimulation to the gingival tissues, as it is not

covered with metal.
Disadvantages

• Patient’s discomfort

• Chances of food lodgement

• Difficulty in accurate insertion of the prosthesis

Labial bar

• This is the only major connector which is located labially to the

mandibular anteriors.

• Its half pear-shaped design is similar to that of the lingual bar.

• Because of the arc, the labial bar is greater in length than the lingual
bar.

Indications

• When there is excessive lingual inclination of the mandibular

anterior teeth

• Presence of large mandibular tori

• Presence of severe lingual tissue undercut

Disadvantages

• It is uncomfortable to the patient.

• Bulk of the labial bar distorts the lower lip.

• It results in poor aesthetics.

Swing-lock partial denture.

Swing-lock partial denture was first described by Dr Joe J. Simmons in
1963. It consists of a hinged buccal or labial bar which can permit open
and close movements (Fig. 16-10).

• It has a small vertical projection arm that contacts the labial and
buccal surfaces of the teeth gingival to the height of contour.

• Labial bar can also be attached to acrylic resin components in those

cases where there is extensive loss of gingival tissues.

FIGURE 16-10 Swing-lock design.

Advantages

• All the remaining teeth are used for retention and stabilization of
the prosthesis.

• It is relatively inexpensive treatment.

Disadvantages

• It has questionable aesthetics.

• It puts excessive pressure on the distal most abutment teeth.

Indications

• In cases where remaining teeth are less in number and are mobile.
• In cases where teeth are lingually inclined.

• It provides retention and stabilization in cases where large number

of teeth and alveolar ridge are lost due to trauma.

Selection of the metal

• Chrome is the material of choice for fabricating metallic framework

of the swing-lock partial denture framework, as it provides
adequate rigidity and strength.

• Gold and gold alloys are not preferred, as they show considerable
wear of parts in short time.

Minor connectors
Minor connectors are one of the components of the RPD, which are
connected to the major connector.
They are defined as ‘the connecting link between the major connector or
base of a removable dental prosthesis and the other units of the prosthesis,
such as the clasp assembly, indirect retainers, occlusal rests, or cingulum
rests’. (GPT 8th Ed)

Purpose of minor connectors

• These connect the major connector with other parts of the denture
such as clasps, rest and indirect retainers.

• These transfer stresses to other components of the prosthesis.

• These transfer stress from the prosthesis to the abutment teeth and
the edentulous ridge.

Design consideration

• Minor connector should be rigid so that it can withstand functional

stresses.
• It should be positioned in the embrasure areas between two teeth.

• It should be thickest lingually and should taper towards the contact

area.

• There should be 5 mm (minimum) space between the two vertical

minor connectors.

• These should contact the guiding planes of the abutment tooth or

teeth to facilitate its path of placement.

• These should provide enough space for teeth arrangement.

Types of minor connectors

There are four types of minor connectors:

(i) Connector which connects the direct retainers (clasp assembly) to

the major connectors

(ii) Connector which connects the indirect retainers to the major

connectors

(iii) Connector which joins the denture base to the major connector

(iv) Connector which acts as an approach arm in bar-type clasp

Minor connector which connects the direct retainers to the major

connectors

• Design should be rigid and have adequate bulk to withstand

functional stresses.

• Minor connector should lie interproximally.

• It should be broad buccolingually and thin mesiodistally to help in

arranging teeth in proper position.
• Minor connector is never placed on the convex lingual surface of the
tooth.

Minor connector which connects the indirect retainers to the

major connectors

• It should connect at right angle but the junction should be rounded.

• It should be designed in such a way that it lies in the embrasure

between the teeth so as to disguise the bulk.

Minor connector which joins the denture base to the major

connector
These are of three types.

Lattice type (fig. 16-11)

• This type consists of two metal struts 12–16 gauge in thickness,

which extend longitudinally over the edentulous ridge.

• In the lower arch, one strut is placed buccally to the crest of the
ridge, whereas the other is placed lingual to it.

• In the upper arch, one strut is placed buccally to the crest, while the
other forms the border of the major connector.

• Smaller struts of 16-gauge thickness are placed in between the struts

and form a lattice-type design.

• One cross strut is placed for each tooth to be replaced.

• This type of design is used when multiple teeth are replaced.

• It provides the strongest retention of acrylic denture base to

removable denture.

• It is easy to reline the denture base in case of ridge resorption.

• Tissue stop is required in distal extension cases.

FIGURE 16-11 Lattice type minor connector.

Mesh type

• It consists of a thin metal sheet with multiple holes.

• It can be used in cases of multiple missing teeth.

• It is difficult to pack acrylic resin, as excessive pressure is required

to flow the resin dough through the holes.

• It does not provide as strong attachment to the denture base as the

lattice-type design.

• Tissue stop is required in distal extension cases.

Nail head or bead shaped

• This type of design is used with metal denture base which directly
contacts the edentulous ridge.

• Projections on the metal denture base in the form of metal nail head
or beads are provided for direct attachment of acrylic resin and the
artificial tooth.
• It should be used on well-rounded and healed ridges.

• It is indicated in tooth-supported class III cases.

• Hygienic design and better soft tissue response are its advantages.

• Its disadvantage is that the resin attachment is weakest of all the

designs.

• Relining of the metal base is not possible.

Minor connector which acts as approach arm in bar clasp design

• This is the only minor connector which is not rigid.

• It should taper from origin to terminus.

• It should not cross the tissue undercut.

Internal and external finish lines in
relation to minor connectors
Finish lines are essential in the type of minor connectors which join
the denture base to the major connectors. It is a definite line on the
cast framework where acrylic resin blends evenly with the major
connectors. Often a butt joint is given so that adequate space is
provided for acrylic resin. Also, it reduces the amount of stress at the
junction of metal and acrylic resin. Two types of finish lines are seen
in the cast framework, namely, internal and external finish lines.

Internal finish line

• It is formed by relief wax given over the ridge area of the master
cast before duplication of the cast.

• This relief wax is 24–26 gauge thick and provides sufficient space for
acrylic resin to flow below the lattice-type or mesh-type minor
connector.

• Margins of the relief wax become the internal finish line which is
sharp and well defined.

External finish line

• This type of finish line is produced during the wax-up procedure
(Fig. 16-12).

• It is sharp and well defined and forms an acute angle to produce

slight undercut.

• This undercut is important to retain acrylic resin sufficiently

adjacent to the major connector.
FIGURE 16-12 External finish line in cast framework.
Rests and rest seat
Rests are components of partial denture which transfer the forces
along the long axis of the abutment teeth and thus provide support.
They fit into the prepared tooth surface or restoration called the rest
seat.

Definition
Rest is defined as ‘a rigid extension of a fixed or removable dental
prosthesis that prevents movement towards the mucosa and transmits
functional forces to the teeth or dental implant’. (GPT 8th Ed)
Rest seat is defined as ‘the prepared recess in a tooth or restoration
created to receive the occlusal, incisal, cingulum, or lingual rest’. (GPT 8th
Ed)

Functions of rests
• These provide support.

• These act as a vertical stop and prevent injury to the soft tissues.

• These direct the functional forces along the long axis of the tooth.

• These help to maintain the components of the partial denture in the

planned positions.

• Secondary or auxiliary rests serve as indirect retainer for distal

extension cases.

• These can provide reciprocation to the retentive clasp of the direct

retainers.

Rests can be of two types:

(i) Primary rests

(ii) Secondary rests

Primary rests
• This is the part of the clasp assembly through which the fulcrum
line passes.

• Primary rests fulfil most of the above-mentioned functions.

Secondary rests
• These are also called auxiliary rests.

• These additional rests can provide indirect retention in distal

extension cases.

• These are placed as far anterior or posterior as possible to the

fulcrum line in order to prevent rotation of the prosthesis.

• For best mechanical advantage, the primary rest is located next to the
edentulous ridge and the secondary rest is located as far away from
the edentulous ridge as possible.

Types of rests used in partial dentures

Rests can be classified as follows:

(i) On the basis of location on the abutment (Fig. 16-13)

• Occlusal rest: Located on occlusal surface of the

posterior teeth

• Cingulum or lingual rest: Located on the lingual area

 of usually maxillary canine

• Incisal rest: Located on the incisal edge of the teeth

(ii) On the basis of its relation to the direct retainer

• Primary rest

• Secondary rest

FIGURE 16-13 Diagram showing three forms of rests: (A)

occlusal rest; (B) canine rest; (C) incisal rest.

Occlusal rest
• This is located on the occlusal surface of the posterior teeth.

• Outline form of the rest is triangular with base of the triangle

towards the marginal ridge and rounded apex towards the centre.

• Size of occlusal rest is one-half of the buccolingual width measured

from cusp tip-to-cusp tip and one-third to one-half the mesiodistal
width.
• Floor of the occlusal rest should be directed towards the centre of
the tooth and should form an acute angle to effectively transmit the
forces vertically downwards.

• If the angle is more than 90°, the forces are not transmitted vertically
but are subjected to inclined plane effect.

• This effect tends to slide the prosthesis away from the abutment
tooth and thus compromising the retention and stability of the
prosthesis.

• The marginal ridge should be sufficiently reduced to avoid breakage

of the rest on function.

• The rest should be at least 1.0–1.5 mm thick at the marginal ridge

region and at least 0.5 mm thick at the thinnest point.

Cingulum or lingual rest

• It is usually placed on the maxillary canines.

• It is not preferred on the mandibular canine, as the thickness of

enamel is not adequate and has steeper lingual slope.

• It is always preferred to the incisal rest, as it is closer to the centre of

rotation and the proper cingulum rest directs the forces along the
long axis of the tooth.

• Rest seat of the cingulum rest is an inverted V-shape and the apex is
located incisally.

• All the line angles should be rounded and the cingulum rest is placed
on sound enamel.

• The outline form is crescent or half moon shaped.

• Occlusal rest is preferred to the cingulum rest, as it has better

 mechanical advantages.

• Quasicingulum rest is given on the mandibular first bicuspid which

has rudimentary lingual cusp.

Incisal rest
• It is usually placed on the mandibular canines.

• Incisal rest is not preferred to the incisors, as this may tend to tip the
incisor teeth.

• It is a V-shaped notch located 1.5–2.0 mm from the proximoincisal

angle of the tooth with its deepest part located towards the centre.

• It is placed on the incisor teeth to provide stabilization and splinting

of teeth.

• The incisal rest is placed on the distoincisal angle on the lingual

surface because of aesthetic reasons.
Direct retainers and intracoronal
retainers
Definition
Direct retainer is defined as ‘that component of a partial removable dental
prosthesis used to retain and prevent dislodgement consisting of a clasp
assembly or precision attachment’. (GPT 8th Ed)
Direct retainers can be classified as follows:

(i) Extracoronal retainers: Retentive clasp assembly or external

attachments

(ii) Intracoronal retainers: Internal or precision attachment

Intracoronal retainers
• The principle of internal attachment was first given by Dr Herman
E. Chayes in 1906.

• The retainer consists of male and female components (key and

keyway) which are either custom made or prefabricated (Fig. 16-14).

• Female part acts as a receptacle and is located within the crown and
the male component is attached to the RPD.

• Retention is achieved by wedging or binding action of the prosthesis

against the vertical dislodging forces.
 FIGURE 16-14 Diagram showing intracoronal retainer.

Advantages
• Aesthetically superior to the extracoronal attachments, as visible
clasp arm is eliminated

• Provides horizontal stabilization

Disadvantages
• Prone to wearing of the component parts

• Difficult to repair

• Costly and requires precision in fabrication

• Complicated laboratory procedure

Contraindications
• Young patients with large pulp horns

• Short clinical crowns

Clasp assembly
Definition
Clasp assembly is defined as ‘the part of a removable dental prosthesis that
acts as a direct retainer and/or stabilizer for a prosthesis by partially
encompassing or contacting an abutment tooth-usage: Components of the
clasp assembly include the clasp, the reciprocal clasp, the cingulum, incisal or
occlusal rest, and the minor connector clasp’. (GPT 8th Ed)
Parts of the clasp assembly (Fig. 16-15):

• Rest: It provides vertical support.

• Body: It connects rest and shoulder of clasp to minor connectors.

• Shoulder: It connects body to clasp terminal.

• Reciprocal arm: It must be rigid and should lie above the height of
contour.

• Retentive arm: It consists of shoulder and retentive terminal; it lies

above the height of contour.

• Retentive terminal: It lies below the height of contour and provides

retention.

• Minor connector: It connects body of the clasp to other parts of the

prosthesis.

• Approach arm: It is a component of the bar clasp; it is the only minor

connector which can be flexible.
 FIGURE 16-15 Diagram showing parts of clasp assembly.

Requirements of the clasp assembly

The clasp assembly should satisfy the following requirements:

Retention: Retentive terminal of the retentive arm is flexible and lies in

the undercut region and provides retention to the prosthesis.

• The amount of retention depends on the flexibility

of clasp arm, depth of the undercut and the length
of the clasp arm below the height of contour.

• Retentive undercut for cast chrome metal is 0.010 inch,

for wrought metal it is 0.020 inch and for cast gold it is
0.015 inch.

• Clasp flexibility depends on length, diameter, taper,

cross-sectional diameter and the material.

• Clasp flexibility is directly proportional to the cube of

the length of the clasp.

• It is inversely proportional to the diameter of the

clasp.
• Round clasp has greater flexibility, as it can flex in
all the spatial planes in comparison to the half-
round clasp which can flex only in single plane.
Stability: All components of the clasp, except the retentive terminal,
provide stability to the prosthesis.

• Circumferential clasp provides the maximum

stability because of its rigid shoulder.
Support: Rests (occlusal, cingulum or incisal) provide the vertical
support to the prosthesis.

Reciprocation: It is provided by the reciprocal arm which is positioned

opposite to the retentive arm.

• The reciprocal arm should be rigid and should

always lie above the height of contour.

• It should touch before the retentive arm touches

during prosthesis placement.

• It stabilizes the denture against the horizontal

movement.
Encirclement: Each clasp should encircle more than 180° of the
abutment tooth.

• Continuous encirclement, as in the case of

circumferential clasp.
• Discontinuous or broken encirclement, as in the
case of bar clasp which must have at least three-
point contact on the tooth surface.
Passivity: Clasp should be passive when seated completely.

• It should not exert any pressure onto the tooth

unless dislodging force is applied during removal
or function.
Circumferential clasp
Definition
Circumferential clasp or Akers’ clasp is defined as ‘a retainer that
encircles a tooth by more than 180°, including opposite angles, and which
generally contacts the tooth throughout the extent of the clasp, with at least
one terminal located in an undercut area’. (GPT 8th Ed)

Indication
It is indicated in tooth-supported RPDs (class III and class IV).

Advantages
• It is easy to fabricate and design.

• It is easy to repair.

• It has less chances of food lodgement.

• It provides excellent support, bracing and reciprocation.

Disadvantages
• It covers a large surface of the abutment tooth, and there are more
chances of decalcification of tooth structure.

• It can change the morphology of the abutment tooth.

• It is difficult to adjust with pliers because of its half-round

configuration.

Design features
• It always originates above the height of contour.

• The retentive arm should extent cervically and circumferentially in a

gentle curve.

• The retentive terminus should pass over the height of contour and
enter the infrabulge portion of the abutment to engage in the desired
undercut (Fig. 16-16).

• Reciprocal arm should be located on the opposite surface of the tooth

and should be located above the height of contour.

• Retentive terminus should always be directed towards the occlusal

surface and never towards the gingiva.

• Retentive arm should be directed as apically as possible on the

abutment tooth.

• It should terminate at the mesial line angle or distal line angle and
never at the midfacial or midlingual surfaces.

• The retentive clasp should be kept as low on the tooth as possible

because in this position, it provides better mechanical advantage
and also better aesthetics.

Types of circumferential clasp:

(i) Simple circlet clasp

(ii) Reverse circlet clasp

(iii) Multiple circlet clasp

(iv) Embrasure clasp or modified crib clasp

(v) Ring clasp

(vi) Fishhook or hairpin clasp

(vii) Onlay clasp

(viii) Combination clasp

(ix) Half and half clasp

(x) Back action clasp

FIGURE 16-16 Design features of circumferential clasp.

Types of circumferential clasp

Types of circumferential clasp are described in the following
headings.

Simple circlet clasp

• It is the most simple and versatile clasp design.

• It is mostly indicated for tooth-supported partial dentures.

• The clasp approaches the undercut from the edentulous area.

• The retentive undercut is located away from the edentulous area

(Fig. 16-17).

FIGURE 16-17 Simple circlet clasp.

Advantages

• It provides satisfactory support, stabilization, reciprocation,

encirclement and passivity.

• It is easy to fabricate.

• It is easy to repair.

Disadvantages

• It cannot be used in the anterior region owing to aesthetic reasons.

• It cannot be used in distal extension cases.

• It covers greater surface area of the tooth.

• It can be adjusted only buccolingually and not occlusogingivally.

Reverse circlet clasp
• It is also called reverse approach circlet clasp.

• The retentive undercut is located next to the edentulous area, i.e. the
distal undercut.

• Mesio-occlusal rest is provided and retentive terminal terminates in

the distal undercut.

• It is used in distal extension cases where the bar clasp is

contraindicated.

• Bar clasp is contraindicated when there is soft tissue undercut due to

buccoversion of the abutment tooth or when there is an undercut
area in the edentulous ridge.

Advantages

• It resists the torsional forces better.

• It can be used in distal extension cases where bar clasp is

contraindicated.

• It provides better retention and stability because of location of the

undercut.

Disadvantages

• In cases where the occlusal clearance is not sufficient, the thickness

of the clasp is reduced and this may compromise the strength of the
clasp. An additional occlusal rest is needed next to the edentulous
area in order to protect the marginal ridges of the abutment tooth
and prevent food lodgement between the tooth and the denture.

• As the clasp runs from the mesial to the distal surface, it gives poor
aesthetics and is not used in premolars.
• Wedging may occur between the abutment and the adjacent tooth, if
the occlusal rests are not prepared properly.

Multiple circlet clasp (fig. 16-18)

• This is a combination of two simple circlet clasps joined at the
terminal ends of the reciprocal arms.

• It is primarily used to share retention between multiple teeth.

• It is indicated when the primary abutment has compromised

periodontal support.

• Mode of splinting periodontally compromised teeth by RPD.

• Its disadvantages are similar to the simple circlet and reverse circlet
clasps.

FIGURE 16-18 Multiple circlet clasp.

Embrasure clasp
• It is also called modified crib clasp.

• It consists of two simple circlet clasps joined at the body (Fig. 16-19).

• It is mostly used on the side of the arch where there is no edentulous

space.

• This type of clasp crosses the marginal ridges of two teeth and
engages the undercut on the opposing line angles on both the teeth.

• Adequate tooth structure is removed from the buccal inclines of

both the teeth to provide adequate space for metal thickness of the
clasp.

• It is indicated in unmodified Kennedy class II and class III cases.

• It has two retentive arms and two reciprocal arms either bilaterally
or diagonally opposite.

• It may be possible to close a small edentulous space by a modified

embrasure clasp called the pontic clasp.

FIGURE 16-19 Embrasure clasp.

Disadvantages

• Frequent fracture of clasp may occur because of insufficient metal

thickness.

• Two occlusal rests are necessary; otherwise, there will be tendency

for food lodgement or even separation of the teeth.

Ring clasp
• This type of clasp encircles nearly all the tooth surface from its point
of origin (Fig. 16-20).

• It is indicated on the tilted molars (maxillary molars tilt

mesiobuccally and mandibular molars tilt mesiolingually).

• The ring clasp is used when the proximal undercut cannot be

approached by other means.

• It engages the proximal undercut by encircling the entire tooth from

point of origin. Like in tilted mandibular molars, it approaches from
the mesiobuccal surface and terminates in the infrabulge region of
the mesiolingual surface. Reverse is seen in cases of tilted maxillary
molars.

• Because of its greater length, the clasp requires an additional

support in the form of additional bracing arm (minor connector)
and auxiliary rest.
 FIGURE 16-20 Ring clasp with auxiliary bracing arm for
reinforcement.

Contraindications

• When buccinator muscle attachment is close to the lower molar

• In cases of soft tissue undercut which must be crossed by the

bracing arm

Disadvantages

• Large surface area of tooth is covered.

• It is difficult to adjust and repair.

• Contour of the crown is drastically altered.

Fishhook or ‘C’ or Hairpin clasp

This type of ‘C’ clasp is a form of simple circlet clasp which after
crossing the tooth surface loops back into the retentive undercut
below the point of its origin (Fig. 16-21).

• Upper part of the clasp is rigid and the lower part is flexible.
• This clasp design is used on the tooth with sufficient clinical crown
height.

FIGURE 16-21 Hairpin or fishhook clasp.

Indications

• Retentive undercut is located next to the edentulous area or adjacent

to the occlusal rest.

• In cases where bar clasp cannot be used because of soft tissue

undercut.

• In cases where reverse circlet clasp cannot be used because of

insufficient occlusal clearance.

Disadvantages

• Large surface area of tooth is covered.

• It is prone to food lodgement.

• It results in poor aesthetics.

Onlay clasp
• It is an extended occlusal rest with buccal and lingual clasp arms.

• Indicated where the occlusal surface of one or more teeth is below

occlusal plane and is restored with an onlay.

• Onlay clasps are indicated in caries-resistant mouth.

• It covers a large surface area of tooth and may lead to enamel

breakdown.

• If the onlay is made of cobalt–chrome alloy, the opposing occlusion

should be fabricated with acrylic resin or gold crown.

Combination clasp
• It consists of flexible retentive arm made of wrought wire and cast
reciprocal arm.

• A cast circumferential clasp should not be used to engage the

mesiobuccal undercut adjacent to the distal edentulous space
because it tends to produce damaging torsional forces on the
abutment tooth.

• In such cases, the retentive arm is made of wrought wire which

provides greater flexibility.

Advantages

• It can be placed in deeper undercuts.

• It has higher flexibility, as it can flex in all the planes.

• It has a thin line contact rather than surface contact and is, therefore,
less caries prone.

Disadvantages
• It requires additional steps in laboratory procedure.

• It has a tendency to break or distort.

• It has poor stability or bracing property.

Half and half clasp

• It consists of retentive arm originating from one direction and the
reciprocal arm originating from the other (Fig. 16-22).

• The retentive arm is joined to the occlusal rest by a minor connector

on one side and the reciprocal arm is joined by another minor
connector on the other side.

• In order to avoid large coverage of tooth surface, the reciprocal arm

can be made in the form of short bar or auxiliary occlusal rest.

• Thus, clasp design provides dual retention and is indicated in

unilateral partial denture designs.

FIGURE 16-22 Half and half clasp.

Back action clasp

• It is a modification of ring clasp.
• In this design, the occlusal rest is left unsupported and the minor
connector is given at the end of the clasp arm.

• Its greatest disadvantage is that the occlusal rest is left unsupported

and thus this design cannot provide adequate support to the
prosthesis.
Gingivally approaching clasp
Definition
Gingivally approaching clasp or bar clasp is defined as ‘a clasp retainer
whose body extends from a major connector or denture base, passing adjacent
to the soft tissues and approaching the tooth from a gingivo-occlusal
direction’. (GPT 8th Ed)
Bar clasp is also called vertical projection clasp, infrabulge clasp
and roach clasp.

Design features
• It approaches the undercut or retentive area from the gingival
direction (Fig. 16-23).

• ‘Push’ type of retention is seen here, whereas ‘pull’ type of retention is

provided by the circumferential clasp.

• Push type of retention is more effective than the pull type of

retention.

• It has a flexible minor connector called the approach arm.

• It provides limited bracing action because of limited three-point

contact.

• The approach arm should cross the free gingival margin at 90° and
should not impinge the soft tissues and should uniformly taper
from the origin to the clasp terminus.

• The bar clasp should be placed as low on the tooth surface as

possible.

• This type of clasp is used when the retentive undercut is adjacent to

 the edentulous area.

FIGURE 16-23 Gingivally approaching clasp.

Advantages
• Push-type retention is more effective than pull-type retention of the
circumferential clasp.

• This type of clasp is easier for the patient to insert but difficult to
remove.

• It is aesthetically superior to circumferential clasp, as it approaches

from the gingival area.

• It is less prone to caries, as it has limited three-point contact on the

tooth surface.

Disadvantages
• It has a tendency of food lodgement.

• It provides less bracing action and stability due to increased

flexibility of the retentive arm.
• Additional stabilizing units are needed.

• It cannot be used when there is a shallow vestibule.

• It cannot be used in cases of excessive buccal or lingual tilt of the

abutment tooth.

Indications
• In case of small undercut (0.01 inch) which exists in the cervical
third of the abutment tooth and is approached from the gingival
direction

• In tooth-supported partial dentures or modification areas

• In distal extension cases where use of cast circumferential clasp is

contraindicated due to aesthetic reasons

Contraindications
• In cases of deep cervical undercut or soft tissue undercut which
require excessive block out

• If the retentive undercut lies away from the edentulous space in the
distal abutment tooth

Types of bar clasps

(i) ‘T’ clasp

(ii) Modified ‘T’ clasp

(iii) ‘Y’ clasp

(iv) ‘I’ clasp

‘T’ clasp
• It is mostly used in combination of cast circumferential reciprocal
arm.

• It is usually used in distal extension cases where retentive undercut

is present towards the edentulous ridge (distobuccal undercut) (Fig.
16-24).

• The nonretentive arm of the ‘T’ clasp lies above the height of
contour and the retentive arm lies into the retentive undercut. But
both the arms should point towards the occlusal surface.

• It should not be used in cases where the undercut is located away

from the edentulous area.

• It can be used in tooth-supported partial denture cases with natural

undercuts. As natural undercuts are used without creating new
ones, it is referred to as the clasping for convenience.

• This type of clasp should not be used where the soft tissue
undercuts are present.

• Also, ‘T’ clasp should not be used, if the retentive undercut is

located close to the occlusal surface. This will encourage food
lodgement and will be unaesthetic in appearance.
 FIGURE 16-24 ‘T’ clasp.

Modified ‘T’ clasp

• It is similar to the ‘T’ clasp, except the removal of nonretentive arm.

• It is mostly used on canine and premolar for aesthetic reasons.

• It normally does not provide the 180° encirclement of the abutment

tooth.

‘Y’ clasp
• This type of clasp design is similar to the ‘T’ clasp.

• It is indicated when the survey line is high in the mesial and distal
line angles but low in the middle of the facial surface.

‘I’ clasp
• It is mostly used on the distobuccal surface of the upper canines
because of aesthetic needs.
• As only the tip of the retentive clasp contacts 2–3 mm of the area,
the horizontal stability and encirclement is diminished.

‘I’ bar
• It is a modified I type bar clasp which was first introduced by F.J.
Kratochvil in 1963.

• It consists of ‘I’ bar retainer, long guide plane and the mesial rest.

• Rest should be of sufficient bulk to provide maximum vertical

support.

• In distal extension cases, rests are placed on the mesial aspect of the
abutment tooth because tipping forces are directed mesially and the
prosthesis moves into firm contact with support of anterior teeth.

• Also, anterior placement of the rest helps in verticalizing the force

on the supporting mucosa.

• The long guide plane (proximal plate) provides horizontal stability

and reciprocation and helps in distributing the functional forces
throughout the arch.

• Proximal plate helps in distributing the forces throughout the arch

and helps in improving the retention of the prosthesis.

• The ‘I’ bar retainer should engage the undercut passively and help
in resisting vertical displacement.

• However, this type of clasp design provides less horizontal stability

and retention than other retentive elements.

• As the tooth contour is not altered, chances of food lodgement are

minimized.
RPI and RPA concept
RPI concept
• RPI concept is the modification of ‘I’ bar retainer system proposed
by F.J. Kratochvil.

• It was first developed by A.J. Kroll in 1973.

• This design concept was based on the principle of minimizing stress

by minimal tooth and gingival coverage.

• It consists of mesial rest, proximal plate and ‘I’ bar (Fig. 16-25).

• The mesial rest extends only into the triangular fossa even in the
molar preparation.

• In the canine region, it is confined to the mesial marginal ridge in

the form of concave circular depressions and not to the entire
marginal ridge.

• The guide plane is prepared about 2–3 mm high occlusogingivally

and the proximal plate contact only 1 mm of the guide plane in the
gingival area.

• The reduction of the proximal plate is believed to improve the

gingival health.

• ‘I’ bar is designed as pod shaped to allow more tooth coverage.

• It is placed more towards the mesial embrasure space so as to

improve the reciprocation.

• Functional forces on the distal extension base tend to disengage the

retentive tip into the mesial embrasure space.
• It is also called the self-releasing clasp.

FIGURE 16-25 RPI concept (mesial rest, proximal plate and I

bar).

Indication
Tooth-supported and distal extension partial dentures

Contraindications
• Tilted abutment teeth

• Shallow vestibular depth

• Excessive soft tissue undercut

RPA concept
• This concept was proposed by Kroll in 1980.
• It consists of mesio-occlusal rest, proximal plate and Akers’ clasp (Fig. 16-
26).

• The retentive component of circumferential clasp arises from the

proximal plate adjacent to the edentulous area.

• The retentive arm approaches above the height of contour and the
retentive terminal engages into the undercut which is located away
from the edentulous space on the facial surface.

• Here, the reciprocal arm contacts the lingual surface.

FIGURE 16-26 RPA concept (mesio-occlusal rest, proximal

plate and Akers’ clasp).

Indications
• Tipped or tilted abutments

• Soft tissue undercuts

• Shallow vestibular space

• Retentive undercut is located away from the edentulous space

Contraindication
• Where aesthetics is the prime concern.

Commonly used direct retainers for distal extension RPDs:

1. Kratochvil design (1963): It uses mesial rest or cingulum rest, distal

guide plate and I bar clasp with 0.01 inch undercut located
midfacially.

2. Roach design (1934): This design uses distal or cingulum rest, distal
guide plate, T bar with 0.01 inch retentive undercut located
distofacially and lingual reciprocation.

3. Applegate design (1955): This design uses distal or cingulum rest,

distal guide plate, wrought wire or platinum gold–palladium clasp
with 0.02 inch retentive undercut located mesiofacially and lingual
reciprocation.
Indirect retainers and their importance
in distal extension cases
Definitions
Indirect retainers are defined as ‘the component of a removable dental
prosthesis that assist the direct retainers in preventing displacement of the
distal extension denture base by functioning through lever action on the
opposite side of the fulcrum line when the denture base moves away from the
tissues in pure rotation around the fulcrum line’. (GPT 8th Ed)
Indirect retention is defined as ‘the effect achieved by one or more
indirect retainers of a partial removable denture prosthesis that reduces the
tendency for a denture base to move in an occlusal direction or rotate about
the fulcrum line’. (GPT 8th Ed)
Fulcrum line is defined as ‘an imaginary line, connecting occlusal rests,
around which a partial removable dental prosthesis tends to rotate under
masticatory forces. The determinants for the fulcrum line are usually the
cross-arch occlusal rests located adjacent to the tissue-borne components’.
(GPT 8th Ed)
Retentive fulcrum line is ‘an imaginary line, connecting the retentive
points of the clasp arms, around which the removable dental prosthesis tends
to rotate when subjected to dislodging forces’. (GPT 8th Ed)

Rationale
In distal extension cases (unilateral or bilateral), there is a tendency for
the prosthesis to rotate around the fulcrum line in function. Therefore,
there is a need to resist the rotational forces by providing indirect
retention through indirect retainer.

Functions of indirect retainers

• It resists rotation of the prosthesis around fulcrum line under
masticatory stresses.
• It aids in additional support and stability to the prosthesis.

• It helps in accurate repositioning of the prosthesis during relining or

rebasing procedure, as it acts as a third point of tooth contact.

• Major connectors such as lingual plate supported on both the ends

with rests can provide effective indirect retention.

• Contact of its minor connector with the axial tooth surface helps in
providing stabilization against horizontal movement of the
prosthesis.

Indirect retainers in distal extension cases

• In Kennedy class I arch, the fulcrum line passes through the most
posterior abutments, provided some of the rigid components of the
framework are located occlusal to the abutments’ height of contour.

• In Kennedy class II arch, the fulcrum line is diagonal, passing through

abutment on the distal extension side and the most posterior
abutment on the opposite side.

Factors influencing the effectiveness of the

indirect retainers
Distance between the fulcrum line and indirect retainer: Greater the
distance between the fulcrum line and the indirect retainer, greater
and more effective will be the indirect retainer (Fig. 16-27).

• Indirect retainer should always be placed perpendicular to the

fulcrum line.

• It should be located as far away from the fulcrum line as possible.

• Indirect retainers are not capable of resisting displacement of the

prosthesis.
Rigidity: The indirect retainers should be rigid.

Lingual plate can effectively provide indirect retention, if it is

supported with rests on both the ends.

Location of the fulcrum line influences the effectiveness of the indirect

retainers.

Effectiveness of the supporting tooth surface: The indirect retainers should

be placed in definite rest seats that transmit forces along the long
axis of the teeth.

FIGURE 16-27 Effectiveness of indirect retainer depends on

distance between the fulcrum line and the indirect retainer.

Types of indirect retainers

1. Occlusal rest: This is most commonly used.
• Definite occlusal rest seat should be prepared on the
occlusal surface so that the forces are transmitted
along the long axis of the tooth.

• It is most commonly placed on the mesial marginal

ridge of the first premolar in Kennedy’s class I
situation.

• In class II situation, it is commonly placed on the

first premolar on the opposite side.
2. Canine rest: Given in case the first premolar is closer to the fulcrum
line.

• It is placed on the cingulum of the canine.

• Canine rest is always preferred to the incisal rest

because of its mechanical advantages.

• This type of rest becomes more effective, if the

minor connector is placed in the embrasure space
anterior to the canine and arcs backward into the
lingual rest seat.
3. Canine extension from the occlusal rest: A finger extension from a
premolar occlusal rest is placed on the lingual slope of the canine.

• This extension helps in providing indirect retention.

• This type of extension is used in cases where the

 first premolar serves as the primary abutment.
4. Lingual plate: When the lingual plate is supported with the rests on
both the ends, it provides effective indirect retention.

5. Modification area: In cases of class II modification I, the secondary

abutment can serve as an indirect retainer.

6. Rugae area: The rugae area of the maxillary arch, if covered in the
partial denture, can serve as effective indirect retainer as in horseshoe
design where posterior retention is not sufficient.

• Tissue support provided by the rugae region is less

effective than the tooth-supported indirect retainer.
Denture base and functions of distal
extension partial denture base
Definition
Denture base is defined as ‘the part of the denture that rests on the
foundation tissues and to which teeth are attached’. (GPT 8th Ed)

Purpose of denture base

• It provides attachment to the artificial teeth.

• It helps in distributing the forces to the supporting oral tissues.

• With characterization of the denture base, it can satisfy the aesthetic

demand of the patient.

• It helps in stimulation of the underlying supporting tissues.

Requirements of ideal denture base

• It should have adequate strength to resist fracture or distortion.

• It should accurately adapt to the tissues with minimal volume

change.

• It should be aesthetically acceptable.

• It should be easy to clean.

• It should be dense and easy to finish.

• It should be capable of relining.

• It should be cost-effective.

• It should have low-specific gravity.

Functions of distal extension partial denture

design
• In distal extension cases, the denture bases provide support to the
prosthesis, although the primary support is provided by the
abutment tooth.

• As the distance from the abutment tooth increases, the contribution

of support by denture base becomes more significant.

• Maximum support is provided by broad and accurate denture

bases.

• Consideration of quality of ridge is important in assessing the

amount of support which will be provided by the denture base.

• Denture bases also provide secondary retention to the prosthesis;

the primary retention is provided by the direct retainers.

• Physical factors of retention are the same as in complete denture.

Some of the factors are adhesion, cohesion, surface tension, effect of
gravity, atmospheric pressure and physical moulding of tissues
around the prosthesis. However, the role of atmospheric pressure in
retention of RPD is questionable.

Metal denture base

Metal base is defined as ‘the metallic portion of a denture base forming a
part or the entire basal surface of the denture. It serves as a base for the
attachment of the resin portion of the denture base and the teeth’. (GPT 8th
Ed)
Metal denture bases are usually indicated in tooth-supported partial
dentures.

Advantages
• Metal denture bases are more accurate and maintain the accuracy of
form without alteration in the mouth.

• Accurate castings are not subjected to distortion by the release of

internal strains as observed in acrylic resins.

• These are easy to clean and contribute to more healthy oral tissues
than acrylic resin bases.

• Thinner section of metal can provide adequate strength and rigidity

to the prosthesis.

• Temperature changes in the oral cavity are transmitted by the metal

denture bases and contribute in better patient acceptance of the
prosthesis and maintenance of healthy tissues.

• Better tissue response as the metal denture bases have greater

density and bacteriostatic activity provided by the ionization and
oxidation of the metal base.

Disadvantages
• These are difficult to repair and reline.

• These are difficult to adjust.

• These have poor aesthetic outcomes.

• Overextension and underextension of the prosthesis are difficult to

correct and contribute to injury of the tissues.

Anterior teeth replacement

Usually anterior teeth replacements are best treated by fixed
restorations. However, there are instances where the RPD is logical
and the preferred choice.
Methods of Replacing Anterior Teeth with RPD (Table 16-1):

(i) Acrylic teeth

(ii) Porcelain teeth

(iii) Interchangeable facings

(iv) Tube teeth

(v) Reinforced acrylic pontics (RAPs)

TABLE 16-1
VARIOUS METHODS OF REPLACING ANTERIOR TEETH
Posterior teeth replacement
Methods of replacing posterior teeth with RPD are described in the
following headings.

Acrylic resin

• The wear of acrylic resin is clinically significant when opposing

natural teeth or porcelain teeth.

• These can lead to gradual decrease in vertical dimension.

• Unlike porcelain teeth, they do not chip and have softer impact
sounds.

• They can be easily adjusted and grinded in close interridge spaces.

• These require recall visit for repair or replacement.

• These can be easily arranged over the ridge in natural position.

• They have poor wear resistance and cause minimal wear of the
opposing natural teeth.

• They are capable of bonding with denture base material.

Porcelain

• Posterior teeth are retained in acrylic denture base by diatoric holes.

• These should be used when opposing teeth are artificial and not
natural.

Advantages

• These have excellent aesthetics.

• Wear resistance and abrasion resistance are good.

Disadvantages

• These have poor fracture resistance.

• Strength is compromised in thin sections.

• There are high chances of abrading the opposing teeth.

Metal tooth

• Metal tooth or pontic is indicated where the interarch space is

highly limited or restricted and strength is required.

• A facial veneer can be processed on the metal surface to improve

aesthetics.

• Gold is ideally used for occlusal surface of the replacement tooth.

Advantages

• These have excellent strength.

• These have good wear resistance.

• These are easy to maintain.

• These can be used in limited space.

Disadvantages

• These may add to the bulk of the prosthesis.

• These have poor aesthetics.

Metal pontic with acrylic windows

• When aesthetics is required and the available space is limited, the

facial surface of the pontic is removed and acrylic resin is processed
 in the recess (Fig. 16-28).

• Aesthetics is inferior to porcelain or acrylic teeth.

FIGURE 16-28 Metal pontic with acrylic window.

Tube teeth

• These can be used to replace one or two posterior teeth in mostly

tooth-supported partial denture cases.

• These are best used for the replacement of maxillary first premolars.

• These are not indicated for distal extension cases.

• These should be placed on well-healed ridges.

• These cannot be relined.

Key facts
• Fulcrum line is an imaginary line which joins the occlusal rests
 around which the prosthesis tends to rotate in function.

• Continuous gum denture is an artificial denture consisting of

porcelain teeth and tinted porcelain denture base material fused to a
platinum base.

• Fulcrum line is an imaginary line, connecting occlusal rests, around

which a partial denture tends to rotate under functional stresses.

• The maxillary palatal strap should be minimum 8 mm in width.

• Quasicingulum rest is given in mandibular first premolar which

has rudimentary lingual cusp.

• The rest seat in mesially inclined molar is prepared with the floor
perpendicular to the long axis of the teeth.

• Rest seat should always be prepared in sound enamel whenever

possible.

• Push type of retention is given by bar clasps.

• Pull type of retention is given by the reciprocal clasp.

• The clasp terminal should be placed below the height of contour of

the tooth to act as a primary retainer.

• The amount of undercut required by the wrought clasp is 0.020 inch.

• Terminal third of the retention arm is the component of direct

retainer which lies below the height of contour and provides
retention to the prosthesis.

• Indirect retainer should be placed as far anterior or far from the

saddle as possible to get best mechanical advantage.

• Porcelain teeth are mechanically retained in an acrylic base through

diatoric holes.
CHAPTER
17
Principles of RPD design

CHAPTER OUTLINE
Introduction, 270
Surveyor and Surveying, 270
Definition, 270
Objectives of Surveying, 271
Parts of Ney’s Surveyor, 271
Survey Line, 272
Uses of Dental Surveyor, 273
Objectives and Principles of Surveying, 274
Methods of Stress Control in RPD, 284
Reducing Load on Abutment and the
Ridge, 284
Distribution of Load between the Teeth and the
Ridge, 285
Distribution of Load, 285
Stress Breaker, 285
Precision Attachments, 286
Shortened Dental Arch Concept, 287
Indications, 288
Contraindications, 288
Advantages, 288
Disadvantages, 288
Introduction
It is essential to understand various principles in designing of
removable partial dentures (RPDs). Success in RPD depends not only
on understanding these principles but also on applying them in
relevant clinical situation. Broadly, RPDs can be tooth and tissue
supported or completely tooth supported. According to the situation,
the principles are applied.
Surveyor and surveying
Definition
Dental surveyor is defined as ‘a paralleling instrument used in
construction of a dental prosthesis to locate and delineate the contours and
relative positions of abutment teeth and associated structures’. (GPT 8th Ed)
Surveying is defined as ‘an analysis and comparison of the prominence
of intraoral contours associated with the fabrication of the dental prosthesis’.
(GPT 8th Ed)

• A surveyor is essentially a parallelometer, which is used to

determine the relative parallelism of the surfaces of teeth or other
areas on a cast.

• Dr A.J. Fortunati introduced dental surveyor in 1918.

• Ney’s surveyor was first commercially used dental surveyor in

1923. It is one of the most widely used surveyors.

Objectives of surveying
• To design a removable prosthesis

• To determine suitable path of insertion

• To locate and measure the retentive undercut

• To trim or eliminate blockout material parallel to the path of

placement before duplication

• To determine any soft tissue or hard tissue interference

Types of surveyor
Two surveyors are commonly used in dentistry:

(i) Ney’s surveyor

(ii) Wills surveyor by Jalenko: It is similar to Ney’s surveyor, except

for the following differences:

• The surveying arm is spring loaded and when not

in use it is held at its most vertical position by
spring tension.

• The horizontal arm is capable of revolving

horizontally around vertical column, whereas
horizontal arm in Ney’s surveyor is fixed.
Other commercially available surveyors are:

• Micro-analyser

• Optical surveyor

• Stress-O-graph

• Bachmann’s parallelometer

• Retentoscope

• Intraoral surveyor

• Bego paraflex

• William’s surveyor

• Ney turbo-torque surveyor

Parts of Ney’s surveyor (fig. 17-1)
• Surveying platform: Flat metal base which is parallel to the floor or
bench top on which the surveying table or the cast holder can move
smoothly.

• Vertical column: Vertical arm arising from the base of the surveying
platform. It supports the horizontal arm and the surveying arm.

• Horizontal arm: It arises from the vertical column at right angle and
at the other end extends a surveying arm. In the Ney’s surveyor, it
is fixed, whereas in the Wills surveyor, it can revolve horizontally
around the vertical column.

• Surveying arm: It extends from the horizontal arm vertically

downwards. It is capable of moving in the vertical direction. At its
lower end, mandrel is attached, where the surveying tools are
locked in position.

• Surveying table or cast holder: On this table, the cast to be studied is

locked-in position by means of a clamp. The base of the surveying
table is mounted over the ball and socket joint, which is capable of
tilting the cast in various horizontal planes. At the desired tilt, the
cast can be locked by means of locking device.

• Surveying tools: These tools are attached to the mandrel of the

surveying arm. Different types of surveying tools are:

• Analysing rod or the paralleling tool: It is a cylindrical

metal rod which is used to determine the relative
parallelism between the tooth surfaces. It contacts
the convex surface of the object to be surveyed
much in the same way as the tangent contacts the
curve.
• Undercut gauges: These are used to determine the
specific amount and location of the retentive
undercut on the surface of the abutment.

• Carbon marker: It is used to scribe the height of

contour or the survey line of the object which is
surveyed. It is also useful in delineating an
undercut area of the soft tissue or the residual
ridge.

• Wax knife: It is used to eliminate or block out

undercut during wax-up of the cast before
fabrication of the framework.
 FIGURE 17-1 Ney’s dental surveyor.

Survey line
Survey line is defined as ‘a line produced on a cast by a surveyor marking
the greatest prominence of contour in relation to the planned path of
placement of a restoration’. (GPT 8th Ed)
Survey lines are scribed by the carbon marker on abutment tooth
during surveying. It denotes the height of contour on the abutment
tooth. The significance of survey line is that all rigid components of
the removable prosthesis are kept occlusal to it. Only the retentive
terminal is kept gingival to the survey line. It helps in identifying
undesirable undercut that is avoided or eliminated by contouring or
placing restorations on the teeth.
The height of contour is defined as ‘a line encircling a tooth and
designating its greatest circumference at a selected axial position determined
by a dental surveyor; a line encircling a body designating its greatest
circumference in a specified plane’. (GPT 8th Ed)
Types of Survey Lines

(i) High survey line

(ii) Medium survey line

(iii) Low survey line

(iv) Diagonal survey line

High survey line

• This survey line lies closer to the occlusal third of the abutment
tooth.

• Usually, there will be deep undercut and wrought clasp will be

preferable.

• It is seen in inclined teeth or teeth with broader occlusal diameter

than the cervical diameter.

Medium survey line

• It lies between the occlusal third and the middle third of the
abutment tooth.

• Circumferential clasp is usually preferred.

Low survey line

• It lies closer to the cervical third of the abutment tooth.
• A modified ‘T’ clasp is usually preferred in low survey line.

Diagonal survey line

• It lies between the occlusal third of the near zone and cervical third
of the far zone.

• It is commonly seen on the premolars and canines.

• Reverse circlet clasp is commonly used.

• Ring type Akers’ clasp or T-type bar clasp can be used.

The concept of near zone and far zone was given by L.A. Blatterfien.
He divided the buccal and lingual surfaces of the tooth adjacent to the
edentulous space into two halves by an imaginary line passing
vertically through the long axis of the tooth.
The half of the tooth closer to the edentulous space is called the near
zone and the half of the tooth away from the edentulous space is
called the far zone. This concept can also be applied similarly to the
proximal surface. Proximal surface closer to the edentulous space is
the near zone and the proximal surface away from the edentulous
space is called the far zone.

Uses of dental surveyor

• To survey the diagnostic cast:

• Diagnostic cast is always surveyed before

formulating the treatment plan.

• Relative parallelism is studied on the cast which

helps in designing the framework.
• Soft tissue and hard tissue undercuts are
determined and evaluated for any correction
during mouth preparation procedure.

• The tilt of the cast can be altered to best suit the

conditions of the mouth without much alteration.

• At the final tilt, the survey lines can be scribed on

the cast with carbon marker.
• Tripoding of the cast:

• Cast should be tripoded in the position of the final

tilt.

• Three widely separated marks are scribed on the

cast with analysing rod at the same vertical height.
• To transfer the tripod marks to another cast:

• The second cast can be positioned at the same tilt as

the diagnostic cast.

• Analysing rod is positioned at the selected three

points on the diagnostic cast at same vertical height.

• The second cast is positioned at the survey table

and the cast is tilted till three widely separated
points are located at the fixed vertical height.
• Three additional reference points can be scribed on
the diagnostic cast to ensure that the second cast is
mounted at the same vertical height and tilt.

The additional reference points are:

(i) Distal marginal ridge of the right first premolar

(ii) Incisal edge of the lateral incisor

(iii) Lingual cusp tip of the left first premolar

• The tilt of both the casts should be exactly same at

this location.
• To contour crowns and cast restorations:

• It is important to contour the final restoration as

planned in the wax pattern.

• For this, the restoration with the die is placed on the

survey table at the original tilt.

• Handpiece attached to the vertical column of the

surveyor and the restoration is refined with the
help of cylinder stone.

• Analysing rod is finally used to verify the contours

of the restoration.
• To contour wax patterns:
• The wax patterns of the cast restoration are
contoured on the surveyor at the final tilt selected
during treatment planning.

• The survey line can be adjusted to place the

retention and reciprocal arm at the most desired
position.
• To survey the master cast:

• Master cast is made after mouth preparation is

done.

• Master cast is surveyed on the surveyor to verify

whether the alteration sought in the mouth during
mouth preparation are successfully accomplished
or not.

• If the mouth preparation did not give satisfactory

result, the mouth preparation procedure is repeated
and a new impression is made.
• To place internal attachment and rests in intracoronal retainers:

• Surveyor is very useful to place the intracoronal

attachments during the wax pattern stage on the
abutment tooth.

• This requires utmost precision as absolute

 parallelism is desired.

• Internal rests or occlusal rests can be prepared in

the wax pattern of the restorations using the
straight handpiece.
• Mock preparation on the diagnostic cast:

• Mock preparation can be done on the cast before

mouth preparation to determine the outcome of the
treatment.
• To survey the ceramic veneers before final glazing:

• Contour of the ceramic crown is determined on the

surveyor before the final glazing procedure.

• The height of contour is modified and verified on

the surveying table.

Objectives and principles of surveying

Objectives of surveying
• To locate and evaluate tooth and soft tissue undercuts on the cast

• To identify the height of contour

• To identify the proximal tooth surface to prepare the guide planes

• To determine the most favourable path of placement which has least

interference and provides best aesthetics
• To identify the most favourable cast tilt and preserve it for future
references

Principles of surveying
1. To analyse the cast

• The cast is positioned on the surveying table at

horizontal tilt or zero tilt.

• At the zero tilt, the occlusal surfaces of the teeth are

at or nearly parallel to the horizontal plane.

• The four basic tilts from the horizontal or reference

position are anterior tilt, posterior tilt, right lateral
and left lateral tilt.

• The cast can be tilted in any of the above-mentioned

positions until the most effective use of the
available undercut is achieved. It should be
remembered that the established tilt should not be
more than 10º otherwise extensive mouth
preparation will be required to design a prosthesis.
2. To survey the abutment teeth

• To determine the height of contour: Once the tilt is

determined, the height of contour is scribed on the
cast by carbon marker. Rigid components of the
direct retainers should lie above the height of
 contour and the flexible component should lie
below it.

• To locate and determine the depth of the undercut:

It is done by using the undercut gauges. Greater the
depth of undercut, greater will be the flexibility of
the retention arm required to achieve proper
retention. Undesirable undercut should be blocked
using blocking wax.

• To determine guide planes: In order to achieve

parallelism between the abutment teeth, guide
planes are prepared. Parallelism is necessary for
easy path of placement and removal of the
prosthesis (Fig. 17-2).

• To determine the path of insertion: The tilt of the

cast determines the path of insertion and removal
of the prosthesis. Single or multiple path of
insertion depends on the type of the RPD design,
i.e. whether totally tooth supported or tooth-tissue
supported.
3. To survey the soft tissue contours on the cast

• Soft tissue undercuts should be determined during

surveying.
• Any unfavourable soft tissue undercut may require
preprosthetic surgery to eliminate it.

FIGURE 17-2 Guide plane should be parallel to each other

and to the path of insertion.

Tripoding of the cast

Tripoding is defined as ‘those marks or lines drawn on a cast in a single
plane perpendicular to the survey rod to assist with repositioning the cast on
a dental surveyor in a previously defined orientation’. (GPT 8th Ed)
Basically, tripoding is a procedure of indexing the cast in a
horizontal plane after the final tilt of the cast is determined on the
surveyor. This procedure helps in repositioning the cast accurately in
the same horizontal plane in which it was surveyed.

Types of tripoding

1. Tissue surface tripoding

• Three widely separated and easily identifiable

marks are placed on the tissue portion of the cast
after the final tilt of the cast is determined (Fig. 17-
3).
• These marks are placed in the same horizontal
plane.

• This permits the cast to be repositioned accurately

by realigning the cast in the same horizontal
position.

• Carbon marker, trimmed at 45°, is used for this

purpose.

Procedure

• Tripoding procedure is done once the tilt of the cast

is determined.

• At this tilt, the cast is positioned on the surveying

table.

• Three widely separated points on the anatomical

portion of the cast are touched at the same vertical
height.

• Analysing rod is used to scratch the cast at these

three points.

• The analysing rod can be substituted with a carbon

marker.

• A small line of 3 mm length is made at these three

 points.

• A mark is made across this line and is circled to

identify the area of tripoding.
2. Art portion tripoding

• It is accomplished by using an analysing rod, which

is held against the art portion of the cast at a
determined tilt.

• Three lines are drawn with the lead marker, one on

the anterior aspect and one each on the posterior
aspect of the art portion of the cast.

• Disadvantage of this method is that there are

chances of smudging of the lines during handling
of the tripoded cast.
 FIGURE 17-3 Tissue surface tripoding.

Purpose of tripoding
• It preserves the tilt of the cast.

• It permits the cast to be removed and repositioned accurately

whenever desired.

• It helps in recording the spatial orientation of the cast in a particular

plane.

Path of insertion
Path of insertion is defined as ‘the specific direction in which prosthesis is
placed on the abutment teeth or dental implant(s)’. (GPT 8th Ed)
The tilt of the cast on the surveyor determines the angle at which
the partial denture will seat over the remaining teeth. The path of
insertion is always parallel to the vertical arm of the surveyor and is
determined by the final tilt of the cast. The type of partial denture
design determines the number of paths of insertion of the dentures.

• In Kennedy class I situation, there can be multiple paths of

insertion. Since the distal extension bases are controlled by two
terminal abutment teeth, additional guide planes are created on the
lingual surface to limit the path of insertion.

• In Kennedy class II cases with a modification space, the path of

insertion is determined by the modification space. This results in a
single path of insertion and removal.

• Usually, the tooth-bounded spaces (Kennedy class III) with guiding

planes created on the proximal surface of all the teeth will have
single path of insertion.

• In Kennedy class IV situation, there will be usually single path of

insertion.

• Minor connectors are usually the components of the partial denture

which contacts the guiding planes and, therefore, govern the path of
insertion.

• If the guiding planes are created on the lingual surface of the teeth,
the reciprocal arm or the lingual plate can definitely influence the
path of insertion.

Factors influencing the path of insertion

1. Retentive undercut

• One of the basic requirements in designing partial

denture is that there should be a retentive undercut
on the abutment tooth in horizontal tilt.
• Tilt of the cast may be varied to alter the position of
the survey line so that the clasp may be placed
more favourably.

• The retentive undercut is measured by the undercut

gauge. The shank of the gauge contacts the height
of contour of the tooth and the undercut gauge
contacts the surface of the tooth in the undercut.

• The amount of the retentive undercut required if

cast chrome alloy is used is 0.010 inch undercut and
if wrought wire combination clasp is used, it is
0.020 inch.
2. Interferences

• There are certain regions in the patient’s mouth

which can interfere with the path of insertion of the
partial denture.

• These areas can be identified and treated either by

surgical removal or by altering the tilt of the cast on
the surveyor.
Interferences in the mandible:

• Lingual tori

• Lingual inclination of the remaining teeth

• Bony exostosis or bony undercuts

• Mylohyoid ridge prominence

Interferences in the maxilla:

• Palatal tori

• Prominent tuberosity

• Soft tissue undercut

• Anterior undercut
3. Aesthetics

• This factor can influence the path of insertion of the

partial denture.

• Optimum aesthetics can be obtained by placing the

artificial teeth in the natural position and by placing
the metal clasps more gingivally. Bar clasps are far
superior to the circumferential clasp.

• Mesially tilted abutment will create large

unaesthetic undercut. This undercut can be
eliminated by tilting the cast or by selectively
grinding the teeth to establish proper guide planes.
4. Guiding planes
• These are formed by the proximal or the axial
surfaces of the teeth which contact the minor
connectors during insertion or removal of the
prosthesis.

• Guiding planes protect the periodontally

compromised teeth from harmful lateral forces.

• These provide stabilization and retention to the

prosthesis.

Principles of RPD designing

The principles of RPD designing were first given by A.H. Schmidt in
1956. According to him, the principles were:

• The clinician should have thorough knowledge of the biological and

the mechanical factors involved in RPD design.

• The treatment plan is based on thorough examination and diagnosis

of the individual patient.

• The clinician should correlate the pertinent factors and determine

the proper plan of treatment.

• An RPD should restore form and function without injury to the

remaining oral structures.

• An RPD is a form of treatment and not a cure.

Concepts of RPD designing

There are three basic concepts of designing an RPD. These concepts
are based on distributing the forces acting on the partial denture
between the soft tissue and the teeth.
These concepts are:

(i) Stress equalization

(ii) Physiologic basing

(iii) Broad stress distribution

Stress equalization.
Based on the concept that the resiliency of the periodontal ligament is
smaller in comparison to the resiliency of the mucosa covering the
edentulous ridge, a nonrigid connection is required to distribute the
stresses over the abutment and the edentulous ridge. This nonrigid
connection is called stress equalizer or stress director (Fig. 17-4).

FIGURE 17-4 Split lingual bar used to equalize forces

transmitted by the partial dentures.

Its purpose is to equalize the forces transmitted by the RPD.

Advantages

• Minimal direct retention

• Useful in distal extension cases

• Stimulating effect on the supporting tissues during function

Disadvantages

• Difficult to repair

• Costly

• Fragile

• Complex in fabrication

• Unable to prevent lateral forces

Physiologic basing.
The proponents of this concept believe in recording the edentulous
ridge in functional form either by using functional impression
technique or by functional reline method.

• During the functional impression, the mucosa covering the

edentulous ridge gets displaced to its functional form.

• Direct retainers and retentive clasp designed with minimum

retention and number of direct retainers is also minimum.

• Denture fabricated with functional impression compresses the soft

tissues even at rest. This can lead to excessive residual ridge
resorption (Fig. 17-5).

• When the partial dentures are at rest, the artificial teeth will be
positioned slightly above the plane of occlusion because of the
rebound of the compressed tissues.
 FIGURE 17-5 Dentures made with functional impression
compress the soft tissues even in rest state.

Advantages

• Functional loading has a physiological stimulating effect on the

supporting tissues.

• For proper vertical movement of the partial dentures from rest to

functional position, this direct retainer should be minimum in
number and retention.

• Simplicity of designing and fabrication results in lightweight

prosthesis.

• Less forces are transmitted on the abutment tooth.

Disadvantages

• There are greater chances of premature contacts.

• It is difficult to produce effective indirect retention.

• Greater forces are transmitted to the edentulous ridge.

• There are chances of premature contact, as the teeth will be

positioned slightly above the plane of occlusion.

Broad stress distribution.

This concept advocates wider distribution of stresses by the prosthesis
using additional rests, clasp assembly and broad denture base. The
partial dentures feature maximum coverage of the teeth and the soft
tissues (Fig. 17-6).

FIGURE 17-6 Removable partial denture made with broad

stress distribution concept.

Advantages

• Less concentration of stress

• Greater resistance to lateral stresses

• Less expensive in fabrication

• Increased horizontal stabilization

Disadvantages

• Chances of bulky prosthesis

• Because of wider coverage, difficult to maintain oral hygiene

Factors which influence the amount of stresses on the abutment

tooth.
Factors which influence the amount of stresses on the abutment tooth
are:

Length of edentulous span: Greater the length of the edentulous span,

greater will be the length of the denture base and thus more forces
will be transmitted to the abutment tooth.

Form of residual ridge: Broad, well-formed ridges provide better

support and stability to the prosthesis than thin knife-edged ridges.
Also, firmly bound healthy keratinized mucosa is capable of
resisting the functional stresses better than the loose, atrophic and
flabby tissues.

Clasp quality: More flexible the clasp, greater lateral and vertical
forces will be transmitted to the residual ridge. More flexibility of
the clasp, lesser will be force transmitted to the abutment.

Length of the clasp: Flexibility of the curved clasp is better than the
straight one. Flexibility of the clasp is directly proportional to the
length of the clasp.

Clasp design

• Passively fitting clasp exerts less stress on the abutment tooth than
the active one.

• The framework should be completely seated in order to ensure that

the retentive clasp will be passive.

• Disclosing wax can be used to seat the framework completely.

Clasp material: Greater the rigidity of the clasp material, greater will
be the stress transmitted to the abutment.
• Cast clasp will exert more stress on the abutment
tooth than the gold clasp.

• As the cast clasp has greater rigidity in comparison

to the gold clasp, it should be made of smaller
diameter.
Tooth surface: Intact enamel offers less frictional movement to the
clasp arm than full veneer crown or restoration.

• Greater stress will be created on the tooth restored

with gold or cast metal rather than with tooth
enamel.
Occlusion: Deflective or disharmonious occlusal contact and the type
of opposing occlusion influence the amount of force on the
abutment tooth.

• Type of the occlusion and the area of the denture

base determine the amount of stress transmitted
onto the abutment tooth and the residual ridge.

• Partial denture opposing complete denture will be

subjected to less occlusal stress than if opposed by
natural occlusion.

• The occlusal load should be applied in the centre on

the residual ridge, both anteroposteriorly and
buccolingually. Usually, the second premolar and
the first molar are the best areas to bear the
 masticatory load.
Design considerations in controlling stress in an RPD.
 The following are the design considerations which are important in
controlling stresses in an RPD:

Direct retention: The retentive clasp arm transmits most of the

leverages forces to the abutment tooth. Clasp retention should be
kept to the minimum but without compromising on the retention of
the prosthesis.

• Retention is enhanced by accurately fitting and

maximal coverage denture base.

• Retention by frictional control is enhanced by

creating guiding planes on as many teeth as
possible.

• Properly extended partial denture can aid in better

neuromuscular control by the patient, therefore,
contributing in retention of the prosthesis.
Clasp position: The position of the clasp in relation to the height of
contour influences the amount of stress on the partial denture. The
number of clasps used is governed by the classification.

Quadrilateral configuration: It is indicated in Kennedy class III cases

with a modification space on the opposite side. A retentive clasp is
placed on all abutment teeth adjacent to the edentulous space (Fig.
17-7).

Tripod configuration: It is indicated in Kennedy class II cases with a

modification space on the opposite side. All the abutment teeth on
 both sides are clasped to result in tripod configuration (Fig. 17-8).

Bilateral configuration: It is indicated in Kennedy class I cases

without any modification space. The retentive clasp is located on
abutment on both sides adjacent to the edentulous space (Fig. 17-9).

Clasp design: Circumferential clasp originating from the distal

occlusal rest and engaging into the mesiobuccal undercut should be
avoided in distal extension cases, as it produces harmful leverage
forces on the abutment tooth. Reverse circlet clasp can be used.

• Bar clasp is indicated in distal extension cases when

distal undercut is located. It should never be used
when there is mesiobuccal undercut.

• It is advantageous to place the mesial rest more

anteriorly than the distal rest because of better
mechanical advantage.

• T clasp with disto-occlusal rest and rigid

circumferential reciprocating clasp is thought to
produce least stress on the abutment tooth.
Splinting: Splinting of two or more teeth helps in distributing the
stress over a larger area of support, as it increases the periodontal
ligament attachment area.

• For splint to stabilize teeth in the arch in the

buccolingual direction, it should extend across the
arch curvature.
Indirect retention: It is essential in distal extension cases.
• It resists the rotation of the prosthesis.

• It is usually located anteriorly and perpendicular to

the fulcrum line.

• It should be located as far anteriorly as possible to

provide long lever arm. Also, the indirect retainers
should be located in definite rest seat in order to
transmit the forces along its long axis.

• It also contributes to the stability and support of the

denture.
Occlusion: Harmonious occlusion minimizes the stress on the
abutment teeth and the residual ridges.

• The buccolingual width of the artificial teeth should

be reduced in order to minimize stress on the
abutment and edentulous ridge.

• Steep cuspal inclines should be avoided.

• Posterior teeth should have sharp cutting surfaces

and sluiceways.
Denture Bases: The denture base should be extended over wider ridge
area in order to distribute the stresses.

• Denture base flanges should be made as long as

possible in order to stabilize the denture against
 horizontal stresses.

• Denture base should be accurate and closely fitting,

as this will ultimately reduce the stresses
transmitted to the abutment teeth.

• Selective pressure impression technique is useful in

reducing stresses on the ridge and the abutment.
Major connector: It should be rigid.

• In mandibular arch, lingual plate design can

effectively support periodontally compromised
teeth and can distribute stresses to the remaining
teeth, if supported by the rests at the distal
abutments.

• In maxillary arch, the complete palatal design

contributes to stability, support and retention of the
prosthesis. This helps in distributing the functional
forces over wide surface area, thereby reducing the
amount of forces on the abutment and the ridge.
Minor connector: It joins the clasp assembly to the major connector
and the guide planes on the abutment tooth.

• It provides horizontal stability to the partial denture

against the lateral forces.
• Because of its contact with abutment tooth, it
stabilizes the tooth against lateral stresses.

• In order to minimize the stresses on the abutment

teeth, guide planes should be prepared on
additional teeth.
Rests: It helps in directing the stresses along the long axis of the teeth.

• It provides support to the prosthesis.

• It should form an acute angle with the

perpendicular line passing through the long axis of
the tooth.

• In distal extension cases (class I and class II), rest

seat should be saucer-shaped to allow freedom of
movement of the rest within the rest seat. The
action is similar to the ball and socket joint.

• More the number of teeth with rest seat, lesser will

be the stress transmitted to each abutment tooth.
FIGURE 17-7 Quadrilateral configuration in Kennedy’s class
III partial denture.
FIGURE 17-8 Tripodal configuration in Kennedy class II
modification I.

FIGURE 17-9 Bilateral configuration in Kennedy class I

partial dentures.
Design considerations in distal extension partial
denture
Design consideration in a distal extension cases (Kennedy class I and
class II).

Direct retention

• Properly contoured and closely fitting denture base is important to

restore function and appearance.

• Accurate fitting of the framework against the guide planes.

Clasps

• Simplest type of clasp design should be selected.

• Selected clasp should possess a good stabilizing quality and should

be passive in nature.

• These should be strategically positioned so that these can best

control the stress.

In Kennedy class I situation, two retentive clasp arms are required,

one each on the terminal abutment.

• In case retentive undercut is located in the distobuccal region, a bar

type clasp should be used.

• If the retentive undercut is located in the mesiobuccal region,

wrought wire clasp should be used.

• The reciprocal or the bracing arm should always be rigid.

In Kennedy class II situation, the prosthesis should have three

retentive clasps.
• On distal extension side, the terminal abutment has one retentive
clasp.

• On the tooth supported side, one clasp is placed as far anterior and
one clasp is placed as far posterior.

• If modification space is present, retentive clasp is placed on teeth,

both anterior and posterior to the edentulous space.

Rests

• Rests should be placed next to the edentulous space.

• Rest seat should be prepared so that the functional forces are

directed along the long axis of the tooth.

• Teeth which can provide maximum support should be selected.

• Rest seat should be saucer-shaped which should not have any sharp
angles and ledges.

• Rest should freely move in the rest seat in order to release the
stresses which otherwise would have been transferred to the
abutment tooth.

Indirect retention

• It should be located as far anterior to the fulcrum line as possible.

• Two indirect retainers are indicated in class I situation and usually

one is indicated in class II situation.

• It should be prepared with positive rest seats which can direct the
forces along the long axis of the tooth.

• Lingual plate can act as an indirect retainer, if supported at both

ends with rest seats.
Major connectors

• It should always be rigid and should not impinge on the gingival

tissue.

• In maxillary major connector, support should be derived from the

hard palate.

• In mandibular major connector, extensions into the lingual surface

of the teeth should be used in order to increase rigidity and
distribute the lateral stresses.

Minor connectors.
These should be rigid and should be positioned such that they
increase the comfort and cleanliness.

Occlusion

• A harmonious occlusion is desired without any interfering contact.

• Artificial teeth should be arranged such that they minimize the

stresses produced by the prosthesis.

• To minimize the stress, fewer teeth with reduced buccolingual

width are selected:

• Teeth with sharp cutting edges and sluiceways are

selected.

• For better mechanical advantage, the teeth should

be positioned over the ridge.

• The centric relation should be coincided with the

centric occlusion.
Denture base

• Denture base should have broad coverage to distribute the stresses

over wider area.

• The tissues are recorded in functional form using a selective

pressure technique.

• The form and contour of the denture should be highly polished.

Design consideration in tooth-supported partial

denture
Tooth-supported partial denture is included in Kennedy class III
situation. The components of the partial denture should be designed
after surveying the master cast on the surveyor.

Direct retainers

• The location of the retentive undercut is not critical as in distal

extension cases.

• The abutment teeth are not subjected to harmful stresses during

function.

Clasp design

• Quadrilateral configuration of the clasps should be ideal.

• Simplest type of clasp design should be selected.

• The reciprocal arm should always be rigid.

Rests

• Rests are usually placed next to the edentulous ridge.

• The rests provide support to the prosthesis.

Indirect retainers

• These are usually not required.

• If posterior abutment is not clasped, the requirements are similar to

the distal extension cases.

Major, minor connector and occlusion.

These should be rigid and design consideration similar to distal
extension cases.

Denture base

• Functional impression is not needed here.

• Extension of the denture base depends on factors such as comfort

and aesthetics of the patient.

In class IV situation, the aesthetic need may necessitate the

placement of the teeth more anterior to the crest of the ridge. This may
result in transmission of harmful leverage forces on the abutment
teeth. In order to minimize the stresses on the abutment:

• As many teeth as possible should be retained.

• Labial alveolar process should be preserved.

• The edentulous span should be small.

Quadrilateral configuration of the clasp system is desirable. The

broad palatal type of major connector is preferred. In case of extensive
edentulous space, functional impression is indicated.

Biomechanical problems associated with

extension base RPDs and their remedies
Biomechanical problems in distal extension partial dentures
• The distal extension partial denture can be subjected to a number of
movements on functional or parafunctional loading.

• The movements are dependent on the quality of supporting

structures, accuracy and extent of the denture base and the
magnitude, direction, duration and frequency of the functional
force.

• Possible movements of the partial dentures can occur:

• About an axis through the most posterior abutment

teeth.

• Around the longitudinal axis formed by the crest of

the residual ridge.

• Around the vertical axis located near the centre of

the arch.
Rotation about the axis through the most posterior abutments

• On the application of the functional load, the rotation of the distal

extension partial denture occurs around the line joining the occlusal
rests which is called the axis of rotation or the fulcrum line.

• The amount of rotation of the denture base depends on the

resiliency of the mucosa covering the residual alveolar ridge and the
accuracy of the adaptation of the denture base.

• Movement of the denture base in opposite direction is resisted by

the action of the retentive clasp arm of the terminal abutment and
the indirect retainer.

• The indirect retainer should be placed as far as possible from the

 distal extension base to afford the best possible mechanical
advantage.

• The denture base should cover as large area as possible in order to

reduce the load per unit area.

• The occlusal rests should be placed mesially on the abutment tooth

in order to move the arc of movement of the saddle more
perpendicular to the mucosa.

• Effect of clasping is that more the rigidity of the clasp, greater the
leverage on the tooth and less the load on the alveolar ridge;
whereas, more the flexibility of the clasp, less leverage on the tooth
and more load on the ridge.

Rotation around the longitudinal axis formed by the crest of the

ridge

• Fulcrum line extends posteriorly distal to the terminal abutment.

• It passes along the crest of the ridge to its posterior extent on the
same side.

• In class I situation, there are two fulcrum lines around which lateral
movement of the partial denture can occur.

• The lateral movement of the extension base can occur due to the
inclined plane of the cusp of the posterior teeth.

• The steeper the cusp, more will be the lateral load.

• The anatomy of the residual ridge will play a significant role in

resisting lateral movement of the denture base.

• Flat ridge with movable submucosa will offer less resistance to

lateral movement as compared to well-formed ridge with firmly
bound mucosa.
• Cast clasp transmits more rotational or lateral force on the abutment
tooth in comparison to the wrought clasp.

• However, the wrought clasp will convey more lateral stress on the
residual ridge in comparison to the cast clasp.

• Lateral loads are also exerted on the denture by the adjacent facial
and lingual musculature during swallowing.

Rotation around the vertical axis located near the centre of the
arch

• The rotation of the prosthesis is along the vertical axis located near
the centre of the arch.

• When vertical forces are acting on the denture base, most of the
periodontal ligament fibres are activated.

• If lateral forces are applied to the denture base, only part of the
periodontal fibres will be activated and this will result in harmful
forces on the abutment.

• This rotation is resisted by the stabilizing component of the partial

denture such as the reciprocal clasp and the minor connectors.

• Stability component on one side of the arch acts to stabilize the

partial denture against the horizontal forces applied on the opposite
side.

• To minimize the movement, the arms of the three-arm clasp should

brace the tooth completely on its buccal and lingual surfaces.

• The minor connector should be made rigid.

• The magnitude of the stress on the abutment will be greater, if the

clasp is made of cast alloy than with wrought alloy.
• The magnitude of stress will be less on the ridge posteriorly, if the
clasp is made of cast alloy than with wrought alloy.
Methods of stress control in RPD
Methods of controlling stress in RPD are:

(i) Reduce the load on the abutment and the ridge

(ii) Distribution of load between the teeth and the residual ridge

• By varying the connector between the clasp and

saddle

• Stress breaking

• Combination of rigid connection and bar clasp

• Combination of rigid connection and Akers’ clasp

• The disjunct denture

• By anterior placement of the occlusal rest

• RPI system

• Balance of the force system

• By mucocompression
(iii) Distributing the load widely

• Over more than one abutment tooth on each side

• Over the maximal area of the edentulous ridge

Reducing load on abutment and the ridge

• By reducing the buccolingual width of the teeth

• By reducing the number of teeth on the denture base particularly the

distal most tooth

• Broad coverage of the denture base

• This ensures decreased load on the ridge and abutment teeth,

thereby increasing the chewing efficiency.

Distribution of load between the teeth and the

ridge
Distribution of load between the teeth and the ridge is done by
varying the connection between the clasp and the denture base.

Stress breaking: It provides a certain degree of movement between the

clasp unit and the denture base.

• Most of the load here is borne by the ridge rather

than the abutment tooth
Combination of rigid connection and the bar clasp: The resiliency of
the portion of the bar clasp which contacts the abutment tooth
depends upon its length, cross-section and the type of alloy used.

• Greater the resiliency of the clasp, lesser will be the

horizontal and lateral stresses borne by the
abutment.
Combination of rigid connection and the Akers’ clasp: Here there is
more load on the abutment tooth and less on the ridge.

• To reduce the stress, saucer-shaped rest seat should

be prepared in distal extension cases.
Disjunct denture: In patient with severe gingival recession and
periodontically weakened teeth, a two-part denture called disjunct
denture is constructed.

• The denture consists separately of tooth-borne and

mucosa-borne segments which act independently
of each other on the supporting tissues.

By anterior placement of the occlusal rest

• By doing so, the stresses on the saddle is changed from class I lever
system to the favourable class II lever system.

• This ensures even distribution of stresses on the ridge and less stress
on the abutment.

• This principle is utilized in RPI system and the balance of force

system.

Distribution of load
• Wider load distribution over the teeth takes place by anterior
placement of the rest on the abutment.

• Broad coverage of the denture base reduces the load over the
edentulous ridge.
Stress breaker

Definition
Stress breaker is defined as ‘a device or system that relieves specific dental
structures of part or all of the occlusal forces and redirects those forces to
other bearing structures or regions’. (GPT 8th Ed)
Stress breaker is a device which allows movement between the
denture base and the clasp assembly.

Role of stress breaker in RPD

• Role of stress breaker is to distribute the load between the ridge and
the teeth.

• Both the vertical and horizontal components of the forces are

favourably distributed.

• The vertical component of the force is to the greater extent

distributed to the edentulous ridge and to lesser extent to the
abutment tooth.

• The horizontal or lateral forces acting on the stress breaker sadly are
greatly distributed to the edentulous ridge and not to the abutment
tooth.

• The magnitude of harmful lateral torquing forces on the abutment

tooth is greatly reduced.

• Since the edentulous ridge bears greater amount of horizontal and

lateral forces, it is more likely to show signs of greater resorption.

• Stress breakers are usually indicated for periodontally compromised

abutment teeth, where it is desirable to distribute the stresses over
the edentulous ridge rather than the teeth.

• Poorer the condition of the teeth, more flexible connection between

 the ridge and tooth is desired and vice versa.

Advantages

• Horizontal or lateral forces acting on the abutment teeth are

minimized.

• It is possible to seek a balance of stress between the abutment and

the ridge by proper selection of the flexible connector.

• Intermittent pressure on the denture base massages the mucosa.

• Splinting of the weak teeth by the denture is possible despite the

movement of the distal extension base.

Disadvantages

• Fabrication is complex.

• It is costly.

• Concentration of horizontal and vertical stresses leads to increased

ridge resorption.

• Effectiveness of the indirect retainer is reduced or eliminated.

• Repair and maintenance are difficult.

• There are chances of wear of the attachments.

• The spaces between the components can attract food lodgement.

Precision attachments

Definition
Precision attachments are defined as ‘an interlocking device, one
component of which is fixed to an abutment or abutments, and the other is
integrated into a removable dental prosthesis in order to stabilize and/or
retain it’. (GPT 8th Ed)

Classification of the precision attachments

According to Alan A. Grant and O.A. Wesley:
On the basis of site of attachment to the abutment tooth:

(i) Class 1: Coronal attachments – divided into extracoronal

attachments and intracoronal attachments

(ii) Class 2: Root-face attachments – divided into stud attachments and

bar attachments

According to H.W. Prieskel (1979)

On the basis of shape of attachments:

(i) Intracoronal attachments – frictional type

• Mechanical lock

• Semiprecision attachment (custom-made)

(ii) Extracoronal attachments – projection units

• Connectors

• Combined units
(iii) Stud attachments

(iv) Bar attachments – bar joints

• Bar units
(v) Auxiliary attachments – screw units

• Friction devices

• Bolts, hinged flange

Function of precision attachments

• Labial or buccal clasp arm is eliminated.

• These are aesthetically superior.

• These direct the forces along long axis of the teeth.

• These can provide effective reciprocation.

Indications

• Tooth supported partial dentures

• To break stress in distal extension cases

• To retain hybrid dentures

• To stabilize unilateral saddles

• Use in overdentures

• When few remaining teeth are present

• When splinting of teeth is indicated to aid in their stabilization

• For superior aesthetics, since there is elimination of the clasp.

Contraindications

• In case of teeth which are narrow buccolingually and have short

 clinical crown.

• In a patient with poor oral hygiene.

• In a patient with high caries index.

• In case of teeth with large pulp horns.

• In case of decreased patient dexterity.

• In case of inadequate space for the attachment.

• In case of compromised restorative and endodontic treatment.

Advantages

• It improves aesthetics.

• It has better mechanical advantage, as it directs the forces along the

long axis of the tooth.

• Force applications are closer to the fulcrum line.

• In distal extension cases, there is decreased stress to the abutment

tooth.

• In comparison to the clasp, the attachments are less bulky and are
more aesthetic and lead to less food stagnation.

Disadvantages

• It has complexities of design, procedures for fabrication and clinical

treatment.

• Minimum 4–6 mm of occlusogingival abutment height is required to

incorporate attachment without overcontouring.

• Anatomy of the tooth – limited faciolingual tooth width.

• It is expensive.

• Wearing of attachment components is a disadvantage.

Shortened dental arch concept
The primary aim of restorative dentistry is to preserve the complete
dental arch. It may not be possible or affordable for majority of the
elderly patients; therefore, the concept of shortened dental arch (SDA)
can be considered.
Definition: SDA is an arch with reduction of teeth starting posteriorly,
mostly in the permanent molars.
This concept was first developed by A.F. Kayser (1981). The concept
suggests that the minimum number of occluding pairs of teeth
(anterior and the premolars) are required to provide satisfactory oral
functional demands of the patient.
The number of occluding pairs can vary according to age and other
factors illustrated in Table 17-1.

TABLE 17-1
FACTORS ON WHICH OCCLUDING PAIRS VARY

Age Functional Level Occluding Pairs

20–50 I – Optimal 12
40–80 II – Suboptimal 10 (SDA)
70–100 III – Minimal 8 (ESDA) extreme

Note: ESDA, extreme shortened dental arch; SDA, shortened dental arch.

Prognosis of SDA depends on:

• Excellent oral hygiene

• Spatial relationship between the maxillary and mandibular arch

• Age of the patient

• Periodontal condition of the anterior teeth

• Adaptive capacity of the TMJ

• Occlusal load

Indications
• Progressive caries/periodontal disease confined mainly to the
molars

• Periodontal condition of the anterior and premolars favourable

• Financial and other limitation to the restoration of dental arch

Contraindications
• Class III and severe class II skeletal relationship

• Alveolar support of remaining teeth is markedly reduced

• Parafunctional habits

• TMJ disorders

• Excessive or abnormal wear of existing teeth

Advantages
• It results in simplification of oral hygiene maintenance.

• It results in enhanced prognosis of the remaining teeth.

Disadvantages
• Decreased occlusal table.

• No support from the edentulous ridge.

Key Facts
• Gillett Bridge consists of a partial denture which utilizes the Gillett
clasp system. It is composed of an occlusal rest which is notched
deep into the occlusal axial surface with a gingivally placed groove
and a circumferential clasp for retention. The occlusal rest is
custom-made with a cast restoration.

• Angle of gingival convergence is located apical to the height of

contour on the abutment tooth.

• Every denture is an all acrylic type of dentures which restores

multiple edentulous spaces in the maxillary arch. There is minimal
contact between the acrylic teeth and the abutment teeth to reduce
the lateral stresses. The posterior most teeth are bounded by the
wrought clasp which aids in retention and prevents distal tipping of
the posterior teeth.

• Embrasure clasp is best used in Kennedy class II cases.

• Dr A.J. Fortunati was first to use dental surveyor.

• Surveyor is essentially a parallelometer which is used to determine

the relative parallelism of two or more surfaces of the teeth or other
parts of the cast.

• Microanalyser is a type of surveyor which electronically measures

the amount of undercut.

• Cast should not be tilted more than 10° at the time of surveying.

• One of the most important functions of the clasp is to distribute the

stresses.

• The main purpose of tilting the cast in surveying is to determine the

most desirable path of placement.

• The scriber on the surveyor marks the greatest convexity of the

tooth.
• Gold is the best material to fabricate clasp.
CHAPTER
18
Mouth preparation in RPD

CHAPTER OUTLINE
Introduction, 289
Objectives of Mouth Preparation and Preprosthetic Phase of Mouth
Preparation in Partially Edentulous Patients, 289
Objectives, 290
Relief of Pain and Any Infection, 290
Oral Surgical Procedures, 290
Conditioning of Abused or Irritated Tissues, 290
Prosthetic Phase of Mouth Preparation in Partially Edentulous
Patients, 292
Preparation of the Rest Seat, 293
Rest Seat Preparation on Tooth Enamel, 293
Rest Seat Preparation on New Gold
Restorations, 293
Rest Seat Preparation in Amalgam
Restorations, 293
Rest Seat Preparation for Embrasure
Clasp, 293
Rest Seat Preparation on Anterior Teeth, 294
Incisal Rest Seat Preparation, 294
 Creation of Retentive Undercuts, 294
Modification of Height of Contour, 294
Inlay, Onlay and Crowns, 294
Preparation of the Guiding Planes, 295
Definition, 295
Purpose of Guiding Plane, 295
Preparation of the Guiding Planes, 295
Introduction
Mouth preparation is one of the most critical steps in successful
removable partial dentures (RPDs). It helps not only in replacing what
is missing but also in preserving the remaining tissues. It aims to
bring oral tissues to optimum health and removes any cause which
may interfere in success of RPD.
Objectives of mouth preparation and
preprosthetic phase of mouth
preparation in partially edentulous
patients
Mouth preparation is a procedure which changes or modifies the
existing oral conditions in order to facilitate the placement and
removal of the prosthesis and to ensure its long-term functioning.

Objectives
• To eliminate any condition which may interfere in the placement or
removal of the prosthesis

• To establish abutment teeth and supporting structures in optimum

health

• To establish an acceptable occlusion plane

• To alter or shape the contour of the abutment tooth so that it can

best accommodate the removable prosthesis

Mouth preparation is often accomplished by two phases:

• Preprosthetic phase: This involves the elimination of any condition

which can hinder the placement or removal of the prosthesis and
long-term success of the prosthesis.

• Prosthetic phase: This involves shaping or altering the contour and

form of the teeth or supporting structures to receive the removable
prosthesis.
Preprosthetic phase of mouth preparation includes the following
stages:

(i) Relief of pain and any infection

(ii) Oral surgical procedures

(iii) Conditioning of abused tissues

(iv) Periodontal therapy

(v) Occlusal plane correction

(vi) Orthodontic correction for misalignment

(vii) Splinting of weakened teeth for better support

Relief of pain and any infection

• Any aetiology which causes pain to the teeth should be treated first
and immediately.

• The most common cause of pain is caries or defective restoration.

• Acute pain or abscess should be treated first in this phase of

treatment.

• Deep carious lesions need to be treated with intermediate

restoration until definite treatment plan is formulated.

Oral surgical procedures

After the relief of pain, oral surgical procedures should be done so
that enough time is given between the surgery and the impression
procedures.
• These procedures include extraction of teeth with hopeless
prognosis

• Extraction of residual root, impacted teeth or unerupted teeth

• Surgical removal of cysts, palatal or mandibular tori, exostosis

• Preprosthetic surgical procedures such as ridge augmentation or

vestibular extensions

• Removal of abnormal soft tissue lesions such as polyps and

papillomas

• Removal of sharp bony spicules and rounding of sharp knife-edge

ridges

• Surgical correction of jaw deformity

Note: In any surgical procedure, the main objective should be

preservation of as much bone as possible.

Conditioning of abused or irritated tissues

All the abused or irritated tissues should be treated before
impressions are made of the edentulous ridges.

Clinical features
• Inflammation of the mucosa covering the denture-bearing area.

• Burning sensation in residual ridge, the tongue, the lips and the
cheeks.

• Distortion of normal anatomical structures such as retromolar pads,

incisive papilla or the rugae region.

• Causes: Ill-fitting dentures, unstable removable prosthesis with

 deflective occlusion, nutritional deficiencies and endocrine
imbalance are the probable causes.

• Treatment: It depends on the condition of the tissues. If the tissues

are slightly inflamed, then symptomatic treatment such as massage,
saline rinses and rest to the tissues are advised. If tissues are
abused, wearing of the prosthesis is discontinued for some time.
Tissue conditioners are advised, which give a cushioning effect on
the tissues.

Periodontal therapy
This therapy is done to restore the mouth to a healthy state. The
objective is to establish and maintain the periodontium in a healthy
condition.
The criteria to satisfy the objective are as follows:

• To eliminate aetiological factors causing periodontal disease

• To eliminate periodontal pockets

• To establish harmonious occlusal relationship

• To develop a proper plaque control programme

Caution: It is important to ensure that the periodontium is in a

healthy state before other phases of the treatment are initiated.

Occlusal plane correction

It is often observed that in partially edentulous patients the occlusal
plane is uneven. This may be due to supraeruption of the opposing
teeth or due to mesial migration of the adjacent teeth or tipping of the
teeth adjacent to the edentulous area.
There are many methods to correct the uneven occlusal plane;
however, selection of a particular method depends on the severity of
the occlusal plane.
Methods to correct uneven occlusal planes

1. Enameloplasty: It is a procedure involving intentional removal of a

portion of tooth structure in order to correct the occlusal plane.
However, the amount of correction possible by this method is very
limited. Often the reduction is confined to tooth enamel, except in
older patients where the reduction can be in dentine. The cut surface
should always be polished (Fig. 18-1).

2. Onlay: Occlusal surface of teeth to be restored with onlay should be

free of pits and fissures. Cast gold onlays are most effective in
establishing the occlusal plane through this method.

Advantages:

• Natural contours of tooth can be maintained.

• It requires lesser tooth reduction.

Disadvantages:

• It has less retention.

• Chrome alloy onlays can rapidly wear the enamel of

the opposing tooth.
3. Crown: A full veneer crown is normally indicated, if crown height
of the tooth is desired to be changed or if the facial, lingual or
proximal surfaces are to be altered. The mounted diagnostic casts are
an important diagnostic aid to decide the desired amount of tooth
reduction.

4. Endodontically treated tooth with a coping: Teeth which are

supraerupted or with compromised bone support can be
endodontically treated and covered with a coping or a crown and can
be used as an abutment tooth (Fig. 18-2).

5. Extraction: It is indicated when tooth is severely malposed and

those that cannot be orthodontically corrected should be removed. It
is also advised in the following situations:

• When certain teeth can complicate and compromise

the success of the treatment.

• Teeth interfering with the placement of the major

connector wherein it cannot be corrected by crown
or other method.
6. Surgical repositioning: This involves repositioning of the jaws (by
surgical methods) to correct severe malocclusion.

FIGURE 18-1 Enameloplasty done to correct the occlusal

plane.
 FIGURE 18-2 Endodontically treated tooth with coping can
be effectively used as abutment tooth.

Correction of misalignment
Following are the methods used to correct misalignment:

• Orthodontic repositioning

• Enameloplasty

• Crowns

Provision of support to weakened teeth

Teeth with compromised periodontal support require additional
support which can be provided by the following methods:

• Removable splinting

• Fixed splinting

• Overdenture abutments
Prosthetic phase of mouth preparation
in partially edentulous patients
The prosthetic phase of mouth preparation includes the alteration of
the tooth contour usually in the enamel or on the surface of existing
restoration or on new restoration in the form of crown, onlay, etc. It is
always better to do the desired reduction on the mounted diagnostic
cast before doing the reduction into the mouth. Clinicians should
employ conservative approach during mouth preparation.
Prosthetic phase of mouth preparation includes the following stages:

(i) Preparation of the guiding planes

(ii) Preparation of the rest seat

(iii) Creation of retentive undercuts

(iv) Modification of height of contour

(v) Inlays, onlays and crowns

Preparation of the rest seat

Rest seat is always prepared after guiding planes are prepared on the
abutment tooth. Rest seat preparation is done differently for tooth
enamel, existing restorations or new restorations.

Rest seat preparation on tooth enamel

A small round diamond stone bur is used for the preparation of the
rest seat on the tooth enamel.

• The outline form of reduction is triangular with the base of triangle

at the marginal ridge and the apex towards the centre of the tooth.
• It is 1 mm thick at the thinnest portion, if chrome alloy is used and
1.5 mm thick, if gold is used.

• Properly prepared rest seat is round, smooth and spoon-shaped.

• The rest in the rest seat should act as a ball and socket joint
(especially in the distal extension cases).

• Beading wax is used to check the amount of available space for the
occlusal rest by asking the patient to bite on the wax in the centric
relation.

• Thickness of the wax is then measured by using Boley gauge.

• After preparation, the altered tooth surface should be highly

polished.

Rest seat preparation on new gold restorations

The proposed rest seat preparation is carved in the wax pattern after
the guiding planes are carved.

• A small depression is made on the wax pattern to accommodate the

thickness of the rest and the crown casting.

• Once the restoration is cast with gold, the rest seat is highly
polished.

• In cases of existing gold restorations, the rest seat is directly

prepared on the restoration.

• If the existing restoration is not adequately thick, a new restoration

should be advised to the patient.

Rest seat preparation in amalgam restorations

This procedure is less desirable than tooth enamel or gold
restorations.
• The rest seat is prepared with a small round bur.

Note: Amalgam alloys tend to warp when placed under constant

load.

• If care is not taken during the preparation of proximal portion, it

may result in fracture of the amalgam restoration.

• Polishing of the prepared rest seat on the amalgam restoration is a

must.

Rest seat preparation for embrasure clasp

Embrasure clasps are two simple circlet clasps joined together at the
body.

• The rest seats are prepared on two adjacent posterior teeth

extending from the mesial fossa of one tooth to the distal fossa of
the other tooth.

• The preparation is continued on the buccal and lingual surfaces.

• A small round diamond stone is used to accomplish the reduction.

• Marginal ridges on both the teeth are simultaneously reduced.

• Contact point between the teeth should be left intact to prevent

wedging action between the teeth.

• Alternatively, preparation can also be done by cylindrical diamond

stone.

• The preparation for this clasp should be 1.5–2 mm wide and 1–1.5
mm deep (Fig. 18-3).

• The occlusal clearance is checked by utility wax.

 FIGURE 18-3 Embrasure clasp.

Rest seat preparation on anterior teeth

Cingulum or lingual rest seat preparation is more preferred than the
incisal rest.

• In cast restorations, the lingual rest seat is carved in the wax pattern.

• Safe-sided disk or inverted cone diamond stone is used to prepare

rest seat in the enamel.

• The preparation should be polished with carborundum-

impregnated rubber wheel.

Incisal rest seat preparation

These rest seats are usually placed on the incisal angles of the canines.

• The seat should be avoided on the incisors because of poor

aesthetics and poor mechanical advantage.

• It is prepared by small safe-sided diamond disk.

Creation of retentive undercuts

• If the proposed abutment does not have sufficient retentive
undercut, it should be created.

• It is created in the form of gentle depression by a small round-ended

tapered diamond.

• The procedure for creating a retentive undercut is called dimpling.

• It is prepared parallel and as close as possible to the gingival

margin.

• The preparation is created approximately 0.010-inch deep with

slight concavity when measured from the perpendicular line which
parallels the path of insertion.

• The dimension of the depression is approximately 2 mm of

occlusogingival height and 4 mm of the mesiodistal length.

• The prepared depression should be highly polished with the

carborundum-impregnated rubber (Fig. 18-4).

FIGURE 18-4 Dimpling done with round-ended tapered

diamond bur to create retentive undercut.

Modification of height of contour

This procedure is performed to ideally locate the clasp arm and
lingual plating.
• It is done by reshaping the abutment tooth in tooth enamel.

• Minor reshaping of the tooth surface can drastically improve the

mechanical and aesthetic properties.

Inlay, onlay and crowns

When the cast restoration is indicated on the abutment tooth, the
retentive undercut, height of contour and the guiding planes can be
incorporated in the wax pattern itself.

• First the diagnostic cast is surveyed and carefully analysed.

• If the tooth planned for cast restoration is lingually tilted, more

reduction should be accomplished lingually.

• Wax patterns of the crowns to be placed on the abutment are carved

to receive the clasps.

• In a casted restoration, the contour created in the wax patterns is

verified on the surveyor table.
Preparation of the guiding planes
Guiding planes are parallel surfaces on the proximal or the lingual
surface which are made parallel to the planned path of insertion of the
removable prosthesis. The intentional conservative tooth reduction to
prepare guiding planes is called enameloplasty. It is defined as ‘the
intentional alteration of the occlusal surface of the teeth to change their form’.
(GPT 8th Ed)

Definition
Guiding plane is defined as ‘vertically parallel surfaces on the abutment
teeth or/and dental implant abutments oriented so as to contribute to the
direction of the path of placement and removal of the removable dental
prosthesis’. (GPT 8th Ed)
Guiding planes are necessary for smooth placement and removal of
the dentures. These are prepared during the prosthetic phase of
mouth preparation of the abutment teeth (Fig. 18-5).

FIGURE 18-5 Guide plane with 2–4 mm occlusogingival

height is considered ideal.
Purpose of guiding plane
• Guiding plane helps in smooth placement and removal of the
prosthesis.

• It helps in stabilization of the prosthesis against horizontal forces.

• It ensures predictable clasp assembly function.

• It helps in reducing wedging forces between the teeth.

• It improves retention by frictional resistance.

• It decreases undesirable space between the tooth and the prosthesis,

thus aiding in oral hygiene maintenance.

• It can provide indirect retention to the prosthesis.

• It helps in restoring original width of the edentulous space.

Types of guiding planes on the basis of their

location
(i) Guiding planes on the abutment in tooth-supported cases

(ii) Guiding planes on the abutment next to the distal extension

edentulous space

(iii) Guiding planes on the lingual surfaces of the abutment teeth

(iv) Guiding planes on the anterior abutment teeth

Preparation of the guiding planes

• After the diagnostic cast is surveyed and the tilt of the particular
design of partial dentures is planned.
• Similar relationship is duplicated in the patient’s mouth during
mouth preparation.

• A cylindrical diamond point is used to make the preparation. A

light sweeping stroke from the buccal to the lingual line angle is
usually used.

• Approximately, 2–4 mm of flat surface is created on the

occlusogingival surface parallel to the planned path of insertion.

• Usually, five to six light sweeping strokes are sufficient to produce

desired reduction.

• Reduction should always follow the contour of the tooth.

• All the prepared tooth surfaces should be polished with

carborundum-impregnated rubber wheel after preparation.

• Fluoride gel application can be advantageous on the prepared

surface.

• In distal extension cases, the occlusogingival height of the plane is

reduced to 1.5–2 mm in order to facilitate the rotation of the partial
denture around the distal occlusal rest.

• Guiding planes on the lingual surface ensure maximum resistance

to the lateral stresses, thereby, providing additional stabilization.

Key Facts
• Shape of the rest seat in natural posterior teeth should be saucer-
shaped.

• A rest helps to transmit the occlusal stresses parallel to the long axis
of the tooth.
CHAPTER
19
Impression making in removable
partial denture

CHAPTER OULINE
Introduction, 297
Impression Making in Tooth-Supported Partial Denture Cases, 297
Factors Influencing the Support of the Distal
Extension Denture Base, 297
Factors Influencing the Support of the Distal
Extension Partial Dentures, 298
Introduction
Impression making is done after the mouth preparation is completed.
This is one of the most fundamental areas for the success of removable
partial denture (RPD). The impression of the teeth is made using
impression material in anatomic form, whereas impression of residual
ridge is recorded in functional form. Therefore, dual impression is
required to obtain the master cast. It is essential to study various
impression techniques and impression materials used in fabrication of
RPDs.
Impression making in tooth-supported
partial denture cases
The impression making in tooth-supported partial denture cases is
simpler when compared with tooth tissue-supported denture cases. In
tooth-supported partial denture cases (Kennedy class III and most of
Kennedy class IV), the functional forces are transmitted directly along
the long axis of the teeth through the rests. In this case, the edentulous
ridge will not contribute to the support of partial denture, as the
abutment teeth bear the forces before they reach the edentulous ridge.
Therefore, in tooth-supported partial denture cases, functional
impression is not required and the impression can be made in
anatomic form. The denture can be fabricated on the cast made by
impression of the tissues in anatomic form. Irreversible hydrocolloids are
the most widely used material for making impression in anatomic
form. The alginate impression should be poured within 12 min after
being removed from the mouth. The alginate impression material is
easy to handle, relatively inexpensive, dimensionally accurate and
does not require expensive armamentarium.

Factors influencing the support of the distal

extension denture base
In distal extension cases, the support is derived from both the
edentulous ridge and the abutment tooth. Therefore, a dual
impression technique is advocated to equalize the support derived
from both the edentulous ridge and the abutment teeth. The
impression of the teeth is recorded in the anatomic form and the
impression of the soft tissues is recorded in the functional form.

Factors influencing the support of the distal

extension partial dentures
Type of soft tissue covering the edentulous ridge: A firmly bound
adequately thick attached mucosa provides the maximum support
to the denture.

Type of alveolar bone constituting the denture-bearing area: Cortical

bone with adequate thickness provides best support for the denture.

Design of the partial denture: It is important to reduce the amount of

stress on the edentulous ridge in distal extension cases. This is made
possible by the following ways:

• Placing indirect retainers anterior to the fulcrum

line in order to resist the rotational movement of
the denture.

• Additional components such as minor connectors

are used to contact the proximal guide plane to
resist the rotation of the denture around the
fulcrum line.
Magnitude of occlusal force: Amount of force per unit of the denture
base is reduced to enhance the longevity of the prosthesis. It is done
by:

• Broad coverage of the edentulous ridge.

• Narrowing of the occlusal table.

• Increasing efficiency of the occlusal table by

providing sluiceways to improve the mastication.
Amount of tissue covering the denture base: Broader the coverage of
 the edentulous ridge, greater will be the distribution of the stresses.

Nature of the denture-bearing area: The primary support or the stress-

bearing area should be identified in the maxillary and mandibular
ridges to provide maximum support.

• In the maxillary arch, buccal slopes of the ridge are

capable of resisting the lateral forces and the bony
palate is capable of resisting the vertical forces.

• In the mandibular arch, buccal shelf region is an

excellent primary stress-bearing area.
Fit of the denture base: Accurate fit of the denture is important in
transmitting forces to the primary stress-bearing area.

Impression methods used for distal extension

removable partial denture
The dual impression technique is often indicated for distal extension
RPD. There are basically two types of dual impression techniques:

(i) The physiological or functional impression techniques

• McLean and Hindel’s method

• Functional relining method

• Fluid wax method

(ii) The selected pressure impression technique
Functional impression techniques used in distal
extension RPD
The functional impression technique records the edentulous ridge by
placing occlusal load on the impression tray during impression
making. By doing this, the underlying tissues are displaced under
function.
Types of functional impression techniques:

(i) McLean and Hindel’s physiological method

(ii) The functional relining method

(iii) The fluid wax method

Mclean–Hindel’s physiological method

• The physiological impression technique was first advocated by

D.W. McLean.

• According to the proponents of this technique, the tissues of the

residual ridge of distal extension cases are recorded in functional
form and then a second impression is made over it.

• A custom impression tray is fabricated over the primary cast of the

arch without spacer.

• Occlusal rim is made on the custom tray.

• The custom tray is loaded with the impression paste and the tray is
seated over the ridge area.

• The patient is asked to bite over the occlusal rim as the impression
paste sets (Fig. 19-1).

• With the biting, the underlying tissues are compressed and the
tissues are recorded in functional state.
• Without removing the custom tray, a second impression is made
with alginate using a stock tray.

• While making the second impression, the finger pressure is applied

until the alginate impression material sets.

FIGURE 19-1 The patient is instructed to bite on a loaded

custom tray.

Disadvantages

• Finger pressure is not equal to the biting pressure applied during

functional impression.

• The small amount of alginate material present between the occlusal

rim and the stock tray acts as buffer and restricts transfer of entire
load (finger pressure) to the custom tray.

Hindel’s modification

• According to G.W. Hindel, the first impression which is made of the

edentulous ridge should be an anatomic impression, i.e. the
impression is made with impression paste without applying any
pressure.

• Hindel developed a stock tray for the second impression which was
provided with holes so that the finger pressure could be applied
 through it.

• While making the second impression, a finger pressure is applied

through the holes provided in the stock tray (Fig. 19-2).

• The finger pressure is maintained until the alginate sets.

• This pressure simulates the condition as if the masticatory force was

taking place.

• The primary aim of this technique was to record the edentulous

ridge in the form of functional loading.

FIGURE 19-2 Impression making with Hindel’s modified

stock tray.

Disadvantages

• In a denture made with this technique, if the clasp assembly is

effective, it will allow the denture base to displace the soft tissue in
functional form. This will lead to adverse tissue reaction and
resorption of the bone.

• If the clasp assembly is not effective, it will maintain the denture

base slightly occlusal in rest position. When the patient occludes,
the artificial teeth come in contact before the natural teeth which is
uncomfortable to the patient.
Functional relining technique

• Here, a physiological impression is obtained to support a distal

extension denture base (after the completion of partial denture).

• It consists of adding a new surface to the tissue surface before the

insertion of the denture or at a later stage.

Steps in functional relining technique

• First an anatomic impression is obtained using irreversible

hydrocolloid.

• The impression is poured to get the master cast.

• The master cast is duplicated to obtain a duplicating cast.

• Over the duplicating cast, a soft metal spacer is provided to ensure

uniform space for the impression material between the denture base
and the ridge.

• The cast framework is then fabricated.

• After processing, the metal spacer is removed and an even space is

created between the denture base and the ridge.

• A low-fusing modelling plastic is flown over the tissue surface of the

denture base, tempered in water bath and seated in the patient’s
mouth.

• This procedure is repeated until an accurate impression of the ridge

is made.

• Border moulding is accomplished by proper manipulation of the

border tissues.

• After completion of this procedure, a final impression is made by

uniform scrapping of modelling plastic to a depth of 1 mm to
 provide adequate space for the impression material.

• The final impression is made with free flowing zinc oxide eugenol
paste. In case of undercuts, light-bodied polysulphide or addition
silicone is used.

• During this technique, the patient is instructed to maintain the

mouth in partially open position.

• This is done in order to best control the movement of cheeks and the
tongue and observe the relationship between the framework and
the teeth.

Advantages

• Fit of the denture base on the edentulous ridge is superior.

• The amount of soft tissue displacement can be controlled by the

amount of relief given. Greater the relief provided to the modelling
plastic before the final impression, lesser will be the tissue
displacement.

Disadvantages

• As this is an open mouth impression technique, it is difficult to

maintain a correct relationship between the framework and the
abutment teeth during impression making.

• It is difficult to maintain correct occlusal contact following relining.

Fluid wax technique

Purpose

• This technique is used to reline the existing partial denture

framework.

• This technique is used to correct the distal extension edentulous

 ridge portion of the original master cast.

Objectives

• To obtain the maximum possible extension of the peripheral borders

of the denture base without interfering with the function of the
border tissues

• To record the stress-bearing areas in the functional form

• To record the non-stress-bearing areas in the anatomic form

Procedure

• This is an open mouth technique.

• Fluid wax consists of special waxes which are rigid at room

temperature and it has the ability to flow at mouth temperature
(e.g. Iowa wax developed by Dr Smith and the Korrecta wax
developed by Dr O.C. Applegate and Dr S.G. Applegate).

• Approximately, 1–2 mm relief space is desired between the

impression tray and the edentulous ridge.

• Once the loaded tray is seated in the patient’s mouth, it should be

left undisturbed for 5–7 min in order to allow the wax to flow
sufficiently without pressure build up.

• For the clinical technique, a water bath is maintained at a

temperature of 51–54°C into which the wax container is placed.

• The fluid wax is painted on the tissue surface of the impression tray.

• Borders of the impression tray should be short by 2 mm of all

movable border tissues.

• It is important to note that the fluid wax lacks sufficient strength to

support itself, if the border is made short by more than 2 mm.
• The loaded tray is positioned in the patient’s mouth for at least 5
min before making another addition.

• Before every addition, the impression tray is inspected for proper

tissue contact.

• If tissue contact is there, the wax will appear glossy; it will be dull, if
there is no contact.

• The peripheral extensions are recorded by proper tissue movements

of the patient.

• These movements are repeated a number of times until a positive

tissue contact is observed.

• Once complete tissue contact with anatomy of the limiting border

tissue is evident, the impression tray is again placed in the mouth
for the final time for about 12 min to ensure complete flow of the
wax.

• The finished final impression is poured as soon as possible, as the

fluid wax is subjected to distortion, if not handled carefully.

Advantage

• This technique can produce an accurate impression, if the steps are

properly followed.

Disadvantages

• The procedure is time consuming and technique sensitive.

• Proper time period during impression procedure should be

followed; otherwise, an impression with excessive tissue
displacement will result.

Selective pressure technique

• This technique is based on the concept of loading the stress-bearing areas
and adequately relieving the non-stress-bearing areas.

• By doing this, greater functional stress is directed to the stress-

bearing areas and lesser stress is directed to the non-stress-bearing
areas.

• The custom tray is selectively relieved by trimming with acrylic bur.

• The primary stress-bearing areas are minimally relieved and the

non-stress-bearing areas are sufficiently relieved.

• Greater the relief, lesser will be the tissue displacement and vice
versa.

• In the lower arch, the buccal shelf area is the primary stress-bearing
area and should be slightly relieved.

• The lingual slope of the residual ridge that resists the horizontal or
the rotational forces should also be relieved minimally.

• In patients with easily displaceable tissues covering the ridge, more

relief can be obtained by making holes in the impression tray so as
to avoid excessive pressure of the impression material.

Advantages

• This technique provides a closely fitting denture base.

• The tissues are selectively loaded depending on the stress-bearing

capacity.

Disadvantage

• It is difficult to accurately demarcate and relieve the stress-bearing

and non-stress-bearing areas.
Altered cast technique or corrected cast
technique
• In both the fluid wax impression technique and the selective
pressure impression technique, an impression of the edentulous
ridge is made by the impression tray attached to the metal
framework.

• The master cast is then altered to accommodate new ridge

impression.

• This technique is called the altered cast or the corrected cast technique.

Altered cast partial denture impression is defined as ‘a negative

likeness of a portion or portions of the edentulous denture bearing areas made
independent of and after the initial impression of the natural teeth. This
technique employs an impression tray(s) attached to the removable dental
prosthesis framework or its likeness’. (GPT 8th Ed)
Altered cast is defined as ‘a final cast that is revised in part before
processing a denture base also called corrected cast or modified cast’. (GPT
8th Ed)
The altered cast method is composed of the following three main
steps:

Step 1: Individual acrylic resin impression base is added to the lattice

framework.

• Holes are placed along the alveolar groove for the

excess impression material to escape.

• Framework with the attached trays is adjusted in

the patient’s mouth.

• Borders of the tray are trimmed 2–3 mm short of all

 the reflections but should cover the retromolar pad.

• Low-fusing modelling plastic is used for border

moulding.

• Completed border moulded tray is inspected for fit

and extension.
Step 2: Final impression is made with zinc oxide eugenol paste, fluid
wax or rubber base impression materials.

• Framework should be completely seated and

maintained in position during the setting of the
impression material.
Step 3: Altering the master cast.

• The master cast is altered to accommodate the

newly corrected impression.
Procedure

• The edentulous ridge area of the master cast, originally recorded in

anatomic form, is removed with the help of saw in two planes (Fig.
19-3).

• One cut is made perpendicular to the longitudinal axis of the ridge,

1 mm distal to the abutment tooth.

• The second cut is made just lingual and parallel to the lingual
sulcus, as recorded in original impression.

• The cut surface of the cast is grooved for additional retention of the
 stone poured to get the altered cast.

• Completed final impression is seated on this cut cast and secured in

position with the help of sticky wax (Fig. 19-4).

• The assembly with new impression and cast is reversed.

• The peripheral borders of the impression are protected with the

utility wax and the entire assembly is wrapped with boxing wax.

• Before pouring stone, the original cast is saturated with 12 mm of

water for 5 min.

• The ridge areas are then poured with stones of different colours to
differentiate the new impression from the rest of the cast.

• After final set of stone, the boxing wax is removed and the cast is
trimmed.

• This corrected cast or the altered cast is used to complete the partial
denture (Fig. 19-5).
 FIGURE 19-3 Sectioned master cast.

FIGURE 19-4 Framework with final impression seated on a

sectioned master cast.
 FIGURE 19-5 An altered master cast.

Key Facts
• Dual impression technique is usually indicated in distal extension
cases.

• Fluid waxes have ability to flow at mouth temperature and be firm

on room temperature.

• Iowa wax was developed by Dr E.S. Smith.

• Zinc oxide eugenol paste is the material of choice for recording

edentulous ridge, which is without gross undercut.
CHAPTER
20
Laboratory procedures, occlusal
relationship and postinsertion of
removable partial denture

CHAPTER OUTLINE
Introduction, 304
Steps Involved in the Fabrication of Cast Partial Denture, 304
Block Out of Master Cast, 305
Relief in Relation to Fabrication of Cast Partial
Framework, 306
Waxing of the Cast Partial Framework, 306
Refractory Cast, 307
Spruing in Relation to Cast Partial Denture
Fabrication, 307
Procedure of Burnout, Casting and Finishing
and Polishing of the Cast Framework, 308
Methods of Establishing Occlusal Relationship for Partial
Dentures, 309
Articulator or Static Technique, 309
Aesthetic Try-In in Removable Partial Dentures, 310
Purpose, 310
Procedure, 310
Introduction
This chapter includes various laboratory steps involved in the
fabrication of cast partial dentures. It is essential to have the
knowledge of principles and techniques involved in the fabrication of
removable partial denture (RPD) for better understanding and success
of partial dentures.
Steps involved in the fabrication of cast
partial denture
The steps involved in the fabrication of cast partial framework are as
follows:

(i) Fabrication of the master cast

(ii) Surveying of the master cast

(iii) Block out and relief of master cast

(iv) Master cast duplication

(v) Refractory cast fabrication

(vi) Beeswax dip

(vii) Waxing of the partial denture framework

(viii) Spruing of the waxed framework

(ix) Investing of the waxed framework

(x) Burnout

(xi) Casting

(xii) Finishing and polishing

Fabrication and surveying of the master cast have already been

described in Chapters 17 and 19.

Block out of master cast

Definition
Block out is defined as ‘the process of applying wax or another similar
temporary substance to undercut portions of a cast so as to leave only those
undercuts essential to the planned construction of the prosthesis’. (GPT 8th
Ed)

Objective of block out

Objective of block out is to eliminate undercut areas on the master cast
that will be crossed by the rigid parts of the partial denture.

Procedure prior to block out

• Before the block out procedure, maxillary cast will require beading.

• Beading is not done on the mandibular cast because the major

connector lies on thin, attached mucosa, which will not tolerate the
positive contact.

• Mater cast should be sprayed with a sealer to protect the design

through the block out and duplication procedures.

Block out procedure

• Block out wax should always be placed below the height of contour
on the cast.

• Any wax placed above the height of contour and not removed will
result in cast framework which will not contact the tooth on the
cast.

• Cast scrapping during wax removal will result in oversized casting

which will require adjustment during framework fitting.

• The shaping of the wax should take place when excess of block out
wax is placed in all the undercut areas.
Types of block out
(i) Parallel block out

(ii) Shaped block out

(iii) Arbitrary block out

Parallel block out

• In this type of block out, all the undercuts below the height of
contour are blocked.

• It is done once the master cast is surveyed and the desired path of
insertion is determined.

• Block out wax is used to fill all the undercuts below the survey line
and parallel to the determined path of insertion.

• Excess wax is trimmed by the parallel wax carving blade-like device

mounted on the surveyor.

• Parallel block out is usually accomplished in all tooth-borne partial

dentures.

Shaped block out

• This is indicated just below the retentive tip of the clasp arm on the
primary abutment.

• Block out wax is shaped to provide a slight ledge just apical to the
clasp tip.

• This ledge helps in guiding the placement of the wax or plastic

pattern for the clasp arm so that it lies at the desired position in the
 undercut area.

Arbitrary block out

• This is indicated in all the areas not involved in the framework
design in order to minimize distortion during duplication.

This block out is also indicated in the following areas:

• All areas of gross soft tissue undercuts

• Tissue undercuts distal to the cast framework

• Labial and buccal tooth and tissue undercuts not involved in

denture design

Relief in relation to fabrication of cast partial

framework
During the fabrication of the partial denture, certain areas require
relief. The common areas which require relief are:

• Below the lingual bar connectors or bar portion of the linguo-plates

• Maxillary or the mandibular tori

• Below the framework, over the edentulous ridge for attachment of

the acrylic resin

The purpose of relief is to create a space between the framework and

the cast. To provide relief, a sheet of wax is adapted over the ridge
area of the cast. The amount of space provided for the acrylic resin is
determined by the thickness of the relief wax. It is important to have
at least 1 mm of thickness of the acrylic resin. Thinner resin is often
porous and weak.
Relief is also required to obtain sharp and definite internal finish line.
This ensures the metal resin junction to be at right angles. A small
square of wax of dimension 2 mm is cut in the relief wax to form the
tissue stop (Fig. 20-1).

FIGURE 20-1 Diagram showing relief wax and tissue stops.

Waxing of the cast partial framework

The waxing procedure of the cast partial denture framework is started
after the design is transferred from the master cast to the refractory
cast. Boley gauze is used for the accurate transfer of the design to the
refractory cast. A sharp lead pencil is useful in copying the outline of
the framework on the refractory cast. The position of the clasp tip is
the most critical part during design transfer.
Commercially available plastic patterns are commonly used during
wax-up procedure.

Procedure
• The plastic patterns are adhered to the refractory cast using an
adhesive.
• The shape of the clasp greatly affects its flexibility.

• The clasp pattern is cut greater than that required.

• Once the plastic patterns are placed on the cast they are adapted to
contours without distortion.

• Care is taken so that the pattern is not stretched.

• Plastic pattern once contoured is joined together with wax similar in

composition to the blue inlay wax.

• This wax is used to seal the margin of the major connectors. This is
also used in freehand waxing of minor connectors and rests.

• Soft blue casting wax is used to reinforce the wax joints, occlusal rest
seat and for build-up of the periphery of the pattern.

• Waxed-up framework is then finished and polished with precise

flame (Fig. 20-2).
 FIGURE 20-2 Complete wax-up maxillary framework.

Refractory cast
Refractory cast is defined as ‘a cast made of a material that will withstand
high temperatures without disintegrating also called investment cast’. (GPT
8th Ed)
Duplication of the master cast is important in fabrication of the cast
partial denture. The duplication of the master cast results in the
formation of the refractory cast. Duplication begins after the block out
and relief of the master cast are completed. The material and the type
of technique used for duplication depend on the type of alloy used for
fabrication of cast partial denture.
The investment material or the refractory is chosen depending on
the alloy selected for fabrication. Low heat investment such as the
gypsum-bonded investment material is used for casting type IV gold
alloy and ticonium. This refractory material can be burned out at 704°C
without causing breakdown of the investment. High heat investment
material such as the phosphate-bonded investment material is used
for casting cobalt–chrome alloy. The burnout temperature of this
material is 1037°C.
The investment material is mixed following the manufacturer’s
instructions and is poured over the colloid mould. Once the
investment material is completely set, the refractory cast is carefully
removed and placed in the drying oven at 93°C. The dry refractory
cast is soaked in hot beeswax dip to ensure smooth and dense surface.
The heated cast is dipped in beeswax at 138–149°C for 15 s.

Spruing in relation to cast partial denture

fabrication

Spruing of the framework

Sprue is defined as ‘the channel or hole through which plastic or metal is
poured or cast into a gate or reservoir and then into a mold’. (GPT 8th Ed)

Purpose of spruing
• It acts as a reservoir of the molten metal.

• It leads the molten metal from the crucible into the mould cavity.

Principle of spruing
• Sprues should be large enough to feed the molten metal into the
empty mould.

• It should consist of 8–12 gauze round wax.

• Channel should lead into the cavity as directly as possible for

minimum turbulence for flow.

• The primary sprue should be attached to the most bulky portion of

 the wax framework.

• Secondary or accessory sprues should be attached to the thinner

section to complete the casting.

• All the sprue channels should originate from a common point in the
crucible.

• The point of attachment of the sprue to the wax pattern should be

flared rather than at right angle.

Types of spruing
Based on the number of sprues
Single: It consists of using a single sprue such as with casting ticonium
alloy.

Multiple: It consists of using multiple sprues such as with casting gold

alloys and high heat chrome–cobalt alloy.

Based on the location of the main sprue

Direct or top spruing: This is done for mostly spruing the maxillary wax
framework. It consists of sprue originating from the top of the wax
pattern from the crucible former.

Indirect or bottom spruing: This is usually done for the mandibular

partial dentures. The spruing is done from the centre of the
refractory cast. It consists of a 7-mm wide and 10-mm long central
sprue coming out from the central hole. The auxiliary sprues are
attached to the central sprue about 7 mm below the tip of the central
sprue.

Rear spruing: This consists of a single large sprue attached to the rear
of the maxillary complete palatal major connector.
Procedure of burnout, casting and finishing and
polishing of the cast framework

Burnout
Purpose of burnout

• To drive off moisture in the mould

• To completely eliminate the plastic and wax pattern

• To expand the mould in order to compensate for the shrinkage of

the metal

• To completely remove the carbon residue from the investment

material

Burnout cycle
The investment ring is placed in the burnout furnace. At the start of
the burnout cycle, the investment should be moist.

1st hour: Temperature is maintained at 100°C; water is driven out

during this phase.

2nd hour: Temperature is increased to 238°C.

• Temperature equalization between the mould and

furnace phase takes place.

• Wax vaporization takes place and there is complete

removal of water during this phase.
3rd hour: Temperature is raised to 675–710°C for 1.5–2 h.
• This is called the soaking period.

• There is complete removal of carbon residues, wax

pattern and moisture from the interstices of the
investment during this phase.

Casting
Purpose of casting.
 Purpose of casting is to quickly inject the molten metal into the
empty mould using force.

Types of force used

• Centrifugal force

• Air pressure under vacuum

Casting methods
• Gas oxygen blowtorch

• Oxyacetylene mixture

• Induction casting: It is the most common method used for modern

casting. It is based on the alternating electric current by the
induction of the magnetic field.

Temperature measurement.
It is done by the optical sensor which is located above the crucible.
Some of the sensors may be activated by the infrared wavelengths
emitted by the metal and are called optical pyrometers.

Procedure
• Casting machine is set according to the manufacturer’s instruction.

• Metal of required quantity is placed in the uncontaminated crucible.

• Metal is melted by activating the alternating current.

• Meanwhile, the mould is removed from the furnace and placed in

the holding mechanism.

• Once the desired temperature is achieved, the lever is released.

• Molten metal is released from the crucible and enters the empty
mould.

• Casting is completed.

Finishing of the casting

• The casted framework is retrieved after removing the investment

material.

• First the sprues are cut using high abrasive discs.

• Coarse finishing of the framework is done using abrasive stones or

sintered diamonds.

• Fine stones are used to finish the critical areas such as the retentive
clasp and rests.

Fitting of the framework

• Fitting of the framework is checked on the master cast using sprays,

disclosing media.

• Seating and grinding continues until the framework completely fits

the master cast.

Final finishing of the framework

• The framework is finally given a satin finish using the rubber
wheels, rag and felt wheels.

• The framework is placed in ultrasonic cleanser to remove debris

collected during the polishing procedure.
Methods of establishing occlusal
relationship for partial dentures
There are two methods of establishing occlusal relationship:

(i) Functionally generated path technique (refer Chapter 28)

(ii) Articulator or static technique

Articulator or static technique

This technique includes the following.

Direct apposition of the casts or hand articulation: This technique is

used when only a few teeth are missing and need to be replaced, as
sufficient number of opposing teeth are present to establish a
satisfactory relationship.

• Occluded casts are secured together with a sticky

wax and mounted arbitrarily on the hinge
articulator.
Using interocclusal record: It is used when adequate number of teeth
is present but the relation of the opposing natural occlusion does
not permit hand articulation.

• Metal-reinforced wax such as the Aluwax is used

for interocclusal record in centric occlusion or
centric relation position.

• If wax record is used, it should be corrected by

flowing rigid zinc oxide eugenol paste.
Jaw relation record entirely made on occlusion rims: This method is
used when there are no posterior natural teeth. For example, when
maxillary complete denture opposes the mandibular class I
situation or when both the maxillary and mandibular arches are
having class I situations.

• Vertical dimension is established in such cases as in

conventional complete dentures.
Occlusal relation using bite rims on the denture bases: This method
can be used with distal extension cases or in totally tooth-supported
cases with large edentulous spaces.

• Accurately fitting record bases are fabricated on the

edentulous ridge.

• Bite rims are fabricated over the record bases to

establish the jaw relationship.

• Bite registration paste or the impression plaster is

used to make interocclusal record at the established
vertical dimension.
Aesthetic try-in in removable partial
dentures
Aesthetic try-in of the denture is an essential step before the insertion
of the final prosthesis. This step is indicated when all the posterior
teeth are missing in both the arches or distal extension RPD is
opposed with complete denture.

Purpose
• Any correction in tooth size, shape, position or shade can be easily
accomplished during this stage.

• Jaw relation can be verified.

• To give the psychological satisfaction to the patient.

Procedure
• The patient is seated comfortably on the chair and is instructed not
to bite with too much force.

• The waxed partial dentures are completely seated in the patient’s

mouth and he/she closes the mouth lightly.

• First the gross error, if any, is corrected.

• The anteroposterior positioning of the anterior teeth is examined.

• The anterior teeth should provide adequate support to the lip and
should aid in natural appearance of the profile.

• Tooth length in relation to the lip length and length of the remaining
teeth are carefully evaluated.
• In patients with average lip length, the incisal edge of the anterior
teeth is slightly visible when the lips are relaxed.

• In the smiling position, gingival portion of the denture base is just

visible.

• Proper overjet and overbite are evaluated.

• The midline of the denture should be in harmony with the midline

of the face.

• The shade of the selected teeth should be verified in natural light.

• The final satisfaction and appearance of the denture should be left to

the patient.

Key Facts
• Aerosol spray is useful in fitting the framework on the master cast.

• Functionally generated pathway technique eliminates the need for

facebow transfer.

• Gypsum-bonded investment is used for casting type IV gold alloys

and ticonium.
CHAPTER
21
Insertion, relining and rebasing

CHAPTER OUTLINE
Introduction, 311
Troubleshooting during Metal Try-In and Fitting of the Framework in
Patient’s Mouth, 311
Troubleshooting during Metal Try-In of the
Framework, 311
Troubleshooting during Fitting of the Framework
in the Patient’s Mouth, 312
Postinsertion Instructions to the Partial Denture Patient, 312
Insertion and Postinsertion Problems and Their Management in
Relation to RPD, 312
Problems Encountered during Insertion, 312
Problems during Postinsertion, 313
Relining of RPD, 314
Indications, 314
Method of Relining, 314
Special Removable Partial Dentures, 315
Guide Plane Removable Partial Denture, 315
Role of Lingual Plate, 315
Disjunct Denture, 316
Spoon Denture, 316
Computer-Aided RPD Designing, 317
Flexible Dentures, 317
Introduction
The insertion of new removable partial dentures in patient’s mouth is
an important step in denture fabrication, as the patient appreciates the
final outcome of his/her treatment. The clinician ensures that the
dentures have a good fit, retention, aesthetics and comfort. The
removable partial dentures require far greater level of maintenance
than the fixed partial dentures because the edentulous ridges resorb
and the soft tissue support gets loose with time. The procedures of
relining and rebasing are indicated to maintain the fit and accuracy of
the removable partial dentures.
Troubleshooting during metal try-in
and fitting of the framework in patient’s
mouth
Troubleshooting during metal try-in of the
framework
• First, the metal framework should be examined on the master cast
for its fit. The framework should not fit too tightly on the cast.

• Any undercut should be relieved on the cast so as to avoid excessive

flexing of the retentive clasp arm.

• The tissue side of the framework is then carefully examined for any
blebs or metal artefacts which interfere during insertion. Any such
interference is removed with the help of suitable abrasive stone.

Troubleshooting during fitting of the framework in

the patient’s mouth
• The framework is tried in the patient’s mouth for complete seating.

• Any interference during seating of the framework is disclosed using

disclosing white paste or wax.

• Any interference is eliminated by using an appropriate abrasive.

• Framework is aligned along the path of insertion and with light

finger pressure is seated on to the abutment teeth to the final
position.

• Excessive force during seating should be avoided.

• The framework in the areas of occlusal rest and the clasp assembly
is checked thoroughly for any interference in occlusion.

• Any interference is checked by articulating paper and corrected with

equilibration procedure.

• The aim of this procedure is to adjust the occlusion in all functional

positions.
Postinsertion instructions to the partial
denture patient
After the insertion of the cast partial denture, the patient is given
instructions regarding its usage and maintenance. The written
instructions should preferably be given to the patient.

• The patient is advised for possibility of minor discomfort with the

use of artificial prosthesis.

• The patient can have difficulty with speech and during eating.

• The patient is advised to maintain proper hygiene.

• After every meal, the dentures should be cleaned with a small stiff
brush.

• The patient is advised to soak the dentures in cleansing solution for

at least 15 min once daily.

• The patient should always remove the denture at night and place it
in a water-filled container.

• The patient should follow strict follow-up regime.

• There may be a possibility of gagging with the new prosthesis.

• The patient should be taught the insertion and removal of the

prosthesis in determined path of placement.

• The patient should never bite on the prosthesis to seat it.

Insertion and postinsertion problems
and their management in relation to
RPD
The primary objectives of the insertion of the removable partial
denture (RPD) are:

• To accurately fit the denture base to the edentulous ridge

• To adjust the retentive clasps and correct occlusal discrepancies, if

any

• To instruct the patient on the maintenance of the prosthesis

Problems encountered during insertion

Problems regarding correct fit of the denture base

• Cast metal denture base should not be corrected during insertion
because any correction or adjustment is done during framework
try-in.

• If the denture base is made of acrylic resin, it may require correction

due to polymerization shrinkage during processing.

• Pressure-indicating paste is used to identify any overextensions or

pressure on the ridge.

• Denture base is altered or adjusted accordingly.

Occlusal discrepancies
• During insertion, occlusal discrepancy can occur between the
 artificial teeth in one arch and the natural teeth or artificial teeth in
another arch.

• Any discrepancy or interference is identified and then corrected

using a suitable abrasive.

• Occlusal correction can also be corrected by laboratory remount

procedure.

• The completed partial denture is remounted on the articulator and

any occlusal discrepancy is identified and corrected. This procedure
saves the chairside time during insertion.

Problems with the retention of the prosthesis

If retention of the prosthesis is poor, the clasp arms are carefully
adjusted by applying a controlled force using pliers.
Caution: Overadjustment of the clasp may lead to breakage of the
clasp.

Problems during postinsertion

The dentures are evaluated 24 h after the insertion. Postinsertion
problems can be due to the following reasons:

• Irritation of the soft tissues

• Irritation of the hard tissues

• Miscellaneous problems

Irritation of the soft tissues

This can be due to some reasons which are as follows:

Overextended denture base: Overextended denture base can result in

soreness or ulceration of the soft tissues.
• Overextensions are checked using pressure-
indicating paste.

• Any overextension is trimmed using an acrylic

trimmer.

• After correction, the denture base is smoothened

and polished.

• Topical anaesthetic gel is prescribed for local

application.
Tissue side of the denture base is rough: Rough tissue surface of the
denture can cause redness and soreness.

• The rough tissue surface is identified using

pressure-indicating paste.

• Any rough surface is identified and smoothened

using stone burs.
Occlusal prematurities or discrepancies: This can result in pain.

• Occlusal discrepancies are checked using

articulating paper.

• Occlusal prematurities are checked in both the

centric and the eccentric positions.

• Occlusal adjustment is done using appropriate

 abrasive.

Irritation of the hard tissues

• Once the causes of soft tissue irritation are identified and treated,
the abutment teeth and the remaining teeth should be carefully
examined.

• If excess of pressure is applied by the metal framework or the resin

on the tooth, it is carefully identified using disclosing wax and
relieved using high-speed carbide bur.

Miscellaneous problems
Gagging: It occurs commonly due to overextended maxillary denture.
Overextension is removed using stone bur.

Cheek biting: Cheek biting is caused by trapping of the cheek mucosa

between the posterior occlusal tables. This is caused by improper
placement of the artificial teeth with insufficient horizontal overlap.
It is corrected by proper placement of teeth or by selectively
grinding mandibular buccal cusp.

Tongue biting: This is caused by lower posterior teeth arranged too far
lingually into the tongue space. It is corrected by reshaping the
lingual surfaces of the teeth or by proper positioning of the
posterior teeth.

Pain on chewing: This could be due to occlusal discrepancy. Occlusal

discrepancy or prematurities are identified and corrected by
selective grinding. The patient is advised soft diet during the early
periods of adjustment.

Problems with phonetics: This can be due to change in contour of the

speech area such as anterior part of the palate or because of
improper positioning of the anterior teeth. In such situations:
• The patient should be given some time to adjust to
the new prosthesis.

• If the problem is due to contour, adjustment should

be done accordingly.

• If the problem is due to improper positioning of the

teeth, teeth should be removed and repositioned in
the correct position.
Relining of RPD
Relining is defined as ‘the procedure used to resurface the tissue side of the
removable dental prosthesis with new base material, thus producing an
accurate adaptation to the denture foundation area’. (GPT 8th Ed)

Indications
• When partial denture has lost its fit.

• Loss of occlusion.

• The indication of the partial denture requiring relining procedure is

assessed by visual inspection of the loss of supporting tissues.

It can be inspected by two methods:

1. Using thin mix of alginate: A thin mix of alginate is placed on the

tissue surface of the denture. It is placed firm in position till it sets.
The bulk of alginate is assessed. If ≥2 mm of alginate is present, then
relining should be done.

2. Finger pressure: Finger pressure is applied at the distal end of the

denture base and the amount of anterior lift of the indirect retainer is
evaluated. If the amount of space below the indirect retainer is more
than 2 mm, the relining procedure is indicated.

Method of relining

Intraoral reline
• Uniform amount of resin is removed from the tissue surface of the
denture base.
• Autopolymerizing resin is mixed by following the manufacturer’s
instructions.

• The external surface of the denture base is covered with an adhesive

tape.

• The mixed resin is applied over the tissue surface of the denture
base.

• The denture is secured in proper position and the resin is allowed to

set.

• Once the resin is completely polymerized in 12–15 min, the denture

is finished and polished.

• This method of reline is inferior to the laboratory reline method and

should be used in temporary situations.

Laboratory reline
Uniform amount of resin is removed from the tissue side of the
denture base and the undercut region because of the following
reasons:

• There should be adequate space for the impression material so that

the material does not displace the soft tissues.

• The tissue side of the resin should be removed in order to make

space for the new resin.

• Selection of the impression material depends on the condition of the

tissues.

• If the tissues are mobile, the free-flowing zinc oxide paste is used.

• If the tissues are firm and tightly bound to the ridge, silicones,
polysulphide or functional waxes can be used.
• Once the impression material is loaded, the denture is seated on the
ridge with firm pressure and the tooth–denture relationship is
maintained.

• The patient should not bite till the set impression is removed from
the mouth.

• Denture is invested in one-half of the flask with a stone replica of

the tissue surface of the denture base in the other flask.

• Both the flask should close completely.

• Once the invested material sets, the flasks are opened and the
impression material from the denture base is removed.

• After applying separating media on the cast, the resin is mixed

following the manufacturer’s instructions and packed.

• Both the flasks are closed completely.

• Once polymerization of the resin is complete, deflasking is done in

conventional manner and the denture is finished and polished.

• Alternately, the relined impression can be mounted on a duplicating

device.
Special removable partial dentures
Guide plane removable partial denture
Guide plane RPDs are used to stabilize periodontally weakened teeth
in three directions, i.e. mesiodistally, vertically and buccolingually.
Fixed partial denture, if periodontically compromised, provides
stabilization only in buccolingual direction. Therefore, RPD is
preferred in periodontally compromised dentition as it provides cross-arch
stabilization.
Guide plane RPD consists of multiple guide planes, multiple rests,
clasps and rigid major and minor connectors (Fig. 21-1).

FIGURE 21-1 Guide plane RPD.

Design considerations
• Design is based on broad stress distribution principle.

• Stress is distributed through rigid major and minor connectors and

multiple clasps and rest.

• It is essential to note that all the clasps will not be retentive but are
useful in stabilizing the dentition and preventing tooth movement.

• Only two of the clasps on both sides should be retentive and the
remaining clasps should be designed such that these lie above the
height of contour.

• The reciprocal arm should contact the tooth before the retention arm
to reduce the lateral forces on the teeth.

• Framework should have a passive fit.

• Multiple parallel guide planes are essential in the design.

• To determine parallelism between the teeth, intraoral paralleling

device can be used.

Drawbacks
• May not work in cases with severe bone loss

• Compromised aesthetics

• Contraindicated in Kennedy’s class IV cases

Role of lingual plate

• It is indicated in supporting periodontically weakened mandibular
anterior teeth.
• It provides cross-arch stabilization and support to the remaining
teeth (Fig. 21-2).

• It helps in stabilizing the teeth by splinting action.

• Mesial and distal incisal rests can be prepared on the anterior teeth
and engaged into the lingual plate by metallic extension.

• Also, lingual plate prevents food impaction between the

interproximal spaces between the teeth.

FIGURE 21-2 Lingual plate provides cross-arch stability and

adequate support.

Disjunct denture
Disjunctor is defined as ‘any component of the prosthesis that serves to
allow movement between two or more parts’. (GPT 8th Ed)
Disjunct dentures are special type of stress breakers which consist
of a bar and a slot.

Indication
These dentures are indicated in distal extension partial dentures
where the remaining teeth are periodontically compromised.

Design considerations
• In the lower, lingual plate is used as major connector which is
supported at both the ends by rests and clasps.

• It has a small projection which is called the disjunct bar.

• This bar engages into the disjunct slot which is housed in the
denture base (Fig. 21-3).

• The bar–slot connection allows freedom of movement during

function.

• This helps in minimizing stress transferred to the abutment teeth

which are already periodontically compromised.
 FIGURE 21-3 Disjunct denture.

Advantages
• It is used in periodontally compromised dentition.

• It allows freedom of movement and reduces stress on abutment.

Disadvantages
• It results in patient discomfort due to movement of the parts.

• It is difficult to construct.

• Wearing of the parts occurs.

Spoon denture
Spoon denture is defined as ‘a maxillary provisional removable dental
prosthesis, without clasps, whose palatal resin base resembles the shape of a
spoon’. (GPT 8th Ed)

Indications
• It is indicated in Kennedy class IV partial dentures in the maxilla.

• It is used as provisional partial dentures during the course of

periodontal treatment as plaque control is easy.

Design features
• This denture does not have any clasp and is confined to the central
portion of the palate.

• It resembles a spoon (Fig. 21-4).

• It does not contact the lingual surfaces of any tooth.

• Any premature contact will highly compromise on the retention of

the prosthesis.
 FIGURE 21-4 Spoon denture is indicated in class IV partial
dentures.

Advantages
• It can be used as interim dentures in periodontically compromised
patients.

• It makes plaque control easier.

• There are less chances of food impaction and caries.

Disadvantage
• Retention is poor.

Computer-aided RPD designing

Recently there has been renewed interest in digitally designed RPDs
with the use of high precision scanners, CAD/CAM software and 3D
printers. The CAD/CAM designed partial dentures have eliminated
multiple time-consuming traditional laboratory procedures in the
fabrication of RPDs.

Design considerations
• The master cast of the patient is digitally surveyed and scanned.

• The computer software and rapid prototyping technology

integrated with 3D printing are used to design a sacrificial pattern.

• This pattern is then casted using chromium–cobalt alloy or titanium

alloys.

• The metal framework is finished and polished and the fit is adjusted
intraorally.

Advantages
• Improved and accurate fit

• Reduced time of fabrication

• Reduced manual labour

• Less chances of error (porosity, defects in casting, etc.)

Disadvantages
• Cost

• Initial time required for training

Flexible dentures
In these dentures, the entire framework and the essential components
are fabricated using flexible nylon polyamide denture base resins. The
retention is provided by flexible nylon retentive clasps. The dentures
are fabricated using injection moulding technique in specially
designed flasks. The flasking and the dewaxing procedures are similar
to that followed in compression moulding technique, e.g. Valplast
material is commonly used.
One drawback of flexible RPDs is that these do not contain any
vertical displacement component such as occlusal or canine rests.
These RPDs depend solely on the soft tissues (residual ridge) for
support.
Key Facts
• Shim stocks are useful in verifying the presence and location of the
occlusal contacts.

• Spoon denture is the maxillary interim RPD which is without clasp

and whose palatal resin base resembles the shape of the spoon. It is
usually used during periodontal treatment.
SECTION III
Fixed Partial Dentures
OUTLINE

22. Introduction to fixed prosthodontics

23. Diagnosis and treatment planning in fixed

partial denture

24. Design of fixed partial denture

25. Clinical crown preparation in fixed

prosthodontics

26. Impressions in fixed partial denture

27. Provisional restoration

28. Occlusion relationship

29. Laboratory procedures in fixed prosthodontics

30. Finishing and cementation

CHAPTER
22
Introduction to fixed
prosthodontics

CHAPTER OUTLINE
Introduction, 320
Indications of Fixed Partial Denture (FPD), 320
Contraindications of FPD, 320
Fixed Dental Prosthesis, 321
Parts of FPD, 321
Classification of FPD, 321
Introduction
Replacement of missing teeth with fixed dental prosthesis helps in
improving function, aesthetics, comfort and speech of the patient.
Successful fixed restorative treatment begins with thorough diagnosis
and treatment planning which enhance not only comfort, aesthetics
and function but also harmony of stomatognathic system.
Fixed prosthodontics is defined as ‘the branch of prosthodontics
concerned with the replacement and/or restoration of teeth by artificial
substitutes that are not readily removed from the mouth’. (GPT 8th Ed)

Indications of fixed partial denture (FPD)

• In a patient who cannot tolerate removable prosthesis.

• In a patient with systemic condition such as epilepsy wherein fear of

aspiration of removable prosthesis.

• In case of short edentulous span.

• In a psychiatric and physically handicapped patient with limited

dexterity.

• Morphology of the abutment teeth requiring alteration.

• Greater stability during function enhances patient confidence and

satisfaction.

• Teeth adjacent to the edentulous area requiring a restoration.

Contraindications of FPD
• Poor oral hygiene

• Long edentulous span

• Paediatric patients and young adults due to the presence of short
clinical crowns, large pulps, high caries rate and increased chances
of trauma

• Inability of the patient to cooperate due to medical reasons

• Advanced periodontal disease

• Unfavourable condition of the abutment tooth/teeth

• Unfavourable tilting or rotation of the abutment teeth

• Bilateral edentulous span requiring cross-arch stabilization

• Large amount of tissue loss in the edentulous region

Fixed dental prosthesis
Fixed dental prosthesis or fixed partial denture (FPD) can be defined
as ‘any dental prosthesis that is luted, screwed or mechanically attached or
otherwise securely retained to natural teeth, tooth roots and/or dental
implant abutments that furnish the primary support for the dental
prosthesis’. (GPT 8th Ed)
Fixed dental prosthesis is also commonly referred to as fixed bridge
(Fig. 22-1).

FIGURE 22-1 Parts of fixed partial denture.

Parts of FPD
Abutment: A tooth, root or an implant which provides attachment to
FPD.

Pontic: An artificial tooth or teeth that replace the missing tooth or

teeth in FPD.
Retainers: A part of the FPD which connects the pontic and is
cemented onto the prepared tooth. It is of two types, namely,
extracoronal and intracoronal.

Connector: A part of the FPD that unites the retainer and the pontic. It
can be rigid or nonrigid depending on its indication.

Classification of FPD
FPDs can be classified into different types depending on the location,
span, abutment, connector and material.
FPDs can be broadly classified as follows:

On the basis of type of material used

(i) All metal

(ii) Metal–ceramic

(iii) All ceramic

(iv) Metal–acrylic

(v) All acrylic

On the basis of type of movement

(i) Fixed–fixed partial denture

(ii) Fixed–movable partial denture

(iii) Removable partial denture

(iv) Combination

On the basis of length of edentulous span

(i) Short-span FPD

(ii) Long-span FPD

On the basis of type of abutment used

(i) Conventional FPD

(ii) Cantilevered FPD

(iii) Resin-bonded FPD

(iv) Fibre-reinforced FPD

(v) Implant-supported FPD

(vi) Splints

(vii) Pier abutment-supported FPD

On the basis of type of support provided at each end

of pontic
(i) Fixed–fixed design

(ii) Fixed–movable design

(iii) Cantilever design

(iv) Spring cantilever design

(v) Combination or hybrid design

Retainers
Retainer is defined as ‘any type of device used for the stabilization or
retention of prosthesis’. (GPT 8th Ed)
 A retainer can be defined as a casting cemented to an abutment tooth
which retains or helps to retain a pontic.

Factors required for ideal retainer

• Retention qualities: Retainer should have adequate retention to bear

the functional forces. The axial walls of the preparation should be as
parallel as possible. Length of the edentulous span, type of design
and surface area are some of the factors which affect the retention of
the retainer.

• Strength: Adequate strength to resist deformation under functional

stresses is an important requirement for ideal retainer.

• Biological factors: Conservation of tooth structure, relation of

margins of restoration to the gingival tissues and contour of
restoration.

• Aesthetic factors: These factors should be aesthetically pleasing.

• Ease of preparation.

Classification of retainers
On the basis of location
(i) Class I: Extracoronal retainers

(ii) Class II: Intracoronal retainers

(iii) Class III: Radicular retainers

On the basis of type of material used

(i) All ceramic
(ii) All metal

(iii) Metal–ceramic

(iv) All acrylic

Selection of retainers.
 Selection of retainers depends on the following characteristics:

• Condition of the abutment tooth/teeth or implant: Height,

mesiodistal width, location, periodontal status and angulation are
some of the factors which greatly influence the selection of the type
of retainer (refer Chapter 23).

• Functional relation of adjacent gingival tissues: The axial contour

of the natural teeth, position of the contact areas and nature of the
embrasure greatly influence the health of the gingival tissues. Full
veneer or complete crown produces the maximum and mesio-
occulso-distal (MOD) restoration produces least disturbance to
these factors.

• Available interocclusal space: Amount of interocclusal space

determines the type of retainer that will be most suitable.

• Presence and extent of caries: This determines the type of retainer to

be selected. Small and shallow caries indicate intracoronal retainers,
whereas large and extensive caries demand the use of extracoronal
retainers.

• Material used for pontic.

• Morphology of the crown of the abutment: To some extent, crown

morphology determines the type of retainers used. For example,
peg-shaped lateral usually requires complete coverage crown.

• Periodontal condition: The periodontal status of the abutment teeth

greatly influences the choice of retainer. More advanced generalized
 chronic periodontal problem leads to gingival recession, bone loss
and even mobility. Splints or appropriate extracoronal retainers are
usually indicated.

• Length of edentulous span: This will influence the extent of the

functional forces transmitted to the retainers. Longer the span,
greater will be the stresses and greater will be the need for bulk and
strength of retainers to resist torsional forces.

• Position of the tooth: Partial veneer crowns are usually indicated in

the anterior region and full veneer crowns are indicated in the
posterior region.

• Occupation, age and sex of the patient: Selection of appropriate

retainer is influenced by these factors as well. For example, younger
patients have higher pulp horn, and therefore, have higher chances
of pulpal damage than older patients.

Extracoronal retainers.
Extracoronal retainers are cast metal restorations or crown that
encircles all or part of the remaining tooth structures. More tooth
structure is removed to provide adequate bulk for strength than
intracoronal restorations. These retainers are also sometimes referred
to as major retainers.

Types of extracoronal retainers

There are two types of extracoronal retainers, which are:

(i) Full veneer crown

(ii) Partial veneer crown

Intracoronal retainers.
 Intracoronal retainers are defined as ‘within the confines of the cusps
and normal/axial contours of a tooth’.
Intracoronal retainers lie within the normal contours of the clinical
crown of a tooth.

Types of intracoronal retainers

(i) Proximo-occlusal inlay

(ii) MOD onlay

Proximo-occlusal inlay (fig. 22-2).

 Proximo-occlusal inlay is defined as ‘a fixed intracoronal restoration; a
dental restoration made outside a tooth to correspond to the form of the
prepared cavity, which is then luted onto the tooth’.

FIGURE 22-2 Proximo-occlusal inlay.

Indications

• Minimal caries or old restoration that requires a mesio-occlusal or

disto-occlusal restoration

• Adequate dentinal support

• Low caries rate

• Patient’s request for all ceramic or gold restoration instead of
amalgam or composite

Contraindications

• High caries index

• Poor oral hygiene

• Young adolescent patient

• Parafunctional habits such as bruxism

• MOD increases the risk of fracture

• Small teeth

• Poor dentinal support requiring extensive preparation

Advantages

• Superior material properties

• Longevity

• No discolouration from corrosion

• Least complex cast restoration

• Less wear in comparison to composites

Disadvantages

• Less conservative than amalgam

• Display of metal

• Utilizes wedge retention which exerts some outward pressure on

 the tooth

• Time consuming

• Costly

• Accurate occlusion is difficult to achieve

• Intraoral adjustment is difficult as it is fragile before bonding

• Any adjustment requires careful finishing and polishing, which is

time consuming

Mod onlay (Fig. 22-3).

MOD onlay is a restoration that restores one or more cusps and adjoining
occlusal surfaces or the entire occlusal surface and is retained by mechanical
or adhesive means.

FIGURE 22-3 MOD onlay on maxillary first premolar.

Indications

• Worn/carious tooth with intact buccal and lingual cusps

• MOD amalgam requiring replacement

• MOD restoration with wide isthmus

• Low caries rate

Contraindications

• High caries rate

• Patient with poor oral hygiene

• Short clinical crown

Advantages

• It provides support for cusps.

• It has high strength.

• It has longevity.

Disadvantages

• It does not have adequate retention.

• It is less conservative than amalgam.

• Castable glass ceramic is less abrasion resistant than traditional

feldspathic ceramic.

• Resin flash or overhangs are difficult to detect and clean, which

ultimately may lead to periodontal problems.

• Finishing of the margins is difficult in less accessible area.

Pontic and its design

Pontic is an artificial tooth or teeth that replace the missing natural
tooth or teeth to restore function, aesthetics, comfort and oral health.
Pontic is attached to the retainer with the help of a connector which
may be rigid or a nonrigid (Fig. 22-4).

FIGURE 22-4 Pontic is an artificial tooth replacing missing

natural tooth.

Definition.
 Pontic is defined as ‘an artificial tooth on a fixed dental prosthesis that
replaces a missing natural tooth, restores its function and usually fills the
space previously occupied by the clinical crown’. (GPT 8th Ed)
Careful design selection is of utmost importance, as this will affect
the function, aesthetics, oral hygiene maintenance and patient comfort
to a larger extent.

Requirement of a pontic

• It should restore function.

• It should provide good aesthetics.

• It should be biologically acceptable.

• It should facilitate plaque control.

• It should provide comfort to the patient.

• It should have adequate strength.

• It should stabilize the occlusion.

• It should not impinge or apply pressure on the underlying tissue.

• It should aid in preserving health of the underlying tissues.

Pontic design.
Selection of appropriate pontic design plays an important role in the
success of treatment with fixed prosthesis. The design of the pontic is
dictated by restoring the form, function and appearance of the tooth
that is replaced.
The principles guiding design of the pontic are:

• Cleansability

• Appearance

• Strength

Factors affecting pontic design

• Tissue contact: The area of tissue contact between the pontic and the
ridge should be small and passive in nature. The area of pontic
contacting the tissue should be convex and, if possible, should only
contact the attached keratinized gingiva. The pontic should never
apply pressure or be placed on the movable tissue as it may cause
inflammation or ulceration of the underlying mucosa.
• Interproximal embrasure: There should be sufficient clearance in the
interproximal embrasure area to facilitate plaque control. Gingival
embrasure should be made wide so as to allow cleaning. In the
anterior region, the space provided is less due to aesthetic reasons
in comparison to the posterior region.

• Occlusal surface: The occlusal form of pontic should correspond to

the tooth it replaces. Usually, the width of the pontic should be 85%
of the original, although it is governed by factors such as strength of
the abutment, ridge form and contour and length of the edentulous
span.

• Length of the span: Longer the span of FPD, more the stress will be
imposed on the pontic and the connector. As the length of the span
increases, there will be increased tendency of flexion of the FPD.

• Material used: Choice of the material to fabricate pontic is very

critical for the success of fixed restoration. The material should be
biocompatible, rigid and aesthetic. Usually, glazed porcelain contact
is provided with the tissue for easier oral hygiene maintenance.

• Ridge contour: Shape of the contour should be carefully studied to

provide an aesthetically successful pontic. In most anterior cases,
modified ridge lap is usually recommended. Although in the
posterior region, more hygienic pontic design is desirable.

Classification of pontic
Pontics can be classified on the basis of following characteristics:

• Mucosal contact

• Material used

• Method of fabrication

(i) On the basis of mucosal contact

• With mucosal contact

• Ridge lap

• Modified ridge lap

• Conical

• Ovate

• Without mucosal contact

• Sanitary (hygienic)

• Modified sanitary
(ii) On the basis of type of material used ( Fig. 22-5)

• All metal

• Metal and ceramic

• All ceramic

• Metal and acrylic resin

• All acrylic resin

(iii) On the basis of method of fabrication
• Customized pontic

• Prefabricated pontic

• Flat backs

• Trupontics

• Long pin facing

• Reverse pin facings

• Pontips

• Modified pin facings

• Interchangeable facing

FIGURE 22-5 Types of pontic based on the material: (A) all

metal; (B) metal and ceramic; (C) all ceramic; (D) metal and
acrylic resin.

(A) On the Basis of Mucosal Contact

(I) With mucosal contact

(i) Ridge Lap or Saddle Pontic

• It is called ridge lap as it overlaps the ridge, both

labially and lingually (Fig. 22-6).

• It closely resembles the natural tooth because it

replaces all the contours of the missing tooth.

• It forms large concave contact with the ridge.

• This design obliterates the proximal, facial and

lingual embrasures.

• The biggest disadvantage of this design is that it

is not possible to clean with dental aid like floss.

• Plaque accumulation leads to gingival

inflammation.

• This design is not recommended or indicated in

any area.

(ii) Modified Ridge Lap

• In this design, the pontic contacts the ridge only

in the facial surface to give an illusion of a tooth
emerging from the gingiva (Fig. 22-7).

• The lingual surface does not contact the ridge and

 has convex surface to aid in cleaning.

• The tissue contacting area should always be as

convex as possible because it facilitates plaque
control.

• Ridge contact of this pontic design is ‘T’ shaped.

• The vertical arm of ‘T’ ends at the crest, whereas

the horizontal arm forms the contact along the
facial surface of the ridge.

• This is the most aesthetic design and is

recommended commonly in the high aesthetic
areas such as upper and lower anterior teeth and
upper premolars and first molar.

(iii) Conical

• It is also called egg-shaped, bullet-shaped or

heart-shaped pontic (Fig. 22-8).

• It is rounded and provides good access for oral

hygiene maintenance.

• It is indicated in lower molar region with thin

ridges.

• It has poor aesthetics and is, therefore, used in

 areas of minimal aesthetic concern.

• This design is not suitable for broad flat ridges, as

small area of contact over broad ridge creates
areas of plaque accumulation.

• This design was called ‘sanitary dummy’ by E.T.

Tinker (1918).

(iv) Ovate

• This design has superior aesthetic with negligible

food entrapment and is easy to clean.

• This design gives an impression of the tooth

emerging from the gingiva (Fig. 22-9).

• Its convex surface is rounded and lies in the soft

tissue depression passively.

• This area is easy to clean and floss.

• The concavity on the ridge can be created by

placing a temporary tooth into the extracted
socket.

• It can also be surgically created in pre-existing

ridge cases.
• It is recommended in highly aesthetic areas, such
as maxillary incisor, canines and premolars.

• Its disadvantage is need for surgical preparation

and extra cost.

(II) Without mucosal contact

(i) Hygienic or sanitary pontic

• This design allows easy cleaning, as there is no

contact with the residual ridge.

• It is usually recommended in unaesthetic zones

such as mandibular molar region.

• Pontic should be at least 3 mm thick

occlusogingivally (Fig. 22-10).

• There should be adequate space below the pontic

for cleaning or flossing.

• This design of the pontic is made convex, both

faciolingually and mesiodistally.

• The undersurface of the pontic is made round to

facilitate easy flossing. This round undersurface
is referred to as fish belly (Fig. 22-11).
 • Disadvantage of the fish belly design is that the
bulk of the connector is decreased and thereby
strength is compromised.

(ii) Modified sanitary pontic

• It is also called arc-fixed partial denture, modified

sanitary pontic or Perel pontic (Fig. 22-12).

• This pontic design is hyperbolic paraboloid

shaped where the tissue surface of the pontic
forms a concave archway mesiodistally.

• The size of the connectors is increased here,

which increases its strength and also allows
better access for cleaning.

• It is indicated in nonaesthetic zones such as

mandibular molar region.

• It is contraindicated in aesthetic area and areas of

reduced vertical dimension.
(B) On the Basis of Method of Fabrication

(I) Prefabricated pontic facings: These are

commercially available porcelain facings which are
preformed and are adjusted according to the
edentulous space. Some of the prefabricated designs
 are:

(i) Trupontic (Fig. 22-13)

• This can be used in both anterior and posterior

regions.

• Occlusal surface is made of gold and the tissue

surface is made of porcelain.

• This has a horizontal slot approaching from the

lingual aspect which accommodates both the
occlusal gold and porcelain.

• To strengthen the gold supporting the pontic,

bevel is given on the lingual aspect to increase its
resistance to occlusal forces.

• Advantage: This has adequate strength, good

aesthetic.

• Disadvantage: This should not be used where

interarch space is less.

(ii) Steele’s facing

• It is the reverse of trupontic.

• Here, gold contacts the ridge tissue and porcelain

 provides the occlusal contact.

• It has a horizontal slot on the lingual aspect for

occlusal porcelain and tissue contact gold.

• Advantage: It is aesthetic.

• Disadvantage: It is weak, so it tends to fracture.

(iii) Pin pontic

• It is most versatile of the manufactured pontic

designs.

• It is used in patients with limited interarch space.

• Here, there are two pins projecting from the

lingual aspect and riveted into gold to aid in
retention.

• Good thickness of gold is provided on occlusal or

incisal surface and glazed porcelain provides the
tissue contact.

• It is also called interchangeable pontic.

(iv) Modified all ceramic pontic

• It is also called tube tooth.

• All ceramic crowns are with dowel hole.

• This all ceramic pontic is cemented with gold

casting which contacts the gingival surface.

• It is used where occlusion is favourable.

• It has tendency to fracture and also it cannot be

repaired.

(v) Modified pin facing (Fig. 22-14)

• Here, additional ceramic is added to the pin

facing to form the saddle area.

• It can be used in the patients with decreased

interarch space.

• Advantage: It is aesthetic, can be easily cleaned,

tissue tolerant and comfortable to the patient.

• Disadvantage: It is time consuming, costly and

difficult to repair.
FIGURE 22-6 Saddle or ridge lap pontic with large concave
contact with the ridge.

FIGURE 22-7 Modified ridge lap with ‘T’-shaped contact with

the ridge.
 FIGURE 22-8 Conical or egg-shaped pontic.

FIGURE 22-9 Ovate pontic lies passively in soft tissue

depression of the ridge.
 FIGURE 22-10 Hygienic or sanitary pontic.

FIGURE 22-11 Fish belly or conventional sanitary pontic.

FIGURE 22-12 Perel pontic or modified sanitary pontic.

 FIGURE 22-13 Trupontic.

FIGURE 22-14 Flatback interchangeable pontic.

Connectors
Connectors are an essential part of FPD that join the individual
retainers and pontics together. It is defined as ‘the portion of the fixed
dental prosthesis that unites the retainers and pontics’. (GPT 8th Ed)

Requirements for appropriate connector design

• It should be sufficiently large to prevent distortion or fracture
during function.

• It should provide adequate space for effective plaque control.

• Its shape, size and position of connector determine the success of the
prosthesis.

• Tissue surface of the connectors should be highly polished.

• Tissue surface of the connector should curve labiolingually to aid in

cleaning.

• In the aesthetic zone, the connectors are usually placed lingually.

Types of connectors
(A) Rigid connectors

• Cast connectors

• Soldered connectors

• Welded connectors
(B) Nonrigid connectors

• Dovetail

• Split pontic

• Cross-pin and wing

(A) Rigid connectors

• These are the most widely and commonly used

connectors in fixed–fixed bridges.

• All the components are rigidly joined.

• Forces are distributed over two or more abutment

teeth.
(i) Cast connectors

• These are made by flowing wax between the wax

patterns of the retainers and the pontic such that
the bridge is casted in a single unit.

• Advantages:

• These are stronger than soldered or welded

connectors.

• These are convenient, as they do not require

additional procedure of soldering.

• Disadvantages:

• They have more chances of distortion, especially in

long-span bridges.

• Multiple unit bridges are casted preferably in

 several sections and then soldered to get best
results.
(ii) Soldered connectors

• These involve the use of an intermediate metal alloy

whose melting temperature is lower than that of the
parent metal.

• The parts being joined are not melted during

soldering but must be thoroughly wetted by the
liquefied solder.

• Soldering is the process in which the filler metal has

a melting point below 450°C (842°F) and brazing is
the process in which the filler metal has a melting
point above 450°C.

• The recommended width between the two

sectioned surfaces to be soldered is 0.25 mm (Fig.
22-15).

• Large gap decreases solder accuracy, whereas

smaller gap hinders proper solder flow.

• They are indicated in long-span bridges where

multiple units are involved.

• They are also indicated in cases where pontic and

 retainers are made separately (e.g. complete metal
crown retainer joined with metal–ceramic pontic).
(iii) Welded connectors

• It is another method of rigidly joining the metal

parts.

• Here, the connection is created by melting adjacent

surfaces by heat or pressure.

• A filler metal whose melting temperature is about

the same as that of the parent metal can be used.
(iv) Loop connectors

• It is used when the diastema is to be maintained in

fixed prosthesis.

• It consists of a loop on the palatal aspect that

connects adjacent retainers and/or pontic.

• It can be casted with sprue wax or made with

platinum–gold–palladium alloy (Pt–Au–Pd) wire.

• Adequate space should be provided for effective

plaque control.
(B) Nonrigid connectors
• It is indicated in cases where stress breakers are
required usually in long-span bridges. It prevents
the pier (middle) abutment from acting as a
fulcrum either buccolingually or occlusocervically.

• It is used in cases where abutment teeth are

nonparallel and single path of insertion is difficult
to achieve.

(i) Dovetail or Tenon–Mortise or Key–Keyway

• This design consists of a keyway or mortise (female

component) prepared on the retainer and key or
tenon (male component) attached to the pontic (Fig.
22-16).

• This is the most commonly used nonrigid

connector.

• The alignment of this design is critical, as it must

parallel the path of withdrawal of the other
retainer.

• Parallelism is usually achieved by means of a

dental surveyor.

• The mortise (female component) may be prepared

free hand in wax pattern or with a precision milling
 machine.

• Alternatively, a special mandrel is inserted in the

wax pattern and the abutment retainer is cast.

• The female component is refined as necessary; the

male key is fabricated with autopolymerizing resin
and attached to the pontic.

• Another approach is to use a prefabricated plastic

component for mortise and tenon of a nonrigid
connector.

Advantages

• Normal movement of a tooth is not interfered with

the use of this type of connectors and, therefore, the
deleterious effects to the supporting tissues are
prevented.

• It is advantageous from an aesthetic point of view,

as it allows simple type of retainers that require less
cutting of tooth structure which results in a more
aesthetic restoration.

• It permits the clinician to finish and cement one

retainer before the rest of the bridge is cemented.

• These do not transmit torsional type of forces from

 the bridge to the anterior retainer.

(ii) Split Pontic

• This type of connector was advocated by R.P.

O’Conner, W.F. Caughman and C. Bemis (1986).

• This is used only in cases with a pier abutment,

which requires excessive preparation due to tilting.

• The connector is incorporated entirely within the

pontic.

• The pontic is split into mesial and distal segments.

• Each of these segments is attached to their

respective retainers.

• First, the mesial segment consisting of mesial

retainer, pontic and pier retainer is fabricated.

• The distal arm of the connector is attached to the

pier retainer and is shaped like tissue contacting
area of the pontic (Fig. 22-17).

• The distal segment is then fabricated with a keyway

to fit over the shoe.

• Surveyor is used to align the two segments.

• Cement is not used between the two segments of
the pontic.

(iii) Cross-pin and wing

• It consists of a two-piece pontic system that allows

the two segments of the bridge to be rigidly fixed.

• It was advocated by F.C. Eichmiller and E.E. Parry

(1994) in cases of tilted abutment.

• Here, the path of insertion of each tooth is made

parallel to its long axis.

• A vertical wing is attached to the mesial surface of

the distal retainer.

• The wing should be fabricated such that it aligns

with the long axis of the mesial abutment.

• The mesial wing along with the distal retainer is

termed as retainer wing component (Fig. 22-18).

• The pontic is attached to the mesial retainer and

designed to fit to the wing in the retainer wing
component.

• The pontic along with the mesial retainer is termed

as the retainer pontic component.
• The retainer pontic component is seated finally.

• After fabricating the retainer wing components,

these are aligned on the working cast and a 0.7 mm
pilot hole is drilled across the wing and pontic
using a twisted drill.

• A rigid pin of 0.7 mm diameter is fabricated using

the same alloy (to avoid galvanic corrosion).

• A pin of 0.7 mm dimension is casted with the same

alloy.

• The distal retainer and wing assembly are cemented

first.

• Then retainer pontic component is cemented.

• The pin is seated within the pinhole created on the

pontic and wing with the help of a mallet and
punch.
FIGURE 22-15 Soldering gap of 0.25 mm is recommended to
allow proper flow of solder.

FIGURE 22-16 Key–Keyway nonrigid connector.

 FIGURE 22-17 Split pontic nonrigid connector.

FIGURE 22-18 Cross-pin and wing.

Key Facts
• FPD replaces one or more teeth and is permanently cemented on the
remaining teeth.

• Replacement tooth is called pontic. If pontic is supported only at

one end, it is called cantilever pontic.

• Keyway of the connectors should be placed on the distal side of the

pier abutment so that on mesial movement the key has a seating
effect into the keyway.

• If keyway is placed on the mesial side of the pier abutment, it will

have unseating effect on mesial movement.

• If the tilted molar tooth is mesially and lingually inclined, then

nonrigid connectors should be used.

• Sanitary or hygienic pontic is indicated in posterior region of the

lower jaw, as it provides good access for hygiene maintenance.

• Undersurface of the sanitary pontic is made round for easier

flossing. This design is called fish belly.

• Modified design of sanitary pontic is concave archway

mesiodistally. This design is called arc-fixed partial denture or
Perel pontic.

• Modified ridge lap design is indicated in the high aesthetic zone in

maxillary anteriors and bicuspid region.

• Ovate pontic provides superior aesthetic and is indicated in the

maxillary anterior region and bicuspids.

• Conical or egg-shaped or bullet-shaped or heart-shaped pontic is

indicated in the nonaesthetic zone, i.e. in cases of lower posterior
region.

• Scalloped or trestle design of the connector is desired as the height

 of the metal strut is increased incisogingivally in order to enhance
the strength.

• Recommended gap width between two surfaces to be soldered is

0.15 mm and optimum width should be 0.20 mm.

• Borates are used as soldering flux for noble metal alloys and
fluorides are used as soldering flux for base metal alloys.

• The occlusal surface of the pontic should not be more than 85% of
the occlusal surface of the tooth to be replaced.

• Brazing takes place when the melting temperature of the filler metal
is greater than 450ºC.

• Soldered parts should not be quenched immediately, as this will

produce thermal stresses, which lead to distortion.

• The intracoronal retainers are usually contraindicated in young

adults because of high pulp horns.
CHAPTER
23
Diagnosis and treatment
planning in fixed partial denture

CHAPTER OUTLINE
Introduction, 333
Common Medical Conditions Which Influence
the Treatment of FPD, 333
Diagnostic Aids Used in Fixed
Prosthodontics, 334
Abutment and Factors Influencing Abutment
Selection, 335
Different Types of Abutments used in Fixed
Partial Denture, 337
Residual Ridge Defects and Their
Management, 340
Periodontal Factors Which Influence Treatment
Planning in Fixed Prosthodontics, 342
Introduction
A successful fixed partial denture (FPD) depends on the accurate
diagnosis and treatment planning. For this, the patient’s intraoral and
extraoral conditions along with the psychological needs are
thoroughly evaluated. The diagnostic information is collected after
taking a proper medical and dental history and clinically examining
the patient. This information helps in formulating a treatment plan
which best suits the condition of the patient.
Diagnosis is defined as ‘determination of nature of disease’. (GPT 8th
Ed)
The essential elements which are necessary for proper diagnosis in
fixed prosthodontics are:

• Medical and dental history

• Extraoral examination including TMJ and occlusal evaluation

• Intraoral examination

• Diagnostic casts

• Diagnostic wax-up

• Radiographs

Common medical conditions which influence the

treatment of FPD
There are a number of medical conditions which influence the
treatment in fixed prosthodontics. The most common medical
conditions encountered in dentistry are given below.
Diabetes: A diabetic patient should be under medication and strict
diet supervision of the physician. These patients require proper
education on oral hygiene maintenance, eating habits and tissue rest.
A patient with uncontrolled diabetes is under the risk of:

• Bacterial, viral and fungal infections including candidiasis.

• Xerostomia may cause dry atrophic oral mucosa, inflamed

depapillated, painful tongue.

• Poor wound healing.

• Chronic periodontitis.

• Burning mouth syndrome.

• Insulin shock in patient treated with insulin.

Diabetic patients should be given short appointment which should

not interfere with their meal time.

Cardiovascular diseases: The patients with a history of rheumatic fever

and rheumatic heart disease are at an increased risk of infective
endocarditis. Prophylactic antibiotic is must for such patients. A
patient with pacemakers should be treated with caution. The
patient’s physician should be consulted before performing any
invasive procedure. Short appointment preferably in the morning
should be given. The patients can be premedicated with diazepam
5–10 mg to reduce anxiety. The procedure should not stress the
patient, as stress and anxiety can precipitate angina. Adrenaline
dose in the local anaesthesia should be reduced.

Neurological disorders: The patients with disorders such as cerebral

palsy, Bell palsy or Parkinson disease should be treated with utmost
care. It is difficult for the patient to give adequate interocclusal
record. Such patients have poor dexterity and have difficulty in
maintaining good oral hygiene.

Disease of the skin: Dermatological conditions such as pemphigus

often have oral manifestations that are extremely painful. Invasive
 procedures in such patients should be avoided.

Disease of joints: Conditions such as osteoarthritis mainly affects the

weight-bearing joints (e.g. hips, knee and spine). In some cases,
terminal joints such as fingers and TMJ may also be affected. This
condition is more common in females than in males. Osteoarthritis
of TMJ makes the jaw relation recording difficult. Sometimes due to
limited mouth opening, special impression trays or sectional trays
may be required to make impressions.

Radiation therapy patient: The patients who have undergone

radiation therapy tend to develop problems such as mucositis,
muscle contractures, xerostomia and secondary infection such as
candidiasis, loss of taste and in extreme cases osteoradionecrosis.

Diagnostic aids used in fixed prosthodontics

Complete clinical examination along with the use of certain diagnostic
aids is important for accurate diagnosis and treatment planning in
fixed prosthodontics. Some of the diagnostic aids commonly used for
diagnosis and treatment planning in fixed prosthodontics are:

• Diagnostic casts

• Diagnostic wax-up

• Photographs

• Radiographs

• Vitality testing with thermal or electrical stimulation

Diagnostic casts
Diagnostic casts are one of the most vital aids used for accurate
diagnosis and treatment planning. Diagnostic casts are fabricated after
making accurate impressions of both the arches. The impression
material commonly used is irreversible hydrocolloid (alginate). The
casts are mounted on the semi-adjustable articulator after facebow
transfer and accurate interocclusal record.
Accurately mounted diagnostic casts are helpful in assessing the
following characteristics (also refer to Chapter 15):

• The teeth, soft tissue contours, bony undercuts and frenal

attachments

• The edentulous ridge and span length

• The interocclusal space

• Location, height, rotation and tilt of the abutment

• Analysis of the occlusion, to assess any premature contact

• Unobstructed view of occlusion from the lingual side

• Assess the occlusal plane

• The available pontic space

• Crown length morphology and vestibular depth

• Gives preview of the aesthetic form

Importance of radiographic interpretation for

successful treatment planning in fixed
prosthodontics
Radiographic examination is a crucial diagnostic aid which should be
used as an adjunct to the complete clinical examination. It provides
information which usually is not determined clinically. The findings
from radiographic examination should be carefully correlated with
other findings in order to achieve an accurate and definitive diagnosis.
The radiographs are helpful in detecting the following characteristics
(also refer to Chapter 33):

• Carious lesions, condition of existing restoration

• Quantity and quality of the supporting bone

• Root morphology, crown-to-root ratio

• Any periapical pathology

• Inclination of the abutment tooth

• Pulpal morphology and quality of any previous endodontic

treatment

• Retained root fragments, impacted tooth/teeth

• Continuity and integrity of the lamina dura

• Status of periodontal ligament space, calculus deposits

Abutment and factors influencing abutment

selection
Abutment is defined as ‘a tooth, a portion of the tooth or that portion of an
implant used for the support of a fixed or removable prosthesis’. (GPT 8th
Ed)
Selection of the appropriate abutment is very crucial for the success
of fixed prosthesis. Abutment tooth should be strong enough to bear
the functional forces directed not only to them but also to the missing
teeth/tooth. There are a number of criteria for selecting an appropriate
abutment.

Criteria for selection

• It should not be mobile.
• It should have a good bone support.

• It should have a good periodontal status.

• It should be healthy without any inflammation.

• It should have adequate amount of coronal tooth structure.

• It should have a favourable crown-to-root ratio.

• It should be vital tooth, if not then an endodontically treated tooth

can be selected.

Factors Influencing Abutment Selection

• Crown-to-root ratio

• Root configuration

• Location, angulation and condition of the abutment

• Root surface area

• Rigidity of FPD

Crown-to-root ratio: This is the ratio between the tooth which is

above the alveolar crest and the portion of the root which is
surrounded by bone. The recommended ratio between the crown
and the root is 2:3 for an ideal abutment. However, minimal ratio of
1:1 may be acceptable for abutment under normal condition. In
cases where the opposing occlusion consists of denture teeth or the
natural teeth which are periodontally weak, crown-to-root ratio
greater than 1:1 may be acceptable but with caution. Longer the
edentulous span, greater the torque on the abutment tooth and
more favourable should be the ratio. Multiple abutments can
sometimes compensate for poor crown-to-root ratio or be useful in
long-span FPDs (Fig. 23-1).
Root configuration: This factor determines the suitability of the
prospective abutment tooth. Multirooted posterior teeth provide
better support than the single-rooted anterior teeth. Posterior teeth
have a broader occlusal table and better bone support than anterior
teeth. Multirooted teeth with divergent roots are advantageous than
teeth with convergent or fused root. Likewise, a single-rooted tooth
with curved root or irregular configuration is preferable to a single-
rooted tooth with tapered root (Fig. 23-2).

Condition of the abutment: Healthy abutment tooth is always more

preferred to periodontally compromised or mobile tooth.

Location of the prospective abutment: This is an important factor as

the configuration and the design of fixed prosthesis can be planned
accordingly. Narrow dental arch will be subjected to greater
leverage forces than the wider arch.

Angulation of the abutment: J.M. Reynolds (1968) has suggested that

the abutment tooth should not incline more than 25–30°, as the
tooth is in best position to bear the vertically directed forces along
the long axis of the tooth. If the tooth is severely inclined, the
harmful torquing forces will be distributed to the tooth. Mesially
tilted or distally tilted tooth requires modification in tooth
preparation. The situation can demand more tooth reduction or
even endodontic treatment.

Root surface area: It is also called the pericemental area of the

abutment tooth; this is another important consideration. Larger is
the tooth, more the root surface is available and better it is to bear
the functional forces. Ante’s law is followed as a clinical guideline
to select an appropriate abutment.
 FIGURE 23-1 Recommended crown–root ratio.

FIGURE 23-2 Various root configuration of teeth.

Ante’s law
I.H. Ante in 1926 stated that ‘the abutment teeth should have a
combined pericemental area equal or greater than the tooth or teeth to
be replaced’. This statement was referred by J.F. Johnston in 1971 as
Ante’s law (Fig. 23-3).

FIGURE 23-3 Ante’s law – the combined pericemental area

of second premolar and second molar should be greater
orequal to first molar.

Importance of Ante’s law.

Ante’s law helps in evaluating the pericemental area of the abutment
teeth. Larger tooth with greater surface area bears the functional
forces better than smaller tooth with lesser surface area. The root
surface areas of maxillary and mandibular teeth have been reported
by A. Jepsen. The values given by Jepsen may not always be relevant
to the given clinical situation. In the clinical situation, the proposed
abutment tooth may have reduced bone support due to periodontal
reasons. In such cases, the capacity to bear functional forces by this
tooth may be questionable and this should be considered while
making proper diagnosis and treatment planning.
Ante’s law is used as a clinical guideline to plan treatment in fixed
prosthodontics. The recommended crown-to-root ratio is 2:3 and a
ratio of 1:1 is considered minimal to accept the prospective abutment
for FPD. A ratio of 1:1 or more will satisfy Ante’s law. Shorter span
FPD has better prognosis than the longer span dentures. Abutment
tooth should be carefully selected by giving due consideration to the
location, occlusion, angulation, bone support and periodontal status.
In cases of bone loss due to periodontal reasons, mesial or distal
drifting of abutment, endodontically treated tooth, mobility or
unfavourable occlusion, the law can be modified by increasing the
number of abutments.

Rigidity of FPDs: The lack of rigidity of the prosthesis is one of the

major causes of failure. The denture should be rigid and should
have good flexural strength to resist the masticatory forces. Flexure
can have a damaging effect on the abutment, especially in cases of
long-span FPDs.

Different types of abutments used in fixed partial

denture
The type, status and location of the abutment tooth determine the type
of FPD.
Types of Abutments Commonly Used in
Fixed Prosthodontics
• Unrestored or ideal abutment

• Pier abutment

• Cantilevered abutment

• Tilted molar abutment

• Endodontically treated abutment

• Implant abutment

(i) Unrestored or ideal abutment

This type of abutment is a healthy, caries-free,
periodontically sound tooth with adequate clinical
height. It provides best prognosis for fixed
prosthesis. Some desirable features of ideal
abutment are as follows:

• It should be caries-free.

• It should have adequate bone support.

• It should have optimum crown-to-root ratio.

• It should be periodontically healthy.

• It should have sound tooth structure with adequate

enamel and dentin.
(ii) Pier abutment

Pier abutment is defined as ‘a natural tooth located

between the terminal abutments that serve to support a
fixed or removable dental prosthesis’. (GPT 8th Ed)

A pier abutment is a lone standing tooth with

edentulous spaces present both mesially and
distally to it. In long-span FPD where support is
sought from the pier abutment and the adjacent
teeth, there are chances of more stress concentration
around the abutment teeth when rigid connectors
 are used. Factors which influence the amount of
stress on the abutment teeth are position of the
abutment in the arch, physiological tooth
movement and retentive capacity of the retainers.
The middle abutment acts as the fulcrum and the
excessive forces transmitted to the terminal
retainers cause the weaker retainer to loosen. This
causes marginal leakage, secondary caries and
ultimately prosthesis failure. In such situations,
nonrigid connectors are recommended which help
in transferring the stresses to the supporting bone
(Fig. 23-4).

The commonly used nonrigid connectors or the

stress-breaking device consists of key and
keyway. The stress-breaking device is usually
placed on the pier abutment. The keyway is placed
on the distal contour of the pier abutment and the key
is placed on the mesial side of the distal pontic. Mesial
movement of the posterior teeth in function results
in proper seating of the key into keyway.

However, nonrigid connectors should be avoided in

situation where the following characteristics are
observed:

• The abutment tooth/teeth are mobile.

• The posterior abutment and the pontic are opposed
with removable denture or are unopposed. In such
situations, the posterior teeth tend to supraerupt
thereby unseating the key from the keyway.
(iii) Tilted molar abutment

Molar teeth posterior to the edentulous space tend to

drift mesially into it, if the space is not restored.
Tilted molar tooth, if used as an abutment, makes it
difficult to achieve a single path of insertion. The
situation becomes even more complex, if third
molar is present next to the tilted second molar
tooth. Severely tilted tooth should be avoided, if it
is used as an abutment. However, if only single
tilted tooth is present distal to the edentulous space,
it should be considered as an abutment.

Tilted molar tooth used as an abutment can be

corrected by one of the following methods:

(a) Recontouring or restoration of the mesial

surface of the tilted molar: This is followed in
case of slight tilt.

(b) Orthodontic treatment: If there is severe tilting

of the molar tooth, the treatment of choice should
be orthodontic uprighting of the tilted molar
 tooth. This is achieved by using a fixed appliance.
If third molar is present next to the tilted second
molar, it is best extracted to allow distal
movement of the second molar.

(c) Modified partial veneer crown: Mesial half

crown or modified partial veneer crown can be
used as retainers on the tilted abutment tooth.
The distal half of the crown is left unprepared,
whereas the mesial half is prepared to achieve
single path of insertion.

(d) Telescopic crown: It is defined as ‘an artificial

crown constructed to fit over a coping (framework).
The coping can be another crown, a bar or any other
suitable rigid support for the dental prosthesis’. (GPT
8th Ed)

The tilted molar abutment is radically reduced to

fabricate a coping. This coping ensures good
marginal adaptation. A telescopic crown is then
fitted over this coping to get a favourable path of
insertion (Fig. 23-5).

(e) Nonrigid connector: A full veneer preparation is

done for the tilted molar tooth along its long axis.
The mesial abutment is prepared on its distal
surface to form a keyway. An FPD is fabricated to
 slide into this keyway. The distal abutment (tilted
molar tooth) has a rigid connector, whereas the
mesial abutment (premolar) has a nonrigid
connector. The nonrigid design should not be
indiscriminately used as its cantilevering effect
produces additional lateral stresses harmful to
the abutment tooth with rigid connector. This
method is more useful, if the molar tooth is tilted
both mesially and lingually. The nonrigid design
is avoided in long-span bridges (Fig. 23-6).
(iv) Cantilevered fixed dental prosthesis

Cantilevered dental prosthesis is defined as ‘a fixed

dental prosthesis in which the pontic is cantilevered, i.e.
is retained and supported only on one end by one or more
abutments’. (GPT 8th Ed)

As this type of design is supported only at one end, it

has the potential to damage the supporting
abutment tooth. The pontic of the cantilevered FPD
acts as a lever which tends to apply harmful
leverage forces to the abutment tooth. The
abutment tooth or teeth supporting a cantilevered
FPD should have the following characteristics:

• Good bone support

• Healthy periodontium

• Favourable crown-to-root ratio

• Long roots with sufficient height of clinical crown

(Fig. 23-7)

Cantilevered FPD can be used to replace maxillary

lateral incisor taking support from the canine and
can be used to replace mandibular first premolar
taking support from the second premolar and the
first molar. The cantilevered pontic should not have
any contact in lateral excursion and should have
light occlusal contact. Posterior cantilevered pontic
should be made of smaller size so as to avoid
excessive forces on the abutments. Cantilevered
FPD should be avoided in periodontically
compromised dentition.

An endodontically treated tooth is contraindicated as

an abutment to a cantilevered FPD, as it is subjected
to fracture because of considerable loss of
significant supporting dentin. However, double
abutment with splinted retainers can be used in
such cases.
 FIGURE 23-4 Pier abutment.

FIGURE 23-5 Telescopic coping used on tilted molar to

achieve favourable path of insertion.
FIGURE 23-6 Nonrigid connector given on the distal surface
of premolar to compensate for inclined molar.
 FIGURE 23-7 Cantilevered pontic tends to apply leverage
forces to the supporting abutment tooth.

Residual ridge defects and their management

During the intraoral examination, it is very important to assess the
condition of the residual ridge. The shape, consistency, type, location
and the amount of resorption determine the course of treatment in
fixed prosthodontics. Proper assessment of the amount of destruction
of the residual ridge helps in determining the design of pontic.
J.S. Siebert (1983) Classified the Residual
Ridge Defects into the Following Three
Categories:
(i) Class I: Has a normal ridge height with loss of faciolingual ridge
width (Fig. 23-8).

(ii) Class II: Has a normal faciolingual ridge width with loss of ridge
height (Fig. 23-9).
(iii) Class III: Loss of both ridge height and width (Fig. 23-10).

(iv) Class N: No loss or minimal deformity of the ridge; this category

was later added and was not a part of the original Siebert’s
classification.

FIGURE 23-8 Siebert’s class I – normal height, reduced

width.

FIGURE 23-9 Siebert’s class II – reduced height, normal

width.

FIGURE 23-10 Siebert’s class III – reduced height, reduced

width.

Residual ridge defects can be surgically corrected by various

techniques. These techniques are helpful in changing the shape of the
ridge to create an aesthetically acceptable and easy cleanable area.
Techniques Used to Correct Ridge Defects
(i) Soft tissue ridge augmentation

(ii) Interpositional graft

(iii) Siebert’s onlay graft or thick free gingival graft

(iv) Gingival porcelain

(v) Ridge augmentation

(vi) Andrews’ bridge

(i) Soft tissue ridge augmentation: H. Abrams (1980) gave the roll
technique to augment the ridge with soft tissues for class I defects. In
this technique, the palatal epithelium is removed and is rolled back
upon itself in order to thicken the facial aspect of the residual ridge.
Pouch technique can also be used to increase the width of the ridge.

(ii) Interpositional graft: This can be used to correct class II and class
III defects. The epithelium is removed from the facial aspect and then
the pouches are formed into which the connective tissue graft is
inserted. It ensures an increase in the ridge height and is helpful in
treating class II defects.

(iii) Siebert’s onlay graft or thick free gingival graft: It is useful in

treating class III defects, as it increases both the ridge height and the
width. In this technique, the recipient bed is prepared by removing
the epithelium and making striations to induce bleeding. These
induced bleeding points encourage vascularization in the connective
tissues. Onlay graft is then harvested from the palate region of
tuberosity or premolar–molar vault region and is sutured in place. A
temporary crown is placed immediately so as to allow tissue
adaptation during healing. Healing requires around 6–8 weeks.

(iv) Gingival porcelain: Gingival or pink porcelain can be added to

simulate the interdental papilla. It is helpful in mandibular molar and
mandibular incisor region.

(v) Ridge augmentation: This can also be done with allograft material
such as hydroxyapatite, tricalcium phosphate or freezed dried bone.
Ridge defects are usually not filled with these materials until implants
are planned in these sites.

(vi) Andrews’ bridge:

Andrews’ bridge is defined as ‘the combination of a

fixed dental prosthesis incorporating a bar with a
removable dental prosthesis that replaces teeth within the
bar area, usually used for edentulous anterior spaces.
The vertical walls of the bar may provide retention for
the removable component’. (GPT 8th Ed)

This bridge system was first advocated by James

Andrews (1983) to restore large ridge defects (class
II and class III). It is composed of fixed retainers
which are connected by a rectangular bar that
follows the ridge curve. A removable denture is
seated onto the rectangular bar by means of a clip.
This kind of fixed removable prosthesis is indicated
for restoring large vertical ridge defect.
Disadvantages of this system are food lodgement
and plaque entrapment (Fig. 23-11).
 FIGURE 23-11 Andrews’ bridge.

Periodontal factors which influence treatment

planning in fixed prosthodontics
There are a number of periodontal factors which can influence the
diagnosis and treatment planning in fixed prosthodontics. Some of
them are:

(i) Periodontitis: It is an inflammatory disease of the gums and is

characterized by pocket formation and bone destruction. It is one of
the common reasons for which the patient may lose one or more teeth
and require fixed prosthodontic treatment. Periodontal therapy is
indicated for a patient with periodontitis. The goals of this therapy are
to resolve inflammation, provide adequate attached gingiva and
convert periodontal pockets to clinically normal sulcular depths.

(ii) Trauma from occlusion: This refers to tissue injury produced by

the functional forces. Clinical signs that suggest trauma from
occlusion are excessive tooth mobility, angular or vertical bone loss,
pathological tooth migration and infrabony pockets.
(iii) Embrasure spaces: The space located below the contact area
between teeth is called the embrasure space. Embrasures deflect the
food at the time of mastication and protect the gingiva from food
impaction. The proximal surfaces of restoration should be designed in
such a way that it does not encroach into the embrasure space or else
it leads to gingival inflammation. Therefore, the restoration should not
be overcontoured or undercontoured.

(iv) Margin placement: Supragingival margins are always

recommended whenever possible for proper periodontal health.
However, subgingival margins are indicated in cases of extension of
caries, pre-existing restoration, areas of cervical erosion and root
fracture or for aesthetic reasons.

(v) Biologic width: A combined width of the connective tissue and

epithelial attachment averaging 2.04 mm is called biologic width. A
minimum dimension of 3 mm to the alveolar crest is necessary for
proper healing and restorations. The width should not be violated, as
it results in attachment loss and ultimately bone loss (Fig. 23-12).
 FIGURE 23-12 Schematic diagram representing biologic
width.

Key Facts
• Xerostomia is common to autoimmune disorders such as Sjogren
syndrome, rheumatoid arthritis, lupus erythematosus and
scleroderma.

• Ante’s law is the abutment teeth should have total pericemental

area equal to or greater than the pericemental area of the tooth/teeth
to be replaced.

• Ideal crown:root ratio is 1:2, optimum or recommended is 2:3 and

 minimum ratio is 1:1.

• If edentulous space exists on either side of the abutment tooth, such

tooth is called pier abutment.

• Tilted molar is best uprighted by orthodontic means.

• Root amputation is removal of root without touching the crown.

• Hemisection is a procedure in which tooth is separated through

crown and furcations.

• Radectomy is a process of resection of root.

• Ratio of 1.618:1.0 is called golden proportion and is a constant.

• Andrews’ bridge is indicated when there is large anterior ridge

defect. It is a rectangular bar which is connected to the fixed
retainers and follows the curve of the arch.

• Mandibular first molar is most frequently replaced by FPD.

CHAPTER
24
Design of fixed partial denture

CHAPTER OUTLINE
Introduction, 344
Different Designs in Fixed Prosthodontics, 344
Biomechanical Factors Affecting FPD
Design, 345
All Ceramic FPDs, 347
Laminate Veneer, 347
Indications, 347
Contraindications, 347
Advantages, 347
Disadvantages, 348
Crown Preparation, 348
Steps in Tooth Preparation, 348
Rationale of Restoring an Endodontically Treated Tooth and Ideal
Requirements of Post, 348
Functions of a Post, 349
Ideal Requirements of a Post, 349
Prefabricated Posts, 349
Tapered Smooth-Sided Post, 350
 Tapered Post with Self-Threading Screws, 350
Parallel-Sided Posts, 350
Carbon Fibre Post, 350
Glass Fibre Post, 350
Quartz Fibre Post, 350
Light-Transmitting Post, 351
Parallel Flexi-Post, 351
Steps Involved in Fabrication of Custom-Made
Dowel Core, 351
Ferrule, 353
Resin-Bonded Bridge, 353
Indications, 353
Contraindications, 354
Advantages, 354
Disadvantages, 354
Spring Retained FPD, 356
Resin Cements Used to Lute FPDs, 357
CAD/CAM Assistance in Fixed
Prosthodontics, 357
Introduction
One of the most important reasons for success of fixed dental
prosthesis is proper designing of FPDs. It is essential for a clinician to
understand different designs of FPDs, which can be used in a given
clinical situation.
Different designs in fixed
prosthodontics
Different designs in fixed prosthodontics are:

• Fixed–fixed partial denture (FPD)

• Resin-bonded tooth-supported FPD

• Implant-supported FPD

• Fixed–removable partial denture

Factors influencing the design of FPD are:

• Crown length

• Crown-to-root ratio

• Root length and form

• Ante’s law

• Periodontal health

• Mobility

• Length of the span

• Arch form

• Axial alignment

• Occlusion

• Pulpal health
• Alveolar ridge form

• Age of the patient

Biomechanical factors affecting FPD design

The major biomechanical factors affecting the design of FPD are:

• Length of edentulous span

• Arch curvature

• Occlusogingival height of the pontic

• Direction of forces acting on FPD

• Number of abutment teeth

(i) Length of edentulous span

• Longer the edentulous span, more will be the load

placed on the abutment tooth.

• As the length of span increases, the destructive

torquing and leverage forces increase on the
abutment tooth.

• Length of the span influences the number of

abutment to be used – Ante’s law can be a useful
guide here.

• Flexion of the FPD is directly proportional to the

cube of length and inversely proportional to the
 cube of occlusogingival height of the pontic.

• Two-tooth pontic will show eight times more

flexion than single-tooth pontic.

• Similarly, three-tooth pontic will show 27 times

more flexion than a single-tooth pontic.
(ii) Occlusogingival height of the pontic

• Flexion or bending of FPD can be minimized by

selecting the pontic design with greater
occlusogingival height.

• If the occlusogingival height of the pontic is halved,

it is likely to flex eight times more than the original
height (Fig. 24-1).

• To minimize flexion, the prosthesis can be

fabricated with material having higher modulus of
elasticity (e.g. nickel–chromium alloy).

• The problems encountered in long-span FPD or

unfavourable crown-to-root ratio can be overcome
by using double abutment (primary and
 secondary).

• The secondary abutment should have as much

surface area and favourable crown-to-root ratio as
the primary abutment.

• It should also have retainers as retentive as the

primary abutment in order to bear the forces of
flexion of FPD.
(iii) Direction of forces acting on FPD

• The forces applied on FPD are different in

magnitude and direction as compared to the single-
tooth restoration.

• Usually all FPDs (long or short) show flexion to

some extent.

• The dislodging forces on the single restoration act in

the buccolingual direction and in cases of FPDs,
these act along the mesiodistal direction.

• In order to counteract these dislodging forces, the

preparation should be modified by providing
multiple grooves to enhance the structural
durability and resistance form.
(iv) Arch curvature
• The curvature of the arch affects the amount of
stresses in FPD.

• If a pontic lies outside the interabutment axis, it acts as

lever arm which produces harmful torquing forces
that may weaken the abutment or facilitate
dislodging of the FPD.

• In order to counteract the torquing forces,

secondary abutment is used in the direction
opposite to the lever arm and the distance between
the interabutment axes should be made equal to the
length of the lever arm.

• For example, when all four maxillary incisors are to

be replaced, the maxillary canine on both the sides
acts as primary abutment and the maxillary first
premolar forms the secondary abutment. The
distance between the primary and secondary
interabutment axes is made equal to the distance
between the primary interabutment axis and pontic
lever arm to best counteract the torquing forces
(Fig. 24-2).
(v) Number of abutment teeth

• Number of teeth to be used as abutment influences

the design of FPD.
• Position of the edentulous span, position of the
abutment teeth which they occupy in the arch and
periodontal health of the teeth influence the design
of FPD.

FIGURE 24-1 If occlusogingival height of pontic is halved, the

flexion of FPD will be eight times greater.
 FIGURE 24-2 Distance between primary and secondary
interabutment axes and pontic lever arm.

All ceramic FPDs

In recent times, all ceramic FPDs are becoming popular due to
aesthetic reasons. Although their use was discouraged because of
inferior strength in comparison to metal ceramic FPDs, lots of
materials are tried to fabricate all ceramic FPDs with varied success. In
the past, aluminous porcelain was used to fabricate by connecting
alumina cores with pure alumina rods without much success. Then
leucite-reinforced heat-pressed ceramic was tried but failed due to
inferior strength. Recently introduced In-Ceram zirconia, lithium
disilicate, heat-pressed ceramic and CAD/CAM (computer-aided
designing and computer-aided machining) Procera systems are
becoming popular fast, as they possess adequate strength to be used
successfully in fabricating anterior FPDs. All ceramic FPDs made of
any material should have connectors of dimension 4 × 4 mm in
comparison to metal connectors which require 2 × 3 mm of width.
Disadvantage of this excess width of connector is difficulty in plaque
control. The core material containing 33% of zirconia can provide
adequate strength to be used in posterior FPDs.
Laminate veneer
Laminate veneer is defined as ‘a superficial or attractive display in
multiple layers’.
Or
‘a thin sheet of material usually used to finish’. (GPT 8th Ed)
Laminate veneer is a conservative method to aesthetically restore
the appearance of discoloured or deformed tooth. It consists of thin
ceramic laminate which is luted onto the labial surface of the affected
tooth. Tooth preparation is mostly confined only to the enamel.

• Porcelain veneers were first used by Charles Pincus between 1930

and 1940.

• Laminate veneers evolved with time with the introduction of bis-

glycidyl methacrylate resins, bonding agents, and acid etch
techniques.

• Preformed veneers were bonded onto the etched tooth surface and
this procedure is called laminating.

• Using glazed ceramic improved colour stability, abrasion resistance

and was well tolerated by the gingiva.

• Etching the ceramic veneer with hydrofluoric acid improved the

bond strength between the luting agent and the veneer.

• Again incorporation of silane coupling agent improved the shear

bond strength of ceramic veneer and expanded its use.

Indications
• Discoloured tooth/teeth

• Teeth with intrinsic staining (e.g. tetracycline stains)

• Enamel hypoplasia

• Diastema closure

• Correction of mild form of malformed anterior teeth

Contraindications
• Patient with poor oral hygiene

• High caries index

• Parafunctional habits

• Extensively restored tooth

Advantages
• It requires minimal preparation.

• The preparation is confined only to enamel.

• It has superior aesthetics.

• It is wear and stain resistant.

Disadvantages
• It is technique sensitive.

• It is expensive.

• There are chances of debonding.

Crown preparation
• Minimal preparation is required and this is confined usually only to
the enamel.

• Finish line is a slight chamfer which is placed at the gingival crest or

slightly subgingivally.

• Minimal thickness for ceramic veneer is about 0.3–0.5 mm.

Steps in tooth preparation

Labial reduction
• Cuts of about 0.3–0.5 mm depth are given.

• Round-end-tapered diamond is used to reduce the labial surface.

• Slight chamfer finish line is created at the level of the gingiva.

Proximal reduction
• It is an extension of the labial reduction proximally.

• Preparation is extended to the gingival crest and into the contact

area.

• The contact area should be left intact.

Incisal reduction
• It involves two techniques of placing incisal finish line.

• In the first technique, there is no incisal reduction and the

preparation of the labial surface ends at the incisal edge.

• In the second technique, the incisal surface is reduced and the

ceramic overlaps the incisal surface and ends on the lingual aspect.
• Ceramic is said to be stronger in compression than in tension, and
therefore, the second technique is preferred.

Lingual reduction
• Lingual finish line is created with round-end-tapered diamond.

• The finish line should be at least 1.0 mm away from the centric
contact.

• Finish line extending in the lingual aspect increases the mechanical

retention and increases the surface area for bonding.

Finishing
• The prepared tooth surface is smoothened and all sharp line angles
are rounded (Fig. 24-3).

FIGURE 24-3 Completed laminate preparation using finishing

bur.
Rationale of restoring an
endodontically treated tooth and ideal
requirements of post
During endodontic treatment of the tooth, intracoronal and
intraradicular dentines are removed which leads to changes in actual
composition of the remaining tooth structure. Restoration of
endodontically treated tooth is dictated by the amount of coronal
tooth destruction and location of the tooth. The changes occurring in
endodontically treated tooth are:

• Considerable removal of coronal dentine makes the remaining tooth

susceptible to fracture to even normal functional forces.

• An endodontically treated tooth becomes more brittle due to loss of

moisture and loss of vital dentine.

• Usually, the tooth is prone to get discoloured after endodontic

treatment.

• Therefore, it is important to restore an endodontically treated tooth.

Functions of a post
• A post provides retention for core and coronal restoration.

• It protects remaining tooth structure by dissipating the functional

forces along the length of the post.

• It reinforces the remaining tooth structure.

Ideal requirements of a post

• It should provide adequate retention within the root.

• It should provide adequate retention of the core and the crown.

• It should have rigidity in comparison to the dentine.

• It should be aesthetic, if indicated.

• It should be easily retrievable.

• It should be biocompatible.

Post–core systems
Classifications of post and core systems
On the Basis of the Technique of Fabrication

(i) Custom cast posts

• Endopost

• Endowel

• Parapost
(ii) Prefabricated posts

• Parallel-sided, serrated and vented post, e.g.

Parapost

• Tapered self-threading systems, e.g. Dentatus

• Tapered smooth-sided systems, e.g. Kerr, Ash

• Parallel-sided, threaded post systems, e.g. Radix
Anchor, Kurer Anchor post systems

• Parallel-sided, threaded, split shank systems, e.g.

Flexi-post
On the Basis of the Fit of the Posts

(i) Passive retention posts

• Cast posts

• Smooth tapered post

• Serrated parallel posts

(ii) Active retention posts

• Threaded parallel/tapered posts

• Flexi-posts

• Kurer Anchor posts

On the Basis of the Material Used

(i) Metals

• Custom cast posts

• Gold alloys
• Chrome–cobalt alloy

• Nickel–chromium alloys

• Prefabricated posts

• Stainless steel

• Titanium

• Brass
(ii) Nonmetals

• Carbon fibre

• Fibre reinforced

• Glass fibre

• Quartz fibre

• Woven polyethylene fibre

Prefabricated posts
Prefabricated posts are commercially available in different shapes and
sizes. They are very popular because of their simplicity.

Salient features of prefabricated posts

• These have less chairside time with no laboratory procedure.

• These need single appointment.

• These are cost-effective.

• These are easy to temporize.

• These have good strength.

• Comparatively less tooth structure is removed.

• As these posts are prefabricated, they cannot be designed according

to the anatomy of particular root.

• If coronal tooth structure is less, these should be used with caution.

These can be made of either metal or nonmetal. These can be of

different types, namely, tapered, parallel-sided, carbon fibre post or
glass fibre post.
Some of the commonly used prefabricated posts are described
below.

Tapered smooth-sided post (fig. 24-4)

• This is most widely used and is the oldest one.

• This is a cemented post which is least retentive.

• This should not be used in the teeth that are subjected to high
functional stresses.
 FIGURE 24-4 Tapered post: (A) smooth sided; (B) serrated;
(C) threaded.

Tapered post with self-threading screws

• This is more retentive than smooth-sided cemented post.

• This produces greatest stress in dentine during placement.

• There is a high chance of fracture of the remaining tooth.

Parallel-sided posts (fig. 24-5)

• These provide much greater retention than tapered post.

• These produce less stress in dentine.

• These are cemented posts which can be used where high functional
 forces are expected.

FIGURE 24-5 Parallel-sided posts: (A) smooth sided; (B)

serrated; (C) threaded.

Carbon fibre post

• Nonmetallic post introduced by P.B. Duret, M. Reynaiid and F.
Duret in 1990.

• It is more flexible than metal post and its rigidity is similar to

dentine.

• It is available as tapered, parallel-sided, smooth or serrated forms.

• There are less chances of tooth fracture.

• It is less aesthetic due to its dark colour.

• Adhesive system forms weaker bond with carbon fibre post than
with stainless steel.

Glass fibre post

• It has lower elastic modulus than the carbon fibres.

• It can be made of E-glass (electrical glass) or S-glass (high strength).

Quartz fibre post

• Glass fibre post can be made of quartz fibre additionally.

• Quartz is pure silica in crystallized form with low coefficient of

thermal expansion.

• It is aesthetically compatible.

• It has easy retrievability.

• It has greater fracture resistance.

• It is useful in curing by transmitting light through the post.

• It flexes with tooth structure.

Light-transmitting post
• Translucent posts allow light transmission during polymerization of
light-cured resin cements.

• It facilitates the union of remaining dentine with light-cured resin

 cement to restore the lost dentine.

• It effectively cures the light-cure resin deep into the canal.

• It provides strong foundation for the restorations.

• It has greater aesthetics.

• It can be effectively used in high aesthetic regions.

Parallel flexi-post
• It is a prefabricated split shank, parallel-sided threaded post.

• It provides maximum retention.

• It has greater flexure and fatigue strength than metal or zirconium

posts.

• Its modulus of elasticity is close to dentine.

• It has improved aesthetics.

• Sandblasting the posts prior to cementation enhances their

retention.

Steps involved in fabrication of custom-made

dowel core
The principles of tooth preparation for endodontically treated tooth
are the same as that for any tooth.
Steps involved in preparing these teeth are (Fig. 24-6):

(i) To remove root canal filling material

(ii) Enlargement of the canal

(iii) Fabrication of dowel core

FIGURE 24-6 Ideal requirements for post space preparation.

To remove root canal filling material

• Obturation of the root canal is first completed with gutta-percha.

• Gutta-percha is then removed either by heated endodontic plugger

or by a rotary instrument.

• The apical seal should not be disturbed by any of the methods used.

• Minimum 3–5 mm of the apical seal should be left intact.

• Peeso reamers or Gates Glidden drills are commonly used for post
space preparation (Fig. 24-7).

FIGURE 24-7 Post space preparation done with Peeso

reamer.

Enlargement of the canal

• Peeso reamer or low-speed drills of different sizes are used to
enlarge the canal.

• The aim is to remove any undercuts and to receive an appropriate

 size post.

• The post space should not be prepared more than one-third of the
root’s diameter.

• Tooth structure should always be preserved as much as possible.

Fabrication of dowel core

• A custom made post can be fabricated using two techniques,
namely, direct or indirect.

Direct technique
• Pattern is fabricated directly in the patient’s mouth using pattern
resin or inlay wax.

• Canal is lubricated and plastic dowel is extended to the apical end of

the prepared canal.

• Resin is incrementally added onto the plastic dowel and placed and
removed several times into the canal.

• The resin should not be allowed to harden to the prepared canal.

• This step is repeated until properly fitting resin-coated dowel is

polymerized.

• Pattern post is rechecked for its fit and ease of removability.

• Pattern post is invested and casted.

Indirect technique
• An orthodontic wire of appropriate length is tried into the apical
end of the canal.
• The wire is made J-shaped.

• The wire is coated with tray adhesive and the canal is lubricated.

• A light body elastomeric impression material is coated on the wire

and the canal is filled with the material using lentulo spiral.

• Wire is placed into the canal and elastomeric impression material is

injected around and over the prepared tooth.

• Impression tray is loaded with medium-body elastomeric

impression material or heavy-body elastomeric impression material.

• The impression tray is inserted and removed after the

polymerization.

• The impression is evaluated and poured with stone to get a working

model.

• Wax pattern is fabricated in laboratory with inlay pattern wax.

• Core of the dowel is fabricated with wax.

• Fabricated dowel core is invested and casted.

Materials used
• Gold alloys

• Chrome–cobalt alloys

• Nickel–chromium alloys
Ferrule
Ferrule is defined as ‘a metal band or ring used to fit the root or crown of a
tooth’. (GPT 8th Ed)
Ferrule is provided by extending the axial wall of the crown apical
to the missing tooth structure. The circumferential band of cast metal
reinforces the coronal portion of the tooth. Ferrule effect is enhanced
by giving a bevelled finish line and when the walls are very close to
parallel. It improves the structural durability of the endodontically
restored tooth by counteracting the lateral forces exerted during the
placement of the post (Fig. 24-8).

Roles of ferrule
• It counteracts the lateral forces during post placement.

• It counteracts the functional leverage forces.

• It counteracts the wedging effect of tapered post.

 FIGURE 24-8 Restoration with ferrule effect.

Inadequate ferrule may result in:

• Root fracture

• Post loosening and cement failure

• Post fracture
Resin-bonded bridge
Resin-bonded prosthesis can be defined as ‘a fixed dental prosthesis
that is luted to tooth structures, primarily enamel, which has been etched to
provide mechanical retention for the resin cement’. (GPT 8th Ed)
Resin-bonded bridges were first described by A.L. Rochette in 1973.
The primary aim of these bridges was to replace missing tooth with
maximum conservation of the tooth structure. Earlier, mechanical
retention was employed to retain the prosthesis but with introduction
of electrolytic etching, micromechanical retention was used to bond
metal surface to enamel.

Indications
• To replace missing anterior tooth in children or young adults

• Short edentulous span

• Single posterior tooth

• Adequate crown length

• Excellent moisture control

Contraindications
• Long edentulous span

• Parafunctional habits

• Grossly damaged or restored abutments

• Insufficient enamel for bonding

• Inadequate occlusal clearance

• Deep vertical overbite

• Patient allergic to base metal alloys (nickel)

Advantages
• It involves minimum reduction of the abutment tooth.

• Usually anaesthesia is not required.

• Supragingival finish line is usually given which aids in proper

impression making.

• Temporary crown is not required.

• Preparation is in enamel only.

• It results in increased patient comfort.

• It results in reduced chances of pulpal damage.

• It involves less chairside time.

Disadvantages
• Longevity is less than conventional FPDs.

• Space correction is difficult with resin-retained bridge.

• Small laboratory error is difficult to correct.

Classification
Resin-bonded bridges can be classified into the following types on the
basis of type of retention employed by the retainer.

(i) Bonded pontic

(ii) Mechanical retention – Rochette bridge

(iii) Micromechanical retention – Maryland bridge

(iv) Macroscopic mechanical retention – Virginia bridge

(v) Cast mesh FPD

(i) Bonded pontic

• A natural tooth or acrylic tooth was bonded onto

the proximal and lingual surfaces of the abutment
tooth with composite resin.

• Usually a wire or steel mesh is used to support the

connector with composite resin.

• Limited durability, therefore, should be used for

replacement for shorter duration.
(ii) Rochette bridge (Fig. 24-9)

• Rochette (1973) employed the mode of mechanical

retention by perforating the metal casting and
bonding onto the tooth structure by silane coupling
agent.

• The wing-like retainers with funnel-like perforation

were heavily filled with composite resin to bond
onto the prepared tooth.
• Livaditis used it on the posterior tooth by
extending the winged metal casting interproximally
and occlusally on the abutment tooth.

Limitations of cast perforation technique

• Due to metal perforation, strength is compromised.

• Wear of resin at the perforation can lead to

marginal leakage, increased stress and abrasion.

• Adhesion provided by perforations is limited.

(iii) Maryland bridge (Fig. 24-10)

• G.J. Livaditis and V.P. Thompson (1981)

developed an electrolytic pit corroding technique
for etching base metal alloys.

• Livaditis and Thompson used 3–5% nitric acid with

250 mA/cm2 of current for 5 min, followed by
placing in 18% hydrochloric acid in ultrasonic
cleaner for 10 min to achieve internal etching of the
metal casting. This type of etched metal prosthesis
is called Maryland bridge.

Advantages of etched cast retainers

• Retention is improved three-fold as compared with

 resin–enamel bond.

• The retainer can be made in thin section which can

resist flexing.

• External surface of the metal retainer is highly

polished and resists plaque accumulation.

Limitations

• Procedure is technique sensitive.

• Contamination of the surface decreases the bond

strength.
(iv) Virginia bridge (Fig. 24-11)

• It is based on lost salt crystal technique.

• P.C. Moon and J.L. Hudgins, F.J. Knap

incorporated salt crystals on the retainer pattern to
produce roughness on the internal surface of the
retainer.

• Working cast is the first model sprayed and outline

of the framework is made on the abutment.

• Within these outline, cubic salt crystals of specific

size are sprinkled on the die leaving 0.5–1.0 mm
 margin as crystal free around the outline.

• Retainer patterns are then fabricated with acrylic

resin.

• Patterns are removed after resin is polymerized

completely, cleaned, and placed in water to
dissolve the crystals.

• Cubic voids on the pattern are replicated in the cast

retainers which provide a mode of retention of
fixed bridge.

• Internal surface of the retainer is treated by air

abrasion with aluminium oxide.

• Nickel–chromium alloys required oxidation with

dilute solution of sulphuric acid and potassium
manganate.
(v) Cast mesh FPD (Fig. 24-12)

• In this technique, net-like nylon mesh is placed on

the lingual surface of the abutment tooth on the
working model.

• This is then included in the retainer wax pattern.

• The wax pattern is casted in conventional manner.

• Meshed internal surface is seen on the cast retainer
which eliminates the need to etch the casting.

• This technique can be used in noble metal alloys.

Disadvantages

• Material tends to be rigid.

• Its retentive ability is compromised, if mesh is

blocked during wax pattern fabrication.

FIGURE 24-9 Rochette resin-bonded fixed partial denture.

FIGURE 24-10 Maryland bridge.

 FIGURE 24-11 Virginia bridge.

FIGURE 24-12 Cast mesh fixed partial denture.

Spring-retained FPD
In spring-retained FPD, the pontic is connected to the retainer with
flexible palatal bar (Fig. 24-13).

• A tooth and tissue-borne prosthesis where the masticatory forces

from the pontic are transmitted to the palatal mucosa before
reaching the abutment tooth.
 FIGURE 24-13 Spring-retained FPD.

Advantages
• Only one tooth, usually the posterior tooth, is prepared to be the
abutment.

• It is the only design where diastema on either side of the pontic can
be given.

• Flexion of the palatal bar bears the forces and acts as a shock
absorber.

Disadvantages
• It is technique sensitive.

• It is difficult to fabricate.
Resin cements used to lute FPDs
Resin cements have evolved rapidly in recent years.

• These are flowable composites of low viscosity.

• Initially, unfilled resin was used to lute perforated retainers.

• Then unfilled/filled composite resin with thin film thickness was

specifically used to bond resin-bonded bridges.

• Dentine bonding agents are incorporated into the cement as most of

the preparation is in dentine.

• HEMA (hydroxyethyl methacrylate), 4-META (4-methacryloxyethyl

trimelliate anhydride), and an organophosphate, such as 10-
methacryloxydecamethylene phosphoric acid, were incorporated
into resin cement.

• The most commonly used resin cements are chemically-cure system

or light-cure system or dual-cure systems.

• Resin cements are insoluble in oral fluids.

• Chemically activated resin cements are supplied as two pastes; both

pastes are mixed on mixing pad for 20–30 s and used to lute crowns
and bridges.

• Light-cure resin systems are single component systems used to lute

resin-bonded prosthesis, veneers or orthodontic brackets.

• Dual-cure resin system again is supplied as two pastes. Chemical

activation is slow and it provides extended working time till the
time light is shown, thereafter it cures rapidly.

• Dual-cure cements should be used in prosthesis which has thickness

of up to 2.5 mm; beyond this, chemically activated resin should be
used.
• Dual-cure cements have become the most commonly used luting
agents to bond FPDs in recent times.

• The excess cement should be removed before the cement fully

polymerizes.

• Tin plating can improve bonding of noble metal alloys.

• Air abrading surface of base metal alloys with 50 microns alumina

particles improves its bonding.

• Silica bonding can again improve bonding to both noble metal and
base metal alloys.

CAD/CAM assistance in fixed prosthodontics

CAD/CAM system means computer-aided designing and computer-
aided machining. It was introduced to dentistry in the 1980s. In 1984,
Duret developed the Duret system which is a CAD/CAM system
capable of generating single unit and multiple unit restorations.

Historical background
• 1957: Dr Patrick J. Hanratty – father of CAD/CAM technology–
developed CAM software program called PRONTO

• 1971: Dr Francois Duret (France) – first dental CAD/CAM device

• 1979: P. Heitlinger and F. Rodder milled the equivalent of the stone

model used by a dental technician to make the crown, inlay or
pontic

• 1983: Dr Matts Anderson (Sweden) developed Procera.

• 1983: First CAD/CAM restoration by Dr F. Duret – introduced in the

Ganaciene Conference (France).
• 1985: Dr Werner Mormann and Dr Marco Brandestini
(Switzerland) – first commercial CAD/CAM system (CEREC).

• 1980s: Dr Dianne Rekow (USA) developed CAD/CAM system

using photographs and high resolution scanner – mill restorations
using 5-axis machine

Components of CAD/CAM system

• A digitalization tool/scanner: It is an optical or mechanical scanner
(Fig. 24-14A). Optical scanner works on ‘triangulation procedure’,
e.g. Lava Scan ST and Everest scan. In mechanical scanner, master
cast is read mechanically line-by-line by a ruby ball to measure the
three-dimensional structure, e.g. Procera scan.

• Software that process data: Its basis is STL (standard

transformation language) data (Fig. 24-14B).

• Production technology: Subtractive manufacturing or additive

manufacturing (Fig. 24-14C). Subtractive manufacturing, e.g. CNC
(computerized numerical control) machining; additive
manufacturing, e.g. rapid prototyping.
 FIGURE 24-14 Components of CAD/CAM system.

Processing devices distinguished by means of the number of milling

axis – 3-axis devices, 4-axis devices and 5-axis devices.

CAD/CAM production concepts

• Chairside production: Fabrication of restoration is done chairside in
one appointment, e.g. Cerec system (Sirona).

• Laboratory production: It is done on the master cast; 3D data are

formed in the laboratory with scanner. After this, CAD data
production restoration is fabricated by a milling machine.

• Centralized fabrication: It is done in a production centre.

Centralized production is done in a milling centre. Satellite scanners
in laboratory are connected with production centre via internet, e.g.
Procera.

CAD/CAM manufacturing is done by two methods:

(i) Additive manufacturing

(ii) Subtractive manufacturing

Additive manufacturing or 3D printing

Definition.
‘Additive manufacturing is a process of joining materials to make objects
from three-dimensional (3D) model data, usually layer upon layer, as
opposed to subtractive manufacturing methodologies’. [ASTM International
(ASTM 2792-12)]
The process of additive manufacturing involves using images from
a digital file to create an object by laying down successive layers of a
chosen material.

Application of additive manufacturing in prosthodontics

• Fabrication of ceramic inlays, onlays, crowns and bridges

• Fabrication of maxillofacial prosthesis, drug delivery

• Used in tissue engineering

• Used for making surgical guides for implant placement

• Used for fabrication of temporary crowns and bridges

• Used for fabricating customized implants

• Used for modelling scaffolds for tissue engineering and organ

printing

• Used as ceramic paste for creating bone and bioresorbable polymers

• Used in direct metal laser sintering (DMLS) technique

Types of 3D printing

• Stereolithography
• Laminated object manufacturing

• Laser powder forming techniques

• Solid ground curing

• Fused deposition modelling

• Selective electron beam melting

• 3D Inkjet printing

• Robocasting

Subtractive manufacturing.
It involves removal of material from the raw block to obtain object of
desired shape and size through milling or unconventional machining
such as laser machining, electrical discharge machining.

• It uses images from a digital file to create an object by machining

(cutting or milling) to physically remove material and achieve the
desired geometry.

• It is widely used in prosthodontics.

• It is the modern method of designing, developing and producing

restorations partially or completely.

Uses of the CAD/CAM systems

• To design and mill metal, alumina and zirconia frameworks

• To scan and mill all ceramic crowns and bridges

• To fabricate inlays, onlays and ceramic laminates

• To fabricate stronger and better-fitting restorations

• In implant restorations

• For orthodontic purposes

Key Facts
• Maxillary first molar has maximum root surface area of 433 mm²
and mandibular first molar has root surface area of 431 mm²; among
anterior maxillary teeth, canine has maximum root surface area of
273 mm² and mandibular central incisor has minimum 154 mm²;
among posterior mandibular teeth, first premolar has minimum
root surface area of 180 mm².

• Tooth preparation becomes difficult, if the long axis of the tooth

diverges or converges more than 25º from parallelism.

• Multirooted posterior teeth provide better periodontal support

than single conical roots.

• Bending or flexion of the fixed bridge varies directly to the cube of

the length and inversely with the cube of cervicoincisal thickness of
the pontic.

• More parallel the opposing walls of the preparation, more will be

the retention.

• Optimum taper for prepared walls is 2–6º.

• For short clinical crown, additional retentive features such as

grooves, pins, slots and boxes are advocated.

• Self-threading pins are about five times more retentive than

cemented pins.

• Ferrule helps in binding the remaining tooth structure together

preventing root fracture during function.
• Lost salt technique is used to fabricate Virginia bridge.

• Rochette bridge was the first used perforated retainer.

• Maryland bridge is the etched metal prosthesis.

• Single piece platinum reinforced porcelain bridge is called Swann

bridge.
CHAPTER
25
Clinical crown preparation in
fixed prosthodontics

CHAPTER OUTLINE
Introduction, 360
Finish Lines, 363
Types of Finish Lines, 364
Porcelain Jacket Crown, 367
Preparation of Full Cast Crown, 368
Occlusal Reduction, 369
Buccal Reduction and Lingual Reduction, 369
Proximal Reduction, 369
Finishing the Preparation, 369
Indications, 369
Contraindications, 370
Advantages, 370
Disadvantages, 370
Preparation for Partial Veneer Crown, 370
Lingual Reduction, 370
Incisal Reduction, 371
Proximal Axial Reduction, 371
 Additional Features, 371
Indications, 372
Contraindications, 372
Advantages, 372
Disadvantages, 372
Preparation for PFM Crown, 372
Occlusal Reduction, 372
Proximal Reduction, 373
Lingual Reduction, 373
Buccal Reduction, 373
Advantage, 373
Disadvantages, 373
Introduction
Successful fixed prosthodontic treatment warrants successful crown
preparation. The crown preparation is essentially governed by the
following principles:
Principles of Tooth Preparation
• Conservation of tooth structure

• Retention and resistance

• Structural durability

• Marginal integrity

• Preservation of periodontium

(I) Conservation of tooth structure

Sound tooth structure should be conserved as far as

possible. Unnecessary reduction of the tooth should
be avoided. Even grossly damaged tooth should be
preserved with post and cores after endodontically
treating them.

Simple guidelines to ensure preservation of tooth

structure during crown preparation:

• By giving minimal taper to the axial wall of the

prepared tooth.
• By following the anatomic planes during tooth
preparation.

• By selecting a conservative finish line for the

restoration, if possible.

• By avoiding unnecessary extension of the

preparation apically.

• By preferring partial veneer restoration over full

veneer restoration when indicated.
(II) Resistance and retention

Retention prevents the restoration from getting

dislodged by forces parallel to the path of
withdrawal. Retention is defined as ‘that quality
inherent in the dental prosthesis acting to resist the
forces of dislodgement along the path of placement’.
(GPT 8th Ed)

• Resistance is ‘the ability of the restoration to resist

its dislodgement by apically or obliquely directed
forces’.

• Retention and resistance are often inter-related

properties in tooth preparation.

Some of their features are mentioned as follows:

 (a) Taper

More parallel the axial walls of preparation, more is

the retention. However, achieving parallel walls is
almost impossible and, therefore, 3–6° of taper is
recommended for optimum retention.

If the taper is increased by more than 20°, stress

concentration increases sharply on the abutment
tooth. Therefore, during tooth preparation, taper
should be kept minimum for maximum retention.

Retention and resistance also depend on the surface

area of the preparation.

Greater the surface area of the prepared tooth, greater

is the retention. Preparations on the larger teeth are
more retentive than preparation on the smaller
teeth. Surface area can be enhanced to a limited
extent by providing features such as boxes and
grooves on the preparation.

(b) Freedom of displacement

• Retention is proportional to the paths of insertion

and removal. Maximum retention is achieved, if the
preparation has only single path of placement and
least when there are multiple paths.
• Resistance is also dependent on freedom of
displacement. More the freedom of displacement is
limited to twisting and torquing forces in a
horizontal plane, more will be the resistance of the
restoration.

• Walls of the preparation should be made

perpendicular to the direction of force for adequate
resistance.

(c) Height of the preparation

• The occlusogingival height of the preparation is an

important factor for both retention and resistance.

• Longer preparation has more surface area and,

therefore, more retention. Longer preparation with
less inclination of the axial walls also enhances the
resistance.

• Resistance to displacement for a short-walled

preparation on a large tooth is improved by adding
grooves or boxes on the axial walls.

(d) Substitution of internal features

• Resistance and retention can be improved by

incorporating internal features such as boxes, grooves
 and pin holes on inclined axial walls.

• Substitution of internal features is done in cases

where it is difficult to achieve retention such as
overtapered short preparation, partial veneer
crowns.

(e) Path of insertion

It is defined as ‘the specific direction in which a prosthesis

is placed on the abutment teeth or implant’. (GPT 8th
Ed)

• It is important to survey the abutment teeth before

and during preparation visually to detect any
undercut or overtapering. Usually, one eye should
be closed to detect undercut in prepared tooth.

• Path of insertion should be considered

faciolingually and mesiodistally. The faciolingual
inclination of the path of insertion should be
avoided in porcelain fused to metal (PFM) or
partial veneer crown preparation, as it affects the
aesthetics.

• Mesiodistal inclination of the path of insertion

should parallel the contact areas of the adjacent
teeth for proper aesthetics.
(III) Structural durability

Sufficient tooth structure should be removed in order

to create a space to accommodate adequate bulk of
restorative material which can withstand the
functional forces. The bulk of this material provides
adequate rigidity to the prosthesis and ensures its
longer durability.

Preparation Features that Ensure Durability

to the Prosthesis
• Occlusal reduction

• Axial reduction

• Reinforcing struts

(a) Occlusal reduction

During preparation of the tooth structure, adequate

clearance is provided for the restorative material to
build back the occlusion.

• The reduction should be done along the geometric

inclines of the natural tooth and the occlusal surface
should not be made flat, as it tends to shorten the
height of preparation.

• Occlusal reduction depends on the type of material

 used for restoration.

• For gold crown: Functional cusp is 1.5 mm and

nonfunctional cusp is 1.0 mm.

• For PFM: Functional cusp is 1.5–2.0 mm and

nonfunctional cusp is 1.0–1.5 mm.

• For all-ceramic crowns, there should be all round

2.0 mm of reduction.

Functional cusp bevel: Wide bevel is placed on the

functional cusp of the posterior teeth to provide
adequate structural durability.

• Functional cusp bevel is placed on the buccal cusp

of the mandibular teeth and palatal cusp of the
maxillary teeth (Fig. 25-1).

• Nonfunctional cusp should always be rounded to

avoid stress concentration.

• If functional cusp bevel is not provided, it may

result in overcontoured crown.

(b) Axial reduction

Adequate axial reduction should be done to provide

sufficient space for the restorative material or else
 may result in overcontoured crown.

(c) Reinforcing struts

Structural durability in the preparation is improved

by providing sufficient space for the reinforcing
struts.

• Features that improve durability of the restoration

are occlusal shoulder, isthmus, incisal or occlusal
offset, proximal grooves, boxes, etc.

• In partial veneer crown, the incisal offset is joined to

the proximal grooves on the either side to improve
structural durability and give the ‘truss effect’ (Fig.
25-2).

• Reinforcement in the MOD onlay is provided by

joining the isthmus with the proximal boxes.
(IV) Marginal integrity

Marginal adaptation of the restoration is of utmost

importance for its longevity in the oral cavity. It is
affected by the type of finish line and restorative
material used. Proper marginal adaptation and
complete seating of the restoration on the prepared
tooth is desirable for successful treatment. Bevels
may be given on the finish line to improve marginal
 adaptation.
(V) Preservation of periodontium

• The location of the finish lines has direct bearing on

the health of the periodontium.

• The finish lines should be located supragingivally

whenever possible.

• Subgingival finish lines should be avoided, as they

may result in gingival inflammation, periodontal
pockets or even loss of alveolar bone.

• The finish line should not violate the biological

width.

• They should be smooth and easily cleanable.

• The crown or restoration should not be

overcontoured or undercontoured.
 FIGURE 25-1 Functional cusp bevel on the buccal cusp of
mandibular molar.

FIGURE 25-2 The incisal offset connects the grooves to give

the ‘truss effect’.
Finish lines
Finish line can be defined as ‘the terminal portion of the prepared tooth or
the peripheral extension of a tooth preparation’. (GPT 8th Ed)
Classification of Finish Lines
On the basis of location
(i) Supragingival

(ii) Subgingival

(iii) Margin at the crest of the gingiva

On the basis of configuration and margin design

(i) Shoulder

(ii) Shoulder with bevel

(iii) Chamfer

(iv) Knife edge

(v) Feather edge

Basic criteria for successful finish lines are:

• Acceptable marginal adaptation

• Proper contour

• Sufficient bulk for restorative material

• Acceptable aesthetics
• Well tolerated by the tissues

Types of finish lines

(i) Shoulder

• It is formed when external line angle of the

preparation is perpendicular to the long axis of the
tooth.

• It is indicated for all-ceramic crowns (margin of

choice), injectable ceramic and facial margin of
metal–ceramic crown.

• Gingival crest should be adequately supported with

the wide ledge which provides resistance to
functional forces and minimizes stresses that might
fracture ceramic.

• It is should be 90° to the external surface and 1.2–1.5

mm in width (Fig. 25-3).

• Flat-ended tapered cylinder bur is used to prepare

shoulder margin and is kept perpendicular to the
plane being prepared.

• Sloped shoulder (120°) is an alternative to 90°

shoulder for labial margin of a PFM crown.
• Sloped shoulder provides sufficient bulk for the
restorative material and minimizes the possibility
of unsupported enamel (Fig. 25-4).

Advantages

• It provides adequate space for restorative material.

• It offers maximum aesthetics.

• It provides adequate space for gingival contour.

• It provides excellent strength.

• It resists distortion due to inherent bulk of metal at

the margin.

Disadvantages

• It is less conservative for tooth structure.

• Its sharp internal line angles are susceptible to stress

concentration and fracture of the tooth at margin.
(ii) Shoulder with bevel

• Bevel with rounded axial angle is believed to

improve marginal adaptation of the restoration on
the prepared tooth (Fig. 25-5).
• Small flame-shaped diamond bur is used in bevel
placement.

Indications

• Proximal box of inlays and onlays.

• Occlusal shoulder of onlays and mandibular three-

quarter crowns.

• Facial margins of PFM crowns where aesthetics is

not a primary issue.

• Preparation with short walls.

Advantages

• It has improved marginal adaptation.

• It has better seal at the margin.

• It has minimal unsupported enamel.

• It provides adequate bulk of metal to resist

functional distortion.

Disadvantages

• It has a less conservative preparation.

• The preparation extends more apically into the
gingival sulcus.

• It is possible to create sharp edge of metal at the

margin.
(iii) Chamfer

• It is a concave, obtuse-angled finish line.

• Torpedo diamond bur is commonly used to develop

chamfer.

• Less than half the diameter of the tip is used for

chamfer margins.

• About 0.5 mm of reduction is usually recommended

for chamfer finish line (Fig. 25-6).

• Heavy chamfer may be used to provide a 90°

cavosurface angle for a ceramic crown, if shoulder
margin is not used.

Indications

• Margin of choice for metal crowns.

• Lingual margin in a PFM crown.

• Usually indicated for molars.

Advantages

• It involves less tooth reduction.

• It provides adequate seal at the margin.

• It has a distinct margin; readily visible on the tooth,

impression and die.

• It provides adequate bulk for restorative material.

Disadvantage

• There are chances of unsupported enamel.

(iv) Knife-edge finish line

• It is an acute angle thin finish line.

• It is not routinely used but may be indicated in

some situations as mentioned below.

Indications

• Young patient.

• Lingual surface of tilted mandibular molar.

• Pinledge preparation.

• Teeth with very convex axial surface.

• Finish line on cementum.

Advantage

• It conserves tooth structure.

Disadvantages

• It is difficult to locate on the die.

• It is difficult to accurately wax and cast.

• It may result in overcontoured crown.

• It has potential for metal display.

• It lacks aesthetics.

• There are more chances of distortion.

(v) Feather-edge finish line

• It is similar to knife-edge finish line.

• Although more conservative to tooth structure, it is

not recommended clinically.
• It does not provide sufficient space for the bulk of
restorative material.

FIGURE 25-3 Shoulder finish line.

FIGURE 25-4 Sloped shoulder.

 FIGURE 25-5 Shoulder with bevel.

FIGURE 25-6 Chamfer finish line.

Supragingival and subgingival finish lines

Supragingival finish lines.
Supragingival finish lines are those margins that are located above the
gingiva. It is always desirable to prepare the margins above the
gingiva because they are easy to prepare accurately without injuring
the soft tissues. There are number of advantages to prepare the
margins supragingivally than subgingivally. Supragingival finish
lines:

• Are usually prepared on tooth enamel.

• Can be easily finished.

• Impressions can be easily evaluated.

• Are easier for the patient to clean and maintain.

• Restorations can be easily evaluated at recall appointment.

• Chances of plaque accumulation are less.

Subgingival finish lines.

They are defined as ‘the restoration margin or tooth preparation finish line
that is located apical to the free gingival tissue’. (GPT 8th Ed)

• The concept of subgingival finish lines was based on the mistaken

belief that gingival sulcus is caries-free.

• Current research indicates that subgingival margins create protected

area which encourages rapid plaque accumulation resulting in
marginal and papillary gingivitis and may even progress to
periodontitis.

• Subgingival finish lines should be avoided whenever possible and

supragingival margin should be preferred.

• However, there are instances when subgingival finish lines become

unavoidable.

Indications

• Caries extending subgingivally.

• Old restoration or cervical erosion extending subgingivally.

• Aesthetics is the primary concern, especially in the maxillary
anterior teeth.

• Short crowns where additional retention is required.

• If axial contour requires modification.

• In cases where root sensitivity cannot be controlled by conservative

means.

• In endodontically treated tooth, if cervical crown ferrule is prepared.

• When the proximal contact area lies in or near the gingival crest.

Factors that influence the extent of inflammatory changes

associated with subgingival margins.
There are four factors which primarily affect the degree and extent of
inflammatory changes associated with subgingival margins:

(i) Emergence profile

• Contour of the tooth or restoration that extends

from the base of the gingiva is called the emergence
profile.

• If the restorative margin extends subgingivally, the

emergence profile of the tooth is likely to be
changed.

• The resulting restorations have overcontoured

crown which encourages plaque accumulation
resulting in periodontal problems.
(ii) Improperly finished margin

• Margin which is placed subgingivally is difficult to

finish and forms a plaque-retentive area.

• Overhanging of the restoration with open margins

is commonly associated with subgingival finish
lines and results in chronic periodontal problems
and greater attachment loss.
(iii) Inadequate zone of attached margins

• Subgingivally placed margins can sometimes lack

band of firmly bound attached gingiva.

• Subgingival finish lines are contraindicated in

patients with little or no attached gingiva, as it may
result in gingival inflammation followed by
attachment loss (periodontal pockets) and gingival
recession.
(iv) Violation of biological width

• Any margin which is placed more than 0.5 mm

subgingivally will violate the biological width and
results in chronic periodontal problems and
eventually alveolar bone loss.
Porcelain jacket crown
Porcelain jacket crown (PJC) produces best aesthetic results to replace
and restore anterior teeth. Originally PJC was made of feldspathic
porcelain which was susceptible for fracture. Recently aluminous
reinforcement porcelain is becoming more popular because of higher
strength but still uses of PJC is restricted to anterior teeth. As the
restoration is made entirely of ceramic, it requires adequate tooth
reduction to provide space for the bulk of ceramic to provide
adequate strength. It is one of the least conservative preparations and
the size and position of the pulp chamber should be thoroughly
evaluated before selecting this preparation. Various features of PJC
and their functions are listed in Table 25-1.

TABLE 25-1
FEATURES OF PORCELAIN JACKET CROWNS

Features Functions
Shoulder finish line Marginal integrity, structural durability
Axial reduction Retention and resistance, structural durability
Rounded angles Structural durability
Vertical lingual wall Retention and resistance
Concave cingulum reduction Structural durability

The steps involved in preparing PJC are as follows:

(i) Incisal reduction

(ii) Axial reduction

(iii) Labial reduction

(iv) Lingual reduction

Incisal reduction
• Before reduction, depth reduction index is made
with silicone putty. It is divided into facial and
lingual index by sectioning the putty along the
incisal edges of the putty.

• Depth orientation grooves are placed on the labial

and incisal surfaces with flat end-tapered diamond
bur.

• Recommendation of the incisal reduction ranges

between 1.5 and 2.0 mm. Approximately 2.0 mm of
incisal reduction is considered adequate for
fabricating aesthetically pleasing restoration.

• Over-reduction of the incisal or labial reduction is

avoided, as it may increase the stresses on the labial
surface and may result in half moon fracture.

• Reduced incisal plane should be perpendicular to

the masticatory forces.

• Incisal reduction is done at an angulation of 45°

(palatally) to the long axis of tooth in normal
occlusal relationship.

• This provides a broad, flat surface which is capable

of tolerating the compressive forces of the opposing
dentition.
Axial reduction

• A long, thin, tapered diamond bur is used for axial

reduction.

• During reduction, adequate precaution is taken not

to harm the adjacent tooth in any way.

• Usually, 2–5° of taper is given.

• Minimum 1 mm of shoulder width is uniformly

provided for the porcelain.

Labial reduction

• It is done with flat end-tapered diamond bur.

• It is commonly done in two planes, namely, incisal

two-thirds and cervical one-third.

• The cervical one-third reduction is done by

positioning the diamond bur parallel to the cervical
portion of the labial surface (along the long axis of
the tooth).

• The incisal two-thirds preparation is done by

positioning the diamond bur parallel to the incisal
aspect of the labial surface (along the plane of the
tooth surface).
• Incisal two-thirds reduction of the labial surface
should be lingually inclined to provide adequate
space for porcelain.

• Labial reduction is extended onto the axial surface

to prepare the shoulder finish line.

Lingual reduction

• Lingual reduction is done in two planes, namely,

vertical lingual wall and concave cingulum.

• The vertical lingual wall is reduced with flat end-

tapered diamond with 2–5° taper and 0.75 mm
shoulder.

• Wheel-shaped diamond is used to prepare the

concave cingulum reduction.

• Concave reduction of the cingulum ensures

maximum clearance on the middle of the lingual
surface.

• Recommended lingual reduction is 0.5–1.0 mm.

• There should be adequate clearance on lateral and

protrusive movements.

• In the canine teeth, two concave areas are prepared

 because of the presence of canine lingual ridge.

• A sharp chisel is useful in removing unsupported

enamel.

• Uniform shoulder is prepared around the tooth

using end-cutting diamond bur (Fig. 25-7).

Precautions

• Excessive incisal reduction should be avoided, as it

reduces the retention and resistance form.

• Taper should not be given excessively.

• Labial and lingual reduction should be done in two

planes.

• Excessive reduction of the labial surface should be

avoided.

• Precaution should be taken to ensure that adjacent

tooth is not harmed in any way during tooth
preparation procedure.

• Undercuts in the preparation should be avoided.

• Adequate lingual reduction is necessary to provide

sufficient space for porcelain.
• Prepared tooth should be smoothened and finished
well before impression making.

• Sharp angles and unsupported enamel are

removed.

FIGURE 25-7 Completed porcelain jacket crown preparation.

Preparation of full cast crown
A full veneer crown preparation involves all the surfaces of the crown.
This type of preparation demands extensive tooth preparation and,
therefore, should be used with caution. Steps involved in preparing
full metal cast crown on a maxillary first molar are given below.

Occlusal reduction
• Round end-tapered diamond is used.

• Depth orientation grooves are made on the triangular ridges and

development groove.

• Recommended occlusal reduction for functional cusps is 1.5 mm

and for nonfunctional cusps, it is 1.0 mm.

• Functional cusps in the maxillary molar tooth are the lingual cusps
and nonfunctional cusps are the buccal cusps.

• Occlusal reduction is done preserving the occlusal morphology.

• Functional cusp bevel is given with the help of round end-tapered

bur.

• Occlusal clearance is checked using red utility wax and asking the
patient to bite in maximum intercuspation.

• The thickness of the wax is checked for thin spots.

Buccal reduction and lingual reduction

• Orientation grooves are placed on both the walls with round end-
tapered diamond.
• The grooves placed on both the walls should be parallel to the
proposed path of withdrawal of the restoration.

• These grooves are joined to each other to accomplice reduction.

• Torpedo diamond is usually used for buccal and lingual reductions.

• Chamfer finish line is the margin of choice for full veneer cast
restoration.

• The buccal axial reduction is prepared as far into the interproximal

embrasure as possible without damaging the adjacent tooth.

• Lingual reduction is done with the same bur and should also extend
as far interproximally as possible.

• In case of lingually tilted mandibular molars, the chamfer finish line

may be less defined but adequate reduction of the lingual axial
surface is desired to avoid overcontouring of the crown.

Proximal reduction
• Long, thin, tapered diamond is initially used to reduce the proximal.

• The thin tapered diamond is held upright against the buccal wall
and moved towards the contact area with light pressure.

• Up and down, sweeping motion is used to break the contact.

• Torpedo diamond is subsequently used, once the contact area is

broken.

Finishing the preparation

• All the axial walls are finished with a torpedo diamond finishing
bur.
• All the line angles are rounded off.

• Nonfunctional cusp bevel is placed.

• Additional retentive features such as grooves or boxes are placed

with the tapered diamond.

• The seating groove should extend gingivally 0.5 mm short of the

chamfer finish line on the axial surface.

• Seating groove enhances the resistance and retention form (Fig. 25-
8).

FIGURE 25-8 Completed full veneer preparation.

Indications
• Grossly damaged teeth due to caries or trauma.

• Root canal-treated tooth.

• Tooth requiring maximum retention and resistance.

• Short clinical crown.

• Correction of occlusal plane.

• Retainers of long-span fixed partial denture where extensive

dislodging forces are expected.

• Existing restoration.

Contraindications
• It has a high aesthetic demand.

• If less retention and resistance are required, more conservative

preparation is preferred.

Advantages
• It has good strength.

• It has better resistance and retention than other restorations.

• It offers freedom to modify axial contours.

• It allows easier occlusion modification.

Disadvantages
• It involves extensive removal of tooth structure.

• It can affect the gingival tissues.

• It results in unaesthetic display of metal.

• Tooth vitality testing is unreliable after crown cementation.

• Marginal adaptation is time-consuming.

Preparation for partial veneer crown
Partial veneer crown preparation is conservative to tooth removal.
Anterior partial veneer crown was first developed by J.P. Carmichael
in 1901. The labial surface of the tooth remains intact whereas rest of
all the surfaces are prepared. These preparations are not indicted for
all the teeth and in all the patients. Patient selection is critical for the
success of the restoration. A thick, square anterior tooth with
sufficient labiolingual thickness is best suited for such preparations.
Anterior three-quarter crowns can sometimes be used as retainers for
short-span bridges provided they are healthy and caries-free. Various
features of partial veneer crown and their function are listed in Table
25-2.

TABLE 25-2
FEATURES OF PARTIAL VENEER CROWN

Features Functions
Lingual reduction Structural durability
Axial reduction Resistance and retention form, structural durability, preservation of periodontium
Proximal flare Marginal integrity
Incisal offset Structural durability
Proximal groove Retention and resistance, structural durability
Chamfer finish line Marginal integrity, preservation of periodontium

Steps involved in preparing maxillary canine for accepting partial

veneer crown are described in the headings below.

Lingual reduction
• Depth orientation grooves are made on the lingual surface to ensure
uniform reduction.

• A small wheel diamond bur is used to do a concave cingulum

reduction.

• Occlusal clearance of 0.7 mm is required.

• Cingular reduction of canine is done in two planes with a slight
ridge extending incisogingivally.

• Two concave depressions are made on the lingual surface.

• Lingual axial wall reduction is done with a torpedo diamond bur.

• The diamond bur should be kept parallel with the incisal two-thirds
of the labial surface.

• Vertical lingual axial wall enhances retention.

• Chamfer finish line is created during reduction with the torpedo

diamond bur.

• In tooth with short lingual wall, retention can be improved by

giving the bevelled shoulder finish line on the lingual surface and
cingulum pin.

Incisal reduction
• It is done with wheel diamond bur.

• It parallels the inclination of the incisal edge.

• The mesial and distal inclines of the canines are followed.

• About 0.7 mm of reduction is done at the incisal edge.

• Labioincisal line angle should not be touched during incisal

reduction.

Proximal axial reduction

• Long thin tapered diamond and torpedo diamond burs are used.

• First long thin tapered diamond bur is used in a sawing motion.

• Precaution is taken not to damage the adjacent tooth.

• Contact with the adjacent tooth should be barely broken with

enamel hatchet and not diamond bur.

• Torpedo diamond is then used to create a definite chamfer finish

line.

Additional features

Proximal grooves
• These grooves are placed by making an outline onto the tooth with a
pencil.

• Mesial groove preparation is started with No. 170 bur to a depth of

1.0 mm.

• Then the grooves are prepared gingivally in increments until it

reaches the final position.

• The bur should be parallel to the incisal two-thirds of the labial

surface.

• The grooves should be placed as far labially as possible.

• The distal groove is placed parallel to the mesial groove in order to

have a single path of insertion and removal.

• The grooves are prepared just short of the finish line.

Proximal flare
• It is prepared by flame-shaped diamond on the labial aspect of the
groove.
• It is wider at the incisal end than at the gingival end.

• Flame-shaped carbide bur is useful in preparing a smooth flare with

sharp, definite finish line.

• In case of incisors, enamel hatchet or chisel is useful to prepare the

flare.

Incisal offset
• It is prepared on the lingual surface with No. 170L bur by joining
the proximal grooves on the either side.

• It is inverted V-shaped on the maxillary canine and a straight line

on the incisors.

• Incisal offset enhances the structural durability and provides the

truss effect, i.e. the metal occupying the offset tends to reinforce the
margin.

• Sharp angles are rounded.

Labioincisal bevel
• About 0.5 mm bevel is placed on the labioincisal edge.

• Flame-shaped diamond is used to prepare the bevel.

• The bur is placed perpendicular to path of insertion on the mesial

incline.

• Contrabevel can be placed on the distal incline of the canine but

should never be used on incisors due to aesthetic reasons (Fig. 25-9).
 FIGURE 25-9 Completed partial veneer crown preparation on
maxillary canine.

Indications
• Healthy tooth with adequate crown length.

• Intact labial surface which does not require contour modification.

• Patient with good oral hygiene.

Contraindications
• Short teeth

• Nonvital teeth
• High caries rate

• Cervical caries

• Extensive destruction, decalcification

Advantages
• It results in the preservation of tooth structure.

• It has an ease in cleanability of the margins for patient.

• Complete seating of the restoration can be verified.

• It has a good seating, as it provides easy escape for cement.

• Electric vitality testing is possible.

Disadvantages
• It is a less retention and resistance form than complete veneer
crown.

• A limited adjustment of the path of removal is possible.

• Display of metal is possible in the incisal edge.

Preparation for PFM crown
PFM is useful to restore teeth requiring aesthetic replacement in the
posterior region. The maxillary premolar usually lies in the
appearance zone where aesthetics is a concern. Apart from maxillary
premolars, mandibular premolars and mandibular first molars also lie
in appearance zone.
Steps in the preparation of maxillary first premolar to receive PFM
crown are given below.
Before preparation, an index is formed using silicone putty on the
labial, lingual and occlusal surfaces. The polymerized index is cut in
the centre of the occlusal surface to separate the facial and lingual
index.

Occlusal reduction
• Depth orientation grooves are made on the occlusal surface with
round end-tapered diamond.

• About 1.5–2.0 mm of reduction is recommended in the areas

requiring ceramic coverage.

• Reduction is done in definite planes reproducing general basic

geometry of the occlusal surface of tooth.

• Functional cusp bevel is given on the lingual inclines of the

maxillary lingual cusp and buccal inclines of mandibular buccal
cusp.

• About 1.5 mm reduction is recommended for metal coverage and

2.0 mm reduction for porcelain coverage.

• All the planes of occlusal reduction are smoothened with No. 170L
bur.
Proximal reduction
• Long thin tapered diamond is used.

• The bur is used in up and down or sawing motion.

• Reduction should not be overtapered.

Lingual reduction
• Torpedo diamond is used for lingual reduction.

• Chamfer finish line is created.

• Chamfer finish line and axial surfaces are smoothened with torpedo
carbide finishing bur.

Buccal reduction
• Flat end-tapered diamonds are used for buccal reduction.

• Shoulder finish line is created which extends lingual to the proximal

contact.

• Junction of the shoulder and chamfer on the lingual finish line

results in creation of wing.

• Shoulder finish line or shoulder with bevel is recommended on the

buccal wall for PFM preparation.

• In those preparations where metal collar is recommended, the finish

line is placed within the sulcus to hide the metal (Fig. 25-10).
 FIGURE 25-10 Completed metal–ceramic preparation on
maxillary first premolar.

Advantage
• It has better aesthetics than cast metal crown.

Disadvantages
• More tooth reduction is required to accommodate porcelain.

• There are increased chances of fracture of brittle porcelain.

• It has inferior aesthetics as compared with all-ceramic crowns.

• It is more expensive than cast metal crown.

Key Facts
• Functional cusp bevel is given on the lingual inclines of the
maxillary lingual cusps and buccal inclines of the mandibular
buccal cusps.
• Finish line of choice in cast metal is chamfer, in all-ceramic is
shoulder, in PFM is shoulder with bevel on labial surface and
chamfer on lingual and proximal surfaces, shoulder with bevel is
proximal box of inlay and onlay.

• Knife-edged finish line is advocated in lingually tilted mandibular

posterior teeth.

• Truss effect is provided to enhance the structural durability.

• Half moon fracture is produced in the labiogingival area of all-

ceramic crown due to overshortening of the preparation.

• All-ceramic crowns should be avoided in edge-to-edge occlusion

cases and deep overbite.

• Disadvantage of porcelain is high firing shrinkage.

• In winged preparation for PFM, the shoulder finish line should be

lingual to the proximal contact.

• Porcelain bonded to metal is strongest when it is fired under

compression.

• Proximal grooves in anterior partial veneer crown should be placed

parallel to the incisal two-thirds of the facial surface.

• In posterior partial veneer crown, the proximal grooves should be

parallel to the long axis of the tooth.

• Grooves should have definite lingual walls to resist displacement

in partial veneer crown.

• Reverse three-quarter crown is used on mandibular molars to

preserve intact lingual surface in cases of severe lingual inclination.

• Proximal half crown is a three-quarter crown which preserves the

 distal surface as the tooth is rotated by 90°.

• Vertical lingual wall in anterior partial veneer crown is essential for

retention.

• In partial veneer crown, contrabevel is never placed on the incisor

because of aesthetic concern.

• Minnesota ditch is a ‘V’-shaped groove at the junction of axial wall

and gingival floor in proximo-occlusal inlays used to enhance
resistance to displacement by occlusal forces.

• Principle of substitution is used to compensate for mutilated or

missing cusps or when clinical crown length is inadequate.

• Shade tabs should be moistened during shade selection.

• First all-ceramic crown was developed by Charles H. Land in 1886

and called it as PJC.

• Dicor was the first commercially castable ceramic material used.

• Dr Charles Pincus first used porcelain veneers to improve

aesthetics.

• Periodontal bridge is the most common cause of missing tooth in a

dental arch.

• Full veneer crown has the maximum retention among all the
retainers.

• Richmond crown was the first crown on which porcelain facing was
given.

• Davis crown is an all-ceramic crown which is attached to the tooth

by means of post.
CHAPTER
26
Impressions in fixed partial
denture

CHAPTER OUTLINE
Introduction, 375
Methods of Fluid Control, 375
Various Methods of Gingival Retraction during
Impression Making in Fixed
Prosthodontics, 376
Techniques Used for Gingival Retraction, 380
Importance of Impression Making in Fixed
Partial Denture, 381
Various Impression Techniques Used in Fixed
Prosthodontics, 382
Post-space Impression Technique, 385
Introduction
Successful restorative procedures demand dry operating field and
clear visibility. For that, fluid control is essential.
Fluid control provides the following:

• It provides a dry, clear operative field.

• It improves accessibility and visibility.

• It is comfortable for both the operator and the patient.

• It aids in impression making.

Methods of fluid control

There are essentially two methods of fluid control, namely,
mechanical and chemical methods.

Mechanical methods
• Rubber dam

• High-volume suction

• Saliva ejector

• Svedopter

Chemical methods
• Antisialagogues

• Local anaesthetics (adrenaline)

Rubber dam
• It was introduced by S.C. Barnum.

• This is the most effective isolation method.

• It is used during tooth preparation of inlays and onlays, post and

core fabrication, cementation and pin-retained amalgam.

• It should not be used with polyvinyl siloxane impression material

because it inhibits its polymerization.

High-volume suction
• It is very useful during crown preparation.

• It is used effectively by assistant.

• It is an excellent lip retractor.

• It is not used during impression making or cementation procedure.

Saliva ejector
• It is most useful when used as an adjunct to high-volume
evacuation.

• It can be used alone for maxillary arch during impression making

and cementation.

• It is placed at the corner of mouth, opposite to the quadrant being

treated and head of patient is tilted towards it.

Svedopter
• It is used for isolation of the mandibular arch.

• It consists of metal saliva ejector with attached tongue deflector.

• Cotton rolls can be used along with it during cementation or
impression making.

• It is most effective when the patient is upright.

Drawbacks

• Accessibility to lingual surface of lower teeth is limited.

• It should not be used in patients with mandibular tori.

• Metal component may injure the soft tissues in the floor of the
mouth.

Antisialagogues
• These drugs are helpful in controlling the salivary flow (e.g.
methantheline bromide and propantheline bromide).

• These are gastrointestinal (GI) anticholinergics which act on the

smooth muscles of the GI tract, urinary or biliary tract and produces
dry mouth as side effect.

Contraindications

• Hypersensitivity to this drug, glaucoma, asthma, congestive heart

failure, patient on corticosteroids.

Another drug used effectively as antisialagogue is clonidine

hydrochloride. It is an antihypertensive agent and should be used
with caution in hypertensive patients taking other medications. Its
side effects are dry mouth and drowsiness.

Various methods of gingival retraction during

impression making in fixed prosthodontics
Indirect restoration, such as cast crowns, partial veneer crowns,
complete all-ceramic crowns, porcelain fused to metal crowns, inlays
or onlays demand accurate impression with defined cervical margin
for accurate fit. Gingival retraction is essential to accurately capture
the cervical margins. The primary aim of gingival retraction is to
displace the gingival tissues at the margins reversibly in order to
allow the impression material to capture the marginal detail.

Methods of gingival retraction

• Mechanical methods

• Mechanico-chemical methods

• Surgical methods

Mechanical methods
• The gingiva is physically displaced to ensure adequate reproduction
of prepared finish line.

• Common mechanical methods are copper band, cotton cord and

rubber dam.

Copper band

• It serves as a receptacle to carry impression material as well as

displaces gingiva physically.

• The copper band is contoured and trimmed according to the

prepared tooth.

• The band or tube is then loaded with impression compound or

elastomeric impression material and placed along the path of
insertion (Fig. 26-1).

• Impression is poured with die stone or electroplated metal.

• It is used when multiple abutments are prepared and their
impressions are made individually for more accuracy.

• Its disadvantage is that it may injure the gingiva.

FIGURE 26-1 Copper tube impression.

Cotton cord

• Plain cotton cords are used to displace the gingiva physically.

• Its effectiveness is limited because it is based on pressure

application, which is not enough to control the sulcular
haemorrhage.

Rubber dam

• It is used when limited number of teeth in a quadrant are prepared.

• The preparation should not extend too far subgingivally.

• The wings of the bow and clamp are blocked out and modified trays
are used to make impression.

• Elastomeric impression materials should not be used with rubber

dam as they interfere with its polymerization.

Retraction cord
Mechanico-chemical method (retraction cord)

• This is the most commonly used method for gingival retraction.

• In this method, the chemical action of the material is combined with

pressure cord to control the sulcular fluid and reversibly enlarge the
gingival sulcus.

• It is supplied in three basic designs which include knitted cord,

braided cord and twisted cord.

• Selection of the type of retraction cord depends on the clinician’s

preference.

• Largest cord which can adequately physically displace the gingiva

should be selected.

• There are a number of chemicals which are used to impregnate the

retraction cord to produce effective haemostasis.

Criteria for selecting appropriate retraction material

• It should effectively displace gingiva and produce haemostasis.

• It should not irreversibly damage the gingiva.

• It should not produce any systemic side effect.

• Chemicals which are commonly used with the retraction cord to

 provide adequate displacement of the gingiva are aluminium,
potassium sulphate, aluminium sulphate, aluminium chloride and
epinephrine.

Epinephrine

• Although epinephrine is commonly used, its potential to produce

systemic side effect has been questioned recently.

• It produces haemostasis and causes local vasoconstriction, resulting

in transitory gingival shrinkage.

• It causes increase in blood pressure and heart rate.

• The amount of epinephrine absorbed depends on the area and time

of exposure to the tissues.

Contraindications

• Hyperthyroid patient

• Patients on monoamine oxidase inhibitors or tricyclic

antidepressants

• Patients on beta-blockers or cocaine

• Diabetic or cardiovascular patient

• Patients hypersensitive to epinephrine

Technique of using retraction cord

• The operating field is kept dry by using high-vacuum suction and

cotton rolls.

• Around 5 cm of retraction cord is drawn from the dispenser bottle.

• It is moistened by dipping in 25% of aluminium chloride solution.

• The retraction cord should not be touched with gloves, as latex
inhibits polymerization of elastomeric impression material.

• Cord is looped around the prepared tooth.

• Gently the cord is slipped into the sulcus using a cord-packing

instrument.

• Cord is first tucked in the mesial side and then moved buccally,
distally and lingually.

• Cord packer should be inclined towards the area where the cord has
already been placed.

• Cord is left in the mouth for 10 min and then removed slowly (Fig.
26-2).

• The impression material is injected in dry and clean sulcus area.

• An impression is made of the prepared tooth with a material of

choice.

FIGURE 26-2 Position of retraction cord in the sulcus.

Surgical method of gingival retraction
Surgical method of gingival retraction is of two types:

(i) Rotary curettage

(ii) Electrosurgery

Rotary curettage

• The aim of this method is limited removal of the epithelial tissue in

the sulcus while creating the chamfer finish line.

• This method is also called gingettage.

• It should always be done on healthy gingival tissues.

• The method was first described by M. Amsterdam in 1954.

• It was developed by F.J. Hansing and R. Ingraham.

Criteria for gingettage

• There should be no bleeding on probing.

• Sulcus depth should be less than 3 mm.

• The patient should have adequate keratinized gingiva.

Technique

• It is usually done along with cervical margin preparation.

• Torpedo diamond bur is extended into the sulcus up to half of its

depth to remove the epithelium.
• Chamfer finish line is formed along with the removal of the sulcular
epithelium.

• Abundant water spray is used during preparation.

• Cord impregnated with aluminium chloride is placed in the sulcus

for 4–8 min to control haemorrhage.

Disadvantages

• It has poor tactile sensation.

• There are chances of injuring the periodontium.

Electrosurgery

• It is used to enlarge the gingival sulcus by controlled tissue

destruction to facilitate impression making (Fig. 26-3).

• It consists of a high-frequency oscillator or radio transmitter that

uses either vacuum tube or a transistor to deliver a high-frequency
electric current of at least 1 MHz.

• It is also called surgical diathermy.

 FIGURE 26-3 Electrosurgical electrode used to enlarge
gingival sulcus.

Indications

• Removal of inflamed or irritated tissues proliferating over the

cervical margin to be prepared.

• In situations, where retraction cord use is not feasible.

Contraindications

• Patients with cardiac pacemaker

• Use of topical anaesthetics (e.g. ethyl chloride or other flammable

aerosol should be avoided)

Advantages

• It can be done in irritated or inflamed tissues.

• It results in less or no bleeding.

• It is less time-consuming.
Disadvantages

• It is a sensitive technique.

• It is difficult to control lateral heat dissipation in this technique.

• It cannot be done in dry field.

• Foul smell during the procedure may be unpleasant for the patient.

• It is costly.

Commonly used electrosurgical electrodes:

• Coagulating probe

• Diamond loop

• Round loop

• Small straight probe

• Small loop

Technique

• Profound anaesthesia is given before beginning the procedure.

• All the connections are checked and the cutting tip should be
completely seated into the handpiece.

• Cutting electrode is applied onto the tissues with a quick stroke by

applying light pressure.

• Speed of the electrode should not be more than 7 mm/s in order to

avoid lateral heat build-up.

• The tissues should always be kept moist for best results.

• High-volume suction is kept adjacent to the cutting electrode to
ward off any unpleasant odour.

• A plastic-handled mouth mirror and wooden tongue depressor

should be used.

• The tip of the electrode should be frequently cleaned with alcohol-

soaked sponge.

Electrosurgery is commonly employed for gingival sulcus

enlargement, removal of edentulous cuff and crown lengthening
procedure.

Techniques used for gingival retraction

There are different techniques which are used for gingival retraction.
Retraction cord impregnated with a medicament is common to all
these techniques. Operator’s choice and clinical situation are
important in deciding the type of technique to be used.
Common techniques for gingival retraction are:

(i) Single cord technique

(ii) Double cord technique

(iii) Infusion technique

Single cord technique

• This is the most commonly used method of gingival retraction.

• It is indicated when impression is made of one to three prepared

teeth.

• Approximate length of the retraction cord is selected depending on

the anatomy of the prepared tooth.
• The retraction cord is moistened with medicament of choice and is
placed on the prepared tooth with the help of cord packer.

• Cord is allowed into the sulcus for around 8–10 min before it is
removed (Fig. 26-4).

• Usually, the cord is soaked with water before it is removed.

• Tooth preparation is dried and impression is made with material of

choice.

FIGURE 26-4 Single cord technique.

Double cord technique

• It is used during impression making of multiple prepared teeth or
when tissue health is compromised.

• Small diameter cord is placed in the sulcus such that the cut ends
meet each other. This cord is left in the sulcus during impression
making.

• Second cord of largest diameter is soaked in haemostatic agent of

 choice and placed over the small cord into the sulcus (Fig. 26-5).

• After 8–10 min, the larger cord is removed.

• Prepared tooth is dried and the impression is made with small cord
in place.

• After impression making, the small cord is soaked in water and

removed from the sulcus.

FIGURE 26-5 Double cord technique.

Infusion technique
• Dento-infusor with 20% of ferric sulphate chemical is commonly
used to control the haemorrhage during cervical margin
preparation.

• The dento-infusor or syringe is effective in extruding the chemical

into the gingival sulcus.

• When haemorrhage is controlled a knitted retraction cord is soaked

in ferric sulphate solution and placed into the sulcus.

• The cord is left in place for only 1–3 min.

• After this, the cord is removed, sulcus is rinsed with water, the
prepared tooth is dried and the impression is made.

• The time provided for the cord to stay in sulcus may not be
sufficient to allow adequate lateral displacement of the sulcus.

• Also, ferric sulphate may temporarily darken the gingival sulcus for
a few days.

Recently introduced materials in the form of synthetic polymers are

injected into the undisplaced sulcus. The material expands and
provides displacement and haemostasis. The efficacy of such
materials is not established.

Importance of impression making in fixed partial

denture
An accurate impression is of utmost importance for fabricating a
precisely fitting restoration. Most of the restorations in fixed partial
denture are made by indirect method on the cast in the laboratory.
This saves a lot of chairside time and is comfortable for both the
clinician and the patient. As the restoration is fabricated on the
working model, handling of impression material till the time it is
poured with gypsum product is important. Also, use of proper
technique is essential for achieving an accurate impression. There are
a number of impression materials available from which the clinician
has to choose an appropriate material.

Properties of ideal impression

• Should be dimensionally stable

• Should reproduce accurate detail

• Should adequately wet the oral tissues

• Should have sufficient elasticity after cure so as to facilitate multiple
pouring of impression

Ideal requirements of impression material

• Should be biocompatible

• Should have an excellent shelf life

• Should have pleasant taste, odour and colour

• Should be economical

• Should be easy to manipulate requiring less equipment

• Should have sufficient tear strength

• Should permit multiple pour without distortion

• Should have sufficient working, mixing and setting time

• Should be easily removed from the mouth after setting

• Should have adequate flow to record minute details

Various impression techniques used in fixed

prosthodontics
There are a number of impression techniques which can be used by
the clinician to make impression for fixed restorations. Selection of a
particular technique depends on factors such as time, accuracy, cost
and clinical acumen of the clinician.
Impression techniques can be classified on the basis of type of
impression trays used:

(i) Stock trays/putty wash impression technique

(ii) Custom tray

(iii) Dual arch or closed bite or triple tray impression technique

(iv) Segmental impression technique

(v) Post-space impression technique

Stock tray/putty wash impression technique

There are three methods of making a putty wash impression with
elastomers.

Advantages

• Metal stock trays are rigid and do not distort easily.

• Stock trays are readily available.

• It saves extra cost of fabricating custom trays.

Disadvantages

• There is a need for sterilization of trays.

• More impression material is required.

Method 1

• In this technique, a putty material is used to make a custom tray.

• First, one layer of wax is placed over the primary cast as a spacer,
removing wax from the nonfunctional cusp region which acts as
occlusal stop.

• Putty impression material is loaded on the stock tray and placed

over the wax spacer on the primary cast.
• This results in a putty custom tray.

• Wax spacer is then removed and the prepared teeth are injected
with light body elastomer and putty custom tray.

• This loaded tray is then used to make complete arch impression.

• This technique is considered to be most acceptable (Fig. 26-6).

FIGURE 26-6 Impression technique in which putty material is

used as custom tray.

Method 2

• This is a two-step technique.

• In the first step, preoperative putty impression is made intraorally.

• A plastic sheet is placed over the teeth to be prepared to act as

spacer.

• After the complete polymerization of putty material, the plastic

sheet is removed and putty material is removed over the teeth to be
prepared.

• The second step is done after the completion of tooth preparation;

the putty impression is then washed or relined with low-viscosity
elastomer (Fig. 26-7).
 FIGURE 26-7 Two-step impression technique.

Disadvantages

• It is difficult to control wash impression material in the relieved

region.

• As the impression material flows into the unrelieved areas, it creates

a problem of hydraulic distortion of the putty material as it is seated
intraorally.

Method 3

• This is a single-step technique, also called squash or simultaneous

technique.

• Here, stock tray is loaded with putty material and the low-viscosity
elastomer is injected around the prepared tooth or teeth
simultaneously.

• Tray with putty material is placed over the prepared teeth.

• Impression is made once, both the putty and syringed materials

polymerize simultaneously.

• This approach should not be used, as it is not possible to control the

thickness and bulk of the impression material used.

• It is impossible to control the flow of either material onto the

prepared tooth surface.
• Usually, putty material displaces the low-viscosity material and
captures the prepared margin.

• Putty material lacks ability to accurately record details of the margin

(Fig. 26-8).

FIGURE 26-8 Single-step impression technique.

Custom trays
Advantages

• Impression material used is less in comparison to stock trays.

• Hygienic, as it is custom-made for particular patient.

• Uniformity of thickness of impression material decreases the

chances of distortion.

Disadvantages

• It is time-consuming during fabrication.

• It cannot be used in patients sensitive to monomer.

Indications
• When impression is made of distal most tooth in the arch.

• Where arch does not conform to the dimensions of a stock tray.

• Multiple prepared teeth.

Technique

• This is a single-step technique.

• On the diagnostic cast, two sheets of baseplate wax are adapted over
the cast.

• After applying tin foil substitute over the cast, acrylic resin special
tray is fabricated with acrylic resin on the diagnostic cast.

• Vents may be given on the tray to allow easy escape of excess

material.

• Tray adhesive is applied over the internal surface of the special tray.

• Medium body elastomer is loaded onto the tray.

• Low-viscosity elastomer is syringed over the prepared teeth.

• Loaded tray is then seated over the teeth to make complete arch
impression.

• The impression is removed after it is polymerized and evaluated.

Dual arch or triple tray or closed bite impression

tray technique
Advantages

• Less impression material is needed as only one section of the arch is

recorded.
• Both the arches are recorded simultaneously.

• Teeth are recorded in maximum intercuspation position.

• There may be less chance of gagging.

• It eliminates any mandibular flexure that may occur during

opening.

Disadvantages

• As the trays are not rigid, distortion of impression may occur.

• Sometimes buccolingual width of the arch is wider than the tray.

Indications

• It should be used in patients with existing anterior guidance.

• It should be used in patients who can completely close in maximum

intercuspation.

• It should be used for a maximum of two prepared teeth.

• There should be unprepared teeth (vertical stops), both anterior and

posterior to the prepared teeth.

Contraindications

• Patients with rapidly ascending ramus

• Presence of third molar

• Excessive soft tissues posterior to the last molar

Technique

• Fit of the tray is evaluated and the patient is instructed to bite the
 tray. The occlusion on the opposing arch is checked using Mylar
strips.

• Mix a low-viscosity elastomer and load it in a syringe.

• Then high-viscosity elastomer is mixed and loaded onto the tray.

• The syringe material is injected onto the prepared tooth.

• The patient is asked to bite in maximum intercuspation position.

• Once the material is set, the patient is asked to open the mouth
slowly.

• Impression is then evaluated.

Segmental impression technique

• It is indicated in cases where simultaneous impression is made of
multiple teeth.

• It is indicated in patients where moisture control is difficult.

Technique

• Impression of the arch with multiple prepared teeth is made in

segments.

• Individualized custom trays are fabricated for each segment with

acrylic resin over the diagnostic cast.

• All the segmented trays should be able to seat on the cast

simultaneously.

• Tray adhesive is applied on each segmented tray on the internal

surface.
• Automix polyvinyl siloxane is loaded onto the tray and seated on
the segment of the arch.

• Once the material is set, the tray is not removed and another
segment is loaded and seated over that segment.

• Procedure is repeated till impression of all the segment is made.

• Then an oversized stock tray is used to make a pick up impression

with appropriate material.

• The completed impression is evaluated and poured.

Post-space impression technique

See Chapter 24.
Key Facts
• Electrosurgical procedure for impression making is contraindicated
in patients with pacemakers.

• Epinephrine should be avoided in patients suffering from

hypertension or cardiovascular disease, as it increases the heart rate
and blood pressure.

• Rubber dam should not be used when impression is made with

polyvinyl siloxane, as it inhibits the polymerization of the
impression material.

• Svedopter is usually used in mandibular arch when the patient is

seated in nearly upright position.
CHAPTER
27
Provisional restoration

CHAPTER OUTLINE
Introduction, 386
Definition, 386
Biological Requirements, 386
Mechanical Requirements, 387
Aesthetic Requirements, 387
Provisional Restoration—an Excellent
Diagnostic Tool, 387
Commonly Used Resin-Based Materials in
Fabricating Provisional Restorations, 387
Techniques Used for Fabrication of Provisional
Restorations, 389
Commonly Available Prefabricated
Crowns, 390
Limitations of Provisional Restoration, 392
Introduction
Provisional restoration refers to a type of restoration that is provided
to maintain the health of the prepared tooth until definitive or
permanent restoration is given. It is fabricated after the tooth
preparation and is cemented in the same appointment.

Definition
Provisional restoration is defined as ‘a fixed or removable dental
prosthesis, or maxillofacial prosthesis, designed to enhance aesthetics,
stabilization and/or function for a limited period of time, after which it is to
be replaced by a definitive dental or maxillofacial prosthesis. Such prosthesis
is used to assist in determination of the therapeutic effectiveness of a specific
treatment plan or the form and function of the planned definitive prosthesis’.
(GPT 8th Ed)
An ideal restoration should meet certain requirements necessary for
successful treatment. These requirements can be grouped into three
categories, namely, biological, mechanical and aesthetic.

Biological requirements
• It should seal and provide insulation to the prepared tooth to avoid
postoperative sensitivity.

• It should have a good marginal fit to prevent plaque accumulation

or food lodgement.

• It should have a smooth surface and proper contour to permit easy

cleaning.

• It should not impinge on the gingival tissues and should be

biocompatible.

• It should have proper contact with the opposing tooth so as to avoid

 its supraeruption.

• It should have adequate proximal contact with the adjacent teeth so

as to avoid drifting or horizontal movement.

• It should protect the prepared margins of the tooth to prevent

microleakage.

• It should not have overextended or underextended contours to

prevent plaque accumulation.

• It should have appropriate pontic, in order to maintain proper

gingival health and aesthetic contours.

Mechanical requirements
• It should have adequate strength to withstand the functional forces
of chewing without fracturing.

• It should adapt well to the prepared tooth to avoid movement or

drifting of adjacent teeth.

• It should remain intact on its removal so that it may be reused.

• It should establish proper occlusal and proximal contacts.

• Anterior provisional restoration should have proper lateral and

protrusive guidance.

Aesthetic requirements
• It should satisfy the aesthetic need of the patient, especially in the
anterior region.

• It should be colour stable.

• It should be made of biocompatible material which is easily

 contourable.

• It should be translucent and colour compatible with adjacent

teeth/tooth.

Provisional restoration—an excellent diagnostic

tool
Provisional restoration or interim restorations are an excellent
diagnostic tool used in fixed prosthodontics. Provisional restoration
serves as guide to determine whether the planned restoration satisfies
the functional, physiological or aesthetic requirement or not. Once the
diagnostic wax-up is done after completing the mock preparation on
the cast, the provisional restorations are fabricated with appropriate
material. This restoration helps in determining whether the proposed
treatment will satisfy the functional and aesthetic need of the patient
or not. The importance of provisional restoration in diagnosis is
magnified with the increase in complexity of the fixed treatment.
It is useful in:

• Determining the changes in centric occlusion and incisal guidance.

• Determining the changes in vertical dimension.

• Determining the changes in occlusal or incisal plane, tooth length or

contour.

• Aiding the diagnosis and treatment planning of periodontally

compromised teeth.

• Aiding the preprosthetic, endodontic and orthodontic procedures.

• Serving as an excellent guide in procedures such as crown

lengthening, ridge augmentation and pontic site preparation.

• Serving as a guide for the laboratory technician to fabricate the

definitive prosthesis.
 Provisional restoration, therefore, proves to be a valuable diagnostic
tool which provides a blueprint for a predictable, functional and
durable definitive prosthesis.

Commonly used resin-based materials in

fabricating provisional restorations
The most common materials used for fabricating single or multiple
unit provisional restorations are resin-based materials. There are a
number of resin-based materials which are available in the market.
The basic properties of these resins are similar to each other but only
differ in filler composition, type of monomer and method of
polymerization.
The commonly used resin materials for fabricating provisional
restorations are:

• Poly(methyl methacrylate) (PMMA)

• Poly(ethyl methacrylate)

• Polyvinylethylmethacrylate

• Bis-acryl composite

• Visible light-cured (VLC) dimethacrylate

Type of Resin Material Advantages Disadvantages

PMMA (poly[methyl methacrylate])Most • High fracture toughness • High temperature
commonly used resin for provisional • High flexural strength increase during
restoration • Good marginal fit and polymerization
durability • Chemical irritant to
• Can be highly polished pulp due to free
monomer
• High volumetric
shrinkage
• Poor colour stability
Polyethyl methacrylate • Can be highly polished • Decreased transverse
• Colour stable and minimal strength
heat increase during • Less fracture toughness
polymerization and less durability
• Low polymerization • Decreased surface
shrinkage hardness
Bis-acryl composite • High modulus of rupture • Brittle cannot be used
• Good marginal fit for long-span bridges
• Low exothermic heat increase • Limited shade selection
• High transverse strength • Limited polishability
• Low polymerization • Less colour stable
shrinkage • Decreased surface
hardness
VLC urethane dimethacrylate • Less polymerization • Brittle, should be
temperature increase avoided in long-span
• High surface hardness bridges
• Working time under the • Expensive
control of operator • Limited shade selection
• High transverse strength and • Marginal fit is not good
abrasion resistance • Less stain resistance
• Good colour stability

Classification of provisional restoration

On the basis of method of fabrication
(i) Prefabricated restoration

(ii) Custom-made restoration: Mainly made by direct technique or the

indirect technique or combination of both

On the basis of fabrication technique

(i) Direct technique

(ii) Indirect technique

(iii) Indirect–direct technique

On the basis of material used to fabricate

provisional restoration
(i) Resin-based autopolymerizing and dual-cure resins (e.g. PMMA,
poly(ethyl methacrylate), bis-glycidyl methacrylate resins, bis-acryl
resin composites, VLC resins)

(ii) Metal-based (e.g. aluminium, stainless steel, tin–silver, nickel–

 chromium)

On the basis of time duration

(i) Short-term temporary: For smaller time duration less than 2 weeks
(e.g. single crown, short-span bridges)

(ii) Long-term temporary: Longer time duration (between 2 weeks and

few months). This type includes periodontally compromised teeth,
in full mouth rehabilitation cases.

Custom-made provisional restoration

The custom-made provisional restorations are made by direct or
indirect technique or combination of both. Custom matrix is formed
to create the proximal and occlusal contours of the provisional
restoration. These are preferred for fabrication of multiple unit or
complex interim restorations. Usually, an elastomeric or alginate
overimpression is made on the diagnostic cast or in the mouth before
tooth preparation. This overimpression can then be used to fabricate
the provisional restoration. Elastomeric impression material provides
better stability than alginate, but because of the cost factor alginate is
most commonly used. Another method is to form a template on the
diagnostic cast with clear thermoplastic vacuum-formed resin
material. This template is filled with resin and applied on the
prepared teeth/tooth or check cast of the prepared teeth. Templates
are very stable and good acceptable provisional restoration is
fabricated by this method.
A thin oversized, shell crown or bridge can be fabricated by
autopolymerizing resin through sprinkle-on method on the diagnostic
cast. This shell can also be heat cured in the laboratory. This shell is
loaded with resin and placed on the prepared tooth or cast of the
prepared tooth. Provisional restoration made can then be shaped to fit
the prepared tooth.

Techniques used for fabrication of provisional

restorations
A number of techniques are available for fabricating provisional
restorations. The external contours of the provisional restoration are
formed by a matrix and the internal adaptation is formed by either
direct technique or the indirect technique.

Matrix
A matrix is always required to form the external contours of the
provisional restoration. Matrix can be custom-made or prefabricated.
The prefabricated or preformed matrix is usually used for single unit
restoration. The internal adaptation is done with direct technique or
indirect technique.

Direct technique
It is indicated for single crowns and short-span bridges. In this
technique, the matrix of choice is tried over the prepared teeth. The
matrix is formed from the preoperated diagnostic cast with preferred
material. After tooth preparation, the matrix is seated in the patient
mouth to check its fit. The prepared tooth is then isolated and
Vaseline is applied gently over the tooth surface. Next, the selected
material is mixed according to the manufacturer’s instructions and
loaded into the matrix. This loaded matrix is gently seated onto the
prepared tooth and allowed to set. The matrix should be moved in
and out in order to prevent interlocking of the resin onto the prepared
tooth. After the material has reached the rubbery stage, the
provisional restoration is carefully teased out and reseated several
times, till the polymerization is completed. The area needs to be
continuously flushed with water during the completion of this
procedure. This technique is not preferred these days because it has a
number of disadvantages.

Advantages

• Less time is consumed.

• Less material is consumed, as intermediate impression, etc. are
avoided.

Disadvantages

• There is a high chance of pulpal damage due to chemical irritation

of free monomer.

• Exothermic reaction of resin may damage the pulp.

• There are chances of resin interlocking onto the prepared tooth.

• There is poor marginal integrity.

Indirect technique
A sectional impression is made with elastomeric impression material
of the diagnostic cast or diagnostic wax-up to make the matrix. After
completion of tooth preparation, impression with preferred material is
made and is poured with dental plaster or stone. The matrix is then
tried on the cast to check its fit. The cast is coated with a separating
medium. Once the fit is satisfactory, the resin of choice is mixed
following the manufacturer’s instruction and is loaded onto the
matrix. The loaded matrix is placed on the cast and allowed to
polymerize. The matrix should be firmly seated onto the cast and can
be stabilized by elastic bands. The cast–matrix assembly can be placed
in warm water in a pressure pot to increase its density and strength.

Advantages

• The material used does not polymerize in the mouth.

• The prepared tooth is not exposed to exothermic reaction of the

resin.

• There is no chemical irritation due to the free monomer onto the

pulp.
• It can be used even in cases with complex fixed partial designs with
multiple units.

• Undercuts, if any, can be blocked on the cast for easy removal or

placement of the temporary bridge.

• Marginal fit is more accurate than the direct technique.

• It results in increased patient comfort.

Disadvantages

• This technique is time-consuming.

• More material is required in the technique.

• It may require reline in the margin intraorally.

Indirect–direct technique
This technique combines both the above-mentioned techniques to
provide an accurately fitting provisional restoration. A thin shell in
the form of matrix is fabricated on the diagnostic cast. This thin shell
is tried on the prepared tooth and the appropriate resin material
(preferably light cure) is mixed and relined intraorally. After
polymerization, the provisional restoration is finished and polished in
the laboratory (Fig. 27-1).
 FIGURE 27-1 Matrix is relined and cured using light-cure
resin.

Advantages

• It provides best marginal accuracy.

• It is least damaging to the pulp.

Disadvantages

• More time is needed for this technique.

• Laboratory help is needed.

Commonly available prefabricated crowns

Prefabricated or preformed crowns are available in variety of tooth
shapes and sizes and different materials. Their use is limited mostly to
the single crowns, as it is difficult to fabricate pontic for fixed partial
dentures. These crowns mostly require relining with
autopolymerizing resin or light-cure resin to achieve best fit and
accurate marginal adaptation.
Preformed or prefabricated crowns can be classified into the
following two groups on the basis of type of material used:

(i) Resin-based crowns (e.g. cellulose acetate, polycarbonate)

(ii) Metal-based anatomical crowns (e.g. aluminium, silver–tin, nickel–

chromium)

Polycarbonate crowns (fig. 27-2)

• These are indicated for anterior single crown.

FIGURE 27-2 Polycarbonate crowns of different shapes,

sizes and shades.

Advantages

• These are made of highly colour-stable resin.

• Aesthetics are similar to ceramic crown.

• These are supplied for use in the anterior incisors, canines and
premolar region only.

Disadvantages

• It is supplied only in one shade and requires a particular shade

relining resin to modify its shade.
• It may require extensive reshaping and recontouring to get a proper
shape.

• It may have sharp ledges or overhangs, if not contoured properly.

Cellulose acetate
• It is often supplied as thin shells (0.2–0.3 mm) which act as matrix.

• It is available in various tooth shapes and sizes.

• It can be used in both anterior and posterior regions.

• Particular shade resin is loaded into the matrix and placed onto the
prepared tooth and allowed to polymerize.

• This thin shell does not bond to the resin chemically and
mechanically and, therefore, can be easily removed.

• The final provisional crown is then shaped, finished and polished.

Preformed or prefabricated anatomical metal

crown
Prefabricated anatomical metal crowns are mostly indicated in the
posterior region which requires immediate coverage of the crown like
in cases of fractured molar tooth.

Aluminium and Tin–silver

• It is used in the posterior regions only.

• It is supplied in the form of both anatomical crowns and nonanatomical

cylindrical shells.

• Nonanatomical cylindrical shells are inexpensive but require

 elaborate modification to achieve an acceptable fit.

• Anatomical crowns are mostly preferred.

• Preformed crowns should be modified outside on the swaging block

and not inside the patient mouth.

• In any case, the patient should be allowed to bite on unmodified

preformed crown.

• This may even lead to fracture of the natural tooth.

• Although the crowns are more ductile and can easily be contoured
onto the tooth.

• Overhanging margin may irritate the gingiva.

Nickel–chromium (fig. 27-3)

• It is rigid, more durable and has high strength.

• It is indicated for damaged deciduous dentition and sometimes for

permanent tooth.

• The crowns are adapted using contouring and crimping pliers.

• These usually cannot be relined with resin material.

• These are luted with high-strength luting cement.

• It is usually used as long-term provisional restoration.

• Disadvantage: These are difficult to adapt and often do not produce

good occlusal contact.
 FIGURE 27-3 Nickel–chromium anatomic crowns.

Limitations of provisional restoration

Provisional restoration is fabricated to function for short duration of
time. It satisfies the functional and aesthetic requirement till the time
the definitive prosthesis is fabricated. However, it has limitations too.
Some of the limitations are:

• Lack of strength: Provisional restorations fracture in long-span

bridges can occur.

• It has poor marginal adaptation.

• Colour instability: This can occur, if the provisional restorations are

placed for longer duration.

• Poor wear properties: Resin wears in the proximal contact area and
may result in drifting of the teeth.

• Detectable odour emission: As the resins are porous, bad odour is

sometimes reported.

• Inadequate bonding characteristics: Eugenol-based cements are

incompatible with methyl methacrylate resins, as these interfere in
their polymerization.
Key Facts
• Indirect technique is preferred over direct technique to fabricate
provisional restoration for its accuracy and protection of pulp, in
case acrylic resin is used.

• Prefabricated polycarbonate crowns are used on prepared single

anterior tooth.

• Bis-acryl composite resin should not be used in long-span bridges,

as these are brittle in nature.
CHAPTER
28
Occlusion relationship

CHAPTER OUTLINE
Introduction, 393
Different Concepts of Occlusion in Fixed Prosthodontics, 393
Bilateral Balanced Occlusion, 394
Unilateral Balanced Occlusion or Group
Function, 394
Canine-Guided Occlusion or Mutually Protected
Occlusion or Organic Occlusion, 395
Functionally Generated Pathway, 396
Definition, 396
Requirements before Using this Technique, 396
Advantages, 396
Technique, 397
Role of Diagnostic Wax-Up, 397
Role of Articulators in Fixed
Prosthodontics, 397
Pros and Cons of Semi-Adjustable Articulators in Fixed Partial
Denture, 398
Pros of Semi-Adjustable Articulators, 398
 Cons of the Semi-Adjustable Articulators, 398
Fully Adjustable Articulators and their Utility in FPD with Multiple
Abutments, 398
Pathological Occlusion, 398
Definition, 398
Splints, 399
Definition, 399
Purpose of Splinting, 399
Different Splints Used in Fixed
Prosthodontics, 399
Myofascial Pain Dysfunction Syndrome, 400
Occlusal Therapy in Fixed Prosthodontics, 400
Aims of Occlusal Therapy, 400
Introduction
The maintenance of occlusal harmony is one of the most important
factors in determining the long-term success of fixed restorations. It is
important to understand different concepts of occlusion in fixed
prosthodontics in order to diagnose and treat occlusal disharmonies.
Different concepts of occlusion in fixed
prosthodontics
There are three concepts or schemes of occlusion which are commonly
used in fixed restorations. These concepts are bilateral balanced
occlusion, unilateral balanced occlusion and mutually protected
occlusion.

Concepts of occlusion
1. Bilateral balanced occlusion

2. Unilateral balanced occlusion or group function

3. Mutually protected occlusion

These are described in brief below.

Bilateral balanced occlusion
• Balanced occlusion is bilateral, simultaneous contact of all the teeth in
maximum intercuspation and during all eccentric movements of the
mandible.

• This type of occlusion is ideal for fabrication of complete dentures, as

it improves the stability of dentures.

• This occlusal scheme helps to distribute lateral forces throughout

the teeth and condyles during mastication.

• It has both cross-tooth and cross-arch balance (Fig. 28-1).

• Balanced occlusion is based on three classic theories of occlusion:

Bonwill’s three points of occlusal balance, Spee’s curve of Spee and
Monson’s spherical theory of occlusion.

• At the start of the century, this type of occlusion was used in the
treatment of dentulous and edentulous patients.

• It was widely used by B.B. McCollum and E.R. Granger but was
criticized by H. Stallard and C.E. Stuart.

• Occlusal surface wears due to excessive contact area; it is thought to

be the key cause of failure.

• It is extremely difficult to find a balanced occlusion in the natural

dentition. It may be found in the cases of advanced attrition.
FIGURE 28-1 Bilateral balanced occlusion.
Unilateral balanced occlusion or group
function
• Clyde Schuyler (1929) advocated the group function occlusion.

• This type of occlusion occurs with all the teeth contacting only on
the working side with no contact on the balancing side (Fig. 28-2).

• This occlusion has been frequently observed in natural dentition.

FIGURE 28-2 Unilateral balanced occlusion or group

function. Simultaneous contact occurs on the canine and
posterior teeth on the working side during lateral movement.

H.L. Beyron (1969) listed the characteristics of this type of occlusion:

• Teeth should receive stress along their long axis.

• Total stress should be distributed among the tooth segment in

lateral movement.

• No interferences occur from closure into intercuspal position.

• Keep proper interocclusal clearance.

• Teeth contact in lateral movement without interferences.

Characteristics of group function occlusion

The characteristics of group function occlusion include:

• Theory of long centric: Long centric is a 0.5–0.75 mm free space

between maximum intercuspation and centric relation position
without changing vertical dimension of occlusion.

• It follows concept of all working side teeth sharing lateral pressures

during lateral movements.

• It follows concept of nonworking side teeth free from contacts

during lateral movements.

• Group function does not have harmful effects as seen with a

balanced occlusion and is not difficult to fabricate.

• Group function has been advocated by Mann and L.D. Pankey for
full mouth restorations.

• The functionally generated path technique described by F.S.

Meyer is based on group function.
Canine-guided occlusion or mutually
protected occlusion or organic
occlusion
• This concept originated from the work of A. D’Amico, C.E. Stuart,
H. Stallard, C.E. Stuart and V.O. Lucia.

• This is one of the most widely used occlusal schemes because of ease
of fabrication and greater acceptability by the patient.

Definition
‘An occlusal scheme in which the anterior teeth disengage the posterior teeth
in all mandibular excursive movements, and the posterior teeth prevent
excessive contact of the anterior teeth in maximum intercuspation’. (GPT 8th
Ed)

• It is found in patients with good periodontal health and minimal

wear such that anterior teeth prevented the posterior teeth from
making any contact during mandibular excursions on the working
or the nonworking sides (Fig. 28-3).

• This separation from occlusion is also called disocclusion.

• According to GPT, disocclusion is defined as ‘separation of opposing

teeth during eccentric movements of the mandible’.

• In the position of maximum intercuspation, the posterior teeth

occlude with the forces being directed along the long axis of the
teeth and the anterior teeth have minimal or no contact.

• Thus, the anterior teeth protect the posterior teeth and the posterior
teeth protect the anterior teeth from the obliquely directed forces.
• This type of occlusion is, therefore, known as the mutually protected
occlusion and is advocated for full mouth rehabilitation provided the
teeth are periodontally healthy.

• In cases where there is anterior bone loss or missing canines, group

function should be the occlusion scheme of choice for restoration of
the mouth.

• The mutually protected occlusion cannot be used in class II, class III
or crossbite cases, where the mandible cannot be guided by the
anterior teeth.

FIGURE 28-3 Canine-guided occlusion.

Various movements of mandible

Mandibular movement occurring in all excursions is a complex three-
dimensional movement. It is made possible by the simultaneous
movements of both the TMJs. There are two types of movement
occurring in the TMJ, namely, rotational and translational.
Rotational movement: Movement of body about an axis
Translational movement: Movement of all the points in the body with
same velocity and direction
Movement of the mandible occurs around three axes:
1. Horizontal axis: Movement occurs in a sagittal plane when
mandible makes a purely rotational opening and closing movement
around the terminal hinge axis passing through both the condyles.
This type of movement is called a hinge movement. This type of
movement occurs till about 20–25 mm of separation in the anterior
teeth and beyond it translatory movement occurs.

2. Vertical axis: Movement occurs in horizontal plane when the jaw

moves laterally to one side. Condyle moving to one side is called the
working side condyle and the opposing condyle is called the
nonworking side or balancing condyle. The working side condyle
moves anteriorly out of the terminal hinge position and the balancing
condyle rotates around the terminal hinge position. This bodily shift
of the working side condyle is called the Bennett movement.

3. Sagittal axis: Movement occurs in the frontal plane when the

mandible moves laterally. The nonworking or balancing condyle
moves down and medially, whereas the working condyle rotates
around the sagittal axis perpendicular to this plane.

U. Posselt (1957) first described the extremes of the mandibular

movements and called them border movements.
Factors affecting mandibular movements are:

• TMJ

• Teeth

• Neuromuscular coordination

• Ligaments and muscles

Determinants of mandibular movement (also see chapter 5)

Anterior determinants: Teeth are the anterior determinants which guide

the mandible in various excursive movements. Anterior teeth
provide the incisal guidance, i.e. the overjet and overbite.
Posterior determinants: It is the condylar guidance which is influenced
by the slope of articular eminence.
Functionally generated pathway
Definition
Functionally generated path is defined as ‘registration of the paths of
movement of the occlusal surfaces of teeth or occlusion rims of one dental
arch in plastic or other media attached to the teeth or occlusal rims of the
opposing arch’. (GPT 8th Ed)

• This technique was first described by F.S. Meyer (1934).

• In this technique, a soft plastic material, such as wax, is used to

carve the pathways travelled by opposing cusps on lateral excusive
movements of the mandible.

• This record of static and dynamic occlusion is made in the patient’s

mouth and reduces the role of articulator as a simple hinge
instrument.

• This technique is indicated for single-tooth restorations only.

Requirements before using this technique

• It is used for single restorations.

• There should be no posterior interferences.

• There should be no missing or damaged opposing teeth.

Advantages
• Technique is simple, if well versed.

• It is time saving.
• It is inexpensive.

Technique
• Soft plastic material such as wax or pattern resin is adapted over the
prepared tooth.

• The patient is asked to bite in intercuspal position and move the jaw
in all excursive movements.

• The cusp tips carve grooves on the wax which represent the border
movements of the mandible in three dimensions.

• This impression is then cast in the mouth by painting plaster or

stone using brush.

• This stone functional core is then used to fabricate posterior tooth

restorations.

• The cast is then mounted in the laboratory and used in conjugation

with the normal opposing model.

• This functional core indicates not only the cusp tips of the opposing
teeth in intercuspal position but also where these move relative to
the proposed crown. This is a static record of the patient’s dynamic
movement.

Role of diagnostic wax-up

Diagnostic wax-up is a process in which correctly mounted and then
equilibrated casts are modified by application of wax, so as to mock-
up the final definitive prosthesis. The diagnostic wax-up is a very
important diagnostic tool which should be fabricated by the
technician under the guidance of clinician.
The features of diagnostic wax-up are:
• It is a valuable guide to the treatment objective for both the clinician
and technician.

• It provides information related to the occlusal scheme which is to be

generated.

• It provides the patient with an opportunity to visualize the outcome

of the treatment.

• It provides the template for provisional restorations.

• It provides information about the need for crown lengthening and

orthodontic tooth movement.

• It acts as a guide for optimum crown preparation.

• It helps in creating an occlusal plane.

Role of articulators in fixed prosthodontics

An articulator is a mechanical device which represents the TMJ and
simulates some or all the mandibular movements. The main principle
of articulator is to replicate the movements of TMJ as closely as
possible.

• It maintains casts at an established vertical height and centric

relation and simulates the mandibular movements as closely as
possible.

• These are classified on the basis of accuracy in reproducing

mandibular border movements.

• These can be nonadjustable, semi-adjustable and fully adjustable

articulators.

Uses
• The upper and lower casts are attached to the articulator to study
the functional and parafunctional relation between the teeth for
diagnosis, occlusal rehabilitation and equilibration.

• These are also used to accurately fabricate fixed and removable

prosthesis which are in harmony with various mandibular
movements.

• Articulator is used to establish occlusion in maxillofacial prosthesis

and for fabrication of occlusal splints.

• It is used for functional analysis of occlusion.

• It is used for full mouth rehabilitation.

• No articulator can reproduce the mandibular movements exactly.

Selection of the articulator depends on the complexity of restorative
need required by the patient.
Pros and cons of semi-adjustable
articulators in fixed partial denture
Pros of semi-adjustable articulators
• For most routine fixed prosthodontic procedures, the semi-
adjustable articulators are sufficient to provide valuable diagnostic
information.

• Use of this instrument does not require more time or expertise.

• These are capable of accepting lateral and protrusive records.

• Arcon-type semi-adjustable articulators are usually used in fixed

prosthodontics.

• Use of this articulator reduces adjustments during try-in and

insertion stages.

• This articulator has same spatial dimension as the condyle to the

teeth and, therefore, the discrepancies between the radius of
movement of articulator and the arc of tooth closure are minimal.

• One advantage of this articulator over nonadjustable is that it can be

adapted to the patient’s specific condylar movements.

• This type of articulator is used for fabrication of single crowns and

fixed partial dentures (FPDs).

• Arbitrary facebows are used with semi-adjustable articulators.

• Some articulators can allow adjustments to condylar inclinations

and progressive or immediate side shift.
Cons of the semi-adjustable articulators
• Intercondylar distance is not fully adjustable, as it can be adjusted to
small, medium or large configurations in some instruments.

• All the border movements are not reproducible.

• Some articulators reproduce the condylar path as a straight line

rather than a curved path.

• These are more time-consuming and more expensive than the

nonadjustable articulators.
Fully adjustable articulators and their
utility in FPD with multiple abutments
Fully adjustable articulators are considered to be the most accurate
instruments which are capable of accepting three-dimensional
dynamic registrations.

• These can reproduce an entire range of border movements of the

patient mandible.

• Accuracy and reproduction are highly dependent on the skill of the

clinician.

• Here, pantographic tracings are used to record the border

movements in the form of series of tracings.

• The intercondylar distance is completely adjustable.

• Kinematic facebow is used to locate true hinge axis.

• The ability of the articulator to track irregular pathways of the

mandible allows for fabrication of restorations of multiple
abutments. This is especially useful in full mouth rehabilitation
cases.

• Correct use of this articulator can reduce the chairside time during
try-in and insertion of the prosthesis.

• Although not required in general practice, their use become more

sensible when complex prosthesis are fabricated, especially in cases
where atypical mandibular movement exists.
Pathological occlusion
Definition
Pathological occlusion is defined as ‘an occlusal relationship capable of
producing pathologic changes in the stomatognathic system’. (GPT 8th Ed)
In pathological occlusion, disharmony between the teeth and the
TMJ exists resulting in signs and symptoms that require treatment or
intervention. The stomatognathic system consists of teeth,
periodontium, muscles and the TMJ. In a pathological occlusion, one
or more aspect of the system is affected.
In pathologic occlusion, the common signs and symptoms noticed
are:

• The teeth may show hypermobility, open contacts or abnormal

wear.

• Parafunctional habits, such as bruxism or clenching, may show

abnormal tooth wear, cuspal fracture or chipping of the incisal
surfaces.

• There could be trauma from normal occlusion when the periodontal

status of the teeth is compromised.

• Acute or chronic muscular pain on palpation may indicate habits

related to psychic tension, such as bruxism or clenching.

• Chronic muscular fatigue can lead to muscular spasm or pain.

• Pain, clicking sound or popping sound in the TMJ can indicate

temporomandibular disorder.

• Clicking of the joints may indicate internal derangement of the

joints.
 The acute signs and symptoms of the patient should be addressed
first and should be relieved. It is important to select an occlusal
scheme which prevents the recurrence of the signs and symptoms of
the pathological occlusion. An optimum occlusion should be provided
so that the patient requires minimum adaptation to the new occlusal
scheme.
Splints
Definition
‘A rigid or flexible material used to protect, immobilize, or restrict motion in
a part’. (GPT 8th Ed)

Purpose of splinting
• Mobility is reduced drastically.

• Forces are distributed to a number of teeth.

• Food impaction is prevented and proximal contacts are stabilized.

• Migration and overeruption is prevented.

• Discomfort or pain is eliminated.

• Appearance may be improved.

Splints can be of two types, namely, temporary splints and permanent

splints.

Different splints used in fixed prosthodontics

Night guard
• It is used in management of bruxism and clenching.

• It is made over the occlusal surfaces of the teeth with heat-cured

acrylic resin.

• It can be fabricated for one or both the jaws depending on the

 availability of freeway space.

• Most commonly, it is fabricated in the upper jaw.

• If it is used in one jaw, the occlusal contact of the opposing jaw is

adjusted, so that there is smooth maximal contact in gliding
movements.

• The acrylic resin should extend just below the height of contour for
ease of insertion and removal and retention.

Occlusal splint
• It is used in management of TMJ disorders and bruxism.

• It has been found to be effective in controlling myofascial pain.

• The patient is given a new occlusal scheme made in acrylic resin

overlay.

• The patient is asked to wear the splint for certain duration of time.

• If the patient adapts well and becomes comfortable over a period of

time, the proposed restorative treatment is likely to be successful.

• It is an important diagnostic procedure before treating cases

requiring full mouth rehabilitation.

Cast metal resin-bonded FPDs or maryland

bridges
• It is used with intact or very slight alteration of enamel.

• This type of prosthesis is functional, aesthetic, reversible and

economical.
• It consists of a metal frame bonded with resin cement to the tooth
structure.

• Although more successful in the anterior region, it can also be used

for posterior teeth.
Myofascial pain dysfunction syndrome
Myofacial pain is a type of regional muscular pain which is
characterized by localized areas of firm, hypersensitive muscular
bands of tissues called the trigger points.
Causes: Local and systemic factors, such as trauma,
hypervitaminosis, viral infection, muscle fatigue and emotional stress.
Signs and symptoms of myofascial pain dysfunction syndrome
(MPDS) are:

• Unilateral dull pain in the ear/periauricular area which radiates to

the angle of mandible, temporal area. Pain is relatively constant and
usually reported as worse in the morning.

• Tenderness over the neck of the mandible in region distal to the

tuberosity. Area of tenderness is presumed to be the spasm area of
masticatory muscles.

• Clicking or popping sound over TMJ. If only this symptom is

present, the patient is not included in MPDS.

• Limited jaw movement: Fourth cardinal symptom of MPDS. It is

characterized by the inability to open the mouth widely or there is
deviation while opening the mouth.
Occlusal therapy in fixed
prosthodontics
One of the primary objectives of restorative dentistry is to restore and
replace teeth in harmony with TMJs. If the teeth are not in harmony
with the joints and mandibular movements, it is understood that there
is some occlusal interference.
Occlusal interference can occur in the following:

• In centric contact

• On the working side when mandible makes lateral

excursion.

• On the nonworking side when mandible makes

lateral excursion.
• In protrusive contact

• When occlusal interference occurs, occlusal therapy

should be considered.

Aims of occlusal therapy

• To direct the occlusal forces along the long axis of the teeth

• To have centric relation coincide with maximum intercuspation

• To have simultaneous contact of the teeth in centric relation

• In protrusive contact, there should be disocclusion of the posterior

teeth
• To attain the occlusal scheme selected for the patient (canine guided
or group function)

• Physiological plane of occlusion

• A functional incisal guidance, i.e. proper overjet and overbite of the

anterior teeth

• An aesthetic and phonetic relationship of anterior teeth

Occlusal therapy can include treatment, such as orthodontic

treatment for tooth movement, selective grinding or restoration or
replacement of missing teeth. Proper diagnostic aids are very useful in
providing proper occlusal treatment. Diagnostic wax-up on the
mounted diagnostic casts at established vertical dimension is the
fundamental guide for providing a suitable restorative treatment.
Key Facts
• Group function is characterized by contact of all teeth on the
working side and no contact on the balancing side during lateral
excursions.

• Maximum limit of transverse hinge axis movement is 18–22 mm.

• In natural occlusion, the centric relation position is located 0.5–1.0

mm posterior to the centric occlusion position.

• The point at which the maximum opening of the jaws occurs

without translation movement of the condyle is called terminal
hinge axis position.

• Mutually protected occlusion or canine-guided occlusion is

characterized by posterior teeth protecting the anterior teeth in
intercuspal position and anterior teeth protecting the posterior teeth
in all mandibular excursions.
• Arcon articulators are preferred for fixed prosthodontics because of
accuracy and ease during occlusal waxing.

• Pantographic tracings are used with fully adjustable articulators.

• Functionally generated path technique was first advocated by F.S.

Meyer.

• The most important factor in the success of the artificial crown is

restoration of proper occlusion.
CHAPTER
29
Laboratory procedures in fixed
prosthodontics

CHAPTER OUTLINE
Introduction, 402
Dies and Various Materials Used for Making Dies, 402
Requirements of a Die Used in Fixed
Prosthesis, 402
Materials Used for Fabricating a Die, 403
Various Die Systems, 403
Alloy and Historical Perspective of Dental Casting Alloy, 406
Definition, 406
Historical Perspective of Dental Casting
Alloys, 406
History of Dental Casting Alloys, 406
Classification of Dental Casting Alloys and
Critical Evaluation of Precious, Semiprecious
and Nonprecious Alloys in Prosthodontics, 407
Casting Techniques for Casting of Base Metal
Alloy and Titanium, 408
Casting Defects and their Remedies, 409
 Investment Materials Used in Fixed
Prosthodontics, 411
Shade Selection for the Patient Requiring FPD, 412
Characteristics of Colour, 412
Procedure of Shade Selection, 413
Dentist–Technician Inter-Relationship—Important Key to Success in
Fixed Partial Denture, 413
Guidelines for Dentist, 413
Guidelines for Technician, 413
Introduction
Accurately fitting casting is important for successful fixed prosthesis.
To obtain precisely fitting casting, knowledge of various laboratory
procedures involved in fixed prosthodontics is critical. The
procedures are briefly explained in this chapter.
Dies and various materials used for
making dies
A die is defined as ‘the positive reproduction of the form of a prepared tooth
in any suitable substance’. (GPT 8th Ed)

Requirements of a die used in fixed prosthesis

• It should reproduce the prepared tooth accurately.

• Prepared surfaces and unprepared surfaces should be recorded

accurately.

• It should be easily mounted onto the articulator.

• It should be resistant to abrasion.

• It should have adequate strength.

• It should reproduce details accurately.

• It should be easily wetted by wax.

• It should not stick with wax and should be available in colour

contrasting to the wax.

Materials used for fabricating a die

Gypsum products
• Type IV and type V gypsum products are usually used as die
materials.

• These are capable of reproducing a 20-micron wide line according to

 American Dental Association (ADA) (specification no. 19).

• They have poor resistance to abrasion which is overcome by using

gypsum hardeners (e.g. colloidal silica).

• The surface of the die can also be impregnated with low-viscosity

resin such as cyanoacrylate.

Resin
• The resins that are commonly used as die materials are epoxy resins
and polyurethane.

• Epoxy resins are cured at room temperature and are dimensionally

stable.

• It has very good abrasion resistance.

• It has higher strength.

Disadvantages

• It is more expensive than die stone.

• It undergoes some shrinkage during polymerization.

• Prosthesis fabricated on resin dies fits more tightly.

• It is not compatible with materials such as polysulphides and

hydrocolloids.

• It is a time-consuming, complex procedure.

Electroplated dies
• Electroplated dies are used to provide good abrasion resistance and
high strength.
• It involves the deposition of a coat of pure silver or graphite.

• A layer of pure metal is deposited on the impression and is

supported by die stone.

Disadvantages

• The procedure should be done slowly.

• It is time-consuming and requires special equipment.

• Silicone impression material is difficult to electroplate due to low

surface energy.

• Because of its hydrophilic nature, it tends to imbibe water and hence

it cannot be used in polyether impression materials.

• Polysulphide impression can be silver plated but difficult to copper

plate.

• Drawback of silver plating is that it involves the use of cyanide

solution which is highly toxic.

Various die systems

Die systems can be classified on the basis of their design as follows:

(i) Working cast with a separate die

(ii) Working cast with a removable die

• Dowel pin systems – straight and curved

• Pindex system

• Di-Lok system
• Accu-trac system

Working cast with a separate die

In this method, either two separate impressions are made to get two
casts or a single impression is poured twice to get two separate casts.
Cast poured first from the impression is used as a die and the cast
poured second is used as a working cast. First cast is sectioned to form
a die and the other cast is used as a working cast. Wax pattern is
fabricated on the sectioned die and is then transferred and fitted onto
the working cast. This system is also called multiple pour system.

Advantages

• This technique is simple and easy to use.

• No special equipment is required.

• As gingival tissues are left intact, they can be used as a guide to

make accurate restoration.

Disadvantages

• There are chances of distortion of wax pattern during transfer from

die to working cast.

• It is difficult to transfer fragile wax pattern from die to cast.

• Seating of pattern on the cast may be difficult, as the second poured

cast is slightly larger than the first.

Various removable die systems

These systems have become more popular in recent times because of
ease of manipulating wax pattern during transfer from die to working
model. Also, manipulation of porcelain restorations is simpler.
Ideal requirements of removable die system

• Dies should be stable.

• Working cast with dies should be easy to mount on an articulator.

• Dies should be replaced accurately in their position originally

occupied.

Various removable die systems available are:

• Dowel pin system

• Pindex system

• Di-Lok system

• Accu-Trac system

Dowel pin system.

This is of two types, namely, straight and curved.

1. Straight dowel pin system

• Dowel pins are tapered, flat-sided pins made up of

brass (Fig. 29-1).

• They resist horizontal displacement.

• Dowel pin is positioned over the prepared tooth.

• There are two techniques in which the impression

can be poured with dowel pins, namely, prepour
and postpour techniques.
(a) Prepour technique

• In this technique, the dowel pins are positioned

over the prepared tooth and are stabilized using
wire clips or bobby pin and joined by sticky wax.

• Impression is poured with die stone till the area

which covers the tooth part of the impression.

• Dowel pins should never touch the impression and

should be positioned parallel to the long axis of the
prepared tooth.

• Once the die stone sets, the bobby pins are

removed.

• A small ball of wax is placed over the tip of the

dowel pin or a plastic sleeve is placed over the
exposed dowel.

• Separating medium is applied around the dowel to

aid in easy separation of die from working model.

• Second pour is done with die stone to form the

base.

• After setting of stone, the cast is removed from the

impression.
• The dies are sectioned with thin saw blade.

• The dowel is tapped from behind or wax is

removed and the dowel is pushed upwards to ease
its separation from the working model.

(b) Postpour technique

• In this technique, the impression is poured till the

level of teeth.

• Hole is drilled once the stone sets.

• Dowel pins are cemented with cyanoacrylate into

these holes.

• The remaining steps are similar to those described

above.
2. Curved dowel pins

• The technique followed for using curved pins is

similar to the one followed for straight pins.

• Curved dowel pins project from the base of the cast.

• After sawing, the die is removed by pressing the

curved dowel exposed with flat-ended instrument.
 FIGURE 29-1 Straight dowel pins.

Pindex system (fig. 29-2)

• It is the reverse drill press system.

• Postpour technique is used here.

• The first poured cast is placed on the worktable of the Pindex drill
press.

• The prepared tooth is positioned below an illuminated red dot.

• The machine accurately drills parallel holes from the underside of

the cast by pressing the worktable downwards.

• The dowel pins are cemented with cyanoacrylate cement.

• Plastic sleeves are placed on the flat end of the dowel pin.

• The procedure is repeated for other prepared tooth/teeth.

• A thin sheet of utility wax is placed over the tip of the dowel pin.

• Stone is poured to make the base.

• After setting of the stone, the dies are sectioned with a saw blade.

• Dies are removed by tapping the dowel below the base of the cast.

FIGURE 29-2 Pindex system.

Advantages

• This system has removable die.

• It facilitates accurate placement of die pins.

Disadvantages

• Special equipment is required.

• It is costly.

Di-Lok system

• In this system, a special form of plastic tray is used which has

internal grooves and notches.

• A full arch impression is poured with die stone.

• After setting, the cast is removed and trimmed in shape so as to fit

into the Di-Lok tray.

• Then a second pour is made with the stone into the tray with the
cast.

• After setting of the stone, the tray is disassembled to free the cast.

• The die is sectioned with a saw blade till the internal grooves on the
cast.

• The die is broken with finger pressure.

• The process is repeated to separate other dies from the cast.

Advantages

• It is less costly than Pindex.

• It is simple and easy to prepare.

• There is no use of dowel pins.

Disadvantages

• It is bulky.

• It requires more space for mounting on articulator.

• It requires proper maintenance of the parts of the tray for refitting.

Accu-trac system

• It is a modification of plastic tray with internal grooves and notches.

• It is used for making working models and dies in laminate veneer

cases.

• The technique is similar to the Di-Lok system described above.

• Care is taken during sectioning of the die by saw blade.

• The saw cut is made through the interdental papilla but about 1 mm
short of the interproximal finish line.

• The die here is broken with finger pressure.

Alloy and historical perspective of
dental casting alloy
Definition
An alloy is defined as ‘a mixture of two or more metals or metalloids that
are mutually soluble in the molten state; distinguished as binary, ternary,
quaternary, etc. depending on the number of metals within the mixture’.
(GPT 8th Ed)

Historical perspective of dental casting alloys

Newer developments in dental casting alloys were influenced by the
following factors:

• Price changes, especially the noble metal

• Improved characteristics

• Aesthetic properties

History of dental casting alloys

• 1907: Introduction of lost wax technique.

• 1933: Replacement of CoCr for gold alloys in removable partial

denture.

• 1950: Introduction of resin veneers for gold alloys.

• 1959: Introduction of porcelain fused to metal technique.

• 1968: Alternatives to gold alloys such as palladium-based alloys.

• 1971: Nickel-based alloys replacing gold alloys.

• 1980s: Introduction of all-ceramic technique.

• 1999: Gold-based alloys as alternative to palladium-based alloys.

Classification of dental casting alloys and critical

evaluation of precious, semiprecious and
nonprecious alloys in prosthodontics

Classification of dental casting alloys

On the basis of total noble metal content given by American Dental
Association (1984):

(i) High noble: Must contain ≥40% wt Au and ≥60% wt of noble metal
elements (Au, Pt, Pd, Rh, Ru, Ir, Os); also called precious alloys.

(ii) Noble: Must contain ≥25% wt of noble metal elements (Au, Pt, Pd,
Rh, Ru, Ir, Os); also called semiprecious alloys.

(iii) Predominantly base metal: Must contain <25% wt of noble metal

alloys; also called nonprecious alloys.

On the basis of mechanical property requirements given by ISO Draft

International Standard 1562 for casting gold alloys (2002):

(i) Type 1: Low strength – Casting which can tolerate very less stress
(e.g. inlays; minimum yield strength is 80 MPa, and minimum
percentage elongation is 18%).

(ii) Type 2: Medium strength – Casting which can tolerate moderate

stress (e.g. inlays, onlays, complete crowns; minimum yield
strength is 180 MPa and minimum percentage elongation is 10%).

(iii) Type 3: High strength – Castings which can tolerate high stresses
(e.g. onlays, thin coping, pontics, crowns and saddles; minimum
yield strength is 270 MPa and minimum percentage elongation is
 5%).

(iv) Type 4: Extra-high strength – Castings which can tolerate very high
stresses (e.g. saddles, bar, clasps, certain single units and partial
denture frameworks; minimum yield strength is 360 MPa and
minimum percentage elongation is 3%).

Classification of casting metals for all metal and metal–ceramic

prosthesis and partial dentures is given in Table 29-1.

TABLE 29-1
CLASSIFICATION OF CASTING METALS

Note: Alloys of all metal restorations cannot be used for metal–

ceramic restorations but alloys of metal–ceramic restorations can be
used for all metals because of the following reasons:

• Melting range could be too low to resist sag deformation at

porcelain firing temperature.
• Coefficient of thermal contraction may not match that of porcelain.

• Alloys may not form stable oxide layer for bonding to porcelain.

Classifying casting alloys on the basis of noble metal content as

precious, semiprecious and nonprecious is often misleading. This
classification was given on the basis of cost factor. The term ‘precious’
refers to the cost of the metal and term ‘noble’ refers to the chemical
behaviour of the metal. Both gold and palladium are considered as
noble and precious; palladium is noble but not precious and it is
categorized as semiprecious alloy. Semiprecious alloys include silver–
palladium alloys and alloys containing gold percentage between 10
and 60% although mechanical properties are similar to that of gold
alloys. Nonprecious alloys are referred to as alloys which are low
costing and do not contain noble metal alloys and commonly called
base metal alloys. These have high strength, hardness and are also
tarnish resistant. But the disadvantage of base metal alloys is that
certain contents in them have questionable biocompatibility (e.g.
beryllium does have carcinogenic potential and the patient may be
sensitive to nickel).

Casting techniques for casting of base metal alloy

and titanium

Casting technique of base metal alloy

• Base metal alloys are high-fusing alloys that experience high degree
of shrinkage on cooling.

• To achieve mould expansion, the invested pattern should be placed

in a water bath at 38°C.

• The investment ring is placed in oven at room temperature. The

temperature is brought to 815°C in 1 h.
• The investment ring is heat soaked for 2 h.

• Preheat the quartz crucible in oven.

• The quartz crucible is removed with casting tongs from the oven
and placed in the bracket of casting machine.

• The metal ingots are then placed into the crucible.

• Multiple orifice tip of gas–oxygen torch is used.

• The alloys are heated evenly by moving the torch over it.

• The ingots glow in uniformity and start to flow.

• The machine is released and the molten metal flows in the mould.

• The ring is then bench cooled.

• After cooling, the ring is cleaned and the casting is retrieved and
sandblasted.

Casting techniques for casting titanium alloys

• Ti and its alloys are highly biocompatible on the basis of widespread
use as implant material.

• Other advantages are its low cost, capability of bonding to ceramic

and resin cements and low thermal conductivity.

• Disadvantage is that it is difficult to cast.

• Ti has a very high melting point of 1668°C and reacts with

conventional investment and oxygen.

• Ti has low specific gravity and flows less than gold alloy when
casted in centrifugal casting machine.
• Special casting machine with arc melting capability and argon
atmosphere is used.

There are three specially designed casting systems:

(i) A pressure/vacuum casting system with separate melting and

casting chamber (Castmatic, Dentaurum).

(ii) A pressure/vacuum system with one chamber for melting and

casting (Cyclare, J Morita).

(iii) Vacuum/centrifuge casting system (Tycast, Jeneric/Penetron, and

Titaniumer, Ohara).

• Introduction of newer alloys of Ti with nickel can be cast with

conventional casting methods. Also, they have good bonding with
ceramic and have lesser release of ionic nickel.

• Recently introduced computer-aided design and computer-aided

manufacturing system avoids the use of available casting methods.

Casting defects and their remedies

There can be defects in casting, if proper casting procedure is not
followed. Defected casting results in prosthesis with inferior
mechanical properties and loss of time.

Classification of casting defects

(i) Distortion

(ii) Surface roughness

(iii) Porosity

(iv) Incomplete casting

1. Distortion

Distortion of the casting is usually due to distortion of

the wax patterns.

Causes

• Setting and hygroscopic expansion of the

investment material can produce uneven
movement on the walls of the pattern.

• Internal release of the stresses in wax pattern can

result in distortion of the casting.

Remedy

• Distortion can be prevented or minimized by

proper manipulation of the wax at high
temperatures.

• Wax pattern should be invested as soon as possible.

2. Surface roughness

(a) Investment breakdown: Too rapid heating of the

investment results in fins.

Remedy

• Proper heating of the mould and alloy

(b) Air bubbles on wax pattern: This results in small
nodules on the casting (Fig. 29-3).

Remedies

• Proper mixing of the investment

• Correct application of the wetting agent

• Use of vacuum investing technique

(c) Rapid heating rates: This results in fins or spines on

casting (Fig. 29-4).

Remedies

• Heat the ring gradually to 700°C (for 1 h minimum).

• Greater the bulk of the investment, more slowly it

should be heated.

(d) W-to-P ratio: Higher the ratio, rougher the casting.

• If the ratio is lesser, the investment may be thick

and cannot be properly applied to the pattern.

Remedy

• Use of correct ratio and selecting investment

 material of proper particle size.

(e) Prolonged heating: Prolonged heating of the

investment causes disintegration of the investment
and the walls of the mould are roughened.

(f) Pattern position: If several patterns are invested in

the same ring, care should be taken that there is at
least 3 mm spacing between the patterns.

Remedy

• Casting should be completed as soon as the ring is

heated and is ready.

(g) Casting pressure: Too high or too low casting

pressure results in rougher surface of the casting.

Remedy

• Adequate recommended pressure should be used

during casting.

(h) Composition of the investment: The amount of silica

and quartz influences the surface texture of casting.
3. Porosity in dental casting

Porosity in dental casting is of two types, namely,

internal and external. Internal porosity occurs in the
internal surface of the casting and tends to weaken
it. External porosity occurs on the surface and can
cause discolouration or even secondary caries.

FIGURE 29-3 Air bubbles on wax pattern result in small

nodules on the casting.
 FIGURE 29-4 Fins or spines on casting result due to rapid
heating.

Classification of porosity
(i) Solidification defects

• Localized shrinkage porosity

• Suck-back porosity

• Microporosity
(ii) Entrapped gases

• Pinhole porosity

• Gas inclusions

• Subsurface porosity
(iii) Residual air

Localized shrinkage porosity

• It is usually caused by incomplete flow of molten metal during
solidification.

• It occurs normally at the sprue casting junction.

• It occurs due to freezing of sprue before the rest of the casting which
results in deficient flow of molten metal and thus causes localized
shrinkage void.

• It can also occur in the interior portion of the crown where the sprue
attaches; there can be a hot spot created by the molten metal
impinging from the sprue.

• This causes the local region to freeze last resulting in suck-back

porosity.

• It can be prevented by reducing the temperature difference between

the mould and the molten metal.

Remedies

• Using sprue of correct dimension.

• Additional sprue of small gauze can be used.

• Flaring the point of sprue attachment.

• Placement of reservoir close to the wax pattern.

Microporosity
These are small irregular voids in the casting due to rapid
solidification of the mould or if the casting temperature is too low.
Pinhole porosity
• Most of the metals dissolve gases when they are in molten state.

• On solidification of the metal, the dissolved gases are released

causing pinhole porosity.

Gas inclusion porosity

• These porosities are spherical in shape and are similar to the pinhole
porosity but these are larger in size.

• It is also caused by the absorption of gases during solidification.

• Castings severely contaminated with gases are black in colour after

these are removed from the investment material.

• These large porosities can also result from gases occluded from
poorly adjusted flame.

Subsurface porosity
• It is caused by the nucleation of solid grains and gas bubbles
together such that the metal freezes at the wall of the mould.

• It can be prevented by controlling the flow of molten metal into the

mould.

Back pressure porosity

• This type of porosity occurs, if air in the mould is not allowed to
escape from the investment.

• It results in the formation of large concave depression on the surface

of the casting.
• The entrapment of the air can also occur in dense modern
investment which results in increased mould density.

Remedies

• Sufficient mould and casting temperatures.

• Sufficiently high casting pressure.

• Proper W-to-P ratio of the investment material.

• Placing the wax pattern not more than 6–8 mm away from the end
of the casting ring.

Investment materials used in fixed prosthodontics

An investment is a type of material used for forming a mould into
which a molten metal or alloy is casted. The process of forming a
mould is called investing.
Investing is defined as ‘the process of covering or enveloping, wholly or
in part, an object such as a denture, tooth, wax form, crown, etc. with a
suitable investment material before processing, soldering, or casting’. (GPT
8th Ed)

Types of investment material

There are three types of investment material commonly used in fixed
prosthodontics:

(i) Gypsum-bonded investment

(ii) Phosphate-bonded investment

(iii) Silica-bonded investment

Requirements of investment material

• Investment mould should expand sufficiently in order to
 compensate for alloy shrinkage on hardening.

• It should have sufficient strength to withstand the heat of burnout.

• It should be easy to manipulate.

• Mix mass should have smooth consistency.

• After casting, it should break easily.

• It should be cost-effective.

• It should accurately replicate the fine detail of the wax pattern.

Gypsum-bonded investment
• It is used for casting low-fusing alloys such as types I, II, III gold
alloys and inlays.

• Based on the temperature, gypsum-bonded investment is of two

types: (i) type I – for use with high-temperature technique and (ii)
type II – for use with low-temperature technique.

Composition

• Alpha-hemihydrate (gypsum matrix) acts as a binder: 30–35%.

• Silica (quartz or cristobalite) acts as a refractory material: 60–65%.

• Chemical modifiers: 5%.

• A rigid metal ring is lined with asbestos liner, which allows

expansion to take place in radial direction.

• This investment material should not be heated above 700°C.

• Above 700°C, it shows shrinkage and releases sulphur dioxide

which contaminates the casting.
• Alpha-hemihydrate and chemical modifiers enhance the strength of
the investment material.

Phosphate-bonded investment
It is used for casting high-fusing alloys (e.g. metal–ceramic alloys,
high-fusing noble metal alloys, base metal alloys).

Composition.
The powder form consists of the following:

• Ammonium diacid phosphate: Acts as a binder and gives strength.

• Silica: Acts as a refractory material and provides high thermal

expansion.

• Magnesium oxide: Reacts with phosphate ions.

The liquid form consists of the following:

• Aqueous suspension of colloidal silica.

• Ammonium diacid phosphate reacts with magnesium oxide to

form ammonium magnesium phosphate.

• Carbon is added to the powder to produce clean casting and aids in

divesting when gold alloys are casted but should not be used with
palladium-based alloys.

• This investment material has poor surface wetting property and has
chances of air bubble incorporation.

• Wax patterns of metal–ceramic fixed partial denture (FPD) should

be invested and casted as a single unit because of problems during
soldering.

Silica-bonded investment
• It is not popular because the procedure takes more time and is
complicated.

• It consists of silica which acts as a binder and is formed from

aqueous suspension of colloidal silica or ethyl silicate.

• Magnesium oxide is added to increase the strength.

• The powder is mixed with hydrolysed silicate liquid rapidly to form

a mould.

• The mould is placed on a special vibrator that provides tamping

effect, i.e. the heavier particles settle at the bottom and the liquid
part comes to the top.

• This investment can be heated between 1090°C and 1180°C and can
be used for casting high-fusing base metal alloys.
Shade selection for the patient
requiring FPD
Selection of proper shade is an important aspect in delivering an
aesthetic restoration. There are three essential factors which are
responsible for proper shade match: (i) light source, (ii) the object and
(iii) the observer.
The light source used for shade matching can have definite effect on
the perception of colour. There are three light sources which are
common in dental operatory – natural light, incandescent and
fluorescent. The visible portion of electromagnetic spectrum lies
between 380 and 750 microns. Shade should be matched under more
than one type of light in order to avoid the problem of metamerism.
‘Metamerism is a phenomenon of an object which appears different under
different sources of light’.
When shade is selected, characteristics of the colour are important
to understand.

Characteristics of colour
• Hue: Quality which distinguishes one colour from another.

• Chroma: It is the saturation or intensity of hue.

• Value: It is the relative brightness or darkness of the hue.

Procedure of shade selection

• Shade should be matched before tooth preparation.

• Selected shade guide should be same as porcelain used by the

technician.

• Teeth should be clean before the shade match.

• Make up, if any, should be removed.

• Patient is seated in an upright position with his mouth at the

operator eye level.

• If possible, natural light should be used and the tooth should be

moistened.

• Observations should be made quickly (within 5 s) to avoid fatigue of

cones in the retina.

• The entire shade guide is scanned quickly and worst matching

shade tabs are selected first and then eliminated.

• By this process of elimination, only a few tabs are left from which
the final shade is to be selected.

• If confusion exists between two tabs, both the tabs are placed on
either side of the tooth.

• Finally, the closest shade is selected.

• In order to provide life-like restoration, the natural tooth should be

carefully observed so that the restoration can be characterized for
features such as craze lines, hypocalcification.

• It is best to draw the facial surface of the tooth in the patient chart
clearly indicating the shade, translucency areas, areas to be
characterized, etc. and this information is given to the technician.
Dentist–technician inter-relationship—
important key to success in fixed
partial denture
A good communication between the clinician and technician is the key
to high-quality fixed and removable prosthodontics. This can be
achieved by close working relationship of the dentist and laboratory
technician. Clinician should have good knowledge of the laboratory
procedures and its limitation. ADA has listed guidelines for both
dentist and technician to improve inter-relationship so as to deliver
prosthesis of high quality.

Guidelines for dentist

• Provide verbal or written instructions for the lab to proceed with the
fabrication or modification of the prosthesis.

• Provide the laboratory with accurate impression, working models,

interocclusal records or mountings.

• Provide with a description of the selected shade, photographs, pre-

extracted model or smile photograph.

• Retain a copy of the written instructions to the laboratory for a

period of time, as this may be required for medicolegal purposes.

• Follow proper infection control methods as laid down by ADA.

Guidelines for technician

• Produce prosthesis as instructed by the clinician using the
impression, cast or records.
• In case of doubt, clarify with the clinician.

• Provide the closest shade match as possible with the available

material.

• Inform the clinician immediately, if there is a delay in the work.

• Inform the clinician about the material used for fabrication.

• Properly follow the infection control protocol given by ADA.

• Finish the laboratory procedure in time.

Following the guidelines by both clinician and technician and

mutual respect will ensure fabrication of high-quality prosthesis with
minimum failures.
Key Facts
• Lost wax technique was first used in casting of alloys by W.H.
Taggart (1906).

• Gypsum-bonded investment material is used for casting gold

alloys.

• Pickling is a method of cleaning gold casting by hot acid solution

for several minutes.

• Phosphate-bonded investment is used for casting metal–ceramic

alloys having high-melting temperature.

• The minimum fineness required for dental solder to be corrosion

resistant is 580 fine.

• Beryllium added to base metal alloys to control oxide formation is a

carcinogen.

• Rounded margins on the casting may be caused by wax which is

 not completely eliminated during burn out procedure.

• Expansion of the investment by heat during elimination of the wax

is called thermal expansion.
CHAPTER
30
Finishing and cementation

CHAPTER OUTLINE
Introduction, 415
Internal Surface, 415
External Surface, 415
Commonly Used Abrasives and Polishing Agents, 416
Biocompatibility of Various Dental Cements Used in Fixed
Prosthodontics, 416
Failures in Fixed Partial Denture (FPD), 418
Factors Responsible for FPD Failures, 418
Introduction
The prosthesis retrieved after casting is very rough and should
undergo a series of finishing procedures before it is placed in the
mouth. The internal and the external surfaces of the prosthesis are
finished separately and have different objectives.

Internal surface
• The internal surface of the prosthesis should conform and accurately
seat on the prepared tooth.

• Proper marginal fit should be inspected and the internal surface

should not bind but seat onto the prepared tooth.

• Internal surface of the casting should be inspected under

magnification for small nodules or bubbles.

• It should provide space for film thickness of the cement.

• The internal surface should be conducive to strong luting cement.

• Sandblasting is recommended on the internal surface so that it

becomes more conducive to nonadhesive cement.

• When resin cement is used, special surface treatment may be

recommended for better bonding.

External surface
• It should have a highly polished external surface because rough
surface attracts plaque accumulation.

• Before try-in, the metal surface should be given satin finish and at
the time of cementation, the external surface should have high
 lustre.

• Porcelain restoration should be polished and reglazed after a bisque

try-in.

• Finishing and polishing are done with abrasives of various particle

sizes ranging from coarse to fine.

• When gold restorations are polished, some minute amounts of

abraded surface material are filled into the surface irregularities.
This microcrystalline surface is called the Beilby layer.
Commonly used abrasives and
polishing agents
An abrasive is a very hard material with sharp cutting edges, which if
slided over the softer surface cuts a series of grooves.
Polishing agents consist of abrasives which are comparatively softer
and are reduced to very fine sizes for finishing of restoration.
Abrasives can be classified as follows:

(i) Finishing abrasives

(ii) Polishing abrasives

(iii) Cleansing abrasives

Some commonly used abrasives and polishing agents are:

• Silicone carbide: This is one of the most commonly used abrasives in

the laboratory. It is sintered or pressed with a binder into grinding
wheels or discs.

• Diamond: This is the hardest abrasive used for tooth enamel or

porcelain. If used with ductile material, such as gold, the abrasive
particles become clogged with the softer material and the disc or the
wheel becomes ineffective.

• Aluminium oxide: This is manufactured from bauxite. Coarse-grit

aluminium oxide is abrasive and used for finishing metal–ceramic
restorations. Fine-grit aluminium oxide is used for polishing. The
stones of this grit are called poly stones.

• Emery: This is a mixture of aluminium oxide and iron oxide, called

corundum. The greater the content of alumina, finer is its grade. It is
used for finishing porcelain or gold restorations.
• Garnet: This is a red abrasive consisting of silicates of aluminium,
cobalt, manganese and iron. It is bound to paper discs with glue
and used for cutting both metal and ceramic.

• Tin oxide: It is used as fine powder for final intraoral polishing of

the metal restorations.

• Tripoli: This is a fine siliceous polishing powder and is combined

with wax binder to polish gold restorations initially.

• Rouge: This is a fine red powder consisting of iron oxide, supplied

in cake form. It is an excellent polishing agent for gold restorations.

• Sand: Sand or other forms of quartz called flint are coated on discs
and are available in various grits. It is used for finishing and
polishing of gold restorations.

• Pumice: This is a highly siliceous material used as abrasive or

polishing agent. It is used for polishing dentures and smoothening
teeth intraorally.

• Kieselguhr: It is a mild abrasive and polishing agent.

• Cuttle: This is made from internal calcified shell of cuttlefish. It is

used as a fine polishing agent as paper discs.
Biocompatibility of various dental
cements used in fixed prosthodontics
The purpose of dental cement is to occupy space between the indirect
restoration and the tooth. There are various cements available to lute
the indirect restorations to the tooth. Some of the commonly used
dental cements are briefly mentioned in Table 30-1.

FIGURE 30-1 Resin cement bonds to tooth enamel by

micromechanical means.

TABLE 30-1
DENTAL CEMENTS USED IN FIXED PROSTHODONTICS

Type of
Salient Features
Cement
Zinc phosphate • One of the oldest available luting agents
• Gold standard when compared with newer cements
• Compressive strength: 104 MPa
• Bonds with mechanical interlocking and has low water solubility
• At the time of cementation, pH of the cement is 2.0 and it increases rapidly to 5.5 after
24 h
• Pulpal irritation is likely because of the acidic pH
 • Cavity varnish is used to reduce the irritation, but its application reduces retention
Zinc • First cement developed which bonds to tooth chemically
polycarboxylate • It has higher tensile strength but lower compressive strength than zinc phosphate
• It shows pseudoplastic behaviour, i.e. increased thinning at increased shear rate
• It also has low pH (4.8), but is less irritant to the pulp because large-sized polyacrylic
acid molecules penetrate less into the dentinal tubules
• It can bond with stainless steel crowns but not with gold
Zinc oxide • This has the least pulpal irritation amongst all available cements
eugenol • It has a low compressive strength range between 3 and 55 MPa
• Smaller particle size cement is more stronger
• Usually used as temporary cement
• Presence of eugenol interferes with the polymerization of the composites
• Modified cement can be used as a long-term provisional luting agent.
• o-Ethoxybenzoic acid (EBA) cements are reinforced with alumina oxide
• The compressive strength of improved cement was acceptable but was much low in
comparison to other cements
Glass ionomer • This is the most commonly used luting agent
cement • It contains fluoride and has anticariogenic property
• Its compressive strength is 150 MPa and the tensile strength is 6.6 MPa
• Bonds chemically with both enamel and dentine
• Reasonably biocompatible
• Less soluble than zinc phosphate and releases fluorides at a higher rate than silicate
cement
• Vulnerable to postcementation hypersensitivity
• Layer of calcium hydroxide is recommended when cement is applied close to the pulp
• Cement at the crown margin should be protected by applying varnish or petrolatum
• It is more translucent than zinc phosphate cement and chances of metal see through
are possible
Resin cements • These are flowable composites of low viscosity
• These have higher strength than conventional cements
• These have very low solubility
• These cements can be chemically activated or light-activated or dual-cured
• Application of dentine bonding agent is critical for its use, as it reduces the pulpal
sensitivity and microleakage
• The cement bonds by micromechanical means (Fig. 30-1)
• The cement is useful when preparation is confined to enamel and has accessible finish
lines
• These are the luting agents of choice to bond all ceramic inlays, crowns and bridges
• These are available in different shades and give good aesthetic results
Hybrid • These are resin-modified polyalkenoate cements
ionomer • These have good strength and low in solubility and also contain fluoride
cements • These have anticariogenic property
Failures in fixed partial denture (FPD)
Classification of failures in FPD by Bernard G.
Smith
(i) Loss of retention

(ii) Mechanical failure of crown or bridge components: This is

subclassified as follows:

• Porcelain fracture

• Failure of solder joints

• Distortion

• Occlusal wear and perforation

• Lost facings
(iii) Changes in abutment tooth

• Periodontal diseases

• Problems with the pulp

• Caries

• Fracture of the prepared natural crown or root

• Movement of the tooth
(iv) Design failures: This is subclassified as follows:

• Underprescribed bridges

• Overprescribed bridges
(v) Inadequate clinical or laboratory technique: This is subclassified as
follows:

• Positive ledge

• Negative ledge

• Defect

• Poor shape and contour

(vi) Occlusal problems

Factors responsible for FPD failures

The factors can be of three types:

(i) Biological factors

(ii) Mechanical factors

(iii) Aesthetic factors

Biological failure
This includes the following:
• Caries

• Pulp degeneration

• Gingival recession and periodontal breakdown

• Occlusal problems

• Tooth perforation

• Cementation failure

Mechanical failure
This includes the following:

• Loss of retention

• Pontic failure

• Connector failure

• Occlusal wear

• Tooth fracture

• Porcelain fracture

Aesthetic failure
This includes the following:

• Improper shade selection

• Failure to identify patient expectation

• Failure to communicate proper shade to laboratory

• Opaque layer too thick

• Thick metal margin at incisal and cervical regions

• Failure to produce translucency

• Over- or undercontoured crown

• Exposed metal margin in connector, incisal or cervical region.

• Overglazing

Key Facts
• In chronic xerostomic patient, cervical caries and periodontitis are
prime reasons for FPD failure.

• Beilby layer is a microscopic surface layer produced during

polishing of gold crowns.

• Metamerism is a phenomenon of an object appearing of different

colours when viewed under different light source.

• The use of dissimilar metallic restorations in the same mouth may

result in the creation and flow of galvanic currents.
SECTION IV
Maxillofacial Prosthodontics
OUTLINE

31. Introduction and materials

32. Maxillofacial defects and prosthesis

CHAPTER
31
Introduction and materials

CHAPTER OUTLINE
Introduction, 422
Definition, 422
Objectives, 422
Scope, 423
Indications, 423
Contraindications, 423
Effect of Radiation on the Oral Cavity, 423
Oral Mucosa, 423
Bone, 423
Salivary Glands, 424
Taste Buds, 424
Teeth, 424
Periodontium, 424
Evolution of Maxillofacial Prosthesis, 424
Materials Used in Prosthetic Restoration of the Facial Defects, 425
Desirable Properties of Ideal Materials, 426
Definitive Materials Used in Maxillofacial
Prosthesis Fabrication, 426
Stents and Splints Used in Maxillofacial Prosthesis, 431
Splints, 431
Antihaemorrhagic Stent, 432
Introduction
Maxillofacial prosthodontics is a branch of prosthodontics involved in
treating congenital, developed and acquired maxillofacial defects with
variety of techniques and materials. This chapter outlines effects of
radiation on oral tissues and various materials used in maxillofacial
prosthodontics.

Definition
Maxillofacial prosthodontics is defined as ‘the branch of prosthodontics
concerned with the restoration and/or replacement of the stomatognathic and
craniofacial structures with prosthesis that may or may not be removed on a
regular or elective basis’. (GPT 8th Ed)
Maxillofacial prosthesis is defined as ‘any prosthesis used to replace
part or all of any stomatognathic and/or craniofacial structure’. (GPT 8th
Ed)

Objectives
The important objectives of maxillofacial prosthodontics are:

• Restoration of the function

• Restoration of aesthetics

• Therapeutics and healing effect

• Psychological therapy

Scope
• It is an alternative to plastic surgery but not a substitute to plastic
repair.
• Large defects which are not restored with plastic surgery are
rehabilitated by means of appliances or devices used for restoring
the aesthetics and function.

• It is beneficial to patients who refuse further surgery or are at poor

surgical risk for extensive plastic surgery.

Indications
• If anatomical part is not replaced with vital tissues

• When recurrence of malignancy is envisaged

• When radiation therapy is given

• When fragments of the facial bones are displaced in the fracture

• When surgery is not possible due to advanced age, reduced blood

supply, large defect requiring extensive surgery or when the patient
is not willing

• To fabricate a temporary appliance to cover the defect when plastic

surgery repairs require many steps

Contraindications
• When the defect is small and can be restored with surgery.

• When the defect area has good blood supply.

• When prognosis after surgery is good.

Effect of radiation on the oral cavity
Radiation therapy is widely used for the management of malignant
lesions in the oral cavity and other parts of the body. It is used as an
adjunct to surgery or in combination with chemotherapy. The effects
of postradiation are well known and sometimes may result in needless
morbidity. The effects of radiation on the various areas of the oral
cavity are given below.

Oral mucosa
• Initially starts as erythema and leads to extensive ulceration with
severe mucositis.

• Severity of mucositis depends on the area of radiation and the

amount of dose.

• It is most severe in the soft palate followed by mucosa of

hypopharynx, floor of the mouth, buccal mucosa, base of the tongue
and dorsum of the tongue.

• Healing is rapid after radiation therapy and usually completes by 2–

3 weeks.

• Oral candidiasis is the most common complication.

Bone
• As the bone is 1.8 times denser than the soft tissues, it absorbs
considerable amount of radiation than the soft tissues.

• The mandible absorbs more radiation than the maxilla and since it
has reduced blood supply, there is a greater chance of mandibular
osteoradionecrosis.
• The early effect of radiation leads to significant aberration of the fine
vasculature and to progressive occlusion and obliteration of the
smaller blood vessels.

• The late effect of radiation leads to acellularity and avascularity of

the marrow tissues along with its significant fibrosis and fatty
degeneration.

• Gross changes in the bone matrix can make the bone virtually
nonvital.

Salivary glands
• Irradiation of the salivary glands can lead to changes in the
viscosity, pH and organic and inorganic constituents of the saliva.

• Changes in saliva can predispose the patient to caries and

periodontal diseases.

• Deglutition becomes difficult and the patient complains of loss of

appetite.

• With irradiation of the salivary glands, there is progressive

degeneration of the acinar epithelium with increased inter- and
intralobular fibrosis.

• Ultimately, the glands shrink in size and adhere to the surrounding

tissues.

• Retention of the removable prosthesis is compromised due to

reduced flow of saliva.

Taste buds
• Taste buds are readily affected by the radiation therapy and show
signs of degeneration and atrophy.
• There is a partial or complete loss of taste sensation during and
after irradiation.

• Reduction of saliva decreases the number of taste buds and alters

the form and function of the remaining buds.

Teeth
• Irradiation leads to greater chance of teeth decalcification.

• It is believed that pulp undergoes fibrosis and atrophy accompanied

with reduced blood supply.

• The patient may complain of root sensitivity after irradiation.

• High doses of radiation can significantly affect the development of

the tooth leading to various anomalies.

Periodontium
• The network of fibres becomes disoriented and thickening of the
periodontal ligament is evident.

• There is decreased acellularity and vascularity to periodontal

ligament which predisposes it to infection.

• The cementum shows severely reduced capacity to repair and

regenerate.

• Periodontal procedures should be planned with caution, especially

in the mandible.
Evolution of maxillofacial prosthesis
Maxillofacial prosthodontics has evolved many folds over the period
of time. A brief description about the evolution of various prostheses
and materials are given below.

Egyptian mummies: Auricular, nasal and ocular prostheses were

fabricated with various materials.

Before AD 1600, Chinese were known to fabricate nasal and auricular

prosthesis using natural waxes, resins and metals such as
gold/silver.

1541: The first obturator was made by Ambroise Pare which consisted
of a simple disc attached to sponge.

First artificial eye was made of glass in 1579 in Venice.

Tycho Brahe (1546–1601) was famous Danish astronomer who made

an artificial nose of gold and silver.

1710: Pierre Fauchard fabricated a silver mask for a French soldier

named Alphonse Louis who was wounded by shell fragment,
which removed nearly all of the left side of the mandible and
maxilla. The soldier was called gunner with the silver mask.

1800s: William Morton fabricated nasal prosthesis using enamel

porcelain to match the complexion of the patient.

1823: J. Snell fabricated gold plate obturator.

1855: C. Goodyear developed vulcanite rubber used for improved

velar design.

1880: N. Kinsley described a combination of nasal palatal prosthesis

using ceramic material.
1894: F.L.R. Tetamore fabricated a nasal prosthesis of light-weight
nonirritating material called cellulose nitrate developed by John
Wesley Hyatt.

1900–1940: Upham fabricated nasal and auricular prosthesis from

vulcanite rubber.

1905: Ottofy, Baird and Baker reported the use of black vulcanized
rubber for fabricating maxillofacial prosthesis.

1913: Gelatine–glycerine compounds were introduced for use in

facial prosthesis in order to mimic softness and flexibility.

During the same period, V. Kazanjian used celluloid

prints for colouring vulcanized rubber facial
prosthesis.
1937: Acrylic resin was introduced and replaced by vulcanite rubber.

1940–1960: Adolph Brown administered colours in facial prosthesis.

1942: A.H. Bulbian introduced the use of prevulcanized latex for

pliable facial prosthetic restoration.

1953: American Academy of Maxillofacial Prosthetics was formed.

1960–1970: The introduction of various kinds of elastomers resulted in

major changes.

1965: G.W. Barnhart was the first to use silicone rubber for
construction and colouring of facial prosthesis.

1975: A. Koran and R.G. Craig investigated the properties of selected

silicone elastomers, polyvinyl chloride (PVC) and polyurethane.

1976: D.N. Firtell and C.R. Anderson introduced the concept of

 combining materials to achieve improved properties.

1977: P.I. Branemark and associates first placed extraoral implant in

the mastoid region to support a bone conduction hearing aid.

1982: A. Udagama and J.B. Drane introduced a new silicone elastomer

(medical adhesive type A, or Dow Corning A-891).

1984: M. Abdelnnabi et al. compared a new material

polydimethylsiloxane (PDMS) with MDX 4-4210.

1987: A. Udagama presented a technique for bonding polyurethane

film to silicone.

1970–1990: J.B. Gonzalez described the use of polyurethane

elastomers.

1988: BAHA, i.e. bone-anchored hearing aid, was approved by the

Swedish health system.

1990s: Rapid prototyping technology used in maxillofacial

prosthodontics is used to create three-dimensional models from a
three-dimensional representation (CT scan or MRI).

2008: 3D printing used to bioprint maxillofacial prosthesis (Fig. 31-1).

2014: 3D Bioplotter is used to create human body parts although it is

still under research.
FIGURE 31-1 Bioprinting of ear prosthesis.
Materials used in prosthetic restoration
of the facial defects
Classification of different materials used in fabrication of maxillofacial
prosthesis is as follows:
On the basis of usage, maxillofacial materials can be broadly
classified as:

(i) Impression materials

• Impression compound

• Irreversible hydrocolloids

• Impression plaster

• Condensation and addition silicones

• Waxes and impression pastes

(ii) Mouldable and sculpting materials

• Modelling clay

• Plaster

• Waxes

• Plastolene
(iii) Definitive materials

• Acrylic resins

• Acrylic copolymers

• Vinyl polymers and copolymers

• Polyurethane elastomers

• Silicone elastomers – heat temperature vulcanizing

(HTV) and room temperature vulcanizing (RTV)

• Metal implants

Desirable properties of ideal materials

• Should have good aesthetic property; it should simulate the colour,
form, texture and translucency of the adjacent natural skin

• Should be easy to fabricate

• Should be biocompatible

• Should have suitable working time

• Should be easily mouldable

• Should be dimensionally stable

• Should be soft, resilient, flexible and simulate the feeling of real

flesh

• Should be easily duplicated

• Should be easily cleaned without damage or deterioration

• Should be easily available and inexpensive

• Should be light in weight

• Should have sufficient edge strength even in thin margins

• Should have low thermal conductivity

• Should be stable during temperature variations

• Should be durable and resistant to stains

• Should be stable when exposed to ultraviolet (UV) rays, oxygen or

adhesive solvents

Definitive materials used in maxillofacial

prosthesis fabrication
Definitive materials used in the fabrication of the maxillofacial
prosthesis are:

• Acrylic resins

• Acrylic copolymers

• Vinyl polymers and copolymers

• Polyurethane elastomers

• Silicone elastomers – HTV and RTV

Acrylic resins
Uses
• These are used in cases where little movement of tissue bed occurs
during function.

• These are used in the fabrication of both intra- and extraoral

prostheses.

• These are derivatives of ethylene and contain a vinyl group in their

structural formula.

Physical properties

• The polymerization can be initiated by UV light or heat as well as by

chemical initiations.

• Shrinkage of 21% occurs during the polymerization of the pure

monomer.

• It is a hard resin with a Knoop hardness number of 18–20.

• Tensile strength is approximately 8500 pounds per square inch (600

kg/cm2).

• Modulus of elasticity is approximately 350,000 pounds per square

inch.

• It is soluble in organic solvents such as chloroform and acetone.

• Water absorption: 0.3% absorption is observed after 24 h, which is

reversible, if the resin is dried.

• Heat polymerization is preferred compared to autopolymerization

because of colour stability and also because of the presence of free
toxic tertiary amines in the latter.

Advantages

• Durable
• Colour stable

• Cosmetic

• Can be relined or repaired

• Compatible with most adhesive system and can be easily cleaned

• Easy and quick to fabricate

Disadvantages

• It has higher rigidity.

• Duplicate prosthesis is not possible, because of mould destruction

during processing.

• Water sorption – increased weight 0.5% after 1 week.

• Its use is doubtful in the movable tissue bed.

• Because of relatively high thermal conductivity, the patient may

complain of discomfort in cold climatic conditions.

Acrylic copolymers (palamed, polyderm)

These are soft elastic but are not widely accepted because of the
following reasons:

• These have poor edge strength.

• These have poor durability.

• These are susceptible to degradation when exposed to sunlight.

• Processing and colouration is difficult.

• Completed restoration is often tacky and predisposing to dust

 collection and staining.

• J.M. Antonucci and J.W. Stansburry reported the new generation of

acrylic monomers, oligomers and macromers.

• These are thermal, chemical and photoinitiated.

• These can eliminate the shortcomings of traditional acrylic

copolymers.

PVC and copolymers (realistic, mediplast)

• It consists of a combination of PVC and plasticizer.

• PVC is a clear, hard resin. It is tasteless and odourless.

• Copolymers of vinyl chloride and vinyl acetate are more flexible but
less chemically resistant than polymethyl chloride.

• It darkens when exposed to UV light and heat.

• It requires heat and light stabilization to prevent discolouration

during fabrication and use.

• Polyvinyl acetate is stable to light and heat but has an abnormally

low-softening point (35–40°C).

Realistic

• It is a PVC compound and solidifies into a flexible material when

heated.

Advantages

• It is easy to handle and is ideal for an inexperienced person using

maxillofacial materials.
• It is flexible and provides acceptable initial appearance.

• It is available in a wide variety of colours to match the patient’s skin

tone.

• Staining can be achieved both internally and externally. Ferrous

pigments incorporated into the mixture give the long life and the
best aesthetic results.

Disadvantages

• Migration of plasticizer leads to discolouration and hardening of

prosthesis.

• These can be stained easily when exposed to UV light, peroxides

and ozone.

• These lack lifelike translucency and tend to absorb sebaceous

secretions, cosmetics and solvent.

• Edges, if thin, tear easily and may be reinforced with nylon fabric.

• These require metal moulds, as they polymerize at high

temperatures.

Chlorinated polyethylene (CPE)

• D.H. Lewis and D.J. Castleberry tested and found this material to
be similar to PVC in both chemical composition and physical
properties.

• The processing procedure involves high-heat curing with

pigmented sheets in metal moulds.

• The system consists of the industrial CPE which is blended with

additives – low-density polyethylene, calcium stearate and soya
bean oil.
• The mechanical properties of formulated material are good.

• No chemical reaction is involved in fabrication.

• Material is relatively cheap.

• Disadvantage: Metal moulds are required for fabrication, as they

polymerize at high temperatures.

Polyurethane elastomers (Epithane-3)

• Polyurethane elastomers contain a urethane linkage.

• In the presence of catalyst, isocyanate combines with a hydroxyl

group.

• Varying amount of isocyanates will change the physical properties

of final products.

• These have excellent properties such as elasticity and ease of

colouration.

• Deficiencies are moisture sensitive leading to gas bubbles and cause

local irritation.

• Epithane-3 is a commercially available four-component system.

Advantages

• These can be made elastic without compromising the strength at the

margins.

• Their flexibility made them to be used on movable bed.

• These can be coloured extrinsically and intrinsically.

• Superior cosmetic results can be obtained.

• These are durable and resemble the living tissue.

Disadvantages

• These are difficult to process consistently.

• Isocyanate is moisture sensitive.

• Water contamination is difficult to control and leads to gas bubbles.

• These are not colour stable.

• These have poor compatibility with adhesive systems.

• Clinical usefulness is less than 6 months.

• Isocyanate is a toxic compound and can cause local irritation.

• Cleaning of adhesive from prosthesis can be difficult for the patient.

Silicone elastomers
The silicones were introduced in 1946 and are one of the most widely
used materials for facial restorations.

• They consist of alternate chains of sodium and oxygen which can be

modified by attaching various organic side groups to the silicone
atoms or by cross-linking the molecular chains.

• G.W. Barnhart (1960) was the first to use silicone elastomers for
extraoral prosthesis.

• These are a combination of organic and inorganic compounds.

• Chemically, polydimethyl siloxane (PDM) combines with water to

form a polymer.

• These polymers are translucent, watery and white fluids, whose

 viscosity is determined by the length of polymer chain.

• PDM is commonly known as silicone.

• Additives are added to give colour and fillers provide strength.

• Antioxidants and vulcanizing agents are used to convert the raw

mass from plastic to a rubbery resin during processing.

• The process of cross-linking of polymers is referred as

vulcanization. It can occur with or without heat and is dependent
on the catalyst or the cross-linking agent used.

Classification
On the basis of vulcanization
(i) RTV

(ii) HTV

On the basis of their application

(i) Class I: Implant grade, which requires the material to undergo
extensive testing and must meet the FDA requirements.

(ii) Class II: Medical grade, which is approved for external use. This
material is used for the fabrication of maxillofacial prosthesis.

(iii) Class III: Industrial grade, which is commonly used for industrial
applications.

HTV (heat vulcanizing silicones)

• These involve the use of a diorganopolysiloxane (e.g. PDM).

• The vulcanizing agent is benzoyl peroxide.

• The filler added to the polymer is finely divided silica with particle
size of 30 microns.

• Amount of filler added to the polymer can be varied depending on

the requirement of strength, hardness and elongation.

• There is more intense mechanical milling of the solid HTV

elastomers compared with the soft putty RTV silicone.

Various types of HTV silicone

• Silastic 370, 372, 373, 4-4514, and 4-4515 are white, opaque materials,
with putty-like consistency.

• Catalyst or vulcanizing agent of HTV is dichlorobenzoyl peroxide or

platinum salt.

• These exhibit excellent thermal stability and are biologically inert

but lack elasticity.

• PDM may be added to reduce the stiffness and the hardness of the
prosthesis.

• Silastic S-6508 is in raw state which is similar to sticky modelling

clay. It must be vulcanized at high temperatures and is formed in
pressure moulds.

• Silastic 399 resembles white Vaseline in its raw state. It is easily

spatulated, but nonflowing.

Advantages

• Excellent thermal stability

• Colour stable
• Biologically inert

Disadvantages

• Not adequate elasticity in function

• Low edge strength

• Opaque, lifeless appearance

RTV (room temperature vulcanization silicones)

• These are composed of comparatively short-chain silicone polymers

which are partially end blocked with hydroxyl groups.

• Filler: Diatomaceous earth particles.

• Catalyst: Stannous octoate.

• Cross-linking agent: Orthoalkyl silicate.

• These are available as clear solutions that enable the fabrication of

translucent prosthesis.

• RTV silicone is blended with suitable earth pigments to produce the

patient’s basic skin colour.

Advantages

• These are colour stable.

• These are biologically inert.

• These retain physical and chemical properties at wide range of

temperatures.

• These are easier to process.

Disadvantages

• These have poor edge strength

• These are costly.

• Cosmetic appearance of the material is inferior to other materials.

Advantages of HTV over RTV

• Less chances of air bubble entrapment, because hand mixing of

catalyst with the elastomer is avoided.

• Increased tear strength, mechanical durability and chemical

resistance

• Increased biocompatibility

Silastics
It is a medical grade silicone rubber material.

• It is in the form of thick white liquid. When combined with

organometallic catalyst, it vulcanizes without the use of heat or
pressure.

• Dibutyltin dilaurate will prolong the vulcanization time and will

cause skin irritation unless prosthesis is washed thoroughly.

• Working time varies from 2 to 60 min by adjusting the catalyst.

Thinner is added to the catalyst to increase accuracy (thinner can be

added 10% of weight without noticeable changes in the prostheses).

Advantages

• Silastic 382 can be moulded without difficulty with the simple bench
press pressure. RTV silicones are virtually unaffected by oxygen,
 ozone, and UV light.

• Intrinsic colouring agents: Methyl methacrylate monomer, polymer

and ferrous oxide pigments in Silastic base.

• Extrinsic colouring agents: Methyl methacrylate monomer–polymer

admixture in a precatalysed Silastic base.

• Average life is 6–8 months.

Disadvantages

• Air bubbles incorporation: To compensate, mixing has to be done on

flat surfaces. If a void occurs on the surface of the finished product,
repair can be instituted by meticulously cleaning the surface with
xylene and by adding a fresh mixture of precatalysed material in
that area.

• Difficulty in internal colouring: As the material is white, translucency

is decreased. In order to overcome this, clear Silastic C55 392 can be
used.

• Low edge strength: To overcome this, white nylon material is

embedded in the prosthesis. This gives added strength.

• High weight: To overcome this, a foam-type Silastic (55370) for the

internal portion of the thick prosthesis can be used.

• Special adhesives are used in retention of prosthesis. To offset the

deleterious effect of adhesives, mechanical retention employing
undercuts, magnets or other means are preferred.

Silastic 399.
It is in the form of a clear gel which makes tinting appreciably easier.
It resembles white Vaseline in raw state, easily spatulated but
nonflowing. Upon mixing with first catalyst (the cross-linking agent),
it becomes somewhat milky; when the second catalyst is added, it sets
into a translucent rubber in 10–15 min.

Advantages

• It is tougher, translucent, nonflowing and easier to handle.

Foaming silicones

• Silastic 386 is a form of RTV silicone.

• The purpose of foaming is to reduce the weight of prosthesis.

• The gas forms bubbles within the vulcanizing silicone. After

processing of silicone, gas is released resulting in a spongy material.

Advantages

• Formation of bubbles within the mass can cause the volume to

increase by seven-folds.

• It reduces the weight of the prosthesis.

Disadvantages

• It results in reduced strength and is susceptible to tearing.

• To improve the properties, the foaming silicone is coated with

another silicone. Although it improves the strength, the product is
made more rigid.
Stents and splints used in maxillofacial
prosthesis
Stent is defined as ‘any device or mould used to hold a skin graft in place or
provide support for anastomosed structures’. (GPT 8th Ed)
Splint is defined as ‘a rigid or flexible device that maintains in position a
displaced or movable part’. (GPT 8th Ed)

Types of splints
(i) Gunning splint

(ii) Functional occlusal splint

(iii) Cap splint

(iv) Provisional splint

(v) Interdental splint

(vi) Essig splint

(vii) Kingsley splint

(viii) Resin-bonded splint

(ix) Soft splint

(x) Surgical splint

(xi) Labiolingual splint

(xii) Cast metal splint

Types of stents
(i) Antihaemorrhagic stent

(ii) Surgical stent

(iii) Nasal stent

(iv) Radiation stent

(v) Trismus stent

(vi) Occlusal stent

Splints

Gunning splint
• This prosthetic device is fabricated to hold together fractured
segments of edentulous mandibular or maxillary jaws for
immobilization.

• One-piece gunning splint consists of upper and lower base plates

that are joined in proper vertical and centric relation with a bite rim.
This splint is immobilized by an extraoral Barton bandage or elastic
chin bandage.

• Two-piece gunning splint consists of separate splints for both

maxilla and mandible. Both the bite rims are constructed in centric
relation and in the anterior region; space is provided to facilitate
breathing, feeding and postanaesthesia vomiting.

• Two to four wire hooks are provided on the buccal flange for future
anchoring with intermaxillary rubber bands.

Labiolingual splint
• It is constructed for dentulous or partially edentulous arches to aid
 in reduction of fractures in children.

• Splint consists of an acrylic band that fits around the labial and
lingual aspects of the teeth, except the occlusal surfaces.

• The maxillary and mandibular labiolingual splints are joined in

occlusion by intermaxillary rubber bands (Fig. 31-2).

FIGURE 31-2 Labiolingual splint.

Fenestrated splint
• This is a one-piece prosthetic device contoured to fit a dentulous
maxilla and mandible through fenestrations created for the occlusal
surfaces of the teeth.

• It is used in case of short clinical crowns, for deciduous teeth, when

no undercut is available for retention and for badly decayed teeth.

Kingsley splint
• It is constructed for both dentulous and edentulous patients and
covers the palate and the alveolar ridge.

• It has anterior extension of the metal rods protruding bilaterally

from the commissures of the mouth.

• It is helpful in lifting the fractured maxilla.

• This splint is immobilized by an extraoral plaster headgear.

Cast metal splint

• This type of splint is used when long-term immobilization is
required.

• Cobalt–chromium–aluminium and gold are the common materials

used for its construction.

• This splint may be left open at the occlusal surface or it may be

hinged.

• Its disadvantage is that it is expensive and its fabrication is time-

consuming.

Antihaemorrhagic stent
• It is used to control bleeding, as it is lined by haemostatic agent
(Fig. 31-3).
 FIGURE 31-3 Antihaemorrhagic stent.

Occlusal stent
• It is a diagnostic and therapeutic device used for the evaluation of
occlusion and vertical dimension in the treatment of
temporomandibular joint pain dysfunction syndrome.

Trismus stent
These are of two types, namely, externally activated stent and
internally activated stent (Fig. 31-4).
 FIGURE 31-4 Trismus screw for bite opening.

Internally activated stent

• Bite opening

Externally activated stent

• Dynamic bite opener

• Screw-type mouth gags

• Tongue blades

• Continuous dynamic jaw extension apparatus

Radiation stent
• It is used to deliver the radiation dose to the local area in order to
 limit the post-therapy morbidity (Fig. 31-5).

FIGURE 31-5 Peroral cone positioner to deliver radiation

dose.

Functions of radiation stent

• To maintain the position of structures to be treated

• To remove structures from the radiation field

• To position peroral cones

• For shielding

• To position the dosimetric device

• To recontour tissues to simplify dosimetry

• To position the radioactive source

Nasal stent
• This type of stent provides support to the cartilage transplant
during postsurgical healing for the correction of the nasal deformity
in cleft lip patients.

• These help in maintaining contour and minimize scar contracture

following skin grafting procedure.

Key Facts
• Ambroise Pare (1517–1590) was first to close palatal perforations.

• Tycho Brahe (1546–1601) was famous Danish astronomer who

made an artificial nose of gold and silver.

• First artificial eye was made of glass in 1579 in Venice.

• Pierre Fauchard (1728), considered as the father of modern

dentistry, used palatal perforations to retain artificial dentures.

• Snell (1823) fabricated gold plate obturator.

• Goodyear (1855) developed vulcanite rubber used for improved

velar design.

• Bulbian (1942) introduced the use of prevulcanized latex for pliable

facial prosthetic restoration.

• American Academy of Maxillofacial Prosthetics was formed in 1953.

• Branemark and associates first placed extraoral implant in the

mastoid region to support a bone conduction hearing aid in 1977.

• BAHA, i.e. bone-anchored hearing aid, was approved by the

Swedish health system in 1988.
• Barnhart was first to use silicone rubber for construction and
colouring of facial prosthesis.

• Magnus Jacobsson described the role of osseointegrated skin-

penetrating titanium fixtures used for retaining facial prosthesis.

• George Washington springs are preformed springs which are

inserted into the upper and lower set of dentures to stabilize them
on the ridges during function.

• Newer orbital implant materials are polyethylene implants,

bioceramic implants and synthetic HA implants.
CHAPTER
32
Maxillofacial defects and
prosthesis

CHAPTER OUTLINE
Introduction, 435
Cleft Lip and Palate, 436
Aetiology, 436
Dysfunctions Associated with Cleft Palate
Patient, 437
Rehabilitation of Cleft Lip and Palate
Patients, 437
Prosthodontic Rehabilitation of the Cleft Palate
Patient, 437
Types of Removable Prosthesis, 438
Aramany’s Classification of Maxillary
Defects, 442
Palatal Lift Prosthesis, 444
Meatal Obturator, 445
Mandibular Defects, 445
Prosthetic Management of the Mandibular
Defects, 446
Extraoral Prosthesis, 447
Ocular or Eye Prosthesis, 447
Auricular Prosthesis or Ear Prosthesis, 448
Nasal Prosthesis, 449
Retention Aids in Maxillofacial Prosthesis, 451
Extraoral Retention, 451
Intraoral Retention, 452
Role of Magnets in Maxillofacial
Prosthesis, 452
Introduction
The maxillofacial defects often require prosthetic intervention in
restoring the contours of defect and restoring the function of the
tissues. This chapter includes various defects and different types of
maxillofacial prosthesis used to restore such defects.

Classification
Maxillofacial defects can be classified as follows:

On the basis of the onset

(i) Congenital defects

• Cleft palate

• Cleft lip

• Facial cleft

• Missing ear

• Prognathism

• Various syndromes
(ii) Acquired defects

• Accidents

• Surgery
• Pathology
(iii) Developmental

• Prognathism

• Retrognathism

On the basis of location or area involved

(i) Intraoral

• Tongue

• Floor of the mouth

• Alveolar ridge

• Hard and soft palates

• Maxilla and mandible

(iv) Extraoral

• Auricular defect

• Nasal

• Ocular

• Midfacial defect
(v) Combined

• Any combination of the intraoral and extraoral

defects
Cleft lip and palate
Cleft palate is defined as ‘an opening in the hard/or soft palate due to
improper union of the maxillary process and the median nasal process during
the second month of intrauterine development’. (GPT 8th Ed)

Classification of cleft palate

V. Veau (1922) classified cleft palate as follows:

Class I: Cleft involving the soft palate only; can also be submucous
cleft which appears normal.

Class II: Midline cleft involving the posterior part of the hard palate.

Class III: A unilateral cleft extending along the mid-palatine suture

and a suture between the premaxilla and the palatine shelves (Fig.
32-1).

Class IV: A unilateral cleft extending along the mid-palatine suture

and both the sutures between the premaxilla and the palatine
shelves (Fig. 32-2).
FIGURE 32-1 Unilateral cleft.
 FIGURE 32-2 Bilateral cleft.

Aetiology
• Drugs

• Infection

• Poor diet

• Hormonal imbalance

• Genetic factors

Dysfunctions associated with cleft palate patient

• Altered swallowing pattern

• Difficulty in speech

• Tight, inactive or hypotonic upper lip

• Abnormal position of the tongue and the jaw

• Altered maxillary vertical development

• Increased freeway space

• Changes in lower face height

• Deviated jaw movement

Rehabilitation of cleft lip and palate patients

Rehabilitation of the cleft palate involves multidisciplinary approach
involving number of specialists.
Primary consideration for such patients depends on the following:

• Extent and location of the cleft

• Growth potential of the patient

• Parental cooperation

• Design of the appliance

Prosthodontic rehabilitation of the cleft palate

patient

Infants
Primarily, two types of appliances are given:
(i) Passive or holding appliance

(ii) Active or expansion appliance

All the appliances are fabricated or inserted before the lip closure.
The primary aim of the appliance given before surgery is to guide the
maxillary segments into proper spatial position with each other and
the mandibular arch.
Once the segments are in good alignment, surgery is performed to
close the defect. The pressure of the surgically closed cleft lip along
with the appliance is helpful in creating an ideal arch form.

Prosthetic appliance for children

Three types of appliances are given to aid in speech, which are:

(i) Obturator with palatal–velar–pharyngeal closure: It is a type of

temporary appliance which is used for diagnosis and training.

(ii) Baseplate type with functions to obturate the palate and helps in
speech. This is indicated when there is perforation in the hard palate
and the surgeon desires more growth of the child before surgical
closure.

(iii) Anterior prosthesis which improves the occlusion and helps in

contouring the upper lip: Because of the stunted growth of the maxilla
and the normal growth of the mandible, mandibular prognathism is
often seen in such patients. This appliance is used to improve the
appearance of the patient at this stage.

Prosthesis for adults

(i) Fixed prosthesis: It is the treatment of choice when the ridge defect
is small, as it contributes to stability, longevity, comfort and hygiene.

A fixed partial denture can be constructed from

 cuspid-to-cuspid in the maxilla to restore the
integrity of the maxillary arch by stabilizing the
premaxilla and to provide adequate aesthetics.
(ii) Removable prosthesis: It is preferred, if there is a large anterior
ridge defect and the midface is depressed.

Types of removable prosthesis

(i) Snap on prosthesis with no speech bulb.

(ii) Removable partial denture with no speech bulb: This is indicated

in large ridge defect and extremely poor occlusion.

(iii) Complete superimposed denture with no speech bulb: Overlay

denture restores the vertical dimension of the face and gives an arch
form to the upper arch. Also, all the teeth are restored.

(vi) Snap on prosthesis with speech bulb: It helps in velopharyngeal

valving. The pharyngeal section is placed high to prevent any
interference with the tongue movement.

(v) Conventional speech prosthesis with bulb: A patient with all the
teeth need only framework that can clasp the healthy abutment teeth.
This framework carries the palatal, velar, pharyngeal portion
necessary for speech impairment.

(vi) Complete superimposed denture with speech bulb: Overlay

denture may or may not have the speech bulb. It is indicated in
patients with loss of vertical dimension with hypernasality and
having dished out appearance of the midface.

Obturators
Obturators are defined as ‘a maxillofacial prosthesis used to close a
congenital or acquired tissue opening, primarily of the hard palate and/or
contiguous alveolar/soft tissue structures’. (GPT 7th Ed)
Obturator is derived from the Latin verb ‘obturare’ which means ‘to
close’ or ‘shut off’.

Objectives of obturators

• To restore aesthetics or cosmetic appearance of the patient

• To restore function

• To protect the tissues

• To provide psychological therapy

• Has a therapeutic or healing effect

Classification
(I) Classification by A.O. Rahn and L.J. Boucher
(1970)
On the basis of origin or discrepancy

(i) Congenital defect obturator

(ii) Acquired defect obturator

On the basis of anatomical location of the defect

(i) Labial/buccal obturator

(ii) Alveolar obturator

(iii) Hard palate obturator

(iv) Soft palate obturator

(v) Pharyngeal obturator

On the basis of type of obturator attachment to the basic maxillary

prosthesis

(i) Fixed obturator

(ii) Hinged/movable obturator

(iii) Detachable obturator

On the basis of physiological movement of the oral, nasal and

pharyngeal tissues adjacent to or functioning against the obturator

(i) Static obturator

(ii) Functional obturator

(II) Classification on the basis of timing of the

fabrication
(i) Surgical obturator

• Immediate surgical

• Delayed surgical
(ii) Interim or temporary obturator

(iii) Definitive obturator

• Closed hollow bulb

• Open type
Historical background of obturators

Ambroise Pare was the pioneer to use obturator to close palatal

perforations in the early 1500s.

Pierre Fauchard described two types of palatal obturator; one type

had wings in the shape of propellers and the other type had
butterfly-shaped wing for retention. Both types were operated by a
special key.

William Morton (1819–1868) is known to treat cleft palate patient

with gold plate.

Delabarre described hinged obturator in 1820.

Claude Martin described the use of surgical obturator prosthesis in

1875.

Norman Kingsley described a method to reconstruct the palatal

deformity in 1880.

E. Fry described the use of impressions before surgery in 1927.

American Academy of Maxillofacial Prosthetics was established in

1953.

B. Steadman described the use of an acrylic resin prosthesis lined

with gutta-perch to hold a skin graft within the maxillectomy defect
in 1956.

K.W. Coffey: In 1984, he first described the inflatable balloon

obturators which were useful in minimizing displacement of soft
tissues.

Functions of obturators

• Helps in enhancing the healing of the postsurgical or traumatic

 defects

• Can be used for feeding purpose

• Helpful in reshaping and reconstruction of the palatal contour

and/or soft palate

• Improves speech

• Can improve aesthetics by correcting the lip and cheek contour

• Prevents ingress of food into the defect or exudates into the oral
cavity

• Can be used as a stent to hold dressing or surgical packs after

surgery

• Provides psychological comfort to the patient

• Reduces postoperative bleeding

Indications

• When size and extent of the defect contraindicate surgery

• To serve as temporary prosthesis during surgical correction

• Old age patient where surgery is contraindicated

• When local avascular conditions of the tissues contraindicate

surgery

• To rapidly restore patient’s cosmetic appearance

• To act as a framework over which tissues are shaped by the surgeon

• Patient’s medical condition which contraindicates surgery

• When the patient is not willing for another surgery

Types of obturators.
Obturators are of three types on the basis of interventional time
period used in the maxillofacial rehabilitation of the patient:

(i) Surgical obturator

(ii) Interim obturator

(iii) Definitive obturator

Surgical obturators.
 Surgical obturator is defined as ‘a temporary maxillofacial prosthesis
inserted during or immediately following surgical or traumatic loss of a
portion or all of one or both maxillary bones and contiguous alveolar
structures (i.e. gingival tissues, teeth)’. (GPT 8th Ed)

Types of surgical obturators

(i) Immediate surgical obturators: Placed immediately after surgery.

(ii) Delayed surgical obturators: Placed 7–10 days postsurgery.

Principles related to the design of surgical obturator (J. Beumer,

T.A. Curtis, et al., 1979)

• It should terminate short of the skin graft mucosal junction.

• It should be simple, light weight and inexpensive.

• It should reproduce palatal contours to aid in postoperative speech

and deglutition.

• Posterior occlusion should not be given on the defect side until the
surgical wound is well healed.
• Existing prosthesis can be utilized as surgical obturator provided it
will obturate the surgical defect adequately.

• Obturator for the dentulous patient is perforated at the

interproximal extensions with a small dental bur to allow the
obturator to be wired to the teeth at the time of surgery.

Advantages

• It provides the matrix on which the surgical packing can be placed.

• It reduces the oral contamination of the wound immediately during

postsurgical period.

• It aids in speech and deglutition.

• It reduces the psychological trauma of surgery.

• It may reduce the period of hospitalization.

• Anterior teeth, if required, may be added to enhance the aesthetics.

Fabrication

• Impression is made of the upper arch before surgery and cast is

poured.

• Teeth in the path of resection are trimmed on the cast.

• The vestibular depth on the defect side determines the superior

extension of the obturator.

• Surgical obturator is fabricated with either autopolymerizing resin

or the heat-cured resin.

• Heat-cured resin is generally preferred.

• Holes are provided in the flange region to aid in wiring to the

 alveolar ridges or zygomatic arch or nasal spine. At times,
circumzygomatic and frontal wiring is employed to support the
affected side.

• Clear acrylic resin is recommended as the extensions and the

pressure areas are easily visualized at the time of surgery (Fig. 32-3).

FIGURE 32-3 Surgical obturator.

Interim obturator.
 Interim obturator is defined as ‘a maxillofacial prosthesis which is made
following completion of the initial healing following surgical resection of a
portion or all of one or both maxillae; frequently many or all teeth in the
defect area are replaced by this prosthesis’. (GPT 8th Ed)

• Interim obturators are fabricated after the defect margins are clearly
defined and further surgical revisions are not planned.
• These obturators are used till healing of the surgical site is complete
and the site is dimensionally stable.

• This type of obturator is fabricated from the postsurgical impression

cast which has false palate, false ridge and has no teeth.

• Closed hollow bulb extends into the defect.

• Patient is recalled after every 2 weeks for evaluation, as there are

rapid changes occurring within the defect due to healing of the
tissues (Fig. 32-4).

• The interim prosthesis is relined frequently.

• It is advisable to change the reline material rather than placing over

the old one to avoid bacterial contamination, mucosal irritations or
precipitation of undesirable odour.
 FIGURE 32-4 Interim closed hollow bulb obturator.

Definitive obturator.
Definitive obturator is defined as ‘a maxillofacial prosthesis that replaces
part or all of the maxilla and associated teeth lost due to surgery or trauma’.
(GPT 8th Ed)

• This type of prosthesis is indicated when the surgical site is

completely healed and is dimensionally stable.

• It is usually given after 6 months of surgery.

• The timing of the obturator fabrication will depend on the size of

the defect, progress of healing, prognosis of tumour control and
presence or absence of teeth.

• It is important to fabricate a definitive prosthesis, as the periodic

 relining of the interim prosthesis makes it heavy and bulky.

• Secondly, it may become rough and unhygienic.

• Thirdly, retention and stability of the prosthesis can improve by

adding teeth on the defect side.

• Changes associated with healing and remodelling will continue to

occur in the border areas of the defect for at least 1 year.

Different types of definitive obturator are:

(i) Closed hollow bulb design

(ii) Open obturator design

Hollow bulb obturator

• Hollow bulb obturator is a type of a definitive obturator which is

given approximately 6 months postsurgery.

General considerations

• Bulb fabrication is not necessary in cases where the central palate

defect is small.

• It should not cause movement of the eye during mastication.

• It should be a single piece rather two piece to aid in colour matching

and better patient acceptance.

• It should not be too large because insertion of the prosthesis will be

tedious to the patient, especially in cases where there is restricted
mouth opening.

Advantages
• As it is hollow, the weight is considerably reduced on the
unsupported side.

• It results in better acceptance by the patient.

• As the prosthesis is light, it is better retained and improves the

physiological function.

• Lightness of obturator does not cause excessive atrophy and

physiological changes in the muscle balance.

• It aids in speech resonance.

• It aids in deglutition, as it decreases pressure on the surrounding

tissues.

Types of hollow bulb obturator

(i) Closed hollow bulb obturator – single/two piece type

(ii) Open hollow bulb obturator

Methods of fabrication

• Acrylic resin obturator

• Silicone bulb obturator

• Balloon obturators

• Light-cured hollow obturators

Technique for fabrication for edentulous patients (V.A. Chalian)

• After final impression, cast is poured and the undesirable undercuts

are blocked.

• Stabilized baseplate is flowed in the defect area.

• Wax lid is placed over the defect area to leave it hollow and to
provide the effect of complete palate.

• Occlusal rims are fabricated and the jaw relations are recorded.

• Teeth are arranged and wax try-in is done in conventional manner.

• During the laboratory procedure, the palatal defect is filled with

modelling clay and is given a palatal shape.

• A false lid is fabricated with autopolymerizing acrylic resin.

• The remaining temporary waxed denture is flasked and processed

conventionally.

• The lid is then added to the master base to close the palatal portion
of the hollow bulb and is sealed with self-curing acrylic resin.

• The denture is later finished and polished as routine procedure (Fig.

32-5).
 FIGURE 32-5 Definitive closed hollow bulb obturator.

Aramany’s classification of maxillary defects

M. Aramany (1978) classified postsurgical maxillary defects on the
basis of the relationship of the defect to the remaining abutment teeth.

Rationale for classification

• Increase in number of patients undergoing resection of the maxilla

• Need for definitive prosthesis after resection

• Increase in percentage of younger patients

Classification
Class I: The resection is done along the midline of the maxilla and the
teeth are maintained on one side of the arch; this is the most
common maxillary defect (Fig. 32-6).

Class II: The defect is unilateral, retaining the anterior teeth on the
contralateral side. The central incisor and sometimes all the anterior
teeth to the canine or premolars are preserved (Fig. 32-7).

Class III: The defect occurs in the central portion of the hard palate
and may involve part of the soft palate (Fig. 32-8).

Class IV: The defect crosses the midline and involves both sides of the
maxilla (Fig. 32-9).

Class V: Surgical defect is bilateral and lies posterior to the remaining

anterior teeth (Fig. 32-10).

Class VI: Surgical defect which is anterior to the remaining abutment

teeth; this is the least frequently occurring class, occurs mostly in
trauma or congenital defects rather than in planned surgical
intervention (Fig. 32-11).
FIGURE 32-6 Aramany class I – midline resection of maxilla.
FIGURE 32-7 Aramany class II – unilateral defect with
retained anterior teeth on contralateral side.
FIGURE 32-8 Aramany class III – central defect in hard
palate.
FIGURE 32-9 Aramany class IV – defect crossing the
midline.
FIGURE 32-10 Aramany class V – bilateral defect posterior
to remaining anterior teeth.
 FIGURE 32-11 Aramany class VI – bilateral defect anterior to
remaining teeth.

Soft palate obturators

Classification of the soft palate defects on the basis of location and
nature of the defect was given by J. Beumer and T.A. Curtis.
The classification is as follows:

(i) Total soft palate defects: This involves the entire soft palate.

(ii) Posterior border defects:

• Median posterior border defects: This involves the

 posterior half of the soft palate.

• Lateral posterior border defects: This involves the

lateral half of the soft palate and often the lateral
pharyngeal wall.
Types of the soft palate obturator

Palatal lift prosthesis: Given when all the structures are intact except
the posterior border of the soft palate.

Meatus obturator: Given when defect involves the hard and soft
palates.

Objectives of soft palate obturators

• To control nasal emission during speech

• To prevent leakage of foreign material into the nasal passage during

deglutition

Palatal lift prosthesis

• This was first described by P. Gibbons and H. Bloomer (1958).

• It is indicated in patients with palatopharyngeal incompetence

exhibiting compromised motor control of the soft palate and related
musculature.

Objective
To displace the soft palate to the level of the normal palatal elevation
enabling closure by pharyngeal wall action (Fig. 32-12)
 FIGURE 32-12 Palatal lift prosthesis.

Indications
• Myasthenia gravis

• Cerebrovascular accidents

• Traumatic brain injuries

• Cerebral palsy

• Injuries of the soft palate

Contraindications
• In case of inadequate retention of the prosthesis

• If the patient is not cooperative.

• If palate cannot be displaced.

Advantages
• Gagging is minimized.

• Access to the nasopharynx for the obturator is facilitated.

• Function of the tongue is not compromised.

• Lift portion of the prosthesis can be developed sequentially to aid in

patient’s adaptation of the prosthesis.

Meatal obturator
• It is first described by A. Schalit (1946) and J. Sharry (1950).

• It is indicated in patients with extensive defect of the soft palate

and/or patient having very active gag reflex.

• It is the obturator of choice when retention of the prosthesis is an

issue in edentulous patients.

• It extends superiorly and slightly posteriorly from the hard palate

border and separates the oral and nasal cavities at this level (Fig. 32-
13).
 FIGURE 32-13 Meatal obturator.

Advantages
• It has less weight than a conventional obturator.

• Downward displacement force from the obturator extension is

closer to the supporting tissues of the parent prosthesis.

• It provides improved retention and stability of the prosthesis.

• It provides more physiological separation between oral and nasal

structures.

Disadvantages
• It does not provide valving mechanism for speech.

• It provides static obturation.

Mandibular defects
Classification of mandibular defects
R. Cantor and T. Curtis (1971) devised a prosthetic classification of
the mandibular defects on the basis of amount of resection of the
mandible and was limited to edentulous patients.

Class I: Radical alveolectomy with preservation of mandibular

continuity. A portion of the alveolar process and body of the
mandible along with the mucoperiosteum was resected. Prognosis
of the treatment was good.

Class II: Lateral resection of the mandible distal to the cuspid. The
condyle, ramus and body of the mandible distal to the cuspid were
resected. Prognosis for this class is fair.

Class III: Lateral resection of mandible to the midline. Tissues

resected in class II and the anterior portion of the mandible.
Prognosis for this class is poor (Fig. 32-14).

Class IV: Lateral bone graft surgical reconstruction. This can be

performed in the patients of any of above three classes.
Reconstruction is done by augmentation procedures, bone graft
connecting a residual condyle with large mandibular segment or
lateral bone grafts. Prognosis varies with the type of reconstructive
surgery (Fig. 32-15).

Class V: Anterior bone graft surgical reconstruction. Anterior portion

of the mandible is resected along with the adjacent structures.
Prognosis depends on how well the graft takes up.

Class VI: Resection of the anterior portion of the mandible without

reconstructive surgery to unite the lateral fragments. Prognosis is
very poor for this type of defect.

FIGURE 32-14 Class III – resection.

 FIGURE 32-15 Class IV – Lateral bone graft surgical
reconstruction.

I.K. Adisman (1962) classified mandibular resection as follows:

Partial resection: In this type, part of mandible is resected in definite

sections (e.g. ramus, hemimandibulectomy, between the mental
foramen).

Partial and step resection: In this type, part of the mandible is

resected but steps are made surgically in the residual mandible to
preserve the anterior mandibular arch by retaining as much of the
lower border of the mandible as possible.

Total or subtotal resections: In this type, entire mandible is resected

or mandible is resected up to the coronoid process and the condyle
is left intact.

Marginal resection: In this type, only marginal sections of the

mandible are resected and the continuity of the bone is intact.

Segmental resection: In this type, segments of the body of the

 mandible are removed involving the condylar process. These are
repaired by splint or bone grafts at the time of the surgical resection.

Prosthetic management of the mandibular defects

For dentulous patients

(i) Guide plane prosthesis

• Mandibular guidance appliance

• Palatal-based guidance
(ii) Snap-on prosthesis for segmental resection of partially dentulous
mandible

(iii) Prosthesis for segmental resection of fully dentulous mandible

(iv) Overlay or superimposed prosthesis for marginal excision of

dentulous mandible

(v) Superimposed prosthesis

For edentulous patients

(i) Complete dentures with double row of teeth in the upper denture
on the nonresected side (Fig. 32-16).

(ii) Complete denture with palatal ramp on the nonresected side.

 FIGURE 32-16 Complete denture with double row of teeth on
unresected side.

The treatment of the maxillofacial patients should include a careful

preoperative evaluation consisting of the following:

• Careful clinical and radiographic evaluation

• Diagnostic models

• Jaw relation records

• Facial photographs

• Interaction of prosthodontist with other surgeon

The rehabilitation of the maxillofacial patient depends on the extent

and location of the defect:
• Amount of residual mandible

• Amount of deviation

• Remaining kinaesthetic sense and control

• Nature of denture-bearing area

Extraoral prosthesis
Ocular or eye prosthesis
It is defined as ‘a maxillofacial prosthesis that artificially replaces an eye
missing as a result of trauma, surgery, or congenital absence. The prosthesis
does not replace missing eyelids or adjacent skin, mucosa or muscle’. (GPT
8th Ed)

• Ocular prosthesis is an artificial replacement for the bulb of the eye.

• Causes of ocular defects are trauma, neoplasm or congenital

conditions such as cryptophthalmos and microphthalmos.

• Ocular prosthesis is made 10–14 days postsurgery.

• At the time of surgery, a conformer is usually placed into the socket

to maintain the fornices.

• Conformer is made of clear acrylic and should be large enough to

support the lids and keep them from collapsing until the artificial
eye is fabricated.

• The eye socket is carefully examined to analyse the amount of

orbital adipose tissue and the extent of atrophy of muscle and other
related tissues.

• Plastic ocular prosthesis is superior to the glass ocular prosthesis.

Advantages of plastic acrylic ocular prosthesis

• As it is custom-made, adjustability to the size and form is easier.

• It offers actual three-dimensional effect in iris constriction.

• Prefabricated iris buttons can be stocked.

• Plastic acrylic eye permits elimination of time-consuming steps such

as multiple mould fabrication and precision grinding.

• It is relatively easy to fabricate.

• It has more strength and is less fragile as compared with glass eye.

Procedure
• The patient is lowered in a supine position and two drops of
ophthalmic local anaesthetic solution is administered.

• Impression material, such as elastomer or irreversible

hydrocolloid, is injected into the socket with a syringe.

• After setting, cheek, nose and the eyebrow region are massaged to
break the seal.

• The patient is instructed to gaze upwards and the impression is

removed from the socket.

• Impression is boxed and the lower half of the impression is poured

in dental stone.

• Once the stone is set, separating medium is applied and key ways
are made.

• Again the upper half of the impression is poured in dental stone.

• After the stone is set, both the assemblies are separated and the
impression is removed.

• Wax is flown into the empty mould to form a wax pattern.

• Preformed iris of appropriate size is attached to the wax pattern

 after checking the distance of iris in the normal eye when the
patient looks straight.

• Wax pattern is tried in the patient’s socket and checked for form, fit
and contour.

• After satisfactory trial, the wax pattern is invested and processed

with heat-cured acrylic resin.

• Various colouring procedures are available to give colouration to

the eye in order to match the normal eye.

• Processed prosthesis is finished and polished.

• The final ocular prosthesis is inserted in the socket.

Postinsertion care of ocular prosthesis

• Adjustability to the new prosthesis varies between individuals.

• The prosthesis should never be left dry and should always be kept
in lens solution or water.

• The patient is advised to wear eyeglasses in order to protect the

natural eye.

• The ocular prosthesis may not make all the movements possible
with the natural eye.

• The patient is educated about the postinsertion care of the

prosthesis.

• Rough cloth or paper towels should not be used to clean the

prosthesis, as it may produce scratch.

• The patient should be kept on regular recall so as to assess the

prosthesis.
Auricular prosthesis or ear prosthesis
It is defined as ‘a removable maxillofacial prosthesis that artificially restores
part or the entire natural ear called also artificial ear, ear prosthesis’. (GPT
8th Ed)

• Causes of auricular defects are congenital, trauma or malignancy.

• It is easier to restore total resected auricle than a partially resected

auricle.

• If the surgical reconstruction of the auricle is not contemplated, the

entire ear should be removed, leaving a fixed tissue bed.

• Residual tissue tags, if any, should be removed, as they prevent

proper sculpting and positioning of the prosthesis.

Definitive auricular prosthesis

• This type of prosthesis is given after the wound has completely
organized.

• The definitive prosthesis should not only match in colour, form and
feature but also be correctly oriented to the surrounding tissues.

Impression procedure
• The patient is made to lie in the supine position with defective side
facing upwards.

• The external auditory meatus is blocked with wet cotton gauze or

cotton.

• The entire skin is coated with petroleum jelly.

• The entire area is outlined with the boxing wax.

• In the boxed area, silicone or irreversible or reversible hydrocolloid
is poured.

• Prebent L-shaped paper clips or suitable support gauges are used to

provide reinforcement.

• Quick setting plaster is poured over it as backing.

• The impression is carefully removed after it is set.

• Similarly, impression is made of the natural ear on the other side.

• Stone is poured into the impression to form the master cast.

Wax pattern fabrication

• If presurgical cast is available, it is reproduced in the wax and
compared with the remaining ear.

• Wax ear is positioned and adjusted to achieve natural symmetry in

all planes with opposite side.

• Modified facebow can be used to verify the position of the wax

prosthesis.

• If presurgical cast is not available, the prosthesis is sculpted from

the beginning or made from the donor.

• The wax pattern is checked for the form, contour and position.

• The entire surface is stippled to match the skin texture of the patient.

• Stippling should be made more prominent as some of the details are

lost during processing.

• Margins are then feathered and wax pattern is then luted to the cast.
Processing and surface characterization
• Wax ear is invested and after dewaxing, cured with appropriate
material.

• Surface characterization can be done either intrinsically or

extrinsically.

• Intrinsic colouration is better because extrinsic colouration tends to

wear off with time.

• Intrinsic colouration is done during the processing and extrinsic

colouration is done after complete processing is done.

• Completed auricular prosthesis is supported with eyeglass frame.

• For additional retention, adhesives can be used.

• Retention can also be improved by extending the prosthesis into the

enlarged canal.

• After the removal of prosthesis, the adhesive should be removed

from the skin and prosthesis.

• Most of the patients wear the prosthesis for 2–3 days before
removing it.

Nasal prosthesis
It is defined as ‘a removable maxillofacial prosthesis that artificially restores
part or the entire nose’. (GPT 8th Ed)
They are fabricated after partial or total rhinoplasty.

Aetiology of nasal defects

• Congenital deformity of nose such as fissure, double nose, bifid nose
or cleft nose
• Trauma: During birth, burns, sports accidents, automobile accidents,
injuries, gunshot wounds

• Neoplasms: These are rare, usually the squamous cell carcinoma or

adenocarcinoma of mucous glands of the nose.

Prosthetic rehabilitation of the nasal defect

• Most of the nasal defects are corrected with surgery.

• Smaller defects are reconstructed with plastic surgery using local

flaps, composite grafts or forehead flaps.

• Larger external defects are rehabilitated using prosthesis.

• Choice of rehabilitation depends on the size, type of defect and

present condition of the remaining tissues.

Impression making
• The facial tissues are coated with Vaseline, undercuts are minimized
using wet gauze packing and the nostrils are packed to prevent
adherence, seepage and breakage of the impression material during
removal.

• Irreversible hydrocolloid is mixed in order to make a thin mix.

• The material is painted over the defect and the surrounding

structures.

• Preshaped L-shaped paper clips are placed in the hydrocolloid

before setting of the impression material.

• Quick setting plaster is added as a backing to the setting material.

• The patient is instructed to wrinkle the facial muscles to aid in

 removal of the impression.

• Impression is poured with stone to form a master cast.

Wax pattern
• Wax pattern of the nose is carefully carved keeping in mind the skin
texture and the dominant wrinkle.

• Preoperative photograph of the patient is useful in carving the nose

closely.

• Final wax pattern is invested and acrylized in conventional manner.

Ideal characteristics of the male and female nose

• Nose is relatively larger in male than in females.

• Dorsum of nose is wider in males.

• In females, the narrow tip of the nose is desirable.

• Wide nares are desirable in males as compared to females.

• Textured surface can be acceptable in males, whereas smooth

surface is desirable in females.

Painting of the external mould and the tissue-side

mould
• To give life to the prosthesis, the external surface and tissue-side
mould is painted with a layer of vinyl resin.

• Skin-coloured resin is painted to enhance the effect.

• The painted mould is processed and the final prosthesis is finished

 and polished before inserting it into the defect.

Role of implants in maxillofacial prosthodontics

P.I. Branemark and his associates in 1977 first placed osseointegrated
implants in the cranial skeleton to retain a prosthetic ear (Fig. 32-17).

FIGURE 32-17 Implant supported auricular prosthesis.

Dental implants can be placed in root of zygoma, palatal vault,

nasal floor, and pterygoid region to stabilize or retain a facial
prosthesis.

Advantages

• Reliability of retention from the implant and the abutment

• Reduced dependence on availability of undercuts and use of

adhesives

• More aesthetics
• Increased psychological comfort to the patient

• Increased patient’s sense of security

• Valuable in patients where use of adhesive is limited due to

perspiration

Contraindications

• The patient may refuse an additional surgery.

• The patients who had undergone radiotherapy have additional risk

of osteoradionecrosis.

• Elderly patients may not agree for implant treatment.

General principles

• Site is assessed to determine the quality and quantity of bone

available for implant placement.

• Computed tomographic scan may be utilized to evaluate the bone

quality.

• Estimation of the difficulty of access should be made to ensure

feasibility of surgical instrumentation.

• Expected load and resistance are assessed well in advance.

• Implant-supported auricular, ocular and nasal prostheses are well

documented.

• For implant-supported auricular prosthesis, minimum two implants

are used in the temporal bone from the centre of the external
auditory meatus 15 mm from each other.

• For nasal implant-supported prosthesis, minimum two implants are

placed in the lateral rounded nasal eminences.
• For implant-supported ocular prosthesis, three to four implants are
placed in the superior, lateral and inferior orbital rims.
Retention aids in maxillofacial
prosthesis
Successful prosthetic rehabilitation of the maxillofacial defect needs
adequate retention, stability, support and acceptable aesthetics.
Retention is defined as ‘that quality inherent in the dental prosthesis
acting to resist the forces of dislodgement along the path of placement’. (GPT
8th Ed)

Classification of retention aids

According to Chalian V.A., retention can be extraoral or intraoral.

(i) Extraoral

• Anatomical – soft and hard tissues

• Mechanical – magnets, snap buttons, straps,

adhesives

• Combination
(ii) Intraoral

• Anatomical – soft and hard tissues

• Mechanical – temporary and permanent

Extraoral retention

Anatomical retention
It is essential to use both hard and soft tissues of the head and neck
region for retention. Retention in the extraoral area depends on
number of factors such as:

• Location and size of defect

• Mobility of the tissues

• Amount of undercuts

• Weight of the final prosthesis

Hard tissues: These behave as a base against which

the prosthesis is seated to provide excellent seal of
the prosthesis with the use of adhesive.

Soft tissues: Difficulty in achieving retention in soft

tissues because of their:
• Flexibility

• Mobility

• Less resistance to displacement

• Lack of bony support

• Physiological nature of the ectodermal tissues

Mechanical retention
Additional retention is required in cases where large defects are
present involving one-half of the face or tissues are heavily radiated
where adhesives are not useful to retain the prosthesis. Eyeglasses can
be used as an indirect mechanical retention aid. The eyeglasses should
be kept free of the prosthesis and should not be a part of it. An elastic
strap is often useful to hold the eyeglasses and retain the prosthesis.

Magnets: These are embedded in the nasal or the orbital prosthesis to

aid in retention of the extraoral prosthesis.

Snap buttons and straps: These are useful in retaining large extraoral
prosthesis.

Adhesives: These help in enhancing retention of the prosthesis by

means of surgical grade extraoral adhesive. The adhesives aid in
retention, marginal seal and border adaptation. These help in
securing the prosthesis against accidental dislodgement.

Intraoral retention

Anatomical retention
• Intraoral retention should be derived from the both hard and soft
tissues, i.e. the remaining teeth, mucosal and bony tissues. The
amount of retention depends on the size and location of the defect.

• Anatomical undercuts aid in retention of the prosthesis.

• Large alveolar ridges and high-arched palate provide more

retention than the flatter ridges and shallow palate.

• Intraoral anatomical retention can also be achieved by providing

proper occlusion, surface adhesion and proper post damming.

Mechanical retention
This can be of two types, namely, temporary and permanent.

Temporary mechanical retention

• Stainless steel wrought wire of 18 gauge can be used in retaining

 temporary prosthesis during the healing period.

• Preformed wire clasps can be incorporated in the prosthesis or

Adams’ arrowhead clasps can be used.

Permanent mechanical retention

• Cast clasps are the most commonly used as these also provide
stability, splinting, bilateral bracing and reciprocation.

• Prefabricated precision attachments.

• Semi-precision attachments.

• Snap-on attachment (e.g. Baker bar or Anderson bar) is a rod

connecting two abutment crowns and the clip is used to engage the
rod.

• Overlay crown/thimble crown is a telescopic crown which is used

on extremely malposed abutment teeth.

• Magnets are useful in hemimaxillectomy cases or highly resorbed

ridges.

• Swing-lock devices are indicated in periodontally compromised

dentition when other methods are ruled out.

• Implants are widely used intraorally to retain prosthesis.

• Suction cups are inflatable balloon suction cups which are useful in
maxillary resection cases.

• Adhesives: Their use is limited and should be avoided in the regions

of perspiration or tissues undergoing radiation or surgery. These
can be used with materials made with resilient materials.

• Occlusion: Proper occlusal contact is important for prosthesis

retention.
Role of magnets in maxillofacial prosthesis
A magnet is defined as ‘a material which has the ability to attract iron and
lie in a north–south direction when suspended. Strongly magnetic substances
are known as ferromagnetic (iron, steel, cobalt, nickel and alloys of these
metals)’.
These can be used to aid in retention in maxillofacial prosthodontics
utilizing both attractive and repulsive properties.

Types of magnets
(i) Rare earth metals (Nd–Fe–B and Sm–Co)

(ii) Samarium–cobalt

Samarium–cobalt magnets

• These are encapsulated in acrylic resin and are attached to extension

of the bar splint.

• Paired magnets are also resin encapsulated with wires attached to

the nonmatting surface.

• These allow better retention without compromising on the

aesthetics.

• These allow retention to be placed remotely from the fixture base for
greater margin fixation.

Indications

• In areas of high muscle activity adjacent to the prosthesis

• In areas of muscle activity combined with a rigid prosthesis

• In patients with poor digital dexterity

• In cases where bone is thin

Advantages

• Excellent retentive qualities

• Increased patient satisfaction and security

• Marginal integrity is maintained allowing fabrication

• Extended longevity without necessity for constant remake or repair

Disadvantages

• Low corrosion resistance

• Increased cost

• Cytotoxic effect

• Chances of wear

Key Facts
• Rapid prototyping technology used in maxillofacial prosthodontics
is used to create three-dimensional models from a three-
dimensional representation (CT scan or MRI).

• Essig splint is used to stabilize fractured or repositioned teeth and

the involved alveolar bone.

• Inflatable balloon obturators were first described by K.W. Coffey

in 1984. These are used to minimize displacement of the soft tissues.
SECTION V
Implant Dentistry
OUTLINE

33. Diagnosis and treatment planning

34. Osseointegration and materials

35. Surgical and prosthetic phase

CHAPTER
33
Diagnosis and treatment
planning

CHAPTER OUTLINE
Introduction, 456
Dental Implant and its Scope and Limitations, 456
Historical Background of Dental Implants, 456
Indications, 457
Contraindications, 457
Advantages, 457
Disadvantages, 458
Limitations, 458
Radiographic Planning of Dental Implants, 460
Role of Radiographs in Implant Treatment, 461
Panoramic Radiography, 461
Periapical Radiography, 461
Lateral Cephalogram, 461
Role of CT Scans in Implant Dentistry, 461
Scan Ora, 462
CBCT, 462
Role of Radiographic Stent in Treatment
Planning in Implant Dentistry, 463
Bone Density—a Key Determinant for
Treatment Planning in Implants, 463
Dense Compact (D1) Bone, 464
Dense to Thick Porous Compact and Coarse
Trabecular Bone (D2), 464
Porous Compact and Fine Trabecular Bone
(D3), 464
Fine Trabecular Bone (D4), 464
Importance of Evaluating Edentulous Ridge for
Implant Placement, 466
Introduction
The use of implants in dentistry has become an indispensible tool in
rehabilitation of partially or completely edentulous patients. Their use
has improved not only oral functions but also quality of life of an
individual.
Dental implant and its scope and
limitations
Dental implant is defined as ‘a prosthetic device made of alloplastic
materials implanted into the oral tissues beneath the mucosal or/and
periosteal layer, and on/or within the bone to provide retention and support
for a fixed or removable dental prosthesis’. (GPT 8th Ed)

Historical background of dental implants

• 600 AD: First evidence of dental implants was found in the Mayan
civilization. Ancient Egyptians implanted animal teeth or teeth
made from ivory.

• 1000–1799 AD: Medieval period was primarily concerned with

transplantation of teeth. Albucusis fabricated implants made of
ivory, shells or ox bone.

• 1809 AD: Maggiolo inserted gold roots into freshly extracted sockets
soldered to 24 carat gold.

• 1906: Greenfield first described and inserted endosseous implant

which was round basket-shaped and hollow, made of iridium–
platinum alloy.

• 1939: Strock anchored vitallium screw into the bone and placed
porcelain crown on the implant.

• 1943: G.S. Dahl first advocated subperiosteal implant. He fabricated

a metal structure on the maxillary alveolar crest with four projecting
posts.

• 1948: N.I. Goldberg and A. Gershkoff fabricated a subperiosteal

implant with an extension of the framework on the external oblique
 ridge.

• 1953: Sollier, R. Chercheve and Small introduced the transosteal

implants.

• 1965: P.I. Branemark first placed endosseous dental implant made of

titanium.

• 1966: L.I. Linkow introduced the blade vent implant which were
originally designed for knife edged ridges but were later adopted
for other clinical situations.

• Late 1960s: A. Roberts and R. Roberts developed the ramus blade

endosseous implant. This type of implant was made of 316 stainless
steel and was anchored between the two cortical plates.

• Early 1970s: C.M. Weiss and K.W. Judy used the intermucosal
inserts for retaining maxillary removable prosthesis.

• Early 1970s: Roberts and Roberts developed the ramus frame

implant which received anchorage bilaterally from the mandibular
symphysis region.

• 1974: IMZ implant system was introduced. The speciality of this

system was that it used elastic compensating component which was
inserted between the osseointegrated implant and the prosthetic
superstructure. It has two components, one implant body and the
other intramobile connector (IMC).

• Mid-1970s:Branemark developed the Nobelpharma implant

company in Sweden.

• 1982: Branemark introduced the first commercial implant made of

pure titanium. It became a standard by which all other root from
implants were evaluated.

• Early 1980s: Gerald A. Niznick developed the internal hex-threaded

 design for better implant stability.

• Late 1980s: Plasma-sprayed and hydroxyapatite-coated implants

were introduced.

• Early 1990s: Frialit 2 system were developed by Dentsply, which

had excellent prosthetic options.

Indications
• Inability of the patient to wear removable partial or complete
dentures

• Need for long-span fixed partial denture with questionable

prognosis

• Unfavourable number and location of the potential natural tooth

abutments

• Single tooth loss that would necessitate preparation of minimally

restored teeth for fixed prosthesis

Contraindications
• Acute and terminal illness

• Pregnancy

• Uncontrolled endocrine disorders

• Patient on radiotherapy

• Patient with unrealistic expectation

• Improper patient motivation

• Lack of experience of clinician

• Inability to restore with a restoration

Advantages
• Preserves bone

• Improves masticatory efficiency

• Maintains proper vertical dimension

• Immune to dental caries

• High level of predictability

• Improves aesthetics and phonetics

• Increases retention and stability

Disadvantages
• High initial cost of treatment

• Involves surgical procedure

• Procedure depends on quantity and quality of bone

• Depends highly on clinician skills

• Limitations in placement in medically compromised patient

Limitations
Limitations of dental implant are given in Table 33-1.

TABLE 33-1
ANATOMIC LIMITATIONS TO IMPLANT PLACEMENT
Anatomic Structure Minimum Distance between Implant and Structure
Nasal cavity 1 mm
Buccal plate 0.5 mm
Lingual plate 1 mm
Maxillary sinus 1 mm
Inferior alveolar nerve 2 mm from superior aspect of the body canal
Mental nerve 5 mm from the anterior loop or bony foramen
Interimplant distance 3 mm between the outer edge of implant
Adjacent natural tooth 0.5 mm

Classification of dental implant

1. On the basis of placement of implants within the tissues

2. On the basis of type of material used

3. On the basis of treatment options of completely edentulous arches

4. On the basis of treatment options of partially edentulous arches

5. On the basis of treatment options

6. On the basis of their reaction to bone

On the basis of placement of implants within the

tissues
(a) Subperiosteal implants: In these implants, a framework derives its
support by resting over the bony ridge without penetrating it. G.S.
Dahl conceived the concept of the subperiosteal implants. N.I.
Goldberg and A. Gershkoff made subperiosteal implant with
vitallium in 1948 (Fig. 33-1).

(b) Transosteal implants: These penetrate both the superior and

inferior cortical plates passing through the entire thickness of the
mandible. Sollier, R. Chercheve and Small introduced the transosteal
implant in 1953 (Fig. 33-2).

(c) Endosteal implants: These can extend into the basal bone, usually
penetrates only superior cortical plate. It is of two types, root-form
implants and the plate-form implants (Fig. 33-3).

On the basis of type of material used

(a) Metallic implants: Titanium and its alloys, cobalt–chromium,
molybdenum alloy, iron–chromium–nickel-based alloys are some
examples of metallic implants.

(b) Nonmetallic implants: Ceramics and carbon are some examples of

nonmetallic implants.

On the basis of treatment options of completely

edentulous arches (Misch)
The completely edentulous jaw is divided into three segments. The
anterior component lies between the mental foramen or in front of the
maxillary antrum. The left and the right posterior segments
correspond to the left and right sides.

Type 1 div A: It has abundant bone in all the three segments.

Type 1 div B: It has adequate bone in all three segments; narrow

diameter root-form or plate-form implants are used.

Type 1 div C-w: It has inadequate bone width for implant placement;
augmentation with autogenous bone may improve the bone
category.

Type 1 div C-h: It has a crown–implant ratio greater than 1; for long-
term success removable prosthesis is indicated; it is most commonly
found in posterior maxilla with subantral augmentation.

Type 1 div D: Severely atrophied edentulous arches; bone

augmentation or conventional dentures are indicated.

Type 2 div A, B: Anterior segment has abundant bone and the

 posterior segment has adequate bone for narrow diameter implant.

Type 2 div A, C and Type 2 div A, D: As described in type 1.

Type 2 div B, C: It has two treatment options, since anterior div B is

not adequate, it is converted to div A by osteoplasty, posterior
segment requires subantral augmentation.

Type 2 div B, D: It presents advanced atrophy in the posterior

segments and adequate ridge width and height in the anterior
segment; this situation can occur in the maxilla but never in the
mandible.

Type 3 div A, B, D arch: It has abundant bone in anterior segment,

moderate bone in the posterior right side and severe atrophy in the
left posterior segment; sinus augmentation is commonly indicated
in posterior atrophied maxilla and in the atrophied mandible
additional anterior implants with cantilever is more suitable.

Type 3 div C, D, C: It presents severe atrophy in the right section and

moderate atrophy in the left section; mandibular arch uses the
anterior segment with cantilever design and in the maxilla posterior
segment is treated with subantral augmentation and anterior
segment is treated with subnasal elevation.

On the basis of treatment options for partially

edentulous arches (Misch CE)
Class I: Partially edentulous arch with bilateral edentulous areas
posterior to the remaining natural teeth.

Div A: Edentulous areas have abundant bone height (10 mm) and
length (5 mm) for endosteal implant.

• Crown–implant ratio is <1.

• Direction of load is within 30º of implant body axis.

• Root-form implants and independent prosthesis

often are indicated.
Div B: Edentulous areas have moderate bone width (2.5 mm) and
adequate bone height (10 mm) and length (15 mm).

• Direction of load is within 20º of implant body axis.

• Crown–implant ratio is <1.

• Surgical options include osteoplasty, narrow

diameter implants with/without augmentation.
Div C: Edentulous area has inadequate available bone for endosteal
implant with a predictable result, because of too little bone width,
height and length.

• Crown–implant ratio is >1.

• Surgical option such as osteoplasty or augmentation

is indicated.
Div D: Edentulous ridges are severely resorbed involving the portion
of the basal or cortical supporting bone.

• Crown–implant ratio is >5.

• Surgical options usually require augmentation

before implant placement.
Class II: Partially edentulous arch with unilateral edentulous area
posterior to remaining teeth.

Div A–D: Same as for class I.

Class III: Partially edentulous arch with unilateral edentulous area

with natural teeth remaining anterior and posterior to it.

Div A–D: Same as for class I.

Class IV: Partially edentulous arch with edentulous area anterior to

remaining natural teeth and crosses the midline.

Div A–D: Same as for class I.

On the basis of treatment options (Misch)

• C.E. Misch (1989) reported five treatment options of implants. First
three of the five options are fixed prosthesis that may be partial or
complete replacements depending on the amount of hard and soft
tissue structures that are replaced.

• The remaining two are removable prostheses that are classified on

the basis of support as follows:

FP1: Fixed prosthesis; replaces only the crown; looks like a natural
tooth.

FP2: Fixed prosthesis; replaces the crown and a portion of the root;
crown contour appears normal in the occlusal half, but is elongated
or hypercontoured in the gingival half.

FP3: Fixed prosthesis; replaces missing crowns and gingival colour

and portion of the edentulous site; prosthesis most often uses
denture teeth and acrylic gingiva, but may be porcelain to metal.

RP4: Removable prosthesis; overdenture supported completely by

 implant.

RP5: Removable prosthesis; overdenture supported by both soft tissue

and implant.

On the basis of their reaction to bone

(a) Bioactive: Ability of the implant to simulate bone formation, e.g.
hydroxyapatite.

(b) Bioinert: These materials do not bond directly to the bone but are
mechanically held in contact to the bone.

FIGURE 33-1 Subperiosteal implants.

 FIGURE 33-2 Transosteal implants.

FIGURE 33-3 Endosteal implants.

Radiographic planning of dental implants

Dental radiographs help the clinician to assess the bone levels
available for implant placement. Since they are two-dimensional
images, they do not indicate the bone width. Along with the clinical
examination, they are important aid in treatment planning of dental
implants. Recently introduced tomographic examinations (computed
tomography [CT] and cone beam computed tomography [CBCT])
provide cross-sectional and three-dimensional images which are
useful in assessing both the bone quality and quantity.
Radiographs are used in treatment planning, during the placement
of the implant or the prosthesis, postsurgery in assessing the
angulation and placement of the implant, to assess the
osseointegration and in long-term maintenance.

Role of radiographs in implant treatment

• To assess initial osseointegration

• To evaluate seating of abutments

• To assess fit of the restoration or prosthesis

• To evaluate baseline bone level after completion of the final

treatment

• For longitudinal evaluation of the bone levels

Various types of radiographs used in implant dentistry are

periapical radiographs, panoramic, lateral cephalometric and the
computed tomographic images. The radiographs are useful to
clinician:

• To assess the overall status of the teeth and the supporting bone

• To identify implant sites where implants can be placed without

using complex procedures

• To identify sites where implants are placed using complex

procedures
• To identify sites where implant placement is not advisable

• To assess the quality and quantity of bone

• To identify any anatomical anomaly or pathological lesion

Panoramic radiography
For screening of the implant cases, the panoramic radiographs are
radiographs of choice. These provide reasonably accurate
approximation of the bone height, the position of the neurovascular
bundle, size and position of the maxillary sinus and pathology, if any.

Advantages
• The radiation dosage is less than the full mouth periapical
radiographs.

• The associated anatomical structures are better identified than the

periapical radiographs but with less fine details of the teeth.

• Bone height can be assessed.

• Procedure is convenient, fast and easy to perform.

Disadvantages
• Nonuniform magnification of the images

• Geometric distortion, especially in the anteroposterior dimension

• Overlapping of images

Periapical radiography
• It is useful in assessing the length and height of the bone.
• It is indicated for placement of the single-tooth implant in patient
with minimal bone loss.

• Intraoral radiographs are taken with a long cone parallel technique.

• Paralleling technique reduces the geometric distortion, gives better

resolution and produces more accurate images.

Lateral cephalogram
• It is used to evaluate the vertical height, width and angulation of the
bone in the midsagittal region of the maxilla and the mandible.

• It also helps to evaluate the loss of vertical dimension, skeletal

interarch relationship, anterior crown–implant ratio and the
anterior tooth position.

Role of CT scans in implant dentistry

CT scan was first introduced to medical field by G.N. Hounsfield in
1942. CT uses X-rays to produce sectional images of high resolution by
scanning in the axial plane keeping thin sections.

• The radiation is detected by highly sensitive crystals or gas detectors

which are then converted into the digital data.

• This digital data is stored and manipulated by the computer to

reconstruct the image of the object.

• The patient head is aligned in the scanner with the help of light
markers.

• Mandible is scanned with the slices parallel to the occlusal plane

and maxilla is scanned using the occlusal plane or the plane parallel
to the base of the nose.

• The images can be produced on the radiographic film, photographic

 paper in book form or on the computer monitor.

Uses
• Used in planning complex cases such as full arch maxillary
reconstruction

• Patient requiring complex procedures such as sinus lift or nerve

repositioning

• To assess the bone quality and quantity

• Determination of the bone density

• Useful in scanning the premaxilla without overlapping of the

images

Advantages
• It gives an accurate assessment of the bone quality and quantity in
the area of interest.

• Overlapping of images is not there.

• Direct measurements can be made on the cross-sectional image

using the digital millimetre ruler or caliper.

Disadvantages
• It is a costly procedure.

• Radiation dosage is high and the scan should be only limited to the
area of interest.

• Harmful to the radiosensitive tissues such as eye.

• Artefacts from the metallic restorations produce the scatter-like
interference pattern.

Scan ora
These are recently introduced tomographic devices which are capable
of generating high-quality sectional images.

• It uses complex broad beam spiral tomography and is able to scan in

multiple planes.

• The scans are dependent on the accurate positioning of the patient

and the experience of the clinician.

• The tomographic sections are 2–4 mm thick.

• The overall radiation exposure is less than the CT scan.

• Although the amount of detailed information is less than a CT, it is

sufficient for the routine procedures.

• To facilitate treatment planning, the overlay virtual implants can be

superimposed on the scan to reveal angulation and the positioning
of the implant.

CBCT
CBCT is currently the most popular method of generating three-
dimensional radiographic images in implant dentistry. The CBCT
scanner produces a cone-shaped radiographic beam which exposes a
series of planar images to form a three-dimensional image which can
be visualized according to the need of the clinician.

Advantages
• The primary benefit of CBCT is that a three-dimensional image of
the osseous area of interest can be constructed and viewed in
 multiple planes.

• Radiographic exposure is less as compared to CT scans.

• Treatment planning using CBCT leads to reasonable level of

accuracy.

Disadvantages
• Motion-related artefacts cause blurring of images.

• In CBCT, metallic restorations cause streak artefacts in all directions.

Guidelines for prescribing CBCT imaging in dental

implant placement
• To evaluate morphology of residual alveolar ridge

• To determine orientation of alveolar ridge

• To identify anatomic feature that can limit implant placement

• To evaluate pathologic conditions that would restrict implant

placement

• To match imaging findings with that of the restorative plan

• In cases where hard tissue grafting is required

• To evaluate hard tissues after augmentation procedures

Role of radiographic stent in treatment planning in

implant dentistry
Radiographic stent has become an important tool in treatment
planning in implant dentistry in recent times. A stent helps in
assessing the position and the angulation of the implant in relation to
the final prosthesis planned by the clinician.

• A radiographic stent mimicking the final restoration is constructed

using the radiographic markers such as gutta-percha or metal
markers which are placed at the proposed position and angulation
of the implant.

• If the patient is a denture wearer, either the denture is duplicated

with acrylic resin having radiographic marker in it or the markers
are placed in the occlusal or palatal surface of the teeth.

• Alternatively, the labial surface of the stent can be painted with a

radio-opaque varnish in order to evaluate the relation of the bone
ridge to the proposed final restoration.

• The radiographic marker should be chosen such that it should not

interfere with the scan.

• Metal markers should not be used during CT scan, as these can

produce scattering on the image.

• Radiographic stents can also be made by placing the radiographic

marker such as ball bearings of various diameters into the wax rim
over the base plate to determine the mesiodistal location.

• Radiographic stents also help to stabilize the jaws, especially in

edentulous patient, during the procedure of the scan.

• The stents are useful during the surgical placement of the implants.

• It helps the clinician to decide on the optimum location, number and

type of implants.

Bone density—a key determinant for treatment

planning in implants
The density of the available bone in the edentulous area greatly
influences the treatment planning of the implant. The success of the
implant depends on the quality of the bone. Good quality bone
assures good primary stability during the placement of the implant.
The bone density is grossly determined using radiographic aid such as
computed tomographs. The thickness of the cortical plate and the
density of the trabecular pattern are best determined during the
placement of the implants.
Bone can be classified on the basis of macroscopic density into the
following groups (Fig. 33-4).

1. Dense compact bone (D1)

2. Porous compact bone (D2)

3. Coarse trabecular bone (D3)

4. Fine trabecular bone (D4)

FIGURE 33-4 Bone quality classification.

Dense compact (D1) bone

• It consists of dense cortical bone.

• It is mostly found in resorbed anterior mandible, thick lateral

aspects of the anterior mandible.
• It can provide excellent stability to the implant prosthesis.

• This type of bone is highly mineralized and is capable of bearing

high functional loads.

• D1 bone has limited blood supply and is dependent on the

periosteum for nutrition.

Dense to thick porous compact and coarse

trabecular bone (D2)
• It is a combination of dense to porous compact bone on the outside
and the coarse trabecular bone in the inside.

• It is commonly found in the anterior and posterior mandible and

occasionally in the anterior maxilla.

• It provides excellent healing and predictable osseointegration.

• It has an excellent blood supply.

• It has good primary stability during implant placement.

• Healing period of 4 months is recommended.

Porous compact and fine trabecular bone (D3)

• It is composed of thin porous compact bone and fine trabecular
bone.

• It is found in the anterior or posterior maxilla and posterior

mandible.

• Osteotomy can be done rapidly.

• This type of bone has excellent blood supply.

• A hydroxyapatite coated implant is recommended to enhance the
bone contact and accelerate bone healing.

• For threaded implant, high torque handpiece is required to insert

the self-tapping threaded implants.

• Healing period of 6 months is recommended.

• Progressive gradual loading is recommended.

Fine trabecular bone (D4)

• It has very light density with little or no cortical bone.

• It is found in the posterior maxilla.

• Its primary stability during implant placement is limited.

• Osteotomy should be done with drills narrower than the proposed

size of the implant.

• Press fit implants are recommended.

• Sinus elevation and subantral augmentation procedures are advised

to increase the surface area of support.

• Additional implants and progressive loading is recommended.

• Healing period of 8 months is suggested (Table 33-2).

TABLE 33-2
RECOMMENDED MINIMUM HEALING PERIOD

Location Minimum Healing Period

Anterior mandible 3 months
Posterior mandible 4 months
Anterior maxilla 6 months
Posterior maxilla 6 months
With bone grafts 6–9 months

Types of implant restoration

Types of implant restorations are:

1. Single-tooth implant restorations

2. Implant-supported overdentures

3. Multiple fixed implant restoration

Single-tooth implant restorations

Single-tooth implant restorations are those restorations which are not
connected to other teeth and to adjacent implant.

• These are similar to conventional single crown.

• These single crowns are cemented or screw retained on

prefabricated or customized abutment.

• Cantilevering to the single crown should be avoided.

• If more than two teeth are missing, the edentulous space can be
restored with individual implant-retained crowns or a fixed bridge.

• Higher success rate is reported in single implant cases.

• When replacing posterior teeth with the implant-supported

restoration, wider diameter implant is recommended.

Implant-supported overdentures
These are removable complete dentures which are retained with bar
or ball attachments.

• Retention and the stability of the denture are greatly improved.

• Support for the dentures is improved anteriorly and the posterior
part of the denture derives support from the underlying mucosa.

• Classic example of implant-supported overdenture is in the

mandible where the denture is supported by two implants placed in
the region of canines. High success rate is reported for implants
placed in the lower anterior region.

• In the maxilla, the failure rate is higher because of the higher

mechanical forces and the poor quality of the bone.

• It is often recommended to place at least four implants which are

rigidly joined together with the bar in the maxilla.

Multiple fixed implant restorations

These are basically implant-retained bridges which can be short span
or can be complete arch restorations in edentulous jaws.

• There are two types of basic designs—one is the Branemark design

and the other is fixed design similar to conventional fixed partial
dentures.

• Branemark design is called the bone-anchored bridge which

consisted of cast metal bar attached to the acrylic teeth and
gumwork attached to the number of implants. This resembles
denture on stilts.

• The modern bridge designs similar to the conventional fixed partial

denture are having cast framework extending below the soft tissues
to connect to the implant abutments. The prosthesis can be either
screw retained or cemented. The results are favourable in cases of
minimal bone resorption. This type of design should not be used in
cases of advanced bone loss, especially in the anterior region
because of unfavourable biomechanics and inadequate lip support.

• Cantilevering of the fixed prosthesis with more than one tooth

 posteriorly and two teeth anteriorly is not advisable.

Indications

• When there is minimal bone resorption

• When the patient has strong gag reflex

• When there is good dentition in the opposing jaw which can

destabilize the denture

Importance of evaluating edentulous ridge for

implant placement
The clinical evaluation of the edentulous ridge is important for proper
diagnosis and treatment planning for implant placement. The
edentulous ridge should be carefully palpated and visually assessed
for the height, width and contour of the ridge and the quality of the
soft tissue covering the edentulous ridge.

• The bone height and width should be assessed both clinically and
radiographically.

• Clinical technique, such as ridge mapping, is helpful in assessing the

bone width and the soft tissue thickness.

• The angulation of the ridge is important to assess as proclined or

retroclined ridge will lead to placement of implant in that
angulation and that will drastically affect the aesthetics and result in
unfavourable loading.

• The interarch space is important to evaluate, as this will determine

the amount of space available for the restoration and the implant.

• The soft tissue profile over the edentulous ridge is important to

assess. Keratinized tissues which are firmly bound to the
underlying bone have better prognosis than the soft tissues which
 are loosely attached and mobile.

• The length of the edentulous ridge determines the number of

implant which can be placed to get best result. However, this
should always be correlated with the appropriate radiograph.

Key facts
• Dahl of Germany introduced the mucosal inserts or button implants
for maxilla in 1940.

• Dahl also conceived the concept of the subperiosteal implants.

• Goldberg and Gershkoff made subperiosteal implant with

vitallium in 1948.

• Sollier, Chercheve and Small introduced the transosteal implant in

1953.

• L.I. Linkow in 1966 introduced the endosseous blade vent implant.

• First extraoral implant was placed for the auricular prosthesis by

P.I. Branemark in 1977.

• Implants can be placed minimum 6 months after the radiotherapy.

• Radiation dose of OPG is less than the full mouth periapical

radiographs.

• Lateral skull radiograph is used to study ridge profile of both upper

and lower jaws in the midline.

• In CT scans, the metal markers should be avoided as these produce

scattering of the image.

• Scan Ora is a new generation sophisticated tomograph which is

used to generate high-quality sectional image.
• Narrow diameter implants less than 3.5 mm should be avoided in
the posterior region or number of implants should be increased.
Narrow diameter implants greatly reduce the strength and the
surface area for osseointegration or load distribution.

• D4 type of bone represents the worst type of bone used for implant
placement.

• The factors such as the quality of bone, type and design of implant
to be used, the anatomical anomaly and technique of use determine
the efficacy of the osteotome used in the posterior maxilla.

• The effective radiation dose with CBCT is significantly lower than

that of conventional CT.

• The CT imaging 3G software can produce high-quality images on

the paper, films or in the digital form.

• Surgical template is a useful diagnostic tool to guide the implant in

desired angulation during placement.

• Implant-supported prosthesis has the poorest prognosis of the

patient with parafunctional habits such as bruxer.

• Microstrain can be a favourable stimulus during healing period of

implants resulting in increased bone density.

• The ‘All and 4 Shelf’ concept was first described by Dr Paula Malo
in 1998.
CHAPTER
34
Osseointegration and materials

CHAPTER OUTLINE
Introduction, 467
Minimum Success Criteria for Implant
Systems, 467
Osseointegration, 468
Factors Influencing Osseointegration, 468
Concept of Osseointegration, 468
Materials Used in Dental Implants, 470
Healing Process in Dental Implants, 473
Osteophyllic Phase, 473
Osteoconductive Phase, 473
Osteoadaptive Phase, 473
Mechanism of Bone Augmentation in Dental
Implants, 474
Bone Grafts Used in Implant Dentistry, 474
Introduction
Dental implants provide an excellent option to patients who desire
fixed restorations or in those patients who cannot tolerate removable
prosthesis. The long-term favourable outcome with implant
restorations is well documented.

Minimum success criteria for implant systems

The minimum success criteria proposed by T. Albrektsson, G.A.
Zarb and P. Worthington (1986) are:

• An individual, unattached implant is immobile when tested

clinically.

• Radiographic examination does not reveal any peri-implant

radiolucency.

• After the first year in function, radiographic vertical bone loss is less
than 0.2 mm per annum.

• The individual implant performance is characterized by an absence

of signs and symptoms such as pain, infections, neuropathies,
paraesthesia or violation of the inferior dental canal.

• As a minimum, the implant should fulfil the above criteria with a

success rate of 85% at the end of a 5-year observation period and
80% at the end of a 10-year period.
Osseointegration
Osseointegration is defined as ‘the apparent direct attachment or
connection of osseous tissue to an inert, alloplastic material without
intervening connective tissues’.
Or
‘The process and resultant apparent direct connection of an exogenous
materials surface and the host bone tissues, without intervening fibrous
connective tissues’. (GPT 8th Ed)

Factors influencing osseointegration

1. Biocompatibility and implant design: Commercially pure titanium
implants are the most commonly used material to establish
osseointegration.

• Related material, such as niobium, is used to

produce high degree of osseointegration.

• The implant design influences greatly the initial

stability and its function.

The design parameters are:

• Implant length: Commonly used implant lengths

are between 8 and 15 mm which correspond closely
to the natural root length.

• Implant diameter: For adequate implant strength at

least 3.25 mm diameter implants are used. Most
 commonly used diameter is 4 mm. Implant
diameter rather than length influences the amount
of force distributed to the surrounding bone.

• Implant shape: Implant shapes such as hollow

cylinders, hollow screws, solid cylinders or solid
screws influence the amount of osseointegration
and provide initial stability. Alteration in the size or
pitch of the threads can influence the initial stability
of implants.
2. Surface characteristics: Degree of roughness influences the
osseointegration. Surface treatment, like grit-blasting, etching, plasma
sprayed hydroxyapatite coating, improves osseointegration by
increasing the bone to implant contact.

3. Bone factors: Quality and quantity of bone greatly influences the

stability of implant during placement.

• Qualities of bone most desirable during placement

of implants are well-formed cortical and densely
trabecular bone with good blood supply. Quality of
bone is influenced by factors such as infection,
smoking or irradiation which decreases the blood
supply to the bone.
4. Loading factors: Adequate healing period should be given to the
implant before loading. Ideally 6 months for maxilla and 4 months for
mandible are recommended.

5. Prosthetic considerations: Properly planned occlusal loading will

help in increased bone to implant contact and long-term
osseointegration.

6. The functional loading condition depends on the:

• Type of occlusal factors: Shallow cuspal inclines and

reduced loading during lateral excursion results in
lesser load transferred to the surrounding bone.

• Loading also depends on the nature of the opposing

occlusion.

• Type of prosthetic reconstruction: It may vary from a

single tooth replacement to full arch reconstruction
or implant supported overdentures.

• Number, location and design of implants: The greater

number of implants will distribute the functional
forces over the larger surface area, thereby reducing
the amount of load per area.

• Patient habits: Any parafunctional habits will

drastically influence the prognosis of the treatment.

• Design and properties of implant connectors: Rigid

connectors which are having passive fit help in
distributing load between the multiple implants
and also provide good splinting.

Concept of osseointegration
P.I. Branemark coined the term ‘osseointegration’ in 1977. It means a
direct structural and functional connection between ordered living bone and
the surface of a load carrying implant.
The rationale behind osseointegration was to achieve direct contact
between the bone and the implant without any fibrous tissues
between the two interfaces (Fig. 34-1).

• At the light microscopic level, there is a very close adaptation of the

bone to the implant surface.

• At higher magnification detected with the electron microscope,

there is a gap of about 100 nm width between the bone and the
surface of implant.

• This gap is occupied by the collagen-rich zone adjacent to the bone

and the amorphous zone adjacent to the implant surface.

• Bone proteoglycans help in initial attachment of the tissues to the

surface of implant (titanium dioxide in case of titanium implants).

• Degree of osseointegration depends on the total implant surface

contacted with bone.

• Greater osseointegration is observed in cortical bone with good

blood supply than in the cancellous bone.

• The degree of osseointegration increases with time and function.

• During placement of the implant, there should be a good contact

between the bone and the implant surface to ensure adequate
primary stability.

• Blood clot forms at the osteotomy site, which is replaced by bone

over a period of time.

• Initial bone trauma will lead to bone resorption which will reduce
the primary stability which was initially achieved.
• After the critical period of 2 weeks, the bone formation takes place
and the level of bone contact and implant stability is enhanced.

• Osseointegration can be considered as a dynamic process where bone

turnover takes place.

• The degree of osseointegration is influenced by the factors described

above.

• Osseointegrated implant is similar to the ankylosed tooth where

there is absence of mobility and there is no intervening fibrous
connective tissue between the tooth and the bone.

• Greater forces applied to the implant may lead to apical movement

of the bone margins resulting in some loss of osseointegration.

• An undisturbed and unloaded healing phase is recommended for

adequate osseointegration (two-stage implant procedure).

FIGURE 34-1 Osseointegration—bone fills the implant thread

 without a visible gap.

Materials used in dental implants

Classification of materials used in dental implants

On the basis of type of material used

• Metals:

• Stainless steel

• Cobalt–chromium–molybdenum based

• Titanium and its alloys

• Surface-coated titanium

• Other metals and alloys

• Ceramics:

• Bioglass

• Hydroxyapatite

• Aluminium oxide
• Polymers and composites

• Carbon and carbon silicone compounds

Stainless steel
• Austenitic steel with 18% chromium, 8% nickel and iron–carbon
(0.05%).

• Chromium imparts corrosion resistance and nickel helps in stabilizing

the austenitic structure.

• It should not be used in a patient sensitive to nickel.

• Alloy is mostly used in wrought and heat treated form.

• It is not in common use currently; it was used to fabricate ramus

blade, ramus frame, stabilizer pins, etc.

Advantages

• It has high strength and ductility and thus is resistant to brittle

fracture.

• It is cheap and easily available.

Disadvantages

• Alloy is subjected to crevice and pitting corrosion and care is taken

to preserve the passivating layer.

• Iron-based alloys have galvanic potential and have corrosion

characteristics when interconnected with titanium, cobalt,
zirconium or carbon implant biomaterials.

Cobalt–chromium–molybdenum alloy
• It is used in cast or cast and annealed condition.

• It is used in fabrication of subperiosteal frames.

• It is composed of cobalt 63%, chromium 30% and molybdenum 5%
and in traces carbon, manganese and nickel.

• Cobalt provides continuous phase for basic properties.

• Chromium provides corrosion resistance.

• Molybdenum provides strength and stabilizes the structure.

• Carbon acts as hardener.

Advantages

• Good strength and high modulus of elasticity

• Excellent biocompatibility

• Low cost

Disadvantages

• Ductility is least and, therefore, bending should be avoided.

• It is technique sensitive during fabrication.

• It is critical to use all the elements in proper concentration.

Other metals and alloys

• Early implants were made of metal such as tantalum, platinum,
gold, palladium and its alloys.

• Recently tungsten, hafnium and zirconium have been used.

• Gold, platinum and palladium have low strength.

• Gold and platinum are costly and have limited use in dental
implants.
Titanium and alloys
• Commercially pure titanium (cp-Ti) is considered the material of
choice for fabricating dental implant because of its predictable
reaction with the biologic environment.

• It consists of 99% titanium and 0.5% oxygen and minor amounts of

impurities such as nitrogen, hydrogen and carbon.

• Titanium is a highly reactive material which oxidises (passivates) on

contact with air or normal tissue fluids to form a passivating layer of
titanium oxide. Since the passivating layer minimizes biocorrosion,
this property is desirable for implant devices.

• With the formation of titanium oxide, titanium or its alloy is highly

corrosion resistant. The titanium oxide layer, nevertheless, releases
titanium ions slowly when it comes in contact with electrolyte such
as blood or saliva.

• When a cut surface of titanium is exposed to atmosphere, a

passivating layer 10 Å forms on the surface within a millisecond.

• Any abrasion or scratch on the surface during placement of implant

repassivates in vivo. The passivating property of titanium and its
alloy is further enhanced by treating it with nitric acid to form a
thick and durable layer on the surface.

• Density of titanium is 4.5 g/cm³ and is, therefore, 40% lighter than
steel.

• Modulus of elasticity (97 GN/m²) is one-half of that of steel but is 5–

10 times more than that of compact bone.

• It has a high strength to weight ratio.

Titanium alloy
• The most common alloy of titanium used in implant dentistry is
titanium–aluminium–vanadium (Ti–Al–V) alloy.

• This alloy contains 90% titanium, 6% aluminium and 4% vanadium

by weight.

• The mechanical properties of the titanium alloy are better than the
cp-Ti.

• The passivating layer of titanium oxide has a high dielectric

property which is responsible to make the surface of the implant
more reactive to the biomolecules through the increased
electrostatic forces. It, therefore, helps in osseointegration.

Bioactive materials used in implant dentistry

The most commonly used bioactive materials in implant dentistry are
ceramic-based materials.
Ceramic materials can be divided into two types:

1. Bioactive, e.g. hydroxyapatite, bioglass and beta-tricalcium

phosphate; these materials exhibit chemical contact with the host
bone.

2. Bioinert ceramics, e.g. aluminium oxide and titanium oxide; these

materials do not bond directly to the bone but are mechanically held
in contact with the host bone.

General properties

• The ceramic biomaterials are osteoconductive materials.

• These are alloplastic graft materials.

• These materials are used in augmentation of the resorbed ridges and

reconstruction of the osseous defects.
• These provide a scaffold or matrix to enhance new bone formation.
These materials do not have capacity of its own to develop bone.

• These have excellent biocompatibility.

• These exhibit good compressive strength and poor tensile strength

similar to the property of the bone.

• On account of poor tensile strength, their use is limited to low-

stress-bearing regions.

• These are available in different shapes, sizes and textures.

Bioactive materials can be classified as:

• On the basis of structure

• Dense crystalline—least resorption of bone occurs

• Amorphous—faster resorption occurs

• On the basis of porosity

• Dense—least resorption occurs

• Macroporous—larger spaces and slower resorption

• Microporous—smaller spaces and faster resorption

• On the basis of pH: Low pH—all CaPO4 compounds resorp rapidly,
whereas at high pH—resorp slowly.

Various biomaterials commonly used are:

• Hydroxyapatite

• Bioglass

• Bovine-derived anorganic bone matrix material (Bio-Oss)

• Calcium sulphate

• Tricalcium phosphate

Hydroxyapatite: It is a mineral which is primarily inorganic having

composition similar to bone and teeth.

• Chemical formula is Ca10 (PO4)6(OH)2.

• It is highly biocompatible and readily bonds with adjacent hard and

soft tissues.

• Its mechanism of bone regeneration is osteoconduction.

• Its physical and chemical properties determine the clinical

application and the rate of resorption.

• Larger particle sizes resorb faster.

• More porous the particles, more scaffolding it provides for new

bone regeneration but lesser will be the strength.

• These are bioactive and biodegradable ceramics.

• Amorphous grafts resorb faster as compared to the crystalline

grafts.

• Hydroxyapatite crystals are used for augmenting alveolar ridges

and for filling osseous defects.

• Solid dense bone particles possess high-compressive strength but

are brittle and are, therefore, used in low-stress-bearing areas.
Bio-Oss: It is bovine-derived anorganic bone matrix material.

• It is chemically treated to remove its organic component.

• It is osteoconductive graft material and it undergoes physiologic

remodelling to get incorporated in the surrounding bone.

• It can be used in treating periodontal defects, in dehiscences and

fenestrations around the implant and in small sinus osteotomies.

• When treating large defects, it can be combined with autogenous

bone for successful augmentation.

Bioglass: This consists of calcium and phosphate salts (CaO, P2O5)

similar to that found in bone and teeth and sodium salts with silicon
(Na2O, SiO2) which helps in mineralization of the bone.

• It is available in amorphous form only and not in crystalline form.

• It has high rate of reaction with the host cells and it has an ability to
bond with the collagen found in the connective tissues.

• The bioactivity level of bioglass is high; therefore, the process of

osteogenesis starts soon after implantation.

• It has unique property to bond both with the bone and the soft
connective tissues.

• Perio Glass is a synthetic particulate form of bioglass that is used to

treat the infrabony defects.

Advantages of bioactive materials

• Highly biocompatible

• Composition similar to bone

• Can bond to both the hard and soft tissues

• Minimal thermal and electrical conductivity

• Modulus of elasticity similar to the bone

• Colour is similar to the bone

Disadvantages of bioactive materials

• Low-tensile strength and shear strength

• Relatively low-attachment strength

• Solubilities are variable depending on the product and its clinical

application
Healing process in dental implants
The healing process around the dental implant is similar to the
process that occurs for primary bone.
The healing process in implants occurs in three phases, namely:

• Osteophyllic phase

• Osteoconductive phase

• Osteoadaptive phase

Osteophyllic phase
• Once an implant is placed into the cancellous bone, primary clot
forms between the rough implant surface and the bone.

• Cytokines are released during the initial implant–bone interaction.

• While inflammatory phase is in progress, the vascular ingrowth

begins from the surrounding vital bone starting from the 3rd day.

• It develops into more mature vascular network during the first 3

weeks following implant placement.

• Also, cellular differentiation, proliferation and activation occur

during this phase.

• Ossification occurs from the first week itself when the osteoblast
cells migrate from the endosteal surface of the trabecular bone.

• This phase lasts for 1 month.

Osteoconductive phase
• During this phase, as the osteoblast reaches the implant, it spreads
along the metal surface to deposit the osteoid.

• Initially, immature connective tissue matrix in the form of thin

woven bone is laid down. This is called the foot plate.

• Fibrocartilaginous callus matures into the bone callus similar to the

endochondral ossification of bone.

• This phase occurs for the next 3 months.

• After 4 months of implant placement, maximum surface of implant

is covered by the bone.

• At the end of this phase, a steady state is reached and there is no

more formation of the bone.

Osteoadaptive phase
• This phase occurs 4 months after placement of the implants.

• In this phase, remodelling of bone occurs even after the implants are
exposed and loaded.

• After loading, the bone surrounding the implant thickens in

response to the load transmitted to the implant.

• Reorganization of the vascular pattern is observed during this

phase.

• 4–8 months of healing period is recommended for adequate

osseointegration depending on the quality of the bone.

Mechanism of bone augmentation in dental

implants
There are primarily three mechanisms for bone regeneration:

• Osteogenesis

• Osteoinduction

• Osteoconduction

Osteogenesis is defined as ‘development of bone, formation of bone’. (GPT

8th Ed)

• Osteogenic graft is composed of tissue involved in the natural

growth or repair of bone.

• Osteogenic cells initiate bone formation in the soft tissue or activate

rapid bone formation at the bony sites.

Osteoinduction is defined as ‘the capability of the chemicals, procedures,

etc. to induce bone formation through the differentiation and recruitment of
osteoblasts’. (GPT 8th Ed)

• It is a process of stimulating osteogenesis.

• Osteoinductive grafts are used to increase bone regeneration and

can even induce bone to extend into the site where it is primarily
not located.

Osteoconduction provides a matrix or scaffolding necessary for the

deposition of the new bone.

• Osteoconductive grafts are conducive to bone formation and allows

bone apposition from the existing bone or differentiated
mesenchymal cells, but are incapable themselves to produce bone
when placed within the soft tissues.

• This type of graft requires the presence of existing bone or

differentiated mesenchymal cells.
• These graft materials are useful in augmenting the resorbed alveolar
ridges or reconstruction of the bony defects.

• Healing of bone around an osseointegrated implant is an

osteoconductive process and it undergoes phases of remodelling at
the bone–implant interface.

• Some examples of osteoconductive materials are ceramics, polymers

and composites.

Bone grafts used in implant dentistry

Bone grafts are used to augment bone in the areas which are deficient
of bone.
These grafts can be of following types:

• Autogenous bone graft

• Allograft

• Alloplast

• Xenograft

Autogenous bone graft: These types of bone graft are harvested from
the adjacent site or from within the body.

• This bone graft is considered gold standard for all other graft
materials.

• These are readily available from the adjacent or remote site.

• These are biocompatible and nonimmunogenic.

• Mechanism of bone formation is osteoinduction or osteoconduction.

• These are easy to manipulate.

• These are considered as sterile.

• Autogenous graft can be harvested from the intraoral and extraoral

sites depending on the requirements.

• For smaller defects, intraoral sites are preferred.

• Common intraoral sites are chin, retromolar area, ramus of

mandible and third molar region.

• Common extraoral sites are iliac crest and rib crest.

• Bone harvesting can be done by using trephine burs or surgical bone

traps.

• Highly osteoconductive osseous coagulum is collected and placed in

the area of defect.

• When the graft material is placed in the bone, it should be ensured

that the graft material is stable and closely adapted.

• Graft stability may be improved by using a membrane, e.g. guided

bone regeneration (GBR).

Allograft: Human bone material in the form of freezed dried bone or

demineralized freezed dried bone is commonly used in implant
dentistry.

• The donor bone is harvested from cadavers and is processed and

sterilized.

• These are available in different shapes such as particulate, thin

cortical plates or large blocks of bone.

• The mechanism of bone regeneration is osteoconduction.

• This type of bone acts as scaffold for bone regeneration and is

resorbable.
Alloplast: It includes materials such as hydroxyapatite, tricalcium
phosphate and bioactive glass material.
Xenografts: These graft materials are derived from different animal
species.

• Example: Bio-Oss is a bovine bone in which the organic component

is completely removed to form a mineralized bone architecture.

• These are nonimmunogenic and there are chances of trans-species

infection.

Key Facts
• The term osseointegration was coined by P.I. Branemark in 1977.

• Minimum period required for osseointegration of the implants in

the maxilla is 6 months and for mandible is 4 months.

• Implants should be placed after 16 years of age in a young patient

once the alveolar growth is completed; otherwise, it leads to
submerged implants.

• The factors affecting the osteogenic potential of the implant surface

are chemical composition, surface energy, surface roughness and
surface morphology.

• Autogenous bone graft is the gold standard of all the bone grafts, as
it gives the best and most reliable results.

• Platelet-rich plasma is used for reconstruction of mandible as bone

grafts or in sinus lift procedures.
CHAPTER
35
Surgical and prosthetic phase

CHAPTER OUTLINE
Introduction, 476
Parts of Dental Implant, 476
Surgical Phase of Implant Placement in
Moderately Resorbed Ridge, 477
Postoperative Care, 479
Implant Transfer Impression Coping
Techniques, 479
Implant Abutment, 479
Single-Tooth Abutment, 480
Overdenture Abutments, 480
Fixed Bridgework Abutments, 480
Biomechanics in Implant-Supported
Restorations, 480
Occlusal Considerations in Dental
Implants, 482
Implant Failures and their Management, 483
Failures in Implants Related to Initial Healing
Period, 484
 Failures in Implants Related to Abutment
Connection and Initial Loading, 484
Failures in Implant Detected during Follow-
ups, 484
Peri-Implantitis, 485
Immediate Loading of Implants, 486
Types of Immediate Loading, 486
Rationale for Implant Immediate Loading, 486
Introduction
Long-term success of implant therapy depends on proper treatment
planning which is prosthetically driven such as adequate restorative
space, favourable implant angulation, position and length of implants
and reducing or minimizing cantilevering. Also, patient maintenance
of oral hygiene and the prosthesis add the overall success of implant
treatment.

Parts of dental implant

Components of dental implants (fig. 35-1)

Implant body: It is placed within the bone during stage I surgery.
These can be threaded or nonthreaded with or without
hydroxyapatite coatings. It is usually made up of titanium or
titanium alloy.

Cover screw: The screw is placed in the implant during healing.

Healing cap or gingival former: It is the dome-shaped screw that is

placed after stage II surgery. It ranges from 2 to 10 mm and projects
through the soft tissue into the oral cavity.

Abutment: It is that component of the implant system that screws

directly into the implant. It will eventually support the prosthesis
directly. It is made of titanium and can be straight or angled.

Impression post: It facilitates the transfer of the intraoral location of

the implant or abutment to a similar position on the dental cast. It is
directly screwed into the implant and then impression is made
intraorally. The impression post is then removed from the mouth
and attached to the lab analogue before being transferred into the
impression in the properly keyed position.
Laboratory analogue: It is a component which is machined to exactly
simulate the implant or the abutment in the dental cast. The
laboratory analogue is screwed into the impression post after it is
removed from the mouth and placed back in the impression before
pouring into stone cast.

Waxing sleeve: It may be a plastic pattern or metal component which

is casted to eventually become part of the prosthesis.

FIGURE 35-1 Components of dental implant: (A) implant

body; (B) cover screw; (C) gingival former; (D) abutment; (E)
impression post; (F) lab analogue.

Surgical phase of implant placement in

moderately resorbed ridge
The success of surgical phase of implant placement depends on
proper diagnosis and treatment planning. Prior to surgery, few
important requirements should be fulfilled which are:

• The patient should be healthy.

• Proper medical history should be taken and medical consultation, if

needed, should be taken prior to surgery.

• Mounted diagnosed casts, radiographs and surgical stent should be

available.
• Informed consent of the patient should be taken.

Surgical phase of implant placement can be considered under the

following headings:

(i) Anatomical considerations

(ii) Crestal incision and flap design

(iii) Osteotomy of the implant site

(iv) Implant placement

Anatomical considerations
The clinician should be well aware of the anatomical structures in the
proximity of the proposed implant site. Important anatomical
landmarks which should be considered before placement of implant
are (Fig. 35-2):

• Maxillary landmarks: The maxillary sinus, nasopalatine canals,

floor of the nose and the nasal spine, palatine and pterygoid plexus.

• Mandibular landmarks: Sublingual vessels, mental nerve, inferior

alveolar nerve, incisive branch of inferior alveolar nerve, genial
tubercles and sharp mylohyoid ridges.

• The angulation, position and length of the tooth adjacent to the

implant site should be considered.

• The bone and the soft tissues of the edentulous ridge should be
assessed.
 FIGURE 35-2 Anatomical landmarks critical during implant
placement.

Crestal incision and flap design

• A mid-crestal horizontal incision is given after the tissues are
adequately anaesthetized.

• Full thickness periosteal flap is elevated after giving vertical

releasing incision.

• Some clinicians avoid giving vertical releasing incision due to

aesthetic reasons.

• The flap should be reflected adequately to visualize any bony

concavity that may lead to perforation of the bone during implant
placement.

Osteotomy of the implant site

• Surgical stent is tried and is used for guiding the drill into proper
 angulation and position.

• Small round bur is first used to penetrate the crestal bone at the
proposed site.

• This is followed by using pilot drill which has a noncutting end and
penetrated into the bone taking guide of the purchase point given
by the bur.

• The osteotomy site is enlarged in increments using twist drills of

increasing diameters.

• Sharp drills should be used and drilling procedure takes place in

increments using the increased diameter drills.

• It is important to note that during osteotomy the bone should not be

heated above 47°C.

• For this, copious sterile saline irrigation both internal and external is
mandatory.

• The osteotomy process continues till the appropriate length and

diameter of the cortical drill are used.

• The angulation and the parallelism between various implant sites

are checked using direction indicators.

• In general, the final bone preparation site diameter is slightly

smaller than the implant.

• Size of the site is dependent on the quality of the available bone.

• In cases with poor quality bone, the osteotomy site should be

prepared smaller than the proposed implant, so that the implant has
good primary stability during placement.

• In cases with good quality bone, the osteotomy site should be

 prepared of the same size as the proposed implant.

Implant placement
• Once the osteotomy of the implant site is completed, the implant of
appropriate diameter and length is retrieved from the sterile pack.

• The implant is placed directly into the osteotomy site.

• Care should be taken that the surface of the implant should not
touch anything, except the titanium surface.

• The implants are either self-tapped or threaded using appropriate

ratchet at determined torque.

• Excess torque should be avoided, as it tends to decrease the primary

stability of the implant.

• It is important to achieve primary stability of the implant into the

prepared site.

• The cover screw is placed and the site is closed by suturing.

Postoperative care
• The patient is advised oral analgesics to control pain.

• Antibiotics may be indicated, if necessary.

• The patient is advised to maintain proper oral hygiene.

• The patient is advised to use chlorhexidine mouthwash to control

plaque.

• Ice packs may be used to reduce swelling.

• The patient is strictly advised not to smoke.

• The patient should be on soft diet.

Implant transfer impression coping techniques

The aim of impression making is to record the implant positions in a
master working cast. Selection of impression material is critical. The
impression material should be flexible enough to be removed from the
tooth and tissue undercuts as well as adequately rigid to allow for
accurate seating of the components into the impression. It should also
prevent movement of the components during pouring of the cast.
Primary impression is usually made of alginate material using stock
tray. The final impression is made using custom tray, as it ensures
adequate thickness of material for dimensional stability and sufficient
recording of the tissues. The standard approach of impression making
is at the level of implant abutment using transfer coping.
There are two methods of transferring impression coping, namely,
pick-up technique and reseating coping technique.

1. Pick-up technique

• In this technique, open-faced impression tray is

used.

• The tray allows access to the retaining screw to

secure the impression post to the implant.

• The retaining screw should extend 2–3 mm above

the impression tray opening.

• Impression material is injected first around the

impression coping and then the material is loaded
onto the tray.
• The loaded tray is then seated in the patient’s
mouth.

• Once the material is set, the retaining screw is

unscrewed, leaving the pick-up impression coping
inside the impression.

• Laboratory analogues are attached to the

impression coping and then the impression is
poured with stone.
2. Reseating coping technique

• In this technique, conventional technique of

impression making is used.

• The impression material is syringed around the

impression coping and the loaded tray is seated in
the mouth.

• Once the material is set, the tray is removed.

• Then the impression coping is unscrewed and

attached to the laboratory analogue, outside the
patient’s mouth.

• The entire assembly of the impression coping and

the analogue is then seated into the impression.
• This technique is used in cases where there is
limited space to use pick-up technique.
Implant abutment
Implant abutment is defined as ‘tooth, a portion of a tooth, or that portion
of the dental implant that serves to support and/or retain a prosthesis’. (GPT
8th Ed)
Abutments are those components which attach to the implant head
and are retained to the implant by an abutment screw which extends
through the abutment into the body of the implant.

Classification of implant abutments

On the basis of type of restoration
(i) Single-tooth abutment

(ii) Fixed bridgework abutment

(iii) Overdenture abutment

On the basis of type of retention

(i) Screw-retained abutment

(ii) Cement-retained abutment

On the basis of fixation with implant

(i) Single-piece implant: The abutment is attached to the implant as a
single unit.

(ii) Two-piece implant: Both the abutment and the implant are separate
entities.

The following are the main types of implant abutment.

Single-tooth abutment
• This abutment should incorporate antirotational feature both at the
junction of the abutment to the implant and between the abutment
and the restoration.

• The final restoration can be screw retained or cement retained.

• Cement-retained restoration is more popular because it is more

aesthetic and angulation of the implant is of less importance, as
compared with the screw-retained restoration.

Overdenture abutments
• In case of implant-supported overdenture, the abutment should be
selected depending on the available interarch space.

• The dentures are retained over the abutments by means of various

attachments.

• The ball attachments or magnetic attachments are incorporated into the

abutment.

• If multiple implants are splinted by means of bar, all the abutments

are connected to the bar and are casted in single piece to form a
superstructure.

• In case of bar-supported overdentures, the denture is retained by

means of clip.

Fixed bridgework abutments

• These abutments are connected to each other similar to that
followed in conventional fixed bridge.

• Usually, these do not require antirotational features.

• The abutments are screwed to the implant head and all the
abutments are milled to have a single path of insertion.

• Angled abutments are used to overcome severe alignment problem

between the implants.

• The final fixed bridge is either screw-retained or cemented on the

abutments.

Comparison of cement-retained restorations with

screw-retained restorations
Comparison of cement- and screw-retained restorations is given in
Table 35-1.

TABLE 35-1
CEMENT- AND SCREW-RETAINED RESTORATIONS:
COMPARATIVE FEATURES

Cement-Retained Restorations Screw-Retained Restorations

Superstructure is passively fitting Achieving passive superstructure difficult
Correction of nonpassive superstructure is Correction of nonpassive superstructure is difficult, the
possible in same appointment implant position and angulation are critical
No screw required; small discrepancy in fit Tendency of wearing, loosening or fracture of screw
is corrected by luting cement
Easy to achieve aesthetics Aesthetics can be compromised
Less chances of ceramic fracture More chances of ceramic fracture, as screw holes provide
weakened area
Accessibility to posterior abutment is easy Accessibility in posterior area is difficult
Decreased laboratory cost Increased laboratory cost and costly special components
Axial loading of implant is easier Axial loading of implant occurs over the screw
Difficult to retrieve Retrievability of screw is easy; screw acts as fail-safe
component
Progressive loading is easy Progressive loading is difficult
Abutments may be splinted to decrease Increased forces on the remaining abutments
workload

Biomechanics in implant-supported restorations

Biomechanics in implant-supported prosthesis can be described under
the following headings.
Implant number
• Greater the number of implants, greater the distribution of occlusal
load and lesser the stress to the bone.

• Increase in implant number decreases the cantilever length which

again reduces overall stress to the bone.

Implant diameter
• Wider diameter implant increases the surface area over which the
occlusal load can be dissipated.

• Also, these exhibit greater bone to implant contact as compared to

narrow diameter implant.

• Larger the width of the implant, more closely it simulates the

emergence profile of the natural tooth.

• However, the diameter of implant should not be more than 6 mm

because the rigidity of the implant (titanium) is 5–10 times more
than the natural tooth.

Implant design
• Shape of the implant determines the amount of surface area
available to transfer occlusal load and initial stability.

• Smooth-sided, cylindrical implants result in greater shear stress at

the bone–implant interface. In order to decrease it, the surface
should be coated with hydroxyapatite or plasma spray.

• Tapered-implants provide greater component of compressive load

at the bone–implant interface and provide ease of surgical
placement.
• However, the taper of the threaded implant should not be more
than 30°.

• Tapered-threaded implant has lesser surface area as compared to

parallel-threaded implant.

• Threaded implants have unique ability to convert the type of load

imposed at the bone–implant surface by controlling the thread
geometry.

• There are three thread geometry parameters, namely, thread pitch,

thread shape and thread depth.

• Smaller the pitch, greater the number of threads per unit length and
thus greater the functional surface area.

• Greater the thread depth, greater will be the functional surface area
of the implant body.

• The thread shapes can be of three types: square, ‘V’-shaped or

buttress-shaped.

• Square or power threads experience least amount of shear stress as

compared to V-shaped or buttress threads. Also, it can transfer
more axial load onto the implant body.

• Implant thread design can also influence the bone turnover rate
(remodelling rate) during occlusal load conditions.

Implant length
• Greater the implant length, greater will be the functional surface
area.

• Longer implants are believed to provide greater stability to lateral

loading conditions.
• It is recommended to use longer implants in poor quality bone.

Crest module factor

• Crest module is an area which is subjected to high-mechanical stress.

• It is designed such that it is larger than the outer thread diameter.

• This provides a seal to bacterial ingress or fibrous tissues.

• The larger diameter increases the functional surface area and thus
helps in dissipating occlusal stresses.

Occlusal load direction

• There should be narrow occlusal tables and no posterior offset
loads.

• Forces should be directed along the long axis of the implant bodies.

• Axial load over the long axis of the implant body generates greater
amount of compressive stress than the shear or tensile stress.

• If the implant is placed at an angle, greater angled load will result in

greater crestal bone loss.

• Angled abutment which is loaded along the abutment axis

transmits a significant moment load onto the crestal region.

• Posterior cantilevers should be avoided (Fig. 35-3).

• If the patient has parafunctional habits, the occlusal scheme should

be selected which can minimize occlusal trauma to the bone.

• Any premature occlusal contact should be eliminated, as its

presence increases the duration and magnitude of the occlusal load
to the implant body and the bone.
 FIGURE 35-3 Posterior cantilevers should be avoided.

Occlusal overload leads to the following:

• Crestal bone loss

• Early implant failure

• Screw loosening

• Loss of cementation

• Ceramic fracture

• Implant component fracture

• Peri-implantitis

• Prosthetic failure

Quality of bone
• Cortical bone is strongest in compression, 30% weaker in tension
 and 65% weaker in shear stress.

• Better the quality of bone, greater is the chance of osseointegration.

• Poorer the quality of bone, lesser are the chances of osseointegration

and more are the chances of failure.

Occlusal considerations in dental implants

Implant restorations should be designed such that the implant–bone
interface is minimally subjected to the damaging forces. Occlusion of
the restoration is planned in such a way that the forces are directed
along the long axis of the implant. Occlusal consideration in implant
restorations can be studied by evaluating the following factors:

• Transosteal forces

• Direction of load to the implant body

• Bone biomechanics

• Biomechanical factors

• Occlusal forces and muscles of mastication

Transosteal forces: As the implants are osseointegrated and do not

have periodontal ligament, these will not move under occlusal
contact when compared with natural teeth.

Implant when subjected to repeated occlusal load can

lead to crestal bone loss.
Direction of load to implant body: Occlusal forces should be directed
along the long axis of the implant body, so as to reduce forces on
the crestal bone (Fig. 35-4).
• More the angulation of the abutment, greater will
be the compressive and the tensile stresses to the
crestal bone.

• Implant body should be loaded with vertical forces

rather than horizontal forces because horizontal
forces greatly enhance the compressive and tensile
forces on the crestal bone which leads to greater
bone loss.

• Premature contacts should be avoided, as it

increases stress on the implant body.

• Screw-retained prosthesis subjects the implant body

to greater offset load as compared to the cement-
retained prosthesis.
Bone biomechanics: Strength of the bone is maximum in compression
and lesser in tensile and least in shear forces.

• Axial loading along the long axis of the implant

distributes more compressive forces compared with
tensile or shear.

• Any load applied at the angle will increase the

amount of tensile and shear forces on the implant.

• Greater the angle of force, greater will be the shear

forces on the implant.
• It is important, therefore, to select an occlusal
scheme which reduces the horizontal or the lateral
forces on the implant.
Biomechanical factors:

Occlusal forces and muscles of mastication: Natural

teeth have greater stress-relieving element than
implants because of the presence of periodontal
ligament.

• The posterior segments should be discluded in all

lateral excursions to reduce overall stress on the
stomatognathic system.

• In eccentric jaw movements, it is important not to

have contact on the implant-retained restoration.
Whenever possible, disclusion is preferred over the
natural canine.

• Whenever possible, the implant should be placed in

the middle of the edentulous crest of the bone.
FIGURE 35-4 Greater crestal bone loss occurs when
angulated abutments are given.
Implant failures and their management
Failures in implants can be classified as follows:

Failures in implants related to surgery and initial

healing period:
(i) Mobile fixtures

(ii) Mucosal fixtures

Failures in implant related to abutment connection

and initial loading:
(i) Abutment loosening

(ii) Occlusal factors

(iii) Screw loosening or cement failure

Failures in implants detected during follow-ups:

(i) Wear or breakage of the components

(ii) Soft tissue complications

(iii) Exposed implant threads

(iv) Fracture of abutment screw

(v) Fracture of fixture

(vi) Loss of implant

Failures in implant due to bacterial-induced factors:

(i) Poor oral hygiene of the patient

(ii) Retention of cement in the subgingival area

(iii) Macroscopic gaps between the implant components subgingivally

(iv) Marked inflammation, exudation and proliferation of the soft

tissues

Failures in implants related to initial healing

period
Mobile fixtures: If primary stability is not achieved during implant
placement, the fixture is primarily unstable and this prevents
adequate osseointegration.

• Overheating of bone during placement or failure to

achieve primary stability can result in loss of
osseointegration.

• It can be managed by placing a standard length

implant with bigger diameter, if possible.

• Implant failure rate in smokers is almost twice as

that of the nonsmokers.

• The patient is advised to quit smoking at least

during the first week of implant placement.
Mucosal fixtures: It can occur due to defective flap adaptation, suture
remnant granulomas or decubitus ulcer below the denture.
• It can be managed by excision of the perforation
site, flap mobilization, resuturing and proper
adjustment of the denture.

Failures in implants related to abutment

connection and initial loading
Abutment loosening: It can occur due to repeated loading of the
implant during chewing cycles or due to any parafunctional habits
of the patient.

• It can be managed by relieving any premature

occlusal contact and adequately tightening the
abutment screw.
Occlusal factors: Factors which can lead to implant failures are:

• Patient having parafunctional habits

• History of breakage of the superstructure or

retaining screws

• An angular pattern of bone loss

• Too few implants to replace missing teeth

• Excessive cantilevering
Screw loosening or cement failure: This can occur due to ill-fitting
prosthesis or excessive loading.
• Screw loosening can also occur, if the arch form is
not maintained.

• The causative factors should be eliminated to

correct the problem.

• If there is repeated incidence of screw loosening, the

screw should be replaced.

Failures in implant detected during follow-ups

Wear or breakage of the components: The common cause of wear or
breakage of components is ill-fitting prosthesis.

• Broken component is replaced and the ill-fitting

prosthesis is remade.
Soft tissue complications: The mucosa surrounding the abutment
should be checked for any inflammation.

• It may be caused due to poor implant positioning.

• The soft tissue is checked for increased probing

depth, soft tissue proliferation, bleeding, exudates
or tenderness.

• The area is examined radiographically to determine

the loss of bone or loss of integration.

• Soft tissue complications may require surgical

 correction.

• If there is adequate attached gingiva, simple

excision is given.

• A loosely tightened abutment screw may cause the

formation of the granulation tissue at the
abutment–fixture connection.

• The granulation tissue is removed once the

abutment is unscrewed.

• After the removal of granulation tissue, the

abutment screw is adequately tightened.
Exposed implant threads: It may occur due to horizontal bone loss.

• There may be soft tissue proliferation over the

exposed threads.

• At the time of placement, the implant is placed deep

enough.

• Proper oral hygiene maintenance is important.

• There may be a need for periodontal therapy to

create attached gingiva by free mucosal or skin
grafts.
Fracture of abutment screw: Ill-fitting prosthesis or overloading of
implant is common cause for fracture of the abutment screw,
although the incidence is low.

• The fractured abutment screw is first retrieved and

then the cause is evaluated.

• New properly fitting prosthesis is constructed and

the broken screw is replaced with the new one.
Fracture of the fixture: Progressive horizontal bone loss is an
indication for stress concentration which can result in fracture of the
fixture over a period of time.

• The fractured fragment is removed using a small

diamond cutter.

• The area is inspected after removal of the fragment

and a new long abutment is placed.

• The junction of the abutment and the fixture is

checked for intimate fit using a radiograph.
Loss of implant: This may occur due to rapid horizontal and vertical
bone loss.

• The cause is evaluated and then treated first.

• After stabilization, another implant next to the site

is placed.
Peri-implantitis
Peri-implantitis is defined as ‘inflammation around the dental implant,
usually the dental abutment’. (GPT 8th Ed)
The inflammation occurs at the soft tissue implant interface. The
clinical signs of inflammation in the peri-implant soft tissues are:

• Gingivitis

• Suppuration

• Soft tissue oedema

• Bleeding

• Increased pocket depth

Aetiology
• Plaque accumulation in peri-implant mucosa

• Calculus

• Occlusal trauma

Diagnosis
• Periapical and vertical bitewing radiographs are helpful in
diagnosis.

• Plastic periodontal probe is used to assess the gingival health and to

monitor the pocket depths.

• No bleeding occurs on probing around implants because more rapid

breakdown occurs around implants in patient having poor oral
hygiene.
• Crestal bone loss with loss of perimucosal seal may occur.

• Mobility of implant can occur.

• Changes in the biochemical configuration of the crevicular fluid

may indicate implant failure.

Prevention
• Good oral hygiene maintenance

• Patient education

• Proper use of oral hygiene aids

• Chlorhexidine mouthwash

• Plastic or titanium instruments used to remove plaque and calculus

Management
• Nonsurgical treatment is used by proper plaque control, oral
hygiene instructions, use of chlorhexidine mouthwash, treatment
with citric acid and sodium hypochloride to remove bacterial
endotoxins.

• Surgical methods used for treating peri-implantitis are

mucogingival therapy, open debridement, apically positioned tissue
grafting, guided tissue regeneration and removal of implant.

• Implant is removed only in rare cases.

Immediate loading of implants
Immediate loading refers to a nonsubmerged implant which is placed
in single-stage surgery and is loaded with the provisional restoration
in the same appointment or shortly thereafter.
Immediate loading is a technique in which implants are restored, and
thus loaded at the time of the placement.

Types of immediate loading

Immediate functional loading

• Temporary restoration fitted on the same day as surgery and is in
occlusion.

• Patient is advised soft diet.

Immediate nonfunctional loading

• Temporary restoration fitted on the same day as surgery but is not
in occlusion (Fig. 35-5).

• Patient is advised soft diet.

 FIGURE 35-5 Immediate functional loading.

Rationale for implant immediate loading

• Minimizes thermal injury and surgical trauma

• Acceleratory phenomenon of bone repair

• The interface is the weakest, at risk of overload at 3–6 weeks after

insertion

• Temperature: 38–41°C (M. Sharawy, C.E. Misch, N. Wellner, 2002)

and not above this range during osteotomy

• Slow intermittent pressure with irrigation and usage of sharp drills

• To reduce the risk of fibrous tissue formation

• To minimize woven bone formation and promote lamellar bone

maturation

Advantages
• It saves time and cost.

• It preserves alveolar bone; biostimulation occurs, so ridge height

and width are maintained.

• Aesthetic results can be obtained.

Disadvantages
• Case selection would be difficult.

• It may need soft tissue and hard tissue augmentation at a later date.

Key Facts
• In implant-retained overdenture for completely edentulous patient,
balanced occlusion or lingualized occlusion is given.

• In full fixed arch implant-supported bridges, there should be

simultaneous contact on the anterior and posterior teeth in centric
relation with anterior group function and multiple contacts in
eccentric jaw movements.

• Guided bone regeneration is used for the treatment of localized

ridge defects and to regenerate bone in dehiscence and
fenestrations.

• During osteotomy, care should be taken that the bone should not be
heated above 47ºC, as this will lead to bone cell death.

• Oil rig style bridge is made of standard cylindrical abutments

which are joined together with a composite resin bar used mostly in
the lower arch where aesthetics is not a primary concern.

• Misch occlusal analyser is used to evaluate the occlusal plane of the

patient before the restoration of the opposing arch.
• Minimum crown height space needed for the fixed implant
prosthesis is 8 mm.

• The distance from the centre of the most anterior implant to a line
joining the distal aspect of the two most distal implants is called the
anteroposterior distance or (A-P spread).

• Greater the A-P spread, more favourable is the situation of the

posterior cantilever.

• The tip of the osteotomes is usually concave and blunt so as to

minimize the chances of tearing the Schneiderian membrane
during sinus lift procedures.

• In group function occlusion, there is contact of all the teeth on the

working side and there is no contact on the balancing side.

• Shim stock is the most accurate method of checking occlusion for a

fixed prosthesis.

• Anterior mandible is the ideal location for placement of implants.

• The intraoral sites for harvesting bone for autogenous graft are
maxillary tuberosity, mandibular symphysis, mandibular ramus or
third molar region.

• Recently introduced zirconia abutments provide excellent

aesthetics.

• The implant should be placed at least 2 mm longer than the tooth

socket for good primary stability.
Question bank
Section I: Complete dentures
1. Write problems associated in cases of having single complete
dentures opposing natural remaining teeth.

2. Discuss dentogenic concept with reference to aesthetics in complete

denture prosthodontics.

3. ‘Establishing and verification of correct vertical jaw relations for

complete dentures always poses a challenge to prosthodontist’.
Discuss.

4. Write causes and methods of correcting occlusal discrepancies in

processed complete dentures.

5. Discuss the advantages and shortcomings of balanced occlusion in

complete dentures.

6. Describe the techniques of producing balanced occlusion.

7. Describe Bennett movement. How are these incorporated in various

articulators?

8. Describe the biological aspects to be considered during complete

denture impression making.

9. Discuss the importance of centric relation in complete dentures.

10. Describe the methods of obtaining centric relation for the

edentulous patient.

11. Discuss the usefulness of facebow. Give a brief historical account

of the origin and development of facebow.

12. Discuss the effects of complete dentures on hard and soft tissues of
the oral cavity with special reference to measures to minimize it.

13. Discuss the rationale for selecting artificial teeth for edentulous
patients.

14. Give an account of the evolution of artificial posterior tooth form.

15. Give an account of factors affecting occlusion in complete

dentures.

16. Discuss the evolution of articulators.

17. Discuss the significance of ‘hinge axis’ theory of mandible. Give

your comments on its clinical importance in prosthodontics.

18. Discuss the objectives and procedure of selective grinding in

complete dentures.

19. Discuss aesthetics and phonetics in complete denture prosthesis.

20. Discuss the factors for retention of complete dentures with a

special reference to posterior palatal seal.

21. Discuss the role of mandibular rest position as it relates to

complete denture prosthodontics.

22. Discuss how facial and functional harmonies are achieved during
arrangement of artificial teeth for complete dentures.

23. Discuss the muscle tone and its relationship to vertical dimension.

24. Discuss the importance of anterior guidance during aesthetic

restoration.

25. Define patient education. Discuss the role of patient education and
patient motivation in the success of a complete denture therapy.

26. Describe the nutritional factor in complete denture patient.

27. Write briefly the procedure of making an impression of flabby
ridge.

28. Discuss the treatment of abused tissues in complete denture

construction.

29. Define vertical jaw relations. What are the different methods by
which vertical jaw relations can be recorded?

30. Write a note on neutral zone.

31. Describe the peripheral structures affecting mandibular dentures.

32. Discuss the degenerative changes in the oral cavity on account of

ageing and its effects in the fabrication of complete dentures.

33. Discuss the preprosthetic surgery in the treatment of completely

edentulous patient.

34. Write a short note on masticatory efficiency of complete dentures.

35. Write a short note on denture cleansers.

36. Discuss posterior palatal seal as an indispensable clinical step in

maxillary complete dentures. Describe the methods of recording
posterior palatal seal.

37. Discuss the theories of impression making in complete dentures.

38. Discuss the critical role played by border moulding lingual flange
of the special tray in the stability of mandibular complete dentures.

39. ‘Troubleshooting in complete dentures prosthesis’. Discuss the

statement and your management.

40. ‘Immediate denture service designed to preserve oral structures’.

Discuss the merits and demerits of this statement.
41. Write importance of incisive papilla in the arrangement of anterior
teeth.

42. Discuss the gothic arch tracings as related to the various

movements of lower jaws with special reference to the development of
balanced occlusion.

43. What are jaw relations? How will you record the following
relations with maximum accuracy: (i) orientation of the plane of
occlusion, (ii) vertical dimension of occlusion (VDO) and (iii) centric
relation.

44. Define centric relation. Describe the technique of registering

centric relation in clinic for an edentulous case.

45. Write a short note on age changes in edentulous patients.

46. Write a short note on special tray for edentulous mouth.

47. Describe briefly about the sequelae of wearing complete dentures.

48. Describe briefly about the anatomy of maxillary denture-bearing

area.

49. Write a short note on residual ridge resorption.

50. Write a short note on alveololingual sulcus.

51. Define retention, stability and support. Describe the biological,

mechanical and physical factors which promote these qualities in
complete dentures.

52. Define impression. Classify the different types of impression in the

field of dentistry.

53. Differentiate between the mucostatic and mucocompressive

impression techniques.
54. Discuss the statement ‘artificial denture can be a boon to the
patient, but artificially looking denture a curse’.

55. Explain in detail about the anatomy and physiology pertaining to

the maintenance of physiological rest position of the mandible with a
detailed note on muscle tone, muscle spindle and myotatic reflex.

56. Explain the significance of centric and eccentric jaw relations. Give
a critical evaluation of the methods to record centric jaw relations.

57. Explain the methods of making interocclusal records and

establishing the centric relations of partially edentulous conditions.

58. Discuss the rationale and technique of relining complete dentures.

59. Discuss the movements and the various reference positions of the
mandible.

60. Describe the rationale and technique of ridge augmentation for

complete dentures.

61. Write a short note on the evaluation of methods to obtain vertical

space for complete dentures.

62. Write a short note on bar designs in overdentures.

63. Write a short note on Bennett movement.

64. Write briefly about the theories of occlusion.

65. Critically evaluate the various posterior tooth forms with respect
to balanced occlusion and masticatory efficiency.

66. Write a short note on border moulding of lingual crescent.

67. Write a short note on reduction of residual ridge.

68. Write a short note on semi-adjustable articulators in practice.

69. Discuss the statement ‘temporomandibular joint controls
biomechanical phase of prosthetic rehabilitation’.

70. Discuss the recent trends in prosthodontics research in complete

denture prosthodontics.

71. Describe the importance of characterization of the denture base

and anterior teeth with reference to the aesthetics in complete
dentures.

72. Discuss the concept of ‘overdenture philosophy’ in preservation of

the residual alveolar ridges.

73. How do you select posteriors for edentulous patients with

moderate ridges?

74. Write short note on resilient permanent soft liners?

75. Define denture aesthetic. Discuss its importance in complete

denture prosthodontics.

76. Describe the types of denture teeth on the basis of materials and
morphology.

77. Write about the selection of anterior teeth in complete denture

prosthodontics.

78. Describe the role of pre-extraction guides in teeth selection.

79. Differentiate between natural and artificial occlusion.

80. Differentiate between acrylic resin teeth and porcelain teeth.

81. Write in detail about the importance of medical history.

82. Write a short note on the effect of natural tooth loss.

83. Write a short note on palatal throat form.

84. Describe briefly about vestibuloplasty.

85. Write a short note on peripheral sealing.

86. How will you assess your complete denture at the time of
delivery?

87. Write a short note on retromolar pad.

88. Describe briefly about biological width.

89. Write a short note on buccal shelf area.

90. Write note on border moulding.

91. Describe briefly Valsalva manoeuvre.

92. Describe briefly index areas.

93. Write a short note on mandibular movements.

94. Describe briefly Silverman’s closest speaking space.

95. Write a short note on freeway space.

96. Write a short note on problems related to increased vertical

dimension in complete denture.

97. Describe briefly graphic method for recording centric relation.

98. What is an articulator? Classify them and discuss in detail mean

value articulator.

99. Write a short note on zero degree posterior teeth.

100. Write a short note on squint test.

101. Write a short note on neutrocentric concept of occlusion.

102. Write a short note on realeff.

103. Describe arcon articulators.

104. Discuss lingualized occlusion.

105. Write a short note on laboratory remount procedure.

106. Discuss stepwise the procedure to be followed at the try-in

appointment.

107. Write a short note on compression moulding technique.

108. Describe briefly denture sore mouth.

109. Describe briefly gagging and management.

110. Write a short note on complete denture hygiene.

111. Write a short note on postinsertion instructions for complete

denture patients.

112. Give brief description of sequelae of ill-fitting dentures.

Section II: Removable partial dentures
1. ‘Surveying is the most essential but a neglected aspect in removable
partial denture prosthodontics by dental surveyor’. Discuss. Also,
discuss ‘survey line’ influencing clasp design.

2. Discuss mouth preparation in removable prosthodontics.

3. Write a short note on ‘swing-lock’ removable partial denture.

4. Discuss the rationale of impression techniques in removable partial

denture prosthodontics.

5. Give a critical review of classification related to the removable

partial denture construction.

6. Discuss the various types of clasps along with their merits and
demerits used in removable cast partial dentures.

7. What do you understand by the term ‘support’? Discuss the

problems encountered in providing support in partial dentures.

8. Discuss the role of ‘stress distribution’, ‘stress equalization’ and

‘stress breaking’ in successful removable partial dentures.

9. What are precision attachments? Describe some of the commonly

used precision attachments.

10. Discuss the principles of removable partial designs.

11. Discuss the application of the principles of stress breaking in

designing a Kennedy class I type of partial dentures. Also, discuss the
control of various movements in designing class I cases.

12. Discuss the biomechanical problems associated with extension

base removable partial dentures (RPD) and their remedies.

13. Describe indirect retention in removable partial dentures.

14. Write a short note on fluid wax functional impression method in

distal extension partial dentures.

15. Write a short note on the merits and demerits of Kennedy’s

classification.

16. Write a short note on the fabrication of splints in the treatment of

edentulous and dentulous alveolar ridges.

17. Describe the laboratory procedure for fabricating a cast partial

denture from the stage of wax pattern onward.

18. Describe the procedure of occlusal records for removable partial

dentures.

19. Explain about the merits and demerits of various types of existing
classifications for removable partial dentures.

20. Give an account of stress distribution in planning various

components of partial dentures.

21. State the importance of determining a path of placement of

removable partial dentures. Explain its methodical determination.

22. Describe retention in different types of removable partial dentures.

23. Write a short note on management of stresses in removable partial

denture (RPD).

24. Discuss role of occlusal rest in removable partial denture (RPD).

25. Discuss the concepts of surveying and undercut blocking.

26. Discuss the rationale of functional impression procedure in

removable partial denture (RPD).

27. Briefly describe the use of enameloplasty for mouth preparation.

28. Briefly describe the methods of duplication of casts.

29. Mention and justify the use of various metals in removable partial
denture (RPD).

30. Write a short note on the role of surveyor and milling machine in
removable partial dentures.

31. Write a short note on maxillary major connectors.

32. Explain about achieving retention, stability and support in rest,

plate, I bar (RPI) system.

33. Describe clasp design and explain how it helps in achieving

retention.

34. Discuss the stresses induced by removable partial denture (RPD)

and suggest the measures for their control.

35. Discuss the role of modern implants in removable partial denture

prosthodontics.

36. Discuss periodontal considerations in removable partial denture

(RPD) designing.

37. Discuss the various types of mouth preparation required during

fabrication of removable partial denture (RPD).

38. Describe the problems associated with distal extension removable

partial dentures, while mentioning the management techniques to be
followed.

39. Describe the importance of tripodal stabilization.

40. Discuss the postinsertion problems and their management in
relation to removable partial denture (RPD).

41. Discuss your procedure of management in a case of partial

dentition having reduced vertical dimension due to mutilation of the
remaining natural teeth.

42. Enumerate the steps involved in the fabrication of cast partial

denture.

43. Write a short note on the block out of master cast.

44. Write a short note on relief in relation to fabrication of cast partial

denture.

45. Write a short note on waxing of the cast partial framework.

46. Give a step-by-step explanation of cast partial denture preparation

and insertion in the patient’s mouth.

47. What are diagnostic casts? Write about its importance in diagnosis
and treatment planning.

48. Rationalize the importance of radiographs in removable

prosthodontics.

49. What are the objectives of prosthodontic treatment for partially

edentulous patients?

50. Define surveyor. Write briefly about its parts.

51. Describe briefly about the factors that determine the path of
placement or removal of the prosthesis.

52. Write a short note on tripoding.

53. Write a short note on survey line.

54. Differentiate between shaped block out, arbitrary block out and
parallel block out.

55. Write a short note on relief of master casts.

56. Enumerate the objectives of mouth preparation. Describe briefly

about mouth preparation in partially edentulous patients.

57. Discuss the statement ‘to date no ideal classification of the partially
edentulous condition has been devised’.

58. Describe the different methods of obtaining the impression for

partially edentulous arches.

59. Write short note on functional relining method?

60. Critically analyse various impression techniques used in

removable partial dentures.

61. Briefly describe lug rest/lug seat preparation in RPD.

62. Briefly describe Kennedy’s classification.

63. Briefly describe the parts of cast removable partial denture.

65. Differentiate between Akers’ clasp and bar clasp.

66. List the various components of a removable partial denture and

write in detail about rests and rest seats.

67. Describe class II Kennedy removable partial denture (RPD).

68. Briefly describe duplicating flask.

69. Write a short note on split cast technique.

70. Write a short note on Applegate’s modification in RPD.

71. Write a short note on guide plane.

72. What is circumferential clasp? Describe indication,

contraindications, advantages and disadvantages and its parts along
with their functions.

73. Define direct retainer. What are the requirements of clasp design?
Discuss combination clasp.

74. Write a short note on three-arm clasp.

75. Write a short note on intracoronal retainers.

76. Write a short note on roach clasp.

77. Write a short note on indirect retainers. What measures do you

employ to achieve indirect retainer in distal extension partial denture
case.

78. What is gingival approaching clasp? Describe indication,

contraindications, advantages, disadvantages and types of gingival
approaching clasp.

79. Describe briefly stress breakers in RPD.

80. Write a short note on metal denture bases.

81. What is the concept of fulcrum lines? Discuss different types of

movements possible in distal extension RPD and the components and
methods to limit these movements.
Section III: Fixed partial dentures
1. ‘Selection of abutment plays a vital role in the success of crown and
bridge work’. Discuss.

2. Write about cementation in fixed prosthodontics in detail.

3. Write a note on different investment materials in fixed

prosthodontics.

4. Discuss the various forms of retainers and the choices of selection in

fixed partial denture (FPD) prosthodontics.

5. Discuss the tissue management in crown and bridge

prosthodontics.

6. Discuss the intricacies involved in the soldering a 5-unit FPD. Is

soldering essential in FPD?

7. Discuss the principles of tooth preparation.

8. Discuss the precision attachments in crown and bridge

prosthodontics.

9. Discuss the biocompatibility of various dental cements used in fixed

prosthodontics.

10. Describe the laboratory procedure of fabricating a porcelain jacket

crown.

11. Describe the validity of the cantilever principle in FPD design.

12. What is your concept of retention and resistance form, as applied

in fixed partial prosthodontics?

13. Write a note on the role of high-speed rotary instruments and their
application in restorative dentistry.

14. Discuss the rationale of restoration and reuse of endodontically

treated teeth for crown and bridge work.

15. Discuss the impression material and technique applicable to crown

and bridge prosthesis.

16. Classify bridge retainers with examples. Outline the basis of your
classification.

17. Discuss the measures of temporary tooth protection during crown

and bridge therapy. Discuss significance and methods of preparation
of temporary restoration.

18. Write a short note on adhesive bridges.

19. Discuss the various types of casting failures and the measures to
avoid them.

20. Write a short note on porcelain laminates.

21. Discuss the rationale of using shoulder porcelain.

22. Discuss the connectors in FPD.

23. Discuss the indications and contraindications of partial veneer

crown.

24. Write a short note on mesial half crown.

25. Write a short note on pathological occlusion.

26. Write a short note on electroplated dies.

27. Discuss the importance and methods of crown lengthening.

28. Write pros and cons of semi-adjustable articulators in FPD.

29. Write a short note on structural durability.

30. Compare precious and nonprecious alloys in FPD.

31. Write a short note on Ante’s law.

32. Write advantages, disadvantages, indications, contraindications

and the sequential steps in tooth preparation for all-ceramic
restorations and porcelain laminate veneers.

33. A patient is coming to you with missing upper incisor. Discuss the
key factors for reaching correct diagnosis and treatment planning.

34. Write briefly about spring-retained FPD.

35. Write a short note on hybrid bridge.

36. Discuss the various treatment modalities in a patient with severe

attrition, some broken down and missing teeth.

37. Write a short note on the limitations of endodontically treated

teeth.

38. Briefly describe Maryland bridge.

39. Write a short note on resin cements.

40. Elaborate the advances in metal-free ceramics. Write briefly about

its advantages and disadvantages.

41. Write a short note on critical evaluation of resin-bonded bridges.

42. Write a short note on casting techniques for casting of base metal
alloy and titanium.

43. Write a short note on casting defects and their remedies.

44. Discuss fully adjustable articulators and their utilities in FPDs with
multiple abutments.

45. Dentist–technician inter-relationship is the key to success in FPD.

Discuss.

46. How will you manage a case with various levels of furcation
involvement to be treated with FPD?

47. How will you select a shade for a patient requiring FPD?

48. Describe role of occlusion in FPDs.

49. Write a short note on precision attachments in FPD.

50. Write a short note on finishing and polishing materials.

51. Write short notes on computer-aided design and computer-aided

manufacturing (CAD/CAM) assistance in FPD.

52. Write a short note on consideration of occlusion in FPD with

multiple abutments.

53. Write a short note on importance of X-ray in fixed partial denture.

54. Write in detail on examination, diagnosis and treatment planning

for fixed partial dentures.

55. Pontic is the key component in FPD. Explain the statement in

detail. Write briefly about types of pontics.

56. Write a short note on nonrigid connectors.

57. Write a short note on metal–ceramic bond.

58. Metal–ceramic or all-ceramic. Which is better? Describe.

59. Write a short note on pier abutment.

60. Write a short note on canine-guided occlusion.

61. Describe various types of finish lines in FPD.

62. Describe in detail the entire procedure of preparing an anterior

tooth to receive jacket crown prosthesis. What precaution would you
take?

63. Write a short note on three-quarter crown.

64. Write a short note on retraction cords.

65. Discuss in detail about impression techniques in fixed partial

denture prosthodontics.

66. Write importance of temporization in fixed partial denture.

Describe various techniques of fabrication of provisional restoration.

67. Write a short note on individual dies in fixed partial denture.

68. Write a short note on soft liners.

Section IV: Maxillofacial
prosthodontics
1. Write a short note on ear prosthesis.

2. Write a short note on fabrication of eye prosthesis.

3. Classify cleft lip and palate? Write briefly about prosthetic

management of cleft cases?

4. Discuss fabrication of splints in fractured edentulous and dentulous

alveolar ridge.

5. Write a short note on nasal prosthesis.

6. Write a short note on surgical requirements of obturators.

7. Add a note on role of magnets in different types of prosthesis.

8. Enumerate the congenital anomalies of palate and their prosthetic

management.

9. Discuss the problems faced in prosthetic rehabilitation of cleft

palate patient.

10. Discuss the rationale and procedure for rehabilitation of cleft

palate patient.

11. Describe management of a case of hemimandibulectomy—a

challenge to prosthodontist.

12. Write a short note the scope of maxillofacial prosthesis in current

prosthodontics.

13. Write about the psychological evaluation of maxillofacial patient.

14. Write briefly about silastics.

15. Write briefly about hollow obturators.

16. Write briefly about prosthesis for hearing aids.

17. Write the materials used for fabrication of maxillofacial prosthesis.

18. Write briefly about retention of maxillofacial prosthesis.

19. Write briefly about prosthetic management of hemimaxillectomy.

20. Classify and discuss acquired mandibular defects and their

prosthodontics management.

21. Write a short note on retention of extraoral prosthesis.

22. Discuss the prosthetic management and rehabilitation of patient

having undergone complete maxillectomy.

23. Define obturator. Describe the fabrication procedure of obturator

in hemimaxillectomy cases.

24. Describe briefly about material used in obturator fabrication.

25. Write a short note on types of intraoral maxillofacial prosthesis.

26. Classify and give uses of obturator.

Section V: Implant dentistry
1. Discuss the composition and physical properties of currently used
implant materials.

2. Enumerate the classification systems of classifying the implant

systems and various options being employed in implant dentistry.

3. Give the different types of implant materials discovered so far.

Discuss the material of your choice and give reasons in support of
your answer.

4. What are the general bone considerations that aid in predicting

long-term implant success?

5. Write a short note on biomechanics in implants.

6. Discuss implant failure.

7. Write a short note on immediate loading of implants.

8. Discuss the scope and limitations of implant-supported prosthesis.

9. Write about osseointegration.

10. Discuss occlusion for osseointegrated implant-supported

prosthesis.

11. Discuss the success and failures of implant dentures.

12. Discuss the prosthetic phase of implant denture construction.

13. Discuss the radiographic planning for dental implants.

14. Discuss the role of modern implants in removable partial denture

prosthodontics.
15. Write a short note on diagnosis and treatment planning in implant
prosthodontics.

16. Write a short note on principles of occlusion in implant

prosthodontics.

17. Write a short note on implant loading.

18. Write a short note on evidence-based dentistry.

19. Discuss aesthetics in dental implants.

20. Bone density is a key determinant for treatment planning. Discuss.

21. Write a short note on peri-implantitis.

22. Write about endosteal implants.

23. Discuss various biomaterials used in implant dentistry.

24. Discuss the role of implants in fixed prosthodontics.

25. Write a short note on the composition and physical properties of

currently used implant material.

26. Describe role of titanium and its alloys in dental implants.

27. Discuss the oral implants available for the successful management
of a complete denture patient.

28. Write a short note on advantages and disadvantages of implant

overdenture.
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Index
Note: Pages followed by ‘f” for figure, “t” for table, “b” for box.

A
Abfraction, 34
Abrasive, 416
Abrasive paste, 182
Abused tissues,

causes of, 44
treatment of, 44–45
Abutments, 335

with attachments, 214–215

with copings, 213
Abutment teeth, 346

location of, 212

periodontal status of, 212
radiographic evaluation of, 235
Ackerman clip and CM clip, 220
Acrylic denture base, 4
Acrylic resin teeth vs. porcelain teeth, 130, 130t
Adhesive green wax, 182
Aesthetics, 108
Ageing, 27–29

and changes in size of basal seat, 28

characteristics of, 28
definition of, 27
effects of, 28–29
effects on tongue and taste, 29
and nutritional impairment, 29
oral changes, 28
oral mucosa and skin changes, 28
physiopathological conditions of, 28
psychosocial changes, 28
residual bone and maxillomandibular relation
changes, 28
and salivary flow, 29
Akers’ clasp, 255
Alloplast, 475
Altered cast, definition of, 302
Altered cast technique, 301–303
Altered vertical dimension, 111f
effects of, 111
Aluminium crowns, 391–392
Alveolar bone,

preservation of, 211

relationship of natural teeth to, 102
Alveololingual sulcus, 65, 65f
Anatomic tooth, 6f, 164, 165t
Andrew’s bridge, 341, 342f
Anterior teeth replacement, 267–269
Anteroposterior curve, 162–163, 163f
Anteroposterior palatal strap, 245, 245f
Ante’s law, 336–337, 337f
Antihaemorrhagic stent, 432–434
Articulator technique, 309
Andrews bar, 220
Angled abutment, 482
Angular cheilitis, 34
Anterior hyperfunction syndrome, 202
Anterior reference point, 85
Anterior teeth, 199

arrangement of, 136–138, 136f

colour or shade of, 129
composition of material of, 130–133
form of, 128–129, 128f
maxillary, 137–138, 140–141
porcelain teeth vs. acrylic resin teeth, 130, 130t
relationship with incisive papilla, 137
relationship with soft tissue reflection, 137
rest seat preparation on, 294
selection of, 124. See also Anterior teeth selection
Anterior teeth selection,

distance between canine eminences, 127

evolution of, 124–133
factors for, 125
form of teeth, 128–129, 128f
jaw relations, 127
lip support and, 127–128
residual ridge, contour of, 127
shade selection, prerequisites for, 129b
size of maxillary arch in, 126–127
size of teeth in, 125–126
vertical distance between ridges and, 127
Antisialagogues, 376
Appropriate connector design, 329–332
Attachment fixation overdenture, 214–215

advantages of, 214

disadvantages of, 214–215
factors during selection, 215
types of, 214–215b
Arbitrary facebow, 84
Arch curvature, 346
Arcon articulators, 94t
Articulator,

advantages of, 88–89

arcon vs. nonarcon, 94t
classification of, 90–93
definition, 88
evolution of, 89–90
limitations, 89
requirements of, 88b
uses, 88
Attachments, in overdenture, 215–220

bar attachments, 219–220

Ceka attachments, 216, 216f
extracoronal attachment, 215
Gerber attachments, 215–216
intracoronal attachment, 215
introfix attachment, 218
magnets, 218
Rothermann attachment, 217, 218f
Zest anchor attachment, 216–217, 217f
Automix polyvinyl siloxane, 385
Avery Brother’s scissor-bite teeth, 150f

B
Baker clip, 220
Balanced occlusion, 155
Balkwill, F. E., 115
Bar attachments, 219–220

Ackerman clip and CM clip, 220

Andrews bar, 220
Baker clip, 220
bar joints, 219
bar units, 219
Dolder bar, 219, 219f
Hader bar, 219, 219f
Bare tooth overdenture, 213
Basal seat,

ageing and changes in size of, 28

mandibular, 20
maxillary, 20
Bennett movement,

definition of, 96
importance, 96–98
Bergstrom point, 86
Berry biometer ratio method, 125
Berry biometric index, 126
Beyron’s point, 86, 86f
Bilateral balanced occlusion, 394
Bimeter, 109
Bio-Oss, 472
Bite forks, 83
Block out procedure, 305
Block out wax, 305
Boley gauze, 306
Boley’s gauge, 107
Bone,

dense compact, 464

density, 463
quality classification, 463b, 463f
Bone factor,

negative, 235, 236f

positive, 235, 236f
Bone grafts, 474
Bone grafting, in ridge augmentation,

inferior, 39–40, 40f

interpositional, 39–40
onlay, 39
Bone index area, 235
Bonwill theory articulators, 92, 93f
Bony undercuts, 26–27
Border moulding, 70
Buccal flange, 5
Buccal reduction, 369

C
Canine-guided occlusion, 395–396
Canine rest, 265
Cantilevered dental prosthesis, 339, 339f
Cardiovascular diseases, 334
Caries, 212
Casting defects, 409–411
Cast metal denture base, 312
Cast partial framework, 306
Casting methods, 308
Ceka attachments, 216, 216f
Cellulose acetate crowns, 391
Central bearing device, 181–182
Centric relation, 111–112

definition of, 111

ligament theory, 112
meniscus theory, 112
methods of retruding mandible in, 112–113
muscle theory, 112
osteofibre theory, 112
records., See Centric relation records
significance of, 112b
theories of, 111–112
Centric relation records,

concepts of, 113–114

factors affecting, 113
graphic recordings of, 114–117
Chewing cycle, 13
Chlorinated polyethylene (CPE), 428
Circumferential clasp, 255, 256f
Clapp’s tabular dimension table method, 125
Clasp assembly, 254
Cleft palate, 436
Clinical remount procedure, 177

advantages, 177
procedure, 177
Closed horseshoe, 245, 245f
Cobalt–chrome alloy, 307
Closed mouth relining technique, 57, 191–194

F.W. Shaffer’s technique, 191

J.F. Bowman’s technique, 192
L.G. Jordon’s technique, 192
N.J. Hansen’s technique, 191–192
N.S. Javid et al. technique, 193–194
Cobalt–chrome alloy, 307
Combination syndrome, 202

features of, 202b

pathophysiology in, 203
schematic diagram, 202f
Compensating curve, 162–164
Complete denture,

definition of, 2
finishing and polishing of, 174
occlusion, 151–152
parts of, 3–5, 4f
patient education and, 9
patient motivation and, 9
physiological rest position in, 10
relining, rationale for, 190
soft tissue changes, 11–12t, 11–13
temporomandibular joint in, 7–8
Complete denture prosthetics,

definition of, 2
objectives of, 2
Complete denture prosthodontics, 13

definition of, 2
Condylar inclination, 159
Condylar rods, 83
Conical theory articulators, 92, 93f
Connectors, 329
Continuous clasp devices, 239
Copper band, 377
Copper tube impression, 377f
Corrected cast technique, 301–303
Cotton cord, 377
Cross-arch stabilization, 226
Crowns, 294

aluminium, 391–392
cellulose acetate, 391
nickel–chromium anatomic, 392, 392f
Polycarbonate, 391, 391f
prefabricated, 390–392
tin–silver, 391–392
Crown-to-root ratio, 335–336, 336f
Curved dowel pins, 405
Curve of wilson, 164
Cuspal inclination, 161–162
Cusped teeth vs. noncusped teeth, 136t
Custom tray, 68–70
Custom-made dowel core, 351–352
Cyclic jaw movements, 13

D
Deflasking, 173
Denar reference point, 86
Dental cement, 416, 417t
Dental implant, 456, 467, 476–477

advantages, 457–458
anatomical landmarks, 478f
background, 476–477
bone augmentation in, 474
components of, 469476–477
disadvantages, 458
healing process, 473–475
limitations, 458–460
materials, 470–473
radiographic planning of, 471
surgical phase of, 477–479
Dentists’ supply company, 125
Denture aesthetics, 100–101

definition of, 123

factors affecting, 123
Denture base, 3–5, 4f, 266

acrylic, 4
characterization of, 10
metallic, 4–5, 4f
purpose of, 266
Denture borders, 4f, 5

definition of, 5
preparation of, 192f
trimmed flat and adhesive tape, 193f
Denture cleansers, 187
Denture design, 53f
Denture flange, 4f, 5

buccal flange, 5
definition of, 5
labial flange, 5
lingual flange, 5
Denture placement, objectives of, 175
Denture sore mouth, 11–12t
Denture stomatitis, 11–12t
Denture surfaces, 3f
Denture teeth, 4f, 5

classification of, 5b
Depth grinding, 131–132
De-waxing procedure, 200
Diabetes, 334
Diagnosis, 197

definition of, 14
factors for, 15b
Diagnostic cast, 233–235, 334

definition of, 233

importance of, 234b
mandibular, 234f
maxillary, 234f
mounted, 234–235
Diagnostic mounting, 234f

importance of, 235b

objective of, 235
Diagnostic wax-up process, 397
Die systems, 403b
Di-Lok system, 405–406
Dimpling, 294f
Direct retainer, 254
Disjunctor, 316, 316f
Disuse atrophy, 28
Dolder bar, 219, 219f
Dual impression technique, 199
E
Eccentric jaw relation, 120–121

definition of, 120

procedures, 121
records, 120
Edentulous state,

morphological changes associated with, 10–11

Education, patient, 9–13
Embrasure clasp, 258, 258f, 293, 293f
Enameloplasty, for occlusal plane, 291, 291f
Engrams, 34
Envelope of motion, 79, 80f, 81f
Extracoronal retainers, 323
Epinephrine, 378
Epithelial graft vestibuloplasty, 41–42
Epulis fissuratum, 11–12t, 12f, 45
External finish line, 252
Extracoronal attachment, 215
Extracoronal retainers, 225
Extraoral examination, 16–18

facial examination, 16–18

TMJ examination, 18
Extraoral prosthesis, 447–451
F
Fabrication method, 69
Facebow,

definition of, 82
evolution of, 82
method, 84–85
parts of, 82f
significance of, 85b
types of, 83–84, 84t
Face mask, 108
Facial complexion, 17
Facial examination, 16–18

facial complexion, 17
facial form, 16, 17f
facial height, 17
facial profile, 17, 17f
lip examination, 18
TMJ examination, 18
Facial form, 16, 17f
Facial height, 17
Facial profile, 17, 17f
Failures in FPD, 418–419
aesthetic failure, 419
biological factors, 418–419
mechanical failure, 419
Feminine smile, 132f
Ferrule, 353
Fibrous cord-like ridge, 24
Finishing, of complete dentures, 174

procedure, 174
Finish line,

classification of, 363b

types of, 364–367
Fishhook, 259
Fixed bridgework abutments, 480
Fixed dental prosthesis, 324
Fixed partial denture (FPD), 333

contraindications of, 320

indications of, 320
Fixed prosthodontics, 320
Flabby tissues, 52
Flasking, 170–171

definition of, 170

preparation of cast before, 171
procedure, 171
Flat palatal vault, 34
Flexible dentures, 317–318
Fluid control, 375

chemical methods, 375, 376

mechanical methods of, 375, 376
methods of, 375–376
Fluid wax technique, 62, 300–301
Freeway space, 109–110
Frenal attachments, 26
Fulcrum line, 264
Full cast crown, 368–370
Functional impression techniques, 298–301

altered cast technique, 301–303

fluid wax technique, 300–301
McLean–Hindel’s physiological method, 298–299
relining technique, 300
selective pressure technique, 301
Functionally generated pathway, 396

G
Gag reflex, 29–30
aetiology, 29
definition of, 29
pavlovian conditioned reflex, 29–30
Gas inclusion porosity, 410
Gerber attachments, 215–216

advantages of, 215

disadvantages of, 216
resilient, 216
Geriatrics, See Ageing
Gingival bulge area, 168
Gingival retraction, during impression making, 376–380

double cord technique, 381, 381f

electrosurgery, 379–380, 379f
infusion technique, 381
mechanical methods, 377
mechanico-chemical method, 377–378
methods of, 377b
single cord technique, 380, 380f
surgical method of, 378–380, 379f
techniques used for, 380–381
Gingivally approaching clasp, 260
Golden proportion, 126, 127f
Gothic arch tracer, 114
Gothic arch tracing,

definition of, 114

evolution of, 115
factors considered during, 115
importance of, 116
procedure of, 116
Group function occlusion, 395
Guiding planes, 295, 295f

definition of, 295

preparation of, 295
purpose of, 295
types of, 295b
Gypsum products, 403
Gypsum-bonded investment, 411–412

H
Hader bar, 219, 219f
Hairpin clasp, 259
Hard palate, 23, 23f, 58
Hardy’s vitallium occlusal teeth, 151f
High-volume suction, 376
Hinge axis, 87
Hollow bulb obturator, 441
Hooper duplicator, 194, 194f
Horizontal jaw relation, 111–120

centric relation, 111–112

functional methods, 117–118
methods of recording, 114b
physiologic method, 118–119
pressureless method, 120
pressure method, 120
staple pin method, 120
swallowing method, 120
Horseshoe-shaped connectors, 244
Hydroxyapatite, 472
Hyperplastic tissue, 52

I
Ideal abutment, 337
Implant abutment,

classification of, 480b

crest module area, 482
definition of, 479
design, 481
diameter, 481
length, 481–482
types of, 480
Immediate denture,

advantages of, 197

clinical procedures, 199–200
contraindications of, 197
definition of, 196
disadvantages of, 197
fabrication of, 198–200
indications of, 197
postinsertion care of, 201
requirements of, 196–197
types of, 197b
Immediate loading technique, 486

advantages, 486
disadvantages, 486–487
implant failures, 483–486
management, 483–486
types of, 486
Immediate side shift, 96, 97t

definition of, 47–48

objectives of, 47b
Impression making, 297

custom trays, 384

distal extension denture base, factors influencing
support of, 297
distal extension partial dentures, factors influencing
support of, 298–303
dual arch/triple tray/closed bite impression tray
technique, 384–385
gingival retraction during, methods of, 376–380
ideal impression, 381
importance in fixed partial denture, 381–382
impression material, ideal requirements of, 381–382
segmental impression technique, 385
stock tray/putty wash impression technique, 382–383
techniques used in fixed prosthodontics, 382–385
in tooth-supported partial dentures, 297–303
used for distal extension RPD, 298–301
Impression surface, 3
Impression techniques,

classification of, 56
Incisal guidance, 160–161, 160f
Incisal rest, 253–254
Incisive papilla, 106, 106f
Indirect retainers,

factors of, 261–262, 265

types of, 265–266
Interarch space, 22, 22f
Interim obturator, 440, 440f
Internal finish line, 251
Interocclusal rest space, 109–110
Interproximal brush, 221
Intracoronal attachment, 215, 225
Intracoronal retainers, 225, 254, 323–324
Intraoral retention, 452
Intraoral examination, 19–27

bony undercuts, 26–27

fibrous cord-like ridge, 24
floor of mouth, 26
frenal attachments, 26
hard palate, 23, 23f
lateral throat form, 27, 27f
mandibular basal seat, 20
maxillary basal seat, 20
oral mucosa, 19–20
palatal throat form, 27, 27f
residual alveolar ridge, 20–23
saliva, 26
soft palate, 23–24, 24f
tongue, 24–26
Intraoral tracing devices, 115
Introfix attachment, 218
‘Inverted cusp tooth’, 150
Irreversible hydrocolloids, 297

J
Jaw relation,

eccentric, 120–121
horizontal, 111–120
tentative, 119–120
vertical, 105–109

K
Kinematic Facebow, 84

L
Labial flange, 5
Laminate veneer, 347
Leon Williams typal form method, 125
Lingual bars, 246–247, 246f
Lingual flange, 5
Lingual plate, 315
Lingual reduction, 369
Lingual rest, 253
Lingualized occlusion, 152–154
Lip examination, 18
Lip lines, visibility of teeth in, 138f
Lip switch technique, of vestibuloplasty, 42, 42f
Lost salt crystal technique, 355
Lott’s chart, 158f
Lott’s laws of occlusion, 158
Lundeen’s point, 86

M
Magnets, 218, 452
Mandibular defects, 445–447
Mandibular osteoradionecrosis, 423
Mandibular anterior teeth,
arrangement of, 141f
mandibular canine, 141
mandibular central incisor, 141
mandibular lateral incisor, 141
Mandibular canine, 139
Mandibular equilibration, 174
Mandibular major connectors, 246
Mandibular movements, 19, 77–79, 78f, 79f

types of, 77b

Mandibular posterior teeth, 142

arrangement of, 142f

mandibular first molar, 142
mandibular first premolar, 142
mandibular second molar, 142
mandibular second premolar, 142
Mandibular tori, 38, 45
Major connectors, 241

types of, 242–246

Maryland bridge, 355, 355f
Masculine smile, 132f
Masseteric notch, 34
Master cast,
altered, 303f
sectioned, 302f
Maxillary anterior teeth, 140–141

arrangement of, 140f

maxillary central incisor, 140
maxillary lateral incisor, 141
vertical positions of, 137–138
Maxillary complete denture, 204f
Maxillary defects,

Aramany’s classification of, 442–444, 443f

prosthetic management of, 446–447
Maxillary impressions, 57–60

landmarks of, 58f

Maxillary posterior teeth, 141–142

arrangement of, 141f

maxillary first molar, 142
maxillary first premolar, 141
maxillary second molar, 142
maxillary second premolar, 141
Maxillary tori, 45
Maxillofacial prosthesis, 422, 424–425
Maxillofacial prosthesis fabrication,

acrylic resins, 426–427

acrylic copolymers, 427
PVC and copolymers, 427–428
chlorinated polyethylene., 428
Maxillofacial prosthodontics, 422
Maxillomandibular relationship,

occlusal rims, 101–104

overview, 99
physiological rest position, 104–105
record bases, 100–101
vertical jaw relation, 105–109
Maximum hinge opening (MHO), 80
McLean–Hindel’s physiological method, 298–299

disadvantages of, 299

Hindel’s modification, 299
Mean foundation plane, 34
Mental attitude, of patient, 15

classification of, 15b

House classification, 16
Metal base, 267
Metallic denture base, 4–5, 4f

advantages of, 5
definition of, 4
disadvantages of, 5
Meatal obturator, 445
Metamerism, 412
Microporosity, 410
Modiolus, 142–143

anatomy, 143
definition of, 142
importance of, 143
muscles meeting at, 143
MOD onlay, 324, 324f
Monoplane occlusal scheme, 154–155
Motivation, patient, 9–13
Mounted diagnostic casts, 198, 234–235, 234f, 480
Mouth, floor of, 26
Mouth preparation, for complete dentures,

nonsurgical methods, 35, 36t

objectives of, 35b
overview, 35
preprosthetic surgery, 36–42
resilient liners, 42–43, 42f
tissue conditioners, role of, 44–45
Mouth preparation, in removable partial dentures, 289

abused tissues, conditioning of, 290–292

height of contour, modification of, 294
inlay, onlay and crowns, 294
objectives of, 289–292
oral surgical procedures, 290
preprosthetic phase of, 289–292
prosthetic phase of, 292–294
relief of pain/infection, 290
rest seat preparation, 293. See also Rest seat
preparation
retentive undercuts, creation of, 294
Mucocompressive impression technique, 57
Mucostatic Impression technique, 56
Multiple circlet clasp, 258f, 258
Muscle tone, 19
Mylohyoid ridge reduction, 38–39
Myofascial pain dysfunction syndrome, 400
Myotatic reflex, 13
N
Nasal prosthesis, 449–451
Nasal stent, 433–434
Needle–House method, 118, 118f
Nelson’s chopping blocks, 151f
Neurological disorders, 334
Neuromuscular control, 79
Nonrigid connectors, 338
Neuromuscular examination, 18–19

mandibular movements, 19
muscle tone, 19
neuromuscular coordination, 19
speech, 18
Neutral zone, 53
Neutrocentric occlusion, 154–155
Nickel–chromium anatomic crowns, 392, 392f
Nonanatomic teeth, 150, 164–166, 165t
Nonanatomic tooth, 6f
Nonarcon articulators, 94t
Nutrition, of edentulous patients, 32–34

carbohydrates, 33
fat, 33
goals of, 33b
minerals, 33
proteins, 33
role in prosthodontics, 34
vitamins, 33
water, 34

O
Obturators, 438
Occlusal discrepancy, 313
Occlusal disharmony correction, 181–188
Occlusal error, 179t
Occlusal harmony, 393
Occlusal prematurities, 313
Occlusal rest, 253, 265
Occlusal splint, 399
Occlusal therapy, 400–401
Optical pyrometers, 308
Occlusal reduction, 362, 369, 372
Occlusal rims, 54, 101–104, 109

clinical guidelines for, 102–103

definition of, 101
dimensions of, 103, 103f
fabrication techniques, 103–104
factors affecting fabrication of, 102–104
functions of, 102b
made with plaster and pumice mix in Patterson
method, 117f
mandibular, 103, 104f
maxillary, 103, 104f
position of, 102f
preformed, 104
record base with, 101f
relationship to residual alveolar ridge, 102
rolled wax technique, 103–104
tracing devices attached to, 116f
Occlusal wax, 182
Occlusal surface, 3
Occlusion, 149
Open mouth relining technique, 190–191

advantages of, 191

Carl O. Boucher’s reline method, 190–191
disadvantages of, 191
Oral mucosa, 19–20, 423

ageing effects, 28–29

classification of, 20, 20b
Oral mucosa, 423
Orofacial musculature, 52
Osseointegration, 468, 469f
Osteoconduction, 474
Osteogenesis, 474
Osteoinduction, 474
Overdentures, 239

abutments, 480
advantages of, 209–210
attachment fixation, 214–215, 214f
bare tooth, 213
classification of, 209b
contraindications of, 210
definition of, 208
designs, 212b
disadvantages of, 210
indications of, 210
maintenance of, 220–221
occlusal forces in, 211
overview, 208
patient selection for, 212
principles of, 209b
requirements of, 209
retaining teeth for, rationale of, 210–211
telescopic, 213, 213f
Overextended denture base, 313

P
Packing, 172

definition of, 172

procedure, 172
Palatal lift prosthesis, 444–445, 444f
Palatal portion,

large parts of, 191f

preparation of, 192f
Palatal strap, 243f
Palatal tori, 38
Palate,

hard, 23, 23f

sensitivity of, 24
soft, 23–24, 24f
Palateless denture, 30f
Panoramic radiography, 461
Papillary hyperplasia, 11–12t

in palatal vault, 12f

Parallelism, 330
Parallel-sided posts, 350
Partial veneer crown, 370–374, 370t
Partially edentulous arches,

Applegate’s modifications, 228

classification of, 226
commonly used classification for, 228–230
Partially edentulous patient,

medical condition before oral examination, 233

periodontal evaluation of, 236–237
prosthodontic treatment for, objectives of, 233
Partially edentulous patients,

mouth preparation in, preprosthetic phase of, 289–292

Pascal’s law, 56
Patterson method, 117
Pavlovian conditioned reflex, 29–30

acupuncture technique in, 30, 30f

clinical techniques in, 30
management of, 29–30
pharmacological measures, 30
prosthodontic management, 30
psychological intervention, 30
radiographic technique in, 30
Periapical radiography, 461
Pear-shaped pad, 64
Period of edentulism, 136
Phonetics, 108, 143

anteroposterior position of incisors, 145

components of speech, 144
definition of, 143
dental arch, width of, 146
denture thickness, 144
occlusal plane, 145
peripheral outline, 144
postdam area, 145
prosthetic considerations and, 146
role in complete denture, 144–146
vertical dimension, 145
Phosphate-bonded investment, 412
Physiological rest position, 10, 104–105
active mechanism, 104
definition of, 104
factors influencing, 104–105
Niswonger’s method of recording, 105
significance of, 104b
Pier abutment, 337, 338f
Pindex system, 405, 405f
Pinhole porosity., 410
Plane of orientation, 161, 161f
Pleasure curve, 164
Polished surface, 3
Polishing agents, 416
Polishing, of complete dentures, 174

procedure, 174
Polycarbonate crowns, 391, 391f
Polyurethane elastomers, 428
Pontic,

classification of, 325b

definition of, 324, 324f
design of, 324–325
egg-shaped, 326f
fish belly, 327f
perel pontic, 328f
saddle/ridge, 326f
sanitary, 327f
types of, 325f
Porcelain jacket crown (PJC), 367

features of, t0010

Porcelain teeth,

attached to acrylic resin by pins/diatoric holes, 130f

pins embedded in, 130f
vs. acrylic resin teeth, 130, 130t
Post–core systems, 349b
Posterior palatal seal area (PPS), 34, 60, 61f

functions of, 61b

techniques to record, 62b
Posterior reference point, 86–87
Posterior teeth,

arrangement of, 138–140

buccolingual positioning of, 140
buccolingual width of, 134, 134f
colour of, 136
form of, 135
horizontal positioning of, 139
mandibular, 142
material of, 136
maxillary, 141–142
mesiodistal length of mandibular ridge, 134–135, 135f
occlusogingival height of, 135, 135f
replacement, 267–269
selection of, 133–136
size of, 134–135
vertical positioning of, 139–140
Postmylohyoid space, 27, 27f
Postpour technique, 405
Pound’s formula, 126
Pre-extraction records, 31, 31t, 107–108, 124
Prefabricated anatomical metal crown, 391
Prefabricated crowns, 390–392
Prefabricated posts, 349
Preliminary impression,

classification of, 67b

definition of, 67
principles of, 68
Preprosthetic surgery, 36–42

alveoloplasties, 36–37
definition of, 36
excision of redundant soft tissues/papillary
hyperplasia/epulis fissuratum, 37
exostosis removal, 37
frenectomy, 37, 37f
maxillary tuberosity reduction, 37
mylohyoid ridge reduction, 38–39
procedures, 36–42
ridge augmentation, 39
tori removal, 38, 38f
vestibuloplasty, 40–42
Pressure-indicating paste, 312
Preventive prosthodontics, 210–215
Primary copings, 213

advantages of, 213

disadvantages of, 213–214
types of, 213–214, 213f
Processing of denture, 172–173

definition of, 172–173

rapid processing, 173
slow processing, 172
Progressive side shift, 97t
Profile silhouettes, 107
Proprioception,

definition of, 211

preservation of, 211
Prosthetic restoration, 425–431
Proximal reduction, 369
Provisional restoration, 386

aesthetic requirements for, 387

biological requirements for, 386–387
classification of, 388b
custom-made, 389
definition of, 386
as diagnostic tool, 387
direct technique for, 389
indirect–direct technique for, 390
indirect technique for, 389–390
limitations of, 392
matrix for, 389
mechanical requirements for, 387
prefabricated crowns, 390–392
resin-based materials used for fabrication, 387–389,
388b, 388t
techniques used for fabrication of, 389–390

R
Radiographic examination, 32
Rebasing,

articulator method, 195, 195f

definition of, 189, 194
flask method, 194, 194f
indications for, 189–190
jig method, 194, 194f
procedure, 194–195, 311
vs. relining, 195
Record bases, 100–101

definition of, 100

materials used for, 100–101t, 100–101
selection criteria for, 100
stabilization of, 101
Reduction,

buccal, 369
lingual, 369
occlusal, 369
proximal, 369
Refractory cast, 307
Reinforcing struts, 362
Relief areas, divisions, 60
Relining,

closed mouth technique, 191–194

complete dentures, rationale for, 190
contraindications, 189–190
definition of, 189
indications for, 189–190
open mouth technique, 190–191
procedures, 190, 311
techniques of, 190–194
vs. rebasing, 195
Remount procedure, 173–174

definition of, 173

procedure, 173
selective grinding, rules for, 173–174
Removable partial dentures (RPDs), 224, 241, 304, 312, 315

benefits of, 225

classification of, 225
contraindications, 226
indications, 225–226
mouth preparation in. See Mouth preparation, in
removable partial dentures,
Removable prosthodontics, 224

classification of, 224–225

definition of, 224
radiographic examination, 235–237
Residual alveolar ridge, 20–23, 64

arch form, 21, 21f

arch relationship, 21–22, 22f
Atwood’s classification of, 6, 6f
height of, 20, 21f
interarch space, 22, 22f
relationship of occlusal rims to, 102
ridge parallelism, 23
shape of, 21
Residual ridge, 58

contour of, 127

horizontal relation with, 137
Residual ridge defects, 340–341
Residual ridge resorption (RRR), 6–7

aetiology, 7
anatomical factors, 7
definition of, 6
mechanical factors, 7
metabolic factors, 7
pathogenesis of, 6
pathology of, 6
treatment and prevention of, 7
Resilient liners, 42–43, 42f

composition of, 43
drawbacks of, 43
requirements of, 43
role in edentulous patient, 43
types of, 42
Resin, 403
Resin-bonded bridges, 354
Resin-bonded prosthesis, 353
Rests,

functions of, 252

types of, 253–254, 253f
Rest seat, 252
Rest seat preparation, 293

in amalgam restorations, 293

on anterior teeth, 294
for embrasure clasp, 293
incisal, 294
on new gold restorations, 293
on tooth enamel, 293
Retention, 48–51, 451

biological factors, 48–49

mechanical factors, 49
muscular factors, 49
psychological factors, 50
surgical factors, 50–51
Retentive undercuts, creation of, 294
Retraction cord, 377–378
Retromolar fossa, 138
Retromolar pad, 138
Retromolar papilla, 138
Ridge augmentation, 39, 334

definition of, 39
diagnosis, 39–40
factors affecting, 39
inferior bone grafts, 40, 40f
interpositional bone grafts, 39–40
onlay bone grafting, 39
rationale of, 39
techniques for, 39–40
treatment planning, 39–40
vestibuloplasty, 40–42
visor osteotomy, 39
Ridge parallelism, 106
Ring clasp, 258–259
Rochette bridge, 354
Rolled wax technique, 103–104
Rotary curettage, 379
Rothermann attachment, 217, 218f
RRR α-anatomic factors, 7
Rubber base impression, 74–75
Rubber dam, 376, 377

S
Saliva, 26

amount of, 26b

classification of, 26b
consistency of, 26b
role of, 30–31
Saliva ejector, 376
Salivary glands, 424
Sandblasting, 415
Sears anthropometric cephalic index, 126
Segmental impression technique, 385
Selective grinding, 178
Selective pressure technique, 57
Semi-adjustable articulators, 398
Semi-anatomic tooth, 6f
Shanahan swallowing method, 120, 120f
Sharp drills, 478
Shim stock, 174
Silica-bonded investment, 412
Silicone elastomers, 428–430
Silverman’s closest speaking space, 108, 110, 110f
definition of, 110
method to record, 110
Single complete denture, types of, 203–204
Single impression technique, 199
Single-tooth abutment, 480
Slight convex effect, 168
Snow shoe principle, 34
Soft palate, 23–24, 24f

class I type of, 34

Soft palate obturators, 442–444
Soft tissue changes, in denture patients, 11–12t, 11–13
Soldering process, 330
Somatoprosthetics, 13
Spherical occlusion, 155
Speech, 18

classification of sounds, 144

components of, 144
Splint,

definitions of, 431

types, 431–432
Splinting, 237–239

advantages of, 238

contraindication, 238
definition of, 237
disadvantages of, 238–239
fixed, 237
indications, 237
objectives of, 238
removable, 237
requirements of splints, 238
Splints, 399

permanent, classification of, 239b

removable permanent, 239
requirements of, 238
types of, 238b
Split cast method,

benefits, 95
definition of, 94
uses, 95
Split pontic, 331
Spoon denture, 316, 317f
Sprinkle-on method, 69–70
Sprue, 307
Stability,
biological factors, 51–53
definition of, 51–54
mechanical factors, 53–54
physical factors, 54
quality of, 54
Squint test, 131
Static technique, 309
Stippling, 168, 174
Stock tray/putty wash impression technique, 382–383
Straight dowel pins, 405
Stress-breaking device, 338
Supragingival finish lines, 366
Support,
Surgical template,

advantages, 201
definition, 201
disadvantages, 201
fabrication procedure, 201
Svedopter, 376
Swallowing threshold, 109
Swing-lock devices, 239, 249f

T
Tactile sense method, 109
‘T’ clasp, 261–262
Tapered smooth-sided post, 350
Teeth selection,

anterior, 124–133
on basis of facial profile, 129f
posterior, 133–136
Telescopic overdenture, 213, 213f
Temporomandibular joint (TMJ), 7–8

anatomy of, 78, 8f

examination of, 5
physiology of, 78
role in prosthetic rehabilitation, 8–9
Throat form,

lateral, 27, 27f

palatal, 27, 27f
Tilted molar abutment, 338–339
Tin–silver crowns, 391–392
Tissue conditioners, 44–45

abused tissues, 44–45

applied over impression surface of denture, 193f
characteristics of, 44
composition of, 44
uses of, 44
Tongue, 24–26

enlarged, problems with, 25

large, management of, 25
positions, 25, 25f
size of, 25
Tori, 24, 24f

mandibular, 38, 45
maxillary, 45
palatal, 38
removal of, 38, 38f
Two-piece pontic system, 331
Treatment planning, edentulous patients,

definition of, 15
factors for, 15b
Transverse horizontal axis (THA), 87
Truss effect’, 362, 363f

U
Unilateral balanced occlusion, 394–395, 394f
Unwaxed dental floss, 221
U-shaped frame, 82–83
U-shaped major connector, 244

V
Valderrama’s molar tooth basis, 125
Valsalva manoeuvre, 61
Vertical dimension, 105–106

altered, 111
Vertical jaw relation, 105–109

definition of, 105

facial measurements, 107, 107f
former dentures, measurements of, 107
mechanical methods, 106–108
methods of determining, 106b
physiologic methods, 108–109
pre-extraction records, 107–108
ridge relations, 106
vertical dimension, 105–106
Vestibuloplasty, in ridge augmentation, 40–42

contraindications for, 41
epithelial graft, 41–42
indications for, 41
mucosal advancement, 41
secondary epithelialization, 41, 41f
techniques, 41
transitional flap, 42, 42f
Virginia bridge, 355f
Visor osteotomy, 39
V-shaped palate, 51

W
Wax elimination, 171

definition of, 171

procedure, 171
Waxing,

definition of, 167

procedure for maxillary trial denture, 168
Waxing-up,

definition of, 167

methods of, 168b
procedure for mandibular trial denture, 168–169
requirements of, 167–168
Wax spacer, 69
Wax try-in, 169–170

definition of, 169

procedures, 169–170
rationale for, 169b
Wright’s photometric method, 125

X
Xenografts, 475
Xerostomia, 334

Z
Zest anchor attachment, 216–217, 217f
Zinc oxide, 73–74