REMOVABLE & IMPLANT PROSTHETICS (CR II): Partial Dentures

Charlotte Guerrera

Introduction to Removable Partial Dentures & Terminology and Classification of Partially Edentulous Arches
10/18/17

Prosthesis • An artificial replacement of an absent part of the human body

Prosthetics • The art and science of supplying missing parts of the human body
Prosthodontics • The branch of dental art and science pertaining to the restoration and
maintenance of oral function by replacement of missing teeth and
structures with artificial devices
• (1) Fixed
o Crowns
o Bridges
o Implant restorations
• (2) Removable
o A. Partial dentures: a prosthesis which artificially supplies teeth
and associated structures in a partially edentulous jaw, and which
can be removed from the mouth and replaced at will
o B. Complete dentures: dental prosthesis which replaces the entire
dentition and associated structures of the maxilla or mandible
Types of RPDs • (1) Transitional (all acrylic) – these are usually used as a temporary
restoration until the patient gets their final restoration (like implants)
o Transition between complete and partial dentures – extracted
teeth can be added to it as they are lost while the patient is
awaiting treatment
• (2) Cast (includes a framework)
Components of RPD • Major connector
• Minor connector
• Rests
• Direct retainers
• Reciprocal or bracing components (resists lateral forces)
• Indirect retainers
• Bases supporting replacement teeth
Framework and RPD

You never make a unilateral

partial denture

Abutment • A tooth used for the support or anchorage of a

fixed or removable partial denture
 Two main types of RPD • (1) Tooth supported (tooth-borne)
• (2) Tooth and tissue supported (tooth and tissue borne)
Tooth Supported RPD • A removable partial denture which drives its support
from the abutment teeth at each end of the
edentulous arch

Toot and Tissue Supported • A removable partial denture that

RPD drives it support from both the
teeth and the tissues of the
residual alveolar ridge
• Needs to be curve along the
retentive arm to avoid the abutment tooth from shifting
Denture Base • The part of the RPD which supports the artificial teeth and is in contact
with the edentulous ridge
Distal Extension Base • Denture base extending posteriorly in a tooth and tissue supported RPD
Dental Surveyor • An instrument used to determine the relative
parallelism of two or more surfaces of the teeth or
other parts of the cast of a dental arch
• Place the cast on the table and you can tilt it in
different directions – scribe a line on the periphery of
the teeth which delineates the most prominent part of
the tooth
Terminology (synonyms) • Height of contour
• Survey line
• Area of greatest convexity
Classification of Partially • There are over 65,000 combinations of teeth and edentulous spaces in a
Edentulous Arches single arch
• Requirements of an acceptable method of classification:
o (1) Immediate visualization of the type of edentulous arch
o (2) Immediate differentiation between the tooth-supported and
the tooth and tissue supported RPDs
o (3) Should serve as a guide to the type of design to be used
o (4) Should be universally accepted
Kennedy Classification • Class I
• Class II
• Class III
• Class IV
Kennedy Class I • Bilateral edentulous areas located posterior to
the remaining natural teeth

Kennedy Class II • A unilateral edentulous area located posterior

to the remaining natural teeth
 Kennedy Class III • A unilateral edentulous area with natural
teeth remaining both anterior and posterior to
it

Kennedy Class IV • A single but bilateral (crossing the midline)

edentulous area located anterior to the
remaining natural teeth

Applegate Rules for • RULE 1: Classification should follow, rather than precede, any extraction
Kennedy Classification of teeth that might alter the original classification
• RULE 2: If the third molar is missing and 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 an abutment, it is
considered in the classification
• RULE 4: If the second molar is missing and it is not to be replaced, 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 MODIFICATIONS and are designated by their numbers
(the number of extra edentulous spaces)
o If you have a main class I with two modifications, you call it “class
I, modification 2”
• RULE 7: The extent of the modification is not considered, only the number
of additional edentulous areas
• RULE 8: There can be no modification in class IV

Principles of Surveying for Removable Partial Dentures

10/25/17

Dental Surveyor • An instrument used to determine the relative parallelism of two or more
axial surfaces of the teeth and to locate and delineate the contours and
relative positions of abutment teeth
Surveyor’s Tools • Analyzing rod – does
not mark the teeth,
used to measure
position of cast and
path of insertion
• Wax carver – use in
lab to block out
undercuts
• 3 undercut gauges –
determine location of
the end of the clasp as far as the amount of retention is concerned
• Carbon marker – marks the tooth like a pencil, used to mark the neight of
contour
• Protective sleeve – holds the carbon marker
 Surveying • The procedure of locating and delineating the contour and position of
the abutment teeth and associated structures before designing a
removable partial denture
Use of the Surveyor • (1) Surveying the diagnostic cast – mark heights of contour so you know
where to put your clasps
• (2) Contouring wax patterns
• (3) Surveying ceramic crowns
• (4) Placement of intra-coronal retainers – male attachment on partial
denture and female attachment on PFM or metal crown – they engage
one other to provide retention and resistance
• (5) Matching cast restorations
Purposes of Surveying • (1) Determine the most acceptable PATH OF INSERTION
• (2) Identify proximal tooth surfaces that can act as GUIDE PLANES
• (3) Locate and measure areas of the teeth that may be used for
RETENTION
• (4) Determine soft or bony tissue undercuts that would act as
INTERFERENCE
• (5) Determine the most suitable path of insertion to satisfy ESTHETICS
• (6) Aid in determining restorative procedures and TOOTH PREPARATION
• (7) Delineate HEIGHT OF CONTOUR and LOCATE UNDERCUTS to be
blocked out before duplication of master cast
Path of Insertion • The direction in which a restoration moves from
(Placement) the point of initial contact of its rigid parts with
the supporting teeth to its terminal resting
position, with rest seated and the denture base in
contact with the tissues
• Determined by axial contour of adjacent teeth
Guide Planes (Guiding • Axial tooth surfaces made parallel to the path
Planes) of insertion to direct the prosthesis during
placement and removal
• Need to re-contour proximal surfaces of
adjacent teeth to create guiding planes so that there are flat surfaces the
partial denture will contact to allow it to slide into place
Retention • The quality inherent in the removable partial denture that resists the
vertical forces of dislodgement
• Sticky foods should not pull the partial denture out of place
Height of Contour • A line encircling a tooth, designating its greatest circumference at a
selected position determined by a dental surveyor
• Conceptually, the axial height of contour of an abutment resembles two
cones sharing a common base
o The top cone represents the occlusal
convergence contour while the bottom
cone represents the apical
convergence contour
o The line formed at the junction of the
two cones represents the height of contour
Undercut (in reference to • That portion of the tooth that lies
an abutment tooth and between the height of
other oral structures) contour/survey line and the gingiva
• The contour or cross-section of a
residual ridge or dental arch that
would prevent the placement of a denture
Clasps

• Clasp assembly: retentive clasp arm, reciprocal clasp arm, rest which
provides support, minor connector (connects components to framework)
• Retentive clasp arm: should be FLEXIBLE – so it can open up and go into
the undercut
o Should have uniform taper
o End of the clasp goes into the undercut to provide retention
o As the patient bites down, the retentive clasp will open up and go
over the height of contour in order to be fully seated
o Only 1/3 of the clasp should go into the undercut, 2/3 should be
above the survey line
• Reciprocal class arm: should not be flexible
o Uniform thickness
o Placed entirely above the survey line
o NOT in an undercut
Interference • Torus mandibularis – make sure the partial denture framework works
around the undercuts present
Tooth Preparation • May have to restore/reshape teeth to create better placement of the
height of contour before making the partial denture
Factors Determining the • (1) Guide planes
Path of Insertion • (2) Retentive areas
• (3) Interferences
• (4) Esthetics
Tilt • Tilting the cast can help reduce undercuts but can also accentuate existing
undercuts
• The tilt should equally distribute the undercuts on either side
• The end result of selecting a suitable antero-posterior tilt should be to
provide the greatest area of parallel proximal surfaces that may act as
guide planes
• The end result of selecting a suitable lateral tilt should be to provide
reasonable uniformity of retention (angle of cervical convergence)
Tripoding • Recording the relation of the cast to the vertical
arm of the surveyor by placing three widely
divergent dots on the tissue side of the cast on
a fixed plane (need to be able to recreate the
same tilt)
 Impressions for Removable Partial Dentures
11/8/17

Principles and Objectives: • The tissues must be healthy

Impression Making • The impression must include all of the basal seat
• Impressions must be in harmony with the anatomical and physiologic
limitations of peripheral structures
• Proper space for the selected impression material
• Proper positioning of the tray in the mouth
• The tray and impression material should be dimensionally stable
Goals • Support
• Retention
• Stability
• Maintain the health or oral tissues
• Foundation for improved appearance
• Improve phonetics and esthetics for the patient
Materials • (1) ELASTIC
o Reversible hydrocolloids: agar-agar
o Irreversible hydrocolloids: alginate
o Rubber-base
o Polyether
o Silicone
• (2) RIGID
o Plaster of Paris
o Metallic oxide paste
• (3) THERMOPLASTIC
o Modeling plastic
o Impression waxes and natural resins
Preliminary Impressions: • ADVANTAGES
Alginate o Hydrophilic
o Pleasant taste and odor
o Non-toxic
o Non-staining
o Inexpensive
• DISADVANTAGES
o Must be poured immediately
o Low tear strength
o Less surface detail
o Not as dimensionally stable
Stock Trays • Metal or Plastic
• Perforated and Rigid
• Sizes – small, medium, and large
• Sometimes need to put wax in the center of the tray so you don’t get a
void – this way you capture all of the palate accurately
• Have to use the correct water to powder ratio and don’t forget to use
alginate adhesive when taking the impression
 Custom Tray • 2-3mm thick
• Stepped handle in the anterior region
• Border 2mm short of the depth of the sulcus – so that you can properly do
border bolding
• Cover the hamular notches and retromolar pads for distal extension of
partial dentures
o When you are putting denture teeth distal to the most distal tooth
in the mouth, you need to make sure you have the right support
• VLC Resin – Triad
Wax Spacer • Need two layers on the teeth and one layer on the edentulous areas
Custom Tray Fabrication • 1st layer of baseplate wax over
teeth
• 2nd layer of baseplate wax over
teeth and edentulous areas
• Cut occlusal stops into wax to
maintain space for impression
material
o These will create space and
also maintain the orientation
of the tray in the mouth
• Adapt Triad to cover wax
• Do not overly thin the Triad material over the teeth or the posterior
border area
• Attach a handle by molding excess VLC material into the desired shape
• A paper clip or similar wire may be
shaped and used to reinforce the handle
• Trim Triad 2-3mm short of the depth of
the vestibule
• Cure in Triad machine
• Trim to create smooth rolled borders of
custom tray
• Border molding is primarily limited to the
EDENTULOUS AREAS – do not need to border mold where there are teeth
• You might even want to block out undercuts around the teeth with wax
• There should be ease of removal with these trays – should not be so
tightly locked into place because you need to keep enough space for the
impression material
Making Final Impression • TOOTH SUPPORTED
o An impression records the anatomic form of the teeth and their
surrounding structures and is needed to make a tooth-supported
removable partial denture
o Need a functional impression of the teeth, and the tissue too
• TOOTH-TISSUE SUPPORTED
o To accurately record the moving tissues of the floor of the mouth,
an individual impression tray should be used, rather than an ill-
fitting or overextended stock tray
o Need to record tissues in the functional form
 Support for Distal • Contour and quality of the residual ridge
Extension Denture Base • Extent of residual ridge coverage by the denture base
• Type and accuracy of the impression registration (whether you are doing
a functional or anatomical registration)
• Accuracy of the fit of the denture base
• Design of the partial denture framework
• Total occlusal load applied – need to make impressions according to
which areas will be taking functional loads and which will not
• Usually there is a lot of stress placed on the distal extension and the
abutment teeth – want to make sure there is equal distribution of load
between these areas
Contour and Quality of • Ideally want cortical bone that covers relatively dense cancellous bone
Residual Ridge • Broad, rounded crest with high vertical slopes
• Firm, dense with fibrous connective tissue
Important slide! • Such a residual ridge would optimally support vertical and horizontal
stresses placed on it by denture bases
Extent of Residual Ridge • The broader the residual ridge coverage, the greater is the distribution of
Coverage the load, which results in less load per unit area
Type and Accuracy of • ANATOMIC FORM: the surface contour of the ridge when it is
Impression Registration not supporting an occlusal load

• FUNCTIONAL FORM: the surface contour of the ridge when it

is supporting a functional load
Support for Distal • THE ANATOMIC FORM:
Extension Denture Base o One stage impression
o Records hard and soft tissue at rest
o More masticatory load on soft tissue
• THE FUNCTIONAL FORM:
o Maximum support for RPDs
o Records and relates the supporting soft tissue under some loading
o Distributes the load over as large an area as possible
Selective Pressure • Based on histologic nature of tissues that covers residual alveolar bone
Impression Technique • Nature of the residual ridge bone
• Positional relationship to the direction of stresses that will be placed on
the ridge
• Specially designed individual trays are used for these impressions:
denture bases can be developed that will use those portions of the
residual ridge that can withstand additional stress and at the same time
relieve the tissues of the residual ridge that cannot withstand functional
loading and remain healthy
Design of Partial Denture • The greatest movement takes place at the
Framework most posterior extent of the denture base
• The retromolar pad region of the mandibular
residual ridge and the tuberosity region of the maxillary residual ridge
therefore are subjected to the greatest movement of the denture base
 Total Occlusal Load • The number of artificial teeth, the width of their occlusal surfaces, and
Applied their occlusal efficiency influence the total occlusal load applied to the
removable partial denture
• Kaires conducted an investigation under laboratory conditions and
concluded that “the reduction of the size of the occlusal table reduces the
vertical and horizontal forces that act on the removable partial dentures
and lessens the stress on the abutment teeth and supporting tissues
Border Molding • Greenstick modeling compound
• Added to tray in sections
• Must be adequately softened
• Must be tempered in a water bath 135oF
• Chilled after removal from mouth
• Rounded contours
Maxillary Border Molding • Anterior labial region
o Lip: elevated & extended outward, downward, and inward
• Buccal frenum region
o Cheeck: elevated, pulled downward and inward, moved backward
and forward
• Posterior buccal region
o Cheeck: outward, downward, and inward
o Patient opens wide and moves mandible from side to side
Mandibular Border • Anterior labial region
Molding o Lip: liften outward, upward, and inward
• Buccal frenum region
Need to border mold the o Cheeck: elevated, upward and inward, moved backward and
entire lingual of the forward
mandibular RDP, regardless • Posterior buccal region
of presence of teeth o Cheeck: outward, upward and inward
because the tongue is in o Patient exerts a closing force while downward pressure is exerted
that area by dentist to activate masseter muscle
• Anterior lingual region
o Tongue protruded: determines length of lingual flange
o Tongue pushed against front part of palate: determines thickness
• Mid-lingual region
o Tongue protruded: determined length and slope of lingual flange
o Tongue touches cheek on both sides
• Posterior lingual region
o Tongue protruded: activates the superior constrictor muscle
• Retromolar pad
o Patient opens wide: determines length of posteromedial border
Elastic Impression • Advantages:
Materials: Silicone o Hydrophobic
o Most accurate of elastic
o Less shrinkage
o Low distortion
o Fast recovery from deformation
o Moderately high tear strength
o Can be poured up to 1 week
 • Disadvantages:
o Expensive
Rigid Impression Materials • Rigid impression materials are capable of recording tooth and tissue
details accurately, but cannot be removed from the mouth without
fracture and reassembly
Thermoplastic Impression • Softens at higher temperatures and resume their original form when
Materials cooled
• Cannot record minute details accurately because they undergo
permanent distortion during withdrawal from tooth and tissue undercuts
Impression Waxes • Iowa Wax and Korecta Waxes
o Have the ability to flow as long as they are in the mouth and
thereby permit equalization of pressure and prevent over
displacement
• Jelenko Adaptol Impression Material
o For impression techniques that attempt to record the tissues
under occlusal load techniques
Reasons for Remaking • Incorrect positioning of the tray
Impressions • Large voids or discrepancies
• Incorrect consistency of impression material
• Movement of the tray before final set
• Incorrect border molding procedures
• Using too much or too little impression material
Boxing Impressions • Preserves functional width of sulcus
• Preserves functional depth of sulcus
• Boxing wax strip attaches 2-3mm below border
• Vertical wall extends 10-15mm above impression
• Seal wax with hot spatula
McLean/Hindels Technique • McLean was the original one who talked
about the functional form of impression
making
• In this example you have bilateral distal
extensions
• Made a custom tray (individualized) by
making an anatomic alginate impression,
then make your custom tray that is more like a denture base, then make a
final impression
• Just recorded the posterior areas under functional load – had the patient
bite down when taking the impression
• Teeth related to this by makin and alginate ON TOP OF the posterior
imprression
• Can use tray with cutouts to put occlusal load during the impression by
using your fingers
• Do it separately this way so you don’t stress the teeth or the tissue too
much – make sure they receive equal loads this way
Corrected Cast Procedure • Already have a final master cast, and you have a custom tray
• Have the metal framework from the lab, and take an impression with this
in place – make sure forces are transmitted equally so there is no torque
 • Pour the impression and section the cast so you can capture individual
parts under functional load
• Then place the framework back on, with the edentulous portions cut off,
and take an impression that only records the functional impression of the
areas that are edentulous – this allows you to distribute load on the
tissues so it’s putting too heavy a load on the teeth
• Most clinicians don’t do this because it is not very practical

Rest Seats for Anterior and Posterior Abutment Teeth

12/6/17

Rest • Definition: A rigid extension of a removable partial denture that contacts

the occlusal, incisal, cingulum, or lingual surface of a tooth or restoration,
the surface of which is commonly prepared to receive it
Role • Rest: The unit of a partial denture that rests on a tooth surface to provide
vertical support
• Rest Seat: The prepared surface of an abutment to receive the rest
Goal • Maintain RPD components in their planned position
• Direct occlusal forces along long axis of
abutment tooth
• Direct and distribute occlusal loads to abutment
teeth
• Maintain established occlusal relationships by
preventing settling of the denture
• Prevent impingement of soft tissue
• Requires tooth modifications – Restore
topography of tooth before modifications
Restore Topography • Casting + Rest = Normal Contour

Placement • Rests are usually placed on abutment teeth

next to every edentulous space except with
the RPI clasp assembly
• Sound enamel – people might have worn
down teeth to the point where the dentin is exposed – this makes them
more prone to caries down the road which can lead to failure of the
abutment teeth and RPD
• Metal restoration
• Metal ceramic restoration
• Restorative material resistant to fracture and distortion
Exposed Dentin • Place amalgam then complete rest seat preparation
• Place material or metal ceramic restoration into which rest seat has been
incorporated
Contraindications • Dentin
• Composite
• Porcelain
 Armamentarium • Handpiece
• Round carbide burs
• Round and tapered diamond stones
• Round end cylindric diamond stones
• Inverted cone diamond stone
• Abrasive rubber polishing disks and
points
• Pointed brush and polishing cup
• Flour of pumice
Types • Occlusal rests: Seated on the occlusal surfaces of posterior teeth
• Lingual or Cingulum rests: Seated on the lingual surfaces of anterior
teeth, usually maxillary canines
• Incisal rests: Seated on the incisal edges of anterior teeth
Occlusal Rests • The outline form should be a
“rounded” triangular shape with the
apex towards the center of the
occlusal surface
Dimensions and Shape of • The floor of the occlusal rest should
Occlusal Rest be concave or spoon shaped (no
sharp edges or line-angles)
• The marginal ridge should be reduced
to permit a sufficient bulk of metal (1.5mm) for strength and rigidity
Occlusal Rests • The angle formed by the
occlusal rest and the vertical
minor connector should be
<90 degrees
Geometry • Rounded triangular shape
with the apex toward the
center of the occlusal
surface
• Shallow – 2.5 mm for both
molars and premolars
• Reduction of the marginal ridge of approximately 1.5 mm
• Base is saucer-shaped and should function as ball-and-socket joint – this
geometry permits dissipation of potentially harmful lateral forces
• The floor of the occlusal rest seat should be apical to the marginal ridge
and the occlusal surface and should be concave, or spoon-shaped
(deepest towards the center of the tooth)
• The angle formed by the occlusal rest and the vertical minor connector
from which it originates should be < 90 degrees
Orthodontic Tooth • Inclined plane, angle >90 degrees
Movement • It will slip out of the confines of the rest
seat restoration if the angle is greater
than 90 degrees

Tooth Modification Guide • Guide plane – do this first

• Rest seat preparation – then do this after guide planes are prepared
 Diagnostic Cast • A. Outline periphery of rest seat
o Molars:
§ #8 round bur to reduce marginal ridge 1.5mm
§ #6 round bur to develop spoon shape
o Premolars:
§ #6 round bur to reduce marginal ridge 1.5mm
§ #4 round bur to develop spoon shape
• B. Reduce marginal ridge 1.5mm
• C. Smooth all line angles and polish
Molar Rest Seat • Buccolingually: ½ width between lingual and buccal cusp tips
• Mesiodistally: ¼ of the occlusal surface
Premolar Rest Seat • Buccolingually: ½ width between lingual and buccal cusp tips
• Mesiodistally: 1/3 of the occlusal surface
Embrasure/Interproximal • Be careful of occlusion and to
Occlusal Rest Seats make sure food won’t get stuck
• Have to make sure they are big
enough that you don’t
compromise the amount of metal
you are using but also that the
metal does not interfere with
occlusion
Guage • Use to measure the thickness of the rest
seat
• 2mm in the center of the tooth and
1.5mm at the marginal ridge

Rest Seats in Restorations • Full cast crowns

• Metal-ceramic crowns
• Onlays
• Inlays
• 3⁄4 crowns
• Resin-bonded restorations
Rest Seats in Restorations • Advantages:
o Complete control of design
o Accommodates teeth with caries, faulty restorations or
unacceptable morphology
o Longevity
Considerations • Root form
• Root length
• Inclination of the tooth
• Ratio of clinical crown to the alveolar support
Dimensions of Lingual or • Mesiodistal length of the preparation should be a minimum of 2.5-3 mm
Cingulum Rests • Labio-lingual width about 2 mm
• Incisal-apical depth a minimum of 1.5 mm
 Preparation Design for • Slightly rounded ‘V’ is prepared on the lingual surface
Cingulum Rests • Location: Junction of gingival 1/3rd & middle 1/3rd of tooth
• The apex of the V is directed incisally
• Bur used: Inverted cone
Indications for Incisal Rest • Teeth show little or no enamel wear
• Esthetics is not important
• Occlusion allows adequate thickness for minor connector
Dimensions and Design for • Rounded notch
Incisal Rests • Incisal angle of a canine or incisal edge of an incisor
• Deepest portion of the preparation apical to the incisal
edge
• The notch beveled both labial & lingual
• Width 2.5mm
• Depth 1.5mm
Lingual Rest vs. Incisal Rest • Preferred over incisal rest:
o Closer to center of rotation
o Esthetics
• Lingual rests are more stable than incisal rests

Primary vs. Auxiliary or • Primary rest: Part of a retentive

Secondary Rest clasp assembly
• Auxiliary rest or secondary rest:
responsible for additional
support or indirect retention
• As you move the rest more anteriorly, you will get more retention
Establish Occlusal • Before you put any framework in the patient’s mouth, you have to check
Relationship how the teeth will come into contact
• You are not recreating the plane of occlusion – you are conforming to
what the patient has already
• If you do not properly prepare the rest seats, you can end up causing an
open bite in your patient
• To prevent this and to be able to replicate what the patient had originally,
you have to be able to survey and design these rests correctly
• Need a minimum thickness of metal so it does not fracture – if you end up
having to adjust after the fact, you can compromise the thickness of the
metal
• If you maintain the relationship they had before, you have a better chance
that the patient will accept the RPD
• Patients usually do not like RPDs becauase of all the clasps and metal in
their mouth
Conclusions • Primary purpose: Vertical support for the RPD
• Maintains established occlusal relationships by preventing settling of the
denture
• Prevents impingement of soft tissues
• Directs and distributes occlusal loads to abutment teeth – axial loading is
very important
 Components of the Removable Partial Dentures – Palatal Major Connectors
12/13/17

Major Connectors • The component of the RPD that connects the parts of the prosthesis
located on one side of the arch with those on the opposite side
Characteristics of Major • (1) It should be made of alloy compatible with oral tissues
Connectors • (2) It should be rigid and use the principles of broad distribution of stress
• (3) It should not interfere with and is not irritating to the tongue
• (4) It should not substantially alter the natural contour of the lingual
surface of the mandibular alveolar ridge or the palatal vault
• (5) It should not impinge on oral tissues when the prosthesis is inserted
or removed or rotates in function
• (6) It should cover no more tissues than is absolutely necessary
• (7) It should not contribute to the retention or trapping of food particles
• (8 It should have support from other elements of the framework
• (9) It should contribute to the support of the prosthesis (maxillary)
Requirements of the Major • (1) RIGIDITY
Connectors • (2) LOCATION
o a. Free of movable tissues
o b. Avoid impingement of gingival tissues (5-6mm clearance for
maxillary, 3-4mm for mandibular)
o c. Avoid bony and soft tissue prominences during placement and
removal
o d. Provision of relief (tori, median palatal suture)
Maxillary Major • (1) PALATAL BAR
Connectors o Bulk
o Location
Borders of a maxillary • (2) PALATAL STRAP
major connector should o Rigid
always cross the palatal o Not bulky
midline at 90 degrees o Minimum 8mm width (antero-posterior dimension)
• (3) U-SHAPED PALATAL CONNECTOR
o Least desirable
o Lack of rigidity
o Mostly used when an inoperable torus exists
o U-shaped major connectors have a tendency to flex or deform
when a load is placed – therefore it is a poor choice for most
maxillary applications
• (4) ANTERIOR-POSTERIOR (A-P) CONNECTOR
o One of the most rigid connectors
o Could be used in almost any designs
o Both the anterior and posterior straps of an antero-posterior
palatal strap major connector should be at least 8mm in width
• (5) PALATAL PLATE
o Covers half or more of the palate
o It is a thin and broad plate
o Increase retention (adhesion, cohesion)
o Full metal or combination of metal and acrylic resin
 Location of the major • Either support the connector by definite rests on the teeth contacted,
connector in relation to the bridging the gingivae with adequate relief, or locate the connector far
teeth and gingival tissues enough away from the gingivae to avoid any possible restriction of blood
supply and entrapment of food debris
Location of the anterior • Follow the outline and contour of the rugae
border of the major • Termination in the valley between the folds
connector
Major connector crossing • The borders of a maxillary major connector should always cross the
the midline palatal midline at 90 degrees
Beading the Master Cast • The process of scribing a shallow groove (0.5mm) on the maxillary master
cast, outlining the palatal major connector
Purpose of Beading the • (1) To transfer the major connector design to the refractory cast
Maxillary Cast • (2) To provide a visible finishing line for casting
• (3) To insure intimate tissue contact of the major connector with the
selected palatal tissues (peripheral seal)
Blatterfein systematic • (1) Outline the stress bearing areas
approach to major • (2) Outline the non-bearing areas
connector design o Free gingival margin
o Mid palatal suture/torus
o Tissues located posterior to the vibrating line
• (3) Outline the connector areas
• (4) Select the type of connector
o Palatal bar, palatal strap, U-shaped palatal connector, A-P
connector, palatal plate
o Mouth comfort
o Rigidity
o Location of the denture bases
o Indirect retention
• (5) Unification

Mandibular Major Connectors

1/3/18

Major Connectors • The component of the RPD that connects the parts of the prosthesis
located on one side of the arch with those on the opposite side
Requirements of the Major • (1) RIGIDITY
Connectors • (2) LOCATION
o a. Free of movable tissues
o b. Avoid impingement of gingival tissues (5-6mm clearance for
maxillary, 3-4mm for mandibular)
o c. Avoid bony and soft tissue prominences during placement and
removal (do not place in an undercut)
o d. Provision of relief (tori, median palatal suture)
Mandibular Major • (1) LINGUAL BAR
Connectors o Half pear shaped in cross section (broadest
portion of the bar is located near the floor of the
mouth)
o Flat on the tissue side
 o Superior border 3-4 mm away from the free gingival margins
o 4mm in width (can’t use a lingual bar if you don’t have 7-8mm
space before you start to impinge on tissues)
o Greatest bulk in the lower third
o Tapered superiorly
o No tissue contact
o Made of 6 gauge wax (reinforced with 24 gauge wax)
Lingual plate and • (2) LINGUAL PLATE (linguoplate)
continuous lingual bar o Inferior border same as lingual bar
should be supported by o Superior border on the middle third of the lingual surface of the
terminal rests. Connector teeth (support major connector with a rest at the end, for example
borders resting on on a cingulum)
unprepared tooth surfaces o Terminal rests at each end
can lead only to slippage of o Indication of linguoplate:
the prosthesis along § a. High frenum attachment (less than 8mm space)
inclines, to orthodontic § b. Stabilization of periodontally weak teeth
movements of the teeth, or § c. Contingency planning (future replacement of the teeth –
both. teeth can be added to the plate)
§ d. Excessive vertical ridge resorption in class I
• (3) LINGUAL BAR WITH CONTINUOUS BAR RETAINER
o a. When a linguoplate is otherwise indicated but excessive
interproximal block-out is required
o b. When diastema exists between the teeth
• (4) LABIAL BAR
o a. Extreme lingual inclination of the teeth
o b. Inoperable mandibular tori
Determination of the • (1) Use of periodontal probe
Height of the Floor of the • (2) Border molding the individualized impression tray
Mouth
Lateral Forces • Lateral forces resisted by the slopes of the ridge
• Forces transmitted through major connector to the other side of the RPD
• Connecting teeth through a lingual plate distributes lateral forces along all
the teeth covered by the lingual plate (vs. just the rest teeth on the
opposite side in a lingual bar)
Systematic Approach to • (1) Outline the basal seat areas
Mandibular Major • (2) Outline the inferior border of the connector
Connector Design • (3) Outline the superior border of the connector (3mm rule)
• (4) Unification
Minor Connector • Part of the partial
denture that connects
different components
to the major connector
• Junctions of major and
minor connectors should be gently curved
• Meshwork covers 2/3 of the distal extention of the mandibular ridge
antero-posteriorly
 Tissue Stop • Part of the retention meshwork that contacts the ridge
and prevents distortion of the framework during
processing of the acrylic resin

Finishing Line • Junction between the metal framework and the

acrylic denture base
• It should be a butt joint

Direct Retainers
1/10/18, 1/24/18, 1/31/18

Direct Retainer • Any unit of a removable partial denture that engages an abutment tooth
in such a manner as to RESIST DISPLACEMENT of the prosthesis away
from the basal seat tissues
o (1) Intracoronal
o (2) Extracoronal
Advantages of Intracoronal • Esthetics
Attachments • Favorable force distribution
Disadvantages of • Preparations and castings
Intracoronal Attachments • Complicated clinical and laboratory procedures
• Wear and loss of retention
• Difficult to repair and replace
• Least effective on short teeth
• Difficult to place completely within tooth circumference
Limitation of the Use of • Size of the pulp
Intracoronal Attachments • Length of the clinical crown
• Cost
• Distal extension cases
o Distal hinge can be used as a stress breaker
Extracoronal or Clasp • Types of Clasp Arm
Direct Retainers o Circumferential clasp
(suprabulge)
o Bar clasp (infrabulge)

Amount of Class Retention • Depends on size of the angle of cervical convergence

o If you look at a cross section of the tooth and draw a line parallel
to the height of contour, and a line perpendicular to that at the
height of contour, you divide the tooth into superior and inferior
sections, the angle of convergence is between the vertical line and
the contour of the tooth
• Depends on how far into the angle of cervical convergence the clasp
terminal is placed
• And depends on flexibility
 Factors Influencing the • (1) Length
Flexibility of the Clasp Arm o Flexibility is directly proportional to the length
o If you have a longer clasp you should use a larger undercut gauge
• (2) Diameter
o The flexibility of the clasp is inversely proportional to its diameter
• (3) Cross sectional form
o Round cross section (wrought wire)
provides universal flexibility – like an
orthodontic wire
o Half circle can only flex in one direction
o Should be uniform taper of retentive clasp arm
• (4) Material used
o Chromium – cobalt
o Type IV Gold (more flexible)
o Microstructure of cast metal is less flexible than wrought metal
alloys (forced through a hole)
• (5) Method of fabrication
Clasp Assembly • Retentive clasp arm – the end of this clasp is
retentive
• Reciprocal clasp arm
• Rest
• Minor connector
Basic Principle of Clasp • More than 180 degrees tooth coverage
Design • Provision of an occlusal rest
o Free from movable tissues
o Any tooth adjacent to an edentulous space should have a rest to
provide support
• Reciprocation
o Rigid component reduces lateral movement
o As it crosses the height of contour, the reciprocal arm pushes the
tooth towards the rigid arm, which resists the force and prevents
the tooth from moving
• Guide planes
• Stress breaking action (distal extension)
o Tooth supported or tooth and tissue supported
o Occlusal load is resisted by the occlusal rests on the teeth
o If you have a distal extension space, the denture base is
compressed since there is no posterior abutment tooth – the
farther back you go, you get more and more support from the soft
tissue, and the closer you bite towards the abutment tooth, that
tooth receives more of the force
o Tip of the clasp in the undercut gets pushed up and back which
causes and extraction force in a case with a distal extension – so to
prevent this you would use a more flexible clasp or another RPI
system
• Location of retentive and reciprocal components
o Near zone: middle third
o Far zone: junction of the middle and gingival third
 Two Main Types of RPD • (1) Tooth supported (tooth-borne)
• (2) Tooth and tissue supported (tooth and tissue borne)
Ideal location of the survey • The ideal location of the survey line is in the middle of the middle third of
line the tooth in the near zone and slightly lower in the far zone
• Near Zone: in the middle of the middle third of the tooth
• Far Zone: slightly lower
Location of retentive and • Retentive clasp arm: middle third with the terminal end in the gingival
reciprocal components third (make sure it is not too short and that it is curving upward)
• Reciprocal clasp arm: middle third entirely above the survey line
Circumferential Clasps • (1) Basic circumferential
• (2) Embrasure clasp
• (3) Ring clasp
• (4) Back action clasp
• (5) Reverse action clasp
• (6) Half and half clasp
• (7) Multiple clasp
Basic Circumferential Clasp • Simple circlet (Stewart)
(AKERS)

Retentive Clasp vs.

Reciprocal Clasp Arms

Retentive Reciprocal
Cross Arch Stabilization

Embrasure Clasps • If you do not have an edentulous

space along the back to create a
circumferential clasp but you
need support from posterior
teeth
• Basically two basic
circumferential clasps between two teeth placed back to back against
each other that goes through the occlusal embrasure between the teeth
• Rests are prepared the normal way, but you have to create an opening for
the body of the clasp, without interfering with the occlusal table and
compromising occlusion of the opposing teeth
Ring Clasp • If the distobuccal aspect doesn’t have an undercut and
you only have an undercut on the mesial aspect of the
tooth
• This consists of a mesial rest minor connector, and a
buccal arm
 • Usually used on teeth with a mesial inclination
• Covers a lot of the tooth structure and food can get trapped
• Retentive arm comes from the distal
Back Action Clasp • Don’t usually use these
• Reciprocal arm and occlusal rest on the distal
• No distal guide plate and no support for the occlusal
rest
• Occlusal rest doesn’t have a minor connector
Reverse Action Clasp • C-clasp (Stewart)
(Hairpin) • Used when you have an undercut in the near zone
– no undercut in the back to place a retentive arm
• Originates from a minor connector
• Clasp arm on the buccal goes above the survey line
and then wraps around to the undercut
• Food can get stuck in this and it covers a lot of the tooth
Half and Half Clasp • Not a conventionally used clasp

Multiple Clasp • Two basic circumferential clasps connected on the

lingual, placed in the embrasures of the teeth
• Arms facing towards each other
Combination Clasps • ADVANTAGES:
o Flexibility
Usually in distal extension o Adjustability
cases o Esthetic advantage
o Minimum tooth coverage
• DISADVANTAGES:
o Extra lab work
o Easily distorted
• When there is a distal extension you use a wrought wire clasp for more
support
Bar Clasp (infrabulge) • A clasp that originates from the framework and approaches the undercut
from a gingival direction
• Basic bar clasp design
o Rest
o Retentive clasp arm
o Reciprocal clasp arm
o Minor connector
• Bar Clasps
o I-bar
o T-bar
o Y-bar
o Modified T-bar
• Contraindication of the bar clasp
o High frenum attachment
o Deep tissue undercut (it will create a food trap)
 RPI Design • Rest (mesial) – connect to the major
connector via a minor connector
• Plate (distal)
o Distal plate contacts 1mm of the
gingival portion of the guide
plane
o Distal plate is extended slightly
to the lingual surface – there is
no reciprocal arm here, so since we don’t have a reciprocal arm in
this design we extend the distal plate slightly towards the lingual
to brace the lingual aspect of the tooth and resist the pressure
from the I-bar
o Minor connector in contact with the tooth
• I-bar
o Placed in the middle of the buccal surface
o Engages the undercut below the survey line
• Advantages of RPI design
o Less torque to the abutment tooth
o Elimination of the reciprocal arm
o Esthetic
o Minimal tooth contact
Lever Direction • Moving the clasp
from the mesial to
the distal changes
the direction of
rotation
• Occlusal load puts
pressure down
and upward on
the abutment
tooth – change
the flexibility of
the clasp to reduce the torque
• Tendency for partial dentures to be lifted off the tissue when a patient
eats sticky food
• Can reduce movement of distal extension by placing another rigid
component (another rest) anterior to the fulcrum line – this is called an
indirect retainer
Indirect Retainer • The component of the removable partial denture which prevents the
movement of the denture base away from the tissues
Fulcrum Line • An imaginary line passing through the most
distally located rests
• Partial denture rotates around this line
• Best location for an indirect retainer in theory
for a straight fulcrum line (like in the image on
the upper right) would be on the incisors, but
since this would put pressure on these teeth, it is preferable to put it on
the canines or premolars instead
Factors influencing the • (1) Effectiveness of the direct retainers
effectiveness of the • (2) Distance from the fulcrum line
indirect retainers o a. Length of the distal extension (indirect retainer becomes less
effective the longer the distal extension is)
o b. Location of the fulcrum line
o c. How far from the fulcrum line the indirect retainer is placed
• (3) Rigidity of the minor connector connecting the rest
• (4) Effectiveness of tooth support (definite rest seat, weak teeth)
Ideal Location of the • MECHANICALLY: the longest perpendicular to
Indirect Retainer the fulcrum line
• BIOLOGICALLY: not on central and lateral
incisors (canines and premolars are stronger)

Sequence of Designing • (1) Select the tilt of the cast (path of insertion) and mark the survey line
• (2) Locate the rests (support, indirect retention)
• (3) Select the clasps
• (4) Select the major connector
• (5) Unify
Selection of the Clasp • (I) Clasps engaging undercut areas adjacent to the edentulous area
o (1) Ring clasp
o (2) Reverse action (hairpin) clasp
o (3) Embrasure clasp
o (4) Bar clasp
• (II) Clasps engaging undercut away from the edentulous area
o (1) Basic circumferential clasp
o (2) Combination clasp
o (3) Half and half clasp
o (4) Back action clasp
o (5) Bar clasp
• (III) Clasps on non-modification (dentulous) side
o (1) Embrasure clasp
o (2) Multiple clasp
Blatterfein Systematic • (1) Outline the bearing areas
Approach to Major • (2) Outline the non-bearing areas
Connector Design o Free gingival margin
o Mid-palatal suture – torus
o Tissues located posterior to the vibrating line
• (3) Outline the connector areas
• (4) Select type of connector
• (5) Unification
 Laboratory Steps in RPD Fabrication
1/31/18

Laboratory Procedures • Work authorization

o Same thing we used in lab
o One the computer that we use in clinic
o Draw the design and write which teeth numbers have which kinds
of clasps
• Properly surveyed diagnostic case
• Properly articulated master case (reproducing hard and soft tissues)
Design Transfer • Retripoding the master cast
• Heights of contour (teeth and soft tissues)
• Design transfer
Cast Preparation • Beading
• Blockout and relief in preparation for duplication
Beading • 0.5mm deep
• Produces a raised edge at the border of the major connector
• Ensures positive contact with the palatal tissues to minimize food
impaction
• Maxilla only
Blockout and Relief • Surveyed for hard and soft tissue undercuts
• Surface sealer to protect design during blackout and duplication
o Acetone, diethyl phthalate, and cellulose acetate
• Undercuts eliminated with blockout wax (hard baseplate wax, gutta
percha, sticky wax, and a colorant)
• Shaped with a surveyor
• Blockout process creates a smooth vertical surface apical to the height of
contour
• Wax removed and ledges are placed in the areas of clasp’s retentive
terminus
• Appropriate blockout gingival to guide planes permits placement of the
clasp
• Arbitrary blockout to minimize distortion/tearing during duplication
(reversible hydrocolloid rebound is <3mm)
• Relief
o Framework has intimate contact except in retentive mesh (1mm)
and mandibular major connector (28g) areas
o Internal finish line – butt joint
o 2x2mm cast stops
• Relief also include:
o Deep palatal clefts
o Small or inoperable tori
Sprue Guide Placement • May be made from wax, plastic, or metal
Duplication • Put cast in a flask and pout it with duplicating hydrocolloid
• Can be re-melted and used repeatedly
• Working temperature (63oC/145oF) should be lower than the melting
temperature of the wax/blockout material
 • Let it cool off (1 hour) and separate the two parts
• Master cast removed
• Refractory material poured
• Set in humidor to prevent distortion
Refractory • Higher melting temperature than the melting range of the alloy
materials/investment • No chemical reactions between the allow and the investment
properties • Should yield a fine surface finish on the coasting
• Permeable to gases
• Adequate strength to withstand the incoming allow
• Should be expandable to compensate for cooling shrinkage
Plaster-bonded (low heat) • Used with allows with melting temperatures up to about 700-1000
investments degrees C (primarily gold casting alloys)
• If subjected to higher temperatures, may cause porosity or corrosion
Phosphate bonded (high • Used with chromcobalt allows with melting temperature of 1400-1500
heat) investments degrees C
• Set by way of an acid base reaction
Ti investments • Used with Ti, melting temperatures of 1700 degrees C
• Based on alumina, zirconia, or magnesia
Refractory cast • Drying oven at 93 degrees C for 30-60 minutes
• Trimmed on DRY cast trimmer to within 6mm of the proposed design
• Dipped into beeswax at 130-149 degrees C for 15 seconds
Design transfer • Freehand design transfer
• Ledges created in blockout positions of retentive clasp tips
Waxing • Plastic patterns
• Tacky liquid (acetone mixed with plastic pattern scraps)
• Connected and finished with blue inlay wax
Spruing • Large enough (8-12 gaugue round wax)
• Secondary sprues 1/3-1/4 of main sprue former
• Induce a minimal amount of turbulence in the steam of molten metal
• Provide reservoir for cooling shrinkage of metal
Investment process • Two part investment process
• Sprue former removal
Wax Elimination • Stored in bags to prevent dehydration
• Burnout
o Drives off moisture
o Vaporizes/eliminates the pattern
o Expands the mold to compensate for contraction of the metal on
cooling
Physical Properties of RPD
Metals
 Chromium-Cobalt • 60% chromium (corrosion resistance)
• 30% cobalt (strength, hardness)
• Molybdenum, Silicon (increase hardness, decrease grain size)
• Mg (scavenger for O2)
• Carbon (hardness and ductility
• Iron (improves ability to be cold-worked0
• PROS:
o High strength
o Corrosion resistant
o Fatigue Resistant
o Lighter than gold
o Cost
• CONS:
o Work-harden easy (increased brittleness after clasp adjustments)
Casting • 1371 degrees C
• Induction casting is based on the electric currents in a metal core induced
from a magnetic field
• Mold is positioned in the casting arm and counterweighted to balance
• Centrifugal force drives molten metal
Finishing • Sprue removal
• Rests, retentive clasp tips, and proximal plates receive minimum ???
Electropolishing • Anodic dissolution or “reverse plating”
• Atoms from rough projections dissolve first
• Orthophosphoric acid heated to 49 degrees C
• 1 square inch of surface area = 2 amperes of current for 6 minutes
(average is 6 amp for 6 minutes)
Fitting • Fitting cast is relieved in the areas of retentive clasp tips
• Disclosing media used to identify interferences
• Relieved by spot-grinding
Final Polish • Rubber wheels
• Polishing compounds on rag and felt wheels
• Ultrasonic cleaning
• Returned on the master cast
Try In • Fitting the framework
o Occlude, fit-checker or waxes
• Occlusal adjustment
Processing split-mold • Gypsum separating medium is applied
investing
Wax Elimination • Boiling water for 5 minutes
• Flushed with boiling slurry
• Alginate separating medium applied
• Diatorics (retention features)
Packing • Polymer monomer ration is 3:1 by volume
• Mixed for 30 seconds
• Tightly closed for 1 minute or until doughlike
• Split-packing technique
 • Trial packing with plastic sheets is repeated until a minimal amount of
flash is present (3 times)
• After final closure, bench cure for 1 hour before processing
Processing Partial Denture • Long cure cycle
o Curing unit with room temperature water
o Temperature is raised slowly to reach 74 degrees C in 1 hour
o Maintained for 7 hours
o Brought to a boil for 30 minutes
• Short cure cycle
o From room-temperature raised to 74oC in 1 hour
o Maintained for 90 minutes
o Brought to a boil for 30 minutes
Deflasking • Stone mold removal
• Removal of layers of investment
 REMOVABLE & IMPLANT PROSTHETICS (CR II): Complete Dentures
Charlotte Guerrera

Introduction to Complete Dentures: Anatomic Landmarks

7/5/17

Edentulism • Loss of all permanent teeth

• FACTORS CAUSING EDENTULISM:
o Biologic Processes: caries, periodontal disease, pulpal pathology,
trauma, oral cancer
o Nonbiologic Factors: access to care, patient preferences, third
party payments for selected procedures
• INCIDENCE OF EDENTULISM (between ages 65-74):
o USA: 26%
o Ireland: 48.3%
o Malesia: 56.6%
o Netherlands: 71.5%
• The rate of edentulism is inversely proportional to education and the
income level
• CONSEQUENCES OF EDENDULISM:
o Edentulous patients are considered to be:
§ DISABLED due to inability to eat and speak effectively
§ HANDICAPPED as they tend to avoid eating and speaking in
public
Terminology • PROSTHESIS: an artificial replacement of an absent part of the human
body
• PROSTHETICS: the art and science of supplying missing parts of the
human body
• PROSTHODONTICS: that branch of dental art and science pertaining to
the restoration and maintenance of oral function by replacement of
missing teeth and structures with artificial devices
Prosthodontics • (1) Fixed
• (2) Removable
o a. Partial dentures
o b. Complete dentures
Removable Partial Denture • A prosthesis which artificially supplies teeth and associated structures in a
partially edentulous jaw, and which can be removed from the mouth and
replaced at will
Complete Dentures • Dental prosthesis which replaces the entire dentition and associated
structures of the maxilla or mandible
Immediate Denture • A complete denture constructed for insertion immediately following the
removal of the natural teeth
Denture Terminology • Polished surface: denture teeth + denture base
• Tissue surface/Intaglio surface: in contact with the basal seat
• Basal seat: oral structures which are in contact with dentures and keep
the denture in place
o Residual alveolar ridge, palate, etc.
 • Denture teeth
• Denture base
• Labial notch
• Labial flange: part of denture between labial notch and buccal notch
• Buccal flange: part of denture distal to buccal notch
• Lingual flange
Retention • The resistance to the movement of a denture from its basal seat in a
direction opposite to that in which it was inserted
• Factors influencing retention:
o (1) INTERFACIAL FORCE: the resistance to separation of two well-
adapted contacting surfaces that are imparted by a film of liquid
between them
o (2) ADHESION: the physical attraction of unlike molecules for each
other
o (3) COHESION: the physical attraction of like molecules for each
other
o (4) ORAL AND FACIAL MUSCULATURE: supply supplementary
retentive forces, provided (1) the teeth are positioned in the
“neutral zone” between the cheeks and tongue, and (2) the
polished surfaces of the dentures are properly shaped
o (5) ATMOSPHERIC PRESSURE: the pressure applied by the
atmosphere (14.7 lb/in2)
Atmospheric pressure is a § The dentures have an effective seal around their borders
significant factor for § Proportional to the area of coverage
retention § Atmospheric pressure can act to resist dislodging forces
applied to dentures, if the dentures have an effective seal
around their borders
Support • The resistance of the denture to the vertical components of mastication
and to the occlusal or other forces applied in a direction toward the basal
seat
Stability • The quality of being firm, steady, and constant in position when forces are
applied to the denture
Maxillary Anatomic • Residual alveolar ridge (primary stress bearing area)
Landmarks • Labial frenum (need to allow enough space for this with denture by
creating a labial notch)
• Labial vestibule (between labial frenum and buccal frenum)
• Buccal frenum (band of mucus membrane from the cheek)
• Buccal vestibule (goes from buccal frenum to the maxillary tuberosity/
pterygomaxillary notch)
• Zygomatic process (place finger above first/second molar area to feel this
bone)
• Maxillary tuberosity (difficult to get a good denture seal here – denture
has to pass bulbous area to get into the undercut)
• Pterygo-maxillary (Hamular) notch
• Incisive papillae (mass of tissue covering incisive foramen)
• Papillary hyperplasia (caused by ill-fitting denture – not normal)
• Rugae (secondary stress bearing area)
 • Torus palatinus
• Mediane palatal suture
• Fovea palatine (two little openings of salivary glands in the posterior
palate)
• Vibrating line
Bony foundation of • Palatine process of maxilla
maxillary arch • Horizontal plate of palatine bone
Mandibular Anatomic • Residual alveolar ridge (secondary stress bearing area)
Landmarks • Labial frenum
• Labial vestibule (between labial frenum and buccal frenum)
• Buccal frenum
• Buccal vestibule (between buccal frenum and retromolar pad)
• Buccal shelf (primary stress bearing area)
• Masseter groove (near first molar area)
• Retromolar pad
• Lingual sulcus has an S-shaped curve and is divided into three areas:
o (1) Mylohyoid area
o (2) Retromylohyoid fossa
o (3) Premylohyoid fossa
• Pterygo-mandibular raphe
• Retromylohyoid curtain
• Retromylohyoid fossa
• Mylohyoid ridge
• Premylohyoid fossa
• Alveololingual sulcus
• Lingual frenum (needs freedom to move by notch in denture)

Preliminary and Secondary Complete Denture Impressions

7/12/17

Impressions? • Definitions:
o A negative likeness or copy in reverse of the surface of an object
o An imprint of the teeth and adjacent structures for use in dentistry
Making Impressions • Critical intraoral landmarks
o Supporting areas or stress bearing
areas (basal seat)
o Peripheral or limiting area (border
seal)
• Preliminary impressions have to be as
accurate as possible
Principles and Objectives: • The tissues must be healthy
Impression Making • The impression must include all of the basal seat
• The border must be in harmony with the anatomical and physiological
Denture bases must look limitations of peripheral structures (physiologic border molding)
exactly the same as the • Proper space for the selected impression material in impression tray
final impression • Proper positioning of the tray in the mouth
• The tray and the impression material should be dimensionally stable
Ensuring Health of Tissues • Use tissue conditioners with the existing denture
• Make necessary occlusal adjustments in existing dentures
• Recommend leaving the denture out at least 24 hours prior to making
final impressions and to massage supporting tissues
• Explain the importance of oral and denture hygiene
• Evaluate clinically and discuss the need for pre-prosthetic surgery
Preliminary Trays and • Preliminary impressions are made with stock trays – these come in several
Impressions size but might need to be slightly customized for certain patients
• The better the preliminary impressions, the better your final impression
and dentures will come out
• You can customize the trays by trimming them in certain places, adding
wax where there it needs to be extended, or heating it up with a torch to
change the shape
• Try in the tray BEFORE putting on the adhesive (it tastes bad)
• Put adhesive all over the inside of the tray and a little on the outside
edges (make sure the adhesive is dry before placing the alginate
(otherwise it will mix with the alginate and alter the setting time)
• If any of the alginate separates from the tray you need to take a new
impression otherwise it will not be accurate
• You can cover the alginate in a wet paper towel for up to 30 minutes
before pouring up the stone model
• For the mandibular tray, don’t have access alginate in the tongue space
Pouring Impressions • Use the correct water/powder ratio so you have the proper consistency
• Start pouring from one corner and turn it, letting the material flow to the
other end, while holding it on the vibrator
• Once all the surfaces are coated, add more stone on top without putting it
on the vibrator and let it dry à this is the FIRST POUR
• For the second pour, make a thicker stone consistency and create a
mound on the table – put your first pout on this mound so they come
together, creating a base for the preliminary casts
Preliminary Casts • Identify the peripheral outline of the custom tray on laboratory stone cast
• Mark the deepest part of the vestibule, because this is the area where you
are going to end your denture base
Custom Tray • Custom tray extends just past the junction of the attached and
unattached mucosa
• 2-3mm thick
• Border 2mm short of depth of sulcus (to leave room for greenstick
compound)
• Stepped handle in the anterior region
• Cover the hamular notches (which lie distal to the tuberosities)
• 2mm posterior to vibrating line
• VLC Resin – Triad
• How to fabricate custom trays:
o Block out undercuts to make it easier to take tray in and out
§ Use pink wax for block out
§ Apply Vaseline or Petroleum jelly
o Adapt the triad material to the cast
 § Border is 2mm short of vestibular depth
§ Create handle at 45 degrees
§ Make sure borders are rounded
Border Molding • Tray tried and adjusted if necessary
• Flanges should be 2mm short of the vestibular depth
• Incrementally add the greenstick compound to recreate the borders
o It is a thermoplastic material that will soften under flame (roll it
while heating it up so it softens uniformly and does not burn)
o Greenstick compound should be tempered in a water bath
(temperature 135 F)
Custom Tray Try-In • Relieve the tray where there are frenum attachments
• Use a burr to do this
Border Molding • Anterior region: labial flange
Movements – Maxilla o Outward, downward, and inward lip movement
• Posterior region:
Move the lips in these ways o Buccal flange
to properly mold the § Outward, downward, inward
border of greenstick o Buccal frenum
compound for the patient’s § Outward, downward, inward, backward, and forward
anatomy o Distobuccal flange
§ Patient opens wide and moves mandible from side to side
(coronoid contour)
Greenstick Compound • Add incrementally
• Temper
Try to use the water bath as • Roll and smooth borders
much as possible and limit • Posterior palatal seal
flame use because it can • Venting and adhesive (must be the correct kind of adhesive – NOT
burn the greenstick alginate adhesive)
compound • Polyvinyl Siloxan (PVS) impression – reprosil medium body consistency
• Making the final impression – do not overload the tray because the tray is
very customized and if there is too much impression material it will go
down the patient’s throat
o Apply Vaseline on the lips/chin so the sticky impression material
doesn’t stick to the patient’s face
o Hold it in the mouth for a few seconds and do the border molding
movements again to make sure all the borders are properly
captured by the impression material
Border Molding • Anterior region: labial flange
Movements – Mandible o Outward, upward, and inward lip movement
• Posterior region:
o Buccal flange
§ Cheek is lifted outward, upward, inward
o Buccal frenum
§ Cheek is lifted outward, upward, inward, backward, and
forward
• Masseteric area:
o Ask patient to close his mouth while simultaneously applying
downward pressure on the custom tray
 • Anterior lingual flange
o Protrude the tongue (length, slope) and push the tongue against
rugae area (thickness) – activates the mylohyoid muscle
• Mid-lingual flange
o Protruding the tongue (length), a “k” sound activates the
mylohyoid muscle, tongue protruded – activates the mylohyoid
Retromylohyoid area might • Posterior-lingual flange (retro-mylohyoid region)
have good undercuts which o Ask patient to protrude his tongue and then move left and right –
can help hold the denture activates the superior constrictor
in place – make sure you o Retromolar pad area doesn’t change over time so make sure they
capture the “S” curve are COVERED so the denture will fit properly (helps retention)
• Pterygomandibular raphe
o Ask patient to open mouth wide
Impression Materials • Mucostatic
o Eg: zinc oxide eugenol paste
o More fluid
o Minimal displacement of tissues
• Mucodisplacive
o Eg: polyvinylsiloxane (PVS), polysulphide
o More viscous
o More displacement of tissues
Remaking the final • Voids or discrepancies that are too large to be corrected accurately
impression • Incorrect positioning of the tray
• Incorrect consistency of the final impression material when the tray was
positioned in the mouth
• Movement of the tray while the impression material was setting
• Incorrect border molding procedures
• The use of either too much or too little impression material
Boxing Impressions • Preserves functional depth of sulcus
• Boxing wax strip attached 2-3mm below border
• Vertical wall extends 10-15mm above impression
• Seal wax with hot spatula

Biological Consideration of Jaw Relations and Jaw Movements

8/2/17

Mandibular Movements • (1) Functional

o Mastication, swallowing, speech, yawning
• (2) Parafunctional
o Clenching, grinding, bruxing
Movements in the TMJ • (1) Rotation
o The process of turning around an axis
o Movements of a body about an axis
o A movement in which all points within a body describe concentric
circles around a common axis
• (2) Translation
o A movement in which all points within a body are moving at the
same velocity and in the same direction
 TMJ • Upper compartment: translational movement
• Lower compartment: rotational movement
Mandibular Movements: • (1) Horizontal axis (transversal) – movement around sagittal plane
Axes of Rotation • (2) Frontal axis (vertical) – movement in horizontal plane
• (3) Sagittal axis – movement in frontal plane
Border Position • The extreme position of the mandible in any given direction
o Centric relation (most retruded border position) – this position is
very important for making dentures
o Lateral
o Protrusive
Border Movements • Movement of the mandible through the outer range of motion
• Mandibular movements at the limits dictated by anatomic structures, as
viewed in a given plane
• Border movements are limited by LIGAMENTS and ARTICULAR SURFACES
of the TMJ as well as by the morphology and alignment of the TEETH
Mandibular Movements in • Can trace mandibular movements with a facebow device that creates a
the Sagittal Plane Posselt Diagram
Sagittal Plane Border and • (1) Superior contact border movement (centric relation and maximum
Functional Movements intercuspation)
(Posselt Diagram) • (2) Anterior opening border movement (from all the way
protrusive to opening completely)
• (3) Posterior opening border movement (from all the way
retrusive and start to open completely)
o First stage of rotational movement of the mandible
with condyles in terminal hinge position
o Pure rotation until the anterior teeth are 20-25mm
apart (12 degrees)
o Second stage of movement during opening:
translation
• (4) Functional movement
o Chewing stroke with border movements in the sagittal plane (tear
drop shape in diagram)
Rest Position • Mandible in postural position (PP) = rest position
• Located 2-4mm below the maximum intercuspation position
Jaw Relations • (1) Orientation
o Hinge axis
o Face-bow
• (2) Vertical relations (how far the mandible and maxilla are in natural
dentition when supported by teeth)
o VD of rest position
o VD of occlusion
o Inter-occlusal distance
• (3) Horizontal relations (relation of mandible and maxilla
forward/backward/laterally)
o Centric relation
o Protrusive relation
o Lateral relation
 Vertical Dimension • Refers to the length of the face
• (1) Vertical dimension of the rest position
o The vertical separation of the jaws when the opening and closing
muscles of the mandible are at rest in minimum tonic contraction
o VD of rest is relatively CONSTANT
• (2) Vertical dimension of occlusion
o The vertical separation of the jaws when the teeth are in occlusion
Interocclusal Distance • The distance or the gap existing between the upper and lower teeth when
the mandible is in the physiological rest position
• It is usually 2-3mm when observed at the first premolar area
VD Relationships • VD of occlusion = (VD of Rest) – (Interocclusal Distance)
• VD of occlusion = (VD of Rest) – (2-3mm)
• Need to figure this out in edentulous patients so we can make denture
teeth in the proper proportions
Terminal Hinge Position • The position of the mandible from which or in which pure hinge
movement is possible
• The maximum range of terminal hinge rotation is 12 degrees and creates
a range of 20-25mm in inter-incisal opening
Centric Relation • The most retruded relation of the mandible to the maxilla 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
• The maxillomandibular relationship in which the condyles articulate with
the thinnest avascular portion of their respective disks with the complex
in the antero-superior position against the shapes of the 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
• Significance of centric relation
o (1) It is a reference point in recording maxillomandibular relations
o (2) it can be verified and repeated
o (3) It serves as a definite reference point during the time frame of
denture construction
o (4) It is a starting point for developing occlusion
o (5) It is a functional position
Interocclusal Check Record • Have patient say F sounds like fifty five while the occlusal rim is in their
Technique mouth
• If the lip is too full that means the occlusal rim is too high and needs to be
reduced
• When saying F sounds the incisal edge of the maxillary teeth should lightly
touch the lower lip
Plane of • ANTERIORLY: parallel to the interpupillary line
Orientation/Occlusion • POSTERIORLY: parallel to the Ala-Tragus line
• Use a Fox Plane to verify the plane of occlusion
Articulation of the master • Use labial frenum as a guide to mark the midline of the maxilla
casts • Mark the canine line
• Mark where the lip hits when the patient smiles
• Make V notches in the premolar and molar region
• Remove 2mm of wax in molar regions of mandible and put alu-wax in this
space
Face-Bow • A caliper-like device that is used to record the relationship of the maxilla
to the TMJ or the opening axis of the jaws and to orient the casts in the
same relationship to the opening axis of the articulator
• Purpose of using the face-bow: to orient the maxillary cast to the opening
axis of the articulator in the same relationship the maxilla has to the
opening axis of the jaws
• Anterior part of ridge should be parallel with interpupillary line
• Types of face-bow:
o (1) Kinematic (hinge-bow): trace rotation of condyle
o (2) Arbitrary
§ (a) Rods placed on a line extending from the outer canthus
to the top of the tragus and approximately 13 mm in front
of the external auditory meatus
§ (b) Ear-bow
Arbitrary location of the • 13 mm anteriorly from the posterior border of the tragus along a line
terminal hinge axis connecting the tragus to the outer canthus of the eye
Forward mandibular • There is a supero-anterior shift of the mandible from centric relation to
movement maximum intercuspation position
• As the mandible moves forward, contact of the incisal edges of the
mandibular anterior teeth with the lingual surfaces of the maxillary
anterior teeth creates an inferior movement
• Continued forward movement of the mandible results in a superior
movement as the anterior teeth pass beyond end-to-end positon,
resulting in posterior tooth contact
• Continued forward movement is determined by the posterior tooth
surfaces until maximum protrusive movement is reaches
Envelope of Motion • The three-dimensional space circumscribed by mandibular border
movements within which all unstrained mandibular movement occurs
Envelope of Function • The three-dimensional space contained within the envelope of motion
that defines mandibular movement during masticatory function and/or
phonation

Selection & Arrangement of Artificial Anterior Teeth for Complete Dentures

8/16/17

Important Considerations • Factors that influence complete denture esthetics

o Face form
o Head shape
• Selection of anterior teeth mould is also influenced by
o Sex
o Personality
o Age
 • Use of denture teeth mould selection guide
Questions to ask • Pre-extraction smile photographs?
• Old complete denture prostheses?
• Esthetics (size, shape, color)?
• Function? (do existing dentures function?)
• How would they like us to help address their concerns?
Factors influencing denture • Incisal edge position: has to correspond to maxillary occlusal rim (incisal
teeth selection aspect of the rim)
• Inter-canine width
• High smile line
• Lip support
• Plane of occlusion (retromolar pad helps with this)
• VDR (vertical dimension of rest) & VDO (vertical dimension of occlusion)
Incisal Edge Position

Must have patient speak

with the occlusal rims in
their mouth to make sure
they can pronounce F
sounds

Plane of Occlusion • Put in maxillary rim and make sure the rest
position is correct, then put in the mandibular
rim and check vertical dimension of occlusion
• Plane of occlusion should match the halfway
point of the retromolar pad
• Imaginary line from inferior border of the ala of
the nose to the tragus of the ear is called the
Camper’s line – occlusal plane should be parallel to this line
• Anteriorly: maxillary anterior arch
• Posteriorly: ½ retromolar pad
Maxillary Arch Form • Teeth are set up in arch along
white dotted line – labial surface of
anterior teeth should not protrude
past this line
• Incisal edge should be 8-10mm
anterior from incisive papilla

Front Face • Interpupillary line

• Line marking midline of the face
o Don’t go by the nose – many people do not have symmetric noses
– draw line from philtrum to right between the eyebrows
 • When you insert the rim into the patient’s mouth line up line up the
midline of the teeth with the midline of the face
Verification • Vertical dimension at rest/of occlusion
• Incisal length
• Phonetics (closest speaking space)
• Mark junction of maxillary lip to maxillary occlusal rim –
this denotes maximum length of central incisors
(height)
Lines to follow

(1) (2)

• (1) Black line is canine line, white horizontal line is the Camper’s line
• (2) midline of maxillary rim is in line with midline of the face, plane of
occlusion is parallel to interpupillary line
Selection of Teeth Moulds • Need to help patient because there are a lot of options
Intercanine Width • Need a flexi-ruler to measure inter-canine width
Mould Guides • The one we are using is the portrait IPN mould guide
Shade Selection • Color corrected light (not light from dental chair) – try to find natural
lighting
• Shade tabs – hold them against the patient’s upper lip
o Try to limit the patient to a few shade you think will work because
they will be confused if you give them too many options
o Don’t want dentures that are way too white – they will look
unnatural
o Give more yellow shades (like A1-A3) so they look natural
o Have the patient look in the mirror and hold up the guides to help
decide what is the right shade for them
• Shapes: square, square tapering, tapering, ovoid, etc.
Example • 47mm inter-canine width
• 7.0mm high smile line
Anterior Tooth Mould • Anterior mould identified by
form and size
 Tooth Shape and Form

Based on this the patient

will want different shapes
of their teeth

Basic Facial Forms • (1) Square

• (2) Square tapering
• (3) Square ovoid
• (4) Tapering
• (5) Tapering ovoid
• (6) Ovoid
• (7) Square tapering ovoid
First Number • Denotes facial form (ex: 2 = square tapering)

Proportion and Contour Proportion of the Tooth Facial Contour

(1) Long Straight
(2) Medium Straight
(3) Short Straight
(4) Long Curved
(5) Medium Curved
(6) Short Curved
Second Number • Proportion and contour (classification from
1-6)

Width of Maxillary • B = below 44mm

Anterior Teeth • C = 44-4mm
• D = 46-48mm
• E = 48-50mm
• F/X = 50-52mm
• G = 52-54mm
• H = 54-56mm
• J = above 56mm
 Letter • Width of teeth
• Green dotted lines show inter-canine width

Dentogenic Concept • “The physical environment of an edentulous mouth is in constant and

permanent change. For this reason, our creative effort in treating
edentulous patients should follow this change and progression.”
Other Factors • Gender
• Personality
• Age
Sex • Feminine:
o Curved, delicate
o Ovoid, tapering
o Lateral incisor rounding
• Masculine:
o Strong
o Square lateral incisors
o Large canines
Personality • Personality spectrum
• Some patients want more delicate teeth and
some might want more robust teeth
• This depends on their personality
• Refer to pre-extraction photographs

Age • Youth:
o Mammelons
o Lighter
o Pointed cusp tips
• Aged:
o Wear
o Darker
o Worn cusp tips

YOUTH

MIDDLE-AGED

AGED

Porcelain Teeth Advantaged Disadvantages

• Superior esthetics • Brittle
• Resistance to abrasion (hard) • Poor bond to denture base
• Color stable • Difficult to polish after occlusal
• Dimensionally stable adjustments à wear of
• Insoluble in oral fluids opposing teeth
• Occasional cracking
Articulation of Occlusal • Once you have your occlusal rims ready to go you will be mounting them
Rims on an articulator (you will use centric relation records to recreate their
occlusal morphology)
Arrangement of Maxillary • All labial surfaces of anterior teeth follow the curve
Anterior Teeth • Central incisors and canines – same flat plane
• Lateral incisors – 0.5mm above the flat plane
• Long axis of the central incisors and canines – vertical
• Long axis of the lateral incisors and canines – slightly to distal
• Cervical portion (neck) of only the canines – slightly labially

Completed Maxillary
Anterior Teeth
Arrangement

Arrangement of • All incisal edges of anterior teeth are on a flat plane

Mandibular Anterior Teeth • Long axis of the central incisors and canines – vertical
• Long axis of the lateral incisors and canines – slightly to distal
• Cervical portion (neck) of central incisors – slightly lingual
• Cervical portion (neck) of lateral incisors – straight
• Cervical portion (neck) of only the canines – slightly labially

Completed Mandibular • No vertical overlap and only

Teeth Arrangement 1mm horizontal overlap
(non-anatomic occlusion)

Try-in and Verification • Midline

• Smile line – make maxillary central incisors the correct length to make
them as esthetic as possible
• Esthetics – color, size, and shape
• Phonetics – “F” sound (fifty-five)
Key Points to Remember • Listen to your patient – it is very important to understand their chief
concerns
o “My teeth don’t show anymore”
o “My teeth are yellow”
o “I don’t look the same as I used to”
• Existing or previous prostheses
• Let your patient participate
 Arrangement of Non-Anatomic Teeth
8/16/17

Classification of Artificial • (1) Anatomic teeth

Teeth • (2) Semi-anatomic teeth
• (3) Non-anatomic teeth
Anatomic Teeth

Have real cuspal

inclinations of 30 degrees
and above

Anatomic Tooth • Centric occlusion is when any contact of the teeth when the jaw is in
Arrangement centric relation (this usually does not correspond with maximum
intercuspation)
• In complete dentures we relate the upper and lower casts in centric
relation
• Side that jaw moves towards is called the working side (on the balancing
side there should be contact between the lingual cusps of the maxillary
teeth and the buccal cusps of the mandibular teeth)

Semi-Anatomic Teeth

Non-Anatomic Teeth

Do not have any cuspal

inclination

Hall Inverted Cusps

Occlusal surface is flat and

there are depressions to
create ridge for a cutting
edge
 Sears Channel Teeth

Hardy’s Steel Cutters

Steel blades implanted into

porcelain

Trubyte Rational Teeth

IPN Portrait

These are the ones that we

are using – they are 0
degree cusps – basically
two flat occlusal surfaces

Advantages of Non- • (1) Easier to set

Anatomic Teeth • (2) Freedom in centric occlusion (non-locking)
• (3) Elimination of horizontal forces which are more
damaging to supporting tissues
o Reduction of cuspal inclination results in
reduction of lateral forces
• (4) Increase denture stability
• (5) More adaptable to class II and III jaw relations and
cross bite situations
• (6) Easier to correct the occlusion after relining or
rebasing
• (7) Use in maxillofacial prosthodontics
Disadvantages of Non- • (1) Poor esthetics
Anatomic Teeth • (2) Reduction of chewing efficiency
Monoplane Occlusion • Two flat surfaces of the teeth contacting each
other (flat plane of occlusion)
• Less cuspal inclination causes less lateral forces,
so the dentures will be more stable during
function
Re-line • Ideally if a denture needs to be re-lined, you would use impression
material and send it back to the lab to fix
 Neutro-Centric Concept • Natural teeth are set in a neutral zone between the tongue at rest and the
cheek
• We want to use this same neutral zone to place denture teeth
• If you set the teeth too far to one side, the tongue and cheek will be
pressed upon and the patient will not be comfortable
• There is horizontal overlap between upper and lower teeth (about 1mm)
– when you go into the working side they will be edge-to-edge
• Buccal and lingual cusps are all in the same plane of occlusion
• To place the teeth in that neutral zone the central fossae of the
mandibular teeth will be in line with the ridge
• There should be 1mm horizontal overlap of the teeth
• There should be no vertical overlap of anterior teeth, and 1mm of
horizontal overlap
How to set posterior teeth • Mark the mandibular landmarks on the casts – center of the crest of the
ridge
o Central fossa of mandibular teeth should be in line with this
• Remove a little bit of wax buccal to the line on the center of the ridge so
you can see where the teeth need to line up
• To set these teeth you have to remove some of the wax, set the tooth,
and use the plane of occlusion to make sure the teeth are at the right
height
• The lingual cusps of maxillary teeth should be centered over the crest of
the ridge of the mandibular arch
• Any time you set a tooth and are satisfied with its position, heat up the
wax at the neck of the tooth to secure it in place
• Look from the lingual of the denture to make sure that the lingual cusps of
the teeth are also in contact with the occlusal plane
• Maxillary: labial aspect of the canine, labial aspect of premolars, and labial
aspect of mesiobuccal cusp of the first molar should all be parallel
• Mandibular: central fossa should be lined up with the crest of the ridge
line
• Have to create 1mm horizontal overlap to prevent cheek-biting
Christensen Phenomenon • As the mandible moves forward in protrusive excursion, the condyles
move downward and forward
• This downward movement of the posterior part of the mandible has the
effect of moving the mandibular posterior teeth downward, creating
space between them and the maxillary posterior teeth or occlusion rims
• This effect is known as the Christensen Phenomenon
Compensating curve • To create a curvature that prevents separation of posterior teeth
Ramping the second molar • All the teeth are set on a flat plane of occlusion
except for maxillary and mandibular second
molars
• This is no longer monoplane occlusion
• This curvature is created to prevent dentures
from sliding forward
Create proper horizontal • Cheek biting usually due to
overlap to prevent cheek insufficient overjet (in posterior
biting region), lax cheeks, or reduction
of vertical dimension
• If your teeth are edge-to-edge,
there is a tendency for the
patient to bite the cheek
• Re-contour the buccal aspect of the mandibular teeth if the patient comes
back with cheek-biting issues due to lack of horizontal overlap

Arrangement of Artificial Posterior Anatomic Teeth

9/6/17

Inclination • Decreasing the cusp inclination results in reduction of lateral forces so you
are only left with vertical forces
Horizontal Overlap • Posterior teeth set with 1mm horizontal overlap – this prevents cheek
biting – and NO vertical overlap
Balanced Occlusion • The bilateral, simultaneous, anterior and posterior occlusal contact of the
teeth in centric and eccentric positions
• Centric relation in both anatomic and non-anatomic teeth à anterior
teeth should not be in contact
• Complete dentures: centric occlusion = centric relation
• Natural dentition: centric occlusion is not necessarily the same as centric
relation
Establishing the plane of • Establish the plane of occlusion posteriorly by marking half the height of
occlusion the retromolar pad and extending it on either side
• You MUST get this perfect before moving on setting the teeth or you will
have to rip out the teeth and start over
• Remove slice of wax buccal to the center of the crest of the ridge line so
you can see the space where the teeth will occlude
• ANATOMIC TEETH: anterior teeth should have 1mm vertical and 1mm
horizontal overlap
• NON-ANATOMIC FLAT PLANE (MONOPLANE) OCCLUSION: 1mm
horizontal overlap and NO VERTICAL OVERLAP
Setting Condylar Guide • Horizontal condylar guide angle (about 25)
Angles • Lateral condylar guide angle (about 15)
Condylar Guidance • Mandibular guidance generated by the condyle and the articular disc
traversing the contour of the Glenoid fossae
• When there is no teeth guidance (open mouth or edentulous) only
condylar guidance is left
Lateral Condylar Guidance • Hanau formula: L = H/8 + 12
• L = lateral condylar guidance
• H = horizontal condylar guidance
Compensating curve • Anterior/posterior relationship of the maxilla and mandible in the
posterior region
• There is also a discrepancy in the heights of the buccal and lingual cusps,
creating a compensating curve buccal-lingually as well
 • Lingual cusps of the first and second premolar and ML cusp of first molar
are ON the plane of occlusion
• Buccal cusps of the first and second premolars and the MB of the first
molar is 0.5mm ABOVE the plane of occlusion – this is how you start to
create a curvature
• From this point on, the lingual cusps and the buccal cusps of the molars
will have an increment of 0.25mm higher and higher above the plane of
occlusion, so the DL cusp of the 1st molar will be 0.25 above the plane, the
ML of the 2nd molar will be 0.5mm above, etc.
• By keeping the buccal cusps ABOVE the plane of occlusion, not touching
the occlusion, you are also creating a curvature on the opposite side on
the buccal-lingual aspect
Note: 0.5 mm distance DISTANCE ABOVE THE PLANE OF OCCLUSION: MAXILLARY TEETH
between corresponding Lingual Cusp Buccal Cusp
buccal and lingual cusps & st
1 Premolar 0 mm 0.5 mm
0.25 mm increments nd
2 Premolar 0 mm 0.5 mm
sequentially on the molar ML Cusp DL Cusp MB Cusp DB Cusp
cusps both buccally and st
1 Molar 0 mm 0.25 mm 0.5 mm 0.75 mm
lingually 2nd Molar 0.5 mm 0.75 mm 1.0 mm 1.25 mm

• Occlusal view of maxillary teeth: straight line from the distal/buccal of

the canine to the mesio-buccal cusp of the first molar, and the straight
line from the disto-buccal cusp of the first molar to the second molar

Setting mandibular teeth • If the maxillary teeth are set properly, it will be easy to set the mandibular
teeth
• Mesiobuccal cusp of maxillary molar will sit in the mesial groove of the
mandibular first molar
• Central fossa of mandibular teeth will end up in line with the center of the
ridge

Occlusion in Complete Dentures

9/13/17

Occlusion • The static relationship between the incising or masticating surfaces of the
maxillary and mandibular teeth
Maximal Intercuspation • The complete intercuspation of the opposing teeth independent of
condylar position (best fit of teeth)
Articulation • Dynamic contact relation between the occlusal surfaces of the teeth
during function
 Occlusion • (1) CENTRIC OCCLUSION: the occlusion of the opposing teeth when the
mandible is in CENTRIC RELATION
• (2) ECCENTRIC OCCLUSION: an occlusion other than centric occlusion
o Positive position (incisal guidance)
o Lateral position
Centric Relation • The most retruded relation of the mandible
to the maxilla when the condyles are in the
most posterior unstrained position in the
glenoid fossa from which lateral movement
can be made, at any given degree of jaw
separation
• The maxillomandibular relationship in which
the condyles articulate with the thinnest
avascular portion of their respective discs with the complex in the antero-
superior position against the shapes of the articular eminences
• This position is INDEPENDENT OF TOOTH CONTACT (ligament guided)
• 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
Significance of Centric • (1) It can be verified and REPEATED
Relation • (2) It is a reference point in recording maxillo-mandibular relations
• (3) It serves as a definite REFERENCE POINT during the time frame of
denture construction
• (4) It is a starting point for developing occlusion
• (5) It is a FUNCTIONAL position
Concepts of Occlusion • NATURAL DENTITION:
o (1) Cuspid protected occlusion: a form of mutually protected
articulation in which the vertical and horizontal overlap of the
canine teeth disengage the posterior teeth in the excursive
movement s of the mandible
o (2) Group function: multiple contact relations between the
maxillary and mandibular teeth in lateral movements on the
working side whereby simultaneous contact of several teeth acts
as a group to distribute occlusal forces
• COMPLETE DENTURES:
o (1) Monoplane occlusion: an occlusal arrangement wherein the
posterior teeth have masticatory surfaces that lack any cuspal
height and are positioned in a single plane
o (2) Balanced occlusion: the bilateral, simultaneous, anterior and
posterior occlusal contact of the teeth in centric and eccentric
positions
Philosophy of Complete • Tooth contacts of opposing maxillary and mandibular teeth at a jaw
Denture Occlusion relation position that demonstrates REPRODUCIBILITY (centric relation)
• Degree of INCISAL GUIDANCE established through positioning of the
anterior maxillary and mandibular teeth
 • ABSENCE OF DEFLECTIVE OCCLUSAL CONTACTS and a free-gliding
articulation between opposing maxillary and mandibular anterior and
posterior teeth during jaw movements
• Positioning anterior and posterior teeth to provide NATURALNESS IN
APPEARANCE
Articulation of Artificial • Mechanical balanced articulation involves precise laws of articulation
Teeth based on geometry and occlusion constructed on an articulator
completely controlled by mechanics
Laws of Articulation • (1) Inclination of condylar guidance (average 25 degrees) – this is the only
(for Protrusive) factor that the dentist cannot change
“Hanau’s Quint” • (2) Inclination of the cusps
• (3) Orientation of the occlusal plane
• (4) Prominence of the compensating curve
• (5) Inclination of the incisal guidance – the dentist can change this
Controlling End Factors • (1) Inclination of condylar guidance
• (5) Inclination of the incisal guidance
• (2)-(4) are the intermediary factors
Condylar Guidance • Mandibular guidance generated by the condyle and the articular disk
traversing the contour of the glenoid fossa
• The only factor that could not be changed by the dentist
Incisal Guidance • The influence of the contacting surfaces of the mandibular and maxillary
anterior teeth on mandibular movements
• In complete dentures the incisal guidance is set by the dentist
• INCISAL GUIDE BY ANGLE: the angle formed by the
intersection of the plane of occlusion and a line
within the sagittal plane determined by the incisal
edges of the maxillary and mandibular central
incisors when the teeth are in maximum
intercuspation
• (A) An increase in VERTICAL overlap will result in an INCREASE in the
incisal guide angle
• (B) An increase in HORIZONTAL overlap will result in a DECREASE in the
incisal guide angle
(A) (B)

Intermediary Factors • Inclination of the cusps – can change cuspal inclination by changing
inclination of the tooth
• Orientation of the occlusal plane (in relation to retromolar pad)
• Prominence of the compensating curve (curve of Spee in real teeth)
 Compensating Curve • The anteroposterior curvature in the
alignment of the occluding surfaces and
incisal edges of the artificial teeth that are
used to develop balanced occlusion
Importance of Incisal • The incisal guidance is more important because the posterior teeth are
Guidance in Complete closer to the action of incisal guidance than condylar guidance
Dentures – we want to
keep this at 0 degrees

Conclusion • The posterior teeth are closer to the action of incisal guidance than
condylar guidance
• Reduction of the incisal guidance will result in flatter cusp inclination
• Reduction of cuspal inclination results in reduction of lateral forces and
increased stability of the dentures
• Therefore in complete denture construction, we keep the incisal guide
angle at ZERO

Waxing, Contouring, Processing, and Remounting the Complete Dentures

9/27/17

Denture Surfaces • CAMEO: polished side

• INTAGLIO: basal or impression side
• There are many directional forces from all sides due to the muscles of
mastication
• Need to make sure there is room for the tongue to move around
• Concavity on the cheek side but then becomes more convex towards the
facial
Festooning • Adding wax
• Gingival contours
• Once you set all your teeth you need to add a layer of wax on the facial
and lingual surfaces, and contour it back with a knife/contour to create
the gingival areas around the teeth
• All teeth have different gingival levels
Interdental Papillae • Proper convex contours prevents food impaction
• Patient doesn’t have the ability to clean between
the teeth – not able to floss – so you have to make
sure the patient can keep them clean
Gingival Margins & Contact • Must extend to the point of tooth
Areas contact
• Must be of various length
• Must be convex in all directions
• Must be shaped according to age
Develop Root Indications • In between the gingival areas,
scoop out some wax and
smoothen it to create a root
convexity
• Root indications are different
lengths
Lingual and Palatal • Lingual contour has the tongue occupying most of the space – must make
Contour sure the fit allows for proper speech
• Lingual area has to be concave but then towards the lingual surface of the
teeth it should be more convex
• Palatal contour
• Usually try to keep 2.5mm thickness to keep enough rigidity in the
denture when it is replaced with acrylic resin
Rolled Gingival Margins • Gingival margins have to be rolled

Denture Flask • Parts of Flask:

o Drag (bottom)
o Cope (middle)
o Cap (thin top)

Plaster Index • Made prior to removal of master casts from the articulator
• Make an impression of the teeth on a mounting jig on the lower level of
your articulator
• Once the dentures come back process you will be able to put them back
on the same articulator you were working on – this will help you check
that the teeth are in the same position as they were when you waxed
them up
Processing the denture • Separate from articulator (water helps to do this)
• Place master cast with waxed up denture in Drag – make sure top of Drag
is flush with master cast
o Before you do this, apply separating media so it can be separated
from the stone you will be pouring
• Place Cope on top of Drag
• ¼ inch (3-6mm) of space should be available between the teeth and the
top of the flask
• Bevel excess stone
• Pour stone – a mix of artificial stone is placed in the bottom half of the
flask
• Apply separating media
• Master cast is placed in stone
 • Separating medium has been applied to the exposed stone in the flask
• Develop cores – the top of the cores should be 2-3mm below the occlusal
plane of the teeth
• Place cope
• Expose cusp tips – after the upper half of the flask has been put in place, a
heavy mixture of dental stone is poured to the level of the tips of the
cusps
o This is to create a guide for you when you are disassembling it
• Pour remaining stone
• Close the cap – should be about 2-3mm
Flanked Denture • Layers:
o Mix of stone and plaster
o Plaster
o Stone
• Separating medium painted between
layers
• Put in boiling water for 4-6 minutes for
wax to melt away
• Separate cope from drag
• Softened wax – clean off completely so resin adheres completely – the
teeth will be embedded in the mix of stone and plaster
• Tin foil substitute (like a separating media) so that the acrylic resin sticks
to the teeth and not to the stone
Acrylic Resin • Polymethyl Methacrylate (PMMA) – powder and liquid
o PMMA: solid polymer
o Methyl methacrylate: liquid monomer
• Methods of polymerization:
o HEAT CURE: initiator (benzoyl peroxide) in the powder
o CHEMICAL CURE: an activator (tertiary amine) in the liquid attacks
the initiator (benzoyl peroxide)
• Stages:
o Wet sandy
o Early stringy
o Late stringy
o Doughy (most important stage)
o Rubbery
o Stiff
• Mixing acrylic resin:
o Polymer-monomer ratio is 3:1 by volume
o Mix for 30 seconds
o Tightly closed for 1 minute or until dough like
Packing the mold • Pack when acrylic is in doughy consistency
• Close and press the flask (use spring clamp)
• Trial packing – with plastic sheet – repeated until a minimal amount of
flash is present (3 times)
• Remove excess resin
• After final closure, bench cure for 1 hour before processing
 Polymerization • LONG CURE CYCLE:
o Curing unit with room-temperature water
o Temperature is raised slowly to reach 74 degrees Celsius (165 F) in
1 hour
o Maintained for 7 hours
o Brought to a boil for 30 minutes
• SHORT CURE CYCLE:
o From room-temperature, raised to 74 degrees Celsius (165 F) in 1
hour
o Maintained for 90 minutes
o Brought to a boil for 30 minutes
Deflasking • The flask must cool to room temperature prior to de-flasking
• Reposition master cast
• Remounting jig – positioned on the lower member of the articulator
• Processing errors?
• Adjust premature contacts
Separate Denture • Separate denture from master cast using pneumatic chisel
• Smoothen borders with burrs and scrapers
• Smoothen palatal surface
Finishing and Polishing • A final high polish is given to all the surfaces with a rag wheel and
polishing material (Tripoli, tin oxide, and water)
• Polish with pumice
Examination of Final • Tissue surface
Denture • Polished surface
• Borders
• Frenum notches

Occlusal Equilibrium
10/4/17

Occlusal Equilibrium • The modification of the occlusal form of the teeth with the intent of
equalizing occlusal stress, producing simultaneous occlusal contacts or
harmonizing cuspal relationships
Why the need? • To eliminate occlusal discrepancies/errors caused by:
o Technical errors or errors in judgement made by the dentist
o Technical errors developed in the laboratory
o Inherent deficiencies of the materials used in the fabrication of the
dentures
Causes of occlusal • Inaccurate maxilla-mandibular relation records
disharmony • Errors in transfer of relation records to the articulator
• Ill-fitting temporary record bases
• Incorrect VDO
• Incorrect posterior tooth set-up
• Failure to close the flasks completely during processing
• Warpage of the dentures by overheating during polishing and/or incorrect
removal from master cast
• Unavoidable changes in denture base material
 Errors in Occlusion • PROCESSING ERRORS: eliminated by laboratory remounting
• TECHNICAL ERRORS: eliminated by clinical remounting
Laboratory Remount • Selective grinding to fix processing errors after you place master cast back
on original mounting
Examination of the • Tissue surface
finished dentures • Polished surface
• Borders
• Frenum areas
Denture Insertion • Tell patient not to wear old dentures for 24 hours so if any part of it
irritated the tissues, the tissue has time to heal so you can properly seat
the new dentures
Eliminate Errors in the • Paint PIP paste over intaglio
Basal Seat (inner surface)

PIP Paste • Relived pressure spots using a #8 round burr

Uniform seating of denture • Interference depicts incomplete seating of the denture in its correct
base position
Making clinical remount • Block-out undercuts
casts • Use fast setting plaster for clinical remount casts to be able to remount
these dentures again with new records so that you can make those
occlusal corrections
• Facebow index – might have to make your own facebow index and mount
it to the upper member of the articulator
Important Terminology • CENTRIC OCCLUSION (CO): the occlusion of opposing teeth when the
mandible is in centric relation – this may or may not coincide with the
Need to know! maximal intercuspal position
• CENTRIC RELATION (CR): a maxillomandibular relationship, independent
of tooth contact, in which the condyles articulate in the anterior-superior
position against the posterior slopes of the articular eminences
o In this position, the mandible is restricted to a purely rotary
movement
o From this unstrained, physiologic, maxillomandibular
relationship, the patient can make vertical, lateral, or protrusive
movements
o It is a clinically useful, repeatable reference position
Checking for errors in • Guide the patient into CR
occlusion • Hold the mandibular denture into the patient’s mouth and move their jaw
into centric relation
Clinical remount CR record • The Aluwax is immersed in a 130 degree F (54 degrees C) water bath for
30 seconds
• Must not have any tooth contact
• Articulate mandibular cast and verify CR
 Balanced Occlusion • Balanced articulation: the bilateral, simultaneous occlusal contact of the
anterior and posterior teeth in excursive movements
Lateral Excursions • Mandible
moves to the
right à right
working
• Working has to
do with the
movement of
the mandible

Protrusion • Forward
movement of
the mandible

Objectives • (1) To make MIP equal CO

• (2) To re-direct occlusal forces along the long axis of the teeth
• (3) To distribute occlusal forces to as many teeth as possible
Goals • Balancing side contacts to appear across the arch and within the tooth on
the working side of the arch
• Maintain the integrity of the “stamp” or central bearing cusp tips in both
arches (maxillary lingual and mandibular buccal cusps) and allow all cusps
to move through the “sluce ways of the opposing dentition” (working and
balancing groove sand mesial and distal inclines)
Occlusal Adjustments • A refinement, NOT a correction for poor technique
Selective Grinding • Adjust articulator to proper settings after the remount casts have been
mounted
• Carried out using articulating paper to mark premature contacts centric
and eccentric movements
• Use acrylic burrs to make necessary adjustments
Sequence of Occlusal • Centric relation position (black)
Equilibrium • Lateral (red)
• Protrusive (green)
• Re-check centric
Jaw Movements • WORKING: the side to which the mandible moves
• BALANCING (non-working): the side opposite to the side to which the
mandible moves
• PROTRUSION: forward movement of the mandible
• RETRUSION: backward movement of the mandible
Cusp-Fossa Relationship in • Maxillary palatal cusps in central fossa of mandibular
MIP molars
• MIP does not necessarily coincide with CO

Working and Balancing • Working side is side mandible

Sides moves to
• Balancing side is other side

Centric Relation • Lock the upper arm of the articulator in CR

• Check the occlusion by opening and closing the articulator, and lightly
tapping the teeth together on red articulating paper
• If the cusp tip is high in centric occlusion, only deepen the opposing fossa
• If the cusp is high in both centric and eccentric positon, then reduce the
cusp
Interferences in Centric • Goal: eliminate occlusal contacts on inclines
Occlusion (CO) • If cusps are too long you have to deepen
the fossae
• You may need to change the incline and
widen the fossa
Burrs Used • There are different kinds of burrs, like acrylic burrs, to make the
corrections
Premature Contacts in CO • Only see contacts on one side here
• You want to distribute contacts bilaterally so
they are all uniform

Bilateral Occlusal Contacts • Here we see multiple bilateral

contacts
• Must establish this before you give
it to the patient or they will not be
able to chew correctly because the
denture will not be stable

Occlusal Equilibrium: CR • After perfecting of CO, holding

cusps must NOT be shortened
Interferences in Working • Buccal and lingual cusps are too long
Side • If they are too long they might prevent the
balancing side from contacting
• Either touch the fossa or the incline, try not to
touch the stress bearing cusps
Interference in Working- • Rule of BULL
Side B-L Relationship • You may grind the BUCCAL cusps of the UPPERS & the LINGUAL cusps of
the LOWERS
• Reduce lingual inclines of buccal cusps of maxillary teeth
• Reduce buccal inclines of lingual cusps of mandibular teeth
Interference in Working- • Rule of MUDL
Side M-D Relationship • In lateral excursion you may grind the MESIAL incline of the
UPPER cusps & the DISTAL incline of the LOWER cusps

Occlusal Equilibrium: • See how teeth are

Working Side interdigitating
• You want to make sure this is
even among all teeth on that
side
Working Side Contacts • Use different colored articulating paper to measure different excursions
• You want 2 contacts in the back and one in the front

Interferences in Balancing- • Balancing side interferences can prevent you from

Side having working side contacts
• With natural dentition you don’t want contacts on the
other side
• But with dentures you do, otherwise they will tip during
function
Occlusal Equilibrium: • The lingual of the maxillary
Balancing Side and the buccal of the
mandibular are contacting
• Make sure they are
contacting and also not
interfering with the working
side function
Balancing Side Contacts • Note contact of lingual cusps of the maxillary
and buccal cusps of the mandibular
Interferences in Protrusion • Rule of DUML
• In protrusive excursion you may grind the DISTAL incline of
the UPPER cusps & the MESIAL incline of the LOWER cusps

Occlusal Equilibrium: • You want bilateral posterior contacts

Protrusion • Denture will tip during protrusion if there is no
posterior contact

Protrusive Contacts • One point of contact anteriorly and 2 points of contact posteriorly is
minimum you require for a balance
• The more contact you have, the better it is

Implant Retained Complete Dentures

10/11/17

Edentulous • Re-establish esthetics and phonetics

• Patterns of resorption
• Determination of prostheses type
Aging & Edentulism • 40% of the US population 65+ are edentulous in at least one arch
• By 2035 there will be a greater population over the age of 70 than under
70 in the US
Resorption • Ridges will resorb INDEFINITELY – continues for life of individual – one of
the things we can do to slow this down is placing implants
• Maxillary: ridges resorb in a backward and upward direction
o So as a guide you start setting the anterior teeth 10mm anterior to
the incisive papilla (to compensate for the resorption)
• Mandibular: ridge gets thinner which makes it appear wider

Resorption, Loss, and • Residual ridge remodeling

Healing • Rate is variable
o Fastest in the first 6 months
o Variable between different individuals
o Variable between same individual at different times
o Variable between same individual at different sites
• More in female patients, mostly post-menopausal women
 • More resorption happens in the mandible than the maxilla
• #1 complaint of edentulous patients: retention problems with the
mandibular denture
o 2 implant overdenture is one relatively inexpensive treatment that
deals with that
Implant Overdenture: • Chewing sensation (when patients lose all their teeth they lose their
Evidence of Improved proprioception – implants help patients regain some of this sensation)
Quality of Life • Improved stability and retention
• Improved chewing ability
• Improved health and nutritional status
Steps • (1) Denture fabrication and implant placement
• (2) Abutment selection
• (3) Abutment connection and torque
• (4) Pick up of attachments
• (5) Occlusion
• (6) Recall and follow up
Dentures – Guide for • Can mark the ideal implant location on the intaglio surface of the denture
Surgical Placement and transfer that to the mouth – then analyze that area in the mouth to
see if it is a good site for implant placement
Implant Placement • Look to place implant in between the mental foramina where there are no
nerves, and where the type of bone is most likely to have implant success
• No sinuses, no nerves – there is 99% success rate in this location
• There is a hole inside every implant fixture to receive the variety of things
that can be placed in the implant
o We put a healing cap/healing abutment to hold this space so
bacteria/tissue doesn’t get into the hole
Abutment Selection • Measure from implant head to
deepest tissue
• Immediately replace the healing
abutment
• We are either going to use a
narrow platform (pink) or a regular
platform (yellow) – they are all
color coded
• Pick the abutment according to the tissue height there
Locator Driver • Comes in two different styles
• Three-in-one driver

Abutment Connection • Hand tighten and take an x-ray

• Take an x-ray after you initially screw in the abutment to make sure you
have it completely seated – if it is not completely seated and you have
caught some tissue in there, it will cause a lot of discomfort for the
patient and can lead to infection
• If there is a lot of excess tissue getting in the way of screwing it in, the
tissue will need to be cut away
 Abutment Torque • Use to torque the screw to make
sure it is completely in place

Pick up of Attachments • Place white spacer ring over the collar of the
locator abutment before you pick it up with
acrylic – IF YOU FORGET THIS, THE DENTURE
WILL BE PERMANENTLY LOCKED INTO THE
PATIENT’S MOUTH (DO NOT LET THIS
HAPPEN!!!!!!!!! Major disaster.)
• Place housing with black processing male
over locator abutment
• Place marking medium on metal housing, in order to locate
implant/abutment position in underside (intaglio surface) of denture
• Seat denture until contact is made between the housing and the
underside of the denture
• Try in the denture, visualize attachments
o Make a through-and-through hole, so you can make SURE you
have enough space for the acrylic and that everything is in the
correct place and that the denture is seated fully
o Through the lingual access window, add acrylic resin to
housing/acrylic complex
o Make a dense mix – “cream cheese” consistency
If denture teeth are • Adequate amount of denture base should be
present over locator… removed in order NOT to alter the existing vertical
dimension of occlusion (VDO)
• Make a vent hole as well
Pick up Housing • Seat denture in centric occlusion to pick up housing
• Remove ring and black processing male (with attachment removal
instrument)
• Seat retention MALE into housing with attachment insertion tool
• Do a week of no retention with just the housing and then decide how
much pressure you want to include in the attachment
Overdenture Satisfaction • 98% of OD treated patients at NYU said that they would recommend it to
a friend
Summary • Every edentulous patient should be given the OD choice for the mandible
• Attachment male inserts should be changed approximately every year
• There is no such thing as a two implant overdenture for the maxilla –
more implants are required
• Treatment planning for the maxilla is far more complex
Retention Pressure • Blue: 1.5 lbs pressure
Options • Pink: 3 lbs pressure
Know this!! • Clear/White: 5 lbs pressure
 ANATOMY AND CLINICAL
SIGNIFICANCE OF DENTURE OUTLINE
BEARING AREAS
GROUP 3 INTRODUCTION
ANATOMY OF DENTURE BEARING
DEN/2012/004……….. Chairman
AREAS
DEN/2012/001……….. Secretary
DEN/2012/003 CLINICAL SIGNIFICANCE OF
DEN/2012/024
DENTURE BEARING AREAS
DEN/2011/015 CONCLUSION
DEN/2012/019 REFERENCES

ANATOMY OF DENTURE BEARING

INTRODUCTION AREAS
M.M Devan Dictum “Aim of a prosthodontist is not only the The anatomy of edentulous ridges in the maxilla and
meticulous replacement of what is missing, but also perpetual mandible is very important for the design of the complete
preservation of what is present” denture.

The total area of support from the mandible is significantly

A prosthesis must function in harmony with the tissues that less than from the maxilla.
support them and those that surround them.

The average available denture bearing area for an

Hence the dentist must understand the macroscopic as well edentulous mandible is 14cm2,whereas for edentulous
as microscopic anatomy of the supporting and limiting maxilla it is 24cm2. Therefore the mandible is less capable of
structures of the denture. resisting occlusal forces than the maxilla.
THE ORAL MUCOUS MEMBRANE
Serves as a cushion between the denture base and the
supporting bone.

Mucous membrane is composed of mucosa and sub mucosa.

ORAL MUCOUS MEMBRANE

Sub-mucosa is formed by connective tissue that varies from

dense to loose areolar tissue.

Mucosa covering the hard palate and the crest of the ridge is
classified as MASTICATORY MUCOSA.

The mucosa is characterized by its well defined

KERATINIZED EPITHELIUM.

ANATOMY OF DENTURE
BEARING AREA - MAXILLA
The ultimate support for the maxillary denture are the bones
of the two maxilla and the palatine bone.

The anatomical land marks in the maxilla are

LIMITING STRUCTURES
SUPPORTING STRUCTURES
RELIEF AREAS
 LIMITING STRUCTURES OF THE
MAXILLA LABIAL FRENUM
Single or double fibrous band covered
Limiting structures are sites that will guide us in having an by mucous membrane which extends
optimum extension of denture so as to engage maximum from labial aspect of residual alveolar
surface area without encroaching upon the muscle action. ridge to the lip.

Absence of muscle fibers.

These are structures that limit the extent of the denture:
1. Labial frenum CLINICAL SIGNIFICANCE
2. Labial vestibule Limits labial flange of denture.
3. Buccal frenum
4. Buccal vestibule It has to be relieved while making
impression in other to prevent
5. Hamular notch dislodgement of the denture and to
6. Posterior palatal seal prevent ulceration. It is seen as a V-
shaped notch in the impression.
7. Fovea palatinae

LABIAL VESTIBULE BUCCAL FRENUM

It extends from buccal frenum on one side to Band of fibrous tissue overlying the levator
the other, being divided into right and left by anguli oris, that divides labial vestibule from
buccal vestibule.
labial frenum.
Anteriorly: orbicularis oris muscle The orbicularis oris pulls frenum forward and the
Posteriorly: labial aspect of alveolar ridge. buccinator pulls it backward.

CLINICAL SIGNIFICANCE
It has a thin mucosa and thick submucosa Since it has muscular attachments, adequate
with large amount of loose areolar tissue and relief must be provided to prevent the
elastic fibers. dislodgment of denture.(that is, it can move
posteriorly as a result of the buccinator muscle
and anteriorly as a result of the orbicularis oris.)

CLINICAL SIGNIFICANCE It requires more clearance for its action than

The labial flange of the denture will be in labial frenum because it moves mesially,
complete contact with labial vestibule to buccally and vertically by orbicularis oris,
buccinator and levator anguli oris respectively.
provide a peripheral seal in the denture.
 BUCCAL VESTIBULE
Buccal vestibule extends from the buccal
frenum to the hamular notch.

Bounded externally by cheeks and internally by

residual alveolar ridge.
The size of the vestibule varies with the
contraction of the buccinator muscle.

CLINICAL SIGNIFICANCE
The patient’s mouth must be half open during
impression taking, because opening of mouth
during final impression causes the coronoid
process to move anteriorly narrowing the
buccal vestibule.

Compared to labial flange, buccal flange has

less interference and so provides maximum
retention.

HAMULAR NOTCH POSTERIOR PALATAL SEAL AREA

Hamular notch forms the distal limit of the
buccal vestibule, located between the tuberosity
and the hamulus of the medial pterygoid plate. Also known as post dam.

Pterygomandibular raphe is attached to the

hamular notch. “The soft tissues at or along the
junction of the hard and soft
It has thick submucosa made up of loose areolar palate on which pressure along
tissue. the physiological limits of the
tissues can be applied by the
CLINICAL SIGNIFICANCE the denture to aid in the
If denture border is short of the hamular notch retention of the denture.”-GPT
The denture will not have a posterior seal
resulting in loss of retention of the denture. (GLOSSARY OF
PROSTHODONTICS TERM)
If denture extend beyond hamular notch The
pterygomandibular raphe is pulled forward when
patient opens mouth causing dislodgement of
denture.
POSTERIOR PALATAL SEAL AREA DIFFERENCES
PARTS
Pterygomaxillary seal Postpalatal seal
postpalatal seal
pterygomaxillary seal It is the part of the It is the part of the
posterior palatal seal that posterior palatal seal area
extends across the that extends between the
hamular notch and two maxillary tuberosities.
extends 3 to 4 mm
EXTENSIONS anterolaterally to end in
anteriorly- anterior vibrating line the mucogingival junction
posteriorly- posterior vibrating line on the posterior part of the
maxillary ridge.
laterally- 3-4mm anterior-lateral to hamular notch

POSTERIOR PALATAL SEAL AREA VIBRATING LINE

“The imaginary line across the posterior part of the palate marking
Pterygomaxillary seal Postpalatal seal the division between the movable and immovable tissues of the
soft palate which can be identified when the movable tissue is
moving’’-GPT

Denture should extend 1-2mm posterior to this vibrating lines.

Types:

Anterior vibrating line

Posterior vibrating line
ANTERIOR VIBRATING LINE POSTERIOR VIBRATING LINE
It is an imaginary line lying at the It is an imaginary line located at the junction of the soft palate that
junction between the immovable shows limited movement and the soft palate that shows marked
tissue over the hard palate and movement.
the slightly movable tissues of
the soft palate.
This line is usually straight.

It is cupid bow shaped(because

of the shape of the underlying
bone).

Valsalva maneuver: The patient

is asked to close his nostrils
firmly and gently blow through his Arrow showing the bone that gives
bow shape to anterior vibrating line
nose, to locate the anterior
in edentulous patients.
vibrating line.

POSTERIOR PALATAL SEAL CONTD FOVEA PALATINAE

These are the depresssions or indentations situated on
CLINICAL SIGNIFICANCE: the soft palate on the either side of the midline.
It maintains contact with the anterior portion of the soft palate during
functional movements of the stomatognatic system (i.e mastication, It is formed by coalescence of the duct of several
deglutition and phonation). Therefore, the primary purpose of the mucous glands.
posterior palatal seal is the retention of maxillary denture.
The position of the fovea palatinae also influences the
Reduces the tendency for gag reflex as it prevents the formation of the posterior border of the denture.
gap between the denture base and the soft palate during functional
movements. The secretion of the fovea spreads as a thin film on the
denture therefore aiding in retention.
Prevents food accumulation between the posterior border of the denture
and the soft palate.
CLINICAL SIGNIFICANCE
In patients with thick ropy saliva, the fovea palatinae
should be left uncovered or else the thick saliva flowing
between the tissue and the denture can increase the
hydrostatic pressure and displace the denture.
SUPPORTING STRUCTURES OF
MAXILLA HARD PALATE
PRIMARY STRESS BEARING It is formed by palatine shelves of
the maxillary bone and the
HARD PALATE premaxilla.
POSTERO-LATERAL SLOPES OF THE RESIDUAL
ALVEOLAR RIDGE
Lined by keratinised epithelium.

The horizontal of the hard palate

SECONDARY STRESS BEARING AREA provides the PRIMARY STRESS-
RUGAE BEARING AREA.
MAXILLARY TUBEROSITY
ALVEOLAR TUBERCLE
CLINICAL SIGNIFICANCE
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.

POSTERO-LATERAL SLOPES OF
THE RESIDUAL ALVEOLAR RIDGE RUGAE
“The portion of the alveolar ridge and its soft These are the mucosal folds located in the anterior
tissue covering which remains following removal region of the palatal mucosa.
of the teeth.”-GPT
In the area of rugae, the palate is set at an angle to the
Lined by thick stratified squamous epithelium. residual alveolar ridge and is thinly covered by soft
tissue which contributes to the secondary stress
bearing area.
Even though the sub-mucosa is thin it sufficiently
provide adequate resiliency to support the
denture. CLINICAL SIGNIFICANCE
It resorbs rapidly following extractions and It is associated with the sensation of taste and the
continues throughout life at a reduced rate. function of speech.
They assist the tongue to absorb via its papillae.
They also enable the tongue to form a perfect seal
CLINICAL SIGNIFICANCE when it is pressed against the palate in making linguo-
palatal constant stops of speech.
The vertical forces during physiological activities Rugae should not be displaced, otherwise the
like mastication falls on denture and is rebounding may dislodge the denture.
transmitted posteriorly. The postero-lateral
slopes of the ridge bears the force and hence is They provide antero-posterior resistance to movement
the primary supporting structure. of the denture and increased surface surface area
helps in retention.
MAXILLARY TUBEROSITY NOTE
It is the bulbous extension of the
residual alveolar ridge in the 2nd Residual ridge was first considered to be a primary stress bearing
and 3rd molar region, terminating in area but it is now considered a secondary stress bearing area
the hamular notch. because of the fact that bone is subjected to continuous resorption
though it decreases as the span of edentulism increases.

CLINICAL SIGNIFICANCE
The area is less likely to resorb.

Artficial teeth are not set on

tuberosity region.

The tuberosities sometimes

exhibit buccal undercuts, if it is
unilateral it can be utilized for the
retention.

RELIEF AREAS INCISIVE PAPPILAE

These are areas in the denture bearing areas which should be It is the midline structure situated behind the
relived during construction of dentures. central incisors.

Incisive papillae
Incisive foramen lies immediately beneath
Mid-palatine raphe the papillae.
Fovea palatine
Palatine torus As resorption progresses, it comes to lie
Rugae nearer to the crest of the ridge.
The naso-palatine nerves and vessels pass
through it.

CLINICAL SIGNIFICANCE
While making final impression pressure
should not be applied on this region.
MID-PALATINE RAPHE FOVEA PALATINE
This is the median suture area covered
by a thin sub-mucosa, so the mucosa Bilateral indentations near the midline of
layer is in close contact with the palate. Posterior to junction of hard and soft
underlying bone palate
These are a pair of mucous gland duct
orifice near the midline at the junction of the
For this region, the soft tissue covering
hard and the soft palate
the median palatal tissue is non-
Formed by coalescence of several mucous
resilient in nature and may need to be
gland duct
relieved.

CLINICAL SIGNIFICANCE
CLINICAL SIGNIFICANCE Aids in determining vibrating line
If pressure is applied during These landmarks provide a guide to the
impression making,the denture base position of the posterior palatal border of a
will cause soreness over the denture
midpalatine raphe area.

PALATINE TORUS RUGAE

A developmental bony prominence Irregular shaped ridges of the
sometimes seen in the centre of the connective tissue covered by
palate. This structure is often covered mucous membrane in the anterior
by relatively incompressible third of the hard palate
mucoperiosteum

CLINICAL SIGNIFICANCE CLINICAL SIGNIFICANCE

If it is small, the denture is relieved Should not be disturbed by
A mucosally supported denture may impression for maximum comfort
need to be relieved over the torus to
prevent the denture rocking and flexing
about the mid line.
ANATOMY OF DENTURE BEARING
AREAS- MANDIBLE
These are areas in mandible that are closely related to the base of
the mandibular complete denture. They are covered with mucosa
and sub mucosa of varying degree of thickness and compressiblity.
ANATOMICAL LANDMARKS OF
EDENTULOUS MANDIBLE
The anatomical landmarks in the mandible are ;

LIMITING STRUCTURES
SUPPORTING STRUCTURES
RELIEF AREAS

LIMITING STRUCTURES OF THE

MANDIBLE LABIAL FRENUM
It is a fold of mucous membrane at the
LABIAL FRENUM median line. It divides the labial vestibule into
LABIAL VESTIBULE left and right labial vestibule.
It consist of band of fibrous connective tissue
BUCCAL FRENUM and helps to attach orbicularis oris muscle.
BUCCAL VESTIBULE
LINGUAL FRENUM It is shorter and wider than the maxillary labial
frenum.
ALVEOLOLINGUAL SULCUS
RETROMOLAR PAD CLINICAL SIGNIFICANCE
PTERYGOMANDIBULAR RAPHE During final impression, making sufficient
relief must be given without compromising
the peripheral seal.
The frenum is quite sensitive and active,
and the denture must be fitted carefully
around it to maintain a seal without causing
soreness.
LABIAL VESTIBULE BUCCAL FRENUM
It runs from the buccal frenum to buccal The buccal frenum forms the dividing
frenum. It is divided into left and right by line between the labial and buccal
labial frenum.
vestibule.
Fibers of orbicularis oris,incisivus and May be single or double, broad U
mentalis are inserted near the crest of shaped or sharp V shaped.
the ridge. Mentalis muscle is an active It overlies depressor anguli oris
muscle.
muscle.
Fibres of the buccinator muscle
CLINICAL SIGNIFICANCE attach to the frenum.
Extent of the denture flange in this region is
often limited because of muscle that are
inserted close to the crest of the ridge. CLINICAL SIGNIFICANCE
Relief for buccal frenum is given in
Thick denture flanges may cause denture to avoid displacement of
dislodgement of dentures when patient
opens the mouth wide open. the denture.

BUCCAL VESTIBULE LINGUAL FRENUM

Extends from buccal frenum to retromolar pad. It is a fold of mucous membrane existing when
the tip of the tongue is elevated.
It is nearly at right angles to biting forces. It overlies the genioglossus muscle which takes
origin from the superior genial tubercle.
Extent of the buccal vestibule is influenced by The anterior region of the lingual flange is
buccinators muscle,which extends from modiolous called sub-lingual crescent area.
anteriorly to pterygomandibular raphe.

The masseter muscle contracts under heavy closing CLINICAL SIGNIFICANCE

force and pushes inward against the buccinators
muscle to produce a massetric notch in the distobuccal The relief for the lingual frenum should be
border of the lower denture. registered during function.
CLINICAL SIGNIFICANCE A short frenum is called tongue tie. It should be
corrected if it affects the stability of the denture.
The distobuccal border of the lower denture should
accommodate the contracting masseter muscle so that
the denture does not dislodge during heavy closing
force.
 ALVEOLOLINGUAL SULCUS-
ALVEOLOLINGUAL SULCUS RETROMYLOHYOID SPACE
It is the space between residual ridge and tongue.
The retromylohyoid space lies at
Extends from lingual frenum to rectomylohyoid curtain
distal end of the alveololingual
It has 3 regions (anterior, middle and posterior) sulcus
The anterior region extends from the lingual frenum back to where mylohyoid
muscle curves above the level of the sulcus (premylohyoid fossa)
The middle region extends from premylohyoid fossa to the distal end of the It is bounded by anterior tonsillar
mylohyoid ridge, curving medially from the body of mandible. The curvature is pillar, posteriorly by the
caused by the prominence of mylohyoid ridge and the action mylohyoid retromylohyoid curtain
muscle
The posterior region: here, the flange passes into the rectomylohyoid fossa
and completes the TYPICAL S FORM of the correctly shaped lingual flange

CLINICAL SIGNIFICANCE
The lingual flange of the lower denture will be short anteriorly than posteriorly
The lingual flange in the middle region slopes medially towards the tongue

ALVEOLOLINGUAL SULCUS-
RETROMYLOHYOID CURTAIN RETROMOLAR PAD
It is a non-keratinised triangular pear-shaped pad
Formed posteriorly by the of tissue at the distal end of the lower ridge.
superior constrictor muscle, Submucosa contains glandular tissue, fibers of
laterally by the mandible and buccinators and superior constrictor muscle,
pterygomandibular raphe and terminal part of the
pterygo-mandibular raphe,
tendon of the temporalis.
anteriorly by lingual
The retromolar papilla is a pear shaped area just
tuberosity, and inferioirly by anterior to the retromolar pad, it is a dense
the mylohyoid muscle fibrous connective tissue.

CLINICAL SIGNIFICANCE
NOTE: RMC IS The distal end of the denture pad should
RETROMYLOHYOID cover 2/3rd of the retromolar pad.
CURTAIN
The retromolar pad provides the
peripheral posterior seal for the lower
denture.
 SUPPORTING STRUCTURES OF THE
PTERYGOMANDIBULAR RAPHE MANDIBLE
Raphe is a tendinous insertion of two These are areas responsible for bearing loads in the
muscles. mandible.
Arises from the hamular process of the
medial pterygoid and gets attached to the
mylohyoid ridge. Buccal shelf area
Muscular attachments present here are: Residual alveolar ridge
superior constrictor: postreolaterally
Buccinator: anterolaterally

CLINICAL SIGNIFICANCE
Since it is very prominent in some
patients, a notch like relief must be
provided on the denture.

BUCCAL SHELF AREA BUCCAL SHELF AREA

It is the area between buccal frenum and anterior
border of masseter muscle.
BOUNDARIES:

Medially-the crest of the ridge.

Distally-the retromolar pad
Laterally-the external oblique ridge.

The mucous membrane covering the buccal shelf

area is loosely attached, less keratinized and
contains a thick submucosa overlying a cortical plate.
CLINICAL SIGNIFICANCE
It lies at right angles to the vertical occlusal
force; this makes it suitable as primary stress
bearing area for lower denture.
RESIDUAL ALVEOLAR RIDGE RELIEF AREA
The edentulous mandible may become flat, due to resorption;
which results into outward inclination and progressively
widening of mandible. Mental foramen
Similarly maxilla resorbs upward and inward making it smaller. Genial tubercle
It is the reason for edentulous patients to have prognathic
Mylohyoid ridge
apperance Mandibular tori
The slopes of residual alveolar ridge have thin plate of cortical
bone. The slopes of the ridge are at an acute angle to occlusal
forces.

Hence, it is considered as a SECONDARY stress bearing

area.

Since crest of the ridge has cancellous bone, it is not

favourable as primary stress bearing area.

CLINICAL SIGNIFICANCE.
Any movable soft tissue overlying the ridge should not be
compressed while making impression.

MENTAL FORAMEN GENIAL TUBERCLE

It lies between the 1st and 2nd
premolar region. The genial tubercle are a pair of dense
prominences at the inferior border of the
mandible at the lingual midline
Due to ridge resorption, it may lie
They represents the muscle attachment of
close to the ridge.
the genioglossus and geniohyoid muscle.

CLINICAL SIGNIFICANCE CLINICAL SIGNIFICANCE

It should be relieved in these areas
They only become relevant in the denture
as pressure over the nerve passing
when there is excessive resorption of the
through it can get compressed by
residual ridge.
denture base leading to
paraesthesia (numbness) of lower
lip.
MYLOHYOID RIDGE MANDIBULAR TORI
The mylohyoid ridge is a bony These are the abnormal bony
prominence along the lingual aspect of prominence found bilaterally on the
the mandible lingual side, near the premolar region
Soft tissue usually hides the sharpness of but they may extend posteriorly to the
the mylohyoid ridge molar area
Anteriorly, this ridge with mylohyoid It is covered by thin mucosa.
muscle is close to the inferior surface of
the mandible
Posteriorly, after resorption, it often CLINICAL SIGNIFICANCE
flushes with the residual ridge.
It has to be relieved or surgically removed,
according to its size and extent.
CLINICAL SIGNIFICANCE Small tori may only require relief in the
The mucosa membrane overlying the denture
sharp or irregular mylohyoid ridge needs
Large tori requires removal before a
to be relieved because denture base
might easily traumatize it. denture can be fabricated.

CONCLUSION REFERENCES

Thus, we see that a sound knowledge of the Prosthodontic treatment for edentulous patient : Zarb
anatomical landmarks of the denture bearing area is a Bolender
prerequisite, if one has to achieve the objective one
Preclinical manual of prosthodontics : S Lakshmi
has in mind; fabrication of a complete denture that has
maximum retention, stability and support with Impressions for complete dentures : Bernard Levin
preservation of underlying structures with minimum Textbook of Prosthodontic : Nallasyamy
post insertion problems. Boucher’s prosthodontics treatment for edentulous
patients. 13th Edition
Heartwell’s syllabus of complete denture. 4th edition.
 significance of maxillary
denture bearing area and
good related anatomy
morning
PRESENTED BY
DR NARAYAN SUKLA
1ST YEAR PG
DEPART MENT OF PROSTHODONTIA

- Introduction introduction
- bony structures The anatomical significance and the anatomy of the
edentulous ridge in the maxilla and mandible is
- mucous membrane very important for the design of a complete
- limiting structures denture
Our objective in fabrication of a complete
- supporting structures denture is to provide for a prosthesis that
- relief areas restores lost teeth and associated structures
functionally, anatomically and aesthetically as
-conclusion much as possible with preservation of
- reference underlying structures and the knowledge
landmarks help us in achieving our objective.
osseous structures Mucous Membrane
The osseous Boucher pg no 148 Mucous membrane
structures not only fig serves as a cushion
------compact bone
support the denture between the
but also have an denture base and ---------periosteum
direct bearing on supporting bone.
impression making Mucous membrane
is composed of -------sub mucosa
procedure. mucosa and sub
Maxillary denture is mucosa. --------mucosa
supported by two Sub mucosa is
pairs of formed by
connective tissue
bones, maxillae & that varies from
palatine bone. dense to loose
areolar tissue and
varies in thickness.

Mucous Membrane
Thickness and consistency of the sub mucosa
are responsible for the support that the
mucous membrane affords a
denture, because the sub mucosa makes up
the bulk of mucous membrane.
In healthy mouth the sub mucosa is firmly
attached to the periosteum of bone and will
withstand the pressure of dentures.
If sub mucosa is thin, soft tissue will be non
resilient and mucous membrane will be easily
traumatized.
 Limiting structures
According to the clinical significance
These are the sites that will
guide us in having an optimum extension
Landmarks of the denture so as to engage
of edentulous jaws maximum surface area without
encroaching upon the muscle actions
Encroaching upon these structures will
Limiting structures
Supporting
Relief areas lead to dislodgement of the denture
structures
and/or soreness of the area while failure
to cover the areas upto the limiting
structure will imply decreased retention
stability and support.

Labial vestibule
Labial frenum Labial vestibule (sulcus)-The part of the
oral cavity which is bounded on one side
by the teeth, gingiva and residual
It is a fold of mucous alveolar ridge and on the outer side by
membrane at the median line lips. It runs from one side of the buccal
frenum of one side to the other side
It contain no muscle fiber ;dividing in two compartments-left and
and has no action of his own right by the labial frenum

CLINICAL SIGNIFICANCE Labichal notch This area is covered by non keratinized

epithelium with areolar tissue
Sufficient allowance should CLINICAL SIGNIFICANSE
be created in final impression The outer surface of the labial vestibule
is the orbicularis oris.* Its fibers run in a
and in complete denture horizontal direction; so it has an indirect •Labial flange
prosthesis effect on the denture base
If the frenum is attached Reflection of the m m superiorly marks
close to the creast the height
frenectomy should be done The area of reflection has no muscle
attachment
The labial notch of the Due to this the tissue in this region is
denture should be narrow but movable and lead to over extension
deep enough to avoid Overextension causes
interference instability/soreness.
Buccal frenum Buccal vestibule (sulcus)
Single or double folds of mucous
membrane. Extends from anteriorly buccal frenum
Broad and fan shaped. to the hamular notch posteriorly.
Laterally by buccal mucosa, medially
The buccal frenum is the dividing line by the residual alveolar ridge
between the labial & buccal vestibules.
It is related to three muscles, so it The size of the vestibule is dependant
requires more clearance than the labial
Buccal notch upon- contraction of buccinator Buccal flange
frenum muscle
Buccal frenum-Attachment of following position of the mandible
muscles;levator anguli oris,orbicularis
oris,buccinator. amount of bone loss
The caninus ( levator anguli oris) CLINICAL SIGNIFICANSE
attaches beneath and affects its To record maxillary buccal sulcus, the
position mouth should be half way closed
The orbiculeris oris pulls the frenum The size & shape of distal end of buccal
forward and buccinators pulls flange depend up on movement of
backward
ramus of mandible at the disital end of
CLINICAL SIGNIFICANCE the buccal vestibule
Moves with muscles of cheek during Hence the patient move the mandible in a
speech and mastication. lateral protrusive relation so that
During final impression and in coronoid process dose not interfere
prosthesis clearance should be with these function
created for the movement of the Improper extension causes
frenum overriding will cause pain and
dislodgement of denture instability/soreness
During impression the cheeck should
be reflected laterally and posteriorly

The pterygomaxillary (hamular) notch Posterior palatal seal area[post

It is depression situated between the
dam]-
Soft tissue at or along the junction of the
maxillary tuberosity and the hamulus soft and hard palate on which the
of the pterygoid plate .It is a soft area pressure within the physiological
of loose connective tissue. limits of the tissue can be applied by
clinical significance a denture to aid in the retention of the
Used as a boundary of the posterior denture
border of maxillary denture Made of two regions·→
In cases showing gross alveolar [Link] seal-The part of the
resorption the hamular notch posterior palatal seal that extends
disappear, so the back edge of the across the hamular notch. It extends
denture is not carried too far 3-4 mm anterolaterally to end in the
The denture border should extend till mucogingival junction on the posterior
hamular notch part of the maxillary ridge.
Aids in achieving posterior palatal [Link] palatal seal-This is a part of
seal area
the posterior palatal seal area that
Over extension cause soreness extends between the two maxillary
Underextention cause poor retention tuberosity
Posterior palatal seal area[post
dam]-
Clinical significance
Supporting structures
Reduces the tendency for gag reflex due to Masticatory forces produce quite a
downward movement of the denture during pressure on the underlying structures
incising
.it maintains contact of denture with soft and not everyplace beneath the
tissue denture can take such stress hence
during functional movements of stomatognathic we need to know the areas which can
system, by which it decreases gag reflex.
bear the stresses well.
. Decreases food accumulation with
adequate tissue compressibility. Support is the resistance to the
Decrease patient discomfort of tongue with displacement towards the basal tissue or
underlying structures.
posterior part of denture.
Compensation of volumetric shrinkage that These can be divided into-
occurs during the polymerization [Link] stress bearing area
Increases retention and stability by creating [Link] stress bearing area
partial vacuum.
Increased strength of maxillary denture
base.
ref JIADS VOL -1Issue 1 Jan-March,2010 |20|

Supporting structures Primary stress bearing area

These are the areas that are most
capable to take the masticatory
load providing a proper support
to the denture.
Primary stress bearing area Secondary stress bearing Some desired properties for
area primary stress bearing area
are-
[Link] horizontal portion of 1. the rugae area [Link] adherent sufficient fibrous
the hard palate [Link] tubeorcity connective tissue with an
overlying keratinized mucosa
lateral to the [Link] of cortical bone cover
midline –posterolateral [Link] be at right angles to the
vertical occlusal forces.
slopes [Link] underlying structures should
[Link] of residual alveolar be present that will get harmed
due to stress
ridge
Primary stress bearing area
Hard Palate
Residual alveolar ridge
- The anterior region of the hard
palate is formed by the palatine The portion of the residual
selves of maxillary bone
bone , soft tissue covering
- The posterior part is formed by
horizontal part of palatine bone that remains after the
- Covered by keratinized stratified removal of teeth .
squamous epithelium The residual ridge consist of
- Anterolaterally, the sub mucosa
contains adipose tissue. mucosa sub mucosa
- Poster laterally, it contains periosteum and the residual
glandular tissue. alveolar bone
Clinical significance Clinical significance
- The horizental portion of the hard
palate provides the primary It is the foundation of
stress-bearing area. denture
It is the primary stress
bearing area

Secondarystressbearingare Maxillary Tuberosity

arugae area It is the bulbus extension of the
residual ridge in the 2nd and 3rd molar
Raised areas of dense connective region
tissue radiating from the median
suture in the anterior 1/3rdof It is the distal aspects of the posterior
palate ridge terminating in the hamular notch
It consists of series of ridges in Clinical significance
the anterior part of the hard
palate The medial & lateral walls resist the
Sets at an angle to residual horizontal and torquing forces which
ridge & covered by thin soft would move the denture base in
tissues
lateral or palatal direction.
Clinical significanse Therefore, maxillary denture base Area of tuberosity
It is considered as a secondary should cover the tuberosities and fill
stress bearing area
the hamular notches.
Should not be distorted in the
impression. Gross enlargement(fibrous or bony –
surgical correction.
 Incisive papilla
Relief area Incisive papilla is a mass of fibrous
tissue about 1cm behind the upper
These are the areas which either resorb incisors.
under constant load or have fragile It is an exit point of nasopalatine
nerves and vessels
structures within or are covered by thin
mucosa which can be easily clinical significance
Its position in the edentulous mouth
traumatized indicates where the incisors and
& hence should be relieved. canines should be set.
It should be relieved failure of which
Incisive papilla would result in necrosis of the
distributing areas and paresthesia of
Mid palatine raphae anterior palate. burning sensation
and pain.
fovea palatinae
Denture base should be relieved over
the area to avoid pressure to the
nerves & blood vessels.

Mid palatine raphe

Median suture area covered by thin sub Fovea Palatina
mucosa Bilateral indentations near the midline of
Extends from incisive papilla to distal end palate. Posterior to junction of hard and
of hard palate. soft palate.
In the region of medial palatal suture , the These are a pair of mucous gland duct
sub mucosa is extremely thin ; so relief orifices near the midline at the junction of
should be provided to avoid trauma or
rocking of the denture
the hard and soft palate.
Formed by coalescence of several
Clinical significance mucous gland ducts.
Relief is to be provided as it is
supposed to be the most sensitive part clinical significance
of the palate to pressure Aids in determining vibrating line.
Relieve adequately to avoid trauma from These landmarks provide a guide to the
denture base. Median palatine groove position of the posterior palatal border of
a denture
 Conclusion References
Thus, we see that a sound Boucher's Prosthodontics
knowledge of the anatomical
Essential of complete denture prosthesis
landmarks of the edentulous
jaw is a prerequisite if one by Sheldon Winkler
has to achieve the objective Clinical dental prosthetics by h r b fenn
one has in mind; fabrication of
a complete denture that has
maximum retention, stability
and support with preservation
of underlying structures with
minimum post insertion
problems.

Thank u
 ADVANCED PROSTHODONTICS: Exam 1
Charlotte Guerrera

Diagnosis and Treatment Planning for Fixed, Removable, and Implant Restorations
4/10/18

Class Information • There are NO MAKE-UPS for missed quizzes

• A make-up exam can be offered ONLY students who have approved
There is going to be a excuse/leave of absence from Dean's Office for Academic/Student Affairs
question on this the exam date. If you have an approved excuse/leave of absence from the
Dean's Office for Academic/Student Affairs, you need to contact the
Dean's Office for Academic/Student Affairs before the exam and I need to
receive an email DIRECTLY (NOT FROM YOU) from the Dean's Office
confirming your approved excuse/leave of absence before the exam.
Otherwise, I am not allowed to give you a make-up exam.
Treatment Planning • “Treatment planning consists in formulating logical sequence of
treatment designed to restore the patient’s dentition to good health, with
optimal function and appearance”
• IDENTIFICATION OF PATIENT NEEDS
• Successful treatment planning is based on proper identification of the
patient’s needs. If an attempt is made to have the patient conform to the
“ideal” treatment plan rather than have the treatment plan conform to
the patient’s needs, success is unlikely. Frequently, several treatment
plans are presented and discussed, each with advantages and
disadvantages. Indeed, failing to explain and present alternatives may be
considered legally negligent.
• Treatment is necessary to accomplish one or more of the following
objectives: correcting an existing disease, preventing future disease,
restoring function, and improving appearance.
Decision Making Process • 1. Gathering information and defining diagnosis
• 2. Predicting diagnosis
• 3. Deciding on a treatment option
• Consider: chief complaint, personal details, medical history, dental history
Chief Complaint • The accuracy and significance of the patient’s primary reason or reasons
for seeking treatment should be analyzed first. Therefore, when a
comprehensive treatment plan is proposed, special attention must be
given to how the chief complaint can be resolved.
• The inexperienced clinician trying to prescribe an “ideal” treatment plan
can lose sight of the patient’s wishes. The patient may then become
frustrated because the dentist apparently does not understand or does
not want to understand the patient’s point of view.
• Chief complaints usually belong to one of the following four categories:
o Comfort (pain, sensitivity, swelling)
o Function (difficulty in mastication or speech)
o Social (bad taste or odor)
o Appearance (fractured or unattractive teeth or restorations,
discoloration)
Personal Details • The patient’s name, address, phone number, sex, occupation, work
schedule, and marital and financial status are noted. Much can be learned
in a 5-minute, casual conversation during the initial visit.
Medical History • An accurate and current general medical history should include any
medication the patient is taking, as well as all relevant medical conditions.
• 1. Conditions affecting the treatment methods (e.g., any disorders that
necessitate the use of antibiotic premedication, any use of steroids or
anticoagulants, and any previous allergic responses to medication or
dental materials). Once these are identified, treatment usually can be
modified as part of the comprehensive treatment plan.
• 2. Conditions affecting the treatment plan (e.g., previous radiation
therapy, hemorrhagic disorders, extremes of age, and terminal illness).
These can be expected to modify the patient’s response to dental
treatment and may affect the prognosis.
• 3. Systemic conditions with oral manifestations. For example,
periodontitis may be modified by diabetes, menopause, pregnancy.
Dental History • 1. Periodontal history
o Current oral hygiene and patient education
• 2. Restorative history
o Reflects the prognosis and probable longevity of any future
restorations
• 3. Endodontic history
o Periapical health should be monitored for any recurring lesions
• 4. Orthodontic history
o Root resorption may be attributable to previous orthodontic
treatment
o As the crown/root ratio is affected, future prosthodontic
treatment and its prognosis may also be affected
• 5. Removable prosthodontic history
o Listening to the patient’s comments about previously unsuccessful
removable prostheses can be very helpful in assessing whether
future treatment will be more successful
• 6. Oral surgical history
o Information about missing teeth and any complications that may
have occurred during tooth removal is obtained
• 7. Radiographic history
o Previous radiographs may prove helpful in judging the progress of
dental disease
• 8. Temporomandibular joint dysfunction history
o A history of pain or clicking in the TMJs or neuromuscular
symptoms, such as tenderness to palpation, may be caused by TMJ
dysfunction, which should normally be treated and resolved
before fixed prosthodontic treatment begins
Diagnosis Phase • Gathering of relevant information
o Radiographs and photographs
o Clinical examination
o Impressions
o Mounted casts
Treatment Planning Phase • Evaluation of dentition
• Single tooth replacement
o Dental implant (offer as first option)
o 3-unit FPD (offer as second option)
o Do nothing (last resort)
• Loss of a mandibular first molar not replaced with a fixed dental
prosthesis. The typical consequences are supraclusion of opposing teeth,
tilting of adjacent teeth, and loss of proximal contacts. (test question)
Evaluating Abutments • Available sound tooth structure (crown to root ratio)
• Endodontic status
• Periodontal status
Periodontal Prognosis • Supporting tissues should be evaluated for:
o Presence/absence of Inflammation
o Crown-to-root ratio (ideal is 2:3, acceptable is 1:1)
o Root configuration (divergent better than fused)
o Loss of attachment
o Mobility
• Periodontal ligament area:
o Combined surface area of premolar and molar is GREATER than
missing tooth – this is the best
o Combined surface area of premolar and molar is EQUAL to missing
teeth – this is minimally acceptable
o Combined surface area of premolar and molar is EXCEEDED by
that of the missing teeth – CANNOT make a bridge with this – the
only case in which this might not be contraindicated is in the lower
anterior area where the teeth are really narrow
Normal Periodontal • No loss of attachment
Ligament • Probing depths of 1-3mm
• No BOP
• No furcation, no mobility
• Biologic width: epithelial attachment (0.9mm) + connective tissue
(1.07mm) (this is important)
Biologic Width • Violation of the biologic width:
o Edema
o Erythema
o Bleeding
• The margin of your restoration should be located 0.5-1mm AWAY from
the biologic width
• Finish line can’t be on a restoration material – must be on sound tooth
structure
Periodontal Prognosis • GOOD: less than 25% of attachment loss
• FAIR: 25% attachment loss, CL I furcation
• POOR: 50% attachment loss, CL II furcation, pocket depth 6-8mm
• HOPELESS: 75% attachment loss, CL III furcation, pocket depth 8-10mm,
mobility class III
• QUESTIONABLE: 50% or more attachment loss, CL II furcation, pocket 6-
8mm, poor root form, poor Crown:Root ratio
 Endodontic Prognosis • Supra-crestal tooth structure
• Ferrule
• What are the treatment options for failing endo?
o Re-treatment, crown lengthening, post/core, crown
o Apicoectomy, crown lengthening, new crown
o Extraction, implant, crown
• Before making a final decision, DETERMINE RESTORABILITY of tooth or
abutment
o Evaluate need for crown lengthening
o Excavate decay
Multiple Missing Teeth à • Treatment options:
Partial Edentulism o Removable (just RPD, survey crowns + RPD)
o Fixed (implant, FPD)
o Do nothing
Conclusions • Multiple factors need to be assessed when treatment planning a patient
• Collection of records is crucial to determine the best treatment plan
option for a patient
• It is important to assess the mouth as a system, and then each individual
tooth
• Final treatment plan should always consider patient desires and well-
being, as well as long term prognosis of restorations

Principles of Tooth Preparation and Concept of Margin Design

4/10/18

Lecture Objectives • Principles of tooth preparation

o Retention and resistance form
§ Angle of convergence
§ Height/width ratio
§ Arc of displacement
§ Auxiliary grooves
• Margin preparation
o Types of margin design
o Selection of margin design
o Location of the margin
What is tooth preparation? • To remove tooth structure with certain principles to replace it with dental
materials in order to restore form, function, and esthetics
Aims of Tooth Preparation • Preserve as much tooth structure as possible to provide retention and
resistance to the restoration
• Provide enough space for restorative materials to withstand occlusal
forces
• Create harmonious axial contours and margin location to provide proper
emergence profile
Retention & Resistance • Retention: path of insertion
• Resistance: apical or oblique direction
• Taper: 6 degree angle of convergence/3 degree angle of inclination
• Optimum angles of convergence for various teeth groups:
o Anterior teeth: 10 degrees
 o Premolars: 15 degrees
o Molars: 20 degrees
§ It is more difficult to prepare parallel
walls in the posterior
• Correlation between height and angle of convergence
• Correlation between height and arc of displacement
o Height should be in contact with inner
surface of crown and prevent it from
dislodging
o If it is not high enough, there will be nothing
to prevent this tooth from tipping off the
preparation
Minimum Height • Molars: ≥4mm
Requirement o Greater taper
o Greater diameter
o Greater occlusal forces
• Other teeth: ≥3mm
Height/Width Ratio • Occlusal-cervical: height
• Mesial-distal: width
• Height/width ratio: ≥0.4mm
Correlation between width • Alternatives:
and the arc of o (1) Prophylactic endodontic
displacement treatment + post/core
o (2) Crown lengthening
• Narrow vs. wide teeth but same height –
the one with narrower diameter is more retentive because it will have a
greater arc of displacement
• Can increase resistance by:
o Adding auxiliary grooves
o Post and core
o Crown lengthening
Auxiliary Grooves • Facial & lingual grooves: prevent dislodgement in mesial and distal
direction
• Mesial & distal groove: prevent dislodgement in facial and lingual
direction
o We prefer these grooves because usually there are teeth on the
mesial and distal sides of the tooth (which are preventing
dislodgement in the mesial/distal direction) so we are more
worried about dislodgement in the facial/lingual direction
• Proximal grooves – what we prefer
o Complete resistance to faciolingual dislodgement
o Mesiodistal preparation more parallel, less taper
• Faciolingual grooves
o Complete resistance to mesiodistal dislodgement
o Faciolingual preparation less parallel, more taper
Axial Wall Preparation • Remove enough tooth so that we
have enough room for restorative
materials so it doesn’t break
• If you don’t have enough
reduction, either the technician will
make the restorative material too thin to prevent a bulky restoration, but
this will be more likely to fracture – OR they will use a sufficient amount
of material, but this will give you a bulky restoration that will not look
natural and that will have undercut areas which will accumulate plaque
and eventually cause periodontal issues
Occlusal Surface • We want anatomical tooth
Preparation preparation so that we can have
even thickness of restorative
material on the occlusal surface
• If you don’t recreate the occlusal
surface, you will either end up with some areas that are not reduced
enough, or some areas that are reduced too much
Consequences of Poor
Tooth Preparation

No Undercuts • Mostly happens when preparing the margin, due to overtipping the bur
• Remember:
o On a non-prepared tooth, the height of contour is at the mid
portion of the clinical crown
o On a prepared tooth, the height of contour should be at the
closest portion to the margin
• If undercuts seating problems cement wash-out
• Follow the geometric shape of the root throughout the axial wall
o Developmental grooves on the roots of canines and premolars
o Furcations of premolars and molars
o If not overcontour at the gingiva level periodontal
problems, caries at the margins
Rule of Thumb • Remove all pre-existing fillings that you have not placed in to make sure
the tooth structure is caries-free
• Radiographs may be misleading and not show recurrent caries due to
overlapping of filling material and caries lesion
Margin Preparation • Types of margin design
o Chamfer is the gold standard
• Selection of margin design
• Location of the margin
 Chamfer • Full ceramic restorations
• Ceramo-metal restorations
• Full metal restorations
• Easy to form
• Readily visible on prepared tooth, impression and die
• Strength and esthetics for ceramic
Rounded Shoulder – Labial • Full ceramic restorations
Butt Margin/Ceramic Butt • Ceramo-metal restorations
Margin • Full metal restorations
• Strength and esthetics for ceramic
Shoulder with Bevel • Ceramo-metal restorations
• No esthetic concern
• Cement may prevent full seating
• No porcelain may be placed on a bevel
• Bevel cannot be less than 45 degrees
because this will prevent excess cement from
squeezing out so the restoration will not seat completely and it will be in
hyperocclusion
Knife Edge • No definite finish line
• Causes overcontour
• Difficulty in waxing and casting
Location of Margin • Supragingival
• Gingiva level
• Subgingival
Advantages of • Dentist:
Supragingival Margins o Easy tooth preparation
o Easy impression
o No tearing of impression
o Easy fit evaluation
• Technician:
o Readable margin
• Patient:
o Easily cleansable
o No biological width injury
Subgingival Margin • Previously existing restoration
Indication • Caries
• Retention and resistance
• Esthetics
• Hypersensitivity
Rule of Thumb • Place margins on the tooth structure, never on fillings, core materials or
cast post and cores
• Very subgingival à crown lengthening
• The fact that the finish line is subgingival is NOT AN EXCUSE to place your
crown margin on fillings or post and cores
Summary • 1. Ideal 6° of angle of convergence
• 2. Minimal height: 4 mm for molars
• 3. Height/width ratio of 0.4 or greater
 • 4. Proximal grooves to resist faciolingual dislodgment
• 5. Follow the geometric shape of the root throughout the axial wall
• 6. Anatomical occlusal surface preparation with functional cusp reduction.
• 7. Remove all pre-existing fillings
• 8. Prefer supragingival or gingiva level margin location
• 9. Prefer chamfer or shoulder preparations. Avoid knife-edge preparation.
• 10. Bevel should be more than 45° angled
• 11. Place margins on the tooth structure, never on fillings, core materials
or cast post and cores

Impression Making, Provisional Restorations, and Tissue Management in Fixed Prosthodontics

4/18/18

Lecture Objectives • Understand the goals of soft tissue management

• Identify the factors influencing soft tissue
• Understand the purpose of provisionals
• Describe the final impression-making procedure for fixed restorations
Clinical steps involved in • Diagnosing and treatment planning à
the fabrication of a fixed • Tooth preparation à
restoration • Provisional fabrication à
• Final impression à
• Cementation
Provisional Restorations • Pulpal protection
• Positional stability
• Occlusal function
• Periodontal health
• Strength and retention
• Esthetics
• Template for the final restoration
Types of Provisional • PRE-FABRICATED
Restorations o Tooth-colored polycarbonate crown forms
§ Single unit provisional restorations
§ Crown forms for incisors, canines, and premolars (of
different sizes)
§ Only one shade provided
§ Need to adjust the size/shape and then reline with acrylic
resin after adaptation
o Pre-formed bisacryl crowns
§ Single unit provisional restorations
§ Crown forms of premolars and molars (of different sizes)
§ Light cured after adaptation (low heat polymerization)
• CUSTOM
o Direct
§ Entail the use of the patient’s mouth as a “template” for
the fabrication of the provisional restoration
§ Vacuum formed acetate matrix
§ For single to three unit provisionals
 o Indirect
§ Require an impression and cast to be used for fabrication
of the provisional restoration in the lab
§ Utilized in cases of 4 unit provisionals or more
Polycarbonate Resin Crown • Possess a number of superior properties relative to PMMA
Forms • These crowns combine micro-glass fiber with polycarbonate plastic
material
• Commonly used as a matrix material around the prepared tooth that is
relined with acrylic resin to customize the fit
• The material possesses HIGH IMPACT STRENGTH, abrasion resistance,
hardness, and good bond to Methyl methacrylate resin
Direct Restorations: • STEP 1: fabricate a full contour wax up of the tooth/teeth to be restored
Vacuum Form Acetate • STEP 2: make an impression of the wax up and fabricate a cast
Sheet • STEP 3: make a matrix over the stone model
• STEP 4: try the matrix over tooth/teeth preparation (can see if it is seated
properly since it is clear)
• STEP 5: load the matrix with acrylic resin and place it in the mouth (you
can light cure through the vacuum form since it is clear)
• STEP 6: contour margins of provisional and cement
Indirect Techniques • STEP 1: fabricate a full contour wax up of the tooth to be restored
• STEP 2: make an impression of the wax up and fabricate a duplicate cast
• STEP 3: fabricate a matrix over the duplicate stone model
• STEP 4: prepare teeth on cast to be provisionalized minimally
• STEP 5: fabricate an acrylic shell over the stone tooth preparation model
using a matrix
• STEP 6: reline intra-orally
• STEP 7: temporarily cement
Other Indirect Techniques • Rationale for use
– Lab processed heat cured o Is inherently stronger, of greater stability & more resistant to
provisionals (with or polymer breakdown than is autopolymerized resin
without metal o It has the advantage of:
reinforcement) § Color stability
§ Maintenance of surface finish
§ Resistance to wear
o They can function for extended periods of time
o Long-span acrylic resin provisional restorations, however, are
subject to fracture under occlusal forces
o Esthetic restorations can be made with these resins and when
reinforced, will function satisfactorily for long periods of time
• Lab processed provisional is then relined intra-orally with auto-
polymerizing acrylic resin and cemented
Final Impression • According to the GPT, an impression is a negative likeness or copy in
Procedures reverse of the surface of an object
o (1) Removal of provisional restoration
o (2) Preparation refinement
o (3) Placement of retraction cord
o (4) Impression making
 Tissue Management • Displacement of Gingival Tissues
o Mechanical: most effectively achieved by placement of a cord
(generally impregnated with a chemical agent)
o Chemical
o Surgical
Types of Retraction Cords • EPINEPHRINE IMPREGNATED RETRACTION CORD
o Its use is controversial due to the systemic effects it can cause
o When systemically absorbed it can cause “Epinephrine Syndrome”
§ Tachycardia
§ Rapid respiration
§ Elevated blood pressure
§ Anxiety
§ Post-operative depression
o CONTRAINDICATED in patients with cardiovascular disease,
diabetes, hypersensitivity to the drug
o The amount of epinephrine lost (and presumably absorbed) from
2.5cm of typical retraction cord during 5 to 15 minutes in the
gingival sulcus is approximately 71 micrograms
o This amount is slightly less than the obtained from administering 4
carpules of local anesthetic containing epinephrine (1:100,000)
• Other gingival retraction medicaments:

KNOW THIS TABLE!!!

2nd and 3rd on the list are
the most commonly used

• Available gingival retraction medicaments:

o Hemodent aluminum chloride – available in clinic
o Viscostat clear 20% aluminum chloride
o Astringident 15.5% ferric sulfate
o Viscostat 20% ferric sulfate – available in clinic
Double Cord Technique • Place the 1st (smaller) cord first
• This cord will EXPOSE the preparation margin (APICAL RETRACTION)
• Place 2nd (larger) cored which will provide LATERAL RETRACTION
Impression Trays à • Provide even thickness of impression material all around the tooth
Custom Trays structure allowing proper polymerization of the impression material and
(use for removable) making the impression more dimensionally stable
• Save material
Impression Trays à • Single unit restorations
Stock Trays • Three-unit fixed partial denture
• Variety of trays (Rimlock, disposable plastic trays)
Steps Involved in Making a • Removal of provisional restoration à
Final Impression • Preparation refinement à
• Placement of retraction cord, if needed à
• Impression making
 Sequence of Complete Dentures
4/27/18

Aging Population • Fabrication of complete dentures is one of the most difficult things in
dentistry – every edentulous patient is going to be different
• The number of edentulous patient is on the rise
• Elderly patients require special considerations due to their compromised
oral anatomy, medical & nutritional status, reduced physiologic reserves
and adaptive capacity
o Denture support area
o Neuromuscular control – different in every patient
o Chewing force
o Salivary flow due to medication(s)
o Healing capacity
o Quality of denture bearing tissues
• Nutritional status is so important – if they cannot eat well their overall
health will rapidly decline
• Understanding complete dentures will help with any kind of full mouth
reconstruction
Sequence

Light blue = clinical steps

Darker blue = laboratory
steps

VERY important to be able

to evaluate what is wrong
with their existing
prosthesis

We will not set posterior

teeth – just need to know
how to evaluate the lab
work
(1) Intraoral Exam • Have the patient take out their own prosthesis so you can evaluate how
well it fits them and how comfortable it is for them
Dentures should be • Ask them how happy they are with their existing denture – what they like
changed about every 4 about it and what they do not like
years, but Medicaid will • Examine:
only pay for a new one o Lips and cheeks
every 8 years o Lateral border of the tongue
o Base of tongue
Resorption will continue for o Floor of the mouth
the life of the patient o Tonsillar region & soft palate
o Oropharynx
o Neck
o TMJ
 • Examine the denture bearing surfaces, the soft palate, tonsillar region, the
vestibules, and the buccal mucosa
o Note the hamular notches and the definition of tuberosities
o Should not feel bulky extra-orally
o Frenums are a common place to see irritation
• Inflammatory fibrous hyperplasia
o Fibrous hyperplasia begins as a traumatic ulcer secondary to an ill-
fitted denture flange (looks like a white spot)
o Papillary hyperplasia is secondary to ill-fitting maxillary dentures
and is sometimes complicated by chronic candidiasis – if you see
something like this, the first think you should ask the patient is if
they are wearing their denture at night, and the second question is
if they use denture adhesive
o If a patient insists on wearing their denture at night, they must do
extra work to make sure it is cleaned impeccably – understand the
social implications for these patients – they might not want to ever
be seen without their denture
• Keratinized attached mucosa is the remnant of attached gingiva
o The more keratinized attach mucosa available on the denture
bearing surfaces, the better the support
• The frenum area is often overextended – this will cause the denture to
come out when the patient is functioning
• Mandibular mucosa – the mucosa overlying this region is poorly
keratinized and prone to trauma from complete dentures
o Denture flange should extend to the retromylohyoid space – this
will give it lateral stability
• Anatomical variations
o The size and position of the buccal shelf vary relative to the
degree of alveolar ridge resorption – the buccal shelf is a load
bearing area for the mandibular arch – it is a very stable area
o Mental foramen – the anterior exit of the mandibular canal and
the inferior alveolar nerve – in cases of severe residual ridge
resorption, the foramen occupies a more superior position – they
will feel numb if the denture compresss the nerves here
#1 complaint is that their o The position of the mylohyoid ridge varies relative to the degree
mandibular denture is of alveolar ridge resorption
loose – most patients are • Testing maxillary denture retention
okay with their maxillary o Wet the denture before you test this on the patient – have them
denture suck down on it to create a seal
o Apply a tipping force to the incisors in an attempt to break seal
Seat the back FIRST before o If it comes right out, you know that it is ill-fitted or that the
you seat the front when posterior palatal seal is missing
taking a mandibular • Testing maxillary denture stability (stability = does it rock?)
impression – o Apply unilateral force to posterior occlusal surface of denture to
retromylohyoid space is the make sure that the other side doesn’t lift up
most critical area to get • Testing stability and retention of mandibular denture
o Alternately apply unilateral force to posterior occlusal surface
 (2) Final Impression & • Leave space for border molding when making
Custom Trays custom trays – 3-5 mm above the depth of the
sulcus
• Make sure your tray is really smooth to the touch
• Impressions and dentures made for patients with
favorable floor of mouth posture and favorable
(anterior) tongue position. Note length of lingual flange are impression.
This will greatly enhance stability and retention.
• Laboratory will box and bead the cast
(3) Jaw Registration & • Maxillary wax rim check list:
Teeth Selection o The occlusal portion of the rim thickness
§ a) Molar region – 8 mm
§ b) Premolar region – 6 mm
§ c) Anterior region – 3 mm
o As viewed from the lateral perspective the rim should project
anteriorly to just beyond the outer edge of the land of the cast
o Lingual contours must not impinge on the tongue space
• With the lips at rest, the wax rim should project 1-2mm below the lip line
• Anterior teeth should be 10-12mm anterior to the incisive papilla
• Adjust the plane of the wax rim so that it is parallel to Camper’s plane
• Adjust the plane of the wax rum so that it is parallel to the interpupillary
line
• Mark the midline on the wax rim
• VDO vs. VDR: 2-5mm between VDO and VDR
o VDO = vertical dimension of occlusion
o VDR = vertical dimension of rest
(4) Anterior Teeth Try-In • The teeth should be in the same alignment as the wax – should not go
anterior to the wax rims
• Mark your midline on the cast in case you lose it on the wax when you are
melting wax
(5) Posterior Teeth Try-In & • Different occlusal schemes are acceptable
Verification of Occlusion • Patient and articulation should be identical
• Posterior Palatal Seal
o Greatly enhances retention and the shrinkage of acrylic resin
during processing is compensated for by scoring the cast in the
postdam area
o Butterfly-shaped area at the junction of the hard palate and the
soft palate
o If the denture ends on the hard palate and not the soft palate or
the junction, it will create soreness in that area
o If the denture moves a little, and you have a bead of tissue that
maintains contact, you do not lost suction
o At the time the denture is processed, there is shrinkage – the
amount of material that is added as excess will be a reservoir that
will counter the shrinkage so you don’t lose denture retention
(6) Adjustments and • There is a pressure indicating paste – create brush strokes with the cream
Delivery in one direction – when you put it in the mouth and take it out, you
should no longer see the brush strokes
 • If you still see the strokes you know it is not even touching in that area
• If it pushes away the paste too much then it is too high in that area
(7) Recall and Follow-Up • Statistics of all edentulous patients:
o 66.7%: Fully Satisfied
o 25.6%: Moderately Satisfied
o 7.7%: Dissatisfied
• Out of 33 million edentulous patients, only 2-4% have received implant
treatment
Systemic Conditions • (1) Diabetes
• (2) Dehydration
• (3) Xerostomia causing medications

Spectrum of Treatment for Edentulous and Partially Edentulous Patients

4/27/18

Edentulous • Re-establish esthetics and phonetics

• Patterns of resorption
• Determination of prostheses type
Aging & Edentulism • US population 65+: 40% are edentulous in at least one arch
Maxillary Resorption • Upward and backward
• Jawbone will look like it is further back and up, so your wax rim has to go
down and out to counteract this
Mandibular Resorption • Pattern of resorption is wider and out
• Stable area is the buccal shelf
Resorption, Loss, and • Residual ridge remodeling
Healing • Rate is variable:
o Fastest in the first 6 months after extraction
o Between different individuals
o Between the same individual at different times
o Between same individual at different sites
• Usually the resorption is symmetrical after people lose their teeth
Spectrum of Treatment • Predoctoral options: complete dentures, with or without 2-implant
overdenture in the mandible (2-implant overdenture is standard of care) –
at NYU with or without
the implants is the same
price so that people are
not making this decision
based on money
• Postdoctoral implant
retained mandibular
prosthesis options:
o Mandible:
§ 2 implant overdenture
§ 2 implants BAR
§ 4 implants: implant retained removable or fixed prosthesis
§ 6-8 implants: implant supported fixed prosthesis
o Maxilla: 4-6 implants: OD or fixed (6 recommended for fixed)
 • Two ways of fabricating removable dentures:
o Traditional construction – minimum 7 appointments
o CAD/CAM construction – quicker for the patient (2-3
appointments)
• Implant RETAINED mandibular prosthesis = terminology for removable
denture that is held in place by implants
• Implant SUPPORTED fixed prosthesis = terminology for fixed denture
• Implant Bar is becoming outdated because it has more problems
• You can do removable appliances with 4 implants if there is a lot of
resorption and a fixed appliance would be too difficult for the patient to
keep clean
• 6-8 implant fixed prostheses are difficult to make – and more expensive
Implant Overdentures: • Chewing sensation is re-established
Evidence of Improved • Improved stability and retention
Quality of Life • Improved chewing ability – improve the kind of food patient is able to eat
• Improved health and nutritional status
Fixed Restorations • Long-term data show success
• New designs are modifications of the traditional
concept
• Cantilever length < 2 x A-P spread
o If you need teeth extending past the most
distal implants in the mouth, this is a
cantilever
o Figure this out with a line through the two most posterior implants
and a line connecting the two most anterior implants – the
distance between these lines (yellow arrow) is the anterior
posterior (A-P) spread
o This is how we figure out the mechanics
o Cantilever length has to be less than twice the A-P spread – if it is
longer than this, it will fracture
o This would never be cleansable if it were fixed – has to be
removable
• Have to figure out the anatomical limitations of the patient when deciding
where to place implants
• We can do a CBCT of the patient and of their denture and use this as a
guide for where to place implants
Guided Surgery • Traditional teeth set up and hours of planning
• CT Scan and use of specialized softwares
• 3D computerized anatomy reconstruction
• Fabrication of a “stent” for guided surgery – fixed in location
• Often immediate loading with cross arch stabilization, fixed restoration
immediately after surgery is possible
Partial Edentulism • Fixed vs. Removable
• Can do an implant retained bridge for a segment of missing teeth
• Implant retained RPD – this can be done without clasps
Standard of Care • 2-implant retained overdenture
 Review of Removable Partial Dentures
5/2/18

Palatal Major Connectors • (1) Palatal bar connector

• (2) Horseshoe
• (3) Palatal strap
• (4) Anteroposterior palatal bar
• (5) Anteroposterior palatal strap
• (6) Complete palatal plate
Palatal Bar Connector • A major connector of a removable partial denture that crosses the palate
and is characterized by being relatively narrow anterior and posteriorly
• If placed too anteriorly it will interfere with the
action of the tongue
• Not rigid as it is narrow in size
• A palatal bar is not a good choice

Horseshoe or U-Shape • Consists of a thin sheet of metal which has less

resistance to flexing
• Is a poor choice for distal extension RPD
• Because of the flexing it can damage the abutments
Palatal Strap • A maxillary major connector having an anterior/posterior dimension of 13
(Anterior or Posterior) to 20 mm that directly or obliquely traverses the palate and is generally
located in the area of the second premolar and first molar
• Anterior Palatal Strap may be used when a torus is
present to circumvent it
• Also used when anterior teeth are missing
• Posterior strap used in tooth borne RPD specially in
Kennedy class lll situations
• This is much thinner than the palatal bar making it
more comfortable to the patient
• Minimum Anteroposterior width should be 8mm
• Rigidity can be increased by thickening the mid section to approximately
1.5mm
• Placing it in two planes also will increase its rigidity
Anteroposterior Palatal • Can be used for both tooth borne or tooth and
Strap/Bar tissue borne RPD
• Used when torus is present and is not to be removed
• For long-span distal extension bases where rigidity is
critical an anteroposterior palatal strap is indicated
• Both the anterior and posterior straps width should be at least 8mm
Complete Palatal Plate • A maxillary major connector covering the entire palate
o (1) Complete cast metal covering the entire
palate
o (2) Combination of anterior metal and
posterior resin
• Provides ultimate rigidity and support for the RPD
• Used when few anterior teeth are remaining
 • When no tori are present
• Metal should be extended to the vibrating line and beaded
• If combination of anterior metal and posterior resin is used planning for
complete denture then use Posterior palatal seal – otherwise if no CD is
contemplated no PPS is needed
• All metal palate conducts thermal conductivity
• Since metal does not provide porosity healthier to the tissue preventing
Candida albicans
• Only disadvantage may be occasional phonetic problem due to extensive
coverage
Blatterfein Steps • Louis Blatterfein has recommended the following 5 steps for selecting the
maxillary major connectors:
o (1) Outline denture base areas
o (2) Outline non-bearing areas
o (3) Outline bar areas
o (4) Select the bar type
o (5) Unification
Considerations in Selecting • Mouth Comfort
Maxillary Major o Minimum bulk
Connectors o Positioned so that it is least detectable
o The bar which will fulfill these requirements are the poster strap
• Rigidity
o Double straps provides maximum rigidity
o The A P strap meets this requirement
• Saddle Location
o Choice of bar is dictated by the location of the saddle ridge area
• Indirect Retention
o Mostly needed in the free end saddle cases
o Long ridge areas
o Ridges lacking vertical height
Mandibular Major • (1) Lingual bar
Connectors • (2) Sub-lingual bar
• (3) Lingual plate
• (4) Interrupted lingual bar
• (5) Kennedy bar or cingulum bar
• (6) Labial bar
Lingual Bar • Most commonly used amongst the mandibular major connectors
• Used when the functional depth of the lingual sulcus is
7mm or more
• Measurement is made from the floor of the mouth to
the gingival margin of teeth
• Ask patient to raise tongue and gently touch the
vermillion border of upper lip
• Its shape is half pear with 4mm in height and 2mm in width
• The inferior border should be rounded so that it will not impinge on the
lingual tissue in the floor of the mouth
• Should be relieved on the tissue surface with 28 G wax
Lingual Major Connectors – • If the soft tissues are vertical or nearly so, only minimal relief is required
Relief • Tissues that slope towards the tongue require the greatest amount of
relief
Sub-Lingual Bar • Measuring the functional depth of the floor of the mouth is same as for
Lingual Bar
• Variation of the Lingual Bar when the space does not allow to place a
Lingual Bar
• Used when the functional depth of the lingual sulcus is 5mm
• The sublingual bar is essentially a lingual bar but rotated 45 to 90 degrees
• Its shape is half pear with 2mm in height and 4mm in width because of
this it is more rigid than the Lingual Bar in the horizontal direction
Lingual Plate • Indications for the Lingual Plate are:
o When the functional depth of the lingual
sulcus is less than 5mm
o Presence of Lingual Tori
o High Lingual Frenum
o When future loss of anterior teeth are anticipated facilitating
addition of teeth to RPD
• Measuring the functional depth of the floor of the mouth is same for all
Lingual Bars
• The superior margin is placed near the junction of Middle and Gingival
third extending interdentally to the contact points – should not be placed
above the middle third
• The superior margin should be thin and must contact the tooth
• In the presence of overlapping/crowded teeth the lingual interproximal
surfaces must be recontoured
• There should be relief between the tissue surface of the plate and soft
tissue
• The terminal abutments must have rest seats to prevent facial movement
of teeth
Interrupted Lingual Bar • The interrupted Lingual Bar is basically the same as
the Lingual Plate
• Used when there is a diastema (plural – diastemata)
in the anterior teeth
Kennedy Bar/ • The Kennedy Bar is another variation of the Lingual
Double Lingual Bar/ Bar
Cingulum Bar • In addition to the Lingual Bar it includes the
Cingulum Bar
• Not a good choice because of the large open space
between the Lingual Bar and the Cingulum Bar leading to food impaction
• Closing the open space with metal eliminates the food impaction and
becomes a Lingual Plate which is a better choice
Labial Bar • Used when mandibular teeth are severely lingually
tilted
• Used in the presence of extremely large tori which
cannot be removed
• Must have adequate labial sulcus depth to fabricate a Labial Bar
 • Check for interferences with labial or buccal frenum
• Need relief under the bar as all mandibular major connectors
Types of Clasps • (1) CIRCUMFERENTIAL or SUPRA BULGE CLASPS
o a. Akers Clasp/Cast circumferential/Circlet
o b. Hairpin Clasp/C Clasp/Fishhook Clasp/Reverse Loop
o c. Ring Clasp
o d. Embrasure Clasp
o e. Extended Arm Clasp
o f. Overlay Clasp/Onlay Clasp
• (2) INFRABULGE / BAR CLASPS/ ROACH CLASPS/ VERTICAL PROJECTION
o a. L, I, S, T, U, Y
• (3) COMBINATION CLASPS
o a. Cast Clasp with Wrought wire Clasp
Circumferential Or Supra • Akers Clasp/Cast circumferential/Circlet
Bulge Clasps o CCC most commonly used
o Rest – Bracing Arm – Retentive Arm – Minor
Connector
o Design of choice for tooth supported RPD
• Hairpin Clasp/C Clasp/Fishhook Clasp/Reverse Loop
o Used when Atypical A survey line exists
o Undercut in the near zone at the facial or lingual
o Superior margin of the retentive arm must not
interfere with the occlusion
o Cannot be used in short teeth
o Disadvantage food trap
• Ring Clasp
o Indicated on tipped mandibular molars
o Retentive clasp engages the ML or MB undercut
• Embrasure Clasp
o Two CCC clasp joined together in the body facing in
opposite directions
o Mostly indicated when there are no edentulous
space on the other side of the arch
o Rest seats must be prepared with sufficient depth to
accommodate the rests to prevent interference with the occlusion
o Need to prepare marginal ridges to create space for adequate bulk
of metal or else the clasps will fracture
o When preparing marginal ridges should maintain contact points
• Extended Arm Clasp
o Similar to CCC but covers two teeth
o Remains above the survey line on the first tooth
and crosses into the undercut of adjacent tooth
• Overlay Clasp/Onlay Clasp
o The rest covers the occlusal surface of a tilted molar
from which the clasps originate
o Helps in establishing the proper plane of occlusion
o Eliminates the need for a crown
 Infrabulge/ • There are many variations of the Infrabulge clasps
Bar Clasps/ • They are often referred to by the names of the letters they resemble
Roach Clasps/ • The most common types used are the I, T
Vertical Projection • In an RPI Removable Partial Denture the I bar is used
• The infrabulge clasp approaches the undercut from the gingival direction
• They exhibit a push type (Tripping action) rather than pull type of
retention of the suprabulge clasps
• The push type exerts a tripping action

RPI • Rest, Proximal Plate, I Bar

• Contraindications for the RPI Clasp:
o (1) Insufficient vestibular depth – a functional vestibular depth of
5mm is required
o (2) Deep tissue undercut – a deep undercut forms a food trap
o (3) Lack of facial undercut – due to buccal or lingual tilt of
abutments
o (4) Mesial inclination of abutments – no undercut present gingival
to the distal proximal guide plane – the proximal plate cannot
disengage from the tooth during function
o (5) Combined with a lingual plate – will produce buccal torqueing
during function
• Used in tooth mucosa borne partial dentures
• Concept of mesial rest
o As the rest is moved mesially the forces on the RPD become
vertical and less damaging to the abutment tooth and the ridges
• Esthetic advantage
Combination Clasp • Consists of a rest, cast reciprocal arm, and a retentive wrought wire clasp
• Advantage of this clasp is its flexibility and that it can be easily adjusted
• Commonly used on weak abutments which cannot tolerate a cast clasp
• Due to its flexibility, less changes of fracture
Types of Survey Lines • Typical goes from the middle
to the junction of the middle
and gingival thirds of the
tooth

Types of Survey Lines and

Location of Undercuts
Atypical Survey Lines and • Hairpin Clasp / C Clasp / Fishhook Clasp / Reverse loop
Clasps: o Used when Atypical A survey line exists
Atypical Survey Line A o Undercut is in the near zone at the facial or lingual
o Superior margin of the retentive arm must not interfere with the
occlusion
o Cannot be used in short teeth
o Disadvantage food trap
• Reverse Circlet / Reverse attachment clasp arm
o Used when Atypical A survey line exists
o Must create space between the embrasure between the contact
area where the clasp crosses the occlusal surface
o In sufficient space will interfere with the opposing occlusion
• Use Roach Clasp / Infra Bulge Clasp to engage the undercut
o A Roach bar / Infra Bulge Clasp L T may be used
o However if the sulcus depth is shallow it cannot be used
Atypical Survey Lines and • High survey line
Clasps: • Recontour the tooth to move the survey line down
Atypical Survey Line B • Ora fabricate a survey crown

Atypical Survey Lines and • Extended arm clasp so you can utilize the undercut on the
Clasps: next tooth if the abutment tooth does not have an undercut
Atypical Survey Line C • Cannot have an extended arm clasp go more than 2-3 teeth

Types of Rests • (1) Occlusal Rests

o a. Conventional
o b. Extended
o c. Overlay/Onlay
o d. Interproximal
o e. Auxillary or Secondary
• (2) Incisal Rests
• (3) Cingulum Rests
Occlusal Rest • Maintains components of RPD in their planned positions
• Prevents settling of the dentures
• Prevents impingement of the tissues
• Directs and distributes occlusal loads to
abutment teeth
• Transmits forces along the long axis of the
abutment teeth
• Help transmit lateral or horizontal forces applied to RPD during function
• Prevents food impaction where the rest is adjacent to the abutment tooth
Overlay/Onlay Rest • Tipped Molars
• Establish occlusal plane
• Eliminate the need for cast restoration on abutment
tooth
• Prevents further tipping
• Clasps may originate from the overlay rest to engage the undercuts
 Interproximal Rests • An embrasure clasp is essentially two CCC joined at their bodies
• Frequently used on the side where there is no edentulous space
• Clasps originate from a minor connector that traverses the marginal
ridges between teeth
• Marginal ridges and adjacent facial inclines must be prepared to ensure a
sufficient metal bulk for clasp strength
• Inadequate preparations will result in thin metal resulting in fracture of
the clasp
• Occlusal rests should be properly prepared to accommodate the rests and
to avoid occlusal problems
Auxiliary/Secondary Rests/ • A denture base that is supported at one end by a healthy natural
Indirect Retainer abutment and at the other by movable soft tissues will rotate toward or
away from the residual ridge when subjected to occlusal forces or the pull
of sticky foods
• This rotation occurs along an imaginary line called fulcrum line
• Indirect retainers are used to prevent this rotation
Indirect Retainer • The component of a partial removable dental prosthesis that assists the
direct retainer(s) 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
Indirect Retention • 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
Auxiliary or Secondary • Kennedy Class I,
Rests Class II, and Class IV
removable partial
dentures require
indirect retention
• Kennedy Class lll do
not require indirect
retention because it
is tooth borne RPD
• Any of the following rests can act as an indirect retainer:
o Occlusal
o Cingulum
o Embrasure
o Incisal
Incisal Rest • Incisal rests are prepared on the incisal edges
• Mostly used on the canines
• Dimensions depth 1.5 mm width 2.5 mm
• Esthetic disadvantage and patient should be informed of its esthetic
impact similar to the 20 degree facets / MD Clasp as in the picture on the
right
• When compared to a cingulum rest (A) the incisal rest (B) may deliver
potentially harmful forces because of the greater distance from the
abutment’s center of rotation
 Cingulum Rest • Cingulum rest is preferred over the incisal rest
• Dimensions are width 2.5 mm depth 1.5 mm same as incisal rests
• Mostly used on Maxillary canines because of the well developed cingulum
• Mandibular canines do not have well developed cingulum and a cast
restoration may be placed either by a cast metal rest seat bonding, pin
inlay or a survey crown
Selecting Retentive Clasps • Placing the retentive clasp terminal in a
as Related to Undercut greater horizontal undercut will result in
increased retention
• Placing the retentive clasp terminal in a
greater angle of cervical convergence will
result in increased retention
• Materials used in fabricating RPD
o Chromium Cobalt
o Wrought Wire

Principles of Occlusion
5/8/18

Maximum Intercuspal • Complete intercuspation of the opposing teeth independent of condylar

Position (MIP) position
Centric Relation (CR) • Maxillo-mandibular relationship in which the condyles articulate with the
thinnest avascular portion of their respective discs, with the complex in
antero-superior position against the shapes of the articular eminences
• This position is INDEPENDENT of tooth contact
Centric Occlusion (CO) • Occlusion of opposing teeth when the mandible is in centric relation,
which may or may NOT coincide with maximum intercuspal position
• MIP occurs naturally at CO in 1 of 10 adult patients
Conformative Approach to • The principle of providing a NEW restoration that DOES NOT ALTER the
Restorative Dentistry patient’s existing occlusion
• Jaw relationships
• Clinically, this means that the occlusion of the NEW RESTORATION is
provided in such a way that the occlusal contacts of the other teeth
remain UNALTERED
Restorative Approach to • The principle of providing a NEW restoration that ALTERS the patient’s
Restorative Dentistry existing occlusion
• Example: full mouth implants – the definitive maxillary and mandibular
porcelain fused to metal FPDs completely change the occlusion
Occlusion • Success of any restoration that we fabricate will be dependent on
maintaining OCCLUSAL HARMONY
History of Occlusion • Where did it all start?
o With dentures
• Gariot articulator à Bonwill’s triangular theory à Curve of Spee (anterior
posterior curve) à Snow facebow à Christensen’s phenomenon à
Bennet’s movement à Monson’s spherical theory à Hanau’s articulator
à Meyer – Functionally Generated Path
• You only need the curve of Spee if you have cuspal inclinations (anatomic
or semi-anatomic teeth) – don’t use it with monoplane teeth
• Curve of Spee is a part of Monson’s spherical theory
Modern Occlusal Concepts • Edentulous à Restored with
dentures à Bilateral Balanced
Occlusion
• Dentate à Requiring fixed
restorations à Occlusal scheme
o Mutually protected occlusion
§ Canine Guidance
§ Group Function

Gnatology • "Gnathos", meaning jaw and "ology", meaning study of, or knowledge of.
One who adheres to gnathological principles is practicing dentistry with
respect to the entire stomatognathic complex and understands how the
dynamics of mandibular movement have a profound effect upon the
anatomy of all the teeth and their stance in the dental arches.
• It is taking the time to measure and record mandibular movements so
that an accurate diagnosis can be made. This personalized information
can be programmed into an adjustable articulator. A mutually protected,
organized occlusion can be prescribed and provided for the patient.
• Gnathological treatment objectives include a centric relation occlusion;
proper coupling of the anterior teeth; a comfortable, frictionless anterior
disclusive angle and long term stability of the treated result.
• This "Organic Occlusion" will minimize excessive stress to the teeth, the
periodontium, the muscles, the ligaments and the temporomandibular
joints.
Bilateral Balanced • The bilateral, simultaneous, anterior and posterior occlusal contact of
Occlusion teeth in centric and eccentric positions
Mutually Protected • Posterior teeth prevent excessive contact of the anterior teeth in
Occlusion maximum intercuspation, and the anterior teeth disengage the posterior
teeth in all mandibular excursive movements
 Group Function or • Occlusal scheme, teeth on the working side (canines & premolars) should
Unilateral Balanced be in contact during a lateral excursion
Occlusion • Teeth on the non-working side are contoured to be free of any contact
• The group function of the teeth on the working side distributes the
occlusal load
Canine Guidance or Canine • Canine guidance is disocclusion by the canines of all other teeth in lateral
Protected Occlusion excursion
Determinants of • Anatomic
Mandibular Movements • Neuromuscular
Neuromuscular • Muscles of Mastication
o Temporalis
o Masseter
o Medial Pterygoid
o Lateral Pterygoid – superior and inferior heads (inferior one is
responsible for opening jaw)
Anatomic • Components of the TMJ
o Condyle
o Temporal bone
o Articular disk
o Ligaments
§ Functional ligaments of the TMJ
• Collateral ligaments
• Capsular ligament
• Temporomandibular ligament
§ Accessory ligaments of the TMJ
• Sphenomandibular
• Stylomandibular
• Posterior determinants (right and left TMJs) are unchangeable
• Anterior determinants (anterior teeth) provide guidance to the
mandibular in lateral and protrusive movements
• The closer a tooth is to a determinant, the more that it will be influenced
by it
Features of Occlusal • (1) Uniform bilateral and anteroposterior occlusal contacts in MIP.
Stability • (2) Absence of tooth surface loss (other than age- appropriate wear)
• (3) Absence of non-axial loading or tooth migration
• (4) Absence of anterior and posterior occlusal plane discrepancies
• (5) Acceptable OVD (occlusal vertical dimension)
• (6) Acceptable MIP
• (7) Acceptable Anterior Guidance or Group Function
• (8) Absence of posterior balancing interferences
• (9) Absence of Muscle disorders
• (10) Absence of TMJ disorders
Occlusal Trauma • Tooth wear/fractures
• Widened PDL
• Pain
• Root resorption
 Articulators and Facebow
5/8/18

Articulator • A mechanical instrument that represents the temporo-mandibular joints

and jaws, to which maxillary and mandibular casts may be attached to
simulate some or all mandibular movements
Determinants of • Posterior determinants are TMJs
Mandibular Movements • Anterior determinant is anterior guidance
Purpose of an Articulator • Diagnose and treatment plan
• Reproduce mandibular movements
• Fabricate restorations in harmony with patient’s oral system
Mandibular Movements • (a) The condyle is in a superoanterior position in
the fossa with the articular disc interposed when
the teeth are in maximal intercuspation
• (b) In the initial stage of opening, the condyle
rotates in position, with the disc remaining
stationary
• (c) In maximum opening, the condyle translates
forward, with the disc still interposed

Mandibular Movement • Mandibular movement can be broken down into a series of motions that
Axes occur around three axes:
o (1) Horizontal axis à sagittal plant
o (2) Vertical axis à horizontal plane
o (3) Sagittal axis à frontal plane

Lateral Mandibular • Mandibular movement to one side will place it in a working, or

Movement laterotrusive, relationship on that side and a nonworking, or
mediotrusive, relationship on the opposite side; eg, if the mandible is
moved to the left, the left side is the working (W) side and the right side
the nonworking (NW) side
• When the mandible moves into a left lateral excursion, the right condyle
(A) moves forward and inward, while the left condyle (B) will shift slightly
in a lateroposterior direction
• The bodily shift of the mandible in the direction of the working side was
first described by Bennett and called Bennett movement
• The angle (SPB) formed in the horizontal plane between the pathway of
the nonworking condyle, the mandibular lateral translation, and the
sagittal plane is called the Bennett angle
Condylar Inclination and • A shallow protrusive condylar inclination requires short cusps, while a
Anterior Guidance steeper path permits the cusps to be longer
• A shallow anterior guidance requires short cusps, while a steeper path
permits the cusps to be longer

Articulator Parts &

Classification

• Class I:
o Non-adjustable
o Single-static registration
o Vertical motion ONLY
• Class II:
o Permits horizontal and vertical motion
o NOT oriented to the temporomandibular joints
• Class III: most useful kind – these are the ones we use
o Semi-adjustable
o Accepts facebow registration, CR/ Protrusive records
o Orients the casts relative to the joints (arbitrary hinge axis)
o Semi-adjustable articulators generally use an ‘Arbitrary face-bow’
record
o This orients the cast in the antero-posterior position and the
medio-lateral position in the articulator to anatomical average
values (External Auditory Meatus)
• Class IV:
o Fully-adjustable
o Accepts three-dimensional dynamic registrations
o Orients the casts to the kinematic hinge axis of the temporo-
mandibular joints
Non-Adjustable • Does not reproduce the full-range of mandibular movement
Articulators • The arc of closure is NOT the same as the patient’s because the distance
(Classes I and II) between the hinge and the teeth is significantly shorter than the existing
in the patient
• This difference may affect the fabrication of fixed restorations causing
premature contacts and incorrect ridge and groove direction
 Semi-Adjustable • Some semi-adjustable articulators allow the use of KINEMATIC
Articulators FACEBOWS, allowing more accuracy when mounting the casts
• The kinematic face-bow is placed on the hinge axis which location has
been previously determined
• Using the hinge axis is especially important when VERTICAL DIMENSION
OF OCCLUSION will be altered
Arcon Articulator • In an Arcon articulator, the condylar path elements are located within the
More similar to a real upper member
person than non-Arcon • Condylar elements are located within the lower member
• Condyles remain constant in all excursive movements
Non-Arcon Articulator • In a Non-Arcon articulator, the condylar path elements are located within
the lower member
• Condylar elements are located within the upper member
Fully Adjustable • Are capable of duplicating a wide range of mandibular movements
Articulators • Are generally set to follow the patient’s BORDER MOVEMENTS
• The terminal hinge axis is located and a Pantograph is used to record the
mandibular movements
• These mandibular movement tracings are used to set the articulator
• Usually used to treat complex mouth rehabilitation
• Uses a kinematic face-bow to orient and articulate the maxillary cast
Facebow Theory and • To transfer information from patient to articulator
Transfer • Purpose of the facebow transfer:
o To articulate maxillary cast in relation to condylar hinge axis
o To orient the cast in the center of the articulator
• Use facebow to determine the relative position of the maxilla in space to
the condyles – it is not for measuring the position of the mandible
Facebow Transfer • Positions the maxillary cast in three dimensions by:
o (a) Relating the maxillary cast to the condylar elements antero-
posteriorly
o (b) Relating the maxillary cast vertically with some third point of
reference
§ Relating the maxillary cast with a tentative occlusal plane,
which is parallel to the ala-tragus line, orbitale, or incisal
pin notch.
§ Allows the teeth to be within a close radius of the correct
arc of closure when the articulator is used in hinge
movement
§ Allows the teeth to more accurately reproduce the lateral
arc during excursions
§ Minimizes occlusal discrepancies cause by changes in
vertical dimension
 Articulator Selection

How does all this • Panadent PSH Articulator

information transfer to the • Condylar guidance is adjusted at an average value of 26 degrees – In the
use of our articulator? PANADENT articulator is set in increments of 4 degrees!
• Round ended pin with the custom incisal table for fixed restorations
• Flat ended pin with the mechanical table for removable restorations
Do we always need to use • No!
a facebow record? • Use a facebow record IF:
o You are fabricating a Fixed partial denture involving a terminal
abutment
o A single unit restoration involving a terminal abutment
o Fixed partial denture where there needs to be a greater control
over the plane of occlusion, e.g. restoration of 6 anterior maxillary
teeth or an extensive posterior bridge
o Where restoration or adjustments of the occlusal vertical
dimension may be necessary

Introduction to Digital Dentures

5/10/18

CAD-CAM • Computer Aided Design – Computer Aided Manufacturing

CAD-CAM RPD Frameworks • Sends the information to a 3D printer which prints out a plastic version
DENTCA • Started in 2007
• Created unique impression trays
• Denture bases and teeth are 3D printed
Avadent • Started in 2011
• All denture bases are milled
Traditional Techniques – • Medical/dental history
Complete Dentures • Intraoral examination – rule out soft tissue pathology
• Radiographic examination
• Preliminary impressions
• Custom trays
• Border molding
• Final impressions
• Box impression
• Pour impression
 • Master cast
• Baseplate/wax occlusion rims
• CRR/VDO/OP/Lip Support
• Anterior tooth try-in
• Posterior tooth try-in
• Send to lab for processing
Traditional Technique • Denture flask
• Compression molding
• Mechanical flask press
The Digital Process • Start-up kit from one of the companies that offers them
• Comes with trays in multiple sizes to take impressions
The Clinical Process • Step 1: Proper tray selection
o No preliminary impression
o No custom tray
o Use old existing denture – compare border to border
o Try tray in the mouth, adjust if necessary
o Thermoplastic – can hit with a flame and mold
o 80% of the time: medium tray
• Step 2: Impressioning
o “Massad Technique”
§ Heavy bodied PVS first, adjust, wash with light bodied PVS
– replaces the need to use compound for border molding –
here you are essentially doing the border molding with the
heavy bodied PVS
§ Look for “show through” areas that displace too much
impression material and adjust those areas to prevent sore
spots in the patient’s mouth
o Final impressions – challenges
§ 1st challenge: records of VDR/VDO – use an extra-oral
tracing device to fix this problem
§ 2nd challenge: posterior clearance – solved this problem
using detachable/sectional trays
§ 3rd challenge: processing error – we know there is 6.5-7.9%
shrinkage – we compensate for this shrinkage traditionally
by scoring the cast
• Avadent uses a pre-cured disc of acrylic that is
already shrunk to compensate for this problem –
this is what goes into the milling machine and once
it is milled teeth are put in place
• Vivodent mill the teeth and the denture base all in
one piece so the teeth are less likely to fall out
• Dentca 3D prints their denture bases which has very
little shrinkage (<1%) – then they either print it in
segments or in 1 piece
Resorption Pattern • Maxillary and mandibular tray may NOT always be the same size
• Maxillary arch appears to get smaller and mandibular arch appears to get
bigger as they resorb
 Intraoral or Extraoral • Gothic arch tracer – trace jaw movement of patient from CR: protrusive,
Tracing Device left lateral, and right lateral movements
• Coble balancer
• Arrow point tracing
• Needle point tracing
• Adjustable pin and a plate – allows you to increase/decrease VDO
Centric Relation • (1) Condyles in most retruded position
• (2) Unstrained, physiologic position
• (3) Patient must be able to make lateral movements
Not CR Position • Not physiologic – if the jaw is retruded too much past CR position
• No lateral movement from here – cannot use this position
Dentca Trays • Detachable (sectional) – maxillary trays snap into 2 pieces, mandibular
trays snap into 3 pieces
• Unsnap the pieces to prepare to do Gothic arch tracing
• Central bearing pin: VDO and CRR
o Use central bearing pin to adjust VDO
• Central bearing pin marks E-Z tracer in order to record the protrusive,
right lateral and left lateral movements
• Make a notch in the CR location so that the trays lock into each other
• Record position with bite registration paste to maintain the position for
the lab
• This is all done without stone casts – the impressions are then scanned
into the computer system
Avadent • Gothic arch tracing without separating trays
Anatomical Landmarks and • Computer uses 26 anatomical landmarks with a complicated algorithm to
Parameters decide which teeth will fit best in each particular patient’s mouth
• Dentca wants you to provide two of these parameters:
o Lip ruler
o Jaw gauge (VD gauge)
• Other parameters we know about and use:
o Height of the occlusal plane is about 1/2-2/3 the retromolar pad
o Want to set denture teeth on top of the crest of the ridge
o We want to set the central grooves of the teeth in a straight line
o We know based on averages where the occlusal plane should sit in
relation to the border of the denture
o Position of the facial surface of the central incisors is about 8-9mm
anterior to the incisive papilla
• You take the driver’s seat during the impressions but then hand over
responsibility to the company – they offer one more time for you to check
over everything using a 3D printed denture to try-in on the patient
3-D Printer • Dentca 3-D printed denture for try-in
• “Functional prototype” – you can check everything about the denture on
the patient except the final esthetic result – they have now made these a
little bit more esthetic for the patient to try on
• Then you fill out a try-in adjustment form to check off what is okay and
what you want them to change
 • Then if it is just minor changes you can just order the final denture, but if
it is a bigger change then you can request a second try-in
• Avadent does it differently – there is a technician who sets teeth in wax
Advantages of milling? • AVADENT test results
o Acrylic porosity: no micro-porosity, negligible Candida albicans
§ Traditional kinds that are more porous allow bacteria to
grow in the pores
o Color stability: more color stable than conventional dentures
o Residual monomer: 20% less than conventionally fabricated
dentures
Clinical Processes Traditional Digital
7-8 visits 2-3 visits
1. I/O Exam + Preliminary 1. I/O Exam, Final impression,
impressions records
2. Border mold + Final impression 2. Try-in (optional)
3. Records + Tooth selection 3. Delivery
4. Anterior try-in
5. Posterior try-in
6. Delivery
7. Adjustment(s)
ADVANTAGES
• Withstood the test of time • Fewer visits
• Extensive tooth selection • Less treatment time
• Better control of esthetics • Easier duplication
DISADVANTAGES
• More visits • Limited control of esthetics
• Longer treatment time • Limited tooth selection
• Harder to duplicate
Skill and Knowledge are • Materials, anatomy, occlusion
Still Required! • Esthetics, function
CD Principles Remain the • Make accurate impressions
Same • VDO/CR

**This is the most important slide! Even though these are made digitally, you
still REALLY need to know how to evaluate all of these things in order to end
up with a good denture for your patient
Costs AVADENT DENTCA
• Two arches complete: $630 • Two arches complete: $600
Really all about productivity • Single arch: $315 • Single arch: $300
– takes you a lot less time • Spare denture: $215/arch • Spare denture: $225/arch
so you end up with higher • Startup kit: $700 • Starter kit: $100
productivity • Try in: $230/arch • 3D try in: free
• Functional try in: free
Digital Dentures • Fewer visits
• Faster treatment
• Easier duplication
 Digital Impression Technology and CAD-CAM Restorations
Date

CAD-CAM • Scanning (data acquisition) à Computer aided design à computer aided

manufacturing à finishing and customization
Scanning • Older scanners: probe in contact with your die to create a digital die in the
computer system – not super accurate because the end of the probe is
about 1mm thick
• Newer scanners:
o Structured light – light patterns projected on the object that are
analyzed by the computer
o Conoscopic holography – currently used by Nobel Biocare Procera
– NASA developed this technology to make space shuttles
Conoscopic Holography • Crystal that creates a pattern when it is hit by light
• This creates a pattern on the sensor depending on the distance
• It creates a map of the structure you are scanning
Software • You have to show the computer exactly what you want to scan
• Outline the areas and number the teeth
• Scan just the die of the tooth you are restoring first and then scan it again
with the neighboring teeth
• With implants you need to know the contour of the tissues
o Hard for the scanner to see implants since they are subgingival, so
you can use position indicators – these are abutments with known
dimensions to the software
o When you scan it with the abutment in place it now knows the
exact orientation of the implant
• Some of the new softwares scan in color so this helps you to select the
color of the restoration
Computer Aided Design • The crowns we make are layered so we just make the coping on the
computer system
• You mark the path of insertion and it will make undercuts in red
• Then you mark the finish line to make sure it is in the correct place
• You can also make a full contour crown
• It can show you a cross section of your future restoration
• Designed coping can then be emailed to the milling facility and you will
get the restoration in 24-48 hours
• Steps are very similar to make a bridge
• Software can subtract 1.5mm so there is enough room to add porcelain
over the coping
• Steps for fabrication of the implant bar are also basically the same
Materials • Acrylic – for example, denture bases can be milled this way
• Emax
• Metal
• Zirconia
Milling Units • The number of axes in which the block can be moves increases the ways
the bur can contact the surface
• 5 is usually the right number
 Zirconia • Comes in a pre-made block based on the size of your restoration
• Manufacturer company will tell you how much shrinkage will happen
during processing
• Shrinkage during centering is about 25% – need to know this in order to
get accurate restorations so the software can enlarge it before processing

Introduction to New State of the Art Materials

5/14/18

Zirconia: Monolithic INDICATIONS PROPERTIES EXAMPLE(S)

Monochromatic • Single crowns • Glass-infiltrated • Lava
• Posterior teeth (not • 1200 MPa • Zirlux
Monolithic = comes in one great for anterior • CAD/Cam • BruxZir
block because it is just • Can’t be bonded
Monochromatic = one color one color/opaque) • One of the
• Discolored teeth strongest materials
Will block color, but no light • Esthetic demands we have
transmission so looks duller • Metal allergies
Layered Zirconia (with INDICATIONS PROPERTIES EXAMPLE(S)
color gradient) • Single crowns • Glass-infiltrated • BruxZir
• Laminates • 1200 MPa • Lava – two layers
High end product – • Posterior teeth • CAD/Cam • Katana (is
expensive, we don’t use it • Discolored teeth • Can’t be bonded monolithic but look
• 3-4 units (4mm layered)
If you add a second layer à joint)
more translucent à more • Esthetic demands
esthetic • Metal allergies
Procera Zirconia INDICATIONS PROPERTIES EXAMPLE(S)
• Single crowns • Glass-infiltrated • Nobel Procera
Zirconia is the strong • Anterior teeth • 1200 MPa
understructure, like a metal • Posterior teeth • CAD/CAM
coping, and there is a • First premolars • Bilayer
ceramic overlay on top of it • Esthetic demands
• Metal allergies
Alumina INDICATIONS PROPERTIES EXAMPLE(S)
• Single crowns • Glass-infiltrated • Nobel Procera
Alumina starts with “A” so • Laminates • 687 MPa • Lava
it is for Anterior teeth • Anterior teeth • CAD/CAM
• First premolars • Bilayer
• Esthetic demands • Translucent
• Metal allergies
Lithium Disilicate (E-Max) INDICATIONS PROPERTIES EXAMPLE(S)
• Single crowns • Translucent • Ivoclar vivadent
Not as strong as Zirconia – • Up to 4 unit bridge • 900 MPa
so you need more thickness • Laminates • Pressed
• Anterior teeth • CAD/CAM
 • Esthetic demands • Monolithic
• Metal allergies • Can be bonded
• Occlusal clearance
is key
Lucite Reinforced INDICATIONS PROPERTIES EXAMPLE(S)
(IPS Empress) • Single crowns • Translucent • Ivoclar vivadent
• Anterior teeth • 160 MPa
Not as strong as E-Max but • Laminates • CAD/CAM
even more esthetics • High esthetic • Can be bonded
demands (once they are
bonded they get
more strength from
the tooth)
PFM INDICATIONS PROPERTIES EXAMPLE(S)
• Single crowns • Bilayer – Casted • High Noble
• Bridges (no limit) metal coping • Noble
• Discolored teeth covered with • Base Metal
• Proven longevity feldspathic
porcelain
• Can’t be bonded
Gold INDICATIONS PROPERTIES EXAMPLE(S)
• Single crowns • Can’t be bonded • Metal casting
• 3-unit bridges • Favorable gingiva
• Mainly in posterior tissue
• Not in esthetic • Wear compatible to
areas enamel
• Many margin
options
• Lack of occlusal
clearance
CAD/CAM Dentures INDICATIONS PROPERTIES EXAMPLE(S)
• Easier duplication • Greater strength • Avadent
• Fewer visits • Milled or 3D • Dentca (WholeYou)
• Less treatment printed
time
 JL 2020

Anatomy of the Edentulous Maxillary Arch

Edentulism loss of all permanent teeth, often associated with loss of vertical dimension, collapsed lips, obliterated philtrum and
collapsed nasolabial sulcus
Causes:
o Biological Caries, periodontal disease, pulpal pathology, trauma, oral cancer
o Non-biological access to care, pt preference, 3rd party payments for selected procedures
Rate of edentulism is inversely proportional to education and income
Edentulous pts are considered to be:
o Disabled ineffective mastication and speech
o Handicapped avoid eating and speaking in public
Prosthesis artificial replacement of an absent part of the body
Prosthetics field of supplying missing body parts of the body
Prosthodontics restoration and maintenance of oral function by replacement of missing teeth and structures with artificial
devices
o Fixed prosthodontics
o Removable prosthodontics
Removable Partial Denture (RPD) supplies teeth and structure in partially edentulous jaw
Complete Dentures (CD) supplies teeth and structures that replace the entire dentition
Immediate Dentures a complete denture constructed for insertion immediately following removal of
natural teeth

Parts of Complete Dentures

Tissue (intaglio) surface contacts the basal seat (buccal surface, residual alveolar ridge
(RAR), labial surface, palate)
o RAR is not uniform in shape and the height depends on the duration of missing
teeth
Denture base composed of pink acrylic resin (methyl methacrylate)
o Labial notch fits labial frenum
o Labial flange fits into labial vestibule
o Buccal flange fits into buccal vestibule

Properties of CD
Base 0
Retention resistance to the movement of a denture from its basal seat in a direction opposite in
o
which it was inserted
Interfacial force the resistance to separation of 2 well adapted contact surfaces that are
imparted by a film of liquid between them
Cohesion the physical attraction of like molecules for each other

8
Adhesion is a physical attraction of unlike molecules for each other
Muscles of oral cavity and face supply supplementary retentive forces, provided
o The teeth are positioned in the neutral zone between the cheeks and tongue
o Polished surfaces of the dentures are properly shaped
Atmospheric pressure
o
o
o
O
The pressure applied by the atmosphere is 14.7 lbs/inch 2
Dentures have an effective seal around their borders
Proportional to the area of coverage

O
Support Resists the vertical components of mastication and other forces applied in a direction towards the basal seat

o
Stability Firm, steady, and constant in position when forces are applied to the denture (mostly horizontal forces)

1
 JL 2020

Maxillary Anatomic Landmarks

Residual Alveolar Ridge (RAR) Labial Vestibule Buccal Frenum
Labial Frenum
fits
labialnotch
here

Buccal Vestibule Zygomatic Process

quicalflange
PMhere

Maxillary tuberosity Rugae Median Palatal Suture

Incisive Papillae

Pterygomaxillary (Hamular) Notch Fovea Palatina Vibrating Line

Torus Palatinus

Mandibular Anatomic Landmarks

Labial Frenum Residual Alveolar Ridge (RAR) Buccal Shelf
Buccal Vestibule
Buccal Frenum

2
 JL 2020

Retromolar Pad Retromylohyoid fossa

Masseter Groove Mylohyoid area
Premylohyoid fossa

Retromylohyoid curtain RMC) Sublingual caruncle

retromylonyorf curtain
Anterior border of Masseter

Stress-Bearing Areas
Maxillary Mandibular
Primary RAR Buccal Shelf
Secondary Rugae RAR

Effect of Tongue Position on the Floor of the Mouth

Mandibular arch has an additional lingual vestibule which the maxillary arch does not to
allow the tongue to move
Make a custom tray that is lower than the border of the vestibule to capture the anterior and posterior molds (border molding)

Preliminary and Secondary Impressions

Impressions a negative likeness or copy in reverse of the hard and soft tissues in the mouth in which a positive reproduction can be formed
via a stone cast
Retention of a complete denture is a vacuum between the denture base and the supporting tissue
o Basal seat supporting areas or stress bearing areas
o Border seal peripheral or limiting area

Principles and Objectives of Making Impressions

Tissue must be healthy
o Use tissue conditioners with existing dentures
o Make occlusal adjustments in existing dentures
o Leave dentures out at least 24hrs prior to making final impression and to massage supporting tissues
o Good oral and denture hygiene
o Pre-prosthetic surgery if needed

O
Impression must include all of the basal seat
o Adjust the tray with bur, flame, or wax
o Maxilla covers maxillary tuberosity and hamular notch
o Mandible covers lingual flanges and lingual sulcus
Border molding to maintain anatomical and physiological limitations of peripheral structures
o Should be properly present but not overextended
Proper space for the selected impression material in impression tray
The tray and the impression material should be dimensionally stable

3
 JL 2020

Procedure
1. Preliminary Adapt tray to pt by trimming overextended areas, rope wax for
0 Alginate
Impression
underextended areas, and flame/bend flanges to adapt lingual sulcus

2. Diagnostic/ Two Pour Technique

Preliminary 1st pour Mix dental plaster and pour into alginate impression and allow
Cast it to set face-up for 15mins
2nd pour Mix a thicker consistency of dental plaster on cardboard and
invert the impression onto it as a base
Trim
o Preserve 2mm of art border
o Base is 1/2 thick

3. Custom Tray Block out undercuts on preliminary casts with pink wax and outline the
depth of the mucobuccal and mucolingual areas with black pencil
Draw second line 2mm above the black line with red pencil border of
the custom tray
Apply Vaseline or petroleum jelly
applyVaseline
Adapt light polymerizable VLC-resin (Triad) material to cast and trim to
red line

O
Round all borders and add handle on anterior ridge (45o)
Cure in machine for 2 mins (on cast)
Remove from cast, cure in machine upside down for 5 mins
Trim and smoothen edges
4. Border Trim away areas where frenum exists
Molding Add greenstick compound incrementally to custom tray using a hot water
bath at 135oF
o Is a thermoplastic material that reflects soft tissue contours
Maxillary Mandibular
Anterior labial Anterior labial flanges
flanges o Out, up, in
o Out, down, in Posterior buccal flanges
Posterior buccal o Out, up, in
flanges Posterior buccal frenum
o Out, down, in o Out, up, in, back, forward
Posterior buccal Masseteric area
frenum o Pt closes mouth while applying
o Out, down, in, downward pressure on tray
back, forward Anterior lingual flange
Posterior o Protrude tongue and push tongue
distobuccal flange against rugae area to activate
o Pt opens wide mylohyoid muscles
and moves Mid-lingual flange
mandible side to o P o de ong e and make k
side (coronoid sound to activate mylohyoid
contour) Posterior lingual flange
o Pt protrudes tongue and moves L to
R to activate superior constrictor
Pterygomandibular raphe
o Pt opens mouth wide
Vent the custom tray by adding a hole posterior to incisive papilla
Apply adhesive to custom tray covering all borders
5. Secondary/ 2 Types
Final Mucostatic (ex. Zinc oxide eugenol paste) not used anymore
Impression o More fluid minimal displacement of tissue
Mucodisplacive (ex. polyvinylsiloxane/PVS) – Reprosil
o More viscous more displacement of tissue

4
 JL 2020

O
6. Final Master Boxing Impressions preserves functional depth of sulcus
Cast mum
Boxing wax attached 2-3mm below border
Vertical walls extend 10-15mm above impression
Seal the wax with hot spatula
Pour stone

O7. Posterior
Palatal Seal
and Record
Area of soft tissue along the junction of the hard and soft palate on which
pressure can be applied by a denture to aid its retention
Goes from the pterygomaxillary (hamular) notches from one side to the
Base other
Vibrating line an imaginary line that is not straight that marks the
junction of moveable and non-moveable

Biological Considerations of Jaw Relations and Jaw Movements

Mandibular Movements
Functional mastication, swallowing, speech
Parafunctional clenching, grinding, bruxism (detrimental to health)

TMJ Movements (both occur together)

Rotational process of turning (concentric circles) around Translational all points within a body are moving at the
an axis same velocity and in the same direction

O
O O
Occurs in the lower compartment (disc to condyle) of TMJ Occurs in the upper compartment (glenoid fossa to disc) of
the TMJ

Mandibular Movements Axis of Rotation

Any movement on a plane occurs around an axis perpendicular to the plane

Horizontal (Transverse) Axis Frontal (Vertical) Axis Sagittal Axis

Movement on sagittal plane Movement on horizontal plane Movement around frontal plane

HFS 1h5 HESS HFS 5

SFA
 JL 2020

Border Position the extreme position of the mandible in any given direction
Centric Relation (most retruded BP)
Lateral
Protrusive

Border Movements movement of the mandible through the outer range of motion
Mandibular movements at the limits dictated by anatomic structures as viewed in a given plane
Border movements are limited by the ligaments and articular surfaces of the TMJ as well as by the morphology and alignment of the
teeth
Can be visualized by a Posselt Diagram

Superior Contact Border Movements Anterior Opening Border Movements

Centric Relations (CR) Continuous movement
o Most retruded position From the most protruded
o Ligament guided postion to maximum opening
Centric Occlusion (CO)
o Maximum intercuspation
o Tooth guided
o Habitual bite

Posterior Opening Border Movements (2 parts) F nc ional Mo emen inne ea d op

Rotation only Occurs within the boundaries set by superior contact border,
o Condyles in terminal anterior opening order, and
hinge position posterior opening border
o Rotation until anterior
teeth are 20-25mm Chewing stroke the teardrop
apart (12o) shape occurring within the border

Translation
o Opening beyond 12o of
anterior teeth

Postural Position (PP) aka Rest Position

PP is located 2-4mm below the CO
PP is used to establish the vertical dimension of the pt

Envelope of Motion 3D space circumscribed by mandibular border movements within which all unstrained mandibular movement
occurs
Envelope of Function 3D space contained within the envelope of motion that defines mandibular movement during mastication
of phonation

JAW RELATIONS relation of the Mandible to the Maxilla

Vertical Relations vertical distance between maxilla and mandible, established by occlusion
Horizontal Relations how forward or backwards the maxilla is relative to mandible, established by teeth

VERTICAL RELATIONS

Vertical Dimension (VD) refers to length of face

VD of Rest Position
o Teeth not touching
o Muscles of occlusion are not contracted
o Is relatively constant and is used as a guide to obtain the VD occlusion in
edentulous pt
o Inter-occlusal (inter-arch) distance gap between the upper and lower teeth when the mandible is in the physiological
rest position
Usually 2-3mm observed at the 1st premolar area
VD of Occlusion
o Vertical separation of the jaws when the teeth are in occlusion
o Is about 2-3mm shorter than vertical dimension of rest
o VD occlusion = VD rest Inter-occlusal distance

6
 JL 2020

Procedure in clinic
1. Ask pt to swallow and relax and guide them in RP
2. Measure a point from the tip of the nose to the point in the chin to obtain VD rest
3. Calculate VD occlusion from VD rest
4. Place occlusal rims into pt mouth
5. Adjust the height of rims until the space between the reference points are equal to VD occlusion
a. Rims determine the position of the teeth in the dentures so the proper dimension must be achieved before setting
horizontal dimension
b. Max rim: 1-2 mm below the lip line
c. When pronouncing the F-sound, the rim should touch the lower vermillion border because in health, incisal edge of
incisors touches the junction between the wet and dry lower lip
d. When pronouncing the S-sound, lower incisal edge and upper Incisal edge comes in close within 1mm

HORIZONTAL RELATIONS
Centric Relation (CR)
o Most retruded, most posterior unstrained position in the glenoid fossa from which lateral movement can be made at any
degree of jaw separation
o Condyles articulate with the thinnest avascular portion of the disc with the complex in the antero-superior position
against the shapes of the articular eminences
o Ligament guided, independent of tooth contact
o Is clinically discernable when the mandible is directed superiorly and anteriorly and is restricted to a purely rotary
movement about the transverse horizontal axis
o Terminal Hinge Position
Position of the mandible where pure hinge movement is possible
Maximum range of terminal hinge rotation is 12o
Creates a range of 20-25 mm of inter-incisal opening
o Significance of CR
A reference point in recording maxillomandibular relations
Can be verified and repeated
Is a starting point for developing occlusion
Is a functional position

Interocclusal Check Record Technique

Place the rum in the mouth and guide pt into CR to relate upper and lower cast
Plane of occlusion using a fox plane
o Anterior parallel to the interpupillary line
o Posterior parallel to the alar-tragus line
Mark the midline of the maxilla using the labial frenum as the guide
Mark the canine line
Mark the lip when the pt smiles
Make V-shaped notches on premolar and molar regions on maxilla, remove 2mm of wax in corresponding
molar region on mandible and flute alu-wax
Place rim in pt and have pt bite down
Mount the cast and set up the teeth using the facebow index

Orientation
Hinge Axis
Face-bow an caliper-like device that is used to:
o Record the relationship of the maxilla to TMJ
o Record the relationship of the maxilla to opening axis of the jaws
o Orient the maxillary to the opening axis of the articulator in the same relationship the maxilla has to the opening axis of
the jaw

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 JL 2020

Kinematic (hinge-bow) Arbitrary (Face or Ear-bow)

Rods are placed on a line extending from the outer canthus to the top of
the tragus and approx. 13mm in front of the external auditory meatus

Ear Bow Face Bow

Selection and Arrangement of Anterior Teeth for Complete Dentures

Factors influencing complete denture esthetics face form, head shape
Incisal edge position
o Lips at rest should show 1-2mm of incisal edge
o Vermillion border of the lower lip at the junction of the moist and dry mucosa
F-sound
High smile line
Lip support
Plane of occlusion
o Anteriorly maxillary anterior teeth
o Posteriorly 1/2 of retromolar pad
VD rest and VD occlusion

Anterior Tooth Mold

1st Number Facial Form

1. Square
2. Square tapering
3. Square ovoid
4. Tapering
5. Tapering ovoid
6. Ovid
7. Square tapering ovoid

2nd Number Proportion Contour

1. Long Straight
2. Medium Straight
3. Short Straight
4. Long Curved
5. Medium Curved
6. Short Curved

Letter Width of Maxillary Anteriors Measured from Canine to Canine

B below 44mm
C 44-46mm
D 46-48mm
E 48-50mm
F/X 50-52mm
G 52-54mm
H 54-56mm
J above 56mm
Shade

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 JL 2020

Other Factors
Gender Feminine
Curved, delicate
Ovoid, tapering
Lateral incisors rounding
Masculine
Strong
Square lateral incisors
Large canines
Personality

Delicate Medium Vigorous

Age Youth
Mammelons
Lighter
Pointed cusp tips
Aged
Wear
Darker
Worn cusp tips

Porcelain Teeth
Pros Cons
Superior esthetics Brittle
Resistance to abrasion Poor bond to denture base
Color stability Difficult to polish after occlusal adjustment
Dimensionally stable wear of opposing teeth
Insoluble in oral fluids Occasional cracking

Arrangement of Maxillary Anterior Teeth

All labial surfaces of anterior teeth follow the curve
Central Incisors and Canines same flat plane
Central Incisors and Canines (long axis) vertical
Lateral Incisors 0.5mm above flat plane
Lateral Incisors and Canines (long axis) slightly distal
Canine (cervical portion) slightly labial

Arrangement of Mandibular Anterior Teeth

All incisal edges are on a flat plane
Centrals and Canines (long axis) vertical
Laterals and Canines (long axis) slightly distal
Centrals (cervical portion) slightly lingual
Laterals (cervical portion) straight
Canines (cervical portion) slightly labial

No Vertical Overlap only 1mm horizontal overlap (Non-anatomical occlusion)

Try-Ins and Verification

Midline
Smile line
Esthetics color, size, shape
Phonetics F-sounds when pronouncing fifty-five

Key Points to Remember

Listen to your pts complaints
Existing or previous prostheses
Let your pt participate

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 JL 2020

Classifications of Artificial Teeth

Anatomic Teeth has natural cusp angulations (30o or above)
o Designed for pts with high ridges

Semi-Anatomic Teeth less natural cusp angulations (10o) and higher cusp inclines
o Designed for pts who have a minimal ridge height
o By reducing the cusp angulation, it reduces the lateral forces on the denture

Non-Anatomic Teeth Monoplane and have no cusp angulations (0o)

o No clinically significant difference between chewing efficiencies between all the different types
of non-anatomic teeth

Hall Inverted Cusps Universal Dr. French Posts Sears Channel Teeth

Hardy s Steel Trubyte Rational Teeth IPN Portrait Dentsply

The Arrangement of Non-Anatomic Teeth (Monoplane Occlusion) – used at NYUCD

Advantages
Easier to set
Freedom in centric occlusion (non-locking) due to lack of cusps
Elimination of horizontal forces which are more damaging to supporting tissues
o Reduction of cuspal inclinations reduces horizontal forces
o Since there are not cusps, only vertical forces present
Increase denture stability
More adaptable to class II and III jaw relations and cross-bite situations
Easier to correct the occlusion after relining or rebasing
Use in maxillofacial prosthodontics

Disadvantages
Poor esthetics
Reduction of chewing efficiency due to no cusps being present

Centric Occlusion (CO) Working Occlusion (working side) Balancing Occlusion

Bilateral balanced occlusion

The side that you move the jaw Contact between the maxillary
Teeth in contact through all
towards lingual cusp with the mandibular
motions of the jaw
Buccal cusps of maxillary teeth and buccal cusp
Position of lingual cusps of
should contact the buccal cusp of
maxillary teeth will be in central
mandibular teeth (same with
fossa of mandibular teeth
lingual cusps)
1mm horizontal overlap prevents
cheek biting

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 JL 2020

Monoplane Occlusion Neutro-centric Occlusion Plane of Occlusion

All the teeth are set in a flat Teeth are not interfering with 1/2 the height of the retromolar
plane of occlusion tongue or cheek pad
Neutral zone is when teeth are Mark the crest of the ridge line
centered over the ridge so that the central fossa of the
Central fossa of the mandibular lower and the lingual cusp of
teeth must be set over the center the upper line up with the ridge
of the ridge

Setting Up
Anterior height of the rim established intra-orally
Posterior height of the rim half the height of the retromolar pad
Anterior set-up of non-anatomic teeth exhibits NO VERTICAL OVERLAP, only a 1mm horizontal overlap
Anterior set-up of anatomic teeth exhibits a 1mm horizontal AND vertical overlap
Maxilla DB of canine, B of 1st PM, B of 2nd PM, and MB of 1st M are aligned while lingual cusps are centered over the mandibular
ridge
Mandible central fossa of all posteriors are centered over the ridge

Christiansen Phenomenon
During protrusion, the downward and forward movement of the condyle creates a space in the posterior
region
Downward movement of the posterior part of the mandible have the effect of moving the mandibular
posterior teeth downward, creating space between them and the maxillary posterior teeth or occlusion rims
Since the anteriors are still in contact, the posterior teeth will dis-occlude while anteriors are still in contact
Decreases the stability of maxillary dentures
Solution
o Use anatomical teeth where height of the cusps in the posteriors will maintain contact
o Ramping the 2nd molars so that the teeth stay in contact

Horizontal Overlaps and Cheek Biting

Cusps placed edge to edge cheek biting
1mm of horizontal overlap cheeks pushed out of the way
Cross-bite trim the buccal cusps of the mandibular teeth

The Arrangement Anatomic Teeth (Balanced Occlusion)

Balanced occlusion
The bilateral, simultaneous, anterior and posterior occlusal contact of the teeth in centric and eccentric positions
Working side lingual and buccal cusps should contact the lingual and buccal cusps on the adjacent arch
Balancing side lingual cusps of the maxillary should contact the buccal cusps on the mandibular
Protrusion mesial incline of mandibular posteriors should contact the distal incline of maxillary posteriors

Establishing the Plane of Occlusion with Anatomic Teeth

Must incorporate different compensating curves (Wilson and Spee)
In complete dentures, centric occlusion (CO) = maximum intercuspation
In natural dentition, centric occlusion (CO) may not be the same as maximum intercuspation
Posteriorly the height of the plane of occlusion is 1/2 the height of the retromolar pad
Lingual cusp of the maxillary and the central fossa of the mandibular are centered over the mandibular ridge
o To visualize maxillary lingual alignment on the center of the ridge on the mandibular wax, remove 1mm of wax from the
buccal aspect of the indicating line

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 JL 2020

Arrangement of the posterior teeth for bilateral balanced occlusion

Setting condylar guide angles
o Horizontal condylar guide angle 25o obtained from protrusive records
o Lateral condylar guide angle 15o calculated from plugging in H into Hanau s formula
Condylar Guidance (CG)
o Mandibular guidance is generated by the condyle and the articular disk traversing the contour of the glenoid fossa
o Once the mouth is open, there is no teeth guidance, only condylar guidance
o Lateral condylar guidance Hanau s formula H where H is the Hori ontal CG o on average)

Compensating Curve
In natural dentition, it is known as the Curve of Spee
Lingual cusps are longer than buccal cusps
Lingual cusp of 1st PM, 2nd PM, ML cusp of 1st Molar are in the same plane of occlusion
o The buccal cusps of these teeth are about 0.5mm above the plane of occlusion
DB cusp of 1st Molar, MB and DB cusp of 2nd Molar are the rising curvatures
o There is an increase of 0.25mm from the plane of occlusion as we count the cusps towards the posterior
o DL cusp of 1st molar is 0.25mm higher from the occlusal plane
o ML cusp of 2nd molar is 0.5mm higher
o DL cusp of 2nd molar is 0.75mm higher

Distance from the Plane of Occlusion (Maxillary)

Lingual Cusps Facial Cusps
1st Premolar 0 mm 0.5 mm
2nd Premolar 0 mm 0.5 mm
Mesiolingual Cusp Distolingual Cusp Mesiobuccal Cusp Distobuccal Cusp
1st Molar 0 mm 0.25 mm 0.5 mm 0.75 mm
2nd Molar 0.5 mm 0.75 mm 1.0 mm 1.25 mm

Straight line from buccal cusp of canine to the MB cusp of 1 st Molar

Straight line from the DB cusp of 1st Molar to DB cusp of 2nd Molar

Setting Up Mandibular Teeth

Once the Maxillary teeth are set properly, setting the mandibular teeth is very easy
#30 MB groove receives #3 MB cusp
#19 MB groove receive #14 MB cusp
Working side Lingual cusps of maxillary teeth contacts lingual cusps of mandibular teeth
Balancing side Lingual cusps of maxillary teeth contacts buccal cusps of mandibular teeth
Protrusion Mandibular incisors contacts the labial surface of the Max centrals (anteriors) and there is
contact between the mesial incline of mandibular teeth with the distal incline of maxillary teeth ahead of it
(posteriorly)

12
 JL 2020

Occlusion in Complete Dentures

Terminology
Occlusion static relationship between the incising or masticating surfaces of the maxillary and mandibular teeth
Maximal Intercuspation complete intercuspation of the opposing teeth independent of condylar position (best fit)
Articulation dynamic contact relation between the occlusal surfaces of the teeth during function
Centric occlusion (CO) occlusion of the opposing teeth when the mandible is in centric relation (CR)
o Centric Relation the most retruded position when the condyles are in the most posterior unstrained position in the
glenoid fossa from which lateral movement can be made, at any given degree of jaw separation
Eccentric occlusion an occlusion other than centric occlusion
o Protrusive position incisal guidance
o Lateral position canine guidance or group function

Concepts of Occlusion

Natural Dentition
Cuspid Protected Occlusion Group Function
Form of mutually protected articulation in which the Multiple contact relations between the maxillary and
vertical and horizontal overlap of the canine teeth mandibular teeth in lateral movements on the working side
disengage the posterior teeth in the excursive whereby simultaneous contact of several teeth act as a group
movements of the mandible to distribute occlusal forces
Working side only canines in contact Working side C, PM, M in contact
Balancing side no teeth in contact Balancing side no teeth in contact

Working Side Balancing Side Working Side Balancing Side

Complete Dentures
Monoplane occlusion (for Non-anatomical teeth) Balanced Occlusion (for Anatomical teeth)
Arrangement where posterior teeth have masticatory Bilateral, simultaneous, anterior and posterior occlusal
surfaces that lack any cuspal height and are positioned contact of the teeth in centric and eccentric positions
in a single plane We are creating a compensating curve
Maintains 1mm of horizontal overlap Maintains 1mm of horizontal and vertical overlap

Philosophy of Complete Denture Occlusion

Opposing maxillary and mandibular teeth contacts in a position that demonstrate reproducibility (Centric Relation)
Degree of incisal guidance established via positioning of anterior maxillary and mandibular teeth
Absence of deflective occlusal contacts and a free-gliding articulation between opposing maxillary and mandibular anterior and
posterior teeth during jaw movements
Positioning anterior and posterior teeth to provide a natural-ness in appearance

Articulation of Artificial Teeth Rudolph Hanau 1925

Mechanical balanced articulation involves precise laws of articulation based on geometry and occlusion constructed on an
articulator completely controlled by mechanics
Law of Articulation (protrusive) Hana s Q int
o Inclination of condylar guidance
o Inclination of the cusps
o Orientation of the occlusal plane
o Prominence of the compensating curve
o Inclination of the incisal guidance

13
 JL 2020

Controlling End Factors controls protrusive movements

o Condylar Guidance Angle
Mandibular guidance generated by the condyle and the articular disc
traversing the contour of the glenoid fossa
Only factor that could not be changed by the dentist
o Incisal Guidance
Influences of the contacting surfaces of the mandibular and maxillary
anteriors on mandibular movement
In complete dentures, the incisal guidance is set by the dentist

Incisal Guide Angle

Angle formed by the intersection of the plane of occlusion and a line within the sagittal plane determined by the incisal edges of the
maxillary and mandibular central incisors when the teeth are in maximum intercuspation

in vertical overlap in the incisal guide angle in horizontal overlap in the incisal guide angle

Articulation
Articulator imitates the movement of the mandible
Casts are related the same way the maxillary and mandibular are
related
Achieve bilateral balanced occlusion by adjusting these intermediary
factors
o Inclination of the cusps
o Orientation of the occlusal plane
o Prominence of the compensating curve

Cuspal Inclination
Influenced by condylar guidance (CG) and incisal guidance (IG)
Steep CG requires a steep cuspal inclination
Less steep IG will result in flatter cusp inclination
If CG and IG are different from cuspal angulation, the cusps must be grinded
Reduction of cuspal inclination results in reduction of lateral forces

The IG is more important because the posterior teeth are closer to the action of IG than the CG
Reduction of IG will result in flatter cusp inclination
In complete denture construction, we keep the IG angle at 0o

14
 JL 2020

Occlusal Plane Orientation Prominence of the Compensating Curve

Plane of occlusion can deviate slightly from 1/2 the Antero-posterior curvature of the occluding surfaces
height of the retromolar pad to achieve bilaterally and incisal edges is used to develop balanced occlusion
balanced occlusion Compensating curve is affected by:
Above 2/3 of the retromolar pad results in unstable o The shape of the manufactured teeth
denture o How the teeth are set up in wax
Below 2/3 of the retromolar pad, the tongue would
be caught between the upper and lower dentures

Waxing, Contouring, Processing, and Remounting the Complete Dentures

Steps in selecting and arranging artificial teeth:
Final arrangement and try in Waxing and contouring Flasking the dentures Dewaxing and preparing for packing Packing
and processing the dentures Finishing and polishing the dentures

Surfaces
Cameo (Polished) External, where the teeth are set
Intaglio (Basal or Impression) Internal, rests on the alveolar ridges

Directional Forces
Spaces need to exists (concave surface)
If the contour of the denture is done well, then the tongue and cheeks will help to retain
the dentures

Festooning
Carvings in the base material of a denture that simulates the contours of the
natural soft tissues that are being replaced by the denture

Self-Cleaning Interdental Papillae

Creating a proper convex contour to replicate the interdental papillae
Prevents the impaction of food particles
Allows the dentures to last longer since it will stain less and less plaque build up

Gingival Margins and Contact Areas

Must extend to the point of tooth contact
Must be of various length
Must be convex in all directions
Must be shaped according to age

Developed Root Indications

Scoop out the excess wax with number 7 spatula
Every tooth has a different root indication
o Longest is the maxillary canine
o Smallest is the lateral incisors

Lingual/Palatal Contour
This space is mostly occupied by the tongue in mandibular denture
Contributes to the S and H sounds during speech
Must be flushed smooth and concaved
We want to have about 2.5mm of the denture to maintain integrity

15
 JL 2020

Steps
Make a Plaster Index (impression)
Used as a base on the articulator table that the maxillary teeth fit prior to removing
the master cast from the articulator
Helps minimize/check for errors when dentures are returned

Layering
A mix of artificial stone is placed in the bottom half of the flask (Drag)
Apply separating medium (tin-foil substitute) onto the master cast
Place the master cast into the drag and adjust the master cast
o There should be a 1/4 (3-6mm) space between the teeth and the top of the
flask
Bevel the excess stone
o Land area of the master cast should be level/flush with the drag
Place the Cope (middle section) on top of the drag
Apply separating medium to the exposed stone in the flask
Develop the core/add height with the plaster mix but the top of the core should be 2-
3 mm below the occlusal plane of the teeth
Expose cusp tip so we know location of the denture when removing the layers
Assemble the Cap (top portion)
Fill the top portion with stone (stone cap)
Processing
Place the flask into boiling water for 4-6 mins to melt away the wax
Open the flask at the bottom and middle portion and remove wax completely
o Teeth will be embedded into the layer that consists of stone and plaster
(secure)
o Ensure that there is no more wax by pouring boiling water onto the teeth so
that it melts off
Apply separating medium to the master cast (but not teeth) since we want the acrylic
to adhere to the teeth only and not the master cast
Setting the Acrylic Resin
Mix the acrylic for 30 secs
o Polymer-monomer ratio is 3:1 by volume
o Cover to prevent evaporation for 1 min or until in doughy state
Push the acrylic into the mold to allow better adaptation
Trial Packing squeezing out the excess acrylic
o Place a plastic film between the flasks and press with high pressure
o Repeat until a minimal amount of flash (excess) is present (~3X)
Remove excess resin
Curing Long Cure Cycle Maintained for 7 hrs
Temperature is raised slowly to 74oC (165oF) in 1 hr
Brought to boil for 30 mins
Porosities are reduced in the long cure and you end up with a more dense product
Short Cure Cycle Maintained for 90 mins
Cure from room temp water and raised to 74oC (165oF) over 1 hr
Brought to boil for 30 mins
Flask must be cool to room temperature prior to de-flasking to allow the acrylic to harden
De-Flask with a chisel being careful not the damage teeth
Split-Cast Technique
o Remount the master cast onto the 3 wedges of the articulator base
Reposition/remount the dentures (not separated yet) onto the articulator to visualize
any discrepancies
o 1-2 mm of errors can be corrected
o make adjustments with articulating paper
Dentures separated from the master cast with a pneumatic chisel
Smoothen denture surfaces (using burs and scrapers)
Polish
o Rag wheel with pumice (tripoli)
Examine the final dentures (surfaces, borders, frenum notches)

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 JL 2020

Review of Acrylic Resins

Types Stages of Acrylic Resin
Polymethyl Methacrylate (PMMA) 1. Wet sandy not usable
o PMMA solid polymer 2. Early stringy
o Methyl Methacrylate liquid monomer 3. Late stringy
Methods 4. Doughy working stage
Heat Cure Benzoyl peroxide in the powder (initiator) is activated by heat 5. Rubbery cannot be adjusted
Chemical Cure Benzoyl peroxide in the power (initiator) is activated by tertiary 6. Stiff gives off heat
amines in the liquid

Occlusal Equilibrium
The modification of the occlusal form of the teeth to equalize occlusal stress, produce simultaneous occlusal contacts or harmonizing cuspal
relations (often overlooked but the MOST IMPORTANT according to Dr. Karande)

It is needed to eliminate occlusal discrepancies caused by:

Technical errors or judgment errors made by the dentist
Technical errors developed in the lab
Inherent deficiencies of the material used in the fabrication of the dentures

Causes of Occlusal Disharmony

Inaccurate maxilla-mandibular relation records ex. aluwax bite
Errors in transfer of relation record to the articulator
Ill-fitting temporary record bases
Incorrect vertical dimension of occlusion (VDO)
Incorrect posterior teeth setup
Failure to close the flask completely during processing
Warping the dentures by overheating during polishing and/or incorrect removal from master casts
Unavoidable change in denture base material

Errors in Occlusion
Processing Errors eliminated by laboratory remounting
o 1-2mm discrepancies can be fixed
Technical Errors eliminated by clinical remounting
o First inform pts to leave out their old dentures for 24hrs
Places certain stresses on the tissue
o Apply pressure indicating paste (PIP) on the fitting surface (intaglio)
Areas that are ill-fitting will be indicated by the PIP (darker shade)
o Ensure uniform seating of denture base
Relieve the pressure spots using a no. 8 round bur
o Making clinical remount casts
Block-out undercuts with wax to prevent stone from getting stuck
Use fast-setting plaster
Use a facebow index to help you remount the cast
o Clinical remount CR record
Guide the pt into centric relation (CR) try 3X to ensure repeatable
A repeatable, clinical reference position, independent of tooth contact
Must not have any tooth contact
Use Aluwax to re-establish the CR in the articulator
Immersed in 130oF (54oC) water for 30 secs
Make sure the teeth do not penetrate the Aluwax
o Articulate Mandibular Cast and verify CR
Ensure balanced occlusion
The bilateral, simultaneous occlusal contact of the anterior and posterior teeth in excursive
movements
MIP, lateral excursions, protrusions are all balanced

Objectives
To make MIP equal to CO
To re-direct occlusal forces along the long axis of the teeth
To distribute occlusal forces to as many teeth as possible

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 JL 2020

Goals
Balancing side contacts to appear across the arch and within the tooth on the working side of the arch
Maintain the integrity of the stamp or central bearing cusp tips holding cusps in both arches maxillary lingual and mandibular
buccal and allow all cusps to move through the sluce ways of the opposing dentition working and balancing grooves and mesial
and distal inclines)

Selective Grinding
Adjust articulator to proper setting after the remount casts have been mounted
Carried out using articulating paper to mark premature contacts centric and eccentric movements
Use acrylic burs to make necessary adjustments

Sequence to Check for Occlusal Equilibrium

Centric relation position (black) Lateral (red) Protrusive (green) Re-check centric (potentially need to deepen the fossae)

Jaw Movements
Working side that mandible moves to
Balancing (Non-Working) the side opposite to the side that the mandible moves to
Protrusion forward movement of the mandible
Retrusion backward movement of the mandible

Centric Relation (CR)

Lock the upper arm of the articulator in CR
Check the occlusion by opening and closing the articulator and lightly tapping the teeth
together on red articulating paper
o If the cusp is high in CO, only deepen the opposing fossa
o If the cusp is high in both centric and eccentric position, then reduce the cusp
o Goal to eliminate occlusal contacts on inclines

Remount Dentures in CR
Check for any premature contacts and fix
Goal is to have multiple bilateral occlusal contacts (1 anterior point and 2 posterior points)
After perfecting CO, the holding cusps must not be shortened

Interference in Working Side Interference in working side Interference in working side

(B-L relationship) (M-D relationship)
Rule of BULL Rule of MUDL
You may grind the buccal In lateral
cusps of the uppers and excursion, you
the lingual cusps of the may grind the
lowers mesial incline of
Reduce lingual inclines of the upper cusps
buccal cusps of maxillary and the distal
teeth inclines of the
Reduce buccal inclines of lower cusps
lingual cusps of
mandibular teeth

Interference in Balancing Side Interference in Protrusions Re-check centric occlusal contacts

You want contact Rule of DUML
on the balancing Reduce the distal
side in dentures incline of the
(unlike real teeth) upper cusps and
Prevents the tipping the mesial inclines
of dentures on one of the lower cusps
side This ensures
anterior contact
and bilateral
posterior contacts

18
 JL 2020

Important Terminology
Centric Occlusion (CO)
o Occlusion of opposing teeth when mandible is in centric relation this may or may not coincide with the maximal
intercuspal position
Centric Relation (CR)
o A maxilla-mandibular relationship, independent of tooth contact in which the condyles articulate in the anterior-superior
position against the posterior slopes of the articular eminence
o In this position, the mandible is restricted to a purely rotary movement
o From this unstrained, physiologic, maxilla-mandibular relationship, the pt can make vertical, lateral, or protrusive
movements
o Is a clinically useful and repeatable reference position
o Established on the articulator using Aluwax taken on the pt

Implant Retained Complete Dentures (Overdentures)

A complete denture that has an implant that snaps-on
Many professors say that overdentures should be the standard of care
o Edentulism is very high in Canada and the US (40% are edentulous in at least one arch)
o By 2035 in the US, there will be a greater population over the age of 70 than under the age of 70
As dentist, we WILL be seeing pts with edentulism and we MUST be able to construct CD as part of tx
o Dentures are necessary for a higher quality of life (evidence-based)
Chewing sensation (proprioception)
Improved stability and retention
Improved chewing ability
Improved health and nutritional status (done by blood tests)
o Insurances should cover the cost sometime during out lifetime
o Most expensive care in medicine and dentistry is elder care

Edentulous Pts
Once a pt has teeth extracted, the remaining area undergoes residual ridge resorption (RRR)
o Resorption occurs indefinitely (for the life of the pt)
o Fastest in first 6 months
o Different individuals have different rates
o Same individuals will have different rates at different times and at different sites
o Implant can slow down this process
o RRR occurs faster in women due to post-menopause
o RRR slower in the maxilla since the palate is a very stable bone

Pattern of Resorption
o Maxillary arch: backwards and upwards
Reason why we set it a bit more buccal (about 10 12mm from the incisal papilla) just a guide
Clinically, we set the anterior teeth based on esthetics and phonetics
o Mandibular arch: down and out
Number 1 pts complaint is about how loose the mandibular dentures get but is easily fixed with overdentures

Overview of Clinical Process

1. Denture fabrication and Implant placement
2. Abutment selection
3. Abutment connection and torque
4. Pick up of attachments
5. Occlusion
6. Recall and follow up

Implant Placement
We want to place the implant in the parasymphyseal region (between the mental
foramina)
Lacks nerves or sinuses
Highest success of implant (99%)
12mm height minimum

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 JL 2020

Abutment Selection
Measure from the implant head to the deepest tissue
Immediately replace the healing abutment
Soft tissue height (not always even)
o Used to be soft tissue height +1mm
o Manufactures now include the 1mm
Comes in either 10 or 13mm
When the screw for the implant is removed, the deeper the implant is, the greater the
collapse of the tissues around the implant
We measure from the flat portion of the implant to the height of the tissue with a perio
probe and pick the largest number which will allow you to select the abutment
We want the abutment to protrude through the gums
Tissue height will remain the same regardless of the length of the implant

Abutment Connection and Torque

Hand tighten with three-in-one driver and take an x-ray
X-ray ensures that the implant is seated and not loose
We need to torque to measure at 30 Ncm (used to be 20 NCm)

Pick up of Attachment
Place White Spacer Rings over the collar of the locator abutment which blocks out the
undercut that is designed for the denture to snap into while we continue the
procedure
Place housing with black processing male over the locator abutment
Place marking medium/dye on metal housing
o Marks the implant/abutment position on the intaglio (underside) surface of the
denture
Seat denture until contact is made between the housing and the intaglio surface
Drill all the way through the denture where the marker makes contact to ensure the
denture is fully seated and not rocking otherwise it will fracture
Mix acrylic into a creamy cheese consistency and pour into hole
o While setting, the acrylic will release heat
o This exothermic heat can be controlled by spraying cold water until it is set
Ensure pt is clamping down on the denture to ensure the denture does not move
If the denture teeth are present over the locator:
o Drill a lingual vent hole
Seat denture in centric occlusion to pick up the housing
Remove ring and black processing male with attachment removal instrument
Seat retentive male into housing with attachment insertion instrument
o There are different pressures associated with the retention of the inserts:
o Blue (1.5lbs of pressure)
o Pink (3 lbs of pressure)
o Clear (5 lbs of pressure) most retentive
o Check with pt to see if they can easily (but not too easily) pop out their dentures

SUMMARY
o Every edentulous pt SHOULD be given the choice of OD for the mandible
o Attachment male inserts SHOULD be changed roughly every year rough
guideline
o 2-implant ODs for maxilla does not exists pts do not complain of the
maxilla and there is not enough bone
o Tx planning for the maxilla is far more complex
o 98% of overdenture treated pts at NYUCD said that they would
recommend overdentures to a friend

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 FIXED AND IMPLANT PROSTHETICS (CR I):
Prosthodontics (Exam 2)
Charlotte Guerrera

Periodontal Considerations for Fixed Prosthodontic Restorations, Part I

9/28/17

Two fundamental • Does the patient have periodontal disease?

questions • Are the teeth good candidates for restorative treatment?
Gingivitis • First indication of periodontal disease
• Bacteria
• Immune system cells
• Inflammatory infiltrate
Sequence of inflammatory • Vascular changes
events • Migration of PMNs
• Collagen breakdown
• Fibroblast cell damage
• Formation of a gingival pocket
Clinical manifestations • Clinical manifestations of gingivitis can have a profound effect on the
restorative outcome
• EDEMA – change in shape
• POCKET FORMATION – probing depth
• BLEEDING – in response to:
o Probing
o Air jet
o Pressure
Periodontitis • More destruction
• Different bugs
What’s the difference? • Loss of epithelial attachment is
present in periodontitis
• Gingivitis is just inflammatory
• CAL = clinical attachment loss

Summary • Edema
• Erythema
• Bleeding
• Pocket formation
• Loss of attachment
Inflammatory periodontal • Bacteria à untreated periodontal disease à tooth loss
disease itself can cause • It is important to establish periodontal health BEFORE performing
tooth loss restorative dentistry
• And with respect to gingivitis, it is important to establish stable gingival
margins before tooth preparation
 o Healthy tissues are less likely to change shape following
restorative treatment
o The absence of bleeding results in more predictable restorative
and aesthetic procedures
o In certain cases, resolution of inflammation may actually result in
the repositioning of teeth
• Traumatic forces placed on teeth with ongoing periodontal disease may
increase tooth mobility, discomfort, and the rate of attachment loss
• Inadequate amount of keratinized tissue may jeopardize plaque control
or compromise the integrity of crown margins
• Successful esthetic or implant procedures may be difficult or impossible
without specialized periodontal procedures for “site development”
Clinical crown length • Periodontal procedures may also be necessary to establish clinical crown
length
o Crown retention
o Access for tooth
preparation, impressions,
and finishing margins
o Fracture
Make an accurate • Health, gingivitis, periodontitis?
periodontal diagnosis • HEALTH:
o Probing depths of 1-3mm
o No history of attachment loss
o No clinical signs of inflammation
• GINGIVITIS:
o Probing depths 1-3mm
o No history of attachment loss
o Clinical signs of inflammation
• PERIODONTITIS:
o Attachment loss
What’s next? • Initial therapy à re-evaluation à surgical therapy à periodontal
maintenance therapy, supportive periodontal therapy, preventive
maintenance, and recall maintenance
• Goal of initial therapy: to control active dental disease
• At the completion of initial therapy, patients should be in a state of dental
health:
o Caries controlled
o Absence of gingival disease (gingivitis)
More questions • Are the teeth good candidates for restorative treatment?
• Is there an adequate zone of keratinized tissue?
• Is there adequate length of clinical crown?
• Is there a favorable ratio of the “crown-to-root”?
Zone of keratinized tissue • If the zone of keratinized gingiva is minimal or absent, adequate plaque
control may be problematic and the site may be more susceptible to
trauma
• Is there an esthetic problem?
• Is the area sensitive?
o Mechanical
 o Thermal
o Osmotic
• Is the recession progressive?
Connective tissue graft • The CTG is an ELECTIVE surgical procedure to correct this gingival defect
• Recipient site – flap reflected
• Donor site
o Initial incision is oriented perpendicular to the tissue surface
o Second incision is made parallel to the hard palate
o PALATE is a perfect donor site because it is all keratinized
o Donor site is sutured
• Flap is repositioned coronally, and the recipient site is sutured
Free gingival graft • FGG is less esthetic than CTG
• Post-operative is worse for FGG
Lateral sliding graft • Slide over tissue from adjacent tooth
Summary • Gingival graft procedures provide stability of the free gingival margin and
surrounding gingival tissues and increase the zone of keratinized tissue
Summary • Plaque control
• Sensitivity
• Aesthetics
• Trauma
• Progressive
• Prosthetic considerations
• Connective tissue graft
• Free gingival graft
• Lateral sliding graft
Clinical crown • By definition, the clinical crown is the portion of the tooth that is coronal
to the FGM
• And one very critical issue is whether the length of the clinical crown is
adequate for retention of a restoration
• In situations in which a tooth has a short clinical crown, it may be
necessary to “increase” its length by exposing more tooth structure
• The “crown-lengthening” procedure is a way to create adequate crown
retention without extending the crown margins deep into the periodontal
tissues
• In other words, the crown-lengthening procedure is a way to
accommodate to, and preserve, the biologic width of the restored tooth
Biologic Width • Studies have demonstrated a space of ~2.1mm
coronal to the alveolar crest to accommodate the
supracrestal connective tissue and the junctional
epithelium
• The distance, from the alveolar crest to the most
coronal aspect of the epithelial attachment (A) is
referred to as the “Biologic Width” (~2.1mm)
o B: clinical sulcus
o C: epithelial attachment
o D: supracrestal fiber attachment
 Margin Design and Tissue Management
9/28/17

Restoration Margin • The peripheral extension of a tooth preparation

Preparation Margin • The peripheral extension of a tooth preparation
• Finish line
• Junction of cut and uncut tooth structure
Retainer Margin • The outer edge of a crown, inlay, onlay, or other restoration
Emergence Profile • The contour of a tooth or restoration as it relates to the adjacent tissues
Emergence Profile • Must be flat or concave
• It is really easy to over-contour when creating an emergence
profile with a crown

Biologic Width • The combined dimensions of the

connective tissue attachment and the
epithelial attachment
• Average is about 2mm

Factors affecting margin • Caries

location • Esthetics
• Tooth location
• Caries index
• Height of available healthy tooth structure
• Crest of alveolar bone
• Sulcus depth
• Dental material requirements
• Pulp vitality
• Previous restorations
• Trauma
• Erosion, abrasion, attrition
• Root sensitivity, exposure
• Root proximity
Margin Placement • Supra-gingival margin – GOOD
• Intra-crevicular margin – GOOD
• Epithelial attachment – BAD
• Connective tissue attachment – BAD
• Margin at crest of bone – BAD
Biologic Width • If you have caries/fracture apical to gingival sulcus:
o Crown-lengthening AND/OR orthodontic eruption
NYU Study on Subgingival • Histological data revealed reformation of a new supracrestal attachment
Preparation unit within one week following crown placement
Subgingival Preparation • Even though attachment is replaced, it causes problems when you violate
biologic width:
o Reformation of attachment
o Unpredictable
 o Impressioning difficulty
o Ill-fitting restorations
• Naked eye can resolve 50µm margin
• Up to 120µm sub-gingival
o Leads to greater than 120µm marginal discrepancy – not good
• Size of one bacterium? About 0.1-10µm – crowns that fit with 100µm
margin or less, it is clinically acceptable and works, but if it is greater than
this it increases the risk of the crown failing
Clinically Defective • A niche for plaque
Margins • Gingival inflammation
o Gingival index
o Crevicular fluid volume
• Predisposed to caries
• The response of the periodontal tissues is the criterion by which the value
of the prosthesis is measured
Finish Line Designs • Shoulder
• Shoulder/bevel
• 45 degree bevel
• Chamfer
• Chamfer/bevel
• Heavy chamfer or rounded
shoulder
• Knife-edge

Bevels • The process of slanting or sloping the finish line and

curves of a tooth preparation
• Bevel variation
• Seating inaccuracies
• Effects of cement
o Die spacer
o Cement line
• Indications for bevels
o Estehtic placement for metal margins
o Full cast gold restorations
o Partial coverage
o Endodontically treated teeth
Knife-Edged Margin • Partial coverage, proximal surfaces
• Lost periodontal support
• Mandibular anterior (small so want to preserve tooth structure)
• Tilted teeth
• Can use flame shaped burrs
• Conservative full coverage margin
• Not enough reduction for veneering
• Can be difficult to cast
• Margins can be difficult to read
Limitations of Dental • Marginal integrity of metal vs. porcelain
Materials o Ideally <100µm
 • Preparations for metal castings should be smooth and consistent
• The minimum thickness for adequate strength
Metal-Ceramic Crowns • Porcelain: 1mm ideal thickness
• Cast metal: 0.55 minimal thickness
• Uniform thickness of porcelain
• Variable thickness of metal
Porcelain at Gingival • Reduction is least near the margin
• Porcelain bust be supported
• Porcelain must not be placed on bevels
Different ways you can add
porcelain to metal

No metal to show: • Full porcelain crown – margins and resin cement

alternatives to sub-G • Porcelain Butt Facial
o Porcelain margin on facial only
o Metal margins interproximal and lingual
Esthetic Preparations • Shoulder (flat/rounded), chamfer
• Preparation follows the contour of the soft tissue – also known as tissue
tracking

Emergence Profile and Clinical Practice

10/5/17

Biologic Contours • Relates to gingival health

• Teeth have facial and lingual convexities
• Height of contour on facial and lingual: 0.5 mm
o Except on lingual of lower molars and premolars, where it may be
0.75-1.0 mm (greater bulge because of lingual inclination)
• Teeth also have mesial and distal concavities – but it can also be straight
• Concavity makes room for the interdental papilla by creating a space in
the cervical region
o If you have too large an emergence contour, it will push on the
gingiva causing inflammation
Transitional Line • Where the crown blends into the tooth
Contours relate to gingival • (1) Healthy gingiva at ideal crown
health • (2) Healthy gingiva at undercontouring
• (3) Observe the bulky transitional line
Straight Emergence Profile • Must follow three dimensional contours
• Series of planes that are blended

Three Planes • #1 is straight

• #2 is the blending line
• #3 belnds into the cusps
• #1 and #3 are determined by the interdigitation
of the opposing teeth
• #2 is determined by you and the lab technician
Embrasures • Minor embrasures are food spillways and esthetic necessities
• Occlusal embrasures are the minor embrasures
• Gingival embrasures are the major embrasures
• Lingual embrasures are slightly larger – these are also food spillways to
take the pressure off your teeth when you are eating
• Anterior teeth are for grasping food
• Posterior teeth are for grinding food
Splint • Teeth are all helping hold each other in place
• Attachments for removable partial denture
included

Cervical Curvature • Anterior teeth have a very marked gingival line

• This line gets to be much flatter at the molar

Marginal Ridges • Opposing cusps nestle in marginal ridges so they

must be good receptors for cusps
• Marginal ridges cannot be too high or too low –
need proper shaping of contact area
• If the marginal ridges are too high it will not be
able to receive the opposing cusp
• If the marginal ridges are too low it will trap food
• Neighboring marginal ridges must be the same height – the correct height
can be determined based on the opposing teeth
Non-Biologic Contours • We have to work well with our technicians to get the best results
(from laboratory) • If we do not give enough instruction, we will end up with more work for
ourselves
o We will end up having to reshape by adding or subtracting
material
Tooth Reduction • You have to be careful not to take off too much tooth structure, because
this can put the pulp at risk
 • We want to get an emergence angle that works and allows us to put on
the right amount of material – too little reduction and we will end up with
a bulky restoration
Overcontoured Crowns • Overcontoured crowns contribute to periodontal disease
• Unnatural unpleasant appearance when crowns are too bulgy
Pontics • The pontic should cover the ridge as much as possible, coving it, but not
wrap around making it difficult to clean
• Gingiva is healthier when there is space on the lingual, but then food gets
trapped too easily
Occlusal Form • You have to be a bit of an artist to recreate the occlusal form
• Chewing table is not the width of the whole tooth – it is about 60%
• The surface is 3 dimensional
• Cusp tip is highest part
• Marginal ridges are lower than the cusps
• Cusp ridges lead from the cusp tips (ex: mesial distobuccal cusp tip)
• Triangular ridges give the teeth character – they don’t go straight across,
rather they point towards the center
• Triangular fossa has depth to allow opposing cusp to sit inside

Interocclusal Registrations
10/5/17

Two Types of Dentistry • Conformative

• Restorative or Reconstructive
Maximum Intercuspal • The complete intercuspation of the opposing teeth independent of
Position (MIP) condylar position
Centric Relation • The maxilla-mandibular relationship in which the condyles articulate – in
the mist anterior-superior position against the shapes of the articular
eminences
• This position is INDEPENDENT of tooth contact
Centric Occlusion • The position of the teeth when the condyles are in centric relation
• May or may not coincide with MIP
Obsolete Terminology • Centric relation occlusion
• CRO (now synonymous with centric occlusion)
Objectionable vs. Correct Bite Occlusion
Terminology Bite record Occlusion record
Take a bite Make the record
Have a bite Incise, masticate
Open the bite Increase vertical dimension
Centric Relation • Repeatable
• Physiologically acceptable
• Convenient
• Used in reconstructive dentistry
• Used when changing vertical dimension
Recording Centric Relation • Chin-point guidance
• Bilateral manipulation – this is the most repeatable and accurate centric
relation method
 • Unguided/muscle guided
Facebow Transfer • Relates maxillary cast to the upper member of the semi/fully adjusted
articulator
• Relates maxillary teeth to condylar elements
• Useful in changes in vertical dimension
Articulators • Used to relate upper and lower casts
• You can have the kinds of
articulators we have, or you can
have simple hinge articulators
o AHA: Articulator hinge axis
o MHA: Mandibular hinge axis
• The more anatomically correct
articulators work better and better
repeat the occlusion of the patient
Verifying Centric Relation • Take 3 records and compare them all to make sure you have an accurate
record of CR
• Wax-wafer
o Make sure this is NOT perforated – if your relationship is just a tiny
bit off the restorations will be too high and your patient will have
discomfort
• Split cast
• Two of three
Split Cast Technique • Make notches on maxillary cast
• Lubricate the top of the base with Vaseline because you want to be able
to separate them once they are mounted
• If your casts do not line up the same way with all wax-wafer recordings,
the split cast technique will accentuate your error
• You want to make sure you have at least two wafers that match up so you
know they are correct
Recording MIP • Most accurate = hand articulation
o Accurate cast and counter
o Clearance between tuberosity and pad
o No bubbles on cast
• Polyvinyl siloxane, poly-ether rubber
• Occlusal rims
MIP for Quadrant Dentistry • Hand articulation not always possible
• Transfer copings
o Made of resin, directly on dies – to
relate dies from multiple casts
o Inter-occlusal registration (CR or
MIP)
o Useful in mounting casts
o Also useful in making ONE master
cast
o Require an additional visit
 Scope of Prosthodontics
10/10/17

Contemporary Fixed • When your central incisors are broken off in half they will need to have
Prosthodontics root canals because the pulp is exposed, and they will need post and core
to replace missing tooth structure before crowns can be placed
Implant Fixed • Implants have been around for about 45 years
Prosthodontics • Once you lose your two front teeth, you immediately lose the papilla and
it can never be replaced, so anterior maxillary implants can be very
difficult to get them to look esthetic
Congenital Abnormalities: • Developmental defect of enamel
Amelogenesis Imperfecta • Enamel chips away and there is extreme sensitivity and pain
• Interdisciplinary:
o Prosthodontics
o Orthodontics
o Periodontics
Prosthodontics • “Prosthodontics transcends materials, technology, operator skills,
perceived successes, fame or ego. It cultivates relationships, trust,
honesty, and integrity.”
Occlusion • Articulators help recreate occlusion
Full Mouth Reconstruction • Treatment of edentulism – when patients lose all of their teeth, it is
almost like a loss of a limb
Meth Mouth – • Meth is super acidic so patients who abuse it will lose all their teeth
Methamphetamine Abuse • The meth acts like a painkiller so they don’t even feel sensitive
• Very difficult cases
Overdentures • Maintain a couple of teeth of put in a few implants to maintain bone
height
Anatomical Reconstruction • Guided surgery – template
of Edentulous Patient • Scan the denture and scan the patient to determine exactly where we
want the implants to be
• Mandible can get really thin in edentulous patients due to resorption –
this can lead to mandibular fracture
Maxillofacial • Intraoral obturators
Prosthodontics • Extraoral orbital appliances

Models and Gypsum Products

10/10/17

Models • (1) Gypsum products: plaster/stone

• (2) Alternative materials: silicon and milled epoxy (cad-cam)
Applications • Used in:
o Sculptures
o Dental models
o Immobilization
o Construction
o Agriculture
• Calcium sulfate dehydrate à calcium sulfate hemihydrate
 • We have stone in nature (calcium sulfate dehydrate) that we are
transforming to calcium sulfate hemihydrate in order to make the stone
we use in dentistry
Production • Mineral gypsum à trituration à heating à plaster/stone à processing
à product
• Products:
o Plaster: beta hemihydrate
o Stone: alpha hemihydrate
• We get different types of gypsum depending on how we apply the heat

• Just heat: you get the first type of gypsum, which is plaster
• Heat under pressure steam: you get another type, which we call stone
• Heat under pressure steam + calcium chloride: most used type, which is
high strength dental stone
Setting/Reverse Process

• Add water, which causes release of heat

• You can tell how much the gypsum has set by feeling how much heat it is
letting off
Classification • TYPE I: Plaster of Paris, impression plaster (don’t have this anymore)
• TYPE II: Plaster model
Types II, III, IV are the most • TYPE III: Dental stone
important • TYPE IV: High strength dental stone, die stone
• TYPE V: High strength and high expansion dental stone

Indications TYPE I Plaster of Paris, Impression of total prosthesis

impression plaster
TYPE II Plaster model Study models, articulators,
filling of muffles
TYPE III Dental stone Working and study models,
antagonist model
TYPE IV High strength dental Precision models, ceramic and
stone, die stone PFM models, die cast
TYPE V High strength and high Casts for metal allows with high
expansion dental stone contraction
 Type I • Used in the past as impression materials
• Difficult to remove the model
• Rarely employed today
Type II • Beta-hemihydrate (plaster)
• Porous particles, irregular shape à more sorption of water, less
resistance
Type III • Alpha-hemihydrate (dental stone)
• Cylindrical or prismatic shaped particles à less consumption of water,
more resistance
Type IV • This is the most used type these days
• Alpha-modified hemihydrate (high strength dental stone)
• Denser particles à less consumption of water, more resistance
• Type IV variation:
o Resin in the composition
o Smooth surface – epoxy resin
o High compressive resistance
o Smaller particles
o Prismatic and cuboidal shape
Stone Die Hardener • Most systems use a polymer dissolved in a solvent
• Mixture penetrates 100-300µm into the surface
Setting Reactions • Mix of particles and water à gypsum crystals begin to approximate à
formation of the nuclei of crystallization à growing of the crystals à
enlargement of the crystals
• Growing of the crystals: amount of water – increasing H2O, decreasing of
resistance
Setting Expansion

Time Setting • Time from the beginning of the mixing until the crystallization of the
material: 30-60 minutes
• Mixing time: elapsed time from the addition of the powder to water until
the mixture is completed
o Manual: 1 minute
o Mechanical: 30 seconds
• Working time: time the mixture remains in a consistency to permit use: 3
minutes
• Time to measure the setting: loss of gloss test
o Indicates that all the water was used in the reaction
o Generally 10-15 minutes
o This is the initial set time
• Tests
o Initial Gilmore Test: indicates that the mass begins to acquire
resistance by the crystallization
 § Gilmore needles (1/4 pound for the initial set, 1 pound for
the final set)
§ This is just testing the surface
§ Generally 10-15 minutes
o Final Set Gilmore Test: generally 30-14 minutes – after 50
minutes, the stone presents 80% of the final resistance – ready to
use
§ After this the model is ready to work with
§ There are ways to get faster setting models, though
Setting Time Control

• Too much water – setting time will be slower

• High temperature – the setting time will be slower (different than other
materials)
• Faster mixing – the setting time will be faster
• RETARDERS (increase setting time): glue, gelatin, gum Arabic, sodium
chloride (>2%), sodium sulfate (>3.14%) borax, potassium citrate
• ACCELERATORS (decrease setting time): sodium chloride (<2%), sodium
sulfate (<3.14%), potassium sulfate (>2%) gypsum powder
• Most common methods to accelerate:
o (1) Sodium chloride
o (2) Gypsum powder (not adding more powder – this means adding
gypsum from a model you already have – calcium sulfate
dehydrate – inside the mix)
Manipulation • Necessary
• Digital/analog scale
• Becker
• Recommended by the manufacturer:
TYPE WATER/POWDER RATIO
Plaster Type II 45mL/100g (3.5oz)
Stone Type III 25mL/100g (3.5oz)
Improved Stone Type IV 22mL/100g (3.5oz)
Type V 18-22mL/100g (3.5oz)
Add powder to water • Manual mixing: 1 minute
(this will help minimize
o Mix until dough is smooth and creamy
bubble formation)
o Vigorously mix against the walls
• Mechanical mixing: 20-30 seconds
• Manipulation after mixing:
o The gypsum must be poured slowly under vibration until the
complete filling of the mold
o After pouring the gypsum, wait for hardening so the model can be
separated from the mold (generally: 50 minutes)
Gypsum Product • Spray disinfectants: aldehydes
Disinfectants • Immersion in hypochlorites or iodophores
o Minutes not hours or lose cast surface à becomes very rough
 Silicon • High elastic modulus addition silicon material: materials for chair side
technique for out of the mouth restorations
• Quick-Die: high Durometer, low viscosity, fast setting (~90 seconds)
Cad Cam – looking forward • Trend to eliminate pouring stone models
– next lectures

Periodontal Considerations for Fixed Prosthodontic Restorations, Part II

10/26/17

Biologic Width • BIOLOGIC WIDTH is the

distance from the alveolar
crest to the most coronal
aspect of the epithelial
attachment (A) (~2.1mm)
• The biologic width
includes the epithelial
attachment and the
subjacent connective
tissue
• When the margin of a restoration intrudes into this space, inflammation
and osteoclastic activity are stimulated
o The best outcome that can
be expected is that the
Image: showing bone epithelial attachment and
resorption due to underlying connective tissue
restoration that is violating will reform, albeit, at a more
biologic width apical level
• Bone resorption will continue until
the alveolar crest is ~2mm from the margin of the restoration
Clinical Crown • By definition, the CLINICAL CROWN is that portion of the tooth that is
coronal to the free gingival margin
• One very critical issue is whether the length of the clinical crown is
adequate for retention of a restoration
• Ex: mandibular molars might have only minimal crown remaining after
advanced tooth destruction, or the maxillary anterior teeth might only
have minimal clinical crown after severe abrasion
Severe Abrasion Example • The maxillary anterior teeth have only
minimal clinical crown after severe
abrasion

Crown Lengthening • (1) Surgical flap

Procedure • (2) Removal of supporting bone (ostectomy)
• (3) Apical repositioning
• (4) Suture (stop here)
• Goal is to gain enough crown length to
ensure adequate retention for a restoration
 • Crown lengthening is a RESECTIVE surgical procedure that’s indicated for:
o (1) Subgingival caries
o (2) Perforation or fractures in the coronal third of the root
o (3) Inadequate retention for a restoration due to a short clinical
crown
Crown to Root Ratio • Is there excessive loss of alveolar bone height?
• Crown to Root ratio is a measure of the length of tooth structure occlusal
to the alveolar crest of bone compared with the length of root embedded
in the bone
• As the level of the alveolar bone moves apically, the lever arm of that
portion out of bone increases, and the chance for
harmful lateral forces is increased
• (A) The optimum crown-root ratio for a fixed
partial denture abutment is 2:3
• (B) A ratio of 1:1 is the minimum that is
acceptable
Two additional • (1) Furcation involvement
biomechanical risk factors • (2) Tooth mobility
for restorative dentistry
Mobility Index • I. Mobility of the crown of the tooth 0.2-1mm in a horizontal direction
o Slight increased mobility
• II. Mobility of the crown of the tooth more than 1mm horizontally
o Definite to considerable increase in mobility, but no impairment of
function
• III. Mobility of the crown of the tooth in a vertical direction
o Extreme mobility; a lose tooth that would be uncomfortable in
function
What are the elements of a • (1) Crown margins
good restoration from the • (2) Interdental spaces, crown contours
perspective of periodontal • (3) Pontic-to-tissue interface
health? • (4) Functional dynamics
Margin Placement • Supragingival
Minimum distance between • Equigingival
the crown margin and the • Subgingival*
alveolar crest? • Using the sulcus to guide margin placement
Biologic width ~2.1mm; o The first step in using SULCUS DEPTH as a guide to margin
minimum distance of crown placement is to achieve gingival health
margin to JE =0.5mm, so it o Once the tissue is healthy, the following guidelines can be used to
is 2.6mm place intracrevicular margins (see below)
Clinical Procedures in • If the depth of the sulcus is 1.5mm or less, place the
Margin Placement restoration margin ~0.5mm below the gingival tissue crest
• During preparation, the finish line is initially established level
with the free gingival margin
• A single thickness of retraction cord is placed ~0.5mm below
the previously prepared margin
• The final margin is established at the level of the cord
What about a patient with • If the sulcus probes more than 1.5mm, place the finish line below the free
a deep sulcus? gingival margin at about half the depth of the sulcus
• This places the crown margin far enough below the gingival
crest so that it will still be covered if the patient is at risk for
recession
• Place retraction cord – two if necessary
• Extend the preparation to the top of the second cord,
thereby finalizing the margin location
Embrasures • Interdental spaces defined by teeth in contact
• Each interdental space has four embrasures:
o Facial embrasure
o Lingual embrasure
o Occlusal embrasure (coronal to
contact area)
o Gingival embrasure (between contact
area and alveolar bone
• From a periodontal viewpoint, the GINGIVAL
embrasure is the most significant
• What is the ideal interproximal embrasure?
Papilla • Interproximal papilla and free gingival margin
relative to the underlying bone

• Papillary height is established by the level of

the bone (B), the biologic width (BW), and
the size of the gingival embrasure (E)
• Thus, chances in the shape of the embrasure
or position of the contact area can impact
the height and form of the papilla

• The free gingival margin averages about ~3mm above

the underlying facial bone, whereas the tip of the
papilla averages 4.5-5.0mm above the interproximal
bone
• If the biologic width is constant, the interproximal area
will have a sulcus 1.0-1.5mm deeper than that found
on the facial surface
• When the gingival level of the interproximal tooth contacts measured
5mm or less to the alveolar bone, the papilla always filled the space
• When the contact was 6mm from bone, only 56% of the papillae could fill
the space
• Finally, when the contact was 7mm form bone, only 37% of the papillae
could fill the spaces
Correcting Open Gingival • “Black triangles”
Embrasures Restoratively • Fix with composite interproximally
 Pontics • The principles of crown contour apply equally to pontics, but with pontics
there is an additional concern associated with the contour of the tissue-
facing surface
• In general, this surface should be kept as convex as possible, and all
concavities should be eliminated
Pontic Design Guidelines • The buccal and lingual tissue surfaces should be convex
• Gingival contours and line angles should be rounded
• A highly polished or glazed surface should be used on the tissue contact
surface
• Contiguous pontics should be used on the tissue contact surface – this will
help facilitate home care
Ideal Pontic Requirements • Hygienic/cleansable
• Smooth
• Convex in shape
• Minimal tissue contact
• Passive contact with the ridge
Pontic Designs • SANITARY: ~3mm above tissue
• RIDGELAP: straddles the ridge
• MODIFIED RIDGELAP: lingual removed
• OVATE: fits into “receptor” site
The Ovate Pontic • The ovate pontic is creased by forming a “receptor” site in the edentulous
ridge
o The site is shaped to create either a flat or concave contour such
that, when the pontic is adapted to the site, it will have a flat or
convex shape
o In highly esthetic areas such as the maxillary anterior region, it is
necessary to crease a receptor area that is 1.0-1.5mm below the
surface
o This creased the appearance of a free gingival margin and
produces optimal esthetics
• First, the ridge height needs to match the ideal height of the interproximal
papillae where interproximal embrasures are planned, either between
pontics or next to abutment teeth
o Second, the gingival margin height must also be at the ideal level,
or the pontic will appear too long
o Third, the ridge tissue must be facial to the ideal cervical facial
form of the pontic so that the pontic can emerge from the tissue
• For an ovate pontic to be properly created, the soft-tissue ridge must be
labial to the desired cervical portion of the pontic
o When the pontic is facial to the ridge, it is not
possible to create what appears to be a “free
gingival margin” correctly
o The shaded area represents the necessary amount
of tissue that would be augmented to produce an
ideal ovate pontic in this particular site
• When a tooth is removed, the papilla is lost, followed by 1.5-2.0mm of
gingival recession on adjacent teeth – this can be prevented by inserting
the pontic into the extraction site on the day of the extraction
Tissue Management • Home care instructions must be given
• Provisional coverage should mimic the final restoration and should be
smooth, polished, and in passive contact with the tissue surface
• Home care must be followed up
• 33% of all pontic sites display clinical inflammation
• 95% of all pontic sites display some degree of an inflammatory response
under the bridge
• Tissue surfaces must be highly polished and in passive contact with the
tissue surface
• Home care:
o Floss
o Proximal brushes
o Water pic
o Home care instructions begins with the provisional restoration
Contour • Contour (size) of solder joint
• Contour of contact area
• Contour of interproximal areas apical to contact area
• OVERCONTOURING is a significant factor in gingival inflammation,
whereas undercontouring has little, if any, effect on gingival health
• Contouring crowns:
o (1) The free gingival margin is normally
CORONAL to the facial bulge of the
anatomic crown
o (2) Gingival RECESSION results in excessive
contour and plaque accumulation
o (3) The crown of the tooth is reshaped so
that the gingiva is accessible for proper oral hygiene procedures
• Bucco-lingual crown contours:
o Inadequate removal of dentin during cavity
preparation prevents original contour of the
tooth, because there is not enough space for
porcelain and metal in the gingival third
• Contacts:
o Left: correct shape of a soldered joint or contact area
o Right: excessive apical extension of
soldered joint or contact area – the
gingival col is disrupted, and the buccal
and lingual portions of the papilla are
split
• Ridge Modification:
o Hydroxyapatite
o Autogenous bone graft
o Alveoplasty
o Gingivoplasty
o Gingivectomy
o If the ridge contour is poor, it can be modified to a more ideal
contour prior to restorative procedures
 Occlusion and Periodontal Disease
10/31/17

Relationship between • Malposed teeth may interfere with plaque removal and/or result in local
occlusion and periodontal tissue damage
disease? • With adequate levels of plaque control, there is no difference in
susceptibility to periodontal disease between ideally positioned and
malposed teeth
• Reshaping and levelling malposed teeth can help with plaque control and
ease of interdental hygiene
Occlusal Trauma • Occlusal trauma may be a factor in the onset and/or progression of
periodontal disease
• When occlusal forces exceed the adaptive capacity of the tissues, injury
results – the resultant injury is termed OCCLUSAL TRAUMA
• Occlusal trauma (OT) may be caused by:
o (1) Excessive occlusal forces
on a healthy periodontium
o (2) Reduced capacity of the
periodontium to withstand
normal occlusal forces
o (3) Combination of (1) and
(2)

Primary Secondary
Primary Occlusal Trauma • PRIMARY OCCLUSAL TRAUMA occurs if the trauma is considered the
primary etiologic factor in periodontal destruction and if the only local
alteration to which a tooth is subjected is from occlusion
• Causes of Primary TFO (trauma from occlusion)
o Overcontoured restorations
o Malposed teeth (drifting/extrusion/migration)
o Orthodontic repositioned teeth à premature occlusal contacts
• There are no changes in the clinical attachment levels
• There is no pocket formation
Secondary Occlusal Trauma • SECONDARY OCCLUSAL TRAUMA occurs when the adaptive capacity of
the tissues is impaired – the periodontium becomes more vulnerable to
injury, and previously well-tolerated occlusal forces become traumatic
• Adaptive capacity impaired by:
o Inflammatory periodontitis à
o Loss of clinical attachment à
o Reduced alveolar bone height
• Alteration of the biomechanics
Acute TFO • Causes:
o Abrupt (excessive) occlusal impact
o Restorations/prosthetic appliances
• Clinical manifestations:
o Tooth pain
o Percussion sensitivity
o Increased tooth mobility
 Chronic TFO • More common and with more significant periodontal stability
• More gradual alterations in form and function
o Tooth wear
o Shift in tooth position
o Associated with parafunctional habits
Is there injury? • Force dissipated by:
o Shift in tooth position
o Tooth wear
o Recontouring the faulty restoration
• Force not dissipated à periodontal injury
Direction of force affects • ACIAL (VERTICAL) forces, parallel to the long axis of the tooth, as the least
the response of the traumatic
periodontium • LATERAL (HORIZONTAL) forces and TORQUE (ROTATIONAL) are more
likely to injure the periodontium
Duration and frequency • Constant pressure on the bone is more injurious than intermittent force
affect the response of the • The more frequent application of intermittent force, the more injurious is
periodontium the force to the periodontium
Orthodontics • What kind of force does orthodontic tooth movement utilize?
• What can result from excessive orthodontic forces?
Adaptive Capacity • Under ideal conditions, the periodontium can accommodate the forces up
to the “adaptive capacity” of the periodontium
o Widening of the periodontal ligament space
o Increasing the number and width of periodontal ligament fibers
o Increasing the density of alveolar bone
Axis of Rotation • Under the forces of occlusion, a tooth rotates around a
fulcrum or “axis of rotation,” which in single-rooted teeth
is located at the junction between the middle third and the
apical third of the clinical root

Intact vs. Reduced

Periodontium

Pressure & Tension • Slightly excessive PRESSURE stimulates resorption of the alveolar bone,
with a resultant widening of the periodontal ligament space
• Slightly excessive TENSION causes elongation of the periodontal ligament
fibers and apposition of alveolar bone
Tissue Injury & Remodeling • Tissue injury is produced by increasingly excessive occlusal forces, and
disappears if:
o (1) The forces decrease
o (2) The tooth migrates away from the forces
• If these forces are sustained, the periodontium remodels to cushion the
impact
 • The PDL widens at the expense of the surrounding bone, resulting in
angular bone defects without attachment loss, and the tooth becomes
mobile
• OCCLUSAL PRESSURE exceeding physiological limits results in severe
compression of the PDL fibers, producing:
o (1) HYALINIZATION and injury to connective tissue cells leading to
necrosis
o (2) VASCULAR CHANGES resulting from stasis of blood flow and
disintegration of blood vessel walls
o (3) RESORPTION of alveolar bone and tooth
• Severe TENSION causes:
o Widening of the periodontal ligament thrombosis
o Hemorrhage
o Tearing of the periodontal ligament
o Resorption of alveolar bone
• The areas of the periodontium MOST susceptible to injury from excessive
occlusal forces are the FURCATIONS
Lateral Forces • Example: direction of force from lingual to facial
o Lingual surface: new bone formation in response to TENSION on
the periodontal ligament – the incremental lines indicate previous
additions to the bone
o Facial surface: COMPRESSION of the periodontal ligament and
osteoclastic resorption of the bony plate
Buttressing Bone • Buttressing bone formation is an occasional response of the alveolus to
excessive occlusal forces, and is an important feature of the reparative
process associated with trauma from occlusion
• Buttressing bone occurs:
o Within the jaw – “central” buttressing
o On the bone surface – “peripheral” buttressing
• CENTRAL: buttressing occurs when the endosteal cells deposit new bone,
which restores the bony trabeculae and reduces the size of the marrow
spaces
• PERIPHERAL: buttressing occurs on the facial and lingual surfaces of the
alveolar plate
Adaptive Remodeling of • Results in a THICKENED periodontal ligament, which is funnel shaped at
the Periodontium the crest, and ANGULAR DEFECTS in the bone, with no pocket formation
• The involved teeth display increased mobility
The stages of traumatic
occlusion have been
differentiated
histometrically using the
relative amounts of
periodontal bone surface
undergoing resorption or
formation
 Glickman’s Concept • Can occlusal trauma cause periodontitis?
• Traditionally, clinicians assigned an important role to trauma from
occlusion in the etiology of periodontitis
• Irving Glickman – Glickman’s concept: “the pathway of the spread of
plaque-associated gingival lesion can be changed if abnormally strong
forces are acting on teeth with subgingival plaque”
o ZONE OF IRRITATION includes marginal and
interproximal gingiva – not affected by occlusal
forces – lesion propagates apically first by involving
the bone then the periodontal ligament
o ZONE OF CO-DESTRUCTION includes the ligament,
cementum, bone, and the transseptal and
dentoalveolar fibers
• Fibers can be affected from the lesion in the zone of irritation, or from
trauma-induced changes in the zone of co-destruction
More recently… • Eastman Center, Rochester, NY
o Animal model (squirrel monkey)
o Produced trauma by repetitive interdental wedging
o In the presence of mild-to-moderate gingival inflammation – “the
presence of trauma did not increase the loss of attachment
induced by periodontitis”
University of Gothenborg • Animal model (beagle dog)
(Sweden) • Produced trauma by placing cap splints and orthodontic appliances
• In the presence of severe periodontal inflammation – “occlusal stresses
increase the periodontal destruction induced by periodontitis”
• That is, when trauma from occlusion was eliminated, a substantial
reversal of bone occurs, except in the presence of periodontitis,
suggesting that inflammation inhibits the potential for bone regeneration
Current Concept • The interaction of dental plaque and the host takes place in the gingival
sulcus
• Trauma from occlusion manifests in bone
• Thus it is important to eliminate the marginal inflammatory component in
cases of trauma from occlusion because the presence of inflammation
may affect bone regeneration after the removal of the traumatizing
contacts
Clinical Signs of Trauma • Tooth mobility
from Occlusion o Fremitus
o Pathologic migration
• Pain (pulpitis)*
o Percussion/mastication
o Thermal sensitivity
• Attrition (wear facets)
• TMD symptoms (?)
• Fracture
The cardinal clinical sign of • I. Mobility of the crown of the tooth 0.2-1mm in a horizontal direction
occlusal trauma is o Slight increased mobility
increased (or increasing) • II. Mobility of the crown of the tooth more than 1mm horizontally
tooth mobility
 o Definite to considerable increase in mobility, but no impairment of
function
• III. Mobility of the crown of the tooth in a vertical direction
o Extreme mobility; a lose tooth that would be uncomfortable in
function
Pathologic Migration • Migration of the maxillary incisors resulting from bone loss and TFO
• Pathologic migration may continue after a tooth no longer contacts its
antagonist
• Pressures from the tongue, the food during mastication, and the
proliferating granulation tissue provide the driving force
• Pathologic migration is also an early sign of localized aggressive
periodontitis
• Weakened by the loss of periodontal support, the maxillary and
mandibular anterior incisors drift labially and extrude, thereby creating a
diastema between the teeth
• Other causes of increased tooth mobility include severe bone loss,
inflammatory periodontal disease, and systemic conditions that affect the
periodontium, e.g. pregnancy
Pain • Pain and/or thermal sensitivity is largely associated with PRIMARY
OCCLUSAL TRAUMA
o Short duration
o Reversible
• Clinical signs
o Attrition (wear facets)
o TMD symptoms (?)
o Fracture
Radiographic signs of • Increased width of the periodontal space, often with thickening of the
Trauma from Occlusion lamina dura along the lateral aspect of the root, in the apical region, and
in bifurcation areas
• A “vertical” rather than “horizontal” destruction of the interdental
septum
• Radiolucence and/or condensation of the alveolar bone
• Root resorption
Summary • Trauma from occlusion does not initiate gingivitis or periodontal pockets,
but it may constitute an additional risk factor for the progression and
severity of the disease
• The current consensus is that trauma from occlusion has the potential to
alter disease severity and prognosis – however, the therapeutic priority is
to control inflammation, and this must be successful for healing of the
periodontal tissues to occur
• Therefore it is recommended that occlusal interventions be deferred until
inflammation is controlled and reevaluation determines that any residual
mobility is the result of adverse tooth loading rather than decreased
support
• The following information should be collected in all cases:
o Wear facets and signs of abrasion (parafunctions)
o Tooth mobility in relation to remaining support (parafunctions,
occlusal trauma)
 o Premature contacts in centric and in intercuspation
o Articular interference (hyperbalance)
o Neuromuscular symptoms, pressure sensitivity or pain at muscle
insertions
o TMD symptoms
Parafunction • Tooth to tooth
o Bruxism
o Clenching
• Soft tissue related to tooth
o Lip biting
o Tongue thrusting
• “Foreign object” to tooth
o Nail biting
o Other objects
• Duration of tooth contact increased
• Magnitude of force increased
• Musculature typically involved
Therapy for Occlusal • Occlusal adjustment
Traumatism • Occlusal bite guard – the “Michigan” splint
• Conventional splinting
Trauma • Loss of supporting structure due to periodontitis
• Alterations of supporting structures due to trauma from occlusion
• Short-term trauma to the periodontium due to treatment of periodontitis
• Combinations of the above
Indications for Types of • Temporary splinting is indicated to stabilize severely mobile teeth before
Splinting or during periodontal therapy
• Semipermanent or permanent splinting may be used to stabilize highly
mobile teeth that impair function
• Permanent splinting to stabilize abutment teeth that support a
prosthesis, particularly when such abutment teeth have minimal
periodontal support but have been successfully treated periodontally
• Mobile teeth whose degree of mobility is not increasing do not generally
require splinting
• Teeth with increased mobility traced to occlusal trauma should be treated
by occlusal adjustment, not by splinting
• While it is true that mobile teeth can be immobilized by splinting, and that
this may provide some comfort for the patient, it does not lead to any
long-term biologic stabilization of teeth
Bruxism • Parafunctional habits such as bruxism are another potential cause of
occlusal trauma
• Bruxism is defined as diurnal or nocturnal parafunctional activity including
clenching, bracing, gnashing, and grinding of the teeth
• Although there is no association between bruxism and gingival
inflammation or periodontitis, bruxism definitely has the potential to
cause tooth wear, fracture, and periodontal and muscle pain and is a
major cause of mobility
 • There is no significant evidence that malocclusions or interferences are
causal factors in bruxism, and occlusal adjustment has not proven to be
an effective means of treatment
• Instead, the maxillary stabilization appliance is generally considered the
most effective means of managing bruxism

Principles of MCR and FPD Design

11/7/17

Fixed Prosthetics • Retainer and abutment selection

• Coping design
• Mechanical properties of FPDs
• Physiologic movement of abutment teeth
• Design for partial dentures
Retainer and Abutment • Tooth vitality
Selection • Periodontal health
• Tooth position/angulation
• Crown:root ratio
• Root surface area (PDL)
• Root configuration
• Span length: “Ante”
Tooth Vitality • Make sure there is no periapical pathology or acute situations
• Want to make sure periodontium is healthy – doesn’t have to be perfect,
but has to be healthy
Tooth Position and • Angulation less than 25o – if it is angled more than
Angulation this, you will not be able to make successful fixed
prosthodontics
• If there is a small space, you might want to create
a contact, but if the space is big enough that it is
cleansable you don’t necessarily need to close it
Crown:Root Ratio • 2:3 is optimum
• 1:1 is minimum

Root Surface Area

• When they are young, happy teeth, you have lots of periodontal ligament
with minimal recession
• The amount of periodontal ligament surface area dictates which teeth will
be good abutment teeth for fixed prosthodontics
• For example, a lower incisor is not a good abutment tooth for a bridge
 Root Configuration • Broad
• Multi-rooted
• Root spread – if a root is conical, and you put the right forces on it, you
can spin it out of its socket – however if a tooth it multi-rooted and
spread, it is stronger and will make a better abutment
• Irregular – apical tilt
Span Length • Span – how much distance (how many teeth) are you trying to cross and
what material are you using?
In general, you need o Before implants existed, the only other option was removable
abutment teeth that have prosthodontics
the same amount of PDL • Ante guideline
that you are replacing from o Periodontium
the missing teeth • Ante guideline: PDL of abutment teeth equals PDL of missing teeth
• Where A = abutment, P = pontic
o A-P-A = Ideal
o A-P-P-A = Acceptable
o A-P-P-P-A = Poor Risk
Length of Pontic Structure • Mediated by:
o Root configuration
o Crown:root ratio
o PDL
o Materials, etc.
Mechanical Properties • Flexure – want to minimize the bend
• Amount of deflection varies with the
cube of the length:
o A-P-A = 1 unit
o A-P-P-A = 8 units
o A-P-P-P-A = 27 units

Beams • Beams: their relationship to length of span

• Beams force distribution: amount of deflection varies with the inverse
cube of thickness
• Thickness:
o X thickness = 1 unit
o ½ X thickness = 8 units
• The thinner it is, the more flexure you will have –
this is not good!

MCR Coping Design • Coping is the understructure – metal is

more flexible, and porcelain is more rigid
• Dotted line represents where the
porcelain would be, the dark orange is
the metal portion that porcelain will be
attached to, and the lighter orange is solid metal
that won’t be covered by porcelain
o Metal collar at gingiva
 • Proximal struts – structure that will strengthen and stiffen the
interproximal portion
o All of the lighter orange in a vertical direction
• Lingual surface
• Thickness of metal –
o Need to put an opaquer porcelain over the metal (baked on with
an oxide layer), and then put the more translucent/esthetic
porcelain over that
FPD • Beveled preparations:
o Reinforcing collar
o Esthetics? – we don’t do
these as much today
because we don’t want
metal to show when
there is recession
• Anterior design – esthetics are VERY important – 1/3 of the proximal
struts towards the buccal and 2/3 toward the lingual
• Posterior design – also do 1/3 of the proximal struts towards the buccal
and 2/3 toward the lingual
Mechanical Properties • Beams and their strength
o Length = cubed
o Width = squared
• Beams: deflection varies directly with cute of
length and inversely with cube of thickness
Dimensions of Connectors • Minimum thickness of connector
• Posterior FPD
o High noble metal (high gold content):
3mm x 3mm
o Noble metal (more silver/palladium):
§ Occluso-gingivally: 2.5mm
§ Facio-lingually: 2.5mm
• Anterior FPD
o Do NOT compromise esthetics
o Occluso-gingivally: as long as possible
o Facio-lingually: as thick as possible
• Connectors can extend to occlusal for additional strength – don’t want to
go the other way – if it is too far to the gingival it will irritate the tissues
• Scalloping:
o Increases strength in the occluso-gingival direction
Physiologic Movement: • Each tooth moves in a
Abutment Teeth different direction
• Pier abutment = abutment
between two terminal
abutments in a fixed bridge
of two or more abutments
• This allows for natural
movement of the teeth during function
 Connectors • Rigid
o Cast
o Solder
• Non-rigid
• If you don’t have enough reduction and the porcelain gets too thin at the
gingival, it can chip and create an unesthetic sitaution
Design of FPDs for RPDs • Treatment planning stage
o Rest seats
o Retentive areas
o Reciprocating areas
• Must have the enture RPD and all crowns planned before you pick up a
handpiece

Principles of Fixed Denture Pontic Design and Selection

11/14/17

Healed Extraction Site • Steps in healing:

o Clot formation (4-10 minutes)
o Epithelialization (day 4)
o Granulation tissue replacement of the clot (day 7)
o Connective tissue replacement of the clot (day 20)
o Bone fill of socket (day 38)
• Complete healing of an extraction site takes approximately 38 days
• You will always have at least 2mm of bone resorption after an extraction
Point to Ponder • “So doctor, when can I get my permanent bridge?”
• “I would like to wait about 6-8 weeks to get complete healing”
• We wait until the complete reshaping of the edentulous part during
healing, and then we will reline our restoration so it fills the space created
from post-extraction bone resorption
Shapes of Healed Ridges • Sharp – this is the most difficult to deal with
• Rounded
• Broad
Diagnosis • Time and care taken in the diagnostic phase will undoubtedly enhance the
probability of a successful restoration
• A clinical exam, radiographic exam, and study casts are essential
o Take PAs because they are more detailed than a panoramic
• Look at abutment teeth, bone height, orientation of teeth, etc. – then
decide what the right treatment is
o When you have a missing space, you can either place an implant,
bride, or removable partial denture
o Check to see if there are carious lesions on the adjacent teeth
o If the teeth you want to use for abutments are tipped/inclined,
how severe is the incline?
o Also check the opposing tooth to see if it is supraerupted
• If there is a space that is smaller than the original space due to tooth
movement or rotation, explain to the patient that the pontic tooth will
look smaller than their original tooth
 o Make sure they are ok with the tooth being a different size before
you palce the restoration
• Also if the abutment tooth is tilted, in order to get a proper line of draw,
you might have to drill too close to the pulp and risk a pulp exposure – in
which case you will have to do elective endodontics
Information Obtained from • (1) Condition of the abutment teeth
the Diagnosis • (2) Amount of tooth reduction necessary
• (3) Angulation of the abutment teeth
• (4) Length of the crowns
• (5) Givens regarding pontic design
Cantilever Bridges • Cantilever bridges are used for the replacement of:
o Maxillary lateral incisors
o Mandibular first premolars
• Why?
o Because these two teeth don’t function heavily
in occlusion (they are small)
• If you must use a cantilevered bridges in the posterior region it should be
small and no bigger than a premolar
o Cantilever pontic CANNOT be a molar
• You cannot make a bridge with one natural tooth and one implant – has
to be either two implants or two natural teeth abutments
Frameworks • The purpose of the framework is to:
o Support the porcelain to prevent fracture
o Transmit masticatory forces from the retainer(s) to the abutment
teeth
• STRESS AND FORCE TRANSFER
o The purpose of good bridge design is to transmit the forces of
occlusion from the pontic to the retainers and axially down the
teeth to the bone
o The thickness of the material, and the length of the span have to
be considered in the design stages of the bridge
• The porcelain must be supported by the framework

• Rigid connectors must be large enough to transmit forces without

impinging on the interproximal and occlusal embrasures
• If you make the connector too wide, you will invade on the gingival
emrbasure, making it difficult to floss – this will cause periodontal
problems
Pontic Design Guidelines • The buccal lingual tissue surface should be convex
• Use round gingival corners, avoid sharp line angles
 • A highly polished or glazed surface should be used on the tissue contact
surface
• Contiguous pontics should havae a single saddle with no gingival
embrasure space – this will help facilitate home care
• The pontic design may be modified lingually if this results in better
function
Ridge Modification • Tissue cuffs may form around teeth abutting an edentulous area
• These tissue cuffs may be removed to improve the pontic space
• If the ridge contour is poor, the ridge can be modified to a more ideal
contour prior to bridge fabrication
o Hydroxyapatite
o Autogenous bone grafts
o Alveoplasty
o GIngivectomy
o Cadaver bone, etc.
Ideal Pontic Requirements • (1) Hygienic/cleansable
• (2) Smooth
• (3) Convex in shape
• (4) Have minimal tissue contact
• (5) Have passive contact with ridge
Pontic Designs • Styles of pontics
o Ridgelap – difficult to floss under
o Modified ridgelap – we usually do this one, but it’s not perfect
because you can still get food stuck under it
o Lap facing – sometimes done on anterior restorations
o Hygienic – not used anymore really
o Ovate
o Saddle design
o Modified saddle
o Modified stein
o Stein
o Sanitary
o PG
Pontic Selection • The variables:
o (1) The ridge contour
o (2) The space available (span)
o (3) The horizontal axis
o (4) The interocclusal space
• When evaluating the pontic space, you must determine what space is
available, what pontic design will function best in that space, and what is
the inter-arch relationship and how that is going to relate to the occlusal
scheme
• The well-contoured and well-polished modified ridgelap pontic has been
selected as the pontic of choice
o It is readily accepted by patients
o It minimizes the impaction of food particles
o It allows for a high degree of hygiene
o It rarely exhibits significant gingival irritation
 • The modified ridgelap pontic is used in the posterior areas and the lap
facing design is used in the anteriors
• A hygienic design may be used in non-esthetic areas only if at least 3mm
of metal thickness can be used and that 3mm of height is available above
the tissue
• Connectors must be broad enough to transfer the occlusal load
• Embrasures must be wide enough to be maintainable
• A posterior pontic may be up to 20% narrower than the tooth it is
replacing to reduce the occlusal load
Tissue Management • Home care instructions must be given
• Provisional coverage should mimic the final restoration and should be
smooth, polished, and in passive contact with the tissue surface
• Home care must be followed up
• 33% of all pontic sites show clinical inflammation
• 95% of all pontic sites show some inflammatory response under the
bridge
• The framework must be checked and rechecked at each stage of work to
ensure a passive contact
o Use fit checkers and pressure indicator paste
• If the surface is shy, add material, or food will become impacted
• If contact is tight, relieve it
• Home care:
o Floss
o Proximal brushes
o Water pik
o Home care instructions begin with the provisional restoration

Prosthodontic Alloys and Metal Ceramics

11/14/17

Metals and Alloys • Extensively used in dentistry although losing popularity

• Dentistry is shifting from metal-based restorations to the all-white holistic
type of approach for restorative materials
• Even some implants made of white looking materials – like structural
ceramics and polymeric materials – up for discussion whether those work
as well as the metal materials
• Metallic restorations don’t look nearly as good as the ones made of
ceramics and polymeric materials
All-Ceramic Oral • Statistics of clinical success have not been nearly as good as when one
Rehabilitations uses metal and metal-ceramic restorations
• More esthetic to use all ceramic restorations – can make things look really
good without a lot of effort
• People who work with metal and metal-ceramic have also been able to
make really good looking and sometimes even better looking restorations
than the all ceramic ones
• Zircona – make a crown with a zirconia core and a ceramic veneer on the
outside
 • Lithium disilicate – robust mechanics and very esthetic as well (has gotten
better recently because it is more challenging to achieve esthetics with
this compared to other all ceramic systemcs)
Ceramic Restorations vs. • Ceramic materials look really good, but they are very brittle – no ability to
Other Materials keep a crack from propagating after its nucleation – this causes
catastrophic failures, especially when you have multiple units
• Semi-lunar failure happens because ceramic materials are very strong, but
they have very little ductility (will break instead of deform)
• Ideally we want a material that is relatively strong and that will deform a
lot before it does break
• Systematic review of all ceramic crowns – not very good research –
conclusion is that all ceramic materials tend to fail at much higher rates
than restorations including metal
Metals • Generally stron,g ductile, good electricity and heat conductors, opaque
• They have valence electrons between
atoms that can freely move
• Very ductile and very strong – this is
ideal and what we want in ceramics
• Metal Stress-Strain Curce
o High strength
o High ductility
o High toughness
• Metals and Dentistry
o Most used
o All specialties
o Recall instrumentation!
o Restorative matierals: highest longevity!
o Orthodontics and OMFS: transient (appliances that are used
temporarily and then removed)
o Dental implantology: permanent
Metals and Alloys in • Single or multi-tooth restoration
Dentistry • Highest longevity in prosthodontics (versus metalloceramic, all ceramic,
and composite restorations)
• Operative dentistry – amalgam restorations last longer in poor oral
hygiene patients
o Composite engineering has improved so dramatically that now
there is no real difference in longevity in patients with good
hygiene
Restoration Survival Curve • X-axis = time
• Y-axis = cumulative survival of restoration
• Start with 100% and as the restorations
start failing the curves start dropping
• Composite restorations fail earlier than
amalgam in high-risk groups
 Ortho Appliances • Transient materials
• Long-term biocompatibility not critical
• Resistance is a major concern
OMFS • Short and long-term
• Short: ligatures and other transient obsolete fixation modes (stainless
steel wires – corrosion prone)
• Long: most currently used rigid fixation
o Titanium alloy – tend to be very stable over time, present very
good mechanics and of course you want to make sure that you
don’t have to go back in again for a second surgical procedure to
remove these alloys
Dental Implants • Titanium alloys, long-term stability
• In Europe there has been a minor shift to implants that are ceramic in
nature – don’t really compare to metal in terms of stability
• Want these to last forever
• Good osseointegration with titanium – very biocompatible material
Fabrication: Cast vs. • Cast: melt and solidify to near net shape
Wrought Structures o Uniform microstructure
• Wrought: physically deformed to shape
o Textured surface when you mechanically deform the shape
Dentistry: Primarily Alloys • Single component metals are too soft, need alloying for mechanical
and NOT Pure Metals strength
• Binary system such as Au-Cu
o Copper is a reinforcer for the gold
o Substantially increases the strenght of gold
• Ternary system such as Au, Cu, Ag or Ti-6Al-4V (implants – robust surgical
alloy)
Types of Alloys • Solid solutions: complete miscibility, enhances property with ductility
o Gain mechanical strengh – material gives before fracturing
§ Copper and zinc
§ Carbon and iron
• Intermetallic compounds: specific site occupancy – increase strength and
hardness, but brittle
o Ductility is compromised – will fail earlier
• Gold and copper alloy – can occupy just about any lattice site
o Can burnish the margins so they close seamlessly with the tooth
o Gold alloys are very reliable clinically because you can adapt the
margins to the tooth structure and later adapt the material
through heat treatment (in the lab) to gain strength and have a
perfect fit of a harder alloy
ADA Classification • Lab will
process
the alloy
based on
your
decision
• Know these percentages
 Metal Classification • Noble metal: metal that is resistant to oxidation
o Includes: gold, platinum, palladium, and the other platinum group
metals
• Precious metal: metal that is relatively high in cost
o Includes: gold, platinum, palladium, and silver
o Not necessarily a noble metal
Alloys • Alloys have different proportions of noble to high noble
Noble Alloys • Overall these are solid solutions
• Tend to be relatively strong
• Composition goes from high content of gold – as you decrease the
content of gold, you increase the amount of other noble and non-noble
components
Role of Metals in High • Gold: soft, malleable, corrosion resistant
Noble Alloys • Copper: hardening, heat treatment (>15% by weight), dark/red color
• Silver: low cost diluent, color correction for copper
• Platinum: hardening, heat treatment, increase casting temperature
• Palladium: lower cost, increase casting temperature
• Osmium, ruthenium, iridium:
o Grain refiners – act as grain nucleation sites – causes finer
microstructure
o Fine grains – better casting, higher strength + elongation
Types of High Gold (>60%) • American National Standards Institute/American Dental Association
Alloys Specification no. 5 for Dental Casting Gold Alloy:
o Type I: Soft (VHN 60-90) (Class I Restorations)
o Type II: Medium (VHN 90-120) (Class II Restorations)
o Type III: Hard (VHN 120-150) (Onlays, crowns, all metal short span
bridges)
o Type IV: Extra-hard (Quenched VHM minimum 150; Hardened VHN
minimum 220) (Intended for PDs but on longer span all metal
bridges)
Metal Ceramic • Results can turn out really esthetic and nice
Restorations • Role of PFM alloy substructure:
o Typical thickness of 0.3-0.5mm
o Provides high modulus substrate (120-200 GPa) for prevention of
porcelain bending (tension) under loading
o Porcelain stiffness ~80 GPa – esthetics
Composition (Weight %) • Metal ceramic restorations – have noble and high noble
Noble Alloys • Some gold based and some palladium based
• Can use different metal alloy compositions as well when using ceramics
• Whole range of prices
Performance • 10 year longitudinal study of fixed prosthodontics
• MC single crowns (688) in service 1-10 years
o 356 crowns 5-10 years in service
• 25 replacements in entire population (pretty reliable)
• ~15% molar crowns – all with porcelain occlusal surfaces
o No porcelain failures found
 • General estimates – 2-3% failure at 10 years (failure 2-5% with all ceramic
PER YEAR depending on the kind of system used)
• Failures generally not due to the restoraions themselves, but instead due
to the abutments
• Recall of evaluation of 1209 abutments and 885 pontics (1-15 years in
function)
o Mean service life ~8.5 years
• Failures limited with regard to restorative matierals
o Porcelain fracture (3%)
o Metal fracture (3%)
o Abutment fractures (30%
o Periodontal involvement (27%)
• Metal substructure allows for design variations in challenging clinical
scenarios
CTE Match • Coefficient of Thermal Expansion (CTE) must be within 0.1% over
solidification/fusion and cooling temp range
• Both alloy oxide and porcelain opaque layer must be designed for bonding
o Co-diffusion at porcelain firing temperature
o Typically 900-950oC
• Porcelain firing shrinkage (>20%) stresses the interface
• Metal will contract more than porcelain when things are cooling down –
this puts the porcelain in the state of stress you want in order to resist any
type of occlusal loading
Dental Casting and • Objective: take a wax pattern and reproduce it in metal while allowing for:
Investment o Wax shrinkage
o Metal casting shrinkage
• Using investment
o Setting expansion
o Thermal expansion
• Shrinkage/expansion balance for accurate fit – want to compensate
Casting Overview • Wax pattern is sprued and removed from die
• Sprued pattern attached to sprue base and invested (investment expands
a small amount)
• Invested wax pattern is burned out at high temperature (investment
expands) – end up with a negative impression of your crown
• Heated investment placed in casting machine and molten metal cast
• Cooled investment removed from casting
• Casting pickled in acid to remove oxides
• Sprue removed and casting finished and polished
• Then deliver it to the patient
Investing • Wax pattern has sprue attached
• Objective is to provide a path for molten metal into the mold created by
investment of the wax pattern
Spruing Concerns • Diameter of sprue at least as thick as the thickest portion of the wax
pattern
o Too small – it freezes before pattern and no metal can flow to
offset shrinkage
 • Sprue length to allow for position of pattern within investment ring
o Middle of ring length or about 6mm for non-sprue base end
• Sprue must be attached with fillet to thickest portion of wax pattern – to
avoid deformation of the margins
• Sharp edges can break under molten metal flow andpieces lodge at distal
margins
o Defects at margins
• Flow of metal from thick portion of pattern to thin – want to optimize the
flow of metal
o If poor flow path à metal hitting flat surface
o Can use addition of auxiliary sprue for thickness
o Addition of 2nd sprue to connect 2 areas separated by a thin area
Investing • Powder and liquid mixed
o Specific powder to liquid ratio for expansion required (related to
the type of alloy you are using)
o Some have control liquid to mix with water (phosphate bonded
investments)
o Mixing time controlled
• Investment provides:
o Setting expansion
o Thermal expansion (as you burn out the wax)
o Hygroscopic + some thermal expansion for some types
Dental Casting Investments • Composed of:
o Binder to allow setting with some expansion and provude strength
§ Gypsum for low temperature casting
§ Phosphate for high temperature casting
o Refratory to not break down at high temperature and to provide
expansion
§ Silica in several allotropic forms is mixed with the binder to
provide such strength at high temperatures
Investment Expansion • Setting expansion and thermal expansion of gypsum or phosphate bonded
investment are influenced by the same variables
o Powder/Liquid radio – thicker (or more “control liquid” for
phosphate bonded) – more setting and thermal expansion
o Extra water while setting (hygroscopic) – more setting expansion
o More spatulation – more setting expansion
Investing • Casting ring is lined with porous fabric (high temperature) liner
o Allows for investment setting expansion
o Provudes water to aid in setting expansion of investment
• Given the linear expansion you need, you can tailor the water needed by
the system
• Sprued pattern is attached to the crucible former
• Length must be adjusted to fit the casting ring
Investing Concerns • Wax pattern must not be too close to end of casting ring as investment is
of limited strength
• Pattern position ~6-8mm from end of ring – allows for:
o Strength
o Gas escape
 • Wax pattern is cleaned/sprayed with a long chain alcohol solution to
permit investment wetting or wax pattern
o Missing this step can lead to bubbles on casting
Investing • Mixed investment poured into ring with vibration to eliminate porosity
• Investment allowed to set in air
o Hygroscopic technique – invested pattern is immersed in water at
5 minutes after mixing investment (if you need extra expansion)
Casting • Crucible former removed for the ring
• Ring placed in burnout oven
o Temperature raised to 650oC over time
o Wax burns out
o Investment expands
• Centripetal fasting machine is prepared
• Pattern must be oriented so that fine margins trail machine rotation
• Steps:
o Metal ingots are added to the casting crucible
o Torch is used to generally heat the crucible
o Torch is applied to metal at proper distance
o Metal becomes fluid
o Retrieve heated investment from burn-out oven
o Place investment ring in casting cradle
o Casting machine released and molten metal thrown into
investment
o Upon cooling, investment removed
o Casting cleaned and pickled in acid
o Try on die
Casting Shrinkage and • If you ever have something that comes from the lab and doesn’t fit, look
Investment Expansion for potential pitfalls that the lab may have fallen into
Required (By Restoration
Type)
Casting Accuracy • Excellent casting fits can be achieved with bevels and burnishing
• Difficult with combinations of intra- and extra-coronal design
• Casting with poor margin design (lack of enamel bevels) as well as failure
to adjust fit and burnish margins can occur
• Something with a poor margin will have cement wear and solubility – will
have decay between tooth structure and restoration
Common Casting Defects • Sprue diameter is a critical factor
o At least as thick as the thicknest portion of the casting
• Sprue length important
• Problems with either can lead to holes in casting just beneath the sprue =
shrink-spot porosity
o Find during adjusting or finishing
Casting Accuracy • [Wax cooling shrinkage + metal casting shrinkage] = [investment setting
expansion + wax expansion/distortion + hygroscopic expansion + thermal
expansion]
• Mix and match of expansion and contraction – must have a balance
• Alloy manufacturers are suppsoed to provide matching systems
 Principles of Connectors and Soldering
11/30/17

Connectors • Ridig – to support the brittle porcelain

• Non-Rigid – you can use attachments that allow for movement
• Attachments:
o Female
o Male
Soldering Indications • Long spans of cast restorations
• Corrections of casting shrinkage
• Thermal expansion of investment
• Thermal expansion of parts
Rigid Connectors • Provides strength/stability to the
prosthesis
• Minimizes associated stresses
• Not indicated for all prostheses
• Would use a non-rigid connector to
connect abutment teeth with
different levels of movement to
minimize destruction to the
abutment teeth
Solder • Used for joining or adding or metals by the use of a filler metal
o Connectors
o Deficient contacts
• NOT used to correct:
o Deficient margins – it is too soft for this and will break off and
leave you with the same open margin
o Casting defects such as occlusal holes
Gap Distance • Size of a credit card = 1mm
• If larger, shrinkage of solder will cause inaccuracies
• Need enough room for material, but not too much that you are
weakening the bridge because the solder material is softer
Clinical Steps in Soldering • First step is to assure fit of casting to abutments
• Check the aligntment
• Provision of solder gap
• Unite abutments and pontic teeth with red resin and hold all the
substructures of the crowns in place while the resin sets to make sure you
have the alignment perfectly recorded
Solder • Increase in surface area = increased strength
• Select greatest possible length for solder joint
• Stay away from margins – as heat from solder can damage margins
• Mid-pontic diagonal solder is often ideal
Joint Dimensions • POSTERIOR:
o High noble: 3mm
o Noble: 2.5mm
o Base: 2mm
o Porcelain: 4mm
 • ANTERIOR:
o As much as possible without interfering with esthetics and/or
periodontal health (use as much of the lingual as you can)
• Ex: 2mm vs. 4mm – 4mm has 8x the rigidity
Connect Joint • Incremental application of red resin to decrease shrinkage
• Ideally after connection with resin, double check the internal fit of
castings
Pick up of solder in plaster • To provide stability
index • Impression plaster, PVS, etc. can be used – need something where you
can pick up bridge & not lose connection while transporting it to the lab
Lab Steps in Soldering • Invest and Assemble
• Trim investment but make sure margins are protected
• Apply anti-flux graphite
• Pre-heat
• Adjust solder torch
• Solder the joint
Flux • FLUX = flow (Latin)
• Cleaning material that removes the oxide in the gap space – need to solde
to a clean area
• Provides tarnish-free surface
Anti-Flux • I.e. Rouge/graphite
• Confines slow of solder so it doesn’t flow where you don’t want it to go
Solder Selection • Corrosion and tarnish resistant
• Fusion range LOWER than casting metal
• Free flowing
• Non-pitting
• Strength
• Color
Solder Steps • Solder is placed into the lingual notch
• Flux applied
• Heating
• Solder displaces the flux out of the way
• Temper or quench it
• Investment removed
• Polishing – don’t polish area where the solder will go before soldering –
only polish after it is already soldered
o Start with coarse
o Refine with fine
• The new solder bridge will NOT fit the old cast – there has been enough
dimensional change that it no longer seats – needs a new cast
• A new cast is fabricated and retro-fitted to the prosthesis
Solder Techniques • Noble, High Noble Metals
o Torch
o Oven
• Base Metals – higher temperatures
o Infrared
o Laser
 Welding • Joining of metals by causing coalescence, causing a solid blend with no in
between material
Mechanical and elemental • “On the basis of fatigue resistance of the joints, neither infrared solder
characterization of solder joints nor laser welds were stronger than torch or furnace soldered joints”
joints and welds using a • “It is usually recommended to select a filler metal that has high diffusion
gold-palladium alloy and optimal properties with the parent metal”
Post Solder • Term used for soldering AFTER ceramic is applied
• This has to be planned from the beginning – heat for solder has to be
lower than the metal framework and the porcelain
• Ceramic application onto framework can cause shrinkage, and warping of
framework
• Lower fusing solder is used
Indications: Non-Rigid • Non-parallel (tipped) teeth – this has nothing to do with your
Connectors preparations, it has to do with the natural inclination of the teeth
o Use connector to provide parallelism when abutment teeth are
not parallel
o If a tooth is tipped, seat that crown first with a slot for the non-
rigid connector, then you can slide in the key portion that locks in
and is now able to go in with a line of draw that did not previously
exist
• Pier abutment – arch position
• Reduction rotational motion – flexion
• Segmentation
Pontic & Retainer • Pontic has the key
• Retainer has the keyway

Pier Abutment • Can do a three unit

bridge and then the
last two units (which
has the pontic) lock
into the pier abutment
• Stress broken to distal
of pier by sectioning it
that way
• If this were a solid 5 unit bridge that would put way too much torque on
the middle abutment tooth and put it at risk of becoming loose
• Segementing it in this way ensures that each segment absolutely fits and
allows for the individual physiology of each tooth
• You can even use these designs when you are combining bridges and
removable partial dentures
 Fitting of Castings
12/12/17

Evaluate Preps • Axially

• Occlusally
Fabricate Provisionals • Template for final restoration
• Make final impression and fabricate/trim dies (make sure margins are
clear and marked)
o Dies are “pindex” dies – stands for “pin index”
o We will get pre-fabricated ones in lab
Wax Pattern Fabrication • Errors in waxing
o Overextensions
o Underextensions
• Stresses and distortions – for example if the wax is heated up passed its
melting temperature
Overextension of Wax • Overextension of wax margins in undercut area apical to finishing line
Margins leads to:
o Over-contour
o Open margins
§ The wax has flexibility – so it can flex to get over the
natural undercut that exists on the natural tooth surface
that the wax has been overextended onto, which will
deform it and leave an open margin
o Broken margins
o Incomplete seating of castings
o May deform when removed from die – could result in an open
margin and failure to seal the finising line
Underextension of Wax • Short margins
Margins • Under-contour
• Tooth sensitivity
If original contour is lost • Wax to correct
• Then, cut back
Contours • Facial
• Occlusal
• Must MEASURE when you are correcting contours to avoid perforation
Fitting a Casting to a Model • To its respective DIE AND MASTER CAST
o Instrumentation
o Technique (in order, respectively)
• BEFORE putting it on the die, evaluate:
o Margins for overextension
o Internal fit for “blebs” (bubbles of metal)
• THEN, on the die, evaluate (in order, respectively):
o (1) Internal fit
o (2) Margins
o (3) Contact areas on master cast (second cast; uncut)
o (4) Occlusion on master case (second cast; uncut)
o (5) Shape and final contours
 Die Spacer • Lab will do 4 layers in alternating colors of die spacer in order to get
enough thickness to create room for cement
• This will be done in the laboratory before they made your casting
• You will use liqui-mark to check to see where the crown is tight on the die
o Use a 330 burr to adjust the areas that have been marked red until
you re sure that it is seating properly
Correction of an • Lowspeed rotating clockwise
Overextension • Run handpiece from the inside of the crown to the outside so that any of
the excess metal will curl to the outside – if it curls to the inside it will not
ruin your internal fit
• Once you have fixed it, reseat it and check your margin
• Then reduce the thickness of the outside wall
Contact Areas • Next check your contact areas with floss
• Don’t want the floss to shred or be too difficult to pop out (too tight)
• Adjust as needed
Occlusion • Check occlusion on the cast and correct as needed
Iwanson Guage • You can measure the thickness – for example of your provisionals
• Metal substructure needs to be at least 0.5mm – so measure when you
are adjusting to make sure you will have enough support for the porcelain
Be aware! • Once the casting has been fit to the die, it (the die) is NO LONGER
ACCURATE de to abrasion
o Do NOT use it for a new casting
o Do NOT use it to evaluate margins, etc.
o So, whoever fit the casting to the die is the last person to do so
o Beware of abraded contacts on adjacent teeth
Fitting a casting to the • Instrumentation
patient • Technique (in order, respectively)
o (1) Contact areas
§ On the PATIENT you have to check contact FIRST, unlike on
the die where you check internal fit first
o (2) Internal fit
§ Use Fit-Checker – silicone paste-paste system that we use
to fit the internal surface
§ This is the patient version of the liqui-mark used earlier
o (3) Margins
o (4) Occlusion
§ You must check occlusion, but you also ALWAYS must
check occlusion in EXCURSIONS
o (5) Refine margins/final contour
o (6) Final polish
§ The better it is polished, the less plaque can adhere
Incomplete seating of • (1) Loss of occlusal integrity through creation of pre-mature contacts in MI
crowns cause: • (2) Alterations of contact areas with adjacent teeth – because the PDL has
give
• (3) 19-32% reduction of crown retention
o Most of your retention is in the gingival third
• (4) Discrepancies of marginal fit of the crown
 Dental Ceramics
12/12/17

General Concepts • Ceramics are non-metallic, inorganic materials

• Very resistant to abrasion
• Very brittle and rigid (so not that resistant to fractures)
• Present highly polished surfaces and have low plaque adherence
• Glass + crystalline components
o More glassy = more translucent = less resistant
o More crystalline = more opaque = more resistant
• Once you have the beginning of a crack, it is difficult to keep it from
propagating and causing a true fracture
Classification Based on • (1) Feldspathic (glass-based) – most esthetic
Microstructure • (2) Leucite reinforced (glass based with leucite filler)
1-3: Glass Ceramics • (3) Lithium disilicate reinforced (glass based with lithium disilicate filler)
4: Polycrystalline Ceramics • (4) Zirconia yttria stabilized (crystalline based system) – most
opaque/least esthetic

Feldspathic • Silica + aluminum (one can increase alumina until 50% increasing
resistance)
• It is the most esthetic of all ceramics
• The weakest among all types
• First one used in dentistry
• Still the most used ceramic (popular)
• Indications:
o Metal-ceramics
§ Cost
§ Crowns over implants because one still has to use metals
§ Metal infrastructure acting as a reinforcement of the
restoration
o Laminate veneers (highly esthetic outcomes)
§ Veneers have 0.6mm thickness – still on enamel
§ Adhesion to enamel acting as reinforcement
Leucite Reinforced • Improved mechanical
and physical properties
• Leucite is a second
crystalline phase able to
to decrease crack
propagation
• Increased clinical
indications
• 55% weight of leucite
 • Indications:
o Laminate/veneers
o Inlays/onlays
o Crowns
• The most common brand is IPS Empress (Ivoclar vivadent)
• Leucite ceramics can be used until 2nd PREMOLARS – CANNOT BE USED
ON MOLARS
• You can have more conservative preps with this material
Lithium Disilicate Based • Improved mechanical and physical properties compared to leucite and
feldspathic – but you still keep the esthetic properties
o Double the resistance of leucite, which is double the resistance of
Feldspathic
o Also has increased LONGEVITY of the restoration
• Lithium disilicate fillers decrease crack propagation
• Increased clinical indications (bridges)
• 60-65% weight of lithium disilicate
• Indications:
o Laminate veneers
o Inlays/onlays
o Crowns
o Thin veneers (0.4mm) – including no-prep veneers
o Occlusal veneers – used on teeth with a very eroded occlusal
surface to increase the dimension and avoid the need for a full
crown prep
o 3-unit bridges (up to second premolar)
§ Can use instead of metal frame
o Conservative crowns – crowns with 0.5mm thickness of the prep
• Going forward, this is becoming the most popular kind of ceramic, as
opposed to Feldspathic
• Commercial name is Emax (this is what people usually call it)
Zirconia Yttria Stabilized • Indications:
o So far only for infrastructure due to high opacity (copings,
infrastructures)
§ It means that it needs another glass cement to cover it
o Implant abutments
• When you got the zirconia from the lab,
the crystalline form is:
o Tetragonal (after heat
treatment)
• If you have a very high load/mechanical/
thermal aggression, the crystalline form becomes:
o Monoclinic (after phase transformation due to mechanical or
thermal aggressions)
§ For example if you use a burr to adjust the occlusion or if
the patient bites hard on something
o This causes a 4% volumetric expension – which helps it avoid crack
propogation
• Biocompatible – used specially in implant abutments
 • Adhesion of fibroblasts (junctional epithelium, not conjunctival
epithelium)
• You can do a bridge with a ponic between two onlays/inlays instead of
between two full crowns using a Zirconia intfrastructure
Classification based on • Powder/liquid
processing techniques o Only Feldspathic ceramics
o High possibility for failure because it takes many steps to make
• Pressable
o Feldspathic, leucite reinforced, and lithium disilicate reinforced
o Similar to the metal casting technique
o Easier, faster, cheaper for the lab – but you lose the ability to layer
with colors/translucency – it will be all one color/translucency
§ To get a better esthetic outcome you apply surface stains
§ Not as esthetic as the powder/liquid technique
• CAD/CAM
o Mill a restoration from a block
o Advantage is that you have less mistakes – no technical failures so
it is a very reliable result
o CAD/CAM better than pressed after thermal and mechanical
cycles, but no difference before cementation
o You still only have one color when you mill from a block, so you
have to apply stains to get a more esthetic look
• FUTURE?
o 3D printing
Feldspathic/Leucite/ • (1) Hydrophuoric acid 5-10%
Lithium Disilicate o 60 seconds: Feldspathic and leucite
Cementation o 20 seconds: lithium disilicate
• (2) Wash with water and ultrasound cleaning
• (3) Silane (1 minute)
• (4) Adhesive