Removable partial denture

Abeer Abu sobeh

3esam-el3alem

17/2/2013

Prosthodontics II: lec III. Title: Provisional Partial Dentures.

The references for this lecture

Chapter 19, Stewarts Clinical Removable Partial Prosthodontics, 4th Ed, 2008 (pages 469 - 485). Dr. said:Wire bending and impression slides at end of lecture are discussed in greater detail in the lab.
As we said: Provisional prosthesis are always in 99.99% of the time is entirely made out of acrylic and stainless steel wrought wires ,definitive prosthesis usually have a metal framework base . Here we have missing teeth in the front so we replace it with an acrylic partial denture, usually the major plate is made out of acrylic and the clasps are made out of wrought wire,(what you see in the palate is actually the acrylic base plate or the major connector).

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 the main difference between the Provisional prosthesis and the definitive prosthesis is not only material in terms of design ,the acrylic partial denture takes its support almost entirely from the tissue, the metal framework partial denture gets its support from the teeth and the tissue, and in some cases when we are lucky we get the support entirely from the teeth , this is due to the presence of certain components which are called rests, rests are able to transfer the force from the denture onto the natural teeth, so the forces directed to the periodontium to the bone . the periodontium was designed to take occlusal force as oppose to mucosa ,which wasnt designed to take occlusal force.

usually a metal framework partial denture are made out of cobalt chromium, the trade name for it (the most famous one) is called Vitallium it contains +-65%cobalt , 30%chromium ,and 5% molybdenum, cobalt is the main element of the alloy.

Stainless steel is made of iron, added to it components which prevent its corrosion (thats why its called stainless).The materials which we add for the wrought wire stainless steel are: 80% chromium,10%nickle.

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Whats the common factor between stainless steel and cobalt chromium Vitallium?
It is chromium, which provides certain qualities, but the main quality it provides protection for the main metal in the alloy ,so chromium is in the Stainless steel to protect iron, and it is in the metal framework partial denture to protect cobalt. Chromium reacts very quickly with the oxygen in the air, and it forms chromium oxide layer ,these layer on the surface of any alloy (where chromium is present in it) will protect the underlying layers ,if you scratch cobalt chromium and you remove the chromium oxide layer, then the newly exposed chromium will reacts with new oxygen to protect the cobalt underneath, because chromium reacts much faster with oxygen than cobalt but if the chromium wasnt there the cobalt will deteriorate and the partial denture would essentially corrode. Just like iron when we leave it exposed to the air or to the water it ends up with iron oxide, but if we had chromium into it ,the chromium reacts with the oxygen faster than the iron ,and protect it, thats why stainless steel is nice and shiny .

Whats the provisional RPDs used for? provisional RPDs are also known as temporary prosthesis ,but we dont like to say temporary or permanent .because temporary implies to the patient that its low quality, actually its high quality but it is not meant to be there forever .we dont like to say permanent, because nothing last forever, thats why we use definitive but both terms are acceptable .in the Clinique youll find that we use temporary interchangeably without being worry about it, but technically provisional is a more correct term.

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One of the main disadvantages of provisional prosthesis that its supported by the soft tissues only, its made from acrylic resin, and It retained by either : a resin lobe (In rare cases we can make a partial denture which essentially goes into undercuts in a special way we wont talk about that now). but usually like youll learn in the lab this week we make wrought wire clasps made from stainless steel ,which are going to be into the undercut of each tooth and will help keeping the denture in place, but sometimes we can Abandon it for some esthetics reasons or other reasons.

It usually requires less time and cost less than a cast RPD, (because like I told you the metal framework RPDs need two lost wax processes so we have more material, more processes the technicians must have more information and have to be more skilled) ,and usually has a limited life span because it is there provisionally until we are able to provide the patient with the final results.

So why are not we making a definitive prosthesis from the first time? because there are reasons and indications for using the interim prosthesis, thats the topic that we are going to talk about today.

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The provisional RPD here has no clasps

This one engages the undercut in the lingual and in the proximal, it can be done but it requires a good survey (you will learn it later in this semester).

Otherwise we need to use this wrought wire clasps many of the patients reject to show up stainless steel in their mouth while they are smiling, it doesnt look nice especially if its in the front teeth.

But notice that theres a labial flange here like a labial flange in the complete denture, just confined to the space where the teeth are missing.

There are different types of provisional prosthesis as described in

Stewarts textbook, its divided into three basic types:

provisional partial denture

interim transitional treatment
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Interim (:)
There are occasions in treatment (and you will learn more about this when you learn oral medicine and oral diagnosis ) that you need to place a treatment plan for the patient ,sometimes the patients mouth has so many problems thats you dont know what to do first, and one of the most important things youll learn in dentistry is to stage and to sequence treatment correctly ,for example: whats the point of making a partial denture and the three weeks later finding out that two or three of the teeth need to be extracted, then you have to make new prosthesis . the idea to do things that have priority first and then to make the prosthesis later .this creates a dilemma,patient comes to you and his teeth are not in the ideal order, but you tell him before prosthesis you still need to do extraction ,periodontal treatment, endodontic treatment, need to clean your teeth ,the gingiva needs to heal , this means you will be without teeth for few weeks maybe couple of months he says :what!! I came to you for the better not worse .so during the period of treatment I need to put something in the patients mouth, we have a compromise solutionthe provisional interim removable prosthesis ,so Im providing it for the patient till I finish all( the periodontal, endodontic, fillings, bridges.. )treatments ,at a specific period Im going to take it and throw it away, and then make a new one in the final situation .in this stage its so important that the patient proves to me that he can maintain a good oral hygiene ,and he is motivated to go to the next level of treatment. (This is the ideal one that we do, but the reality unfortunately in the private practices a little bit different.)

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 Young patients with large pulps are also an indication for interim prosthesis , child comes to you and he has a deep caries in his central incisor, his pulp is still large and its vital ,such teeth if it grossly broking down they require definitive crown ,and you know children continue to grow up into the adulthood (depending on the actual childs development) but usually between the age of 18-24 dental alveolar growth reaches its final stages (in the age of 17,18 almost all of the growth is complete but in some people some changes still occur for one or two years ), this means in many cases we cant place the final bridge or crown when the child is still a teenager so you know the younger the tooth the larger the pulp ,you also know hopefully that the way you place a crown or a bridge is: we trim the tooth axially all the way around the sides and we trim the incisal or the occlusal edge ,we make the tooth small, in young children the pulp is so large ,thats sometimes when we do this we expose the pulp ,or sometimes even if we dont expose the pulp the trauma is so much because the pulp is so large ,so the pulp might become non-vital (thats in terms of the pulp ). also the gingival margin with age becomes higher not necessarily recession, its not a disease ,usually the gum level rises with age especially in children , usually in young children if you see permanent tooth you will see half or 2/3 the actual clinical crown .into young adulthood the margin rises much closer to the cervical margin of the tooth, and this means if you want to replace permanent bridge on the childs teeth who is about 13-14 (if you manage not to hit the pulp), maybe when he is 18 19 the margin of the tooth will be exposed then we can see the edge of the crown ,because the gingiva went up so it is
not a good idea to put the final fixed prosthesis at a young age. so what do you do for such a child? if you can make something temporary fixed for him then its ok, but if they were many missing teeth you stuck with placing the compromise solution which is an interim prosthesis!

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 This is a child which has congenital missing teeth ,you can make an interim prosthesis until the child is older ,and he has a better dental value and dental alveolar development ,later you can replace it with an implants. maybe child who are 11 ,12 ,13 years old, still not having a mature jaw to place a definitive prosthesis ,or crowns on the anterior teeth, so you would make an interim prosthesis until they are older and surgery can be done to replace the teeth with a dental implants or many crowns in the anterior teeth.

You might be indicated to make a metal frame work partial denture for your patient, Yet he cant afford it. So in financial constrains you may make an interim for your patient until he has enough money to afford a definitive prosthesis with understanding that the interim is not going to be there forever (remember there are problems with the interim prosthesis because its entirely supported by soft tissue and this is not good ). In case of trauma or any sudden loss of teeth ,patient comes to you he had trauma ,he made a car accident ,and he asks you to place something in his mouth before treatment is done ,we need an immediate denture, So we use an interim prosthesis.

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 Immediate RPD
Immediate prosthesis ( )means: we extract the teeth and we place the denture in the patients mouth right away.

-Prosthesis is made prior to extraction of teeth - Prosthesis is inserted at the time of tooth extractions.
If you are going to extract this teeth (essentially evaluates and more detailed procedures you will learn about in your 4th year), you will evaluate where the alveolar bone height is, this gingival margin is not where the bone is ,the bone is usually 2-3 mm apical to the gingival level ,so we mark where it is, and then we essentially do alveo-plasty on the cast, we guess based on our measurements essentially where the final board is going to be, and we make a prosthesis according It, so we wax it up.

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if the patient still has the teeth, we extract them and we give the patient the denture, this is an immediate removable partial denture ,and later on after we have a healing of tissues, usually between 1-5 months later, depending on the problem and the severity of extraction ,we will trim the adjacent teeth and we will place a fixed partial denture. So this is an immediate interim partial denture (2) which last until we prepare the final denture after the tissues healed. (1) (2) (3)

what type of bridge is this?If you take a look at the adjacent teeth they are not really prepared can you see this holes what do you think this holes lead to?

this is an implant retained and supported prosthesis sometimes we cant extract the teeth or put the implant right away ,sometimes we extract ,wait for healing then we place the implants (again it is something you will learn much about in your future years)

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 This is an interim removable partial obturator remember that divisions of dentistry :removable, fixed and maxillofacial .in this case the patient had missing the pre-maxilla(1) this is called an obturator (2)it closes the space between the nasal cavity and the oral cavity ,in some cases as in this case between the nasal cavity , the sinuses and the oral cavity some of them are simple like this one ,some are much more extreme, can be missing as little as the pre-maxilla in the cleft palate cases, or sometimes due to trauma or malignancy we lose the entire half of the palate or sometimes all of the palate, so we need prosthesis which fits in this cases .when the patient comes and he has diagnosed with a malignant tumor in the palate, they cant go into the surgery one moment find out that he has a tumor and hours later suddenly lose his jaw and not has a replacement !because remember after surgery there is going to be scaring ,healing and it takes several weeks . Usually before we can make a definitive maxillofacial prosthesis it takes about six months, so what do we use in the middle we use an interim maxillofacial obturator.

(1)

(2)

In this indication where we would use an interim prosthesis a patient he is going into surgery he would have a tumor removal from one or either jaws , (usually it is in the maxilla) , we will make him an obturator when he wake up from surgery he can still swallow ,he can still speak, and sometimes if you placed teeth he can still smile.

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Transitional partial denture :

It implies transitioning from a dentate patient to a partially or fully edentulous patient. Patient comes to you, you look at his mouth all of his teeth are highly mobiled they have lots of calculus, and you know if you treat this teeth, this teeth will not heal, from day one you have to
explain to the patient that I have to remove your teeth youve two choices:

1)to schedule an appointment, extract all the patients teeth ,and tell him : come back after 1-3 months, live without teeth and then I will make you set of a complete upper and lower dentures, actually this is easier for us as dentists we dont have to worry about the patients problems, he comes back ,he is edentulous, nice smooth jaw bone, we can take an impressions and its straight forward .but for the patient its a nightmare specially to the patient with periodontal disease who was looking ok and suddenly surprised that all of his teeth need extraction . 2) the other solution is to go to transitional stage and usually we segment treatment between the anterior and posterior teeth ,so the patient comes we tell him: you are going to be fully edentulous, we consult it with the surgeon, the periodontist ,the endodontist there is nothing we can do for you the teeth that you have are going to fall up by themselves we can plan ahead and we extract them, he says: I cant live without my teeth how will I get used for the complete denture?! what we do is that we extract the teeth in stages, we extract the posterior teeth first and we make an upper essentially Kennedy class I bilateral free incisal denture. then we set the denture and the anterior teeth remain as a natural teeth (they are mobile but they are still there) this gives the patient a transitional period where he get a custom to an odd body in his mouth, he gets try the denture and then later on after several weeks, after we get healing posteriorly, we
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extract the front teeth at the same day we add the front teeth to the denture we have .it just like learning riding on the bike ,we have training wheels and bicycles for children ,before they actually learn to ride on wheels ,a transitional partial denture is like a training wheels for a partially edentulous patient before he get the final complete denture Psychologically, physically and neuro- muscularly to the new full arch prosthesis .sometimes its not only two stages sometimes we extract molars , premolars and then anterior teeth but usually its posterior then anterior upper and lower. Here we have a patient who essentially has advanced caries, or gingival decay this problem is not common in the Arabs part of the world ,is essentially soda drink habit erosion, if you ever been to MacDonalds or KFC essentially what they have is soda drink in a large cup ,abroad some of this cups look more like a pockets, There is unmoral size of pockets , I havent seen this problem so much here but abroad it is very common because they usually have a standing offer you can refill your container as many times as you want and if you have essentially a one liter or two liters cup that means you are sipping and drinking a very acidic drink all the day! some people drink one or two pockets full of Pepsi or seven up and they refill it and walk out and keep sipping on it and thats means very low PH for long period of time! so as a student abroad I met several patients who I treated who have no teeth they have roots but they just dont have teeth, teeth were eroded, enamel was so eroded, they had severe sensitivity going down to the gums .Im sure that many of you in schools have tried to put a natural tooth in Pepsi for a week or two, and find that it becomes flexible and soft.

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 If there wasnt saliva in our mouth, and recalcification continuously, we would have many dental problems, and patients with no saliva xerostomia had many problems with caries and periodontal diseases, you can use an interim prosthesis for such a patient .this is a patient where we have an anterior partial denture, we are going to extract the posterior teeth because now they are no longer good, whats kind of classification here? long span class score which actually tooth tissue borne, but this is an acrylic partial denture so its tissue borne only. so here we tried to save the posterior teeth as long as possible but maybe now its the time to extract them,so the next step is to add teeth in the back so we extract the teeth on the cast in the lab ,we add the teeth with wax ,and then we change the wax into acrylic so we are transitioning the patient from partially dentate to fully
edentulous.

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 Treatment RPDs:
Used for a short period of time to treat or condition (heal) tissues before fabrication of a definitive metal-framework RPD May be used to evaluate changes in vertical dimension, esthetics, contours etc.
so can you see here like rough appearance, the patients old prosthesis was made so poorly, or its so old where the patient never took it out at night, so the tissue became unhealthy ,and now you are familiar with a specific disease that can affect such patient :we can affected with candida wich will result in papillary hyperplasia or Epulis fissuratum .now I have a problem the patient comes to me and he says my denture is not good anymore, I have pain, I have redness there is a bad odor under the denture , I tell him: why didnt you take it out and wash it at night and let your gums breathe? He says: well that s what happened solve my problem now !! . So for such a patient I can take the best easy solution, is to remove the caustic factor from the patients mouth, to remove the denture which contains Candida and spores and let the patient flush with antifungal. but the patient says no!! I cant take the denture out!! I want a solution keep the denture in and solve my problem ..so now what well do is called tissue conditioner, is to place a special soft material(there are different types of relining materials) on the inside of the denture and put it in the patients mouth ,and we change it every 1-3 weeks ,its not infective with Candida and because its soft and cushiony it massages the tissue and it increases the blood flow. So we can use the interim prosthesis to treat the patient, we are essentially massaging the tissue, increasing the blood flow, allowing tissue to heal over a period of time .

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 Another indication for using the treatment removable partial denture: when an edentulous patient comes to us and we made a complete denture for him, he tries the denture he says you know what I dont like this denture isnt there something you can made for me to be just more stable? You say yes but it is a bit more expensive, its called titanium dental implant but when we place the implant you wont be able to wear your denture ,you put the implants, you have to wait for 3-6 months until the implants integrate with the bone ,then we will make the fixed prosthesis for you .he says: I cant sir I cant live 3-6 months without teeth ,you say: we can make an interim prosthesis and we reline it with tissue conditioning relining material ,and the soft material will not irritate the implant while its integrating with bone because we cant put a heavy load on the implant otherwise it will ends up with failure.

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 Alteration of vertical dimension .

We also use the treatment prosthesis to change the vertical dimension,some

patients like the patient I talked about before they drink a lot of soda or maybe they grind their teeth for long enough, there wont be any clinical crown left (1-2 mm above the gums) the patient comes and he says to you: look my teeth are all worn away. and you think what would be the problem if I put a crowns?! remember the crown sets on the top of the natural tooth ,the shorter the crown means the crown will not hold, then the best solution to improve the patient is not to go down into the roots, its to go up to make the tooth long again. remember the patient worn his teeth not in one day, one week or one year, he worn his teeth over several years, sometimes decades .now his jaw is a custom to a new vertical dimension if we elongate his teeth suddenly, it will be too much pain for him, he says: I look better but I cant sleep at night I have TMJ disorder. Now to make sure the patient can get used to the increase vertical ,you have to increase the vertical dimension gradually (P.S: I cant make crowns and bridges every year to increase the vertical dimension slowly),instead I can use a treatment provisional prosthesis ,I make it removable, and I tell the patient you have to wear it everytime when you eat ,essentially it makes the teeth taller ,it goes
over the incisal and occlusal edges, so we call it an over denture we will gradually increase the vertical dimension so the TMJ will get used it. And later when the patient is fine, and dont have pain, I can make the final definitive crown or prosthesis.
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 Surgical splints. Sometimes the patient has a maxillary torus and asks for a definitive prosthesis. Instead you have to provide him treatment prosthesis. You will surgically remove the torus and provide treatment prosthesis to prevent hematoma, keep the soft tissue up by the palate and the prosthesis will act like a bandage.

Done by: Abeer Abu sobeh

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