Chapter 3 Mouth preparation

CHAPTER 3

3. Mouth preparation for removable partial

denture

outh preparation refers to these procedures done to return the

mouth optimum health and eliminate any condition that would be detrimental
to the success of the partial denture. It follows the preliminary diagnosis and
the development of a tentative treatment plan, but precedes the visit of the final
impression. Final treatment planning may be postponed until the response to the
preparatory procedures can be ascertained. Mouth preparation has two main
categories:
I- Preprosthetic mouth preparation:
This includes the following:
A. Oral surgical preparation
B. Conditioning of abused and irritated tissues
C. Periodontal treatment
D. Orthodontic treatment
E. Conservative treatments including restorative and endodontic
therapies
F. Fixed Prosthodontic treatment
G. Correction of occlusion

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II- Prosthetic mouth preparation:

This includes the following preparations of the abutment teeth:
A. Guiding planes
B. Occlusal and incisal rest seats
C. Modifying facial or lingual surfaces for retention

Mouth preparation must be accomplished before the impression

procedures are performed that will produce the master cast on which the
removable partial denture will be fabricated. Oral surgical and periodontal
procedures should precede abutment tooth preparation and should be completed
far enough in advance to allow the necessary healing period. If at all possible, at
least 6 weeks, and preferably 3 to 6 months, should be provided between
surgical and restorative dentistry procedures. This depends on the extent of the
surgery and its impact on the overall support, stability, and retention of the
proposed prosthesis.

I- Preprosthetic mouth preparation:

A. Oral Surgical preparation:
Surgical preparation may be in the form of:
1. Extraction :
Teeth with unfavorable diagnosis, remaining roots, or impacted third
molar should be extracted.
 Examples of advised extraction are:
a. Grossly over-erupted teeth touching the edentulous ridges of the
other jaw or locking the occlusion should be extracted even if they
are not involved in design (Figure ‎3-1).

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b. Impacted third molar. Its extraction depends on the situation.

However, early removal of impaction prevents later serious acute
and chronic infection, with extensive bone loss.

Figure ‎3-1: Overerupted maxillary first molar

 Examples of advised saving are:

a. Single standing molars that enable the saddle to be tooth supported at
both ends (Figure ‎3-2).

Figure ‎3-2: Single standing molars kept to provide posterior support

b. Single standing tooth which interrupts what would otherwise be a long

free end saddle, e.g. if a lower second premolar is the only standing tooth
posterior to the canine.
c. Single standing teeth to support partial or complete overlay dentures.

 Retained roots to be removed: ( Figure ‎3-3)

a. Roots in close proximity to the tissue surface.
b. Roots related to any evidence of associated pathology.

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Chapter 3 Mouth preparation

c. Roots close to abutment teeth that may contribute to progression of

periodontal pocket.

Figure ‎3-3: Retained roots that need extraction

2. Bone consideration:
 Cysts and odontogenic tumors
 Removal of sharp bony spicules.
 Removal of sharp large bony exostoses and tori (Figure ‎3-4).
 Alveoplasty.
 Ridge augmentation or bone grafting.

a. b.
Figure ‎3-4: a. Large mandibular tori that require surgical excision
b. Cyst related to an unerupted tooth

3. Soft tissue consideration:

 Frena and muscle attachments
 Mentalis muscle (Figure ‎3-5)

 Hyperplastic tissues (overgrowth of maxillary tuberosity)

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Figure ‎3-5: Mentalis muscle attachment affects length of denture flange

and thus its retention

B. PERIODNTAL PREPARATION:
The initial step is the control of inflammatory periodontal disease. Complete
periodontal charting that includes the recording of pocket depths, assessment of
attachment levels, and recording of furcation involvements, mucogingival
problems, and tooth mobility should be performed. Determining the severity of
periodontal disease should also include the use of appropriate radiographs.
When considering removable partial denture fabrication must be certain that
these criteria have been satisfied before continuing with impression procedures
for the master cast.

 Objectives of periodontal therapy:

1. Removal of all etiologic factors responsible for periodontal disease
such as calculus.
2. Elimination of all pathologic pockets with the establishment of
gingival sulci free of inflammation.
3. Restoration of physiologic gingival and osseous architecture.
4. Establishment of harmonious, functional occlusion.
5. Maintenance of result achieved by oral physiotherapy procedure
and periodic recalls visits to the dentist.
6. Splinting of periodontally weak teeth (Figure ‎3-6 ).

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Figure ‎3-6: Temporary splinting using composite resin

If the causative factor can be removed, many grade I and grade II mobile
teeth can become stable and may be used successfully to help support, stabilize,
and retain the removable partial denture. Grade I and II mobile teeth can be
splinted temporarily and then definitively. Mobility in itself is not an indication
for extraction, unless the mobile tooth cannot aid in support or stability of the
removable partial denture, or mobility cannot be reduced. (Grade III usually
cannot be reversed and will not provide support or stability.)

C. Occlusal therapy
1. Occlusal Adjustment
During the evaluation of occlusal disharmony of the natural dentition,
accurately mounted diagnostic casts are extremely helpful in determining static
cusp-to-fossa contacts of opposing teeth and as a guide in the correction of
occlusal anomalies in both centric and eccentric functional relations. Occlusion
can be coordinated only by selective spot grinding. Ground tooth surfaces
should be subsequently smoothed and polished.
 Objectives:
a. Checking coincidence of the muscular position (MP) of the
mandible with the intercuspal position (IP). Non –

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coincidence is acceptable if it does not result in any signs of

occlusal disharmony.
b. Checking freedom in movement from one occlusal position
to another.
c. Evaluation of the existing occlusal vertical dimension.
 Signs of occlusal disharmony
a. Clicking or painful joints.
b. Tender or painful muscles.
c. Severe attrition.
d. Periodontal signs of occlusal trauma.
e. Impaired mandibular function such as:
 Limited opening of mandible.
 Deviation on opening or closing.
 Difficulty or inability to chew on either side.

2. Occlusal Splint or Nightguard:

The removable acrylic-resin splint, originally designed as an aid in
eliminating the deleterious effects of nocturnal clenching and grinding. The
night guard may prove helpful as a form of temporary splinting if worn at
night when the removable partial denture has been removed. The flat
occlusal surface prevents intercuspation of the teeth, which eliminates
lateral occlusal forces (Figure ‎3-7).

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Chapter 3 Mouth preparation

Figure ‎3-7: The removable acrylic-resin splint with a flat occlusal plane

D. CONSERVATION PREPARATION
During examination and subsequent treatment planning, in conjunction
with a survey of diagnostic casts, each abutment tooth is considered
individually as to what type of restoration is indicated. Abutment teeth
presenting sound enamel surfaces in a mouth in which good oral hygiene
habits would be considered for use as removable partial denture abutments.
 The following objectives should be full-filled:
1. Carious lesions should be treated with suitable restorations.
2. Any existing fillings with ragged margins, broken contacts, and
leaks, overhanging margins or other defects should be repaired or
replaced.
3. Teeth that are to support clasps should be ideally restored with gold
inlays. However, an amalgam restoration, properly condensed, is capable
of supporting an occlusal rest.
4. Each restoration should be planned so as to be consistent in contour with
the path of insertion of the prosthesis.

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E. ENDODONTIC PREPARATION:
Development of simple and predictable procedures for endodontic
treatment lead to the wide use of edodontically treated teeth to support
and retain fixed bridges, partial dentures, and partial or complete
overdentures.
F. ORTHODONTIC PREPERATION
Pre-prosthetic orthodontic treatment is infrequently planned as partial loss
of teeth results in drifting and extrusion of adjacent & antagonistic teeth.
Malposed teeth that were once indicated for extraction should be considered
now for repositioning and retention. The additional stability provided for a
removable partial denture by uprighting a tilted or drifted tooth may mean much
in terms of comfort to the patient.
 Examples:
1. Up righting tilted molars
2. Repositioning drifted rotated or over erupted teeth (Figure ‎3-8).
3. Closed inter dental spaces.

Figure ‎3-8: Intrusion of over-erupted tooth using mini-screws

 Objective:
1. To ensure optimal force distribution over the retained root surfaces.
2. To improve & enhance the aesthetic result.
3. To facilitate the technical aspect of prosthetic therapy.

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Chapter 3 Mouth preparation

G. INITIAL PROSTHETIC TREATMENT

Modification of existing denture (repairs, additions, and relining).
1. Denture removal:
a. The simplest procedures for restoring tissue health is to remove
the offending restoration and permit normal healing .Usually 48 to
72 hours are required for recovery, but the time will vary
according to the age and general health of the patient.
b. Mucosal conditioning by lining the dentures using soft liners and
leaving the tissues to regain their health within 10 days to two
weeks. Persisting lesion should be considered for excisional
biopsy. However, nutritional deficiencies, endocrine imbalances,
severe health problems (diabetes or blood dyscrasias), and bruxism
must be considered in a differential diagnosis.
c. A suggested home care program includes:
 Rinsing the mouth three times a day with a prescribed saline
solution;
 Massaging the residual ridge areas, palate, and tongue with
a soft toothbrush; removing the prosthesis at night;
 And using a prescribed therapeutic multiple vitamin along
with a prescribed high-protein, low-carbohydrate diet.
2. Provision of an interim prosthesis (acrylic partial denture)
Fabrication of a new prosthesis should be delayed until the oral
tissues can be returned to a healthy state. If there are unresolved
systemic problems, removable partial denture treatment will
usually result in failure or limited success.

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II- Prosthetic mouth preparation

After surgery, periodontal, endodontic treatment, and tissue conditioning of the
arch involved, the abutment teeth may be prepared to provide support,
stabilization, reciprocation, and retention for the partial denture.
Abutment preparations may be grouped as follows:
A. Abutment teeth that require only minor modifications to their coronal
portions:
They include teeth with sound enamel, those with small restorations
not involved in the removable partial denture design, those with
acceptable restorations that will be involved in the removable partial
denture design, and those that have existing crown restorations requiring
minor modification that will not jeopardize the integrity of the crown.
B. Abutment teeth that should receive restorations other than complete
coverage crowns
C. Abutment teeth that should receive crowns (complete coverage):
Complete coverage restorations provide the best possible support for
occlusal rests. If the patient’s economic status or any other factors prevent
the use of complete coverage restorations, then an amalgam alloy
restoration, if properly condensed, is capable of supporting an occlusal
rest without appreciable flow for a long period. Any existing silver
amalgam alloy with any doubt should be replaced with new amalgam
restorations. This should be done before guiding planes and occlusal rest
seats are prepared, to allow the restoration to reach maximum strength
and be polished.

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A. Sequence of Abutment Preparations on Sound Enamel or Existing

Restorations
1. Improving occlusal plane
2. Preparation of guiding plane
3. Modification of unfavorable survey line
4. Rest seat preparation.

1. Improving the occlusal plane:

This will be discussed in details in chapter 5.
2. Preparation of guiding planes:
Guiding planes are two or more parallel axial surfaces on
abutment teeth which guide insertion and removal of the partial
denture. Proximal surfaces should be prepared parallel to the path
of placement to provide guiding planes ( Figure ‎3-9).

Figure ‎3-9: The proximal surface is prepared parallel

to the path of placement to create a guiding plane

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3. Modification of unfavorable survey line:

a. Tooth contours should be modified lowering the height of contour
so that:
 The origin of circumferential clasp arms must be placed well
below the occlusal surface, preferably at the junction of the
middle and gingival thirds.
 Retentive clasp terminals may be placed in the gingival thirds
of the crown for better esthetics and better mechanical
advantage (Figure ‎3-10).
 Reciprocal clasp arms should be placed on and above a height
of contour. This contour should be no higher than the cervical
portion of the middle third of the crown of the abutment tooth.

Figure ‎3-10: Height of contour on the buccal and lingual surfaces lowered to permit the
retentive clasp terminus to be located within the gingival third of the crown

 After alterations of axial contour are accomplished and before rest

seat preparation are instituted, an impression of the arch should be
made in irreversible hydrocolloid and a cast formed in a fast-setting
stone. This cast can be returned to the surveyor to determine the
adequacy of axial alterations before proceeding with rest seat
preparations. If axial surfaces require additional axial recontouring,

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Chapter 3 Mouth preparation

this can be performed during the same appointment and without

compromise.
b. Retentive undercuts:
 The retentive undercut must be created in the form of a gentle depression,
not a pit or hole. The term dimpling has been applied to this techniques
but the name appears to be misleading, implying a definite pit rather than
a gentle depression ( Figure ‎3-11).

Figure ‎3-11: Dimpling is a gentle depression not a pit or a hole

 The depression of undercut is prepared by using a small, round-ended,
tapered diamond stone. The preparation is made parallel to and as close
as possible to the gingival margin.
 It is approximately 4mm in mesio-distal length, 2mm occluso-gingival
height. Care must be taken not to develop a ledge or shoulder in the
enamel.

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4. Rest seat preparation:

It is essential that a rest seat preparation be made for each rest
before final impressions are made. If this is not done, the forces
transmitted from the prosthesis to the abutment teeth will occur against
inclined planes, resulting in transmitting unfavorable lateral forces on the
abutment teeth, and a sliding effect on the prosthesis. Besides, the rest
placed on the tooth surface without rest seat preparation will interfere
with the opposing occlusion and will not have adequate metal thickness
suitable for the strength of the rest.
 Design Considerations:
a. Rests for posterior teeth
They may take three forms:
 Conventional occlusal rests
 Extended occlusal rests.
 Overlay occlusal rests

 Conventional occlusal rests:

 It has a rounded triangular outline form when viewed occlusally.
 The tissue surface of the rest should be smooth and rounded.
 Should be on one third the faciolingual width of the tooth, or one
half the width of the tooth measured at the cusp tips (Figure ‎3-12).

Figure ‎3-12:Occlusal rest should be on 1/3 the faciolingual width

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 Marginal ridge should be reduced 1.5 mm for base metal alloys,

and 2 mm for gold alloys.
 Floor of the rest seat preparation should be spoon shaped and
inclined apically as it approaches the center of the tooth
 The angle between minor connector and rest should usually be less
than 90 degrees ( Figure ‎3-13).

’8
Figure ‎3-13: The angle between floor of the occlusal rest seat
and minor connector should be less than 90 degrees

 For distal rests on distal extension base partial dentures, the angle
between the minor connector and rest should be 90 degrees. This
permits release of rests during function ( Figure ‎3-14).

Figure ‎3-14: Rests on distal extension bases should be 90 degrees

 Rests for embrasure clasps are formed by two adjacent occlusal

rests (Figure ‎3-15 ).

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Chapter 3 Mouth preparation

Figure ‎3-15: Embrasure rest seats prepared on two teeth

 Extended occlusal rests:

 For tooth born segments of partial dentures. Rests may be carried more
than half way across the occlusal surface in order to promote axial force
direction (Figure ‎3-16 ).

Figure ‎3-16: Extended occlusal rest on the mandibular first molar, designed to ensure
maximum bracing from the tooth. If placed on a mesially inclined molar next to a
modification space, the extended rest would ensure that the forces are directed down the
long axis of the abutment, and therefore a distal rest is not needed

 For tipped molars extended occlusal rests should be used to minimize further
tipping, and to direct forces along the long axes of the teeth.

 Overlay occlusal rests (Figure ‎3-17)

 Some abutment teeth may require the restoration of their occlusal surface by
the partial denture framework. The occlusion is restored with the base metal
or gold occlusal overlay as part of the partial denture framework.
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Chapter 3 Mouth preparation

 Overlay rests may contact occlusal, facial, lingual and proximal surfaces.
 The primary indication for overlay rests is restoration of the occlusal plane,
vertical dimension and to resist further tipping of the teeth.

Figure ‎3-17: Overlay cast restoration on tipped molar

b. Rests for anterior teeth

Undercuts and sharp line angles in all should be avoided. May be in
three forms:
 Lingual rest; it has the following forms:
- Cingulum rest
- Canine rest
- Ball rest
 Incisal rest

 Lingual rest:
 They are more preferred than incisal rests because of esthetics,
being closer to center of tooth rotation, and less bothersome to the tongue.
- Cingulum rest
 It has a rounded inverted V OR U shaped outline when viewed
from the lingual and the proximal (Figure ‎3-18 ).
 It is broadest from the center and merges with normal tooth
anatomy proximally.

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Chapter 3 Mouth preparation

 Often difficult to obtain an apical inclined rest seat due to tooth

angulations or anatomy. This may require the use of a restoration to
establish a definite rest seat.

Figure ‎3-18: V shaped cingulum rest

 Bonded, cast, or machined metal cingulum rests may be described

when an adequate rest seat cannot be prepared in tooth structure
(Figure ‎3-19 ).

Figure ‎3-19: Cast cingulum rest

- Canine ledge
 A step like preparation placed on the proximal half of the maxillary
canine usually at the junction between the middle and the ginigival
thirds.
 The ledge seat should be perpendicular to the long axis of the tooth.
- Ball (Lug) rest
 Ball shaped rest with rounded outline form.

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Chapter 3 Mouth preparation

 Placed on the mesial or distal marginal ridge of the tooth, usually at

the junction of the middle and gingival thirds.
 It is 1.5 mm deep and 2.5 mm wide.
 It is used when the cingulum or the incisal rests are contraindicated
due to esthetics or insufficient interocclusal clearance.
 Preparation of a positive rest seat often results in dentin exposure. If
the dentin is exposed the preparation may be modified to accept an
amalgam, composite resin, pin ledge or cast restoration ( Figure ‎3-20 ).
 Ball rest permits rotational movements to occur during function to
tooth – mucosa removable partial dentures.

Figure ‎3-20: Ball rest on casted restoration

 Incisal rest (Figure ‎3-21 )
 Outline form of the rest is saddle shaped.
 It is concave when viewed from the facial and convex when viewed from
the proximal.
 The display of metal may be objectionable.
 It provides greater leverage than lingual rest.

Figure ‎3-21: Incisal rests

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B. Abutments that should receive restorations other than complete

coverage crowns

 When an inlay is the restoration of choice for an abutment tooth,

certain modifications of the outline form are necessary. To prevent the
buccal and lingual proximal margins from lying at or near the minor
connector or the occlusal rest, these margins must be extended well
beyond the line angles of the tooth. This is accomplished by widening
the conventional box preparation.The additional extension prevents
damage to the thin margin of the cast restoration by the clasp during
prosthesis insertion and removal (Figure ‎3-22).

Figure ‎3-22: Inlay preparation

D. Abutment teeth that should receive crowns (complete coverage):

 Regardless of the type of crown used, preparation should be made
to provide the appropriate depth for the occlusal rest seat (Figure ‎3-23).

Figure ‎3-23: Metal-ceramic crown preparation shows mesial-occlusal

(MO) rest seat preparation

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Chapter 3 Mouth preparation

 When multiple crowns are to be restored as removable partial

denture abutments, it is best that all wax patterns be made at the same
time. After the wax patterns have been preliminarily carved for
occlusion and contact, proximal surfaces that are to act as guiding planes
are carved parallel to the path of placement with a surveyor blade.
Guiding planes are extended from the marginal ridge to the junction of
the middle and gingival thirds of the tooth surface involved.
 Retentive undercuts can be also created and occlusal rest seats are
carved in the wax pattern (Figure ‎3-24). Critical areas prepared in wax
should not be destroyed by careless spruing or polishing.

Figure ‎3-24: The wax patter of a crown with rest seat carved in it

 Ledging of the lingual or palatal surfaces provides effective stabilization

and reciprocation (Figure ‎3-25). A ledge on the abutment crown acts as
a terminal stop for the reciprocal clasp arm. It also augments the
occlusal rest and provides indirect retention for a distal extension
removable partial denture. A reciprocal clasp arm built on a crown ledge
reproduces more normal crown contours.

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Chapter 3 Mouth preparation

Figure ‎3-25: A, Preparation of the ledge in a wax pattern with a surveyor blade parallel to
the path of placement. B, Refinement of the ledge on casting, using a suitable stone or
milling device in a handpiece attached to the dental surveyor or a specialized drill press
for the same purpose. C, Approximate width and depth of the ledge formed on the
abutment crown, which will permit the reciprocal clasp arm to be inlaid within the
normal contours of the tooth. D, True reciprocation throughout the full path of
placement and removal is possible when the reciprocal clasp arm is inlaid onto the ledge
on the abutment crown. E, Direct retainer assembly is fully seated. The reciprocal arm
restores the lingual contour of the abutment.

 Ideally crown restoration for a removable partial denture abutment

satisfies all requirements for support, stabilization, and retention without
compromise for cosmetic reasons (Figure ‎3-26, Figure ‎3-27).

Figure ‎3-26: Metal ceramic crowns for teeth #4 and #5 with occlusal rests in metal. The
distal surface of #4 provides a guide-plane surface that is continued onto a portion of
the lingual surface for maximum stabilization.

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Chapter 3 Mouth preparation

Figure ‎3-27: A porcelain veneer crown is resurveyed following adjustment, glazing, and
polishing. It is important to survey crowns returned from the laboratory before
cementation

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