Textbook of Removable Prosthodontics

Textbook of
Removable Prosthodontics
– the Scandinavian Approach
Removable_Prosthodontics_mat_1opl_lh.indd 1 11/3/11 8:47 AM

Textbook of
Removable Prosthodontics
Editors
Margareta Molin Thorén
Johan Gunne
MunkSGA ARd dAnMARk

Textbook of Removable Prosthodontics
1st e-book edition, 2014
© Munksgaard Danmark and the authors, Copenhagen 2012
ISBN: 978-87-628-1370-0
Publishing editor: Britta Østergaard

Copy editors: Anne Sofie Steens and Liva Skogemann
forlaget@munksgaard.dk
munksgaard.dk
Layout and typesetting: Carsten Valentin

Illustrations: Birgitte Lerche
Cover design: Nete Banke, Imperiet
e-book production: Marketsquare A/S
Printed edition:
1. edition, 1. printrun, 2012
Printing: Livonia Print, Latvia
ISBN: 978-87-628-0955-0
This publication may only be reproduced in accordance with agreement

with Copy-Dan and Danish Ministry of Education.
Editors and authors Professor, DDS, PhD
Professor, DDS, PhD
Asbjorn Jokstad
Margareta Molin Thorén
Faculty of Odontology
Department of Odontology
University of Toronto
University of Umeå
Canada
Sweden
Professor, DDS, PhD

Professor emeritus, DDS, PhD
Ulf Lerner
Johan Gunne
Umeå University and Institute for
University of Umeå
Medicine
Sweden
University of Gothenburg
Sweden
Authors
Professor emeritus, DDS, PhD DDS, PhD
Einar Berg Percy Milleding
Department of Odontology Dental Competence Center
University of Bergen Tromsö
Norway Norway
Senior lecturer, DDS, PhD University lecturer, DDS

Tom Bergendahl Harald Nesse
Institute for Postgraduate Dental Department of Odontology
Education University of Bergen
Jönköping Norway
Sweden
Associate professor, DDS, PhD
Professor emeritus, DDS, PhD Gunilla Nordenram
Gunnar E. Carlsson Department of Odontology
Department of Odontology Karolinska Institute
University of Gothenburg Sweden
Sweden
Associate professor, DDS, PhD
Professor emeritus, DDS, PhD  Per Stål
Tore Dérand Department of Integrative Medical
Faculty of Odontology Biology
Malmö University Umeå University
Sweden Sweden
Professor, DDS, PhD Assistant professor, DDS, MSc

Flemming Isidor Bo Sundh
Faculty of Odontology Department of Odontology
Aarhus University University of Gothenburg
Denmark Sweden
Removable_Prosthodontics_mat_1opl.indd 5 11/4/11 8:34 AM

Preface is a trait uniquely Scandinavian, it is per-
The aim of this book is to present the haps fair to say that it is typically so.
Scandinavian treatment philosophy of re-
movable prosthodontics in which biology While the above treatment philosophy,
and function have priority over the more particularly relevant for tooth-borne
technical approach favoured by others. prostheses, is largely based on reasonable
scientific evidence, this is almost absent
Our ambition has been to include basic in regard to complete dentures. For that
theoretical principles and clinical pro- reason the undocumented use of time-
cedures for both complete and partial consuming and costly procedures with
removable dentures. Without question, complicated face bows, articulators and
there is a need for dental students to ac- occlusal schemes are rejected in Scandi-
quire adequate knowledge and clinical navia in favour of simpler methods. This
skills within this field. For several rea- also means that treatment with complete
sons, the advent of implants and reduced dentures is unquestionably more an art
prevalence of edentulousness does not than a science. Accordingly, the proce-
alter this fact. Even in affluent Scandina- dures must be mainly based on clinical
via the percentage of prostheses retained experience such as is presented in this
by implants is still in the single digits. textbook, with all the uncertainties
Globally the percentage is even smaller. thereof.
Accordingly, implants cannot now, nor in
the foreseeable future, solve all problems The editors have consciously avoided too
associated with missing teeth. The great much “streamlining” of the different
majority of patients with these afflictions styles, ways of expression and degree of
must still be treated with removable den- penetration exhibited by the co-authors.
tures. Without adequate knowledge of On the contrary, the authors have been
such treatment, future dentists fail in pro- given the opportunity of leaving their in-
viding competent treatment to a substan- dividual mark on the text.
tial proportion of future patients. Finally,
knowledge regarding removable dentures Without the effort of all co-authors, this
may be indispensible when manufactur- textbook would not have come into be-
ing extensive fixed restorations. ing. The editors would therefore like to
express their gratitude and deep respect
The Scandinavian treatment philosophy for the work that they have diligently
is largely based on periodontal and clini- invested. We are also most grateful to the
cal prosthodontic research, which has publisher Munksgaard, for taking on the
demonstrated that the critical factor in task of publishing this book.
tooth (and abutment) survival is estab-
lishing and maintaining good periodon-
tal health by plaque control, not by trying Umeå, October 2011
to reduce or distribute widely mechanical
loading. While we do not claim that this Margareta Molin Thorén Johan Gunne

Contents
Editors and authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1 Missing teeth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Prevalence of removable prostheses . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Complete dentures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Removable partial dentures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Consequences of missing teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Physical and anatomical consequences . . . . . . . . . . . . . . . . . . . . . . . . 22
Bone resorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Mucosal lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Changes in oral muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Pain and discomfort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Loss of taste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Biomechanical consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Psychosocial consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Patients’ perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Present trends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Psychological studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Quality of life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Phonetic consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
The effect of dentures on speech . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Speech problems and adaptation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Managing speech problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
To what extent are denture wearers satisfied with their dentures? . . . . . . . . . . . . 29
Prevalence and causes of dissatisfaction . . . . . . . . . . . . . . . . . . . . . . . . 29
Prediction of patient acceptance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2 Anatomy of the oral cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Tempomandibular joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Muscles of mastication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Oro-facial muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Muscles of the tongue and floor of the mouth . . . . . . . . . . . . . . . . . . . . . 40
Muscles of the soft palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Oro-facial region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Oral cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Oral vestibule and cheeks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
The roof of the mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Tongue and floor of the mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Final remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
3 The biology of bone remodelling in jaw bones with and without teeth . . . 51
Bone cells . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Bone formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Bone resorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Osteoblast control initiation of bone resorption . . . . . . . . . . . . . . . . . . . . . 54
Bone remodelling and modelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Osteoporosis in jaw bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Inflammation induced bone remodelling . . . . . . . . . . . . . . . . . . . . . . . . 57
Bone remodelling under jaw prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . 57
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4 Nutrition in old age with special regard to dentition . . . . . . . . . . . . . . 61

Body composition in old age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
nutritional assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Food intake in old age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
nutrition and dentition in old age . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Effect of dentures on nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5 Denture-induced sequelae in oral tissues . . . . . . . . . . . . . . . . . . . . . 69

Residual ridge resorption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Clinical impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Crista flaccida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
denture stomatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Aetiology and local factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
denture plaque biofilm. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Yeasts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Treatment and maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Angular chelitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Traumatic ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
denture irritation hyperplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
10

Oral cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Burning mouth syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Concluding remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
6 Prognosis and evidence based prosthodontics . . . . . . . . . . . . . . . . . . 85

Prosthodontic therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Prognosis, general considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Qualitative (What can happen over time?) . . . . . . . . . . . . . . . . . . . . . . 90
Time factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Quantitative (What’s the probability that certain events will develop?) . . . . . . . . 93
Observation viewpoint (Therapy defined disease versus patient
experienced illness?) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
documentation estimations on prognosis (aggregated data from
published studies of populations versus the individual clinician and patient?) . . . . . 95
Treatment planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
The operator and patient factor . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Correct identification of the patient’s problems . . . . . . . . . . . . . . . . . . . . 97
How should we explain prognosis to our patients? . . . . . . . . . . . . . . . . . . 97
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
7 Examination and diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

disease and illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Practical aspects of disease and illness . . . . . . . . . . . . . . . . . . . . . . . . 102
Anamnestic information and interview . . . . . . . . . . . . . . . . . . . . . . . . 102
unstructured interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Structured interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
General health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Previous and present diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Hypersensitivities and allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Social aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
dental history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Patient experiences and expectations . . . . . . . . . . . . . . . . . . . . . . . . . 104
Clinical examination and diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Extraoral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Facial changes of the edentulous . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Findings of aesthetic importance . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Signs of mandibular dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Intraoral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
11

Ridges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
The relationship between maxilla and mandible . . . . . . . . . . . . . . . . . . . . 106
Mucosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Tongue and intraoral muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Saliva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Residual dentition and surrounding tissues . . . . . . . . . . . . . . . . . . . . . . . 107
Existing dentures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
diagnostics and therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
General principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Important aspects related to diagnostics and therapy . . . . . . . . . . . . . . . . . . 109
8 Treatment planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

Primary treatment plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Initial treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Second treatment plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Aesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Social aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Chewing ability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Occlusal support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Phonetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
General and local conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Removable partial dental prostheses versus fixed dental prostheses . . . . . . . . . . 116
Tooth supported versus mucosally supported removable partial dental prostheses . . 118
Treatment with removable partial dental prosthesis or not? . . . . . . . . . . . . . . 118
Main points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
9 Jaw relation registration and articulators . . . . . . . . . . . . . . . . . . . . 121

Articulators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Classification of jaw relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Orientation relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Vertical jaw relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Occlusal vertical dimension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Rest vertical dimension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Interocclusal rest space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Establishment of the vertical maxillomandibular relations for complete dentures . . . . . . 126
Methods of determining the vertical dimension . . . . . . . . . . . . . . . . . . . 127
Mechanical methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Physiologic methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Horizontal jaw relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Horizontal position of occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
12

Eccentric relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Recording the horizontal position of occlusion . . . . . . . . . . . . . . . . . . . . . 129
Short summary of clinical procedures in recording of jaw relations. . . . . . . . . . 130
Removable partial dental prostheses . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
10 Retention of complete dentures . . . . . . . . . . . . . . . . . . . . . . . . . 133

Factors of retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Physical retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Function of adhesion, cohesion, atmospheric pressure and flow properties
of thin films of liquid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
How to influence different physical factors of retention . . . . . . . . . . . . . . . 134
Physical retention of maxillary and mandibular dentures . . . . . . . . . . . . . . 134
Clinical importance of physical retention . . . . . . . . . . . . . . . . . . . . . . 134
Muscular retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
How to influence muscular retention . . . . . . . . . . . . . . . . . . . . . . . . 135
Retention and stability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
denture supporting tissues and retention of dentures . . . . . . . . . . . . . . . . . 137
Retention and surgical intervention . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Retention and occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Retention and pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
11 Removable complete dental prosthesis – clinical procedures . . . . . . . . 139

Impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
General aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Mucostatic impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Compression impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
dynamic impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Primary impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Special tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Final impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Intraoral adaptation of special tray . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Border moulding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Securing attachment of impression material . . . . . . . . . . . . . . . . . . . . . . 145
Procedures for final impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Inspection of final impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Special impressions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Recording jaw relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Occlusion rims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
determining the basis for aesthetics . . . . . . . . . . . . . . . . . . . . . . . . . 149
13

Lip support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Level of incisors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Orientation of occlusal plane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Midline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Choice of artificial teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
determining the relationship between jaws . . . . . . . . . . . . . . . . . . . . . 154
Occlusal vertical dimension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Horizontal relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Choice of horizontal relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
determining RP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Fixation of occlusion rims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Recording materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Transferring recording to articulator . . . . . . . . . . . . . . . . . . . . . . . . . 159
Try-in stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Controlling and adjusting horizontal relationship and occlusion . . . . . . . . . . . 159
Controlling and adjusting the vertical relationship . . . . . . . . . . . . . . . . . . 159
Controlling and adjusting the aesthetics . . . . . . . . . . . . . . . . . . . . . . . 160
determining the A-line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Insertion stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Inspection of the denture prior to insertion . . . . . . . . . . . . . . . . . . . . . 161
Inspection and clinical control of the denture after insertion . . . . . . . . . . . . 161
Information and post insertion control appointment . . . . . . . . . . . . . . . . 162
Post insertion problems and treatments . . . . . . . . . . . . . . . . . . . . . . . . 162
Immediate dentures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Clinical procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Optimizing the denture supporting area . . . . . . . . . . . . . . . . . . . . . . . . 164
Preliminary impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Insertion and post insertion treatment . . . . . . . . . . . . . . . . . . . . . . . . 167
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
12 Removable partial dental prosthesis – clinical procedures . . . . . . . . . 169

Classification of RPdPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
According to type of framework . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
According to type of support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
According to location of missing teeth (kennedy classification) . . . . . . . . . . . . . 170
Indications and contraindications for RPdPs . . . . . . . . . . . . . . . . . . . . . 171
In relation to the functions of the dentition . . . . . . . . . . . . . . . . . . . . . . 172
In relation to possible harmful effects . . . . . . . . . . . . . . . . . . . . . . . . . 173
In relation to type of RPdP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
14

In relation to alternative treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Summing up indications for RPdPs . . . . . . . . . . . . . . . . . . . . . . . . . . 179
The Scandinavian approach to RPdPs . . . . . . . . . . . . . . . . . . . . . . . . 179
Measures to avoid/reduce mechanical trauma . . . . . . . . . . . . . . . . . . . . . 179
Measures to avoid/reduce the effect of added plaque retention . . . . . . . . . . . . . 179
Treatment planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Preliminary treatment plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Journal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Clinical examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Radiographs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Analysis of study casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Treatment options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Pre-prosthetic treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Final treatment plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Assessment of oral condition, definite treatment plans . . . . . . . . . . . . . . . . . 182
Treatment optimizing clinical outcome . . . . . . . . . . . . . . . . . . . . . . . . 183
Anticipated additions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Supporting, retaining and stabilizing components . . . . . . . . . . . . . . . . . . . 183
Supporting components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
dental rests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Mucosal support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Retaining components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Surveyor: function and basic concepts . . . . . . . . . . . . . . . . . . . . . . . . . 186
Active/direct retainers, clasps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Active/direct retainers, attachments . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Passive/indirect retainers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Stabilizing components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
designing the construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Sequence in designing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
determining position and extension of saddles . . . . . . . . . . . . . . . . . . . . . 194
Choosing major connector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
determining number and position of dental rests . . . . . . . . . . . . . . . . . . . 198
Surveying cast, determining path of insertion/removal, positioning clasps,
their number and type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Evaluating need for passive/indirect retention . . . . . . . . . . . . . . . . . . . . . 200
Evaluating if the construction is sufficiently retained and stabilized . . . . . . . . . . . . 201
Special problems with free-end dentures (kennedy Class I and II) . . . . . . . . . . . . 201
Special problems for RPdPs with a unilateral free-end saddle (kennedy Class II) . . . . . . 203
Special problem with kennedy Class IV . . . . . . . . . . . . . . . . . . . . . . . . 203
Clinical procedures, removable partial dentures . . . . . . . . . . . . . . . . . . . . 203
15

Preliminary measures prior to impression . . . . . . . . . . . . . . . . . . . . . . 203
Occlusal adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Recontouring tooth surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Procedures when crowns and FPds are manufactured at the same time . . . . . . . . . 205
Blocking out interdental spaces and large undercuts . . . . . . . . . . . . . . . . . . 205
Impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Special tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Final impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Altered cast impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Choice of impression material . . . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Inspection of the final impression . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Recording the jaw relations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Metal framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Controls on the cast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Controls in the mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 210
Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Framework does not seat properly . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Adjustment of clasp arms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Occlusal adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Borderlines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Try-in stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Tooth set-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Controlling and adjusting the set-up . . . . . . . . . . . . . . . . . . . . . . . . 212
Insertion stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213
Inspection of the denture prior to insertion . . . . . . . . . . . . . . . . . . . . . 213
Inspection and clinical control of the denture after insertion . . . . . . . . . . . . 213
Information and post insertion control appointment . . . . . . . . . . . . . . . . 214
Post insertion problems and treatments . . . . . . . . . . . . . . . . . . . . . . . . 214
General comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Specific problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Repairs, relinings, rebasements . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Concluding remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
13 Relining and rebasing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

Reline or rebase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Clinical procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
16

Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Extraoral examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Intraoral examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Examination of denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Measures prior to impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Impression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Special observations when relining a RPdP . . . . . . . . . . . . . . . . . . . . . . 222
Post operative aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
14 Removable complete dental prosthesis – laboratory procedures. . . . . . 225

Production of primary casts and individual trays . . . . . . . . . . . . . . . . . . . . 226
Master cast and occlusion rims . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Mounting of casts in the articulator and tooth set-up . . . . . . . . . . . . . . . . . 227
The artificial teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
The tooth set-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Some theoretic background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
The set-up of anterior teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
The set-up of posterior teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
The build-up of the occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
The wax-work design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232
The acrylic processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Investing and Pressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233
Grinding and polishing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Occlusion equilibration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234
Further reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 236
15 Removable partial dental prosthesis – laboratory procedures . . . . . . . 237

The written instructions to the dental laboratory – the requisition . . . . . . . . . . . 238
Study cast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Master cast production – surveying . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Master cast production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Surveying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 239
Surveying of the study-cast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 240
Transfer of the guiding plane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Surveing of the master cast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Final RPdP design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Connectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Maxillary major connectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242
Mandibular major connectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 244
Retainers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Mastercast duplication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
17

Blocking out . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Relieving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
duplication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Waxing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Fabrication of the frame-work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Spruing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Investing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Wax elimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Casting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Alternative production techniques . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Finishing and polishing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Clinical try-in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Tooth set-up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
The acrylic processing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Interim removable partial dental prosthesis . . . . . . . . . . . . . . . . . . . . . . 255
Relining of a RPdP – technical procedures . . . . . . . . . . . . . . . . . . . . . . . 256
Repair of RPdP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Loss of an artificial tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Fracture of a clasp arm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Fracture of the metal framework . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Fracture of the acrylic base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Abutment tooth fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
18

1
Missing teeth
E i n a r B E rg and H a r a ld nE ssE
INTRoDucTIoN. Loss of teeth represents a serious event in a person’s life for a number of
reasons. In most if not all respects, removable dentures fall short of the natural dentition it re-
places. These shortcomings may be of a biomechanical, physical or psychosocial nature. They
are usually related to the number of teeth lost, and consequently they are most pronounced
in cases where all teeth are lost and replaced by a removable complete dental prosthesis
(RCdP).
The use of dentures may have a number of deleterious effects on the oral tissues. den-
tures expose the supporting tissues to an unphysiological loading, which is accompanied by a
continuing resorption of bone. Various pathological reactions of the mucosa may ensue, and
discomfort and even pain are not uncommonly associated with wearing removable dentures.
denture retention depends on physical and, more importantly, muscular fixation and is by no
means assured under all circumstances. As a consequence, chewing of hard, fibrous or sticky
food becomes difficult or impossible, with probable dietary consequences. For all patients,
but to varying degrees, the loss of teeth and supporting structures and their restoration by
means of a removable denture thus represents an impairment of a bodily function. For some
it may connote a serious handicap.
It is not only a physical problem to loose teeth and wear dentures, but it may also repre-
sent a severe social and psychological burden that to some extent affects the patient’s quality
of life. For the above reasons, it requires a degree of adaptation by all patients to wear a re-
movable prosthesis. In some cases, the requirement for adaptation may exceed the patient’s
capability.
However, the tale of missing teeth, dentures and problems with the same is not solely
a negative one. Extractions and subsequent restoration of missing teeth with removable
dentures may offer a relief from pain, discomfort, halitosis and poor aesthetics, which often
characterises a dilapidated rest dentition in its last stage of existence. Also, one of the para-
doxical problems of denture wearing is the fact that many patients over-adapt to inadequate
dentures – to the possible detriment of the supporting tissues. Moreover, in most patients the
harmful consequences on the oral tissues of wearing dentures develop slowly over extended
periods of time. Consequently, from the patient’s point of view, they may be acceptable.
Also, there is no doubt that a removable denture is the fastest, simplest and least expensive
way of restoring missing teeth, and the great majority of patients manage to adapt to and
19

appear satisfied with them. Even in affluent societies such as the Scandinavian ones, where
the use of implants becomes steadily more prevalent, it still remains the method of choice
for the majority. In addition, for biological reasons implant retained restorations cannot be
used for all patients. In a global perspective complete and removable partial dental prosthesis
(RPdP) is presently, and in the foreseeable future will remain, the only realistic treatment al-
ternative for the majority of edentulous people in the world.
The transition from the complete dentition to the edentate stage is a gradual process
that normally spans many years. With any tooth loss two fundamental questions have to be
answered: 1) should the lost teeth be replaced and 2) if so, with what. Statistically, the need
for replacement becomes manifest primarily for those over the age of 50. The molars are the
first to be lost, followed by the premolars. The dental arches thus become shorter. The pre-
sent scientific consensus is that such shortened dental arches should only be restored with a
prosthetic device if the tooth loss significantly interferes with oral function, because the ad-
vantage of any prosthetic replacement must outweigh possible harm it may cause to the oral
tissues. In this research it has been documented that most lost teeth are in fact not restored,
and that there is no difference of any clinical significance in oral function or pathology be-
tween subjects who have lost three to five occlusal units and those who have complete denti-
tions. Aside from these general considerations, in the individual case, whether or not a tooth
loss is to be restored depends on the actual oral function after the loss, the number of lost
teeth, their position, socio-demographic and economic variables, preferences and attitudes
among dental professionals and patients.
Prior to the advent of implants, only three classical treatment modalities were available
for restoring lost teeth, all of which are still in use: RCdPs for the edentate, RPdPs or fixed
partial dental prosthesis (FPdP) for the partially dentate. Implant retained restorations have
extended the treatment panorama significantly, both in terms of FPdPs and overdentures.
However, for the reasons mentioned above, their relative share in the treatment of lost teeth
is quite modest in most countries. For the purposes of this book the subsequent discussion
will therefore be limited to Cds and RPdPs.
Some of the above and other aspects of importance related to missing teeth are discussed
in more detail in the following.
Prevalence of removable because prevalence data change very rap-
prostheses idly, results cannot readily be compared if

they are recorded as little as 5 years apart.
complete dentures Another reason is that the proportion of
Figures indicating prevalence of eden- edentulism in the adult population is of-
tulism that enable comparison between ten only reported in 10-year age cohorts,
countries are hard to find. Moreover, as opposed to the proportion in relation
20 Missing teeth

likely no longer valid, and it makes com-
country Data collected %
parisons between the countries uncertain.
uSA 2004 3.8
Interesting and comparable data rel-
uk 1998 13 evant in a discussion of edentulism is the
denmark 2000 8 calculated number of edentulous jaws in
norway 2004 2.5 the UK, Sweden and Finland. Based on
these figures, for the projected time peri-
Sweden 1997 3
od 2005–2008, the proportion of edentu-
Finland 1997 6 lous jaws in relation to the total number
Table 1.1. Prevalence of edetulism in some western of jaws is 9 % for the UK, 4.5 % for Swe-
countries. den and 10 % for Finland. This confirms
that significant differences still exist in
to the entire adult population. However, this area; even between neighbouring
for various reasons the pattern of change Scandinavian countries with generally
within and between each of these cohorts closely related educational systems, eco-
in time is often quite intricate, and it nomic circumstances, and culture.
makes comparisons between countries ad- There may be several explanations
ditionally complex. Thus the effect of co- for these differences, related to financial
hort edentulism on population edentulism models for payment of dental treatment,
may also be difficult to analyse due to the culture and tradition in the population
situation that an increasing proportion of and dental profession etc. However, even
individuals survive into old age. For this in a country such as Sweden, with an ex-
reason, data based on population studies tremely low prevalence of edentulism, the
best show the state of edentulism, its de- estimated number of edentulous jaws for
velopment over time and how it compares 2005 is still nearly 800 000. In Finland
between countries. the corresponding projected number for
Only in a few western countries are 2007 is 1 044 000 and for UK 10 800 000.
studies performed in this way. These These countries all have highly developed
include the ones referred to in Table 1.1, health care systems. Nevertheless, in
which indicates the situation approxi- spite of decreasing prevalence over time,
mately at the turn of the millenium. As the sheer number of edentulous jaws
can be seen, edentulism varies quite indicates a treatment need that should
markedly, from around 2.5 % for Norway, be taken seriously by dental schools and
to 13 % for UK. However, even these fig- politicians alike.
ures should be interpreted with caution.
The data represent a time span of 7 years Removable partial dentures
during which time edentulism has been The comments regarding the difficulties
significantly reduced in all western coun- of comparing the prevalence of edentu-
tries. The oldest figures are therefore most lism between countries apply equally to
Missing teeth 21

resorb to a varying degree. The rate with
country Data collected %
which it changes is highest initially, but
uk 1998 29
resorption continues throughout life.
denmark 2000 19 Whether the bone resorbs because of in-
Germany 2001 24 activity atrophy or unphysiological load-
Sweden 1991 13 ing still appears unresolved according to
the dental literature. From a clinical point
Switzerland 2002 19
of view, however, it is more important
Table 1.2. Prevalence of RPDPs in five european that over time gradual reduction of the
countries. height of the alveolar ridges causes a re-
duction of the vertical dimension in den-
similar data on RPDPs. Only studies from ture wearers, albeit with great individual
five European countries on the latter are variation. If the reduction becomes severe,
thus suitable for direct comparison (Table it may have dramatic effects on the physi-
1.2). ognomy of the patient for several reasons:
As can be seen, the numbers, like it may discernibly reduce the height of
those for edentulism, are strikingly dif- the inferior 1/3 of the face, it may in-
ferent. In fact, in reality the difference terfere with the support of the lips and
is probably even greater, as the data col- cheeks, and it may change the relative
lected regarding the Swedish prevalence position of the dentures in relation to the
are approximately 10 years older than the skull and facial features. In order to main-
others, during which time the prevalence tain unchanged aesthetics, it therefore
of RPDPs has most likely fallen further. becomes necessary to make adjustments
Factors explaining these differences are and/or remake the dentures from time to
basically the same as those discussed for time to compensate for the changes that
RCDPs. have occurred.
Furthermore, the pattern of bone re-
consequences of missing sorption is unequal in the two jaws. In
teeth the maxilla it tends to reduce the width
When teeth are lost and replaced by den- of the supporting area, whereas the op-
tures, a number of consequences may posite is usually the case in the mandible,
ensue. In the following, some of the more particularly in the posterior region. As a
important ones are mentioned. result, if the denture teeth are maintained
in the same positions as the natural ones
which they replace, the dentures may
Physical and anatomical become unstable because the forces are
consequences directed to areas without adequate sup-
Bone resorption port. If, on the other hand, the position
The bone underneath dentures tends to of the teeth is adjusted to the changed
22 Missing teeth

position of the ridges, the stability of the into close and often traumatising contact
denture would be favoured, but this could with the mucosa, promoting infection.
then interfere with muscular balance. A frequent sequela of this is stomatitis,
Problems with phonetics and aesthetics ranging from relatively minor reversible
may ensue, the tongue may feel cramped, conditions to irreversible papillary types,
which might give rise to many diffuse often related to angular cheilitis. Al-
complaints. The experienced clinician though such conditions are rarely accom-
usually chooses a compromise between panied by subjective symptoms, they are
these two methods. no doubt detrimental to oral and some-
Not infrequently, the resorbed bone is times perhaps even general health.
substituted by fibrous displaceable tissue. Another effect of denture wear on
Such flabby ridges are most frequently the mucosa may be the development of
found in the frontal part of the maxilla, pressure sores and hyperplastic reactions.
but may also occur in other parts of the These may be the result of a denture part
denture supporting areas. This causes that impinges on the mucosa. They are
problems for the patient in terms of chew- most frequently located along its peri-
ing ability, retention and stability of the phery. Even though such problems main-
denture, and for the dentist in that it ly occur with new dentures, they can also
makes impression and intermaxillary re- develop over time as a result of the un-
cord proceedings technically challenging. equal rate of bone resorption in different
It should also be mentioned that in areas covered by the denture. Finally they
some cases, due to extreme bone resorp- may be the result of premature occlusion
tion of the mandible, the mental forami- causing extra load to be transferred to the
na may be positioned on top of the alveo- corresponding supporting area.
lar ridge, thus exposing the mental nerves
to direct mechanical trauma via the changes in oral muscles
denture. Similarly, severe resorption of Successful function of RCDPs and also
the maxillary alveolar ridge may lead to a to some extent RPDPs depends mainly
traumatising of the naso-palatine nerve. on the muscular control necessary for
Unfortunately, removal of base acrylic in their retention. In stroke patients with
these areas only partly solves such prob- partial paralysis of the oral muscles, use
lems due to the instability of the dentures of removable dentures may therefore be
during function. impaired or even impossible. For wearers
of removable dentures, and particularly
Mucosal lesions those wearing RCDPs, the increased
The wearing of dentures also has a num- functional demands generally result in
ber of adverse effects on the mucosa. The a degree of hypertrophy of the oral mus-
fitting surface of a denture tends to be cles. In addition to an increased muscle
colonised by microbes, which are brought volume, the tongue frequently changes
Missing teeth 23

shape and becomes shorter and wider. is not limited to denture wearers, but may
Similarly, the genioglossus and mylohyoid be aggravated by the use of dentures. It
muscles may balloon into the floor of the is most commonly found in post meno-
mouth, impinge on the denture space pausal females, but may on occasion also
and compromise denture stability and affect males. As a rule, BMS is without
retention. Thus, paradoxically, the added objective findings of oral pathology. The
function of the intra- and extraoral mus- aetiology appears to be multifactorial.
cles supplying muscular fixation of the A number of possible causes have been
denture, may secondarily compromise the suggested, including local, systemic and
very fixation. psychogenic factors, so far with no clear
conclusion. Treatment has to be individu-
Pain and discomfort alised and symptomatic, and is often dif-
Denture wear is frequently accompanied ficult and with limited success.
by some degree of pain and discomfort.
Dentures are rarely completely stable. Loss of taste
Food particles will therefore inevitably Particularly new denture wearers may
lodge between the denture and support- complain of loss of taste. This is some-
ing tissues. During mastication these what surprising as taste buds are only
particles are pressed into and could trau- found in the tongue. Taste sensation is,
matise the mucosa. This is one of the however, due to more than mere neural
reasons why denture wearers rarely eat transmission from the taste buds. It is
raspberry jam. More serious problems also related to smell, visual, tactile and
may be caused by bony protuberances thermal features of the food. To some
such as tori, or sharp edges in the alveolar extent, the latter two factors are naturally
bone, particularly when they are covered influenced by a denture that covers and
by only thin unyielding mucosa. When a insulates large areas of the oral mucosa.
denture is forced into such areas during Nevertheless, the subjective feeling of loss
function, painful trauma may ensue. In of taste is usually of a transient nature,
addition, the denture tends to tilt around probably because patients become accu-
these areas with detrimental effects on stomed to the altered condition.
denture stability and retention. Also,
as mentioned above, direct mechanical Biomechanical consequences
trauma on the mental and naso-palatine Even optimal physical and muscular re-
nerves via the denture in cases with much tention is rarely sufficient to maintain
bone resorption may cause severe pain. RCDPs in a stable position when chewing.
Another painful condition is Burning During normal function, the dentures
Mouth Syndrome (BMS), which is char- will slide, tilt and loosen to a greater
acterised by a burning sensation of the or lesser extent. Moreover, the forces
tongue and oral mucosa. This condition of chewing are not always optimally
24 Missing teeth

transmitted to the supporting tissues. happens at the time when the last teeth
Sometimes a force, directed through an are lost – with everything that means in
artificial tooth, may tend to destabilise terms of grief at the loss of a body part.
the denture if the occlusal surface and For many, this event represents the anti-
plane is at a skewed angle to or outside thesis of youth, beauty and attractiveness,
the alveolar ridge. Also, the soft tissues which are the ideals of a modern western
covering the bony support represent a society. Loss of self image, anxiety and
degree of padding that tends to dissipate depression may ensue. For these and other
the chewing forces, particularly in cases reasons, some will go to extreme lengths
with flabby ridges. The pain threshold of in order to conceal their edentulism and
the supporting tissues may represent a dentures to the outer world.
limiting factor to the masticatory forces
at disposal for comminuting the food, as Present trends
does the fact that masticatory muscles It seems reasonable to assume that the
tend to atrophy in denture wearers. gravity of these problems has increased
As a consequence of these and other during the last decades. In the not so dis-
factors, chewing efficiency of a full den- tant past, edentulism was more the rule
ture is only approximately 25 % com- than the exception among older subjects,
pared with that of a natural dentition. and to the patient there may be some
This reduces the choice of foods that can comfort in numbers. Moreover, the only
be readily eaten, with deteriorating di- way to restore multiple missing teeth at
etary intake as a possible consequence. that time was to use a removable prosthe-
sis. Knowledge about such treatment and
what results are possible and impossible
Psychosocial consequences to achieve, was more widespread. Also,
Patients’ perspective patients nowadays usually become eden-
So far the discussion regarding removable tulous later in life, when the capacity to
dentures has mainly been from the point adapt to dentures is diminished. In addi-
of view of the dentist. It is at least equally tion, it is generally known that prostheses
interesting to consider the patient’s per- can be retained by implants, radically
spective. What does the average denture improving function. Many patients (and
wearer, and particularly the edentate one, dentists) therefore tend to regard a con-
perceive when she receives her first den- ventional removable denture as an infe-
ture? First of all, she does not generally rior treatment.
meet an environment particularly em-
pathic for her predicament or problems. Psychological studies
On the contrary, she will sometimes be Whereas it is generally agreed that psy-
the object of ridicule. To add insult to chological factors play an important role
injury, for the novice denture wearer this in patient acceptance of dentures, there
Missing teeth 25

appears to be less agreement as to what indicated that edentulism has a marked
they are. There have been many attempts negative impact on social and sexual life,
to investigate these factors over the past that oral problems occur almost twice
30–40 years. A number of instruments as often in patients treated with RPDPs/
used in general psychology have been RCDPs compared with patients treated
employed to measure various aspects of with a fixed prosthesis, and that OHRQoL
personality traits or other psychological tended to improve following the provi-
phenomena. The implicit premise for us- sion of new dentures.
ing these instruments has been that the The inherent problem with all quality
dissatisfied denture wearers would have of life (QoL) indices, including the ones
some deviating personality traits that related to oral health, is that this concept
might explain or at least might be associ- may mean widely different things to dif-
ated with their dissatisfaction. ferent people. No index should therefore
Although some researchers have found be expected to encompass all or some-
statistically significant positive correla- times even most aspects that might be
tions between the results of such instru- relevant for the individual patient. Thus,
ments and dissatisfaction with RCDPs, QoL indices are primarily instruments
the overall finding is that the psychologi- for research, limited to indicating trends
cal profiles of dissatisfied denture wearers within groups of individuals.
by and large do not deviate from the pop- Therefore, the mere score of a pa-
ulation in general. Even if some research- tient’s OHRQoL index is of limited value
ers have reported statistically significant for the clinician. If circumstances of spe-
associations between psychological meas- cial importance for QoL of the patient are
ures and the degree of satisfaction with to be revealed, it is always necessary to
RCDPs, the causal relationship is uncer- use time and energy to communicate ver-
tain and none have sufficient strength to bally as well as with body language. No
be of practical clinical value. detailed formula for such communication
exists, only general guidelines. According
Quality of life to these, the dentist is advised always to
During the last decade different so-called approach the patient unhurriedly, show-
Oral Health Quality of Life (OHQoL) in- ing patience, sensitivity, respect and em-
dicators have been developed to measure pathy. Perhaps, the most important thing
functional, social and psychosocial out- is that the clinician is conscious that this
comes of oral disorders as a supplement is indispensable, particularly in the treat-
to clinical indicators. Some OHQoL indi- ment of RCDP wearers.
ces specifically focus on functional and The time and energy thus spent may
psychosocial impacts of edentulism and be regarded as an investment in future
prosthetic rehabilitation. treatment success; not only for all the
Studies using such instruments have reasons described in the preceding para-
26 Missing teeth

graphs, but also because it creates a rap- is particularly prone to cause speech prob-
port that facilitates human relationships lems – sometimes because it is too bulky
and makes patient satisfaction more – at other times because it is too thin or
probable. From a more practical point of has an inappropriate shape. This tends
view, the aspects that are most important to interfere with the pronunciation of
to the patient may then be identified sounds formed by narrowing the flow of
and addressed appropriately. Thus, these air, such as the sibilant sounds s, sh, and
simple measures may be the key to a zh. Incisors and canines positioned too
high OHRQoL. It cannot be emphasized dorsally, premolars and molars positioned
enough that the treatment of missing too medially, or a palatal coverage, which
teeth is unlikely to succeed if it is regard- is too thick, restricts the tongue space
ed as a mere technical procedure. and may predispose to the same kind of
speech problems.
All efforts should therefore be made
Phonetic consequences that especially upper incisors and canines
The effect of dentures on speech occupy approximately the same positions
After insertion of a new removable den- as the natural ones – usually in front of
ture most patients will find that the pro- the alveolar ridge because the bone re-
nunciation of some speech sounds will sorption of the maxilla occurs mainly
be different from what they are used to. facially. Regrettably, reliable information
This is caused by an altered flow of air on the positions of the natural teeth is
through the oral cavity during speech normally only available when they are
because the denture has changed the in- replaced accurately by an immediate den-
traoral conditions spatially. The speech ture. For these reasons, when a denture
changes occur particularly during dento- without speech problems is renewed, the
alveolar articulation, i.e. when the apex positions of the teeth should normally be
of the tongue and the lower lip form copied in the new one. Supposedly, the
narrow passages during the pronuncia- incisive papilla does not change position
tion of voiceless s and f, and voiced z, v, d during resorption and it has therefore
and ch (tje in Scandinavian). Fortunately, been used as a rough landmark for the
the other consonants and all the vowels placement of the maxillary incisors in the
are normally articulated away from the edentulous. On average, the horizantal
teeth. The intraoral resonance may also distance between the incisal edge and the
be changed as a consequence of denture posterior border of the incisive papilla is
wear, but this only rarely influences 12–13 mm. However, the inter-individual
speech permanently. variation is great (~ 4 mm).
Feedback from the oral cavity is im-
Speech problems and adaptation portant for speech adaptation. In the
The area palatal to the maxillary incisors edentate mouth, mechanoreceptors in
Missing teeth 27

the periodontium and to some extent the error. It is, however, always advisable
alveolar ridges are lost and impulses from to evaluate the patients’ speech prior to
other parts of the oral cavity are impaired treatment, and all patients should be
due to coverage of the denture, which made aware of possible speech problems
impedes adaptation. Also, patients tend with a new denture. If a definite impedi-
to listen to their own speech and auto- ment exists, such as a distinct lisp, it is
matically attempt to adjust the sounds imprudent to suggest that the problem
if the pronunciation is defective in any might be solved with a new denture. In
way. If the patient’s hearing is reduced, cases where problems are anticipated, the
as is frequently the case in the elderly, patient should be advised that consider-
the auditory feedback may not function able time is required for speech adapta-
optimally, and the above adjustment will tion and also the fact that for some, such
be impaired. Most, but unfortunately not problems may even be permanent.
all patients relatively quickly adjust to the If a speech problem persists even after
new situation. an extended period of adaptation, altera-
Initial problems with speech may oc- tions to the denture may be required. The
cur in more than 3/4 of all patients who following experience based steps may
have new dentures inserted. Experienced prove useful, although an improved pho-
denture wearers usually have lesser prob- netic result is by no means assured.
lems than those who are adapting to their • Encourage the patient to read out loud
first dentures. Most phonetic problems in order to train speech.
are solved after 2–4 weeks, but this may • Enlarge the tongue space by removing
vary widely. However, speech problems some of the palatal surfaces of the up-
occur in 15 % of denture patients even per premolars and molars.
after as long as 4–6 weeks. Some patients • Assess the shape of the palate posterior
persistently feel that they have phonetic to the upper incisors. Consider creat-
problems, even though their speech ap- ing a convexity in this area in cases
pears perfect to others. Such patients are where the shape is concave.
probably afraid that the subjectively felt • Thin out the acrylic base posterior to
speech impediment discloses the fact that the upper incisors. Add and reduce
they have dentures, thus creating a self- wax to the area and observe the ef-
reinforcing problem. Referral to a speech fects of the differing shapes and vol-
therapist may on occasion remedy the umes on speech. If results are good,
problem. convert the wax into acrylic.
• Assess the positions of the upper inci-
Managing speech problems sors, and if need be, change them. If
Regrettably, management of speech prob- a previous denture without speech
lems is not based on scientific evidence. problems exists, try to copy its tooth
Often treatment is a matter of trial and positions in the new one.
28 Missing teeth

To what extent are theses fabricated lege artis. Even if none is
denture wearers satisfied found, the explanation is sought among
with their dentures? some of the other factors commonly be-
lieved to have a negative influence on the
Prevalence and causes of function of a denture: unfavourable shape
dissatisfaction and degree of resilience of the supporting
No treatment can be considered a success tissues, small quantity and watery qual-
unless the patient is satisfied. Based on ity of saliva, old age and female sex of the
all of the above consequences of eden- patient, to mention but a few.
tulism and wearing of dentures, most of However, there is little support for the
which are negative, it seems reasonable contention that patient satisfaction is a
to expect that most RCDP wearers would reflection of the technical quality of the
be dissatisfied with the oral function. denture, the quality of the supporting
This, however, is fortunately not the case. tissues, age or gender. In the few studies,
Only between 10 % and 15 % of patients where statistically significant correlations
are dissatisfied with new and well made have been demonstrated, the tendency
RCDPs. With older dentures that no has been too weak to be of practical use.
longer fit or function adequately, the pro- Of course, this should not be interpreted
portion of dissatisfied patients increases to mean that high quality in the produc-
to about 25 %. tion of dentures is of no consequence.
There is no doubt that the vast major- On the contrary, it should be regarded as
ity of patients express relative satisfac- absolutely indispensable. If for no other
tion with their dentures, because of the reasons, the preservation of the health of
amazing capacity of humans to adapt the supporting tissues and optimization
to changes and difficult situations. The of important functions such as aesthetics
implicit and sometimes even explicit ar- and chewing should be sufficient justifi-
rogant and exaggerated claims from some cation.
authorities that the favourable satisfac-
tion expressed by most denture wearers is Prediction of patient
primarily a consequence of their superior acceptance
biological knowledge and technical adept- The anatomical and physiological condi-
ness, is completely without scientific ba- tion, the biomechanical situation as well
sis. Even so, it is generally believed. as psychosocial factors may all contribute
One of the unfortunate consequences to patient dissatisfaction, but to different
of this widespread superstition is that degrees in different patients. Certainly
some conscientious clinicians, facing a no simple and strong associations have
dissatisfied patient for whom they have been demonstrated that would enable the
made new dentures, will naturally be dentist to predict individual patient suc-
looking for some tangible error in pros- cess. Nor have indices based on advanced
Missing teeth 29

statistical methods been able to demon- RCDPs, and patient satisfaction. However,
strate predictive power of clinical value. in a two-year follow-up of the same pa-
This is of course partly a consequence of tient sample, the significant associations
the complex nature of human adapta- of these factors could no longer be de-
tion, but also of the difficulty of finding monstrated. Relevant to this discussion,
instruments that are able to measure the the reader should be aware that a statisti-
contributing variables with precision and cal significance only describes a trend
accuracy. that is mathematically discernable. It may
The above conclusion arrived at in the not be of practical, clinical significance.
1990s, that there are no reliable means Although most studies have focused
of predicting patient satisfaction with on patients who are dissatisfied, it should
RCDPs, has recently been challenged, not be forgotten that the vast majority of
when in a large sample of denture wearers denture wearers are in fact satisfied with
statistically significant relationships were their dentures.
found between the quality of the residual
edentulous ridges and the quality of new
Further reading
Allen PF, McMillan AS. A review of the functional and psychosocial outcomes of edentulous-
ness treated with complete replacement dentures. J Can Dent Assoc. 2003; 69:662-662e.
Åstrøm AN, Haugejorden O, Skaret E, Trovik TA, Klock KS. Oral impacts on daily performance
(OIDP) in Norwegian adults: the influence of age, number of missing teeth and socio-de-
mographic factors. Eur J Oral Sci 2006; 114:115-121.
Berg E. Acceptance of full dentures. Int Dent J 1993; 43:299-306.
Dye BA, Smith V, Lewis BG & al. Trends in oral health status: United States, 1988-1994 and
1999-2004. Vital Health Stat 11. 2007:1-92.
Kanno T, Carlsson GE. A review of the shortened dental arch concept focusing on the work by
the Käyser/Nijmegen group. J Oral Rehabil 2006;33:850-62.
Kelly M & al. Adult dental health survey. Oral health in the United Kingdom 1998. The sta-
tionary office; London 2000.
Mojon P, Thomason M, Walls A. The impact of falling rates of edentulism. Int J Prosthodont
2004; 17:434-40.
Österberg T, Carlsson GE, Sundh V. Trends and prognoses of dental status in the Swedish
population: analysis b ased on interviews in 1975 to 1997 by Statistics Sweden. Acta odon-
tologica Scandinavica 2000;58:177-182.
Petersen PE, Kjøller M, Christensen LB, Krustrup U. Changing dentate status of adults, use of
dental health services, and achievement of national dental health goals in Denmark by the
year 2000. J Public Health Dent 2004; 64:127-35.
30 Missing teeth

Suominen-Taipale AL, Alanen P, Helenius H, Nordblad A, Uutela A. Edentulism among Finnish
adults of working age, 1978-1997. Community Dent Oral Epidemiol 1999; 27:353-65.
Zitzmann NU, Hagmann E, Weiger R. What is the prevalence of various types of prosthetic
dental restorations in Europe. Clin Oral Impl Res 2007; 18:20-33.
31

2
Anatomy of the oral cavity
P E r s tå l
INTRoDucTIoN. A good knowledge of the anatomy of the oral cavity and function of sur-
rounding structures is fundamental in constructing removable dentures. The retention and
stability of removable dentures are intimately related to the condition of the oral mucosa,
number of remaining teeth, skeletal framework of jaws and the degree of bone resorption.
Structures such as frena, ligaments, nerves, glandular tissue and openings of the saliva ducts
into the mouth should be identified to establish their precise relation to the denture base.
The form and function of dentures should support and not interfere with natural oral func-
tions. It is very important to understand position and action of muscles as well as joint and
jaw movements, since the dentures should be stabilized rather than displaced during oral
activities. Sometimes, surgical corrections must be made to optimize retention and stability
of the dentures. This requires specific knowledge of the anatomy of both hard and soft tissue
in the oral cavity. This chapter is an overview of anatomical structures and landmarks of pros-
thetic importance.
Tempomandibular joint ten patients adapt with little consequence

Adequate functions of tempomandibular and the joint structures rebuild to fit the
joints (TMJs) are essential for the stability new position. The TMJ is a synovial hinge
and function of dentures in prosthetic joint that permits movements in three
rehabilitation. An existent joint dysfunc- planes. The bony parts of the TMJ are
tion may impair the outcome of treat- made up of the condylar process of the
ment. Internal causes to TMJ dysfunction mandible, the articular tubercle of the
may be occlusal disharmonies due to temporal bone and the mandibular fossa
missing and not replaced teeth and due to (Fig. 2.1 and 2.2).
the fact that TMJs are susceptible to many An avascular layer of highly resistant
of the conditions that affect other joints fibrocartilage covers the articular surfaces
in the body, including arthrosis and ar- of the joints that are directly subjected to
thritis. The prosthetic treatment can also load-bearing pressure. A fibrosus articu-
cause TMJ problems, since corrections in lar disc divides the joint cavity into two
occlusal condition can affect joint func- separate synovial compartments. The disc
tion and lead to pain. However, most of- is curved to fit the bony joint surfaces and
33

A B
Fig. 2.1. Mandible A. lateral view B. medial view.
A B
Fig. 2.2. Sagittal view of the tempomandibular joint (TMJ) A. Anatomy with the mouth closed.
B. Anatomy with mouth open.
its anterior part is attached in the margin the posterior margin of the condyle. The
of the condyle and to the superior portion joint is surrounded by a thin lose capsule
of the lateral pterygoid muscle. Posteriorly of collageneous tissue that attaches to the
the disc becomes bilaminar and the upper margins of the articular area on the tem-
part attaches to the posterior walls of the poral bone and around the neck of the
mandibular fossa and the lower part to mandible. When the mandible is opened
34 Anatomy of the oral cavity

more than when you just separate the up- and stabilize rather than dislocate the
per and lower teeth, the head of the man- dentures. In the optimal situation, the
dible and articular disc move anteriorly dentures should occupy a space, termed
(by translation) on the articular surface the neutral zone, where all muscular
until the head lies inferior to the articular forces acting on them will be in harmony,
tubercle. If the translation occurs unilat- between lips and cheeks on the one side
erally, the condyle on the retracted side and the tongue on the other. Importantly,
rotates, permitting side to side chewing or the jaw muscles are sensitive to acute
grinding. During protrusion or retrusion changes in occlusion, which can create
of the mandible, the condyle and articu- muscle co-contraction response leading to
lar disc on both sides slide anteriorly or muscle and joint pain and disturbed pat-
posteriorly on the articular surface of the terns in jaw movements.
temporal bone.
Muscles of mastication
Muscles The muscles of mastication are a collec-
Forces developed through muscular tive term for four pairs of muscles that
contraction during various functions of pass from the skull to the mandible, the
chewing, speaking and swallowing influ- masseter, the temporalis and the medial
ence the stability of dentures. The muscu- and lateral pterygoid. Although many
lature of the denture space can be divided muscles, both in head and neck, are in-
into muscles, which primarily dislocate volved in mastication, these muscles are
the denture during activity, and those responsible for the main power in jaw
that fix the denture by muscular pressure. movements. The masticatory muscles also
The denture surfaces must be shaped so act in a number of other important func-
that the surrounding muscles act to fix tions such as swallowing, breathing and

Fig. 2.3. Muscles of mastication.
Anatomy of the oral cavity 35

Muscle origin Insertion Main action
Masseter
superficial portion Anterior part of Lower lateral surface Elevation and protru-
zygomatic bone of ramus of mandible sion of mandible.
deep portion Posterior part of upper lateral surface Elevation
zygomatic arch of ramus of mandible
Temporalis Temporal bone and Coronoid process of Elvation and retru-

temporal fascia mandibula sion of mandible
Medial pterygoid Medial surface of Medial lower surface Elevation and side to
lateral pterygoid and of ramus of mandible side movements of
tuberosity of maxilla the mandible
Lateral pterygoid Capsule and articular Acting bilaterally;

superior head Roof of infratemporal disc of TMJ and the protrusion of the
fossa neck of mandible. mandible. Acting
inferior head Lateral surface of Pterygoid fovea on unilaterally; side
pterygoid process the neck of mandible movements of the
mandible
Table 2.1. Masticatory muscles.
sound production. For location, muscle insert upon the upper half of the ramus.
attachments and actions of the mastica- Depending on the anatomy of muscle and
tory muscles see table 2.1 and figure 2.1, bones, the masseter muscle may bulge
2.2, 2.3. into the inferior sulcus on the distobuccal
Actions of the masseter and to a lesser flange of the denture during contraction.
extent the temporalis and medial ptery- Overextension of lower dentures in the
goid muscles may destabilize dentures molar region may result in displacement.
with an incorrect shape. The temporalis muscle has a wide
The masseter muscle consists of a su- origin from the surface of the temporal
perficial portion and deep portion. The bone and the deep temporal fascia. The
superficial part arises from the anterior posterior muscle fibres pass horizontally
lower border of the zygomatic bone and forwards and the anterior fibres vertically
passes obliquely downward and backward down towards their tendinious insertion
to insert into the lower half of the lateral on the tip and medial surface of the coro-
side of the mandibular ramus. The deep noid process and anterior border of the ra-
portion arises from the inner surface mus of the mandible. When the mouth is
and lower border of the zygyomatic arch closing, muscle fibres attached low down
and passes nearly vertically downward to on the mandible might interfere with

Levator labii superioris
alaeque nasi
Levator labii superioris
Zygomaticus minor Levator anguli oris

Zygomaticus major Buccinator
Risorius
Modiolus
Platysma
Orbicularis oris
Depressor anguli oris
Depressor labii inferioris

Mentalis
Fig. 2.4. Oro-facial muscles.
dentures that have an incorrect extended oro-facial muscles

distal flange. The muscles of the face, sometimes re-
The medial pterygoid muscle runs al- ferred to as muscles of facial expression,
most parallel to the masseter, but on the surround and control the apertures of the
medial side of the mandibular ramus. The eyes, nose and mouth. The face muscles
muscle arises from the pterygoid plate are not attached to the skeleton at either
of the sphenoid bone, the palatine bone, end and some lie directly subjacent to the
and the tuberosity of the maxilla and in- freely movable skin with muscle bundles
serts into the lower medial surface of the inserting into the subcutaneous tissue
ramus of the mandible. Sometimes, small or the cutis. The muscles surrounding
muscle bundles insert more anteriorly on the oral cavity cause additional retentive
the mandible and to the posterior fascia forces on dentures by resting and acting
of the mylohyoid muscle. Lower dentures against its surfaces. Oro-facial muscles of
with posterior overextended lingual significance in fixation of the dentures
flange may interfere with these muscle are the muscles of the lips, the orbicularis
bundles. oris, and the muscular component of the
The lateral pterygoid muscle is located cheek, the buccinator. The major muscles
on the medial side of the mandibular ra- involved in dislocation of dentures are
mus and has a superior and inferior head, the mentalis muscle. For location, attach-
which insert into the articular capsule ments and actions of oro-facial muscles
of the TMJs, the articular disc, and the see table 2.2 and figure 2.4.
superior part of the mandibular neck (Fig. The orbicularis oris muscle lacks skele-
2.2 and 2.3). Since the lateral pterygoids tal attachments and surrounds the open-
are involved directly in TMJ movements, ing of the mouth in a sphincter like man-
muscle dysfunction may affect the stabil- ner. The dentures should be constructed
ity of dentures. so that the tongue balances forces gener-

Muscles of the lips
Orbicularis oris Surrounding muscles, Forms an ellipse Closes, purses and pro-
maxilla and mandible around mouth trudes lips
in the midline
Angle of the mouth
Buccinator Pterygomandibular Blends with or- Compresses check

raphe, alveolar pro- bicularis oris and
cesses of mandible into lips
and maxilla
Risorius Fascia over masseter Skin at the corner draws corner of mouth
muscle of mouth laterally
Elevators of the lip
Levator labii superio- Frontal process of upper lip at dilitates nares and el-
ris alaque nasi maxilla philtrum evates upper lip
Levator labii supe- Maxilla below the Skin of lateral half Elevates upper lip
rioris infraorbital margin of upper lip
Levator anguli oris Canine fossa of max- Corner of mouth Lifts corner of mouth,
illa helps form nasolabial
furrow
Zygomaticus minor Anterior part of zygo- upper lip me- Elevates upper lip
matic bone dial to corner of
mouth
Zygomatic major Temporal process of Skin at the corner Lifts corner of mouth
zygomatic bone of mouth upward and laterally
Depressors of the lip
depressor anguli oris Oblique line of man- Skin at the corner draw corner of mouth
dible of mouth and down and laterally
blending with
orbicularis oris
depressor labii infe- Anterior part of Lower lip, blends draws lower lip down-
rioris oblique line of man- with nuscle from ward and laterally
dible opposite side
Mentalis Incisive fossa of man- Skin of chin Wrinkles chin and and
dible protrudes lower lips
Table 2.2. Oro-facial muscles.

ated by the lips during the contraction directly into the upper or lower lips while
of this muscle. The muscles that elevate others cross to form a chiasma with other
or depress the lips originate from bony face muscles, the modiolus, near the an-
structures and blend into the orbicularis gle of the lips (Fig. 2.4). Failure to contour
oris muscle. These elevator muscles raise the buccal flange of lower dentures in the
the lip and the corner of the mouth, premolar region to accommodate with
protrudes the upper lip and deepens the the activity of the modiolus might result
furrow between the nose and the corner in displacement of the denture. The buc-
of the mouth. The main actions of the cinator muscle arises from the buccal side
depressor muscles are to lower the lip and of the maxillary and mandibular alveoli
corner of the mouth and move it laterally. in the molar region and posteriorly from
The mentalis muscles arise from the a tendinoius band, the pterygomandibu-
mandible just inferior to the incisor teeth, lar raphe (Fig. 2.6). This tendinious band
and pass down to insert in the skin of extends from the pterygoid hamulus
the chin. The muscle raises the labial of the sphenoid bone to the mylohyoid
sulcus and protrudes the lower lip as it crest of the mandible and separates the
wrinkles the skin of the chin. Depth and buccinator from the superior pharyngeal
space of the oral vestibule is considerably constrictor muscle that surrounds oro-
decreased during this action. When the pharynx. Contraction of the buccinator
edentulous mandible is severely resorbed, presses the cheek against the teeth to
the muscle may cause displacement of the keep the cheek taut and prevent the food
denture, since the muscle insertion is of- from accumulating between the teeth
ten close to the crest of the residual ridge. and cheek during mastication. The pres-
The principle muscle of the cheek, the sure from the buccinator can be used for
buccinator, merges anteriorly with the additional retention of dentures.
orbicularis oris muscle. Some fibres run
Styloid
process
Stylohyoid muscle
Styloglossus Posterior belly of
Genioglossus digastric muscle
Hyoglossus Hyoid bone
Mylohyoid muscle
Hyoid bone Infrahyoid muscle
Geniohyoideus Anterior belly of
digastric muscle
A
B

Fig. 2.5A. Lateral view of extrinsic tongue muscles and geniohyoideus muscle B. Lateral view of
suprahyoidal muscles.

Muscles of the tongue and ful and it is important that the dentures
floor of the mouth are formed so that the forces generated by
The tongue is a muscular organ of consid- the tongue do not dislocate the dentures.
erable significance in most oral functions. In correctly formed dentures, the tongue
The motion of the tongue can be power- has a strong advantageous influence on
Genioglossus Mental spine of man- Entire length of Protrudes tongue,

dible tongue, hyoid depresses centre of
bone tongue
Hyoglossus Hyoid bone Lateral surface of depresses tongue

tongue
Styloglossus Styloid process of Lateral surface of Retracts tongue and

temporal bone tongue elevates its margins
Palatoglossus Palatine aponeurosis Lateral margin of depresses palate, moves

tongue palatoglossal fold to-
ward midline, elevates
root of tongue
Mylohyoid Mylohyoid line of the Median raphe, the depresses mandible

mandible hyoid bone when hyoid bone is
fixed, elevates tongue
and hyoid bone when
mandible is fixed
Geniohyoiod Mental spine of man- Body of hyoid draws hyoid bone an-
dible bone teriorly
Anterior belly of di- Mastoid notch of Intermediate ten- Raises hyoid bone ante-
gastric temporal bone don to body of riorly, opens mandible
hyoid bone when hyoid bone is
fixed
Posterior belly of digastric fossa of Intermediate ten- Raises hyoid bone pos-
digastric mandible don to body of teriorly
hyoid bone
Stylohyoid Stylohyoid process Body of hyoid draws hyoid bone pos-

bone teriorly and superiorly
Table 2.3. Extrinsic tongue muscles and suprahyoid muscles.

denture lateral stability during chewing of the mouth. Lower dentures with incor-
and biting. Two groups of tongue muscles, rect extended lingual flange can interfere
the extrinsic and intrinsic muscles, al- in the act of swallowing and destabilize
low for precise changes in both position the dentures.
and shape of the tongue. The extrinsic
muscles arise from nearby bone structures Muscles of the soft palate
and insert from different directions into The muscles of the soft palate forms a
the body of the tongue. The main action valve that can depress and close the open-
of these muscles is to move the tongue ing to the pharynx or elevate and stretch
body and to some extent alter its shape. the valve to close the nasal passage to the
For location, attachments and actions of pharynx. These functions are important
the extrinsic tongue muscles, see table 2.3 to the act of swallowing, breathing and
and figure 2.5. speech. Upper dentures with incorrect
The genioglossus muscle raises the distal shape might disturb these func-
floor of the mouth when the tongue is tions and run the risk of being dislo-
protruded and styloglossus muscles lift cated. Two palate muscles, the tensor veli
the floor when the tongue is retracted. palatini and levator veli paltini muscles,
Lingual overextended lower dentures descend into the soft palate from the base
may be displaced during these actions. of the skull, and two other muscles, the
The anterior attachment of the muscle, palatopharyngeus and palatoglossus mus-
the mental spine or genial tubercle, may cles, ascend from the tongue and lateral
interfere with the dentures by becom- walls of the pharynx to form the arches
ing prominent and located higher than a of the palate. An overextended lingual
ridge with severe resorption. The intrinsic flange on mandibular dentures might
tongue muscles lack bony attachment interfere with the action of the anteriorly
and comprise the main part of the tongue positioned palatoglossus muscle. The
body. Their muscle fibres run both paral- uvula muscle descends backwards from
lel and perpendicular to the tongue’s long the posterior nasal spine to form the bulk
axis and may thereby alter its shape in all of the uvula. The soft palate is strength-
directions. ened by the palatine aponeurosis, formed
The main muscle forming the mo- by the expanded tendon of the tensor veli
bile floor of the mouth is the mylohyoid palatini, to which other palate muscles
muscle (Fig. 2.5). The muscle takes origin attach. When the palate moves during
from the mylohyoid ridge of the mandible swallowing and yawning, the tensor veli
and insert to a median raphe extending palatini tenses the soft palate and opens
from the hyoid bone to the middle infe- the pharyngotympanic tube to equalize
rior margin of the mandible. When the the pressure between middle ear and at-
mandible is fixed during swallowing, this mosphere. The dentures should be shaped
muscle elevates the tongue and the floor in such a way that they not interfere with

Fig. 2.6. Palate dissected to show muscles of the soft palate.
Tensor veli palatini Sphenoid bone, Palatine aponeurosis Tenses soft palate
fibrosus part of pha- and opens the pha-
ryngo-tympanic tube ryngo-tympanic tube
Levator veli palatini Petrosus part of tem- Palatine aponeurosis Elevates soft palate
poral bone
Palatoglossus Palatine aponeurosis Lateral margin of depresses palate,

tongue moves palatoglossal
fold toward midline,
elevates root of
tongue
Palatopharyngeus Palatine aponeurosis Lateral wall of phar- depresses palate,

ynx moves palatoglossal
fold toward midline,
elevates pharynx
uvula Posterior nasal spine, Connective tissue of Shortens uvula and

palatine aponeurosis uvula pulls it superiorly
Table 2.4. Muscles of the soft palate.

Fig. 2.7. Anatomy of the lips and adjacent area in the face.
Uvula
Palatopharyngeal arch
Palatoglossal arch
Posterior wall of oropharynx Pterygomandibular fold

Foramen caecum Palatine tonsil
Terminal groove
Dorsum of tongue
Papillae vallate
Median groove
Labial frenulum
Fig. 2.8. Structures of the oral cavity.
the natural functions of the soft palate. cial muscles, gives contour to the cheek in
For location, attachments and actions of the anterior region. As we age, the volume
palate muscles, see table 2.4 and figure 2.6. of fat in the face decreases, particularly
the buccal fat pad. The volume loss of the
oro-facial region cheek will be more accentuated in eden-
The thin and pliable skin covering under- tulous patients, since teeth and bones do
lying bones, teeth, muscles, glands and not support cheeks and lips. The lips, the
subcutaneous tissue determines the basic mobile anterior walls of the mouth, en-
shape of the face (Fig. 2.7). A thick buccal close the orbicularis oris muscle, connec-
fat pad, which is partly covered by the fa- tive tissue, vessels, nerves and glands. The

A

B
Fig. 2.9A. Roof of the mouth B. Floor of the mouth.
red portion of the lips, whose coloration corner of the lips, the labial commisure, is
is caused by a rich vascular bed visible usually adjacent to the maxillary canine
through the thin epithelium, is termed and mandibular first molar. Loss of max-
the vermillion zone. The sharp demar- illary teeth can cause sunken cheeks and
cation between the red of the lip and dropped angle of the mouth. In the upper
normal skin is the vermillion border. The lip the vermillion forms a distinct labial

tubercle in the midline. Medially above is drastic, the mental foramen on the
the upper lip is philtrum, a depression mandible may be located below the mu-
extending from the labial tubercle to the cosa on the crest of the alveolar process.
septum of the nose. Rehabilitation with Relief of the denture is necessary to avoid
upper dentures can change the profile of excessive pressure on the nerves and ves-
philtrum and lips. The upper lip is sepa- sels that exit through the foramen. Com-
rated from the cheek by the nasolabial pression might result in paresthesia in the
sulcus, a furrow extending from the wing lower lip. For structures of the oral cavity,
of the nose to the corner of the mouth. see figure 2.8 and 2.9.
The lower lip is visually seperated from
the chin by the mentolabial sulcus. The oral vestibule and cheeks
furrows in the face become more promi- The labial frenulum is a small mucosa
nent during aging and loss of teeth, but covered fold in the centre of the upper
can be restored by proper construction of and lower oral vestibule. It extends from
the dentures. the alveolus gums or residual ridge to
the inner surface of the lip. Although the
oral cavity movements of the fold are passive, ade-
The oral cavity consists largely of two quate relief in the denture base is needed.
parts, the outer oral vestibule and the in- The laterally situated buccal frenulum
ner oral cavity proper. The oral vestibule varies more in shape and form and con-
is the space between lips and checks and nects the alveolar ridge to the cheeks in
upper and lower dental arches. The oral the region of the canines and premolars.
cavity proper is the space inside the teeth Since the action of surrounding oro-facial
and it communicates in the posterior muscles strongly influence the position
region by the oropharyngeal isthmus, of the buccal frenula, the corresponding
the opening to the pharynx. The gingiva buccal notch on the dentures must al-
(gums) cover the alveolar bone of the low for full range of movements, or the
maxilla and mandible. The gingiva can muscle actions will dislodge the denture.
anatomically be divided into the kerati- The structures of cheeks and lips are
nized attached gingiva that are tightly continuous and they functions as an oral
bound to the underlying periosteum of sphincter that pushes food from the oral
alveolar bone and the unattached free vestibule in between the occlusal surfaces
or marginal gingiva that surround the of the teeth or into the oral cavity proper.
teeth. The gums are continuous with the The non-keratinized mucosa of the
mucosa of the oral vestibule and the roof cheek, which is well supplied by small
and floor of the mouth. The alveolar or buccal glands, is tightly bound to the
residual ridge is the remnant of the al- buccinator muscle. The duct of the largest
veolar process after natural teeth are lost. salivary gland, the parotid gland, enters
When the resorption of the alveolar ridge the mouth in the cheek opposite of the

second upper molar upon the parotid 2:10A). To avoid interference between up-
papilla. A ridge of bone, the oblique line, per dentures and coronoid process in the
forms a bony base on the mandible in upper oral vestibule during mouth open-
the posterior sulcus (Fig. 2.1). The line ing and side-to-side movements of the
extends from the mental tubercule and mandible, the distal end of upper buccal
progresses upwards until it becomes flange should be adjusted appropriately.
continuous with the anterior edge of the
ramus. The bone ridge is very faint until The roof of the mouth
it reaches the region of the molars, where The roof of the mouth, the palate, con-
it becomes prominent. In the edentulous sists of two components, the immobile
patient, the relatively broad area between hard palate and the movable soft palate
the residual ridge and the oblique line, (Fig. 2.9A). The hard palate, formed by the
the buccal shelf, is the primary bearing palatine process of the maxilla and the
area of lower dentures, especially when horizontal plates of the palatine bones, is
the remaining residual ridge is small. covered by a keratinized mucosa. A me-
Medial to the oblique line and distal dian longitudinal ridge, the median pala-
to the third molars is a shallow triangu- tine raphe, covers the median palatine su-
lar depression, the retromolar triangle of ture in the hard palate. The submucosa is
the mandible. Distal in the triangle lies very thin and firmly attached to the bone
a freely movable mass of fibrosus tissue over the raphe. This is the part of the pa-
and mucous glands, the retromolar pad. late most sensitive to pressure and relief
After loss of the most posterior molar, should be provided when it is covered
the scarring tissue often forms a distal by a denture. A bony prominence, torus
pear shaped pad. Covering the pads with palatinus, is sometimes seen in the centre
the denture base can reduce the rate of of the palate and may require removal
alveolar ridge resorption. The pads may before dentures can be constructed. At
also be used as a guide for determining both sides of the median palatine raphe
the plane of occlusion, since the position lies a mass of submucous soft tissue that
of the pads remains constant even after contains fat, salivary glands and some
loss of teeth. From the area of the retro- taste buds. This area is the primary sup-
molar triangle a fold of mucosa extends port area for maxillar dentures.
to the point at which the hard and soft Anteriorly in the midline behind
palate meet, the pterygomandibular fold. the maxillar incisors is a distinct oval
This movable fold, which covers the ten- prominence, the incisive papilla. The in-
dinous connection between the buccina- cisive papilla overlies the incisive canals
tor and superior constrictor muscle, may through which nerves and vessels enter
be prominent and a relief groove on the to the hard palate. If this area is not re-
denture may be required to avoid pain lived, the denture may compress nerves
or dislocation of the dentures (Fig. 2.8, and vessels here, which may lead to pain

Medial pterygoid
Mandibula
Masseter
Superior pharyngeal
constrictor Pterygomandibular
raphe
Buccinator
A
Sublingual fold
with openings
Medial pterygoid
Sublingual papilla
Sublingual gland
Genioglossus Lingual nerve
Submandibular duct
Geniohyoid Submandibular gland
Mylohyoid
Hyoid bone
B
Fig. 2.10A. View of the raphe pterygomandibularis and connecting muscles. B. Medial view of the floor
of the mouth.
and parasthesia of the anterior palate. The and to aid proper function of the tongue
papilla is generally located in the exact in sound production.
midline of the palate and can therefore be Immediately posterior to the region
used as a reliable guide for determining of maxillary last molars is a firm tissue
the midline relationships of upper ante- bulge over the alveolar bone ridge, called
rior denture teeth. From the incisive pa- the maxillary tuberosity, which is present
pilla and the anterior part of the palatine even after all molar teeth are lost. This tu-
raphe radiate numerous somewhat trans- berosity is considered to be an important
verse palatine elevation folds, the palatine area for denture support and retention.
ruga or transverse palatine ridges. The The hamular notch, a depression in the
function of the ruga may be to allow tac- mucosa located posterior to the maxil-
tile sensing of objects or food positioning lary tuberosity, is the posterior boundary

of the denture base in this region. The cosa and comprises mainly of the mus-
posterior border of the denture should cles that control position of the tongue,
not extend further because it will cause two pairs of salivary glands and nerves
pressure on the pterygoid hamulus, and and vessels. The sublingual sulcus, the
will interfere with the action of the ptery- broad space in between the tongue and
gomandibular raphe that moves forward mandibular gingiva, contains two large
as the mouth is opened. salivary glands, the submandibular and
Muscles, fat, connective tissue and sublingual glands with their associated
salivary glands mainly form the mov- ducts (Fig. 2.10B). In the oral cavity, the
able soft palate. The imaginary line that submandibular glands are located in the
marks the division between the movable posterior region of the sublingual sulcus,
and immovable tissues in the palate is in between the mandible and hyoglossus
defined as the vibrating line (Fig. 2.9A). It muscle of the tongue. The submandibular
is not necessarily the junction of the hard duct arises from the gland and opens on
and soft palates, but marks the motion of the summit of a small sublingual papilla
the soft palate. Dentures with a posterior (caruncula) in the midline of the floor.
extension largely above this line might The sublingual gland lies more anteriorly
affect soft palate function and run the above the mylohyoid muscle in the region
risk of being displaced. Near the midline between mandibular sublingual fossa and
and just posterior to the hard palate is the the extrinsic genioglossus tongue muscle.
palatine fovea, a small depression or pit The superior margin of the glands rises as
that receives the orifices of ducts of some an elongated fold of mucosa in the sub-
of the palatine glands. The denture base lingual sulcus, the sublingual fold. The
can normally extend slightly across the gland secretes saliva via numerous small
fovea. The free posterior border of the soft sublingual ducts, which open to the floor
palate, palatine velum, terminates in the of the mouth along the lingual folds.
midline in the uvula (Fig. 2.8). Extend- The mylohyoid ridge, the attach-
ing laterally from the free border of the ment for the mylohyoid muscle, runs
soft palate is the palatoglossal and more along the lingual surface of the mandible
posteriorly positioned palatopharyngeal (Fig. 2.1B). When the alveolar ridge is
arches, which covers the palatoglossal and resobed, the muscle attachment to the
palatopharyngeus muscles. In between the mylohoid ridge is often quite high on the
palatine arches are the palatine tonsils, a mandible. Since the ridge is often sharp
collection of lymphoid tissue of variable and the mucosa covering the ridge thin,
size that is likely to atrophy in the adult. it may become traumatized and therefore
the dentures may need to be adjusted to
Tongue and floor of the mouth relieve pressure. The undercut below the
The movable floor of the mouth is cov- ridge can be used to increase retention
ered by a lining of non-keratinized mu- of the denture. In the premolar region of

lingual sulcus, developmental bony swell- mucous membrane, the lingual frenulum,
ings, mandibular tori, are occasionally extends from the midline of the inferior
seen. To provide optimal stability of lower surface of the tongue to the floor of the
dentures these structures may need to be mouth (Fig. 2.9B). When the tip of the
removed surgically. tongue is lifted, the lingual frenulum will
The tongue is a muscular organ cov- become passively stretched and lifted. To
ered by a mucous membrane that con- avoid dislocation of dentures, the anterior
tains papillae, taste buds, salivary glands part of the lingual denture flange must be
and lymphatic tissue. The role played shaped to allow for the full function of
by the tongue in denture retention is the lingual frenulum.
to locate the denture by means of tac-
tile sensation and to support the forces Final remarks
counteracting denture dislodgement. If It is important to understand that ana-
there are many missing teeth in the lower tomical variations exist. Structures de-
jaw and if prosthesis is not applied, the scribed in the text in this chapter do not
tongue may tend to grow towards the always conform exactly to the anatomy
spaces in the jaw. An enlarged tongue will observed in patients. Major structures
deteriorate the stability of the prosthesis may not vary much, but in finer details
and make the outcome of rehabilitation variation clearly exist. For example, the
with partial denture more unceratin. In individual processes on the bones and
the posterior region, the upper surface their relationships are not always con-
of the tongue is divided by a V-shaped stant from one individual to another and
groove, the terminal groove (sulcus) some muscles may display slightly dif-
(Fig. 2.8). The superior surface of the body ferent origins, insertions, and tendons.
of the tongue has a characteristic rough Moreover, ageing and disease might af-
appearance because of the presence of fect form and location of both hard and
numerous papillae. The posterior part of soft tissue structures in the face and oral
the tongue has no lingual papillae, but cavity. In prosthetic rehabilitation, it is
the underlying nodules of the lingual of great importance to recognize ana-
lymphatic follicles give this part of the tomical variations and to interpret the
tongue its rough appearance. The inferior significance of these variations for the
surface of the tongue is covered by a non- proper construction and function of the
keratinized mucosa that is tightly bond dentures.
to the underlying muscles. A small fold of
Further reading
Moore KL, Dalley AF, Abur AMR. Clinically Oriented Anatomy, 6th ed, Lippincott Williams &
Wilkins, 2010.

3
The biology of bone remodelling in
jaw bones with and without teeth
U l f H. l E r n E r
INTRoDucTIoN. Bone tissues, together with enamel, dentin and cementum, are unique tis-
sues in the human body because of the presence of large amounts of mineral crystals in the
extracellular matrix. It is a common misconception that mineralized tissues of the body are
dead tissues with the only task of forming the skeleton and the teeth. However, bone tissue is
a living organ with different cell types that have important functions for mineral homeostasis
and for remodelling as well as modelling of the skeleton in order to renew it and to adapt to
functional demands.
Two morphologically distinct bone tissues make up all bones; the cortical bones in the
periphery and the network of trabecular bone in the inner part of the bones. Some bones
have only small amounts of trabecular bone, whereas others are filled up more densely. It is
not known why some osteoblasts are producing cortical bone and others trabecular bone.
Interestingly, trabecular bone is more frequently remodelled. This is the reason why meta-
bolic bone diseases, such as osteoporosis, affect bone with large amounts of trabecular bone
more severely. Much remains to be understood about the different processes of bone forma-
tion, how it is controlled and why we have two types of bone. Although the general view is
that all osteoblasts and osteoclasts in the body are very similar, it has become clearer during
recent years that a substantial heterogeneity exists in osteoblasts and osteoclasts present in
different bones. Most studies are performed on bone cells isolated from calvarial bones and
long bones and very few from jaw bones. This is important, since the biology of osteoblasts
and osteoclasts in maxilla and mandible is not necessarily similar in all aspects to the one ob-
served in cells from other areas.
This chapter presents a brief summary of bone cell biology, bone remodelling and mo-
delling including the effects by inflammatory processes on bone cell activities and, finally,
summarizes the relatively spare information available on bone remodelling in the vicinity of
removable prosthetic dentures.
51

Bone cells mesenchymally derived cells, osteoclasts
Bone tissue is produced by osteoblasts originate from hematopoetic stem cells
which is a cell type very closely related derived from white blood cells, namely
to fibroblasts, odontoblasts and cemento- the type of white cells which can give rise
blasts. These cells originate either from to either macrophages, dendritic cells in
mesenchymal stem cells, multipotent the immune system or osteoclasts.
stromal cells in bone marrow or from
premature mesenchymal cells in the Bone formation
periosteum. The stromal cells, which are Bone tissue consists of the organic bone
present together with all the blood form- matrix impregnated with hydroxyapatite
ing cells in bone marrow, are multipotent crystals. The osteoblasts are responsible
cells which can differentiate not only to both for the synthesis of bone matrix and
osteoblasts but also to adipocytes and un- the formation of the mineral crystals. The
der some circumstances also to chondro- matrix consists mainly (90%) of type I
cytes or muscle cells. collagen fibers, exactly the same type of
During the bone formation process, fibers which fibroblasts in the oral mu-
some of the osteoblasts will be incorpo- cosa or skin are synthesizing and which
rated in the bone tissue and will make odontoblasts are producing for dentin
up the large population of osteocytes, the formation. What makes the bone extracel-
most common bone cell. These cells are lular matrix unique is the presence of very
present inside bone tissue and have very many different so-called non-collagen
many cellular extensions through which proteins in bone, a large and still increas-
they communicate with each other and ing family of proteins to which e.g. os-
with osteoblasts on the surface of bone. teocalcin, osteopontin, bone sialoprotein
The function of osteocytes is still elu- belong. Although some details about the
sive, although evidence indicates that crystallization process are known, it is
they may be the cells that sense load on still essentially unknown how osteoblasts
the skeleton and transmit this signal to (and also odontoblasts, cementoblasts,
the bone forming osteoblasts. The most ameloblasts) can control the formation of
uncommon bone cell is the osteoclast, a mineral crystals.
multinucleated giant cell which is the It is well known that adequate con-
only cell which can degrade or resorb centrations of calcium and vitamin D are
bone. In its fully differentiated state, oste- important and that the enzyme alkaline
oclasts are only present on the surface of phosphatase plays a crucial role for forma-
bone. The mononucleated osteoclast pro- tion of bone and maintenance of bone
genitor cells, from which the osteoclasts mass. In clinical practise, the levels in
are formed, are present in hematopoetic blood of this enzyme can be used to assess
tissues, blood circulation and periosteum. the degree of bone formation in patients.
Whereas osteoblasts and osteocytes are As will be discussed in more detail
52 The biology of bone remodelling in jaw bones with and without teeth

A B
Fig. 3.1. Bone can only be resorbed by multinucleated osteoclasts formed from mononucleated progenitor cells
originating from hematopoetic stem cells. A. The multinucleated osteoclast adheres to bone tissue using a
sealing zone in a restricted area of the cell membrane. Once the intimate contact is created, the cell membrane
area between the sealing zones develop a ruffled border and this area constitutes a sealed compartment with
a unique environment in which the resorption process takes place. By secreting protons and chloride ions into
this area, osteoclasts create such a low pH that the hydroxyapatite crystals will be dissolved, making the bone
matrix proteins accessible for a cocktail of proteolytic enzymes released. When the proteins have been degrad-
ed, a Howship´s lacuna is created and the bone tissue is completely resorbed. The osteoclasts then continue
the process deeper into mineralized bone whereby a larger resorption lacuna is created. B. All blood cells are
formed from the hematopoetic stem cells in bone marrow, including a subset of leukocytes, which can differ-
entiate either to macrophages, dendritic cells or osteoclast progenitors. The latter cells can finally differentiate
into mononucleated cells, which fuse into a multinucleated osteoclast.
below, osteoblasts are not only responsible attaching to bone surfaces via a sealing
for bone formation; they are also the cells zone in the cell membrane (Fig. 3.1A).
which control osteoclast formation. Then, the area of the osteoclastic cell
membrane next to bone develops a ruf-
Bone resorption fled border and in this ruffled border a
The only cells in nature which can resorb proton pump is expressed which, together
bone are the osteoclasts. They do so by with an osteoclast specific chloride chan-
The biology of bone remodelling in jaw bones with and without teeth 53

nel, produces hydrochloric acid extracel- activator of NF-kB ligand), which creates
lularly in the ruffled border region. The the unique signal for osteoclast differ-
low pH created dissolves the mineral entiation. Signalling through these two
crystals and then the extracellular matrix receptors will turn on a cascade of genes
is exposed and can be degraded by pro- important for the differentiation of the
teolytic enzymes released from the osteo- mononuclear cells and for their final fu-
clasts to the extracellular environment. sion to active osteoclasts.
The loss of minerals and matrix will lead
to the formation of a Howship´s resorp- osteoblast control
tion lacuna underneath the osteoclasts. initiation of bone
Thus, breakdown of bone is not only a resorption
demineralization process, but it involves It has been shown that most hormones
loss of both mineral crystals and bone and cytokines, which can activate bone
extracellular matrix, i.e. total disappear- resorption, do not stimulate the osteoclast
ance of bone tissue. progenitor cells. Instead, common to all of
Regulation of bone resorption is most- them is that they initially activate osteo-
ly dependent on formation of new osteoblasts. When this was first found during
clasts locally in the area to be resorbed. the early 1980s it was hard to understand
The formation of these multinucleated what role osteoblasts might play in bone
cells is dependent on several interactions resorption. Only in the past ten years have
between different cells and many com- the molecular events been discovered.
plicated signalling mechanisms in the When a hormone or a cytokine initi-
mononucleated progenitor cells, which ates the bone resorptive process it binds
will only be very briefly outlined here. It to its specific receptors in either stromal
is now well established that osteoclasts cells in bone marrow or osteoblasts in
are derived from a myeloid precursor cell periosteum. This will turn on the gene for
which may either become a macrophage, RANKL. In parallel, the gene for OPG (an
a dendritic cell in the immune system, inhibitor of RANKL) will be turned down
or osteoclasts, depending on which tran- and thereby the amount of RANKL, which
scription factors (intracellular proteins can activate RANK on mononucleated os-
which are responsible for turning on teoclast progenitors, will be enhanced.
genes) are activated (Fig. 3.1B). For such a
progenitor cell to become an osteoclast, Bone remodelling and
the receptor c-Fms has to be stimulated by modelling
M-CSF (macrophage colony-stimulating Osteoclasts are not only cells involved
factor) to expand the number of cells in bone loss due to diseases such as peri-
and to increase their survival. Equally odontitis, periimplantitis, rheumatoid
important is the activation of the recep- arthritis, orthopaedic prosthesis loosen-
tor RANK by its ligand RANKL (receptor ing and osteoporosis, but also cells most

A
B
c
D

Fig. 3.2. Bone tissue in all bones of the skeleton is continuously removed and rebuilt by a process called
remodelling. It is not known which molecules initiate remodelling during physiological conditions. However,
very many molecules have been identified as initiators in pathological conditions such as periodontitits,
rheumatoid arthritis and metastases of malignant tumours. Remodelling starts by initiating processes in
osteoblasts (A). This forces these cells to stop making bone. Instead they express molecules that stimulate os-
teoclast formation and activity. They then leave the area and the multinucleated osteoclasts formed attach
to bone and creates a Howship´s lacuna (B). Eventually, the osteoclasts cease resorbing bone and leave the
area. However, coupling factors are released during the resorption phase and this stimulates recruitment of
osteoblast progenitors to the resorption lacunae and enhances their bone forming activity (C). Remodelling
is completed when osteoblast have filled up the resorption lacunae with new bone (D).
important for physiological modelling mation in the area resorbed (Fig. 3.2).
and remodelling of the skeleton and for It does not change size or shape of the
release of calcium from the skeleton in bones and is important for the removal of
mineral homeostasis. damaged bone. The remodelling of bone
Modelling of bone occurs when osteo- is a life-long process and results in a 10%
clasts resorb bone without subsequent renewal of the skeleton each year.
bone formation, or when ostoblasts form Not only modelling and remodelling
bone without preceeding bone resorption. determines bone mass, but it is also af-
Modelling is important for bone size and fected by the amount of bone formed dur-
for the shape of the bones. It also prevents ing younger years. Bone mass increases up
damage by adapting bone structure to to the age of 20 and this amount of bone
loading and it is regulated by genes and are called peak bone mass. Bone mass is
by loading. Remodelling is a process where related to genetic factors, nutrition during
bone resorption is followed by bone for- growth and development and to physical

activities. There is much concern that the osteoporosis in jaw bones
reduced physical activities in childhood Osteoporosis is defined by WHO as a
during the latest decades will reduce peak systemic skeletal disease characterized by
bone mass and that, therefore, primary low bone mass and microarchitectual dis-
osteoporosis will be more severe in the fu- turbances in trabecular bone, leading to
ture. Loading of the skeleton is an impor- increased bone fragility and increased risk
tant mechanism to preserve bone mass, for skeletal fractures. A lifetime risk of ex-
well illustrated by the fact that weightless hibiting an osteoporotic fragility fracture
astronauts and patients in bed for a long at the age of 50 is 46% for a woman and
time loose substantial amount of bone 22% for a man. For reasons unknown,
tissue in a short period of time. It is also osteoporotic fractures are most common
known that low physical activity will lead in Sweden and Norway. The most com-
to decreased amount of bone and that mon sites for osteoporotic fractures are
high physical activity will stimulate bone vertebrae, distal radius and hip. Such hip
formation. To what extent loading of fractures cause the most severe problems
the jaw bones is important to their bone due to their occurrence at older age and
mass is not known. It might be argued due to associated comorbidities. In Swe-
that these bones are not physically loaded den, 70,000 osteoporotic fractures occur
and that preservation of bone mass in each year.
skull bones is not dependent on load- The most common form of ostepo-
ing at all. For these reasons it is thought rosis is post-menopausal osteoporosis in
that bone mass in skull bones are mostly women due to decreased levels of estro-
controlled by genetic factors. It is largely gen. Not only estrogen defiency caused by
unknown which molecules generate the menopause will increase the risk for oste-
bone forming activity of osteoblasts due porosis, but also estrogen defiency due to
to increased loading and which molecules ovariectomy, excessive physical training,
will activate osteoclast formation in un- anorexia or cytostatic treatment increase
loading situations. Recently, however, the the risk for bone loss. Also elderly men
osteocyte unique protein sclerostin has may exhibit osteoporosis due to decreased
been found to be important to bone mass. testosterone as well as decreased bioavail-
Sclerostin expression is sensitive to load- able estrogen. Besides primary osteoporosis
ing and capable of regulating osteoblastic induced by sex hormone defiency, second-
bone formation. These observations cur- ary osteoporosis may be observed as a con-
rently have spurred large efforts for phar- sequence of pharmacological treatment
macological intervention. or as a comorbidity associated with very
many other diseases. The most common
form of secondary osteoporosis is caused
by treatment with corticosteroids.
The pathogenesis of estrogen defi-

ciency induced osteoporosis involves in periapical granuloma at the apices of
increased formation and activity of os- necrotic teeth, all will affect remodelling
teoclasts and subsequent excessive bone of the skeleton locally. This is because
resorption, as well as decreased bone inflammatory cells release an abundance
forming activity of osteoblasts. Both of signalling molecules called cytokines,
mechanisms lead to reduced bone mass. which primarily are important for regula-
Pharmacological intervention is usu- tion of the inflammation and immune
ally directed at inhibiting the resorptive processes. Some of these molecules may
events, but recently, intermittent treat- also interact with resident cells in the tis-
ment with parathyroid hormone has been sue in which the inflammatory process is
introduced to enhance the bone forming present. Thus, some cytokines have been
activity of osteoblasts. found to be able to interact with recep-
Whether or not osteoporosis may be tors in osteoblasts leading to enhanced
observed also in jaw bones is still an open expression of RANKL and M-CSF and
question. Circumstantial evidence argues thereby stimulation of osteoclast forma-
for both the existence of the disease as tion and bone resorption. There are other
well as for its absence in jaws. There is cytokines with the opposite effect, which
currently no ideal device or method for can inhibit osteoclast formation and it
assessing bone mass in jaw bones and is the balance between pro- and anti-os-
the design of the published studies var- teoclastogenic cytokines, which will de-
ies considerably, making it impossible to termine to what extent an inflammatory
come to any firm conclusions. There is a process will affect the nearby skeleton.
marked need for longitudinal studies us- We have shown that kinins formed in the
ing assessments of the three dimensional kallikrein-kinin cascade during inflam-
structure of cortical and trabecular bone, mation are also important molecules
as well as bone mass, in jaws compared to activating bone resorption both by them-
other well studied parts of the skeleton, selves, but also by synergistic interaction
i.e. hip, distal forearm and vertebrae, pref- with cytokines.
erably including intevention with drugs
to increase bone mass in osteoporotic pa- Bone remodelling under
tients. jaw prosthesis
It is well known that the loss of teeth
Inflammation induced will result in substantial loss of bone tis-
bone remodelling sue in the alveolar ridge, regardless those
Inflammatory processes in the vicinity of teeth are lost because of periodontitis or
the skeleton such as in the gingiva of a as a result of extractions. Many of these
periodontitis patient, or in the synovium patients wear complete overdentures and
of a patient with rheumatoid arthritis, the decrease of the alveolar bone and con-
or in the interior of the skeleton such as comitant flabby ridges is a clinical pro-

blem since it is associated with increasing increased bone resorption; in very many
difficulties to stabilize the dentures, more cases decreased formation of bone con-
so in the mandible than in the maxilla. tributes as well. Thus, “bone loss” is a
It is highly debated to what extent wear- more appropriate term than “bone re-
ing of complete dentures would affect sorption”. It is not known to what extent
the degree of bone loss. In old literature, increased resorption and/or decreased
the reduced bone mass in the jaws of formation is the cause of alveolar bone
edentulous patients was considered an loss in edentulous patients. The reason is
atrophic process and it was suggested that that it is not possible to follow the natural
the use of overdentures would prevent history of this phenomenon by histologi-
the process. Subsequent studies have both cal studies, nor is any imaging technique
confirmed this view and shown the op- currently available to follow osteoclast
posite, but it is generally thought that the formation and activity.
use of dentures increases the loss of bone, It is likely that the initial phases of
although this is not scientifically proven. alveolar bone reduction after tooth loss
The loss of alveolar bone in edentu- is due to excessive bone resorption and
lous patients is seen in all patients. It is uncoupled remodelling (i.e. too little
progressive and irreversible, but for rea- bone produced in relation to the amount
sons unknown it shows a considerable resorbed). However, once the extraction
degree of individual variation. It has been alveolae have healed it is not known
attributed to a variety of factors including how bone mass decreases, although bone
age, gender, duration of edentolousness, resorption must be part of the process
anatomy of the jaws, systemic diseases, since existing bone cannot disappear un-
oral hygiene, number of dentures worn, less osteoclasts are present. It would be
occlusal loading, but no conclusive expla- interesting to see to what extent current
nation has been found. The most likely drugs directed to inhibit bone resorption
reason for this is that the loss of bone is could influence the loss of alveolar bone
not caused by a single factor, but is multi- in edentulous patients. Systemic treat-
factorial. ment is not a realistic route of administra-
In the dental literature this loss of tion, but local treatment with longlasting
bone is usually described as “resorption of drugs such as bisphosphonates could be
residual ridge” or “maxillary/mandibular worth trying, although it should be bal-
resorption”. It is not uncommon in many anced against the risk of bisphosphonate
dental and clinical disciplines to use the induced osteonecrosis of the jaws.
word “resorption” when a patient shows An important, but hitherto unsolved
a decreased amount of bone, either ob- issue is whether remodelling of jaw bones,
served intraorally or on x-rays. However, either physiologically in an individual
a clinical phenotype of reduced amount with teeth or in edentulous patients, is
of bone is not always caused solely by sensitive to loading. It has been argued

that the more extensive loss of bone in anecdotal reports are not conclusive.
the mandible in edentulous patients The remodelling of jaw bones might
might be due to the fact that the support also be influenced by the inflammatory
surface for the lower denture is smaller process often present in the oral mucosa
and, therefore, the pressure is more fo- underneath overdentures, mainly in the
cused and stronger. Although this might maxilla. However, not all patients exhibit
be correct, it is still a speculation since it mucositis and patients without mucositis
is not known whether the pressure by the loose bone as well.
upper and lower dentures has any impact One important and interesting issue is
on the remodelling of bone underneath. whether the metabolism of the skeleton
Another aspect on this issue is whether in general affects the reduction of residu-
more traumatic loading caused by dis- al ridges, i.e. is an edentulous patient with
turbed occlusion, or poor fit of dentures, osteoporosis more prone to develop rapid
will enhance loss of alveolar bone. The loss of alveolar jaw bones. The literature
results from studies on these phenomena does not present any conclusive view
are inconclusive and the general conclu- whether osteoporotic patients loose more
sion when all published data are sum- bone and, as discussed above, it remains
marized is that occlusion only has minor to be shown if the trabecular and cortical
impact on bone loss. bone in the jaws are affected by loss of
Special attention has been paid to the estrogen, although some circumstantial
situation when patients wear a complete evidence is in favour of this hypothesis.
upper denture with remaining natural Recently, we found that loss of teeth, in a
teeth in the anterior mandibular area, or large cohort (n=567) of 70-year-old wom-
wear mandibular overdentures on anteri- en, is significantly associated not only
or lower jaw implants. Such patients have with decreased bone mass in the hip and
been reported to show enhanced bone whole body, but also with the number of
loss in the anterior part of the maxilla, osteoporotic fragility fractures. Total loss
overgrowth with soft tissues in the tube- of teeth was an independent risk factor
rosities and in the palatum and extrusion for previous fractures with an odds ratio
of the lower anterior teeth. This pheno- of 2.37.
type was described initially by Kelly in
1972 and has been termed the Combina- Summary
tion Syndrome. It has been argued that Bone tissue in the jaw bones, similar to
excessive loading of the anterior maxilla other bones in the skeleton, is continu-
and a negative loading on the more pos- ously remodelled through the concerted
terior parts of the maxilla cause these activities of bone resorbing osteoclasts
clinical phenomena. There are, however, and bone forming osteoblasts. Recently,
no epidemiological studies, which show it has been shown that osteoblasts not
the existence of this “syndrome”, and the only produce bone, but are also the cells

responsible for formation and activity intra-osseous implants stimulate new
of osteoclasts from hematopoetic stem bone formation and preserve alveolar
cells. Loading and osteotropic hormones jaw bone height. It is not known to what
such as sex steroids control remodelling. extent generalized osteoporosis affects
Loss of estrogen or testosterone results in bone remodelling in edentulous patients
substantial loss of bone in femur, radius or in patients with dental implants. The
and vertebrae, causing increased risk cellular and molecular events involved
for osteoporosis. It is likely, but not yet in edentulous bone loss and implant in-
proven, that osteoporotic patients loose duced new bone formation are not well
bone also in the jaws. Loss of teeth will understood.
result in unbalanced jaw bone remodel-
ling and loss of alveolar bone. In contrast,
Further reading
Karsenty G. The complexities of skeletal biology. Nature 2003; 423:318-318.
Kelly E. Changes caused by a mandibular removable partial denture opposing a maxillary
complete denture. J Prosthet Dent 1972;27:140.
Lerner UH. Inflammation induced bone remodelling in periodontal disease and the influence
of post-menopausal osteoporosis. J Dent. Res. 2006; 85:596-607.
Lerner UH. New molecules in the tumor necrosis factor ligand and receptor superfamilies with
importance for physiological and pathological bone resorption. Crit. Rev. Oral Biol. Med.
2004; 15:64-81.
Lerner UH. Osteoclast formation and resorption. Matrix Biol. 2000; 19:107-120.
Seeman E, Delmas PD. Bone quality – The material and structural basis of bone strength and
fragility. New Engl. J. Med. 2006; 354:2250-2261.
Teitelbaum SL, Ross FP. Genetic regulation of osteoclast development and function. Nat. Rev.
Genet. 2003; 4:638-649.
http://depts.washington.edu/bonebio/ASBMRed/ASBMRed.html

4
nutrition in old age with special
regard to dentition
gU n ill a nor dEn r a m
INTRoDucTIoN. As in most Western populations, the elderly are a growing part of the popu-
lation in Scandinavia, and life expectancy is increasing. The average life expectancy in the nor-
dic countries can be seen in table 4.I.
during the last century economical improvements have made it possible to choose food in
new ways, so consumption of cereals, potatoes and milk has decreased and intake of cheese,
fruit, vegetables and sugar has increased. Generally, healthy elderly people have good food hab-
its, but just like food habits have changed in society, so have the habits of the elderly who now
receive an increasing proportion of energy from fat and a decreasing portion of fibre intake.
Males (years) Females (years)
Denmark 74.8 79.5
Finland 74.5 81.2
Norway 76.1 81.4
Sweden 77.7 82.3
Table 4.I. Estimated life expectancy (WHO 2001).
Body composition not only derives from increasing cell

in old age death in the organs, but also from disuse
Ageing as a biological process means of skeletal muscle tissue.
alterations in body composition and Ageing is associated with loss of fat
a gradual decline in height and body free mass and a concomitant gain in
weight. Physiological changes in body body fat so that elderly persons have a
composition with a decrease in body cell higher body fat percentage compared
mass and body water and an increase in to younger people with the same body
body fat are seen as a consequence of mass index (BMI, kg/m 2).
ageing. The decrease in body cell mass Dehydration because of decline in
61

total body water is a major concern in Nutritional assessments
the elderly, and because of an age-related When BMI (kg/m2) is used to describe nu-
impaired thirst threshold the elderly are tritional status, the age related differences
less prone to drink than young adults. must be taken in consideration and the
Dehydration can be insidious and unre- BMI should be interpreted with caution in
cognized until serious side effects occur. the elderly. For example, a man weighing
One complaint may be xerostomia and 80 kg and measuring 1.80 m has a BMI
difficulties to wear a denture on a dry score of 24.7. If he loses 4 cm in height
oral mucosa. The changes of body water while his weight remains stable, his BMI
in both healthy and ailing elderly have will increase to 25.8. The threshold of ac-
clinical implications, since it may alter ceptable BMI is 20-25, underweight < 20,
the pharmacological properties of drugs. overweight 25-30 and obese > 30. BMI <
Healthy elderly should be encouraged to 20 is associated with increased mortality
drink six to eight glasses of fluid daily, and a modest increase in BMI with ageing
not including caffeine-containing beve- has been shown to be advantageous for
rages, which are diuretic. survival. Longitudinal data show a pre-
Osteoporosis is another age-related served body weight up to old age groups,
change in body composition. It begins in as long as people stay healthy, in contrast
middle age and reduces the body length to involuntary weight loss among the frail
in old age. Height and body weight de- and sick elderly.
crease significantly in both men and As BMI is influenced by osteoporo-
women after the age of 70 with a gender sis, fluid balance and body composition
bias, since elderly females loose more BMI-assessments of the elderly are often
height and weight than elderly males. combined with markers such as triceps
Throughout middle age and old age skinfold (TSF) and arm muscle circumfer-
there is a progressive loss of lean body ence (AMC) to estimate body fat and sub-
mass. This loss rate increases in later life. cutaneous fat mass.
The loss of lean body mass is largely ac- The mini nutritional assessment
counted for by skeletal muscle which can (MNA) includes BMI and is developed
shrink as much as 40 % between the ages especially for elderly patients and often
of 20 and 80. used in geriatric studies. Recent weight
The shrinking lean body mass reduces change, drug consumption, diseases,
the basic metabolism and energy intake cognitive and physical functioning, oc-
diminishes. currence of pressure sores, questions
The quantitative effect of the decreas- of dietary intake and the subject´s own
ing body cell mass is influenced by vary- opinion of health and nutritional status
ing degrees of physical activity, and the are registered. The total score is 30 points,
differences in energy intake influence less than 17 points indicates malnutrition
body fat. and 17-23.5 points risk of malnutrition.
62 Nutrition in old age with special regard to dentition

Protein-energy malnutrition (PEM) or risk energy reduction must be combined with
of PEM is common in the frail elderly, an increase in nutrient density.
occurring in 25-60 % of elderly persons Sufficient intake of vitamins and mine-
admitted to the hospital and 1-7 % in rals such as calcium, phosphorus, iron,
independently living elderly in Western zinc, vitamin C, D and folic acid are of
populations. Fatigue, apathy, depression, special importance in old age. Since wom-
weakened immune system, loss of muscle en have lower energy needs in general,
mass, muscle strength and functional they run a greater risk of having too low
decline are consequences of involuntary intake of essential nutrients, especially
weight loss as seen in PEM. calcium, iron, vitamin C and D (Table
4.3).
Food intake in old age There is an important social aspect of
Energy expenditure is lower with ageing eating and loneliness that may be a ma-
because of loss of metabolizing tissue, jor contributing factor to malnutrition.
decreasing number of cells in the organs A new life situation that occurs when a
and decreased physical activity. As a con- spouse dies is known to carry the risk of
sequence, the nutrient needs must be met depression and loss of appetite leading
within less caloric intake per day (Table to dietary deficiencies. To be dependent
4.2). An 80-year old man has about two homebound and living alone is not fa-
thirds of the energy need of a 30-year old vourable to the nutritional status of the
man, but his need of essential nutrients elderly.
is the same. The decrease in total energy An age-related decrease in intestinal
need for a man ranges from about 3300 function may be associated with consti-
calories a day at the age of 30 to about pation. Consequently, fibres in the diet
2600 kcal at the age of 70. Energy need is are of importance. Low-fibre diets in
seen in table 4.2. response to chewing difficulties and den-
Western diets contain much fat and tures can exacerbate this condition. It is
refined sugar and have low nutrient den- not advisable to solve the problem with
sity, which makes it hard to simply reduce constant use of laxative, since this may
energy intake and still keep essential contribute to malnutrition by causing
nutrients at a satisfactory level. Therefore nutrient malabsorption.
Males Males Females Females

61-74 years >75 years 61-74 years >75 years
Body weight kg 74 73 63 62
MJ*/Day 12.0 10.8 9.5 9.3
Table 4.2. Energy need in old age according to the Swedish National Food Administration, NFA. Referring to
a healthy, reasonably active person. *1 megajoule (MJ) = 240 kcal.
Nutrition in old age with special regard to dentition 63

Males Males Females Females
61-74 years >75 years 61-74 years >75 years
calcium mg 800 800 800* 800*
Phosphorus mg 600 600 600 600
Potassium g 3.5 3.5 3.1 3.1
Magnesium mg 350 350 280 280
Iron mg 9 9 9 9
Zinc mg 9 9 7 7
copper mg 0.9 0.9 0.9 0.9
Iodine µg 150 150 150 150
Selenium µg 50 50 40 40
Vit.D µg 10 10 10 10
Thiame mg 1.3 1.2 1.0 1.0
Riboflavin mg 1.5 1.3 1.2 1.2
Vit. B6 mg 1.6 1.6 1.2 1.2
Folic acid µg 300 300 300 300
Vit. B12 µg 2.0 2.0 2.0 2.0
Vit. c mg 75 75 75 75
Table 4.3. Nordic nutrition recommendation. Recommended intake of certain nutrients, expressed as daily
intake over time. The requirement is lower for almost all individuals. * Supplementation with 500-1000 mg
calcium per day may possibly, to some degree, delay age-related bone loss.
Age dependent atrophy of the gastric ping, the decrease in physical activity and
mucosa may have implications for nutri- too little exposure to daylight increase
tion, as malabsorption of folic acid and the risk of osteoporosis.
loss of intrinsic factor secretion are associ- Diabetes type II is a common disease
ated with impaired protein and vitamin among the elderly in Western societies.
B12 absorption. There is a decrease in insulin production
There is an influence of calcium and and decreased tissue responsiveness to
vitamin D dietary intake on osteoporo- insulin. Diet is important and weight loss
sis and hip fractures. The two sources of is often desired as overweight is a risk fac-
vitamin D are the diet and the action of tor and weight loss will improve the glu-
ultraviolet light in the skin. During win- cose metabolism. The diet must provide
ter, when many elderly people stay inside a variety of foods, avoid refined sugars,
because of the cold and the risk of slip- include complex carbohydrate and it must

have a reduced amount of fat. In addition consult or include a dietician in the den-
to dietary restrictions physical activity is tal team. A retained, life-long functional
recommended. dentition is also a health promoting strat-
All severe infections are associated egy for the elderly that should be empha-
with catabolism and should be met with sized by all health care professionals, not
an increase in energy intake. Patients only dental professionals.
with chronic obstructive pulmonary dis- A functional natural dentition in old
ease often show malnutrition with loss age has been defined as having at least
of subcutaneous fat and muscle atrophy. twenty teeth, but in addition to the num-
They have high-energy requirements for ber of natural teeth there is a relationship
the work of breathing, stress and catabo- between the number of occluding pos-
lism from infections. They need more terior pairs of teeth and the level of food
calories per day, but instead they often intake. The numbers of teeth may not be
have poor dietary intake because of loss the most adequate measure of masticatory
of appetite and fatigue. function but having posterior teeth that
Parkinson´s disease also increases en- occlude, may be more relevant. Insuf-
ergy requirements because the tremor is ficient intake of nutrients is also related
energy requiring and the patient often to dental invalidity when measured with
steadily loses weight as the disease pro- Eichners´s index. An association between
gresses. Because there are problems with low BMI and the number of teeth has
dysphagia and obstipation associated been reported where people had a few
with Parkinson´s disease it is important teeth but were not edentulous. Impaired
not only to eat enough, but also to have a mastication alters the sensory and psycho-
good chewing function in order to swal- logical aspects of eating and causes restric-
low a smooth bolus of food, rich of fibres. tions in food selection, and edentulous-
ness is often correlated with lower nutri-
Nutrition and dentition ent intake. People wearing dentures have a
in old age reduced masticatory ability in comparison
The condition of the oral cavity may to patients with natural dentition. Den-
affect nutrition and vice versa. Poor ture wearers often shift their food choice
dentition and bad oral health decreases towards soft products and their intake
the ability and desire to eat and leads to easily becomes nutritionally unbalanced.
insufficient food intake. But dietary and Patients with impaired chewing ability
nutritional factors may conversely result often have difficulties in eating fruit, veg-
in symptoms in the oral cavity. As dental etables, some types of bread and meat and
status has an impact on diet, nutritional the diet becomes higher in fat and sugar.
status, general health and well being of A full upper denture covers the hard
the elderly, it is important for the dentist palate and the taste buds it contains, so
to take this in account and when needed taste sensitivity may be reduced. The

sense of taste is also related to the olfac- more slowly and cut fibrous foods such as
tory system. Poor nutritional status is apples and carrots into bite-sized pieces.
expected to be influenced by diminished Nutritional information must emphasise
sense of smell and odour perception. Peo- the importance of fibres, calcium and
ple with poor odour perception tend to Vitamin D intake and reduction of the
have lower nutrient intake levels and good saturated fat intake.
odour perception has been associated Masticatory efficiency and subjective
with higher water intake. Odour percep- experience of masticatory performance
tion has been shown to decline between may increase after treatment with remov-
60-90 years of age and this might increase able partial denture, but a concomitant
consumption of simple sugars to make change of dietary intake is not always
food more appealing. Enriching food by seen. A study of intake of energy and nu-
adding volatile flavours can stimulate the trients before and after dental treatment
taste, the salivation and the appetite and in geriatric long-term patients did not
thus increase the intake of nutrient dense reveal any differences concerning energy
food among elderly persons. intake, anthropometrics or salivary secre-
Hyposalivation was once considered a tion rate. There was a slight change in
consequence of normal aging, but it is no dietary habits, food consistency and food
longer seen as simply part of aging, but selection towards consumption of fish
more as a side effect of age related dis- and hard bread. Taking in account that
eases and their medication. Low salivary geriatric patients living in institutions
secretion is a risk factor for dental caries generally lose weight, a “no change” re-
and infections of oral soft tissue and it sult may be a positive outcome after all.
may impair complete denture retention, Most nursing home residents are suffer-
cause soreness of the oral mucosa and ing from cognitive disorders and multiple
chewing and swallowing difficulties. This handicaps and diseases and they often
may affect food intake and food selection show signs of nutritional depletion. In a
and contribute to poor nutritional status. group of nursing home residents a pos-
sible association was found between
Effect of dentures on impaired chewing capacity and early de-
nutrition velopment of malnutrition. Therefore, in
With nutritional guidance, denture wear- order to affect malnutrition, dental treat-
ers can have a nutritionally adequate food ment should be undertaken before severe
intake. New denture wearers may initially nutritional deterioration has occurred.
want to consume a soft diet while they When a nursing home resident exhibits
adapt to the new denture. They can begin malnutrition, the patient’s cognitive and
by cutting foods into small pieces and physical status is usually impaired to such
chewing them with their molars. Denture an extent that better chewing capacity no
wearers generally need to chew longer, eat longer has an impact on the nutritional

status. Of course, the malnourished pa- Prosthodontic rehabilitation always
tients must have proper dental treatment has an important role to play to improve
too, but one cannot expect it to result in dietary intake. Today “young elderly”
better nutritional status as for patients, on average experience a satisfactory
who are only at risk of malnutrition. The nutritional situation in contrast to “old-
risk of developing malnutrition in old elderly” who are more vulnerable and
age is multifactorial and age per se is one with frequent nutritional problems. As
factor. Diseases, drug consumption, func- the “old- elderly” is a growing part of the
tional disabilities, poor social conditions elderly population and nutritional status
and loss of appetite are other risk factors. plays an important role for their general
Unfortunately an impaired chewing func- health, good oral function is of impor-
tion is often ignored as a nutritional risk tance for their quality of life and life-long
factor among medical professionals. well-being.
Further reading
Cederholm T, Jägrén C, Hellström K. Outcome of protein-energy malnutrition in elderly medi-
cal patients. Am J Med 1995;98:67-74.
Faxén Irving G. Nutritional status and cognitive function in frail elderly subjects. Thesis. Karo-
linska Institutet, Stockholm 2004.
Griep MI, Verleye G, Franck AH et al. Variations in nutrient intake with dental status, age and
odour perception. European Journal of Clinical Nutrition 1996;50:816-825.
Gunne J. Masticatory ability in patients with removable dentures. A clinical study of mastica-
tory efficiency, subjective experience of masticatory performance and dietary intake. Swed
Dent J Suppl 1985;27:1-107.
Mobley C C. Nutrition issues for denture patients. Quintessence International 2005;36(8):627-
631.
Nordenram G, Ljunggren G, Cederholm T. Nutritional status and chewing capacity in nursing
home residents. Aging Clin Exp Res 2001;13:370-377.
Palmer CA. Gerodontic nutrition and dietary counselling for prosthodontic patients. Dent Clin
N Am 2003;47:355-371.
Parker MG, Ahacic K, Thorslund M. Health changes among Swedish oldest old: Prevalence rates
from 1992 and 2002 show increasing health problems. Journal of Gerontology: Medical
Sciences 2005;60(10):1351-1355.
Vellas B, Guigoz Y, Garry PJ et al. The Mini Nutritional Assessmnet (MNA) and its use in grad-
ing the nutritional status of elderly patients. Nutr 1999;15:116-121.
http://www.slv.se. Reommended Dietary Allowances in Sweden. Jan 2010.

5
denture-induced
sequelae in oral tissues
to m B E r g E n da l
INTRoDucTIoN. A removable prosthesis is a foreign body in the oral cavity. Its interaction
with surrounding tissues creates a risk for side-effects and clinical signs and symptoms. Surface
imperfections of the dentures and a continuous deterioration of function will with time cause
trauma and subsequent damage to the supporting denture-bearing tissues. These are the inevi-
table consequences of wearing a denture. Therefore, the delivery of a removable denture ought
to be the starting point for a continued follow-up of the patient, for maintenance care and ad-
justments of the prosthesis.
The number of edentulous or partially edentulous individuals has decreased dramatically in
Scandinavia in recent decades. Edentulousness is strongly correlated with social background fac-
tors, and the majority of denture wearers will be found among elderly people with limited eco-
nomic resources. The relation between dentist and denture patient ought to be a long-standing
commitment, and rather than undergoing the traditional finishing of the treatment phase when
new dentures are delivered, these patients should be on a recall system. Like any other patient,
the denture wearer needs instruction in the elimination of microbial plaque and routines which
promote good oral comfort.
The direct presence of a denture can have traumatic, microbiological, toxic and allergic ef-
fects on the supporting tissues. The denture base is a carrier of plaque and as such promotes in-
fection. The local trauma may influence the mucosa and create an increased permeability, allow-
ing allergens and toxins from the denture base material or the plaque to penetrate the mucosa.
Thus, it is difficult to distinguish between the causative factors since they interact so closely.
One principle in the treatment of clinical denture-related sequelae is correction of inaccura-
cies of the dentures. Such measures include adjustments of the peripheral denture base, correc-
tions of surface irregularities and cracks, rebasing/relining of the dentures and even making new
dentures.
An important measure is always to evaluate and optimize a balanced occlusal function of the
dentures in order to avoid trauma. Failure to correct errors of occlusion may cause pain and a
traumatized supporting mucosa. However, it has been difficult to show significant effects of oc-
clusal variations (e.g. choice of tooth material, occlusal pattern, tooth form, and tooth arrange-
ment) on residual ridge resorption.
69

direct effects of the presence of a removable denture are bone resorption, flabby ridges,
denture stomatitis, angular cheilitis, glossitis, traumatic ulcers, denture irritation hyperplasia,
oral cancer, and burning mouth syndrome.
Residual ridge resorption prognatic appearance and jaw relation.

After tooth extraction there is a docu- This has to be compensated for when the
mented onset of an immediate remodel- dentures are made (Fig. 5.1A-C).
ling of the alveolar bone and consequent- During the first year after tooth extrac-
ly a resorptive process of the residual tions there will be comprehensive bone
ridge. It appears to be an ongoing process resorption of 2-3 mm in the mandible
with great individual variations in degree and 4-5 mm in the maxilla. The resorp-
of resorption in partially as well as totally tion continues in a lifelong process, but at
edentulous jaws. Seemingly, the mere a slower rate of an average of 0.2 mm per
presence of removable dentures plays a year. The resorption in the mandible and
significant role in bone resorption. the maxilla has been calculated to occur
at a ratio of 4:1 over time.
clinical impact Bone loss leads to a decrease in the size
As a result of bone resorption, the maxilla of the denture-bearing area (Fig. 5.2A, B).
grows narrower, while the mandible gets With bone loss, anatomical structures may
progressively wider during edentulous- become more prominent and interfere
ness. This results in a complicated intra- with the denture base. The crest of the re-
alveolar relationship. The remodelling sidual alveolar ridge in the resorbed man-
process in both jaws may also result in a dible consists of cancellous bone, in many
A c
Fig. 5.1. A, B, C, panoramic radiographs of edentulous patient and complete denture wearer (Ten years interval
between radiographs A and B).
70 Denture-induced sequelae in oral tissues

A B
Fig. 5.2. Evaluation of denture supporting areas in the maxilla (A) and mandible (B). (Black = primary sup-
port area; red = area with secondary support capacity; blue = relief area).
cases without covering cortical bone.

A
This results in a porous and rough
structure covered with a mucosa, which
is not suitable as a primary stress-bearing
area. Instead, the horizontal buccal
shelves, which are more resistant to re-
sorption, are chosen as primary support
areas, while rough and tapered ridges of-
ten have to be relieved (Fig. 5.3A+B). Other
structures in the mandible need special
attention in order to avoid trauma, and
these sometimes also need to be relieved.
Such structures are the attachments of the
mental and buccinator muscles, and the
B mylohyoid ridge which posteriorly, follow-
ing resorption, often lies on a level with
the superior surface of the residual ridge,
leaving a flat denture-bearing area with-
out sulci.
Because of resorption, the location of
the mental foramina changes, so that they
approach the top of the crest and have to
Fig. 5.3. Conventional tomography (Scanora®) of be identified by palpation and possibly re-
spiny mandibular alveolar ridge (A), relieved with lieved in order to avoid pressure and pain
tinfoil on plaster model (B). from the denture (Fig. 5.3). Other anatom-
Denture-induced sequelae in oral tissues 71

Residual ridge resorption
• Continuous, life-long resorption of the alveolar process

• Resorption in the mandible is four times larger than in the maxilla
• Resorption is most pronounced during the first year after tooth extraction
• degree of resorption and the resorptive pattern vary individually
• Correlation between the form of the mandible and degree of resorption
Table 5.1. Residual ridge resorption – some concluding remarks.
ical structures require attention because of complete dentures, alternatives such as

resorption. These are the genial tubercle overdentures should be considered. Thus,
and tori mandibularis. The tori are usually overdentures may contribute to preventive
located bilaterally and lingually close to prosthodontics, which may delay or elimi-
the floor of the mouth. nate future prosthodontic problems and
In the maxilla the hard palate provides preserve bone to make future alternatives
the primary support area for a denture. possible.
The horizontal area close to the midline
has good stress-bearing capacity since the crista flaccida
hard palate is resistant to resorption. The As a consequence of residual ridge resorp-
crest of the edentulous ridge is an impor- tion, resilient fibrous tissue replaces the
tant area for support of the upper denture. lost bone and a displaceable crista flac-
However, the bone is exposed to resorp- cida, also called a flabby ridge, is estab-
tion and sometimes a rough and irregular lished (Fig. 5.4A). The process is chronic
texture of the residual ridge may be identi- and the connective tissue is inflamed and
fied. This ridge limits the stress-bearing may influence the ongoing resorptive
capacity of the maxillary bone. Therefore, process. Therefore, the displaceable tissue
the maxillary alveolar ridge should be re- may be partly or completely surgically
garded as having a secondary supporting removed. In most situations, however, the
capacity (Fig.5.2A). soft ridge is left alone, since it provides at
Because of continuous alveolar bone least some retention and stability particu-
loss, functional problems will occur in larly to removable maxillary dentures in
wearing complete dentures (Table 5.1). It patients with alveolar ridge atrophy. How-
has been shown in longitudinal studies ever, a flabby mucosa requires a special
that bone resorption may be prevented impression technique to avoid distortion,
with overdenture therapy where healthy and the flabby ridge sometimes has to be
roots of natural teeth as well as implants relieved in the denture (Fig. 5.4B-D).
support the denture. Before teeth are Flabby ridges have been reported to
extracted and patients are provided with be most frequent in the maxillary front,

A B
c D
Fig. 5.4. Special impression technique for minimal displacement of flabby tissue. A. maxillary flabby ridge.
B. acrylic custom tray with anterior open window. C. border moulded impression. Excessive material re-
moved. D. completed impression with plaster on top of the tray to minimize distortion of flabby ridge.
A B
c D
Fig. 5.5. Illustration of the so-called combination syndrome. A. in the maxilla alveolar atrophy and flabby
ridge. B. old malfunctioning denture. C+D. in the mandible shortened dental arch with Class I RPDP. Heavily
resorbed alveolar bone posterior to the remaining anterior teeth (patient on panoramic radiograph other than
patient on clinical pictures).

especially if residual anterior teeth in the However, the patients often discard bilat-
mandible are present (Fig. 5.5A-D). From eral free-end dentures in the mandible.
a prosthetic point of view it is important
to evaluate the individual need for poste- Denture stomatitis
rior occlusal contacts in order to obtain Removable dentures may induce in-
stability of the maxillary complete den- flammatory reactions in the underly-
ture. This can be done in the antagonistic ing mucosa. These changes are usually
mandibular shortened dental arch with called denture stomatitis, but several
cantilevered fixed dental prostheses or other names have been suggested, such
with implant-supported crowns or fixed as Candida-associated denture stomatitis,
partial dental prostheses, or with remov- denture-induced or denture-related sto-
able partial dental prostheses (RPDPs). matitis, denture sore mouth or chronic
A B
c D
Fig. 5.6. Subclassification of denture stomatitis.

E
A. type I, localized simple inflammation. B. type
II, generalized simple inflammation. C, D, E. type
III, inflammatory papillary hyperplasia (C) papil-
lary projections separated by a blast of air (D), and
a partially dentate patient wearing an RPDP (E).

atrophic candidiasis. In this chapter den- Aetiology and local factors
ture stomatitis will serve as an overall The mere presence of a denture is the pre-
term, with Candida-associated added if requisite for development of denture sto-
the yeast Candida is involved, as proposed matitis. If the denture is removed the ery-
by Budtz-Jörgensen (2004). thema will heal. C. albicans may induce
Denture stomatitis may be subclassed denture stomatitis, but not alone, since
into three groups according to Newton’s this disease is multicausal and there are
classification (1962) with regard to the other causative factors, such as trauma,
clinical appearance (Fig. 5.6A-E): microbial infection, and allergy. C. albi-
Type I. A localized simple inflammation in- cans rarely causes disease in the absence
cluding pinpoint erythema and diffuse of predisposing local and systemic factors
inflammatory reddening of a limited area (Table 5.2). The denture base causes local
of the palatal mucosa. This lesion has trauma to the denture-bearing mucosa,
been reported to be associated mainly serves as a carrier of the microbial plaque
with trauma from the dentures. and creates an environment favourable for
Type II. A generalized simple inflammation yeast colonization. This local trauma from
with a diffuse erythema and oedema, the denture base may stimulate the mu-
smooth and atrophic mucosa extending cosal epithelium and thus initiate a faster
over a part or all of the denture-bearing turn-over of the epithelial cells, and the
area. Increased growth of bacteria and patient may end up with a para- or non-
yeasts in the plaque on the mucosal side keratinized mucosa. This creates an open-
of the denture base has, among other facing of the epithelial barrier, so that toxins
tors, been associated with this lesion. from yeasts and bacteria in the denture
Type III. An inflammatory, papillary hy- plaque may penetrate the mucosa.
perplasia of the palate (the granular type) There is reliable evidence that poor
is characterized by a hyperaemic mucosa oral and denture hygiene are signifi-
with nodular appearance mostly cover- cant predisposing factors for developing
ing the central part of the palate. Three Candida-associated denture stomatitis.
variants of inflammatory, papillary hy- Reduced salivary flow rates, tobacco-
perplasia are described: one nodular, one smoking, high carbohydrate intake, and
diffuse papillary and one mossy form. A nightly denture wearing are other factors
combination of trauma and infection by that influence colization of the fitting
microorganisms in the denture plaque on denture surfaces.
the fitting surface of the denture and the General background factors, which
supporting mucosa are mentioned as ae- may influence resistance to microbial
tiological factors of the hyperplasia. The infection, are old age, general diseases
clinical and histological appearance of (diabetes mellitus, malignancies), immune
the different types of denture stomatitis is deficiencies (HIV), and medical treatment
in many respects similar and confluent. (e.g. antibiotics) (Table 5.2).

cause different disease variants both in the
causative factors
oral cavity and elsewhere. Biofilms have
Trauma
been defined as “a complex, functional
Infection
community of one or more species of mi-
Allergy
crobes, encased in an exopolysaccaride
Predisposing factors matrix and attached to one another or
Saliva (dryness of the mouth) to a solid surface” e.g. denture acrylic. A
diet (carbohydrate intake) biofilm consists of a heterogeneous popu-
Oral hygiene lation of cells with different growth rates.
Tobacco-smoking After attachment to the prosthetic surface,
denture plaque C. albicans is able to divide and form mi-
denture usage crocolonies, which secrete exopolymeric
denture base material material and finally form a three-dimen-
denture surface texture sional biofilm. A rough acrylic surface with
Background factors cracks is a perfect habitat for colonization
of yeasts and bacteria as compared to a
General diseases (diabetes mellitus,
smooth surface. Microorganisms on rough
malignancies)
structures and in cracks are better protect-
nutritional deficiencies
ed from cleaning measures, and biofilms
Immune defects
appear to have an increased resistance to
Old age
the effect of antiseptics. This emphasizes
Medical treatment
the difficulty of achieving good hygiene
Table 5.2. Development of Candida-associated on dentures with surface imperfections.
denture stomatitis. The biofilm-associated resistance in the
treatment of denture plaque contributes to
Denture plaque biofilm the explanation of high recurrence rates in
Patients with denture stomatitis show the treatment of denture stomatitis. How-
significantly more microbial plaque and ever, the pathogenic process and mecha-
yeasts on the fitting surface of the den- nisms of the resistance of Candida biofilm
ture base compared to those with healthy formation are still not fully understood.
mucosa, and it is generally agreed that the
denture plaque biofilm with yeasts and
bacteria is of a critical importance for the
development and maintenance of denture
stomatitis.
Microbial biofilms are present in any
colony-forming situation. Biofilm forma-
tion is a major characteristic that helps
microorganisms, and also C. albicans, to

Yeasts very similar to the situation before tooth
Candida albicans is a yeast strain from the eruption in a child. However, the intro-
genus Candida and the most important duction of a prosthetic device will change
fungal pathogen in the oral cavity. the oral microbial composition again, and
C. albicans is a saprophytic, indigenous the growth of Candida species is increased
organism, and under normal circum- after the introduction of acrylic dentures.
stances a limited pathogen that colonizes In elderly individuals the prevalence of
the normal oral and gastrointestinal tract Staphylococcus aureus and lactobacilli is
microbial flora in 50-60% of all individu- high. The denture plaque has been shown
als. Yeasts are oval cells (3-5 μm), blasto- to be like the plaque on enamel but may
spores budding daughter cells. Many include a significant amount of yeasts.
types of yeast develop hyphal forms (Fig. When C. albicans is present in large num-
5.7A) as most Candida species do. bers, it is described as pathogenic. Can-
Late in life, after tooth loss and in an dida species do not invade the epithelium.
edentulous state, the patient’s experience Candida-associated denture stomatitis is
of colonizing bacteria in the mouth is often present in combination with other
A B
Fig. 5.7. A. smear, stained by the Gram method, from the fitting denture surface in a patient with Candida-
associated denture stomatitis. The smear shows budding blastospores and hyphal structures. B. swabs from
the denture bearing mucosa (left) and fitting denture surface (right) cultured on Sabouraud agar medium
(Oricult®). The heavy yeast growth comes, as always, from the plaque of the denture base.

mucosal lesions such as angular cheilitis
Attaque plaque strategy
and glossitis. This indicates a spread of
(revised from Samaranayake, 2006)
microorganisms from the denture reser-
• Meticulous denture hygiene with soft
voir to neighbouring mucosal sites.
brush and unperfumed soap
Visualization of denture plaque (Fig.
Treatment and maintenance
5.8A-C)
The presence of microbial plaque and
Removal of dentures during night
yeasts on the fitting surface of the den-
(these steps without antifungals are
ture base appears to be of a critical
adequate in most cases)
importance for the development and
• Optimize denture function
A • Polished acrylic surface that fits the

mucosa
• diet with low carbohydrate intake
• Regular disinfection by immersion of
the dentures in chlorhexidine
• use of polyene antifungals: nystatin
amphotericin B (lozenges, pastilles etc.)
Table 5.3. Attaque plaque strategy.
maintenance of denture stomatitis. The

treatment strategy may be expressed in
one sentence: Attack plaque! (Table 5.3).
B c
Fig. 5.8. Attaque plaque! Disclosing solution (Diaplac®) to stain and visualize denture plaque. Cleaning the
denture by hand with soft brush and soap.

Hygienic measures aimed at elimination favour plaque formation and make plaque
of plaque on the denture base and the difficult to remove. A clinically smooth
denture-bearing mucosa are proposed as surface could be achieved by tin-foiling
the primary objective in the prevention the plaster cast, correct processing of the
and treatment of denture stomatitis. The denture base acrylic, grinding of sharp
patient is instructed to remove the den- edges on the mucosal surface of the den-
tures after meals and with a soft brush ture and polishing the fitting surface with
gently clean the denture-bearing mucosa a non-abrasive paste. In order to obtain
and tongue with water, and clean the an optimal result, a new denture should
dentures with a soft brush and soap be- be provided only when the mucosa has
fore reinserting them (Fig. 5.8). Patients healed.
are also advised to avoid nightly denture In type III denture stomatitis the in-
wearing to let the mucosa rest. When flammatory reaction of the mucosa may
the denture is kept extraorally there are disappear after hygienic and prosthetic
two ways to handle it. After the denture treatment. However, the papillary out-
is carefully cleaned, it may be stored in growths often persist and the hyperplas-
water or a denture cleanser over night, tic tissue becomes reinfected. Compli-
but in patients with recurrent infections, mentary surgical removal of the papillary
the denture may very well be kept dry tissue is therefore sometimes necessary.
after cleaning to avoid microbial growth. Antifungal agents are used in an at-
A common question is how to use com- tempt to eradicate the yeasts on the oral
mercial denture cleansers. They can only mucosa and the fitting denture surface.
be considered a complement to cleaning The clinical diagnosis should be con-
the denture by hand, and cannot prevent firmed with a mycological test. Smears
recolonization of the denture. To avoid and swabs are the most common samples
trauma and infection from an old and taken for testing. The swabs from the
ill-fitting denture, a temporary soft tissue- lesions and denture base can be evenly
conditioner can be used. However, many applied on the surface of a dip-slide to be
soft liners have a porous surface that is cultured on the Sabouraud agar medium
rapidly contaminated by microorganisms, at room temperature (Oricult®) (Fig. 5.7B).
which necessitates frequent full or partial Since clinical evaluation of adequate spec-
reconditioning of the denture. imens for culture or microscopy is easily
As mentioned above, local factors available, in general there is no need for
that influence the sequelae of wearing serological tests for Candida. Antifungal
a denture are rugged fitting surfaces in drugs may be warranted when the clinical
tightly fitting dentures which cause local diagnosis has been confirmed in patients
tissue trauma and predispose for infec- with a burning sensation in the mouth,
tion. A rough palatal fitting surface as a in patients where the denture is the yeast
result of exact impression techniques will reservoir and infection has spread to oth-

er sites in the oral cavity or the alimenta- angles of the mouth and shows an ery-
ry tract, and finally in patients with com- thema (stomatitis) often macerated and
promised general health, mental illness with crusting (Fig. 5.9A-D). The fissures
or dementia. Treatment with antifungals sometimes even include the buccal mu-
should continue for at least four weeks in cosa and can be painful with spontane-
patients with Candida-associated denture ous bleeding. Angular cheilitis appears
stomatitis. When the antifungal treat- more frequently among patients with
ment is discontinued, a relapse of denture Candida-associated denture stomatitis
stomatitis may occur. It is important that than in patients with a healthy denture-
the treatment of patients with denture bearing mucosa. Yeasts as well as bacteria
stomatitis is carried out consistently. (especially Staphylococcus aureus) are in-
teracting and predisposing local factors.
Angular chelitis Crustings may indicate the presence of
Angular cheilitis, also called angular staphylococcal infection. It has been sug-
stomatitis or perlèche, is characterized gested that malfunctioning prostheses,
by fissures or wounds of the skin in the especially in the vertical dimension and/
A B
c D
Fig. 5.9. Subclassification of angular cheilitis. A. lesion in the corner of the mouth (sometimes involving
buccal mucosa). B. rhagade more extensive in length and depth involving the skin. C. more than one small
rhagade radiating from the corner of the mouth (A, B and C often with crustings). D. erythema of the skin (no
rhagade) radiating toward the vermillon border (from Ohman et al., 1986).

or old age, and muscular atrophy can denture and denture function by check-
result in overclosure of the jaws forming up of the vertical dimension, occlusion
deep, closed folds in the skin at the angles and stability, form the basis for decisions
of the mouth. of whether relining/rebasing or remaking
When saliva with yeast and bacterial of the denture is indicated. The adjust-
cells, e.g. from a maxillary denture, leaks ments of the denture also aim at sup-
out, there will be a local, moist habitat porting the tissues in the commisures in
predisposing for angular cheilitis. How- order to smooth down the folds and keep
ever, it is also likely that some important away saliva, which moistens the angles
general factors predispose for the emer- of the mouth. Topical treatment with
gence of angular cheilitis/stomatitis, such the antifungals nystatin, amphotericin B
as vitamin deficiency (B2, B12, folic acid) (polyens) or miconazole (azoles) can be
and iron deficiency anaemia. Therefore it advocated. Of these, miconazole has both
is important to take a thorough anamne- antifungal and anti-staphylococcal effect.
sis of the patient for evaluation of a medi- When there are wounds or fissures, the
cal background to the symptoms. patient should be instructed to rub the
infected area gently with an antimycotic
Treatment or antibacterial ointment or cream after
Angular cheilitis appears in combination cleaning. If the infection resists treatment
with Candida-associated denture stoma- the patient should be referred for comple-
titis and/or glossitis and in many cases mentary medical follow-up in order to be
it is caused by the prosthesis. Therefore, investigated for possible malnutrition or
elimination of the plaque reservoir of systemic diseases.
the maxillary denture base is warranted
in order to cure denture stomatitis le- Traumatic ulcers
sions (compare the treatment of denture It is quite common for a newly made
stomatitis) (Table 5.3). Evaluation of the denture to generate traumatic ulcers
A B
Fig. 5.10. A. traumatic ulcer. B. denture irritation hyperplasia.

soon after delivery. These ulcers are often are painless, but ulcers may be present
small and painful and described in size as in the bottom of the crypts between the
“grain-shaped” or “raisin-like”. The ulcer flaps.
is inflamed, greyish and often with a sur-
rounding red area (Fig. 5.10A). It is often Treatment
caused by contact with an overextended To treat this condition, the badly function-
border or is a result of an irregularity or an ing denture has to be optimized, e.g. by
uneven texture of the denture base. relieving the traumatic area, trimming the
border with peripheral tissue conditioner,
Treatment checking the occlusal function or avoiding
Taking care of traumatic ulcers comprises wearing the denture for a period of time.
fast follow-up control of the fitting surfac- The mucosal flaps will decrease in size
es of the dentures, elimination of acrylic and the inflammation will moderate. In
irregularities and sharp edges and adjust- severe cases it is important to avoid wear-
ment of the extended periphery of the ing the dentures in order to decrease the
denture. However, perhaps the most im- hyperplastic tissue before the remaining
portant measure is to examine and grind- tissue can be surgically removed and new
in the occlusal function in the follow-up dentures made. Control of healing is man-
of traumatic ulcers. If the condition is not datory since there is a risk that the hyper-
properly taken care of, it may develop into plastic tissue may be hiding a neoplastic
a chronic state, a denture irritation hyper- process.
plasia.
oral cancer
Denture irritation The development of oral cancer in as-
hyperplasia sociation with denture wearing has been
Chronic irritation as a consequence of discussed above. However, the mechanism
wearing old, often badly extended den- behind the process is not fully understood.
tures, resulting in hyperplastic tissue in Many of the medical and socio-economic
permanent traumatic contact with the factors known to increase the risk of den-
periphery of the denture base, may cause tal disease and becoming edentulous are
denture irritation hyperplasia. This pro- also known to be risk factors for oral can-
liferation of the peripheral mucosa may cer development. Rather than a risk factor
be seen as a single fold or numerous folds per se, denture wearing could be a con-
(Fig. 5.10B.) consisting of inflamed hyper- founding factor in the multifactorial back-
plastic connective tissue. The denture rubs ground of oral malignancies. However,
into the vestibular sulcus or floor of the if sore spots or ulcers do not heal after
mouth, giving rise to irritation and in- denture adjustment, the denture should be
creased tissue thickness and grooves. taken out for a week. If the lesion persists,
In most instances these hyperplasias the patient must be immediately referred

for further medical examination on the with BMS. However, if evaluation of the
suspicion of a neoplasm. dentures shows no obvious shortcomings
in denture form and function, the dentist
Burning mouth syndrome ought to be careful and not extend the
Burning mouth syndrome (BMS) is a com- prosthetic treatment further. In taking
plex and multifactorial condition char- care of patients with BMS both physi-
acterized by diffuse sensations of pain ological and psychological factors must be
from a mouth with normal mucosa. BMS managed. This demands collaboration in
has been subcategorized as primary BMS teams with multidisciplinary expertise to
meaning a chronic, idiopathic intraoral bring the condition under better control.
mucosal pain condition, which is not ac-
companied by clinical lesions or systemic concluding remarks
disease. Secondary BMS is defined as oral Methods to produce complete dentures
burning sensations from various local or most often follow traditional prosthetic
systemic abnormalities. Many secondary procedures in order to attain a good pros-
local conditions have been proposed in thetic result. However, there are only few
the pathogenesis of BMS (nerve trauma, evidence based procedures used in the
oral parafunctional habits, salivatory production of complete dentures.
gland dysfunction or dental treatment). Many common clinical measures lack
Systemic factors may predispose devel- scientific support and are based on stud-
opment and severity of BMS symptoms ies of anecdotal character, not seldom
such as menopausal disorders, diabetes, with contradictory results.
and nutritional deficiencies. A strong psy- This chapter has shown effects of
chological component in BMS has been complete dentures on oral tissues and
identified and recently neuropathic dys- how to diagnose, treat, and avoid damage
function factors have been suggested to from the dentures. Overdentures sup-
be involved in BMS pathology. ported by natural tooth roots or dental
There is only limited evidence to implants as opposed to complete dentures
guide clinicians in the management of might be better at preserving oral mucosa
patients with BMS. A correct medical and bone tissue. These so-called preven-
and clinical history together with details tive prosthodontics, where overdentures
about occurrence and sites of pain as well are chosen as a treatment of edentulous-
as a careful examination of the oral mu- ness of the mandible, have been advo-
cosa are the first steps an initial diagnosis cated as the first treatment of choice.
of BMS. There are conflicting opinions Often, the correlation between the
about the impact of wearing dentures in dentist´s judgement of denture quality
BMS. Correcting malfunctioning den- and patient satisfaction is poor. A major-
tures seems to be the first prosthetic treat- ity of denture wearers are satisfied with
ment of choice in taking care of a patient their dentures, irrespsctive of denture

quality. However, a denture must be care- which makes it easier for the patient to
fully and consistently made according to accept the dentures. For patient satisfac-
known prosthodontic principles. The pation, good relations between dentist and
tient will appreciate the dentist’s commit- patient seem to be even more important
ment to make accurate complete dentures. than a technically perfect denture.
This is an important psychological factor,
Further reading
Bergendal T. Treatment of Denture Stomatitis. A Clinical, Microbiological and Histological
evaluation. Thesis. Stockholm: Karolinska Institutet, 1982.
Bergendal T, Engquist B, Palmqvist S. Overdentures. Report from Scandinavian Society for
Prosthetic Dentistry; 2002.
Budtz-Jörgensen E. Candida-associated denture stomatitis and angular cheilititis. In: Samara-
nayake LP, MacFarlane TW (eds.). Oral Candidosis. London: Wright 1990:156–183.
Budtz-Jörgensen E. Sequelae caused by Wearing Complete Dentures. In: Zarb GA, Bolender
CL (eds.). Prosthodontic Treatment for Edentulous Patients. 12th ed. St. Louis, Mo: Mosby;
2004, pp 34-50.
Carlsson GE. Critical review of some dogmas in prosthodontics. J Prosthodont Res 2009;532:3-10.
Newton AV. Denture sore mouth. Br Dent J 1962;112:357–360.
Ohman SC, Dahlen G, Möller A et al. Angular cheilitis: a clinical and microbial study. J Oral
Pathol 1986;15:213-217.
Palmqvist S, Carlsson GE, Öwall B. The combination syndrome: a literature review. J Prosthet
Dent 2003;90:270–275.
Ramage G, Tomsett K, Wickes BL et al. Denture stomatitis: A role for Candida biofilms. Oral
Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:53–59.
Samaranayake LP. Essential Microbiology for Dentistry. 3rd ed. Edinburgh: Elsevier Churchill
Livingstone; 2006.
Samaranayake LP, Leung WK, Jin L. Oral mucosal fungal infections. Periodontology 2000.
2009;49:39–59.
Scala A, Checchi M, Montevecchi M, Marini I. Update on Burning Mouth Syndrome: Overview
and Patient Management. Crit Rev Oral Biol Med 2003;14:275-291.
Tallgren A. The continuing reduction of the residual alveolar ridges in complete denture wear-
ers: a mixed longitudinal study covering 25 years. J Prosthet Dent 1972;27:120–132.
Zakrzewska JM, Forssell H, Glenny AM. Interventions for the treatment of burning mouth syn-
drome. Cochrane Database of Systematic Reviews 2005,(1):CD002779.

6
Prognosis and evidence
based prosthodontics
a s B jö r n j o k s ta d
INTRoDucTIoN. The word prognosis is derived from Greek, and literally means fore-know-
ing or foreseeing. Physicians coined the term in the 17th century for a prediction of the most
probable prospect for the patient based on the patient’s signs and symptoms. We may imag-
ine that the “prognosticators” at that time were aware of the negative effects of e.g. under-
nutrition, old age and co-morbidity due to concomitant diseases on the patient’s chances
for improvement. using current nomenclature, we would call these attributes for “prognostic
factors”.
Today, the term “prognostic factor” is used for any intrinsic or extrinsic characteristic that
can be associated with a likely outcome of a condition. This differs from the term “risk factor”,
which is used for characteristics that may be associated with the initiation of a condition or a
disease. neither prognostic factors nor risk factors necessarily entail a cause and effect rela-
tionship nor is there any consensus about what constitutes the numerical thresholds between
“strong/significant” and “weak/unimportant”. Risk factors and prognostic factors can have
various qualities: They may be disease-specific, they may constitute a state of co-morbidity,
or they may consist in a demographic factor etc. Risk factors and prognostic factors may be
similar, but not necessarily of similar predictive strength nor direction. E.g., men have a sig-
nificantly higher risk for myocardial infarct than women, but the prognosis is relatively good.
For women it is the opposite; myocardial infarcts are infrequent, but when they do occur,
the morbidity and mortality is significantly greater than in men. Another difference is that
risk factors usually predict low probabilities of an event that may take a long time to appear,
while prognostic factors often are associated with events that are more frequent. Risk factors
are consequently often appraised through case-control study designs, while prognostic fac-
tors are identified by means of a range of study designs beyond prospective cohort studies.
Moreover, while the outcome of interest for risk factors is the onset or implications of a health
condition or disease, the outcome of interest for evaluating prognostic factors may range
from recovery to the disease recurring or a range of medical complications and even death
(Table 6.1).
The term prognosis is today being used within all fields of biomedicine and denotes a pre-
diction of how a patient’s disease will progress, and whether there is chance of recovery with
85

Differences Risk factors Prognostic factors
Factors, associated …an increased risk of de- …a worsening of a condition

with… veloping a condition or dis-
ease
Study population …healthy individuals …individuals with a condition or dis-

consists of… ease
The event of inter- …onset of a condition or …consequences of a condition or dis-

est is the… disease ease
Rates usually pre- … rare events that may take a …more frequent events that develop
dict… long time to happen over a relatively short period of time
Table 6.1. Some differences between risk factors and prognostic factors.
and without active intervention. Sometimes, the term “natural history” is used to describe
the prognosis of disease without medical intervention, while the term “clinical course” of a
disease describes a change in prognosis of the disease that has come under medical manage-
ment. An active medical intervention can be considered as one prognostic factor amongst
several other prognostic factors. This can perhaps be understood using cancer treatment and
survival as an example. Besides age, gender and cancer invasiveness, active interventions are
each separately, as well as possibly synergistically identified as prognostic factors for patient
survival. Active interventions might be a surgical operation technique and/or supplemented
with x Gray of radiation therapy and/or supplemented with chemotherapy and/or strict di-
etary regimes and/or smoking-cessation interventions and/or mental or physical exercise etc.
From a hypothetico-deductive reasoning perspective, risk and prognostic factors can be
regarded as similar, and they are inferred from the data of studies of different methodological
designs. Multiple clinical study designs can be applied to identify potential prognostic factors,
but the risk of bias will depend on the choice of study design. The Oxford Centre for Evidence-
based Medicine has suggested a hierarchy of levels of evidence for estimating prognosis that
seems to have obtained general consensus amongst scientists and clinicians (Table 6.2).
Prosthodontic therapy as replacements for oral tissues with

Prosthodontic therapy is characterized by a wide spectrum of reasons for loss
certain traits that make the application of of teeth. This means that the disease
the different terms described in the previ- condition that traditionally is central
ous section complicated in a traditional in an evaluation of prognosis is poorly
medical context: defined.
1. Removable prostheses are being used 2. It is not uncommon to regard the spe-
86 Prognosis and evidence based prosthodontics

Level Prognosis
1a • Systematic Review with homogeneity* of inception cohort studies

• Algorithms/scoring systems which lead to a prognostic estimation validated in dif-
ferent populations
1b • Individual inception cohort study with > 80% follow-up

• Algorithms/scoring systems which lead to a prognostic estimation validated in a
single population
1c • All or none case-series
2a • Systematic Review with homogeneity* of retrospective cohort studies

• Systematic Review with homogeneity* of untreated control groups in Randomized
Controlled Trials
2b • Retrospective cohort study

• Follow-up of untreated control patients in a Randomized Controlled Trial
• derivation of algorithms/scoring systems which lead to a prognostic estimation
or validated on split-sample only (i.e. collecting all the information in a single
segment, and then artificially dividing this into “derivation” and “validation” sam-
ples.)
2c • “Outcomes” research (Clinical evaluations that focus on 1) the status of partici-

pants after receiving care and on 2) the process of care itself)
3a • Case-series
3b • Prognostic cohort studies of poor quality (i.e. sampling was biased in favour of
patients who already had the target outcome, or the measurement of outcomes
was accomplished in <80% of study patients, or outcomes were determined in an
unblinded, non-objective way, or there was no correction for confounding factors.)
4 • Expert opinion without explicit critical appraisal

• Expert opinion based on physiology
• Bench research
• Pathophysiological principles used to determine clinical practice
Table 6.2. Levels of Evidence according to the Oxford Centre for Evidence-based Medicine (http://www.cebm.
net/?o=1025). * Free of variations (heterogeneity) in the directions and degrees of results between individual
studies which may raise doubt about conclusions of the review.
cific removable prosthesis as the core afflictions due to lack of teeth, and
of the therapy. The prosthesis, howev- expected to have a minimal impact on
er, should rather be regarded as one of eventual further disease progression.
several means to resolve the patient’s 3. It is advocated and presumed that a
Prognosis and evidence based prosthodontics 87

removable prosthesis should first be sidered a risk factor for both caries and per-
inserted after a causal therapy has iodontitis of the remaining teeth in order
been instituted and following a return of magnitude from the abutment teeth,
to acceptable oral health and optimal the teeth covered or adjacent to the pros-
biological condition of the remaining thesis and the remaining dentition. The
tissues. Reality, unfortunately, is that design and ability of the individual com-
prostheses often are adapted where ponents to resist mechanical breakdown
such ideal conditions seldom are ob- is an additional dimension. Concurrently,
tained. the RPDP design and remaining integrity
4. The patients’ objectives for acquiring is a prognostic factor as regards negative
a removable prosthesis will differ, and outcome such as an unstable occlusion
an estimate of prognosis will therefore or oral discomfort, or regarding positive
build on different combinations of outcome such as satisfactory aesthetics,
criteria. speech and mastication. Moreover, this
5. The technical quality of the remov- dual perspective of removable prostheses
able prosthesis as well as the resistance can also be attributed to the past uncer-
of the individual components to with- tainties of aetiology of several oral diseas-
stand wear, discoloration and break- es and afflictions. E.g. temporomandibu-
age will clearly affect the prognosis. lar dysfunction (TMD) and even bruxism
Indirectly, the clinician’s competency was previously believed to be caused by
and proficiency as well as ability to lack of posterior teeth or “instable occlu-
prescribe an adequate treatment plan sions according to a set of criteria”, and as
are additional confounding variables. such a removable partial dental prosthesis
6. Finally, several observations indicate was regarded as a prognostic factor to al-
that patients’ somatic and psychologi- leviate the diseases. Today, there is general
cal adaptation ability to a removable consensus that such a relationship is at
prosthesis as a foreign intraoral object best weak or non-existent. Nevertheless,
will vary greatly, and this important an incorrectly designed removable den-
factor for prosthodontic treatment ture can certainly induce TMD and must
success can hardly be predicted before therefore rather be regarded as a risk fac-
commencing the therapy. tor in this perspective. The same applies
to our current understanding of residual
It is difficult to employ a rigid separation ridge resorption, which is a physiologi-
between prognostic factors and risk fac- cal remodeling process following tooth
tors when they are applied to removable extractions where the relevance of the de-
prostheses. All removable prostheses per sign and/or diurnal use of the removable
se increase the risk for the development of denture as a potential risk factor for ac-
new oral diseases. Thus, a partial remov- celerated local jaw bone loss still remains
able dental prosthesis (RPDP) can be con- unsolved following decades of debate.

To summarize, the term prognosis is Prognosis, general
in the prosthodontic literature applied considerations
not only in the context of describing As clinicians, we are faced with con-
the natural history and clinical course of siderations of prognosis continuously.
diseases, but also used to describe their The patient may sometimes ask the direct
possible adverse consequences on remain- question: “How long can I expect my new
ing oral tissues as well as ability to satisfy removable prosthesis to last?” This question
the patient’s subjective needs and finally contains three elements; (1) a time aspect
the durability of prostheses of different (when), (2) a qualitative element (what)
designs. The philologist may correctly and (3) a quantitative estimate (probabil-
point out incongruent uses of the term in ity). In relation to removable prostheses, it
prosthodontics papers, e.g., “prognosis of is not uncommon to consider and discuss
osseointegrated implants” and even in com- the durability for specific forms of pros-
prehensive dictionaries such as the Glos- theses, e.g., partial prostheses made for
sary of Prosthodontic Terms (edition 4): Kennedy class 1 versus 4 situations, com-
”denture prognosis: an opinion or judgment plete versus partial prostheses, implant
given in advance of treatment for the pros- supported versus tooth retained, etc.,
pects for success in the fabrication of dentures as a rough estimate for prognosis. This
and for their usefulness”, and (edition 7): is, however, only one component of the
“Preprosthetic surgery: surgical procedures de- foundation we need to build on when we
signed to facilitate fabrication or to improve estimate the prognosis of different the-
the prognosis of prosthodontic care”. Further rapy alternatives. More important is the
examples of how the term prognosis is need to elucidate the patient’s past and
being applied within the field of prostho- current medical and dental histories in
dontics are e.g. as “probability of reaching a combination with a comprehensive evalu-
predetermined objective of a therapy” or “to ation of oral status and relevant medical
what extent patient satisfaction is obtained”. elements and integrate these findings
The intention of this review is not to with the patient’s subjective needs and
completely befuddle the reader, but rather preferences. Not until we have conducted
to point out that the word “prognosis” is these procedures will it be possible to
an example of a term that is used without apply the true term of informed consent.
knowledge of the etymology of the term As health care providers we must ask our-
nor its precise definition or general con- selves if there is a benefit or need for any
sensus for use. One cannot say that one or interventions at all. One example is an
the other usage of the term prognosis is elderly person, with a substantially worn,
incorrect, as long as it’s made understand- but otherwise problem free, dentition.
able in context with other words. What will happen, or likely fail to de-
velop with or without an e.g., tooth borne
prosthesis that augments the vertical

dimension of occlusion? A tentative an- 5. Documented estimations on prognosis
swer to a patient’s inquiry must build on (aggregated data from published stud-
past and current presence of oral disease, ies of populations versus the individu-
expected wear progression and expected al clinician and patient?)
biological response to the removable
prosthesis as an intraoral foreign object. Qualitative
Aspects that are important to evaluate in (What can happen over time?)
this context are for example: A long list of clinical signs and symptoms
• What will happen with the quality of is considered in prosthodontic therapy in
the remaining tissues, including even- context with prognosis. Typical measures
tual remaining teeth, with or without are a selection of usual problems encoun-
this prosthetic therapy? tered in prosthodontic patient groups.
• How will the functions of the stoma- They are categorized as technical, related
tognathic system change with or with- to the actual prosthodontic construction,
out this prosthetic therapy? or biological, that is, development of new
• How will the patient centered out- oral disease or return of previous oral
comes, e.g. aesthetics, function or disease, which from more or less reliable
comfort, change with or without this criteria can be causally associated with
prosthetic therapy? executed or avoided prosthodontic ther-
• What will happen with an already apy (Table 6.3).
existing prosthesis, if this is the case, Individually, the incidence of out-
with or without this prosthetic the- comes as reported in the literature can
rapy? provide a content restricted relatively
precise description of prognosis. Poten-
Thus, discussions about the prognostic tial threats against the integrity of the
elements of prosthodontic therapy have remaining tissues, against the dentition’s
to encompass different perspectives. The attempted/expected functional qualities,
actual fate of the prosthesis is just one ele- and against patient “oral comfort” de-
ment of these considerations: fined qualities need to be identified and
1. Qualitative (what can happen over addressed in order to provide meaningful
time?, i.e., “an (adverse) event”) prognostic estimates to the patient in a
2. Time factor, i.e., the time to an (ad- comprehensible manner. Moreover, the
verse) event technical quality of prosthesis and its in-
3. Quantitative (what is the probability dividual components, and the ability of
that a certain (adverse) event will de- each component to resist wear and tear,
velop?) are additional confounding elements in
4. Observation viewpoint (therapy de- this context.
fined disease versus patient experi- Technical and biological problems
enced illness?) may be easy or difficult to identify. Both

prostheses that function adequately in all objective to determine prognosis it is im-
ways, and the opposite, a prosthesis that portant to recognize some thumb rules. A
is damaged beyond usability, are easy to potential for bias is introduced if a prog-
detect, although the reasons for the dam- nosis is based on a subjective appraisal of
age can be debatable. outcomes of past patients. There is a need
Between these two extremes there is a to use predetermined criteria that are rec-
wide spectrum of therapy results that can ognized as relevant throughout follow-up
be more or less difficult to identify or ac- observation period. These criteria need to
knowledge and where the examiner must be objective enough to describe precisely
use clinical judgment to establish how the results that are of primary interest.
adverse events can be registered. An assessor of the patient may introduce
When evaluating reports on prognosis a subjective dimension if he or she knows
or if planning a new clinical trial with the about the previous patient history or if it
Risk factor Reference
Caries & Periodontitis Öwall et al., 2002

Wöstmann et al., 2005
Mucosal injury Creugers & kreulen, 2003

• Allergy
• Stomatitis
• Hyperplasia
• Burning mouth syndrome
Temporomandibular dysfunction de Boever et al., 2000
Prognostic factor
Occlusal stability (“tooth malpositions”) Celebi & knezovi -Zlatari , 2003
Bone remodeling (“Alveolar bone loss”) Palmqvist et al., 2003
“Oral discomfort” (esthetics, mastication, speech, etc.) Gotfredsen & Walls, 2007
nutritional aspects n’gom & Woda, 2002
Quality of life Strassburger et al., 2006
Patient satisfaction Zlatari & Celebi , 2001
Technical quality deterioration Grundström et al., 2001

Table 6.3. Key references with focus on function period and technical quality of the removable prosthesis (i)
in context to potential risk factors for future disease or (ii) as prognostic factors for impact on oral discomfort
and/or disease, or (iii) as a function of time.

is the same person who has undertaken strategies can be applied to the problem.
a clinical intervention. If an intervention The first is a simple variant of a “what
has been provided to patients the asses- if…” approach, or so-called sensitivity
sor of the outcomes should preferably not analysis. Imagine that the prognosis of
know the type or extent of the therapy, 100 prostheses were to be estimated over
i.e., attempts should be made to have a 5 years in a prospective study. Let’s say 10
blinded assessor. From a methodological prostheses fractured over this period. At
perspective, it is also preferable that even the same time, 25 patients with the same
the patient and the provider are blinded number of prostheses withdrew for vari-
although this is evidently difficult in ous reasons. A number of “success” can
prosthodontic care. be calculated as 100% -10/75 = 87%. How
can one account for the prostheses in the
Time factor 25 patients that withdrew? Maybe some
Events following prosthetic therapy gen- of these also fractured? In a “worst-case”
erally take a long time to develop and it is scenario all would have fractured, which
understandable that each patient cannot will give a “success” of 100%- 35/100 =
be followed up until some biological or 65%. Reciprocally, in a best-case scenario
technical problem develops. One main none would have fractured and provide
question is what should be considered as an estimate of “success” of 100%- 10/100
a relevant follow up time. Short observa- = 90%. The large difference between 65%
tion periods do not provide especially and 90% after the sensitivity analysis
meaningful information to present to our indicates perhaps that the proportion of
patients. With a long observation period withdrawals in this study was too high
follows often the problem that patients to make any meaningful conclusions.
disappear. It is important to establish The other possibility is to apply the so-
the reasons for such withdrawals. Some called 5-20-rule of thumb. This rule is
reasons for withdrawal, such as change interpreted such that less than 5% with-
of address, death and incapacitation are drawal can be ignored, while more than
inevitable and usually independent of 20% withdrawal reduces the validity of
prognosis. We don’t have to worry too the study. These percentages are of course
much about these withdrawals, especially only indicative and must be evaluated in
if the rates are trivial. Other reasons can relation to the incidence of technical and
be age or medical condition, or desire to clinical problems. Since the incidence of
no longer be recalled. If the latter group adverse events in prosthodontic therapy
is large, the validity of any conclusions is relatively low, it is difficult from a
becomes reduced – regardless of whether methodological perspective to estimate
this is based on own practice data or pub- prognosis from studies with high patient
lished clinical study data. withdrawals.
In the analysis of published data, two

Quantitative (What’s the probabil- for quantifying how the clinical perfor-
ity that certain events will develop?) mance of prostheses will be affected. The
A discussion about incidence of lack of incidences of biological and technical
quality requires different approaches failures can be established and reported
for addressing technical defects on one for certain time intervals, e.g. after 1 year
hand, and biological effects on the other. or 5 years. More common in prosthodon-
Technical defects are a component of tics is to report time-to-event of various
the estimation of prognosis that is di- outcomes. Two common measures in this
rectly related to the prosthodontic part category are median-time and survival
of the therapy, and is directly related to estimates. Median time is defined as
the quality of the technological process, when the time-to-event of interest has
including material qualities. For the developed in 50% of the statistical units.
biological parameters there is no similar The statistical unit can be defined either
direct relationship. In this case, the prog- as the patient, the jaw or the prosthesis.
nosis will often primarily be dependent Survival curves indicate estimates for any
of the underlying disease and only de- given time of the percentage of statistical
pendent of the prosthodontic therapy to unit that is defined as intact according to
such degree that it per se predisposes for a specified criterion. Several events can be
disease progression or affects the danger described, e.g., degrees of successive devi-
of recurrence. Meaningful information ations from perfect function or aesthetics,
to the patient about biological prognosis secondary caries or endodontic complica-
must therefore include a comparative ele- tions of abutment teeth, fractures, oral
ment where the relevance of the original candidiasis, etc. Survival curves provide
diagnosis is emphasized and where the the most information since the curve
role of the prostheses as a prognostic fac- shape will indicate whether the prognosis
tor is contextualized. is constant throughout the observation
Several investigators have presented period, alternatively improve or worsen
the relative and absolute risks, alterna- over various time spans (Fig. 6.1).
tively as odds ratios for such events to de-
velop as functions of, e.g., patient demo- observation viewpoint
graphics, modifications of prosthesis de- (Therapy defined disease versus patient
sign, prior dissatisfaction with prosthesis, experienced illness?)
etc. Thus, specific prognostic factors have The criteria for success or failure of pros-
been identified as predicting treatment thodontic interventions can vary de-
success, which needs to be taken in con- pending on the observation viewpoint.
sideration when diagnosing and planning Operator defined criteria can markedly
treatment for the individual patient. deviate from the criteria that patients
Unfortunately, relative risks or odds value. Moreover, the patient expecta-
ratios are somewhat vague constructs tions may vary greatly within these main

%
100
90
80
70
60
50
0 5 10 15 Years 20
Fig. 6.1. Examples of three differently shaped survival curves over 20 years. The vertical bars indicate the
confidence interval (C.I.) of the estimates, usually the 95% C.I. The red curve indicates a survival estimate
that is linear over time and does not vary, but with a wide C.I. The green curve (with a narrow C.I.) shows
a good survival until about 15 years followed by a marked drop in survival estimates. The blue curve sug-
gests a relatively rapid drop in survival estimate, but after 5 years the survival estimate remains relatively
stable, and in this constructed example it demonstrates the best survival after 20 years. If the C.I. bars do
not overlap on the graph, one may deduce that there is a statistically significant difference between the sur-
vival curves. Please note that the vertical axis for illustrative purposes stops at 50% in this example, while
some journals require a scale between 0 and 100%.
groups. In general, the operator will re- The patient’s perception of the success of
gard lack of defined disease conditions prosthodontic therapy is an important
as important criteria in addition to the dimension. This outcome causes inter-
technical characteristics of the prosthetic pretative problems when we evaluate
device. From the patient’s perspective, the success or failure of prosthodontic
however, sometimes modest biological therapy. One term that is often used is
symptoms may appear as uninterest- “oral discomfort”, acknowledging that
ing, while details related to the experi- this state is strongly influenced by indi-
ence of the prosthesis as a foreign object vidual predispositions as well as consid-
and deviation from expected aesthetic ered in a cultural context. Several papers
achievements are highly relevant. with focus on the effects of loss of tooth

on patients’ quality of life report findings On the other hand, one may argue that
ranging from a description of a near sui- even randomized well controlled trials of
cidal state to an almost complete lack of large populations also have limited value
any outward indication of loss explained when the results are to be applied on an
by a societal conditioning. individual level. The reason is that pa-
Both the clinician and the patient tients who consent to extensive follow-up
have opinions on what is most import- studies are probably not representative of
ant. Different emphasis can be placed on the average patient.
the quality of the remaining dentition, Preferably, all dentists should have
to what extent stomatognathic functions systematized their own documentation
may be restored or maintained and to of prognosis based on accrued data fol-
what extent patient defined criteria are lowing prosthodontic treatments. Unfor-
acceptable, for example as relates to aes- tunately, this is seldom the case, perhaps
thetics, function and comfort. Finally, except for implant based prostheses. Most
there may also be discrepancy of opinions dentists therefore base their estimates on
as regards different criteria to describe the reported data from the literature. There
qualities of the prosthesis and relevance is no principal difference between criti-
for describing or evaluating the prognosis. cally appraising one´s personal empirical
All in all, it is debatable what the most data generated in own practice differently
relevant outcome is when we evaluate the from evaluating the data in published
prognosis of prosthodontic therapy. clinical studies. For both information
sources, the same requirements apply re-
Documentation estimations garding validity, outcomes and usability
on prognosis of the information applicable to prog-
(aggregated data from published studies nosis. Firstly, it is important to appraise
of populations versus the individual clini- whether the data applied as basis for
cian and patient?) estimating prognosis are valid. Threats to
The ideal situation is that a systematic validity are patient withdrawal rates and a
documentation of experiences in own clarification of the reasons for patient dis-
clinical practice should provide a founda- appearing or withdrawing from clinical
tion for opinion about prognosis of pros- trials.
thodontic therapy. The moment that this A published study claiming that spe-
is not systematized conveying prognoses cific subpopulations may have different
to patients becomes very inaccurate. If prognoses must be appraised specifically
one is to base opinions on prognosis from for several aspects: First one must estab-
the literature there is general consensus lish whether all important prognostic fac-
that case reports about treatment results tors were considered. In other words, we
have a limited value. Indeed, the term expect that the authors have considered
anecdotal value is used for such reports. whether or not other important subgroup

predictors have influenced the treatment Treatment planning
outcome. E.g., in a study claiming that In daily clinical practice, published data
elderly patients with xerostomia have may be of interest, but only if they can be
a worse prognosis regarding prosthesis directly applied to specific treatment deci-
function than younger patients, a central sions. In this perspective, it is important
question is whether age or xerostomia is to be conscious about several elements
the critical factor? There are both easy relative to clinical studies:
solutions to adjust for potential interac-
tions between these predictors or more The operator and patient
advanced methods, that are either strati- factor
fied cross-tabulations or multiple regres- Several reservations must be made before
sions. In both cases we must evaluate the we may translate numerical findings in
materials and methods section to appraise the literature regarding prognoses within
whether this has been attempted, before prosthodontics: first of all, the operator in
we proceed to accept the author’s even- most of the core studies is often specially
tual conclusions. selected and trained. Studies are often
Discussing prognosis by using the carried out by experienced clinicians
terms “success”, “survival”, “complica- within special institutions such as dental
tion” and “failure” is fraught with risks faculties, competency centers or specialist
of misunderstandings, both in reporting, clinics. There are reasons to believe that
reading, interpretation, and patient both the selection of patients, choice of
communication. There is no universally treatment, control of technical quality
agreed taxonomy, and this should be re- and maintenance and follow-up routines
membered when we explain to patients deviate markedly from the conditions
the potential risks of adverse events as- that exists for the patient or patient group
sociated with removable prosthodontics we encounter in our own practices. It may
therapies. Moreover, it should also be be tempting to state that the numbers
borne in mind that the most likely rea- we operate with when informing about
sons for failure of partially removable prognoses are overestimations of treat-
prostheses, i.e., caries and periodontitis, ment success. These study data reflect to a
and for removable, i.e., loss of retention, large extent the potentials of the different
can be counteracted by maintaining an prosthodontic therapies under optimal
individually adapted patient supportive conditions, rather than the predictive
program. Perhaps this, in the end, is the outcomes for the average patient in real
most likely factor that determines success life practical dentistry. Two terms are be-
of removable prosthodontics care. ing used in the literature to denote the
difference in interpretation of such study
results: Efficacy describes the potential of
an intervention under optimal conditions

while effectiveness is a description of the sus sporadic controls, etc. Known biologi-
results under realistic settings amongst a cal/technical factors that may affect the
population of non-selected clinicians. prognosis for removable prosthodontics
are alloy, prosthesis extension, dimen-
correct identification of the sioning and abutment vitality, marginal
patient’s problems periodontitis, patient hygiene, etc. for cast
It is always presumed that the dentist partial removable dental prostheses. For
makes a correct and complete diagnosis. complete removable dental prostheses the
How often is this true when removable prognosis is dependent on the patient’s
prosthodontic therapy is planned? Diag- ability to accommodate to a new situ-
nosis of both the operator-defined disease ation, jaw morphology, extent of bone
as well as the patient experienced illness resorption, osteoporosis, xerostomia,
will indicate the most appropriate choice etc. For implant-retained prostheses ad-
of therapy and thereby guide the object- ditional factors are also relevant, such as
ives of the therapy significantly. It would smoking, bone quality and dimensions,
seem evident that population based implant material and -dimensions, etc.
prognosis-estimates based on a purely For all therapies, the level of prosthodon-
morphological diagnosis criterion such as, tic competency as well as competency of
e.g. lost maxillary incisor, have a limited the dental technician will have an effect
translation value to single patients with on prognosis, and for the latter therapeu-
different basis diagnoses such as agenesis tic approach it will also depend on the
or juvenile periodontitis. Too often, the competency of the oral surgeon.
prosthodontic diagnosis is indeed limited
only to morphological observations of How should we explain
remaining dentition or periodontal sup- prognosis to our patients?
port and short term result of eventual One must not forget that we all have dif-
preprosthetic causal therapy against caries ferent attitudes to risk and risk evalua-
and periodontitis. tion. What seems rational to one person
For all categories of prosthodontic may be considered precarious by some
therapy there are specific subgroups of and unproblematic by others. Our obliga-
patients that will have a divergent prog- tion as doctors is therefore to present to
nosis apart from the general population. our patient in the most objective manner
The prognosis for all forms of prostho- available knowledge and data relative to
dontic therapies can be associated with the prognoses of alternative prosthodon-
any or is cumulative in presence of man- tic therapies, including none, as a basis
dibular dysfunction, rheumatoid arthritis, for our patients’ selection of what they
situation in antagonistic jaw, bruxism, consider the most appropriate alternative
positional instability of the remaining from their holistic perspective.
dentition, routine follow-up controls ver- We all wish to satisfy our patients by

providing prosthodontic solutions with about prognosis, it is our professional ob-
a precise description of how long it will ligation to point out that the predictabil-
last. Unfortunately, this is not possible. ity of an “average prognosis” is dependent
All numbers from studies are based on on specific main criteria (e.g. such that
averages, which mean that for some pa- the prostheses not necessarily MUST be
tients, the prosthesis will function for a removed due to adverse biological dam-
very long time, while in others for a very age), that an average of 10 years can mean
short time. Our discussions with the pa- that both 3 or 18 years are “normal”, and
tient must reflect this fact and not lead finally that technical success and a proper
us to infer to the patient or ourselves that oral hygiene regime does not guarantee,
we “guarantee” longevity and/or treat- although it increases the chances, of suc-
ment success. Unrelated to our knowledge cessful prosthodontic therapy outcomes.
Further reading
Bergman B. Prognosis for prosthodontic treatment of partially edentulous patients. In: Pros-
thodontics. Principles and management strategies. Öwall B, Käyser AF, Carlsson GE (eds).
London: Mosby-Wolfe, 1996, 149-160.
Celebi A, Knezovi -Zlatari D. A comparison of patient’s satisfaction between complete and
partial removable denture wearers. J Dent 2003; 31: 445-451.
Creugers NH, Kreulen CM. Evidence for changes in removable partial and complete denture
treatment and biologic compatibility. Int J Prosthodont 2003; 16 Suppl: 58-60.
De Boever JA, Carlsson GE, Klineberg IJ. Need for occlusal therapy and prosthodontic treat-
ment in the management of temporomandibular disorders. Part II: Tooth loss and prostho-
dontic treatment. J Oral Rehabil 2000; 27:647-659.
Gotfredsen K, Walls AW. What dentition assures oral function? Clin Oral Implants Res 2007;18
Suppl 3: 34-45.
Grundström L, Nilner K, Palmqvist S. An 8-year follow-up of removable partial denture treat-
ment performed by the Public Dental Health Service in a Swedish county. Swed Dent J
2001; 25: 75-79.
Jokstad A, Bayne S, Blunck U, Tyas M, Wilson N. Quality of dental restorations. FDI Commis-
sion Project 2-95. Int Dent J 2001; 51: 117-158.
N’gom PI, Woda A. Influence of impaired mastication on nutrition. J Prosthet Dent 2002; 87:
667-673.
Öwall B, Budtz-Jørgensen E, Davenport J, Mushimoto E, Palmqvist S, Renner R, Sofou A, Wöst-
mann B. Removable partial denture design: a need to focus on hygienic principles? Int J
Prosthodont 2002; 15: 371-378.
Palmqvist S, Carlsson GE, Öwall B. The combination syndrome: a literature review. J Prosthet
Dent 2003; 90: 270-275.

Strassburger C, Kerschbaum T, Heydecke G. Influence of implant and conventional prostheses
on satisfaction and quality of life: A literature review. Part 2: Qualitative analysis and eval-
uation of the studies. Int J Prosthodont 2006; 19: 339-348.
Wöstmann B, Budtz-Jørgensen E, Jepson N, Mushimoto E, Palmqvist S, Sofou A, Öwall B. In-
dications for removable partial dentures: a literature review. Int J Prosthodont 2005; 18:
139-145.
Zlatari DK, Celebi A. Treatment outcomes with removable partial dentures: a comparison
between patient and prosthodontist assessments. Int J Prosthodont 2001; 14: 423-426.

7
Examination and diagnostics
Ei na r BErg
INTRoDucTIoN. The basic purpose of supplying a patient with a prosthetic restoration is to

satisfy a need. The extent to which this need is satisfied is reflected in the degree of patient
satisfaction with the prosthodontic device. The purpose of examination and diagnostics is to
gather all relevant information regarding medical and psychological factors and the status of
the oral tissues. These factors govern the type and quality of what prosthetic devices can be
constructed. They also define to what extent the prosthesis is able to satisfy the functional and
aesthetic needs of the patient.
This information thus forms the basis for the appropriate treatment and for informing the
patient of the possibilities, limitations and other circumstances inherent in the suggested resto-
ration. Conscientiously informing the patient accordingly is obviously of importance; thus ex-
pectations can be adjusted to a realistic level. Of the greatest importance, through the dialogue
with the patient in which these matters are discussed, a rapport with the patient is hopefully
established. This means that the dentist has to treat the entire patient – not just the area be-
tween nose and chin. Failure to inform the patient properly at this time (and later) is probably
the reason why some do not wear or are dissatisfied with their dentures. However, in order to
appreciate the clinical relevance of the findings, the fundamental difference between the pa-
tient’s approach to his condition and the one by the professional operator must be understood.
Disease and illness as experienced by the patient. True, a

Disease and illness are two central con- discussion on disease and illness related
cepts in understanding the psychological to prosthodontics is perhaps not entirely
and social aspects in any treatment of hu- appropriate in the classical sense, because
mans. The present discussion will largely partial and complete edentulousness per
be limited to aspects especially relevant se are not sicknesses, which normally
for removable prosthodontics. connote some kind of pathological condi-
tion. However, a need to restore missing
Definitions teeth is usually conceived as a sickness by
Disease relates to a state of sickness as the patient. Also, it is normally the seque-
diagnosed and defined by the therapist. lae of a pathological condition.
In contrast, illness is a state of sickness
101

Practical aspects of disease Anamnestic information
and illness and interview
It is important to recognize that the The first part of the examination is to
interpretations regarding disease and ill- obtain sufficient anamnestic informa-
ness are not necessarily in agreement. A tion, i.e. a preliminary case history of all
patient’s problems in relation to a sick- relevant medical and dental aspects. In
ness may thus not be limited to observ- addition, it is important to try to disclose
able symptoms. An objectively successful relevant psychological and social aspects
treatment that alleviates most or all such related to the patient’s need. To that end,
symptoms is therefore not always success- it is crucial that the illness aspect dis-
ful from the patient’s perspective. Unless cussed above is revealed so that the den-
the difference between disease and illness tist can deal with the patient’s subjective
is recognized, appropriate treatment may problems appropriately.
not be administered, and the risk of a dis- There are no generally accepted guide-
satisfied patient will increase. lines as to how this interview should be
The risk is further strengthened if the performed, except that it is essential to
treatment in question is unable to restore allocate sufficient time for it. A minimum
the patient completely to the former oral of 30 minutes – and not infrequently
function. This is particularly relevant more – is usually necessary. Based on clin-
for removable prostheses because of ical experience the interview may profit-
their considerable physical and aesthetic ably be divided into an unstructured and
shortcomings as compared to the natural a structured part.
dentition, but also because of the negative
social and psychological impact that loss unstructured interview
of teeth and their replacement entail for A suitable way to start is to ask the patient
many patients. what the present problem is and what the
It is therefore to be expected that for patient expects from the treatment. The
some, the illness aspects in regard to re- patient ought not to be interrupted while
movable dentures may be difficult or even answering, even though the response may
impossible to satisfy entirely. A removable sometimes be both longwinded and parts
prosthesis may thus be made lege artis in of it irrelevant. If cut short, the patient
every respect, but for a number of reasons may be sidetracked from what is impor-
still be unsatisfactory from the patient’s tant to him, which defeats the purpose
point of view. This fact should be taken of the interview. During the response,
into account when informing the patient the dentist should look for clues to pos-
both during treatment planning and im- sible hidden problems. Such problems are
plementation. often related to social or psychological
issues of a sensitive nature, and must be
probed with sensitivity and empathy.
102 Examination and diagnostics

The patient should also be asked if he usually be resolved before any dental
suffers from any pain or discomfort from treatment is commenced. Also, some
the mouth. This may be significant, partic- chronic diseases may have a direct or in-
ularly if related to existing prosthodontic direct impact on prosthetic treatments,
restorations. Such information may some- particularly in terms of prognosis, and
times reveal problems with adaptation if thus on indications for treatment.
no obvious cause of the pain is found, or Some of these diseases have the effect
it may be a symptom related to mucosa or of reducing infection resistance (such as
other oral tissues and require further clini- diabetes and the sequelae of organ trans-
cal examination and diagnosis. plants); other conditions interfere with
Not until the patient has completed his muscular control important in retaining
answers, should supplementary questions removable dentures and maintaining
in areas indicated during the interview be adequate plaque control (such as some
asked in order to reveal relevant issues. rheumatic conditions, Parkinson’s disease,
stroke and other motor diseases). Diseases
Structured interview causing dry mouth such as Sjögren’s dis-
The information above often tends to ease are of obvious importance, as are
be of a general nature. Additional spe- serious heart conditions, which may pre-
cific and clinically useful information is clude procedures that require prolonged
usually needed. This includes relevant treatments. Psychiatric conditions may
medical and dental histories. In addi- be important in relation to prosthodontic
tion, information regarding the patients’ treatment for many reasons; perhaps the
experience with present restorations and most important ones are a reduced capa-
expectations with future ones should be city to accept and adapt to a removable
gathered. prosthesis.
General health Medication

Information regarding the patient’s gen- Most of the above diseases are treated
eral health should always be collected. with a plethora of medications. Their
It forms part of the background for any perhaps most important effect in terms
intervention, prosthodontic or otherwise. of prosthodontics is that the majority of
As indicated below, not infrequently gen- them reduce salivation. Immune-sup-
eral health aspects are relevant for the pressing drugs used in connection with
prosthetic treatment. transplants and rheumatic conditions are
also becoming increasingly common and
Previous and present diseases tend to reduce resistance towards infec-
It is not possible to list all or even most tion. Such and other drugs with possible
diseases that might occur under this detrimental side effects on oral tissues
heading. However, acute diseases must and the function of prosthodontic de-
Examination and diagnostics 103

vices should be taken into account during Patient experiences and
treatment planning. Sometimes a change expectations
of medication may be discussed with the For the veteran denture wearer, further
physician. information can be collected by provid-
ing the structured interview with detailed
Hypersensitivities and allergies and specific questions pertaining to pa-
Claims regarding hypersensitivities and tient experience and expectations regard-
allergies should be noted and considered ing retention, stability, speech and masti-
in relation to the choice of materials used catory and aesthetic function of existing
during treatment procedures and in the dentures. For the patient about to receive
prosthetic device. Frequently such claims the first denture, a similar form, contain-
are based on unverified suspicion. If this ing basically the same items, but relating
seriously interferes with the procedures or solely to the patient’s expectations, may
choice of prosthesis, it might be advisable be used. The main purpose of both is to
to refer the patient to a dermatologist for enable the dentist to evaluate what specif-
verification. ic patient requirements and expectations
can and cannot be achieved with the new
Social aspects prosthesis.
The subjective need for treatment may be
influenced by a number of social factors clinical examination and
such as social stratum, education, culture, diagnosis
economy etc. These aspects may therefore
influence choice of treatment.
Extraoral
Dental history Facial changes of the edentulous
The patient’s dental history is of major The extraoral examination of the edentu-
interest in formulating a treatment plan. lous patient may reveal certain changes of
It may reveal the progression of patho- the facial profile, particularly in the elder-
logical conditions – with and without ly. Thus the mandible tends to approach
interventions, and thus indicate tissue the maxilla, giving the face a puckered,
resistance and patient compliance with overclosed appearance. Furthermore, the
suggested therapies. It may also reveal the lips and cheeks tend to collapse because
longevity and quality of previous restora- the teeth and alveolar bone previously
tions, indicating the prognosis of future supporting them have disappeared. The
interventions. redness of the lips becomes less visible
and the bow shape of the upper lip tends
to flatten out. The angles of the mouth
are drawn downwards, the nasolabial
sulci become more accentuated and fovea

Fig. 7.1. Changes in the facial appearance with and Fig. 7.2. Changes in the facial appearance with
without dentures, frontal view. and without dentures, lateral view.
mento-labialis tends to disappear (Fig. 7.1, and compared with possible anamnestic
7.2). In addition to an observation of the information on pain and discomfort.
above symptoms the extraoral examina- Other signs of mandibular dysfunction,
tion should include assessments of any such as a reduced opening or mobility of
other condition of prosthetic interest; the jaws, deviating jaw movement or ten-
some of the more common ones are men- derness of the closing muscles may indi-
tioned below. cate temporo-mandibular dysfunction.
Findings of aesthetic importance Intraoral

Findings of possible significance for sub- The intraoral examination should include
sequent aesthetic evaluations such as all oral tissues. For the present purposes
facial asymmetries, skin colour, lip mobil- only the most important aspects in rela-
ity during speech and smiling should be tion to removable dentures will be men-
noted and taken into consideration when tioned here.
a denture is constructed. If these aspects
are not observed or disregarded, the likeli- Ridges
hood that the future denture will blend The degree of resorption of the ridges
harmoniously with other facial features is should be assessed and possibly classified.
significantly reduced. This is important because of their effect
on denture retention and stability. Both
Signs of mandibular dysfunction aspects are adversely influenced if severe
The extraoral examination should include resorption has occurred. Maxillary or
palpation of the temporo-mandibular mandibular tori or other exostoses should
joint (TMJ). Swelling, clicking sounds and be identified (Fig. 7.3A+B). These often
crepitations of the TMJ should be noted create problems when removable dentures

A B
Fig. 7.3A. maxillary and B. mandibular tori.
are constructed and worn. For that reason quently found. This condition may vary
they sometimes have to be surgically re- in severity from small patchy red areas
duced or removed. to the chronic, fissurated kind covering
all denture-supporting tissues. Angular
The relationship between maxilla cheilitis, which is often associated with
and mandible denture stomatitis, may also occur. These
The sagittal and transversal relation- conditions are usually infected with can-
ships between the jaws should also be dida albicans, but may also be associated
examined. This examination must be with hormonal imbalance and vitamin
performed at an approximately correct deficiencies. Another commonly occur-
physiological distance between the jaws ring pathological condition is pressure
as the sagittal relationship changes with ulcers. These are usually caused by an
different degrees of jaw opening. Ideally, existing ill fitting denture, and should al-
the denture supporting areas are localised ways be relieved and observed before fur-
opposite one another. Deviations from ther treatment to eliminate the possibility
normal relationships may influence both of cancer. Sometimes these pressure ulcers
choice of therapy, for example implant may induce a hyperplastic reaction of the
retained over-denture, and prognosis. mucosa, usually along the periphery of
the denture, which needs to be relieved or
Mucosa removed surgically.
The mucosa should be examined for pos- The consistency of the mucosa is
sible pathology. Only the two most com- also of importance. Areas of pronounced
mon conditions of particular importance resilience should be identified because
for removable dentures will be mentioned they may be detrimental to retention and
here. stability of a removable denture (Fig. 7.4).
Particularly in denture wearers in- On the other hand, the latter aspects are
flammation or denture stomatitis is fre- favoured by a small degree of resilience

Tongue and intraoral muscles
The tongue should be examined, and its
size, shape and colour noted. The tongue
may be hypertrophied, shorter and wider
than normal in long-term denture wear-
ers as a consequence of its activity in
muscular control of removable dentures.
This change in shape may influence
the form of new dentures. It also tends
Fig. 7.4. Unsupported mucosa due to resorption of to make impressions and wearing the
alveolar bone. denture a challenge. Equally, the other
intraoral muscles, particularly the myelo-
hyoid and genioglossus muscles should be
examined for hypertrophy or abnormal
function.

Saliva

The quantity and quality of saliva are of
decisive importance in retaining complete
dentures, in lubricating and preventing
the formation of pressure sores of the
mucosa, in tasting, masticating and swal-
Fig. 7.5. Localisation of the pterogo-mandibular ra-
lowing food. If saliva is absent or present
phe and retromolar pad.
in insufficient quantities, such as is found
in Sjögren’s disease and other similar con-
acting as a shock-absorbing cushion for ditions, caries and periodontal diseases
the denture, preventing pressure sores. are difficult to control and pressure sores
The existence of fraena should also be from denture wear are likely to develop.
looked for, particularly if attached to the The saliva may have viscosities varying
top of the ridge, as they may interfere from almost watery to ropy, which is of
with the retention of a denture. consequence for physical retention of
The pterygo-mandibular raphe should dentures.
be localised and its insertion by the retro-
molar pads noted (Fig. 7.5). It is particu- Residual dentition and
larly important to identify its insertion surrounding tissues
under tension, as this will avoid extend- If the patient is a candidate for a remov-
ing a mandibular denture too far distally, able partial denture the residual denti-
which may cause dislocation of the den- tion and surrounding tissues should be
tures and pressure sores. examined conscientiously. This includes

clinical and roentgenographic examina- tacts or occlusal gaps, and if this contact
tion of caries status (including caries inci- is established with a “normal” degree of
dence and status of fillings), periodontal separation between the jaws. The aesthe-
condition (including measurements of tic and fonetic functions must also be
periodontal pockets, hygiene status, bony examined and evaluated. Finally, the den-
support of the teeth and mobility) and ture should be examined regarding qual-
pulp vitality. Existing and future occlusal ity of base material and artificial teeth.
loading of teeth and the occlusal condi-
tions should also be evaluated.
Diagnostics and therapy
Existing dentures General principles
Existing removable dentures should be All of the information that has been gath-
examined both intraorally and outside ered during the examination of the pa-
the mouth. Also, their effect on the patient, both verbally and physically, should
tient’s physiognomy in general and the enable the dentist to form a complete
aesthetics must be considered specifi- picture of the patient’s oral state, with all
cally. Intraorally, the denture should be possible diagnoses therein. This know-
examined for fit and function. The fit of ledge, which forms the basis for treatment
complete dentures may sometimes be dif- planning and therapy, leads to a limited
ficult to assess because the actual degree number of treatments that are profession-
of contact between the fitting surface and ally appropriate.
the underlying tissues cannot be observed The actual choice between them
directly. The use of a light bodied impres- should never be decided lightly, but be
sion material or a pressure indicating the result of unhurried deliberations
paste may be helpful in assessing the fit. where relevant factors are considered. It
Also, the degree of retention and stability is not possible to make an exhaustive list
of the denture should be examined and of such factors. However, the biological
related to the anatomy of ridge and mu- condition; the patient’s motivation and
cosa. The examination should also reveal expectation; to what extent the treatment
if there are obvious errors in the exten- may fulfill these; a risk-benefit evaluation,
sion of facial and lingual flanges. Regard- expected longevity and cost factors of the
ing removable partial dentures, a lack of treatment and the experience and compe-
fit is usually easily discovered, primarily tence of the dentist and dental technician
by observing if the various components are perhaps among the more important
supposed to be in close contact with the ones. To complicate matters further, these
teeth, still indeed are so. factors are sometimes in opposition to
Regarding occlusal function, the pri- one another. In view of these rather com-
mary occlusal contacts should be tested plex deliberations, the fact that different
in order to reveal possible premature con- dentists arrive at different conclusions

is hardly surprising. Importantly, this Furthermore, sufficient information
means that diverging treatment sugges- regarding the chosen treatment must be
tions may still be appropriate – provided given to the patient before prosthodontic
they are based on acceptable premises, treatment has commenced, particu-
and have been arrived at with the consent larly such related to the limitations of
of a properly informed patient. removable dentures. Information about
Even if an appropriate treatment a problem arising after the denture has
has been chosen according to the above been inserted – information that has not
principles, and performed lege artis, there been given to the patient beforehand,
is no guarantee that all patients will be even though the problem may have been
satisfied. This general statement is true caused by limitations that are specific
for all types of treatment, but perhaps to the prosthesis per se – is likely to be
especially for removable dentures, mainly conceived as an attempt to explain away
because of their shortcomings in terms a poor treatment result. At any rate, it
of oral function, as explained in Missing is certainly likely to undermine the pa-
teeth. This fact is challenging, but at the tient’s confidence in the dentist.
same time so interesting with removable Finally, even if diagnosed pathological
prosthodontics, and serves to underline conditions ideally should be treated and
the fact that removable prosthodontics further procedures postponed until the
undoubtedly is more of an art than a sci- condition is cleared up, not all conditions
ence. respond well to treatment. One example
is a chronic case of denture stomatitis,
Important aspects related to which often responds poorly to treatment
diagnostics and therapy and may sometimes be irreversible. Even
Some important aspects related to diag- if the treatment succeeds in clearing up
nostics and therapy merit special mention: the condition, it is prone to relapse when
The responsibility for the treatment active treatment is discontinued. The
choice as well as the treatment itself rests same can be said in relation to treatment
unquestionably with the dentist. Treat- of resistant periodontal diseases and oc-
ment should only be performed if the casionally caries. It is the responsibility
dentist is convinced that the overall ben- of the dentist to evaluate the status and
efit to the patient dominates. In the final determine the severity of the condition
analysis, the dentist is responsible and and decide to what extent treatment is
must decide – both because he has supe- meaningful, and at what stage of such
rior knowledge and experience in these treatment prosthodontic procedures are
matters compared to the patient, and for appropriate.
ethical and legal reasons.

8
Treatment planning
flEm mi ng isidor
INTRoDucTIoN. The patient’s subjective and objective needs are essential when treatment
planning in prosthetic dentistry is considered. It is also important that the planned treatment
as far as possible secures a good prognosis for the prosthetic reconstruction as well as the
remaining teeth.
Many factors varying from biological, psychological, mechanical, material related, and
economical aspects to treatment skills influence the completion of an oral prosthetic treat-
ment, and in any given case all these factors should be evaluated and create the basis for the
prosthetic decision making.
This chapter will only deal with treatment planning of dentate patients. For treatment
planning of edentulous patients see other chapters.
To perform prosthetic treatment on a patient with an untreated marginal periodontitis or
a high caries activity implies that abutment teeth, and thereby the prosthetic reconstruction,
may be lost. Even if other teeth than abutment teeth are lost and subsequently have to be re-
placed, the prosthetic reconstruction may have to be replaced. Patients with dental problems
except missing teeth should, therefore, be treated prior to prosthetic treatment and a mainte-
nance programme should be scheduled before the prosthetic treatment is carried out. Since
the pre-treatment not always has a successful longterm outcome, it is important to have an
appropriate observation period and to use relevant parameters to predict this outcome.
Treatment planning of patients with more advanced dental problems includes several ele-
ments and can be divided into a series of steps:
• initial examination with evaluation of the general and oral status of the patient
• primary treatment plan
• motivation for and instruction in oral hygiene measures and if needed advice about ap-
propriate diet
• initial, causal treatment
• re-examination
• second treatment plan
• prosthetic treatment
• post-treatment phase
A high standard of oral hygiene following prosthetic treatment plays a decisive role in pre-
111

venting the recurrence of disease. Since patients rarely remove all plaque on all surfaces, sup-
portive therapy after prosthetic treatment may reduce the risk of recurrence of dental caries
or periodontitis. A good oral hygiene and supportive therapy and also necessary adjustments
of the removable partial dental prostheses seem as important as the design of the dental
prostheses for the prognosis of the remaining teeth.
Primary treatment plan treatment. This should be related to

First of all it should be decided if pros- knowledge about positive and negative ef-
thetic treatment can be avoided or if the fects of the prosthetic treatment options.
patient may have a need for prosthetic The benefits of a dental prosthesis should
treatment with the present dental status always outweigh the possible damage it
or after necessary tooth extractions. may cause to the hard and soft tissues.
The need for prosthetic treatment is To make this primary treatment plan
assessed by combining the diagnoses with in a systematic way it is often suitable to
aesthetics, social and phonetic aspects, assess the prognosis tooth by tooth and
occlusal support, chewing capacity, hy- divide them into three categories: Teeth
gienic aspects, general comfort, technical- that can be maintained, teeth that can-
mechanical considerations, and also the not been maintained, and teeth that may
patient’s wishes and attitudes towards possibly be maintained (questionable).
A B c
D E F
Fig. 8.1. A patient before (A, B and C) and after (D, E and F) treatment with a removable partial denture in the
maxilla. The second molar in the right side was extracted, since the third molar had an acceptable prognosis
(A and D). On the other hand, it was important to keep the “questionable” molar in the left side (C), since
a free-end saddle could thereby be avoided. The buccal roots of this tooth were resected and the palatinal
root treated with a post and core and also gold crown (F). The right central incisor was treated with a metal-
ceramic crown, whereas the left central incisor was extracted (B and E).
112 Treatment planning

Teeth that can be maintained are those relining the prosthesis. Even medicamen-
that have no or an un-complex treatment tal treatment of a candida albicans infec-
need that will not jeopardize the progno- tion may be needed. Surgical procedures
sis. In the category of teeth that cannot should also be done at this stage. Fabri-
be maintained are those in a condition cation of temporary/interim prosthetic
where even the most advanced approach- reconstructions or correction of the exist-
es cannot save the tooth or at least the ing dental prostheses can be necessary for
tooth will not be able to function after the sake of the patient’s comfort in the
treatment. The questionable teeth are in observation period that elapses between
a state where they can only be saved with the initial treatment and the re-examina-
more advanced (technical or biological) tion. Minor occlusal adjustment may also
procedures. Teeth with a hopeless prog- be necessary and in advanced cases even
nosis have to be extracted before the pros- orthodontic treatment may be an option.
thetic treatment is initiated. If keeping a Minor occlusal adjustment does not
tooth with a questionable prognosis is im- mean to change the occlusal position.
portant for the whole treatment, it should The advantage with this approach is to
be adequately treated (Fig. 8.1). On the facilitate the adaptation of the prostheses
other hand, if the presence of a question- for the patient and to simplify the clinical
able tooth is unimportant, it should not and laboratory procedures. This princi-
be included in the prosthetic restoration, ple should be applied on patients with a
and it may even be the most appropriate masticatory system in a stable, functional,
solution to extract the tooth instead of healthy, and comfortably steady state, i.e.
using resources on it before commence- with teeth and occlusal relations adapted
ment of the prosthetic treatment. to the surroundings with acceptable
aesthetics and without pathology or tem-
Initial treatment poro-mandibular dysfunction. However,
Before the final treatment plan can be when prosthetic reconstructions have to
carried out, the initial, causal-related be made on partially edentulous patients
treatment should be performed. This in- who for a long period of time have been
cludes motivation for and instruction in missing teeth, a pre-prosthetic adjust-
oral hygiene measures and if needed ad- ment will often be expedient, since the
vice about appropriate diet. Furthermore, neighbouring or antagonizing teeth to
to secure a good prognosis for the teeth the edentulous area often have migrated,
the necessary cariologic, endodontic and tilted or over-erupted. In the presence of
periodontal treatment should be carried deflective contacts or other minor occlus-
out. A possible denture stomatitis should al problems that can easily be eliminated
be treated by instruction in cleaning the this should be done prior to prosthetic
removable dental prosthesis and possibly treatment.
by improving the tissue adaptation by In patients with extensive tooth wear
Treatment planning 113

or loss of most occlusal support (on mo- natural appearance may be far from iden-
lars and premolars) the vertical dimen- tical. For instance, an elderly person may
sion should be evaluated for possible want to have white, bright teeth where
changes in the final reconstruction. dark, worn teeth would give a more age
The dental re-evaluation should be related natural appearance. The dentist
made after an appropriate observation should have a dialogue with the patient
time, depending of the type of treatments of what is a realistic and suitable ap-
that have been performed. The effect of pearance of the new prosthesis. But it is
the initial treatment can hereby be evalu- also very important not to constitute a
ated and the second treatment plan can treatment on unrealistic expectations of
be performed. the appearance of new prostheses or the
influence on the appearance, e.g. that the
Second treatment plan general appearance will be much younger
After the re-evaluation it can be seen if after treatment. On the other hand, the
the questionable teeth were treated suc- treatment should be planned with as
cessfully or if they have to be extracted. much concern as possible about the aes-
The treatment plan is adjusted accord- thetics of the prosthetic reconstruction,
ingly. Teeth that can be preserved and for instance with the type and position of
used for a prosthetic reconstruction can clasps or the design of saddles.
be identified and the actual need for pros-
thetic treatment can be assessed and the Social aspects
possible treatment options can be decided Teeth or dental prostheses are not a pre-
upon. requisite for survival in modern society.
But in many social contexts partial or
Aesthetics complete edentulism are less acceptable.
Impaired aesthetics is probably the most Impaired appearance due to lacking teeth
frequent reason for a patient to seek pros- may influence how you are perceived by
thetic treatment. Loss of teeth, especially your surroundings. Likewise, reduced
front teeth influence the appearance ability to chew may have an impact on
tremendously, and even though you can how social gathering is experienced. In
live and eat without teeth or dental pros- other words, untreated partial or com-
theses, the need for improvement of the plete edentulism can have a great impact
appearance will often be the subjective on the quality of life.
indication for treatment. Missing teeth Furthermore, many persons feel un-
may result in lack of support of lips and specific discomfort when they loose one
cheeks with great impact on aesthetics. or more teeth. The event of loosing teeth
The dentist should realise that the may be associated with defectiveness or
patients’ expectations as to the aesthetic aging. Often this unspecific discomfort
outcome and what the dentist judges as decreases after a while, as the patient

grows accustomed to the new situation. there are insufficient occlusal contacts
Consequently, the dentist should be re- due to resorption of residual ridge and
luctant to constitute prosthetic treatment wear of denture teeth. On the other hand,
immediately after the patient has lost a this type of prosthesis may enhance the
tooth solely on the basis of unspecific chewing ability and, thereby, have a posi-
complaints. An observation period is rec- tive effect for the patients.
ommended during which the subjective
need may be seen to disappear. Phonetics
The tongue´s relation to the teeth and the
chewing ability lips’ contact to the front teeth are impor-
Inadequate chewing ability is associated tant for the production of sound during
with a reduced dentition, however, partial speech. Generally, only marked changes,
edentulism is seldom a problem until less such as loss of teeth in the incisor re-
than 20 teeth are present. gions, affects speech permanently, and,
The stability of the removable dental therefore, creates a need of dental treat-
prosthesis is important for the patient’s ment. Adjustment of the speech articula-
chewing ability. Both for patients with tion pattern within a few weeks may in
complete or partial removable dental most subjects compensate minor changes.
prostheses the nuisance is often lack of Since sounds are produced slightly dif-
stability. ferently in various languages and even
dialects, it is difficult to give any uni-
occlusal support versal recommendations of the design
Lack of occlusal support as the cause of of the prosthetic reconstruction, but the
temporomandibular dysfunction has dentist often have to rely on the method
been exaggerated over the years. For most of trial and error in each case. The other
persons bilateral support from the premo- way round, it is very often seen that the
lars will give a satisfactory mandibular insertion of partial or complete remov-
stability without essentially changes in able dental prostheses influences speech
function. This has resulted in ”The short- in a short period of time. If the problem
ened dental arch concept”. Further reduc- can not been solved solely with prosthetic
tion in the occclusal support may result means, cooperation with a speech thera-
in problems of functionality, although pist is advisable.
there is a large individual variation. Gen-
erally, in the oldest age groups even less General and local conditions
support can be tolerated. It should be ac- Treatment with RPDPs is difficult and
knowledge that free-end RPDP normally may be avoided when the patient’s mental
does not prevent or cure temporomandib- attitude to prostheses is not satisfactory
ular dysfunction. This is probably due to or the physical condition of the patient is
the fact that after a short period of time leading to prosthetic difficulty. Such con-

ditions can be general medical problems ported by the patients is generally higher
as debilitating illness, Parkinson’s disease, with fixed than removable dental prosthe-
facial palsy, epilepsy, chronic mucosal ses.
disease, neuromuscular disorders, but can The number, position, alignment and
also be local factors such as dry mouth, status of the remaining teeth often limit
atrophy of alveolar process of free-end the possibilities of giving the patient a
saddle area, atrophy of mucosa in eden- fixed prosthesis. An RPDP can, however,
tulous area, reduced sulcus depth, pain or be constructed for most situations.
discomfort on palpation of mucosa, gross Patients with RPDPs will often have
malposition of teeth, severe malocclusion, a more cariogenic microbial flora in the
and facial deformity, e.g. cleft palate post- mouth and often exhibit more plaque
surgical defect or traumatic injury. than persons without prosthetic recon-
struction or with fixed dental prostheses.
Removable partial dental A patient wearing RPDPs will not neces-
prostheses versus fixed sarily have an increased caries activity,
dental prostheses but the risk increases. Especially, but not
The reasons for choosing a treatment with solely, tooth surfaces in contact with a
RPDP instead of fixed dental prosthesis are denture have a higher risk of developing
mostly related to cost and biomechanical caries. Furthermore, it has been shown
possibilities (Table 8.1). Removable dental that patients with RPDPs are likely to de-
prostheses are for a large extent construct- velop more caries than patients with fixed
ed of polymeric materials and, therefore, dental prosthesis.
cheaper. Furthermore, they are more easily Patients suffering from hyposaliva-
repaired and it will often be possible to tion may have great difficulties in wearing
replace a natural tooth, lost at a later date, removable dental prostheses mainly due
by a simple addition to an RPDP. A fixed to the soreness of the supporting oral mu-
dental prosthesis can seldom if ever be cosa.
adapted in this manner and, if damaged, In a few situations where not only
the repair is often difficult and costly. teeth are lacking, but atrophy or trauma
In contrast to a RPDP, a fixed dental have resulted in a severe lack of alveolar
prosthesis normally only occupies the bone and soft tissue as well, patients may
same space as the natural teeth it replaces, prefer removable dental prosthesis to fixed
and, therefore, it feels more comfortable dental prostheses, since the replacement
in the mouth. Consequently, the patient of the lacking tissue with fixed prosthesis
becomes accustomed to it more readily. may either make cleaning difficult or re-
The patient has a firm sensation with a sult in unsatisfactory aesthetics or speech
fixed dental prosthesis and cannot move it problems.
with the tongue, as often happens with an
RPDP. Furthermore, the satisfaction re-

Remov- Fixed Comment
able
Initial cost + The construction of fixed prosthesis is time consuming and requires
great precision
Easiness of con- + The construction of a removable prosthesis is simpler than that of a fixed
struction prosthesis
Easiness of repair + An RPdP is to a large extent constructed of polymeric materials and,

and extension at a therefore, more easily repaired or extended
later date
Tooth preparation + Construction of an RPdP normally does not involve much preparation of
teeth. Consequently, preparation trauma to the pulp is less
Plaque accumula- + Patients with an RPdP will often have more plaque and a more cario-
tion and progres- genic microbial flora. Especially, but not solely, tooth surfaces in contact
sion of caries with the prosthesis have a higher risk of developing caries.
Progression of mar- (+) no difference in patients recalled regularly

ginal periodontitis
Increased mobility + Splinting effect of a fixed dental prosthesis

of teeth at start of
treatment
Severe lack of bone + Replacement of the lacking tissue with fixed dental prosthesis may
either make cleaning difficult or result in unsatisfactory aesthetics or
speech problems.
Biomechanics – + number and position of teeth can make the prognosis for a fixed pros-
possibilities thesis poor. An RPdP can be constructed for most situations.
Biomechanics – + Firm sensation with a fixed dental prosthesis

function
Mandibular support + Free-end saddles do not offer increased support for the mandible
Soft tissue damage + A fixed dental prosthesis requires no support from the mucosa and may
not even be in contact with it
Acceptance of + Most often.

treatment and oral A fixed dental prosthesis normally only occupies the same space as the
comfort natural teeth it replaces. A firm sensation with a fixed dental prosthesis
Cosmetics (+) Fixed dental prostheses have no embrassures or saddles, but on the
other hand artificial veneers
Hypo salivation + A vulnerable mucosa is not suitable to support an RPdP
Table 8.1. Removable partial dental prostheses (tooth supported) versus fixed dental prostheses. + Indicates that the treatment is
advantageous in this aspect. (+) Indicates only a small advantage of the treatment in this aspect.

Tooth supported versus interim prosthesis before a more perma-
mucosally supported nent prosthetic reconstruction can be
removable partial dental fabricated. It can also be used as a transi-
prostheses tional RPDP (trainer partial dentures) in
Removable partial dental prostheses only patients where the loss of remaining teeth
supported by mucosa have an increased seems inevitable, since these dentures can
risk of traumatizing the gingival tissues be extended gradually as the need ap-
resulting in gingival “stripping” (reces- pears.
sion) and of causing alveolar atrophy With few remaining teeth, especially
(Fig. 8.2). They have a shorter lifetime front teeth in the maxilla, an RPDP often
and more technical complications, e.g. will have insufficient retention and stabil-
fracture, than tooth-supported prostheses ity. In these cases there might be an indi-
with a metal framework. Furthermore, cation for alternative designs, for example
when a denture covers the gingiva there overdentures or removable prostheses re-
is an increased risk of developing caries tained by attachment or conical crowns.
and periodontal problems. Therefore, this However, these treatment modalities lie
type of RPDP should only be used as an without the scope of this textbook.
Treatment with
A removable partial dental
prosthesis or not?
The decision to fit a prosthesis when teeth
are missing should be based on several
parameters. General or local factors may
act as relative contra-indications for fit-
ting RPDP. In these cases the suitability of
treatment with RPDP should be carefully
considered and, consequently, prosthetic
B treatment may either be avoided or a
fixed solution chosen. In many situations
an RPDP is not necessary, but the final
conclusion can only be obtained after
careful evaluation of advantages and dis-
advantages in each individual case.
Main points
Fig. 8.2. A mucosal supported removable partial • Impaired aesthetics is probably the
denture (A) has lost occlusal contact because of most frequent reason for a patient to
alveolar atrophy (B). ask for treatment with removable den-

tal prostheses • RPDP solely supported by mucosa
• The final treatment plan can be de- should only be used as an interim or
cided when general dental treatment transitional prosthesis
has been performed and the prognosis • A patient wearing a RPDP has an in-
of the dentition can be evaluated creased risk of developing caries
• The reasons for choosing treatment • Treatment with RPDPs should always
with removable instead of fixed dental be preceded by careful evaluation of
prosthesis are mostly related to cost advantages and disadvantages of the
and biomechanical possibilities treatment in each individual case.
Further reading
Bergman B, Hugoson A, Olsson CO. A 25 years longitudinal study of patients treated with re-
movable partial dentures. J Oral Rehabil 1995; 22:595-599.
Budtz-Jørgensen E. Restoration of the partially edentulous mouth – a comparison of overden-
tures, removable partial dentures, fixed partial dentures and implant treatment. J Dent
1996; 24:237-244.
Budtz-Jørgensen E, Isidor F. A 5-Year Longitudinal-Study of Cantilevered Fixed Partial Dentures
Compared with Removable Partial Dentures in A Geriatric Population. J Prosthet Dent
1990; 64:42-47.
Elias AC, Sheiham A. The relationship between satisfaction with mouth and number and posi-
tion of teeth. J Oral Rehabil 1998; 25:649-661.
Isidor F, Budtz-Jørgensen E. Periodontal conditions following treatment with distally extend-
ing cantilever bridges or removable partial dentures in elderly patients. A 5-year study. J
Periodontol 1990; 61:21-26.
Jepson NJ, Moynihan PJ, Kelly PJ, Watson GW, Thomason JM. Caries incidence following res-
toration of shortened lower dental arches in a randomized controlled trial. Br Dent J 2001;
191:140-144.
Öwall B, Käyser AF, Carlsson GE. Prosthodontics – Principles and managements strategies.
London: Mosby-Wolfe, 1996.
Wöstmann B, Budtz-Jørgensen E, Jepson N, Mushimoto E, Palmqvist S, Sofou A et al. Indica-
tions for removable partial dentures: a literature review. Int J Prosthodont 2005; 18:139-145.

9
Jaw relation registration and articulators
Gu n na r E . Ca r l sson and Bo su n dh
IntroductIon. The recording of jaw relations is an important step in the treatment of

totally and partially edentulous patients. The aim is to facilitate the adaptation of the pros-
theses to the masticatory system and to give them an optimal and comfortable function. To
achieve this goal the recording must include an appropriate vertical dimension of occlusion,
stable occlusal contacts in harmony with the existing temporomandibular joints (TMJs) and
masticatory muscle functions, as well as the relationship between the prostheses and oral
and facial soft tissues and musculature. There are many ways to perform these recordings
and opinions differ among clinicians regarding which are the best. However, most agree that
the main component in the recording procedure is the occlusion rims that should be shaped
similar to the final prostheses. The fabrication of removable prostheses is performed in the
laboratory by dental technicians, and much of the work is done in an articulator, which is a
device that simulates the patient’s jaw movements.
Articulators All restorations fabricated in an articula-

An articulator is a mechanical apparatus tor must therefore be carefully checked
for mounting maxillary and mandibular and adjusted in the patient’s mouth.
casts. It allows movement of the casts so Articulators have frequently been di-
that various contact relations between vided into three categories: simple (cast
the jaws and teeth may be studied. Ar- relators and hinge-type), mean value
ticulators were originally devised to ap- articulators, and adjustable instruments
proximate jaw movement to facilitate the (semi- and fully adjustable) (Fig. 9.1). Cast
arrangement of artificial teeth in the con- relators are not really articulators since
struction of complete dentures. A great they do not allow any movements and
number of articulators have been devel- can only hold the casts in the recorded
oped over the years and are now available position. The simple hinge type allows
for varying uses in prosthodontics and a simulation of the rotation of the man-
restorative dentistry as well as for diagno- dible but no lateral movement. Mean
sis of occlusion. It is evident that no artic- value articulators allow vertical and
ulator, irrespective of sophistication, can horizontal movements based on average
completely reproduce actual jaw function. settings. The adjustable instruments can
121

A B
c D
Fig. 9.1. Different types of articulators. A. Hinge-type articulator (Bång’s articulator). B. Mean value articula-
tor (Stephen). C. Adjustable articulator (Dentatus AR-H). D. Adjustable articulator of Arcon type (Dentatus
AR-A Arcon).
accept a number of recordings aimed at followed. In fact, such devices can be

better reproduction of jaw movements. It used for any type of prosthodontic work.
has often been stated that using the more
advanced instruments will lead to better classification of jaw
clinical results of the prostheses, however, relations
this has never been documented. Mean Jaw relations are classified into three
value and semi-adjustable articulators groups to make them more easily under-
used with mean values can give fully ac- stood: (1) orientation, (2) vertical, and (3)
ceptable results in fabrication of remov- horizontal relations. Considered in this
able dentures provided careful recording, manner, the relation of the mandible to
mounting and laboratory procedures are the maxillae (or cranium) can be accu-
122 Jaw relation registration and articulators

rately determined in three dimensions. bow). When face-bows are being used in
Orientation relations establish the refer- complete denture techniques the arbitrary
ences in the cranium. Vertical relations one is the most common and is consider-
establish the amount of jaw separation al- ed adequate for this purpose.
lowable for dentures. Horizontal relations However, there is no evidence that the
establish the front-to-back and side-to- clinical result will improve by the use of
side relationships of one jaw to the other. a face-bow orientation. Instead, studies
have corroborated that mounting in the
orientation relations articulator with or without face-bow gives
Orientation relation establishes the refer- similar clinical results. Thus, it is possible
ences in the cranium and orients the casts to simulate mandibular orientation by
of the edentulous jaws to the articulator, an arbitrary ”average” technique without
traditionally by means of some type of a using a face-bow. Based on the available
face-bow record. Depending on the clini- evidence, it is somewhat surprising that
cian’s belief of the importance of simula- practically all prosthodontic textbooks up
ting the patient’s jaw movements on the to now continue to recommend the use
articulator a great variety of registration of face-bow records, and 84% of dental
methods and instruments are being used. schools in the USA include it in their pre-
The face-bow is a caliper-like device that clinical curriculum even in the new mil-
is used to record the relationship of the lennium.
jaws to the temporomandibular joints or In Scandinavia the use of face-bows has
the opening axis of the jaws and to orient been abandoned long ago, not only for
the casts in this same relationship to the complete denture fabrication, but also in
opening axis of the articulator (Fig. 9.2). other types of prosthodontic work. The
There are two basic types of face-bows: reason, supported by the Scandinavian
the arbitrary and the kinematic (or hinge- Society for Prosthetic Dentistry, is that
A B
Fig. 9.2. Face-bow. A. Face-bow mounted on a subject. B Face-bow, occlusion rim and cast mounted on an
articulator aimed at approximately translating the relationship between the maxilla and the condyles from
the patient to the articulator.
Jaw relation registration and articulators 123

there is no published evidence showing
A
that the use of a face-bow will lead to
better clinical end results than without
a face-bow. Probably, this concept has
become popular because the most critical
factor is an appropriate record of the hori-
zontal occlusal position, while the face-
bow is of minor importance. It is recom-
mended that when not using a face-bow
the record of a retruded position be made
at or very close to the selected vertical di-
mension of occlusion. In that way the po-
tential errors of not having recorded the
true hinge axis will be greatly reduced.
An arbitrary mounting of the maxil-
lary cast can be easily accomplished on
any semi-adjustable articulator by align- B
ing the occlusal plane of the wax occlu-
sion rim horizontally with a rubber band
placed halfway up the articulator’s three
vertical posts so the apex of the Bonwill
triangle coincides with the middle point.
The lower cast is then mounted using the
record of the retruded position (Fig. 9.3A).
The Bonwill triangle, first described by the
American dentist WGA Bonwill in 1858,
Fig. 9.3A. Casts mounted on an articulator accord-
is a 4 inch (100 mm) equilateral triangle
ing to an average value technique.
connecting each condyle with the contact
B. Casts mounted in an articulator without face-
point at the incisal edge of the mandibu-
bow, using the Bonwill triangle for the antero-
lar central incisors, or in complete denture
posterior orientation.
construction with the corresponding
point on the occlusion rims (Fig. 9.3B).
Bonwill suggested these distances based Vertical jaw relations
on average values from his studies. Even The vertical jaw relations are expressed in
if later investigations demonstrated that the amount of separation of the maxillae
they are subject to considerable variation, and mandibles under specified condi-
the use of Bonwill triangle is thought to tions. They are classified as the vertical
reduce possible errors when the casts are dimensions of (1) occlusion, (2) rest, and (3)
mounted without a face-bow. other positions.

occlusal vertical dimension factors, e.g. the position of the head.
The occlusal vertical dimension (OVD) Bending one’s head down or backwards
is established by the natural teeth when can verify this. When you bend your
they are present and in occlusion. In head down, the distance between the
people who have lost their natural teeth teeth is less than when you are holding
and wear dentures it is established by your head in a normal alert position;
the vertical height of the two dentures when you are bending your head back-
when the teeth are in contact. Thus the wards, the distance is greater. Therefore
vertical dimension of occlusion must be the patient’s head should be upright and
established for edentulous people so their unsupported when observations of physi-
denture teeth will be properly related to ologic rest position are being made.
each other.
Interocclusal rest space
Rest vertical dimension The value of the rest vertical dimension
Muscles and gravity establish the rest ver- in denture construction lies in its use as
tical dimension. The rest position is also a guide to the lost vertical dimension of
called physiologic rest or postural posi- occlusion. This is possible because the
tion of the mandible. Several studies have difference between the occlusal vertical
shown evidence of electromyographic dimension and the rest vertical dimen-
(EMG) activity in the rest position. It is sion is the interocclusal rest space. The
also well known that the jaw drops when interocclusal rest space (formerly referred
one falls asleep and muscle tension is to as the ”freeway space”) is the distance
reduced further. The current consensus or gap between the upper and lower teeth
is that the physiologic rest position is ac- when the mandible is in its physiologic
tively determined. The clinically recorded rest position. Usually, it is 2 to 4 mm
rest position does not always correspond when observed at the position of the first
to recorded minimal EMG activity. The premolars. However, the clinically record-
mandible in the EMG rest position is usu- ed rest position is quite variable during
ally several millimetres lower than in the different conditions, as indicated above,
clinical rest position. A range of reduced and therefore the interocclusal rest space
muscle tension up to an interocclusal dis- is not a reliable basis for the determina-
tance of about 10 mm has been reported. tion of the occlusal vertical dimension. It
It is therefore more accurate to refer to a should be combined with other evalua-
”range of posture” rather than to a single tions, such as patient comfort, acceptable
rest position. function and aesthetics.
The physiologic rest position is a postural
position controlled by the muscles that
open, close, protrude, and retrude the
mandible. It is also influenced by several

Establishment of the vertical max- is no certain scientific basis for determin-
illomandibular relations for coming a correct occlusal vertical dimension.
plete dentures Many of the methods include the use of
There are several different methods for es- the physiologic rest position and the in-
tablishing the vertical maxillomandibular terocclusal rest space, i.e. the separation
relationship in treatment with complete between the teeth or occlusion rims when
denture. No systematic comparative stud- the mandible is relaxed. A common re-
ies of such methods are available, so there commendation is to have such a space of
128
126 Without dentures; sounding “m”
Without dentures; relaxation

Mean postural face height (N-Gn)(mm)
Without dentures; sounding “m”

124
Without dentures; relaxation
occlusion
122
120
118
Insertion
12 days 90 days
A P
Exam I Exam II Exam III
Fig. 9.4. Variation in physiological rest position and face height (N=Nasion GN=Gnatio) during a 90-day
follow-up period with different methods of determining the physiological rest position (phonetic sounding m,
and relaxation) and with and without dentures inserted. (From Carlsson and Ericson 1967, with permission).

2 to 3 mm. Besides the questionable use Mechanical methods
of mean values when individual variation 1. Ridge relation
is great, both intraoral and general factors a. Distance from the incisive papilla to
can substantially influence the postural the mandibular incisors
position of the mandible. The methods b. Parallelism of the ridges
used for determining the postural position 2. Measurement of the former dentures
(e.g. relaxation, swallowing, or phonetics) 3. Pre-extraction records
as well as the presence or absence of den- a. Profile radiographs
tures or occlusion rims and the height of b. Casts of the teeth in occlusion
these can affect the rest position (Fig. 9.4). c. Facial measurements
Even though this was demonstrated long
ago, many textbooks still recommend this Several of the mechanical methods may
method. The method with an average not be available, and even if they are,
interocclusal rest space in determining the they often have limitations. There is cur-
occlusal vertical dimension is not reliable rently a trend to favour physiologic meth-
and should be combined with assessment ods rather than mechanical methods.
of patient comfort as well as aesthetic and
functional considerations. Physiologic methods
1. Physiologic rest position
Methods of determining the 2. Phonetics and aesthetics
vertical dimension 3. Swallowing threshold
The methods for determining verti- 4. Patient-reported perception of comfort
cal maxillomandibular relations can be
grouped roughly into two categories. The Most patients will adapt to a vertical di-
mechanical methods include use of pre-ex- mension that is established by means of
traction records and measurements, ridge a combination of aesthetic, functional,
parallelism, and others. The physiologic and patient-reported comfort consider-
methods include use of the physiologic ations, together with information derived
rest position, the swallowing phenom- from studying the patient’s rest position.
enon, and phonetics as a means for de- However, compromises between comfort,
termining the facial dimension at which aesthetics, and function are often advis-
occlusion should be established. able and may be necessary e.g. to reduce a
All determinations of the vertical dimen- too excessive occlusal vertical dimension.
sion must be considered tentative until Attempts to restore the youthful verti-
the teeth are arranged on their trial bases. cal dimension of the face with dentures
At try-in, observations of phonetics and are likely to encounter difficulties. Such
aesthetics can be used as a check against dentures may have favourable aesthetics
the vertical relations established by me- but still not be comfortable because the
chanical or physiologic means. excessive height make them difficult to

manipulate, they may be easily dislodged Horizontal jaw relations
and occlusal contacts may result in click-
ing of the denture teeth. Horizontal position of occlusion
On the other hand, a reduced occlusal It is almost universally presumed that the
vertical dimension may result in a facial so-called centric relation (CR) is the man-
expression that is not desirable; the lower dibular position of choice when the hori-
third of the face is changed because the zontal position of the occlusion in com-
chin has the appearance of being too plete denture construction is recorded. A
close to the nose and too far forward, the complication is that there is no consensus
lips lose their fullness, and the vermilion about how to define CR. The current
borders are reduced to approximate a line. Academy of Prosthodontics Glossary of
In such cases the vertical dimension of Prosthodontic Terms (2005) gives seven
the face should be increased to a point definitions. Although the definitions are
that will be satisfactory and comfortable. somewhat different, they all agree that CR
In patients who have had an extremely is determined not by the dentition, but by
reduced occlusal vertical dimension for the TMJ structures, i.e. the relationship
a long time, the old dentures should be between the condyles and the glenoid fos-
used as treatment dentures. The vertical sae and/or the articular eminences. When
dimension of occlusion should be built up treating edentulous subjects without any
gradually (for example by adding acrylic remaining teeth it is helpful that the TMJs
on the occlusal surfaces of the lower den- usually offer a stable reference. However,
ture). Complete restoration of the original in the clinical situation it is not possible
occlusal vertical dimension in a set of to determine the position of the condyles
new dentures will likely result in failure in relation to the temporal bone compo-
because the patient is unable to accom- nents of the joints without radiographic
modate to this great change in so short a examination (and using radiography for
time. this purpose is complicated and not re-
Given the advantages and disadvantages commendable). There is also disagreement
of establishing an open or a closed vertical on the best way to determine CR clini-
dimension, most experienced prosthodon- cally. Conflicting ideas still exist and have
tists prefer to have the vertical dimension evoked strong emotions over many years.
a little too small rather than too great. Most probably, however, the small devia-
This solution must include information to tions in location of mandibular positions
overoptimistic patients that it will not be resulting from the variation of methods
able to restore the facial appearance as it used are of minor clinical importance in
was at at a younger age and that the new complete denture fabrication. In Scandi-
dentures cannot eliminate all wrinkles. navia the terms retruded position (RP)
and the retruded contact position (RCP)
are preferred instead of CR. (The terminol-

ogy is further discussed in Chapter 11.
When one constructs complete dentures
RCP is usually recommended for the
antero-posterior horizontal position of oc-
clusion. In the most retruded relation the
30°
mandible can rotate around an imaginary
axis running through or close to the con-
dyles. The identification of the retruded
15°
hinge movement is an important step in
the recording of the horizontal relation-
ship. The RCP is recorded when this re-
Fig. 9.5. Average settings of the articulator: 30 de-
truded movement is halted with contacts
grees for the sagittal and 15 degrees for the lateral
between the occlusion rims in a suitable
condylar path.
occlusal vertical dimension.
Even if it is almost conceeded that RCP (or
CR) is preferable when the horizontal jaw mining the sagittal and lateral condylar
relation is recorded, there is a less unani- path inclination. Already in the 1960s
mous agreement about the location of the Swedish studies demonstrated extremely
maximal intercuspal position (MIP, previ- large variations in the determination of
ously often called intercuspal position, condylar path with protrusive interoc-
ICP). The most common concept in texts clusal records. The method was therefore
on complete denture fabrication is to have abandoned in Swedish dental education
maximum intercuspation in RCP. Since it from the 1970s. Nevertheless, still at the
is known that the great majority of people beginning of the new millennium two-
with a natural dentition have their maxi- thirds of the undergraduate programs in
mum intercuspation slightly – up to 1 mm US dental schools teach the use of protru-
– anterior to the RCP, some clinicians ar- sive record to set the articulator. Average
gue in favour of a “long centric” or “free- setting of the articulator appears to be
dom in centric” also in complete dentures. adequate, e.g. 30 degrees for the sagittal
In the clinical situation this is usually and 15 degrees for the lateral condylar
solved without specific measures by not path (Fig. 9.5).
using too steep cusp inclines on the den-
ture teeth or by a minor adjustment of the Recording the horizontal position
teeth to allow occlusal contacts without of occlusion
interferences between RCP and MIP. Several techniques for making RCP re-
cords have been presented. Some clini-
Eccentric relations cians prefer graphic or hinge-axis records,
There is no evidence to support the value but the most common ones are interoc-
of eccentric relation records for deter- clusal records. The registration of the RCP

is considered difficult and it is true that it in small movements up and down. It can
requires clinical training and experience easily be felt when the hinge movement
to achieve acceptable results. There are is performed. After such training the regi-
biologic difficulties arising from lack of stration is facilitated.
coordination of mandibular musculature, There is probably no best method for
psychological difficulties because patient recording the RCP. A method proved to
and/or dentist are uncertain or tense be good for one dentist might fail for
during the important recording, and another. Both accurate and incorrect
mechanical difficulties due to unstable records of RCP have been made by these
and poorly fitting base-plates and vary- methods. This means that, irrespective
ing tissue resiliency. The consistency of of the method used, subsequent clinical
the recording material is of significance checking and rechecking must be done
– it must not be too hard, but impression throughout the denture construction
plaster, well-softened wax and other ma- phases.
terials with soft uniform resistance have
proven acceptable. Short summary of clinical
A simple and often effective way of procedures in recording of
causing a retrusion of the mandible is jaw relations
by verbal instruction to the patient. “Let 1. The trial denture bases must be well
your lower jaw relax, pull it back, close on fitting and stable.
your back teeth”. Such recommendations 2. The occlusion rims are formed to give
have a long tradition in clinical practice, adequate support to lips and cheeks.
but their effectiveness is not supported by 3. The occlusal plane is placed approxi-
documented evidence. Patient-governed mately halfway between the maxillary
activity to close in a retruded position has and mandibular ridges when the jaws
proven to give extremely variable results. are in occlusion. Sagittally it largely
On the other hand, research has shown follows the Camper plane, transver-
that the most reproducible recording of a sally it is made parallel to the inter-
retruded mandibular position in dentate pupillary line.
subjects is achieved by gently guiding the 4. The occlusal vertical dimension is es-
mandible backward with the subject re- tablished by modifying the heights of
laxing his jaws. This can also be effective the occlusion rims to evenly meet in
in helping to record a retruded position in RCP considering patient comfort, aes-
edentulous patients. Many clinicians have thetics and function.
obtained good results by training the 5. The occlusion rims are prepared for
patients to perform a hinge-axis rotation, the RCP registration with grooves for
before the actual registration, by having retention of the registration mate-
the patient as relaxed and passive as pos- rial. While stabilizing the trial bases
sible, and actively guiding the mandible with the fingers the dentist guides the

patient’s mandible into the RCP. This and a RPDP in the mandible. In situations
procedure should be rehearsed before where there are remaining dentitions in
the recording medium is applied. both jaws and enough teeth to ensure a
6. The registration should be carefully stable record of the intermaxillary rela-
checked and remade if necessary. tion, a wax record can be obtained with-
out the use of occlusion rims. Provided
Removable partial dental the occlusion of the remaining dentition
prostheses is acceptable and stable, the maximal
The same principles and clinical prac- intercuspal position may be chosen for
tice as described for complete denture the record and not the RCP. In partially
construction are relevant for a tooth re- edentulous dentitions when the remain-
tained removable partial dental prosthesis ing teeth do not allow a secure jaw regis-
(RPDP). This is especially so for the com- tration, occlusion rims should be used.
bination of a maxillary complete denture
Further reading
Academy of Prosthodontics. The Glossary of Prosthodontic Terms. J Prosthet Dent 2005;
94:10-92.
Carlsson GE. Biological and clinical considerations in making jaw relation records. In: Zarb
GA, Bolender CL, Carlsson GE, eds. Boucher´s Prosthodontic Treatment for Edentulous Pa-
tients. 11th ed. St. Louis: Mosby; 1997;197-219.
Carlsson GE. Facts and fallacies: An evidence base for complete dentures. Dent Update
2006;33:134-42.
Carlsson GE. Critical review of some dogmas in prosthodontics. J Prosthodont Res
2009;53:3-10.
Carlsson GE, Ericson S. Postural face height in full denture wearers. A longitudinal X-ray ceph-
alometric study. Acta Odontol Scand 1967: 25: 145-62.
Carlsson GE, Tangerud T. Functional aspects. In: In: Karlsson S, Nilner K, Dahl BL, eds. A Text-
book of Fixed Prosthodontics. The Scandinavian Approach. Stockholm: Gothia, 2000;95-
115.
Gross MD, Nissan J, Ormianer Z, Dvori S, Shifman A. The effect of increasing occlusal vertical
dimension on face height. Int J Prosthodont 2002;15:353-7.
Heydecke G, Vogeler M, Wolkewitz M, Türp JC, Strub JR. Simplified versus comprehensive fab-
rication of complete dentures: patient ratings of denture satisfaction from a randomized
crossover trial. Quintessence Int 2008;39:107-16.
Rashedi B, Petropoulos VC. Preclinical complete dentures curriculum survey. J Prosthodont
2003;12:37-46.
Tangerud T, Carlsson GE. Jaw registration and occlusal morphology. In: Karlsson S, Nilner K,
Dahl BL, eds. A Textbook of Fixed Prosthodontics. The Scandinavian Approach. Stockholm:
Gothia, 2000;209-30.

10
Retention of complete dentures
Ei na r BErg
INTRoDucTIoN. Retention of complete dentures is one of the major factors determining to

what extent they become functional for the patient. If a denture does not retain satisfactorily,
it is of no avail that the aesthetics are pleasing or that the facial contours are perfectly re-
stored – the patient still cannot wear it successfully. True, the degree of retention considered
by the patient as acceptable is highly variable; most will adapt even to relatively poor reten-
tion, whereas a few will never be satisfied because they do not tolerate the slightest dislodge-
ment of the denture. Regardless, it is obviously important that the dentist fully understands
the factors involved in denture retention and how to optimize them.
Factors of retention hyposalivation – the physical retention of

Denture retention depends on a number the denture becomes imperfect or com-
of factors: some are related to physical pletely absent.
and muscular conditions, others to the
nature of the denture supporting tissues. Function of adhesion,
In addition, surgical interventions may cohesion, atmospheric
sometimes enhance retention, and even pressure and flow properties
denture occlusion may play a part. It is of thin films of liquid
most practical to discuss these factors one Adhesion is defined as the tendency of
by one. However, it should be clearly un- dissimilar molecules to cling together
derstood that they always work together due to forces of attraction. In our context
in the mouth it expresses the tendency of the water
molecules of the saliva to adhere to the
Physical retention denture and surrounding tissues. Cohe-
Several physical factors are involved in sion is the intermolecular force that holds
denture retention. Their common de- together the molecules in a solid or li-
nominator is the film of saliva between quid. The importance of these two factors
denture and the tissues surrounding it. in terms of denture retention is that the
In fact, if there is no or insufficient saliva adhesion wets the tissues and denture
in the mouth – as may be the case in pa- surface and the cohesion maintains the
tients who for some reason suffer from integrity and continuity of the saliva
133

film – even when exposed to low pres- sealed by lips and cheeks. This is attempt-
sures. Such low pressures may arise when ed by means of “post damming”, defined
removal of a well fitting denture from its and discussed in chapter 11. The dentist
supporting tissues is attempted. The den- can influence both the fit and peripheral
ture may then function like a piston in a seal during impressions.
cylinder, where the contact with cheeks If saliva is too sparse or absent, the
and lips represents the cylinder walls. dentist may prescribe a saliva substitute.
When the pressure within the cylinder Unfortunately, the long-term effect of
(or underneath a denture) decreases, the this is limited. The physical retention of a
ambient higher atmospheric pressure denture can also be improved by applying
tends to push it back into place. a denture adhesive which functions by
Another factor of importance in this increasing manifold the viscosity of the
context is related to the flow properties saliva.
of thin films of liquid, such as is found
around a well fitting denture. In order for Physical retention of
the denture to be removed, the saliva film maxillary and mandibular
must be broken, i.e. it must flow from the dentures
periphery towards its center. The slower Physical retention is less important for
the saliva flows, the better the denture mandibular dentures than for maxillary
retains. The amount of liquid flowing, ones for a number of reasons: Saliva col-
and the speed with which it does so, de- lects in the floor of the mouth and tends
creases to minus the third power with the to flow underneath a mandibular denture,
thickness and proportionally with the in practice rendering a persistent thin
viscosity of the film of saliva. This means film of saliva impossible. Furthermore,
that if the thickness of the film is halved, a peripheral seal is difficult or impossi-
the flow decreases to 1/8, if the viscosity ble to achieve for mandibular dentures,
is doubled, the flow is halved. particularly lingually, because of the nor-
mally great mobility of the musculature
How to influence different in the area. On the other hand, the force
physical factors of retention of gravity helps keeping the mandibular
In practical terms the physical retention denture in place
is best served by a denture with optimal
fit so that the film of saliva becomes as clinical importance of
thin as possible, and with the tightest physical retention
possible seal along its periphery so that The physical retention of complete den-
the atmospheric pressure will aid in keep- tures is rarely or never sufficient to with-
ing it in place. The latter also depends on stand forces necessary to chew food. Its
the continuation of a tight seal across the main clinical importance is to hinder dis-
palate where the periphery is no longer lodgement during social functions such
134 Retention of complete dentures

as talking, smiling, laughter, singing etc. denture should normally be shaped
If these functions are not served well, the concavely to facilitate this (Fig. 10.1). In
patient is considerably less likely to suc- special cases, where the requirements for
ceed adapting to the denture. retention are very high, impression of
the facial surfaces of the denture with a
Muscular retention low-viscosity material may be attempted
Muscular retention is of vital importance and later replicated in the base material
in any forceful functions such as chew- in order to optimize muscular retention.
ing, bruxing and the like, which tend Such an impression procedure may be
to dislodge the dentures. The denture is performed either on the bite rim or on
then actively stabilized and supported the finished denture. The effect of this is,
by the oro-facial muscles. The tongue is however, uncertain.
particularly important in this respect.
There is some evidence to suggest that How to influence muscular
experienced denture wearers stabilize a retention
maxillary denture primarily by pressing To a large extent muscular retention is
the tongue against the tuberocity regions. a matter of adaptation on the part of
The importance of muscular retention the patient. Like most matters that re-
during chewing compared with physical quire muscular dexterity, it is a matter of
retention is indicated by studies show- natural talent and practice. The skill of
ing that a reduction of palatal coverage manipulating a denture is difficult and
(which tends to interfere with post dam- thus rarely achieved quickly. For some,
ming) does not reduce the patient’s ex- intensive practice lasting weeks and even
pressed chewing ability. months may be required; a few never
In order to obtain added muscular master the art.
retention the external surfaces of the However, in order to facilitate the
learning process, the dentist should

explain to the patient how muscular re-

Fig. 10.1. In order to obtain added muscular reten-

tion the external surfaces of the denture should
normally be shaped concavely, schematically illus- Fig 10.2. Illustration of how the tounge can stabi-
trated in the figure. lize the denture during incising.
Retention of complete dentures 135

Fig. 10.3. In an erroneous attempt to avoid a cross-
bite relationship, the mandibular teeth may be tilt-
ed too far lingually. Then the tongue gets caught be- Fig. 10.4. Another relevant factor that needs to be
tween the medially inclining lingual surfaces of the kept in mind is the fact that the muscles of the
mandibular denture and lifts it during movements. tongue may with time change in size and form.
tention can function and how to make the mandibular teeth may be tilted too
use of it in practice. The experienced far lingually and the maxillary ones too
denture wearer will know how by reflex, far buccally. Then the tongue gets caught
and many novices will do so intuitively, between the medially inclining lingual
but some need to have this explained surfaces of the mandibular denture
explicitly in order for them to learn how (Fig. 10.3) and lifts it during movements.
to master the denture. Regardless, a little Another relevant factor that needs to
verbal instruction and showing a few pic- be kept in mind is the fact that the mus-
tures illustrating the mechanism do not cles of the tongue may in time change in
take much time and may save more time size and form (Fig. 10.4). Indeed, some-
later (Fig. 10.2). times these muscles tend to dislodge the
Furthermore, the dentist should pay denture rather than retain it. This may
attention to the inclination of the exter- represent a veritable challenge for the
nal surfaces of the denture and the posi- dentist, who must attempt to accommo-
tioning of the artificial teeth. Generally, date the muscles when shaping the lin-
muscular retention may be compromised gual surface of the dentures. This some-
if the tongue becomes cramped due to a times entails a reduction of the lingual
placement of teeth too far lingually. This part of the cheek teeth.
not uncommon situation may occur as a Finally, due to the crucial importance
consequence of the different patterns of of muscular retention, any motor disease
resorption of the two jaws, whereby there interfering with muscular control also
is a lingual shift of the top of the maxil- influences to what extent dentures may
lary alveolar ridge and a buccal shift of be worn successfully by the patient. This
the mandibular one. In an erroneous at- means that patients suffering from stroke,
tempt to avoid a cross-bite relationship, Parkinson’s disease, myasthenia gravis

and the like have poor prognoses for den-
ture wear and should, if possible, be treat-
ed with implant retained restorations.
Retention and stability

Retention and stability are frequently and
incorrectly used as synonymous concepts.
However, the former relates to the ability
of the denture to stay in place against dis-
lodging forces, whereas the latter is an ex-
Fig. 10.5. If it is possible to rotate the denture
pression of the degree of movement of the
around the protuberance, such undercuts can
denture when exposed to forces in any
sometimes be used to secure the denture in place.
direction. Thus a denture can be perfectly
retained and still be unstable if supported ridges with vertical areas will obviously
by resilient tissues. On the other hand, a resist horizontal forces better than flat
denture can be unstable to such a degree resorbed ones. Sometimes the existence
that it looses its retention. of alveolar undercuts have to be relieved
Retention can be influenced by the – either by reducing the height of the
dentist if the factors governing physical flange to the level of the greatest contour
and muscular retention are fully exploit- or by relieving the inside of the denture.
ed. With regard to stability, “anatomical” Both methods are unfortunately liable to
teeth (with cuspal angles of about 30°) are interfere with physical retention. On the
claimed to transfer more horizontal forces other hand, if it is possible to rotate the
on to the denture than “cuspless” teeth denture around the protuberance, such
(with cuspal angles of 0°). This makes undercuts can sometimes be used to se-
the denture less stable. The same can be cure the denture in place (Fig. 10.5).
said if the teeth have been placed too far Ideally, the supporting tissues should
outside the alveolar ridge. With these ex- have a thickness that allows a certain
ceptions, stability can ordinarily not be amount of movement of the denture with-
influenced by the dentist. out dislodging it. If too thin, even slight
movements will tend to dislodge the den-
Denture supporting ture and cause it to loose its retention. For
tissues and retention of this reason, patients with well formed al-
dentures veolar ridges, but thin unyielding mucosa
In addition to the above physical and will often complain of poor retention of
muscular aspects, denture retention and their denture. Nor is it an advantage with
stability are influenced by the anatomy a very thick and resilient mucosa. In such
and consistency of the supporting tissues. cases, when the denture is subjected to a
In terms of stability well formed alveolar force, the support becomes displaced and
Retention of complete dentures 137

the denture, even if it retains its retention, scribed, because the subjective results are
tends to move with it. generally disappointing.
Further complicating the issue is the
fact that the supporting tissues normally Retention and occlusion
have quite uneven thicknesses, and are Occlusion may also be related to per-
often particularly thin where there are ceived denture retention. A premature oc-
bony protuberances like tori (maxillary clusal contact tends to rotate the denture
and mandibular), sharp edges or spicules away from the tissues on the opposite side
and the like. The denture tends to rock and may thus dislodge the denture from
around such areas where the mucosal its support. For the same reason, patients
padding is thin and most unyielding, and should be encouraged to place equal
the peripheral seal of the denture is likely amounts of bolus on either side of the
to break as a consequence. denture while eating to avoid dislodge-
ment.
Retention and surgical
intervention Retention and pain
Preprosthetic surgery may improve the The wearing of dentures is not infre-
anatomy of the denture supporting quently associated with pain. This may
area in terms of retention. Minor inter- be of a transient nature, as may happen
ventions, like frenulectomies, removing when a morsel of hard food becomes
denture related hyperplasia, sharp under- lodged underneath the denture during
lying bone spicules or edges may improve chewing. It may also occur, more perma-
the retention appreciably and thereby nently, as a result of pressure on underly-
the prognosis for the restoration. Major ing bony protuberances only covered by
preprosthetic surgical interventions, on thin mucosa. A general reaction in such
the other hand, involving lowering of the cases is avoidance of what produces the
vestibular areas intended to provide an pain, resulting in abnormal movements.
increased supporting area and more ver- These tend to interfere with retention. In
tical parts in an attempt to improve the particular, the training process necessary
ability of the denture to resist horizontal for adaptation to the denture then be-
displacements, are nowadays rarely pre- comes hampered.
Further reading
Akeel R, Assery M, al-Dalgan S. The effectiveness of palate-less versus complete palatal coverage
dentures (a pilot study). Eur J Prosthodont Restor Dent. 2000;8:63-6.
Fløystrand F, Karlsen K, Saxegaard E, Ørstavik JS. Effects on retention of reducing the palatal
coverage of complete maxillary dentures. Acta Odontol Scand. 1986;44:77-83.
Ørstavik JS, Fløystrand F. Retention of complete maxillary dentures related to soft tissue func-
tion. Acta Odontol Scand 1984;42:313-20

11
Removable complete dental prosthesis
– clinical procedures
E i n a r B E rg and m a r ga r E ta m o l i n tH o r é n
INTRoDucTIoN. Before commencing a discussion of clinical procedures, it is important to

realize that, no matter how excellently a removable complete dental prosthesis (RCdP) is con-
structed, it must be regarded as a failure if the patient is dissatisfied. A denture can thus only
be considered a success if it satisfies the patient subjectively and meets the requirements of
proper denture construction at the same time. The issues of biomechanical, physical and not
least of all psychosocial nature, which may be the consequences of edentulism and wearing
of complete dentures, all have to be addressed by the dentist. Although proper clinical pro-
cedures are obviously important for making good dentures, it is crucial that the dentist estab-
lishes a good communication and rapport with the patient, and accepts that this takes time.
Even when all the above issues have been satisfied, success is not always assured. As expe-
rienced therapists of any profession know, no treatment is successful every time. With regard
to new, well-made complete dentures, studies have indicated that 10-15 % of patients are for
some reason dissatisfied. Treatment failure may in such cases sometimes be caused by clash-
ing personalities between dentist and patient, by the patients’ inability to adapt to the den-
ture, by unrealistic expectations of the restoration or by insurmountable treatment problems
in the case at hand.
It is important to examine the oral conditions thoroughly and interview the patient sys-
tematically before treatment. Only in this way may procedural and subjective problems be re-
vealed. Importantly, this is the prerequisite for informing the patient of what problems exist,
and which of these may or may not be solved or at least reduced. This is also the time, par-
ticularly for the patient who is going to wear complete dentures for the first time, to inform
the patient about the limitations (and sometimes advantages) of the treatment: the inher-
ent instability and inadequate retention in many situations of complete dentures, the role of
muscular retention to counteract this, and necessary training in order to achieve acceptable
adaptation. Finally, this is the opportunity to adjust patient expectations to a realistic level.
139

Impression ing one must be based on clinical experi-
General aspects ence.
The seemingly obvious objective when
taking impressions for complete dentures Mucostatic impression
is to reproduce the denture supporting With this kind of impression the inten-
tissues and to shape the periphery, also tion is to reproduce the tissues with as
called the vestibular area, as accurately as little displacement as possible. A denture
possible. However, how to obtain these made on the basis of such an impression
ideals is considerably less obvious, and would have a perfect fit when unloaded.
views on the subject are often diverging. When loaded, particularly if there is a
Many methods of taking impression have pronounced unevenness of resilience of
been suggested – none of which are based the supporting tissues, it will tend to rock
on scientific research. With any of them or rotate around areas less well padded
the intention is to shape the denture in and therefore compromise the stability. A
such a way that the oral tissues are not more serious objection is that in order to
harmed and that the factors involved in avoid displacement of the tissues, an im-
retention are optimally exploited. pression material with the lowest possible
In accordance with the latter factors, viscosity must be used (such as impres-
the more accurate the reproduction of sion plaster or a light bodied elastomere).
the denture supporting tissues is, the This makes a proper impression of the
thinner the film of saliva and the bet- periphery technically challenging.
ter the physical retention will be. At the
same time the impression of the vestibu- compression impression
lar area is important because it should Here the objective is the opposite: to
ideally function as a peripheral seal displace movable tissues by means of a
around the denture, but without coming very viscous impression material such as
into conflict with the muscular function composition material, elastomere putty or
in the area – two considerations which fairly hard impression wax. The instabil-
are not infrequently in conflict. ity of the denture during loading would
Below, three main schools of thought then be less likely to occur because the
on impressions of complete dentures will well padded tissues would already be
be presented. Only one of them, dynamic displaced and these tissues would receive
impression, will be described in detail a more even load. One of the problems
because this method appears to combine with this method is that the viscous im-
the best qualities of the other two, but pression material also tends to displace
with fewer of their drawbacks. However, the vestibular tissues, and therefore in-
as stated earlier, no convincing evidence terferes with normal muscular function
supports either of them. In the absence in the area. Compression impressions are
of such evidence the rationale for choos- rarely advocated in modern textbooks;
140 Removable complete dental prosthesis – clinical procedures

the method is said to result in question-
able denture retention over a period of
time and increased bony resorption.
Dynamic impression
As can be seen, the above methods may
have problems associated with their use.
The dynamic impression represents an
attempt at retaining the advantages of the
two methods and avoiding their disadvan-
tages. With this impression method one Fig. 11.1. Primary impression taken in alginate of
attempts to minimize possible displace- an edentulous maxillary jaw with marked periph-
ments of the denture supporting tissues. ery indicating the extension of the special tray.
Consequently, a light or medium bodied
impression material is used for the final
impression. The periphery is either shaped means of wax or a composition material.
using the same material (more easily This impression is usually taken in al-
achieved if a medium viscosity material ginate, which is a quite viscous material.
is used) or by trimming the periphery of In order to avoid vestibular displacement,
the impression tray by means of a more it is advisable for the dentist to manipu-
viscous material specially designed for the late the cheeks and lips of the patient
purpose. This is then followed by a wash before the material sets. For the same rea-
impression with a light bodied material. In son, the patient should be asked to move
this textbook the dynamic impression will the tongue when the impression is taken
be described in detail in the following. in the lower jaw. It is equally important
to avoid the risk that tongue, cheeks and
Primary impression lips prevent the impression material from
The object of a primary impression is to flowing into the vestibular areas, which
produce a cast on which a special tray can might result in an incomplete impression.
be made. It is important that this cast is How these procedures are performed is
as close to the final cast as possible. For described in detail below.
this purpose a stock tray is selected which The primary impression may profit-
allows 2-3 mm space for the impression ably be marked with an instrument ap-
material over the entire denture support- proximately 2 mm from the vestibulum
ing area. It may be necessary to adjust the (Fig. 11.1), which would indicate the
tray into an appropriate shape in order to periphery of the special tray. A tray made
satisfy this requirement. If its flanges are according to such a marking would nor-
too extended, they should be reduced; mally need a minimum of adjustment
if too short they should be added to by in the vestibular area, and considerable
Removable complete dental prosthesis – clinical procedures 141

chair-side time may thus be avoided. order to permit at least 1 mm impression
From these impressions the dental techni- material between the tray and the ridge.
cian can produce the primary casts and This may be accomplished by covering
special trays. the entire cast by a 1 mm layer of wax,
over which the tray is constructed. In or-
Special tray der to maintain this space during impres-
The use of a special tray facilitates taking sion, some sort of stop point may be used.
an optimal impression, both in terms of
accurate reproduction of the denture sup- Final impression
porting tissues and an optimally formed Intraoral adaptation of special
impression of the vestibular area. The tray tray
should be manufactured on the primary The special tray should be tried in the
cast in a rigid material, hard enough to mouth and checked for fit and exten-
resist distortion when removed from the sion. If made on a cast from an adequate
mouth. An acrylic material designed for primary impression, the fit of the tray
the purpose meets this requirement, un- should not pose a problem. The periph-
like thermoplastic materials often used ery of the tray, on the other hand, needs
for reasons of expedience. The handle special attention. It may be too long or
of the tray should be such that it does overextended because the primary im-
not interfere with the lips, therefore an pression material or tray has displaced the
internal handle is made as a protruding vestibular tissues, or it may be too short
internal ridge made from the tray mate- or underextended because the flow of the
rial (Fig. 11.2). material has been hindered locally.
When the denture supporting area is The ideal impression of the vestibule
fairly flat, the tray may be manufactured should allow all “normal” muscular activ-
directly on the cast, without relief. If the ity associated with speech, smiling, sing-
alveolar ridges have pronounced verti- ing and eating, but not extreme ones like
cal areas, the cast ought to be relieved in yawning, sneezing or coughing. If the lat-
Fig. 11.2. Special trays with internal handles for Fig. 11.3. The periphery of the tray ideally located
maxillary and mandibular jaws. to the vestibulum.

ter muscular activities were adjusted for, dible comes into close proximity with
the denture would be underextended, and this part of the ridge when the mandible
its physical retention compromised. In is widely opened. With the mandible
order to accommodate this, the periphery only half opened this space widens, and
of the tray should ideally be located ap- examination of the extension of the tray
proximately 2 mm short of the vestibule in the region with a dental mirror is then
at rest, allowing this area to be shaped by more easily accomplished.
soft impression material (Fig. 11.3). The mandibular denture undoubtedly
The priority when adapting the tray poses the greatest challenges in terms of
intraorally is to avoid overextension. This border adjustment of the special tray. The
error will unavoidably result in a corre- tongue hides the lingual border and floor
sponding overextended denture periphery of the mouth. The tongue and mylohyoid
with discomfort, even ulceration and loss muscle are frequently hypertrophied, and
of retention as possible consequences. It is the fact that saliva collects in the floor of
less critical if the tray is underextended. the mouth, makes the examination even
This may be compensated, either by more difficult.
border moulding by means of a special One adjustment method is to intro-
material for the purpose or by appropriate duce a dental mirror into the crevice and
manipulation of facial tissues and tongue instruct the patient to move the tongue
during the impression procedure. over to the opposite side, while at the
Identifying over- or underextensions same time the dentist pushes sufficiently
and locating the periphery of the tray against the side of the tongue to allow a
according to the above principle is often mirror vision of the area. In some cases
a challenge. In order to examine the ves- the mandibular ridge is totally resorbed,
tibular areas visually the lips and cheeks the denture supporting area is but a ditch
have to be lifted away from the denture between the tongue and the facial tissues,
supporting tissues. When you do this, the and these tissues are all movable. Such
very movable tissues will be displaced – cases often call for special impression
to an extent defeating the purpose. One techniques (see Special impression prob-
landmark to look for, sometimes helpful, lems).
but unfortunately not always reliable, is One final test, which should be at-
the borderline between the attached and tempted before the final impression com-
the freely movable mucosa. If the tray is mences, is to seat the tray in the relaxed
extended to this line, the impression will mouth and observe if it stays in place. If
at least not be overextended; however, it so, there is less likelihood that the tray is
may then be underextended. overextended. If the tray is displaced, the
In the maxilla, the areas facial to the cause may be overextension. However,
tuberocities are often difficult to examine the test is by no means reliable, since a
because the coronoid process of the man- hyperactive tongue may easily displace

a mandibular tray, even if it is not over-
A
extended. In the end, only the final im-
pression may disclose if the tray has been
over- or underextended.
Border moulding
Border moulding is a procedure whereby
a special material is attached to the pe-
riphery of the tray in order to facilitate
impression of the vestibular area. This is
normally fairly viscous, such as some sort
of slow setting plastic polymer or “Green B
stick” composition (Fig. 11.4A). The main
object of their use is to ensure that the
periphery of the denture is neither over-
nor underextended by optimizing the fit
of the periphery of the tray. The popular
belief that the procedure will enhance
the retention of the denture is, however,
without scientific basis.
Because of their normally high vis-
cosity, inappropriate use of the border c
moulding materials may cause general
overextension of the impression. In order
to avoid this, the dentist should manipu-
late the facial border moulding fairly
forcefully (Fig. 11.4B).
At this time, the border moulding ma-
terial may also be applied to the posterior
periphery of the maxillary tray where it
crosses the palate. During impression the
material is placed in firm contact with
the underlying tissues in order to create a Fig. 11.4A. Border moulding of the mandibular
pressure zone in the area (Fig. 11.4C). The tray with a ”Green stick” composition material.
purpose of this procedure is discussed in B. Manipulating the facial border in order to avoid
the chapter Retention of Complete Dentures overextension. C. Posterior border moulding of the
and in this chapter, under the heading maxillary tray.
Determining the A-line.

Regarding the mandible the dentist

A
Fig. 11.6. A careful border moulding make it possi-

ble to produce casts that give adequate information
B about the anatomy of the vestibular area.
pression so that a hard contact between

the border moulding material and the
denture supporting tissues is avoided.
This may most easily be accomplished by
cutting it away with a scalpel or a very
sharp knife.
The thickness of the denture peri-
phery should be determined at this stage
Fig. 11.5A. The dentist must manipulate the lips
and ideally incorporated in the impres-
and cheeks forcefully. B. The patient must assist in
sion. In order to retain the shape of the
the border moulding of the mouth floor by moving
vestibular area, the cast must be poured
the tongue from side to side.
so that it reproduces at least 2 mm of the
facial and lingual surfaces (Fig. 11.6). For
must manipulate the lips and cheeks fair- further discussion on the importance of
ly forcefully as previously explained and this aspect, se Lip support.
the patient should be instructed to extend As stated above, border moulding may
the tongue fully and move it from side to also be accomplished without the use of
side as much as possible (Fig. 11.5A+B). special materials, by manipulating the
That way the borders become slightly wash material into the vestibular crevice.
underextended, and this allows for a suf- This calls for a somewhat higher degree
ficient thickness of the final wash impres- of experience and practice. The practical
sion. It is advisable to work with only on method of doing so will be explained in
¼ of the periphery at a time – much more the following paragraphs.
than that may be difficult to manipulate
in practice. Securing attachment of
An inevitable result of such border impression material
moulding is that some of the material Before the final wash impression, suffi-
extends into the inner surface of the tray. cient attachment between the impression
This should be removed prior to final im- material and tray must be secured. This

can be achieved by painting the inside In order to satisfy both conditions, the
and periphery of the tray with the ap- dentist should first “pump” the mate-
propriate adhesive or even perforating it rial into the vestibule using the patient’s
when deemed necessary. cheeks and lips in an upward movement
(Fig. 11.7). The lips and cheeks should
Procedures for final impression thereafter be moved downwards to im-
To the impression tray, prepared in the part the functional movements on the
above fashion, a low- or a medium-vis- borders. This can either be accomplished
cosity wash material is applied. The tray by the patient performing “functional”
is inserted into the mouth and should movements such as smiling, pursing his
be seated slowly with small lateral move- lips or by manipulations by the dentist.
ments to facilitate the flow of the mate- Both methods have advantages and
rial. Overly firm pressure tends to displace drawbacks. If the patient himself per-
the tissues unduly and result in direct forms the movements, the shape of the
contact between tray and supporting tis- vestibule may be more correct in terms
sues. of function. The main problem with this
Border moulding with the wash mate- method is that the patient’s movements
rial should take place after the tray has may be difficult to control, they can be
been in place long enough to obtain a so forceful that the impression becomes
slightly more viscous consistency that underextended. Additionally, this poses
will allow easier manipulation. The den- the problem for the dentist of keeping the
tist then faces the double task of both tray stable during the setting of the mate-
assuring that the wash material fills the rial. Alternatively, the movements may be
vestibular crevice, and forming it into the too lax, in which case the impression is
optimal shape. likely to become overextended.
Under any circumstances, the lingual
side of a mandibular impression has to
be formed by the patient. This should
commence as soon as the facial manipu-
lation is complete. Unlike border mould-
ing with a special material, where the
tongue should be maximally extended
and moved from side to side, these move-
ments should be moderate, and the pa-
Fig. 11.7. In order to reproduce the anatomy of the tient instructed accordingly. A favoured
vestibular area in the final impression the dentist method is to ask the patient to lick his
must ”pump” the impression material into the ves- upper lip. However, the latter may some-
tibule and thereafter move lips and cheeks down- times be so powerful that the stability of
words simulating functional movements. the impression is compromised. During

this process it is advisable to stabilize the Special impressions
tray with fingers placed on either side, in The above method may be used success-
the premolar area. fully in the large majority of cases. How-
ever, special impression methods may be
Inspection of final impression indicated in cases with extremely resilient
The finished impression should be in- denture supporting tissues or extreme
spected for possible defects or pressure resorption.
zones of fitting surface or borders (Fig. Such areas also called “crista flaccida”
11.8). If there are significant deficiencies or “flabby ridge”, are not an infrequent
inside the impression, it should normally finding. The condition is most often local-
be retaken, as it is almost impossible to ised to the anterior region of the maxillary
obtain a satisfactory impression by add- ridge, but may also occur in other regions
ing material to it. A deficiency along the and occasionally comprise an entire jaw.
border may sometimes be acceptably ad- The problem when taking impression
justed by adding new impression materi- in such cases is to avoid displacement of
al, reinserting the impression and border the resilient tissues, which would tend to
moulding once more. render the denture uncomfortable and
If definite contact areas between compromise retention. If the condition is
the tray and the tissues are identified, limited to a specific area and the resilient
or the edge of the tray shows through part is not extremely movable, an impres-
the impression material, the impression sion may be accomplished by fabricating a
should be rejected and retaken. Dentures special tray where extra space is provided
made from such impressions are likely to over the flabby ridge.
cause pressure sores or be overextended. The area in question should then be
Instead, the pressure areas should be outlined on the primary cast and covered
relieved before a new impression is at- with two or even three extra layers of wax
tempted. Thus, one may hopefully avoid over which the tray is made. The final
the same problem from occurring again. wash impression should be carried out as
described previously, but with special care
in order to avoid displacing the tissues.
An alternative impression method in
such cases is to manufacture a tray with a
window over the flabby ridge and take a
separate impression of the flabby area with
soft gypsum, as illustrated in the chapter
4 (Fig. 4.4). In cases where the entire jaw is
extremely resilient, probably the best ma-
Fig. 11.8. The impression should be inspected for terial to use is still a thin mix of impres-
possible defects or pressure zones of fitting surface sion plaster. Sometimes a mandibular re-
or borders.

sorption is so extreme that special impres- occlusion rims
sion techniques are indicated. Success may The occlusion rims are manufactured
be achieved by taking impression with a on the definitive casts. The rims should
tray, trimmed to the best ability of the op- be controlled so that they are stable on
erator, in which a light bodied impression the casts before controlling them in the
material is primarily used as a pressure patient´s mouth. The rims are instrumen-
indicating paste. The pressure zones then tal in all recordings involving jaw relations
revealed are adjusted and new impressions (Fig. 11.9A+B). The periphery of the rims
taken until the impression show no sign should be controlled clinically for obvious
of the tray material. This “trial and error” errors. The retention may still be challeng-
method is bound to take a considerable ing, as the fit will never equal the finished
time, though hopefully accomplishing the denture. A denture fixative may be useful
task. and should be attempted in many situ-
ations. However, its efficacy is unfortu-
Recording jaw relations nately least in the mandibular rim, where
The purpose of recording jaw relations is, it is usually most needed. In all procedures
in the order in which it is performed clini- involving occlusion rims it is important to
cally, to determine: keep them moistened with water or saliva.
• basis for the aesthetics Dry occlusion rims may cause faulty reten-
• spatial relationship between the jaws tion and lips that adhere to the surfaces
• transference of these recordings to the and interfere with some of the procedures
articulator. and evaluations discussed below.
A B
Fig. 11.9. The mandibular (A). and maxillary (B). occlusion rims must be stable on the definitive casts as well
as in the mouth.

Determining the basis for Moreover, to some extent the vertical
aesthetics dimension affects the above factors. Con-
The aesthetic consequences of loss of sequently, all decisions have to be made
teeth and their bony support can be quite with this in mind.
dramatic, particularly in the elderly. The
loss of occlusal support leads to reduced Lip support
facial height (Fig. 11.10). In addition, There are no reliable landmarks indicat-
the loss of dental and bony support may ing the position of the lost alveolar bone
cause a collapse of the lips. In order to and teeth. As related in some detail in the
counteract these changes, the facial con- chapter “Missing teeth”, loss of teeth causes
tour of the patient must be restored; the a reduction of the width of the support-
ideal being the face as it would have been, ing area of the maxilla due to a resorption
fully dentate. In restoring the facial con- of the facial alveolar bone, whereas the
tour, not only teeth, but also lost bone opposite is usually the case in the mandi-
and soft tissue must be compensated for ble (Fig. 11.11A).
by the denture. Regarding the maxilla, the artificial
To this end, occlusion rims are used to incisors therefore have to be placed in
determine appropriate lip support, posi- front of the ridge if they are to occupy
tion of the incisal edges of the maxillary the same positions as the natural incisors,
incisors, inclination of the occlusal plane and the occlusion rim should be shaped
and midline of the dentition. It is advis- accordingly. Although it tends to make
able to determine these aspects in the the denture less stable, this is nevertheless
above sequence: usually accepted, because in the front aes-
Lip support influences the position of the thetics are favoured.
incisal edges, which in turn influence In the maxilla, the resorption of the
the orientation of the occlusal plane. facial alveolar bone occurs mainly near
the top of the ridge, whereas the resorp-
tion of the bone in the region of the pe-
riphery of the denture in the frontal area
is quite modest. The border of the occlu-
sion rim here should therefore be fairly
thin. From this border, the facial surface
of the occlusion rim should normally be
shaped as a straight or only slightly con-
vex surface (Fig. 11.11B). Another com-
mon error is a massive build-up in the
frontal vestibular area in an attempt to
Fig. 11.10. Reduced facial height and lip collapse eliminate wrinkles and generally “pad” a
due to loss of occlusal support. sunken face. The result is an unnaturally

A B

Fig. 11.11. A. Loss of bone in jaws without teeth resulting in an unfavourable relation between the maxillae
and mandible. B. A maxillary occlusion rim with a thin facial border and slightly convex surface.
rounded lip contour, particularly near the cial teeth are to occupy the same positions
nose, easily identified by the observer. as the natural incisors (Fig. 11.12A). The
Posteriorly, on the other hand, a certain need for this concavity is greater when
build-up may be advantageous, both in there is much resorption of the ridge.
terms of facial contour and improved pe- This shape of the ensuing denture is also
ripheral seal. necessary to maintain the natural fovea
Conversely, in the mandible, because mento-labialis. If the mandibular teeth
of the widening of the denture supporting are set up without a facial concavity, the
area due to the pattern of resorption, the surrounding tissues will tend to push the
occlusion rim should to varying extents denture posteriorly, or the fovea mento-la-
be shaped concavely labially if the artifi- bialis may tend to disappear (Fig. 11.12B).
A B
Fig. 11.12A. A mandibular occlucion rim and set-up shaped cancavely in the incisor area maintains fovea
manto-labialis and favours muscular balance. B. A mandibular occlusion rim and set-up without a concave
shape in the incisor area tends to obliterate fovea mento-labialis and push the denture posteriorly.


Fig. 11.13. Trimming of the occlusal rim will recon- Fig. 11.14. A maxillary occlusal rim that will expose
tour the lip support and decrease a too deep sulcus approximately 1-2 mm of the teeth.
nasolabialis.
the maxillary occlusion rim, which has

The ultimate test of the shape of the oc- the greatest effect on facial contour. How-
clusion rims is to what extent the aes- ever, this must never be regarded solely
thetics are pleasing. Consequently, it is on its own, but always seen in relation
essential to control the effects of the ma- to the mandibular one. Otherwise seri-
nipulations with the occlusion rims visu- ous errors in the horisontal relationship
ally (Fig. 11.13). These controls should be between the dentures can be made, par-
made, when the patient closes his mouth ticulary if the lip support of the maxillary
lightly and is completely relaxed. Old occlusion rim has been evaluated with a
dentures may be useful in deciding lip grossly incorrect vertical dimension. The
support, particularly if the patient wants subsequent shaping of the mandibular oc-
to replicate their aesthetics. However, due clusion rim normally takes considerably
to the continued resorption of the den- less time than the maxillary one, as most
ture supporting tissues, normally a degree relations between the ridges then have
of supplementary lip support is required already been established.
if a natural lip support is to be main-
tained. Old photos showing the patient’s Level of incisors
facial contour while dentate can also be The level or height of the maxillary inci-
helpful. Finally, it is strongly advised to sors determines the amount of tooth the
involve the patients and seek their advice patient exposes. A rule of thumb frequently
already at this stage because this is where referred to states that 1-2 mm of the max-
the facial positions of the teeth are deter- illary occlusion rim (and hence tooth)
mined. If errors in lip support are made, should be exposed in the midline below a
the entire set-up and at worst the denture relaxed upper lip (Fig.11.14).
will have to be remade. The length and mobility of the upper
The whole process commences with lip and the amount of teeth exposed var-

A B
Fig. 11.15A. The occlusal plane parallel to an imaginary line drawn between the pupils. B. Camper’s plane.
ies considerably from person to person, orientation of occlusal plane

and changes throughout life. The lip tends When the level of maxillary incisors has
to loose some of its muscular tone with been determined, one point of the occlus-
age and therefore lengthens, its mobility al plane is already fixed. This plane now
may also decrease to some extent, and a needs to be angled correctly as viewed
significant tooth wear is normally found from the front and side.
among the elderly. These factors reduce the Regarding the frontal perspective, it
amount of tooth that should be exposed is normally suggested that the occlusal
below the lip from that advocated in the plane should be made parallel to a line
above rule of thumb. drawn through the pupils of the eyes,
Under all circumstances, it is advisable which in most cases would ensure that
to record on the occlusion rim the high- the dentition does not appear skewed to
est level of the lip during functions such the observer (Fig. 11.15A). However, this
as smiling, which normally should expose recommendation should not be followed
approximately 2/3 of the clinical crown of blindly – in cases where the face is asym-
the incisors. metric such frontal orientation of the
As was the case with lip support, the de- occlusal plane may not be harmonious.
ciding factor regarding the level of incisors In this decision, the contour of the lips
should be the aesthetics. In the evaluation, should be considered and where there is
an attempt should be made at making the a discrepancy between the inter-pupillary
patient speak and smile. However, because line and the contour of the lips a compro-
the occlusion rim is usually more bulky mise should be made.
than the waxed-up denture, it may be hard When the patient’s face is viewed
for the patient to do so in a natural man- from the side, the recommendation is to
ner. The final test must therefore always be place the occlusal plane midway between
left to the try-in of the tooth set-up. the ridges at the chosen vertical dimen-

such records exist, some simple, rough, ex-
perienced based guide lines have to suffice:
In terms of size normally a big tooth
should be chosen for a big face and a
smaller tooth for a small face. Choosing
a tapered tooth for a tapered face, a more
rectangular tooth for a similarly shaped
Fig. 11.16. The midline of the dentition marked on
face frequently functions aesthetically. The
the maxillary rim.
hue of the teeth should preferably have
some common trait with the hue of the
sion or to make the occlusal plane paral- skin. It is advisable to test the effect of the
lel to Camper’s plane, which runs from tooth colour in relation to the skin to as-
ala to tragus (Fig. 11.15B). However, the sure that the two colours are in harmony.
deciding factor should be the aesthetics. A relatively light tooth may be appro-
With this in mind, the dentist should priate for a person with fair skin; a darker
observe the occlusion rim, with its chosen tooth may be chosen for a person whose
plane of occlusion, in order to evaluate face is more weather-beaten.
whether the contour exposes the posteri- The choice of artificial tooth must be
or dentition pleasingly and harmoniously made in cooperation with the patient.
in relation to the face and lips. However, to the untrained eye artificial
teeth usually appear darker on a card than
Midline in the mouth, where they contrast with
The midline of the dentition should nor- the lips, skin and the darkness of the oral
mally coincide with the imagined mid- cavity. It is therefore advisable for the den-
line of the face (Fig. 11.16). If the contour tist to make a preliminary selection and
of the mouth deviates from the midline avoid showing the teeth to the patient be-
of the face, this fact ought to be taken fore they can be regarded in the mouth at
into account before a decision is made. the try-in stage.
Again, the deciding factor should be In conclusion, successful choice of ar-
the aesthetics. tificial teeth is frequently a matter of trial
and error, with contributions from the
choice of artificial teeth dental team, patient and, not infrequently,
At this point in time a choice of artificial from an accompanying outside person.
teeth may be made. There are no evidence- Fortunately, this usually leads to an ac-
based procedures for this. If pre-extraction ceptable result – probably because there
record exists, either in the form of casts or is a fair amount of tolerance in regard to
photographs, these should be used to de- aesthetics.
termine tooth size and shape and may also
be indicative of the surface structure. If no

results of one always controlled through
an alternative method. Fortunately, and
despite what has been claimed in the past,
there is usually a fair amount of tolerance
by the patient in regard to this variable.
Both physiological and mechanical
methods may be used to determine the
occlusal vertical dimension. The physi-
ological methods and previous dentures
are discussed below, because these are
Fig. 11.17. One method of recording the vertical di-

the method most commonly used in the
mension.
clinic. For a discussion of other mechani-
cal methods, see Jaw Relation Registration
and Articulators.
Determining the relationship
between jaws Physiologic rest position and
Next, the occlusion rims, thus formed interocclusal rest space
according to aesthetic requirements, are This method is based on determining the
used to determine the relationship be- position of the mandible at rest, which is
tween the jaws. The theory associated governed by the relaxed opposing closing
with the latter is discussed in detail in and opening muscles and gravity. In this
the Chapter Jaw Relation Registration and position, there is a 2-4 mm gap between
Articulators. opposing teeth in the natural dentition
For the purposes of the present chap- called the interocclusal rest space. The
ter emphasis will be on clinical evalua- occlusal vertical dimension in the eden-
tions and procedures. The occlusal verti- tate is similarly found by first recording
cal dimension must be determined first, the rest vertical dimension and thereafter
the horizontal relationship thereafter. reducing the vertical dimension from this
position by an interocclusal rest space.
occlusal vertical dimension In practical terms, when the dentist
In the dentate the occlusal vertical dimen- records the rest vertical dimension, the
sion is determined by opposing teeth in patient should sit in an upright position
contact. In attempting to determine a and be asked to try to relax as much as
corresponding vertical dimension in the possible. The distance between the jaws
edentate, considerably less definite land- may then be measured in a number of
marks, such as those discussed below, have ways, a special instrument may be used
to be employed. It must be emphasized that records the distance from the lower
that none of them are reliable. No single border of the chin to the lower part of the
method should therefore be used, but the nose. Another method consists of mark-

ing one point on the skin somewhere on measurements should be repeated several
the upper face and another on the chin times to reduce the risk of making serious
and measuring the distance between errors.
them (Fig. 11.17). However, there are a Finally, no scientific methods are avail-
number of problems associated with using able to indicate the size of the interoc-
the mandibular rest position as a basis for clusal rest space, which therefore has to be
recording the vertical dimension. determined arbitrarily.
Firstly, it may be difficult to assure that
the patient’s mandible is in the true rest Phonetics
position. It is not easy for a patient to relax Another method that has been suggested
completely in a dental setting. One meth- is recording the relationship between
od that has been suggested in this context the jaws during a dynamic function like
is asking the patient to say the letter m, speaking. This method is based on the fact
another one is asking the patient to make that the closest distance between oppos-
a swallowing movement. The mandibular ing teeth during speech occurs when sibi-
position should be recorded a short time lants like s, sh and z are pronounced. The
thereafter. interocclusal distance then, also called
Secondly, the rest position is not a the closest speaking space, is normally
constant. Radiographic evidence indicates between 1 and 3 mm – somewhat smaller
that the intermaxillary distance at rest than the comparable interocclusal rest
increases significantly when the recording space based on the rest vertical dimension.
is made with dentures inserted. It becomes
permanently increased if new dentures Using previous denture
with an increased vertical dimension Previous dentures can be of use in deter-
have been in use for some time. Also, the mining the vertical dimension. The first
mandibular position in a relaxed patient step is to examine if the vertical dimen-
and the one that occurs after pronouncing sion of the dentures is acceptable. Due to a
the letter m do not coincide. Moreover, more precise fit, the retention of dentures
the position of the head will influence the is normally superior to that of occlusion
rest position. If it is bent backwards, the rims, although a denture adhesive is still
interocclusal distance is liable to increase recommended. The rest position of the
because of the greater pull of the opening mandible may also be used; if the patient
muscles of the mandible. is able to maintain the jaw in a steady
Thirdly, both of the abovementioned position while the lips are deflected, the
measuring methods show great variability. occlusal freedom can be inspected. The
The measurements are made on very mo- vertical dimension thus determined then
bile tissues. Furthermore, the soft and lax has to be transferred to the occlusion rims
tissues covering the mandible may mask by means of the measuring methods dis-
its movements. For that reason, these cussed above.

Clinical evaluation corresponding layer of chemically cur-
The ultimate test of the vertical dimen- ing acrylic may be added to the lower
sion is a clinical evaluation of the patient’s posterior teeth of the old denture and the
facial contour with the trimmed occlusion patient given sufficient time to become ac-
rims inserted. The operator should then customed to each new increase in vertical
routinely look for obvious signs which dimension.
might indicate that the chosen vertical
dimension is incorrect. Horizontal relationship
One such sign that the vertical dimen- choice of horizontal relationship
sion may be too high is that the patient Three horizontal relationships (centric
has problems closing his lips or that they relations) of the jaws are of special inter-
quiver after a while due to the effort of est when dentures are constructed:
keeping them closed. Another sign of the 1. Retruded position of the mandible (RP),
same error is if the occlusion rims or teeth defined as the position of the man-
constantly contact one another during dible with the condyles in their most
speech. retruded relation. In this relation
A puckered face and an appearance the mandible can rotate around an
showing a lower 1/3rd of the face, which imaginary axis running through the
seems out of proportion with the rest of condyles. This concept is a modifica-
the face, may be a sign of the opposite. tion of the more conventionally used
These are obvious signs that most op- retruded contact position (RCP). How-
erators ought to be able to identify. Less ever, due to the absence of teeth when
obvious ones can be considerably more complete dentures are constructed,
difficult to disclose. However, it may be RCP is a contradiction in terms.
helpful to ask the patient if the occlusion 2. Maximal intercuspal contacts (MIP), de-
rims feel comfortable with regard to their fined as the complete intercuspation
height. Any strong views on the subject of the opposing teeth independent of
ought to be taken seriously. condylar position.
A significant increase in vertical di- 3. Muscular contact position (MCP), de-
mension when new dentures replace old fined as the interdental contact that
ones may cause considerable problems occurs when the mandible closes from
for the patients and sometimes lead to its rest position. This is an unstrained
rejection. Clinical experience therefore contact position which, in a perfectly
discourages an increase of more than 4-5 harmonious natural dentition, coin-
mm in one go. If an objective examina- cides with MIP.
tion suggests the need for a greater in-
crease, it is strongly recommended that Normally MIP and MCP lie between 0.5
this be made in increments of no more and 1 mm in front of RP.
than 3-4 mm at a time. To this end, a It is recommended that RP be used

to record the horizontal relationship of
the jaws for the construction of complete
dentures, because this position can be
reliably reproduced. It may perhaps be
imagined that MCP would be the most
favourable position to record because it is
unstrained. However, recordings of MCP
are usually quite widely dispersed and
this position is therefore not sufficient
reliable for practical use.
If a denture is constructed in RP and Fig. 11.18. The relation between the maxillary and
the patient closes in the more forward mandibular jaw is registered with the mandible in
muscular position, the resilience of the a retruded position.
supporting tissues will most likely com-
pensate for the resulting minute move- ing the chin of the patient between finger
ment. An easy solution to the discrepancy and thumb, applying a light dorsal pres-
between RP and MCP is to use artificial sure and at the same time manipulating
teeth with low cuspal inclines. Alterna- the mandible with small opening and
tively, if it is deemed necessary, the dental closing movements. When the mandible
technician may adjust the artificial teeth has reached its RP-position, it is no longer
in the articulator in such a manner that held in a forward position by somewhat
the patient may occlude without cuspal yielding muscles (Fig. 11.18). The opening
interference between RP and MCP. The and closing movements in this position
zone thus established is often called long execute a hinge-axis rotation, usually fair-
centric or freedom in centric. ly easily identified by the dentist. A heavy
dorsal pressure is counterproductive, be-
Determining RP cause many patients find this uncomfort-
When the patient opens his mouth able or even painful and therefore tend to
widely, the condyles slide forward towards resist the movement.
the eminences, precluding a retruded po- This may also be the case in patients
sitioning of the mandible. When the RP is who find it difficult to relax during this
recorded, the patient should therefore be procedure. In such cases it is sometimes
instructed to relax and open his mouth advantageous to ask the patient to “push
only moderately: i.e. no more than 2 cm. the upper jaw forwards”. Even though this
Within such an opening the condyles are is an anatomic impossibility, nevertheless
normally centrally placed in the glenoid it frequently works and the patient imme-
fossa. diately retrudes the mandible into RP.
In most cases the mandible can then As indicated above, it is crucial that
be pushed further back into RP by hold- the patient is relaxed while RP is deter-

mined. To this end, sufficient time should
therefore be allocated in order to create a
quiet, unhurried ambiance.
Fixation of occlusion rims

Fixation of the occlusion rims is a pro-
cedure whereby the above variables are
brought together and their relationships
fixed. The spatial relationship of the jaws
can then be transferred to the articula-
tor. The fixation is made to the predeter-
Fig. 11.19. Occlusal rims with wax removed in the
mined vertical height, after the mandible
premolar region before the jaw relation registration.
has been guided into RP as described
above. To this end, it is recommended to
remove some wax from the mandibular tive grooves, will flow into and fill these
rim in the premolar region (Fig. 11.19). wedges. After the material has set, the oc-
Ideally, the fixation should not exert any clusion rims may be separated. The wedg-
pressure on the underlying tissues. The es function as keys, securing a correct
primary contacts of the dentition of the repositioning of the rims. Also, possible
resultant complete dentures will then be displacements of the rims during setting
evenly distributed. of the material are more easily discovered
Unfortunately, all recording materials due to the steep inclines of the wedges.
exert pressure during the fixation proce-
dure to varying degrees. For that reason, Recording materials
the underlying tissues and occlusion rims Special elastomers have been developed as
may be displaced, rendering the record- recording materials for fixation of the oc-
ing inaccurate. As a result, in areas where clusion rims. Their main advantage is that
the tissues are particularly displacable, they flow easily and therefore offer little
supracontacts between the artificial teeth resistance when the rims are brought
of the subsequent denture are likely to into proximity with one another. They
occur. It is therefore essential to control set quickly, become quite hard after they
the fixation before it is transferred to the are set, and thereafter allow separation of
articulator for later procedures. the occlusion rims so that a control of the
To facilitate this, transversal wedges recording can be made.
are cut across the maxillary wax rim Wax is also frequently used for
on either side in the region of the first fixation of the occlusion rims. Its main
premolar and molar (Fig. 11.19). The advantage is that it is by far the most in-
recording material, applied to the man- expensive and fastest method. However,
dibular rim and retained there by reten- it may exert more pressure to the underly-

ing tissues than the recording pastes, and contacts of the posterior teeth will be
it is less stable to handle. evenly distributed, and the intercuspation
does not differ from the situation in the
Transferring recording to articulator. Premature contacts, gaps be-
articulator tween the teeth or deviating intercuspa-
The fixated occlusion rims and the casts tion are signs that the fixation of the rims
are mounted in an articulator, which to or the horizontal relationship has been
a greater or lesser extent emulates the faulty. In that case a new fixation of the
movements of the mandible. This enables jaw relation should be made, either the
the dental technician to set op the arti- mandibular or maxillary cast remounted,
ficial teeth according to the information and the error adjusted in the articulator.
embedded in the recorded jaw relations. Before a new recording is attempted, ma-
For a discussion of the various types of ar- jor premature occlusal contacts should be
ticulators and their function, see the Jaw eliminated. If they are not, the same error
Relation Registration and Articulators. tends to recur because the early contacts
will transmit more force to the underly-
Try-in stage ing surface. To correct even minor errors
At the try-in stage the artificial teeth are in the final denture is usually more time
set-up according to the above recordings, consuming than making a new recording.
which should all be checked and adjusted
systematically. Also, the posterior bor- controlling and adjusting
der of the denture must be determined. the vertical relationship
Because the vertical and horizontal re- All the methods described under the
cordings may significantly influence the heading Determining the spatial relation-
aesthetics, these aspects must be satisfac- ship between the jaws can be employed in
tory before any work on the latter is at- order to control the vertical dimension. If
tempted. In principle, the same methods the chosen vertical dimension is too high,
used to control the various recordings of it may impinge on the interocclusal rest
jaw relations are used to control the set- space or even the closest speaking space,
up. It is recommended to proceed in the and the teeth chatter during speech.
sequence described below. However, the clinical evaluation and the
patient’s opinion regarding the distance
controlling and adjusting separating the jaws are the ultimate tests.
horizontal relationship and If the vertical dimension needs to be al-
occlusion tered, this should not be corrected in the
The set-up mandibular denture is guided articulator; instead a new recording of the
into closure in RP. If the horizontal re- jaw relation should be made. Otherwise
lationship and the fixation of the rims errors in occlusion are likely to occur.
have been correctly recorded, the primary

skewed, crowded or with spacing, worn or
untouched et cetera. Photographs, even
old ones, of the patient’s natural dentition
can be very helpful in creating a “natural”
appearance.
Throughout this process, the dentist
should advice, but never dictate. Only
in rare cases, where the patient’s wishes
might interfere with the function of the
denture, should the advice of the den-
Fig. 11.20. The result of well trimmed occlusal rims tist be more forceful. By his cooperation
and carefully choosen artificial teeth may result in with the dentist the patient should feel
dentures that harmonize with the face in a natural a shared responsibility for the aesthetic
way. outcome, which bodes for better accept-
ance of the final denture. Patients are
controlling and adjusting frequently hesitant and unsure in these
the aesthetics matters. If so, they should be encouraged
No universally accepted rules regarding to bring along a spouse, friend or relative.
denture aesthetics exist. Therefore only a Frequently, it is advisable to make another
few general guidelines can be given: Eva- appointment and thus enable the patient
luate if the tooth positions give proper lip to reconsider the aesthetics.
support, if the midline is correctly placed,
if a satisfactory amount of incisor tooth Determining the A-line
is exposed – both with relaxed and smil- The posterior limitation of the maxillary
ing lip, if the plane of occlusion exposes denture is located at the junction of the
the teeth pleasingly – without appearing immovable and movable (soft) palate. A
skewed as viewed from both front and
side (Fig. 11.20). If errors are disclosed, the
set-up must be partially or totally revised.
Therefore, only when these basic aspects
are acceptable, it is advisable to show the
set-up to the patient.
With this reservation, both evidence
and experience indicate that it is im-
perative to involve the patient in the
aesthetics. This includes an evaluation
of the above as well as all other aspects Fig. 11.21. The border between the immovable and
of aesthetics like the colour and shape of movable soft palate, the so-called A-line, marked
teeth, if the teeth should be regular or on the mucosa.

common method used in determining its to the dental laboratory for final produc-
position is to observe the palate when the tion.
patient says the vowel a. This causes the
movable soft part of the palate to vibrate. Insertion stage
Another method is to squeeze the pa-
tient's nostrils while asking him to blow Inspection of the denture
his nose. This creates a intranasal pressure, prior to insertion
pressing the soft palate downwards and Minor porosities in the gypsum cast may
forwards against the tounge, clearly expos- lead to the formation of small acrylic glob-
ing its demarcation from the hard palate. ules on the fitting surface of the denture.
Finally, the two fovea paltina can be helpful These cause small ulcers and often con-
indicating the position of the A-line, as they siderable discomfort to the patient. The
are usually located about 1 mm behind it. globules are usually easily removed with a
The demarcation between the movable knife. Equally, the denture supporting sur-
and immovable palate, is called the A-line or face should be inspected for sharp edges,
vibrating line (Fig. 11.21). such as those caused by corresponding
The A-line is marked on the mucosa crevices of the mucosa. The edges should
with an indelible or colour pencil, the be rounded and later polished. Finally,
marking transferred on to the base of the before the finished denture is inserted into
occlusion rim and eventually to the cast. Its the patient’s mouth, it should be inspected
position should be marked by cutting into for possible visual defects in the material.
the cast at a right angle to the surface, be- If there are porosities or discolorations in
tween the two hamuli. the acrylic because of improper polymeri-
In this area the denture should exert zation, the denture needs to be remade.
some degree of pressure on the underlying
tissues in order to create a so-called post- Inspection and clinical
palatal seal. The purpose and function of control of the denture after
this is discussed in the chapter Retention of insertion
Complete Dentures. A postpalatal seal may After insertion, the denture is inspected
be accomplished by applying some border for retention, stability, peripheral exten-
moulding material in the A-line area during sion and fit. Due to the visco-elastic na-
impression, thus creating a pressure zone. A ture of the denture supporting tissues,
pressure zone may also be created by a hori- optimal physical retention of a denture
zontal carving into the surface of the cast may not be reached immediately after in-
tapening and deepening towards the A-line; sertion because the tissues need some time
the depth of wich depends on the resilience to adapt to the new form. It is advisable to
of the tissues. inform the patient of this fact.
If all of the procedures above are deter- Subsequently, the finished denture
mined as satisfactory the set-up can be sent is controlled in the same manner as de-

scribed regarding jaw relations and try- Post insertion problems
in. Particular attention should be paid and treatments
to occlusion and articulation due to the Faced with a dissatisfied patient it is im-
fact that the artificial teeth tend to move portant that the dentist examines the oral
slightly within the flask during polymeri- conditions and denture as objectively as
zation. The occlusal adjustments should possible, and corrects any defects in the
be made systematically: i.e. first in centric latter that might be revealed. However, for
and, when this is satisfactory, in eccentric a number of reasons this is not easy. Mak-
occlusions. The requirement for satisfying ing dentures involves a series of compro-
the former is that simultaneous primary mises, some of which may be in contra-
contacts are established between all op- diction to each other. A typical example
posing premolars and molars in RCP. The of this is a facial placement of the anterior
purpose of adjusting the occlusal surfaces teeth for aesthetic reasons, which, how-
in eccentric positions is to remove obvi- ever, tends to make the denture less reten-
ous occlusal interferences. If major adjust- tive and stable. Such compromises are
ments of the occlusion and articulation always questionable, and the patient and
are needed, a new jaw relation registration indeed other dentists may judge the deci-
should be taken and the dentures sent to sions made differently.
the dental laboratory for correction. Because such problems arise sooner
Sometimes, tori, other bony protube- or later, even for the best of dentists, this
rances or sharp edges need to be relieved, should be taken into account. If, on the
and that may be performed at this stage. other hand, the patient’s complaints are
In these procedures, some kind of pres- hard to pinpoint or appear unreasonable,
sure indicating paste, for example a light the dentist is ill advised to perform ad-
bodied elastomere, may be useful in locat- justments based on wishful thinking that
ing areas with excessive pressure. they will miraculously solve the problem.
Any adjustments then are likely to intro-
Information and post duce new defects or errors in the denture,
insertion control appointment leaving the dentist prone to justifiable
The patient should now be given indi- criticism. Better then to refrain from ir-
vidual information that might be deemed reversible procedures, await development
necessary, and a new post insertion con- and possible clarification so that causal
trol appointment made, if possible, after treatment may be carried out. A valid
no more than three days. Most problems principle for all post insertion problems,
will be revealed and are usually easily conscientious diagnoses should always
rectified within this short period of time. precede individualised treatment.
If left for longer, it may turn the patient Finally, if dissatisfaction is related to
against the denture because of the dis- inadequate communication or lack of rap-
comfort and pain it may have caused. port and confidence between patient and

dentist, remedial actions are unlikely to
succeed and the advice is to refer the pa-
tient to another dentist.
Immediate dentures
Introduction
It is generally believed that the ability to
adapt to removable dentures decreases
with increasing age. However, there may Fig. 11.22. Panoramic radiograph showing a poor
be a point where teeth inevitably have dental situation in the maxillary jaw, indicating
to be removed. There can be a number need for treatment with a maxillary immediate
of reasons for this; to mention but a few: denture
The teeth may be subject to marginal or
apical chronic or acute infections, which
do not respond satisfactorily to treatment. arch form and horizontal as well as
Also, rampant caries, pain and discomfort vertical dimension are well defined
may prove impossible to control. In addi-
tion, patients may be unable or unwilling In addition, the denture will cover the
to make the effort needed to maintain extraction alveoli and may thereby some-
healthy teeth (Fig. 11.22). Such teeth can what relieve the patient from post-opera-
be restored with an immediate denture, tive pain.
defined as any removable dental prosthe- To gain these advantages, fabrication
sis fabricated for placement immediately of an immediate denture entails a close
following the removal of a natural tooth/ cooperation with a dental technician who
teeth. produces the dentures in advance so that
When extracted teeth are replaced by they can be inserted immediately follow-
an immediate denture, some advantages ing the extractions.
are obvious: However, there are also some disadvantag-
• avoidance of the social and functional es with immediate denture production:
handicap of being without teeth while • inability to try-in the dentures in ad-
a restoration is manufactured vance
• maintenance of unchanged facial mus- • problems to obtain a precise definitive
cular support and face height impression
• easier adaptation to the denture due to • more post insertion appointments in
unchanged anatomic and physiologi- order to correct for reduced retention
cal situation due to wound healing and bone re-
• easier clinical procedure as the exist- sorption
ing tooth position, form and color,

In some situations treatment with imme- total procedure and the fact that a total
diate dentures is contraindicated. Patients extraction is going to be performed in one
in poor general health and where surgical treatment session. The extractions may be
treatment is unsafe are not candidates for a rather stressing situation for the patient
immediate dentures. Patients in whom and therefore it may be advisable to ask
the extractions are believed to be very the patient to be accompanied by some-
complicated due to for example ana- one during the extraction appointment.
tomical reasons may need to be treated in It is also necessary to inform the patient
several sessions. In these situations bone early on that the retention of the dentures
resorption can be expected to be rather se- will decrease rather quickly and that this
vere and the definitive denture treatment must be compensated for in several treat-
can only begin after proper healing of the ment sessions until the bone resorption
denture supporting area. has diminished and that this will take
The three following basic principles quite some time.
regarding immediate dentures should be
adhered to: optimizing the denture
1. Teeth should be extracted and replaced supporting area
only when it is absolutely necessary Before the impression procedures start,
2. When that is the case, the possible the denture supporting area must be
consequences for the oral function optimized and any inflammations, due
following the loss of the teeth should to for example advanced periodontal dis-
be evaluated with and without pos- ease, must be properly treated in order to
sible prosthetic restorations. If the oral achieve an optimal definitive impression
function is adequate after the extrac- and thereby a better fitting immediate
tions, there is no objective reason why denture. Also, it may be an advantage
the missing teeth should be restored, to extract molar teeth first unless they
although the patient who sometimes are important for keeping the occlusion
may subjectively be of another opinion height or for esthetic reasons. The result-
usually will decide the issue ing preliminary wound healing make the
3. It is important to perform the extrac- final impression more accurate, thus im-
tions as gently and with as little tissue proving the fit of the immediate denture.
trauma as possible. That way bony
resorption will be kept to a minimum Preliminary impression
and the need for subsequent adjust- A preliminary impression of the jaw is
ments to compensate for this reduced. taken in alginate with a stock metal tray.
A custom tray for the final impression
clinical procedure may either be one that covers the whole
It is important to provide the patient impression area, booth teeth, palate and
with very detailed information about the vestibular area or it may be one tray cover-

A B
Fig. 11.23A. Trimmed section tray after final impression of edentolous areas. B. after a secondary impression
involving remaining teeth.
ing only edentulous parts of the jaw. In way as for a complete denture, followed by
the first case the tray is trimmed in the a final impression of the mucosal and ves-
vestibular and palatal parts like a complete tibular parts. In order to relate this impres-
denture tray. However, before the final sion to remaining teeth a second external
impression is taken, the remaining teeth impression, covering booth teeth and the
must be blocked out with wax so that no inner tray, is taken. This may preferably
undercuts may interfer with the impres- be taken in a standard metallic tray and
sion or unintentionally “extract” the alginate (Fig. 11.23A+B). At the same ap-
teeth. A tray only covering the edentu- pointment, an impression of the opposing
lous areas may be used when only anterior jaw is taken and jaw relation registration
teeth remain in the jaw, a tray only cover- made.
ing the edentulous areas may be used. The If a sufficient number of teeth are
borders are again trimmed like the same present, jaw relations are registered with
A B
Fig. 11.24A+B. Mounted casts with occlusion rims for tooth set-up for an immediate upper denture.

an occlusal index, if not, an occlusion rim crevice and will therefore not impinge on
or rims must be ordered and used for the alveolar bone.
registration (Fig. 11.24A+B). Together with Instead of removal of all gypsum teeth
information about tooth color and details before tooth set-up, every other anterior
about any specific alteration in the tooth tooth is removed and replaced by an arti-
set-up the dental technician can start ficial tooth that may be positioned in re-
with this work. lation to remaining gypsum teeth. There-
Unlike the setting of teeth for an ordi- by, one may gain important information
nary complete denture, the tooth set-up from the oral situation of the patient (Fig.
for an immediate denture may use impor- 11.25A). Thereafter, remaining gypsum
tant information from remaining teeth teeth may be removed and replaced by
in the cast. The set-up always starts in the artificial teeth. If an occlusion rim has
anterior region. The first step is to mark been used for registration of missing pos-
– with a sharp pencil – the gingival mar- terior teeth, the tooth set-up in this area
gins of the gypsum teeth that are going follows the information from the occlusal
to be extracted. When a gypsum tooth is rim (Fig. 11.25B).
removed from the cast the marked out- If it is necessary, the final wax-up may
line of the gingival margin should be un- be checked with the patient in an extra
touched. Apart from a minor rounding of recall. A separate try-in may even be made
possible prominences, the lingual outline of the posterior edentulous areas (Fig. 11.
should remain throughout all subsequent 26A+B). At this appointment small rear-
procedures. Facially, on the other hand, rangement of tooth positions also may be
a groove should be carved into the gyp- made. Thereafter the finalization of the im-
sum cast in the direction of the root to a mediate denture can be made in the usual
depth of approximately two to three mm, manner for a complete denture.
tapering to zero towards the lingual part In case many teeth are extracted, it may
of the gingival margin. This is justifiable be an advantage to manufacture a clear
because it corresponds to the gingival acrylic indicator plate made on the pre-
A B
Fig. 11.25A. Every other anterior gypsum tooth removed and replaced by artificial teeth. B. Posterior teeth
set-up.

A B
Fig. 11.26. Try-in and control of posterior maxillary tooth set-up (A) and anterior tooth set-up (B).
pared cast or a duplicate of the same (Fig.

11.27A). This plate, when inserted after the
teeth are extracted, makes it possible to
identify pressure spots, which are displayed
as blanched areas (Fig. 11.27B). Pressure
spots should then be relieved correspond-
ingly from the inside of the denture.
Insertion and post insertion

treatment
After extraction and insertion of the im-
A mediate denture the extension, retention
and stability has to be checked. Overex-
tended areas, especially at frenas, must be
relieved. Pressure areas must be trimmed.
If the denture has very poor retention,
a temporary relining may be made with
a tissue conditioning material. If so, it is
important to remove tissue-conditioning
material that has extended into the extrac-
tion alveoli. A preliminary correction of
the occlusion is made in order to obtain
B
bilateral contact. However, a more detailed
Fig. 11.27A. Indicator plate made on the defitive

correction is normally made at a later oc-
cast. B. Blanched areas due to heavy pressure on the

casion. Patients who have had an imme-
posterior part of the anterior teeth detected through

diate denture inserted should preferably
the indicator plate.

be checked the next day, particularly if

area and the dentures and makes a careful
inspection of the denture supporting area
(Fig. 11.28). Any tissue reactions due to
improper extension of the denture must be
corrected.
If need be, the occlusion must be ad-
justed additionally, since unstable occlu-
sion may also be the reason for sore spots.
Also, the retention must be controlled and
Fig. 11.28. At the 24-hours recall the denture sup-
temporary relined with tissue condition
porting area is cleaned and inspected and the exten-
material may be necessary.
sion, retention, stability and occlusion checked.
Instructions about handling the den-
ture, removal, insertion and cleaning both
many teeth have been removed, so that denture and denture supporting area must
possible problems may be handled quickly be given at this appointment. Further-
and efficiently. It is important to inform more, recalls are determined individually,
the patient not to remove the immediate but normally a second post insertion visit
denture during these 24 hours. First of all, is needed after another week. In the fol-
the denture acts as an effetive seal over the lowing months the alveolar ridge will
extraction sites and prevents possible, on- resorb to a greater or lesser extent. Most
going bleeding. Secondly, if the denture is of the resorption will take place within
removed, swelling of the denture support- the first six months after the extraction,
ing area due to extensive extraction, can although some degree of resorption will
make it impossible to reinsert the dentures continue thereafter. Accordingly, the fit
maybe for several days. The patient must of immediate dentures must be adjusted
be informed that they may eat as long as by means of a reline or rebase, usually
it does not hurt, but soft food and soup is after three to six months – depending on
recommended. the speed of resorption. Not infrequently,
At the recall the dentist removes the more than one such adjustment is neces-
immediate denture, cleans the supporting sary within the first year after insertion.
Further reading
Berg E. Acceptance of full dentures. Int Dent J 1993;43(3 Suppl 1):299-306.
Carlsson GE, Omar R. The future of complete dentures in oral rehabilitation. A critical review. J
Oral Rehabil 2010; 37: 143-56.
Garrett NR, Kapur KK, Perez P. Effects of improvements of poorly fitting dentures and new den-
tures on patient satisfaction. J Prosthet Dent 1996; 76: 403-413.
Geerts GAV, Stuhlinger ME, Nel DG. A comparison of the accuracy of two methods used by pre-
doctural students to measure vertical dimension. J Prosthet Dent 2004;91:59:66.

12
Removable partial dental prosthesis
– clinical procedures
E i n a r B E rg and joH a n gU n n E
INTRoDucTIoN. A removable partial dental prosthesis (RPdP) is a dental prosthesis replac-

ing missing teeth and oral tissues such as gingiva or alveolar bone in the partially dentate
mouth. The prosthesis can be removed and replaced by the patient. The different compo-
nents of RPdPs are shown in Fig. 12.1 A and B. Their main functions are described below. It
should be noted that a specific component may have more than one function:
• Denture corpus – incorporates all the elements of the RPdP (as follows).
• Denture base – (acrylic or metal) covers the alveolar ridge where teeth are missing (saddle
area). In maxillary RPdPs, the palatal plates and bars connecting the saddle areas are part
of the denture base.
• Framework – connects the different parts of the denture. Most RPdPs have a metal frame-
work which is usually made in a cobalt-chromium alloy. The different parts of the denture
may also be connected by the acrylic base material (acrylic RPdPs).
• Major connectors – (maxillary and mandibular) connect the saddles to the metal frame-
work. If there are no saddles on one side of the mouth, they connect the saddle or sad-
dles and the supporting and retaining teeth (abutment teeth) on the opposite side.
• Minor connectors – parts of metal frameworks that connect elements supporting and re-
taining the RPdP.
• Perforated saddles – part of the framework covering the edentulous ridge, in which the
denture base is embedded and retained.
• Artificial teeth – usually heavily cross-linked acrylic, but may sometimes have occlusal sur-
faces in a composite material.
• Supporting components – transmit to abutment teeth and edentulous areas some or all oc-
clusal loads to which the RPdP is subjected, through:
• Dental rests – transmit loads to the abutment teeth.
• Denture base – transmit loads to the edentulous areas.
• Palatal plates and bars – transmit loads to the edentulous areas.
• Retaining components – oppose forces that tend to dislodge the RPdP through:
169

Denture base Active retainer
• Active retainers /direct retainers – oppose forces that tend to dislodge the RPdP in the
Major connnector Artificial teeth
direction in which it is inserted.
• Passive/indirect retainers – together with the direct retainers stabilize the denture
Major against
connnectorrotating away from the ridge.
• Stabilizing components – stabilize the RPdP against horizontal forces.
Active retainer
Artificial teeth all of the occlusal forces to which it is

Denture base Active retainer subjected to the abutments through the
Denture base
dental rests.
A Tooth-tissue supported. The RPDP trans-
mits some of the occlusal forces to which
it is subjected to the abutments through
the dental rests and some to the alveolar
Major connnector Artificial teeth
ridges.
Tissue supported. Such RPDPs have no
Denture
Major rest
connnector Passive retainer dental rests. Apart from some lateral forc-
es that may be transmitted to the contig-
Active retainer B
uous teeth via the approximal contacts,
Artificial
Peforated teeth
saddle all occlusal forces to which the RPDP is
Minor connector
subjected are transmitted to the alveolar
Denture base
ridges.
Palatal plate The importance of this classification
is that it indicates the prognosis of the
Fig. 12.1. The components of the RPDP and their RPDP, which is best for tooth-supported
functions. dentures – poorest for tissue supported
ones.
Denture rest Passive retainer According to location of missing

classification of RPDPs teeth (Kennedy classification)
According to type of framework This classification (Fig. 12.2) is based on
There are two
Peforated types of RPDPs depending
saddle where the missing teeth are located:
Minor connector
on whether the framework is metal or Class I. The RPDP has bilateral saddles
acrylic. with no posterior abutments (free-end
Palatal plate saddles).
According to type of support Class II. The RPDP has a unilateral
RPDPs can be classified according to the free-end saddle.
degree to which they are supported by Class III. All saddles of the RPDP are
the abutments: bounded, i.e. the patient has remaining
Tooth supported. The RPDP transmits teeth on either side of the tooth gap.
170 Removable partial dental prosthesis – clinical procedures

Indications and
contraindications for RPDPs
General principles
Teeth are lost due to caries, a periodontal
disease, trauma or other oral diseases.
A B However, missing teeth may also be con-
genital. Whatever the reason, this state
may lead to altered functional and aes-
thetic oral conditions (Fig. 12.3). If teeth
are missing in the frontal region a pros-
thetic restoration is normally required for
c D aesthetic reasons. It is considerably more
Fig. 12.2. Kennedy classification. challenging to decide whether the loss of
posterior teeth justifies treatment. One of
the deciding factors in this respect is the
Class IV. The RPDP has a saddle in the propensity within the dentition to adapt
frontal region only. If there are other sad- to the altered functional condition.
dles, the denture is classified as a class III. Sometimes a natural compensation
The classes are numbered in order of ensues so that acceptable functional and
occurrence: i.e. class I occurs most often, aesthetic conditions are re-established
class IV least often. It should be noted after some time. This outcome may be
that a free-end saddle, which is not to be caused by a favourable response of the
restored (for instance when one or two periodontium to the increased load, to
molars are missing) should be disregarded minor tooth migrations or even the ac-
when classifying. The connection between ceptance by the patient to the changed
the two above classifications is as follows: conditions (Fig. 12.3, left side).
Provided the RPDPs are equipped with However, no or insufficient adaptation
dental rests, class 1 and 2 dentures are may take place for a number of reasons:
tooth-tissue supported because a free-end The aesthetic or functional changes may
saddle is only tooth supported anteriorly. be unacceptable to the patient, major
RPDPs class III and IV are usually tooth tooth migrations may occur and result-
supported, but in cases where the edentu- ing pathologic conditions may develop,
lous area is long and curved, the denture both locally in regard to teeth or gingiva,
will to some extent be tooth-tissue sup- or elsewhere such as in the temporoman-
ported because then the dental rests are dibular joints and masticatory muscles
unable to transmit all occlusal loads. (Fig. 12.3, right side). In such cases some
The importance of this classification kind of artificial compensation is indi-
is that each class has common treatment cated, ranging from a simple adjustment
and design problems. of the occlusion, to fixed or removable
Removable partial dental prosthesis – clinical procedures 171

Masticatory function. This important
function of the dentition affects incising,

comminuting food, mixing with saliva
and swallowing. Mastication represents
the first phase of the digestive process.
Nevertheless, a decision to restore because

of a reduction in masticatory function is
not an easy one. Indeed, it may seem rea-

sonable to hypothesize that a reduction
in masticatory efficiency is unfavourable

for the digestive system. However, no
clear cut scientific evidence confirms this.

Also, even if a number of reports have
Fig. 12.3. How loss of teeeth can lead to acceptable indicated that the ability to comminute
or unacceptable function. the food is generally reduced in step with
a reduction in the number of functional
teeth, there is a marked difference in
prostheses or orthodontic treatment. The masticatory function between individuals
main object of this oral rehabilitation is with the same number of teeth. This indi-
to restore and/or maintain the oral func- cates that masticatory ability is not solely
tion, but always with the fundamental related to the number of remaining teeth.
principle in mind that the prosthetic res- In addition, other factors may play a part,
toration should do more good than harm. such as the fact that masticatory function
can be subjectively important since it in-
In relation to the functions fluences the enjoyment of eating.
of the dentition In the final analysis there are few ab-
Relevant to the above object is a discus- solute objective indications for restoring
sion of the various functions of the denti- missing teeth for the sake of masticatory
tion, to what extent missing teeth influ- function. Accordingly, as with the social
ence them, and more specifically, when functions of the dentition, the need for
dysfunction requiring treatment can be prosthesis for this reason is to a large
said to exist. extent defined by the patient. Since the
Aesthetic and phonetic functions. These patient’s perceived need for a prosthetic
functions affect facial appearance and device frequently changes with time as a
speech and are therefore normally of result of adaptation, it may be prudent to
overriding importance to the patient. wait for some time after tooth loss before
Consequently, the decision whether or commencing treatment.
not to treat is simple, as normally the pa- Occlusal function. This affects differ-
tient decides the issue. ent kinds of occlusal contact situations

and accompanying muscular activities. In relation to possible harmful
Occlusal function rarely indicates treat- effects
ment with RDPD's on its own. However, One of the most important factors that
a number of occlusal, muscular and even should be evaluated in deciding whether
joint dysfunctions may occasionally de- or not missing teeth should be restored
velop as a consequence of tooth loss. Such by RPDPs, is the propensity for harmful
dysfunction may be caused by the elonga- effects such restorations may have on the
tion of unopposed teeth that may lead oral tissues. These harmful effects have
to traumatic deviation of the occlusion. two major causes: Mechanical trauma and
Elongated teeth may also seriously inter- increased plaque retention.
fere with planned or future restorations Mechanical trauma. This is particularly
in the opposing jaw. Tipping of teeth into likely to occur when the load transmitted
the gaps may open up approximal con- to the RPDP is completely or in part trans-
tacts causing food impaction, discomfort, ferred on to the mucosa and bony support
possible periodontal problems and caries. rather than to the teeth (tissue supported
Joint problems may develop with ensuing and tooth-tissue supported dentures re-
muscular dysfunction. spectively). The general effect of RPDPs of
However, the operative word in this this kind is that they tend to sink into the
context is “may”. For a number of reasons tissues, initially due to the visco-elastic
these events may not occur: The older properties of the mucosa; later, and more
the patient, the less likely it is that teeth importantly, as a result of resorption of
migrate. The tendency to tooth migration the ridges. The latter has several undesir-
differs from person to person. In some in- able clinical consequences: The denture
dividuals the thrust of the tongue can be is likely to end up in infraocclusion (Fig.
sufficient to maintain unopposed teeth in 12.4A) thus loose its contact with the
their positions. Even a minor antagonist opposing dentition. As a consequence,
contact may suffice in hindering a tooth its masticatory efficiency will be signifi-
from elongating, although this situation cantly reduced and the aesthetics often
appears to promote tooth tipping. Also, unfavourably affected. Such dentures may
joint and muscular problems rarely occur also traumatize the mucosa by causing
even in cases with considerable occlusal pressure sores and hyperplastic reactions.
dysfunction. Accordingly, and also in view In addition to the bony resorption
of the increased biological risks associated mentioned above, there may be direct
with replacing missing teeth discussed contact and pressure on the gingival mar-
below, it is never advisable to restore auto- gins of teeth in close contact with com-
matically in order to avoid occlusal prob- ponents of the denture. At first this tends
lems. Better then to observe the situation to flatten the gingival margin (Fig. 12.4B).
for some time and only intervene if or Later, the periodontal response to the
when occlusal problems develop. pressure is an increase in pocket depth

In view of the problems associ-
A
ated with RPDPs in which the loads are
transmitted to the ridges, it would seem
sensible to try to avoid these harmful ef-
fects by transmitting the loads as much
as possible to the abutments, by means of
dental rests. However, there has been con-
cern, occasionally explicitly expressed in
some textbooks, but more often implicit,
that the extra load on the abutments
might be harmful. The premise for this
B concern is that the extra loading of the
abutments may exceed the physiologic
tolerance of their supporting tissues and
result in increased tooth mobility, peri-
odontal disease and eventual tooth loss.
Moreover, the concern regarding possible
overloading of abutments has led to spe-
cial RPDP designs intended to reduce the
c loading of these teeth, particularly forces
that are mainly horizontal.
However, this hypothesis lacks sci-
entific evidence. On the contrary, it is
refuted by long term controlled follow-up
studies on RPDPs. True, no such studies
have been conducted on cases where the
periodontal support of abutments has
been seriously reduced (by more than
50%), so the aforementioned clinical re-
sults are strictly speaking only valid for
Fig. 12.4 A. Tissue supported RPDP in infraocclu-
patients with more favourable periodontal
sion due to bony resorption. B. Flattened trauma-
support.
tized marginal gingiva due to direct mechanical
In a discussion on possible overload-
pressure from a tissue supported RPDP. C. Possible
ing of abutment teeth that support and
stagnant area favouring plaque retention.
retain RPDPs, the general principles of
and resorption of the supporting bone of how the periodontium responds to ex-
the abutment teeth. In consequence, the treme loads are obviously relevant. The
mobility of the teeth may progressively effects of extreme uni- and multidirec-
increase and they may eventually be lost. tional loadings on teeth were determined

in studies conducted more than 40 years problems have been successfully treat-
ago. The results of these clearly show that: ed, a reduction of the mobility can be
• Even extreme loads do not lead to api- achieved by some sort of splinting be-
cal migration of the epithelial cuff, or fore the teeth are used as abutments
to permanent loss of bony tooth sup- • periodontal diseases must be treated
port. before RPDPs are inserted and prophy-
• Increased tooth mobility that may lactic measures initiated so that this
ensue should be regarded as a physio- situation is maintained.
logic response to the loading, and is
reversible once the loading is reduced. Increased plaque retention. The presence of
• The consequence of a severe reduc- a large foreign body in the mouth such
tion of the bony support of abutment as an RPDP tends to increase plaque re-
teeth (by 50% or more) is an increased tention for a number of reasons: Plaque
mobility. In extreme cases the mo- collects on all components of the denture
bility may increase progressively as itself. It also causes unfavourable qualita-
even normal forces of occlusion may tive changes in the composition of the
exceed the physiologic limitation of plaque. More importantly, it inevitably
the periodontium, terminating in the creates stagnant areas around the various
mechanical extraction of the tooth. components of the denture, which are
• The progress of an existing periodon- close to or in contact with the teeth (Fig.
titis is likely to increase if the tooth is 12.4C and 12.5), and may cover large ar-
subjected to heavy loading. eas of oral tissues in general and marginal
gingivae in particular. This all tends to
On the basis of these findings, in the con-
text of RPDPs, the following conclusions A
may be extrapolated regarding the same
points:
• in patients with a reasonable bony
support of the abutment teeth, over-
loading is not a problem
• minor increase of abutment mobil- B c
ity frequently observed in connec-

tion with the insertion of RPDPs is a
physiologic occurrence and usually
transient
• in patients with severely reduced bony Fig. 12.5. A minimum distance of 3 mm has been
support of abutment teeth, and in established between (A) a dental bar, (B) interproxi-
particular, where the mobility of these mally with minor connector, and (C) interproximal-
teeth is great, although periodontal ly with base acrylic.

interfere with the natural cleansing of cumulation. Also, for technical and eco-
tongue, cheeks, lips and the scouring of nomical reasons, such dentures are nor-
food, and consequently adds significantly mally made without dental rests and are
to the bacterial load in the mouth. In ad- thus tissue supported, with the potential
dition, because the RPDP promotes plaque for mechanical trauma described above.
formation and retention, adequate oral The main advantage with RPDPs of
hygiene measures will be more difficult to this type is that they are easy and inex-
execute. pensive to manufacture. However, be-
The well-known and most important cause of their potential for causing harm
consequences of increased plaque reten- to the oral tissues, they are only indicated
tion are increasing prevalence of caries for temporary use. One such use is as a
and periodontal diseases. Caries in this replacement, pending permanent treat-
group of patients mostly manifests itself ment, of teeth extracted in connection
as root caries, which may be difficult to with periodontal treatment. It may also
handle satisfactorily in terms of aetiology, be used as a transitional denture facilitat-
restoration and prophylaxis. Because of ing adaptation to a future complete den-
the unfavourable local factors described ture when the rest dentition is doomed or
above, the periodontal diseases may like- when the patient is bedridden, seriously
wise be difficult to treat. However, the or terminally ill. Occasionally it may be
most important methods involved in indicated when there is insufficient time
treating these diseases and maintaining to perform a more permanent treatment.
oral health are simple in principle al- RPDPs with metal framework. Such den-
though sometimes difficult to implement: tures have also been shown to be poten-
systematic plaque control, fluoride treat- tially harmful to the oral tissues. Howev-
ment and dietary habits. er, the effects were less serious than those
recorded for RPDPs with acrylic connec-
In relation to type of RPDP tors. Furthermore, it has been demon-
The two types of RPDPs have different strated in well-controlled follow-up stud-
indications for use. ies that RPDPs with metal frameworks,
Acrylic RPDPs. Such dentures have under certain conditions, have been used
been clearly shown to have harmful ef- more than 10 years without damage to
fects on all oral tissues after being worn the periodontium of the abutment teeth
for no more than a year. There are a num- and without increase in caries activity.
ber of reasons for this rather dismal re- The main difference between these fa-
sult: Because of low mechanical strength, vourable results and those reported from
RPDPs with acrylic connectors have to be previous (and some later) studies is not
quite bulky and therefore usually cover related to details of construction, load
large areas of gingival margins and rest distribution between abutment teeth and
dentition. This tends to favour plaque ac- the alveolar ridges nor to any other me-

chanical factor. The difference is attribut- risk to oral tissues resulting from attempts
ed to the fact that these patients were giv- to restore missing teeth by means of RP-
en conscientious individual instructions DPs in such cases normally clearly out-
in oral and denture hygiene and adequate weigh the advantages. Consequently, in
periodontal treatment before the pros- such cases prosthetic restorations should
thetic treatment was started, and given generally not be made.
systematic and individual maintenance Fixed partial dental prostheses (FPDPs).
after insertion. Given these premises and The general consensus is that fixed resto-
other important conditions discussed rations are preferable to removable ones.
below, the consensus today seems to be This conclusion also includes fixed tooth
that RPDPs with metal frameworks can supported partial dental prostheses, de-
be used as permanent restorations with a spite the fact that such restorations may
minimum of harm to the oral tissues. also cause harm to the oral tissues, partic-
ularly due to the invasiveness of the prepa-
In relation to alternative treatment rations of the abutments. Furthermore,
Even though RPDPs, under the above cir- the marginal area between the crown and
cumstances, may be used with minimal abutment tooth, with its imperfect fit and
harm to the oral tissues, alternative treat- rough plaque retaining area of dental ce-
ments with less risk in that respect should ment, is located at, near or below the gin-
always be explored. Also, in view of the gival margin, potentially inducing caries
potential for harmful effects of any pros- and periodontal diseases.
thodontic restoration in general and RP- To a large extent these risk factors can
DPs in particular, the need for replacement be neutralised by hygiene measures and
of the missing teeth must be considered. use of fluorides. Moreover, the longevity
Shortened dental arches. In view of the of FPDPs is normally considerably better
said potential for harmful effects of any than for RPDPs. More importantly, disre-
prosthodontic restoration, the need for garding the greater cost of such restora-
replacement of the missing teeth should tions and the discomfort of the treatment
always be considered. This aspect has fos- involved, it is usually much preferred by
tered a discussion of the minimum num- patients. In this context, there is no ques-
ber of teeth needed for an adequate oral tion that the deciding factor in choosing
function of the dentition. In this context RPDPs rather than FPDPs is normally
the concept “shortened dental arches” has the cost involved. But even this factor is
been coined. The essence of it has been to not as clear-cut as might be imagined by
show that subjects with the dental arches just looking at the numbers. The average
shortened due to loss of molars, and with longevity of RPDPs has been reported to
approximately 20 contiguous teeth in an- be no more than approximately 8 years
tagonist contact can function satisfactori- – considerably less than that recorded for
ly. The disadvantages in terms of potential FPDPs. Also, whereas the cost of maintain-

ing FPDPs is usually negligible, it may be “as many as necessary, but as few as pos-
considerable for RPDPs: In addition to the sible”. In the individual case it will always
cost of yearly extensive regular controls be necessary to regard all circumstances
(or shorter intervals if deemed necessary), with a bearing on this matter, such as the
such measures include frequent relines, number and anatomy of the abutments,
denture repairs and remakes. root areas available for distribution of oc-
A treatment alternative to RPDPs es- clusal loads, mobility, occurrence of brux-
pecially relevant in relation to Kennedy ism etc.
Class I and II (free-end cases) is the tooth- If the number and location of the rest
supported extension FPD that may restore dentition are such that a tooth supported
one or two missing posterior teeth. How- FPDP is deemed contraindicated, and the
ever, the mechanical risk of breakdown of patient does not wish an RPDP, an implant
this alternative is considerably higher than supported FPDP may be used. However,
for a conventional FPDP, particularly if the the cost of such restorations is usually
extension has more than one pontic. even higher than for tooth supported
Another important aspect in the ones, which precludes their use for the ma-
choice between FPDPs and RPDPs is the jority of patients. Furthermore, as much
dental support of the abutment teeth. as 1/3rd of patients, even when offered im-
If the bony support is severely reduced plants free of charge, decline for a number
and the abutment teeth are quite mobile, of reasons.
FPDPs should normally be preferred since Especially in relation to free-end cases
fixed restorations reduce the mobility of with all their inherent disadvantages im-
the abutments, whereas RPDPs tend to in- plant-tooth supported FPDPs may offer an
crease it. alternative treatment to RPDPs. Although
However, FPDPs cannot be used in all this treatment can also be used in cases
clinical situations. There needs to be a where the edentulous space is too great to
sufficient number of abutments for sup- be spanned by a tooth supported FPDP, if
port, which cannot be placed too far apart. possible a purely implant supported resto-
What is a sufficient number of abutments ration is preferred.
and an acceptable length of tooth gap to Complete dentures. Such dentures may
be bridged with an FPDP without an unac- be an option if the rest dentition is so
ceptable mechanical or biological risk has poor, either in terms of restorations, caries
been and is a constant matter for discus- activity or periodontal support, that only
sion in the literature. Suffice it to say that a limited prognosis can be expected. This
there is a tendency to depart from the may also be a sensible treatment alterna-
previous overcautious attitude of “better tive in the event that the patient lacks mo-
safe than sorry”, involving a large number tivation is unable or unwilling to make the
of abutments, to a more conservative and effort necessary to maintain oral health
restrictive attitude inherent in the adage when using an RPDP.

Summing up indications for RPDPs to mean that mechanical factors are with-
When it has been decided to restore miss- out importance when RPDPs are designed.
ing teeth, RPDPs are indicated 1) when The results of the above-mentioned
tooth or implant supported FPDPs for the research and the clinical experience of
above reasons cannot be used or 2) when a experts in the field have fostered the fol-
patient has become so adapted to an exist- lowing general advice for treatment of the
ing RPDP that he fails to see the point of partially dentate with RPDPs:
alternative treatments. In such cases the
advice is to inform the patient fully of the Measures to avoid/reduce
fixed restorative alternatives, but without mechanical trauma
persuasion, so that he may make an in- Use dental rest. These transmit the loads to
formed choice. the abutment teeth.
Use rigid major connectors. These reduce
The Scandinavian approach the risk of deformation of the construc-
to RPDPs tion and allow distribution of loads to all
The above deliberations regarding indica- supporting structures.
tions and contraindications form the basis Extend free-end saddles maximally. This
for the Scandinavian approach to RPDPs. reduces the load per surface saddle unit.
The scientific basis of this approach is fur- Repair fractured component, and when
nished by findings from long-term clinical needed remake the denture. This prevents
studies of RPDPs, general periodontal and direct trauma to the soft tissues. This is
cariological research, and studies indicat- particularly important if dental rests are
ing local quantitative and qualitative fractured, the major connector is warped
changes in plaque retention related to the or the fit of the denture is no longer satis-
use of RPDPs, to mention but the most im- factory.
portant ones. Based on these, it would ap- Reline/rebase free-end saddles when need-
pear that the weight of scientific evidence ed. This compensates for saddle resorp-
is that the limiting factors in prognosis of tion.
the partially dentate restored with RPDPs
are biological rather than mechanical. Measures to avoid/reduce the
Consequently, the Scandinavian ap- effect of added plaque retention
proach is to give more attention to aspects Instruct and motivate RPDP patients in oral
such as establishing and maintaining hygiene. The purpose of this is to convey
gingival health and measures of caries to the patient the importance of main-
prophylaxis than to mechanical factors taining a satisfactory oral hygiene and to
such as the effects of special clasp con- enable him to accomplish this.
structions and loading of abutments, the Treat all pathological conditions before the
location of dental rests, rotational axes etc. RPDP is manufactured. Caries, periodontal
This should, however, not be interpreted and other necessary treatments should in

principle be successfully completed. If the With regard to treatment planning
patient is unable or unwilling to cooperate in prosthodontics the following phases
or if the disease is treatment resistant, the should be included: Preliminary treat-
patient should be informed that this may ment plan, preprosthetic treatment and
worsen the prognosis. final treatment plan.
Maintain adequate plaque control for as The object of a preliminary treatment
long as the patient has teeth and RPDP. This plan is to decide if a prosthetic treatment
is necessary in order to maintain long- ought to be performed at all, and if so,
term good oral health. what treatments might be possible. Only
Make the construction as simple as pos- after all necessary pre-prosthetic treat-
sible. This reduces plaque retention. ments have been performed a final treat-
Establish a minimum distance of 3 mm ment plan may be determined and the
between the marginal gingiva and the compo- prosthetic treatment commence.
nents of the denture. This reduces the pos-
sibility that plaque collects at or near the Preliminary treatment plan
gingival margins of the teeth. In visible In order to make a preliminary treatment
areas aesthetic considerations may indi- plan, all relevant information must be
cate smaller distances (Fig. 12.5A+B). The gathered.
retentive arm of clasp (Fig. 12.14) may for
functional and aesthetic reasons be posi- Journal
tioned closer. The journal should contain anamnestic
Systematic maintenance. This entails information (including general diseases,
that the dentist organizes a regular recall patient motivation for seeking treatment
system with individually determined and previous experience with prosthetic
intervals, which should never be longer devices), present status and diagnoses as
than 1 year. During these recalls both well as other relevant factors. In addition,
biological and technical problems must be the bases for evaluations and choice of
diagnosed and rectified. alternative treatment, what information
was given to the patient, the patient’s
Treatment planning informed consent and daily treatment
A simple clinical examination may not procedures should be noted. After the
suffice in determining whether or not a completion of the treatment a case sum-
partial tooth loss should be restored with mary should be added.
a prosthetic device. Various factors of im-
portance have to be studied and assessed Interview
separately and the results of these collated During the interview the psychologi-
before a decision is made. A conscientious cal status of the patient, motivation and
planning is an absolute precondition for a expectations of the treatment should be
successful treatment outcome. assessed. This also offers an opportunity

to develop a trustful relationship, which dietary habits and use of fluorides is of
is of crucial importance for the outcome importance in assessing caries activity.
of treatment. Apart from extreme situations, the assess-
ments of caries and periodontal diseases
clinical examination at this stage will be preliminary. The final
The clinical examination should include assessment can usually only be made after
a recording of missing and migrated the pre-prosthetic treatments have been
teeth, periodontal and mucosal condi- completed.
tions, the degree of ridge resorption, oral
hygiene, quantity and consistency of the Radiographs
saliva, tongue space and occlusal, joint Radiographs supplement the clinical in-
and muscular function or dysfunction. formation and are essential in studying
In this context it is of major impor- apical and marginal conditions, caries,
tance to evaluate the periodontal support size of the pulp chamber, and density of
of the rest dentition and its resistance in the alveolar bone. Radiographs are par-
relation to periodontal diseases. Accord- ticularly important in regard to abutment
ingly, attention should be paid to the teeth for mandibular free-end dentures,
amount of loss of supporting bone and which are exposed to considerable verti-
the degree of tooth mobility in relation to cal and horizontal forces. The density of
the standard of oral hygiene, because this the supporting bone surrounding pro-
has a direct bearing on the prognosis: A spective abutments may often indicate
situation where there is little periodontal the teeth’s reaction to existing loads.
damage and poor oral hygiene has a bet- Depending on the requirements of the
ter prognosis than one with the opposite individual case, it may be necessary to
constellation. obtain ordinary dental images, orthopan-
Furthermore, in order to estimate the tomograms, or on rare occasions, special
ability of the abutment teeth to support images of the temporo-mandibular joints
an RPDP, other relevant aspects should or other structures.
be considered. In addition to periodontal
pocket depth, mobility and gingival re- Analysis of study casts
traction, the length, number, anatomical Impressions should be taken and study
peculiarities of the roots and their area of casts poured. Except in cases where there
periodontal ligament should be assessed. is a complete denture in the opposing
Furcation involvements and concave root jaw the casts should be mounted in an
surfaces (such as is frequently found me- articulator, in intercuspation if possible
sially on maxillary first premolars) and or else in accordance with an occlusal
other factors hampering hygiene meas- index. This allows a more comprehensive
ures and reducing prognosis are impor- study of the occlusal conditions than
tant factors in these evaluations. Equally, may be possible in an intraoral examina-

tion. Thus aberrations of occlusion and resistant. Even such patients have a right
articulation, tooth migrations, tippings, to be treated as well as possible under the
elongations and wear facets may be evalu- circumstances, but should be informed
ated in more detail than what is possible that this worsens the prognosis. Not in-
in a clinical examination. On the cast frequently a choice of simpler and less ex-
trial wax-ups can be made so that one pensive treatment may then be indicated.
may form an opinion as to the possible An important aspect of pre-prosthetic
outcome of the intended therapy in terms treatment should not be overlooked: it
of function and aesthetics. “Orthodontic” may take as long as a year or more for the
movements of gypsum teeth may also be full recovery of the periodontal tissues
made so that one may determine if ortho- after treatment or before one may evalu-
dontic preprosthetic therapy is indicated. ate the effect of cariologic treatment.
Also, the ability of the patient to establish
Treatment options and maintain a sufficiently high standard
After the above examinations and evalu- of oral hygiene may take an equally long
ations have been completed, the patient time. However, if the existing restoration
should be informed of professionally ac- is very harmful to the oral tissues or if
ceptable treatment options, and the actu- the patient is unwilling to wait for such a
al choice of treatment should be made in long period of time, treatment may have
a discussion between patient and dentist. to be precipitated. Another possibility in
However, the patient should be informed such a situation is to make a less harm-
that this treatment plan is preliminary ful temporary restoration. An individual
and may have to be changed according to evaluation of risk/benefit in such cases
the results of the pre-prosthetic treatment. should always be made.
Pre-prosthetic treatment
Final treatment plan
The purpose of pre-prosthetic treatment is
ideally to render the oral cavity free from Assessment of oral condition,
any pathological conditions. This may definite treatment plans
require treatment for existing periodon- After the pre-prosthetic treatments have
tal, cariological, endodontic, orthodontic, been carried out, a total assessment of
oral function, and surgical or other prob- the oral condition is made. As a result of
lems. Pre-prosthetic treatments of such this treatment, changes in the patient’s
diseases or conditions do not in principle motivation or in the oral conditions may
deviate from ordinary treatment, and are occur – sometimes to a more favourable
outside the scope of this textbook. restoration – occasionally, when the treat-
As mentioned earlier, sometimes the ment response or patient cooperation is
patient may be unable or unwilling to poor, to a less favourable one. The dentist
cooperate or the disease may be treatment needs to be on the alert to such changes

and alter the treatment plan accordingly. bilities and the clinical consequences this
The definite treatment plan should be for- might have.
mulated in accordance with this.
Anticipated additions
Treatment optimizing clinical If possible extraction of a tooth with a
outcome doubtful prognosis is anticipated, the
In the final treatment plan, the construc- denture should be constructed in such
tion of the RPDP has to be determined. a way that the lost tooth may easily be
This may necessitate further treatment added to the denture. If the tooth is ad-
in order to optimize the clinical out- jacent to the denture base acrylic, this
come. Thus imperfect fillings in contact is accomplished simply by retaining the
with the RPDP should be remade. Single artificial tooth by extending the denture
crowns or FPDs are also indicated in cases base acrylic. If, on the other hand, the
where the abutment teeth are so mechan- tooth in question is not in contact with
ically weakened by large fillings or wear the acrylic, the framework should be con-
that they are likely to break down under structed in such a way that it contacts the
the mechanical strains imposed by the tooth – usually in the form of a dental bar
RPDP. Occasionally it may also be indicat- or an extended reciprocal arm. When the
ed to splint abutment teeth to lessen the tooth is extracted, a peg is easily brazed
mobility caused by reduced periodontal on to the framework, thus affording suf-
support. However, uncritical use of fixed ficient retention for the artificial tooth.
restorations without absolute indications
and proper rationale should never be per- Supporting, retaining and
formed, because they may cause more risk stabilizing components
than benefit to the patient for the reasons The main functions of the components of
previously explained. RPDPs have been presented at the begin-
FPDs and single crowns should always ning of this chapter. Before designing RP-
be planned together with the RPDP, so DPs it is necessary to understand in more
that they become integral parts of the re- detail what purpose the supporting, re-
construction. Thus optimal use of the ad- taining and stabilizing components serve
vantages of combining fixed and remov- in relation to the function of RPDPs.
able dentures can be made. This can only
be achieved if FPDs and crowns are milled Supporting components
in the dental laboratory. At an early stage The supporting components of RPDPs
of the planning, the dental technician consist of dental rests and the denture
should be involved so that he is properly base including palatal plates. All these
informed of the treatment plan, but also eventually transfer the loads to the bone;
because he may offer important feed-back either through the periodontium of the
regarding technical limitations and possi- abutment teeth or through the mucosa.

Occasionally, supporting components rests should therefore never be placed on
may also function as passive/indirect re- inclined surfaces. In that case the tooth
tainers or stabilising elements. will be exposed to a skewed load and a
horizontal force, which is likely to push it
Dental rests away from its position (Fig. 12.6B).
Dental rests are metal parts, which extend For the same reason, the dental rest
from the metal framework on to the abut- should primarily be placed on the highest
ment teeth, through minor connectors. part of markedly tipped abutment teeth
They are usually placed on occlusal sur- in order not to increase the tipping. If for
faces of molars and premolars, but may some reason this is not possible, the abut-
also be placed on the lingual surfaces or ment must be secured against further tip-
incisal edges of incisors and canines. ping by establishing a broad approximal
Principles for constructing dental rests. contact with the metal framework (Fig.
Two principles govern the construction of 12.7). In order to satisfy the requirement
dental rests. First, the rests should transfer
as much as possible of the loads to the
abutment teeth. To this end, dental rests
must be placed as close to the saddle areas
as possible. Where the rests should be po-
sitioned on the abutment teeth is a matter
of debate and will be discussed in detail
under the heading “Special problems asso-
ciated with free-end dentures”.
Fig. 12.7. A tipped abutment is secured against
Second, the rests should be positioned
further tipping by establishing a contact with the
in such a manner that the abutment teeth
metal framework.
are loaded axially (Fig. 12.6A). Dental
A B
A B Fig. 12.8A. Preparation for occlusal rest should be

spoon-like. B. Occlusal rest should extend compa-
Fig. 12.6. Loading of abutments. A. axially (tooth rable to about 1/3rd of the mesio-dist width of a
remains in position). B. On an occlusal incline premolar. The clasp should embrace more than half
(tooth is pushed away from the dental rest). the periphery of the tooth.

of axial loading of the abutment tooth,
it is usually necessary to prepare a seat
for the rest in the occlusal surface of the
tooth.
Occlusal rests. The preparation of oc-
clusal rests should be spoon-like (Fig.
12.8A). The bottom of the preparation
should be deeper than the marginal ridge
Fig. 12.9. An occlusal rest placed over the lingual
of the tooth, but still in the enamel, to
cusp with little or no preparation.
ensure definite seating and a greater
material thickness of the dental rest. Oc-
clusal rests should extend comparable to
about 1/3rd of the mesio-distal width of

a premolar, irrespective of the size of the
occlusal surface (Fig. 12.8B). A small re-

duction of the opposing tooth in the con-

A B
tact area for the rest may not infrequently
be indicated to the same end. Fig. 12.10A. The internal part of an incisal rest is
Rests that satisfy the requirement for prepared in enamel; the rest has to be built up with
axial loading may sometimes be placed adhesive technique in composite. B. the lingual shelf
on lingually tipped mandibular premolars should follow the contour of the gingival margin.
with only a minimal amount of grind-
ing because the lingual cusp is usually
in infraocclusion (Fig. 12.9). Also, space
permitting, occlusal rests may cover the
entire occlusal surface like an onlay.
Lingual rests. In order to satisfy the re-
quirement of axial loading, rests on front
teeth can sometimes be placed on pre-
pared horizontal shelves on the lingual
Fig. 12.11. Modest grinding of the lingual surface
surfaces. Canines are usually more suit-
and incisal preparation.
able for such lingual rests than incisors
because of their more pronounced cin-
gulum areas, which facilitate the making built up with adhesive technique in com-
of lingual shelves. Because such shelves posite (Fig. 12.10A). Furthermore, lingual
have to be approximately 1 mm deep in shelves should follow the contour of the
order to secure axial transference of loads, gingival margin and extend along most
usually only the internal part may be pre- of the lingual surface (Fig. 12.10B). If tra-
pared into the enamel; the rest has to be versed in a straight line the shelf is likely

to touch the approximal papillae, which Retaining components
should be avoided. Retaining components consist of different
Incisal rests. Such rests are mainly kinds of devices, designed to resist forces
indicated if a lingual shelf for anatomi- that tend to dislodge the denture. They
cal reasons cannot be used. The prepara- are usually integral parts of or attached to
tion involves a modest grinding of the the metal framework. Denture bases and
enamel of the lingual surface leading up palatal plates may also have this function.
to the incisal preparation (Fig. 12.11). Retaining components may be active/
This should be prepared with a diamond direct or passive/indirect. The former
burr at right angles to the long axis of the are designed to resist forces that tend to
tooth. In accordance with the principle dislodge the denture from the abutment
of preparing a seat for occlusal rests, the teeth in an axial direction; the function
deepest part should be slightly deeper of the latter is to resist forces that tend
than the proximal part of the enamel. A to rotate the denture away from its seat.
disadvantage with the incisal rest is that In order to design active/direct retainers,
a small amount of metal will unavoidably the cast has to be analysed by means of a
be visible. This fact may preclude its use special instrument discussed below (Fig.
in some cases, even though undoubtedly 12.12A).
it offers the best solution to the problem
of proper dental support. Surveyor: function and basic
concepts
Mucosal support The function of surveying can be illus-
In free-end cases, where a considerable trated as follows: If a cast is illuminated
part of the load is transferred to the un- from above, with the direction of the
derlying bone, the saddle area should light source approximately parallel with
be maximally extended (like a complete the long axes of the teeth, only parts of
denture) in order to reduce the load per the crowns will be exposed to the light;
square unit. Although the load is not the the rest will be in the shade. The border
only factor governing ridge resorption, line between illuminated and shady ar-
it is an important one. It is therefore ad- eas is called the line of prominence (also
visable to try to reduce it. In some cases called survey line or height of contour),
with bounded saddles (Kennedy Class because it represents the greatest girth of
III and IV), where the denture is com- the structure. Areas underneath this line
pletely tooth supported, the saddle may and in the shade are defined as undercut
be pontic-shaped. If such a denture is not (Fig. 12.12B).
entirely tooth supported because the sad- Both lines of prominence and un-
dle areas are long and curved, and also dercut areas are relative to the chosen
for aesthetic reasons, the saddle should be direction of the light source. If the cast is
more extended. illuminated from another direction, both

A

Fig. 12.13. Undercut areas (blue) change when
light source (path of insertion) changes.
Determining path of placement. In practical

terms, a graphite rod, fixed in the prolon-
gation of this axis, is brought into contact
with the teeth and moved along their
axial surfaces (and sometimes other sur-
faces of the cast), thus marking the line of
B prominence, relative to the chosen path of
Graphite rod of surveyor placement. If the resulting undercut areas

are favourable in terms of position and
Line of prominence depth of undercut this path of placement

is retained. If they are not, the table on
which the cast is mounted is tilted some-
Undercut area
what, a new analysis made etc. until an
optimal result is achieved.
Fig. 12.12A. Surveyor with analysing rod. B. line of
The process of surveying may thus
prominence and undercut areas (green).
sometimes be a matter of trial and error
because there is no set answer as to what
the line of prominence and the shaded/ constitutes an optimal path of placement.
undercut area will change correspond- Determining factors are the horizontal
ingly (Fig. 12.13). depth of undercuts, important for the
The surveyor is basically a parallelo- function of the retaining components,
meter. Its axis can be compared to the aesthetics and avoidance of interferences
light source in the analogy above. When with oral tissues. The latter sometimes
a cast is surveyed, this axis defines the need to be adjusted. Other determining
direction in which the RPDP will be in- factors may be the axial direction of the
serted or removed from the dentition, rest dentition. These requirements and
called its path of placement. considerations may sometimes be conflict-

ing. Accordingly, the chosen path of place- clasp is usually combined with a dental rest,
ment quite often has to be a compromise. although in theory the dental rest may be
Sometimes it is not possible to find a placed away from the clasp.
path of placement that satisfies all consid- The function of clasps. When the path
erations. Re-contouring tooth surfaces or, of placement has been determined, the
more rarely, surgical correction of the soft abutment teeth are surveyed. The special
tissue or the bone may then be required. line of prominence then defined, is called
More details of factors that may influence the line of retention. The area of the tooth
the choice of path of placement are de- occlusal to this line is called the stabilizing
scribed in the following paragraphs. zone; the area gingival to it is called the re-
Securing insertion/removal without in- tentive zone. The retentive arm is normally
terference. Due to its ability to identify on the facial side of the abutment tooth,
undercuts, the surveyor is instrumental in with its outer 1/3rd placed in the retentive
securing that the denture can be inserted zone, i.e. in an undercut. In some types
or removed from the teeth without inter- of clasps the entire retentive arm is placed
ference from hard structures. Undercut in the retention zone (Fig. 12.15A, B). The
areas cannot be in contact with the rigid reciprocal arm is always on the opposite
part of the framework, and must therefore side of the tooth and placed in the stabiliz-
be blocked out by the dental technician ing zone, thus never gingival to the line of
prior to casting procedures. The definitive retention.
cast thus treated is then duplicated and The retention of a clasp is due to the
poured in investment on which the metal resistance of the retentive arm towards de-
framework is later waxed up and cast. formation in the following manner: An at-
Communicating the determined path of tempt to dislodge the RPDP with a vertical
placement with the dental technician. By force is resisted by the retentive clasp arm,
means of the analysing rod of the sur- because it then has to deflect in order to
veyor used as a ruler, lines may be drawn adapt to the greater girth of the tooth as it
on all the facets of the socket of the cast. approaches the line of retention. When the
These will enable the dental technician clasp is seated on the abutment, both clasp
to reposition the cast on the table of his arms should be in passive contact with the
surveyor with an acceptable degree of ac- tooth surface.
curacy, thus replicating the determined

path of placement.
Active/direct retainers, clasps

A clasp consists of a flexible retentive arm,
a rigid stabilizing reciprocal arm and a mi-

nor connector, which connects the clasp to
the rest of the framework (Fig. 12.14). The Fig. 12.14. Circumferential clasp with its parts.

A

A
B
B Fig. 12.16. Different horizontal undercuts with dif-

ferent paths of insertion.
Fig. 12.15. The entire retentive clasp is placed in the not, the clasp arm will be subject to per-
retentive zone. A. T-bar, B. I-bar. manent deformation. Then it no longer
contacts the tooth surface when the den-
ture is seated, and thus no longer actively
One of the decisive factors in determin- retains the denture. Permanent deforma-
ing the path of placement of the denture tion is intentionally used when a reten-
is to what extent an optimal degree of un- tive arm is adjusted. Retentive arms made
dercut for the clasp is attained. In this con- of cast cobalt-chromium alloys are brittle
text, the degree of retention of a clasp de- and can withstand only small and few
pends on two factors: the horizontal depth adjustments before they fracture, whereas
of the undercut, which it engages, and the gold alloys in general and wrought ones
elastic deflexion of the retentive arm. in particular, can tolerate larger and more
The horizontal depth of the undercut frequent adjustments before fracture.
shown in figure 12.16A is smaller than that Fatigue fractures may also occur when
shown in figure 12.16B, even if the two fig- a material is subjected to multiple loads
ures depict the same anatomy of the abut- within its elastic limits, such as the re-
ment, because they have different paths of peated loads on a retentive arm during
insertion/removal. The retentive ability of function.
a clasp arm in the example shown in figure The elastic deflexion of the retentive
12.16A is therefore less than that shown arm depends on its length, diameter,
in figure 12.16B, because the retentive arm shape of cross section and the mechanical
has to deflect less when the denture is dis- properties of the material used: Other fac-
lodged. tors being equal, the longer the retentive
The deflexion of a retentive clasp arms arm, the more its tip may deflect elasti-
has to be kept within the elastic limits of cally, and the deeper the horizontal depth
the material from which it is manufac- of undercuts it may engage. The deflexion
tured. If it is, the arm will return to its of a retentive clasp arm to a given force
original position after deflexion. If it is is inversely related to its diameter: the

this movement. Also, a clasp can only
function properly if it embraces more
than half the periphery of the tooth (Fig.
12.8B). Otherwise it will tend to slide off
the tooth rather than retain the denture.
A
B
Periodontal and aesthetic considerations.
Fig. 12.17. Flexibility of retentive arm. A. greatest So far, only the physical factors govern-
in facio-lingual direction. B. equal flexibility in all ing the function of clasps have been dis-
directions. cussed. However, because periodontal and
aesthetic considerations are of overriding
greater the thickness of the arm; the less importance in the construction of RPDPs,
it will deflect. Consequently, provided the best possible path of placement and
the deflexion of the retentive arm is kept type of retentive arm should be selected
within the elastic limits of the material, to this end. Also, if necessary, the shape
a smaller diameter is indicated for a large of abutment teeth may be altered.
undercut and vice versa. The shape of the In order to avoid harming the peri-
cross section of the retentive arm is also odontal tissues, the retentive arms should
of importance. In figure 12.17A, the de- ideally be positioned no less than 1 mm
flexion is thus greatest in a facio-lingual from the gingival margin. When the line
direction, whereas in figure 12.17B it is of retention is located on the middle 1/3
equal in all directions. of the tooth, the retentive arm can nor-
The modulus of elasticity of the clasp mally be placed away from the gingival
material determines the force of deflex- margin without compromising the reten-
ion of the retentive arm. The higher the tive properties of the clasp. On the other
modulus, the stiffer the material and the hand, it may be difficult or impossible to
less the clasp arm is deflected when sub- establish adequate active clasp retention
jected to a given force. If a rigid material on a peg-shaped, tipped or rotated tooth
is required, i.e. for the reciprocal arm of because such teeth may only exhibit mi-
a clasp, a cobalt-chromium (CoCr) alloy, nor or no undercut areas.
with its high modulus of elasticity, is par- In terms of aesthetics, it is important
ticularly suitable. to establish how much the patient ex-
Two other aspects regarding function poses his teeth during speech and laugh-
of clasps are of importance: Every time ing, and also to what extent the patient is
the retentive arm is deflected in order concerned about his appearance. In most
to resist dislodging, it exposes the abut- cases, it is possible to comply with the
ment tooth to a lateral force, which, if wishes of the patient. However, it is the
unopposed, would tend to shift the tooth responsibility of the dentist to make sure
permanently. However, the reciprocal arm that aesthetic requirements do not inter-
on the opposite side of the tooth prevents fere too much with the functional ones.

A facial retentive arm on a maxillary Combination clasps consist of a wrought
front tooth represents a major aesthetic wire retentive arm combined with a
challenge. In cases with bounded saddles, cast reciprocal arm and dental rest. The
adequate active retention may be attained wrought wire, usually made from a gold
by the use of clasps in the posterior region alloy, is specially manufactured for the
combined with appropriately shaped ap- purpose (Fig. 12.18B). This way both
proximal planes anteriorly as well as pos- materials can be optimally used: the ri-
teriorly. gidity of the cobalt-chromium and the
Types of clasps. The most common superior elastic deflexion of the wrought
types are circumferential clasps and bar- wire. The latter is particularly indicated
clasps. The reciprocal arm is always cast in cases with large horizontal depth of
– irrespective of clasp type. The mechani- undercuts. The retentive arm in such
cal aspects governing the construction cases can be brazed to the dental rest, to
of clasps are only explained regarding the framework in the saddle area or it can
circumferential clasps, because the princi- be retained in the denture base material.
ples described are the same for all types of Combination clasps are frequently used
clasps. for free-end dentures in Scandinavia.
Circumferential clasps may be cast in Two special types of circumferential
the same material as the framework of the clasps are the ring clasp and the Bon-
denture, usually a cobalt-chromium alloy will clasp. The former of these encircle
(Fig. 12.18A). With its high modulus of almost the entire tooth (Fig. 12.19A+B).
elasticity, it is able to resist even a small It consists of a single arm, where the re-
deflexion forcefully. It is therefore a suit- tentive arm is in the prolongation of the
able material for use as a retentive arm in
cases where only a small depth of under-
cut is available for retention. It is primarily
indicated in cases with bounded saddles.
A B
Fig. 12.18. A circumferential clasp. A. both arms B
cast in same material as frame-work (Co-Cr). B. the
retentive arm in wrought gold wire and the recipro- Fig. 12.19A. A circumferential ring clasp. B. a cir-
cal clasp arm as a part of the frame-work. cumferential Bonwill-clasp.

reciprocal arm and dental rest. The ring according to the shape of the tip of the
clasp can be useful in cases with bonded retentive arm, such as T-bars (Fig. 12.15A)
saddles and tipped molars (facially in and I-bars (Fig. 12.15B). The tips of the
the maxillary jaw, mesio-lingually in the arms are often modified according to the
mandibular jaw). Dental rests may profit- characteristics of the undercut.
ably be placed both mesially and distally. Except for its tip the entire retentive
In order to distribute the load to two arm is relieved from the underlying tis-
abutments, the Bonwill clasp can be used. sues by approximately 1 mm. In cases
This clasp can be likened to a double with shallow vestibular areas or with wide
circumferential clasp; it has two reten- frenula, the bar-clasp should be relieved
tive and two reciprocal arms and double even more, but not to the extent that
dental rests, thus it engages both teeth. there is a risk of decubital ulcers on lip or
The retentive arms can be cast, but may mucosa.
also be manufactured in wrought wire.
Some tooth substance normally has to be Active/direct retainers,
sacrificed to make adequate space for the attachments
dental rests. As a consequence, the antag- RPDPs can also be retained by means of
onist tooth may also have to be reduced attachments. These may be individually
somewhat. manufactured or, more commonly, com-
Bar-clasps (Fig. 12.15) are character- mercially prefabricated ones. A multitude
ised by a long retentive arm, often 2-3 of the latter is available on the market.
times longer than that of a circumfer- Almost without exception, the use of at-
ential clasp, since it originates from the tachments involves crowning the abut-
saddle area. Due to its correspondingly ment teeth. It will not be discussed in
increased elastic deflexion, this type of this book.
clasp is indicated for cases with occlus-
ally positioned lines of retention and Passive/indirect retainers
deep horizontal undercuts. A flexible bar The function of passive/indirect retention
clasp retentive arm can be placed more is to counteract forces that tend to rotate
gingivally, which is often more acceptable the distal part of free-end saddles away
aesthetically. The best mechanical proper- from the ridge when the patient chews
ties of such a clasp arm are obtained by sticky food or if the distal part of a max-
making it in a special wrought clasp wire. illary denture tends to fall down due to
This arm should preferably be brazed to gravity. This rotation is believed to occur
the metal framework in the saddle area, around the so-called retentive fulcrum
but may also be attached to the base ma- line, which is an imaginary line connect-
terial. ing the retentive points of clasp arms
There are several different types of placed on either side of the mid-line. In
bar-clasps. These are normally named theory, any supporting component such

as a dental rest, a part of a maxillary plate Designing the
or dental base placed on the frontal side construction
of the retentive fulcrum line tends to op- Designing RPDPs serves two purposes:
pose this rotation. The passive/indirect The obvious one is to place all necessary
retention will only function if the active/ components in correct positions accord-
direct retainers prevent the denture from ing to their function(s) and according to
loosening, hence the expression passive/ the requirements of the individual case.
indirect retention. The further away from The aim is a construction, which provides
the retentive fulcrum line the more effec- the patient with a denture that functions
tive the passive/indirect retention will be. well and does minimal harm to the oral
It is believed that the forces exhibited tissues. The second one, perhaps less obvi-
through passive/indirect retention are ous, but nevertheless of major importance,
so low that the passive/indirect retainers is to provide the dental technician with
may be placed on unprepared inclined sufficient information so that the design
surfaces without the risk of shifting the of the dentist is transformed into the final
tooth. However, if the tooth is weakened denture.
periodontally, it might be prudent to In order to satisfy both purposes the
extend the passive/indirect retainer to a dentist needs to draw fairly accurately the
dental rest. design on the study cast (never on the de-
The need for passive/indirect reten- finitive cast to avoid scratching its surface).
tion is in dispute and has never been cor- In addition, it is recommended that a writ-
roborated scientifically. Nevertheless, it is ten order, containing the same informa-
mentioned in all textbooks. tion, follows the case in order to preclude
misunderstandings. Except in cases where
Stabilizing components there is a complete denture in the oppos-
Stabilizing components may be which- ing jaw the casts should be mounted in an
ever part of the RPDP that resists displace- articulator so that the framework can be
ment by vertical, horizontal or rotational designed in relation to the occlusion.
stresses. Examples of such components
are dental rests, clasps, major or minor Sequence in designing
connectors in contact with the teeth, When designing RPDPs it is important to
plates or the acrylic base in contact with proceed in a manner so that the dentist
a skewed ridge and guiding planes. If the does not need to adjust preceding steps as
RPDP is not sufficiently stabilized with the designing process progresses. Further-
existing construction, adding further sta- more, within each step the dentist should
bilizing components may be considered. know and be able to choose among all
possible designing options. The three prin-
ciples for the choice have previously been
discussed:

• the distance between the gingival mar- Sometimes, for aesthetic reasons, the ex-
gin of the rest dentition and compo- tension may be reduced to the shape of a
nents of the RPDP should preferably be pontic, at other times it may be necessary
no less than 3 mm (sufficient distance) to extend it maximally because it needs
• the construction should be as simple as to compensate for loss of bone or because
possible (simplicity of design) it functions as an element for passive/in-
• the entire construction should be as direct retention.
rigid as possible.
choosing major connector
The following sequence of steps is recom- The saddles have to be connected by
mended: means of a major connector. In theory
• determining the position and exten- six mandibular major connectors are
sion of the saddles possible. However, only lingual bars,
• choosing major connector sublingual bars, dental bars (sometimes
• determining number and position of erroneously called a continuous clasp),
dental rests and a combination of lingual and dental
• surveying cast, determining path of in- bars Fig. 12.21A-D) are commonly used in
sertion/withdrawal, positioning clasps, Scandinavia, and are described in detail
their number and type in the following. Other possible major
• evaluating the need for passive/indirect connectors are lingual plates and facial
retention bars. The former of these extends from
• evaluating if the construction is suffi- short of the incisal edges to short of the
ciently retained and stabilized. lingual sulcus. Unlike the lingual and
dental bars, lingual plates cover the gin-
At completion of each step the chosen gival margins of the rest dentition, which
design should be drawn on the study cast. promotes plaque retention. This disad-
These steps, the designing options within vantage is the main reason why it is rarely
each and the hitherto undefined concepts used in Scandinavia. Facial bars are posi-
will be discussed in detail in the following. tioned on the labial side of the teeth and
only used in the extremely rare occasion
Determining position and
extension of saddles
The saddles and their approximate exten-
sions are marked on the cast (Fig. 12.20).
If the saddles are free-end they should be
maximally extended, comparable to the
extension of a complete denture in the
same area. If bonded, the desired exten-
sion of the saddles should be indicated. Fig. 12.20. Saddles and their extension marked.

when the residual dentition is retroclined
precluding any lingually placed bar.
In the maxilla the alternative major
connectors are to a lesser extent discrete.
There the connectors are plates traversing
the palate with varying extensions.
A
Mandibular major connectors. Lingual
bars have an oval or pear shaped cross-
section (its thickest part toward the sul-
cus), normally approximately 2 x 3 mm,
placed parallel to the alveolar ridge (Fig.
12.21A). Sublingual bars are similarly
dimensioned, but with this construction
the bar is horizontal (Fig.12.21B). Dental B
bars should be similarly dimensioned in
order to obtain sufficient rigidity (Fig.
12.21C). When dental and lingual bars
are combined, the cross sections may be
thinner than those of the single bars (Fig.
12.21D). To some extent, dental bars fol-
low the contour of the teeth and therefore
c
have a scalloped shape.
Lingual bars are constructed at a dis-
tance of about 1 mm from the alveolar
ridge (Fig. 12.21A and B). If the ridge has
a fairly flat inclination the distance needs
to be greater, particularly in free-end
cases. This space is necessary to prevent
the bar from traumatizing the mucosa;
D
an event which may occur in cases with
anterior abutment teeth and free-end
Fig. 12.21. Mandibular major connectors. A. lin-
saddles that sink due to bony resorption.
gual bar. B. sublingual bar. C. dental bar, and D.
These bars are placed as far down towards
combination of lingual and dental bars, each bar
the lingual sulcus as possible without in-
has been manufactured in smaller dimensions that
terfering with the movements of tongue
normally.
or lingual fraenum, and sublingual bars
are placed underneath the tongue. Con- ing to an overextended impression may
sequently, an accurate impression of the traumatize the mucosa and a new denture
area is essential; an RPDP made accord- may then have to be manufactured.

Dental bars are positioned in contact lingual sulcus precluding an ordinary lin-
with unprepared lingual surfaces of the gual bar, a sublingual bar may sometimes
rest dentition, usually at and above the solve the problem (Fig. 12.21B) . This
cingulum, but short of the incisal edges alternative presupposes that an accurate
(Fig. 12.21C). If made together with the impression has demonstrated that there is
RPDPs, single crowns or FPDPs may be sufficient space for the bar.
milled so that the dental bar is incorpo- A dental bar is similarly indicated for
rated into the fixed restoration. The main cases where the clinical crowns of the
advantage with lingual and dental bars is rest dentition are long and the distance
that they do not cover the gingival mar- between gingival margins and the lingual
gins of the teeth. However lingual bars sulcus is short (Fig. 12.21C). There is a
may traumatize the mucosa in free-end special indication for using dental bars
cases as a result of saddle resorption. For where loss of teeth is anticipated. In case
this reason, RPDPs with such connectors a tooth is lost, a small peg can usually
must be monitored regularly and with easily be soldered to the bar, providing
fairly short intervals. For the same reason, sufficient retention for an artificial tooth.
relines/rebasings of such dentures should If there is spacing of the mandibular
be performed when necessary. teeth, the metal of a dental bar will show
Dental bars lie on the outside of teeth through the spaces, contraindicating its
(except when furnished with milled use.
crowns), and may therefore in theory Occasionally, there may be cases
interfere with phonetics and adaptation. where the rest dentition has short clinical
Unless clinical crowns have sufficient crowns and also a short distance between
length, it may sometimes be difficult the gingival margins and the lingual
to dimension these bars sufficiently for sulcus. In such cases lingual and dental
adequate rigidity, possible fractures and bars, made less bulky than normal, may
resistance against warping. The above be combined. Each bar will then occupy
advantages and disadvantages should be less space, and the double bar will still
considered in regard to choice of major give the denture sufficient strength (Fig.
connector. However, the choice is primar- 12.21D). Because it violates the principle
ily governed by what best agrees with the of simplicity of design, this construction
two principles previously described (suf- should be reserved for cases where no bet-
ficient distance to gingival margins and ter solution is possible.
simplicity of design). Summing up choice of mandibular major
A lingual bar is thus preferred if connectors. Lingual bars should be used
there is ample distance between the in cases where the height of the alveo-
gingival margins and the lingual sulcus lar ridge allows a placement 3 mm or
Fig. 12.21A). If there is a short distance more from the gingival margins of the
between the gingival margins and the teeth. Dental bars are used where clinical

crowns of the rest dentition are so long
that it satisfies the same criterion. Outside
these connectors, which cover the great
majority of cases, double bars or facial
bars, are only indicated if no other solu-
tion is possible. Lingual plates are to be
avoided if possible. A
Maxillary major connectors. The major
maxillary connectors are usually plates,
but may also be bars, and are all in con-
tact with the palate (Fig. 12.22A-C). The
two principles that govern the choice of
denture major connector (sufficient dis-
tance to gingival margins and simplicity B
of design) are considerably easier to com-
ply with in the maxilla than in the man-
dible. With palatal plates it is never a prob-
lem placing the borders of the connectors
at a distance of 3 mm or more from the
gingival margins of the rest dentition.
Rather, the question is the extension of
the connector. c
The mechanical strength and rigid-
ity of a palatal connector depends on its
thickness, the area it covers and its curva-
ture. The thickness of most palatal plates
is normally about 1 mm. If subjected to
high amounts of stress and strain, such
as in free-end cases, the plate must have
a wide extension to give it sufficient me- D
chanical properties. On the other hand,
the major connector of a denture with Fig. 12.22. Maxillary major connectors. A. palatal
bonded saddles is only subjected to a plate with completet coverage, B. posterior palatal
minimal amount of load, and a fairly nar- bar, C. doubly curved palatal plate, and D. fenes-
row bar may suffice. The curvature is also tred palatal plate.
important: a doubly curved surface, such

as is found in the anterior part of the pal- Mechanical properties are not the only
ate, improves the mechanical properties of criteria for choice of connector. In free-
the plate. end cases generally, and particularly if

the saddles are long, or in cases where the indications or contraindications to any
abutment teeth are few, weak and mobile, of the maxillary major connectors. The
a complete palatal coverage (Fig. 12.22A) choice should be made in consideration
is indicated in order to distribute the loads of mechanical properties, need for sup-
as widely as possible and improve den- port and stability, existence of exostoses,
ture stability. Although quite weak, the stomatitis and patient preference. In
physical forces of adhesion and cohesion conclusion, the choice of maxillary ma-
in complete palatal coverage may also to jor connector is most likely not of major
some extent improve the retention in free- importance in most cases and can safely
end cases. be made in accordance with the clinical
Patient adaptation is another factor experience of the dentist.
that may be dissimilar for the different
palatal connectors. Some prosthodontists Determining number and position
believe that palatal bars, placed just ante- of dental rests
rior to the a-line, are easier for the patient The design should be supplied with
to adapt to than connectors with complete dental rests according to the principles
palatal coverage, but bars must be 2 mm presented earlier and marked on the cast.
in thickness to obtain sufficient strength, In clinical practice this means that den-
which may interfere with adaptation. In tal rests should be positioned where the
this context, what a patient is familiar saddle contacts the tooth (Fig. 12.23A).
with is likely to be preferred in a new den- In cases with bonded saddles, this state-
ture. There are also claims that one should ment is uncontroversial. Where dental
avoid covering the rugae area because this rests should be placed on abutment teeth
area is particularly prone to develop sto- in free-end cases is in considerably more
matitis when covered, and that connectors dispute. This matter will be discussed in
with complete palatal coverage interfere detail later.
with taste sensation. However, no scien- There are some possible exceptions to the
tific evidence exists to corroborate any of above rule: In order to improve stabiliza-
these claims. tion of the denture against mainly hori-
There may be a special indication for a zontally directed forces, a dental rest may
fenestrated plate in cases where the patient sometimes be placed on the tooth surface
has a pronounced torus palatinus or simi- away from the saddle (on its mesial side
lar hard exostoses. Such structures are usu- in free-end cases) (Fig. 12.23B). Also, if
ally covered with a very thin layer of mu- the tooth closest to the saddle has little
cosa. A metal coverage of these structures bony support and particularly if it is fairly
may thus cause instability of the denture mobile, it may be prudent to place the
due to rocking, ulcerations and pain. dental rest on the neighbouring tooth. A
Summing up choice of maxillary major possible disadvantage of this is that the
connector. There are few, if any, absolute contact area between abutment tooth and

A B
Fig. 12.23. Dental rests. A. close to the saddles. B. away from the saddles (mesial placement).
denture may open up due to the mobil- stood by studying the illustrations in fig-
ity of the tooth and food impaction may ure 12.24A-C. The supporting area of the
then ensue. Finally, a dental rest placed maxillary case is the area inside the red
further mesially in relation to the saddle lines drawn between the dental rests and
may be justified in order to improve pas- the denture base (including palatal plate).
sive/indirect retention. The supporting area of a mandibular case
is similarly indicated. It should be noted
Surveying cast, determining path that the lingual bar is not a supporting
of insertion/removal, element because it does not lie in contact
positioning clasps, their number with the mucosa, and consequently it is
and type not included in the supporting area. It
The construction now has to be supplied should also be noted that the supporting
with adequate retention. The major princi- area can be extended by adding support-
ples involved in doing so is surveying the ing elements to it. The object of this is
cast, determining the path of insertion/ related to the possible need for passive/
removal, choosing clasp type in relation to indirect retention.
retentive fulcrum line, presence, location, Retentive fulcrum line. Retentive ful-
and horizontal depth of undercuts. It is also crum lines are normally found inside the
possible to alter the anatomy of the tooth, area of support. However, in some cases
which may solve problems that may arise. the retentive elements (retentive arms or
In order to understand the requirements for attachments) will be in front of the sup-
adequate retention, the interaction of the porting area. In theory, if the denture has
following concepts must be explained: more than two retentive elements there
Supporting area. The supporting area of may be several retentive fulcrum lines;
RPDPs is the area limited by straight lines one for each possible connection between
drawn between peripherally placed sup- them.
porting elements. This rather daunting Positioning clasps. The optimal reten-
definition is perhaps more easily under- tion of an RPDP is achieved if a retentive

A B c

Fig. 12.24. Supporting area is within red lines. Dotted red lines are tetentive fulcrum lines (which pass through
retentive clasparm on either side of the midline). Green area is the extension of supporting area. Blue line is
the fulcrum line (wich pass through the most distral rests). A-C: see text.
fulcrum axis between two clasps bisects of the tooth may facilitate a more optimal
its supporting area. If there are more than placement of a facial retentive clasp arm
two possible abutments, the clasps should and improve its function.
therefore be placed on the abutments that Balanced retention. Retention of RPDPs
are best is in accordance with this ideal. should always be balanced, i.e. be located
Number of clasps. In cases where the bilaterally in the dental arch on the abut-
retentive fulcrum line bisects the support- ment teeth that supply the main reten-
ing area the denture may be adequately tion. Retentive forces should ideally be of
retained by only two clasps, as these are equal sizes and oppose each other. This
able to resist forces of removal in the normally entails that retentive arms are
direction of the path of placement as located facially and reciprocal arms lin-
well as rotational forces that tend to lift gually on abutments.
free-end saddles away from the ridge. In
cases where possible abutment teeth are Evaluating need for passive/
unfavourably located, adding more clasps indirect retention
may strengthen the retention of the den- The function of passive/indirect retention
ture. However, the need for extra reten- concerns primarily free-end RPDPs. The
tion must always be balanced against the need for passive/indirect retention can be
general requirement of simplicity of the evaluated on the basis of the designs as it
design. appears after all previous steps have been
Type of clasps. The choice of type of drawn on to the cast. If the line of reten-
clasp is mainly governed by the location tion bisects the supporting area, there is
and horizontal depth of the available no need for passive/indirect retention, be-
undercuts, aesthetic and periodontal con- cause then the supporting elements will
siderations. Finally, altering the anatomy hinder the saddles from rotating away

from the ridges. As possible retentive ful- should be systematically evaluated with
crum lines shift towards the periphery of regard to its ability to withstand any dis-
the supporting area, the theoretical need locating forces that might be applied to it:
for passive/indirect retention increases against primarily vertical forces (mainly
(Fig. 12.24B). counteracted by clasps), against rotational
A peripheral position of the retentive forces (mainly counteracted by passive/in-
fulcrum line or even a position outside direct retainers), against horizontal forces
the area of support can be made more directed posteriorly, anteriorly and trans-
favourable by extending the area of sup- versally (counteracted by clasps, denture
port of the denture by means of indirect base, minor connectors, dental rests and
retainers (Fig. 12.24C). These will then bars). If the design is found to be want-
in theory hamper the inclination of the ing in this respect, it may be supplied
free-end saddles to lift from the ridges with appropriate components. However,
when the user is chewing sticky food. any addition of components to counter-
In an evaluation of whether or not to act instability and poor retention of the
add passive/indirect retainers to a design, denture must always be weighed against
it must be kept in mind that in doing so, the risk of adding to the plaque retaining
the design becomes more complicated, properties of a more complicated design.
contrary to the ideal of greatest possible Free-end RPDPs frequently have a spe-
simplicity. In this evaluation, the absence cial need for stabilizing against posterior
of scientific evidence that passive/indirect movements, especially if the most poste-
retention is useful, and also the personal rior abutment tooth is a canine. This can
clinical experience of the dentist, should be counteracted by placing the rest mesi-
be taken into account. However, it seems ally on the tooth.
reasonable to believe that whereas pas-
sive/indirect retention is perhaps of Special problems with free-end
limited importance in mandibular cases, dentures (Kennedy class I and II)
it may be more effective in cases of max- The problem associated with all free-end
illary free-end RPDPs and, as will be RPDPs is their lack of stability caused by
shown, even in Kennedy Class IV. In such the difference in support between the
cases it counteracts the forces of gravity abutment teeth and the muco-periost.
that tend to rotate the free-end saddles While a normal tooth is pressed into its
away from the ridges. socket by about 1/10 mm when loaded oc-
clusally, a loaded saddle may sink as much
Evaluating if the construction is as 1 mm or more, depending on the degree
sufficiently retained and stabilized of tissues displacement. This results in a
This represents the final step before com- rocking movement of the denture during
pletion of the design thus far drawn on chewing, believed to take place around
the study cast. At this stage the design a so-called fulcrum line, defined as a line

drawn between the most distal dental
rests. This definition is not entirely ac-
curate as in actual fact the rotation under
certain circumstances takes place posterior

to the fulcrum line due to the viscoelastic
nature of the tissues. Of greater clinical
interest, it should be noted that as the
saddle rotates downwards during occlusal
loading or as a result of bony resorption, Fig. 12.25. Rest, Proximal Plate and I-bar clasp
dental rests and any other supporting ele- (RPI).
ments placed in front of the fulcrum line
lift away from the supporting tissues and of free-end saddles have been suggested in
thus do not transfer occlusal loads. order to reduce saddle displacement dur-
The fulcrum line should not be con- ing loading, thus reducing the rotation.
fused with the similarly sounding reten- Neither of these claims is verified
tive fulcrum line, which is drawn between scientifically. The few in vivo studies that
retentive elements. True, in many cases the have been made indicate that abutments
two lines coincide. However, whereas the teeth are torqued in all directions by the
fulcrum line is related to rotation during RPDP under function, and that this torque
occlusal loading, the retentive fulcrum does not depend on the clasping system
line is related to rotation in the opposite used. Furthermore, except in extreme
direction – which occurs when the saddles cases the loading of the abutment teeth is
are pulled away from the ridges during well within physiological limits and will
chewing of sticky food. not be harmful. The conclusion is that
A lot of debate and numerous claims these special measures to reduce the load-
have been presented as to the clinical ing or torque on the abutment teeth are
importance of the inherent instability not necessary, and they may have serious
of free-end RPDPs and how this problem biological drawbacks. The special clasp-
should be solved. Regarding the clinical ing systems, such as the well-known Rest,
importance of the rotational movements Proximal Plate and I-BAR clasps (RPI) (Fig.
of such dentures, claims have been made 12.25), contain considerably more plaque
that some clasp systems expose the abut- retaining elements than the simpler ones
ment teeth to a distal torque, and that this described in this textbook. Consequently
torque is potentially harmful to the peri- they add to the complexity of the con-
odontium and should be avoided. In construction, which is contrary to the princi-
sequence, special and complicated clasp- ple of simplicity of design.
ing systems, designed to counteract the Although it has never been scientifi-
torsion on the abutment teeth have been cally documented, RPDPs made as a result
developed. Also, compression impressions of compression impressions may perhaps

initially reduce the rocking movements needed, and the retentive fulcrum line is
of the denture when the saddle is loaded. always placed near the distal periphery
However, when it is not, the compressed of the supporting area. The saddle may
tissues will tend to recoil, causing an therefore tend to rotate away from the
upward rotation of the saddle. If so, the ridge due to gravity and when the user
clasps will tend to pull at the abutment eats sticky food. As with other free-end
teeth coronally. At any rate, the resulting cases, in order to prevent this movement
permanent pressure on the supporting tis- the supporting area has to be extended by
sues that may result is most likely followed passive/indirect retainers, but unlike the
by a rapid bony resorption, cancelling out case of free-end dentures the extension is
the effect of compression impression. made in a posterior direction.
Special problems for RPDPs with a clinical procedures,

unilateral free-end saddle removable partial
(Kennedy class II) dentures
Such RPDPs present a special problem with
regard to placement of clasps, inasmuch as Preliminary measures prior
they have a fulcrum line that traverse the to impression
supporting area diagonally. Like in all free- Before impressions are taken the teeth
end RPDPs, the saddle rotates downwards may have to be prepared according to
during occlusal loading. Any clasp placed the final treatment plan. Preparation of
in front of the fulcrum line will therefore dental rests and a number of other pre-
tend to lift away from the abutment tooth. prosthetic treatments may also have to
The resulting pull on the abutment tooth is be implemented. Clinical aspects of these
probably not a physiological problem, but specially relevant and adapted to RPDPs
it reduces the retaining efficiency of the are discussed below.
clasp. For that reason and the fact that it
adds to the complexity of the construction, occlusal adjustments
clasps in such situations are not advised. Ideally, the primary occlusal contacts of
the cheek teeth in the muscular contact
Special problem with position (MCP) should be evenly distrib-
Kennedy class IV uted. If they are not, and particularly if
In designing RPDPs Kennedy Class IV the patient has subjective symptoms of
the steps of designing RPDPs have to temporomandibular dysfunction, oc-
be somewhat modified to fit the special clusal adjustment to remedy this situ-
situation of such dentures, even though ation should be evaluated. Under any
the principles involved are unchanged: circumstances, occlusal contacts that
As Kennedy Class IV has only one sad- cause a deviation of the mandible during
dle, no conventional major connector is closing movement should be adjusted.

Also, pointed cusps opposite occlusal rests
A
are sometimes adjusted in order to create
more space.
Elongated teeth can cause a number of
functional and aesthetic problems both
in the restored and opposing jaw. Neces-
sary treatment may range from a simple
occlusal adjustment to a radical shorten- B
ing of the tooth requiring endodontic

treatment and crown therapy. On rare

occasions even extraction may be have to
be performed.
Recontouring tooth surfaces Fig. 12.26A. Clinically obtainable guiding planes

Recontouring of teeth may be needed will always diverge somewhat form the path of in-
to augment the retention and stability sertion. B. Undercut created by composite build-up
of RPDPs. The most important reasons (blue).
for recontouring tooth surfaces are men-
tioned below: avoid undercuts (Fig. 12.26A). Guiding
Guiding planes. Guiding planes are planes can also be used for flattening
prepared on the sides of the abutments, sharp or pointed contact areas, which
as parallel to the path of placement as may interfere with optimal retention, and
possible. They are normally performed stability of RPDPs, or for lowering occlus-
in tooth enamel, but may also be per- ally placed lines of retention and reduc-
formed on artificial crowns. The main ing deep undercuts.
purpose of guiding planes is to augment Preparations of undercut. A small under-
the retention and stability of the denture, cut area can be established by a cautious
particularly in cases with bonded saddles. preparation of the enamel. However, in
They function in much the same way as a many cases this is difficult or impossible
drawer in a tight chest – unless the drawer because the preparation should always
(or RPDP) is removed exactly as it was in- be performed within the enamel, which
serted, it will tend to stick. is usually quite thin near the neck of the
The planes should ideally be prepared tooth. The ground surfaces should always
exactly parallel to the path of placement. be polished and fluoride treated.
However, a perfect degree of precision is Composite build-up. In some cases abut-
impossible to achieve clinically. Guiding ment teeth are without undercuts usable
planes prepared in the mouth will there- for clasp retention. This may be remedied
fore coronally always diverge somewhat by means of a favourably positioned small
from the path of placement in order to composite lump, attached with adhesive

technique (Fig. 12.26B).
Fillings. Large fillings that are not op-
timal may have to be remade and should
be contoured so that they will function
optimally in connection with the RPDP.

Rounding of sharp edges after recontour-
ing. It is difficult to avoid that sharp edges
on a gypsum cast become rounded in the
Fig. 12.27. Milled crown. The axial wall of the mil-
course of the technical procedures. Any
led area is exactly parallel with the path of inser-
sharp edges left after the above prepara-
tion/withdrawal.
tions or on other teeth in contact with
the RPDP should therefore be carefully
rounded to avoid subsequent problems in Procedures when crowns and
fitting the framework. FPDs are manufactured at the
Crowning. If neither of the above so- same time
lutions is practicable, the tooth may be If crowns or FPDs are needed, and par-
entirely reshaped by crowning. If a crown ticularly if they are milled, they should
is indicated on an abutment it should al- not be cemented before impression of the
ways be milled in a jig in the dental labo- RPDPs. Instead, they should be finished
ratory, with the axial wall exactly parallel up to the biscuit stage, seated on the
to the path of insertion/withdrawal (Fig. tooth and picked up with the impression
12.27). Only thus can the optimal advan- for the RPDP. This has two important ad-
tages in terms of increased retention and vantages: technically it is easier and more
stability of the RPDP be gained. In this accurate to wax-up, cast and adopt the
context is should be noted that a milled framework to the hard metal surface of a
crown may require more removal of tooth crown than to a stone replica of the same.
substance than an ordinary crown in Also, this makes it possible to change the
order to accommodate the milling and shape of the tooth in the dental laborato-
avoid overcontouring. ry if the need should arise – which clini-
The dental rest function should also cal experience shows that it frequently
be included in the milling or casting – does. The axial discrepancy of 70-100 µm
either as a horizontal shelf at the gingival that occurs during cementation of such
part of the milling or as an occlusal rest. crowns is normally too small to cause
Crowns manufactured in this way should clinical problems.
have the components of the RPDP in con-
tact with the crown incorporated into the Blocking out interdental spaces
crown, completing its form. and large undercuts
Interdental openings between the teeth
due to gingival retraction should be

Fig. 12.28. Interdental openings are blocked with Fig. 12.29. Different spaces for different impression
wax. materials; silicone (left) and alginate (right).
blocked out with a soft carding wax (Fig. the sometimes quite considerable forces
12.28). Other large undercuts may also applied to it when the impression is re-
have to be similarly blocked out. The wax moved from the dentition. For the same
is better retained if the surfaces are blown reason it is essential that adequate reten-
dry before application. When the wax has tion between the tray and impression ma-
been applied it is important to inspect the terial is secured, either chemically using
dentition to make sure that it does not appropriate adhesives, or mechanically by
cover surfaces in contact with denture perforating the tray.
components. The extension of the periphery in
free-end saddle areas and lingually should
be similar to complete dentures, i.e. with
Impression maximal extension. Facially, where there
Special tray are bounded saddles, and opposite teeth,
Clinical experience indicates that a spe- the extension of the tray may be some-
cial tray makes it easier to take good final what reduced. It is particularly important
impression. The tray may be made on the that the tray is not overextended lingually
preliminary cast. Apart from aspects dis- in cases where lingual bars are used.
cussed below, the principles regarding spe-
cial trays for complete dentures discussed Requirements
in Clinical procedures, complete dentures, are Satisfactory impressions for RPDPs should
also applicable for trays used for RPDPs. reproduce accurately all the details of the
The tray must be constructed with suf- dentition, the soft tissues and the periph-
ficient space for the impression material; eral areas without compression. In regard
i.e. 2 mm for elastomeric impression ma- to mandibular RPDPs equipped with a
terials, 3 mm for irreversible hydrocolloids lingual bar it is particularly important to
(alginate) (Fig. 12.29). It must be solid obtain a true representation of the lingual
enough to withstand without distortion condition – not only the vertical exten-

sion, but in case a sublingual bar is con-
templated, also the horizontal one, under-
neath the tongue.
Provided every one of these require-
ments is met, the resulting cast may be
used for all following technical proce-
dures. Clinical experience shows that this
may be difficult to achieve. The impres-
sion may sometimes show a perfect repro-
Fig. 12.30. Trays attached to the metal framework.
duction of the rest dentition, but defects
in the saddle areas. In the mandible a
hypertrophic and active tongue that is fre- tray. The framework is manufactured on
quently found in the partially dentate pa- the resulting cast and its clinical fit as-
tient often complicates taking impression. sured. Over the saddle areas bases shaped
like trays are subsequently adapted to the
Final impression ridges, if deemed necessary with a small
Clinical procedures in taking the impres- spacing, and attached to the perforated
sion and inspection of the result are the framework (Fig. 12.30). The periphery of
same as those described in Clinical pro- these saddle trays may then be adjusted
cedures, complete dentures. In accordance in the usual manner.
with the importance of not overextend- The tissue side of the saddle trays
ing the tray lingually, attention should should be covered with a light-bodied
be paid to the lingual border moulding, elastomeric impression material. The
particularly when the RPDP is provided framework with saddle trays are next in-
with a lingual or subligual bar. serted into the mouth and border mould-
ed as usual. The saddle areas of the cast
Altered cast impression are removed, the denture mounted on
One solution in overcoming the problem the gypsum teeth and new saddle areas
of satisfying all requirements of an im- poured (Fig. 12.31A, B). There is a possible
pression is to use special saddle impres- risk in using the altered cast technique.
sions – also called altered cast impres- Unless the framework is definitively lo-
sions. This method is only applicable for cated to the rest dentition it should not
mandibular free-end RPDPs. Its purpose be used. Otherwise an unintended and
is to secure an optimal impression of the undetected rotation of the saddles may
free-end saddles. take place. Consequently, during setting
The procedure is as follows: An ir- of the impression material the framework
reversible hydrocolloid (alginate) impres- should be firmly held in close contact
sion, which replicates the rest dentition with the rest dentition.
satisfactorily, is first taken with a stock The altered cast technique has also

A
Fig. 12.32. A silicone impression of an upper jaw.
used for the final impression. Of these,

B
alginate is sufficiently accurate for the
purpose; it is the least expensive, easi-
est to manipulate and fastest to use. It is
also considerably more pliable than the
elastomers after the impression is set. The
softness of set alginate is an important
advantage since it makes the removal
Fig. 12.31. Altered cast impression. A. Separate
from the mouth easy and significantly
saddle impressions. B. Prepared for puring.
reduces the risk of breaking the gypsum
teeth of the cast. However, it is technique
been used for the explicit purpose of sensitive and the recommendations of the
taking compression impressions. As dis- manufacturer must be strictly adhered to.
cussed earlier, this is not recommended. Furthermore, it has to be poured imme-
For that reason a light-bodied impres- diately if it is to retain its precision, so it
sion material and, in some cases, relieved cannot be transported to the dental tech-
saddle bases should be used. Nevertheless, nician for pouring.
a minute compression is difficult to avoid Elastomeric impressions, on the other
completely. For that reason the altered hand, are usually sufficiently stable to be
cast technique is not suitable for maxil- transported (Fig. 12.32). Their superior
lary cases because it is difficult to avoid ability to reproduce fine details compared
that the impression material flows below to alginates is not clinically important as
the palatal connector. alginates are sufficiently accurate. Their
fairly long clinical setting time, sometimes
choice of impression material unpleasant smell and taste, hard set and
Any elastic impression material may be high cost are unfavourable aspects. How-

ever, in the final analysis the choice of
material is a matter of personal preference.
Inspection of the final impression

In general terms, the final impression
should be inspected in the same manner
as described in Complete dentures-clinical
procedures. The impression of the rest
dentition should be specifically inspected
for possible defects, particularly failure to Fig. 12.33. Jaw relation registration with use of oc-
reproduce preparations for dental rests, clusal rims attached to the metal framework.
guiding planes and other contact areas
between the framework and the teeth.
If the rest dentition allows definite
Recording the jaw relations positioning of casts, no occlusal index
The occlusion has to be recorded either is required. The dental technician then
before or after the framework has been mounts the casts in the articulator accord-
produced, depending on the situation in ingly. In all other cases a partial occlusion
the opposing jaw. When there is a com- rim is needed in order to make an accurate
plete denture in the opposing jaw, the recording of the occlusion. If such a rim
occlusion can be recorded after the frame- is manufactured on the study cast, it may
work has been produced, using the frame- fit intraorally, but not the definitive cast
work as an occlusion rim, because any ad- because of the minute differences between
justments due to prominent dental rests or the two. To overcome this problem, two
other occlusally interfering components casts should be poured from the final im-
of the RPDP can easily be made in the ar- pression – the first one (the definitive cast)
tificial teeth. A recording of the occlusion is used for all the subsequent technical
may then be made using the framework procedures, the second one (duplicate cast)
as an occlusion rim (Fig. 12.33). In free- for making an occlusion rim. This entails
end cases, the framework can also be used an extra visit for the patient to the dentist
as an occlusion rim.. The saddles must to have the occlusion recorded. However,
then be supplied with bases that close the it is considerably easier and faster to make
1 mm gap between the perforated sad- an accurate occlusal index than to adjust
dles and the ridge. This will reduce the chromium-cobalt framework that does
tendency of the saddles to rotate towards not fit occlusally, particularly in situations
the tissues due to the inevitable pressures with close or complex occlusal contacts.
during recording. For the same reason, the It should be noted that a new cast of
softest possible recording medium should the opposing jaw is necessary if it has
be used. been subjected to occlusal adjustments.

adjusted in the dental laboratory, some
unintentional wear may have occurred
on the gypsum surface. This means that
even if the framework fits on the cast, it
may still not seat properly in the mouth.
For that reason, the surface of the cast
must be carefully examined in order to
reveal possible areas of wear (Fig. 12.35).
Fig. 12.34. Two metal frames are controlled on the As a final test of the fit of the framework
cast. it should be repositioned on the duplicate
definitive cast. In a well fitting framework,
dental rests, dental bars and clasps must
be in full contact with the rest dentition.
controls in the mouth

The framework is inserted into the
mouth, and gently pressed home. All con-
Fig. 12.35. An area of wear is detected on the cast. tacts with the teeth must be controlled;
the fit should equal that on the cast. It is
important to check the relationship be-
Metal framework tween a lingual bar and the soft tissues.

The patient should thus be asked to per-
controls on the cast form functional, i.e. moderate extensions
Before the framework is tried in the and lateral movements of the tongue,
mouth, the fit should be controlled on the during which it is ascertained that the
definitive cast on which it was designed mucosa does not impinge on the bar.
(Fig. 12.34). It should also be tested in The fit of a dental bar and the position
relation to the antagonist cast. Occasion- of the clasp arms in relation to the teeth
ally, the dental technician may have made they contact should also be controlled. It
a minor adjustment of the latter in order must be verified that the clasp arms are
to improve the functionality of the RPDP. no closer than about 1 mm to the mar-
The adjusted area should then be clearly ginal gingiva, and that the dental rests
marked on the cast so that it can be simi- are properly positioned in relation to
larly adjusted in the mouth. However, their prepared rest seats.
with careful treatment planning it should The framework must be controlled
normally be possible to avoid such meas- for overall passive stability in relation to
ures altogether. the rest dentition. This implies that when
When the framework is repositioned pressure is applied to dental rests, dental
on the definitive cast and if necessary bars or bounded saddles, there should

be no movement of the framework. On
the other hand, if pressure is applied to
a free-end saddle, it will rotate since it
is constructed approximately 1-1.5 mm
from the underlying tissues, in order to
allow for the intervening acrylic.
Fig. 12.36. A retentive clasp arm is carefully ad-
Only minor functional interferences
justed.
in occlusion and articulation should oc-
cur if the relationship between the jaws
has been accurately recorded and the den- a hitherto unobserved area of wear is
tal technician has considered the func- discovered, a minor adjustment of the
tional contacts during fabrication of the corresponding area of the framework may
framework. Nevertheless, these aspects be attempted. Possible supracontacts may
have to be controlled. Additional possible also be disclosed by applying pressure
interferences with hard or soft tissues indicating pastes, impression materials or
have to be identified as well. occlusion foils to the framework and sub-
sequently inserting it. Supracontacts may
thus be located and adjustments made
Adjustments accordingly.
General principles
It is advisable that only minor adjust- Adjustment of clasp arms
ments on a framework be attempted. Af- In principle, a clasp arms should be mini-
ter adjustment, the site should be properly mally adjusted as this severely reduces its
polished. Even though a poorly fitting mechanical properties and increases the
framework may be improved by adjust- risk of fracture substantially (Fig. 12.36).
ments, it will rarely be perfect. Further- This is particularly important with cast
more, the considerable and costly time retentive arms, which ought to be ad-
used in an attempt to obtain improve- justed only once. Even though a retentive
ments could more profitably be used in arm in wrought clasp wire can endure
making a new framework. adjustments to a much larger extent than
a cast one – and particularly a cobalt-
Framework does not seat properly chromium one – adjustments should be
One possible reason why a framework will kept to a minimum.
not seat completely may be unintentional
wear of the definitive cast or investment occlusal adjustments
surface occurring before the framework If interferences in occlusion and articu-
is modelled in wax. The definitive cast lation are found when the framework
should therefore always be conscien- is inserted, these should be ground in
tiously examined with this in mind. If appropriately. For this purpose articulat-

ing paper is commonly used to identify Try-in stage
the location of the supracontacts. How-
ever, the highly polished surface of the Tooth set-up
chromium-cobalt alloy may prevent the The artificial teeth are set-up according
deposit of the colour markings and thus to the occlusal record. The set-up should
preclude accurately located adjustments be such that even occlusal contacts are
from being made. This problem may be established between the opposing denti-
overcome by painting the surface with tions. Furthermore, the occlusal loads
tooth varnish. Identification of supracon- must be evenly distributed to the artificial
tacts may also be accomplished by means teeth and the rest dentition. To this end,
of occlusion wax. if natural teeth are in infraocclusion they
In cases of occlusal interferences, judi- may be furnished with onlays or dental
cious minor adjustments in the enamel rests shaped so that they make contact
or restorations of the antagonist dentition with the antagonist dentition. Under no
rather than on the framework may some- circumstances should the occlusal load be
times be acceptable. If considerable oc- applied to the artificial teeth of free-end
clusal adjustments are needed, but these saddles only. If so, discomfort and rapid
are not so serious that a new framework bony resorption most likely ensue.
should be considered, a new occlusal re- In order to reduce the loads to which
cording is advised so that the adjustment free-end RPDPs are subjected, it is recom-
can be made in the dental laboratory after mended to narrow the artificial teeth
the casts have been remounted in the ar- facio-lingually, particularly in mandibu-
ticulator. lar free-end RPDPs. For the same reason
no tooth distal to the first molar should
Borderlines normally be replaced.
There should always be a distinct border-
line between the parts of the framework controlling and adjusting
covered by acrylic denture base material the set-up
and those that are not. In the absence of The waxed-up RPDP is inserted into
such borderlines, the acrylic denture base the mouth and controlled for occlusal
material tends to taper into a thin sliver, contacts in RCP, MIP and MCP. If a new
which may cause it to separate slightly complete denture is manufactured at the
from the metal. The resulting gap quickly same time in the antagonist jaw the verti-
becomes discoloured and unhygienic as it cal dimension should also be controlled.
is filled with plaque and food debris, or it These controls are the same as those de-
may break off altogether. scribed for complete dentures.
If there are deviations of the occlusion
a new recording should be made using
the framework as an occlusion rim. In

case of serious inaccuracies the artificial denture does not seat without problems,
teeth may have to be removed. this is most likely due to errors in poly-
merization. As mentioned above, unde-
Insertion stage tected flakes of acrylic on components

may be one cause. Another may be warp-
Inspection of the denture ing of metal parts that may occur during
prior to insertion a too violent deflasking after polymeriza-
The inside of the denture should be in- tion. Finally, clasp arms are sometimes
spected and adjusted for defects in the base caught in the polishing brushes and bent
material, small acrylic globules on the fit- in consequence.
ting surfaces and sharp edges as described The extension of the saddles and the
in Clinical procedures, complete dentures. It occlusion is controlled and necessary ad-
is particularly important to inspect minor justments made. All major adjustments
connectors and the inside of clasps and of the occlusion should be completed in
dental rests for thin flakes of acrylic that the laboratory. If a new occlusal recording
may have flowed under these elements must be made the RPDP should be seated
during polymerization. These are often on the duplicate cast and remounted in
quite difficult to discover, but will hinder the articulator according to the new in-
proper seating of the denture (Fig. 12.37A). dex. If no duplicate cast is available or
usable an alginate impression should be
Inspection and clinical taken of the jaw with the denture in situ.
control of the denture after The denture will then be picked up in the
insertion impression (or repositioned if not). The
The seating of the denture, the fit of resulting cast and denture will then repro-
clasps, dental rests, guiding planes and duce the condition in the mouth.
other contacts between the rest denti- If the interdental openings are occlu-
tion and the denture are controlled and ded by acrylic (Fig. 12.38A), they should
adjusted if necessary (Fig. 12.37B). If the be opened up (Fig.12.38B) and polished.
A B
Fig. 12.37. The dentures are controlled, A. on the cast, B. in the mouth

A B
Fig. 12.38. Interproximal openings. A. closed by acrylic. B. opened up after adjustment.
The vertical flanges of the saddles should may take quite some time. The patient
taper where they contact the alveolar ridg- should also be informed that initial prob-
es so that the passage from flange to ridge lems are not uncommon, but that these
is as unnoticeable as possible. usually recede after a period of adaptation.
Information and post Post insertion problems

insertion control and treatments
appointment
The patient must be given adequate and General comments
individual information pertaining to Some general post insertion problems as-
the maintenance of the rest dentition as sociated with RPDPs may be the same as
well as the denture. The need for regular those experienced by complete denture
controls, during which problems that wearers: To mention but the most fre-
might arise are detected and appropriate quent ones, there may be difficulties with
measures implemented, should be empha- chewing and speech, the tongue may feel
sized, and an agreement regarding regular cramped – particularly if the patient has
call-ups made. The responsibility for this been without posterior teeth in the area
lies unequivocally with the dentist. A post for a long time and the tongue therefore
insertion control appointment should be has become hypertrophied. Hypersaliva-
made, if possible, after one to two days. tion may also occur. As with complete
No more time is usually needed to disclose dentures pressure sores may develop. Such
initial problems, which can then be effec- problems should be remedied in the same
tively dealt with. If the first post insertion manner as with complete dentures.
appointment is made much later, the oral
tissues may sometimes be serious harmed, Specific problems
causing unnecessary pain and discomfort Other problems are more specific to this
and loss of confidence in the dentist. type of denture. Particularly novices may
The patient must be taught how to have higher expectations of RPDPs than
remove and insert the RPDP and should what is possible to fulfil. Even though RP-
not leave the dental surgery before he has DPs are clasp retained, they will not retain
mastered the art. With some patients this in all possible situations. Patients may ob-

ject to unavoidably visible clasp arms and auto polymerizing resin in the base mate-
complain of the inherent instability of rial. Repairing fractured dental rests or
free-end dentures. A transient soreness of other components of the framework, ne-
abutment teeth is also quite common. cessitating casting a new part and attach-
Neither of the latter problems can be ing it by brazing, is rarely sensible, because
effectively remedied, since they are in- the cost of the repair will only be margin-
trinsic to RPDPs. It is therefore important ally smaller than that of a new denture.
to inform the patient at an early stage of The need for relining or rebasing free-
the nature, possibilities and limitations end saddles has to be examined at every
of RPDPs. Thus when such problems regular control. The choice between reline
occur, they do not come as a surprise. and rebase is largely a matter of personal
The dentist may then refer to previous preference. However, it may be argued to
information and otherwise comfort the reline if the degree of resorption is only
patient and solve those problems that are moderate and the base material is satisfac-
solvable. On the other hand, if the patient tory, whereas a rebasing may be indicated
is unprepared for these problems, a more if a more severe degree of resorption must
serious situation may develop, with pos- be compensated for and particularly if the
sible loss of confidence in the dentist. technical quality of the base material is
Fortunately, clinical experience indicates poor.
that in the majority of cases adaptation is If the resorption has resulted in loss of
fairly rapid. occlusal contact in a free-end RPDP, the
posterior end of the saddle should be lifted
Repairs, relinings, by means of a small piece of soft carding
rebasements wax placed on the tissue side of the saddle
As previously discussed, there is conside- opposite the retromolar pad. The soft wax
rable need for maintenance with RPDPs in should be adjusted until an even occlusion
order to preserve oral health in the den- is achieved. Thereafter an impression with
ture wearer. When components are frac- a light-bodied impression material should
tured or warped, and repairs are deemed be taken. Then, after an initial muscle
necessary, possible and expedient, an algi- trimming of the borders, in accordance
nate impression is taken with the denture with the altered cast technique, the im-
in situ. As described above, the denture is pression material should be left to set with
then picked up in the impression. This al- the denture in light occlusion.
lows the dental technician to pour a cast,
which may be used for subsequent repairs. concluding remarks
Broken retentive arms cause the most When teeth are missing and have to be
frequent repairs. These are usually rela- replaced the dentist has a number of
tively easy to perform, with a wrought treatments at his disposal for restoring
gold clasp wire, which can be retained by the oral function, including both tooth

and implant supported fixed and remov- compared with the other options: the
able restorations. No doubt, when missing treatment is considerably less costly, it is
teeth are replaced with RPDPs the oral quickly performed and it functions well
function is less perfectly restored com- for most patients provided the option
pared with most of the alternative treat- is used with correct indications. These
ments. Also, as discussed at some length reasons and the fact that the alternative
in this chapter, the potential for harm to treatments sometimes, and for a number
the oral tissues with RPDPs is certainly of reasons cannot be used, make RPDPs
present – perhaps to a greater extent than a viable alternative in the foreseeable fu-
most of the alternatives. Certainly, the ture. When indicated, both dentist and
risk may be avoided or at least reduced, dental technician should feel obliged to
but this requires efforts by dentist and approach the task with the same respect,
patient alike. dedication and competence as with other
On the other hand, the following and perhaps more prestigious treatments.
three advantages of RPDPs stand out
Further reading
Berg E. Periodontal problems associated with use of distal extension removeable partial prosthesis –
a matter of construction? In Oral Rehab 1985;12:69-79.
Bergman B, Hugoson A, Olsson CO. Periodontal and prosthetic conditions in patients treated with
removable partial dentures and artificial crowns. A longitudinal two-tear study. Acta Odontol
Scand 1971;29:621-38.
Bergman B, Hugoson A, Olsson C-O. Caries, periodontal and prosthetic findings in patients with
removable partial dentures: A ten-year longitudinal study. J Prosthet Dent 1982;48:506–514.
Brill N, Tryde G, Stoltze K, El Ghamrawy EA. Ecologic changes in the oral cavity caused by remov-
able partial dentures. J Prosthet Dent 1977;38:138-148.
Carlsson GE, Hedegård B, Koivumaa KK. Studies in partial denture prosthesis. IV: Final results of a
4-year longitudinal investigation of dentinogingivally supported partial dentures. Acta Odon-
tol Scand 1965;23:443-72.
Jokstad A, Ørstavik J, Ramstad T. A definition of prosthetic dentistry. Int J Prosthodont
1998;11:295-301.
Käyser AF. Teeth, tooth loss and prosthetic appliances. In: Öwall B, Käyser AF, Carlsson GE (eds).
Prosthodontics. Principles and management strategies. London: Mosby-Wolfe, 1996:35-48.
Koivumaa K. K. Changes in periodontal tissues and supporting structures connected with partial
dentures. Suom Hammaslaak Toim 1956; 52, Suppl. I, Dissertation.
Öwall B, Budtz-Jørgensen E, Davenport J, Mushimoto E, Palmquist S, Renner R, Sofou A, Wöstman
B. Removable partial denture design: a need to focus on hygienic principles? Int J Prosthodon.
2002;15:371-8.

Petridis H, Hempton TJ. Periodontal considerations in removable partial denture treatment: a re-
view of the literature. Int J Prosthodont 2001;14:164-72.
Svanberg G. Influence of trauma from occlusion on the periodontium of dogs with normal or in-
flamed gingiva. Odontol Revy 1974;25:165-178.
Steele JG, Walls AW, Murray JJ. Partial dentures as an independent indicator of root caries risk in a
group of older adults. Gerodontology 1997;14:67-74.
Walton JN, MacEntee MI. Choosing or refusing oral implants: a prospective study of edentulous
volunteers for a clinical trial. Int J Prosthodont 2005;18:483-8.
Wærhaug, J.: Pathogenesis of pocket formation in traumatic occlusion. J Periodontol 1955; 26: 107-
118.
217

13
Relining and rebasing
Ei na r BErg
INTRoDucTIoN. A reline is a procedure whereby the inner surface of an ill fitting remov-
able dental prosthesis is resurfaced with new base material, thus producing an accurate
adaptation to the denture supporting tissues (Fig. 13.1A). A reline is usually performed with
a light- or autopolymerizing acrylic resin, but a heat-cured acrylic resin can also be used for
the purpose. Relining should be performed indirectly in the dental laboratory according to
the clinical procedures described below. using autopolymerizing acrylic resin directly in the
mouth for the purpose of relining a denture is not recommended for biologic and mechanical
reasons.
Semi-permanent soft relining materials such as resilient methacrylates and silicones are
also available. These usually have a life span of 1-3 years and may be indicated for patients
who cannot otherwise wear their dentures without severe discomfort or pain.
Temporary relinings, usually called tissue conditioners, lasting from a few days to some
weeks, are sometimes used in order to clear up infections of the denture supporting tissues
and to reduce possible mechanical trauma.
A rebase is a process whereby the entire denture base material on an existing prosthesis is
replaced (Fig. 13.1B).

A
B

Fig. 13.1. The principle difference between A. a reline and B. a rebase.
219

Reline or rebase rebasing may be preferred because techni-
In most cases relining a denture is pre- cally it is difficult to obtain an optimal
ferred to rebasing it. Provided the reline result with autopolymerizing acrylic resin
is made with a light- or autopolymerizing in bulk, both in terms of porosity and col-
acrylic resin, the laboratory procedures our stability.
can be carried out within a few hours,
which means that the patient can have Indications
the adjusted denture back within a work- The primary use of these procedures is to
ing day. There are some theoretical disad- improve the fit of a denture, which has
vantages to relines made with autopoly- deteriorated because of resorption of the
merizing acrylic resin. Perhaps the most supporting bone. The need to adjust the
important one is that it contains between denture for this reason is particularly im-
eight and ten times more free potentially portant for immediate dentures because
allergenic monomer than the heat cured of the great speed with which the sup-
variety. Also it is usually more porous, fa- porting bone usually resorbs after extrac-
vouring microbial colonisation. However, tions. However, the need to improve the
in most cases, these disadvantages are not fit of a removable denture may arise at
clinically important. any time, as a result of alveolar resorp-
A rebasing, on the other hand, is usu- tion, inadequate extension of the denture
ally performed with heat-cured acrylic or for other reasons. Consequently, any
resin. The denture then has to be invested denture with suboptimal retention or sta-
in a flask, subjected to a complete cur- bility may thus be a candidate for a reline
ing cycle and deflasked before it can be or rebase.
trimmed and polished. These procedures From a practical viewpoint, relining
are not possible to perform within one or rebasing may extend the lifetime of
working day. Also, because this method a denture. Compared to a new one, the
is more complex and time consuming, procedure is less expensive; there are less
it is considerably more expensive than a problems with adaptation and little or
relining. Nevertheless, a rebasing can pro- no aesthetic change. Occasionally the
vide a solution in cases where the patient procedures are performed if the patient
wishes to keep the denture for aesthetic for some reason does not have the time
or other reasons, and the quality of the needed to have a new denture made. Also,
denture base material is unacceptable in cases with inflammatory problems of
due to porosities, colour change, repeated the denture supporting tissues, a denture
fractures, suspected allergy etc. Further- may be relined as a step in rehabilitating
more, if the vertical dimension needs to the tissues. A new clean fitting surface is
be increased or if great alveolar resorption then provided. Furthermore, the fit will
underneath a free-end denture saddle be improved, which is likely to reduce
of an RPDP must be compensated for, a trauma to the tissues. Finally, a vertical
220 Relining and rebasing

dimension that has become too low as a Examination of denture
result of ridge resorption (usually of the The condition of the denture must be
mandibular denture) can be increased. evaluated in regard to the indications
or contraindications mentioned above.
contraindications Defects of base material or artificial teeth
Relining or rebasing a denture is con- may be particularly relevant in this con-
traindicated if the denture has major text.
defects that cannot easily be remedied
by the procedures. Artificial teeth notice- Measures prior to impression
ably worn, chipped or broken, aesthetics Possible defects in occlusion and articu-
that for some reason are unsatisfactory lation should be corrected by selective
or grave defects of the occlusion neces- grinding at this stage in order to reduce
sitating replacement of teeth thus usually adjustments to a minimum after the re-
contraindicate both procedures. In the lined or rebased denture is inserted (Fig.
evaluation the preference of the patient, 13.2A). Next, all undercuts in the flanges
properly informed of the advantages and of the denture should be removed in
disadvantages of the alternative treat- order to assure that the denture may be
ments, usually decides the matter. removed from the subsequent cast with-
out problems (Fig. 13.2B). The periphery
clinical procedures of the denture usually needs to be ad-
justed in some way: it may be indicated
Examination to reduce it somewhat in height to avoid
Extraoral examination overextension of the impression, or to
The extraoral examination is valuable in add to it if underextended. Sometimes it
order to evaluate if the vertical dimension may be more expedient to border mould
is acceptable or needs to be increased, if the entire periphery, whereby both exten-
the lip support is satisfactory or needs to sion and thickness may be controlled (Fig.
be adjusted or if the anterior teeth and oc- 13.2C).
clusal plane are pleasingly displayed.
Impression
Intraoral examination The impression should be taken with the
A systematic intraoral examination denture, using a light bodied elastomere
should be carried out with regard to impression material, basically employ-
• extension of the periphery of the den- ing the same technique as is described
ture in Clinical procedures, complete dentures.
• vertical dimension It is important that the denture is seated
• condition of the denture supporting completely in order to avoid unintended
tissues increase of vertical dimension, changes
• occlusion and articulation in aesthetics, the orientation of the den-
Relining and rebasing 221

impression material left to set with the
A denture in light occlusal contact. The im-
pression should be examined for defects
or imperfections in the usual way, and if
found deficient the impression material
has to be removed and a new impression
made. Before sending the prosthesis to
the dental laboratory, it should be reinsert
in order to make sure that the aesthetics
and occlusion are unchanged and that
the fit and retention are satisfactory.
B
Special observations
when relining a RPDP
The general procedure when relining a
RPDP corresponds well with the one de-
scribed for complete dentures. There are,
however, a few things to be observed. Most
importantly, the clinician must control
that the framework fits well to the occlusal
rests and to other supporting parts of the
c dentition. If not production of a totally
new prosthesis must be considered.
A low-viscosity impression material
is used to reproduce the saddle areas and
the patient is allowed to let the maxillary
and mandibular jaws make light contact
with each other after the partial denture
has been inserted into the mouth. It is
important to control that the framework
adapts to the remaining teeth. The RPDP
Fig. 13.2A. Occlusion and articulation are correct-
must also be related to the remaining
ed. B. undercuts are removed prior to impression. C.
teeth, which is accomplished by lifting
The periphery of the prosthesis is border moulded.
out the RPDP in an alginate impression
using a standard perforated impression
tray (Fig. 13.3).
ture in relation to the ridges or occlusal One problem quite often encountered
interferences. To ensure the latter the at the delivery of the relined RPDP is
occlusion should be controlled and the premature occlusal contacts posteriorly.
222 Relining and rebasing

tion, or clinical errors caused by improper
impression procedures. Minor premature
contacts may be adjusted by occlusal
grinding in the mouth. More pronounced
discrepancies have to be corrected by first
removing most of the base material that
was added during relining and subse-
quently repeating the procedure.
Post operative aspects

Guidelines regarding inspection and in-
Fig. 13.3. The RPDP is lifted out in an alginate im- sertion of the relined or rebased complete
pression. denture/RPDP, relevant information to
the patient, post insertion appointments
This may be due to laboratory errors such and handling and treatment of post in-
as using too much acrylic material or sertion problems are similar to those de-
insufficient pressure during polymeriza- scribed for a new produced prosthesis.
Relining and rebasing 223

14
Removable complete dental prosthesis
– laboratory procedures
to r E d é r a n d and P E rC y m i l l E d i n g
INTRoDucTIoN. Complete denture treatment is teamwork between the dentist and the
dental technician. With emphasis on technical procedures the flowchart below gives an over-
view of the various steps in the complete denture production (Fig. 14.1).
Indirect production of restorations, i.e. in collaboration with the dental laboratory, will
result in a high quality product if the professionals involved are manually and technically skil-
ful, if due considerations have been taken to biology and patient preferences, if there exists
a thorough know-how of the various treatment steps and last but not least if there is a well
established line of communication between the dental clinic and the dental laboratory. The
contact with the dental laboratory often takes place via the requisition, but occasionally also
by direct contact between the dentist and the technician. An important issue in the relation-
ship between dental clinic and dental laboratory is the time planning and the fact that the
time necessary for the production of the restoration has to be respected.
Clinical procedures ending up Production of primary casts

with a requisition to the and individual trays
laoratory. Primary impressions
Master cast production and Adaptation of individual trays.

occlusal rims Secondary impressions
Clinical bite registration. Mounting of casts in the

Determinating tooth form articulator. Tooth set-up
and colour
The acrylic processing. Clinical try-in of the wax

Finishing/polishing prosthesis. Functional and
aesthetic evaluation
Clinical try-in of the full Occlusion equilibration

dentures. Indes for occlusion
equilibration
Delivery
Fig. 14.1. The light-green text-boxes refer to dental technician’s production phases and the dark-green text-
boxes refer to the clinical treatment phases.
225

Production of primary
casts and individual trays
The alginate impressions of the upper and
lower jaws received from the dental clinic
are supposed to be disinfected. However,
this is not always true and therefore the
impressions should be gently rinsed in
water and treated with a disinfection so- Fig. 14.3. Trays for secondary impression.
lution. Dental stone (a gypsum product
type 2) is used for the careful infill of the to allow an individual forming of the
impressions. This first set of stone casts is periphery intraorally, prior to the impres-
used for the fabrication of individual im- sion (Fig. 14.3). Adequate space must be
pression trays intended for the secondary prepared for the fraenula. The u-formed
or anatomic impression of the edentulous handle should be placed in approximately
jaws (Fig. 14.2). the position of the former teeth and with
The trays are often made of autopo- a height of 5-10 mm.
lymerising acrylic resins, since the tem-
perature in the mouth will not distort Master cast and occlusion
these materials during the impression rims
procedure and since they are also known The secondary impressions in silicon or
to have good handling characteristics. polyether materials should be boxed with
Any undercuts present will be blocked wax and placed in a metal ring or a rub-
out or the fabricated tray will be difficult ber holder. A stick of soft wax (boxing-
to remove from the cast. The periphery wax) may be placed along the border
of the impression trays will be intention- of the impression to make it possible to
ally made short of the sulcus, floor of the inspect the sulcus area on the definitive
mouth as well as of the posterior borders cast. A stone for permanent use and with
a low expansion coefficient, type 2 or 3
(ISO), is recommended.
On the final models base plates are
oriented and occlusion rims are made.
Identified undercut areas should be
completely eliminated with light-curing
blocking-out material. Base plates made
of autopolymerized resins will be closely
adapted to the edentulous areas of the
casts after which the occlusions rims are
Fig. 14.2. Stone cast of the upper jaw with a border built-up with modelling wax (Fig. 14.4).
line illustrating the extension of the impression The height of the rim should be ap-
tray.
226 Removable complete dental prosthesis – laboratory procedures

Fig. 14.4. Maxillary and mandibular occlusion rims
on the definitive casts.
proximately equivalent to the length of Fig. 14.5. Definitive casts with occlusion rims
the missing tooth crowns and resorbed mounted in an articulator.
bone. An average recommendation for the

maxillae might be in the front area ap- or less mandatory for the mounting of the
proximately 20 mm and in the posterior upper jaw cast. Nowadays the face-bow
region 10 mm measured from the mar- is neither used in the daily clinical work
ginal ridge, which will result in a certain nor being taught at the dental faculties
inclination of “the occluding surfaces” in Scandinavia, since no specific benefits
of the wax rims in the anterior-posterior have been associated with the use of this
direction. The mandible rim can be some- equipment. The articulator is set accord-
what lower in height. The frontal part of ing to mean values, i.e. an inclination of
the maxillary rim must be made wider the path of the condyles of 30-40 degrees
than the mandibular rim to support the and of the Bennet-angle to 15 degrees.
upper lip and to conform to the anatomic Removal of the occlusion rims from the
characteristics of the jaws. mounted casts will reveal available space
Mounting of casts in the

articulator and tooth
set-up
The upper and lower casts, as well as the
adjusted occlusion rims, clamped toge-
ther, are delivered to the dental laborato-
ry for mounting in the articulator and for
the artificial tooth set-up (Fig. 14.5). They
are affi xed with gypsum to cast holders
or more conveniently to specific magnetic
holders. Fig. 14.6. Casts without occlusion rims mounted
Earlier, the use of a face-bow was more in an articulator.
Removable complete dental prosthesis – laboratory procedures 227

and inter-arch relations (anterior-posterior
as well as in lateral aspects) between the
upper and lower alveolar ridges (Fig. 14.6).
Frequently, in advanced resorption cases,
the width of the lower jaw is larger than
that of the upper jaw. This results in a
cross-bite relation, which calls for specific
considerations at the tooth set-up.
The artificial teeth Fig. 14.7. Anterior and posterior teeth for tooth set-
Artificial teeth for removable dentures up.
vary in anatomic form, size, and mate-
rial. Highly cross-linked polymer artificial
teeth dominate and have replaced porce- Regarding the size of the posterior teeth,
lain teeth as artificial tooth material. For a small size is recommended except in
improved retention of the artificial teeth cases with markedly wide and favourable
the cervical part of the teeth are made of ridges. Small sized teeth reduce the load
less cross-linked material. If too exten- on the supporting tissues and provide the
sively reduced by grinding this part of desired shape for the polished surface.
the artificial tooth will disappear, which
will cause a weaker link to the acrylic The tooth set-up
base plate material. The aesthetic build-up The wax rims on their casts and mounted
of an artificial tooth is accomplished by in the articulator represent the starting
building in layers of different colour and point for the set-up of artificial teeth. The
translucency. facial outline of the maxillary wax rim
The producers of artificial teeth fab- must be indicative of the position of the
ricate anterior artificial teeth in basically frontal artificial teeth. The mid-line of
three different anatomic forms: ovoid, the maxillary wax rim has been marked
rectangular and triangular. Besides be- by the dentist, as has the position of the
ing fabricated in various tooth forms the maxillary cuspid teeth and the high-smile
width and length of the teeth will also line. Nevertheless it will be difficult for
vary to conform to the individual situa- the dental technician to produce a set-
tion. The mandibular anterior artificial up of artificial teeth for a person known
teeth are available in a restricted number by the edentulous casts only. Improved
of anatomic forms. The premolar and mo- quality will result if a photo of the patient
lar artificial teeth – also called diatorics is attached or even if the patient might
– are available in three different designs: show up in the dental laboratory.
normal, cross-bite and deep-bite designs The final position of the artificial
(Fig. 14.7). teeth will be a compromise between

retention-stability factors, aesthetics and
chewing efficiency.
Some theoretic background

From the perspective of the dental tech-
nician the position of the artificial teeth
will be monitored by the outline of the
wax rims, the inclination of the occlusal
plane as well as the inter-arch relations.
There is, however, also a theoretical back-
ground to the positioning of artificial Fig. 14.8. Effect of different loading situations on
teeth. Ideally the artificial teeth should be denture teeth. A. Most favourable artificial tooth
positioned: position and loading conditions. B. Most unfavour-
• strictly over the alveolar ridge able artificial tooth position and loading condi-
• close to the alveolar ridge tions. C. Favourable artificial tooth position, but
• with reduced cusp inclination unfavourable outward direction of forces. D. Unfa-
vourable artificial tooth position, but more favour-
In clinic, these recommendations will able central direction of forces.
often have to be modified. In situations
with favourable height and anatomic • depth of the sagittal and transversal
form of the alveolar ridges this can be occlusion curves (Ok)
done without much loss of functional • inclination of the incisal plane (I)
stability, whereas in more advanced re- • cusp inclination of the artificial teeth
sorption cases retention and stability, i.e. (Ci)
stability will be seriously impaired. • inclination of the plane of the con-
The localization of the loading in rela- dyles (C)
tion to the supporting alveolar crest will
display a multitude of possible situations. These factors have been arranged in a
In figure 14.8 four different and typical formula (Thielmann´s formula), which
loading situations are displayed. displays the relation between the effects
During functional movements nu- of the various factors on the balanced
merous contact position will occur be- occlusion (Fig. 14.9). Not all factors are
tween the teeth in both jaws. In order equally easy to alter.
to promote the stability of the dentures The formula is intended for making
simultaneous tooth contacts bilaterally the abstract more real, i.e. what will have
are an important aim for the tooth set-up. to be done for the teeth to remain in a
Balanced occlusion is a dynamic concept, state of balanced occlusion if one of the
including factors such as: factors is altered. The inclination of the
• inclination of the occlusal plane (Op) condyles is virtually impossible to change

C⋅I
Op ⋅ Ok ⋅ Ci
C = inclination fo the path of the condycles

I = inclination fo the incisal plane
Op = inclination fo the plane of occlusion
Ok = depth of the curve of occlusion
Ci = cusp inclination
Fig. 14.9. Thielmann´s formula.

Fig. 14.11. Tooth set-up of maxillary and mandibu-
for obvious reasons and the inclination of lar teeth.
the incisal plane is only partially adjust-
able due to its impact on the aesthetics. of these teeth might give a more natural
The remaining three factors are in reality look, but must never be done unless ac-
those possible to use as compensatory cepted by the patient (Fig. 14.10).
factors. The inclination of the occlusal The upper anterior teeth are in most
plane and the cusp are the two most of- cases placed anterior of the crest in or-
ten adjusted factors. It is also possible to der to support the lip. The tooth set-up
adjust the occlusion curves – the sagittal is continued with the positioning of the
and the transversal ones. If they are too lower anterior teeth, by which procedure
extensively adjusted, though, they may the overlap (vertical) and the overjet (hor-
increase the instability of the dentures izontal) will be formed. Ideally the values
instead of reducing it. for both should not exceed 2 mm (Fig.
14.11).
The set-up of anterior teeth The anterior teeth of the mandible
The maxillary incisors are the first artifi- should not touch the lingual surfaces of
cial teeth to be set-up. the maxillary anterior teeth and the pala-
The maxillary lateral incisors in the tal surface of these teeth should have a
upper jaw may be placed 1 mm cervically contour as close as possible to the normal
in relation to the central incisor to give palatal curvature to make it easy to pro-
a younger look. Some minor angulations nounce the “s-sounds”.
The set-up of posterior teeth

The posterior tooth-set-up starts in the
mandible. The mandibular premolars and
molars are positioned straight over the
crest without tilting. The mesio-distal
Fig. 14.10. Upper front teeth set-up with minor central fissure of the occlusal surfaces
angulations. should follow the crest and extend from

Fig. 14.14. Cross-bite relation in a heavily resorbed
mandible.
Fig. 14.12. Mandibular posterior teeth positioned
over the crest. consequence will be an unaesthetic effect
since the palatal cusps of the maxillary
the retro-molar pad to the cusp tip of the premolars will be hanging down, below
canine (Fig. 14.12). the plane of occlusion.
The teeth in the maxillae as well as in If the mandible is heavily resorbed a
the mandible will be arranged in such a cross-bite relation should be considered
way that a concave curve in the sagittal since in such cases a neutral contact
direction will be the result (Fig. 14.13) makes the dentures too wide and thereby
The curve will start at the mesial contact very instable (Fig. 14.14). Teeth with dis-
of the first molar tooth and is aimed at tinct cusps should be avoided or reduced
promoting posterior contacts during pro- by grinding as they make articulation
trusive movements of the mandible. If it movements difficult to perform.
is too extended, however, it may cause a The following tooth set-up in the
sliding dislocation of the lower denture. upper jaw advisably starts with the first
If the posterior teeth are positioned molar in order to get it ideally positioned
correctly, i.e. in an upright position, the during articulation. The premolars will
inherent anatomy of those teeth will then be put in place and the second mo-
form a moderate transversal curve. This is lars if there is enough space. Frequently
important in order to establish balancing the second molar teeth will have to be
contacts at lateral movements of the man- omitted due to space deficiency. Proximal
dible. However, if this is exaggerated, the grinding of the maxillary posterior teeth
may be necessary to make it possible to
place them in a correct position relative

the posterior teeth in the lower jaw.
There is great variation in the prin-
ciples for tooth set-up but the above de-
Fig. 14.13. Sagital curvature of the posterior teeth. scription is an accepted procedure.

The build-up of the occlusion form the gingival area. If the the wax-
The teeth in a set of upper and lower ar- work in the upper anterior region is too
tificial teeth are manufactured in such a extensively built-out, it will lend the up-
way that they fit into each other anatomi- per lip a “snuff” appearance, i.e. it will
cally, provided they are correctly posi- look too thick and tense and result in a
tioned in the dental arches. One crucial thinning-out of the lip’s red area (labium
factor for this fit is the conformity of rubor). The opposite will be true for inad-
tooth length axes between artificial teeth equately built-out lip support. The upper
in upper and lower jaws. Another factor is lip area will display a concave profile and
the conformity of the size and anatomy small pluckers will appear around the
of the jaws. A perfect match does not ex- mouth. In the front area of the lower jaw
ist and it will therefore be the task of the the displacing effect of m. mentalis will
dental technician to modify the artificial have to be considered in connection with
tooth anatomy so as to make the teeth fit the wax design in this area.
reasonably well into each other. Functional stability The complete
One of the main objectives of the dentures are surrounded by muscles,
tooth set-up is to stabilize the dentures which may be used for stabilization of the
against each other. This is achieved by dentures pending that the anatomy of the
• restoring a functional vertical dimen- vestibular and lingual surfaces (muscular
sion retention) will conform to the anatomy
• establishing stable occlusion contacts of the adjacent soft tissues. A moderate
• creating smooth sliding paths be- concave form will coexist with m. bucci-
tween teeth of the upper and lower nator. If overextended on the lingual side
dentures the tongue may displace the denture in
• arranging for simultaneous tooth con- an occlusal direction, which may also be
tacts on working and balancing sides the result of a too lingual inclination of
• securing retention and stability the posterior teeth or if these are too wide
through well-adapted dentures. in the buccal-lingual direction. A discrete
concave or straight plane will be a more
The wax-work design favourable lingual design.
The design of the buccal flanges and lin- Phonetics Enough space must be at
gual/palatal surfaces of the dentures will hand for the tongue to form the various
have impact on several functions of the syllables. Mainly the anterior-palatal re-
denture gion of the upper denture may encroach
Aesthetics The gingival margin must upon the pronunciation of particularly s
possess an even and symmetrical form. and f. Also, the wax design in the premo-
The papillae are given a convex form and lar palatal areas may be responsible for
must completely fit the proximal spaces. phonetic problems with complete den-
Preformed wax plates may be used to tures involved.

The wax set-up should be inspected residues. Check that all teeth are affixed
in the mouth of the patient when small in one half of the form. The palatal or
corrections may be performed by the den- crestal part of the gypsum model must be
tist, especially corrections that concern isolated before the acrylic processing. This
aesthetics, the extensions of the periph- can be done with a metal foil, liquid var-
eral parts of the dentures and occlusion/ nish, alginate solution or Vaseline, which
articulation. is painted over the surfaces. The gingival
parts may also be covered with some elas-
The acrylic processing tomer to prevent dental stone contamina-

tion of the acrylic. It is sometimes advis-
Investing and Pressing able to cut grooves in the basal part of the
The definitive cast is positioned in the artificial teeth to guarantee good retention
lower part of a mould, which is infilled in the acrylic.
with dental stone up to the border of the Acrylic resins can easily be mixed to
cast. When the surface has set, it will be achieve a doughy consistency and used
coated with a separating liquid or Vaseline to infill the mould. The upper and lower
to facilitate separation after the second parts of the mould are clamped together
infill of dental stone. If pressing or pour- prior to the polymerization of the acrylic
ing resin techniques are to be used wax resins. This is effectuated by placing the
sprues must be attached. For an upper mould in hot water for several hours.
denture one sprue is sufficient when di- Modern systems are designed for injection
rected against the palate whereas in the techniques by use of a polymer and mono-
lower denture two sprues will have to be mer-containing capsule. When the acrylic
attached to the dorsal extensions of the resin material has been mixed, it is pressed
dentures. The outer surface of the denture into the mould by means of air. Like in
cast may be coated with a silicone layer the aforementioned technique the flask is
investment to preserve the details of the then placed in boiling water for around 30
sculptured denture base and to minimize minutes for the polymerization process.
frustrating hours of laboratory grinding The two parts of the mould are then sepa-
and finishing work. The upper flask is rated and the denture is recovered from
mounted and filled with the second mix
of dental stone.
After complete hardening of the den-
tal stone the mould is placed in very hot
water for at least 5 minutes to soften the
base-plate and the wax. The two halves
are then separated. The base plate is
eliminated and the dental stone form is
rinsed with hot water to eliminate all wax Fig. 14.15. Upper denture after polymerisation.

the gypsum investment (Fig. 14.15).
It is recommended to mark the pros-
thesis for identification purposes. In Swe-
den this is a general recommendation,
but it may be rejected by the patient.
Grinding and polishing

After polymerisation the prosthesis must
be ground and polished on all surfaces Fig. 14.17. Upper and lower dentures after final
except the intaglio surfaces. Grinding the polishing.
outer surfaces of the dentures starts by

using carbide burs of different shapes and different grades such as pumice stone and
sizes and will be followed by rubber based chalk powder to create a glassy surface
polishing wheels and silicone points in (Fig. 14.17). It addition, it should be ascer-
some consecutive steps (Fig. 14.16A+B). tained that there are no sharp extensions
Sandpaper discs can be used in some ar- in the mucosal surfaces caused by small
eas. air bubbles in the gypsum model. Dissipa-
The final polishing is made with motion of heat must be avoided since this
tor-driven brushes and polishing paste of may distort the denture.
Time has come for the clinical try-in
A of the complete dentures, which should
be exposed to a disinfection solution
before the departure from the dental
technician laboratory. In the dental clinic
various aspects of the complete denture
will be evaluated. As an effect of the pro-
duction (in specific the acrylic process-
ing) the artificial teeth may be slightly
displaced which calls for occlusion adjust-
B ments. For the final occlusion equilibra-
tion the dentist will perform an occlusion
index in a pressure-less material and the
dentures will be sent to the dental labora-
tory.
occlusion equilibration
A final step in the rehabilitation with
Fig. 14.16. Grinding of the denture with (A) sand- removable full- and partial dentures is the
paper and (B) silicon point before final polishing. occlusion equilibration with the aim of:

• supporting and improving the stabil- to index.
ity of the denture. • Tooth contacts between the retruded
• creating smooth functional contacts position and the inter-cuspal position
between opposing teeth – natural or are adjusted if necessary (freedom in
artificial. centric or long centric).
• One of the most important issues in
The objective is to arrange for as many the occlusal equilibration is the ad-
tooth contacts between opposing jaws as justment of the tooth contacts in the
possible, which does not necessarily im- inter-cuspal position of the jaws. No
ply all contacts in all possible inter-arch interferences will be allowed. The cor-
contact positions. The methods used for rection of tooth contacts in the inter-
the occlusion equilibration vary from cuspal position infers a reduction of
intra-oral grinding-in, which is difficult premature contacts. A decision has to
due to the ever-existing potential for be made whether the reduction is to
displacement of the dentures on the sup- be concentrated to the cusp or to the
porting mucosa, to indirect adjustments fossa. If a cusp makes premature con-
performed in the dental technician labo- tact in all positions of the jaw within
ratory. A bite registration (wax or silicon the functional range, the cusp must
index) will form the basis for an adjust- be reduced. In all other situations the
ment of the contacts between opposing reduction is made in the fossa.
teeth. • By definition occlusal balance is: “a
The occlusal equilibration may be condition in which there are simultane-
subdivided into several consecutive steps, ous contacts of opposing teeth on both
which will be commented upon briefly sides of the opposing dental arches dur-
below: ing eccentric movements within the
• In the laboratory the dentures are functional range”. This is achieved by
mounted in the articulator according selective grinding of opposing teeth
MudL-RuLE: When adjusting premature contacts between the retruded and intercuspal
positions the adjustments are preferably concentrated to the mesial facets of the teeth in
the upper jaw and to the distal oriented facets of the teeth in the lower jaw.
BuLL-RuLE: When adjusting premature contacts on the the working side, the adjustments
are to be performed on the buccal cusps of the upper jaw teeth and on the lingual cusps
of the lower jaw teeth.
REVERSE BuLL-RuLE: To be used on the balancing side.
Fig. 14.18. MUDL-rule and BULL-rule.

A
Fig. 14.19. Bearing cusps of the maxillary and man-

dibular teeth.
B
until simultaneous bilateral contacts

are reached. Several grinding-in rules
exist, the most well known being the
MUDL and the BULL rules (Fig. 14.18).
• Any reduction of the vertical dimen-
sion must be avoided. This infers no
or restricted
• reduction of occlusion bearing cusps Fig. 14.20. Ideal contacts on the working-side (A)
i.e. buccal cusps of the teeth in the and an optimal relationship between the artificial
lower jaw and lingual cusps of the teeth in central occlusion (B).
teeth in the upper jaw (Fig. 14.19).
When the occlusion equilibration has
Another concern is to preserve tooth been finalized, the prosthesis is disinfect-
anatomy of the artificial teeth and also ed and can be sent to the dentist for final
preserve the aesthetic results, but without delivery to the patient.
compromising the principles for a bal-
anced articulation (Fig. 14.20A+B).
Further reading
Hayakawa I. Principles and practices of complete dentures. Quintessence Publishing Co., Ltd.
1999.
Muraoka H. Complete denture fabrication. Quintessence Publishing Co, 1989.

15
Removable partial dental prosthesis
– laboratory procedures
P E rC y m i l l E d i n g
INTRoDucTIoN. The removable partial dental prosthesis (RPdP) therapy involves several
treatment steps some of which are performed by the dentist and some by the dental techni-
cian. In order for this sequence of treatment steps to end up in an accurate and well-accepted
appliance, it is crucial to have a thorough knowledge of the various treatment phases in-
volved. The dentist and the dental technician have different treatment foci; while the dentist
focuses on biological and technical factors, the dental technician focuses on production fac-
tors, materials, detailed designing and dimensioning. In the end, however, the two foci will
merge into the same end-point; the ready-made and delivered prosthesis. The various pro-
duction phases are shown in figure 15.1.
Clinical procedures ending up Master cast production.

with a requisition to the Surveing.
laoratory. Primary impressions Final RPDP design.
and index
Waxing of the RPDP framework Duplication of the master cast

in a thermostable material
Investing.
Spruing. Clinical try-in and
Wax elimination. Jaw record registration
Casting.
Finishing of the framework Mounting in a articukator.
Tooth set-up
Clinical try-in of the wax set-up Wax-design
Aesthetic evaluation
The acrylic prossing. Delivery

Finishing/polishing.
Occlusal equilibration.
Fig. 15.1. The dark-green text-boxes refer to dental technician production phases and the light-green text-
boxes to dentist intermediate treatment phases.
237

The written instructions incisal rests as well as their locations
to the dental laboratory • retention through active and passive
– the requisition elements
The communication with the dental • stabilization through reciprocal parts
laboratory concerning the production of of the clasp system
various prosthodontic restorations is usu- • artificial teeth
ally accomplished through written in- • aesthetics through information on
struction, in which the dentist prescribes tooth colour, anatomic form and indi-
the design of removable partial dental vidual characteristics
prosthesis (RPDP). The design of the • materials to be used
RPDP is the responsibility of the dentist,
who is familiar with the intraoral condi- The dental laboratory supplies the den-
tions as well as with patient preferences. tist with printed order-forms in which
Designing a partial denture without ad- relevant information must be written
dressing the many individual factors may down. Additionally a drawing of the
lead to serious impairment of the RPDP; functional elements of the RPDP is to be
both technically and biologically. Sadly included (Fig. 15.2A+B) The document is
enough, it seems as judged from clini- to be regarded as a business contract with
cal surveys that many dentists leave the the dental laboratory and is also a legal
RPDP design work to the dental techni- document. The laboratory is compelled to
cian, which is not a good clinical practice. deliver a prosthesis corresponding to the
A RPDP requisition should include infor- instructions given – pending not other-
mation about the: wise has been agreed upon.
• denture base through the acrylic part The information to the dental labora-
covering the alveolar ridge tory can be further improved. Clinical
• type of connector images of the intraoral situation will add
• support through occlusal, lingual and valuable information to the dental tech-
Fig. 15.2A. The planned design of the RPDP. Fig. 15.2B. The ready-made RPDP according to the
instructions in the order-form.
238 Removable partial dental prosthesis – laboratory procedures

nician. Apart from the drawing of the special impression tray to be made for the
RPDP in the order-form the inclusion of final impression. A duplicate cast is prefer-
a study cast in which the various func- ably used for the impression tray fabrica-
tional elements are traced will reduce the tion.
risk of misunderstandings and faulty de-
signs. The access to a surveyor will allow Master cast production
the dentist to analyze the study cast for – surveying
a suitable path of insertion, possible un-
dercut areas for clasp retention and how Master cast production
to arrange for well-functioning guiding After the dental technician has received
planes. This will be the ideal procedure. the impressions and index of the clinical
Since not all clinicians have access to a case prepared by the dentist a gypsum
surveyor the RPDP design drawn will be master cast will be poured by the dental
descriptive only and not final as to the technician. A high quality cast is a pre-
exact location of the various functional requisite for a high quality framework.
elements. Defects in the cast will inevitably affect
the fitting surfaces of the RPDP and result
Study cast in an inferior accuracy of the framework.
Before the actual start of the RPDP fabri- A thorough inspection of the master cast
cation, the dentist will order study casts will reveal possible problem areas related
to be made from alginate impressions to the path of insertion, the support-
of the upper and lower jaws. The study ing and retentive surfaces as well as the
casts are used by the dentist for the initial available space. It may be necessary to
planning of the case, but are also used for mount the casts in an articulator e.g. in
documenting the clinical as-before situ- situations when only few teeth remain
ation (Fig. 15.3). Furthermore the study or when large occlusal rests, onlays and
casts are used to fabricate an individual/ crowns are to be included in the RPDP
design. The use of occlusal rims for the
jaw relation registration will increase the
quality and accuracy of the jaw relation
registration and will reduce the necessity
of elaborate adjustments. When the denti-
tion displays a stable occlusion an index
in intercuspal position will function satis-
factorily.
Surveying
Fig. 15.3. Initial planning on the study-cast. In order to attain the best possible func-
tion of an RPDP, the remaining teeth and
Removable partial dental prosthesis – laboratory procedures 239

edentulous areas must be analyzed for quently. Well-functioning guiding planes
retentive areas and possible obstacles for will make it easier for the patient to insert
a normal seating of the RPDP will have the RPDP.
to be identified. Visual inspection is not
good enough. For a more detailed analysis Surveying of the study-cast
a surveyor is used. In figure 15.4A the de- By inspection of the study-cast the dentist
sign of a simple but for the purpose very will get an idea of a possible path of inser-
useful surveyor is displayed. tion and what surfaces will be necessary
The model to be analyzed is affixed to adjust. In more complicated clinical
in the surveying table, which can be set situations the dental laboratory can be
in various inclinations, equivalent to of valuable assistance in determining the
various paths of insertion for the RPDP best possible path of insertion. The path
(Fig. 15.4B). Whether or not the selected of insertion should be chosen so as to:
inclination – the path of insertion – is the • Allow an easy and distinct seating of
most favourable one, can only be deter- the RPDP
mined after analysis of all structures the • Save vital tooth tissues
RPDP will come in contact with. • Secure retentive areas on the abut-
Correctly positioned and designed guid- ment teeth
ing planes are probably the most impor- • Avoid interference with undercut areas
tant single factor for a continuously well • Enable best possible aesthetic result
functioning RPDP. Inadequately attended
to, the functions of the RPDP, in specific A well functioning guiding plane must:
retention and stability, will be impaired • Be of adequate vertical extension (ap-
and technical failures will occur more fre- prox 2-4 mm)

Fig. 15.4A. A surveyor for the analyses of the Fig. 15.4B. The analyzing table for the fixation of
RPDP cast. the cast by locker-screw. By a bottom locker-screw
the cast can be angulated in any direction.

• Cover the middle third of the tooth • A non-acceptable situation will appear
surface e.g. if too extensive tooth preparation
• Be found on several teeth in contact will be necessary in order to establish
with the rigid parts of the RPDP the guiding planes or if undercut areas
• Ideally follow the local outline of the for clasp retention are too shallow or
tooth, alternatively be formed as a dis- too deep or located too close to the
tinct plane gingival margin.
• Be parallel with each other. • If no acceptable path of insertion can
be found unless gross reduction of the
The use of a surveyor is not particularly abutment teeth will have to be under-
complicated. A tentative path of inser- taken, crown therapy will probably be
tion – usually perpendicular to the oc- needed. The vertical surfaces of the
clusal plane – is selected. By this start of crown/crowns will then be adapted
the surveying all tooth surfaces as well as to a selected path of insertion (milled
other anatomic structures that will be in crowns).
contact with the rigid parts of the RPDP • If a change of the selected path of in-
are analyzed (Fig. 15.5). The extent of sertion is done, i.e. if the inclination
necessary tooth preparation is estimated. of the analyzing table has been al-
With unchanged position of the cast the tered, all surfaces previously analyzed
tooth surfaces intended for clasp reten- will have to be analyzed again.
tion will be analyzed for adequate depth • For a maximum effect of the guiding
of undercut, as well as reciprocal surfaces planes these will have to be parallel
for the position of the stabilizing parts of to each other giving the path of inser-
the clasp system tion.
As a result of the surveying the follow- • Besides the path of insertion there will
ing situations may appear: also be a potential path of dislodge-
ment acting perpendicular to the oc-
clusal table during mastication. The
zero starting inclination of the study
cast will have to be slightly altered so
as to counteract a vertical dislodge-
ment of the RPDP.
• To be able to reanalyze the model –
if necessary – the analyzing rod is
aligned along the vertical sides of the
study-cast and the direction is marked
Fig. 15.5. The surveying is started by addressing with a pencil.
all vertical surfaces that will come in contact with • With the study-cast still affixed in
the rigid parts of the RPDP. the surveyor table the surfaces to be

altered are cut by a scalpel according the dental technician for a discussion
to the orientation of the analyzing on how to solve the problem that has
rod. To be more easily observed the come up. Under no circumstances is the
adjusted surfaces in the study cast are dental technician allowed to change the
marked with a coloured pencil. original prescription without previous
contact with the dentist. General recom-
Transfer of the guiding plane mendations are available, but it must be
Usually the intraoral reproduction of the emphasized that infrequently individual
in-model-guiding-planes is performed modifications will be necessary. From a
by freehand preparation. Only very oc- dental technician perspective, however,
casionally is this done with the use of an some complementary information needs
intraoral paralleling device. to be added.
Surveing of the master cast connectors

A final surveying is undertaken, but this The exact extension of a connector must
time on the master cast, i.e. the working be specified in the order form from the
model. The cast is oriented in the direc- dentist. Factors such as metal alloy fabri-
tion of the guiding planes (Fig. 15.6A). cate, dimensions (thickness), relation to
The purpose of the surveying is now to specific anatomical structures as well as
establish the prominence line so as to prescribed surface characteristics must be
give the retentive and reciprocal clas- defined. The dentist will be fully respon-
parms a correct position on the abutment sible for the prosthetic appliance installed
teeth (Fig. 15.6B-E). in the mouth of the patient.
For the documentation of the position
of the prominence line, the analyzing
Maxillary major connectors
rod is exchanged with a carbon marker.
Sometimes the depth of the undercut area Complete palatal coverage major
intended for the active clasp arm is mea- connector (Palatal plate)
sured. This may be performed with a very This connector is the most frequently
simple depth indicator or more sophisti- used and will allow optimal load-transfer
cated electronic devices. to the palate. It can be made very thin
(0.5mm) and still remain rigid – if pro-
Final RPDP design duced in a cobalt-chromium alloy (Fig.
The RPDP-design will be finalized pri- 15.7). In other selected alloys, for example
marily according to the requisition from titanium, the thickness will have to be
the dentist but adjusted in detail by the increased. The extension of the connec-
dental technician. If for some reason the tor will vary with the extent of tooth loss
RPDP prescription cannot be followed areas. The posterior border must not in-
the dentist will have to be contacted by terfere with the soft palate.

A B

Fig. 15.6A. An efficient guiding plane has been cre- Fig. 15.6B. The surveying of tooth surfaces in-
ated on the mesial surface of the first maxillary mo- tended for clasp arm retention (red) and reciprocal
lar. The contact between the RPDP framework and support (blue). Notice that the position of the re-
this plane will guide the prosthesis safely in position. ciprocal support is not functioning.
c D

Fig. 15.6C. L1-L2 vertical displacement must be
congruent with the transport of the flexible clasp
arm B1-B2. Fig. 15.6D. One purpose of the surveying of the
master cast is to evaluate the position of retentive
E clasp arm and reciprocal supporting structure.
Fig. 15.6E. The vertical lingual parts of the milled

crown will determine the path of insertion of the
RPDP.

Single anterior or posterior palatal plate
This connector has limited load transfer
to the supporting tissues and is therefore
used in clinical situations where only few
teeth are missing and no posterior exten-
sion saddles are included. The width of
the plate is usually 8-10 mm (Fig. 15.8A+B)
Fenestrated plate
The outline of this connector is square
Fig. 15.7. A palatal plate type of connector.
with the central part uncovered. The
lateral parts are situated parallel to the
orientation of the arches and may not
A extend closer to the gingival margin than
5-6 mm. The width of the plates is usu-
ally 8-10 mm.
Mandibular major connectors

Lingual bar
This connector will be located in between
the floor of the mouth and the gingival
margin of the teeth, but no closer than 5
mm from the gingival margin (Fig. 15.9).
The cross section will be pear shaped
Fig. 15.8A. Single anterior palatal bar connector. with the wider part oriented downwards.
Fig. 15.8B. Single posterior palatal bar connector. Fig. 15.9. A mandibular lingual bar connector.

The width of the bar is usually 3-4 mm cuts that will complicate the seating of
and the thickness individually adapted. the RPDP. This has to be observed by the
The longer the bar, the thicker the cross- dental technician. The dental bar is espe-
section must be. The bar must also be cially appropriate in clinical situations
relieved versus the soft tissues beneath, where a single tooth is missing or is likely
in specific at a more horizontally aligned to be lost, since an artificial tooth may
lingual part of the mandibular alveolar easily be affixed to the rigid dental bar. At
process. short clinical crowns this type of major
connector is not suitable.
Dental bar
This is a connector that is located on the Lingual – dental bar
lingual surfaces of the mandibular teeth A combined lingual and dental bar may
and conforms to the lingual anatomy sometimes be used. The lingual bar con-
of the teeth it covers (Fig. 15.10A+B). It stitutes the major connector and the den-
functions as connector as well as indirect tal bar an additional connector that will
retainer. Teeth that are not straight, but also function as an indirect retainer.
rather obliquely aligned may form under-
Lingual plate
This plate is sparingly used in Scandina-
A via due to its hygienic impairment forms
a continuous plate between a dental bar
and a lingual bar and has a scalloped lin-
gual contour.
Facial bar
The connector, seldomly used, has the de-
sign of a lingual bar but is situated on the
labial side of the mandibular teeth due to
the presence of lingual obstructions such
as extensively lingually aligned teeth or
B large torus mandibularis/lingualis.
Retainers
Retainers are functional elements that
counteract the effects of various displac-
ing forces acting upon the RPDP. They
constitute a group of elements dominated
Fig. 15.10. Lower jaw RPDP with a dental bar con- by clasps – circumferential and of bar-
nector. type, but other types of retainers also

exist such as attachments. The active and proper care must be taken not to damage
retentive clasp-arm constitutes one unit the wire material. Too extensive bending
in a four-unit assembly, the other being will impair the mechanical strength of
the minor connector, the occlusal/incisal/ the wire by extensive cold working, which
lingual rest and the rigid reciprocal clasp causes the material to re-crystallize. The
arm. Retentive clasps differ in:
• material (wrought gold, wrought steel,
cast Co-Cr)
• diameter
• length of the clasp arm

• form (round or oval transverse square)

• resiliency (easily adjustable or with
restricted adjustable properties)
• design (circumferential or bar clasp Variables Effects
type) Force F Increased force =
increased deflec-
The most frequently used clasp system is tion
the circumferential clasp system advocat- Length of L The longer the
ing wrought gold (Fig. 15.11). An undercut the beam higher deflec-
depth of 0.20 mm will be sufficient for a tion
retentive clasp arm of this material. The
Modules af E Higher modukus
only flexible part is the tip of the clasp
elasticity value will lower
arm. The retentive clasp arm is activated
the flexibility
(deformed) when vertical forces are try-
Width of W Increased width
ing to displace the RPDP from its original
the beam will lower the
position and by that counteract the dis-
deflection
placing forces.
Bending the wrought wire to form a Thickness of T Increasing the
clasp arm is technically challenging and the beam cross-sectional
area will strongly
reduce the de-
flection of the
beam
design fac- C Higher deflec-

tor tion when the
beam is only af-
Fig. 15.11. Examples of various designs of wire fixed on one side
clasps – circumferential on 26 and a bar clasp de-
sign on 23. Fig. 15.12. Beam-deflection computation formula.

clasp arm must have a correct relation have to be counteracted on the opposite
to the prominence line and be oriented side by a rigid, passive reciprocal part of
in such a way that the outer third of the the clasp system (Fig. 15.6C). The posi-
clasp arm will be positioned in the un- tion of the active and non-active parts of
dercut area and the remaining part of the the clasp system must be coordinated or
clasp arm will cross the prominence line the tooth will be subjected to horizontal/
and enter the more coronal zoon. The oblique displacing forces, which may
flexibility of a clasp arm is an important eventually force the tooth out of its origi-
property and is determined by several nal position. The surveying of the study
inter-related factors, shown in the formula cast will supply information on the rela-
below. The formula was originally used in tion and on the necessity of adjusting the
technology for beam-deflection computa- lingual surface by grinding. This must be
tions (Fig. 15.12). done before the final impression is taken.
The flexible or active clasp arm will Wire clasps can be attached to the
framework either by embedding the wire
into the acrylic base material or by solder-
A ing it to the framework (Fig. 15.13A+B).
The soldering is preferably located at a
distance from the flexible part of the clasp
arm, since otherwise the heat dissipated
during the soldering may cause a re-
crystallization of the microstructure and
reduce both the mechanical strength and
the flexible properties of the wire. The
two currently used soldering techniques
are electro-soldering and laser soldering.
Fig. 15.13A. Wire gold clasps affixed to the frame- Cast clasps are less flexible and can
work with acrylic resin material. be used in situations where the undercut
depth is very small. They are less suitable
for activation due to their high stiffness
B and typical microstructure. If a cast clasp
is activated by mechanical deformation
material fracture may easily occur.
Tooth coloured material of high
strength acrylic resin (flexible ethyl vinyl
acetate) is available if highly aesthetic
clasp arm material is required, but is still
Fig. 15.13B. Gold wire clasp soldered to the Co/Cr a rather uncommon clasp material. Even
framework. though the use of clasp-arms dominates

as retentive elements for the RPDP, inter- metal substructure to be enclosed by the
nal or external precision attachments may acrylic material.
form an alternative. A multitude of preci-
sion attachment designs are available but Duplication
it is beyond the scope of this textbook. The duplication of the master model into
a thermostable, refractory model, is made
Mastercast duplication with various elastic materials – either
Before duplicating the stone cast some ad- colloid- or silicon-based. Any inexactness
ditional measures have to be taken. introduced during this phase will have
implications for the RPDP accuracy, since
Blocking out the waxing of the framework will be per-
Any remaining undercut area located cer- formed directly on this model.
vically to the guiding plane and crossed
by rigid parts of the denture will have Waxing
to be blocked out by means of hard wax. Preformed and prefabricated plastic pat-
The applied wax should not be allowed to terns are universally used for the frame-
extend outside the surface of the guiding work wax-up. This improves work-flow,
plane. Preferably the wax can be trimmed precision and accuracy. The more me-
by use of a wax spatula included in the ticulously this is done the more accurate
surveyor accessories. will be the result. The plastic patterns are
Depending on the inclination of the adapted to the refractory model and may,
path of insertion undercut areas may if necessary, be modified with dental hard
arise at various locations along the facial wax (Fig. 15.14)
or lingual surfaces of the alveolar ridge
both in the anterior and posterior regions. Fabrication of the
For the blocking-out measures, oil-based frame-work
modelling clay is frequently used.
Spruing
Relieving The molten metal is flushed into the
Relieving of the master cast is performed mould through the main sprue channel
to avoid tissue impingement beneath con- and further distributed through the ac-
nectors crossing soft tissue areas, i.e. the cessory sprue channels until a complete
lingual bar. Due to RPDP movements dur- infill of the mould is accomplished. The
ing mastication, in specific the tendency diameter, length, direction and attach-
to anterior and posterior rotation, the tis- ment to the object to be cast are all of ma-
sues may be locally strongly compressed jor importance for reaching a high qual-
resulting in pain and tissue destruction. ity casting, i.e. distinctly reproduced and
By use of a sheet of wax a relief is created with a dense non-porous microstructure.
beneath the saddles so as to allow the Additionally the surface of the casting

remains e.g. in the sprue channels, a refill
of metal into the porous areas may take
place.
Investing
The investment material used must con-
form to the shrinkage value of the alloy
or else framework misfit will follow. Due
to this, the melting temperature of the
Fig. 15.14. The wax-up of the RPDP displays the alloy has to be taken into consideration
palatal plate connector, preformed retention grid as well. Cobalt-chromium alloys have
and lingual parts of the circumferential clasp sys- very high melting temperature (1300°C-
tem. 1400°C), which calls for a specific invest-
ment material containing quartz and
should be smooth so as to avoid lengthy mixed with an ethyl silicate binder. The
and elaborate finishing sequences. powder/liquid proportions regulate the
The diameter of the sprue channels thermal expansion and will influence the
may not be too small since otherwise the final accuracy of the metal framework.
infill of the mould will be delayed (Fig. The refractory model with its wax-plastic
15.15). During solidification the shrinkage framework skeleton and with the sprue
of the metal alloy will result in internal system affixed to it is oriented in a metal
areas with porosities. If molten metal still ring (Fig. 15.16). The mixed investment
material is applied to the wax-construc-
tion by means of a brush. This has to be
done with great care since otherwise sur-
face porosities and/or malformed casting
Fig. 15.15. Sprue channels attached to the wax Fig. 15.16. Sprue channels with the conical sprue
framework. former. Plastic-ring for the investment of the wax
framework.

A
Fig. 15.18A. RPDP – cast during scanning.
Fig. 15.17. Cast frameworks after the elimination Fig. 15.18B. The virtual RPDP on the computer
of the investment material. screen.
may follow. Finally the metal-ring is com- casting

pletely filled with the investment material Several casting techniques are available
and is allowed to set. and the contemporary method of choice
is the induction casting technique, in
Wax elimination which the heating is based on electric
In daily language wax elimination is des- currents from a magnetic field, super-
ignated “ burnout”. The mould should vised by an electronic sensor. When the
be placed in a cold burnout oven with set temperature and correct viscosity of
the sprue opening down, after which the melt is reached, the casting process is
the temperature is raised until the final initiated (Fig. 15.17).
temperature is reached. Decomposed wax
and plastic material will then more easily Alternative production
escape from the interior of the mould. techniques
The traditional product line, which in-
cludes all the various steps described, is

laborious and time consuming. Due to the
very complex shape of an RPDP it has up A
to now not been possible to use CAD-CAM

technology for design and production of
RPDP frameworks. However, the continu-
ous development of computer-assisted
production methods has resulted in a tech-
nique, which might be looked upon as a
breakthrough. According to this, the mas-
ter cast is scanned by white light and a vir-
tual model is created in the computer (Fig.
15.18A+B). The framework is designed in
the computer, which controls the produc-
tion of a resin framework, which is sprued,
invested and cast according to traditional
techniques. At present this technique does Fig. 15.19A. Grinding and polishing of the frame-
not result in a ready-made metal alloy work.
framework. In the fully developed form
the rapid prototyping machine used will B
allow a direct production of the metal
alloy framework. Recently (2010) another
step has been taken towards CAD-CAM
production of RPDP. After scanning of the
master cast the path of insertion is elec-
tronically determined and altered until the
survey lines are satisfactory. The design
phase comprises three steps: deciding the
contour of the components, building the
tissue surface and creating the polished
Fig. 15.19B. Electro-polished framework seated on
surfaces. For the production of the metal
the master cast.
alloy framework, selective laser melting
(SLM) data are stored as stereolithography
(STL) files. Further development work still nating the investment material from the
has to be done before the CAD-CAM tech- casting, after which a preliminary exami-
nique may be universally used. nation of the framework will be possible.
Before trying-in the framework on the
Finishing and polishing master cast, a correction of the borders is
Post casting the mould is allowed to cool done followed by finishing and polishing
off and the casting is recovered by elimi- of the framework (Fig. 15.19A). This must

be done with great caution in specific jaw relation registration together with in-
when it comes to the intaglio surfaces. formation of tooth colour and tooth form
Many polishing systems are available and is needed for the tooth set-up.
it is often a matter of personal “taste”
what system is preferred. Important is, Tooth set-up
however, to follow the various steps in Mounting of the upper- and lower jaw
the finishing and polishing procedure models will be made according to the jaw
systematically. The final polishing is relation registration (Fig. 15.21). In most
achieved by use of an electronic strip- cases an occludator is not good enough
ping technique named electro-polishing, since it is important to monitor also the
which will result in a very smooth surface tooth-contacts in lateral and protrusive
(Fig. 15.19B). positions of the mandible.
The principles for the set-up of the
clinical try-in artificial teeth follows known principles
The framework will be sent to the dentist from the complete denture technique.
for try-in, examining the precision of fit, However, one specific problem with
the stability (resistance) and the overall RPDPs is the difficulty to manage the
quality of the casting. The insertion and natural antagonist teeth due to their
removal of the framework is tested as well varying positions in the tooth arch and
as the retention. Frequently dental wax on the occlusal anatomy that is not con-
has been added to the saddles forming formed to that of the artificial teeth. One
an occlusion rim for the jaw relation reg- very important measure is the occlusal
istration (Fig. 15.20). It should be noted equilibration, which facilitates the dental
that the wax sometimes might obstruct a technician’s work and enhances the func-
correct seating of the prosthesis, in which tional stability of the RPDP. This should
case parts or all of it has to be removed. have been performed at an earlier stage
The framework with trimmed rims and – preferebly before the impression for the
Fig. 15.20. Build-up of wax-rims for the jaw rela- Fig. 15.21. Mounting of the casts in the articulator
tion registration. ahead of the set-up of artificial teeth.

framework production was taken. The principles for the wax design con-
The artificial teeth are made of strongly forms to those in complete denture tech-
cross-linked acrylic except for the base, nique. Whereas the complete denture has
which is to be anchored in the acrylic a base-plate that covers all the supporting
resin of the saddles. If too heavily reduced tissues, the situation in RPDP therapy is
by grinding (e.g. due to shortage of space) more variable. In free-end saddle prosthe-
the less cross-linked base part will be sis a saddle is mandatory. In limited eden-
eliminated with the result of an impaired tulous areas contained between natural
retention. To reduce loading outside the teeth or with a natural tooth mesial to
primary supporting parts of the alveolar the edentulous area the vestibular part of
ridges in the posterior regions it is recom- the saddle may be omitted for aesthetic
mended to use artificial teeth that are reasons. The first artificial tooth behind
smaller in the bucco-lingual dimension the residual set of natural teeth can be
than natural teeth. set-up with a pontic mucosal contact,
Sometimes it is necessary for the den- which will benefit the aesthetic result.
tal technician to adjust the antagonist The design of the gingival parts is
natural teeth by grinding, either to level- more easily sculptured in wax than
out the plane of occlusion or to create ground in acrylic. The finish line of the
some extra space for the artificial teeth. acrylic bases is made in some excess so as
It is strongly recommendable for the den- to allow a finishing after the processing of
tal technician to contact the dentist and the acrylic base. This is also true for areas
discuss the matter. It is not self-evident where the metal framework meets the
that a corrective grinding can always be acrylic material. The outline of the gin-
performed either due to the existence of gival margin must be adjusted according
earlier restorations or due to the attitude to the ideal form and the artificial teeth
of the patient versus grinding on intact freed from wax to let the full anatomy of
natural teeth. the teeth be exposed. The buccal and lin-
When it comes to the balance of gual surfaces of the saddles are designed,
functional contacts in occlusion and in already in trimming the occlusion rims,
articulation the emphasis will be to create to conform to the anatomy of the muscles
a stable occlusion whereas the contacts in in the area. On the buccal side a concave
laterotrusion and protrusion will be more profile is best adapted to the muscles
controlled by the natural teeth. In free- such as m. buccinators with its horizontal
end saddle RPDPs it is advisable to omit muscle-fibre orientation. Also lingually,
the set-up of the second molar teeth – if a concave profile better conforms to the
not needed for antagonist contact – and anatomic form of the tongue.
also to relieve the first molar teeth of too Before the final step in the RPDP pro-
heavy distal loading, thereby reducing duction the dentist and the patient will
the displacement of the free-end saddle. have the opportunity to examine the re-

sult of the dental technician work. Since investment surface has been smoothened
the artificial teeth are fixed in wax only, as well as covered with a separator to fa-
the patient is recommended to rinse the cilitate the separation of the upper and
mouth with cold water repeatedly during lower halves of the flask. The isolation
the test-period or the wax will turn very of the wax surface used to be performed
soft. The artificial teeth are then likely with tinfoil, which is still regarded as
to be displaced. As a result of this try-in the optimal method. However, since this
the dentist may wish to have corrections method is quite laborious, simpler and
performed. If they are substantial another faster application of a resinous liquid has
try-in is recommended otherwise the come to dominate.
RPDP can be made ready in the dental The upper half of the flask is attached
technician laboratory. and completely filled-up with gypsum.
After setting the two halves are separated
The acrylic processing – the artificial teeth being fixed in the up-
The replacement of the wax base of the per part and the master cast mucosal side
RPDP by acrylic resin involves several exposed (after eliminating the wax) in
treatment steps that may either cause the lower half. The acrylic resin material
considerable extra work or make the fi- will then be loaded into the flask either as
nal steps in the production line proceed dough, or in the form of a viscous liquid,
smoothly (Fig. 15.22). the latter of the two being the newer and
Initially the master cast with the increasingly used. Exposed to a tempera-
RPDP included will be invested in the ture increase the acrylic resin material
lower half of a flask. Only the artificial will polymerize whereafter the RPDP is
teeth and the wax are exposed, and the recovered by deflasking.
Fig. 15.22. The artificial teeth are affixed in acryl- Fig. 15.23. The ready-made RPDP on the working
ic resin material. model.

If the waxwork has received proper at-
tention earlier the number of adjustments A
will be few. The acrylic and metal surfaces
are finished and polished using grinding
material with successively finer grit-sizes
(Fig. 15.23). Before RPDP delivery to the
dentist the denture is decontaminated in
Fig. 15.24A. Interim RPDP with inadequate func-
a disinfection solution.
tion due to loss of occlusal contact and risk for
After visual inspection, the ready-
gingival trauma from the buccal clasp.
made RPDP is tried-in in situ, where
precision of fit to the supporting teeth,
stability, retention, and aesthetics are B
evaluated according to the dentists´ pro-
tocol. Tooth contacts in occlusion are
also analyzed and corrected if necessary.
The dentist may adjust smaller deviations
intra-orally or, if more extensive adjust-
ments are needed, refer these corrections
to the dental technician laboratory. If the
occlusion equilibration is to be performed
by the dental technician a new index will Fig. 15.24B. Occlusal aspect of the interim RPDP
be needed as well as a new stone model display a lack of occlusal support.
onto which the RPDP is oriented. This is
accompliced by lifting out the RPDP in an
alginate impression. c
Interim removable partial

dental prosthesis
Interim RPDPs are to be used for a shorter
period of time. As a short time solution
the interim partial denture has a simpler
design than RPDPs for permanent use.
This implies the use of simpler materi-
als and production techniques, but not
a departure from basic functional quali- Fig. 15.24C. Interim RPDP with Adams clasp re-
ties. If so, the interim RPDP will cause tentive device.
impaired function and possibly also af-
fect both hard and soft tissues in contact
with the prosthesis, thus creating a more

complicated clinical situation than before are attached – the spoon denture (Fig.
the interim prosthesis was inserted (Fig. 15.25). No specific retentive facilities are
15.24A+B) included. The retention and stability of
Important design factors for interim as the spoon denture is achieved by the
well as for permanent RPDPs are the load direct contact between the periphery of
transfer to the remaining teeth, the reten- the base-plate and the lingual/palatinal
tion and the stabilization of the RPDP surfaces of the remaining teeth and the
relative functional forces. build-up of a transient vacuum between
Retentive clasp arms are usually fabri- the mucosal support and the base-plate
cated from a wrought steel thread in the of the RPDP. They are most frequently
form of a traditional circumferential clasp used in clinical cases where the patient is
arm. By use of an Adams clasp unit (Fig. awaiting for example installed implants
15.24C) good retention, tooth support to osseo-integrate. The spoon denture
and patient acceptance will be reached. represents a non-complicated and non-
If the intermediate RPDP is expected expensive method.
to function for a longer period of time,
greater effort must be put into the plan- Relining of a RPDP
ning of the design. Ideally the RPDP – technical procedures
should be dentate supported relieving By relining is understood the procedure
underlying soft tissues and establish func- at which the accuracy of the fit of the
tional retention and stability by clasp- RPDP to the supporting mucosal surfaces
arm retention. is improved. Even though both upper and
The simplest interim partial denture lower RPDPs can be relined the procedure
is the one with a base-plate to which one is more frequent in the lower jaw and in
or two denture teeth replacing lost teeth specific in free-end saddle cases.
After the impression of the extension
saddle areas by means of a silicon impres-
sion material, the RPDP is lifted out in an
alginate impression (Fig. 13.3). Before this
an index is taken by means of a pressure-
less material. A gypsum cast is produced
and the RPDP is prepared for the relining
procedure, which involves removal of the
impression material as well as removal
of the surface acrylic layer on the muco-
sal side of the saddles through grinding.
Any undercut areas not previously elimi-
nated will also have to be removed. The
15.25. Interim spoon denture. acrylic resin material is mixed to form a

paste, which is dispensed in the saddles, resin. Infrequently the gold- or steel clasp
after which the upper and lower casts arm is soldered to the metal framework.
are assembled and axially loaded. Excess This, however, means a more complicated
acrylic resin material is removed and the technical procedure.
polymerisation of the relining material
is accomplished in a pressure vessel at Fracture of the metal
increased temperature and pressure. After framework
a final finishing of external surfaces the Fracture of a metal framework e.g. a major
relined RPDP is delivered to the dental or a minor connector is often a compli-
office. cated repair since even small discrepan-
cies will lead to an unacceptable degree
Repair of RPDP of misfit. Unless very favourable condi-
Occasionally an RPDP may be subject to tions exist, a revision involving a new
failure, which may be of various origins processed RPDP is a better choice than
and have various effects and call for vari- a repair. If the fractured parts display a
ous solutions. Some of the most common perfect fit the dental technician will affix
RPDP failures will be commented on in them to each other, after which a gypsum
the following text. or dental stone cast is fabricated. Solder-
ing or welding is used for the process of
Loss of an artificial tooth reassembling the fractured sections. If,
A missing artificial tooth is easily re- however, the fractured surfaces do not fit
solved. The dentist will take an impres- exactly to each other the repair will be
sion with the RPDP in situ and a gypsum much more difficult to perform and the
cast is produced at the dental technician result more uncertain to predict. In a case
laboratory. An additional artificial tooth like this the dentist will have to orient the
is affixed by use of cold-curing acrylic two segments intra-orally and affix them
resin, after having removed the previous by use of a special type of acrylic resin,
most superficial layer by grinding. after which the RPDP is lifted out in a low
viscosity silicon impression material. A
Fracture of a clasp arm working-cast is produced in dental stone
Resolving a clasp arm failure can be and the repair is conducted by the use of
more or less complicated. As mentioned soldering or welding technique.
above, a gypsum cast is produced from
an impression. If a cast clasp arm is to Fracture of the acrylic base
be replaced it cannot be replaced with Fracture of the acrylic base e.g. the vesti-
an identical one. Either a gold- or a steel bular plate is resolved after having re-
clasp arm is formed by the dental techni- ceived an impression from the dentist
cian and is usually affixed to the near-by including the RPDP. A dental gypsum or
acrylic base by use of cold curing acrylic stone cast is produced. After application

of a separating medium the missing part will fit to the tooth preparation as well
is rebuilt by use of cold curing acrylic as to the existing metal framework. After
resin. Sometimes the RPDP will have to completed preparation an impression is
be relined in a second treatment phase. taken with the RPDP in situ. A cast in
dental stone is produced and the artificial
Abutment tooth fracture crown will be formed in wax and cast.
A fracture of an existing abutment tooth, The patient will have to be left without
which functions as occlusal support and the RPDP during the fabrication of a new
as a direct retainer will implicate the crown.
fabrication of an artificial crown which

Index
A cohesion 133
acrylic RPDP 176 condylar process 33
adhesion 133 condyle 34
aesthetics 149, 232 coronoid process 46
A-line 160 crista flaccida 72, 147
altered cast 207
angular chelitis 80 D
aponeurosis 41 dental bar 194
articular disc 33 denture base 169
articular tubercle 33 denture corpus 169
articulator 121, 159, 227 diabetes 64
attachment 192 diagnostics 101, 108
disease 101
B
bar-clasp 191 E
beam-deflection 246 effectiveness 97
biofilm 76 efficacy 96
body mass index 61 evidence based prosthodontics 85
bone cells 52 examination 101
bone loss 58
bone modelling 54 F
bone remodelling 54, 57 fixed partial dental prosthesis 177
bone resorption 53, 54 flabby ridge 72, 147
Bonwill clasp 192 fovea mento-labialis 150
border moulding 144, 146 framework 169, 170, 176, 210, 248
buccinator muscle 45 freedom in centric 157
burning mouth syndrome 83

G
C genial tubercle 41
candida 74, 75, 79 genioglossus muscle 41
Candida albicans 75, 77 guiding planes 204
caruncula 48
H
casting 250
hamular notch 47
centric relation 128
hard palate 46
circumferential clasp 191
hyoglossus muscle 48
clasp 188
hyoid bone 41
Index 259

hyperplasia 82 minor connector 169
hyposalivation 66 modiolus 39
muscular contact position 156
I mylohyoid muscle 41
I-BAR clasp 202 mylohyoid ridge 48
illness 101
immediate denture 163 N
impression 140, 146, 164, 206-207, 221 nutrition 61, 65
incisive papilla 46 nutritional assessments 62
inflammation 57, 75
intercuspal position 129 O
interim prosthesis 255 occlusal plane 152
interview 102-103, 180 occlusion rim 148, 226
investing 233, 249 orbicularis oris 37

orbicularis oris muscle 43
J oro-facial muscles 37
jaw relation 121, 124, 128, 148, 209 oropharyngeal isthmus 45
journal 180 osteoblast 52
osteoclast 52
K osteocytes 52
Kennedy Class 201, 203 osteoporosis 56, 62
Kennedy classification 170
P
L palatal bar 198
lingual bar 194, 244 palatal plate 197, 242
long centric 157 palatine glands 48
palatine raphe 46
M
palatine ruga 47
major connector 169, 194, 197, 242, 244
palatoglossus muscle 41
malabsorption 64
palatopharyngeus muscle 41
mandibular fossa 34
parotid gland 45
mandibular ramus 36
parotid papilla 46
masseter muscle 35
path of placement 187
master cast 239, 242
philtrum 45
maximal intercuspal contacts 156
phonetics 155, 232
maximal intercuspal position 129
plaque 76, 175, 180
mental foramen 45
preprosthetic surgery 138
mentalis muscle 37, 39
pressing 233
mental spine 41
prognosis 89
mentolabial sulcus 45
prognosis based prosthodontics 85
260 Index

prognostic factor 85, 88 surveyor 186
pterygoid muscle 34, 35
pterygoid hamulus 48 T
taste 24
Q tempomandibular joint 33
quality of life 26 temporalis muscle 35-36
Thielmann´s formula 229
R torus palatinus 46
rebase 220 traumatic ulcers 81
reline 220, 256 treatment plan 112, 114
resorption 70 treatment planning 180
rest position 154
rest, proximal plate 202 U
rest space 154 uvula 41
retaining component 169, 186
retention 133-134, 137 V
retentive fulcrum line 199 veli palatini 41
retromolar pad 46 vermillion border 44
retromolar triangle 46 vermillion zone 44
retruded contact position 128

W
retruded position 128, 156-157
waxing 248
risk factor 85, 88
X
S
xerostomia 62
saliva 107, 134
shortened dental arch 177 Y
soft palate 46 yeast 77
speech problems 27, 28
spruing 248 Z
stability 137 zygomatic bone 36
stabilizing component 170, 193
stomatitis 74, 79
stromal cells 52
study cast 181, 239
sublingual bar 194
sublingual fold 48
sublingual glands 48
submandibular glands 48
supporting components 169, 183
surveying 239, 242
Index 261

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Removable_Prosthodontics_mat_1opl_lh.indd 1 11/3/11 8:47 AM

MunkSGA ARd dAnMARk

Removable_Prosthodontics_mat_1opl_lh.indd 3 11/3/11 8:47 AM

Publishing editor: Britta Østergaard

Layout and typesetting: Carsten Valentin

This publication may only be reproduced in accordance with agreement

Professor, DDS, PhD

Senior lecturer, DDS, PhD University lecturer, DDS

Professor, DDS, PhD Assistant professor, DDS, MSc

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2 Anatomy of the oral cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

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4 Nutrition in old age with special regard to dentition . . . . . . . . . . . . . . 61

5 Denture-induced sequelae in oral tissues . . . . . . . . . . . . . . . . . . . . . 69

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6 Prognosis and evidence based prosthodontics . . . . . . . . . . . . . . . . . . 85

7 Examination and diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

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8 Treatment planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

9 Jaw relation registration and articulators . . . . . . . . . . . . . . . . . . . . 121

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10 Retention of complete dentures . . . . . . . . . . . . . . . . . . . . . . . . . 133

11 Removable complete dental prosthesis – clinical procedures . . . . . . . . 139

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12 Removable partial dental prosthesis – clinical procedures . . . . . . . . . 169

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13 Relining and rebasing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

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14 Removable complete dental prosthesis – laboratory procedures. . . . . . 225

15 Removable partial dental prosthesis – laboratory procedures . . . . . . . 237

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Prevalence of removable because prevalence data change very rap-

prostheses idly, results cannot readily be compared if

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Tempomandibular joint ten patients adapt with little consequence

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Fig. 2.1. Mandible A. lateral view B. medial view.

34 Anatomy of the oral cavity

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Fig. 2.3. Muscles of mastication.

Anatomy of the oral cavity 35

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Temporalis Temporal bone and Coronoid process of Elvation and retru-

Lateral pterygoid Capsule and articular Acting bilaterally;

Table 2.1. Masticatory muscles.

36 Anatomy of the oral cavity

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Zygomaticus minor Levator anguli oris