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MUST University Faculty of Dentistry Department of Prosthodontic

Principles of

REMOVABLE COMPLETE PROSTHODONTICS Advanced clinical course
(502)

By

Prof. Dr. Amal F. Kaddah
Professor &Chairman, Department of Prosthodontics Faculty of Dentistry Misr University for Science and Technology

AMAL F. KADDAH

Principles of

REMOVABLE COMPLETE PROSTHODONTICS Advanced clinical course
(502)

2007-2008

Contributors
MEMBERS OF PROSTHODONTIC DEPARTMENT

Prof. Dr. Amal Kaddah Prof. Dr. Yusr Omar Mady Dr. Iman Rostom. Dr. Fardous Dr. Mostafa Dr. Eatemad Taha Rekaby.

Fathy Kaddah 1914 . an honored clinician and a superb teacher.Dr. He enriched my life by his kindness. patience and respected memory .1967 A great father.

Dedicated to My daughters who gave a meaning to my life .

I would like to express my heartfelt thanks and sincere appreciation to my husband Prof. George and Dr. Amal Kaddah. Fardous . I owe her a sincere appreciation and due thanks for her human concern. without her support. . Essam El Ghamrawy for his immeasurable support and encouragement for making facilities possible to carry my work forward. I wish also to acknowledge all the members of the staff of my department who have made many helpful suggestions for improvements and particularly to Dr. Dr. I am deeply grateful to Professor Dr.Acknowledgment First of all I would like to thank God who paved the way and only by his will every thing can be achieved. Amina Ads. publishers. My thanks are also to all professors. and continuous encouragement. and editors for their permissions to utilize passages and illustrations from their books and papers. I would like to express my thanks. Dr. Khaled El Toukhy for his kind appreciation and superb veneration that have been of great assistance to me in the preparation of this work . I will remain indebted to him and always remember his superb cooperation in the development of this work. the completion of this work would have been impossible. Without his infinite patience and understanding for the time and effort required this book wouldn’t have been produced. Words are not enough to express how deeply I am grateful to Prof. deepest respect and sincere gratitude to Dr. Sahar Khalaf who have assisted in proof reading the manuscript and for their constructive suggestions and helpful concern which have been of great values to this work. Dr. Kaddah. great devotion. Adel Abdel Hakeem for his cooperative assistant and for scarifying much of his time for pre-editing the manuscript.

In such instances. localized severe areas of resorption occur at a more rapid rate than the overlying soft tissues resulting in redundant.com The main problems associated with improper denture use are hypertrophy and inflammation of the basal seat mucosa (Flabby ridges).CHAPTE I MANAGEMENT OF FLABBY RIDGES MANAGEMENT OF FLABBY RIDGES Egypt Dental Online Community www. It is usually reversible and will resolve when the source of trauma is removed. Hyperplasia: It is the abnormal multiplication or increase in the number of normal cells in normal arrangement in tissue. This also occurs if a mandibular partial denture is present but no longer provides for posterior occlusal support due to tissue changes (Fig. caused by an increase in volume but not in number of tissue elements. 7 . Fibrous hyperplasia of the mucosa is irreversible and necessitates surgical removal (Fig. Flabby ridge tissues are commonly found at the maxillary anterior region and are usually associated with a maxillary complete denture opposing natural mandibular anterior teeth without posterior replacements. The management of hypertrophic mucosal tissue or flabby ridges could be achieved by rehabilitation of the abused oral tissues. Hypertrophy of the mucosa: It is a bulk of tissue beyond normal size.egydental.1-1: 1-6). easily displaced "Flabby" residual ridge.1-7).

5.Load concentration on the anterior segment of the ridge as a result of decreased vertical dimension accompanying occlusal wear. .1-7).Long denture use without serviceability i.CHAPTE I MANAGEMENT OF FLABBY RIDGES Forms of hyperplasia and Location of Flabby Tissue . 6.1-5. 1-2). occlusal disharmony and traumatic occlusion.Over-eruption of natural teeth against edentulous span. Causes: Abused oral mucosal tissues covering the denture bearing area may be related to any of the following conditions: 1.1-8). . 7.1-1. 1-8). 2. . 8 .e.Dentures constructed with anterior porcelain teeth and posterior resin teeth.1-3.Posterior segment of mandibular ridge.Most common: Anterior segment of maxillary and mandibular ridges (Fig.Not removing denture during night to allow the basal seat mucosa to regain its resting form.The lesion may be localized. 3.Complete maxillary denture opposing natural mandibular anterior teeth and partial denture (Fig. without relining or rebasing of the dentures when indicated (Fig.Single or multiple flaps or folds of fibrous tissue related to the border of a denture (Fig. or generalized over the entire ridge crest (Fig. 4.Badly constructed dentures such as loose ill-fitting dentures as well as dentures with wrong centric occluding relation. 1-6).

or generalized over the entire ridge crest.CHAPTE I MANAGEMENT OF FLABBY RIDGES Fig.1-5. Fig. 1-6: The lesion may be localized.1-1: flabby ridge Fig.1-2 hypertrophied mucosa Fig. 9 . Figs.1-7: Complete maxillary denture opposing natural mandibular anterior teeth and partial denture.1-8: The primary cause of this condition is over extension of denture border which may be the result of sinking of the denture. Fig.1-4: epulis fissuratum.1-3: hyperplasic tissues Fig.

The treatment is as follows: a.CHAPTE I MANAGEMENT OF FLABBY RIDGES The rehabilitation of abused oral tissue: The rehabilitation of abused oral tissue is to allow the hypertrophic. b. c. Restoring the lost occlusal vertical dimension: To correct the occlusal vertical dimension. Correct the adaptation of the denture base to the underlying tissues using tissue conditioning material (TCM) (Fig. 10 . Elimination of contact between natural anterior teeth and opposing artificial teeth. Detect and Correct any pressure area or sore spot using pressure indicating paste (PIP). This material should be changed every 72 hours as the plasticizer will be leached out on long standing in the patient's mouth and thus. 2. start a recovery program to allow the tissues to regain its normal healthy form.Removal of the cause: ie: Remove the denture from the patient's mouth for few days before making new impressions to allow the inflammation to subside. d. Correction of occlusal disharmony by clinical remounting procedure. the material will lose its conditioning effect. Treatment plan and recovery program: 1. However. traumatized and inflamed tissues to regain its original form.Another line of treatment is to treat each case by elimination of the cause and then.1-9 a: f).1-10). this procedure does not suit every patient especially those with some social obligations. e. a dough of self curing acrylic resin is applied to the palatal cusps of the second premolar and first molar of the maxillary denture after Vaseline application to the opposing mandibular teeth (Sears and nelson occlusal pivots) (Fig.

CHAPTE I MANAGEMENT OF FLABBY RIDGES a b c d e f Fig.1-9 a:f: Tissue conditioning material application 11 .

. b: Restoring the lost occlusal vertical dimension.1-10 a. .Eliminate the load on the anterior segment.Restore the correct vertical dimension. b b Fig. Trim the resin to reestablish the contours of the teeth.colored self –curing resin on the posterior occlusal surfaces of the mandibular denture. B.CHAPTE I MANAGEMENT OF FLABBY RIDGES a Fig. 12 . Add tooth.1-11: a.Restore the correct position of the condyle. a This will help to: . the occlusal surfaces of maxillary posterior teeth are recorded in the resin. When the patient closes the mouth with the mandible guided to the centric occlusal position.

A modified impression making procedure (Sectional impression technique) can be used to record this tissue under minimal pressure without distortion as any distorted tissue tends to rebound leading to denture instability. 1-13).1-12.Primary impression is made using alginate impression material of low viscosity. 2. 13 .Instruct the patient to dissolve one-half teaspoon of table salt in a half glass of warm water and vigorously swirl the solution against the tissues by inflating and deflating the cheeks. than the treatment will be either: .Surgical removal of the hypertrophic tissues.The removal of the dentures from the mouth for at least eight hours of the twenty-four hours. 2. . since it can be accomplished during sleeping hours.Massage of the soft tissues two or three times a day to stimulate the blood supply and aid in recovery. 3. Patients usually agree to this program.CHAPTE I MANAGEMENT OF FLABBY RIDGES Recovery program: It consists of: 1. Or using two stage (Sectional) impression technique as follows: • Acrylic special tray is constructed having a window opposite the area of flabby tissues (Fig. If the condition persists after this recovery program. Prosthetic management: 1.Secondary impression is made applying the selective impression technique.

N. 3. • The jaw relation is recorded using check bite technique (with the least possible displacement of the supporting structures) (Fig.1-14. .1-17).After denture insertion.B. After the impression plaster sets. .If the fibrous tissue is distorted during impression taking.1-16).: .Final impression should be done according to the degree of mucosal displacement. .Cross-linked cuspless acrylic teeth are used to decrease the lateral component of force.Teeth are placed in relation to the neutral zone and the bucco-lingual width should be reduced. an overall impression using a suitable stock tray loaded with impression plaster is used to remove both sections together (Fig.CHAPTE I MANAGEMENT OF FLABBY RIDGES • Border moulding is carried out in the usual manner and zinc oxide and eugenol impression is made and excess passing through the widow is trimmed out (Fig. 5. 1-15). by occlusal pressure. In addition intermittent occlusion can traumatize the tissues. Elastic recoil of displaced tissue forces the denture downwards and eliminates retention (tissue rebound).1-18) .14 -.Minimal displacement could be achieved by taking a working impression in a spaced tray using an impression of low viscosity as impression plaster or low viscosity silicone impression material (Fig. the patient is instructed for periodic check-up of the denture. 4. • The flabby area is recorded using plaster impression material applied with a brush several times with the secondary impression in place.

CHAPTE I MANAGEMENT OF FLABBY RIDGES a b Fig.1-15: zinc oxide and eugenol impression is made and excess passing through the widow is trimmed out . Fig. Fig.15 - .1-14: Border moulding is carried out in the usual manner.1-13: A close fitting tray is constructed in cold-curing acrylic resin and designed so that flabby area of the ridge is uncovered.

Fig.1-17: check bite technique: C.CHAPTE I MANAGEMENT OF FLABBY RIDGES Fig.1-18: Minimal displacement could be achieved by taking a working impression in a spaced tray using an impression of low viscosity .R should be recorded with the least possible displacement of the supporting tissue by applying minimal closing forces on an easily displaceable recording material as using softened wax or silicon or mix of plaster. Fig.O.1-16: The flabby area is recorded using plaster impression material applied with a brush several times with the secondary impression in place.

egydental. The loss of alveolar bone is more pronounced in the mandible than in the maxilla.Egypt Dental Online Community www.com ADVANCED RESORPTION OF THE RESIDUAL ALVEOLAR RIDGE Introduction: Advanced resorption of the ridges in the edentulous patient has multiple causes. to the extent that the mental foramen may be located near or directly at the crest of the ridge (Fig. The magnitude of bone loss is extremely variable. relatively unchanging structure on the mandibular denture bearing surface is the retromolar pad (Fig. One constant.17 - . The pad contains glandular tissue. fibers of the buccinator. It is an irreversible process. . 2-1: 2-7). It may occur in all edentulous patients. 2-2). The bone beneath does not resorb secondary to the pressure associated with denture use. but is most often observed in the advanced age group. and superior constrictor and fibers of the temporal tendon. loose areolar connective tissue. The differential residual ridge resorption between the mandible and the maxilla providing a smaller surface area for support. the lower margin of the pterygomandibular raphe. The retromolar pad is one of the primary support areas. bone resorption in the mandible may be severe.

Sex: Alveolar atrophy occurs most often in the female. c. are contributing factors. f. decrease in vitamin C intake and/or protein utilization and/or dysfunction of carbohydrate metabolism. such as calcium deficiency. Nutritional: Dietary deficiencies. Age: Ridge atrophy generally increases with senescence. There is usually a hormonal imbalance after menopause with an increase of anabolic hormones and a decrease of estrogen which causes demineralization and osteoporosis of the bone. b. e. Systemic health: Blood dyscrasias prevents proper tissue nourishment. Uncontrolled diabetes and other debilitating disease cause metabolic hard and soft tissue destruction with a decrease in tissue resistance.18 - . . anatomic and functional prosthodontic factors.Etiology: The conditions causing alveolar ridge atrophy can be classified according to biologic. Severe periodontal disease also contributes to more alveolar atrophy than when the teeth are lost due to dental caries. 1-Biologic metabolic factors: a. b. Treatment for systemic diseases: Radiation therapy reduces bone regeneration Hormonal drugs may have an adverse effect on the soft and hard tissues. Loss of natural teeth: Extraction of the natural teeth causes the reduction of the residual ridge.

grinding and tapping of teeth may cause advanced resorption of the ridges depending upon the frequency. . centric relation.19 - . direction and amount of force to the remaining residual ridges. c. 2. non balanced occlusion and incomplete coverage of basal seat area. Prosthodontic factors: 1.Long denture use without serviceability. Type of bone: Cortical bone will resorb slower than cancellous bone.Constant wearing of dentures without giving rest to the basal seat tissues during night hours. 4. b. Functional factors: Habits with complete dentures such as bruxing. Size and shape of the ridges: Well-formed broad ridges will show less resorption than narrow thin ridges as the force received per unit area will be less in the former. 3. b.2-Anatomic factors: a. Facial skeletal morphology: Individuals with longer faces and obtuse gonial angle are more likely to have atrophy of their ridges than those with short faces and right angle gonial angle. All these factors contribute to severe resorption of the residual alveolar ridge.Porcelain teeth and/or anatomic teeth with high cusp angles transmit more force to the underlying ridge tissues.Improperly made dentures with improper vertical dimension of occlusion. 3-Functional/prosthodontic factors: a.

Fig. Mental Foramen is the anterior exit of the mandibular canal and the inferior alveolar nerve.f : pattern of bone resorption of the mandible. Fig.Note the position of the mylohyoid ridge as it varies relative to the degree of alveolar ridge resorption. the foramen occupies a more superior position and the denture base must be relieved to prevent nerve compression and pain. resorption.2-5: In severe alveolar ridge ridge to determine its contour. when pressure is applied by the denture. relatively Fig. In cases of severe residual ridge resorption.2-4:Palpate the mylohyoid Fig. mandible. the mylohyoid ridge sharpness and degree of becomes prominent and cause pain undercut.2-1 A.2-3: In severe alveolar ridge unchanging structure on the resorption the genial tubercles mandibular denture bearing appear on the surface of the surface is the retromolar pad.2-2: One constant. . Fig.

Fig.2-10: Distraction implant Fig.2-9: Vestibuloplasty Fig.21 - .2-7: The external oblique ridge runs outside the buccal shelf bone anteroposteriorly.2-6: Fig.2-11a.2-8: ridge augmentation Fig.b: Osseo-integrated implants: . it is not involved in resorption Fig.

Prosthetic management with surgical intervention: a.Management: Either surgical or prosthetic management: 1. A surgical stent lined with tissue conditioning material is helpful in retaining the flap in position and promoting rapid healing of the denuded tissues. 2-9). c. b.22 – . buccal or palatal mucosa) and is not left to heal by secondary intention. These tissues are positioned at a lower level on the bone to obtain maximum height of the residual alveolar ridge (Fig. ii. Secondary epithelialization procedure: An apically repositioned flap is sutured to the periosteum at a predetermined vestibular depth. Mucosa advancement: The subepithelial connective tissue and muscle insertion are separated from the mucosa and periosteum through supraperiosteal tunnels. Vestibuloplasty with epithelial grafts: This approach is similar to the secondary epithelialization procedure except that the denuded tissue is covered with a free epithelial graft (skin. . Prominent mylohyoid ridge: It is some times trimmed to allow proper extension of the lingual flange of the mandibular denture. This could be achieved by any of the following techniques: i. Removal of genial tubercles: This is done to provide for an extension in the sublingual fold space. The free mucosa is then advanced to its new position by an over extended border of a carefully made surgical stent. Vestibuloplasty: It is a surgical procedure designed to restore alveolar ridge height and/or width by detachment of buccal and/or labial and lingual tissues.

Osseo-integrated implants: For patients with atrophic edentulous mandible. muscles. A variety of materials has been used for this purpose such as: • Autogenous bone (from the iliac crest or rib). the placement of two or more implants anteriorly in the area between the two mental foramina can be of value in improving horizontal stability and retention of the constructed implant supported overdenture. These implants can be used with or without ridge augmentation (Fig. The disadvantages include a long treatment period. Injected through one or more subperiosteal tunnels to build up sufficient height of the residual ridge. . The prosthetic super structure is loaded 4 to 6 months after distraction. need for a suitable distracter and danger of infection (Fig. The block form of hydroxyapetite material avoids many of the problems accompanying the use of the granular form such as: Diffusion into adjacent areas resulting in disfigurement of the patients face. f. 2-11). blood vessels and nerves. 2-10). Bony augmentation of the alveolar ridges often undergoes resorption in a short period of time whereas the non-resorbable hydroxyapetite prevented this problem. The advantage of distraction is that there is no need for donor site.23 - . Nonautogenous bone and Hydroxy apetite (either in the granular or block form).Distraction implants: Recently alveolar ridge distraction has been introduced for augmentation of the atrophied mandible and maxilla by the help of distraction implant which contain two mobile endosteal parts which enable heightening of the alveolar ridge up to 6mm. e.d. Paresthesia and reduction in the planned height of the alveolar ridge. simultaneous lengthening of the surrounding soft tissues as skin. Ridge augmentation: This procedure is used to increase the width and height of the residual alveolar ridge.

Proper relief of hard and sensitive areas. 2-12). .An activated resin tray is made on the primary casts and an occlusion rim is added on both the upper and lower trays. 4. without muscle 2.Maximum extension impingement. .II. . 2-13).Primary impression is made with impression compound using suitable stock tray (Fig.Prosthetic Management without Surgical Intervention An ideal impression should provide: 1.24 – .Border molding of the periphery is carried out in the usual manner using green stick compound until a stable and retentive tray is obtained.Intimate contact with the tissue area covered. This record is used to mount the primary casts on a high articulator. . 3.Muco-compressive impression technique: . . being parallel to the ridges. meet each other evenly and at an acceptable occlusal vertical dimension.Final impression is made using zinc oxide and eugenol impression paste while the patient is closing on the occluding rims (closed mouth technique) (Fig. Different impression techniques could be made according to the condition of the supporting tissue: 1.A rough record of ridge relationship is made using T-shaped roll of wax seated intraorally between the upper and lower ridges and ask the patient to close to reach a reasonable occlusal vertical dimension.Proper form of the borders including the posterior border of the maxillary denture.

. Each application is allowed to remain in the mouth for 8-10 minutes pressure areas are corrected after each application. . very thick and confirming buccal borders. . .Butterfly impression technique: This technique is indicated in case of advanced resorbed ridge with projecting sublingual glands. . .Three applications of tissue conditioning material are used for making this impression with closed mouth technique.A suitable metal tray is selected and the lingual border is made nearly flat to cover the sublingual crescent area and a primary impression is made using alginate impression material. an acrylic resin special tray is fabricated with a butterfly extension over the sublingual crescent area and an occlusion rim is added to simulate the height and position of the anterior and posterior teeth.Then. .Using the resulting cast.2.The borders are adjusted so that the lingual flange and sublingual crescent area are in harmony with the adjacent tissues during rest and function.25 - . . the third and final wash is made using either a soft tissue conditioning material or a light-bodied rubber base impression material.Two application of a viscous tissue conditioning material.The end result is an impression that has tissue placing effect. relatively thick lingual and sublingual crescent areas and covering the maximum possible basal seat area within the functional limits of the adjacent tissues.

Three stops of impression compound are added to the fitting surface of the tray. The loaded tray is seated in the patient's mouth and pressed gently until the stops are firmly seated on the residual ridge (Fig. . 2-14). . .This technique is used to record the range of muscle action as well as spaces into which the denture can be extended without displacement.The patient is instructed to swallow 3-4 times and forcefully protrude the lips forwards. .Then.Also.Final impression is made using a thin mix of alginate impression material.A special tray of activated acrylic resin is constructed on the primary cast. . one at the anterior region and one at each side posteriorly in the first molar region to allow a room of two millimeters between the tray and the surface of the cast. .3-Dynamic impression technique: . .In this technique. a compound tongue rest is added in the anterior region to secure a correct tongue position during impression making. complete utilization of the active and passive tissues is obtained as the impression material is being shaped by the function of the muscles and muscle attachments allowing properly formed denture borders.Mandibular rests of impression compound are placed bilaterally on the occlusal surface of the tray in the molar region. the patient is asked to close slowly until the mandibular rests firmly contact the maxillary arch and keep his tongue in contact with the tongue rest. . .26 - .

• Cross-linked cuspless acrylic teeth are used to decrease the lateral component of force and improve denture stability.. .After making the final impression with any of the previously mentioned impression techniques the complete denture construction is continued in the usual manner. • Setting up of teeth in the neutral zone would help to achieve denture stability.27 - .The resulting impression covers the maximum possible basal seat area and the borders are in harmony with the adjacent moving tissues. taking into consideration the following points: • Jaw relation registration is carried out using check bite technique. • Occlusal plane is adjusted nearer to the flat ridge to decrease the lever arm. • A metal denture base is preferred to increase retention by interfacial surface tension. .

2-12:Well-formed impression of (lower) lingual sulcus area Fig.2-13:Muco-compressive impression technique a: A lower acrylic special tray with metal spurs to aid retention of the impression material b.28 – .Occlusal pillars have been built up in green stick to the correct occlusal height C.Fig. a completed viscogel impression Fig. Establishing the correct occlusal height D.2-14 a:df: Dynamic impression technique: .

After healing. and inserted immediately following removal of the remaining natural teeth (Complete clearance). A transitional denture may become an interim complete denture when all of the natural teeth have been removed from the dental arch. or convenience. o A complete denture or RPD fabricated for placement immediately following the removal of natural teeth. Immediate transitional denture: A Temporary partial denture to which artificial teeth are added one or two at a time as natural teeth are lost until it finally serves as a temporary complete denture.29 - . the denture is placed at the same appointment of extraction.e. 2. 3-1).egydental.Egypt Dental Online Community www. mastication.com IMMEDIATE DENTURES Definition: o Immediate denture is a denture which is entirely constructed before the extraction of the teeth and inserted immediately after the extraction of the teeth. the denture can be relined and refitted to be used as a definitive denture. i. Types Immediate Dentures: 1. occlusal support. it is worn only during the healing period until more definitive prosthetic therapy can be provided (Fig. It is used for a short interval of time for reasons of esthetics. . Immediate interim denture: A temporary dental prosthesis constructed to replace the lost dentition and associated structures of the maxillae and /or mandible.

of the partial .3-1: Immediate interim denture Fig.Fig. a: Before construction of the b: After construction immediate denture immediate treatment denture Fig.30 - .3-2: immediate transitional partial denture.3-3 a.b: Immediate transitional denture.

Fig. Diagnostic Immediate denture: Used to diagnose a patient’s problem and the posterior segments consist of flat occlusal blocks made of plastic resin. Fig.3-6: Immediate treatment or diagnostic partial . 3.3-Immediate Conventional Complete denture. Immediate Definitive cast partial denture.3-5). 4.3-5: Definitive cast partial Fig. A denture placed immediately after the extraction of the remaining 6 anterior teeth. the posterior teeth having been removed 6 weeks prior to making the dentures. indicated for patients with advanced periodontal disease (Fig.3-4: An interim acrylic resin partial denture that is placed at the same appointment of extraction to restore esthetic and function immediately.

A dressing and bandage effect to the wounds of extraction and alveolectomy and help to reduce bleeding 5.Protect the tissues at the sensitive extraction sites from irritation. 8. 6. 9. The patient can better tolerate the transition from the dentulous to the edentulous state since they are not without teeth for an extended time. 3.Provides a guide for The vertical dimension of occlusion .Hastens patient adaptation to dentures.Prevents collapse and changes of facial and oral musculature.The functions of speech and mastication are sustained when natural teeth are immediately replaced.Prevents patient embarrassment after extraction of teeth. Thus. preclude any change in patient’s appearance.32 – .Advantages: 1.Provides a guide for optimal individualized patient esthetics and the remaining natural teeth serve as an excellent preextraction guide helping the dentist to reproduce the position and appearance of the natural dentition 2. 7.Promotes better ridge form 4. Promotes better healing. tongue action or the opposing teeth. because it can serve as a protective bandage and surgical stent to protect the open sockets and blood clots from injuries from food.

rebases or remakes are necessary in a short period of time. 2. 4. 5.Post-placement adjustments are more numerous than with conventional complete dentures. 2. 5. 4. Contraindications: 1.Patients with general medical conditions which make them poor surgical risks such as cardiovascular diseases or other systemic abnormalities. 7.Increased patient discomfort 6. is indicated before the teeth are removed.Increased complexity of clinical procedures. 3.Patients with a limited mental capacity or who are emotionally disturbed and uncooperative.Patients who have undergone radiation therapy should not be considered for immediate dentures because of the danger of osteoradionecrosis. 3. 6.Increased treatment time and cost.Patients with a severe gagging reflex.Subsequent relines.There is potentially less retention. . Conditioning of such patients with a training appliance.33 – .Disadvantages: 1.Patients with limited or no neuromuscular control. such as a mouth guard.Patients with acute infections which may require surgical drainage.Patients with neurologic or psychological conditions.No possibility of 'Try-in" of the anterior teeth to get the patient's acceptance for esthetics and phonetics. 7.

adjust tissue surface & flanges. Lab procedures . 2nd Clinical Appointment .custom tray fabrication.34 - .process dentures 5th Clinical Appointment .24 hour post-insertion checks adjust dentures & care instructions 7th & 8th Clinical Appointments . and tooth selection Lab procedures.Exam & preliminary impressions.72 hour.wax trial denture fabrication if indicated 4th Clinical Appointment . Lab procedures . • Condition of the patient. clinical remount & reinforce care instructions . A healing period of 6-12 weeks is allowed to ensure proper healing of the extraction sockets depending on: • Number of teeth extracted.master cast. and one week postinsertion checks adjust dentures. start construction of the immediate denture as follow: 1st Clinical Appointment .in (confirm mounting & esthetics) if indicated Lab procedures .Maxillomandibular relation records. record base & occlusion rim fabrication if indicated 3rd Clinical Appointment .Immediate Denture Treatment Sequence: Extraction of posterior teeth: All the remaining posterior teeth are extracted with the exception of two opposing premolars or molars standing into good occlusion as their extraction is postponed till the recording of the jaw relationship.Extractions & denture insertion.Master impressions.Wax trial denture try. adjust occlusion & care instructions 6th Clinical Appointments . Then after complete healing of the extraction sockets.

restorations.35 - .3-7: A hand-drawn chart for the locations of stains in the anterior teeth.Diagnosis o Initial interview o History o Oral examination o Mounted diagnostic casts o Radiographic interpretation o Subjective appraisal of patient o Pre-extraction Records o A diagram of the anterior teeth indicating shading. etching. . and so on o Profile wire record and facial measurements Fig. Fig.3-8:The vertical overlap may be measured in this manner to serve as a pre-extraction record of the vertical relation.

This can be performed either by: 1. The results are far better than can be obtained by using stock teeth. .3-9). 7. 3-11). 10. 11. but also the exact arrangement of the patient's anterior teeth. The impression should be examined to be sure that it has no bubbles or other defects over the teeth. Wax elimination is carried out. 4. 3-12. An acrylic tray is formed over the wax to obtain an impression of the anterior teeth only. The procedure described above enables one to duplicate not only the size. 3-14). 313). leaving the teeth and approximately 1 mm of gingiva remaining (Fig. The impression is then filled with a white carving wax above the level of the gingiva and allowed to set (Fig. and a strong wire handle is attached. and individual stains. Finished and polished (Fig.Duplicating the Patient's Natural Teeth: One of the greatest pleasures of accomplishment can be gained from duplicating the patient's natural teeth. The wax pattern is then invested in a suitable flask. color. They can then be set into their proper place on the cast and waxed to place.3-10). 6. Duplicating the anterior teeth is remarkably simple and rewarding.The teeth are then removed as a block of six teeth. The wax is carefully removed from the rubber-base material by peeling the latter from the wax pattern. Anterior tray is formed over a wax blockout present no undercuts. 2. Because of the great pleasure inherent in this procedure. This eliminates the probability of fracturing the pattern (Fig. A strong wire handle is attached (Fig.The appropriate shade for the incisal edge and the body of the teeth of a suitable heat-cured acrylic resin is packed into the mold and processed. Two thicknesses of base-plate wax are adapted over the remaining anterior teeth on the study model. Preliminary alginate impressions poured twice (once with teeth in wax and once in stone). 9. The wax pattern is trimmed of excess gingival areas. 5. 8. a step-by-step recipe is given below: 1. or 2. A rubber-base impression material is made. 3.

and wetting the whole with monomer. Fig. 3-11: Wax model of the upper anterior teeth. The should present no undercuts. and a carving wax. dusting in polymer. 3-9:The wax blockout Fig. 3-13: All material above Fig. All material above the dotted line can be trimmed away.37 - . . The anterior tray is not perforated and no adhesive is used because the impression material will have to be removed and replaced later.Fig. 3-12:Fine lines can be simulated by holding apart clean cut into the dough. strong wire handle is attached. Fig. 3-10:Rubber-base impression of the anterior teeth. 3-14: Lightning disk or the dotted line can be separating saw used to separate trimmed away. impression filled with white The anterior tray is then formed over the wax. the incisal edges. Fig.

3-16). o Preservation the maximum ridge bulk. 2.An activated resin special tray is constructed over the relieved master cast covering both the anterior teeth and the posterior edentulous area (Fig. .Fundamentals for impression making: o Area of coverage o Borders o Valve seal without interference of function o Accurate adaptation of the underlying tissues without injurious displacement. 3-17). Primary impression: Primary impressions of the upper and lower arches are made by alginate impression material using suitable stock trays.An activated resin special tray is constructed.Sectional (two stage) impression technique: 1.Single final impression technique: . 3-18).38 - . 3-15). .Second method .Using rubber base impression material (Fig. Covering the edentulous area posteriorly and resting on the lingual surface of the remaining anterior teeth (Fig. .. 3-19).An overall impression is made using alginate impression material in a suitable stock tray to record the anterior teeth and relate the previous impression of the edentulous area to these teeth (Fig. Final impression: Two types of final impression procedures are employed.First method .The tray is border molded using green stick compound and then the impression is made into zinc oxide and eugenol impression paste (Fig. the sectional (two stages) impression or the single impression: a. b.

Fig.This technique may be used when there are no severe labial under cuts present. or Small oral opening.3-15A. .b: Two-piece tray technique using rubber base impression material.B:Two-piece tray technique: for very divergent maxillary anterior teeth. B A Fig. severe ridge undercuts. . Fig.3-17: Overall alginate split acrylic tray impression with stock tray Split Impression Tray – zinc oxide and eugenol paste and Alginate. and/or the anterior teeth are not protruded.The tray is border molded using green stick compound and then the impression is made using rubber base impression material to record all the areas in one impression.3-18:a..3-16:Zink oxide impression in Fig.

3-20: Single tray with rubber base impression material Fig.Evaluate the VDO .3-21: Use wax to block out interdental embrasures Fig.3-22: Single tray with alginate Fig.3-19: Two-piece tray technique for very divergent teeth or severe ridge undercuts Fig.CR record .Fig. . over the obtained casts.40 - .Mark and transfer the posterior palatal seal.Occlusion blocks are constructed. . 3-24: 3-27).Face bow record . the centric occluding relation is recorded at a proper occlusal vertical dimension guided by the retained occlusal stops that will be extracted after making this record (Fig.Protrusive record .the Maxillomandibular Relation Records include: .3-23: Single tray with alginate is only used when considerable is only used when considerable tooth misalignment or great tooth misalignment or great mobility present mobility present Jaw relation registration: .

b Fig.3-24 a,b: The normal vertical overlap on the left is maintained by the molar teeth. When posterior teeth have been lost, the mandible may close further and increase the vertical overlap to the degree shown on the right.

a

Fig.3-25:Adequate Fig.3-26: If your immediate denture teeth to support patient has existing edentulous the bite space (s) fabrication of record base and wax rim is recommended to registration material verify records and esthetics. Selecting & arranging anterior teeth:

Fig.3-27:Mark and transfer the postpalatal seal.

First method: For tooth set-up: – Anterior teeth: – Cut anterior teeth off cast at gingival level. – Set anterior teeth on cast for patient viewing. – Posterior teeth: – Arrange posterior teeth on record base balanced/monoplane/lingualized) occlusion and – Wax-up for try-in evaluation. - 41 -

in

Second method: The Alternating Tooth Setup Technique • Trim and set only one anterior tooth at a time • Alternate from side to side to keep natural neighboring tooth as angulation, length, and contour orientation (Fig.329-3-33)

Third method: – Performed by removal of all teeth from the plaster cast and the patient got a complete immediate denture delivered with the anterior teeth in one time.

2mm

B Fig.3-28 a: First method: The teeth are removed from the cast in a manner that They are not cut below the gingival crest. B: The terminal 5 mm of gingiva should be trimmed in the manner shown above so that the denture gingiva may not appear too thick

Positioning of the anterior teeth: This can be accomplished by various methods according to the technique applied. Techniques applied for immediate denture construction: 1- Simple extraction with no more surgery: It includes two types: a- Socketed immediate denture: - It is indicated only in upper arch and contraindicated in the lower arch as the presence of a labial flange in the lower denture is important to guard, against backward movement of the denture by the pressure of the lower lip. - 42 –

- The plaster teeth cut from the cast and replaced by the artificial teeth. This is best achieved by removing and replacing one tooth at a time so the form of the arch and the position of each individual tooth can be easily reproduced. - Root sockets are made in the plaster cast into which the necks of artificial teeth are fitted taking into consideration the following: - The socket depth should not exceed 5mm labially and 2mm palatally (Fig. 3- 28 b). - The sockets should not be carried too far towards the palatal side i.e the socket should slope from the palatal margin upward toward the labial aspect. - The direction of the socket should follow the long axis of the tooth. The advantages of this technique are as follows: - It provides anterior seal that assists in the retention of the denture. - It provides resistance to movement during mastication. - It provides a natural appearance as if the teeth are growing from the gums. b- Flanged type immediate denture: - This technique is indicated in cases having sufficient available space to accommodate a labial flange without giving the feeling of excessive lip fullness. On replacing the plaster teeth by artificial ones, either one tooth is removed each time, or remove all teeth on one side of the arch, keeping the more acceptable side as a guide for the arrangement of artificial teeth. - 43 -

3-29 a.b:Preserve the incisal edge position and tooth angulation information prior removal of stone teeth. Use a sharp pencil to mark the gingival outline buccally and lingually.3. . – Alternate from side to side to keep natural neighboring tooth as angulation. length.3-31: The Alternating Tooth Setup Technique Fig. Then mark the long axis of each tooth.Fig.3-30:Esthetic convenience groove Fig. and contour orientation.44 - . Fig.33:The Alternating Tooth Setup Technique – Trim and set only one anterior tooth at a time.

shallow sulci and narrow upper jaw with a wide lower jaw that necessitate the creation of a room for a labial flange to provide better retention and stability.3-:35 a. .45 - . II.Patients with poor posterior ridge.34: Objectives of the occlusion development (upper ID/lower RPD): Centric: Bilateral even centric contacts.Immediate denture with alveoloplasty: It includes two types: a-Labial plate alveoloplasty: This technique is only indicated in the following conditions: 1. b: Eccentric: Fully balanced occlusion during lateral/protrusive movements. Patients exhibiting a very deep overbite with the incisal edge of the upper teeth touching the gingival margins of the lower teeth.3.Patients having a very prominent premaxilla with the teeth tilted outward and resting on the external surface of the lower lip and wash for an improvement in appearance. Fig. 2. Today’s goal: Complete the posterior teeth setup that obtains solid bilateral even centric contacts.Fig.

A suitable antibiotic is prescribed and the patient is instructed to make cold fermentation to minimize hematoma formation.The bony septa are then removed using bone rongeur.A mucoperiosteal flap is reflected by making two inclined incisions distal to the canines. .The patient is instructed not to take of the denture till the next appointment 24 hours later. the labial alveolar plate of bone is cut off.The technique is as follows: . b. .Then the bony septa are cut off using a side cutting rongeur. a bone rongeur is used to cut a V shaped wedge from the labial cortical plate distal to the canine or each side. .Suturing of the flap is carried out using.The immediate denture is inserted in the patient's mouth after being lined with tissue conditioning material. slight knocks are applied with the chisel edge directed toward the labial cortical plate. .A bone file is used to trim any remaining sharp edges.A chisel is inserted deep in the sockets and with the help of a mallet. . . .Interseptal alveoloplasty: In this technique.The flap is repositioned and excess soft tissue is trimmed. .46 - . extraction of the six anterior teeth is carried out. . . .First. .After extraction of the six anterior teeth.Hand pressure is applied to the labial cortical plate to affect green stick fracture and moving the labial cortical plate towards the palatal cortical plate. .Using bone rongeur. The technique is as follows: . 000 black silk suture. no mucoperiosteal flap is reflected.

Excess soft tissue is trimmed and the wound is sutured using 000 black silk suture. the interseptal alveoloplasty is to be preferred as it will cause less damage and preserve as much of the residual ridge as possible . the patient will be recalled for changing the tissue conditioning material periodically and making any necessary adjustments. .After three months.It affects the same purposes of the previous technique without flap reflection. 36 a.Maintain the heamatoma between the two cortical plates and thus any pressure will not result in excessive bone resorption.47 - .Immediate denture insertion and patient instructions are the same as the previous technique. relining.Minimizing the possibility of bone resorption by keeping the labial cortical plate of bone and avoiding flap reflection. Note: . NB. the construction of a transparent acrylic template over a duplicate cast of the reduced one is helpful in detecting areas requiring further modifications before suturing (Fig. . in cases where surgical reduction of the alveolar process is considered necessary. b). rebasing or even making a new denture is indicated after complete healing of the tissues following extraction. 3. . 2.It could be noted that the best approach for immediate denture construction is the simple extraction with no more surgery. .. However.Following immediate denture insertion.: For both technique of immediate denture with alveoloplasty. The advantages of this technique are as follows: 1.

It the patient require the shape.Then. colour and surface characteristic of his teeth to be copied exactly. .A Fig.Proper centric occluding relation.Even bearing on both sides. Denture trimmed according to blanched mucosa observed under template B B. the patient is dismissed and given appointment for extraction of the anterior teeth and complete denture insertion. 3-36 A: Surgical Template: Fabricated after cast trim. . .Reasonable occlusal vertical dimension. The wax is chilled in cold water and removed from the impression and reproduced into tooth-coloured acrylic resin of the same shade. Try in: Try-in of the set up posterior teeth is carried out to check the following: . Used to locate pressure areas on mucosa at time of surgery.48 - . :Trimmed areas sanded smooth Avoid removing incisive papilla. an additional rubber base impression of the anterior teeth should be taken into which molten wax is poured to a level just above the gingival margins. .

3-37 a.49 - .Post Extraction Instructions Do not remove denture Keep head elevated Small amounts of blood in saliva is normal Diet: soft and warm. The patient should not remove the denture until the next day. . when it is examined by the dentist. the patient may remove it whenever he or she wishes. not hot Avoid: – Spitting. rinsing – Strenuous activity – Alcohol.b: b Try-In of a socketed type denture of the Posterior segment for check record Delivery and Aftercare The immediate denture is inserted when the surgical procedures have been completed. Subsequent to that appointment. smoking a Fig.

The immediate-denture patient should be recalled every 3 months after the dentures have been properly fitted.3. .Post Insertion Management .Recall next day to remove the denture.38 : The immediate denture is inserted. The majority should be rebased at 10 to 14 months). . . (Some patients lose alveolar bone rapidly.Apply topical anesthetic to traumatized mucosa .Locate over extensions and pressure areas and adjust . - Fig. and their dentures require rebasing within a few months.50 - .Reappoint 1 week. to determine when they must be rebased or relined.

3.Natural teeth.Esthetic and phonetic problems due to the fixed positions of the mandibular teeth. This situation is the result of the displacement of the maxillary denture due to unfavorable occlusal relationship as a result of tipped. 3. The single complete maxillary denture opposing all or some of the mandibular natural teeth is a very common clinical situation Problems of single denture: 1. 2.Removable partial denture. 4. (Excessive load from the natural teeth). 5.The occlusal form of the remaining natural teeth and the uneven occlusal plan (“mutilated” dentition).egydental. Acrylic teeth are abraded by natural teeth and porcelain teeth abrade natural teeth.Single denture syndrome. It is presented as mucosal irritation and ridge resorption of the edentulous ridge.The firmness and rigidity in which the natural teeth are retained in the bone and the magnitude of the force. malposed or supererupted natural teeth. 2. It could be constructed against: 1.A previously constructed complete denture.Egypt Dental Online Community www.Mandibular single denture. .Artificial teeth selection. 6.51 - . How to Overcome These Problems The primary consideration for a continued success of a single complete denture is the preservation of that which remains.com THE SINGLE COMPLETE DENTURE The construction of a single denture may be presented in a variety of dental combinations.

. Applying the principles of complete denture construction: • Lip support • Minimal vertical overlap (Overbite) • Balancing occlusion and free articulation. 5. If this situation is left unaltered there would be no occlusion in protrusive and lateral excursions except for contact on the distal half of the lower molar. 2. • Avoid broad inclined planes.Complete case history is taken and oral examination is done. This results in the maxillary denture being easily dislodged during functional movements.Study upper and lower casts are obtained.) Reduction of the forces to which the denture is subjected Diagnosis and treatment planning: 1. which favors success for this denture.The upper cast is mounted on the articulator using a face bow. 4. Maximum base extension within functional anatomical limits (distributed forces over the largest possible area of supporting structures and the force per unit area kept at minimum. Common Occlusal disharmonies: The remaining molars are often severely inclined mesially and then distal halves supererupted.The lower cast is mounted on the articulator using a provisional centric interocclusal record at an acceptable vertical dimension. 3.52 - .Eccentric records are made and the condylar elements of the articulator are adjusted.Proper diagnosis and full use of every factor.

(A) Teeth before preparation. or a fixed bridge if a large edentulous space exists mesial to the molars.' the distal cusps have been lowered.4-1: Upright preparation of a premolar and tilted second molar as abutments. onlays.a) If the molars are not severely tilted they may be reshaped by selective grinding. (C) Correct preparation of the molar and premolar. This template is often an aid in detecting minor deviations in the occlusal scheme (Fig 4-2). resulting in an overtapered preparation. d) If the molars are severely tilted forward and supererupted. (B) The mesial surface of the molar has been aligned to the existing long axis. another alternative treatment is to design a removable partial denture that would restore the mesial half of the molars by using an onlay mesial rest (Fig 4-1). The mesial cusps of the molar have been raised. Methods used for detecting occlusal modifications: Several techniques could be used to determine occlusal modifications that are necessary prior to denture construction: 1. the ideal treatment is to restore the tilted molars with cast gold crowns. and the correct occlusal plane has been restored. c) If a large space does exist mesial to the tilted molars. b) When tooth reduction is found necessary.Use of a commercially available U shaped metal occlusal template that is slightly convex on the lower surface. Fig. (D) The completed fixed partial denture. extraction is necessary. .53 - . and modification is not possible.

54 - . the prosthodonticsts must provide a harmonious occlusal scheme free of interference in any jaw relationship this will lead to a better retention and stability of the single denture which will lead to least residual ridge damage.Upper and lower casts are mounted on the articulator. they are adjusted on the cast and the area is marked with a pencil. If the lower natural teeth interfere with the placement of the denture teeth.Use of a clear acrylic resin template fabricated over the modified stone cast.4-3:Plane of Occlusion Evaluation Methods used for a harmonies balanced occlusion: In the construction of dentures to articulate with natural teeth. This technique is simple but time consuming. The inner surface of the template is coated with pressure indicating paste and placed over the patient's natural teeth.Static equilibration of occlusion with an adjustable articulator. of a 2.4-2: U shaped 20° occlusal Template Fig.2. They basically fall into two categories: 1. Fig. 3.Dynamic equilibration of occlusion by the use functionally generating path. . The natural teeth are them modified using the marked diagnostic cast as a guide. Many techniques have been used to achieve a balanced occlusion of a complete maxillary denture opposing natural teeth. The upper denture is constructed.

Porcelain.Excessive resorption of lower ridge due to greater stresses per unit area delivered to the mandibular ridge by the natural teeth.55 - .Minimal denture foundation area 4. 2. Mandibular single denture: The prognosis of a mandibular single denture against natural teeth is less favorable than when the full upper denture is opposed by natural lower teeth (Fig.Or to steeping the posterior cusp angles so that the posterior teeth will disocclude the anterior teeth during eccentric movement. 4-5). It would be difficult to classify this case as clinically successful. 5. 6. 4.Occlusal problems: The presence of natural teeth will present difficulties in controlling the occlusal scheme.Acrylic resin. .Gold (Fig 4-).Acrylic resin with amalgam stops.To create enough horizontal overlap to allow freedom to balance in eccentric movements. Esthetic of single maxillary denture: The fixed positions of mandibular teeth limit the esthetic position of maxillary anterior teeth. How to solve the esthetic problem? 1. 3. 4-4.Fracture. 2. 3. This is due to: 1.Materials for artificial posterior teeth: The materials available for occlusal posterior tooth forms are 1.Tooth wear. Fig 4-3: Gold occlusal posterior teeth.Tissue abuse. 2.

The alternative line of treatment plan for such patient could be either: 1.4-6 a. and complete upper and 2.Extraction of remaining teeth lower denture are constructed.4-4 a.4-7).b:Retaining roots in key positions facilitate support and prevent compression of the periosteum . a b Fig. 46. a Fig.Use of implant supported fixed or overdenture prosthesis (Fig.Use of resilient denture liner in the mandibular denture.4-5: Conventional lower single dentures are contraindicated because they cause severe resorption as seen in this patient. b: mandibular single denture against natural teeth b a b Fig. 3.

4-9). 4.4-8b). 2.Fig.Loss of bone from the maxillary anterior edentulous ridge (Fig.Periodontal changes. It usually has six associated changes: 1. 2. 3. 6.4-7 a. 5.b:Implant assisted overlay dentures opposing dentate maxilla.Poor adaptation of the prosthesis and.Down growth of the maxillary tuberosities (Fig.57 - .4-8 a).4-10). Combination Syndrome and Associated Changes ( Kelly’s Syndrome) A Combination Syndrome By Kelly (1972): destructive problems. 3.Papillary hyperplasia of the tissues of the hard palate.Anterior spatial resorption of the mandible.Loss of bone beneath the removable partial denture bases. . 4.Loss of vertical dimension of occlusion. that may be encountered as a result of long term use of a mandibular distal extension partial denture against a complete maxillary denture This syndrome consists of: 1. 5.Occlusal plane discrepancy (Fig.Development of epulis fissuratum (Fig.Extrusion of the lower anterior teeth and.

4-9: When mandibular anterior teeth remain. Fig.b: Premaxilla mostly soft tissue Advanced bone loss: premaxilla and posterior mandible b . and • the particularly unfavorable occlusal relationship. a Fig.4-8 a.4-11 a. Resulting In Development Of Epulis Fissuratum.The Combination Syndrome Is a Result of Three Main Factors • the great magnitude of forces involved. Fig.4-10:The Labial Flange Of The Denture Produces A Low Grade Irritation In The Surrounding Soft Tissues. patient will attempt to function in protrusive relationship to sense feeling of mastication.b:A specific pattern of resorption : The premaxilla undergoes severe resorption and is usually accompanied by the development of fibrous hyperplasia of the maxillary tuberosity. • the unsuitability of the denture foundation to resist them. Fig.

3. b:Retaining the abutments and Preserving the remaining residual ridge . root structure and/or dental implants. overlay prosthesis or super imposed prosthesis.Egypt Dental Online Community www. Fig. 2.5-1a. The overdenture is also called overaly denture. Preserving the remaining residual ridge by decreasing the rate of bone resorption (Fig. Preserving the response of proprioceptive exist in the periodontal membrane of the abutment tooth.59 - . Retaining the abutments as part of the residual ridge to gain support and retention (Fig. 5-1 a).com OVERDENTURE The overdenture is a complete or partial denture prosthesis constructed over existing teeth. 5-1 b). Objectives of overdenture prosthesis: 1.egydental.

microdontia.Patients with class II or class III Angle's classification. 6.Patients presenting congenital defects as cleft palate.Remaining teeth present with unhealthy periodontal condition.e.Interarch space inadequate to accept the denture and the abutments. 5. Contraindications: 1.Overdentures are contraindicated in case of poor oral hygiene. amelogenesis or dentinogenesis imperfecta or partial anodontia. 4. 2. 3.Cases having few remaining teeth unsuitable for fixed or removable partial dentures. The reduction of the coronal portion of the tooth i.The construction of over-denture is an alternative line of treatment to single dentures opposing few natural teeth.Indications: 1. .Patients presenting abnormal jaw size large maxillary or mandibular bone defects.60 - .Inadequate zone of attached gingiva with grade II mobility of the abutments. 2. decrease crown-root ratio will decrease the hypermobility of the teeth and make them favorable for supporting overdentures. 3.

4. 2.Preservation of the abutments as part of the residual ridge to gain support. occlusal loading and help to preserve vertical dimension and facial support.Implant supported overdenture.Conventional dental procedures.Preservation of the proprioception that exist in the periodontal membrane of the abutment tooth.Overdentures can be classified into: 1. .Tooth supported over denture.Convertibility: overdentures can be converted into a conventional complete denture after loss of the abutments and relining or rebasing of the denture. Advantages of tooth supported overdenture prosthesis: 1. 1.Tooth supported overdenture: The tooth supported Overdentures improve stability retention. 6. 2. 3.61 - . 7. masticatory performance.Provide retention through the attachments.Preservation of the remaining residual ridge by decreasing the rate of bone resorption.Patient acceptance and Psychological Benefits 5.

b:Encroachment of the interocclusal distance leads to bad Esthetics.Encroachment of the interocclusal distance leads to bad Esthetics.5-2 a.Inadequate reduction of the abutment teeth may increase vertical dimension.5-2) 2. 4.The bony undercuts adjacent to the abutment teeth (usually buccally) cause limitation of path of insertion of the over denture.Disadvantages of tooth supported overdentures: 1.Caries and periodontal break down of the abutments teeth (Fig.b:Caries and periodontal break down of the abutments teeth Fig. Fig. 3. . 5.5-3 a.Overdenture construction is time consuming and expensive line of treatment compared to the conventional complete denture.

2. most of which are to be lost. The remaining teeth are reduced to accept the overdenture (on the cast). into: Immediate overdenture: Is made for patients with almost a full complement of teeth. Tooth reduction and cast coping of vital abutment Thimble or dome.shaped 3. Complete or partial overdentures with metal or acrylic bases can be fabricated. Telescopic Overdenture .Tooth supported overdenture can be classified according to the time expected to the denture to be worn.63 - . Endodontic therapy with cast coping and attachments 6. Definitive (Remote) overdenture: Is constructed for insertion at sometime remote from the removal of hopeless natural teeth. Tooth supported over denture can be classified according to its design into: 1. Vital tooth with simple reduction. Endodontic therapy and amalgam plug 4. the overdenture are constructed prior to the preparation of abutment teeth and is inserted after the preparation. Transitional or intermediate overdenture: Is obtained by converting an existing removable partial denture to an overdenture by making impression over prepared abutments. Endodontic therapy with post and coping 5.

Adequate interarch space.Attrition or abrasion of teeth with severe pulp recession. . The technique requires preparations for full crowns. 5-5 b). 5-5 a). and the occlusal portion of the preparation is rounded or parabolic in form. . considerable vertical and It is mainly used in cases with partial anodontia and in cases exhibiting enough inter-ridge space. 5-4).I.Tooth reduction and cast coping: Copings may be placed on vital abutments. The crown is reduced to the dome-shape and wax pattern is made for cast coping (Fig.In case of good oral hygiene and low caries index. . preferably with shoulders. II.This types is indicated: . The thimble coping occupies buccolingnal space (Fig.The thimble-shaped coping: Copings may be placed on vital abutments.Tooth reduction and cast coping of vital abutment: a. B.Simple tooth reduction of vital tooth: The tooth is modified by reducing the buccal surface 30° and lingual surface 15°. The mesial and the distal surface are modified to remove the undercuts (Fig.

Fig.5-4:Simple tooth modification of vital abutment Thimble-shaped coping B-Tooth reduction Endodontic therapy and cast coping and amalgam plug f Endodontic therapy Endodontic therapy with cast coping and with post and cast attachments coping.5-5 a:d : abutments ofTooth supported over denture .Fig.65 - .

.66 - . V.Normal crown height. .The metal coping takes its retention from a short post inserted in the root canal.Normal inter-arch distance. the reduced height is 1-2 mm above the gingival margin. The abutments are prepared as in short-coping but with long intraradicular post to prevent root-coping dislodgment. two attachments are enough to retain a denture. The crown needs severe reduction so endodontic therapy is necessary.Abutments are endodontically treated with root canal filling and sealed with cement. 5-6 b). 5-6 c).Endodontic treated tooth with amalgam plug: This type is indicated in: . . IV-Endodontic treated tooth with cast coping (shortcoping): . 5-5 a. Clinically. The root canal is filled with gutta percha and the opening is sealed with amalgam plug (Dome-shape appearance) (Fig.Good oral hygiene. . A third attachment adds unnecessary complexity and weakens the denture (Fig.Endodontic treated tooth with cast coping and attachment: Overdentures retained by attachments offer the patient the idea of a fixed removable bridge instead of a denture. 55 e-f.Pulp is not recessed. . .The crown is reduced to the dome-shape and wax pattern is made for cast coping.III.

b:Cast coping C: Endodontic therapy with post and attachment d:Posts and cast copings.5-6 a: f: types of overdenture prosthesis. These supporting abutments may simply be endodontically treated.67 - . Retention is generally obtained through the frictional resistance produced between the semi-parallel walls of the copings and tissue side of the denture base (Fig. a: Endodontic therapy and amalgam plug. smoothed and polished to support this denture.VI. 5-6 f). . e: Partial overdenture f: telescopic crowns Fig. reduced slightly.The telescopic overdenture: It is constructed to fit over natural teeth like a sleeve.

CLINICAL PROCEDURES The treatment plan starts first with the proper selection of the abutments which will support the overdentures. o Minimal mobility o At least 6mm of bone support o Attached gingiva around the abutments o Good oral hygiene o Proper emergence profile to support the marginal gingiva Endodontic evaluation. one should consider root form. Periodontal evaluation. space between abutments and the opposing dentition. amount of bone support. – Decay or previous restorations. masticatory loads. abutment location.Abutment Selection: Position of abutments and Number of abutments. – There should be several millimeters of space between the reduced tooth forms. – At least one tooth per quadrant. . – Inter-arch space: there should be an adequate inter-arch space for the overdenture. 5-8 a: d). – Canines and premolars are the best overdenture abutments to reduce adverse forces at this site (Fig.68 - . I. – Retained teeth should preferable not be adjacent ones.

.Centric occluding relation record used to mount the lower cast. IVSecondary impression: . . The coping is then cemented on the prepared abutments. Crown reduction with or without endodontic treatment is usually required.Fitting surface of the trial dentures should be relieved over the abutments to ensure proper denture seating. III- Primary impression: Impression is made using stock tray and alginate impression material. . impression is made to obtain casts for the coping-covered abutments. . Special acrylic tray is constructed on the primary cast.Check the vertical dimension.Check of denture stability and support. . VI- Try-in: .II- Abutment preparation: c.Setting up of teeth is then carried out.Wax patterns for the coping are made and cast in metal. Periodontal treatment including supragingival and sublingual scaling is carried out to attain healthy gingival tissue. .69 - . .Check the occlusion and the premature contact. d.Secondary impression are made using rubber base material and poured into stone. V- Jaw relation records: .Mount the upper casts on semi-adjustable articulator by the help of face bow records.

Dentures are then processed. 5-7: Abutment preparation: Crown reduction with or without endodontic treatment is usually required. Fig. finished. .The patient should follow the oral hygiene instaiction .70 – .VII. IXPost insertion care: . . VIII-Denture insertion: At overdenture insertion the fitting surface should be relieved over the abutment to avoid pressure on the gingival margin of the abutments.The patient should brush his denture after each meal.The denture should kept in tap water when not in use. polished and clinically remounted to eliminate any errors.

It consists of two or more parts. . Their components are machined in special alloys under precise tolerances. They are considered: semi-precision" since in their fabrication they are subjected to inconsistent water/ powder ratio. Attachments fall into two categories: precision and semiprecision.Semi precision attachments: A semi-precision attachment is fabricated by the direct casting of plastic. 2. One part is connected to a root. Since the specific hardness of the alloys is controlled.com ATTACHMENTS An attachment is a mechanical device used for retention and stabilization of a prosthesis. wax or refractory patterns.CHAPTE VI ATTACHMENTS Egypt Dental Online Community www. precision attachments offer the advantage of less wear on the abutments and standard parts which allow the components to be interchangeable and usually easier to repair when necessary. burn out temperature and other variables. tooth or implant and the other part to a prosthesis (Fig. Their main advantages are: economy.Precision attachments: Precision attachments are just that "precision". 6-1 a: f). 1. There are some attachments having one manufactured part and the other part is constructed by the dentist or the dental technician. easy fabrication and ability to be cast in a wide choice of alloys.71 - . There is a wide variety of attachments available today for overdenture prosthesis and more are being developed.egydental.

6-1 A:F: overdentures with stud attachment .Fig.72 - .

Type of coping. Crown root ratio and alignment of the roots. 2. Available inter-arch space. 10.classification of over denture attachments according to location: a.Clinical experience and personal preference. Bar type. Amount of bone support.Factors affecting Attachment selection: 1. 6. 11. 12. I. Intracorornal. Vertical space available. 8.The type of the opposing dentition whether it is complete denture. Whether the overdenture is a tooth supported or toothtissue-supported. b. 3. Number of teeth present. . Location of abutments. overdenture. fixed appliance or natural dentition. Radicular/intraradicular stud type. 5. 9.The maintenance problems and the cost.73 - . d. 7. Location of the strongest abutments. Extracoronal. 4. c.

It is however. minimal tooth reduction is necessary and the possibility of devitalizing the tooth is reduced. Intracoronal: Intracoronal attachments are incorporated entirely within the contour of the crown. 63). . A disadvantage arises when the abutment is over contoured by placing the intracoronal attachment outside the crown contour. more difficult to maintain hygiene with extracoronal attachments and patients should be instructed to use dental floss and hygiene accessories. Fig. removable partial dentures and segmented bridge (Fig. Fig 6-3: Extracoronal attachment. b. 6-2 : Intracoronal attachment. The advantage of an intracoronal attachment is that the occlusal forces exerted upon the abutment tooth are applied close to the long axis of the tooth. The advantages of this type of attachments are that the normal tooth contour can be maintained.74 - .6-2). Extracoronal: Extracoronal attachments are positioned entirely outside the crown contour.a. Most extracoronal attachments have some type of resiliency (Fig. Since all intracoronal attachments are non-resilient it is indicated for fixed bridge restorations. this often results from insufficient tooth reduction.

The stud attachment consists of male stud that snugly fits a female housing.c. 6-7a. Radicular / intraradicular stud type: Radicular and intraradicular stud type attachments are connected to a root preparation (Fig. 6-6: Female housing is embedded in the fitting surface of the acrylic overdenture.g. Some types are directly cemented into the prepared root without a cast coping e. new direct O-ring. The stud is usually attached to the metal coping cemented over the prepared abutment. Fig. 6-4: 6-11). The female element of intraradicular stud type fit within the root frame contour e. 6-5: Rigid stud attachments. . Fig. Fig. while the female housing is embedded in the fitting surface of the acrylic overdenture exactly opposite to the abutment.b: Resilient stud attachments.g. 6-4 a:c: Ball and socket stud attachment with different design. Fig. Zest attachment.

6-9: Extraradicular attachment. 6-8: Intraradicular attachment: Metal and plastic sections (male) are incorporated within the root Metal section (female) is incorporated within the root.Fig. Fig. 6-12 a. 6-10: Extraradicular attachment Fig. into which the bar will slot. 6-11: Magnets Fig. Fig. .b: Bar attachment with Sleeve plastic or metallic clips.76 - .

d. Resilient attachments reduce vertical and lateral forces on the abutments by distributing more of the masticatory load to the tissues. 6-5). Bar type: A bar attachment is in the form of a bar contoured to run parallel and overlie the residual ridge connecting the abutments together. 6-4. Abutment/tooth supported restorations are considered non-resilient or solid. blanching of the tissues. . clips or plungers. The advantages of bar attachments are that they splint questionable abutments together for mutual support. II.77 - . while abutment and tissuesupported restorations are considered resilient (Fig. 6-12). The overdenture fits over the bar and is connected to it with one or more retention sleeves. Bar restorations. when properly related to the gingiva should not cause food entrapment.classification of over denture attachments according to Function: It is important to differentiate between resilient or non resilient type restorations. The bar provides support and retention for the overdenture and splinting of abutment teeth (Or implants) (Fig. nor encourage tissue proliferation.

The vertically resilient type attachment allows only movement in the vertical plane. and magnets (Fig. The rotational and vertical type resilient attachment allows both rotational and vertical resiliency e. while the other pole is attached to the denture base opposite to it (Fig. . III- classification of over denture attachments according to retention mean: It can be obtained by frictional. e. The vertical and hinge type resilient attachment allows movement in both the vertical plane and hinge axis simultaneously e. Mini Dalbo. Magnets: One magnet pole is cemented in a prepared cavity in the endodontically prepared tooth. Dalbo.g. Resilient attachments are indicated with very weak abutment and when the opposing is natural or non-resilient appliance. 6-11).78 - . mechanical.Resiliency is a special advantage when the denture base fits poorly due to alveolar resorption. 6-5: 6-11).g. anchor the Universal. Omni-planar resilient type allows movement in any plane.g. The hinge type resilient attachment allows movement around a given point. frictional and mechanical. Resilient attachments may range from vertical to universal resiliency.

and in South America in the 18th century.egydental. and/or periosteal layer.Vitallium implants were developed as an inert biocompatible material. . surgically implanted into the oral tissues beneath the mucosa.Then a gold implant in 1807 and a platinum post were used to replace missing teeth. its corrosion properties are inferior to titanium. For this reason.Stainless steel and titanium were used in the fabrication of wire spiral implants. Ancient implant materials include the use of wood. Historical development of implant biomaterial 1. which are a castable alloy cobalt-chromiummolybdenum. it has not been approved as a dental implant material.Replacing lost teeth with a bone-anchored device is not a new concept. . cheaper and easier to machine. 2.com Dental Implants Dental implant is defined as “A prosthetic device made of alloplastic biomaterial. carved stone and animal teeth. .CHAPTE VII Egypt Dental Online Community IMPLANTOLOGY www.Lead coated platinum root shaped rods in 1886. Metallic implants: . During the ancient Egyptians era. Stainless steel alloy is stronger. however. . and/or within the bone to provide retention and support for a fixed or removable prosthesis”. Ancient implant materials: .Silver implantation around the end of the nineteenth century. .

2. while conducting research into the healing patterns of bone tissue. 5. the two literally grow together to form a permanent biological adhesion. In 1952.Psychological inability to wear denture. The first fixtures were placed in patients in 1965.. 7.stage dental implant system utilizing pure titanium screws. accidentally discovered that when pure titanium comes into direct contact with the living bone tissue. . .Massive bone and tissue loss following surgical removal of tumors. These patients are usually presented with one or more of the following features: 1.Active or hyper-active gag reflex precipitated by removable denture. especially when it becomes clear that conventional denture therapy is not the correct prescription.He developed and tested a two. He named this phenomenon "osseointegration".Unrealistic prosthodontic expectation. Indication: Patients who can not wear partial or complete denture or who wear them with varying degrees of difficulty are very frustrating. 3. 6.Recently the wide scale use of implants can be attributed to the Swedish research team directed by Branemark.Poor oral muscular coordination. a Swedish surgeon.Para-functional habits leading to recurrent soreness and denture instability. Professor Per-Ingvar Branemark. which he termed fixtures. even with adequate one. and intensive clinical studies have proceeded ever since.80 - . 8. 4. The titanium fixtures were implanted by a meticulous technique that aimed at direct contact between the implant material and the living healthy bone.Low tolerance of mucosal tissues.Severe bone loss that significantly endanger denture retention.

the endosteal blade and the endosteal root.-Such patients are candidates for implant prescription it is believed now that this advantage could lead to therapeutic strategies in prosthodontics that will considerably. fixed partial denture. over denture or any type of restoration connected to the implant and the abutment. During this period one begins to see the mergence of implant concepts developing into those that are presently the most refined and popularly utilized. these three are the most popular. The abutment: it is the core area which is connected to the implant where the prosthetic part is attached to it. Modern implant dentistry is delineated by the period from the mid 1930 to present. but other implant designs such as the ramus frame. These methods include the subperiosteal. Implant designs are traceable to early Egyptians. by time reduce the need to conventional removable prostheses. zygomatic implant and the fiber mesh are being utilized successfully as well. .81 - . Currently. transosteal mandibular implants.form implants. Components of a typical implant restoration: The typical implant restoration is composed of: The implant (fixture): it is the actual part that is inserted into the bone. The prosthesis: it is either single crown.

a b c Fig:. 7- 1). III.Tooth implants which include transplantation.Mucosal inserts IV.Non tooth implants which include subperiosteal. Classification of implants according to position: I. transosteal and endosteal balde and root. V.7-1a: b: Endodontic stabilizer . Endodontic stabilizer II. This was first used by Cuswell and Senia in 1983 (Fig.form implants.Transosteal implant.Endosteal implants I-Endodontic stabilizer It is a Smooth or threaded metallic pin implant that extends through the root canal into the periapical bone to stabilize the mobile tooth.Subperioteal implant.CLASSIFICATION OF DENTAL IMPLANTS Dental implant can be classified into two groups: 1. 2. reimplantation and endodontic endosseous implants.

An insert of double head connected with a bar and called the Tandom Denserts concept was also introduced in 1983. It is an effective and simple way to provide significant retention to a maxillary removable prosthesis (Fig. 1 4 Fig:.83 - . The maintenance of this seal is essential for providing the initial peri. The keratinized oral epithelium is continuous with nonkeratinized sulcus epithelium.integrated implants results in a structure similar to the gingival tissues around natural tooth. These types of implants have the unique feature of penetrating through lining epithelium.implant tissue inflammation that can lead to destruction of the implant support. Establishment of an adequate CT seal around implant provides a barrier to the ingress of oral toxins and bacteria. 7-2).7-2: Mucosal inserts . Epithelial regeneration around well.II-Mucosal inserts (Mucoperiosteal -implant interface): They are stainless steel inserts attached to the tissue surface of a removable prosthesis that mechanically engage undercuts in surgically prepared mucosal sites.

7-6) Because there is often not enough bone in which to place an endosteal implant. A three.III. with abutment posts and intraoral bars to attach a prosthesis (Fig.Subperiosteal implants: Its framework is made of cobalt chromium molybdenum based alloy resting on the alveolar bone beneath the periosteum. dentists turned to placing implants on and around bone. Fig:. making it no longer mandatory to carry out extensive surgical dissection for a direct bone impression. CAD-CAM generated model (only one surgical exposure) (Fig. 7-3: 75). however. CT generated models.7-3: Severely atrophied mandible . Construction The shape of bone for frame construction is obtained through: 1. Direct bone impression (2 surgical exposures) 2. and many operators prefer the direct technique. The second stage was performed for fixation of the casted metal frame to rest on bone and to be covered by the mucoperiosteal tissues.dimensional replica of the mandible can be developed from computerized tomography (CT) images. are not as precise as those obtained from a direct bone impression. Silicon impression material is used for this record. The metal frame was casted with four abutments designed to perforate the covering mucoperiostium to give support to a denture.

7-7: Transmandibular (Transosteal) dental implant.85 - . Fig.The staple bone plate is used to rehabilitate the atrophic edentulous mandible.IV-Transmandibular (transosseous) dental implants “staple boneplates”: . Fig:.7-6: A three.7-4: Upper framework Fig:. .It is a transosteal threaded posts which penetrate the full thickness of the mandible and pass into the oral cavity in the parasymphysial area (Fig.dimensional replica of the mandible can be developed from computerized tomography (CT) images.7-5: Lower framework Fig:.7-7). .

V. fixed detachable prosthesis.Various implant designs emerged in the early 1960.In 1978 Branemark presented his work.Blade form endosseous implants.86 - . Sweden "the two. d. .form implants with osseo-integration concept" . .Root form endosseous implants. .Endosteal (Endosseous) implants: .stage titanium screw root. 1.Classification of endosseous implants according to their design: a. . c.The discovery of osseo-integration has undoubtedly been one of the most significant scientific breakthroughs in dentistry over the past 30 years.Cylinders endosseous implants. overdenture and in cases of single tooth replacement.The implant is placed into the alveolar bone and composed of anchorage component (body) and a retentive component (abutment). The majorities are screw-shaped but some are cylindrical.link extension. which done in Gothenburg. b. It has to be noted that the era of placing root form implants into bone to support a tooth was started very early with various degrees of success.Endosseous implants are the most frequently used implants today for fixed.Screws or spiral post endosseous implants. with or without vents and some have a fin.

b.a.7-9 a-b). 7-10-7-11). .Cylinders which may be either tapered or baskets (hollowed with fenestrations). It is a wedge shaped implant composed of head.Blade form endosteal implant. The blade implant was restorable within a month of placement by the superstructure. Fig. The blade implant is a mean of utilizing the narrow and/ or shallow areas of remaining alveolar bone where dimensions do not permit the use of root form implants.Screws or spiral post implant which may be either solid or hollowed.87 - . Ramus frame implant was designed to be placed in the ramus of the mandible (Fig.7-8 a: Smooth Cylinder design B: Solid Screw Design C: Hollow vented D: Ripped with apical vent c. neck and body with vents which develops fibro osseous integration with bone. The blade vent implant was designed to solve the problem that existed in knife edge ridges (Fig.

88 - .7-9A-e : The blade implant is a mean of utilizing the narrow and/ or shallow areas of remaining alveolar bone .A: a wedge shaped Blade Vent implant b c e d Fig.

89 - .In 1973 Flander a new design of endosseous implants to decrease the high rate of failure of the old screw implants .Root form implants: .7-10.A: Ramus blade implant b c Straight Ramus frame d Bent Ramus frame Fig. A-d: Ramus blade & ramus frame d.

The endosteal implant shaped in the approximate shape of the tooth root (Fig. . 7-12). implant Fig.It requires more than 10 mm vertical bone height. and more then 8mm mesiodistal width to avoid undesirable complications. removable or fixed detachable prosthesis.. 7-11 a:d: All the implant designs are obtained by the modification of existing designs. . more than 6mm buccolingual thickness. b a c First Implant Design by Branemark Implant Core– Vent Branemark. .It may be used for fixed. 7-11.

Surgical Procedure Fig.7-12 a: e: Different types of root form implants.91 - . .

d. b. the implant threads are used to tap its site during insertion. in case of very dense bone.Titanium Plasma Sprayed surface (TPS). in this type of threaded implants.Pure titanium: the titanium oxide surface was responsible for the formation of the direct bone.Press fit technique. c.Titanium alloy: the titanium alloys exist in three forms: alpha. the implant site is drilled slightly smaller than the actual implant size. b. in this type of unthreaded implants. beta and alpha beta phases and they all originate when pure titanium is heated and mixed with aluminium and vanadium.Pre-tapping technique. where the implant is pressed into the recipient site with slight friction.Classification of endosseous implants according to the insertion technique: The insertion techniques of endosseous implants have been classified into either: a.2. c.Hydroxyapetite coating 4.Titanium oxide surface: coating the implants to make the inert metal a bioactive one.implant interface.Classification of endosseous implants according to their material: The endosseous implants may be made from either: a. 3Classification of endosseous implants according to surface characteristics: a. the implant sites are better to be previously tapped using the bone tap instrument before insertion of the threaded implant. b. it has satisfactory results regarding the osseointegration and the clinical prognosis. .Sand blasted surface.Self tapping technique.92 - .

b.Classification of endosseous implants according to surgical stages: a.Classification of endosseous implants according to biologic tissue response: According to the type of implant bone interface.Osseointegration: it is a direct structural and functional connection between ordered living bone and the surface of a load carrying implant. b. it is doubtful to achieve a long-term anchorage by means of connective tissue layer between the implant and the bone.Single stage design (none submerged – transgingival): the body of the implant is inserted into the bone with its abutment portion penetrating through the mucoperiosteum during the healing period. The implant body is then exposed and the healing abutment is placed for soft tissue healing before the impression is made for prosthesis fabrication. 6.93 - . d.Biointegration: anchorage may be achieved through a non mineralized zone. the dental implants are classified into either: a. This type of connection is considered the most desirable one by many authors. which is claimed to be a pseudoperiodontium.Ligamental integration: Cranin the presence of soft tissue layer surrounding the implant.Fibrointegration: researches revealed that clinical success rating was not convincing with the presence of a connective tissue layer surrounding the implant. .Two stage design: in this design the implant body is completely embedded in bone for complete osseointegration. c.5.

B. • The response of hard and soft tissues to surgical preparation and implant placement. • Meticulous tissue handling to give the bone and marrow tissues the power to repair as such. • The immediate and long. which is expected to result in osseointegration.term adaptation of tissues to functional load. .Osseointegration: Osseointegration Defined by Misch in 1993 as: Direct contact between ordered living bone with the surface of an implant on the microscopic level of magnification without any intervening tissues The key for success of osseointegration. Fig.7-13. and not as low differentiated s car tissues. To establish TRUE& LASTING osseointegration we should know. Non osseo-integrated. • A minimum volume of the remaining bone should be removed and the original jaw bone topography must as far as possible be left intact. • The time needed for healing process.94 - . a: Osseo-integrated.

Classification of endosseous implants according to time of prosthetic loading: a. or . delayed loading is done in maxillary implants after 4-6 months and in mandibular implants after 3-4 months to allow for better osseointegration due to the difference of the investing bone composition. this type of dental implants is made of either . b.Classification of endosseous implants according to the time of installation: a. an acrylic resin prosthesis which is designed to be out of occlusion is placed immediately after implant placement.Carbons which decreases the induced stresses in bone.Polymers.Metallic implants. c. b.Non metallic implants.Delayed loading implant.Immediate delayed implants. . when complete healing and bone remodeling occur.Immediately loaded implants.Endosseous implants are also classified according to the material into: a. they are placed into a prepared extraction socket following tooth extraction. they are placed within 6-12 weeks after the tooth loss. It is one of the most suitable types. 9. b. this type of dental implants is made of high strength metals. 8. specially in anterior region for esthetic purposes.95 - . they are placed within 6-12 months after tooth extraction.Immediate implants. but it was found to be of lower strength quality and thus it is not used any longer.7.Delayed implants. .Ceramics.

A week Vander waals bond. aluminum oxide. theoretically it is either: 1. have a minimum to nonexistent interfacial chemical bond. and then the body is called on to "heal" with direct contact of the implant to bone (osseous integration). The implant material is one of the important factors that determine the chemical nature of this interface. the bond strength is of lesser magnitude than that experienced with HA. such as calcium phosphate ceramics. such as alloys.96 - . 3.HEALING OF ENDOSSEOUS IMPLANTS (WOUND RESPONSE) Surgical procedure is performed in a patient to insert a foreign material into bone.Combination of 1& 2. . which must be considered.Direct chemical bond (ionic or covalent bond). There are many requirements for successful osseous integration. It is controversial. during the placement of endoseous implants. whether commercially pure titanium form a direct chemical bond to bone. Bone implant interface The exact chemical nature of the interface that forms between the bone and the metallic implant is yet to be determined. but it is believed that although a chemical bond may be present. however. carbon. 2. but they have excellent bone contact. and most polymers. Other materials. Chemical bonding of the implant material to the surrounding bone is a welldescribed phenomenon with certain material.

Under favorable mechanical condition a direct bone contact (osseo-integration) will result. which also creates a chemically non. Glass and calcium phosphate. Bio.g.g. making it unsuitable for articulating surface. 2. Bioactive materials e. however.g. Titanium& Titanium based alloys Commercially pure Titanium and Titanium based alloys are low density metals that have chemical properties suitable for implant applications. . The higher the impurity content of the metals.reactive surface to the surrounding tissues. 3. Titanium has poor strength a wear resistance.Biocompatibility The development of biomaterials science has resulted in classification of implantable materials according to their biologic response and toxicity into: 1.97 - .inert materials e. Bio-tolerant materials e. the higher the strength and brittleness. titanium and aluminum oxide: these are materials which are non-reactive to surrounding tissue. The modulus of elasticity is at least five times greater than bone. Implanting of such material. under favorable mechanical condition will result in direct chemical bond between implant and bone. Titanium has a high corrosion resistance attributed to an oxide surface layer. polymethylmethacylate: if these materials are implanted in bone a thin fibrous tissue interface will be formed around them due to their chemical nature.

hygiene. 1. location of the implant.Factors affecting healing There are many factors that can affect the healing process. whereas other deal with patient selection. and site selection. 2. frictional heat. Excessive trauma leads to fibrous encapsulation of the implant. A longer healing period will be required before loading implants then surgical fit less then optimal. Surgical trauma must be minimized during all aspects of implant surgery to optimize success rates.Surgical fit Even with the best technical precautions. bone contacts only portions of the implant and a perfect microscopic contact is not possible. .Premature loading Time should be allowed for healing of necrotic bone. The temperature for impaired bone regeneration has shown to be as low as 44 to 47 c for one minute.Surgical technique All surgical procedures are traumatic. The level of trauma is a critical factor that determines whether healing will progress toward fibrous or osseous integration. Movement of the implant during this healing phase will result in fibrous encapsulation. Some of these factors deal with surgical technique and treatment plane. Surgical preparation on hard tissue causes a necrotic zone of bone (interface) due to cutting of blood vessels. For this reason it is recommended by many operators to keep the recently placed implants unloaded for a period of two to eight months depending on the clinical situation.98 - . formed due to surgery. implant coating. loading pattern. and whether the implant is placed into bone grafts. and vibrational trauma. 3.

Physical condition of the patient: Nutritional status.Changing the implant angulation's. Team approach Some authors believe that the same operator should place and restore the implants. more porous cortex. corticosteroids therapy and radiation treatment are among many factors which can affect healing. 5. .Bone quality and quantity The mandible has a denser cortex and a coarser thicker cancelli than the maxilla. it is very frequent to find that bone amount is not enough for implant placement. .in second opinion . aging.4. blood diseases.99 - .Subantral augmentation (sinus lift) in the maxilla. Because it allows for the utilization of expertise of the two individuals. and a finer cancelli. jaws tend to have a thinner. there is a built. . A surgeon should place the implants. these changes can be incorporated into the treatment plan more readily. When we go posterior.Bone synthesis (ossified tissue can be created in predetermined shapes and dimensions). Because the same individual is responsible for the prosthetic treatment. The rationale is that it is more efficient form a patient's point of view. Others believe that a team approach is more appropriate to follow. The following measures can be done to overcome this problem: . Bone regeneration is more likely to progress at a faster rate if the surrounding is denser. It also allows the practitioner more freedom in changing the predetermined position of the implants at the time of surgery. . diabetes mellitus.The use of shot implants. .Transpositioning of the neurovascular bundle in the mandible. and a prosthetic dentist should complete the restoration.Ridge augmentation.

The prosthetic dentist should: 1. 5.up.Ensure recall of the patient to evaluate maintenance and provide care as required.100 - . The oral surgeon responsibilities include: 1. 7.Placement of the implants (first stage surgery). 4. 4. Additionally. 3. 8. 6. .Confirmation of the physical evaluation.Perform the initial radiographic evaluation.Obtain the diagnostic casts. there is shared responsibility and shared liability.in the approach.Provide oral hygiene care and instructions.Design and fabricate the prosthesis.Uncovering of the implants (second stage surgery).Obtain the diagnostic wax. and it should be clear that dental implant is a prosthetic technique with a surgical step.Confirmation of osseo-integration of the implants.Determine the location and number of implants and fabricate a surgical template.Select the proper abutment following the implant exposure. 5. 3.Confirmation of the radiographic evaluation.Determination of the location and number of implants within limits set by the prosthetic dentist. 6.Perform the initial clinical evaluation. 2. 2. it is well to delineate the responsibilities at each stage of implant therapy. 9. Regardless of the philosophy followed.

Dental Implants Materials and Composition General requirements of implant biomaterial 1. 5. 2-Tantalum was considered to be mechanically inferior and susceptible to corrosion (39). Commercially pure titanium and titanium alloys as dental implant material. Radiopaque. 6. 3. High esthetic properties. Sterilizable. 7. of adequate strength properties to withstand the occlusal forces without permanent deformation but should be of low modulus for optimum force transfer. Mechanically compatible. 2. Taitanium and Niobium and their alloys Disadvantage: 1-difficult to cast because of their high melting points which are 2996 °C and 2468 °C respectively.101 - . .e. Additionally. i. Economically reasonable. Not complicated surgically or prosthetically. they should elicit physiological reactions within the surrounding tissues. nor carcinogenic and they must not cause local or systemic damage. 4. they must not be toxic. Biologically compatible. they must be processed with powder metallurgical techniques and high vacum centering.

advanced casting techniques. carbon and nitrogen stabilize the alpha phase of titanium because of their increased solubility in the hexagonal close packed structure. centrifugal –force casting machines.It is paramagnetic and has low electrical conductivity and thermal conductivity. new investment materials. oxygen enriched and hardened surface layer of about 100 micrometer thick. i. at temperature up to 882 °C.5 kg\m3. titanium surfaces will be contaminated with alpha case. and advanced melting techniques have been developed.e.It is highly reactive nature in the presence of such gases as oxygen. and gravity casting . cooling cycles . aluminum.Physical properties of titanium: 1. Above this temperature. the structure is body centered cubic (beta phase). to prevent metal contamination during casting.102 - . It exists as a hexagonal close-packed atomic structure (alpha phase). 5. (In the last 10 to 15 years. iron. these advances have led to the feasibility of casting titanium. chromium and vanadium. pressure .Titanium is an allotropic metal that can exist in two different crystallographic forms. vacuum . based materials in the dental laboratory. Without a well controlled vacuum.melting point 1668 C . 4. 2. The elements that stabilize the beta phase include manganese. This surface layer reduces strength and ductility and promotes cracking because of the embrittling effect of the oxygen. The elements oxygen. Its atomic structure is affected by high temperature. . mold material and special casting equipments. because of its low density it is difficult to cast in conventional. the casting must be done in a vacuum furnace.high melting point of titanium makes its casting process so expensive as it require special melting procedure . 3- Density of titanium is 4. which combine centrifugal.

Alpha alloys are suitable for somewhat elevated temperature applications. Heat treatment is dependent on the cooling rate from the solution temperature and can be affected by the size of the component. When strengthening alpha + beta alloys the components are normally quickly cooled from a temperature high in the alphabeta range or even above the beta transus. .Titanuim Alloys There are three principal types of titanium alloys: Alpha alloys. Alloys with beta contents less than 20% are weldable. Alpha + beta alloys have chemical compositions that result in a mixture of alpha and beta phases. Alpha alloys commonly have creep resistance superior to beta alloys. but are not as readily forged as many beta alloys. Beta alloy sheet is cold formable when in the solution treated condition. Beta alloys can be strengthened by heat treatment.103 - . The beta phase is normally in the range of 10 to 50% at room temperature. Beta alloys are prone to a ductile to brittle transition temperature. is an alpha-beta alloy. Titanium aluminum-vanadium alloy (Ti6-Al-4V). it is the most commonly used alloy for dental implant. alpha-beta alloys and beta alloys. Beta alloys have good forging capability. Solution treatment is then followed by aging to generate a proper mixture of alpha and transformed beta. While Ti-6Al-4V is fairly difficult to form other alpha + beta alloys normally have better formability. Alpha alloys cannot be strengthened by heat treatment. Alpha + beta alloys can be strengthened by heat treatment. The most commonly used titanium alloy is Ti-6Al-4V. They are also sometimes used for cryogenic applications. and weldability for various applications. Alpha alloys have adequate strength. an alpha + beta alloy. toughness. Typically beta alloys are solutioned followed by aging to form finely dispersed particles in a beta phase matrix.

3.Range of problems included fractures during surgery.Carbon A.104 - . infection. Hydroxyapatite implant Different forms of hydroxyapatite were used for augmentation of resorbed ridges and both hydroxyapatite and tricalcium phosphate materials were used for coating of different types of dental metal implants. fractures after loading. . Ceramics A single crystal sapphire aluminum oxide endosseous implant Advantage: . and lack of osseointegration A zerconia implant Gray color of a titanium implant might hamper the esthetic appearance of the entire reconstruction in cases of thin periimplant soft tissue or tissue retraction. bone loss.Ceramic. pain.Non metallic implant Types of non metallic dental implants a. Hydroxyapatite root implants were used experimentally for bone preservation after teeth extraction. b.Its excellent soft and hard tissue biocompatibility. mobility. Disadvantage: .Polymer c.

Polyactive implants function clinically adequately and resemble the mobility of natural teeth Polyactive implants showed a statistically significantly higher bone contact.The Procera abutment.with a low modulus of elasticity. .High-strength silicon nitride implant. that exhibits bone-bonding characteristics. Polymers - Silicone implants. . .The ZiReal Post: A new ceramic implant abutment. B. It was found that this material was very effective in minimizing bone resorption. as compared to the HA implants. flexible bone bonding implants might be more capable of transferring stresses to the surrounding bone and are therefore promising alternatives to "routine' rigid implants.105 - .Flexible (Polyactive) (hydroxylapatite) dental implants Polyactive is an elastomeric polyethylene-oxide polybutylene-terephthalate (PEO:PBT) copolymer.Aluminum oxide implant abutment.Hard tissue replacement (HTR) This hard tissue replacement material to fill the bone channel over the shoulder of blade vent implant in an attempt to control bone resorption in this critical area.(46) Ceramic dental implant abutment: . increasing bone density and controlling implant mobility.Alumina-zirconia machinable abutments . connective tissue does not attach to the surface of silicone or any other polymeric material . .

Bioactive glass ceramic cervical coating of metal implant .Hydroxyapatite-based composite dental implant The HA-based composites were fabricated by mixing HA with Al(2)O(3)-coated ZrO(2) powders .Plasma spray HA. C. 2. Titanium oxide surfaces the excellent biocompatibility.Composite implant .. Another two types of carbon were used as dental implant material which are less brittle as the vitreous carbon pyrolytic carbon the vapor deposited carbon Surface characteristics of dental implants 1.plasma-spraying coating bioactive ceramics onto silicon nitride surface . FA onto its surface as composite endosteal implants.Because silicon nitride has high strength and hydroxylapatite (HA) and flourapatite (FA) have good biocompatibility .106 - . Carbons Vitreous carbon implants are made of glassy carbon layer on a stainless steel core. Hydroxyapetite coating 6. Sandblasted surface 3. Plasma sprayed surface coating 5. Laser induced surface roughening 4. it can be placed in either fresh tooth extraction sites or in sockets prepared in the edentulous ridges. It is indicated for single tooth replacement as single free standing unit or splinted to adjacent teeth but it is easily fractures or chipped if not properly handled.

2.The advantages of hydroxyapatite coated implants include: Improved biointegration and faster bony adaptation as bone growth from both surfaces of implant and the cut bone. . Requirements for achieving proper osseointegration: Proper osseointegration is mandatory for the desirable long term prognosis of the dental implants. rapid and destructive peri-implant crestal bone loss. Bacterial colonization. due to unknown etiology (32). coating failure has been attributed to two main reasons: a) Dissolution of hydroxyapatite layer. Saucerization phenomenon: is a sudden occasional. Disadvantages of hydroxyapatite coated implants are: 1. It shows improvement in the bone implant interface area in comparison to pure titanium implant in the early phases. Bioactive glass ceramic ceravital coating forms a physicochemical bonding with bone which is capable of withstanding stress caused by tension. 3. Several factors are involved in the direct bone to implant relation. b) Fracture of titanium hydroxyapatite bond. this new implant is suitable for the combination of metal implant stability and tissue compatibility of glass ceramic. that is usually occur after an initial successful period of biointegration.107 - .

Bone drilling should be perfomed using a graded series of drill sizes rather than using one large drill . 3.108 - .The implant design: The design should allow intimate contact between the implant and its prepared bone site to provide immediate immobilization after installation and during the healing period”.The implant surface: The implant surface should be clean.The host bone properties: Bone combining good vascularity and mechanical resistance provide a good implant prognosis.These factors are summarized as follows: 1. The bone will heal and new bone is formed only if certain local conditions are optimized concerning bone drilling and cooling system. sterile and free from any metallic contaminants capable of causing corrosion (107). . 4.The surgical technique: The surgical technique for implant insertion should aim to cause minimal tissue trauma.The implant material: The implant should be made of an inert material that resists corrosion and has sufficient strength to allow for proper long term osseointegration . 2. Bone resorption may occur due to unavoidable surgical trauma and that bone integration may be distorted by irradiation. 5.

paresthesia or violation of the mandibular canal. The relation between the implant and jaw bone can be divided into three partly overlapping time periods which are: healing stage.Bone loss is less than 0. This requires careful listening and sufficient time.109 - .The implant design should not interfere with the placement of a crown or prosthesis with a satisfactory appearance to the patient and/or the dentist. 3. mastication or phonation. 2. Criteria for success of dental implants: The criteria for success of osseointegrated implants includ: 1. 5.6.Absence of pain.Immobile implants when tested clinically. aesthetic. 4. Clinical Evaluation Chief Complaint: The practitioner must determine which is the most important for the patients.2 mm annually after the first year of service. .No peri-implant radiolucency in radiographs.The condition for healing at the implant site: Premature implant loading before sufficient implant stabilization is a potential hazard for its osseointegration. remodeling stage and steady stage. infections. necropathies.

Physical Evaluation: The medical history normally taken in the modern dental office often is enough for implant patient. It must be kept in mind that there are few contraindications to the use of dental implants. Proper evaluation should be made whether the patient can tolerate the planned procedures or not consultation with the surgeon at this point may be necessary to arrive at proper evaluation in- patients with complicated medical history. The physical ability or limitations of the patient also play a part in the design of the prosthesis, the selection of the final restoration.

Psychological Evaluation One must realize that. For many patients, the perception of what constitutes implant therapy has been formed from information provided by friends, publications, and other mass media. This is not necessarily all negative, because it results in the patient seeking implant therapy. Many times, however, the patient cannot properly evaluate the information, and limitations of therapy are not clearly

understood therefore, it is necessary to educate the patient concerning the necessity of specific procedures for the case. Probably the most frequent misconceptions expressed by the patients concerning the use of implants are the time involved to complete treatment, the surgical techniques used to achieve integration, the effects of resorption of the residual alveolar ridge on the final restoration, the requirement for maintenance of the restoration, and the coast involved.

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Dental Evaluation In addition to the usual dental evaluation, the prosthodontist must incorporate into this evaluation the possible effects of the conditions present in the oral cavity on implants placed in this environment. A history of bruxism, mal-aligned dentition and extruded teeth, which preclude the development of harmonious occlusion and a hygienic restoration should alert the operator to problems in this area. The patient's commitment to a life long- term maintenance program must be evaluated. Implants represent only a part of the overall treatment of a patient. The entire dentition must be considered in the treatment plane. Restoration of carious lesions, elimination of spaces by conventional fixed restoration, elimination of periodontal disease, and restoration of a harmonious occlusion, are all requisites for successful implant therapy, it is recognized that active periodontal disease has the potential to spread to periimplant tissues.

Bone The age of the patient and the amount and type of bone available to support the implants must be determined. The types of radiographs used depend on the number of implants to be placed, the location in the jaws, and the availability of the equipment. Another method, which can be used in determining the amount of bone available, is palpation. This method is particularly useful in the mandible. It is often possible to encircle the mandible completely with forefinger and thumb and obtain an indication of the size and shape of the arch at a particular point. - 111 -

Soft tissue The soft tissue through which implants exist in the oral cavity is a critical area in terms of long- term success. This is the area that the patient must maintain to ensure gingival health and therefore must be capable of withstanding the hygiene manipulation (brushing and flossing). Fixed keratinized tissue is the preferred tissue in this area. This is the only type of tissue that has ability to form a tight collar around the implant necks. If soft tissue grafting is anticipated, it is probably best done before implant placement.

Ridge relationships The relationship of the maxilla to the mandible plays an important role in determining the type of prosthesis that can be done and is a deciding factor in the type of occlusion that can often be determined by visual examination, the best observation of this relationship is achieved from mounted diagnostic casts.

Radiographic evaluation The first step in formulating a treatment plan for dental prostheses using implants must be determination of sufficient bone quantity and quality to support the implants. The choice of radiological technique appropriate for a given patient depends on a number of factors, including the type of restoration and implants to be used, the position of the remaining dentition, the extent to which bone quality or quantity is in question, the availability of the machine needed, and the coast. The following radiological techniques are available: 1- Periapical radiographs. 2- Panoramic radiographs. 3- Lateral cephalometric radiographs. - 112 -

stability.. Therefore. This requires knowledgeable practitioner. and support. The aim of placing such marker (metal ball of known diameter) is the determination of actual ridge height because ordinary radiographs do not have one. The patient must be educated to other treatment options available to provide a stable. on the panoramic film they measure 6 mm. Implants can also be used to improve conventional prostheses.Computed tomography.Magnetic resonance imaging(MRI) A maker of known size should be placed directly on the mucosa during the exposure. when a periapical or panoramic radiographs was selected as the preferable technique.Conventional tomograms (CT). supported. 6. if the actual diameter of the maker is 5 mm. However. Visual aids that illustrate similar cases from previous patients can be of great help.113 - . Implants can also be splinted with superstructures to provide the required retention. and aesthetic restoration. If the patient's desire is not possible to be achieved owing to the condition present. retentive. . a 20% magnification occurred.3 mm is actually available. 5.to one correspondence with regard to size. For example.4. Implants placed in strategic positions in the partially edentulous residual ridge can also be used to support removable partial dentures. PROSTHODOCTIC OPTIONS Prosthesis required The type of prosthesis required depends on a large measure on the patient's desires and chief complaint. if the bone measure above the interior dental canal is measured 22 mm on the film only 18.

. the problem of encroachment on tongue space becomes critical. . The following are the measures needed to guard against the problem of mal-positioned implant: .Use of surgical stent. It is obvious that the prosthodontist has limited options when trying to restore a mal-positioned implant. Bone or allogenic material to rebuild the residual ridge. the anterior portion moves posteriorly and superiorly. before implant placement. . and the patient desire. The prosthetic options to ensure an aesthetic result depend on implant placement.Communication with the patient about esthetic problems. This is due to the encroachment that occurs to the tongue. can often correct severe resorption of the ridge.Number of implants required The number of implants required depends on the type of prosthesis to be placed. Phonetics This is more frequently a problem in the maxilla than in the mandible.114 - . or a greater number for a fixed type of restoration. When the thickness of the prosthesis is added to cover the implants and it's superstructures. the length of the gap that is going to be restored. Aesthetics Aesthetics is an area in which the prosthodontist can encounter a great deal of problems.up that includes the anticipated thickness of the prosthesis. The main key factors are to quality and quantity of bone available. This means that implants placed in the anterior resorbed maxilla are more palatal than were the natural teeth. This can vary from single implant to support one tooth.Communication with the surgeon. The solution to this problem is to use a diagnostic wax. It is most often the patient with a severely resorbed maxilla who is likely to complain with phonetic difficulties. As the maxilla resorbs. two implants to improve the retention of an overdenture.

The surgical stent can be fabricated using a clear heatcured or autopolymerized acrylic resin and of approximately 4mm in thickness. metal. In general lateral forces must be avoided. The loading on the implants must be minimized to the greatest extent possible. and acrylic resin. Surgical stent Once the position of the implants is determined by palpation clinical.bone interface. the surgical stent is fabricated. the first is to guide the operator to the selected places for implant placement and the second is to direct the operator drill to a proper direction through which he should drill in bone (Fig. however. That is each patient brings with him or her unique occlusal determinates that guide in developing a specific harmonious occlusion for that particular patient. longterm beneficial results of one material over the other have not been evident. and all efforts must be made to direct the forces to the long axis of the implants. It should be noted that discrepancies in the horizontal relationship of the two arches could lead to difficulty in attempting to develop a harmonious occlusion. Again mounted diagnostic casts are an essential aid in determining the correct maxillomandibular relationship. Occlusion is an individual requirement. Some general occlusal requirements. There are two main functions for the stent.).Occlusal Surface Materials There are essentially three materials used on the occlusal surfaces of prostheses. must be entertained at the time of treatment planning. Occlusion Occlusion is a complex subject. The manner in which the occlusion is developed determines how occlusal forces are directed to the implant and how these are distributed at the implant. Porcelain.115 - . . radiographic and diagnostic cast examination.6. We should not attempt to bring all patients into a particular philosophy of occlusion.

we look for prosthesis with an occlusion where maximum intercuspation coincides with the position of condylar centric relation. This is partially due to this condition being totally asymptomatic.116 - . those clinicians who regularly treat patients with dysfunctional TMJ problems frequently observe that the meniscus is poorly placed. To avoid iatrogenic damage to the stomatognathic system.OCCLUSION IN IMPLANTOLOGY Introduction Mandibular closure is very important. because it ends with the contact of teeth from the upper and lower arches. Prosthesis design. Now we will define the basic principles of occlusion: A) Centric relation This is the physiological position of the condyles when they are centered in the fossae in their uppermost position and related correctly with the meniscus against the posterior incline of the articular eminence. in . which is sometimes underrated in implantology. On few occasions is its physiological position restorable. will be important for the future prognosis of the installed appliance. functionally speaking. which will hinder our task in arranging tooth contacts correctly. it is important to consider the principles of occlusion. The successful introduction of the term meniscus into the definition of centric relation is a sign of openness within the occlusal philosophies. Implants will not always be perfectly positioned. In general. However. and in MRI studies it is seen ahead of the condyle.

Maximum tooth contact does not interfere with the correct condyle position. presenting clinically with reciprocal clicks of variable intensity. C) Working condyle and working side When the mandible moves laterally. which will prove useful in preventing advanced lesions.many cases.117 - . . the (working) condyle on the side to which the jaw moves (working side) carries out an almost pure rotation on a vertical axis without any lateral displacement. B) Maximum intercuspation This is the tooth position where maximum occlusal contacts exist in the active chewing cusps (lower buccals and upper linguals) in relationship with the opposing teeth. if a lateral displacement occur. a Bennett movement would be present. which are painless and which sometimes go undetected by the clinician. In any event. we shall still consider centric relation as the ideal physiological condylar position. For this reason. eliminating overloads in the closed position over soft tissues. What we pursue in ideal occlusion is to have both positions (centric relation and maximum intercuspation) coincided. we are inclined to believe that in the future centric relation will be referred to as the physiological position of the condyles in the fossae. to achieve better communication with the readers.

This induction maneuver should be done on both sides while exploring lateral excursions of the mandible. On occasion. when the TMJ allows this to occur. forward. and in other cases. downward. This covers the possibility that when the patient is sleeping on his/her side he or she could start a grinding parafunction. The condyle travels forward. groove and incline positioning. These changes in condylar position during lateral movements greatly influence occlusal anatomy. or a combination of these. E) Bennett movement The Bennett movement is a full mandibular side-shift in which the working-side condyle will initially travel out from the glenoid fossa. . as well as the lingual aspect of the upper anterior segment. Since we foresee this situation. giving place to variations in cusp height. downward.118 - . The Bennett induction maneuver is done by forcing the mandibular angle on the nonworking side towards the working condyle. backward. depending on the presence or absence of the Bennett movement variations that may exist. it must be induced. and medially. The Bennett movement does not always appear during lateral excursions. producing on this side an outward sideshift. with sideshift induction at the time of occlusal equilibration we can introduce adequate grooves that will allow an escape route for opposing cusps.D) Nonworking condyle and nonworking side These are the opposite condyle and side of the working condyle and side. later being able to move upward. it does not exist.

119 - . In this way. It should be noted that because of the osseous anatomy of the anterior maxillary area.5 mm separation in the opposing teeth on the nonworking side and a 1-mm separation on the working side. lateral and central incisors). F) Anterior disocclusion guide In the ideal occlusion. especially to hyerlaxitudes. If we follow these principles. avoiding unwanted TMJ tension originating from the occlusion. laterals. we would like strong contacts in maximum inter posterior teeth (molars and premolars) and softer contacts in the anterior teeth (canine. we should pay special attention to the Bennett movement when adjusting the occlusion. This is due to the fact that the lingual aspects of the canines.The Bennett movement takes place through different mechanisms. it seems that its presence is related to TMJ pathology. permitting physiological function of the stomatognathic system. implant inclination will be similar to that of the eminence. the whole system will function in harmony. The anterior guide should be as flat as possible allowing for posterior disocclusion. leading to joint overloading. As a general rule. and centrals will be in harmony with the inclination of the articular eminence. disoccluding the posterior teeth. overloading of the structures that keep the condyle in the articular fossa and of the anterior implants will not occur. At t his time. a condylar sideshift of 3mm should have a 1. the anterior teeth immediately become the guidance. whether or not they have an occlusal origin. once eccentric movements ( (lateral or protrusive( begin. Since most implant patients have lost a great deal of teeth. .

.120 - .First and second premolars (one active cusp).. distal cusps . fossae. the anterior guide must be created first.Molars (three active cusps). mesiobuccal.Molars (two distolingual cusps active cusps).. the active cusps are the linguals: .. distobuccal. When developing the occlusion in a restoration.. mesiolingual and In the mandibular arch.Fig. once it is perfectly incorporated. lingual cusp . G) Posterior occlusal anatomy The construction of posterior occlusal anatomy consists of correctly positioning cusps.... while searching for tooth-to-tooth and cusp-to-fossa relationships. In the maxillary arch.First and second premolars (one active cusp). buccal cusp . the active cusps are the buccals: . we move on to adjust the occlusion in the posterior.7-14: Relationship between the inclination of the eminence and lingual aspect of the anterior segment. and pathways.

Upper active cusps (lingual) First upper premolar . mesial fossa of first upper premolar.Lower active cusps (buccal) First lower premolar. distal fossa of the lower first premolar Second upper premolar.. distal fossa of the lower second premolar Upper molars: Mesiolingual cusp to central fossa of the opposing mandibular molar Distolingual cusp to distal fossa of the opposing mandibular molar -...... the lingual . mesiobuccal and distobuccal The lingual cusps are nonactive in the mandibular arch: .The buccal cusps in the maxillary arch are nonactive: .Molars (two cusps). the buccal .. Second lower premolar.. Distribution of active cusps with their corresponding fossae is done in the following way: -.... the active cusps must have their corresponding opposing fossae. To achieve proper occlusion and efficient masticatory function. mesiolingual and distolingual The nonactive cusps participate in fossae configuration and bolus retention during mastication.First and second premolars (one cusp). mesial fossa of second upper premolar...First and second premolars (one per tooth)..Molars (two per tooth)..121 - . .

the absence of prematurities. Three contacts per cusp is considered the ideal situation but is seldom achieved.122 - . We try to obtain one. The grooves that will allow the cusps to exit from their fossae during working. and disocclusion . We do not believe that the cusp tip should be at the fossa’s bottom. In this way we have arranged the cusps and fossae of the posterior component of the occlusion. and protrusive movements are now designed. Some philosophies of occlusion support tripodization. or three contact points. we believe that this is enough to obtain adequate masticatory function. Distobuccal cusp to central fossa of the opposing maxillary tooth. because to avoid lateral contacts. the active part will probably be very small. while others prefer that the cusp tip contact the bottom of the fossa. the condyle in centric relation. . nonworking. even if we only achieve one contact in each fossa. The next step will be to relate the cusp within the fossa. two.Lower molors: Mesiobuccal cusp to mesial fossa of the opposing maxillary tooth. Distal cusp to distal fossa of the opposing maxillary tooth. Our philosophy is to seek cusp contact on the fossa incline. This means we would have at least two in premolars (corresponding to one cusp and one fossa) and five in molars (cusps and fossae). Now we have the cusps seated in the fossae (with point-like contacts). which would give sufficient occlusal stability.through good anterior guidance. Considering that we can relate 38 cusps to 38 fossae. making sure they are really contact points and not surface contacts.

Upper arch: Working groove: Protrusive groove: transversal towards buccal towards mesial Nonworking groove: oblique towards mesial and lingual . and medial) condylar movement must be considered for groove inclination and direction that will permit.123 – . the exit routes of the cusps follow their corresponding grooves. Occlusion of the lower active cusps (buccal) into their corresponding opposing upper fossae. the cusps to exit their fossae without posterior contacts. according to the different mandibular movements. that is. Occlusion of the upper active cusps (lingual) into their corresponding opposing lower fossae. the fossae exit paths are completely opposite in the upper and lower teeth. Working (rotation and perhaps outward or other combinations) and nonworking (downward. Evidently. B.A B Fig. 7-15: A. forward.

. In lateral excursions. 7-17: Diagram of maxillary exit paths. thus avoiding loads on the anterior teeth. However.5 only one upper and lower teeth have been shown. while the posterior teeth remain completely free. Fig.4 and 3.124 - . in closure. Lower arch: Working groove: transversal towards lingual Nonworking groove: oblique towards distal and buccal Protrusive groove: towards distal It should not forget that all fossae need grooves to allow cusp exist without interferences. In Figs. this will only allow anterior tooth contact. the anterior teeth remaining almost free contact. but the direction of all grooves is similar in the rest. 3. 7-16: Diagram of the active masticatory area. only the posterior teeth will be in contact (cusps in fossae).Fig. The forces applied on the implants will be vertical with respect to the axis of the posterior teeth.

the fact that full force is applied in one point (initially) implies osseous and implant overloading. as well as alterations of masticatory dynamics conductive to pathology in the long run. 7-18: Diagram of mandibular exit paths. . because of the leverage that is produced. On the other hand. with the condyles in centric relation that occurs before maximum intercuspation. L Red(left) nonworking Blue(center) protrusive Green(right) working H) Prematurities Prematurities represent any tooth contact during mandibular closure. Fig. If there are parafunctions.125 - . Prematurities force the condyles out of centric relation.R. but also on the rest. this can lead to articular and muscle overloading. not only on the tooth closest to the prematurity.

The lateral forces generated cause implant overloading and loss of harmony among the anatomical structures within the articular fossa. which predisposes to hyperlaxitudes and meniscal displacement (Fig. * Overloading of the implants due to the presence of lateral forces.126 - . which in turn produces: * A compressive component on the working condyle. * A tensional component in the non-working condyle.Fig. I) Interferences These are the nonphysiological contacts that appear in the anterior and posterior teeth in lateral and protrusive excursions. 719). 718). 7-19: Diagram of prematurity. a) The nonworking interferences are very important because the mandible must pivot avoid them. predisposing to arthrosis and discal pathology in their external insertions (Fig. b) The working interferences create large frictional surfaces in premolars and molars during lateral excursions due to the presence of multiple contacts. .

Fig.: 7-20

Fig.: 7-21

Fig.: 7-2

Fig. 7-23

If anterior guidance cannot be accomplished, group function should be used. This should be done following the anatomical components and obtaining contact in the first premolar, second premolar, and mesiobuccal cusp of the upper first molar (Fig. 7-22). The presence of anterior guidance implies that posterior contacts during working movements should be eliminated (Fig 7-23). c) Protrusive interferences create a tensional component in both condyles and implant overloading (Fig 7-24). Prematurities and interferences will be more or less pathological depending on whether parafunctions are present.

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During mastication, the teeth should only contact at the end (before that, a bolus exists that separates them). Contacts also occur when swallowing saliva. The duration of both functions totals approximately 10 minutes daily. If parafunctions exist, the time for both functions may increase enormously, thus causing the appearance of a traumatic factor. Unless there are remaining teeth, it will be impossible to determine the relationship between stress, parafunctions, and the patient. The patient's occlusal restoration should not only focus on the masticatory function (as mentioned before, these occlusal contacts are not long-lasting, so they will not be of great importance) but also and particularly on parafunctions. For this reason, avoiding prematurities and interferences is important; however, it is also important to inform patients of the dangers of clenching and grinding, which in many cases they are not aware of. On occasion, we must protect the whole system through the use of nocturnal occlusal splints.

Fig. 7-24

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Levers and masticatory forces It is important to go into detail here to know how far we must extend the prosthesis and what happens should there be overloading on the anterior teeth. The force vectors of the masticatory muscles (especially the masseter) are produced on the mesiolingual cusp of the upper first molar, making this the major loading point. Figure 7-25 shows the resultant of these force vectors of mastication and its influence on mandibular stability.

Fig.: 7-25 shows the resultant of these force vectors of mastication and its influence on mandibular stability.

Fig. 7-26

If the first contact happens in the area of the anterior teeth, it could lead to posterior condylar displacement, producing overload capsulitis(Fig 7-26).

If we can achieve contact from front to back up to the upper first molar, mandibular distalization will be avoided. Consequently, to have a stable TMJ it is important to have at least occlusion on the mesiolingual cusp of the upper first molar (Fig 7-27). - 129 -

we recommended mutually protected occlusion. In maximum intercuspation. Occlusion in implant-supported prostheses A) Fixed or removable restorations with opposing natural dentition: In these cases. This is also known as organic occlusion.to tooth and cuspfossa posterior occlusion. This will confirm the absence of heavy contacts there and will prevent future compressions of the posterior TMJ area Fig. it must be emphasized that the anterior teeth should not contact in maximum intercuspation. 7-27 .On other hand. because in practice it is very difficult to differentiate between physiological and excessive contacts. the occlusion from canine to canine should allow for a Mylar strip to be pulled with a certain resistance.130 - . with anterior guidance and tooth . yet not being fully held by the teeth. .

which in turn will destabilize the mucosa-supported segment.B) Fixed removable restoration with opposing fixed or removable implant-supported prosthesis Organic occlusion is recommended for the following reasons: 1.131 - . thus increasing muscular contraction force and the possibility of osseous resorption. If it supported by mucosa and we can achieve a disocclusion as flat as possible. Organic occlusion is easier to adjust by simply eliminating all non-anterior contacts during lateral movements. . The articulator is of great importance for prosthesis construction regardless of the type. It is easier to produce. Yet we believe that the final occlusal adjustments should be carried out in the mouth. in the case of bilateral balanced occlusion. we should consider that there are many factors not in harmony with anatomical and physiological realities. 3. In the case of an overdenture. 2. there will be many contact surfaces in lateral excursions. the tension on the implants will be minimal. like the fact that the joint has soft tissues (resilience) and mandibular flexibility that on occasion produces natural positions that can’t be reproduced in a rigid instrument such as the articulator. If a bilateral balanced occlusion is created. because it brings us closer to what truly happens. it could be difficult to differentiate physiological contacts from true interferences. because the mouth is the only articulator that provides 100% of the necessary information. However. Even if the occlusal scheme is constructed on an articulator. this could progress into an overload of the stomatognathic system and the implants if it is not relined periodically.

132 - . it is wiser to eliminate both (balancing or hyperbalancing contact) so as to achieve disocclusion. They found that canine guidance produces less activity in both muscles during lateral movements. thus. but let us not forget that the patient being rehabilitated can have parafunctional problems that must not be overlooked. . 4. imagine the muscular force needed to drag a hoop along the ground (this corresponds to canine guidance) and the force needed to drag a barrel with more surface friction the same way (this corresponds to bilateral balanced occlusion) In 1989. 6. which can be considered a factor in preventing parafunctional activity. Bull. Organic occlusion is the most physiological scheme for the stomatognathic system and implants. stabilizing occlusion and avoiding parafunctions. As an example to help understand this situation.guided dentures. it is nearly impossible or at least very difficult to distinguish between equilibrium (physiological) contacts and interferences non-physiological) contacts. Miralles. 5. which would help initial mastication. and Manns performed an electromyographic study comparing the activity of the elevator muscles (temporal and masseter) in balanced full dentures and canine. however. Since there is no posterior seal in cases of implant restoration with upper overdentures. The presence of canine guidance prevents posterior tooth wear.In the mouth. the presence of bilateral balanced occlusion does not increase retention during parafunctions.

during parafunctions and with teeth clenching in different positions. through a "vacuum-type" effect. Maintenance of the neuromuscular mechanism avoids overloading of the muscular system and the appearance of trigger points. which will benefit patient food mastication. with adequate mucosal adjustment and seal. We support bilateral balanced occlusion because we look for increased full-denture stability in patients without implants. C) Fixed or removable implant-supported restoration with opposing removable full denture without implants This is the case in which we advocate bilaterally balanced occlusion. This will improve prosthesis stability and avoid implant overload. We should not forget that. In cases with only two implants supporting a lower overdenture. However.7. Forces are transmitted evenly. resulting in a more stable prosthesis with increased adhesion and fit. In conventional full dentures (without implants). consequently neutralizing balance. teeth are arranged in bilateral balance when the patient is not chewing. 8.133 - . while eating. Here it is perfectly logical. the food bolus separates occlusal surfaces. . the adhesion that was previously produced through bilateral balanced occlusion greatly facilitates chewing without denture displacement. it is advisable to use bilaterally balanced occlusion.

Single implants in the posterior area should be limited to premolars. The lingual surface of the anterior teeth should be constructed as flat as possible.To create better anterior guidance. . and in this forced position we omit the contacts. so if opposing tooth extrusion leads to occlusal contact there will not be contacts in lateral movements. .To change inclines. The prosthesis should only contact in a position of forced closure. The objectives are the following: .134 - . The recommended occlusion in these cases is adjusted for forced biting.To deepen fossae. reducing their surface area so that they just fulfill esthetics and space maintenance. resilience will be introduced into the occlusal adjustment. .D) Partial-prosthesis occlusion In cases with cantilevers. In this way. Occlusal Adjustment in Implant Supported Prostheses General aspects This consists of modifying tooth anatomy to obtain a good occlusion.To have centric relation and maximum intercuspation. The only solution here is the placement of two implants in the place of the mesial and distal roots to serve as support for a molar. E) Single-implant occlusion Single implants should be free of any occlusal overload and function.To position cusps. the resilience of the neighboring natural dentition and of the TMJ should be taken into consideration. At this time we do not advocate the use of single implants for molars. . all interferences and prematurities should be eliminated with care. As always. leaving only point like occlusion. .

because the final adjustment will be carried out directly in the mouth. Occlusal adjustment must be performed in the upper and lower arch jointly. at the same time.To locate the exit paths. they all lead to a common goal. explained previously. First. Technique There are many different occlusal-adjustment technique philosophies. and considering that articulators are not perfect since they do not simulate soft tissues. we should look for information on prematurities and interferences. and on both sides. and whether canine or anterior guidance is feasible. In our opinion. or once it is placed in the mouth or in finished cases where it is decided to readjust the occlusion. However. the case is mounted on an articulator with a face bow related to the orbital point and the hinge axis. . They can also be used in natural dentition.135 - ..To eliminate prematurities and interferences. either when checking a case prior to laboratory work. we do not feel it is necessary to complicate initial phases with previous registrations (orthopanography) but we must register the patient's condylar inclination. All of the following adjustments refer to implant-supported prostheses. . We will make a compendium of those techniques taught to us by our teachers. however.To build in vertical-dimension holding contacts to avoid implant overloading." as mentioned before. We deliberately used the term "general idea. to get a "general idea" of the treatment the patient needs. .

we eliminate the interferences (Fig. once we have analyzed the case. 22-15).136 - . we will need more than one appointment to obtain this.The information we wish to obtain can be determined through the use of a semiadjustable articulator (Dentatus. We believe that it is fundamental to have centric relation and maximum intercuspation coincide. allowing only point-like contacts with the internal fossa walls. It is very important. In some cases. etc). so as to avoid large contact surfaces that can lead to implant overloading. to know where we want to start and determine our objective. 7-28 . Fig. We try to avoid cusp-tip contact with the floor of the fossa. Denar Mark II. eliminating all prematurities. Once we have achieved anterior coupling.

: 7-29 .A) Eliminating prematurities To mark tooth contact.137 - Fig. 7-29). we should remember that in normal occlusion (Class I) the lower teeth (premolars and molars) are ahead of the upper. the distal lower inclines and the mesial upper inclines contact in condylar centric relation. 7-30). So we can observe that when occlusion occurs.Cusp distal inclines Eliminate the most distal part (DI) and preserve the most mesial contact point (M) (Fig. we should follow these steps: 1. 2. : 7-30 . we use double colored thin articulating paper or black marking ribbon and we have the patient close from centric relation (CR) to maximum intercuspation (MI) several times. Fig. To adjust.Active-cusp outer inclines Eliminate the whole surface except the zone next to the cusp tip (the highest part) (Fig. 1) Mandible To adjust the lower occlusion.

Mesial cusp inclines Eliminate the most mesial part and leave the most distal contact point. 2.3. 2) Maxilla In the upper arch we always adjust opposite of the lower arch. except for the most mesial and medial contact point (anterior and towards the center of the fossa) (Fig. except for the area nearest to the active cusp tip (the lowest part) (Fig. 7-33).7-31. 3.Inner inclines Eliminate the most mesial and leave the most distal and medial contact point (Fig.Active-cusp outer inclines Eliminate the whole surface.Inner inclines Eliminate the most distal area (DI).138 - . Fig. Fig.7 -32. 1. 7-31). 7-34) .

139 - . because it will preserve active cusp anatomy and masticatory activity. The large surface marking that appears on the cusp tip after deepening the opposing fossa will be reduced simply to two contact points. 7-36). There are two possibilities: a) Spare the lateral cusp marks while eliminating the intermediate zone. which we always try to avoid. it will create a large contact surface. 7-33. Occlusal maintenance contacts will still be present.Fig. which will cause loss of active material for chewing and will decrease efficiency (Fig. Fig. 7-35) b) Deepen the fossa while preserving its lateral aspects. The best solution is the second one. B) Deepening fossae: maxilla and mandible If the cusp contacts the floor of the fossa. 7-34. which will permit preservation of the cusp surface (Fig. .

placing it in the mouth and having the patient close from centric relation to maximum intercuspation. The presence or absence of excessive contact in the anterior teeth must be checked during closure. noting slight resistance while pulling it from the teeth.140 - . 7-36 . It should be done with very thin ribbon. will appear on the occlusal surfaces. The next step is to verify anterior guidance Fig. Fig.It should be emphasized that the thinnest possible black doublecolored marking ribbon should be used while eliminating prematurities and deepening fossa. 7-35. not surfaces. At the end of this phase of adjustment a great number of black contact points.

C) Anterior guidance The anterior guidance should be as flat as possible to avoid overload in the anterior teeth in lateral excursion (on the canines and anterior teeth) and in protrusion (the contact of the mesial incline of the first lower premolar on the distal incline of the upper canine. and protrusive movements. . nonworking. depending if they are working. as well as centrals. eliminate all red marking except the guide marks of anterior disocclusion. we shall merely emphasize that we must avoid producing TMJ tension and any contact in the posterior when the guidance is in function. nonworking. or protrusive movements The importance of inducing lateral movements to detect if Bennet movement is present must not be forgotten. This is always checked with red marking ribbon. we must again use red ribbon and have the patient go through working. it is convenient to eliminate them following the corresponding direction. All surfaces or points that appear which are not black must be eliminated (except black on red).141 - . laterals. and canines between them). D) Eliminating interferences For this. As the desired occlusal scheme was detailed previously. The next step is to place black ribbon and have the patient close to maximum intercuspation (centric relation coincides at this time with maximum intercuspation). because these would constitute interferences. When these red markings coincide with shallow or nonexistent disocclusion. allowing for fine surfaces of anterior disocclusion. in other words.

the contacts created must occur during forced biting and at the same time as the rest. we must be sure that the introduction of new cusps in the rehabilitation does not create occlusal problems in the opposing dentition. we should adjust the natural dentition without hesitation If the opposing dentition is a full denture that is not implantsupported. If we have opposing natural dentition. we can bypass the techniques involving physiological interferences because we are dealing with a bilateral balanced occlusion. periodic occlusal checkups (every 3 to 6 months) are strongly recommended. this is why screws loosen. The opposing natural dentition must also be checked. If this happens. When adjusting the occlusion on partial prostheses. though sometimes this is related to the lock of passive fit of the prosthesis over the abutments. .Conclusions Occlusal adjustment is necessary in any kind of fixed or removable restoration supported by implants.142 - . Occlusal problems will cause bone resorption at the implant site. (Occlusion in single implants was explained before) Because of possible TMJ and occlusal instability. avoiding the introduction of new prematurities or interferences. however. we must take care in eliminating prematurities. On occasion.

The posterior occlusal zone must be absolutely flat and the anterior. concave. so special attention must be given to the patient's new occlusion if an occlusal splint is not being used. Occlusal adjustment will be undertaken considering the contact markings with their corresponding fossae and upper inner inclines. If this should change with the appearance of new prematurities or interferences. In these cases we search for canine guidance in lateral excursions. eliminating the rest that do not correspond to the lower active cusps (see fossae adjustment and upper inner inclines). The implant-supported prosthesis and the natural teeth (should they be present) must be readjusted. acrylicresin nocturnal occlusal splints are indicated. It must relax the TMJ muscle complex. This should be checked periodically. a lower splint is used. it indicates that mandibular position is changing. guiding the mandible to centric relation without any impediments. an upper occlusal splint is employed. and posterior fossa wall contacts against the opposing active cusp tips that will serve as the deepest part of the corresponding fossa. . without any kind of tooth print.Occlusal splints If it becomes necessary to protect the occlusion of the stomatognathic system from parafunctions and overloads. Guidance should be as flat as possible.143 - . The presence of minimal contacts and the absence of interferences and prematurities reduce muscular forces during parafunctions (bruxism). if the distribution of occlusal leverages permits it (minimum occlusal contacts up to the first molar). so as to allow freedom of movement in maximum intercuspation and laterally. If an upper splint is not feasible. disoccluding anterior guidance in protrusions.

clinical cases and laboratory procedures. Ed.Reference Jimenez . 1995.: Implant-supported prosthesis: Occlusion. Quintessence a Publishing Co. Adam Haus. .144 - . Illinois. V. Carol Stream.Lopez.

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