PROSTHODONTICS Major Topic Abbreviation Acrylic Resins Acrylie Resins Complete Dentures: Complete Dent Crown & Bridge Cm & Bridge Gypsum Products GP Impression Materials Impr Mat Miscellaneous Misc. Occlusion Occlusion Porcelain Pore Removabie Partial Dentures RPD Copyright © 2004 — DENTAL DECKS:PROSTHODONTICS Acrylic Resins In dentistry, the most frequently used polymer system is: + Bis-GMA * Polyether » Methyl methacrylate * Polyvinyl« Methyl methacrylate ***Methy! methacrylate is the liquid monomer and is abbreviated MMA, polymethyl methacrylate is the powder polymer and is abbreviated PMMA. Heat-cured materials — heat is used as an accelerator to decompose benzoyl peroxide (the initiator) into free radicals. These free radicals initiate the polymerization of MMA. into PMMA. The polymerization process continues as new PMMA is formed as a matrix around residual PMMA powder particles. Self-cured (auto-cured, cold cured) materials — a chemical activator such as dimethyl-p-toluldine (which is a tertiary amine) is added to the monomer (MMA). This chemical activator causes decomposition of the benzoyl peroxide (the initiator) into free radicals. These free radicals initiate the polymerization of MMA and PMMA. The polymerization process continues the same as in heat-curing above. Notes: 4. The polymerization range is the temperature range, approximately 60°C (140°F) to 77°C (170°F), at which the major part of polymerization occurs in a heat-cured resin. 2. The heat-cured resins have less residual monomer and a higher molecular weight than the self-cured resins; therefore, they are stronger. They also have superior color stability. Other monomers (liquids) used are ethyl methacrylate, viny! ethyl methacrylate, and epimine resins. These all are less irritating to the pulp.PROSTHODONTICS Acrylic Resins The powder (polymer) used in self-cured acrylic resins is usually: * Benzoyl peroxide * Polymethyl methacrylate (PMMA) * Hydroquinone « Methyl methacrylate (MMA) Copyright © 2004 — DENTAL DECKS+ Polymethyl methacrylate (PMMA) Components of Acrylic Resins + Powder: Polymethy! methacrylate (PMMA) polymer, benzoyl peroxide initiator, and pigments. * Liquid; Pure methyl methacrylate (MMA) monomer, Hydroquinone inhibitor, cross- linking agents, and chemical activator (dimethyl-p-toluidine). Note: This activator is only present in self-cured resins to bring about polymerization. Remember > mechanical properties of resins are influenced by the following: » Molecular weight of the polymer * Degree of cross-linking (need difunctional monomers which contain two areas for reaction) + Composition of monomers used to prepare the polymer Notes; 1. Acrylic resins will expand when immersed in water and become distorted when dried out. 2. Excessive shrinkage may occur if too much monomer (liquid) is added to the polymer (powder). 3. The polymerization reaction of methyl methacrylate is exothermic — gives out heat. 4. Inhibitors are added to the monomers to aid in preventing polymerization during storage. 5. Cross-linking contributes greatly to the strength of the polymer.PROSTHODONTICS Complete Dent When border molding a mandibular custom tray that will be used for a final denture impression: * The distofacial extension is determined by the position and action of the temporalis muscle and the distolingual extension is limited by the action of the superior constrictor muscle + The distofaclal extension is determined by the position and action of the masseter muscle and the distolingual extension is limited by the action of the superior constrictor muscle * The distofacial extension is determined by the position and action of the mylohyoid muscle and the distolingual extension is limited by the action of the inferior constrictor muscle «The distofacial extension is determined by the position and action of the genioglossus muscle and the distolingual extension is limited by action of the inferior constrictor muscle ‘Copyright © 2004 — DENTAL DECKS* The distofacial extension Is determined by the position and actlon of the masseter muscle and the distolingual extension ts limited by the action of the superior constrictor muscle Note: The custom tray for a final mandibular or maxillary complete denture impression should have a spacer with stops to insure that the tray will be seated in proper relationship to the arch and that there will be adequate room for the impression material. The space is created with wax covered by aluminum foil over the master cast prior to forming the tray. The primary difference between border molding with a ZOE impression material and border molding with modeling plastic is the ZOE impression material must be border molded during one insertion and within the setting time of the material + as opposed to two insertions with modeling compound. Remember: The palatoglossus, superior pharyngeal constrictor, mylohyoid, and genioglossus muscles are influential in molding the lingual border of the mandibular impression for an edentulous patient.PROSTHODONTICS Complete Dent How will the alveolar ridge respond to a mandibular complete denture base that terminates short of the retromolar pad? + Marked ridge resorption will occur * The apposition of bone on the ridge will occur * The alveolar ridge will not be affected at all ‘Copyright © 2004 —- DENTAL DECKS* Marked ridge resorption will occur ** Key point — underextension of the peripheral border of a complete mandibular denture decreases tissue-bearing surfaces, thereby affecting denture stability. The underlying basal bone (beneath the retromolar pad) is resistant to resorption. Coverage of this area will also provide some border seal. An overload of the mucosa will occur if the bases covering the area are too smail in outline. Remember: Mandibular dentures do not rely on suction from a peripheral seal for retention (as do maxillary dentures) but rather on denture stability in covering as much basal bone as possible without impinging on the muscle attachments. The active border molding performed by the lips, cheeks, and tongue determines the peripheral areas of a mandibular arch, thus establishing maximal base bone coverage. Note: Thin mucosa is found in the following areas: * In the mylohyoid area + mandibular denture. * On the midline of the palatal vault — maxillary denture. * Over a torus palatinus > maxillary denture. * Over a mandibular tori > mandibular denture.PROSTHODONTICS Complete Dent Immediate dentures should be scheduled for relines at: * 4 month and 3 months post extraction * 4 months and 7 months post extraction * 5 months and 10 months post extraction * 1 year and 2 years post extraction Copyright © 2004 — DENTAL DECKS«6 months and 10 months post extraction Recontouring of the healing ridge progresses rapidly for four to six months and does not become stable in form until 10-12 months post extraction. Due to this, immediate dentures become progressively more ill-fitting. They should be relined five months and ten months after delivery in order to compensate for contour changes. Note: This is a general timeline; each case needs to be evaluated monthly and, if necessary, relines performed. Areline is indicated on any denture when the diagnostic information indicates that a teline will effectively solve the patient's chief complaint + when the denture base adaptation is the major defect in the prosthesis. A reline is contraindicated when there is excessive overclosure of the vertical dimension > a large decrease in vertical dimension. In this case, new dentures are indicated at the proper vertical dimension. Note: When a patient wears a complete maxillary denture against the six mandibular anterior teeth, itis very common to have to do a reline every so often due to the loss of bone structure in the anterior maxillary arch — evidenced by a flabby maxillary anterior ridge.PROSTHODONTICS All new dentures should be evaluated: +3 hours after delivery * 12 hours after delivery * 24 hours after delivery « 48 hours after delivery Copyright © 2004 — DENTAL DECKS Complete Dent* 24 hours after delivery This is done for the purpose of correcting undetected errors. Tissue trauma attributed to denture function manifests as hyperemia, inflammation, ulceration, and pain. The basic sequence of the clinical procedure for a 24 hour recall appointment is: 1. Remove the dentures from the mouth. 2. Thoroughly examine the mouth. 3. Ask the patient about the areas of tissue trauma which have been observed. 4. Permit the patient to describe additional complaints. **After collecting all of the diagnostic information, the dentist can determine the source of the problem and the cure. Remember: During the first few days following the insertion of complete dentures, the patient should expect some difficulty in masticating most foods and excessive saliva > which is due to reflex parasympathetic stimulation of the salivary glands. Over time this will subside and become normal.PROSTHODONTICS Posterior teeth that are set edge to edge may cause: * Gagging * Cheek biting + Reduced taste * Speech aberrations ‘Copyright © 2004 — DENTAL DECKS Complete Dent* Cheek biting ane men anaes Causes of Cheek Biting with New Dentures a edge to edge | Reduce the facial surfaces of mandibular molars to create proper horizontal overlap inadequate vertical dimension | Reline at corrected VDO, patient remount, of occlusion fabricate new denture Biting corners of the mouth Reset cuspids/bicuspids Notes: 4. Lip biting may be due to reduced muscle tone and / or a large anterior horizontal overlap. 2. Tongue biting may be caused by having posterior teeth too far lingually.PROSTHODONTICS Complete Dent Maxillary anterior teeth in a complete denture are usually arranged: * Facial to the ridge * Linguat to the ridge + Exactly over the ridge ‘Copyright © 2004 — DENTAL DECKS+ Facial to the ridge — for best esthetics Setting anterior teeth directly over the ridge usually causes poor esthetics of dentures. Also, it is important to have accurate adaption of the border seal and adequate bulk of the maxillary facial flange for good esthetics. Vertical dimension of occlusion affects the lip support as well. For most patients, the labial surface of the central incisor should be approximately 8 mm anterior to the center of the incisive papilla. The labioincisal one-third of the maxillary central incisors should support the lower lip when the teeth are in occlusion. Remember: Maxillary central incisors are the most important teeth when esthetics is under consideration. Their placement controls the midline, speaking line, lip support and smiling line composition. Some of the common errors in the arrangement of teeth include: Setting mandibular anterior teeth too far forward to meet the maxillary teeth + Failure to make canines the turning point of the arch + Setting the mandibular first premolars buccal to the canines + Establishing the occlusal piane by an arbitrary line on the face * Not rotating anterior teeth enough to give an adequately narrower effectPROSTHODONTICS Complete Dent A patient who wears a complete maxillary denture complains of a burning sensation in the palatal area of his / her mouth. This is indicative of too much pressure being exerted by the denture on the: + Incisive foramen + Palatal mucosa + Hamular notch * Posterior palatal seal Copyright © 2004 —- DENTAL DECKS+ Incisive foramen Notes: 1. A burning sensation in the mandibular anterior area is caused by pressure on the mental foramen. 2. A patient having trouble swallowing may have insufficient interocclusal space — decreased freeway space caused by excessive vertical dimension of occlusion. 3. The best dietary advice for an elderly denture patient is to eat foods rich in protein and vitamins A, C, D, and B complex. Important: Learning to chew satisfactorily with new dentures requires at least 6-8 weeks. This time is spent on establishing new memory patterns for both facial and masticatory muscles. Residual ridges can be ruined by the use of denture adhesives and home-reliners. Therefore, patients should be specifically warned about their uses. These agents can modify the position of the denture on the ridge and result in change of both vertical and centric relations.PROSTHODONTICS Complete Dent The treatment plan for a patient indicates that both mandibular and maxillary immediate dentures are to be fabricated. The ideal way to do this is: * Fabricate the maxillary immediate denture first * Fabricate the mandibular immediate denture first * Fabricate the maxillary and mandibular immediate dentures at the same time Copyright © 2004 — DENTAL DECKS+ Fabricate the maxillary and mandibular immediate dentures at the same time The main reason for this is to avold setting the maxillary teeth to the likely malpositions of the remaining mandibular teeth. Important: if the master casts are altered in an immediate denture procedure (e.g., elimination of gross undercuts), it is advisable to construct a second denture base that is transparent (called a surgical stent or template). This surgical stent is placed over the ridge after the teeth are extracted. Pressure points and undercuts are readily visible and surgical ridge correction can be performed. Remember: The duplication of the master cast used for the construction of the surgical template to be used at the time of immediate denture insertion is best made after wax elimination and after the cast is trimmed. Note: A major advantage with immediate dentures is being able to duplicate the Position of the natural teeth.PROSTHODONTICS Complete Dent The first step in the treatment of abused tissues in a patient with existing dentures is to: ¢ Fabricate a new set of dentures + Reline the dentures * Educate the patient + Excise the abused tissues Copyright © 2004 — DENTAL DECKS+ Educate the patient important: The patient should understand both the cause of the tissue deterioration and the eventual outcome if the process is not arrested. If the constant wear of unacceptable dentures is the cause of the tissue abuse, the most efficient preliminary treatment is removal of the dentures. However, business and social commitments may not permit removal for extended periods. In such patients, resilient tissue conditioning materials may be used to assist in the tissue recovery program. Other procedures recommended as aids in the treatment of abused tissues include massage and warm saline rinses.PROSTHODONTICS Complete Dent The most important benefit of an overdenture (root-retained denture) is: * The psychological comfort of avoiding the loss of all teeth *The continuous functional feedback for the neuromuscular system from proprioceptors in the periodontal membrane * The preservation of the alveolar ridge * The improved support and stability for the denture + The increased retention of the denture Copyright © 2004 — DENTAL DECKS:* The preservation of the alveolar ridge Accomplete overdenture is a denture whose base is constructed to cover all of the existing residual ridge and selected roots. Retained roots help to prevent resorption of the alveolar ridges. These roots also improve retention and afford the patient some proprioceptive sense of “naturalness” in function of the dentures. Itis not always necessary to cover a root beneath an overdenture, however, if a root is not covered, the exposed surfaces are highly susceptible to decay. The oral hygiene of the patient must be impeccable to prevent the decay of these roots. Note: Retained roots are the most common findings when taking routine panoramic radiographs of patients who wear complete dentures (nof necessarily overdentures).PROSTHODONTICS Complete Dent A patient who was delivered a complete denture some time ago, complains that whenever she tries to make an “s” sound, it sounds like “th”. What are the two most probable causes of this problem? + Increased occlusal vertical dimension * Palatal vault is too high + Incisor teeth are set too far palatally + Palate is made too thick * Palate is made too constricted Copyright © 2004 — DENTAL DECKS* Incisor teeth are set too far palatally * Palate is made too thick *** An increased occlusal vertical dimension can result in clicking of teeth. ** A high palatal vault or a constricted palate can cause whistling sounds. Note: If the teeth are positioned too far tingually, the "t" will tend to sound like a "d." If the teeth are positioned too far labially, the “d” will sound more like a “t.” "S$" sound — the mandibular incisal edges should be even with or just behind the incisat edges of the maxillary teeth. Most people form the "s" sound with the tip of the tongue approaching the anterior palate and lingual surfaces of the maxillary teeth. Note: These sounds bring the mandible and maxilla close together. "Th" sound — when forming the "th" sound, the tongue should protrude slightly between the maxillary and mandibular anterior teeth. It should normally protrude 2-4 mm. “F" and “V" sounds — are formed by the incisal edges of the maxillary teeth and the lower . The incisal edges of the maxillary teeth should just touch the wet / dry line of the lower lip. “P" and “B" sounds — are formed totally by the lips. Words with the sibilant sound (hissing sounds) are pronounced correctly with the incisal edges of maxillary and mandibular almost touching. These sounds are usually produced between rest and the occluding position.PROSTHODONTICS The primary role of anterior teeth on a denture is: *To incise food * Occlusion + Esthetics * Stability of the denture Copyright © 2004 — DENTAL DECKS. Complete Dent+ Esthetics Spaces, lapping, rotation, and color changes can be judiciously used to create a natural appearance. Setting the anterior teeth either too far lingually or facially to satisfy esthetic concerns should not be done. When selecting teeth, pre-extraction records are very valuable. Maxillary and mandibular anterior teeth should not contact in centric relation. The outline of anterior teeth should harmonize with the form of the face: + Convex profile faces should have a similarly convex iabial surface of anterior teeth. + Broader contact areas of teeth look more natural on dentures as they seem more compatible with advanced age. Whistling when a patient speaks with dentures (complete or partial which repiaces the incisors) may be caused by any of the following: + Vertical overlap is not enough. * Horizontal overlap is too much. + The area palatal to the incisors is improperly contoured. Note: In general, functional needs overshadow those of esthetics when selecting posterior teoth. Do not set mandibular molars over the ascending area of the mandible because the occlusal forces in the area will dislodge the mandibular denture.PROSTHODONTICS Complete Dent Which of the following changes are usually evident on the maxillary arch in a patient who wears a complete maxillary denture and lacks posterior occlusion? * Excessive amount of hyperplastic tissue present on the anterior portion of the maxillary ridge * Poor bone structure in the anterior part of the maxilla + Fibrous tuberosities + Alll of the above Copyright © 2004 — DENTAL DECKS+ All of the above The patient's chief complaint will be looseness of the maxillary denture. They will also state that they can no longer see their upper teeth on the denture. These signs and symptoms are caused by a lack of posterior occlusion. Important: A patient wearing a maxillary complete denture and a mandibular bilateral distal-extension removable partial may show: * Decreased vertical dimension of occlusion » Aprognathic facial appearance Note: When a complete maxillary denture opposes natural mandibular anterior teeth, the maxillary anterior ridge often becomes very flabby.PROSTHODONTICS Complete Dent The primary Indicator of the accuracy of border molding is: * Adequate coverage of tray borders with the material used for border molding * Uniformly thick borders of the periphery * Contours of the periphery similar to the final form of the denture * Stability and lack of displacement of the tray in the mouth ‘Copyright © 2004 DENTAL DECKS* Stability and lack of displacement of the tray in the mouth The ease and accuracy of the border molding depends upon: 1. An accurately fitting custom tray 2. Control of bulk and temperature of the modeling compound 3. A thoroughly dried tray The custom tray fabricated on the preliminary cast is trimmed approximately 2 mm short of the mucosal reflection and frenae. This is done by first checking the borders in the mouth and then trimmed down. This will allow a uniform thickness of 2 mm of modeling compound when borders are molded. Proper border molding results in contours resembling the final form of the denture. However, the primary indicator of the accuracy of border molding is the stability and lack of displacement of tray in the mouth Border molding is completed in two stages. In the first stage the molding should approximate the borders but should be slightly overextended. Excess compound is trimmed from inside and outside of the tray. The remaining modeling compound is then refined by repeating the process. The final form of the border molding should represent an accurate impression of the peripheral tissues. The modeling compound should have a smooth, almost polished appearance. Remember: Modeling compound (p/astic) has a relatively low thermal conductivity.PROSTHODONTICS Complete Dent You are in the process of making a complete maxillary denture for a patient. Which of the following structure(s) will be the primary support area(s)? * Residual ridges » Palatal rugae * Incisive papilla * Maxillary tuberosity » Buccal vestibule Copyright © 2004 — DENTAL DECKS+ Residual ridges *** The secondary support areas of the maxillary complete denture are the palatal rugae. In the mandibular arch, the primary support area is the buccal shelf because of its bone structure and its right angle relationship to the occlusal plane. The residual ridges if large and broad can also be considered as the primary support areas. Remember: *The secondary peripheral seal area for a mandibular complete denture is the anterior lingual border. * If you are fabricating a mandibular complete denture for a patient with a knife-edge ridge, you need maximal extension of the denture to help distribute the forces of occlusion over a larger area.PROSTHODONTICS Complete Dent An overextended distobuccal corner of a mandibular denture will push against which muscle during function? * Zygomaticus * Orbicularis oris * Temporalis * Masseter ‘Copyright © 2004 — DENTAL DECKS+ Masseter This is a very common area of overextension and should be checked very well when delivering the mandibular denture. The buccinator muscle lies under the denture flange in this area but the fibers run anteroposterior in a horizontal plane and their action is weak; the anterior fibers of the masseter muscle pass outside the buccinator at the distobuccal corner of the mandibular denture and will push against the buccinator during function causing dislodgement. important: When the posterior maxillary buccal space is entirely filled with the denture flange, the coronold process may interfere with the denture upon opening of the mouth. This will cause distodgement of the maxillary denture. Notes: 1. The superficial layer of the masseter muscle originates from the zygomatic process of the maxilla and inserts at the angle and lower lateral side of the ramus of the mandible. 2. The pterygomandibular raphe lies between the buccinator and superior constrictor muscies.PROSTHODONTICS Complete Dent After border molding the mandibular custom tray, it is important to check for dislodgement in order to detect areas of: + Underextension of the tray + Overextension of the tray * Thickness of the tray * None of the above ‘Copyright © 2004 —- DENTAL DECKS* Overextension of the tray Check for dislodgement using the following techniques: * Pull gently upward on the patient's cheek. * Pull the lower lip gently forward in a horizontal direction. * Have the patient open widely. + Have the patient move the tongue into the right and left buccal vestibutes. * Have the patient protrude the tongue to touch the lower lip. Have the patient move the tip of the tongue from one comer of the mouth to the other. Dislodgement indicates overextension and the border molding process should be refined in the offending area. Common areas of overextension of the mandibular impression are the labial and the buccal. This is suspected when the impression raises when the mouth is opened. The most critical area in the border-molding procedure for a maxillary denture is the mucogingival fold above the maxillary tuberosity area. This area is extremely important for maximal retention. Other critical areas are the labial frena in the midline and the frena in the bicuspid area. Overextension in these areas often leads to decreased retention and tissue irritation.PROSTHODONTICS Complete Dent Before an accurate face-bow transfer record can be made on a patient, which of the following must be determined? * Location of the hinge axis point * The inclination of each condyle * Vertical dimension of occlusion + Centric relation Copyright © 2004 — DENTAL DECKS+ Location of the hinge axis point -» axial center of opening-closing A face-bow is a caliper-like device used to record the patient's maxilla / hinge axis relationship (opening and closing axis). It is also used to transfer this relationship to the articulator during the mounting of the maxillary cast. If the face-box transfer procedure is properly done, the arc of closure on the articulator should duplicate that exhibited by the patient. This hinge-axis face-box transfer enables alteration in vertical dimension on the articulator. When altering vertical dimension (either through restorations or with dentures), casts should be mounted on the hinge axis. When the maxilla / hinge axis relation is transferred to the fully adjustable articulator, it may be necessary to obtain the precise tracing of the paths followed by condyle. Pantograph is an instrument which carries out this task with the help of two face bows. ‘One is attached to the maxilla and the other to the mandible using a clutch that attaches the teeth in the respective arches.PROSTHODONTICS Complete Dent Which method is the preferred method to preserve the face-bow transfer? * Taking a plaster index * Using 10X wax * Hand mount * None of the above ‘Copyright © 2004 — DENTAL DECKS* Taking a plaster index When fabricating dentures, there are two methods used to preserve the face-bow transfer: 1. Taking a plaster Index of the occlusal surfaces of a maxillary denture before femoving the denture from the articulator and cast (see picture below). 2. Placing a piece of 10x wax on the occlusal surfaces of the mandibular teeth and closing the articulator in centric relation. Chill the wax, drop the incisal guide pin to touch the incisal guide table (do not change). The plaster index method is the preferred method due to possible distortion of wax. t— Maxillary Denture Plaster Index CastPROSTHODONTICS Complete Dent Ageneralized speech difficulty with complete dentures is usually caused by which two of the following? * Faulty tooth position « Excess vertical dimension of occlusion « Faulty palatal contours + Faulty occlusion nnnurieaht monn. RENTAL RECKS+ Faulty tooth position « Faulty palatal contours Speech problems due to faulty tooth position can be avoided by placing the denture teeth as close as possible to the position of the natural teeth. Note: The most effective time to test for phonetics is at the time of the wax try-in of the trial denture (this is usually the fourth appointment). Faulty palatal contours can be corrected by trial and error. Add wax to increase contours and reduce as needed to improve articulation of sounds. Note: Patients who have been edentulous for many years often have more distorted speech than those who have been edentulous for a short time. This is usually due to a loss of tonus of the tongue musculature.PROSTHODONTICS Complete Dent A patient returns to your office a few days after delivery of new dentures and complains of generalized irritation of the basal seat. The cause could be attributed to: * Premature occlusal contacts * Lack of denture hygiene * Nutritional and hormonal imbalance + Excessive vertical dimension of occlusion * Any of the above Copyright © 2004 — DENTAL DECKS+ Any of the above **Premature occlusal contacts or the occlusion, however is the most likely cause of such a probiem. At the first appointment after insertion of complete dentures, the presence of generalized soreness on the crest of the mandibular ridge is most likely due to improper occlusion (premature occlusal contacts). To identify these, the best method in the mouth is to use disclosing wax that is slightly warmed. Insert the wax bilaterally and have the patient close into centric. The prematurities will show up as windows in the wax. Once centric is complete, be sure to check eccentric movements. Important: Acrylic spicules, inaccurate denture bases and trapped food can all cause ulcers as well. If an acrylic spicule is found, it should be reduced. If an inaccurate denture base is suspected, it should be relined. Notes: 1. After relining dentures, if a patient constantly returns for adjustments due to sore spots on the ridge, check the occlusion. The relining procedure may have changed the centric relation contacts. 2. Errors in occlusion may be checked most accurately by remounting the dentures on the articulator using remount casts and new interocclusal records.PROSTHODONTICS Complete Dent Occlusion rims are used to: * Determine and establish the vertical dimension of occlusion * Make maxillo-mandibular jaw records * Establish and locate the future position of the artificial teeth ° All of the above Copyright © 2004 — DENTAL DECKS° All of the above Occlusion rims are the resultant product after adding base plate wax to a record base in order to approximate the tooth position and arch form expected in the completed denture. Notes: 4. Th ferior surface of the maxillary occlusion rim should be parallel to Camper's line, which is the line running fron the inferior border of the ala of the nose to the superior border of the tragus of the ear. 2. When recording centric relation for a removable partial denture, the occlusion rim should be attached to the completed partial denture framework instead of a record base as used with a complete denture. 3. if at the tooth try-in appointment the teeth need to be adjusted to correct the centric occlusion, the best way to do this is to take a new centric relation record and remount.PROSTHODONTICS Complete Dent The most frequent cause of porosities in a denture is: Insufficient pressure on the flask during processing * Insufficient material in the moid *Arapid elevation in temperature to 212°F causing vaporization of the liquid Copyright © 2004 --. DENTAL DECKS.« Insufficient pressure on the flask during processing Acrylic resin used for denture repairs should be under 20-30 psi air pressure while being processed to help eliminate porosities. These porosities, if present, will usually occur in the thickest part of the denture. Self-cured resins are generally used for repairs instead of heat-cured resins because the risk of distorting the denture is less. Notes: 1. When there is a rapid elevation in temperature causing vaporization of the liquid, the vapor is then trapped as gas bubbles. nN . Porosities will also occur if the packing and processing of the powder and liquid resin is too plastic (stringy or sandy). This permits the liquid to vaporize and, at the same time, does not allow sufficient pressure during closure of the flask.PROSTHODONTICS Complete Dent All of the following are disadvantages to immediate denture therapy. Which one is considered to be the major disadvantage to immediate denture therapy? + Increased post-insertion care * Increased post-insertion soreness * Not being able to have an anterior tooth try-in to evaluate esthetics + Greater complexity of clinical procedures + A higher cost of treatment Copyright © 2004 — DENTAL DECKS* Not being able to have an anterior tooth try-in to evaluate esthetics Other drawbacks of immediate dentures: * Increased post-insertion care, including relining or remaking the dentures. Contour changes occur in the healing residual ridge for 8-12 months. «Increased post-delivery soreness. The combination of post-extraction pain and denture related trauma often produces greater discomfort during the first few days following insertion. *Greater complexity of clinical procedures. For example, border molding and final impressions are more difficult when natural teeth remain. * Higher total cost of treatment. There is an increased expense due to the need for relines and repeated equilibration of the occlusion. Recommended two-step schedule of tooth removal: + First step — extract all posterior teeth except a maxillary first premolar and its opposing tooth. This leaves a posterior “stop” in order to maintain the vertical dimension of occlusion. * Second step — after the posterior residual ridges exhibit acceptable clinical healing, the second phase of treatment, that of denture fabrication, can begin. The anterior teeth will be extracted at the time of denture insertion.PROSTHODONTICS Complete Dent The disadvantage(s) of an immediate complete denture is (are): + Esthetic is compromised * Speech adaption is difficult + Extraction site is susceptible to trauma * Relining / rebasing of the denture is required in 8-12 months. * Masticatory function is lost during the healing phase + All of the above Copyright © 2004 — DENTAL DECKS+ Relining / rebasing of the denture is required in 8-12 months *** Relining though simple has to be carried out within 8-12 months depending upon the rate of alveolar ridge resorption. Also increased post-delivery soreness for a few days can be encountered. Advantages of immediate dentures: * Continuously acceptable esthetics. Immediate dentures are esthetically advantageous in that the patient is never without either natural or artificial teeth. Improved speech adaption. immediate dentures require only one period of speech adaptation, whereas conventional denture treatment requires two; one after the teeth are extracted and another after the dentures are delivered. Protection of the extraction sites from trauma. Dentures act as a type of bandage over the clot filled sockets. Continuously acceptable masticatory function. The patient retains some semblance of chewing ability during the healing process. * Prevention of tongue enlargement. When natural teeth are lost and not replaced, the tongue tends to expand into the available space. To help the patient get through the first day of wearing immediate dentures, instruct him to do the following: + Do not remove the dentures + Eat soft foods + Retum in 24 hoursPROSTHODONTICS Complete Dent All of the following statements are true concerning a face-bow or a face-bow transfer, except: * The face-bow is a caliper-like device used to record the patient's maxilla / hinge axis relationship (opening and closing axis) * If the transfer is done properly, the arc of closure on the articulator should duplicate that exhibited by the patient * The face-bow transfer is a maxillo-mandibular record * The face-bow transfer is used to transfer the maxilla / hinge axis relationship to the articulator during the mounting of the maxillary cast Copyright © 2004 -—~ DENTAL DECKS* The face-bow transfer is a maxillo-mandibular record “This is false; it is a record used to orient the maxillary cast to the hinge axis on the articulator. T = Tragus of ear OC = Outer canthus of the eye Several varieties of arbitrary face-bows are available. All are based on an average location of the hinge axis and will yiefd an error of 2 mm or less in the majority of patients. Arbitrary rotational centers are generally located over measured points on the face or by some type of earpiece. One average measurement (above picture) places the rotational point 13 mm anterior to the distal edge of the tragus of the ear, along a line from the superior-inferior center of the tragus to the outer canthus of the eye. The condylar styli of the face-bow are then placed directly over the dots.PROSTHODONTICS Complete Dent Which of the following statements is true concerning the posterior palatal seal? * The outline and depth of the posterior palatal seal is the same for every patient * The posterior paiatal seal will vary in outline and depth according to the palatal form of the patients * A posterior palatal seal is not necessary when fabricating a complete denture on a patient with a flat palate * Once the complete denture fits properly, it is okay to remove the posterior palatal seal Copyright © 2004 — DENTAL DECKS* The posterior palatal seal will vary in outline and depth according to the palatal form of the patient The figure demonstrates the following depths along the posterior denture border: ‘a. .6 mm extending 3 mm on both sides of the midline. b. 1.5 mm lateral to a.) above, extending up to the medial boundary of the pterygomaxillary notches. c. The width of the seal anteriorly is characterized by a concave surface, 3 mm in the midline and 6 mm in the mid-laterat areas. Note: These measurements are generalizations. Remember: The placement of the posterior palatal seal is the responsibility of the dentist and should never be delegated to a lab technician.PROSTHODONTICS Complete Dent Which of the following are functions of the posterior palatal seal? * Completes the border seal of the maxillary denture * Prevents impaction of food beneath the tissue surface of the denture * Improves the physiotogic retention of the denture « Compensates for shrinkage of the denture resin during processing +All of the above Copyright © 2004 —. DENTAL DECKS+All of the above Landmarks for Posterior Palatal Seal + The posterior outtine is formed by the “ah" line or vibrating line and passes through the two pterygomaxillary (hamular) notches and is close to the fovea palatini. * The anterior outline is formed by the "blow" line and is located at the distal extent of the hard palate. Note: Excessive depth of the posterior palatal seal will usually result in unseating of the denture. Remember: The posterior palatal seal will vary in outline and depth according to the palata! form of the patient.PROSTHODONTICS Crn & Bridge In metal-ceramic restorations, failure or fracture usually occurs: * In the porcelain * At the porcelain-metal interface ¢ In the metal Copyright © 2004 — DENTAL DECKS+ In the porcelain One of the major reasons for the acceptance of porcelain fused to metal restorations is its greater strength and resistance to fracture. The combination of porcelain and metal, fused together, is stronger than porcelain alone. Because true adhesion occurs, the bond strength is such that failure or fracture wil! occur in the porcetain father than at the porcelain-metal interface. Important points concerning the metal-ceramic crown: * The necessary thickness of the metal substructure is 0.5 mm * The minimal porcelain thickness is 1.0-1.5 mm * Based on the above points, the tooth reduction necessary for the metal-ceramic crown is approximately 1.5-2.0 mm. The labial shoulder width is ideally 1.5 mm. * The most frequent cause of porosity in the porcelain is inadequate condensation of the porcelain. * The effectiveness of condensing porcelain powder to reduce shrinkage is determined by the shape and size of the particle. Remember: Porcelain is much stronger under compressive forces than it is when subjected to tensile forces by the opposing teeth. Porcelain fracture in all-ceramic restorations can be avoided by keeping the angles of the preparation rounded.PROSTHODONTICS Crn & Bridge The process of the joining of two metals by the use of a filler material which has a substantially lower fusion temperature than that of the metal parts being joined is called: Pickling * Soldering + Fluxing * Casting Copyright © 2004 — DENTAL DECKS* Soldering Soldering is used in dentistry to connect bridgework and in fabricating orthodontic appliances. Gold solders are generally used for fixed bridgework and silver solders for orthodontic appliances. It is important that the solder melt at least 150°F below the fusion temperatures of the metals or alloys being solders (for obvious reasons). Note: The bonding of the solder is contingent upon wetting of the joined surfaces by the solder, and not upon melting of the metal components. Cleanliness is the most important prerequisite of soldering, since the soldering process depends upon wetting of the surfaces to achieve bonding. Fluxing is the oxidative cleaning of the area to be soldered. Fluxes (most commonly borax) are used to dissolve surface impurities and to protect the surface from oxidation while heating. Note: Fluxing is also performed on molten metat alloys during the casting of a crown or partial denture framework. Pickling is the process of removing surface oxides from a casting prior to polishing. The casting is placed in an acidic solution which reduces the surface oxides. To prevent injury, safety goggles should always be wom when pickling.PROSTHODONTICS Crn & Bridge Which of the following are indications for fixed bridgework or important considerations to think about when contemplating the fabrication of fixed bridgework for a patient? + A limited number of edentulous areas which would not otherwise be more satisfactorily restored with a removable partial denture +The need to prevent the over-eruption of opposing teeth and the drift of teeth neighboring the edentulous space «The presence of suitable abutment teeth — favorable crown / root ratio, adequate alveolar support, absence of apical pathology, etc. * Esthetics » Patient motivation, including time availability * Clinical and technical ability + All of the above Copyright © 2004 — DENTAL DECKS+ All of the above Contraindications for fixed bridgework: + Poor oral hygiene + High caries rate + Multiple spaces in the arch or teeth likely to be lost in the near future + Space not detrimental to the maintenance of arch stability or dental health + Unacceptable occlusion + Bruxism Notes: 4. If the clinical and technical skills of the dentist do not match the demands of the case, fixed bridgework should not be undertaken because a failed bridge is likely to be more detrimental to dental health than a failed removable partial denture. 2. Unless specifically contraindicated, fixed restorations are always the treatment of choice. 3. Fixed bridgework can be used in conjunction with removable partials. Example: A patient with a couple of missing anterior teeth and no posterior teeth. Treatment could be fixed bridgework in the anterior and a partial denture replacing posterior teeth. 4. Although somewhat controversial, the literature recommends that you should not splint natural teeth and implants in a fixed partial denture. Implants have no periodontal ligament and so do not have the same capacity to absorb shocks as do natural teeth (they have different mobilities). When this bridge is subject to occlusal loading, the difference has been shown to be detrimental to the natural teeth as well as cause bone loss around the impiants.