GUIDES TO STANDARDS IN PROSTHETIC DENTISTRY

- COMPLETE AND PARTIAL DENTURES

A Report by the British Society or the St!"y o Prosthetic De#tistry M $ B%rsby &Ch%ir'( A $oh#so#( R D )e* %re( R B )i#st%#*ey +ore,or" At the request of the Council of the British Society for the Study of Prosthetic Dentistry in 2003, a Working Party was con ened to re iew the !uides to Standards in Prosthetic Dentistry for"ulated #y the Society in $%%&' We are (leased to re(ort that ery few changes were considered necessary' )his is a tri#ute to the foresight and hard work of the original Working Party whose re"it was set out in their re(ort$' )he re ised guidelines relate to the (ractice of co"(lete and (artial Prosthodontics including the technical as(ects of denture construction' )hey refer to the "ini"u" acce(ta#le standards a((ro(riate to the *nited +ingdo"' ,t was agreed #y Council that standards for i"(lant retained (rostheses and for i""ediate dentures should for" the re"it of another grou(' )he (ro ision of satisfactory co"(lete dentures and (artial dentures is a tea" a((roach in ol ing clinician, technician, and (atient' All should #e in ol ed in the design and construction of dentures in their res(ecti e ways' )he clinician "ust #e aware of the (atient-s require"ents and take the ulti"ate res(onsi#ility for the final (rosthesis' )he technician should #e in ol ed with the (racticalities of the design and "ust follow the (rescri(tion e.actly' ,t is #eneficial, where feasi#le, to in ol e the technician in the surgery where he/she can see the (atient and understand any (ro#le"s' )he nurse should su((ort the (atient during the selection of teeth and encourage the (atient-s co""ents' ,t has #een necessary since 0une $%%1 for all (rostheses "anufactured in dental la#oratories to co"(ly with the 2uro(ean *nion 3edical De ices Directi e 43DD5, and for la#oratories to #e registered with 3DD6 Article 22(4) of Directive 93/42/EEC requires Member States to accept the placi ! o the mar"et a # the putti ! i to service of #evices $hich co form to the rules i force i their territor% o 3& December &994 (pre'e(isti ! atio al rules) #uri ! a perio# of five %ears follo$i ! the a#optio of the aforeme tio e# Directive) i*e* e #i ! o &4 +u e &99,* Accor#i !l%) si ce &st +a uar% &99-) $he Directive 93.42/EEC became first applicable) it has bee possible to place me#ical #evices o the mar"et a # put them i to service either i accor#a ce $ith the

pre'e(isti ! atio al rules or i complia ce $ith Directive 93/42/EEC* /rom &- +u e &99,) it $ill o l% be possible to place me#ical #evices o the mar"et a # put them i to service if the% compl% $ith Directive 93/42/EEC*

7ne require"ent of the Directi e is that the de ice is "anufactured according to the (rescri(tion requiring the clinician to (ro ide this for all (atients' +!rther i# or-%tio# %bo!t the Me"ic%* De.ices Directi.e c%# be obt%i#e" ro- the Me"ic%* De.ices A/e#cy &si#ce Apri* 0112 p%rt o the Me"ici#es %#" He%*thc%re pro"!cts Re/!*%tory A/e#cy'

I#ter#et sites3
,,,4-hr%4/o.4!5 ,,,4-e"ic%*-"e.ices4/o.4!5

The Co#str!ctio# o Co-p*ete De#t!res

Co"(lete dentures are constructed to restore nor"al s(eech, (ro ide occlusal and facial su((ort and adequate "asticatory function' )hey should ha e a (leasing a((earance, #e co"forta#le to wear, and not (re8udice the health of the su((orting tissues' )here can, howe er, #e no guarantee that they will satisfy all these criteria for (atients who ha e (oor denture control skills, (oor "oti ation, inadequate foundations, or intolerance to (rostheses' Pre(aration of the "outh (rior to treat"ent and the design of co"(lete dentures is the res(onsi#ility of the clinician'

A' CLINICAL PROCEDURES

Di%/#osis %#" tre%t-e#t p*%# ,n order to for"ulate the treat"ent (lan a "edical and dental history should #e taken and a clinical e.a"ination carried out, together with any a((ro(riate in estigations' 9adiogra(hs should only #e taken when there are clear clinical indications' Pre ious dentures should #e e.a"ined in con8unction with any co"(laints fro" the (atient' Any (athological conditions should #e in estigated and a((ro(riate treat"ent (ro ided in order to render the oral tissues healthy #efore final i"(ressions are "ade' Any electi e surgery should #e carried out at an a((ro(riate stage' )here should #e a clear treat"ent (lan and e.(ected outco"e (ut to the (atient, ideally in writing, so that they are a#le to "ake an infor"ed decision of acce(ting the treat"ent (ro(osed and related costs' ,t is well to re"e"#er that dentures are seen as goods and therefore su#8ect to the Sale of !oods Act' )his "eans that that they are suita#le for the (ur(ose for which they were "ade 4i'e' to re(lace "issing teeth5 or according to the contract with e.(lanation of any (ossi#le shortco"ings'

Pri-%ry i-pressio#s )he require"ents of the (ri"ary i"(ressions are that they should accurately record clinically rele ant land"arks of the edentulous "outh without e.cessi e tissue distortion' )hey should #e "ade in rigid stock trays "odified as necessary to fit the for" of the denture #earing area' 3a.illary i"(ressions should record the following6 i5 )he residual ridge, tu#erosities and ha"ular notches' ii5 :unctional la#ial and #uccal sulci, including the fraena iii5 )he hard (alate and its 8unction with the soft (alate' 3andi#ular i"(ressions should record the following6 i5 )he residual ridge and retro"olar (ads' ii5 :unctional la#ial and #uccal sulci, fraena and the e.ternal o#lique ridges' iii5 )he lingual sulcus, lingual fraenu", "ylohyoid ridge and retro"ylohyoid area' )he i"(ression should #e recorded with the "ylohyoid "uscle in a functional raised (osition' Where the i"(ression is o er;e.tended in relation to the functional de(th of the sulcus, a clear indication should #e "ade on the i"(ression or resultant cast to hel( the technician in the construction of s(ecial trays' A((ro(riate s(aced or close fitting rigid trays should #e requested in the la#oratory (rescri(tion, de(ending on the ty(e of i"(ression "aterial and technique to #e used and the anato"y of the denture #earing area' )he site for any sto(s, the ty(e and (osition of the handle, as well as the a"ount of s(acing should #e sti(ulated #y the clinician' )or5i#/ i-pressio#s )hese should record the entire functional denture #earing area to ensure "a.i"u" su((ort, retention and sta#ility for the denture during use' 2ach s(ecial tray should #e e.a"ined in the "outh and ad8usted as necessary to satisfy the a#o e require"ents' )o ensure adequate li( and cheek su((ort the "a.illary i"(ression should show an intact rounded record of the la#ial and #uccal sulci, together with the fraena' ,t should e.tend (osteriorly to the ha"ular notches and 8ust #eyond the 8unction of hard and soft (alates' )he "andi#ular i"(ression should show an intact rounded record of the la#ial, #uccal and lingual sulci, including the fraena' ,t should e.tend (osteriorly to co er the retro"olar (ads' ,"(ressions should #e #o.ed or the #orders "arked a((ro(riately #efore the casts are (oured in order to (reser e an accurate record of the functional de(th %#" ,i"th of the sulci' Recor"i#/ 6%, re*%tio#s &-%7i**o--%#"ib!*%r re*%tio#s' )he #ases which carry the occlusal ri"s should #e rigid and sta#le' )he u((er ri" is "odified to gi e correct li( su((ort, which will ary fro" (atient to

(atient' )he incisi e (a(illa (ro ides a useful #io"etric guide to the (ro"inence of the ri", its centre lying 1;$0 "" (alatal to the la#ial surfaces of the "a.illary central incisors 4in the natural dentition5' Patients- wishes, or (re ious satisfactory dentures, "ay so"eti"es dictate otherwise' )he length of the u((er ri" should #e ad8usted to indicate the le el for the u((er anterior denture teeth and the antero;(osterior 4occlusal5 (lane "ade (arallel to the inter(u(illary and alar;tragal lines 4unless facial asy""etry warrants an alternati e5' A centre line should #e "arked on the u((er ri"' )his will usually #e coincident with the "idline of the face' <igh and low s"ile lines, and the corners of the "outh "ay also #e indicated' ,t "ay also #e ad antageous to "ark the centre line of the lower ri"' )he occlusal ertical di"ension should (ro ide for "ost (atients a "ini"u" inter;occlusal clearance 4freeway s(ace5 of 2;& "" in the (re"olar region' ,t is esta#lished #y ad8ust"ent of the lower occlusal ri" and erified using arious techniques of clinical "easure"ent' :ailure to (ro ide sufficient freeway s(ace "ay lead to "uscular disco"fort, (ain in ol ing the denture #earing areas, and (ossi#le increased #one resor(tion' 2.cessi e freeway s(ace "ay lead to cheek #iting, angular cheilitis, (oor a((earance and contri#ute to disco"fort fro" the te"(oro"andi#ular 8oints' Progressi e incre"ental additions of acrylic resin to the occlusal surfaces of e.isting or diagnostic dentures "ay #e necessary #efore a satisfactory occlusal ertical di"ension can #e esta#lished' ,t is essential to o#tain a (atient-s consent #efore "aking "odifications to their e.isting dentures' )he hori=ontal 8aw relationshi( to #e recorded at the esta#lished occlusal ertical di"ension is retruded contact (osition 49CP5' )his is a re(roduci#le (osition at which the denture teeth are (laced in intercus(al (osition 4,CP5' 7nce this (osition can #e re(roduced, the #ucco;lingual width of the occlusal ri"s should #e ad8usted to identify the >denture s(ace? 4neutral =one5' )his is i"(ortant in order to (ro ide tongue s(ace, facial soft tissue su((ort, and denture sta#ility' ,n so"e instances functional recording of the "andi#ular denture s(ace "ay #e a((ro(riate using a suita#le i"(ression "aterial on a sta#le #ase' )he occlusal ri"s "ust #e located securely together in 9CP in the "outh using an acce(ted technique' S"all @;sha(ed notches "ay #e cut #ilaterally in the occlusal surfaces of the ri"s (rior to the use of a suita#le registration "aterial' Wa. as a recording "ediu" in these circu"stances is not generally reco""ended' Ainc o.ide/2ugenol i"(ression (aste or rigid silicone registrations ha e the ad antage of relocation if the ri"s #eco"e detached during trans(ortation' )he use of a face;#ow "ay #e desira#le with a se"i; ad8usta#le articulator, although in the "a8ority of situations an a erage alue articulator will suffice' ,n this latter case, any change in occlusal ertical di"ension will require new records to #e "ade' )he (rescri(tion acco"(anying the registration should gi e details of "ould, shade, "aterial, and "anufacturer-s #rand of chosen teeth' A diagra" "ay

hel( the technician with the arrange"ent' )he cus( for", "aterial, and si=e of (osterior teeth should #e selected' )he nu"#er of teeth to #e used and their anato"ical ty(e should #e recorded' When setting u( the teeth it is usual to li"it the lower occlusal ta#le to the hori=ontal (art of the ridge and to a oid (lacing teeth o er an inclined (lane of the ascending ra"us' Where (atients ha e e.tre"ely resor#ed lower ridges, and ha e had (ro#le"s with (re ious lower dentures, the use of (re"olars rather than "olars for the lower set u( is suggested' An i"(ression of a (re ious denture "ay #e hel(ful to the technician where a (articular for" of anterior tooth arrange"ent is to #e re(eated' Photo/r%phs ,hich sho, the p%tie#ts #%t!r%* teeth %#" %ci%* %ppe%r%#ce -%y %*so be he*p !*4 The tri%* i#sertio# )he occlusal (lane, occlusal ertical di"ension, and 9CP should #e erified as correct' )ooth (osition and arrange"ent should (ro ide adequate li( and cheek su((ort and tongue s(ace, allow clear s(eech, and gi e a (leasing a((earance to the (atient' Where alterations are required to the hori=ontal or ertical 8aw relationshi(, a new recording will #e required and a re;try necessary' )he (osition of the (osterior (alatal #order of the "a.illary #ase should #e e.a"ined to ensure it is correctly e.tended 8ust #eyond the 8unction of hard and soft (alate lying on dis(lacea#le #ut non;"o ing tissue' )he fo eae (alati act as a useful land"ark, lying 2;3 "" #ehind the (osterior "argin of the hard (alate' ,t is the clinician-s res(onsi#ility to cut a (ost da" on the "aster cast in the a((ro(riate (osition unless a functional (ost da" was incor(orated into the final i"(ression' )he (atient should #e gi en the o((ortunity to see the trial dentures in (lace at this stage' ,t is wise for the" to agree er#ally 4and ideally in writing5 that the a((earance is satisfactory' )he e.tension of the lower #ase onto the retro"olar (ad should #e clearly indicated on the cast for the technician' I#sertio# o the "e#t!res )he denture #ases should #e ins(ected and any re"aining surface #le"ishes or defects re"o ed' 2ach denture should #e inserted and assessed for retention, e.tension, a((earance, and sta#ility' :actors assessed at the trial stage such as li( su((ort, s(eech, and hori=ontal and ertical 8aw relationshi(s should #e reconfir"ed as correct' Articulating (a(er or foil "ay #e used to e.a"ine occlusion and articulation in the "outh, although this should #e carried out with caution to a oid errors' A (ressure indicating (aste or other suita#le recording "aterial "ay #e used on the fitting surfaces of the dentures to indicate e.cessi e tissue dis(lace"ent' A check record is a useful "ethod for refining the occlusion, the dentures #eing re;"ounted on the original articulator and ad8ust"ents carried out to

(ro ide correct articulation' ,t is strongly reco""ended that the (rocessed dentures are routinely re"ounted on the articulator following deflasking 4using the s(lit;cast "ethod5, and the occlusion ad8usted and ground in to o erco"e (rocessing inaccuracies #efore returning to the clinic/surgery' A check record "ay not then #e necessary at the insertion stage, #ut could #e alua#le at the re iew a((oint"ent after the dentures ha e #een worn for a (eriod and the su((orting tissues ha e ada(ted to the"' ,nstructions 4#oth er#al and written5 on the use and care of dentures should #e gi en to the (atient, and a re iew a((oint"ent "ade a((ro.i"ately one week later' I#spectio# %#" re.ie, At the re iew a((oint"ent, any ad8ust"ents should #e "ade to the dentures in the light of the (atient-s e.(eriences or co"(laints' )he denture #earing areas should #e e.a"ined for signs of trau"a e en in the a#sence of (atient co"(laints' )he occlusion and articulation should #e e.a"ined at this stage' )he i"(ortance of attending for regular re iew should #e e.(lained to the (atient' A""e#"!)he a#o e guidelines are "eant to co er techniques used in the different stages of co"(lete denture construction' <owe er, it is acce(ted that ariations "ay occur, so"e of which are listed #elow6 Co(y/du(lication techniques are e.tre"ely alua#le for "any (atients, (articularly the elderly' )he techniques ha e #een well docu"ented 2;B and ena#le reasona#ly si"ilar co(ies of (re ious satisfactory dentures to #e "ade with a "ini"u" of clinical isits' 3aking working i"(ressions in a (atient-s e.isting dentures "ay eli"inate the need for (ri"ary i"(ressions, s(ecial tray construction and occasionally 8aw registration ri"s' *sing a((ro(riate i"(ression "aterials, and #y "odifying stock trays, acce(ta#le working i"(ressions can #e "ade without the need for s(ecial trays in so"e situations'

Disi# ectio# ,n all cases due regard should #e gi en to the disinfection of all "aterials/(rostheses which (ass fro" clinician to la#oratory and ice ersa, according to health and safety require"ents' CB )he British Dental Association ,nfection Control Worksho( held in 2003 is reco""ended reading, (articularly Worksho( & on deconta"ination and disinfection' )his can #e accessed fro" the following address6 http0//$$$*b#a'#e tistr%*or!*u"/p#fs/1C2or"shop4*p#f Current (ractice and disinfection agents are su#8ect to change and it is a clinician-s res(onsi#ility to kee( u( to date on such "atters'

B' TECHNICAL PROCEDURES )he clinician is res(onsi#le for the (ro ision of co"(lete dentures' At each stage the dentist should (ro ide a clear (rescri(tion for the la#oratory' ,f the technical quality of the dentures is inadequate it is the clinician-s res(onsi#ility to ha e the (ro#le" re"edied' Pri-%ry c%sts %#" speci%* tr%ys Surface "oisture should #e re"o ed fro" the i"(ressions after rinsing and #efore casting' Plaster of Paris and dental stone 4B0/B0 w/w5 are acuu" "i.ed with water' )he i"(ressions are cast using i#ration to eli"inate air #u##les and se(arated fro" the cast after &0 "inutes' )he cast should record the de(th and width of the sulci and #e surrounded #y a >land? width of at least 3""' )he #ase should #e $0 "" thicker than the dee(est (art of the i"(ression' )he >land? area should always #e recorded unless the e.tent of the s(ecial tray has #een indicated on the i"(ression #y the clinician' S(ecial trays are "ade according to the clinical (rescri(tion, which will sti(ulate the a"ount of s(acing 4if any5 and sto(s' <andles "ust #e designed to a oid distortion of the tongue or li(s and finger rests are required in the (re"olar region on the "andi#ular tray to (re ent the o(erator-s fingers distorting the soft tissues' )he #orders of the tray should nor"ally e.tend to the dee(est (art 4or slightly short if #order "oulding techniques are to #e used5 of the functionally recorded sulcus, or to an outline on the cast "ade #y the clinician' ,n the "a.illa it should e.tend (osteriorly to the ha"ular notches and fo ea (alati D in the "andi#le to the distal as(ect of the retro"olar (ads' )or5i#/ c%sts %#" re/istr%tio# ri-s Surface "oisture should #e re"o ed fro" the i"(ressions after rinsing and #efore casting' Dental stone in the correct "easure is acuu" "i.ed with water and the i"(ression cast' )he thickness of the #ase and the width of the >land? is the sa"e as for (ri"ary casts' )he #ase of the registration #lock should nor"ally #e "ade of a rigid "aterial' Close ada(tation of the #ase to the working cast is essential for sta#ility in the "outh and accurate registration of 8aw relations' 9egistration ri"s are usually "ade of wa.' )he u((er #lock should "easure a((ro.i"ately 22 "" in height fro" the dee(est (art of the sulcus ad8acent to the "idline fraenu"' )he equi alent di"ension of the lower #lock should "easure a((ro.i"ately $% "" anteriorly Wa. ri"s are (ositioned #ucco;lingually in the sa"e (lace as the lost teeth, according to the a"ount of resor(tion that has taken (lace' )he occlusal surface of the lower ri" (asses (osteriorly fro" its anterior edge to a (oint 2/3 u( the retro"olar (ads' )he u((er ri" should #e created using an occlusal ri" inclinator so that in the "outh it can easily #e ad8usted to #e (arallel to the alar;tragal line antero;(osteriorly'

Mo!#ti#/ %#" setti#/ !p )he registration ri"s are "ounted on a se"i;ad8usta#le or a erage alue articulator 4according to clinical require"ents5, (refera#ly using the s(lit cast technique' After noting the (rescri(tion for tooth arrange"ent, the "a.illary anterior teeth are set u( in accordance with the "arked centre line, always confor"ing to the contour of the wa. ri"' *nless the (rescri(tion says otherwise, or a neutral =one 4(ie=ogra(h5 technique has #een used, the "andi#ular (osterior teeth are (laced to confor" to the #uccal contour of the wa. ri"' ,t is wise, (articularly with flat lower ridges, to a oid the "ost (osterior tooth #eing (ositioned o er an inclined (lane, and to achie e this, the last tooth should #e at the (osterior e.tre"ity of the hori=ontal (art of the ridge' )he teeth are ad8usted to allow #alanced articulation in lateral and (rotrusi e e.cursions' Any (art of the try;in #ase which was re"o ed to facilitate registration is re(laced unless this interferes with occlusal #alance' Processi#/ %#" i#ishi#/ While in ,CP on the articulator, the try;in is sealed to the casts with wa. around the denture #orders' :ollowing (rocessing, the dentures 4still on casts5 should #e re(laced on the articulator, #y "eans of the s(lit cast, and any (rocessing errors re"o ed #y occlusal ad8ust"ent' :inishing and (olishing is carried out carefully to (reser e the full width and de(th of the recorded #orders' A(art fro" the re"o al of i"(erfections, the fitting surface re"ains untouched' )he co"(leted dentures should #e stored in clean water 4with antise(tic as a((ro(riate5 after re"o al of traces of (olish' Denture identification is a desira#le o(tion with co"(lete dentures' Chec5 recor" Where this is requested, it is (refera#ly carried out on the original casts if (ossi#le' :ailing this, the dentures "ay #e re"ounted on an articulator using quick setting (laster and occlusal ad8ust"ents carried out'

The Co#str!ctio# o P%rti%* De#t!res

Partial dentures should assist the "astication of food, #e cos"etically (leasing and hel( "aintain nor"al s(eech' )hey "ay also #e required to "aintain oral health and (re ent tilting and o ereru(tion of natural teeth' )hey should ne er #e "ade "erely to >fill ga(s? in the "outh and should #e designed and constructed in such a way as to "ini"ise oral da"age' A high standard of oral hygiene is necessary on the (art of the (atient' )he underlying (rinci(les of su((ort, retention and sta#ility should #e understood whate er ty(e of (artial denture is to #e "ade'

A'

C*i#ic%* Proce"!res

Di%/#osis %#" tre%t-e#t p*%# ,n order to for"ulate the treat"ent (lan a "edical and dental history should #e taken, noting the (atient-s co"(laints, dental e.(erience and attitude to treat"ent' )he natural teeth should #e e.a"ined, their nu"#er, (osition and occlusal relations noted, and e idence of caries, (laque, (eriodontal diseases and tooth "o#ility recorded' )he state of the "ucosa should #e e.a"ined and (re ious dentures ins(ected in relation to the natural teeth and the (atient-s e.(erience' 9adiogra(hs of the teeth and su((orting tissues "ay #e necessary' Pathological conditions should #e in estigated and treated a((ro(riately' 2.traction of teeth, (eriodontal treat"ent or restorati e treat"ent of any kind should #e co"(leted (rior to (artial denture construction' <owe er, it is essential that the (ro isional design of the dentures is "ade early in the treat"ent (lan so that the "ost a((ro(riate restorations are (laced in any natural teeth which will act as a#ut"ents for the (artial denture' When crowns or cast restorations are to used to restore a#ut"ent teeth they should #e designed to incor(orate suita#le features for the (artial denture 4e'g' guide (lanes, rest seats, "illed ledges and suita#le undercuts for clas(s5' Dietary ad ice and attention to oral hygiene should #e gi en as a((ro(riate' I-pressio#s or st!"y c%sts Study casts are essential, along with clinical and any radiogra(hic e.a"inations, in the assess"ent and (lanning of (artial dentures' A suita#le elastic i"(ression "aterial in a rigid tray, "odified where necessary, should #e used to record the teeth, (alate, edentulous areas and la#ial, #uccal and lingual sulci' Casts should #e (oured in stone and, where the occlusion is self;e ident, "ounted on an articulator in the intercus(al (osition 4,CP5' ,n so"e instances it is (ossi#le to hand;hold the casts for analysis of the occlusion' Where the occlusion is not self e ident, occlusal ri"s should #e constructed and either ,CP or the retruded contact (osition 49CP5 recorded, de(ending on the natural teeth (resent and (osition required' A face;#ow record "ay #e taken where a se"i;ad8usta#le articulator is to #e used' )he "ounted casts should #e e.a"ined and the 9

occlusion co"(ared with that of the (atient' ,t is i"(ortant that they e.actly coincide unless alteration to the relationshi( is #eing "ade deli#erately' )he use of a (lasterless articulator and silicone registration "ay #e an acce(ta#le alternati e for designing (artial dentures in the surgery where there are no facilities for "ounting with (laster' P%rti%* "e#t!re "esi/# C'B' ,n order to design a (artial denture correctly, a sur eyor is an essential (iece of equi("ent in the surgery' )he design of a (artial denture is the duty and res(onsi#ility of the clinician' )he dentist should sur ey the cast and choose the "ost a((ro(riate (ath of insertion for the denture in relation to suita#le guide (lanes, tooth and #one undercuts and a((earance' )he (ath of insertion and re"o al should #e trans"itted to the la#oratory #y "arking lines (arallel to the analysing rod on each side and #ack edge of the study cast' 9estorati e work in ol ing technical (rocedures requires a close relationshi( #etween clinician and technician and discussion of a (ro(osed design firstly with the technician and su#sequently with the (atient can only enhance the likely success of the treat"ent' )he fra"ework should #e designed outlining the saddle areas, occlusal and other su((ort, the direct retainers and any necessary indirect retention to (re ent rotation' 9esistance to lateral and antero;(osterior dis(lacing forces should #e (lanned, and connectors should #e rigid and strong with "ini"al gingi al co erage' )he (osition of the undercut to #e engaged #y each clas( ar" should #e indicated on the cast, and the ty(e of clas( and "aterial to #e used included in the (rescri(tion' Any tooth alteration (rocedures necessary to i"(ro e the effecti eness of the design should #e noted' ,n addition to the (re(aration of guide (lanes, rest seats, recontouring of #uccal or lingual tooth surfaces and occlusal ad8ust"ents, it is so"eti"es useful to "odify the natural teeth #y addition of adhesi e restorati e "aterials' )he design and written instructions should for" a co"(rehensi e (rescri(tion for the la#oratory to follow, aided where (ossi#le #y a design drawn on the study cast' Where anterior teeth are #eing re(laced, it is alua#le at this stage 4and certainly (rior to construction of a "etal fra"ework5 to try in a wa.ed u( denture to deter"ine the final (osition of the teeth so that the technician can (lace the retenti e co"(onents for the teeth and saddle in the "ost fa oura#le (osition' )or5i#/ i-pressio#s After all tooth (re(aration and restorati e (rocedures ha e #een carried out according to the treat"ent (lan, erification should #e "ade that there is sufficient clearance for the denture #ase and co"(onents' :inal i"(ressions should #e recorded using either a "odified "etal stock tray or (refera#ly a rigid s(ecial tray' When a cast "etal fra"ework is to #e constructed such i"(ressions should #e recorded in a di"ensionally sta#le elasto"eric

10

"aterial' )o (re ent tearing and distortion of the i"(ression "aterial, large interdental s(aces #eneath contact (oints should #e #locked out in the "outh using soft ri##on wa. or other suita#le "aterial, (rior to co"(letion of the i"(ression' Where alginate is used, stone casts should #e (oured i""ediately to "ini"ise di"ensional change' 2ach i"(ression should #e e.a"ined for defects and the surface should e.hi#it clear detail' Co (art should #e detached fro" the tray' Any e.cess unsu((orted #ulk of "aterial should #e re"o ed with a shar( instru"ent to (re ent distortion' 3aster casts should #e treated with great care to a oid the risk of a#rasion' Du(licate "aster casts should #e "ade for use at a later stage' Recor"i#/ 6%, re*%tio#ships )he occlusion will already ha e #een recorded as outlined under >,"(ressions for study casts?' <owe er, for greater accuracy where a cast "etal fra"ework is to #e constructed, the 8aw relationshi( should #e recorded again using occlusal ri"s 4if a((ro(riate5 constructed on a du(licate "aster cast' Where anterior teeth are #eing re(laced, a wa. trial denture should ha e #een constructed on a du(licate "aster cast and tried in the "outh #efore construction of the "etal fra"ework in order to indicate to the technician the (osition of retenti e co"(onents and/or any necessary >#ackings?, as outlined (re iously' Co#str!ctio# o the -et%* r%-e,or5 ,t is essential that written and diagra""atic instructions are su#"itted to the la#oratory on an a((ro(riate (rescri(tion for"' Both clinician and la#oratory should retain a co(y' )he (ath of insertion, and the (ositioning of critical #orders of "a8or connectors, tissue relief 4where necessary5 and tissue sto(s for free;end 4distal e.tension5 saddles indicated #y the clinician should #e noted #y the la#oratory along with the rest of the design' 3ounted du(licate casts should #e returned to the la#oratory at this stage to indicate occlusal relationshi(s, as should wa. trial dentures using anterior teeth' Try-i# o the r%-e,or5 )he fra"ework should #e (resented on "ounted "aster casts' )he returned fra"ework should confor" (recisely to the design (rescri(tion sent to the la#oratory #y the clinician' Criteria for the o#8ecti e assess"ent of co#alt; chro"iu" castings ha e #een de elo(ed and "ini"u" standards that "ay #e a((lied in clinical (ractice suggested E' 7n trying in the "outh, any "inor errors "ay #e located using a disclosing "aterial and corrections "ade to ensure a (recise fit' ,f a casting fits the "aster cast #ut does not fit the "outh then the "ost likely source of error is the i"(ression 4unless the cast has #een da"aged or inaccurately F#locked out-5' A new i"(ression and re"ake of the casting is then necessary' 7cclusal relationshi(s should #e e.a"ined with the fra"ework in the "outh and any interferences with the o((osing teeth noted' 7nly "inor interferences can #e dealt with #y altering the fra"ework since e.cessi e thinning increases the risk of su#sequent fracture' )here should #e a "ini"u" thickness of $"" at the rest/"inor connector 8unction' Although ad8ust"ent of o((osing teeth as (art of the treat"ent (lan to (ro ide a 11

satisfactory denture is acce(ta#le, "odification at the try;in stage #ecause of lack of roo" de"onstrates (oor clinical (ractice' An occlusal ri" "ay #e added to the fra"ework to record the 8aw relationshi( again if this is found to #e in error, (ro ided the fra"ework does not interfere with the occlusion' With a free;end 4distal e.tension5 saddle, the altered cast or other differential i"(ression technique "ay #e used to gi e a "ore sta#le denture' )he shade, "ould and "aterial of the denture teeth should #e selected at this stage if not already recorded' Tri%* i#sertio# )he trial (artial denture should #e tried in the "outh to check occlusion, a((earance and s(eech, and should #e satisfactory to #oth clinician and (atient' ,t is wise for the" to agree er#ally 4and ideally in writing5 that the a((earance is satisfactory' +i#%* I#sertio# )he finished (artial denture, which has #een (rocessed on the #locked;out "aster cast, should ideally #e (resented to the clinician on the du(licate "aster cast "ounted on the articulator' )he occlusal relationshi( should #e checked once again to ensure that there are e en #ilateral contacts at the correct hori=ontal and ertical 8aw relationshi( and that the denture does not cause any occlusal interference' 3ini"al ad8ust"ent should #e required, although it "ay #e necessary to correct (rocessing errors' )he fitting surface of the saddles should #e checked with a disclosing (aste or other suita#le "aterial and any (ressure areas relie ed' Patients should #e instructed on the insertion and re"o al of their new denture4s5' @er#al and written instructions should #e gi en to the (atient on the use and care of the (artial denture, in (articular the need to "aintain good oral hygiene and health of the natural teeth and soft tissues' )he need for careful handling of delicate co"(onents should #e stressed' I#spectio# %#" re.ie, After the denture is fitted, the (atient should attend for re iew a((ro.i"ately one week later' Any ad8ust"ents "ay #e carried out, and the need to attend for regular re iew stressed' CB Due regard should #e gi en to the disinfection and sterilisation of all "aterials/(rostheses which (ass fro" clinician to la#oratory and ice ersa, according to health and safety require"ents' )he British Dental Association ,nfection Control Worksho( held in 2003 is reco""ended reading, (articularly Worksho( & on deconta"ination and disinfection' )his can #e accessed fro" the following address6 http0//$$$*b#a'#e tistr%*or!*u"/p#fs/1C2or"shop4*p#f

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B'

Tech#ic%* Proce"!res

)he clinician is res(onsi#le for the (ro ision of (artial dentures' At each stage the dentist should (ro ide a clear (rescri(tion to the la#oratory' ,f the technical quality of the dentures is inadequate it is the clinician-s res(onsi#ility to ha e the (ro#le" re"edied'

Pri-%ry c%sts %#" speci%* tr%ys Surface "oisture is re"o ed fro" the i"(ressions #efore casting' Plaster of Paris and dental stone is the (ro(ortions B0/B0 4w/w5 are acuu" "i.ed with water, the i"(ression #eing cast using i#ration to eli"inate air #u##les and re"o ed fro" the cast after &0 "inutes' ')he #ase "ust #e at least $0"" thicker than the dee(est (art of the i"(ression' S(ecial trays are "ade according to the clinician-s (rescri(tion which will sti(ulate the a"ount of s(acing 4this will de(end on the ty(e of i"(ression "aterial to #e used for the working i"(ression5 and (osition of any sto(s' )or5i#/ c%sts %#" re/istr%tio# ri-s )he surface of the i"(ression is rinsed with water and dried with air' Dental stone for acrylic resin dentures, and class & die;stone for co#alt chro"iu" dentures, in correct "easure, is acuu" "i.ed with water and the i"(ression cast in the sa"e way as for (ri"ary casts' )he tray should #e carefully re"o ed and "ay need to #e #urnt off to a oid fracture of teeth on the cast' )he casts should #e sur eyed using the (ath of insertion already indicated #y the clinician on the (ri"ary casts' *nwanted undercuts should #e #locked out using a((ro(riate "aterials 4(refera#ly (laster rather than wa.5 and the cast du(licated' )he #ase of the registration ri" is "ade fro" a suita#le rigid "aterial' !ood ada(tation of the #ase to the working cast is essential for sta#ility in the "outh and accurate registration of the 8aw relations' Wa. registration ri"s are (ositioned onto the saddle areas to #e le el with and no wider than the re"aining standing teeth, and should #e constructed on the du(licate "aster cast in the case of a "etal fra"ework' Mo!#ti#/( -et%* ,or5 co#str!ctio# %#" set-!p )he "aster casts are "ounted with the aid of the registration ri"s on a se"i; ad8usta#le or an a erage alue articulator, (refera#ly using the s(lit;cast technique' )he "etal (artial denture fra"ework is constructed on a du(licated in est"ent "aster cast, after the "aster cast has #een (re(ared' )he "etal fra"ework should fit accurately with no shar( edges, ensuring that clas( ar"s will not i"(inge on the "ucosa and will ter"inate in the correct de(th of undercut' ,t should also #e highly (olished on the non;fitting surface'

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Altered cast technique 3he cli icia ma% at this sta!e have use# a a##itio al impressio $here free'e # (#istal e(te sio ) sa##les are prese t* 4 receipt of the e$ sa##le impressio the ol# sa##le area shoul# be remove# from the master cast) the #e ture frame$or" seate# a # a e$ sa##le cast (the e$ master cast $ill ee# to be re#uplicate#)* 3he tissue stop ma% o lo !er touch the crest of the ri#!e o the e$ cast but this co tact ca be re'establishe# before processi ! b% placi ! a small amou t of self'curi ! resi bet$ee the stop *a # the cast After noting the (rescri(tion for tooth arrange"ent, the "a.illary and "andi#ular teeth are set u( to confor" to the contours and occlusion of the re"aining natural teeth, as (er the (rescri(tion fro" the clinician' With free; end saddle 4distal e.tension5 cases (re"olars "ay #e (referred to "olars as discussed (re iously in relation to the lower co"(lete denture' Processi#/ %#" i#ishi#/ While in occlusion on the articulator the try;in is sealed to the cast with wa. around the #orders of the saddles' After (rocessing, the denture 4still attached to the cast5 is re"ounted on the articulator and any occlusal (rocessing errors ad8usted' S"oothing and (olishing is carried out taking care to (reser e the recorded #orders' A(art fro" the re"o al of surface i"(erfections, the fitting surface "ust re"ain untouched' After co"(letion, the denture is thoroughly cleaned of traces of (olish #efore #eing (laced in antise(tic to "aintain the water #alance and (re ent cross infection' )he denture should #e (resented to the clinician on 'the du(licate cast Chec5 recor" ,f the new occlusion was recorded incorrectly the clinician will "ake a new registration' )he dentures should #e re"ounted onto the articulator using the new occlusal record (ro ided and the occlusal surfaces of the artificial teeth ad8usted until an e en occlusion is achie ed 4where se ere "odification of the denture teeth is needed to achie e this, it "ay #e necessary to re(lace the"5'

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RE+ERENCES $' !uides to Standards in Prosthetic Dentistry G Co"(lete and Partial Dentures' 5ritish Societ% for the Stu#% of 6rosthetic De tistr%) &994* 9e(rinted in !uidelines in Prosthetic and ,"(lant Dentistry, Huintessence Pu#lishing Co' Itd', Iondon *+, $%%E' 2' 3assad 00' Connelly 32' Da is W0' A si"(le, cost;effecti e "ethod of denture du(lication' Dentistry )oday 2000 D893 E2;% 3' 3oha"ed )0' :ara8 SA' Du(lication of co"(lete dentures using a sectional "old technique' 0ournal of Prosthetic Dentistry 200$D :;3$2;$&' &' +i((a. A' Watson C0' Basker 93' Pentland 02' <ow well are co"(lete dentures co(iedJ British Dental 0ournal' $%%1 68:; 3 $2%;$33 B' ' Iindquist )0' Carhi )7' 2ttinger 9I' Denture du(lication technique with alternati e "aterials' 0ournal of Prosthetic Dentistry* $%%KD << 3 %K;1) E' Bars#y 3 0, Schwar= W D' )he qualitati e assess"ent of co#alt;chro"iu" castings for (artial dentures' Br' Dent' 0' $%1% D 8== 6 2$$;2$E

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