CHAPTER 12 - Diagnosis and Treatment - 2011 - McCracken S Removable Partial Pros PDF

12
CHAPTER
Diagnosis and Treatment Planning

Chapter Outline Comparative physical properties of gold and
chromium-cobalt
Purpose and Uniqueness of Treatment
Wrought wire: selection and quality control
Patient Interview
Summary
Shared Decision Making
Clinical Examination
Objectives of Prosthodontic Treatment
Oral Examination
Purpose and Uniqueness of Treatment
Sequence of oral examination The purpose of dental treatment is to respond to a patient’s
Diagnostic Casts needs, both the needs perceived by the patient and those
Purposes of diagnostic casts demonstrated through a clinical examination and patient
Mounting diagnostic casts interview. Although similarities have been noted between
Sequence for mounting maxillary cast to axis-orbital partially edentulous patients (such as Classification designa-
plane tions), significant differences exist, making each patient, and
Jaw relationship records for diagnostic casts the ultimate treatment, unique.
Materials and methods for recording centric relation The delineation of each patient’s uniqueness occurs
Diagnostic Findings through the patient interview and diagnostic clinical exami-
Interpretation of Examination Data nation process. This includes four distinct processes: (1)
Radiographic interpretation understanding the patient’s desires or chief concerns/com-
Periodontal considerations plaints regarding his or her condition (including its history)
Caries risk assessment considerations through a systematic interview process, (2) ascertaining the
Evaluation of the prosthesis foundation—teeth and patient’s dental needs through a diagnostic clinical examina-
residual ridge tion, (3) developing a treatment plan that reflects the best
Surgical preparation management of desires and needs (with influences unique
Analysis of occlusal factors to the medical condition or oral environment), and (4) exe-
Fixed restorations cuting appropriately sequenced treatment with planned
Orthodontic treatment follow-up. The ultimate treatment is individualized to
Need for determining type of mandibular major address disease management and the coordinated restorative
connector and prosthetic needs that are unique to the patient. Provi-
Need for reshaping remaining teeth sion of the best care for a patient may involve no treatment,
Infection Control limited treatment, or extensive treatment, and the dentist
Differential Diagnosis: Fixed or Removable Partial must be prepared to help patients decide the best treatment
Dentures option given his or her individual circumstances.
Indications for use of fixed restorations
Indications for removable partial dentures
Choice Between Complete Dentures and Removable
Patient Interview
Partial Dentures
Clinical Factors in Selecting Metal Alloys for Removable Although oral health is an important aspect of overall health,
Partial Denture Frameworks it is an elective health pursuit for most individuals. Conse-
150
Chapter 12 Diagnosis and Treatment Planning 151
quently, the patient presents for professional evaluation (1) nance of the prosthesis can be improved to provide a more
to address some perception of an abnormality that requires positive experience.
correction, or (2) to maintain optimum oral health. In either
situation, but especially for the patient presenting with some
Shared Decision Making
chief complaint (often with an important history related to
that complaint), it is mandatory that the dentist clearly When helping patients understand their oral health status,
understand what brings the patient to this evaluation. Failure comprising both disease and deficit considerations, and the
to do so leads to the chance that the patient will be unhappy means to address both, we should carefully consider what it
with the treatment result, as it might not address the very is they need to hear from us. For most partially edentulous
reason he or she came for help. With experience, this subtle patients, the discussion may involve fairly complex rehabili-
point becomes a major component of a clinician’s manage- tation options for addressing their missing teeth. Because of
ment focus. this complexity, our responsibility is to help them sort
A fundamental objective of the patient interview, which through the options in an attempt to help them come to the
accompanies the diagnostic examination, is to gain a clear best decision for them. Using a communication model
understanding of why the patient is presenting for evalua- termed shared decision making gives structure to a process
tion; this involves having the patient describe the history where the provider and the patient identify together the best
related to the chief complaint. For complicated clinical course of care. This process recognizes that there may be
problems, the interview and diagnostic examination require complex “trade-offs” in care choice, and it addresses the
two appointments to allow complete gathering of all diag- need to fully inform patients about risks and benefits of care
nostic information needed to formulate a complete plan of options, as well as ensuring that patient values and prefer-
treatment. ences play a prominent role in the process. Although it is
The interview, an opportunity to develop rapport with clear that not all patients desire to participate equally in care
the patient, involves listening to and understanding the decisions, because the options can vary significantly (some
patient’s chief complaint or concern about his or her oral are more invasive, have greater risks, are accompanied by
health. This can include clinical symptoms of pain (pro- higher treatment burden than others; there are often varying
voked or unprovoked), difficulty with function, concern maintenance needs between options), we should actively
about appearance, problems with an existing prosthesis, or engage them in the process. This is more important given
any combination of symptoms related to the teeth, peri- the fact that the tooth replacement is often an elective
odontium, jaws, or previous dental treatment. It is impor- pursuit, and because of this, there is seldom great urgency
tant to listen carefully to what the patient has stated is the involved in making a decision.
reason for presenting for evaluation; this is because all sub-
sequent information gathered will be used to discuss these
concerns and to relate whether the proposed treatment will
Clinical Examination
affect the patient in any way. Such a discussion at the outset
of patient care helps to outline realistic expectations.
Objectives of
Although formats for sequencing the patient interview
Prosthodontic Treatment
(and clinical examination) vary, to ensure thoroughness the
dentist should follow a sequence that includes: The objectives of any prosthodontic treatment may be stated
1. Chief complaint and its history as follows: (1) the elimination of disease; (2) the preserva-
2. Medical history review tion, restoration, and maintenance of the health of the
3. Dental history review, especially related to previous pros- remaining teeth and oral tissues (which will enhance the
thetic experience(s) removable partial denture design); and (3) the selected
4. Patient expectations replacement of lost teeth; for the purpose of (4) restoration
It is from the above interaction that patient uniqueness, of function in a manner that ensures optimum stability and
as mentioned earlier, is best defined. The expectations comfort in an esthetically pleasing manner. Preservation is
described by the patient are critical to an understanding of a principle that protects from decisions that place too high
whether a removable partial denture will satisfy the stated a premium on cosmetic concerns, and it is the dentist’s
treatment goal(s). The fact that removable partial dentures obligation to emphasize the importance of restoring the total
by necessity require material bulk and often use oral soft mouth to a state of health and of preserving the remaining
tissues for support may be hard to comprehend by patients teeth and surrounding tissues.
with no such prosthetic history. Helping the patient under- Diagnosis and treatment planning for oral rehabilitation
stand the normal phase of accommodation to such a pros- of partially edentulous mouths must take into consideration
thesis is an important discussion point in selection of a the following: control of caries and periodontal disease, res-
prosthesis. For those patients with a negative past prosthesis toration of individual teeth, provision of harmonious occlu-
experience, it is necessary to determine before treatment is sal relationships, and the replacement of missing teeth by
started whether the design, fit, occlusion, or lack of mainte- fixed (using natural teeth and/or implants) or removable
152 Part II Clinical and Laboratory
prostheses. Because these procedures are integrally related, accomplished by an evaluation of factors that generate func-
the appropriate selection and sequencing of treatment tional forces and those that resist them. The stability of tooth
should precede all irreversible procedures. and prosthesis position is the goal of such an evaluation. The
The treatment plan for the removable partial denture, following sequence of examination allows attention to be
which is often the final step in a lengthy sequence of treat- paid to aspects of each of these critical features of evaluation
ment, should precede all but emergency treatment. This for removable partial denture service.
allows abutment teeth and other areas in the mouth to be
properly prepared to support, stabilize, and retain the Sequence for Oral Examination
removable partial denture. This means that diagnostic casts, An oral examination should be accomplished in the follow-
for designing and planning removable partial denture treating sequence: visual examination, pain relief and temporary
ment, must be made before definitive treatment is under- restorations, radiographs, oral prophylaxis, evaluation of
taken. After the major factors that create functional forces teeth and periodontium, vitality tests of individual teeth,
are evaluated and those that resist it are understood, the determination of the floor of the mouth position, and
removable partial denture design is drawn on the diagnostic impressions of each arch.
cast, along with a detailed chart of mouth conditions and 1. Relief of pain and discomfort and caries control by place-
proposed treatment. This becomes the master plan for the ment of temporary restorations. A preliminary examina-
mouth preparations and the design of the removable partial tion is conducted to determine the need for management
denture to follow. of acute needs and whether a prophylaxis is required to
As was pointed out in Chapter 1, failure of removable conduct a thorough oral examination. It is advisable not
partial dentures can usually be attributed to factors that only to relieve discomfort arising from tooth defects but
result in poor stability. These can result from inadequate also to determine as early as possible the extent of caries,
diagnosis and failure to properly evaluate the conditions and to arrest further caries activity until definitive treat-
present. This results in failure to prepare the patient and the ment can be instituted. If tooth contours are restored
oral tissues properly before the master cast is fabricated. The with temporary restorations, the impression will not be
importance of the examination, the consideration of favor- torn on removal from the mouth, and a more accurate
able and unfavorable aspects relative to movement control, diagnostic cast may be obtained.
and the importance of planning the elimination of unfavor- 2. A thorough and complete oral prophylaxis. An adequate
able influences cannot be overemphasized (see Chapter 2). examination can be accomplished best with the teeth free
As was mentioned earlier, for complex treatment, two of accumulated calculus and debris. Also, accurate diag-
appointments are often required. The first will likely include nostic casts of the dental arches can be obtained only if
a preliminary oral examination (to determine the need for the teeth are clean; otherwise the teeth reproduced on the
management of acute needs), a prophylaxis, full-mouth diagnostic casts are not a true representation of tooth and
radiographs, diagnostic casts, and mounting records if base- gingival contours. Cursory examination may precede an
plates are not required. The follow-up appointment includes oral prophylaxis, but a complete oral examination should
mounting of the diagnostic casts (when baseplates and be deferred until the teeth have been thoroughly cleaned.
occlusion rims are needed), a definitive oral examination, 3. Complete intraoral radiographic survey (Figure 12-1). The
review of the radiographs to augment and correlate with objectives of a radiographic examination are (a) to locate
clinical findings, and arrangement of additional consulta- areas of infection and other pathosis that may be present;
tions when required. Following collection and synthesis of (b) to reveal the presence of root fragments, foreign
all patient and clinical information, including surveying objects, bone spicules, and irregular ridge formations; (c)
of the casts, a treatment plan (often with options) is to reveal the presence and extent of caries and the relation
presented.
Oral Examination
A complete oral examination should precede any treatment
decisions. It should include visual and digital examination
of the teeth and surrounding tissues with a mouth mirror,
explorer, and periodontal probe, vitality tests of critical
teeth, and examination of casts correctly oriented on a suit-
able articulator. Clinical findings are augmented by and cor- Figure 12-1 Complete intraoral radiographic survey of rem
related with a complete intraoral radiographic survey. aining teeth and adjacent edentulous areas reveals much
During the examination, the objective to be kept fore- information vital to effective diagnosis and treatment planning.
most in mind should be the consideration of possibilities for The response of bone to previous stress is of particular value
restoring and maintaining the remaining oral structures in in establishing the prognosis of teeth that are to be used as
a state of health for the longest period of time. This is best abutments.
of carious lesions to the pulp and periodontal attach- 4. Impressions for making accurate diagnostic casts to be
ment; (d) to permit evaluation of existing restorations as mounted for occlusal examination. The casts preferably
to evidence of recurrent caries, marginal leakage, and will be articulated on a suitable instrument. The impor-
overhanging gingival margins; (e) to reveal the presence tance of accurate diagnostic casts and their use will be
of root canal fillings and to permit their evaluation as to discussed later in this chapter.
future prognosis (the design of the removable partial 5. Examination of teeth, investing structures, and residual
denture may hinge on the decision to retain or extract an ridges. The teeth, periodontium, and residual ridges can be
endodontically treated tooth); (f) to permit evaluation of explored by instrumentation and visual means. Recording
periodontal conditions present and to establish the need of relevant patient history and clinical data on diagnosis
and possibilities for treatment; and (g) to evaluate the charts is important to document features important to
alveolar support of abutment teeth, their number, the clinical presentation. These can be recorded on electronic
supporting length and morphology of their roots, the or paper charts for future reference (Figures 12-2 and
relative amount of alveolar bone loss suffered through 12-3).
pathogenic processes, and the amount of alveolar support Visual examination will reveal many of the signs of dental
remaining. disease. Consideration of caries susceptibility is of primary
REMOVABLE PARTIAL PROSTHODONTICS
PATIENT NAME PATIENT NUMBER
TREATMENT PLAN LABORATORY INSTRUCTIONS
DESIGN SPECIFICATIONS:
7 8 9 1. RESTS
10
6 11
5
12
4
13 2. RETENTION
3
14
2
15
1
3. RECIPROCATION
16
R L
4. MAJOR CONNECTOR
R L
32 17 5. INDIRECT RETENTION
31 18
30
19 6. GUIDE PLANES
29
20
28
21
27 22
26
25 24 23 7. BASE RETENTION
COLOR CODE:
8. AREAS TO BE MODIFIED
BLUE:---- CAST METAL
OR CONTOURED
RED: ----- RESIN BASE AND WROUGHT WIRE
GREEN:-- AREAS TO BE CONTOURED
INSTRUCTOR:
APPROVAL TO SEND TO LABORATORY: DATE:
Figure 12-2 A, Diagnosis record for recording pertinent data. Continued

Figure 12-2, cont’d B, Treatment record chart for recording treatment plan and treatment progress.
Name: John Doe Date: July 1, 1999
Summary Plan: 7 8 9 10
6 11
Maxillary Conventional Complete
5
denture 12
4
Mandibular Class II mod. 1 13
3 14
removable partial denture
Porcelain fused to metal abutment 2 15
Crowns #18, #29 1 16
Right Left
Procedures:
32 17
Tissue conditioning maxillary
arch 31 Cr 18
Primary impression-both arches; 30 19

make impression trays Cr
29 20
Preparations. Contour and rest seats 28 21
#21, #28. Abutment crown 27 22
preparations #18, #29 26
25 24 23
Try-in abutment crowns; pick-up
for cast for framework casting Try-in trial set-up;
verify jaw relations
Try-in abutment crowns and framework
Fluid wax functional impression: Make Placement: Mandibular
altered cast crowns, partial denture,
maxillary complete
Jaw relation records; denture
shade and mold selection
Follow-up care
Tooth arrangement
Red line each completed unit
Figure 12-3 Simple working chart. Restorations for individual teeth, crowns, and fixed partial dentures to be made may be marked
on the chart and checked off as completed during mouth preparations.
importance. The number of restored teeth present, signs of resorbed and has been replaced by displaceable, fibrous con-
recurrent caries, and evidence of decalcification should be nective tissue. Such a situation is common in maxillary
noted. Only those patients with demonstrated good oral tuberosity regions. The removable partial denture cannot be
hygiene habits and low caries susceptibility should be con- supported adequately by tissues that are easily displaced.
sidered good risks without resorting to prophylactic mea- When the mouth is prepared, this tissue should be recon-
sures such as the restoration of abutment teeth. At the time toured or removed surgically, unless otherwise contraindi-
of the initial examination, periodontal disease, gingival cated. A small but stable residual ridge is preferable to a
inflammation, the degree of gingival recession, and muco- larger unstable ridge for providing support for the denture.
gingival relationships should be observed. Such an examina- The presence of tori or other bony exostoses must be detected
tion will not provide sufficient information to allow a and their presence in relation to framework design must be
definitive diagnosis and treatment plan. For this purpose, evaluated. Failure to palpate the tissue over the median
complete periodontal charting that includes pocket depths, palatal raphe to ascertain the difference in its displaceability
assessment of attachment levels, furcation involvement, as compared with the displaceability of the soft tissues cover-
mucogingival problems, and tooth mobility should be per- ing the residual ridges can lead to a rocking, unstable,
formed. The extent of periodontal destruction must be uncomfortable denture and to a dissatisfied patient. Ade-
determined with appropriate radiographs and use of the quate relief of the palatal major connectors must be planned,
periodontal probe. and the amount of relief required is directly proportionate
The number of teeth remaining, the location of the eden- to the difference in displaceability of the tissues over the
tulous areas, and the quality of the residual ridge will have a midline of the palate and the tissues covering the residual
definite bearing on the proportionate amount of support ridges.
that the removable partial denture will receive from the teeth During the examination, not only each arch but also its
and edentulous ridges. Tissue contours may appear to occlusal relationship with the opposing arch must be con-
present a well-formed edentulous residual ridge; however, sidered separately. A situation that looks simple when the
palpation often indicates that supporting bone has been teeth are apart may be complicated when the teeth are in
occlusion. For example, an extreme vertical overlap may is dental plaster. Generally the improved dental stones (die
complicate the attachment of anterior teeth to a maxillary stones) are not used for diagnostic casts because of their cost.
denture. Extrusion of a tooth or teeth into an opposing Their greater resistance to abrasion does, however, justify
edentulous area may complicate the replacement of teeth in their use for master casts.
the edentulous area or may create occlusal interference, The impression for the diagnostic cast is usually made
which will complicate the location and design of clasp retain- with an irreversible hydrocolloid (alginate) in a stock (per-
ers and occlusal rests. Such findings subsequently will be forated or rim lock) impression tray. The size of the arch will
evaluated further by careful analysis of mounted diagnostic determine the size of the tray to be used. The tray should be
casts. sufficiently oversized to ensure an optimum thickness of
A breakdown of the fee may be recorded on the back of impression material to avoid distortion or tearing on removal
this chart for easy reference if adjustments or substitutions from the mouth. The technique for making impressions is
become necessary because of changes in diagnosis as the covered in more detail in Chapter 15.
work progresses.
6. Vitality tests of remaining teeth. Vitality tests should be Purposes of Diagnostic Casts
given particularly to teeth to be used as abutments and Diagnostic casts serve several purposes as an aid to diagnosis
those having deep restorations or deep carious lesions. and treatment planning. Some of these are as follows:
This should be done through both thermal and electronic 1. Diagnostic casts are used to supplement the oral exami-
means. nation by permitting a view of the occlusion from the
7. Determination of the height of the floor of the mouth to lingual, as well as from the buccal, aspect. Analysis of the
locate inferior borders of lingual mandibular major connec- existing occlusion is made possible when opposing casts
tors. Mouth preparation procedures are influenced by the are occluded, as is a study of the possibilities for improve-
choice of major connectors (see Figure 5-6). This deter- ment by occlusal adjustment, occlusal reconstruction, or
mination must precede altering contours of abutment both. The degree of overclosure, the amount of interoc-
teeth. clusal space available, and the possibilities of interference
The fee for examination, which should include the cost with the location of rests may also be determined. As was
of the radiographic survey and the examination of articu- stated previously, opportunities for improvement of the
lated diagnostic casts, should be established before the exam- occlusal scheme, by occlusal adjustment or occlusal
ination is performed and should not be related to the cost reconstruction, are best evaluated by analysis and modi-
of treatment. It should be understood that the fee for exami- fication of mounted diagnostic casts. Such procedures
nation is based on the time involved and the service ren- often include diagnostic waxing to determine the possi-
dered, and that the material value of the radiograph and bility of enhancing the occlusion before definitive treat-
diagnostic casts is incidental to the effectiveness of the ment is begun (Figure 12-4). In other words, diagnostic
examination. casts permit the dentist to plan ahead to avoid undesir-
The examination record should always be available in the able compromises in the treatment being given a patient.
office for future consultation. If consultation with another 2. Diagnostic casts are used to permit a topographic survey
dentist is requested, respect for the hazards of unnecessary of the dental arch that is to be restored by means of a
radiation justifies loaning the dentist the radiograph for this removable partial denture. The cast of the arch in ques-
purpose. However, duplicate films should be retained in the tion may be surveyed individually with a cast surveyor to
dentist’s files. determine the parallelism or lack of parallelism of tooth
surfaces involved, and to establish their influence on the
design of the removable partial denture. The principal
Diagnostic Casts
considerations in studying the parallelism of tooth and
A diagnostic cast should be an accurate reproduction of all tissue surfaces of each dental arch are to determine the
the potential features that aid diagnosis. These include the need for mouth preparation: (a) proximal tooth surfaces,
teeth locations, contours, and occlusal plane relationship; which can be made parallel to serve as guiding planes; (b)
the residual ridge contour, size, and mucosal consistency; retentive and nonretentive areas of the abutment teeth;
and the oral anatomy delineating the prosthesis extensions (c) areas of interference with placement and removal; and
(vestibules, retromolar pads, pterygomaxillary notch, (d) esthetic effects of the selected path of insertion. From
hard/soft palatal junction, floor of the mouth, and frena). such a survey, a path of placement may be selected that
Additional information provided by appropriate cast mount- will satisfy requirements for parallelism and retention to
ing includes occlusal plane orientation and the impact the best mechanical, functional, and esthetic advantage.
on the opposing arch; tooth-to-palatal soft tissue relation- Then mouth preparations may be planned accordingly.
ship; and tooth-to-ridge relationships both vertically and 3. Diagnostic casts are used to permit a logical and compre-
horizontally. hensive presentation to the patient of present and future
A diagnostic cast is usually made of dental stone because restorative needs, as well as of the hazards of future
of its strength and the fact that it is less easily abraded than neglect. Occluded and individual diagnostic casts can be
A B
Figure 12-4 A, Following mounting of the diagnostic casts, tooth arrangement for the mandibular occlusal plane requirements can
be accomplished. B, Following placement of the maxillary anterior teeth in an ideal position, diagnostic arrangement of occlusion results
in a space posterior to surveyed crown #27. If such a finding were objectionable, alternative arrangements could be investigated. This
is not possible unless a diagnostic workup is completed. C, Occlusion of the mandibular removable partial denture will be enhanced
by improving the maxillary posterior occlusal plane of the super-erupted molars.
used to point out to the patient (a) evidence of tooth impression. If wax blockout is to be used in the fabrica-
migration and the existing results of such migration; (b) tion of individual trays, a duplicate cast made from an
effects of further tooth migration; (c) loss of occlusal irreversible hydrocolloid (alginate) impression of the
support and its consequences; (d) hazards of traumatic diagnostic cast should be used for this purpose. The diag-
occlusal contacts; and (e) cariogenic and periodontal nostic cast is too valuable for purposes of future reference
implications of further neglect. Treatment planning actu- to risk damage resulting from the making of an impres-
ally may be accomplished with the patient present, so that sion tray. On the other hand, if oil-based clay blockout is
economic considerations may be discussed. Such use of used, the diagnostic cast may be used without fear of
diagnostic casts permits justification of the proposed fee damage.
through the patient’s understanding of the problems 5. Diagnostic casts may be used as a constant reference as
involved and of the treatment needed. Inasmuch as the work progresses. Penciled marks indicating the type
mouth rehabilitation procedures are frequently lengthy of restoration, the areas of tooth surfaces to be modified,
and often irreversible, there must be complete accord the location of rests, and the design of the removable
between dentist and patient before extensive treatment is partial denture framework, as well as the path of place-
begun, and financial arrangements must be consum- ment and removal, all may be recorded on the diagnostic
mated during the planning phase. cast for future reference (Figure 12-5). Then these steps
4. Individual impression trays may be fabricated on the may be checked off the worksheet as they are completed.
diagnostic casts, or the diagnostic cast may be used in Areas of abutment teeth to be modified may first be
selecting and fitting a stock impression tray for the final changed on the duplicate diagnostic cast by trimming the
placement of the maxillary cast in a position relative to the

opening axis on the articulator, which is similar to the posi-
tion of the maxilla in relation to the temporomandibular
joint of the patient (Figure 12-6). The mandibular cast is
then placed beneath the maxillary cast in a horizontal posi-
tion dictated by mandibular rotation without tooth contact,
at a minimal vertical opening.
The Glossary of Prosthodontic Terms* describes an articu-
lator as a mechanical device that represents the temporo-
mandibular joints and jaw members, to which maxillary and
mandibular casts may be attached. Because the dominant
influence on mandibular movement in a partially edentu-
lous mouth is the occlusal plane and the cusps of the remain-
ing teeth, an anatomic reproduction of condylar paths
is probably not necessary. Still, movement of the casts in
relation to one another as influenced by the occlusal plane
and the cusps of the remaining teeth, when mounted at
Figure 12-5 Proposed mouth changes and design of the a reasonably accurate distance from the axis of condylar
removable partial denture framework are indicated in pencil on rotation, permits a relatively valid analysis of occlusal
the diagnostic cast in relation to the previously determined path relations. This is more anatomically accurate than a simple
of placement. This serves as a means of communicating with the hinge mounting.
patient and as a chair-side guide to tooth modification.
It is better that the casts be mounted in relation to the

stone cast with the surveyor blade. A record is thus made axis-orbital plane to permit better interpretation of the
of the location and degree of modification to be done in plane of occlusion in relation to the horizontal plane.
the mouth. This must be done in relation to a definite Although it is true that an axis-orbital mounting has no
path of placement. Any mouth preparations to be accom- functional value on a nonarcon instrument because that
plished with new restorations require that restored teeth plane ceases to exist when opposing casts are separated,
be shaped in accordance with a previously determined the value of such a mounting lies in the orientation of the
path of placement. Even so, the shaping of abutment casts in occlusion. (An arcon articulator is one in which
teeth on the duplicate diagnostic cast serves as a guide to the condyles are attached to the lower member as they are
the form of the abutment. This is particularly true if the in nature, the term being a derivation coined by Berg-
contouring of wax patterns is to be delegated to the tech- ström from the words articulation and condyle. Many of
nician, as it may be in a busy practice. the more widely used articulators such as the Hanau H
6. Unaltered diagnostic casts should become a permanent series, Dentatus, and improved Gysi have the condyles
part of the patient’s record because records of conditions attached to the upper member and are therefore nonar-
existing before treatment are just as important as are con instruments.)
preoperative radiographs. Therefore diagnostic casts
should be duplicated, with one cast serving as a perma-
nent record and the duplicate cast used in situations that Sequence for Mounting Maxillary Cast
may require alterations to it. to Axis-Orbital Plane
The initial steps allow recording of the maxilla–temporo-
Mounting Diagnostic Casts mandibular joint (TMJ) relationship:
For diagnostic purposes, casts should be related on an ana- 1. Identify the anterior and posterior reference points for
tomically appropriate articulator to best understand the role the facebow (e.g., external auditory meatus, orbitale).
occlusion may have in the design and functional stability of 2. Prepare the bite fork and occlusion rim.
the removable partial denture. This becomes increasingly 3. Place the bite fork centered to the arch, indexing it to
important as the prosthesis replaces more teeth. If the patient the teeth with wax or elastomer.
presents with a harmonious occlusion and the edentulous 4. Place the facebow over the bite fork rod anteriorly.
span is a tooth-bound space, simple hand articulation is
generally all that is required. However, when the natural
dentition is not harmonious and/or when the replacement
*The Journal of Prosthetic Dentistry, Vol. 94, No. 1, The Glossary of
teeth must be positioned within the normal movement pat- Prosthodontic Terms, 8th edition, 2005, pp. 10-81. Available at: http://
terns of the jaws, the diagnostic casts must be related in an www.journals.elsevierhealth.com/periodicals/ympr/ar ticle/
anatomically appropriate manner for diagnosis. This means PIIS0022391305001757/fulltext
Figure 12-6 Use of the facebow makes possible the recording of the spatial relationship of the maxillae to some anatomic reference
points and transference of this relationship to an articulator.
5. Place the bow evenly into the ears posteriorly.

The facebow is a relatively simple device used to obtain a
6. Secure the bow anteriorly.
transfer record for orienting a maxillary cast on an articu-
7. Position the bow anteriorly to the third point of refer-
lating instrument. Originally, the facebow was used only
ence (establishes the horizontal plane).
to transfer a radius from condyle reference points, so that
8. Secure the bite fork vertical rod, then the horizontal rod
a given point on the cast would be the same distance from
(holding the bow securely to prevent torque).
the condyle as it is on the patient. The addition of an
9. Release the bow anteriorly to allow spread, and disen-
adjustable infraorbital pointer to the facebow and the
gage from the ears.
addition of an orbital plane indicator to the articulator
10. Remove the fork downward and out of the mouth with
make possible the transfer of the elevation of the cast in
the attached bow.
relation to the axis-orbital plane. This permits the maxil-
11. Carefully check the security of the attachments.
lary cast to be correctly oriented in the articulator space
The next steps allow transfer of the recorded relationship
comparable with the relationship of the maxilla to the
to the articulator:
axis-orbital plane on the patient. To accommodate this
1. Position the posterior reference points on the articulator
orientation of the maxillary cast and still have room for
(usually a posterior attachment point).
the mandibular cast, the posts of the conventional articu-
2. Secure the posterior points by securing the bow
lator must be lengthened. The older Hanau model H
anteriorly.
articulator usually will not permit a facebow transfer with
3. Vertically relate the secured bow to the articulator ante-
an infraorbital pointer.
rior reference point.
A facebow may be used to transfer a comparable radius
4. Seat the maxillary cast into the bite fork registration (wax
from arbitrary reference points, or it may be designed so
or elastomer).
that the transfer can be made from hinge axis points. The
5. Close the articulator and check clearance for mounting
latter type of transfer requires that a hinge-bow attached
plaster (modify the cast as needed).
to the mandible should be used initially to determine the
6. Mount with low-expansion plaster.
hinge axis points, to which the facebow is then adjusted

for making the hinge axis transfer.
A facebow transfer of the maxillary cast, which is ori-
ented to the axis-orbital plane in a suitable articulator, is
an uncomplicated procedure. The Hanau series Wide-
Vue 183-2, all 96H2-0 models, the Whip-Mix articulator
(Whip-Mix Corp, Louisville, KY), and the Dentatus
model ARH (Dentatus USA, New York, NY) will accept
this transfer. The Hanau earpiece facebow models 153
and 158, the Hanau fascia facebow 132-2SM, and the
Dentatus facebow type AEB incorporate the infraorbital
plane to the articulator. None of these are hinge axis
bows; they are used instead at an arbitrary point.
The location of the arbitrary point or axis has long
been the subject of controversy. Gysi and others have
placed it 11 to 13 mm anterior to the upper third of the
tragus of the ear on a line extending from the upper
margin of the external auditory meatus to the outer
canthus of the eye. Others have placed it 13 mm anterior
to the posterior margin of the center of the tragus of the
Figure 12-7 The base of the cast has been prepared for
ear on a line extending to the corner of the eye. Bergström mounting by placing three triangular grooves to allow indexing
has located the arbitrary axis 10 mm anterior to the when mounted. The grooves are prepared with a 3-inch stone
center of a spherical insert for the external auditory mounted in a laboratory lathe.
meatus and 7 mm below the Frankfort horizontal plane.
In a series of experiments reported by Beck, it was
shown that the arbitrary axis suggested by Bergström falls
consistently closer to the kinematic axis than do the other Therefore the wax imprints of the soft tissues will not be
two. It is desirable that an arbitrary axis is placed as close true negatives of the edentulous regions of the diagnostic
as possible to the kinematic axis. Although most authori- casts.
ties agree that any of the three axes will permit transfer For purposes of illustration, a facebow using the exter-
of the maxillary cast with reasonable accuracy, it would nal auditory meatus as the posterior reference point, the
seem that the Bergström point compares most favorably Whip-Mix Facebow technique (DB 2000, Whip-Mix
with the kinematic axis. Corp, Louisville, KY), will be shown. The facebow fork is
The lowest point on the inferior orbital margin is covered with a polyether, polyvinyl siloxane or a roll of
taken as the third point of reference for establishing the softened baseplate wax with the material distributed
axis-orbital plane. Some authorities use the point on the equally on the top and on the underneath side of the
lower margin of the bony orbit in line with the center of facebow fork. Then the fork should be pressed lightly on
the pupil of the eye. For the sake of consistency, the right the diagnostic casts with the midline of the facebow fork
infraorbital point is generally used and the facebow corresponding to the midline of the central incisors
assembled in this relationship. All three points (right and (Figure 12-8). This will leave imprints of the occlusal and
left axes and infraorbital point) are marked on the face incisal surfaces of the maxillary casts and occlusion rim
with an ink dot before the transfer is made. on the softened baseplate wax and is an aid in correctly
Casts are prepared for mounting on an articulator by orienting the facebow fork in the patient’s mouth. The
placing three index grooves in the base of the casts. Two facebow fork is placed in position in the mouth, and the
V-shaped grooves are placed in the posterior section of patient is asked to close the lower teeth into the wax to
the cast and one groove in the anterior portion (Figure stabilize it in position. It is removed from the mouth and
12-7). chilled in cold water and then replaced in position in the
An occlusion rim properly oriented on a well-fitting patient’s mouth. An alternative method of stabilizing the
record base should be used in facebow procedures involv- facebow fork and recording bases is to enlist the assis-
ing the transfer of casts representative of the Class I and tance of the patient.
II partially edentulous situations. Without occlusion If an earpiece facebow is to be used, the patient should
rims, such casts cannot be located accurately in the be reminded that the plastic earpieces in the auditory
imprints of the wax covering the facebow fork. Tissues canals will greatly amplify noise. With the facebow fork
covering the residual ridges may be displaced grossly in position, the facebow toggle is slipped over the anterior
when the patient closes into the wax on the facebow fork. projection of the facebow fork (Figure 12-9). The patient
infraorbital point previously identified with an ink dot. It

is then locked into position with its tip lightly touching
the skin at the dot. This establishes the elevation of the
facebow in relation to the axis-orbital plane. Extreme care
must be taken to avoid any slip that might injure the
patient’s eye.
With all elements tightened securely, the patient
is asked to open, and the entire assembly is removed
intact, rinsed with cold water, and set aside. The facebow
records not only the radius from the condyles to the
incisal contacts of the upper central incisors, but also
the angular relationship of the occlusal plane to the
axis-orbital plane.
The facebow must be positioned on the articulator in
Figure 12-8 Orienting the facebow fork to the maxillary cast the same axis-orbital relation as on the patient. If an
and occlusion rims will avoid displacing the occlusion rim in the
arbitrary-type facebow is used, the calibrated condyle
mouth through patient closure or another uneven force. Polyvinyl
rods of the facebow ordinarily will not fit the condyle
siloxane material has been evenly distributed around the facebow
fork, and care is exercised to position the fork to be centered at shafts of the articulator unless the width between the
the mid-incisal position without any fork extension posterior to condyles just happens to be the same. With a Hanau
the record base, which could cause discomfort. model 132-25M facebow, the calibrations must be
reequalized when in position on the articulator. For
example, they have read 74 (mm) on each side of the
patient but must be adjusted to read 69 (mm) on each
side of the articulator. Some later model articulators have
3
adjustable condyle rods and may be adjusted to fit the
facebow. It is necessary that the facebow be centered in
either case. Some facebows are self-centering, as is the
2 Hanau Spring-Bow (Whip-Mix Corp, Louisville, KY).
The third point of reference is the orbital plane indica-
tor, which must be swung to the right so that it will be
4 above the tip of the infraorbital pointer. The entire
facebow with maxillary cast in place must be raised until
the tip of the pointer contacts the orbital plane indicated.
The elevation having thus been established, for all practi-
1 cal purposes the orbital plane indicator and the pointer
may now be removed because they may interfere with
placing the mounting stone.
Figure 12-9 The horizontal toggle clamp of the Whip-Mix
An auxiliary device called a cast support is available;
earpiece facebow (1) is slid onto the shaft of the facebow fork
protruding from the patient’s mouth. The patient then helps
it is used to support the facebow fork and the maxillary
guide plastic earpieces into the external auditory meatus and cast during the mounting operation (Figure 12-10). With
holds them in place while the operator tightens three thumb this device, the weight of the cast and the mounting stone
screws (2) and centers the plastic nosepiece (3) securely on the are supported separately from the facebow, thus prevent-
nasion. The horizontal toggle clamp is positioned and secured ing possible downward movement resulting from their
near (but not touching) the lip. The T screw (4) on the vertical combined weight. The cast support is raised to support-
bar is tightened. Note: Extreme care should be exercised not to ing contact with the facebow fork after the facebow height
tilt the facebow out of position when tightening. has been adjusted to the level of the orbital plane. Use of
some type of cast support is highly recommended as an
adjunct to facebow mounting.
can assist in guiding the plastic earpieces into the external The keyed and lubricated maxillary cast is now attached
auditory meatus. The patient can then hold the arms of to the upper arm of the articulator with the mounting
the facebow in place with firm pressure while the opera- stone, thus completing the facebow transfer (Figure
tor secures the bite fork to the facebow. This accom- 12-11). Not only will the facebow have permitted
plishes the radius aspect of the facebow transfer. the upper cast to be mounted with reasonable accuracy,
If an infraorbital pointer is used, it is placed on the it also will have served as a convenient means of support-
extreme right side of the facebow and angled toward the ing the cast during mounting. Once mastered, its use
Jaw Relationship Records for Diagnostic Casts

One of the first critical decisions that must be made in a
removable partial denture service involves selection of the
horizontal jaw relationship to which the removable partial
denture will be fabricated (centric relation or the maximum
intercuspal position). All mouth-preparation procedures
depend on this analysis. Failure to make this decision cor-
rectly may result in poor prosthesis stability, discomfort, and
deterioration of the residual ridges and supporting teeth.
It is recommended that deflective occlusal contacts in the
maximum intercuspal and eccentric positions be corrected
as a preventive measure. Not all dentists agree that centric
relation and the maximum intercuspal position must be har-
Figure 12-10 Facebow fork support used to maintain the fork monious in the natural dentition. Many dentitions function
and cast in position while mounting. satisfactorily with the opposing teeth maximally intercusped
in an eccentric position without either diagnosable or sub-
jective indications of temporomandibular joint dysfunction,
muscle dysfunction, or disease of the supporting structures
of the teeth. In many such situations, no attempt should be
made to alter the occlusion. It is not a requirement to inter-
fere with an occlusion simply because it does not completely
conform to a relationship that is considered ideal.
If most natural posterior teeth remain and if no evidence
of temporomandibular joint disturbances, neuromuscular
dysfunction, or periodontal disturbances related to occlusal
factors exists, the proposed restorations may be fabricated
safely with maximum intercuspation of remaining teeth.
However, when most natural centric stops are missing,
the proposed prosthesis should be fabricated so that the
maximum intercuspal position is in harmony with centric
relation. By far the greater majority of removable partial
dentures should be fabricated in the horizontal jaw relation-
ship of centric relation. In most instances in which edentu-
lous spaces have not been restored, the remaining posterior
Figure 12-11 Facebow mounting is complete. The relation- teeth will have assumed malaligned positions through drift-
ship of the maxillary cast to the articulator condylar components ing, tipping, or extrusion. Correction of the remaining
is anatomically similar to that between the patient’s maxilla and natural occlusion to create a coincidence of centric relation
the bilateral temporomandibular joint (TMJ) complex. Any sub- and the maximum intercuspal position is indicated in such
sequent tooth arrangement and occlusal contact development situations.
will represent the mouth more accurately than more arbitrary Regardless of the method used in creating a harmonious
mountings. The benefits of the anatomic similarity are seen in functional occlusion, an evaluation of the existing relation-
more accurate occlusion for the finalized prosthesis (i.e., less
ships of the opposing natural teeth must be made and is
intraoral adjustment required).
accomplished with a diagnostic mounting. This evaluation
is performed in addition to, and in conjunction with, other
diagnostic procedures that contribute to an adequate diag-
nosis and treatment plan.
becomes a great convenience rather than a time-consum-
Diagnostic casts provide an opportunity to evaluate the
ing nuisance.
relationships of remaining oral structures when correctly
It is preferable that the maxillary cast be mounted
mounted on a semiadjustable articulator with use of a
while the patient is still present, thus eliminating a pos-
facebow transfer and interocclusal records. Diagnostic casts
sible reappointment if the facebow record is unacceptable
are mounted in centric relation (most retruded relation of
for some reason. Not too infrequently, the facebow record
the mandible to the maxillae) so that deflective occlusal con-
has to be redone with the offset-type facebow fork repo-
tacts can be correlated with those observed in the mouth.
sitioned to avoid interference with some part of the
Deflective contacts of opposing teeth are usually destructive
articulator.
to the supporting structures involved and should be elimi-
nated. Diagnostic casts demonstrate the presence and loca- the arch. If occlusion rims are necessary to correctly orient
tion of such interfering tooth contacts and permit casts on an articulator, a centric relation should usually be
visualization of the treatment that would be necessary for the horizontal jaw relationship to which the removable
their correction. Necessary alteration of teeth to harmonize partial denture will be constructed.
the occlusion can be performed initially on duplicates of the
mounted diagnostic casts to act as guides for similar neces- Materials and Methods for Recording
sary corrections in the mouth. In many instances the degree Centric Relation
of alteration required will indicate the need for crowns or Materials available for recording centric relation are (1) wax;
onlays to be fabricated, or for recontouring, repositioning, (2) modeling plastic; (3) quick-setting impression plaster;
or elimination of extruded teeth. (4) metallic oxide bite registration paste; (5) polyether
As was previously mentioned, the maxillary cast is cor- impression materials; and (6) silicone impression materials.
rectly oriented to the opening axis of the articulator by Of these, wax is likely to be least satisfactory unless carefully
means of the facebow transfer and becomes spatially related handled. If not uniformly softened when introduced into the
to the upper member of the articulator in the same relation- mouth, it can record a position with unequal tissue place-
ship that the maxilla has to the hinge axis and the Frankfort ment. Also, it does not remain rigid and dimensionally stable
plane. Similarly, when a centric relation record is made at after removal unless carefully chilled and handled upon
an established vertical dimension, the mandible is in its most removal (Figure 12-12).
retruded relation to the maxilla. Therefore when the maxil- Modeling plastic is a satisfactory record medium because
lary cast is correctly oriented to the axis of the articulator, it can be flamed and tempered until uniformly soft before it
the mandibular cast automatically becomes correctly ori- is placed into the mouth. After modeling plastic is chilled, it
ented to the opening axis, when attached to and mounted is sufficiently stable to permit the mounting of casts with
with an accurate centric relation record. accuracy. For these reasons, it is a satisfactory medium for
Unlike recording the fixed relationship of the maxilla to recording occlusal relations for complete or partial dentures.
the mandibular opening axis (using the facebow transfer It also can be used with opposing natural teeth.
record), the mandibular position is recorded in space and is Impression plaster has advantages of softness when intro-
not a fixed point. Consequently, it is necessary to prove that duced and rigidity when set, which make it a satisfactory
the relationship of the mounted casts is correct. This can be material for recording jaw relations. Its use is highly recom-
done simply by making another interocclusal record, at mended when occlusion rims are used to mount casts cor-
centric relation, fitting the casts into the record, and check- rectly or to adjust articulators with interocclusal eccentric
ing to see that the condylar elements of the articulator are records.
snug against the condylar housings. If this is not seen, Metallic oxide bite registration paste offers many of the
another record is made until duplicate records are produced. advantages of plaster, with less friability. Although not
Because centric relation is the only jaw position that can be strong enough to be used alone, when supported by a gauze
repeated by the patient, mountings in this position can be mesh attached to a metal frame, it is a satisfactory recording
replicated and verified for correctness. medium. Also it may be used with occlusion rims. After the
A straightforward protrusive record is made to adjust the paste sets, the frame is removed from the mouth and the
horizontal condylar inclines on the articulator. Lateral buccal side of the gauze released where it was secured with
eccentric records are made so that the lateral condylar incli- sticky wax. The tube on the lingual side may then be slid off
nations can be properly adjusted. All interocclusal records the lingual extension of the frame. The frame is not needed
should be made as near the vertical relation of occlusion as when casts are mounted with this type of registration because
possible. Opposing teeth or occlusion rims must not be the tube alone lends sufficient support to the interocclusal
allowed to contact when the records are made. A contact of record.
the inclined planes of opposing teeth will invalidate an inter- Elastomeric materials are excellent for recording interoc-
occlusal record. clusal relationships (Figure 12-13). Some are specially for-
In some instances, a mounting of a duplicate diagnostic mulated for this purpose and have the qualities of extremely
cast in the maximum intercuspal position may also be desir- low viscosity, minimal resistance to closure, rapid set, low
able to definitively study this relationship on the articulator. rebound, lack of distortion, and stability after removal from
Because articulators simulate only jaw movements, it is not the mouth. Care should be exercised to ensure that no elastic
unreasonable to assume that the relationship of the casts rebound results when the record is related to the cast during
mounted in centric relation may differ minutely from the the mounting procedure.
maximum intercuspal position seen on the articulator and The mandibular cast should be mounted on the lower
observed in the mouth. When diagnostic casts are hand arm of the articulator, with the articulator inverted (Figure
related by maximum intercuspation for purposes of mount- 12-14A). The articulator is first locked in centric position,
ing on an articulator, it is essential that three (preferably and the incisal pin is adjusted so that the anterior distance
four) positive contacts of opposing posterior teeth are between the upper and lower arms of the articulator will be
present, having widespread molar contacts on each side of increased 2 to 3 mm greater than the normal parallel rela-
A B
Figure 12-12 A wax interocclusal record made on a cast framework. The modification spaces first had baseplate wax added; these
were adjusted intraorally to provide space at the occlusal vertical dimension for recording wax, the wax was softened using a wax spatula
and a hot water bath, the framework was placed in the mouth, and care was exercised to guide the patient to close into a previously
verified (and practiced) interocclusal position deemed appropriate (in this instance, centric relation position). The record was recovered
from the mouth, excess wax was removed with a warm scalpel, and the wax was chilled and replaced in the mouth to verify the record.
If not verified, the wax was resoftened (with additional wax added as needed) and the procedure was repeated. B, Immediately after
verification, the framework with interocclusal registration was replaced on the mandibular cast and inverted on the maxillary cast for
mounting.
An articulator mounting thus made will have related the

casts in centric relation (Figure 12-14B). The dentist then
can proceed to make an occlusal analysis by observing the
influence of cusps in relation to one another after the articu-
lator has been adjusted by using eccentric interocclusal
records.
After an occlusal analysis has been made, the casts may
be removed from their mounting for the purpose of survey-
ing them individually and for other purposes as outlined
previously. The indexed mounting ring record also should
be retained throughout the course of treatment in the event
that further study should be needed. It is advisable that the
mounting be identified with the articulator that is used,
so that it may always be placed back onto the same
articulator.
Figure 12-13 Elastomeric interocclusal registration material Diagnostic Findings

used to record mandibular position.
The information gathered in the patient interview and clini-
cal examination provides the basis for establishing whether
tionship of the arms. This is done to compensate for the treatment is indicated, and if so, what specific treatment
thickness of the interocclusal record so that the arms of the should be considered. More than one treatment option can
articulator will again be nearly parallel when the interoc- be considered, and financial implications need to be consid-
clusal record is removed and the opposing casts come into ered against long-term expectations if the best decision is to
contact. be reached. Provision of a removable partial denture does
The base of the cast should be keyed and lightly lubricated not often preclude future consideration for other treat-
for future removal. With the diagnostic casts accurately ments, a fact that is not often the case for alternative treat-
seated and secured in the occlusal record, the mandibular ments. The patient interview can reveal medical considerations
cast is affixed with stone to the lower member of the inverted that influence the decision to provide any prosthesis. When
articulator. it is felt that general medical health is being neglected,
A B
Figure 12-14 A, Mandibular cast inverted on the mounted maxillary cast, making sure that the cast is fully seated into the interoc-
clusal record and stabilized to the opposing cast. It is important to check the posterior occlusion rim contact to ensure that no interfering
contact has altered the record. Space should be observed between the opposing record bases (or record base and opposing occlusion).
B, Mounted casts demonstrating the occlusal plane as found in the mouth. The Frankfort plane of the patient is oriented parallel to
the articulator base and the floor. Also, inspection of the posterior rims demonstrates space between the rims, which ensures that the
recorded position was registered without influence from rigid contacting components, only from softened wax.
patients should be strongly encouraged to seek a general is required if one is to have a chance to correct it with a
medical examination. Alternatively, patients who regularly similar prosthesis. If examination does not confirm any such
see their physician may be found to take multiple medica- relationship, it would be difficult to proceed without some
tions that can contribute to a dry mouth and, potentially, an concern for repeating the patient response to therapy unless
altered oral microflora with some increased risk for plaque- a different form of therapy is selected (e.g., replacing a prob-
induced disease. Although such a condition can influence lematic removable partial denture with an implant-
any prosthodontic care, given the unique features of remov- supported prosthesis).
able partial denture service relative to the need for increased
hygiene awareness and care, any factor that places an addi-
Interpretation of Examination Data
tional risk for plaque-induced disease should be emphasized
with the patient and corrected if possible. Health conditions As a result of the oral examination, several diagnoses are
that negatively affect oral mucosal health (e.g., diabetes mel- made that are related to the various tissues, conditions, and
litus, Sjögren’s syndrome, lupus, atrophic changes) may clinical information gathered. The integration of these diag-
pose a risk for patient comfort for a tissue-supported pros- noses serves as the basis for decisions that will ultimately
thesis and factor into a treatment decision. identify the suggested treatment. The treatment decision
For the patient who has had previous experience with reflects a confluence of several aspects of the patient’s past,
some form of prosthesis, the patient interview provides present, and potential oral health status.
additional information that can influence treatment deci- It is helpful to consider how the various diagnoses are
sions. Identifying possible reasons (or more importantly, a integrated; consequently, a suggested framework is provided
lack of any reason) for both positive and negative past pros- that highlights aspects of disease management, followed by
thesis experiences is important for determining whether a reconstruction considerations for (1) prosthesis support,
patient can predictably be helped. Although the clinical and (2) prosthesis design-specific aspects.
examination will point out the oral tissue responses to such Disease management takes into account findings from
therapy, the interview will highlight the subjective patient the radiographic examination, periodontal disease and caries
response to therapy and provides significant information assessments, and pathology requiring endodontic consider-
that should be pursued. As was mentioned previously, a ations. Reconstruction considerations include diagnoses
patient complaint regarding the prosthesis needs to be con- relative to prosthesis support (teeth and residual ridges)
firmed through evaluation. The patient generally expresses and prosthesis-specific design elements. Prosthesis support
concern about a symptom that can be related to support, related to the remaining teeth requires radiographic exami-
stability, retention, and/or appearance. Confirmation of a nation of alveolar support and root morphology, endodon-
design feature or oral condition that can explain the symptom tic evaluation, analysis of occlusal factors, assessment of the
benefit for fixed prostheses or orthodontics, and evaluation forces but to torque as well because of movement of the
of the need for extraction. Residual ridge support involves tissue-supported base. Vertical support and stabilization
radiographic examination of ridge contours and height, and against horizontal movement with rigid connectors are
evaluation of the need for pre-prosthetic surgical interven- just as important as they are with a tooth-supported
tion. Prosthesis-specific design considerations include deter- prosthesis, and the removable partial denture must be
mination of anatomic relationships related to mandibular designed accordingly. In addition, the abutment tooth adja-
major connector design, the need for tooth modification to cent to the extension base will be subjected to torque in
facilitate prosthesis function, and analysis of the occlusion. proportion to the design of the retainers, the size of the
Each of these is considered in the following sections. denture base, the tissue support received by the base, and the
total occlusal load applied. With this in mind, each abut-
Radiographic Interpretation ment tooth must be evaluated carefully as to the alveolar
Many of the reasons for radiographic interpretation during bone support present and the past reaction of that bone to
oral examination are outlined herein and are considered in occlusal stress.
greater detail in other texts. Aspects of such interpretation It is important to judge whether the teeth and their
that are most pertinent to removable partial denture con- respective periodontium can favorably respond to the
struction are those relative to the prognosis of remaining demands of a prosthesis. Can radiographic interpretation
teeth that may be used as abutments. provide clues to predicting tooth response to increased
loading from prostheses? Assessment of regions within
Disease Validation the mouth that have been subjected to increased loading
It is important to verify by clinical examination disease can provide some clues as to the predictability of future
found through radiographic interpretation. Also, if the clini- similar response. An understanding of bone density,
cal examination reveals dental caries and/or periodontal index areas, and lamina dura response is helpful for these
disease, its severity can be confirmed by radiographic inter- judgments.
pretation. It would be important to delineate caries severity,
in terms of numbers of lesions and dentin/pulpal involve- Bone Density
ment, to gain insight as to level of disease risk associated with The quality and quantity of bone in any part of the body are
the patient, as well as to identify what therapy is required to often evaluated by radiographic means. A detailed treatise
maintain teeth. The same is true for periodontal disease risk concerning bone support of the abutment tooth should
and severity, as such a diagnosis affects both current and include many considerations not possible to include in this
future tooth prognosis for prosthesis support. text because of space limitations. The reader should realize
Radiographic interpretation allows diagnosis of bone that subclinical variations in bone may exist but may not be
lesions associated with both the jaws and the teeth. The observed because of the limitations inherent in technical
implications for tooth stability and ridge support are methods and equipment.
important to factor into prosthesis prognosis. Surgical Of importance to the dentist in evaluating the quality and
and postoperative management of such lesions can vary sig- quantity of the alveolar bone are the height and the quality
nificantly with diagnosis (benign vs. malignant), and defini- of remaining bone. In estimating bone height, care must be
tive prosthesis treatment is often complicated by resective taken to avoid interpretive errors resulting from angulation
procedures. factors. Technically, when a radiographic exposure is made,
the central ray should be directed at right angles to both the
Tooth Support tooth and the film. The short-cone technique does not
The quality of the alveolar support of an abutment tooth is follow this principle; instead the ray is directed through the
of primary importance because the tooth will have to with- root of the tooth at a predetermined angle. This technique
stand greater stress loads when supporting a dental prosthe- invariably causes the buccal bone to be projected higher on
sis. Abutment teeth providing total abutment support to the the crown than the lingual or palatal bone. Therefore in
prosthesis, whether fixed or removable, will have to with- interpreting bone height, it is imperative to follow the line
stand a greater load and especially greater horizontal forces. of the lamina dura from the apex toward the crown of the
The latter may be minimized by establishing a harmonious tooth until the opacity of the lamina materially decreases. At
occlusion and by distributing the horizontal forces among this point of opacity change, a less dense bone extends
several teeth through the use of rigid connectors. Bilateral farther toward the tooth crown. This additional amount of
stabilization against horizontal forces is one of the attributes bone represents false bone height. Thus the true height of
of a properly designed tooth-supported removable prosthe- the bone is ordinarily where the lamina shows a marked
sis. In many instances, abutment teeth may be aided more decrease in opacity. At this point, the trabecular pattern of
than weakened by the presence of a bilaterally rigid remov- bone superimposed on the tooth root is lost. The portion of
able partial denture. the root between the cementoenamel junction and the true
In contrast, abutment teeth adjacent to distal extension bone height has the appearance of being bare or devoid of
bases are subjected not only to vertical and horizontal covering.
Radiographic evaluation of bone quality is hazardous

but is often necessary. It is essential to emphasize that Index Areas
changes in bone mineralization up to 25% often cannot Index areas are those areas of alveolar support that disclose
be recognized by ordinary radiographic means. Optimum the reaction of bone to additional stress. Favorable reaction
bone qualities are ordinarily expressed by normal-sized to such stress may be taken as an indication of future reac-
interdental trabecular spaces that tend to decrease slightly tion to an added stress load. Teeth that have been subjected
in size as examination of the bone proceeds from the root to abnormal loading because of the loss of adjacent teeth or
apex toward the coronal portion. The normal interproxi- that have withstood tipping forces in addition to occlusal
mal crest is ordinarily shown by a relatively thin white loading may be better risks as abutment teeth than those that
line crossing from the lamina dura of one tooth to the have not been called on to carry an extra occlusal load
lamina dura of the adjacent tooth. Considerable variation (Figures 12-15 and 12-16). If occlusal harmony can be
in the size of trabecular spaces may exist within normal improved and unfavorable forces minimized by the reshap-
limits, and the radiographic appearance of crestal alveolar ing of occlusal surfaces and the favorable distribution of
bone may vary considerably, depending on its shape and occlusal loading, such teeth may be expected to support the
the direction that the ray takes as it passes through the prosthesis without difficulty. At the same time, other teeth,
bone. although not at present carrying an extra load, may be
Normal bone usually responds favorably to ordinary expected to react favorably because of the favorable reaction
stresses. Abnormal stresses, however, may create a reduc- of alveolar bone to abnormal loading elsewhere in the same
tion in the size of the trabecular pattern, particularly in arch.
that area of bone directly adjacent to the lamina dura of
the affected tooth. This decrease in size of the trabecular Other index areas are those around teeth that have been
pattern (i.e., so-called bone condensation) is often subjected to abnormal occlusal loading; that have been
regarded as a favorable bone response, indicative of an subjected to diagonal occlusal loading caused by tooth
improvement in bone quality. This is not necessarily migration; and that have reacted to additional loading,
an accurate interpretation. Such bone changes usually such as around existing fixed partial denture abutments.
indicate stresses that should be relieved because if the The reaction of the bone to additional stresses in these
resistance of the patient decreases, the bone may areas may be either positive or negative, with evidence of
exhibit a progressively less favorable response on future a supporting trabecular pattern, a heavy cortical layer,
radiographs. and a dense lamina dura, or the reverse response. With
Increased thickness of the periodontal space ordinarily the former, the patient is said to have a positive bone
suggests varying degrees of tooth mobility. This should factor, which means the ability to build additional support
be evaluated clinically. Radiographic evidence coupled wherever needed. With the latter, the patient is said to
with clinical findings may suggest to the dentist the inad- have a negative bone factor, which means the inability to
visability of using such a tooth as an abutment. Further- respond favorably to stress.
more, an irregular intercrestal bone surface should make
the dentist suspicious of active bone deterioration.
It is essential that the dentist realize that radiographic
evidence shows the result of changes that have taken place
Alveolar Lamina Dura
and may not necessarily represent the present condition. The alveolar lamina dura is also considered in a radiographic
For example, periodontal disease may have progressed interpretation of abutment teeth. The lamina dura is the thin
beyond the stage visibly demonstrated on the radiograph. layer of hard cortical bone that normally lines the sockets of
As was pointed out earlier, radiographic changes are not all teeth. It affords attachment for the fibers of the periodon-
observed until approximately 25% of the mineral content tal membrane, and, as with all cortical bone, its function is
has been depleted. On the other hand, bone condensation to withstand mechanical strain. In a roentgenogram, the
probably does represent the current situation. lamina dura is shown as a radiopaque white line around
Radiographic findings should serve the dentist as an the radiolucent dark line that represents the periodontal
adjunct to clinical observations. Too often the radio- membrane.
graphic appearance alone is used to arrive at a diagnosis; When a tooth is in the process of being tipped, the center
therefore radiographic findings should always be con- of rotation is not at the apex of the root, but in the apical
firmed by clinical examination. Radiographic interpreta- third. Resorption of bone occurs where there is pressure, and
tion will also serve an important function if used apposition occurs where there is tension. Therefore during
periodically after the prosthesis has been placed. Future the active tipping process, the lamina dura is uneven, with
bone changes of any type suggest traumatic interference evidence of both pressure and tension on the same side of
from some source. The nature of such interference should the root. For example, in a mesially tipping lower molar,
be determined and corrective measures taken. the lamina dura will be thinner on the coronal mesial and
apicodistal aspects and thicker on the apicomesial and
Figure 12-15 The reaction of bone adjacent to teeth that have been subjected to abnormal stress serves as an indication of probable
reactions of that bone when such teeth are used as abutments for fixed or removable restorations. Such areas are called index areas.
A B
Figure 12-16 A, The canine has provided support for the distal extension removable partial denture for 10 years. There has obviously
been positive bone response (arrow) to increased stress generated by the removable partial denture. B, The mandibular first premolar
has provided support for the distal extension denture for 3 years. Bone response (arrow) to past additional stress has been
unfavorable.
coronal distal aspects because the axis of rotation is not at

the root apex but is above it. When the tooth has been tipped
into an edentulous space by some change in the occlusion
and becomes set in its new position, the effects of leverage
are discontinued. The lamina dura on the side to which the
tooth is sloping becomes uniformly heavier, which is nature’s
reinforcement against abnormal stresses. The bone trabecu-
lations are most often arranged at right angles to the heavier
lamina dura.
Thus it is possible to say that for a given individual, A
nature is able to build support where it is needed and on this
basis to predict future reactions elsewhere in the arch to
additional loading of teeth used as abutments. However,
because bone is approximately 30% organic, and this mostly
protein, and because the body is not able to store a protein
reserve in large amounts, any change in body health may be
reflected in the patient’s ability to maintain this support
permanently. When systemic disease is associated with faulty
protein metabolism and when the ability to repair is dimin-
ished, bone is resorbed and the lamina dura is disturbed.
Therefore the loading of any abutment tooth must be kept
to a minimum inasmuch as the patient’s future health status B
and the eventualities of aging are unpredictable.
Figure 12-17 A, The prognosis for abutment service is more
favorable for a molar with divergent roots (shaded) than for the
Root Morphology
same tooth if its roots were fused and conical. B, Evidence that
The morphologic characteristics of the roots determine to a
prospective abutment has conical and fused roots indicates the
great extent the ability of prospective abutment teeth to necessity for formulating a framework design that will minimize
resist successfully additional rotational forces that may be additional stresses placed on the tooth by the abutment service.
placed on them. Teeth with multiple and divergent roots will
resist stresses better than teeth with fused and conical roots,
because the resultant forces are distributed through a greater
number of periodontal fibers to a larger amount of support-
ing bone (Figure 12-17).
Third Molars
Unerupted third molars should be considered as prospective
future abutments to eliminate the need for a distal extension
removable partial denture (Figure 12-18). The increased sta-
bility of a tooth-supported denture is most desirable to
enhance the health of the oral environment.
Periodontal Considerations
An assessment of the periodontium in general and abutment
teeth in particular must be made before prosthetic restora- Figure 12-18 First and second molars have been lost by this
tion. One must evaluate the condition of the gingiva, looking 18-year-old patient. A distal extension removable partial denture
for adequate zones of attached gingiva and the presence or may be constructed until the third molar erupts and is fully
formed. A tooth-supported restoration may then be considered.
absence of periodontal pockets. The ideal periodontal condi-
tion is a disease-free periodontium with adequate attached
mucosa in regions at or adjacent to removable partial denture
component parts that cross the gingival margins to best Oral hygiene habits of the patient must be determined,
resist the mechanical challenges posed as the result of func- and efforts made to educate the patient relative to plaque
tion and use. The condition of the supporting bone must be control. The most decisive evidence of oral hygiene habits is
evaluated, with specific attention to reduced bone support the condition of the mouth before the initial prophylaxis.
and mobility patterns recorded. If mucogingival involve- Good or bad oral hygiene is basic to the patient’s nature, and
ments, osseous defects, or mobility patterns are recorded, although it may be influenced somewhat by patient educa-
the causes and potential treatment must be determined. tion, the long-range view must be taken. It is reasonably fair
to assume that the patient will do little more in the long- methylcellulose base, which can be enriched with fluoride in
term future than he has done in the past. In making deci- an effort to counteract caries. Frequent use provides an
sions as to the method of treatment based on oral hygiene, excellent means of maintaining high fluoride intraorally for
the future in years, rather than in weeks and months, must long periods of time, thus enhancing the remineralization
be considered. It is probably best not to give the patient the of incipient caries. Although providing instructions for
benefit of any doubt as to future oral hygiene habits. Rather, improvement of oral hygiene is a duty of the dental team,
the benefit should come from protective measures where any suspected problems of dietary deficiencies should be referred
doubt exists about future oral hygiene habits. Therefore for to a nutritionist.
patients at greatest risk, an oral prophylaxis with continued
oral hygiene instructions should be scheduled for 3- to Evaluation of the Prosthesis Foundation—Teeth
4-month intervals. In addition, the patient must be advised and Residual Ridge
of the importance of regular maintenance appointments for An evaluation of the prosthesis foundation is required to
tissue-supported prostheses to maintain occlusal relation- ensure that an appropriately stable base of sound teeth and/
ships. When these ongoing observations and prophylactic or residual ridge(s) is provided to maximize prosthesis func-
requirements are described, the patient is faced with the tion and patient comfort. To that end, the evaluation focuses
realization that he or she must be willing to share responsi- on the identification of conditions that are inconsistent with
bility for maintaining the health of the mouth after restor- sound support and predictably stable function.
ative and prosthodontic treatment.
The remaining teeth and prosthesis will require meticu- Surgical Preparation
lous plaque control after placement of a removable partial The need for pre-prosthetic surgery or extractions must be
denture. Because of the nature of material coverage of oral evaluated. The same criteria apply to surgical intervention
tissues, the oral microflora can change with the use of a in the partially edentulous arch as in the completely edentu-
removable prosthesis. Coupled with this microbial change is lous arch. Grossly displaceable soft tissues covering basal seat
the potential for a mechanical challenge to tissue integrity if areas and hyperplastic tissue should be removed to provide
the appropriate relationship of the prosthesis and soft tissues a firm denture foundation. Mandibular tori should be
of the residual ridge, as well as the marginal gingival, is not removed if they will interfere with the optimum location of
maintained. a lingual bar connector or a favorable path of placement.
Any other areas of bone prominence that will interfere with
Caries Risk Assessment Considerations the path of placement should be removed also. The path of
Caries activity in the mouth, past and present, and the need placement will be dictated primarily by the guiding plane of
for protective restorations must be considered. The decision the abutment teeth. Therefore some areas may present inter-
to use full coverage is based on a need to reshape abutment ference to the path of placement of the removable partial
teeth to accommodate the components of the removable denture by reason of the fact that other unalterable factors
partial denture, prevention of restoration breakdown when such as retention and esthetics must take precedence in
abutments have large direct restorations, or evidence of selecting that path.
recurrent caries risk. Occasionally, three-quarter crowns Clinical research in pre-prosthetic surgical concepts has
may be used where buccal or lingual surfaces are completely contributed significant developments to management of the
sound, but intracoronal restorations (inlays) are seldom compromised partially edentulous patient. Bone augmenta-
indicated in any mouth with evidence of past extensive caries tion and guided bone regeneration procedures have been
or precarious areas of decalcification, erosion, or exposed used with varying degrees of success as an alternative method
cementum. of improving ridge support for the denture base areas. Skill
Frequent consumption of sugars can lead to carious and judgment must be exercised in patient selection, proce-
involvement of roots, caries around restorations, or caries dural planning, and surgical and prosthetic management to
associated with clasps of removable partial dentures. Intel- optimize clinical results. Use of osseointegrated implants can
ligent consumption of sweets (smaller amounts and less fre- provide a foundation for developing suitable abutment
quent consumption) and frequent plaque removal are the support for removable partial dentures. As in any surgical
recommended countermeasures. Excellent protection from procedure, results depend on careful treatment planning
caries can be provided by fluoride applications via tooth- and cautious surgical management.
pastes, mouth rinses, or (in extreme cases, such as postradia- Extraction of teeth may be indicated for one of the fol-
tion xerostomia) 1% NaF gels applied daily with plastic lowing three reasons:
trays. 1. If the tooth cannot be restored to a state of health, extrac-
Xerostomia, caused by degeneration of salivary glands tion may be unavoidable. Modern advancements in the
(Sjögren’s syndrome) or various medications, will enhance treatment of periodontal disease and in restorative pro-
the occurrence and severity of caries, as well as contribute to cedures, including endodontic therapy, have resulted in
irritation of the oral mucosa. A possible way to alleviate the saving of teeth that were once considered untreatable.
xerostomia is the use of synthetic saliva, with a carboxy- All reasonable avenues of treatment should be considered
from both prognostic and economic standpoints before ments, and consequently do not increase the functional
extraction is recommended. burden on the natural dentition. Although the predictability
2. A tooth may be removed if its absence will permit a more of contemporary implant procedures (surgery and prosth-
serviceable and less complicated removable partial odontics) makes them a consideration for short span pros-
denture design. Teeth in extreme malposition (lingually theses, the main advantage is the opportunity to provide
inclined mandibular teeth, buccally inclined maxillary replacement teeth without involving adjacent teeth in the
teeth, and mesially inclined teeth posterior to an edentu- reconstruction. Therefore, when the adjacent teeth are in
lous space) may be removed if an adjacent tooth is in need of restoration, a conventional prosthesis should be
good alignment and if good support is available for use considered.
as an abutment. Justification for extraction lies in the
decision that a suitable restoration, which will provide Longer Modification Spaces
satisfactory contour and support, cannot be fabricated, or Longer span modification spaces (≥4 missing teeth) present
that orthodontic treatment to realign the tooth is not a greater challenge for natural tooth–supported fixed pros-
feasible. An exception to the arbitrary removal of a mal- theses. Consequently, options for treatment include the
posed tooth occurs when a distal extension removable removable partial denture and the implant-supported pros-
partial denture base would have to be made rather than thesis. An implant prosthesis has the same bone volume
using the more desirable tooth-supported base of the requirements as stated above, and for an increased span will
tooth in question. If alveolar support is adequate, a pos- likely require additional implants. Because residual ridge
terior abutment should be retained if at all possible in resorption can be greater with longer spans, the need for
preference to a tissue-supported extension base. Teeth augmentation may also be greater. Both of these character-
deemed to have insufficient alveolar support may be istics of longer spans cause implant use to be more costly
extracted if their prognosis is poor and if other adjacent and can significantly increase the cost difference between
teeth may be used to better advantage as abutments. The treatment options. The increased morbidity associated with
decision to extract such a tooth should be based on the augmentation procedures can also limit universal applica-
degree of mobility and other periodontal considerations tion. Because the removable partial denture remains largely
and on the number, length, and shape of the roots con- tooth supported (unless the span includes anterior and pos-
tributing to its support. terior segments that may cause it to function similar to a
3. A tooth may be extracted if it is so unesthetically located distal extension), the functional stability requirements
as to justify its removal to improve appearance. In this should be efficiently met through the tooth support.
situation, a veneer crown should be considered in prefer-
ence to removal if the crown can satisfy the esthetic needs. Distal Extension Spaces
If removal is advisable because of unesthetic tooth posi- Without tooth support at each end of the missing teeth, the
tion, the biomechanical problems involved in replacing removable partial denture and the implant-supported pros-
anterior teeth with a removable partial denture must be thesis are the primary treatment considerations (double-
weighed against the problems involved in making an abutted cantilevered fixed prostheses opposing maxillary
esthetically acceptable fixed restoration. Admittedly, the complete dentures have been suggested to be a reasonable
removable replacement is commonly the more esthetic of option for some patients). It then becomes obvious that
the two, despite modern advancements in retainers and when anatomic limitations to implant placement exist and
pontics. However, the mechanical disadvantage of the surgical measures cannot be taken to correct this, the remov-
removable restoration often makes the fixed replacement able partial denture is the only option (unless no treatment
of missing anterior teeth preferable. is elected). Current surgical options are available to correct
Another consideration for pre-prosthetic surgery involves most anatomic limitations, yet frequently implant therapy is
the decision between use of a removable partial denture and not elected because of patient medical factors, concerns for
an implant-supported prosthesis. The following categories the risk of surgical morbidity, increased time required for
of tooth loss are presented with comparative comments treatment, and costs. It is important to note that a compari-
germane to such decisions. son of long-term maintenance requirements between these
two options may demonstrate little cost difference over time.
Short Modification Spaces This is related to the effects of continued residual ridge
For short spans (≤3 missing teeth), natural tooth– and resorption acting on the removable prosthesis and not the
implant-supported fixed prostheses as well as removable implant prosthesis.
partial dentures can generally be considered. Implant place-
ment requires the decision that ample bone volume exists, Endodontic Treatment
or can be provided with minimal morbidity, to adequately Abutments for removable partial dentures are required to
house sufficient implants to support prosthetic teeth. withstand various forces depending on the classification.
Implant prostheses have the advantage of not requiring the The requirement for a distal extension abutment is different
use of teeth for support, stability, and retention require- than that of a tooth-supported prosthesis in that torsional
forces exist in the distal extension situation. For this reason, with isolated abutment teeth and distal extension bases. Bio-
an abutment for a distal extension that is endodontically mechanical considerations and the future health of the
treated carries a greater risk for complications than a similar remaining teeth should be given preference over economic
tooth not involved in removable partial denture function. considerations when such a choice is possible.
Because tooth support helps control prosthesis move-
ment, the need for endodontic treatment should include Orthodontic Treatment
assessment of overdenture abutments for removable partial Occasionally, orthodontic movement of malposed teeth fol-
dentures, especially to control movement of distal lowed by retention through the use of fixed partial dentures
extensions. makes possible a better removable partial denture design
mechanically and esthetically than could otherwise be used.
Analysis of Occlusal Factors Although adequate anchorage for tooth movement can be a
From the occlusal analysis made by evaluating the mounted major limitation in partially edentulous arches, carefully
diagnostic casts, the dentist must decide whether it is best to placed implants that subsequently can be used for prosthesis
accept and maintain the existing occlusion or to attempt to support have been used to expand orthodontic applications
improve on it by means of occlusal adjustment and/or res- for this patient group.
toration of occlusal surfaces. It must be remembered that the
removable partial denture can supplement the occlusion Need for Determining Type of Mandibular
that exists only at the time the prosthesis is constructed. The Major Connector
dominant force that dictates the occlusal pattern will be the As was discussed in Chapter 5, one of the criteria used to
cuspal harmony or disharmony of the remaining teeth and determine the use of the lingual bar or linguoplate is the
their proprioceptive influence on mandibular movement. height of the floor of the patient’s mouth when the tongue
The goal of artificial tooth placement is to harmonize with is elevated. Because the inferior borders of the lingual bar
the functional parameters of the existing occlusion provid- and the linguoplate are placed at the same vertical level, and
ing bilateral, simultaneous functional contact. because subsequent mouth preparations depend in part on
Chapter 17 identifies schemes of occlusion recommended the design of the mandibular major connector, determina-
for partially edentulous configurations. A review of these tion of the type of major connector must be made during
recommendations will provide a guide for modifying the the oral examination. This determination is facilitated by
existing occlusion or developing the appropriate occlusal measuring the height of the elevated floor of the patient’s
scheme for each partially edentulous configuration. mouth in relation to the lingual gingiva with a periodontal
Improvements in the natural occlusion must be accom- probe and recording the measurement for later transfer to
plished before the prosthesis is fabricated, not subsequent to diagnostic and master casts. It is most difficult to make a
its fabrication. The objective of occlusal reconstruction by determination of the type of mandibular major connector to
any means should be occlusal harmony of the restored denti- be used solely from a stone cast that may or may not accu-
tion in relation to the natural forces already present or estab- rately indicate the active range of movement of the floor of
lished. Therefore one of the earliest decisions in planning the patient’s mouth. Too many mandibular major connec-
reconstructive treatment must be whether to accept or reject tors are ruined or made flexible because subsequent grinding
the existing vertical dimension of occlusion and the occlusal of the inferior border is necessary to relieve impingement of
contact relationships in centric and eccentric positions. If the sensitive tissues of the floor of the mouth.
occlusal adjustment is indicated, cuspal analysis always
should precede any corrective procedures in the mouth by Need for Reshaping Remaining Teeth
selective grinding. On the other hand, if reconstruction is to The clinical crown shapes of anterior and posterior teeth are
be the means of correction, the manner and sequence should not capable of supporting a removable partial denture
be outlined as part of the overall treatment plan. framework without appropriate modification. Without the
required modifications, the prosthesis does not adequately
Fixed Restorations benefit from the support and stability offered by the teeth
There may be a need to restore modification spaces with and consequently will not be comfortable to the patient.
fixed restorations rather than include them in the removable Many failures of removable partial dentures can be attrib-
partial denture, especially when dealing with isolated abut- uted to the fact that the teeth were not reshaped properly to
ment teeth. The advantage of splinting must be weighed establish guiding planes or to receive clasp arms and occlusal
against the total cost, with the weight of experience always rests before the impression for the master cast was made. Of
in favor of using fixed restorations for tooth-bounded spaces particular importance are the paralleling of proximal tooth
unless the space will facilitate simplification of the remov- surfaces to act as guiding planes, the preparation of adequate
able partial denture design without jeopardizing the abut- rest areas, and the reduction of unfavorable tooth contours
ment teeth. One of the least successful removable partial (Figure 12-19). To neglect planning such mouth prepara-
denture designs is seen when multiple tooth-bounded areas tions in advance is inexcusable and leads to unsuccessful
are replaced with removable partial dentures in conjunction removable prosthesis service.
A B
Figure 12-19 A, Unmodified buccal surface of the mandibular premolar illustrates a typical height of contour location natural for
this tooth (middle and occlusal thirds of the tooth). B, Proximal surface modification is required (hatched region) to produce a guide-
plane surface. C, Buccal surface modification is needed to position the height of contour for favorable clasp location. The tooth modi-
fication is a continuation of the proximal surface modification onto the buccal surface, and generally requires less than 0.5 mm of tooth
removal.
The design of clasps is dependent on the location of the restoration is fully seated. Such a lingual bar will be located
retentive, stabilizing, reciprocal, and supporting areas in so that it will interfere with tongue comfort and function.
relation to a definite path of placement and removal. Failure These are only some of the objectionable consequences of
to reshape unfavorably inclined tooth surfaces and, if neces- inadequate mouth preparations.
sary, to place restorations with suitable contours not only The amount of reduction of tooth contours should be
complicates the design and location of clasp retainers but kept to a minimum, and all modified tooth surfaces not only
also often leads to failure of the removable partial denture should be repolished after reduction but also should be sub-
because of poor clasp design. jected to fluoride treatment to lessen the incidence of caries.
A malaligned tooth or one that is inclined unfavorably If it is not possible to produce the contour desired without
may make it necessary to place certain parts of the clasp so perforating the enamel, then the teeth should be recon-
that they interfere with the opposing teeth. Unparallel proxi- toured with an acceptable restorative material. The age of
mal tooth surfaces not only will fail to provide needed the patient, caries activity evidenced elsewhere in the mouth,
guiding planes during placement and removal but also will and apparent oral hygiene habits must be taken into consid-
result in excessive blockout. This inevitably results in place- eration when one is deciding between reducing the enamel
ment of the connectors so far out of contact with tooth or modifying tooth contours with protective restorations.
surfaces that food traps are created. To pass lingually inclined Some of the areas that frequently need correction are the
lower teeth, clearance for a lingual bar major connector may lingual surfaces of mandibular premolars, the mesial and
have to be so great that a food trap will result when the lingual surfaces of mandibular molars, the distobuccal line
angle of maxillary premolars, and the mesiobuccal line angle (contaminated instruments, operatory equipment, or envi-
of maxillary molars. The actual degree of inclination of teeth ronmental surfaces), and contact with airborne contami-
in relation to the path of placement and the location of nants present in droplet spatter or in aerosols of oral and
retentive and supportive areas are not readily interpretable respiratory fluids. For infection to occur via any of these
during visual examination. These are established during routes, the “chain of infection” must be present. This
comprehensive analysis of the diagnostic cast with a sur- includes a susceptible host, a pathogen with sufficient infec-
veyor, which should follow the visual examination. tivity and numbers to cause infection, and a portal through
which the pathogen may enter the host. For infection control
procedures to be effective, one or more of these “links” in
Infection Control
the chain must be broken.
The American Dental Association follows the Centers for Studies from the CDC report that clothing exposed to the
Disease Control (CDC)–recommended infection control acquired immunodeficiency syndrome (AIDS) virus may be
procedures for dentistry. The most recent recommendations safely used after a normal laundry cycle. A high-temperature
were made in 2003 and included updates from the previous (140° F to 160° F, 60° C to 70 °C) wash cycle with normal
1993 guidelines. Most of the updates will be familiar to prac- bleach concentrations, followed by machine drying (212° F,
titioners and are already largely practiced routinely. They 100° C, or higher), is preferable if clothing is visibly soiled
are designed to prevent or reduce the potential for disease with blood or other body fluids. Dry cleaning and steam
transmission from patient to DHCW (Dental Health Care pressing will also kill the AIDS virus, according to these
Worker), from DHCW to patient, and from patient to studies. Patients with oral lesions suggestive of infectious
patient. The document emphasizes the use of “standard pre- disease and patients with a known history of hepatitis B,
cautions” (which replaces the term “universal precautions”) AIDS, AIDS-related complex, or other infectious diseases
for the prevention of exposure to and transmission of not should be referred for appropriate medical care. In addition
only bloodborne pathogens, but also other pathogens to environmental surface and equipment disinfection, all
encountered in oral health care settings. instruments, stones, burs, and other reusable items should
Major updates and additions include application of stan- be disinfected in 2% glutaraldehyde for 10 minutes, cleaned
dard precautions rather than universal precautions, work of debris, rinsed, and patted dry before the sterilizing process
restrictions for health care personnel infected with, or occu- is initiated. Heat-sensitive items can be sterilized with the
pationally exposed to, infectious diseases; management of use of ethylene oxide (gas).
occupational exposure to bloodborne pathogens, including For items that have been used in the mouth, including
postexposure prophylaxis for work exposures to hepatitis B laboratory materials (e.g., impressions, bite registrations,
virus (HBV), hepatitis C virus (HCV), and human immu- fixed and removable prostheses, orthodontic appliances),
nodeficiency virus (HIV); selection and use of devices with cleaning and disinfection are required before they are
features designed to prevent sharps injury, contact dermati- manipulated in the laboratory (whether on-site or at a
tis, and latex hypersensitivity; hand hygiene; dental unit remote location). Any item manipulated in the laboratory
waterlines; and biofilm and water quality; special consider- should also be cleaned and disinfected before placement in
ations include dental handpieces and other devices attached the patient’s mouth. Fresh pumice with iodophor should be
to air lines and waterlines, saliva ejectors, radiology, paren- used for each polishing procedure, and the pumice pan
teral medications, single-use or disposable devices, pre- should be washed, rinsed, and dried after each procedure.
procedural mouth rinses, oral surgical procedures, handling Because materials are constantly evolving, DHCWs are
of biopsy specimens and extracted teeth, laser/electrosurgery advised to follow manufacturers’ suggested procedures for
plumes, Mycobacterium tuberculosis, Creutzfeldt-Jakob specific materials relative to disinfection procedures. As a
disease and other prion diseases, program evaluation, and guide, use of a chemical germicide that has at least an inter-
research considerations. The recommendations provide mediate level of activity (i.e., “tuberculocidal hospital disin-
guidance for measures to be taken that will reduce the risks fectant”) is appropriate for such disinfection. Careful
of disease transmission, among both dental health care communication between dental office and dental laboratory
workers (DHCWs) and their patients. regarding the specific protocol for handling and decontami-
Dental patients and DHCWs potentially may be exposed nation of supplies and materials is important to prevent any
to a variety of microorganisms. Exposure can occur via cross contamination.
blood and/or oral or respiratory secretions. The microor-
ganisms may include viruses and bacteria that infect the
Differential Diagnosis: Fixed or
upper respiratory tract in general, as well as cytomegalovi-
Removable Partial Dentures
rus, HBV, HCV, herpes simplex virus types 1 and 2, HIV,
Mycobacterium tuberculosis, staphylococci, and streptococci. Total oral rehabilitation (disease management, defective
The transmission of infection in the dental operatory can tooth restoration, and tooth replacement) is an objective in
occur through several routes. These include direct contact treating the partially edentulous patient. Although replace-
(blood, oral fluids, or other secretions), indirect contact ment of missing teeth by means of fixed partial dentures,
support does not place additional functional demands on

adjacent teeth likely contributes to their preservation,
although this has not been universally demonstrated.
For conventional fixed prostheses, lack of parallelism of
the abutment teeth may be counteracted with copings or
locking connectors to provide parallel sectional placement.
A
Sound abutment teeth make possible the use of more con-
servative retainers, such as partial-veneer crowns, or resin-
bonded-to-metal restorations, rather than full crowns. The
age of the patient, evidence of caries activity, oral hygiene
A
habits, and the soundness of remaining tooth structure must
be considered in any decision to use less than full coverage
for abutment teeth.
Two specific contraindications for the use of unilateral
fixed restorations are known. One is a long edentulous span
with abutment teeth that would not be able to withstand the
trauma of nonaxial occlusal forces. The other is abutment
teeth, which exhibit reduced periodontal support due to
Figure 12-20 Class III, modification 2 arch, in which modifi- periodontal disease, which would benefit from cross-arch
cation spaces on the patient’s left (spaces designated at A) will stabilization. In either situation, a bilateral removable resto-
be included in the design of the removable partial denture rather ration can be used more effectively to replace the missing
than restored with a long-span fixed partial denture. The design
teeth.
for a removable restoration is greatly simplified, resulting in
significantly enhanced stability.
Modification Spaces
A removable partial denture for a Class III arch is better
either tooth or implant supported, is generally the method supported and stabilized when a modification area on the
of choice, there are many reasons why a removable partial opposite side of the arch is present. A fixed partial denture
denture may be the better method of treatment for a specific need not be used to restore such an edentulous area because
patient. its inclusion may simplify the design of the removable partial
The dentist must follow the best procedure for the welfare denture. However, when a modification space is bound by a
of the patient, who is always free to seek more than one lone-standing single-rooted abutment, it is better restored
opinion. Ultimately, the choice of treatment must meet the by means of a fixed partial denture. This acts to stabilize the
economic limitations and personal desires of the patient. at-risk tooth, and the denture is made less complicated by
The exception to this guideline is the Class III arch with a not having to include other abutment teeth for the support
modification space on the opposite side of the arch, which and retention of an additional edentulous space or spaces.
will provide better cross-arch stabilization and a simpler When an edentulous space that is a modification of a
design for the removable partial denture (Figure 12-20). Class I or Class II arch exists anterior to a lone-standing
Although uncommon, unilateral tooth loss is sometimes abutment tooth, this tooth is subjected to trauma by the
inappropriately treated with a unilateral removable partial movements of a distal extension removable partial denture
denture in place of a fixed partial denture. This type of pros- far in excess of its ability to withstand such stresses. The
thesis is not enhanced by cross-arch stabilization and places splinting of the lone abutment to the nearest tooth is manda-
excessive stress on abutment teeth. Possibly more important, tory. The abutment crowns should be contoured for support
the risk for aspiration is significant if such a prosthesis is and retention of the removable partial denture; in addition,
dislodged during use. For these reasons, use of the unilateral a means of supporting a stabilizing component on the ante-
removable partial denture is strongly discouraged. rior abutment of the fixed partial denture or on the occlusal
surface of the pontic usually should be provided.
Indications for Use of Fixed Restorations
Tooth-Bounded Edentulous Regions Anterior Modification Spaces
Generally any unilateral edentulous space bounded by teeth Usually any missing anterior teeth in a partially edentulous
suitable for use as abutments should be restored with a fixed arch, except in a Kennedy Class IV arch in which only ante-
partial denture cemented to one or more abutment teeth at rior teeth are missing, are best replaced by means of a fixed
either end. The length of the span and the periodontal restoration. There are exceptions. Sometimes a better esthetic
support of the abutment teeth will determine the number of result is obtainable when the anterior replacements are sup-
abutments required. As was mentioned earlier, such a span plied by a removable partial denture, at other times treat-
could be managed with the use of dental implants if deemed ment is simplified by inclusion of an anterior modification
feasible and elected by the patient. The fact that implant space into the removable partial denture (Figure 12-21).
A B
Figure 12-21 A, Diagnostic waxing of this complex case revealed the best means to manage replacement of tooth #’s 6 and 7 was
with a fixed prosthesis, especially since the ridge defect was not severe and the adjacent teeth offered good retainer support. B, In
contrast, this complex situation requires the maxillary anterior to be repositioned palatally to address an esthetic concern caused by
the condition of the maxillary canines and the need to replace the posterior teeth as well. C, The anterior teeth will be more easily
managed as part of the removable partial denture. (Courtesy Dr. M. Alfaro, Columbus, OH.)
This is also true when excessive tissue and bone resorption tilever-fixed prosthesis is most applicable if the second molar
necessitates placement of the pontics in a fixed partial is to be ignored, then only first molar occlusion need be
denture too far palatally for good esthetics or for an accept- supplied with the use of a cantilever-type fixed partial
able relation with the opposing teeth. However, in most denture. Occlusion need be only minimal to maintain occlu-
instances, from mechanical and biological standpoints, ante- sal relations between the natural first molar in the one arch
rior replacements are best accomplished with fixed restora- and the prosthetic molar in the opposite arch. The cantile-
tions. The replacement of missing posterior teeth with a vered pontic should be narrow buccolingually and need not
removable partial denture is then made much less compli- occlude with more than one half to two thirds of the oppos-
cated and gives more satisfactory results. ing tooth. Often such a restoration is the preferred method
of treatment. However, at least two abutments should be
Replacement of Unilaterally Missing Molars used to support a cantilevered molar opposed by a natural
(Shortened Dental Arch) molar.
Often the decision must be made to replace unilaterally To replace unilaterally missing molars with a removable
missing molars (Figure 12-22). The decision must balance partial denture necessitates the use of a distal extension pros-
the impact of the treatment on the remaining oral structures thesis. This involves the major connector joining the eden-
with the potential benefit to the patient long term. To restore tulous side to retentive and stabilizing components located
the missing molars with a fixed partial denture would require on the non-edentulous side of the arch. Leverage factors are
a cantilever prosthesis or the use of dental implants. A can- frequently unfavorable, and the retainers used on the non-
A B
Figure 12-22 A, Unilaterally missing molars. If the patient exhibits opposing contacts to the remaining six posterior teeth (bilateral
premolars, right first and second molars), functional gain attained by replacing the left molars may be minimal. B, By contrast, the
functional gain resulting from replacement of the posterior occlusion in this patient is likely significant.
edentulous side are often unsatisfactory. Two factors impor- of a multiple-abutment cantilevered fixed restoration or an
tant to consider in making the decision to provide a implant-supported prosthesis. The most common partially
unilateral, distal extension removable partial denture include edentulous situations are the Kennedy Class I and Class II.
the opposing teeth and the future effect of the maxillary With the latter, an edentulous space on the opposite side of
tuberosity. the arch is often conveniently present to aid in required
First, the opposing teeth must be considered if it is con- retention and stabilization of the removable partial denture.
sidered important to prevent extrusion and migration. This If no space is present, selected abutment teeth can be modi-
influences replacement of the missing molars far more than fied to accommodate appropriate clasp assemblies, or intra-
any improvement in masticating efficiency that might result. coronal retainers can be used. As was previously stated, all
Replacement of missing molars on one side is seldom neces- other edentulous areas are best replaced with fixed partial
sary for reasons of mastication alone. dentures.
Second, the future effect of a maxillary tuberosity must
be considered if concern exists for tuberosity enlargement. After Recent Extractions
Often when left uncovered, the tuberosity increases in size, The replacement of teeth after recent extractions often
making future occlusal treatment difficult. However, cover- cannot be accomplished satisfactorily with a fixed restora-
ing the tuberosity with a removable partial denture base, in tion. When relining will be required later, or when a fixed
combination with the stimulating effect of the intermittent restoration using natural teeth or implants will be con-
occlusion, helps maintain tuberosity size and position. In structed later, a temporary removable partial denture can be
such an instance, it may be better to make a removable used. If an all-resin denture is used rather than a cast frame-
partial denture with cross-arch stabilization and retention work removable partial denture, the immediate cost to the
than to leave a maxillary tuberosity uncovered. patient is much less, and the resin denture lends itself best
to future temporary modifications, including those required
Indications for Removable Partial Dentures after implant placement and before restoration.
Although a removable partial denture should be considered Tissue changes are inevitable following extractions.
only when a fixed restoration is contraindicated, there are Tooth-bounded edentulous areas (as a result of extractions)
several specific indications for the use of a removable are best initially restored with removable partial dentures.
restoration. Relining of a tooth-supported resin denture base is then
possible. This is usually done to improve esthetics, oral
Distal Extension Situations cleanliness, or patient comfort. Support for such a restora-
Replacement of missing posterior teeth is often best accom- tion is supplied by occlusal rests on the abutment teeth at
plished with a removable partial denture (see Figure 12-22B), each end of the edentulous space.
especially when implant treatment is not feasible for the
patient. The exception to this includes situations in which Long Span
the replacement of missing second (and third) molars is A long span may be totally tooth supported if the abutments
inadvisable or unnecessary, or in which unilateral replace- and the means of transferring the support to the denture are
ment of a missing first molar can be accomplished by means adequate, and if the denture framework is rigid. There is
little if any difference between the support afforded a remov- position of the natural dentition for normal tongue and
able partial denture and that afforded a fixed restoration by cheek contacts. This is particularly true of a maxillary
the adjacent abutment teeth. However, in the absence of denture.
cross-arch stabilization, the torque and leverage on the two Anteriorly, loss of residual bone occurs from the labial
abutment teeth would be excessive. Instead, a removable aspect. Often the incisive papilla lies at the crest of the resid-
denture that derives retention, support, and stabilization ual ridge. Because the central incisors are normally located
from abutment teeth on the opposite side of the arch is anterior to this landmark, any other location of artificial
indicated as the logical means of replacing the missing teeth. central incisors is unnatural. An anterior fixed partial
denture made for such a mouth will have pontics resting on
Need for Effect of Bilateral Stabilization the labial aspect of this resorbed ridge and will be too far
In a mouth weakened by periodontal disease, a fixed restora- lingual to provide desirable lip support. Often the only way
tion may jeopardize the future of the involved abutment the incisal edges of the pontics can be made to occlude with
teeth unless the splinting effect of multiple abutments is the opposing lower anterior teeth is to use a labial inclination
used. The removable partial denture, on the other hand, may that is excessive and unnatural, and both esthetics and lip
act as a periodontal splint through its effective cross-arch support suffer. Because the same condition exists with a
stabilizing of teeth weakened by periodontal disease. When removable partial denture in which the anterior teeth are
abutment teeth throughout the arch are properly prepared abutted on the residual ridge, a labial flange must be used
and restored, the beneficial effect of a removable partial to permit the teeth to be located closer to their natural
denture can be far greater than that of a unilateral fixed position.
partial denture. The same method of treatment applies to the replacement
of missing mandibular anterior teeth. Sometimes a man-
Excessive Loss of Residual Bone dibular anterior fixed partial denture is made six or more
The pontic of a fixed partial denture must be correctly units in length, in which the remaining space necessitates
related to the residual ridge and in such a manner that the leaving out one anterior tooth or using the original number
contact with the mucosa is minimal. Whenever excessive of teeth but with all of them too narrow for esthetics. In
resorption has occurred, teeth supported by a denture either instance, the denture is nearly in a straight line because
base may be arranged in a more acceptable buccolingual the pontics follow the form of the resorbed ridge. A remov-
position than is possible with a fixed partial denture (Figure able partial denture will permit the location of the replaced
12-23). teeth in a favorable relation to the lip and opposing dentition
Unlike a fixed partial denture, the artificial teeth sup- regardless of the shape of the residual ridge. When such a
ported by a denture base can be located without regard removable prosthesis is made, however, positive support
for the crest of the residual ridge and more nearly in the must be obtained from the adjacent abutments.
A B
Figure 12-23 A, Occlusal view of the anterior ridge defect (Kennedy Class IV) shows the palatal position of the ridge crest. Incisal
edges of opposing dentition require a more labial position, which would create a difficult pontic form. B, Labial view of the same cast
shows the significance of the vertical bone loss. Replacement of the teeth and ridge anatomy is best accomplished with a removable
partial denture.
Unusually Sound Abutment Teeth

Sometimes the reasoning for making a removable restora-
tion is the desire to see sound teeth preserved in their natural
state and not prepared for restorations. As was mentioned
previously, if this decision is made because it is felt that no
tooth modification is necessary for removable partial den-
tures, then the prosthesis will lack tooth-derived stability
and support.
When this condition exists, the dentist should not
hesitate to reshape and modify existing enamel surfaces
to provide proximal guiding planes, occlusal rest areas,
optimum retentive areas, and surfaces on which nonreten-
tive stabilizing components may be placed. Continued dura-
bility of the natural teeth is best ensured if the modifications
that optimize prosthesis function are provided. This is due A
to the fact that such modifications also ensure the most
harmonious use of the natural dentition.
Abutments With Guarded Prognoses

If the prognosis of an abutment tooth is questionable or if
it becomes unfavorable while under treatment, it might be
possible to compensate for its impending loss by a change
in denture design. The questionable or condemned tooth or
teeth may then be included in the original design and,
if subsequently lost, the removable partial denture can be
modified or remade (Figure 12-24). Most removable partial B
denture designs do not lend themselves well to later addi-
tions, although this eventuality should be considered in the
design of the denture.
When the tooth in question will be used as an abutment,
every diagnostic aid should be used to determine its prog-
nosis as a prospective abutment. It is usually not as difficult
to add a tooth or teeth to a removable partial denture as it
is to add a retaining unit when the original abutment is lost
and the next adjacent tooth must be used for that purpose.
It is sometimes possible to design a removable partial
denture so that a single posterior abutment, about which
C
there is some doubt, can be retained and used at one end of
the tooth-supported base. Then if the posterior abutment is
Figure 12-24 Kennedy Class II, modification 1, where the
lost, it could be replaced by adding an extension base to the molar abutment has a guarded prognosis. A, Anterior abutment
existing denture framework. Such an original design must of the modification space has a clasp assembly that accommo-
include provisions for future indirect retention, flexible dates for potential future loss of the distal molar while currently
clasping of the future abutment, and provisions for estab- providing adequate support, stability, and retention. B, Premolar
lishing tissue support. Anterior abutments that are consid- clasp assembly comprises a mesial rest, a distal guide plane, and
ered poor risks may not be so freely used because of the a wrought-wire retainer design, which will accommodate future
problems involved in adding a new abutment retainer when distal extension movement. C, Buccal view shows guide-plane
the original one is lost. It is rational that such questionable contact and a wrought-wire location that is appropriate for a
teeth should be condemned in favor of more suitable abut- distal extension.
ments, even though the original treatment plan must be
modified accordingly.
tated by these considerations must be described clearly to
Economic Considerations the patient as a compromise and not as representative of the
Economics should not be the sole criterion used to arrive at best that modern dentistry has to offer. A prosthesis that is
a method of treatment. When, for economic reasons, com- made to satisfy economic considerations alone may provide
plete treatment is out of the question and yet replacement only limited success and result in more costly treatment in
of missing teeth is indicated, the restorative procedures dic- the future.
decision to maintain teeth is again based on risk assessment,

Choice Between Complete Dentures
costs for use of the teeth, added benefit to prosthesis func-
and Removable Partial Dentures
tional stability, and comparative functional expectations
One of the more difficult decisions to make for the partially between a mucosal-borne denture and a removable partial
edentulous patient involves making the choice of a complete denture that uses teeth for some support, stability, and
denture over a removable partial denture. Many factors need retention.
to be considered when one is making such a decision; these The remaining tooth location and distribution can also
generally fall under the categories of tooth-related factors, affect the decision to maintain teeth. It makes a difference
factors of comparative functional expectations between pros- whether the remaining teeth are located on only one side of
theses, and patient-specific factors. Because the difference the arch. Having bilateral teeth remaining, especially if
between a tooth-tissue–born prosthesis and a tissue-born they are in similar locations (canines-canines, canines/
prosthesis can be significant, especially since it is difficult for premolars-canines/premolars), offers advantages for pros-
the partially edentulous patient to conceptualize the tissue- thesis design and occlusal development compared with
born situation, such an irreversible decision is not trivial. asymmetrical tooth locations. Some teeth may not serve well
An evaluation of the remaining teeth will determine as a stabilizing component for a removable partial denture
whether any caries or periodontal disease exists. The deci- and should not be maintained. If the remaining terminal
sion as to whether a tooth is useful for inclusion in a pros- tooth adjacent to a distal extension base is an incisor, the
thetic treatment plan can be made on the basis of an likelihood of long-term support, stability, and retention is
understanding that with appropriate disease management, poor.
the tooth provides a reasonable 5-year prognosis for sur- An additional factor for consideration when one is decid-
vival. This takes into account the added functional demand ing between a complete denture and a removable partial
by the prosthesis and a risk assessment for recurrent disease. denture is whether there is a strong patient desire to main-
Because this scenario concerns teeth with disease, the expec- tain teeth. As was mentioned previously, because the change
tation is that tooth structure and/or support is compro- to a complete denture is a significant transformation, suffi-
mised. The added functional burden, along with a potentially cient discussion must take place before this decision is made.
increased risk for disease, is an important concern when one The dentist must be very clear that the patient understands
is determining the long-term benefit for retaining teeth with the functional differences between a mucosal-borne pros-
a removable partial denture. thesis for all aspects of function (i.e., chewing, talking, etc.)
If the teeth can be maintained with a reasonable progno- and the natural dentition or a removable partial denture.
sis, the next questions to ask are “Do they require restoration The uniqueness of the patient is again appreciated these
with surveyed crowns?” and “How much improvement to issues are discussed with the patient. One patient may prefer
the prosthesis support, stability, and retention do they complete dentures rather than complete oral rehabilitation,
provide?” If the expected prognosis for a given tooth is ques- regardless of ability to pay. Another may be so determined
tionable, the costs associated with restoration high, and the to keep his own teeth that he will make great financial sac-
added benefit to the prosthesis low, the tooth should likely rifice if given a reasonable assurance of success of oral reha-
not be maintained unless the patient strongly desires to bilitation. Listening to the patient during the examination
maintain all teeth. However, if the same scenario exists and and the diagnostic procedures pays off significantly when the
the long-term impact on the support, stability, and retention treatment options differ so vastly as complete and removable
of the prosthesis is great, the decision strongly favors keeping partial dentures often do. During the presentation of perti-
the tooth. nent facts, time should be allowed for patients to express
The question of whether retained teeth offer a significant themselves freely as to their desires in retaining and restoring
advantage to the prosthesis from a support, stability, and their natural teeth. At this time, a treatment plan may be
retention standpoint requires comparative evaluation of influenced or even drastically changed to conform to the
potential denture-bearing foundations. If the expectation is expressed and implied wishes of the patient. For example,
that an edentulous arch would have unfavorable physical there may be a reasonable possibility of saving teeth in both
features (poor ridge form, poor arch configuration, displace- arches through the use of removable partial dentures. With
able mucosa, high frena attachments, minimum denture only anterior teeth remaining, a removable partial denture
bearing area, and/or an unfavorable jaw relationship), then can be made to replace the posterior teeth with the use of
retention of teeth is likely to provide a more significant good abutment support and, in the maxillary arch, use of
benefit. If retention of teeth can help to prevent or delay full palatal coverage for retention and stability. If patients
age-related denture-bearing foundation changes seen with express a desire to retain their anterior teeth at any cost,
complete denture use, then retention of teeth can be of sig- and if the remaining teeth are esthetically acceptable and
nificant benefit. functionally sound, the dentist should make every effort to
When evaluation demonstrates that the remaining teeth provide successful treatment. If patients prefer a mandibular
have no active disease, then the often-negative impact of removable partial denture because of fear of difficulty in
disease management on prognosis is not a concern. The wearing a mandibular complete denture, then, all factors
being acceptable, their wishes should be respected and treat-

Clinical Factors Related to Metal
ment should be planned accordingly. The professional obli-
Alloys Used for Removable Partial
gation to present the facts and then do the best that can be
Denture Frameworks
done in accordance with the patients’ expressed desires still
applies. The cast framework offers significant advantages over the all
Other patients may wish to retain remaining teeth for an acrylic-resin removable partial denture. In general, the
indefinite but relatively short period of time, with eventual ability to predictably utilize the remaining teeth for support,
complete dentures a foregone conclusion. In this instance, stability, and retention over time is best assured when the
the professional obligation may be to recommend interim interface between prosthesis and teeth consists of a cast
removable partial dentures without extensive mouth prepa- structure and not a polymer. Although the utility of all
ration. Such dentures will aid in mastication and will provide acrylic-resin prostheses can be extended if wire “rests” are
esthetic replacements, at the same time serving as condition- provided, typical polymer properties do not allow for a
ing restorations, which will make the later transition to com- durable interface, which is required if one is to take
plete dentures somewhat easier. Such removable partial advantage of the stabilizing effects of tooth contact. Expecta-
dentures should be designed and fabricated with care, but tions of how the metal framework improves functional per-
the total cost of removable partial denture service should be formance are related to the properties of the metal alloy.
considerably less. Various alloys can be considered for use. Following is a
An expressed desire on the part of patients to retain only discussion of the most common framework alloys in use
six mandibular anterior teeth must be considered carefully today.
before this is agreed to as the planned treatment. The advan- Practically all cast frameworks for removable partial den-
tages for patients are obvious: they may retain six esthetically tures are made from a chromium-cobalt (Cr-Co) alloy. The
acceptable teeth; they do not become totally edentulous; and popularity of Cr-Co alloys has been attributed to their low
they have the advantages of direct retention for the removable density (weight), high modulus of elasticity (stiffness), low
partial denture that would not be possible if they were com- material cost, and resistance to tarnish. The term stellite alloy
pletely edentulous. Retaining even the mandibular canine historically has referred to this class of alloy. Today the more
teeth would accomplish the latter two objectives. Potential common alloys contain 60% to 63% Co, 29% to 31.5% Cr,
disadvantages relate directly to the patient keeping up with and 5% to 6% Mo, with the balance including Si, Mn, Fe,
prosthesis maintenance procedures. The disadvantages relate N, and C. The addition of controlled amounts of nitrogen
to the poor response of the anterior maxilla to functional (<.5%) is reported to improve physical properties. Titanium
stress concentrated from the opposing natural dentition. If is also used as a removable partial denture (RPD) frame
the functional forces of occlusion are not well distributed, the material; however, production difficulties continue to hinder
natural anterior can concentrate stress to the anterior maxil- its widespread use. The dentist should become familiar with
lary arch. The possible result of such poorly distributed func- the alloy used by her/his laboratory and should closely
tional force includes the loss of residual maxillary bone, monitor fit, density, and rigidity.
loosening of the maxillary denture caused by the tripping The following are comparable characteristics of gold
influence of the natural mandibular teeth, and loss of the alloys and chromium-cobalt alloys: (1) each is well tolerated
basal foundation for the support of future prostheses. by oral tissues; (2) they are equally acceptable esthetically;
However, if the maxillary anterior teeth are arranged to (3) enamel abrasion by either alloy is insignificant on
contact in balanced eccentric positions and if patients comply vertical tooth surfaces; (4) a low-fusing chrome-cobalt
with periodic recall to maintain these relationships, these alloy or gold alloy can be cast to wrought wire, and wrought-
problems are minimized. Prevention of this sequence of wire components may be soldered to either gold or
events lies in the maintenance of positive occlusal support chrome-cobalt alloys (these characteristics are important
posteriorly and the continual elimination of traumatic influ- in overcoming the objection by some dentists to the
ence from the remaining anterior teeth. Such support is increased stiffness of chromium-cobalt alloys for the por-
sometimes impossible to maintain without frequent relining tions of direct retainers that must engage an undercut of
or remaking of the lower removable partial denture base. The the abutment tooth); (5) the accuracy obtainable in casting
presence of inflamed hyperplastic tissue is a frequent sequela either alloy is clinically acceptable under strictly controlled
to continued loss of support and denture movement. investing and casting procedures; and (6) soldering proce-
Although some patients are able to successfully function dures for the repair of frameworks can be performed on
with a lower removable partial denture supported only by each alloy.
anterior teeth against a complete maxillary denture, it is
likely that undesirable consequences will result unless the Comparative Physical Properties of Gold
patient faithfully follows the instructions of the dentist. In and Chromium-Cobalt
no other situation in treatment planning are the general Chromium-cobalt alloys generally have less yield strength
health of the patient and the quality of residual alveolar bone when compared with gold alloys used for removable partial
as critical as they are in this situation. dentures. Yield strength is the greatest amount of stress an
alloy will withstand and still return to its original shape in is indicated for the bilateral distal extension removable
an unweakened condition. Possessing a lower proportional partial denture. Weight is a factor that must be considered
limit, the chromium-cobalt alloys will deform permanently when the force of gravity must be overcome, so that usually
at lower loads than gold alloys. Therefore the dentist passive direct retainers will not be activated constantly to the
must design the chromium-cobalt framework so that the detriment of abutment teeth.
degree of deformation expected in a direct retainer is less The hardness of chromium-cobalt alloys presents a dis-
than a comparable degree of deformation for a gold compo- advantage when a component of the framework, such as a
nent. The modulus of elasticity refers to the stiffness of rest, is opposed by a natural tooth or by one that has been
an alloy. Gold alloys have a modulus of elasticity approxi- restored. We have observed more wear of natural teeth
mately one-half that for chromium-cobalt alloys for similar opposed by some of the various chromium-cobalt alloys as
uses. The greater stiffness of the chromium-cobalt alloy is contrasted with type IV gold alloys.
advantageous but at the same time offers disadvantages. It has been observed that gold frameworks for removable
Greater rigidity can be obtained with the chromium-cobalt partial dentures are more prone to produce uncomfortable
alloy in reduced sections in which cross-arch stabilization is galvanic shock to abutment teeth restored with silver
required, thereby eliminating an appreciable bulk of the amalgam than are frameworks made of chromium-cobalt
framework. Its greater rigidity is also an advantage when alloy. This may not be a valid criterion for the selection of a
the greatest undercut that can be found on an abutment particular alloy when the dentist has complete control over
tooth is in the nature of 0.05 inch. A gold retentive the choice of restorative materials.
element would not be as efficient in retaining the restoration Commercially pure (CP) titanium and titanium in alloys
under such conditions as would the chromium-cobalt containing aluminum and vanadium, or palladium (Ti-O
clasp arm. Pd), should be considered potential future materials for
A high yield strength and a low modulus of elasticity removable partial denture frameworks. Their versatility and
produce greater flexibility. The gold alloys are approximately well-known biocompatibility are promising; however, long-
twice as flexible as the chromium-cobalt alloys; in many term clinical trials are needed to validate their potential use-
instances, this provides a distinct advantage in the optimum fulness. Currently, when CP titanium is cast under dental
location of retentive elements of the framework. The greater conditions, the material properties change dramatically.
flexibility of the gold alloys usually permits location of the During the casting procedure, the high affinity of the liquid
tips of retainer arms in the gingival third of the abutment metal for elements such as oxygen, nitrogen, and hydrogen
tooth. The stiffness of chromium-cobalt alloys can be over- results in their incorporation from the atmosphere. As
come by including wrought-wire retentive elements in the interstitial alloying elements, their deleterious effect on
framework. mechanical properties is a problem. Also, reactions between
The bulk of a retentive clasp arm for a removable partial molten titanium metal and the investment refractory
denture is often reduced for greater flexibility when chro- produce gases, which cause porosity. With alpha-beta
mium-cobalt alloys are used as opposed to gold alloys. This, alloys, such as Ti-6Al-4V, a surface skin of alpha titanium
however, is inadvisable because the grain size of chromium- can form (alpha-case zone), which has a tremendous effect
cobalt alloys is usually larger and is associated with a lower on electrochemical behavior and mechanical properties.
proportional limit, and so a decrease in the bulk of chro- This could be important for small thin structures, such as
mium-cobalt cast clasps increases the likelihood of fracture clasp assemblies and major and minor connectors. The CP
or permanent deformation. The retentive clasp arms for grades of titanium have yield strengths that are too low for
both alloys should be approximately the same size, but the clinical use as clasps (450 MPa minimum), although the
depth of undercut used for retention must be reduced by ductility is high. The much higher yield strengths of the
one half when chromium-cobalt is the choice of alloys. Ti-6Al-4V alloys are the same as that of a typical bench-
Chromium-cobalt alloys are reported to work/harden more cooled cobalt-chromium alloy, but with far superior ductil-
rapidly than gold alloys, and this, associated with coarse ity. The typical Young’s modulus of elasticity of titanium
grain size, may lead to failure in service. When adjustments alloy is half that of cobalt-chromium and just slightly higher
by bending are necessary, they must be executed with than that of type IV gold alloys. This would require a differ-
extreme caution and limited optimism. ent approach to clasp design than is used with cobalt-
Chromium-cobalt alloys have a lower density (weight) chromium alloys, and would present some advantages.
than gold alloys in comparable sections and therefore are Wrought titanium alloy wires are also flexible because of
about one half as heavy as gold alloys. The weight of the alloy the same low elastic modulus. Beta alloys, which are used in
in most instances is not a valid criterion for selection of one orthodontics, have two-thirds the elastic modulus of CP
metal over another because after placement of a removable titanium and Ti-6Al-4V. The joining of titanium by brazing
partial denture, the patient seldom notices the weight of the is a problem because like-casting inert atmospheres must be
restoration. The comparable lightness of chromium-cobalt used. The corrosion and fatigue behavior of brazed joints
alloys, however, is an advantage when full palatal coverage has yet to be tested for long-term corrosion resistance and
clinical efficacy. Clinical use has demonstrated reasonable The tensile strength of the wrought structure is approxi-
short-term results, but laboratory fabrication difficulties mately 25% greater than that of the cast alloy from which it
need to be addressed, and long-term advantages over exist- was made. The wrought structure’s hardness and strength
ing alloys must be demonstrated before titanium will gain are also greater. This means that a wrought structure that
broad clinical use. has a smaller cross section than a cast structure may be
used as a retainer arm (retentive) to perform the same
Wrought Wire: Selection and Quality Control function. It has been suggested that a minimum yield
Wrought-wire direct retainer arms may be attached to the strength of 60,000 psi is required for the retentive element
restoration by embedding a portion of the wire in a resin of a direct retainer. A percentage elongation of less than
denture base, by soldering to the fabricated framework, or 6% is indicative that a wrought wire may not be amenable
by casting the framework to a wire embedded in the wax to contouring without attendant undesirable changes in
pattern (Figure 12-25). The physical (mechanical) proper- microstructure.
ties of available wrought wires are most important consid- Regardless of the method of attaching the wrought-wire
erations when a proper wire for the desired method of retainer that is used, that is, embedding, soldering, or cast-
attachment is selected. These properties include yield to, tapering the wrought arm seems most rational. A retainer
strength or proportional limit, percentage elongation, tensile arm is in essence a cantilever that can be made more service-
strength, and fusion temperature. After the wire is selected, able and efficient by tapering. Tapering to 0.8 mm permits
the procedures to which the wire is subjected in fabricating more uniform distribution of service stresses throughout the
the restoration become critical. Improper laboratory proce- length of the arm, being readily demonstrated by photoelas-
dures can diminish certain desirable physical properties of tic stress analysis. Uniform tapering of an 18-gauge, round
the wrought structure, rendering it relatively useless for its wire arm can be accomplished by rapidly rotating the wire
intended purpose. For example, when wrought wire is in angled contact with an abrasive disk in the dental lathe.
heated, as in a cast-to or soldering procedure, its physical It is then polished by rotating the wire in angled contact with
properties and microstructure may be considerably altered, a mildly abrasive rubber disk in the dental lathe. The appro-
depending on temperature, heating time, and cooling opera- priate taper is shown in Figure 12-26.
tion. All manufacturers of wrought forms for dental applica-
tions furnish charts listing their products and the physical
properties of each product. The percentage of noble metals
is given. In addition, most manufacturers designate wires
Table 12-1
that may be used in a cast-to procedure. American Dental
Association (ADA) Specification No. 7 addresses itself to Comparative Specifications Contained in ADA
wrought gold wire in terms of both content and minimum Specification No. 7
physical properties (Table 12-1).
Type I Type II
Content of metals of the gold, 75% 65%
platinum group (minimum)
Minimum fusion temperature 1742° F 1898°F
Minimum yield point value 125,000 psi 95,000 psi
(hardened or oven cooled)
Minimum elongation 4% 2%
(hardened)
Minimum elongation 15% 15%
(softened)
ADA, American Dental Association.
D ½D
Figure 12-25 The wrought-wire retainer arm has been con-

toured to design and incorporated into the wax pattern of this Figure 12-26 Round, 18-gauge wrought wire for the retentive
frame, where it will become an integral part of the framework. component of the direct retainer assembly (clasp) is uniformly
The wire is contoured in two planes and will be mechanically tapered to 0.8 mm from its full diameter to its terminus. Taper-
retained in the casting. ing should precede contouring of the wire for the retainer arm.
sibility of the decision still rests with the dentist, who must
Summary
evaluate all factors in relation to the results desired. In any
In selecting materials, it must be remembered that funda- instance therefore, the dentist must weigh the problems
mentals do not change. These are inviolable. It is only involved, compare and evaluate the characteristics of differ-
methods, procedures, and substances—by which the dentist ent potential materials, and then make a decision that leads
effects the best possible end result—that change. The respon- to delivery of the greatest possible service to the patient.

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12

Diagnosis and Treatment Planning

REMOVABLE PARTIAL PROSTHODONTICS

PATIENT NAME PATIENT NUMBER

TREATMENT PLAN LABORATORY INSTRUCTIONS

APPROVAL TO SEND TO LABORATORY: DATE:

Figure 12-2 A, Diagnosis record for recording pertinent data. Continued

Name: John Doe Date: July 1, 1999

Primary impression-both arches; 30 19

placement of the maxillary cast in a position relative to the

It is better that the casts be mounted in relation to the

5. Place the bow evenly into the ears posteriorly.

hinge axis points, to which the facebow is then adjusted

infraorbital point previously identified with an ink dot. It

Jaw Relationship Records for Diagnostic Casts

An articulator mounting thus made will have related the

Figure 12-13 Elastomeric interocclusal registration material Diagnostic Findings

Radiographic evaluation of bone quality is hazardous

coronal distal aspects because the axis of rotation is not at

support does not place additional functional demands on

Unusually Sound Abutment Teeth

Abutments With Guarded Prognoses

decision to maintain teeth is again based on risk assessment,

being acceptable, their wishes should be respected and treat-

ADA, American Dental Association.

Figure 12-25 The wrought-wire retainer arm has been con-

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