http://dentalbooks-drbassam.blogspo qa 11 understanding partial denture design Kenneth Tyson Robert Yemm Brendan Scott “a8 http://dentalbooks-drbassam.blogspot.comhttp://dentalbooks-drbassam.blogspot.com Understanding partial denture design K. W. Tyson BDS DDS FDS RCS Edin. Formerly Head of the Department of Prosthetic Dentistry and Consultant, Edinburgh Dental Hospital and School. R. Yemm BDS BSc PhD FDS RCS Edin. Emeritus Professor and Consultant, Dundee Dental Hospital and Sehool. B. J. J. Scott BDS BSc PhD FDS RCS Edin. (Rest. Dent.) Senior Lecturer and Consultant in Restorative Dentistry, Dundee Hospital and School. OXFORD UNIVERSITY PRESShttp://dentalbooks-drbassam.blogspot.com OXFORD UNIVERSITY PRESS Great Clarendon Street, Oxford ox2 Gu Oxford University Press isa department ofthe University of Oxford Itfarthers the University's object ve of excellence in research, scholarship, ‘and education by publishing worldwide Oxford. New York Auckland Cape Town Dares Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City” Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary ttaly Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford isa registered trade mark of Oxford University Press In the UK and in certain other countries Published in the United states by Oxford University Press Inc., New York © Oxford University Press 2007, ‘The moral rights of the authors have beer asserted tabase right Oxford University Press (maker) First published 2007 All rights reserved. No part of this publication may be reproduced, stored in aretrieval system, or tra nsmitted, in any form or by any means, without the prior permission in writing of Oxford University Press or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope ofthe above sheuld be sent to the Rights Department, Oxford University Press, at the address above ‘You must not citculate this book in any other binding or cover ‘and you must impose the same condition on any acquirer British Library Cataloguing in Publication Data Data available Library of Congress Cataloging in Publication Data Data available Typeset by Graphic raft Limited, Hong Kong Printed in Spain on acid-free paper by Graficas Estella S.A. ISBN 0-19-851092-6 (Pbk.)978-0-19-8519092. 13579108642 (Pbk)http://dentalbooks-drbassam.blogspot.com Foreword In the United Kingdom, it is clear from a succession of national starveys that the oral health of the population is improving. ‘The proportion of edentulous adults is falling, significantly. There is good evidence that people are keep- ing their natural teeth for longer: Furthermore, with an Increased tife expectaney, the proportion of the popula tion who are classtied as elderly is increasing. Although it Is likely that the proportion of edentulous patients will continue to drop, this does not mean that the remainder will have intact dentitions. Lass ofa few teeth may occur leaving spaces that may or may not need restoring. Some of these patients will wish to explore fixed restora tions (bridges supported on the natural teeth or implants) asameans toreplace teeth that have been lost, However this will not be feasible for a signiticant proportion of patients, particularly as they lose more teeth, For these reasons it would seem likely that the need for partial dentures is not diminishing and may even increase im the future, Alongside the retention of teeth over a much longer period other challenges may be evident, Medical conditions may affect the oral tissues, Many forms of medication ma result in a reduced salivary llow which renders the teeth sus- ceptible to further disease. ‘The remaining teeth may be affected by toothwearorthey may bein positions which are rnot acceptable for partial dentures, These situations will mean that great care will have to be exercised in the design of partial dentures. ‘The main purpose of this book isto givean understand- ing of the essential principles used (o design partial dentures such that they will be stable in function snd will not result in damage to the tissues. We have explored an approach based on an understanding of mechanical principles to introduce key concepts that should help the reader understand how to formulate suitable denture designs. We have also highlighted the important prin- ciples of designing dentures so that they are biologically favourable, An understanding of how dental plaque causes, destruction of the mineralized tissuesof the teeth and sup- porting tissues ofthe periodontium is outside the remit of this ext. However itis critical that anyone involved in par- tialdenturedesign hasasound knowledge of these disease processes. his Is necessary so that the denti municate in such a way so as to ensure that the patient can com thas an insight into their susceptibility to plaque-related diseases. The patient and dentist together can institute Coral bygiene regimes and maintenance to prevent further disease initiation orprogression. This isespecially import- ‘ant as even well-designed partial dentures can result in 18 greater susceptibility for plaque accumulation around the natural teeth. ‘The final factor involved in good partial denture design is an understanding of the limitations of the materials themselves, This may range from using the most appropriate material for the denture base to making decisions about clasp design. ‘The most appropriate design of partial dentures is clependent ox having good information. For this reason Ahe dentist should be prepared to spend the time required to record a full dental, denture and medical history from the patient. 1 is critical that all oral tissues are examined thoroughly, both clinically and radiographically, where required, Surveyed und articulated study casts will allow the three-dimensional relationships of the maxillary and mandibular teeth to be assessed, Finally, integrated treat- ‘ment plans need to be formulated to eliminatedisease as well ‘as addressing the needs of the patient by the replacement ‘ofmissing teeth, Continuingadviee on oral hygiene after the prostheses have been constructed should alert the patient to the potential for further disease. ‘The design of partial dentures should ideally be based ‘on a team approach. It is not an activity that should be lelegated to. technician norisitone that should be in the exclusive domain of the dentist, Although the dentist has ‘theultimate responsibilty or the patient and will therelore ‘have the lead role, theré is much to be gained by involving ‘the technician in decisions about design at an early stage Apart from the practical skills to fabricate the applian ‘the dental technician will often have particular expertise Jn the limitations of the materials under certain cond tions. There is therefore much to be gained from involving the dental technician, not least in that It may give an alternative design viewpoint which can be explored, ‘The need for well-designed partial dentures isas critical today as it has ever been. It is our hope that this book will, give the reader a sound foundation, from which the prin- «ciples can be applied to the wide range of elinical presen- ‘tations in patients requiring partial dentures.http://dentalbooks-drbassam.blogspot.com Section 1 General principles of partial dentures and how they work This section deals with how partial dentures work: Itis not possible to design a well-functioning and physiologically acceptable denture without a thorough understanding of the mechanisms involved A partial denture is a device placed into the mouth to replace lost teeth and the accompanying alveolar process. tis therefore a substitute for part of the masticatory mechanism and, as such, should become a part of that system. If the denture is not properly designed, it cannot full that function. Section 1 examines the way in which partial dentures and their components function, and pro- vides a basis for the understanding of the requirements of the design process. Without this understanding you cannot design a denture to work successfully within the physio- logical framework as a part of the massticatory mechanism.http://dentalbooks-drbassam.blogspot.com Loads and levers You cannot even begin ta design a satisfactory partial denture unless you understand the essential physics involved in the workings of the appliance. Revision of these properties is therefore essential, Once understood, the development of a good design is greatly simplified. Partial dentures are subject to many forces, such as chew- ing (vertical and lateral, lifting (sticky foods), and actions, ofthe tongue, ipsand cheeks, Wemust employ theunder- standing of loads and levers during the development of good design. It could be argued that this short chapter cont the information about which the major part of this book hinges, It is purely a revision of some elementary school physics which you use daily without thinking. Fundamental to understanding partial denture design isa solid grasp of simple mechanical principles. Without these you might as well eave the design to your laboratory orcopy a design that happens to take your fancy, neither of which takes into consideration the physiological needs of the patient, 'The result is, rather than providing an appliance which compliments the oral tissues and masti- catory mechanism, the patient isgiven a prosthesis which accelerates the degradation and destruction of the oral tissues. If you have taken note of the diagram with nomenclature at the end of the last chapter, you should not suddenly hit a term with which you are unfamiliar. | Ifyou understand howa machine works then you know | how to use it, Similarly if you understand how a partial | denture works, you will know how to approach each | design problem. | Itso happens that the theory underlying partial denture design is simple ifyou spend a litle time revising someele- mentary physics. Weare going to look at two essential mechanical areas, load distribution and levers, two supports, the load will be d supports. Ifthis was applied to the saddle ofadenture then the premolar would carry an equal load to the molar, Load distribution Tooth support Any load applied to a beam will be passed to the supports, ‘upon which the beam rests. Itis self-evident ifthe load is applied to a single support then the full oad is passed directly to that support. ® On the other hand ifa load is placed centrally between ded equally between the EX FX a Should one support be moved further away from the load then the weight distribution would be unequal, thehttp://dentalbooks-drbassam.blogspot.com Classification of partial dentures ] 3 @ For convenience in the discussion and description of partial dentures some form of classification is useful, One whic bby Kennedy. ILis helpful to have a method of describing the type of denture required. The form and shape of partial dentures: are virtually numberless, so a classification is needed to divide them into manageable groups when they are to be described or discussed. ‘There are two common ways of classifying partial dentures; one is based on the distribution of missing teeth saddles, the other on how the denture is to be supported Both have merits and drawbacks, Classification by missing teeth gives an immediate mental picture of what a den- ture might look like but gives no indication of how the masticatory load is to be applied to the tissues. The con- verse applies to the classification indicating the support available. Really the two compliment each other. ‘The classification which is generally used isthat described by Kennedy. Based on the pattern of missing teeth, it is universally understood, but gives no indication of the condition of the teeth, the supporting structures, or how the masticatory load be applied. Note: A bounded saddle is an area where a tooth or teeth are missing but there is an abutment tooth at each end. A free-end saddle or distal extension saddle is one where there is an abutment tooth at the anterior end only. Third molars are frequently ignored in design discussion. (being so variable) unless they have a direct use or bearing on the design under consideration. most universally understood is that described ‘Kennedy Classification ‘Class [Bilateral free-end ‘Class I Unilateral free-end ‘Class Il Unilateral bounded Class IV Anterior (crossing the mid-line) ‘The other classification is based on the way the partial denture is supported (Beckett). Here you are only given the type of support employed, not the number, distribution or condition of the missing teeth, Classification by support Class 1 Tooth supported Class Tissue supported (Class 11 Tooth and tissue supported. Reminder. A saddle is an area of a denture base, cover- ‘ing the oral mucosa, to which the artificial teeth are attached Partial dentures classified by missing teeth—Kennedy Kennedy class | Bilateral free-end saddles ‘There are no teeth standing distal to the abutment teeth, ‘Therefore the free-end or distal extension saddles can only derive tooth support at one end,http://dentalbooks-drbassam.blogspot.om Cast surveying You cannot begin to design a partial denture without first surveying the casts to demonstrate undercut areas. Such areas need to be eliminated to insert/remove the denture or used to aid retention. Surveying is an essential step in the design and construc tion of partial dentures. The surveying instrument draws lines on a cast so that the dentist can be sure that no rigid part of a partial denture lies in an undercut in relation to the path of insertion and removal of the appliance, An undercut is the area below the greatest diameter of a tooth, similar to the area below an overhanging cliffedge (arrowed). Cure OVERHANG. UNDERCUT AREA iy If there were undercuts present and the denture con- structed to fit them, then the denture could not be fitted, or if it were forced into position, it would snap into place and be very dillicult, painful or even impossible to remove (sometimes referred to as an ‘insertional interference’). Om ‘We must also find where to put claspsto hold thedenture in place and how to make the prosthesis blend naturally with the tissues by avoiding unsightly gaps where the denture and tissues meet. d d Oo (== bo . ‘The diagram above shows the construction of a cast ‘surveyor. Ithas: + atable (a), the angle of which can be adjusted + amovable arm (b) carrying + marker lead (c) which is always held vertical by ++ special joints (d)http://dentalbooks-drbassam.blogspot.com | / Retention e A removable partial denture must be held firmly in place. This is usually arranged by clasps, or part of the denture base, engaging hatd tissue undercuts. The position and action of retainers must not damage any tissues. Special attachments are not considered in this chapter. DESIGN SEQUENCE teeth to replace support connectors retention refine Before you start this chapter we expect you to be familiar with the chapter on surveying (Chapter 1.4). The usual way of retaining partial denturesis by means of metal clasps, Direct retention is gained through a clasp which engages an undercut on a tooth and, through its resistance to removal from the undercut, holds that part of the denture in place. ‘The degree ofresistance toremoval ofa clasp depends on, three principal features: + the flexibility of the arm (type of metal and whether wrought or cast) + the length and cross-section of the arm + the depth of the undercut engaged Clasps are divided into two main types: Occlusally approaching clasps are those which enter the undercut from the occlusal area of the tooth (upper diagram) and gingivally approaching clasps which enter the undercut by crossing the gingival margin. Of the two, gingivally approaching clasps are the ‘more efficient due to the ‘trip action’ when removal is ‘attempted. Let us explain this action. ‘The ‘trip action’ of gingivally approaching claspsis best explained by analogy. Ifyou push a stick along the ground in front of you and it meets an obstruction, it will tend to dig in and be hard to move,CHAPTER 1.7 RETENTION http://dentalbooks-drbassam.blogspot.com VA SS y what happens when you try to remove a ly approaching clasp from a tooth. ‘The tip of the clasp is angled against the enamel in the undercut below thesurvey line and any attempt to removeit will makeit try to digin, Thisis called the ‘trip’ action of the clasp. Compare this to the action of an occtusally approaching clasp, using the same analogy, i'you trail a stick along the ground behind you, it will just bump over any obstruction without difficulty. ett S his sjust what happens when an occlusally approach- ingelaspispulled offa tooth. The tip of the clasp isdragged from the undercut and slides over the survey line. There is no ‘trip’ action to enhance its retention. Never forget that the point ofaction of clasp is atthe tip no matter where it arises from the denture base or how gets into the undercut. This is exactly ging For the sake of simplicity in this chapter, we will only consider retention of a denture in the path of displace- ment, that s, a path at right angles to the occlusal plane, Have a look at a few of the undercuts you may have to engage. You have already seen some common survey lines, similar to these, showing the greatest diameter of a tooth, Remember that above the survey line is the non- undercut area of the tooth, and below is the undercut area where we look for retention. eS OO ‘The undercut areas shown are quite good, in that there is plenty of room to place the tip of the clasp and they are casily approached occlusally or gingivally. However the size and shape of undercuts vary. The type of clasp depends on the amount of undercut a available and whether there is enough of the under- cut in the horizontal plane for the clasp to resist removal. 43ce | Lo Standard crown KS Bulbous crown These illustrations show the same undercut gauge ind - cating the same horizontal undercut on teeth with differ- ing buccal contours. The depth of the horizontal undercut engaged will depend on the resilience of the clasp arm. So thereare two major factors to consider, the magnitude of the undercuts in the vertical plane and the horizontal plane: Here are three other examples of ways of entering undercuts, SS C2 he http://dentalbooks-drbassam.blogspot.com SECTION 1 GENERAL PRINCIPLES OF PARTIAL DENTURES AND HOW THEY WORK. An occlusally approaching ‘extended arm’, to engage ‘an undercut where a nearer one is not satisfactory, is not often used nowadays unless the tooth adjacent to the saddle is crowned and has little undercut. Where teeth are not bulbous, composite resin can easily be added to enamel to provide an undercut (see later), An occlusally approaching ‘recurved arm’, to pick up an area next toa saddle, allows the arm to belong enough for flexibility. A gingivally approaching clasp attached to a small shallow area provides good retention (trip action) and is hardly visible. Three more examples follow: zivally approaching clasps are sometimes referred to as roach clasps. ‘Some ofthese are given fancy names, such asT, U,L, land .thesedescriptionsarejust ashorthandfortheshapeot | the retentive part ofthe arm. | Of course there are times, with very low survey lines, when the only useful retentive area is in the interdental embrasure. In these cases a ball-ended or arrowhead clasp can tuck into the gingi part of the interdental embrasure (occlusally approaching arms are usually wrought to give suflicient flexibility).http://dentalbooks-drbassam.blogspot.com Indirect retention Indirect retention is a means of preventing the displacement of a saddle which is cantilevered out from the direct retainer(s), such as a free-end saddle or curved anterior saddle. A lever system must be created to keep the saddle in place. DESIGN SEQUENCE teeth to replace support connectors retention refine Let us look at the forces involved in the retaining parts of partial dentures which cannot be held in place by direet means, Indirect retention relates to saddles that cannot have a retainer at each end, or do not have the pontics in a straight line between the abutment teeth. ‘An example is a free-end saddle where ther an abutment tooth at one end. Another example is an anterior saddle which is curved outside a straight line between the abutments. 1K will be useful to be reminded of the Class IIT lever system, for itis the method by which indirect retention is effected. To help your memory of levers little diagrams have been added to many of the illustrations. Load w For alower denture or Fulcrum Eefort oe pt Foran upper denture : Indirect retention is always a Class II lever syster can never work ata mechanical advantage overhanging the edge ofa table, pose that itis a block of wood. then the opposite end would rem tableas the block hinged upwards. about its edge at F. it Here is an everyday situation where a book or a tray is, in thisinstance let ussup- Look at the table and block from above If you were to lift the block at the overhanging edge, Jin in contact with the Apart from the weight of the block there is nothing to prevent this movement, is there?52 | SECTION 1 GENERAL PRINCIPLES OF PARTIAL DENTURES AND HOW THEY WORK On the left you can see modifications have been made to the block and table, Whatever alterations are made, ifthe overhanging part is lifted, the other end will stil lie on the table top and hinge about its edge. Do you think that, with a little imagination, the third illustration on the left looks a bit like an outline partial denture (with free-end saddles) lying on an occlusal table: ‘You could stop the outer edge of the block being lifted by nailing the block to the table near to the table edge. Common sense tells you to put the nail near the edge, nat- urally you would not put the nail near the left hand edge ofthe block, Why? Because you know that when you lifted the block the leverage would pull the nail out, This simple fact tells you how to make indirect retention work well, Check the lever diagrams, asa Class II system the nearer is tothe lifting load I. the better http://dentalbooks-drbassam.blogspot.comhttp://dentalbooks-drbassam.blogspot.com 5.5 Partial dentures around difficult dentitions and oral structures {In some circumstances there are localized areas of the mouth which might create some problems in the construction of partial dentures. These may be related to the position of the teeth orr due to other anatomical structures. Some of the problems and solutions will be considered, such as ‘overerupted teeth tilted teeth drifted teeth In some circumstances the position of the teeth in the remaining dentition may present challenges in designing partial dentures, ‘This can occur either because teeth ‘may move to a position where there is insulficient space for a prosthesis or because of the particular way that the maxilla and mandible are related. ‘This chapter will explore some of these issues and suggest thoughts as to how partial denture design can take account of this. Overerupted teeth ‘Teeth which are unopposed can in certain circumstances move because the physiological mechainisms of eruption become reactivated. We have alreacly alluded to this previously in the discussion related ta tooth wear, Teeth which overerupt can create significant problems or denture design, In many patients who are partially dentate, there is little evidence to suggest that unopposed teeth will overerupt. However in others, it seems clear that un- ‘opposed teeth have moved over time. There i still no clear way of predicting which teeth will havea greater potential toovererupt. Clearly there are biological factors operating of which we have very litle understanding. incisal overbite and overjet maxillary or mandibular tori lesions of the soft tissues Problems created by overerupted teeth + Disruption to the occlusal plane. The occlusal plane may be irregular in height and there may be steps between the denture or natural teeth with the over- erupted teeth. Where severe this may make mastica- tion less efficient, Overerupted teeth resulting in disruption of the acclusal plane + Not enough space in the saddle area opposing the overerupted tooth to get a sufficient thickness of the denture base material. This would result in the denture being liable to fracture,CHAPTER 3.5 DIFFICULT DENTITIONS AND ORAL STRUCTURES | 103 https //dentalbooks-drbassam.blogspot.com Wear facet on a premolar tooth achurediaseilietn the poster obtedt Occlusal interference from an opposing tooth Limited space for maxillary denture + In some circumstances the tooth may be directly in contact with the opposing ridge and there isnospace Design solutions for overerupted teeth at all in which a prosthesis can be placed. If such @ —_[ some circumstances it may be possible to work around prosthesis is constructed at an increased vertical overerupted teeth and accept that an uneven occlusal dimension, it will often result in considerable trauma plane may result. It would appear that patients can fune- to the supporting tissues asitisheavily loaded during ton around uneven dentitions, but it is not known how function, It is always dangerous to encroach on the {heir functional activities are compromised. Providing the free-way space, and to exceed it, as you should know, ‘uption to the occlusal plane is not severe, this may can be disastrous, be a perfectly acceptable solution. In other situations. a + They may result in occlusal interferences with the specific design of the denture or an adjustment to the opposing dentition. The patient may change their teeth may be necessary. chewing pattern which can sometimes lead to problems elsewhere in the arch, for example, tooth wear in a more anterior region or joint/muscular problems + Striking plate: this is a modification to the design of a partial denture where the space for a prosthesis which Is opposed by an overerupted tooth is. very restricted. A denture with a cobalt chromium base can be designed so that it does not carry an artificial tooth in this area, Alternatively, where an acrylic resin-based denture Is being used, a small piece of cobalt chromium material or a stainless steel cap may be embedded in the area. In both situations the very small thickness of metal required to give adequate strength may permit a partial denture to be designed around the abnormal position of the opposing tooth,Understanding Partial Denture Design provides a step-by-step, highly illustrated guide to this difficult but core area of dentistry. The first section of the book is dedicated to general principles of partial dentures, focussing on how they Work. The second section allows students to put theory into practice including assessment and the associated design sequence. The final section of the ‘book concentrates on problem solving, including more challenging areas of denture design, such as the provision of partial dentures for complex and deteriorating dentitions. + Unlocks difficult concepts by means of well explained, simple examples + A wealth of line drawings allows stepwise visualisation of mechanical points, and associated design considerations * Colour presentation is used to present key points, and support the scheme of diagrams + Novel layout provides the reader with a seamless and straightforward account of the subject ‘A key strength of the book js its ability to de-mystify the biological and mechanical principles underlying good partial denture design. This will give stuclents and newly qualified dentists the fundamental understanding they need to succeed in this aspect of clinical dentistry. About the authors: The authors have extensive experience of teaching partial denture design, and years of clinical provision of partial denture solutions. Kenneth Tyson was head of the Department of Prosthetic Dentistry and Consultant at Edinburgh Dental Hospital and School; Robert Yemm is Emeritus Professor and Consultant, and Brendan Scott Senjor Lecturer and Consultant, both of Dundee: Dental Hospital and School. Together, they have distiled the key principles and practices that students and new clinicians will need to design successful partial dentures. Also published by Oxford University Press: Essential Skils for Dentists ‘New-look cover from P ‘Mossey etal (eds), isan 9780198526103 Otel et anata) ’ Pickara’s Manual of Operative Dentistry 8€ Kidd, Smith & Watson, SBN 9780198509288 Cele m Cnt eLeLe PLC kid, 198N 9780198529781 Essentials of Dental Caries 3 ($8V978-0-19.8510925, 9 I I 0925