4th Grade Prosthodontics Dr.

Hasanain Kahtan

PLACEMENT, ADJUSTMET, AND SERVICING OF

THE REMOVABLE PARTIAL DENTURE

At the initial placement stage of the definitive Co/Cr fabricated removable partial
denture (RPD), a procedure of certain preclinical and clinical steps should be
followed to produce a biologically acceptable prostheis. This procedure includes
several steps that are performed in a specific sequence:
 First: Final inspection of the prosthesis before insertion
 Second: Verifying the framework fit.
 Third: Assessment of acrylic resin denture base adaptation.
 Fourth: Assessment of peripheral extension of the denture base.
 Fifth: Evaluating occlusion.
 Sixth: Adjusting retentive clasp assembly, if needed.
 Seventh: Providing instructions for the patient how to use and care the
prosthesis.
First: Final inspection of the prosthesis
Prior to the insertion appointment, the dentist should check and adjust the
following:
l. Nodules or spicules of acrylic resin on the tissue surface of the prosthesis: The
simplest way to locate these nodules is to run a finger over the intaglio surface
(tissue side) of the prosthesis. Once identified and marked, the nodules can then
be removed with a small, acrylic bur mounted in a slow - speed hand piece. When
the nodules have been removed, do not polish the intaglio (tissue) surface; leave
the surface finish as processed against the master cast.
2. Surface and internal porosity in the acrylic resin reduces both the quality and
ultimate strength of the completed RPD. A porous surface will be difficult to keep
free of denture plaque. A rebase of the RPD is recommended.
3. Examine denture teeth for any fractures that may have occurred during the
processing or finishing procedures. Replace fractured teeth before the RPD is
inserted.
4. Evaluate the denture tooth - acrylic resin junction. If the junction of the denture
tooth and acrylic resin denture base is improperly contoured and finished after
processing, any crevices left in this area will become a potential site of food
entrapment or staining.
5. Examine the acrylic resin/metal framework junction. The junction should be a
butt (90о) joint with no overlap of the acrylic resin onto the metal framework. All
acrylic resin flash should be removed so there is a smooth, continuous exactly
duplicate the borders recorded in the transition between the two materials.
6. Finally, inspect the finish and polish of the RPD. A poorly finished and -
polished prosthesis may unfavourably affect the patient's attitude towards the
dentist and diminish patient - dentist rapport. The polished surface contours
should have a smooth, high lustre appearance without surface defects (a brand-
new appearance).
Store the RPD until the insertion appointment in a plastic bag partly filled with
sterile water or diluted denture-soaking solution. This will keep the prosthesis
moist to prevent dehydration and possible distortion of the acrylic resin base until
the prosthesis is inserted.

Second: Verifying the framework fit

It is highly recommended to check the fit of the cast metal framework intraorally
before try-in and insertion appointments. Nevertheless, the completed RPD
should be carefully inserted into position on the abutment teeth. If there is
considerable resistance to seating, stop and check for the following problems:
I. Clasp assemblies or other components of the framework may have been bent
or distorted.
2. Acrylic resin may have been cured into undercuts adjacent to the abutment
teeth, preventing the uniform seating of the prosthesis.
3. A layer of acrylic resin flash may be covering part of the metal casting.
Remove the acrylic resin before attempting to seat the RPD. A sharp dental
explorer or dental floss can be used to check for the complete seating of the
occlusal rests. There should be an intimate fit between the teeth and retentive
clasp assembly.
If the occlusal rests on the prosthesis do not seat completely in their respective
rest seat preparations, a minor discrepancy in the cast metal framework can be
identified and corrected.
Third: Evaluation of denture base adaptation
When the cast metal framework has been fully seated, check the fit of the acrylic
resin portions of the prosthesis. An accurately fitting acrylic resin denture base is
a primary consideration in the comfort and acceptance of an RPD. Excessive
pressure may lead to discomfort, pain, and soft - tissue damage. A common
contributor to excessive pressure is the dimensional changes that occur in the
acrylic resin denture base during processing. Apply pressure indicator paste (PIP)
evenly on the intaglio (tissue) surface of the prosthesis with a stiff, short, coarse
- haired brush. A coarse brush will leave thin brush marks on the acrylic resin
surface that displace under pressure. Apply an even, thin layer of PIP to register
pressure areas. Currently, there are a variety of pastes that may be used in denture
base evaluation. These materials, known as pressure indicator pastes, consist
principally of zinc oxide powder combined with a medium consistency vegetable
fat. Other ingredients are added to improve the flavour and consistency of the
paste. The brush can be used to place a distinct stroke pattern in the paste. The
removable partial denture is then inserted, firmly seated, removed, and carefully
inspected. Where no contact between the denture base and the soft tissues has
occurred, the brush strokes will remain in place where moderate contact has
occurred, the brush stroke pattern will be indistinct or obliterated where heavy
contact has occurred, the pink denture base material will clearly show through the
white paste. Areas of heavy contact should be relieved using appropriate rotary
instruments.

Pressure areas most commonly encountered are as follows:

In the mandibular arch—(l) the lingual slope of the mandibular ridge in the
premolar area. (2) the mylohyoid ridge, (3) the border extension into the
retromylohyoid space, and (4) the distobuccal border near the ascending ramus
and the external oblique ridge.
While in the maxillary arch—(l) the inside of the buccal flange of the denture
over the tuberosities. (2) the border of the denture lying at the malar prominence.
and (3) the point at the pterygomaxillary notch where the denture may impinge
on the pterygomandibular raphe or the hamulus. In addition. bony spicules or
irregularities in the denture base that will require specific relief may be found in
either arch.
Fourth: Assessment of denture base peripheral extensions
The peripheral borders of the denture base have a direct effect on retention,
stability, and patient comfort. Overextension of the prosthesis denture borders
may cause the following:
The muscles and frenums will tend to dislodge the RPD during function. The
resultant dislodging force may be transferred to the abutment teeth by the
retentive clasp assemblies. These forces may be especially destructive when the
denture base borders of a bilateral distal - extension RPD are overextended. The
longer the distal-extension base, the longer the lever arm, and the greater the
potential for transmitting destructive forces to the supporting structures of the
abutment teeth.
Denture base overextension may cause ulceration, pain, and swelling of the
vestibular tissues. If this is not corrected, over an extended period of time a
redundant tissue (denture hyperplasia) or called (epulis fissuratum) may form in
the vestibule as a response to chronic irritation.
Impingement on the muscles of mastication may interfere with muscle function
during mastication and speech.
Denture border extensions of modification spaces may interfere with the
complete seating of the RPD.
Under extended denture borders may cause the following:
 Inadequate distribution of masticatory force. The lower denture base
should cover the retromolar pads and buccal shelf area to the external
oblique ridges to obtain maximal support for the RPD.
 Food may collect under the tissue surface of a RPD leading to annoyance
and/or irritation.
 The prosthesis may lack stability where under extended denture borders
will not satisfactorily resist lateral or horizontal stresses.

Evaluating the denture base extension

Extension of acrylic resin denture flanges plays an important role in the support
and stability of a removable partial denture. Maximum flange extension, within
physiologically tolerable limits, provides optimal support and stability for the
prosthesis. Extension of denture flanges into the facial vestibules and lingual sulci
enhances resistance to horizontal displacement. Therefore, acrylic resin denture
base flanges should not be arbitrarily reduced. Rather, they should be critically
evaluated and adjusted only when physiologic limits have been exceeded.
Visual and digital evaluation of the resin flanges should be performed during the
insertion appointment for purposes of examination, the buccal tissues should be
held between the thumb and index finger and moved apically, laterally, and then
occlusally. Soft tissue movement adjacent to each denture flange should be noted.
Restriction of soft tissue movement can lead to irritation. Over extension of the
borders also may result in the application of dislodging forces by the movable
soft tissues. Therefore, while maximum tissue coverage is essential to support
and stability, it is equally important to avoid overextension of denture borders.
Mandibular lingual and distolingual flange lengths may be evaluated using
physiologic movements of the tongue and floor of the mouth. Clinical evaluation
is accomplished by placing an index finger on the occlusal surfaces of the denture
teeth on one side of the patient's mouth. The patient is then instructed to extend
the tongue straight forward and then into the cheek on the opposite side of the
mouth. If lingual or distolingual flanges are overextended, the denture base will
lift away from the supporting tissues. This displacement is readily identified by
pressure against the operator's index finger, allowing necessary flange
adjustments to be made.
Where it is difficult to observe border extensions, disclosing wax can be placed
on denture base flanges to help identify areas of overextension .Unfortunately,
the flow characteristics of disclosing wax are not well suited to this application.
Mixing petroleum jelly with the disclosing wax improves the flow characteristics
of the disclosing material. This mixture is more reliable when used routinely to
disclose regions of flange overextension. Any areas of overextension will be
visible where the wax has been flattened or displaced by muscle action. The use
of disclosing wax is especially effective on the distobuccal border of a mandibular
RPD, which is controlled by the masseter muscle.
The most common areas of overextension of a maxillary RPD are the tissue side
of the distobuccal flange and continuing through the pterygomaxillary notch area.

Contouring the anterior denture base flange

When designing a denture base for the anterior portion of the mouth,
consideration must be given to the esthetic requirements of the patient. Slight
overextension or over-contouring of the labial flange may cause a successful
prosthesis to be esthetically failed. The first step in anterior denture base
adjustment is the application of pressure indicator paste to the intaglio surface of
the resin. The removable partial denture is then positioned in the mouth and seated
with gentle pressure. As resistance to the seating of the labial denture base flange
is encountered, the partial denture is removed. Careful evaluation of the pressure
indicator paste often will reveal excessive tissue contact along the border of the
denture base.
Correction of this interference involves vertical reduction of the flange length to
the point of contact with the edentulous ridge. Following adjustment, the pressure
indicator paste and grinding residue are wiped from all denture surfaces and fresh
paste is applied. This procedure is repeated until the removable partial denture
can be completely seated without encountering resistance, producing blanching
of the soft tissues, or causing patient discomfort.
Fifth: Occlusal adjustment
Teeth arrangement of the prosthesis should be accomplished to provide bilateral
simultaneous contact at the maximal intercuspal position (MIP). At the try-in
visit, the maxillomandibular relationships and the esthetic, phonetic and
arrangement of the denture teeth are verified. Therefore, the occlusal adjustment
of the RPD following processing of the denture bases should involve only minor
processing changes. Processing changes can be corrected with a laboratory
remount of the prosthesis before removal of the master cast. Minor interceptive
occlusal contacts can be corrected by selective grinding adjustments, which are
made after the contacts are marked with articulating paper. If gross premature
occlusal contacts are noted, a new interocclusal (centric relation) record should
be made. Remount the RPD on a dental articulator and make the necessary
occlusal corrections by selective grinding at an acceptable vertical dimension of
occlusion. This is accomplished outside of the mouth and away from the patient.
The same method is used for opposing prostheses. The clinical remount is the
most efficient method of adjusting occlusion because it allows direct observation
during adjustment.
The master cast is usually destroyed when the RPD is finished and polished.
To obtain an accurate remount cast to correct occlusal disharmonies, make an
intraoral irreversible hydrocolloid (alginate) impression of the prosthesis
correctly positioned 'on the supporting tissues; that is, a pickup impression.
To remount removable partial dentures in an articulator, it is necessary to secure
casts of both the dental arch restored by the removable partial denture and the
opposing arch. An irreversible hydrocolloid impression is made with the
removable partial denture completely seated in the patient's mouth. In most
instances, the prosthesis will remain in the impression when the impression is
removed from the mouth. If the prosthesis remains in the mouth, it must be
retrieved and carefully repositioned in the impression. Undercuts within the
removable partial denture are then blocked out using baseplate wax, clay, wet
paper towels, or wet facial tissues.

Dental stone is mixed and vibrated into the impression. When the dental stone
has hardened, the cast is recovered and trimmed in preparation for mounting
procedures. A cast of the opposing dentition must also be fabricated, at this stage
of the procedure; the maxillary cast is mounted on the articulator using a face
bow record. The mandibular cast is mounted using jaw relation record.
After the occlusion of the RPD has been refined on the articulator, appropriate
occlusal anatomy is restored using fine burs and a low speed hand piece.
Criteria to be followed before adjusting occlusion:
 It is better to consider one arch as an intact arch so that the other one can
be adjusted according to the intact arch.
 If one partial denture is tooth supported and the other tissue supported, the
tooth-supported arch is first adjusted and is considered as the intact arch
for adjustment of the tissue supported denture.
 If both partial dentures are entirely tooth borne, the one occluding with the
most natural teeth is adjusted first, and considered as the intact arch.
 If both dentures are tissue supported, the final adjustment of occlusion on
opposing tissue supported base is usually done on the mandibular denture,
since this is the moving member. Hence, even if the mandibular denture
has more natural teeth and is considered as the intact arch, the final occlusal
adjustments are made only on it.

Sixth: Adjusting retentive clasps

In the practice of removable partial prosthodontics, two pliers are generally
sufficient. These are the No. 139 or "bird-beak" plier, and the No. 200 or "three-
prong" plier. Proper technique for adjusting a clasp involves holding the clasp
stationary between the beaks of a No. 139 plier and applying a bending force with
the fingers of the opposite hand. This results in a gentle curvature of the clasp
arm and minimizes the likelihood of clasp fracture. Clasp adjustment may also be
performed using a No. 200 Plier. This is accomplished by engaging the clasp arm
with the beaks of the plier and gently squeezing the handles until the desired bend
has been achieved.
Seventh: Patient Instructions
Oral hygiene:
Providing the patient with appropriate oral hygiene instructions is extremely
important. The patient must understand that meticulous home care is a
prerequisite to removable partial denture success. Inadequate home care will
hasten the destruction of the remaining teeth.
*Though provided earlier in the patient education stage, instructions regarding
the care and maintenance of the remaining natural teeth and oral soft tissues must
now be reviewed. Proper brushing techniques and the use of dental floss as a
routine part of the patient's home care should be emphasized.
*The patient must accept the need for periodic dental evaluation of oral tissues
and dental prostheses. The interval between successive examinations will vary
depending on the oral conditions and type of prosthesis, but should not exceed 1
year.
*Use of plaque-disclosing tablets is an excellent way to shed the light on the need
for thorough attention to oral hygiene. Areas that are susceptible to plaque
accumulation are readily visualized. The patient should be instructed to chew the
disclosing tablets with the partial denture in the mouth. The denture can then be
removed and examined for areas of plaque accumulation, although accumulation
on the removable partial denture will not be evident at the insertion appointment,
the disclosing tablet technique should be demonstrated so the patient can
periodically check the effectiveness of home care efforts.
*Appropriate methods for denture hygiene should be demonstrated. Emphasis
should be given to physically brushing the denture on a daily basis, rather than
relying on a cleaning or soaking agent to remove debris. The use of common
toothpastes should be avoided since these pastes often contain abrasive particles.
*Scouring powders and abrasive household cleaners should also be avoided
because of their potential for damaging both acrylic resin and metal components
of a removable partial denture.
*The patient must understand that the denture should never be brushed while in
the mouth. Instead, the prosthesis should be removed to permit access to all
surfaces.
*The patient should also be instructed to clean the denture over a partially filled
basin of water so as to prevent denture fracture if the denture is dropped.
*The patient should be cautioned against using any cleansing solution containing
chlorine. If a chromium-based metal framework is soaked in this solution, the
chlorine will irreparably damage the metal.
*The patient should also be instructed to remove the prosthesis (or prostheses)
before going to bed at night. The soft tissues covered by the denture bases and
the major connectors must be given the opportunity to recover from constant
mechanical stresses applied when the prosthesis is in place. While in place, the
removable partial denture prohibits the beneficial bathing effects of saliva, which
flush food and bacterial debris from the hard and soft supporting tissues. The risk
of enamel decalcification and soft tissue inflammation is greatly increased when
the prosthesis is worn for long periods. If a patient has only a few remaining
natural teeth and has a history of bruxism, less damage may be done to the
remaining natural teeth if the denture is worn at night. If night-time denture wear
is necessary, the patient must identify several hours each day when the prosthesis
can be removed from the mouth.
*The patient should also be told to store the prosthesis in water when it is not in
the oral cavity. Failure to do so may result in drying, cracking, and warpage of
acrylic resin components. This is extremely damaging to the prosthesis and may
necessitate repair or refabrication.
Prosthesis placement and removal:
-Teaching the patient how to insert and remove a dental prosthesis is essential.
The patient's ability to adequately manage this task depends to some extent on his
or her manual dexterity, muscular coordination, visual acuity, and physical
condition.
-Additionally, design of the removable partial denture, the number and position
of direct retainers, and the total amount of retentive force affect the ease with
which the prosthesis can be removed from the mouth.
-Insertion of a removable partial denture is generally less of a problem than is
denture removal. The patient should be positioned in front of a wall-mounted
mirror while the dentist inserts the prosthesis. It is important that the patient
understand the need to properly align the removable partial denture over the
abutments before applying seating pressure. The patient should be cautioned
about trapping soft tissues of the cheeks, lips, or tongue between a clasp and its
abutment. The amount of force needed to seat the prosthesis should be
demonstrated, and the patient warned that if excessive pressure is required,
alignment of the denture is probably incorrect. Seating the denture with biting
pressure should be discouraged because damage to the denture, natural teeth, or
soft tissues can easily result.
-After the patient has observed insertion of the removable partial denture, its
removal also should be demonstrated. The most convenient method for engaging
the prosthesis is to position a fingernail or thumbnail apical to a facial clasp arm
on each side of the dental arch and to move the clasp occlusally. This method is
acceptable when cast circumferential clasps are readily available. However, if
only wrought-wire clasps are available, this technique should be avoided.
Wrought-wire clasps are easily distorted when using this technique. When
wrought-wire clasps are present, the patient should grasp the acrylic resin denture
bases on each side of the arch and carefully remove the removable partial denture
from the mouth.
-For a prosthesis that incorporates one or more infra-bulge clasps, positioning a
fingernail apical to the approach arm and forcing the clasp occlusally is not an
acceptable method of removal. This technique may lead to laceration of the
adjacent soft tissues by the patient's fingernail. Additionally, this approach tends
to force the retentive terminus of the clasp toward the abutment, making removal
of the prosthesis even more difficult.
-The best method of removing a denture of this design is to engage the non-
retentive portion of the T-clasp and apply occlusal pressure. The denture will
disengage easily. Before leaving the office, the patient should be asked to
demonstrate the proper methods of removable partial denture insertion and
removal for the dentist.