Module 7 2011 Tanima Mannan

SECTION A

Question 1.

Describe the anatomical features which need to be taken into consideration when deciding to
place implant fixtures. Explain how these features may influence your treatment decisions. [200
marks]

A full history and clinical assessment is vital before embarking upon any treatment. A full assessment
of the patient’s anatomy may distinguish conventional prosthodontic options from surgical
prosthodontic options. Anatomical features may describe the hard and soft tissues of the head and
neck region relevant to implant dentistry.

1. Extraoral anatomical features

-Temporomandibular joints are assessed carefully.

Ideally TMJs would be asymptomatic, with no pathology, note any crepitus, clicks or abnormalities.
Are there signs of internal derangement or relevance to medical bone and joint disease? Is the
patient a bruxist?

One must treat any underlying TMJ problems before performing any complex prosthodontic
treatment; this may include a referral to the oral maxillofacial department for further investigation,
or warrant the provision of a stabilisation splint to deprogramme the musculature. A CR record,
facebow, upper and lower impressions are taken for laboratory construction. If implants are placed
in cases where there is TMJD this may potentiate the issue further.

-Skeletal profile class I, II or III

Does the patient have any orthognathic discrepancies such as a rerognathic maxilla or mandible?
Check the nasio labial angle, relevant to elderly patient, does the patient show signs of facial
degeneration or muscle atrophy. This is relevant to space available for implant supported dentures,
function and aesthetics. In some cases orthognathic surgery s indicated to restore occlusion.

-Facial dimensions

Note the resting vertical dimension and occlusal vertical dimension, freeway space, is there enough
interocclusal space for implant fixed prosthesis or implant supported prosthesis? Look for facial
symmetry this is important for aesthetics. Are the lips competent to provide good oral seal and
adaptation to any prosthesis?

-Facial and oral musculature are assessed and palpated for abnormalities

Relevant muscles: obicularis oris, mentalis, buccinator. Are all muscles functionally properly? This
may not be the case for patients with Parkinson’s or having suffered a stroke or trauma. This is vital
for retention of removable implant supported and muscular adaptation to any prosthesis.

Check the muscles of mastication: temporalis, masseters, lateral and medial pterygoids. Are the
muscles symptomatic? When clenching does the patient exhibit signs of over activity or prominence,
do they experience facial pain in the morning? Patients who demonstrate signs of parafunction may
consider treatment to alleviate the underlying issue such as: acupuncture, botox to the masseters
and although controversial hypnosis.

2. Intraoral anatomical features

- Soft tissue examination (mucosa, tongue, FOM, fauces, palate)

Assess the buccal and labial mucosa for signs of keratosis or abnormalities, patient who exhibit linear
alba may have restricted space for larger units thus, the pontic size and occlusal table can be made
smaller to allow occlusal adaptation and facilitate cleaning.

-Gingivae and biotype

There should be healthy gingivae, pink and stippled. No bleeding upon probing. It is essential that
the patient is dentally motivated, can maintain good oral hygiene and attend the hygienist regularly
prior to any complex treatment.

A thin gingival biotype may be likely to receed upon tooth brushing abrasion, excessive occlusal
loading or where an implant fixture is placed and there is poor postoperative wound healing. This
affects the success rate of the implant and can dramatically affect aesthetics in the smile zone.

Where tissues have suffered periodontal disease in the past the host response is likely to be
demonstrate susceptibility to peri-mucositis or peri-implantitis especially where the patient is unable
to maintain meticulous oral hygiene.

-Bone density

The bone quality, whether trabecular or cortical? and dimensions are assessed using a preoperative
by radiography, or more advanced methods DEXA, CT or CBCT scan. It is important that the area is
free of pathology and, there is a solid area of bone available for surgery if not the implant is likely to
osseointegrate.

Up to 6mm of space may be required for one unit thus at least 1 mm of bone is required adjacent to
either side of the implant fixture, to allow primary stability and osseointegration.
There are various implant sizes and dimensions available for use however, it could be stated that the
greater the volume and quality of bone present the high the chances of primary stability providing
all other clinical and patient factors are suitable.

Misch bone density classification (Misch et al, 2008)

Bone density Description Tactile analogue Typical anatomic Hounsfield

location units
D1 Dense cortical Oak/maple Anterior mandible >1250

D2 Porous cortical and White Anterior and posterior 850-1250

coarse trabecular pine/spruce mandible,
anterior maxilla

D3 Porous cortical (thin) & Balsa wood Posterior mandible, 350-850

fine trabecular anterior and posterior
maxilla

D4 Fine trabecular Styrofoam Posterior maxilla 150-350

D1 Highly compact, strongest bone, but has the least amount of vascularity, require thread forming
implants, longest time for placement, high failure rates.

D2 Strong bone, good regeneration capacity, implant can achieve primary stability, excellent
vascularity.

D3-D4 More spongy, soft bone, good vascularity, but primary stability can be difficult to achieve.

The implant should provide functional service for 5 years in 85% of cases, up to 10 years in 80% of
cases. Bone loss over time may be considered: vertical bone loss of less than 0.2mm annually
following the implants first year of service (Albrektsson & Zarb et al, 1986).
Clinical trials show 90% success at 5 years whilst 85% at 10 years in the anterior zone. Whilst, 85%
success at 5 years and 80% at 10 years in the posterior zone. (ADA, 2004)

Bone quality index (Ribeiro-Rotta et al 2010)

Type I: homogenous cortical bone

Type II: thick cortical bone with marrow cavity

Type III: thin cortical bone with dense trabecular bone of good strength

Type IV: very thin cortical bone with low density trabecular bone of poor strength.

Of course type IV has the highest chance of implant failure.

A full diagnostic assessment of the space using articulated study models for occlusal assessment and
mock ups are essential. They are used to fabricate provisional to test the limits of the prosthesis in
the way of: cleansibility, aesthetics and function. A surgical stent may also be fabricated from the
working models.

Vital structures, blood supply, nerves:

When the implant is surgically placed, one must consider the position of vital structures to avoid
damage to them. For example, avoiding the mental nerve in the lower premolar region or the
incisive canal in the upper incisal region, there are risks or anaesthesia of paraesthesia if contacted
by the fixture. Upper laterals are placed slightly distally to midline without contacting the adjacent
canine. In the upper molar region great is taken to avoid unintended perforation of the sinus floor;
full implant training is mandatory before placing implants. However, sinus lifts require
comprehensive knowledge of all anatomy and higher levels of technical skill.

Overall, a full anatomical assessment of the patient requires an in depth understanding of the
patient’s extraoral and intraoral features relevant to prosthetic-surgical procedures to promote
success of any implant. Without careful consideration to every aspect of implant assessment and
treatment planning and without patient compliance implants may fail.
Question 2.

Critique the various types of pontic design used in fixed prosthodontics giving evidence from the
literature for your decisions. [200 marks]

There are various pontic designs in fixed prosthodontics to aid function, maintenance of oral hygiene
and achieve optimal aesthetics.

Careful patient assessment is essential when designing fixed prosthesis. Restorations should provide
protection, comfort, aesthetics, durability and cleansibility (Selby, 1936). The aid of provisional
restorations assists in testing the function, aesthetics, speech and plaque control. Below are the
various designs each of which has advantages and disadvantages:

A pontic is the suspended member of fixed partial denture; it replaces the lost natural tooth,
restores function and occupies the space of the missing tooth (Tylman)

Role of pontic: False tooth bridge a gap, ideally smooth, cleansable, functional, emergence profile,
aesthetic, speech, avoid over loading abutments.

Function: mastication, speech, aesthetics.

A successful pontic is:

Classification of types of pontics:

Rosenstiel

A- Mucosal contact

Ridge lap

Modified ridge lap

Ovate

Conical

B - No mucosal contact

Sanitary hygienic

Modified sanitary

Tylman

1. Conventional pontic on the ridge ovate (Conventional fixed) contact more labially than
ovate, easy to clean, need for surgical augmentation, id cleaning may impede upon labial
gingival margin. (Liu et al, 2004) Good for anterior maxillary teeth.

2. Modified ridge lap or modified sanitary pontic – reduced stresses at solder joints the
maximum deflection at the centre as compared to the sanitary pontic. Highly aesthetic,
anterior dentition, moderately cleansable.

The maximum shear stresses for the soldered joints between the pontic and the abutment
preparations under a 60 pound load in decreasing order were:

-the conventional pontic (2,400 p.s.i, mesially and 1,920 p.s.i, distally),
- the sanitary pontic (1,200 p.s.i, mesially and 960 p.s.i, distally),
- the modified sanitary pontic (720 p.s.i, mesially and 720 p.s.i, distally).

The modified sanitary pontic reduced the stresses at the solder joints. Furthermore, the
amount of gold alloy required by the modified sanitary pontic is significantly less than that
required by the conventional pontic. (Hood, 1975)
 Shillingburg et al classified pontics based upon: shape of the pontics contacting tissues, materials
and manufacturer’s design.

 According to the form sanitary or hygienic, anatomic type

 Based on materials used metal porcelain, metal and resin
 Prefabricated pontics: flat back, long pinfacing, trupontic, reverse pin facings, pontips

Residual ridge contour to be considered Sieberts classification (Abrams et al)

Main types of pontics:

1. Ridge lap - May present concave gingival surface, may not be accessible for cleaning. Tissue
inflammation is likely.
2. Saddle – Overlaps the ridge bucco-lingually, not recommended due to inefficiency for
cleaning but aesthetic

3. Modified ridge lap or sanitary pontics- Are good for anterior and posterior region, overlaps
the ridge buccally without being concave lingually. This allows good access for cleaning
lingually, improved aesthetics to ridge lap alone. Residual ridge contour – To determine the
frequency and nature of tissue reactions to underlying ridge mucosa, adaptation to pontic
design, compare frequency of tissue reactions to various materials used for construction.
(Stein, 1966). He postulated that pontics should be convex, smooth, minimal pin point at
gingivae, functional harmony, bucco-lingual no interferences, overall length of the buccal
surface should be equal to that of the adjacent abutments or pontics.

4. Spheroidal/ Conical – “bullet shaped” or “heart shaped”. Useful for molars where aesthetics
is not of concern, good access for cleaning but poor aesthetics. Dependent upon the width
of the residual ridge; a knife edge residual ridge will necessitate flatter contours with narrow
tissue contact areas. Not suitable for broader ridges as the mergence profile may create a
food trap.

5. Ovate- aesthetically pleasing, convex in shape, socket preservation, tissue surface resides in
a soft tissue depression or hollow in the residual ridge allowing the pontic to emerge from
the gingivae. Careful occlusal assessment is required to avoid gingival trauma.

6. Reverse pin facing – Rarely used but, can serve as modified denture teeth, porcelain teeth
can be trimmed as a bridge facing. The pins are ground off and porcelain is added to the
lingual aspect. It is adapted to the ridge and multiple precision pin holes are drilled into the
lingual surface with a tungsten carbide drill. Nylon bristles are placed in the holes and
incorporated into the backing wax pattern.
Passive contact should occur exclusively on keratinized attached tissue. When a pontic rests on
mucosa, some ulceration may appear as a result of the normal movement of the mucosa in contact
with the pontic.

Fixed bridge/ implant supported denture pontics metal ceramic pontics uniform veneer of porcelain
1.2mm, metal surface smooth and free of pits round angles, occlusal centric contacts 1.5mm away
from junction.

Glazed high fusing porcelain is generally considered biocompatible of the various materials with
excellent optical properties (Harmon, 1958) 11 and clinical studies support this 7 the most important
factor would be plaque retentive factors. Well-polished gold is smoother and less prone to corrosion
and plaque retention. Acrylic can irritate gingival tissues in some cases (Henry et al, 1966)

Inciso-gingival length, obtaining the correctly sized pontic simply by duplicating the original tooth is
not possible. Ridge resorption will make such a tooth look long in the cervical region. Where
possible, produce a pontic of good appearance by recontouring the gingival half of the labial surface
to create an illusion to the eye. In extreme cases apply gingival camouflage to the gingival aspect of
the pontic or ridge bone augmentation prior to fit. (Daniel et al, 2002)

Consider the mesiodistal width of the pontic in relation to adjacent teeth and symmetry; with
restricted space orthodontic realignment of teeth or minimal interdental reduction of enamel may
be required to gain space.

Reducing the bucco-lingual width of the pontic by a third has been suggested to reduce occlusal
forces from heavy loading, furthermore flatter occlusal surfaces in bruxists or during parafunction.
Follow anatomy of adjacent teeth, in line with the occlusal third.

Pontics may be available in a variety of materials: acrylic, composite, resin retained pontics, fibre
reinforced composite pontics, all ceramic pontics, all metal hygienic pontics and metal ceramic
pontic.

Advantages Disadvantages Indications Contraindications

Metal ceramic Aesthetic All units must be Suitable in most Long span high
biocompatible metal ceramic cases stress
All metal Strong, No aesthetic Molars, areas of Where aesthetics
conservative high stress is of concern
Fibre reinforced Conservative with Limited to shorter Where aesthetics Long spans not
all resin inlays, aesthetic spans is of concern possible

To conclude, the pontic design is critical to the success or failure of the fixed prosthesis. The design
must facilitate plaque control, minimising tissue contact and irritation (biocompatible) and restore
function and aesthetics. The conical pontics are used to prevent the extraction site from collapsing
and create an emergence profile from the socket however the adjacent teeth can become inflamed
as cleaning is challenging, despite good aesthetics. The hygienic pontic is great for maintaining a
healthy periodontium as the gap between the pontic and alveolar ridge allows for cleaning but not
large enough for food entrapment. The saddle shaped pontic achieves high aesthetic results if the
alveolar ridge area is free of defects; the emergence profile is similar to the natural tooth ensuring
no palatal gaps for phonetic problems. Food entrapment is not expected because the pontic
seamlessly adapts itself to the alveolar ridge however; the large concave shape is not hygienic for
plaque control. A ridge lap pontic is not suitable for cleaning either as it is concave in shape. The
modified ridge lap is the most popular type of pontic as it is convex at the base and rest of the small
area of the alveolar ridge fulfils the recommendation made in the dental literature with regard to
hygiene and prevention of gingival irritation. However, with a careful clinical assessment of the
specific case and knowledge of the advantages and disadvantages of each design, one can prescribe
the most suitable design for the individual case.

Review of literature:

Harmon C B, Pontic design, J Prosthet Dent 1958; 8: 496.

Stein R S, Pontic-residual ridge relationship: A research report. J Prosthet Dent 1966; 16: 251.

Henry P J et al, Tissue changes beneath fixed partial dentures. J Prosthet Dent 1966; 16: 937.

Cavozos E, Tissue response to fixed partial denture pontics. J Prosthet Dent 1968; 20: 143.

Perel M L, A modified sanitary pontic. J Prosthet Dent 1972; 28: 587. – A modified sanitary pontic
which has a free archway and is concave mesiodistally, proximally the solder joints of the pontic are
elongated, this increases the strength of the joints.

Donald A B, The design of multiple pontics. J Prosthet Dent 1981; 46: 634 – A V shaped notch
between multiple pontics in the inter-pontic embrasure serves no useful purpose, plaque retentive.
Consider an unbroken surface, smooth but still hygienic.

Antony H L. A sanitary “Arc- fixed partial denture”: Concept and technique of pontic design. J
Prosthetic Dent 1983; 50 338. – Proposed a pontic design for extreme ridge resorption, the
undersurface of the pontic is slightly convex bucco-lingually to aid complete disruption of dental
plaque.

Porter C B, Anterior pontic design; a long logical progression. J Prosthetic Dent 1984, 51; 774-776.
With exception to Stein’s pontic design has been replaced by saddle type pontic but limited to one
unit.

Parkinson C F, Pontics design of posterior fixed partial prosthesis; is it a microbial misadventure? J

Prosthet Dent 1984; 51;51-54. Designs without replacement of soft tissue can cause: whistling, food
entrapment, calculus build up and overall patient dissatisfaction.

Jacques L B et al, Tissue sculpturing: An alternative method for improving aesthetics of anterior fixed
prosthodontics. J Prosthetic Dent 1999; 81: 630. – Condition tissues beneath pontic by displacing by
restoration, gradual controlled pressure enhances the interdental papillae to improve aesthetics.
Daniel E H Spiekermann; A review of esthetic pontic design options. Quintessence Int 2002; 33@
736-746. – Gingival coloured ceramic pink gingival masks, pink veneering materials.

Kumbulolu O et al, A different Pontic Design for Fiber-reinforced Composite Bridgeworks: A clinical
report, Eur J Dent 2007; 1 (1); 50-53.

Kim T H Y et al Stimulated tissue using pontic design, J Prosth Dent 2009; 102; 205 -210.

SECTION B

3. “Precision attachments are an outmoded treatment choice”. Discuss the reasons for and
against this statement. [100 marks]

In the advent of more complex fixed prosthesis such as implant assisted dentures and implant
retained bridges one could argue that precision attachments are an outmoded treatment choice.
However, there still remains a place of precision attachments in removable prosthesis in Dentistry
today. Below are reasons for and against the above statement.

General patient evaluation and assessment is needed to consider the aesthetic demands, treatment
needs and motivation when treatment planning for the possible use of precision attachments.
Careful space assessment is needed in three dimensions to determine whether there is sufficient
space available for any attachment and therefore helps with attachment selection.

Precision attachments are features added to the abutment teeth and denture to enhance retention
and support and stability of the removable partial denture. They can be classified into either:

 Precision or, semi-precision.

 Rigid or resilient.

The path of insertion of any potential removable or fixed prosthesis must be planned with the
potential orientation of any precision attachment.

Design type of location (e.g. intracoronal or extracoronal) or shape (e.g. stud, bar magnetic retainers,
telescopic crowns or auxiliary type). Consider, specific design features such as temporary minor
retainers and means of attaching the precision attachment to the denture.

The principal indication for precision attachments in their use with partial dentures is aesthetics.
(Burn and Ward, 1990)
Reasons for Precision attachments:

 Improve aesthetics of an existing removable partial denture, elimination of the unaesthetic

clasp.
 Better force distribution to abutment teeth. The point of force application is more apical
than occlusal rests and so decreases torquing forces (Burns and Ward, 1990).
 Improved lateral support and reciprocation.
 Maintenance of natural tooth contours in abutment teeth.
 Reduction of food impaction, plaque and caries.
 Improved patient comfort and chewing efficiency.
 Better control of occlusal forces.
 Resistance to rotational displacing forces.
 Ease of future modification and repair. This depends very much upon attachment selection.
 Improve retention, stability and support of existing removable partial denture.
 Favourable abutments with healthy periodontal tissues and ideal for common parallel path
of insertion.
 The patient can easily remove for denture hygiene and ease of cleaning.
 Surgical implant dentistry is contraindicated for medical reasons.

A careful assessment of local factors:

 Abutment teeth

1. The prognosis of the abutment teeth.

2. The effect on the prognosis on the potential replacement.

 Span.
 Ridge factors of:

1. Contours.
2. Quality of bone.
3. Support provided by the mucosa.

 Occlusal factors.
 Aesthetics.

Attachment selection depends upon the amount of space available, alignment of abutments, the
intended use, design, rigid or resilient nature of the attachment, whether they are precision or semi-
precision or the means in which retention is achieved.

When using precision attachments specific thought may be given to tooth preparation, the means of
incorporating attachments to fixed retainers, types of pick-up impressions, means of connecting
attachments to denture frameworks, and how to process partial dentures.

Precision attachments involve high maintenance requirements which your patient should be aware
of and accept prior to embarking on a treatment plan utilising precision attachments.
Reasons against precision attachments:

 Increased numbers of clinical stages.

 Increased cost vs conventional denture
 Increased difficulty in both clinical and laboratory procedures.
 Abutment tooth considerations such as crown length, size and pulp position. Prognosis of
abutment teeth.
 Lack of rotational control.
 Repair or alterations can be difficult or impossible with some attachments
 Other options available SDA > 10 pairs functional teeth (World Health Organisation)
 Implant assisted dentures, implant retained dentures without need for preparation to
abutment teeth.

Ultimately, individual patient assessment will reveal their specific treatment needs and realistic
treatment options available within the patient’s expectations. The patient will need to be dentally
motivated when maintaining meticulous oral hygiene and attendance of recall examination and
maintenance.

4. How is retention achieved in removable prosthodontics? [100 marks]

Retention can be described as features of prosthesis preventing displacement of it against its path of
insertion/long axis of teeth.

Removable Prosthodontics (tooth and tissue supported) include: Acrylic/Chrome/Implant assisted

dentures. For optimum retention we consider the extraoral and intraoral features:

Extroral:

1. lip/cheek support; the nasio labial angle approximately at 90 degrees

2. Oral and facial musculature, muscle and tone. Muscles favour oblique surfaces of dentures
for support and adequate retention. The lower lip line should rest approximately below 1/3
of incisal edge of the lower anterior teeth. With age the tone of muscles decreases through
atrophy and likely to be less control of dentures. For complete dentures the neutral zone
may be identified through piezography.
3. TMJs check for facial symmetry, clicks, crepitus and symptoms.
4. OVD = RVD- Freeway space

Intraoral: soft and hard tissues, full denture bearing area, posterior border seal post dam, alveolar
ridge shape and form, no proprioception as artificial teeth do not have PDL.
1. Maximise dental bearing area - large baseplate increases surface area. Residual alveolar ridge
resorption occurs overtime which reduces the surface area available for denture coverage.
(Tallgren, 1972) Dentures are likely to require reline/ rebase or new dentures subject to
assessment of support, retention, stability.
2. Use favourable undercuts used for “wedging retention”
3. Interdental wedges of acrylic retentive but unhygienic and “gum stripping”
4. Control of dentures by muscles- tongue, mentalis, mylohyoid, buccinator etc
5. Post dam upper denture, salivary flow suction effect
6. Surveyed to identify guide planes and path insertion –retention by only one path of insertion
similar to fixed prosthesis limit free of displacement
7. Clasps- terminal 1/3 of clasp engaged undercut. gingivally approaching, occlusally approaching,
ring clasps
8. Framework tripod clasp design rests on mesial and distal surfaces of abutment teeth, bracing
and reciprocation. Indirect retention by rest at the fulcrum of the denture to prevent rotation of
free end saddle.
9. Auxiliary features – precision attachments/ fixed movable prosthesis/swinglock dentures.
10. Implant supported- but still a removable prosthesis.

Partial denture Overdenture

Intracoronal √ X
Extracoronal √ X
Stud type √ √
Bar type √ √
Magnet X √
Telescopic crowns √ √

Stud type - They are one of the simplest types of attachments and are unlikely to be rigid due to
their size. A reasonably close degree of alignment is required for stud attachments, with increasing
divergence (up to 10° can be tolerated) being associated with greater wear and maintenance
required for the attachments (Preiskel, 1996)

Advantages:

 Provide additional stability for the denture.

 Provide support for the denture.
 Provide retention that helps to maintain border seal of the denture.
 Should be easy to keep clean. Caries rates with overdentures made with copings, however,
have been reported to be between 6% (for a well maintained population) and 15% (without
maintenance) (Mericske-Stern, 1994). This indicates the need for maintenance appointments
even for relatively easy to access surfaces.
Disadvantages:

 Need acrylic to hold the attachment into the denture and therefore this may represent a
potential for gingival irritation.
 Extracoronal type requires sufficient space for the female part of the attachment within the
denture in both vertical and bucco-lingual directions.

Bar attachments- They span an edentulous ridge area between roots or implants, e.g. Dolder bar
[Cendres et Metaux]. An overdenture may then fit over the bar and be connected by retention
sleeves or clips. Bar attachments may be attached between abutment teeth crowns that can be used
as part of the retention system for partial dentures.

Advantages: (Preiskel, 1996)

 Robust design.
 Effective retention.
 They may overcome the divergence between roots or implants by means of screw
attachments; this overcomes problems of common paths of insertion (Evans et al, 1992).
 Less leverage and more apical resolution of forces when used with roots (Thayer et al, 1980).
 Significant stability.
 Splinting action between roots.

Disadvantages:

 Bulk of bar and related structure - space requirements bucco-lingual and vertical.
 Plaque accumulation - more difficult and requires patient skill. They appear to be associated
with more gingival hyperplasia than ball attachments (Naert et al, 1999).
 Adequate and equal retention for abutment retainers needed.
 High degree of technical skill.
 High degree of clinical expertise.
 Rebasing and repairs can be complicated

The use of a spacer above the bar during processing allows some resilience in multiple bar systems.
These bars should not be bent otherwise rotation is not possible around the bar and undue leverage
forces may be applied to the abutments (Preiskel, 1996). Multiple bar systems have retaining sleeves
or clips that are quite short allowing the curvature of the arch to be followed and so consequently
can have a potential for developing high leverage forces on the bar and allow location at sites of
greatest available space. Sufficient rigidity is needed in the bar to prevent stress being transmitted to
the abutments (root or implant).
Magnets-
Magnets
Using rare earth alloys can be produced that are not much larger than studs. Magnetic keepers may
be attached to either root copings or implants and embedded in the fit surface of the overdenture.
The magnets are conversely located in the copings or implants or embedded in the fit surface of the
denture.

Advantages:

 They have no effect on the path of insertion of the denture.

 They do not require parallel abutments.
 They are self-seating, which is an advantage for the elderly or physically handicapped.
 Retentive force is constant or can increase with time (Saygili and Sahmali, 1998).

Disadvantages:

 Magnets undergo corrosion when exposed to intra-oral fluids leading to loss of retention or
loss of magnet.
 Only offer retention and not stability.
 Retentive forces are often a lot less than mechanically retentive attachments

Telescopic crowns

The use of telescopic crowns allows (Preiskel, 1996):

 Optimum use of scattered and irregularly distributed abutment teeth.

 Degree of retention and support determined by the operator.
The principle, utilising as it does a thimble coping covered by a surrounding coping or double
crown, is technique sensitive (Langer, 1980). Considerable space is required for the use of
telescopic crowns. The space requirement can mean that devitalisation of teeth is indicated
prior to tooth preparation. It has been suggested that it is a requirement for the use of
telescopic crowns on anterior teeth, premolars and occasionally molar teeth (Preiskel, 1996).

 Telescopic crowns have been suggested as an alternative to the use of bar attachments for
overdentures retained by implants (Besimo and Graber, 1994). The telescopic crowns
allowed the implants to be splinted together by the overdenture framework rather than
directly by the use of bars. In vitro studies have shown better force distribution using this
technique (Besimo and Graber, 1994). The telescopic abutments need a height of 5 -7mm
with a taper of between 4-6°.

 The use of telescopic crowns may be relatively contraindicated or at least lead to

complications where one or more of the abutment teeth are inclined (Preiskel, 1996).
Telescopic retainers achieve their retention through creation of a tapered coping. Retention can be
ideally achieved through 5 degree taper with 4mm height. If too small a taper is used then this may
be technically difficult to achieve and also problematic for the patient to insert the denture in the
correct path of insertion. The coping should also possess a chamfer at the bottom of the taper to
prevent jamming on to the coping.

Occlusal reduction should be between 2-3mm minimum occlusal reduction in order to incorporate a
minimum of 0.5mm thickness of coping and 1.5 - 2.5mm for the overlying metal and acrylic or
ceramic of the overlying partial denture. If only metal is planned on the occlusal surface then
reduction can be kept to 1.5mm minimum (Brudvik, 1999). Axial reduction requires similar figures.

Insufficient reduction can lead to problems of either bulky prosthesis or casting failures.

Auxiliary

The attachments contain a number of differing mechanical means which can be used to
provide retention (Brudvik, 1999b):

 Screws - These are used within implant systems but may also be used within bridge work.
Threads that are cast-to or tapped into the restoration (usually on a non-vital tooth) or
within a pontic. Example, Locking Screw 1.4mm [Sterngold].
 Spring-loaded plugs - Incorporation of a ball-ended plunger pushed against a divet placed
within the axial wall of a milled crown placed on abutment teeth. Example, IC attachment
[Sterngold] (Reagan and Rold, 1996).
 Bolts - Two-part dentures can be linked together using bolts.
 Hinges - These allow sectional dentures to utilise areas of undercuts for retention by hinging
sections of a denture into these areas, e.g. Swinglock dentures

Overall, achieving retention in removable prosthodontics is challenging but, through tissue and tooth
supported features one can maximised anatomical features available to resist forces against the
path of insertion. Clasps or for aesthetics, precision attachments, auxiliary features can be
incorporated into the denture and abutment teeth to enhance the: retention, support and stability.
The best available option is the implant assisted or supported denture as most retentive, aesthetics
and ease of cleaning in a removable prosthesis.
5. How is infection control achieved in a prosthodontics practice? [100 marks]

Clinical

 Up to date immunisation of all staff members Hep B boosters titre levels >10 mIU/ml
ideally >100mIU/ml good immune response.
 Patient and staff PPE: eye protection, masks, visor, gloves.
 Wash hands between patients where visible remnants on hands, alcohol rub
between every patient.

 Sticky single use tubing on suction tubes and light handles for every patient.
 Use autoclaved sterilised instruments open pouch when patient arrives into clinic.
Open sterilised instruments can be stored unpouched for 1 week and pouched
instruments for up to a year in storage. Autoclave at 121◦C for 15-20 minutes or
134◦C for 3-4 minutes. Having Class 6 TST strips as evidence of cycle performance
should be evidence enough to prove that the cycles have been performed
successfully.

 Clean and dirty zones in the clinical area: clean when handed by nurse dirty
instruments left on side on dentist on tray.
 Single use equipment which cannot be effectively sterilised: stock impression trays,
matrix bands, rosehead burs, endodontic files, scalpels.
 Impression materials mixed in clean zone using clean gloves using predisinfected
missing bowls and spatulas. Plastic or glass slabs may be wiped with disinfectant
wipes between patients. Again where possible single use items such as mixing pads
and micro brushes, and PVS impression tips.
 Safe disposal of sharps by dentist: LA syringes, needles, matrix bands.

 Cold disinfection using Perform solution of impressions, shade guides, 10 minutes

minimum according to manufacturer’s guide before sending to the laboratory. 1 g
perform® ID contains 0.2 g potassium peroxomono sulphate, 0.15 g sodium
benzoate, 0.1 g tartanic acid. Other ingredients (according to EU recommendation):
5-15% anionic surfactants, 5-15% non-ionic surfactants, less than 5% soap and
phosphanate, fragrance. COSHH regulations 2002 states the responsibility for
ensuring impressions and appliances have been cleaned and disinfected prior to
dispatch to the laboratory lies solely with the dentist.
 After patient has left removal of all dirty items for correct clinical waste disposal
dirty instruments into dirty box contained, change of gloves and wipe surfaces with
disinfectants and bleaches where possible.
 Separate decontamination room compliant with HTM01-05 for best practice
sterilisation procedures of instruments.
 Patient

The patient is asked to use alcohol hand rub before entering the practice and after leaving
the clinic stetting to disinfect hands in an attempt to prevent cross contamination from the
clinic to the reception area.

Laboratory
 Disinfected prior to arrival
 Labelled lab work no cross over
 After laboratory work complete bagged and sealed to be disinfected by clinic again
prior to try in or fit.

To conclude, nothing is sterile in Dentistry once in contact with the air and oral cavity instruments
will be exposed to all kinds of bacteria however, infection control measures are employed to protect
staff, patients and the wider public alike from the spread of infectious diseases. Universal
precautions are paramount in busy general practice.