Improve Your Partials: Simple Materials, Techniques...

Improve Your Partials:

Simple Materials, Techniques and Designs

M. Nader Sharifi, D.D.S., M.S.

Maryland Academy of General Dentistry

Baltimore, MD

Friday December 5, 2014

2012 M. Nader Sharifi, D.D.S., M.S. Page 1

About Your Speaker:

M. Nader Sharifi, D.D.S., M.S. holds a certificate in prosthodontics and a

masters degree in biomaterials from Northwestern University. He received

his dental education at the University of Illinois. He has presented

numerous topics on implant dentistry since his graduation. His

presentations on restorative dentistry and patient care have earned him

recognition from esteemed study groups, societies and associations

nationwide. Dr. Sharifi is a former assistant professor at Northwestern

University and former on-call consultant for Nobel Biocare.

Dr. Sharifi currently maintains a full-time private practice of adult general

dentistry in Chicago’s downtown loop. As a five day a week wet gloved

dentist, he is interested in ensuring time saving and cost effective care. In

1996 he was named to the American Dental Associations Speakers Bureau

and in 2007 Chicago Dental Society honored him with the Gordon

Christenson Distinguished Lecturer Award. He has also been honored with

Fellowship in the American College of Dentists and Membership in the

American Academy of Restorative Dentistry.

If you would like, you may find additional information regarding other

courses and additional handouts on his website at www.DrSharifi.com. If

you have interest in the live denture course where CORE provides the

patient send an inquiry email to [email protected].

Please feel free to direct any other questions or comments you may have to

Dr. Sharifi’s personal Email address at [email protected].

About this handout: This handout isn’t meant to follow along slide for

slide to the program today. It does somewhat, but this is more meant to be

a resource in the future as you encounter these cases. This handout is

written in such a manner that it can be used as a step-by-step guide when

treating removable cases in your office.

http://www.drsharifi.com/

mailto:[email protected]

mailto:[email protected]


Removable Prosthodontic Classification M. Nader Sharifi, D.D.S., M.S.

I. Partially Edentulous: McGarry, et al.: J Prosthodontics 2002; 11:181-193.

A. Class I

1. Edentulous area in a single arch only.

2. Edentulism limited to 2 teeth in the maxillary anterior –

or – 4 in the mandibular anterior – or 2 in the posterior

(molars excluded).

3. Abutments are ideal and require no restoration.

4. Angle Class I jaw classification.

5. High, well rounded residual ridge.

B. Class II

1. Edentulous areas can exist in both arches.

2. Edentulism limited to 2 teeth in the maxillary anterior –

or – 4 in the mandibular anterior – or 2 in the posterior

(molars excluded).

3. Abutments or occlusion requires mild intervention.

4. Angle Class I jaw classification.

5. High or low, well rounded residual ridge.

6. Mild systemic or psychological modifiers.

C. Class III


2. Edentulism of more than 3 teeth in any area or 2 molars.

3. Abutments or occlusion requires moderate therapy.

4. Angle Class I, II or III jaw classification.

5. Occlusion is compromised with supra-eruption.

6. Moderate systemic or psychological modifiers.

D. Class IV


2. Edentulism of more than 3 teeth in any area or 2 molars.

3. Abutments require multi-disciplinary treatment.

4. Angle Class I, II or III jaw classification.

5. Occlusion requires a change in vertical dimension.

6. Severe systemic or psychological modifiers.

7. Hyperactive gag reflex.

8. Maxillary-mandibular incoordination (Parkinson’s)

9. Refractory patient (unrealistic expectations).


M. Nader Sharifi, DDS, MS • 30 North Michigan • Suite 1303 • Chicago, IL 60602 • 312-236-1576

Patient Name Social Security Number Date

Prosthetic Findings

Maxillary Arch: U Shaped V Shaped O Shaped Square Shaped

Ridges: High Low Post-extraction Knife-edged Basal bone

Hard Palate: Deep Shallow Medium Soft Palate Class

Tuberosities (R) (L) Torus Attached Mucosa %

Frenum: Anterior (R) (L) Teeth

Mandibular Arch: U Shaped V Shaped O Shaped Square Shaped

Ridges: High Low Post-extraction Knife-edged Basal bone

Lateral Throat Form Class Torus Attached Mucosa %

Buccal Shelf: Large Medium Small

Frenum: Anterior (R) (L) Teeth

Tongue: Position Movement

Saliva Consistency Amount

Jaw Classification: Class I Class II Class III

Existing Prosthesis:

Pt.’s Opinion:

Retention: Good Adequate Poor

Stability: Good Adequate Poor

Support: Good Adequate Poor

Esthetics: Good Adequate Poor

Phonetics: Good Adequate Poor

Occlusion: Good Adequate Poor

Facial Shape: Square Square-tapering Ovoid Triangular Round

Profile: Flat Rounded Inverted

Coloring: Hair Eyes Complexion


Course Outline: Complete Course on Partial Dentures

I. Definition of an Overdenture – I know, it’s a partial course, but this is the base.

A. Implant Retained Overdenture – A patient removable prosthesis that receives

retention and limited stability from retained roots [natural or man-made

(implants)]. Support should come from the hard and soft tissue of the denture

bearing mucosa, not just the natural or man-made roots.

1. Typically fewer implants – concentrated in the anterior

B. Implant Supported Overdenture – Patient Removable Fixed Bridge – A

prosthesis that is fixed in place with attachments and locks, yet is removable

by the patient for hygiene access. The natural or man-made roots provide all

retention, stability and support – just like a fixed bridge. The denture bearing

mucosa provides no support what so ever.

1. Requires more implants – placed under anterior and posterior teeth

II. Partial Dentures, Attachment Retained RPDs and Implant Assisted RPDs A. Implants or Attachments may be added, but basic design remains

1. Keep Guide Planes and Rest Seats 2. Only Change Attachments on C&B or Implants for Clasps

B. Implant Ideal Locations: Canines and 2nd Molars 1. Attachments in the 2nd Molar are Rotational to Seat the Frame 2. Attachments within the Saddle are Resilient to allow Frame to Seat

C. Avoid Attaching RPDs to Implant Retained Crowns – Only “Overpartials” D. With this entire Handout – Attachments are Treated the exact same regardless

if they are on implants or a part of your crown and bridge restorations.

II. Kennedy Classification (Visual Learning)

A. Class I – Bilateral Distal Extensions. Can also have anterior modification

B. Class II – Unilateral Extension. Can have anterior or posterior modifications

C. Class III – Tooth Borne Posterior Edentulous. Can have additional posterior

or an anterior Modification.

D. Class IV – Anterior Tooth Borne. Never has modifications.

III. Patient Evaluation

A. Partially Edentulous Case Classification - See Page 2

B. Anatomic Limitations – Problems with removable prosthodontic success

related to the clinical situation of the patient. Changes can only be achieved

with surgical correction. (See Exam Sheet Pg 3)

IV. Removable Partial Denture Requirements – Retention, Stability, Support, Esthetics,

Phonetics and Occlusion

A. Retention – Clasp Arms and Attachments

B. Stability – Guide Planes and Major Connector

C. Support – Rest Seats, Major Connector and Saddles

D. Esthetics, Phonetics and Occlusion – Denture Teeth


V. Removable Partial Denture Components

A. Guide Planes – Horizontal stop (lateral) is secondary requirement of the

remaining tooth in RPD design.

1. Indication for Guide Planes – Path of insertion, stability.

2. Preparation of Guide Planes – Parallel sided burs.

3. Anterior versus Posterior Path of Insertion.

a) Eliminate one or the other with C&B or Implants

b) Or...apply posterior to anterior – check papilla areas

B. Reason for Rest Preps – Vertical stop is primary requirement of the remaining

tooth for RPD design. Creates the Fulcrum line.

a) Shares Saddle Forces With Existing Teeth

b) Identifies Complete Seating of Prosthesis

c) Keeps the Direction of Force Down Long Axis

d) Can Create More than 180º encirclement

e) Provides Indirect Retention

2. Rests for Cuspids

a) Cingulum (Chevron) Rest

b) Horizontal Rest – Fill exposed dentin with composite

c) Finger Rest – No Vertical Stop – Indirect rest only

3. Rests for Premolars and Molars

a) Occlusal Rest – accentuating the mesial or distal pit

C. Indirect Retention

1. Prevention of Saddle Area Lifting for Free-End Saddles

2. Preparation – Tooth appropriate.

3. Fulcrum Selection –

a) Combine most distal REST SEATS.

b) Greatest perpendicular placement – contralaterally.

c) Required for Kennedy Class I and II

d) Necessary for Tooth Borne?

(1) Yes, Class III can act like a free-end (Class II)

(2) Class IV is really a Class I turned around.

4. Indirect Retention as a Reline Indicator

a) Need for Reline – Pressure on saddle lifts indirect rest.

b) Confirms Reline Seating– No biting during impression

c) Adjust occlusion at delivery.

D. Clasp Design

1. Suprabulge Clasps –above height of contour

a) Akers Clasp – Basic use (free-ends?)

b) Wrought Wire Clasp – For wrong Side of Fulcrum

c) Equipoise Clasp – Terminal tooth is an incisor

d) Ring Clasp – Tipped Mandibular Second Molar


2. Infrabulge Clasps

a) I-Bar Clasp – Contraindications: molars, buccal vestibule

undercuts, lingual tipping and high frenums

b) T-Bar Clasp – Modification (not any more)

3. Free-End Saddle Clasp Design

a) Major Options: Distal Akers vs. RPI

(1) Suprabulge versus Infrabulge

(a) Pushing versus Pulling Retention

(2) Engage during load versus Disengage

(3) “Esthetic” options

4. Clasp Conclusions:

a) RPI – Free-End Saddles

b) Equipoise – Terminal Incisors

c) Akers – Always Points Backwards

d) Wrought Wire – Wrong Side of Fulcrum Line

5. Attachments – Ensure they are necessary

a) Only replace clasps – Keep Guide Planes/Rest Seats

b) Intracoronal Attachments – Tooth Borne RPDs only

(1) Stern G/L, Number 7, etc.

(2) Virtually all Intracoronal Attachments are Non-Resilient –

and we want them to be so that we gain support from fixed

abutments.

c) Extracoronal Attachments – Preferred method for C&B

(1) All Extra-coronal Attachments also connect to Implants

(2) Must Double Abut. – Creates cantilever (a) Law of Beams: Stress/Strain = (K)l3

(3) Bredent Attachments – Smallest on the market

(a) Non-resilient

(4) ERA – My favorite

(a) Resilient

(b) Has non-resilient Processing Component

(c) Black Male Can be used for relines

VI. Removable Partial Prosthodontics Impression Techniques

A. Canned alginate – Will you weight measure the powder?

B. Custom Tray Fabrication/Selection – Reinventing the wheel?

C. Impression Materials

1. Irreversible Hydrocolloid (Alginate) – Mucostatic

a) Canned Alginate – canned.

b) “System 2” Syringable Alginate – Simple, inexpensive, quick to

retake when necessary.


(1) System 2 with ERA attachment impression procedure is

outlined later in this handout.

2. Rubber Base – For use with custom trays.

3. Polyvinyl siloxane – not ideal, but best if you don't pour

a) Follow Massad/Dentsply Aquasil impression tech.

4. Polyether – Ridgidity is best for Square imp. copings.

D. Free End Saddle Registration

1. Altered Cast Technique – Lacks Confidence – reline is required when it

fails => Cut out the middle man and…

2. Reline at Delivery with PVS, Polyether, or Rubber Base

a) Hydrocast (outlined below) is preferred technique

b) Massad Aquasil PVS Technique – Dentsply DVD

(1) 30 to 60 seconds of border molding

c) Tissue Stop with Heavy Body (fast set)

d) Border Mold with Monophase (regular set)

(1) Need ideal borders to procede - expect to repeat

e) Final Wash with Light Body (regular set)

A. Hydrocast Reline Technique - This gives 24 hrs of border molding

1. Fabricate RPD in standard fashion from System 2 Alginate impression

with one modification – Add three times normal relief for retention

webbing in the saddles for the frame.

2. For Processing, ask your lab to process the lingual flange past the

myohyoid ridge, but cut the facial flanges short (Use Myostatic Outline

Technique). Have them relieve the saddle area acrylic after processing.

3. Mix Microseal and bench set for one minute. Load saddles and seat in

the mouth for 7 minutes holding the framework in place – do not let the

patient bite, nor apply pressure to the saddle areas. Trim Microseal to

be 2 mm short of the flange. This is the “tissue stop” to support

vertical.

4. Check and adjust the centric and eccentric occlusion – do it now, the

RPD will be too sticky after the Hydrocast is used.

5. Mix Hydrocast and bench set for three to five minutes. Fill the denture

with Hydrocast and seat it in the mouth.

6. Have the patient read aloud for ten minutes then remove

7. Trim excess Hydrocast with a hot spatula (#7 works great)

8. Reseat, patient wears for 24 hours – including meals and bedtime.

(1) To clean: they only use fingers and running water.

9. At next day appointment pour stone to support the saddles & create a

base overlapping onto the Hydrocast material. Send cast to the lab for

a lab processed reline and then redeliver.

VII. Removable Partial Denture Framework Design


A. Framework Requirements

1. Stability – Guide Planes, Major Connector and Flanges

2. Support – Rest Seats (fulcrum), Major Connector, Saddles

3. Retention – Clasp Arms or Attachments

B. Basic Kennedy Class II Framework – Page 14 in this Handout

1. Kennedy Class I and III – Page 17 and 18 in this Handout

C. Frame Fit More Important than Design

1. Occlude Spray – Dry Frame, Spray Frame, Dry Teeth, Seat Frame,

Rock over Fulcrum Line, Remove & Adjust Shiny.

D. Class IV Rotational Path RPD

1. Engage Fists under Guide Planes

E. Class III Rotational Path RPD

1. Prefer Mesial Rest to Distal Rest for Rotational Point

2. Length of Guide Plane Dictates Undercut, not Rest Seat

a) 3 mm Guide Plane: Standard 0.01” undercut

b) Less than 3 mm Guide Plane: Use 0.02” undercut

3. Rotational Path Only for Tooth Borne RPDs

F. Attachments necessary for Free-End Saddles

1. Prefer to Double Abut and Use Resilient Attachments (not stress

breakers, resilient). Attachment Options

2. Attachments – ERA, Stern G/L and Dalbo attachments. SternGold-

Implamed. 800-243-9942 ERA is Resilient

a) This is my preferred attachment because it can be used with the

Black ERA male for relines – especially the Hydrocast walking

reline. When ERA is resilient, abutment stress is zero. However,

double abut for future protection – reline needs increases stress.

3. Attachments – VKS - SG vertical or horizontal Bredent Ball

attachment. Bredent USA, Miami, FL; 800-328-3965.

a) Use vertical attachment on the guide plane (VKS) it is non-

resilient, but less than 2mm cantilever. For strong lower canines;

lateral as double abutment is worthless.

b) Horizontal version (trailer hitch) increases cantilever but can be

used resiliently (still prefer ERA)

4. Attachments – Ceka, Hader and Dolder Bars. Preat, 800-232-7732

(Ceka can be Resilient – so can SOME bars)

5. Attachments – Zaag, Locator. Zest Anchors 800-262-2310

a) Zaag can be resilient, Locator is not – it rotates.

6. Attachments International 800-999-3003

VIII. Occlusal Design – Neurocentric and Balanced Not Covered

A. Lingualized Occlusion – Very Easy to Deliver this Occlusion

B. We should have confidence with fit, spend time on bite.


C. Lab should complete selective grind before breakout

D. Opposing Arch that is Natural Gets Adjusted

1. Protects the Design Occlusal Pattern of Denture Teeth

2. Lab Should Make Recipe of Adjustments to Follow Clinically

3. Patient Should be Told of This at the Beginning of Treatment

E. Clinical Delivery is Three Steps: Adjust Centric Prematurities, Eliminate

Buccal Interferences, Remove Hitches to Eccentrics.

F. Centric Occlusion

1. Use Occlusal Indicator Wax to eliminate prematurities.

a) Tap, tap, tap, squeeze with 80% pressure.

b) Prosthesis - equal retention with and without wax

2. If set up is lingualized occlusion, eliminate buccal contacts.

G. Eliminate Buccal Interferences

1. Use Blue/Blue articulating paper (or any other)

a) Mark side to side movement

b) Obliterate all buccal interferences by adjusting the premolars in

the lower arch and molars in the upper

H. Remove Hitches to Eccentrics – Observe, Ask, Mark, Adjust

1. Observe the patient sliding side-to-side, watch for hitches

2. Ask the patient if they feel the hitches – try to identify where

3. Review denture for abnormally steep cusp that may be involved in

creating this hitch then mark with paper

a) Red to lower, slide side-to-side; Black to Lower, tap-tap-tap in

centric, then adjust the steep cusp identified on the lower

denture.

b) Red to Upper, slide side-to-side; Black to Upper, tap-tap-tap in

centric, then adjust the prominent palatal cusp on the upper

denture.

c) In lingualized occlusion, eliminate all buccal contacts.

IX. Prosthesis Delivery – Not covered in Lecture – Only on Handout

A. Ensure Frame Seats – acrylic may impede seating

1. Occlude Spray works best for this just like Frame Trial Visit

B. Ensure Saddle is Well Adapted – Must be completed before occlusal

1. Pressure Indication Paste

a) Dab Vertically to make marks with brush

b) Seat with Pressure on Frame First – adjust

c) Seat with Pressure on Saddles Second – Adjust

d) Eliminate Undercuts on Lingual of Lower PRN

e) Prefer to See Pressure on Buccal Shelf rather than Ridge

C. Adjust Occlusion as needed and described above

X. Post Delivery Adjustments – Not Covered in Lecture – Only on Handout


A. Most Sores are Occlusal Related: Always adjust occlusion first

1. Pressure Indicating Paste – Vertically dab, apply PIP to entire intaglio

surface, seat and have patient chew on cotton rolls as you move them

2. Crestal Marks – Adjust centric prematurities with wax

3. Non-crestal Ridge Marks – Adjust eccentrics with paper

4. Flange Extensions – Adjust pink acrylic and pumice.

XI. RPD Case Completion - Start to Finish (short outline)

A. Initial Models – Diagnosis and Offers Patient Treatment

B. Prep and Impress – Guide Planes, Rest Preps, Impression

C. Frame Trial – Use Disclosing, Centric Bite with Separate Baseplate

D. Wax Trial – Confirm Esthetics and Bite – lab processes case

E. Reline at Delivery – PVS, Rubber Base or Microseal & Hydrocast

F. Delivery – Confirm Centric and Balance

G. One Week – Confirm Centric and Balance

XII. Fee should be more than Three Unit Bridge

A. Three Unit Bridge Fee is a Strong Fee in Our Offices

1. Replaces One Tooth

a) Chairtime and Lab bill are Similar or Less for FxPP

B. RPD replaces Many Teeth, Similar Lab Fee, More Chairtime

1. Minimal Fee of 2 Units C&B

2. Ideal Fee of 4 Units C&B

C. Reline is one-third Cost of RPD

D. Rebase with new teeth is two-thirds cost of RPD

XIII. RPD Attachment or Implant Assisted Case Completion Follows on Next Pages


Combination Case – Start to Finish Detailed Steps

I. Attachments may be added to an RPD via Crown and Bridge or with Implants, but

the basic RPD framework should remain the same.

A. Keep guide planes, rest seats and Major Connectors all the same

B. If an attachment RPD, eliminate the clasps and add the attachments

C. If an implant assisted RPD, keep the clasps and add the attachments

II. RPD Requirements: Retention, Stability, Support, Esthetics, Phonetics, Occlusion

A. Retention – Clasp Arms and Attachments

B. Stability – Guide Planes and Major Connector

C. Support – Rest Seats, Some Major Connectors and Denture Base

D. Esthetics, Phonetics and Occlusion from Teeth

A. First Visit: Initial Models – Diagnosis

1. Basic Study Casts – Staff can make these, but consider making them

yourself as a “Trial Run” for the final impression.

2. Design Free End Saddle framework or Rotational Path frame

a) Free End Saddle Frame for Kennedy Class I, II, III (free-end with extra

tooth) and Class IV (free-end saddle turned around)

b) Nearly All Labs Can Assist, But Call and Discuss

B. Second Visit and more: Caries Control, Endo & Perio PRN, C&B

1. First Complete all caries control, endo, perio and other treatement

2. If C&B is involved, do the following steps, though they will be repeated

later, this is what makes combination cases successful.

a) Visit 3+: System 2 impression of arch receiving combination

(1) Fabricate baseplates and wax rims

b) Visit 4+: Wax records, CR bite, tooth selection – lab sets teeth

c) Visit 5+: Wax trial – Then Process and Duplicate interim RPD

(1) Deliver interim partial denture PRN

(2) Make an impression on the model using the baseplate as the

“impression tray.” Use light body Rubber Base for this with a small

amount of vasaline on the model.

3. Visit 6: Prep Crown and Bridge

a) Seat Wax trial and confirm prep clearances

b) Make final impression for crown and bridge with wax trial

PROPERLY seated

(1) Use a stock impression tray. Cut a large hole in the middle of the

palate. When making the final impression of the preps, have the

wax trial (with rubber base model impression) already seated.

Inject light body PVS impression material for your preps and


partially seat the loaded stock impression tray. Before fully seating

the impression tray, press one finger through the hole you’ve made

in the palate and ensure the wax trial is properly seated – then fully

seat tray.

4. Laboratory Fabricates Crown and Bridge

a) Use wax trial on Master Die model to ensure C&B are planned,

waxed, cast and fabricated to meet denture teeth

b) Use a Milled Anterior Strap when Indicated

c) Double Abut for Cantilevered Attachments

d) Consider Ney MS attachment in #8//9 area to separate right and left

sides, create an appearance of separate crowns, and simplify preparation

(1) Standard Use – Female Supports

(2) Inverted – Male Supports

(3) Have lab make die model before removing the wax up and a solid

model after removing the wax up

(4) Fabricate C&B with an intimate understanding of where the denture

teeth are supposed to be

C. Visit 7: Deliver Crown and Bridge – Impress for RPD Framework

1. Prepare for RPD – Guide Planes, Rest Preps, System 2 Imp.

2. Prep Guide Planes on any other teeth in the arch First

3. Prep Rest Seats on any other teeth in the arch second

4. Impression Options for RPD Framework

a) Pick Up Impression of C&B

(1) Have had problems with poor impressions in the palate –

something that never happens with System 2.

b) Cement C&B – Make Standard RPD frame Impression

(1) First Iteration I made an Impression of C&B without any

impression copings or attachments in place

(a) Had problems with Lab guessing where the black male

was going to be for the pick up

(2) Second Iteration I used ERA’s impression copings

(a) Had problems with frames that had a lot of adjustment

then overseated the attachment

(3) Best Technique – Cement C&B and seat ERA Black males –

then complete RPD Frame Impression

(a) Now lab knows exactly the shape of our pick up will be and

they build up a flange around the male

(b) Now we can complete the pick up after the frame is adjusted

– and before the case is processed.

(c) Order a separate wax rim for records

c) System 2 Alginate Technique with ERA Attachments


(1) My preferred technique for implants & attachments

(2) Measure water for System 2 syringe gel and tray gel

(3) Clean and clear intra-oral female component on attachments

(4) Seat ERA BLACK MALE (with metal housing) on any and all

implants & attachments ensure the attachment’s completely seated

(5) Make and Remove the System 2 Imp as Noted Below

(6) Remove ERA BLACK MALE, save, but don’t place in imp

(7) Pour the impression immediately – vacuum mix stone.

(8) Send to the lab to fabricate RPD framework. The lab will cast the

frame with “Thickened” latticework around the stone where the

ERA Black Males were positioned. During the Frame Trial, you’ll

need to seat the Black Males again, and pick them up with Acrylic

before making any centric relation records. More to follow.

d) System 2 Alginate Impression: Contact Ivoclar for video


(2) Mix water & powder for syringe gel, back load syringe with all the

mixed alginate, place intra-oral tip on syringe.

(3) Mix water and powder for tray gel, load tray – ensuring to use

enough pressure to extrude some alginate through the retentive

holes on the tray. While you are using the syringe gel intra-orally,

have your staff soak the tray gel under cool water.

(4) Wipe the mouth with 2X2 gauze.

(5) Use the syringe filled with syringe gel and beginning behind the most

distal tooth and express the alginate out if the syringe while you

follow the arch form along the occlusal surface to the midline –

switch to the other side and repeat. Don’t go back-and-forth.

(6) Remove the intra-oral tip and syringe material into the vestibule on

the right and left side.

(7) If this is an upper impression, syringe a dollop on the palate, for a

lower, syringe into each lingual vestibule.

(8) Receive the tray from your auxiliary and seat – only far enough to

merge the syringe gel with the tray gel. Border mold gently –

alginate is easy to over border mold.

(9) Set your timer and stabilize the impression.

(10) After 3 minutes in the mouth, remove by loosening the alginate

in the posterior vestibule – not by the handle. Soak and treat as you

would standard alginate material.


(12) Send to the lab to fabricate RPD framework


D. Visit 8: Frame Trial – Most Important Step

1. Use Occlude Spray

a) Clear rest seats and any attachments of food debris

b) Dry frame, spray with Occlude, dry teeth, seat, rock across fulcrum line

(1) Remove and check for shiny areas on the frame where the partial

denture binds. Adjust rest seats and indirect retainers more than

guide planes to achieve full seating of rest seats into the teeth.

c) Pick up attachments today if you did that impression technique

(1) Seat the Black Males again, and pick them up with GC Pattern

Resin before making any centric relation records.

2. Complete wax records – a GREAT trick is to ask the lab to fabricate a

separate baseplate and wax rim from the same model that the framework was

made. That will allow you to check the framework for proper fit without

baseplates attached to it AND we can do the Record visit the same day as

the frame trial AND we can use an intra-oral tracing device if this is the

upper by having an acrylic palate.

a) Trim wax to be just below the proper occlusal plane

b) Carve notches into bite rim on all edentulous areas

c) Make CR record – Intra-oral tracing devices are ideal

3. Complete tooth selection

E. Visit 9: Wax Trial – Confirm Esthetics and Bite

1. Last chance to make changes without a fee

F. Visit 10: Free-End Saddle Registration – Done 100% of the time –always better

to reline than to evaluate if you need a reline.

1. Reline at Delivery – If ERAs were used, then Black Males in place now.

a) PVS, Polyether, or Rubber Base gives you 30 seconds of border molding

versus 24 hours with Hydrocast technique

G. Visit 11: Delivery – If ERAs were used, seat White Males in RPD

1. Centric Occlusion

a) Use Occlusal Indicator Wax to eliminate prematurities.

2. Eccentric Occlusion – Use horseshoe paper for group function

a) With Blue/Blue Horseshoe Paper – Slide side-to-side and Obliterate Upper

Molar Buccal Contacts and Lower Premolar Buccal Contacts

H. Last Visit: One Week Post Delivery Adjustment – Confirm Centric and Balance

and Check for Sore Spots - most are occlusally created

1. Use PIP to locate sore spots, but adjust occlusion, not intaglio

a) Crestal Marks – Adjust centric prematurities with wax

b) Non-crestal Ridge Marks – Adjust eccentrics with paper

2. One post op is all that is scheduled unless major changes were made


XIV. Combination Case – Start to Finish Detailed Steps

E. First Visit: Initial Models – Diagnosis

1. Basic Study Casts – Staff can make these, but consider making them

yourself as a “Trial Run” for the final impression.

2. Design Free End Saddle framework or Rotational Path frame

a) Free End Saddle Frame for Kennedy Class I, II, III (free-end with extra

tooth) and Class IV (free-end saddle turned around)

b) Nearly All Labs Can Assist, But Call and Discuss

F. Second Visit and more: Caries Control, Endo & Perio PRN, C&B

1. First Complete all caries control, endo, perio and other treatement

2. If C&B is involved, do the following steps, though they will be repeated

later, this is what makes combination cases successful.

a) Visit 3+: System 2 impression of arch receiving combination

(1) Fabricate baseplates and wax rims

b) Visit 4+: Wax records, CR bite, tooth selection – lab sets teeth

c) Visit 5+: Wax trial – Then Process and Duplicate interim RPD

(1) Deliver interim partial denture PRN

(2) Impress the model using the baseplate as the “impression tray.” Use

light body Rubber Base for this with a small amount of vasaline on

the model.

3. Visit 6: Prep Crown and Bridge

a) Seat Wax trial and confirm prep clearances

b) Make final impression for crown and bridge with wax trial PROPERLY

seated

(1) Use a stock impression tray. Cut a large hole in the middle of the

palate. When making the final impression of the preps, have the

wax trial (with rubber base model impression) already seated.

Inject light body PVS impression material for your preps and

partially seat the loaded stock impression tray. Before fully seating

the impression tray, press one finger through the hole you’ve made

in the palate and ensure the wax trial is properly seated – then fully

seat tray.

4. Laboratory Fabricates Crown and Bridge

a) Use wax trial on Master Die model to ensure C&B are planned, waxed,

cast and fabricated to meet denture teeth

b) Use a Milled Anterior Strap when Indicated

c) Double Abut for Cantilevered Attachments

d) Consider Ney MS attachment in #8//9 area to separate right and left

sides, create an appearance of separate crowns, and simplify preparation

(1) Standard Use – Female Supports


(2) Inverted – Male Supports

(3) Have lab make die model before removing the wax up and a solid

model after removing the wax up

(4) Fabricate C&B with an intimate understanding of where the denture

teeth are supposed to be

D. Visit 7: Deliver Crown and Bridge – Impress for RPD Framework

3. Prepare for RPD – Guide Planes, Rest Preps, System 2 Imp.

4. Prep Guide Planes on any other teeth in the arch First

5. Prep Rest Seats on any other teeth in the arch second

6. Impression Options for RPD Framework

a) Pick Up Impression of C&B

(1) Have had problems with poor impressions in the palate –

something that never happens with System 2.

b) Cement C&B – Make Standard RPD frame Impression

(1) First Iteration I made an Impression of C&B without any

impression copings or attachments in place

(a) Had problems with Lab guessing where the black male

was going to be for the pick up

(2) Second Iteration I used ERA’s impression copings

(a) Had problems with frames that had a lot of adjustment

then overseated the attachment

(3) Best Technique – Cement C&B and seat ERA Black males –

then complete RPD Frame Impression

(a) Now lab knows exactly the shape of our pick up will be and

they build up a flange around the male

(b) Now we can complete the pick up after the frame is adjusted

– and before the case is processed.

(c) Order a separate wax rim for records

c) System 2 Alginate Technique with ERA Attachments

(1) My preferred technique for implants & attachments


(3) Clean and clear intra-oral female component

(4) Seat ERA BLACK MALE (with or without metal housing – I prefer

to skip the metal housings for RPDs since they are loose) ensure the

attachment’s completely seated

(5) Make and Remove the System 2 Imp as Noted Above

(6) Remove ERA BLACK MALE, save, but don’t place in imp


(8) Send to the lab to fabricate RPD framework. The lab will cast the

frame with “Thickened” latticework around the stone where the

ERA Black Males were positioned. During the Frame Trial, you’ll


need to seat the Black Males again, and pick them up with GC

Pattern Resin before making any centric relation records. Read on

for recommendations.

d) Visit 7 Alternative Technique - System 2 Alginate Impression:

Contact Ivoclar for video


(2) Mix water & powder for syringe gel, back load syringe with all the

mixed alginate, place intra-oral tip on syringe.

(3) Mix water and powder for tray gel, load tray – ensuring to use

enough pressure to extrude some alginate through the retentive

holes on the tray. While using the syringe gel, have your staff soak

the tray gel under cool water.

(4) Wipe the mouth with 2X2 gauze.

(5) Use the syringe filled with syringe gel and beginning behind the most

distal tooth and express the alginate out if the syringe while you

follow the arch form along the occlusal surface to the midline –

switch to the other side and repeat. Don’t go back-and-forth.

(6) Remove the intra-oral tip and syringe material into the vestibule on

the right and left side.

(7) If this is an upper impression, syringe a dollop on the palate, for a

lower, syringe into each lingual vestibule.

(8) Receive the tray from your auxiliary and seat – only far enough to

merge the syringe gel with the tray gel. Border mold gently –

alginate is easy to over border mold.

(9) Set your timer and stabilize the impression.

(10) After 3 minutes in the mouth, remove by loosening the alginate

in the posterior vestibule – not by the handle. Soak and treat as you

would standard alginate material.



e) Visit 7 Alternative Technique: System 2 Alginate with ERA

Impression Copings – The ERA way of doing it


(2) Clean and clear intra-oral female component

(3) Seat ERA impression coping, ensuring the attachment is completely

seated

(4) Make and Remove System 2 Imp as Detailed Above

(5) Remove the ERA impression coping.

(6) Seat an ERA replica fully onto the ERA impression coping and snap

these replicas back into the impression – confirm seating.




I. Visit 8: Frame Trial – Most Important Step

1. Use Occlude Spray

a) Clear rest seats and any attachments of food debris

b) Dry frame, spray with Occlude, dry teeth, seat, rock across fulcrum line

(1) Remove and check for shiny areas on the frame where the partial

denture binds. Adjust rest seats and indirect retainers more than

guide planes to achieve full seating of rest seats into the teeth.

c) Pick up attachments today if you did that impression technique

(1) Seat the Black Males again, and pick them up with GC Pattern

Resin before making any centric relation records.

2. Complete wax records – a GREAT trick is to ask the lab to fabricate a

separate baseplate and wax rim from the same model that the framework was

made. That will allow you to check the framework for proper fit without

baseplates attached to it AND we can do the Record visit the same day as

the frame trial AND we can use an intra-oral tracing device if this is the

upper by having an acrylic palate.

a) Trim wax to be just below the proper occlusal plane

b) Carve notches into bite rim on all edentulous areas

c) Make CR record – Intra-oral tracing devices are ideal

3. Complete tooth selection

J. Visit 9: Wax Trial – Confirm Esthetics and Bite

1. Last chance to make changes without a fee

K. Visit 10: Free-End Saddle Registration – Done 100% of the time –always better

to reline than to evaluate if you need a reline.

1. Reline at Delivery – If ERAs were used, then Black Males in place now.

a) PVS, Polyether, or Rubber Base gives you 30 seconds of border molding

versus 24 hours with Hydrocast technique

L. Visit 11: Delivery – If ERAs were used, seat White Males in RPD

1. Centric Occlusion

a) Use Occlusal Indicator Wax to eliminate prematurities.

2. Eccentric Occlusion – Use horseshoe paper for group function

a) With Blue/Blue Horseshoe Paper – Slide side-to-side and Obliterate Upper

Molar Buccal Contacts and Lower Premolar Buccal Contacts

M. Last Visit: One Week Post Delivery Adjustment – Confirm Centric and Balance

and Check for Sore Spots - most are occlusally created

1. Use PIP to locate sore spots, but adjust occlusion, not intaglio

a) Crestal Marks – Adjust centric prematurities with wax

b) Non-crestal Ridge Marks – Adjust eccentrics with paper

2. One post op is all that is scheduled unless major changes were made


Partial Denture Lab Prescription

M. Nader Sharifi, D.D.S., M.S. Lics. No.:019-021617

30 North Michigan

Suite 1303

Chicago, IL 60602 Phone: 312-236-1576

Laboratory: Phone:

Patient: Date Sent:

Next Appt.: Time:

Tooth Guide Plane Rest Clasp Undercut

Material

Major Connector

Retention Webbing

Tissue Stops

Opposing Arch

Signature:

Page 1

Framework Design Kennedy Class II Lingual Bar

Distal GP #20

Mesial Rests #20, 31

I-Bar #20, Akers #31

Mesial Rest #28

Three Times Relief & Distal Tissue Stop

Framework Design Kennedy Class I Lingual Bar

Distal GPs #20, 29


I-Bar #20, 29



Framework Design RPI Clasp Design Akers Clasp Design

Framework Design Kennedy Class II Modifications Additional Space

Non-Free End

Rest Each Side

Long Guide Planes

No Clasp Arms

Framework Design Kennedy Class I Lingual Plate

Distal GPs #22, 27

Cingulum Rests #22, 27

I-Bar #22, 27

Lingual Plate


Framework Design Kennedy Class III Lingual Bar

Mesial GP #19; Distal GP #21

Mesial Rests #19, 31, 21

Akers #19, 31; I-Bar #21

Mesial Rest #28

Standard Design

2013 M. Nader Sharifi, DDS, MS Page 142013 M. Nader Sharifi, DDS, MS

Framework Design Atlas

Page 2

Framework Design Kennedy Class IV Horseshoe

Mesial GPs #6 & 11

Cingulum Rests #6 & 11

Mesial Rests #2 & 15

Akers #2 & 15

I-Bars #6 & 11

Mesial #2 and 15

Framework Design Rotational Path Mesial GPs #6 & 11


Mesial Rests #2 & 15

Clasps Akers #2 & 15

Fists: Mesial #6 & 11

Mesial Rests #2 and 15

Framework Design Rotational Path

Lingual Bar

Guide Planes on Proximals

Rest Seats Bracket Pontics

Akers Reaching Back

Fist Retention Under GPs

Framework Design Kennedy Class I Treatment Planning

Distal GPs #6 & 11


I-Bars #6 & 11

Implants #2 and 15

Rotational Attachments

Framework Design Kennedy Class I Treatment Planning

Distal GPs #6 & 11


Implants #5 and 12

Resilient Attachments

Framework Design Kennedy Class I

C&B 6-11

A-P Strap

Distal #6 Through 11

Cingulum #6 Through 11

Attachments Distal #6 & 11

Milled Anterior Strap

Page 152013 M. Nader Sharifi, DDS, MS

Framework Design Atlas


Reference List

Textbooks: (Sorry, I’ve yet to review an acceptable Attachment Textbook.) 1. Brudvick, JS: Advanced Removable Partial Dentures. Quintessence Publishing Co.,

Inc. Chicago, IL 1999.

2. Hayakawa I: Principles and Practices of Complete Dentures – Creating the Mental

Image of a Denture. Quintessence Publishing Co., Chicago, IL 2004.

3. Johnson DL and Stratton RJ: Fundamentals of Removable Prosthodontics. Quintessence

Publishing Co., Inc. Chicago, IL 1980.

4. Kratochvil FJ: Partial Removable Prosthodontics. W.B. Saunders Co., Philadelphia, PA

1988.

5. Krol AH, Jacobson TE, Finzen FC: Removable Partial Denture Design - Outline

Syllabus. University of the Pacific Dental School, 1990. Call School

6. McGivney GP, Castleberry DJ: McCracken’s Removable Partial Prosthodontics. 8th

Edition. C.V. Mosby, St. Louis, MO 1989.

7. Sharifi MN: Essential Dental Handbook: Chapter on Removable Prosthodontics.

Edited by Edwab RJ, Penn Well Publishing Co., Tulsa, OK 2002. Call 800-752-9764

(10%Coupon: DOAE05)

8. Stratton RJ, Wiebolt FJ: An Atlas of Removable Partial Denture Design. Quintessence

Publishing Co., Inc. Chicago, IL 1988.

9. Stewart KL, Rudd KD, Kuebker WA: Clinical Removable Partial Prosthodontics. C.V.

Mosby, St. Louis, MO 1983.

Journal Articles: 1. Atwood D: Clinical, cephalometric and densitometric study of reduction of residual ridges. J Prosthet Dent 1971;

26:280.

2. Barco MT Jr, Flinton RH: An overview of four removable partial denture clasps. Int J Pros 1988; 1:159-64.

3. Becker CM, Swoope CC, Guckes AD: Lingualized occlusion for removable prosthodontics. J Prosthet Dent 1977;

38:601.

4. Berg T, Caputo AA: Comparison of load transfer by maxillary distal-extension removable partial denture with a

spring loaded plunger attachment and I-bar retainer. J Prosthet Dent 1992; 68:784-789.

5. Browning JD, Meadors LW, Eick JX: Movement of three removable partial denture clasp assemblies under

occlusal loading. J Prosthet Dent 1986; 13:549-557.

6. Brudvik JS, Howell PG: Evaluation of eccentric occlusal contacts in complete dentures. Int J Prosthet 1990;

3:146-157.

7. Burns DR, Ward JE: A review of attachments for removable partial denture design: Part 2 - Treatment Planning

and attachment selection. Int J Pros 1990; 3:169-170.

8. Burns DR, Ward JE: A review of attachments for removable partial denture design: Part 1 - Classification. Int J

Pros 1990; 3:98-102.

9. Chou TM, et al.: Photoelastic analysis and comparison of force transmission characteristics of intracoronal

attachments with clasp distal-extension removable partial dentures. J Prosthet Dent 1989; 62:313-319.

10. Chow TW, Clark RK, Clarke DA: Improved designs for removable partial dentures in Kennedy Class IV cases.

Quintessence Int. 1988; 19:797-800.

11. Clough H, Knodle J, Pudwill S, Myron L, Taylor D: A comparison of lingualized occlusion and monoplane

occlusion in complete dentures. J Prosthet Dent 1983; 50:176.

12. Curtis T, Langer Y, Curtis D, Carpenter R: Occlusal considerations for partially or completely edentulous skeletal

class II patients. Part I: Background information. J Prosthet Dent 1988; 60:202.

13. Demer WJ: An analysis of mesial rest, I-Bar clasp designs. J Prosthet Dent 1976; 36:243-253.

14. Eliason C: RPA clasp design for distal extension removable partial dentures. J Prosthet Dent 1983; 49:25.

15. Feingold GM, Grant AA, Johnson W: Abutment tooth and base movement with attachment retained removable

partial dentures. J Dentistry 1988; 16:264-268.


16. Feingold GM, Grant AA, Johnson W: The effect of partial denture design on abutment tooth and saddle

movement. J Oral Rehab 1986; 13:549-557.

17. Grady R: Objective criteria for relining distal extension removable partial dentures: A preliminary report. J

Prosthet Dent 1983; 49:178.

18. Haines R, Barrett S: The structure of the mouth in the mandibular molar region. J Prosthet Dent 1959; 9:962.

19. Hochman N, Yaniv O: Comparative clinical evaluation of RPDs made from impressions with different materials.

Compend 1998; 19:200-206.

20. Hosman HJ: The influence of clasp design of distal extension RPDs on the periodontium of the abutment teeth. Int

J Protho 1990; 3:256-265.

21. Kapur KK, et al.: A randomized clinical trial of two basic RPD designs, Part I: Comparisons of five-year success

rates and periodontal health. J Prosthet Dent 1994; 72:268-282.

22. Kelly E: Changes caused by a mandibular removable partial denture opposing a maxillary complete denture. J


23. Ko SH, McDowell GC, Kotowicz WE: Photoelastic stress analysis of mandibular removable partial dentures with

mesial and distal occlusal rests. J Prosthet Dent 1986; 56:454-460.

24. Kotwal K: Beyond classification of behavior types. J Prosthet Dent 1984; 52:874.

25. Kratochvil FJ: Influence of occlusal rest position and clasp design on movement of abutment teeth. J Prosthet Dent

1963; 13:114-124.

26. Krol AJ: RPI clasp retainer and its modifications. DCNA 1973; 17:631-649.

27. Krol AJ: Clasp design for extension base removable partial dentures. J Prosthet Dent 1973; 29:408-415.

28. Lang BR, Razzoog ME: Lingualized integration: tooth molds and an occlusal scheme for edentulous patients.

Implant Dentistry 1991; 1:204-211.

29. LaVere AM: Clasp retention: the effects of five variables. J Prosthod 1993; 2:126-131.

30. Leupold RJ, Flinton RJ, Pfeifer DI: Comparison of vertical movement occurring during loading of distal extension

removable partial denture bases made by three impressions techniques. J Prothet Dent 1992; 68:290-293.

31. Mazurat RD: Longevity of partial, complete, and fixed prostheses: a literature review. J Can Dent Assoc 1992;

58:500-504.

32. McHenry KR, et al.: The effect of RPD framework design on gingival inflammation: A clinical model. J Prosthet

Dent 1992; 68: 799-803.

33. Myers RE, et al.: A photoelastic study of rests on solitary abutments for distal-extension removable partial

dentures. J Prosthet Dent 1986; 56:702-707.

34. Niedermeier WH, Kramer R: Salivary secretion and denture retention. J Prosthet Dent 1992; 67:211-216.

35. Pound E: Accurate protrusive registration for patients edentulous in one or both jaws. J Prosthet Dent 1983;

50:584.

36. Pound E: Controlling anomalies of vertical dimension and speech. J Prosthet Dent 1976; 36:124.

37. Pound E: Let “S” be your guide. J Prosthet Dent 1977; 38:482.

38. Pound E: The mandibular movements of speech and their seven related values. J Prosthet Dent 1966; 5:835.

39. Rissin LR, et al.: Six year report of the periodontal health of fixed and removable partial denture abutment teeth. J


40. Roach FE: Principles and essentials of bar clasp partial denture. JADA 1930; 17:124-137.

41. Saunders T, Gillis R Jr., Desjardins R: The maxillary complete denture opposing the mandibular bilateral distal

extension partial denture: Treatment considerations. J Prosthet Dent 1979; 41:124.

42. Shannan J: A bilaterally balanced occlusal scheme for patients with arch width and curvature discrepancies. J


43. Sharifi MN: Functional Impression for the Complete Denture. Quintessence Dental Technology Yearbook 2002.

44. Tallgren A: The continuing reduction of the residual alveolar ridges in complete denture wearers: A mixed

longitudinal study covering 25 years. J Prosthet Dent 1972; 27:120.

45. Thayer H, Caputo A: Effects of overdentures upon remaining oral structures. J Prosthet Dent 1977; 37:374.

46. Thayer H, Caputo A: Photoelastic stress analysis of overdenture attachments. J Prosthet Dent 1980; 43:611.

47. Toolson L, Smith D: A 2-year longitudinal study of overdenture patients. Part I: Incidence and control of caries on

overdenture abutments. J Prosthet Dent 1978; 40:486.

48. White J: Abutment stress in overdentures. J Prosthet Dent 1978; 40:13.


Product List

Blue Dolphin Products – Papilla Meter, Wax Spatulas, Bunsen Burner. 800-448-8855

Brassler – NSK Lab Handpiece, Acrylic Adjustment Burs, Ultra Denture Polishers. 800-841-4522

Dentsply – Fox plane, Aquasil Impression Material, Aquasil Impression Trays, Portrait, Trublend &

Porcelain Denture Teeth, Alma Gauge, Trubyte Tooth Indicator, Vitallium Clasp Adjuster (N001960)

Dentsply Prosthetic 800-786-0085

Kettenbach – Panasil Impression Material, Futar Bite Registration Material. 877-532-2123.

Panadent – PCH Articulator, Kois Occlusal Analyser (Fox Plane). Panadent 800-368-9777.

Ivoclar – Blue Line, Postaris and Phonares Denture Teeth, System 1 and System 2 Impression Material

and Impression Trays, Stratus 2000 Articulator, Smile Design Kit. 800-533-6825

Kerr – Permalastic Rubber Base Impression Material, Pink Baseplate Wax, Occlusal Indicator Wax,

Green Stick Compound. 800-537-7123

Bosworth Dental – New Truliner (chairside reline material). 708-679-3400

GC America – Unifast TRAD (repair acrylic). 800-323-7063

Lee Mark Dental – Coble Balancer, Massad Balancer, Lessman Wax Knife, Wax Spatulas, Electric

Waxer, Water Bath for Compound. 866-533-6275

Miscellaneous Products: 1. Articulating Paper – Whip Mix Blue/Blue Horseshoe. Benco 800-462-3626.

2. Attachments - VKS vertical or horizontal attachment. Bredent; 800-328-3965.

3. Attachments - ERA attachment & EZ Pick Up with Light Cure Varnish to pick up

attachments. SternGold. 800-243-9942

4. Attachments - Preci Clix attachment. Preat 800-232-7732

5. Attachments - Locator attachment. Zest Anchors 800-262-2310

6. Denture Teeth – Physiodens and Porcelain. Vita; 800-828-3839.

7. Functional Impression Material – Microseal – holds VDO for functional impressions.

AMCO International; 800-523-0740

8. Functional Impression Material - Hydrocast. Sultan Chemists; 800-842-8844.

9. Intra-oral post dam tissue marking sticks - Dr. Thompson’s Sanitary Applicators. Great

Plains Dental, Kingman, KS; 316-532-3888.

10. Lang Aquapress Pressure Pot - For Strengthening Acrylic. Benco; 800-462-3626.

11. Mizzy Pressure Indicating Paste - For Post Delivery Adjustments of Denture Sore Spots.

Benco; 800-462-3626.

12. Occlude - Marking RPD frameworks. Pascal Co. 800-426-8051.

13. Wonderfill – Impression Boxing Putty. Dental Creations. 254-772-4661

tel:254-772-4661

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