Prosthodontics: Lecture # 1: Date: 27/9/2011 NOTE: I didnt have the slides when I wrote this lecture, so please, to avoid

any confusion refer to the slides while studying. Your Laboratory sections have been changed again, Its for your own good.. Is there anybody who is not registered for the course yet, but hes attending today? There will be a list which will be turned around, I need you to sign your name.. ok? If your name is not on the list, please write it, Ill understand that you are not registered for the course yet.. In the future, Ill be taking the attendance according to the seat number.. but for now, the number is not complete.. Ill give the seat numbers to your CR or Ill put it on the e-learning. I was informed yesterday that the maximum number of students allowed in each section is about 63 students, I think what they did is they took the first 63 students in each section and kept them, and the ones which are above 63 were moved into the remaining sections which are not full (sections 3 & 4). Ill hang the list outside the prosthodontics laboratory, section 2 is on Sunday, 3 is on Tuesday, 1 is on Thursday, section 4 is divided on Monday and Wednesday. A lot of you asked me about the exam, we have a midterm exam on the 19th or on the 12th of November, at 8:45 am , 10 H1,H2,H3 and H4.. so Itll be Saturday morning. Now, very quickly I am going to repeat some of the things which I said in the lab (some of you have taken them), and some of the things that Ive said during the last lecture.

Quick introduction to the removable prosthodontics, and what the divisions are for removable prosthodontics.. You already know that prosthodontics in general is divided into: Fixed ( Crowns & bridges ) Removable Its not our business to discuss crowns & bridges during this course, we said that we are (not) involved in bridges replacing specific teeth, fixed restorations which are cemented to the teeth , like this, which are made usually of enforced metal, or ceramic materials, or metal materials. Our job this semester will be to replace arches which have no teeth at all (complete dentures) .. Complete dentures come in different forms, we will learn about the conventional or the traditional technique this semester, there are also things called immediate dentures or over dentures, you may hear about them, and like I said these are more advanced, youll learn more about them in your 4th and 5th year. An immediate denture.. If a patient comes, and we extract all their teeth, they have to wait for healing of the extraction sites before we can make a new denture, that means we have patients in society, stay 1, 2 ,3 ,4 and sometimes six months without any teeth, and for some people that is unacceptable, depending on the patients age, occupation, and their social status, in such cases we can make something called an immediate denture. We make impressions, we take records before the teeth are extracted, and the day the teeth are extracted we give the patient the denture. It sounds simple, but its more complicated than that, which is delayed until we learn the conventional technique, thats what an immediate denture is. (, ) An over denture is a denture over roots, sometimes we can have teeth in the mouth but we still can make a complete denture, we cut the tooth off the crown, and we leave the root, and thats why the
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denture instead of setting on the soft tissues of the gums, it has some support from the natural roots. Again, its not as simple as it sounds, it has specific requirements and the way that we deal with it inside the patients mouth.. Youll learn more in the coming years. So essentially we are replacing the entire arch for patients without any teeth at all, like I said, next semester youll take a detailed course on how to make removable partial dentures, I said in the lab, if you have one tooth missing, or you have fifteen teeth missing, and one tooth left, the replacement is still called partial denture. ( ) , These prosthesis (partial dentures) are usually two types: Is made entirely of acrylic or plastic. Is usually based on metal (cobal cronium alloyed) (not sure of the spelling) With plastic. So in this case you can see that we have a metal frame work to make it stronger, and the acrylic is there just for the appearance not for support.. ok? In this case we have no teeth on one side entirely, and you can see we have partial denture going from one side to the other .. Youll learn that we dont make removable prosthesis in only one side of the mouth, if we have one or two teeth missing on this side, we cant make removable prosthesis just on this side, we have to extend to the other side for balance and support, because if we make a small one on one side, and its removable, it will come out of the patients mouth, or they might swallow it, or chock, so we have to take advantage of the other side. Whereas fixed prosthesis, because they are not removable, can be made unilaterally, or on one side. And there are two branches of removable prosthodontics which you will take a lecture or two about in your undergraduate education but you wont practice.

The fist one is Maxillofacial prosthodontics, its

something we usually teach in details in higher specialty courses. In Maxillofacial Prosthodontics we are not talking about missing tooth or gum structure, we are talking about missing entire parts of the mouth or the head and neck region, the entire palate maybe gone, for congenital reasons, for traumatic reasons, or due to malignancy after surgery. Sometimes patients lose a large part of their palate or jaw, or even sometimes their face, so in this case, which we can see on the screen, is an example of a soft palate obturator. Everything in the body is there for a reason, even the appendix, regardless what they tell you, everything is there for specific reason, if the soft palate goes, you lose a very important valve, which divides the flow of air, water and food, nose and the oral cavity, if its removed, the patient can no longer swallow normally, no longer breathe normally, no longer speak normally.. So what we do is we replace it, its not as good as the original, but at least blocks ..Its called obturator. () Here parts of the soft and the hard palate were gone, needs a surgery, and you can see we are making denture with an extension. Sometimes larger parts of the face are missing, if the plastic surgeon or the surgeon is not able to replace certain parts of the face, and if you read the news, over the past few years, theyve been talking about entire or partial facial transplants, this is very recent, but in the past, many many decades ago, the only way to replace missing facial structure is using the state prosthesis, and its based on silicon that looks very close to natural, but is not identical (not sure) , very difficult to fabricate but its also part of the prosthodontics specialty. And these procedures are done at the university.

And the second is Implant prosthodontics, hopefully if

your course schedule doesnt change, in the 5th year you are going to take an entire course composed of two semesters. We will take a detail of the theory, not so much practice.. and itll be incorporated with the number of courses. The implant prosthodontics isnt yet called a specialty by itself, there are few programs in the world that teach something called implant
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prosthodontics, but in general implant prosthodontics at the higher level is divided between different specialties, theres: A surgical part. A restorative part (which is the prosthodontics part) So, as a specialist I dont usually do the surgery, the surgeon does, he places the implants, then sends the patient to me, and then I complete the restoration on top of the implant. Examples, if you are not familiar with what the dental implant is, its a screw or something that looks like a screw which is made of material, which is not only biocompatible, its bioactive. So the bone thinks its natural tooth structure, so it builds up against it and attaches to the body, the body is deceived into thinking its a bone, so Itll attach to it, so once its attached to the bone, we can use it for support and attach teeth to it, and dentures.. Theres a misconception, some think Implant always means fixed prosthesis, I have an implant, I put the tooth on top of it, Its not necessarily so, some patients cant afford 14 implants, so we place few implants, then we place a complete denture, so it becomes an over denture ( , ), So most of the implants are made of Titanium, titanium is a very special material: Its strong enough to support a prosthesis. The body thinks its a natural tissue. There are implants in different shapes and forms, youll be surprised ( , , , ) This is a process you will learn, its called oceo integration, Gold is not used in implants In implantation we use natural products, so the body can attach to it. This is another prosthesis on the same implants, you can see an entire arch was placed on these five implants, it was actually screwed in place, sometimes its screwed in place using cement.

These are the basics of different procedures we use to make different types of prosthesis in dentistry, youll learn about some procedures next semester, and if you continue your education after your graduate youll learn more procedures. Like I said that our job this semester is complete denture, and those of you who came to the lab, have already seen this specific sequence that we talked about at the end of last lecture, you have to repeat it several times, because I want you to know it by heart, the sequence of fabricating a complete denture, Its very important, you need to be able to close your eyes, and immediately visualize the steps of complete dentures fabrication. So those of you who were with me during last lecture and in the lab.. How many steps are there for the fabrication of complete denture? There are 9 steps; these steps are divided in between: Clinic Lab Remember, complete denture is something called an indirect restoration , unlike CONs where the patient walks into the clinic, has their tooth restored at the same day, these restorations require the help and the support of a dental laboratory technician. And the problem with these is that they are made out of materials that need to be polymerized or cured, we need high temperatures, these materials are poisonous when they are being processed, I cant make these inside the patients mouth, its just not practical. So if you were in the lab, youd also know my entire objective for the first three clinics is just to take records to make a copy of the patient, not just a copy of the arches, but also the relation between the arches, and we said for the first three visits we are just taking records, I havent made anything yet. 1) In the first visit, Ill take something very simple, Ill make something called primary impression , I cant just make a ball and put it in the patients mouth like a chewing gum, I need to use some kind of container to carry the impression material from my work area into the patients mouth, we call this a tray .. ok?
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In the clinic: We put our impression material inside the tray, we take it to the patients mouth, its soft, but inside the patients mouth it will solidify, either because of temperature, itll cool down and become stable and solid, or due to a chemical reaction.. it will set and become ready to be taken out of the patients mouth. Now, In general, almost all impression materials last for about 2 10 minutes. Actually very few last to 10 minutes, most of the materials between 2-6 minutes maximum, because the patient cant stand it, you cant keep your mouth open, and breathe and feel comfortable with the material inside your mouth for so long, so most of the materials last for 2-6 minutes. In the lab well talk about some examples of the materials that well be able to use. So we take a tray, now, you are seeing the patient for the first time; the tray we have wasnt specifically designed for the patient. We said in the lab that this tray is one size, fits all, just like you walk into a store and ask for small, medium or large clothes, when the patient comes to our clinic, we first take the impression, I ask for a small/ medium/large tray, its made by a company, it should fit in the patients mouth closely, but not closely enough to take an accurate impression, just good enough to be able to take a general impression, just to know how the patients mouth looks like when Im in the lab.. So Ill take this impression using a moderately accurate material, not the most accurate materials, using a moderately accurate stock tray, so I take my stock tray and I take my initial or primary impression. I am done in the clinic as a dentist, now I refer the work to my dental laboratory technician, I write a prescription, just like a doctor writes a prescription for a pharmacist, I say (Hello Mr. technician, can you please . using plaster) , in this case we use (gypsum type 2 (Plaster)) In the lab:
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So the technician mixes the dental plaster, pours the impression, and he ends up with a solid cast, so we have a negative replica turning into a solid or a positive replica which is the initial cast. We are going to use this cast to prepare for the next clinic, Ill say this again in the lab today, I know its boring, sorry, I keep repeating because I need you to fully understand it. Every clinic is the preparation for the next lab, and every lab is the preparation for the next clinic. So the technician will pour up the cast.. so again, we said its a primary impression, which isnt that accurate, that means my main objective in the next clinic is to take a secondary (or final or more accurate) impression. How can I do that? I take my primary cast, the one which I have here, and I can fabricate a special individually tailored custom tray .. So the technician makes this tray using a cold or a light type of acrylic, its a tray that I only use once. So the technician makes this tray, well see the steps in a moment, and then he will send this tray to me in the clinic, 2) In the clinic: Its the patients second visit.. and like I told you, you have to tell the patient on the first visit, that he has to make 6-7 visits, you should explain to him the steps, and why we are doing those steps.. This time, the tray is better, it fits better, and Ill use more accurate material to take the impression, well talk about that in the coming two lectures.. So I take my second or my final impression of the upper and lower, using the custom trays, so I take the impressions, or lets say I make them, I dont take them , I make the impression, and now Im done with the second clinical visit, I send them to the technician, and notice that the dental technician is very important in this process.. so he will receive them, read my instructions.. In the lab:
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This time, just like the last time, hes going to pour it up with a gypsum product, but this time Im going to use a material which is stronger, and more accurate.. Instead of gypsum 2 (plaster), hes going to use gypsum type 3 (stone).. So he pours it waits for it to set, separates it.. now he has two accurate models of the patients mouth.. But the technician still cant do anything with these two models to make a denture, because he has to know the relation between the upper and lower arches, which is specific to each individual patient.. So he prepares for my next clinic, my next clinic is called Jaw relationship records/ Jaw registration records or the bite registration.. In order to do this, he makes bases, covered with wax, we call these bases Record blocks .. Theres a plate which is made out of acrylic, and theres a RIM of wax which looks like a teeth, well them in a moment, hes just getting things ready for the next visit, hell send them back to me to the clinic (this is my 3rd clinic)..

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3) In the clinic: In the 3rd clinic, I take these record blocks and put them in the patients mouth, they wont fit in the patients mouth well, because the technician made the wax rims according to the average numbers, so in the clinic Ill modify them according to specific guidelines which well talk a lot more about in the future, in terms of height, support for the lip, statics, where the midline is, a lot of things Well modify the wax so that the patients face looks normal, so they can talk normally, smile and chew normally.. When I modify them, I seal them together, then Ill send them back to the technician.. In the lab: Now the technician has a relationship..so now the information is complete for the technician.. In the 3rd laboratory, the technician is ready to start making the denture.. so what hes going to do now.. he has teeth which are provided by the company, different shapes, different colors, hell set the teeth according to specific guidelines, and then hell return them to me in the clinic, in the 4th clinic, so I can check to see if they look good in the patients mouth, and this is called the try-in .. Again. 1st impression, 2nd impression, bite registration, try-in.. 4) In the clinic: So after the try-inif the patient is happy thats great, I need to turn the wax into the final acrylic which you learned in the dental materials called polymethal methacrylic (PMMA)

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In the lab: So we send it to the lab, theres along procedure, we do whats called flasking/ or dewaxing/ polishing/finishing/packing/puring , its one form of the lost wax technique, so weve turned the wax denture into a final acrylic denture, its end of the 4th laboratory. 5) In the clinic: Bach to the 5th clinic, now the patient gets the denture; its a long road.. In private clinics, they sometimes compress some of these steps, instead of taking primary impression and secondary one, they only take one, a good one.. but no matter how fast you are, itll take no less than a couple of weeks.. In our clinics in the university, a denture usually doesnt take any less than five weeks, If you are lucky, thats if you dont repeat steps, so it takes a while.. So when you treat patients, you need to make them aware of how much effort is placed into making a denture, its not a onetime procedure.. And like I said in previous lectures, the denture is not a replacement for natural teeth.. The tooth when its inside the mouth, its attached using a large periodontal membrane.. And we said that the periodontal membrane has a number of functions, its able to transmit force to the bone, the denture is not able to do this.. When you chew on the right, your left teeth do not touch, but with the denture, the denture is one piece, and its not attached using a periodontal membrane, its just attached using certain atmospheric pressure forces.. will learn about that next lecture.. Were talking about a patient who is 60-65 years oldthey dont want to get used to something new, its annoying, every time I chew my teeth move, so its difficult for the patient to adapt to it.. So as a prosthodontist when youre a dentist, youre a part psychologist, you spend all of 4 or 5 visits preparing the patient for what they are
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going to receivebut regardless what you tell them, theyll be surprised at the end.. Unless they had an old denture, and you make a better one.. If they like there old denture more than yours, then may god help you :P Because you have to start from zero. But the point is, its a challenging procedure, the rewards are very good at the end, if you did everything correctly, If not, it can be very disappointing and depressing.. Most students like doing prosthodontics preclinically (in the lab), and when they go to the 4th year, they stop liking it.. its a shame, because most dentists when they graduate, they dont make many removable prosthesis.. Actually, its a very relaxing part of dentistry, Im a proshtodontist, I was trained to do fixed and removable. Maybe for every 10 patients I see, I make one complete denture, but I look for them, because they relax me in clinic.. the amount of stress in making complete denture is much less for a partial denture, I know how to do it, because Im a specialist, but when I ask student who graduate, they are afraid to do it, because they had a bad experience during the clinical years.. In life, the things that take more effort, are usually the things that give a larger reward.. Lets take a look at these steps.. The patient comes in, we take a history of examination, we examine the patient in detail, just like medicine, when you go into a medical office, the doctor asks specific questions, as dentists, we do the same.. I am looking for information like, how long have you had your teeth extracted? 1 month ago, 1 year ago10 years, 100 years ago??? Dont laugh, I had a patient who had her teeth extracted when she was 18and now shes over 100 years old.. and she was wearing the same denture since she was 18. So people can have dentures for a long long period of time, it makes a difference to your treatment and how you proceed, you need to make sure if your patient had previous dentures.. you tell me, a patient comes to you a says, I extracted my teeth 10 years
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ago, and Ive been wearing the same denture since that time, I want a new one another patient comes and says, I had my teeth extracted two years ago, and I made 8 dentures since then.. Which one you think youll like better? Which one is probably going to give you more problems? The second one, theres a reason why he made all of these dentures, he didnt choose you because youre the best dentist, its because hes exhausted of all the dentist in the area, his problem is he doesnt like dentures, you need to start thinking about other options. So the history of examination is very important, because it makes you understand what your expectations are for the patient, and what the patients expectations are.. So the patient comes in, you examine, take the primary impression, in the lab Im going to talk in more details about this we have different materials to take impressions, and we have different types of trays.. Most of the materials can be used in 80% of the impressions, but some materials are only good for specific types of people.. The material that you see here on the screen is alginate, its a synthetic type of sea weed, not made of it, but based on sea weed products, its a complex of polysaccharide, technically, its known as irreversible hydrocolloid.. So you examine the patient, see where the teeth where extracted, and you will learn in the coming lectures, that when you look at this ridge, and you look again after a year, it wont be the same, does anybody know why? Because of resorption what do you know about resorption? Do you know the concept of function-maintaining the body structure? If you dont use a part of your body, youll lose it.. the body has no reason to maintain it.
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The same for teeth, the reason you have alveolar bone is because there are teeth.. people who have congenital diseases who were born without teeth, dont have alveolar bone, so when you extract the teeth, the body says ( I dont need this bone anymore), the root is no longer inside the alveolar bone, so slowly and over time it resorps, specially in the first year, in the first year we lose a lot of bone.. Its one of the reasons why, when I make a denture today, they have to come 3-5 years later, and modify the denture and reline it.. ( ) When taking the impression, the patient should be setting right, not laying back, not bend forward.. The position of the doctor in relation to the patient is important, how you approach the patient for the mandibular arch we approach from the front, for the maxillary arch from behind.. We can use alginate for the impression compound, alginate is on the left, we just need a mixing bowl, or a rubber bowl, and on the right we need a hot water bath.. the trays are different, they can be plastic or metal, perforated or not, it depends on the material used. Impression compounds have non-perforated trays, alginate has perforated trays, you can see we are mixing the alginate, and then we take our primary impressions.. We use different materials in different locations.. So the impression compound is placed in the tray, seated inside the patients mouth, and when we take it out of the patients mouth, itll record the ridge of the patients mouth, we have to help the patient to move their cheek and lips and tongue.. its not just a static impression, its a dynamic impression, we send it to the lab, mix the dental plaster, we pour it inside, and we end up with a model.. This is our primary cast,

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Type 2 plaster, we make a tray, a custom tray, and then using a special procedure called border molding well talk about it later, we take an accurate impression of the patients mouth The secondary impression is taken in two stages We take an impression of the border. And we take an impression of the surface. This is the border impression, and this is the surface impression using an accurate type of impression material.. this impression will be more accurate than the primary impression.. Now, in the laboratory, they make record blocks ( ,)we put these in the patients mouth, youll notice that when the patient loses their teeth they dont have lips support, their jaw will close more than normal, its our job to put the patients face back to the way it was when teeth were present, thats why we need the record blocks, youll notice now that the patient has lips support.. youll also notice that they have the correct relation between the upper and lower lip, we have to make a specific occlusal planes, so that when the patient smiles, they dont look like rabbits, or they look too old we need to know where the midline is, it needs to be lined with the midline of the face, we need to know where the canines are.. There are specific instruments and guidelines that you need to learn about in the coming lectures So we seal the upper and lower arches together using a special wax, we select the teeth that we want, the teeth which are appropriate for the patients skin color, age, habits, and then we put it on the articulator, like the one you have, and then we do wax try-in, we check these teeth inside the patients mouth then we process. Im not going to talk about the details of processing because its a little bit complicated. We process the dentures, then we give the denture to the patient, and we make sure that it fits correctly, and we give them instructions and this is not the end of the story,

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Making the denture is half of the story, the patient need to come back to frequent appointments.. This is called an articulating paper, because the lower and upper teeth articulate together, so to make sure that the teeth meet evenly , we place the teeth on it, and where it touches we can know its (not clear)

Forgive me if theres any mistake, I did my best =)

THANK YOU!!! Done by: Katreen Suleiman

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