Prosthodontics

Enhanced CPD DO C

Deviprasad Nooji

Guy Lambourn, Himanshi Aggarwal, Kiran Kumar Krishnappa Salian, Ewen McColl and Prashanti Eachempati

A Comprehensive Guide to
Removable Partial Dentures.
Part 2: Impressions, Laboratory
Procedures, Insertion and
Case Studies
Abstract: This two-part series provides a comprehensive guide to fabricating definitive metal partial dentures, addressing the challenges
dental practitioners face in mastering prosthesis design. It aims to equip dental professionals with a thorough understanding of the theoretical
foundations and clinical methods for effective metal partial denture fabrication. Part 2 covers removable partial denture (RPD) design
philosophies, tooth preparation, secondary impressions, laboratory procedures, trial and final insertions, as well as post-insertion complications
and their management. Additionally, four case scenarios are included to help readers apply the knowledge gained from both parts to design a
metal partial denture.
CPD/Clinical Relevance: This series provides essential knowledge and practical techniques for designing and fabricating effective metal
partial dentures.
Dent Update 2024; 51: 534–540

Part 1 of this series explored key elements, design principles, surveying techniques, algorithms for metal partial dentures.
including indications, success factors, workflow for fabrication and decision In this part of the series, various
philosophies of removable partial
denture (RPD) designing, tooth
Deviprasad Nooji, BDS, MDS (Prosthodontics), Professor, Department of Prosthodontics, preparation, secondary impressions,
KVG Dental College and Hospital, Sullia, Karnataka, India. Guy Lambourn, BDS, MFDS laboratory prescriptions, laboratory
RCPS, MClinDent, MRD, FHEA, FDS RCS, FDTFEd Associate Professor, Consultant in
procedures, trial insertion and final
Prosthodontics, Peninsula Dental School, University of Plymouth. Himanshi Aggarwal,
insertion of RPDs are discussed.
BDS, MDS (Prosthodontics), Prosthodontics Resident, Department of Restorative
Sciences, School of Dentistry, University of Alabama at Birmingham, AL, USA. Kiran
Kumar Krishnappa Salian, BDS, MDS (Prosthodontics), Prosthodontist, Saligrama Case studies
Dental Care, Karnataka, India. Ewen McColl, BSc (Hons), BDS, FDS RCPS, FCGDent, The authors have presented
MRD RCS Ed, MClinDent, FDS RCS(Rest Dent), FDTFEd, FFD RCSI, FHEA, Head of School, hypothetical case scenarios for readers
Director of Clinical Dentistry, Peninsula Dental School, University of Plymouth. Prashanti to solve, offering an opportunity to
Eachempati, BDS, MDS (Prosthodontics), MSc, MPhil, DICOI, FADI, FICCDE, FAIMER, apply and practise the design concepts
FAoME, Peninsula Dental School, University of Plymouth; Professor, Manipal University learned in the two parts of this article
College Malaysia, Melaka, Malaysia.
series. The four case studies can be
email: [Link]@[Link]
found throughout this article.

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Philosophy of designing RPDs

When designing a tooth tissue-supported
prosthesis, there are diverse theories
guiding the allocation of support between
the edentulous ridge and remaining teeth.
These are stress equalization, physiological
basing and broad stress distribution.1,2
Stress equalization suggests using the
resilient mucosa as a cushion, incorporating
stress reducing features to transfer loads
from abutment teeth to the edentulous
ridge. Physiological basing relies on mucosal
resilience, emphasizing equalization
using impression techniques to record
the anatomy under function. Broad stress
distribution aims for rigidity in the partial
denture framework, using connectors, rests,
Figure 1. Ideal preparation features of an occlusal rest.
clasp assemblies, and coverage to minimize
strain on abutment teeth. Combining these
philosophies ensures an optimal balance
between stability, comfort, and preservation
technique6) is advocated for Kennedy class I
of the oral tissues.1,2
and II situations. This technique aims to
enhance denture base support, maintaining
Tooth preparation occlusal contact and minimizing denture
base movement under load.5,6
Abutment preparations on sound enamel or
Functional impressions can be
existing restorations
achieved through physiological impression
We recommend that tooth preparations
techniques (McLean physiologic
in sound teeth do not compromise Figure 2. Anatomic impression for Class III,
impression, functional reline method,
the integrity of the enamel and due modification I situation with optimal recording of
consideration is given to the planned fluid wax technique) and the selective
the functional depth of sulcus.
occlusion. The first step in tooth preparation pressure technique.6 For example, in
should be to prepare the guide planes on the functional impression technique, a
the proximal surfaces of the abutment custom tray is made for the saddle area,
teeth to limit the path of insertion and abutment tooth over the buccal and lingual and border molding is performed using
withdrawal of the planned prosthesis walls as well as base of the occlusal rest seats a low-fusing compound. Subsequently,
while simultaneously improving frictional must be incorporated.3 a functional impression is made using
retention.3 It is advisable to verify the an appropriate secondary impression
adequacy of preparations through a material that replicates the functional
Secondary impressions for loading of the tissues. The secondary
check-cast. Once the guide planes are
placed, the rest seats can be prepared over metal partial dentures impression is re-inserted into the oral cavity,
the occlusal and/or cingulum surfaces.3,4 The single-stage impression technique is and an over-impression is made using
Finally, additional retentive features such appropriate for a partial denture that is alginate with a stock tray, capturing the
as changing the height of contour on primarily tooth supported (Figure 2) because anatomical impression simultaneously. This
abutment teeth either by subtractive resistance to functional loading is provided process is commonly known as the dual
or additive techniques may be useful in predominantly by the teeth.5–7 This impression impression technique.6
some cases. Rounding off preparation technique leads to a cast that captures the Secondary impressions for the digital
margins is essential to eliminate sharp oral structures in their resting position. workflow involve the use of an intra-oral
edges and unsupported enamel, reducing This impression technique does not scanner where the software subsequently
stress concentration in these areas.3 Ideal capture the soft tissues under loading combines the scans to generate a
preparation features for the occlusal rests conditions which will occur during normal comprehensive full-mouth image.8
are outlined in Figure 1. function in the posterior portion of the Intra-oral scanning is suitable for tooth
denture in Kennedy class I and II scenarios. supported cases (Kennedy class III and IV).
Abutment preparations for crowns with As a result, this may create uneven However, it cannot adequately capture the
denture features (contoured crowns) masticatory load distribution, increasing physiological and functional extension in
Contoured crowns must have suitable space stress on abutment teeth and the bone Kennedy class I and II cases.8,9 Therefore, in
for all planned components of the denture, beneath the distal extension area, potentially such cases, master casts generated using
for example guide planes, rest seats, leading to bone loss and tooth mobility.5,6 the conventional impression techniques are
undercuts, and space for minor connectors.3 For this reason, the functional impression preferred, and these can then be scanned to
Additional preparation of the underlying technique (altered cast or Applegate generate STL files (Figure 3).

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Case 1
A 48-year-old patient reported to the clinic  Maxillary and mandibular diagnostic
with multiple missing teeth, requesting a impressions were made to obtain
partial denture. The case was evaluated for diagnostic casts.
the suitability for a metal partial denture and
the design needed to be planned. Summary of findings after surveying
Undercut noted on potential abutment teeth
Intra-oral examination  UR5: undercut: 0.25 mm at mesio-buccal
 Edentulous ridge is low and well rounded; and mid-facial surface;
 The mucosa is firm and resilient;  UL5: undercut: 0.25 mm at mesio-buccal Figure 7. Arbitrary blockout.
 The patient has a low smile line, with the and mid-facial surface.
posterior teeth not visible during speech;
 All the teeth present are periodontally
instructions. The prescription must
sound, minimally restored and caries free.
effectively convey the positions of all
components within the removable partial
Maxilla denture.12 To achieve this, the design of
 UL6, UL7, UL8, UR6, UR7, UR8 are missing; the removable partial denture should be
 Absence of tori. illustrated and explained in detail as part
of the prescription. The design diagram
Mandible can be clarified by employing a color-
 All the mandibular teeth are present coded system to distinguish between
except LL8 and LR8. various components or functions of the
RPD. There is no universally accepted
Radiographic evaluation colour coding and different countries
 Nothing abnormal detected, with follow different color schemes. However,
Design an appropriate metal partial denture for the colour scheme must be mutually
adequate bone support for all this patient.
abutment teeth; agreed upon by the dentist and technician
to avoid confusion. 11–13
The dentist needs to furnish the dental
laboratory team with:
 A detailed prescription delineating the
desired prosthesis;
 A meticulously surveyed diagnostic cast
with a specific design;
 A precisely articulated master cast that
faithfully reproduces the existing hard
and soft tissue contours.
Figure. 3 Scanning of master casts.
Figure 5. Parallel blockout.
Framework design and
wax patterns
There are two methods of framework
fabrication: analogue and digital.

Analogue method
This method involves a conventional wax
pattern fabrication, investing, casting
Figure 4. Locating the retentive undercuts. Figure 6. Shape blockout. and finishing of the framework.10 Before
commencing with the construction of
the framework, the dental laboratory
technician must transfer the specified
Dentist–laboratory relations encompassing the design and materials design from the diagnostic cast to the
For achieving optimal outcomes it is crucial used in any partial denture fabrication.10 master cast. This includes transferring
for the dentist and dental technician, or A written prescription (work tripod points from diagnostic cast to
clinical dental technician to work cohesively authorization order) should always master cast, surveying for marking
as a team in the construction of removable accompany any clinical information sent the height of contour and locating
partial dentures.10–13 The dentist bears the to the dental laboratory to ensure the suitable areas for retentive components
ultimate responsibility for the prescription final prosthesis conforms to the provided (Figure 4). It is followed by placing

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Case 2
A 52-year-old patient reported to the clinic Radiographic evaluation
with multiple missing teeth, requesting a  Nothing abnormal detected, with
partial denture. The case was evaluated for adequate bone support for all
the suitability for a metal partial denture abutment teeth.
and design needs to be planned.
Summary of findings after surveying
Intra-oral examination Undercut noted on potential abutment teeth
 Edentulous ridge is low and  LR7: undercut: 0.25 mm at
well rounded; mesio-lingual surface;
Figure 8. Mould for cast duplication.  The mucosa is firm and resilient;  LR3: undercut: 0.25 mm at
 The patient has a low smile line, mesio-facial surface;
with the posterior teeth not visible  LR4: undercut: 0.50 mm at
during speech; mesio-facial surface;
 All the teeth present are periodontally  LL7: undercut: 0.25 mm at the
sound, minimally restored and disto-facial surface.
caries free.

Maxilla
 All teeth present.

Mandible
 LR8, LR6, LR5, LR4, LL5 and LL6
are absent;
Figure 9. Pouring of investment material.
 LR8 is not to be replaced;
 LR7 is mesiolingually tilted;
Design an appropriate cast partial denture for
 The minimum lingual sulcus depth this patient.
is 10 mm.

the design on the duplicate cast using (acetal resin), polyamides,

prefabricated patterns. polyaryletherketone polymers (PAEK),
The refractory cast is then invested, aryl ketone polymers (AKP), and
followed by wax burnout and casting in polyetheretherketone (PEEK). Cobalt
a chrome cobalt (Figures 10 and 11) or chromium and titanium can be fabricated
any other suitable alloy. The framework is through conventional lost-wax methods
finally finished and polished. or using milled/3D printed castable
Figure 10. Sprue attachment. patterns employing techniques such as
selective laser sintering (SLS) and selective
Digital method
layer melting (SLM).15 Milled patterns offer
Advancements in digital technology,
the advantages of eliminating the labour-
along with the rapid progress in
intensive process of creating a refractory
computer-aided manufacturing methods
cast from the master cast and forming
and innovative materials, have opened
the wax pattern manually. Additionally,
new possibilities beyond traditional cast
the milling process ensures consistent
removable partial denture frameworks.
size and thickness based on the software
Additive and subtractive protocols
design. Frameworks cast from CAD/CAM
within computer-aided design and
milled patterns typically require minimal
manufacturing (CAD/CAM) are being
adjustment, finishing, and polishing
refined to surpass the limitations and
(Figures 12–14).14
Figure 11. Casting. inaccuracies associated with casting.14
Simultaneously, different resin-based
polymers have emerged in the market Try-in and insertion
wax to block out undesirable undercuts to meet the growing need for more The fitting of the framework involves
(Figures 5–7) and relief as required. aesthetically pleasing clasp assemblies.14 both pre-clinical inspection and clinical
The master cast is then duplicated in Various materials suitable for digitally adjustment, ensuring proper adaptation to
refractory material (Figures 8 and 9) and fabricating frameworks including cobalt the hard and soft tissues and conforming
the framework is waxed-up according to chromium, titanium, polyoxymethylene with the chosen occlusal scheme.1

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Case 3
A 55-year-old patient reported to the clinic Radiographic evaluation
with multiple missing teeth, requesting a  Mandibular anteriors had moderate
partial denture. The case was evaluated for horizontal bone loss.
the suitability for a metal partial denture
and design needs to be planned. Summary of findings after surveying
Undercut noted on potential abutment teeth
Intra-oral examination  RL6, RL5, RL7: undercut: 0.2 5mm
 Edentulous ridge is high and on mesial and distal surface on the
well rounded; buccal side;
 The mucosa is firm and resilient;  RL4: undercut: 0.25 mm at mid-facial
Figure 12. Addition of spacer.  The patient has a low smile line, surface of the teeth;
with the posterior teeth not visible  No soft tissue undercuts were present.
during speech;
 Class III buccal frenal attachment is
noted bilaterally in the mandibular arch;
 All the teeth present are periodontally
sound, minimally restored and caries
free unless noted.

Mandible
 LL5, LL6, LL7 and LL8 are absent;
 Grade I mobility with diastemas is
noted between all the anterior teeth;
 The minimum lingual sulcus depth
is 10 mm.
Figure 13. Digital wax-up.

Maxilla
Design an appropriate cast partial denture for
 All teeth are present except UL8
this patient.
and UR8.

master cast include checking for proper for occlusal interferences are the rests,
seating of rests, contact of reciprocal arms indirect retainers and minor connectors.
and proximal guide plates, intimate contact It is important to remember that the
of major connectors with the cast, adequate majority of cases will be restored in an
distance of major connector from abutment occlusally conformative approach and
teeth for hygiene purposes, ensuring as such the vertical dimension should
uniform taper of clasp arms and proper remain unchanged by the framework and
Figure 14. Digital framework. finishing/polishing of the framework.10,15 the interarch tooth contacts should be
identical with and without the framework
Clinical adjustment in the mouth. Following adjustment, any
Pre-clinical inspection Inadequate seating of a framework may roughened surfaces should be smoothed
The clinician must inspect the framework be due to binding against one or more and brought to a high polish. Knife-edge
to ensure that it follows the planned design of the abutment teeth. Identification of wheels, blue clasp polishers or other
and is accurately adapted to the master these areas can be facilitated by use of carborundum-impregnated points for
cast. If the framework does not fit the indicating media, such as paint on powders chrome cobalt alloys may be used to
master cast accurately, it is highly unlikely (Rouge with chloroform), spray type remove scratches and bring the adjusted
that the framework will seat precisely powders (Occlude), disclosing wax (Kerr), surface to a high shine quickly. For final
intra-orally. Even the best-looking partial silicone impression materials or indicating polishing, tripoli placed on a bristle brush
denture framework may not fit perfectly medium (e.g. Fit Checker).15,16 Following and rouge on a small diameter cloth wheel
in the mouth and therefore must be identification of these areas, adjustment may be used.10
adjusted intra-orally. A metal framework can be made with heatless stones, diamond After adjusting the partial denture
try-in appointment should be carried out burs, Brasseler E-Cutter burs, carborundum framework, it is essential to record the
at the earliest opportunity to minimize the disks and coarse stones. maxillomandibular relationship, and transfer
chance of intra-oral changes such as tooth Only once the framework is seated this on to the articulator for facilitating
migration. Key evaluation criteria when completely can any occlusal interferences setting of replacement denture teeth on the
assessing the fit of the framework on the be evaluated. The most common location framework The teeth try-in is then done to

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assess aesthetics, speech, and functionality.

Following try-in, final processing is done in
Case 4
the laboratory. The finished partial denture A 47-year-old patient reported to the clinic Radiographic evaluation
is delivered to the patient with necessary with multiple missing teeth, requesting a  No abnormalities detected.
adjustments carried out on the day of partial denture. The case was evaluated for
placement and during the post-placement the suitability for a metal partial denture Summary of findings after surveying
recall appointments. and design needs to be planned. Undercut on the tooth
 UL6, UL4, UR14, and UR6: undercut:
Post-insertion complications Intra-oral examination 0.25 mm on mesial and distal surface
and management of  Edentulous ridge is high and on the buccal side;
 UL7 and UR7: undercut: 0.25 mm at
common issues well rounded;
disto-facial surface of the teeth;
 The mucosa is firm and resilient;
Complications associated with a new partial  No soft tissue undercuts were present.
 The patient has a low smile line,
denture can be categorized into immediate,
with the posterior teeth not visible
intermediate, and delayed for ease of
during speech;
comprehension. In the following section we
 All the teeth present are periodontally
have outlined some of the potential issues.
sound, minimally restored and
caries free.
Immediate complications
Immediate complications arise during
the insertion of the prosthesis and are Mandible
commonly related to fit, peripheral  All teeth are present.
extension, and the occlusion. Pressure
indication paste, applied to the prosthesis’s Maxilla
intaglio surface with a brush stroke pattern,  UR3, UR2, UR1, UL1, UL2, and UL3
helps identify pressure points for necessary are absent;
adjustments, preventing future sore spots.15  A tori measuring 6 x 6 mm diameter is Design an appropriate cast partial denture for
Disclosing wax can reveal overextension in present in the centre of the hard palate. this patient.
peripheral borders, with caution exercised
to reduce it only if exceeding physiological
limits. Adjustments of the denture
occlusion should only commence after the
partial denture through use leading to Once the initial active phase of
prosthesis is fully seated in the patient’s
damage or wear of components. treatment has been completed it is
mouth, to generate harmonious contact
In distal extension prosthesis cases, equally important that a maintenance
in centric and eccentric positions and with
loss of retention may occur due to residual and monitoring plan is instigated with
natural teeth.15,16
ridge resorption, necessitating prosthesis periodic recalls based upon the patient risk
relining.18 Loss of natural teeth can be factors for ongoing support and treatment
Intermediate complications addressed by adding retentive tags on as required.
Intermediate complications commonly the major connector, but if an abutment
involve component fractures. Patient is lost, the adjacent tooth’s suitability
mishandling often causes fractures, must be evaluated for potential use as
Conclusion
necessitating patient education on proper an abutment, incorporating necessary The field of removable partial
prosthesis care and usage. Fractured modifications into the existing denture or prosthodontics stands at the intersection
retentive clasp arms may result from may require new prosthesis fabrication.17 of mechanical and biological factors,
improper design, and replacement with Improper oral and denture hygiene requiring a meticulous blend of scientific
a wrought wire clasp can be achieved maintenance and poor dietary control understanding and clinical expertise.
through soldering or embedding it into the in certain patients may lead to problems A thorough understanding of all the
framework.17 Fractured occlusal rests can such as the development of caries, design principles along with meticulous
be repaired by soldering a new rest, with periodontal disease and oral candidiasis. examination, diagnosis, and treatment
consideration for rest seat modification To mitigate these risks, it is important planning, plays a pivotal role in the success
if insufficiently prepared. Significant that every patient’s treatment plan is of removable partial denture. Above
complications such as fracture of the personalized, addressing their specific all, it is the utmost responsibility of the
major connector may require remaking risk factors for caries, periodontal and dentist to communicate effectively with
the prosthesis.17 other oral disease processes through diet the laboratory. The laboratory steps in the
analysis and advice, a tailored oral hygiene fabrication of metal partial dentures are just
Delayed complications and fluoride regime as well as specific as crucial as the clinical procedures.
Delayed complications may stem from medicaments to address other pathology The unavailability of a single best design
physiological or pathological changes in such as antifungal treatments for oral highlights the complexity of the decision-
the oral cavity or from changes to the metal candidiasis as necessary.19 making process, with multiple acceptable

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designs often emerging for a given partially 110–111. between dentists and dental technicians during
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