Single complete denture/ academy laser dentistry

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Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.

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Single complete denture/ academy laser dentistry

  1. 1. SINGLE COMPLETESINGLE COMPLETE DENTUREDENTURE INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 2. CONTENTSCONTENTS 1)1) INTRODUCTION.INTRODUCTION. 2)2) PROBLEM WITH SINGLE COMPLETE DENTURE.PROBLEM WITH SINGLE COMPLETE DENTURE. 3)3) COMMON OCCLUSAL DISHARMONIES ANDCOMMON OCCLUSAL DISHARMONIES AND WAYS TO ADJUST THEM.WAYS TO ADJUST THEM. 4)4) SINGLE COMPLETE DENTURE OPPOSINGSINGLE COMPLETE DENTURE OPPOSING A)A) NATURAL TEETH.NATURAL TEETH. www.indiandentalacademy.comwww.indiandentalacademy.com
  3. 3. B)B) RPDRPD C) FPDC) FPD D) EXISTING COMPLETE DENTURED) EXISTING COMPLETE DENTURE E) IMPLANT SUPPORTEDE) IMPLANT SUPPORTED PROSTHESIS.PROSTHESIS. 5) METHODS TO ACHIEVE5) METHODS TO ACHIEVE BALANCED OCCLUSIONBALANCED OCCLUSION www.indiandentalacademy.comwww.indiandentalacademy.com
  4. 4. www.indiandentalacademy.comwww.indiandentalacademy.com
  5. 5. 6) CINICAL PROCEDURE OF MAKING6) CINICAL PROCEDURE OF MAKING SINGLE COMPLETE DENTURE.SINGLE COMPLETE DENTURE. 7) OCCLUSAL MATERIALS FOR SINGLE7) OCCLUSAL MATERIALS FOR SINGLE COMPLETE DENTURESCOMPLETE DENTURES 8) SUMMARY8) SUMMARY 9) CONCLUSION9) CONCLUSION 10) REFERENCES10) REFERENCES www.indiandentalacademy.comwww.indiandentalacademy.com
  6. 6. INTRODUCTIONINTRODUCTION Many patients become edentulous in one archMany patients become edentulous in one arch while retaining some or all of their natural teethwhile retaining some or all of their natural teeth in the opposing arch. In this situation a singlein the opposing arch. In this situation a single complete denture is fabricated.complete denture is fabricated. www.indiandentalacademy.comwww.indiandentalacademy.com
  7. 7. A single complete denture may be desirableA single complete denture may be desirable when it is to oppose any one of them:when it is to oppose any one of them: 1.1. Natural teeth that are sufficient in number notNatural teeth that are sufficient in number not to necessitate a fixed or removable partialto necessitate a fixed or removable partial denture.denture. 2. A partially edentulous arch in which missing2. A partially edentulous arch in which missing teeth have been or will be replaced by RPD.teeth have been or will be replaced by RPD. www.indiandentalacademy.comwww.indiandentalacademy.com
  8. 8. 3. A partially edentulous arch in which missing3. A partially edentulous arch in which missing teeth have been or will be replaced by FPD.teeth have been or will be replaced by FPD. 4. An existing Complete denture.4. An existing Complete denture. 5. Implant supported Complete denture.5. Implant supported Complete denture. www.indiandentalacademy.comwww.indiandentalacademy.com
  9. 9. Dentist faces many difficulties in rehabilitatingDentist faces many difficulties in rehabilitating the patients with this clinical pattern.the patients with this clinical pattern. Malposed, tipped, or supraerupted teeth make itMalposed, tipped, or supraerupted teeth make it difficult to achieve a harmonious balanceddifficult to achieve a harmonious balanced occlusion and also interfere in proper placementocclusion and also interfere in proper placement of artificial teeth to achieve adequate esthetics.of artificial teeth to achieve adequate esthetics. As a result of unfavorable occlusalAs a result of unfavorable occlusal relationships there is a tendency of denture torelationships there is a tendency of denture to get displaced, causing soreness, mucosalget displaced, causing soreness, mucosal changes and ultimately ridge resorption.changes and ultimately ridge resorption. www.indiandentalacademy.comwww.indiandentalacademy.com
  10. 10. PROBLEM WITH SINGLEPROBLEM WITH SINGLE COMPLETE DENTURECOMPLETE DENTURE www.indiandentalacademy.comwww.indiandentalacademy.com
  11. 11. 1.1. Greater magnitude of forcesGreater magnitude of forces Changes in the underlying boneChanges in the underlying bone Denture in the long term will beDenture in the long term will be compromised.compromised. www.indiandentalacademy.comwww.indiandentalacademy.com
  12. 12. 2.2. Related to occlusal form of the remainingRelated to occlusal form of the remaining natural teeth:natural teeth: This occlusal form dictates occlusal form of theThis occlusal form dictates occlusal form of the denturedenture  might be unsuitable for the denture.might be unsuitable for the denture. www.indiandentalacademy.comwww.indiandentalacademy.com
  13. 13. Supraerupted Tilted teeth www.indiandentalacademy.comwww.indiandentalacademy.com
  14. 14. Occlusal scheme causingOcclusal scheme causing more horizontal forcesmore horizontal forces www.indiandentalacademy.comwww.indiandentalacademy.com
  15. 15. These factors causes occurrence of “These factors causes occurrence of “ SingleSingle denture syndromedenture syndrome”” - loose or tilting denture- loose or tilting denture -damage of mucosa-damage of mucosa - ridge resorption.- ridge resorption. www.indiandentalacademy.comwww.indiandentalacademy.com
  16. 16. COMMON OCCLUSALCOMMON OCCLUSAL DISHARMONIES AND WAYSDISHARMONIES AND WAYS TO ADJUST THEMTO ADJUST THEM www.indiandentalacademy.comwww.indiandentalacademy.com
  17. 17. 1. Tilted molars with distal halves supraerupted www.indiandentalacademy.comwww.indiandentalacademy.com
  18. 18. Steeply inclined occlusal surfaces tend to drive denture forward when brought into centric occlusion. www.indiandentalacademy.comwww.indiandentalacademy.com
  19. 19. Only contact is on the distal half of lower molar in protrusive and lateral excursions Denture easily dislodged during functional movements. www.indiandentalacademy.comwww.indiandentalacademy.com
  20. 20. ADJUSTMENTS FOR TILTEDADJUSTMENTS FOR TILTED MOLARSMOLARS A)A) If molars are notIf molars are not severely tiltedseverely tilted can be reshaped bycan be reshaped by selective grinding.selective grinding. www.indiandentalacademy.comwww.indiandentalacademy.com
  21. 21. B)B) If more toothIf more tooth structure is neededstructure is needed to be removedto be removed Restore with crown orRestore with crown or FPD.FPD. www.indiandentalacademy.comwww.indiandentalacademy.com
  22. 22. C)C) If large space existIf large space exist mesial to tilted molarmesial to tilted molar RPD restoring the mesialRPD restoring the mesial half of the molars,half of the molars, lower the distal cuspslower the distal cusps (mesial half onlay(mesial half onlay mesial rest .)mesial rest .) www.indiandentalacademy.comwww.indiandentalacademy.com
  23. 23. D)D) OrthodonticOrthodontic repositioningrepositioning of tilted molarof tilted molar E)E) If severely tilted andIf severely tilted and supraeruptedsupraerupted ExtractionExtraction www.indiandentalacademy.comwww.indiandentalacademy.com
  24. 24. 2.2. Natural lower cuspids andNatural lower cuspids and incisors are supraeruptedincisors are supraerupted www.indiandentalacademy.comwww.indiandentalacademy.com
  25. 25. SelectiveSelective grindinggrinding www.indiandentalacademy.comwww.indiandentalacademy.com
  26. 26. Cuspid region, occlusal adjustment should aim atCuspid region, occlusal adjustment should aim at providing a definite distal slope on the lowerproviding a definite distal slope on the lower cuspid so as to allow space for free passage ofcuspid so as to allow space for free passage of the upper artificial cuspid between the lowerthe upper artificial cuspid between the lower cuspid and first premolar in lateral movements.cuspid and first premolar in lateral movements. www.indiandentalacademy.comwww.indiandentalacademy.com
  27. 27. www.indiandentalacademy.comwww.indiandentalacademy.com
  28. 28. A)A) SINGLE COMPLETE DENTURE OPPOSINGSINGLE COMPLETE DENTURE OPPOSING NATURAL TEETHNATURAL TEETH 1.1. Maxillary complete dentureMaxillary complete denture opposing natural mandibularopposing natural mandibular teeth.teeth. www.indiandentalacademy.comwww.indiandentalacademy.com
  29. 29. PROBLEMSPROBLEMS a)a) Malposed ,tipped and supraerupted teeth inMalposed ,tipped and supraerupted teeth in lower arch and unfavorable plane oflower arch and unfavorable plane of occlusion.occlusion. b)b) Fixed position of mandibular anterior teethFixed position of mandibular anterior teeth c)c) Problem of wear of teeth:Problem of wear of teeth: i)i) Artificial teethArtificial teeth If acrylic is used.If acrylic is used. ii)ii) Natural teethNatural teeth If porcelain is used.If porcelain is used. d)d) Frequent fractures of dentureFrequent fractures of denture www.indiandentalacademy.comwww.indiandentalacademy.com
  30. 30. Diagnostic procedures shouldDiagnostic procedures should determine the following:determine the following: 1.If there are sufficient teeth in the mandibular1.If there are sufficient teeth in the mandibular arch.arch. According toAccording to SharrySharry: if there is class II jaw: if there is class II jaw relation, a complete denture often may berelation, a complete denture often may be constructed against lower anterior teeth andconstructed against lower anterior teeth and premolars without replacing molars.premolars without replacing molars. The lower premolars areThe lower premolars are far enough posteriorfar enough posterior in relation to the maxillary ridge, that the forcesin relation to the maxillary ridge, that the forces of occlusion are directed to theof occlusion are directed to the middle-posteriormiddle-posterior part of the upper denture.part of the upper denture.www.indiandentalacademy.comwww.indiandentalacademy.com
  31. 31. Forces directed to Middle Posterior part of Upper denture www.indiandentalacademy.comwww.indiandentalacademy.com
  32. 32. But if class III jawBut if class III jaw relationrelation situation issituation is differentdifferent becausebecause mandibular premolarsmandibular premolars would apply occlusalwould apply occlusal forces against theforces against the anterior part of theanterior part of the maxillary ridge.maxillary ridge. www.indiandentalacademy.comwww.indiandentalacademy.com
  33. 33. Acc to WinklerAcc to Winkler: In any event, replacement of: In any event, replacement of missing posterior teeth will enhance themissing posterior teeth will enhance the retention and stability of the maxillary completeretention and stability of the maxillary complete denture and help to distribute the functionaldenture and help to distribute the functional forces more evenly on the residual maxillaryforces more evenly on the residual maxillary ridge.ridge. www.indiandentalacademy.comwww.indiandentalacademy.com
  34. 34. Ellinger et al (JPD 1971:26;6) :Ellinger et al (JPD 1971:26;6) : A lower RPD should be indicated in all situations whenA lower RPD should be indicated in all situations when all molarsall molars are missing.are missing. • If upto first molar leftIf upto first molar left RPD may not be necessary.RPD may not be necessary. www.indiandentalacademy.comwww.indiandentalacademy.com
  35. 35. • If one side uptoIf one side upto premolars andpremolars and others upto firstothers upto first molarmolar RPD mayRPD may not be necessary.not be necessary. Missing molar beMissing molar be replaced by areplaced by a cantileveredcantilevered premolar ponticpremolar pontic having 2-3having 2-3 abutments.abutments. www.indiandentalacademy.comwww.indiandentalacademy.com
  36. 36. 2)2) Periodontal health of the remaining teeth isPeriodontal health of the remaining teeth is acceptable.acceptable. 3)3) There are no missing teeth to be replaced.There are no missing teeth to be replaced. 4)4) position of mandibular anterior teeth.position of mandibular anterior teeth. www.indiandentalacademy.comwww.indiandentalacademy.com
  37. 37. 5)5) Condition of posterior teethCondition of posterior teeth a)a) Irregular occlusal plane.Irregular occlusal plane. b)b) Occlusal surface of natural teeth too largeOcclusal surface of natural teeth too large bucco-lingually.bucco-lingually. c) Occlusal form.c) Occlusal form. www.indiandentalacademy.comwww.indiandentalacademy.com
  38. 38. Prior to any occlusal modifications of the naturalPrior to any occlusal modifications of the natural teeth, maxillary and mandibular casts should beteeth, maxillary and mandibular casts should be mounted on articulator.mounted on articulator. Now whatever adjustments that may beNow whatever adjustments that may be necessary can be planned.necessary can be planned. www.indiandentalacademy.comwww.indiandentalacademy.com
  39. 39. Techniques to determine theTechniques to determine the necessary tooth modificationsnecessary tooth modifications prior to denture construction.prior to denture construction. www.indiandentalacademy.comwww.indiandentalacademy.com
  40. 40. 1)1) BY SWENSONBY SWENSON Casts mounted on articulator using provisionalCasts mounted on articulator using provisional CR at acceptable vertical dimension.CR at acceptable vertical dimension. Maxillary record base made and teeth are setMaxillary record base made and teeth are set If lower teeth interfere with placement of dentureIf lower teeth interfere with placement of denture teethteeth adjusted on cast and areas markedadjusted on cast and areas markedwww.indiandentalacademy.comwww.indiandentalacademy.com
  41. 41. Areas to be modified are marked with pencil on the cast www.indiandentalacademy.comwww.indiandentalacademy.com
  42. 42. Natural teeth modified accordinglyNatural teeth modified accordingly New diagnostic cast of lower arch made andNew diagnostic cast of lower arch made and mountedmounted If more adjustments neededIf more adjustments needed  repeat therepeat the procedure.procedure. Tech.Tech. simplesimple butbut time consumingtime consuming.. www.indiandentalacademy.comwww.indiandentalacademy.com
  43. 43. 2)2) BRUCEBRUCE (JPD 1971:26:448-455)(JPD 1971:26:448-455) Advised reshaping natural teeth using a resinAdvised reshaping natural teeth using a resin templatetemplate www.indiandentalacademy.comwww.indiandentalacademy.com
  44. 44. Areas to be modified are marked with pencil on the cast www.indiandentalacademy.comwww.indiandentalacademy.com
  45. 45. Clear acrylic resin template is formed over the corrected cast www.indiandentalacademy.comwww.indiandentalacademy.com
  46. 46. Initial modifications done. Template coated with pressure Indicating paste and placed over patients teeth. www.indiandentalacademy.comwww.indiandentalacademy.com
  47. 47. Interferences can be seen through the clear template and can be removed accordingly. Process repeated till template fits the teeth perfectly  Advantage: produces accurate results. www.indiandentalacademy.comwww.indiandentalacademy.com
  48. 48. 3)3) BY YURKSTAS:BY YURKSTAS: Advised useAdvised use of a metalof a metal ‘‘U’ shapedU’ shaped occlusalocclusal templatetemplate www.indiandentalacademy.comwww.indiandentalacademy.com
  49. 49. 2.2. Mandibular complete dentureMandibular complete denture opposing natural maxillaryopposing natural maxillary teeth.teeth. www.indiandentalacademy.comwww.indiandentalacademy.com
  50. 50. 1)1) Preservation of residual alveolar ridge:Preservation of residual alveolar ridge: a)a) Greater force exerted +smaller basal seatGreater force exerted +smaller basal seat area.area. rapid loss of supporting bone fromrapid loss of supporting bone from mandiblemandible  decreased retention and stability +decreased retention and stability + frequent fractures of denturefrequent fractures of denture Factors that must be evaluated before thisFactors that must be evaluated before this treatment option is consideredtreatment option is considered www.indiandentalacademy.comwww.indiandentalacademy.com
  51. 51. b) Mandible movable member of stomatognathicb) Mandible movable member of stomatognathic systemsystem more difficult to stabilize the denture.more difficult to stabilize the denture. c) Proximity to tongue.c) Proximity to tongue. Therefore, considering preservation ofTherefore, considering preservation of residual ridgeresidual ridge onlyonly as the main factor foras the main factor for dictating the treatment plan of a completedictating the treatment plan of a complete mandibular denture then this plan is totallymandibular denture then this plan is totally contraindicated.contraindicated. www.indiandentalacademy.comwww.indiandentalacademy.com
  52. 52. 2.2. Necessity of retainingNecessity of retaining maxillary teeth:maxillary teeth: MaxillaryMaxillary dentition maydentition may be neededbe needed to retainto retain a prosthesis.a prosthesis. 3.3. Mental traumaMental trauma www.indiandentalacademy.comwww.indiandentalacademy.com
  53. 53. B)B) SINGLE COMPLETESINGLE COMPLETE DENTURE OPPOSINGDENTURE OPPOSING REMOVABLE PARTIALREMOVABLE PARTIAL DENTUREDENTURE www.indiandentalacademy.comwww.indiandentalacademy.com
  54. 54. www.indiandentalacademy.comwww.indiandentalacademy.com
  55. 55. Ellinger et al (JPD 1971:26;6) :Ellinger et al (JPD 1971:26;6) : A lower RPD should be indicated in all situationsA lower RPD should be indicated in all situations when all molars are missing.when all molars are missing. If upto first molar leftIf upto first molar left RPD may not beRPD may not be necessary.necessary. If one side upto premolars and others upto firstIf one side upto premolars and others upto first molarmolar RPD may not be necessary.RPD may not be necessary. Missing molar be replaced by a cantileveredMissing molar be replaced by a cantilevered premolar pontic having 2-3 abutments.premolar pontic having 2-3 abutments. www.indiandentalacademy.comwww.indiandentalacademy.com
  56. 56. Ellsworth KellyEllsworth Kelly (JPD1972:27;140)(JPD1972:27;140) gave the term “gave the term “COMBINATION SYNDROMECOMBINATION SYNDROME” to” to those changes that are seen in patients withthose changes that are seen in patients with maxillary complete denture and a mandibularmaxillary complete denture and a mandibular bilateral distal extension RPD.bilateral distal extension RPD. www.indiandentalacademy.comwww.indiandentalacademy.com
  57. 57. Some characteristic changes in CombinationSome characteristic changes in Combination syndrome( Anterior hyperfunction syndrome)syndrome( Anterior hyperfunction syndrome) are:are: i)i) Loss of bone from anterior part of the maxillaryLoss of bone from anterior part of the maxillary ridge.ridge. ii)ii) Overgrowth of the maxillary tuberosities.Overgrowth of the maxillary tuberosities. www.indiandentalacademy.comwww.indiandentalacademy.com
  58. 58. iii)iii) Papillary hyperplasia in the hard palate.Papillary hyperplasia in the hard palate. iv)iv) Extrusion of lower anteriors.Extrusion of lower anteriors. v)v) Loss of bone under the lower partial dentureLoss of bone under the lower partial denture base .base . www.indiandentalacademy.comwww.indiandentalacademy.com
  59. 59. www.indiandentalacademy.comwww.indiandentalacademy.com
  60. 60. BY SAUNDER’S ET AL (JPD 1979:41:124) www.indiandentalacademy.comwww.indiandentalacademy.com
  61. 61. Sequence of changesSequence of changes First change to occur?First change to occur? Acc to Kelly et alAcc to Kelly et al (JPD1972:27;140)(JPD1972:27;140)  loss ofloss of bone from the anterior part of the maxillary jaw.bone from the anterior part of the maxillary jaw. Saunders et alSaunders et al ((JPD 1979:41:124)) bonebone resorption under the mandibular partial dentureresorption under the mandibular partial denture base.base. www.indiandentalacademy.comwww.indiandentalacademy.com
  62. 62. Loss of bone from anterior maxilla Flabby hyperplastic tissue Characteristic deep fold or crease www.indiandentalacademy.comwww.indiandentalacademy.com
  63. 63.  Maxillary denture displaced anteriorly and superiorlyMaxillary denture displaced anteriorly and superiorly  Tendency to develop epulis fissuratum associatedTendency to develop epulis fissuratum associated with labial flange.with labial flange.  Bone resorption also under mandibular DentureBone resorption also under mandibular Denture base.base.  Occlusal plane migrates up in anterior region andOcclusal plane migrates up in anterior region and down in posterior region.down in posterior region.www.indiandentalacademy.comwww.indiandentalacademy.com
  64. 64. With posterior palatal sealWith posterior palatal seal negative pressurenegative pressure produced posteriorly.produced posteriorly. Enlargement of tuberositiesEnlargement of tuberosities && Papillary hyperplasia.Papillary hyperplasia. www.indiandentalacademy.comwww.indiandentalacademy.com
  65. 65.  Lower anterior teethLower anterior teeth migrate upward andmigrate upward and periodontal changesperiodontal changes occur.occur. (change in occlusal(change in occlusal planeplane encouragesencourages protrusive occlusalprotrusive occlusal contactcontact risk ofrisk of extrusion andextrusion and flaring of mandibularflaring of mandibular anterior teeth)anterior teeth) www.indiandentalacademy.comwww.indiandentalacademy.com
  66. 66. Maxillary anterior teethMaxillary anterior teeth on the complete dentureon the complete denture disappear underdisappear under patients lips.patients lips. Esthetics become poorEsthetics become poor www.indiandentalacademy.comwww.indiandentalacademy.com
  67. 67. Loss of mandibular supportLoss of mandibular support Gradual decrease of occlusal load posteriorly andGradual decrease of occlusal load posteriorly and increased occlusal load anteriorlyincreased occlusal load anteriorly Resorption of maxillary anterior ridgeResorption of maxillary anterior ridge www.indiandentalacademy.comwww.indiandentalacademy.com
  68. 68. Ellsworth Kelly (JPD 1972:27;140) :Ellsworth Kelly (JPD 1972:27;140) : 3 yr study: all patients showed3 yr study: all patients showed a)a)1-3 mm loss of ridge height in maxillary anterior1-3 mm loss of ridge height in maxillary anterior regionregion b)b) 1-2.5 mm increase in height of tuberosity1-2.5 mm increase in height of tuberosity c)c) 1-1.5 mm extrusion of lower anteriors.1-1.5 mm extrusion of lower anteriors. www.indiandentalacademy.comwww.indiandentalacademy.com
  69. 69. Saunders et al (JPD 1979;41:126)Saunders et al (JPD 1979;41:126) Changes associated with combination syndromeChanges associated with combination syndrome are not necessarily seen in all patients withare not necessarily seen in all patients with maxillary complete denture and mandibularmaxillary complete denture and mandibular distal extension RPD.distal extension RPD. www.indiandentalacademy.comwww.indiandentalacademy.com
  70. 70. Prevention of combinationPrevention of combination syndromesyndrome Treatment planning to avoid this combination ofTreatment planning to avoid this combination of prosthesis.prosthesis. 1)1) Try and retain weak posterior teeth by means ofTry and retain weak posterior teeth by means of endodontic and periodontal therapies.endodontic and periodontal therapies. 2)2) Using lower anterior roots and givingUsing lower anterior roots and giving overdenture.overdenture. 3)3) Giving bilateral balanced occlusion.Giving bilateral balanced occlusion. www.indiandentalacademy.comwww.indiandentalacademy.com
  71. 71. Management of combinationManagement of combination syndromesyndrome • Diagnosis of cause and its correction.Diagnosis of cause and its correction. • Use of Tissue conditionersUse of Tissue conditioners • Surgical correction of changes in basal seatSurgical correction of changes in basal seat (flabby tissues, papillary hyperplasia, enlarged(flabby tissues, papillary hyperplasia, enlarged tuberosities.)tuberosities.) • Restorative treatment of remaining teethRestorative treatment of remaining teeth www.indiandentalacademy.comwww.indiandentalacademy.com
  72. 72. SINGLE COMPLETE DENTURESINGLE COMPLETE DENTURE OPPOSING PARTIALLYOPPOSING PARTIALLY EDENTULOUS ARCHEDENTULOUS ARCH RESTORED WITH FPDRESTORED WITH FPD www.indiandentalacademy.comwww.indiandentalacademy.com
  73. 73. Once fixed restoration is placed in a dental arch,Once fixed restoration is placed in a dental arch, the restored arch can be thought of as a naturalthe restored arch can be thought of as a natural teeth opposing a complete denture.teeth opposing a complete denture. Placement of fixed restoration can correct manyPlacement of fixed restoration can correct many occlusal disharmonies.occlusal disharmonies. For example: tilted molarsFor example: tilted molars www.indiandentalacademy.comwww.indiandentalacademy.com
  74. 74. Orthodontic correction and then give FPD www.indiandentalacademy.comwww.indiandentalacademy.com
  75. 75. Prepare tooth to get proper plane of occlusion www.indiandentalacademy.comwww.indiandentalacademy.com
  76. 76. Proximal half crown www.indiandentalacademy.comwww.indiandentalacademy.com
  77. 77. Cantilevered premolar pontic www.indiandentalacademy.comwww.indiandentalacademy.com
  78. 78. Single complete dentureSingle complete denture opposing an existing completeopposing an existing complete denturedenture www.indiandentalacademy.comwww.indiandentalacademy.com
  79. 79. 11. Duration of the existing denture. Duration of the existing denture 2.2. Condition of the teeth:Condition of the teeth: a)a) AppearanceAppearance b)b) Alignment with regard to residualAlignment with regard to residual ridge.ridge. www.indiandentalacademy.comwww.indiandentalacademy.com
  80. 80. c) Is occlusal plane Desirable? www.indiandentalacademy.comwww.indiandentalacademy.com
  81. 81. d) Occlusal surface worn out www.indiandentalacademy.comwww.indiandentalacademy.com
  82. 82. 3.3. Condition of denture baseCondition of denture base a)a) Accuracy of tissue adaptation and borderAccuracy of tissue adaptation and border extensionextension b)b) Any fracture repairsAny fracture repairs c)c) Esthetic contouring and thickness adequate toEsthetic contouring and thickness adequate to support the perioral structures.support the perioral structures. d)d) Stability and retention.Stability and retention. www.indiandentalacademy.comwww.indiandentalacademy.com
  83. 83. Single complete dentureSingle complete denture opposing implant supportedopposing implant supported prosthesisprosthesis www.indiandentalacademy.comwww.indiandentalacademy.com
  84. 84. B.Jacobs et al(JPD 1993:70;135-140)B.Jacobs et al(JPD 1993:70;135-140) Compared the anterior and posterior ridge resorptionCompared the anterior and posterior ridge resorption in three group of patients with different mandibularin three group of patients with different mandibular prosthetic constructions i.e.prosthetic constructions i.e. i)i) Overdenture supported by two implantsOverdenture supported by two implants ii)ii) Fixed prosthesis supported by 6 implantsFixed prosthesis supported by 6 implants iii)iii) Complete denture.Complete denture. www.indiandentalacademy.comwww.indiandentalacademy.com
  85. 85. Results indicatedResults indicated 1)1) A more pronounced annual bone resorption inA more pronounced annual bone resorption in complete denture wearers compared to patientscomplete denture wearers compared to patients with implant supported Overdentures.with implant supported Overdentures. www.indiandentalacademy.comwww.indiandentalacademy.com
  86. 86. 2)2) A limited but continuing bone resorptionA limited but continuing bone resorption observed in patients with implant supportedobserved in patients with implant supported overdentures.overdentures. 3)3) A slightly higher annual bone resorptionA slightly higher annual bone resorption occurring in the implant supported fixedoccurring in the implant supported fixed prosthesis group.prosthesis group. www.indiandentalacademy.comwww.indiandentalacademy.com
  87. 87. Maxillary complete dentureMaxillary complete denture opposing implant supportedopposing implant supported overdentureoverdenture www.indiandentalacademy.comwww.indiandentalacademy.com
  88. 88. Permits free rotational Movement of denture upon Posterior loading www.indiandentalacademy.comwww.indiandentalacademy.com
  89. 89. Bone resorption in mandibular posterior regionBone resorption in mandibular posterior region settling of denture base and loss of posteriorsettling of denture base and loss of posterior contactscontacts upward rotation of anterior mandibular dentureupward rotation of anterior mandibular denture more forces on anterior maxilla supporting themore forces on anterior maxilla supporting the maxillary denture.maxillary denture. www.indiandentalacademy.comwww.indiandentalacademy.com
  90. 90. Barber et al (J OMFS 1990:48:1283-1287)Barber et al (J OMFS 1990:48:1283-1287) Maxson et al (JPD 1990:63;554-558)Maxson et al (JPD 1990:63;554-558) Sybille et al (IJP 1996:9:58-64):Sybille et al (IJP 1996:9:58-64): Found that combination syndrome occurred in patientsFound that combination syndrome occurred in patients with implant supported overdenture and maxillarywith implant supported overdenture and maxillary conventional complete dentures.conventional complete dentures. www.indiandentalacademy.comwww.indiandentalacademy.com
  91. 91. Maxillary completeMaxillary complete denturedenture opposing implantopposing implant supported fixedsupported fixed denturedenture www.indiandentalacademy.comwww.indiandentalacademy.com
  92. 92. Opinion is divided over the functional forces borneOpinion is divided over the functional forces borne by the maxillary complete denture opposingby the maxillary complete denture opposing implant supported fixed denture.implant supported fixed denture. www.indiandentalacademy.comwww.indiandentalacademy.com
  93. 93.  Stafford et alStafford et al ; found that loading forces did not; found that loading forces did not increaseincrease  Falk et al (JOMI 1989:44; 55-62)Falk et al (JOMI 1989:44; 55-62) found thefound the loading forces to be comparable to those ofloading forces to be comparable to those of partially restored natural dentitions, with greaterpartially restored natural dentitions, with greater forces in the posterior region of the maxillaryforces in the posterior region of the maxillary denture opposing cantilever units of the implantdenture opposing cantilever units of the implant prosthesis.prosthesis. www.indiandentalacademy.comwww.indiandentalacademy.com
  94. 94. Difference in opinion regarding the anteriorDifference in opinion regarding the anterior maxillary bone loss under complete denturesmaxillary bone loss under complete dentures opposing implant supported fixed prosthesis.opposing implant supported fixed prosthesis. www.indiandentalacademy.comwww.indiandentalacademy.com
  95. 95. Jacobs et al (JPD 1993):Jacobs et al (JPD 1993): reported an increasereported an increase annual bone loss maxillary anterior region.annual bone loss maxillary anterior region. Henry et al (IJP 1999:12;492-497):Henry et al (IJP 1999:12;492-497): reported noreported no anterior resorption and no occurrence ofanterior resorption and no occurrence of condition like combination syndrome in thiscondition like combination syndrome in this clinical state.clinical state. www.indiandentalacademy.comwww.indiandentalacademy.com
  96. 96. METHODS TOMETHODS TO ACHIEVE BALANCEDACHIEVE BALANCED OCCLUSIONOCCLUSION www.indiandentalacademy.comwww.indiandentalacademy.com
  97. 97. TWO TECHNIQUESTWO TECHNIQUES:: 1)1) Those that dynamically equilibrate theThose that dynamically equilibrate the occlusion by use ofocclusion by use of functionally generated pathfunctionally generated path i.e.i.e. Functional chew in techniquesFunctional chew in techniques.. 2)2) Those that statistically equilibrate the occlusionThose that statistically equilibrate the occlusion by using an articulator programmed to simulateby using an articulator programmed to simulate patients jaw movements.patients jaw movements. www.indiandentalacademy.comwww.indiandentalacademy.com
  98. 98. Functionally generated pathFunctionally generated path techniques / Functional chewtechniques / Functional chew in techniques for singlein techniques for single complete dentures.complete dentures. www.indiandentalacademy.comwww.indiandentalacademy.com
  99. 99. Contraindications:Contraindications: 1)1) Record base not stable.Record base not stable. 2)2) Patients with poor neuromuscular control.Patients with poor neuromuscular control. www.indiandentalacademy.comwww.indiandentalacademy.com
  100. 100. StansburyStansbury (JPD 1951;1;692-699)(JPD 1951;1;692-699) andand Rudd and MorrowRudd and Morrow (JPD 1973:30;4)(JPD 1973:30;4) www.indiandentalacademy.comwww.indiandentalacademy.com
  101. 101. Cast mounted on articulator in CR at acceptableCast mounted on articulator in CR at acceptable vertical dimension.vertical dimension. Remove record base and occlusal rimRemove record base and occlusal rim adaptadapt new base plate and fabricate occlusal rimsnew base plate and fabricate occlusal rims made of compoundmade of compound www.indiandentalacademy.comwww.indiandentalacademy.com
  102. 102.  (twice the normal width-atleast twice the width of(twice the normal width-atleast twice the width of molar teeth)molar teeth)  6 mm anterior to mandibular incisor,6 mm anterior to mandibular incisor,  sufficient in height to receive an impression ofsufficient in height to receive an impression of the central fossa of the lower teeth.the central fossa of the lower teeth. www.indiandentalacademy.comwww.indiandentalacademy.com
  103. 103. Compound occlusal rim heatedCompound occlusal rim heated Placed in articulatorPlaced in articulator closedclosed Impression of fossae of all lower teeth recorded.Impression of fossae of all lower teeth recorded. www.indiandentalacademy.comwww.indiandentalacademy.com
  104. 104. Occlusal rims trimmedOcclusal rims trimmed B-L.B-L. Compound extensionCompound extension in the central fossa.in the central fossa. www.indiandentalacademy.comwww.indiandentalacademy.com
  105. 105. Anterior regionAnterior region trimmed till level oftrimmed till level of indentation ofindentation of incisors(2mm spaceincisors(2mm space between rim andbetween rim and mandibular anteriormandibular anterior teeth)teeth) www.indiandentalacademy.comwww.indiandentalacademy.com
  106. 106. Place in patients mouthPlace in patients mouth Pt asked to make chewing slowlyPt asked to make chewing slowly Excess compound wears offExcess compound wears off Free action in lateral movement.Free action in lateral movement. www.indiandentalacademy.comwww.indiandentalacademy.com
  107. 107. Record base removed fromRecord base removed from patients mouth, soft waxpatients mouth, soft wax (carding wax) added on(carding wax) added on B-L sides.B-L sides. www.indiandentalacademy.comwww.indiandentalacademy.com
  108. 108. Placed in patients mouthPlaced in patients mouth Patient asked to perform eccentric chewingPatient asked to perform eccentric chewing movementsmovements www.indiandentalacademy.comwww.indiandentalacademy.com
  109. 109. Lower teeth cut theirLower teeth cut their pathspaths in the soft wax.in the soft wax. Compound inCompound in central fossa actcentral fossa act as a guide toas a guide to preserve cusp height.preserve cusp height. www.indiandentalacademy.comwww.indiandentalacademy.com
  110. 110. Occlusal rim removedOcclusal rim removed  stonestone poured into wax paths.poured into wax paths. First mandibularFirst mandibular cast is removedcast is removed Maxillary occlusalMaxillary occlusal rim with generatedrim with generated occlusal paths and stone recordocclusal paths and stone record is placed in articulatoris placed in articulator www.indiandentalacademy.comwww.indiandentalacademy.com
  111. 111. Stone record is securedStone record is secured to the lower member ofto the lower member of the articulator withthe articulator with plaster.plaster. www.indiandentalacademy.comwww.indiandentalacademy.com
  112. 112. 2 lower casts-first-duplicate of lower teeth,2 lower casts-first-duplicate of lower teeth, second replica of generated path.second replica of generated path. Original mandibular cast placed on articulatorOriginal mandibular cast placed on articulator Maxillary teeth setting done (ant. teethMaxillary teeth setting done (ant. teeth acc. toacc. to esthetics, post. teeth ground and adjusted toesthetics, post. teeth ground and adjusted to CO.CO. www.indiandentalacademy.comwww.indiandentalacademy.com
  113. 113. Checked in mouth for esthetics and centricChecked in mouth for esthetics and centric occlusionocclusion .. Denture processedDenture processed Remounted.Remounted. Any interference in centric occlusion checkedAny interference in centric occlusion checked and correctedand corrected www.indiandentalacademy.comwww.indiandentalacademy.com
  114. 114. will be established. Once correct in COwill be established. Once correct in CO removeremove the lower castthe lower cast put chew-in mandibular castput chew-in mandibular cast Interferences removedInterferences removed Thus in CR and eccentric movement bilateralThus in CR and eccentric movement bilateral balanced occlusionbalanced occlusion www.indiandentalacademy.comwww.indiandentalacademy.com
  115. 115. By Robert G.VigBy Robert G.Vig (JPD 1964;14:214-220)(JPD 1964;14:214-220) Similar techniqueSimilar technique like Stansbury butlike Stansbury but he recommendedhe recommended use of ause of a fin of resinfin of resin placed into theplaced into the central groovescentral grooves instead of compound.instead of compound. Maintains Vertical Dimension better.Maintains Vertical Dimension better. www.indiandentalacademy.comwww.indiandentalacademy.com
  116. 116. Articulator EquilibrationArticulator Equilibration TechniqueTechnique Equilibrate the occlusion by using an articulatorEquilibrate the occlusion by using an articulator programmed to simulate patients jawprogrammed to simulate patients jaw movements.movements. www.indiandentalacademy.comwww.indiandentalacademy.com
  117. 117. Indications:Indications: • If denture base lacks stability.If denture base lacks stability. • Patient unable to performPatient unable to perform movements properly.movements properly. www.indiandentalacademy.comwww.indiandentalacademy.com
  118. 118. Maxillary occlusal rims fabricatedMaxillary occlusal rims fabricated face bowface bow transfer donetransfer done maxillary casts mounted onmaxillary casts mounted on articulator.articulator. Mandibular cast mounted on articulator usingMandibular cast mounted on articulator using centric records at established vertical dimension.centric records at established vertical dimension. www.indiandentalacademy.comwww.indiandentalacademy.com
  119. 119. Bucco-lingual position of the lower teeth and theirBucco-lingual position of the lower teeth and their relation to maxillary arch is studied.relation to maxillary arch is studied. Teeth arrangement done according to naturalTeeth arrangement done according to natural teeth.teeth. Interferences in centric and eccentric positions areInterferences in centric and eccentric positions are removed by grinding the natural teeth andremoved by grinding the natural teeth and artificial teeth until a bilateral balanced occlusionartificial teeth until a bilateral balanced occlusion is achieved.is achieved. www.indiandentalacademy.comwww.indiandentalacademy.com
  120. 120. OCCLUSAL MATERIALS FOROCCLUSAL MATERIALS FOR SINGLE COMPLETESINGLE COMPLETE DENTURESDENTURES www.indiandentalacademy.comwww.indiandentalacademy.com
  121. 121. a)a) Porcelain teeth:Porcelain teeth: AdvantageAdvantage: minimal wearing, therefore vertical: minimal wearing, therefore vertical dimension maintained.dimension maintained. DisadvantageDisadvantage:: Rapid wearing of opposing naturalRapid wearing of opposing natural teeth.teeth. Occlusal adjustment of artificial teeth neededOcclusal adjustment of artificial teeth needed porcelain becomes weak.porcelain becomes weak. www.indiandentalacademy.comwww.indiandentalacademy.com
  122. 122. b)b) Acrylic resin teeth:Acrylic resin teeth: Advantage:Advantage: No wear of opposing teethNo wear of opposing teeth Easy to do occlusal adjustments.Easy to do occlusal adjustments. Disadvantage:Disadvantage: Wears off easilyWears off easily loss of vertical dimension andloss of vertical dimension and change in centric occlusion.change in centric occlusion. www.indiandentalacademy.comwww.indiandentalacademy.com
  123. 123. c)c) Gold occlusalsGold occlusals ConsideredConsidered best materialbest material to opposeto oppose natural teeth. Minimum wear.natural teeth. Minimum wear. Disadvantage:Disadvantage: ExpensiveExpensive Time consuming.Time consuming. www.indiandentalacademy.comwww.indiandentalacademy.com
  124. 124. Schultz (JPD 1951:1:38-48)Schultz (JPD 1951:1:38-48) • Showed that the chewing efficiency of acrylicShowed that the chewing efficiency of acrylic resin teeth was 26-35% less than that ofresin teeth was 26-35% less than that of porcelain teeth.porcelain teeth. • Chewing efficiency of acrylic resin teeth withChewing efficiency of acrylic resin teeth with gold occlusal surface is equal to that of porcelaingold occlusal surface is equal to that of porcelain teeth.teeth. www.indiandentalacademy.comwww.indiandentalacademy.com
  125. 125. Technique of fabrication ofTechnique of fabrication of gold occlusalsgold occlusals (JPD 1964:14;326-333)(JPD 1964:14;326-333) www.indiandentalacademy.comwww.indiandentalacademy.com
  126. 126. Dentures made in usual manner usingDentures made in usual manner using acrylic resin posterior teeth.acrylic resin posterior teeth. Remounted on articulator-occlusalRemounted on articulator-occlusal disharmonies removed by selectivedisharmonies removed by selective GrindingGrinding Denture finished and patient is allowedDenture finished and patient is allowed to wear them for 3-4 weeksto wear them for 3-4 weekswww.indiandentalacademy.comwww.indiandentalacademy.com
  127. 127. With dentures in mouthWith dentures in mouth  impression made with irreversibleimpression made with irreversible hydrocolloidhydrocolloid Denture in impressionDenture in impression applyapply petroleum jellypetroleum jelly dental stonedental stone poured into the denture.poured into the denture. www.indiandentalacademy.comwww.indiandentalacademy.com
  128. 128. Buccal and palatal surfaces covered with modeling clay All undercuts blocked Lingually- 2mm short of occlusal surface Labially-1mm short www.indiandentalacademy.comwww.indiandentalacademy.com
  129. 129. Stone counter dies poured www.indiandentalacademy.comwww.indiandentalacademy.com
  130. 130. Grooves cut A-P 3mm wide and 3mm deep. Hole approximately 2mm depth made in centre of each tooth www.indiandentalacademy.comwww.indiandentalacademy.com
  131. 131. Counter die www.indiandentalacademy.comwww.indiandentalacademy.com
  132. 132. Final wax pattern Sprue attached www.indiandentalacademy.comwww.indiandentalacademy.com
  133. 133. Castings cemented www.indiandentalacademy.comwww.indiandentalacademy.com
  134. 134. d)d) Acrylic resin teeth with amalgam stopsAcrylic resin teeth with amalgam stops (JPD(JPD 1979:41:16-20)1979:41:16-20) Advantage:Advantage: • Reduces occlusal wear of resin teeth.Reduces occlusal wear of resin teeth. • Less expensive than goldLess expensive than gold • Facilitates the final stages of occlusal adjustment.Facilitates the final stages of occlusal adjustment. www.indiandentalacademy.comwww.indiandentalacademy.com
  135. 135. Occlusal preparation in acrylic teeth Amalgam condensed www.indiandentalacademy.comwww.indiandentalacademy.com
  136. 136. Centric holding areas as well as excursions are recorded in amalgam www.indiandentalacademy.comwww.indiandentalacademy.com
  137. 137. CLINICAL PROCEDURE OFCLINICAL PROCEDURE OF FABRICATINGFABRICATING A MAXILLARYA MAXILLARY COMPLETECOMPLETE DENTURE OPPOSINGDENTURE OPPOSING A MANDIBULAR NATURALA MANDIBULAR NATURAL TEETHTEETH www.indiandentalacademy.comwww.indiandentalacademy.com
  138. 138.  Proper diagnosis related to:Proper diagnosis related to:  Periodontal health of the remaining teethPeriodontal health of the remaining teeth  If any missing teeth to be replaced.If any missing teeth to be replaced.  Tooth modifications needed.Tooth modifications needed. www.indiandentalacademy.comwww.indiandentalacademy.com
  139. 139.  Impression of lower teethImpression of lower teeth  cast obtainedcast obtained  Maxillary archMaxillary arch Secondary impressionSecondary impression master cast obtainedmaster cast obtained occlusal rim fabricatedocclusal rim fabricated contoured for adequate lipcontoured for adequate lip support.support.  Using face bow mount the maxillary cast on theUsing face bow mount the maxillary cast on the articulatorarticulator  mount mandibular cast using centricmount mandibular cast using centric records at correct VDrecords at correct VD www.indiandentalacademy.comwww.indiandentalacademy.com
  140. 140.  Set teeth and achieve a balanced occlusion bySet teeth and achieve a balanced occlusion by selective grinding.selective grinding.  If gold restorations needed on the teeth, modifyIf gold restorations needed on the teeth, modify the teeth.the teeth. www.indiandentalacademy.comwww.indiandentalacademy.com
  141. 141.  If FPD neededIf FPD needed  do thedo the tooth preparation beforetooth preparation before making impression.making impression.  Wax patterns areWax patterns are carved to conform to thecarved to conform to the existing occlusion ofexisting occlusion of maxillary denture.maxillary denture. www.indiandentalacademy.comwww.indiandentalacademy.com
  142. 142. CONCLUSIONCONCLUSION The problems involved in providing comfort,The problems involved in providing comfort, function, proper esthetics and retention is a vigorousfunction, proper esthetics and retention is a vigorous challenge for practising dentist. The damage to thechallenge for practising dentist. The damage to the edentulous ridge and inability to wear the dentureedentulous ridge and inability to wear the denture may be avoided by good prosthetic treatment whichmay be avoided by good prosthetic treatment which include adequate denture base, correct jaw relationinclude adequate denture base, correct jaw relation record and proper occlusion.record and proper occlusion. www.indiandentalacademy.comwww.indiandentalacademy.com
  143. 143. REFERENCESREFERENCES 1.Stansbury C B. Single denture construction1.Stansbury C B. Single denture construction against a non-modifiednatural dentition.against a non-modifiednatural dentition. J ProsthetJ Prosthet DentDent 1951;1951; 11: 692-699.: 692-699. 2.Meyer: Generated path technique :JPD 1957:72.Meyer: Generated path technique :JPD 1957:7 354.354. 3.Vig R G. A modified chew in and functional3.Vig R G. A modified chew in and functional impression technique.impression technique. J.Prosthet DentJ.Prosthet Dent 1964;1964; 1414:: 214-220.214-220. 4.Bruce: CD opposing natural teeth:JPD4.Bruce: CD opposing natural teeth:JPD 1971:26;5:448.1971:26;5:448. www.indiandentalacademy.comwww.indiandentalacademy.com
  144. 144.  5.Ellinger:Single complete denture:JPD5.Ellinger:Single complete denture:JPD 1971:26:4-101971:26:4-10  6.Kelly E. Changes caused by a mandibular6.Kelly E. Changes caused by a mandibular removable partial denture opposing a maxillaryremovable partial denture opposing a maxillary complete denture.complete denture. J Prosthet DentJ Prosthet Dent 1972;1972; 2727:: 140-150.140-150. 7.Rudd and Morrow: occlusion and single7.Rudd and Morrow: occlusion and single denture:jpd1973;31:4denture:jpd1973;31:4 www.indiandentalacademy.comwww.indiandentalacademy.com
  145. 145. 8.Saunders T R, Gillis R E, Desjardins R P. The8.Saunders T R, Gillis R E, Desjardins R P. The maxillary complete denture opposing themaxillary complete denture opposing the mandibular bilateral distal-extension partialmandibular bilateral distal-extension partial denture.Treatment considerations.denture.Treatment considerations. J ProsthetJ Prosthet DentDent 1979 ;1979 ;4141: 124-128.: 124-128. 9.Schmitt ;combination syndrome :treatment9.Schmitt ;combination syndrome :treatment approach :JPD 1985:54:664approach :JPD 1985:54:664 10.Shen:prevalance of Combination syndrome10.Shen:prevalance of Combination syndrome among denture wearers: JPD 1989:62;642among denture wearers: JPD 1989:62;642 11.Maxillary bone resorption in patients with11.Maxillary bone resorption in patients with mandibular implant supported OD or fixedmandibular implant supported OD or fixed prosthesis.:JPd 1993:70:135-140)prosthesis.:JPd 1993:70:135-140) www.indiandentalacademy.comwww.indiandentalacademy.com
  146. 146.  13.Yair Langer13.Yair Langer :Modalities of Treatment for the:Modalities of Treatment for the Combination Syndrome :Combination Syndrome :J Prosthod 1995;4:76-J Prosthod 1995;4:76- 8181  14.CS in relation to osseointegrated implant14.CS in relation to osseointegrated implant supported OD :IJP 1996:9;58-64supported OD :IJP 1996:9;58-64  15.Maxillary changes under CD opposing15.Maxillary changes under CD opposing mandibular implant supported fixed prosthesis:mandibular implant supported fixed prosthesis: IJP 1999:12;492IJP 1999:12;492  16.combination syndrome: a literature16.combination syndrome: a literature review:Jpd 2003:90:270-275review:Jpd 2003:90:270-275 12.Maxillary CD opposing osseointegrated12.Maxillary CD opposing osseointegrated mandibular prosthesis:IJP1993:6;446-450mandibular prosthesis:IJP1993:6;446-450 www.indiandentalacademy.comwww.indiandentalacademy.com
  147. 147.  17.Essentials of complete denture17.Essentials of complete denture prosthodontics:winkler:2prosthodontics:winkler:2ndnd edtedt  18.Text book of complete denture :518.Text book of complete denture :5thth edt:Heartwell.edt:Heartwell.  19.Prosthodontic treatment for edentulous19.Prosthodontic treatment for edentulous patients:12patients:12thth edt:Zarbedt:Zarb www.indiandentalacademy.comwww.indiandentalacademy.com
  148. 148. www.indiandentalacademy.comwww.indiandentalacademy.com

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