M. NADER SHARIFI, DDS, MS - · PDF fileM. NADER SHARIFI, DDS, MS THURSDAY, MAY 6, ......

140TH ANNUAL MEETING

MAY 6 – MAY 7, 2010

JEWEL OF THE GREAT LAKES

M. NADER SHARIFI, DDS, MS

THURSDAY, MAY 6, 2010

2:00 TO 4:30 P.M.

AA PPAARRTTIIAALL CCOOUURRSSEE OONN PPAARRTTIIAALL

DDEENNTTUURREESS

CCOO--SSPPOONNSSOORREEDD BBYY

AASSPPEENN DDEENNTTAALL®®

A Partial Course on Partial Dentures

M. Nader Sharifi, D.D.S., M.S.Wisconsin Dental Association

Milwaukee, WIThursday, May 6, 2010

2009 M. Nader Sharifi, D.D.S., M.S. Page 1

About Your Speaker:

M. Nader Sharifi, D.D.S., M.S. holds a certificate in prosthodontics and a mastersdegree in biomaterials from Northwestern University. He received his dental educationat the University of Illinois. He has presented numerous topics on implant dentistrysince his graduation. He has completed over 300 presentations on restorative dentistryand patient care that has earned him recognition from esteemed study groups, societiesand associations nationwide. He is a former assistant professor at NorthwesternUniversity and former on-call consultant for Nobel Biocare.

Dr. Sharifi currently maintains a full-time private practice of adult general dentistry inChicago’s downtown loop. As a five day a week wet gloved dentist, he is interested inensuring time saving and cost effective care. In 1996 he was named to the AmericanDental Associations Speakers Bureau. The Chicago Dental Society honored him in2007 with the Gordon Christenson Distinguished Lecturer Award.

If you would like, you can reach Dr. Sharifi easiest via the internet. Please feel free todirect any questions or comments at any time to his Email address at MNSDDSMS @AOL.com.

mailto:[email protected]

mailto:[email protected]


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

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

1. Edentulous area in a single arch only.2. Edentulism limited to 2 teeth in the maxillary anterior – or – 4 in

the mandibular anterior – or 2 in the posterior (molars excluded).3. Abutments are ideal and require no restoration.4. Angle Class I jaw classification.5. High, well rounded residual ridge.

B. Class II (underlined items are different)1. Edentulous areas can exist in both arches.2. Edentulism limited to 2 teeth in the maxillary anterior – or – 4 in

the mandibular anterior – or 2 in the posterior (molars excluded).3. Abutments or occlusion requires mild intervention.4. Angle Class I jaw classification.5. High or low, well rounded residual ridge.6. Mild systemic or psychological modifiers.

C. Class III1. Edentulous areas can exist in both arches.2. Edentulism of more than 3 teeth in any area or 2 molars.3. Abutments or occlusion requires moderate therapy.4. Angle Class I, II or III jaw classification.5. Occlusion is compromised with supra-eruption.6. Moderate systemic or psychological modifiers.

D. Class IV1. Edentulous areas can exist in both arches.2. Edentulism of more than 3 teeth in any area or 2 molars.3. Abutments require multi-disciplinary treatment.4. Angle Class I, II or III jaw classification.5. Occlusion requires a change in vertical dimension.6. Severe systemic or psychological modifiers.7. Hyperactive gag reflex.8. Maxillary-mandibular incoordination (Parkinson’s)9. Refractory patient (unrealistic expectations).


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

Patient Name Social Security Number Date

Prosthetic Findings

Maxillary Arch: U Shaped V Shaped O Shaped Square Shaped

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

Hard Palate: Deep Shallow Medium Soft Palate Class

Tuberosities (R) (L) Torus Attached Mucosa %

Frenum: Anterior (R) (L) Teeth

Mandibular Arch: U Shaped V Shaped O Shaped Square Shaped

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

Lateral Throat Form Class Torus Attached Mucosa %

Buccal Shelf: Large Medium Small

Frenum: Anterior (R) (L) Teeth

Tongue: Position Movement

Saliva Consistency Amount

Jaw Classification: Class I Class II Class III

Existing Prosthesis:Pt.’s Opinion:

Retention: Good Adequate PoorStability: Good Adequate PoorSupport: Good Adequate PoorEsthetics: Good Adequate PoorPhonetics: Good Adequate PoorOcclusion: Good Adequate Poor

Facial Shape: Square Square-tapering Ovoid Triangular Round

Profile: Flat Rounded Inverted

Coloring: Hair Eyes Complexion


Course Outline:I) Patient Evaluation – Will not be covered

A) Partially Edentulous Case Classification - See Page 2B) Anatomic Limitations – Problems with removable success related to the clinical situation of

the patient. Changes can only be achieved with surgical correction. Existing ConditionsSheet identifies critical anatomical structures: will they help or hurt the patient desire forsuccess. See Exam Sheet-Page 31) Occlusal Plane Discrepancies from Unrestored Teeth2) VDO Compromise from Wear and Unrestored Teeth

C) Evaluation of Existing Prosthesis1) Retention – Doctor’s Perspective: Good/Adequate/Poor2) Stability – Doctor’s Perspective: Good/Adequate/Poor3) Support – Doctor’s Perspective: Good/Adequate/Poor4) Esthetics – Doctor and Patient Perspective

(a) May not agree5) Phonetics – Doctor and Patient Perspective

(a) Does the patient notice problems?6) Occlusion – Doctor and Patient Perspective

(a) How does the patient eat?7) Clinical Limitations – Problems with the existing prosthesis due to insufficient use of the

patient’s available anatomy. Changes can be achieved with fabrication of new prostheses.D) Are the patient’s complaints in line with their anatomic and clinical limitations?

1) Can we improve their current clinical situation?II) Occlusal Design – Will not be covered.

A) Lingualized Occlusion – Lingual (palatal) Cusp Contact Only.1) Indications – Excellent for RPDs – also for completes.2) Bilateral Working and Balancing Side Contacts

(a) Controlled in Set-up on the Articulator.(i) Cusp Form Teeth in Maxilla, Flatter Plane in Mandible

(b) Maxillary incisors, cuspids, premolars and first molar mesial cusps all on same plane.(c) Cusps then rise to shallow Curve of Spee.(d) Mandibular posterior teeth have central groove contact to palatal cusps of the maxilla.(e) No posterior contact of maxillary buccal cusps.

(i) True in Centric & all Eccentric Movements(f) Anterior open bite. If lowers are 0° – no overbite.

III) Clinical Records – Will not be coveredA) Many RPD cases use maximum intercuspation for VDO & CRB) Wax Rims: Use Complete Denture Tenets

1) Maxillary Wax Rim – Use first.(a) Anterior Contour – Profile esthetics(b) Anterior Vertical Height – Use fricatives as the starting point. We can get clear

fricatives through about 3-5 mm of vertical height variation, therefore use incisal edgeshow as the final esthetic determinate for anterior vertical height.

(c) Maxillary Horizontal(i) Intrapupillary Line – Side to side plane.(ii) Fox Plane (Dentsply) – level: right to left


(iii)Ala-Tragus Line – Ala of the nose and the Tragus of the ear as the horizontal plane(iv)Buccal Corridor – Meet the opposing or esthetic needs

2) Mandibular Wax Rim(a) Anterior Contour –tends to be a thin area(b) Anterior Vertical Height – Sibilant sounds are the final determining factor, but I start

with the first premolar area being approximately the level of the lower lip at rest.IV)Prosthesis Delivery – Will not be covered.

A) Have confidence with the fit, spend time on bite.B) Lab should complete selective grind before breakoutC) Occlusal Indicator Wax to eliminate centric prematurities.

1) If lingualized occlusion, eliminate buccal contacts.D) Eccentric Occlusion – Use horseshoe articulating paper to develop working and balancing

side contacts in group function.1) Lingualized – Use Blue/Blue paper to eliminate all buccal interferences.

(a) Slide side-to-side - adjust buccal interferences on the upper molars & lower premolars2) Without Paper: Watch and ask patient where “hitches” occur

(a) Red to lower, slide side-to-side; Black to Lower, tap-tap-tap in centric, then adjust redmarks on the lower denture to eliminate hitches.

(b) Red to Upper, slide side-to-side; Black to Upper, tap-tap-tap in centric, then adjust redmarks on the upper denture to eliminate hitches.

(c) In all lingualized occlusion adjustments, continue to eliminate all buccal contacts.V) Kennedy Classification – Visual Learning

A) Class I: Bilateral Distal Extension – No Posterior TeethB) Class II: Unilateral Distal Extension – One Side: No PosteriorC) Class III: Posterior Tooth BorneD) Class IV: Anterior Tooth Borne

VI)Removable Partial Denture – Tooth PreparationA) Guide Planes – Lateral stability is secondary requirement of teeth in RPD design.

1) Indication for Guide Planes – Path of insertion, stability.2) Preparation of Guide Planes – Parallel sided burs.3) Anterior versus Posterior Path of Insertion.

B) Reason for Rest Preps – Vertical stop is primary requirement of teeth for RPD design.1) Fulcrum Line for Prosthesis Rotation on Teeth2) Seating Confirmation of Prosthesis – Most Important Step – More than Frame Design3) Direction of Force Down Long Axis to load the tooth axial from the rotational forces4) More than 180º encirclement to prevent drift of the abutment tooth from clasp forces5) Indirect Retention – covered below in6) Rest Seats for Cuspids

(a) Cingulum (Chevron) Rest(b) Horizontal Rest – Filled with Composite(c) Finger Rest – No Vertical Stop

7) Rest Seats for Premolars and Molars(a) Occlusal Rest(b) Round burs then ceramic inlay burs

8) For All Rest Seats on Teeth with Existing Fillings: Prep Onto Sound Tooth Structure(a) If PFMs, Prep to Metal


9) Indirect Retention(a) Prevention of Saddle Area Lifting for Free-End Saddles(b) Preparation – Tooth appropriate.(c) Fulcrum Selection – Free-End Saddles

(i) Combine most distal REST SEATS.(ii) Greatest perpendicular placement – contralaterally(iii)Required for Kennedy Class I and II(iv)Necessary for Tooth Borne?

Yes, a Class III can act like a free-end Class IV is really a Class I turned around.

(d) Indirect Retention as a Reline Indicator(i) Need for Reline – Pressure on saddle lifts rest.(ii) Notes Correct Reline Seating– Do not Bite!(iii)Adjust occlusion at delivery.

VII) Clasp DesignA) Suprabulge Clasps –above height of contour

1) Akers Clasp – Basic use (free-ends?)2) Wrought Wire Clasp – Wrong Side of Fulcrum3) Equipoise Clasp – Terminal tooth is an incisor4) Ring Clasp – Tipped Lower Second Molar

B) Infrabulge Clasps1) I-Bar Clasp – Contraindicated in molars, buccal vestibule undercuts, and high frenums2) T-Bar Clasp – Modification (not any more)

C) Free-End Saddle Clasp Design – Distal Akers v. I-Bar1) Suprabulge versus Infrabulge2) Pushing versus Pulling Retention3) Engage during load versus Disengage4) “Esthetic” options5) Mesial Rest with Akers: RPA (reach back)

D) Conclusions:1) RPI – Free-End Saddles2) Equipoise – Terminal Incisors3) Akers – Always Points Backwards4) Wrought Wire – Wrong Side of Fulcrum Line

VIII) Framework Design Worksheets in this Handout – See page 9IX)Framework Fit – Most Important: Evidenced based research

A) Occlude Spray – Spray paint without adhesive1) Dry frame, spray frame in tooth contact areas2) Dry teeth, seat frame, rock across fulcrum line3) Adjust shiny areas of minor connectors, side walls of rest seats, avoid guide planes4) Adjust until rest seats bottom out on prepped tooth

X) Attachments – Ensure they are necessary – they replace claspsA) Extracoronal Attachments – Preferred method

1) Must Double Abut. – Creates cantilever2) Law of Beams: Stress/Strain = (K)l 3

3) Bredent Attachments – Smallest on the market


(a) Non-resilient4) ERA – My favorite because of processing male

(a) Resilient(b) Has Processing Male (non-resilient)

(i) Can be used for relines(c) Easy to Change and Vary Retention Degree

XI)Removable Partial Prosthodontics Impression TechniquesA) Custom Tray Fabrication/Selection – Reinventing the wheel?B) Impression Materials

1) Irreversible Hydrocolloid (Alginate) – Mucostatic(a) Canned Alginate – canned.(b) “System 2” Syringable Alginate – Simple, inexpensive, quick to retake when needed

2) Rubber Base – Functional – For use with custom trays.3) Polyvinyl siloxane and polyether – not ideal, but okay

C) Free End Saddle Registration1) Altered Cast Technique – Lacks Confidence2) Reline at Delivery with PVS, Polyether, or Rubber Base

(a) 30 seconds of border molding(i) Use Massad Aquasil Technique – Dentsply DVD

3) Hydrocast Reline Technique – 24 hrs of border molding(a) Fabricate RPD in standard fashion from System 2 Alginate impression with one

modification – Add three times the normal relief below the retention webbing in thesaddles for the framework. This will create the space necessary for the reline.

(b) At delivery, hollow grind saddle intaglio and trim flanges short of the full extensionwith Myostatic Outline technique.

(c) Mix Microseal and bench set for two minutes. Load saddles and seat in the mouth for7 minutes holding the framework in place – do not let the patient bite, nor applypressure to the saddle areas. Trim Microseal to be 2 mm short of the flange. This isthe “tissue stop” to support vertical.

(d) Check and adjust centric and eccentric occlusion.(e) Mix Hydrocast and bench set for about five minutes. Fill the denture with Hydrocast

and seat in the mouth. Have the patient read aloud for ten minutes then trim buccal andlingual excess from the outside of the denture with a hot spatula.

(f) Reseat and have the patient wear for 24 hours straight – including meals and bedtime.(g) At next day appointment pour stone to support the saddles and create a base. Send

cast to the lab for a lab processed reline. Redeliver when ready.XII) RPD Case Completion - Start to Finish

A) Initial Models – Diagnosis and Offers Patient TreatmentB) Prep and Impress – Guide Planes, Rest Preps, ImpressionC) Frame Trial – Use Disclosing, Centric BiteD) Wax Trial – Confirm Esthetics and BiteE) Reline at Delivery – PVS, Polyether or Rubber BaseF) Delivery – Confirm Centric and BalanceG) One Week – Confirm Centric and Balance

XIII) Conclusions – Three Steps to Quality Removable ProsthodonticsA) System 2, Hydrocast Reline at Delivery, Framework Design


Partial Denture Lab PrescriptionM. Nader Sharifi, D.D.S., M.S. Lics. No.:019-02161730 North MichiganSuite 1303Chicago, IL 60602 Phone: 312-236-1576

Laboratory: Phone:Patient: Date Sent:Next Appt.: Time:

Tooth Guide Plane Rest Clasp Undercut

Opposing ArchMaterialMajor ConnectorRetention WebbingTissue Stops

Signature:





Opposing ArchMaterialMajor ConnectorRetention WebbingTissue Stops

Signature: Date





MaterialMajor ConnectorRetention WebbingTissue StopsOpposing Arch

Signature: Date


Kennedy Class I

Kennedy Class II

Modification Space

Kennedy Class III


Posterior Rotational Path

Kennedy Class IV

Rotational Path


Reference ListTextbooks:1. Brudvick, JS: Advanced Removable Partial Dentures. Quintessence Publishing Co., Inc.

Chicago, IL 1999.2. Johnson DL and Stratton RJ: Fundamentals of Removable Prosthodontics. Quintessence

Publishing Co., Inc. Chicago, IL 1980.3. Kratochvil FJ: Partial Removable Prosthodontics. W.B. Saunders Co., Philadelphia, PA 1988.4. Krol AH, Jacobson TE, Finzen FC: Removable Partial Denture Design - Outline Syllabus.

University of the Pacific Dental School, 1990. Call School5. McGivney GP, Castleberry DJ: McCracken’s Removable Partial Prosthodontics. 8th Edition.

C.V. Mosby, St. Louis, MO 1989.6. Sharifi MN: Essential Dental Handbook: Chapter on Removable Prosthodontics. Edited by

Edwab RJ, Penn Well Publishing Co., Tulsa, OK 2002. Call 800-752-9764 (10%Coupon:DOAE05)

7. Stratton RJ, Wiebolt FJ: An Atlas of Removable Partial Denture Design. QuintessencePublishing Co., Inc. Chicago, IL 1988.

8. Stewart KL, Rudd KD, Kuebker WA: Clinical Removable Partial Prosthodontics. C.V. Mosby,St. Louis, MO 1983.

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Prosthet Dent 1971; 26:280.2. Barco MT Jr, Flinton RH: An overview of four removable partial denture clasps. Int J Pros 1988;

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denture with a spring loaded plunger attachment and I-bar retainer. J Prosthet Dent 1992; 68:784-.6. Brewer AA, Reibel RB, Nassif MN: Comparison of zero degree teeth and anatomic teeth on

complete dentures. J Prosthet Dent 1967; 17:28.7. Browning JD, Meadors LW, Eick JX: Movement of three removable partial denture clasp

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Prosthet 1990; 3:146-157.9. Burns DR, Ward JE: A review of attachments for removable partial denture design: Part 2 -

Treatment Planning and attachment selection. Int J Pros 1990; 3:169-170.10. Burns DR, Ward JE: A review of attachments for removable partial denture design: Part 1 -

Classification. Int J Pros 1990; 3:98-102.11. Chou TM, et al.: Photoelastic analysis and comparison of force transmission characteristics of

intracoronal attachments with clasp distal-extension removable partial dentures. J Prosthet Dent1989; 62:313-319.

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14. Colon A, Kotwal K, Mangelsdorff A: Analysis of the posterior palatal seal and the palatal form asrelated to the retention of complete dentures. J Prosthet Dent 1983; 47:23.

15. Curtis T, Langer Y, Curtis D, Carpenter R: Occlusal considerations for partially or completelyedentulous skeletal class II patients. Part I: Background information. JPD 1988; 60:202.

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saddle movement. J Oral Rehab 1986; 13:549-557.20. Friedman N, Landesman H, Wexler M: The influences of fear anxiety and Depression on the

patient’s responses to complete dentures. Part II. J Prosthet Dent 1988; 59:45.21. Frush JP, Fisher RD: Introduction to dentogenic restorations. J Pros Den 1955; 5:586-595.22. Frush JP, Fisher RD: How dentogenic restorations interpret the sex factor. JPD 1956; 6:160-172.23. Frush JP, Fisher RD: How dentogenic restorations interpret the personality factor. J Prosthet Dent

1956; 6:441-449.24. Frush JP, Fisher RD: The age factor in dentogenics. J Prosthet Dent 1957; 7:5-13.25. Frush JP, Fisher RD: The dynesthetic interpretation of the dentogenic concept. J Prosthet Dent

1958; 8:558-581.26. Frush JP, Fisher RD: Dentogenics: Its practical application. J Pros Dent 1959; 9:914-921.27. Grady R: Objective criteria for relining distal extension removable partial dentures: A preliminary

report. J Prosthet Dent 1983; 49:178.28. Haines R, Barrett S: The structure of the mouth in the mandibular molar region. J Prosthet Dent

1959; 9:962.29. Hochman N, Yaniv O: Comparative clinical evaluation of RPDs made from impressions with

different materials. Compend 1998; 19:200-206.30. Hosman HJ: The influence of clasp design of distal extension RPDs on the periodontium of the

abutment teeth. Int J Protho 1990; 3:256-265.31. Jacoboson T, Krol A: A contemporary review of the factors involved in complete denture

retention, stability and support: Part I: Retention. J Prosthet Dent 1983; 49:5.32. Jacoboson T, Krol A: A contemporary review of the factors involved in complete denture

retention, stability and support: Part II: Stability. J Prosthet Dent 1983; 49:165.33. Jacoboson T, Krol A: A contemporary review of the factors involved in complete denture

retention, stability and support: Part III: Support. J Prosthet Dent 1983; 49:306.34. Kapur KK, et al.: A randomized clinical trial of two basic RPD designs, Part I: Comparisons of

five-year success rates and periodontal health. J Prosthet Dent 1994; 72:268-282.35. Kelly E: Changes caused by a mandibular removable partial denture opposing a maxillary

complete denture. J Prosthet Dent 1972; 27:140.36. Ko SH, McDowell GC, Kotowicz WE: Photoelastic stress analysis of mandibular removable

partial dentures with mesial and distal occlusal rests. J Prosthet Dent 1986; 56:454-460.37. Kotwal K: Beyond classification of behavior types. J Prosthet Dent 1984; 52:874.38. Kratochvil FJ: Influence of occlusal rest position and clasp design on movement of abutment

teeth. J Prosthet Dent 1963; 13:114-124.


39. Krol AJ: RPI clasp retainer and its modifications. DCNA 1973; 17:631-649.40. Krol AJ: Clasp design for extension base removable partial dentures. JPD 1973; 29:408-415.41. Lang B, Razzoog M: A practical approach to restoring occlusion for edentulous patients. Part I -

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Arranging the functional and rational mold combination. J Prosthet Dent 1983; 50:599.43. Lang BR, Razzoog ME: Lingualized integration: tooth molds and an occlusal scheme for

edentulous patients. Implant Dentistry 1991; 1:204-211.44. LaVere AM: Clasp retention: the effects of five variables. J Prosthod 1993; 2:126-131.45. Leupold RJ, Flinton RJ, Pfeifer DI: Comparison of vertical movement occurring during loading

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47. Mazurat RD: Longevity of partial, complete, and fixed prostheses: a literature review. J Can DentAssoc 1992; 58:500-504.

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Product List

1. Alma Gauge - For fabricating maxillary wax rims: Dentsply; 800-877-0020.2. Attachments - VKS vertical or horizontal attachment. Bredent USA, Miami, FL; 800-328-

3965.3. Attachments - Stern G/L and ERA attachment. SternGold-Implamed.4. Compound for border molding impression trays - Green Stick Compound. Kerr, Romulus,

MI; 800-537-7123.5. Denture Teeth - Antaris/Postaris and Ortholingual. Ivoclar, 800-533-6825.6. Denture Teeth - Physiodens. Vita; 800-828-3839.7. Denture Teeth - Trublend. Dentsply; 800-877-0020.8. Denture Teeth - Enigma. Leach and Dillon Products; 800-535-2633.9. Denture Teeth - Myerson Lingualized Integration Teeth. Austenol; Chicago, IL; 800-621-

0381.10. Denture Tooth Selection Face Shield - Trubyte Tooth Indicator. Dentsply; 800-877-0020.11. Fox Plane - For Leveling Occlusal Plane. Dentsply; 800-877-0020.12. Functional Impression Material - Hydrocast. Kay See Dental, Kansas City, MO; 800-842-

8844.13. Functional Impression Material - holds VDO for functional impressions – Microseal. AMCO

International; 800-523-074014. Intra-oral device for CR and occlusal evaluation - Coble Balancer. Order from Lantz Dental

Prosthetics, Maumee, OH 800-788-5385.15. Central Bearing Device - Y&M Dental, Overland Pk, KS 913-851-8079.16. Intra-oral post dam tissue marking sticks - Dr. Thompson’s Sanitary Applicators. Great

Plains Dental, Kingman, KS; 316-532-3888.17. Impression Material - System 1 & 2 Alginate. Ivoclar; 800-344-5457.18. Occlude - Marking RPD frameworks. Pascal Co. 800-426-8051.19. Occlusal Indicator Wax - For Occlusal Adjustments and Delivery of Dentures. Kerr,

Romulus, MI; 800-537-7123.20. Pressure Indicating Paste - For Post Delivery Adjustments of Denture Sore Spots. Order from

your dental supplier.21. Reline Material - New Truliner. Bosworth Dental Products, Skokie, IL 708-679-340022. Rubber base impression material (light and medium) - Permlastic. Kerr, Romulus, MI; 800-

537-7123.

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