Th 281609

Dr. Joe Blaes conducts a rare one-on-one interview with Dr. Joe Massad

April 1, 2008
Why don't more clinicians embrace removable prosthetics?

For more on this topic, go to and search using the following key words: removable dental prosthetics, fixed dental prosthetics, TMJ health, dentures.

Q: Why don't more clinicians embrace removable prosthetics?
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A: In my many years of teaching, many practitioners have told me they feel more comfortable with fixed prosthetics since they produce more predictable results. They have been confronted with numerous situations in which they simply cannot satisfy their denture or partial patients with esthetics, fit or function. Dentists usually become apprehensive when on the day of delivery, they realize there is little to no retention, even on the maxillary prosthesis. They feel that many denture patients have unreasonable expectations. This uncertainty of predictable results combined with patient dissatisfaction has discouraged many clinicians from pursuing complete removable prosthetics. The fact of the matter is that a successful case of complete removable prosthetics depends on total reconstruction of the facial contours, the vertical and horizontal relationships, the esthetics of the smile, TMJ health, and the occlusion of two arches dependent on bone height, tissue character, and tissue movement (displacement).
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Q: Does advance training in denture prosthetics still make sense for practitioners in light of all the advancements made in implant restorations? A: Absolutely. We place implants in an attempt to fix the problems of fit, and without the ability and confidence in treating the complete denture patient, we cannot meet the qualifications of proper vertical and facial contours. If the design of the prosthesis does not meet all the necessary criteria for function, this could lead to TMJ discomfort and food deflection into undesired areas such as the buccal vestibules and beneath the denture, thereby compromising the success and patient satisfaction of the case. There is no way to get around this issue. We need to constantly stay up-to-date on the most improved training methods and materials in order to produce the best results.Q: Do you think there is still a growing need for dentures in the U.S.?A: Yes. In fact, studies have reported that the total edentulous denture population is growing by about 3 percent annually. These published studies integrated findings from the U.S. Census Bureau, current population reports 2000 AACD poll, U.S. stats on edentulism projections based on the third national health and nutrition exam survey (NHANES III), and several studies by Chester Douglas DDS, PhD.This increase is partly due to the increased longevity of our population. As the percentage of edentulism may increase, the numbers of removable prostheses are growing.
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Q: What would you suggest for a dentist interested in removable prosthodontics and increased patient inflow?
First, I would emphasize the need to update the dentist's skills so that he or she is ready to deliver today's state-of-the-art prosthesis. Second, it is extremely vital that all of the armamentarium be available and the staff be fully trained on the proper utilization of each instrument. Third, each dentist must determine his or her policies with a very detailed informed consent that explains in simplified terms what each patient should expect. Finally, and possibly the most important, it is crucial to secure a well-trained laboratory to handle all removable procedures. The prosthetic lab technician is the vital thread to sew up cases with predictability. Q: How can removable prosthetics be a profit center in a dental office?
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A: First, we all must think differently about the whole subject of dentures, partials, and implant overdentures. Today's practices do not generally have replacement protocols. How long should a prosthesis last? When and how often should patients have relines performed? There is an old saying, "Once a denture patient is adjusted, the best practice is not to see him or her again." The MIA (missing in action) patient generally complains behind closed doors. We should have these patients on shorter recall intervals to help them maintain the best oral health. If patients are told at the beginning that the life expectancy of the prosthesis is five to eight years, and that refitting (reline) procedures should be performed every one to three years to maintain an ideal fit, then we are helping our patients by reducing the degenerative processes, and we are also increasing our bottom line financially.

When patients maintain dentures or partials for 20 plus years, we often see conditions such as severe bone atrophy, premature tissue character loss from fibrous to fragile, and increased tissue mobility. These degenerative processes can be slowed down significantly by maintaining a proper fitting prosthesis. In actuality, dentistry has a shelf life that we should make our patients aware of. As the body ages, we must intervene to give patients the best quality of life available.

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Here are the protocols I suggest for my patients. I will start with complete dentures. Patients are asked to return every six months for a tissue check and denture fit evaluation. At the one-year recall, patients are evaluated for both fit and occlusion. Some patients may need minor occlusal adjustments and some may need relining. If, for example, resilient liners are placed at delivery, there is a good chance the severely resorptive patient will need a replacement liner. On average, soft liner should be replaced every one to two years depending on the overall condition and health of the patient.

Next, I will talk about implant overdentures. Since two to four implant abutments are average, we still have tissue load and indications of relining from time to time. If a ball ring, nylon female attachment or soft liner is used for the retention, then each of these will lose its resiliency and need to be replaced. Replacement is generally attributed to hygiene, occlusal load, dry mouth, and some medications that create unfavorable mouth environments. On average, attachment retentive elements should be replaced every one to three years for optimal performance.

Finally, I'll discuss partial denture prostheses. Depending on the number of remaining teeth, relining the edentulous area should be treated like complete dentures. If the patient does not seem to have loose partial dentures, it does not necessarily mean the fit is optimal. Total replacement of cast metal frame on conventional partials should occur every five to 10 years. There are, however, many more factors due to the presence of dentition. From a health perspective, we are helping our patients. From a financial perspective, we are increasing the billable procedures and are thus building a profit center rather than a depression center.

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Q: How about the immediate dentures? How long do they last and are they still considered the temporary disposable prosthesis?A: If you had asked me that question two years ago, I would have told you that the first immediately placed prosthesis on the day of extraction was a very temporary and inaccurate replica of the second denture that would be made six months to one year later. But due to recent advancements in this field, I can now confidently say that the immediate dentures are equally as accurate and well-fitting as the replacement prosthesis. This is provided we follow a protocol of staged refitting after placement.Q: Does it take you more time to make a denture or partial than the average practitioner, or are there shortcuts?A: I am asked this question at every presentation, and the answer is yes and no. In general, the overall treatment may take longer, but ultimately the completion time and number of appointments are usually much fewer. I believe that spending more time in the assessment and treatment planning stages will shorten or eliminate postoperative adjustment visits. If a patient returns more than twice in need of an adjustment, the dentist will not only add to the overall appointments, but will see the patient's attitude change in his or her perception of the quality of the prosthesis and the experience of the dentist. The amount and time of each appointment can vary due to several factors, but typically I take four appointments to deliver the prosthesis and one to two visits for postoperative adjustments. In general, shortcuts are not that predictable for optimum prostheses.Q: What makes the curriculum for removable prosthetics offered by the Scottsdale Center for Dentistry unique as compared to other educational facilities?A: In a nutshell, the live patients on whom each participant will train create an optimal learning experience. In our two-day hands-on training, we plan on having 36 dentists with 10 patient models and four faculty members. These are very good ratios for private training. Q: Is there any money to be made on removable prosthetics, especially when compared to all other procedures in dentistry?A: Of the more than $100 billion spent by U.S. consumers on dentistry, it has been reported that $13 billion of this amount is spent on removable prosthetics. So, you tell me who is keeping this secret to themselves.

References available upon request.

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