Robert Kreyer, CDT

	We have all experienced the inadequately written dental laboratory prescription: “Pour impressions.” “Make baseplates and rims.” “Set teeth.” “Process and finish.” These all are various vague terms that we have read on work authorization orders or prescriptions.

	To write a comprehensive dental laboratory prescription, a clinician must have technical knowledge of removable prosthetic laboratory needs. Understanding these technical needs is a necessary component of effective clinical and technical interdisciplinary communication. The parameters of interdisciplinary communication are prosthetics, esthetics, occlusion, design and materials.

	Achieving consistency in clinical and technical communication during treatment planning will result in a predictable and consistent prosthetic product during delivery of the prosthesis.

	I so passionately believe in improving communication and collaboration between clinicians and technicians that I wanted to devote this column to a new removable prosthetics digital tool that sequentially provides a clinician with the necessary technical knowledge to create a comprehensive laboratory prescription.

	The InteRcom Case Planning System from Ivoclar Vivadent is a web-based portal that provides a sequential approach to clinical understanding of technical needs while assisting the clinician and technician in exceeding expectations and achieving consistent prosthetic results.

 Fig. A shows the Welcome page to InteRcom Case Planner. After completing your personal login, this page will appear and give you the option of creating a new case plan, continuing with an existing case plan or tracking a case.

 The system gives the clinician an option of creating a new “Fixed Restoration” or “Removable Restoration” case plan (Fig. B). Because my column is devoted to removable prosthetics, I will cover only the complete removable option in this article.

 Page one is “Patient Information,” (Fig. C) which allows the clinician to enter pertinent information to this case. This information includes a case identifier, due date, first and last name, age and gender.

 Page two of the Case Planner is “Appliance” and gives the clinician the option of designing a case plan for Complete or Partial prosthetics (Fig. D). The complete option includes implant retained and supported restorations.

 Fig. E shows page three of the Case Planner, “Teeth,” which enables clinicians to select which type of teeth they would like to use on this removable restoration.

 Page four, “Base,” gives the clinician an option between Injection or Conventional Press Pack compression processing (Fig. F). In the clinical resources section on the lower right. there are pdf brochures that explain the difference in technique and materials.

 Page five is “Shade” selection (Fig. G). Just click on the desired tooth shade, and it pops up from its guide. Selecting a denture base shade is necessary as well, so the options are listed, and the clinician just clicks on the desired base shade.

 Fig. H shows the “Mould and Occlusion” selection. Because this should be a clinical responsibility, a help video is available under Clinical Resources instructing on the proper approach for correct mould selection.

 Page seven is “Patient Records,” which includes Denture Gauge and Papillameter measurements (Fig. I). These two measurements are critical for a technician to create a clinically acceptable occlusal rim and esthetic control base and for setting anterior teeth. For recording correct incisal and gingival display in relation to lip length, use a papillameter as shown in the video under Clinical Resources. Denture gauge records are important for duplicating an existing denture’s vertical and horizontal anterior tooth placement in relation to incisive papilla. A denture gauge video is available as well.

 Digital patient photos can be uploaded and attached to your web-based prescription (Fig. J). Ten photos of various facial and intraoral shots can be uploaded to the digital case planner. This section reminds the clinician of how important it is to include photos with a prescription, thus giving the dental laboratory technician optimal information about patient needs and desires.

 The review section (Fig. K) allows the clinician to double check the accuracy of all information that has been included in sections 1-8. He or she simply scrolls down to review and verify all information in the case planner before generating the Removable Prescription.

 Finally, the case planner generates the digital “prescription” (Fig. L), which contains all removable prosthetic information that a dental laboratory will need to predictably and consistently create a successful complete denture that meets or exceeds expectations of a compromised edentulous patient.

	Interdisciplinary Communication (InteRcom) case planning uses a sequential approach to treatment that is supported by the Clinical Resources section and should be an essential part of a multidisciplinary prosthetic team dedicated to improving collaboration and communication between the clinician and technician. 

	Ivoclar Vivadent’s InteRcom system can be accessed by visiting 

Articles

Kreyer on Removables: Digital prescriptions

	Root retained overdentures are a clinical and technical treatment option, which should be considered as part of removable prosthodontic treatment. All prosthodontic treatment is dictated by biology with a goal to maintain, not destroy, these biologic considerations. One major biologic consideration is the periodontal ligament that surrounds the roots of each tooth.

	Periodontal ligaments have an array of proprioceptors, which receive mechanical stimulation and are very active during mastication and functional movements in the biologic condition of natural dentition. Proprioception provides patients with information on how much pressure and load they are applying during mastication and parafunctional movements. Proprioception also is linked to sense of mandibular position and movements of the body such as posture.

	To maintain biology within the oral environment roots can be saved with endodontic therapy thereby saving periodontal ligaments as well and preserving a patient’s proprioception. The role of proprioception nerve endings in the periodontal ligament and this loss due to extraction of natural teeth has been documented in literature. The discussion regarding implants to replace teeth is: Does the presence of proprioceptive nerve endings in periosteum, muscles of mastication, oral mucosa and temporomandibular joint compensate for those lost from the missing periodontal ligament?

	In this article I will present a simple and effective stud attachment technique for root retained overdentures using the Preci-clix from Preat.

	The roots have been endodontically treated then the titanium post is tried into the canal by the dentist before cementation (Fig. A).

	After cementation of titanium posts the black impression tools are screwed into post before final impression (Fig. B). An impression of maxillary edentulous arch and impression tool is taken by the clinician and prepared for pouring cast. Impression tool and female analogue are screwed together and the black impression tool is placed into the impression with silver female analogue above intaglio surface ready to be embedded in master cast (Figs. C and D).

	The master cast is poured and impression tools remain screwed into female cast analogues (Fig. E). The impression tools also provide a visual aide for parallelism of titanium posts in each root.

	Black impression tools are removed from analogues and Preci-clix male balls are screwed in place (Fig. F). O-ring spacers are placed with metal housings and female retention caps over male Preci-clix balls.

	An advantage of a ball attachment is its ability to rotate the female on ball, thus decreasing any divergency between abutments. The master casts are next blocked-out and prepared for fabrication of baseplate for records appointment (Figs. G, H, I, and J).
	The ability to try-in a baseplate that contains attachments for a root retained overdenture enables the clinician to record accurate records with a stable and retentive base while maintaining the biologic condition of proprioception.

	Root retained overdentures is a treatment option that should be considered before extraction of teeth and implant placement. Maintenance of roots and oral hygiene should always be a consideration as well during design and treatment options.
	Root retained overdentures are still a viable treatment option for today’s complete denture prosthetics.

 Root retained overdentures are a clinical and technical treatment option, which should be considered as part of removable prosthodontic treatment. All prosthodontic treatment is dictated by biology with a goal to maintain, not destroy, these biologic considerations. One major biologic consideration is the periodontal ligament that surrounds the roots of each tooth.

Kreyer on Removables: Don't forget about overdentures

	Excellence in service is a unique ability to anticipate the needs of your customer. As dental technicians, we offer a technical prosthodontic service for consulting, designing and manufacturing complete denture prosthetics according to a clinician’s dental laboratory work authorization or prescription. It is through excellent communication and collaboration that we are able to understand all the technical variables involved in ­removable prosthodontic treatment.

	With the current economic conditions, we will experience more immediate complete dentures involving provisional prosthetics that are transitioned over a period of time to definitive conventional or implant-retained/-supported dentures. In this article, I present a case showing before-and-after photos of maxillary and mandibular complete denture prosthetics from provisional to definitive.

	The emphasis of this case presentation is excellence in communication to exceed a patient’s expectations and desires. I would like to thank Dr. Kerry Whitten and the American Academy of Cosmetic Dentistry for assistance with clinical photos and the case.

	To exceed expectations, the clinician and technician must understand what each other’s needs are during treatment. If the goal is to provide optimal prosthetic treatment and care, there must be clinical and technical collaboration.

	The best way for a dental technician to understand these expectations is to see the current prosthetic situation through digital photos. The digital camera should be an everyday tool in the dental office. All dental laboratory prescriptions should be accompanied by a series of photos. Preliminary impressions should be sent with photos of patient full face, profile and intraoral (

). The ability to provide before-and-after photos adds value to the prosthetic service provided.

	In this case presented, a technician can visualize the intraoral environment before and after extractions, understanding inter-arch relationships of provisional complete dentures (

	Collaborating as a multidisciplinary team to design and provide interdisciplinary treatment and care for complete or partially edentulous patients requires excellence in communication.

	Instruments that measure vertical or horizontal dimensions and planes aid communication and provide us with the exact information we need to design complete denture prosthetics. Instrumentation can be used to create correctly contoured occlusal rims and thus establish a preliminary baseline for the smile design.

	To measure existing provisional denture and communicate vertical and horizontal planes, a denture or Alma gauge works very well. At chairside, the clinician measures the provisional and communicates this to the dental laboratory technician (

	Another instrument that is excellent for communicating facial measurements is the Papillameter (

). In this case, it is only possible to use this tool after extractions, surgical healing and residual ridge resorption has taken place, which is usually 4-6 weeks after surgery. Used to measure length of a maxillary lip, the Papillameter shows length of the lip at rest, tooth display at rest, smile line and high lip line. The superior portion of a Papillameter is cut with a V-groove providing room for the labial frenum when placed in the anterior vestibule. At zero on the millimeter ruled portion, there is a horizontal extension on the back that is placed on the incisive papilla, where zero is set on the ruled face. These measurements are used when designing the occlusal rims and anterior tooth arrangement.

	Other tools of communication for the dental laboratory include a Facial meter, which measures the width of a patient’s nose for anterior mold selection (

) and a Centric Tray that records a preliminary OVD and CR for construction of occlusal records or placement of a central bearing device for an intraoral tracing (

	An essential photo is the selected shade tab in relation to the patient’s lip (

). This not only verifies shade tab used but also helps the prosthetic dental technician visualize the shade in relation to a patient’s complexion. Cases such as this with a bleach shade for a younger patient are better communicated with digital photos.

 shows a profile of the definitive complete dentures, which adds value to treatment when compared to 

and explains the patient’s desire for bleached prosthetic teeth.

	A comprehensive complete denture treatment involves clinical and technical collaboration and communication to provide optimal patient care. The ability to analyze and recognize individual variables involved in prosthetic treatment enables the technician to exceed expectations.

	Attaching digital photo files to a dental laboratory prescription enables the dental technician to visualize expectations and desires for complete denture prosthetics and understand the functional and esthetic value. 

 Excellence in service is a unique ability to anticipate the needs of your customer. As dental technicians, we offer a technical prosthodontic service for consulting, designing and manufacturing complete denture prosthetics according to a clinician’s dental laboratory work authorization or prescription.