POLYMERS

Polymer is a molecule that is made up of many units. Oligomer is a short polymer composed of two, three, or four mer( mer = unit) units. Monomers (mono= single) are the molecules that unite to form a polymer, and the process by which this occurs is termed polymerization.If monomers of two or more different types are joined, copolymers are formed.Copolymers may be either random(mers do not appear in specific order) or block (large numbers of one type of mer appear arranged in sequence).Atoms along the length of any polymer are joined through strong, primary covalent bonds. There are three basic spatial structures of polymers: linear, branched, and cross- linked. Linear and branched molecules are discrete but are bonded to one another through weak, physical bonds.Upon heating, the weak bonds break and the ability of the chains to then slide past one another results in a softened material.Upon cooling, the bonds reform and hardening occurs.Materials that are able to undergo this process are termed thermoplastic (polyvinylacrylics, poly(methyl methacrylate)). Cross- linking results in the formation of a network structure of covalently bonded atoms;primary linkages occur between chains, and the polymer actually becomes a single giant macromolecule.The spatial structure that allows chain sliding upon haeting is not present in crosslinked materials.cross- linked polymers therefore do not undergo softening upon heating and are termed thermosets (sylicones, cross-linked poly(methyl methacrylate), bisphenol A-diacrylate,cispolyisoprene). Longer chains and higher molecular weight result in the polymers increased strength, hardness, stiffness, resistance to creep along with increased brittleness.Small plasticizer molecules, when added to a stiff uncross-linked polymer, reduce its rigidity.When small molecules surround large ones, the large molecules are able to move more easily.A plasticizer therefore lowers the glass-transition temperature of the polymer,so a material that is normally rigid at a particular temperature may become more flexible.The glass-transition temperature is the temperature at which a polymer ceases to be glassy and brittle and becomes rubberlike.

Polymerization

There are two types of polymerization reactions: additional polymerization, in which no byproduct is formed, and condensation polymerization, in which low molecular weight by- product such

as water or alcohol is formed.Polymerization has four stages: activation, initiation, propagation, termination.Reaction may be accelerated by light, heat, radiation or small amount of peroxides.Free radical additional polymerization is used for the synthesis of polymers.The free radicals are produced by reactive agents called initiators.The most popular initiator is benzoyl peroxide.Activation-involves decomposition of the peroxide initiatior using special conditions.Initiation-involves production of free radicals, which will encourage a polymer chain to begin growing.Activator allows polymerization to occur at low temperature(aromatic tertiary amines). Free- radical molecules have chemical groups with unshared electrones.In chemically activated systems, free radicals are produced by the reaction of an organic poroxide initiator and amine accelerator.In light- activated systems, the scission of camphorquinone results in the production of two molecules with one production, the free radicals attack the double bonds of available monomer molecules, resulting in the shift of the unshered electron to the end of the monomer and the formation of activated monomer molecules.Propagation- Activated monomers attack the double bonds of additional available monomers, resulting the rapid addition of monomer molecules to the free radical.This stage continues as the chain grows and length.Termination-it is posible for the propagation to continue until the supply of monomer molecules is exhausted.These reactions produce dead polymer chains which are not capable of further additions.Small amounts of inhibitors, such as hydroquinone, may be added to the monomer to increase storage life.Hydroquinones react with free radicals, thereby decreasing the rate of initiation.

Classification of denture base, liners and tissue conditioners:

Denture base: I. Heat cured (PMMA ) 1. conventional Unfilled Re-inforced (Carbon,Polyfiber) 2.high impact II. Autopolymerized(PMMA) III.Injection molded 1. PMMA polycarbonate nylon Soft liners: I. Acrylic II.silicone a) room temperature vulcanizing (RTV) heat cured

Tissue conditionersplasticized acrylics

Denture base polymers The polymeric denture base can consist of either a simple stiff base on which the teeth are arranged, or a sandwich of stiff base and a resilient liner to provide greater retention and comfort.When the tissue underlying a loose denture is traumatized due to the constant motion of the hard plastic over the mucosa, a viscoelastic gel known as a tissue conditioner can be molded onto the fitting surface of the denture in situ so the tissue can heal and an accurate impression of the untraumatized fitting surface can be taken prior to making a new, better-fitting denture.

Requirements of denture base polymers:

Physical properties: good esthetic, thermal conductivity, dimensional stability,light, radiopaque. Mechanical properties: high value of modulus of elastisity,sufficient flexural strength,sufficient abrasion resistance. Chemical properties: materials should be chemically inert, insoluble in oral fluids, should not absorb water. Biological properties: should not be harmful to the technician, doctors and patients;should be non- toxic and non- irritant to the patients, should not be able to sustain the growth of bacteria or fungi.

Heat-cured acrylic It consists of powder and liquid.The major component of powder is polymer (beads of polymethylmethacrylate), pigments(pink pigment-cadmium salts) and initiator-benzoyl peroxide ~0.5%.The liquid: monomer (methylmethacrylate), cross- linking agent(improves the physical properties of the set material), inhibitor(prolongs the shelf life of the liquid components).The inhibitor, which is usually hydroquinone, works by reacting with radicals formed within the liquid to form stabilized radicals which are not capable of initiating polymerization.The ratio of powder to liquid is important since it controls the workability of the mix as well as the dimensional change on setting.A powder/liquid ratio by weight is 2.5:1.The mixture should be lefted for few minutes, and the mixing vessel should be closed to prevent evaporation of monomer.There are few stages of this material: sandy consistency, after the short period of time it becomes sticky,which forms strings of material.The dough stage.The material can be moulded like plasticine and does not stick to the mixing vessel.The material is packed in the mould at this stage.Later can be rubber and hard stages. The dough is packed into a two-part gypsum mould.The excess of dough is removed, then the flask is closed again using the pressure and the heat.The polymerization reaction itself is exothermic, so if the rate of reaction is too high, it cal lead to porosity.Under the pressure the dough flows into every part of mould and you can avoid of porosity.There are few kinds of porosity: granular porosity-it can be then there is insufficient amount of monomer to bind all the polymer beads together,evaporation

of monomer.Contraction porosity-the use of insufficient dough to create an excess in the mould or the application of insufficient pressure during curing can lead to this kind of porosity.Gaseous porosity-it can be then the temperature of dough during polymerization is rised significantly above 100.3C, the monomer at this temperature will boil and will produce spherical voids.

High- impact acrylic High-impact acrylic denture base is also made by the hear- cured dough method.Impact resistance arises from the incorporation of a rubber phase into the beads during their suspension polymerization.

Autopolymerizing denture base (cold curing resines) The autopolymerizing denture base is chemically similar to the heat- cured denture base except that a reducing agent is added to the monomer.The reducing agent is usually a tertiary aromatic amine, although barbituric acid derivates.The reducing agent reacts with the benzoyl peroxide at room temperature to produce peroxy free radicals, which initiate the polymerization of the monomer in the denture base.Autopolymerizing materials are used for repairing and relining of dentures, because their mechanical properties are weak, and there is high residual free- momomer content. Injection- molded plastic The injection- molded plastics have the advantage of consistent molecular weight, but the disadvantage of capital equipment costs, and difficulties associated with attachment of teeth to the denture base.The plastics still offered for the use as injection-molded denture base acrylic are polycarbonate and nylon.They represent very small fraction of the market, although they offer a real alternative to metal dentures for patients sensitized to conventional methacrylate or to nickel or cobalt. The technician has little leeway when using injection-molded plastics.The mold should be dry to prevent the generation of steem during molding.Patience is required to ensure the melt has reached the right temparature and cools sufficiently after molding.Inadequate spruing will lead to underfilled molds, as can underheating the melt;overheating the melt can cause explosions, especially when polycarbonate is injected into moist molds. Injection moldings rely almost totally on mechanical forces to retain the teeth.Low melt temperatures will cause strong forces to be put on the teeth during the injection phase and may dislodge some molars, even from plaster molds.Depolymerization or oxidation from overheating the melt can result in porosity, loss of strength, color changes, and increased fouling.

Light- activated materials

This material consists of a urethane dymethacrylate matrix with an acrylic copolymer and has a microfine silica filler.It is supplied in premixed sheet or rope form.A base plate is made by adapting the material to a cast and polymerizing in a light chamber at 400 to 500nm(blue light).Teeth are added to the base with additional material followed by a second light exposure.The system eliminates the need for flasks, wax, boil-out tanks, packing presses, and heat processing units required for the construction of the conventional dentures.Light- activated materials contain no methylmetacrylate monomer, they may be considered for use in those patients who have demonstrated a sensitivity.polymerization shrinkage is smaller than conventional systems.

A comparison of denture base materials

1.Heat cured

Advantages: good apperance high glass-transition temp. Easy fabrication Low capital costs Good surface finish Disadvantages: free monomer content or formaldehyde can cause sensitation low impact strength fatique life too short radiolucency

2.Heat cured, rubber Advantages: improved impact strength reinferced Disadvantages: reduced stiffness

3.Heat cured, fiber Advantages: high stiffness reinforced very high impact strength good fatique life

polypropylene fibers make good translucency good surface finish

Disadvantages: carbon and Kevlar fibers make poor color poor surface 4.Autocured Advantages: easy to deflask dimensional accuracy capable of flexural strength than heat cured Disadvantage: no cheaper over long term increased creep increased free-monomer content color instability reduces stiffness tooth adhesion failure 5.Injection molded Advantages: dimensional accuracy low free-monomer content polycarbonate and nylon make good impact strength Disadvantages: high capital costs difficult mold design problems less craze resistance less creep resistance

6.light activated Advantages: no methylmethacrylate monomer decreased polymerization shinkage possible improved fit compared to conventional materials requires little equipment time savings Disadvantage: decreased elastic modulus Denture lining materials

Permanent soft lining materials Permanent soft lining materials are resilient polymers used to replace the fitting surface of a hard plastic denture, either because the patient cannot tolerate a hard fitting surface or to improve retention of the denture.Because the lining is soft, its dimensional stability is important, as are its durability and resistance to fouling.However, because by definition soft lining materials are above their glass-transition temperature when in the mouth, such physical phenomena as water absorbtion, osmotic presence of soluble components, and biodegradability play a greater role in the clinical success of a liner than they do in the glassy polymers used as denture bases. Acrylic soft liners The acrylics consist of either highly plasticized intrinsically glassy polymers or soft acrylics that have a natural glass-transition temperature (softening temp.) at least 25C less than that of the muoth.The plasticizer used to soften the acrylic can either be unbound to the acrylic and hence free to diffuse out during use, resulting in a loss of resilence, or it can be reacted into the cured matrix of the acrilic. Silicone soft liners The silicones used as soft liners can be devided into two types: room temperature vulcanizing (RTV) and heat cured.The resilence of silicones makes them at first seem to be the ideal soft materials.However, silicones have poor tear strength, no intrinsic adhesion to acrylic denture base, and, if not properly cured, a tendency to osmotic pressure effects.RTV silicones geatest drawback is their lack of adhesion, which is especially a problem around the edges of the attachment between acrylic and silicone.Heat cured silicones have in their formulation a silicone methacrylate than can polymerize into curing denture base and into the heat- cured addition silicone.The RTV silicones use a condensation cross-linking system based on organo-tin derivates such as those used in impression rubbers.Their degree of cross-linking is lower and their serviceability is low as a result, with frequent reports in the literature of swelling and buckling during use and excessive sensitivity to denture cleansers.The rupture strength of some RTV silicones is known to deteriorate cosiderably when exposed to waterfor long periods.The heat-cured silicones achieve a greater degree of crosslinking and have much longer clinical lifetime. Temporal soft lining materials These materials are similar to tissue conditioners, but they are not so soft as conditioners immediately affter setting but they retain their softness for longer, taking up to a month or two to harden.These materials are viscoelastic.Some kinds of cleansers can cause surface degradation and pitting of material.Temporal soft lining material can be used improving the fit of ill-fitting denture until such a time as a new denture will be maden.These materials will go hard, when this occurs, the surface is rough and increases the risk of trauma.In this state the base can be colonized by Candida,it leads to stimatitis.

Tissue conditioners Tissue conditioners are soft denture lining material which may be applied to the fitting surface of a denture, to the dentures of patients who have undergo surgery.,they are useful when a tooth is being added to a denture( very shortly after extraction).The material consists of powder (polymer beadspolyethylmethacrylate) and liquid (solvent-ethyl alcohol; + plasticizer- butylphthalyl butylglycolate).

A comparison of soft liners and tissue conditioners 1. Soft liners: a) Acrylic Advantages : high peel strength to acrylic denture base high rupture strength some can be polished if cooled reasonable resistance to damage by denture cleansers Disadvantages: poor resilience loses plasticizer in time some buckle in water b) Silicone(RTV) Advantage: resilience Disadvantage: low tear strength low bond strength to dentures attacked by cleaners buckle in water poor abrasion resistance c) Silicone heat cured Advantages: resilience adequate bond strength to acrylic more esistant to aqueous environment and cleanser than RTV Disadvantages: low tear strength poor abrasion resistance 2. Tissue conditioners

Advantages: viscoelastic properties almost ideal can be applied chairside denture fit well can record freeway space Disadvantages: low cohesive strength affected by cleanser alcogol can sting inflamated mucosa.

Complete denture

Diagnosis is the evaluation of the existing condition, more specifically; it requires identifying and making judgment about departures from normal. It is: The act or process of deciding the nature of a diseased condition by examination. A careful investigation of the facts to determine the nature of a thing. The determination of the nature, location and causes of a disease. Diagnosis for the prosthodontic care requires the use of general diagnostic skills and accumulation of knowledge from other aspects of dentistry and its supporting sciences. Diagnosis in complete denture is a continuing process and is not accomplished in a short time. The dentist should be the first to recognize the problem and be ready to change the treatment plan to meet the new findings. These findings will be governed by:

1) Patient's mental attitude. 2) Patient's systemic status. 3) Past dental history. 4) Local oral conditions Mental attitude (psychological factor)

The success of dental prosthesis is related to many factors, including functional, biological, technical, esthetic and psychological factors. Psychological factors include the preparedness of the patients and their mental attitudes towards dentures, their relationship with the dentist and their ability to learn how to use the dentures. Prosthodontists must fully understand their patients because such understanding predisposes the patient to accept the kind of the treatment they need. De Van said "meet the mind of the patient before meeting the mouth of the patient". Patients seeking prosthodontic care usually arrive with accumulation of experiences and resulting attitude. These may range from optimism through resignation to despair; all may be set against a background of psychosis. In the discussion with the patient, the dentist must seek an understanding of the patient's health, particularly their attitude toward receiving new dentures. House classified the patients into 4 categories: 1. Philosophical patients. 2. Exacting patients. 3. Indifferent patients. 4. Hysterical patients. Philosophical patients These patients are rational, sensible, and calm and composed in a different situation. Their motivation is generalized as they desire dentures for the maintenance of health and appearance and feel that having teeth replaced is a normal acceptable process. These patients usually overcome conflicts and organize their time and habits; they eliminate frustrations and learn to adjust rapidly. The best mental attitude for denture acceptance is the philosophical type. Exacting patients These patients may have all of the good attributes of the philosophical type, however, they may require extreme care efforts and patience on the part of the dentist as they like each step in the procedure to be explained in details, and they require extra hours spent prior to the treatment in patient education until an understanding is reached. Indifferent patients These patients are apathic, uninterested and lack motivation. The do not care to their self image; they manage to survive without dentures and pay no attention to the instructions. They do not cooperate and mostly blame the dentists for their poor dental health. In most of them, questionable or unfavorable prognosis may be expected. For such patients, educational program in dental conditions and treatments is recommended before denture construction. Hysterical patients These patients are excitable, apprehensive, emotionally unstable and hypertensive. They are neglectful of their oral health and unwilling to try to adapt to wear dentures. Additional professional help is required prior to and during

treatment. Although these patients may try to wear the denture, they fail to use it as they expect it to look and function like the nature teeth. Social information It is necessary as a first step of all patients. It is the establishment of their identity. Personal information as the name, address, telephone number, work and hours of work might help the dentist in the primary estimation of the dental health and prognosis. Social setting can help to understand the patient's expectation and the dental status developed. Social information may clarify some habits, specifically those might contribute of their present conditions and those might help ensure success or failure for the treatment. Modifications or reinforcements of these habits should be noted for the inclusion in the treatment plan.

Systemic-medical status No prosthodontic procedure should be planned until the systemic status of the patient is evaluated. It must be realized that dentistry is part of health services and that oral health is closely associated with the general health of the patient. The dentist is not entitled to just make dentures; they are responsible on the wellbeing of the patient as a health professional. Except in cases of accident, individuals who are losing their teeth are manifesting pathological conditions because their loss may be as a result of systemic factors or associated with unfavorable systemic condition. Furthermore, these systemic factors must be considered in the treatment plan by the dentist. Many of the systemic diseases have local manifestations with no systemic symptoms and others have both local and systemic reactions. Some systemic diseases have a direct relation to the denture success even though, no local manifestations are apparent. Debilitating diseases These patients requires extra instructions in the oral hygiene and tissue rest, also frequent recall appointments should be arranged because the supporting bone may be affected to keep the denture bases adapted and the occlusion corrected.

Debilitating diseases include, for example, diabetes, tuberculosis, blood diseases etc. Cardiovascular diseases Patients with cardiovascular diseases may require consultation with cardiologist as some denture procedures may be contraindicated. Such patient must be controlled before dental treatment. Joint diseases Joint involvement, particularly osteoarthritis, presents different problems. If the disease involves the TMJ, alteration in the treatment plan may be essential. In extreme conditions, special impression tray and technique are often necessary because of the limited access from reduced ability to open the jaws. Furthermore, jaw relation records are difficult and occlusion correction must be made often because of the subsequent changes in the joints. Neurological disorders Some neurological involvement, as Bell's palsy or Parkinson's disease, requires some attention. The dentist has to deal with some problems related to the denture retention, maxillomandibular records and supporting musculature. Skin diseases Many of the dermatological diseases may have oral manifestations such as pemphigus vulgaris. Medical support mostly needed because these oral lesions are painful that prevent proper work. Other conditions, as congenital diseases, endocrine diseases, malignancy, menopause, psychological, nutritional deficiencies, and infectious diseases may require disease understanding to prepare for successful work. Past dental history Success or failure in the provision of prosthodontic care is frequently the direct result of the adequacy of taking the patient's dental history. By talking, the patients would provide the essence of a diagnosis of their dental health and needs. An understanding of the etiology of teeth loss by a patient would help a dentist to estimate the patient's appreciation of the dentistry and contribute to the prognosis for prosthodontic success. Although patients can change their attitude and habits, it is reasonable to be suspicious that patients were lost their teeth in an accident might be much unhappy about their edentulous state than patients who lose their teeth as a consequence of decay resulting from neglect. Similarly, expectation of the amount of alveolar remaining would be greater for the patients with a history of rapid tooth loss from decay than for patient with a long history of progressive periodontal diseases. Dental experiences may be the source of both good and bad habits. Patients may reveal instances of traumatic experiences dating to their first visit to the dentist. Traumatic experiences have very lasting effects and make the patient tense in the dental chair, this may lead to neglecting of the oral health by the

patient and lead to negative attitude. Experiences with previous prosthodontic restorations, whether partial or complete, are important in determining the patient tolerance, tissue tolerance and esthetic acceptability and what the patient expect from the denture. Any existing prosthesis must be examined thoroughly in an objective manner. Quality of the denture material, teeth type, occlusion and occlusal discrepancies between the teeth, occlusal plan, retention and stability, and the age of the denture can be estimated from the old denture. Patient oral hygiene can be reflected well by the old denture and the condition of the supporting tissues also can be expected. Evaluation of the esthetic of the existing denture should be approached from a professional judgment of the dentist and to correlate with the information about the natural teeth; this evaluation must take into consideration the patent's view. Although it is important to strive to raise the quality of care to match the highest of the patient's expectations, also is appropriate to lower patient's expectations through education about denture wearing. Local factors Unfortunately, local factors are the only ones considered by many dentists. However, it is not enough to make a cursory examination and note the presence and absence of the teeth. Local factors that are considered to afford the ideal environment for complete dentures are: 1) Broad square ridges devoid of undercuts and bony abnormalities. 2) Definite cuspid eminences and alveolar tubercles, broad palate with uniform depth of vault in the maxillary arch. 3) Broad buccal shelves and firm retromolar pads in the mandibular arch. 4) A definite vestibular fornix devoid of muscle attachments. 5) Frenum attachments high in the maxillary and low in the mandibular arches. 6) A clearly defined and well-developed lingual sulcus. 7) A lateral throat form that allows suitable extension into the retromylohyoid space. 8) A firm mucosal covering over the denture-bearing area. 9) Mucous membrane in the vestibular fornix and floor of the mouth, which is loosely movable and attached for denture seal. 10) A gradually slopping palate with a passive reflection at the junction of the hard and soft palate. 11) A tongue is normal in size, position and function. 12) A normally-related maxilla to the mandible. 13) Good muscular tone and coordination in the mandibular movement. 14) Adequate inter-ridge space for a favorable placement of the teeth. 15) Saliva is suitable in viscosity and quantity. 16) Hard and soft palate tissues devoid of any signs of pathological disorder.

An appreciation of the influences of the local factors is based on the anatomy and physiology of the supporting tissues. Evaluation of the local factors would help in the selection of the type of the impression to be made, impression materials, method of making maxillo-mandibular relations, occlusion and even selection of the teeth. Deviations from these ideal conditions are more often; this does not mean inability to do proper, successful dentures. Any deviations should be noted in the diagnosis, so appropriate procedures and modifications can be incorporated in the treatment plan. The local factors are usually evaluated during clinical examinations. Examination must divide into extraoral, which must exam the orofacial and oral surrounding structures (muscles of the face, TMJ, symmetry of the face, lips, and cheeks). Intraoral examination must include the ridge form (square, round or v-shaped), mucous membrane (healthy firm, flabby, ulcerated, inflamed or normal or any other variations). Tongue position, size and function. The residual ridge if it is flat or not and palate height (high, shallow and medium). Saliva quality and quantity. The presence of retained roots and tori or any bony enlargement and sharpness. Mostly, the clinical examination precedes radiographic examination, although in some cases, this order may be reversed. X-ray films (extra and intraorally) may provide additional information especially about the alveolar bone, joints, unerupted or retained roots and foreign bodies. It can be determined if the patient will accept or reject the dentures at the time of local factors evaluation. Other investigations may be decided individually according to the needs of the patient's case.

Diagnostic casts In addition to the construction of the special tray, diagnostic cast is used for: 1. It reveals new information or confirms that which has already been observed intraorally. 2. It allows for an evaluation of the anatomy and relationships in the absence of the patient.

3. The dentist will be able to look at each size and symmetry, interarch space, arch concentricity, anteroposterior jaw relationship, and lateral jaw relationships; especially posteriorly, where an occlusal crossbite might be present. 4. Measurement and determination of other structures would assist in making a decision on preprosthodontic surgery. 5. Undercuts may be observed unaided, or their significance can be determined more precisely with the aid of the dental surveyor. 6. Education and explanation of some treatment steps would be easier by using diagnostic casts in some occasions. Treatment plan Treatment plan is a consideration of all of the diagnostic findings (systemic and local), which influence the surgical or any preprosthetic preparations of the mouth, impression making, maxillo-mandibular relations, occlusion, form and material of the artificial teeth and instructions in the use and care of the dentures. It is matching the possible treatment options with patient's needs and symmetrically arranging the treatment in order of priority but in keeping with logically or technically necessary sequences. The process requires a broad knowledge of treatment possibilities and detailed knowledge of the patient's needs determined by a careful diagnosis, otherwise, the patient would be placed in jeopardy of receiving inadequate or inappropriate treatment. Treatment does not terminate with the construction and delivery of the complete denture and the patient should be so advised. Treatment plan must have a parallel process of developing diagnosis; it is driven by the diagnosis but must take other factors, such as prognosis, patient health and attitude, into account. The patient must be informed about the time required for the procedure and expense. Limitation of the denture must be outlined for the patient with any expected problems. Treatment plan is used to specifically state the treatment that would address a particular patient's need; this treatment must state in a logical sequences and care. Treatment plan is a problem-solving techniques; it involves a careful analysis of the problem, breaking to components, as possible, generating a list of possible component solutions are implemented; some believed that it is a mental exercise but written a list may assist thinking.
LAW OF CONSERVATION OF KNOWLEDGE: "No matter how long the lecture may be, the knowledge before and after the lecture remains constant"