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Lecture title : Mouth preparation Lecture Date : 19-4-2012 Doctor: Qais George. ------------------------------------------------------------------------------
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Our Lecture today is Mouth Preparation. Simply speaking its just like a patient receiving a surgical operation, you have to prepare the patient for the surgical operation. For the metal framework RPD steps we have: In the Clinic- History & exam Primary Impressions, Mouth preparation, Final Impression.
Mouth Preparation:
The most important thing is that you make an appliance thats relieving for the patient and that the patient could wear it and remove it as easy as possible. And you on your own create the most appropriate path of insertion and removal, and so facilitating the thing to you and to your patient. Because if the patient finds any difficulties in the rpd, he will not wear it, hell give it back to you, and itll be very difficult to correct it, because its made from cast materials. We have objectives which is: -To return the mouth to optimum health and to eliminate any condition that would lead to failure of the prosthesis. -Its usually done after treatment planning, but should always precede secondary impression procedures and master cast formation.
-Periodontal therapy, to treat the tissue surrounding the tooth (bone, ligaments), to allow using the tooth as an abutment and make it fixed, otherwise we have to exclude it from our design. -Conditioning of abused teeth. -Occlusal adjustments. -Preparation of abutment teeth (Were going to concentrate on this in this lecture), Includes:
1) Conservative restoration of abutment teeth (might have
caries, might be inclined we have to fix this). 2) Preparation of guiding planes, for easier insertion and removal of the RPD. 3) Alteration of tooth contours, to adjust our desirable undercut areas, otherwise itll be useless, without any retentive means. 4) Rest seat preparation. *Surgical intervention and Periodontal therapy, carried out FIRST, to allow for an adequate healing period before denture construction.* First of all, were going to make our :
-Removal of interferences such as bony exostosis, enlarged tuberosities or tori that cannot be accommodated by modification of the denture design. -Removal of hyperplastic tissues as fibrous tuberosities and flabby ridges that are not resolved by conservative-tissue conditioning program. Because they wont withstand occlusal loading. -Excision of abnormal soft tissue lesions such as cysts, polyps or papillomas. -Ridge augmentation (Increase the level of the ridge which is highly resorbed to make space for the metal framework and the other components of the RPD) and Vestibular extension may sometimes be required in severely resorbed ridges.
-Periodontal flap to correct deep periodontal pockets. -Free gingival grafts to establish an adequate area of attached gingiva, especially on abutment teeth. -Correction of occlusal trauma to prevent recurrence of periodontal disease. The main problem here is that the healing will be very difficult. Patient should be followed up every 3-6 months for his periodentium, otherwise, were going to lose the abutments, and the end result will be Complete denture rather than Partial denture. -Splinting of periodontally weakened teeth by temporary immobilization of teeth. Splinting: to support teeth that have minimum grade of mobility. Can be achieved by Inter-dental wiring or Splints, which may be either in the form of Acrylic or cast removable splints. Permanent splinting following Periodontal treatment is achieved by two or more cast restorations cemented on teeth. Done also by doing crown and attach wire especially on the palatal or lingual surfaces to support the mobile teeth (just like the ortho wires).
-Tissue massaging using a soft tooth brush. -Tissue rest (tissue will not be subjected to load). -Tissue conditioning material (Soft reline material) could be used for patients with old dentures. Were going to put a pushing material on the tissue surface of the denture to relieve the pressure on the soft tissue. -Denture Stomatitis may require additional treatment with antifungal agent (e.g. Nystatin) when infection with Candida Albicans is evident. -Hypertrophied or Hyperplastic tissue growth in the form of Palatal Papillary Hyperplasia or Epulis Fissuratum may either completely resolve or may only shrink in size after treatment. -Although surgical removal of unresolved tissues causes scar formation, surgery may sometimes be indicated if these tissues interfere with the design and placement of the denture. We have to create a healthy environment that can receive our RPD. Sometimes we need the 2 steps mentioned above (Surgical and Periodontal treatments), sometimes we dont need them, so we just begin with the 3rd step (Conditioning).
Objectives :
-Eliminate Premature contact resulting from Over-eruption of teeth. -Eliminate deflective occlusal contact to establish harmony between Centric occlusion and centric relation. -Obtain simultaneous contact in eccentric positions. -Establish an even occlusal plane.
Done by:
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If over-eruption is accompanied by migration of the maxillary tuberosity, correction may either require the use of a the metal denture base instead of a thick acrylic base or surgical reduction of the tuberosity if the position of the maxillary sinus allows.
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Sometimes the maxillary sinus is too big that we cannot reduce the bone , it means we are going to penetrate the sinus , once the maxillary sinus is penetrated it will cause chronic inflammation & chronic headache to the patient 2- Infra occlusion. Its better to correct than supra occlusion ( supraeruption) It means Lengthen the clinical crowns of teeth that are in infra-occlusion by placement of cast overlays or crowns. Main purpose is to Elevate them to reach the corrected Occlusion Sometimes we can do : - Extractions : of severely malposed or over erupted teeth
As we can see in this picture , there is no interocclusal distance , and its very important to detect these malforemed teeth while Examination
. its mostly due to the patients neglection of his teeth once the patient do multiple extractions and he dont replace the missing teeth he will end up with Irregularities such us : supraeruption and this will impair the occlusal plane of Course .. - In such cases we should correct these teeth to Adjust our occlusal plane and get an ideal contact RPD Treatment Planning Occlusal relationship must be evaluated with mounted diagnostic casts to study the following:
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Vertical Dimension of Occlusion (existing VDO assessment) Occlusal plane Amount of interocclusal space .. Very important thing Horizontal and vertical relationship of anterior teeth Centric occlusal contacts Occlusal eccentric schemes (anterior guidance, group function)
Once you take your cast on the Articulator you have to study And recognize these steps in order not to suffer while constructing the RPD Preparation Of Abutment Teeth
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Abutment teeth supporting removable partial dentures especially distal extension partial dentures are subjected to distal tipping, rotation and horizontal movement.
- Every effort should thus be made to preserve and protect abutments from destruction.
And this is Achieved by proper treatment planning and adequate abutment preparation .
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Abutment teeth should also be adequately prepared to provide support, stability, reciprocation and retention for the partial denture.
Preparation of the abutment teeth is preferably carried out first on a duplicate of the diagnostic cast and then performed in the patient's mouth. - Abutments are grouped according to the extent of preparation required into:
1- Abutments Require Minor Modifications , these are
sound 2- Abutments requiring conservative direct restorations or indirect cast inlay/onlay preparation. And these Abutments Exhibit Extensive carious lesions 3- Abutments requiring indirect surveyed crown restoration, And this one to correct Long Access of the teeth we cannot remove, because its important in Our Design . Mouth Preparation for RPD framework Objectives : obtain parallel guiding surfaces to achieve positive rests to remove excessive undercut//lower the height of contour Sometimes we tend to lower the height of contour To Achieve Esthetics , because we dont want the retentive Arm of the clasp to show .
to create desired undercut for retention Preparation of abutment teeth in any of the previous groups should be carried out in a planned sequence:
1- Conservative restoration of abutment teeth. 2. Preparation of guiding planes. 3. Alteration of tooth contours. 4. Rest seat preparation.
(1) Conservative Treatment of Abutment Teeth. a) Carious lesions in abutment teeth should be conservatively treated and restored with either properly condensed amalgam or preferably cast inlay restorations b) Pulpal exposures are endodonticaly treated and the tooth is preferably protected by cast crown restoration (surveyed crown).
Endonditcally treated teeth should not be Subjected to
load ,because its Brittle and subjected to breakage of crown . so We have to Crown it or what we call it ( . ) c) Construction of cast crowns (surveyed crowns) either full crowns ( the whole crown will be Covered ) OR veneered crowns ( Only the buccal or facial Surfaced will be covered )
This Procedure for : preservation and protection of
When Does One Choose to Fabricate a Crown to Serve as a Removable Partial Denture Abutment?
When correction of unacceptable tooth contours cannot be achieved through enamel modification alone leading to significant it means we prepare the tooth by using Straight fissure burs , if it cannot be done We have to crown the tooth Dentine Exposure Caries & sensitivity
To restore a badly broken down clinical crown ( picture slides 8 ) To reestablish a proper occlusal plane (i.e. supra-erupted teeth ) To provide proper rests, especially with anterior teeth and adequate retentive undercuts for direct retainers I-bar, C clasp) when inadequate contours exist.
Here the doctor started to read the slides Which are not included in the Exam so please if you want to have An idea about it .. Go back to pages (8,9,10,11)
Guiding planes are also prepared on the lingual surfaces of teeth to provide maximum resistance to lateral stresses
As you can see in this picture ( from 2-4 ) is the guiding plane, so when you prepare it you have to Follow the Anatomy of the tooth ( as represented with the arrows ) using straight diamond fissure bur . you never make straight cut to the tooth
These stars represent the position of our guiding planes ( Goes up & Down ) in vertical movement which is the most appropriate path of insertion and removal
Locate the reciprocal clasp arm in the proper position Allow for an easy and more direct placement of the retentive clasp arm by modifying the proximal side. (2) Moderate grinding of the incisal or occlusal surface may be required to achieve proper occlusion (3) To create or modify retentive in such cases like improperly insufficient undercut we tend to do : undercut areas located or an
[DIMPLE UNDERCUTS] : A dimple or a hole is prepared in the gingival third of the tooth. Mainly done for the Retentive Arm (4) eliminate sharp edges and angles resulting from attrition or abrasion (5) Modification of the lingual surfaces of lower teeth to facilitate insertion of mandibular major connectors .
Contor of RPD Abutment Example of promoting Esthetics by modifying the Contour of RPD Abutment : As you can see in this picture the survey line has changed By using Parallel sided bur
Here the doctor started to pick few points and talked about it : Burs used for rest seat preparation :
1- Diamonds & Medium round carbide
Long, medium diameter cylindrical bur or diamond For Cingulum Rest Seats & Guiding Planes .
Types Of Rests :
- Occlusal Rests
Incisal Rests Small Vshaped notch, Located 1.5 to 2.0 mm from the proximal incisal angle of the tooth.
Composite Bonded Cingulum Rests Flat emergence profile Pumice, rinse, etch, bond using rubber dam Ensure cervical composite well adapted
Part (2) Done by :
Saleh Al-Naimi
Thanks everyone who participated in the Trip, You have made it Very special =] And Also not to forget Our Group Team work.. Allah ya36ekom Alf 3afye Good Luck in your Exams colleagues !!