good morning examination and evaluation of diagnostic data: the second diagnostic appointment...
TRANSCRIPT
GOOD MORNING
EXAMINATION AND EVALUATION OF DIAGNOSTIC DATA: THE
SECOND DIAGNOSTIC APPOINTMENT
Presented by:
Dr. Kamleshwar Singh BDS, MDS, ICMR-IF(Japan)
Assistant Professor
Department of Prosthodontics
King George’s Medical University, Lucknow
Second appointmentThe second diagnostic appointment is used to complete the
gathering and the evaluation of the diagnostic data.Diagnostic mounting:
a) supplement examination of oral cavity.b) analysis of occlusionc) patient educationd) provide a record of patients condition before
treatmentProcedure: Facebow transfer Centric relation registration Mounting casts Protrusive record, setting condylar elements
Face bow transfer:
Preparation of bite fork Orientation of face bow
to bite fork and reference points
Orientation of face bow to articulator
Attachment of maxillary cast to articulator
Centric relation record
Recommended method Backrest at 60 degrees.
Deprogram oral musculature.
Slight backward and downward
pressure on patient mandible
Then CR record made.
Centric relation record: Using wax
We can also use elastomeric registration materials (wax tends to change dimension over time and can become brittle)
Centric relation record: Using Record bases
If patient does not have enough teeth to mount lower cast to upper (i.e. no posterior teeth), fabricate record bases.
Wax-up, take relation in centric relation.
Setting condylar elements
Protrusive record: with either wax or elastomeric material.
Patient instructed to protrude mandible by 5-6mm, then close into recording material.
Setting condylar elements
Too steep
Correct inclination
Too shallowThe condylar setting is…
Extra-0ral examination:
Facial form and symmetry, jaw opening and closing movements, palpation of TMJ and muscles of mastication.
Definitive Oral Examination: Caries and existing restorations
Carious lesions:
surface restorations
cast restorations
crowns Margins of cast
restorations. Possible extractions.
Definitive Oral Examination: pulpal tissues
Possible pulp testing should be used to
determine the vitality of the teeth.
Selection of endodontically treated tooth
as abutments is NOT contraindicated.
Better prognosis with full crown
coverage restoration.
Definitive Oral Examination: sensitivity to percussion
Unstable occlusion Tooth in traumatic
occlusion PA abscess Acute pulpitis Cracked tooth
syndrome
Definitive Oral Examination: Periodontium
Trauma of occlusion Inflammation of
periodontium Colour, contour ,
form and stippling of gingiva
Loss of bone support
Not useful as an abutmentfor a partial denture
Useful for an abutment foran over denture
Definitive Oral Examination: Tooth mobility
Degree of mobility (Grant, Stern & Everett 1972) NP mobility – 0.05 -0.1 mm - Viscoelastic property of pdl (Carranza)
Class1: More than normal physiologic mobility but less than 1mm of movement in any direction.Class 2: A tooth moves 1 mm from normal position in any directionClass 3: A tooth moves more than 2 mm in any direction, including rotation or depression.
Need for periodontal treatment:
Pocket depth>3mm Furcation involvement Gingivitis, ginigival cleft,
festooning Marginal exudate Proposed abutment teeth
exhibiting < 2mm attached gingiva width
Definitive Oral Examination: Periodontium:
Definitive Oral Examination:Oral mucosa:
Uicers, inflammation, rough
teeth, existing prosthesis Pathologic lesions Papillary hyperplasia Epulis fissuratum Denture stomatitis
(Candida infectn) Soft tissue
displacement- tissue support
Biopsy, m washes, nutritional deficiencies & nystatin
Definitive Oral Examination:Denture bearing residual ridge
Ideal denture bearing residual ridge (ATWOOD, 1973)
Wide, Smooth, Rounded and Covered With tough, firmly
attached, keratinized mucosa
Definitive Oral Examination:
Hard tissues abnormalities:
Torus palatinus & mandibularis
Exostoses & undercuts.
Definitive Oral Examination:
Soft tissues abnormalities:
Labial frenum
Unsupported and hypermobile
gingiva
Space for mandibular major
connector: 8mm space for
lingual bar
Definitive Oral Examination:
Radiographic evaluation of prospective abutments:
Root length, size and form Crown-root ratio Lamina dura Periodontal ligament space
Evaluation of mounted diagnostic casts
Interarch distance Ridge relationship Tissue contours Occlusal plane
Irregular occlusal plane
Malpositioned occlusal plane
Selective grinding, crown, endo Rx, Extraction
Evaluation of mounted diagnostic casts
Tipped or malposed teeth
Occlusion
Role of occlusal equilibration
Interferences need to be corrected
Evaluation of mounted diagnostic casts
Occlusal indicator wax, articulating paper or tape, and thin
metal foil may be helpful in assessment of occlusion.
treatment at centric relation ….
To observe the contacts of the teeth in the centric
relation, the dentist should ask the patient to touch the
teeth together slowly and lightly until the first contact is
felt and then to “ close all the way”.
Demonstration of a “slide” between the initial contact
and the position of maximum intercuspation indicates
a discrepancy in jaw closure between centric relation
and centric occlusion positions.
treatment at centric relation.....
The recontouring or restoration of the teeth to make
the centric relation and centric occlusion positions of
the jaw coincide is not always required.
Certainly, premature contacts in normal closure and
deflective occlusal contacts that causes the mandible
to slide protrusively or laterally must be corrected.
treatment at centric relation ….
According to Renner, following conditions should be
met:
1. The jaw closes smoothly and consistently into the centric
occlusion position.
2. Multiple, simultaneous, stable occlusal contacts in the centric
occlusion position.
3. No evidence of a slide following the initial occlusal contact.
4. No symptoms of dysfunction.
Finally….
Diagnostic wax-up
Provides a great deal of information regarding tooth preparation, placement and occlusion.
Development of Treatment plan
How do I develop a Treatment Plan????
Developing a sequenced treatment plan
Phase I:Evaluation of diagnostic data Immediate Rx – pain, discomfort, infection
controldiagnostic mounting, wax-up, partial
design,referral to other specialties (endo, ortho,
oral surgery etc.), patient education (OHI, etc).
Developing a sequenced treatment plan
Phase II: Removal of caries, extractions, periodontal treatment –plaque control
measures, occlusal equilibration- deflective and
premature contacts elimination, placement of temporary restorations
(temporary crowns, etc).
Developing a sequenced treatment plan
Phase III (continuation of Phase II): Pre-prosthetic surgeries, root canal therapies, definitive restoration of teeth,RPD mouth preparation.
Phase IV: Placement of RPD, Instruction for patient and written consent.
Phase V: Periodic recall, reinforcement of education and motivation of the patient .
Typical problem.....Changes caused by a mandibular Rpd opposing maxillary CD
Ellisworth Kelly -1972
Five changes may constitute combination syndrome, as they are quite characteristic. These changes are
loss of bone from the anterior part of the maxillary ridge,
overgrowth of the tuberosities,
papillary hyperplasia in the hard palate,
extrusion of the lower anterior teeth, and
the loss of bone under the partial denture bases.
CONCLUSION......
In no other phase of dentistry is the need for knowledgeable planning and forethought so vital to a successful outcome as it is in the practice of removable partial prosthodontics.
The multitude of procedural and clinical details that must be coordinated into an orderly sequence makes it imperative that all factors bearing on the treatment be carefully evaluated so that each phase of therapy can be coordinated with the overall plan.
Bibliography:
Removable partial denture prosthetics- STEWART, 3rd edition.
Removable partial dentures – Robert Renner & Louis Boucher
McCracken's Removable partial prosthodontics- McGivney
Essentials of removable partial denture prosthetics- OLIVER C APPLEGATE.
A colour atlas of removable partial dentures- DAVENPORT, BASKER.
Partial dentures- OSBORNE & LAMMIE, 5th edition.
Dental implant prosthetics- CARL E MISCH
JPD, Vol. 11, No. 3, 2002:pp 181-93
JPD, 16, 1966: 533-39
DCNA- Vol.34. No.4,1990:607-09
JPD, october,1973: 526-32
Removable partial prosthodontics- SYBILLE K
LECHNER.
Removable partial prosthodontics- Miller & Grasso
JPD, December, 1974: 639-45
JPD, July, 1953: 506-16
JPD, July, 1953: 517-24
Q1. The first step in the diagnostic mounting procedure is the mounting of the maxillary cast on a
a) Fully adjustable articulator
b) Semi-adjustable articulator
c) Denar articulator
d)Free plane articulator
Q2. Face bow which requires styli to be placed on selected points on the face is
a) Whip mix
b) Hanau spring bow
c) Hanau SM
d)Hanau H2
Q3. Beyron’s point is located _ mm anterior to the posterior margin of the tragus of the ear on a line to the outer canthus of the eye
a) 11
b) 12
c) 13
d)14
Q4. While adjusting the articulator, the following setting are followed for condylar guidance, Bennett guide and incisal table respectively
a) 30, 15, 0
b) 0, 30, 15
c) 15, 30, 0
d) 30, 0, 15
Q5. Ramfjord and Ash (1971) have stated that three factors must be controlled in order to succeed in determining centric jaw relation. Which one is not among them?
a) Psychologic stress
b) Pain in temporomandibular joints
c) Muscle memory
d) Systemic illness
Q6. In which method of recording jaw relation does the operator place all four fingers of his hand on the lower border of the mandible and thumbs over the symphysis?
a) Bilateral manipulation of the mandible
b) Alternate protrusion and retrusion
c) Both a and b
d) Use of an occlusal splint
Q7. Frequently the lateral pterygoid muscle prevents relaxation and free rotation of the mandible. This method attempts to fatigue this muscle sufficiently so that it will reduce its contraction and allow retrusion of the mandible
a) Bilateral manipulation of the mandible
b) Alternate protrusion and retrusion
c) Both a and b
d) Use of an occlusal splint
Q8. Which of the following is not used to record centric jaw relation
a) Acrylic resin
b) ZoE paste
c) Dental stone
d) All of the above are used
Q9. Wax is the most commonly used recording medium while making jaw relations. Which is not true about it?
a) It is most unreliable and unpredictable
b) Can distort when the records are made, when the records are stored and when the cast is mounted
c) Exhibits “memory”
d) The hard wax, Alu-wax, contains aluminium or bronze for filler
Q10. While using metal impregnated wax, water bath temperature kept is
a) 40°C
b) 43°C
c) 45°C
d) 37°C