good morning examination and evaluation of diagnostic data: the second diagnostic appointment...

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