DEPTT OF PROSTHODONTICS CROWN AND BRIDGE

Mouth preparation for removable partial denture

Seminar

Dr. Vikas Aggarwal

CONTENTS 1. Introduction 2. Pre prosthetic mouth preparation Surgical preparation Conditioning of abused and irritated tissues Periodontal preparation Treatment of muscular symptoms Correction of occlusal plane Conservative/endodontical preparation Correction of malalignment 3. Prosthetic mouth preparation Developing guiding planes Changing height of contour Modifying retentive undercut. Rest seat preparation 4. Conclusion 5. References

INTRODUCTION The preparation of the mouth is fundamental to a successful removable partial denture service. Mouth preparation, perhaps more than any other single factor, contributes to the philosophy by Devans that the prescribed prosthesis must not only replace what is missing but also preserve the remaining tissue and structures that will enhance the removable partial denture

"Mouth preparation" is a term intended to cover all types of changes effected in the teeth, foundation ridges or oral structures which may be deemed necessary to accomplish a better partial denture result. (Applegate 3rd ed) Mouth preparation follows the preliminary diagnosis and the

development of a tentative treatment plan. Final treatment plan can be deferred until the response to the preparatory procedures can be ascertained. Mouth preparation can be generally classified as pre-prosthetic mouth preparation that involves removal of any hindrances to prosthetic treatment and prosthetic mouth preparation that involves mouth preparation done to facilitate prosthetic treatment.

1. Pre prosthetic mouth preparation Surgical preparation Conditioning of abused and irritated tissues Periodontal preparation Treatment of muscular symptoms Correction of occlusal plane Conservative/endodontic preparation Correction of malalignment

2. Prosthetic mouth preparation Developing guiding planes Changing height of contour Modifying retentive undercut. Rest seat preparation

1) SURGICAL PREPARATION They should be planned and completed well in advance. The longer the interval between the surgery and the impression procedure, the more complete the healing and consequently the more stable the denture bearing mucosa. The important consideration is that the patient not be deprived of any treatment that would enhance the success of the partial denture.

a) Extractions b) Removal of residual roots c) Removal of impacted teeth d) Malposed teeth e) Cysts and odontogenic tumors f) Exostosis and tori g) Hyperplastic tissues h) Muscle attachment and freni i) Bony spines and knife edge ridges j) Polyps, papilloma and traumatic haemangiomas k) Hyperkeratosis,erythoplakia,and ulceration l) Dentofacial deformity m) Ridge augmentation n) Osseointegrated devices

a) Extractions Planned extraction should be carried out after thorough evaluation of the remaining teeth in the dental arch. The non-strategic teeth that present complications or those whose presence may determine the design of the partial denture should be extracted. Teeth with doubtful prognosis of which retention would contribute little if anything, even if successfully treated and maintained, are contraindicated. b) Removal of residual roots All retained roots or root fragments should be removed particularly if they are in close proximity to the tissue surfaces or when they contribute to the progression of periodontal pockets. The removal of root tips can be carried out from the facial and palatal surfaces without compromising the alveolar bone height or harming the adjacent teeth. c) Removal of impacted teeth All impacted teeth are indicated for extraction because they can become source of spread of infection to the adjacent healthy teeth. The skeletal structure of the body changes with age. Asymptomatic impacted teeth covered with bone in elderly individuals with no evidence of pathology should be left to preserve the arch morphology. This should be documented in patients records. Age alterations that affect the jaws can result in minute exposures of impacted teeth to the oral cavity through the sinus. Early elective removal of impactions can prevent later serious acute and chronic infection with extensive bone loss.

d) Malposed teeth The loss of individual or groups of teeth may lead to extrusion, mesial drifting, or combinations of malpositioning of remaining teeth. In some cases the alveolar bone will be carried occlusally along with the extruded teeth.
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Orthodontics can be used to correct such occlusal discrepancies. Otherwise surgical repositioning of the malposed teeth and the supporting bone can be done. e) Cysts and odontogenic tumors All radiolucencies or radiopacities observed in the jaws should be investigated. Panoramic radiographs are recommended to survey the jaws for unusual pathologies. Cysts, odontogenic tumors, should be removed because their presence may compromise the design of the removal partial dentures. f) Exostoses and tori The presence of abnormal bony enlargements should not be allowed to compromise the design of the partial denture. Although modification in design to accommodate for exostoses can be done, this will place additional stresses to supporting elements and compromise the function. The mucosa covering these enlargements is thin and friable. Partial denture components in proximity to this type of tissue can cause irritation and chronic ulceration. Also exostoses close to gingival margin lay complicate maintenance of periodontal health and lead to eventual loss of strategic abutment teeth. g) Hyperplastic tissue They are seen in form of fibrous tuberosities, soft flabby ridges, folds of redundant tissue in the vestibule or floor of the mouth and palatal papillomatosis All these forms of excess tissue should be removed to form a firm base for the partial dentures. Hyperplastic tissue can be removed with any preferred combination such as scalpel, curette, electrosurgery, or by laser. Some form of surgical stent should be considered for such patients for a comfortable and enhanced healing. All such excised tissues should be sent to oral pathologist for microscopic study.
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h) Muscle attachments and frena Loss of alveolar bone height renders the muscle attachments near the alveolar crest making the designing of the partial dentures difficult. Mylohyoid, buccinator, mentalis and genioglossus muscles are those which can cause problems. Sometimes some muscles (mentalis, genioglossus) produce bony protuberances at their attachments which interfere with design of partial denture. Repositioning of these supra-placed muscles by ridge extension is necessary in such condition to enhance comfort and function. Mylohyoid can be easily repositioned but genioglossus is much more difficult to reposition. The maxillary labial and mandibular lingual freni may interfere in partial denture design. These should be modified with surgical interventions.

i) Bony spines and knife- edge ridges Sharp bony spicules should be removed and knife-edge ridges rounded to facilitate easy designing of the partial dentures. These procedures should be carried out with minimal bone loss. Vestibular deepening or ridge augmentation procedures can be considered.

j) Polyps, papilloma and traumatic haemangiomas All abnormal soft tissue lesions should be excised and submitted for pathologic examination. New or additional stimulation to the tissue may produce discomfort or even malignant changes.

k) Hyperkeratosis, erythoplakia, and ulceration All abnormal red, white and ulcerative patches should be investigated and treated accordingly. A biopsy of areas larger than 5 mm should be completed, and if the lesions are large (more than 2 cm in diameter), multiple biopsies should be taken. The biopsy report will determine whether the margins of the
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tissue to be excised can be wide or narrow. The lesions should be removed and healing accomplished before fabrication of the removable partial denture. l) Dentofacial deformity Surgical correction of jaw deformity can be made in horizontal, sagittal or frontal planes. Mandible and maxillae may be positioned anteriorly/posteriorly and their relation to the facial planes may be surgically altered.

m) Ridge augmentation Ridge augmentation can be carried out with either alloplastic materials like hydroxyapatite or with autogenous bone graft materials for proper bone support to the partial dentures. n) Osseointegrated devices A number of implant devices to support the replacement of teeth have been introduced to the dental profession. These devices offer a significant stabilizing effect on dental prostheses through a rigid connection to living bone. Osseointegrated implants can be used as abutments for the partial dentures. The use of commercially pure titanium endosseous implants has revolutionized the concept of modern dentistry

2) CONDITIONING OF ABUSED AND IRRITATED TISSUES Many removable partial denture patients require some conditioning of supporting tissues in edentulous areas before the final impression phase of treatment. Patients who require conditioning treatment often demonstrate the following symptoms 1. Inflammation and irritation of the mucosa covering the denture-bearing areas 2. Distortion of normal anatomic structures, such as incisive papillae, the rugae, and the retromolar pads 3. A burning sensation in residual ridge areas, the tongue, and the cheeks and lips
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These conditions are usually associated with ill-fitting or poorly occluding removable partial dentures. However, nutritional deficiencies, endocrine imbalances, severe health problems (diabetes or blood dyscrasias), and bruxism must be considered in a differential diagnosis. If a new removable partial denture or the relining of a present denture is attempted without first correcting these conditions, the chances for successful treatment will be compromised because the same old problems will be perpetuated. The patient must be made to realize that fabrication of a new prosthesis should be delayed until the oral tissues can be returned to a healthy state. The first treatment procedure should be an immediate institution of a good home care program. A suggested home care program includes rinsing the mouth three times a day with a prescribed saline solution; massaging the residual ridge areas, palate, and tongue with a soft toothbrush; removing the prosthesis at night; and using a prescribed therapeutic multiple vitamin along with a prescribed high- protein, low-carbohydrate diet. Some inflammatory oral conditions caused by ill-fitting dentures can be resolved by removing the dentures for extended periods.

Use of tissue conditioning materials The tissue conditioning materials are elastopolymers that continue to flow for an extended period, permitting distorted tissues to rebound and assume their normal form. These soft materials apparently have a soothing effect on irritated mucosa, and because they are soft, occlusal forces are probably more evenly distributed.

Maximum benefit from using tissue-conditioning materials may be obtained by: Eliminating deflective or interfering occlusal contacts of old dentures (by remounting on an articulator if necessary) Extending denture bases to proper form to enhance support, retention, and stability Relieving the tissue side of denture bases sufficiently (2 mm) to provide space Applying the material in amounts sufficient to provide support and a cushioning effect Following the manufacturer's directions. The conditioning procedure should be repeated until the supporting tissues display an undistorted and healthy appearance. Usually intervals of 3 to 4 days between changes of the conditioning material are clinically acceptable. An improvement in irritated and distorted tissues is usually noted within a few visits, and in some patients a dramatic improvement will be seen. Usually three or four changes of the conditioning material are adequate, but in some instances more changes are required. If positive results are not seen within 3 to 4 weeks, one should suspect more serious health problems and request consultation from a physician.

3) PERIODONTAL PREPARATIONS The periodontal procedures follows surgical procedures and done

simultaneously along with tissue conditioning procedures. The periodontal procedures are necessary to restore the mouth to the state of health required for definite treatment. The periodontal health of the remaining teeth especially the abutment teeth is evaluated carefully and corrective measures are instituted before fabricating the removable partial denture.

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Objectives of periodontal therapy: Removal of all etiologic factors contributing to periodontal diseases. Elimination or reduction of all pockets with the establishment of gingival sulci free of inflammation. Establishment of functional atraumatic occlusal relationships and tooth stability Development of a personalized plaque control programme and definite maintenance schedule. Periodontal diagnosis and treatment planing Diagnosis The diagnosis of periodontium is based on systematic and careful observation of the periodontium. It follows the procurement of health history of patient. It is performed using direct vision, palpation, periodontal probe, mouth mirror, and other auxiliary aids such as curved explorers, furcations probes, diagnostic casts and roentgenograms. Most important is careful exploration of the gingival sulcus and recording the probing pocket depth. The probe is inserted gently but firmly between the gingival margin and the tooth surface, and the depth of gingival sulcus is determined circumferentially around each tooth. A critical assessment of the sulcular health can be done by judging the amount of bleeding on probing. This along with the pocket depth is an excellent indicator of health and disease.

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Dental roentgenograms They are used to supplement clinical examination but cannot substitute it. The extent and pattern of bone loss can be estimated. They also provide information regarding the following: Type location and severity of bone loss Location, severity and distribution of furcation involvement. Alteration of periodontal ligament space. Alterations of the lamina dura Calcified deposits Location and conformity of restoration margins Evaluation of crown and root morphologies. Root proximity Caries Evaluation of other associated anatomic structures, such as mandibular canal or sinus proximity.

Mobility Each tooth should be evaluated for mobility. It is graded according to ease and extent of tooth movement. Normal mobility is in order of 0.05 to 0.10 mm. Grade I mobility slightly more than normal. Grade II moderately more than normal. Grade III severe mobility with vertical displacement.

Mobility is assessed with ends of two instruments. If fingers are used the movement of soft tissue may mask accurate determination of mobility If etiologic factors are removed most Grade I and II mobile teeth will become stable and can be used to support the partial denture. Mobility in itself is not an

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indication for extraction. Grade III cannot be reversed and thus cannot be used for support of the partial denture.

Treatment planning

Depending on the severity of periodontal changes a series of simple to complex procedures may be indicated. The treatment planning can be divided into the following phases. Phases in Treatment Disease control therapy phase-phase 1 Definitive periodontal surgery phase-phase 2 Maintenance phase- phase 3

Disease Control Therapy Phase-Phase 1

This phase consists of: Oral hygiene instructions The patient should be instructed in the use of disclosing wafers, soft nylon toothbrush, and unwaxed dental floss. At subsequent appointments oral hygiene can be

evaluated carefully, & other oral hygiene aids added, such as a rubber tip stimulator. Without good oral hygiene any dental procedure,

regardless of how well it is performed, is ultimately doomed to failure.

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Scaling & root planing Ultra sonic instruments are used for gross calculus removal. This is followed by root planning with sharp curettes. Elimination of other local irritating factors Overhanging margins of amalgam & inlay restoration. Overhanging crown margins. Open contacts leading to food impactions. Deep carious lesions should be eliminated before the start of definitive prosthetic treatment . Elimination of occlusal interferences Poor occlusal relationship may act as a factor that contributes to more rapid loss of periodontal attachment. Selective grinding procedure is generally applied at this stage. Traumatic cuspal interferences are removed by judicious grinding procedures. Deflective contacts in the centric path of closure are removed, eliminating mandibular displacement from the closing pattern. The indication for occlusal adjustment is based on the presence of pathology rather than on a preconceived articulation pattern. Occlusion on natural teeth needs to be perfected only to a point at which cuspal interference within the patients functional range of contact is eliminated and normal physiologic function can occur. Guide to Occlusal Adjustment (Schuyler) Accurately mounted diagnostic casts are extremely helpful in determining static cusp to fossa contacts of opposing teeth and as guide in the correction of occlusion anomalies.
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1) A static coordinated occlusal contact of the maximum number of teeth when the mandible is in centric relation to the maxillae should be the first objective. The procedure is as follows: a) A prematurely contacting cusp should be reduced only if the cusp point is in premature contact in both centric and eccentric relations. If a cusp point is in premature contact in centric

relation only, the opposing sulcus should be deepened. b) When anterior teeth are in premature contact in centric relations, or in both centric and eccentric relat ions, corrections should be made by grinding the incisal edge of the lower teeth. c) Usually, premature contacts in centric relation are relieved by grinding the buccal cusps of the lower teeth, the lingual cusp of upper teeth, and the incisal edges of t he lower anterior teeth. Deepening the sulcus of the posterior tooth or the lingual contact area in centric relation of an upper anterior tooth changes and increases the steepness of the eccentric guiding inclines of the tooth; although this relieves trauma in centric relation, it may predispose the tooth to trauma in eccentric relations.

2) After establishing a static, even distribution of stress over the maximum number of teeth in centric relation, evaluate opposing tooth contact or lack of contact in eccentric functional relations. First balancing side contacts are seen. Subluxation, pain, lack of normal functional movement of the joint, or loss of alveolar support of the teeth involved may be evidence of excessive balancing contacts. Balancing side c ontacts receive less

frictional wear than working side contacts, and premature

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contacts may develop progressively with wear. In all corrective grinding to relieve premature or excessive contacts in eccentric relations, care must be exercised to avoid the l oss of a static supporting contact in centric relation. This static support in

centric relation may exist between the lower buccal cusp fitting into the central fossae of the upper tooth or between the upper lingual cusp fitting into the central fossae of the lower tooth or may exist in both cases. Often only one of these cusps has this static contact. In such instances the contacting cusp must be left untouched to maintain this essential support in the planned intercuspal position, and all corrective gri nding to relieve premature contacts in eccentric positions would be done on the opposing tooth inclines. The lower buccal cusp is in a static

central contact in the upper sulcus more often than the upper lingual cusp is in a static contact in its opposing lower sulcus.

3) To obtain maximum function and the distribution of functional stress in eccentric positions on the working side, necessary grinding must be done on the lingual surfaces of the upper anterior teeth. Corrective grinding on the posterior teeth at this time should always be done on the buccal cusp of the upper premolars and molars and on the lingual cusp of the lower premolars and molars. The grinding of lower buccal cusps or

upper lingual cusps at this time would rob these cusps of their static contact in the opposing central sulci in centric relation. 4) Corrective grinding to relieve premature protrusive contacts of one or more anterior teeth should be accomplished by grinding the lingual surface of the upper anterior teeth.
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Anterior te eth

should never be ground to bring the posterior teeth into contact in either protrusive position or on the balancing side. In the

elimination of premature protrusive contacts of posterior teeth, neither the upper lingual cusps nor the lower buccal cusps should be ground. Corrective grinding should be done on the surface of the opposing teeth on which these cusps function in the eccentric position, leaving the centric contact undisturbed.

5) Any sharp edges left by grinding should be rounded off

Splinting In many partially edentulous mouths some of all the remaining teeth lose their periodontal and bone support rendering them mobile and not suitable to provide support to the partial dentures. In order to use such teeth as abutments additional support for these teeth by splinting them together is necessary. The cause of mobility must be assessed and the causative factors should be eliminated. Secondary mobility resulting from presence of inflammatory lesion may be reversible. Teeth may be immobilized during periodontal treatment by acid etching teeth with composite resin, with fiber reinforced resin, with cast removable splint, or with intracoronal attachments. Splinting can be achieved by a removable restoration or by fixed restoration which becomes a permanent splint. Splinting of weakened teeth in partially edentulous arch located in a position where the partial denture will not require an unusual amount of support, is achieved by using fixed splinting, this maintains the continuity of the arch, avoids additional modification spaces, thus simplifying the construction and
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fitting of partial dentures and improving prognosis. Fixed splinting must be accomplished with full or partial coverage crowns soldered together; this gives additional resistance to antero-posterior stresses. To offer resistant to lateral forces, the splint must be extended anteriorly to include canine teeth and also include the lateral plane of the posterior teeth.

Periodontal Surgery Phase 2 It is a definitive periodontal surgery phase. If oral hygiene is optimal, yet pockets with inflammation and osseous defect are present, various surgical techniques like gingivectomy,

periodontal flap should be considered to improve periodontal health.

Gingivectomy Gingivectomy is indicated when there are supra bony pockets of fibrotic tissue, absence of deformities in the

underlying bony tissue & pocket depth confined to attached gingiva. If osseous deformities are present or if pocket depth traverses mucogingival junction gingivectomy is not the treatment of choice.

Periodontal Flap The flap is widely employed for the treatment of periodontal diseases. It may be used to gain access for root planing, osseous recontouring for pocket elimination or crown lengthening and also for osseous grafts.

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Maintenance Phase This is phase 3 of the periodontal procedures. It includes reinforcement of plaque control measures, thorough debridement of root surfaces of subgingival & supra gingival plaque. Frequency of recall is according to patients requirements. In moderate to severe periodontitis, 3-4 months recall system is followed.

4) TREATMENT OF MUSCULAR SYMPTOMS Prior to adjustment of the occlusion of the teeth the muscular symptoms should be analyzed. Patients with partially edentulous arches often show symptoms of muscle spasm. Therefore the first objective of the operator is to eliminate this muscle spasm. This can be achieved by giving the patient an acrylic overlay splint with a flat occlusal surface which will eliminate premature tooth contacts causing deviation of the mandible leading to spasm. Adjunct therapies like short-wave therapy, infra-red radiation, and light massage are designed to increase the volume of the blood flowing through the muscles and thereby removing the offending metabolites. The use of muscle relaxant drugs like Diazepam 5-10 mg B.D is effective in relaxing the symptoms.

5) CORRECTION OF OCCLUSAL PLANE The occlusal plane in most partially edentulous mouths will be uneven. The severity of this irregularity will determine the treatment necessary to correct the condition. Teeth that have been unopposed for a long time tend to overerupt, e.g. the maxillary molars if unopposed will migrate downwards carrying the maxillary tuberosity with them creating a problem to reestablish the occlusal plane. This is because surgery to reduce the bone height may encroach upon the maxillary sinus.

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Normally the occlusal plane is corrected by reduction of the height of overerupted teeth. Methods undertaken are: Orthodontic tooth movement Enameloplasty Onlay Crowns Endodontics with crown or coping Extraction Surgery Orthodontics is the ideal treatment to upright the tilted teeth and re- establish the occlusal plane. If this is not possible other methods are employed.

Enameloplasty word used to describe the removal of a portion of enamel surface of tooth to accomplish specified purpose. It consists of reduction of cusp height in order to level the curve of spee. Penetration of enamel layer should be avoided, However in older individuals with wear and subsequent secondary dentine formation slightly more tooth structure can be removed. Care to be taken not to mutilate the anatomic contours such as accessory grooves, and sluiceways must be restored. Reduction is done with tapered diamond cylinder or stones in high speed hand piece. The cut enamel surface is smoothened with carborundum containing rubber wheels and fluoride gels. Onlays were common previously but now rarely used. The occlusal surface can be covered with onlay rest free of pits and fissures. The use of chrome- cobalt can cause extreme wear of natural teeth. Tooth colored resin may be processed over the metal, however this will wear rapidly. The simplest method is the use of cast gold onlays. One of main advantages of onlay is maintain the natural

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contours of enamel surfaces of tooth. However full crowns,are replacing onlays presently because of esthetic and retentive concerns. Crowns are indicated when the facial and lingual surfaces need to be altered, to produce desirable height of contour, a guiding plane, or a retentive undercut. If tooth reduction is too great then endodontic treatment should be considered. If the strategically positioned teeth need to be retained as abutment teeth for partial denture and required to be corrected extensively then intentional endodontics with crowns are considered. Extraction-It should be the goal of a designer of removable partial dentures to retain as many of the remaining teeth as possible. However, at times retaining certain teeth can greatly complicate or even compromise the success of the treatment. For example, if orthodontic treatment cannot be accomplished to realign severely malposed molars or premolars, extraction must be considered. When teeth interfere with the placement of the major connector and no other solution (such as crowning the tooth) feasible, extraction must be planned. Surgical repositioning- Surgical repositioning of one or both jaws or of segments of one or both jaws can be performed to correct malrelationship of teeth. Various forms of mandibulectomies, usually to correct gross prognathic jaw relationships, have been performed. Maxillary segmental osteotomy is done to superiorly repositioning posterior segments of maxillae. This is one of the most effective methods of regaining interarch space lost due to downward migration of the teeth and tuberosity

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6) CONSERVATIVE/ENDODONTIC PREPARATION Fillings Onlays Endodontic treatment with crown/coping Fillings: When fillings are required in abutment or other teeth, only gold or amalgam are suitable materials lo come into contact with partial dentures as these materials have the necessary strengths to form a foundation for occlusal rests. Amalgam fillings or gold inlays are used to restore lost contours of the teeth. Onlays: The occlusal surfaces of worn teeth can be restored by onlays. The occlusal surface of a tooth to be covered by an onlay should be free of pits and fissures and if present, should be removed by an enameloplasty. If onlay rests are placed than they should be constructed short of occlusal contact with retentive beads present on the metal surface, for tooth-colored acrylic resin to be processed over it. This is done to prevent the metal coming in contact with natural teeth which if otherwise would cause rapid wear of the opposing enamel surface. Endodontic with crown/coping: Some of the strategic important teeth present in the arch, like an anterior tooth present in a long anterior edentulous span, should be retained and used as abutment for the partial denture. But most of the time these strategic important tooth/teeth are over erupted are have lost some of their periodontal support which is needed to serve as an abutment. In such cases endodontic therapy followed by cementation crown will allow such tooth/teeth to serve as normal abutments. Porcelain jacket crowns should generally be avoided in partially edentulous mouths as they make very poor abutments

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7) CORRECTION OF MALALIGNMENT Teeth that are malposed, facially or lingually are more difficult to correct There are definite, limitation to the repositioning of these malposed teeth. Orthodontic correction of these malposed teeth is the first line of treatment. Enameloplasty and crowns are also treatment choices. Surgical intervention is planned only if all other measures fail to reposition these malposed teeth.

II) Prosthetic Mouth Preparation

It is done to modify the existing structures to further enhance the placement of prosthesis. It mainly involves reshaping of teeth

The steps involved are: Developing guiding planes Changing height of contour Modifying retentive undercut. Abutment preparation using cast crowns Rest seat preparation

Tooth surfaces often need to be reshaped to accomplish specific purposes. This changing of tooth contour may be accomplished in the enamel, on the surface of an existing restoration, or by placing a new restoration. Enameloplasty Conservatism must be the rule when tooth preparation is to be accomplished on enamel surfaces for a removable partial denture. Sufficient tooth reduction must be accomplished to ensure adequate space or proper contour, but never at the expense of overcutting the tooth

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Enameloplasty to Develop Guiding Planes Guiding planes are those surfaces on the teeth, of sufficient area and parallel relationship to each other, so that they may serve to determine positively the direction of appliance movement (Applegate 1954) Two or more vertical parallel surfaces of abutment teeth, so shaped to direct prosthesis during placement and removal.(McCracken 12th edn) Two or more vertically parallel surfaces of abutment teeth, so orientated as to direct the path of placement of removable partial dentures.( GPT 8th )

Functions of guiding planes 1. To provide one path of placement and removal 2. To ensure planned and intended action of the retentive and bracing components of the partial denture 3. To eliminate detrimental strain to the abutment teeth and the components of the framework in placing and removing the prosthesis 4. To eliminate gross food traps between the abutment teeth and the denture base 5. To provide retentive characteristics against dislodgement of the denture when the dislodging force is other than parallel to the path of removal 6. To provide bracing characteristics against horizontal rotation of the denture

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Guiding Planes On Abutment Teeth Adjacent to Tooth Supported Segments A cylindrical diamond point is generally the instrument to make the preparation. A gentle, light sweeping stroke from the buccal line angle to the lingual line angle should be used. The flat surface created should ideally be 2 to 4mm in occluso-gingival height The reduction must not be a straight slice across the tooth surface; rather it should follow the curvature of the surface so that nearly uniform amounts of enamel are removed

Guiding Planes on Abutment Teeth Adjacent to Distal Extension Edentulous Spaces The tooth preparation on the proximal surface of abutment teeth adjacent to distal extension edentulous spaces is accomplished in the same manner with a cylindrical diamond stone held parallel to the path of insertion. A guiding plane prepared adjacent to a distal extension space should be slightly shorter than a guiding plane prepared adjacent to a tooth supported segment. Typically, a guiding plane adjacent to a distal extension space is 1.5 to 2.0 mm in height. The reduced height results in decreased contact with the associated minor connector (ie, proximal plate) and permits greater freedom of movement for the associated removable partial denture as a result; potentially destructive torquing forces are minimized Guiding Planes On Lingual Surfaces Of Abutment Teeth Mandibular posterior teeth are usually inclined lingually with a resultant high lingual survey line. Minor recontouring can frequently improve the position of the survey line to allow placement of the reciprocal clasp arm in its proper position The purpose of providing guiding planes on lingual surfaces of teeth is to provide maximum resistances to lateral stresses. The more teeth involved in

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guiding plane preparation, the less will be the stress transmitted to each individual tooth. The occluso-gingival height of the preparation is 2 to 4 mm. The plane ideally should be located in the middle third of the clinical crown of the tooth. Special care must be shown to avoid changing the contour of the gingival third of the tooth because damage to the marginal gingiva through the improper shunting of food may occur if the normal morphology of the gingival third of the crown is lost

Guiding Planes on Anterior Abutment Teeth Guiding planes on anterior teeth adjacent to edentulous spaces provide the parallelism needed to ensure stabilization, minimize wedging action between the teeth, decrease undesirable space between the denture and the abutment tooth, and increase retention through frictional resistance. Another important purpose of these guiding planes is to reestablish the normal width of an edentulous space. If one or more anterior teeth are lost,adjacent teeth tend to drift or tip into these spaces.Both actions result in reduced space and make esthetic replacement of the missing teeth much more difficult. Tipping is relatively common and often results in a large undercut apical to the height of contour If the tooth is not recontoured, this undercut will appear as an unsightly space between the tipped tooth and the removable partial denture. Such a space detracts from the esthetic value of the removable partial denture and acts as a food trap. Recontouring should be performed to minimize the effects of tipping and to improve the esthetic and functional results of the removable partial denture service. This recontouring should be performed with the proposed path of insertion in mind, and the resultant guiding planes should be parallel to the planned path of insertion.
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Enameloplasty to Change Height of Contour The height of contour is changed most frequently to provide better positions for clasp arms or for lingual plating. Ideally the retentive clasp arm should be located no higher than the junction of the gingival and the middle thirds. This position not only enhances the esthetic quality of the clasp, but also places clasp nearer the tooths centre of rotation

The amount of correction that can be accomplished by recontouring the enamel surface is limited by the thickness of the enamel. Care has to be taken not to penetrate the enamel and expose dentin The height of contour is best lowered by using tapered diamond stones.

Enameloplasty to Modify Retentive Undercuts It is used to increase a less than adequate retentive undercut only if the oral hygiene of the patient is good & caries index is low. But this should not be substituted for adequate design procedures. For the procedure to be successful, the buccal and lingual surfaces should be nearly vertical. If surface to receive undercut is sloped, indentation has to be excessively deep. If opposing surface is sloped, the reciprocal clasp arm cannot prevent retentive clasp tip from dislodging. Retentive undercut should be in the form of a gentle depression. Create slight concavity (0.010 inch deep, 4mm MD, 2mm OG), parallel to gingival margin without encroaching it. A round end tapered diamond held parallel to gingival margin is used to create a gentle depression.

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Abutment preparation using Inlays Onlays and Crowns If the remaining teeth do not possess usable natural contours and enamel surfaces cannot be corrected to produce them, cast restorations must be planned. Guiding planes, height of contour and retentive undercuts can be placed in the wax patterns for the cast restorations. Also many abutment teeth will require restorations for more routine reasons such as caries, endodontic therapy etc.

Shaping the Wax Pattern The die of the tooth preparation in the cast of the remainder arch is analyzed on the surveyor. Working cast is mounted at the same tilt as the diagnostic cast. Once correct tilt is established substitute analyzing rod with wax knife and carve guiding plane by shaving the wax. Pattern must be hand carved to place height of contour at the junction of gingival and middle third for retentive clasp. Refining can be done in cast restoration.

Occlusion Rest Seat Preparation Rest -rigid extension of a partial removable dental prosthesis that contacts the occlusal surface of a tooth or restoration, the occlusal surface of which may have been prepared to receive it Rest seat -the prepared recess in a tooth or restoration created to receive the occlusal, incisal, cingulum, or lingual rest Functions Direct forces of mastication parallel to long axis. Prevent gingival displacement of denture. Maintain the clasp in proper position. Function as indirect retainer in distal extension partial denture.

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Occlusal Rest Seat in Enamel Form Triangular in outline with base at marginal ridge and apex pointing

towards the centre of the tooth. Apex of the triangle should be rounded as should all external margins of preparation Should follow outline of mesial or distal fossa. Minimum 0.5mm at thinnest point, 1-1.5mm at marginal ridge.

Extension 1/3rd to 1/2 of mesiodistal diameter. 1/2 of the distance between buccal and lingual cusp tips.

Floor Inclined towards the centre. Spoon shaped. Enclosed angle with the proximal surface less than 90.

Preparation Round diamond stone is used approximating no.4 round carbide bur for preparation. Create an outline using small round diamond stone. The island of enamel within the outline can then be removed with the same bur. Deepest portion of the rest seat is towards the center of the tooth. Verify preparation by red beading wax. Polishing of preparation is done using carborundum impregnated rubber point in low speed hand piece

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Occlusal Rest Seat in New Gold Restoration It should always be placed in wax patterns. Sufficient occlusal clearance must be given to permit proper dimensions of rest seat. A depression can be added to the preparation to accommodate rest seat. Rest seat in wax pattern is prepared by using no.4 round steel bur.

In Existing Gold Restoration Patient must be warned of the possibility of the need to replace the restoration. If restoration has marginal integrity and occlusal harmony, attempt can be made to contour a rest seat in it.

Occlusal Rest Seat Preparation In Amalgam Restorations An occlusal rest preparation in a multi surface amalgam restoration is less desirable than that in either sound enamel or a gold restoration. Amalgam alloy tends to flow when placed under constant pressure. Care must be taken not to weaken the proximal portion of the amalgam restoration at the isthmus during the preparation. This may result in fracture during function.

Rest Seat Preparation For Embrasure Clasp This preparation extends over the occlusal embrasure of two approximating posterior teeth, from the mesial fossa of one tooth to the distal fossa of other. Insufficient tooth removal will generally lead to occlusal interferences between the metal of the clasp and the opposing cusps. Relieving the metal to gain occlusal freedom ultimately leads to breakage of the clasp during function. Repair of the embrasure clasp is usually difficult.

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As the preparation passes over the buccal and lingual embrasures it should be approximately 3.0 to 3.5 mm wide and 1.5t o 2.5 mm deep. All contours of the preparation must be rounded after the preparation is complete

Rest Seat Preparation on Anterior Teeth An occlusal rest on a molar or a premolar is preferred over a lingual or an incisal rest on anterior teeth to provide support for a partial denture. Forces are better directed down the long axis of the abutment tooth by an occlusal rest than by a lingual or incisal rest. A canine is preferred over an incisor for support of a denture. When a canine is not present, multiple rests on incisor teeth are needed in place of a single rest on a single incisor tooth. A lingual rest is preferred to an incisal rest.

Lingual Rest Seat preparation In Enamel A lingual rest seat may be prepared in the enamel surface of an anterior tooth if the tooth is sound, the patient practices good oral hygiene, and the caries index is low. The cingulum should also be prominent to present a gradual slope to the lingual surface rather than a steep vertical slope. This is the principal reason why mandibular canines are poor candidates for a lingual rest. The lingual surface of the tooth normally has too great a vertical slope to permit the rest seat to be prepared without penetrating into dentin. In some instances a lingual rest can be placed on maxillary central incisors that have prominent cingulum, but most, often this is a compromise effort unless it is placed in a cast restoration. The lingual rest can be prepared nearer the center of the tooth, preventing the tipping action that an incisal rest may produce. Lingual rests are also more acceptable esthetically and less subject to breakage and distortion. The most satisfactory lingual rest from the standpoint of support is one that is placed on a prepared rest seat in a cast restoration. This should be used wherever possible. A lingual rest on a cast restoration may be used on any anterior tooth, either
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maxillary or mandibular. A lingual rest prepared in a enamel surface should be used primarily on maxillary canines and on a limited number of maxillary incisor teeth. Outline Form Half moon shaped forming smooth curve from one marginal ridge to other. Should cross the centre of tooth incisally to cingulum. The rest seat itself is V shaped. The labial incline of lingual surface makes one wall. Other wall starts of cingulum and inclines labio-gingivally towards the centre of tooth. Preparation Preparation of a cingulum rest seat is accomplished using a No. 38 carbide bur in a high-speed handpiece. The No. 38 bur is an inverted cone with side- and end cutting surfaces. During the preparation process, the bur is oriented at a slight angle to the lingual surface of the tooth. The bur is then used to create a crescent-shaped rest seat that begins on one marginal ridge, passes over the cingulum, and terminates on the opposite marginal ridge .The walls of the rest seat are relatively smooth and that they do not present any mechanical undercuts. The preparation is finished using a green stone in a low-speed handpiece. Polishing is accomplished using a carborundum impregnated rubber wheel or point in a low-speed handpiece

Lingual rest seat preparation in cast restorations If a cast restoration is to be placed on abutment tooth, the rest seat should be carved in the wax pattern and not cut in the cast restoration. A definite rest seat thus developed will direct the forces of occlusion through the long axis of the abutment tooth.
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Incisal Rest Seat Incisal rest seats should be used only on enamel surfaces. If a cast restoration is planned for the abutment tooth a lingual rest seat should be included in the restoration. Although incisal rests are the least desirable rests for anterior teeth, they may be used successfully on select patients if the abutment tooth is sound. The incisal rest seat is usually placed near one of the incisal angles of canines. If the incisal rest is used in conjunction with a circumferential clasp, the rest should be placed at the distal incisal angle. Although the incisal rest may be used on maxillary canines, it is not the rest of choice for that tooth because too much must be sacrificed in esthetics and in mechanical advantage. On incisor teeth an incisal rest is usually used as a last resort to stabilize the removable prosthesis. The prognosis for these teeth is usually poor. Preparation The incisal rest seat preparation is begun with a flame-shaped diamond bur in a high-speed handpiece. The bur is oriented parallel to the proposed path of insertion, and a notch is created .This notch should be located 2 to 3 mm from the proximal angle of the tooth and should be 1.5 to 2.0 mm in depth. The notch is extended slightly onto the facial surface of the tooth. This provides a method to prevent facial movement of the abutment The preparation is finished using a green stone in a low-speed handpiece. A carborundum-impregnated rubber point or wheel is used to finish the prepared surfaces

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Conclusion The preparation of mouth is fundamental to a successful removal partial denture. The prime objective of all the mouth preparation procedures is to return the mouth to optimum health and to eliminate any condition that compromises the success of the partial denture.

REFERENCES 1. McCrackens removable partial prosthodontics 12th edition 2011 2. Stewarts: Clinical removable partial prosthodontics,3rd edition 2003 3. Applegate OC. Essentials of Removable Partial Denture Prosthesis, 3RD . Philadelphia: Saunders, 1965 4. Osborne & Lammies Partial prosthodontics 5th edition 1986 5. McCracken .L.W.Mouth preparation for partial dentures , J. Prosthet. Dent 1956;6,(1) :39-52 6. Glan G.W., Appleby R.C. Mouth preparation for removable partial dentures. J. Prosthet. Dent. 1960;10:124-134. .

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