THE ULTIMATE STUDY GUIDEFOR CONQUERING THE

PERI (lIlt|NTAL ASSESSM ENT/O IAG N OSISANtl PROSTH(lD(lNTICS

COMPUTER SIMULATION EXAM

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CHAPTER I

N(lTES PERI(|Dlll{TICS

The two most critical factors that determine ihe PR|)Gll|)SlS 0l a peri0dotltally inv0lvedt00th are l 0B|UIY and ATIACilME T [0SS (the m0st critical factor). -

PERI0D0NTAL PRoGtl0SlS a l0recasi 0fthe possible rcs ponse to trcatment and long termoutlook for maintaining a healthy, functional dentit ion.

1. G00d Prognosis, patient has at least 1 0f these, healthy 0r slight CAL, adequateperi0dontalsupport, n0 m0bility, n0furcation, and control0fetiologicfact0rs t0assure

the tooth would be relatively easyt0 maintain underfull paiient compliance.

Fair Progn0sis: patient has at least I ofthese: moderate 0r severe CAI and/or GlassI mobility 0r furcation involvement. The furcation depth and location allows propermaintenance with full 0atient comDliance.

ouestionable Prognosis' patient has at least 1 0fthese:severe CAt (>5mm) causinga p00r crown-ro0t ratio, p00r r00t lorm. Class ll turcali0ns n0t easily access'ble t0mainienance, 0r Class lll furcations. Grade ll 0r lll mobiliiy, significant r00t proximiiy.

ll0peless Pr0gnosis: I or more 0f the factors under questionahle pr0gnosis withinadequate attachment i0 maintain the tooth in health, comf0rt, and function.E)(IRACTI0 iS srggested because active periodontal therapy (surgical orn0n-surgical) is unlikelyt0 improve the t00th's status.

T00TH M0BltlTY i00th movement in its s0cket dueto an externally applied force. Measuredby pushing the t00th gently in a F-L directi0n using the blunt ends 0f two metal instruments.Afinger is not acceptable t0 assess mobility.

l. Class I mobility, total F-Lt00th movement of < lmm.2. Class 2 m0bility:total F L m0vement l-2mm with N0 verticaydepressihle m0vement.3. Class 3 mohility:total F L movement > 2mm and/or movement in a

vertical/deIressible directi0n.

P0CIGI DEPTH (PD)- each t00th has 6 measurements (8, L, MB, l!ll, DB, DL). Measuredfrom sulcus base " GlV.

CEJ"GM distance in mm lrom the CEj"gingiyal margin. iveasurements are taken at thesaflre six sites used t0 rec0rd probing depth.. Gingivaltissue abovethe CEI is recorded as a IIEGATIVE number. Gingival tissue bel0w the CEJ is recorded as a P0SlIlvE number

Ctll{loAt ATTACHIIIEIIT [0SS (GA[) distance from ctl in an a0ical direction to thep0ckevsulcus base. CAL = {PD) - (distance lrom G t0 CEJ). In disease, GIV's locati0n maybe unrelated t0 the apically migrating sulcus base, its position is used only t0 calculate CAL.Heallh (llormallD0cket deDth is c0r0nalt0lhe CEJ with n0 CAL.

l. Slighi Periodontitis-pocket depth is deepened, but the gingival margin is unchanged.CAL l-zmm.iloderate Periodontitis greatef atta ch m ent l0ss, blt since GM is at the C EJ, CAL = PD.GAt 3-4mm.Severe oisease-even greater attachment loss, and because 0f recession, the GIV isbelow the CEJ. Thus, CAL = CEJ t0 the pocket base (0r recessior measurement + PD).CAL > smm.

Ex: lf a probing depth is 4mm and recession i! 3mm, total attachment l0ss = 7nm.

lll0 0l{ PR0Bll{G (B0P) indicated on the patient's chart bya RED 00Tforsites thatIritl"in 30 sec 0f prohing. BEST way t0 eyaluate SRP success is ll0 BtEEl)lllS 0llG (BoP indicates active inflammatory Deriod0ntal d ise ase\. 80P indicates creviculal

is ulcerated dae t0 active pe odontal disease. gleeding sc0res (bleeding) isREI-|ABIE indicat0r 0l lhe gingival 0r period0rhl inl{ammation.

CATl0tl ll{V()LVEMEtlT n0ted in RID on the patients chart. Use a Nabels Probe t0and clinically diagn0se a furcaiion. Radi0graphs are helpful, but are oNLY an adjunct

tie clinical examination.L Class | ( )-incipient involvement. Tissue destruction extends l-2mm measurcd

hoizontallyfrom the furcation\ most coronal aspeci. Probe tjp feels the depression 0fthefurcation 0pening. Incipient b0ne {0ss.

2. Class ll (Z): Cul-de-sac involvemenl. llssue destructi0n is deeler lhan 2mmmeasured horizontally from the furcation's most coronal aspect, but D0ES fi07C0iIPLETEIY PASS IHRoUGH THt fURCAT||)tl. Partiatbone loss. Probetip enters underthe furcrtion roof.

3. Class lll (Z): Thr0ugh-&-Through involyement. Jlssue destructi0n exiends thro0ghthe enlire lurcati0n s0 a blunt Naber's Probe can pass between lhe f00ts and emerge0n the other side. Total bone loss, but the furcation entrance is not visible, but stillcovered by gingiva.

Grade I Grade ll Grade lll

IAll{ 0biective of lrealing lurcaii0ns is l0 ELltllllATE FURCAT|l)il lilV0wt tilT, but sometreatments only increas accessibility fff plaque rem0val. Bone grafts are not effective t0Ueat furcati0ns. H0wever, &TR successlully treats Grade ll furcati0ns. Furcationhy0lvement oI ma{llary 2d molars have the P00REST PR|)Gtl0SlS after therapy.

N{1TES

l't0TEs PER|0D0llTAt SCRIEI{ll{G & REC||RDItIE (PSR) a screening exa$ that promotes eartydetection and treatment 0f period0ntal diseases. PSR all0wsthe dentislt0 rapidly assess andrecord a patient's periodonial slatus, but d0es NOT replace the need t0 d0 a com0rehensiveperi0dontal exam and charting when warranted.. PSR uses a special probe (0.5mm ball tip and c0lored hand from 3.5-5.5mm) inserted

inio the gingival crevice under the contact until resistance is felt and is walkedDISIAI ESIAI, watchingthe colored band relative t0 the gingivalmargin.Scoring sysiem uses se\tants.6 sitespert00lh are lecorded, but0nlythe HlGHESTscoreis rec0rded per sexlant. An (*) can be added for other clinica' abnormaliiies.Code 0: colored band is c0mpletely visible, n0 B0B calculus, 0r defective margins.Code'l: colored band is completelyvisible, B|)P present. No calculus 0r defective margins.Code 2: c0l0red band is completely visible, but calculus 0r defective margins are ptesent.Code 3, colorcd band is partly visible.C0de 4, c0lored band is iloTvisible.Code *, lurcation involvement, mobility, mucogingival defects, recession.

H0RlzotllAt B0llE t|,SS- bone loss is parallelto an imaginary line from the CU t0 CEjofadjacentteeth. ileasured from 2mm bel0wthe CU to the t00th's apex, based 0n the normalbone crest p0siti0n. Alveolarcrest's normal position is n0 more than 2mm below the CEl.

VERIICAL B|lt{E L0SS angulaf bone loss al0ng the side 0f the tooth from the mostc0r00al aspect 0f the interp.0imal horc. Comm0n in Localized Aggressive Period0ntitisaround fimolars and incis0rs in children.

0lAGlll)SlS 0F PER|000i{TITIS is based 0n RAIE 0F PR0GRtSSloll & oISEASE SIVERIIY,l. Rate of Progression:

. Chr0nic Period0nlitis-inflammati0n within supportingteeth tissues, progr€ssiyeattachment and bone loss, pocket forrnation and/orgingival recession. lllost conmoni[ adults, but begin t0 0ccur at any age..lf < 30% of sites are inv0lved = Chronic L0calized Peri0do[titis.. lf > 30% 0l sites are involved = Ghr0nic Generalized Pe.iodontitis.. Chronic periodontitis is a SIoWLY prog.essive disease, but s0me patients may

experience short periods of rapid progression. Thus, ntes 0f progression is a criteriaused t0 exclude pe0ple from being diagnosed with Chronic Peri0d0ntitis.

. Aggressive Periodontitis-rapid attachment loss & bone destruction. Amounts ofmicrobial deposits are ri?corsijtedwith the severity 0l periodontaltissue destruction.Classified as either L0calized Aggressive Peri0dontitis 0rGeneralized AggressivePeriodontitis.

2. Severity 0l Periodonlal Disease,. Gingivitis-gingival inflammation with eiiherchanges in color, contour 0f gingival

papillae/margins, 0r changes in tissue consistency.. Slight Periodontitis, l-2mm CAL.. Moderate Period0ntitis: 3-4mm CAl", possibly accompanied byt00th mobility and

lurcation involvement.. Severe Period0ntitis: at least 5mm CAt, usually accompanied byt00th mobility,

furcalion involvement, & muc0gingival delects.

Bacte a ass0ciated with PERI0D0ilTA[ HEAITH are gram (+), non-m0tile, facultaliveanaeroies. In period0ntal disease, the bacteria shiltst0gram C), m0tile, strictly anaer0hicbacteria.

PLA0llE IGY ETl0t0GlC AGEllTin causing gingiyitis and peri0d0nta I disease.is an accumulation of a mixed bacterial c0mmuniiy in a DtXInA ATRII( formed 0n

t00th surface within minutes c0m00sed 0l 80% waier & 20% solids/bacteria.is most likely i0 accumulate 0n inter-pr0ximal tooth surfaces first.

N{lTES

UE-I1{DUCED GIl{GIVAL DISEASES

of dental plaque development is an early predoninance 0l GRA (+) FACUTTATIVEa, t0 a later domination 0l GRAiI (-) AIIAER|IBIC bacteria (r0ds, fusiform.

hetes), as the plaque mass acc!mulates and matures.

ahundant bacleria in a ilEALTHY Sl,mUS areies. Gram (+) cocci (Sirept0cocci) & filamentousdant in a healthy sulcus.

E-ll{0UGE0 GIIIGIVAI DISEASES- can occuron a leriodontium without attachmeni0rwith attachment loss 0n a peridontium that is not progressing. Can be affected by local

and may be modified by specific systemic faciors folnd in the host. oingivitis is the0illllAllT Deriododal dtsease.

I diseases are limited to GINGIVA, but the inflammatory resp0nse initiated in gingivalis a prerequisite c0ndition for peri0d0ntitis. Gingivitis does not always lead l0

ontitis, but periodontitis atways pr0gresseslrom gingivitis. lg8-the immun0globulinahundant in gingival exudates common in gingivitis.

are l{0 radiographic leatures 0f gingivitis kadiographic appearance 0f bone isl). But, there are radiographic features 0f periodontitis (ioss of lamina dura, horizontal

yertical bone res0rption, & widening of PDL space). GlllclVlTlS 00ES ll0T CAUSE B0tlE 0R

Bleeding, pocket depths > snm, and changes in tissue c0l0r and tone cannot lead t0a diagn0sis 0f periodontitis V{|TH0UT radiographic evidence ol b0ne loss. Periodontalp0ckets CAil 0T be determined lrom radi0graFhs.

cteristics 0l All Gingival Diseases:L Signs and sympt0ms conlined t0 the gingiva.2. Dental plaque t0 initiate and/or exacerbatetlre severity 0f the lesion.3. Clinical signs 0f inflammation (enlarged gingival contours due to edema/fibrosis, c0l0r

transition t0 red and/0r bluish red, elevated su lcu la r tem perature, BoP, increasedgingivalexudates).

4. Clinicalsigns and sympt0ms are associated with stable attachmeni levels 0n aperiodontium with n0 attachment loss 0r 0n a stable, but reduced periodontium.Disease is reversible by rem0ving the etiology.Possible role as a precurs0rt0 attachment loss around teeth.

STREPT0C0CCUS & ACTII{0i|YCESbacteria (Actinomyces) are the most

5.5.

l{0TEs 2 Categories 0l Plaque-lnduced Gingival Diseases:L Gingivdl diseases affecled by localfactors.2. Gingival diseases affected by local fact0rs, bul modified hy specific h0st systemic

lactors via the endoc ne system, hematologic diseases, drugs, 0r malnutrition.

P[A0UE-|I{DUCED Slt{GlVlTlS - lhe most common type 0l Plaque-ass0ciated gingivaldisease. lt is gingival inflammation duet0 bacteria atlhe gingival margin. occu rs at allages0f dentate 00DUlation and is IHE lil0sT Colllill)il Fl)n 0t PtRl0DoilTA[ 0ISEASE. Begins atthe gingival margin and spreads through renaining gingival unit. Reversible with plaqueremoval.. Characteristics: plaque at the gingival margin (where it slarts). Changes in gingival

c0l0r (redness), edema, erythema, B0B contour & c0nsistency changes, sulculartemperature change, increased gingival exudates, B0B histologic changes, sensitivity,tenderness, and enlargemeni. Presence 0l calculus and/or plaque.

Treatment 0di0ns: goal is to eliminate eti0logic lactors (plaque, calculus, plaque-retentive features) through patient educaiion & 0Hl, debridement 0f calculus, anti-micr0bial anti plaque agents, correct plaque retentive factors (over contoured cruwns,open/overhangilrg margins, na(ow embras!rcs, open contacts, ill-fitting fixed 0rremovable denturcs, i00ih malposition). Surgical correction may be required t0 correctgingival def0rmities that hinder ptaque contr0l. Attel active therapy is complete,evaluati0n is required t0 determine furthel course oftreatment.

Treatment may be affected by systemic sk lactors (diabetes, smoking, periodontalbacteria, aging, gendergenetic predispositi0n, stress, nutriti0n, pregnatcy, HIV substanceabuse. medicaiions. other {actors that may contribute t0 the condition not resolving(patient n0n-compliance, remaining calculus).

. lf condition does not improve, additi0nal 0Hl/educati0n, medical/denial consultation,debridement, increasing pr0phylaxis frequency, micr0bial assessment and c0ntinu0usmonitoring and evaluati0n Bay be required.

PLA0UE-|I{0UCED GltlGlVlTlS 0l{ A REDUCED PERl0DoNTlUtl after periodontaltreatment and resolution 0f periodontal inflammati0n in periodontitis, the periodontaltissueis healthy, but with a reduced C.l atiachment and alveolar bone height. Characterized bythereturn 0f bacleria-induced inllanmationt0 the gingivalmargio on a redqced periodontiumwith n0 progressive attachment loss (no indication 0f active disease). Same clinical lindingsas plaque-induced gingiYitis, butthere is pre-existing attachment loss

CHL0RHEXIDIIIE GLUC(II{ATE (0.12%) - kills bacteria in situati0ns when used lor 30secadday.The m0st effeciive anti nic.obia I agent for red ucing plaqueand gingivitisover long{erm.

Gingival diseases are affected by local lactors (plaque) but moditied by specific hostsystemiclactorsviatheEilD0CRttlESYSIE,hematol0gicdiseases,drugs,0rmalndrit ionTfltRE tS flo ATIACHI EIII0R Bl)llE t0ss lvlTH GlllclvlTlsl

Cingival oiseases modilied bythe Eil00CRlilt SYSITI'iated Gingivitis: the dramatic rise in SIER0l0 fi0Ril0ilE I-EVEIS

Duherty in b0th sercs has a transient eafect 0n gingival inllammati0nival inJlammation can develop with 0nly small amounts 0f plaque during the

pubertal period (this is what distingrishes this disease). Characteristics:Faque atthe gi'rgival margin, pronounced inflammatory response 0fthe gingiva.llust be circumpubedal (gi s estradiol > 26; boys testoster0ne > 8.7).Change in gingivalc0l0r, contour, with possible changes in size.Increased gingival exudates and BoPReversible after puberty.'

al Cycle-Associated 0ingiviiis: 0ccurs duingthe menslrualcycle due t0 sexhormones (estr0gen & pr0gesterone) causing gingival inflammation and anin gingivalexud

. Plaque at the gingivalto ovulation.

. Must be atthe ovulatorysurge when luteininzing h0rmone levels are > 25mlu/mland/0r estradi0l levels >200pg/ml.

. Increase in gingival exudate by at least 20% during ovulation. Reversibleafter ovulation

Pregnancy-Ass0cialed Gingivitis: plaque ai the gingival margins, prcn0uncedinflammatory gingiva response, onset zrd 0r 3d trimester. Change in gingival color(bright red), contour, increase in gingival exudates, BoP Reversible at parturition.Iain clinicallinding is gingival hem0rftage (bleeding) upon gentle Fressure.. lf a w0men is in her l310r 2'd trimester, scaling, polishing, & 0Hl can be performed.

It she is well into her3i trinester, prudent trcatment may betojusi give 0Hl andreapp0int her after childbirth forscaling and p0lishing.

Pregnancy-Associated Py0ge[ic Granuloma (Pregnancy Tumorf not a tumor(neoplasm), but a[ exaggerated inllammat0ry response during pregnancyt0 anirriiation causing a solitary polyploidy capillary hemangioma that bleeds easily onprovocation. May develop as early as the lsttrimestel. Clinical Features: painless protuberant, mushroom-like sessile 0r pedunculated mass

atthe gingival margin or inter-proximalspace. Affects upt0 5% 0f pregnant women.lilore common in lilAXlLLA & ll{ItRPR0XlilAttY.

. Gharacteristics: plaque atthe gingival margin, pronounced inflammat0ry rcsponse0{ gingiva. Can occurANYT|l!'lE DURING PREGNANCY. Regresses 0rcompletelydisappears after parturition.

li0TEs

ate (GCF) especially during ovulati0n. Characteristics:margin. modest inrlammalory response ot gingivaJ priol

t{0TEs DRUGltl0UCtD (Medicati0ns) Gingiyal 0is€ases:l. Drug-lnduced Gingival llyperplasia (Enlargemenv0vergr0wth): caused by anti-

c0nvulsants (0ilantin/P[enyt0in), imnun0sup0ressants (Cycl0sp0rin A-preventsorgan transplant rejection), & calcium-channel bl0ckers (llifedipine (Pr0cardia),Verapamil, Biltiazen, S0dium Valpr0ate). occurs more often in AtlTERl0R GUGIVAand in children. onsetwithir 3 m0nths 0f taking meds,lirst observed in PAPlLlAassociated with attachment 0r bone l0ss.. Phenytoin causesthe highest gingival enlargement in 50% 0f patienlsi Cyclospori

25 30%; & Calcium channelblockers cause 0vergroMh 20% oftiBe.. oral hygiendpiaque removalcan limitthe severily 0f enlargement, but does ll0l

shrinkthe gingiva. Plaque is not required t0 producethe enlargement.. Characteristics: variation in inier-patient & intra-patient pattern, change in gin

c0ntour causing changes in size. Enlargement is first obseryed at interdentalchange in gingivalcolor, increase exudates, BoR found in gingiva with orwiihoutbone loss, hut is l{0Iassociated with attachment loss.

2. oral C0ntracedive-Associated Giryivitis pre-nen0pausal w0mer taking thesehormones can develop plaque atthe gingival margins, pronounced gingivainflanmatory response in the presence 0f little plaque, changes in gingival color,conaour, and possibly size. Increased GCF (crevicularfluid), BoP Reversible afterdisc0niinuing the oral contraceptive-

Plaque-lnduced Gingival Diseases Associated with SYSTEilIC DISEASI,l. Diabetes l{ellitus-Associated Gingivitis f0und in Clllll)REll yrith p00 y controlled

Iype I Lil (plasma glucose levels-insulin dependent). Similarfeatures t0 plaqueinduced gingivitis, erceFt cootr0llingthe diahetes is m0re important than plaquecontrol in lhe severity 0l the gingiyal inllammation. Characteristics: plaque atgingival nargins, pronounced inflammatory response 0f gingiva, change incol0rhontour, increased exudates, BoP il0st common in cbildren witi poorlyc0tltrolled Iype I Dil. Reversible if can contrul the diabetic state. Plaque reductioncan limit the c0ndition's severity.

2. teukemia-Associated Gingiyitis (Hematologic 0ingivitis)-malignant bl0od disorder(bl00d dyscrasia-associated gingivitis)0f abn0rmal leukocyte developmeni andproliferation in bl00d and marrow. Acute leukemias can cause oral maniJestations likecervical aden0pathy, petechiae, mucosal ulcers, and gingival inllammalion &enlargement. Gingiya is swollen, glazed, and slongy tissues are red t0 deep purple.Gingival bleeding 0n probing is common and is the ltllTlAt 0RAt SlGil. Pronouncedinflammal0ry resp0nse 0f giigiva in relati0n t0 the plaque present, but plaque is NoTrequired forihe condition t0 occur.

Gll{GlVAt DISEASES & MAttlUTRlTl0l{ nutriiional deficiencies can significantly worsenthe gingiva's responset0 plaque bacteria, and malnourished people l'rave a compromised hostdefense system that may aflect infeciion susceptibility. Ascorhic Acid-Deficiency 0ingiyiiis:vitamin C (ascorbic acid) deficiency (Scunl) especially in infants, instituti0nalized elderly, &alcoholics are at risk. Causes the gingiva t0 appear bright red, swollen, ulcerated, andsusceptible to bleeding.

10

TON-PTAOUE INDUCEI] GINGIVAL LESI()NS

l) l l-PLAoUE IIIDUCED GINGIVITIS is caused by specil ic bacteriai, vrral, and fungal.iections. This g ngival inflammatior may also be caused by alle.gic reactions 0r torictlactions, foreign body reactions, or mechanicaland thermalirauma.

rfEcTt0us G ctvtTts,1. Bacterial Infections that cause gingivitis. Infective slomatitis & g ngivitls in

immun0c0mpetenl and immun0c0mpr0mised individuals, occuring when n0n-p aque pathogens overwhelm host resistance. Gingrva lesions may occ!r due t0fieclions by lleisseria gonufiea, frcponena pallidun, & Strcptqcocci. G ngi.vamay appear as flery red, edematous painlLr u cerat 0ns, as asymptomatic cancres ormucous patches, or as atypica non-ulcerated, high y inflamed ging va. 0ral lesionsrr'ray or may n0t be accompanied by lesi0ns n other body sites.

2. Viral Intecti0ns that cause gingivitis. Mainly Herpes Simplex 1 & 2 and Varicella-Zoster when reactivated from therr atent per ods due t0 trauma, IJV ght, 0r feverHSV I !s!ally causes oRAL maniJestations, while HSV-2 in maif y anogenrtal, but mayals0 cause ora infectiors. HSV has been found n th€ g ngiva, ANUG, & periodontil is.lmnun0c0mpfom sed patients are at ircreased risk of acquiring the lffection.. Primary flerpetic Gingivostomatitis class c aanifestat 0n of HSV-l infection. I\4zinly

in y0ung children, but also ad! ts. Pa fful, severe gingivit is w th ! cerations andedema accompanied by stomatitls. Classic Features: VESICLES THAT RUPTURE,c0alesce, & leave fibrin-c0ated ulcers, feyer & lymphaden0pathy.

. Recurrent Intra-oral Herpes-cluster 0f sma painful ulcers in ATIACHED Gl AlVA.Less severe than primary herpetic girgivostomatit is. Diagnosjs s made by cultures,efzvme- nked assavs. PCR methods.

. Varicella-Zoster Virus: latent ln the dorsal root gang 0f of trigem nal unti l i t sreactivated in adults t0 cause SHINGLES. Both chickenpor and shingles can allectthe gingiva and initiaie as VESICIES THAT RUPIIJRE t0 leave fibdn-coated llcersthat coalesce t0 irregular lorms. ln immurocomprom sed patients (HlV), the infecti0ncaf cause severe tissue destructior tooth exloiration, afd alveolar bone necrosis.lr it ial rf ira-oral symptoms may be pain and paresthesia beforethe U tIAIERAI-rEsr0[s 0ccuR.

3. Fungal Inf€ctions that cause gingivitis. Dlagnosed by culture, smear, and biopsy. Buts nce C. A b cans s common in heaithy indlv duals, quattitative assessmert andnoticing clinical changes are needed for a reli,ble d agnosis.. Candid0sis (C. Albicans) oppoltLrnistic infection due t0 redLrced host delefses,

!sually a superficial infection 0f the oral mucosa. lvlay occur n HIV and othermmunocompromised patients as erythema 0f attached girgiva

. H|V-Associated Gingivitis = tinear Gingival Erythema. LGE is a glfg valmanifestation 0f imm!fosr.rpression appearing as a djstinct l l fear red band I mitedto the FREE CINGiVA. LGE lesion dOes f0t resoond t0 Dla0ue Temova .

. Pseudomembranous Candidosis (Thrush) white patches that wipe off leaving as ightly bleeding surface lJsual y n0 major symptoms.

. Histoplasm0sis: a granu 0matous disease. oral lesions affect any area of the Ofalmuc0sa, inii iating as n0dular 0r papil lary afd latet ulcerate and are painful. Clinicallymay fesemble a malignafttumor'

4. Hereditary fingivolibromatosis-a rare GEIIETIC DISEASE. A pr0gressive pr0lilerati0n0l the gingiva {genetic-derived fibrolic gingival enlargement). C inically,generalized ditfuse gingival enlargement, often extensjve enough t0 c0ver theteeth. l lssue is dense and lirm, w th cofs derab e disiodion 0l normal c0nt0ur.Gingival color is normal, but er!4hemat0us chafges are a rcsu t 0f secondarybacterial lnvolvelirent.

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Dermatological Diseases: may present gingival manifestati0ns in the form 0JDES0UAiIATIVE lesions (peels away) 0l the gingiva 0r gingival ulcerati0n. LichenPlanus, Pemphigoid, Pemphigus Vulgaris, Er$hema lilultitolme, Lupus.. 0esquamative Gingivilis-a chronic gingival diseasecharacterized byerythematous,

er0sive, vesiculobull0us, and/or desquamative involvemenl 0l FREE & ATTACHEDGltl0lvA. Most patients are postmenopausal FEI{ALES ages{0-70yrs. DG is a paicondition where ihe outer gingiva layer desquamates (peels away), exposing anacutely red surlace. Many diseases and conditions are ass0ciated with DG, but m0are dermatologic. Plaque's role isvague. DG usually 0ccurs due t0 an allergicreaclion 0r is ass0ciated with skin diseases (lichen planus, BMMB bull0uspemphigoid, & pemphigus). DG generally resolves when the alle.gic reaciion or skindisease is treated and clears u p. lreatment: Topical corticosteroids.

6. Allergic Reactions: oral muc0sa reacti0ns are either lype | (immediate) mediated bylgE 0r Type lv (delayed) mediated byT-cells duet0 dental restorative materials,toothoastes, mouthwash, and food.

7. Ioxic Reaclions: chlorehexidine induced mucosal desquamation, aspirin burn.8. F0reign Body Reactiofls, all0ws entry 0f a forcign material into the gingival C.l via

abrasion 0r cutting (i.e. amalgam tatto0). "Foreign Body Gingivitis".g. lilechanical lrauma: sell intlicted lesions "gingivitis artefacta caused bv excessive

brushing force, scratching the gingiva with a fingernail. lvlost common in childrenyoung people (2/3 are females).

10. Themal Trauma: therma I bums 0f oral nucosa are rare (hot beverages). Palatal &labial muc0sa arethe most common sites. Painful, red, and nay slough the coagulsurface. Cotfee, piza, dental keatment with improper handling 0f hot hydrocolloidrmpression materials, h0t wax, etc.

PERIllD()I'ITITIS

T0 diagnose peiodontilis, radiogralhic Gvidenc€ 0l hone loss MUST be evident. Biiewingsare lhe t{0ST accurale tool to assess B0llE L0SS (RES0RPIl0ll). lf extensive bone l0ssoccuned, vertical bitewings siould be iaken as they reveal m0re 0f period0ntium. > 30% olthe bone mass atthe alveolar crest must be lostlor a change in bon€ height t0 be evidenton radiograIhs.

A REDUCTI0II ll{ llUi[BER 0R FUtlCTl0il 0F PMtls (polymorphonuclear leukocytes) resultsin an increased rate and severiiy 0l period0ntal destruction. Peri0dontal disease may be anAUT0lM Uilt DIS0RDER where the body's inmune factoN (cytokines) attack tie p€rs0n\own cells and tissues.

Radiographic Chatlges in Pefodontal Disease,l. Early periodontilis-areas 0f localized er0si0n 0fthe alveolar h0ne crest (blunting 0f

the crest in anterior regi0ns, and rounding 0fthe junction between the crest and lamindura in posterior regions).l{oderate pe odontitis- alve0lar bone destruction extends heyond ea y c[anges inthe alveolar cresl, and may include buccal 0r lingual plate resorption, generalizedhorizontal erosi0n, 0r localized vertical defects and possible tooth mobility.

3. Advasced periodontitis bone l0ss is s0 extensivethai remaining teeth showmobility and drifting, and are in danger0f being lost. Enensive h0riz0ntal bone lossor extensive bony defects.

A reduction 0l only 0.5-l .omm thickness 0f c0 ical Plate is ssflici€nt t0 allow radio$aphicyisualization 0l destruction 0fthe inner cancelloxs trabeculae. The crest of alveolar b0ne isalfected in periodontal disease. In health, the alveolar crest is 1-2mm bel0vr the CEI 0fadiacentteeth.12

tdols that contrihute t0 Pefi0dontitis: smoking, stress, drugs,Gironic gingivitis often leads t0 Peri0d0ntitis. Fact0rs that can

risk:Downs syndrome, HIV/AIDS, horrnone imbalances (pregnancy), unc0ntrolled Type I & llDiabetes melli ius.Rare WBC disorders (Neutropenia, Agranulocyiosis, Leukemias), genetic predisp0sition,medications, smoking (major preventable isk fact0r), & 0ste0p0r0sis, Cr0hn's Disease,RA, lupus erythematosus.

l000llTALTHERAPYG0A[S t0 alter 0r eliminate microbial eti0logy and contributing

-l

factors lor periodontilis, thus arresting the disease progression and preseruing the

-fltition

in c0mfort, lunction, and esthetics t0 prevent recurrence. Regeneration 0fItachment apparatus may be attempted. When c0ntrol 0f the disease is not possible due t0tstemic factors, immune defects, & microblal flora, a reasonable treatment objective is t0'slow the disease progression".

RESSIVE PER|0D0l{Tlns can be localized 0r generalized. Patients are clinicallyIthy except for the periodontitis. Rapid attachment loss & bone destruction. L4ay be 0filial aggregation/nature.Secondary Fealures, am0unts 0f mlcr0bial dep0sits are inconsisient with the severitv 0fperiodontal t issue destruction, elevated levels of AA & P gingivalis. Phag0cyteabnormalities and hyper-responsive macrophage phenotype (elevated levels o1PGt2 & lL-lb). Progressim 0l attachment and bone loss nay he sell-arresting.[0calized Aggressive Peri0d0ntitis (l0rmerly iuyenile Peri0d0ntitis) circumpuberta]0nset with a robust serum Ab rcsponse t0 infecting agents is detected. Localized t0 ldmolars & incisors (vertical bone loss) with inteFlroximal attachment loss 0n at least 2permanent teeth (one is a ld molar, and involves no mo.e than two teeth other than l"'molars & incis0rs). Caused by M. one outsianding negatile feature is the relativeabsence 0l local fact0rs (plaque) t0 explain the severe period0ntal destruction present.Possible etiologic factors: genetic predispositi0n 0r neutr0phil dysfunction (achemotactic defect). SIJDDEIi DRlFIlllc 0F TETTH lll CHltlREl{.Generalized Aggressive Peri0d0ntitis usually affects people under 30yrs (but patientsnay he older). P00r serum Ab response t0 infecting agents is detected. Pronouncedepisodic naiure of destruction 0f attachment and alveolar bone. Generalized inter-pr0ximal attachrnent loss affecting A1 IEAST 3 PERMAIIEI{T TETTH |lIllER THAII 1.'t|}t lRS & ll lc|S0RS. Caused by Actin0bacil lus A., P gingivalis, & neutrophil functionabnormalit ies.lggressive Period0ntitis Treatment: 0Hl, rcinforcemert and evaluation 0f patient'splaque control, SRB control 0f other local factors (occlusal therapy, pe odontal surgeryand maintenance).Additional treatment considerations, general medical evaluati0n t0 deiermine if systenicdisease is present in children &young adults, especia ly if init ialiherapy is uns!ccessful.Adjunctive antimicrobial therapy combined with SRB and/or evaluati0n and counsellng offamily members due to its Dotential familial nature.

L0calized Aggressive Period0ntitis

sex hormones, etc.increase Periodo al

fioTEsn

tu5,Iparrlu

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N(|TES Desired 0utc0mes: significant reducti0n 0f gingival inflammati0n and probing depthstabilization 0r gain 0f clinical attachment, radiographic evidence 0f resohti0n of 0sse0lesions, progress toward occlusal stability, and reducing detectable plaque i0 Icompatibre wilh periodontal hpallh.

CHRoI{lC PtRl0D0tlTlTlS - gingival inflammation extending into the adjaceni attachmaDDaratus. Clinical attachment l0ss due t0 destruction 0f the PDL and adjacent supportibone. llll)ST Ct}MM|)lt FoR 0F DESIRUCTIVE PEnl0D0ilTAt DISEASE lil ADULTS, huta wide raflge 0l ages. Slow-t0-moderate rates 0l pr0gression, but may have Deriodsrapid progression.. Clinical Features, edema, erythema, BoP and/or suppuraiion. ill)ST C0ilil0tt t0R[l 0

PEll0D0ilTlTlS. lts prevalence & severity increases with age.. Localized if < 30% 0f sites are affected. Gefieralized if > 30% 0f sites are affected.. Patient can simultaneously have ateas 0f health and chronic peridontii is with slig

moderate, and advanced desiruction

CHR0I{lC PERl0D0l{TlTlS WITH StIGHT-T0-M0DERATE DISTRUCTI0tl loss of up33% of supporting peri0dontal tissues. In molars, if the furcati0n is involved, cliniattachment loss should not exceed Class l(incipient). Pr0bing depths uP t0 6mmvrilh cliniattachment l0ss up t0 4mm. Radiographic bone loss and increased tooth mobility maypresent. May be localized (involving one area 0f the tooth's attachment) 0r generalize(involving several teeth 0rentire dentiti0n).. Initial Treatment: eliminate, alter, 0r conirol risk faciors that coniribule t0 Chr0ni

Periodontitis (diabetes, smoking, aging, siress, pregnancy, systenic diseases, nuirition)0Hl, SRB & anti-microbial agents, remove local contrihuting factors (reshapinrestorations, correcting illfitting prosthesis, odontoplasty, t00th movement, restoring0contacts, 0r treating occlusal trauma). ll initial treatment is effective, PERll)ll0t{AlllIEtlA}lCE is SCHE0UtE0. lf initial therapy d0es not resolve lhe chroniperidontitis, PER|000 IAI SIJRGERY is considered:. Surgical Treaiments: gingivalaugmentation, regenerativetherapy (bone grafts, GTR),

resective thempy (flaps with 0rwlihout 0sse0us surgery), & gingivect0my.

CHR0ltlC PERl0D0l{TlTlS WITH ADVAT{CED-I0-M0DERATE DESIRUCTI0 - saclinical features as slight to-moderate but with advanced l0ss 0f > l/3 0l supporti0eriod0ntal tissues. Loss 0f clinical attachment in the furcation if present is class ll 0r lllPr0hi[g depths > 6mm with attachment loss > 4mm. Radiographic evidence 0l boneand oossible increased t00th m0bility. Can also be localiTed 0r genera ized. In certain cases due t0 the sevedty and extent 0f the disease and patient age/health,

treatment may not be lntended to atta in optimal rcsults, s0 initialiherapy may become tend-point which include timely peri0dontal maintenance.

and patient eftorts t0 stop the progression. Prim a ry cliflical Iealute is additiqnalIoss after rcpeated anenpts to contolthe inlection with cqnYentional thetary. "Refractory" diagn0sis is l)tllY made in [atients who satislacl0rily c0mply wilh 0Hl and

who lolloyred a rig0rous peri0dontal maintemnce pr0gram, and is diagnosed ATIERc0nventi0nal actiye therapy has c0ncluded.

. Periodortal Surgery C0nsidered: gingival augmentation, regenerative therapy (grafts,GTR), resective therapy (flaps, rooi resective therapy, gingivectomy).

REFRACToRY PERl0D0llTlTlS apolies t0 all lorms 0f destructive pe odontal diseasethat are non-resDonsive t0 treatment (Re{ractory Chronic Periodontitis & RefracioryAggressive Periodontitis). oiagnosed in palients previously diagnosed with peri0dontitis,who have addili0nal attachmenl loss at 0ne 0r more sites despite vrell-executed therapy

1{

Periodontiiis is iloT diagnosed in patients: who received incomplete 0rte conventionaltherapy, wh0 have identifiable system conditions that increase

suscepiibility, have localized areas 0f rapid attachmert loss related t0 root fracture,disease, foreign body impactiOn, or root anomalies, 0r patients with recurrence ofive periodontitis after many years 0f successful periodontal maintenance.

Goal: arrest 0r slowthe disease pr0gression.once the reffact0ry diagnosis isc0llect subgingival micr0bial samples to analyze, administer antibiotics withional periodontal iherapy, c0ntrcl risk factors (i.e. smoking), with an intensifiedntal maintenance program with shorter intervals between appointments.

IC CIII{DITI(]NS THAI AFFECTllDllNTAT DISEASE

COI{DITI()I{S MAY AFFECT THE PERII)DOI{IIUM AI{l) TREATMEI{T OFt 0ISEASE Physical disabil it ies, pregnancy, xe6t0mia, mucocutaneous

gingival overgroMh, ocessive gingival bleeding, drugs (anti convulsants, calciumbl0cke6, cyclosporine), smoking, history 0f recent chronic diseases (Diabetes Mellitus

psych0l0gical facto6, family history ol disease.laboratory as needed and refer 0r consult with other healthcare providers

walranted.treatnent 0utc0me of the peri0dontal therapy may be directly affected by c0ntrolllngsystemic condition.

should take their medication and maintain an appropriate diet 0n the day 0fItherapy.

ni patientswith period0ntaldisease, c0nsultwiththeir physician, c0nsider p0stponingduringthe l"trimester. Can perf0rm emergency periodontal treatment anytine during

ancv. Perform Deriodontal maintenance as needed. Administer antibiotics with cautionlanesthesia is preferred t0 generalanesthesia 0r conscious sedatl0n.

llAGlC Glt{GlVAL EllLARGEMEltT a common early manifestation 0l ACUTIA where chem0therapy 0r bone marrow transplant therapy may adversely alfectiva.

c0nsiderali0ns: c00rdinate with patient's physican, minimize pe 0d0ntalions hy pr0viding treatment prior to treatmenl 0l leukemia 0r lransplantation.

id e ective treatment during peri0ds 0f exacerbati0n 0f the malignancy or during activeses 0f chemotherapy. Consider antibi0tics for emergency periodontal therapy whenulocyte counts are low l\40nitor for host-vs.-graft disease and drug-induced gingival

aJter bone marlow iransplantation. Period0ntal therapy and surgery is fine0atients with stable. GHR{|lllC IEU|(EI{lA.

DIS0RDERS ASS0CIATE0 WITH PERl0DOtlTlTlS (80t{E L0SS) Down'se, Chronic Granulomatous Disease, Leuk0c'4e Adhesi0n Deficiency Syndrome,phatasia (decreased blood alkal ine ph0sphates and b0ne l0ss), Papil l0n-Lefevre(skin lesions, palmar plantar keratosis), Chediak-Higashi Syndr0me (neutr0phil

N{]TES

;nmeportrn

uIl inicfinicnay

naprng0

00veo0s

;hronlntion,

grafts.

b€ase€ct0rlrtitis,Efapt

ie?lth.melhe

axis abn0rmal), Ehlers-Danl0s Syndome, glyc0gen storage disease, Cohen's Syndr0me.

15

l{(lTEs PERI|)D()NTAI- DISTASE AFFECTING SYSTEMIC HEATTH

lhe periodontium is a reservoir for bacteria that produce inflammatory and immune medithat interact wiih body organ systems besides the oral cavity. Period0ntal i[fecti0nsincrease the risk 0l ce(ain conditi0ns (Diahetes, Pregnancy, & Cardiovascular DiseaThe dentist should inform the patient of possible interactions and establish periodontal heat0 minimize period0ntal negative influences 0n systemic health.. l)iahetes lilellitus: periodontitis can affect glycemic control and increased the risk

cardiovascular complications ass0ciated with diabetes.. Pregnancy: increased risk 0f prelerm low bidh weight delivery.. CoronaryArtery Disease: individuals lllith peri0dontal disease may have increased risk

head disease, angina pectoris, & Ml. Periodontalpath0gens naycontributet0 atherogenichanges and thromboembolic events in corcnary arteries. lvlay also increase the riskcerebral ischemia and non hemmorhasic stroke.

. Inlective Bacterial End0carditis, bacteremias are intensified in cardiovascular diseapatients with periodontitis. Patients with IVIVP with rcgurgitation reqlire pre,medicatiopri0r t0 probing and SRP Usually 2g Amoxicillin lhr pri0r t0 treatment in non-penicilliallergic patients.

MUG 0G il{G tVAt C0t'tll tTt 0t{s

MUC0GIIIGIVAL DEF0RMITIES deviations fr0m the n0rmal anatomic relati0nshipgingival margin & mucogingival junction (li|cl). N4ay be congenital (missing teetdevel0pmental (tooth eruption in a F 0r L position, cleft palate, cysts), 0r acquired(neoplasms). These delormities occur around teeth, implants, and in edentulous ridInfecti0ns ass0ciated with muc0gingival delormities, peri0d0ntitis, peri-implantitis,periapical infections.. Mrcogingival C0nditiofls: gingival recession, ]ack 0f keratinized tissue, aberrant frenu

positions, pobings beyond the [4GJ, gingival excess (pseudopockets, gummy smilgingival hyperplasia), abn0rmal c0l0r.

. Mucogingival-0ral mucosa covering the alveolar pr0cess, gingiva (keratinized tissue) aadjacent alveolar nucosa.

. Gingival Recession (Atropiy) 0ccurs when the gingival margin is apical t0 the CEJ.

. oingival Excess: pseud0pockets, incOnsistent gingival margin, excessive gingival displagingivalenlargement.. Pseud0pocketing ("gingival pocket" 0r "relative pocket"lcondition where pockeli0ccurs WITH0I,TATTACHMEIIT l-0SS due t0 expansion 0fthe marginaliissue C0R0llALLY

. lrflammatory Gingival Enlargement a form 0fgingivitis easilydifferentiated fron simpglngivitis. Cli[ical findings are increase gingivalsize, distortion 0f normallorm, andtissue t0ne change. There is significant increase in sulcus depth with pocketl0{pseud0p0cket 0r relalive p0cket). The pseu0dp0cket is caused byexpansi0n 0fthemarginal tissue coronally, ratherthan apical m0vemeni 0f epithelial attachme.t bevondits physiological level.

Anatomic variations that may complicate treating mucogingival conditions:positi0n, frenulum inserti0ns, and vesiibule depth. Variations in ridge anatomy mayass0ciated with mucogingival c0nditi0ns.liluc0gingiyal del0rmitics are ll0T 0ETECTED 0ll RADI0GRAPHS,help when c0mbined wiih a medical/dental history, probingexamination.

but radiographs

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lreatmenl: non-surgical & surgical c0rection to help maintain the dentition 0r ltsreplacements in health with g00d function and esthetics, and to reduce the isk oforogressive recessron via r00t coverage, gingival angmentaii0n, p0cket reduction,croy/n leflgthening, ridge augmenlati0n, vestihul0plasty, papilla regenerati0n,ad0ntoplasty, t00th movement, and controlling etiologic lactors & intlanmation viay'aque c0ntr0l, SRR anM0r antimicr0bials.

Ht0 Gll{GIVA tl(ERATlt{IZE|)) - measured from sulcus base (periodontal oocket) ontogingiva surface t0 the mucoginglval junction ([4GJ). Calculated by suhtracting

depth fr0in the width 0l gingiva from the free gingival margin t0 thengival margin.

Attachedt0 undedying periosteum 0f alveolar bone and cementum byC.lfibers and epithelialattachment. Fimly joined t0 underlying tooth structure, periosteurn, & bone. ATIACHEDGlilolVA is n0rmally CoRAL PlllK. lts c0l0r varies depending on the degree 0fleratinizati0n, thickness 0tepithelium, presence 0fmelaniB, and numher 0l bl00d vessels.IARRoWEST BAll0 is 0n FACIAI SURFACIS 0l mandibular canine & l,r[remolar. andlngual surfaces adiacent t0 mandibular incis0rs & canines. llarrow zones nay ais0occur at llB r00l 0l maxillary first molars (associated with proinjnent rcots andsometimes bony dehiscences), and at mandihular 3d molars.lVidth 0l FACIAt attached gingiva ranges from l-gmm. WIDEST 0n facial 0f maxillarybteral incisor, & narrowest 0n lacial of mandibular canine & first premolar.Ittached gingival boundaries extend from the MGJ t0 the tree gingival gro0ve(sulcus hase).. iluc0gingiyal Junction (l Glfseparates attached gingiva lr0m alveolar mucosa.. Free gingivalgroove (base ofsulcus)-separates free gingiva from attached gingiva.

tral mucosa is STRATIFIID S0UA 0US EPITHELIUiI resardless if it is keratinized 0r

lon-Keratinized (]ral ilucosa: buccal & alveolaf mucosa, tongue's inferior (ventral)surface, sott palate, f l0or of mouth, and lining mucosa, gingival col, and creviculareoithelium.. Alve0lar Mucosa a LlNll lC l lSSUE,located APICAIt0 attached gingiya 0n facial&

lingualsudaces. C0nsists 0fthin, N0 -KtRATI IZED epithelium, loosely textured,c0ntains elasticfihers and is loosely bound to periosteum olalveolarb0ne. Well-adaptedto !ermit movement, but cann0twithstand lricti0nal stresses.

lcratinized l)rall{ucosa: hard palate & attached gingiva.

GlilGlVA (Marginal gingiva) - non keratinized collar 0f tjssue not attached t0 t00thdre0laf bone that extends from the free girgival groove (sulcus base) to the gingival

in. lt s composed oflgingival margin-the most coronal part ofthe free glngiva.free gingival groove separates free gingiva from attached gingiva. The beginring 0fthe attached gingiva.gingivalsulcus-shall0w groove between the marginal gingiva & t00th surface, boundby sulcular epitheliuflr laterally, and JE aplcally.interdenta I gingiva occupies intel dental spaces coronal to the alve0lar crest.

ol{TllrM tissues that sur.ound and support the leeth. Conslsts of the gingiva,ccmentum, alveolar & supporting b0ne. lvlain functions are t0 support, pr0tect, and

teeth. Attachment apparatus-consists ol alveo at bone proper, PDL fibers, &um that attaches the r0ot t0 alveolar bone.

rjfi, the lE is on enamel or at the CU. In disease, the JE migrates apically along thetUrlace. lt is measured from an established reference p0int (CF.J 0r rest0ration nafgin)to

l{0TEs

ment with a periodontal probel7

N{1TES ACUTE PERI()DllI{TAL DISEASES

ACUTE PER|0D0I|TAL BISIASES clinical conditions 0f RAPI0 0 sEI that involveperiod0ntium or associated structures, characterized by PAIN, D|SC0 F0Rl & liltECTI0ihat may 0r may not be related t0 gingivitis 0r peri0dontitis. ll'lay be localized or generalwiih p0ssible systemic manifestations. Acute Peri0d0ntal Inlecti0ns:. l{ecrotizing Peri0dontal Diseases (ilUG & ilUP). 0ingiYalAhscess. Periodontal Abscess. Peric0r0nalAbscess(Pericornitis). Herpetic Gingivostonatitis. CombinedPeri0d0ntal-End0d0nticlesi0ns.

ECRoltZnG UtCEMTIVE G[{GtVtTtS ( UG) "V[{CEl{T'S FECT|0lt"'IREIICH M0UTH' an acuie infeciion 0f the gingiva. Necrosis 0f gingivaltissue (i& F.drginal). All 3 characterislics MIJST be present t0 diagnose as lllJc. An inteclicharacterized lrygingivalnecr0sis presenting "punched-0ut" papillaewith gingival bleeding anpain. Fetid breath and pseudonembrane formation may be secondary diagnostic featu.es.

1. l TEtiSE PAlil (hallmark 0f ilUG), usually rapid 0nsei.2. Inter-dentalgingival necr0sis "punched-0ut" ulcerated papillae (yell0l'1/ish white

grayish s ough pseud0 mem brane formati0n of gingiva). Papil laetips a.e bluntedand cratered.

3. Gingival bleeding (least distinctive clinical sign) that 0ccurs with 0r with0utprovocati0n. Brighi red marginal gingiva.

Predominant factor in lllrc development is ll{l{Ull|)SUPnESSl()il, which may be associatwith all 0f its predisp0sing factors: pre-existjng gingivitis, smoking, psychologicai streimmune suppressi0n (HlV), malnutrition, gross neglect (p00r 0ral hygiene), fatigue, antrauma. ilEUTR0PHII is the dominant WBC in the inflammatory iniltrate of ANUG.

ADolTI0l{At l{UG SlGl{S & SYMPT0MS lymphadenopathy, fetor ex ore (fetid breath), fevmalaise; are not palh0gnomonic symptoms as they often 0ccur in many other fomsperiodontal disease. Fever & ma aise may also suggest Primary Herpetic Gingivostomatitisl\4ononucleosis.. llUG Etiology, fusiforms, Spir0chetes, & Prevotella intermedia.

L0ss of attachment and bone is uncOmmon, but can 0ccur after multiple recurrcnces 0fthe disease.0ccurs m0st 0ften in adults l8-30yrs.

llUG TREATMEI{T Debride necrotic areas & t00th surfaces, water 0r warm salirinses/irrigati0n, and antibiotic therapy (Penicillin v) if systemic involvement (fever, malaiselymphadenopathy). Patienls vJith Hlv-associated llljG require gentle dehridementantimicrobial rinses. NliG resolves within a few davs after treatment with debridement aanti microbial rinses, but patients remain at risk for recurrences. Paiient counselingnutrit i0n, 0ral ca'e, l luid inlake. !moking cessati0 ..

tlECR0TlZltlG UTCERATIVE PERl0D0tlTlTlS ( UP) a severe and rapidly progressiveinfection with a distinctive erythema and necrosis 0f free and attached gingiva, PDL, andalveolar bone. There is severe l0ss 0l attachment and alveolar hone. NUP has many 0f theclinical & etiol0gic faclors of NtlG, except there is loss 0l clinical attachment and bone ataffected sites.. Treatment: ora I hygiene measurcs (SRP) combined with systemic antibiotics ( letr0nidaz0le).. Conm0nlv observed in individuals with systemic conditions, (i.e. HIV), severe malnutrit ion,

and immunosuooression.t8

CESSES ()F IHE PERI()DllI{IIUM

ing periodontal abscesses is prmarily based 0n location of the infecli0n. Abscessesbe assoclated with pain, swelJing, col0r change, m0bility, teeth extrusi0n, purulence,tract formati0n, fevel, lymphadenopathy, and radi0lucency 0f the affected alveo ar bone.

, all of these ciinical features are not always present.

lVAl- ABSCESS - a lOcalized, painfu swelling with purulent exudate inlection 0t thelghgiva 0r interdental papilla with a red, sm00th, shinysurface. Lesion may be painful

appear pointed. Treatment: eliminate the acute signs and sympt0ms ASAP via DRAlllAGtlfthe abscess does not resolve. it can become a chronic condition.

It is usually an acute inflamflatory response to foreign substances f0rced intothe gingiva,appearlng as a red, smooth shiny swelling in its early stages. Within 24-48hrs, it isfllctuant and pointed, with purulent exudates. lf ii progresses, the lesion rupturessp0ntane0usly. Pulpal hypersensitivity may be a symptom. lf the abscess is limited t0narginalgingiva 0r interdental palilla with n0 preyi0us disease, and a f0reign rnaterialx trauma exists,lhe lesion is usually a gingival abscess.

oD0ltTAt ABSCESS THE llll)sT Cl)MM0tl ABSCISS, usually associated with a pre-ng peri0d0ntitis. A l0calized infection/accumulation 0f pus in the gingival wall 0f a

pocket that may destroy PDt & alveolar bone. Srnooth, shiny gingiva swelling;with the area 0f swelling tender to touch, and purulent exudates and/or increase inng depth. T00th may he sensitiye t0 percussion and mobile. Rapid loss 0l attachmentoccur. Caused by gram ( ) anaercbic rods (SPIRoCHETES).

S{'ns & Symptoms: swelling, suppuraUon, rcdness, extrusion 0f the involved t00th,bosening, tenderness t0 percussion, and slightternperature eevation.llY BE ASS0CIATED Wllil EllD{]o0tlTlC PATH0SIS. Can be a common clinical feature ingatients with moderate 0r advanced periodontitis. Strcp. vitidans is XD nost cqnn\nislate in the exudates ol peiqdmtal ahscesses lgtan C) a naerob ic rods). lJsually resultstom p.e-erisling cases 0l CHR0lllC periodontitis. Ca[ be a common clinicallinding inr0derate-t0-advanced peri0dontitis patients.factors associated with the formation 0f acute period0ntal abscesses: occlusion 0l pockettifices due t0 f00d impaction 0rloreign h0dies prevents draiflage of erudate, furcation

-rclvemefll,

systemic antibiotics, diabeles, or due t0 incomplete femoval 0f calculus 0ristrumenlation lorces bacteria into the lissues.Dy become ch.onic if ils purulent Gontents drain through a FISIUU into lhe 0uterirgivalsurface 0r into the p0cket. A chr0nic abscess is usually asympi0matic, but someFtients feel a d! I pain, slight elevation 0f the t00th, and desue t0 bite tightly and grind.*onic reri0dontal abscess can become acute if lhe sinus tract orilice is blocked.lppears as an 0V0lD GlllclvAL ELEVATl0l{ AI0NG THE IATERAL R00T. Feeling "pressure inae gum" is a common complaint- Abscesses are als0 often found in furcations. ilostF0d0ntal abscesses 0ccur in 0LARS.

in chlldrcn, but if it occurs, it is usually due t0 a foreign body int0 previously healthy

N{lTES

fdenlalfectionmg an0

fiite or{

)cratedstress.e, ano

. fevefrms oltitis or

es ol

sa ineatalseent &m anong 0n

essivel- ancof theone al

u0tel|ntr0n

$temic antibiotics taken by a patient with untreated advanced periodontal disease causea$perinfecti0n by 0pp0rtunistic 0rganisms causing a peri0dontal abscesses.

ues.

hrly conk0lled diahetics are prone to acule periodontal abscesses duet0l0wered hostlsrstarce (impaired cell immunity). Diabellcs also have vascular changes and altered

gen metabolism that nay increasethe r susceptibility.trauma via perloration 0f the lateral wall during RCT, anatomic anomalies (enamel

1S

rls in m0larfurcations & invaginated r00ts) can aiso cause an acute periodontal abscess-

l'l0TES Treatment: ESTIBLISH DRAIIIAGE by debridirg the pocket and rem0ving [laqcalculus, and 0ther irrilants and/or incising the abscess- 0ther lrealmentsirrigation, limited 0cclusal adjustment, antibiotics, aid managing patient comSurgical procedure for access to debridement {flap) may be c0nsidered. T00th extramay be necessary in s0me cases. A comprehensive periodonial evaluaiion shouldresoluiion 0f the acute conditi0n. lf the periodontal ahscess is not localized, patientllaced 0n antibiotics (Penicillin V) and instrucled t0 rirse with warm saliClindamycin is used in penicil l in allergic paiients.Radi0graphic fidings associated with the periodontal abscess are ll0T specific.may be n0 change radiographically in the early acute lesion. However, there is oftenlocalized discrele radiolucemy lateralt0 the r00t 0r in a lurcati0n which canrapid alveolar bone destruciioni,l0ST G0 |)tl symptom a patient will report with a periodontal abscess is ACIJTEthat is constant, severe, and dull throbhing. Thermal changes d0 not cause 0r chathe discomlori. onset 0f discomfort is rapid and progressively intensifies- Patientalso notice an increase in t00th mobility, and say it is dilficult t0 close theirt0getier yrith0st striking the involved t00th first, causing increased pain.

. PR08lilG reveals DEIP P0CKETS ass0ciated with the 0eriod0ntal abscess. EPT athermal tests exclude the pulp as the unlikely cause as the tooth vrith a periabscess is usually VITAL. Meth0ds t0 distinguish a peri0dontal abscess from a pul(peri-apical) abscess is done via pr0hing, EPT, thermaltesting. A perialical radiis not a g00d diagn0stic method t0 distingrish a period0ntal and pulpal ahscess.

. ilEUIR0PHILS ar€ thB 0SI ilUilER0US cells in the i[flammatory exudates 0t an aDperiodonlal abscess.

PERIC0R0NAt ABSCESS (PERIC0R0l{lTlS) a localized accumulation 0f pus withinove.lying gingival flap sirrrou0ding a crown 0f a paiially 0r fully erupted tooth {USUAitAl{olBUutR 3'd t{01rR ARtr).. Clilical Fealures, tissu€ llap is localized, rod, swollen lesion, painfult0 touch. Puru

exudates, trismus, lymphadenopathy, fever, malaise, and leuk0cltosis may beInJection can spread into the or0pharyngeal area and t0 ihe tongue base and inv0lve rcgiolymph n0de5. Patients may have 0IFFICUUY SWAL[0WltlE. Caused by gam O anae

. Treatrnent: DIBRIDEI{EI|T & IRRIGATI0il of the fla!'s undersurface. antibi0tics.rec0ntouring, 0r extraclion 0f the involved and/or opposing tooth. Home care iGoal is t0 relieve inflanmation and infection and restore tissue to healthy functi0n.

C||MBltlED PER|0D0t{TAl"-El{D0D0tlllC ABSCESS (tEsl0tl) localized. circumscriareas 0f infection that 0riginate in the peri0dontal and/0r pulpal tissues. lilFECTloil ARIl{AllltY FR0l{ PUtPAL llltllil All0N 0n ilECR0SIS ex0ressing itself through lhe PDLalye0lar hone l0 the oral cavity. May also arise mainly lrom a periodontalcommunicating through accessory canals 0f the t00th and or apical communicationsec0ndarily infect the pulp. ll4ay also arise from a fractured tooth.. Clinical teatures: smooth, shiny swelling 0l the gingiya 0r mucosa. Pain with swell

tendert0t0uch and/or purulent exudate. Tooth may be sensitive t0 percussion and mobilFISTUL0US TRACI( l{Ay Bt PREStilT. Rapid loss 0fthe PDt aitachment and periradicultissues may occur' FACIAL SWELUNG andior CELLULITIS may be present.

2n

ucency 0l the periodontium and rootapex, signilicant probingdepths, and pulpal. A "conbined" ahscess is qne where an endodontica y induced pe apical

e sts on a pe odontally involved t00th. A pdlp inleclion/inltrmmaiion can!nicate and spread into the peridontium thr0ugh the rcot apex, LATERAL CANALS,ory foramina, cresial extensi0ns of granulomatous esi0ns along lateral roots, andh dentinaitubules. Periodontally derived endodontic lesi0ns can also occurthr0ughgrooves, r00Vt0oth fractures, cemental hyp0plasia, trauma-induced

resorption.ie t00th is |)fl-VlIAl", it is most likely a PIRIAPICAI ABSCESS. Usually periapical

ses occur singly, lt may be efiruded, tender t0 percussi0n, hypermoblle, markedphaden0pathy, and facial sweli ing, fever, malaise.

exacerbati0ns 0f chrcnic periapical infections are 0ften associated with P gingivalis

HOTES

IIE PTI P endodontal is.cnan

atient isalin

ftracIld fol l

ic. Theotten

tn ca

enlt r l

EPT aiodon

i: Pocc0mf0

[SUA

ated 2-3 moflths after RCT is com0lete. Periodontal surserv can be d0ne if neededaccess. bl. s pprl0rmed 7-3 moni'rs atter c0nplel irg lhe RCI

a pulpis essentialfor a diflereltialdiagn0sis. lfthe pulp is vital, but a pocket exists, thenperiodontal tissues arc m0st likelythe origin of infecti0n. ll the pulp is NlCRoTlC, themmatr0n that passes through a lateral canal 0r apical foramen into ihe periodontium

naVERTICAI R00T FRACTURT 0l a n0n-RCT t00th can aloear as combined

c 0eri0dontal lesion. Pain du ng occlusi0n or masticati0n is the main symptorn.tiin t sensitivity, gingival swelling, and perl0d0ntal abscess or sinus tracts are als0

Pulps may 0r may not respond t0 EPI but deep p0ckets are usually detected onWidening 0l the PDL space and periapical radiolucency and/or peiodonial

Purule may help wilh the diagnosis.ples aL r00t fractuTes often occur with RCT teeth and arc associated with a dee0 Docket

ESTABIISil DRAI AGE hy debriding the pocket and/or incising lhe abscess.. pocket irrigati0n, limited occlusal adjustmeni, and antibiotics. Extraction mav berred in sone cases. PULP lS TRTATED FIRST, then the periodontal conditi0n is re-

of endodontic origin.

the t00th surface which may or may not be abscessed. PAlll 0ll THE t0A0lllc CUSPSIIII}ICATE A Rl}l)T FRACTIJRE

rcglnrci. trssuction.

lltRPETlC Gltlc|V0ST0MAT|T|S a HERPES VIRUS INFECTI0N of the oral mucosageieralized pain in the gingiva and oral mucous membranes, inflammation,

$crlon, and ulcerati0n 0f the gingiva and/0r oral muc0sa, lymphadenopathy, lever, &The cordition is self limiting and conlagious at certain stages. Ireatment:

mtsP0r

|l)n an

ive. Goal is paln reliet t0 facil i taie maintenance 0f nutrit i0n, hydration, and basic oralTreat with gentle debridement and t0pical anesthetic rinses for pain relief. Patient

p0c ing and possible anti virals.fL A 6-year old boy complains his mouth has hurt for 4 days. 3 days belore ihe onset 0fbcal sympt0ms, he had palpable, tender, subnandibular lymFh nodes, and oralHperature 0f 101.2"F. oral exam reveals generalized inllammation 0f lhe attached

and alveolar mucosa. Loose, white debris covers free gingival margins and lillsaer pr0ximal embrasures. oiscrete areas 0l ulcerations wiihin rings 0f intense

-flammati0n

0n the facial muc0sa and palate. Interdental papilla are in tact, and sallvarylovr is hea\ry and viscous. ACUTE HERPETIC GltlG|V0ST0MAI|T|S.

21

I'l0TES PERI|]Dl)NTAL SURGICAT TREATMEl{TS

GI GIVECT0MY -surgicalprocedure t0 tllillilATE P(ISKET DTPTHS (peri0dontitis thatnot rcsp0nd i0 initial treatmeni) hy removing tissue cor0nal t0 lhe pocket base. B(contour) the wounds coronal margin t0 provide the mosl physiological shape a||d mathickness s0 adequate oral hygiene techniques can he perl0rmed.. Indicati0nsr treat pseud0pockets, hereditary gingival enlargement, suprabony

and gingival hyperplasia. Corrects gingival contours for Herediiary Gingiv0fibr0matosisdrug-induced inf lammatory gingival enlargement.

. Contraindications: inlra-b0ny pockets {delecls) and lack 0f attached tissLimitations include c0mpr0mised esthetics with l0nger teeth, lack 0J access to bdefects, and having a broad, open wound post surgically.

. Factors to consider when electing t0 pedom a gingiveclomy rather than a flap,depth (if the pocket base is at the MGJ 0r apical t0 the alveolar crest, d0 not performgingivectomy)i need for access t0 b0nei and amount 0f existing attached gingiva.

GltlGlV0PLASTY surg;cdl procedure l0 RESHAPE the gingiva & papilla todelormities and pr0vide the gilgiva with normal & lunctionall0rm. objective is NoTeiiminate periodontal pockets, but to provide a more physi0logical tissue contour.portions of the gingiva are excised during a gingiv0plasry, RESHAPIil0 is theC0mmonly used t0 c0rrecttissue contou[ from AllUG.

0SIE0P|-ASTY reshaping 0r recontorring alve0lar bone that does nolanachment f0r peri0d0fltalfihers ([0n-supp0rting b0[e) witi0ul removing sulp0alveolar b0ne. Similar t0 a gingiv0plasty since it is [0t directed t0ward elimipocket walls, iut REC0ilT0URltlG & RESHAPIIIG underlying osseous0sse0us reducti0n does not reduce ihe bone that the PDL is attached (supp0rting. l{0n-supporting bone-alveolar b0ne not directed related t0 t00th supp0f (bo

ex0stoses, edentulous ridges, tori, flattened inteFdental contours & ledges). Wallssome 0sse0us deferts may consisl 0f n0n-sulp0ning bone.

{)SIECI|)MY - remoyes osseous defecls 0r inlrahony pockets (pockets helowthe crestbone) by eliminating b0[y pocket walls. REIVoVES SUPPoRTIVE BoNE because eliminatithe pocket is w0rth the price 0fthe loss in attachment apparatus. After removing thepocket walls, some re-contouring is done t0 pr0vide 0ptimal osseous architeciure for0verlying gingival tissues t0 conform t0 and be maintained.. Itaior contraindication 0f rem0ving crestal bone il the rcmoval will weaken

adiacent tooth's hony support.

0SSE|IUS DEFECTS pattern 0l bone losslr0m periodontilis can be horizontal0.

H0RIZ0I{TAL BotlE t()SS the pattern 0f inter-proximal bone loss parallels the cEiadiacent teeth. Usually generalized by involving multiple teeth in a segment.

22

BotlY P0CIGTS the lattern 0f fi|)Rlz0ilTAL h0ne loss and not intra osseous.lf ibers are usually normally arranged, but form at a more apical level, and the

base (e[ithelial attachment) is C0n0 AL t0 the crest oI alveolar bone. Su0rabonvmay be further classified as a,

thgival pocket ("relative 0r "pseud0pocket"fa conditi0n where there is expansion 0fmarginai tissue coronally (not apical m0vement). Pocketing 0ccurs WITH|)UT

lachment loss.od0ntal pocket ("true pocket") a deepened gingival sulcus wherc epithelium

]|dergoes ulceration. CharacterDed by APICAI [,llGRAT|0l{ 0l the epithelial attachmentleyond its physi0logical level which is nornally at or nearthe CEl.

rrdiograph illustrates h0rizontal b0ne loss ln the posteri0r sextant. The crestal borein is horizOntal and parallel t0 CEJ. The bottom 0f p0cket is corcnal t0 the adjacent

r bone. Note the "crateFirke" lnterproximal defect comnon t0 the mandibular arch.

CAI- B(}tlE t0SS - inter proximal h0ne l0ss d0es not larallel the CEJ. hut occurs|S0|-ATED teeth. BoH0r 0 pockF' rs apical t0 the ddjacpnl alveoldr 00re.

f'ltlTES

naI.

l :PocKEriotm

tissuto bo

r l'{0T Ir .Whlurp

dprovlIortirinati

00neJt (bolfalls

l{0TEs PERl0D0llTAt 0SSE0US DEFtGIS (ll{FRAB0tlY P0CKETS) classified bythe numberbony walls remaining that surr0und the t00th. Ihe pocket hase (epithelial attachment)APICAI t0 the crest of hone s0 there is a delecl 0r h0le i! the borc (intra-0sse0us). Fdefect t0 have a bony wall, it m ust be intra osseous (i.e. partially or comp letely within a lveobone; i.e. ramps, tiemiseptums, interdentalcraiers, intrabonydefects, & moat defects). Ibony pockets are associated with VERTICAI (AtltUtAR) Bl)ilE [0SS tharholevdelecls within the bone, and are classilied as follows:

1. l-vJall delects: Hemiseptum 0nly the proximal wall is present. Raml-only a facialor l ingualwall is present.

2. 2-wall defects: inleFdental crater.3. 3-wall defects: an intrabony pocket; offers the best 0pponunity fo. Done graft

c0ntainment and periodontal rcgenerati0n procedures.4. 4-wall defects: circumferential 0. m0al defecls. t0ur-walled moat defects also

the best opportuniiyJor bone graft c0ntainment and peri0dontal regenerati0nprocedures.

5. zero-wall defecls: alyeolar dehiscences & lenestntions. D0 not treat with0sse0us surgery.

FRAB0ilY 0EFECTyP0CTGTS ARt C0llTRAlllDlCAI|0l{S tl)R ilUC0GllllGVAt SWith infrabony p0ckets, interproximally the transseptal fibers run in an angular directionhorizontally. Transseptal fibers extend in a sloping configurati0n fr0m the cementum below0ocket base alongthe bone and down 0ver the crest of bonei0the cementum of the adjacert

0SSE0US CRATERS -concavities in the crest 0f inteFdental bone c0nfined wilhin faciallingualwalls. Craters compise l/3 (35.2%) 0f alldefects, (02%) 0l allmandibulardt{0RE C0t{il01.| in posteri0r segne s, and are best treated with 0SSt0tS(recontouring).

Periodontalosseous defects are classified bythe number 0f osseous walls present/remaininat the time 0f their surgical exposure, and may have l, 2, 3, or 4 walls. When evahating a0sse0us defect, the |)tltY WAY T0 DETERIilIilE the numher d nE Allllllt ossGoussurrounding the t00th is by EXPL0RAT0RY SURGERY. Radi0graphs D0 tl|)TSE|)Wlie nu0l walls left surr0undiu the t00th, the exact c0nligurati0n 0f the defect 0r l0cationepithelialattachmeflt because a dense buccdl and/f i l ingual plale 0[bone masks lheand blocks it on the radiographs.

24

[g is M0ST successlul with a 3-Walled Delect. Success of periodontal bonen es directly vllth lhe number of bony walls oJ the defect (vasculaized, 0sseousarca), and inveqely wilh the sudace area 0f the r00t against which the graft is

alve . A narrow 3-walled inlrabony defectyields the greatest success, then a 2-wailedt . l then a I walled defect (infra bony defecyhemiseptal defect = least successful).ctea lldefects 0ccur mainly in the ltlTERDEtlTAt REGl0tl. Success is bestwith a 3-walled

pocket and IEAST successful with a thr0ugh-&-thr0ugh furcation defect 0n am0rar.

RESoRPTl0tl ihe m0st c0mmon side effect 0l an aut0gen0us hone graft ining an inlrabony pocket and often extends into dentin and pulp. 0ther postoperatives that sonetimes 0ccur atter 0sseous kansplants: infection, graft exloliation,and sometimes prolo0ged healing rates, and rapid defect recurrence.

TISSUE REGEllERAT|0ll (GTR) placing n0n resorbable barriers or res0rbablenes & physical barriers (bovine, calcium sullateJ 0ver a bony defect. GIR Bt|lCKS re-ion 0l the r00t surlace by long lt & gingival C.T t0 allow PDt and bone cells t0 .e-

the periodontal delect (this techrique assumes only PDL cells can regenerate theattachment a00aratus). 0TR Indicali0ns:patient exhibits exemplary plaque control both before and after regenerative therapy.patient does not smoke-there is occlusal stability o{the teeth at the regenerative site.osseous delects are VtRTlCAt. The m0re walls 0f bone remaining, the greaterregenefattve success.

Gll{GlVAt GRAFT an aliogenous graft 0f gingiva placed on a viable C.l bed wherebuccal 0r labial muc0sa were present. The d0n0r site from where the graft is taken

edenlulous region 0r palatal area. The graft epithelium degenerates alter it is placed,sloughs. Epithelium is reconstructed in I week by the adjacent epithelium and

ion 0f suruiving donor basal cells. In 2 weeks, trssue reforms, but maturation is notunti l 1016 weels. Haaling t i e reqLired is proporional lo .he grdtl) .hichnp ..

RGERY gealesl .mounl o[ \ l i rhage occu s lai l ' ]rn lhF ft- | 6 weaks.

natnlntGG retains ll()llE 0l its own hl00d supply and is totally dependent on the bed 0lEcipient b,ood vessels. FGG rcceives its nulrients from the viable t.l hed. Alnason a FGt fails is disrupti0n 0l the vascular supply hefore engraftnent. Inlecti0n isae 2'd most common reason 0f FG0lailure.

tings wal

umDerment)|s). For

lacial

att

Don n

IU

nTrc

,ow t lEmoves a secti0n 0lattached gingiva lron anotherarea ofthe mouth (hard palate ordtooth region) and sulures itt0 the recipientsite. FGG success depends 0n the graft

immobilired atthe recipient site. FGG is used t0 increasethe zone 0l attached gingivapssibility 0f gaining r00l coverage during recessi0n. The difliculry in getting c0mpletecoverage lies in ihe factthat an avascular graft is placed 0ver a r00t surface also devoid

supply.

lacial tlelectsln0tRl

tron hdications:tDyent further recession and successlully increase the width 0f attached gingiva.Co/er non-path0l0gic dehiscences &lenestrations.terlormed with a lrenectony t0 prevent reformation of h gh frenal attachments.tover a r00t surlace with a narow denudation. FGG may or may not yield a successfulEsult when used to obtain r00t coverage (FGG result is not highly predictahle in r00tarYerage cases).

| 0eTec:

25

N{lTES . Used t0 widen attached gingiva afler recession occurs, and pr0phylacticallyrecession where the band 0J attached gingiva is na(0w and thin.

. C0rrect localized naff0wrecessions 0rclefts. hntill]T oEEPWIDE RECESSI0ilS.lncases, the laterallyrepositioned flap (pedicle grrft) is more predictabe. FGG is rarelyon lacial 0r lingual surfaces 0l mandihular 3'd m0la$ (especially facial).

nockets, regr0w alveolar h0rc, maintain biological vridth, and eslablish adequatetissue contours.

FGG HtAtlN0 involves grall revascularization. Grdfl's l0p layers dre re-vasculdri/ed IThus, the epithelium dies olf (degenerates), producing the necrotic slough. During healepithelium 0f FGG degenerates (necrotic sl0ugh), and re epithelizati0n occurs by proli0f epithelial cells from adjacenttissue and surviving basal cells 0fthe graft tissue.

FREE MUC0SAL AUToGRAFT ditfers from a FGG in that the trans0lant is C.l withoulepithelial covering.. Epithelial differcntiation is induced by the underlying C.l s0 that free grafts 0f dense

taken from keratinized arcas result in formaiion 0f keratinized tissue eventransplanted t0 non-keratinized zones. Fl\44 is more ditficultthan FGG, and is often usedCAlllllES where little keratinized giryiva efists t0 create a band 0fgingiva-like

PERl0D0l{TAl, FIAP a segment 0f marginal periodonta I tissue that is surgically scoronally from its underlying support and blood supply, and attached apically by a pediclesupporting vascular C.l FIIPS ARE l0ST Cl|ilil0t{ 0l all period0ntal surgicaltechl|iFlaps sh0uld be uniformly thin and Fliable, the flap base must be unilormly thinihick), and allllap coners are R0lJNDEll.. PR|I{ARY 0B.IECTIVE 0f FIIP SURGERY in treating periodontal disease is t0

access t0 r00t sqrlaces l0r debridement. Common goal 0l all flap procedures isPR0VlDt ACCESS for instrumentation and allow the clinician t0 visualize the r00tscalculus can be removed more comDletely.

. Surgical flap G0als lo treat Periodoltal disease reduce 0r eliminale pe

4 Rules of tlap 0esign:1. Flap base is WIDER lhan the free margin to allow sufficient bl00d circulation to i

flap's free margin.Incision must not be placed over any defect in bone to prevenl delayed healing.Incisions that traverse a bonv eminence (carine) arc av0ided because mucosabony eninences is thin and healing is slow, and may result in scarformation. Incisimade in tissues that harbor uncontrolled inlection may cause rapid i[fectionspread. M0si periodontal surgical procedures are performed 0nly after anti-infectivetherapy is conplete.

4. Flap corrcrs are r0unded, as sharp p0ints delay healing.

Deep peri0d0ntal p0ckets are often treated by llap surgery. These cases often resultreduced pockei depth byformation 0f a l0ngJE (soft tissue reattachmeni), even ifthere ischange in the p0sition 0f the gingival margins. The best indicator 0f periodofialsuccess is p0stoperative maintenance and patient plaque control.

2.3.

26

ICKNESS MUC0PERI0STEAI FIAPS refiects ALL 0f sott tiss ue and periosteumt0underlying bone. Used where attached gingiva is T (< 2mm wide). Apically &

p0sitioned flaps are fullthickness flapsWidman Flap ( WF)-a full-thlckness flap used in 0pen flap debridement and

rative periodontal procedures, and is a nainstay ol periodontal surgery 0n singleteeth and on flap surfaces 01 molars atfected by moderate pockets and infrabonyobleclive is t0 gain access t0 underlying hone & r00t surfaces, reduced pocket

by establishing a new attachmenl at a more cor0nal leyel, preserye an adequateof attached gingiya, and t0 pr0vide an environment l0r healing by primary cl0sure.

Sications: pocket bases located c0r0nalt0 the ltlcj, areas 0f little 0r n0thickening 0ftarginal bone, reduce shallowt0 m0derate pocket depths, and when estheiics is imp0rtantlanterior region).

ositi0ned Flaps: include replaced flaps, lVWl and exc;sional new attachmentFcedures. These heal by repair (by a l0ng JE and C.l adhesion 0r attachment), and areF[et reduciion pr0cedures. Pocket reduction is achieved mainly by gains jn clinical.tachment mediated by repart

FUIPS.Pedical Flap (Laterally Positioned tlapfa positi0ned full-thickness flap t0 correctrhfecis in morphology, position, or amount 0f attached gingiva. tisually a ful -thickness flap attached ai its base with its free end adjacentt0 the delect (recipientsite). The defect is covered by stretching the flap laterally until the lree end covers tt.. Indicatiofls, areas where narrowgingiyal recessi0n is adjacentio a wide band of

attached gingiva that can be used as the d0nor site. C0rrects 0r prevenls recessionby providing root coverage, creating a wider band 0f gingiva, and in the absence 0frecession t0 widen the zone 0l gingiya.

. Positioned & Repositioned tlaps are really pedicle flaps physically attached attheirapical base by a pedicle 0f l ining muc0sa and an intact bl00d supply.

. lm porlant lactors t0 evaluate before perfoming a laterally p0sitioned llap,presence 0f bone on the facialsurface 0fthe d0nort00th, gingiva thickness, andwidth 0f attached gingiva at the donorsite.

l0ically Positioned Flap a lull-thickness, mucoperi0steal llap with a high degree 0fFedictability that is the "w0rk horse" 0f periodontal surgery/iherapy. 0hiectiye is t0$rgically EUll|I ATE deep pockets by p0sitioning the llap apically while retainingCtached gingiva. l\4ost c0mm0nly used in conjuncti0n with osseous surgery as surgicalaccess is 0btained for osseous surgery, treatmeni 0f infrabony (intrabony) pockets, andrut planing.. Indications: moderate 0r deep pockets, furcati0n- nvolved teeth, and

crown lengthening.. Contraindicationsr patients at riskfor root caries, as excesslve r00t surfaces are 0ften

exposed AFIER performing an apically p0sltioned flap, and where tooth exposure w0!ldbe unesthetic.

. In the coulse 0fflap surgery, after galning access t0 underlyrng osseous tissue andperl0rmingthe requlred therapy, the apically positioned flap is sutured t0 a place ata more alical level, exp0sing the alyeolar margin. When this is d0ne, additionalattached gingiva grarulates from the PDL and covers the barely exp0sed bone. Thisadditional tissue joins the apically positioned attached gingiva t0 form a broaderzone of gingiva.

Cxonally P0siti0ned Flap-a fullthickness muc0peri0stealflap alm0st exclusiyelyteed t0 restore gingival [eight and zone 0f attached gingiva 0ver lS0I,ITED AREASa gingival recession.

l't0T€s

0sedtrssue

epatae0lc einiquh (2m

ense c

. ln sely u

)n

I cov

ES tS

ro0ts

iodoEte

lncisitl

lective

27

t{0TEs There is n0 necr0iic slough 0l Dositioned flaps iecause p0sitioned flaps carryyascular supply with lhem. In a FGG, healing inv0lves revascularization oi the graft.grafts top layers are revascularized last. Thus, the epithelium dies offproducing the necroiic slough.

PARTIAI-THlCl0lESS PER|0D(ltlTAL FIAP incises 0NLYthe mucosa epithelium and I0f underlying C.l Mucosa is separated from the peri0sieum by sharp dissectiofl. Alveborc is not e40sed. Used t0 prcpare rccipient sites lu lrce gi0gival gatts,Qt whdehiscence or fenestration is present 0n a promineni r00t. Used when attached gingivalillcfi (> zmm).

R0otAmputati0n & Hemisecti0n lilllsT be done in c0njunclionwith RCTola padicularEndod0ntic therapy is perlorned first, then peri0dontal therapy:

R00T AMPUTAIIoI{S selaration 0f an individual root lrom the crown. lllostamputations iny0lve llAXlu.ARY 1d & 2d oL,[RS. Burs and diamond stones severthe cand root bef0re extracting by r0ot tip f0rceps. After ihe r00t amputrti0n is complete,remaining apical area of the crcwn and furcation regi0n are re-c0ntoured t0 the shapepontic s0 maximal access for oral hygiene is pr0vided.

llEMlSECTlotl vedical sectioning 0f the tooth through the cr0wn & r00t. Usednandibular molar region werethe crown is divided through the biJurcati0n region.50% 0ft00th is extracted if one specific r00t has excessive l0ss i[ osseous suppoll, andremaining half 0fthe molart00th is nowtreated as a PREI 0UR.

DISTAI WtDGt FIAP (PR0Xll{At WED6E) the simplest distaltlap pr0cedure usedRETR0I{0LlR reduction. 0tten perf0rmed after 3'd molar extractions because the b0ne filluslally p0or, leaving a periodontal defect. This region ;s occupied by glandular and aditissue c0vered by unattached, n0n-leratinized muc0sa.0nly if sufficientspace exists dithe last molar, a band of attached gingiva may be present (in this case, as distaloperation can be performed).. Distal wedge flaps are perf0rmed in lhese areas: maxillary tuber0sity

mandibxlar relromolar triangle area, & distalt0 the last tooth in the arch, 0r mesiala t00lh lhat approximales an edentul0us area.

. l l lake at least 2 incisions distal0r mesialt0thet00th, and carrythese incisions parallelthe 0uter gingivalwallt0 form a wedge (the wedge base is the [eriosleum ove.lyinghone, and aper isthe coronal gingival surface). Detachingthe wedgefrom the peribase and elininating involved tissues in the distal pocket region reduces tissue bulk,allows access to underlying bone.

0SSE0US REC0I{T0URlllG SIIRGERY-main goalis to EtlillilATE PER|0D0ilTAt P0Fxisting b0ny topography is changed t0 eliminate periodontal pockets. This su.gery doescure periodontaldisease, but givesthe patieni accessto maintain theirown periodontiumdentition with routine oral hygiene pr0cedures.. Bef0re using osseous resecti0n 0r recontouring t0 treat an infrab0ny defect, c0nsiderth

treatment alternatives: maintenance with periodic SRe i0ne gratts, reattacfimentprocedures, hemisecti0n 0r r00t amputati0n-

. 0sse0us resection surgery should l{0I be done until etiologic lact0rs thal causedosseous delects are arrested. Clinicallv detectable inflammation must be eliminated

28

SRP and hythe patients abilityt0 maintain optimal plaque control

USAT TRAUMA

TRAUMA inj!ryfrom occlusalf0rce (functi0nal0r p a r a J u n c t io n a lf 0 r c e s )c a ! s in gdanges (trauma) within the attachment apparatus. There js trauma because theforce exerted exceeds the peri0dontium\ adaptive ard reparative capabillties. ta,an intact peri\dontiun ot pe odqntiun rcduced hy inflannatory disease.

?rimary 0cclusalTrauma excessive occlusalf0rces are applied i0 ieeth with normalng structures (n0 periodontal disease). Pathol0gic occlusallorces are the

Fmary etiol0gy for periodoniium changes. Usually reversible when the excessivelces are contr0lled. An early eflect 0f primary occlusal trauma is HEM0RRHAGE &flRl)itB0srs 0F PDr Br00D vEssEr-s.Sccondary 0cclusal lrauma-0ccurs when the peri0d0ntium is already c0mpr0mised

anllammation and b0ne l0ss. Injury resulting in tissue changes from normal 0r@essive occlusal forces applied t0 tooth/teeth with rcduced support. occurs in theIesence 0f bone loss, attachment l0ss, and n0rmal 0r excessive occlusal forces.Consequently, occlusallorces that may 0lherwise be wellt0lerated in a healthyFriodontium have deleterious effects due t0 p.e-e{sting periodontal disease.ft€th with a reduced adapiive capaclry and compromised penodontium may thenrigrate when subjected t0 certain occlusal forces. Factors llke Jrequency, duration, andtrlociry of occlusal forces, may be more important factors in causing t00th hyper-robility (common clinical sign 0f occlusa I tra uma).

n sign 0l 0cclusal trarma is T0lllH ill)BlUTY. othersigns. migration 0f teeth &t0 percussr0n-

lC SlGl{S 0F 0CCtUSAt TRAUMA widened PDI sDace. lanina durag/disruption, angular (veirical) bone loss, inffa b0ny pocket formation, root

& hypercement0sis, radi0lucencies in the furcation 0r apex 0f a vital t00th,

SlGtlS 0t 0CCLUSAL TRAUMA mObilih, lremitus, occiusal Drematurities. weartooth migration, fractured tooih/teeth, thermal sensitivity. These features may be

- other conditions, s0 always use other diagr0stic criteria like EPT 0r evaluateional habits t0 attain a definitive diagnosis.mobil i ty, loolh mig'ai 0r , l00l"r pd 10n c\Fw rg or perru5sion.

ss 0f mucles 0f masticaiion and/or TiVl dysfuncti0n.facets beyond the n0r'ial level rclative t0 the patient's age ard diet. Chipped enamel

atown/root lractures-

lt0TEs

distal

!sedre fi l lta0rp

€ral l€llyrng

tct€00es II |um a

pflost

bull. a

oerInent-

used

I tUS.

trauma is reversible, as bodycan repairthe damage ijexcessive occlusalforces are. 0cclusal tnuma does not cause perjod0ntal pockels. A local irritant andion are necessary t0 cause an aplcal shift 0f the JE (attachment loss).

ngs ass0ciated with |]cclusalTramua, alternating areas 0f res0rption and repairr bone, fibrosis 0f alveolar bone marnw spaces, cemental resofption leading to

inated

resorption, cemental tears, ankylosis, occasional pulpal necrcsis and calcif icati0n

29

l'l0TES 0CCLUSAI IRAUMA TREATi|ENT usually addressed during initjat therapy (except aconditi0ns) t0 eljminate 0r minimize excessive f0rce 0r stress 0n the t00ih (teeth). Treatmfor a patient with Chronic Periodontitis with occlusal traumatism may include:. 0cclusal adjustment and/or management 0f parfunctional habits.. Temp0rary 0r long term stabilization 0f m0bile teeth with a RPD 0r FPD.. 0rthodontic movement, occlusal reconskuction, or extracti0n.

lf there are n0 clinical signs 0r symptoms, pr0piylactic 0cclusal adiuslnent t0 0btain"ideal" occlusion provides no benelit, thus is c0ntraindicated. 0cclusal relationshipsbe evaluated as Dart 0f oeriodontal maintenance.

SPLll{Tll{G the primary reason lor splinting teeth is io ttrtil0BlLlzE ercessivelyteelh for patient comfort. Temporary stabilization is achieved by splinting one 0r moreteeth t0each otherandt0 more stable teeth in a positi0n that facilitates a moreAXlAtanddistfibution 0t 0ccfusaf torces (geneally pertuned on teeth ytitlt teduced rctil$rpporo. Rationalfor splinting is impr0ved paiient c0mfort, function and plaque c0ntr0l,distdbution 0f occlusal forces, and improved to0th staiility during clinical procedures.. Ihere is n0 reason t0 sFlilt non-m0bile teeth as a preventive meas0rc. Splinting is

one type 0f measure used t0 treat periodontal disease, and sh0uld be used withneeded measures like r00t planning, 0Hl, pocket elimination, and occlusal adjustment.

. L00se teeth splinted t0 adjacent tecth may hec0me stabilized. When many teethl00se, adjaceni sextants sh0uld be included in the s0lint. Teeth tend t0 loosen B-1.may remain firm l!l-D. Even when teeth d0 n0t tighten, the splint serves as an 0rth00bracethat permits usefulfunction t0 loose teeth.

Reasons t0 Perl0rm Selective Grinding in the llatural 0entition:1. Achieve a morc fav0rable directi0n and disiribution 0f f0rces.2. C00rdinate the median occlusal p0sition with the terminal hinge position 0f

the mandible.Eliminate pre-maturities in excursive m0vements t0 gain gr0up function 0r canineprotected occlusion.Direct occlusal forces centrally rl0ng the long axis 0f the t00th.lmprove 0r maintain masticatoty perfo.mance.Accomplish 0cclusal adjustmeni without reducing VDo and by retaining an acceinter occlusal distance.Reduce or elimirate fremitus.

3.

4.5.6.

1.

C0nlraindicalions t0 Selective Grinding the llatural Dentiti0n:. targe pulp chambers ort00th sensitivi8. ll4aj0r 0cclusal discrepancies that may require odh0d0ntics 0r reconstructi0n.. P00rcandidates forfull mouth reconstruction duet0 psych0logic factors.

STEPS I0 ADIUST |}CC rSl0l{ eliminate [rematuritiesprotrusive movements, and lateral excursive n0vements. Then0cclusal anatomy and carefully polish allground surfaces.

in centric relation {CR),re establish the physi

30

- an aggressive, repetitive, 0f continu0us grinding, grittiflg, 0r clenching 0f thepping/hollowed out areas 0n the 0cclusaltable olthe mostterminall00th)during

and/or night in other than functi0nal activities (chewing 0r swallowing). 0cclusalities, muscle tension, and emotional lactors are causes.& sympt0ms: P0Lwidening & thickening 0f lamina dura, sore muscles and jaw pain,

dysfunction and dlfliculry 0pening the mouth, increased tooth rnobility (especially inrnorning), occlusal wear facets.

ive forces pr0duced by iruxism can cause increased t00th mohility.: behavioral, emotional, & interceptive modalities

l|(]TES

rtain ahrps m

ng s0th ot

tlDllNIAL TREATMENI PTANNING

NARY PHASE treats E[4ERGENCIES 0NLY (pulpal, peri0d0nta l, 0r 0th er efl]ergency).Plase | (lnitial Therapy)-plaque c0ntrol, extracl hopeless leeth, molth lreparali0n(i0itial full-m0uth scaling, & definitive r00t-planing). Als0 includes:

Iment.t€ethI B-l-,rthoped

. 0Hl is the most important part 0f initialtherapy. flygienist 0r defltistteaches,m0tivates, and guides the patient in the performance 0f measures for disease conkol.Paiient is shown proper brushing/flossing technlques, and these techniques arerepeated t0 see ifthey undentand what you are sh0wing them. l loralhygiene is p00r,surgery is C0 lRAlill)lCATED.

. l)cclusa I adiustmenls, night guards (if bruxism exists), spli0ting(stabil izing loose teeth).

. Re-examination that involves chart ng probing depths.Phase ll {Periodontal Surgery)Phase lll (Restorative Phase)Phase lV (llaintenance Phase)-started after c0mpleting active peri0dontal therapyand conlinues at varying intervals for the lile 0l lhe dentili0n 0r implant. Anextension 0f active periodontal therapy superulsed by the dentist. The phase whereperiodontal diseases and conditions are m0nitored and etiologic factors are reduced 0reliminated. I{ost patients with a history ol period0ntilis should have maintenanceevery 3 lll()ll]Hs t0 rnaintain and esiablish gingival health. Eased on ihe evaluation olthe clinicalfinding duringthe maintenairce, the frequency may be m0dified 0fthepatient may be returned t0 active treatment.

3l

il(lTES MtscEu.At{E0usAIVE0LAR PRl)CESS -the part 0f the naxilla & mandible that HoUsEs IEETH.

Peri0dontal ligament (PDL) a Lomplex. specidli/ed. soft, librous C.T.;onbining cvessels. neryes. & extra-cellular suhstances. HIGHIY VASCUIIR & CEttULAR C.fsurrounds teeth r00ts, c0nnecting r00t cemertum with alveolar booe. ilost abundantcells are FIBR0BLASIS.. 0rthodontic treatment is possible asthe PoL c0nlinu0usly responds al|d charges

0n lunctional requirements imposed 0n il by externally applied f0rces. Pl)fsthickness in an adult is .25mm

. Age (PDL gets thinner with age) due t0 incrcased deposit 0f cenentum andComp0sed primarily 0l Type I C0tLAGEll tlBIRS

. Princilal FibeG-PDL collagen fibers include, alveolar c.est fibers, horiz0ntal, 0bliapical, & interfadicular fibers. C0il ECT R00T CEtlEllTUl{ T0 [wE0LlR BDistinguished by iheir l0cation and directi0n- Sharpey's Fibers-terminal portions 0fPDI principal collagen fihers embedded into cementum & alveolar b0ne. DiameterSharpey's fibers is much greater 0n thc B0llE SIDE than cementum side.

lE specialized epithelium surrounding each i00th that begins at the sulcus base. A coll ike band 0f strati l ied squamous epiihelium lirmly altached l0 the t00thHEM|0ESM0S0ii|ES. 10-20 cell layers thick. In IDEAI GlilGlVAL HEALTfi, the lt isEilTlRttY 0il tilAlilEL ah0ve the CEJ.

ULTRAS0I{IC SCAtltlG oEVICES based 0n HlSH-FRE0UtilcY Sl)U D WAVTS & inlavage, vibration, & cavitation. Removes supragingival and subginval calculus, indebridement 0{ an ANUG patient, gross scaling priort0 extractions, and mmoves orthodcement, bonding material, and overhanging restorati0ns. llever t0uch the tip 0tultras0nic 0n the t00th, rse 0nly the sides. Ullmsolic instruments ARE IJSED l0r scclreiting, and removing stains.. Contraindications: cardiac pace rnal(ers unless the pacemaker is shielded (n

models). tirst consult with patients cadiol0gist.

SCALII{G & R00I PLAlllllG - removes calculus. bacteria. & endotoins. When exteSRP must be performed, the best approach is to schedule a SERIES 0l aFpointments t0a segment 0r quadrant 0f teeth at a time. D0 ll0l d0 gross debddement (subgisupragingival) 0fihe entire m0uth, then schedule a se,ies 0l appointments l0r lineand polishing.. Re-evaluation aller SRP is 4-6 weekst0 allow time for repair 0l the dentogingival lunct. lllAlil |)BJECTM 0F R00T Pu lilG: provide optimally smoolh r00t surlaces t0 red

bacte al accumulation t0 achieve soft tissue reattachment.. BESI CLlillcALAlD t0 determine if sub-gingival calculus is removed is an

BITI-WIilGS to sh0w inter proximal calculus.

AVEnAGI TI E for this entire calculus tormaii0n orocess l0 occur is 1 2 days.Slpragingival Calculus-main s0urce 0f its minerals is lrom SALIVA. occurs AB0VEfree gingival margin and is white 0r pale yellow, and easily ren0ved by prophyl0ccurs mosl0ften 0n the lingual 0I mandibular incisors and buccal 0l malillarydue to the salivary ducts that secrele saliva rich in minerals needed for its formation.Sllgingival Calculus-darker due t0 bl00d breakd0wn pigments, harder, & morethan supragingivalcalculus. lts source 0f minerals is fr0m GREVICUIIR FLUID.the lree gingival margin. lvore difficult t0 remove than supragingival calculus, andusually evenly distributed thr0ughout the m00th.

Al0S ll0Tlllllc REPIICES BRUSHIIIG & Ft0SSlilG t0 disru0t and removePatient can also use a perio aid (round p0lished toothpick, g00d for furcati0ns and

I margins), Stim-U-Dent (wood wedges)forgingival massage and inter-dental ecess1on.h for wide embrasure spaces. Interdental stimulaior- rubbertip attached to a handle

0f a toothbrush that massages and stimulates circulation 0fthe interdental gingivaIng cec.t 0tl BEI{EFIIS reduces gingivitis, reduces/alters microbial flora, subgingivaldant P (penetrates below the ginglval margin), and deiivers antimicrobial agents. Fluoride,

cs, & chlorhexidine eflectively inhibil microbial plaque.les ba gation does not remove acquired t00th pellicle and cannot rcmoveave hner lhar l0ollbrLshe\. l l removes non-adherent bacteria lrom

tno D!!pragingival sites.tal irdgation devices are C0ilTRAIIIDICATED tll PAilEllTS WITH PERll)00llTAtf,fuil All0t{. Water ifligation devrces may be c0ntra]rdicated in patients requiringtrtihiotic premedicati0n prioft0 dentaltreatment sincethese devices have the p0tefltialtr causing a bacteremia.

, obl iqu

ameter BRUSlllllG METH0!S the effectiveness 0f toothbrushins is BEST measured bv theand location 0l plaque. The manual toothbrush should have S0FT, ilY[0il hristles

a small head.lass ileth0d ("Sulcular Technique")-t00thbrush bristles arc placed 45' t0 the t00thltrlace atthe gingival margin t0 try and get the bristles intothe gingivalsulcus. The brushb then moved ln a back-andjodh motion tor -20 stokes. Thls is currently lhe prelerredrethod 0f manual toothhrushing. Ihe most efleclive l0othhrushing technique.

& invol

}t0Trs

adherent plaquesubgingival &

IR B())ns 0f

rAcoltooth

us, Inlrthodoipol tr scalin

e{ in

I extensldstoS€ingiYalhe scali

have > g0% success rate for both maJdllary& rnandihular implants. lmplants withsudaces 0ffer advantages than sn00th surface implants, and implants placed in the

dlble have higher success rates than in the maxil la.

ARE ll0 ABS0IUTE lilEDlCAt C0llTRAlllDlCAT|0lls tl)R PIAClilG IMPLIilTS.Ihere areABl)VE e" c0ntraindicati0ns: unc0ntolled diabetes, ac0h0lisn, hea\ry smoking, p0st-)r0pnyrax ated jaws, p00r oral hygiene. However, /at etts with a strung susceptihilit! t0ary m0 is CAfl RE SUCCESSFAIU TREAIED WITH IMPU|IIS

i to redu

pr-0RtR

'matr0n.n0re den is NoT ar important factor ihat affects implant survival, but implants placed after ageIID. BET

PI-ANTS

IEGRATI0t{ - direct bi0chemical b0nd 0f b0ne t0 the implant surface at the electronlevel. Independent o1 any mechanical interlocking.

lMPLAl{I SYSTEMS - subDeriosteal. transosteal. & Eil00SSE0US (the mostPlacing end0sseous implants is a predictable pr0cedure. Criteria l0r success:

l{0 persistent signs/symptoms 0f pain, infecti0n, neuropathies, paresthesia.Inplant imm0bility and n0 contifu0us peri-implant rad 0 Lrcency.t{egligible progressive b0ne oss (< 0.2'nm annually) after physi0l0gic remodeling durlngthe first year of function.Patienydentlst satisfaction with the implant restofation.

l lus, andin girls and l8y6 in boys have a better prognosis than when placed in younger chlldren.

HBTES 3-D computerized tomograpiy (CI) scans can provide accurate lnf0rmation aboutanatomy (max sinuses, f0ramina, mandibular canal, a d ja c e n t t e e t h / r 0 0 t s ).

Ll)W[n success rates are associated with CAIIGEIL0US B0ilE (20-25% bpne density)with cortical bone (80-90% volume density ol bone). Thus, cortical bone 0rovidesinplant-bone c0ntact and f ixati0n.

PRE-IREATMEI{T Col{SlDERATl|ll{S oral health status, medical/psych0togicalpatient m0tivation and home care ability, patient expectations, and assessingconditi0ns that increase lie risk 0f implant lailure (alcoholism, smo*ing, high ASAhruxisn, periodontal diseas€, and radiatiu theraly).

Surgical c0nsiderations require evaluating the anat0my and locati0n of vital structures,quality, quantity, and contour, and soft tissues. Diagn0stic aids used in pre-suconsiderations t0 determine the number, locati0n, type, and aogulation 0f the implantsabutments {m0unted 0r unmounted diagnostic casts, CT imaging, surgical temDlate).

Placing implants inv0lves anallzing the number & location 0f missing teeth,distrnce, number, type, & locati0n 0f implants to be placed, existing/prop0sed occlschene, design of the planned restoraiion.

A "staged" approach has been used to place Elllll)SsE|)t S l Pt-AllTS. lmplants can alplaced at the time 0f extracti0n. lvlech anica I fa ilu rcs 0fthe implant comp0nents and prosuperstructures have been ass0ciated witl'r 0CCIUSAL 0VERI0AD. The desired outcomimplanttherapy is maintenalce 0f a stahle, fu0cti0nal, edhetic t00th reDlacenent.

lilPtAl{T C0MPtlCATl0tlS prosthesis instability, fixture mobility, occlusalfractured/loose conponents, inflammation/infection, excessive progressive l0ss 0f hatissues, pain, neuropathy/paresthesia.

Al)DlTl0tlAt I{EGATIVE 0UTC0 ES - implant mobility 0r loss, peristent paifuncti0n, progressive bone loss, persistent peri-implant radi0lucency and uninflammati0n/inlection, implant lracture, increased pr0bing depths.

34

CHAPTER 2

I stat!abtut sco

rDs, bo-surgirants ab).

I also[0stn(bomed.

traunhard/s

rut0ss!ni.ol

f$il$It1$$$ltll$$

t{0TEs REMI}VABLE PARTIAL DENTURES

lGl{llEDY CLASSlFlCATl()llS based 0n the l,l0ST P0STERI0R EDEilTUI0US AREA toresiored. Although Class lll & lV RPDS are entirely supported by abutmentleeth, Class IRPDS are supported by atutmentteeth, the residualridges, subjacefit tissues, and liiC.L overlying the alveolar pr0cess. Alveolar ridge resorption underthe distal exters:0nis a concern, but is rcduced by maximizing c0verage 0f these supporting areas. Peri0ddamage t0 abutment teeth is avoided with firm tissue support (maintaining a stabletissue relationshiD).

l. Class l: bilateraledentulous areas posteri0rt0the naturalteeth. BlLAItRAtDrsrar ExTEilst0lt.

2. Class ll:u n ila t e r a Ie d e n t u l0 u s area p0sterior t0 remaining naturalteeth-DrsTAr" EXTE St0lt..lGnnedy Class | & ll, must haye a ilESIAL REST 0n the abutment next t0 the

Dosterior edentxlous space.3. Class lll: unilateral edentul0us arca with naturalteeth both anterior and oosterior

it. A tooth-borne RPI t€cause il depends entitely 0n ahutnenl leeth for suD[04. Class lV: a single, but bilateral (it must cross the midline), edentulous area

the remaining naturalteeth. Anterio. teeth are missing and across the midlin€.ll0T HAVE ltl||olFlCATl|)ll SPACES. Ato0lh-bome RPD type because it dependsentirdy 0n abutment teeth l0r supp0d.. |)cclusal REsTs aRr PUGED 0[ ]fit DlslAt 0f THt flRsT PREil0lIRs!

Applegate's Rules l0r lpplyiu the lGnnedy Classification:I . Rule I : classification is done AFTrR extmcti0ns are d0ne.2. Rule 2: il a 3'd molar is m issing and will not be replaced, it\ NoT pa rt 0f the

classification.R0le 3: il a 3'd m0lar is present and not used as an abutment, it's NoT part 0ftheclassification.Rule 4: if a 2"d molar is missing and will not be replaced, it\ not c0nsidered in theclassification.

5. Rnle 5: l{ost p0sterior area always determines lh€ classification-6. Rule 6: edentulous areas otherthen those determinins the classification are

"modifications".Rule 7: the exlent 0fthe modification is not considered, 0nlythe nurnber 0f additi0edentulous areas.Rule 8: ll0 modification areas in a lGrnedy Class lV.

1.

l{AloR & illl{llR connectors I{USI BE RlSlDt0 evenly distribute lunctional stressesto the RPo throughoutthe mouth.

ilAloR C0t{llECT0RS c0nnects c0mponents between b0th sides 0f the arches. I{c0lneclor must be RIGID s0 stresses applied t0 any area 0f the denture are etfectdistributed overthe entire supporting area.. lllajor con0ector is free 0f movabletissues and does not impinge 0n gingival tissues. Rel

should be provided.. Bony and softtissue prominences are avoided during placement and. Malor c0nnectors most faequenily encounter interferences fr0m

mafldihular orenolars.

36

lirgually inclin

C0l{llECToRS a RIGI0 c0mponent that c0nnectsthe mai0r c0nnector (RPD base)t0components (direct retainers, indirect retainers). Also translers funciional stress t0teeth, and transfers the effects 0f the retainers, rests, and stabilizing components

ast 0f the denture ("abutment-to-prosthesis" functi0n)thick, preserves tissue idoes not impinge marginal gingiva) and is highiy polished.

um gingival exposure = joins at right angle.0f 5mm space between vertical components.

OIBUTAR RPD MAJOR CllNI{ECTllRS

coss-section l0rm is HAIF-PEAR SHAPED l0cated above moving tissues but as fartie gingival margins as possible. To determine which mandibular maj0r connector t0

sure fron the height 0f ihe fl00rt0 the lingual gingival margins.

UilGlJAl- BAR: superior border must be at least 4mn helow the gingiyal margins(tooth-tissue lunclion) t0 prevent plaque collecti0n and margin infLammati0n. Therenust be at least 7mn 0l space/clearance beiween the gingival margin and m0uthfl0or HAtF-PEAR SHAPTD in cross-section.. Indication: Used when sufficient space exists between the slightly elevated alveolar

l ingual sulcus and lingual gingivaltissues. frlust be a minimum 0l7mm verticalheight between the gingival margin and mouth ll00r (inlerior horder 0llhe har).3mm space between superior hofder 0f the bar and gingival margin + the barmusl be 4mm wide = 7mm.

. Contraindication; when severely tlpped prem0lars and m0lars are present, analternate framework 0r crowns are recommended.

l,l0TES

tA toassl&dt ist0nfl0do

ble ba

terior$p0rt

$e

l ine.t0s

37

N(lTES S|JBUllGlJAl BAR: used when there is INSUFFICIENT SPACE for a lingual bar.HAIF-PIAR SHAPEO.. tised when the height 0flhe m0|Ih fl00r is < ommfr0mthe lree gingival

. Bar's sxperior border illlsl be at leasl Smm bel0wthe free gingivalmargin.

. Bar\ inferi0r horder is at the height 0I alveolar lingual sulcus when the Dtongue is slightly elevated.

. Requires a FUilCTl0ilAt lMPRtSSl0il.

. C0ntraindicaii0n: remaining natural anie.iorteeth are severely linguallytilted.

3. c suluM BAR (C0I{I U0US BAR):. l jsed when a l ingual plate 0r sublingual bar is indicated, but the axial alignthe anieriorteeth is such that excessive blockout 0f inteFpr0ximal undercutsis required.

. Contraindicalions: anteriorteeth severelytilted lingually, wide diastemasanterior teeth causing the &etal c;ngulum bart0 be displayed.

. ltt a thin, narr0w (3mm) strap l0cated on the cingula 0f anterio.teeth, scallfollow inter-proximal embrasures with its supeior b0rde6 tapered t0 t00th surfa0riginates bilaterallyfrom rests oi adjacent abutments.

LlllGU0Pt-ATt, lndications:. High fl00r0fthe m0uth (< 7mm vertical height) 0r high lingualfrenum.

over a lingualbarwhen there is ll0 space h lhe floor 0f the mouth.. Iil0PERAB[E ling(al mandibular torithat cannot be rem0ved.. Anticipated l0ss oi one 0r more 0fthe remaining teeth.

orwhen it is desirablet0 keep the free gingival margins 0fthe remaining anteri0rteeth exposed, and there is inadequate depth ol the mouth fl00r t0 place a lingual

. lts bulkiest portion is t0 the lingual and its tapered is toward the labial.

. used in Class I designs where residual ridges have undergone excessiveverticalresorption.

. Used t0 stabilize periodontally weakened teeth {splinting) 0r linguallytiliedmandibular incisors.

38

.ljsed when future replacement of I or more incisors is facilitated by adding retentionloops to an existing l inguoplate

. Used t0 avoid gingival irritation orfood entfapment, 0r t0 cover generously relievedareas that w0uld irritate the tongue.

. Extends t0 the rests 0n ihe terminal abutments, t0 the c0ntacts inter proximally, andc0ve6 anterior cinguli. D0 not use if there are wide 0pen anterior contacts becauseit is un esthetic 0r if anterior overlapping exists

. Superior border is at the middle l/3 0f the teeth's lingual surface and extends upwardto cover inter proxima spaces t0 the contact point.

.llandibular lingualtori require a linguoplate because there is often not 7mm 0fvertical slace for a lingual bar. llssue c0vering the tori is thin and cann0t t0leratevertical oressure from the maior connector. 00 ll0T USE lF SEVERT AllTtRl0RcR0wDNG EXISTS.

I.,IBIAt BAR:. Indications: when severe lingual inclinations of renaining premolars & incisors

cannot he c0rrected orthodontically, preventing placing a lingual bar. Whensevere linguallori cannot be removed and prevent using a Lingual bar 0r plate. Alsoused when severe and abrupt l ingualtissue undercuts prevent uslng a l ingual bafor olate.

. Superi0r b0rder is at least 4mm below the labial and buccal gingival margins.

. Inferi0r border is in the labiallruccalvestibule at iuncti0n ol attached (imm0bile) &unattached (mobile) mucosa.

. UlltESS f0RISURGERY lS ABS0IUTEIY Cl)llTRAltlDICAIED, interlering t0ri areremoved l0 av0id using a labial bar.

. Trauma and congenital deficiencies occasionally produce dental arrangements whereonlv a lablal connect0r is feasible.

|1I}UBI.E LIIIGUAT BAR (WITII CI)IITIIIUl)US BAR);. Placed above the cingula and bel0w inter-proximal contacts.. NEED 7-8rnm above the mouth floor 0r cannot use.. Best indicated l0r PERI0SURGERY CASTS FoR Wl0E EMBRASURES.. lllust have rests on the superiof bar 0n at least the canines.

NOTESE|rglrcn0trgual

agrn.ft ients

gnmenr0ts

2I0pe0r surl

3S

t{0TEs

l .

2.3.

6.1.

AIITERIl)R-Pl)$TNOR PAIITAI- STRAP.. I{AXILUIRY iIAIOR COIIIIECTOR Tt) ATMI)ST ATWAYS USE FOR AI.I. KEIIIIEI)Y CIISSES.

Major c0nnect0r oJ choice for inoperable tori cases where there is 6-8mm r00m t0vibrating l ine.GREATEST SInEilGTH & RlGll)lIY b/c 0f its circular shaDe and b/c its metal straDs lidifferent !lanes.

. Primarily used for a TARGE EDEilTUL0US SPAil l(cnnedy Class lll mod I RPDS withresldual ridges and str0ng abutment teeth (not g00d t0 use when edentulous spacessnall). A better choice than a single palatal strap because it covers less tissuemininal mlatal snrlace area).

. l{ust he at TEAST 15mm tetween the anteriff and posterior straps!

. The anterior and posteri0r straps are 6-8mm wide, and must be 6mm below thegiogival maryin t0 avoid rugae c0verage and tongue interterence. Ante 0r straD is jp0steri0r to a rugae crest 0r in a valley hetween two crests.

. Posterior strap is lhin, at least 8mm wide, and located entirely 0n the hard palright angles t0 the midline (n0t diagonally) t0 protect the I0tlGUt. lt is tltvER pon mobile tissue (soft palate).

. 00 ll0l USE vrhen an inoDerahle palataliorus exteds posteri0rly 0nt0lhe s0ft

MAXI TLARY MAJllR Cl)l{NECT()RS

USI BE nlcl0. Superior b0rder MIIST be at least 6mn belowthe free gingivalmalgins and parallelt0the mean curve 0lthe lree gingival margin. -llse metal plating il < 6mm exists fr0m the gingival margins.Posteri0r border 0f the major connector must cr0ss the palate at RI6HTAilGUSt0 the palate midline and exiend backward PARALLELT0 the residual ridges t0tongue sensitivity.Anterior border 0fthe malor coflnect0r is perpefldicllarl0 the midline and [uin the VALLEY 0F RUEAE.lltVER PIACED AllTERloR to indirect retainers (anlerior palatal coverageis avoided).Exposed borders are headed t0 produce a positive contact with the tissue.It4eial is in intimatetissue contaci.

BEAD Lll{E (BEADED B0RDERS} UsEo olltY 0ll ilAxlLLARY lilAl0R C0llllEcloRs t0the interface 0f ihe maxillary major connectort0 the tissues. lt tapers otf as it approachesmarginal gingiva around the abutment teeth.. Beading is done along the border 0l the mai0r connector t0 seal it t0 the soft

Bead is made by scoring the casi .75-lmm wide and deep. The groove fadesapproaches within 6mm 0f the gingival margins and fades over a hard midline sutu

. Sealis lmm thick (deep)t0 provide P0SIIIVE DE IURE C0ilTAGI wlTH IISSUE t0 pf00d entrrpnent under the maxillary major connect0r and retenlion when placed atposlerior b0rder ofa palatal plate maior conneclo'

40

l)E (U.SHAPE PAI.AIAI. C(]IIIIICTI)N):0ESlRABtt [,lAXlttARY MAI0R C0il ECT|IR because has ihe TEAST slreldh

rigidity.d ody t0 g0 ar0und lll0PERABLE PAIATAI T0Rl 0r with lilfll)R GA0G[RS. Lised only

en large inoperable palrtaltorus prevent using palatal coverage in the posterior area

LES (S KS RlGlDllY (unless it is bulky), can cause lateral flexure 0f abutments, and cant0p pinge tissue during occlusion.

in Class lll mod I designs and/ff when a palatal torus is within 6 8mm 0f thed buri rating line.

uires g00d residual ridges and strong abutments.

WI|)E {iIIl|PATAIAI) STRIP:inly used in GtAss lll designs.

NOTES

width is kept within the b0rders 0f the rests (does extend posterior of anteriorrestsl.

1che51I t0

fties asiuture.

f teftp is l

0pm at l

sEs.MIOI

rPsle

dthECeS

for a I-ARGE-SPAN Class lll mod I when residual ridges are g00d quality, butr abutnent are weak. Provides additional palatal support io the RPD

en ahutmenls arc weakweak abutments in a Ciass lll, m0re palatal support is desired and a wide

latal stfap is preferred.

PI"ATE (COiIPIIIE TI)VENAGT): AKA "MTTAI. PI.ITI"mainly in Class I desigr. IVAIN INDICATI0N: when the last ahutment t00th on either0f a bilateral distal e ersion is a CAt{l t 0r ls PREM0IIR c0mDlete oalatal

ge is advised, especially when the residual ridges have undergone excessiveal resorption.

ed for l0ng span Class I BILATERAT DISTAI EXTEtlSl0tlS with poor residual ridges,d/0r Deriodontally inv0lved weak abutment teeth.

be used in a Class ll vvhere there are missing anteriors with a posteriof modi{icationrs al least 50% olthe hard Falate and .eplicates the anatomy 0l lhe palate.ior border is at the luNCTl0N 0f the hard & soft palate, bui does not extend to the

parale.ld be anteriort0 the p0sterior palatal seal.

lE0 PAtlTAL PLlTE: used for maxillary Class ll designs and may or may not include

|le (us rect rctention is a problem and can interfere with the patient's tongue and taste (s0meients cannot tolerate). lt acts more in I DIRECT RETENTI0 .

Palaten pbr

It Fa

4l

lp lat ing.

l{0TEs l1{lllRECT RETAII{ERS (Rests & Proximal Plates)

lndired netainers:. Are placed as far away from ihe distal extensi0n base as possible to PRwEilT VIRTI

DISLI)DGE EilT 0l the hase lr0m the tissue (i.e. 0pening when eating sticky f00ds).Increases the effectiveress oldirect retainers (clasps) when the RPD triesto disl0dge,prevents the nPD lron r0tating around lhe fulcrum line (axis 0f rotati0n).lR should be 90' (right angles) t0 the {ulcrum line, and is placed in rest seats t0 dlorces along lhe abufireni's long axis.

. Ihe greater the distarce helween the fulcrum li[e and lR, the m0re eflective the

. lR may include, RESTS, PR0XIMAL PIITES, & lillll0R C|)llllECT0nS.

Indirect Relainer Funcli0ns when the denture basetriest0 M0Vt AWAY from the residuall. ilAlil FuilCTloil: Preverts VERTICAL DISLI|I)GEI EII 0l the distal extension base

away lrom tissues (sticfty lood).2. Protects softtissues impingement bythe major connector during d0wnward

(limits m0vement in a cervical/gingival direction).3. Decreases a n t e r 0 - p 0 s t e r i0 r i ilt in g leverages when an is0lated t00th is an abut

(hut avoid this).

FUTCRUM tlllE (AXIS 0F R0TATl0t{) the axis the RPD r0tates ar0und when thebase moves AWAY {r0m the residual ridse.

4. Helps stabilize against h o r iz o n t a ld e n t u r e movement by c0niact ol the minor connwith the axialt00th surfaces (guide planes).

5. Stabilizes against lingual movement 0f anteriorteeth when used.6. May act as an auxillary rcst t0 support part 0lthe major connector7. May providethe first visual indication forthe need to reline a distalextension by

as a reference for seating frameworks and making altered cast jmpressions (i.e.lell you if the rest is notfully seated in ih rest seat).

. Fulcrum line is rnainly determined by the placement (location) 0l prinary rests.Iulcrum passes through the rigid metalaboyethe iooth's height 0t cortourandto the edentulo||s soaee.Fulcrum line isthe center 01rotation as thedistalextension base movestoward su000tissues when an occlusal load is a00lied.Class | & ll always have a lulcrum line!. Class l: fulcrum passes through the most p0slerior ah[tment next t0 the edentspace.. Class ll: lulcrum line is diagonal and passes thr0ugh the most p0sterior abutmentthe distal extension side, and most oosteriort00ih 0n the non-disialextension side.

. Class lll & lV: T00TH-BoRNVSUPPoRTED RPDSthat d0 not m0ve t0ward tissue dufunclion thus (physiologic relief/adjustment is not required). In Class lll & lV drests are placed immediately next t0 the edentulous space.

lfthe framew0rk is properly desjgned, the fulcrum line will pass thr0ugh the mostREST on each side.CLASS lll design does not hav€ a lllcrun line (n0 aris 0f r0tati0n).

42

gass lvr fulcrum line passes thruugh the MESIAI rests nextt0 the edenlulous space.

S -the indirect retainer united wilh lhe major connector by a nin0f connect0r. Restsent mechanical retenti0n. Rests sh0uid restore the originaltooth t0pographythat existedthe rest seat was DreDared. Rests mLst be RlGlD. Rest Functi0ns;

PRIMARY Full0Tloll lS T0 PnoVlDE RPD VERTItAL SUPP0RTI Prevents verticallslodgement.Iaintains com0onents in Dosition.Iaintains established occlusal relationships by preventing settling 0f the denture.kevents soft tissue inpingemeni if a cervical directl0n.Directs and distributes occlusal l0ads (vertical forces) t0 the abutment tooth's long axis.Rests are prepared BEF0RE the final lmpression is i lrade and master cast is poured.IIEI] A MII{II{UII,I OT 3 RESTS Il)R ANY PARTIAI. DEI{TURE.llere [4UST be a MESIAI rest on lhe most posterior abutment l00th with a dista]ertension.

l. 0CCtUSAt REST' prepared only in enamel 0r any restorative material pr0ven to resistlractLre and dr\Lortion l/vher a forLe r\ dDoLred.zmm deep in the center (0.5mm deeper than the l.5mm thatthe marginal ridge

is lowered).. 0UTtlllE F0RM, R0Ull0El) TRIAI{G[E with the aoex toward the center 0f the

occlusalsurface.. C0tICAVE (sD00n-sha0ed) occlusal surface..occlusa rcst is as long as it is wide, and the triangle base (marginal ridge) is at

least 2.5mm wide for molars & premolars.. l\4arginal ridge is reduced/lowered 1.5mm t0 prov de sufficieni bulk 0f metal l0r

strength and rlgidity of the rest and minof connector. Rest fl00r is slightly l Cl-l E0 APICAILY (deeper), than the 1.5mm depth 0f the

marginalidge.. Angie formed bythe occlusal rest and vertical min0r connectorthat is orig nates from

musi be IESS THA 90' t0 direct occlusal fOrces a ong the abutment's long axis.. occlusal resi is always be attached t0 a igid minor confect0r..occlusal rest is ATWAYS PREPAREI AFTTR THE PRI)XIMAI GUIDE PUIIS!

0CCLUSAL REST the most common indirect retarner

N(}TES

o dir

tie IR

alrbase

ERTICts).lge, a

ovenl

ment

sts. Tct0

a duflrsrgns

t DIST

ent 0nide.

placed on the occlusal

enIUt0e as far away frOm ihe distal extension base as p0ssible.

Class I design: it is placed bilaterally on the lt4-marginal ridge oi 1" prcmolars.Class ll design: placed 0n IVI marginal ridge 0f l" premolar 0n the non distal extens 0n side.

0E0 0CCIUSAI- RIST usedin Class lt (m0d l) & lll RPDS when the most posteriOrIlinimizes lurther MESlAL tipping t0 help direct lorcesabutment is MESIAIIY TIPPED.

the abutments long axis.[xtends more than ], the t00th\ M D width and is 1/3 the B L width.Allows m nimum 0f lnm metalthickness.Rounded rest seat preparati0n with n0 undercuts.

2. EMBRASURUII{TERPR()){IMAI- REST;. ljsed to prevent inteFproximal wedging 0f the framework and shuni food away lom

contact points.. Rest seat is preparat 0n is extended LINGUALLY for bu k strength, but prepared just

l ike an occlusal rest.. l\4arglnal ridge is lOwered 1.5mm 0n each abutment. Avoid creating a vertica groovet0 prcventthe minorconneciorfrom torquing 0fthe

abutment tooth.43

l{0TEs c tcutuit REST 0-[{GUA|" RtsT):. The most saiisfactory lingual rest for suppod is placed 0n a prepared rest seat i

cast restoratioo.. Canines are Dreferred over incis0rs.. Preferred L0 an incisal resl because il is more eslhelic.. Limited to maxillary canines and centrals with exaggerated cingulums. Rarely

satisfactory 0n mandibular anteriors due to lack 0f ena mel thickness. A riskypreparation on lower i[GisoF.

. Preparation is a slightly rounded inverted V (semi-lunar) placed atthe irncti0n

.2mm wide F-1.

.2.5-3mm M-D len$h.

. lVinimum 1.5mm deep (incisal-apically)

[{ctsat REsT:. Used mainly as an auxillary rest 0r indircct retainer.. Rounded notch is placed 3-4mm trom either the Ml 0r Dl edge (canirDs 0r inci. IEAST ISIHETIC RESI and nost likely l0 caxse orthod0nlic movement duet0

unfavorable leverage.. Preparation is 2.5mm wide and l.5mm deep (deepest portion is apical t0 the

incisaledge).. Not used on maxillary incisors unless it is the 0nly 0pti0n.. Beveled labially and lingually.

MAXlttlRY RU0AE AS ltlDlRECT RETEI{T|0I{ WITH RP0s Broad coverage overcan pr0vide s0me sulport, but is IESS EFFIGTIVE than l00th supp0rt, is undesirable,av0ided. Rugae can provide indireci retention with a PAUIAI H0RSESH0I l)ESlGil becathe horseshoe\ oosterior retention is inadeouate.

Guide Plate Functions:. Helps establish a delinite palh ol inserti0n/dislodgement 0fthe RPD.

Strbilizes the RPD by controlling its horiz0nial position.Provides contact with the adjaceni t00th.Should extend just past the DL line angles t0 pr0vide 180' encirclement, bracing,and reciprocaiion.Prepared in the occlusal 1/3 0n the pr0ximal surface.Guide plane is -2-3mm in height occluso-gingivally, but its F-Lwidth is determined bytooth's contour-

4.

Sl GlVAt& IDDIE U3 0lthe lingualsnrlace (iust above the cingu lum, but Ienough t0 minimize abutmenttorquing forces).

Guide plates for Class lll & IV designs can extend above the abutments height 0f c0because there is n0 tunctional movement.Gxide plates iIUSI be belowthe abutment's height of cortoff with Class | & ll dt0 prevent abutment torquing during functional movements.When plates are used with l-bals afid mesial rests 0[ [rem0la6 t0 av0id linguallie plate must end HfiCItY at the heigbt 0l cont0ur.Suiding planes ensure prediclable clasl retedion. Failure 0f parlials due to poorretention design can be avoided by alterilg t00th contoufs. Guiding planes serve

44

assure predictable clasF retenlion.

GT RETAII{ERS (CTASPING)

ctlSPS {DlRICT RETAITIERS) hoth suprabulge & inlrabllge are IEVER placedi0 the lulffum line (axis 0l rotation) because they w0uld release d0ring function

the abutment. 0nly indirect relainers aId stress hreakers (Wr0ughtt'Jires) areanlerior to lhe lulcrum li[e.

ine lnumher 0f clasps t0 use in an RPI] = [Xennedy class + l]not apply to Hass lV designs

R[TEllTl{)N - provided by mechanically placing retaining elemenis 0n thet teeth

DARY RETEtlTl0tl pr0vided by iniimate relaiionship 0f minor connector c0ntact withplanes, deniure bases, and maj0r connectors with underlying tissues.

I Arm of SurYeyor:areas 0f retenti0n, areas 0f suppoft 0n the abutment t00th, and tooth/tissue

rferences t0 the path 0f insertion.vertica! arm represents the paih of placement and removal 0f an RPD

Garbon markef is used t0 determine ihe tooth's height 0f contour (greatest convexity)Zrc Stearate Powder caf identify the survey line (height 0f contouf) l0r a crown wax-upsbutnent tooth. lt is brushed 0n the Vvax up and the analyzng rod is passed over waxsurface and removes the Powder.

T REIAIIIER gives ihe RPD mechanical retention. Any RPD unit that engages ant to resist disllacement AWAY from basal seat tissues using fricti0n, engaging a

ion, 0r undercut cervical (gingival) t0 the tooth's helghi 0f contour'

ECT RETAIIIERS, .0i - .25nm Cast Claspt. tntra-C0ronal Retainer ("Precisi0n Attachment 0r "lnternal Attachment"):

. Advantages: the most esthetic direct tetainer Provides the best vertical supportihrough a rest seat l0cated mole favorably lelatlve to the abutmeni's hotizontal axis(does not allow horizontal movement)

. lt is cast 0r attached totally within the abutment's restored natural contours

. Has a 0lefabricated key & keyway wlih 0pposing vertical parallel !1/alls t0 limitmovement and resist removal by friciion

. llot used with exlensive tissue-supported distal extensions unless a shess-hreaker is used between the movable RPD base and rigid attachment.

2. Ertra-Co.onal netainer (Clasps), placed 0n EXTERNAL surfaces 0f abutment teeth. Has a REIIilTIVE claso am that is FLE)(IBtE and placed in areas helow (cervical)

t0 the t0oth's height 0l contour (t0oih's gingival l/3). Pr0vides resistance t0deformati0n from a vedlcal disl0dging force This generates the retentive action 0iihe clasp. Which has a passive relationship with the abutment unti l a dislodginglorce is aDDlied.

. Lingual arms 0n molars arc usually retentive b/c there are usually n0 usable facialunde(cuts 0n nandibular 2"d 0f 3'd molars

li0TEs

ction

)lyrl

ncllre to

gual

,00r claseNe

-r

45

l{0TEs Clasp Arm Flerihility:. Longer and thinner (smaller diameter) the clasp arm = m0re. Most clasps are tt r0und in form. A round clasp form is the only

circumferential clasp form that can be safely used t0 engage an uon the side 0f an abutment awayfrom the distalextension base.

. Retentive arm must be flexible t0 provide stress reliefforthe abutm

. UilotRCUT t0GATl0N is ihe most imp0rtant factor when selecting afor distalextensions. tEllTlST decides which clasp design is best0n the diagnosis and keatment plan established.

. Has a BRACI S (stabilizing/recipr0cating) clasp arm placed 0CCIUSAL to thetooth's height 0f contour (cr0wn's middle l/3). MUST BE RlGl0.

. Composed 0f chromium-cobalt alloys t0 give greater rigiditywith less bulk.

. RIGID because it is greater in dianeter (thicker) than the retentive arm.

. TaDered in one dimension onlY.

. Horizontal force is transmitted by placing rigid portions of clasps in ll0tl-Ullllareas ot abutme teeth.

the height 0f c0ntour and engages the undercut, the rigid bracing arm must maintainwith the abuiment. Tllillllc lS CRITICAL lll REClPR0CATloll.

RECIRP|ICATI0I{ 0ccurs 0nlywhen lhe retentive arm and bracing arm C0I{IAGItheatthe sametime during seating and rem0vinglhe RPD. As the retentive arm tip passes

Clasp Assemtly C0mp0nents: Ctasp assembly comp0nents pr0vide 180'encirclement 0fabutment (clasp arms, minorconnect0rs, guide plates all contribute to the 180" enci

l. 1-2 rests & at least I min0r connector.2. Retentive clasp arm (flexible) t0 engage and terminate in undercuts.3. Recipr0cating (bracing) clasp arm (rigid).

When an RPD is fully seated, ihe clasp tips should NoT EXERT ANY PRESSURE againstabutmentteeih. lt must betotallv 0assive. The retentive arm is activated 0lltY whendislodging f0rces attempt t0 unseatth€ RPll anay from the iasalseat tissues.

Fundamenial Principles 0t a Clasp Assemhly:l. Clasp should be completely passive and its retent'vefunciion is activated only

dislodging forces are applied.2. Each retenfive clasp must be opposed by a reciprocal (bracing) clasp arm 0r

RPD element capable 0f resisting horiz0ntal forces exerted 0n the t00th by ttreretentive arm.Each claso must be designed t0 encircle more than 180'(more then hthecircumference) 0l ihe abutmeni t00th.Rest should only lrovide VERTICAI SUPPoRL

EXTRA-C0R0l{At RETAII{ERS suprabulge & infrabulge clasps MUST have I retentive(flexible) and I rigid reciprocal bracing arm.

46

BUTGE RITAIIIERS approach the retentive undercui fr0m ABoVE the t00th\ heishtr (usually from an occlusal rest)

r. ctRcur{rEREt{flAr ctAsP {A|(ER's ctAsP),. Engages > 180' of the abuiment\ crrcumference-. Term nal end of its retentive clasp arm povides reteniiOn (buccal) by engaging

an unoetcut.. Has a n0n liexible kigid) l ingual c asp arm for stabil ization/reciprocation. lVust

always lie ai 0r ab0ve the height 0f contour because it canf0t flex t0 gei in and outol undercuts.

. 0riginates 0n or occlusal t0 the tooth's height 0f cont0ur, then crosses in the terminalthifd, and engages an !ndercut as its taper decrcases and flexibility increases.

. Consists 0f I retentive clasp arm + I non-retentive reciprocal arm.

. Clasp 0l choice in Class lll & lV {t0oth-borne designs) when the m0st posteriorahutment undercut is AV{AY fron the edentulous space {i.e. MB) surlace.

. lJndercut must be on the opposite side 0f the t0otl/rest from where theclasp originates.

. D0 ll0T USE when an undercut is adlacent t0 the edentulous space (DB or Dt).

. RPI Clasp Assembly; consists ol mesial rest + d stal guide p ate +circumferential clasp.

Z RING CTISP.. lndicated t0 engage an undercut ol a MESIALLY-LlllGUAI TlLTED M0IIR when a

seyere tissue undercut erists that prevents using an l-bar.. Used almost exclusively 0n mandihular molars that drifted |tlESlAtl-Y & U GUAIIYto engage a GUAT UilDRCUT.

. Indicated in rcverse 0n an abutment anterior t0 a "tooth-bound" edentulous space.

. tncifcles nearly all 0f a tooth from its point of 0rigin.

.ljsed t0 engage a prox mal undercui ( .e. lllI undercnl0n mandihular molar cannothe direclly engaged b/c 0l its pro{mity to the occlusal rest and cannot beapproached with a bar clasp (iffra bulge) due to the molals l ingual inc inati0r.

. Allows the undercut t0 be aolroached from the to0lh's distal.

. Has a mesiai primary rest & dlstal auxl ary rest. ljsed almost exclusively 0n MLtilted molar abutmenls. Always used with a supporting strut 0n the non-retent veside with 0r w thout an aLxil lary rest on the opposite trargina I dge.

. used 0n protected abutments because it covers l0ts 0ft00th surface.

. Used when caries fsk is LOW and ir NoN-ESTHETIC areas.

. ljsed when a DB 0r Dt undercut 0n a molar cannot be approached directly fr0mthe 0cclusal rest and/or when lissue undercuts prevent engagement with a harclasp (inlrabulge).

. Clasp can originate 0n the N4B surface t0 engage a ltll undercut, 0r IVIL to engage aNIB undercut.

3. REVERSE ACTIl}I{ (HAIRPIII) CI.ASP:. Used 0f y 0n abutments 0f "t00th bOrne" dertures (Class 3 & 4) where a proximal

undercut is BELoW ihe p0int 0f origin 0nly when a bar clasp (iffra-bulge) iscontraindicated due to a tissue undercut, t i l ted t00th, shallOw vestibule, 0r h ghtissue attachment.

. Used when lingual undercuts prevent plac ng a supporting strut with0!ttongue interference.

.0nlythe lower paft 0fthe clasp arm (afterthe curue) is f lexible to engagethe urdelcut.

HOTISRexib

unc

utrnet:rgac;t ba

IIDER

ntof lcleme

rinst iYen

tn0Ine'

t ive !

41

l,l0TES ETIBRASURE CI-ASP.. Used on sound teeth with retentive areas 0rwhen multiole rest0rati0ns are iust. used when n0 edentulous space exists 0n the opposite side 0f an edentulous C

ll or l l lwith no modifications.. Requires at least l.5mm marginal ridge reduction t0 nrevent lracl{re 0l ihe

clasp assembly.. ATWAYS USED WITH DOUBLE oCCLUSAt RESTS t0 preveni inteFproximat wedgithe framework.

. A retentive arm and rigid reciprocaling arm must be present foreach abdo not have to be on the same side.

.Wroughl wires are lltVER used with embrasure clasps.

HAI.F-&-HALF ClASP.. INDICAIED roR tl GUALtY lllctltlED PRE 0URS (LlllGUAI UllDtRCUrS). Consists 0{ I circumferential retentive arm from 0ne direction, and reci0rocatithai arises from the nin0r connect0l

BAC|(-ACTI0lt CUSP,. A ring clasp modificati0n. lts use is ditficult t0 justily because you could easily

a conventi0nal circumferential clasp.. Can be used 0n a prem0lar abutment anteriort0 an edentulous space.

MUTIIPI.E ClISPJ. Two 0pposing circunferenlial clasps ioined at the terminal end 0l the two

reciFrocal arms.. used when additional rctention and stabilization is needed (tooth-supp0rted. Disadyantage: two embrasurc approaches are necessary ratherthan a singleembrasure for both clasps.

c0MBrlraTr0il cusP:.lilost commonly used when an abuiment next t0 a disblextension (Class Il,where 0nlya l{B undercut exisls 0r if large tissue undercuts prevent a barlrom being used.

. Used when maximum flexibility is required (i.e. an abutment next t0 a distal

1.

5.

s.

0n a weak abutment when a bar direct retainer is contraindicated, 0r whenrs a concern].

. C0nsisls 0t a bracing arm, wroughtwire rclentive circumlerential arm, anddistal rest.

. Use when the undercnt is or lhe side 0lthe abutment away lrom the edentuspace because it is more llexihle than a cast clasp arm thus can dissipatelunctiolal stresses.

EXITIIDTD ARIi CI.ASP:. NEVTR used with Class I& ll (distal extensions) b/c functi0nalf0rces cause

ar0und the rest and upward movement 0f the clasp tip. Used for abutment t00th-borne dentures next to an edentulous space.

48

UtGE RETAItIERS {BAn CUSPS = R0ACH CTASP):kises from the framework or metal base and appr0ach the abutment's reteftive undercutftom a GI GIVAI DIRECTI0N (BEI0W THE HEIGHI 0F C0llT0UR).hdicatl0fs, when a small undercut (0.01 lnch) exists in the cervicalthird 0f ihe abutment,m abutmeft teeth for Class l l l & lV designs (i00th supported), in drstal extension baseiituat ons, and when esthetics is a cofcern.lontraindications:when a DEEP cervrca undercut exists 0rwhen a severe t00th 0rtissue!0defcut exists. l{01 used il a tissue undercut exists (because is i0thers the tongue anddeek and traps food debris) or with high lrenum attachments (shall0w vestibule) orercessive buccal 0r lingualtilt 0l the abutment t00th.ldyantages, inter proxil]ral location for ESTHETICS, ncreased retenti0n witholt abutmenthpplrg, less chance of accidental d stOdlon due t0 its proximity t0 the denture border.Tiey type 0f bar clasp is insigr f icant as long as it is mechanicaily and Jlrctionallygilective, covers as little tooth surface as poss ble, and displays as little metal possible.Vertical portion 0f the approach afm crosses the gingival rflargin at 90'.Hrabulge Claps:T bar, Modilied T bar, I bar, Y bar, Roach Clasp.

Iways place the tip 0f I har's retentive arm l ESlAt t0 the greatesl M-0 curvature 0nfie abutment's facial su.lace to ensure retenti0n in lhe undercut. The undercut mustl€ MESIAt (in lront of) the greatest |||-D curvature 0n the abutmeflt's lacial surlace.l-bar retentive arm with a MESIAI rest and distal guide plate (RPl SYSTEM) is the BESTclasp assembly to be placed on the terminal abutment ior distal ertensions.Indicated for a Class | 0r ll RPDS using a [4ESlAL REST wher there is no tissue undercut.Used t0 engage a l\41 undercut when there is no tiss!e undercut below the abutment.I,bar's sLperior border s located more than 3rnrn from the lree gtngival mafglf.Indicated for Class l l m0d | 0n a lvlL ti l ted molar with l itt le i issue Lirdercut.lhe l00t 0l the l-bar is completely below the height 0f contour (suryey line) in distalrrtension designs s0 it can release during lurcti0nal movements 0f the extensi0n base.lhen a [atient bites down. the l-bar should release from the undercut.Ihe retentive.rm sh0uld only tuncti0n when there is an attempt to dislodge the RPD (opening therouth when chewing sticky food).

FIED T BAR:8ar 0f choice for DB undercuts helow the height 0l count0ur immediately nert lo anedentulous soace.Primary indicat 0n is when abutmeft undercuts are immediately neJd t0 an edentulous.rea ard r0 t ssle uideTcuts. Can be used with a mesial or d stal occllsa restintooth-suppoded desigfs since no funct 0fal mOvement 0ccurs.Wlef lsed on a terminal abutment l0r a CLass I design, it is lsed with a mesial rest andlhe arm ti0 is 0laced into a l)B undercut.Itsverticalarm mustapproach and engage MESlALt0the greatestlrl-D curvature 0n theabutment's lacial surlace t0 prevent the RPD from being dlsl0dged up and back.

N OTFSustiliEs Cla. :

tent. I

at ng

r5 yLl

mod Iclasp

en€trslnel

nd

ntulo

49

i't0TEs "RPl" SYSTEM (REST, PR0XIMAI PIATE, I-BAR) an l-bar clasp that consists 0f aresi, and distal guide plate with the ninor connect0r placed into the ML embrasure, hutcontacting the adiacent tooth.. lJsed 0nly with Kennedy Class l0r ll (DISTAI t)tTtilSl|)tls).

lllust be 180 degrees around the ioothDistal guiding plane extending from the marginal ridge to the junction of middgingival l/3 oithe abutment is prepared t0 receive a proximal plate.iIESIAT RESTS ARE PIACEO OII THE TERIilIIIAI" ABUII{IIII TOI]TII FOR AITDtsTAt EXIEilStoltS.

RPlsystem is designed t0 allow vertical r0iation 0f a distalextension saddle intothe debearing mucosa under occlusrl loading without damaging the supporting structures 0fabutmentt00ih. Asthe saddle is pressed intothe denture bearingmucosa,thedentureab0ut a point cl0se t0 the mesial .est. Both the distal guide plate and l- bar move indirections indicated and disengage from the t00th surlace. Potentially harmfult0rque isavoided.

RPD STRESS BREAKERS

SIRTSS-BREAIGR a device that relieves the ahulment teeth to which an FPD 0rattached, of all 0r part 0l the f0rces generated by occlusal lunction. When a slresis incorporated next t0 a free-end distalextension RPD, the lunctional stress is directedthe residualridge and only ninimaltransler 0l lunctional stress to abutmentteeth 0Since vertical and horiz0ntall0rces are concenirated 0n the residual ridge, increasedresorption f requently occurs.

WR0UGHT WIRE RETEI{TIVE CIASP (STRESS-BREAKER) a stress breaker used0f its increased flexibility {it minimizing abutment torquing). The simplest form 0lreliel. Has a flexible connection between the dircct retainer and dentu.e base. Advahigheryield strength, greater llexibility, more ductile and resilient.. 0ften used with a liltslAt rest in class I & ll designs 0n the most posterior

t0oth (terminal abutment) when there is a tissue undercut, or high frenum attacthat prevents using an l-bar

. lt occlusion prevents using a mesial rest 0n the m0st posterior abutment in aextension,0nly a WW can be used with a distalrest hecause it is 0l(l0r its retet0 ie in front 0f the axis 0f rotati0n (lulcrum).

. Used on teeth wiih indirect reiainers 0n them (both are anterior to the fulcrum IProvides stress reliei to the abutment tooth due i0 its fJexibiliiy when the distal extenmoves toward the residual ridse.llp 0f its retentive arm should engage the undercut AIITERI0R t0 the fulcrum line0f rolati0n). Terminal end 0l its retenlive arm is optimally placed in the rniddlegingiyal l/3 0f the clinical crown. H0wever, jt is acceptahle to place it at the jthe gingival and middle l/3 0f the clinical crown. When the partial is compleiely sthe reteltiye arm should be passive and applyi0g n0 pressure 0n the teeth.0T USED in Class lll & lV (t00lh-b0rne) designs because there is n0 fun

novement ol the RPD.00 ll0l USE wr0ughl wires through embrasures 0r with embrasure clasps.Has, tensile strength at least 25% greaterthan the castalloyfrom which it wasWr0ughl-t!ire clasps have greater flexihility and adjustahility than the cast cla

50

t0ugher and m0re drctilelhan cast clasps, and have greater tensile strength.Thus

]ut nbe used in smaller diameters t0 provide greater llexibilib/ without fatigue and lracture.l lroughtwireisincorporatedintotheRPDbysolderingitt0theminorconnector,meshwo,incorporating it into the wax pattern, 0r is embedded into the acrylic resin (makes it thenost flexible). 20 gauge wrought lvire is 2r more flexible than an 18-gauge wirc.Jl2 =.smm wrought wire. ilusl be at least 8mm long and tapered round 18 gauge wire.-03 =.75mm and lS NOTIUSTIFIED.

ltEs:Externalfinish tine-the exiernaljunction {butt joint) 0fthe metalframework anddenture base plastic (acrylic).. The external finish line 0n a maxillary Class I RPD originates from the lingual 0f the

guide plate 0f the terminal abutment and ands at the HA|ULAR N0TCH.

Internal Finish tine-the buttj0int between the metal and acrylic 0n the TISSUE SIDE ofthe edentulous area.. Juncti0n of the maj0r and minof c0nnector at palaial finish ng lines are 2mm med alfrom the imagrnary l ine that would cOnnect l ingua surfaces 0f missing posteriordenture teeth.

. Internal and External f inish l ines are normally 0FFSET lr0m each other t0 avoidf ramework weakness/lracture.

. Locati0n of the l inishing l ine at the junct 0n 0f ihe major and minor connector isbased on restoring the natural palatal shape while considering the locationof replacement teeth.

. Finishing l inejunction with the majorconnector sh0uld be no greaterthan 90', thusbeing somewhai undercut.

. luncti0n 0f minor connect06 and bar clasps are 90' butt-joints that f01lOw thegu delines for base c0ntour and clasp length.

NOTES

entuiof irOIAI) rn

tsps,Thus

rs tn

'RPDibrcard0cc{ r id

RVEYIl{G RPD ABUTMENTS

IM Ldsts al low. lhe denli \ l l0 reco d the dFltures path of inserl '01, posil .0r 0l lherchme line, and locati0n of undercut and n0n-undercut areas. T0 d0 this, TRlP00 MARKS are

d on lhe cast t0 record the cast's orientation t0 the survevor.adi lripod marks 3 spots placed at 3 different locati0ns around abutmeftteeth from a single

Doint 0l view t0 ensure a repr0ducible 0rientation 0l the cast t0 lhe surveyor. Recofdsthe casi\ posilion.oental Survey0r !sed i0 determine the relative parallel sm of oral anatomy. Areas usedhr suppori CA iloT be determined by surveying. When surveying casts, the correctprocedure is t0lirst adjust the ti l t t0 permit the establishment 0f guiding planes. Theanterj0r edentulous space wil l Jrequently dictate the angulation needed. Nomally, sonere-contouring 0f the prox mal walls 0f abutrnent teeth is needed t0 improve guideplanealignmeni by disking the pr0imal surface parallel t0 the path 0f insertiOn.Iiltingthe cast during surveying ch a nges the path 0f insertion, survey line p0sition, andhcation 0l the undercut ald non-undercut areas 0f each t00ih.

mtve

rm lrne{tens

Ine tarle olnctiont seat

rnction

as mad

il|1TES PURP0SE 0F SURVEYIII0 (lJsing oiagnostic Casts):. Determine the most desirable oath 0l Dlacement that wil l eliminate or mini

interference t0 removal and placemeni the RPD.. ldentit surfaces for guiding planes for the prosthesis.. Locate and measure areas of teeth for retention.. Determine if a tooth and/or bony areas require surgical

insertion wil lsuffice.Determine the most suitable path 0f placement that will design 0l retainers and teethbe most esthetic.Prepare an accurate chading for any mouth preparati0n t0 be made.Determine and delineate the t0oth\ height 0f contouf.

removal or if another path

FACE Bl)W - caliper like 0evice to record the patients maxilla/hinge axis relation(openingand closing axis) andt0transferthis relationship t0 the articulator during mou

. Before an accurate face bow transfer recofd can be made, the locati0n 0f the hingepoint {axial center 0l opening-cl0siBg), must first be determined.

0f the maxillary cast. lf the transfer is done propeiy, the arc 0f closure on the articulshould du0licatethe oatient's true arc 0f cl0sure.

A lace-how transfer rec0rd D0ES ll0T: all0w the dentist t0 locate the hinse axis.

Facehoyr transfer is ll0T a maxillo-mandihular record, bul a record t0 0rientmaxillary cast t0 the hinge axis on the articulalor. The facebow iransfersmaxilla/hinge axis relationship to the articulator during m0unting ofthe maxillary ca

rec0rd CR more reliably, n0r position the maxilJary casi pr0perly in relati0n t0mandibular cast, nor transfer the cast t0 the articulator maintaining the pr0per i0cclusal relationshi0s Dresent in the m0uth.

. llilge-afis lace bowtransfer enables the deniidt0 alter VD|) 0n the articulator.altering VDo (either via restorations 0r with dentures), casts should be m0unted onhinge axis. Hinge Axis Face Bow used t0 record opening and cl0sing 0f the mandibl

FNA EWI)R(TRY-III:. Belore trying in a framework, inspect tl're master cast for damage and inspect

framework for sharp meial fins.. When making maxillary & mandibular RPDS 0n the same patient, the dentist should

try each framework one at a time {0r fit, then adjust occlusi0n for each if needed,adiust occlusion with b0th frameworks in 0lace.

. llamaged areas 0n the cast are the first areas adiusted ifthe framework does not

. lf the framework fits the cast but not in ihe mouth. all other Dossible causes sh0uldeliminaied beforc making a new impression.lf atiempts l0 fit the framework t0 the mouth are unsuccessJul after adjusting,assume the impression 0f cast is inaccurate and lhe impression will need t0 be remA liASItR CASIl0r a RPD should be blocked outand du0licated BEF0nEthe lrais waxed up.

52

ES 0F RPD CHR0MIUM-C0BALT ALL0YS corrosion resistance, high strength,c gravity & VERY RIGID (inflexible). N0 duciility 0r malleability afte.they are cast.

0n 0f Chromium Base l{etal Allovs for RPDS,Chr0mium responsible f0r C0RR0Sl0 nESlSTAtlCf in c0balt-chr0mium all0ys.Ensurcs the all0y will resist tarnish and c0rosion by f0rming a c0mplex chr0mium oxidefilm. An RPD made 0f a base metal alloy is resistant l0larnish and corrosionbecause 0l ils surface oxide layer.C0balt-increases the f.ainework's RlGlDITY, strength, and hardness.llickel-increases DlJCTlLllY. ll,leasured as a percentage 0f elongation and determineshow much margins can be closed via burnishing. llickel is the metallic component 0fa RPl| with the greatest potential for ALLERGIC REACTI0IIS in the mouth.

t[0Y cusstFtcAlt0lt:l : used for small inlays.l l: larger inlays & onlays.l l l : 0nlays, crowns, and short span FPDS.lV, thin veneer cr0wns, long-span FPDS & RPos

cAsI tMPRtSSt0 ,urpose is to obtain the maximum support possihle from the edenlulous ridges in Class& ll designs.ptures edentul0us ridge tlssues ln relation t0 the way the framew0rk lits lN THE lVl0UTH

hot cast).avoid overextension that is c0mmon when a stock+ray alginate impression is used.

CAST TECHI{l0UE the DUr00se is t0 record the form 0fthe edentul0us secmenltissue displacement and t0 accurately relate the edentul0us segment 0f the teeth

e metal framevJork. The goal is t0 provide maximum supp0ri fOrthe RPD denture base,maintainins occlusal contact t0 distribute occlusal load 0ver both naiurai and artificial

t0ils:It a mandibular RPD abutment must be crowned, the FPD impressi0n should include a fullarch impressi0n is required to capture all abutmentteeth and the ret.omolar pads.Y{hen crowing an abutment tooth for an RPD, you must reduce m0re than the normalocclusal reduciion for the rest seat.

N{lTES

otl

|Untrc! l

ontdible

!d

castus.torin

td 1ld, th

I st0ck tray will ped0rm adequately in areas where teeth emain but re atively poorer incdentul0us areas. This is one 0f lhe major reasons an altered cast impressi0n is done.

r0t)Ut0

s, while minimizing movemeff 0f the base that would create leverage 0n thetteeth.

Altered cast technique helps oblain s0lt tissue support to aid abutments in resistingfunctional stresses. lt is a secondary impression system that uses the metal frameworkl0 hold cust0mized imDression trays forthe edentul0us areas.

nade

53

t{0TEs Cl)MPLETE DEI{TURES

Complete Denture Design Characteristics:1. Stability{he quality 0f a denture 0r prosthesis t0 be firm, steady, constant, and

suhiectt0 change positi0n when forces are a[plied. In dentures, stability is therelationship 0f the denture base t0 bone that resists dislodgement olthe denturea HoRlZ0 IAL direction.. Stability involves resistance io horizontal, lateral, & torsionalf0rces(most imIortant).

. All RPD c0mponents, exceptthe retentive clasp tip, contribute t0 denture stabi2. Support resists VIRTICAt seating forces Frovided by resls and denture bases.

RPDs, support is provided by occlusal rests and edentulous ridge areas. Supportthe IVoST imp0rtant design characteristic for oral health.

3. Retenti0n resists the force 0f gravity, stickyfoods, and forces associated withmandibular m0vement. Ilirect & indirect retainers lrovide retertion. CI-ASPSin undercnt areas 0f ahuiment teeth Dr0vide retention.

tactors that impact retention, stahility, & support: quality 0f oral muc0sa, alve0lar ricontour, muscle attachments, saliva, and neuromuscular conlrol {the m0st impobecause patient\ muscles learn to hold their denture in place and chew efficiently).

B0RDER l'l0LDll{G:. l{asseter l{uscle: powerlul muscle whose liber run superi0Finleri0r [hdI pushes

buccinat0r into the DB corner 0f the denture base durins c0ntracii0n. S0IST0BUCCAI AREA durjng an altered cast impression. 0verextensi0n 0f a manddenture base in the distolacial area causes dislodgement of ihe denlure during funas the result 0fthe action 0fthe ASSETER. An overenended DB cornerofa manddenture pushes against the ASSETER during function.

. Su0eri0r Constrictor Muscle: shaDes the DlST0LlilGUA[ BoR0ER 0l0lilG. Atfectsmost distal portion 0f the lingual flange. An overextended lingual flange can cause athroai.

. 0ST criticalarea in border moldinga llN(lLtARY DEIIIURE isthe MUC0GlilGlVALabove the malillary tuberosity area as this area is extremely important for maxireteniion. other critical areas are the labial lrenum in the midline. and {rena inbicuspid area. Overextension in these areas often leads t0 decreased retention and tiirritation.

. When border moldins a ilA DIBI,IAR IEI{TURE for a final im0ression.lhe DBdetermined hy the p0sili0n and action 0f the MASSETER MUSCLE. The 0I extensionihe mandibular impression for a complete dentlre is limited hy the action 0fSUPERIOR Cl)IISTRICT|)R MUSCLE,

FREIIUM folds of nucus membrane containing fibrous C.T. l\4ust providerelief/space in this area because it can Iimit the denture's ertension.

54

Tray & Border lllolding:custom tray fabdcated on a preliminary cast is trimmed -2nm short ofthe mucosal

ti lection and frenae. This is done by first checking the borders in the fltouth and thenimmed down t0 allow uniiorm thickness 0f 2mm 0f modelins c0mDound when the borders

molded. However, the primary indicator 0l h0rder m0lding a ccIracy is STABILIIY and0f displacement 0f the cust0m tray in the mouthm lray lor a l inalndndrbLld 0rmari l laryc0 plete denrure imprpssi0n should havF

spacer with tissue stops t0 ensure the tray seats in prcper rclationship t0 the arch, andb ensure adequate room for the impression material. The space is c.eated with waxroyered hy aluminum foil0verthe masier cast priort0lorming the tray.lorder m0lding is c0mpleted in two stages. The m0lding should approximate the trayhorders and should be slightlyoverextended. Excess compound istrimmed from inside andqitsjde the cust0m tray. The remaining modeling compound is then refined by repeatingtie pmcess. The final form 0f the b0rder molding should represent an accuratehpression 0l the peripheral tissues. The border modeling c0mpound sh0uld have asmooth, polished appearance.Palatoglossus, superior pharyngeal c0nstrjctOr, mylohyoid, and geni0glossus muscles areinfluential in border m0lding the LlllcIJAL borde. ol the mandibular inpression for an€dentulous paiient.

extraction, alveolar ridge resorption 0ccurs because there is no l0nger bone stimulationhy ol supp0rting structurcs occurs kesidual ridge resorption).

laxillary arch: b0ne loss/resorption occurs ln a VERTICAt & PAIATAI direction (UPWARD& IilWARD). (0.1mm/year is sustained). Initial loss in first year is greater, but varies.landibular arch, b0ne l0ss occurs in VERTICAI direction (DoWNWARD &[0RWARD/0UTWAR0). Bone loss is oriented al0ng the cr0ss-sectional shape 0f thenandible. I\4andibular bone res0rpti0n is 4)( faster than in the maxilla, but varies. Severebone resorpti0n can ca!se a Pseudo Class l l l malocclusi0n appearance.

Sl0l{ RIMS the resultant product after adding base piate wax t0 a record base t0imate the t00th positl0n and arch form expected ln ihe compieted deniure. Functions:

Detpr - ine ard estab '5h t 'rF patiert s VDo fvel icJl dimension 0[ occ Js 0n) aro level ofocclusalplane.Make maxil l0-mandibLlar preliminary iaw relati0n rec0rds.Establish and locatethefuture position 0f dentureteeth (arch forthe lips, cheeks, tongue).Maxil lary rim is 22mm and nandibLlar rim 18flm.

rec0rding CR for an RPD, the 0cclusionmetallramework instead 0ft0 a recofd

r surface 0f the maxillary occlusion rim sh0uld be PARAttEt t0 CAMPER'S LlllE (theplane running from the inlerior border 0f the nose ala t0 the supedor b0rder oJ the ears). Signil icance 0f Campe/s l ine:the occlusal plane, established by the wax 0cclusionsurlaces is parallelt0 Camper's line & interlupillary line.

0n making 0f Complete 0entures Rec0mmend using a technique that:Affords placement and control 0f the impression material in recording border tissues(border moldirg).Results in minimal t issue displacement under the denture kegisters tissues n theirpassive position).ls dependent on the oral conditions present.Best impression technique for a patient with loose hyperplastic tissue is t0 register thetissue in its PASSIVE positi0n. Ihere must he irtimate contact 0f lhe impressionmaterial with the tissue.

NTEC

tabi l '

dibu

s. Forport s

hes t

dibu

unaxtnl

tnId t iss rim is attached t0 the completed partial

base as used with a complete denture.

55

l,t0TEs MAl{DIBUI.AR C|]MPLETE DEl{TURES

MAiIDIBUIAR C0MPLETE DEIITURES a primary srpport (stress-bearirg) area isBUCGIL SHELF iecause 0f its bone structure (resists resor0tion because ii iscorticalbone and d0es not change) and its trabeculati0n rightangle (parallel) relalito the occlusal plane.

A StC0ilI)ARY peripheral seal arca for a mandibular complete denture is thelingual horder.A SEC0NDARY relief area is the CREST 0F RESIDUAL RIDGE WHEN IT lS SHARP

l{andihular Support Areas:1. Euccal shelf-the prinary suFport area l0r a mandibular denture. Euccinat0r

muscle limits a denture's extension in this area. The biggerthe buccal shelf, thedentuae suooort.. masseter muscle atfects ihe nandibular denture.. The boundaries 0l lhe buccal shelt are lhe buccalfrenum to the retr0molar

crest 0f the r€sidual ridges t0 the external 0blique line (

Alevoalar ridge- SEC0IIoARY area ol mandibular dentu,e supFort.. RESIDUAt RIDGIS il large and broad, may be Frimary support areas, but are

usually SEC0ilDARY STRESS-BEARI G AREI hecause it is cancellous hone.

Retr0m0lar pad-does not change 0r resorb. ll0T a primary supponarea, but mucaptured in the inpressi0n. Lies at the crest 0fthe mandibular residual ridge.

ftralinized tissue- the more keratinized tissue, the better denture supportand comfort.

When fabricating a rnandibularcomplete denturefora patient with a "knite-edgedyou need naximum e*ensi0n 0f the denture i0 help distribule occlusal torcesatget arca.

ilarked RES0RPTI0il 0f the alye0lar ridge will occur if a mandibular complete debaseterminates sh0rt 0fthe retrum0lar pad.lrnderextension 0l the peripheral borda complete mandibular denture decreases tissue-bearing s laces, thus afledeniure STABILITY.

Underlying basal b0ne (umer the retromolar pad) resistsresoft). Covering this area also provides s0me boder seal.occurs ifthe bases coverinsthe area are too small in outline.

hone resorytion (doesAn overload of the mu

Mandjbular dentu.es d0 not rely 0n suction from a peripheral seal for retentionmaxillary dentures, but rely 0n dentnre stahility in coverirg as much hasal bpossible with0ut impinging 0n tnuscle attachmenls. Tlre active border moldingbythe lips, cheeks, and tongue determines the peripheralareas 0f a mandibular arch,establishi8g maximal basal bone coverage.

D0 tl0T PTACE mandibular molars ove. the ascending area 0f the mandibleocclusalforces 0ver the inclined ramus DISI0DGE the mandiiular denture.

56

nuc0sa is lound in myl0hyoid area & over mandibular tori (mandibular dentures) andmidline 0f the palatal vault and 0ver a torus palatinus (maxillary dentures).

rtori, sharp prominent mylohyoid ridges, and Epulis fissuratum areevaluated forI removai before the fabrication 0f new dentures besins.

position affects denturc stabiliU & retenti0n in the mouth. A patient with aD/RETRUotD tongue is a p00r denture candidate

Y0lD MUSGtt aflectsthe slopeofthe l ingualflange 0lthe impression in the molar(at its most PoSTERI0R (distal) aspect) causing the llange t0 slope toward theF()RilS THE IiIUSCUtAR Ft|l0R 0F IHE M0UTH. Arises from the mylohyoid ridge 0fthe

NOTES

ible near the mandible\ inferior border n the INCIS0R REGIoN and becof0es higher 0nandible's p0stei0r body until lt terminates just distal t0 the lingual tuberosity.

C0nnects at the midline and can tlFI THE ||lA DIBUUR 0E TURE when the T0I{GUE lS

'n0TRUDED. lt influences the m0laf regi0n and slopes toward the tongue.

blingual gland and antedor p0rtion 0f the irylohyoid flruscle cause the LINGUAL FLANGTbe l0wer in height in the anteri0r region.

ItTR0l{YL0HY0lD ClJRIAll l-c0mp0sed 0f the superior pharyngeal corstrict0r &Dalatoglossus. Determines how far posteriorlythe l ingualflange can g0.|[TRo|tlYt0HY0lD FossA-located atthe distalend 0fthe alveotar tltlcUAtSUIDUS. This isthere the lingual flange turns towad the ramus making the famous "S-CURVE" with thefrange sl0ping toward the tongue in the molar region 0f the myl0hy0 d muscle. Bordered$dially hythe anleri0r tonsillar pillar and p0steri0rly bythe retromylohyoid curtain.. S-CURVE is seen in a mandibular impression due to the MY[oHY()lD iIUSCIE (slopes

t0ward the tongue) and RETn0MYI0HY0|0 F0SSA wh ch slopes toward the buccal.

()MATI!IBUI.ARRAPHE a TEltDoil lying between the buccinator & superiorictor muscles.

lTubercle = Lingual Tuberosity

nGUAI SULCUS -the space between the ridge and tongue.

IILARYSALIVARY CARUIIC[E eminenceon eithers]de 0f ihefrerum onwhlch thesub inguai ducts and submandlbular ducts open.

on lrlbolormi. th

57

li0TEs MAXILTARY C()MPLETE DE]ITURES

PRI ARY supp0rt denture bearing areas (stress-hearing area) is the RESI0UAL RIDGPAI.IIE-

SEC0il0ARY suFport areas is the PALATAI RUGAE. Secondary RETEIII|VE area isglaldular regio! 0n each side 0Iihe midlile.

P0SIERIoR PATATAI SEAL extends through tie HAill,L,[R I)TCHES in the maxitta,passes 2mm in lr0nt 0l the F0VEA PAI-ATIilAE. lt is in an area 0f imm0vable tissueconpensates l0rdenture p r 0 c e s s in g e r r 0 r s. Posterior palaline saliyaryglands help maperipheral seal.. [,lark it in the mouth with a Thompson stick and carve/scribe this area into the cast.. Compensates for acrylic shrinkage and is in I 0VABIE TISSUE.. Butterfiy shape and in shallower in ihe center and hamular notch areas.. Carried -5mm AtlTERl0R T0 THt VIBRATIIIG tlllE.. Posterior palatal seal outline and depth ditfers for every patient according t0 the

form of the patient.. A posterior palatalsealis necessarywhen fabricating a c0mplete denture on a patient

a flat palate. IilE FLATTER THE PALlTE, THE WIDER TllE P0SI[R|0R PAIAIAI SEAL.. Posteri0r palatal seal should never be removed.. lviddle of the posterior palatal seal is 0.5mm deep extending 3mm on both sides 0f

midline.. Seal is l.5mm deep lateral to the middle 0f the seal and sh0uld extend up t0 the

boundary of the pterygomaxillary (hamular) notches. Width is l-l.5mm high and Lbroad at its base.

. Excessive depth 0Ithe posteri0r palatal seal usxally results in unseating 0lthe I

. WIDTH of the sealanteriort0 posterior is chamcterized bv a concave surface,3mnthe midline, and Smrn wide in the midiaieral areas.

. Placemeni 0fthe posterior palatalseal is always done bythe 0EilTlSL

Posterior Palatal Seal Functions:1. Completes the border seal0fthe maxil lary denture.2. Prevents food impaction beneath the denture's tissue surface.3. lmproves the denture's physi0l0gic retenti0n.4. Compensates l0r polymerization and cooling shrinkage 0t lhe denture resin

during processing.

HAMUIAR I{0TCH (PTERYG0MAXILIIRY) - a cleft 0f loose C.T. thai extends frommaxil larytuberosityt0 the hamulus 0fthe medial pterygoid plate.

FoVEA PALATll{l - a group 0f muc0us gland ducts wh0se locaiion varies, but isslightly nosterior t0 the iuncti0n 0l the hard & soft [alates rcar the midline.. VIBRATIilG LlllE: -2mm anteri0r t0 the f0vea lalaiinae and ATWAYS 0ll THt

PAlllTE.lhe imaginary line acrcss the posteri0r palatethat narks the division betweenmovable & immovable l issues.

Posterior Palatal Seal landmarks:. Posteri0r ontline is formed bythe "ah" line (vibrating line) and passes through the

pteryg0maxillary (hamular) notches and is 2mm anterior t0 the fovea Dalatini. Vibline lS AN AREA (imaginary line) that dictates the distal palatal termination 0lmaxillary c0mplele denlure rec0rd base.In determiningthe posteri0r limit 0f a maxildenture base the hamular n0tch is 0llthe [osterior h0rder.

58

0r outline-formed bv the "blow" line (valsalva line). l0cated at the distal extenl 0lhard palate. The bl0w line is anteriort0 the vibrating line which freely moves when theient attempts t0 blowthrough the nose when it is squeezed tightiy. Blow line js a close

imdrion lo rhp Jdncl,0n of lhe h,rd and soft palat€.

ToRl- bony enlargements at the hard palate midline, occurring in 20-25% oftheion, more prevalent in w0men. llsually covered by thinner and less rcsilient mucosa

the residual ridge, s0 it may act as a lulcrum and cause rocking 0f the maxillary

ause the soft tissues over the torus are generally ti'n with a p00r bl00d supply,-operative healing is slow. lt is best to coverthe 0perated site with a surgical stentd with a sedative dressing. lf a patient is having all maxillaryteeth extracted at 0nce,

is besi t0 also remove the tori at lhai timeusually removed for denture labrication. However, mandibular tori ARE usually

pior to denture fahrication.

ons for Removing Palatal Iori:t. lmpinges 0n the soft tissue 0rthe tori is undercut.2 S0 large it lills the vault and prevenis formation 0f an adequate dent!re base.1 Extends too far posteriorlyihus interferes with the posteri0r palatal seal.{. Psych0l0gically disturbing to the patient {cancerphobia).i Large paiatal tori can cause problems with pOsterior palatal seal. Use a Y-incisi0n t0

.emove palataltori directly over the tori.

Ftient complains "when I smile, my upper denture doesn't h0ld", the area 0t thebase needs t0 he adiusted is the buccal notch & huccal flanse due t0 E)(tISSIVE

Nt]TES

med

ESS 0f the area. As the buccal frenum m0!es postedorly during smiling 0r other facialions, it encroaches on the denture border that is too thick, causing the denture to

e loose

PAIATAL RAPHE (SUTURE) area 0f very thin and tight attached t ssue extendingthe incisive papilla t0 the end 0f the hard palate. This is where the palatine pr0cesses 0f

naxilla join together. ilAxlLL"[RY DENIURE SH0ULD Bt REIIEVE0 lll THIS AREA.

s Due t0 ill Fitting C0mplete Dentures:l. Angular Chelitis-cracking in ihe c0rner 0f the lips secondary i0 chronic candidiasis, or

caused by a L0SS 0l VERTICAI Dl EilSl0 , 0r vitamin B deliciency.

.Ireatwith anti-fungaltherapy: Nystatin powder applied t0 denturc undersurface3x/dayfor 3-4 weeks, or reline 0r remake the denture. llystatin rinse in inelfectivel

. Closed vertical dimension is the most likely cause 0f cheilosis in patiert l/vho !l/earsa complete denture and whose medical history is non-contributory.

t1t

nexadui

59

N(lTES Intlammalory Fibrous Hyperplasia (fpulis Fissuralum) begins as a traumatic usecondaryt0 an ill-fitting denture flange. Can be caused by c0ntinued dentureand irritati0n. Treat:with SURGlCAL EXClsl0ll. tirsl thirg you must d0 is CUTIHT0EIIURE FUlilGt BACI hecause lhe denture is |lVtnEXTtllDEll. Then considertissue conditionins.

. 0entu.e-induced fibrous hlperplasia (tpulis tissuralum), duet0 clefts f0undhyperplastic tissue, is also related t0 chr0nic trauma pr0duced by an ill-fittingdenture. lt occurs in the yestibular mucosa where the denture flange coniactstissue. Ap[ears as PAlllLESS F0IJS 0ffibr0us tissue ssroundingth€oyerertended denture llange. lf the amount 0f hyperplasia is minimal, tissuec0nditioning, fabrication 0f new dentures, and a change in denture habits naysufJicieni to arresttissue changes. However, surgical excision is usually requIhe 0atient can alsoleave the denture out 0fthe n0uih.

. The most likely tissue reaction t0 gross 0VEREXTtllSl0l{ 0f a complete denturehas been worn l0r a l0ng time is an EPULIS FISSUnATUM (caused hy an ill-littidenture flange). This cleft-like lesion are caused mainly by overextension 0ldenture flanges. The overextension may resultJrom long-term neglect 0rsettlingsxbsequentto residual ridge resorption. Traumatic occlusim 0l naturalteethopposing an anificial denture may also cause an epulis fissuratum.

3. Inflamnatory Papillary Hyperplasia-second a ry l0 ill-fitting ltlAt(lLURY IEilTURESand s0metimes com0licated bv chr0nic candidiasis. Treatment; c0ndition the tissuIherapy, topical anti fungal medication. ln extreDe cases, surgical excision.Frequeltlyfound under an ill-fitling denture, esptcially dentures with a reliefchamber lroduced in resD0nse t0 irritati0n from delture movement andaccunulating f00d debris. The nasses present as PAlilIESS, FlRlil, pink 0r redn0dular proliferati0ns ofthe muc0sa. Candida Albicans may contributet0the inflammation.

.l{ost patients are lnay/are 0l ib presence. lt usually inv0lves onlythe HAR|)PAUIE, but may also involve the residual ridges. IPH trealment depends on thlesion size. Although the nodules are not completely reversible, smaller papillausually regress with treatment {removing the denture, soft relines, g00d oraland Nystatin therapy).

Denture Stomatitis-a l0calized 0r generalized chronic inllammation (redless andburning) 0l lhe denture-iearilg nucosa. Discomfort may be 0r may not be pCassed by denlure trauma and secondary lungal inlecti0ns. Treatment: improvedoral hygiene, tissue rest, anti-fungal therapy (Nystatin), resilient tissue conditionand new, well-fitting dentures.

Gl|

m0st imp0rtaft reason t0 treat hyperplastic t'ssue bel0re making a c0mplete 0r RPD is t0a lirm, stahle base forthe denture. Treat hyperplastic lissue: tissue rest, s0ft reline

istrng dertures, change denture habits (n0twearirgthem 24hrs/day),0r surgical removalue (for extensive tissue changes).

Bl ATl0 SYtl0R(}ME - caused when an edentulous marilla is 0pposed by a partiallymandible (anteri0r teeth 0nly), causing StVERt B0 E RES0RPIl0 0f AilTERI0R

lll. Thus,, during chewing,the deninre tips anteri0rly c0 mpress the mucoperiostieump.e-maxilla.

Gharacteristics, flaxillary tuberosity hypertr0phy (flbr0us hyperplasla), 0cclusa planeproblems, & premaxilla resorpti0n.

a previously edenlnlous aged patient who now wears a complete maxillary denturethe 6 mandibular anterior teeth l0r many years, it is very common to have t0 do a

due to loss 0l bone in lhe AilTlRl0R maxillary arch. Thls is evident by a FUBBYIIARY Al{TERl0R RIDGE (loss 0f 0sseous structure in the anteri0r maxillary arch). A

maxillary anterior ridge under a complete denture is frequently associated withI{EO I{ATURAT MAIIOIBUUIR AI{TERI|]RS.

flabby ridges are due t0 unstable occlusion and or excessive loading 0f t issues. CausesreDlacement 0f bone by fibnus tissue. use a VERY FL0WABLE |I4PRESSI0N IIATERIAL t0rec0rd flabby ridges like Zltlc oXIDE EUGEtl0t PASTE.n$IUEilTU ER isindicatedt0 impfovdpromote healing, wherethere isvery little ridge left,0r when a maxillary natural teeth oppose a mandibular full denture (decreases pressure 0nlhe ndge and causes less damage t0 vascularitywhich decrcases bOne resOrpti0n.

put pressureon incisive papillae,the patientfeels hurning. T0treatrelieve the incisiyelae area. A patient who wears a complete maxil lary defture complains 0f a burningi0n in the palatal area 0f their m0uth. This indicates too much pressLfe being exerteddentLre on the INCISIVE F0RA[4EN.

ISIVE PAPItLA soft fibro!s C.l elevati0n that covers the incisive fOramen (0pefing).areas are the ME|)IAL PAIATAL SUTURE & lllClSlVE PAPILIA when burnins occurs ort0

compromise blood supply.

ns sensation in the mandibular anterior a.ea is caused bv Dressure 0n the MEtlTAtElt

NSTES

erybe

drnc

t re: l[iiIIngI

IlneI

tI

eni€d

els

nt returns t0 your office a few days after delivery 0f new dentures and complains oJralized irritati0n 0f the hasalseat. Potential Causes:

PRE ATURE 0CCIUSAL C0 TACTS = M()ST common cause 0f seneralized irritation 0lthe basalseat.Lack of denture hygiene, nutrit ionaL and hormonal Lmbalance.kcessive V00

61

N|1TES METAT otl{TURE BASI - netal is LEss irritatingt0 tissuethan acryJic, and more accufits the tissues.. Has betterthermal conductiviiv, s0 is better fortissues.. Increased stfen$h allows for less bulk t0 allow more t0ngue space and better phoneti. lrcreased weighi which is better for mandibular denturc stability.

IMMEDIATE DEI{TURES

All new dentures sh0uld be evalualed 24hrs after deliveryt0 correct any undeteciedlcsue .rdL-a artr 0uted l0 dpnlLrp [unction manifesl as hyperemia, inf lammatiulceration, and pain. Ihe basic sequence 0f the clinical procedure tor a 24hrappointment is:

1. Remove the dentures from the mouth and thoroughly examine the mouth.2. Ask the patient about the areas 0f tissue trauma observed. Permit the patieni t0

describe additional complairts.3. After c0 lecting all diagnostic information, the dentist can determine the s0!rce 0f

problem and cure.

During the first few days after inserting complete dentules, the patjent should expect s0difficulty in masticating m0st loods and excessive saliva due t0 refler parasympstimulati0n 0l the salivary glands. 0vertiflre, th s will subs de and return i0 normal.

ldeal treatment ls t0 labricate the maxil lary &simultaneously t0 avoid setting maxillary teeth to themandibularteeth.

mandihular immediate dlikely malpositions ol the remaln

. lf the mastercastsareallered inan immediate denturepr0cedure (e.g. elimination 0fundercuts), it is advisable t0 construct a second transparent denture base using a surgislerl lempate. l lestenl \ 0a.ed over lhp ridge afterthe teetl" a'e et'rdcted.points and undercuts are readily visible and surglcal ridge conection can be perfomed.

. Duplicating a master cast t0 cOnsiruct a surgical stenvtemp ate that is t0 be lsed attime 0l irnmediate denture inseirion is best made afteI wax eliminati0n and aftef theis trimmed. D0 not make a 2'd denture set for at least 6 m0nths.

62

schedule for t00th removal prior t0 delivery 0f immediate complete dentures: ilOTESl. Step l, e*{fact all posterior teeth EXCEPT a maxillary first premolar and its opposing

t00ih to Dr0vide a oosterior "stoD" to maintarn the VDo.

ctgaa55_!

al t -E

Step 2: after the posterior residual ridges exhibit acceptable heal ng, the 2"d treatmentphase (denture iabrication) can begin. Anlerior teeth are extracted at the time ofdenture insertion.

the patient get through the lirst day 0l wearing imnediate dentures, instruct themlll REM|)VI THt DII{TURES, eat soft l00ds, and return in 24hrs for lhe tirst

envevaluation. KIEP THE lti THt 0UTH F0R 24hrs after delivery.

ale Complete Denture AdvantagestAril n0rcATr0il ts EsTflETtcs.lbility l0 duplicate the position of the naturalteeth.Sontinuously acceptahle esthetics as the patient is never withoui elther natura 0rarUficialteethlnproved speech adaptati0n. lmmediate dentures require ofly one peri0d 0f speechadaptation, while conveftional denture trcatment requircs iwo lone after ext.actions andanother atter the dentures are dellvered).Protects exlraction sites from trauma byacting as a bandage overthe clot-filled sockets.Continuously acceptable masticatory lunction. Patient retains some perception oJchewing during healing.Prevents tongue enlargement. When natural teeth are lost and not replaced, thetDngue e4ands into the availahle space.

ate Complete Dentu.e DisadvantagesIll0R disadvantage 0f immediate denturetherapy is not being ahlet0 have an anteriort00th try-in t0 evaluate esthetics (anterior t00th lry-in is impossible).lelinilg/rebasing the denture is required in 8-12 months. Relinifg is simple, but mustbe caned out within 8 l2 morths dependirg on the rate ol alveolar ridge resorption. Als0,increased post delivery soreness for a few days can be enco!rtered.Increased post-inserti0n care (including relining or remak ng the dentures). Contourchanges 0ccur in the residual ridge during the 8 l2 month healing period.hcreased post-delivery soreness. The combinati0n 0f post-extracti0n pair and denture-related trauma often produces grcaier discomfort dur ngthe fLrst few days after inserti0n.Greater complexity 0l clinical pr0cedures (i.e. border molding & ljnal rnpressions aremore ditficult when natural teeth remain).lligher total cost ol t.eatmert due io the need for relines and repeated equilibrat 0n ofthe occlusion.

ediate dent[res should be scheduled for REtltiES at 5 months and 10 m0nths 00st-ction t0 compensate for contour changes. Re collourirB of 'he fe"l ing ' idgF

ses fapidly for 4-6 months and does not stabil ize in form until 10 12 months postion. Due to this, mmedrate dentures become progressively more i l l f i tt ing. This is a

altimel ne, as each case must be evaluated monthly and if necessary, relines performed.

t lE l l{ l1l0All()Ns dny dentlre when d agqosric intormalr0r ldi ale\ d 'al ire. !1,, Ily solve the patieni's chief complaint (Vvhen the denture record base adaptat 0n is the

defect in the prosthesis.

t{E c0t{TRA[{0 tcATt 0t{s excessive 0ver-closure 0f vertical dimensi0n (a largenew dentures are indicated at the proper vertical dimension.inVDl)). In this case,

63

IIl|TES After relining dentures, if a p a t ie n t c 0 n s t a n t ly r e t u r n s for adjustments due t0 sore spots 0nridge, checlthe occlusion because the relining may have changed the CR contacts.

IIITERII{ PARTIAT DTIITURES CAII CAUSE IISSUE IRRIIAIIl)II

littlEDlATE DEiITURES rernove posterior teeth and allow iissue to healio provide anfor support. Can keep the premolars t0 pr0vide a VDo reference point

l)VERllEl{TURES

G0 PIETE 0VERDEI{TURE -a denture whose base is constructed t0 c0ver all0f an o{iresidual aidge and selected roots. Retained r00ts help prevent res0rption 0fthe alve0lar riimprove denture retention, and allow the patient some pr0prioceptive sense 0f "naturalnlin function 0f the deniures. it|lsl imnorlant bemfit 0f an ovedeniu.e (root-retai

radiographs or patients who wear complete dentures (not necessarily over-dentures). For overdentures, retain mandibular canines bilaterally hecause they provide SUPP

ll0T retention (a locator pr0vides retenti0n).

0ccLusl0l{ARC0il ARTICUIAT0R (ARTICULAIE0 G0I{0YLE) an articulator with itselem€nts 0n the L0WER nember0fthe articulaioland col ylar path elemefis 0n themember. The angle between the condylar inclination and occlusal plane is FIXED 0narticulator. AllGtt BETWEE}I C0llllltAR lllCLlllAll0ll & 0CCLUSAL PtAl{E REilAlCOIISIAIII OTORE AGCURATE).. C0mmonly used for diagnostic mourting 0f sludy casls t0 allow examinati0n of occl

contacis in the retruded contact p0sition and analysis 0f t00th contacts during excu

denture) is PRESERVATIllil 0F TllE AwE0IIR RlllGE.. lt is not always necessaryto coYer a r00t heneat[ an overdedure. However, if a r00t

not covered. the exDosed surfaces are highly susceptible t0 decay The patient'shygiene nust be impeccable i0 prevent root decay.

. Retairud r00ts are the most common lindings when taking r0utine pa

movements of the mounted models.. 0cclusal records in right and left lateral excursions are necessary for setting b0th

medial and superi0r c0ndylar guides. Fabrication 0f cast and p0rcelain restorations t0 ensure c0rrectt00th contacts in occlu

and mandibular movements.

64

|}tl ARIICUIAT0R (I|0I{-ARIICUIATED C0I{DY[E) has condvlar elements 0nupper member and condylar path elements 0n the lower member.lngle hetween condy,ar inclination and occlusalplafle is ll0T C0tlSTAllT (ll0T FIXED) WHEIIl|PEil vs. CL0SED (IESS ACCURATE). This desjgn is more populart0 fabricate dentures.Ion-adiustahle-has a SMALL AXIS 0F R0TAT|0N.Semi-adlustable gives a cl0ser approximation of the axis of rotati0n & teeth and does notall0w intemediate tracking 0f condylar elements.fully adjustable: reproduces ALL border movements lncluding progressive slde shilt andimmediate side shitt (BtllNFI'S |0VEi,{ENT).

l{G SIDE - teeth 0n the side the mandible is movins toward.When the mafdibleis the working side.least 4 other cusps

t0 the right and maxillary and mandib! af teeth 0n the RIGHT sideacceptab e workifg contaci, a denture must have the canine and al

cting the opposing leeth.

CltlG SIl)E the side 0PPoSITE t0 the side the mandible is movinstoward. When theble movestothe right,the maxil laryand mandibularteeth 0n the LEFIis the balancing

t{0TEs

(with natura{ teeth, the balancing side = n0n-working side). For acceptable balancingcontact, at least 3 cusps must t0uch, but il(lT THE CA I E.

llSlVE forward movement ot themandible during which ihere must be at least 3one tooth 0n EACH slde 0f the arch as far posteri0rnts of c0ntact (the anteri0r incis0r, and

oossible).Pr0tr!slve record, records the relati0n 0f the maxilla & mafdible, and is used t0 set thelrorrontalcondylargurdance0ntheartlculato.l\4adewlthmandlbularanteriorieeth6mflforward 0f CR, 0r with mandibular & naxj lary anteri0rteeth edge-to-edge).Christensen's Phenomenon the space tlrat opens b/t posterior teeth during anteriormovement 0f the mandible. Amouft 0f posteri0r separati0n is affected by b0th the ifclsalgu dance and the h0 zontal condylar guida'rce.Protrusive Movement-accomplished when the mandible is moved straight f0Mard untithe maxil lary and mandibular ncisors contact "edge-t0-edge". This movement isbilaterally svmmetrical in that both sides 0f the mandible move in the same directi0n. Themandihle can orotrude - lomm.

65

tl0TES CURVE 0F SPEE (ilAxlttARY ARCH) - anterior-posteri0r curve fr0m incis0rs t0 m0larsCoNVEX with respect t0 the maxillary arch and concave with respect to the mandibular. Gomle$ating Cune-the anteroposteri0r and lateral curvature in the alignment 0f

0ccluding surfaces and incisal edges 0f artificial teeth which is used t0 developbalanced 0cclusion. The form 0f the compensating curve is entirely under the denliconkol (i.e. if during a try in evaluation a dentist notes that a protrusive excursmovemeni rcsulis in the separati0n 0l posterior teeth, the problem can be correctedsimply increasing the c0mpensating curve).

. Conpensating curve all0ws the dentist t0 alter the elfective cu$ angulationcianging the l0rm 0f the manufactured denture teeth. The lunction 0f this curve ishelp provide a balanced occlusim. A pr0ninent compensating curve is requiredthere is a steep c0ldylar path associated with a low degree of incisal guidance.

CURVE 0t Wltsotl mesio distal concave curve acr0ss from one side 0f the mandiarch to the other side.

IEETH C0IIIACT lll ALt EXCURSIoIIS (CEllTRlC & ECCEIITRIC P0SITl0ilS) l0r DESTABILITY. P0sleriorleeth Contacts in a Balanced occlusion:

BII.ATERAI BAIAI{CE0 0CCL|JS|0ll the stable simulta0eous contact 0f 0pp0sing& lowerteeth in CR position with a smooth bilateral gliding contact to aiy eccentric p0siwithin the normal range 0f mandibular lu|lciion, devel0ped to lessen 0r limits tipDingrolation 0f denture bases in relation t0 the suDD0rtins structures. ilAxlilull tlUl{BER

Cuso-t0-Jossa contact in centric occlusion (lvllCP) in an ideal Class l0cclusion.During lateralexcursions,opposing cusps c0ntact 0n the W0RK|N0 SIDE.During lateral excursi0ns, 0n the balancing side, maxillary liflgual cusps (lingual inclic0nlacl ndadibular [acial cusps (l ingual inclines).

Balanced occlusi0n occurs when a c0mplete denture has balance 0n the working side,w0rking side, and in protrusion. This assumes the denture has been constructed in prcperand VDo. BIIATERAI BAUttlCt0 lS IllE 0CCtUSl0ll FoR C0i{PLETE DEIITURES.

5 Factors G0vern Estahlishing Balanced Articulation (some ofthese, it not all, are controlbY the dentist),

l. Inclination 0lthe condylar guidance which is completely dictated bythe PATIE2. Inclination o{ the incisal guidance (horizontal and v e r t ic a lo v e r la p ).3. lnclination ofthe occlusal plane {plane of orientation).4. Convexities 0fthe compensating curve.5. Angle and height of cusps.

GR0UP FU CTI()N ("Ut{lLATERAl, BAIA CED oCCtUSlol{") Arr TErfi 0rlwoRxlllc SIDE [0llIACT 0URlllc WoRlflllc tl0vtilEilT. oNtY v{0rking side contactsanterior and posteri0rteeth and n0 non-working side conbcts.. Att posteriorteeth 00 a side c0ntact eve[ly as the jaw movest0ward that side

side). Nlteeth 0n the n0n-workingside D0ll0T contact. 0nly teeth onthe w0rlingcontact during a lateral ercursion.

. llon-worfting (balancing) interlerences: occur on inner inclines 0l FACIAL cuspsmandibular molars.

. Working side (n0n-balancing) interferences: occur inner aspects 0f LlllGUAL cuspsmaxillarv molars.

. Protrusiye lnterlereoces-occur between DlSTAL inclines 0l FACIAL cusDs 0lp0sterior teeth and MESlAL inclines 0l FAClAL cusps 0f maodibular p0ste 0.Purp0se 0f making a record 0l protrusive relation is t0 registerthe condylar path a

66

adiusttie condylarguides of the aniculator s0 they equalthe patient's cordylar p

TICAI DIMENSIl1I{ llF I|CCLUSIt]N

complete denture patient, when the teeth, occlusal rims, and central bearing point arecontact, and the riandible is in CR, the [Etl0TH 0f the face is the occlusal vertical

t0n

Vl)l) is evaluated using 4 methodsl. evaluating 0verall appearance 0f facial support.2. visual observati0n 0f space between the occlusal rims at rest.3. measurment b/t dots 0n the face (placed 0n the tip 0f n0se a[d chin with a Thompson

stick) when thejaws are at fest and when ihe r ms are in contact.l.observaiionwhen"s"soundisenunclatedaccuratelyandrepeatedlyt0ensure

adequate speaking space between the occlusal rlms/occl!sal plane.

VD() may result in trauma t0 unde.lying supporting tissues. A CLoSED verticalsion is the most likely cause 0f IHElLl)SlS in patients who wear a c0nplete denture

a n0n-contributory medjca hist0ry.

il{]TES

t :loc

e{

tstablish the VD0 BEF0RI making a CR record.Teeth c0niact during swallowing, but N0T during speech. lf teeth touch d!ring speaking,vD0 is too great.

rE

bfsa

the mandible is in it's physiol0gic rest {p0stural position), TEETH D0 tl0I G0 TACLi0l0gc rest position 0ccufs when the mandibe and all 0f its supp0rting muscles (8cles 0f mastication + suprahyoids & infrahyoids) are ln thelr resting posture (ihere iscular equllibiufl). This lack of t00th contact is lhe "freeway space" 0r "inter0cclusal

ce" and averages 2-6mm. This position is a "rnuscle-guided" posit 0n and is thenning and end poirt 0f most mandibular movements.

0CCtUSAt DISTAI{CE ("FREEWAY SPACE") the vertical dislance 0r soace createdthe mandible is in its physiologic rest posit 0n betweef lnclsal and occluding sLdaces

max llary and mandibular teeth or occlirsron rims. EVEI lllCRtASE the freeway spacethan 1.5mm.

Rest position 0f the mandible (postural posltion) is determined mosily by musculature. Theusuai rellex cited as the basis for the mandible's postura position is the tonic stretchrellex 0f the elevat0r muscles. The rest posjtion is a "muscle-guided" position.

TlCAtDlMEtlSI0ll 0F 0CCtUSl0ll (Vl)0) thevedica ersth of thefaceas measuredeen tow arbitrary selected 00ints (one above and 0ne bel0w the m0uth) when ihe teeth 0rsubstitute material (0cclusal rims) are if contact in CR. Phonetics and esthetics help

a satient's vertical dimensi0n 0f occluslon.

ESSIVE VERIICAt DlMENSl0l{ (V00) may result from trauma t0 underlyingpporting tissues (defture patient), strain ng of the elevator/closifg muscles, and adversely

rnter0cclusal clearance (decreased freeway space) causing l0ss 0f inter0ccLusalce in the rest position. Excessive veriical dimension s the usual causes 0f Cl"lCKll{G

DE TURE IEEIIi (t0 treat remount and fabricate a new complete denture).Clicking of dentures can als0 he caused by lack 0f retention of the maxillary &mandibular dentures. To treat, il due t0 underexlension, b0rder m0ld and reline. ll dueto 0verextension, reduce as indicated with PIP and discl0sing wax.Porcelainteeth can also causedenture clicking. T0 treat, use acrylc resin teeth.IncreasedV00 is the usuai cause of contacling/clicking 0f posteriofteeth when a patient speaks.

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67

NOTES DECREASED VERTICAL lllilEl{Sl0tl fl00) an occludins vertical dimensionIXCESSIVE lllTER-|lCCLUSAI DISTAilGE (increased lreeway space) when the mandible isthe physiological rest position.. Example: pe0ple with n0 teeth 0rwho have worn dentures for a longtimepresent with

lower p0rtion 0f the face scrunched up, 0r d0 not show their lips anymore (p00rpr0file). T0 correcl, rnake new dentures and increase V00. This decreases inter-occldistance (freeway space).

. DECREASEo V00 ofien results in CHEE( BlTlilG.

Factors t0 c0nsider when verifying V00:. Pre-extraciionrecords

Am0unt of interocclusal distance (freeway space) t0 which the patient wrspreviously accustomed.Esthetics (facial harm0ny and facial expression are considered).Phonetics (speech sounds).Length 0f the lip in relation to ihe teeth.Condition and amount 0f shrinkage 0l the ridges.

VERTICAL DIMEt{Sl()ll 0F REST (VDR) the vertical lensth 0f the face measuredtwo arbitrary points (1 point above & 1 below the mouth) when the mandible is in thepositi0n. ln a physi0l0gically healthy individual, there is always a vertical space betweenteeth (freeway space) when the mandible is in the rest position. This position is importantcomplete denturc fabricati0n because it prcvides a guidet0 the VDo.VIR = Veftcal Dimensi0n 0f l)cclusi0n (VD0) + Inter0cclusalllistance.

Balanced Centric 0cclusi0n in pa.tial dentures is necessary for appliance stability.franework's design and relationship 0f the teeth t0the r;dges als0 influence RPD stability.

Bilateral Eccentric llcclusi0n is tl0T an objective in RPD construction, UNLESS the [aprosthesis is opposed by a conplele denture. The veriical relation for RPDS is usuadetermined by the remaining natural teeth {unlike complete dentures).

TEMP0R0MAiIDIBUIAR .l0ll{T (TMl) a combi0ed hinge & gliding j0int Ginglymoarft0diloid)that permits both hinge like rotati0n and gliding (sliding) m0vements. Ginglymus"rotation" and arihr0dial flreans "freely movable".. In the l0wer (c0ndyle-disc) c0mpartment, only a hinge-lype (rotary m0tion) can

This rotaiional 0r terminal hinge-axis opening 0f the mandible is possible 0nly whenmandible is retruded in CR wjth a conscious etfort by the patient or by ttre dentist'sA pure hinging m0vement is possible only in the terminal hinge positi0n.

. In the upper compartment (mandibular l0ssa-disc) only sliding movemeds (translaticar 0ccur. When the lateral pterygoid muscles contact simultane0usly, the discs ac0ndyles slide l0ni/ard d0wn overthe articuJar eminence (protrusion), orcan movetogether (retrusi0n)during 0pening and closing 0fihe mouth, respectively.

l{uscles Acting on the Tru:. Elevator l{uscles (Close) mandihle: masseter, medial pterygoid, & temp0ralis (a

fibers)- P0steri0r fibers 0i iemD0ralis retract the mandible. lf the mandible fractuUPWARD displacenent 0fthe fractured segment would be caused bythe elevator mu(masseter, medial pterygoid, & temporalis).

. Depress0r ilxscles (0pen) mandible/m0uth: lateral pterygoid, anteri0r belly 0f digast& omohyoid.

. Protrusi0n l{uscles, lateral pierygoids together (individually, lateral pterygoids caulateral exclrsi0n). Lateral pteryg0ids are mainly responsible for positioning atranslating the condyles.

68

IC REtATl0l{ T"RETRUDEl) C0IITACT P0SlTl()tl') a "ligament-guided" positionis the supero-anterior position 0l the condyle along the articular eminence 0l the

dylewiththe adicular disc interposed hetweenthe condyle and eminence. This positl0nan 0ptimum rclative position between all anatomic components, and is a REPEATABLErence position t0 mount casts 0n the adiculatorCR is the mostundrained, retruded anatomic and lunctional positi0n 0fthe mandibularcondyle heads in the mandihular glenoid lossae 0f the TMJS. CR is a "bone{o-bone"relationship (bones 0f the lpper and lower jaws) independent 0l t00th contact. Thepresence 0r absence ofteeth and type 0f occlusi0f are n0t factors.il,lalposed 0r super-erupted teeth can cause a discrcpafcy beiween CR & C0, s0 opposingteeth sh0!Jd not contact when naking a CR record to mount diagnostic casts becausethecontact causes the mandlble t0 defleci 0r move away fr0m CR.lvandible cannot be forced int0 CR from tlre rest position because the patient's reflexneuromuscular defense would resist the applied force. Raiher, the mandible should berelaxed and gently guided into CR.To place a patient in CR, have the patient swallow, t!rning the tongue upward tOwards thepalate, rela( the jaw muscles, or protruding and retruding the mafdible can be effectivewavs to helo record CR.h fixed and removable prosthodontics, CR sh0uld be established PRIoR t0 designing theltamewofts.When a CR record is taken inthe naturaldentition, imprjnts oftheteeth should be confinedt0 CUPS TIPS and the registration material should n0t be pedorated.CR is a "ligament-guided" p0silion. CR is the cl0sing end-poinl 0l the retruded bordermovement (terminal-hinge novement).Tra$verse Horizontal AIis (Terminal Hinge Position) the one rclation 0f the condyles t0ihe fossae in which a pure hinging movenent is poss ble.In complete denture prosthodontics, the positl0f 0fthe planned lVlC 0fthe teeth in centricocclusion is established t0 coincide with the patient's CR (C0 = CR).

ary Requirements for making a CEI{TRIC REtATl0 record when fabricating a RP0:Record the corrcct horizontal relation 0f the mandible t0 the maxilla.Stabilize the lower rec0rd base with equalized veftical pressure.Retain the.ecord in an undistorted c0nditi0n untilthe casis have been accurately mounted0n the articulator 0r untii a previous record can be veril ed.

erials u s e d t o r e c 0 r d ja w r e la t 0nships have varied widely 0verthe years. An idea recordingium is easy i0 hafdle, uniformiy soft while the record is being made, rap d setting, andlly rigid but not brittle when set. Rapid setting plaster zinc oxide & eugenol pastes, and

plaslic are ideal. Avoid sott waxes as a rec0rding material because they nevercome rigid and are likely t0 distort during the cast mounting procedure.

I sufficieft natura posterior occlusion exists, the m a n d ib u la r c a s t m a y b e mounted in C0Ging a ZoE relnforced wax bite. In the case 0f a distal extension RPD, base plates andacclusi0n rims should be placed 0n the framework, and the patient closed into sottenedlccording wax 0r zinc oxide-eugenol paste (preferred)- Whether this record will be in C0 0fCR depends on the case, and is dictated by the presence 0r absence of any natura posteriof@clusion in the oatieni-

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il()TES CEIITRIC 0CCtUSl(ltl (MICP) a "t00th-guided" position defined as the maxiintercuspation 0f the teeth. During typical "empty mouth swallowing" the mandiblebraced in lhe inter-cuspal position.. Empty nouth swallowing occurs frequently during the day and is an important t0 rid

mouth of saiiva, and m0isten the oral structutes. The hourly rate 0l non-mastiswallowing is related t0the amount0l salivaryfiow and is usually an involuntary refler activ

. Masseter muscles contract and the t0ngue tip touches lhe r00l 0l the molth durinormalswallowins.

. T00th conlacts are longer during swall0wing than chewing, but thts varies among peo

ART|CULATl0l{ relationship oJ teeih during movements into and away from theposrtion, while the teeth contact.

CotlDYtAR GUII)AiICE a factor T0TALLY dictated hy the patient. tt is the mechandevice on or ar icJlal0r intended to produ.p similat BUidances in arl iculalor rcovemelt thare pr0duced bythe c0ndyle paths dudng rnandibular movements.. Condylar guidance is completely dictated by the patieni and cann0t be varied

"adiusted" by the dent'st.. The inclination 0l condylar guidance depends 0n:shape & slze 0fthe bony contour of

Tll4J (fossae afd disc), action of the muscles attached to the mandible, limiting etfectsthe lrgaments, and the meth0d used fof registration.The incline (arg!lation) 0f the condylar element 0n the articulaior is anatomicallv relat0 the sl0pe 0f the condylar articular eminences (c0ndylar inclination).When adjusting the condylar guidance for protrusive relati0nship, the incisal guide pinthe adlculator sh0uld be raised out ofcontact wtth the incisaJguide table. The pr0trusrec0rd is pr0bably the TEAST reproducible maxillomandihular rec0rd.When restoing the entite mouth with cr0wns, the protrusive condylaf path inclinatinflLences tlre mesial inclines o1the mand bular cusps.RETRUSIVE M|)VEME T re0uires the c0ndyles t0 move BACXWARD & UPWARD.UTTERAI ill)VEMtilTS, thew0rking c0ndy]e moves down,lorward, and laterally, and nworking condyles move d0wn,lorward, and medially.The inc inati0n 0f ihe condylar path during protrusive tr'tovement lorms an avefage aof -30' with ihe h0rizontal relerence plane. lf the protrusive inclinaiion is steep, the cheight may be obviously l0nger Jf the inclinati0n is shallow, the cusp will be shoder Thlactor is the M0SI important aspect 0l condylar guidance that affects the selectionposteri0r teeth with appr0priate cusp height.

. In complete dentures, the condyle path duingfree l'tandibular m0vements is g0verned maibythe SHAPE 0fthe fossa and meniscus (articular disc) and the muscular inltuence.

0eterminants ol 0cclusion:. Rlsht & left TIVUS. 0cclusal surfaces ol teeth and the neur0nuscular system. The concepts ol 0cclu

arrangenent aim t0 place artificial teeth i,t harmony with the JIIIJ and neuromuscusystem. 11 done properly, it results in minimum stress 0n the teeth and rcquires min!etf0rt by the neuromuscular system when perf0rming mandibular movemerts. 00tiocclusi0n requires minimum adaptation bythe patient.

4 Dentition Features that Directly Efiect PDL llealth & Hard lissue Anchorage lo0cclusalForce,

1. ante 0r teeth have slight 0r n0 contact in MlCP (intenuspal position).2. occlusal tahle is < 60% of the 0verall F L width 0f the t00th.3. occlusal table is at right angles to ihe t00th's long axls.4. mandibular molar cr0wns are inclired 15-20'towafd the l insual.

70

ll€0retical 0eterminants Re0uired t0 Restore a C0mIlete & Functi0nal 0cclusal Surfacea Toothl1. Amount 0f vertical overlap ol anterior teeth. The anterior determinant olocclusion is

the horizontal and vertical overlap rclatiOnship 0f the anteri0r teeth.2. C0nt0ur 0f the articular eminence.3. Amount and directl0n 0f laieral shift in the working side condyle.1. Tooth position in the arch.

, the jaw relationship most comm0nly used in the ACTUAL design ol restorations is iheRED centric 0cclusi0n. The height 0f the pulp h0rn ol a particular t00th is ll0T a

ired determinantt0 restore a complete and functional occlusalsurface

CLUSAt PtAtlE dn .magindry srr la e reated aralomically to Lle cJanLm andically touches the incisal edges 0f the incisors and tips 0f the occluding srdaces oJ the

riorteeth. lt is n0t really a plane, but represeirts the mean curvaiure ofthe surface.Anterl0r p0int 0f the Occlusal plane s determined by the position 0f the anterl0r teeth.P 0 s t e r i0 r d e t e r n in a n t s arc anatomica landmarks (2/3 the heights 0f the retrom0lar pads).Thus, it is debatable as t0 the extent of controlthe dentist may ererc se overthe orientationoftlre occlusalplane.

ll{Ctl l{ATl0ll ang e nade bythe sl0pesof a cuspwith a perpendicular l ine bisectingcusp, measured mesiodistally 0r buccolingually. Cusp ifcl ination ls under the dentistt

| (choosing 30'teeth, m0n0plane teeth, etc.).In a protrusive c0ndylar movement (protrusion), lnterferences can occur between 0ISTALinclines of maxillary posterior cusps and I{ESlAt inclines 0f mandibular posterior cusps.In a protrusive movement, the mandibular condyles move 00WIWARD & F0RWARD.During profrusrve movemeni, there are occlusal contacts occufiing on the maxillary distalinclines and mandibular mesial inclines. Anteriorlv, the faclal surface 0f the mandibularincisors wil l c0ntact the guiding inclines (l ingual) 0f the maxil lary incisors and canines.In any rcstorative case involvlng ALL teeth in the mouth, the protrusive condylar pathinclinati0n wil l have its primary iff luence 0n the same incljnes (disial 0l maxil lary &mesialol mandibular).The pathwayfollowed by the anterl0r teeth during protrusion may not be sm00th 0r straightbecause ol contact between the anteriOrleeth and s0metimes the posteriorieeth.Centric Interlerence (Forward Slide)-corrected by grinding IVIESIAL INCLINES oJ maxil aryteeth and DISTAL INCLINtS 0f nandibular teeth.This gr0up functi0n 0f teeth on the working side evenly distributes the occlusal load.While, the lack 0l contact 0n the non-workjng side prevents those teeth from receivingdestructlve, 0b iquely direcied f0rces found in n0n working interferences, and saves thecentric holding cusps (i.e. mandibrlar buccal cusps and maril lary cusps) fr0rn excessivewear The advantage is tlre maintenance 0f the 0cclusion.

uAttY PRoTECTED 0CCtUSt0lt ('CAil tE GUtDED" 0R 0RGA tC 0CCtUSt0t{) -ior teeth orotect the Dosterior teeth in all mandibular excursions. Canines 0ISCLIJDE theiorteeth during wOrking and non-working m0vements.

Canine Guidance is an 0cclusal relati0nship exists where the vertical overlap 0fmaillary & mandibular canines causes disclus'on (separation) of AtL posteri0r teethwhen the mandible moves t0 either side. All other teeth do rot contact once they movefrom CR. lf there is contact of other teeth, "working side" or "fof-working side"irterferences occur depending on which side the mandible m0ves towards.When placing a crown 0n a maxillary canine, ijy0u change a canine pr0tected occlusi0n i0gr0up function, you increase the chance for "n0n-w0 ing side" interferefces.

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N(lTES At{TERl0R GUIDAI{0E (AI{IERl0R C()UPtlt{G) result 0l h0rizontal & verlical overlap

anterior teeth. A tightly overlapping relati0nship 0f 0pp0sing maxillary and mandibuincisors and canines that DISCIUDE the posterior teeth when the mandible protrudes

m0ves in lateral excursion. Anterior guidance also atfects lhe surface morphology 0l p0s1

teeth.Ihe greater oYerlaD, the l0nger the cusp height.

lllclsAL GUI0ANCE a measure 0f the anount 0f movement and the angle at which I

l0wer incis0rs and mandible must move from the overlapping Dositi0n 0f centric occlusi0n

an edge-|o-edge relaLionsnip with the maxillary incisors lncisal guidanc e is the sec0nd

cont;lling fa;tor in articulator movement and is t0 some degret, under.the der

controt. tittuencing tactors are eslhetics, Dh0nelics. ridge relali0ns, arch space'

inter-ridge space.. Esih;tics& pholelics arethe nain factors the LllVlT a deniist\ c0ntrol 0f incisal. lncisal suidance 0n ihe articulator is the mechanical equivalent 0f h0rizontal and

verticaloverlaP.

SUPPoRIltl0 CUSPS ("STAMP CUSPS" 0R "GEI{TRIC CUSPS') these cusps contact

opposingteeth in theircorresponding t-Lcenter0n a marginalridge 0riossa These cusps

more ro'bust and hetter suited t0 CRIISH l00d When posterior teeth are in a norm al ir

relationship, maxillary lingual cusps + mandihular huccal cusps are considered

SUPPllRTII{G CUSPS.. Centric st0ps-areas 0f contact that a supporting cusp makes with opposingteeth {ie

ML cups 0f the maxillary l"t m0lar {a supporting cusp) makes contact with ihe

f0ssae (centric stop) 0f the mandibular 1't m0lar'

5 Characteristics ol Suppofting Cusps,1. contactthe opposing l00th in the in t e r c u s p a lp o s it i0 n '2. supp0rt the vertical dimensi0n 0f the face3. are closer t0 the F-L center 0f the t00th than non-supporting cusps

4. their ouier incline has a potential for contact5. have broader, more rounded cusp dges lhan n0n-supp0rling cusps

tl0tl-SUPP0RTltl0 CUSPS C'GUlDltlG" 0R "SHEARII{G" CUSPS) - ma llary

{facial) cusps + mandibular lingual cusps These cusps overlap the opposing t00th wit

contaciins tie tooth anl have nafi0wer and sharper cusp ridges that serve to SHEAR

as they p;ss cl0se t0 the supporting cusp ridges during chewing strokes .- .. .. theinne,occlusalinclineslpading1olheguidingcuspsare guiding inclines" becausF

contact movements, they guide suppoding cusps away Jrom ihe midline Thus, there

the bucco-occlusal inclines (lingual inclines 0{ buccal cusps) 0f the maxillary postl

ieeth, and the l inguo-0cclusal inclines (buccal inclines 0f l ingualcusps) 0fthe mandibuposteriorteeth.

In a posterior cross-bite situati0n' slpp0rting and guiding cusps are opposite

maxillary buccat and mandibular lingual cusps are now lhe supporting cusps and

maxil lary l ingual and mandibular buccal are the guiding cusps'

CTIVI GRltloltlG the reduction of occlusal interlences ustally done BEF0REcting a fixed hridge 0r denture for a patient to PREVET{I duplicating the deflective

lusal c0nlacts in the final restoration. Ihe purpose 0l selective grinding is to removeinterterences without destroying cusp height. Thus, when interferences exist in centric,not in lateral exculsiors, the lossa 0f marginal ridge opposing the premature cusp isned. lt s imporiani that whenever a premat!rity is found, the occlusion be checked in

centric p0sitions bef0re any adjustment is made. lf cusps interfe.e with each other inrsions, then 0nly the n0n-holding cusps are gr0und t0 prevent a decrease in VDo.A comm0n case where it is preferableto selectively grind AFIER a flxed bridge 0r RPD is inplace is when a FPD 0r RPD is t0 be constructed for a space 0ver which the opposing toothhas extruded slightly. The brldge 0r partial is lrequently constructed to the ideal plane 01occ usion and the 0pposing tooth rs adjusted after inserti0n.The m0st common c0mplaint atter cementation 0f a frxed bridge is sensitivitt0 hot & coldand indicates a deflectiye 0cclusal c0ntact. The involved teeth may be sensitive t0 t0uchand when brushing. In these cases, an immedrate correction of occlusion must be made.lmportant if you plan 0n changing a patienl\ veriical dimension using crowns, it iscrit ical t0 m0unt the casts 0n the true hinge axls (face b0w).

Selective Grinding in Comllete Denture Fabricati0n in Cenlric Relati0fl (CR),Secondarycentdc holding cusps arcthe mandibular buccalcusps. Grind thesecusps onlyif there is a balancing slde interfererce.Primary centric h0lding cusps are the maxillary lingual cusps. t{ever grind these cusps.ldeally, selectlve grindlng sh0uld result lr harm0ri0us cusp fossa contacts 0f all upperand lower f0ssa (and marginal idges 0f prenolars). D0 ll0T grind the upper lingual 0rlower huccal cusps. A foMad slide from CR can be corrected by grinding the fltes:alinclines 0f maxil lary teetlr and distal inc ines ol mandibular teeth.Selective grinding of inner inclines 0f secofdary centrc h0ding cusps ls d0ne if abalancing (n0n-working) side if terf erence exists.0nly gdfld cusp tips 0n maxillary buccai & mandihular lingual (BlJLL) cusps if tiey arepremature in centric, lateral, or prolrusive movements. Check belore gr nding.Selectiye Grinding in Working Side (non-balancing side) Relation, the rule Jor selectivegrindlng intederences during wOrking side movements follows the rule of BULL (huccalcusp inne. inclines 0f upperteeth & l ingualcusp infer inclifes of lowerteeth).Selective Grinding in l{on-W0rking Side (balancing side) Relati0n: grind the innerinclines 0f mandibular buccal cusps, and IIEVER GRltll| A(ltt"ARY Llt{GUAt cusPs(pimary centric holdlng cusps).

lasic Principles 0l 0cclusal Adiustment:1. The maximum dislribution 0f occlusalstfesses ir centrlc relati0n (CR).2. torces 0f occlusi0n should be borne as much as possjble by the l0ng axis 0f teeth.3. When surface t0 sLrface coniact of flat cusps 0ccurs, it should be changed to a

"p0int-t0-surlace" c0ntact (lhe cusp tip 0f the t00th 0ccludes with the flat surfaceof it's opposing tooth's cusp).

d. When centric occlusi0n is established. IIEVER take the teeth out of centric occlusi0n.5. llever adlust cusp tips. 0f ly marginal ridges and fossa.

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73

t{0TEs DEl{TURE TEEIH SELECTIllN

SMIIE tlllE (ltlClSAL CURVE) c0mposed 0n the incisal edges oi maxillary anteriors aparallels the inner curvaiure 0f the lower lip. Parallel with the inteFpipillary axisFrpendicular t0 the midlile (middle 0l the lace).. PHI tl.6l8t) EACH NUMBER lS THE SUM 0t THE M0 NUMBERS PRECEEDING ll The

0{the front teeth sh0uld become progressively smaller as you proceed toward the backthe mouth in ihe rati0 of 1.6 t0 1.0 t0 0.6 = Golden Pro[ortion.

Long axis 0f posteriorteeth are inclined toward the LINGUAL.Long axis 0f maxillary incisor cr0wns CoNVERGE slightlytoward the midline.There should be slight iregularities 0n eithe. side of the midline, even though theare similar in size, shape, and alignment.ln younger paiients, maxillary incisors are more prominent, while mandibular incis0rs amore visible with age.

Guides for selecting artificial denture teeth for edentul0us patients: pre-edraction rec0rdteeth of close relaiives, diagn0stic casts, radiographs, photographs, extracted teeth, afollowing ihe lines placed 0n the occlusal rims.

Rlles for Setting Teeth:. Incisal edges 0f maxillary central incis0rs and cusp tips 0f canines lie 0n the

CURVED tlNE with the incisal edges 0f lateral incis0rs lmm abovethe same line.. Interproximal contacts 0f the maxillary anteri0r teeth are situated progressively closer

the gingiva the more distalthey are from the midline.. Incisalenbrasure become progressively LARGTR from the centraiincis0r, lateral,locanin

(the more posterior you g0). Incisal embrasures in younger paaients hec0me smalsometimes t0the point 0f disappearing as the teeth vvear.

. I\4ANDIBUI-AR PoSTERIoR teeth are placed 0ver the crest 0f the residual ridge. lVMlP0STERIoR functi0nal cusps are placed in the fossae 0f mandibularteeth, and can be nfarther than the tacial vestibule.

. l!'lMltLARY ANltRIo R teeth are set FACIALt0the ridge fof phonetics and esthetics. Canincups tips should be parallel t0 the posterior border 0f the incisive papilla. I,IANDlBANTIRIOR teeth are set base 0n the maxillarv anteriorteeth.

14

role 0l AilTERI0R TEETH 0n a denture is ESTHETICS. Spaces, lrpping, rotation, andr changes can be judiciously used to create a natural appearance.

ifg anteri0r teeth t00 far lingually or facially t0 satisf] esthetic c0ncerns sh0uld NoT beWhen selecting teeih, pre extraction records are extremely valuable. Maxillary andbular anterior teeth should l{0T contact in centric relation. Settins maxillarv aid

dibular anteriff teeth s0 they contact in CR prodrces an unsatisfactory arrangement 0ficialteeth l0r com0lete dentures.

that most often contributet0 p00r denture esthetics is placing maxillary anleriorteethctly over the edentulous ridge. Maxillary anterior denture teeth should be placed

ANIERI0R to the ridge.

outline0fanteli0rteeth should harmonize wth theJacef0rm. Convex Drolile faces shoulda similarconvex abialsurface0f anteriorteeth. Broaderc0ntact areas 0fteeih look more

ural 0n dentufes as they are more c0mpatible with aglng.

best esthetics, maxillary anteriorteeth in a complete dent!re are arranged FACIALT0 THE8E. Settirg anter 0r teeth directly overthe ridge causes p00r esthetics. Also, lt is importanthave accufate adaptation 0f the border seal and adequate bulk 0f the maxil lary facialnge for g00d esthetics. VDO als0 affects the lip support. |||axillary central incisors are theST important teeth l0r esthetics. Their placement c0ntrols the midline, speaking I ne, ippport, and smiling line compositl0n.

most Datients, the labial surface of the central inclsor sh0uld be-8mm anterior to theincisors should support0fthe incisive papilla. The lab 0incisal l/3 of maxillary central

lower lip when the teeth are rn occlusion.

llcTl0tlAt needs overshadow esthelic needs when selectins Pl]STtRl{lR TEETH.00 notmandihular m0lars over the ascending area 0f the mandible as occlusaJ forces in thed slodge the mandlbular derture.

0l P0STERIoR TEETH for a RPt is determined primarily hy the amount 0l useful0r t00th space and characterislics 0flhe denture-supporting tissues. Other factors

evant t0 selecting posterl0r RPD teeth inc ude:l.0ccluso-gingivallength,l\40STimp0rtantfactort0determineposteri0rt00thlengthis

ayailable inter-arch s0ace.M-B width, the total [4D space available fof poster]0r teeth is determined by measuringfrom the disial 0f the lower canine t0 the p0int whete the mandibular res dual ridgebegins to slope upward.B-l-width, ihe BL width is narrowed in reiation t0 the m ssifg naturalt0oth. Reducingthe area 0f the occlusal table decreases stress translered to the denture suDDod areaduring f00d bolus penetfat 0n. Als0, reducing the B L width increases t0ngue space.Shade: oosteriortooth shade o1 is usuallv selected t0 harm0ntze wtth the anterior teeth.llcclusalsurface lormr n0 superioft00th form 0r arrangement is identified. Thus, t lslogical to use the least compllcated approach that fulf i ls the paiient's needs.

6. ilaterials: plastic bonds well t0 acryllc resin. Thus, plastic teeth are retained betterthan porcelain teeth. Primary reason for using PUSTIC teeth in a denture is becauseplastic teeth are retained well in acrylic resin.

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ruSTFS C0mm0n Errors Made When Arranging Denture Teeth:. Seitlng mandibular anteriorteeth too far forward t0 meet the maxil iaryteeth.. Failure t0 make canines the turning poift 0f ihe arch.. Seiting mandibuiar f irst premolars buccal t0 the cantfes.. Establishing the occlusal plane by an arbitrary l ine on the face.. Not rotating anter 0r teeth erough to give an adequately narrower effect.

L0wer 1/3 0f a patient's lace appeaF too short afd there s aDlarent loss 0f the vermilionborder 0f the lips. The procedure indicated t0 correct ihis sit!ation is increasinq 0cclusalYertical dimension (VD0).

Errors in occlusion are checked most accurately by REII|0U Tl G the dentures on thearticulat0r using remount casts and new inteFocclusal records.

Potential Problems with llew Dentures:1. Cheek Biting is caused byl

. Posterior teeth set edge-to-edge. Treat by reducing BUCCAL CUSPS 0f mandibutarmolars t0 create proper horizontal overlap.

. Inadequate VD0. Treat by relining dent!res at the corrccted VDo, CR rernount, andlabricate a new dent!re.

. Biling corners 0f the mouth. Treat by RESET CANINES & pREI!10LARS.2. tjp Eiting caused by reduced rnuscletone and/ora large anterior h 0 r iz 0 n t a l0 v e r la ! (overbiie).3. Tongue Eiting-caused by having poster 0r teeih set t00 far lingually.4. Generalized speech difliculty with complete dentures is !sua y caused by faulty

tooth p0sition and/or faulty palatal contours.. Speech problems due to laulty t00th position are avoided by placing the denture

as close as p0ssible i0 the position 0lthe naturalt€eth. Note: the most effective tito test lor phonetics is at the time 0f the wax try-in of the trial denture (usually the4rhappointment).

. Faulty palatal c0nlours are corrected by trial and errOr Add wax to increase contouand remOve wax t0 improve airiculati0n 0f s0unds.

PHl)ENETICS

Palients edentulous tor many years often have more distorled s0eech thafl 0atientsedentulous for a short time due t0 a loss 0t tonus 0f the tongue musculalure.

"S" Sound: mandibular ncisal edges should be even with 0rjust l ingualthe maxil laryteeihinc saledges. Formed whenthetip0ftheirtongueappr0achestheanteriofpalate and ljngualsurfaces 0f maxillary teeth. These sounds bring the mandible and maxilla cl0se logether."S" sounds are the speech sounds that hringthe mandible closes o the maxilla.

lfa patient complalrs when he/shet est0makean"s"sound,itsoundslike,,th",thetwom0st probable causes is either the maxillary incisors are set i00 far palatally, 0rthe palateis rnade too thick-W0rds with the sihilant sound (hissing sounds) are pr0nounced corrcc y with the ifclsaledges 0f maxil lary and mandibular alrnost touching. These sounds are usual y producedbetween resi and the occluding positi0n.Incisal edges of mandib!lar incisors arc established by Occlusal contact with maxil laryincisors and by their posltion lmrn behlfd llingual) and 1mm bel0w the maxillary incisaledges when saying "S". Incisal edges 0l mandjbular incisors are imm antel0r afd l ingualt0 maxil lary incisal edges when making "S" soun0SIBIAilTS {CH, J, Sfproduced by maxil lary and mand bular incisors appr0xinating eachothet Palate and tongue control ing valve.

76

'IH" tlNGU0DEllIAL S0UllD t0ngue sh0uld protrude slightly (2-4mm) between maxillarymandibular anteriof teeth t0 form this sound. fulade by putting t0ngue b/t max and

ibular teeth (1/8 inch (3mm) tlp 0f iofgue sh0uld be visible

" & "V" LABl0DEl{TAL S0lJllDS lormed by incisal edsesof the maxillary incison afdlower l ip).l ip (incisaledges should jusit0uch the wevdry l ine ofthe

'P" & "8" [ABlAt S0Ull0S are formed t0ially by the lips. l\,lade by pressure behind thelps. lf teeth are not set correctly, it can affect this seal 0f llps t0 blild up pressure. P & B

nds are afJected by, anteri0r posteri0r position 0f teeth, incorrcct VDo, and labial llangeickness.

'T" & "0" (Al{lERl0R tlNGUAl- PAIATAL S0UtlDS) lfteeth are set t00 FAR LINGUAL. "t"ilke "d". lf the teeth are set too FAR LABIAL, thef "d" sounds ike "t". A patient whocomplete dentures is having difl iculty trouble pron0uncifg the letter "t" due to

positioning 0f the marillary incisors. l\4ade by tip 0l longLe lou, hing .hp aniFrio'

1(" & "G" VETAR S0UllDS (POSTERI0R tll{GUAL PAIAIAL) Droduced when tonsueches posterior palate. T00th set-up 0l)ES 0I AFFECT VEUTR S0UNDS.

high palatal vault 0r a constricted paiate can cause whisil ing sounds. lvhistl ing durirgh with dentures (complete 0r RPD ihat replaces the inc sors) can be caused by either

ient vertical 0verlap (overjet), ercessive [oriz0ntal 0verlap (overbite), 0r the areaatalt0 the incisors is impr0perly contoured.

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FIXED PARTIAT DENTURES

IEMPl)RARY (PR|)VISI()IIAT) REST(lRATIl)IIS MUST PRl)VIDI:l. Pulpal protection: restoration must be fabrlcated from a naterial t0 prevent

conductifg temperature extremes. lvargjns should be adapted well en0ugh t0 preventsaliva leakage.

2. Positional stability: the tooth sh0uld not extrude 0r drift s0 lITERPR0XIilAtC|)NiACTS PR||VIDE IHIS,

3.0cclusalfuncti0n,thetemporary'sabij lrytofuncti0nocclusallyaidsinpatjentcor.tfort& prevents i00th migrati0n, and prevent joinvneur0muscular imbalance.

4. Easily cleaned: the temp0rary musi be made 0l a mater al ard cont0!r that the patjentcan xeep ctean.

5. ll0n-lmpinging ilargins: it is VERY impodant that the temporary's gifgival margins d0not impinge 0n the gingival t issues t0 prevent inflam{ration that can causehypertrophy, gingival recession, bone loss. N4argins should be well p0lished. AnoVERHANG can res!lt from a prclormed metal 0r resin pr0visional mprope ycontoured, while a CllsT0ltl PRoVISI0NAL can cause horizontal overhang ifimproperly trimmed.

0. Slrength & retention: temporary must withstand the forces it is subjected to withoutbreaking or coming off.

7. Esthetics: if the te m porary ls 0r an anteriortooth, it must provjde a good cosmeUc tesult.

CUST(]I{ INDInECT iECHlll0UE (outside the rnouth in the tAB) F|)R MAI(l{c TE P0RARYCR(IWIIS IS PRETFERED BECAUSE IT IS III()REACCURATT. BETIIR FII & PR|)TECISTHT PUIPbecause when p0ly(methyl-methacrylate), is placed on freshly cut dentin, (as in a directtechnique), it can cause thermaL irritati0n and acute pulpal nflammation. Can make custonlprovisionals using ovef imperssions, templates, or a thin shell crown.

11

ffnTr5 cR0wl{sPrinciples 0f to0th preparati0n for a c0mplete crown:

L Relentiol & Resistance form:. RETE ll0lI prevents removal0f the tesioration

axis of lhe preparation.. Achieved by two 0pposlng vertical surfaces (i.e. buccal & l ingual walls).. Tooth prepafation taper is kept to a minimum to enhance rctenlion (as taper

decreases, retentlof increases).. Greaier surface area 0f a preparation, ihe greater retention (boxes and grooves

increase sudace area.. lvlaximum retenti0r is achieved when there is 0fly one path 0f draw. PINS INCREASI RETENTI0N by increasing length internally and apically

(not externally).. RESISTAIICE, prevenis DISLoDGEIVIENT 0f the restoration by f0rces directed apical

0r obl que and prevents any rnoveflent 0f the rcstoration under occlusal(vedjcal)foices.

Structuraldurabilityarginalintegrity

Preservation of tooth structure.

IDEAI TAPER F0R A CR0W is 5-6" (2.5-3.0" inclination 0n each opposing axialwall). tuialwalls in a crown preparation should taFer no more than 3-6'.

GUlDll{G GR00VES PIACED lN THE CR0WN PRtPARATl0ll PR0VIDE Resistance t0rotaiion, Retention, & path for seating the crowr. liAlN purp0se 0f a buccai 0r lingual groovein a slngle crowJl preparation is IN4PRoVE CR0W RETEilTI0N.

|)CC[USA[ CI-EARAIICE is one 0f the mOst impodant features t0 provide adequate bulk olmeialand strength.. G0tD Crown = 1.5mm clearance functi0nal cusps (l ingual max, buccal mafd). lmm for

fon-functional.. PtM Crown = 1.5-2mm lunctional cusps; 1-1.5mm nonJLnciionalcusps.. AIL-CERAMIC Crowns = 2mm clearance 0n pleprations.

A wide FUNCTI0 A! CUSP BEVEI- provdes space for adequate bulk of netal and preventsperforatl0r 0f the metal due t0 hea!ry occlusal cortact.

PFM Coping Alloys:1. High Noble all0ys: used t0 fabricate metal-ceramic restoraiions (PFVls) c0nsist of 98

gold, platinum, & palladium (with lrace elements). These noble alloys (g0 d, platinupalladium) d0 not 0xidize 0n casting. This feature is mpoirant in a metal substrateso that oxidatr0n at the metalp0rcelain nterface is controlled by adding traceelemefts t0 the metal (s l icon, ndium, iridlrm). This is the BEST T0 USE.. Gold Platinum-Palladiumr Gold-Palladium Silver, G0ld Pallad um.

2. Palladium-Silver alloys ( oble)' 50-60% palladium + 30-40% silver (n0t a noblemetal, th!s oxldizes on casting).

3. ltickel-Chromium all0ys (Base metal all0ys): 70-80% nickel + 15% chrcmium.hase metalalloys readily oxidlze and can create p0rcelain-to-metal interlaceproblems. Nickel Chrom um; Nickel-Chromium-Bery l ium; Cobalt Chr0mium.

along the path of irsertion or lofg

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Coping Features:1. Thickness 0f metaland l0ir ng porcelain. Nob e metal(0.3-0.5mn ihickness).

Base metal (can be as thin as 0.2mm, and must have a higher yield strengihand meltrrg temperature).Piacement olocclusal and proximal contacts.Extens 0n 0f the areas to be veneered l0r porcelainlacial margin design

0LUTE Mlll|l UM P0RCELAlil THICI0IESS is 0.7mm (ideal is lmm).

MARGIIIS.Bevel {Feather-Edge) lllargin-the best linishing margin for CAST FUIL G0LDrestorations allowing burnishing and adaptati0f 0l the gold to the tooth. H0wevef, irpraciice it is diff icult l0 read 0n the impression and die, and may ead t0 inaccurateertension and dislortion ol the wax pattern, and subsequent casting, as a fesuit ofthe thin wax. lt a s0 has the IEAST MAREIIIAI STREII0TH to the casting. An acuteedge/angle with a nearby bulk 0f meta is the 0ptim!m margin for a casting becauseit is easilv burnlshed to mDr0ve crown ft.

Chamfer l\,largin{he PREFERRTD FltllSflltlc tlt{E for casl lullgold restorations. Theresultant casting has sufficient marginal sircngth l/vh e allowing the sliding joint at itsperlphery t0 minimize the gap between the tooth and preparati0n, thus reducing thecement thickness. Combines the advantage ol an easily delinahle margin 0n theimpression and die, with minimalt00th preparation. Preferred gingivalfinish tinefor veneer melal restorations.

3. Shoulder argin (Butt lointffinishing line 0f choice l0r ALt CERAMIC crowns{porcelain lacket crown). Edge sirength of porcelaln is low, tlrus a BUn J0llll isrequired. Sh0ulder provides resistance t0 0cclusall0rces and minimizes !0rcelainstresses. The margin is easily read 0n the impression and die. Main disadvantage isany inaccuracies in lhe crown lit a.e reproduced at the margin, causing increasedlhickness 0f cement. SHoUtDER |||ARolil (butt iojflt) is the P00REST finish tine usedwith cast metal restorations.. Unlike the PF[4 restorati0n which accepts afy marginal design lbevel, chamier,

shoulder), rnarglnal tooth preparation for the At[-ceramic crown or porcelainiacket crown fiUST BE A SH0ULIER.

. Radial Shoulder a modif ed form 0f a shoulder used on a lceramic cr0wns thatcombines max mum s!ppOd 0l the ceramic, wiih a stfess reducing roundedg ngioaxialangle.

. Heavy Chanfer can be used 0n allceramic cr0\{rs (but n0t as g00d as a shoulder).A bevel can be added for metal restorat ors.

. All-Ceramic Crown margin des gn s I TERIIAILY R0Ull0ED SH0Ut0tR.

.l l lain reason t0 use lorcelaif iacket crowns and allceramic crOwns is ESTHETICS.These cr0wfs can flrimic the 0ptical properties 0f a naiural tooth. However, theguidelines for usage, such as t00th preparaii0n are more crit ica and morecompl cated than fOr PFIII restorat ons. lt is advisable to !se all ceramtc crowns 0nlVin the anteri0r regi0n where esthet cs is crit ical.

. All-ceramic crowns are known fortheir L(lW FIEXURAI- STRE 0TH (th's inability t0llex is the mai0r weakness 0f all-ceramic cr0wns). Their relat ve tendency t0fracture at a minimum deformation. Microscolic surlace detects. under load ieadt0 crack propagati0n and eventua lly l0 la ilure.

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NtlTES 4. Sh0ulderwith a Bevelthis margin allows a sliding lit t0 occur at the margin, thusmay be used 0n the proximal box 0f inlays and occlusal sh0ulder 0f the mandibularcrowns, 0r labial margins 0l PFIV cr0wns (metal ceramic). lf these mafgins are placin the gingival crevice (subgingival), l i t t le display 0f metal is seen. Can be used formeta. cerdmic (PflV)!1,.h mplalc0l lars. Useo as lhe l inish l iFe 0n the proxiFal borinlays and 0nlays, and 0cclusal shoulder of 0nlays and % crowns. Als0 used forthefacialfinish line 0f PFIV restorations !|ihere gingival esthetics is not critical.

Periodontium remains heallhier when crown marsins are AB0VE TllE Gll{GIVAI(SUPRAGIilGIVAL), however, supragingival margins are often not pOssible due t0 estheticscaries, so the margins must be placed subgingivally. Il a margin mud besubgingivally, lhe malor concern h il|]l f0 EXTElll) the preparati0n into the t00thatlachment apparatus (invade hiologic width). lfthe margin extends intothe biologic wia constant gingjval irritant 0ccurs and ultimatelythe crown wil l fail. In this case, the tsh0uld have crown lengthening perf0rmed PRIoR to final crown pteparation.

CR0WN TENGTHENING may be done t0 surgically move the ALVE0LAR CREST 3mm apicallhe pr0p0sed finish line {margin) to ensure hiologic width and prevent periodonpathology.

EMERGEIICE PRoFltE the axialc0ntourlhat extends flom the base of the sulcus, Dast thfrce gingival margin. lt extends t0 the tooth's height of coniour t0 produce a STRAICHT LlPR0flLE in ihe gingival 1/3 0f the axial surface. A STRAIGIIT tlllE ACCESS (EI{ERGEIIPR{|FltE) lS IHE T)( G(]ALWHE REST0RI G IEEIH, because itlacililates ACCESS F0R GoRAL HYGIEilE (to0thbrush bristles can reach inlo lhe sulcrs).. The most common eror is creating a bulge 0r excessive convexity.

FEATURES 0t THE Al{iERl0R PFM,L Radial shoulder: periodontal preservati0n and structural durabillU-2. Chamfer: marginal integrity and perl0dontal preservaiion.3. axia reduction, retention and resistance and structural durability.4. lncisal notch: structural durability.5. Wing: retention and resistance, & prcservati0n of t00th structure.

Pl]RCELAIl{ SHADE SELECTI()N

l)Et{TAt P()RCEl"Alll a mifilre 0l FEIDSPAR (main c0nstituent). qUARTZ. & metallicoxides used to impart proper shade t0 the porcelain. When feldspar undergoes fusion, itfomsa glassy material, which gives porcelain its translucency. lt acts as a matrix for the high-fusing quartz, which then forms a refractory skeleton for the othef materials to luse around.Porcelain's compressive strength is GRTATER than il's tensile 0r shear strengths. Dentalporcelain restorations are BRITTTE and are not capable ol much plastic delormation.

MEIAMERISM a phenomenon that causes teeth/p0rcelain t0 appear c0lor matchedunder one light source, but appear very different under an0ther light source (appearsdifferenl under diflerent lights). This property is lmp0dant in matching the shade 01 a PFIVcrown t0 a naturalt00th-

80

E 0l a ceramic crown is matched first based 0n the colols value. Ghroma. then hue.1. Value-a c0lor's brightness. The most critical characteristic that is matched lirsl.

Value is the relative amount 0f lightness 0r darkness in a color (intensity oi a c0lod. Inesthetics, the value 0f a dentufe t0oth depends on ihe relative whiteness 0r blackness0f its c0l0r. Staining a porcelain rcstoratr0n or using a c0mplementary color will reducethe value. lt is almost impossible t0 increase the value. A 60-year old patient,compared t0 a 25 year old patient is most likely t0 have teeth with a c0l0r that is lowerin value and higher in chroma.

2. Chroma-a color's strength 0r saturation. Aspect 0l c0l0r that idicates the degree 0lSATURATI0 0f the hue. The single mOst important factor in shade matching that issuccessiully increased by !sing stains.

3. Hue-the basic colols (c0l0r families) like red, blue, ye 0w, green. Drastic changes 0fhue (color or shade) are often impossible. 0range stain is m0st often used t0 changethe hue.

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Iight sources used in the dental olfice:1. Natural2. Incandescent lacks blue, but ircrease in RE0 & YELLoW3. Fluorescent-decrcase in red, but increase ir BLUE & GREEN.

ll0T place the ruhberake-up removed from the

dan 0n before selecting the shade. Teeth should be clean andpatient' sface.

TYoes of Dental Porcelains:l. High-tusing porcelains used t0 manufacture DENTIJRE TEETI.2. ilediumJusing p0rcelains-used for all-ceramic and p0rcelain lackel crowns.

ll ledium fusing porcelains also contain oxides of l i thium, magnesium, and ph0sphate(in additiOn t0 sil icone d!oxide, alumlnum oxide, potass !m oxide, and sodium Oxide).

3. Low-lusing p0rcelains-used f0r metal-ceramic (PFi,l) cr0wns. Aluminum oxide agentadded t0 l0w fusing p0rcelains during rts manufacture to increase its resislance t0"slunping down" during firing.

ONTIC DESIGN

llTlC -the suspended rnember 0f a fixed brldge that replaces a missing t00th that IIUSTde patieni comfort, convenient contoufs fOr hyg ene, and be esthetlc.

Propef design is more important t0 cleanab ity and good tissue health than s ch0ice 0fmatefla s.Excessive tissue contact is a major factor in the lai ure 0f FPDS.Area 0f contact between p0ntic & ridge should be small and the part touching the ridgeshould be CoNVEX.Pontic tip should not extend past the mucogingival juncti0n t0 prevent ulceration.Pontic should 0nly touch AfiACllE0 KEnATltllZED Gll{GIVA t0 prevent ulcers.lvlesial, distal, and l ingual gingival embrasure of the pontic should be open for easyclea ng access.P0ntics placed in the non-appearancezone are therct0 restorefunction and prevent drft fg.Success 0rlailure 0l a hridge depends m0stly 0n the pontic design which is diciated byfuncti0n, esthetics, ease 0f cleaning, patiert c0mfort, and the mairtenance by the patient0f healthvtissues on the edentul0us ridse.

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ilt,TES I. MODIFIEO RID6E I.IP P|)IITIG:. P0ntic 0f choice in ihe "APPERAilCE Z0 E" for maxillary & mandibular FPDS.. ljses a ridge lap for minimal ridge contact, but gives the illusion 0l heing a. HAS Att C0llvEx SURFACES FOR EASY CLEAlllllG & PREVEIII F000 ll{PACTl0ll.. Ridge contact cannot extend farther linguallythan the midline (CR[ST) 0f the

edentulous ridge.. C0ntact with the tissue sh0uld not fall just al0ng ihe gingivofacial line angle (t

sh0uld be no space between it and the cresi, a debris trap results.. Pontic contact with the ridge should be compact, iacial t0 the ridge crest, slightlywider lVl-D at the {acial, and narr0wer at the lingual aspect.

SADOI.E PI)IITIC {RIl)GE IAP}.. Forms a large C0IICAVE C0ilTACT with lhe ridge. 0verlaps the facial and lingual

aspects of the ridge.. UtlCtEAtl & UilCtEAl{ABLE & GAUSTS TISSUE lllFtAMMAT|0ll S0 D0 ll0T USE!ltyctE rc p0[Trc (sAil|TARY Pl) Ttc): 'FtsH BELLY". D0ES NOT C0NTACT THE IDENIUL0US RIDGE.. P0llTlG 0F Cll0lCE ltl A ll0il-APPERAIICE Z0tlE (replaces mandibular 1'r molars).. 0cclusogingival thickness must be at IEAST 3mm with adequate space under itlor cleaning.

. Restores occlusal function and stabilizes adjacent and opposing teeth(prevenis drifting).

. CoNVEX in all areas (F L & M D) for easy cleaning.

. Floss passes over smooth round surfaces more easily than it does {lat surfaces wsnarp angres.

. "Arc-Fixed Partial 0enture" (Perel Pontic) = an esthetic modification 0f thehygienic p0ntic thai veneers visible parts 0f the p0ntic with porcelain (occlusalsurface and 0cclusal half ofthe lacialsurface which is allolthis pontic'sfacialsurface).. P0ntic has a concave archway ll4-D and c0nvex underside F-L (HYPERB0LIC

PARABOLOID).. Added burk in the connectors decredses slress lo rhe conrecl0 s wilh diminisheddeflection in the pontic's centerwith less g0ld used.lncreased access lorcleanin

COIIIGAI. P(lIITIC:. P0NTIC 0F CH0ICE F0R A THlll MAllolBUuR RIoGE in a non-appearance zone.. R0UNDED & CLEANABLE butthe tip is small relative t0 its 0verall size.When used

a broad, flat ridge it creates large tr;angular embrasure spaces that collect f00d.OVATE PI}IITIC:. P0 TIC 0F CH0lCt with a BR0AD, FLAT RIDGE giving it the appearance that it is

GRoWNG FRoIV THE RIDGE. Used where esthetics is a Drimary concem.. lt is bluntiy rounded (round-ended design that lits into a ridge depression) where

contacts the tissue and is set into a ridge concavity. Can exiend % ini0 the s0cketatter an extracti0n. E)(TRACiI0t{ SIIE P0llllC

82

TITEVER BRIDGES

VER BRIDGE has abutments at 0NLY 0NE ENo and a oontic attached at the 0iherend.

tcATt0 s:IIIUST HAVE A VERY STRONG ABUT]IITNT & IIIINIIIAL OR NO OCCLUSAL CONTACT ON THEPONIIC,Pontic can replace a missing MAXIIIARY IAIERAI, but the CANINE l\4lJST bethe abutment.Pontic can rcplace a FIRST PREI{0LllR if full cr0wns a€ used 0n the 2'd prem0lar and 1,rmolar abutments-P0ntic can replace l'r lvl0lltR to avold UNILATERAL RPD 0R PREVENT SUPRA-ERUPTIoN.

I SITUATIOI{S T() USE CAIITITEVIR SRIDGE:1. I'ISSIIIG MAXITT,ARY IATERAT. CENTRAL INCISOR IS NTVER AN ABUTI!]ENT IN A

CANTILEVER BRIDGE UNLESS a rest seai is prepared 0n the DISTAL 0f the central {inlay0r metallic rest) AND l\4ES|AL 0F THE P0NTIC T0 PREVTNT R0TAI|0N.

2. tiltss c MA D|BUITR 1.r PRtM|)tARl. 2"d prem0lar and 1" molar are the abutmenis and must have lull covefage cruwns

0n Inem.. 0cclusion must be in the [40SI DISTAL F0SSA 0F THE P0NTIC (1"' prenro ar) b/c

sn0tter evet. ldeal when the l" m0lar needs full coverage and the canine is virgin and full

coverage is f0t desirable (cosmetic concern).3. Pontic can replace l{lsslliG ld M0LAR to avoid UllltAltRAt RPD 0R PREVEI{I

SUPRA-EIUPTI().. BOTJ1 PREIIIOLARS NIUST BE ABUTI!]ENTS & THE PONTIC IIIUST RESEIV]BLE A

PREIV0LAR (not a molar) t0 decrease the length 0f the lever arn and mririmize stresson the pfemolar abutments.

In a posterior FPD, a pontic should be: in c0ntact in centric occlusion, may or may n0t be ncontact ln working slde movements, and should NoT be in contact ir ron working sidemovements.. Be non-porous, smooth, wilh a polished surface.. lvlake passive pinp0int c0ntact wlth the gingiva tissue.. l{0t he c0ncaye in two directi0ns.. Be readily cleanable by the patient.. Be narrower at the expense 0f the llngual aspect 0f the ridge.. Be 0n as straight a line as possible between the retarners t0 prevent any torquing 0f

retainers or abutments.

PIER ABUTMENTS

A traditional rigid SoLDERED 5 unit bridge is NoT desirable because 0f physi0l0gical t00thm0vement, arch positi0n 0f abutments, and the retentive capacity of the retainers. S0, youneed a STRESS-BREAKER, NoN RIGID C0NNECT0R to prevent the "PIER ABUTI!4ENT" fromactlng as a FULCRU[] or LEVER.

PIER ABUTMENI freesta nd in g a butment with ed entu lous spaces on each sidethat requiresa NoN RIGIDC0NNECT0R. A pier abutment does n0trequire a rig d connector(i.e. s0lderj0int)which is the PREFERRED way to connect the abutments and pontlc 0f a bridge.

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NI]TES ill) -RlGlD C0I{NECI0R-a hroken stress mechanicalunion 0fa retainer (abutment) & p0ntic. USED (lIITY Il)R A SHI)RI-SPAII BRIDGE REPIACIIIG |)IIT TI)OTH'. NON.RIGID CONNECTORS DECREAST OR NEUIRALIZE DISPI.ACING FORCES ON ABUTIIIENTS

BY ETIMINATING A FULCRUIV EFFECT ON THE PIER ABUTI\4ENI. DO NOT USE IFABUTMENTS HAVE SIGNIFICANT I!,IOBILITY (PERIODONTALLY COIlIPROMISED).. IRAIISFTRS SHTAR STRTSS ltl SUPPONTI O B()IIE, }Il)T I|) IHE COIIIIECT()NS.. IIIINIIMIZES M-D TORQUING OF ABUTI!4ENTS, BUT ALLOWS THEI!] TO IIIOVE INDEPENDENTLY. Stress-brcaking device in a five unii FPD !s PIACE0 0 THE MlIl DtE ABUTiIE T(PIER)t0

eliminate a lever and fulcrum bv ISoLATING THE toRCE oNtY T0 THE tPD SEGI!'IENTWHEREIT IS PI-ACED.

. o0VEIAIL KEYWAY of the connector is placed on the 0lSTAt SllE 0l the pier abutmenl(middle abutrnenit00th) because 98% 0J posteriorteeth TILT IVESIALLY when subjected t0vertical occlusal forces. Thus, mesialtooth movem ent seats the key into the keyway more

solidlv. lfthe keyway were placed 0n the mesial side' the key would unseat during mesial

movements.. KEY is placed 0n the t{tslAt 0F TllE 0lSTAt P0llTlC. The mosi c0mmon key design is a T-

SHAPED KEY. The path 0f inseii0n 0l the key int0 the keway is patalleli0 the Pathway0l the retainerthat is not involved wit[ the keyway.

MARYLAND BRIDGE (RESII{-BllI{DED FPD)

A c0nseryative restoration (etched-material prosthesis) wiih solid metal retainers that

relies 0n the etched innet surface in the enamel 0f the retainers for its REIEilTll) Thegrooves give increase RESISTAIICE F0RM. Requires an abutment MESIAL & DISTAL t0 the edentul0us space. Requires a shall0w preparati0n in enamel (uselul in children with large pulps who are at

risk for ex!osure).. Both abut$ents inclinaiion Nl-D difference cannot be > 15' wiih n0 diflerence in the

abutment's inclination F-1.. Pre0arati0ns demand additional RESISTANCE via long' well defined grooves. Can be noderate rcsorotion with n0 gross soft tissue deiects. Abutment teeth are basical!y left intact. tro0ves l0r a resin-bonded FPD (Maryland Bridge) Provide mainly RISISTAilCE Fl)R

bv preventing B-L rotation. The gro0ves can als0 pr0vide RETENTIoN 0n crowns

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tcATt0ils:RISI0RATI0N 0F CH0ICE t0 replace l-2 missing luAil0lBUIAR lilclS0RS when abutmentsare unblemished icaries free).Replace MAXII|ARY ltlClS0RS if patient has an open bite, end to-end, of moderate overbite.used as a PER|0D0tllAt SPLlllT (but abutment m0bilitv can cause fallurc).Can replace molars i{ childs masticatory muscles are not well devel0ped.Rellace SI GTE P0STERI0R T00T{ (10% higher risk 0f failure if more than I p0ntic).Not used Jor FPDS > 3 units unless a mitigatingtx-plan consideration exists (i.e.0pposingRPD which results in less occlusalstress.

Pre0atation Features:. Should encompass atleast 180'(guide surfaces/planes interproxinalard extend 0nt0the

facial t0 achieve a faclal l ingual lock). Want t0 extefd as far as possible t0 providemaxrmum surface area for bonding.

. Vertical stops are placed 0n all preparations l0r RESISTAIICE & RlGlDmf.

. Grooves increase RESISIAIICE T0 DISPI"ACEMEIIT 0ll AtlTERl0R PREPARATI0IIS.

. occlusal clearance is needed 0n very few teeth prepared for abutments (.5mm is neededlor maxil lary incisors).

. Light chamler (1mm) linish line is placed SI,PRAGIilGIVAL throughout the length t0minimize deleterious effects t0 the peri0donti!m.

C0tlTRAlllDlCATl0llS - patients with DEEP VERTICAI 0vERBlTt (vERTlCAt 0vERlAP),ofiEilstvE cARtts. & l cKEt sEt{srTrvmf. M0BruTy.

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Al)VAIITAGES 0F MARYtAll0 SRIDGES reduced cosi, n0sLpragingival margins (mandat0ry), minimal t00th preparati0r, andthe wings are not bentorsprung.

oisadvantages ol lilaryland Bridges: I. IRREVERSIBLE and uncertain longevity. N0 space correcti0n (lf lVl-D width is verywide, 0nly s0 much porcelaln can be added t0 iill

the embrasure space). N0 alignment c0rrection (cann0t corrcct aLignment 0f teeth due t0 not restoring lacial,

proxinal, & incisal areas).. Difficult to temporize (cannot make a provision FPD).

anesthesia requlred,rebonding is possible if

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FlsTES BRIDGE ABUTMENTS

IDEAI ABUTiIEI{T is VITAI TEETH with ll0 lu0Bltl . Abutment is evaluated fOr 3 fact0rscrown:r00t ratio. r0ol configuration. and periodontalsurface area.

I)PTIMUM CR|)WI{-R(]I)T RATIO Fl)R A T()()TH T() BE USED AS A TPD ABUTME T IS 2:3,1:l is the MI IMUM acceptable abutmeft !fder formalc rcumstances.Cr0wn-t0-r001 ratio: l:2 is the ll)EAL cr0wn{0-r00t rati0 0f an abirlment t00th Jor abridge ABUTI4ENl Th]s high a ratio s fare y achieved, thus a ratio 0f 2:3 is more realisticA l:1 ratio is the minimum acceptable ratio for a pr0spective abutment under normacircumstances. Crown-to r00t ratio al0ne is NoT adequate cri ieda for evaluating aorosoective abutmef t tooth.Secondary Retention double abutments (secondary abutment)to overc()me uffavofablecrown:root ratios and long spans. The secondary abltment MUST have at east as muchr00t surface area and as favorable a crownrroot ratio as the primary abutment (abutmentneJd t0 the edentulous space). A canine is a g00d secondary abutment vs. a lrstpremolar, while a lateral is NOT a g00d ch0ice as a secondary abltnent t0 a can ne.R(ll)T C()I{FIGURATI{IT{ WITH THE WIDEST F.t DIIIIEIISIl)II IS THE BEST ABUTMETIT.1sr M0UR lS THE BtST ABIJT EIIT & CAtllNt lS THE 2n0 BEST ABUTI{EIIT BECAUSE THEYHAVI THE TARGEST R()()T SURFACE AREA,SIIIGIE ROOT TOOTH WITH AN IRREGULAR CONflGURAIION OR CURVATURE IN ITS APICALTHiRD IS PREFFERED IO A ROOT WTH A PERFECT ]APER.R()OTS THAT ARE BR|)AI)ER F L THAN IV] D ARE PREFERRED TO ROOTS THAT ARE ROUND.BIVERGTIIT Rl)OTS ARE BETTER ABUTMEIITS THAII TUSED/CI}IICIAT ROl}TS.

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AI{TE'S IAW the combined abutmeftteeth root surface area must be equal0r greaterthanihe edentL oLs space {pont c space). Any FPD replacing morcthan two teeth is high sk.

TIITED M0LAR ABUTMEI{TS - A 3 urit bridge will not seat if the dista abutment iftrldesltilts mes ally) 0f the ine of draw 98% 0f posteri0r teeth TILT I4ESIALLY when subiected t0occlusal forces. The long axs of FPD abutmenis must converge n0 more than 25-30'. Anygreate. mesial tilt req!ires either:

1. odhodontics (uprighting) h the TREATIVIEIT 0F CH0ICE to better position a mesiallytilted FPD abutment, distriblte forces, and helps e minate bony defects al0ng theroot's nesial surface. Takes ar0und 3 rnonths.

2. PRoXIMAL % crown, !sed if orth0dortics is impossible, (a % rotated 90's0 the distasudace is !ncovered). 0nlv !sed i l the distal is caries-free. C0ntraindicated if there isa severe marginal ridge height discrepafcy between the dista 0lthe2dm0larandmesial 0f 3'd molar dLe t0 the tiping

3. Telescoping cr0wn and coping. A full crown preparation follows the iipped molars l0axis and an nner coping fits the prep, and a proxima y, cr0wn fits over the copifg.A l0ws full coverage wh e c0mpensat ng l0r the discrepafcy between the paths 0finsertion 0f the abutmenis. The c0p ng prov des the marginal adaptation. Indicated fe*rensive facial/ll,rgual rest0rati0ns on the tilted molar ex sts.

4. llon-Rigid Conneclor. Fu I crown preparati0n with a box placed in the distal ol theprem0lar (ke!r,/ay) Ii40st uselLr when the rn0lar lras marked lingual and mesialinclination. l jsed f a post-core 0r D0 amalgam ex sts on ihe premolar abutmert.

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BRIDGES

RIGID C0I{I{ECII)R (solder joints) the PREFERRED !1/ay to conrect the abutments andpontic 0f a bridge (FPD). A rigid cornector distributes occlusal load more evenly than a pierabrtment (n0n-rigid c0nnecior), thus is PREFFEnED F0R TEETH WITH DECREASEI)PERr0D0r{TAr ATTACHT{! T (PtRt0D0ltTAttY [{V0wED CASIS).

tactors that Determine a Fixed gridgework 0esign,1. R00t c0nfigurati0n: important when assessing an abutments peri0d0ntal suitability.

R00ts broader F L than ltl D are preferred t0 r00ts round in cross-section.. lviulti-rooted posteriorteeth with wide separated r00ts provide better periodontal

support than r00ts that c0nverge, fuse, 0r are conical.. Single-rooted teeth with an ifiegular configuration 0r s0me curvature in the Toot's

apical 1/3 are better abutments than teeth with a nearly perfect tapel. R00t surface arca on a !rosDectrve abutment sh0uld also be evaluated.Cr0wn-t0-r00t rati0: l:2 is the idealcr0wn-t0-r00t ratio 0f a tooth t0 be used as abridge ABUTMENI This high a ratio is rarely achieved, but a rati0 ol2:3 is morerealistic. A l:l ratio is the minimum acceplable ratio for a prospective abutment.Cr0wn t0 root fati0 alone is NoT adequate to evaluate a prospectlve abutment tooth.tuial alignmenl 0l teelh, parallelism of abutment prep is BEST determined by the L0NGMJS of ihe orcDarations.tenglh 0l Lever Arm (Span). REPI-ACING 3 TEETH lS THE lllAllMllll,l! The absolutellAxlilUil number 0f p0sterior teeth that can be salely replaced with a lixed bridgeis THREE, and 0nly under ideal condltions. Any bridge replacing more than iwo teethis high risk.. An edentulous space involving 4 adjacent teeth other than l0ur incisofs is usually

best treated with a RPo. lf more than 0ne edentul0us soace exists in the same arch.even thouglr each 0f them could be individually restored with a bridge, lt may bedesirable t0 restore ihem with a RPD, especially if the spaces ate bilatera and eachspace involves two 0r more missing teeth.

. 3d m0lars can rarely he used as abutments since they often display ncompleteeruption, short-lused r00ts, and a marked mesial inclination in the absence 0f a 2"dmolar. T0 !se a 3'd m0lar, it must be c0mpletely erupted, peri0dontally sound, long-separated roots (multirooted), and must display l itt le or no mesial inclinaiion.

. A sinple bridge replaces 1-2 teeth, while a complex bridge replaces 2 0r more teeth.

. Edentul0us areas involving 4 or more missing teeth (except 4 inclsors), sh0Lld berestored wiih an RPD.

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Fixed Bridge Contraindications:. P00f 0ral hygiene, high caries rate,0r multiple spaces in the arch 0rteeth l ikelyt0 be lost

in the near future.. Space not detrimental t0 the maintenance 0f arch stability 0r dental health.. Unacceptable occlusi0n 0r bruxism.. Afteriorfixed bridge is c0ntraindicated when conslderable residualridge resorpti0n exists.

Use an RPD.

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t{0IES ETECTR0SURGERY an acceptable method 0f gingivaliissue retracti0n that passes smallcurrents 0f e le c t r ic it y i h r 0 u g h the g in g iv a lt is s u e s, causing cellst0 desiccate (sc0rch). usuallyresulis in some delayed healing because ofthe lack of proper clot formation, but is very g00dat stopping hemorrhage. Too low 0f an elecirical current in an electrosurgical electrode isdetected by tissue drag.. Electrosurgery 0biectives, coagulation, hemostasis' access t0 cav0surface margins'

and reduce the inner wall 0l the gingival sulcus kem0ving a thin layer ol creviculargingivaltissue).lndications,. Remove hyperplasiic gingival tissue where it has proliferated into preparations or

ovef crown margins..ln place 0f gingival retraction c0rd where substantial attached gingiva is present. Crown-lengthening pr0cedures pri0rt0 fabricating a prcvisional crownContraindications: areas of thin attached gingiva, 0r underlying dehiscence becausegingival recession occur in these areas after electrosurgery. CARDIAC PACEiIAKEnS'|l'tETAL lllSIRU EllTS, Ftll{l{ABtE AGtllTS (t120), KttP THt EIECTR0DE ltl|)vlilG' and d0n0tt0uch a metalrest, t00th, 0r bone.Great care is used during electrosurgery due i0 potenlial seri0us damage t0 the PIlt andsurrounding h0ne, resulting in l0ss of attachment.

EI.ECTROSURGENY WAVEFl)RI{S.1. lJnreclified, Dampened: recurring peaks 0l powerthat diminishes rapidly. Causes

dehydrati0n and necrosis, slow, painful healing, but g00d hem0stasis2. Partially Rectified, 0amlened, damping occurs in the 2'd half 0f the cycle G00d

lateral heat penetraiion, greatertissue destructi0n with slow healing in deepertissuGood coagulation.

3.{.

Fully Rectified: continuous fl0w 0f energy. Good cutting and some hemostasis.Fully Rectilied Filtered: continuous flow of energy Excellent cutting with less tissueinjury and grcater healing.

POSIS (I!(]WELS) & GI)RES

Posts & cores:lf 50% 0fthe clinicalcrown is destroyed, an amalgam orcomposiie core build up is indicated.Comp0site c0res have greater mjcr0leakage than amalgam cores, and they ale not asdimensionally stable.A core must be anch0red t0 the t00th (wiih pins 0r another retentive feature) and not iustplaced to fi l l the void.Not allendodonticallvtreated anteiorteeth requlre posts and a full crown. Placing a postin a conservativelytreated tooth weakens it.Posteriorteeth must have a CAST RESTRoATIoN with occlusalcoverage (at least an onlay)Endodontically treated teeth sh0uld ll0T serve as abutments for distal extemion RPDS(4x greaterlailure rate than non-abutment RCI teeth).Pulpless FPD abutments fail 2x more than vital abutments They should n0t be abutrnentswith a span longerthan l Pontic.For a custom cast-p0st-c0re, place a KEYIVAY or GRl)oVE to prevent r0talion (anti-

rotational deyice). Anti-rotaii0nalleatures (pot holes, slots, channels), but NoT PINS.Post's diameter must not be > 1/3 the root's diameter at the CEJ. l\4ust be a minimumlhickness 0f lmm iooth structurc at the mid-r00t and beyondAllcuspslhinnerthan l4 flust be sh0dened 0r rem0ved.Posts d0 not strengthen roots it's a myth! They simply provide retention for a core Apoorly designed 0r fitted post will cause premature failure of the root

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Primary function 0f Post is t0 PR0V|Dt A PIATFoRM Fl}R THE CR0Wil (retain the core).

Posi material can be meial 0rfiber (esthetic and bondable). Cast post is becoming pass6.. Carb0n & Glass Fiher Posts:flexible, absorbs and disslpates f0rces acting againstthet00th.. Ceramic P0sls: are morc rigid, s0 pr0vide more flexure. Resistancet0 remaining radicular

tooth structure.. Post Shaoes:

. Tapered: usually requires the LEAST internal dentinal structure and corresponds to theshape ofthe rema ining root.

. Parallel: can be iust as conservative if selected within the minimum canal diameter

.2'd Stage, have both parallel and tapered sections.

P0ST WIDIH should involve the m nimum amount of deniin removal, but provide sonepassive engagemefi (non-contact) 0f the 0!tef pedpheryofthe post and inner canal space.

PoST tEl{GTl| - no cleatformula exists for determin ng the idealdepth ofthe post prcparation.Post LENGTH musi be 4 5mm from the apex. The post must be AT LEAST as long as the clinicalcrown. The post should equalthe c.0wn length 0r 2/3 the r00l length (whichever is greater).l lere must be at least 4mm of gutta perchaattheapicalend0lihecanal.

P0SI DESIGI{ active vs. passive. Just because a posi has ihead fg, does not nean it isaciive.The diameter 0fthe preparation drilland postdiameter determine ilthe postisactive.

Post Color:. ldeal coi0r ls that of DENIIN (ceram c restOrations).. Translucent, may need t0 be masked with dentrn-colored core material.. Carbon-fiber posts are black and used with a PFM 0r crown with a comp etely opaque

su0sItucIUte.

fERRUtE EFFECT the preparation margin (finish l ine) [, luST extend at beyond (apica])tothe core and into S0UND T00TH STRUCTURE. Feffule is the 1.5- 2nm 0r s0 ol sound r00tstructure apical to the core that the margins of the crown should engage t0 PR0TECTAGAIIIST R00T FRACTURE. A ferrule makes post-retained full-coverage restorati0nssignificantly more retentive and dramatically strengthens the to0th t0 resist fracture. ltsurnunds the circunference 0f the t00th, holding it together like the metal bands around ihehead of a wooden mallet.. Preparation lor a post c0re sh0uld preserve s0 id tooth structu.e. Ihe margin should be

APICAL l0 the dowel-c0re margin t0 enable the crown t0 girdle the t00th and hrace iterternally.

. lf the tooth is flush with the gingiva, fabricating a post-core and crown w thout efc rclingthe tooth struciure by the crown walls can cause R00T FRACTIJRE.

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t{0T85 Advantages 0l using a post & core, ratherihan a post crown when restoring RCTtreated teeth:. Nlarginal adaptation and fit ol the restoration is independent 0n the l it 0l the post.. Restoration can be replaced in the flture if needed, with0ut disturbing the post and core.. lf the endodontlcally treated tooth is t0 serve as a bridge abutment, il s not necessary t0

maka lf e r00. caqal prFpard i0n parallel wiln the l ire 0t draw 0t other p dparations lrl cdnbe treated as an independent abutment).

. Post and core s made separate frcm thelifal rcstoration. The crown is labricated andcemented over ihe core just as a restoration is placed over a preparation d0ne 0n tooihSITUCIUTC-

. Post & core can be used for teeth with little 0r n0 clinical crown, but rJith r00ts wilhadequate length, bulk, and straightness. For posterior ieeth with less extensivedesiruct 0n of coronal tooth structure, or teeth with less lavorable root configurations, apln reiaifed amalgam 0r composite c0re can be used.

Pt|RCELAIl{ VEl{EERS

Porcelain Veneer Indications,1. Coverlng labial sudace delects l ike eramel hypoplasia.2. l\4asking disc0l0red teeth like teiracycline staining, discoloration after loss of

tooth vita ty.3. Repa r structural damage like fractured incisal edges.4. lmprove t00th contoLr (i.e. peg-shaped laieral incisors).5. Reduclng spaces in cases when 0rth0dont cs are inappropriate.

P0RCEUtll{ VEIIEER C0l{TRAll{DlCAI|0tls severe mbrication 0f teeth, traumatic0cclusa c0ntacis, un{avorable morphology, insufficient tooih structure and enamel. A patientwith a h gh caries index, sh0rt clinica crown, and minimal horizortal overlap are notcandidates for partia veneer crowns. Rather, the restoration 0f ch0lce is a full PFI\4 crown.

Advantages 0l PartialVeneer Restorations (3/4 & 7/8 crowns),l. Prlmary reason for choosing a 94 cr0yvn ovel a full cast crown is T00TH STRUCTIJRE

IS SPARED.2. A great dealolthe margin is in an area accessrblet0the d e n t is i f 0 r f in is h in g and t0

the patient fof cleaning.3. less 0lthe restorati0n margin is fcloseproximrytothegingivalcrevice,thus

decrcasifg the chafce 0f periodontal irritation.4. Can be more easily seated completely du ng cementation. With at least part 0f the

margin visible, complete seating 0f a partial veneer crown is more easiy verif ied bydirect vision.

5. ll it is ever necessary t0 do an electric pllp test (EPT) 0n the tooth, a portion 0f theeflamel is un-veneered & accessible.

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IMPRESSI{1N MATERIATS

HYDR0C0tt()lDS have the advaniage of WETI|t{c tltTRA0RAt SURfACIS we , blt havevery l imited dimefsl0nal stabil lry hecause they are composed of 85% water.

L Reversihle Hydrocolloid (AgaFAgar)-af impression material wh0se physicalstate ischanged lrom a GEt S0L by applying HEAT and is reversed back hy removing heat.Reversible hydrocoli0ids are composed 0f 85% water, 12,15% agar, traces 0f borax,potasslum s! fate, & sodium tetraborate. Agar impression rtaterja s afd dentalcompounds d0 nOt inv0lve a chem cal reaction t0 set.. Advantagesi Easyt0 pour, n0 mixing is requlred lbut a hydr0c0lloid c0nditi0n ng unit

is required). N0 custom tray is required. lvoisture iOlerant, clean & pleasant withacceDjabla 0d0r. excAllenI rhel -l i le. ir exponsive.

. Disadvantages: must be poured im]]ted ately, f inish l ine is diff cult to read, weak ina deep sulcus, and pOtentlally injurious to the patiert if n0t handled pruperly. Verylimited dimensional stability.

2. lrreyersible Hydr0c0ll0ids {A[Gl ATEfan elastic ]apression materialwith yerylimited dimensional stahility.. Advantages; irexpersive, can use stock tray, easl y mixed, and easy to pour.. Disadvantages, unstable, fragl e, may affect the casi surlace, and musi be

poured immediately.

Sol)IUM PHoSPHAIE a component found in alg fate powder that c0ntrols the SETTT GllME ol alginate.

Aftertaking alg nate impressions, lf you placethe impressions n a bowl 0fwaterl0ra fewhours t0 try and preventthem ffom dryifg up before pour ngthe casts, ll,lBlBlTl0l{ can 0cc[r(the impressions absorb water and expands). When rnbibit ion occurs, the impresst0f is not0nger accuTaIe.

Shrinkage occurs in alginale imFressions eyen when placed under 100% relative humidity =SY|IERESIS (0ccurs when exudate like drcplets ol the liqu d medium fOfms on the imoressionsudace). Since shr fkage is undesirable (causes d stortion of impessions), a ginate impressionssh0uld not be left in water (causes expansion) 0r exposed t0 air (causes shrinkage).lmpressions should be poured immed ately t0 ensure accuracy. When immediate pouring s notpossibie, alginate impressi0ns can he stored only briefly in a m0ist paper towel.

Techniques t0 help preyent 0AGGlt{G while taking alginate impressions:. Decrease the t me t0 take an iflpressi0n afd have the patient breathe thr0ugh their nose.. Seat the patienl in an upright positi0n.. Seat the posterior part 0f the tray first. Nl xing the algifaie rapidly causes it to set more

raDidlv.. Decreasing water-t0-powder ralio causes alginate t0 sel laster (affects mix cous stency

as ihe mix is much thicker when less water ls used).. D0 t{0T use cold water t0 mix the alginate because it retards alginate's setting time.

luandibular alginate impressi0n is taken FIRST since gagglng is more likely t0 occur whiletaking the maxillary lmpress 0n. For the fiaxil ary impression, seat lhe posteior portion ol thetray first, then the anteior porUon t0 help prevent a ginate frOm being squeezed out 0fthe traybacktoward the patient's throat. Always remove alginate impressi0ns in one quick moyementwith a snap t0 help decrease permaflent del0rmation. D0 not overseat the tray (0.25 irch)mlnimum 0l a ginate should remaln 0ver all cri l ical stfttctures (espec ally occlusal sudaces).

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?{OT€S When taklng an alginate impression, it is advised that the tray be placed in the mouth afterallcrit ical areas are wiped with alginate. Crit ical areas are buccalto the maxil{arytuberositiesand retr0mylohyoid space. Rest seats and guide planes sh0uld he cove.ed with alginate andany olher sofl l isrue urdercu15.

When taking alginate impressi0n for a RPD, it is best to apply s0me alginate directly 0n theteeth t0 eliminate bubbles and saliva from the rest seat 0rcoarations.

EIAST0MERS impression materials with eiastic 0r ruhherlike qualities used for crown &bridge, secondary impresslons for dentures, and inlays/onlays. When removing elastomericimpressions, use steady force (a snap is not required) t0 minimize permanent deformation.ElastomeE set via a chemical reaction. Elastomers are ll0ll-A0El)US p0lymer-based ru[berimpression materials with good elasticity.

l. Polysulfides (Ruhber Base, ilercaptan, Thi0kol) the base c0ntains a liquidp0lysLlfide polymer (mercaptan polymer) nixed with an lnert filler. The acceleratOr isusually lead dioxide. When these two pastes are mixed, the polymer chains arelengthened and cross l inked through oxidized thiolgroups t0form a rubber l ike material.. Atrayl0r a polysulfide rubber impression that lacks occlusalstops may rcsult in

an inaccurate linalimpressi0n because 0f perflranent distorti0n during polymerizaiion.. Sets in 1214 minutes (the longest setting time).. lvToisture t0lerance in the mouih is acceptable.. Wettability with gypsum is p00r, and it has p00r taste and 0d0r. Has an 18 month

shelf-life.. PolysulJide polymerizati0n 0f is exothermic and accelerated by an increase intemperature or humidiiy.

. Polysullides have g00d fl0w pr0perties, high flexibility, and high tear strength.Polysulfides have the strongest resislance t0 tearing, but impressions can distortwhen removed fron areas where deep undercuts exist. Polysulfides have a l0ngworking tjme and relatively long polymerization time, which may add t0 patientdiscomf0rt. They have a low resistance t0 deformati0n.

2. P0lyvinyl Siloxanes (Addili0nal Silic0nes 0r Vinyl Polysiloranes)-one tube c0ntainssil icone with terminal silane H+ groups and an inert f i l ler The other tube is a vinylsil ic0ne with terminal vinyL gr0ups, chlor0platinic acid catalyst, and fi l ler. Up0n mixing,there is an addition 0f silane hydrogen gr0ups across vinyl d0!ble bonds and does notform by-products, resulting in a very dimensi0nally stable matedal. PVS can be poureduo to I week.. tatex gloves should not be wo.n when mixing polyvinyl siloxanes because sullur

in the latex retards the setting 0l addition silicone materials. Sulfur in ferric anda uminum sulfate reaction s0 uiion may also inhibit polymerization 0f PVS. Somelatex gl0ves might inhibit the sening 0f polyyinylsiloxane.

. [4ixing time (30 45 sec), lt4oderate working time (2 4 min); moderate setting time(6-8 min).

. fxcellent dimensi0nalstability and very l0w permanent deformation.

. Poof tear strength, lowest temperature rise, very high stiffness, very poor wettabilityby gypsum. Addition s;licones are temperature sensitive (increases in temperaiureshortef working & setting times). Easyto mix, easyt0 clean-up, and acceptable 0dorand taste.

. Polyvinyl siloxanes (PVS) are the il0ST Wl0EtY USED & 0ST ACCI,RAIE elasticimpression materials. They have less polymerizaiion shrinkage, low distortion, fastrecovery fr0m deformation, and moderately high tear strength. lv0st PVS can hepoured up to I week after impression making and are stable in moststedlizins solutions.

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3. P0lyethers (lmpregnum/Premier & Polygel (Caulk) are two c0mponent materials. Therubber base includes a polyether p0lymer with ethylene imine groups, sil ica fi l ler, andplasticizer. The accelerator cortalns a cToss linking agent (ar0matic sulfolic acidester) which pr0duces cross-linking by cati0nic poiymer 2ati0n. When mixed, a rubberf0rms by a catl0nic polymerization process.. Advantages, excellent dimensional stability (when dry), clean, pleasant taste & 0d0r,

FAST SETTI G, dimensiona y stable il more than one cast is poured, stable even ifpoured 24hrs afteftaking af imp|essiOn (very l0w pernanent deformation) as it canbe poured up t0 I week, and are truly hydr0phil ic which results in sLperior wettabil iUby gypsum. Polyether impressi0n fiaterial t0lerates m0isture better than anyother elastomer.

. Disadvantages: the most dilficult material t0 remove from the rn0uth {the mostrigid/slitf material), tears easily (p00r tear strength), may adhere to teeth, highwater absorpti0n (dimensionaly unstable in the presence 0f m0isiure), and finemargifs may break. Compared t0 other materials, the ma in disadvantage 0f usingpolyether elastomeric impressi0n materials is they are much stitfer. Has thehrghest temperaiure r se and highest stif lress.

. Polyethers have the SHllRTEST W0RKIIIG & StTTlllc TllylES 0l the elastomerlcimpressi0n materials. lt4 xing tlrne is 30-45 sec0nds (mixes easily); Work ng time ls2-3 minutes; Setting tlme 6-7 minutes-. All elast0meric impressi0n maierials C0IITRACT SLIGHIIY durirg settlng

(they do not expand).. For best results with e astomer c impressi0n material, the prepared t00th sh0uld be

free of surface m0isture. Comparcd t0 hydr0c0lloids, elastomeric impfessi0nmaterials are easierto pTepare, more resistant t0 tearing upon removal, and have asuDer or d mensional stabll i iv.

. Cust0n Trays are an impoltant part of rubber base impression techniques sinceelast0mers are m0re accurate in uniform thin layers that are 2-4mm thick. Withall elast0mers, a cust0m tray sh0uld be fabricated with a plastic material, should berigid, have 0cclusal stops t0 avoid permanent distortion during polymerization,and be coated with an adhesive that sh0uld dry completely before takjng theimpressl0n t0 preveft the impression material from pL ling away.

Zltlo oXIDE-EUGEtl0L-an impression paste whose settingtime is acceleratsd by ADDltlca drop 0f water t0 the mir. To retard lhe setting ol Z0E, add inert 0lls (olive 0r mineral 0ll)during mixing. Zl)E sets via a chemical reaction.. Advantages: can record softtrssle at rest, sets hard n 5 mlnutes, stable, & less e

xpensive than polysulf ides.. Disadvantages: messy to mix, very sticky, tlssre irfitant, not elastic, dilfcult to

manipulate, n0t recommended for gagging patients.

lmpression Problems:1. Grainy Material caused by improper 0r prolonged mixing, undLre gelati0n, 0r t00 low a

waiecpowder ratio.2. Tearing 0l Material: caused by inadequate bu k, m0ist!re contamination, premature

rcmova1 lr0m the mouth, 0T prolonged mixing.3. lrregularly Shaped Voids, due i0 moisture or debris on tissue.4. R0ugh or Chalky Stone Castr caused by inadequate c earing of the mpression, excess

water left in the irfpression. premalure r€moval of the cast, eaving the cast in theimpression 100 long, or improper manip! ation 0f stone.

5. Distorti0n, impression f0t poured mmediatey, movement oftray dLring gelation,premature 0r improper removal lr0m the moLrth, 0rtray was held in the m0uth t00 ong(only with certain brands)

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N$TES Bite Registration Material used t0 make an accurate jnterocclusal record should ofler aMlillllUM RESISTAiICE t0 the patiert's law closure afld haye L0vir ft0w at miring. Recenfly,additi0n-reacti0n silic0ne impression materials have d0ninated the inlerocclusal rec0rd(l0R) market slfce these mater als have VERY t(lw Fl0W when mixed and bec0me rigidafter setting.

GYPSUM

[4ain c0nst]tuent 0f dental plasters afd stones is Calcium Sulfate Hemihydrate.Type l: rarely used tOday.

Type ll: used t0 make casts when sirength is not important (orthod0ntics). Dental odelPlaster (Type ll) heating gypsum in an open kettle. This pr0cess pr0duces porous andiregularly shaped padicles. Dental plaster ls the IVEAKISI GypSUM pR00UCT.

Type ll l : used for preparing casts 0l an alginate impressi0n upon which dentures areprocessed.. DentalStone (Type lll)-produced by HEATINC GYPSUII4 under pressure with watervapor in

an a0toclave. Th s process produces unif0rm shaped and less p0rous padicles. Heatinggypsum in a 30% solution 0l calcium chloride produces high strength (impoved) diestone. Pnd!ces the least p0r0us ard strongest partic es.

Type lV: used when maklrg stone "dies" (reproducti0ns oj teeth with prepafed cavities) usedl0r crown & bridge, and operatlve (inlays and 0nlays).

CEMEIITS - cements do NOT increase cr0wn retention. A t00th must be WtpE0 DRy beforecr0wn cementatiOn, as opposed t0 drying the t00th with alcohol and warm aif to dectease thepossibility 01 pulp damage. Als0, ALWAYS apply cement t0 b0th the rest0ration and the tooth.

l- Composite Resin-the llting material 0l choice t0 cement a cefamic crown and cafprovide the STR0NGEST BoND. Ceramic $owns are bonded with c0rnposite rcsin aftereiching the internal sLrface 0f the cr0wn, and are shown t0 be better if bondingstrength than other materials.

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2. Zinc-Phosphate Cement-rnay also be used t0 cement porcelain crowns. lt ltas g00dcompressive stfength (14,000-16,000 psi), but its high pH is a problem because twoIayers 0f yarnish must be applied t0 pr0tect the putp. ZpC is 0ne 0f the oldest andwidely used cements for luting pelmanent metal restorat Ons and as a used as a base.It rs a high-strcngth cement base, mixed lrom zinc 0xide powder and phosphoric acidliquid. Due t0 its low initial pH, it may cause pulpal i.ritalion, especially where 0nly athir layer of dentin exists between the cement and the pulp.Zinc polycarboxylate 0r Z0Elhese bi0l0gically compatible cements are used 0nteeth wrth preparatiOns with adeqLat€ ength and retentive featurcs, 0r when thepreparatiOn depth raises some concerr rcgarding pulp vitality. Also,lhese cementsexhibit better resistance t0 s0lubility than zinc phosphate cement. Zinc p0lycarborylateand GIC adhere t0 calcif ed denta tissue, and have superiof biol0gic compaiibil i ty thanzinc phosDhate cements.

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4. Glass lonomer Cement (8lC)-a dental restorative matedal used in dentistry forrest0ring ieeth and lutifg cements- These materials are based on the reaction 0fsilicate glass powder and p0lyalkenoic acid. These t00th colored materials werelntroduced in 1972 for use as restorative materials l0r anteriorteeth (Darticuiarlv foreroded areas, Class l l l and V carious lesions). As they bond chemically to dental hardtissues and release fluoride for a relatively long peri0d modern day applications 0f GlCshave expanded. The des rable properties 0f glass i0r0mer cements make them uselulmaterials in the restoration 0f carious lesions in low-stress areas such as sm0oth-surface and small anterio. pr0ximal cayities in prinary teeth.. DC Fuji Ptlls is a resin reinforced glass i0nomer luting cement designed l0r llnalcementation 0f metai, porcelaif-fused-to-meial and metalfree crowns, bridges,inlays and 0flays.l i bonds chemically and mechanicallyt0tooth structure and t0 alltypes 0f core material. lts simple placement technique produces significantly higherbond strengihs than conventional g ass i0n0mer cements whi e maintaining thefavorable characteristics of glass ionomers-fluoride release, low c0efficient 0fthermal expansi0n, and bi0c0mpatibility to t00th structure and soft tissues. Forindirect metal-free restoration that rec0nmend a resin reinforced / resir-m0difiedglass iof0mer for l inal cementation - cemeniable reinforced all ceramic crowns likePR0CERA 0r cemeniable composite resin restoration like GRADIA.

Prolonged sensitivity t0 heat, cold, and pressu.e after cementing a cr0wn 0r fired bridgeis usually related to 0CCLUSAI TRAUMA. lf CR occlusion is high, patient complain 0f coldsefsitivity and pain on biting down hard. Ali patients should have an app0iniment specificallyt0 check the occlusron 0n all crowns and bridges. Excursive movements sh0uld als0 beevaluated, since 0tten patients c0mplair 0f pain 0n chewing soft foods (this indicatesimpr0per balancing orworking c0ntacts). The occlusi0n 0l g0ld resl0rati0ns is best checkedwith stwER PtrsTtG sH[{ sToGK.

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