MOUTH PREPARATION FOR REMOVABLE PARTIAL DENTURE

Varun Menon P Final year BDS

INTRODUCTION
Preparation

of mouth is fundamental to a successful RPD service. Mouth preparation follows the preliminary diagnosis and the development of a tentative treatment plan.

Mouth preparation includes procedures in 4 categories. Oral surgical preparation Conditioning of abused and irritated tissue Periodontal preparation Preparation of abutment teeth

OBJECTIVES
To return the mouth to optimum health To eliminate any condition that would be detrimental to the success of RPD

TIMING

Mouth preparation must be accomplished before the impression procedures that will produce the master cast. Oral surgical and periodontal procedures should precede abutment tooth preparation and should be completed far enough in advance to allow necessary healing period. Atleast 6 weeks but preferably 3-6 months should be provided between surgical and restorative dentistry procedures.

ORAL SURGICAL PREPARATION

The longer the interval between surgical and the impression procedure, the more complete is the healing and consequently more suitable the denture bearing areas. The oral surgical procedures include:Extractions Removal of residual roots Impacted teeth Malposed teeth Cysts and odontogenic tumors

Exostoses and tori Hyperplastic tissue Muscle attachments and frena Bony spines and knife edged ridges Polyps, papillomas and traumatic hemangiomas Hyperkeratosis, erythroplasia and ulcerations Dentofacial deformities Osseointegrated devices Augmentation of alveolar bone

EXTRACTION

The extraction of non strategic teeth that would present complication or those that may be detrimental to the design of the RPD is the necessary part of the overall treatment plan. Regardless of its condition each tooth must be evaluated concerning its strategic importance and its potential contribution to the success of the RPD Attempts made to salvage seriously involved teeth or those with doubtful prognosis, for which retention would contribute little if anything- even if successfully treated and maintained are contraindicated.

REMOVAL OF RESIDUAL TOOTH

All retained roots or retained fragments should be removed. Residual roots adjacent to abutment teeth may contribute to the progression of periodontal pockets. The removal of the root tips can be accomplished from the facial or palatal surfaces without resulting in reduction of alveolar ridge height or endangering adjacent teeth.

IMPACTED TEETH

All impacted teeth , including those in the edentulous areas and those adjacent to abutment teeth should be considered for removal. Asymptomatic impacted teeth in the elderly that are covered with bone with no evidence of pathological condition should be left to preserve the arch morphology. Early elective removal of impactions presence later serious acute and chronic infection with extensive bone loss. Any impacted teeth that can be reached with a periodontal probe must be removed to treat the periodontal pocket and prevent more extensive damage.

MALPOSED TEETH

The loss of individual tooth or groups of teeth may lead to extrusion drifting or combination of the remaining teeth In most instances the alveolar bone supporting the extruded teeth will be carried occlusally as the teeth continue to erupt. In such situations individual teeth or groups of teeth and their supporting alveolar bone can be surgically repositioned.

CYSTS AND ODONTOGENIC TUMOR

A periapical radiograph or a panoramic view of the jaws are recommended . All radiolucencies or radiopacities observed in the jaws should be investigated. The dentist should confirm the diagnosis through appropriate consultation and if necessary perform a biopsy of the area and submit the specimens to a pathologist for microscopic study. The patient should be informed of the diagnosis and provided with various options for resolution of the abnormality

EXOSTOSES AND TORI

The existence of abnormal bony enlargement should not be allowed to compromise the design of the RPD . The mucosa covering the bony protuberances is extremely thin and friable. RPD components in proximity to this type of tissue may cause irritation and chronic ulceration. Exostoses approximating, gingival margins may complicate the maintenance of periodontal health.

HYPERPLASTIC TISSUE

It is seen in the form of fibrous tuberosities , soft flabby ridges , fold of redundant tissue in the vestibule of the floor of the mouth and palatal papillomatosis. All these forms of excess tissue should be removed which will produce more stable denture , reduce stress and strain on the supporting teeth and tissue. The hyperplastic tissue can be removed with any preferred combination of scalpel , curette , electrosurgery or laser. The appropriate surgical procedures should not reduce vestibular depth.

MUSCLE ATTACHMENTS AND FRENUM

As a result of loss of bone height, muscle attachments may insert on or near the residual ridge crest. The Mylohyoid , buccinator, mentalis and genioglossus are most likely to introduce problems. Appropriate ridge extension procedures can reposition attachments and remove bony spines, which will enhance the comfort and function of RPD. Repositioning of mylohyoid is successfully achieved by several methods and genioglossus is most difficult to reposition. Mucosal grafts and transplanted skin can be used. The maxillary labial and mandibular lingual frena are the most common sources of frenal interference with denture design and can be modified with surgical procedures.

BONY SPINES AND KNIFE EDGED RIDGES

Sharp bony spicules should be removed and knife like crests nicely rounded. The procedure should be carried out with minimum bone loss

POLYPS, PAPILLOMAS AND TRAUMATIC HEMANGIOMAS

All abnormal soft tissue lesions should be excised and submitted for pathological examination before the fabrication of RPD

HYPERKERATOSES, ERYTHROPLASIA AND ULCERATIONS

All abnormal white red or ulcerative lesions should be investigated. A biopsy of area larger than 5mm should be completed and if the lesions are large multiple biopsies must be taken. The lesion should be removed and healing accomplished before fabrication of RPD

DENTOFACIAL DEFORMITY

Patients with dentofacial deformity often have multiple missing teeth as part of their problem before specific problems with the dentition can be corrected the patients overall problem must be evaluated thoroughly. Surgical correction of a jaw deformity can be made in horizontal, sagittal or frontal planes. Replacement of missing teeth and development of harmonious occlusion are almost always a major problem in treating these patients.

OSSEOINTEGRATED DEVICES

A number of implant devices to support the replacement of teeth have been introduced to the dental profession. They offer a significant stabilizing effect in dental prostheses long term clinical research has demonstrated good results for the treatment of complete and partially edentulous patients using implants.

AUGMENTATION OF ALVEOLAR BONE

Considerable attention has been devoted to ridge augmentation with the use of autogenous and alloplastic materials. Some of the alloplastic material can migrate or be displaced under occlusal load if not appropriately supported by underlying bone and contained by buttressing soft tissue.

CONDITIONING OF ABUSED AND IRRITATED SOFT TISSUE

Patients who require conditioning treatment often demonstrate the following symptoms:inflammation and irritation of mucosa covering the denture bearing area. distortion of normal anatomic structures a burning sensation in the residual ridge area, tongue,cheeks and lips REASONS:- ill-fitting RPDs , nutritional deficiencies ,endocrine imbalances,diabetes etc

USE OF TISSUE CONDITIONING MATERIALS

These are elasto polymers that continue to flow for an extended period permitting distorted tissue to rebound and assume its normal form. They have a massaging effect on irritated mucosa. Maximum benefit may be obtained by eliminating deflective or interfering occlusal contacts of old dentures. extending denture base to proper form to enhance support ,retention and stability following the manufacturers direction for manipulation and placement of conditioning material.

PERIODONTAL PREPARATION

Follows any oral surgical procedures and is performed simultaneously with tissue conditioning procedures. OBJECTIVE OF PERIODONTAL THERAPY Its the return to the health of supporting structures of the teeth such that the periodontium is maintained. Criteria of satisfying this objective are:removal and control of all etiological factors elimination or reduction of pocket depth establishment of functional occlusal relationship development of personal plaque control program

INITIAL DISEASE CONTROL THERAPY (PHASE I)

ORAL HYGIENE INSTRUCTIONS the most effective motivation technique requires a good understanding by the patient of his periodontal condition. The patient should be instructed the use of disclosing wafers or tablets, soft or medium bristle toothbrush and unwaxed or waxed dental floss.

SCALING AND ROOT PLANING Careful scaling and root planning are fundamental to the re establishment of periodontal health. Use of ultrasonic instrumentation is recommended for calculus removal followed by root planing. Scaling and root planning should precede definitive surgical periodontal procedures.

ELIMINATION OF LOCAL IRRITATING FACTORS OTHER THAN CALCULUS Over hanging restoration margins and open contacts that allow food impaction should be corrected. Patients with severe caries lesion where pulpal involvement is likely excavation of these areas and placement of adequate restoration must be done.

ELIMINATION OF GROSS OCCLUSAL INTERFERENCES Bacterial plaque accumulation and calculus deposits are the primary factors involved in the initiation and progression of inflammatory periodontal disease. Poor restorative dentistry and poor occlusal relationships contribute to more rapid loss of periodontal attachment. Selective grinding is a generally applied procedure.

TEMPORARY SPLINTING If the teeth are mobile, cause of mobility must be determined and a decision must be made for the elimination of the causal factor. Primary mobility caused by occlusal interference should disappear after selective grinding. Teeth may be immobilized during periodontal treatment by acid etching with composite resin , with fiber reinforced resin , with cast removable splints or with intra coronal attachments. After periodontal treatment splinting may be accomplished with cast removable restoration or cast cemented restoration

USE OF NIGHT GUARD It may be helpful in the form of temporary splinting if worn at night after the removable of RPD MINOR TOOTH MOVEMENT Malposed teeth should be considered for repositioning and retention. Additional stability for RPD from uprighting a tilted or drifted tooth may mean much in terms of comfort to the patient.

DEFINITIVE PERIODONTAL SURGERY(PHASE II)

PERIODONTAL FLAPS It involves the elevation of either the mucosa alone or both the mucosa and the periosteum. The important goal is to allow access to the bone and root surfaces for complete instrumentation, pocket elimination caries control crown lengthening root amputation or hemisection.

GUIDED TISSUE REGENARATION Defined as those procedures that attempt regeneration of lost periodontal structures through differing tissue responses. Based on the physiological healing response of the tissue after periodontal surgery. It involves the use of an osseous graft along with a resorbable membrane.

PERIODONTAL PLASTIC SURGERY Objectives include elimination of pocket, creation of an adequate zone of attached gingival and correction of gingival recession. Procedures include lateral sliding flaps,free gingival grafts ,pedicle graft, coronally positioned graft , sub epithelial connective tissue graft and edentulous ridge augmentation

RECALL MAINTENANCE(PHASE III

Reinforcement of plaque control measures and debridement of root surfaces of supragingival and subgingival calculus and plaque. Frequency depends on the susceptibility and severity of periodontal diseases.

ABUTMENT TEETH PREPARATION

ABUTMENT RESTORATIONS Abutment teeth representing sound enamel surfaces in the mouth having good oral hygiene are evident may be considered a fair risk for us e as RPD abutment. Esthetic veneer type of crown should be used when a canine or premolar has to be restored. When there is proximal caries on the abutment teeth gold inlay may be indicated.

CONTOURING WAX PATTERN All abutment teeth to be restored with castings can be prepared at one time and an impression made that will provide an accurate stone replica of the prepared arch. Wax patterns may then be refined on separated individual or removable dies. All abutment surfaces facing edentulous areas should be made parallel to the path of placement by the use of surveyor blade.

REST SEATS After proximal surfaces of wax patterns have been made parallel and buccal and lingual contours have been established to satisfy the requirements of stability and retention with the best possible esthetic placement of clasp arms , occlusal rest seats should be prepared in the wax pattern rather than in the finished restoration.

Important function of a rest is the division of the stress load form RPD to provide the greatest efficiency with the least damaging effect to the supporting abutment teeth. A ball and socket type of relationship between occlusal rest and abutment tooth is most desirable. Sufficient bulk must be provided to prevent the weakness in the occlusal rest at the marginal ridge. The angle formed by the floor of the occlusal rest with the minor connector should be less than 90 degrees.

Rest seats
Rest seats may need to be prepared to: produce a favourable tooth surface for support prevent interference with the occlusion reduce the prominence of a rest

A rest placed on an inclined surface will tend to slide down the tooth under the influence of occlusal loads (1). The resulting horizontal force may cause a limited labial migration of the tooth with further loss of support for the denture. The provision of a rest seat (2) will result in a vertical loading of the tooth, more efficient support and absence of tooth movement.

An occlusal rest placed at the arrow in (1) would create a premature occlusal contact (2), unless a rest seat was prepared to make room for it (3). Space for the rest should not usually be created by grinding the mandibular buccal cusp as this is a supporting cusp contributing to the stability of the intercuspal position.

In addition, a rest placed on an unprepared tooth surface (1) will stand proud of that surface and may tend to collect food particles and possibly create difficulties in tolerating the denture. The preparation of a rest seat (2) will allow the rest to be shaped so that it blends into the contour of the tooth, is less apparent to the patient and also harmonises with the occlusal relationship.

The design of rest seats on posterior teeth is shown in: 1occlusal view; 2mesiodistal view; 3proximal view. It will be seen that preparation involves a reduction in the height of the marginal ridge in order to ensure an adequate bulk of material linking the occlusal rest to the minor connector. Rest seats on posterior teeth should normally be saucer-shaped so that a certain amount of horizontal movement of the rest within the seat is possible. Dissipation of some of the energy developed by occlusal forces acting on the denture can then occur.

The use of a box-shaped rest seat within a cast restoration may result in the rest applying damaging horizontal loads on the abutment tooth. These rest seats should be restricted to tooth-supported dentures where the periodontal health of the abutment teeth is good.

The rest should be at least 1 mm thick for adequate strength. To check that sufficient enamel has been removed during rest seat preparation to accommodate this thickness of metal, the patient should be asked to occlude on a strip of softened pink wax. The thickness of wax in the region of the rest seat will indicate if adequate clearance has been achieved.

Rest seats on posterior teeth Where a clasp is to extend buccally from an occlusal rest and there is no space occlusally for it to do so, the preparation must be extended as a channel on to the buccal surface of the tooth. In some circumstances it may also be necessary to reduce and recontour the cusp of the tooth in the opposing arch.

Where a clasp is to extend buccally from an occlusal rest and there is no space occlusally for it to do so, the preparation must be extended as a channel on to the buccal surface of the tooth. In some circumstances it may also be necessary to reduce and recontour the cusp of the tooth in the opposing arch.

On maxillary anterior teeth, particularly canines, the cingulum is often well enough developed so that modest preparation to accentuate its form creates a rest seat without penetration of the enamel.

A cylindrical diamond stone with a rounded tip should be used to prepare the rest seat. A spherical instrument tends to create unwanted undercuts.

The lingual surface of a mandibular anterior tooth is usually too vertical and the cingulum too poorly developed to allow preparation of a cingulum rest seat without penetration of the enamel. Incisal rest seats therefore have a wider application in this situation, in spite of their inferior appearance. The preparation is shown from the labial (1), lingual (2) and proximal (3) viewpoints.

Incisal rest seats can be prepared using a tapered cylindrical diamond. Alternative, more aesthetic options are to produce a rest seat in composite applied to the cingulum area of the selected tooth, or to bond a cast metal cingulum rest seat to the tooth.

The advantages of guide surfaces

It is widely accepted on the basis of clinical observation that the use of guide surfaces confers a number of benefits in RPD construction. The benefits include the following: Increased stability. Reciprocation. Prevention of clasp deformation. Improved appearance.

Guide surfaces (*) are two or more parallel axial surfaces on abutment teeth, which limit the path of insertion of a denture. Guide surfaces may occur naturally or, as is more often the case, may need to be prepared

Increased stability This is achieved by the guide surfaces resisting displacement of the denture (red arrows) in directions other than along the planned path of displacement.

Reciprocation A guide surface* allows a reciprocating component to maintain continuous contact with a tooth as the denture is displaced occlusally. The retentive arm of the clasp is thus forced to flex as it moves up the tooth. It is this elastic deformation of the clasp that creates the retentive force

Guide surfaces ensure that the patient removes the denture along a planned path (1). The clasps are therefore flexed to the extent for which they were designed. Without guide surfaces the patient may tilt or rotate the denture on removal (2), causing clasps to flex beyond their proportional limit.

Improved appearance A guide surface on an anterior abutment tooth permits an intimate contact between saddle and tooth which allows the one to blend with the other, creating a convincing, natural appearance. Guide surfaces may occur naturally in this situation and if so, tooth preparation is not required.

The preparation of guide surfaces A guide surface should extend vertically for about 3 mm and should be kept as far from the gingival margin as possible.

A guide surface should be produced by removing a minimal and fairly uniform thickness of enamel, usually not more than 0.5 mm, from around the appropriate part of the circumference of the tooth (green area). The surfaces should not be prepared as a flat plane, as would tend to occur if an abrasive disc were used (red area). This is unnecessarily destructive and may even lead to penetration into dentine, thus making a restoration obligatory.

A high survey line on a tooth that is to be clasped is unfavourable because it requires the clasp to be placed too close to the occlusal surface and may create an occlusal interference (arrows).Even if an occlusal interference is not present, a high clasp arm is more noticeable to the patient and may interfere with mastication.

(1) A high survey line may also result in deformation of the clasp because, on insertion, the clasp is prevented from moving down the tooth by contact with the occlusal surface. If the patient persists in trying to seat the denture, the clasp is bent upwards rather than flexed outwards. (2) Shaping the enamel to lower the survey line will allow the clasp to be positioned further gingivally and it also provides a 'lead-in' during insertion, causing the clasp to flex outwards over the survey line as planned.

Retentive areas can be created by grinding enamel. However, the enamel is relatively thin in the gingival third of the crown where the retentive tip of the clasp would normally be placed, so the amount of undercut that can be achieved by these means without penetrating the enamel is strictly limited. It is usually better to establish improved contours for retention by restorative methods

Undercut areas can also be created by the use of acid-etch composite restorations. A broad area of attachment of the restoration to the enamel is desirable as this will reduce the chance of the restoration being displaced and will produce a contour more suitable for clasping. The early composites were not suitable for this purpose as they contained coarse filler particles that caused marked abrasion of the clasp arm with consequent weakening of the clasp and loss of retention. However, the use of modern ultrafine and hybrid composites results in minimal mutual abrasion of composite and clasp so that the technique is a durable, effective and conservative method of enhancing RPD retention.

CONCLUSION

The success or failure of an RPD depends on how well the mouth preparations are accomplished. It is only through intelligent planning an competent execution of mouth preparation that the denture can satisfactorily restore lost dental function and contribute to the health of the remaining oral tissue.

Bibliography

British Dental Journal 190, 288 - 294 (2001) Published online: 24 March 2001 | doi:10.1038/sj.bdj.4800954