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THE ULTIMATE GUIDE STUDY FOR CONQUERING THE (lIlt|NTAL PERI ASSESSM IAGOSIS ENT/O N ANtl PROSTH(lD(lNTICS COMPUTER SIMULATION EXAM
WWW.IlENTATBOARDBUSTERS.C(lM

CHAPTER I

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PERI(|Dlll{TICS
The most two critical factors determine PR|)Gll|)SlS that ihe 0l a peri0dotltally inv0lved (the t00th l 0B|UIY ATIACilME are and T[0SS m0st critical factor). PERI0D0NTAL PRoGtl0SlS l0recasi possible ponse trcatment long a 0fthe rcs to and term outlookmaintaining for a healthy, functional dentition. patient at 1. G00d Prognosis, has least 0fthese, 1 healthy slight adequate 0r CAL, peri0dontalsupport, n0furcation, control0fetiologicfact0rs n0m0bility, and t0assure paiient the tooth would relatively maintain be easyt0 underfull compliance. patient at Fair Progn0sis: has least ofthese: I moderatesevere and/or 0r CAI Glass proper I mobilityfurcation 0r involvement. The furcation and depth location allows maintenance 0atient with full comDliance. (>5mm) patient at Prognosis' has least 0fthese:severe 1 CAt causing ouestionable a p00r crown-ro0t p00r lorm. ratio, r00t Classturcali0ns easily ll n0t access'ble t0 mainienance, lll furcations. ll 0rlll mobiliiy, 0rClass Grade significant proximiiy. r00t pr0gnosis ll0peless Pr0gnosis: more the I or 0f factors questionahle under with inadequate attachment i0 maintain tooth health, the in comf0rt, function. and E)(IRACTI0 iSsrggested because periodontal (surgical active therapy or n0n-surgical) isunlikelyt0 improve t00th's the status. T00TH M0BltlTYi00th movement s0cket anexternally inits dueto applied Measured force. pushing t00th gently a F-L in directi0n theblunt 0ftwometal using by the ends instruments. Afinger notacceptable is t0 assess mobility. l. Classmobility, F-Lt00th I movement lmm. of< total 2. Classm0bility:totalm0vement with verticaydepressihle 2 FL l-2mm N0 m0vement. > 2mm 3. Classmohility:totalmovement and/or 3 FL movement ina vertical/deIressible directi0n. (PD)-each has measurementsMB, DB, Measured (8,L, l!ll, DL). P0CIGI DEPTH t00th 6 from sulcus " GlV. base CEJ"GM distancemm in lromtheCEj"gingiyal iveasurements atthe margin. are taken probing saflre sites t0rec0rd six used depth. . Gingivaltissue abovethe isrecorded IIEGATIVE CEI asa number . Gingival bel0w CEJ recorded P0SlIlvE number tissue the is asa Ctll{loAt ATTACHIIIEIIT(GA[) distance ctl in ana0ical [0SS from direction the to = p0ckevsulcus CAL {PD) (distance G t0 CEJ).disease, locati0n lrom In base. GIV's may migrating base, is only beunrelatedtheapically t0 sulcus its position used t0calculate CAL. (llormallD0cket isc0r0nalt0lhe with CAL. CEJ n0 Heallh deDth l. Slighi Periodontitis-pocket deepened, gingival depth is but the marginunchanged. is CAL l-zmm. greatef ch ent blt iloderate Periodontitis atta m l0ss, since isattheC CAL PD. GM EJ, = GAt 3-4mm. greater Severe oisease-even attachment and loss, because 0frecession, is theGIV below CEJ. CAL CEJ thepocket (0rrecessior the Thus, = t0 base measurement + PD). > CAL smm. i! 3mm, attachment = 7nm. l0ss Ex: a probing is4mm recession lf depth and total

(B0P) indicated patient's bya 00Tforsites lll0 0l{PR0Bll{G on the chart RED that prohing. way eyaluate success ll0 BtEEl)lllS Iritl"in sec0f 30 BEST t0 SRP is 0ll indicates inflammatory active G(BoP dise 80P Deriod0ntal ase\. indicates creviculal gleeding pe (bleeding) is ulcerated t0 active odontal dae disease. sc0res is REI-|ABIE indicat0r lhegingival period0rhl 0l 0r inl{ammation.

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ll{V()LVEMEtlT in RID thepatients Use Nabels t0 CATl0tl n0ted on chart. a Probe and clinically diagn0se a furcaiion. Radi0graphshelpful, are are but oNLY adjunct an examination. tie clinical L Class )-incipient |( involvement. destruction l-2mm Tissue extends measurcd hoizontallyfrom thefurcation\ coronal most aspeci. tjpfeels depression Probe the 0f thefurcation Incipient {0ss. 0pening. b0ne 2. Class (Z): Cul-de-sac ll involvemenl. destructi0n llssue isdeeler 2mm lhan measured horizontallythe from furcation's coronal most aspect, D0ES but fi07 C0iIPLETEIYIHRoUGHfURCAT||)tl. PASS THt Partiatbone Probetip under loss. enters the furcrtion roof. 3. Class (Z):Thr0ugh-&-Through lll involyement. destructi0n thro0gh Jlssue exiends theenlire lurcati0n a blunt s0 Naber's can between f00ts emerge Probe pass lhe and 0n other Total loss, the the side. bone but furcation entrance visible, still is not but coveredgingiva. by Grade I Grade ll Grade lll

of lurcaii0nsl0 ELltllllATE IAll{ 0biectivelrealing is FURCAT|l)il tilT,butsome lilV0wt grafts noteffective only increas accessibility fff plaque treatments rem0val. Bone are t0 H0wever, successlully &TR treatsGrade furcati0ns. Ueatfurcati0ns. ll Furcation oIma{llary molars theP00REST 2d have hy0lvement PR|)Gtl0SlS therapy. after

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(PSR) PER|0D0llTAt SCRIEI{ll{G & REC||RDItIE a screening thatpromotes exa$ earty period0ntal PSR detection treatment and 0f diseases.all0wsthe dentislt0 rapidly assess and periodonial but NOT recordpatient's a slatus, d0es replace need d0acom0rehensive the t0

peri0dontal and exam charting warranted. when . PSR a special (0.5mm tipand probe uses ball c0lored from hand 3.5-5.5mm) inserted iniothe gingival crevice under contact resistancefelt andis walked the until is DISIAIESIAI, watchingthe band colored relativethegingivalmargin. t0 Scoring uses sysiem se\tants.6 sitespert00lh lecorded, are but0nlythe HlGHESTscore per is rec0rded sexlant. (*)can added other An be for clinica' abnormaliiies. Code colored isc0mpletely n0B0B 0: band visible, calculus,defective 0r margins. present.calculus Code'l: colored iscompletelyvisible, band B|)P No 0rdefective margins. Code c0l0red iscompletely but 2: band visible, calculusdefective 0r margins ptesent. are Code colorcd ispartly 3, band visible. C0de c0lored isiloTvisible. 4, band *, Code lurcation involvement, mucogingival recession. mobility, defects, H0RlzotllAt t|,SS-bone isparalleltoimaginaryfrom CU CEjof B0llE loss an line the t0 adjacentteeth. from bel0wthe tothe ileasured 2mm CU t00th's based the apex, 0n normal bone p0siti0n. crest Alveolarcrest's position more 2mm the normal isn0 than below CEl. VERIICAL L0SS angulaf loss B|lt{E bone al0ng side the the 0f tooth themost from c0r00al aspect theinterp.0imal Comm0n 0f horc. inLocalized Aggressive Period0ntitis around fimolars incis0rs and inchildren. 0lAGlll)SlS 0FPER|000i{TITIS 0nRAIE PR0GRtSSloll isbased 0F & oISEASE SIVERIIY, l. Rate Progression: of . Chr0nic Period0nlitis-inflammati0n within supportingteeth progrssiye tissues, attachment bone pocket and loss, forrnation and/orgingival recession. conmon lllost i[ adults, begin 0ccur any but t0 at age. .lf < 30% sites inv0lved = Chronic of are L0calized Peri0do[titis. . lf > 30% sites involved = Ghr0nic 0l are Generalized Pe.iodontitis. . Chronic periodontitis prog.essive but patients isa SIoWLY disease, s0me may periodsrapid progression. ntes0fprogression experience short of Thus, isa criteria pe0ple being used exclude from t0 diagnosed Chronic with Peri0d0ntitis. . Aggressive Periodontitis-rapid attachment &bone loss destruction. Amounts of microbial deposits ri?corsijtedwithseverity are the 0lperiodontaltissue destruction. Classified aseither L0calized Aggressive Peri0dontitis 0rGeneralized Aggressive Periodontitis. 2. SeverityPeriodonlal 0l Disease, . Gingivitis-gingival inflammationeiiherchanges contourgingival with incolor, 0f papillae/margins, intissue 0rchanges consistency. . Slight Periodontitis, CAL. l-2mm . Moderate Period0ntitis: CAl", 3-4mm possibly accompanied mobility byt00th and lurcation involvement. . Severe Period0ntitis: 5mm usually atleast CAt, accompanied mobility, byt00th furcalion involvement, & muc0gingival delects. (+), Bacte ass0ciated PERI0D0ilTA[ aregram non-m0tile, a with HEAITH facultalive anaeroies. Inperiod0ntal disease, bacteria the shiltst0gram m0tile, strictly anaer0hic C), bacteria.

gingiyitis peri0d0nta PLA0llEIGY ETl0t0GlC AGEllTin causing and I disease. is anaccumulation mixed of a bacterial c0mmuniiya DtXInA ATRII( in formed 0n t00th surface within minutes c0m00sed80% 0l waier 20% & solids/bacteria. likely is most i0 accumulateinter-pr0ximal surfaces 0n tooth first.

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UE-I1{DUCED DISEASES GIl{GIVAL

plaque predoninanceGRA(+) FACUTTATIVE of dental development early is an 0l (-) (r0ds, a, t0 a laterdomination GRAiI AIIAER|IBIC 0l bacteria fusiform. plaque acc!mulates matures. hetes), the as mass and ahundant bacleria a ilEALTHY in Sl,mUS STREPT0C0CCUS are & ACTII{0i|YCES (+) cocci (Sirept0cocci) (Actinomyces) most ies.Gram & filamentous bacteria are the in dant a healthy sulcus. E-ll{0UGE0 GIIIGIVAI DISEASES- occuronleriodontium can a without attachmeni attachment 0na peridontium is notprogressing. beaffected local loss 0rwith that Can by and bemodifiedspecific may by systemic folnd thehost. faciors in is oingivitisthe 0illllAllT Deriododal dtsease. I diseases limited GINGIVA,theinflammatory are to but resp0nse initiated gingival in prerequisite peri0d0ntitis. is a c0ndition for Gingivitis notalways l0 does lead gingivitis. ontitis, periodontitis pr0gresseslrom but atways lg8-the immun0globulin ahundantgingival in exudates common gingivitis. in are l{0 radiographic leatures gingivitis 0f appearance 0f bone is kadiographic (ioss l). But, there radiographic are features periodontitis of lamina horizontal 0f dura, yertical res0rption, bone & wideningPDL of space). GlllclVlTlS ll0TCAUSE 0R 00ES B0tlE pocket > Bleeding, depths snm, changestissue and cannot t0 and in c0l0r tone lead a diagn0sis 0f periodontitis V{|TH0UT radiographic evidenceb0ne Periodontal ol loss. p0ckets 0T determined radi0graFhs. CAil be lrom cteristicsAllGingival 0l Diseases: L Signs sympt0ms and conlined gingiva. t0the plaque initiate 2. Dental t0 and/or exacerbatetlre 0fthelesion. severity (enlarged contours toedema/fibrosis, gingival 3. Clinical 0finflammation signs due c0l0r perature, increased transition and/0r t0red bluish elevated la tem red, su r lcu BoP, gingivalexudates). 4. Clinicalsignssympt0msassociated stable and are with attachmeni 0na levels periodontium attachment 0r0na stable, reduced periodontium. with n0 loss but 5. Disease is reversible byrem0vingetiology. the role 5. Possible asa precurs0rt0 attachment around loss teeth.

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Gingival 2 Categories 0l Plaque-lnduced Diseases: by diseases affecledlocalfactors. L Gingivdl hy h0st fact0rs, modifiedspecific systemic bul affectedlocal by 2. Gingival diseases diseases, 0r malnutrition. drugs, ne hematologic via lactors theendoc system, gingival common 0l Plaque-ass0ciated type P[A0UE-|I{DUCED Slt{GlVlTlS most - lhe margin. rsatallages occu atlhe duet0 inflammation bacteria gingival disease. gingival lt is Begins 0ISEASE. at Fl)n 0t PtRl0DoilTA[ Colllill)il and 0fdentate 00DUlation isIHElil0sT gingival Reversibleplaque with unit. through renaining and thegingival margin spreads removal. (where slarts). in . Characteristics: at thegingival it Changesgingival plaque margin changes, sulcular (redness), & B0B edema, erythema, contour c0nsistency c0l0r gingival changes, sensitivity, exudates, histologic B0B increased change, temperature and/or Presence and tenderness,enlargemeni. 0lcalculus plaque. (plaque, plaquecalculus, goal lactors eti0logic Treatment 0di0ns: is to eliminate patient 0f calculus, anti& 0Hl,debridement educaiion features) through retentive (over plaque cruwns, factors contoured retentive agents, correct anti micr0bial plaque ill-fitting fixed0r open embras!rcs, contacts, margins, open/overhangilrg na(ow t0 may Surgical i00ih removable denturcs, malposition). correction berequiredcorrect is ptaque active therapy complete, contr0l. Attel gingival def0rmities hinder that oftreatment. furthel isrequired t0determine course evaluati0n (diabetes, periodontal smoking, sk by may Treatment beaffected systemic lactors pregnatcy,substance predispositi0n, nutriti0n, HIV stress, bacteria, gendergenetic aging, not t0 contributethecondition resolving other that medicaiions. {actors may abuse. (patient remaining n0n-compliance, calculus). consultation, . lf condition notimprove, medical/denial 0Hl/educati0n, additi0nal does and pr0phylaxis micr0bial assessment c0ntinu0us frequency, increasing debridement, Bay required. and evaluati0nbe monitoring after PERl0DoNTlUtl periodontal GltlGlVlTlS A REDUCED 0l{ PLA0UE-|I{0UCED periodontaltissue the in periodontitis, inflammati0n 0f treatment resolutionperiodontal and Characterized bythe bone and C.l ishealthy, with reduced atiachment alveolar height. but a periodontium gingivalmargioredqced ona the inllanmationt0 return bacleria-induced 0f Same lindings disease). clinical loss indication 0factive n0 attachment (no with progressive loss gingiYitis, attachment is asplaque-induced butthere pre-existing (0.12%) when lor bacteriasituati0ns used 30sec in GLUC(II{ATE - kills CHL0RHEXIDIIIE gingivitisover long{erm. I agent red plaqueand for ucing antinic.obia adday.The effeciive m0st

(plaque) moditied specific host by but by lactors are diseases affected local Gingival systemiclactorsviatheEilD0CRttlESYSIE,hematol0gicdiseases,dr GlllclvlTlsl t0ss EIII0R TfltRE floATIACHI Bl)llE lvlTH tS

Cingival oiseases modilied Eil00CRlilt bythe SYSITI' iated Gingivitis: dramatic in SIER0l0 the rise fi0Ril0ilE I-EVEIS in b0th sercs a transient 0ngingival has eafect inllammati0n Duherty ivalinJlammationdevelop 0nly can with small amounts plaque 0f during the pubertal (this what period is distingrishesdisease). this Characteristics: pronounced atthegi'rgival margin, Faque inflammatory response gingiva. 0fthe (gi s estradiol boys circumpubedal > 26; testoster0ne llustbe > 8.7). ingingivalc0l0r, with contour, possible Change changes insize. gingival Increased exudates BoP and after Reversible puberty.' alCycle-Associated 0ccurs 0ingiviiis: duingthe menslrualcycle sex due t0 (estr0gen pr0gesterone) gingival hormones & causing inflammation an and in gingivalexud(GCF) ate especially ovulati0n. during Characteristics: . Plaque gingival atthe margin. modest inrlammalory priol response otgingivaJ ovulation. to . Must attheovulatorysurge luteininzing be when h0rmone are 25mlu/ml levels > and/0r estradi0l >200pg/ml. levels . Increase ingingival exudateatleast during by 20% ovulation. Reversible after ovulation prcn0unced Pregnancy-Ass0cialed plaque thegingival Gingivitis: ai margins, gingiva inflammatory response, zrd 3dtrimester. onset 0r Change ingingival color (bright contour, red), increase ingingival exudates, Reversible BoP atparturition. (bleeding) gentle Iain clinicallinding isgingival hem0rftage upon Fressure. . lf aw0meninherl310r trimester, polishing, can performed. is 2'd scaling, &0Hl be prudent It she well her3i is into give and trinester, trcatment betojusi 0Hl may reapp0int childbirth her after forscaling p0lishing. and (Pregnancy not tumor Pregnancy-Associated Granuloma Py0ge[ic Tumorf a (neoplasm), exaggerated buta[ inllammat0ry response pregnancyt0 during an polyploidy irriiation causing a solitary capillary hemangiomableeds on that easily provocation. May developearly thelsttrimestel as as . Clinical painless protuberant, Features: mushroom-like 0rpedunculated sessile mass gingival atthe margin inter-proximalspace. 5% pregnant or Affects upt0 0f women. lilore commonlilAXlLLA in & ll{ItRPR0XlilAttY. . Gharacteristics: atthe plaque gingival pronounced margin, inflammat0ry rcsponse 0{gingiva. occurANYT|l!'lE PREGNANCY. 0rcompletely Can DURING Regresses disappears parturition. after

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(Medicati0ns) 0isases: DRUGltl0UCtD Gingiyal (Enlargemenv0vergr0wth):antil. Drug-lnduced llyperplasia Gingival caused by (0ilantin/P[enyt0in), (Cycl0sp0rin c0nvulsants imnun0sup0ressants A-prevents (Pr0cardia), organ transplant rejection), &calcium-channel (llifedipine bl0ckers Verapamil, Biltiazen, S0dium Valpr0ate). more inAtlTERl0R occurs often GUGIVA and children. in onsetwithir 3 m0nthstaking 0f meds,lirst observed inPAPlLlA associated attachment l0ss. with 0rbone . Phenytoin gingival causesthe highest enlargement 0fpatienlsi in50% Cyclospori 2530%; Calcium & channelblockers cause 0vergroMhoftiBe. 20% . oral hygiendpiaque removalcan severilyenlargement, ll0l limitthe 0f but does gingiva. shrinkthe Plaquenot is required t0producethe enlargement. . Characteristics: pattern, variation inier-patient in & intra-patient change gin in c0ntour causing changessize. in Enlargement obseryedinterdental isfirst at change gingivalcolor, in increase exudates, found gingiva orwiihout BoR in with bone hutisl{0Iassociated attachment loss, with loss. 2. oralC0ntracedive-Associated pre-nen0pausal taking Giryivitis w0mer these plaque gingival pronounced gingiva hormonesdevelop atthe can margins, inflanmatory response presence plaque, inthe 0flittle changes ingingival color, possibly Increased (crevicularfluid), conaour, and size. GCF BoP Reversible after disc0niinuing contraceptivetheoral Plaque-lnduced Diseases Gingival Associated SYSTEilIC with DISEASI, yrith l. Diabetes l{ellitus-Associated f0und Clllll)REll p00y controlled Gingivitis in glucose Iype Lil (plasma I levels-insulin dependent). Similarfeatures t0 plaque gingivitis, cootr0llingthe induced erceFt diahetes is m0re important plaque than plaque in control lheseveritythegingiyal 0l inllammation. Characteristics: at gingival pronounced nargins, inflammatory 0fgingiva, response change in col0rhontour, increased poorly exudates, il0stcommoncbildren BoP in witi c0tltrolled I Dil. Reversible contrul diabetic Plaque Iype if can the state. reduction limit can thec0ndition's severity. 2. teukemia-Associated (Hematologic Gingiyitis 0ingivitis)-malignant bl0od disorder (bl00d gingivitis)0f dyscrasia-associated abn0rmal leukocyte developmeni and proliferation and inbl00d marrow. leukemiascause maniJestations Acute can oral like petechiae, ulcers, gingival cervical aden0pathy, mucosal and inllammalion & glazed, slongy purple. enlargement. isswollen, Gingiya and tissues red deep are t0 Gingival bleeding probingcommon istheltllTlAt SlGil. is 0n and 0RAt Pronounced present, plaqueNoT inflammal0ry 0fgiigiva relati0ntheplaque resp0nse in t0 but is required condition forihe t0occur. Gll{GlVAt DISEASES & MAttlUTRlTl0l{ nutriiional deficiencies significantly can worsen gingiva's plaque people acompromised the responset0 bacteria, malnourished l'rave and host defense thatmay system aflect infeciion susceptibility. Acid-Deficiency Ascorhic 0ingiyiiis: (Scunl) vitamin(ascorbic deficiency especially C acid) ininfants, instituti0nalized & elderly, alcoholics at risk. are Causes gingiva appear the t0 bright swollen, red, ulcerated, and susceptible to bleeding.

10

INDUCEI] LESI()NS TON-PTAOUE GINGIVAL

IIIDUCED GINGIVITIS is causedspecilic l)ll-PLAoUE by bacteriai, and vrral, fungal This .iections. g ngival inflammatioralso caused alle.gic may be by reactions 0r toric VA foreign reactions, body ormechanicaland thermalirauma. "4.N()l tlactions,
sp0nn 1T rg va1 It

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gingivitis. 1. Bacterial Infections cause that Infective slomatitis ngivitls &g in immun0c0mpetenl and immun0c0mpr0mised occuring n0nindividuals, when paque pathogens overwhelmresistance. lesions occ!r t0 host Gingrva may due gonufiea,frcponena pallidun, Strcptqcocci. fieclions lleisseria by & Gngi.va painlLr 0ns, may appearflery edematous u cerat asasymptomatic or as red, cancres patches, atypica y ging 0ral mucous oras non-ulcerated, highinflamed va. lesions rr'raymay beaccompanied or n0t bylesi0nsother sites. n body gingivitis. Herpes 2. Viral Intecti0ns cause that Mainly Simplex 2 and 1& Varicellaper due Zoster reactivated therr when from atent ods t0trauma, ght, fever IJV 0r y HSV!s!ally I causes maniJestations, inmaif anogenrtal, oRAL while HSV-2 but may g ngiva, & periodontilis. als0 cause infectiors.has found th ora HSV been n ANUG, patients atircreasedofacquiringlffection. lmnun0c0mpfom sed are risk the . Primary flerpetic Gingivostomatitis aanifestatofHSV-l class c 0n infection. I\4zinly y0ung gingivitis ! cerations in children,also ts.Pa severe but ad! fful, wth and edema accompanied by stomatitls. Features: Classic VESICLESRUPTURE, THAT c0alesce, & leave fibrin-c0ated feyer lymphaden0pathy. ulcers, & . Recurrent Intra-oral Herpes-cluster painful inATIACHED 0fsma ulcers Gl AlVA. primary girgivostomatitis. s made cultures, Less than severe herpetic Diagnosjs by efzvme- assavs. methods. nked PCR . Varicella-Zoster Virus: lnthe latent dorsal gang oftrigem until s root 0f nal it reactivated inadults cause t0 SHINGLES. Both chickenpor shingles allect and can thegingiva initiaie VESICIES RUPIIJRE fibdn-coated and as THAT t0leave llcers patients the that coalesce t0irregular lnimmurocomprom (HlV), infecti0n lorms. sed cafcause tissue severe destructior exloiration, tooth afdalveolar necrosis. bone lritial rfira-oral symptomsbepain paresthesia U tIAIERAImay and beforethe

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gingivitis. 3. Fungal Infctions cause that Dlagnosed by culture, and smear, biopsy. But quattitative s nce Abcans common C. s inheaithy duals, indlv assessmert and noticing changesneededa reli,ble clinical are for d agnosis. . Candid0sis (C. Albicans) oppoltLrnistic due redLrced delefses, infection t0 host !sually infection oral a superficial 0fthe mucosa. occur HIV other lvlay n and patients girgiva mmunocompromised erythema as 0fattached . H|V-Associated = tinear Gingivitis Gingival Erythema. isa glfgval LGE manifestation 0fimm!fosr.rpression asa djstinct red I mited appearing llfear band tothe FREE CINGiVA. LGE dOes resoond lesion f0t t0Dla0ue . Temova . Pseudomembranous (Thrush) patches wipe leaving Candidosis white that off a y n0 lJsual major s ightly bleeding surface symptoms. . Histoplasm0sis:0matous oral a granu disease. lesions any ofthe affect area Ofal muc0sa, iniiiating asn0dular 0rpapillary latet afd ulcerate are and painful. Clinically may fesemble a malignafttumor' pr0lilerati0n 4. Hereditary fingivolibromatosis-a rare DISEASE. Apr0gressive GEIIETIC 0lthegingiva fibrolic enlargement). Cinically, {genetic-derived gingival generalized gingival ditfuse enlargement, extensjve t0 c0ver often enough the teeth. llssue dense lirm, thcofs is and w derab e disiodion 0lnormal c0nt0ur. Gingival isnormal, er!4hemat0us are rcsu0fsecondary color but chafges a t bacterial lnvolvelirent.
tl

gingival inthe 0J manifestati0ns form Diseases: present Dermatological may (peels Lichen ulcerati0n. 0l thegingiva gingival 0r lesions away) DES0UAiIATIVE lilultitolme, Lupus. Vulgaris, Er$hema Pemphigoid, Pemphigus Planus, . 0esquamative byerythematous, diseasecharacterized chronic Gingivilis-a gingival involvemenl &ATTACHED 0l FREE desquamative vesiculobull0us, and/or er0sive, DG is FEI{ALES are Most Gltl0lvA. patients postmenopausal ages{0-70yrs. a pai (peels gingiva desquamates away), an exposing layer where condition iheouter with but are Many diseases conditionsass0ciated DG, m0 and red acutely surlace. due DG 0ccurs t0anallergic Plaque's isvague. usually aredermatologic. role (lichen BMMB with diseases planus, bull0us reaclion isass0ciated skin 0r generally when alle.gic reaciionskin or resolves the pemphigoid, DG & pemphigus). p.lreatment: Topical corticosteroids. and u disease istreated clears mediated by are lype reacti0nseither | (immediate) Reactions: muc0sa oral 6. Allergic restorative materials, byT-cells dental duet0 lv mediated lgE Type (delayed) 0r and food. mouthwash, toothoastes, aspirin induced desquamation, burn. chlorehexidine mucosal 7. Ioxic Reaclions: C.l material thegingival via into Body all0ws 0f 8. F0reign Reactiofls, entry a forcign (i.e. "Foreign Gingivitis". Body tatto0). 0rcutting amalgam abrasion g. lilechanical "gingivitis artefacta causedexcessive bv lesions lrauma: intlicted sell in with lvlost the force, brushing scratching gingiva a fingernail. common children (2/3 females). young people are Palatal are (hot therma 0f nucosa rare beverages). & 10. Themal Trauma: I bums oral the red, nay sites. muc0sa most arethe common Painful, and slough coagul labial 0f hydrocolloid piza, with handlinghot keatment improper Cotfee, dental surface. wax, materials, etc. h0t rmpression

PERIllD()I'ITITIS
Biiewings be peiodontilis, Gvidenc loss 0l hone MUST evident. radiogralhic T0 diagnose (RES0RPIl0ll). lf extensive l0ss bone B0llE accurale to assess L0SS tool arelhet{0ST > 30% m0re as reveal 0fperiod0ntium. ol bitewings be siould iaken they vertical occuned, in height beevident t0 a crest be mass alveolar must lostlor changebon thebone atthe onradiograIhs. (polymorphonuclear leukocytes) results 0F 0R AREDUCTI0II ll{ llUi[BER FUtlCTl0il PMtls period0ntal disease be may an destruction. Peri0dontal 0l rate severiiy inanincreased and (cytokines) tie prs0n\ attack inmune factoN where Uilt AUT0lM DIS0RDER thebody's own and cells tissues. Disease, Chatlges Radiographic inPefodontal 0f h0ne (blunting periodontilis-areas er0si0n alveolar crest 0fthe 0flocalized l. Early junction and between crest lamin the and 0fthe in regi0ns, rounding thecrest anterior in regions). dura posterior in ea pe extends alve0lar destruction heyond y c[anges bone l{oderate odontitisgeneralized plate buccal lingual resorption, 0r cresl, may thealveolar and include and tooth vertical erosi0n, horizontal 0rlocalized defects possible mobility. remaining show teeth periodontitis l0ss s0extensivethai bone is 3. Advasced h0riz0ntal loss bone being Enensive and indanger0f lost. are and mobility drifting, orextensive defects. bony t0 radio$aphic is thickness ical 0fc0 Areduction 0.5-l 0lonly .omm Plate ssflicintallow yisualization b0ne The of cancelloxs trabeculae.crest alveolar is 0fthe 0ldestruction inner bel0vr CEI the 0f crest the disease. in alfected periodontal In health, alveolar is 1-2mm adiacentteeth.

12

n
tu5, I

t0 smoking, stress, drugs, hormones, tdols thatcontrihute Pefi0dontitis: sex etc. gingivitis leads Peri0d0ntitis. often t0 Fact0rs canincrease that Periodo Gironic al

fioTEs

risk:
parrlu m0st ikrn by (pregnancy), HIV/AIDS, Downs syndrome, horrnone imbalances unc0ntrolled I & ll Type Diabetes melliius. (Neutropenia, genetic WBC Rare disorders Agranulocyiosis, Leukemias), predisp0sition, (major preventablefact0r), 0ste0p0r0sis, Disease, medications, smoking isk & Cr0hn's RA, lupus erythematosus. l000llTALTHERAPYG0A[S 0r eliminate t0 alter microbial eti0logy contributing and progression preseruing factors periodontilis, arresting disease lor thus the and the prevent in c0mfort, lunction, esthetics and t0 recurrence. Regeneration 0f -l apparatus beattempted. c0ntrol thediseasenot may When 0f is possible t0 Itachment due -fltition factors, immune defects,microblal a reasonable & flora, treatment objective ist0 tstemic progression". 'slow disease the RESSIVE PER|0D0l{Tlns belocalized generalized. can 0r Patients clinically are periodontitis. attachment & bone Ithy except the for Rapid loss destruction. be0f L4ay ilialaggregation/nature. Secondary Fealures, am0unts mlcr0bial 0f dep0sits inconsisient theseveritv are with 0f periodontal destruction, gingivalis. tissue elevated of AA& P levels Phag0cyte (elevated o1PGt2 lLphenotype abnormalities hyper-responsive and macrophage levels & lb).Progressim 0l attachment bone nayhesell-arresting. and loss (l0rmerly Aggressive [0calized Peri0d0ntitis iuyenile Peri0d0ntitis) circumpuberta] 0nset a robust with serum rcsponse Ab t0 infecting agents detected. is Localizedld t0 (vertical loss) inteFlroximal & molarsincisors bone with attachment 0natleast loss 2 permanent (one a ld molar, involvesmo.e two teeth is and no than teeth other l"' than molars incis0rs). & Caused M. oneoutsianding by negatile feature therelative is (plaque)explain severe period0ntal present. absencelocal 0l fact0rs t0 the destruction genetic predispositi0n (a Possible etiologic factors: 0r neutr0phil dysfunction chemotactic SIJDDEIi defect). DRlFIlllc TETTHCHltlREl{. 0F lll (but people 30yrs patients Aggressive Peri0d0ntitis affects Generalized usually under nayhe older). serum responseinfecting P00r Ab t0 agents detected. is Pronounced naiure destruction of episodic 0f attachment alveolar Generalized and bone. interpr0ximal attachrnent affecting IEAST PERMAIIEI{T |lIllERTHAII loss A1 3 TETTH 1.' & t|}tlRS lllc|S0RS. byActin0bacillus Caused A., gingivalis, P & neutrophil function abnormalities. lggressive Period0ntitis Treatment: rcinforcemert evaluationpatient's 0Hl, and 0f (occlusal plaque pe control, control other factors SRB 0f local therapy, odontal surgery and maintenance). general treatment considerations, medical Additional evaluati0ndeiermine t0 if systenic ispresent disease inchildren &young especia initialiherapy adults, lyif isuns!ccessful. Adjunctive antimicrobial combined SRB therapy with and/or evaluati0n counsellng and of family memberstoitsDotential nature. due familial L0calized Aggressive Period0ntitis
stve 0ss

ngs loss 6of lent

ults
t al

xl-s

tmine in

iic et s 0f

t3

N(|TES

and depth inflammati0n probing reducti0ngingival 0f significant Desired 0utc0mes: of radiographic 0f resohti0n0sse0 evidence attachment, 0rgain stabilization 0f clinical plaque I detectable i0 progress stability, reducing and toward occlusal lesions, periodontal hpallh. wilh compatibre attachm extending theadjaceni into inflammation CHRoI{lC PtRl0D0tlTlTlS - gingival and supporti 0f l0ss t0 Clinical aDDaratus. attachment due destructionthePDL adjacent DISEASE lil ADULTS, hut PEnl0D0ilTAt FoR llll)ST bone. Ct}MM|)lt 0FDESIRUCTIVE have rates 0l but 0l Slow-t0-moderate pr0gression,may a wide raflge ages. Deriods progression. rapid . Clinical ill)ST t0R[l0 BoP suppuraiion. C0ilil0tt edema, Features, erythema, and/or increases age. with & severity ltsprevalence PEll0D0ilTlTlS. . Localized 30% sites affected. if > 0f are Gefieralized30% sites affected. if < 0f are peridontiiis slig . Patient simultaneously with 0f and have ateas health chronic can and desiruction moderate,advanced loss DISTRUCTI0tl of up WITH CHR0I{lC PERl0D0l{TlTlS StIGHT-T0-M0DERATE is clini peri0dontal In if tissues. molars, thefurcati0n involved, 33%of supporting Pr0bing uP clini not Class loss attachmentshould exceed l(incipient). depths t06mmvrilh tooth may bone and Radiographicloss increased mobility l0ss attachment upt0 4mm. (involving area thetooth's 0r generalize attachment) present. belocalized one 0f May (involving teeth dentiti0n). several 0rentire . Initial t0 risk that alter, Treatment: eliminate, 0r conirol faciors coniribule Chr0ni pregnancy, diseases, (diabetes, nuirition) systenic aging, smoking, siress, Periodontitis (reshapin localcontrihuting factors remove agents, 0Hl,SRB anti-microbial & restoring0 odontoplasty, movement, t00th illfittingprosthesis, correcting restorations, is PERll)ll0 ll treatmenteffective, trauma).initial 0r occlusal contacts,treating lhe d0esnot resolve chroni lf initialtherapy is SCHE0UtE0. t{AlllIEtlA}lCE isconsidered: peridontitis, IAI PER|000 SIJRGERY (bone grafts, . Surgical gingivalaugmentation, regenerativetherapy GTR), Treaiments: surgery), & gingivect0my. 0sse0us thempy with resective (flaps 0rwlihout

DESIRUCTI0 WITH PERl0D0l{TlTlS ADVAT{CED-I0-M0DERATE - sa CHR0ltlC

l0ss but as to-moderatewithadvanced 0f > l/3 0l supporti clinical features slight is ll inthe if attachment furcationpresentclass 0rlll Loss tissues. 0fclinical 0eriod0ntal evidence bone 0l Radiographic loss > with Pr0hi[g depths 6mm attachment > 4mm. ized 0rgenera Can be increased m0bility. also localiTed t00th and oossible . Incertain due thesevedty extent thedisease patient and age/health, and 0f cases t0 may t rcsults, initialiherapy become s0 to in may treatment notbelntendedatta optimal maintenance. include peri0dontal timely which end-point . Periodortal gingival regenerative (grafts, therapy Surgery C0nsidered: augmentation, gingivectomy). therapy, therapy rooi GTR), resective (flaps, resective pe disease 0f apolies alllorms destructive odontal t0 PERl0D0llTlTlS REFRACToRY (Re{ractory Periodontitis & Refraciory Chronic t0 treatment are non-resDonsive that previously with diagnosed peri0dontitis, oiagnosed in palients Periodontitis). Aggressive vrell-executed therapy sites loss 0r attachmenl at 0ne more despite who have addili0nal Iealute additiqnal is Prim patient the eftorts stop progression. arycliflical t0 and thetary with to anenpts contoltheinlection cqnYentional Ioss rcpeated after . "Refractory" c0mply 0Hl in who isl)tllY diagn0sis made [atients satislacl0rily wilh and pr0gram, is diagnosed ATIER peri0dontal and maintemnce who lolloyredrig0rous a has c0ncluded. actiye c0nventi0nal therapy

1{

;nme portrn
00ve o0s

Periodontiiis diagnosedpatients: received is iloT in who incomplete 0r te conventionaltherapy, identifiable conditions increase wh0 have system that have areas suscepiibility,localized 0frapid attachmert relatedroot loss t0 fracture, foreign impactiOn, anomalies,patients recurrence body disease, orroot 0r with of years periodontal iveperiodontitis many 0fsuccessful after maintenance. pr0gression.once Goal: arrest slowthe 0r disease thereffact0ry diagnosis is c0llect subgingival micr0bial samplesanalyze, to administer antibiotics with periodontal c0ntrcl factors smoking), anintensified (i.e. ional iherapy, risk with program shorter ntalmaintenance with intervals between appointments.

N{]TES

ICCIII{DITI(]NS AFFECT THAI llDllNTAT DISEASE

uI
linic finic nay
;hronl ntion,

COI{DITI()I{S AFFECT PERII)DOI{IIUM TREATMEI{T MAY THE AI{l) OF

pregnancy, t 0ISEASE Physical disabilities, xe6t0mia, mucocutaneous gingival gingival overgroMh, ocessive bleeding, (anti drugs convulsants, calcium (Diabetes cyclosporine), historyrecent smoking, 0f bl0cke6, chronic diseases Mellitus
psych0l0gical family facto6, history disease. ol

providers laboratoryneeded refer consult other as and 0r with healthcare

walranted.

naprn
g0

0utc0metheperi0dontal of treatnent therapy bedirectly may affected c0ntrolllng by systemic condition. should their take medicationmaintainappropriate theday and an diet 0n 0f Itherapy. period0ntaldisease, physician, nipatientswith p0stponing c0nsultwiththeir c0nsider perf0rm periodontal duringthe l"trimester. Can emergency treatment anytine during Perform ancv. maintenance asneeded. Administer Deriodontal antibiotics caution with lanesthesia ispreferred t0generalanesthesia sedatl0n. 0rconscious llAGlCGlt{GlVAL EllLARGEMEltTcommon manifestation ACUTI a early 0l Awhere chem0therapy 0r bone marrow transplant therapy adversely may alfect iva. physican, pe c0nsiderali0ns: c00rdinate patient's with minimize 0d0ntal prior ions pr0viding hy treatment to treatmenl leukemia lransplantation. 0l 0r ideective treatment peri0ds exacerbati0n malignancy during 0f 0fthe orduring active periodontal when 0f ses chemotherapy. antibi0tics emergency Consider for therapy gingival ulocyte counts lowl\40nitor host-vs.-graft are for disease drug-induced and aJter marlow bone iransplantation. Period0ntal and therapy surgery fine is with 0atients stable. GHR{|lllC IEU|(EI{lA.

ie?lth. me l h e

grafts.

base ct0rl rtitis, Efapt

(80t{E DIS0RDERS ASS0CIATE0 PERl0DOtlTlTlS L0SS) Down's WITH

e, Chronic Granulomatous Leuk0c'4e Disease, Adhesi0n Deficiency Syndrome,
(decreased alkaline phatasia ph0sphates b0ne blood and l0ss), Papill0n-Lefevre (skin palmar plantar (neutr0phil lesions, keratosis), Chediak-Higashi Syndr0me

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

15

l{(lTEs

PERI|)D()NTAI- AFFECTING DISTASE SYSTEMIC HEATTH

lheperiodontiumreservoir bacteria produce isa for that inflammatory immune and medi thatinteract body wiih organ systems besides oral the cavity. Period0ntal i[fecti0ns (Diahetes, increase risk0l ce(ain the conditi0ns Pregnancy, & Cardiovascular Disea The periodontal dentist should inform patient possible the of interactions establish and hea period0ntal influences t0minimize negative 0nsystemic health. . l)iahetes periodontitisaffect glycemic lilellitus: can control increased risk and the cardiovascular complications ass0ciated diabetes. with . Pregnancy: increased0fprelerm bidh risk low weight delivery. . CoronaryArtery individuals peri0dontal may increased Disease: lllith disease have risk head disease, pectoris, Periodontalpath0gens angina &Ml. naycontributet0 atherogeni changes thromboembolic in corcnary and events arteries. also lvlay increase risk the cerebral ischemia non and hemmorhasic stroke. . Inlective Bacterial End0carditis, bacteremias are intensified in cardiovascular disea patients periodontitis. with Patients IVIVP rcgurgitation pre,medicatio with with reqlire pri0r probing SRP t0 and Usually Amoxicillin pri0r treatment non-penicilli 2g lhr t0 in patients. allergic

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

MUC0GIIIGIVAL DEF0RMITIES deviations then0rmal fr0m anatomic relati0nship junction gingival (li|cl).N4ay congenital (missing margin mucogingival & be teet (tooth devel0pmental eruptiona F0r L position, palate, in cleft cysts), acquired 0r (neoplasms). delormities around implants, in edentulous These occur teeth, and rid Infecti0ns peri0d0ntitis, peri-implantitis, ass0ciated muc0gingival with delormities, periapical infections. . Mrcogingival gingival C0nditiofls: recession, 0fkeratinized aberrant ]ack tissue, frenu positions, pobings gingival (pseudopockets, smil gummy beyond [4GJ, the excess gingival hyperplasia), c0l0r. abn0rmal . Mucogingival-0ral covering alveolar pr0cess, (keratinized a gingiva mucosa the tissue) adjacent nucosa. alveolar . Gingival (Atropiy) Recession 0ccurs thegingival when marginapical theCEJ. is t0 . oingival pseud0pockets, gingival gingival Excess: incOnsistent margin, excessive displa gingivalenlargement. . Pseud0pocketing pocket" "relative ("gingival pocket"lcondition pockeli 0r where 0ccurs WITH0I,TATTACHMEIIT expansion marginaliissue l-0SS t0 due 0fthe C0R0llALLY . lrflammatory Gingival Enlargement 0fgingivitis aform easilydifferentiated fronsimp glngivitis. findings increase gingivalsize, Cli[ical are distortionnormallorm, 0f and tissue change. issignificant t0ne There increase insulcus with depth pocketl0 p0cket). pseu0dp0cket byexpansi0n 0rrelalive The iscaused {pseud0p0cket 0fthe marginal coronally, tissue ratherthan m0vemeni apical 0fepithelial attachme.t bevond itsphysiological level. Anatomic variations maycomplicate that treating mucogingival conditions: positi0n, frenulum inserti0ns, vesiibule Variations and depth. in ridge anatomy may ass0ciated mucogingival with c0nditi0ns. liluc0gingiyal del0rmitics ll0T0ETECTED are 0ll RADI0GRAPHS, butradiographs help when c0mbined a medical/dental probing wiih history, depihs, clinic and examination.

IE

tl
tiators s may iease). health
Its'( 0T

lreatmenl: non-surgical & surgical c0rection helpmaintain dentition lts to the 0r in health g00d with replacements function esthetics, to reduce isk of and and the gingival p0cket recessron r00tcoverage, via angmentaii0n, reduction, orogressive papilla croy/n leflgthening, augmenlati0n, ridge vestihul0plasty, regenerati0n, t00th ad0ntoplasty, movement, controlling and etiologic lactors intlanmation & via y'aque c0ntr0l, anM0r SRR antimicr0bials. Ht0 Gll{GIVA from tl(ERATlt{IZE|)) - measured sulcus (periodontal onto base oocket) junction gingiva ([4GJ). surface the mucoginglval t0 Calculated suhtracting by depth fr0inthewidth gingiva thefreegingival 0l from margin the t0 ngival margin. periosteum undedying 0falveolar and Attachedt0 bone cementum byC.lfibers epithelial and periosteurn, Fimly attachment. joined underlying structure, t0 tooth & bone. ATIACHED GlilolVA n0rmally is CoRAL lts c0l0rvaries PlllK. depending the degree on 0f presence leratinizati0n, thickness 0tepithelium, 0fmelaniB,numherbl00d and 0l vessels. BAll0 SURFACIS IARRoWEST is 0nFACIAI 0l mandibular canine l,r[remolar. & and surfaces adiacent mandibular t0 incis0rs canines. lngual & llarrow zones ais0 nay (associated proinjnent and occur llB r00l 0l maxillary molars at first with rcots bony sometimes dehiscences), mandihular and at 3dmolars. gingiva lVidth FACIAt 0l attached ranges l-gmm. from WIDESTfacial0f maxillary 0n incisor,narrowestlacial mandibular & firstpremolar. bteral & 0n of canine gingival gingival gro0ve boundaries from MGJ thetree extend the t0 Ittached (sulcus hase). . iluc0gingiyal (l Glfseparates gingiva alveolar Junction attached lr0m mucosa. . Free (base gingivalgroove ofsulcus)-separates from gingiva attached gingiva. free is S0UA EPITHELIUiI tral mucosa STRATIFIID 0US resardless is keratinized if it 0r (]ral (ventral) buccal alveolaf & lon-Keratinized ilucosa: mucosa, tongue's inferior gingival and fl0or surface, palate, of mouth, lining sott and mucosa, col, crevicular eoithelium. . Alve0lar gingiyafacial& Mucosa a LlNlllC llSSUE,located attached 0n APICAIt0 lingualsudaces. 0fthin, -KtRATI epithelium, textured, C0nsists N0 IZED loosely c0ntains elasticfihers isloosely toperiosteum and bound olalveolarb0ne. Well-adapted movement,cann0twithstand stresses. but lricti0nal to!ermit gingiva. l)rall{ucosa: palate attached hard & lcratinized

l{0TEs

risk ol 0genic risk ol lsease catt0n l|icillin

,tween teeth). efech

ldges.

tis, & renufn snlle elar0 rspray.

(Marginal gingiva)non GlilGlVA keratinized 0ftjssue attachedt00th collar not t0 girgival (sulcus to thegingival groove bone from base) dre0laf thatextends thefree keting in.lt s composed ofl IATTY gingival part margin-the coronal ofthe glngiva. most free mple groove gingiva. beginring freegingival separates gingiva attached free from The 0f and gingiva. attached the Nataon gingivalsulcus-shall0w groove gingivat00th between marginal the & surface, bound he by sulcular epitheliuflr and aplcally. laterally,JE eyond interdenta I gingiva occupies dental intel spaces coronalthealve0lar to crest. tooth ol{TllrM tissues sur.ound support leeth. that raybe and the Conslststhegingiva, of pr0tect, ccmentum, alveolarsupporting lvlain & b0ne. functions t0 support, are and proper, fibers, teeth. Attachment apparatus-consists at bone ol alveo t may PDL & inical um attaches r0ot alveolar that the t0 bone. or the migrates apically the along rjfi, thelE is onenamelattheCU. Indisease, JE p0int 0r lt from reference (CF.Jrest0ration tUrlace. is measured anestablished nafgin)to probe ment a periodontal with

l7

N{1TES

DISEASES ACUTE PERI()DllI{TAL

ACUTE PER|0D0I|TAL BISIASES clinical conditions 0f RAPI0 sEIthatinvolve 0 period0ntium structures, characterized D|SC0 byPAIN, F0Rl& liltECTI0 or associated ll'lay or ihatmay may berelated gingivitis peri0dontitis. belocalizedgeneral 0r not t0 0r p0ssible manifestations. Peri0d0ntal Acute Inlecti0ns: wiih systemic . l{ecrotizing (ilUG Peri0dontal Diseases & ilUP) . 0ingiYalAhscess . Periodontal Abscess . Peric0r0nalAbscess(Pericornitis) . Herpetic Gingivostonatitis . CombinedPeri0d0ntal-End0d0nticlesi0ns. ( UG) G[{GtVtTtS "V[{CEl{T'S FECT|0lt" ECRoltZnG UtCEMTIVE (i infeciion gingiva. 0fthe Necrosis 0fgingivaltissue 'IREIICH M0UTH' anacuie MIJST t0 as & F.drginal).3 characterislics be present diagnose lllJc.Anintecli All "punched-0ut" gingival presenting papillaewith lrygingivalnecr0sis bleeding an characterized pain. breath pseudonembrane may secondary formation be diagnostic featu.es. Fetid and rapid 1. l TEtiSE (hallmarkilUG), PAlil 0f usually 0nsei. papillae (yell0l'1/ish "punched-0ut" 2. Inter-dentalgingival necr0sis ulcerated white grayish pseud0 brane mem formati0n ofgingiva). Papillaetips a.e blunted s ough and cratered. (least with bleeding distinctive sign) 0ccurs 0rwith0ut clinical that 3. Gingival gingiva. provocati0n. red Brighi marginal which factor is ll{l{Ull|)SUPnESSl()il, beassociat may Predominant inlllrcdevelopment predisp0sing pre-existjng gingivitis, psychologicai factors: smoking, stre withall 0f its (HlV), (p00r gross fatigue, an immune suppressi0n malnutrition, neglect 0ralhygiene), WBC iniltrate trauma. ilEUTR0PHII dominant intheinflammatory ofANUG. isthe l{UG & lymphadenopathy, ore fetor ex (fetid breath), fev ADolTI0l{At SlGl{S SYMPT0MS palh0gnomonic asthey often 0ccur many in other foms malaise; not are symptoms periodontal Fever may suggest Primary Herpetic Gingivostomatitis disease. & maaise also l\4ononucleosis. . llUG fusiforms, Spir0chetes, & Prevotella intermedia. Etiology, after recurrcnces L0ss attachment bone uncOmmon, 0ccur multiple of and is butcan 0f the disease. l8-30yrs. 0ccurs 0ften adults m0st in Debride necrotic & t00th areas surfaces, 0r warm water sali llUGTREATMEI{T (Penicillin if systemic (fever, v) involvement malaise and therapy rinses/irrigati0n,antibiotic gentle llljG dehridement lymphadenopathy). vJith Patienls Hlv-associated require rinses. resolves a fewdavs treatment debridement NliG within after with a antimicrobial rinses, patients remain riskfor recurrences. counseling at Paiient antimicrobial but .. 0ral lluid !moking cessati0 nutriti0n,ca'e, inlake.

t8

( UP) a severe rapidly progressive PERl0D0tlTlTlS and tlECR0TlZltlG UTCERATIVE gingiva, and 0f and PDL, infection a distinctive with erythema necrosisfree attached and l0ss and hone. has 0f alveolar Theresevere 0l attachment alveolar NUP many the bone. is faclors except is loss clinical there 0l attachment bone and at clinical etiol0gic of NtlG, & affected sites. . Treatment:I hygiene (SRP) ( letr0nidaz0le). measurcs combined systemic with antibiotics ora . Conm0nlv inindividuals (i.e. severe HIV), malnutrition observed with systemic conditions, and immunosuooression.

()F CESSESIHEPERI()DllI{IIUM
ingperiodontal abscesses is prmarily 0nlocation theinfecli0n. based of Abscesses purulence, with beassoclated pain, swelJing, change, col0r m0bility, extrusi0n, teeth tract formati0n, lymphadenopathy, fevel, and radi0lucency affected arbone. 0fthe alveo present. ciinical features not are always , allofthese painfu lVAlABSCESS lOcalized, swelling purulent with exudate inlection the - a 0t papilla a sm00th, lghgiva interdental with red, 0r shinysurface. may painful Lesion be pointed. Treatment: eliminate acute and the appear signs sympt0ms viaDRAlllAGt ASAP lfthe abscess not does resolve. become it can a chronic condition. gingiva, It is usually acute an inflamflatory response toforeign substances intothe f0rced asa red, smooth swelling its early shiny in stages. Within 24-48hrs,is it appearlng pointed, purulent progresses,lesion fllctuant and with exudates. lf ii the ruptures Pulpal sp0ntane0usly. hypersensitivity a symptom. abscesslimited may be lf the is t0 palillawithn0preyi0us 0r narginalgingivainterdental disease, af0reign and rnaterial exists,lhe is usuallygingival lesion a x trauma abscess. oD0ltTAt ABSCESS llll)sT THE Cl)MM0tl ABSCISS, associated a preusually with ngperi0d0ntitis. A l0calized infection/accumulation thegingival 0f a in 0f pus wall pocket may that destroy & alveolar Srnooth, gingiva PDt bone. shiny swelling; purulent with area swelling to touch, the 0f tender and exudates increase and/or in ngdepth. may sensitiyepercussion mobile. loss attachment T00th he t0 and Rapid 0l ( rods occur. Causedgram ) anaercbic (SPIRoCHETES). by & swelling, suppuraUon, extrusionthe involved rcdness, S{'ns Symptoms: 0f t00th, tenderness t0percussion, and bosening, slightternperature eevation. ASS0CIATEDEllD{]o0tlTlC Wllil PATH0SIS. bea common llY BE Can clinical feature in periodontitis. vitidans XDnostcqnn\n gatients moderate with 0radvanced Strcp. is ol ahscesses C)anaerob icrods). lJsually results islateintheexudatespeiqdmtal lgtan periodontitis.bea common cases Ca[ clinicallinding in tom p.e-erisling 0l CHR0lllC peri0dontitis patients. r0derate-t0-advanced period0ntal associatedthe with formation factors 0facute abscesses: occlusion 0l pocket prevents t0 impaction 0rloreign h0dies draiflageerudate, of furcation tificesdue f00d systemic antibiotics, diabeles, t0 incomplete 0fcalculus ordue femoval 0r into lissues. istrumenlation bacteria the -rclvemefll, lorces ch.onic ils purulent if Gontents throughFISIUU lhe0uter drain a into Dy become 0rinto p0cket. the Achr0nic abscess isusually asympi0matic, but some irgivalsurface pain, elevation t00th, desue bite grind. feel slight 0fthe and t0 tightly and Ftients a d! I abscess become if lhesinus orilice blocked. can acute tract is *onic reri0dontal "pressure as GlllclvAL ELEVATl0l{ THE AI0NG IATERAL Feeling R00T. in lppears an0V0lD gum" a common is complaintAbscesses often are als0 found furcations. in ilost ae abscesses in 0LARS. 0ccur F0d0ntal but it inchlldrcn, if it occurs,is usually t0 a foreign int0previously due body healthy ues. periodontal cause taken with advanced disease $temicantibiotics bya patient untreated by 0rganisms a peri0dontal causing abscesses. a$perinfecti0n0pp0rtunistic periodontal diahetics prone acule are to abscesses duet0l0wered host hrly conk0lled (impaired immunity). cell Diabellcs have vascular also changes altered and lsrstarce gen metabolism nayincreasethe that r susceptibility. (enamel trauma perloration lateral during anatomic via 0fthe wall RCT, anomalies periodontal invaginated can cause acute r00ts) aiso rlsinm0larfurcations & an abscess-

N{lTES

fdenlal fection mgan0

fiiteor {

)crated

stress.
e, ano

. fevef

rmsol titis or esol

saine atalse ent & m ano ng0n essive l- anc ofthe one al
u0tel |ntr0n

1S

l'l0TES

Treatment: ESTIBLISH DRAIIIAGE by debridirg pocket rem0ving the and [laq incising abscess- lrealments the 0ther calculus, 0ther and irrilants and/or patient adjustment, antibiotics, managing aid com irrigation, limited 0cclusal procedure foraccessdebridement may c0nsidered. extra to T00th Surgical {flap) be periodonial ins0me A evaluaiion should may necessary cases.comprehensive be periodontal patient resoluiion acute 0fthe conditi0n. lf the ahscessnotlocalized, is (Penicillin andinstrucled rirse withwarm V) t0 sali llaced0n antibiotics isused allergic Clindamycin inpenicillin paiients. with abscess ll0T are specific. Radi0graphic associated theperiodontal fidings in the acute lesion. However, is often there may n0change be radiographically early localized discrele radiolucemy lateralt0 r00t in a lurcati0n can the 0r which rapid alveolar destruciion bone i,l0ST |)tlsymptom a patient report a periodontal will with abscessACIJTE is G0 and throbhing. Thermal changes notcause cha d0 0r thatis constant, severe, dull is rapid progressively intensifiesPatient thediscomlori. 0f discomfort onset and in mobility, sayit is dilficult close and t0 their also notice increaset00th an yrith0st pain. the t00th causing increased t0getier striking involved first, . PR08lilG reveals P0CKETS DEIP ass0ciated the0eriod0ntal with abscess. a EPT pulp theunlikely asthetooth a peri as cause vrith thermal exclude tests the abscessusually is VITAL. Meth0dsdistinguish t0 a peri0dontal from pul abscess a (peri-apical) isdone pr0hing, thermaltesting. abscess via EPT, Aperialical radi g00d method distingrish t0 a period0ntal pulpal and ahscess. is nota diagn0stic . ilEUIR0PHILS arthB 0SIilUilER0US inthei[flammatory cells exudatesanaD 0t periodonlal abscess. (PERIC0R0l{lTlS) ABSCESS a localized accumulation within 0f pus PERIC0R0NAt gingival sirrrou0ding 0f tooth ove.lying flap a crown a paiially0r fullyerupted {USUA 3'd t{01rR ARtr). itAl{olBUutR . Clilical painfult0 rod, lesion, touch. Puru Fealures, llapis localized, swollen tissu malaise, leuk0cltosis be may exudates, trismus, lymphadenopathy, fever, and area and base inv0lve InJection spread theor0pharyngeal t0ihetongue and can into rcgio Patients have may 0IFFICUUY SWAL[0WltlE. bygamO anae Caused lymph n0de5. . Treatrnent: of the antibi0tics. DIBRIDEI{EI|T & IRRIGATI0il fla!'sundersurface. 0rextracliontheinvolved opposing Home i 0f and/or tooth. care rec0ntouring, inflanmation infection restore to healthy and and tissue functi0n. Goal t0 relieve is

ABSCESS circumscri C||MBltlED PER|0D0t{TAl"-El{D0D0tlllC (tEsl0tl) localized.

in and/0r tissues. lilFECTloil ARI areas infection 0riginate theperi0dontal pulpal 0f that itself FR0l{ PUtPAL llltllil All0N ilECR0SIS 0n ex0ressing through PDL lhe l{AllltY May mainly lroma periodontal alye0lar l0 the oral cavity. alsoarise hone communication through canals and communicating accessory 0f thet00th or apical pulp. also from fractured ll4ay arise a tooth. sec0ndarily the infect . Clinical Pain swell teatures: smooth, swellingthegingiya mucosa. with shiny 0l 0r Tooth be t0 and tendert0t0uch purulent and/or exudate. may sensitivepercussion mobil PREStilT. loss Rapid 0fthePDt aitachment periradicul and FISTUL0US l{AyBt TRACI( FACIAL SWELUNG CELLULITIS present. andior may be tissues occur' may

2n

i: Poc c0mf0
ftracI ld foll

atient i
salin ic.The otten tn ca

probingdepths, pulpal ucencytheperiodontium 0l and rootapex, signilicant and y induced apical pe . A "conbined" ahscess qnewhere endodontica is an involved e stson a pe odontally t00th. pdlpinleclion/inltrmmaiion A can !nicate spread theperidontium and into thr0ugh rcotapex, the LATERAL CANALS, foramina, extensi0ns cresial ory ofgranulomatous along esi0ns lateral and roots, h dentinaitubules. Periodontally endodontic can occurthr0ugh derived lesi0ns also grooves, r00Vt0oth fractures, cemental hyp0plasia, trauma-induced

HOTES

resorption.
is it is likely PIRIAPICAI a ABSCESS. periapical ie t00th |)fl-VlIAl", most Usually lt ses occur singly, may efiruded, t0 percussi0n, be tender hypermoblle, marked
phaden0pathy, sweliing, malaise. and facial fever,

periapical exacerbati0ns 0fchrcnic infections 0ften are associated P gingivalis with IIEPTI cnan
enl t rl P endodontalis.

ESTABIISil AGE debriding pocket DRAI hy the and/or incising abscess. lhe pocket irrigati0n, occlusal limited adjustmeni, antibiotics. and Extraction be mav . periodontal PULP rred sone in cases. lSTRTATED then FIRST, the conditi0n reis 2-3 ated moflths RCT com0lete. after is Periodontal canbed0ne needed surserv if
bl. 7-3 atter access. s pprl0rmed moni'rs c0nplelirg RCI lhe

EPT a iodon a pulp na tiin t

[SUA

is essentialfor a diflereltialdiagn0sis.pulp vital, a pocket then lfthe is but exists, periodontal arcm0st tissues likelythe ofinfecti0n.thepulp NlCRoTlC, origin ll is the mmatr0n passes that throughlateral a canal apical 0r foramen iheperiodontium into ofendodontic origin. VERTICAI FRACTURT n0n-RCT canaloearas combined R00T 0l a t00th c 0eri0dontal Pain ngocclusi0nmasticati0n main lesion. du or isthe symptorn. gingival perl0d0ntal sensitivity, swelling, and abscess sinus or tracts als0 are p0ckets usually Pulps 0r may respondEPIbutdeep may not t0 are detected on Wideningthe PDL 0l space periapical and radiolucency peiodonial and/or
may wilh diagnosis. help the

Purule
ples rcgl

nrc
i. trss

aL fractuTes occur RCT andarcassociated a dee0 r00t often with teeth with Docket which or thet00th surface may may beabscessed. 0ll THE not PAlll t0A0lllcCUSPS IIII}ICATE FRACTIJRE ARl}l)T lltRPETlC Gltlc|V0ST0MAT|T|S a HERPES INFECTI0N oralmucosa VIRUS ofthe pain geieralized in thegingiva oralmucous and membranes, inflammation, on,and ulcerati0n gingiva 0fthe and/0r muc0sa, oral lymphadenopathy, lever, & Thecordition selflimiting conlagiouscertain is and at stages. Ireatment: reliet ive. ispaln t0facilitaie Goal maintenance 0fnutriti0n, hydration, and basic oral Treat gentle with debridement and t0pical anesthetic forpain rinses relief. Patient ing possible virals. and anti old complains mouth hurt 4 days. days his has for 3 belore onset ihe 0f fL A6-year boy he bcalsympt0ms, hadpalpable, tender, subnandibular nodes, oral lymFh and generalized 0f oral reveals inllammation attached 0f lhe Hperature 101.2"F. exam mucosa. white and alveolar Loose, debris covers gingival free margins lills and embrasures. oiscrete areas ulcerations 0l wiihinrings intense aer pr0ximal 0f papilla in the muc0sa palate. 0n facial and Interdental are tact,and sallvary and ACUTE GltlG|V0ST0MAI|T|S. lovrishea\ry viscous. HERPETIC -flammati0n

uctio n.
$crl

mts
P0r
p0c |l)nan

21

I'l0TES

PERI|]Dl)NTAL TREATMEl{TS SURGICAT

(peri0dontitis GI GIVECT0MY t0 tllillilATEP(ISKET DTPTHS that -surgicalprocedure notrcsp0nd initial i0 treatmeni) removing cor0nal lhe pocket hy tissue t0 B base. (contour)wounds physiological a||d the coronal t0provide mosl margin the shape ma thicknessadequate hygiene s0 oral techniques heperl0rmed. can . Indicati0nsr pseud0pockets, gingival treat hereditary enlargement, suprabony gingival andgingival hyperplasia. Corrects contours Herediiary for Gingiv0fibr0matosis gingival drug-induced inf lammatory enlargement. . Contraindications: pockets inlra-b0ny and tiss {delecls) lack 0f attached Limitations include esthetics l0nger with lack c0mpr0mised teeth, 0Jaccess b to post defects, havingbroad, wound surgically. and a open . Factorsconsider electingpedom gingiveclomy than flap, to when t0 a rather a (if depth thepocket is attheMGJ apical thealveolar d0notperform base 0r t0 crest, gingivectomy)i accessb0nei amountexisting gingiva. need for t0 and 0f attached procedureRESHAPEgingiva papilla l0 GltlGlV0PLASTY surg;cdl the & to pr0vide gilgiva normal lunctionall0rm. delormities and the with & objectiveNoT is periodontal pockets, to provide more physi0logical contour. eiiminate but a tissue portions thegingiva excised of are during gingiv0plasry, a RESHAPIil0 is the from C0mmonly t0 c0rrecttissue used contou[ AllUG.

0SIE0P|-ASTY reshaping recontorring 0r alve0lar thatdoes bone nol

([0n-supp0rting witi0ulremoving anachment peri0d0fltalfihers f0r b0[e) sulp0 alveolar b0ne. Similar a gingiv0plasty it is [0t directed t0 since t0ward elimi pocket walls,iut REC0ilT0URltlG & RESHAPIIIG underlying osseous (supp0rting 0sse0us reducti0n not does reduce bone thePDL attached ihe that is

. l{0n-supporting (bo bone-alveolar notdirected b0ne related t00th t0 supp0f ridges, flattened inteFdental & ledges). ex0stoses, edentulous tori, contours Walls some 0sse0us may deferts consisl n0n-sulp0ning 0f bone.
pockets (pockets {)SIECI|)MY osseous defecls inlrahony 0r helowthe crest - remoyes bone) eliminating pocket by b0[y walls. REIVoVES SUPPoRTIVE because BoNE eliminati is in apparatus. removing After thepocket w0rth price the 0ftheloss attachment the pocket some pr0vide walls, re-contouring t0 is done 0ptimal osseous architeciure for gingival 0verlying tissuesconform bemaintained. t0 t0and . Itaiorcontraindication crestal bone il the rcmoval weaken will 0f rem0ving adiacent tooth's support. hony pattern bone periodontilisbehorizontal0. DEFECTS 0l losslr0m can 0SSE|IUS

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

22

naI .

BotlY P0CIGTS lattern fi|)Rlz0ilTAL lossandnotintra the 0f h0ne osseous. lfibers usually are normally arranged,form a more but at apical and level, the (e[ithelial base attachment) is C0n0 t0thecrest alveolar Su0rabonv AL oI bone. may further be classifieda, as ("relative "pseud0pocket"fa where is expansion pocket 0r thgival conditi0n there 0f (not marginai tissue coronally apical m0vement). Pocketing 0ccurs WITH|)UT loss. lachment ("truepocket") deepened pocket gingival od0ntal a sulcus wherc epithelium ulceration. CharacterDed byAPICAI [,llGRAT|0l{ epithelial ]|dergoes 0l the attachment its level which ator leyond physi0logical isnornally nearthe CEl.

f'ltlTES

tissu to bo
l:PocK Eriotm

r l'{0T I r .W hl

urp provl d Iorti rinati

00neJ t (bol falls

rrdiograph illustrates h0rizontal loss theposteri0r b0ne ln sextant. crestal The bore and in is horizOntal parallel CEJ. bottom p0cket corcnal theadjacent t0 The 0f is t0 r bone. the"crateFirke" Note lnterproximal comnonthemandibular defect t0 arch. B(}tlE t0SS interproximal l0ss CAIh0ne d0es laralleltheCEJ. occurs not hut
|S0|-ATED BoH0r pockF'apical theddjacpnl teeth. 0 rs t0 alveoldr 00re.

l{0TEs

(intra-0sse0us). of s0 is 0r i! F APICAIthecrest hone there a delecl h0le theborc t0 (i.e. or letely a defect have bony it m beintraosseous partially comp within lveo t0 a wall, ust tiemiseptums, interdentalcraiers, intrabonydefects, defects). & moat I bone; ramps, i.e. (AtltUtAR) with Bl)ilE [0SSthar bonypockets associated VERTICAI are holevdelecls thebone, areclassiliedfollows: within and as proximal is present. wall Raml-only 1. l-vJall delects: Hemiseptum the 0nly a facial ispresent. orlingualwall inleFdental crater. 2. 2-wall defects: pocket; thebest graft fo. 3. 3-wall defects: intrabony an offers 0pponunityDone periodontal procedures. rcgenerati0n c0ntainment and t0ur-walled defects moat 4. 4-wall defects: circumferential defecls. 0. m0al also bone c0ntainmentperi0dontal and regenerati0n thebest opportuniiyJorgraft procedures. defecls: alyeolar dehiscences &lenestntions.not with D0 treat 5. zero-wall surgery. 0sse0us

(ll{FRAB0tlY P0CKETS) classified number bythe PERl0D0llTAt 0SSE0US DEFtGIS pocket (epithelial the Ihe hase attachment) bony remaining surr0und t00th. walls that

ARt C0llTRAlllDlCAI|0l{SilUC0GllllGVAt tl)R S FRAB0ilY 0EFECTyP0CTGTS p0ckets, fibers With infrabony interproximally thetransseptal runin anangular direction fibers in configurati0n thecementum fr0m below horizontally. Transseptal extend a sloping cementum adjacert ofthe base alongthe and 0ver crest bonei0the bone down the of 0ocket in 0f bone wilhin 0SSE0US CRATERS -concavities thecrest inteFdental c0nfined facial (02%) compise (35.2%)alldefects, 0lallmandibulard l/3 0f lingualwalls. Craters with t{0RE C0t{il01.| posteri0r in segnes, andarebest treated 0SSt0tS (recontouring). walls defects are bythe 0f Periodontalosseous classified numberosseous present/remainin When evahating atthetime theirsurgical 0f exposure, may l, 2,3,or4 walls. and have a WAY thenumher nE Allllllt ossGous d 0sse0us defect, |)tltY T0DETERIilIilE the is SURGERY. D0tl|)TSE|)Wlie nu surrounding t00th byEXPL0RAT0RY Radi0graphs the the the c0nligurati0n defect l0cation 0f the 0r 0l walls surr0undiu t00th, exact left
plale buccdl and/fi lingual 0[bone masks lhe epithelialattachmeflt a dense because

it and blocksontheradiographs.

24

umDer ment) |s). For

alve

t.l
ctea lacial

successlul a 3-Walled with Delect. [g is M0ST Successperiodontal of bone (vasculaized, n esdirectly lhenumberbony oJ defect vllth of walls the 0sseous arca), inveqely thesudace 0f ther00t and wilh area against thegraft which is . Anarrow 3-walled inlrabony defectyields greatest the success, a 2-wailed then (infra defecyhemiseptal = least then I walled a defect bony defect successful). lldefects mainly theltlTERDEtlTAt Successbestwith 3-walled 0ccur in REGl0tl. is a pocket IEAST and successful a thr0ugh-&-thr0ugh with furcation defect a 0n m0rar. ihe RESoRPTl0tl m0st c0mmon effect an aut0gen0us graftin side 0l hone pocket often postoperative aninlrabony and extends dentin pulp. into and 0ther ing graftexloliation, s thatsonetimes atter 0ccur 0sseous kansplants: infection, prolo0ged rates, rapid and sometimes healing and defect recurrence. (GTR) REGEllERAT|0ll placing resorbable or res0rbable TISSUE n0n barriers (bovine, nes physical & barriers calcium sullateJ a bony 0ver defect. Bt|lCKS GIR regingival t0 allow and ion0l ther00tsurlace long & by lt C.T PDt bone t0 .ecells delect techrique theperiodontal (this assumes PDL can only cells regenerate the a00aratus). Indicali0ns: 0TR attachment patient plaque exemplary control before after exhibits both and regenerative therapy. patient not does smokeis stability teeth theregenerative o{the at site. there occlusal The walls osseous delects VtRTlCAt. m0re 0fbone are remaining,greater the regenefattve success. graft placed a viable bed GRAFT aliogenous 0fgingiva an on Gll{GlVAt C.l where 0r muc0sa present. d0n0r from were The where graftis taken buccal labial site the region edenlulous 0r palatal The epithelium area. graft degeneratesit is placed, alter Epithelium is reconstructed in I week theadjacent sloughs. by epithelium and ion suruiving basal In2 weeks, reforms, maturation 0f donor cells. trssue but is not

nTrc

att

RGERY
Donn

.. 1016weels. Haaling e reqLiredproporional grdtl).hichnp until ti is lo .he lhF gealesl .mounl \l irhage s lail']rn ft- | 6 weaks. o[ occu

,owt
dtooth

lacial t lelects ln0tRl

natnln

(hard gingiva anotherarea mouth palate a secti0n 0lattached lron ofthe or lEmoves region) sulures therecipientsite. success and itt0 FGG depends graft 0n the gingiva immobilired recipient FGGused increasethe 0lattached atthe site. is t0 zone pssibility gaining coverage recessi0n. difliculrygetting r00l 0f during The in c0mplete graft lies an coverage inihefactthat avascular isplaced a r00t 0ver surface devoid also supply. ll()llE its own 0l hl00d supply is totally and dependentthebed0l on tGGretains b,ood vessels. rcceives nulrients theviable hed. Al FGG its from t.l Ecipient a fails 0lthe supply engraftnent. Inlecti0n is nason FGt isdisrupti0n vascular hefore most reason FG0lailure. common 0f ae 2'd
hdications:

ting s wal
IU

tron
| 0eTec:

gingiva. further recession successlully and increase width attached the 0f tDyent non-path0l0gic dehiscences &lenestrations. Co/er with reformationghfrenal t0 ofh attachments. terlormed a lrenectonyprevent with denudation. may may yield successful FGG or not a tovera r00tsurlace a narow (FGG is predictahle when to obtain coverage result nothighly used r00t in r00t Esult cases). arYerage

25

N{lTES

. Used widen gingiva recession afler occurs, pr0phylactically t0 attached and gingivana(0w thin. recession theband attached where 0J is and . C0rrect localized naff0wrecessions hntill]T 0rclefts. oEEPWIDE RECESSI0ilS.ln (pedicle is predictabe.israrely flap FGG cases, laterallyrepositioned grrft) more the (especially onlacial lingual 0r surfacesmandihular 0l 3'd m0la$ facial). grall FGG HtAtlN0 involves revascularization. l0players re-vasculdri/ed Grdfl's dre I producing Thus, epithelium olf (degenerates), thenecrotic the dies slough. During heal (necrotic epitheliumFGG 0f degenerates sl0ugh), reepithelizati0n byproli and occurs graft 0fepithelial from cells adjacenttissue and surviving cells basal 0fthe tissue. FREE MUC0SAL AUToGRAFT from FGG thatthetrans0lant C.l withoul ditfers a in is epithelial covering. . Epithelial differcntiation isinducedtheunderlyings0that grafts dense by C.l free 0f in taken fromkeratinized result formaiion keratinized even arcas 0f tissue transplanted t0non-keratinized Fl\44more zones. is ditficultthan and often FGG, is used giryiva CAlllllES littlekeratinized where efists create band t0 a 0fgingiva-like periodonta thatissurgically FIAP I tissue PERl0D0l{TAl, a segmentmarginal 0f s coronally its underlying from support blood and supply, attached and apically a pedicle by supporting vascular FIIPS l0ST C.l ARE Cl|ilil0t{ allperiod0ntal 0l surgicaltechl|i the must unilormly be Flaps sh0uld uniformly andFliable, flapbase be thin thin ihick), allllap and coners R0lJNDEll. are . PR|I{ARY periodontal 0B.IECTIVE SURGERY 0f FIIP in treating disease t0 is goal l0r Common 0l allflapprocedures access r00t t0 sqrlaces debridement. is PR0VlDt ACCESS instrumentation allow clinician visualize r00ts for and the t0 the can more calculus beremoved comDletely.
. Surgical G0als treat Periodoltal pe disease reduce eliminale 0r flap lo

regr0w alveolar maintain h0rc, biological and vridth, eslablish adequate nockets, tissue contours. 4 Rules tlap0esign: of 1. Flap isWIDER thefree base lhan margin allow to sufficient circulation bl00d toi flap's margin. free 2. Incision notbeplaced any must over defect bone prevenl in to delayed healing. (carine) av0ided because mucosa 3. Incisions traverse eminence that a bonv arc bony eninences and isthin healing and result scarformation. isslow, may in Incisi made tissues harbor in that uncontrolled inlection cause i[fection may rapid proceduresperformed after spread. periodontal M0si surgical are 0nly anti-infective is therapyconplete. p0ints healing. as delay 4. Flap corrcrs r0unded,sharp are p0ckets often peri0d0ntal treated llapsurgery. cases result by These often Deep are (soft pockei byformationa l0ngJE tissue reduced depth 0f reattachmeni), ifthere even is change thep0sition thegingival in 0f margins. bestindicator periodofial The 0f plaque successp0stoperative is maintenancepatient and control.

26

. lns elyu

ense c
)n 0sed

periosteumt0 ICKNESS MUC0PERI0STEAI refiects 0fsott ueand FIAPS ALL tiss gingiva T (< 2mm underlying Used bone. where attached is wide). Apically & p0sitioned are flaps fullthickness flaps Widman ( WF)-a Flap full-thlcknessused 0pen debridement flap in flap and periodontal procedures, a nainstay periodontal 0nsingle rative and is ol surgery pockets teeth onflapsurfacesmolars and 01 atfected moderate andinfrabony by pocket ist0 obleclive gain access underlying & r00t t0 hone surfaces, reduced preseryeadequate a new attachmenl more byestablishing ata cor0nal leyel, an gingiya, t0 pr0vide environmenthealing primary ofattached and an l0r by cl0sure. pocket located bases c0r0nalt0 ltlcj, the areas little n0thickening Sications: 0f 0r 0f pocket bone, reduce shallowt0 m0derate depths, when and estheiicsimp0rtant is targinal region). lanterior Flaps: replaced lVWl exc;sional attachment ositi0ned include flaps, and new (by These by heal repair a l0ng and adhesion JE C.l 0rattachment), and are Fcedures. jn pr0cedures. reduction gains clinical Pocket isachieved by mainly F[et reduciion mediated byrepart .tachment
FUIPS.

l't0Ts

trssue
epata
e e0lc

iniqu h (2m

ES tS

ro0ts
iodo Ete

I cov lncisi
tl

lective

Flap Positioned positi0ned tlapfa full-thicknesst0 correct Pedical (Laterally flap position, gingiva. in rhfecis morphology, oramount attached 0f tisually a ful (recipient flap ai thickness attacheditsbase itsfree adjacentt0 delect with end the The is by the site). defect coveredstretchingflaplaterally thelree covers until end tt. . Indicatiofls, where narrowgingiyal areas recessi0n isadjacentio band a wide of gingiva can attached that beused thed0nor C0rrectsprevenls as site. 0r recession providing coverage, gingiva, intheabsence by root creating awider 0f band and 0f recession t0widen zone gingiya. the 0l . Positioned pedicle physically & Repositioned arereally tlaps flaps attached attheir pedicle apical by base a 0flining muc0sa anintact supply. and bl00d . lm porlant p0sitioned lactors evaluate perfoming t0 before a laterally llap, presence on facialsurface d0nort00th, thickness, gingiva 0fbone the 0fthe and gingivathe width attached 0f at donorsite. Positioned alull-thickness, Flap mucoperi0steal a high llapwith degree 0f l0ically thatisthe"w0rk horse" periodontal 0f surgery/iherapy. ist0 0hiectiye Fedictability EUll|I deep ATE pockets p0sitioningllapapically retaining $rgically by the while gingiva. c0mm0nly inconjuncti0n osseous l\4ost used with surgery surgical Ctached as (intrabony) and pockets, is for surgery, 0finfrabony access0btainedosseous treatmeni rut planing. . Indications: moderate pockets, 0rdeep furcati0nnvolved and teeth, lengthening. crown . Contraindicationsr atriskfor caries, excesslvesurfaces 0ften patients root r00t as are performingapically p0sltioned and AFIER an exposed flap, where exposure tooth w0!ld beunesthetic. . Inthe coulse surgery, galning t0underlyrng tissue 0fflap after access osseous and perl0rmingthe therapy, apically positioned issutureda place requlred the flap t0 at a more alical level, exp0sing alyeolar the margin. thisisd0ne, When additional gingiva grarulates thePDL covers barely attached from and the exp0sed This bone. joins positioned gingiva form broader tissue theapically additional attached t0 a zone gingiva. of P0siti0ned fullthickness Flap-a muc0peri0stealflapexclusiyely alm0st Cxonally gingival and 0fattached gingiva lS0I,ITED t0 [eight zone 0ver AREAS teed restore gingival recession. a

27

t{0TEs

p0sitioned carry flaps flaps 0l There n0 necr0iic is slough Dositioned iecause yascular healing inv0lves revascularizationgraft. oi the with lhem. a FGG, In supply grafts layers revascularizedThus, epithelium off last. the dies top are producing slough. the necroiic and FIAP 0NLYthe mucosa epithelium I PARTIAI-THlCl0lESS PER|0D(ltlTAL incises bysharp dissectiofl. Alve is from 0f underlying Mucosaseparated theperi0sieum C.l gi0gival gatts,Qtwh prcpare sites Used t0 rccipient lu lrce borcis note40sed. gingiva attached is present a promineni Used 0n r00t. when dehiscence orfenestration lillcfi (> zmm). padicular RCTola lilllsT in R0otAmputati0n & Hemisecti0n bedone c0njunclionwith first, peri0dontal therapy: Endod0ntic isperlorned then therapy root lllost selaration an individual lromthe crown. 0f R00T AMPUTAIIoI{S 1d Burs diamond severthe stones c iny0lve llAXlu.ARY& 2d oL,[RS. and amputations is After amputrti0ncomplete, bef0re extractingr0ot f0rceps. iher00t by tip androot regi0n re-c0ntoured shape are t0the and remaining area thecrcwn furcation apical of pontic maximal fororal hygiene is pr0vided. access s0 through cr0wn r00t. the & Used vedical sectioningthetooth 0f llEMlSECTlotl the region.50% 0f region werethe isdivided crown through biJurcati0n nandibular molar r00t l0ss suppoll, and is if t00th extractedonespecific hasexcessive i[ osseous is as 0UR. remaining 0fthemolart00th nowtreated a PREI half

(PR0Xll{At pr0cedure distaltlap used FIAP WED6E) simplest the DISTAI WtDGt
because b0ne the fill after molar extractions RETR0I{0LlR reduction. perf0rmed 3'd 0tten p0or, periodontal This by and defect. region occupiedglandular adi ;s a uslally leaving muc0sa.0nly if sufficientspace di exists n0n-leratinized tissue c0vered byunattached, (in gingiva bepresent thiscase, distal may as a of thelastmolar,band attached operation beperformed). can . Distal in maxillary tuber0sity wedge flapsare perf0rmed lheseareas: in 0r area, the tooth thearch, mesial mandibxlar relromolar triangle & distalt0 last area. approximales anedentul0us a t00lh lhat . lllake leastincisions mesialt0thet00th, and carrythese parallel incisions 2 distal0r at (the gingivalwallt0 awedge wedge isthe[eriosleum base ove.lying form the 0uter gingival wedgefromperi the surface). Detachingthe hone, aper and isthe coronal pocket reduces bulk, region tissue involved inthedistal tissues base elininating and to bone. allows accessunderlying goalis PER|0D0ilTAt P0 SIIRGERY-main to EtlillilATE 0SSE0US REC0I{T0URlllG pockets. su.gery periodontal This does t0 Fxisting topography b0ny is changed eliminate periodontium givesthe patieni periodontaldisease, maintain theirown but accessto cure pr0cedures. with oral dentition routine hygiene . Bef0re osseous t0treat defect, resecti0n 0rrecontouring aninfrab0ny c0nsiderth using reattacfiment maintenance periodic i0negratts, with SRe alternatives: treatment procedures, hemisecti0n amputati0n0rr00t . 0sse0us lact0rs caused thal should bedone etiologic l{0I until resection surgery must detectable inflammation beeliminated are Clinicallv osseous delects arrested. patients plaque control maintain optimal SRP hythe and abilityt0

28

TRAUMA USAT
(functi0nal0raJ nct io alf 0rces)ca! sin par u n g inj!ryfrom TRAUMA occlusalf0rce (trauma) theattachment within apparatus. js trauma There because the danges force exerted exceeds peri0dontium\ the adaptive reparative ard capabillties. ta, peri\dontiun pe odqntiun anintact ot rcduced inflannatory hy disease. 0cclusalTrauma occlusalf0rces excessive appliedieeth normal ?rimary are i0 with (n0 periodontal ngstructures disease). Pathol0gic occlusallorcesthe are etiol0gy periodoniium Usually for changes. reversible theexcessive when Fmary An eflect0f primary lces arecontr0lled. early occlusal trauma HEM0RRHAGE is &

lt0TEs

PDr vEssEr-s. flRl)itB0srs Br00D 0F

0cclusal lrauma-0ccurs theperi0d0ntium when isalready Sccondary c0mpr0mised and l0ss. resulting tissue anllammation b0ne Injury in changes normal from 0r occlusal appliedtooth/teeth rcduced forces t0 with support. inthe occurs @essive 0f loss, l0ss, n0rmalexcessive forces. 0r occlusal Iesence bone attachment and occlusallorces may that 0lherwisewellt0lerated healthy Consequently, be ina periodontal have deleterious due p.e-e{sting effects t0 disease. Friodontium penodontium a adapiive capaclry compromised ftthwith reduced and may then when subjected t0certain occlusal Factors Jrequency, and forces. llke rigrate duration, of forces, be important incausing hyperfactors trlociry occlusal may more t00th (common clinical 0focclusa uma). sign I tra robility n sign 0cclusal 0l trarma T0lllH is ill)BlUTY. othersigns. migrationteeth 0f & percussr0nt0
!sed

re fill
t a 0r p distal

lC SlGl{S 0CCtUSAt 0F TRAUMA widened sDace. PDI lanina dura (veirical) loss,inffa g/disruption, pocket angular bone b0ny formation, root radi0lucencies furcation apex a vitalt00th, & hypercement0sis, inthe 0r 0f 0t TRAUMA mObilih, SlGtlS 0CCLUSAL lremitus, occiusal wear Drematurities. migration, fractured tooih/teeth, thermal sensitivity. features be These tooth may use other conditions,always other s0 diagr0stic criteria EPT evaluate like 0r ional habits attain definitive t0 a diagnosis. -

ralll

rg pd mobility, mig'ai , l00l"r 10nc\Fw orperru5sion. loolh 0r

lyrng
pflost

a bull.

ss0f mucles masticaiion TiVl 0f and/or dysfuncti0n. level facets beyond n0r'ial rclative thepatient's arddiet. the t0 age Chipped enamel lracturesatown/root
I t US .

tct
I 00es I|uma

is asbodycan repairthe ijexcessive damage occlusalforces traumareversible, are perjod0ntal pockels. local . 0cclusal tnumadoes cause not A irritant and ion necessary anaplcal 0fthe (attachment are t0cause shift JE loss). ngs ass0ciated |]cclusalTramua, with alternating 0fres0rption repair areas and r bone, fibrosis alveolar marnw 0f bone spaces, cemental resofption to leading pulpal resorption, tears, cemental ankylosis, occasional necrcsis calcificati0n and

oer I nentused inated

29

l'l0TES

0CCLUSAI IRAUMA (except TREATi|ENT usually addressed initjat during therapy a conditi0ns)eljminate minimize (teeth). t0 0r excessive 0rstress thet00ih f0rce 0n Treatm fora patient Chronic with Periodontitisocclusal with traumatism include: may . 0cclusal parfunctional adjustment management and/or 0f habits. . Temp0rary term 0rlong stabilization 0fm0bile with RPD FPD. teeth a 0r . 0rthodontic movement, reconskuction, occlusal orextracti0n. pr0piylactic lf there n0clinical 0rsymptoms, are signs 0cclusal adiuslnent0btain t0 "ideal" provides benelit, is c0ntraindicated. relationships occlusion no thus 0cclusal beevaluated 0foeriodontal asDart maintenance. SPLll{Tll{G primary the reason splinting is io ttrtil0BlLlzE lor teeth ercessively teelh patient for comfort. Temporary stabilization is achievedsplinting 0rmore by one teeth t0each otherandt0 stable ina positi0n facilitates more teeth that a moreAXlAtand (geneally pertunedon teethytitltteduced distfibution 0ccfusaf 0t torces rctil paiient $rpporo. Rationalfor splinting impr0ved c0mfort, is function plaque and c0ntr0l, distdbution 0focclusal and forces, improved staiility to0th procedures. during clinical . Ihere n0reasonsFliltnon-m0bile asa preventive is t0 teeth meas0rc. Splinting is periodontal one 0f measure t0 treat type used disease, sh0uld used and be with needed measuresr00t like planning, pocket 0Hl, elimination,occlusal and adjustment. . L00se splinted adjacent may teeth t0 tecth hec0me stabilized. many When teeth l00se, adjaceni sextants beincluded s0lint. tend loosen sh0uld inthe Teeth t0 B-1. may remain l!l-D. when d0n0ttighten, splint firm Even teeth the serves an0rth00 as permits bracethat usefulfunction teeth. t0 loose Reasons t0 Perl0rm Selective Grinding llatural inthe 0entition: 1. Achieve fav0rable a morc directi0n disiribution and 0ff0rces. p0sition the 2. C00rdinate themedian occlusal with terminal position hinge 0f the mandible. pre-maturities 3. Eliminate inexcursive m0vements gr0up t0 gain function canine 0r protected occlusion. 4. Direct occlusal centrally thelong 0fthe forces rl0ng axis t00th. lmprovemaintain perfo.mance. 5. 0r masticatoty 6. Accomplish 0cclusal adjustmeni without reducing andbyretaining acce VDo an inter occlusal distance. 1. Reduce orelimirate fremitus. C0nlraindicalions t0 Selective Grinding llatural the Dentiti0n: . targe chambers sensitivi8 pulp ort00th . ll4aj0r 0cclusal discrepancies require thatmay odh0d0ntics 0rreconstructi0n. . P00rcandidates mouth forfull reconstruction psych0logic duet0 factors.

STEPS ADIUST rSl0l{ eliminate I0 |}CC [rematurities in centric relation {CR), protrusive movements, and lateral excursive n0vements. reestablish physi Then the polish 0cclusal and anatomycarefully allground surfaces.

30

rtaina hrps m

grinding, grittiflg, clenchingthe repetitive, 0fcontinu0us 0r 0f - anaggressive, pping/hollowed 0nthe0cclusaltable mostterminall00th)during out areas olthe (chewing and/or in other functi0nal night than activities 0rswallowing). 0cclusal ities, muscle tension, emotional and lactors causes. are &sympt0ms: P0Lwidening &thickeninglamina sore 0f dura, muscles jawpain, and (especially and 0pening mouth, increased rnobility dysfunction dlfliculry the tooth in rnorning), occlusal facets. wear pr0duced forces ive byiruxism cause can increased mohility. t00th : behavioral, emotional, & interceptive modalities

l|(]TES

TREATMENI tlDllNIAL PTANNING

(pulpal, peri0d0nta 0th efl]ergency). NARY PHASE treats E[4ERGENCIES 0NLY l, 0r er | Therapy)-plaque extracl c0ntrol, hopeless molth Plase (lnitial leeth, lreparali0n (i0itial full-m0uth scaling,definitive & r00t-planing).includes: Als0 . 0Hl themost part is important 0finitialtherapy. flygienist 0rdefltistteaches, m0tivates, guides patienttheperformance and the in 0fmeasures fordisease conkol. proper Paiient isshown brushing/flossing and techniques technlques, these are repeated ifthey t0see undentand you sh0wing lloralhygiene what are them. isp00r, surgeryC0 lRAlill)lCATED. is . l)cclusa (if I adiustmenls, guards bruxism night exists), spli0ting (stabilizingteeth). loose . Re-examination thatinvolves ngprobing chart depths. ll Surgery) Phase{Periodontal lll Phase) Phase (Restorative (llaintenance Phase lV Phase)-startedc0mpleting peri0dontal after active therapy intervals thelile0llhedentili0n implant. and conlinues atvarying for 0r An periodontal superulsed dentist. phase 0factive therapy extension by the The where periodontal and diseases conditionsm0nitored etiologic are are and factors reduced 0r I{ost with ol should maintenance eliminated. patients a history period0ntilis have gingival every lll()ll]Hs rnaintain esiablish 3 t0 and health. oniheevaluation Eased ol clinicalfinding duringthe maintenairce, frequencybe may m0dified the the 0fthe patient bereturnedactive may t0 treatment.

ngs 0 th ot
Iment.

teth I B-l-, rthoped

3l

il(lTES

MtscEu.At{E0us
AIVE0LAR PRl)CESS part thenaxilla mandible HoUsEs 0f & that IEETH. -the (PDL) a Lomplex. Peri0dontal ligament specidli/ed. librous soft, C.T.;onbining c vessels. neryes. extra-cellular & suhstances. VASCUIIR HIGHIY & CEttULAR C.f surrounds r00ts, teeth c0nnecting cemertum alveolar ilostabundant r00t with booe. cells FIBR0BLASIS. are . 0rthodontic treatment ispossible PoL asthe c0nlinu0usly responds charges al|d 0nlunctional requirements 0nil byexternally f0rces. imposed applied Pl)fs thickness adult .25mm inan is . Age(PDL thinner age) t0 incrcased gets with due deposit cenentum 0f and primarilyTypeC0tLAGEll Comp0sed 0l I tlBIRS
. Princilal FibeG-PDL collagen fibers include, alveolar fibers, c.est horiz0ntal, 0bli

apical, interfadicular C0il ECT & fibers. R00T CEtlEllTUl{ [wE0LlRB T0 portions Distinguished l0cation directi0nbyiheir and Sharpey's Fibers-terminal 0f PDIprincipal collagen embedded cementum fihers into & alveolar Diameter b0ne. greater thcB0llE than Sharpey's ismuch fibers 0n SIDE cementum side. lE specialized epithelium surrounding i00th begins thesulcus Acol each that at base. like band0f stratilied squamous epiihelium lirmlyaltached the t00th l0 10-20 HEM|0ESM0S0ii|ES. layers cell thick.In IDEAI GlilGlVAL HEALTfi, lt is the EilTlRttY tilAlilEL theCEJ. 0il ah0ve ULTRAS0I{IC SCAtltlG oEVICESbased HlSH-FRE0UtilcY DWAVTSin 0n Sl)U & Removes lavage, vibration, & cavitation. supragingival andsubginval calculus, in patient, scaling gross priort0 debridement ANUG 0{an extractions, mmoves and orthod cement, bonding material, overhanging and restorati0ns. t0uch tip 0t llever the ultras0nicthet00th, 0nly sides. 0n rse the Ullmsolic instruments IJSED sc ARE l0r clreiting, removing and stains. . Contraindications: pace (n cardiac rnal(ers unless pacemaker the is shielded models). consult patients tirst with cadiol0gist. SCALII{G & R00IPLAlllllGremoves calculus. bacteria.endotoins. exte & When performed, best SRP be must the approach scheduleSERIESaFpointments isto a 0l t0 (subgi a segment quadrantteeth a time. ll0l d0gross 0r 0f at D0 debddement m0uth, schedule supragingival) entire 0fihe then a se,ies appointments 0l l0rline polishing. and . Re-evaluation SRP 4-6 aller is weekst0 time repair thedentogingival allow for 0l lunct . lllAlil provide |)BJECTM R00T lilG: 0F Pu optimally r00t smoolh surlaces red t0 bacte accumulation al t0achieve tissue soft reattachment. . BESI CLlillcALAlD t0 determine if sub-gingival calculusremoved is isan BITI-WIilGS inter tosh0w proximal calculus. AVEnAGI Eforthisentire TI calculus tormaii0n is orocess occur 12 days. l0 Slpragingival Calculus-main 0f its minerals lromSALIVA. AB0VE s0urce is occurs yellow, easily margin is white pale freegingival and 0r and ren0ved prophyl by 0ccurs mosl0ften thelingual mandibular and 0n 0I incisors buccal malillary 0l due thesalivary thatsecrele richin minerals to ducts saliva needed itsformation. for pigments, & more Sllgingival Calculus-darker bl00d due t0 breakd0wn harder, lts source minerals fr0mGREVICUIIR than supragingivalcalculus. 0f is FLUID. margin. difficult remove supragingival lvore t0 thelreegingival than calculus, and usually distributed evenly thr0ughout m00th. the

Ingce

Al0S ll0Tlllllc REPIICES BRUSHIIIG & Ft0SSlilGdisru0t remove t0 and perio (round p0lished g00d furcati0ns Patient also a can use aid toothpick, for and (wood I margins), Stim-U-Dent wedges)forgingival and massage inter-dental ecess1on. hforwide embrasure Interdental spaces. stimulaiorrubbertip attacheda handle to gingiva massages stimulates 0fa toothbrush that and circulation interdental 0fthe gingivitis, 0tl BEI{EFIISreduces reduces/alters microbial subgingival flora, (penetrates theginglval below margin), deiivers and antimicrobial Fluoride, agents.
plaque. eflectively inhibil microbial cs,& chlorhexidine

}t0Trs

c.t
P dant lesba ave

gation notremove plaque does acquired pellicle cannot t00th and rcmove adherent ll removes non-adherent lromsubgingival bacteria & hner lhar l0ollbrLshe\. sites. !!pragingival tno D devices C0ilTRAIIIDICATED are tll PAilEllTS PERll)00llTAt WITH tal irdgation Water ifligation devrces bec0ntra]rdicated may in patients requiring f,fuil All0t{. , obliqu trtihiotic premedicati0n dentaltreatment prioft0 sincethese have p0tefltial devices the IR B() a bacteremia. tr causing )ns0f ameter BRUSlllllG METH0!S effectiveness the 0ftoothbrushins measured is BEST bvthe and location plaque. manual 0l The toothbrush have should S0FT, ilY[0il hristles
r Ac o l tooth head. a small

("Sulcular Technique")-t00thbrush placed t0 thet00th 45' bristles arc lassileth0d get gingivalsulcus.brush margin tryand thebristles t0 intothe The ltrlaceatthegingival moved a back-andjodh tor-20 stokes. is currently prelerred ln motion Thls lhe b then toothhrushing. efleclive Ihemost rethod manual 0f l0othhrushing technique.

& invol
us, Inl rthodo

i polt r scalin
e{ in

PI-ANTS
IEGRATI0t{ bi0chemical 0f b0ne theimplant b0nd t0 surface theelectron at - direct
level. Independent mechanical o1 any interlocking.

(the lMPLAl{I SYSTEMS transosteal. & Eil00SSE0US most - subDeriosteal. pr0cedure. l0r success: Placing end0sseous isa predictable implants Criteria I extensl persistent pain, paresthesia. neuropathies, l{0 signs/symptoms infecti0n, 0f dst oS peri-implantLrcency. imm0bilityn0contifu0us and rad 0 Inplant ingiYal progressiveoss 0.2'nm t{egligible b0ne (< annually) physi0l0gic after remodeling durlng hescali year function. first of the with restofation. Patienydentlst satisfaction theimplant redu i to have g0% > success for both rate maJdllary& rnandihular implants. lmplants with pr-0RtR placedthe implants, implants in sudaces advantagessn00th 0ffer than surface and have success than the rates in maxilla. dlble higher ARE ABS0IUTE ll0 lilEDlCAt C0llTRAlllDlCAT|0lls tl)RPIAClilG IMPLIilTS.Ihere are p0sthea\ry e" c0ntraindicati0ns: unc0ntolled diabetes, ac0h0lisn, smoking, ABl)VE jaws,p00r hygiene. oral However, etts witha strung susceptihilit! t0 )r0pnyrax ated /at 'matr0n. placed age factor implant but after ar survival, implants den is NoT important ihataffects n0re girls l8y6 inboys a better prognosis when placed younger have than in chlldren. in and IID.BET
and llus,

m0 ary

isCAfl SUCCESSFAIU RE TREAIED IMPU|IIS WITH

HBTES

(CI) 3-D computerized tomograpiy scans provide can accurate lnf0rmation about (max anatomy sinuses, f0ramina, mandibular adjacen t ee h r00 s). canal, t t/ t Ll)W[n success areassociated CAIIGEIL0US (20-25% density) rates with B0ilE bpne withcortical (80-90% bone volume density bone). cortical 0rovides ol Thus, bone inplant-bone andixati0n. c0ntact f PRE-IREATMEI{T Col{SlDERATl|ll{S health oral status, medical/psych0togical patient patient m0tivation home ability, and care expectations,assessing and (alcoholism, conditi0ns increase risk0f implant that lie lailure smo*ing, ASA high periodontal hruxisn, diseas, radiatiu and theraly). Surgical c0nsiderations evaluating anat0my locati0n vitalstructures, require the and of quality, quantity, contour, softtissues. and and Diagn0stic used pre-su aids in considerations t0 determinenumber, the locati0n, and type, aogulation implants 0fthe abutments 0r diagnostic CT casts, imaging, surgical temDlate). {m0unted unmounted Placing implants inv0lves anallzing number location missing the & 0f teeth, distrnce, number, & locati0n implants beplaced, type, 0f to existing/prop0sed occl schene, oftheplanned design restoraiion. A"staged" approach been toplace has used Elllll)SsE|)t Pt-AllTS. Sl lmplants al can placed thetime extracti0n. anica ilurcs at 0f lvlech I fa 0ftheimplant comp0nentspro and superstructures been have ass0ciated 0CCIUSAL witl'r 0VERI0AD. desired The outcom implanttherapy is maintenalce stahle, 0fa fu0cti0nal, edhetic reDlacenent. t00th prosthesis lilPtAl{TC0MPtlCATl0tlS instability, fixture mobility, occlusal fractured/loose conponents, inflammation/infection, progressive0f ha excessive l0ss pain, tissues, neuropathy/paresthesia. peristent Al)DlTl0tlAt I{EGATIVE ES pai 0UTC0 - implant mobility loss, 0r progressive loss, persistent peri-implant functi0n, bone radi0lucency un and pr0bing inflammati0n/inlection, implant lracture, increased depths.

34

I stat !abtu t sco

rDs, bo -surgir a ants b).

2 CHAPTER

I also [0stn( bome d.

traun hard/s rut0ss !ni.ol

f$il$It1$$$ltll$$

t{0TEs

REMI}VABLE DENTURES PARTIAL

based P0STERI0R EDEilTUI0US to AREA lGl{llEDY CLASSlFlCATl()llS 0nthel,l0ST resiored. Although lll & lVRPDS entirely Class are supportedabutmentleeth, I by Class residualridges, subjacefit tissues, lii and RPDS supported are byatutmentteeth, the pr0cess. distal C.L overlying alveolar the Alveolar resorption ridge underthe exters:0n c0verage 0fthese supporting Peri0d areas. is a concern, is rcduced maximizing but by (maintaining damageabutment is avoided firmtissue t0 teeth with support a stable tissue relationshiD). posteri0rt0the naturalteeth. BlLAItRAt l. Classbilateraledentulous l: areas

Drsrar ExTEilst0lt.
p0steriorremaining naturalteeth2. Class nila eraIeden ul0us area ll:u t t t0 DrsTAr" St0lt. EXTE .lGnnedy | & ll, must a ilESIAL 0ntheabutment t0the haye REST next Class edentxlous space. Dosterior 3. Class unilateral lll: edentul0us with arca naturalteeth anterior oosterior both and il entitely ahutnenl forsuD[0 0n leeth it.Atooth-borne tcausedepends RPI (it 4. Class a single, bilateralmust themidline), lV: but cross edentulous area Anterio. are and the theremaining naturalteeth. teeth missing across midlin. Ato0lh-bome type RPD becausedepends it ll0THAVE ltl||olFlCATl|)ll SPACES. 0nabutment l0rsupp0d. teeth entirdy . |)cclusal REsTs PUGED ]fit DlslAt THt aRr 0[ 0f flRsT PREil0lIRs! Applegate's l0rlpplyiuthelGnnedy Rules Classification: isdone extmcti0nsd0ne. are I . Rule: classification AFTrR I pa it\ 2. Rule il a 3'd 2: molar m is issing willnot replaced,NoT rt0fthe and be classification. and used anabutment,NoT 0fthe as it's part R0le il a 3'd 3: m0lar present not is classification. be it\ c0nsidered inthe Rule if a 2"d 4: molar missing willnot replaced,not is and classification. p0sterior always 5. Rnle l{ost 5: area determinesclassificationlh areas those theclassification are 6. Rule edentulous otherthen determinins 6: "modifications". 1. Rule theexlent 7: 0fthemodification considered, is not 0nlythe nurnber additi0 0f edentulous areas. areas Class Rule ll0 modification ina lGrnedy lV. 8: evenly distribute lunctional stresses l{AloR illl{llR & connectors BE I{USI RlSlDt0 mouth. totheRPo throughoutthe between sides thearches. 0f I{ ilAloRC0t{llECT0RS c0nnects c0mponents b0th must s0 applied any t0 area thedenture etfect 0f are c0lneclor beRIGID stresses overthe supporting area. distributed entire . lllajor con0ector 0fmovabletissues not isfree and does impingegingival 0n tissues. Rel should provided. be . Bony softtissue prominences and are avoided placement during and . Malor most encounter interferences lirgually fr0m inclin c0nnectors faequenily mafldihular orenolars.

36

tA to
assl & dt i
st0n
fl0do

(RPD a c0mponent c0nnectsthe c0nnector base)t0 mai0r C0l{llECToRSRIGI0 that (direct components retainers, retainers). translers indirect Also funciional t0 stress teeth, transfers effects theretainers, and and the 0f rests, stabilizing components ("abutment-to-prosthesis" functi0n) ast 0fthedenture preserves idoes impinge gingiva) is highiy polished. thick, tissue not marginal and = joins rightangle. gingival exposure at um 0f5mm space between vertical components.

l,l0TES

bleba

RPD OIBUTAR MAJOR CllNI{ECTllRS

$e

l0rm SHAPED above tissues asfar but coss-section is HAIF-PEAR l0cated moving marginspossible. as To determine mandibular connector which maj0r t0 tie gingival gingival sure theheight ihefl00rt0 lingual fron 0f the margins. BAR: border be 4mn the margins UilGlJAl- superior must at least helow gingiyal (tooth-tissue plaque t0 prevent collecti0n margin and infLammati0n. There lunclion) gingival 7mn beiween margin m0uth and nustbeat least 0l space/clearance the fl0orHAtF-PEAR incross-section. SHAPTD . Indication: when Used sufficient exists space between slightly the elevated alveolar gingivaltissues. a minimum vertical lingual and sulcus lingual frlust be 0l7mm height between gingival the margin mouth (inlerior and ll00r horder 0llhehar). 3mm space between superior hofder thebar gingival 0f and margin thebar + musl 4mm = 7mm. be wide . Contraindication; when severely prem0lars m0lars present, tlpped and are an alternate framework 0rcrowns recommended. are

terior
$p0rt

line.
t0s

37

N(lTES

S|JBUllGlJAl used there INSUFFICIENTfora lingual BAR: when is SPACE bar. HAIF-PIAR SHAPEO. . tised theheight m0|Ih is< ommfr0mthe gingival when 0flhe fl00r lree gingival orwhen isdesirablet0 thefree it keep margins remaining 0fthe anteri0r teeth exposed, there inadequate olthemouth t0place lingual is and depth fl00r a . ltsbulkiest portiont0thelingual its taperedtoward labial. is and is the . Bar's sxperior border beat leasl bel0wthe gingivalmargin. illlsl Smm free . Bar\inferi0r horder attheheight alveolar is 0I lingual sulcus theD when is tongueslightly elevated. . Requires a FUilCTl0ilAt lMPRtSSl0il. . C0ntraindicaii0n: natural remaining anie.iorteeth are severely linguallytilted.

3. c suluM (C0I{IU0US BAR BAR):

. ljsed a lingual 0rsublingual indicated, axial plate when bar is but the align theanieriorteeth thatexcessive is such blockout inteFpr0ximal 0f undercuts isrequired. . Contraindicalions: anteriorteeth severelytilted wide lingually, diastemas anterior causing &etal teeth the c;ngulum bedisplayed. bart0 . ltt a thin, (3mm) l0catedthecingula anterio.teeth, narr0w strap on 0f scall follow inter-proximal embrasures itssupeior with b0rde6 tapered t00th t0 surfa 0riginates bilaterallyfrom oiadjacent rests abutments.

LlllGU0Pt-ATt, lndications: . High (< fl00r0fthe m0uth 7mm vertical height) high lingualfrenum. 0r lingualbarwhen is ll0 space lhefloor themouth. over a there h 0f . Iil0PERAB[E mandibular ling(al torithat cannot rem0ved. be . Anticipated oione more remaining l0ss 0r 0fthe teeth. . used Class in I designs residual have where ridges undergone excessive verticalresorption. . Used stabilize periodontally t0 weakened {splinting) linguallytilied teeth 0r mandibular incisors.
38

E|rgl rcn0t rgual

agrn. ftients

.ljsedwhen future replacement more ofI or isfacilitatedadding by retention incisors loops anexisting to linguoplate . Used avoid gingival generously irritation entfapment, cover orfood 0rt0 relieved t0 that irritate tongue. the areas w0uld . Extends rests iheterminal abutments, c0ntacts proximally, inter t0the 0n t0the and anterior cinguli. not if there wide anterior D0 use are 0pen contacts because c0ve6 0r overlapping exists it isunestheticif anterior . Superior isatthemiddle 0fthe border l/3 teeth's lingual surface extends and upward proxima point. tocover inter spacesthe t0 contact .llandibular lingualtori requirelinguoplate a because is often 7mm there not 0f slace a lingual llssue for bar. c0veringtoriisthinand the cann0t t0lerate vertical from vertical oressure themaior connector. USE SEVERT 00ll0T lF AllTtRl0R EXISTS. cR0wDNG

NOTES

gnmenr 0ts

2I0pe0

r surl

I.,IBIAt BAR: . Indications: severe premolars when lingual inclinations ofrenaining & incisors preventing a lingual When placing cannot c0rrected he orthodontically, bar. linguallori cannot removed prevent a Lingual 0rplate. be and using bar Also severe prevent a lingual when and lingualtissue undercuts uslng baf used severe abrupt orolate. . Superi0r isatleast below labial buccal gingival 4mm the and margins. b0rder . Inferi0r isinthe (imm0bile) border labiallruccalvestibule olattached atiuncti0n & (mobile) unattached mucosa. . UlltESS f0RISURGERY lSABS0IUTEIY Cl)llTRAltlDICAIED, t0ri are interlering removedav0id a labial l0 using bar. . Trauma congenital produce arrangements and deficiencies occasionally dental where isfeasible. onlv lablal a connect0r |1I}UBI.E BAR LIIIGUAT (WITII CI)IITIIIUl)US BAR); . inter-proximal Placed the above cingula bel0w and contacts. . NEED 7-8rnm themouth 0rcannot above floor use. . indicated PERI0SURGERY Wl0E l0r FoR EMBRASURES. Best CASTS . lllust rests thesuperiof 0natleast canines. have on bar the

3S

t{0TEs

MAXI MAJllR TLARY Cl)l{NECT()RS

6mn free USI nlcl0. BE Superior MIIST atleast belowthe gingival b0rder be mean 0lthe gingival margin. malgins parallelt0the curve lree and plating< 6mm fr0m gingival the margins. 2. llsemetal il exists must at border connector cr0ss palate RI6HTAilGUS the 3. Posteri0r 0fthemajor PARALLELT0 theresidual t0 ridges t0thepalate midline exiend and backward tongue sensitivity. Anterior border 0fthemalor coflnect0r is perpefldicllarl0 midline [u the and intheVALLEY 0FRUEAE. (anlerior palatal AllTERloR to indirect retainers coverage lltVER PIACED isavoided). borders headedproduce t0 a positive contact the with tissue. 6. Exposed are 1. It4eialinintimatetissue is contaci.
l.

UsEo 0ll lilAl0R t0 BEAD (BEADED Lll{E B0RDERS} olltY ilAxlLLARY C0llllEcloRs
major the lt otf theinterfaceihemaxillary connectort0 tissues.tapers asit approaches 0f gingiva marginal around abutment the teeth. . Beadingdone it is along border themai0r the 0l connectorseal t0 thesoft t0 byscoring casi.75-lmm anddeep. groove the wide The fades Bead made is gingival margins fades a hard and over midline sutu approaches 6mm the within 0f . Sealis thick (deep)t0 provide wlTH lmm P0SIIIVE IURE DE C0ilTAGI IISSUE p t0 when entrrpnent under maxillary connect0r retenlion placed the major and at f00d plate conneclo' poslerior ofapalatal maior b0rder
PAIITAIAIITERIl)R-Pl)$TNOR STRAP. . I{AXILUIRY Tt)ATMI)ST ATWAYS FOR KEIIIIEI)Y USE AI.I. CIISSES. iIAIOR COIIIIECTOR

. . . .

where is 6-8mm t0 r00m oJ for tori there Major c0nnect0rchoice inoperable cases vibrating line. b/c shaDe b/cits metal and straDs li GREATEST SInEilGTH & RlGll)lIY 0f its circular different !lanes. with EDEilTUL0USl(cnnedy lll mod RPDS SPAil Class I Primarily for a TARGE used when edentulous spaces resldual and ridges str0ng abutment (not t0 use teeth g00d palatal because than strap it covers tissue less snall). better A choice a single mininal mlatal snrlace area). 15mm the and straps! l{ust at TEAST tetween anteriff posterior he posteri0r are6-8mm and wide, must 6mm be below the The and straps anterior giogival and interterence. 0rstraD j Ante is maryin avoid t0 rugae c0verage tongue p0steri0ra rugae 0r ina valley crest hetween crests. two to pal and entirely thehard 0n Posterior is lhin, least wide, located strap at 8mm (n0t p lt t0 t0 protect I0tlGUt. is tltvER the right angles themidline diagonally) onmobile (soft tissue palate). palataliorus posteri0rly vrhen exteds 0nt0lhe s0ft 00ll0l USE aninoDerahle

40

l)E(U.SHAPE PAI.AIAI. C(]IIIIICTI)N): 0ESlRABtt [,lAXlttARY C0il ECT|IR MAI0R has because iheTEAST slreldh rigidity. d odyt0 g0ar0und lll0PERABLE T0Rl withlilfll)RGA0G[RS. only PAIATAI 0r Lised palrtaltorus prevent palatal inoperable using coverage posterior inthe enlarge area
(S LES t0p

NOTES

dburi

(unless is bulky), cause RlGlDllY it can lateral flexure abutments, can 0f KS and pinge during tissue occlusion. lll I when palatal is within 8mm the in Class mod designs and/ff a torus 6 0f line. rating g00d uires residual and ridges strong abutments. WI|)E {iIIl|PATAIAI) STRIP: in lll inly used GtAss designs. (does posterioranterior width kept is within b0rders therests the 0f extend of restsl. quality, lll I residual are ridges g00d fora I-ARGE-SPAN modwhen Class but palatal r abutnent weak. are Provides additional supporttheRPD io enahutmenls weak arc palatal weak abutments Ciass m0re ina lll, supportdesired a wide is and stfap preferred. is latal (COiIPIIIE "MTTAI. PI"ATE TI)VENAGT): AKA PI.ITI" mainly Classdesigr. INDICATI0N: thelastahutment oneither in I IVAIN when t00th is t 0f a bilateral distal ersion a CAt{l 0r ls PREM0IIR e c0mDlete oalatal ge is advised, especially theresidual when ridges undergone have excessive al resorption. I DISTAI edfor l0ng span Class BILATERAT EXTEtlSl0tlS poor with residual ridges, inv0lved abutment teeth. d/0r Deriodontally weak beused a Class vvhere aremissing in ll there anteriors a posteriof with modi{ication .eplicates anatomylhepalate. rsal least olthehard 50% and the 0l Falate iorborder at theluNCTl0Nthehard softpalate, does extend the is 0f & bui not to parale. palatal ldbeanteriort0 p0sterior seal. the (s0me rctention problem can isa and interfere thepatient's and with tongue taste rect ients cannot tolerate).actsmore I DIRECT lt in RETENTI0 .

It 0

1che51

ft iesas iuture.
0p m at l

sEs.
MIOI

rPsl e
dth
ECeS

|le (us

ft ef t pi sl Palate n pbr It Fa

lE0PAtlTAL PLlTE: formaxillary ll designs may may include used Class and or not lplating.

4l

l{0TEs

(Rests l1{lllRECT RETAII{ERS & Proximal Plates)

lndired netainers: . Are placed faraway ihedistal as from extensi0n aspossible base toPRwEilT VIRTI (i.e. DISLI)DGE0l thehase the EilT lr0m tissue 0pening eating f00ds). when sticky
(clasps) the triesto Increases the effectiveress retainers oldirect when RPD disl0dge, prevents nPD r0tating the lron around fulcrum (axis rotati0n). lhe line 0f lRshould 90' (right be angles)the{ulcrum and placed rest t0 line, is in seats d t0 lorces lheabufireni's axis. long along . Ihegreater distarce the helween fulcrum and them0re li[e lR, the eflective the . lRmay include, PR0XIMAL & lillll0R RESTS, PIITES, C|)llllECT0nS. Indirect Relainer Funcli0ns thedenture when basetriest0 AWAY theresidual M0Vt from l. ilAlilFuilCTloil: Preverts VERTICAL DISLI|I)GEI thedistal EII 0l extension base (sticfty lrom lood). away tissues 2. Protects softtissues impingement major bythe connector d0wnward during (limits m0vementcervical/gingival ina direction). r 3. Decreases r0 p0st eri0 i ilting leverages anis0lated is anabut ante when t00th (hut avoid this). 4. Helps stabilize againstoriz ntaldent ure movement h o byc0niact theminor ol conn (guide with axialt00th the surfaces planes). 5. Stabilizes lingual against 0fanteriorteeth used. movement when part 6. May asanauxillary t0support 0lthe act rcst major connector providethe visual 7. May first indication need relinedistalextension forthe to a by (i.e. asa reference forseating frameworksmaking and altered jmpressions cast if is in lellyou therest notfully seated ih rest seat). FUTCRUM (AXIS R0TATl0t{) axis RPD tlllE 0F the the r0tates ar0und the when base moves {r0m residual AWAY the ridse. . Fulcrum is rnainly (location)prinary line determined placement bythe 0l rests. passes Iulcrum through rigid the metalaboyethe height cortourand iooth's 0t totheedentulo||s soaee. Fulcrum isthe line center 01rotation asthedistalextension base movestoward su000 tissues anocclusal isa00lied. when load Class& ll always a lulcrum | have line! . Class fulcrum passes p0slerior l: through most the ah[tment t0 theedent next space. . Class lulcrum isdiagonal passes p0sterior ll: line and thr0ugh most the abutment thedistal extension and side, most 0n the oosteriort00ih non-disialextension side. . Class & lV:T00TH-BoRNVSUPPoRTED notm0ve lll RPDSthat d0 t0ward tissue du funclion (physiologic relief/adjustment required).Class & lVd thus is not In lll rests placed are immediately t0theedentulous next space. lftheframew0rk is properly desjgned, fulcrum willpass the line thr0ugh most the REST each on side. (n0 CLASSdesign nothav lllcrunline aris0fr0tati0n). lll does a

42

gasslvrfulcrum passes line rests thruugh MESIAI nextt0 edenlulous the the space. retainer wilh major united lhe by S-the indirect connectora nin0f connect0r. Rests entmechanical retenti0n. sh0uid Rests restore originaltooth the t0pographythat existed Rests be Rest therest was seat DreDared. mLst RlGlD. Functi0ns; PRIMARY Full0TlolllS T0 PnoVlDE VERTItAL RPD SUPP0RTI Prevents vertical lslodgement. com0onents inDosition. Iaintains Iaintains established relationships occlusal bypreventing 0fthedenture. settling inpingemeni cervical if a kevents tissue soft directl0n. and occlusal (vertical t0theabutment long l0ads forces) Directs distributes tooth's axis. Rests prepared the lmpression and are BEF0RE final isilrade master ispoured. cast IIEI]AMII{II{UII,I RESTS ANY OT 3 Il)R PARTIAI. DEI{TURE. posterior rest llere [4UST a MESIAI onlhe most be abutment witha dista] l00th ertension. REST' only material to l. 0CCtUSAt prepared inenamelany 0r restorative pr0venresist l/vher lractLre dr\Lortion a forLedDoLred and r\ .zmmdeep thecenter (0.5mm in deeper thel.5mm than thatthe marginal ridge islowered). . 0UTtlllE F0RM, R0Ull0El) TRIAI{G[Etheaoex with toward center the the 0f occlusalsurface. . C0tICAVE (sD00n-sha0ed) surface. occlusal .occlusa isaslong it iswide, the rcst as and triangle (marginal isat base ridge) least 2.5mm formolarspremolars. wide & . l\4arginal isreduced/lowered prov sufficieni 0fmetal ridge 1.5mm de t0 bulk l0r of and connector strength rlgidity therest minof and . Rest isslightlyCl-lE0 (deeper), the1.5mm 0fthe APICAILY fl00r l than depth marginalidge. . Angie formed occlusal and bythe rest vertical connectorthat nates min0r isorig from THA fOrces the long musi IESS 90't0direct be occlusal a ong abutment's axis. . occlusal isalways attacheda igid minor resi be t0 confect0r. .occlusal isATWAYS rest PREPAREI THE AFTTR PRI)XIMAI PUIIS! GUIDE
placed theocclusal 0CCLUSAL RESTthemost common indirect retarner on p0ssible. frOm extension as base easfaraway ihedistal I design:isplaced it bilaterally lt4-marginal oi 1"prcmolars. onthe ridge Class placed IVI ll 0n marginal 0fl" premolarthenon ridge 0n distal extens side. 0n Class design:

N(}TES

ERTIC ts). lge, a

o dir

tie IR
alr

base ovenl ment

T sts.
ct0

enIUt0

ent0n
ide.

a dufl

rsrgns t DIST

posteriOr RIST in lt l) 0E00CCIUSAI- used Class (m0d & lll RPDS themost when abutmentMESIAIIY is TIPPED. Ilinimizes lurther MESlAL t0 help tipping direct lorces abutments axis. long the more ], M and the [xtends than thet00th\ Dwidth is 1/3 B Lwidth. Allows mnimum lnm metalthickness. 0f with Rounded seat rest preparati0n n0undercuts. REST; 2. EMBRASURUII{TERPR()){IMAI. ljsed prevent to inteFproximal 0fthe wedging framework shuni away and food lom points. contact . Rest is preparat is extended just seat 0n LINGUALLY k strength, prepared forbu but like occlusal an rest. .l\4arglnal islOwered 0neach 1.5mm ridge abutment . Avoid groovet0 prcventthe creating a vertica minorconneciorfrom torquing 0fthe abutment tooth.
43

l{0TEs

c tcutuit 0-[{GUA|" REST RtsT):

. The saiisfactory rest suppod placed a prepared seat lingual for is 0n rest i most restoratioo. cast . Canines Dreferred incis0rs. are over . Preferred incisal because more resl il is eslhelic. L0 an . Limitedmaxillary with to canines centrals exaggerated and cingulums. Rarely satisfactory 0nmandibular anteriors to lack ena thickness. due 0f mel Arisky preparation onlower i[GisoF. . Preparation placed irncti0n isa slightly rounded inverted V(semi-lunar) atthe (iust U3 the lum, Sl GlVAt&IDDIE 0lthelingualsnrlace above cingu butI forces). enough t0minimize abutmenttorquing .2mm F-1. wide .2.5-3mm len$h. M-D . lVinimum deep 1.5mm (incisal-apically) . Used mainly anauxillary 0rindircct as rest retainer. . Rounded is placed (canirDs inci trom notch 3-4mm either Ml0r Dledge the 0r . IEAST ISIHETIC andnostlikely caxse RESI l0 orthod0nlic movement duet0 unfavorable leverage. . Preparation portion is2.5mm and wide l.5mm (deepest isapical the deep t0 incisaledge). . Not onmaxillary used incisors it isthe0nly unless 0pti0n. . Beveled and labially lingually.

4.

[{ctsat REsT:

AS RETEI{T|0I{ RP0s Broad WITH coverage over MAXlttlRY RU0AE ltlDlRECT

pr0vide sulport, is IESS EFFIGTIVEl00th is can s0me but than supp0rt,undesirable, indireci retention a PAUIAI with H0RSESH0I beca l)ESlGil av0ided. Rugae provide can isinadeouate. thehorseshoe\ oosterior retention Plate Guide Functions: . Helps palh 0ftheRPD. establish a delinite ol inserti0n/dislodgement position. Strbilizes RPD controlling the by itshoriz0nial t00th. Provides with adjaceni contact the Should justpast DL angles pr0vide encirclement, extend the line t0 180' bracing, and reciprocaiion. inthe 1/3 surface. Prepared occlusal 0nthepr0ximal plane is Guide is-2-3mm height in occluso-gingivally, F-Lwidth determined butits by tooth's contourplates Class & IVdesigns extend theabutments 0fc0 height Guide for lll can above movement. because is n0 there tunctional plates bebelowthe height with | Gxide iIUSI abutment's ofcortoff Class& ll d prevent torquing functional during movements. t0 abutment plates used l-bals mesial 0[ [rem0la6 av0id are with afid rests t0 lingual When must HfiCItY theheigbt cont0ur. at 0l lie plate end prediclable retedion. planes clasl Failureparlials to poor 0f due Suiding ensure planes retention canbeavoided alterilg by t00th contoufs. Guiding serve design predictable retenlion. assure clasF

44

(CTASPING) RETAII{ERS GT
placed are & hothsuprabulgeinlrabllge IEVER RETAITIERS) ctlSPS {DlRICT (axis rotation) d0ring function release because w0uld they 0l line i0 thelulffum (Wr0ughtt'Jires) are hreakers relainers stress aId 0nly theabutment. indirect li[e. lhelulcrum to anlerior = class t0 in 0f ine lnumher clasps use anRPI] [Xennedy + l] lV apply Hass designs to not placing 0n elemenis the by R[TEllTl{)Nprovided mechanically retaining t teeth connector with c0ntact pr0vidediniimate 0fminor by relaiionship RETEtlTl0tl DARY tissues. with connectorsunderlying planes, bases, maj0r deniure and
ncll reto

li0TEs

)ly rl ction

of I Arm SurYeyor: t00th, tooth/tissue 0n areas 0f areas retenti0n, 0f suppoft theabutment and 0f t0the rferences path insertion. 0f and of represents paih placement removalanRPD the arm vertica! (greatest convexity) height contour 0f ihe t0 markefused determinetooth's is Garbon (height contouf) a crown wax-up l0r 0f line caf the Powder identify survey Zrc Stearate over rod up the 0n tooth. sbutnent lt is brushedtheVvax and analyzng is passed wax the and surface removes Powder. an Any unit mechanical retention. RPD thatengages ihe T REIAIIIERgives RPD a engaging using fricti0n, seat AWAY basal tissues disllacement from t to resist (gingival)thetooth's 0f helghi contour' t0 cervical 0r ion, undercut Cast .0i ECT RETAIIIERS, .25nm Clasp Attachment"): Attachment 0r "lnternal Retainer t. tntra-C0ronal ("Precisi0n support . Advantages: esthetic tetainer Providesbest the vertical direct themost axis hotizontal favorably totheabutmeni's lelatlve mole seat ihroughrest l0cated a (does allow movement) horizontal not natural contours restored . lt iscast attached within abutment's the totally 0r !1/alls vertical . Has 0lefabricated keyway 0pposing parallel t0limit wlih key & a removalfriciion by and movementresist unless . llotused exlensive distal tissue-supportedextensions a shesswith RPD and attachment. between movable base rigid the is hreakerused teeth placed surfaces netainer 2. Ertra-Co.onal (Clasps), 0nEXTERNAL 0fabutment (cervical) in helow and . Has REIIilTIVE am thatisFLE)(IBtEplaced areas claso a (t0oih's gingival Pr0vides resistance t0 l/3). height contour 0l t0 thet0oth's generatesretentive 0i action the force disl0dging This from deformati0n a vedlcal until with the relationship abutment a dislodging Which a ihe clasp. has passive lorce aDDlied. is facial n0 are . Lingual 0nmolars usually retentive b/c there usuallyusable arc arms 2"d molars 0nnandibular0f3'd unde(cuts

gual
cla ,00r seNe

45

l{0TEs

Arm Clasp Flerihility: . Longer thinner (smaller and diameter) clasp = m0re the arm . Most in A clasps tt r0und form. round form theonly are clasp is circumferential form can safely t0 engage u clasp that be used an ontheside anabutment 0f awayfrom distalextension the base. . Retentive must flexible provide reliefforthe arm be t0 stress abutm . UilotRCUT t0GATl0N most isihe imp0rtant when factor selecting a fordistalextensions. decides clasp tEllTlST which designbest is plan 0nthediagnosis keatment established. and . Has BRACI(stabilizing/recipr0cating) placed clasp arm 0CCIUSAL a S tothe (cr0wn's l/3).MUST RlGl0. tooth's 0fcontour height middle BE . Composed greater alloys t0 rigiditywith bulk. less 0fchromium-cobalt give . RIGID (thicker) theretentive because greaterdianeter it is in than arm. . TaDered dimension inone onlY. . Horizontal istransmitted placing portions clasps ll0tl-Ullll rigid force by of in areas abutme ot teeth. 0ccurs lhe arm bracing C0I{IAGIthe arm RECIRP|ICATI0I{ 0nlywhen retentive and and RPD. the arm atthesametime during seating rem0vinglhe As retentive tip passes theheight c0ntour engages undercut, rigid 0f and the the bracing must arm maintain Tllillllc lll REClPR0CATloll. with abuiment. lSCRITICAL the pr0vide Clasp Assemtly C0mp0nents: assembly Ctasp comp0nents 180'encirclement 0f (clasp minorconnect0rs, guide plates contribute 180" all tothe enci abutment arms, l. 1-2 rests at least min0r & I connector. (flexible) 2. Retentive arm clasp t0engage terminate and inundercuts. (bracing) arm 3. Recipr0cating clasp (rigid). When RPD fullyseated, clasp should EXERT PRESSURE is ihe tips NoT ANY against an abutmentteeih. betotallv lt must 0assive. retentive isactivated when The arm 0lltY RPll from tissues. dislodging attempt unseatth anay theiasalseat f0rces t0 Principles Clasp Assemhly: Fundamenial 0ta passive its is activated l. Clasp should completely and retent'vefunciion be only forces applied. dislodging are (bracing) arm 2. Each retenfive must opposed reciprocal clasp be bya clasp 0r horiz0ntal exerted thet00th ttre forces RPD element capable resisting 0f 0n by retentive arm. Each must designed claso be t0encircle than more 180'(more hthe then 0lihe t00th. circumference)abutmeni VERTICAI Rest should lrovide only SUPPoRL RETAII{ERS suprabulge & infrabulge MUST I retentive clasps have EXTRA-C0R0l{At (flexible) I rigid reciprocal arm. bracing and

46

Rexib

BUTGE RITAIIIERS approach retentive the undercui ABoVE t00th\heisht fr0m the (usually anocclusal r from rest)

HOTIS

unc utrnet: rgac ;t ba

r. ctRcur{rEREt{flAr ctAsP {A|(ER's ctAsP),

IIDER

. Engages oftheabuiment\ > 180' crrcumference. Term end itsretentive arm (buccal)engaging nal of clasp povides reteniiOn by anunoetcut. . Has n0n a liexible lingual arm stabilization/reciprocation. c asp for lVust kigid) lie always ai 0rab0ve height contour the 0f because it canf0t t0geiinand flex out olundercuts. . 0riginates occlusal tooth's 0fcont0ur, crosses terminal 0nor t0the height then inthe thifd, engages!ndercut itstaper and an as decrcasesflexibility and increases. . Consists retentive arm I non-retentive 0fI clasp + reciprocal arm. . Clasp choice Class & lV{t0oth-borne posterior 0l in lll designs) them0st when ahutment undercutAV{AY theedentulous {i.e. surlace. is fron space MB) . lJndercut beontheopposite 0fthet0otl/rest where must side from the clasp originates. . D0ll0T when undercut USE an isadlacenttheedentulous (DB Dt). t0 space or . RPI guideate p + Assembly; ol mesial + d stal Clasp consists rest circumferential clasp.

nt ofl
cleme

rinst i Yen

tn0Ine'

Z RING CTISP. . lndicated t0engage undercut MESIALLY-LlllGUAI an ola TlLTED when M0IIR a seyere undercut that tissue erists prevents anl-bar. using . Used almost exclusively 0nmandihular thatdrifted molars |tlESlAtl-Y GUAIIY &U to engage GUAT a UilDRCUT. . Indicated inrcverse abutment t0a "tooth-bound" 0nan anterior edentulous space. . tncifcles all0fa tooth itspoint 0rigin. nearly from of .ljsedt0engage mal ( .e. a prox undercui lllI undercnl0n mandihular cannot molar hedireclly engaged 0l itspro{mity theocclusal and b/c to rest cannot be (iffra with bar approached a clasp bulge) tothe due molals lingual inati0r. inc . Allows undercutbeaolroached theto0lh's the t0 from distal. . Has mesiai primary & dlstal ary ljsed rest a auxl rest. almost exclusively 0nML tilted molar abutmenls. used a supporting 0nthenon-retent Always with strut ve side 0rwthout aLxillaryon opposite with an rest the trargina I dge. . used protected 0n abutments because it covers 0ft00th l0ts surface. . Used caries isLOW ir NoN-ESTHETIC when fsk and areas. . ljsed when DB Dtundercut a molar a 0r 0n cannot approached fr0m be directly prevent the0cclusal and/or lissue rest when undercuts engagementa har with (inlrabulge). clasp . Clasp originatetheN4B can 0n surfaceengage undercut, toengage t0 a ltll 0rIVIL a NIB undercut. 3. REVERSE (HAIRPIII) ACTIl}I{ CI.ASP: . Used y 0nabutments (Class 0f 0f"t00th bOrne" dertures 3 & 4)where a proximal (iffra-bulge) isBELoWp0int origin whenbar undercut ihe 0f 0nly a clasp is contraindicated tissue due a to undercut, t00th, tilted shallOw vestibule,gh 0rh tissue attachment. . Used lingual prevent ng when undercuts plac a supportingwith0!t strut tongue interference. .0nlythe paft lower 0fthe arm clasp (afterthe isflexible curue) toengage theurdelcut.

! tive

41

l,l0TES

ETIBRASURE CI-ASP. . Used sound withretentive 0rwhen on teeth areas multiole rest0rati0nsiust are . used n0edentulous exists theopposite 0fanedentulous when space 0n side C ll orlllwith modifications. no . Requires at least l.5mm marginal reductionnrevent ridge t0 lracl{re ihe 0l clasp assembly. . ATWAYS WITH USED DOUBLE oCCLUSAt t0 preveni RESTS inteFproximat wedgi the framework. . Aretentive and reciprocaling must present arm rigid arm be foreach ab have donot to beonthe same side. .Wroughl arelltVER with wires used embrasure clasps.
5. HAI.F-&-HALF ClASP.

. INDICAIED tl GUALtY (LlllGUAI roR lllctltlED PRE0URS UllDtRCUrS) . Consists I circumferential 0{ retentive from direction, reci0rocati arm 0ne and thaiarises thenin0r from connect0l BAC|(-ACTI0lt CUSP, . Aring you clasp modificati0n. isditficult justily ltsuse t0 because could easily a conventi0nal circumferential clasp. . Can used a prem0lar be 0n abutment anteriort0edentulous an space.
1. MUTIIPI.E ClISPJ

. Two 0pposing circunferenlial ioined theterminal 0lthetwo clasps at end reciFrocal arms. . used additional (tooth-supp0rted when rctention stabilization and isneeded . Disadyantage: two embrasurc approaches necessary are ratherthan a single embrasure clasps. forboth

c0MBrlraTr0il cusP:

.lilostcommonly when abuiment t0a disblextension Il, (Class used an next where preventbar 0nlya undercut 0r if large l{B exisls tissue undercuts a lrom being used. . Used maximum (i.e. when flexibility required anabutment t0 a distal is next 0na weak abutment a bardirect when retainer contraindicated, is 0rwhen rsa concern]. . C0nsislsa bracing wroughtwire 0t arm, rclentive circumlerential and arm, distal rest. . Use when undercnt or lheside the is 0ltheabutment lromtheedentu away space because more it is llexihle a cast than clasp thus dissipate arm can lunctiolal stresses.

s.EXITIIDTD CI.ASP: ARIi

. NEVTR with used Class ll (distal I& extensions) b/c functi0nalf0rces cause ar0und rest upward the and movement clasp Used abutment 0fthe tip. for t00thborne dentures toanedentulous next space.

48

= RETAItIERS CUSPS R0ACH UtGE {BAn CTASP):

ustiliE
sC l a . :

tent. I

atng

kisesfrom frameworkmetal and the or base appr0ach abutment's the reteftive undercut (BEI0W HEIGHI C0llT0UR). ftom GI GIVAI a DIRECTI0N THE 0F (0.01 exists cervicalthird abutment, hdicatl0fs, a small when undercut lnch) inthe 0fihe (i00th abutmeft forClass & lVdesigns supported), extension teeth lll m indrstal base ons, when isa iituat and estheticscofcern. a DEEP cervrca undercut 0rwhen exists lontraindications:when a severe 0rtissue t00th l{01 il exists. used atissue undercut (because exists isi0thers tongue !0defcut the and (shall0w traps debris) with lrenum food or high deekand attachments vestibule) or buccal 0l ercessive 0rlingualtilt theabutment t00th. inter ldyantages, proxil]ral location ESTHETICS, retenti0n for ncreased witholtabutment proximity denture less ofaccidental d stOdlon t0its hpplrg, chance due t0the border. Tiey 0f bar type clasp insigr is ficant long it is mechanicaily as as Jlrctionally and gilective, aslittle possible. covers tooth surface poss and as ble, displayslittle as metal portiontheapproach crosses gingival Vertical 0f afm the rflargin90'. at Claps:T Modilied I bar, bar, bar, Tbar, Y Roach Hrabulge Clasp. place tip0f I har's Iways the retentive l ESlAt thegreatesl curvature arm t0 M-0 0n facial to retenti0nlheundercut. undercut in fie abutment's su.lace ensure The must (in of) |||-D l MESIAt lront thegreatest curvaturetheabutmeflt's surlace. 0n lacial guide (RPl plate SYSTEM) BEST l-barretentive witha MESIAI and arm rest distal isthe assembly placed theterminal to be on clasp abutment distal ior ertensions. Indicated a Class0r ll RPDS a [4ESlAL wher for | using REST there notissue is undercut. t0 a l\41 when is tiss!e Usedengage undercut there no undercut the below abutment. I,bar's sLperior s located than from lree border more 3rnrn the gtngival mafglf. for ll m0d0na lvlL molar little | Indicated Class tilted with iissue Lirdercut. (suryey in distal lhel00t0l thel-bar completely theheight contour is below 0f line) designsit can s0 release lurcti0nal rrtension during movements extensi0n 0fthe base. lhen a [atient bites down. l-bar the should release theundercut.Ihe from retentive (opening .rm sh0uld tuncti0n there anattempt dislodge RPD only when is to the the when chewing food). sticky routh

N OTFS

r 5 yLl

mod I clasp ent rslnel nd

ntulo

T FIED BAR:
for undercuts theheight count0ur 8ar0f choice DB helow 0l immediately lo an nert soace. edentulous Primary indicat is when 0n abutmeft undercuts immediately t0 anedentulous are neJd .rea r0t ssle ard uideTcuts.be with mesiald stal Can used a or occllsa restintoothdesigfs no since funct mOvement 0fal suppoded 0ccurs. Wlef ona terminal lsed abutment CLass l0ra I design, lsed a mesial and it is with rest arm into undercut. lhe ti0is0laced a l)B greatestlrl-D Itsverticalarm mustapproach engage and MESlALt0the curvature the 0n lacial t0 the from dlsl0dged back. upand abutment's surlaceprevent RPD being
49

i't0TEs

(REST, "RPl"SYSTEM PR0XIMAI PIATE, I-BAR) anl-bar clasp consistsa that 0f guide with ninor plate the placed the embrasure, resi, distal and connect0r into ML hut contactingadiacent the tooth. . lJsed with 0nly Kennedy l0r ll (DISTAI Class t)tTtilSl|)tls). lllust 180 be degrees the around iooth guiding extending themarginal to thejunction midd plane Distal from ridge of gingival oithe plate. l/3 abutment isprepared t0receive a proximal iIESIAT ARE RESTS PIACEO THE OII TERIilIIIAI" ABUII{IIII TOI]TII AIT FOR DtsTAt EXIEilStoltS. RPlsystem isdesigned vertical t0allow r0iationa distalextension intothe 0f saddle de bearing mucosa occlusrl under loading without damaging supporting the structures 0f abutmentt00ih. Asthe saddle ispressed denture intothe bearingmucosa,thedenture ab0ut point t0 themesial Both distal guide and barmove plate la cl0se .est. the in directions indicated disengage thet00th and from surlace. Potentially harmfult0rque is avoided.

RPD STRESS BREAKERS

SIRTSS-BREAIGR a device relieves ahulment to which FPD that the teeth an 0r generated attached, 0rpart thef0rces ofall 0l byocclusal lunction. a slres When is incorporated t0afree-end next distalextension thelunctional RPD, stress directed is theresidualridgeonly and ninimaltransler 0llunctional toabutmentteeth stress 0 Since vertical horiz0ntall0rces and are concenirated residual increased 0nthe ridge, resorption f requently occurs.

WR0UGHT RETEI{TIVE (STRESS-BREAKER)breaker WIRE CIASP astress used

0f its increased flexibility minimizing abutment torquing). simplest 0l The form {it reliel. a flexible Has connection thedircct between retainer dentu.e Adva and base. greater higheryield strength, llexibility, ductile resilient. more and . 0ften with liltslAt in class & ll designs themost posterior used a rest I 0n (terminal t0oth abutment) there a tissue when is undercut, frenum orhigh attac thatprevents anl-bar using . lt occlusion prevents a mesial 0nthem0st posterior using rest abutmenta in extension,0nly can used a distalrest a WW be with hecause 0l(l0r rete it is its (lulcrum). t0ie infront theaxis rotati0n 0f 0f . Used teeth indirect (both anterior thefulcrum on wiih reiainers them 0n are to I Provides reliei theabutment due itsfJexibiliiy thedistal stress to tooth i0 when exten moves theresidual toward ridse. llp 0f its retentive should arm engage undercut the AIITERI0R fulcrum t0 the line placed therniddle 0f rolati0n). Terminal 0l its retenlive is optimally end arm in jt is gingiyal 0ftheclinical j l/3 crown. H0wever,acceptahle it atthe to place thegingival middle 0ftheclinical and l/3 crown. thepartial compleiely When is s thereteltiye should passive applyi0g pressuretheteeth. arm be and n0 0n 0TUSED Class & lV (t00lh-b0rne) in lll designs because is n0fun there novementtheRPD. ol 00ll0l USE wr0ughl through wires embrasures embrasure 0rwith clasps. greaterthan castalloyfrom it was Has,tensile strengthleast at 25% the which clasps greater Wr0ughl-t!ire have flexihility adjustahility thecastcla and than t0ugher m0re and drctilelhan clasps, have cast and greater tensile strength.Thus

50

]ut n

greater in diameters t0provide llexibilib/ without fatigue lracture. and beused smaller NOTES llroughtwireisincorporatedintotheRPDbysolderingitt0theminorconnector,meshwo, pattern,is embeddedtheacrylic (makes it into 0r into incorporating thewax resin it the gauge 20 nost flexible). wrought is2r more lvire flexible an18-gauge than wirc. wrought iluslbeatleast long tapered 18gauge wire. 8mm and Jl2=.smm round wire. =.75mm lSNOTIUSTIFIED. and -03 ltEs: joint) metalframework Externalfinish exiernaljunction 0fthe tine-the and {butt (acrylic). plastic base denture . The external line0na maxillary I RPD finish Class originates thelingual the from 0f guide 0fthe plate terminal abutment ands the and at HA|ULAR N0TCH. Internal Finish tine-the buttj0int between metal acrylic theTISSUE of the and 0n SIDE the edentulous area. . Juncti0nthemaj0r minof of and c0nnectorpalaial at finish lines 2mm al ng are med posterior from imagrnary would line that the cOnnect surfaces lingua 0fmissing denture teeth. . Internal External lines normally lr0m other avoid finish are and 0FFSET each t0 framework weakness/lracture. . Locati0n linishing atthe junct 0fihe ofthe line 0n major minor and connector is palatal while the based restoringnatural on shape considering the location ofreplacement teeth. . Finishing linejunctionthe with majorconnector no sh0uld greaterthanthus be 90', undercut. being somewhai .luncti0nminor 0f connect06bar and clasps 90'butt-jointsf01lOw are that the gudelinesbase for c0ntour clasp and length.

entu
iofi rOIAI

)r n

rstn

'RPDi brca

rd
0cc { rid

RPD RVEYIl{G ABUTMENTS

IM

lhe path posil.0r lhe Ldsts allow. denli\l reco thedFltures of inserl'01, l0 d 0l

rchme adi mtve rmlrne {tens

Ine tar

leol nction t seat rnction

asmad

line, locati0n undercut n0n-undercut T0 this,TRlP00 and of and areas. d0 MARKS are t0 the orientation survevor. t0the d onlhecast record cast's placed3 different marks spots 3 at locati0ns abutmeftteeth a single around from lripod 0l t0 a 0rientation cast lhesurveyor. 0l the t0 Recofds Doint view ensurerepr0ducible casi\posilion. the parallel oforal Survey0r i0 determinerelative !sed the sm anatomy. used Areas oental hr suppori iloTbedeterminedsurveying. surveying thecorrect CA by When casts, procedure ist0lirst adjust tiltt0 permit establishment planes. the the 0fguiding The edentulous will space Jrequently the dictate angulation Nomally, needed. anterj0r sone guideplane re-contouring prox walls abutrnent is needed improve 0f the mal 0f teeth t0 parallelthepath insertiOn. by the surface alignmenidisking pr0imal t0 0f cast surveyinganges path insertion, ch the 0f survey p0sition, line and Iiltingthe during 0ltheundercut non-undercut 0feach ald areas t00ih. hcation

tsps, Thus

il|1TES

(lJsing PURP0SE 0FSURVEYIII0 oiagnostic Casts): . Determine most the desirable 0l Dlacement willeliminatemini oath that or placemeniRPD. the interference t0removal and . ldentit planes theprosthesis. surfacesguiding for for . Locate measure ofteeth retention. for and areas . Determine tooth path if a and/or areas bony require surgical removal if another or insertion willsuffice. path Determine most the suitable 0f placement willdesign retainers teeth that 0l and bemost esthetic. preparati0n made. Prepareaccurate for mouth an chading any t0be Determinedelineatet0oth\ and the height contouf. 0f like the maxilla/hinge relation FACE - caliper 0evice record patients Bl)W to axis (openingand axis) closing andt0transferthis relationship articulator mou t0the during propeiy, arc0f closure thearticul cast. is the on 0fthemaxillary lf thetransfer done should du0licatethe oatient's arc cl0sure. true 0f . Before accurate bow an face transfer can made, locati0n thehinge recofd be the 0f point must first center opening-cl0siBg), bedetermined. 0l {axial Facehoyr transfer ll0Ta maxillo-mandihular bula record 0rient is record, t0 maxillary t0 the hinge cast axison the articulalor. facebow The iransfers axis tothe during ofthe maxilla/hinge relationship articulator m0unting maxillary ca A lace-how transfer rec0rd D0ES all0w dentist locate hinse ll0T: the t0 the axis. reliably, position maxilJary pr0perly relati0n n0r in rec0rd more CR the casi t0 mandibular nor cast, transfer cast thearticulator the t0 maintaining pr0per the i 0cclusal relationshi0s inthe Dresent m0uth. . llilge-afis bowtransfer lace enables deniidt0 VD|) thearticulator. the alter 0n altering (either restorations dentures), should m0unted VDo via 0rwith casts be on Bow t0record hinge Hinge Face used axis. Axis opening cl0sing themandibl and 0f FNA EWI)R(TRY-III: . Belore inspect master for damage inspect trying a framework, tl're in cast and framework forsharp fins. meial . When patient, dentist RPDS making maxillarymandibular 0nthesame & the should tryeach framework at a time fit,then one {0r adjust occlusi0neach needed, for if with frameworks in0lace. adiust occlusion b0th . llamaged 0nthecast thefirstareas areas are adiusted framework not ifthe does . lf theframeworkthecast notinihemouth. other but fits all Dossible sh0uld causes eliminaied makingnew beforc a impression. lf atiempts fit theframework mouth unsuccessJuladjusting, l0 t0 the are after and will assume impression is inaccuratelheimpressionneed berem the 0fcast t0 AliASItR CASIl0r RPD a should blocked be outand du0licated BEF0nEthe lra is waxed up.

52

ES0F RPD CHR0MIUM-C0BALT corrosion ALL0YS resistance, strength, high gravity VERY (inflexible). duciility malleability c & RIGID N0 0r afte.they cast. are 0n0f Chromium l{etalAllovs RPDS, Base for Chr0mium responsible f0rC0RR0Sl0 nESlSTAtlCf inc0balt-chr0mium all0ys. Ensurcs all0y resist the will tarnish c0rosion f0rmingc0mplex and by a chr0mium oxide An made metal is resistant film. RPD 0fa base alloy l0larnish corrosion and becauseilssurface layer. 0l oxide C0balt-increases thef.ainework's RlGlDITY, strength, hardness. and llickel-increases DlJCTlLllY. ll,leasuredpercentage asa 0felongation determines and much margins be can closed burnishing. isthemetallic via how llickel component 0f potential ALLERGIC a RPl| thegreatest with for REACTI0IIS mouth. inthe
otl

N{lTES

|Untr
c!l

t[0Y cusstFtcAlt0lt:
l: used small for inlays. ll: larger & onlays. inlays lll:0nlays, crowns, short FPDS. and span lV,thinveneer cr0wns, long-span & RPos FPDS , cAsItMPRtSSt0 possihle theedenlulous in Class istoobtain maximum from ridges urpose the support & ll designs. ptures ridge ln edentul0us tlssues relation theway framew0rk lNTHE t0 the lits lVl0UTH

!d

cast

us. to rin
ont
dible

hotcast).
avoid overextensionis c0mmon a stock+ray that when alginate impression is used. poorer in areas where emain reatively in tray adequately teeth but I st0ck will ped0rm areas. isone lhemajor This 0f reasonsaltered impressi0n an cast isdone. cdentul0us CAST TECHI{l0UE DUr00se record form the ist0 the 0ftheedentul0us secmenl tissue displacement accurately theedentul0us and t0 relate segmenttheteeth 0f framevJork. goal t0 provide The is maximum fOrthe denture RPD e metal supp0ri base, maintainins occlusal contactdistribute t0 occlusal 0ver naiurai artificial load both and

td1l d,th r0t

)Ut0

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

cast helps s0lt support aidabutments to in resisting Altered technique oblain tissue stresses. a secondary lt is impression thatuses metal system the framework functional imDression forthe cust0mized trays edentul0us areas. l0 hold

t0ils:
nade

RPD must a It a mandibular abutment becrowned, FPD the impressi0n includefull should pads. impressi0n isrequired tocapture abutmentteeth ret.omolar all and the arch you crowing abutment for an RPD, must an tooth reduce thanthe normal m0re Y{hen occlusal reduciiontherest for seat.

53

t{0TEs

Cl)MPLETE DEI{TURES
Complete Denture Design Characteristics: quality 0r t0 be steady, constant, 1. Stability{he 0fa dentureprosthesis firm, and positi0n forces a[plied. dentures, suhiectt0 change when are In stabilitythe is relationship denture t0bone resists 0fthe base that dislodgement denture olthe a HoRlZ0 direction. IAL . Stability involves resistance io horizontal, &torsionalf0rces lateral, (most imIortant). . AllRPD c0mponents, exceptthe retentive tip,contributedenture clasp t0 stabi VIRTICAt forces 2. Support resists seating Frovidedresls denture by and bases. RPDs, supportprovided is byocclusal and rests edentulous areas. ridge Support imp0rtant characteristic health. design fororal theIVoST 3. Retenti0n the resists force gravity, 0f stickyfoods,forces and associated with mandibular m0vement. & indirect Ilirect retainers retertion. CI-ASPS lrovide inundercnt 0fahuiment Dr0vide areas teeth retention. quality oral retention, stahility,support: & 0f muc0sa, tactors impact that alve0lar ri contour, muscle attachments, andneuromuscular {them0st saliva, conlrol impo patient\ because muscles tohold dentureplace chew learn their in and efficiently). B0RDER l'l0LDll{G: . l{asseter powerlul whose run muscle liber superi0Finleri0r l{uscle: [hdIpushes into 0f base c0ntracii0n. buccinat0r the DBcorner the denture durins S 0IST0BUCCAI durjng altered impression. AREA an cast 0verextensi0n mand 0f a base area dislodgement denlure fun ofihe during denture inthedistolacial causes 0ftheaction 0fthe ASSETER. Anoverenendedcornerofa DB mand astheresult pushes denture against ASSETER function. the during . Su0eri0r Constrictor Muscle: shaDes DlST0LlilGUA[ the BoR0ER 0l0lilG. Atfects portionthelingual flange. overextended flange cause An lingual most distal 0f can a throai. . 0ST criticalarea border in moldinga llN(lLtARY DEIIIURE MUC0GlilGlVAL isthe area is important maxi for above malillary the tuberosity asthisarea extremely reteniion. critical other areas thelabial are lrenum themidline. {rena in and in inthese often t0 retention ti bicuspid Overextension areas leads decreased area. and

irritation.
. When moldinsilA DIBI,IAR IEI{TUREafinalim0ression.lhe for DB border a determined thep0sili0n action theMASSETER The extension hy and 0f MUSCLE. 0I impression a complete for dentlre limited theaction is hy 0f ihe mandibular SUPERIOR Cl)IISTRICT|)R MUSCLE, provide FREIIUMfoldsof nucusmembrane containing fibrous l\4ust C.T. it can the relief/space area inthis because Iimit denture's ertension.

54

Tray Border & lllolding: trayfabdcated a preliminary is trimmed on custom cast ofthemucosal -2nm short and This by ti lection frenae. is done firstchecking bordersthefltouth then the in and immed t0allow down uniiorm thickness2mm modelins 0f 0f c0mDound theborders when molded. However,primary the indicator h0rder 0l m0lding accIracy STABILIIY is and 0f displacement cust0m inthemouth 0fthe tray
should plete m lray a linalndndrbLld lor 0rmarillaryc0 denrure imprpssi0n havF

N TE C

t a bi l ' s. For ports

spacer tissue t0ensure tray with stops the seats prcper in rclationship arch, t0the and room adequate fortheimpression material. space c.eated wax The is with b ensure hy foil0verthe masier priort0lorming tray. cast the royered aluminum is in two The lorderm0lding c0mpleted stages. m0lding should approximate thetray and be horders should slightlyoverextended. compound Excess istrimmed inside from and qitsjde cust0m The the tray. remaining modeling compound refined repeating is then by The tie pmcess. finalform0f the b0rder molding should represent accurate an peripheral 0l tissues. border The modeling c0mpound have hpression the sh0uld a polished appearance. smooth, superior Palatoglossus, pharyngeal c0nstrjctOr, mylohyoid, geni0glossus are and muscles influentialborder in m0lding LlllcIJAL the borde. themandibular ol inpression an for paiient. dentulous extraction, alveolar resorption because is nol0nger stimulation ridge 0ccurs there bone hy supp0rting ol structurcs kesidual resorption). occurs ridge (UPWARD b0ne occurs laxillaryarch: loss/resorption lna VERTICAt & PAIATAI direction (0.1mm/year issustained). loss first isgreater, varies. Initial in year & IilWARD). but (DoWNWARD arch,b0nel0ssoccurs VERTICAI landibular in direction & [0RWARD/0UTWAR0). is oriented thecr0ss-sectional 0f the Bone loss al0ng shape I\4andibular res0rpti0n faster inthemaxilla, varies. bone is4)( nandible. than but Severe resorpti0n ca!se Pseudo lll malocclusi0n bone can a Class appearance. product adding piate t0 a record t0 Sl0l{RIMS theresultant after base wax base positl0n arch expected compieted imate t00th the and form lnihe Functions: deniure.
-ine fvelicJl '5h patiertVDo Detpr ardestab t'rF s dimension Js0n) level 0[occ aro of

hes t dibu
dibu

u
naxtnl tn I dtiss

occlusalplane. preliminary Make maxill0-mandibLlar iaw relati0n rec0rds. (arch position Establish locatethefuture 0fdentureteeth forthe cheeks, and lips, tongue). rim is and rim Maxillary 22mm nandibLlar18flm. partial rec0rding anRPD, 0cclusion is attached thecompleted for CR the rim t0 metallramework instead a recofd asused a complete 0ft0 base with denture. r surface themaxillary 0f occlusion sh0uld PARAttEt CAMPER'S (the rim be t0 LlllE plane running theinlerior 0fthenose t0the from border ala supedor oJ ear b0rderthe plane, s). Signilicance 0fCampe/s line:the occlusal established wax by the 0cclusion parallelt0 surlaces is Camper's & interlupillary line line. 0nmaking Complete 0f 0entures Rec0mmend a technique using that: placement control theimpression Affords and 0f material recording tissues in border (border moldirg). Resultsminimal displacement thedenture in tissue under tissues their n kegisters position). passive present. lsdependent oral onthe conditions Best impression techniquea patient loose for with hyperplastic ist0register tissue the positi0n. must irtimate in its PASSIVE tissue Ihere he contact lhe impression 0f material thetissue. with
55

l,t0TEs

MAl{DIBUI.AR C|]MPLETE DEl{TURES

(stress-bearirg) is MAiIDIBUIAR C0MPLETE DEIITURES a primary srpport area
(resists BUCGIL iecause its bone SHELF 0f structure resor0tion becauseis ii (parallel) corticalbone d0es change) itstrabeculati0n and not and rightangle relali plane. totheocclusal peripheral arca a mandibular A StC0ilI)ARY seal for complete denturethe is lingual horder. ASEC0NDARYarea theCRESTRESIDUAL WHENlSSHARP relief is 0F RIDGE IT l{andihular Support Areas: prinary 1. Euccal shelf-the suFport l0r a mandibular area Euccinat0r denture. muscle a denture's limits extension area. biggerthe shelf, inthis The buccal the dentuae suooort. . masseter atfects nandibular muscle ihe denture. . The boundaries buccal are buccalfrenum retr0molar 0llhe shelt lhe tothe ( crest thersidual t0theexternal 0f ridges 0blique line Alevoalar SEC0IIoARY mandibular supFort. ridgearea ol dentu,e . RESIDUAt il large broad, beFrimary RIDGIS and may areas, are support but usually SEC0ilDARY STRESS-BEARI hecauseis cancellous GAREI it hone. pad-does change resorb. a primary Retr0m0lar not 0r ll0T supponarea, mu but inthe Lies captured inpressi0n. atthecrest 0fthe mandibular ridge. residual keratinized thebetter ftralinized tissue- more the tissue, denture support and comfort. patient a "knite-edged When fabricating a rnandibularcomplete denturefora with you naximum need e*ensi0n thedenture help 0f i0 distribule occlusal torces atgetarca. ilarkedRES0RPTI0il alye0lar willoccur a mandibular 0f the ridge if complete de pad.lrnderextension peripheral baseterminates0fthe sh0rt retrum0lar 0lthe bord a complete mandibular denture decreases tissue-bearing s laces, afle thus deniure STABILITY.

(does pad) Underlying b0ne basal (umer retromolar resists resorytion the hone resoft). Covering area provides boder Anoverload the mu this also s0me seal. of occurs bases ifthe coverinsthe are small outline. area too in
Mandjbular dentu.es notrely suction a peripheral for retention 0n from d0 seal maxillary dentures, rely0n dentnre but stahility coverirg much in as hasal b possible with0ut impinging tnuscle 0n attachmenls. active Tlre border molding peripheralareas bythe cheeks, tongue lips, and determines the 0fa mandibular arch, maximal bone basal coverage. establishi8g
D0tl0TPTACE mandibular molars theascending 0f the mandible ove. area ramus DISI0DGE mandiiular occlusalforces theinclined 0ver the denture.

56

is in area mandibular (mandibular tori dentures) and nuc0sa lound myl0hyoid & over palatinus (maxillary dentures). midline thepalatal and a torus 0f vault 0ver prominent for rtori, sharp mylohyoid ridges, Epulis and fissuratum areevaluated 0f dentures besins. I removai thefabricationnew before position in A with affects denturc stabiliU retenti0n the mouth. patient a & tongue denture candidate D/RETRUotD is a p00r aflectsthe slopeofthe lingualflange impression molar 0lthe inthe Y0lD MUSGtt (atits most (distal) toward the PoSTERI0R aspect) causing llange slope the t0 Ft|l0R M0UTH. from mylohyoid 0fthe Arises the ridge F()RilS IiIUSCUtAR 0FIHE THE REGIoN becof0es 0n higher the inferior border theINCIS0R n and iblenear mandible\ just p0stei0r until terminates distal thelingual body lt t0 tuberosity. andible's ||lA 0E when lS at and C0nnectsthemidline cantlFI THE DIBUUR TURE theT0I{GUE lt influencesm0laf the regi0n slopes and toward tongue. the gland p0rtion theirylohyoid 0f flruscle theLINGUAL cause FLANGT blingual and 'n0TRUDED. antedor region. bel0werheightthe in in anteri0r pharyngeal 0f the corstrict0r & ClJRIAlll-c0mp0sedsuperior ItTR0l{YL0HY0lD g0. far lingualflange can Determines posteriorlythe how Dalatoglossus. tltlcUAtSUIDUS.is This FossA-located distalend alveotar atthe 0fthe |[TRo|tlYt0HY0lD "S-CURVE" the flange towad ramus turns the making famous the with therethelingual Bordered sl0ping toward tongue themolar the in region themyl0hy0 0f d muscle. frange pillar p0steri0rly retromylohyoid curtain. anleri0r tonsillar and bythe $diallyhythe (slopes . S-CURVE in a mandibular impression totheMY[oHY()lD due iIUSCIE is seen the the and F0SSA wh toward buccal. t0ward tongue) RETn0MYI0HY0|0 chslopes

NOTES

()MATI!IBUI.AR lying the & RAPHEa TEltDoil between buccinatorsuperior ictor muscles. = Tuberosity lTubercle Lingual
and nGUAI SULCUS space between ridge tongue. the -the onwhlch the IILARYSALIVARY CARUIIC[E eminenceon eithers]deihefrerum 0f open. sub inguai and ducts submandlbular ducts

on lr lbo lorm i. th

57

li0TEs

MAXILTARY C()MPLETE DE]ITURES

(stress-hearing is theRESI0UAL PRIARY supp0rt denture bearing areas area) RIDG PAI.IIESEC0il0ARY suFport areasis the PALATAI RUGAE. Secondary RETEIII|VE is area glaldular regio! each 0Iihemidlile. 0n side P0SIERIoR PATATAI SEAL extends through HAill,L,[R tie I)TCHES maxitta, inthe passes in lr0nt 0l the F0VEA 2mm PAI-ATIilAE. in anarea imm0vable lt is 0f tissue pr palaline conpensates l0rdenture0cessingerr0rs. Posterior saliyaryglands ma help peripheral seal. . [,lark inthemouth aThompson and it with stick carve/scribe into cast. thisarea the . Compensates shrinkage isin I 0VABIE foracrylic and TISSUE. . Butterfiy and shallower center hamular areas. shape in inihe and notch . Carried AtlTERl0R VIBRATIIIG T0THt tlllE. -5mm . Posterior seal palatal outline depth patient and ditfers every for according t0the form thepatient. of . Aposterior palatalsealis necessarywhen ac0mplete ona patient fabricating denture aflat palate. FLATTERPALlTE, WIDER P0SI[R|0R IilE THE THE TllE PAIAIAI SEAL. . Posteri0r seal palatal should beremoved. never . lviddle theposterior seal 0.5mm extending onboth palatal is of deep 3mm sides 0f midline. . Seal l.5mm lateral themiddle theseal sh0uld is deep to 0f and extend t0the up (hamular) boundarythepterygomaxillary of notches. is l-l.5mmhigh L Width and broad itsbase. at . Excessive 0Ithe palatal usxally depth posteri0r seal results unseating I in 0lthe . WIDTH sealanteriort0 posteriorchamcterized concave ofthe is bva surface,3mn themidline, Smrn inthemidiaieral and wide areas. . Placemeni posterior palatalseal 0fthe isalways bythe done 0EilTlSL Posterior Palatal Functions: Seal 1. Completes the border seal0fthe maxillary denture. 2. Prevents impaction food beneath denture's surface. the tissue physi0l0gic 3. lmprovesdenture's the retenti0n. 4. Compensates l0r polymerization and cooling shrinkage denture 0tlhe resin processing. during (PTERYG0MAXILIIRY) 0f loose thai extends HAMUIAR I{0TCH - a cleft C.T. from pterygoid plate. maxillarytuberosityt0 0fthe the hamulus medial gland FoVEA PALATll{l group muc0us ducts 0f -a wh0se locaiion varies, is but slightly t0 0l & rcar nosteriortheiuncti0n thehard soft [alates themidline. . VIBRATIilG -2mmanteri0r the f0vealalaiinae ATWAYSTHt LlllE: t0 and 0ll palatethat thedivision PAlllTE.lhe imaginary acrcss posteri0r line the narks between movable & immovable lissues. Posterior Palatal landmarks: Seal . Posteri0r (vibrating and ontline formed "ah"line is bythe line) passes through the pteryg0maxillary (hamular) notches is 2mm and anterior thefovea t0 Vib Dalatini. (imaginary thatdictates distal palatal linelSANAREA line) the termination 0l posteri0r 0fa maxil maxillary c0mplele denlure rec0rd base.In determiningthe limit denture thehamular is0llthe[osterior base n0tch h0rder.

58

0routline-formed "blow" (valsalva l0catedthe bv the line line). at distal extenl 0l palate. bl0w isanteriort0 vibrating which moves the hard The line the line freely when ient attempts blowthrough nose it is squeezed Blow js a close t0 the when tightiy. line
imdrionrhp lo Jdncl,0n h,rdand palat. of lhe soft

Nt]TES

palate ToRl- bony enlargements hard atthe midline, occurring 20-25% in ofthe prevalent w0men. ion,more in llsually covered thinner less by and rcsilient mucosa ridge, act and rocking themaxillary 0f theresidual s0it may asa lulcrum cause ause softtissues thetorus generally with p00r the over are ti'n a bl00d supply, healingslow. is best coverthe is lt to 0perated with surgical site a stent -operative lf a patient having maxillaryteeth d witha sedative dressing. is all extracted0nce, at isbesi also t0 remove toriatlhaitime the removed denture for labrication. However, mandibular ARE usually tori usually pior to denture fahrication. t. 2 1 {. i
med

for Palatal ons Removing Iori: lmpinges soft 0n the tissue toriisundercut. 0rthe vault prevenis formation adequate base. S0 large lillsthe it and 0fan dent!re palatal Extendsfarposteriorlyihus with posteri0r seal. too interferes the Psych0l0gically tothepatient disturbing {cancerphobia). paiatal can problems pOsterior seal. a Y-incisi0n palatal Use Large tori cause with t0 palataltori .emove directly thetori. over

"when my denture doesn't h0ld", area the the 0t Ftientcomplains I smile, upper base needs headiusted buccal t0 isthe notch huccal & flanse t0 E)(tISSIVE due postedorly smiling other As frenum m0!es during 0r facial ESS thearea. thebuccal 0f ions, encroaches denture thatis toothick, it onthe border causing denture the to
e loose

(SUTURE) 0fvery and attached extending PAIATAL RAPHE area thin tight t ssue papilla theend thehard palate. iswhere palatine pr0cesses This theincisive t0 0f the 0f join ilAxlLL"[RY DENIURE SH0ULDREIIEVE0 AREA. Bt lll THIS naxilla together. s Due ill Fitting t0 C0mplete Dentures: inihe i0chronic candidiasis, or Chelitis-crackingc0rnerthelips 0f secondary l. Angular bya L0SS VERTICAI 0l Dl EilSl0 0rvitamindeliciency. B caused , .Ireatwith Nystatin t0 undersurface anti-fungaltherapy: powder applieddenturc 3x/dayfor weeks,reline remake denture. 3-4 or 0r the llystatin ininelfectivel rinse . Closed l/vho vertical dimension most cause cheilosispatiert !l/ears isthe likely 0f in medical isnon-contributory. history a complete and denture whose

ne xa t1
d t ui 59

N(lTES

(fpulis Intlammalory Hyperplasia Fissuralum) asatraumatic Fibrous begins u secondaryt0ill-fitting an denture flange. becaused c0ntinued Can by denture andirritati0n. Treat:with SURGlCAL EXClsl0ll. thirgyou tirsl must is CUTIHT d0 0EIIURE FUlilGt hecause denture|lVtnEXTtllDEll.consider BACI is lhe Then tissue conditionins. . 0entu.e-induced hlperplasia tissuralum), clefts (tpulis fibrous duet0 f0und pr0duced ill-fitting hyperplastic isalso tissue, relatedchr0nic t0 trauma byan denture. lt occurs theyestibular in mucosa thedenture coniacts where flange tissue. Ap[ears PAlllLESS 0ffibr0us ssroundingth as F0IJS tissue oyerertended llange.theamounthyperplasia lf denture 0f is minimal, tissue c0nditioning, fabricationnew 0f dentures, a change denture and in habits nay sufJicieni toarresttissue changes. However, excisionusually surgical is requ Ihe0atient alsoleave denture 0fthe can the out n0uih. . The likely most tissue reaction gross t0 0VEREXTtllSl0l{ 0fa complete denture (caused has worn a l0ng is anEPULIS been l0r time FISSUnATUM hyanill-litti denture flange). cleft-like are This lesion caused mainly overextension by 0l denture flanges. overextensionresultJrom The may long-term neglect 0rsettling sxbsequentto ridge residual resorption. Traumatic occlusim naturalteeth 0l opposinganificial an denture also may cause epulis an fissuratum. 3. Inflamnatory Papillary Hyperplasia-second aryl0 ill-fitting ltlAt(lLURY IEilTURES and s0metimes com0licated bv chr0nic candidiasis. Treatment; c0ndition tissu the Iherapy, topical fungal anti medication. lnextreDe surgical cases, excision. Frequeltlyfound anill-fitling under denture, esptcially dentures a relief with in chamber lroducedresD0nse t0irritati0n delture from movement and presentPAlilIESS, pink red accunulating debris. nasses f00d The as FlRlil, 0r proliferati0ns muc0sa. n0dular ofthe Candida Albicans contributet0 may the inflammation. .l{ost patients lnay/are ib presence. are 0l lt usually inv0lves onlythe HAR|) PAUIE, may involve residual but also the ridges. trealment IPH dependsth on lesion Although nodules not size. the are completely reversible, papilla smaller g00d usually regress treatment with the soft {removing denture, relines, oral and Nystatin therapy).

(redless Denture Stomatitis-a l0calized 0rgeneralized inllammation chronic and p burning) lhedenture-iearilg 0l nucosa. Discomfort be0rmay be may not by lungal Cassed denlure trauma secondary inlecti0ns. and Treatment: improved (Nystatin), oralhygiene, rest, tissue anti-fungal therapy resilient condition tissue and well-fitting new, dentures.
Gl|

imp0rtaft reasontreat t0 hyperplastic bel0re m0st t'ssue makingc0mpleteRPD t0 a 0r is alirm, stahle forthe base denture. hyperplastic tissue s0ft Treat lissue: rest, reline istrng dertures, denture (n0twearirgthem change habits 24hrs/day),0r removal surgical (for ue extensive changes). tissue
drn

NSTES

c
e

Bl ATl0 SYtl0R(}ME when marilla by - caused anedentulous is0pposeda partially (anteri0r 0nly), mandible teeth causing B0 StVERt ERES0RPIl0 AilTERI0R 0f lll. Thus,, during chewing,the tips deninre anteri0rlympress mucoperiostieum c0 the p.e-maxilla. (flbr0us flaxillary hypertr0phy hyperplasla), plane Gharacteristics, tuberosity 0cclusa problems, & premaxilla resorpti0n. a previously edenlnlous patient now aged who wears complete a maxillary denture years, is very anterior l0r many the6 mandibular teeth it commonhave doa to t0 due loss bone lheAilTlRl0R to 0l in maxillary Thls evident a FUBBY arch. is by Al{TERl0R (loss 0sseous RIDGE 0f IIARY structure theanteri0r in maxillary arch). A maxillary ridge anterior under complete a denture frequently is associated with I{EO I{ATURAT MAIIOIBUUIR AI{TERI|]RS. ridges due unstable flabby are t0 occlusionorexcessive 0ftissues. and loading Causes reDlacement byfibnustissue. a VERY 0f bone use FL0WABLE |I4PRESSI0N IIATERIAL t0 flabby like EUGEtl0t PASTE. rec0rd ridges ZltlcoXIDE isindicatedt0 impfovdpromote wherethere littleridge n$IUEilTUER healing, isvery left, (decreases pressure a natural oppose teeth a mandibular denture full 0rwhen maxillary 0n ndge causes damage and less t0vascularitywhich bOne lhe decrcases resOrpti0n. put pressureon papillae,the patientfeels incisive T0treatrelieveincisiye hurning. the who laearea. patient wearscomplete A a maxillary complains burning defture 0f a pressLfe exerted i0ninthepalatal 0ftheirm0uth. indicates much area This too being
F0RA[4EN. dentLre theINCISIVE on

rybe

tre:l

[ii I
Ing
I

I lne
I

(0pefing). PAPItLAsoft fibro!s elevati0n covers incisive C.l that fOramen ISIVE the areas theME|)IAL are PAIATAL & lllClSlVE SUTURE PAPILIA burnins when occurs ort0 blood compromise supply. nssensation mandibular in the anterior is caused Dressure MEtlTAt a.ea bv 0nthe Elt nt returns your t0 office fewdays a afterdelivery new 0f dentures complains and oJ ralized irritati0n thehasalseat. 0f Potential Causes: = ATURE C0 irritation PRE 0CCIUSAL TACTSM()ST common cause seneralized 0f 0l the basalseat. of hygiene, nutritionaL and hormonal Lmbalance. Lack denture kcessive V00

tI

eni
d

els 61

N|1TES

is irritatingt0 tissuethan and accu acryJic, more METAT otl{TURE - netal LEss BASI fits tissues. the . Has fortissues. conductiviiv, s0 better is betterthermal

. Increased phoneti for bulk more space better stfen$h allows less t0allow t0ngue and . lrcreased which better mandibular stability. weighi is for denturc

DEI{TURES IMMEDIATE
correct undetecied any sh0uld evalualed afterdeliveryt0 be 24hrs Allnew dentures
manifesl hyperemia, as inflammati 0uted dpnlLrp l0 [unction lcsue.rdL-aartr

procedure a 24hr sequencetheclinical 0f tor ulceration, pain. basic and Ihe appointment is: and examinemouth. 1. Remove the dentures the from mouth thoroughly the patient theareas tissue 0f trauma observed. thepatieni Permit t0 2. Ask the about additional complairts. describe information, dentist determine s0!rce the can the 0f 3. After lecting diagnostic c0 all problem cure. and dentules, patjent the should expect s0 During firstfewdays inserting after complete the and saliva t0 difficulty masticating loods excessive due reflerparasymp in m0st glands. 0vertiflre,s willsubs and th de return normal. i0 stimulati0n salivary 0lthe immediate d ls the & ldeal treatment t0 labricate maxillary mandihular maxillary to thelikely teeth malpositions remaln ol the t0 avoid simultaneously setting mandibularteeth. (e.g. . lf the inan immediate denturepr0cedure elimination 0f mastercastsareallered a second transparent base denture using surgi a undercuts), advisableconstruct it is t0 \ over ridge afterthe a'e teetl" et'rdcted. slerl lempate. llestenl 0a.ed lhp points undercuts ridge can perfomed. are readily and visible surglcal conectionbe and . Duplicating cast cOnsiruct a surgical stenvtemp ist0be at ate that lsed a master t0
made wax afteI eliminati0n aftef and the denture inseirionbest is time irnmediate 0l a set 6 istrimmed. notmake 2'ddenture for at least m0nths. D0

62

prior schedule t00th for removal t0 delivery immediate 0f complete dentures: l, all teeth first a maxillary premolar itsopposing and l. Step e*{fact posterior EXCEPT "stoD" to a oosterior to maintarn VDo. the t00ih Dr0vide Step after posterior 2: the residual exhibit ridges acceptable ng, 2"d heal the treatment phase (denture iabrication) begin. can Anlerior areextractedthetime teeth at of denture insertion. get thepatient through lirst day wearing the 0l imnediate dentures, instruct them REM|)VI DII{TURES,softl00ds, return 24hrs lhe tirst THt eat in for and lll KIEP F0R envevaluation. THE lti THt 0UTH 24hrs delivery. after aleComplete Denture Advantages ts tAril n0rcATr0ilEsTflETtcs. of l0 the lbility duplicate positionthenaturalteeth. acceptahle esthetics thepatient never as is withoui elther natura 0r Sontinuously arUficialteeth lmmediate require oneperi0d speech speech adaptati0n. dentures ofly 0f lnproved while denture trcatment requircs lone ext.actions iwo after and adaptation, conveftional atter dentures dellvered). are another the exlraction from sites trauma byacting a bandage as overthe clot-filled sockets. Protects perception acceptable masticatory lunction. Patient retains some oJ Continuously during chewing healing. tongue enlargement. natural When teeth lostandnotreplaced, are the Prevents e4ands theavailahle into space. tDngue Dentu.e Disadvantages ateComplete have Ill0R disadvantage 0fimmediate denturetherapy being isnot ahlet0 ananterior (anterior lry-in impossible). try-in evaluate t0 esthetics t00th is t00th thedenture isrequired months. in8-12 Relinifg issimple, must but lelinilg/rebasing caned withinl2 morths out 8 dependirg rate alveolar resorption. on the ol ridge Als0, be post fora days be increased delivery soreness few can enco!rtered. post-inserti0n(including or remak thedentures). care relining ng Contour Increased period. healing 0ccur residual during 8 l2 month ridge the changes inthe post-delivery pair denturesoreness. combinati0n The 0fpost-extracti0n and hcreased grcaier dur fLrst after related trauma produces discomfort ngthe fewdays inserti0n. often (i.e. pr0ceduresborder complexity 0l clinical molding & ljnalrnpressions are Greater more ditficult natural remain). when teeth due for and equilibratof 0n lligher cost t.eatmert io theneed relines repeated total ol occlusion. the dent[res should scheduled REtltiES5 months 10m0nths be for at and ediate 00stfor changes. collourirB 'he fe"ling'idgF Re of ctiont0 compensate contour

ilOTES

c
tgaa
55_!

post ses fapidly 4-6months does stabilize until 12months for and not inform 10 more ill This ion. tothis,mmedrate become Due dentures progressively fitting. is a monthly if necessary, performed. and relines altimel aseach must evaluated ne, case be
dny when agqosric d intormalr0r ale\d 'alire. !1,, ldi I tlEll{l1l0All()Ns dentlre

al t-E

(Vvhen lysolve patieni's complaint thedenture base the chief record adaptat isthe 0n
in defect theprosthesis.

(a t{Ec0t{TRA[{0 0t{s excessive tcATt 0ver-closure 0f vertical dimensi0nlarge inVDl)). case, dentures indicatedtheproper Inthis new are at vertical dimension.

63

IIl|TES

due spots t n if a dentures, pat ie t c0nstant lyre urnsforadjustments t0sore 0n After relining the contacts. have changed CR may the occlusion because relining checlthe ridge, IISSUE CAUSE IRRIIAIIl)II DTIITURES CAII PARTIAT IIITERII{ provide an posterior andallow to iissue healio teeth rernove DEiITURES littlEDlATE point pr0vide reference premolars a VDo t0 Can the forsupport. keep

l)VERllEl{TURES
all0f t0 c0ver ano{i whose is 0VERDEI{TURE -a denture base constructed G0 PIETE prevent ri 0fthe res0rption alve0lar r00ts roots. residual and aidge selected Retained help sense some the retention, allow patient pr0prioceptive 0f"naturalnl and denture improve (root-retai bemfit an ovedeniu.e 0f it|lsl imnorlant in function thedeniures. 0f RlllGE. 0FTllE is denture) PRESERVATIllil AwE0IIR However,r00t if a . lt is notalways heneat[ overdedure. an coYer necessaryto a r00t The susceptible t0 decay patient's are surfaces highly the notcovered. exDosed root i0 prevent decay. nust hygiene beimpeccable pa r0utine when taking . Retairud lindings r00tsare the mostcommon (not over-dentures) dentures necessarily who complete orpatients wear radiographs SUPP hecause provide they . For bilaterally canines retain overdentures, mandibular pr0vides (a retenti0n). retentionlocator ll0T

0ccLusl0l{
(ARTICULAIE0 with G0I{0YLE)an articulator its ARTICUIAT0R ARC0il
path 0n col articulaioland ylar elemefis the nember0fthe 0n elemntstheL0WER plane 0n and inclination occlusal is FIXED thecondylar between member. angle The PtAl{E & 0CCLUSAL REilAl lllCLlllAll0ll C0llllltAR AllGtt BETWEE}I articulator. COIISIAIII AGCURATE). OTORE ofoccl examinati0n casls . C0mmonly fordiagnostic 0f mourtingsludy t0allow used during excu p0sition analysis t00th 0f contacts and contact in contacis theretruded models. movements mounted ofthe forsetting b0th are . 0cclusal excursionsnecessary and recordsright leftlateral in guides c0ndylar medial superi0r and contacts . Fabrication and t0ensure restorations c0rrectt00th inocclu 0fcast p0rcelain movements. and mandibular

64

(I|0I{-ARIICUIATED |}tl ARIICUIAT0R C0I{DY[E) condvlar has elements 0n path member condylar elementsthelower and upper 0n member. (ll0T condy,ar inclination occlusalplafle C0tlSTAllT FIXED) and isll0T lnglehetween WHEII (IESS populart0 l|PEil CL0SED ACCURATE). vs. This desjgn more is fabricate dentures. a SMALL 0F Ion-adiustahle-has AXIS R0TAT|0N. gives cl0ser Semi-adlustable a approximation axis rotati0nteeth does ofthe of & and not intemediate trackingcondylar 0f elements. all0w progressiveshiltand reproduces ALL border movements lncluding fullyadjustable: slde (BtllNFI'S |0VEi,{ENT). immediate shitt side

t{0TEs

l{GSIDE teeth theside mandiblemovins 0n the is toward. themafdible When t0therightand maxillary mandib! teeth theRIGHT isthe and af 0n side working side. e workifg contaci, a denture have canine al least other must the and 4 acceptab cusps cting opposing the leeth. CltlG SIl)E the 0PPoSITE side mandible side t0the the ismovinstoward. the When ble movestothe right,the maxillaryand mandibularteeth 0n LEFIis balancing the the (with natura{ thebalancing = n0n-working For teeth, side side). acceptable balancing must contact,least cusps t0uch, il(lT CAI E. at 3 but THE llSlVE forward movement otthemandible which must at least during ihere be 3 (the incis0r, one 0n nts c0ntact anteri0r and tooth EACH 0fthearch far posteri0r of slde as oossible). Pr0tr!slve records relati0nthemaxillamafdible, is used set record, the 0f & and t0 the lrorrontalcondylargurdance0ntheartlculato.l\4adewlthmandlbularanteriorieeth6mfl forwardCR, with 0f 0r mandibular lary & naxj anteri0rteeth edge-to-edge). posterior during Christensen's Phenomenon thespace opens tlrat b/t teeth anterior movement mandible. 0fthe Amouft posteri0r 0f separati0n is affected b0th ifclsal by the guida'rce. gudance the zontal and h0 condylar Protrusive Movement-accomplished mandiblemoved when the is straight f0Mard unti "edge-t0-edge". ncisors themaxillary mandibular contact and This movement is svmmetrical both inthat sides themandible inthesame 0f move bilaterally directi0n. The mandihle orotrude can - lomm.

65

tl0TES

(ilAxlttARY CURVE SPEE 0F ARCH) anterior-posteri0r fr0mincis0rs m0lars curve t0 maxillary and arch concave respect themandibular with to CoNVEX respect the with t0 . Gomle$ating Cune-the anteroposteri0r and lateral curvature alignment inthe 0f is 0ccluding surfaces incisal and edges artificial which used develop 0f teeth t0 The curve under denli the balanced 0cclusion. form0fthecompensating is entirely (i.e. during tryin evaluation protrusive notes conkol if a a dentist thata excurs movemeni intheseparati0n rcsulis 0l posterior theproblem becorrected teeth, can simply increasing c0mpensating the curve). . Conpensating all0ws dentist alter elfective angulation t0 the cu$ curve the denture The 0f cianging l0rm themanufactured teeth. lunction thiscurve the 0f is providebalanced help a occlusim.pr0ninent A compensating is required curve path guidance. with degreeincisal of there a steep is c0ldylar associated a low from side CURVE Wltsotl mesio concave acr0ss one 0fthemandi 0t distal curve arch theother to side. BAIAI{CE0 the simulta0eous 0f 0pp0sing contact BII.ATERAI 0CCL|JS|0ll stable gliding p0si &lowerteeth CR in position a smooth with bilateral contact aiy eccentric to range lu|lciion, devel0ped to lessen limits 0r tipDing within normal 0f mandibular the ilAxlilulltlUl{BER rolation denture in relation thesuDD0rtins 0f bases t0 structures. (CEllTRlCECCEIITRIC IEETH lll & P0SITl0ilS) DE l0r C0IIIACT ALt EXCURSIoIIS Contacts Balanced ina occlusion: STABILITY. P0sleriorleeth (lvllCP) l0cclusion. Cuso-t0-Jossa incentric contact occlusion inanideal Class During lateralexcursions,opposing 0nthe cusps c0ntact W0RK|N0 SIDE. (lingual side, liflgual cusps incli During lateral excursi0ns, balancing maxillary 0nthe (lingual inclines). c0nlacl ndadibular cusps [acial occurs a denture balancetheworking has 0n side, Balanced occlusi0n when c0mplete w0rking and protrusion. assumes denture been side, in This the has constructed in prcper BAUttlCt0 IllE 0CCtUSl0ll C0i{PLETE lS FoR DEIITURES. and VDo. BIIATERAI (some Balanced Articulation ofthese, notall,are it control 5 Factors G0vern Estahlishing bY dentist), the guidance iscompletely which dictated PATIE bythe l. Inclination condylar 0lthe guidance (horizontalertic loverla ). p 2. Inclination incisal o{the and a v plane of 3. lnclination occlusal {plane orientation). ofthe 4. Convexities compensating 0fthe curve. and of 5. Angle height cusps. ("Ut{lLATERAl, CED BAIA GR0UP CTI()N FU oCCtUSlol{") Arr TErfi 0rl woRxlllc [0llIACT 0URlllc WoRlflllc tl0vtilEilT. v{0rking contacts oNtY side SIDE posteri0rteeth non-working conbcts. and n0 side anterior and . Attposteriorteeth side 00a c0ntact eve[ly the movest0wardside as jaw that D0ll0T onthe w0rling side). Nlteeth then0n-workingside contact. teeth 0n 0nly contact duringlateral a ercursion. . llon-worfting (balancing) interlerences: oninner occur inclines FACIAL 0l cusps mandibular molars. . Working (n0n-balancing) interferences: inner occur aspects LlllGUAL 0f cusps side maxillarv molars. . Protrusiye between inclines FACIAL 0l 0l cusDs lnterlereoces-occur DlSTAL p0sterior and p0ste teeth MESlAL inclines FAClAL 0f maodibular 0. 0l cusps path relationt0 registerthe is condylar a Purp0semakingrecord protrusive 0f a 0l patient's p ofthe s0 equalthe cordylar adiusttie condylarguides aniculatorthey

66

llF I|CCLUSIt]N TICAI DIMENSIl1I{

t: loc
e{ point rims, central bearing are denture when teeth, occlusal and complete patient, the is the 0f vertical and contact, theriandible in CR, [Etl0TH thefaceis theocclusal
t0n

il{]TES

Vl)l) evaluated 4 methods is using 0ffacial l. evaluating appearance support. 0verall 0fspace the rims 2. visual observati0n betweenocclusal atrest. b/tdots face 0n a[d with 3. measurment 0nthe (placed thetip0fn0se chin a Thompson and ihe are stick) thejaws atfest when r ms incontact. when are l.observaiionwhen"s"soundisenunclatedaccuratelyandrepeatedlyt0ensure plane. space the rlms/occl!sal adequate speaking betweenocclusal in t0 supporting tissues. CLoSED A vertical VD() result trauma unde.lying may patients wear c0nplete is likely 0f in who a denture sion themost cause IHElLl)SlS medjca a n0n-contributory hist0ry. makingCR a record. tstablish VD0 the BEF0RI c0niact during swallowing, N0T but during speech.teeth lf touch d!ringspeaking, Teeth is great. vD0 too position), D0tl0I G0TACL is in rest TEETH themandible it'sphysiol0gic {p0stural muscles i0l0gc position when mandibe all0f itssupp0rting (8 rest 0ccufs the and (ihere posture is ln resting cles mastication 0f + suprahyoids & infrahyoids) thelr are equllibiufl). lack t00th This of contactlhe"freeway is space" "inter0cclusal 0r cular posit 2-6mm. position "rnuscle-guided" and the This is a 0n is ce"and averages mandibular movements. nning end and poirt0f most

("FREEWAY DISTAI{CE SPACE") vertical the dislancesoace 0r created 0CCtUSAt

posit lnclsal occluding mandible itsphysiologic 0nbetweef and isin rest sLdaces the rims. lllCRtASE freeway the space max andmandibular or occlirsron EVEI llary teeth
than 1.5mm.

(postural posltion)determined bymusculature. position themandible is mosily The Rest 0f postura isthe stretch rellex asthebasis themandible's position tonic cited for usuai position. muscles. rest The posjtion "muscle-guided" isa rellex theelevat0r 0f (Vl)0) measured 0F0CCtUSl0ll thevedica ofthefaceas ersth TlCAtDlMEtlSI0ll when 0r een arbitrary tow selected (one and bel0w m0uth) iheteeth the 00ints above 0ne (0cclusal are contact CR.Phonetics esthetics rims) if in and help substitute material a satient's vertical dimensi0n 0foccluslon. (V00) may VERIICAt DlMENSl0l{ result trauma underlying from t0 ESSIVE (defture pporting patient), ngofthe muscles, adversely tissues strain elevator/closifg and freeway causing 0f inter0ccLusal l0ss rnter0cclusal (decreased space) clearance position. veriical theusual causes Cl"lCKll{G 0f ceintherest Excessive dimension s remount fabricate complete and a new denture). DETURE (t0 IEEIIi treat of & Clicking dentures als0he caused lack0f retention the maxillary of can by ll dentures. To treat, due underexlension, m0ld reline.due il t0 b0rder and mandibular reduce with and wax. to0verextension, asindicated PIP discl0sing also clicking.treat, acrylc teeth.Increased resin Porcelainteeth causedenture T0 use can is cause 0fposteriofteetha patient when speaks. V00 theusuai ofcontacling/clicking

rE
bf

sa
SJ

[3.t

u
a||
flis

67

NOTES

DECREASED VERTICAL lllilEl{Sl0tl vertical fl00) an occludins dimension IXCESSIVE DISTAilGE lllTER-|lCCLUSAI (increased lreeway space) themandible when is physiological position. the rest . Example: withn0teeth pe0ple 0rwho worn have dentures a longtimepresent for with p0rtion theface (p00r lower 0f scrunched0rd0notshow lipsanymore up, their pr0file). correcl, T0 rnake dentures increase This new and V00. decreases inter-occl (freeway distance space). . DECREASEo V00 ofien results CHEE( in BlTlilG. Factors c0nsider verifying when V00: t0 . Pre-extraciionrecords (freeway t0which patient Am0unt interocclusal of distance space) the wrs previously accustomed. (facial Esthetics harm0ny facial and expression are considered). (speech Phonetics sounds). Lengththelipinrelationiheteeth. to 0f Conditionamount and 0fshrinkage ridges. 0lthe (VDR) thevertical VERTICAL DIMEt{Sl()ll REST 0F lensth theface 0f measured points twoarbitrary (1 point above 1 below mouth) themandible the & the when is in positi0n. a physi0l0gically individual, is alwaysvertical ln healthy there a space between (freeway when mandible therest position. positionimportant teeth space) the isin This is complete fabricati0n denturc because it prcvides a guidet0 VDo. the (VD0) VIR= Veftcal Dimensi0n 0f l)cclusi0n + Inter0cclusalllistance. Balanced 0cclusi0n pa.tial in denturesnecessaryappliance is Centric for stability. franework's and design relationship teeth 0fthe t0the r;dges influence stability. als0 RPD Bilateral Eccentric llcclusi0n tl0Tanobjective RPD is in construction, UNLESS[a the prosthesisopposed a conplele is by denture. veriical The relation RPDS usua for is determined remaining teeth by the natural {unlike complete dentures). (TMl) a combi0ed &gliding Ginglymoarft0di j0int TEMP0R0MAiIDIBUIAR .l0ll{T hinge permits hinge rotati0n gliding (sliding) both like and m0vements. Ginglymus loid)that "rotation" arihr0dial "freely and flreans movable". . Inthel0wer (c0ndyle-disc) (rotary c0mpartment,a hinge-lype m0tion) only can This rotaiional terminal 0r hinge-axis opening themandiblepossible when 0f is 0nly mandibleretrudedCR aconscious by patient by dentist's is in wjth etfort the or ttre m0vement is possible intheterminal positi0n. Apure hinging only hinge . Intheupper (mandibular (translati compartment l0ssa-disc) sliding only movemeds pterygoid When lateral muscles car 0ccur. the contact simultane0usly, a thediscs (protrusion), move c0ndyles l0ni/ard overthe slide d0wn articuJar eminence orcan (retrusi0n)during and together 0pening closing mouth, 0fihe respectively. l{uscles Acting theTru: on . Elevator (Close) (a l{uscles mandihle: masseter, pterygoid, medial & temp0ralis fibers)P0steri0r 0i iemD0ralis themandible. mandible fibers retract lf the fractu UPWARD displacenent fractured 0fthe segment becaused elevator would bythe mu (masseter, pterygoid, medial &temporalis). . Depress0r (0pen) ilxscles mandible/m0uth: pterygoid, belly digast lateral anteri0r 0f & omohyoid. . Protrusi0n (individually, pterygoids pierygoids l{uscles, lateral together lateral cau pteryg0ids mainly positioning lateral exclrsi0n). Lateral are responsible for a the translating condyles.

68

position ICREtATl0l{ C0IITACT T"RETRUDEl) P0SlTl()tl')a "ligament-guided"

position is thesupero-anterior 0l thecondyle thearticular along eminencethe 0l dylewiththe adicular interposed disc hetweenthe and condyle eminence. positl0n This position rclative between anatomic all an0ptimum components, is a REPEATABLE and positionmount 0ntheadiculator rence t0 casts positi0n mandibular is retruded CR themostundrained, anatomic lunctional and 0fthe glenoid condyle inthemandihular lossae theTMJS. is a "bone{o-bone" heads 0f CR jaws) (bones relationship 0f thelpper lower and independent 0l t00th contact. The presence 0rabsence and 0focclusi0fn0t ofteeth type are factors. il,lalposed 0rsuper-erupted can teeth cause discrcpafcy a beiween & C0,s0opposing CR not when teeth sh0!Jd contact naking CR a record mount to diagnostic becausethe casts contact causes mandlble the t0defleci move fr0m 0r away CR. int0 from rest lvandible cannot forced CR be tlre position because patient's the reflex neuromuscular would theapplied Raiher, mandible be defense resist force. the should guided CR. and into relaxed gently place patient CR, thepatient To a in have swallow, t!rning tongue the upward tOwards the palate, thejawmuscles, rela( orprotruding retruding mafdible beeffective and the can wavs helo to record CR. prosthodontics, be h fixed removable and CR sh0uldestablished t0designing PRIoR the
ltamewofts.

$rsTIs

t?',

resl u?
r tl|

Ttrc
I

is inthe naturaldentition, oftheteeth WhenCR a recordtaken imprjnts should confined be pedorated. t0CUPS and registration should be TIPS the material n0t p0silion. is CR a "ligament-guided" CR thecl0sing is end-poinltheretruded 0l border (terminal-hinge movement novement). Tra$verse Horizontal (Terminal Position) one AIis Hinge the rclation thecondyles 0f t0 ihe fossaewhichpure in a hinging movenent ble. isposs prosthodontics, Incomplete denture thepositl0f 0ftheplanned 0fthe lVlC teeth centric in = patient's(C0 CR). occlusion isestablished t0coincide the with CR for a REtATl0 record when fabricatingRP0: aryRequirementsmaking CEI{TRIC a Record corrcct the horizontal 0fthemandible maxilla. relation t0the Stabilize lower the rec0rd with base equalized pressure. veftical Retain the.ecord anundistorted in c0nditi0n untilthe have accurately casis been mounted record be ed. 0n articulator a previous can veril the 0runtii years. have erialssedtorec0rdjawrela 0nships varied u t widely 0verthe Anidearecording ium easy hafdle, is i0 uniformiywhile recordbeing soft the is made, d setting, rap and plaster oxide eugenol pastes, llyrigid not but brittle set. when Rapid setting zinc & and plaslic ideal. sott Avoid waxes a rec0rding are as material because never they procedure. rigid are t0 during castmounting the come and likely distort naturaposterior occlusion them ndibular cast m y be mounted C0 exists, a a in I sufficieft wax In relnforced bite. thecase a distal 0f extension base RPD, plates and Ginga ZoE rims should placed theframework, thepatient be 0n and closed sottened into acclusi0n paste wax Whether record beinC00f this will lccording 0r zincoxide-eugenol (preferred)posteriof dependsthecase, isdictatedthepresence on and by 0rabsence natura ofany CR inthe @clusion oatieni-

rtC
lat\

p )an!

cur
Ina u0l

[on) anc ards

erior lres icles itric

ause and
69

il()TES

(MICP) a "t00th-guided" CEIITRIC 0CCtUSl(ltl position defined the maxi as "empty intercuspation teeth. 0f the During typical mouth swallowing" mandible the position. braced lheinter-cuspal in . Empty nouthswallowing frequently theday is animportant rid occurs during and t0 mouth saiiva, m0isten oralstructutes. hourly 0l non-masti of and the The rate swallowing isrelated amount0l t0the salivaryfiow isusually involuntary activ and an refler . Masseter muscles contract thet0ngue touches r00l0l themolth and tip lhe duri normalswallowins. . T00th conlacts longer are during peo swall0wing chewing, thts than but varies among ART|CULATl0l{ relationshipteeih oJ during movements andaway the into from posrtion, the while teeth contact. CotlDYtAR GUII)AiICE factor a T0TALLY dictated thepatient. is the mechan hy tt
rcovemelt device or aricJlal0r on intended similat to produ.p in arliculalor th BUidances

pr0duced c0ndyle dudng paths are bythe rnandibular movements. . Condylar guidance completely is dictated thepatieni cann0t varied by and be "adiusted"thedent'st. by . The guidance inclination 0lcondylar depends 0n:shape 0fthe contour & slze bony of

(fossae disc), Tll4J afd action themuscles of attached themandible, to limiting etfects thelrgaments, themeth0d fof registration. and used

(arg!lation) thecondylar The incline 0f element thearticulaioranatomicallv 0n is rela (c0ndylar t0the sl0pethe 0f condylar articular eminences inclination). guidance protrusive When adjusting condylar the guide for pin relati0nship, incisal the the adlculator be pr0trus sh0uldraised ofcontact the out wtth incisaJguideThe table. rec0rd pr0bably TEAST is the reproducible maxillomandihular rec0rd. path When restoing entite the mouth cr0wns, protrusive with the condylaf inclinat inflLences tlre mesial inclines mand cusps. o1the bular RETRUSIVE Tre0uires c0ndylesmove M|)VEME the t0 BACXWARD & UPWARD. UTTERAI ill)VEMtilTS, thew0rking c0ndy]e down,lorward, laterally, n moves and and working condyles d0wn,lorward,medially. move and path The inati0n ihecondylar during protrusive inc 0f tr'tovement anavefage lorms a plane. of-30' with h0rizontal ihe relerence lf theprotrusive inclinaiionsteep, c is the height beobviously Jftheinclinati0nshallow, cusp beshoder may l0nger is the will Th guidance affects selection lactor theM0SI is important 0l condylar aspect that the posteri0r with teeth appr0priate height. cusp . Incomplete path dentures, condyle duingfree the l'tandibular m0vements isg0verned mai (articular and muscular bythe SHAPE fossa meniscus 0fthe and disc) the inltuence. 0eterminants ol 0cclusion: . Rlsht left & TIVUS . 0cclusal surfaces teeth theneur0nuscular The ol and system. concepts0cclu ol arrangenent t0 place aim artificial i,t harmony theJIIIJ neuromuscu teeth with and system.done 11 properly, it results minimum 0ntheteeth rcquires in stress and min! perf0rming etf0rtbythe neuromuscular when system mandibular movemerts. 00ti occlusi0n requires minimum adaptation patient. bythe 4 Dentition Features Directly that Efiect llealth Hard PDL & lissue Anchorage lo 0cclusalForce, (intenuspal position). 1. ante0rteeth slight n0 have 0r contact inMlCP 2. occlusal is< 60% the tahle of 0verallLwidth the F 0f t00th. 3. occlusal isat right table anglesihet00th's axls. to long 4. mandibular cr0wns inclired molar are 15-20'towafd linsual. the
70

0eterminants Re0uired ll0retical t0Restore a C0mIlete & Functi0nal 0cclusal Surface

a Toothl

N{OTES

1. Amount vertical 0f overlap anterior ol teeth. anterior The determinant olocclusion is thehorizontal vertical and overlap rclatiOnship anteri0r 0fthe teeth. 2. C0nt0ur articular 0fthe eminence. 0flaieral inthe shift 3. Amount directl0n and working condyle. side positionthearch. 1. Tooth in most used design isihe , thejawrelationship comm0nly intheACTUAL olrestorations pulp particular is ll0T RED centric 0cclusi0n. height the The 0f h0rn a ol t00th a ired determinantt0 a complete functional restore and occlusalsurface
PtAtlE dn .magindry e reated srrla aralomicallyLle cJanLm CLUSAt to and

ically touchesincisal 0fthe the edges incisors tips the and 0f occluding oJ srdaces the riorteeth. n0t lt is reallyplane, represeirts a but themean curvaiure surface. ofthe plane p0int Anterl0r 0ftheOcclusal s determined position anterl0r by the 0fthe teeth. (2/3 pads). r P steri0 detern inants arcanatomica 0 landmarks theheights theretrom0lar 0f Thus, isdebatablet0theextent controlthe it as of may se dentist ererc overthe orientation oftlre occlusalplane. ll{Ctll{ATl0ll e nade ang bythe sl0pesof acuspwith a perpendicular line bisecting measured mesiodistally 0rbuccolingually. ifclination cusp, Cusp ls under dentistt the | (choosing 30'teeth, m0n0plane etc.). teeth, (protrusion), Ina protrusive c0ndylar movement lnterferencesoccur can between 0ISTAL posterior and posterior of cusps I{ESlAt inclines mandibular inclines maxillary 0f cusps. Ina protrusive movement,mandibular the condyles 00WIWARD move & F0RWARD. profrusrve During movemeni, are there occlusal contacts occufiing themaxillary on distal and mesial Anteriorlv, surface mandibular faclal inclines mandibular inclines. the 0fthe (lingual) maxillary and incisors c0ntact guiding will the inclines 0fthe incisors canines. path rcstorative involvlng teeth themouth, protrusive case ALL in Inany the condylar (disial inclinati0nhave primary will its iffluencethesame 0n incljnes 0l maxillary & mesialol mandibular). pathwayfollowed anterl0r during protrusion notbesm00th straight by the teeth may The 0r because olcontact between anteriOrleeth the and s0metimes theposteriorieeth. (Forward Interlerence Slide)-corrected bygrinding IVIESIAL INCLINES ary oJ maxil Centric teeth DISTAL and INCLINtS 0fnandibular teeth. gr0up functi0n teeth theworking evenly 0f on side This distributes occlusal the load. prevents teeth receiving While, lack contact thenon-workjng the 0l 0n side those from destructlve, 0biquely direcied found n0n f0rces in working interferences, and saves the holding (i.e. cusps mandibrlar cusps marillary fr0rn buccal and centric cusps) excessive wear advantage maintenance 0cclusion. The istlre 0fthe
US:

lular rm2 im2

('CAil uAttY PRoTECTED 0CCtUSt0lt tE GUtDED" 0RGA 0CCtUSt0t{) 0R tC iorteeth orotect Dosterior inall mandibular the teeth excursions. Canines 0ISCLIJDE the iorteeth during wOrking non-working and m0vements. is relati0nship where vertical Canine Guidancean 0cclusal exists the overlap 0f (separation) posteri0r maillary mandibular & canines causes disclus'on ofAtL teeth moves either All when mandible the t0 side. other teeth rot contact they do once move "working or "fof-working from lf there contact other CR. is of teeth, side" side" on which the m0ves irterferencesdepending side mandible towards. occur placingcrown a maxillary pr0tected When a 0n canine, changecanine ijy0u a occlusi0n i0 gr0up you function,increase the chance"n0n-w0 side" for ing interferefces.

11

N(lTES

overlap &verlical (AI{IERl0R result C()UPtlt{G) 0l h0rizontal GUIDAI{0E At{TERl0R andmandibu maxillary 0f 0pp0sing relati0nship overlapping A teeth. tightly anterior
protrudes the teeth the that and incisors canines DISCIUDEposterior when mandible 0l p0s1 morphology lhesurface guidance atfects also Anterior excursion. in m0ves lateral height. the greater the oYerlaD, l0nger cusp teeth.Ihe

at I and 0f 0fthe a GUI0ANCEmeasure anount movement theangle which lllclsAL occlusi0n 0f from must Dositi0ncentric and incis0rs mandible move theoverlapping l0wer guidanc thesec0nd eis lncisal incisors with relaLionsnip themaxillary anedge-|o-edge der under.the degret, and movement is t0 some fa;torin articulator cont;lling arch ridge are tactors eslhetics, Dh0nelics. relali0ns, space' tittuencing controt. space. inter-ridge c0ntrolincisal 0f a deniist\ the pholelics nain . Esih;tics& arethe factors LllVlT and 0fh0rizontal equivalent isthe . lncisal 0nihe suidance articulator mechanical verticaloverlaP. cusps these contact CUSPS') 0R CUSPS" "GEI{TRIC CUSPS SUPPoRIltl0 ("STAMP 0riossa cusps a marginalridge These t-Lcenter0n intheircorresponding opposingteeth al posterior arein a norm ir teeth l00d t0 suited CRIISH When more ro'bust hetter and are cusps considered huccal + cusps mandihular lingual maxillary relationship, CUSPS. SUPPllRTII{G with {ie cusp that . Centric 0fcontact a supporting makes opposingteeth st0ps-areas ihe with contact cusp) l"t {a 0f MLcups themaxillary m0lar supporting makes 1'tm0lar' (centric 0fthemandibular stop) f0ssae Cusps, ol Suppofting 5 Characteristics n t l00th theinercuspalpositi0 ' opposing in 1. contactthe face 0fthe dimensi0n the 2. supp0rt vertical cusps than 0f center thet00th non-supporting t0 3. are closer theF-L for has ouier 4. their incline a potentialcontact cusps lhan cusp more broader, rounded dges n0n-supp0rling 5. have CUSPS) llary - ma 0R CUSPS tl0tl-SUPP0RTltl0 C'GUlDltlG" "SHEARII{G" t00th the overlap opposing wit cusps These lingual + cusps mandibular cusps {facial) to thatserve SHEAR cusp and nafi0wer sharper ridges anl tie contaciins tooth have strokes.- ... chewing during ridges cusp p;ss t0 asthey cl0se thesupporting guiding becausF inclines" . theinne,occlusalinclineslpading1olheguidingcuspsare there Thus, midline cusps Jrom suppoding away ihe they movements, guide contact postl 0f cusps) themaxillary 0{ inclines buccal inclines thebucco-occlusal (lingual 0fthe inclines inclines and linguo-0cclusal(buccal 0flingualcusps)mandibu ieeth, the posteriorteeth. are cusps opposite and slpp0rting guiding situati0n' cross-bite In a posterior cusps lhe now supporting and are lingual and buccat mandibular cusps maxillary cusps' buccal the lingual mandibular are guiding maxillary and

12

CTIVIGRltloltlG thereduction occlusal of interlences ustally done BEF0RE patient PREVET{I ctinga fixed hridge denture a 0r for to duplicating deflective the grindingto remove in lusal c0nlactsthefinal restoration. purposeselective Ihe 0l is interterences destroying height. when without cusp Thus, interferencesincentric, exist not lateral in exculsiors, thelossa marginal opposingpremature is 0f ridge the cusp ned. s imporiani whenever lt that a premat!rity isfound, occlusion the bechecked in p0sitions any centric bef0re adjustment is made. cusps lf interfe.e each with other in gr0und preventdecrease rsions, 0nly n0n-holding are then the cusps t0 a inVDo. grind Acomm0n where is preferableto case it selectively AFIERflxed a bridge RPD in 0r is place when FPD RPD t0beconstructeda space which opposing is a 0r is for 0ver the tooth plane has extruded The slightly. brldge partial lrequently 0r is constructed ideal tothe 01 occ and 0pposing rsadjusted inserti0n. usion the tooth after The common m0st c0mplaint cementation frxed atter 0fa bridge sensitivitt0 & cold is hot and indicates a deflectiye 0cclusal c0ntact. involved may sensitive The teeth be t0t0uch when Inthese an and brushing. cases, immedrate correction ofocclusion bemade. must lmportant plan changing if you 0n a patienl\ veriical dimension crowns, using it is criticalm0unt casts the hinge (face t0 the 0n true axls b0w). (CR), Selective Grinding Comllete in Denture Fabricati0nCenlric in Relati0fl holding arcthe cusps mandibular Secondarycentdc buccalcusps.thesecusps Grind only is ifthere a balancing interfererce. slde grind Primary centric h0lding arethemaxillary cusps lingual cusps. t{ever these cusps. grindlng result harm0ri0us fossa ldeally, selectlve sh0uld lr cusp contacts upper 0fall lower (and f0ssa marginal 0f prenolars).ll0T idges and D0 grind upper the lingual 0r grinding fltes:al lower huccal cusps.foMadslide CR becorrected A from can by the inclines 0fmaxillary and teetlr distal ines mandibular inc ol teeth. grindinginner Selective of inclinessecofdary h0ding 0f centrc cusps d0ne a ls if (n0n-working)ifterf balancing side erence exists. gdfld 0nly cusp 0nmaxillary tips buccai mandihular (BlJLL) if tiey are & lingual cusps premature incentric, lateral, prolrusive or movements. belore nding. Check gr Selectiye Grinding inWorking (non-balancingRelation, rule selective Side side) the Jor grindlng (huccal intederences wOrking movements theruleof BULL during side follows cusp inclines inne. 0fupperteeth & lingualcusp inclifeslowerteeth). infer of grind Selective Grinding l{on-W0rking (balancing Relati0n: the inner in Side side) inclines mandibular cusps, IIEVER 0f buccal and GRltll|A(ltt"ARY Llt{GUAt cusPs (pimary holdlng centric cusps).
serl e aT: tri0' D0ta.

NOlES

ThE
I IflE

Adiustment: 0l 0cclusal lasicPrinciples (CR). 1. The maximum dislribution 0focclusalstfesses relati0n ir centrlc 2. torces occlusi0n be 0f shouldborne much possjble l0ng 0fteeth. as as by the axis coniactflatcusps of it should changed 3. When surface sLrface t0 0ccurs, be toa "p0int-t0-surlace" (lhe c0ntact cusp 0fthet00th tip 0ccludes theflatsurface with of it'sopposing cusp). tooth's d. When centric occlusi0n isestablished. take teeth ofcentric IIEVER the out occlusi0n. 5. llever adlust tips. lymarginal and cusp 0f ridges fossa.

73

t{0TEs

DEl{TURE SELECTIllN TEEIH

SMIIE (ltlClSAL tlllE CURVE) c0mposed incisal oi maxillary 0nthe edges anteriors a
parallels inner the curvaiurethelower Parallel theinteFpipillary 0f lip. with axis (middle thelace). t0themidlile 0l Frpendicular . PHI NUMBER SUM THE NUMBERS lSTHE 0t M0 PRECEEDING ll The tl.6l8t) EACH progressively asyou proceed theback 0{the front teeth sh0uld become smaller toward in of t0 t0 = Pro[ortion. themouth iherati0 1.6 1.0 0.6 Golden

inclined theLINGUAL. Long 0fposteriorteeth axis are toward Long 0fmaxillary cr0wns axis incisor CoNVERGE slightlytoward themidline. There should slight be iregularitieseithe. ofthemidline, though 0n side even the are similarsize, in shape, alignment. and paiients, prominent, mandibular lnyounger maxillary incisors more are while incis0rs a more visible age. with patients: pre-edraction Guides selecting for artificial denture foredentul0us teeth rec0rd photographs, relaiives, diagn0stic radiographs, casts, extracted a teeth close of teeth, placed theocclusal following lines ihe 0n rims. Rlles Setting for Teeth: . Incisal central incis0rs cusp 0f canines 0nthe and edges maxillary 0f tips lie tlNE the edges incis0rs abovethe line. lmm same CURVEDwith incisal 0flateral . Interproximal 0fthemaxillary progressively contacts anteri0r are teeth situated closer gingiva more distalthey from midline. are the the the . Incisalenbrasureprogressively from centraiincis0r, become LARGTRthe lateral,locanin (themore posterior g0). you Incisal paaients embrasures in younger hec0me smal point disappearing teeth sometimes t0the 0f asthe vvear. . I\4ANDIBUI-AR teeth placed thecrest theresidual lVMl PoSTERIoR are 0ver 0f ridge. in P0STERIoR functi0nal are cusps placed thefossae mandibularteeth,canben 0f and farther the than tacial vestibule. . l!'lMltLARY ANltRIoteeth setFACIALt0the fofphonetics esthetics. R are ridge and Canin papilla. cups should paralleltheposterior 0ftheincisive tips be t0 border I,IANDlB ANTIRIOR are base themaxillarv 0n anteriorteeth. teeth set

14

role0l AilTERI0R 0na denture ESTHETICS. lrpping, TEETH is Spaces, rotation, and r changes be can judiciouslytocreate used a natural appearance. ifg anteri0r t00far lingually facially satisf] teeth or t0 esthetic c0ncerns NoT sh0uld be When selecting pre teeih, extraction records extremely are valuable. Maxillary and bular anterior should contact centric teeth l{0T in relation. Settins maxillarv aid anteriff dibular teeth they s0 contact CR in prodrces unsatisfactory an arrangement 0f icialteeth com0lete l0r dentures. p00r most contributet0 denture that often esthetics isplacing maxillary anleriorteeth ctlyover edentulous Maxillary the ridge. anterior denture should placed teeth be ANIERI0R ridge. to the outline0fanteli0rteeth harmonize theJacef0rm. Drolile should should wth Convex faces a similarconvex abialsurface0f anteriorteeth. Broaderc0ntact areas 0fteeih more look ural dentufes they more 0n as are c0mpatible aglng. with best esthetics, maxillary anteriorteeth complete ina dent!re arranged are FACIALT0 THE p00r 8E. Settirg 0rteeth anter directly overthe causes esthetics. lt isimportant ridge Also,
have accufate adaptation border andadequate 0f themaxillary 0f the seal bulk facial for esthetics. als0 VDO affects lipsupport. nge g00d the |||axillary central incisors the are

l,{sTEs

ST important l0r esthetics. placement themidline, teeth Their c0ntrols speaking ip I ne, pport, smiling compositl0n. and line most the surface central sh0uld -8mm ofthe inclsor be Datients,labial anterior tothe papilla. lab0incisal of maxillary 0ftheincisive The l/3 central incisors should support lower when teeth rnocclusion. lip the are needs llcTl0tlAt overshadow needs selectins esthelic when Pl]STtRl{lR TEETH.00 not mandihular over ascending 0f themandibleocclusaJ inthe m0lars the area as forces d slodge mandlbular the derture. primarily theamount useful 0l P0STERIoR for a RPtis determined TEETH hy 0l 0rt00th space characterislics denture-supporting Other and 0flhe tissues. factors posterl0r teeth ude: evant selecting t0 RPD inc l.0ccluso-gingivallength,l\40STimp0rtantfactort0determineposteri0rt00thlengthis ayailable inter-arch s0ace. M-B width, total[4D the space available poster]0r is determined fof teeth bymeasuring from disial the the 0f lower t0the canine p0int the whete mandibular ridge res dual beginsslope to upward. B-l-width, BL ihe width narrowedreiation themssifgnaturalt0oth. is in t0 Reducing thearea theocclusal decreases transleredthedenture 0f table stress to suDDod area penetfat Als0, during bolus f00d 0n. reducing B Lwidth the increases space. t0ngue 4. Shade: shade is selectedharm0ntze theanterior oosteriortooth o1 usuallv t0 wtth teeth. llcclusalsurface n0superioft00th 0rarrangement lormr 5. form is identified. t ls Thus, paiient's logicaluse least to the compllcated that lsthe approachfulfi needs. plastic well acryllc Thus, 6. ilaterials: bonds t0 resin. plastic are teeth retained better porcelain Primary than teeth. reason using for PUSTIC ina denturebecause teeth is plastic areretained inacrylic teeth well resin.

ne
ef

tR
ne \R

75

ruSTFS

C0mm0n Made Arranging Errors When Denture Teeth: . Seitlng mandibular anteriorteeth forward the too far t0meet maxiliaryteeth. . Failure t0make poift caninesturning 0fihe the arch. . Seiting mandibuiarpremolars t0the first buccal cantfes. . Establishing plane an the occlusal by arbitraryon face. line the . Not rotating 0rteeth anter erough give adequately to an narrower effect. L0wer 0fa patient's appeaF short there aDlarent 0fthe 1/3 lace too afd s loss vermilion border thelips. procedure 0f The indicatedcorrect sit!ation increasinq t0 ihis is 0cclusal (VD0). Yertical dimension Errors occlusion checked accurately REII|0U Gthedentures the in are most by Tl on articulat0r remount and inteFocclusal using casts new records. Potential Problems llew with Dentures: 1. Cheek iscaused Biting byl . Posterior setedge-to-edge. byreducing teeth Treat BUCCAL 0fmandibutar CUSPS proper molarscreate t0 horizontal overlap. . Inadequate Treat relining VD0. by dent!resthe at corrccted CR VDo, rernount, and labricate dent!re. a new . Biling corners themouth. byRESET 0f Treat CANINES & pREI!10LARS. 2. tjpEiting causedreduced by rnuscletone large and/ora anteriorriz nal0verla (overbiie). h0 0 t ! 3. Tongue Eiting-caused poster byhaving 0rteeih t00farlingually. set 4. Generalized difliculty complete speech with dentures is!suaycausedfaulty by p0sition tooth and/or palatal faulty contours. . Speech problems tolaulty position avoidedplacing denture due t00th are by the asclose p0ssible position naturalteth.the effective as i0the 0lthe Note: most ti totestlorphonetics thetime thewax is at 0f (usually try-in thetrialdenture of the 4rhappointment). . Faulty palatal c0nlours correctedtrialand are by errOr wax increase Add to contou and remOvet0improve wax airiculati0n 0fs0unds.

PHl)ENETICS
Palients years edentulous many tor often have more distorled s0eech 0atients thafl edentulous short due a loss tonus thetongue fora time t0 0t 0f musculalure.

76

"S"Sound: mandibular edges be with ncisal shouldeven 0rjust lingualthe maxillaryteeih inc saledges. whenthetip0ftheirtongueappr0achestheanteriofpalat Formed and ljngual surfacesmaxillary These 0f teeth. sounds themandible maxilla logether. bring and cl0se "S"sounds thespeech are sounds hringthe that mandible closeso themaxilla. lfapatient complalrs he/shet when est0makean"s"sound,itsoundslike,,th",th probable m0st causes either maxillary is the incisors set farpalatally, palate are i00 0rthe is rnade thicktoo W0rds thesihilant (hissing with sound sounds) pr0nounced ywith ifclsal are corrcc the edgesmaxillary mandibular touching. sounds usualproduced 0f and alrnost These y are positi0n. between and occluding resi the Incisal of mandib!lar arc edges incisors established byOcclusal with contact maxillary incisors bytheirposltion behlfd and lmrn and llingual) 1mm bel0w maxillary the incisal "S". edges saying Incisal 0lmandjbular are antel0r lingual when edges incisorsimm afd t0maxillary edges making soun0 "S" incisal when SIBIAilTS J,Sfproduced bymaxillary mand incisors {CH, and bular appr0xinating each othet Palate tongue ing and control valve.

protrude (2-4mm) S0UllD t0ngue sh0uld 'IH" tlNGU0DEllIAL slightly between maxillary putting mandibular anteriof t0 form sound. teeth this fulade by t0ngue max b/t and ibular (1/8 (3mm) 0fiofgue teeth inch tlp sh0uldvisible be

NNTFC

" & "V"LABl0DEl{TAL lormedincisal ofthemaxillary S0lJllDS by edses incison afd

lip(incisaledges jusit0uch wevdry ofthe lip). should the line lower
to 6d

S0Ull0Sare formed bythelips. 'P" & "8" [ABlAt t0ially l\,lade pressure the by behind are it can this 0f t0 lps.lf teeth notsetcorrectly, affect seal llps blilduppressure. B P& posteri0r positionteeth, nds afJectedanteri0r are by, 0f incorrcct and VDo, labial llange ickness. 'T" & "0" (Al{lERl0R "t" tlNGUAlPAIATAL S0UtlDS) lfteeth set FAR are t00 LINGUAL. nd ilke lf theteeth set FAR s "d". are too LABIAL, "d"sounds "t". A patient thef ike who pron0uncifgletter due "t" ts complete dentures is having difliculty trouble the to
positioningthemarillary 0f incisors. l\4ade tip 0l longLe hing.hpaniFrio' by lou,

(POSTERI0R PAIAIAL)Droduced tonsue 1(" & "G" VETAR S0UllDS tll{GUAL when
posterior palate. set-up ches T00th 0l)ES0I AFFECT S0UNDS. VEUTR palatal 0ra constricted can paiate cause vault high whisiling sounds. lvhistling durirg (complete ihatreplaces incsors) becaused either h withdentures 0rRPD the can by (overjet), (overbite), area ient vertical 0verlap ercessive [oriz0ntal 0verlap 0rthe is atalt0 incisorsimpr0perly the contoured.

PARTIAT DENTURES FIXED

(PR|)VISI()IIAT) REST(lRATIl)IIS IEMPl)RARY MUST PRl)VIDI: protection: l. Pulpal restoration be must fabrlcated a naterial prevent from t0 conductifg temperature extremes. should adapted en0ughprevent lvargjns be well t0 saliva leakage. 2. Positional stability: tooth the sh0uld extrudedrift lITERPR0XIilAt not 0r s0 C|)NiACTS IHIS, PR||VIDE 3.0cclusalfuncti0n,thetemporary'sabijlrytofuncti0nocclusallyaidsinpatjentcor.tfort joinvneur0muscular & prevents migrati0n,prevent i00th and imbalance. 4. Easily cleaned:temp0rary bemade a materardcont0!r the the musi 0l al that patjent xeep can ctean. gifgival 5. ll0n-lmpinging ilargins:isVERY it impodant the that temporary's margins d0 gingival t0prevent not impinge 0n the tissues inflam{ration cause that can gingival hypertrophy, recession, loss. bone N4argins be p0lished. should well An pr0visional y res!lt a oVERHANG from prclormed 0rresin can metal mprope contoured, a CllsT0ltl while PRoVISI0NAL horizontal can cause overhang if improperly trimmed. 0. Slrength & retention: temporary withstand forcesissubjected must the it towithout breaking orcoming off. 7. Esthetics: tem ifthe porary ananteriortooth, provjde cosmeUc ls0r it must a good tesult. (outside rnouth the tAB)F|)R CUST(]I{ INDInECT iECHlll0UE the in MAI(l{c P0RARY TE ISPRETFERED ITISIII()REACCURATT.FII & PR|)TECISTHT CR(IWIIS BECAUSE BETIIR PUIP (as when is placed because p0ly(methyl-methacrylate), freshly dentin, in a direct on cut pulpal technique), cause it can thermaL irritati0n acute and nflammation. custonl Can make provisionalsovef using imperssions, ora thin crown. templates, shell

!Ir

lua
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|at
ls2.

ced lary rsal lua ach

11

ffnTr5

cR0wl{s
preparati0na c0mplete for crown: Principles 0fto0th form: L RelentiolResistance & . RETE prevents removal0f tesioration thepath irsertion lofg the along of or ll0lI axis lhe of preparation. (i.e. . Achieved 0pposlng surfaces buccal & lingual walls). by two vertical . Tooth (as prepafation is kept a minimum rctenlion taper taper to toenhance retentlof decreases, increases). (boxes grooves . Greaier ihegreater retention and surface 0fa preparation, area increase area. sudace . lvlaximum path is when is retenti0rachieved there 0flyone 0fdraw . PINS length and INCREASI RETENTI0N by increasing internallyapically (not externally). . RESISTAIICE, DISLoDGEIVIENT prevenis by directed apical 0ftherestorationf0rces que prevents rnoveflent rcstoration occlusal any 0fthe under 0robl and (vedjcal)foices. 2. Structuraldurability 3_ arginalintegrity Preservation structure. oftooth inclination each 0n opposing axialwall). tuial IDEAI TAPER ACR0W 5-6"(2.5-3.0" F0R is preparation taFer more 3-6'. than walls a crown in should no PRtPARATl0ll PR0VIDEResistance t0 PIACED THE lN CR0WN GUlDll{G GR00VES groove the liAlN 0f 0r rotaiion, Retention, forseating crowr. purp0sea buccai lingual & path isIN4PRoVE RETEilTI0N. CR0W ina slngle preparation crowJl impodant features provide t0 adequate ol bulk CI-EARAIICE 0f the mOst is one |)CC[USA[ meialand strength. . G0tD = max, mafd). for lmm clearance functi0nal (lingual buccal cusps Crown1.5mm fon-functional. . PtM = nonJLnciionalcusps. lunctional 1-1.5mm cusps; Crown1.5-2mm . AIL-CERAMIC = 2mm pleprations. 0n Crowns clearance provdes BEVEIspace adequate of netalandprevents for bulk Awide FUNCTI0 CUSP A! perforatl0r metal t0hea!ry due occlusal cortact. 0fthe PFM Coping Alloys: (PFVls) of metal-ceramic restoraiions c0nsist98 1. High Noble all0ys: t0fabricate used (with gold, platinum, palladium lrace These alloys d, & elements). noble (g0 platinu palladium) 0xidize casting. feature mpoirant metal This is ina substrate d0not 0n nterface byadding trace so oxidatr0n metalp0rcelain iscontrolled that atthe (s T0 ndium, iridlrm). isthe This BESTUSE. elemefts metal licon, t0the . Gold um. Platinum-Palladiumr Gold-Palladium Pallad Silver, G0ld ( palladium 50-60% + 30-40% (n0t noble silver a 2. Palladium-Silver oble)' alloys oncasting). metal, oxldizes th!s metal 70-80% + 15% nickel chrcmium. 3. ltickel-Chromium (Base all0ys): all0ys p0rcelain-to-metal interlace readily and create hase metalalloys oxidlze can problems. Chrom Nickel-Chromium-Bery Chr0mium. lium; Cobalt Nickel um;

78

Features: Coping 1. Thickness 0fmetaland ngporcelain. metal(0.3-0.5mn Nob e ihickness). l0ir Base (can asthin 0.2mm, must a higher strengih metal be yield as and have and meltrrg temperature). 2. Piacement olocclusal proximal and contacts. 3. Extens 0ftheareas be 0n to veneered porcelain l0r 4 . lacial margin design (ideal lmm). 0LUTE UM Mlll|l P0RCELAlil THICI0IESS is 0.7mm is MARGIIIS. Bevel lllargin-the linishing best {Feather-Edge) margin CAST G0LD for FUIL restorations allowing burnishing adaptati0fthe tothe and 0l gold tooth. H0wevef, ir praciice difficultread the it is l0 0n impression and ead inaccurate and die, may t0 pattern, subsequent asa fesuit ertension dislortionthewax and ol and casting, of thethinwax. a s0has IEAST lt the MAREIIIAI STREII0TH casting. acute tothe An edge/angle a nearby 0fmeta the0ptim!m with bulk is margin a casting for because it iseasilv burnlshed to mDr0ve ft. crown Chamfer l\,largin{he PREFERRTD tlt{E casl FltllSflltlc for lullgold restorations. The joint resultant casting sufficient has l/vh marginal sircngth e allowing sliding at its the perlphery t0minimizegap the between the tooth preparati0n, and reducing thus the cement thickness. Combinesadvantage easily the ol an delinahle margin the 0n preparation. impression die, minimalt00th and with gingivalfinish Preferred tine forveneer restorations. melal 3. Shoulder (Butt argin lointffinishing 0fchoice ALtCERAMIC line l0r crowns Edge {porcelain crown). sirengthporcelaln tlrus BUn of is low, a J0llllis lacket provides required. Sh0ulder resistance t0 0cclusall0rcesminimizes and !0rcelain stresses. margin easily 0ntheimpression die. The is read and Main disadvantage is any inaccuracies crown a.ereproduced margin, inlhe lit atthe causing increased lhicknesscement. 0f SHoUtDER (butt |||ARolil iojflt) theP00REST tine is finish used with metal cast restorations. . Unlike PF[4 the restorati0n accepts marginal lbevel, which afy design chamier, shoulder), rnarglnal preparationtheAt[-ceramic orporcelain tooth for crown crown BE SH0ULIER. fiUST A iacket . Radial Shoulder ed 0fa shoulder ona lceramic that a modif form used cr0wns combinesmum max s!ppOdthe 0l ceramic, a stfess wiih reducing rounded g ngioaxialangle. . Heavy Chanfer be 0nallceramic (but asg00d a shoulder). can used cr0\{rs n0t as Abevel beadded metal can for restorat ors. . All-Ceramic margin gn s I TERIIAILY Crown des R0Ull0ED SH0Ut0tR. .lllain reason lorcelaif crowns allceramic isESTHETICS. t0use and iacket crOwns properties naiural However, These cr0wfs flrimic 0ptical can the 0fa tooth. the guidelines preparaii0n critica more forusage, ast00th such are more and compl than PFIII cated fOr restorat lt isadvisable allceramtc 0nlV ons. to!se crowns inthe anteri0r where csiscritical. regi0n esthet . All-ceramic are crowns known fortheir FIEXURAI- 0TH inability L(lW STRE (th's t0 llexisthemai0r weakness 0fall-ceramic cr0wns). relat tendency Their ve t0 fracture a minimum at deformation. Microscolic surlace detects. load under iead propagati0n eventua lailure. t0 crack and llyl0

ru&TE5

7g

NtlTES

margin a lit at thus 4. Sh0ulderwith a Bevelthis allowssliding t0occur themargin, proximal 0finlays occlusal box and sh0ulderthemandibular 0f may used the be 0n (metal mafgins plac 0r margins PFIV 0l cr0wns ceramic). lf these are crowns, labial
(subgingival),displaymetal seen. beused little 0f is Can for inthegingival crevice (PflV)!1,.h liFe mplalc0llars. aslhelinish 0ntheproxiFal Useo bor meta. cerdmic shoulder0nlays %crowns. used of and Als0 forthe inlays 0nlays, 0cclusal and and is facialfinish 0f PFIV line restorations gingival !|ihere estheticsnotcritical.

heallhier crown when marsins AB0VE Gll{GIVAI are TllE Periodontium remains (SUPRAGIilGIVAL), supragingival however, margins often pOssible t0 esthetics are not due Il a mud be caries, the margins be placed so must subgingivally. margin preparati0n thet00th concern il|]l f0 EXTElll) h the into subgingivally,malor lhe (invade width). margin lfthe extends intothe biologic wi atlachment apparatus hiologic gingjval 0ccurs ultimatelythe will Inthis irritant and crown fail. case, t the a constant perf0rmed tofinal pteparation. PRIoR crown sh0uld crown have lengthening TENGTHENING done surgically theALVE0LAR 3mm may be t0 move CREST apical CR0WN periodon pr0p0sed line{margin) ensure hiologic width prevent and lhe finish to pathology. PRoFltE theaxialc0ntourlhat flom base thesulcus, th extends the of EMERGEIICE Dast height coniour produce of t0 a STRAICHT Ll frcegingival margin. extendsthetooth's lt t0 (EI{ERGEII in 1/3 surface. STRAIGIIT ACCESS A tlllE PR0flLE ihe gingival 0f theaxial ACCESS G F0R lS T)( REST0RI GIEEIH, because itlacililates PR{|FltE)IHE G(]ALWHE (to0thbrush can inlo oRAL HYGIEilE bristles reach lhesulcrs). . The common iscreating most eror a bulge excessive 0r convexity. PFM, FEATURES Al{iERl0R 0t THE periodontal preservati0n and structural durabillUL Radial shoulder: preservaiion. and 2. Chamfer: marginal integrity perl0dontal retention resistancestructural and and durability. 3. axiareduction, 4. lncisal notch: structural durability. & prcservati0n structure. oft00th 5. Wing: retention resistance, and

Pl]RCELAIl{ SELECTI()N SHADE

qUARTZ. (main P()RCEl"Alll mifilre0l FEIDSPAR c0nstituent). a & metallic l)Et{TAt proper t0theporcelain. feldspar When undergoes itfoms fusion, oxides to impart used shade which porcelaintranslucency. asa matrix thehighits lt acts for a glassy material, gives quartz, a skeleton theothef for materialslusearound. to fusing which forms refractory then strengths. Dental Porcelain's compressive strengthGRTATERil'stensile shear is than 0r porcelain plastic ol delormation. restorationsBRITTTEarenotcapablemuch are and MEIAMERISMphenomenon causes a that teeth/p0rcelain t0 appear matched c0lor (appears very under an0ther source light under lightsource, appear different one but in the diflerent lights). propertylmp0dant matching shade a PFIV This is 01 differenl under crowna naturalt00tht0

80

! I

E0l a ceramic crown matched based thecolols is first 0n value. Ghroma. hue. then 1. Value-a brightness.most c0lor's The critical characteristic ismatched that lirsl. (intensity c0lod. Valuetherelative is amountlightness 0f 0rdarkness color ina oi a In esthetics,value a dentufe dependsiherelative the 0f t0oth on whiteness 0rblackness 0fitsc0l0r. Staining a porcelain rcstoratr0n a c0mplementary reduce orusing color will the value. is almost lt impossible t0 increase value.60-year patient, the A old compared 25year patient most t0have with c0l0r is lower t0a old is likely teeth a that invalue higherchroma. and in 2. Chroma-a strengthsaturation. 0l c0l0r idicates degree color's 0r Aspect that the 0l SATURATI0 hue. single important inshade 0fthe The mOst factor matching is that successiully by increased stains. !sing (c0l0r green. 3. Hue-the colols families) red, ye0w, basic like blue, Drastic changes 0f (color shade) often hue or are impossible. stain m0st 0range is often t0 change used thehue. Iight sources inthedental used olfice: 1. Natural 2. Incandescent but lacks blue, ircrease & YELLoW inRE0 3. Fluorescent-decrcase increaseBLUEGREEN. in red, but ir & place ruhber 0nbefore ll0T the dan selecting shade. should clean Teeth the be and ake-up removed thepatient' from sface. TYoesDental of Porcelains: porcelains t0 manufacture l. High-tusing used DENTIJRE TEETI. p0rcelains-used p0rcelain crowns. 2. ilediumJusing forall-ceramic and lackel ph0sphate llledium porcelains fusing also contain oflithium, oxides magnesium, and (inadditiOn t0silicone alumlnum potass oxide, sodium d!oxide, oxide, !m and Oxide). (PFi,l) p0rcelains-used 3. Low-lusing f0rmetal-ceramic cr0wns. Aluminum agent oxide p0rcelains rtsmanufacture added l0w t0 fusing during toincrease resislance its t0 "slunping down" during firing.

rugTES

ONTIC DESIGN
&

lrtt -

ro64 .d

ha
E'I

PfI

llTlC-the suspended rnembera fixed 0f brldge replaces that a missing thatIIUST t00th depatieni comfort, convenient contoufs hyg and esthetlc. fOr ene, be Propef is more design important t0cleanaband tissue than ch0ice ity good health s 0f matefla s. Excessive contacta major inthe ure FPDS. tissue is factor lai 0f p0ntic Area contact 0f between & ridge should small thepart be and touching ridge the shouldCoNVEX. be juncti0n past Pontic should extend themucogingival t0 prevent tip not ulceration. Pontic should touch 0nly AfiACllE0 KEnATltllZED t0 prevent Gll{GIVA ulcers. gingival pontic lvlesial, and distal, lingual embrasure of the should open easy for be cleangaccess. placed P0ntics inthenon-appearancezone restorefunctionprevent fg. are therct0 and drft pontic Success 0rlailure a hridge 0l depends 0nthe m0stly design isdiciated which by patiert functi0n, esthetics, 0fcleaning, c0mfort, the ease and mairtenance patient by the 0fhealthvtissuesedentul0us on the ridse.
8l

ilt,TES

I. MODIFIEO I.IPP|)IITIG: RID6E . P0ntic choice ihe"APPERAilCE formaxillarymandibular FPDS. 0f in Z0 E" & . ljses ridge forminimal contact, gives illusion heing the 0l a a lap ridge but . HAS C0llvEx SURFACES FOR CLEAlllllG EASY & PREVEIII ll{PACTl0ll. F000 Att . Ridge (CR[ST) linguallythanmidline 0fthe contact cannot extend farther the ridge. edentulous . C0ntact thetissue (t not ihe line with sh0uld falljustal0ng gingivofacial angle nospace between thecresi, debris results. it and a trap sh0uld be . Pontic contact theridge with should compact, t0theridge slightly be iacial crest, wider atthe lVl-D {acial, narr0wer lingual and atthe aspect. SADOI.E {RIl)GE PI)IITIC IAP}. . Formslarge a C0IICAVE C0ilTACT lheridge. with 0verlaps facial lingual the and aspectstheridge. of . UtlCtEAtlUilCtEAl{ABLE TISSUE S0D0 & & GAUSTS lllFtAMMAT|0ll ll0TUSE! p0[Trc (sAil|TARY 'FtsH Pl)Ttc): BELLY" ltyctErc . D0ES C0NTACT RIDGE. NOT THE IDENIUL0US . P0llTlG Cll0lCE All0il-APPERAIICE(replaces Z0tlE mandibularmolars). 1'r 0F ltl . 0cclusogingival must at IEAST with thickness be 3mm adequate under space it lor cleaning. . Restores occlusal function stabilizes and adjacent opposing and teeth (prevenis drifting). . CoNVEX areas L & M D) easy (F for cleaning. inall . Floss passes smooth surfaces easily it does surfaces round more than {lat w over snarp angres. . "Arc-Fixed 0enture" Pontic)anesthetic (Perel = modification 0fthe Partial (occlusal p0ntic visible 0f with hygienic thaiveneers parts thep0ntic porcelain pontic's half lacialsurface isallolthis which surface 0cclusal ofthe and facialsurface). . P0ntic a concave has archway and ll4-D c0nvex underside (HYPERB0LIC F-L PARABOLOID).
. Added inthe decredses lorhe slress conrecl0 diminished s wilh burk connectors

inthe centerwith g0ld less used.lncreased lorcleanin access deflection pontic's COIIIGAI. P(lIITIC: . P0NTIC CH0ICE ATHlllMAllolBUuR ina non-appearance RIoGE zone. 0F F0R . R0UNDED & CLEANABLE tip is small butthe relative its 0verall t0 size.When used f00d. a broad, ridge creates tr;angular flat it large embrasure that spaces collect OVATE PI}IITIC: . P0 TIC CH0lCt a BR0AD, RIDGE it theappearance it is giving with FLAT that 0F isa concem. GRoWNG THE FRoIV RIDGE. where Used esthetics Drimary . lt is bluntiy (round-ended that into ridge design lits a depression) where rounded ridge concavity. exiendini0 s0cket % the contacts tissue isset a the and into Can atter extracti0n. an E)(TRACiI0t{ SIIE P0llllC

82

TITEVER BRIDGES
VER BRIDGE abutments0NLY ENo a oontic has at 0NE and attached the0iherend. at

lt0TEs

tcATt0 s:
IIIUST A VERY HAVE STRONG ABUT]IITNT & IIIINIIIAL NO OR OCCLUSAL ON THE CONTACT PONIIC, Pontic replacemissing can MAXIIIARY a IAIERAI, theCANINE bethe but l\4lJST abutment. Pontic rcplaceFIRST can a PREI{0LllR cr0wns used the2'dprem0lar 1,r if full a 0n and molar abutmentsP0ntic replace lvl0lltR avold l'r can to UNILATERAL PREVENT RPD 0R SUPRA-ERUPTIoN. T() USE SRIDGE: I SITUATIOI{S CAIITITEVIR 1. I'ISSIIIG MAXITT,ARY CENTRAL ISNTVERABUTI!]ENT IATERAT. INCISOR AN INA preparedtheDISTAL central CANTILEVER UNLESS seai BRIDGE a rest is 0n 0fthe {inlay 0rmetallic AND rest) l\4ES|AL P0NTICPREVTNT 0F THE T0 R0TAI|0N. 2. tiltss c MAD|BUITRPRtM|)tARl 1.r . 2"d prem0lar 1" molar theabutmenis must lullcovefage and are and have cruwns 0n Inem. . 0cclusion beinthe[40SI (1"' must DISTAL 0F P0NTIC prenro b/c F0SSATHE ar) sn0tter evet . ldeal the m0lar fullcoveragethe when l" needs and canine isvirgin full and (cosmetic isf0t coverage desirable concern). 3. Pontic replace can l{lsslliG M0LARavoid ld to UllltAltRAt 0RPREVEI{I RPD SUPRA-EIUPTI(). . BOTJ1 PREIIIOLARSBE NIUST ABUTI!]ENTS PONTIC RESEIV]BLE & THE IIIUST A (not PREIV0LAR molar) decreaselength thelever and a t0 the 0f arn mririmize stress pfemolar on the abutments. FPD, should inc0ntactcentric be: in occlusion, ormay ben may n0t Ina posterior a pontic ln working movements, contact slde andshould bein contact ronworking NoT ir side movements. . Be non-porous, wilh polished surface. smooth, a . lvlake passive pinp0int c0ntact thegingiva wlth tissue. . l{0thec0ncayetwo in directi0ns. . Be readily cleanable patient. by the . Be narrowertheexpense llngual at 0fthe aspecttheridge. 0f . Be0nasstraight lineaspossible a between retarners the t0 prevent torquing any 0f retainers orabutments.

s)

|ed ing

9reii

PIER ABUTMENTS
Atraditional SoLDERED bridge NoT rigid 5 unit is desirable because physi0l0gical 0f t00th 0f and capacitytheretainers.you of S0, m0vement, positi0nabutments, theretentive arch need STRESS-BREAKER, C0NNECT0R a NoN RIGID to prevent "PIER the ABUTI!4ENT" from asa FULCRU[] orLEVER. actlng PIER ABUTMENI freesta ingabutment ed lous nd with entu spaces each on sidethat requires a NoN RIGIDC0NNECT0R. Apier abutment n0trequire d connector(i.e. does a rig s0lderj0int) is way to the and 0f which thePREFERREDconnect abutments pontlc a bridge.
83

NI]TES

(abutment) &p0ntic 0fa mechanicalunionretainer hroken C0I{NECI0R-a stress ill) -RlGlD R TI)OTH' |)IIT (lIITY BRIDGE . USED Il)RASHI)RI-SPAII REPIACIIIG ABUTIIIENTS ai FORCES DISPI.ACING ON NEUIRALIZE . NON.RIGID DECREAST CONNECTORS OR R THE ABUTI\4ENI ON PIER AFULCRUIV BY ETIMINATING EFFECT (PERIODONTALLY COIlIPROMISED). th I!,IOBILITY SIGNIFICANT . DO USE HAVE NOT IFABUTMENTS COIIIIECT()NS. OB()IIE, I|) . IRAIISFTRS STRTSS SHTAR ltl SUPPONTI }Il)T IHE INDEPENDENTLY k THEI!] IIIOVE BUT ALLOWS TO . IIIINIIMIZES ABUTI!4ENTS, OF TORQUING M-D T(PIER)t0 tt MlIl ABUTiIE 0 THE DtE !s . Stress-brcaking ina fiveuniiFPD PIACE0 device H tPD toRCE T0THE SEGI!'IENTWHERE oNtY THE bv and a lever fulcrum ISoLATING eliminate ITISPI-ACED. SllE on is . o0VEIAIL of the KEYWAY connectorplaced the0lSTAt 0l thepierabutmenl t0 when TILT 98% (middle because 0Jposteriorteeth IVESIALLY subjected abutrnenit00th) more the into movemseats key thekeyway forces. mesialtooth ent vertical occlusal Thus, mesial during unseat would side' placed themesial thekey 0n were lfthe solidlv. keyway movements. is key The c0mmon design aTP0llTlC. mosi 0lSTAt . KEY placed thet{tslAt 0FTllE 0n is the 0l KEY. path SHAPED The 0f inseii0n thekeyint0thekewayis patalleli0 Pathway wit[ is not 0ltheretainerthat involved thekeyway.

s
t
I

t 3 0 I

FPD) BRIDGE MARYLAND (RESII{-BllI{DED

that metal retainers prosthesis) solid (etched-material wiih restoration A c0nseryative The for its REIEilTll) 0f in innet relies theetched surface theenamel theretainers 0n F0RM give RESISTAIICE grooves increase space t0the . Requires MESIAL anabutment & DISTAL edentul0us pulps are (uselul children large who at with in preparati0n inenamel . Requires a shall0w riskforex!osure). inthe cannot Nl-D . Both inclinaiion difference be> 15'wiihn0diflerence abut$ents F-1. inclination abutment's grooves vialong' defined . Pre0arati0ns additional RESISTANCE well demand deiects soft . Can noderate with rcsorotion n0gross tissue be . Abutment are left teeth basical!y intact Fl)R RISISTAilCE mainly Bridge) FPD . tro0ves a resin-bonded(Maryland Provide l0r 0ncrowns RETENTIoN can pr0vide The B-L bvpreventingrotation. gro0ves als0

I T I T I I

84

nI lr
!E

tcATt0ils: RISI0RATI0N 0FCH0ICEreplace missing t0 l-2 luAil0lBUIAR lilclS0RS abutments when are unblemished free). icaries Replace MAXII|ARY ltlClS0RS if patient anopen end has bite, to-end, moderate of overbite. used a PER|0D0tllAt (but as SPLlllT abutment m0bilitv cause can fallurc). Can replace i{ childs molars masticatory are well muscles not devel0ped. (10% Rellace GTE P0STERI0R T00T{ higher 0ffailuremore I p0ntic). SI risk if than Not Jor > 3 units used FPDS unless mitigatingtx-plan a consideration (i.e.0pposing exists RPD resultsless which in occlusalstress.

N{lTES

ra
db
tll

ic
tl4

Features: Pre0atation . Should encompass 180'(guide atleast surfaces/planes interproxinalard0nt0the extend facial achieve t0 a faclal lingual Want extefd faraspossible lock). t0 as t0 provide maxrmum area bonding. surface for . Vertical areplaced allpreparations stops 0n l0r RESISTAIICE & RlGlDmf. . Grooves increase RESISIAIICE T0DISPI"ACEMEIIT 0llAtlTERl0R PREPARATI0IIS. . occlusal preparedabutments is needed (.5mm clearance is neededvery teeth 0n few for lormaxillary incisors). . Light (1mm) chamler linish is placed line SI,PRAGIilGIVAL thelength throughout t0 minimize deleterious t0the effects peri0donti!m. (vERTlCAt C0tlTRAlllDlCATl0llS with VERTICAI 0vERBlTt - patients DEEP 0vERlAP),

ofiEilstvE &l cKEt cARtts. sEt{srTrvmf. M0BruTy.

Al)VAIITAGESMARYtAll0 0F SRIDGESreduced cosi,n0 anesthesia requlred, (mandat0ry), margins minimal preparati0r, rebonding sLpragingival t00th and ispossible if the wings not are bentorsprung. oisadvantages ol lilaryland Bridges: I . IRREVERSIBLE longevity and uncertain . N0 (lf porcelaln beadded iill space correcti0nlVl-D isverywide, s0much width 0nly can t0 the embrasure space) . N0 (cann0t aLignment due not alignment c0rrection corrcct 0fteeth t0 restoring lacial, proxinal, & incisal areas). . Difficulttemporize makeprovision (cannot a to FPD).

85

FlsTES

BRIDGE ABUTMENTS

IDEAI is VITAI ABUTiIEI{T TEETH ll0 lu0Bltl . Abutment evaluated 3 fact0rs with is fOr nt crown:r00t r0ol ratio. configuration.periodontalsurface and area. p0 I)PTIMUM CR|)WI{-R(]I)T Fl)R T()()TH BE RATIO A T() USED ATPD AS ABUTME 2:3, TIS ab 1:listhe IMUM MI acceptable abutmeft formalc !fder rcumstances. PT Cr0wn-t0-r001 l:2 is thell)EAL ratio: cr0wn{0-r00t 0f anabirlment Jor rati0 t00th a y bridge ABUTI4ENl high ratios fare achieved, a ratio 2:3is more Th]s a thus 0f realistic fac A l:1 ratio theminimum is acceptable fora pr0spective under ratio abutment norma circumstances. r00t Crown-to ratio al0ne NoT is adequate forevaluating criieda a abutmef orosoective t tooth. (secondary Secondary Retention abutments double abutment)to overc()me uffavofable crown:root and spans. secondary ratios long The abltment have east much MUST at as (abutment r00t surface and favorable area as a crownrroot astheprimary ratio abutment neJd theedentulous t0 space). canine a g00d A is secondary abutment a lrst vs. premolar, a lateralNOTg00d while is a ch0icea secondary t0a can as abltnent ne. R(ll)T THE C()I{FIGURATI{IT{ WIDEST DIIIIEIISIl)II BEST WITH F.t ISTHE ABUTMETIT. 1sr M0UR THE ABIJT & CAtllNt THE BEST lS BtST EIIT lS 2n0 ABUTI{EIIT BECAUSE THEY HAVI TARGEST SURFACE THE R()()T AREA, SIIIGIE TOOTH AN ROOT WITH IRREGULAR CONflGURAIION OR CURVATUREAPICAL INITS THiRD IS PREFFERED WTH PERFECT IOAROOT A ]APER. R()OTS ARE THAT BR|)AI)ERTHAN DARE FL IV] PREFERRED THAT ROUND. TO ROOTS ARE BIVERGTIIT ARE Rl)OTS BETTER ABUTMEIITS TUSED/CI}IICIAT THAII ROl}TS. greaterthan AI{TE'S the IAW combined abutmeftteeth root surface must equal0r area be ihe edentL space c space). FPD oLs Any replacing morcthan teeth highsk. two is {pont TIITED M0LAR ABUTMEI{TS urit bridge notseat thedistaabutment will if - A3 iftrldes mes 0f the ineof draw98% posteri0r TILT ally) 0f teeth I4ESIALLY subiected when ltilts t0 occlusal The axsofFPD forces. long abutmenis converge must n0more 25-30'. than Any greate. mesial req!ires tilt either: (uprighting) TREATIVIEIT to better position 1. odhodontics h the 0FCH0ICE a mesially tilted abutment, FPD distriblte forces, helps minate defects the and e bony al0ng root's nesial Takes surface. ar0undrnonths. 3 (a%rotated the 2. PRoXIMAL !sed orth0dortics %crown, if isimpossible, 90's0 dista sudace is!ncovered). il the 0nlv !sed distal caries-free. is C0ntraindicated ifthere is a severe marginal height ridge discrepafcy the betweendista 0lthe2dm0larand mesial3'd 0f molar t0the dLe tiping preparation theiipped 3. Telescoping and cr0wn coping.full crown A follows molars l0 tia y,cr0wn over copifg. prep, a proxima axis an nner and coping the fits and fits the Al0ws coverage c0mpensat the full whe ng l0r discrepafcy the betweenpaths 0f insertion abutmenis. ngprov the 0fthe The c0p des marginal adaptation. Indicated . s f facial/ll,rgual rest0rati0ns tilted e*rensive on the molar sts. ex preparati0n a box placed thedistal the 4. llon-Rigid Fu Conneclor. I crown with in ol (ke!r,/ay) uselLr thern0lar marked prem0lar Ii40st when lras lingual mesial and ljsed inclination. f a post-core amalgam on premolar 0rD0 ex sts ihe abutmert.

86

BRIDGES
(solder the C0I{I{ECII)R joints) PREFERREDconrect abutments RIGID !1/ay to the and (FPD). cornector pontica bridge A rigid 0f distributes load evenly a pier occlusal more than (n0n-rigid abrtment c0nnecior), is PREFFEnED TEETH thus F0R WITH DECREASEI) (PtRt0D0ltTAttY CASIS). ATTACHT{! PERr0D0r{TAr T [{V0wED that a Fixed 0esign, tactors Determine gridgework peri0d0ntal 1. R00t c0nfigurati0n: important assessing when anabutments suitability. preferred round cross-section. R00ts broader than Dare FL ltl t0r00ts in . lviulti-rooted posteriorteethwide with separated provide periodontal r00ts better support r00ts c0nverge, 0rare than that fuse, conical. . Single-rootedwith ifiegular teeth an configuration curvature Toot's 0rs0me inthe perfect apical are 1/3 better abutments teeth a nearly than with tapel . R00t surface ona !rosDectrve arca abutment also evaluated. sh0uld be 2. Cr0wn-t0-r00t l:2 isthe rati0: idealcr0wn-t0-r00t0fa tooth beused a ratio t0 as bridge ABUTMENI a ratio rarely This high is achieved, rati0 ismore but a ol2:3 realistic.l:l ratio theminimum A is acceplable fora prospective ratio abutment. Cr0wn root alone NoT t0 fati0 is adequate toevaluate a prospectlve abutment tooth. parallelismabutment is BEST prep 3. tuialalignmenl teelh, 0l of determined L0NG bythe MJS iheorcDarations. of 4 . tenglh Lever (Span). 0l Arm REPI-ACING lSTHE 3 TEETH lllAllMllll,l! absolute The llAxlilUil number p0sterior that besalely 0f teeth can replaced a lixed with bridge isTHREE, 0nly and under condltions. bridge ideal Any replacing than teeth more iwo ishigh risk. . Anedentulous involving space 4 adjacent other l0urincisofsusually teeth than is best treated a RPo. more 0ne with lf than edentul0us exists the soace in same arch. even thouglr 0fthem each could individually with bridge,may be restored a lt be desirable t0restore with RPD, ihem a if the especially spaces bilatera each ate and space involves 0rmore two missing teeth. . 3dm0lars rarely used abutments they display can he as since often ncomplete eruption, short-lused and marked inclination absence 2"d r00ts, a mesial inthe 0fa molar.!sea 3'd T0 m0lar, it must c0mpletely peri0dontally longbe erupted, sound, separated (multirooted), display ornomesial roots and must little inclinaiion. . Asinple bridge replaces teeth, a complex replaces more 1-2 while bridge 2 0r teeth. . Edentul0us involving more areas 4 or missing (except teeth 4 inclsors), be sh0Lld restored anRPD. wiih Fixed Bridge Contraindications: . P00f hygiene, caries high rate,0r multiple inthe 0rteeth 0ral spaces arch likelyt0lost be inthe future. near . Space detrimental maintenance stabilitydental not t0the 0farch 0r health. . Unacceptable 0rbruxism. occlusi0n . Afteriorfixed isc0ntraindicated when bridge conslderable residualridge exists. resorpti0n Use RPD. an

N{1TES

87

t{0IES

that small retracti0n passes method anacceptable 0fgingivaliissue ETECTR0SURGERY (sc0rch). usually gingivalt issues,causing cellst0 desiccate 0f c currentsele t ricityi hr0ughthe g00d but clot ofthe of because lack proper formation, isvery delayed healing in resulis some electrode in current anelectrosurgical is Too low hemorrhage. 0f anelecirical at stopping drag. by tissue detected margins' access . Electrosurgery hemostasis' t0 cav0surface coagulation, 0biectives, ol a thin sulcus wall kem0ving layer crevicular theinner 0l thegingival andreduce gingivaltissue). lndications, or into gingival wherehas . Remove it proliferatedpreparations hyperplasiic tissue margins. ovef crown gingivapresent is attached .ln place gingival substantial c0rd retraction where 0f crown . Crown-lengthening pri0rt0 pr0cedures fabricating a prcvisional gingiva,underlying dehiscence because 0r ofthinattached areas Contraindications: PACEiIAKEnS' CARDIAC after gingival areas electrosurgery. occur recession inthese (t120), ltl|)vlilG' d0 AGtllTS KttPTHtEIECTR0DE and Ftll{l{ABtE |l'tETAL lllSIRUEllTS, t00th, bone. 0r a n0tt0uchmetalrest, t0 seri0us damage thePIlt and due i0 during electrosurgery potenlial care Great is used of in h0ne, surrounding resultingl0ss attachment. WAVEFl)RI{S. EI.ECTROSURGENY peaks rapidly. diminishes Causes recurring 0l powerthat Dampened: 1. lJnreclified, hem0stasis healing, g00d but slow, and dehydrati0nnecrosis, painful G00d half occurs damping inthe2'd 0fthecycle 0amlened, Rectified, 2. Partially healingdeepertissu in greatertissue with destructi0n slow heat lateral penetraiion, coagulation. Good hemostasis. and Good fl0w continuous 0fenergy. cutting some Rectified: 3. Fully tissue cutting ofenergy Excellent withless flow continuous Rectilied Filtered: {. Fully healing. injury grcater and

(I!(]WELS) & GI)RES POSIS

Postscores: &
core up orcomposiie build isindicated. anamalgam isdestroyed, clinicalcrown lf 50% 0fthe cores, they than mjcr0leakageamalgam and alenotas c0res greater Comp0site have stable. dimensionally (wiih 0ranother pins and retentive feature) notiust t0the Acore beanch0red t00th must placedfillthe void. to Placing a post anteiorteeth posts a Not allendodonticallvtreated requlre and fullcrown. it. tooth weakens ina conservativelytreated (atleast with occlusalcoverage anonlay) RESTRoATIoN must a Posteriorteeth have CAST RPDS for extemion as sh0uld serve abutments distal ll0T treated Endodontically teeth RCI teeth). (4x greaterlailure than rate non-abutment n0t They than fail Pulpless abutments 2xmore vitalabutments should beabutrnents FPD l Pontic. longerthan with span a (antir0talion place to or GRl)oVEprevent cast-p0st-c0re, a KEYIVAY Fora custom (pot butNoT PINS. holes, channels), Anti-rotaii0nalleatures slots, deyice). rotational l\4ust diametertheCEJ. bea minimum at must Post's diameter notbe> 1/3theroot's and atthemid-r00t beyond iooth structurc 0flmm lhickness 0rrem0ved. l4flust sh0dened Allcuspslhinnerthanbe provide for A retention a core They roots Posts not d0 strengthen it'sa myth! simply premature oftheroot post failure poorly fitted willcause 0r designed

88

(retain core). function Post t0 PR0V|DtPIATFoRM THE 0f is A Fl}R CR0Wil Primary the (esthetic bondable).post becoming pass6. material bemeial Posi can 0rfiber and Cast is . Carb0n &Glass Posts:flexible, and Fiher absorbs disslpates acting f0rces againstthet00th. . Ceramic are rigid, pr0vide flexure. P0sls: morc s0 more Resistancet0 remaining radicular tooth structure. . Post Shaoes: . Tapered: requires LEAST usually the internal dentinal structure corresponds and tothe shape rema root. ofthe ining . Parallel: beiust conservative within minimum diameter can as if selected the canal .2'dStage, both have parallel tapered and sections. WIDIH should P0ST involve mnimum the amountdeniin of removal,provide but sone (non-contact)0!tef passive pedpheryofthe inner space. post engagemefi 0fthe and canal tEl{GTl| nocleatformula fordetermintheidealdepth post PoST exists ng ofthe prcparation. LENGTH be4 5mm theapex. post beAT from Post musi The must LEASTlong theclinical as as post (whichever The should equalthe c.0wn length 2/3ther00llength crown. 0r isgreater). perchaattheapicalend0lihecanal. llere must atleast ofgutta be 4mm P0SIDESIGI{ active passive. because has vs. Just a posi ihead does nean is fg, not it diameter preparation postdiameter 0fthe drilland aciive.The determine postisactive. ilthe Post Color: . ldeal lsthat DENIIN c restOrations). (ceram coi0r of . Translucent, t0bemasked dentrn-colored may need with core material. . Carbon-fiber are posts black used a PFM crown a comp opaque and with 0r with etely
su0sItucIUte.

t{{]TES

(apica])to EFFECT preparation (finish [,luST at beyond the margin line) extend fERRUtE thecore intoS0UND and T00TH STRUCTURE. is the1.5-2nm0r s0ol sound Feffule r00t apical that of structure to thecore themargins thecrown should engage PR0TECT t0 post-retained R00T AGAIIIST FRACTURE. A ferrule makes full-coverage restorati0ns more and strengthensto0th resist significantly retentive dramatically the t0 fracture. lt holdingtogether themetal surnunds circunference t00th, the 0fthe it like bands around ihe head a wooden of mallet. . Preparation post sh0uld preserve tooth lora c0re s0id structu.e. margin Ihe should be APICAL dowel-c0re t0 enable crown girdle t00th hrace margin l0 the the t0 the and it erternally. . lf thetooth flush thegingiva, is with fabricating a post-core crown thout rcling and w efc the tooth struciurethecrown can by walls cause FRACTIJRE. R00T

8g

t{0T85

ratherihanpost a crown restoring when RCTtreated teeth: Advantages a post core, 0l using & . Nlarginal post. adaptation olthe and fit restoration isindependent lit 0lthe 0n the . Restoration replaced flture needed, disturbing post core. can be inthe if with0ut the and . lf theendodontlcally tooth t0serve a bridge as abutment, not il s necessary treated is t0 lrlcdn p lf wiln lire makaer00. prFpardparallel the 0tdraw otherdparations caqal i0n 0t abutment). be treatedanindependent as . Post core made frcm The is and s separate thelifalrcstoration.crown labricated and just cemented ihecore asa restoration over is placed a preparation 0ntooih over d0ne
SITUCIUTC-

HY

. Post core beused teeth little n0clinical & can for with 0r crown, rJith but r00ts wilh straightness. posterior withlessextensive For ieeth adequate length, bulk,and root desiruct ofcoronal structure, 0n tooth orteeth less with lavorable configurations, a plnreiaifed 0rcompositecan used. c0re be amalgam

Pt|RCELAIl{ VEl{EERS
Indications, Porcelain Veneer 1. Coverlng sudace labial delects eramel like hypoplasia. staining, discolorationloss after of 2. l\4asking disc0l0red like teeth teiracycline vita tooth ty. incisal 3. Repa r structural damage fractured edges. like (i.e. laieral 4. lmprove contoLr peg-shaped incisors). t00th 5. Reduclng incases 0rth0dont inappropriate. spaces when csare mbricationteeth, P0RCEUtll{ VEIIEER C0l{TRAll{DlCAI|0tls severe 0f traumatic un{avorable morphology, insufficient structure enamel.patient tooih and A 0cclusa c0ntacis, witha h gh caries index, clinica sh0rt crown, minimal and horizortal arenot overlap Rather, is candidates forpartia veneer crowns. therestoration 0fch0lcea fullPFI\4 crown.

s! n

Af ho ftl h

sl sl

(3/4 Restorations& 7/8crowns), Advantages 0l PartialVeneer $ l. Prlmary reason choosing cr0yvn a full cast for a 94 ovel crown T00TH is STRUCTIJRE h ISSPARED. F 2. Agreat dealolthe margin inanarea is accessrblet0the is f0r f inishing and dent i t0 patient cleaning. the fof It restorati0n is fcloseproximrytothegingivalcrevice,thu margin 3. less 0lthe decrcasifg the chafce periodontal 0f irritation. part completelyngcementation.atleast 0fthe du With 4. Can more be easily seated margin visible, complete 0fa partial crownmore verified seating veneer is easiy by vision. direct pllp (EPT) the 5. ll it isever necessary anelectric test t0do 0n tooth,portion the a 0f eflamelun-veneered is & accessible.
I

sll

u
I

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IMPRESSI{1N MATERIATS
HYDR0C0tt()lDS theadvaniage have ofWETI|t{c tltTRA0RAt SURfACIS, blt have we very limited dimefsl0nal hecause are stabillry they composed water. of85% (AgaFAgar)-af L Reversihle Hydrocolloid impression wh0se material physicalstate is changed a GEt byapplying and reversed hyremoving lrom S0L HEAT is back heat. Reversible hydrocoli0ids are composed water, 0f85% 12,15% traces borax, agar, 0f potasslum & sodium s! fate, tetraborate. Agar impression s afddental rtaterja compounds inv0lve d0nOt a chem reactionset. cal t0 . Advantagesi pour, mixing requlred a hydr0c0lloid Easyt0 n0 is c0nditi0nunit ng lbut isrequired). N0 custom isrequired. iOlerant, & pleasant tray lvoisture clean with acceDjablaexcAllenI-lile. exponsive. 0d0r. rhel ir . Disadvantages: poured ately, line diff toread, in must be im]]ted finish is cult weak a deep sulcus, pOtentlally tothe and pruperly. injurious patiertn0t if handled Very limited dimensional stability. yery 2. lrreyersible Hydr0c0ll0idsATEfan ]apression elastic materialwith {A[Gl limited dimensional stahility. . Advantages; irexpersive,use tray, y mixed, easy pour. can stock easl and to . Disadvantages, fragl may unstable, e, affect casi the surlace, musi and be poured immediately. Sol)IUM PHoSPHAIEcomponent inalgfatepowder c0ntrols SETTT a found that the G llME alginate. ol Aftertaking impressions,placethe alg nate lf you impressions 0fwaterl0ra n a bowl few preventthem dryifg before ngthe pour hours tryand t0 ffom up casts, ll,lBlBlTl0l{ 0cc[r can (the impressions water expands). rnbibition theimpresst0f absorb and When occurs, is no t0nger accuTaIe. Shrinkage inalginale occurs imFressions when = eyen placed 100% under relative humidity (0ccurs exudate drcpletstheliqu medium ontheimoression SY|IERESIS when like ol d fOfms (causes sudace). shr Since fkage undesirable d stortion is ofimpessions), impressions a ginate (causes sh0uld beleft in water not expansion) 0r exposed air (causes t0 shrinkage). lmpressions bepoured should immed t0 ensure pouring not ately accuracy. immediate When s possibie, alginate impressi0ns stored briefly a m0ist paper can he only in towel. Techniques preyent t0 help 0AGGlt{G taking while alginate impressions: . Decrease me take iflpressi0n have patient the t0 t an afd the breathe thr0ugh nose. their . Seat patienlanupright positi0n. the in . Seat posterior 0fthe first. xing algifaie part the tray Nl the rapidly it toset causes more raDidlv. . Decreasing (affects cous water-t0-powder ralio causes alginatesellaster t0 mix stency as mix much ihe is thicker less lsused). when water . D0t{0T cold use water mix alginate t0 the because it retards alginate's time. setting luandibular alginate impressi0n is taken FIRST gagglngmore t0 occur since is likely while posteior portion the taking maxillary the lmpress For fiaxilary 0n. the impression, lhe seat ol porUonhelp prevent trayfirst,then anteior the t0 a ginate being frOm squeezed0fthe out tray backtoward patient's Always the throat. remove alginate impressi0ns quick inone moyement permaflent with snap help a t0 decrease del0rmation. overseat tray(0.25 D0 not the irch) (espec occlusal mlnimumginate remaln allcrilical 0la should 0ver stfttctures ally sudaces).

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When taklng alginate an impression,advised the beplacedthemouth it is that tray in after with the allcritical are areas wiped alginate. areas buccalto maxil{arytuberositie Critical are planes retr0mylohyoid Rest and space. seats guide sh0uld cove.ed alginate he with and and any sofl olher lisrue urdercu15. When alginate taking impressi0nRPD,isbest apply alginate 0n fora it to s0me directlythe teeth eliminate t0 bubbles saliva therest 0rcoarations. and from seat qualities forcrown EIAST0MERS impression materials eiastic ruhherlike with 0r used & bridge, secondary impresslons fordentures, inlays/onlays. removing and When elastomeric permanent force is required) impressions, use steady (asnap not t0 minimize deformation. p0lymer-based ElastomeE a chemical set via reaction. Elastomersll0ll-A0El)US are ru[ber impression materials good with elasticity. (Ruhber ilercaptan, Thi0kol) base l. Polysulfides Base, the c0ntains a liquid p0lysLlfide (mercaptan nixed anlnert The polymer polymer) with filler. acceleratOr is usually dioxide. these pastes mixed, polymer are lead When two are the chains lengthened linked and cross through thiolgroups a rubber material. oxidized t0form like . Atrayl0rpolysulfide impressionlacks a rubber that occlusalstopsrcsult may in aninaccurate linalimpressi0n 0fperflranent during because distorti0n polymerizaiion. . Sets 1214minutes longest (the in setting time). . lvToisture inthemouih acceptable. t0lerance is . Wettability gypsum p00r and Has isp00r, it has taste 0d0r. an18month with and shelf-life. . PolysulJide polymerizati0n 0fisexothermicaccelerated increase and byan in temperature orhumidiiy. . Polysullides g00d pr0perties, flexibility, high strength. have fl0w high and tear Polysulfides thestrongest have resislance t0tearing, impressions but can distort fron where undercuts Polysulfidesa l0ng when removed areas deep exist. have working and tjme relatively polymerization may t0patient long time, which add discomf0rt. have low They a resistance t0deformati0n. (Addili0nal 2. P0lyvinyl 0r Polysiloranes)-one Siloxanes Silic0nesVinyl tube c0ntains silicone terminal H+groups aninert The tube a vinyl with silane and filler other is with vinyL chlor0platinic acid silic0ne terminal gr0ups, catalyst, filler. mixing, and Up0n gr0ups there anadditionsilane is 0f hydrogen across d0!ble vinyl bonds does and not form by-products, ina very resulting dimensi0nally matedal. can poured stable PVS be uoto I week. . tatex gloves polyvinyl should bewo.n not when mixing siloxanes because sullur inthelatex retards setting addition the 0l silicone materials. inferric Sulfur and polymerization Some a uminum sulfate reactionuiion also s0 may inhibit 0fPVS. gl0ves inhibit sening polyyinylsiloxane. latex might the 0f . [4ixing (30 sec), lt4oderate time 4 min); time 45 working (2 moderate time setting (6-8 min). . fxcellent very permanent dimensi0nalstability l0w and deformation. . Poof strength, temperaturevery stiffness, poor tear lowest rise, high very wettability (increases bygypsum. Addition s;liconestemperature are sensitive intemperaiure shortef working & setting times). Easyto easyt0 mix, clean-up, acceptable and 0dor and taste. . Polyvinyl (PVS) the siloxanes are il0ST Wl0EtY & 0ST USED ACCI,RAIE elastic impression materials. have polymerizaiion They less shrinkage,distortion, low fast recovery deformation, fr0m and moderatelytear high strength. PVS he lv0st can poured to I week impression and stable most after making are in up solutions. stedlizins

32

(lmpregnum/Premier (Caulk) two 3. P0lyethers & Polygel are c0mponent materials. The p0lymer ethylene groups, filler, rubber includes base a polyether with imine silica and plasticizer. The accelerator cortalnscToss a linking (ar0matic agent sulfolic acid pr0duces poiymer When ester) which cross-linking bycati0nic 2ati0n. mixed, a rubber polymerization process. f0rms a catl0nic by . Advantages, dimensional (when clean, pleasant & 0d0r, excellent stability dry), taste y stable more one is poured, even FAST G, SETTI dimensiona il than cast stable if poured afteftaking (very 24hrs af imp|essiOn pernanent l0w deformation) asit can pouredt0I week, are hydr0philic resultssLperior be up and truly which in wettabiliU bygypsum. Polyether impressi0n t0lerates fiaterial m0isture than better any other elastomer. . Disadvantages: dilficult themost materialremove thern0uth most t0 from {the (p00r strength), adhereteeth, rigid/slitf material), easily tear tears may to high (dimensionaly inthe water absorpti0n unstable presence 0fm0isiure), and fine margifs break. may Compared materials, indisadvantage t0other ma the 0fusing polyether elastomeric impressi0n materials aremuch isthey stitfer. the Has hrghest temperaiure highest r se and stiflress. . Polyethers theSHllRTEST & StTTlllc have W0RKIIIG TllylES elastomerlc 0lthe (mixes Work time impressi0n materials. tlrne 30-45 lt4 xing is sec0nds easily); ng ls 2-3 minutes; tlme minutesSetting 6-7 . All impressi0n C0IITRACT durirg maierials elast0meric SLIGHIIY settlng (they not do expand). . For results eastomer with c impressi0n material, prepared sh0uld best the t00th be free surface of m0isture. Comparcd t0hydr0c0lloids, elastomeric impfessi0n pTepare, resistant materials are easierto more t0tearing removal,have upon and a mensional stablliiv. suDerd or . Cust0n are impoltant ofrubber impression part Trays an base techniques since elast0mers m0re are accurateuniform layers are2-4mm With in thin that thick. a cust0m sh0uldfabricated a plastic allelast0mers, tray be with material, be should permanent polymerization, rigid, 0cclusal t0avoid have stops distortion during and coated anadhesive sh0uld completely takjng be with that dry before the impressl0n t0preveft impression from ling the material pL away.

I't0TES

ZltlooXIDE-EUGEtl0L-an paste settingtime impression whose isacceleratsd by ADDltlc

0f t0 retard setting Z0E, inert (olive mineral lhe ol add 0lls 0r a drop water themir.To 0ll) reaction. during mixing. sets a chemical Zl)E via . Advantages: can record softtrssle rest, hard 5 mlnutes, & less at sets n stable, e xpensive polysulf than ides. . Disadvantages: to mix,verysticky, messy tlssreirfitant, elastic, not dilfcultto gagging manipulate, n0t recommended patients. for lmpression Problems: 1. Grainy Material causedimproper by 0rprolonged undLre mixing, gelati0n, low 0rt00 a waiecpowder ratio. premature 2. Tearing 0lMaterial: by causedinadequatem0ist!re buk, contamination, rcmova1 the lr0m mouth,prolonged 0T mixing. ordebristissue. on 3. lrregularly Voids, i0 moisture Shaped due 4. R0ughChalky Castr or Stone causedinadequate ofthempression, by c earing excess premalure ofthe water inthe left irfpression. rmoval cast, eaving cast the the in manip! 0f impression orimproper ation stone. 100 long, gelation, impression f0tpoured mmediatey, movement dLring oftray 5. Distorti0n, premature 0rimproper lr0m moLrth, was inthe removal the 0rtray held m0uth ong t00 (only certain with brands)
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jnterocclusal should a Bite Registration Material t0 make accurate used an record ofler MlillllUM RESISTAiICE patiert's closure haye ft0w at miring. t0 the afld L0vir Recenfly, law additi0n-reacti0n impression silic0ne materials d0ninated inlerocclusal have the rec0rd (l0R) market these slfce mater have t(lw Fl0W als VERY when mixed bec0me and rigid after setting.

GYPSUM
plasters stonesCalcium [4ain c0nst]tuent 0fdental afd is Sulfate Hemihydrate. Type rarely tOday. l: used Type used make ll: t0 (orthod0ntics). odel casts when sirength notimportant is Dental (Type heating gypsum an open Plaster ll) in kettle. pr0cess pr0duces and porous This pR00UCT. padicles. plastertheIVEAKISI iregularly shaped Dental ls GypSUM Type used preparing 0l an alginate lll: for casts impressi0n which upon dentures are processed. . DentalStone lll)-producedHEATINC under (Type by GYPSUII4 pressure watervapor with in produces ana0toclave. process Th s unif0rm padicles. shaped less and p0rous Heating gypsuma 30% in solution calcium produces strength 0l (impoved) chloride high die p0r0us strongest es. stone. Pnd!ces least partic the ard Type used maklrg "dies" lV: (reproducti0ns with when stone ojteeth prepafed cavities) used (inlays 0nlays). l0rcrown bridge, operatlve and & and CEMEIITS do - cements NOT increase retention. cr0wn At00th must WtpE0 before be DRy cr0wn cementatiOn, asopposeddrying t00th alcohol warm to dectease t0 the with and aif the possibilitypulp 01 damage. ALWAYS cement b0th rest0ration thetooth. Als0, apply t0 the and l- Composite Resin-the materialchoicecement llting 0l t0 a cefamic and crown caf provide STR0NGESTCeramic the BoND. $owns bonded c0rnposite after are with rcsin eiching internal 0fthe the sLrface cr0wn, are and shownbe t0 betterbonding if strength other than materials. 2. Zinc-Phosphate Cement-rnay used cement porcelain lt ltas also be t0 crowns. g00d compressive (14,000-16,000 itshigh isa problem stfength psi), pH but because two Iayers yarnish beapplied pr0tect putp. is0ne the 0f must t0 the ZpC 0f oldest and widely cements pelmanent restorat and a used a base. used for luting metal Ons as as It rsa high-strcngth base, cement mixed zinc0xide powder phosphoric lrom and acid pH, liquid. t0itslow Due initial it may pulpal cause i.ritalion, especially 0nly where a thirlayer dentin betweencement the of exists the and pulp. polycarboxylate 3. Zinc 0rZ0Elhese bi0l0gically compatible cements used are 0n teeth preparatiOns wrth with adeqLat and ength retentive featurcs, 0rwhen the preparatiOnraises concerr depth some pulp rcgarding vitality. Also,lhese cements exhibit better resistance t0s0lubility zinc than phosphate cement. p0lycarborylate Zinc and adhere GIC t0calcif denta ed tissue, have and superiof compaiibility biol0gic than phosDhate zinc cements.

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(8lC)-a 4. Glass lonomer Cement dental restorative used dentistry matedal in for rest0ring and ieeth lutifg cements- materials based thereaction These are on 0f glass silicate powder p0lyalkenoic These colored and acid. t00th materials were (Darticuiarlv lntroduced foruse restorative in1972 as materialsanteriorteeth l0r for eroded Classand carious areas, lll V lesions). bond As they chemically hard todental tissues release for relatively peri0d and fluoridea long modern applications day 0fGlCs properties i0r0mer glass have expanded.des The rable 0f cements them make uselul materials restoration inthe 0fcarious lesions low-stress such sm0othin areas as pr0ximal surface small and anterio. cayitiesprinary in teeth. . DC Ptllsisa resin glass Fuji reinforced i0nomer cement luting designedllnal l0r cementation porcelaif-fused-to-meial 0fmetai, and metalfree crowns, bridges, inlays 0flays.li chemically and bonds and mechanicallyt0toothand all structuret0 placement produces typescore 0f material. ltssimple technique significantly higher g ass bond strengihs conventional than i0n0mer cementse maintaining whi the favorable characteristics ionomers-fluoride low ofglass release, c0efficient 0f thermal expansi0n,bi0c0mpatibility structure soft and tot00th and tissues. For indirect metal-free restoration rec0nmend reinforced that a resin / resir-m0dified glass iof0merlinal for cementation reinforced - cemeniable allceramic like crowns PR0CERA 0rcemeniable composite restorationGRADIA. resin like Prolonged sensitivity t0 heat, and cold, pressu.e cementing after a cr0wn fired 0r bridge patient is usually related 0CCLUSAI to TRAUMA. occlusion high, lf CR is complain cold 0f sefsitivity pain biting and on down Alipatients hard. should anapp0iniment have specifically t0 check occlusron crowns bridges. the 0nall and Excursive movements als0 sh0uld be patients (this evaluated, 0tten since c0mplair pain chewing foods indicates 0f 0n soft g0ld impr0per balancing orworking c0ntacts). occlusi0n resl0rati0ns checked The 0l isbest with stwER PtrsTtG sToGK. sH[{

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