GOOD MORNING

1. EXAMINATION AND EVALUATION OF DIAGNOSTIC DATA: THE SECOND DIAGNOSTIC APPOINTMENT Presented by: Dr. Kamleshwar Singh BDS, MDS, ICMR-IF(Japan) Assistant Professor Department of Prosthodontics King George’s Medical University, Lucknow GOOD MORNING

2. Second appointment The second diagnostic appointment is used to complete the gathering and the evaluation of the diagnostic data. Diagnostic mounting: a) supplement examination of oral cavity. b) analysis of occlusion c) patient education d) provide a record of patients condition before treatment Procedure: • Facebow transfer • Centric relation registration • Mounting casts • Protrusive record, setting condylar elements

3. Face bow transfer: • Preparation of bite fork • Orientation of face bow to bite fork and reference points • Orientation of face bow to articulator • Attachment of maxillary cast to articulator

4. Centric relation record Recommended method • Backrest at 60 degrees. • Deprogram oral musculature. • Slight backward and downward pressure on patient mandible • Then CR record made.

5. Centric relation record: Using wax • We can also use elastomeric registration materials (wax tends to change dimension over time and can become brittle)

6. Centric relation record: Using Record bases • If patient does not have enough teeth to mount lower cast to upper (i.e. no posterior teeth), fabricate record bases. • Wax-up, take relation in centric relation.

7. Setting condylar elements • Protrusive record: with either wax or elastomeric material. • Patient instructed to protrude mandible by 5-6mm, then close into recording material.

8. Setting condylar elements Too steep Too shallow The condylar setting is… Correct inclination

9. Extra-0ral examination: • Facial form and symmetry, jaw opening and closing movements, palpation of TMJ and muscles of mastication.

10. Definitive Oral Examination: Caries and existing restorations • Carious lesions: surface restorations cast restorations crowns • Margins of cast restorations. • Possible extractions.

11. Definitive Oral Examination: pulpal tissues • Possible pulp testing should be used to determine the vitality of the teeth. • Selection of endodontically treated tooth as abutments is NOT contraindicated. Better prognosis with full crown coverage restoration.

12. Definitive Oral Examination:sensitivity to percussion • Unstable occlusion • Tooth in traumatic occlusion • PA abscess • Acute pulpitis • Cracked tooth syndrome

13. Definitive Oral Examination: Periodontium • Trauma of occlusion • Inflammation of periodontium • Colour, contour , form and stippling of gingiva • Loss of bone support Not useful as an abutment for a partial denture Useful for an abutment for an over denture

14. Definitive Oral Examination: Tooth mobility • Degree of mobility (Grant, Stern & Everett 1972) NP mobility – 0.05 -0.1 mm • Viscoelastic property of pdl (Carranza) Class1: More than normal physiologic mobility but less than 1mm of movement in any direction. Class 2: A tooth moves 1 mm from normal position in any direction Class 3: A tooth moves more than 2 mm in any direction, including rotation or depression.

15. Definitive Oral Examination:Periodontium: Need for periodontal treatment: • Pocket depth>3mm • Furcation involvement • Gingivitis, ginigival cleft, festooning • Marginal exudate • Proposed abutment teeth exhibiting < 2mm attached gingiva width

16. Definitive Oral Examination:Oral mucosa: • Uicers, inflammation, rough teeth, existing prosthesis • Pathologic lesions • Papillary hyperplasia • Epulis fissuratum • Denture stomatitis (Candida infectn) • Soft tissue displacement- tissue support • Biopsy, m washes, nutritional deficiencies & nystatin

17. Definitive Oral Examination:Denture bearing residual ridge Ideal denture bearing residual ridge (ATWOOD, 1973) Wide, Smooth, Rounded and Covered With tough, firmly attached, keratinized mucosa

18. Definitive Oral Examination: Hard tissues abnormalities: • Torus palatinus & mandibularis • Exostoses & • undercuts.

19. Definitive Oral Examination: Soft tissues abnormalities: • Labial frenum • Unsupported and hypermobile gingiva Space for mandibular major connector: 8mm space for lingual bar

20. Definitive Oral Examination: Radiographic evaluation of prospective abutments: • Root length, size and form • Crown-root ratio • Lamina dura • Periodontal ligament space

21. Evaluation of mounted diagnostic casts • Interarch distance • Ridge relationship • Tissue contours • Occlusal plane • Irregular occlusal plane • Malpositioned occlusal plane • Selective grinding, crown, endo Rx, Extraction

22. Evaluation of mounted diagnostic casts • Tipped or malposed teeth • Occlusion Role of occlusal equilibration Interferences need to be corrected

23. Evaluation of mounted diagnostic casts • Occlusal indicator wax, articulating paper or tape, and thin metal foil may be helpful in assessment of occlusion.

24. treatment at centric relation …. • To observe the contacts of the teeth in the centric relation, the dentist should ask the patient to touch the teeth together slowly and lightly until the first contact is felt and then to “ close all the way”. • Demonstration of a “slide” between the initial contact and the position of maximum intercuspation indicates a discrepancy in jaw closure between centric relation and centric occlusion positions.

25. treatment at centric relation..... • The recontouring or restoration of the teeth to make the centric relation and centric occlusion positions of the jaw coincide is not always required. • Certainly, premature contacts in normal closure and deflective occlusal contacts that causes the mandible to slide protrusively or laterally must be corrected.

26. treatment at centric relation …. • According to Renner, following conditions should be met: • The jaw closes smoothly and consistently into the centric occlusion position. • Multiple, simultaneous, stable occlusal contacts in the centric occlusion position. • No evidence of a slide following the initial occlusal contact. • No symptoms of dysfunction.

27. Finally…. Diagnostic wax-up • Provides a great deal of information regarding tooth preparation, placement and occlusion.

28. Development of Treatment plan How do I develop a Treatment Plan????

29. Developing a sequenced treatment plan • Phase I: • Evaluation of diagnostic data • Immediate Rx – pain, discomfort, infection control • diagnostic mounting, wax-up, partial design, • referral to other specialties (endo, ortho, oral surgery etc.), • patient education (OHI, etc).

30. Developing a sequenced treatment plan • Phase II: • Removal of caries, • extractions, • periodontal treatment –plaque control measures, • occlusal equilibration- deflective and premature contacts elimination, • placement of temporary restorations (temporary crowns, etc).

31. Developing a sequenced treatment plan • Phase III (continuation of Phase II): • Pre-prosthetic surgeries, • root canal therapies, • definitive restoration of teeth, • RPD mouth preparation. • Phase IV: • Placement of RPD, • Instruction for patient and written consent. • Phase V: Periodic recall, reinforcement of education and motivation of the patient .

32. Typical problem.....Changes caused by a mandibular Rpd opposing maxillary CD • Ellisworth Kelly -1972 • Five changes may constitute combination syndrome, as they are quite characteristic. These changes are • loss of bone from the anterior part of • the maxillary ridge, • overgrowth of the tuberosities, • papillary hyperplasia in the hard • palate, • extrusion of the lower anterior teeth, • and • the loss of bone under the partial • denture bases.

33. CONCLUSION...... In no other phase of dentistry is the need for knowledgeable planning and forethought so vital to a successful outcome as it is in the practice of removable partial prosthodontics. The multitude of procedural and clinical details that must be coordinated into an orderly sequence makes it imperative that all factors bearing on the treatment be carefully evaluated so that each phase of therapy can be coordinated with the overall plan.

34. Bibliography: • Removable partial denture prosthetics- STEWART, 3rd edition. • Removable partial dentures – Robert Renner & Louis Boucher • McCracken's Removable partial prosthodontics- McGivney • Essentials of removable partial denture prosthetics- OLIVER C APPLEGATE. • A colour atlas of removable partial dentures- DAVENPORT, BASKER.

35. Partial dentures- OSBORNE & LAMMIE, 5th edition. • Dental implant prosthetics- CARL E MISCH • JPD, Vol. 11, No. 3, 2002:pp 181-93 • JPD, 16, 1966: 533-39 • DCNA- Vol.34. No.4,1990:607-09 • JPD, october,1973: 526-32

36. Removable partial prosthodontics- SYBILLE K LECHNER. • Removable partial prosthodontics- Miller & Grasso • JPD, December, 1974: 639-45 • JPD, July, 1953: 506-16 • JPD, July, 1953: 517-24

37. Q1. The first step in the diagnostic mounting procedure is the mounting of the maxillary cast on a • Fully adjustable articulator • Semi-adjustable articulator • Denar articulator d)Free plane articulator

38. Q2. Face bow which requires styli to be placed on selected points on the face is • Whip mix • Hanau spring bow • Hanau SM d)Hanau H2

39. Q3. Beyron’s point is located _ mm anterior to the posterior margin of the tragus of the ear on a line to the outer canthus of the eye • 11 • 12 • 13 d)14

40. Q4. While adjusting the articulator, the following setting are followed for condylar guidance, Bennett guide and incisal table respectively • 30, 15, 0 • 0, 30, 15 • 15, 30, 0 • 30, 0, 15

41. Q5. Ramfjord and Ash (1971) have stated that three factors must be controlled in order to succeed in determining centric jaw relation. Which one is not among them? • Psychologic stress • Pain in temporomandibular joints • Muscle memory • Systemic illness

42. Q6. In which method of recording jaw relation does the operator place all four fingers of his hand on the lower border of the mandible and thumbs over the symphysis? • Bilateral manipulation of the mandible • Alternate protrusion and retrusion • Both a and b • Use of an occlusal splint

43. Q7. Frequently the lateral pterygoid muscle prevents relaxation and free rotation of the mandible. This method attempts to fatigue this muscle sufficiently so that it will reduce its contraction and allow retrusion of the mandible • Bilateral manipulation of the mandible • Alternate protrusion and retrusion • Both a and b • Use of an occlusal splint

44. Q8. Which of the following is not used to record centric jaw relation • Acrylic resin • ZoE paste • Dental stone • All of the above are used

45. Q9. Wax is the most commonly used recording medium while making jaw relations. Which is not true about it? • It is most unreliable and unpredictable • Can distort when the records are made, when the records are stored and when the cast is mounted • Exhibits “memory” • The hard wax, Alu-wax, contains aluminium or bronze for filler

46. Q10. While using metal impregnated wax, water bath temperature kept is • 40°C • 43°C • 45°C • 37°C

47. THANK YOU