1.0 General Considerations 1. Replacing teeth with: (a) FDP (b) RPD (c) CD (d) Implant supported 2.

MM relationships, interocclusal records, anterior guidance 3. Diagnostic impressions and casts 4. Articulators 5. Restorative implantology

(c) Custom incisal guide table i. Made of acrylic resin reproduce surfaces that directly influence excursive movements 1. Mainly: lingual concavity and incisal edges of anterior

Diagnostic Impression and Trays

1. IH/alginate: for diagnostic casts (a) Composition i. Mainly sodium/potassium salts of alginic acid ii. React with calcium sulfate insoluble calcium alginate iii. Diatomaceous earth for strength (b) Greater bulk = more favorable SA:volume ratio i. Lower susceptibility to water loss/gain better stability (c) Technique i. Use tray adhesives prevent distortion at removal ii. Remove 2-3 minutes after gelation iii. Rinse/disinfected with glutaraldehyde/iodophore iv. Pour with type 4/5 stone within 15 minutes 1. Allow stone to set 30-60 minutes 2. Store poured impression in humidor : prevent less IH distortion maximize strength and surface detail

REPLACING TEETH WITH

1. FDP (a) Poor prognosis: i. Abutment <1/2 bone support and attachment loss ii. Single retainer cantilever (b) Compromising prognosis i. Multiple-splinted abutment teeth, nonrigid connectors, intermediate abutments (c) Rigid fixed retainers should be at each end of pontic i. Except for cantilever (d) Splinting teeth: to distribute occlusal force i. Used when abutment does not have enough SA to support another prosthesis (FDP/RPD) ii. Splinting central and lateral is needed when replacing maxillary/mandibular canine prevent FPD drift (e) Abutments i. Do not use wakened RCT teeth for abutment ii. Must align to common POI iii. Avoid RTC < 1:2 with conical roots iv. Canines and molars > incisors and premolar respectively v. RA should be tooth replaced (f) Occlusal forces i. Avoid occlusal forces that may cause drift/tooth mobility ii. Natural teeth exert more force than RPD/complete on FPD 2. RPD (a) Distal extension (b) Span of teeth replaced is too much load for abutment (c) Bone loss with questionable prognosis (d) Cost 3. Complete (a) When implant cant be used. (b) Contraindicated when only mandibular anterior teeth present i. Damage to premaxilla

Articulators
1. Nonadjustable (a) NOT full range of mandibular motion (b) Arc of closure: distance between hinge and teeth i. Significantly shorter than patient (c) Cause premature contacts and incorrect ridge and groove direction 2. Semi-adjustable (a) General i. Most allow adjustments in condylar inclination, lateral translation, Bennett angle (side shift), anterior guidance and intercondylar distance (b) Arcon i. Condyles on lower member ii. Mechanical Fossa on upper member 1. Fixed relative to maxillary occlusal plane more accurate for fabricating fixed restoration (c) Nonarcon i. Upper and lower members rigidly fixed ii. Occl. plane relatively fixed to occlusal plane of mandibular cast iii. Easier control in setting complete/partial denture teeth (d) Facebow i. Arbitrary facebow record orient cast position in articulator based on average anatomic values ii. Kinematic facebow :more accurate than arbitrary 1. Placed on hinge axis which has been determined before 2. Especially needed when altering VD or interocclusal record is placed at another VD position 3. Fully Adjustable (a) Set to follow patients border movements (b) Used to treat complex mandibular cases: occlusal rehabilitation (c) Mandibular movement tracing/records used to set articulator i. Terminal hinge axis and pantograph used. (d) Can be adjusted to repeat condylar inclination, Bennett angle, immediate side shift, rotating condylar movement and intercondylar distance (e) Use kinematic facebow Restorative Implantology 1. Implant Material (a) Subperiosteal, transostial and endosteal i. Endosteal (root/cylinder, blades form implants) most common (b) Most made of Ti/Ti alloy with or without hydroxyapatite coating i. Highest biofunctionality (c) Threaded vs nonthreaded (d) Grit-blasted/acid-etched: rough surface increase SA 2. Treatment planning (a) Indications i. Inability to wear RPD/CD ii. Multiple teeth missing and long span FPD contraindicated iii. Unfavorable number and location of abutments iv. Single tooth replacemet that would need preparing an unrestored / minimally restored teeth (b) Contraindications

MMR/Interocclusal Records and Anterior Guidance

1. CR (a) Terminal hinge (b) When condyle articulate with thinnest avascular portion of discs (c) Condyle-disc complex in anterior-superior position against articular eminence (d) Casts often mounted in CR to i. When VD is altered/ interocclusal record is being changed. ii. Perform occlusal analysis 1. Determine if occlusal corrections is needed before protho iii. When MI not possible to maintain 1. Multiple teeth to restore (e) Manipulating into CR i. Bimanual manipulation ii. Anterior deprogramming: leaf gauge/acrylic resin jig (Lucia jig) 1. Keep teeth apart, deprogram proprioceptive reflexes 2. MI/CO (a) 90% of people = CR and CO is not the same (b) Interocclusal records: use wax (Alluwax) and fast-setting elastomers (PVS/PE) i. Casts from irreversible hydrocolloid: mounted more accurately with wax records ii. Casts from elastomeric material: mounted more accurate with Zinc and eugenol paste 3. Anterior Guidance (a) Must be preserved, especially when changing surfaces of teeth that guide in excursive movements (b) Mechanical anterior guide table i. Limited adjustments -> insufficient info for reproduction ii. Mainly used for complete dentures and occlusal appliances

i. Acute/terminal illness ii. Pregnancy iii. Uncontrolled metabolic disease iv. Unrealistic patient expectation/improper motivation v. Inability to restore with prosthesis (c) Clinical and radiographic evaluation i. Detect flabby tissues, sharp ridges, undercuts, width of bone ii. Panoramic is best for initial view to find bone height and nerve iii. Cephalometric: determine anterior maxillary and mandibular widths iv. CT: more accurate info of anatomical landmarks 1. Higher radiation, and expensive (d) Preimplant preparation i. Diagnostic cast to determine: 1. Maxillomandibular relationships 2. Interocclusal space 3. Existing dentition 4. Implant site placement using diagnostic wax-up 5. Construct surgical templates 3. Implant placement (a) Principles for placement i. Should be entirely in bone ii. Should engage 2 cortical plates of bone (ideal) iii. Must be 3 mm apart from each implant, 1 mm from adjacent tooth iv. Restorative needs dictate possible implant selection v. Recommended in edentulous elderly: 1. 2 in mandible 2. 4 in maxilla (b) Implant supported restorations i. Support screw- or cement-retained restorations ii. Stages 1. One stage: project through soft tissue with cover screw 2. Two stage:, cover screw placed then covered with tissue, uncovered later by second operation iii. Healing time before impression: 1. 2 weeks in noncritical esthetic area 2. 3-5 weeks in esthetic iv. Abutment size and angulation depends on: 1. Interocclusal distance available 2. Implant long axis position 3. Orientation of multiple implants 4. Type of implant-supported prosthesis v. Over denture (acrylic resin and metal framework) 1. Indicated when soft tissue and teeth are replaced with prosthesis supported by implants 2. Minimum 5 in mandible 3. Minimum 6 in maxilla (c) Guidelines for implant-supported prosthesis i. Do not attach implant to natural teeth ii. 2 implants can support a 3 unit FPD if crown to implant ratio is good iii. If implant are short and crown is long do one implant for each teeth iv. If retaining prosthesis by implants and natural teeth protect teeth with telescopic copings v. Single implant attached to natural tooth stress concentrated at superior portion of implant (d) Cement-retained implant crown i. More economical ii. Allows minor angle corrections to compensate for discrepancies between implant inclination and facial crown contour iii. Easier to use in small teeth than screw retained iv. More chair time, same chance to loosen (e) Screw-retained implant crown i. Retrievable crown: better cleaning and evaluation ii. Can perform modification in future iii. Access hole is thorugh occlusal table of posterior teeth or lingual of anterior iv. Main disadvantages Loosen screw from 1. excessive lateral force 2. Excessive cantilvever force 3. Improperly screwed crowns (f) Occlusion i. Lateral forces posteriorly are more destructive than anteriorly ii. Sharper cusp inclines and wider occlusal talbes increase force on implant components