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PREPARATION OF MOUTH FOR REMOVABLEPARTIAL DENTURES 231Oral surgical preparation,231 Extractions,232 Removal of residual roots,232 Impacted teeth,233 Malposed teeth,233 Cysts and odontogenic tumors,233 Exostoses and tori,233 Hyperplastic tissue,234 Muscle attachments and frena,234 Bony spines and knife-edge ridges,235 Polyps, papillomas, and traumatic hemangiomas,235 Hyperkeratoses, erythroplasia, and ulcerations,235 Dentofacial deformity,235 Osseointegrated devices,236 Augmentation of alveolar bone,237 Conditioning of abused and irritated tissue,238 Use of tissue conditioning materials,239 Periodontal preparation,241 Objectives of periodontal therapy,241 Periodontal diagnosis and treatmentplanning,241 Initial disease control therapy (phase 1),243 Definitive periodontal surgery (phase 2),246 Recall maintenance (phase 3),248 Advantages of periodontal therapy,248 Abutment teeth preparation,249 Abutment restorations,249 Contouring wax patterns,250 Rest seats,250 Self-assessment aids

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Mouth Preparations
Mouth Preparations Include Procedures in Three Categories1. Oral surgical preparations 2. Periodontal preparations 3. Reshaping of teeth

OBJECTIVE To Return the Mouth to Optimal Health and To Eliminate Any Condition That Would Be Detrimental To the Success of Partial Denture

GENERAL GUIDELINES It must be accomplished before impression procedures for master cast on which denture is to be constructed. Oral surgical & periodontal procedures should precede abutment preparations to allow healing period. There should be atleast 6 weeks, preferably 3 months between surgical and restorative procedures. ORAL SURGICAL PROCEDURES Longer is the time interval between the surgery & impression procedure, more complete is the healing - more stable will be the denture bearing area. Various Conditions Requiring Oro-surgical Intervention

91 Badly decayed non-strategic teeth. Residual roots. Impacted teeth Malposed teeth Cysts & odontogenic tumors exostoses & tori Hyperplastic tissue Interfering muscle attachments & freni Bony spicules & knife edge ridges. Polyps, papillomas, & traumatic hemangiomas. Hyperkeratosis, erythroplasia & ulcerations

Extractions Regardless of its condition each tooth must be evaluated for its strategic importance. No heroic attempts should be made to salvage a seriously involved tooth, which would contribute little to success of RPD. Extraction of non-strategic teeth that are detrimental to the design of RPD is a necessary part of the over all treatment plan.

Residual Roots Generally retained roots or fragments should be removed (esp.

if there is evidence of pathology). Residual roots adjacent to abutment teeth can cause progression of periodontal pockets. Removal is

accomplished from facial or palatal surfaces to preserve ridge height.

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Impacted Teeth All impacted teeth are considered for removal. Periodontal implications of the impacted teeth are similar to that of retained roots. Skeletal structure of body changes frequently. Alterations that affect bony structure of jaws can minute exposure of impacted teeth to oral cavity via sinus tracts. This can cause serious infections & bone destruction. Malposed Teeth Loss of teeth may lead to extrusion, mesial drifting of remaining teeth. Alveolar bone supporting extruded teeth is also carried occlusally. Orthodontics may be helpful in realigning these teeth. Otherwise surgical correction can be done for teeth & the supporting alveolar bone.

Cysts & Odontogenic Tumors Panoramic radiographs must be taken to detect any unsuspected pathology. IOPA should be taken for any suspicious area seen in OPG. The diagnosis must be confirmed through consultation & if necessary biopsy specimen should be submitted to the pathologist.

Exostoses & Tori Exostoses or tori should not be allowed to compromise the design of the RPD. Modifications may accommodate exostoses but result in additional stress to the supporting elements & a compromised

93 function. Mucosa covering these is usually thin & liable to ulcerate. Exostoses approximating gingival margins complicate maintenance of periodontal health and strategic abutment may be lost eventually. Removal of exostoses & tori not a complicated procedure and advantages from their removal are numerous in contrast to the deleterious effect their presence can create.

Hyperplastic Tissue Hyperplastic tissue is seen in the form of fibrous tuberosities, soft flabby ridges, folds of redundant tissues in vestibule or floor of mouth. All these should be removed to provide a firm base for denture. Stable denture reduces stress & strain on supporting teeth & tissues. Hyperplastic tissue can be removed with scalpel, curette, electrosurgery, laser or a combination of these procedures. Care should be taken so that surgical approaches do not reduce vestibular depth. Surgical stents often helpful during the healing phase in such patients. An old denture properly modified can be used as surgical stent. Excised tissue should be sent to oral pathologist for microscopic study.

Muscle Attachments & Freni As a loss of alveolar bone height, muscle attachments may come to lie near the alveolar crest. Mylohyoid, buccinator, mentalis & genioglossus are common in this regard. In addition to that mentalis &

94 genioglossus produce bony protuberances at their attachment

occasionally. Appropriate ridge extension procedures can reposition attachments Genioglossus is difficult to reposition but careful surgery reduces the prominence of genial tubercles & it also increases sulcus depth in anterior lingual area. Skin & mucosal grafts are now common rather than secondary epithelialization for facial aspect of mandible. Palate is often the donor site for mucosal grafts, although skin can be used for larger areas.

Maxillary labial & mandibular lingual freni most commonly interfere with denture design. They can be easily modified using surgical procedures. Freni should never compromise the design & comfort of RPD.

Bony Spines & Knife Edge Ridges Bony spicules should be removed & knife edge ridges gently rounded. Procedures are to be carried out with minimum bone loss. If insufficient ridge support results with correction of knife-edge ridges, vestibuloplasty should be resorted to.

Polyps, Papillomas All abnormal soft tissue lesions should be excised & submitted for pathological examination. Even if patient presents a history for an

95 indefinite period, its removal is indicated. Additional stimulation to area by prosthesis may produce discomfort or malignant changes.

Hyperkeratosis, Erythroplasia & Ulcerations All abnormal white, red, or ulcerative lesions are to be

investigated regardless of their relationship to proposed denture. Incisional biopsies of areas larger than 5mm and multiple biopsies for regions over 2cm should be taken. Biopsy report determines whether wide or narrow margins are to be excised. Occasionally partial denture design has to be radically modified to avoid areas of possible sensitivity, such as after irradiation for malignancy.

PERIODONTAL PREPARATION The periodontal preparation of the mouth usually follows, or is performed simultaneously with, the oral surgical procedure. Periodontal therapy should be completed before restorative dentistry procedures are begun for any dental patient. The periodontal health of the remaining teeth then, especially those to be used as abutment teeth, must be evaluated carefully by the dentist and corrective measures instituted before partial denture fabrication.

96 Objectives of Periodontal Therapy The objective of periodontal therapy is the return to health of the supporting structures of the teeth, creating an environment in which the periodontium may be maintained. The specific criteria for satisfying these objectives are as follows: Removal of all etiologic factors contributing to periodontal disease. Elimination or reductions of all pockets with the establishment of gingival sulci free of gingival inflammation. Establishment of functional occlusal relationships. Development of a personalized plaque control program and definitive

maintenance schedule.

Periodontal diagnosis and treatment planning diagnosis

The diagnosis of periodontal diseases is based on a systematic and carefully accomplished examination of the periodontium. It follows the procurement of the health history.

In the examination procedure, nothing is as important as the careful exploration of the gingival sulcus and recording of the probing pocket depth with a suitably designed instrument. The probe is inserted gently but firmly between the gingival margin and the tooth surface, and the depth of the sulcus is determined circumferentially around each tooth. Usually depths are recorded for the distobuccal mesial,

97 mesiobuccal, distolingual, lingual and mesiolingual aspects of each tooth. A critical assessment of sulcular health, by judging the amount of bleeding produced on probing, is considered an important indication of sulcus condition and, along with pocket depth, is an excellent indicator of health and disease.

The extent and pattern of bone loss can be estimated from radiographs, and this information serves to substantiate the impression gained from the clinical examination. Each tooth should be evaluated carefully for mobility. If the etiologic factor can be removed, many mobile teeth will become stable and can be used successfully to help support and retain the partial denture. Mobility is an indication of the condition of the supporting structures and is caused by inflammatory changes in the periodontal ligament, traumatic occlusion, or loss of attachment. Most often it is a result of a combination of the three. A mobile tooth can be useful if the causes of mobility can be corrected.

Treatment Planning Depending on the extent and severity of the periodontal changes present, a variety of therapeutic procedures ranging from simple to relatively complex may be indicated. The first phase is considered disease control or initial therapy because the objective is to essentially eliminate or reduce local etiologic factors before any periodontal

98 surgical procedures are accomplished. Procedures that are accomplished as part of the initial preparation phase include oral hygiene instruction, scaling, and root planning and polishing, as well as endodontics, occlusal adjustment, and temporary splinting, if indicated.

During the second, or periodontal surgical phase any needed periodontal surgery, for example, free gingival grafts, osseous grafts, or pocket reduction, is accomplished. The maintenance of periodontal health is accomplished in phase 3 and is ongoing. schedule at 3 to 4 months is essential. A definitive recall

Initial Disease Control Therapy (Phase I) The patient should be instructed in the use of disclosing wafers, soft nylon toothbrush, and unwaxed dental floss. At subsequent

appointments oral hygiene can be evaluated carefully, & other oral hygiene aids added, such as a rubber tip stimulator. Without good oral hygiene any dental procedure, regardless of how well it is performed, is ultimately doomed to failure.

Scaling and Root Planning Scaling and root planning are fundamental to performing surgical periodontal procedure. The use of ultrasonic instrumentation for gross calculus removal followed by root planning with sharp periodontal curettes is recommended. The curette is designed specifically for root

99 planning and, when used correctly in combination with ultrasonic instrumentation, will result in calculus removal and root surface decontamination.

Elimination of local irritating factors other than calculus Overhanging margins of amalgam alloy and inlay restorations, overhanging crown margins, and open contacts leading to food impaction should be corrected before definitive prosthetic treatment is started. Although periodontal health predisposes to a much better environment for restorative procedures, it is not always possible or prudent to delay all restorative procedures until complete periodontal therapy and healing have occurred. This is especially true for patients with deep-seated carious lesions, for whom pulpal exposures are a possibility. Excavation of these areas and placement of adequate restorations must be

incorporated early in treatment. The placement of temporary fillings must not, in itself become a local etiologic factor.

Elimination of Gross Occlusal Interferences Bacterial plaque accumulations and calculus deposits are the primary factors involved in the initiation and progression of

inflammatory periodontal disease. However, poor restorative dentistry can contribute to damage to the periodontium, and poor occlusal relationship may act as another factor that contributes to more rapid loss

100 of periodontal attachment. Selective grinding procedure is generally

applied at this stage. Traumatic cuspal interferences are removed by judicious grinding procedures. Deflective contacts in the centric path of closure are removed, eliminating mandibular displacement from the closing pattern. The indication for occlusal adjustment is based on the presence of pathology rather than on a preconceived articulation pattern. Occlusion on natural teeth needs to be perfected only to a point at which cuspal interference within the patients functional range of contact is eliminated and normal physiologic function can occur.

Guide to Occlusal Adjustment Accurately mounted diagnostic casts are extremely helpful in determining static cusp to fossa contacts of opposing teeth and as guide in the correction of occlusion anomalies. a) A static coordinated occlusal contact of the maximum number of teeth when the mandible is in centric relation to the maxillae should be the first objective. The procedure is as follows:b) A prematurely contacting cusp should be reduced only if the cusp point is in premature contact in both centric and eccentric relations. If a cusp point is in premature contact in centric

relation only, the opposing sulcus should be deepened.

101 c) When anterior teeth are in premature contact in centric relations, or in both centric and eccentric relations, corrections should be made by grinding the incisal edge of the lower teeth. d) Usually, premature contacts in centric relation are relieved by grinding the buccal cusps of the lower teeth, the lingual cusp of upper teeth, and the incisal edges of the lower anterior teeth. Deepening the sulcus of the posterior tooth or the lingual contact area in centric relation of an upper anterior tooth changes and increases the steepness of the eccentric guiding inclines of the tooth; although this relieves trauma in centric relation, it may predispose the tooth to trauma in eccentric relations.

After establishing a static, even distribution of stress over the maximum number of teeth in centric relation, evaluate opposing tooth contact or lack of contact in eccentric functional relations. First balancing side contacts are seen. Subluxation, pain, lack of normal functional movement of the joint, or loss of alveolar support of the teeth involved may be evidence of excessive balancing contacts. Balancing

side contacts receive less frictional wear than working side contacts, and premature contacts may develop progressively with wear. A reduction in the steepness of the guiding tooth inclines on the working side will increase the proximity of the teeth on the balancing side and may contribute to destructive prematurities. In all corrective grinding

102 to relieve premature or excessive contacts in eccentric relations, care must be exercised to avoid the loss of a static supporting contact in centric relation. This static support in centric relation may exist

between the lower buccal cusp fitting into the central fossae of the upper tooth or between the upper lingual cusp fitting into the central fossae of the lower tooth or may exist in both cases. Often only one of these cusps has this static contact. In such instances the contacting cusp must be left untouched to maintain this essential support in the planned intercuspal position, and all corrective grinding to relieve premature contacts in eccentric positions would be done on the opposing tooth inclines. The lower buccal cusp is in a static central contact in the

upper sulcus more often than the upper lingual cusp is in a static contact in its opposing lower sulcus.

1. To obtain maximum function and the distribution of functional stress in eccentric positions on the working side, necessary grinding must be done on the lingual surfaces of the upper anterior teeth. Corrective grinding on the posterior teeth at this time should always be done on the buccal cusp of the upper premolars and molars and on the lingual cusp of the lower premolars and molars. The grinding of lower buccal cusps or

upper lingual cusps at this time would rob these cusps of their static contact in the opposing central sulci in centric relation.

103 2. Corrective grinding to relieve premature protrusive contacts of one or more anterior teeth should be accomplished by grinding the lingual surface of the upper anterior teeth. Anterior teeth should never be ground to bring the posterior teeth into contact in either protrusive position or on the balancing side. In the elimination of premature protrusive contacts of posterior teeth, neither the upper lingual cusps nor the lower buccal cusps should be ground. Corrective grinding should be done on the surface of the opposing teeth on which these cusps function in the eccentric position, leaving the centric contact undisturbed.

3. Any sharp edges left by grinding should be rounded off.

Periodontal Surgery Phase 2 It is a definitive periodontal surgery phase. If oral hygiene is optimal, yet pockets with inflammation and osseous defect are present, various surgical techniques like gingivectomy, periodontal flap should be considered to improve periodontal health.

Gingivectomy Gingivectomy is indicated when there are supra bony pockets of fibrotic tissue, absence of deformities in the underlying bony tissue & pocket depth confined to attached gingiva. If osseous deformities are

104 present or if pocket depth traverses mucogingival junction gingivectomy is not the treatment of choice.

Periodontal Flap The flap is widely employed for the treatment of periodontal diseases. It may be used to gain access for root planing, osseous recontouring for pocket elimination or crown lengthening and also for osseous grafts.

Maintenance Phase This is phase 3 of the periodontal procedures. It includes reinforcement of plaque control measures, thorough debridement of root surfaces of subgingival & supra gingival plaque. Frequency of recall is according to patients requirements. In moderate to severe periodontitis, 3-4 months recall system is followed.

RESHAPING THE TEETH Reshaping the teeth includes Enameloplasty Inlays, Onlays & Crowns

Preparation of rest seats.

Enameloplasty

105 In enameloplasty conservatism is the rule. But sufficient reduction must be done to ensure adequate space. Preparations can first be made on diagnostic cast to reveal the need for crowns or inlays. After reshaping polishing with carborundum impregnated rubber wheel is essential. It is used to develop guiding planes, change the height of contour & modify retentive undercuts.

Enameloplasty to Develop Guiding Planes Guiding planes are the surfaces on the proximal or lingual surfaces of the teeth parallel to each other & more importantly to the path of insertion of RPD. Guiding planes are made on abutment teeth1. Adjacent to tooth supported segments 2. Adjacent to distal extension edentulous space 3. on lingual surface 4. In anterior segment

Adjacent To Tooth Supported Segments Diagnostic cast, mounted on the surveying table, at the determined tilt, is placed on the bracket table on the patients chair. It is used to determine the relationship of hand piece to the tooth in patients mouth. Guiding plane is always parallel to the path of insertion. Cylindrical diamond is commonly used for creating the guiding plane. Gentle, light, sweeping strokes from buccal to lingual line angles are to

106 be used. Normally 5-6 strokes are sufficient. It is a flat surface 2-4 mm occlusogingivally. Reduction should follow the curvature of the tooth. All prepared surfaces be polished with carborundum impregnated rubber wheel.

Adjacent To Distal Extension Spaces It is similar to that done for abutment teeth adjacent to tooth supported segments. But the occluso-gingival plane of reduction is kept 1.5 to 2mm. This is done to allow slight rotation around the distal occlusal rest, which avoids torquing forces on distal abutment tooth.

On Lingual Surfaces The purpose of developing the guiding planes on the lingual surface of teeth is to provide maximum resistance to lateral stresses. More are the number of teeth used; less is the stress on an individual tooth. The occluso gingival height 2- 4 mm. The plane should be located in the middle third of the crown. Gingival 3rd contour of the tooth shouldnt be changed as it can cause damage to the marginal gingiva.

On Anterior Abutment Teeth PurposeProvide parallelism for stabilization. Minimize wedging action between teeth. Minimize undesirable space between denture & abutment teeth. Increase retention through frictional resistance.

107 Restore normal width of edentulous space

Enameloplasty to Change Height of Contour Maxillary molars & premolars, if unsupported, tip buccally causing height of contour to be located near the occlusal surfaces. As a result the retentive arm position becomes esthetically compromised. It also causes more leverage on the abutment tooth. Whereas mandibular molars & premolars if unsupported tip lingually. This causes difficulty in placement of reciprocal arm and/ or lingual plate. If tipping is severe then major connector placement may be hindered. Usually this can be accomplished by using a tapered diamond stone.

Enameloplasty to Modify Retentive Undercuts It is used to increase a less than adequate retentive undercut only if the oral hygiene of the patient is good & caries index is low. But this should not be substituted for adequate design procedures.

For the procedure to be successful, the buccal and lingual surfaces should be nearly vertical. If surface to receive undercut is sloped, indentation has to be excessively deep. If opposing surface is sloped, the reciprocal clasp arm cannot prevent retentive clasp tip from dislodging. Retentive undercut -in the form of a gentle depression. Create slight concavity (0.010 inch deep, 4mm MD, 2mm OG), parallel

108 to gingival margin without encroaching it. A round end tapered diamond held parallel to gingival margin is used to create a gentle depression. Inlays Onlays and Crowns If the remaining teeth do not possess usable natural contours and enamel surfaces cannot be corrected to produce them, cast restorations must be planned. Guiding planes, height of contour and retentive undercuts can be placed in the wax patterns for the cast restorations. Also many abutment teeth will require restorations for more routine reasons such as caries, endodontic therapy etc.

Shaping the Wax Pattern The die of the tooth preparation in the cast of the remainder arch is analyzed on the surveyor. Working cast is mounted at the same tilt as the diagnostic cast. Once correct tilt is established substitute analyzing rod with wax knife and carve guiding plane by shaving the wax. Pattern must be hand carved to place height of contour at the junction of gingival and middle third for retentive clasp. Refining can be done in cast restoration.

Occlusion Rest Seat Preparation Functions-

109 Direct forces of mastication parallel to long axis. Prevent gingival displacement of denture. Maintain the clasp in proper position. Function as indirect retainer in distal extension partial denture. Occlusal Rest Seat in Enamel Form Triangular in outline with base at marginal ridge and apex pointing towards the centre of the tooth. Should follow outline of mesial or distal fossa. Minimum 0.5mm at thinnest point, 1-1.5mm at marginal ridge.

Extension 1/3rd to 1/2 of mesiodistal diameter. 1/2 of the distance between buccal and lingual cusp tips.

Floor Inclined towards the centre. Spoon shaped. Enclosed angle with the proximal surface less than 90.

Preparation Round diamond stone approximating no.4 round carbide bur to be used for preparation. Create an outline using small round diamond stone.

110 The island of enamel within the outline can than be removed with the same bur. Deepest portion of the rest seat is towards the centre of the tooth. Verify preparation by red beading wax. Polish the preparation

using no.4 round steel bur revolving in reverse at moderate speed. Occlusal Rest Seat in New Gold Restoration It should always be placed in wax patterns. Sufficient occlusal clearance must be given to permit proper dimensions of rest seat. A depression can be added to the preparation to accommodate rest seat. Rest seat in wax pattern is prepared by using no.4 round steel bur.

In Existing Gold Restoration Patient must be warned of the possibility of the need to replace the restoration. If restoration has marginal integrity and occlusal harmony, attempt can be made to contour a rest seat in it.

Rest Seat Preparation on Anterior Teeth Lingual / Cingulum Rest Canine is preferred over incisor. If canineis missing multiple rest on incisor teeth are used. Lingual rest seat is preferred over incisal rest. Usually it is prepared in a cast restoration. Outline Form -

111 Half moon shaped forming smooth curve from one marginal ridge to other. Should cross the centre of tooth incisally to cingulum. The rest seat itself is V shaped. The labial incline of lingual surface makes one wall. Other wall starts of cingulum and inclines labio-gingivally towards the centre of tooth. If a cast restoration is to be given, the rest seat should be carved in the wax pattern and not cut in cast restoration Lingual Rest Seat in Enamel Lingual rest seat may be prepared in the tooth if tooth is sound, good oral hygiene is present & caries index is low. Prominent cingulum is another essential requirement. This is usually not present in mandibular canines. Preparation A. Sufficient Space AvailableSafe side th inch diamond disk can be used. It must be held parallel to path of insertion. Start low on one marginal ridge, pass over the cingulum, and then pass gingivally to contact the other marginal ridge. B. Sufficient Space Not Available Often the presence of the lateral incisor or first pre molar will preclude use of safe sided disk. In these cases use flat end large

112 diamond cylinder inclined slightly gingivally from horizontal for the preparation. Flat end does the cutting. The rest seat must be gingival to the contact level of opposing tooth. Polish the preparation with carborundum impregnated rubber wheel.

Incisal Rest Seat Preparation Should only be used on enamel surfaces. Least desirable for anterior teeth. Can be used successfully if abutment tooth is sound. Usually placed near one of the incisal angles of the canine. If used in conjunction with circumferential clasp distal incisal angle should be used. If vertical projection / bar clasp, employing distal buccal undercut for retention is used, mesial incisal rest be used for reciprocation.

Preparation Small safe side diamond disk or knife-edge stone is used. Disk / stone is kept parallel to path of insertion. First cut made vertically 1.5-2mm deep in the form of notch and 2-3mm inside of the proximal angle of the tooth. Small flame shaped diamond point is used to rounden the notch. Enamel proximal to notch is slightly reduced.

113 The groove must be carried slightly over to labial surface to prevent facial tipping. Groove should be continued part way down the lingual surface as indentation to accommodate minor connector. All sharp angles be rounded and preparation polished with carborundum impregnated rubber wheel.

REFERENCES Stewart KL, Rudd KD and Kuebker WA: Clinical removable partial prosthodontics, ed. 2, St Louis, 1997, Ishiyaku EuroAmerica, Inc.

McGivney GP and Castleberry DJ: McCraken removable partial prosthodontics, ed. 9, St Louis, 1995, Mosby.

Davenport JC, Basker RM, Heath JR, Ralph JP: A colour atlas of removable partial dentures, 1989, London, Wolfe Medical Publications Ltd.