EXAMINATION AND EVALUATION OF DIAGNOSTIC DATA: THE SECOND DIAGNOSTIC APPOINTMENT

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• 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 Georges Medical University, Lucknow

GOOD MORNING
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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

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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

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Centric relation record

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

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Centric relation record Using wax

• We can also use elastomeric registration
  materials (wax tends to change dimension over
  time and can become brittle)

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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.

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Setting condylar elements

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

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Setting condylar elements
Too steep
Too shallow
The condylar setting is
Correct inclination
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Extra-0ral examination

• Facial form and symmetry, jaw opening and closing
  movements, palpation of TMJ and muscles of
  mastication.

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Definitive Oral Examination Caries and existing
restorations

• Carious lesions
• surface restorations
• cast restorations
• crowns
• Margins of cast restorations.
• Possible extractions.

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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.

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Definitive Oral Examination sensitivity to
percussion

• Unstable occlusion
• Tooth in traumatic occlusion
• PA abscess
• Acute pulpitis
• Cracked tooth syndrome

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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
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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.

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Definitive Oral Examination Periodontium

• Need for periodontal treatment
• Pocket depthgt3mm
• Furcation involvement
• Gingivitis, ginigival cleft, festooning
• Marginal exudate
• Proposed abutment teeth exhibiting lt 2mm attached
  gingiva width

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Definitive Oral ExaminationOral 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

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

• Hard tissues abnormalities
• Torus palatinus mandibularis
• Exostoses
• undercuts.

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Definitive Oral Examination

• Soft tissues abnormalities
• Labial frenum
• Unsupported and hypermobile gingiva
• Space for mandibular major connector 8mm space
  for lingual bar

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Definitive Oral Examination

• Radiographic evaluation of prospective abutments
• Root length, size and form
• Crown-root ratio
• Lamina dura
• Periodontal ligament space

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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

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Evaluation of mounted diagnostic casts

• Tipped or malposed teeth
• Occlusion
• Role of occlusal equilibration

Interferences need to be corrected
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Evaluation of mounted diagnostic casts

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

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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.

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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.

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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.

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Finally.

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

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Development of Treatment plan

• How do I develop a Treatment Plan????

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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).

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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).

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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 .

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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.

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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.

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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.

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• Partial dentures- OSBORNE LAMMIE, 5th edition.
• Dental implant prosthetics- CARL E MISCH
• JPD, Vol. 11, No. 3, 2002pp 181-93
• JPD, 16, 1966 533-39
• DCNA- Vol.34. No.4,1990607-09
• JPD, october,1973 526-32

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• 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

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• 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

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• 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

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• Q3. Beyrons 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

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• 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

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• 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

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• 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

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• 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

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• 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

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• 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

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

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THANK YOU