Prostho Sheet #14 PDF

14 Abdullah Alrawashdeh Asma’a Abu-Qtaish Rasha Alomoush 1|Page  Denture Insertion After the Flasking, packing and curing are finished in the lab, the final denture is ready to be inserted in the patient’s mouth. It’s delivered in...

14 Abdullah Alrawashdeh Asma’a Abu-Qtaish Rasha Alomoush 1|Page  Denture Insertion After the Flasking, packing and curing are finished in the lab, the final denture is ready to be inserted in the patient’s mouth. It’s delivered in a sealed plastic bag with tap water. During denture insertion you must: A- Evaluation of the denture outside patient's mouth. B- Evaluation of the denture inside the patient’s mouth. C- Evaluation for occlusion. D- Instruction to patient receiving dentures. → Denture Evaluation: 1- Dentist’s evaluation 2- Patient’s evaluation 3- Friends’ evaluation Note that before denture insertion the patient should keep his old denture out of his mouth for 12-24 hours. Usually, you would notice some errors in the complete denture, sources of those errors: 1. Errors made by the dentist. 2. Errors made at the laboratory. 3. Inherent deficiencies in the materials. 4. Biological factors. ❖ Prior to the Appointment ✓ Extraoral examination - Inspect for spicules with gauze. - Smooth any sharp areas. - Blend angular changes on periphery with the art portion of denture, because this area can be very traumatic to the patient, so it must be smoothened and blended with other peripheries. - Inspect posterior border (post dam area): (2-3 mm thick) and gradually tapers to the soft palate. 2|Page ❖ Order of Adjustments Check and Adjust: 1. Base Fit with PIP (pressure indicating paste). 2. Peripheries with PIP (one side at a time). 3. Occlusion with Articulating Paper and sometimes we may need to do a Clinical Remount. 4. Esthetics, phonetics, patient concerns. ❖ Insert Maxillary Denture First First ask the patient about comfort, then identify potential areas for adjustment and check resistance to seating. Also, we must check adaptation of the denture base through: Remove a small amount of pressure indicating paste (PIP), place it on a mixing pad and reseal the jar to avoid contamination. Dry the denture, place a thin coat on the tissue surface with a stiff brush and leave streaks in paste. We could also use disclosing wax to detect any errors such as overextension on the periphery. Prior to placement, ensure damp mucosa spray surface of PIP with air/water syringe. Seat denture firmly, don’t contact lips/ridge when inserting. Remove from oral cavity by breaking seal with finger pushing up into height of vestibule. ▪ Reading PIP - Burn through (No paste left): Excessive pressure that should be relieved. - Streaks remaining: No tissue contact, and other areas need to be relieved. - Paste remaining with no streaks: Acceptable contact. - Relieve pressure spots - large acrylic burs. - Take care with undercuts, look like burn through but may not require adjustment. 3|Page You must use care in retentive areas like hamular notch and tuberosity undercuts, don’t trim those areas. Repeat until the denture is fully seated with relatively uniform contact, minimal streaks and no gross burn through. Check for Peripheral Overextensions: Seat denture & border mold. Flanges should fill vestibule but not be dislodged by manipulation. If denture dislodges, use PIP to adjust. ▪ Peripheries Border mold, adjust, check again and adjust high spots or facets. Please pay attention to frenal areas, because there are no sufficient opening for frenai. ▪ Use PIP to Check Contours Root prominences Thick peripheries ▪ Alter Phonetic Remove paste with gauze, cotton rolls, brushes or alcohol for stubborn areas. Rinse and replace denture. Thick palatal, esp. Anteriorly, can affect the phonetics 4|Page ▪ Check for retention As overextension can decrease the retention Pull outward & upward on lingual of canines o Non-retentive denture features: No palatal contact, the flange in the 1st quadrant is short, and there is no peripheral seal. o Evaluate the retention & stability. ▪ Adjust posterior overextensions using an indelible marker If we have posterior overextension we must correct it by identifying part of the vibrating line by using and indelible marker, and remove the overextension. → Now repeat for mandibular denture ❖ Occlusal analysis When we finished the fitting, peripheries, retention, and stability on both upper and lower dentures. It’s time to check the occlusion of the dentures, insert both dentures, Place a cotton roll between posterior teeth bilaterally. Patient bites forcefully for one minute simulating compression of tissues after the patient has worn the denture for a period. Place patient in centric relation, visually check the occlusion, stabilize mandibular denture and check with articulating paper. ✓ Anterior Open Bites or Unstable Posterior Contacts o Posterior denture base contacts, occlusal prematurities. o Use articulating paper to mark and to eliminate gross interferences prior to remount. ❖ Clinical Remount Not always required, especially when the errors are minor, and can be fixed chair side. However, if the errors are gross and the patient is not cooperative then it’s best to remount. 5|Page Remount on an articulator, allows extraoral occlusal adjustment and eliminates continual removal & replacement of dentures. Selective grinding is better to be done on the articulator because we don’t have: 1. Shifting of the denture bases. 2. Tissue distortion. 3. Eccentric closures by the patient. 4. Presence of saliva. 5. Lack of visibility. 6. Time consuming. 7. Psychological factor. Not all dentures require an occlusal remount. Master cast is destroyed during removal of the processed denture, so new remount casts without undercuts, so new recording are required. ❖ Remounting Maxillary Dentures Place remount jig on articulator, seat remount index on jig, seat maxillary denture in index, place remount cast into denture and mount with plaster. ❖ Record Centric Relation You have to record the relation between the upper and lower dentures in the patient mouth, by using small amount of bite registration material just cuspal indentations. Ensure no penetration of material, allow fully set and ensure the record is precise & repeatable. - Place low-fusing modeling compound (softened in a water bath at 110 F) on the occlusal surfaces of the mandibular denture. - Place the mandibular denture in the water bath for 10 seconds. - Place the lower denture with softened compound intraorally and have the patient close in CR just short of tooth contact. - Remove the CR record. 6|Page - Chill in cold water until it is hard and trim the excess with a scalpel so that only the cusp tip indentations remain. - Trim the buccal side so that the seating of the dentures can be visually checked. - The dentures and trimmed CR compound record are positioned together before reinsertion to recheck the accuracy of the record intraorally. ❖ Mount Mandibular Cast We mount it based on the interocclusal relation we recorded. Maxillary denture on remounted cast, interdigitate dentures and stabilize with sticky wax. Place cast in mandibular denture, invert articulator and attach mandibular model. → Make sure that: - There are no debris under dentures and verify centric position after mounting - Verify the protrusive record: Strip of Allu wax over all posterior teeth, patient occludes 4-6 mm in protrusion, chill the wax and set the condylar inclination similar to that taken previously. → For selective grinding: - Use articulating paper of minimal thickness (80 microns….8 microns). - You may start with a thicker one and then finish with a thinner one. - Ensure: No anterior contacts in CO - Uniform simultaneous, bilateral centric contacts - Smooth excursive movements → For balanced occlusion ensure that: - Balanced contacts are present - Balancing contacts not heavier than working contacts - Light grazing contacts of the anterior teeth in excursions - Intraorally verify that contacts are similar, and the occlusion feels comfortable to the patient, check vertical dimension: 2-4 mm of interocclusal distance at physiological rest position. ▪ Now check for phonetics: o ‘F’ sounds: maxillary incisors touch lower lip o ‘S’ sounds: incisors close together posterior teeth do not contact 7|Page Now Check Esthetics, ask the patient for their opinion. ❖ Polish Adjusted Areas Initial polish/minor adjustments: Brasseler Acrylic Polishing, Its recommended to polish the denture again, to ensure that food won't get stuck, and that it wouldn’t get discolored easily. Final Polish: Dazzle Paste mixed with water & liquid soap, Dampened felt cloth wheel (disposable, On lathe in lab. ✓ Provide Care Instructions (post insertion instructions) Mastication and speaking with the new dentures, Oral and denture hygiene instructions. Summary ❖ Denture base should be: - Retentive, does not displace with moderate vertical pressure - Proper flange extension - Indicating medium reveals no areas of significant impingement - No spicules and well-polished - Proper flange thickness (generally not > 4-5 mm, rolled not sharp) - Proper relief of frenula - Bases terminate at proper anatomical landmarks - Patient is comfortable ❖ The Occlusion must be: - Posterior teeth contact bilaterally & simultaneously, w/o shift - Degree of balance evident in centric and eccentric positions - Acceptable interocclusal space - Anterior teeth are not in contact in centric occlusion - Grazing contact in protrusion - Acceptable esthetics - Acceptable phonetics 8|Page ▪ Continuing Care: after we are done, we ask the patient to wear his denture for 24 hours then come back to the clinic, in our studies we will ask the patient to come back after a week. ❖ Post-Insertion Problems ▪ Principles of Diagnosing → Denture Problems o Never adjust unless you can see exactly where to adjust o Use indicator medium (PIP, indelible marker, articulating paper, etc.). o Patients frequently wrong in exactly locating source problem, so spend time, look and think. o Where? Dentist needs to locate (PIP, tip of instrument, indelible stick) o When? (Chewing only?) o How long? o Anything makes it better or worse? o Have patient demonstrate problem. → Usually we have a limited number of problems: - Denture base - Occlusion, Interferences - esp. protrusive - Retention - Vertical dimension - Allergies and infections→ less common - Tooth position 1.Denture Base - Impingements, spicules, sharp edges - Diagnosis - PIP (never adjust unless burn through) - Sore all time - If soreness worsens throughout the day may be occlusion, not denture base - May still be occlusal, if inflammation causes swelling 9|Page Place paste with streaks Streaks - no contact (N) No Paste - Impingement (I) Paste, no streaks - normal contact (C) 2.Occlusion - One of the most common problems - Pain gets worse through day - Difficult to determine, intraorally - reflex avoidance of pain interferences - especially in protrusive - Fingers on canines - should feel smooth - Sore when bite - Fit changes or comfort deteriorates through day---Remount 3. Retention Problems - Short flanges: PIP - still streaky - Fingers on canines outwards (post palatal seal) - If short flanges: Look for space. - May be retentive for a while if a lip seal established, until movements disturbs the lip seal. - Loss of post-palatal seal, If the denture is short of the vibrating line (check with PIP), the denture may bind on hard palate causing. - trauma and loss of retention - Inadequate tissue contact - Food gets underneath - Bubbles as denture is placed (check with PIP) - If over-extended to moveable soft palate, denture loosens during speech, chewing. 4. Occlusal Vertical Dimension (OVD) o Excessive: Continual and generalized pain and fatigue or muscle soreness o Insufficient: No power, no muscle force to bite 5. Allergies and Infections o Rare allergies: General inflammation o Hygiene: Generalized inflammation 10 | P a g e 6. Tooth Position - Instability (teeth not over ridge) - Difficulty chewing (occlusal table not long enough) - Cheek and lip biting (insufficient overjet) - Esthetic, phonetic problem: you may have to change position of teeth ❖Most Common Areas Requiring Adjustments ✓ Maxillary o Hamular notches - ulceration can occur if over- extended o Labial frenum - requires adequate relief (often feels bulky) o Mid-line fulcrum on the bony raphe o Zygomatic impingement ✓ Mandibular o Lingual frenum - impingement can cause displacement of the denture or ulceration o Retromylohyoid overextensions: Sore throat, denture moves when swallowing o Buccal shelf overextension ▪ Phonetic problems o Wait and allow time for adaptation especially for new denture wearer o Add soft wax to palate and check if anterior poorly positioned, then remove and replace THE END OF SHEET #14 The End of The Final sheet of this semester, you are an amazing person for reaching this point, keep working for your dreams and never give up ‫من يتهيب صعود الجبال يعش ابد ن‬ ‫بي الحفر‬ 11 | P a g e