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Prosthodontics - NEETMDS- courses
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Prosthodontics

The mental attitude of patients towards complete dentures plays a significant role in the success of their treatment. Understanding these attitudes can help dental professionals tailor their approach to meet the needs and expectations of their patients. Here are the four primary mental attitudes that patients may exhibit:

1. Philosophical (Ideal Attitude)

  • Characteristics:
    • Accepts the dentist's judgment without question.
    • Exhibits a rational, sensible, calm, and composed disposition.
    • Open to discussing treatment options and understands the importance of oral health.
  • Implications for Treatment:
    • This type of patient is likely to follow the dentist's recommendations and cooperate throughout the treatment process.
    • They are more likely to have realistic expectations and be satisfied with the outcomes.

2. Indifferent

  • Characteristics:
    • Shows little concern for their oral health.
    • Seeks treatment primarily due to pressure from family or friends.
    • Requires additional time and education to understand the importance of dental care.
    • Their attitude can be discouraging to dentists, as they may not fully engage in the treatment process.
  • Implications for Treatment:
    • Dentists may need to invest extra effort in educating these patients about the benefits of complete dentures and the importance of oral health.
    • Building rapport and trust is essential to encourage a more proactive attitude towards treatment.

3. Critical/Exacting

  • Characteristics:
    • Has previously had multiple sets of complete dentures and tends to find fault with everything.
    • Often has high expectations and may be overly critical of the treatment process.
    • May require medical consultation due to previous experiences or health concerns.
  • Implications for Treatment:
    • Dentists should be prepared to address specific concerns and provide detailed explanations about the treatment plan.
    • It is important to manage expectations and ensure that the patient understands the limitations and possibilities of denture treatment.

4. Skeptical/Hysterical

  • Characteristics:
    • Has had negative experiences with previous treatments, leading to doubt and skepticism about the current treatment.
    • Often presents with poor oral health, resorbed ridges, and other unfavorable conditions.
    • May exhibit anxiety or hysteria regarding dental procedures.
  • Implications for Treatment:
    • Building trust and confidence is crucial for these patients. Dentists should take the time to listen to their concerns and provide reassurance.
    • A gentle and empathetic approach is necessary to help alleviate fears and encourage cooperation.
    • It may be beneficial to involve them in the decision-making process to empower them and reduce anxiety.

Articulators in Prosthodontics

An articulator is a mechanical device that simulates the temporomandibular joint (TMJ) and jaw movements, allowing for the attachment of maxillary and mandibular casts. This simulation is essential for diagnosing, planning, and fabricating dental prostheses, as it helps in understanding the relationship between the upper and lower jaws during functional movements.

Classification of Articulators

Class I: Simple Articulators

  • Description: These are simple holding instruments that can accept a static registration of the dental casts.
  • Characteristics:
    • Limited to hinge movements.
    • Do not allow for any dynamic or eccentric movements.
  • Examples:
    • Slab Articulator: A basic device that holds casts in a fixed position.
    • Hinge Joint: Mimics the hinge action of the jaw.
    • Barndor: A simple articulator with limited functionality.
    • Gysi Semplex: A basic articulator for static registrations.

Class II: Semi-Adjustable Articulators

  • Description: These instruments permit horizontal and vertical motion but do not orient the motion of the TMJ via face bow transfer.
  • Subcategories:
    • IIA: Eccentric motion is permitted based on average or arbitrary values.
      • Examples: Mean Value Articulator, Simplex.
    • IIB: Limited eccentric motion is possible based on theories of arbitrary motion.
      • Examples: Monson's Articulator, Hall's Articulator.
    • IIC: Limited eccentric motion is possible based on engraved records obtained from the patient.
      • Example: House Articulator.

Class III: Fully Adjustable Articulators

  • Description: These articulators permit horizontal and vertical positions and accept face bow transfer and protrusive registrations.
  • Subcategories:
    • IIIA: Accept a static protrusive registration and use equivalents for other types of motion.
      • Examples: Hanau Mate, Dentatus, Arcon.
    • IIIB: Accept static lateral registration in addition to protrusive and face bow transfer.
      • Examples: Ney, Teledyne, Hanau Universit series, Trubyte, Kinescope.

Class IV: Fully Adjustable Articulators with Dynamic Registration

  • Description: These articulators accept 3D dynamic registrations and utilize a face bow transfer.
  • Subcategories:
    • IVA: The condylar path registered cannot be modified.
      • Examples: TMJ Articulator, Stereograph.
    • IVB: They allow customization of the condylar path.
      • Examples: Stuart Instrument, Gnathoscope, Pantograph, Pantronic.

Key Points

  • Face Bow Transfer: Class I and Class II articulators do not accept face bow transfers, which are essential for accurately positioning the maxillary cast relative to the TMJ.
  • Dynamic vs. Static Registrations: Class III and IV articulators allow for more complex movements and registrations, which are crucial for creating functional and esthetic dental prostheses.

Bevels are the angulation which is made by 2 surfaces of a prepared tooth which is other than 90 degrees. Bevels are given at various angles depending on the type of material used for restoration and the purpose the material serves.

Any abrupt incline between the 2 surfaces of a prepared tooth or between the cavity wall and the Cavo surface margins in the prepared cavity

Bevels are the variations which are created during tooth preparation or cavity preparation to help in increased retention and to prevent marginal leakage.
It is seen that in Bevels Occlusal cavosurface margin needs to be 40 degrees which seals and protects enamel margins from leakage and the Gingival Cavo surface margin should be 30 degrees to remove the unsupported enamel rods and produce a sliding fit or lap joint useful in burnishing gold.

bevels
Types or Classification of Bevels based on the Surface they are placed on:

Classification of Bevels based on the two factors – Based on the shape and tissue surface involved and Based on the surface they are placed on –

Based on the shape and tissue surface involved:

1. Partial or Ultra short bevel
2. Short Bevel
3. Long Bevel
4. Full Bevel
5. Counter Bevel
6. Reverse / Minnesota Bevel

Partial or Ultra Short Bevel:


Beveling which involves less than 2/3rd of the Enamel thickness. This is not used in Cast restorations except to trim unsupported enamel rods from the cavity borders.

Short Bevel:

Entire enamel wall is included in this type of Bevel without involving the Dentin. This bevel is used mostly with Class I alloys specially for type 1 and 2. It is used in Cast Gold restoration

Long Bevel:

Entire Enamel and 1/2 Dentin is included in the Bevel preparation. Long Bevel is most frequently used bevel for the first 3 classes of Cast metals. Internal boxed- up resistance and retention features of the preparation are preserved with Long Bevel.

Full Bevel:

Complete Enamel and Dentinal walls of the cavity wall or floor are included in this Bevel. It is well reproduced by all four classes of cast alloys, internal resistance and retention features are lost in full bevel. Its use is avoided except in cases where it is impossible to use any other form of bevel .

Counter Bevel:

It is used only when capping cusps to protect and support them, opposite to an axial cavity wall , on the facial or lingual surface of the tooth, which will have a gingival inclination facially or lingually.

There is another type of Bevel called the Minnesota Bevel or the Reverse Bevel, this bevel as the name suggest is opposite to what the normal bevel is and it is mainly used to improve retention in any cavity preparation

If we do not use functional Cusp Bevel –

1. It Can cause a thin area or perforation of the restoration borders
2. May result in over contouring and poor occlusion
3. Over inclination of the buccal surface will destroy excessive tooth structure reducing retention

Based on the surface they are placed on:

1. Gingival bevel
2. Hollow ground bevel
3. Occlusal bevel or Functional cusp bevel

Gingival bevel:

1. Removal of Unsupported Enamel Rods.
2. Bevel results in 30° angle at the gingival margin that is burnishable because of its angular design.
3. A lap sliding fit is produced at the gingival margin which help in improving the fit of casting in this region.
4. Inlay preparations include of two types of bevel Occlusal bevel Gingival bevel

Hollow Ground (concave) Bevel: Hollow ground bevel allows more space for bulk of cast metal, a design feature needed in special preparations to improve material’s castability retention and better resistance to stresses. These bevels are ideal for class IV and V cast materials. This is actually an exaggerated chamfer or a concave beveled shoulder which involves teeth greater than chamfer and less than a beveled shoulder. The buccal slopes of the lingual cusps and the lingual slope of the buccal cusps should be hollow ground to a depth of at least 1 mm.

Occlusal Bevel:

1. Bevels satisfy the requirements for ideal cavity walls.
2. They are the flexible extensions of a cavity preparation , allowing the inclusion of surface defects , supplementary grooves , or other areas on the tooth surface.
3. Bevels require minimum tooth involvement and do not sacrifice the resistance and retention for the restoration
4. Bevels create obtuse-angled marginal tooth structure, which is bulkiest and the strongest configuration of any marginal tooth anatomy, and produce an acute angled marginal cast alloy substance which allows smooth burnishing for alloy.

Functional cusp Bevel:

An integral part of occlusal reduction is the functional cusp bevel. A wide bevel placed on the functional cusp provides space for an adequate bulk of metal in an area of heavy occlusal contact.

Finish lines are the marginal configurations at the interface between a restoration and the tooth structure that are intended to be refined and polished to a smooth contour. In prosthodontics, they are crucial for the proper adaptation and seating of restorations, as well as for maintaining the health of the surrounding soft and hard tissues. Finish lines can be classified in several ways, such as by their location, purpose, and the burs used to create them. Here's an overview:

1. Classification by Width:
a. Narrow Finish Lines: These are typically 0.5mm wide or less and are often used in areas where the restoration margin is tight against the tooth structure, such as with metal-ceramic restorations or in cases with minimal tooth preparation.
b. Moderate Finish Lines: These are 0.5-1.5mm wide and are commonly used for most types of restorations, providing adequate space for a good margin and seal.
c. Wide Finish Lines: These are 1.5mm wide or more and are often used in areas with less than ideal tooth preparation or when a wider margin is necessary for material manipulation or when there is a concern about the stability of the restoration.

2. Classification by Location and Application:
a. Shoulder Finish Line: This finish line is at a 90-degree angle to the tooth structure and is often used for metal-ceramic and all-ceramic restorations. It provides good support and can be easily visualized and finished.
b. Knife-Edge Finish Line: This is a very thin finish line that is beveled at an approximately 45-degree angle to the tooth structure. It is typically used for all-ceramic restorations and is designed to mimic the natural tooth contour, providing excellent esthetics.
c. Feather Edge Finish Line: Also known as a chamfer, this finish line is beveled at approximately 90-degrees to the tooth structure. It is used in situations where the tooth structure is not ideal for a shoulder margin, and it helps to distribute the forces evenly and reduce the risk of tooth fracture.
d. Butt-Joint Finish Line: This is when the restoration margin is placed directly against the tooth structure without any bevel. It is often used in the lingual areas of anterior teeth and in situations where there is minimal space for a margin.

3. Classification by Function:
a. Functional Finish Lines: These are placed where the restoration will be subject to significant occlusal or functional stresses. They are designed to enhance the durability of the restoration and are usually placed at or slightly below the height of the free gingival margin.
b. Esthetic Finish Lines: These are placed to achieve a high level of cosmetic appeal and are often located in the facial or incisal areas of anterior teeth. They are typically knife-edge margins that are highly polished.

Advantages and Disadvantages:
- Narrow finish lines can be more challenging to clean and may be less visible, potentially leading to better esthetics and less irritation of the surrounding tissues. However, they may also increase the risk of recurrent decay and are more difficult to achieve a good margin seal with.
- Moderate finish lines are easier to clean and provide a better margin seal, but may be more visible and can potentially lead to increased tooth sensitivity.
- Wide finish lines are more forgiving for marginal adaptation and are easier to clean, but they can be less esthetic and may require more tooth reduction.

Burs Used:
- The choice of bur for creating finish lines depends on the restoration material and the desired margin design. For example:
a. Diamond Burs: Typically used for creating finish lines on natural tooth structures, especially for knife-edge margins on ceramic restorations, due to their ability to produce a smooth and precise finish.
b. Carbide Burs: Often used for metal-ceramic restorations, as they are less likely to chip the ceramic material.
c. Zirconia-Specific Burs: Used for zirconia restorations to prevent chipping or fracture of the zirconia material.

When creating finish lines, the dentist must consider the patient's oral health, the type of restoration, the location in the mouth, and the desired functional and esthetic outcomes. The correct selection and preparation of the finish line are essential for the longevity and success of the restoration.

Complete Denture Occlusion

Complete denture occlusion is a critical aspect of prosthodontics, as it affects the function, stability, and comfort of the dentures. There are three primary types of occlusion used in complete dentures: Balanced Occlusion, Monoplane Occlusion, and Lingualized Occlusion. Each type has its own characteristics and applications.

Types of Complete Denture Occlusion

1. Balanced Occlusion

  • Definition: Balanced occlusion is characterized by simultaneous contact of all opposing teeth in centric occlusion, providing stability and even distribution of occlusal forces.
  • Key Features:
    • Three-Point Contact: While a three-point contact (one anterior and two posterior) is a starting point, it is not sufficient for true balanced occlusion. Instead, there should be simultaneous contact of all teeth.
    • Minimal Occlusal Balance: For minimal occlusal balance, there should be at least three points of contact on the occlusal plane. The more points of contact, the better the balance.
    • Absence in Natural Dentition: Balanced occlusion is not typically found in natural dentition; it is a concept specifically applied to complete dentures to enhance stability during function.
  • Importance: This type of occlusion is particularly important for patients with complete dentures, as it helps to minimize tipping and movement of the dentures during chewing and speaking.

2. Monoplane Occlusion

  • Definition: Monoplane occlusion involves a flat occlusal plane where the occlusal surfaces of the teeth are arranged in a single plane.
  • Key Features:
    • Flat Occlusal Plane: The occlusal surfaces are designed to be flat, which simplifies the occlusion and reduces the complexity of the denture design.
    • Limited Interference: This type of occlusion minimizes interferences during lateral and protrusive movements, making it easier for patients to adapt to their dentures.
  • Applications: Monoplane occlusion is often used in cases where the residual ridge is severely resorbed or in patients with limited jaw movements.

3. Lingualized Occlusion

  • Definition: Lingualized occlusion is characterized by the positioning of the maxillary posterior teeth in a way that they occlude with the mandibular posterior teeth, with the buccal cusps of the mandibular teeth being positioned more towards the buccal side.
  • Key Features:
    • Maxillary Teeth Positioning: The maxillary posterior teeth are positioned more towards the center of the arch, while the mandibular posterior teeth are positioned buccally.
    • Functional Balance: This arrangement allows for better functional balance and stability during chewing, as the maxillary teeth provide support to the mandibular teeth.
  • Advantages: Lingualized occlusion can enhance the esthetics and function of complete dentures, particularly in patients with a well-defined ridge.

Applegate's Classification is a system used to categorize edentulous (toothless) arches in preparation for denture construction. The classification is based on the amount and quality of the remaining alveolar ridge, the relationship of the ridge to the residual ridges, and the presence of undercuts. The system is primarily used in the context of complete denture prosthodontics to determine the best approach for achieving retention, stability, and support for the dentures.

Applegate's Classification for edentulous arches:

1. Class I: The alveolar ridge has a favorable arch form and sufficient height and width to provide adequate support for a complete denture without the need for extensive modifications. This is the ideal scenario for denture construction.

2. Class II: The alveolar ridge has a favorable arch form but lacks the necessary height or width to provide adequate support. This may require the use of denture modifications such as flanges to enhance retention and support.

3. Class III: The ridge lacks both height and width, and there may be undercuts or excessive resorption. In this case, additional procedures such as ridge augmentation or the use of implants might be necessary to improve the foundation for the denture.

4. Class IV: The ridge has an unfavorable arch form, often with significant resorption, and may require extensive surgical procedures or adjuncts like implants to achieve a functional and stable denture.

5. Class V: This is the most severe classification where the patient has no residual alveolar ridge, possibly due to severe resorption, trauma, or surgical removal. In such cases, the creation of a functional and stable denture may be highly challenging and might necessitate advanced surgical procedures and/or the use of alternative prosthetic options like over-dentures with implant support.

It's important to note that this classification is a guide, and individual patient cases may present with a combination of features from different classes or may require customized treatment plans based on unique anatomical and functional requirements.

Concepts Proposed to Attain Balanced Occlusion

Balanced occlusion is a critical aspect of complete denture design, ensuring stability and function during mastication and speech. Various concepts have been proposed over the years to achieve balanced occlusion, each contributing unique insights into the arrangement of artificial teeth. Below are the key concepts:

I. Concepts for Achieving Balanced Occlusion

1. Gysi's Concept (1914)

  • Overview: Gysi suggested that arranging 33° anatomic teeth could enhance the stability of dentures.
  • Key Features:
    • The use of anatomic teeth allows for better adaptation to various movements of the articulator.
    • This arrangement aims to provide stability during functional movements.

2. French's Concept (1954)

  • Overview: French proposed lowering the lower occlusal plane to increase the stability of dentures while achieving balanced occlusion.
  • Key Features:
    • Suggested inclinations for upper teeth:
      • Upper first premolars: 5° inclination
      • Upper second premolars: 10° inclination
      • Upper molars: 15° inclination
    • This arrangement aims to enhance the occlusal relationship and stability of the denture.

3. Sear's Concept

  • Overview: Sears proposed balanced occlusion for non-anatomical teeth.
  • Key Features:
    • Utilized posterior balancing ramps or an occlusal plane that curves anteroposteriorly and laterally.
    • This design helps maintain occlusal balance during functional movements.

4. Pleasure's Concept

  • Overview: Pleasure introduced the concept of the "Pleasure Curve" or the posterior reverse lateral curve.
  • Key Features:
    • This curve aids in achieving balanced occlusion by allowing for better distribution of occlusal forces.
    • It enhances the functional relationship between the upper and lower dentures.

5. Frush's Concept

  • Overview: Frush advised arranging teeth in a one-dimensional contact relationship.
  • Key Features:
    • This arrangement should be reshaped during the try-in phase to obtain balanced occlusion.
    • Emphasizes the importance of adjusting the occlusal surfaces for optimal contact.

6. Hanau's Quint

  • Overview: Rudolph L. Hanau proposed nine factors that govern the articulation of artificial teeth, known as the laws of balanced articulation.
  • Nine Factors:
    • Horizontal condylar inclination
    • Protrusive incisal guidance
    • Relative cusp height
    • Compensating curve
    • Plane of orientation
    • Buccolingual inclination of tooth axis
    • Sagittal condylar pathway
    • Sagittal incisal guidance
    • Tooth alignment
  • Condensation: Hanau later condensed these nine factors into five key principles for practical application.

7. Trapozzano's Concept of Occlusion

  • Overview: Trapozzano reviewed and simplified Hanau's quint and proposed his triad of occlusion.
  • Key Features:
    • Focuses on the essential elements of occlusion to streamline the process of achieving balanced occlusion.

II. Monoplane or Non-Balanced Occlusion

Monoplane occlusion is characterized by an arrangement of teeth that serves a specific purpose. It includes the following concepts:

  • Spherical Theory: Proposes that the occlusal surfaces should be arranged in a spherical configuration to facilitate movement.
  • Organic Occlusion: Focuses on the natural relationships and movements of the jaw.
  • Occlusal Balancing Ramps for Protrusive Balance: Utilizes ramps to maintain balance during protrusive movements.
  • Transographics: A method of analyzing occlusal relationships and movements.

Sears' Occlusal Pivot Theory

  • Overview: Sears also proposed the occlusal pivot theory for monoplane or balanced occlusion, emphasizing the importance of a pivot point for functional movements.

III. Lingualized Occlusion

  • Overview: Proposed by Gysi, lingualized occlusion involves positioning the maxillary posterior teeth to occlude with the mandibular posterior teeth, enhancing stability and function.
  • Key Features:
    • The maxillary teeth are positioned more centrally, while the mandibular teeth are positioned buccally.
    • This arrangement allows for better functional balance and esthetics.

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