PREPARATION OF MOUTH FOR

REMOVABLE PARTIAL DENTURES

INTRODUCTION
Mouth preparation contributes to the
philosophy that the prescribed
prosthesis must not only replace
what is missing but also preserve the
remaining tissue and structures that
will enhance the removable partial
denture.


Mouth preparation includes procedures in four
categories:



1. oral surgical preparation
2. conditioning of abused and irritated tissue
3. periodontal preparation



4. preparation of abutment teeth.
A)PRE-PROSTHETIC MOUTH PREPARATION
B)PROSTHETIC MOUTH PREPARATION
The objectives of the procedures involved in all four
areas are to return the mouth to optimum health and to
eliminate any condition that would affect the success of
the removable partial denture.

Mouth preparation must be accomplished before the
impression procedures that will produce the master cast
on which the removable partial denture will be fabricated.

Oral surgical and periodontal procedures should precede
abutment tooth preparation and should be completed far
enough in advance to allow the necessary healing period.
If at all possible, at least 6 weeks, but preferably 3 to 6
months, should be provided between surgical and
restorative dentistry procedures.

ORAL SURGICAL PREPARATION
All preprosthetic surgical treatment for the
removable partial denture patient should be
completed as early as possible.
Longer the interval between surgery &
impression procedure, more complete the
healing & more stable the denture bearing
areas.

1. EXTRACTION
o Planned extractions should occur early in the
treatment regimen but not before completion of a
careful and thorough evaluation of each remaining
tooth in the dental arch.
o Each tooth must be evaluated concerning its strategic
importance and its potential contribution to the
success of the removable partial denture.


2. REMOVAL OF RESIDUAL ROOTS
All retained roots or root fragments should be
removed if they are in close proximity to the tissue
surface or if there is evidence of associated
pathological findings.
Residual roots adjacent to abutment teeth may
contribute to the progression of periodontal pockets
and compromise the results from subsequent
periodontal therapy.
3. IMPACTED TEETH
All impacted teeth in edentulous areas and
those adjacent to abutment teeth is
considered for removal.
Asymptomatic impacted teeth in the elderly
that are covered with bone, with no
evidence of a pathological condition, should
be left to preserve the arch morphology.
Early removal of impactions prevents
infections.


4. MALPOSED TEETH
The loss of individual tooth or groups of teeth
may lead to extrusion, drifting, or
combinations of mal-positioning of the
remaining teeth.
Alveolar bone supporting extruded teeth will
be carried occlusally as the teeth continue to
erupt.
Such teeth and their supporting alveolar
bone can be surgically repositioned.

5. CYSTS AND ODONTOGENIC
TUMORS

A periapical roentgenogram should be taken to
confirm or deny the presence of a lesion.
All radiolucencies or radiopacities observed in
the jaws should be investigated for any
pathologies.
6. EXOSTOSES AND TORI
The existence of abnormal bony enlargements should
not be allowed to compromise the design of the
removable partial denture
Mucosa covering the bony protuberance is extremely
thin and friable.
Removable partial denture components in proximity to
this type of tissue may cause irritation and chronic
ulceration.
Exostoses approximating gingival margins may
complicate the maintenance of periodontal health & lead
to eventual loss of strategic abutment teeth.



7. HYPERPLASTIC TISSUE
Hyperplastic tissue is seen in the form of fibrous
tuberosities, soft flabby ridges, folds of tissue in the
vestibule or floor of the mouth, and palatal
papillomatosis.
All these forms of excess tissue should be removed to
provide a firm base for the denture.
Removal will produce more stable denture, reduce
stress & strain on the supporting teeth & tissue.
Surgical approaches should not reduce vestibular depth.
Palatal papillomatosis
8. MUSCLE ATTACHMENTS AND FRENA
As a result of the loss of bone height, muscle attachments
may insert on or near the residual ridge crest.
The mylohyoid, buccinator, mentalis, and genioglossus
muscles are those most likely to introduce problems.
Appropriate ridge extension procedures can reposition
attachments & remove bony spines which will enhance the
comfort & function of removable partial denture.
The maxillary labial and mandibular lingual frena are the
most common sources of frenum interference with denture
design.

9. BONY SPINES AND KNIFE-EDGE
RIDGES
Sharp bony spicules should be removed
and knifelike crests gently rounded.
These procedures should be carried out
with minimum bone loss.

10. POLYPS,PAPILLOMAS AND
HEMANGIOMAS
All abnormal soft tissue lesions should be excised &
submitted for pathological examination before the
fabrication of removable partial denture.

11. HYPERKERATOSES, ERYTROPLASIA AND
ULCERATION

All abnormal, white, red, or ulcerative lesions
should be investigated.
Biopsy of areas greater than 5mm should be
completed & if lesions are large multiple
biopsies should be taken.

12. DENTOFACIAL DEFORMITY
Patients with a dentofacial deformity often have multiple
missing teeth as part of their problem. Correction of the
jaw deformity can simplify the dental rehabilitation.
Before specific problems with the dentition can be
corrected,patients overall problem must be evaluated
thoroughly.
Mandible and maxillae may be positioned anteriorly or
posteriorly, and their relationship to the facial planes may
be surgically altered to achieve improved apperance
13. OSSEOINTEGRATED DEVICES
Implant devices offer significant stabilizing effect on
dental prosthesis through a rigid connection to
living bone.
The system that pioneered clinical prosthodontic
applications with the use of commercially pure (CP)
titanium endosseous implants is that of Branemark.
This titanium implant was designed to provide a
direct titanium-to-bone interface (osseointegrated)
14. AUGMENTATION OF ALVEOLAR
BONE
Ridge augmentation is done with the use of
autogenous and alloplastic materials.
Larger ridge volume gains necessitate consideration
of autogenous grafts.
Clinical results depends on careful evaluation of need
for augmentation,projected volume of required
material & site & method of placement.


CONDITIONING OF ABUSED & IRRITATED
TISSUE
Patients who require conditioning treatment often
demonstrate the following symptoms:
1. Inflammation and irritation of the mucosa covering the
denture bearing areas.
2. Distortion of normal anatomic structures, such as
incisive papillae, the rugae, and the retro molar pads
3. A burning sensation in residual ridge areas, the
tongue, and the cheeks and lips.
These conditions associated with ill fitting or poorly
occluding removable partial dentures.


The tissue conditioning materials are
elastopolymers that continue to flow for an
extended period, permitting distorted tissue
to rebound and assume its normal form.
These soft materials apparently have a
massaging effect on irritated mucosa, and
because they are soft, occlusal forces are
probably more evenly distributed.
Maximum benefit from using tissue conditioning materials
may be obtained by
(1) eliminating deflective or interfering occlusal contacts
of old dentures
(2) extending denture bases to proper form to enhance
support, retention, and stability
(3) relieving the tissue side of denture bases sufficiently
(2 mm) to provide space for even thickness and
distribution of conditioning material
(4) applying the material in amounts sufficient to provide
support and a cushioning effect and
(5) following the manufacturer's directions for
manipulation and placement of the conditioning material.
The conditioning procedure should be repeated until the
supporting tissues display an undistorted and healthy
appearance.




The periodontal preparation of the mouth usually
follows any oral surgical procedure and is
performed simultaneously with tissue conditioning
procedures.
The elimination of exostoses, tori, hyperplastic
tissue, muscle attachments, and frena can be
incorporated with periodontal surgical techniques.
Periodontal therapy should be completed before
restorative dentistry procedures are begun for
any dental patient. The periodontal health of the
remaining teeth, especially those to be used as
abutments, must be evaluated and corrective
measures instituted before removable partial
denture fabrication.


OBJECTIVES OF PERIODONTAL
THERAPY
1. Removal and control of all etiological factors
contributing to periodontal disease, along with a
reduction or elimination of bleeding on probing
2. Elimination of, or reduction in, pocket depths,
with the establishment of healthy gingival sulci
whenever possible
3. Establishment of functional atraumatic
occlusal relationships and tooth stability
4. Development of a personal plaque control
program and definitive maintenance schedule


PERIODONTAL DIAGNOSIS AND
TREATMENT PLANNING
DIAGNOSIS
Diagnosis is done using direct vision, palpation,
periodontal probe, mouth mirror, and other auxiliary aids,
such as curved explorers, furcation probes, diagnostic
casts, and appropriate radiographs.
Most important evaluation procedure-exploration of
gongival sulcus,recording periodontal pocket & sites that
bleed on probing.
A critical evaluation of the following factors should be made:
(1) type, location, and severity of bone loss;
(2) location, severity, and distribution of furcation involvements;
(3) alterations of the periodontal ligament space;
(4) alterations of the lamina dura;
(5) presence of calcified deposits;
(6) location and conformity of restorative margins
(7) evaluation of crown and root morphologies;
(8) root proximity;
(9) caries; and
(10) evaluation of other associated anatomic features, such as the
mandibular canal or sinus proximity.
Each tooth should be evaluated carefully for mobility. Tooth mobility is
an indication of the condition of the supporting structures and is
usually caused by inflammatory changes in the periodontal ligament,
traumatic occlusion, loss of attachment, or a combination of the three.


TREATMENT PLANNING
Periodontal treatment planning can usually be divided into three
phases.
Initial Disease Control Therapy (Phase 1)
Disease control or initial therapy phase.Objective is
to eliminate & reduce local etiological factors before
periodontal surgical procedures are accomplished.
Oral Hygiene Instruction
Scaling and Root Planing
Elimination of Local Irritating Factors ; Other Than
Calculus
Elimination of Gross Occlusal Interferences
Definitive Periodontal Surgery (Phase 2)
Periodontal Surgery
Periodontal flaps.
Guided tissue regeneration.
Periodontal plastic surgery (mucogingival
surgery)

Recall Maintenance (Phase 3)
3- to 4-month recall to maintain results achieved by
nonsurgical and surgical therapy.

ADVANTAGES OF PERIODONTAL
THERAPY
First, the elimination of periodontal disease removes a
primary etiological factor in tooth loss.
Second, a periodontium free of disease presents a
much better environment for restorative correction.
Third, the response of strategic but questionable teeth to
periodontal therapy provides an important opportunity
for reevaluating their prognosis before the final decision
is made to include (or exclude) them in the removable
partial denture design.
And last, the overall reaction of the patient to
periodontal procedures provides the dentist with an
excellent indication of the degree of cooperation to be
expected in the future.

ABUTMENT RESTORATIONS
Esthetic veneer type of crowns should be used
when a canine or premolar abutment is to be
restored or protected. Less frequently does the
molar have to be treated in such a manner, and
except for maxillary first molars the full cast
crown is usually acceptable.
When there is proximal caries on abutment
teeth with sound buccal and lingual enamel
surfaces, in a mouth exhibiting average oral
hygiene and low caries activity, a gold inlay
may be indicated.


CONTOURING WAX PATTERNS
Indirect techniques permit the contouring of
wax patterns on the master cast with the aid of
the surveyor blade. All abutment teeth to be
restored with castings can be prepared at one
time and an impression made that will provide
an accurate stone replica of the prepared arch.
Wax patterns may then be refined on separated
individual dies or removable dies. All abutment
surfaces facing edentulous areas should be
made parallel to the path of placement by the
use of the surveyor blade.
ENAMELOPLASTY
It is the intentional alteration of the occlusal surface
of the teeth to change their form.
It is done when the abutment tooth does not
provide any surface undercut.
It is prepared close to and parallel to the gingival
margin.
The surface should be highly polished and should
measure 2mm occluso-gingivally and 4mm mesio-
distally.
A small round ended tapered diamond stone is
used to make a depression that is very gradual and
smooth.
REST SEATS
After the proximal surfaces of the wax patterns have
been made parallel, and buccal and lingual contours
have been established to satisfy the requirements of
stability and retention with the best possible esthetic
placement of clasp arms, the occlusal rest seats should
be prepared in the wax pattern rather than in the
finished restoration. The placement of occlusal rests
should be considered at the time the teeth are prepared
to receive cast restorations so that there will be sufficient
clearance beneath the floor of the occlusal rest seat.
Occlusal rest are placed so that any occlusal force will
be directed axially and that there will be the least
possible interference to occlusion with the opposing
teeth.

Perhaps the most important function of a
rest is the division of stress loads from the
removable partial denture to provide the
greatest efficiency with the least damaging
effect to the supporting abutment teeth. For
a distal extension removable partial denture,
the rest must be able to transmit occlusal
forces to the abutment teeth in a vertical
direction only, thereby permitting the least
possible lateral stress to be transmitted to
the abutment teeth.

To permit occlusal stresses to be directed toward
the center of the abutment tooth, the angle formed
by the floor of the occlusal rest with the minor
connector should be less than 90. In other words,
the floor of the occlusal rest should incline slightly
from the marginal ridge toward the center of the
tooth.

This proper form can be readily
accomplished in the wax pattern if care is
taken during crown or inlay preparation to
provide the location of the rest. If direct
restorations are used, sufficient bulk must
be present in this area to allow proper
occlusal rest seat form without weakening
the restoration. When the rest seat is placed
in sound enamel, it is best accomplished by
the use of round carbide burs (No. 4, 6, and
8 sizes) that leave a smooth enamel
surface.

Rest seat preparations in sound enamel (or in
existing restorations that are not to be replaced)
should always follow the recontouring of proximal
tooth surfaces. The preparation of proximal tooth
surfaces should be done first because if the
occlusal portion of the rest seat is placed first and
the proximal tooth surface is altered later, the
outline form of the rest seat is sometimes
irreparably altered.

Following proximal surface recontouring (guide plane
preparation), the larger round bur is used to lower the
marginal ridge 1.5 to 2.0 mm while creating the relative
outline form of the rest seat. The result is a rest seat
preparation with the marginal ridge lowered and the
gross outline form established, but without sufficient
deepening of the rest seat preparation toward the center
of the tooth. A smaller round bur (a No. 4 or 6) may then
be used to deepen the floor of the rest seat to a gradual
incline toward the center of the tooth. Enamel rods are
then smoothed by the planing action of a round bur
revolving with little pressure. Abrasive rubber points are
sufficient to complete the polishing of the rest seat
preparation.

SUMMARY
Mouth preparation is fundamental to a successful
removable partial denture.
Mouth preparation includes procedures in four categories-
oral surgical preparation, conditioning of abused & irritated
tissue, periodontal preparation & preparation of abutment
tooth.
These procedures return mouth to optimum health &
eliminate any condition that would affect success of
removable partial denture.
CONCLUSION
The success or failure of a removable partial
denture depends on how well the mouth
preparations are accomplished. It is only through
intelligent planning and competent execution of
mouth preparations that the denture can
satisfactorily restore lost dental functions and
contribute to the health of the remaining oral tissue.