Jane Thomas MB ChB MSc and MRCOG
Non pathologic anatomic soft tissue enlargements such as fibrous tuberosities and soft flabby ridges depression symptoms irritability order bupropion online pills. Abnormalities of the alveolar ridge crests depression remission definition cheap bupropion online, including sharp bony spicules depression facts cheap 150 mg bupropion otc, knife edge ridge crests and excessive bony undercuts depression dsm code purchase generic bupropion online. Patient Wearing Dentures the patient who has previously worn or is wearing a removable prosthesis may present as abused soft tissues caused either by systemic conditions or by mechanical irritation from the prosthesis. Systemic Effects It is not the intent to discuss in detail the systemic conditions, which could directly or indirectly cause a tissue response to abnormal stimulation. It is important to identify any systemic manifestation in the oral cavity and determine whether there is any correlation between the systemic disturbance and the abused tissue. Mechanical Effects Patients wearing ill-fitting or improperly designed removable partial dentures normally present abused tissues on the bearing and/or border areas. The tissues more specifically involved include: Palatal mucosa in the maxillary arch Ridge crest in the mandibular arch Dr. Gebreel Prosthodontic department Preparation of mouth for removable partial dentures Mcobuccal/mucolingual folds in both arches; and Gingival tissue immediately adjacent to the anterior and/or posterior abutment teeth. The abuse may vary from slight irritation to extensive deformation and is encountered more frequently in free-end extension than in tooth form partial denture situations. Specific Soft Tissue Responses to Ill-fitting Dentures the continual wearing of an ill-fitting removable partial denture may cause specific soft tissue responses, which must be recognized and treated accordingly prior to the fabrication and insertion of a removable partial denture. Causes have been attributed to: Ill-fitting dentures, Occlusal disharmony Poor oral hygiene Constant wearing of the prostheses and Sometimes a superimposed fungal infection the lesion is generally asymptomatic, however, some patients may complain of a burning or itching sensation related to both the tongue and the palatal mucosa. Angular cheilitis is often associated with denture sore mouth and if the condition is long continued, the skin may become thickened (Brooke-Candidosis). The treatment would involve removal of the dentures at night and the establishment of a good oral hygiene program. If a smear indicates candida albicans infection, Antifungal therapy should be carried out for at least two weeks. A dose of 3 mg one nystatin suppository 100,000 units twice a day for two weeks or coating nystatin cream on the tissue surface of the denture three times a day. Inflammatory Papillary Hyperplasia Inflammatory Papillary Hyperplasia or multiple papillomatosis is being observed with increasing frequency in the palatal bearing area of the edentulous and partially edentulous patient. The specific etiology is unknown but Lytle stated that the lesion can be identified with mechanical irritation caused by ill fitting or under-extended denture bases, partial dentures with inadequate tooth support in interceptive occlusal contacts. He feels that the irritation is caused by the underlying tissue becoming trapped between the base/connection and the underlying bone. McCracken considers the design of the horseshoe connector could be a contributing factor to abuse of palatal tissues. Jerbi has suggested that papillomatosis is frequently seen in patients presenting high narrow vaults and that the presence of a negative pressure may be one of the primary etiologic factors. Love and Associates reported that the frequency of this condition is more prevalent in patients who wear their dentures continually the combination of the trauma superimposed with candida albicans may influence the chronicity of papillomatosis. Gebreel Prosthodontic department Preparation of mouth for removable partial dentures polypoid masses vary in width and depth of 1-2 mm depending upon the extent of its irritation. The degree of success in treating inflammatory papillary hyperplasia will depend upon the ability of the patient to carry out a strict oral physiotherapy program. If a smear demonstrates the presence of candidiases albicans infection, a therapeutic does of sucking one nystatin suppository 100,000 twice a day for two weeks. Treatment Considerations To ensure a successful prognosis, the soft tissues must be restored to their optimum biologic status and preserved at that level at all costs. Following the diagnosis and treatment planning, tissue preparation should be accomplished in a logical sequence: 1. Patient Education and Oral Hygiene Instruction One of the primary requisites is the education and motivation of the patient to accept, understand and carry out a strict oral physiotherapy regimen regularly and conscientiously. The patient must also be aware of the physiologic limits of the partial denture service and the potential dangers that can result from further negligence. Once the patient understands these ramifications, he/she may be instructed in tissue recovery procedures necessary to preserve the tissues in an acceptable condition. At subsequent appointments, oral hygiene can be evaluated carefully and further treatment should be with held until a satisfactory level has been achieved. Removal of the Prosthesis Lytle demonstrated that if ill-fitting dentures are removed and the soft tissues have not been displaced beyond their normal physiologic limits, the tissues tend to improve in. The demonstrated that it was advisable to remove the denture 48 hours prior to the making of new impressions if the tissue had not been abused beyond its normal tissue recovery capability. Oral Hygiene Measures On conjunction with removal of dentures the patient should be advised to: a. Gebreel Prosthodontic department Preparation of mouth for removable partial dentures c. Tissue Conditioners If tissues are abused excessively, more than a 72 hour recovery period may be required. Depending on the design and outline form of the corrector/base of the partial denture, a resilient tissue conditioner may be placed inside the denture base/connector. The tissue conditioner consisting of a polymer powder and an aromatic ester-ethyl alcohol mixture provides an intimate contact against the underlying tissue during the recovery period. Some of the more resilient tissue conditioners that can be used effectively are: Hydrocast, Temp, Fill, Coe, Soft, Coe Comfort. Birman suggested that to ensure the tissue recovery process has been initiated, the denture must be removed at least 24 hours to insertion of a tissue conditioner. However they do have a short duration effectiveness and should be replaced when necessary. Tissue conditioners become rough, rigid, discolored and usually very foul after 21 days. If the conditioner is left for any length of time, contamination by candida albicans is a common occurrence. Modification to Existing Prosthesis the existing prosthesis should be carefully evaluated to determine the presence of any mechanical deficiencies causing the abuse of soft tissue. Restore the vertical dimension of occlusion to the desired level (in conjunction with the use tooth-colored triad and a resilient tissue conditioner). Correct base extensions to provide maximum coverage and stability within the limits of tissue tolerance. If possible, the free end extension area should be registered in a supporting form to minimize masticatory stresses. Adjust component location and function to discourage tissue impingement, resist torquing forces and enhance denture stability. Interim Prosthesis In some cases, evaluation of the existing prosthesis reveals that it would be more practical to construct an interim prosthesis during the tissue recovery period. If an interim acrylic base prosthesis is to be used, careful consideration must be given to the design of the prostheses. Sufficient tooth support must be provided to ensure uniform distribution of stress between the remaining natural teeth and the soft tissues. The denture base outline and coverage must enhance tissue preservation not destruction. Gebreel Prosthodontic department Preparation of mouth for removable partial dentures 3. There are certain periodontal procedures that should be considered involving soft/hard tissue abnormalities. After oral hygiene measures, scaling and root planning have been carried out periodontal surgery may be recommended for: 1.
At present depression symptoms essay bupropion 150 mg overnight delivery, clinicians and therapists have little to offer to reduce auditory depression definition purchase bupropion 150 mg, tactile and olfactory sensitivity depression symptoms mild generic 150mg bupropion otc. We also need to develop and evaluate programs to encourage friendship and relationship skills mood disorder yahoo answers bupropion 150 mg without prescription, the management of emotions and the constructive application of special interests. Knowledge changes attitudes, which in turn can change abilities and circumstances. His family had recently moved to Birmingham and Jack had been in her class for only a few weeks. Last week he had sat next to Alicia while she was eating her lunch, and as she listened to him, she thought he was a kind and lonely boy who seemed bewildered by the noise and hectic activity of the playground. Her heart went out to him and, despite the perplexed looks of her friends when she said he was invited to her party, she was determined he should come. When I go to bed I like to look at my box of batteries and sort them in alphabetical order before I go to sleep. Jack con tinued to provide a monologue on batteries, how they are made and what to do with them when the power is exhausted. She noticed that when he talked, he rarely looked at her and his vocabulary was very unusual for an eight-year-old boy. He gazed at her face for a few seconds, as if trying to read the expression, and then off he went. She looked out of the kitchen window and watched him run across the grass towards Alicia. As he ran through a group of four girls, she noticed one of them deliberately put out her foot to trip him up. A lack of social understanding, limited ability to have a reciprocal conversa tion and an intense interest in a particular subject are the core features of this syndrome. It was not until the late twentieth century that we had a name to describe such individuals. By the mid-1940s, the psychological study of childhood in Europe and America had become a recognized and growing area of science with significant advances in descriptions, theoretical models and assessment instruments, but Asperger could not find a description and explanation for the small group of similar and unusual children that he found intriguing. The children had difficulty making friends and they were often teased by other children. There were impairments in verbal and non-verbal communication, espe cially the conversational aspects of language. The grammar and vocabulary may have been relatively advanced but, at the end of the conversation, one had the impression that there was something unusual about their ability to have the typical conversation that would be expected with children of that age. Asperger also observed and described conspicuous impairments in the com munication and control of emotions, and a tendency to intellectualize feelings. The children also had an egocentric preoccupation with a specific topic or interest that would dominate their thoughts and time. Some of the children had difficulty maintain ing attention in class and had specific learning problems. Asperger noted that they often needed more assistance with self-help and organizational skills from their mothers than one would expect. He also noted that some children were extremely sensitive to particular sounds, aromas, textures and touch. Asperger considered that the characteristics could be identified in some children as young as two to three years, although for other children, the characteristics only became conspicuous some years later. He also noticed that some of the parents, especially the fathers of such children, appeared to share some of the personality characteristics of their child. He wrote that the condition was probably due to genetic or neurological, rather than psychological or environmental, factors. In his initial and subsequent publi cations and a recent analysis of his patient records for children he saw over three decades, it is apparent that he considered autistic personality disorder as part of a natural continuum of abilities that merges into the normal range (Asperger 1944, 1952, 1979; Hippler and Klicpera 2004). He conceptualized the disorder as a life-long and stable personality type, and did not observe the disintegration and fragmentation that occurs in schizophrenia. He also noted that some of the children had specific talents that could lead to successful employment and some could develop life-long relationships. She had observed that some children who had the clear signs of severe autism in infancy and early childhood could achieve remarkable progress and move along the autism continuum as a result of early diagnosis and inten sive and effective early intervention programs (Wing 1981). The previously socially aloof and silent child now wants to play with children and can talk using complex sen tences. Where previously there was motivation for isolation, the child is now motivated to be included in social activities. After many hours in intensive programs to encourage communication abilities, the problem is no longer encouraging the child to speak, but encouraging him or her to talk less, listen and be more aware of the social context.
Changes in active ankle dorsiflexion range of motion after acute inversion ankle sprain depression and insomnia discount bupropion 150mg without prescription. Wobble board training after partial sprains of the lateral ligaments of the ankle: a prospective randomized study bipolar depression 800 purchase bupropion 150mg without prescription. Effect of attention focus on acquisition and retention of postural control following ankle sprain anxiety vomiting purchase bupropion 150mg on-line. Home-based physical therapy intervention with adherence-enhancing strategies versus clinic-based management for patients with ankle sprains mood disorder lecture notes order bupropion mastercard. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. High-intensity training with a bi-directional bicycle pedal improves performance in mechanically unstable ankles-a prospective randomized study of 19 subjects. Effect of coordination training on proprioception of the functionally unstable ankle. Effects of a 4-week exercise program on balance using elastic tubing as a perturbation force for individuals with a history of ankle sprains. Six weeks of strength and proprioception training does not affect muscle fatigue and static balance in functional ankle instability. Effect of six weeks of dura disc and mini trampoline balance training on postural sway in athletes with functional ankle instability. Star excursion balance training: effects on ankle functional stability after ankle sprain. Enhanced balance associated with coordination training with stochastic resonance stimulation in subjects with functional ankle instability: an experimental trial. Original research: long-term efficacy and safety of periarticular hyaluronic acid in acute ankle sprain. Extensor retinaculum augmentation reinforces anterior talofibular ligament repair. Anatomic reconstruction of the lateral ligament complex of the ankle using a gracilis autograft. Surgical versus conservative treatment for acute injuries of the lateral ligament complex of the ankle in adults. Clinical outcome after anatomical reconstruction of the lateral ankle ligaments using the Duquennoy technique in chronic lateral instability of the ankle: a long-term follow-up study. Anatomical repair of lateral ligaments in patients with chronic ankle instability. Operative and functional treatment of rupture of the lateral ligament of the ankle. A randomized, prospective study of operative and non-operative treatment of injuries of the fibular collateral ligaments of the ankle. Acute syndesmosis injuries associated with ankle fractures: current perspectives in management. Conservative versus operative treatment for displaced ankle fractures in patients over 55 years of age. A prospective trial comparing operative and manipulative treatment of ankle fractures. Tibial plafond fractures treated by articulated external fixation: a randomized trial of postoperative motion versus nonmotion. Maisonneuve fracture without deltoid ligament disruption: a rare pattern of injury. The use of weightbearing radiographs to assess the stability of supination-external rotation fractures of the ankle. Is pulsed shortwave diathermy better than ice therapy for reduction of oedema following calcaneal fractures Computed tomography of calcaneal fractures: anatomy, pathology, dosimetry, and clinical relevance. Displaced intra-articular calcaneal fractures: 15-year follow-up of a randomised controlled trial of conservative versus operative treatment. The association between subtalar joint motion and outcome satisfaction in patients with displaced intraarticular calcaneal fractures. Complications following management of displaced intra-articular calcaneal fractures: a prospective randomized trial comparing open reduction internal fixation with nonoperative management. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Syndesmosis fixation: a comparison of three and four cortices of screw fixation without hardware removal. Does a positive ankle stress test indicate the need for operative treatment after lateral malleolus fracture The influence of three-dimensional computed tomography reconstructions on the characterization and treatment of distal radial fractures. Computed tomography scanning of intra articular distal radius fractures: does it influence treatment Radiography versus computed tomography for displacement assessment in calcaneal fractures. Ultrasonographic examination of the deltoid ligament in bimalleolar equivalent fractures. The use of sonography for evaluation of the integrity and healing process of the tibiofibular interosseous membrane in ankle fractures. A case study: application of ultrasound to determine a stress fracture of the fibula. Double-blind randomized prospective study of the efficacy of antibiotic prophylaxis for open reduction and internal fixation of closed ankle fractures. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Single-dose versus multiple-dose antibiotic prophylaxis for the surgical treatment of closed fractures. Effect of nasal salmon calcitonin on post traumatic osteopenia following ankle fracture. Do steroids, conventional non-steroidal anti-inflammatory drugs and selective Cox-2 inhibitors adversely affect fracture healing Intra-articular block compared with conscious sedation for closed reduction of ankle fracture-dislocations. The efficacy and safety of the hematoma block for fracture reduction in closed, isolated fractures. Hematoma block for ankle fractures: a safe and efficacious technique for manipulations. Comparative study of functional bracing and plaster cast treatment of stable lateral malleolar fractures. Complication rates following open reduction and internal fixation of ankle fractures. Management of complications of open reduction and internal fixation of ankle fractures. Displaced tibial shaft fractures: a prospective randomized study of closed intramedullary nailing versus cast treatment in 53 patients. Comparative multicenter study of treatment of multi-fragmented tibial diaphyseal fractures with nonreamed interlocking nails and with bridging plates. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. Treatment of distal tibia fractures without articular involvement: a systematic review of 1125 fractures. A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. Distal metaphyseal fractures of tibia: a prospective randomized trial of closed reduction and intramedullary nail versus open reduction and plate and screws fixation.
Placebo Group Also mood disorder medications best bupropion 150mg, no an influence chevron sham significant on outcome 6 osteotomy depression symptoms essay generic 150 mg bupropion with amex. A pragmatic comparative trial found no difference between manual manipulative treatment and a night splint at 1 week depression symptoms of cancer buy bupropion 150mg with amex, although better outcomes were reported at 1 month and sustainability was not reported mood disorder types buy bupropion with american express. Surgical Considerations Surgical procedures are generally attempted for moderate to severe hallux valgus. These procedures include distal soft tissue procedures, first metatarsal osteotomies, proximal phalanx osteotomies, fusion, and resection arthroplasties) options. However, some evidence suggests better outcomes with milder cases and those cases should have pain clearly localized to the bunion prominence while also demonstrating inadequate relief with shoe wear adjustments. Risk factors are not defined in quality epidemiological studies, but theorized to include biomechanical dysfunction, hereditary factors, high-heeled or poor fitting shoes, and trauma. There are various surgical procedures used (arthroplasty, flexor tendon transfer, flexor tenotomy, extensor tendon lengthening and metatarsophalangeal joint capsulotomy, fusion, and diaphysectomy) interventions. The incidence of ankle fractures has been estimated to be 107 to 184 per 100,000 person years,(625) (Lin 09) and accounts for approximately 9% of all fractures. Ankle Fractures Most ankle fractures are produced by abnormal motion of the talus, which either pushes off, or, by means of ligamentous attachments, pulls off an alveolus. Type B commonly results from external rotation, and is associated with or without tibiofibular ligament Type C are commonly from adduction (C-1), causing mediolateral oblique break above a ruptured tibiofibular ligament. Type C-2 results from abduction and external rotation, producing more extensive interosseous rupture and more extensive fracture high on the fibular. Both of these classification systems are noted to have significant shortfalls and therefore are used as guides rather than absolute rules in determining management course. Isolated medial malleolar fractures and pilon fracture do not fit into the Weber classification system. Further, the Weber Classification has not been found to be an accurate predictor of complex bimalleolar and trimalleolar fractures, and the Lauge-Hansen classification prediction model has been demonstrated to have significant discrepancies of predicted injury with actual injury. A disruption in one place along the ring is generally considered stable, whereas integrity compromise in two locations is unstable and may result in dislocation and poor outcome if not managed appropriately. In general, undisplaced or minimally displaced injuries are treated non-operatively, whereas displaced or unstable injuries are treated operatively. Tibial fractures involving the tibial plafond result from low or high-energy injuries, and can be described with either classification scheme or as a pilon fracture. Pilon fractures of the tibia result from a high-energy injury such as a fall from heights or motor vehicle accident. The resultant high-energy forces are transmitted axially, causing the talus to impact the tibial articular surface, resulting in fracture of the distal tibia. Fibula Fracture Fractures of the fibula are commonly caused by eversion injuries with ankle sprain, and may be in isolation or associated with tibia fractures. The Maisonneuve fracture, considered to be one of the most unstable ankle injuries,(653) (Charopoulos 10) occurs when an external rotational force is applied to the fixed foot. The course of damaged tissue runs from the tibia, fractured at the ankle, up through the interosseous membrane and ends with a fracture of the proximal third of the fibula, and may result in unstable syndesmosis and bony avulsion or disruption of the syndesmotic ligaments. It transfers vertical weight bearing forces to horizontal support structures of the foot through major articulations with the heel and ankle. Fracture of the talus may involve the head, neck, body, or lateral process (snowboarder fracture). These should be suspected when chronic pain, stiffness, weakness or instability continues for weeks to months following ankle trauma. Calcaneus fractures account for 1 to 2% of all fractures in adults, and often occur in industrial workers most typically jumping or falling from heights or involved in motor vehicle accidents. Approximately 8 to 10% of all displaced intra-articular calcaneal fractures are bilateral. Fractures of the body are more severe as they are related to disruption of the talonavicular and cuneonavicular joints. Frequent cause of Lisfranc injury is when the patient has their foot on the brake and is involved in a car accident. Metatarsal Fractures Metatarsal fractures are usually the result of inversion injury, fall from height or dropping an object on the forefoot. Fifth metatarsal fractures are characterized by where they occur relative to the tuberosity. Avulsion fractures of the tuberosity are the most common fractures of the proximal 5th metatarsal. Phalangeal Fractures Injuries to the toes are usually secondary to stubbing injuries and direct blows from crush injuries. Initial Assessment It is important that clinicians understand the basic anatomy of the ankle and foot in order to assess injuries. The physician performing an initial evaluation of a patient with ankle injury should seek to identify conditions that require immediate treatment. Conditions that require immediate attention include open fracture, vascular compromise, compartment syndrome, and joint dislocation. Medical History the physician should attempt to obtain detailed information on mechanism of injury, symptoms, previous injury, and pertinent past medical history. Symptoms and the progress of symptoms over time should be documented, including pain at initial injury, ability to continue work activities, and pain quality over time. Rupture of the distal tibiofibular syndesmosis frequently occurs in association with external rotation ankle injuries and may give a history of pain in the high ankle. Because of axial transmission of force, these patients should be evaluated for spinal and visceral injuries. Tarsal fractures occur with both inversion and eversion type injuries and are characterized by pain in the hind and mid foot. The history of stress fractures often includes increased physical activity or increase in intensity of activity preceding symptoms. Palpation of bony structures should include the length of the tibia and fibula, the medial and lateral malleoli, mortise syndesmosis, anterior calcaneus, lateral and posterior talus and the base of fifth metatarsal. Workplace Intervention Work Restrictions Distal lower extremity, ankle, tarsal, and foot fractures will most often result in limited or non-weight bearing for a period of time. Management of edema for some fractures, particularly hindfoot and midfoot fractures, may require prolonged elevation of the injured leg. Casting, walking boot, or external hardware can impair ability to drive, walk, perform prolonged standing, climb stairs, work at heights, climb ladders, and other similar safety sensitive activities. The length of time of restrictions depends on the fracture, intervention, and healing rate of the patient, but can last from several weeks to several months. Initial Care the initial treatment of foot and ankle fractures is dictated by injury type (displaced or stable, open or closed) and by concomitant soft tissue injury. Management should be initiated for severe swelling, compartment syndrome, and skin integrity breakdown from fracture blisters. Presence of acute ankle edema greater than 13 to 15mm compared to uninjured ankle may indicate occult fracture. For ankle and foot sprain injuries, the Ottawa Ankle Rules are widely used as a screening tool to predict the absence of fracture (see Ankle Sprain for further discussion). Evidence for the Use of X-ray for Evaluation of Ankle Fractures There are no quality studies incorporated into this analysis. The sensitivity and specificity for diagnosis of the rupture of the interosseous membrane is reported at 88 and 94% compared with intraoperative findings. Ultrasound imaging may be a useful adjuvant to clinical assessment of patients with regards to selection for further radiological examination,(695) (Chen 08) and is therefore recommended in select patients. Evidence for the Use of Ultrasound for Evaluation of Ankle Fractures There are no quality studies incorporated into this analysis. Follow-up Visits No quality evidence exists for specific follow-up care of ankle fractures outside of identified recommendations listed in this section. Changes in ankle girth should be monitored for reduction in swelling after the immediate injury. Purchase 150 mg bupropion with amex. What does it mean to be clinically depressed ? | Health FAQ Channel.
If abutment teeth are locked into the frameworks they can be torqued in many directions depression symptoms and medication purchase 150mg bupropion. Stress-relieving clasps allow for some release of the teeth to minimize torquing potential anxiety xanax and asthma cheap bupropion express. Three Axes of Rotation of a Partial Denture Rotational movements increase with length of span of the distal extension anxiety bc 150 mg bupropion free shipping. Also as arm flexibility increases depression symptoms in kittens order cheapest bupropion, resistance to lateral displaceability decreases. Therefore, it is important to use maximum coverage of the edentulous ridge to reduce the degree of lateral movement. This is particularly effective when there are large, broad ridges which tend to provide greater resistance to horizontal movements. Flabby tissue is more displaceable leading to increased rotation and therefore increased potential for stress transference to the abutment teeth. Principles of Partial Denture Design 68 General Considerations Consider Soft Tissue Variables Soft tissue anatomy such as frenal attachments and vestibular depth can affect the choice of major connectors, and direct retainers. Characteristics of the soft tissues, such as undercuts and tissue compressibility of attached mucosa, may also affect design decisions. These aspects of the tissue need to be identified intraorally, since they can frequently not be determined solely on the basis of a diagnostic cast. Consider Hard Tissue Variables the opposing occlusion, significant abutment mobilities, the access to embrasures, presence of rotations, the positions of tooth undercuts and the presence of restorations can all influence the selection of direct retainers. Design Sequence In general, after the path of insertion and the abutment teeth have been selected, the positions of the rests for the partial denture are chosen, since their placement will affect other parts of the design. Indirect retainers Drawing the Design When drawing a design on a cast, sharpened, coloured pencils should be used. The following colours will be used to designate various components at Dalhousie University: Red: Retentive undercut, Wrought wire arms Blue: All other elements Clinicians should use absolute accuracy in drawing their desired framework elements, in order to avoid guesswork on the part of the laboratory technician. In order for technicians to place elements in proper position, with proper proportions, the design should be drawn with single distinct lines. Principles of Partial Denture Design 69 Summary of Design Principles for Removable Partial Dentures General Principles Minimize framework elements (minimize minor connectors, plating, etc. Draw design & list abutment modifications on the Prosthesis Design page (see attached) 4. Process, adjustment, deliver to patient Clinical Protocol, Final Impressions 80 Diagnosis & Treatment Planning Gather all diagnostic information required for treatment planning complete or partial denture therapy. Treatment plans should be specific, detailing the direct retainers and the degree of undercuts selected, the major connectors to be used, the position of rests, guiding planes, bracing and retentive arms and abutment modifications. No removable partial denture preparations will be allowed to commence unless the final design has been entered and signed for approval in the chart and drawn on the diagnostic cast. Before discussing specific partial denture treatment plans with an instructor, discuss the proposed treatment with an instructor. Students will be expected to defend their treatment plan, based on theoretical considerations discussed pre-clinically. The student is not expected to be able to correctly treatment plan all cases upon initial exposure to the clinic. However, as the student progresses through the clinical experience they will be expected to improve in their diagnostic and treatment planning skills. The instructor may modify treatment plans after the case has been presented and discussed. Final Impressions for Partial Dentures Framework Impressions All framework impressions should be made in a border molded custom tray. A custom tray is a tray made specifically for a cast made from a preliminary impression. It allows closer adaptation of the tray to the tissues so there is less soft tissue displacement. It reduces cost of the final impression by decreasing the amount of impression material needed and it results in greater accuracy of the impression because a more uniform thickness of material. Border molding is the shaping of the border of a custom tray by manipulating the tissues adjacent to the borders to duplicate the contour and size of the vestibule. Custom trays for removable partial dentures are usually border molded in the edentulous areas and areas where framework elements will be close to vestibular tissues. Clinical Protocol, Final Impressions 81 Custom trays should have two thicknesses of baseplate wax spacer over the remaining teeth and one thickness over edentulous ridges. Two thicknesses of baseplate wax over the dentulous portion of the tray provide additional space for increased flexibility to help prevent breakage of the teeth during separation of the impression from the model. The tray should be short of the vestibular depth in dentate areas remote from abutments or framework. When border molding is completed, the custom tray should be stable at rest and during slight manipulation of tissues and the flanges should extend to height of vestibule. Particular attention should be focused on the peripheral extension of the anterior lingual portion of mandibular trays. Overextension in this area will result in a cast with an inaccurate registration of the level of the floor of the mouth, which can affect the selection of the major connector. Similarly, attention should be focused on the extension of the tray in areas of frenal attachments or areas of minimal vestibular depth. Overextension in these areas can result in a master cast that appears to allow for the selection of infrabulge direct retainers even thought soft tissue contours dictate otherwise. The posterior extension for maxillary bilateral extension cases should be marked at or anterior to the vibrating line prior to the impression so that the line can be transferred to the impression and thus the master cast. Do not err in marking the posterior limit past the vibrating line, since the metal will have to be shortened. If the metal is shortened the beading on the posterior border of the denture will be lost, possibly allowing for food to get under the denture. All framework impressions will be made with polyvinyl siloxane material in custom trays. These materials have the following properties, which make them a the impression material of choice for removable prosthodontics: a) low viscosities available (less tissue distortion) b) excellent dimensional stability c) good tear strength d) no taste Polyvinyl siloxanes are sensitive to latex glove powder contamination, so try to minimize or avoid contact of the tray in areas where the impression material will contact. Early silicone impression materials were severely hydrophobic causing bubble formation during pouring, but most materials have improved significantly in this regard. Prior to making a final impression of the mouth preparations, make an alginate impression and pour it in quick setting plaster, and survey the resulting cast to ensure optimum preparations have been achieved. A small amount of alginate should be wiped into the rest seats and over guiding plane surfaces prior to seating the filled impression tray. The student may repeat this process several times if required, but should discuss additional preparations with their instructor before proceeding further. Final impressions cannot be made if there is any plaque or calculus on the teeth, since this will affect the fit of the framework. Therefore it is essential to ensure proper oral hygiene and prophylaxis prior to the tooth preparation appointment. Failure to do so Clinical Protocol, Final Impressions 82 will result in an unacceptable master cast. Additionally, soft tissues should be healthy with no evidence of inflammation or ulceration. Light-bodied impression material should be syringed around the abutment teeth ensuring proper coverage of guiding planes, rest seats and retentive areas. Increased filler content of medium body material will cause less shrinkage of the material during polymerization, and the use of these viscosities will cause less displacement of soft tissues than high viscosity materials. The tray should not be over-filled since gross excess will distend the soft tissues, resulting in an inaccurate impression. Large embrasures or bridge pontics may be blocked out with orthodontic wax using care to avoid placement on occluding surfaces or near abutments. This will make removal of the impression easier, and minimize possible distortions of the impression. |
