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NEMT 9 New England Master Track Program (RPD): September 23-24, 2011 Roya Zandparsa, DDS, MSc, DMD Associate professor Tufts
University School of Dental Medicine Email:
roya.zandparsa@tufts.edu Guideline for Case presentation: All
candidates must submit a patient history and treatment record of a patient for whom the required fabrication of at least one
cast partial dentures involving the maxilla or the mandible has been completed. The partial denture can be a removable partial
denture of any classification. The partial denture may be retained
by natural teeth or by implants. The opposing arch may include (1) an appropriately restored natural dentition
which may or may not incorporate fixed or removable partial dentures; (2) a complete denture or overdenture or; (3) an implant
prosthesis. Valplasts, Interim, or transitional RPDs are not acceptable. The following aspects
of therapy must be described in the order given: 1.
History and chief complaint 2. Clinical findings 3. Diagnosis 4.
Treatment plan and prognosis 5. Treatment 6. Instructions to patient and Post-treatment therapy.
The candidates must include: (note: the highlighted parts are
optional)1. Pre-treatment Records(a) A complete radiographic series made prior to therapy (b) Pre-treatment casts. If the patient
has removable prostheses prior to treatment, casts should be presented with and without the prostheses in place. The casts
without the prosthesis in place should be mounted.(c) Pre-treatment photographs Photographs must clearly show at least:- teeth in maximum intercuspation- teeth in right and left working and non-working positions (frontal and lateral
views)- teeth in protrusion (frontal and lateral views)- occlusal views of maxilla and mandible. If patient has removable prostheses prior to treatment, photographs should be made with and without the prostheses
in place. 2. Post-treatment Records a) A complete radiographic series made after completion of therapy b) Mounted casts with the prostheses in place.c) Post-treatment photographs of the same size as the pre-treatment photographs and showing the same views.
Photographs should be made with and without removable prostheses in place.3. Casts with the diagnostic wax patterns, if used.4. Casts and dies used in fabricating the fixed restorations.5.
Duplicate master cast(s) showing the design of the removable partial denture(s). - Any
personal data in conflict with the Privacy Act, i.e., the patient's name, address and social security number will not be used
in the presentations; however, the age, sex and race of the patient should be included. Full-face photographs that could identify
the patient must have the eyes blocked out or a clearance document presented that includes the patient's written permission
to use a full-face photograph.- The candidate should be prepared
to make a defense of the patient treatment during the Part 2 oral examination. Sample
Presentations for RPD History and Chief Complaint: The
patient, a 38 year old caucasian male, was referred for prosthodontic treatment. His chief complaints
in rank of priority were: "I want to chew better on the left side of my mouth and I want to fix up the rest of my
teeth." The patient did not complain of any pain or physical discomfort.Medical History: A review
of the patient's medical history and health questionnaire revealed that the patient is in good physical condition. Vital signs:
BP - 122/80, P - 62, R- 12. He denies being under the care of a physician, nor is he taking any medications.He presents with no contraindications to any dental treatment.Dental History: Over the past fifteen years, the patient has received regular dental care.During the last three years, the patient underwent endodontic therapy for teeth #'s 28, 29, and 30; received
crowns on teeth #'s 28, 29, and 30; and had tooth #12 extracted due to non-restorable caries. His third molars were extracted
as an elective procedure, and teeth #'s 18, 19, and 31 were extracted due to non-restorable caries. A mandibular removable
partial denture replacing teeth #'s 18 and 19 was made for the patient in 1982. Due to what the patient considered a poor
fit, the patient discontinued using the removable partial denture after six months. His oral hygiene consists of daily brushing
(two times a day) and sporadic flossing (two to three times a week).CLINICAL FINDINGSExtraoral
Findings: The patient exhibited no muscle
tenderness nor palpable nodes.Hemifacial asymmetry,
right side greater than the left. Mandibular range of motion was within normal limits and the temporomandibular joint was
asymptomatic.Intraoral Findings: Multiple blue pigmented lesions were noted on the buccal mucosa,
in the areas of #s 3, 19, 20, 21, & 30 and a raised whitish lesion was noted on the buccal gingiva of #21. Otherwise,
the soft tissues of the lips, tongue, oral mucosa, and pharynx were without pathosis or anatomic anomaly. Salivary flow was
copious and of a serous consistency. The edentulous ridges were broad and rounded with firm, attached gingiva. Missing teeth#s
1, 2, 12, 16, 17, 18, 19, 31, & 32. Defective restorations #3, 4, 27, 28, 29, & 30. Caries #4 mesial. Moderate attrition
noted on teeth #s 3, 4, 5, 6, 11, 13, 21, 22, 26, & 27. No teeth demonstrated clinically detectable pathologic mobility.
Short clinical crowns on teeth #s 3, 4, & 5. All teeth responded to electric pulp testing except for teeth #s 28, 29,
& 30.Periodontal Findings: The patient exhibited generalized mild gingivitis, generalized
1-3 mm probing depths and minimal bleeding on probing. #s 2, 3, 15, & 28 had 4-5 mm probing depths. Class I furcation
involvement was noted on teeth #s 2 B&D, 3 M, 14 B, 15 B&D, & 30 B. 3-4 mm band of keratinized gingiva was present
except on facial of tooth #28 which had gingival recession. Abnormal marginal ridge relationship between #27 & 28.Occlusal Findings: Anterior teeth had 3 mm of vertical overlap and 7 mm of horizontal overlap. Class
II cuspid relationship on the right. CO-MIP was not coincidental. CO contacts were 3/30, 13/20. Protrusive mandibular movement
was guided by incisors and canines. Patient exhibited a group function disclusion pattern during lateral mandibular movements.
Teeth #s 2, 14, & 15 were supererupted, #27 was rotated, and #s 22, 23, and 26 were tilted. Patient denied any bruxism
or other Parafunctional habits.Radiographic
Findings: Patient exhibited a generalized
dense trabecular bone pattern. Localized horizontal bone loss was noted on teeth #s 2, 15, 20, 28, and 30. #3 had a vertical
defect on the mesial. #s 4, 5, and 13 exhibited widened PDL spaces and thickened lamina dura. Crown to root ratios were generally
1:2, except for teeth #s 2 and 15 which were slightly better than 1:1. Other findings include radiopacities in area of #s
18/19, and 32; calculus distal of #2. #s 28, 29, & 30 exhibited a history of root canal therapy.DIAGNOSIS 1.
The patient presents with excellent medical health and has no medicalcontraindications to prosthodontic treatment.2. Periodontal consultation confirmed generalized marginal gingivitis with localized mild periodontitis associated
with teeth #s 2, 3, 15, and 28; minimal attached gingival and gingival recession associated with #28; furcation involvement
on teeth #'s 2, 3, 14, 15, and 30; rotation of #27 has caused an abnormal contact relationship between teeth #s 27 and 28.
Oral hygiene is adequate to prevent generalized periodontitis.3. Maxillary and mandibular partial edentulism exists resulting in supereruption ofteeth #s 2, 14, and 15, occlusal plane discrepancy and reduced interarch distance
between the left maxillary tuberosity and mandibular retromolar pad. Loss of posterior support has contributed to excessive
wear on teeth #s 3, 4, and 13; with opposing porcelain restorations contributing to the wear on teeth #s 3 and 4. Excessive
occlusal forces are a likely contributor to the widened PDL spaces and thickened lamina dura associated with teeth #s 4, 5,
and 13. The patient is a dental Class II, div. 1. Group function disclusion pattern was a result of existing restorations,
wear and tooth movement. A Denar pantographic survey indicates that mandibular movements are reproducible and smooth.4. Defective restorations in teeth #s 3, 4, 28, 29, 30. Short
clinical crowns on teeth #s 3, 4, & 5.5. Oral
pathology consultation confirmed gingival discolorations were consistent with a diagnosis of amalgam tattoos; and the whitish
lesion buccal to #21 was consistentwith a diagnosis of a fibroma of unknown etiology. The radiopaque objects in the area of
#18 and #19 were judged to be foreign bodies consistent with the diagnosis of amalgam particles, while the radiopaque object
in the area of #32 was considered to be a foreign body.6. According to House's personality classification, the patient was judged to be"philosophical". He had reasonable expectations and desires with regards toanticipated dental treatment.TREATMENT PLAN The following treatment
plan was based on clinical findings, evaluation of articulated diagnostic casts, and periodontic and endodontic consultations.Phase I: Preliminary Treatment1. Present and discuss proposed treatment plan with patient and obtain approval.2. Oral health counseling, dental prophylaxis, and prescription
for chlorhexidinegluconate rinse.Phase II: Clinical treatment1. Crown lengthening #'s 3, 4, 5, & 13. Distal wedges and tuberosity reductions
bilaterally. Pocket reduction mesio-lingual #3.
Scaling and root planing.2. Occlusal equilibration
to provide coincidence at centric occlusion and maximum intercuspation. Remake diagnostic casts and remount.3. #3 Full veneer ceramo-metal crown.#4 Full veneer ceramo-metal crown.#5
Three-quarter partial veneer gold crown.#27 Composite,
lingual.#28 Full veneer ceramo-metal crown and
mesial rest seat.#29 Full veneer ceramo-metal
crown.#30 Full veneer gold crown, distal rest
seat, and mesial-buccal 0.01 inchundercut.4. #11-13 Fixed partial denture (Type III gold).#11 & 13-partial veneer retainers.#12 Acrylic-metal modified ridge lap pontic#14 Full veneer acrylic-metal crown (Type III gold).#15 Full veneer metal crown (Type III gold).5. #20 Mesial rest seat and distal guide plane#21 Mesial rest seat6. Mandibular Kennedy
Class II removable partial denture replacing #18,19, with chrome cobalt alloy framework, lingual plate
major connector, and acrylic resin bases.Phase
III: Post insertion treatmentPost insertion instructions,
prosthesis adjustment, and establish periodic recall program. TREATMENT Phase I; II, 1., 2. - Following a thorough explanation of all treatment options, objectives and limitations, the patient consented
to the proposed treatment plan. The patient received a dental prophylaxis, stannous fluoride application, oral hygiene instructions
and a prescription for chlorhexidine gluconate. A periodontist completed crown lengthening, distal wedge procedures, and scaling
and root planing.Diagnostic casts were made using
irreversible hydrocolloid (Jeltrate) and improved dental stone (Diekeen). Casts were mounted on a Denar D5-A articulator using
a kinematic hinge axis facebow and centric relation wax records. A diagnostic equilibration was done on the casts and was
repeated on the patient clinically using the diagnostic casts as a guide. The coincidence of CO and MIP was verified at a
follow up appointment. New diagnostic casts were made and mounted using a kinematic hinge axis facebow and new wax centric
relation records. An electronic pantographic recording was made and used to program the articulator.A Broderick occlusal plane analyzer was used to assist in occlusal plane development.Diagnostic tooth preparations and wax-ups were completed, duplicate
casts werefabricated in stone, and vacuum formed
templates were made to be used aspreparation reduction
guides and stents for interim restorations.Phase
II, 3. - Defective restorations were removed from
#'s 27-30. A composite resin was placed in #27. Existing tooth structure and post and cores of #'s 28-30 were determined to
be clinically acceptable. #'s 28-30 and 3-5 were prepared according to the treatment plan. Gingival tissues were retracted
using braided retraction cord (Gingi-pak)and aluminum chloride (Hemodent). Full arch impressions were made of #'s 3-5 and
28-30 using polyvinyl siloxane impression material (Extrude) in custom acrylic resin trays.Provisional restorations were fabricated in autopolymerizing acrylic resin (Jet)
using thedirect method and the polyvinyl stents, and luted with an interim cement (Tempbond).Working casts were made using Diekeen and the Pindex system. Using a crossmounting technique and interocclusal bite registrations, the
casts were mounted on the articulator. The dies were sectioned, trimmed, marked along the margins, painted with die spacer
(Belle de St Claire), and then coated with a thin layer of cyanoacrylate adhesive. Restorations were waxed to full contour
and occlusion according to the treatment plan and using the diagnostic wax-up as a guide. Ceramo-metal crowns were cut back.Ceramo-metal and gold crowns were invested in phosphate-bonded
investment(Ceramo-gold) and in gypsum-bonded investment
(Beautycast), respectively. Ceramometal crowns and gold crowns were cast in gold-palladium alloy (Olympia) and Type III gold
(Firmalay), respectively. The castings were roughly finished and fit was verified on the dies and working casts. The castings
were tried in the mouth to verify fit and occlusion.Porcelain
(VMK-68) was fused to the ceramo-metal crowns. Ceramo-metal crowns were tried in the mouth to verify esthetics and contours,
and then stained and glazed. After a trial wear period, the crowns were removed, air abraded on the intaglio surfaces with
50 micron aluminum oxide, polished, and cleaned in an ultrasonic cleaner. The prepared teeth were cleaned with flour pumice
and vital teeth were coated with a copal varnish (Copalite). All castings were luted with a zinc phosphate cement (Fleck's).Phase II, 4. - #'s 11-15 were prepared according to the treatment plan. A full archimpression was made, interim restorations were made, and working casts wasfabricated and mounted following the same technique as in Phase II, 3. Restorations were waxed, cast, fitted
and adjusted following the same techniques used in Phase II, 3.Restorations planned for acrylic veneers were finished and polished, silicoated (Kulzer), and veneered with
light activated composite resin (Dentacolor). All castings were cemented following the techniques used in Phase II, 3.Phase II, 5. - Rest seats and guide planes were prepared on #20 and #21, according to the treatment plan. The teeth were
cleaned with flour pumice. A master cast for the framework was made using irreversible hydrocolloid impression material and
Diekeen.A design cast, the tripoded and surveyed
master cast, and a work authorization were sent to the laboratory for framework fabrication in a chrome cobalt alloy.The RPD framework was adjusted intraorally and physiologically
relieved. A mandibular corrected cast was made using light body polysulfide rubber impression material (Permlastic) and Diekeen.
A new maxillary working cast was made and cross-mounted against the mandibular working cast. The mandibular corrected cast
was mounted in MIP using an interocclusal record.Phase
II, 6. - Removable partial denture teeth were
set on the frameworkand the RPD was waxed to full
contour. A wax try-in was performed to verify occlusion and contours. The finalized RPD was flasked and processed with heat
activated acrylic resin (Ch Lucitone). The prosthesis was recovered, a laboratory remount was completed, and the RPD was finished
and polished.The removable partial denture was
inserted and adjusted intraorally with pressure indicating paste. A clinical remount was used to adjust the occlusion. The
prosthesis was polished and delivered to the patient. Post insertion instructions, to include proper home care and handling
of the prosthesis, were reviewed. Post insertion adjustment appointments were scheduled for 24, 72, and 168 hours later. INSTRUCTIONS TO PATIENT Oral hygiene
instructions included a review of sulcular brushing with a soft bristled tooth brush, flossing, and use of a special floss
(Super-floss).Instructions concerning the removable
partial denture included:1. The removable partial
denture needs to be cleaned after each meal with a proper brush and denture paste or liquid hand soap. The denture should
be cleaned over a rubber mat, towel, or water-filled basin to preclude breakage if dropped. The denture should not be squeezed
while brushing. A sample of a denture cleanser with instructions was given to the patient. He was advised not to soak the
denture in bleach solutions.2. The patient was
instructed to remove the partial denture nightly for a period of approximately eight hours. The partial denture should be placed in water to preclude dessication and distortion
of the resin.3. The denture should not be adjusted
by the patient. If a problem arises with fit or retention, the patient should return to the dentist.4. The partial denture should be inserted with finger pressure only. Occlusal forceshould not be used to seat the denture into position.5. The patient was instructed concerning wearing the denture
and what to expectduring its use.POST-TREATMENT THERAPY The patient was seen on a 24 hour follow-up visit at which time the patient stated there was a slight irritation
under the denture base. Pressure-indicating-paste was used to locate the area of irritation and the denture base was adjusted.
At the 72 hour follow up visit the patient indicated there were no problems. He was seen at one and two week recall visits
during which he stated there were no problems and that he was pleased with the esthetics, fit and function of his prostheses.
He was informed of the possible changes of the tissue under the denture base and the need for periodic visits to assure the
fit of the partial denture. Six month prosthodontic and periodontic maintenance recall visits were scheduled.PROGNOSIS The prognosis of the treatment plan is good to excellent, in view of the fact that the patient
has responded favorably to oral hygiene instructions. His low caries activity, stability of remaining teeth, and improved
oral hygiene suggests that restoring posterior support on the left side and incorporating a coordinated pattern of disclusion
will extend the longevity of the patient's existing dentition. Long term prognosis will depend on continued good oral hygiene
practices and periodic recall
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