05 diagnostic app 1
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TheFirstOiagnosticppointment
E Importance f theDiagnosticPhiseof Treatment
Many ailuresn removable art ialdenlure reatment
c a n b e t r a c e d o i n a d e q u a t e i a g n o s i s n d i n -completereatment lanning. herefore, thorough,
proper ly equencedreatment lan s essent ialo suc-
cessfulemovableart ial entureherapy. he ormu-
acion f an appropr iacereatment lan equiresare-
' ; l e v a l u a t i o n f a l l p e r t i n e n t i a g n o s t i c a t a '
r fo rmat ionmust be obta ined rom pat ien t n te r -
. ervs, adiographicvaluat ion, ral examinat ion,i-
. gnos t icmount ing f cas ts , re l iminaryurvey nd
: es ignp r o c e d u r e s ,nd a p p r o p r i a t eo n s u l t a t i o n s
, ' , h medical nddental pecial ists.oo of ten, hede-
- . - : r f a removableart ial enturesdeterminedfter. otherphases f pat ient reatment avebeen om-
: =:ed. hisapproach eneral lyesultsn fai lure. eci-
. :"s regardingeeth o be retained, urgical roce-
:-"es !o oe emproyed,nd restorat ionso be placed
* -s: bemadewith heult imate esign f theprosthe-
: : - n r i nd .H e n c e , u r v e y n d d e s i g n r ocedu r es
- - : : re cons ideredeye lementsn the d iagnos t ic
: - . : C ;Crea tment .
E Organizinghe DiagnosticExamination
The examinat ion an be completedmost ef fect ively
andexpedit iouslyf two appointments reused'Dur-ing the f irst appointment, thoroughhealthhistory
shouldbe completed nd reviewed. prel iminaryx-
aminat ion f the oral cavity houldbe performedo
iden t i f y o n d i t i o n se q u i r i n gm m e d i a t e t t en t r on ,
and a denta lp rophy lax is nd rad iograph ic urvey
shouldbe completed. inal ly, ccuratemaxil lary nd
mand ibu la rmpress ionshou ld e made,and d iag-
nost ic asts hould egenerated.
Dur ing hesecond ppointment,acebow nd aw
relat ion ecords houldbe made.Using hese ecords,
diagnost ic asts houldbe mounted n an approprt-atedentalar t iculator .n addit ion, def init ive ralex-
amina t ion hou ld ecomple ted . ad iograph icva lu -
at ionshouldbe correlated ith cl inical indings, nd
arrangemen$or consultat ionhouldbe made'Pro-
ceduresor the second iagnos t ic ppo in tment re
descr ibedn chapter .
When al l relevantnformat ion asbeengathere:"
thepract i t ionerhould erform urueynddesigr ' : -
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| 5 | TheFirstDiagnostic ppointment
;eJJres. n rurn,a proper ly equencedreatment lan
s-c; d be ormulated ndpresentedo rhepar ient .
=rHealthQuestionnaire
Thepurpose f a health uest ionnaires o providen-
format ion bouta pat ient 's el l-beingnd o highl ight
potent ial roblems. herefore, healthquesr ionnaire
shouldprovide nformat ion egardingocaland sys-
temiccondit ions hat may affect he pat ient 's reat-
ment.Any posit iveesponsesr quescionablenswers
should eexploredur ing he at ientnterview.
Evaluat ion f a pacienc'slood pressures an im-
portantpart of chehealthevaluat ion rocess.t has
beenest imatedhat more han 20 mil l ionAmericans
exhibit ypercension. l ,2f that number, pproximarelyone half havebeendiagnosed nd one ourth are re-
ceiving dequateherapy.3heseacts houldmot ivate
health rofessionalso screen l l pat ientsor hyperren-
sion.Any pat ientwith syscol icressurexceeding30
m m H g o r d ias t o l i c r essu r ex c e e d i n g0 m m H g
shou ldbe cons ideredo havea po ten t ia l l y e r ious
med ica l ond i t ion o r wh ichmed ica l onsu lca t ions
ind ica ted .
E PatientnterviewThe nexc tep n the examinat ionrocedures he pa-
t ien t n te rv iew. ur ing h is phase f t he d iagnosr ic
process,he pract i t ionerhould stabl ishapportwith
the pat ient , ai n nsight nto the psychologic akeup
of the pat ient , xplore hysical roblemshat mayaf-
fect he treatment, nd determinehe patient's xpec-
rations or restorativeheraov.
Establishingapport
I " J=r l Boucher u r the n i t ia lpa t ien t on tac r n ro
: ' : l : ' r e rspec t ivehenhe sa id , The i r s t i vemin-
- : : : :1 . - : rv i rh pa t iencepresenthemost mporcan t
: : - : - : - - :en t is t -pa t ien tn te rac t ion .a t ien tshou ldt==: - z : : -e :enc is tsgenu ine lyn te res tedn hemand- -= : - , : : : sc l , , ' ehe i r en ta l rob lems. "arac t i t ion -
: ' : - , : : - - - : : , e "ook che mpor tancef thesenterac -
: : - : : : : : -s: :-e ' . epresenthegroundworkor uture
i 2 6
dental reatment.n addicion,hese ar ly nLeraccions
provideessent ialnformat ion egarding at ientact i-
tudes ndexDectat ions.
ln 1961,Dr M. M. DeVan tated, Weshouldmeet
the mind of the Dat ient eforewe meet he mouthof
chepat ient ."s eVan's tatement nderscoreshe im-portanceof effective ommunication etween atient
and pract i t ioner.t is essent ialhat a pract i t ioner n-
derscandhe pat ient 's eeds, esires,ndexpectat ions
beforenit iat ingreatment. hepat ient 's t t i tudes nd
o p i n i o n s e l a t i v eo t h e d e n t i s t n d d e n ti s t r y a n
greadynf luencehe success r fai lureof t reatment.
Many cl inical ly cceptable rosthesesavebeendis-
cardedbecause atients erenot mentally reparedo
receivehem.
Gaining nsight into a patient'spsychologicalmakeup
A pat ient 's sychologicalal<eups an important ac-
tor in dental reatment. sychologicalakeupwil l n-
f luence he dif f iculty f c l in ical reatment, s well as
thesuccessr fai lure f t reatment uccomes.
In 1950,Dr M. M. House lass i f iedac ien tsn to
four majorcategor iesased pon psychologicalhar-
acter ist ics:hi losophical,xact ing, yster ical,nd n-
d i f f e ren t .6 h i losoph ica la t ien ts re he eas ies ro
treat .Theyaremental ly el l adjusced nd easygoing.Theyaccept esponsibi l i tyor having ost heirceeth,
and chey ecognizehe need or prosthet ic eplace-
ment .Fu thermore ,hese at ien ts nders tandhat
theyhavea ro le n main ta in inghe i rden ta lhea l th .
These ndividualsdjust o anyprosthesishat is rea-
sonab ly e l ldes igned nd cons t ruc ted ,nd usua l ly
do not present roblemsor thedent ist .
Exact ing at ients reprecisen everythingheydo.
Theyare mmaculaten dress nd appearance.heir
nature s to be sat isf ied nly by perFect ion.heymay
demand hat the dent is texp la in very tepo f the
t r e a t m e n tn d e t a i l . hese a t i e n c sh o u l dno t be
promisedhat theywil l be ableco weara prosthesis
wi thou tany nconven ience ,ecauseheywi l l expec t
t h e d e n t i s t o l i v eup co suchp r o m i s e s . o c e n t i a l
p rob lems nd nconven ienceshou ld e exp la inedn
detai lbefore reatments nit iated. logical xplana-
t ion may be perceived s an excusef givenafcera
p r o b l e m a sa r i s e n . d d i t i o n a l p p o i n t m e n ti me
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Patient Intervierv
shou ldbe schedu ledor exac t ing a t ienrs ecause
rheydemandund iv ided t ten t ion , f for r ,and pa-
t ience. hese at ients avehighexpectat ionsnd are
Cif f lcult o t reat .Yet,when sat isf ied,hesepar ients
Secome nthus ias t icuppor te rs f t he denc is t nd
,aluable ssetso the dental ract ice.A hyster ical at ient must be recognized efore
i.eatments nit iatedo avoida highly npleasancx-
:er ience or both pat ientand dent ist .Hyster ical a-
: enrsmaybeextremelypprehensiveboutundergo-' rg denca l rea tment . heya lso end ro compla in
, ' .t hou t us t i f i ca t ion . anyareconv incedheywi l l-everbe able o wear dentalprostheses. yster ical
:at ientsdo not accept esponsibi l i tyor anyof their
:ental problems. at ients ho havedebil i rar ingys-
:emicor psych ia t r iciso rders reo f ten nc ludedn
:^ is cacegory.heymust be advisedhat theirdental: 'oblems may be related o systemic r psychiatr ic
, - .ndit ions. djunct ive edical nd psychiatr ichera-
l es may be useful n the treatmentof hysterical a-
: : n r s . U n l e s s h e a t t i t udes f s u c hp a c i e n t s r e
:^anged, he probabil i ty f successfulental rear-- en r i sm i n i m a l .
Indif ferent at ients lso present ignif icanr rob-
=ns for dentalpract i t ioners.ndif ferent ar ienrs re
:-aracter izedy ackof mot ivacion r concern bout
: s r ingora l cond i t ions . hese ar ienrs end o ig -
- : ' 'e ins[ruct ions nd to be uncooperat ivehrough-: ,: r reatment. heymayexhibit i t t leconcern bour
: loearance nd unct ionof the remainingeeth.Un-
.ss thesepat ients an be taught o appreciatehe-3orcanceof replacingmissingeethand maintain--_loral health, he prognosisor dental reatment s
: :o r .
Evaluatinghe effectsofon dental reatment
physicalproblems
r -orher object ive f the pat ient nterviews o evalu-a:: physical roblems hat may af fect he pat ient 's
: - :3. tmenc.osit iveesponsesn the healch uescion--: 'e must be exploredn detai l . he symptoms nd- : .n i fes ta t ionso f d isease hou ldbe rev iewed nd
: . 'e fu l l y eva lua tedo de te rmine o ten t ia le f fec ts
- :on dental reacment.hereare oo manysysremic
: s:urbanceso relyon memory lone. herefore,he
:=cr ir ioner shouldconsuJt urrent eference ater i-
als dur ing his process.When any doubt exists, re
most prudentact ion s to seekmedical onsultat ion
before ental reatments nit iated. nowinghat the
pat ient asa systemicisturbancesnot enough. he
dent istmust understand ow the disease ay affect
t reatment f chepat ient . ol lowing resome ystemicdisturbanceshat can exert ignificant ffects n den-
tal treatment.
DiabetesUncontrol led iabetess f requent ly ccompanied y
mul t ip le mal lo ra l abscessesnd poor issue one.
The disease houldbe broughtundercontrolbefore
prosthodont icreatments nit iated. hedecreasede-
sistanceo infect ion xhibicedy diabet ic at iencs e-
cessitatespecial are ur ing reatment nd ol low-up.
Diabet ic at ients f ten display educed alivary ut-pu t . Th iss ign i f i can t lyeduces pa t ien t ' s b i l i t y o
weara Drosthesisnd ncreaseshe ikel ihood f den-
tal caries.
ArthritisArthr i t ic hangesn the emporomandibularoint of a
pat ientmay produce hangesn occlusion. r thr i t ic
changes lsomaycreate i f f icult iesn the determina-
t ion and ecordingf jaw relat ions.
PagetdiseasePat iencs i th Pagec isease ayshowenlargementf
the maxi l laryuberosit ies.hiscan cause hangesn
the f i t and occlusion f prostheses. f requent ecal l
program houldbe nst i tutedor pat ients i th Paget
d sease.
AcromegalyA patientwith acromegalymay haveenlargement f
the mandible. onsequent ly,at ients i th acromegaly
shouldbe examinedrequendyo evaluatehe fic and
functionof removable rostheses.
Parkinson disease
Parkinson iseases character izedy rhychmic on-
tract ions f the musculature,ncludinghe muscles f
mast icat ion. he symptoms resomet imeso severe
that t is mpossibleor a pat ient o nsert nd remove
a removab le a rt ia lden tu re , e t a loneprac t icehe
ora l hyg iene rocedures ecessaryor the ma in te -
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| 5 | Th eFirstDiagnostic ppointment
nance f oralhealth.mpressionrocedureslsomaybe compromised y the presencef excessiveuant i-
c ies f sa l iva .
PemphigusulgarisPemphigus
u lgar iss a d iseasehar usua l ly eg inswith ormat ion f bul laen rheoralcavitywirh radualextensiono the skin.Before1959, he disease asusua l lya ta l ;however , u r ren t rea tment eg imenshave esultedn a goodprognosis.n theacure nase,oral discomfort nd dryness f the moutn arecom-mon symptoms. hese ymptomsmaybe erroneouslyl inked o thepresencef a removablerosthesis.on-sequent ly,at ients ave een nown o go from den-t ist o dent ist or rhe rel ief f pain,or rhe abr icar ionof newprostheses.hen hediseasesconrrol led ith
appropr iatemedicat ions,at ients an wearprosrne-sessuccessful ly.owever, aremust De aKen o es-tabl ish moorh, ol ished ordersn the inished ros-theses. reater han normalpost insert ionarearsocanbeant ic ipated.
EpilepsyEpi lep t ic ac ienrsresenr pec ia l rob lemsn r reac-ment planning nd restorat iveherapy. grandmalseizure ay esultn fracture ndaspirat ion f a pros-t h e s i s , nd p o s s i b l yhe l o s so f a d d i r i o n a l e e r h .
Therefore, onsulrar ion i th the par ienr,s hysicianshou ldbe car r ied u t be fo re rearmenrs n ic ia ted .The cons t ruc t ion f removab le ar t ia lden tu ressusually ontraindicatedf thepar ient as requenr,e-ve r e e i z u r e sha t occu rw i t h l i t t l eo r n o w a r n i n g .However,f the seizuresrewell control led, r i f thepat ienthasadequate remonir iono permit emovalof prostheses,removableart ial enturemaybe n-d ca ted .
Al l mater ials sed n the construct ion f a oros-: 'es is or an ep i lep t ic a t ien tmusrbe rad iopaque
sc :hacanypar t o f rhe prosrhes ishat i s swa l lowed: ' : . s : i ra red dur inga se izurean be loca ted ad io_
_ i ' a : - c a i l v . f t h e p a t i e n r ' sm e d i c a t i o nn c l u d e s: ^ . - . : J - . on e m u s t a kep a r t i c u l a ra r e o ensu r e: - : : - - . . e - o ' , , ab le p a r t i a l en t u r e oe sn o t r r i t a t e: -= g -_ i, : : ssues . therwise ,ing iva l yper t rophy
CardiovasculariseasePat ients i rh the fol lowing ardiovascularondit ionsrequ i remed ica l onsu l ta t ione fo rehe n i r ia t ion fdental rocedures:
. Acuteor recenc yocardialnfarction
. Unstable r recent nset f angina ector is
. Congestiveeart ailure
. Uncontrol ledrrhythmia
. Unconcrol ledyperrension
Several thercardiovascularondit ions lsomaywarrantmed calconsutat ion.prophylact icant i iot ictherapysalwaysecommendedf surgical roceouresareco beaccomplishedor pat ients ith a congenitalor rheumat icalvular eart isease,ardiacmurmLJrs,
or repaired oarctacionf theaorta.There sconf l ict -ingevidenceegardingheneed or prophylacr ic ed-icat ionwhen esser egreesf t issueraumaareant ic-ipaced, uchas he placement f restorat ionsnd hemak ing f impress ions .n add i t ion ,manyphys ic iansdo noc ecommend nt ibiot ic rophylaxisor pat ientswith a history f rheumat icever f rhere asnor oeencardiac nvolvement. ecause pat ient 's nowledgeof the condit ionmaynot becompletely ccurare,nemostprudent rocedureor thedent ist s o requestmedical onsulrat ion i rh he par ient ,s hysician.
Cancer
Due to its many orms,cancermay affect emovablepart ialdencureherapyn numerous ays. he reat-mentof cancerousesions i th onizing adiat ion ndchemotherapy lso may mpacr emovab le ar r ia lden tu reherapy . ra l compl ica t ionsrea commonsideeffecc f radiar ion nd chemorherapyor malig-nanciesn areas ther han cheheadand neck.Themostcommonoral complicat ionsremucosalrr i ta-t ions, erostomia, acter ialnfect ions,nd fungal n-
fec t ions . hese ond i t ions aycompl ica tehe con-struct ion nd wearof removableart ialdentures. ninves t iga t iononducred y Son is nd co l leaguesn1978 indicated hat 40o/o f all patienrs reatedwirhchemotherapynd radiotherapyor malignancrese-mote from the oral cavitydeveloped ome orm oforalcomplicar ion.The ncidencear iedwith rhe ypeo f m a l i g n a n c y : o d g k i n i s e a s e , 00o / o ;e u k e m i a ,66.7%;mesenchymalancer, 7.5o/o;ynecologican-
13 0
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:z ' . 33.3o/o;on-Hodgkinymphoma, 3.3o/o;deno-
: : ' : inoma of bowel, 0o/o;ndbreast ancer, 1.5%.
lransmissiblediseases- : : a t i t i s , t u b e r c u l o s i s ,n f l u e n z a ,u m a n m m u n o -
: = ' c i e n c y i r u s H l V ) ,a n d o t h e r r a n s m i s s i b l ei s -
: isespose part icular azardor pat ients, ental ux-
= ' i e s , a n d d e n t i s t s .T h e s e d i s e a s e sm a y D e
. - r - sm i t t ed y con t ac tw i t h c o n t a m i n a r e dl o o d ,
: : ,a . aeroso ls ,nd ns t ruments .dd i t iona l azards
= - : dur ing he pros thodont ichases f t rea tment .- : -ession traysand mater ials ay be contaminated- = - i m p r e s s i o n sr em a d e . f i m p r e s s i o n sr en o t
- ' - : e r ly d is in fec ted ,he esu l tan tas ts lsomayper -- : : ie t ransmiss ionf d isease .on tamina tedo l ish --_ . r -ee ls , umice , umice ans , ndpros thesesay
:1-s. aerosolontaminat ionf the aboracorynd he- - - := o f f l ce . ence ,c s mpera t ivehat den ta l e r -
, , - - . cake recaut ionso p reventon tamina t ionnd
: : .ase ransmiss ion .
Evaluatingheeffects f drugson:reatment
- : : ' r t ist or physicianan be expectedo remember--. ==ects, ideeffects, nd interact ionsf al l drugs.- , . : . er ,each en t is ts respons ib leor de te rmin ing
-- - - ned icac ionspat ien t s tak ingand or us ing
: - -":^ : referencenformat ion o determine hat ef-j :
- - r -€S€medicat ions ayhave n dental reatment.- : ' e a s i n ga geu s u a l l ys a c c o m p a n i e dy an i n -
: :1: : n (1) rheneed or some ypeof prosthodont ic- : : : -enr and 2) cheuseof prescr ip t ionnd non-
- ' : : - - 'c r i o nd r u g s . h e p r o p o r t i o n f p e r s o n s n
: - : : , peo f med icac ions 1 in 4 fo r teenagers ,in 3: ' . - - ng adults, in 2 for personsn their40s,and2- I ' : 'personsaged 0 andolder.sTherefore,t least
- . ' l ' -hepat ientsequir ing rosthodont icreatment
: = . : , ro be ak ing neor more rugshatcou ld F'=: . : :^cal t reatment. ol lowing resomeof the fre-
- - . - . . : rescr ibed rugs hat anaffect reatment.
rl:::oagulants
: - . : i - ' _ . ca lb l e e d i n g m a ye a p r o b l e mor pa t i en t s
: - : '_ .anr icoagu lan ts .h is s par t icu la r lyrue o r
: ; ' : - : : ,^32.qoin{ exuaccions,sseousecontour--_: - . , - r r issue urger ies.hese at ients houldbe
referredo quali f ied ralsurgeonsr per iocc-:s- : - - - -
managementf thesurgical hases f t rearme-: .
AntihypertensivegentsThe mos ts ign i f i can tidee f fec t f an t ihyper rens i ,
drugs s or thostat ic ypotension,hichmay esulrn
syncope hena pa t ien t udden lyssumesn upr ighr
posit ion. s a result , aremustbe al<en hen he pa-
t ient isesrom hedental hair . hepat ient hould e
quest ioned bouc eel ing izzy r weak. f symptoms
persist ,he pat ient houldnot be al lowedo leavehe
off ice unaccom an ed.Treatment or hypertension
alsomay nclude rescr ipt ionf a diuret ic gent. his
maycontr ibuteo a decreasen sal iva nd an associ-
ateddrymouth.
EndocrineherapyA pat ient ndergoingndocr ineherapymayexper ience
severe raldiscomfort elatedo dry mouth ie,xerosro-
mia). f the pat ients wear ing prosthesis,t couldbe
mistakenlylamedor causinghediscomfort .
Saliva-inhibitingrugsM e t h a n t h e l i n eB a n c h i n e ,ea r le , an . Ja n ,Pue r t o
Rico) , t rop ine , nd he i rder iva t ivesresomet imes
used o controlexcessivealivary ecretion.hese rugs
are part icular ly sefulwhen a pract i t ioners mal<ing
i m p r e s s i o n s .a l i v a - i n h i b i t i n gr ugs r ec o n c r a i n d i -cated n Dat ients ith cardiac isease ecausef their
vagolytic ffects. hese rugsalsoshouldbe avoidedn
pat ien ts i th p ros ta t ic yper t rophy nd g laucoma.
S a l i v a r yl o w s h o u l db e c o n c r o l l e d y m e c h a n i c a l
meansn hese acients.
Ascertainingapatient'sexpectations ftreatment
An importantobject ive f the interviews to ascer-
tain a pat ient 's xpectat ionsf dental reatment. nt u r n , h e p r a c t i t i o n e r h o u l dd e t e r m i n e h e t h e r
these xpectat ionsre real ist icn the ightof the pa-
t ien t ' s ra l and phys ica l ond i t ions . ny removab le
par t ia lden tu rewi l l compl ica te ra l hyg iene roce-
dures, ccupy pace n the oral cavity, nd require
learn ing nd adapta t ion e r iod . f a pac ien t annor
tolerate these nconveniences,he chances or suc-
cess fu lrea tment re ex t remelyimi ted . f rhe p: -
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t ient 'sexpectat ionsannocbe changed hroughex-
p lana t ion nd educat ion ,rea tment hou ldno t beundertaken.
Obstacleso asuccessfulnterview
Several bstacles ustbe overcome uring he nter-
v iewprocessf a den t is t s to p rov ide ppropr ia te
treatment.he irstobstaclesa lackof at tent ion. oo
often hedent ists ectur ingather han istening. er-
tainlypat ient ducat ionsan mporranr arrof denral
t reatment, ut the pat ient nterviews not the appro-
pr iate ime for pat ienteducacion. aluablenforma-
t ion may be gained rom pat ienrs y simplyal lowing
them o talk.Theiropinions egardingreviousenral
careand current ral condit ionsmay be determined
by as l< ing few genera l uesr ions . a t ienr es i res ,needs, nd expeccat ionslsomay be clar i f ied ur ing
thisport ion f che nterview.
In many nstances,he dent ist s nattent ive hen
observa t ionnd in te rp re tac ionf the pat ien t ' s c -
t ionsare equ i red .he pat ienr ' s ody anguagend
th ings ha t a re e f t unsa idmay be more nd icar ive
than the wordsbe ingused.S imp le c r ions uchas
smi l ingwi th a c losedmourhor p lac ing hehand nf ron t o f the mouthdur ingspeechmay nd icacehe
pat ient 'srue eel ings bout he appearancef hisor
her eeth Fig5-1).Middle-agedar ients aysay hatobtaining ood funct ionand comforr s al l theyex-
pec t rom a par t ia l enrure , h i le he i r mmacu la te
dress,manner isms,r excessiveseof cosmet ics ay
communica teha t appearances of c r i t i ca l mpor -
tance. he dent ist houldbe awareof suchbehavior
before egin ng reatment.
Anotherobstacle o a successfulnterviewmay be
the dent ist 's hoice f words.Professionalerms uch
as esthetics,entric elation, ertical imension,tabilil, hy-pertrophy, nd edemamay be misinterpreted r com-
pletelymisunderstoody he pacienr. at ience,lar iryof speech,nd he use f understandableerms rees-
senr ialh oughout ental reatment.
Par ients aybe reluctanto provide nformat ion
thac hevbelieves rrelevanto dental reatment.nfor-
mat ionaboutsystemicroblems r drugusagemaybe
panicular lvi f f iculco obrain. hedent istmustexplain
the mponance f rhis nformat ion ndbe relent lessnobtaining currenr nd horough isrory.
132
Keys o a successfulnterview
Dentist'sattitude and behavior
A dent ist 's t t i tude nd behavior ur ing he nrerview
have great mpacton its ultimate uccessr failure.
pa t ien twho perce iveshe dent is t s car ing , nder -standing, nd espectfulsmore ikelyo be honest nd
cooperat ive.hedent iscancommunicaLeoncernor
thepat ient yemployinghe ol lowing ehavrors:
1.The dent ist hould ace he par ienr, referably r
the same evel, nd shouldappear elaxed nd un-
hur r iedF ig -2 ) .
2.The dent ist houldmakeeyeconracrwith the pa-
t ient , ooking irect ly t the par ienr nd displaying
comple te t ten t ion a ther han s tudy ing ad io -
graphs r wr i t ing see ig5-2).3. The dent ist houldemployappropr iate eadnod-
ding,verbal ol lowing, nd verbal ef lecr ion.n ver-
ba l o l low inghe dent is rmakes shor tcommenr
suchas " l s e e , " I unde r s t and , "r "Tha t s un -
usual," o ndicate t tent ion o what is being aid
and o encouragehepat iento cont inueo provide
informat ion. erbal ef lect ionnvolvesaraphrasing
what the pat ien thassa id o ensurehat the in -
tendedmeaning asbeen nderstood.
PhrasingfquestionsThephrasing f quest ionssvery mportanro che uc-
cess f a pat ient nterview. hengeneralnformat ion
i s sought ,he ques t ion hou ld e phrased o rhaca
simple esor no will not sufTice s an answer.Fo r ex -
ample, uest ionsuchas, Areyou r ightenedr nerv-
ous aboutvis i t inghe dent ist?"imit responseso yes
o r n o .On t he o t he rh a n d ,o p e n - e n d e dt a t e m e n t s
suchas, Tel lmeaboutyour eel ings hen ouhave o
go to the dent ist , " equirehepat ient o providemore
informat ion nd thereby ermita moreaccurate s-
sessmentf thepat ient 's pinions ndexper iences.
Structure of the interview
Dental istoryValuablenformat ionanbeobtained y reviewinghe
pat ient 's ental istory.r is mportanro f indout why
teethwereextracted. quest ion uchas,"Haveyou
had anyof your permanenteeth emoved?"ol lowed
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Patient lnterviesy , ,
Fig5-1 Pat ient ct ions, uchas heplacementf a hand ver hemouth,may ndicateoncern bout ppear-ance f eeth.
:.-l\hy
were hese eeth emoved?"anprovide alu-
a: e nformat ionor treatment lanning.f the teeth
M€rcostasa result f car ies, pecial mphasishould
:e : acedon improvinghe pat ient 's ral hygiene.f
:e :eethwere ost as a resultof periodontal isease,
s,€n effortshouldbe madeco imit ts progression.: rhe pat ient asan exist ingemovableart ial en-
:-"e" rhedencist houldgather nformat ion egarding
:a:ent satisfaction. patientwho has had favorable
er:e-rences ith a n existing emovable artialdenture
:n::ably will have avorable xperiencesith future e-- - - , a b l ep a r c i a l e n t u r e s . h e p a t i e n t h o u l db e
as*ed.What do yo u like bestaboutyour existing e-
- , : , ,ablepart ial enture?"heseeatureshould e n-
::":orated into th e new prosthesis. he patientalso
$-,,-.:ld e asked, What do you like eastabout your
er isrng emovable art ialdenture?"f possible,hese'e' : - res shouldbe modif ied o permit mproved e-- ' : ' ,aDlepart ial enture ervice.
; several rostheses avebeenconstructed vera
? a: \ely short ime, he pat ientmayhave omplaints
: : : areunjust i f ied.heexist ing rostheseshouldbe
er?Jirr€dco determineheir suitabi l i ty.n addit ion,
:e lat ient shouldbe asked, Whywere ou dissat is-=,*: ,'"ith he partialdentures?"f the dentistbelieves
Fig 5-2 The dentistshouldbe seatedat the same evelasth e patient, he dentist hould ace he patient nd appearre laxed ndunhurr ied,
t ha t the compla in ts re us t i f ied , a t ien t rea tment
maybe undertaken.f the complaints ppear njust i-
f ied, he real i t ies f removable art ialdenture ervice
shouldbe explainedo the pat ient . ubsequent ly,he
denc is t hou lddec idewhether o under take en ta l
t reatment.
Diet
Thepacient 'siec hould eevaluated.f cough rops,
b rea thmincs , o f t d r inks ,hard candy , o f feewi th
sugar, r othersugar-containingroducts re usedon
a regular asis, changemust be effected. he p rob-
lemscausedby sugars re compounded y the wear-
ing of a removable art ialdenture ecausehe pros-
thesis hieldshe microorganismsrom the cleansing
and buffering ctionof the patient's aliva.
HabitsOralhabits hould eevaluatedo determine hether
theywill affect he prognosis f restorativereatment.
Bruxism and clenching Bruxismand clenchingmay
exert ignificant ffeccsn the prognosis f removable
part ialdenture herapy Fig5-3). f eitherhabit per-
sists ollowing reatment, t mayresult n unfavorable
1:l:l
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| 5 | The FirstDiagnostic ppointment
Fi g5-3 Bruxismand clenchingma y causesignif icantos sof tooth structure nd complicateherapy.
loading f the proschesisnd ead o the ear ly oss f
abutments. ruxisms often nit iated y inrercepr iveocclusal ontacts ie,occlusal rematur i t ies) .he oc-clusion houldbe analyzedo determine hether or-rection s ndicated.f efforts o eliminatehe bruxism
areunsuccessful,he pat ient houldwearan occlusal
device r nightguard o help protect he remaining
ceeth. omepat ients ho clench heir eeth o rel ievetensionhave uchan ingrained lenching abic hartheydo not realizeha t an interocclusalpace s nor-mal. Pat ienc ducat ion nd specialaw exercisesaybe nstrumentaln el iminat inghese abits.
Tongue hrusting lf a tongue-rhrust abit ha sbeenacontr ibut ingactor n tooth loss, ont inuat ion f thehabitcouldplaceharmful rressesn parr ial enrure
abutments.f possible,he habitshould eel iminatedbefore prosthesissconstrucred.f the habircannot
be el iminated,he removable art ialdenture houldbe designedo distribute he forces o as many eethandsupport ingtructuresspossible.
Expectationsf treatment
Some nd ica t ion f the pat ien t ' s xpec ta t ions ayhavebeenga inedwhen he denta lh is to rywas re-viewed. urther uesr ioning ayprovide ddit ionaln-sighrs. hedentistmayposequestions uchas, What
do you expect ro m havinga partialdenruremade?"
or "What thingswould you like o havechanged f anew parrialdenture s made?" f the patientnasunre-
alist icexpecations eg , a removable arrialdenturewithoura majorconnector rossinghe palate), he
13 4
treatment lanshouldbe altered r pat ientexpecta
t ionsshouldbechangedhrough ducat ion.f neithercan be accompl ished,t wou ld be inappropr ia reo
treat he Patient.
Questionsrom hepatientAskingwhether he pat ienthasspecif ic uesr ions r
concernss a good way o concludehe nterview.n
add i t ion , t a l lows he pa t ien t o opennewsub jec t
areas nd o provide ddit ionalnformarion.
Observinghepatient'sphysical
characteristics
During he nterview,t is mportanr o noteany ele-
vant physical haracteristicsisplayed y the parient.
Forexample,f a pat ienr xhibits speech roblem,tis important hat the problembe recognizedefore
construct ion f a removable art ialdenture.Other-
wise, his problemma ybe artributedo theprosthesis.
Neuromuscularef ic i ts nd neuromotor amage
alsoshouldbe noted.A pat ientwith poor neuromus-
cu la rcoord ina t ionmay requ i re dd i t iona l ime to
adapt to a removable artialdenture.A patientwhoha ssuffered strokeor o ther neuromotor amage s
likely o havedifficulty lacing nd removing remov-
ableparcial enture.Pat ients ith suchdef ic i ts lso
may havedifficultymaintaining dequareevels f hy-
giene f theoralcavity nd heprosrhesis.
The ength nd he mobil i ry f a par ient 'sipsare
also mportantcharacteristicshat shouldbe carefully
examined. a t ien ts i th shor to r h igh lymob i le ips
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InfectionControl n Clinical Prcthodortb | |
Fi g5-4 The patient's pper ip shouldbe evalu-ated o determinets resting ength.
Fi g5-6 A patientwith a shortor highlymobileupper ip s ikelyo exposehe marginal ingi -vae uponsmi l ing. ddi t ional f for t s requi redto ensure hat a prosthesis il l harmonize it hth e patient's xisting ingival ontours nd col-oration.
rresenr ignificant hallengesn theconstruction f es-
: ret ical ly leasingemovablearr ialdencuresFigs -4
:o 5-6). Esthet ics ay be compromisedf the clasp=rms, enture orders, r othercomponents revisi-
: le when hepat ient miles r speaks.
Facial hanges hat ndicate decreasen occlusal
,er t icaldimension houldbe evaluated nd treated
,r ' ich reatcare Fig5-7).Treatmenc hould be pre-
ceded yplacementf an occlusal evice ndderermi-rat ion of an acceptablecclusal er t ical imension.
Failure o identifli he correcrocclusal ertical imen-
sion may result n the fabr icat ion f prosrheseshar
ar ewoefully nadequate. heseprostheses ay cause
inm.rsionr migrat ion f the remainingeeth, esult ing
in failureof the restorative ffort.The importance f
appropr ia te ax i l lomand ibu la re la r ionsh ipss d is -
cussedn chapter13.
Fig 5-5 The patient's pper ip also should beeva lua t ed hen he pa t i en t m i l es . h i swi l lprovide mportant nformat ion egardinghemobilityof the patient's pper ip.
Fi g5- 7 Folding r creasing t he commissures(arrows) ften ndicates decreasen the oa-tient's cclusal ertical imension,
E InfectionControln ClinicalProsthodontics
Dur ing he pas t 15 years ,n fec t ion ont ro lhasas-
sumedan inc reas ing lyrominent o le n the hea l rh
care ciences.he accumulat ionnd disseminat ionf
scient i f icnformacionasplaced he topic n f ronrof
health areworkers nd he general ubl ical ike. s a
result ,numerous nfect ion ontrol procedures avebeen nst i tuted. heseprocedures nd pol ic ies on-
t inue o evolve s addit ionalnformat ions orovided.
Becausef the rapidnature f these hanges,t would
be impossibleor the authors o provide complere
l is t o f cur ren t n fec tion ont ro l ecommendat ions .
Therefore,he fol lowing ect ions rovide nly broad
guidel inesor infect ion ontrol.For morespecif icn-
format ion, eferenceo documents ubl ished y the
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| 5 | TheFirstDiagnostic ppointment
Fig5-8 Medicalwasteproducts nd sharp n-st rumentsmust be placed n appropr iateon-ta iners. isposal f these temsmustconformwith EPA uidel ines.
Amer icanDenta lAssoc ia t ionADA) , he Occupa-t ionalSafety nd HealthAdministrar ionOSHA), ndsimilar rganizat ionss ecom ended.
Personalrotectiveequipment
Th e m o s t m p o r c a n tm e a s u r eo m i n i m i z e i s e a s et r a n s m i s s i o n e t w e e n a t i e n t s n d d e n r a r a r eprov iderss the rou t ine seof g loves . l l personne l
having irectpar ienr onract houldweardisposable
gloves.n most nstances,atex loves repreferred e-cause f their act i le haracter ist ics,vai labi l i ty,ndminimal osc. orpersons ith atex l lergies,var ietyof nonlatex loves reavai lable.
Disposable asks, owns, nd gloves no prorec-
t iveeyewearhouldbe worn dur ingcl inical ppoint-
ments . h is s par t icu la r lympor ran t henaeroso lswil l begenerated.n addir ion, l l medical asre rod-
uctsmustbedisposed f asmandared y heEnviron-
mentalProtect iongencyEPn) Fig5-8).These rod-, ,crsnclude harps ie,needles,lades, roken lass),
^;r ' rdf ' rt rssuesemoved ur ing surgery, nd blood-- .ca<ed ater ials. rate egulat ionsnvolving isposal
: - - : -esemarer ia ls ay a ryand shou ld e consu l tedl= tJ ' . : - r ac t ions aken.
Surtace overage
Disease-ca-s3 - ic roorgan ismsmaybe t rans fe r redFrom niec:ec ar ienrso environmentalurFacesnd
136
Fig 5-9 Operatory urfaces houldbe coveredus ing m perm eab le a r r i e r s uchas p las t i cwrap.Note hat he operatorswear inghe ap-propr iate ersonal rotect ive quipment : is-posablemask,gown,and glovesand protec-tiveeyewear.
t h e s em i c r o o r g a n s i m say r e m a i n i a b l e o r p r o -
longed er iodshours o days).Conracc i rhconram-
ina ted ur faces ay resu l t n d iseaseransmiss ion
Therefore, reventive easures ust be tal<en o con-
trolor blocl<ross- infeccionn cl inical etr ings.
Th e most practical nd effective ethodof manag-
ing operatory urface ontaminat ions the useof im-
permeablearr ierseg,plast ic rap) o shield urfaces
from direct r indirect xposureFig5-9).Plasr ic rap
canbe used n l ighthandles,onrrols, hair wirches,
evacuator ontrols,air-water yringes,alivaejectors,bracketables, oapdispensers,ndotherareas t che
operator's iscretion. urface oversmustbe changedbetween at ien ts o min imizehe probab i l i r yf d is -
easeransmission.
Chemicalcleaningand disinfection
Chemica l lean ing nd d is in fec r ions necessaryor
thosesurfaceshat cannotbe covered ut may be-
comecontaminatedur ing at ienr rearment. num-
berof dis infectanrsreavai lable r rhis ime. Pract i-t ioners re referredo infecr ion ontrolguidel inesorprescr ibedpplicat ions.
Instrument sterilization
All instrumentshat can wirhstand earster i l izat ion
mustbe thorough ly leaned nd heats re r i l i zede-
tween ses. hemical is infect ionf thesetems s un-
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Fig5-10 Metal mpressionrays hould ester-i l ized ndstoredn unopened ags.
. : : ep tab le . nsc rumentso be heac te r i l i zedhou ld- .a red by scrubb ing i rh hocwaterand soapor oy-) -g an ult rasonicleaner ith an appropr iatelean-- . - .s o l u t i o n . n s t r u m e n t s h o u l d h e n b e d r i e d ,' . : p e d , p a c k a g e d ,nd hea ts t e r i l i z e d . e u s a b l e
:=*s tha t cannotbe heats te r i l i zed us tbe c leaned.- : r reated i th ethylene xideor an EpA-registered- . . r ical scer i lant .hepract i t ionerhould nsurehat- =-; facturers 'ecommendat ionsrestr icdyol lowed.
P osthodontic clinicalprotocol
.:oressionrays- - ar ing, ster i l izat ion,nd scorage f stock mpres-: r- r raysminimizes otent ial ealrhhazards.Mecal: "= . shou ld e c leaned
mmedia te lyf te r eparar ing.-= mpressionsndcasts. rays hould esoalcedn a-, ;1: 'gef l tsolut ion ndwipedwith alcohol pongeso':*J! 'e adhesives,eposits, nd stains. rays hould:-=- beplacedn appropr iate ags ndster i l ized.ol -- ' , -g s re r i l i za r ion ,rays hou ld e scoredn the un-
. -= -edbags F ig -1 ) .
.:-struments,rticulators,ustomrays- ^struments,includingaboratorynives, axspar-- : . . . acryl ic urs,and waxcarvershouldbe cleaned
.-: srer i l izedol lowing achuse.Custom mpression. ' : . . ' . ecord ases ,ndocc lus ionimsmustbed is in -'= : :=3a f te rcons t ruc t ion . 2 -minu te pp l ica t ion f. - a :p roved od iumhypoch lo r i t eo lu r ionmay De- : : :o d is in fecchesecems.
I ..infecting mpressionsI = ' - teimpress ionshould
sprayed ithan appropr iareodium ypochlor ireolu-t ion. mpressionshould e oosely rappedn plast icandsetasideor not ess han2 minutes. asts hould
be pourednot more han 12 minutes f ter emoval f
an alginatempressionrom chemourh.Orher mpres-sions uchas polysulf ide,olyvinyli loxane,olyether,
andzincoxide-eugenolhouldbe disinfecreds de-scr ibedor alginatempressions.he prescr ibedimesfo r pouring asts rematerial pecific.
Denture sepsisNew removab le ar r ia l enrures hou ldbe washed
thorough ly i th a b rushand germic ida l oap , nenr insed s ing lean ap warer . nd iv idua l ros theses
shouldbe sprayed ith a di lure odiumhypochlor ice
solut ion nd allowed o srandundisturbedor 2 min-utes.Ac he end of this per iod,prosrheseshouldber insedn tapwateronceagain.Prostheseshenshouldbe sea led n warer r igh t agsconta in ing lean apwater.Short ly efore nserr ion, rostheseshouldberemovedro m the sealed agsand againsprayed itha d i lu te od ium ypoch lo r i reo lu r ion nda l lowedos t a n d o r 2 m i n u t e s . i n a l l y , r o s r h e s e sh o u l d ethoroughlyinsedn tap water o remove ny emain-
ing sod iumhypoch lo r i reo lu r ion rom the exposed
sur faces . emovab lear t ia l en tu res hou ldno t be
immersedn concenrratedodiumhypochlor i teolu-t ions ,nor shou ld heybe exposedo d i lu tesod ium
hypochlor i teolut ionsor prolonged er iods.Mosral-loysused n removab le a r t ia l en tu re ons t ruc r ion
wil l become it tedand/ordiscoloredf these ecom-
mendat ionsrenot ol lowed.
Pros theseshat havebeenworn by the pa lenr
shou ldbe d is in fec redr io r ro mod i f i ca t ion . hes :p ros theseshou ld e d is in fec tedn the samema- - . .
be r insedhorough lyn
al l t races f sal iva no tap wacer to remove
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| 5 | TheFirst Diagnostic ppoinrment
as newprostheses.ol lowing odif icat ion,emovable
par t ia l en tu reshou ldbe d is in fec tedga in . r rh is
s tage , ros theseshou ldbe r insed n coo l runn ing
waterandevaluatedl inical lv.
E Initial Examination
Detectionof problems requiringimmediate ttention
A prel iminaryxaminat ion usrbe performed ur ing
the f irst appointment o ident i f lz roblems equir ing
immediate t tent ion. xtensivear iousesionsmay e-
quireexcavat iono determine hether here s pulpal
involvement.rovis ionalestorat ions aybe required
to rel ieve iscomfort r restoreoochcontours.Oralcondit ions aused y l l - f i t t ing emovablearr ial en-
turesalso may require mmediate t tent ion.Adjust-
m e n to r t e m p o r a r y e l i n i n g f e x i s t i n g r os t heses
shou ld eaccompl ishedo e l iminarea t ienr iscom-
fort andal low ecoveryf thedamagedissues.
Evaluationof oral hygiene
Evaluat ion f a pat ienr 's ral hygienes essenr ialor
appropr iatereatment lanning. nadequate ral hy-
gienemustbe recognizedar lyn thediagnost icroce-dure o allow nitiation f an effective ral hygiene ro -
gram.Hav ingwi tnessedhe dec l ine f a beaur i fu l l y
restoredmouth,one realizeshe truevalueof oral hy-
gienenstruct ionndpat ient ducar ion.t is mportanr
to rememberha t the ultimate uccess f dental reat-
ment el ies n the homecareof the pat ient swellas
the echnical rocedureserformedy hedent isr .
I t s hedent ist 'sesponsibi l i tyo explain
1. Thesigns ndsymptoms f dental isease
2. The mater ialsnd echniquesor proper omecare3 . The pat ien t ' sespons ib i l i r iesn p revenr ingur rher
denta l i sease
Onl; ,af ter pat ientshaveacl<nowledgedheir re-
sponsibi l i t iesnd demonsrraredheirmot ivar ion nd
abil i ry o maintain ood oralhygienehould xtensive
restorat iveherapv e nit iated.
Evaluation f cariessusceptibility
Thepresencef a large umber f restoredeeth, igns
of recurrentar ies, nd evidencef decalcif icat ionn-
dicate hat the pat ient s suscepr ibleo car ies. nles
anexcept ionalevel f plaque ontrol anbe achievedthe prognosisor treacment i l l be poor. Hence, he
placement f crowns, ixedparcial entures, no re-
movab le ar t ia lden tu res hou ldno t be cons idere
unt i l he pat ientdemonscratescceptable,ustaine
oralhygiene ract ices.f this s not accomplished,t is
l ikelyhat the completed estorat ionsi l l fai l asa re-
sultof cont inued ar ies rogression.
Oralprophylaxis
Scaling nd oral prophylaxishouldbe perFormedfnecessary.he def init iventraoral xaminar ion,iag-
nost ic mpressions,nd diagnost icastswil l be more
accuratef the eethar ecrean.
Radiographs
A complete er ies f per iapical nd bice-wingadio-
graphss an indispensableartof the denral xamina
tion for a prospectiveemovable artialdenture atienc
(Fig5-11).Per iapicaladiographsreessenr ialor de-
termininghe crown-to-rootat ios f remainingeethand hecondit ion f theassociateder iodonralissues
Bice-wingadiographsre helpful n idencif lz ingnter-
proximal ar ies n the remainingeeth.A panoramic
radiographs deal or screeningor pathologicondi-
t ions, ut snotadequateor hedef init ivexaminat io
of a removable artialdenture ati ent Fig5-12).Eval
uat ion f radiographssdescr ibedn chapter .
Diagnostic mpressionsand casts
A denta lexamina t ionor a par t ia l l y den tu lousa-t ien tmus tbecons ideredncomple ten lessc nc lude
theevaluat ion f accurate iagnost icasts Fig5-13).
Diagnost ic asts ermitanalysis f hardand sof t is-
suecontours. hese astsprovide aluablenforma-
t ion about hespacehat a removableart ial enture
mayoccupy. heypermitevaluat ion f exist ingooth
contours nd may ndicatehe need or f ixed estora
t ions n oneor more emain ingeeth . n add i t ion , i -
1 3 8
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Initial Examinatin r r
Fi g5-11 A complete eries f bite-wing nd periapicaladiographshouldbe made or any prospectivee-movable artial enture atient.
Fig5-12A panoramicadiographtheexaminat ionrocess.
may be a usefuladjunct ur ing
Fig5-13 Occlusal iew of maxi l lary nd man-dibularcasts.Accurate iagnostic astsare anessent ia l ar t of the dentalexaminat ionor apartially dentulous atient.
a: 'rost ic asts omet imesndicatehe need or surgi-:: correction f exostoses,rominent rena,and soft
: . sueundercu ts .
Dur ing he reatment-planningrocess,iagnost ic
: :sts are surveyed. roposed esigns re drawn di-- : ; r l v on the d iagnos tic as ts F ig5-14) . nd iv idua l
: : s rs then serve s b luepr in tsor the p lacement f
?siorations, he recontouring f teeth,and he prepa-
=:ion of restseats. hesecastsalso may be helpful
Fig 5-14 Occlusal iew of castsaf terdesignshavebeendrawn.Thesedesigns erveas blue-or ints or tooth modi f icat ion nd prosthesis
const ruct ion.
dur ing reatment-planningresentat ions.acientsremore ikelyo approve t reatment lan f theycanvi-
sual ize xist ing roblemshan heyare f theymust ely
upona verbal escr ipt ion.
Diagnost ic ount ing f thecasts n a suitable r-
t i cu la to r l soshou ldbe accompl ished.h isprocesspermits ssessmentf the occlusion nd he avai lable
res to ra t ivepace.Becausehe cas tsare norma l ly
mounced nd evaluatedur ing hesecond iagnosuc
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| 5 | Th eFirstDiagnostic ppointment
appointment,hese roceduresrediscussedn chap-ter 6. The proceduresor makingdiagnost icmpres-s ionsand cas ts re presentedn che o l lowing ec-t rons .
Physicalproperties and working characteristicsofalginatempression ateriall r revers ib leydroco l lo idmpress ion a te r ia l , om-monlyknownas alginare,schemater ial f choiceordiagnost icmpressions.ecause f i ts accuracy nohandling haracter isr ics,lginatempression ater ialissuitableor making iagnoscicnd inal mpressionsfo r removable arrialdentures. lginate s easy o useand s relat ivelynexpensive.owever,c s oneof themostabusedmpression acer ialsn dent isrry.(nowl-edgeof th e physical roperries nd workingcnaraccer-
ist ics f i r reversibleydrocol loids essenr ialf rhe ma-ter ial s o beused uccessful ly.
A lg ina tempress ion arer ia ls supp l iedn pow-dered orm.Warer s mixedwich he powder o form aviscous ol,whichyields n elast ic el hrough ser iesof chemicaleacr ions.
Alginate owder savai lablen bulkconrainersndin pre-weighedackersFig5-15).Akhoughconven-ient , ndividual aclcetsremoreexpensivehanequalvolumes f bul l< lginate.
While rreversibleydrocol loidsnorusual lyonsid-
ered o havea shelf ife, he merhodof scorages veryimpor tan t .A lg ina te erer io ra resap id lywhensub-jected o elevatedemperaruresnd highhumidiry. l-ginate tored r 65oC 149.F) or 1 month hasbeenshown o be unsuitableor use.Evidencef deter iora-t i o n h asevenb e e ns h o w na f t e rs t o r a g e t 5 4 o C(129"F).ehisdeter iorar ions houghto becaused ydepolymerizar ionf rhe alginate onsr iruenr. nceacontainer f alginatesopened,he mater ial anshowmeasurab lee te r io ra r ion i th in 3 days .Repeacedopening f the container nd exposuref i tsconrenrc
to humidity ontr ibuteo rapiddeter iorat ion f rhepon,der. lginatehachasdeterioracedecause f heator moisrure i l l becomehin dur ingmixing, xhibit r -rar ic ercingimes, ave educed trength, nd displayhighdegreesf permanenteformarion ithin he m-pression. lginare lsocan be contaminacedy gyp-sum.Smal l mounrs f den ta l tone ef t n a mix ingbowlor on a sparula ancontaminatelginate ndac-celerarets ser.Therefore.r is essent ialhat mixinq
140
bowlsused or alginatempression arerials e reeofgyPsumProducts.
Th e water-powderatio hasa significant ffecc ntheworking haracrer ist icsf alginarempression a-ter ial.This s parr icular lymporrantwhenalginates
used or mak ing mpress ionsf the den ta la rchesChangesn the water-powderatiowill affect he con-sistencynd set t ingimeof the mixedmacer ialswellas he strength nd qualiry f rhe mpression.n ex-tremelyhickmixwil l not record inedetai l . rhinmixwill flow out of rhe mpressionrayand away rom thet issues . u r thermore ,th in mixo f a lg inace i l l t earupon emovalrom hemouch ndwil l resultn an un-acceptablempression. owever, espite hangesnconsistency nd sett ing ime, the accuracy f ir re-versible ydrocol loids not af fected y changesn the
water-powderat io.Extremelyhin mixes f alginatemaybeused or dupl icacingasts ith no oss f accu-racy. deal ly, dent isr houldwork with a preoece
minedamounto f powder or everympress ion .heamounto f watermay be ad jus redo obta insubt levar iat ionsn consistencyf the mpression ater ial.
Measurementf alginate owdermay be accom-pl ished y volumeor by weighr. olumetr icmeasurement s perFormedsing scoop rovided ycheman-ufacturer. hi s method s inaccuraceecause lginatep o w d e rm ay b e l o o s e l y r t i g h r l y a c k e d n r o r h e
scoop. heamounr f powder erscoop sdependenu p o n w h e t h e r h e m a t e r i l i n t h e c o n t a i n e r a s"f luf fed"or compacted t the t ime of measuremenand whether xcessowderwaspressednt o thescoopor simply craped ff the top. Inconsistenciesn meas-urement roduce ignif icantar iat ionsn water-powde
rat ios. hese ar iat ions f tenresult n unpredictablhandling ropert ies.
Weightmeasurementf alginate owder s moreaccurate nd moreconsistenthanvolumetr icmeas-urementan d therefores th e preferredmerhod or di-v idingand dispensinglginate owder.As was men-t ionedpreviously, anufacturersel lalginaceowoerin pre-weighedoi l packets; owever, urchasinghemater ialn bulk s moreeconomical.sa resurt , anypract i t ionershoose o buy he marer ialn bulk andweigh t pr iorcocl inical se.
Oncea canisrer f alginate owder s opened, tsentire ontents houldbe accurarely eighednt o 28-gincrementstheamountneededor most mpressions
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Initial Examirntion , ,
F ig 5 -15 A lg ina t e m press i on owdersareavai lablen bulkcontainers nd pre-weighedpackets.
. -3 placedn proper lyabeled, oisture-t ightontain-
: ' : Fig5-16).When he mater ials needed, 8 to 72-- of water s accurately easured ndmixedwith the
: : , , , der .Th is rangepermi t s ar ia t ion f the water -
--:,n,deratio o satisfi he requiremencsf the patient
:. rg created.t is mporCanto note hat somewater
; - : r l ies con ta in arge mounts f minera lsha t can
=:,ersely ffect he accuracy nd he setting ime of al-
. -ate impression ater ials.f the pract i t ioners con-
:=red about he mineral ontentof the localwater
.- :c ly, dist i l led r demineral izedater hould eused.
i-he sett ing ime of alginates determined y the
-'rufacturer. Both ast-and regular-set aterials re- ,a able. he dent ist analter he setcingrmesome-
, ' -al by varying he temperature f the water used.r - ' l s rmanu f ac t u r e r se c o m m e n dh e u s eo f 22oC-i 'F)
water.Coolerwaterwil l providemoreworking
: -e . rvhereaslighdywarmerwaterwill hasten he set
: ' : : e impress ion a te r ia l . omebrands f a lg ina te.*'- :ir greater ensitivityo temperature hange han
:: :ers.Cercain roducts ave hownasmuchasa 20-
"=-rndchangengelat ionime or each1oCchangen
:- . remperature f the water.eRefr igerat ion f the
- ' rg bowl and watercan greadyncreasehe work--_ : :rme.The refrigeration f pre-packagednd pre-
'"=ghedpowder s not recommendedince ondensa-
: :- r-nay ffect he accuracy ndworkingproperties f
:= . ra te r ia l .
Scorageof alginate impressionsr : : in i te disadvantagef alginatempressionss hat
: - : , rannocbe s to red or an apprec iab leength f
Fig 5-16 Bulkmater ia ls houldbe accurate lyweighedusingan appropr iate cale. lg inatepowders houldbe stored n proper lyabeled,moisture-proofontainers.
t ime. Measurab le is to r t ion ccurs f a cas t s no t
pouredwithin 12 minutes f impressionemoval. l0-14Thepr imarymechanismsf distorcionreevaporat ion
andabsorp t ionf iqu ids .
Evaporat ion f water resultsn shr inkage f algi-
nate mpression ater ial. hisproduces istort ion f
a lg ina tempress ionsnd inaccuacyo f assoc ia ted
casts. herefore, lginatempressionshouldnot be
exposedo theatmosphereor more han 12 minutes.
Even t 100% umidity, ater s el iminatedrom algi-
na te mpress ion a te r ia l h rougha process a l led
syneres is .s the mois tu re on ten to f the mater ia l
changes,hr inkagef the mpressionccurs.In add i t ion o los ingwater ,a lg ina tempress ion
mater ials lsomayabsorb iquids. hisprocess f ab-
sorption, ermed mbibition,esultsn localized xpan-
sionof the completedmpression.hiscauses istor-
t ion of the moressionnd eadso inaccuraciesn the
correspondingasc. s a result , n alginatempression
shouldnever e wrapped n wet paper owelsor im-
mersedn a iqu id .
Sticking of alginate
A potent ial roblem n using rreversibleydrocol loidis the tendency or this macerialo stick o the teeth
( F i g5 - 17 ) .S t i c k i n g ccu r s he na l g i n a t ea d i c a l s
within he impression ater ialorm chemical onds
with hydroxyapatiterystals f the enamel.As the im-
pressions removed,ear ingof the alginate ccurs.
This produces urfacenaccuraciesn the impression
and he esultantast Fig5-18).
1/ f1
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| 5 | TheFirstDiagnostic ppointment
Fig5-17 Under erta in ondi t ions,lg inatem-pressionmaterialsmaystick o the eeth.
Sticking eneral ly ccurs n rhe acialsurfaces fthe eethand alsomayoccur n thecusp ips.As a re-
su l t ,cheprac t i t ionerhou ldexaminehese ur faces
immediatelyf ter emoving n alginatempression.f
st icking ccurs) lginare houldbe removedrom che
tee thwi th appropr ia rensr rumencs .he prac t ioner
shou ld lso horough lyxamine ach mpress ionm-mediately fcer ts removal. f st icking as occurreo,
the acial ur facesf the mpression i l l presenrhar-
acceristicoughened r scaly u faces.
Three actorscontr ibute o st icking.First ,many
dent ists ol ish he eerh ol lowingmouthpreparar ionf o r r e m o v a b l ea r t i a l en t u r es .f i m p r e s s i o n sr e
madeafter horough olishing f rhe eerh, t ic l<ings
more i lcelyo occur. herefore,nly ighrcleaning f
the ceeth houldbe accomplishedmmediarelyefore
impress ionsremade. f chorough lean ings neces-
sary, mpression rocedureshouldbe deferredo a
su seq ent ppo i tment .
Second,here s a greaterendencyor alginateo
sr ick f the teeth aredry.Adequatemoisrure onrrol
ca n b e a c c o m p l i s h e dy p a c l < i n gh e m o u r hw i r h
;arze padsbeforemaking n impression.auze ads--sr be gent ly emoved efore he mpression are-
s p laced n the ora l cav i t y .Dry ingwi th com-
l '€sseJ i r s con t ra ind ica ted ,ecauseh ismin imizes
: - c - c s a u r e on t en to f t o o t h su r f aces no con -
. - r - : :s : ; : hesr ick ingf a lg inace .
: :e 'e is a greater endencyor st ic l<ingo
occ- . ' - c lea :eaimpress ionsremade. he i lm hat
prorec :s - : -e f rom rhes t ick ing f a lg ina tes os t
14 2
Fig5-18St icking f a lg inateesul tsn an inac-curate ental ast.
dur ing epeated ttempts o mal<e sat isfactorym-pression. nce t icking ccurs,t becomes oresevere
wicheachsubsequentmpression.herefore, good
impressionechniquehould eused o hatseveralt-
temptsarenot necessary.f st icking oesoccur, he
pract i t ionerhould elaympressionroceduresnr i la
subsequentppointmencr takemeasureso prevent
the alginaterom sticking. commonprevenrive eas-
ure sco usea prophylaxisasceo whichsi l icone inc-
menthasbeen dded. hisproduces thin i lmof si l i -
cone hat preventst ic lc ingf the alginatempression
m a t e r i a l . n a l t e r na t i ve e r hod s r o w i p e s m a l l
amounts f s i l icone intment nto hevulnerablereas
o f the tee th.Whenus ing h is echn ique ,he p rac t i -
t ionermusc nsurehat excessi l icones removed r i t
wi l l make he mpressionsnaccurate.lcernat ively,he
dent istmayhavehe pat ient uckon sourcandy, hew
sourgum, or swishwholemil l<. hese roceduresc-
celeratehe product ion f a protect ivei lm over he
teethand minimize t icking f alginate. owever,or
somepatients oneof thesemeasures il l be effective.
ln these ns tances ,mpress ionrocedureshou ld e
delayedor at least 4 hours.
Positionof patient and dentist during
impression-makingroceduresThe posit ion f the pat ienc nd hedenr isr an have
s ign i f i can tmpac tupon impress ion-mak ingroce-
du r es .E x p e r i e n c eu g g e s t sh e p a t i e n t h o u l db e
seated pr ight nd hedenr ist hould estanding ur-
ing theseprocedures.his enhances at ient omfort
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Initial Examinaiion I
i g 5 -19Whenm ak ing m and ibu la rm press i on ,r i gh t -- : - :ed operator hould tand o the r ightand n f rontof- - : r a t i e n t .N o t e h a t h e p a t i e n t s p o s i t i o n e d o t h e- : - : i bu l a r a rch soa ra l l e lo he l oo r .
. - : : .ovides hedent isc i th appropr iate ccess,on-
- : . rd f ie ld fv is ion"- -e
pa t ien t hou ld e pos i t ionedo the occ lusa l
: : - : s paral lelo the loorwhen hepat ient 's outh s
: : . - Thisdif fers l ight lyor maxi l lary ndmandibular
i ' : - :s: therefore,omeadjustment f the chair s nec-
: : : . - , be tweenmpress ions .he he ighc f the cha i r
. - - - : be ad jus ted o the pa t ien t ' smouth s a t the
: . -= er.el s hedent ist 'slbow. hispermitsncreased: : : =:or comfort ur ing mpressionrocedures.
. ' . en mak ing mand ibu la rmpress ion , r igh t --
"- : :3 dent ist hould tand o the r ightand n f ront
- ' : -= ea t iencF ig5-19) . h ispermicshedent is t o- : : : :e impress ionray n the r igh thandwhi lema-" -- . : ing the ightcorner f the pat ient 'smouthwith
:"- : .- : rand. When mal<ing maxi l larympression,--. - - -anded ent ist hould tand o the r ightof and
: i - - : rhe pat ient . hispermitshe dent ist 'sef tarm
;- : - :nd coenc i r c lehe pa t ien t ' s eadand man ipu-
i . . : -? ref t orner f the mouth Fig5-20).
-::rressionrays- : : : . -pressiontrays or dentate nd part ial ly den-
:- : - : :entalarches reof four basicrypes: onperFo-". : . : -eral r rays, erForated etal rays,nonperfo-' : : : : : =st ic rays,and perForatedlast ic rays Fig
: - " \onperforated metal t rays are the t rays of
: - : : : t - . r r e m o v a b l ea r r i a l e n t u r e p p l i c a t i o n s .
Fig 5 -20When m ak ing m ax i l l a r ym press i on , r i gh t -handed perator houldstand o the r ightof and behindthepat ient .
Theserays re igidand proper ly onf ine lginatem-
pression ater ials, al<ingt easieror the operatoro
obcainproper ly xtendedmpressions.l thoughper-
forated raysar e igid, heydo no t confine he mpres-
sion materials swell as nonperforatedraysand may
result n imoressionshat areunderextendednd in-
complete. he useof plast icrays,whicharegeneral ly
too f lexibleo ensurehe accuracy f alginatempres-
sions nd heassociacedasts, hould eavoided.
Checkingmaxillary tray for correct size The width
of the dentalarch s he most moortant actor n de-
termining ray size.deal ly, hereshouldbe a clear-
anceof 5 to 7 mm betweenhe inner langes f the
tray and he facialsurfaces f the remainingeethand
soft issuesFig 5-22)
When checking hesizeof a maxi l larympression
tray, he operator houldstand o the rightof and be-
hind he patient. he operator'sef tarm shouldextend
behind hepat ient 's ead, nd he ef thandshould eused o man ipu la tehe le f t cornero f the pa t ien t ' s
mouth.The mpressionrayshould e held n che ight
handwi th the thumb on toD o f the hand le nd he
indexand middle ingers nder he handle. he r ight
posterior langeof the tray shouldbe used o engage
the r igh tcorner f the mouth .The mpress ionray
should e rotatednto hemouthwhile hedent istma-
n iou la teshe e f t co rner f t he mouthwi th the e f t
143
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| 5 | TheFirstDiagnostic ppointment
Fig 5-21 Stock mpressionrays may be madefrom plastic r metal, nd may be perforated rnonperforated. onperforatedmetal rays arerecommendedor removable art ia ldentureappl icat ions.
Fig 5-22 Thereshouldbe 5 to 7 mm of spacebetween he internal ur faces f the t ray andthe acial urfaces f the eethand soft issues.
hand (Fig 5-23).At this stage, he operator houldvi -sually ssesshe relationship etweenhe tray and the
facial urfacesf the eeth.As previouslyoted,a clear-
ance f 5 to 7 mm should epresent.hisspacesnec-
essaryo ensurehe impression ater ial i l l be thick
enough o springover he undercuts. oo largea tray
may be difficulc o insertbecause f interFe renceit h
thecoronoidDrocessesf the mandible.
Frequent ly,t ray hat displayshe properwidth s
not ongenough o cover he desiredmpressionrea.
In other nstances, ore han 5 to 7 mm i s present
betweenhe rayand he palatal issues.f a maxil laryimpressions at temptedn suchan instance,he algi-
nate mpression ater ialmay sag before elat ion s
complete, esult ingn an impressionhat appearso
be accurate ut is not . mproper lyi t t ing rays hould
always e modif iedbeforemakingalginate mpres-
sions.The lengthof the t ray and excessivealatal
space an be corrected asi lyhrough he useof mod-
el ing last ic.
144
F ig5 -23 When p lac i ng m ax i l l a r yray , hedent ist houlduse he lef thand o manipulatethe eftcornerof the mouth.The rightposterior
f lange f he rayshould e used o manipulatethe r ight orner f he mouth.
Checking mandibular tray for correct size A man-dibular rayshouldprovide to 7 mm of space oth
facialand ingual o che emainin geethand residua
ridge. f a tray extendsoo far lingually,here s a ten-
dency o t rap the tongueor the f loor of the mouth.
The problem houldbecorrected y selecting tray of
a dif ferencize r by bendinghe inguallanges f the
tray o provide he required learance.
When evaluat inghe size f a mandibular ray,a
r ight-handedent ist hould e posit ionedo the r ight
and n f ront of the pat ient . he pat ient 'smandibula
occlusal laneshouldbe at the level f the dent ist 'selbow. he mpressionrayshouldbe held n the r ight
hand,and the ef t humb and index inger houldbe
used o manipulatehe r ight cornerof the pat ienc'
mouth.The eftposter iorlange f the rayshould n-
gage he left cornerof the mouth.As the right lange
of the t ray is ro ta ted oward the mouth , the le f t
thumb and ndex inger houldbe used o manipulate
the ri ght cornerof the mouth. As the tray is rotated
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Initial E-:lar-r-: :r
- :o posit ion,hepat ient hould e nstructedo gent-
, "aisehe ongue. hiswil l ensurehat he tongue s-: : t rapped eneathhe ray.Uponpassinghecorner
: ' rhe mouth, he rayshould estraightenednd po-
. : onedover he eeth. he pat ient hould henbe n-
' : ' -cted to rest he t ip of the tongueon the anter ior.= : : rono f the t ray .By depress inghe ower ip , he
: . - r ist caneasi ly ee he buccal nd ingual learance
r:rr\'€efl he eethand he ray.
Sustomizinga stock impression ray Frequencly,
; - :ck impressionraydoesnot f i t the associateden-
: . a rch . n such ns tances ,he f i t o f the mpress ion
: ' : . canbe mproved singmodeling last icFigs -24
. : 5-30) . hemode l ing las t ichou ld eso f tenedn a
, , : . :erba tha t 60oC 140"F) , neaded,daptedo the
: - . . . and ormed o the genera l on tours f the m-- ' . s s ion a r e a .A t t h i s s t age , he m o d e l i n g l a s t i c
; - : : ld be emperedn thewaterba thand sea tedn
: - . ' r ou th .The rayshou ldbe sea ted nd removed
.= , : .a l imeswh i le he mode l ing las t ics n a so f t -
. - :J state. his s done o ensurehat the t raydoes- : : f ecome ocked nto hardand so f t i ssue nder -
: - : s . Fo l lowing an ipu la t ion ,he rayshou ld e re -- : . ed f rom he ora l cav i t y nd ch i l led n icewater .
- : : sequent ly ,hemode l ing las t ic hou ld e r immed
:- a sharp <nifeo provide ro 7 m m of clearance.
- ,= a te adhes ivehou ld henbe app l iedo the mod-= -_:olast ic nd he nner ur face f the ray.
l:ntrol ofgagging- -=:.tively mallpercentagef Patients xperienceii' - - : es ,wh ichgenera l lynvo lve agg ing , u r ing m-
: - : ison procedures.eforenit iat ingmpressionro-
- : : - 'es. thedent ist hould skwhetherhepat ient as- : : ^ rp ress ionsmade n the pas t . f t h is s the pa-
. : - : s rst exper ience,br iefdescr ipt ionf the proce-
: , ' "s shou ld e g iven . he dent is t hou ld PPeare-
. , = : . andc hee x p l a n a t i o nh o u l d e d e l i v e r e dn a, - : : :^ . evenone. he mpression ater ial aybede-
, : - : : : asa thickcream hat sets o a rubber onsis-
: : - r, - about2 minutes. f terdescr ibinghe mpres-
i : - : ' ccedure ,he dent is t hou ld henproceedn a
- - - - - : . r i manner. ent ists sual ly ncounterroblems
:- .==gingvhenhey re n heear ly tages f c l inical
- - - - : : ard approachmpression al<ingn a nervous
- : - , l - s .nanner . nder o c i r cumstanceshou ldhe
dent ist r ingup the subject f gagging,ince:-"
- ..
causehe pat ien t o become ervous r hes : - : :
shouldonlybe addressedf the patient ePorrs as; '-
f icult ies ithgaggingur ing mpression aking.
The dent is t hou ldemploy he fo l lowingProce-
duresominimize r prevencagging.
1.Thepat ient hould e seatedn an upr ight osit ion
with heocclusal lane aral lelwithhe loor.
2. When ndicated,he maxi l laryrayshould e modi-
f iedusingmodeling last ic. narrow andof unre-
l ievedmodeling last ic hould emaintained t the
poster ior order f the mpressionrea. his band
of mode l ing las t ic hou ldprevent lg ina terom
running oster ior lys he ray s nserted.
3. The pat ient houldbedirectedo usean astr ingent
mouthwash ndcoldwater inseust beforehe m-pressions made. he useof an anesthet icpray s
usually ontraindicated.nesthet icpraywil l cause
numbness f the tongueand soft palateand may
contr ibuteo gagging.
4. The impressionray shouldnoc be overf l l led ith
impression ater ial.
5. The poster ior ort ionof the mpressionray hould
be seatedirst.Then, he anteriorPortionof the ray
should e rotatednto posit ion. hispermicsxcess
impression ater ialo be displacedn an anter ior
direction-awayrom the softpalateand ainvay.6. The pat ientshouldbe instructedo keep heeyes
opendur ing he mpressionrocedure.hisencour-
ages he pat ien t o focusuPon he sur round ings
ra ther han the mpress ion rocedure .t maybe
helpfulo have hepat ientocus n a small bject .
7. The pat ient houldbe directedo breathehrough
the nose. he dent ist houldencouragelow,deep
breaths.
B .A l l i n s t r u c t i o n sh o u l db e g i v e n n a c a l m , i r m
manner .
I t i s impor tan t o recogn izehat mos t gagg ing
problems repsychologicalather han physical. on-
f idencen thedent ist i l l helpel iminate anyof these
prob lems. owever , very mal lpercen tagef pa-
t ientshavea true,uncontrol lableag ref lex.n these
p a t i e n t s ,he s i m p l ep r ocedu r e f i n t r o d u c i n g r r
empty ray nto the mouth may nitiate evere aggi'-.
Therefore, ddit ionalmeasures ay be f lec€sSZ'tC
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| 5 | The FirstDiagnostic ppointment
F ig 5 -24 M ode l i ngp las t i c s so f t ened n awaterbathat 60"C 140"F).
Fig5-26The mpressionray sproperly eatedin heoralcavity.
F ig 5 -28 The im press i on ray assem b l y schil led n icewater o facil itaterimmingof themodel ing last ic.
Fi g5-25 Softenedmodelingplastic s carefullyadaptedo the mpressionray,
Fi g5-27Upon emoval rom he mouth, hemodeling last ics nspectedor evidencefaccuratedaptation.
Fig 5-29 The model ingplast ic s t r immed opermit5 to 7 mm of clearance,
Fig 5-30 Alg inateadhesive s appl ied o themodeling lastic nd nnersurfaces f the ray.
146
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-InitialExaminauon I
Fig5-31 The "leg lift" techniquema y be usedto minimize agging ur ing mpression roce-ou es.
: : -plere the mpressionrocess.he ol lowing roce-
:- 'es iv i l la l lowa dent ist o make mpressionsor al -- , -s: anypat ient ho isphysical lyndpsychological ly
: r : ro fol low nstruct ions.
- -epa t ien t hou ldbe ins t ruc tedo rakea oeep
:.eachand hold r while he dent ist heckshesize
: ."d adaptat ion f the t ray.Most pat ients i l l not
, :aE vhi le olding heirbrearh. s a resuh,he den-
: s r can comple te hor t p rocedures i thou t the:a.nger f thepat ient agging.--e
pat ient houldbe direcredo r inse he mourh
, , - h as t r ingentmouthwash nd then w i rh co ld, ' , : . rer .hiscombinar ion i l l minimizehe low of
s : . vadur ing mpress ionroceduresnd w i l l de-
:-ease he ikel ihood fgagging.i iast-setting lginate houldbe used o hastenhe;e:of rhe mpression ater ial. l ight ly armerwarer
:. -<omaybe used o shorrenhe gelation eriod.--e "leg-1if t "technique aybe used ur ing he m-
: 'ession rocedure.he par ient houldbe direcred
:, - i f t one legoff the dentalchairand ro keep r
=sed aca l l imes F ig5-31) .As fa t igue ers n , r
r, usual ly e necessaryo f irmly ommand hepa-: : - r ro keep he leg if red. he mixing f alginate
=-ouldnot be nit iared nt i l he pat ienr ppearso: : : inng.When ar igue s not iceable,he alginate
= - a u i db e m i x e d n d h e m p r e s s i o n a d e . h e
:: - : isr should nsurehat he pat ient 'seg emains
= sed hroughouche procedure.he eg- l i f t roce-
:- .e is nrendedo distracthe par ient y focusing. : :e-r ion on another rocess.ts successs prooa-
Fig5-32 Gauze s placed n the oral cavi ty ofacil itatemoisture ontrol.
blybased n a combinat ion f distract ion, uscu-
lar at igue, nd anger irected t the dent ist .How-ever, nce he pat ientunderstandshat an impres-
s i o nca n b e m a d ew i t h l i r c l e r no d i s c o m f o r t ,
addit ional rocedures aybe accomplishedith a
reducedendencyoward gagging.
Control fsalivaAs was ment ioned ar l ier , lginate asa tendencyo
scicko teeth f the eerhare oo dry. n contrasr, xces-
sive mounts f sal iva andisplace lginatempression
mater ial ndcontr ibuteo an naccuratempression.n
most cases, aliva an be conrrolled y having he pa-t ient r inse he mouthwirh an asrr ingent outhwash
and thenwichcoldwarer.Subsequendy,he par ient 's
mouthshouldbe packed irh4 X 4- inchgauze hat
hasbeenunfolded o form an absorprivetrip (Fig5-
32). ln the maxi l lary rch,one gauze tr ipshouldex-
tend f rom the poster ior ort ionof the r ight buccal
ves t ibu leo the pos te r io r o r t iono f the e f rbucca l
vest ibule.he pat ient houldbe insrrucredo hold a
second tr ip against he t issues f the palare. n the
mandibular rch,one gauze tr ipshouldextend rom
the r ightbuccal est ibuleo rhe ef tbuccal est ibule.second auze tr ipshouldbe posir ionedn rhe ingual
sulcus y havinghe pat ient aise he ongue, lacing
t h e g a u z e , n d t hen hav ing h e p a r i e n t e l a x he
tongue. hegauze houldbe gendy emovedmmedi-
atelybeforehe mpressions made.
Somepat ients ecrete xcessivemountsof thick
mucinous al ivarom the palatal al ivarylands. his
sal iva isplaceshe alginate nd resultsn inaccurare
14 7
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| 5 | TheFirstDiagnostic ppoinrmenr
F ig 5 -33 Wat e r s p rec i se l ym easu red ndplacedntoa cleanmixingbowl .
Fi g5-35 A broad-bladedpatula s used o in-corporatehe alginate owder nt o he water.
impressions.hesepar ients houldbe instrucredor insewichan astr ingentmouthwash. n turn, gauzesponges ampenedn warmwatershouldbe used oplacepressurever he poster ior alace, ausinghepalatal lands o empry.Pat ienrs hould hen be di-rected o rinse he mouthwich cewater.At rhis pointmaxi l larympressionsanbemade.
In rare nstances, pat ientwil l secrete o much
salivahat it becomes xtremelyifficult o makeaccu-racempressions.heuseof an ant is ialagoguen com-
binacion i th mouth r inses nd gauze acksmay beused o controlsal ivarylow in such nstances. 15-mg propanthe l ineromide ab le t aken30 minuresbefore he mpressionppointmentmaybe ndicated
in cenain nstances. owever, nt is ialagogueshouldno t be p rescr ibedn the presence f med ica l on-traindicat ionsuchasglaucoma, rostat ic yperuro-
phy,or cardiac ondit ionsn whichany ncreasen theheart ate s o beavoided.
148
Fi g5-34 At thisstage, lginate owder s siftedinto he water.
F ig 5-36 Dur ing he mixingprocess, lg inateimpression ater ia ls pressed gainsthe sideof he bowl o minimize i rent rapment .
MixingalginatempressionmaterialAlginatemaybe mixed y handspatular ion, echan
cal spatulat ion, r mechanicalpatulacionnoer ac-
uum.The objectives a smoorh,bubble-free ixof algi-
na t e . n h a n ds p a t u l a t i o n , m e a s u r e dm o u n to f
dist i l led ater t approximately2'C (72"F)should e
p lacednto a rubbermix ing owl (F ig5-33) .Subse
quently, re-weighedlginate owdershouldbe sifted
from its container nto the warer Fig 5-34).Mixing
should egin lowly sing scif l broad-bladedparula
(Fig -35).Whenallof thepowder asbeen horoughlwetted, he speed f spatular ionhouldbe ncrease
Dur ing h is p rocess ,he sparu la hou ldbe used o
presshe alginatempression aterial gainsthe sides
of the bowl (Fig5-36).Thisensuresha t the materials
completely ixed nd minimizesir enrrapmenr.par
ulat ion hould ont inueor a minimum f 45 seconds
Insufficientpatulation an resultn failure f the ngre
dients o dissolveufficienrly.n turn, he changerom
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Fig5-37Vacuum patulat ions: : ' formed usinga specia l ly e-' g n e dm i x i n ga p p a r a t u so n -
: st ing f a rotarymixing evice,: ,acuum ump,and he associ -. : :d mixingbowl .
Fi g5-38 A broad-bladedpatula s used o in-corporatehe alginate owder nt o he water.
F i g 5 - 3 9 T h e m i x i n g b o w l i sproper ly ssembled,hevacuumtubing s at tached, nd he alg i -
nate mpressionmaterials spat-u latedor 15seconds.
5-40).Placingoo largea porr ionof alginare r one
t ime ncreaseshe probabil i ty f t rapping ir . mpres-
sionmacer ialhouldbe addedunt i l r is evel i rh he
f langes f the tray.Overf i l l ing houldbe avoided.
modera te mounto f impress ion a te r ia l approx i -
mately 0 cm3) hould e placednroa large-diamerer
sy r inge s ing spatu la F ig5-a1) .A t th iss rage ,he
p lungerhou ld e ep lacednd he mpress ionhou ld
bemade.
MakingmpressionsThe mand ibu la rmpress ionhou ld e made i rs tbe-
cause t usua l ly n ta i l sess a t ien t iscomfor t , nd
pat ien t on f idences inc reasedhenan impress ion
hasbeen uccess fu l lyomple ted . h i leho ld ing he
t raywi th the le f t hand, he dent is r hou lduse he
r ight hand o remove auzepads rom rhe pat ienr 's
mouth.The syr inge houldbe used o introducem-
pression ater ialnto he acialand ingual esr ibules
f ig 5-a2) .Add i t iona lmater ia l hou ldbe p laced n
the occlusal urfaces f the teeth. he ndex ingerof
the r ight handshouldbe used o force his marer ial
in to the in te rp rox ima lpaces nd occ lusa l epres-
s ions . mmedia te lyherea f te r ,he f i l led mpress ion
trayshould e placednto heoralcaviry nd proper,"
= sol o a gelmaynot occuruniformlyhroughouthe-: .ss of alginate,esult ingn a signif icanreduct ionn
: - : s r reng th f the mater ia l . n incomplere lyparu-
. :eCmixwil l appear umpyand granular nd wil l ex-- 3 t numerousreas f t rapped ir .Completepatula-
. :^ rv i l l esultn a smooth, reamy ixture.Themostconsistent ethod or making smooth,
: - :ble- f reemix s mechanicalpatulat ion noer ac-
--r (Fig5-37).Whenusing hismerhod, prescr ibed: -oun t o f watershou ldbe added o a mechan ica l- ' . ingbowl . Pre-we ighedlg inare hou ldbe s i f t ed-:r the waterand thoroughlyncorporaredy hand
. : a r u l a t i o n F i g5 - 38 ) . h e i d o f r h e m i x i n g o w l
.-c; ld be proper ly osit ioned nd rhevacuum ppa-' : : - s shou ldbe ac t iva ted . he impress ion a te r ia l
. - r r l d b e m e c h a n i c a l l yp a t u l a r e dnde r 0 l b so f
, : :JUm or 15secondsF ig -39) . hor te rpa tu la r ion-a! resultn incomplete ix ing f the mpression a-
: . - : .1.Longer patulat ionmay result n a great ly e-
: - ;ed sett ingime of the alginatemater ial nd could
.=ecr hestrength f thegel.
-oading he mpressionray- : ' r ncrementsf the mpression ater ial hould e
: = : ed n t h e c r aya n d f o r c e du n d e rc h e i m ( F i g
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| 5 | TheFirstDiagnostic ppointment
Fig5-40The ray s oaded y placing mal l n-crements f a lg inatempression ater ia l nderthe r im. mpression ater ia ls oaded nt i l t islevelwith the langes f the ray.
sea t ed F i g5 - a3 ) .Th e l i p sa n d c h e e k s h o u l db e
pulled pical ly nd henoutwardar a 4S-degreengreto proper lyorm he per ipher iesf rhe mpressron.
I t isessent ialhat he dent istmaintainheposit ion
of the traydur ing he enr ire elat ion er iod. hiscanbe accomplished ostef fecr ivelyy placing he ore-
f inger f eachhandon top of the ray n the premorar
area , nd by p lac inghe rhumbs nder he par ienr , s
chin (Fig 5-44). he dencist houldmainrain n even
amounto f p ressure n the t ray even f the pa t ien t
opens r closeshe mouth.Anymovement f the raydur ing he gelat ion er iodwil l resuk n an inaccurare
impression.herefore,l lowinghe pat ient r the as-sistanto hold he rayshould eavoided. elat ion fchealginatempression ater ial houldbe complerew i t h i n 2 t o 3 m i n u r e s .
Fol lowing omplet ion f the setr ing rocess,neimpressionhouldbe removed nd nspecred.n im-pressionhould e repeatedf voids represenrn cr i t i -ca l areas. ee he following ecrionsor addirional e-tai ls n the emoval nd nspecr ionf the mpression.
Whenmakinghe maxil larympression,he denr isr
shou ld e pos i t ionedo the r ighro f and beh ind he
par ienr. he par ient hould e nstrucredo r insewirhan asr r ingenr ouchwasho l lowedby co ld water .
Cauze adsshou ldbe used or mois tu re on t ro l .la rge-d iamerery r inge hou ldbe used o p lace lg i -
nace mpression ater ialnto the vest ibulesnd ontotheocclusal urfacesf che eeth. n addit ion, moo-
era te mounro f impress ion a te r ia l hou ldbe ap-
pl ied o the palare Fig5-45). Fai lureo accomplish
thisstepmay esuh n an impression ith a large oid
1 50
F i g 5 - 4 1 A l g i n a t e m p r e s s i o nm a t e r i a l sloadedntoa large-diameteryr inge.
in the palatalarea.When he mater ial asoeenap-
pl ied o the desired urFaces,r shouldbe wiped nrothe nterproximalpaces ndocclusal epressions.
The loadedmaxil laryray shouldbe grasped i th
the thumb and ore f inger f t he r ighrhand.As the
r ightposter iorlangeof the impressionrayengages
the r ightcorner f the mouth, he dent ist 'sef thand
should e used o rerracrhe ef tcorner f the mouth.
Once he ray s n rhe mouth, he humband oref in-
gerof the ef thandshouldbe used o raisehe upper
l ip.Thispermitshe dent ist o see he elar ionshipe-
tween he labial langeof the tray andche acialsur-
faces f the ceeth r residual idge.Careshou ldbe taken o ensurehat the t ray s
proper ly l igned ur ing he nserr ion rocess.hiscan
be eva lua ted y ook ing r chepar ienr 's ead rom
above nd behind, ndbyobservingheposir ion f rhe
trayhandle. hehandle hould rotruderomrhecen-
terof the mouthandshould eor iented aral lelo the
sagittalplane Fig 5-46).After he properorienration
hasbeen er i f ied,he ray hould eseated. ur inghis
process,he cheeks houldbe liftedupwardand our-
ward o prevenche buccal issuesrom being rapped
by he langes f the ray. heupper ip also hould eliftedupwardand outward o allowgood visibiliry nd
to avoid rapping he ip berweenhe flange f the tray
and the anter io r ee th .The t ray must nor Deover -
seated.Overseatingroduces ontactbetweenhe in-
ternalsurfaces f the tray and the occlusal r incisal
edges f the eeth, hereby roducing n naccurarem-
pression.he rayshouldbestabi l izedhroughouthe
se to f the impress ion a te r ia l y ma in ta in ingighr
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Fig 5-42The syringe sp ress i onm a t e r i a ln t obu les nd i ngua l u l c i .
used o int roducem-t h e m a n d i b u l a re s t i -
*a.
F i g5 - 4 4T h e m p r e s s i o nr a y s s u p p o r t e dth oughouthegelat ion rocess.
Fig5-46Whenviewed rom above ndbehind:1epat ient ,he handle f he mpressionray s: r iented aral le lo thesagi t ta l x is.
= ' rhepremolar reas n bo ths ides f the= * q i n a t em p r e s s i o n a t e r i a l h o u l d e t
-- .. nutes.- - . : omp le t i ono f t heg e l a t i o n r o c e s s ,he' : - - c b e r e m o v e d n d i n s p e c t e d .f
: : . - r n c r i t i ca l reas ,he mpress ionro-
- . r3 repeated . emova l nd nspec t ion. .j r ^ a red iscussedn grea te r eca i ln he
: - , : - ) .
F i g5 ' 4 3 T h e m a n d i b u l a rm p r e s s i o nr a y sn rn n p r l \ / c p a ta a l
Fig5-45Whenmaking maxi l larympression,a moderate mount f a lg inatempression a-ter ia l hould e appl iedo thepalate.
Removalof impression from the mouthCl in ica l ly ,he n i t ia l e to f a lg ina tesdererminedy a
l o s so f su r f acea c l < i n e s s .n a l g i n a t em p r e s s i o n
shou ld e e f t n the mouth o r an add i r iona l to 3
minu tes f te r h is n i t ia l e t o permi t hedeve lopmenr
of addit ionalstrength.ar ly emoval f an alginatem-
pressionmay ead o unnecessaryear ing f the r--
pression ater ial.t is mportanr o nore hat r l-e_.- .s t reng thoub les ur ing he i r s t minu tes f re- , =
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| ! l TheFirstDiagnosricppoinrmenr
Fig5-47A smal lmoundof the or ig inalmix ofa l g i n a t e h a t h a s b e e ns e t a s i d e r a c t u r e scleanly pon bending,ndicat inghat he alg i -na t e m press i onm a t e r i a lm ay be rem ovedfrom he mouth.
gelat ion. eyond minutes, o further trengthening
occurs.n fact , mpressionseft n the mouth or 5 o rmoreminutes xhibit ot iceable istor t ion. herearewo rel iablemethods f derermininghe correct ime
for removal f an alginatempression:
1. A cimer anbe used o measurehe2- to 3-minute
per iod f ter nir ial elar ion.
2 . A smal lmoundof theor ig ina lmixo f a lg inareanbe placed n a glass r meralsurface.When thisalginatewil l f racture leanlywith f ingerpressure,the impress ions ready o be removedrom themouth Fig5-a7).
The physicalt rengrh f alginare el s such hat a
sudden orce s moresuccessfullyesistedhan a srow,sustainedorce.The marer ial lsodisplaysmprovedelast icecoveryhenan mpressionsrapidly emoveo.There fo re , lg ina tempress ionshou ldbe removedfrom the mouthwith a rapid,susrainedug.This re-sultsn a moreaccuratempressionndcast,
The o l lowingechn ique akesr poss ib leo re -movean impression ithoutsignif icancistor t ion f: f e alginate:he ipsandcheekshould e erractedo:an ia l l yb reak he sea land ac i l i t a rempress ione-* : , a l . Fo ra m a x i l l a r ym p r e s s i o n ,h e i g h r h u m b
) - r - : bep laced n ropof rhe ray and le .hemidd lea- : - re \ f ingershou ld ep laced n heunders idef: ' . - ^ : e andshould xtend nto hepalatal egment: ' . - = : " : , . T h i sp r even t she r ay r o m s t r i k i nghe- a-: l - . . : : : :h and issues ur ing ray removal. t: - ) : : - : . : - : - r r e s s i o ns h o u l d e r emoved i t h a'.: : : - r< .:-: : : :aral lel o the ongaxes f the eeth.F c ' a - a - : : - ' - - l . e s s i o n ,t h e i g h t h u m b h o u l dbe p a ; : : : - : - n - - ; e - s r de f t he r ayh a n d l e . h e
t J z
middle nd ndexingers hould xtend ntorheuppersurface f the tray o prevenc amageo cheopposing
tee th . he mand ibu la rmpress ionl so hou ld e re -
movedwith a rapid ug direcred aral lelo rhe ong
axes f the eeth.Rocking r slowlyeasinghe mpres-sion rom he mouthwil l resultn rreversibleistor t ion
of the mpression ater ial ndshould eavoided.
Inspecting the impression
Fo l lowingemova lrom the mouth , he mpress ion
shou ldbe inspec ted s inga good l igh tsource ndmagnif icat ionFigs5-48 and 5-49).An impression
shouldbe repeacedf thereareanydoubrs egarding
i t s accuracy . he p rac t i t ioner hou ldbe awareo f
problemshat occur onsistendyo hat sceps ayDe
taken o addresshese ef ic ienc ies .ommonDroD-lems nc ludeayer ingf the mpress ion a te r ia l ,m-
properposit ioning f the ray,and entrapment f thetongueor other issues y the f langes f the mpres-
sron ray.
Layeringscaused y the premarure elation f the
syr ingemater ia l . lg inare pp l iedwich he syr inge
should e3 to 4 mm thick. f the mpression acer ials
too thin, he heatof theoral cavitymay ausehe mate-rial o setbeforehe raycanbeseated. hi sproduces
dist inctborderberweenhe syr ingemater ial nd the
traymaterial, nd resultsn a layeredmpression.
lmproper rayplacemenrs caused y poorvis ibi l-
i t y . Dur ing nser t ion f rhe mpress ionray , he e f r
handshouldbe used o mani pulatenecorner f thepat ient 'smouth,while he poster iorlange f the m-
pressionrayshouldbe used o conrrol he opposire
corner f themouth. he ingershould eused o ma-
n ipu la tehe ip and prov ide p r imum is ib i l i r yu r ing
the seating rocess. he rayshouldbe carefullyeared
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Initial Exan:-t:a::r-
Fig5-50 Unsupported lg inatemater ia ls re-moved rom he mpression.
: : ' langesareapical o thegingivalmargins f rhe: . . : - Oi,erseat ingaycausehe cusps f the eeth o
-;- : :J:
rhe rayand esultn an naccuratempression.- . : : : ion,great aremustbeexercisedhenseat ing"-i r '?; in a pat ientwith tor i or otherexostosesince- - - : : . - - : ' . r ' i rhtheover ly ingoft issues aycause ignif -: : - : : s c o m t o r t .
: - : "apmento f the tongue nd orherso f t i ssues
: . - c r ld beavo ided . pon eat ingf rhemand ibu-- : .ess ion t ray , he pa t ien t hou ldbe asked o
i: l-orrude,and chen elax he tongue.By raisingi - : : ' o : rud ing he tongue, he pat ien t reventsts- - - - - - . ' renr by rhe ingual langes f rhe ray.With-" :
j- lsequent relaxat ionf the tongue, he form of*: -_.-alvest ibule aybe ecorded.:: t , i ingareothercommon easonsor reject ing
, - - : ' e s s i O n :
- : : .cr . lareextensionf the mpression
- , : : s r c r i t i c a l r e a s
.- . -=' -q in cr ir ical reas
- -_:
::e sr ickingo the eech
Fi g5-49 Followingts removal rom th e mouth,the maxi l larympressions nspected.
5. Alginate eparatedrom cheunder ly ingmpression
tray Althoughr appearshealginareanbepushed
back nto contactwich he ray, hiswill resuk n aninaccuratempressionndan naccurateast . )
6. Rough r granularmpression irh poor r issue e-
cai l This ndicatesnadequareparulat ion,elayed
insert ion,r prematureemoval. )
A r ev iew f c a u s e s n d s o l u t i o n so r c o m m o n
problems ssociated ichmal<ingiagnosciclginare
impress ionss presentedn Tab le5-1 ar rhe end of
the chaoter.
l f the impressions acceprable,nsupported lgi-
natemater ials emovedFig5-50).
Cleaning he impression
Failureo remove alivarom he mpressioni l l result
in an naccuraceast. herefore,al iva hould ecare-fully removed rom the impression urface efore he
assoc ia tedas t s poured .Mos t pa t ien ts ave h in .
serous al iva. his ypeof sal iva an be removed ,,
br ief ly oldinghe mpressionnder gent le rrear o'
Fig 5-48 Upon removalm o u t h , h e m a n d i b u l a roughly nspected.
of the t ray f rom theim press i ons t ho r -
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TheFirstDi lntment
Fi g5-51 Each mpressions cleanedo removesal iva ndunwanted ral lu ids.
Fi g 5-52 A thin layerof dentalstone s sprin_k l edon the su r f ace f the im press i on . h i sstoneserves sa disclosing gent or adherentsal iva.
Fig 5-53 Adherent al iva s removedusingawetcamel-hai rrush nd ightpressure.
Fi g 5-55Th e impressionray is suspended yi tshandle.
Fi g5-54 Th e mpressions sprayedwith an ap -propriate isinfectant nd lightlycoveredwiihplasticwrap.
cool rap water Fig5-S1). f running ap warer s noreffective,he saliva an be removed singa softcamel_hairbrush nda mi lddecergenr.
On rheotherhand,somepatients ave hick, opysalivaha t isdifficulco remove. herefore,t is recom_mended har a thin layerof denralstonebe sprinkledon the surFacef rhe mpressionFig5-52).The sroneadheres o rhe salivaand acrsas a disclosing gent.
154
W hen h e m p r e s s i o ns p l a c e d n d e r u n n i n g a pwater, he saliva an be removed y ightbrushing itha wet camel-hairrush Fig5-53).Al l t races f sal ivashouldbe removed efore roceeding.
Disinfectinghe mpressionF o l l o w i n gh e c l e a n i n g r ocess , a ch m p r e s s i o nshouldbe sprayed i th an appropr iare is infectant .
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Initial ExaminabonJ-t
Fig 5-56 Castwith a dense,abrasion-resistantsu face.
Fig5-58Gypsumproducts houldbe propor-t i onedby we igh tand s t o red n p rope r l y a -beled,moisture-proofontainers,
*-:nrpressionhouldbe oosely overed irh plast ic
* , - - : and seras ide or an appropr ia re er iod F ig
j-5- : . Thisper iodmay ary rom2 to 10 minutes e-:* : - : ,ng on chedisinfeccant.t this t ime,caremust:E : :<en not to placepressuren the per ipher iesf: - r "rpression. uchpressurean ead o distor t ion
: i :*e alginacempression ater ial. he tray should
:e =-spendedy tshand len a r rayho lder F ig -55)
:" = sl ighclypendrawer; lacing he rayon a rable*:, ;ausedistor t ion f the alginate.t i s also mpor--- : :o noce hat heuseof compressedir o remove
: * : : i s in fec tan tmay cause ehydra t ion f the im-
: . :ssionsurface,esult ingn distor t ion f the impres-
; , - and associated ast,and therefore hould bea , ' : , l € d .
-ErDortancef water-powder atio in makingi:e castr :-r rvirh dense,brasion-resiscanturFacesessen-:a r al l phasesf removablearrial enrureesigna*: ;onstructionFigs -56and5-57). hesurface-1-:ressof a srone ast sdirecdyelatedo itscom-
Fi g5-57 Castwith a soft,chalky urfacehat seasi ly braded.
pressivetrength, nd the compressivetrength f a
slonecascsdirectly ffecred y he water-powderatio
used n making he ast .A l l gypsum roduc ts , he ther en ta lp tas re r r
dental tone, equire nly 18.61mL of water o reacc
wi th 100 g o f powder o fo rm ca lc ium ul fa re i -hydrate. ls l l remaining areroccupies pace n the
cas t , he r eby e d u c i n ghe c o m p r e s s i v et r eng t h .
Seeminglymall olumes f wacer anexerr ignif icanr
e f fec ts pon the compress ivet reng ths f den ta l
casts.Fo rexample,f 30 racherhan27 mL of water s
mixedwith 100 g of Type l l denralsrone, he com-
pressivetrength i l l be reducedrom 4,500 o 3,000
psi.As a result ,manufacturers 'ecommendat ionsorwater-powderatiosshouldbestricdyobserved.
To ensure onsistenc ater-powderatios,all gyp-
sum products houldbe measured y weight arher
than by volume.Cypsumpowder houldbe weighed
in amounts u i tab leor pour ing ing le mpress ions
and stored n proper lyabeled,moisture-proofon-
tainers uchasointment jarsFig5-58).Usually 50gis adequateor a single our.Thisprocedure i l l en-
1 5 5
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| 5 | Th eFirstDiagnostic ppointment
F ig 5 -59 Den t a ls t one s m e-chanical lypatulatednder ac-uum or 15 o 20seconds.
surea correctwater-powderat io,prevent eter iora-
t ion, educe aste, ndpromote f f ic iency.
C y p s u m r o d u c t s h o u l d o t b e s t o r e d n o p e n
c o n t a i n e r s ,he r e i r exposu r e i l c a u s eh e h e m i -
hydrateo absorbmoisturerom heair .Moisture on-
taminat ion i l l causehe ormat ion f calcium ulfate
dihydrate rystals ichi n he powder. his mayacceler-
a te or re ta rd he se t t ing f den ta l cone epend ing
upon hesever ityf moiscureontaminat ion. oisturec o n t a m i n a t i o n i l l r e d u c e o t h th e c o m p re s s i v e
screngthnd he surFaceardnessfthe resultant asts.
Mixing dentalstone
The object iven mixing ental tone s to mal<e ho-
mogenous,ubble-f ree ix hat wil l produce oense)
accurate ast.Watershouldbe carefullymeasured nd
p o u r e d n t o a m i x i n gb o w l . P r e - w e i g h e do w d e r
shouldbe slowly i f ted ntothewater o avoidair en-
trapment. he powder houldbe slowly ncorporated
into hewaterusing broad, cif f -bladedpatula. areshou ldbe aken o avo ida wh ipp ing c t ion ,wh ich
rvould ncorporateir nto the mixcure. ix ing hould
concinuent i la smoorh onsistencysachieved;0 to
90 seconds sual lysadequate. rolongedpatulat ion,
whichcan breakup the crystals f gypsum hat have
formedand veakenhe inalcasc, houldbe avoided.
Whenposs ib le , echan ica lpa tu la t ionnder acuum
shou ldbe used ns tead f handmix ing ;mix ing ime
156
should hen e educedo 15 o 20 secondsFig -59)
This process i l l provide educed orosityn a mixo
dental tone. f ter he mixings complete,ightvibra
t ionshou ld eusedo e l imina tei r nc lus ions .
PouringhecastAn acceptablempressionanbe ruined ur ing our in
and r imming rocedures.herefore,he echniqueso
pour ing nd r imming iagnost icasts hould easexactingas thoseused or mal<ingmascer asts.A mini
malexpansionental tone ADATypell or lV)shoul
be used or diagnost ic nd master asts.Minimalex
pansion ental tones xhibit xceptionalccuracy,ur
facedetail,and abrasion esistance,nd are herefor
ideal or removableart ial enture ppl icat ions.
Two-stage ou r technique Alginate mpressionsan
not beboxed ndpouredike omplete enturempre
sions. herefore, two-stageechniquehould e em
ployed or all castsused n the design nd fabricatioof rem ovable artialdentures. hecwo-stageechniqu
oroduces astsn which he teethand soft rssue rea
are he densest nd mostabrasion-resistantarts.
When a f reshmix of dental tone s tappedor vi
brated,water mmediatelyises o the surface.f an
impressions f i l ledwith dental toneand inverted o
the eethand residualidges re acing pward, s im
i la r p rocess ccurs .Man ipu la t ion , ovement , r v i
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initlai Exar::--;::r
Fig5 -60The hand le f t he t ray s p l aced ncontactwith a properly djusted ibrator . ncre-mentsof stone re nt roduced nd he mpres-sion s carefu l lvi l led.
Fi g5-62The mpressionray s suspended y tshandle ntil h e stonehas eachedts nit ial et.
r - : : on of the reshly ixed tone roduces ovement
: t ,, , rer oward he surface f the impression. here-' : '=. rhe stone hat makes o the teethand residual' : , ies containsmorewater han do otherport ions f
:- : .ast .The surface f the resultant ast sweakand- : . f ,eabraded as i ly . o r hese easons , s ing le -
: : - - : :o r nvers ionechn iquehou ld eavo ided .rour ingshou ld e n i t ia ted i th in12 minu tes f
- : 'ession removal.n the wo-stageechnique,n ni-
:. - ix of scones used o f i l l the mpression. small
: - r -1r ofstoneshould e added o oneofthe poste-'": - er tensionsf the mpression.hehandle f the ray
; - : - I beplaced gainst v ibrator, nd he mpression
: " . , ' r ou ld be ipped o permic con t ro l ledlow of
: . - : : . srone Fig5-60).The low of the stone hould
: : : t r , ' , noughhat t canbeobservedi l l ing achndi-
: -3 :ooth mpression.apid low or excessiveibra-
: - - :a^ cause ir o be rapped t the mpression-cast- : : - : . . e .5mal linc rementsf s tone hou ld e added
Fig5-61 rregularmoundsof dental toneareadded o the exposed urface fthe init ialpour.
F i g 5 - 6 3 T h e m p r e s s i o n - c a s ts s e m b l y splacedn a container f c lear lurrywater or 4to 5 minutes.
to the poster ior xtension f the impression nt i l a l l
borders recovered y 6 to B mm of s tone .Stone
should ot be permit tedo f low onto the sides f the
impressionraybecausehiswil l ock he castonto he
tray.The exposed urface f the pouredstoneshould
be ef t rough. r regu la r ounds f scone hou ldbe
added o thissurFaceo provide ockingundercutsor
thesecond our Fig -61).The trayshouldbe suspendedy the handle nt i l
t he s tonehas eachedts n i t ia l e t F ig5-62) .Th is
shou ld ccur n 12 o 15 minu tes .f anymovementrvibrat ion ccurs ur ing his per iod,waterwil l r ise o-
ward the freesurface f the dentalstone) ausing he
stone n the anatomicDor[ ions f checast o become
more ense.
After he init ia lset ,che mpression-castssembl\
shouldbe placedn a bowl of c lear lurrywater o' :
to 5 minuteso thoroughly et he irstpouroFde': : .
stone Fig5-63).Clear lurrys a supersaturarec; - -
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| 5 | TheFirstDiagnostic ppointment
Fig 5-64 ldent ical astswere stored n clearslurry water (left) and tap wate r (right) for 14days.Not ice he dissolut ion f the cast hatwa sstored n ap water.
F ig 5-66 Addi t ionalstone s used o form apatty. he mpressions nverted nd placed nthe stonepatty.
tion of calcium ulfatemadeby placing hipsof den-
tal stone n water or 48 hours.Becauset is a satu-
ratedsolution, learslurrypermirsweningof the firsr
pour withoutdissolut ion f rhe srone.A castshould
never e soaked n tap or distilledwarerbecause en-
tal stone s soluble n these iquids. f a srone ast s
immersedn runningwater) cs inear imensions ay
1 58
Fig 5-65 A f resh mix of dentalstone s pre-paredan dvibrated nto he retentive odules.
Fi g5-67 A spatula s used o shape he baseofthe cast.
Fi g5-68 The mpression ndcastar eseparated45 o 60 minutes fter nit iation f he irstoour.
decrease pproximately .1o/oor every 0 minutesof
exposureFig5-6a).
After he irscpour ha ssoakedor 5 minutes, sec-
ond mi x of dentalstone s prepared s described ar-
l ie r .Someof the fresh lymixed toneshou ldbe v i -
bratedonto the roughened urface f the irstmix Fi g
5-65).The remaining tone houldbe used o form a
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Initia,Lra:::-r-;-:r
Fig 5-69 Casts re soaked n clearslurrywaterbefore r inding roceduresreundertaken.
F i g 5 - 7 1 T h e b a s eo f t h e m a x i l l a r y a s t s
t r immedunt i l t is 10 o 13 mm at i ts h innestooint .
- r : : . . and he m o r e s s i o nh o u l dbe nve r t ed nd: =: :C onto this pat tyof stone Fig5-66).A spatula
- ' : ' r ' ' r i l a r n s t r u m e n th o u l d e used o shape h e
, . '= o f thecas t F ig -67) . n hecase f a mand ibu-
. - -p ress ion ,he ongue pace hou ld esmoothed.
- : : . ; a l ca r e hou ldb e a k e n o a v o i d o c k i n q h e
- - onto he mpressionray.
Senveen5 and60 minutes f ter he irstpour, he
-= . : and mpress ionhou ld e separa tedF ig5-68) .
- - : ginate mpressionhouldnot be al lowed o re--. ^ in contactwith the associatedast or more han
: - * ,nutes. Extended ontactbetween lginate nd::". : : srone i l l esultn etching f thecast ur face.
. : .nming the cast
- . - - Sental ast hould esoakedn clear lurry ater=
_. i-69) o faci l i tate r inding roceduresnd o pre-
:- : srone esiduerom scickingo the surface f the
: . - : \ drv castplaced n a cast r immeracts ikea
: - : : . ' or sponge. r inding esiduerom hecast r im-
F i g 5 - 7 0 l f a c a s t s n o t s o a k e d , r i n d i n g
residuewill stick o the surface f the castan d
compromisets accuracy.
mer sabsorbed nto hesurface f thecastand s m-possibleo remove Fig5-70).At tempts o el iminate
the residue ith a brushwi l lcause amageo the sur-
faceof the cast.The most effective ay to avoid his
problem s to wet the cast horoughly efore haping
it on the cast r immer. he pract i t ioner lsomusten-
sure ha t an adequace t reamof water s f low ing
through he cast r immerdur ing he gr inding rocess.
In addit ion, panof clear lurry ater hould e posi-
t ionednex t o the cas t r immer o g r ind ing es idue
maybe r insedrom hecastper iodical ly.
Thebase f thecast hould ecr immed o hat heocclusal urFacesf the eethareparal lelo the base.
The base hou ld e r immed nt i l t i s 10 to 13 mm
ch ick t ics h innes t o in t ,usua l lyhe cen te r f t he
hardpalate or a maxil laryastand the depthof the
l ingua l u lcusor a mand ibu la ras t F ig -71) .
T h e p o s t e r i o rb o r d e r o f t h e c a s t s h o u l d b e
tr immed o form an angle f 90 degrees ith he ra: :
Whenviewedrom an occlusal erspect ive.he nc.:=-
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| 5 | TheFirstDiagnostic ppoinrment
F ig 5 -72 lm po r t an ts t ruc t u res uch as thehamularnotches arrows)and tuberosit ies fthe maxil lary as thave emainedntact.
Fi g 5-73 The retromolarpads (arrows)havebeenpreserved n the completedmandibularcast.
Fi g5-74 Specificationsor trimmingmaxillary left)an dmandibular right) asts.
r iorsurface houldbe perpendicularo rhe midl ine f
ch epalate.Careshouldbe taken o preservessenrial
landmarksuchas he hamular otches nd uberosi-
tiesof a maxillary ast and rhe retromolarpadsof amandibular ast Figs -72 and 5-73).
The sides f the castshouldbe trimmedat 90 de-
grees o dre base Ftg 5-7q. Care should be taken to
avoidovertrimming he lateralaspects f a cast,which
160
couldel iminatehevest ibularnd buccal helf reas.
landarea f 2 to 3 mm shouldbe maintainedround
cheent ire ast . hesides f the castshouldbe oined
to the posterior urface y trimming ust posterior o
the hamular otches r retromolar ads seeFi g5-74).
As ment ioned ar l ier , vert r imminghese reasmust
be avoided. he hamularnotches nd retromolar ad s
areessentialandmarkshat mustbe preserved.
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Fig5-75The onguespace f the mandibularcast s r immed lat .The ntegr i ty f the ingualsu l cussm a in t a i ned .
Fig5-76 Nodules recarefu l lyemoved singa f ine,pointednst rumenr.
F i g 5 -78An accu ra t e nd p rope r l y r immedm and ibu la ras t ,
soal<inghe ast n clear lurry ater , oids n the base
and othernoncr i t icalreas f rhecasr hould e i l led
with a thin mixof stone.Accurate, roper lyr immed
castsareessent ialn a widevar iety f dentalproce-
dures. s a result , aremustbe taken o ensurehat
impressionsnd castsaccuratelyepresenthe hard
and sof t issue ontours f rhe oral cavity FigsS-77
and5-78) .
Causesf surfaceoughnessndental astsTherear eseveral otential auses fsurFaceoughness
on dental asts.Perhapshe mostcommoncause f
surfaceoughnesss adherencef alginatempression
mater ialo theenamel. hisproducesocal izedearnq
of the mpress ion a te r ia l nd resu l t sn nor icea :
surFacerregular i t iesn cast urFaces.f surf laceo-.--
Fig 5 -77An accu ra t e nd p rope r l y r immedmaxi l larvast .
-^eante r io r o rders f max i l la rynd mand ibu la r
- - : , ; hou ldbecr immedi f fe ren t lysee ig5-7a) .The
: ' - : ' r r border f a max i l la ryast hou ld e angu la r ,
-:^at ingfrom che anine reaon each ideand ex-
. ' " : .g coa po in tan te r io ro thecent ra lnc isors .he
. . : : ' o r border f a mand ibu la ras r hou ld egent ly- , " ' . =1 . r ig ina t ingrom he can ine rea n ones ide'
. - . a rch x tend ingo theoppos i tean ine rea . he. . '= shou ld o l low he ormof the arch . n borh n -
r- :es. care houldbe al<eno avoiddamaqeo the: : r - i . nd es t ibu la rreas .
- 3 r ongue p a c e h o u l d e c r i m m e dl a t ,w h i l e- ' . - : a nrng he n tegr i r yf the ingua lrenum nd he- - . -= su lcusF ig5-75) .Nodu les f s rone aused y
: : r r h e m p r e s s i o nh o u l d e c a r e f u l l ye m o v e d- - r ncn r r ca a r easF i g5 - 76 ) .A f r e r h o r o u g h l y
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| 5 | The FirstDiagnostic ppointment
ness s a cons is ten trob lem, ne shou ld uspec tn -
compatibility etweenhe alginate nd the stoneused
fo r pouring hecast.Changinghe brandof either he
alginate r stonemaycorrect he problem.
SurFaceoughness lsomay be caused y saliva r
otherf luids n thesurface f an mpression.nwantedl iqu ids hou ldbe e l imina tedrom an impress iony
blot t ingwith a dry issue. s ment ioned ar l ier ,om-
pressed ir shouldnot be usedbecauset may cause
dehydration nd distortion f the mp ression aterial.
Otherpossible auses f irregul ar urFacesn a cast n-
clude nsufficientpatulation f the alginate, remature
removal f an impressionrom the mouth, nsufficient
spatulat ion f dental tone, he useof concaminated
stone, r theuse f a single-pourechnique.
It s also mportanco rememberhat an alginatem-
Dressionhould e removedrom he cast45 to 60 min-utesaftercompletion f the first pour. Leavinghe im-
pressionn contactwith the cast o r an extended eriod
may cause tchi ng f the castsurFace.his produces
soft, chalky urFace.here s alsodanger hat the cast
will beabraded s healginate hrinks ndhardens.
A summary f the causes nd solut ionsor corn-
mon problems ssociated ith diagnostic a sts s pre-
sentedn Table5- 2at the endof the chaoter.
Lengthof appointment
Most pract ic ingent ists i l l useauxi l iaryersonnelo
ass is tn comple t ion f t he hea l th ues t ionna i re ,o
record he blood pressure,o performoral prophylaxis,
andco makeand developadiographs.he pat ient n-
terview, rel iminary xaminat ion,nd diagnost icm-
pression roceduresan easi ly e completedn a 1-
hour appo in tment f t he p rocedures ree f f i c ien t ly
organized. ental tudents, ho wil l ikely e complet-ingal l hestepshemselvesi l l probablyequire to 4
hours o completehe irstdiagnost icppointment.
162
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ln i i ia .
Table 5-1alginate impressions
f , rob lem
diagnostic
Probablecause Solut ion
Alginate slisl<se 1ss1h
Llo ids in impression
Der ipheralunderextension
.l : nate earswhen- c.ession emoved
Teeth oo clean rom overlyvigorouspumicing
Teeth oo dry
Lossof protective ilm fromteeth due o repeatedimpressions
Any of the above
Poormix of a lg inate
Alginate id not low to a l l areas
Alginate id not low intoper ipheral reas r poor mixof a lg inate
Tray oo smal l , o mater ia l otcarr ied ntovest ibule
Tray ncorrectly eated
Cheeks,ips,or f loor of moutht rappedunder ray
Mix of a lg inates oo th in ortoo th ick
lmpression emoved ommouth oo soon
Inadequate u lkof a lg inate
Useof deter iorated lg inate
Prolonged r insuf f ic ientspatulat ion
lmproper emoval rom mouth
Pumice ight ly; e lay mpressionmakingunt i after horough prophylaxis; se si cone
as protective oating or teethAvoidai r dry ingof teeth; solate rchwi th
gauze acks
Usegood echnique o repeatedmpressionsnot necessary; elay mpressionuntilanother ay
Usesil icone rotectiveilm; havepatient uc konsour ci t rus) andyor swishwi th whole mi lk
Spatulateor 45 o 60 seconds y handor 15secondsmechanical ly;ipe a lg inate longsideof bowl dur ingspatulat ion; semechanical patu lat ion ndervacuum
Wipe alg inate n teeth,on palate, nd ntovestibularareasafter mouth has beenisolatedwith gauzepacks; void mix that istoo thick or too thin by using correctwater-powder atio;measurealginatebyweight, not volume; avoid deterioration fa lg inate y heator moisture ontaminat ion
SeeNo. 2
Use raywi th 5- o 7-mm clearance
Center raywi th handlepoint ing t ra ight utof mouth; retract ips with f ing ersso correct
posit ionof tray can be seen;seat ray soborders o belowgingivalmarginal reas;avoid overly arge rays,which will interferewith coronoidprocesses f mandible
Pullout cheeks; etract ips;havepatientprotrude ongue before inal seatingof tray
Use water-powder atio recommendedbymanufacturer;measurealginateby weightinstead f volume;avoiddeter iorat ion fa lg inate y heator moisture
Keep mpression n mouth 2 to 3 min after tloses ts ackiness
Select raywi th 5- o 7-mm clearance;enter
t rayproper ly; e l ievemodel ingplast ic sedto modify ray
Storebulkalg inaten ai r tight onta iners troom temperature
Spatulateor 45 o 60 seconds y handor 15secondsmechanical ly
Avoid rocking r teasing ut of impression;removewi th snap,apply ing orcealong ongaxesof teeth
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| 5 | TheFirstDiagnostic ppointment
l&ryXi,||;;rtr,1 '
arglnate lmpresslons
Problem Probable ause Solut ion
5. Lackof detailo, rgratnyappearance
Prolonged r insuf f ic ientspatulat ion
Insufficientlo w of material
6. Alginatesetsbefore ra ycompletelyseated
7. Pat ient agswhen rayis i t or impressionmade
8. Alg inate isplaced ysal iva n palate
9 .A lg i na t e u l l ed wayfrom tray
lmpressionemoved rommouth oo soon
Mixingwater oo warm
Part ic les f dental tone(calc ium ul fate)n mixingbowl
Prolonged patulat ion f a lg inate
Useof deter ioratedlg inate
Layer f mater ia l a inted nmouth oo thin
Fast -set lg inate sed
Pat ients earfu land acksconf idencen dent ist
Alg inate lowingout of t ray andinto patient's hroat
Pat ientense
Palate umb because f useoftopical nesthet ic
Patienthas severega g reflex
Mucinous al iva ot removeofrom palate
Excessive ecretionby palatal
m ucous lands
Pat ient roduces opiousamountsof sal iva
Alginate ot orcedunder im lock
Alginatedoes not stick omodel ing last ic
Alg inate tuck o teeth
Spatulate or 45 o 60 secondsby hand or 15secondsmechanical ly
Use ray hatconf ines lg inate; secorrectwater-powder ratio to avoid a mix that is to ot h i n o r t oo t h i ck ;m easu reby we igh t ;avo i ddeter iorat ionf a lg inate y heator moisture
Holdsteady n mouth fo r 2 to 3 min aftertackinesss gone rom alginate urface
Us ewater emperature f 22"C172"F), r loweri f moreworking ime requi red
Us edifferentmixing bowls and spatulas oralg inate ndstone
Spatulateor 45 o 60 seconds y handor 15secondsmechanical ly
Store at roo m temperature; void moisturecontaminat ion y measur ing nd seal ing l lcontents f bulkcontainers f a lg inate
Wipe arger mountsonto eethand ntovest ibules;nt roduceray mmediate ly yhaving ray i l ledbefore aint ing n mouth
Use egular-setlg inate
Proceed i th conf ident , e l l -organized anner;usesimpleexplanat ions;void alkaboutgagg ing
Seatpat ient pr ightwi th occlusal laneparal le lwith floor;correctmaxil lary ray withmodel ingplast ic; voidoverf i l l ing f t ray
Instructpatient o keepeyesopen an d ocusedon a small object; nstructpatient o breathethroughnoseat normal ate
Avoid opicalanesthetics; seastringentmouthwashan d cold water rinses nstead
As k patient o hold breathwhile tray is fi t orcorrected; se he "leg-lift" procedure; sefast-set lginateor acceleratehe se t ofalginateby usingwarmer water
Havepatientuse astringentmouthwashand coldwater inse;wipe and solate alatew i I h 2 Y 2 - i n c h g a u z e
Usewarm gauze ads o milk palata l lands,followed by cold pads o constrictglandopen ngs
Premedicate i th 15mg of propanthel inebromide Pro-Banthine,ear le, anJuan,PuertoRico) 0 min beforeproceduref nocont randicat ions
Usesmal l ncrements nd orcealg inatentor im lockareas
Us ealginate.o,coatentire nnersurfaces f tra,y,and model ingplast ic
S e e N o ' 1 . . . . . . . . ; . . . . . . . . . . . . ' . . . i ' ' . .
1 6 4
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I aDte 5-
impressionS
Prob lem
madegeSts from alginare
Probable ause So lu t i on'i, Casthas rough surface
Surface f casthaschalkv3ppeara ce
: last hasa soft surface
l :st breaks hen mpressions: larated rom cast
Incompat ib i l i ty etween lg inateand dentalstone
Insuf f ic ientpatulat ion f stone
St icking f a lg inate o teeth
Sal iva etained n imoression
Water ef ton impression
Poormix of a lg inate;nsuf f ic ientspatulat ion
Useo f s i ng l e -pou rechn ique ;water rose o tissue/toothsurface f impression
Incompat i le a lg i ate-stonecombinat ion
Fi lmof stoneslurryon castaf terdry cast r immed on modelt r im m er
lmpressionef t n contactwi thcast or prolonged er iod
Too much water n mix of stone
Useof inverted ingle-stageourtechnique; ater rose o t issue/tooth surface f imoression
Useof moistu e-contaminatedstone
Wateror stoneoowderadded oimproperwater-powder atio mixaf termixing hasbeenstarted
Stonespatulatedoo long
Prematureemovalof impressionfrom cast
Too muchwater n mix of stone
Useof s ingle-stageourtechnique
Water ef t n tooth mpression
Low compressive trengthofdentalstonebecause f moisture-contaminated tone,addingpowderor waterwhi le mixingstone,or prolonged patulat ion
Alginate mpressionef t n contactwith cast overnight
Change randof a lg inate r stone o obtaincom pa t i b l eom b ina t i on
Spatulate nt i lsmoothhomogenousmix isat ta ined 60 o 90 seconds y handor 15 o 20seconds y mechanical patu lat ion ndervacuum)
SeeNo. 1 in Table -1
Rinse n runningwater unt i la lg inate as oughfeel ;usesoapsudsand camel-hai r rush oremovesaliva;use dry dentalstone as adisclosing gentand removesal ivawi thcam e l -ha i rrush nd unn ingwa t e r
Blot water with dry t issuepaper;avoid useofcompressed i r
Spatulateor 45 o 60 seconds y handor 15secondsmechanical ly
Use wo-stage our echnique
Change randof a lg inate r stone oobtaincompat ib le ombinat ion
Thoroughly oakcast n clearslurrywaterbefore r imming; inseper iodical lyn clears l u r r ywa t e rwh i l e r imming
Separatempressionrom cast45 o 60 minafter irst pour
Useacceptable ater-powder at io;measurestoneby weight nstead f volume
Use wo-stage our echnique
Premeasuretoneandstore n a i r t ight onta iner;avoiduseof open bins or stonestorage
Measure orrect mountof water and weighcorrectamount of stone or acceptablewater-powder ratio
Spatulateor 60 o 90 seconds y handor 15 o20 secondsmechanical ly
Separate ast rom impression 5 o 60 minafter irst pour
Measurewater and weigh powder or correctwater-powder atio
Use wo-stage our echnique
Blot all waterwith dry tissuepaper
Storestone correctly;measurewater and weighpowder beforemixing; spatulate or 60 o 90seconds y handor 15 o 20 secondsmechanical ly
. .Separate mpression ro m cast 45 o 60 mi n,,after irst pour
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| 5 | f h e F i r s l D i e o n n s r i c A n n n i n l m pn t
Table 5-2 (cont)
alglnate lmPfesslons
P r o b l e m Probable ause Solut ion
5. Separation f cast betweenfirst and secondpoursof
stone
6. Voids n surface f cast
7. Underextension f cast
8, Erratic etting ime of stone
9. Cast s inaccurate; or atrue reproduction f theanatomyof the mouth
Failure o leavesurface f f irstpourwi th mechanicaletent ion
for second ourFai lureo thoroughly et i rst
pourbefore dding econd our
Ai r t rapped n mix of stonebecause f inadequate rimpropermlxing
Castpoured oo rapid ly nd ai rt rapped n surface f impression
Overvibrat ionur ingpour ing
Castovert r immed; amular otch,ret romolar ad,or vest ibularareasobliterated
Fi rstpourof a lg inate id notcoveral l per ipheral reas fimpression
Per ipheralnderextensionfalg inatempression
Contamination f stoneby heator moisture
Lossof moisturecontentofimpressionbecause f syneresis,resul t ingn re lease f st ra ins
Release f st ra ins nd swel l inodue o water
St ra ins r d istor t ionn impressioncausedby its movementduringgelat ion
lmpression emovedbeforegelat ion omplete
Stra ins nducedn impressiondur ing ts removal rom mouth
Useof nonr ig id mpressionray
Useof inaccuratempression
Surface f cast ost by washingor soaking ast n tap water
Teeth ontacted ray duringmaking f impression, l lowingstone o flow betweenimpression nd ray
Alginate isplaced r st ra insinducedby setting ray onbench oo
Distor t ionn palate ue o fa i lureto correct ray
Leave urfaceof f irst pour rough;add smallirregularmounds of stone o soft surface f
f irst pourAfter nit ialset of f irst pour,soakcastand
impressionn clear lurrywater or 5 min
Sift powder nto water o avoidair entrapment;hand spatulate 0 o 90 seconds, voidingan ywhippingact ion, r mechanical ly ix stoneunder acuum or 15 o 20 seconds;ight lyvibratemix unt i lno moreai r bubbles ome osurface
Add smal l ncrements f stone o the sameposterior xtension f impressionwith l ightvibrationand allow stone o flow slowly o fi l la l l areas f impression
Use ightv ibrat ion nly; lowingstone houldnot bounce
Take are n r immingof casts n modeltrimmer o avoid removalof crit icalareas
Fi l l mpression omplete ly nd coveral lperipheral orderareaswith 5 to 6 mm ofstoneduring irst stageof pour
SeeNo.3 in Table -1
Pre-weigh nd storestone n airt ightcontainers
Pourcastwithin 12 min after removalofimpression rom mouth;avoidexcessivedrying of impression
Do not store mpressionn wateror othersolutions; o not wrap impression n wetpaper owel
Mainta in mpressionn posi t ion nt i l t is readyfo r removal;do no t haveassistant r patienthold mpression
Mainta in mpressionn posi t ionor 2 to 3 minafteralginatehas ost ts ackiness
Remove mpression ith a snap, pply ing orcedirectlyalong ong axesof teeth
Avoid useof trays ha t lack igidity
SeeTable -1
Us eclearslurrywater whenever ast needs obe soakedor washed
Retractips or goodvis ib i l i ty henseat ingt ray;seat raysl ight ly eyond he andmark fthe gingivalmarg!ns
'
Suspendrayby. i tshandle n a t ray holderor asl ight ly pened rawer
Correct a lata l reaof maxi l laryraywi thmodel ing last ic; f termodel ing last ic hi l led,trim to provide5- o 7-mmclearanceor alginate
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rl References
The sixth eportof theJoint NationalCommittee n preven-
r ion, detec t ion, va luat ion, nd t reatment f h igh b loodpressure.rch n ternMed 1997157 2413-2446.
Lit t le W. The impacton dentistry f recent dvancesn he
m anagem en t f h y p e r t e n s i o n .r a l S u r gO r a l M e d O r a l
)a tho lOra lRadio l ndod 000;90:591599.
\ lclnnes CT . Integrated pproacheso management fhy-
:er tens ion:Promot ing reatment cceptance. m Hear t' i999 138:252-255.
3oucherCO (ed) .Swenson 's omple teDentures , d 6. St .
-ou is :Mosby , ' l 70 .
f eVanMM. The transit ion rom natural o art if icial eeth.) .os thetDent1961 11677-688.'ouse MM. Fu l l entureechn ique. reparedrom he notes
: 'S tudy Club#1 byConley J ,DunnAL,Quesnal l j , Rogers
i - ' . i s 5T.Sonis L , L ieberman. Ora lcompl icar ionsn pa-
, : r t s rece iv ingreatmentor mal ignanc iesther han o f the
- .ad andneck .J m DencAssoc978;97:468-472.'. , :ufmanDW, KellyJP,Rosenberg , Anderson E, Mitchell- - Recent a t terns f medicat ion se n the ambula tory
. : . l l r popu la t ionof the Uni tedStates : he S lonesurvey .- ' .1 2002:287337 344.
- -sav ice<J ed) .Ph i l l ips ' c ience f Denta lMater iars ,c
- Pr i lade lph ia :aunders ,996.
: rbe EC,Bur l<e JT,DouglasWH. Denca lB iomater ia ls .
- . :on: K luwer , 999:294.
: r MW. Syneres isn a lg inate mpress ion a ter ia ls . r
= ' ) 1975;1 9 425-430.
' : : ' n eJ , Lam m ie A .T h e m a n i p u l a t i o nf a l g i n a t em -- . - . n m : t o r i a l R r n e n t | 1 9 5 4 ; 9 6 : 5 1 - 5 8 .
-: : KD, Morrow RM, RhodesJE. entalLaboratory roce-- ' .= . Vo 3: Removablear t ia l entures . t . Lou is :Mosby ,: l : : 5 .
, - - : r EW,Car l is le B . he useof a lg inatempress ion a-- : : n t h e S e a rs ' y d r o c o l l o i dm p r e s s i o ne c h n i q u e .
' . - - , - Dcn t1 9 \ 6 ' 64 0 \ - 4 1 1 .
-.. RC, PowersJM eds).Restorat ive entalMateriars, dj : -ou is :Mosby , 002.
Chand le r JA , r udv i kJS . l i n i c a l v a l u a t i o nf l a : . - - . : a - , ,
n ineyears f te rp lacement f , emovable " - . . r - . l -= ,
Pros thet ent '1 84;58:736-73.
Dao N, CaputoAA, Lucatorco M, MatyasJ.Effecso--:. - '=-,
tants on d imens iona l ccuracy f impress ion na:a- : -ProsthetDent 1990;64:25-31
Deneen J,Heid DW, SmithAA. Effect iventerpersonalnd ra--
a g e m e n t k i l l s n d e n t i s t r y . A m D e n t A s s o c1 9 7 3 : 3 ,878-880.
DrennonDC ,JohnsonCH, PowellCL. The accuracy nd eff icacl
of disinfect ion y sprayatomization n elastomericmpres-
sions. Prosthet entl989;62:468-47 .
Fleece , Linton P, DudleyB. Rapideliminacion f a hyperactive
gag ef lex .J ros thet ent '1 88;60:415-417.
Cordon CE ,JohnsonCH, DrennonDC. The effectof tray selec-
t ion on the accuracy f elastomericmpressionmaterials.
Prosthet ent 199 0 63 12-1 5.
HarrisWTJr. Water emperature nd accuracy f alginatempres-
s ions . Pros thet ent1969;21:613-617
Her rera P ,MerchantVA. D is in fec t ion f a lg inate , o lysu l f ide ,
v iny lpo lys i loxanend po lyether enta l mpress ions .Dent
Res 985;64:14.
HouseMM. Fu l ldentureechn ique. o tesof HouseStudyClub
No . 1 ,19 6 0 .
HouseMM. An out l ine or examinat ionf mouthcondi t ion . o-
m i n i o nDen t J 92 1 3 3 : 9 71 00 .
KaiserDA, NichollsJl. studyof distort ionand surface ardness
o f i m p r o v e d a r t i f i c i a l t o n e c a s t s . P r o s t h e tD e n c
1976;36:373-381
l(atberg W. Cross-contaminationia the prosthodontic abora-
tory. Prosthet ent 1974;32:412-419.
l(rolAJ .A new approach o the gagging roblem. ProsthetDent
1963;13:611-61.
LookJO,ClayD) , Cong C, Messer H. Pre l im inaryesu l t srom
disinfect ion f irreversibleydrocolloid mpressions.j Pros-
thet Dent 1990;63:7 1 7 07
MerchantHW, CarrAA. Blood pressure easurement: roblems
andso lu t ions .Am DentAsso 1977 95:98-1 2 .
Mor row RM, BrownCEJr ,S tansbury E,Delor im ierJA, owel l
JM, Rudd (D. Compat ib i l i t y f a lg inatempress ion a ter i -
a l s n dd e n t a l t o n e s . J r o s t h e t e n t 1 9 7 1 ; 2 5 :5 5 6 - 5 6 6 .
Nass i f . A se l fadmin is teredues t ionna i re-Anid n managing
c o m p l e t e e n t u r e a t i e n r s . . J r o s t h e r e n t 1 9 7 8 ; 4 0
363-366.
Phil l ips W, PriceRR ,Renking H.The useof alginateor indirect
restorat ions.Am DentAssoc1953;46:393*403.
Phoen ix D . Depar t m en t f P ros t hodon t i c su n i o rC o m p l e t e
Denture l in ica lManual . anAnton io :Univof Texas ea l thSc ience enter t SanAnton ioDenta l choo l , 000.
Pierce H, CoodkindRJ .A status eportof possible isks f base
m e r a l a l l o y sa n d t h e i r c o m p o n e n t s . P r o s t h e tD e n t
1989;62:234-238.
P la in f le ld. Communicat ionis tor t ion . he anguagef pat ienrs- - r ^ - - ^ - : . : - - ^ - - r f d e n r i s r r v . P r o s r h e r e n t 19 5 9 'i l u
P t d L L t L r u i l g t )u l
2 2 : 1 1 - 1 9 .
: Bibliography
; : ' ! : -_ . F l o w a n d e l a s t i c i t yn a l g i n a t e s . e n t P r o g
. - -': 5 3 - 7 0 .
" : . - l ' Ph i l ps RW, Del lA , HenryRW. Deta i ldup l ica t ion
. , . - . . . j : o eva luate las t icmpress ion ater ia ls .Pros thet
- : - . ' ) 5 ) . 1 0 : 3 7 4 - 3 8 0 .
: , _ . - " - J . ErcsonC. Cross-sec t iona ltudyof the per iodonta l
, .=: - . o t removablear r ia l enture a t ients . Pros thet enc
: : ; : 6 , ] 208 210 .
- . - - -= ' . l l l . Cur - t isA , Mor r ishRBJr .Radia t ionompl ica t ionsn
: r : - rJ ouSpatients. Prosthet ent1976;36:1 3-203.
8/8/2019 05 Diagnostic App 1
http://slidepdf.com/reader/full/05-diagnostic-app-1 42/42
| 5 | The FirstDiagnostic ppointment
Rahn O, Matalon , DraneJB. rostheticvaluationf patientswho have eceivedrradiationo thehead nd neck egions.JProsthet ent1968;1 :174-178.
Rowe H, ForrestJO.entalmpressions:heprobabiliryf con-t a m i n a t i o n n da m e t h o d f d i s i n f e c t i o n .r D e n t1978;145184-186.
RuddKD ,MorrowRM .Premedication:n aid n obtaining ccu-
ratecomplete enturempressions.Prosthet ent1967;1 :86-89.
RuddKD,MorrowRM,Bange . Accurate asts. Prosthet ent1969;21:545-554.
RuddKD,MorrowRM ,BrownCEJr,PowellM, Rahe J.Com-parison f effects f tap waterand slurrywateron gypsumcasts.J rosthet ent197Q;24:563-570.
RuddKD, Morrow RM, StrunkRR .Accurate lginatempression
J ProsthetD ent 1969 22:294-300.
SauserCW . Pretreatment valuation f part ial lyedentulous a-
t ients. Prosthet ent 1961 11 886-893.
SchelbE, CavazosE, KaiserDA, Troendle K. Compatibil i ty of
Type V dentalstoneswith polyethermpressionmaterial.
Prosthet ent 1988;60:540-544.
Schutt RW. Bactericidal ffectof a disin fectant ental stone on ir-reversible ydrocolloidmpressions nd stonecasts. Pros
thet Dent 1989;62:605-606.
TolentinoAT . Prosthetic anagement f patients ith pemphigu
vu garis. ProsthetDent 1977 38:254-260.