Wednesday, July 20, 2011

Acrylic Denture Processing-Laboatory Proceedure : Prosthetic Dentistry Lecture Note

 
Acrylic RPD Processing:

  • similar to complete denture
  • same idea; converting base plate – wax, shellac, cold cured acrylic, light cured acrylic- into heat cured acrylic.

Properties of Heat Cured Acrylic to be used as the final material of RPD:

  • strong "high toughness", but shellac is a very weak material
  • more hygienic; can be polished to highly smooth surface.

There are different techniques but we use the gold standard technique which is called "lost wax/acrylic technique".
We replace the base plate with heat cured acrylic but we leave the acrylic teeth and the clasps.
The clasps and the remaining teeth in RPD make minor differences in the processing.
Steps of processing:
1-    Flasking.
2-    De-waxing.
3-    Acrylic Packing.
4-    Heat Curing.
5-    De-flasking.
6-    Finishing.
7-    Polishing.
Sequence is very important.

In the previous labs we made 3 clasps, base plate and we did the setting of teeth.
In processing, the clasps and the teeth are kept in their places and just the red modeling wax will be replaced by heat cured acrylic.

1-    Flasking:

Flask is made of 2 parts, upper and lower –written on them U & L-.
Every half has 4 components, 2 parts and 2 lids for coverage.
- Pre-vaselination the flask using Vaseline which is petroleum gel to make the de-flasking step easy.

- Fix the model inside the lower part of
      the flask with gypsum type II but here
gypsum will reach the retentive arm of
the clasps and the area of the trimmed
remaining teeth –to prevent hard de-flasking and breakage of the cast or teeth as there are undercuts- not like complete denture where we cover until the border of the model.
- In the first fixation of the cast no need for more than plaster of Paris which provide easy de-flasking as it is weak material.
- if retentive arm of clasps not covered by gypsum, when gypsum added to the remaining parts of the clasp, 3 surfaces will be covered but the forth which touches the tooth may not so in de-waxing there is high chance for displacement of the clasp … the clasp is not in the undercut area any more so retention is lost.

So:
-         any tooth not important .. trim it so we will leave the abutment teeth where clasps are attached.
-         The end of this stage:
Model with retentive part of the clasps covered and the remaining teeth trimmed … nothing visible except acrylic teeth and the wax base plate.
-         Leave it to set –it needs 10-15 mins to set-.

- Put Vaseline for easy de-waxing all around the gypsum but not on teeth & wax, if Vaseline is put on teeth and wax, it will eliminate the anatomy.
- Put the other half of the flask and put mixed gypsum with the usage of vibrator.
Here we use mixed Gypsum because if we use gypsum type II with pressure teeth may be displaced inside the gypsum as it is weak. And if we use dental stone, it is hard to clean the denture –from fissures and embrasion- during finishing and polishing.
- So we use mixture of both plaster of Paris and dental stone so we will get strong material and easy to be removed from the anatomy.
- If you want to make it easy … pour until surface of teeth then pour layer of plaster of Paris to get easier de-flasking… close it by the cover so excess gypsum will go out… leave it to set for 45 mins.
- If you want to accelerate the reaction use hot water, salts increase it to 20% potassium sulfate … tera alba.
Tera alba: is the remnant material of gypsum in the rubber bowel –any thing we add to the mixture from previous mixture will accelerate the reaction-.
Linea alba: occlusal line formed due to biting.
Materia alba: 1st layer of the plaque.

The mixing ratio:
* Plaster of Paris 50-55 ml water : 100 g powder
* Dental stone  30 ml water : 100 g powder
* Modified dental stone 20 ml water: 100 g powder


2-    De-Waxing:

- Hot water path… open the flask into two parts … leave it for 5 min for complete removal of wax …
- The end result is:
Part has the clasp retainer but retentive part inside gypsum
Second part has the acrylic teeth
-         check for stability of the both parts as any mobility during packing and pressure will be a displacement in the denture.
-         Also if no holes in the apical part of the teeth, do it in this stage to get retention mechanically but if the teeth are porcelain there is retentive metal component.
-         use a separator called cold mold seal (sodium alginate) …  make 2 coats but don’t cover the teeth or the clasps as no need for separator here.

3-    packing:

 - Heat cured acrylic; it is found in powder –MMA- and monomer.
Powder is polymer chain, the monomer will do polymerization reaction, powder-powder so co-polymerizations.
- No way to know the exact chemically, how much monomer needed from the monomer to do polymerization reaction for the polymers you have … always we will get excess monomer

*Note:
Always try to add powder to liquid… so you will get less voids, and some manufacturer instructions say add powder to liquid until the surface of the liquid is almost powder.
Mixing done in glass cup as the reaction is an exothermic reaction so easy cleaning and not stick to rubber as if we use a rubber bowel.

Stages the heat cured acrylic go through:

1-    Sandy stage: like beach sand but with water. Cover it with lid to reduce evaporation of monomer as the reaction is exothermic.
2-    Fibrous stage: strings or sticky.
3-    Doughy stage: the proper stage for packing
4-    Rubbery stage: heat generation if felt by hands.
Avoid packing at both fibrous and rubbery stages; in fibrous stage the reaction is not completed but in the rubbery the material start r=to be rubbery with recall effect so distortion of the denture.
5-    Hard set stage: after heat curing
We need to cure it in hot water to initiate the reaction as the initiator here is benzoyl peroxide, this material need 60 degree to destruct the bonds between molecules and start the reaction
But cold cure the initiator start the reaction when mixing occur, and the light cured the initiator needs light to start the reaction.
So we need minimum 60 degree to start the reaction and the reaction is exothermic so it will complete the reaction.
If upper RPD make the heat cured acrylic in the doughy stage as a ball and adapt it, then put the other half of the flask and using hydrolytic pressure excess will leak out … keep applying pressure until both halves of the flask meet each other.
Or during flasking escape channels are made and as the flask is opened posteriorly the excess will go out from the end in addition to the front and the sides until the two parts meet each other.

4-    Curing:

In hot water path.
Remember that here we want the temperature to exceed 60 degree to start the reaction but we don’t want the monomer to evaporate so we should not reach the boiling temperature of the monomer -100.8-.
If evaporation occur, remember that teeth, acrylic and gypsum are poor heat conductors so all vapor of monomer will stay inside the acrylic giving porosities.
Porosities will weaken the acrylic and if go to the surface there will be plaque accumulation, fungal infection, and bad odor. And if rough porosities soft tissue irritation and discomfort will occur.

*Remember:
We don’t want to leave excess monomer, if left in excess it is cyto-toxic material and it may react later on and distort the denture,
And we don’t want to reach the boiling temperature at first stage of curing preventing the evaporation of the monomer specially in thick acrylic RPD.

2 curing cycles :
1.     Gold standard cycle "Slow / Long curing cycle
Room temperature at time zero
Switch on –   Temperature , to make sure of complete degradation above 60 so 74 for 8 hours (above 60 good Rxn . this is Temperature in machine but inside more as Rxn is exothermic
After 8 hours , machine turn off
If rapid cooling >> Warpage distortion
So bench cooling or leave it in the machine to cool slowly
Modification to this cycle >> after it is completely set make the temperature 100 for 1 hour.
So to be sure that there is no excess monomer remains.

2.     Fast / "short " cycle :
Same principle but the curing is for 2h at 74 degree then elevate it to 100 degree to get rid of the excess monomer.
So total it is 3 h.
But this method not good as 2 h might be not enough for the reaction to finished completely.

The worst thing you may do if you insert it in 100 degree water in the first stage as monomer will evaporate. Leading to porosities.
 
The Acrylic found in the lab:

Turn on the light cure machine until it reaches above 100 degree turn it off then put the flask in it; temperature is decreasing so no chance of evaporation, after 15-20 min turn it on again to remove the excess monomer then cooling.

5-    de-flasking

In good separation the model will be without clasps as acrylic is stronger than gypsum so as par of the clasps embedded in it the retentive part will not stay in contact with the gypsum in this stage.
Hammering until denture comes out, the denture will have some sharp areas.
The Dr. showed us RPD  with pink acrylic replacing one tooth.
The reason for this displacement during packing is that the tooth was  not stable at de-waxing stage.
You don’t need to repeat the denture, just trim and fix the tooth with right relation then fix it using cold cured acrylic.

6-    finishing:

to remove sharp areas.
Start with acrylic bur with hand piece remove all excess material and sharp areas and irregularities but don’t touch teeth at all. And don’t touch the fitting surface unless there is sharp areas felt by hand.
If there is gypsum on tooth soak it with water then remove it with wax knife or Lacron carver. Or use round fine tip bur and don’t touch the clasps.
Then use sandpaper with mandrill.


7-    polishing:

to reduce discomfort, reduce plaque accumulation and infection and for esthetic if visible.
Use pumic –volcanic produst- with a wheel made of rugs and cloth using low speed hand piece ---- glossy.
Rouge (Iron oxide) which is white material.
Denture polishing paste ---- shine
Water and soap

Technician send the RPD to the Doctor soaked in water to prevent distortion by heat or monomer as it is a plastic RPD.
Then we insert it in patient mouth.

 Key Words : Acrylic denture Processing,Dental Technician's duty in acrylic denture processing

Three-quarter (posterior) Crown Restorations : Restorative Dentistry Lecture Note

Indications

·         For posterior teeth as a single restoration for teeth that have lost moderate amount of tooth structure with intact buccal wall or as retainer for posterior FPD

Contraindications

·         Teeth that have short clinical crown because the retention may not be adequate.
·         Extensivlely damaged teeth.
·         as retainer for long span ridges.
·         Patients with active caries or periodontal disease.
·         For endontically treated teeth, because insufficient tooth structure remain
·         Thin teeth of restricted labiolingual dimension

Advantages

·         Conservative because it requires less sound tooth structure reduction
·         Less opportunities for periodontal trauma because less restoration margins r in close proximity to gingival
·         Reduced pulpal and periodontal insult during preparation
·         Magins in accessible area to the dentist for finishing and to patient for cleaning
·         Good seating for the restoration coz the luting agent can escape more easily
·         The uncovered labial or buccal surface permits vitality testing

Disadvantages

·         less retention and resistance than complete coverage crowns
·         more difficult preparation
·         some metal is displayed in the restoration

Steps

·         occlusal reduction
·         functional cusp bevel
·         lingual reduction
·         proximal reduction
·         proximal grooves
·         proximal flares
·         occlusal offset
·         buccal cusp bevel

Occlusal reduction (posterior) or incisal reduction (anterior)

·         Depth grooves done on the occlusal surfaces with round-end tapered diamond bur, the reduction then completed by reducing the tooth structure remaining between the depth grooves
In lower teeth:
·         1-1.5mm reduction from buccal cusps
·         2- 1mm reduction from lingual cusps

In upper teeth:
·         1-1.5 mm reduction from lingual cusps
·          2- 1mm reduction from buccal cusps
Functional cusp bevel
·          Done with round end tapered only on maxillary teeth .the bevel extends on the central groove from the mesial to the distal .the difference between maxillary and mandibular teeth that is the buccal cusps of mandibular teeth are the functional cusps so the location of the occlusal finish line on the buccal surface will be different. It will be 1mm gingival to the occlusal contact this result in metal coverage .The occlusal shoulder in buccal aspect of the buccal cusp served as the same purpose of the offset in maxillary teeth so there is no need for an offset in mandibular preparation.

Axial reduction

Lingual reduction:
·         Eliminate the undercut cervical to the height of contour done with round end tapered.
·         -Mesiodistally follow the contour of the tooth
·         -Occlusocervically parallel to the path of insertion with slight occlusal convergence

Proximal reduction:
·         Started by gaining proximal axes with thin tapered diamond then followed by round end tapered to complete the reduction and form chamfer finish line
·         Final extension to buccal surface by thin tapered diamond .the proximal surfaces must be parallel to each other and path of insertion with slight occlusal convergence

Others

Proximal grooves:
·         It must be placed on the buccal half on the proximal surface at the line between the buccal and middle third of proximal surfaces. This increases the bulk of tooth structure lingual to the grooves to resist lingual displacing force.
·         -The I shape groove is the satisfactory form because the lingual form of the groove is prepared to be at right angle to the proximal surface preventing the restoration to be displaced lingually
·         -The box like form is indicated in case of proximal caries or when is made to receive the female portion of precision attachment
·          -The V shaped groove is rarely used due to its reduced retentive quality but it is mainly used for anterior three quarter preparation.
·         Proximal flare:
·          The buccal wall of the groove is then flared buccally by a flame diamond to remove any unsupported tooth structure. The flare should be extended far enough to be reached by the explorer but not so far as to cause display of metal
Occlusal offset:
·         Done with no.171 bur .the offset is a 1mm wide ledge on the lingual incline of the buccal cusp. It connects the groove and plays a major role in the casting rigidity by tying together the proximal grooves. With end cutting bur smooth the offset insuring that it will be a flat ledge.
Buccal cusp bevel:
·          Place a narrow occlusal finish bevel along the occlusobuccal line angle with a flame diamond about 45 degree relative to buccal surface .the bevel should be no more than 0.5mm wide.

 Click here to Download Compare and Contrast among FullCrowns, PFM anterior, PFM posterior, Three quarter anterior and Three QuarterPosterior


Key Words : Restorative dentistry lecture note,Conservative dentistry lecture note,Advanced restorative dentistry,Prosthetic dentistry lecture veneers porcelain veneers dental veneers teeth veneers cost of veneers veneers for teeth

Three-quarter (anterior) Crown Restorations : Restorative Dentistry Lecture Note


Indications
 
·         Anterior teeth as a retainer for FPD
·         As a splint for periodontically involved teeth

·         But the teeth should have the following chch
·         The coronal tooth is intact or minimally restored
·         Anormal coronal form exists (not conical)
·         There is an average crown length
·         When the restoration is to be used as retainer for a fixed prosthesis, the following also are to be consider
o   The abutment teeth are in normal axial alignment
o   Short lever arm
o   Average occlusal forces

Steps

·         lingual reduction
·         proxiaml reduction
·         proximal grooves
·         incisal offset
·         incisal bevel

Occlusal reduction (posterior) or incisal reduction (anterior)

Done with small wheel stone, the incisal edge is reduced along the mesio-distal length.labio-lingually the cut is inclined lingually with 45 degree to the long axis of the tooth. The labial margin of the reduction should end just before the inciso-labial angle. In the canine reduction follow the natural mesial and distal inclines of the incisal edge(two planes),while for incisors, flat plane is cut from mesial to distal

Axial reduction

Lingual reduction:
·         Is made in 2 steps
·         A-reduction of the lingual surface from the crest of the cingulum to the incisal edge. We do first orientation groves by small round diamond bur then reduction done using a small wheel diamond bur. Even reduction of 0.7mmm should be made. In canine the reduced lingual surface should be made in two planes while the incisors the entire surface is concave.
·         B-reduction of the area of the crest of the cingulum to the crest of the gingiva to eliminate the under cut cervical to height of contour this is done using tapered diamond stone with round end
Proximal reduction:
·         Initial reduction is done with long needle diamond then a small diameter tapered round end diamond bur is used to insure chamfer finish line with the depth of cut from 0.3-0.5mm

Others

Proximal grooves:
·         Should be parallel to the incisal 2/3 of the labial surface. Mesiodistally the grooves should be parallel to each other with slight incisal convergence. We use a taper fissure bur no. 170 at the mesial surface to make a depth of 1mm and extenf gingivally to its full length and the second groove is done on the distal surface parallel to the first one just ending short to the chamfer.

Incisal offset:
·         The grooves r connected with an incisal offset using a no.171 bur. the offset is a definite step on the sloping lingual surface. On a canine it forms a V shape, but on incisor it is a line follow the incisal edge
Incisal bevel:
·         A 0.5mm incisal bevel is placed on the labioincisal finish line using a flame diamond bur



 Click here to Download Compare and Contrast among FullCrowns, PFM anterior, PFM posterior, Three quarter anterior and Three QuarterPosterior

PFM (Posterior) Crown Restorations : restorative Dentistry Lecture note

 
PFM (Posterior) Crown Restorations
Indications

·         Teeth are short, tapered, round or lack well developed cingulum
·         Patient with occlusal habit that place heavy forces on the restoration
·         As retainer for RPD
·         To correct minor, malalignment and mal occlusion
·         Severly destructive tooth
·         Endodontically treated tooth and tooth with post and core
·         Correction if abutment tooth for RPD
·         Long span bridges

Contra-indications

·         Young patient due to large pulp chamber and incomplete crown eruption.
·         Patient with active caries and untreated periodontal disease.
·         Intact abutment teeth in short span ridges.
·         When the teeth can be satisfactory restored with a more conservative restoration.

Advantages

·         Glazed porcelain is the most esthetically durable and biocompatible restorative material for teeth (resist wear and plaque adhesion)
·         The metal substructure provide support to the porcelain and hence less liable to fracture than the all porcelain crown
·         The metal substructure allowed the fabrication of fixed partial denture
·         The natural appearance can be closely matched by characterization with internal and/or external staining techniques
·         The preparation of the PFM is much easier than that of the partial coverage restoration

Disadvantages

·         Need a less conservative preparation
·         Less esthetic qualities than the all porcelain crown
·         Needs special equipment and expensive armentarium
·         Fracture liability of the porcelain veneering
·         facial gingival finish line should be carried subgingivally and consequently more potential for gingival involvement and periodontitis
·         Difficult of making an accurate shade reproduction due to metal

Steps

·         Occlusal reduction
·         Axial reduction
·         marginal placement
·         Seating grooves
·         Finishing

Occlusal reduction (posterior) or incisal reduction (anterior)

·         We do depth orientation grooves for even thickness reduction then remove tooth structure in between
·         We use 170 or 171 tapered fissure bur and round-end tapered diamond bur
In lower teeth:
·         2mm reduction in the bucaal cusps (functional cusps)
·         1mm reduction in lingual cusps

In upper teeth:
·         1.5mm reduction for both buccal and lingual cusps (functional cusps)
Functional cusp bevel
·         Is done on both upper teeth (on lingual cusps) and lower teeth (on buccal cusps) with round end tapered diamond bur and bur no.171 the depth is 2mm
·         Angle between functional cusp bevel and functional cusp slope should be 45 degree
·         -To follow the morphology of the tooth
·         -Stability and support
·         -Prevent fracture
·         -Prevent PDL injury
·         -Lateral torque prevention

Axial reduction

·         Buccal and lingual walls reduction then proximal walls reduction
·         We use flat –end tapered diamond bur (shoulder finish line) hold it parallel to the long axis of the tooth otherwise undercut or over tapering will occur
·         For lingual reduction we use turbido bur. or we use the round end tapered diamond bur (chamfer finish line)
·         To open the contact we use short thin tapered diamond bur

Others

We may use retentive grooves if the tooth is too short so we need extra means of retention
Wings at the end of the shoulder are done for:
1.       prevent horizontal movement
2.       preserve tooth structure.
3.       Marginal placement

 Click here to Download Compare and Contrast among FullCrowns, PFM anterior, PFM posterior, Three quarter anterior and Three QuarterPosterior

Key Words : Porcelain fused to metal Crowns, Ceramic fused to metal crowns

Anterior PMF(Porcelain Fused to Metal) Crown Restorations-Restorative Dentistry Lecture note

PFM (anterior) Crown Restorations
Advantages

1.       Stronger than all ceramic
2.       Superior marginal fit over all ceramic
3.       Better esthetic than cast restoration

Disadvantages

Preparation is not conservative as cast restoration

Steps

·         depth orientation grooves
·         incisal reduction
·         axial reduction
·         marginal placement
·         finishing

Occlusal reduction (posterior) or incisal reduction (anterior)

·         We do depth orientation grooves for even thickness reduction then remove tooth structure in between
·         We use flat-end tapered diamond bur to do 2mm reduction

Axial reduction

Labial reduction;
·         -We do depth orientation grooves in two planes to avoid pulp exposure
·         Parallel to gingival 1/2
·         Parallel to incisal 1/2
·         We use flat end tapered diamond bur to do 1.5 mm reduction to do shoulder with bevel (bevel is done to decrease area of exposed cementum.
·         We use enamel chisel, such as hachet or biangle chisel to remove undermined edge of tooth structure. We use the chisel also to produce smooth finish line.
·         Wings: is left standing in each proximal area, lingual to the proximal contact so the metal won’t display.
·         It1- preserves tooth structure 2-and adds some torque and rotational resistance.
Lingual reduction:
·         Depth of reduction is 0.7mm.done by
·         1-round bur
·         2-foot ball
·         3-wheel.  4-turbido
·         2,3 are used above the cingulum
·         1,4 below the cingulum to make heavy chamfer finish line.
Proximal wall reduction:
·         -Initial reduction is done with long needle diamond then a small diameter tapered round end diamond bur is used to insure chamfer finish line.
·         -2_3 degree taper on each side.
Gingival marginal placement:
·         -The end cutting bur no. 957, but is only used to smoothen the SHOULDER finish line and to move the shoulder subgingivally But usually we don’t use it.
·         The internal angle should be rounded to reduce stress concentration



Click here to Download Compare and Contrast among FullCrowns, PFM anterior, PFM posterior, Three quarter anterior and Three QuarterPosterior

Key Words : Crown restorations, Porcelain fused to metal crowns, Ceramic fused to metal crowns, Prosthetic dentistry lecture note

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