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 ' : -



| 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



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



: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: -



| 5 | TheFirstDiagnostic ppoinrment

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



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



| 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



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




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-



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



| 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



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




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



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




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



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




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



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




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



-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



| 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



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




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



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- , =



| ! 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



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 -



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 .



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




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



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; - -




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



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.:=-



| 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.



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




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



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




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


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



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


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


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


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



| 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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)a tho lOra lRadio l ndod 000;90:591599.

\ lclnnes CT . Integrated pproacheso management fhy-

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