ADJUNCTS TO MOUTH

ALEXANDER

RECONSTRUCTION

S. FORSTER, D.D.S.

New York, N. Y.

should become specialists in the practice of good general dentistry. The general practitioner sees many patients with minor dental discrepancies, especially in the younger age group. Therefore, he is charged with the responsibility of correcting and maintaining the oral health of these patients for their entire life. This is a large order. The essential long-range view in diagnosis and treatment planning includes clinical and roentgenographic examinations, the use of study casts, proper periodontal treatment, and patient education for home care. A diagnosis made clinically, roentgenographically, and by accurately mounted study casts is most certainly in the realm of the general practitioner--the operative de?&&. If he is not to render this service, who or what specialty is responsible for this service ? The answer is the dentist zwho specializes in the general

ORE OF THE

PROFESSION

practice

of dentistry.

The general practitioner plays an important role in the execution of a complete service to the patient. The adjuncts to be discussed help in the execution of this concept of modern dentistry. The assumption is that all dentists know, or should know, the techniques of mouth reconstruction. Each of the procedures involved in successful mouth reconstruction is contingent upon the other. Unless all of the procedures are properly carried out, there will be failure.
GOOD ADMINISTRATION OF THE PATIENT1

It is necessary to have the patients confidence and cooperation. Prior to making the roentgenograms and diagnosis, the dentist speaks to the patient and arrives at an understanding regarding his dental health. The patient is encouraged to tell his story and the dentist listens. This is very important. Certain hazards are involved in this procedure that are constantly in the picture. These hazards are any factors that may arise before, during, or after treatment that will militate against, weaken, or defeat the dentists attempt to uperate along the line of optimum dental health.
RASK CONCEPTS OF GOOD PATIENT ADMINISTRATION'

Good patient administration requires that the dentist must (1) keep abreast of the advances of dentistry, (2) must make a careful and thorough diagnosis, (3) must formulate the one best treatment plan for the patient, (4) must render treatment with thoroughness and precision, (5) must, where economic means are
Received for publication Jan. 16, 1958. 1026

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limited, plan for the eventual comzplete treatment in stages to achieve the desired result (this desired result is the optimum in future dental treatment), and (6) must educate each patient so that he will be motivated and equipped to perform his part in maintaining the optimum dental health. These concepts are the ideal and the pleasant way to practice dentistry.
PEACE OF MIND FOR THE DENTIST

There are four hazards to overcome in order to maintain the peace of mind of the dentist. They are: (1) the fear of the fee on the part of the dentist or the patient, (2) the fear of pain, (3) preconceived ideas in the mind of the patient, and (4) a lack of dental consciousness on the part of the patient. A thorough understanding of the treatment involved will eliminate all of these hazards that both the dentist and the patient have to face. Everything must be understood from the beginning. The average patient knows little or nothing about dentistry, so he should be shown that dentistry has made important changes and improvements. Patients should be shown why teeth are lost. This can be done by showing them roentgenograms and study casts.
USE OF A HIGH-SPEED ENGINE WITH JET tLIR .AND W.4TER COOLANTS

Dentists must concentrate on the patients welfare and eliminate the hardships that accompany dental service. The new high-speed techniques are necessary adjuncts to the successful completion of the reconstruction service. When teeth are prepared for any type of restoration, the patient experiences an immediate discomfort. This discomfort should be eliminated or minimized by applying all the available implements. High rotational speeds have many advantages. (1) They eliminate the need for local anesthesia during the first grinding on the tooth. (2) The high speed and water eliminates pain, vibration, and heat from friction. (3) The patient spends less time in the dental chair. This is especially important to a highly nervous patient who needs coddling. (4) At subsequent visits, the patient becomes acclimated to the grinding. Anesthesia can be administered, and preparations of individual quadrants can be completed. (5) High rotational speed reduces the time spent in preparation. (6) The dentist is less fatigued. (7) Impressions can be made with anesthesia, thus eliminating the pain related to making band impressions and requiring less time. (8) Two visits are essential for preparing the teeth in each quadrant. One is made with anesthesia and one without. At the second visit, the preparation can be re-evaluated and, under anesthesia, checks can he made for undercuts, chamfers, shoulders, and finishing lines. This seems to be the perfect procedure. The advantages of high-speed techniques are greater than any possible disadvantages. Many hazards can be eliminated with the use of these new concepts of tooth preparation. Previously, dentists have prepared teeth at one sitting and have found defects in the preparations at the next sitting. Too often they did not correct the preparation but proceeded with the impression. These impressions were faulty, and the entire restoration was a failure. The dentists were fearful

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J. Pros. Nov.-Dec.,

Den. 1958

that the patient would complain of pain, of further preparation. With the use of and a high-speed engine, the preparation seconds, with little or no discomfort to the
PREPARATIOK BY QUADRANTS

discomfort, and additional nervous strain carbide burs, diamond disks and wheels, could have been altered in a matter of patient.

The technique of preparing quadrants of teeth with the minimum of fatigue has a direct bearing on the high-speed technique. The mouth is divided into four quadrants if the entire dentition is to be restored. It makes no difference whether inlays, full crowns, veneers, or platinum-porcelain restorations are to be placed. The preparation of the tooth or teeth in the quadrant is started without anesthesia. At the conclusion of this session, the teeth are covered with aluminum shells or other temporary restoration. At the following visit, the patient is given anesthesia, and the preparations are completed. Impressions are made, and the prepared teeth are covered with splints or individual crowns. These impressions can be made without pain because of the anesthesia, and the patient is not fatigued at the time this is done.
TEMPORARY SPLINTS

The patients welfare is of primary importance. The use of temporary stopping is inadequate protection for teeth in this concept of restorative dentistry. With full coverage restorations, the need for maintaining spaces which are to be subsequently restored with permanent restorations is apparent. The fabrication of these restorations may take weeks or months. The patient is subject to discomfort, pain, loss of vertical dimension, centric occlusion, etc., in this period. Splints will provide the type of temporary restorations that are needed. At the conclusion of the first grinding on a quadrant, an impression for constructing the splint is made. After the enamel of the teeth has been removed, there are spaces between these prepared teeth. Pieces of wax are inserted in the spaces, aluminum shells are placed over the primary preparations, and an alginate impression is made. If the patient is to be seen within a few days, the impression for the splint could be made at this time and placed in water until the next visit. If a longer interval between appointments is required, the alginate impression is made at the second visit when the preparation of the teeth is completed. The alginate impression is filled with self-curing acrylic resin and placed over the prepared teeth. When the resin has hardened (5 to 7 minutes), the impression and the resin is removed, and the excess resin is trimmed away. This provides a space maintainer, coverage, and protection for the teeth. The temporary splint is seated with temporary cement.
ELIMINATION OF PAIiX

The elimination of pain is of vital importance in this type of dentistry. The patient suffers postoperative sequelae, once after the grinding, next after the im-

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pressions, and during the waiting time between appointments which is required for laboratory procedures. We must concentrate on the patients welfare and attempt to eliminate the hardships that accompany the treatment. There are many ways of eliminating pain. A properly constructed splint, cemented with an anodyne cement, will eliminate most of the discomfort. To be effective, the temporary splint must cover the prepared teeth at the gingivae. The use of silver nitrate, calcium hydroxide, Cavitec, and other quieting agents will tend to eliminate the discomfort. The hazards accompanying full coverage must be taken into account. Care should be taken to avoid cutting into the horns of the pulps. If this should happen, it might not become apparent for 6 months after the preparations are completed, Temporary cementation should be employed until the danger period is past.
BISCCIT BAKE SPLINT

In any restoration where the entire mouth or dental arch is involved, a registration of the maxillomandibular relations can be made while the restoration is being completed. This is done by means of the biscuit bake splint. When the laboratory work is completed and the restorations are ready for a trial insertion, an impression is made over the restorations. This is done in the same manner as for splint impressions. The restorations are removed from the teeth, and self-curing acrylic resin is placed in the impression and inserted in the mouth. When the resin is set, it is removed and trimmed. It is a duplicate of the metal restorations in acrylic resin. When this is cemented in place with temporary cement, the occlusion, esthetics, patients comfort, and many other details can be observed and tested.
BINOCVLAR LOUPES

\Vith high rotational speeds and full coverage, it is important see what he is doing. The use of binocular loupes is essential.
COPPER BAND IMPRESSIONS

that the dentist

There is no margin of error in making copper band impressions. When there is a failure, there is a work stoppage, and this is expensive. The work cannot progress until a new impression is made. Attention to a few salient procedures will help to reduce the number of failures. (1) The copper bands should be annealed. (2) The copper bands should be fitted properly. (3) Low heat compound should be used. (4) Th e copper bands should be festooned. (5) The compound in the band should be heated, placed on the tooth, and removed z&hOM~ chilling after it is semihard, and replaced immediately upon the tooth. It should be alIowed to remain on the tooth until it is hard. It is removed by a straight pull and replaced in the same position and allowed to set very hard. Ry this procedure, any possible undercuts were relieved, and the modeling compound was allowed to harden completely while it was in position on the tooth. After it had hardened without chilling, it could be removed and reseated. This provides a test for the final position of the restoration.

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J. Pros. Nov..Dec.,

Den. 1958

On very sensitive teeth where there is a danger of pulp irritation or pain, the rubber or hydrocolloid materials can be used for making impressions, but copper band and modeling compound impressions are best. An over-all impression must be made with plaster of Paris to orient the various restorations in relation to each other.
CEMENTATION

Temporary cementation is important to the success of extensive restorations. These restorations must be examined, periodically, at 6-month or shorter intervals. This has a direct bearing on the proper relationship between the patient and the dentist. A variety of temporary cements are available, and they should be selected according to the individual factors involved.3 Achromycin surgical powder mixed with the selected temporary cement prevents putrefaction and the odor that is characteristic of temporary cements after it has been in the mouth for a time. A small amount of this powder added to the temporary cement is effective.
SUMMARY

The general practice of dentistry requires that dentists be informed about the adjunctive treatment of patients as well as about the strictly technical treatments that are used. These are necessary for maintaining the most favorable relationship between the dentist and the patient. These adjuncts to dental treatment in restorative dentistry have been discussed.
REFEREXCES

D., et al.: The Dentist and His Patient, New York, N.Y., 1944, Revere Publishing Co. 2. Hersh, D. : Are Dentists Ruining Their Eyes? Oral Hyg. 47:37-40, 1957. 3. Ewing, J. E. : Temporary Cementation in Fixed Partial Prosthesis, J. PROS. DEN. 5 :388391, 1955. 400 MADISON
NEW YORK AVE.

1. Friend,

17, N.Y.