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L8 Mouth preparation for RPD

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Mouth Preparation For Rpd

Clinical Presentation and Instruction1

This documentation covers the essential protocols and procedures for preparing a patient’s mouth for a Removable Partial Denture (RPD).

Treatment Planning Spectrum

Mouth preparation encompasses the entire treatment planning spectrum, ranging from the emergency phase to the control phase, and finally the holding phase. It is fundamentally part of the reconstructive phase and involves comprehensive planning conducted on the surveyor using study models.

Presented by:

  • Dr. Matsubara
  • Oral Health Centre of Western Australia
  • The University of Western Australia

Introduction

Mouth preparation consists of a series of procedures executed to repair, alter, and/or protect the remaining teeth.

Critical Consideration

An RPD without a rest near the saddle can cause significant vertical bone resolution underneath the saddle due to overload. Adhering to guidelines regarding rest placement is essential to prevent this outcome and minimize loss of periodontal support.

Objectives of Mouth Preparation2

  • Prevent or redirect adverse forces that may affect the supporting teeth, periodontal tissues, and residual alveolar bone crest.
  • Obtain retention and support for a removable prosthesis for the maximum period of time.
  • Re-establish or maintain the health of the abutment teeth, supporting structures, and ridge tissues.
  • Facilitate a simpler design for the prosthesis.

Mouth preparation is divided into two distinct stages.

  • First Stage: Involves all clinical interventions to restore health conditions in the patient's mouth (Control Phase).
  • Second Stage: Involves interventions related to the surveyor plan, such as rest seat preparation and creating guiding planes.
  • The prognosis of each abutment tooth must be assessed based on periodontal, endodontic, and restorative aspects.

First Stage Clinical Interventions

Clinical Interventions for Tissue Health3

The first stage involves clinical interventions to establish a healthy condition of the remaining teeth and related tissues. These include maneuvers to eliminate factors that harm:

  • Hard tissues (teeth and bones)
  • Soft tissues (periodontium, mucosa, and gingiva)

The first stage of mouth preparation focuses on establishing a healthy environment through clinical interventions and a holding phase to preserve the residual dentition.

Emergency and Control Phase

Treatment Phases4

  1. Emergency and Control Phase: This phase is dedicated to eliminating pain, infection, and inflammation through various treatments:
  • Periodontal treatment
  • Endodontic treatment
  • Restorative treatment
  • Oral surgeries (pre-prosthetic surgeries)
  • Orthodontic treatment
  • Occlusal adjustments
  1. Holding Phase: Focuses on the preservation of the residual dentition.

Complete Treatment Workflow Sequence

  1. Emergency Phase: Acute pain relief.
  2. Control Phase: Disease control (perio, endo, caries).
  3. Holding Phase: Reassessment to ensure everything responded well (e.g., new periodontal charting, checking probing depth and bleeding on probing).
  4. Reconstructive Phase: Definitive treatments (crowns, framework fabrication) once health is established.
  5. Maintenance Phase

Following the initial clinical interventions, the treatment moves into the second stage of preparation.

Emergency Phase Procedures

  • Irreversible Pulpitis: Pain relief (e.g., pulpectomy) should not wait for full treatment plan sign-off. This is done under supervision with a correct diagnosis.
  • Anterior Restoration/Crown Replacement: An Essex retainer can be fabricated as an emergency procedure if an anterior tooth requires extraction due to a hopeless prognosis. This involves taking alginate impressions (upper and lower), shade selection, and sending to the lab for a single-tooth retainer.

Control Phase Caries Management

  • For patients with multiple caries lesions, it is recommended to remove all active caries and place Glass Ionomer Cement (GIC) during the control phase to arrest progression.
  • In the reconstructive phase, these temporary fillings are replaced with composite or crowns.
  • Note: While some clinicians may place composite directly during the control phase, using GIC first allows for controlling multiple teeth in one session and preventing pulp involvement.

Reconstructive Phase

Biomechanical Optimization and Maintenance5

The second stage involves interventions on the remaining teeth aiming at improving biomechanical conditions between supporting teeth and the metal structure.

  • Reconstructive Phase: This phase replaces lost tissues and stabilizes occlusion through:

    • Rest seat preparation
    • Tooth recontouring (adjusting height of contour and creating guiding planes)

  • Maintenance Phase: Following the reconstructive phase, this stage focuses on the prevention of further breakdown.

Objectives of Periodontal Therapy6

  1. Control of Microbiological Factors
    • Removal of calculus deposits.
    • Implementation of plaque control measures.
    • Provision of oral hygiene orientation and education.
    • Management and control of iatrogenic factors.
  • Identify Iatrogenic Factors: Restorations with open margins, overhangs, or lack of proximal contact must be identified and replaced as they cause long-term harm.
  • Important Note: Plaque control will not improve after delivering the denture; it typically worsens due to food trapping and changed microbiota biology. If a patient does not demonstrate progress in oral hygiene, the reconstructive phase cannot proceed.

Periodontal Treatment78

  1. Patient Comfort and Clinical Health
    • Control of pain and gingival bleeding.
    • Improvement in the clinical appearance of the gingiva.

Clinical Procedures

  • Periodontal probing and assessment.
  • Supra-gingival and sub-gingival debridement.
  • Assessment of Debridement: The best way to assess proper debridement is not just tactile during the session, but via follow-up sessions observing a reduction in bleeding and probing depth. Presence of bleeding indicates remaining plaque or calculus.

Surgical and Non-Surgical Interventions

Case Study: Severe Periodontal Case

  • Scenario: X-rays show teeth are not ideal for crowns, with long roots but apical periapical radiolucencies. One crown has fallen off.
  • Decision: Instead of immediate full clearance (which leads to a lower denture that is hard to adapt), options include crown lengthening, surgical debridement, and planning crown preparations according to the biological width created during surgery.
  • Outcome: A surveyor bridge with precision attachments may provide more stability and longevity than a full denture. However, if there is angular bone loss or severe vertical bone loss (infra-bony pockets/one-wall defects), the prognosis for bone grafting is poor, and extraction may be necessary.
  • Scaling and root planing.
  • Crown lengthening procedures.

Advanced Periodontal Preparation

  • Scaling and root planing.
  • Crown lengthening.
  • Post-surgical management and tissue healing.
  • Final restoration alignment with healthy gingival margins.

Mouth preparation procedures are conducted to ensure the oral environment is stable and healthy prior to the fabrication of a removable partial denture.

Endodontic Treatment

First Stage Clinical Indications

Endodontic intervention is required during the initial stage of mouth preparation for the following conditions:

  • Follow-up Timeline: It may take up to one year to see signs of bone formation. During this time, an interim denture may be provided.

  • Abutment Consideration: If a tooth (e.g., a canine) is intended as an abutment, one must wait for signs of bone formation before finalizing the denture. If the tooth is hopeless, it is extracted and included in the denture design.

  • Pulp necrosis

  • Abscesses (endodontic, periodontal, or a combination of both)

Assessment of Existing Root Canal Treatments

During the first stage of mouth preparation, teeth with existing root canal treatments must be evaluated based on the following clinical and radiographic presentations:

  • Completely filled canals, without radiographic signs of apical periodontitis
  • Completely filled canals, but with radiographic signs of apical periodontitis
  • Root canal partially filled, with no signs of apical periodontitis
  • Root canal partially filled, with apical periodontitis

Evaluation Criteria for Obturated Canals

Case Study: Endodontic Prognosis Scenarios

  • Scenario A: Completely filled canals without radiolucency.
    • Action: Check when the RCT was done. If recent, wait to assess properly that the tooth is infection-free.
  • Scenario B: Completely filled but with radiographic signs of apical periodontitis.
    • Action: Perform percussion tests. If standard to percussion, it suggests active infection. Check history; if recent, wait 6 months to 1 year for bone formation. Involve an endodontic specialist.
  • Scenario C: Root canal partially filled but with no signs of apical periodontitis.
    • Action: Check if the canal is calcified or improperly prepared. Specialist involvement is needed.
  • Scenario D: Symptoms present (positive percussion/palpation).
    • Action: Indicates need for retreatment.
  • Guideline: At OCHWA, if the RCT was not done in-house and the tooth will receive a crown or serve as an RPD abutment, retreatment is often offered as the first option to ensure prognosis.

For teeth with completely filled canals and no radiographic signs of apical periodontitis, the following factors must be assessed to determine if the treatment is successful and stable:

  1. Absence of symptoms during percussion or palpation.
  2. The chronological history of when the root canal treatment was performed.
  3. The overall quality of the obturation.

Restorative Treatment

Primary Objectives

  • Ferrule Effect: The amount of natural, sound tooth structure around the cervical area above the gingival margin is critical. A 360-degree ferrule is ideal, but a partial ferrule (especially buccal-lingual) indicates restorability.

  • Establish a healthy oral environment through the restoration of decayed tissues and the replacement of failing restorations.

  • Ensure supporting teeth have adequate restorations capable of receiving rest seats with sufficient depth and width.

Rest Seat Requirements in Amalgam

  • When placing a rest seat within an amalgam restoration, there must be a minimum thickness of 1 mm of amalgam remaining beneath the rest seat to ensure structural integrity.
  • Margin Rule: The margin of the rest preparation must be within the restoration material (e.g., at least 1mm of amalgam around the margin). Avoid margins between the tooth and restoration to reduce the risk of secondary caries and plaque accumulation.
  • Replacement Guidance: If unsure about the quality of an old restoration, replace all fillings before preparing rest seats. When replacing, extend margins buccal-lingually to create space for the rest seat.

Initial Stage Overview

The first stage of mouth preparation focuses on restorative treatment to ensure the oral cavity is prepared for the prosthetic phase.

Oral Surgery910

The first stage of mouth preparation involves various surgical interventions to ensure a healthy foundation for the prosthesis.

Scope of Oral Surgery

  • Tooth extractions
  • Periodontal surgeries
  • Endodontic surgeries

Pre-prosthetic Surgery

Pre-prosthetic surgery refers to surgical procedures that modify the oral anatomy to facilitate the retention and seating of dentures. According to the Glossary of Prosthodontic Terms, these are surgical procedures designed to facilitate fabrication or to improve the prognosis of prosthodontic care.

Common surgical procedures required during the mouth preparation phase include:

  • Combination Syndrome: Common to see flabby ridges in the anterior region. Excess soft tissue may need removal before final impressions.
  • Epulis Fissuratum: Gingival hyperplasia associated with old dentures where the bone resorbs, the denture sinks, and flanges over-compress tissue.
    • Management: Adjust the base of the existing denture to reduce hyperplasia. In extreme cases, excise excess tissue before impressions. Check for vacuum chambers/concavities in the palatal surface of old dentures that stimulate overgrowth.

Surgical modifications are often necessary to create an optimal environment for the Removable Partial Denture (RPD):

  • Extractions
  • Removal of residual roots
  • Removal of mandibular tori
  • Removal of exostosis, hyperplastic tissue, and high muscle attachments
  • Rounding of sharp bony spines and knife-edge ridges
  • Reduction of maxillary tuberosity volume

Alveolar Ridge Preservation

In certain clinical scenarios, the maintenance of a non-vital residual root is utilized for alveolar ridge preservation. This approach helps maintain the bone volume of the ridge.

Root Maintenance Techniques

  • Submerged: The root is covered by the soft tissue.
  • Non-submerged: The root surface remains exposed or partially visible.
  • Root Stumps Preservation: Not all root stumps need extraction. Non-vital teeth can be kept as submerged or exposed root stumps (after RCT and doming) to preserve bone and provide proprioception via periodontal ligament receptors.

Orthodontic Treatment11

Orthodontic treatment represents the first stage of the

Surveyed Crowns Material Considerations

  • PFM (Porcelain Fused to Metal): Ideal to have metal against metal contact where the clasp engages. The coping area where the rest seat and clasp contact can be left in metal to avoid over-reduction
  • Zirconia (CAD/CAM): Full ceramic crowns can be prepared as surveyed crowns with rest seats and correct undercuts
  • Fabrication: Traditional PFM involves waxing up the natural contour, then cutting back the buccal surface to ensure even ceramic thickness for longevity reconstructive phase when the current position of the teeth prevents the development of an ideal RPD design.

Common Indications for Orthodontic Intervention

  • Molar Inclination: Correcting molars that are leaning towards an edentulous area to improve the path of insertion and loading.
  • Tooth Rotation: Realigning rotated teeth to facilitate better clasp positioning and aesthetics.
  • Anterior Migration: Addressing labial migration of anterior teeth to restore proper alignment and arch integrity.
  • Rationale: Reposition teeth via orthodontics rather than creating extensive proximal adjustments or guide planes on tilted teeth. This improves prognosis, function, and longevity by reducing plaque accumulation.
  • Intrusion Consideration: Intrusion of upper teeth may be required but is time-consuming. For elderly patients, other options may be assessed.

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Occlusal Adjustment

Initial Stage of Preparation

The first stage of mouth preparation involves systematic occlusal adjustment to ensure a stable and functional foundation for the Removable Partial Denture (RPD).

Clinical Implementation

This phase focuses on the primary stage of treatment, specifically addressing the requirements for occlusal adjustment.

Visual Assessment and Planning

  • Wax Rim Technique: Reduce the wax rim height until there is no contact against the opposing teeth when the patient bites. This registers the bite in the existing position without increasing the vertical dimension prematurely. Create V-notches on the rim for registration.
  • Guide: Use an acrylic base and block to simulate the correction on the articulator, then transfer to the mouth to guide adjustment.
  • Vertical Dimension: Occlusal adjustment is not only about reducing height; sometimes the bite must be increased to create space without cutting tooth structure. Heavily worn dentitions should be referred to a prosthodontic specialist.

During the first stage of occlusal adjustment, dental moulds are utilized to identify areas requiring modification. This allows for precise planning of the tooth surfaces before clinical procedures begin.

Comparative Analysis

Clinical models are used to demonstrate the progression of the occlusal adjustment:

  • Pre-adjustment state: Identification of interference and high points.
  • Post-adjustment state: Verification of the corrected occlusal scheme and improved alignment.

Continued Preparation Procedures

Ongoing mouth preparation steps are conducted to refine the oral environment for the prosthetic appliance.

Finalization of Preparation

Case Study: Heavily Worn Dentition and TMJ Pain

  • Patient Presentation: Elderly patient with heavily worn dentition complaining of biting lips and TMJ pain.
  • Observation: Teeth were sharp. Opposing teeth were not contacting the “cavities” of the worn teeth.
  • Diagnosis: Cup-shaped lesions indicated erosion (gastric reflux/acidic diet) in addition to attrition.
  • Treatment Plan:
    • Increase the bite (Vertical Dimension).
    • Send wax-up to the lab.
    • Transfer wax-up to the mouth using composite build-ups initially.
    • Once the correct occlusal plane and vertical dimension are established, replace composite with crowns.
    • Material Choice: Gold onlays were suggested for conservation (minimal reduction) and to avoid harming the opposing dentition.

Comparison of dental models illustrating the transition from the initial state to the final prepared state. This ensures that all necessary modifications for the appliance, including prosthetic or orthodontic requirements, have been met.

Mini Implants1213

Mouth preparation procedures are essential for the successful integration of Removable Partial Dentures (RPD).

Mouth preparation continues as a critical phase in the clinical workflow for prosthetic rehabilitation.

Orthodontic Application

Mini implants are mentioned as a tool to facilitate orthodontic movements, specifically intrusion of upper teeth.

Clinical Research and Evidence14

  • Paccini et al. 2016: This study provides relevant data regarding the application and outcomes of mini implants in the context of mouth preparation for prosthetic support.
  • While detailed research was not presented, clinical observation indicates that using mini implants makes intrusion movements easier and faster compared to traditional orthodontic methods. This aids in reestablishing the correct occlusal plane during the reconstructive phase.

Second Stage Biomechanical Interventions

The second stage of mouth preparation involves the adjustment and preparation of the supporting teeth to ensure proper support and stability for the Removable Partial Denture (RPD).

Key Biomechanical Procedures15

  • Rest seat preparation: Creating specific areas on the teeth to direct occlusal forces along the long axis of the abutment teeth.
  • Tooth recontouring: Modifying the natural tooth shape, specifically focusing on:
    • Adjusting the height of contour.
    • Establishing guiding planes.

Rest seat preparation is a critical component of the second stage of mouth preparation, designed to provide vertical support for the prosthesis.

Rest Seat Preparation Details

  • Existing Restorations: Rest seats can be prepared on amalgam or composite if margins are sound
  • Crowns/Onlays: When planning crowns to incorporate rest seats, ensure correct reduction for the restorative material plus the depth of the rest seat (more than the standard 2mm occlusal reduction)
  • Composite Addition: Composite can be added to create a proper lingual rest seat if tooth structure is insufficient

Rest Seat Preparation16

Tooth Recontouring17

Tooth recontouring is performed during the second stage of preparation to optimize the tooth’s surface for the RPD components. This process includes:

  • Height of contour adjustments: Modifying the survey line to improve the placement of clasp arms.
  • Guiding planes: Preparing parallel surfaces on abutment teeth to dictate the path of insertion and removal.

This procedure involves modifying the bulbous portion of the tooth to lower the survey line, allowing for better positioning of the prosthetic components and reducing interference.

Creating Guiding Planes18

This involves the selective removal of tooth structure to create flat, parallel surfaces on the proximal or axial surfaces of the abutment teeth.

Transfer Methods1920

Free Hand Technique21

The second stage of biomechanical intervention involves transferring planned tooth reductions from the diagnostic model to the patient’s mouth using a free-hand approach.

Transfer of tooth reduction from the model to the mouth is performed using the free-hand method.

Free Hand Technique Method

  • Use a wax knife to create a reference line perpendicular to the occlusal plane/path of insertion on the model
  • Use incisal edges or cusp tips as references
  • Transfer this line to the patient's mouth and place the bur parallel to this line to create the guide plane on the proximal surface
  • Limitation: Requires estimation of reduction amount based on the model

During the second stage of mouth preparation, the planned tooth reductions are transferred from the model to the mouth via a free-hand technique.

The second stage of mouth preparation utilizes a Dura-lay guide to transfer tooth reduction from the model to the mouth.

Dura Lay Guide2223242526

Transfer of tooth reduction from the model to the mouth is facilitated by the use of a Dura-lay guide during the second stage of preparation.

The Dura-lay guide is employed as a transfer method for tooth reduction from the model to the mouth.

Clinical application of the Dura-lay guide involves fitting the guide onto the tooth in the patient’s mouth to ensure accurate transfer of the planned reduction from the model.

Dura Lay Guide Fabrication and Transfer

  • Apply a separator (not Vaseline) to the model surface
  • Use acrylic resin (Dura Lay) to create a block on top of the occlusal surface and incisal edges (minimum 5mm height)
  • Trim the acrylic to be in continuity with the prepared cast surface, parallel to the path of insertion
  • Cement the guide in the patient's mouth with zinc phosphate (recommended over GIC for easy removal)
  • Use a long parallel high-speed cylindrical bur to cut the tooth surface until the bur touches the acrylic guide

Second stage biomechanical intervention: Transferring tooth reduction from the model to the mouth using a Dura-lay guide.

Procedural Application

  • A dental handpiece is used to prepare the tooth while it is protected by the Dura-lay guide.
  • The guide acts as a template, resembling a cap, to protect surrounding tissues and define the reduction limits.
  • The final prepared tooth is verified with the guide positioned post-reduction.

Base Plate27

The second stage of mouth preparation involves transferring tooth reduction from the model to the mouth using a base plate as a guide.

Raising Height of Contour28

When there is no retentive area due to a low height of contour, biomechanical interventions are required to ensure the stability of the Removable Partial Denture (RPD).

Additional Strategies for Insufficient Retention

  • Change Path of Insertion: First option to assess if a better undercut can be engaged
  • Swap Arms: If the buccal has no undercut, check the lingual side and swap the reciprocal arm and retention arm positions
  • Surveyed Crowns: If the tooth is tilted, adding composite or cutting structure may create non-look over-contours or require excessive reduction

Strategies for Insufficient Retention29

  • Prepare an undercut using a bur.
  • Add composite resin to create a functional undercut.
  • Fabricate a surveyed crown.

Clinical Requirements

The retentive arm of the clasp must be positioned at least 1 mm away from the gingival margin to maintain periodontal health.

Raising the height of contour is a critical step in the second stage of mouth preparation to facilitate proper clasp engagement.

Preparing Undercut

Technique for Creating Depressions

  • Create a gentle depression in the enamel where the tip of the retention arm will be seated.
  • Ensure the preparation follows the specific shape and design of the selected retentive clasp tip.

Adding Composite Above Retentive Area

Clinical Indications

This procedure is utilized when the lingual and buccal surfaces of the tooth are nearly vertical, providing insufficient natural undercut for clasp retention.

Procedure Overview

Composite resin is bonded to the tooth surface above the intended retentive area to effectively raise the height of contour, allowing the clasp assembly to engage the tooth securely.

Surveyed Crowns30

Surveyed crowns are indicated when tooth morphology cannot be adequately modified through conservative means. These crowns are specifically designed to provide:

  • Parallel guiding planes for a definitive path of insertion and removal.
  • Adequate height of contour for clasp retention and reciprocation.
  • Precisely contoured rest seats for support.

The second stage of mouth preparation focuses on biomechanical interventions, specifically addressing the need for raising the height of contour to ensure adequate RPD retention.

Overview of Clinical Procedures31

Mouth preparation is a critical phase in the construction of a Removable Partial Denture (RPD). This process ensures that the oral environment is optimized to support, retain, and stabilize the prosthesis while maintaining the health of the remaining oral tissues.

Clinical Workflow Overview

The clinical workflow involves completing the First Stage (Control Phase: perio, endo, restorative, surgery) to ensure health, followed by the Second Stage (Biomechanical: rest seats, guiding planes, contour adjustment). Surveying early in the process helps identify issues such as lack of undercuts or the need for surveyed crowns, facilitating better discussion and planning with tutors.

Objectives of Mouth Preparation

  • Hard Tissue Modification: Altering tooth structure to create favorable paths of insertion, provide adequate support through rest seats, and improve retention.
  • Soft Tissue Management: Addressing any inflammatory conditions or hypertrophic tissues that may interfere with the denture base.
  • Periodontal Health: Ensuring the supporting structures are stable and free of disease before the final impression is taken.
  • Caries Control: Completing necessary restorations to provide a sound foundation for the RPD components.

Footnotes

  1. Original PDF page 1: L8 Mouth Preparation for RPD, p.1 ↩

  2. Original PDF page 2: L8 Mouth Preparation for RPD, p.2 ↩

  3. Original PDF page 3: L8 Mouth Preparation for RPD, p.3 ↩

  4. Original PDF page 4: L8 Mouth Preparation for RPD, p.4 ↩

  5. Original PDF page 5: L8 Mouth Preparation for RPD, p.5 ↩

  6. Original PDF page 6: L8 Mouth Preparation for RPD, p.6 ↩

  7. Original PDF page 8: L8 Mouth Preparation for RPD, p.8 ↩

  8. Original PDF page 11: L8 Mouth Preparation for RPD, p.11 ↩

  9. Original PDF page 18: L8 Mouth Preparation for RPD, p.18 ↩

  10. Original PDF page 19: L8 Mouth Preparation for RPD, p.19 ↩

  11. Original PDF page 22: L8 Mouth Preparation for RPD, p.22 ↩

  12. Original PDF page 29: L8 Mouth Preparation for RPD, p.29 ↩

  13. Original PDF page 30: L8 Mouth Preparation for RPD, p.30 ↩

  14. Original PDF page 31: L8 Mouth Preparation for RPD, p.31 ↩

  15. Original PDF page 32: L8 Mouth Preparation for RPD, p.32 ↩

  16. Original PDF page 33: L8 Mouth Preparation for RPD, p.33 ↩

  17. Original PDF page 34: L8 Mouth Preparation for RPD, p.34 ↩

  18. Original PDF page 35: L8 Mouth Preparation for RPD, p.35 ↩

  19. Original PDF page 37: L8 Mouth Preparation for RPD, p.37 ↩

  20. Original PDF page 38: L8 Mouth Preparation for RPD, p.38 ↩

  21. Original PDF page 36: L8 Mouth Preparation for RPD, p.36 ↩

  22. Original PDF page 39: L8 Mouth Preparation for RPD, p.39 ↩

  23. Original PDF page 40: L8 Mouth Preparation for RPD, p.40 ↩

  24. Original PDF page 41: L8 Mouth Preparation for RPD, p.41 ↩

  25. Original PDF page 42: L8 Mouth Preparation for RPD, p.42 ↩

  26. Original PDF page 43: L8 Mouth Preparation for RPD, p.43 ↩

  27. Original PDF page 45: L8 Mouth Preparation for RPD, p.45 ↩

  28. Original PDF page 50: L8 Mouth Preparation for RPD, p.50 ↩

  29. Original PDF page 46: L8 Mouth Preparation for RPD, p.46 ↩

  30. Original PDF page 49: L8 Mouth Preparation for RPD, p.49 ↩

  31. Original PDF page 51: L8 Mouth Preparation for RPD, p.51 ↩

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