Fitting The Metal Framework & Altered Cast Impression Technique Dr.

Saleh started talking about the practical exam which : will be on .for section 1 5\15 .for section 2 5\17 .for section 3 5\19 .Today's topic is very important clinically**

Fitting The Metal Framework:

After finishing the designing process and after

the technician has constructed the metal framework, he will send you a finished and polished metal framework that fit the master cast which we did the block out and relief on it. Some technicians construct two master casts which is good too. First step after you get the metal framework is to examine it by your eyes. The technician will send you the metal framework and the master cast plus all the sheets that you wrote and the primary cast, for you it's enough to examine the master cast and the metal framework because already all the work that you've done is registered on the master cast(surveying and the block out). You need to check that the metal framework was constructed correctly if not you have to send it back to the technician. You need to check that: Does the framework fit the master cast ? Technically speaking the technician will not send you a framework if it doesn't fit the mater cast, but sometimes the technician will be like " it's fine mashi 7alu" and then .send it to you and that's wrong

 What do you've to check after receiving the framework ?

1. Rests: You've to check that the rests fit their seats

accurately, you will pass the probe on the rests and the teeth, you are suppose not to have any steps either negative or positive: Positive this means the rest isn't fully seated on the **.rest seat ** .Negative this means the rest has been over polished

Clasps: especially the tip of the retentive arm .2

because if it isn't in its position it will keep making stress on the tooth and as you know the clasp should be passive not active(without making any force or stress on the tooth) to be passive it should be in the desired undercut .area

The Reciprocating arm: Also the reciprocating .3

.arm should be in its position After constructing the metal framework we need to do ? finishing and polishing, why do we need to do that because of the porosities in the investment material ** that may lead to some roughness and irregularities, also after casting an oxide layer will be formed on the surface so it will interfere with the fitting of the framework that's why we need to do finishing and polishing especially to the reciprocating arm and the fitting surface of the .tip of the retentive arm Over polishing of the reciprocating arm will result in space between the tooth and the reciprocating arm so it'll .not function anymore

Lingual plates: you need to check that the plates .4

.are touching the lingual surfaces of the teeth

The Major connector: you have to apply .5

torques on it if it flexes all the casting should be repeated because as we mentioned before all the components of the RPD except the tip of the retentive arm should be .rigid especially the major connector

The Minor connectors: should cross the .6

gingival margin with right angles, also they should connect all the components to the major connector .strongly All what we've mentioned are clinical steps but they are ** .preformed chair side not in the patient's mouth Does fitting on the master cast mean fitting in the patient's mouth ? and why ? NO, because enamel is very soft and highly polished compared to the master cast(gypsum) so you'll find friction when you insert it on the master cast, so if the partial denture can be easily inserted and removed on the master cast that means it will not be retentive in the patient's mouth there should be a slight resistance on the master cast, sometimes you might need to use wax knife .to wedge it then remove it

The problem might be clinical or technical : Clinical the impression was inaccurate there was** distortion. Like if you are using rubber material after 2 minutes the tray moved while the rubber material was starting to be set so there will be distortion which will lead .to inaccurate master cast Technical if you took an alginate impression and** send it to the technician and he left it for an hour before pouring it that will lead to syneresis, even if it was rubber material and for example it was left near the window in a .sunny day that will lead to distortion

Sometimes the metal framework fit the master cast but doesn't fit the patient's mouth (and it's very common between students why would that happen) why? For students between the two terms there will be like one month holiday, the student took the secondary impression but the try-in will be after one month during this period the teeth will move ( the teeth move continuously even if it not seen by your eyes) so in constructing RPD which is a very accurate process a minor change in the teeth
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position will be significant. So never take the secondary impression if you're not sure that the try-in step will be .done in a short time DON'T expect that your work will be 100% accurate! because all the processes that you've done like the impression aren't 100% accurate so almost all the time you need to adjust.

DON'T push a framework to fit because it can't be removed anymore, the proper way for insertion: there will be a little bit of resistance then you'll hear a click( this click sound is due to the retentive tip of the clasps) then it will be fully seated.

Kennedy class 1 and 2 framework with special mesh, will rock if pressure is applied on the saddle unless tissue stopper has been provided !! (this piece of information is from the slides the doctor just read it ). So you need to check where is the interference to eliminate it.

We use for this procedure disclosing agents they show where the high spots are. It can be spry material or wax material, or we can use pressure indicating paste like the complete denture.

If the discrepancies are minor you can do adjustment to them.

But if the discrepancies are major you've to reject the prosthesis and repeat the final impression for a new metal.

Wax is very good it's soft and when you put it on the fitting surface it will become firm, when you insert the prosthesis you can see where it's washed away so there will be interference in that area, but that doesn't apply on all the components like the guiding plates because we need them to have
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contact, so don't think that any material that is washed away from the guiding plates need to be adjusted. But if the interference was major you can remove a little bit of it but in general we need it to have contact( if you remove more than needed you'll end up with space and it's not functioning as a guiding plate anymore so that will lead to food accumulation and caries). What type of burs do we use? **High speed with diamond bur or high speed with carbide burs ( not the ones we use for cavity preparation).

Check occlusion:

Never check occlusion before the prosthesis is fully seated because if not there will be high occlusion ( this is false high not true). But how do we check occlusion and there is no teeth !! it's not the teeth only some components of the RPD affect occlusion too (very important), like : Rests, lingual plates if they are too high it might affect occlusion, shoulders of circumficial clasps (very common) because they come from the occlusal third to the gingival third, minor connectors, guiding plates.

At the beginning you should have no metal in the mouth either upper or lower and check the occlusion of the patient for example the patient bites and the upper canine touches the lower canine keep this on your mind then insert the framework if the two teeth are still touching each other then the occlusion is good you didn't change anything significantly. If it's a little bit high then there is problem (it's high somewhere). **what do we use to detect where is the interference? articulating paper.

If you have upper and lower metal frameworks at first you check the occlusion without any metal then you insert the upper check the high spots and remove them, after that you do the same thing for the lower then you insert both of them and check occlusion.( removing of the high spots is preformed chair side) **why don't we insert both of them from the beginning ? when you insert them one by one you are checking the interference between the metal and the opposing teeth but if you insert both of them there might be interference between the two metal frameworks.

How do we know that the RPD is fully seated(v. important) ? The rests will be on their rests seats with no steps( and . (this is one of the advantages of having rest seat

If the prosthesis fits the master cast but doesn't fit the patient's mouth never ask the technician to re-do the metal framework on the same master cast, you've to repeat the secondary impression

Two types of occlusion: Static occlusion: maximum intercuspion (open &** (close .Dynamic occlusion: from side to side**

Altered cast impression technique

If we have Kennedy class 3 or short span class 4 it's not a problem because it's tooth supported and during function the compressibility on the periodontal ligament will be equal between teeth. The problem is when we have free end saddle like Kennedy class 1 and 2 or long span class 4( 6 teeth or more are missing crossing the midline) the compressibility of the periodontal ligaments will be much less than the soft tissue
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Altered cast impression technique is used more in the lower with distal extension, why? There are some factors that influence support of the distal extension base: 1. The surface area is smaller in the lower than the upper. 2. The quality of soft tissue: is better in the upper compared to the lower, because of resorption in the lower jaw it becomes thick and flat. 3. Type of bone: is cancellous except the buccal shelf are which is primary stress bearing area 4. RPD Design: like the RPI system. 5. Amount of tissue coverage. 6. Anatomy: in the maxilla the crest of ridge is primary stress bearing area but in the lower it's secondary stress bearing area, the only primary stress bearing area in the lower is the buccal shelf. 7. Fit of denture base: you should have good fitting for the acrylic.
When we take the secondary impression we take it

while the mouth is opening so there is no function on the distal extension so the impression is anatomical not functional.
Altered cast impression technique registers both the

anatomy and the function so you'll end up with RPD that gives you anatomical and functional details.

How do we know that we need functional impression beside the anatomical impression? For example: Kennedy class 2 in the lower we make record block ( only the base plate that is made of acrylic) on the distal extensions and insert it in patient's mouth with gentle pressure if you see there is significant depression in the acrylic that means the tissues are very compressible and you should register them with .functional impression
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Most of the time we use it in the lower with distal extension.

We use it in the maxilla but not too much because there is support from the posterior palate( we use it with patients that have flabby ridges, and patient's with long span class 4).

Impression methods :

Physiologic impression technique: :

you try to stimulate the function in the patient mouth, you register the anatomy of the distal extension of the soft tissue under pressure and there are three types: 1. McLean-Hindels method: 1) Take the secondary impression 2) Construct the base plate and do the border molding only for the distal area( nothing on the teeth). 3) Take the impression only for the free end saddle area under pressure. 4) Put the stock tray that was constructed at the beginning for the whole arch on top of the tray that was constructed to the distal area only, take the secondary impression like for ex. with alginate. **It's like two impressions in one, the free end saddle (ridges) under function and the teeth with anatomical position. 2. Functional reline method: After constructing the metal framework before the final acrylic processing the doctor will put metal foil so the denture has space between the free end saddle and the tissues, chair side before the insertion in the patient's mouth you'll do relining of the acrylic. Fluid wax methods: **Is the same as the selected pressure impression technique that will be explained now the only
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differences are: in this procedure the pressure is not selected and the impression material is wax.

Selected pressure impression technique: it's called selected because it applies

pressure only on the areas that provide good pressure (unlike the fluid wax method) like the buccal shelf area ( we don't have spacer here so it's closely fitting). On the other hand the crest of the ridge have a spacer and we don't apply pressure on it. You'll end up with a metal framework with distal extension having an impression. **The Procedure of the both techniques: 1. Construct a special tray that is attached to the metal framework ( after finishing the metal framework on the free end saddle area you make an acrylic tray only in the mesh area) how do we do that ? you put the metal framework on the secondary model you construct the tray on the distal extension ridges, so you'll have framework with trays on the distal extension ridges. In the patient's mouth you do border molding with green stick on the distal extensions.
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After this preferably with zinc oxide eugenol but maybe rubber (polysulfide) you put it only on the trays in the free end saddle area with a pressure to take the impression ( this for the selected impression technique in the wax method we use wax). In the end you'll have metal framework that was constructed on a master model under anatomical position with distal extensions having an impression with selected pressure in this technique and without selected pressure in the fluid wax method.
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Then you cut all the distal extensions you leave only the teeth (in the master cast). 5. You put the metal framework with the impression of the saddle area on the teeth and in order to know it's good fitting the rest will be on their rests seats and the lingual plates will touch the lingual surfaces. 6. Then you pour the distal extension, so you'll end up with a cast that have part from the master cast ( the teeth) and the other part from the distal extension area (under pressure) that's why it's called altered cast impression technique or corrected cast impression technique. 7. Packing of acrylic.
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I tried to explain it as much as I can , I wrote almost every single word the doctor said, dr.Saleh said he will explain more about the altered cast technique in the lab insh'Allah, these are some pictures I got from the internet.

1) A cast has been sectioned prior to pouring up of the free end saddle on the right hand side of the mouth.

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New free end saddle has been poured up in stone on the original cast (2

Wax try-in constructed on the new free end saddle (3

My Best Wishes, Tuqa Radi Al-Waqfi

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