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Hadeel Saleh

Mohammad Bustani |Page1

 Altered cast technique

There is some sort of a debate on who invented it, whether it was Applegate in
1937 when he described the functional impression meaning that the tissue
should be recorded in a different material than the teeth in their functionally
compressed manner, or Leuopoid & Kartchovil in 1965 when they actually
called it the Altered cast technique.
Definition: a negative likeness of a portion or portions of the edentulous
denture bearing area made independent of and after the initial impression of
the natural teeth; this technique uses an impression tray(s) attached to the
framework of the removable partial denture, or its likeness, then you’ll take
the impression at the try-in step.
Altered cast: a final cast that is revised in a part or more before pouring and
processing a denture base; syn, Corrected cast, Modified cast.
So, at the try-in step once the framework is fabricated, you use it in the
patient’s mouth to record the tissues only and then send it back to the lab to
pour it back again.

1- This is an example of the process, first thing we check everything in the

framework and its fit (try-in two steps).
2- Add a resin material or a special tray material around the saddle area on top
of the framework in that area only, then do border molding, you have the
maximum coverage of the tissues in there.

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3- When we’re happy with the extension we relieve the side just like we do
with the CD.

4- We take a muco-compressive impression in that area; you place the whole

framework in the patient’s mouth with the impression material in the saddle
area and you need to make sure that you don’t apply any pressure on the
saddle area by your fingers, make sure the framework fits properly and exert
force only on rest seats, this is to make sure that framework is properly
positioned and this area is recorded with the impression material.
Force on the saddle area will make the framework rock around the fulcrum,
which is the imaginary line connecting the most distal rest seats, and anterior
portion of the framework will be lifted out, so the final prosthesis won’t fit
properly because there will be a space underneath the saddle while the
framework is good fitting or if the saddle is fitting there will be a space in the
anterior portion of the framework.

5- Go back to the master cast that the lab used to construct the framework,
you section it to remove the edentulous area part.
6- Then you place the framework back on the cast and secure it in place.
7- You will have a space underneath the impression area, place retentive
grooves in the cast.
8- Then beading and boxing and pour gypsum material in that area so you
have a new impression of the saddle area. (He means on the cast)

You will get a cast with two colours just like this
figure.
So the cast is altered in the edentulous area, hence
the name altered cast.
The doctor might bring a picture of a cast with two
colours in the exam and ask about the technique.

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Why do we do it? When do we do it?
You already know that in class 1 & 2
Kennedy we have tooth-tissue
supported RPD, so the support won’t
be uniform in amount.
This is because of the difference in the compressibility between them; the
teeth can sink in their socket for about 20 microns which is the thickness of
the PDL space, while the mucosa can be depressed for about 200 microns,
almost 10x more.
So, upon occlusal load on the saddle area the denture will sink more
posteriorly than anteriorly.

In order to overcome/reduce this difference you need to consider alternative

techniques when taking the impression; taking a functional impression in the
first place using two different materials, then you can do the altered cast
technique, you can use the RPI system (change the mechanics by changing
from class 1 to class 2 lever) to prevent torquing forces on the abutment tooth.

Sometimes, you might do it when you have an extensive long span class 3 or
4 (rare? to be used nowadays).
Altered cast technique is mainly used in the lower arch; in the upper we have
more support from the palate because it’s harder bone with less mucosal
thickness.

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What might go wrong?
-If tray material is added carelessly; might go underneath the framework.
It can alter passive relationship between framework and teeth (interfere with
seating of framework).
*So, double check it and see if all components are fully seated before border
molding.

-Excess impression material under framework.

Might cause incomplete seating.
-If pressure was placed on the saddle area during impression .
Framework will be displaced from its position, and the final RPD won’t fit.
-If inadequately seated, stone over teeth ;
At the last step when you are casting your impression if you don’t have
enough sealing in the area, the stone might go underneath the framework
which will lift it up and interfere with the final prosthesis.
Can’t articulate model.

What else can be done?

We have other techniques to consider when we have a free end saddle; RPI
system, maximum coverage, reduce occlusal tables.
You always need to keep in mind you might need to consider other treatment
options, implants for example or even the shortened dental arch concept.
It was assumed that patients with 10 occluding units meaning remaining teeth
from 2nd premolar to 2nd premolar will function normally without any
functional problems. So, if the patient is not complaining about aesthetics, try
to convince them to go for the shortened dental arch or implants because of
the distorting effects of an ill-fitting class 1 or 2 RPD.
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 Jaw relation registration
The main question that you should think about is: to conform or reorganize?
Definitions:
Vertical relationships:
-VDO
-VDR
Horizontal relationships:
-CO
-CR
-Eccentric movements
The preference reference for definitions in prosthodontics is GPT-9 (latest
edition): glossary of prosthodontics terms.
Vertical relationship
The vertical distance between two selected points, one on the fixed (maxilla)
and one on the movable member (mandible).
It can be measured using:
Willis gauge
Divider

What we are interred in actually is the freeway

space: difference between VDR – VDO.
FWS depends on many factors, such as: age, length
of edentulousim and the remaining teeth.
If you have a patient who already has occlusal
contacts between teeth then you need to follow his
FWS, you shouldn’t alter it unless you’re planning to reorganize occlusion.
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Confirmative Vs Reorganized
Mainly the choice has to do with the VD, if you’re altering it or not.
When?
Loss on inter-arch space, some of the teeth were taken out at different time
intervals, unopposed teeth will over-erupt and encroach on the edentulous
area on the opposing arch.
So, when we restore it we need space for the metal framework, acrylic and the
actual tooth, so you might consider opening up the VD increasing the inter-
arch space and reorganize occlusion.
Tooth wear and loss of VDO
How?
Reorganizing the occlusion is either by:
- placing a restoration on every tooth in the mouth or at least in the arch,
which is called Full mouth rehab (fixed or removable)
- or using Danl concept; placing a couple of restorations high in occlusion
and you depend on the dentoalveolar compensation for the teeth to over-erupt
and close up the space that’s made in between the rest of the teeth.

To explain it more: teeth usually try to achieve contact with the opposing
teeth and this is the way teeth erupt in the first place and the same concept is
used in orthodontics when you have an anterior bite block where the anterior
teeth will be in contact while the posterior teeth disocclude so they over-
erupt/extrude a little bit and the anterior teeth will intrude a little until you
have all teeth in occlusion.
So, when you are restoring some of the teeth, you can place high occlusion
restoration on anterior teeth (conventional way) or the main way is to place
crowns on all anterior teeth (canine to canine) to let posteriors over-erupt then
occlusal plane will be restored.

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Always keep in mind that it should be Reorganized not Unorganized; you
have to plan it on an articulator and you need to do it in CO.

Here, we have limited inter-arch space, on the left side the lower posteriors
are extracted, so the canine and premolars and 6 are over-erupted, and there is
uneven occlusal plane, also on the right side the 6 & 7 are over-erupted, and
notice the deep overbite, tooth wear, erosion and attrition.

So, we placed anterior crowns to restore the

anteriors.

Then we opened up the VD using the RPD.

As you can see we still have spaces in
between the teeth where they should be filled
with either filling material or some sort of a
restoration on anteriors.
In this case, if the lower teeth were in good
shape then we’ll just wait for them to over-erupt to achieve contact (Danl
concept). But, here the teeth are already worn out so we’ll build them up with
composite or crowns.

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Horizontal relationship
Whenever we are reorganizing we need to record the horizontal relationship
in CR; because it’s where the mandible is purely rotating in a returned hinge
axis and there is no component of translations, so any increase in VD in that
space won’t affect the horizontal relationship.
And in confirmative approach we’ll use CO, so we’ll record Maximum
intercuspation rather than CR.
-CR should be recorded with the wax rims, when the patient’s jaw is fully
retruded you record it at the first contact point (between teeth).
-It is recorded at the desired VD, so if you’re gonna open up the VD by 2mm
the material used in CR record should be 2mm in thickness between the teeth.
-You need first to deprogram the patient then record the jaw relation
registration.

Facebow
“An instrument used to record the spatial relationship of the maxillary arch to
some anatomical reference point or points and then
transfer this relationship to an articulator; it orients the
dental cast in the same relationship to the opening axis
of the articulator; customarily the anatomic references
are the mandibular transverse horizontal axis and one
other selected anterior reference point” (GPT-9)
-In CD, the doctor is convinced it’s useless because of the compressibility of
soft tissues and the marginal error is much more than the error that might
happen when you’re using an average value articulator with the average value
mounting table, this should be enough for CD.
-However, it is mandatory in RPD if you’re going to reorganize so the final
occlusion will be more predictable, the inter occlusal record then will be taken
in CR and mount it on the articulator, you will be more in control of your
occlusion.

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-There are mainly two types of facebows; arbitrary and kinematic.
-Kinematic type is usually used with the fully adjustable articulators.
-Arbitrary type is used with the average value articulator.

The doctor prefers the term Average value facebow instead of arbitrary;
Because when this was made all the studies were based on human skulls and
average value measures for the hinge axis location in relation to anatomical
landmarks, so when you place your average value facebow in the ear canal
they already compensated for the difference between the hinge axis and the
ear canal in their actual articulator. When you place a dot in front of the tragus
of the ear by 20mm that’s also the average value of the location of hinge axis
or TMJ whether on ala-tragus line or camper’s line.

-Last type is the digital facebow where you can overlap the proface? scan and
record the mandibular movements using sensors then figure out the position
of hinge axis on the software then you can fabricate your prosthesis more
accurately.

Interocclusal record
-After taking the facebow measure (if needed).
-In CR or CO.
-The figure is for a CD case, but imagine there
are some teeth in, you need always to use a
wax rim. Sometimes if it’s a small class 3 or 4
you can use acrylic material or another
material (didn’t hear the name).

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-The easier way is to use wax because it’s gonna be used to set the teeth in,
but you need to attach the wax after finishing the framework try-in, and make
sure it’s not interfering with the seating of the framework or it’s not
overlapping the rest on the occlusal surfaces not to interfere with occlusion
with opposing teeth.
-After adding the wax rim double check VD and make sure you have FWS (if
reorganize) or make sure it’s the same (if confirmative).
-Once you have the occlusal rim in contact with the lower teeth and the VD is
defined, make 1mm clearance of the wax rim no matter what material you’re
using even if using wax to record the final interocclusal record.
-Then add more soft wax in between the wax rim and the teeth, this way you
can be sure it won’t deflect the mandible on closing.

Materials used for interocclusal record: ordered according to Dr. preference

-PVS: sets really quickly, least viscosity so it won’t deflect the mandible
when closing.
-ZOE: impression paste or the temp bond (preferred). More precise, cusp tips
will be recorded more accurately but it’s more permanent and once you place
it if you try to move cast the ZOE will break, which will indicate there was a
problem after taking the interocclusal record whether in transferring it or
during mounting.
-Wax: less accurate as it will be in a squashed shape instead of a definitive
cusp tip but you will have room to wiggle the lower or upper cast in place a
little bit.
-Modeling compound.
-Plaster.
-Polyether: more rigid and viscous and expensive.

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When the doctor doesn’t have PVS, he takes the record with wax then takes
out the wax and relines it with a little bit of temp bond then place it in
patient’s mouth and ask him to close again after applying petroleum jelly on
teeth so that it doesn’t stick.

RPD’s occlusal schemes

This paper is published in 2020 by Goodacre the father and the son. It’s a
review of the occlusal schemes in RPDs, they included 8 RCT studies.
They found that you always need to look for harmonious contacts posteriorly,
whenever you can go for the confirmative approach.
You always need to have even bilateral posterior contacts in CO or CR, and
no deflective contacts on lateral excursions.
Regarding the eccentric movements, whenever you can go for canine guided
movement but if the canine is lost or periodontally involved you go for a
group function unless it’s class 1 Kennedy consider having bilateral balanced
occlusion in bilateral excursion.
If you have an opposing full CD go for a bilateral balanced occlusion.

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 These are all the senarios that
you might come across
regarding the occlusal scheme.
The doctor urges us to read the
paper in previous page
(discussion and conclusion
parts), the answers:
1 -canine guidance
2- if class 1 then bilateral
balanced occlusion as there
are artificial posterior teeth
on both sides
If class 2 then group guidance, otherwise there will be balanced contacts on
natural teeth.
3-canine guidance 4- group guidance 5- canine guidance (or lingualized
approach)
6- group function+ have Incisal guidance as shallow as possible not to
increase distance that
the mandible will travel to achieve separation posteriorly .
7- Bilateral balanced occlusion.
What’s written in red are my answers (not sure) the doctor didn’t answer
them.
With class 4 we may do lingualized occlusion, to keep it more stable and not
to have anterior teeth in contact in any way, so when you are in protrusion
posterior teeth are still in contact. B.B.O will make it harder to keep posterior
teeth in contact keeping the aesthetics anteriorly with the proper overjet and
overbite.
Remember that reorganize or conform depends on inter-arch space and not on
whether the opposing is natural teeth or CD.
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