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Hadeel Saleh

Mohammad Bustani |Page1

 Metal framework try-in

For whenever you are doing an RPD for your patient, this is an
overview of the steps that you’ll follow.
In this lecture, we’ll talk about clinical steps in 3rd visit.
But first, here’s a quick overview of the preceding lab step
(conventional way).

1- Blockout undesired undercuts, also in interproximal areas

because you don’t want metal going deep in there even when
using a plate?, and we place wax on the saddle area to maintain
a space for the acrylic to be packed under the meshwork or the
minor connector later on.
2- Then the cast will be duplicated, the material used in this step is
not stone but rather harder stone such as investment material or
die stone type 4 in order to withstand the high temperature of the
casting.
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 3- On the duplicated cast, the design will be waxed up whether it’s
prefabricated wax patterns or by hand.
4- Place the cast in an investment ring, you add screws to it, and
pour the investment material around and using the lost wax
technique similar to CD you place it in a water boiler and the
wax will be melted and washed away.
5- Then you will cast your framework using a centrifuge and once
you invest it you cut off the screws.
6- Finish and polish and it’s ready for the try-in.

Nowadays with digital dentistry emerging in, you can scan your cast
or take an intraoral scan, although they’re not that much accurate
when you’re recording the mucosa and soft tissues yet they are very
accurate on the teeth.

You take your scan and digitalise the cast then framework will be
designed on the computer according to comments from the clinician,
then it will be printed. (d) this is how you can design more than one
framework to be printed at the same time. (e) you can see the small
printing legs, when you take it out finish and polish it and it’ll be ready
for the try-in.

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Other than printing, you can use milling where you
have a disc of metal, then you drill or mill your
framework out of the disc, you’ll have lots of waste
material and lots of wear on milling burs because
the material is very hard, so it’s sort of preferred to
have it printed. The material used in the figure is
titanium —>

This is cobalt chromium —>

Nowadays we have resin based material

called Peak material, it comes in white or
pink shade to make it look more natural.
Below is an example of the white one with
the usual acrylic around teeth.

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The last material that you can digitalise in dentistry is
to have wax printed out using the framework design
on the computer, this wax will be invested using lost
wax technique.

These are heat maps in a study

done on different frameworks
made in different techniques,
(A) is lost wax technique (B) is
printing (C) printing out of
stone cast instead of scan (D)
lost wax technique out of
printed model instead of scan.
As you can see, the green and
blue areas are where there is
overlapping and better fit while
in red areas there is some sort of mismatch. So, in this study they found
that lost wax technique produce more accurate frameworks while the
CAD-printing is less accurate especially around the saddle areas
although both were clinically acceptable.

In a different study
they found the exact
opposite; more
inaccuracies around
the framework in
lost wax (casted)
technique while the
CAD-printing was
more accurate.

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This study was to compare different
materials; Titanium and Cobalt
Chromium are a bit more accurate
than Peak material.

Interesting fact?!
Almost 75% of the RPD frameworks don’t fit perfectly no matter what
technique you used to fabricate them, especially around the rest seats
and the clasps.
So, an active clasp will produce some orthodontic movements on the
teeth and should be adjusted to be passive, it would cause discomfort to
the patient in the same way if you have incomplete seating or rests that
are not fully positioned and other components of the RPD are not in
position, the prosthesis in general will tend to rock which will cause
discomfort and pain and will induce more bone resorption around the
saddle area and damaging soft tissue.
That’s why you need to do framework try-in step and make sure it fits
perfectly in the patient’s mouth before you proceed into adding the wax
rims and teeth around the saddle areas. The adjustments should be done
soon after fabrication without denture base.

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 Metal framework try-in – 1st step

-First thing you need to check the

framework on the cast, make sure the
cast is for the correct patient and make
sure that the lab constructed the
framework according to your design
and the lab didn’t cut off by mistake
one of the rest seats while polishing, or
if there were problems during the
casting.
-Make sure the framework fits around the cast properly or if the rest
seats are fully positioned or if the other components are in place.
-You need to practice the path of insertion on the cast so when you place
it in the patient’s mouth it will be easier.
-Check for seating, dimensions
(how far is the upper border of
the major connector from the
free gingival margins in order to
keep good OH), and size.
Then check for all the
components.
-Rests.
-Major and minor connectors; minor connectors should cross the
gingival margins at 90 degrees and not at a slope.
-Clasps (retentive and reciprocal arm); approaching arm of the clasp
should be above the survey line and only the retentive tip is underneath
it, the reciprocal arm above the survey line on its own length.

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-Check how much finishing and
polishing have been done, if there
is any abrasion of the cast (sharp
edges, casting inaccuracy or
shrinkage?) indicating misfitting
or that the clasp is too tight that
every time the technician was
taking it in and out it was abrading
the height of contour of the abutment, or if there is a nodule which
means the framework was not finished properly then you’ll have
scratches on the cast.
Using a piece of gauze or your finger cross the whole surfaces to see if
there is any catches.
At this point you need to decide whether you want to proceed or to send
it back to the technician to be remade.
If you’re happy with the framework so far or if there was a minor
adjustment then you will do it then proceed into the intraoral
examination, but if there was any major problems; in the design,
framework is placed in less than 3 mm away from gingival margins for
example then this should be remade.

Metal framework try-in – 2nd step

-Redo what you did on the cast in the
patient’s mouth.
-First, check for full seating and fit of all
components, if not then find where the
interference is.
-Check for any areas of binding.
-Ask the patient for his feedback.

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-Check for any pressure areas, locate
and adjust.
Use disclosing wax/ fit checker/
occlude spray.

Most common interference areas are:

The inter-proximal areas in lingual plates or around the minor connector.
The underside of the rest seat.
The approaching arm (rigid portion) of the direct retainer.
Shoulder areas of embrasure clasps.
Rarely it’s a soft tissue problem because you have a framework which
should have a tissue stop or have clearance around the soft tissues, these
are usually detected in the insertion visit when you have acrylic.

Aerosol sprays (occlude spray)

-Thin, accurate and not easily displaced.
But,
-Dissolve in saliva.
-Difficult to remove.
-2D; can’t tell how far it is from seating; how
much you need to reduce from the framework.
You place it on the underside of the framework,
there will be a show-through area in case of
interference.
(Doctor prefers this over disclosing wax)

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Disclosing wax
-Sets immediately, inexpensive, 3D
(tells you how much to remove).
But,
-Can stick to the teeth.
-Can be distorted.

Silicone indicating medium (fit checker)

-3D, not easily distorted. (The
doctor prefers this one the most).
But,
-Expensive.
-Sets relatively slowly (2 min).
- Can tear or be pulled off from the
framework.

The doctor sometimes uses it with soft

tissues or CD or partial acrylic denture.
As you can see when you try to adjust it, it
might be pulled out in even one piece.

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When you have interferences you have to mark the interference area
with a copia pencil or anything and adjust it using a bur.
Then you have to replace fit checker or whatever material you’re using.
You need to differentiate the areas where it’s normal to have a show
through such as guiding planes are expected to be in contact with the
teeth, but a minor connector in the inter-proximal areas need to be free
of contact with soft tissues and teeth except in the rest seat area.

-Once you’re done with the adjustment you’ll ask for the patient’s
effort…
-You need to check occlusion, you need to
know your occlusal schemes; in general if
you’re following the confirmative approach
you need to check the Vertical Dimension
before placing RPD in, memorise it then
double check VD after placing RPD and it
shouldn’t be altered.
If you have upper and lower RPDs, you insert them one by one, you
adjust the upper by itself then take it out, insert the lower and double
check for occlusal interferences, then you insert them both and double
check the VD and occlusion again.

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If there is an interference you shouldn’t touch the teeth at all, you adjust
the framework itself. Even at the previous steps.
Whenever you check the occlusion you need to keep in mind the
thickness of the components; rest seats shouldn’t be less than 1.5mm in
thickness otherwise it will be easily distorted and even might fracture.
At that point you need to decide if you need to redo RPD; reprepare your
rest seat and make it deeper and send a new impression to the lab for
remake, OR you need to remove a little bit of the opposing teeth so you
have inter-arch space without thinning down the RPD.
If you’re sure you prepared the rest seat correctly and the rest is fully
seated then you shouldn’t repeat the RPD and it’s a framework design
problem and the lab should remake it for you.

Now, you should ask for the patient’s feedback; how does he feel and
if there are areas impinging on the tissues or if it’s irritating the teeth,
you double check again and if there isn’t any problems then the patient
might just need to get used to it.
In occlusion step sometimes you check it with an articulating paper and
everything’s fine and you ask the patient if he feels high contact and he
reports one then you double check but still everything’s fine, then this
usually has to do with the thickness of your articulating paper.
Articulating paper comes in different thicknesses; number 1 thickness is
rarely used and it’s about 100 micron, the one usually used (U shaped) is
about 50 microns.
So, when you place it around CD the mucosa will sink a little bit and it
won’t make a problem with the patient perception, but around the teeth
the patient can feel less than 10 microns occlusal difference, so when
you have 50 microns between the teeth it will mean more even if the
difference is less than 10. That’s why you need to us thin articulating
papers; 25, 20 or 18 microns.

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In this figure, you can see the shim stock
which is some sort of aluminium foil that is
about 8 microns in thickness.
So, when the patient reports an undetected
high contact when using regular thickness
articulating paper, you bring a shim stock
and place it between the teeth tooth by tooth, if it was pulled away then
this means there is a space between the teeth more than 10 microns,
when you have a catch between the teeth this means space less than 10
microns.
If there is a catch (not able to pull it out) in one area while there is
clearance (able to pull it out) in other areas posteriorly and anteriorly
then you need to adjust the catch area, you bring the articulating paper to
mark it (as shim stock does not leave marks) then adjust it and recheck it
again until adjusted, after that you recheck with the shim stock again in
between all the teeth; it should equally catch on all the teeth, this is
especially in confirmative approach.
Sometimes when the framework is highly polished it’ll be hard to leave
an occlusal mark using articulating paper same as properly polished
porcelain crown, so you should roughen it up with a diamond bur or
abrasive powder.

Once you’re done adjusting and happy with the framework you need to
polish it again.

*Shofu points are usually made of rubber well impregnated in a

polishing material.

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