DENTAL TECHNOLOGY

Kenneth D. Rudd

An accurate method for occlusal registration and altered-cast impression for

removable partial dentures during the same visit as the framework try-in
U. Santana-Penn, MD, PhD,a and J. Gil Lozano, MD, PhDb
Faculty of Medicine and Odontology, University of Santiago de Compostela,
Santiago de Compostela, Spain
Preparation of mandibular distal-extension removable partial dentures usually requires a secondary
impression (the altered-cast impression) to improve the stability of the prosthesis. A potential problem with conventional altered-cast impression procedures is incorrect or incomplete seating of the
framework in the mouth or on the cast. This article describes a procedure for obtaining the interjaw
relationship and an accurate altered-cast impression in a single appointment (that of the framework
try-in). (J Prosthet Dent 1998;80:615-8.)

n recent years, a number of reports have proposed

procedures for registering jaw relation and making the
altered-cast impression during the same visit as the
framework try-in.1,2 By minimizing the number of visits, such an approach reduces both the cost of the treatment and inconvenience to the patient.
To make an altered-cast impression 3 correctly
requires that the framework remain in exactly the same
position as during the try-in. Problems often arise
because the impression material placed between framework and mucosa may cause the framework to lift away
from the mucosa; subsequently, during flasking, the
framework will depress again, producing inaccuracies in
the prosthesis. An attempt can be made to counter this
problem by pressing down on the framework with the
fingers while making the impression; however, this may
not give acceptable results, because it is difficult to
judge how much pressure to exert; in addition, the act
of pressing down may itself cause slight displacements.
An alternative approach is to take the altered-cast
impression first, and then to obtain a jaw relation
record in silicone.2 This procedure has 2 major disadvantages: (1) It is difficult to ensure that the framework
will remain in the correct position, and (2) the impression material used for obtaining the jaw relation record
may be displaced slightly, leading to inaccuracies in the
final structure. Another possibility is to use the framework as record base3,4; however, this procedure is also
sometimes inaccurate.
This article describes an accurate procedure for registering the jaw relation and making the altered-cast
impression during the same session as the framework
try-in for the removable partial denture (RPD).

aProfessor,

Department of Occlusion and Prosthodontics.

Department of Prosthodontics, Faculty of Medicine and
Odontology, University of the Basque Country EHU, Leioa, Vizcaya, Spain.

bProfessor,

NOVEMBER 1998

Fig. 1. Light-cured acrylic resin tray formed over edentulous

ridge portion of framework. Holes are made in tray to allow
resin columns to be built up through it. Position of holes can
be marked with pencil so that it is clear where to locate
bases of columns (arrows).

PROCEDURE
A patient who needed a bilateral distal-extension
RPD and a maxillary complete denture was selected to
illustrate this procedure.
After the framework is completed in the laboratory,
make RPD bases5 (Figs. 1 and 2). These may be of
light-cured acrylic resin tray material as shown, or alternatively of modeling impression compound or thermoplastic baseplate material. With the framework and
RPD bases seated on the cast, mark the framework
through the holes in the denture bases (Fig. 1). To
make certain that the framework is seated correctly, it
must be tried in and fitted in the mouth to ensure that
it is in the same position every time it is seated.6 This
depends on a passive fit, and the absence of occlusal
interferences.
Any defects in the framework should be corrected at
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Fig. 2. Acrylic resin trays (with holes for resin columns)

detached from framework.

SANTANA-PENIN AND LOZANO

Fig. 4. Acrylic resin tray in position on framework after

building up resin column (a) that acts as jaw relation index.
In addition, stone index beneath major connector (b) will
facilitate accurate repositioning of framework on altered
cast.

Fig. 3. Framework in mouth showing 1 resin column built up

as jaw relation index.
Fig. 5. Completed impression seated on cast from which
edentulous ridges have been removed.

this stage. The tissue stops on the intaglio surface of the

resin-retention part of the framework should touc
the soft tissue but should not exert pressure against it
(the purpose of the stops is to touch the cast and prevent the distal end of the framework from depressing
during the packing process).7 After the framework has
been fitted to the mouth, complete the following steps.
1. Build a 14-inch diameter column of light-cured
resin on the resin-retention part of the framework
in the position corresponding to the hole in the
acrylic resin impression tray (Fig. 3), and extend
this column up to the opposing occlusion in the
correct jaw relation position. (The tripoding effect
established by the column of resin on each distalextension framework and the anterior teeth of the
denture ensures that the framework is seated in the
same way each time the patient closes in the established jaw relation position.)
2. Remove the framework with the columns of resin
attached, seat it on the master cast, and mount it
616

on an articulator with an opposing cast. In addition, a stone index may be prepared below the lingual major connector, facilitating and improving
positioning when the framework is reseated on the
altered master cast.8 If necessary, enlarge the holes
in the laboratory-made removable denture bases so
that they fit correctly over the resin columns. Seat
the bases over the framework (Fig. 4), then heat
them and adapt them to the framework, making
certain they are firmly attached to it.
3. Place the framework with attached bases in the
mouth and relieve any overextensions and/or pressure spots, then apply low-heat-softened compound to the borders of the denture bases and
border-mold it.
4. Remove the framework-plus-tray, apply impression
wax into the tray, then reinsert the whole structure
and maintain it in the mouth while the wax adapts
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Fig. 6. Impression is boxed, in this case with plasticine.

5.

6.
7.

8.

9.
10.

11.

12.

to the edentulous ridge. Ask the patient to make

molding movements. At this stage, the occlusal
index serves to maintain the framework in the correct position.
Remove the edentulous ridges from the cast, by
making 2 cuts, the first longitudinally, the second
at right angles to the longitudinal axis of the ridge,
1 mm distal to the abutment (Fig. 5).
Score the cut surfaces with a knife or bur to ensure
good attachment of the new stone to the old.
Position the framework-impression assembly on
the cast with the edentulous ridges removed and
make certain that the framework is seated correctly on the teeth and in the index for the bar (Fig. 5).
If there is any chance that it will change positions
during the boxing procedure, wax it securely in
place with sticky wax.
Bead the impression with beading wax or plasticine
and wrap the cast with boxing wax. Seal the borders with more wax so unset stone will not leak
through when it is poured (Fig. 6).
Pour a mix of stone into the boxing and allow it to
set.
Remove the blockout and boxing material from
the cast (Fig. 7) but do not separate the framework-impression assembly from the cast at this
time.
Mount the mandibular cast in the articulator after
ensuring that the resin columns are correctly positioned against the previously mounted maxillary
cast (Fig. 8).
Remove the framework-impression assembly and
do the necessary procedures to complete the RPD.

DISCUSSION
It is our opinion that the use of altered-cast techniques during the preparation of distal-extension
RPDs3,6 is highly recommendable, because it is easy to
perform and gives predictable results. Such techniques
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THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 7. Finished altered master cast, with impression and jaw

relation indexes (arrows) in place.

Fig. 8. Resin columns (Figs. 3 to 5 and 7) are used to relate

mandibular cast to previously mounted maxillary cast, and
are attached to lower arm of articulator with stone.

were considered to be routinely used in clinical practice, and they are included in basic training.
An apparent disadvantage of such procedures is that
they are time-consuming and require a specific visit.
However, they often save time that would otherwise be
spent on final modifications of the denture. Furthermore, altered-cast procedures produce a better denture
base that not only withstands occlusal forces more
effectively but also improves stability and retention (in
other words comfort for the patient); these are strong
arguments for making the extra effort involved in
preparing an altered cast. Although to the best of our
knowledge there have been no controlled studies, it
seems reasonable to assume that a better adapted and
more stable base will reduce the risk of failure of the
abutments.
The correct execution of an altered-cast impression
requires the framework to be perfectly seated and
maintained in position while the impression material
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hardens.3 However, this may be difficult in certain clinical situations (for example, when the edentulous ridge
is long). In such situations, the framework may lift up
slightly or the dentist may press down too hard on the
retentive grid and push it too far down. Furthermore,
the patient must keep his mouth open while the dentist
makes molding movements by pressing in the impression-tray zone with his fingers; again, the dentist may
apply too much or too little pressure. Subsequently, the
pressure is released so that the patient can close his
mouth to allow the wax impression to be taken, and
this may mean that the framework lifts up (particularly
if the patient is asked to make molding movements
with the mouth closed).
These problems can be overcome by building an
index consisting of a rigid column that arises from the
retentive grid and terminates against the occlusal surface of the opposing teeth or dentures. An index of this
type ensures that the framework remains in the correct
position throughout the impression procedure, independently of pressure applied by the dentist. The index
also acts as a jaw relation record to facilitate subsequent
positioning of the cast in the articulator. The photochemically cured index described in this article can be
made in a short time (seconds) and in the desired intermaxillary position. The technique by Lay et al., 2 for
making a jaw relation record during the same visit as
the framework try-in, has the disadvantage that the
index is elastic and does not remain joined to the
impression. The result of this technique is that it may
not always adopt exactly the same position as during
the try-in. In our opinion, the procedure described in
this article is more reliable, and probably reduces the
likelihood of error when the cast is positioned in the
articulator.
A minor disadvantage of the procedure described in
this article arises when the antagonist is itself a mucosasupported complete denture. In such cases, clenching
can cause slight displacement of the opposing prosthesis, because the pressure exerted by the natural incisors
may cause rotation and detachment of the posterior
part of the denture. To avoid such problems, the
patient should be instructed not to clench tightly, but
simply to bring the maxillary and mandibular arches
together. The dentist should be able to detect excessive
clenching by monitoring the position of the framework
stop with respect to the impression surface. If excessive

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clenching is detected, a new layer of wax should be

applied and the impression should be obtained again to
ensure that the patient does not clench excessively.

SUMMARY
The procedure described in this article presents several advantages: (1) The patient can make molding
movements with the mouth closed to ensure that the
framework remains immobile in its initial position; (2)
the procedure requires little time; (3) the procedure
can be performed in the clinic, without new jaw relation trays; (4) the procedure obviates the fourth stage
in conventional preparation of a removable partial denture (establishment of functional and harmonious
occlusion3); and (5) the jaw relation index obtained is
stable and rigid, eliminating possible errors associated
with the fitting of provisional indices during the laboratory phase.
REFERENCES
1. Kakar A. Simplified one-step procedure for making impressions and jaw
relation records of implant-supported reconstruction. J Prosthet Dent
1995;74:314-5.
2. Lay LS, Lai WH, Wu CT. Making the framework try-in, altered-cast impression, and occlusal registration in one appointment. J Prosthet Dent
1996;75:446-8.
3. McGivney GP, Castleberry DJ, editors. McCrackens removable partial
prosthodontics. 8th ed. St Louis: CV Mosby; 1989. p. 327-37,339-60.
4. Warren K, Capp N. A review of principles and techniques for making
interocclusal records for mounting working casts. Int J Prosthodont
1990;3:341-8.
5. Lund PS, Aquilino SA. Prefabricated custom impression trays for the
altered cast technique. J Prosthet Dent 1991;66:782-3.
6. Stewart KL, Rudd KD, Kuebker WA. Clinical removable partial prosthodontics. St Louis: Ishiyaku EuroAmerica; 1992. p. 45-6.
7. Rudd KD, Morrow RM, Rhoads JE. Dental laboratory procedures. Vol III:
removable partial dentures. 2nd ed. St Louis: CV Mosby; 1986. p. 3057,187-208.
8. Shifman A. Index to reposition the metal framework accurately on the
altered cast. J Prosthet Dent 1992;68:979-81.

Reprint requests to:

DR U. SANTANA-PENIN
DEPARTMENT OF OCCLUSION AND PROSTHODONTICS
FACULTY OF MEDICINE AND ODONTOLOGY
UNIVERSITY OF SANTIAGO DE COMPOSTELA
ENTRERRIOS, S/N
15705 SANTIAGO DE COMPOSTELA
SPAIN
Copyright 1998 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/98/$5.00 + 0. 10/1/92494

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