Prosthodontics Laboratory: 4, Cobalt chromium design. Done by: Hasan Alblwa and Osama Yousef .

Important notes before you start reading this script: In laboratory 3 , we said that the doctor didnt talk about Finishing and Polishing process , well turns out he did talk about it in this laboratory , so please go back to your third lab and study it , it is included . The topic of this lab is ahead of the theory part, some topics might not be very clear because we didnt talk about them in many details. But doesnt worry just take a general idea about them for now. When reading this lab, any tile with a star is considered a main title and all of the processes that come after it are under that title. General overview of the entire lab: you may skip if you want In this laboratory we are going to learn about partial cobalt chromium denture design. In short todays lab is:
Patient comes to your clinic for treatment youll make primary impression Primary impression primary cast ( diagnostic cast ) : well use the dental surveyor Diagnostic survey (well use : Analayzing rod , undercut gauge and the marker ) Using elastomeric materials secondary impression pour stone secondary cast ( master cast) Another survey (verfytion survey ) everything is good we continue , something is wrong we redo Drawing the design on the secondary cast then making blockout and relief then duplicating the secondary cast with either agar-agar or addition silicon by putting inside a mold then making of refractory cast Adding pattern wax that is supplied by companies to the refractory cast putting the refractory cast inside a mold adding another layer of investment ( sandwich ) putting the refractory inside the oven the pattern wax has melted but we have tunnels now well put the cast inside the casting machine with the casy alloys ( ) supplied Cleaing and shaping of the metal Adding the acrylic and teeth conventional ( flasking , dewaxing , deflasking , packing and curing ) now we have a metal framework with acrylic and teeth .

. Well talk about the steps of making cobalt chromium dentures, and Dental Surveying. Just a reminder so you wont forget: how many steps we had in the making of acrylic complete denture? (Primary cast, secondary cast, jaw relation record, try-in and insertion) , and as we said on the first lab partial denture design is unique to each cast , so we might sometimes do all these steps , other times we might only do a few of them . Also its obvious but note that the partial denture differs from the complete denture in that it has clasps for retention and metal framework. When thinking of cobalt chromium design youll notice that its different; we have metal alloy framework and acrylic and teeth. The acrylic and the teeth in partial dentures are processed as the usual method of complete dentures, but for the metal part you might ask how do we get the metal in that shaped? The short answer would be Lost wax technique but the process goes into much more details than this, and youll learn it by the end of this laboratory. So to make a cobalt chromium partial denture I need to have two processes , one for the metal and one for the acrylic , so the steps are more involved and more technique sensitive.

1 The patient will come to your clinic asking for partial denture treatment. The very first step is taking a primary impression with a rectangular stock trays as we said earlier we used Alginate for the demo as in impression material, and after that we convert the impression into the diagnostic cast using type 3 dental stone. (Figure 1).

The diagnostic cast is used to determine my treatment plan, and I examine the cast to see what does the patient need to make him prepare to receive the denture. This is very important because I need to know what Im going to do before taking the final impression. Usually all of the cases the teeth arent parallel to each other, we have undercuts and the teeth are not disturbed in a balanced way inside the mouth. Usually the partially dentate patient has had his teeth extracted at different times, and probably he didnt have the perfect occlusion, all of this indicates that I need to make Mouth Preparation for the patient before my final definitive denture is made. What I mean by mouth preparation is that I study the primary cast I have , and I see what modifications to the patients mouth has to be done before undergoing the making of the denture , if the patient needs to have some of his teeth excreted before starting Ill send him to get that done , other times he might need fillings , crowns and sometimes he might have a good tooth for support but that tooth is a little tilted so I make sure I get that fixed . This is what we mean by mouth preparation. So, we determine which tooth needs modification by clinical conformation . But how do I determine which tooth is good for support for the clasps? We do this with an instrument called Dental surveyor. Well talk a little bit about this device first: 2

We use it to map out the general topography of the cast, what the shape of the teeth where the undercut is and variety of other things, the most important parts of the dental surveyor are shown in the adjacent picture.(figure 2).

Why do I do survey? you remember that a cast with natural teeth has undercuts, if we were to draw a line around the maximum convexity of all the teeth we will have an area above the survey line and an area below the survey line. And as you already know all the area below the survey line is undercut , some of the undercuts are good because I use them for retention and these are called favorable undercuts , some of them are bad because if my metal connecters goes underneath it I cant get the metal in or out . It becomes my objective when designing to change the tilt of the cast in such a way that I have maximum number of parallel surfaces, to be more specific I need the maximum number of Proximal surfaces to be parallel to each other so that when the prosthesis goes in and out itll slide right into its place, and we do this by shifting the angulations. I have to make two pathways, the path of insertion and path of removal. And I have to make it in such a way that the patient only has one path of insertion and not many, and one path of removal and not many, we do this because we want to make it very retentive and stable. On the surveyor the path of insertion is synonym with the direction of the surveying arm, so adjusting the arm will also adjust the path of insertion. Now finding the right path of insertion is the most challenging part of using a surveyor, its almost like solving a Rubiks cube, so there must be a criteria or steps I do when handling the surveyor , remember all of these steps are called Diagnostic surveying ; diagnostic because its done on the diagnostic cast : And they are four: The guide planes (finding the path of inseretion/removal). Retentive Areas (retention). Interferences. Esthetics.

Well talk about each one of these briefly, keep in mind were still using the diagnostic cast and these steps are the essential keys to make my design.

What do I mean by guide planes? They are planes that guide the denture into its correct position. 3 When I first seat the partial prosthesis what is the first thing that is going to touch? Its the guide planes, they are the axial surfaces of the tooth on the proximal and sometimes on the lingual surfaces of the tooth which are parallel to each other . To have an idea of what guide planes are, take a look at figure (3). And the two lines are the guide planes (distal on the premolar, mesial on the molar), and as you can see they are parallel. 4 How do I discover these guide planes? By looking at them visually? No, Ill use something called the analyzing rod (figure 4), which is a rod attached to the surveyor. With it I try to find as many parallel surfaces as I can. When using the analyzing rod I have to put the cast inside the surveyor table at zero tilt, do you know why I do this? Because the natural position of the mouth is at zero tilt and its the position where it comes perpendicular with the occlussal force, thus giving me support and retention. As we said most of the time the guide planes are the mesial and distal, so the first access of rotation will be? Its usually Anterior-Posterior when we have mesiodistal guide planes, and we have that most of the time. So the main concept is that the first access of rotation (the first tilt move I make to the cast in the surveyor) is usually if not always anterior-posterior, I do this because Im looking for maximum parallelism of existing surfaces. If I tilted it and this parallelism cant be found what do I do? Ill make what we said earlier: Mouth preparation to have that parallelism.

Our next brief talk will be about some of the cases where we failed to have parallelism at the first rotation so we made some modifications, these cases are just examples. The doctor talked about them in a hurry and he 5 said were going to take them in the theory part in much more details, but we wrote it anyway but dont worry too much about them: 1. Here you can find that the premolar is tilted and the molar is also tilted, at zero degree (figure 5) can I get my partial denture at that position? No, we cant. So what we should do is we 6 should tilt it anterio-posterioly . And remember we didnt tilt it laterally because the guide planes arent facio-lingually. 2. Here both of the two teeth have undercuts (figure 6) , what Ill do here is that Im going to do mouth preparation as we said earlier well take for example 0.5 mm enamel from each tooth , giving us two parallel surfaces. 3. Here one of the teeth is tilted and one of them is upright? We tilt slightly and we trim a little bit until we have parallelism. So this step was about finding the correct path of insertion and removal.

The next step is finding our retentive areas, what do we mean by retentive areas? They are the places where they show support for the clasps, so to know where I put the clasps I have to look for retentive areas. In contrast to guide planes; we look for retentive areas laterally or facio-lingually (most of the time the retentive areas are on the facial side and rarely they are on the lingual side). The doctor showed an example and he said that its still advanced to us , and he just wanted us to memorize what he said just for now , so when we take this at the theory well be exposed to the concept :

 The example that the doctor showed was about two teeth, one of them is severely tilted with an undercut (premolar) the other one is fine. So here we have to distribute the undercut, so we changed the original rotation degree (which was zero) by tilting the cast laterally. Now I have the premolars undercut distributed, and although it looks like the premolar isnt having an undercut but in truth its still an undercut, do you know why? Because as we said earlier, what gives the retention is not the undercut itself but rather the orientation of the undercut; is it perpendicular to the occlussal plane or not? On this case I realized that after we tilted the premolar is not perpendicular to the occlussal plane so Ill call the premolars undercut : Sudo or false undercut , if it was perpendicular itll be true. What if I have two deep undercuts on both sides? I can recontour the enamel to make the undercut less or put a crown on the tooth. So this step is all about identifying where the undercuts are, for the future clasps to be put in them, dont worry about the examples too much.

Consider this situation: after youve finished your measurements and designing , you discovered that there is a bony trabcule , this is called an interference , we wont talk much about it here in the lab but we can deal with it in three different ways : 1. Change my path of insertion ( redo the path of insertion so I could avoid that interference ) 2. Change my design 3. Blockout the interface, but blockout will turn into an empty space where food and saliva might accumulate. So it is good for the design but not very hygienic if the patient doesnt take good hygiene practice. The last step in the sequence is esthetics, but well talk about it in the theory more.

After I have determine where my retentive areas are (the favorable undercuts), a new question rises, how exactly can I measure where to put the depth of the clasp for the undercut? And this leads us to our next talk:

7 As you already know each type of undercuts (different depths) has its own clasps, undercuts are divided into 0.25 mm undercut, 0.5 mm undercut and 0.75 mm undercut , sometimes its written in inches in the textbooks ( 0.1 inch , 0.2 inch and 0.3 ) . (Figures 7 and 8 respectively) There are many type of clasps, the doctor only talked about two in the lab: Cast clasps ( 0.25 mm ) and gingivaly approaching clasps ( 0.5 mm ) . Cast clasp short, gingivally approaching is long and flexible. So lets say we have a good undercut and we want to put the cast clasp (0.25 mm) on it, how do I measure the depth? Well use an instrument called Undercut Gauge which is: an attachment used in conjunction with a dental cast surveyor to measure the amount of infrabulge of a tooth in a horizontal plane. (Figure 9) So well bring the undercut gauge against the tooth, and a space between the tooth and the gauge will be found. Lets say that the undercut gauge is 0.25 mm, well touch the tooth at maximum convexity at the survey line then Ill bring it up until it touches the tooth, Ill mark where the 0.25 mm is. What do I know now? I know that from here to here is 0.25 mm at this height there will be a 0.25 mm undercut is at that point and a clasp will be put there. (Figure 10) So from this step we concluded where the clasp depth should go. 9 8

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All what weve talked about and all the previous procedures were done on the diagnostic cast when we did diagnostic surveying; the next talk will involve the secondary cast that we make after the diagnostic cast. In this stage well do the following processes: What well do to the patient is something called Rest preparation What well do on the secondary cast is: Verification surveying (to make sure the first diagnostic survey was good) and Blockout and relief.

In the areas of the rests we said that I cant put a rest before I make a room for it. Lets say we have a normal molar and on that molar there is going to be clasp. Using a slow headpiece Ill start trimming the tooth on the patient in the same way as I determine on the diagnostic surveying We call this rest preparation, and this is not as cavity preparation in conservative laboratory, because in conservative laboratory the objective was to remove the decay or carries and to prepare a retentive hole thatll keep the restorative material inside the cavity so it wont come out. But in Prosthodontics the objective is: A) I dont want to go beyond enamel so that the patient doesnt become sensitive B) the rest will come in and out of the patient mouth so it shouldnt be occlusaly convergent but ocllusaly divergent (there must be undercuts here for the clasps to attach ). Now that the patient mouth is ready its time to make the final impression, which will give me the secondary cast, remember with the final impression we have to make custom trays. We take the final impression with any of the elastomeric materials (poly-ether, poly-sulfide, addition silicon ...etc). Well then end up with an impression that is going to be poured with stone and secondary cast is then

formed. Some of the differences that should be noted between secondary and primary: Before making the secondary we trimmed the patient teeth, so we already have trimmed teeth in secondary cast, but in primary thats not the case I didnt trim anything I just imagined it on the cast by drawing lines. I have rests on the secondary cast but not on the primary cast. I have guide planes here ( on the primary I just noticed them ) I have modifications if present as we said earlier.

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In order to fully understand what blockout and relief process is, first well have to understand how the metal relates to acrylic in the cobalt chromium denture. This is an example of metal framework (figure 11, 12), youll see there are clasps on the inside and outside of the denture, there is a major connector and the meshwork or lattice work (minor connectors) , can we see the meshwork when we have our denture done ? No, because the meshwork is the part where the acrylic binds to, and its hidden. So when I attach acrylic to metal I need to have a junction and as you know acrylic cant be made as a knife-edge junction. You can see the acrylic tooth surrounded by acryl. Look at the meshwork and how its filled with acryl, this gives mechanical support and retention. Look also to the junction ( figure 12 : arrow ) between the metal and the acryl this is called finish line and its a line where one material starts and another ends : in this cast where the acrylic ended and metal started , youll see finish lines in crowns , bridges , cobalt chromium and many bridges , this line is very important in Prosthodontics . 12

When I make the metal I have to imagine that there is acryl and I have to make the finish line ahead of time , it doesnt make sense to put the metal and acryl and then start scratching the metal to make that line ( impossible to do ) , it has to be done before . Does the metal touch the ridge in the endtoules areas? No, it should be hovering above the ridge, how do I make this possible? We do this by getting a wax sheet and adapted to form the shape of whatll be the metal, but still I dont want that wax to touch the ridge (because again wax will turn into metal and metal will touch), so from here the idea of blockout comes, I have to invent a space thatll make sure the metal wont touch the ridge on some certain areas , blockout is also not only to make free space later but also to know where my clasps will be by adding a layer of wax and making a step . Because If I draw clasps location with a pencil itll disappear when turning the secondary cast into refractory. Keep in mind were still talking about the secondary cast, and this blockouts will turn into refractory cast. 13

Parallel blockout (figure 13) : its a blockout that is parallel to the path of insertion, as you look in the picture what about the area down? You can notice that its undercut. Can metal go there? No, so I have to block this out so Ill add wax below the guide plane and get my wax chisel and adapt it . Later on when we have metal thisll be a space itll allow the partial denture metal framework to go in and out without any interfering. Hence: it is like the plaster blackout that we did for the acrylic partial denture. (Please note that we do this on the dental surveyor) .

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Shaped/Formed blockout (figure 14) : You have to understand that secondary cast or the master cast is not the final denture , were just drawing designs on it so that I can transfer it into another cast which is the refractory cast ( well talk about this shortly ) .

Now I make the shaped blockout because its the only way I can send the clasp position from the secondary cast to refractory cast , when I finish the process of blockout and relief Ill make an impression for the secondary cast and a step where the shaped blockout was will appear on the refractory cast ; hence the name shape blackout comes from giving the shape of the step to the refractory cast. 15 Arbitrary blackout (figue 15: notice this is a Buccal view): is just to make the copying process easier. As I said in point 2 , the secondary cast will be copied and turned into a refractory cast , I add the Arbitrary blockout wax to locations that are not included in the design of the cobalt chromium denture they dont have any importance . I put the wax in them because when I want to copy it , I dont want the impression material to go into big undercuts and makes the process harder , but rather block it now . Remember this type is not a part of the cobalt chromium design unlike the first two types. After weve finished the blockout we still have to do relief:

16 Relief wax: from its name you might wonder whats relief wax relief used for? the answer as we said in the theory is that the relief wax is used on the edentulous ridge is to make a space between the metal and the edentulous ridge in order when I make the metal framework partial denture the frameworks ( e.g. Lattice ) will be raised a little above . There is another type of relief wax that is used on the sensitive areas (e.g. palate on the upper denture) , so we use this type of wax in order for the metal framework not to press the ginigiva . So relief wax either used to make room for acrylic under the metal or relaxing the soft tissues ( gingiva ) .

Looking at the relief wax (figure 16 ), you can see we made window(s) why did we make that window? Its for stoppers. When I make the final metal partial denture this stopper will become positive, the lattice work (or meshwork) will be above the ridge everywhere expects here in the small window. We do this because when I start adding the acrylic and I do packing the metal can sometimes bend, so we make small leg (stopper) so that the metal cant move. This is the same as when we made special tray with stopper on the inside. So lets recap what we learned so far, a surveyor is a device that is used to determine the correct path of insertions in partial removal prosthesis, so that we disturbed the parallel surfaces anterio-posteriorly and retentive surfaces laterally, taking into consideration interferences and esthetics. We do surveying twice, one for the diagnostic cast to determine what the design will be doing, and we survey again to verify and blockout on the master cast. The instruments we used are the analyzing rod, carbon marker and the undercut gauges. And in the master cast to remove the excess wax we used wax chisel.In the lab you didnt use the chisel but you used the normal carver, this is not true but for the educational purposes we did so. Now that we have our secondary cast done, we can move to the next step which is copying it to make the refractory cast, so far up to this point I didnt explain to you why I copy the cast to refractory, so Ill first explain the idea behind duplicating the cast and then well talk about the refractory cast preparation.

As the title says, why didnt I after making the blockout and relief adapted the metal on the secondary cast? As you remember last semester when we were working on the complete dentures we didnt have such a thing as refractory cast , because all of what I had to do was simply adapt acryl and then exposed it to the

proper curing temperature of acrylic , which was great because the secondary cast withstand the temperature and didnt break . The case in partial cobalt chromium denture is different here we have metal , the curing temperature for metal is very high ( 950- ~1050) , the secondary cast cant tolerate that temperature and itll break , so what well do is that well take the secondary cast and make an impression for and turn it into refractory cast . So in short the advantages we had of duplicating this cast is: Heat resistance : this was not achieved by the stone cast , metal curing occurs in 950-1050 Blockout and Releif came achievable this is cant be achieved by the stone cast , because even if I add wax to make this space the entire cast will break because of the high temperature of the metal . 17 What refractory cast is made of? Its made of a material called Phosphate Bonded Investment Material will pour this material on an impression inside a mold to form this cast. This can tolerate high temperatures hence the name refractory. (Figure 17). What is the best suitable material to make the impression for the refractory cast? (What is the material that we use to make an impression with after weve done blockout and relief on the secondary cast , and then pour it using the phosphate bonded investment material turning it into a refractory cast ? ) Ill use a duplicating material, the choice I have is either Agar-agar or Addition silicon . If we used Agar-agar , we have a container and well pour the agar-agar , it has water content so when we heat it , itll become liquid . So well first mix it in a special machine which is called and then heat and pour it inside the mold. Agaragar is humidity sensitive so itll become fragile if left. The other option is addition silicon but its more expansive yet very accurate, chemically set (cant be used more that once) .

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By now I think you fully understand that refractory cast and the design we made on it will turn into the final shape of the metal including the clasps, connectors and arms. But looking at the fine details of the clasps and the other different components of the chromium cast you might think how did we manage to mold the metal in such an elegant way? What we actually do is that we add a type of wax called pattern wax (figure 18 , 19 ) ; the companies supply many different shapes and forms for it, for many different components of the cast. Later on this wax will be replaced by the metal and takes its shape. So pattern wax is an essential step because without it itd be very hard to mold the metal, and its done on the refractory cast. 18

Weve come to the core step of making partial cobalt chromium dentures; metal is the main charastics for partial dentures and now well learn how we mold it. Well put the refractory cast in a mold and well pour another layer of investment material ending with a shape like a sandwich ( figure 20 next page ) , what well do next is were going to put the cast inside a furnace and expose it to heat , when exposing it to heat the pattern wax will melt away , and what will take its space now ? Nothing I have an empty tunnel that is ready for the metal to get inside it and take its shape (an application of lost wax technique).

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After that well use one of these cast alloys (figure 21: arrow) inside the mold, well put it inside a machine called casting machine (figure 22) that its principal depends on the centrifugal force. After we finished from the pouring process, well have something like this (figure 23) well break it off and then clean the metal, the cleaning process of metal is done by using a special machine called Sand Blaster (figure 24 ), this machine will inject aluminum oxide ( last semester we talked about some similar material ) slowly at the metal and thus cleaning it. And the final polishing is done by another machine which is called ElectroPolishing; its simply a batch of water where we put the metal and then electrical current will give the polish shine appearance. Notice that our refractory cast is destroyed while doing this process.

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After I finished molding the metal how do I make sure that my work is good ? Well simply you have to try the metal on the secondary cast (remember refractory is destroyed) if it fits correctly move on, if not youll have to make the entire work again. The only part reaming in the journey of making the denture is the acrylic part, which is the conventional method for preparing acrylic ( flasking , dewaxing , packing and curing ) . Read it from laboratory 3 23 24

This page is a summary for the entire process: patient comes in we make primary impression, pour up the primary impression and youre going to end up with primary cast (diagnostic cast ) which we are going to study to see which modifications we need to make to the patient before starting to design this and in order to do this we have to use the dental surveyor , if there were any modifications Ill go back to patient and make them ( remove a tooth , filling ..etc) , secondary impression ( custom rectangular trays ) , pouring the impression well get a master cast ( secondary cast ) : secondary cast differs from the primary is that we have rests and guide planes and modifications , we do blackout and relief , duplicate using either agar-agar and addition silicon , using the agar-agar or addition silicon impression we pour phosphate bonded investment material into a mold to make the refractory cast , we draw our design on the refractory cast ( we use the pattern waxes provided by the companies ) , then well put another layer of investment inside a mold , well put the refractory cast inside a furnace ; the wax now will melt creating tunnels for the later metal , after that Ill use the casting machine to cast the metal , after that Ill add the wax and teeth , after that Ill do another lost wax process ( conventional flasking , dewaxing , packing and curing for the acryl ) , finally Ill end up with a metal framework plus acrylic and teeth . The number of deaths in Syria to the date of writing this script is 11297 people, from that number 802 are kids, and 676 are women. My prayers go to you my country.

Done by : Hasan Alblwa and Osama Yousef .