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Articles
Written by Joseph Massad, DDS, William A. Lobel, DMD, and Lily T. Garcia, DDS, MS
Aesthetics Wednesday, 01 February 2006 00:00

Clinical Update Over the years, practitioners have reported frustration when the fit of a removable partial denture framework at try-in does not coincide
with the fit at insertion. Clinical techniques in making impressions, making a master cast, making a framework, and processing resin are
CE Articles factors that must be reviewed when considering possible causes for unacceptable clinical results. Reducing potential errors throughout
clinical and laboratory procedures can benefit the quality of the final prosthesis, as well as the fit at insertion.
Dental Materials
After clinical verification at metal framework try-in and acceptance of occlusion, laboratory factors such as flasking, compression
Dental Medicine molding, and devesting are suspect in creating deformation of the various components, such as minor connectors and major connector
of the framework. Deformation of framework components can be overlooked unintentionally and can be a complicating factor resulting in
Diagnosis improper fit at clinical insertion of the prosthesis. Even after customary adjustment of the resin base material, it may be determined that
the removable partial denture does not seat properly. In a more drastic situation, such as removal of all resin material from tissue-
Digital Impression bearing areas, which still results in the framework not seating completely, it is highly suggestive that deformation of the metal framework
Technology has occurred after processing in conjunction with other lab procedures.

Endodontics This article will follow the care of a patient requiring a maxillary complete denture and a mandibular removable partial denture, and will
highlight the technical steps utilizing a flaskless process in removable partial denture fabrication.
Ergonomics
AVAILABLE PROCESSING TECHNIQUES
Forensic Dentistry

Geriatric Dentistry
Denture base resins are processed through various techniques in an effort to achieve as accurately fitting a prosthesis as possible.
Hygiene These materials have limitations, and certain techniques have been developed to help overcome some of these limitations. These
various techniques utilize the following to create the final prosthesis: denture resin shaped via compression molding; injection molding;
Implants gravity pouring (fluid flow into a vented mold); or physical pressing and shaping of the resin onto a master cast in free space.

Impressions Whatever the technique utilized, denture base resins undergo polymerization changes as free radicals are generated by heat and/or
light and/or chemical reaction. External and internal heat of polymerization activate the crystallization process. External heat sources
Infection Control include variable temperature water baths (with or without pressure), microwave energy, or light energy.

Interview Denture base molds generally consist of paired chambers allowing resin to be introduced directly into open mold halves that are then
pressed together, or the resin is introduced indirectly through a sprueway into closed mold halves. Direct introduction of resin into open
Laboratory mold halves requires a resin with doughy consistency (medium viscosity) to undergo compression shaping as the halves are closed.
Introduction of resin through a sprueway requires a resin with somewhat lighter viscosity properties to create a uniform flow when
Management injected into the closed mold cavity. The resin may be highly fluid (extralight viscosity) and poured through a sprueway, in which case
multiple sprues and a vent are required.
Materials
Both compression molding and injection molding require rigid mold forms to resist distortion during introduction of the resin. Pouring
Microdentistry offers the opportunity to use flexible mold materials–generally hydrocolloid and silicone materials–which allow easy devesting and
recovery of the processed, anatomically shaped prosthesis.
New Directions
Regardless of the technique employed, the quality of the prosthesis may vary according to the material used and the skill of the
Practice Management operator. It is generally agreed that all these techniques can provide clinically acceptable outcomes. The question of which technique
consistently produces the required result is under ongoing investigation.
Restorative
The purpose of this article is to direct the reader to evaluate a method utilizing the shaping of denture base resins by pressing heat-
Oral Cancer Screening softened resins directly onto the master cast and framework, thus eliminating the need for an anatomical wax-up and flasking procedure.
These types of resins have working properties similar to waxes, allowing shaping of the denture base resins and denture tooth
Occlusion arrangement, permitting trial insertion prior to processing in free space. This direct resin system is a unique technique that provides for a
wax-free, flaskless method for fabrication of removable prostheses. The ability to process denture base resins onto a cast removable
Oral Medicine partial denture framework without flasking and devesting helps eliminate or minimize the possibility of errors in flask closure and
removable partial denture framework distortion that can occur during devesting.
Oral-Systemic
MATERIAL
connection

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Orthodontics

Pediatric Dentistry The material presently used in this technique is a light/heat-cured methacrylate (Eclipse Prosthodontic Resin [DENTSPLY Prosthetics]).
There is no vaporizing monomer, which is an advantage of this material. This resin does not chemically bond to acrylic teeth. However,
Periodontics an extremely strong bond is achieved using a bonding agent that enables reactive methacrylate-terminated dimers and oligomers to
diffuse into the surface structure of an acrylic denture tooth.
Pharmacology
The recommended bonding agent is reported to provide excellent bond strength between the resin and the denture teeth. Additional
Pain Management mechanical augmentation can be created by placing diatorics into the denture teeth. Even though this is not required by the
manufacturer, the additional mechanical retention gained and increased surface area for bonding is worthy of consideration. The reader
Prevention should be aware that a large diatoric can weaken the denture tooth, so if modification of the denture tooth is prescribed, it should be
conservative. The bonding agent reacts through the use of a solvent vehicle that encourages penetration of the oligomers into the
Prosthodontics denture teeth. Reactive entities, once initiated, undergo additional polymerization, predictably bonding the teeth to the denture base.

Removable Prosthodontics
PATIENT TREATMENT
Prosthetics

Fixed Prothodontics
A 76-year-old female patient presented with a loose, ill-fitting maxillary complete denture and a poorly adapted mandibular removable
Psychology partial denture. The mandibular removable partial denture was a Kennedy class I with a bilateral distal extension and showed a
"stepped" plane of occlusion between the natural dentition and the RPD occlusal plane (Figures 1 and 2).
Radiography

Post-and-Core
Technique

Regulatory

Restorative
Figure 1. Frontal view of patient with
Sleep Disorders
a maxillary complete denture and a
Kennedy class I removable partial
Sports Dentistry
denture.

Techno-Clinical

Technology

Technique of the Week

Treatment Planning

Viewpoint Figure 2. Frontal view of patient Figure 3. View of the edentulous

showing the mandibular occlusal maxilla. Highlighted area is the
plane discrepancy between the 6 premaxilla surgical site.
anterior teeth and the posterior
denture teeth; appears as a "step"
transition when the denture teeth
wear over a period of use.

Intraoral examination revealed generalized maxillary bony resorption coupled with excessive premaxillary resorption (Combination
Syndrome; Figure 3). The man-dibular arch contained teeth Nos. 21 through 28, and the remaining bilateral posterior edentulous areas
were adequate for the fabrication of a new removable partial denture, even though it was evident that alveolar bone resorption had
occurred. In an effort to preserve the remaining premaxilla from further deterioration, it was decided to correct the occlusal plane,
thereby transferring functional loads to the posterior bearing areas.

The following outline provides an overview of the treatment rendered to this patient:

(1) Surgical modification of the premaxillary redundant tissue with nasal spine refinement.

(2) Fabrication of a new maxillary complete denture restoring the appropriate plane of occlusion.

(3) Fabrication of metal ceramic crowns on tooth Nos. 21 and 28 to facilitate correction of the mandibular occlusal plane. It should be
noted that the patient declined the more conservative treatment option of enameloplasty of remaining mandibular teeth.

(4) Fabrication of a new mandibular removable partial denture with appropriate coverage of all key anatomical areas such as the
retromolar pad and bilateral buccal shelf areas, restoring the patient to the appropriate occlusal plane.

Treatment Sequence

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Figure 4a. View of the Figure 4b. A duplicate Figure 4c. View
previous prostheses; maxillary denture was made of the new
the frontal view and an occlusal splint was prostheses and
demonstrates the incorporated into the the correct plane
inverted curve in the transitional prostheses to allow of occlusion.
anterior area. the patient to accommodate to
the improved occlusal plane.

Figure 5. View of the maxillary Figure 6. View of the mandibular

master impression showing use of
multiple viscosities of polyvinyl
siloxane impression material, and
view of the maxillary master cast
made from master final impression
(Aquasil Ultra PVS [DENTSPLY
Caulk]).
master impression using a medium-
bodied viscosity polyvinyl siloxane
impression material, and view of the
mandibular cast made from master
final impression (Aquasil Ultra PVS
[DENTSPLY Caulk]).

Figure 7. View of the mandibular Figure 8. Frontal view of the patient's

arch with new removable partial lip posture with the previous
denture in position intraorally. prostheses; note the reverse posture
Pictured right is the frontal view of of the lips in repose.
the completed prostheses. The final
occlusion developed for this patient
shows a reverse occlusion in the
posterior areas.

Figure 9. Frontal view of the patient Figure 10. Left, view of the patient's
with the new prostheses with re- profile with the previous prostheses.
establishment of an acceptable nose- Right, view of the patient's profile
lip-chin posture. with the new prostheses.

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Figure 11. Frontal view of the patient Figure 12. Frontal view of the patient
with previous prostheses before with new prostheses after treatment.
treatment.

The clinical procedures for fabrication of the prostheses were initiated after completion of preprosthetic surgical procedures and
appropriate healing time had passed. A duplicate maxillary complete denture was fabricated; the duplicate denture allows for aggressive
alteration of the prosthesis to fit the proposed occlusal scheme and creation of an occlusal splint to allow the patient to accommodate to
the proposed occlusal plane (Figures 4a to 6). Procedures were completed to fabricate metal ceramic crowns on teeth Nos. 21 and 28.
During the fabrication procedures, each wax pattern was surveyed and waxed to incorporate guide planes and rest seats as well as
verification of the design in the final metal ceramic restorations. After metal framework try-in and jaw relation record verification, resin
polymerization was initiated. The mandibular removable partial denture was then seated opposing the new maxillary complete denture.
Necessary occlusal and intaglio adjustments were made (Figures 7 to 12).

Postinsertion instructions were reviewed with the patient, and then the patient was appointed for a 1-week follow-up appointment. Minor
adjustments were completed. Both the maxillary complete denture and the mandibular removable partial denture were inspected at 1-,
3-, and 6-week intervals without additional need for modification. The patient was then scheduled for routine follow-up appointments.

Figure 13. The denture teeth are Figure 14. Both the mandibular
placed, ridgelap down, into a warm master cast and the mandibular
solution of bonding agent for 1 to 5 removable partial denture framework
minutes to coat the contact surface are heated in preparation for making
and ensure final bond. In upper right the final prosthesis. A releasing
insert, a conservative diatoric was agent is applied to coat the
created on the ridgelap surface of the mandibular master cast prior to
denture tooth. adapting the denture base resin.

Figure 15. The resin (Eclipse
baseplate resin) is heated following
manufacturer fabrication instructions. on the master cast and press into
Pictured right: adapt the resin onto
edentulous areas of the master cast
by compressing the material firmly.
Figure 16. After adapting the initial
layer of resin, place the framework
position as judged by adaptation to
the teeth and other anatomical
landmarks. Next, additional resin
application and shaping can be
accomplished using the thermal-
controlled air gun to approximate
appropriate anatomical form.

Figure 17. The denture teeth can be Figure 18. As the denture teeth are

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set into the resin material and fixed positioned, the occlusion is verified in
into position using additional resin the articulator, and any adjustments
between the tooth and denture base are accomplished. The prescribed
material. Use a heated instrument to occlusal vertical dimension is verified
refine cervical and interproximal on the articulator.
contours. Pictured right, occlusal
view of the denture teeth positioned
in the mandibular removable partial
denture.

The laboratory procedures followed in this flaskless technique for fabricating the mandibular removable partial denture are shown in
Figures 13 through 18. The process highlighted for this patient's treatment began after the removable partial denture framework had
been made following an accurate master impression technique and the metal framework fit was verified clinically.

CONCLUSION

A technique has been described that utilizes the shaping of denture base resins by pressing heat-softened resins directly onto the
master cast and framework, thus eliminating the need for an anatomical wax-up and flasking procedure.

Sources

Kelly E. Changes caused by a mandibular removable partial denture opposing a maxillary complete denture. J Prosthet Dent.
2003;90:213-219.

Palmer BL, Coffey KW. Investing and packing removable partial denture bases to minimize vertical processing error. J Prosthet Dent.
1986;56:123-124.

Palmqvist S, Carlsson GE, Owall B. The combination syndrome: a literature review. J Prosthet Dent. 2003;90:270-275.

Rudd RW, Rudd KD. A review of 243 errors possible during the fabrication of a removable partial denture: part I. J Prosthet Dent.
2001;86:251-261.

Rudd RW, Rudd KD. A review of 243 errors possible during the fabrication of a removable partial denture: part II. J Prosthet Dent.
2001;86:262-276.

Rudd RW, Rudd KD. A review of 243 errors possible during the fabrication of a removable partial denture: part III. J Prosthet Dent.
2001;86:277-288.

Tanoue N, Nagano K, Matsumura H. Use of a light-polymerized composite removable partial denture base for a patient hypersensitive
to poly(methyl methacrylate), polysulfone, and polycarbonate: a clinical report. J Prosthet Dent. 2005;93:17-20.

Dr. Massad is adjunct associate faculty, Tufts University School of Dental Medicine and adjunct associate faculty, Department of
Prosthodontics, University of Texas Health Science Center, San Antonio. He has published articles in the Journal of Prosthetic
Dentistry, International Journal of Periodontal and Restorative Dentistry, Compendium of Continuing Dental Education, The In-
dependent Journal England, The Pankey Gram, Bulletin of American Association of Dental Examiners, Journal of the Oklahoma Dental
Association, Dentistry Today, Dental Economics, and others. He can be reached at (918) 749-5600 or joe@drjoemassad.com .

Disclosure: Dr. Massad was a member of the IRB research team to test the Eclipse system, and is an independent consultant for
DENTSPLY Trubyte.

Dr. Lobel is assistant clinical professor at Tufts University School of Dental Medicine. He can be reached at lobeldmd@aol.com .

Dr. Garcia is professor and chair, Department of Prosthodontics, University of Texas Health Science Center, San Antonio. She is a
diplomat of the American Board of Prosthodontics and fellow of the American College of Prosthodontists (ACP). She is secretary and
chair of the Council for the American Board of Prosthodontics for ACP. Dr. Garcia co-authored the text Osseointegration and Occlusal
Rehabilitation. She was named the 2004 ACP Educator of the Year, received the 1999 University of Colorado President's Excellence in
Teaching Award, and was awarded the designation of Rocky Mountain Study Club Professor of the Year, which is awarded by the
private practice community. She maintains a practice limited to prosthodontics. She can be reached at garcialt@uthscsa.edu .

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