Improving Tissue Support- Altered Cast Technique

Improving Tissue Support- Altered Cast Technique ABSTRACT Aim: Cast partial denture made using altered cast technique creates an environment in which the teeth and the edentulous tissues support the denture bases as compatible as possible, resulting in a more stable cast partial denture. Background: The tissues of the edentulous ridge in distal extension removable partial denture are liable to be displaced under occlusal pressure. This is a result of the displaceability of the mucosa. The difference between the resiliency of the residual ridge tissues and the teeth causes disparity of support, that causes the denture to rotate about its distal abutment, inducing heavy tortional stresses on the teeth and possible traumatisation of alveolar ridge. Studies have proved that better support and stability can be achieved in distal extension cases using functional impression along with altered cast technique. Case description: The following article is a case report of a distal extension cast partial denture using altered cast technique for better tissue adaptability and stress distribution. Conclusion: For recording Kennedy’s class I and II edentulous areas, optimum residual ridge coverage with a well fitting denture base is required. This reduces stresses, preserving the remaining supporting structures which can be achieved with the use of altered cast technique. Clinical significance: The altered cast technique allows the residual alveolar ridge to be recorded in functional form and relates to the teeth so that when the prosthesis is seated, it derives support simultaneously from the teeth and the soft tissues. Keywords: distal extension, stress distribution, functional impression, altered cast technique. BACKGROUND: The most important consideration in replacement of missing teeth for a distal extension removable partial denture as per DeVan’s statement must be â€Å"the perpetual preservation of that which remains, and not the meticulous replacement of that which has been lost.†1-4. When occlusal forces are applied to distal extension removable partial dentures, the forces must be distributed equally to the abutments and the tissues of the residual ridge.2 This cannot be accomplished on a master cast made from a single impression. A dual impression technique is used in which a â€Å"corrected cast† can be generated which can record and relate the tissues under uniform loading, distribute the load over as large an area as possible and accurately delineate the peripheral extent of the denture base.2 Functional impressions are defined as â€Å"The impression which records the form of the residual alveolar ridge under some loading whether by occlusal loading, finger loading, specially designed individual tray or consistency of recording medium.†5 Several methods may be used for registering the alveolar mucosa in its supporting form. The dual impression techniques are categorised as 1). Physiologic impression techniques. a). McLean-Hindel method, b). The functional reline method, c). The fluid wax method. 2). Selective pressure techniques.2 According to Leupold6 , the functional reline method is accomplished after the denture base has been processed onto the framework. The disadvantage being it requires a greater degree of occlusal adjustment after processing of acrylic resin and so it is necessary to modify the new denture before delivering it to the patient.6 So to overcome this the master cast is altered to accommodate the secondary impression and thus altered /corrected cast is generated.2,6. Cast partial denture made using the altered cast technique helps create an environment in which the teeth and the edentulous tissues support the base as compatibly as possible resulting in a more stable denture that improves the support for the occlusal relationship of the opposing dentition and the removable partial denture restoration.2,3. For preservation of the residual ridge, Becker and his colleagues, critically reviewed the evolution of removable partial denture and outlined six principles for its design which include a rigid major connector, multiple positive rest seats, mesial rests, parallel guide planes, the I-bar clasp design and the altered cast technique.7 This technique has the potential benefits of reducing the number of postoperative visits, preserving the residual ridges, improving stress distribution, decreasing food impaction and decreasing the torquing of abutment teeth leading to increased patient satisfaction.8-11. The following case report will explain the use of altered cast technique used in the fabrication of a distal extension cast partial denture. CASE DISCRIPTION: A 60 year old male patient reported to the Department of Prosthodontics Dr. D.Y.Patil Dental College and Hospital, Navi Mumbai with the chief complaint of missing teeth and difficulty in eating. Extra-oral examination revealed that the patient had an ovoid tapered face, with mild prognathism, competent and thick lips. Patient had a habit of cigarette smoking since 20 years and so was advised to stop the habit. Intraoral examination revealed that there was only one tooth 23 remaining in the maxillary arch and 31,32,33,41,42,43 in the mandibular arch. The teeth were lost due to caries and periodontitis. (fig.1,2) Radiographs were evaluated and the treatment was planned. Tooth supported overdenture for maxillary arch and cast partial denture for mandibular arch was planned. Diagnostic impressions were made in irreversible hydrocolloid (Imprint, DPI). The impressions were poured using dental stone (type III, kalrock) and casts were procured. For the maxillary arch, the canine was endodontically treated. Pattern resin (DPI) was then used to make a Thimble-shaped coping for the canine which will help in additional retention of the maxillary denture. Primary impression was made using irreversible hydrocolloid (Imprint, DPI) and custom tray was made. The coping was then cemented with zinc phosphate cement (Dentsply). Border moulding was done with low fusing compound (greenstick, DPI) and wash impression was made using polyether impression material (3M ESPE). Master cast was poured in dental stone (type III, kalrock). For the mandibular arch, Diagnostic cast were surveyed and cast partial framework design was planned. The design included Lingual Plate as the Major Connector, Modified Ladder shapped minor connector. RPI system was planned for the rests and guide planes on 33 and 43. Mouth preparation was done which included the preparations of rest seats on 33 and 43, guide planes on distal of canines. Composite build up on the mandibular anterior teeth was done for better anterior giudance. Impression was made in a custom tray using medium bodied polyether impression material (3M ESPE) and master cast was poured using dental stone (type III, kalrock). Cast partial denture framework was fabricated on the master cast. The cast partial denture framework was checked on the master cast and in the patient’s mouth for the fit. (fig.3,4). The cast partial framework was used as a part of the custom tray for recording the functional impression. Spacer wax (DPI) was adapted on the saddle area of the framework and acrylic custom tray was made using Self cure acrylic resin material (DPI). The custom tray was checked in the patient’s mouth for correct extension. Border moulding was done using low fusing impression compound (green stick, DPI). Spacer wax was removed to provide space for the wash impression material. Tray was coated with a layer of adhesives so that the elastomeric impression material adheres to it. Wash impression made using polyether impression material (3M, ESPE). The master cast was sectioned into 3 pieces with the help of a hand saw and the distal edentulous area was removed. (fig.5). The wash impression made on the framework was placed on the sectioned master cast making sure that it seats completely in the rest seat areas. (fig 6). The entire assembly was sealed using utility wax to prevent its dislogement or movement during pouring of the cast. Beading and boxing was done around the framework and sectioned master cast and the impression was poured using a different coloured dental stone (type IV, kalrock) to distinguish with distal extension areas. The cast thus obtained was the altered cast. (fig.7). Jaw relation was recorded and teeth arrangement was done. Try in of the maxillary and mandibular trial dentures was done and dentures were fabricated using Heat cure acrylic resin (Leucitone,Dentsply). At the denture insertion stage dentures were checked in the mouth for retention and stability. (fig. 9,10). Post insertion instructions were given and follow up at the interval of 1month and 3 months was done. DISCUSSION: The fabrication of distal extension partial denture is a difficult task since it involves taking support from both the tissues and the teeth. Both of them have different amount of movements when forces of mastication are applied to them. Thus, the use of special impression techniques becomes necessary. However, in some cases, soft tissue displacement is slight. As a result, the functional and anatomic contours of the ridge may be virtually identical. However, that was not in this case. The decision to use dual impression technique along with altered cast technique was determined in the beginning using a test. Here, first the acrylic denture base was made on the diagnostic cast and placed in the mouth and finger pressure was applied to the base. There was some amount of lift seen in the framework suggesting that there was some soft tissue displacement. So by using the dual impression technique we can get a precise and functionally formed denture border and seal.2,3,7,8. The dual impre ssion used is indicated for mandibular distal extension cases because of a limited ridge area, the mobility of the floor of the mouth, to record the stress bearing area and proper peripheral extension.2 There are two categories of dual impression techniques mainly the physiologic impression techniques and selective pressure techniques. Physiologic impression techniques record the tissues of the residual ridge in its functional form by placing an occlusal load on the impression tray during impression procedures. The methods are the McLean-Hindels method; the functional reline method; and the fluid wax method.2 The need for physiologic impressions was first proposed by McLean and others. He recorded the tissues of the residual ridge in a functional form and the remaining teeth in anatomic form. However the disadvantage of this technique being that the dentists could not produce the same functional displacement generated by occlusal forces because of design of tray being used.2,12 In response to this shortcoming, Hindel developed his impression procedure by modifying the tray as a result of which the finished impression was a reproduction of the anatomic surface of the ridge and the surfaces of the teeth. Disadvantage being that the tissues recorded in this technique continue to be in a functional form all the time. This results in compromised blood flow with adverse soft tissue reaction and resorption of the underlying bone. Also sometimes because of this there is presence of premature contacts of the teeth replaced which will not be acceptable to the patients.2,13,14 The Functional Reline technique and the Fluid wax method where fabrication of the distal extension denture is done before and the new surface is added to the intaglio of the denture base afterwards. It can be done in cases where the denture becomes loose. However, as in the earlier methods this method too, has some difficulties mainly, the problems caused by failure to maintain the correct relationship between the framework and the abutment teeth during impression making procedure and also failure in achieving accurate occlusal contact following the reline procedure.1,2,3,15. To overcome this, along with this method corrected cast procedure was used yielding a better result.1,2,3,9,10,15 In the mentioned case report we have made use of the altered cast technique along with selective pressure impression procedure. The main advantage of this procedure is that the framework was ready before we make the final impression and alter the master cast. So the adaptation of the framework to the teeth and the soft tissues doesn’t change after the final impression. Also the other advantages are, 1. Remarkable stability of the denture base in distal extension removable partial dentures. 2. A positive occlusion which will be maintained for long periods of time. 3. Reduced stress on abutment teeth from unfavorable forces. 4. Reduced numbers of post-insertion adjustments.2,7,10 CONLCUSION: Fabrication of a cast partial denture for mandibular distal extension class I cases is a challenge for the prosthodontist. Several functional methods have been proposed for recording the edentulous area and the abutment teeth. An altered cast technique for fabricating cast partial denture was used in the above article. This impression technique helps in registering and co-relating tissues of different resiliency. This improves the stability and support of the denture, resulting in optimal load distribution. CLINICAL SIGNIFICANCE: An altered cast technique is a way better and faster as compared to other techniques. In this technique the cast partial framework is kept ready before the recording of functional impression. Because of the correct fit of the cast partial framework this technique helps in recording the hard and soft tissues in a better way. Thus, it can be routinely utilized for the recording of distal extension area. 1

How policies and procedures help children Essay

Discuss how policies and procedures help children and young people and their families whilst the child is being looked after. In this essay I am going to discuss 6 policies and their procedures whist a child is being looked after. I am going to expand on why this is important for the child parent or legal guardian and also why they are put in place. Firstly I am going to discuss the Safeguarding Policy. Safeguarding Policy Safeguarding is the policy that describes the function of protecting adults and children from abuse or neglect. It is an important shared priority of many public services, and a key responsibility of local authorities.Safeguarding relates to the need to protect certain people who may be in vulnerable circumstances. These are people who may be at risk of abuse or neglect, due to the actions (or lack of action) of another person usually their parent or carer. In these cases, it is critical that services work together to identify people at risk, and put in place interventions to help prevent abuse or neglect, and to protect Safe guarding helps make sure the people whom are protecting the children are correctly checked for example a CRB is mandatory when looking after a vulnerable child. What is a DBS check and why is it needed? Since March 2002, the Criminal Records Bureau has enabled employers to check the criminal records of employees and potential employees, in order to ascertain whether or not they are suitable to work with vulnerable adults and children. For individuals working in certain positions, a valid DBS disclosure is a legislative requirement. The Disclosure and Barring Service also manage lists of individuals who are barred from working with children and adults. New safeguarding regulations introduced in October 2009 place an obligation on employers, social services and professional regulators to notify the DBS of relevant information. This obligation ensures that individuals who pose a threat to vulnerable groups can be barred from working with them. It also makes it a criminal offence for these individuals to apply to work with these groups and for employers to knowingly employ them. This makes sure the child is safe whilst being cared for by a  professional or a carer whom isn’t their parent or legal guardian. It is also important so the parents or carers know the child is in safe hands whilst being cared for out of their control. Recording and Handling Information Policy Recording and handling data is important when looking after children for example whilst a child is in school all their documents must be kept confidential in case any of the other children or irrelevant staff members read or disclose any confidential information. The only time data or information about child should be revealed is if the child is at risk or in danger. Then the relevant person can inform the carer or relevant person to make sure the child is kept safe. Keeping children’s medical records safe is also important in case they ever need reviewed or used in case of emergency. Health and Safety Policy This policy promotes making sure the child is kept safe and in a safe environment for example there are a few policies put in place to make sure this is possible. They are RIDDOR  (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations) This is an assessment that must be put in place and a report filed upon if a child is injured in school or any other official place of work. For parents or carers this makes sure it is dealt with and supported correctly it also keeps children safe. COSHH (Control of Substances Hazardous to Health) This is similar to the RIDDOR policy I have expanded on above. All people taking care of the child must make sure all harmful substances are kept away from the child to prevent serious or injury or death. Risk Assessments. Risk assessments are carried out everywhere a child is looked after to make sure the environment and building is safe for the child to live or be taught in. This is a mandatory legal document especially in a school or care environment. This could put a parent or carers mind at risk knowing there child is safe. Health Policy It is a legal requirement that all children must get free healthcare throughout their childhood and adolescent life if needed for example medical care, dentistry care and mental support if needed. This helps support the child so they can stay healthy and get the right support they need. It also helps the parent so they don’t need to worry about the financial side as all this support is free. Education Policy Education is mandatory until you are 18 as of 2012. This is so children don’t fall out of education at 16. You can go down many routes when leaving school for example college, sixth form, training or apprentiships. There is also a legal standard of education in the United Kingdom that must be followed, there are 224 policies within 1 policy itself for education ranging from Reducing violent and gun crime to Reforming qualifications and the curriculum to better prepare pupils for life after school. Having policies in place makes sure that children get the right standard of education and that parents and carers can go out to work whilst their children are at school to make sure they can give their children the best standard of life. It also sets the child up for a good standard of life with good qualifications and life skills. Play Policy When children are in education especially primary school it is a legal requirement that they get break time and toys and equipment to use during this time. The best way for a child to learn is using exploratory learning and learning by trial and error. This is how a child learns life and social skills from a young age. When a child starts school this also gets them well adjusted to letting go from spending all their time with there parent or carer. Every Child Matters 1 Be Healthy 2 Stay Safe 3 Enjoy and Achieve 4 Make a Positive Contribution 5 Achieve Economic Wellbeing I believe that all they above policies shape a child’s life and with the right guidance from parents, carers and education you can shape a decent outcome and setup for a child’s life and development. Refrences. http://www.every-child-matters.org.uk/Framework_5_key_outcomes http://www.theguardian.com/politics/education http://www.playengland.org.uk/resources/national-play-policy.aspx https://www.gov.uk/government/publications/health-and-safety-advice-for-school https://www.gov.uk/disclosure-barring-service-check/overview

Divine perfection of a woman Essay

The play Richard III shows power, greed and ambition and how doing these things can effect other people and change how you act and think. In the world today someone who is like Richard in the way that he is greedy and power hungry is Saddam Hussein. The whole play shows how Richard is ambitious, greedy and power hungry. At the start of the play he is ambitious because he has set himself a task to become king. This shows that he is greedy because he is not happy with what position he is at that moment and wants more power. The way in which he does this is by killing anyone who could prevent him from becoming king. I think Shakespeare may have wanted to show that having ambition, power and a little greed is ok but if you lose your head and want more and more power making you become more greedy it could result in not just other people getting hurt but you getting hurt in the end as well. Like in the end of the play Richard ends up dying as a result of his extreme amount of power and greed. I think he wanted the audience to admire him for his cleverness in his schemes and the way he has organised everything. In some points the audience do admire him for his cleverness but straight after he has brought the audience to his side he does something extremely viscous and evil that the audience off liking him. People who are like Richard always end up getting paid back for all their wrong doings, well in some cases any way. Like Adolf Hitler who ended up dying because of all the bad things he had done i.e. WWII. So what Shakespeare is saying is, all bad you do to others you will get back to you. The opening speech that Richard says is to the crowd is directly at them and makes you think he’s a nice person because he makes a few funny comments which makes the crowd laugh and grow to like him. This also makes the audience watching the film like Richard too because he seems like a nice person, but when he walks into the toilets away from the crowd he talks at the audience saying that he’s ugly, which makes the audience feel sorry for Richard. Straight after he says this he tells you about a plan he’s made. First of all you admire him for being ambitious but long after when you find out what his plan will involve, i.e. killing many people who could prevent him from becoming king, you start to really dislike him and wonder how on earth you liked him in the first place. He says, â€Å"I am determined to prove a villain and hate the idle pleasures of the day,† meaning that basically Richard is going to become evil and never have pleasure. This little extract of something that Richard says shows him to be very evil in the fact that he wants to become hated. Another thing Richard says is â€Å"Plots have I laid, induction’s dangerous† which means that Richard is plotting some dangerous schemes, and is another reason why people watching the film would turn their nose up at Richard. The audiences overall impression of Richard is that he is a very ambitious man but his ambition will lead to murders being committed so therefore they would think he is a very sly and wicked man. Also the audience would think that Richard is two-faced because first of all he is very nice to Lady Ann and wants her to marry him, but when he has done this he then wants her to be killed. Shakespeare makes you both admire and hate Richard. For example, you would hate Richard in scene one when he talks to you about what evil things he has planned. Where as in Act one Scene two you grow to admire him again because of the way he flatters and wins over Lady Ann with words. He says things like â€Å"Sweet saint† and â€Å"Divine perfection of a woman† meaning he thinks she is perfect. But when Richard has said these flattering comments to Lady Ann, she immediately repels him by saying insults like â€Å"Diffused infection of a man† meaning that she thinks he is a grotty, disgusting and horrible man and â€Å"Thou unfit for any place but hell† which means that Lady Ann thinks that the only place that Richard could possibly live in is hell. Despite all these insults she throws at Richard he still wins her over with his flattering comments. He eventually marries Ann after having killed her husband and father, which she knew he had done. Richard should be admired for his cleverness for the way he won over Lady Ann and set up his schemes, never the less he shouldn’t be praised too much because he is still an evil and devious man who has committed murders. Also towards the end of Act One Scene Two he starts to get cocky after winning over Lady Ann and says some evil comments like â€Å"Was ever woman in this humour won? I’ll have her; but I will not keep her long† this is saying that he will marry Lady Ann but after a little while he will kill her. This will give the audience a very nasty image of Richard because of his evil antics. Act One Scene Three is where Queen Margaret curses all the people she hates. She says horrible remarks like â€Å"God, I pray him, that none of you may live your natural age† which means that she is saying that all the people she hates she doesn’t want to live a long life, and another quotation is â€Å"Thy friends suspect for traitors while thou livest, and take deep traitors for thy dearest friends† which means that she wants all the people she hates to die so they can’t hurt her friends. Richard is one of the people Queen Margaret hated so therefore she cursed him. When she curses Richard she says to him â€Å"No sleep close up that deadly eye of thine, Unless it be whilst a tormenting dream, affrights thee with a hell of ugly devils!† This curse actually comes true and like the quotation says Richard has a terrifying dream making him panic and sweat. What happens in the dream is ghosts surround Richard and curse him saying â€Å"despair and die!† over and over again terrifying Richard through the night. But the scene with Richards terrifying dream was not included in the film.

Romeo And Juliet Journal Essay - 1433 Words

Romeo and Juliet Journal Act I: nbsp;nbsp;nbsp;nbsp;nbsp;Hi. I am Roberto Montague, Romeos cousin. This is the first of five entries to this journal. Many things happened today. Some of these things are that Sampson and Gregory were talking, and then Abram and Balthasar entered the room. After Abram started to quarrel, they started to sword fight, but then Benvolio came in and broke up the fight. After Benvolio broke up the fight, Tybalt entered and started to fight with Benvolio. Soon later, an Officer entered the room with three or four citizens all armed with clubs, bills, and partisans, or spears. Lord Capulet and Montague with their Ladies entered the room and started to quarrel aswell, but the Prince set them straight.†¦show more content†¦Romeo soon rushes off, and then the Nurse pushed Peter to see if she still has authority over him. nbsp;nbsp;nbsp;nbsp;nbsp;Juliet starts to think why the Nurse hasnt showed up after she sent her to meet Romeo. It had been three long hours before she returned with Peter, but she soon sent Peter back to the gate. The Nurses bones are so weary from her long journey, and she was out of breath, but Juliet needed to know what she and Romeo talked of. The Nurse finally told Juliet the plans for her and Romeos marriage. Act III: nbsp;nbsp;nbsp;nbsp;nbsp;This is the third of five entries to this journal. nbsp;nbsp;nbsp;nbsp;nbsp;Benvolio, Mercutio and some men walk up to a public place talking about the weather. A second later, Tybalt and others come to the public place and begin to quarrel a bit with Mercutio and Benvolio. Another second or two later, Romeo enters the public place. Tybalt calls Romeo a boor, a clumsy stupid fellow and Mercutio draws his sword and calls Tybalt a ratcatcher. Tybalt draws, they begin to fight! Romeo standing aside yells for Benvolio to beat down their weapons, and then says for them to stop, not to have this outrage in the public streets of Verona. 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