DENTAL ABSTRACT ZN

The Altered Cast Impression Technique:

Anatomic and Functional Considerations
K. David Stillwell, DDS, MAGD
UNIVERSITY OF FLORIDA COLLEGE OF DENTISTRY
TEAMS CLINICAL CARE PROGRAM

This is part three in a series of three clinical articles on

removable prosthodontics. Please see part one in June 2009
Today’s FDA (Vol. 21, No.6) and part two July 2009 Today’s FDA
(Vol. 21, No. 7).

Overview
)NTHETOOTH SUPPORTEDREMOVABLEPROSTHESISOCCLUSAL
stresses (functional and para-functional) are transmitted to
THEBONEPHYSIOLOGICALLYBYWAYOFTHEPERIODONTALLIGAMENT
Fig. 1
"ECAUSEALLEDENTULOUSSPACESAREBOUNDEDBYNATURALTEETH
THISPROSTHESISFUNCTIONSINAMANNERSIMILARTOAlXED
PARTIALDENTURE)NCONTRASTTHEtooth-tissue supported remov-
ABLEPARTIALDENTURE20$ MUSTDEPENDONTWOCOMPLETELY
DIFFERENTTYPESOFSUPPORTnTHERELATIVELYIMMOBILETEETH
ANDTHEDISPLACEABLETISSUESOFTHEEDENTULOUSRIDGE)THAS
been reported that tissue resiliency is four to 20 times the
AXIALDISPLACEABILITYOFABUTMENTTOOTHWITHTHEMUCO PE-
RIOSTEUMEXHIBITINGEIGHTTIMESTHETHICKNESSOFPERIODONTAL
ligament. These differences in the support mechanics of the
DISTALEXTENSIONBASECREATESTHEPOTENTIALFORTHEPROSTHE-
sis to rotate around a fulcrum line established through the
MOSTTERMINALRESTSSEATSOFTHE20$FRAMEWORKASSEMBLY
5NCONTROLLEDROTATIONSAROUNDAFULCRUMLINEAREKNOWNTO
be highly detrimental to the RPD abutment teeth through
OFF AXISORNON VERTICALLOADINGFORCES-EASURESMUSTBE Fig. 2
taken in the design and fabrication of a tooth-tissue support-
ED20$TOABSOLUTELYMINIMIZETISSUE WARDMOVEMENTOF
THEPROSTHETICDISTALEXTENSIONBASEUNDERFUNCTIONALLOADING
1-10
. This can be accomplished by selective tissue placement
IEWITHINPHYSIOLOGICLIMITS UTILIZINGACCURATEPERIPHERAL
EXTENSIONSANDBYVARYINGTHEDEGREEOFSOFT TISSUEPRESSURE
applied to the primary supporting areas.
4HEFOLLOWINGTECHNIQUEWILLDESCRIBEASECONDARYIM-
PRESSIONMETHODWHICHUTILIZESTHEMETAL20$FRAMEWORKTO
hold custom impression trays to:
a) record the edentulous areas in a functionally placed
POSITIONSOASTOHELPTHE20$RESISTTISSUE WARD
movement around the primary fulcrum line.
b) obtain proper soft tissue support to aid abutments in
resisting functional stresses.
Please see ABSTRACT, 20 Fig. 3

August 2009 TFDA 19

ZNDENTAL ABSTRACT

ABSTRACT from 19 IMPRESSIONOFTHESOFTTISSUEWOULDBEMADEWITHANOTHER

material that could record the tissues in a functioning form.
!NALTERNATIVESANDWICHTECHNIQUE&") WASPRESENTEDIN
The Problem part one of this series11.
The identified primary problem is to achieve success-
The ideal impression must:
FUL20$FUNCTIONBYEQUILIBRATINGTHISFUNCTIONALRESILIENCY
1) record the hard and soft tissues using similar displace-
DIFFERENTIALSOTHE20$WILLGENERATEANDDISSIPATEFORCES
ment forces.
EQUITABLYBETWEENANDPROTECTBOTHTOOTHANDTISSUEFROM
2) record the maximum amount of surface area of the
eventual destruction. This problem is less severe in the
edentulous ridge.
MAXILLARYARCHBECAUSETHERESIDUALRIDGESARETYPICALLYLARGE
3) record clearly the denture base’s peripheral border.
and broad, providing a greater area of potential denture
The broader the coverage of the edentulous ridge by the
base coverage and thus a greater degree of tissue support.
DENTUREBASETHEGREATERWILLBETHEDISTRIBUTIONOFTHELOAD
)NADDITIONTHEMAXILLARYHARDPALATEAFFORDSANADDITIONAL
occurring against it per unit area. All available space should
area of primary support that does not undergo resorption. A
BEUSEDWITHOUTENCROACHINGONMOVABLETISSUESASOVER
mandibular RPD poses different problems due to anatomical
EXTENSIONOFTHEDENTUREBASEWILLOFTENRESULTIN
deficiencies of primary support areas found in the smaller
a) soft tissue irritation or ulceration.
LOWERARCH4EETHANDTHEIRPERIODONTIUMRESPONDPOORLY
B TORQUINGOFTHECLASPEDABUTMENTTEETHWITHPOSSIBLE
TOLATERALANDTORQUINGTYPESOFOCCLUSALSTRESSESRESULTING
pathologic movement of the teeth.
from the movement of the denture base on its underlying
displaced mucosa. When soft tissues, teeth and the residual
ridge are stressed beyond their physiologic tolerance, mu-
The Altered Cast Impression Technique
cosal ulceration, tooth mobility and increased bone resorp- (Selective Pressure)
tion results. A selective pressure impression method is often seen to
be indicated for many tooth-tissue supported RPD situa-
TIONSWHERETHERIDGEMUSTPROVIDESOMESUPPORT)NTHE
The Solution
MAXILLARYARCHTHEDISTALEXTENSIONRIDGEISUSUALLYCOVERED
#ERTAINORALMUCO OSSEOUSSITESAREKNOWNTOACCEPT
BYAlRMDENSEWELL ATTACHEDMUCOSAORIFTHEMUCOSA
FUNCTIONALLOADSMOREREADILYTHANOTHERSITESnTHESEARE
is mobile, it is typically amenable to routine surgical cor-
KNOWNASPRIMARYSTRESSBEARINGAREAS2EQUIREMENTSFORA
RECTION!SPECIALIZEDIMPRESSIONHASNOTBEENSHOWNTO
primary stress bearing area include:
IMPROVEMAXILLARYSTRESSDISTRIBUTION(OWEVERTHEBORDER
a) dense cortical bone.
definitions and palatal vault should receive added attention
b) located perpendicular to the vertical forces
during final impressions and this is best developed using a
of occlusion.
specialized custom impression tray or by customization of a
C COVEREDWITHMUCOSATHATISlRMDENSEANDIS
STOCKIMPRESSIONTRAY"YCOMPARISONTHEMANDIBULARDISTAL
capable of resisting occlusal forces.
EXTENSIONRIDGEONLYHASALIMITEDAREATHATCANBEUSEDASA
Accepted locations of primary stress bearing areas are
STRESS BEARINGSITE)NADDITIONOBTAININGTHEPROPERperiph-
THEMAXILLARYCRESTOFTHERESIDUALRIDGEANDTHEHARDPALATE
eral extension for the denture base in the mandibular arch is
ANDTHEMANDIBULARBUCCALSHELFAREA)FTHECRESTALMUCOSA
MUCHMORECOMPLICATEDTHANINTHEMAXILLARYARCHBECAUSE
is not firm and dense, it should be surgically corrected to
of the movable tissues in the floor of the mouth. Here,
properly support a denture base. The slopes of both buccal
selective pressure impression methods can be employed to
ANDLINGUALMAXILLARYANDMANDIBULARRESIDUALRIDGESALSO
EQUALIZETHESUPPORTBETWEENTHEABUTMENTTEETHANDTHE
EXHIBITCORTICALBONECOVERAGETHESESITESAREKNOWNAS
SOFTTISSUEWHILEALSODIRECTINGTHEFORCESTOTHOSEPORTIONS
secondary stress bearing areas and contribute to resisting
OFTHERIDGETHATAREMOSTCAPABLEOFWITHSTANDINGTHEFORCE
HORIZONTALFORCESTHEREBYALLOWINGAREDUCTIONINTOTALFORCES
This is accomplished by providing relief in the impression
applied.
tray in selected areas and permitting the impression tray to
!SPECIALIMPRESSIONTECHNIQUEISNEEDEDTOEQUALIZEAS
CONTACTTHERESIDUALRIDGEINOTHERAREAS4HEAREAWHERERE-
much as possible, the support derived from the primary and
LIEFISPROVIDEDnTYPICALLYTHECRESTOFTHEMANDIBULARRIDGE
secondary support areas of the edentulous ridge and that
nWILLBETHELEASTDISPLACEDASTHEIMPRESSIONISRECORDED
RECEIVEDFROMTHEABUTMENTTEETH)DEALLYANIMPRESSIONOF
)NTHOSEAREASOFTHETRAYWHERERELIEFWASNOTPROVIDEDTHE
THETEETHWOULDBEMADEWITHONEMATERIALTHATCAPTURES
buccal shelf of the mandibular ridge and the crest of the
the teeth in an anatomic form, because normally the teeth
MAXILLARYRIDGE GREATERDISPLACEMENTOFTHEUNDERLYINGMU-
do not change position significantly under function. Then an

20 TFDA August 2009

 DENTAL ABSTRACT ZN

COSAWILLOCCUR!NIMPRESSIONOFTHEDISPLACEDEDENTULOUS base made from this impression should be closely adapted

tissues can be made by using a customized impression tray11 TOANDINlRMCONTACTWITHTHETISSUECOVERINGTHEBUCCAL
or by employing the more DIFlCULTTECHNIQUEOFaltering the shelf area of the mandibular edentulous ridge. On the other
master cast by attachment of an impression tray to the RPD hand, the ridge crest area of the final denture base is lightly
FRAMEWORK4HISLATTERTECHNIQUEISOFTENREFERREDTOASTHE ADAPTEDTOTHETISSUEANDTHEEFFECTSOFOCCLUSALLOADINGWILL
“Altered Cast ImpressionvORh#ORRECTED#AST)MPRESSIONv be less in this area. Rubber base materials (or lighter-bodied
TECHNIQUE 603VISCOSITIES AREEXCELLENTFORRECORDINGTHESELECTIVEPRES-
4OPROCEEDWITHTHEaltered cast impression technique, sure impression. Defects in a selective pressure impression
an acrylic resin (or Triad®) segmental impression tray is SHOULDNOTBECORRECTEDBYTHEADDITIONOFASECONDMIX
ADDEDTOTHERETENTIONLATTICEWORKOF the removable par- The entire impression must be stripped out from the tray
TIALDENTUREFRAMEWORK4HEINTERNALSURFACEOFTHETRAYIS and remade. Adhesive should be used to ensure the material
selectively relieved so as to avoid any tray contact in the ADHERESWELLTOTHETRAY4HEMOUTHSHOULDALWAYSBEDRIED
NON SUPPORTEDENTULOUSRIDGEAREAS)TSHOULDRESEMBLEIN WITHGAUZEATTHETIMEOFTHEIMPRESSION4HEMIXEDMATE-
OUTLINETHEAPPROXIMATEAREATOBECOVEREDBYTHElNISHED rial is painted evenly over the tissue surface of the tray and
DENTUREBASE4HEMANDIBULARIMPRESSIONTRAYEXTENSIONS peripheries. Overloading the tray complicates the impres-
SHOULDCOVERTHERETROMOLARPADSANDEXTENDFULLYACROSS SIONTECHNIQUE4HETRAYISSEATEDANDTHEBUCCALLINGUAL
THEBUCCALSHELF4HEFRAMEWORKTRAYASSEMBLYISTAKENINTO and tongue tissues are cleared from under the tray. The
THEMOUTHANDTHEATTACHEDIMPRESSIONBASESAREADJUSTED impression is functionally border molded. During this stage,
SOTHATTHEYAREAPPROXIMATELYMMSHORTOFTHEIRESTI- it is critical for the dentist to visually determine that all the
mated functional length. Clearance should be provided for RESTSANDINDIRECTRETAINERSARECOMPLETELYSEATEDWHILE
any muscle attachments or frenula if impingement is noted the impression material is fluid. The material must not be
at the tray borders by trimming the acrylic resin to accom- ALLOWEDTOmOWONTOTHEINNERSURFACESOFTHEMINORCONNEC-
modate them. Softened modeling plastic (stick compound) tors or under the occlusal rests. Pressure should be applied
is applied to the borders of the impression base one section only to the occlusal rests until the material has set. Care
at a time, and the border tissues are gently manipulated to must be taken to avoid the application of uneven or heavy
CREATEAROUNDEDCONTOURTHATEXTENDSTOTHEmEXURELINEAT DOWNWARDPRESSUREONTHEDISTALASPECTSOFTHEIMPRES-
THEMUCO BUCCALFOLD4HEOBJECTIVEISTOCREATEADENTURE SIONTRAY4HISCOULDCAUSETHEPARTIALDENTUREFRAMEWORKTO
BORDERAROUNDWHICHTHERESILIENTMOVABLETISSUESCANFUNC- rotate around the occlusal rests, lifting the indirect retain-
TIONWITHOUTDISCOMFORTTOTHEPATIENTORWITHOUTEXERTING ERSFROMTHEIRRESTSWHICHWILLPRODUCEINACCURACIESASTHE
a dislodging force against the denture. Further, the primary impression is border molded and sets.
STRESS BEARINGTISSUESWILLBEGENTLYDISPLACEDUPONMAKING
the impression. This “functional tissue placement” impres- Finishing the Case after Altered
sion is then related back to the original anatomic cast and Master Cast Procedures
poured. /NCETHEALTEREDCASTIMPRESSIONOFTHEDISTALEXTENSION
Prior to making the mandibular altered cast impression, AREASHASBEENPROPERLYGENERATEDTHEFRAMEWORKCANNOT
the under surface of the tray over the ridge crest is relieved be returned to the original master cast. A secondary, or
DOWNTOTHEMETALRETENTIONSTRUTSWITHANACRYLICBUR3LIGHT “altered master” cast, must be produced that properly relates
tissue contact should be present on the buccal shelf only THESELECTIVEPRESSUREAREASOFTHEDISTALEXTENSIONIMPRES-
and is provided by the compound modeling plastic dur- SIONBASESTOTHEORIGINALORIENTATIONOFTHE20$FRAMEWORK
ing the preliminary border molding stages. To help prevent seated against the rest seats and indirect retainers. Often,
undesired tissue displacement, relief holes can be provided it is most efficient to employ an alginate (or VPS) full arch
in the impression trays over the ridge crest areas using a No. OVER IMPRESSIONWITHTHEFRAMEWORKDISTALEXTENSIONTRAYAS-
ROUNDBUR4HISHELPSTOVENTEXCESSPRESSUREANDPREVENTS SEMBLYPROPERLYSEATEDWITHINTHEORALCAVITY4HISOVER IM-
air from being trapped inside the tray. As the impression pression must be highly detailed and accurate in all dentate
is made, the material over the crest of the ridge that is not areas represented in the patient, particularly in the sites of
CLOSELYCONlNEDWILLEXERTMINIMALTISSUE WARDFORCEAND THERESTSEATSANDTHEOCCLUSALTABLE4HESEDETAILSWILLALLOW
MINIMALTISSUEDISPLACEMENTWILLRESULT4HEIMPRESSION FORTHEREPRODUCTIONOFALLHARDANDSOFTTISSUEDETAILWHEN
MATERIALOVERTHEBUCCALSHELFBEINGCLOSELYCONlNEDWILL POUREDANDRESULTSINTHEPRODUCTIONOFACOMPLETELYNEW
EXERTSOMEWHATGREATERTISSUE WARDFORCEANDASLIGHTLY “altered” master cast.
GREATERAMOUNTOFTISSUEDISPLACEMENTWILLOCCUR4HEEND
result of this selected pressure impression is that the denture Please see ABSTRACT, 23

August 2009 TFDA 21

22 TFDA August 2009
 DENTAL ABSTRACT ZN

ABSTRACT from 21 When obtaining final intra-oral vertical and centric rela-
tionships, the operator must be certain that:
Another traditional procedure for obtaining the altered a) the opposing teeth do not penetrate to the record base
master cast is often described in prosthodontic literature. at any point
This procedure involves taking the initial master cast and B THATTHEWAXRIMSARETRIMMEDPROPERLYANDARESOFT
REMOVINGTHEORIGINALDISTALEXTENSIONAREASFROMTHECAST enough during the recording of the inter-occlusal record
BYCAREFULLYEXECUTINGSAWCUTSTHROUGHTHECASTSBASE4HE TOPREVENTEXCESSIVEPRESSUREONTHEMUCOSA
FRAMEWORKDISTALEXTENSIONIMPRESSIONTRAYASSEMBLYISTHEN Even though the natural teeth may appear to be oc-
reoriented onto the residual dentate portion of the master cluding properly during registration of centric occlusion,
cast, guided by the rest seats and indirect retainers. The EXCESSIVECLOSINGPRESSUREEXERTEDAGAINSTPOORLYADAPTEDOR
FRAMEWORKIMPRESSIONASSEMBLYISCAREFULLYLUTEDINTOPOSI- EXCESSIVELYHARDOCCLUSIONRIMSDURINGTHEBITEREGISTRATION
TIONONTHEORIGINALCASTWITHSTICKYWAX4HEENTIREMASTER WILLCAUSEDISPLACEMENTOFTHESOFTTISSUESONTHERESIDUAL
CASTFRAMEWORKIMPRESSIONASSEMBLYISTHENBOXEDUPAND ridge. This displacement cannot be compensated for on
CAREFULLYSEALEDINTHEAREAADJACENTTOTHEFRAMEWORKlNISH the stone casts. Therefore, an increased vertical dimension
LINES4HEBOXEDASSEMBLYISRE
POUREDINORDERTOPRODUCE OFOCCLUSIONWILLRESULTWHENTHECASTSAREMOUNTEDONTHE
an “altered master cast” reflecting proper orientation of the ARTICULATOR4HISWILLNECESSITATECONSIDERABLECLINICALADJUST-
FRAMEWORKTOTHERESTSEATSWHILEPROVIDINGDISTALEXTENSION MENTOFTHEOCCLUSIONDURINGTHEDELIVERYAPPOINTMENT)N
edentulous zones recorded in a functionally loaded state. ORDERTOAVOIDTHISUNCERTAINTYITISALWAYSWISETOAPPOINT
Once the altered master cast has been poured and re- THEPATIENTFORAlNALWAXTRY
ININORDERTOOBTAINCENTRIC
covered it should be properly trimmed, in order to preserve verification check bites so as to verify the occlusal relation-
ALLVERTICALANDHORIZONTALLANDAREAS)MPORTANTANATOMIC ships on the articulator prior to final processing.
landmarks should be re-identified and transferred onto
THEALTEREDMASTERCAST0REPARATIONSSHOULDNOWBEMADE References
to return the patient to the clinic in order to register the -C'IVNEY'LEN0#ARR!LAN"McCracken’s Removable Partial Prostho-
DONTICSED3T,OUIS%LSEVIER-OSBY

MAXILLO
MANDIBULARRELATIONSHIPS7HENRECORDINGINTER
(INDELS'EORGE7,OAD$ISTRIBUTIONIN%XTENSION3ADDLE0ARTIAL$EN-
OCCLUSALRELATIONSHIPSFORDISTALEXTENSIONREMOVABLEPARTIAL tures. *0ROSTHET$ENT 

denture cases, if the casts can be oriented in unmistakable (INDELS'EORGE73TRESS!NALYSISIN$ISTAL%XTENSION0ARTIAL$ENTURES*
0ROSTHET$ENT 

centric occlusion by means of the remaining teeth, vertical ,EUPOLD2*!#OMPARATIVE3TUDYOF)MPRESSION0ROCEDURESFOR$ISTAL
PENCILMARKShWITNESSMARKSv SHOULDBESCRIBEDACROSSTHE %XTENSION2EMOVABLE0ARTIAL$ENTURES*0ROSTHET$ENT

!PPLEGATE/#!N%VALUATIONOFTHE3UPPORTFORTHE2EMOVABLE0ARTIAL
FACIALSURFACEOFATLEASTTHREEWIDELYSPACEDMAXILLARYTEETH
Denture. J Prosthet Dent. 1960; 10:112-123.
onto the facial surface of their mandibular occluding teeth. (OLMES*")NmUENCEOF)MPRESSION0ROCEDURESAND/CCLUSAL,OADINGON
4HESEVERYTHINPENCILLINESWILLSERVEASAGUIDETOENABLE 0ARTIAL$ENTURE-OVEMENT*0ROSTHET$ENT

!L%L
3HEIKH(AND!BEL
(AKIM!3ECTIONAL)MPRESSIONS!LTERED#AST
the operator to properly orient the casts during mount- FOR-ANDIBULAR$ISTAL%XTENSION2EMOVABLE0ARTIAL$ENTURES*0ROSTHET
INGPROCEDURES)NTHISINSTANCENOINTER
OCCLUSALRECORDS Dent. 1998; 80(2):216-219.
NEEDBEMADE!LLOTHERCASESWILLREQUIREPRODUCTIONOF
CONVENTIONALRECORDBASESANDWAXOCCLUSIONRIMSWITHA
0IECE#AST*0ROSTHET$ENT 

&RANK2ICHARD0"RUDVIK*AMES3.OONAN#AROLYN*EAN#LINICAL
/UTCOMEOFTHE!LTERED#AST)MPRESSION0ROCEDURE#OMPAREDWITH5SEOFA
/NE
SUBSEQUENTCLINICALVISITTOESTABLISHVERTICALDIMENSIONAND -àHLEMANN(24OOTH-OBILITY*0ERIODONT

centric registrations. 10. Togano, Hiroshi, Hideshima, Masayuki, and Ohyama, Takashi. Repro-
DUCIBILITYOF)NTEROCCLUSAL2ECORDINGFOR-ANDIBULAR2EMOVABLE0ARTIAL
)FAMASTERCASTHASBEENCORRECTEDBYTHEALTEREDCAST $ENTUREIN"ILATERAL$ISTAL%XTENSION#ASES*-ED$ENT3CI

IMPRESSIONTECHNIQUENEWTISSUESTOPSMUSTBECREATEDUS- 3TILLWELL+$%SHELMAN%'4HE&UNCTIONAL"ILAMINAR)MPRESSION4ECH-
ing auto-cure acrylic resin or light cured composite prior to NIQUEFORTHE$ISTAL%XTENSION2EMOVABLE0ARTIAL$ENTURE'EN$ENT
-AR
!PR 

proceeding to apply the record bases. After these stops have
BEENLOCKEDONTOTHEFRAMEWORKTHEREMUSTBENOANTERIOR

Dr. Stillwell serves as clinical associate professor in the De-
POSTERIORVERTICALROTATIONOFTHEFRAMEWORKAROUNDTHE
partment of Operative Dentistry, Division of General Dentistry
posterior primary fulcrum line. Without this procedure, the
and is Director, Patient Admissions and Treatment Planning, at
RECORDBASEISLIKELYTOROTATETISSUE
WARDDURINGINTRA
ORAL
the University of Florida (UF). He also serves as a TEAM Leader
RECORDINGSANDORDURINGACRYLICPACKINGOFTHE20$DEN-
in the comprehensive care pre-doctoral student clinic program
TUREBASEDURINGlNALPROCESSING4HERESULTWILLBEAlNAL
at UF. He can be contacted at (352) 273-6944 or kdstillwell@
prosthesis that demonstrates premature posterior occlusal
dental.ufl.edu.
contacts.

August 2009 TFDA 23