Cast modification for immediate complete

dentures: Traditional and contemporary

considerations with an introduction of
spatial modeling
Rodney D. Phoenix, DDS, MS,a and Jeffrey D. Fleigel, DMD, MSb
Lackland Air Force Base, Tex; and The United States Air Force
Academy, Colorado Springs, Colo
Cast modification for immediate permit uninterrupted function. Such making an accurate polysulfide im-
complete denture applications has prostheses also protect surgical sites pression and generating a cast (Fig. 1,
been based largely upon the recom- and serve as templates for healing. A).1 He placed a series of pencil lines
mendations of a few authors. While Authors have described various on the cast to guide proposed cast
helpful, these recommendations are aspects of immediate denture service, modifications. For each remaining
primarily subjective. This article re- ranging from diagnosis and treatment tooth, Standard outlined the gingival
views 2 long-standing methods for planning to postplacement care.8-15 margins on the facial and lingual sur-
cast modification and, subsequently, Impression procedures have been faces of the cast. In turn, he scribed
introduces the concept of spatial described.16-18 Fabrication of tooth- a second pencil line on the facial sur-
modeling. Spatial modeling involves placement indices and surgical guides face of the cast. This line was 2 mm
the application of anatomic norms have been presented.12,13,19,20 Multiple apical to the line identifying the facial
to gain an improved understanding flange designs have been proposed gingival margin. Standard placed a
of oral tissues and their dimensional and evaluated.13-15 Methods of cast third pencil line on the facial surface
relationships. A cast modification modification have been proposed, of each cast to indicate the beginning
process based upon spatial modeling yet a clear anatomic rationale for cast of the undercut area.
is described. The foregoing cast modi- modification is noticeably absent. The Cast modification and tooth
fication methods are then compared. remainder of this article deals with the placement occurred in 4 distinct
Indications and contraindications for background, rationale for, and modi- phases. In the first phase, a predeter-
the respective techniques are present- fication of dental casts for immediate mined tooth was removed from the
ed. denture construction. Traditional and cast by cutting to the gingival margins
Despite significant improvements contemporary considerations are ex- with a plaster saw (Fig. 1, B). During
in tooth retention and the advent of plored, with an emphasis upon spa- the second phase, a rotary instrument
predictable implant systems, imme- tial modeling. was used to join the lingual gingival
diate dentures remain an important Perhaps the most well-known margin to the intermediate line on
treatment methodology in contem- methods for cast modification were the facial surface (Fig. 1, C). The third
porary dentistry. These prostheses published by Standard in 1958 and phase involved placement of an artifi-
offer significant advantages in tissue- Jerbi in 1966.1,2 These authors pro- cial tooth in the appropriate position.
borne, tooth-tissue-borne, and im- vided detailed instructions and se- This procedure was followed for al-
plant-tissue-borne applications. Con- quential photographs to present ternating teeth until all artificial teeth
sequently, they are applicable to a their respective methods for cast were in the desired positions. In the
wide range of commonly occurring modification in immediate denture fourth and final phase, the wax base
clinical situations. applications. Their techniques were was removed from the cast, and the
The advantages of immediate den- based upon years of clinical practice stone contours were gently rounded
tures have been accepted for many and observation. Both methods have with a sharp knife. This modification
years.1-13 Immediate dentures elimi- been used successfully, and each has extended from the line identifying the
nate the need for potentially embar- advantages and disadvantages. undercut area to the line identifying
rassing periods of edentulism and Standard began the process by the lingual gingival margin (Fig. 1, D).

The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Defense or
other Departments of the United States Government.

a
Director, Prosthodontics Resident Education, United States Air Force Graduate Prosthodontics Residency Program.
b
Chief of Prosthodontics, United States Air Force Academy.
(J Prosthet Dent 2008;100:399-405)
Phoenix and Fleigel
400 Volume 100 Issue 5

A B C

D E F
1 Cast modification technique proposed by Standard. A, Cross-sectional view of cast in posterior region. B,
Coronal segment is removed using saw or laboratory engine. C, Subsequent cut joins lingual gingival margin
to intermediate line on facial surface of cast. Intermediate line is parallel and 2 mm apical to facial gingival
margin. D, Stone contours are gently rounded at facial and lingual surfaces. On facial surface, rounding ex-
tends to soft tissue height of contour. E, Resultant reduction is shown. Dotted line indicates premodification
contours. F, Cross-sectional view of tooth placement and denture base contours proposed by Standard.

The completed cast modification was The second phase of cast modifica- of soft tissues into an extraction site
intended to provide space for place- tion involved the creation of a 1-mm (Fig. 2, F). The sixth and final phase of
ment of an artificial tooth, while elim- recess in the area occupied by the root cast modification was to smooth the
inating the need for aggressive alveo- (Fig. 2, C). During the third phase of surfaces of the cast that were modi-
loplasty (Fig. 1, E and F). the procedure, Jerbi made a relatively fied during the foregoing procedures
Jerbi also recognized the need for vertical cut extending from the facial (Fig. 2, G). Again, cast modification
an accurate impression and a suitable extent of the prepared socket to the was intended to provide space for
dental cast (Fig. 2, A).2 Upon gen- line denoting the junction of the cer- placement of a prosthetic tooth, while
erating the desired dental cast, Jerbi vical and middle thirds of the facial eliminating the need for aggressive al-
placed a series of pencil lines to guide surface (Fig. 2, D). To facilitate the veoloplasty (Fig. 2, H and I).
cast modification. The first of these fourth phase of cast modification, an Both Standard and Jerbi based
lines denoted the level of the gingival additional pencil line was added. This their respective cast modification
margin for each tooth. Subsequent line followed the crest of the ridge, bi- procedures upon clinical observa-
lines were scribed on the facial surface secting the prepared sockets faciolin- tions, and each technique yielded rea-
of the cast, dividing it into cervical, gually. The accompanying cut extend- sonable success. Difficulties generally
middle, and apical thirds. ed from the crestal line to the midway occurred as a result of overzealous
The first phase of Jerbi’s cast point of the modification described reduction at the facial, lingual, and
modification procedure required the in phase 3 (Fig. 2, E). The fifth phase interproximal aspects of the associ-
elimination of a selected stone tooth required modification of the lingual ated dental casts. Denture bases fab-
by cutting away those portions of a contours. This was accomplished by ricated on such casts would “bind”
tooth which projected incisal/occlus- extending the floor of the prepared in these areas during placement (Fig.
al to the gingival margins (Fig. 2, B). socket lingually to mimic the collapse 3). This prevented complete seating
The Journal of Prosthetic Dentistry Phoenix and Fleigel
November 2008 401

A B C

D E F

G H I
2 Cast modification technique proposed by Jerbi. A, Cross-sectional view of cast in posterior region. B, Cor-
onal segment is removed using saw or laboratory engine. C, One-mm-deep recess is created in area occupied
by root. D, Vertical cut extending from facial extent of prepared socket to line denoting junction of cervical
and middle thirds of facial surface. E, Cut extending from faciolingual center of socket to midway point of
cut described in Figure 2, D. F, Floor of prepared socket is extended lingually. G, Stone contours are gently
rounded at facial and lingual surfaces. H, Resultant reduction is shown. Dotted line indicates premodifica-
tion contours. I, Cross-sectional view of tooth placement and denture base contours proposed by Jerbi.

of denture bases, and necessitated ent templates duplicated the intaglio touring at the time of tooth removal.
adjustment of the denture bases, the contours of the associated denture This allowed improved seating of the
supporting hard and soft tissues, or bases and permitted rapid visual as- associated immediate denture and
both. sessment of denture base adaptation. minimized damage to the soft tissues.
To address the difficulties associat- Areas of binding were clearly identi- Unfortunately, modifications were
ed with binding, subsequent authors fied by blanching of the underlying performed at the expense of valuable
recommended the use of surgical soft tissues. Clinicians used this in- osseous tissues.
guides.6,12,13,19,20 These rigid, transpar- formation to guide osseous recon- The purpose of this article is to
Phoenix and Fleigel
402 Volume 100 Issue 5
introduce the concept of spatial
modeling for immediate denture ap-
plications. Extension of the spatial
modeling concept permits develop-
ment of an objective method for cast
modification. The resultant technique
is intended to minimize prosthesis-
induced soft tissue injury, decrease
the need for osseous recontouring,
and promote clinical efficiency. The
current cast modification procedure 3 Binding at time of prosthesis insertion occurs most commonly at facial
is based upon a clinical model derived and interproximal surfaces. Binding at lingual aspect occurs less often.
from values presented in the dental
literature. It is intended as a guideline
for cast modification in immediate
denture applications. The technique
may be altered as dictated by clinical
conditions.
The model is based upon a cross-
sectional view in the maxillary or
mandibular posterior region (Fig.
4). Osseous support is provided by
a relatively thin facial plate, and a A B
more substantial lingual buttress. 4 Spatial modeling was accomplished using values from dental lit-
Facial and lingual sulcus depths of erature. A, Representative values of 1.5 mm and 2.0 mm are used for
approximately 1.5 mm are included, facial sulcus and biologic width, respectively. B, Thicknesses for free
based upon information provided by and attached gingivae are 1.56 mm and 1.25 mm.
Vacek et al21 and Smith et al.22 Mean
biologic widths of approximately 2 this transverse section of the cast to the first line at the mesiolingual line
mm are included, based upon the re- facilitate discussion (Fig. 5, A). The angle, arc to a point 2 mm facial to the
sults of investigations by Gargiulo et resultant model serves as the basis for midlingual surface, and continue to
al23 and Vacek et al.21 Representative cast modification. the distolingual line angle. Draw the
soft tissue coverage is based upon the second line of the lingual/palatal sur-
findings of Goaslind et al24 and Eger TECHNIQUE face of the cast, parallel to and 2 mm
et al.25 Therefore, the thicknesses for from the gingival margin (Fig. 5, E).
free and attached gingivae within this 1. Remove a chosen crown from 5. Use a sharp blade or rotary in-
model are 1.56 mm and 1.25 mm, re- the dental cast using a laboratory en- strument to connect the lines placed
spectively. gine and a suitable bur. Connect the during the preceding step (Fig. 5, F).
The minimal sulcus depths and facial and lingual gingival margins in a 6. Eliminate distinct angles and
negligible bone loss within this sce- linear fashion (Fig. 5, B). lines by scraping the modified surfac-
nario represent challenging condi- 2. Using a pencil, draw 2 lines to es with a bladed instrument. Gently
tions for immediate denture fabri- guide facial reduction of the cast. round the associated crestal contours
cation. Occlusal positioning of the Place the origin of the first line at the (Fig. 5, G).
osseous architecture minimizes soft mesiofacial line angle, arc to a point 7. Examine the cast to ensure that
tissue collapse, which occurs im- 2 mm lingual to the midfacial surface, modifications mimic the projected col-
mediately following tooth removal. and continue to the distofacial line an- lapse of soft tissues (Fig. 5, H). Avoid
Minimal soft tissue thickness provides gle. Draw the second line on the facial aggressive recontouring of the cast,
little opportunity for soft tissue com- surface of the cast, parallel to and 4 since this may prevent complete seat-
pression. As a result, these conditions mm from the gingival margin (Fig. 5, ing of the resultant prosthesis.
necessitate conservative, yet accu- C). 8. Place an artificial tooth in the
rate, cast modification. A dental cast 3. Use a sharp blade or rotary in- desired position (Fig. 5, I and J). Du-
which corresponds to the preceding strument to connect the lines drawn plicate desirable tooth positions to
spatial model is provided for purpos- during the preceding step (Fig. 5, D). maintain the patient’s preextraction
es of illustration. Facial and lingual 4. Draw 2 lines to guide lingual re- appearance and minimize phonetic
bone levels are superimposed upon duction of the cast. Place the origin of impact.
The Journal of Prosthetic Dentistry Phoenix and Fleigel
November 2008 403

A B C D

E F G H

I J K L
5 Cast modification based upon spatial modeling. A, Bone levels superimposed upon cross-section of a representa-
tive posterior segment. B, Coronal segment is removed using saw or laboratory engine. C, Two lines are placed on sur-
face of cast. One line arcs from mesiofacial line angle to distofacial line angle, and is located 2 mm lingual to midfacial
surface. Second line is parallel to and 4 mm from gingival margin. D, Sharp blade or laboratory engine is used to con-
nect lines drawn in Figure 5, C. E, Two lines also guide lingual reduction. One line arcs from mesiolingual line angle
to distolingual line angle, and is located 2 mm facial to midlingual surface. Second line is parallel to and 2 mm from
gingival margin. F, Sharp blade is used to connect lines drawn in Figure 5, E. G, Sharp angles and lines are eliminated,
thereby creating gently rounded faciolingual contour. H, Foregoing cast modifications permit natural collapse of soft
tissues into extraction site to minimize likelihood of binding or tissue compression during placement of prosthesis. I,
Resultant reduction shown. Broken line indicates premodification contours. J, Cross-sectional view of tooth place-
ment and denture base contours as determined by spatial modeling. K, Mesiodistal cross-section of cast with osseous
contours superimposed. Papillae are shortened and rounded to simulate collapse that occurs following extraction
of adjacent teeth. Broken line indicates premodification contours. L, Papillae may collapse due to their relationships
with underlying interradicular bone. Papillae also may “roll” as depicted in Figure 5, H.

9. Repeat steps 1 through 8 until DISCUSSION Aggressive trimming of the cast’s

all artificial teeth have been properly facial surface may result in binding or
positioned. A comparison of the Standard, Jer- soft tissue compression upon initial
10. Complete the associated wax- bi, and proposed cast modifications placement of the resultant prosthesis.
ing, contouring, investment, and wax is presented in Figure 6. Examina- As previously noted, this may neces-
elimination procedures. tion indicates the 3 methods of cast sitate osseous recontouring, relief of
11. Upon completion of the modification are similar at the lingual the denture intaglio, or both. Insuf-
wax elimination process, round and surface, but different as they project ficient adjustment commonly results
smooth areas representing the inter- facially. The differences have signifi- in incomplete seating of the denture
dental papillae (Fig. 5, K and L) using cant clinical ramifications which are base and an uncontrolled change in
400-grit silicon carbide paper. worthy of consideration. the occlusion. Subsequent mastica-
Phoenix and Fleigel
404 Volume 100 Issue 5
the immediate denture fabrication
process. Modeling was based upon
accepted norms from the dental liter-
ature. The model supported develop-
ment of a predictive cast modification
technique intended to minimize the
binding of denture bases, decrease
the necessity for osseous recontour-
ing, and enhance clinical efficiency.

REFERENCES
6 Comparison of cast modification methods dictated by Standard,
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Jerbi, and by spatial modeling. mediate dentures. J Prosthet Dent 1958;
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are an indispensable component compression, and generally will result complete dentures. Dent Clin North Am
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Immediate complete dentures. Dent Clin
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Dent 1968;19:237-45.
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for immediate dentures. J Prosthet Dent Dimensions and relations of the dentog- Dr Rodney D. Phoenix
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Noteworthy Abstracts of the Current Literature

The firing procedure influences properties of a zirconia core ceramic

Oilo M, Gjerdet NR, Tvinnereim HM.

Dent Mater 2008;24:471-5.

Objectives: High-strength ceramics for dental restoration are used as an understructure (core) that subsequently is
covered by veneering ceramic. The veneering process involves a firing procedure at high temperatures at least once,
usually two to five times. The aim of this study was to investigate whether these firing procedures affect the mechani-
cal properties of a zirconia ceramic.

Methods: Thirty-three specimens of an industrially sintered yttria-stabilized zirconia ceramic (DC Zircon, DCS Den-
tal AG, Allschwil, Switzerland) were cut into bars (1.2 mm x 4 mm x 20 mm). One set of specimens (n=13) remained
untreated (controls). Another set of specimens (n=10) was heat-treated once, corresponding to the first step of the
veneering process. The third set of specimens (n=10) was heat-treated five times to mimic the full veneering process.
Flexural strength, microhardness, dimensions and surface roughness were measured. The fracture patterns were as-
sessed by light microscopy.

Results: The untreated specimens showed a statistically significant higher flexural strength (20%) and microhardness
(9%) than both of the test groups (p≤0.001). No significant differences were found for fracture patterns, dimensions
or surface roughness.

Significance: The heat treatment associated with the veneering procedure on a zirconia core material reduced the flex-
ural strength of the core after the first firing. Subsequent firings were not detrimental to the properties measured.

Reprinted with permission of the Academy of Dental Materials.

Phoenix and Fleigel