Woody Allen as a film Autuer Essay Example | Topics and Well Written Essays - 1000 words

Woody Allen as a film Autuer - Essay Example The term â€Å"auteur† has French origins, and it refers to the theoretical approach to filmmaking, where the director is the central creative force in motion pictures (Menne 36); this concept has persisted over the years, and the term film auteur describing film directors that write and direct films through which they express their personal artistic vision. In as much as there is no clear evidence between â€Å"regular directors† and â€Å"film auteurs†, the distinction between the two does become codified, elucidated, and isolated with time with regards to the art, artist, and the particular categories to which they belong. The film auteur does not only express a cinematic vision, they are prolific in what they do by taking direct roles in relation to the medium and craft of filmmaking; the creative influence of a director on a film must be so profound for them to be considered the film auteur. According to the auteur theory in film criticism, a film reflects i ts director’s personal, creative vision, and the directors stand out as the original auteur; the list of strong distinctive film directors who qualify the title â€Å"film auteur† is very short. This paper will explore the world of Woody Allen, as a distinguished and highly talented film auteur, as seen in the movies Midnight in Paris 1978, Annie Hall 2005, and Manhattan 1979, in which he creates a unique world that no one else could bring to life except himself. Born in Brooklyn, New York in 1935, and raised in a Jewish family that had a strong comedy culture, Woody Allen found his niche in comedy, and later in filmmaking when he first directed What’s Up, Tiger Lily in 1996. Since then, Woody Allen has a library of films to his name including his most acclaimed Annie Hall 1977, Manhattan 1978, and Midnight in Paris, where his one of a kind neurotic, unconfident, and flamboyant cinematic vision emerges. An auteur approach to filmmaking is evident in all his film s particularly because Allen uses themes and styles that make him distinguishable and unique from the pack as a film maverick (Quicke 95); for instance, a dominant theme in most of his films is the struggling artist as in the films Manhattan 1978 and Annie Hall 1977. In all these films, the backgrounds to the protagonists, the cinematography, and lighting elucidates auteur style in filmmaking, distinct and unique, unlike other regular directors. In Manhattan 1978, Allen explores the woes of a struggling television writer who is dating a high school girl but still develops feelings for his best friend’s mistress; Isaac, the main protagonist, is uncomfortable in his job and on top of it all, he cannot establish a solid intimate relationship with a woman his age. Isaac is a very frustrated artist, who feels confined in his current position yet his possibility for success seems obscured by his present situations, thereby further heightening his anxiety and unhappiness; his intern al and external struggles are captured vividly to present a picture of the struggling artist, as is often the case in Allen’s masterpieces. In the film Annie Hall 1977, Allen still explores the theme of the struggling artist through the protagonist Alvy Singer, a Neurotic comedian from New York, who falls in love with a woman named Annie Hall and becomes embattled with relationship issues in Manhattan (Knight 214). Allen brings a part of his own persona into the film by reveling a suffering in Alvy and himself by connection, in finding someone who truly understands him and appreciates his presence. This masterpiece reveals many struggles in Alvy, the whining comic persona; through Alvy’s decision to do an unconventional film that entails him talking straight to the camera concerning his problems, Alvy reenacts his life as a

CASE-CONTROL RESEARCH STUDY Article Example | Topics and Well Written Essays - 500 words

CASE-CONTROL RESEARCH STUDY - Article Example of Interest: The subjects recruited for the case study were exposed to trihalomethane, a by-product produced during the chlorination of water, which is done for the purpose of disinfection. Patients who were histologically confirmed to have primary bladder cancer were recruited as the case population for the study and they were identified with the help of urologic services. The other inclusion criteria’s for the recruitment of the case population were: age group between 20 and 80 years and they must reside within the geographical area surrounding the hospital. The study was a multi-center case-control study conducted in Spain and the subjects were recruited from 18 participating hospitals located at five different geographic regions in and around Spain. The cases were recruited through regular reviews of the discharge and pathology records in hospitals at by the research staffs who were involved in the study. The number of cases who participated in the study was 338 out of the 1,457 eligible cases who were interviewed. However the article does not provide any information about the eligible subjects who were not part of the subjects. The reason for their non-participation has not been mentioned. The control population was chosen from the same hospitals where the case subjects were recruited. The control group included patients who suffered from problems like hernias, orthopedic problems, circulatory disorders, and who were admitted to the hospital. Those who had problems that were related to the study were not chosen as controls. About 582 controls from 1,465 eligible controls were selected. Signed informed consents were obtained from both the case and control participants before onset of the study. During the initial interview demographic information and familial, medical, including smoking history, and occupational history of all the eligible participants were collected using computer assisted software. The short listed case and control population were

3 QUESTIONS IN CRIMINAL JUSTICE and deviance Coursework - 1

3 QUESTIONS IN CRIMINAL JUSTICE and deviance - Coursework Example Ermann and Lundman (1982) also offer some suggestions on how to reduce occurrences of corporate deviance, such as â€Å"changes in corporate chartering, the protection of whistleblowers, and the punishment of executives involved in corporate criminality.† All these propositions must be taken together and combined with greater vigilance from the public. This includes ensuring that corporate wrongdoers know that their actions will not go unpunished. Yes, I think there are common threads apparent in the four articles in the book by Thio, Calhoun and Conyers (2008.) One clear apparent commonality is that it demonstrates that human beings who are victims of violence do not always react to violence in the way that other people might think to be commonsensical. Instead of automatic resisting or abhorrence of the abuser, we see a complex mix of pity, self-blame, guilt, feelings of helplessness, and this is true for mothers who are victims of their children’s violence (Jackson, 98), stalkers from previous relationships (Dunn, 94) and battered wives (Bates, 89). This is also true for victims of exclusion who then found themselves as sexual molesters (Lawson, 108.) Also, these articles demonstrate that motivations for committing crimes are more complicated that we think and have psychological motivations. Akers and Sellers (2004) described psychological theory as one wherein the understanding of crime can be traced back to an und erlying personality or psychological disorder. 3. Are there identifiers visible that would indicate potential self-destructive deviance? If so, what are they and what can be done once observed? If not, what can be done to attempt to identify indicators of future self-destructive behaviour? Yes, the research in the field of self-destructive deviance have shown some possible indicators of suicidal tendencies, although the research is also quick to point out that

Case study - knowledge management strategy Essay - 1

Case study - knowledge management strategy - Essay Example MOTO is a large car manufacturer and has underscored to streamline its operations to be environmentally user friendly. Thus, the objective of this proposal is to put forward the strategies pertaining to the knowledge management at MOTO. The strategies proposed would help the company and its employees to have a participatory approach in ensuring proper generation, processing, storage and disposal of knowledge. The strategy has been carefully formulated in relation to the objectives and the vision of the company. The key role of the proposed plan is to utilize and integrate the raw information from different spheres of the organization to aid its vision and key emphasis is on sustainable environmental management by MOTO. The raw information on environmental strategies from the staff comprising of different nationalities would be collected and scientifically analyzed using the proposed knowledge management system. The proposal also covers the peculiar measures to be taken so that the knowledge is stored and retrieved as per the requirements of the policy to be formulated. The market performance of the company, staff participation, their consensus, cost factor, time factor and the conceptual adherence with the key policies of the company are other key factors which have to be taken into consideration during the implementation process. The company’s responsibility towards the environment and the society is well documented and its mission would help shape the formulation process of the environmental policy. The technologies recommended for knowledge management within the environment of MOTO is thus environmental friendly and community oriented. Latest innovations in the knowledge management systems which uphold these values have been carefully selected. To formulate the strategy for the change process, it is important

Use of Acupuncture for Treatment of Lateral Epicondylitis Essay Example for Free

Use of Acupuncture for Treatment of Lateral Epicondylitis Essay Lateral epiconylitis is a commonly encountered condition resulting from minor injury to the extensor muscles of the forearm, which originate from lateral epicondyle of humerus. This condition is characterized by pain and tenderness over the lateral epicondyle of humerus. Pain is typically present upon the resisted dorsiflexion of the wrist, middle finger or both (Buchbinder, Green Struijs, 2007). Lateral epiconylitis is known by many analogous terms like tennis elbow (TE), rowing elbow, tendonitis of the common extensor origin, peritendonitis of the elbow etc. In the United Kingdom, the incidence of tennis elbow in general practice has been estimated to be about four to seven per 1,000 persons a year (Buchbinder et al). Though TE is a self-resolving condition its symptoms can persist for as long as 18-24 months. Pain of tennis elbow can interfere with normal day to day functioning like carrying objects, lifting and gripping things etc. Though pain of TE can be initially cured with various conservative treatment modalities and rest, it can frequently recur after resumption of activity. Thus TE can cause significant amount of chronic pain and disability, which can lead to considerable morbidity and financial cost (Buchinder et al, 2007). Thus there is a need for an efficient treatment modality for TE. Till date, physicians and physiotherapists are uncertain about the exact etiology and best management option for patients with TE. There are several conventional therapies which are being used for treatment of TE. These therapies are believed to relieve pain, promote tissue healing and improve joint mechanics. These conventional therapies include anti-inflammatory medicines [NSAIDS (non-steroidal anti-inflammatory drugs) and corticosteroids], physiotherapy interventions (such as stretching and strengthening exercises), cast immobilization, ultrasound therapy, using ice packs, neural stretches, deep friction massages, surgery etc (Trinh, Philips, Ho Damsma, 2004). Various non conventional therapeutic modalities like acupuncture, pulsed electromagnetic field therapy, transcutaneous electric nerve stimulation etc have also been used for treatment of TE. In 1992, Labelle et al attempted to perform a quantitative meta-analysis in order to evaluate the therapeutic effectiveness of above mentioned treatment modalities (both conventional and non-conventional) for patients suffering from TE. They considered the results of 18 clinical trials conducted in the period from 1966 to 1990. From their analysis they concluded that the various randomized and controlled trials, which they had analyzed, were of poor quality and did not provide sufficient scientific evidence to support or oppose the therapeutic benefit of any of these conventional or non-conventional treatment modalities. Labelle et al (1992) did find some weak evidence supporting the beneficial effect of ultrasound therapy in comparison to that of placebo therapy in treatment of patients with TE. More recently, a systematic review of the literature, comprising of randomized controlled trials evaluating the effectiveness of various treatment options for TE was carried out by Assendelft, Green, Buchbinder, Struijs, Smidt, (2003). They have suggested significant beneficial effect of NSAIDS (both topical and oral) in comparison to placebo in the providing short term relief from pain in patients with TE. However they found little evidence regarding the beneficial effect of NSAIDS (both topical and oral) in providing long term pain relief. While the use of topical NSAIDS was not found to be associated with significant side effects, use of oral NSAIDS, typically aspirin was associated with significant side effects like gastro-intestinal bleeding etc. This review found limited evidence regarding the beneficial effects of steroid injections in comparison to placebo, local anaesthetic agents, elbow strapping or physiotherapy. Assendelft et al also found insufficient evidence to support long term or short term beneficial effect of treatment modalities like acupuncture, physiotherapy exercises, orthoses (elbow strapping), extra corporeal shock wave therapy and surgery. They have recommended long term use of oral and topical NSAIDS and physical therapies (elbow strapping, physiotherapy, etc and avoidance of provoking activities as the first line of treatment, especially in the early stages of the disease.   They have also suggested the use of corticosteroid injections as second line therapy for providing relief from pain. However the pain relief provided by corticosteroids is usually temporary in nature with the pain recurring again after a few months. Thus they have suggested that the patients receiving such therapy should be counselled about not subjecting the extensor muscles to increased activity during the pain-free period resulting from use of corticosteroid injections. On the other hand, Bisset, Paungmali, Vicenzino, Beller,   Herbert, (2005) from their systematic review of literature, comprising of studies evaluating   the effectiveness of   various physical interventions (non pharmaceutical or   non-surgical therapeutic modalities) for treatment of TE have shown short term benefit   with the use of physical interventions like ultrasound therapy, ionisation, and acupuncture. However no evidence of long term benefit due to these therapeutic modalities was observed in this review; benefit due to these interventions was usually seen to last between two to eight weeks. Bisset et al observed insufficient evidence regarding the beneficial effect of manual therapy (involving manipulation of elbow or cervical spine), use of elbow strapping and physiotherapy exercises in the management of TE. They also observed the presence of sufficient evidence that disapproved the beneficial effect of extracorporeal shockwave therapy and laser therapy in the treatment of TE (both in short term and long term). However they have indicated the requirement of larger studies in future in order to confirm this finding. Since no clinical study till date has been able to demonstrate definite clinical efficacy of any conventional therapeutic modality in treatment of TE, there has been increasing trend towards the use of non-pharmacological treatment modalities, especially acupuncture, since last two decades, for alleviation of chronic pain due to TE. One major advantage of using acupuncture for treating   pain of TE over the conventional anti-inflammatory drugs like NSAIDS (oral or topical), corticosteroids etc is that it is free from the numerous deleterious   side effects commonly associated with the use of these drugs. Also the evidence supporting the use of these conventional pharmacological interventions is no better than that supporting acupuncture [National Institute of Health (NIH), 1998]. Despite the growing popularity of acupuncture in treatment of pain related to lateral epicondylitis, presently, there is little evidence which confirms the efficacy of acupuncture in treatment of tennis elbow. The studies conducted until now have produced conflicting results. Bisset et al (2005), in their systematic review of literature considered four studies evaluating the therapeutic effect of acupuncture in treatment of TE. Three studies out of these four compared acupuncture with placebo whereas one study compared acupuncture with ultrasound. The overall evidence considered in this review supports short term beneficial therapeutic effect of acupuncture over placebo in patients with TE. Two studies, (Fink, Wolkenstein, Karst, Gehrke, 2002; Molsberger Hille, 1994) which compared acupuncture with placebo are described below in details. Fink et al (2002) conducted a study to evaluate the clinical efficacy of acupuncture in   treatment of TE. They also tried to compare the therapeutic effects produced by stimulating selected acupuncture points (as defined by traditional Chinese acupuncture) in contrast to those achieved through stimulation at non-specific points (these puncture points were at least 5 cm away from the traditional Chinese acupuncture points). The results of this study indicated that use of acupuncture with correct location and stimulation, in accordance to the recommendations of tradition Chinese acupuncture helped in significantly alleviating the pain, reducing disability of arms, shoulders and hands (measured through DASH questionnaire) and improving the strength of the extensor muscles in the patients suffering from TE. However these therapeutic effects (pain relief and muscle strength) of acupuncture were less evident in long term. In this study, at the time of follow-up after two months, though the overall functioning of the arm was observed to be better in the treatment group as compared to the control group, the differences in pain intensity and muscle strength were no longer found to be significant. The main aim of the study by Molsberger Hille (1994) was to find out whether acupuncture showed an intrinsic analgesic effect even after only one treatment session in comparison to that of placebo treatment for TE pain. In one single session of acupuncture treatment, patients in the treatment group were treated at a non-segmental distal point on the fibulo-tibial joint of the homolateral leg. The painful area of the elbow itself was not needled. The depth of insertion was 2 cm and during the procedure of needling, the patient was asked to move the painful arm. Patients were treated for a total of 5 min. Overall reduction in the pain score was 55.8% in the treatment group and 15% in the placebo group. After one treatment session, 79.2% (19 patients out of 24) patients in the treatment group reported pain relief of at least 50%, whereas in the placebo group only 25% patients (6 patients out of 24) reported pain relief. The average duration of analgesia after one treatment was 20.2 h in the treatment group whereas that after placebo was 1.4 h. All these results show that acupuncture has a statistically significant intrinsic analgesic effect in the clinical treatment of TE pain, which exceeds that of placebo treatment.   Since this study dealt with short term analgesic effects of acupuncture, further studies need to be carried out in future in order to evaluate the long-term therapeutic value of acupuncture for treatment chronic tennis elbow. Davidson et al (2001, cited in Bisset et al, 2005) conducted a study to compare the   therapeutic effect of acupuncture with that of ultrasound treatment in patients suffering from TE. Though significant improvement in two outcome measures i.e. pain reduction and disability prevention were observed in both the groups, no statistically significant differences in terms of these outcome measures were observed between the two groups. Thus this study indicates that there is no difference in therapeutic benefit between ultrasound and acupuncture in patients with TE. However it is difficult to reach to any definite conclusion from the results of a single study. More studies are required in future in order to arrive at a definite conclusion. In a publication by the NIH in 1998, it was determined that the results of various studies conducted till date has been promising enough to support the use of acupuncture as an adjunct treatment or an alternative to classical conventional therapeutic modalities for patients with TE. Trinh, et al (2004) conducted a systematic review of literature regarding use of acupuncture in treatment of TE, using the best evidence synthesis approach (BESA), which aimed at qualitative analysis of clinically homogeneous studies. The results of this review strongly suggested that acupuncture was an effective therapeutic modality for attaining short-term pain relief in patients with TE. Though there was a great deal of clinical heterogeneity between various studies considered in this review, five studies out of six studies considered in this review indicated that acupuncture treatment was more effective compared to placebo treatment. The studies conducted till date have failed to provide us with definite results. This can   be attributed to a variety of factors like: flaws in study design, heterogeneous treatment protocols, small sample size, inherent difficulty in the use of appropriate controls etc (NIH publication, 1998). Selection of method for performing the procedure in control group for these studies poses to be a difficult problem. Method of performing the   procedure in control group is important because the insertion of placebo needles itself results in inherent analgesic effect due to release of local ?-endorphins (opioid like substances), which can influence the outcome of the study too (NIH publication, 1998). Future research is recommended to resolve the issues discussed above. Thus there is a need for large scale, well-designed, multicentric, randomized control trials in future that will use standardized treatment protocol and appropriate methods for performing the procedure in controls. It is evident from the above discussion that various studies which aimed at assessing the   efficacy of acupuncture in treatment of TE had employed different processes for performing acupuncture, in terms of location of puncture points, depth of insertion of needles, the number of needles used, duration of treatment etc. In order to arrive at a definite conclusion regarding the efficacy of acupuncture in treatment of patients with TE and in order to maximize the chances for a successful treatment with acupuncture, there is a need for a uniform, accurate and complete description of the most effective method to be used for performing acupuncture in patients with TE. With this in mind, Webster-Harrison, White Rae (2002) conducted a study in order to develop a standardized treatment protocol for acupuncture therapy in patients with TE. They adopted a modified Delphi’s consensus technique to combine the opinions of fourteen British acupuncture experts into a standardized treatment protocol. This protocol contained eight items pertaining to the treatment of TE using acupuncture and has been described in table 1. The various items considered in this protocol were: selection of acupuncture points; length and diameter of needles used; depth of insertion; duration of treatment; interval between successive treatments; whether the needle should be stimulated or not; the type of response to be achieved upon stimulation and number of treatment cycles needed. Use of this protocol in randomized multicentric trials conducted in future is likely to give accurate results (Webster-Harrison et al). Conclusion From the discussion in this paper it becomes apparent that till date no study in published   literature has been able to demonstrate long term beneficial effects of any pharmacological, surgical or physical therapy in comparison to that of a placebo therapy for treatment of patients with TE. Among various non-pharmacological therapeutic options, acupuncture presents an effective and safe adjunct treatment or an alternative to classical conventional therapeutic modalities, especially in cases where these conventional therapeutic modalities had previously failed (NIH, 1998). Presently, the optimal treatment option for patients with tennis elbow in clinical care largely remains unclear. Acupuncture appears to be a lucrative treatment option for both clinicians and patients. However, the therapeutic benefits provided by use of acupuncture are not supported by sufficient evidence, at present. There is a need for well designed, high quality research studies, especially randomized control trials in future, in order to help in establishing the appropriate place for acupuncture in treatment of patients with TE in modern medical practice. References Assendelft, W., Green, S., Buchbinder, R., Struijs, P., Smidt, N. (2003). Extracts from concise   clinical evidence: Tennis elbow. British Medical Journal, 327, 329-340. Bisset, L., Paungmali, A., Vicenzino, B., Belle, E., Herbert, R.D. (2005). A systematic review and meta-analysis of clinical trials on physical interventions for lateral epicondylalgia. British Journal of Sports Medicine, 39(7), 411 422. Buchinder, R., Green, S., Struijs, P. (2007). Tennis elbow. American Family Physician, 75 (5),   701-702. Retrieved on 30 June 2007 from http://www.aafp.org/afp/20070301/bmj.html Fink, M., Wolkenstein, E., Karst, M., Gehrke, A. (2002). Acupuncture in chronic   epicondylitis: A randomized controlled trial. Rheumatology, 41(2), 205 209. Labelle, H., Guibert, R, Joncas, J., Newman, N., Fallaha, M., Rivard, C. (1992). Lack of scientific evidence for the treatment of lateral epicondylitis of the elbow: An attempted meta-analysis. Journal of Bone and Joint Surgery, 74, 646–51. Molsberger, A., Hille, E. (1994). The analgesic effect of acupuncture in chronic tennis elbow   pain.   British Journal of Rheumatology, 33(12), 1162-1165 National Institute of Health (1998). NIH consensus conference: Acupuncture. Journal of   American Medical Association, 280, 1518–24. Trinh, K.V., Philips, S.D., Ho, E., Damsma, K. (2004). Acupuncture for alleviation of lateral   epicondyle pain: A systematic review.   Rheumatology, 43, 1085–1090. Webster-Harrison, P., White, A., Rae, J. (2002).Acupuncture for tennis elbow: An e-mail   consensus study to define a standardised treatment in a GP’s surgery. Acupuncture in Medicine, 20(4), 181-5.

Juliet And Her Romeo Essay Example for Free

Juliet And Her Romeo Essay â€Å"For never was there a story of more woe than this of Juliet and her Romeo†. Romeo and Juliet is a tragic love story. Whose tragedy is it? Through the metrical composition of the closing lines of the play, Shakespeare informs the audience on whose tragedy Romeo and Juliet is about. By addressing the last verse of the play to us in pyrrhic pentameter, he is suggesting a victory which has come about at too great a cost. The pace of time amplifies the tragic quality of the play. Time is used to set things in a motion that they spiral out of control. Instead of logical decisions, everything is controlled by emotions, which ultimately leads Romeo and Juliet to their path of death. However, Shakespeare’s deliberate use of pyrrhic pentameter reinforces the sound of a pyrrhic victory. Besides the tragedy of Romeo and Juliet, there is something more pervasive suggested, as many characters thereafter also suffer as a consequence of this tragedy, such as the parents and Paris. Essentially, the story is Romeo and Juliet’s tragedy because they are young and pay the ultimate price for their passionate ‘true love’. The chorus tells us that the lovers are necessary sacrifices. Nothing but their death can â€Å"bury their parents’ strife†. Through the words â€Å"here’s much to do with hate, but more with love†, Shakespeare suggests how the world of the play is initially sprouted by hate between two families. So the paradox with Romeo and Juliet is how the one thing that defines them is ultimately the one thing which separates them. Not only are they victims of their families hatred, they are also victim to piteous overthrows and misguided plans which were supposed to unite them. By disregarding patriarchal imperatives and escaping to a world without parents, they place their trust in orders, such as Friar Lawrence and the Nurse. In doing that, they subject themselves to piteous overthrows. Their tragedy is that they have nowhere to turn. In an attempt to come together, the true lovers die; their love was â€Å"death-marked†. They are inexperienced and have the idealistic ardour of first love. Hence, their love is pure. The poetry of the play is written as beautifully and pure as the love it speaks of as this purity enhances the tragedy presented in the play for Romeo and Juliet. It is the parents’ tragedy in this play because of their disobedient children. Romeo and Juliet’s rebellion ultimately leads to them to their own deaths and consequently, the only succession to the Capulet and Montague’s family name is lost. Upon Juliet’s death, Capulet expresses lamentation to this loss of  succession through his words â€Å"death is my heir†. The children’s fatal flaws ultimately pave their parents’ tragedy. The children took little honour in their names and treated it as if it were a piece of clothing which they could just throw away. Juliet questions â€Å"what’s in a name?† and expresses dishonour to the significance of her family name. Juliet’s lack of pride leads her to Romeo, which ultimately leads her to death. Hence, her lack of pride is her fatal flaw. If she had pride in her name, she would not have allowed herself to love Romeo and hence, would not have died. If they did not die, the story would not have been their parent’s tragedy, as they would not have lost their children, or their successor to their family name. Of all the young men who die in the play, Paris is the greatest victim of all, because he dies from being a victim of both love and death. Essentially, Paris was not even part of the two families’ battle. Rather, he was dragged into the whole mess as a result of associations. For the other young men in the story, their tragedy had come about as a result of the ancient grudge however for Paris, he was a victim of love. He dies as a consequence of love in both ways; Romeo’s love for Juliet as well as his own love for Juliet. Paris was a nice guy who happened to get caught in someone else’s love story. As Juliet’s love for Romeo deepens, Paris is increasingly ignored by her. Hence, not only is it a tragic end for Paris in that he dies by the end of the play, but his beloved Juliet also dies and the fact that he never received Juliet’s love or attention since the start adds further depth to his tragedy. Through the use of pyrrhic pentameter, Shakespeare allows us to ‘hear’ as well as understand the pyrrhic victory taken place in the play. The constant battle between family Montague and the family Capulet is the spark which sets off the train for future misfortunes. Romeo and Juliet’s forbidden pure love is definitely a major factor which contributes to the tragedy of both these young lovers. For the parents, their children’s grave death, tragic in itself, also marks the death of their own succession to the family names. For Paris, his tragedy is bought about as a consequence of love. Ultimately, the catastrophic end to Romeo and Juliet is a t ragedy which affects everyone in the play.

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