Impression technique for atrophic ridge: A blend of the past and
present
Dr.Balakumar.V. 1, Dr. Kalpana.R.2, Dr.Haribabu.R.3
ABSTRACT: Long term edentulism or denture wearing leads to a reduction in the height and width of the residual alveolar ridge, resulting in its atrophy. The classification of residual ridge resorption was given by D.A. Atwood, ranging from class I to class VI. According to this classification, class V and VI prove to be the most challenging for a prosthodontist to reconstruct and rehabilitate. In order to fabricate comfortable, functional dentures for such patients, it is important to have knowledge about the biomechanism of edentulism as well as the material science and different techniques used for impression making. This article describes a case where a combination of materials and techniques were used to make impressions for a depressed mandibular ridge. KEYWORDS: atrophic ridge, depressed ridge, McCord’s technique, elastomeric impression material, combination impression
INTRODUCTION: • Order I: pre-extraction One of the physiological sequelae of • Order II: post-extraction extraction of teeth is the resorption of the residual ridge. This is a complex biological • Order III: high well rounded phenomenon which occurs in every • Order IV: knife edged individual. The degree of resorption varies • Order V: low well rounded from person to person due to a variety of • Order VI: depressed factors such as age, systemic health issues, Orders V & VI in this classification have presence of prosthesis [1]. Residual ridge the poorest quantity and quality of bone resorption is a continuous process support due to severe resorption and following extraction, which progresses at a therefore pose a great challenge to fast rate during the first year and then prosthodontists for reconstruction and gradually slows down. Studies also show rehabilitation. that such resorption takes place under denture bases. The resorption pattern is The various options for treatment of such also more pronounced in the mandible than cases include conventional complete dentures, implant supported dentures, in the maxilla [1]. The classification of pre-prosthetic surgeries such as residual ridge resorption was put forward vestibuloplasty, ridge augmentation [3]. by Atwood [2]: The latter options are not always accepted by the patient due to time constraints, multiple surgical phases, dependence on success rates and relatively higher cost factor. Hence the most convenient, non-
1 Professor, Department of Prosthodontics, Sathyabama Dental College and Hospital 2 CRRI, Department of Prosthodontics, Sathyabama Dental College and Hospital 3 Professor and Head of the department, Department of Prosthodontics, Sathyabama Dental College and Hospital sb.prostho@gmail.com invasive approach for treatment of such and a class III profile. Orthopantomogram resorbed ridges is the conventional was taken (Fig-2). complete denture.
An impression is a negative likeness/copy
in reverse of the surface of an object [4]. A complete denture impression is a negative registration of the entire denture bearing, stabilising and border seal areas present in the edentulous mouth [5]. Since impression making is the primary step in making a denture, the quality of the resulting impression lays the foundation for its success/ failure. Fig-1: Depressed mandibular ridge
A high-quality impression must have
adequate border extensions and surface details and also satisfy the objectives of an impression. Various studies and reports have shown that there are many materials and techniques available for taking impressions of such ridges [6-10,12]. It is therefore essential that every clinician is made aware of these different techniques Fig-2: Orthopantomogram and the material science in order to effectively and efficiently treat cases of resorbed ridges and deliver their best to the TECHNIQUE: patient. PRIMARY IMPRESSION
The technique used to make primary
CASE REPORT: impression of the mandibular ridge in this A 70-year-old male patient reported to the case was put forward by McCord and Department of Prosthodontics with the Tyson [11], where a viscous mix of chief complaint of missing teeth for the impression compound and tracing past 10 years. The teeth were extracted due compound is used to remove any soft to decay and periodontal disease. The tissue folds and smooth them over the patient had no previous dentures. Intraoral bone. This process reduces any discomfort examination revealed a flat mandibular that may be felt by the patient due to the ridge whereas the maxillary arch was “atrophic sandwich”, i.e. the tissue sufficient (Fig-1). Extraoral examination between the bone and the denture. revealed reduced vertical dimension, increased inter arch space, sunken cheeks, STEPS: polymerising denture base resin, extending 2 mm short of the sulcus depth with a 1. The impression material used was a handle anteriorly to aid placement of the mix of impression compound tray in the correct position. Sharp margins (brown) and tracing compound in a and excess material were trimmed away 3:7 ratio (McCord’s technique) [11] (Fig-7). (Fig-3). The two materials were placed in hot water and kneaded together to form a homogenous mass, whilst wearing gloves coated with Vaseline. 2. The mixture was then loaded onto a non-perforated, stock impression tray and placed into the mouth and the lower impression was recorded. 3. The mixture has a working time of about 1-2 minutes which allows for adequate peripheral border Fig-3: Impression compound & tracing moulding. compound 4. The tray was then removed from the mouth, chilled and re inserted into the mouth. This time, slight pressure was given in the premolar region and the inferior border of the mandible to check for discomfort. (If such discomfort is felt, a heated instrument may be used to adjust appropriate areas of the impression followed by re insertion to check for any continuing discomfort. This process may be repeated until the patient feels comfortable). Fig-4: Primary impression using 5. The impression (Fig-4) was then McCord’s technique disinfected and the primary cast was poured using dental plaster (Fig-5).
FABRICATION OF CUSTOM TRAY
After separating the primary cast from the impression, wax spacer was adapted over it extending from canine to canine region without covering the buccal shelf area (Fig-6) [8]. A custom tray was then fabricated over the spacer using auto Fig-5: Primary cast Fig-6: Wax spacer adapted on Fig-8: Elastomeric impression material- mandibular cast putty and light body consistency (L-R) Equal amounts of base and accelerator of light body elastomeric impression material (Fig-8) were combined to achieve a uniform homogenous mix. This was then loaded onto the tray and placed in the patient’s mouth. Border moulding movements and tongue motions were repeated again before the material set. The tray was then removed from the mouth [12] (Fig-10). Fig-7: Mandibular custom tray
BORDER MOLDING & FINAL
IMPRESSION Prior to border moulding, the tray was coated with tray adhesive. Single step border moulding was then done using putty consistency of addition silicone (Fig- 8) by taking small amounts and forming them into thin, rope like sections and Fig-9: Putty border moulding attaching them onto the borders of the tray (without the use of gloves). The borders were moulded as per usual on the labial and buccal aspect. The patient was then asked to perform varying functional movements in order to capture lingual extensions [12]. (Fig-9). Once sufficient extensions of the flanges were recorded, the tray was dried and the wax spacer was removed and tray adhesive was applied before proceeding to the final impression. Fig-10: Final impression using light body elastomeric impression material The impression was then inspected for any step and forms the foundation on which inconsistencies, following which it was the denture is constructed. The impression disinfected. After disinfection, master cast must meet all ideal requirements such as was poured using dental stone (Fig-11) preservation of ridge, aesthetics, retention, followed by all the usual lab and clinical stability, support. procedures associated with conventional The primary impression in this case was complete denture fabrication. made using a combination of impression and green stick compound (McCord’s technique) [11]. This viscous mix smoothes over any tissue folds over the bone and reduces discomfort. Additionally, this technique allows for any corrections to be made if any discomfort is felt by the patient in the denture bearing area thereby giving a guide to the load bearing potential of the area when making the final impression. Single step border moulding was done using putty consistency of addition silicone. The final impression was made Fig-11: Master cast using light body elastomeric impression material to capture all minor surface details accurately without overtly DISCUSSION compressing the tissues [12]. There has been much progress in developing other methods to solve the issue of reduced bone quantity and quality, CONCLUSION: such as vestibuloplasty, ridge Successful treatment of a depressed augmentation using alloplasts, autologous mandibular ridge is a test of a overlay grafts, osteotomy grafts, and prosthodontists skill. Constructing a implant supported dentures [3], yet these complete denture for atrophied ridges methods are not readily acceptable to continues to be challenging using patients due to the risks and complications conventional methods, but there is always of surgery, patient willingness for the room for improvement and innovation. surgery, and the cost factor. Constructing Although there are definitely other options retentive stable conventional complete for treatment of such cases, complete dentures on atrophied ridges continues to dentures need not always be overlooked. be a challenge due to the decreased Before proceeding, a thorough amount of tissue coverage. Regardless of understanding of the nature of the ridge, the degree of difficulty of fabrication of a knowledge of the different types of prosthesis on atrophied ridges, the main impression techniques, and the materials goals to be achieved are comfort, used is essential. Using a combination of aesthetics, and function. The impressions impression materials and techniques, both taken of such ridges determine the success conventional and modern, can help in or failure of the prosthesis as it is the first providing a well retained, supportive, Nitte University Journal of Health stable, functional denture for the patient. Science. 2014 Mar 1;4(1):141. The above-mentioned technique blends 10. Manoj SS, Chitre V, Aras M. tradition with modern day materials and Management of compromised ridges: a case report. The Journal of Indian helped achieve a well-rounded prosthesis Prosthodontic Society. 2011 Jun that restored masticatory function and 1;11(2):125-9. aesthetics to the patient. 11. McCord JF, Grant AA. Prosthetics: impression making. British dental journal. 2000 May 13;188(9):484. REFERENCES: 12. Chandrasekharan NK, Kunnekel AT, Verma M, Gupta RK. A technique for 1. Atwood DA. Reduction of residual impressing the severely resorbed ridges: a major oral disease entity. mandibular edentulous ridge. Journal Journal of Prosthetic Dentistry. 1971 of Prosthodontics: Implant, Esthetic Sep 1;26(3):266-79. and Reconstructive Dentistry. 2012 2. Atwood DA. Postextraction changes Apr;21(3):215-8. in the adult mandible as illustrated by microradiographs of midsagittal sections and serial cephalometric roentgenograms. Journal of Prosthetic Dentistry. 1963 Sep 1;13(5):810-24. 3. Jennings DE. Treatment of the mandibular compromised ridge: a literature review. Journal of Prosthetic Dentistry. 1989 May 1;61(5):575-9. 4. Ferro KJ, Morgano SM, Driscoll CF, Freilich MA, Guckes AD, Knoernschild KL, McGarry TJ, Twain M. The Glossary of Prosthodontic Terms. 5. Cm Jr H, Ao R. Textbook of complete dentures. 6. Tan KM, Singer MT, Masri R, et al: Modified fluid wax impression for a severely resorbed edentulous mandibular ridge. J Prosthet Dent 2009;101:279-282 7. Gandage Dhananjay S, Kini Ashwini Y, Gangadhar SA, Lagdive SB, Pai UY. Two‐step impression for atrophic mandibular ridge. Gerodontology. 2012 Jun;29(2):e1195-7. 8. Herekar M, Sethi M, Fernandes A, Kulkarni H. A physiologic impression technique for resorbed mandibular ridges. J Dent Allied Sci. 2013 Jul 1;2(2):80-2. 9. Prasad DK, Mehra D, Prasad DA. Prosthodontic management of compromised ridges and situations.
