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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.
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