oA Dental Teach Series Impressions of Edentulous Patients Masanori NAGAO * Ken-ichi KOBAYASHI Tetsuya SUZUKI Ishiyaku Euro America, Inc. St. Louis. Tokyo Scanned with CamScannerDental Technique Series 4 Impressions of Edentulous Patients Masanori NAGAO Ken-ichi KOBAYASHI Tetsuya SUZUKI Ishiyaku EuroAmerica, Inc. 4, St. Louis + Tokyo Scanned with CamScannerMasanori NAGAO DDS. D.Dse. Professor and Chairman, Department of Geriatric Dentistry, Faculty of Dentistry Tokyo Medical and Dental University Ken-ichi KOBAYASHI D.DS, D.D se Lecturer, Dept. of Geriatrie Dentistry, Faculty of Dentistry. Tokyo Medical and Dental University. Tetsuya SUZUKI DD, D.Dse. Research Associate, Department of Geriatric Dentistry, Faculty of Dentistry Tokyo Medical and Dental University. From the Publisher : Mlustrations in this book show practitioners with bare (gloveless) hands. Given the current atmosphere in which dentistry is practiced, however, we recommend the use of rubber gloves. Translated by Jimmy Chen SHIBA, D-DS., B.S.A., LC.O.. Diplomate Copy Editor : Brian W. COCHRAN, M.P.A, Dental Technique Series 4 Impressions of Edentulous Patients Copyright ©1993 by Oral Health Association of Japan. (Japanese Edition) Copyright ©1995 by Ishiyaku EuroAmerica, Inc. (English Edition) lll rights reserved. No part of this publication may be reproduced, or transmitted, in any form, or by any means, electronic, mechanical, ete, including photocopying or recording. or by any informa- tion storage or retrieval system, without permission-in writing-from the publishers. Ishiyaku EuroAmerica, Ine. 716 Hanley Industrial Court, Brentwood, Missouri 63144, U.S.A. 1-43-9 Komagome, Toshima-ku, Tokyo 170, JAPAN. Library of Congress Catalogue Card Number 94-77403 ISBN 1-56386-028-7 Printed in the United States of America wae 3 Scanned with CamScannerF —= Medial pterygoid muscle ‘Superior constrictor muscle etromolar curtain Pterygomandibular| raphe ig.28. Relationship between medial pterygoid muscle and superior onstrctor muscle (Boucher figure), Swallowing and tongue movement anstricts the medial pterygoid muscle, pushing the superior constictor ‘uscle forward, This will constrict the retomyohyoid fossa (a) © Fig. 34. Lingual Frenum. Althought not apparent while ‘tongue is at rest (a), lifting the tongue reveals prominent raphe (b). alte Fig.64,Relovant muscies for maxllay denture retention. 4. Labia enum 2, Depressor septi muscle 23. Orbicularis fs muscle 4. Buccafrenum 5. Zygomatie process 6 Buccinator muscle Fig. 101.-0 Finished upper working cast 1. Maxilary tuberosity 2. Lingual gingival residual line 3. Palatal torus 4, Incisive papilla 6. Labial frenum 6, Pterygomandibular fold. 7. Hamular notch 8, Foves Palatini 9. Buccal frenum. Fig. 101.-» Finished lower working cast 1, Retromylohyoid fossa 2. Antoromylohyoid fossa 3. Lingual renum 4. Sublingual gland 5. Mylohyoid fine 6. Buccal shelf 7. Retromolar pad 8. Masseter muscle ‘effect area 9. External oblique line 10. Buccal frenum 11. Mentalis muscle origin 30, (2) pression method for sublingual region accorng to Lawson (Lawson Faure) {isonet aad er amet messin ©) No end compan feta, {el When tongue flexed and al res, for of mouths lowered wi concomitant lowering ot + marginal seal. paw ~ Galingual raphe in anteroinferior dection which contacts contacts denture margin resulting in 169} Scanned with CamScannerFig.4. Graphic representation of lower denture’s ‘anatomic landmarks. Myjetyoidine 2, Premylhyoi tonsa i iateionay ictarees :Reronyonyoa tase @ Return S.Bucca set ‘a tue tena aera msce 12 Lab enum Posterior border of denture pad Fig.7. Pear-shaped pad and retromolar pad after teeth loss (from Arwill). Posterior border of lower denture must cover the pear-shaped pad and rest on the retromolar pad. Fig.20, Mylohyoid muscle line (arrow) is 2 prominent bony protruberance that can be felt. Fig. 33. Prominent mandibular toi 3 1. Incisive papila 2. Labial renum 3. Buccal frenum 4. Palatal tous 5. Maxillary tuberosity 6. Anterior vibrating ling | 7. Posterior vibrating ing 8. Fovea palatni 9. Hamular notch 10. Pterygomandibuar Fig. 49. Average buccolingual bulge (BLB) measurement of the various areas (Watt). This Information Is used to determing the thinkness ofthe Fig. Inthe molar area, the denture margin should be set beyond the ‘aemal aligue ine buceally, and the mylohyoid muscle line lingual. By doing so, tregarcess ofthe ridge resorption degree (a,b, ).the, denture form's a constant: cece ‘ | Scanned with CamScannerFig. 48. Buecaingvalbuge (BLE) athe distance rom the ngual gingival margin {oti outros Sez! gna oweing. The BLS n dentous pant italy consistent in individual areas with very Iie discrepancy (Watt Fig.13, Masser msc eet on bursa. Expansion and acy of maar compresses buechator. Denture margin should omporste forthe muscle teraction by haung a one (since museee movement hae wets ‘the denture). ae ae Sublingual gland Mylohyoid muscle line Flg.23. Relationship between inferior border of mandible and lingual inferior flange. Posterior portion of lingual flange crosses over the mylonyck’ line, which cen be set ep. Furthermore, the diection of mylohyoid lin bec now higher 98 rhits posteriorly. Thus, relationship ofthe two is quite 29rsKe' Fg.37. For denture retention and stably, functional harmony with surrounding muscles is necessary. Mentalis muscle 8, Sublingual gland - Depressor labilinferioris muscle 9. Mylohyoid muscle Fig. 39. Levin classification of palatopharyngeal Buccal frenum 10. Superior constictor muscle shapes: In Class Il, where the transion from Buccinator muscle 41, Palatopharyngeal curve hard palate is perpendicular, when compared to Masseter muscle 12, Superior constrictor muscle horizontal type (Class |), posterior border Mentalis hyoid muscle 18, Buccinator muscle ‘extension is diffcut. Geniohyoid muscle (a) (b) LAO Le. ae a | Scanned with CamScannerFig43. The relationship between gig, glands bed and the postdam locaton Fig.22. setial cross-sectional view of dtferent areas, showing relationship of mylohyoid ‘muscle during contraction and extension ( Schreinemakers) a : First premolar distal region, 1b: Second premolar distal regin,c : First molar distal region, d: Second molar cistal region, €@: Third molar distal region, Green line indicates expansion, red line indicates contraction. Denture border extension is more feasible as one moves posteriory ° o-- a on Fig.100. Leaving prominent undereut res ‘area) in the cast rim would lead to potent Leave only necessafy amount so that be Is clear. 4 Be) AEB A Fig. 46.) - Cross-sectional view of uper and lwerantrioravelarrige resorption patem I fom Nagle and Sears). 3 Saft Bow at uper and ower molar epon ig resorption patter (rom Boucher, aan ption progresses, upper ridge shifts Ingualy, meanwhile lower ridge shits buecally. Scanned with CamScannerTABLE OF CONTENTS Chapter I Functional Impression Technique for Complete Lower Denture Borders a Retromolar Pad Buccal Shelf and External Obli ‘Masseter Muscle Region ~~ ‘Mentalis Muscle Attachment Region ~ ‘Mylohyoid Ridge Region « Retromylohyoid Fossa Premylohyoid Fossa Sublingual Gland Region - ‘The Lingual Frenum « 1 2 3 4 5 6 T: 8. 9 Chapter 11 Functional Impression Technique for Complete i Upper Denture Borders 1, Posterior Border of the Denture 2, Anterior Vestibule ----- 3. Frenum Portion ~ Chapter II Practical Procedures for Impressions 1, Examination 2, Preliminary Impression 3, Study Cast and Custom Tray 4, Final Impression 5, Working Cast Adjustments ~ Other Factors Affecting the Impression Chapter IV 1, Flabby Gum Tissue 2, Relief 3, Border Moldi ing and Functional Movement Scanned with CamScannerCHAPTER I FUNCTIONAL IMPRESSION TECHNIQUE FOR COMPLETE LOWER DENTURE BORDERS Full-denture impression making is generally considered difficult. The oral cavity of the full- denture patient has no definite margins, unlike cases with inlays or crown and bridge work. Instead, there are mobile soft tissues, such as the buccal mucosa, tongue and floor of the mouth, which undergo change during function. Therefore, basic knowledge of the anatomy and physiology of the oral cavity is crucial in deciding where critical landmarks are. This is especially true in cases with a severely resorbed mandible. If the operator is well versed in oral anatomy and physiology, he can locate useful landmarks in what appears to be a no- Fig. 1. Appearance of good mandibular al denture’s mucosal side((b) Jandmark oral cavity. Figures 1-3 show the oral cavities and dentures of three different patients, with degree of man dibular resorption increasing from Figure 1 through 3, respectively. However, irrespective of the degree of resorption, the appearance of the lower full dentures’ mucosal side is similar and consistent, Figure 4 is a graphic representation of the anatomy and landmarks. Unless there is a congenital or traumatic defect, consistent common landmarks can be found. Thus, dentures that fit have common forms (Fig. 5). In this chapter, proper impression making of jeolar ridge(a), and the corresponding Fig. 2. Appearance of maderately resorbed alveolar ridge(a), and the corresponding denture’s mucosal side (b). 4 Scanned with CamScannerFig. 3. Appearance of severely resorbed alveolar ridge (negative ridge) (a). and the corresponding denture's mucosal side (b). “Fig. 4. Graphic representation of lower denture's ana tomic landmarks 1, Mylohyoid line 2, Premylohyoid fossa 3, Sublingual gland 4, Lingual frenum 5, Retromylohyoid fossa 6, Retromolar pad 7, Masseter groove 8, External oblique line 9, Buccal shelf 10, Buccal frenum 11, Mentalis muscle 12, Labial frenum the common landmarks is discussed on an anatom- ‘al and physiologic basis. For impression making, a ‘custom tray is employed with a compound border ‘molding method. This is done in order to offer a clear explanation of the impression making for Fig. 5. Inthe molar area, the denture margin should be set beyond the external abique line buccal, and the mylohyoid muscle line lingual. By doing so, iregaré- less of the ridge resorption degree (a, b, ¢), the denture form is a constant. various landmarks. Once this method is mastered, it ‘becomes simple to modify and adapt to other tec niques. The following is the impression making procedure beginning with the bucal region Scanned with CamScanner1. Retromolar Pad The posterior border of the lower denture should cover the retromolar pad. Histologically, the anterior portion of the pad consists of loose connec: tive tissue and the posterior half consists of mucosa glands. This area is also known as the pear-shaped area, due to residual scar formation from the retromolar pad and third molar extraction site. The Posterior portion is movable (Fig. 6). Strictly speaking, based on the Glossary of Prosthodontic Terms (Sth edition), the pad is divided into anterior Fig. 6. Third molar and retromolar papilla, retromolar pad (from Sicher). The retromolar papilla is covered with Keratinized epithelium lacking much tissue beneath ‘and is non-movable. Retromolar pad consists of retromolar papilla and loose connective tissue and is movable. |. Lower third molar, 2. Retromolar papilla, 3. ‘Mucous glands. and posterior regions, and the term “retromolar pad” refers to the posterior half only. However, clinically it is difficult to make a clear-cut distinc. tion between the two regions. Thus, in order to cover the hard connective tissue proper, it is critical to locate the posterior ‘edge of the denture on the posterior region of the ‘mucous glands (Figs.7, 8). By doing this, antero- posterior movement and sinking of the denture can be prevented due to the creation of a resistance point, resulting in maintenance of marginal seal, Posterior border of denture Fig. 7. Pear-shaped pad and retromolar pad after teeth loss (from Aruill). Posterior border of lower denture must cover the pear-shaped pad and rest on the retromolar pad. Fig. 8. Insufficient extension of lower denture border, not covering retromolar pad. Scanned with CamScannerHowever, the retromolar pad is surrounded by the buccinator muscle on the facial side, the superior constrictor muscle on the lingual side, and the pterygomandibular raphe on the supero-postero- medial side. Complex movement of these tissues may cause movement of the distal portion of the retromolar pad. Thus, overextension of the denture margin may lead to displacement and sore spots Fig. 9). At the time of impression, the margin should extend to cover (two-thirds of the retromolar pad’s distal end (in its strict definition). Next, @in order to confirm the movement of the retromolar pad, give tension to the pterygomandibular raphe by asking the patient to open/close their mouth. ‘The final posterior extension is determined in this way. Aside from certain exceptions, since the retromolar pad rarely undergoes resorption and is considered stable in denture patients, it can be used as a landmark for determining the occlusal plane. Fig. 9. when patient opens wide, retromolar pd is pulled in the direction of the arrow by the pterygomar sibular raphe. 2, Buccal Shelf and External Oblique Line The buccal extension of the denture margin should cover the stable buccal shelf, which is sur- rounded externally by the external oblique line, mesially by the buccal frenum, and distally by the retromolar pad (Fig. 10). In contrast to other areas of the mouth, the buccal shelf is composed of dense cortical plate bone, and is perpendicular to the vector of occlusal force. Thus, this area is an ideal region for supporting the lower denture (Fig. 11). Fig. 10. Peripheral structures of the buccal shelf bor- ered externally by external oblique ridge, anteriorly by buccal frenum, and posteriorly by retromolar pad. 3 = Buccal shelf, b : Retromolar pad, ¢ : Mylohyoid muscle Fig. 11. The buccal shelf is covered by dense cortical bbone(a) and is virtually perpendicular to the direction of occlusal force (b), therefore, is ideal as 2 load bearing structure. Scanned with CamScannerFig. 12. Buccal extension tips covering external oblique line. In good ridge the direction is downward, flat ridge Is horizontal and poor ridge is upward. 1, Buccinator muscle However, the buccinator muscle attaches to the buccal shelf, and some portion attaches close to the alveolar ridge, so any extension of the denture ‘margin will rest on the buccinator muscle, Despite this apparent problem, there are two mitigating factors :@in contrast to other masseter and orofacial muscles, the buccinator’s fibers run antero- posteriorly (parallel to the denture margin tine), and @in total anodontia, the buccinator muscle fiber attachment is thin and keratinized. Therefore, even if the denture margin covers the buccinator. no large movement to unseat the denture will occur. During impression-making, use the external oblique line as a landmark, covering slightly beyond this to increase the buccal denture margin. Border mold along the ridge with compound to ‘extend the margins. Extend downward in a good ridge and extend horizontally in flat ridge iti order to reach the external oblique line. However, severely resorbed negative ridye cases with exten- sive buccal flabby tissue, accurate border extension is difficult to determine. In such cases, use com- pound as if to simply take an impression of the buccal wall, and extend superiorly to register the margin naturally (Fig. 12) By extending the denture border beyond the external oblique line as shown in Figure 5, the buccal flange will be consistent regardless of resorp. tion level. 2. External oblique line 8, Masseter Muscle Region Masseter muscle influence must be considered in the distobuccal angle region. Since the anterior portion of the masseter muscle overlaps the poste- rior portion of the buccinator, masseter movement pushes the buccinator medially. Therefore, the denture flange must accomodate for this with concomitant concavity. Otherwise, during masticatory movement of the masseter, the denture gets dislodged or the patient will complain of sore spots in the equivalent area (Fig. 13). This concavity which gets registered in the impression is called the masseter groove. Daring impression making, softened compound should be applied to this region, and the patient should be instructed to close the mouth. Finger pressure is then opplied to the tray to force activa. tion of the masseter muscle and accomplish trim- ming (Fig. 14). However, when masseter activity is weak. influence to the buccinator is minimal, and ccases exist in which no masseter groove can be seen (Fig. 15). Closural movement during impression making may not adequately register all of masticatory myscle activities. Thus, upon denture completion, adjustment of the said area may also be necessary (Fig. 16), Scanned with CamScanner‘Superior Stylogiossus Medial [constrictor Pterygoid muscle muscle Tongue Fig. 13. Masseter muscle's effect on buccinator. Expansion and activity of masseter compresses buc- cinator, Denture margin should compensate for this ‘muscle interaction by having a concavity (since muscle movement here would dislodge the denture). Fig. 15. |.Masseter groove. Same patients may not have symmetrical grooves, since they depend on individ- ual tissue activities. Fig. 14. Activate masseter muscle by asking the patient to close the mouth or press the lower tay. Fig. 16. Masseter muscle contraction induced buc (arrow). Frequent site of denture adjustment during insertion. Scanned with CamScanner4. Mentalis Muscle Attachment Region The labial denture margin side extends over the mentalis muscle attachment region. The ‘menfalis muscle extends from the anterior alveolar ige and attaches to the mentalis (Fig. 17). Activa- tion of this muscle elevates the mentalis tissue and makes the anterior trough shallower. The original attachment of the mentalis muscle is much higher than the labial trough, and with ridge resorption the attachment gets very close to the trough. In such ‘cases, strong mentalis muscle contraction leads to a shallow labial trough. Fig. 17. Origin and attachment of mentalis muscle. Mentalis muscle originates either from the top of ‘alveolar ridge(a), oF anterior to the alveolar ridge (b). and attaches to the mentalis region. The original loca- tion is higher than the attachment, thus ridge resorption leads to shallow anterior trough. Overconsideration given to mentalis muscle activity will lead to excessive border molding dur- impression making, with the patient opening the ‘mouth wide and the lower lip being pulled, resulting in a short labial margin (Fig. 18). This leads to loss of labial border seal. Furthermore, proper lower anterior tooth alignment is difficult, leading to proper lower lip support and facial profile. Con- sidering the daily activities of masticating and swallowing, excessive movement of the masseter muscle is not necessary. Thus, during impression, limit the movement to a minimum and accomplish the task of covering beyond the mentalis: muscle attachment. After the denture is completed and at the time of delivery, check for any dislodge and adjust accordingly. During impression making, @ have the patient close gently without activating the lip, and pull the lip gently and extend the margin only to where it is visible and can be checked visually. Next, @ soften the internal surface compound and have the patient gently protrude the lips to obtain the impression of the mentalis muscle activity. This impression will record mentalis muscle activity as a concavity (Fig. 19). Fig. 18. Attachment of mentalis muscle(a). Strong pulling of lower lip results in shallow trough, leading to lose of attachment(b) 10 Scanned with CamScannerFig. 19. Impression recording mentalis muscle origin ‘and contraction. 1. Attachment of mentalis muscle, 2. Labial frenum. 5, Mylohyoid Ridge Region In the posterior region of the tongue, extend the denture margin beyond the mylohyoid muscle line (Fig. 20). The mylohyoid muscle originates from the mylohyoid line, running antero-inferiorly along the internal surface of the mandible and inserting into the median raphe anteriorly and into the hyoid bbone posteriorly. When the mandible is fixed, mylohyoid muscle action elevates the hyoid bone, Fig. 20. Mylohyoid muscle line (arrow) i @ prominent bony protruberance that can be fel. u resulting in a shallow mouth floor. However, since the mylohyoid muscle anterior to the premolar region runs below the sublingual gland, only the posterior section of the mylohyoid has direct influ cence on the denture border (Fig. 2). Since the mylohyoid line is a palpable bony protuberance, ending the denture margin there would result in a pressure point during mastication. Therefore, it is necessary to finish the lingual denture margin beyond this structure. Figure 2? isa -praphic representation of mylohyoid muscle move- iments from the first premolar to the third molar region. Mylohyoid muscle fiber attachment is quite horizontal in the premolar region and slants down- ward as the fibers move posteriorly. Establishing the lingual denture border over the mylohyoid muscle is possible by extending beyond the mylo hyoid line and extending along the slant. Further more, the lingual denture border becomes deeper, ‘oing beyond the mylohyoid line, as one goes fur- ther posteriorly. The mylohyoid line slopes higher ‘along the mandible as it moves backward, with the resultant lingual denture border quite parallel to the inferior border of the mandible (Fig. 23). If the denture border is extended in the proper direction, ‘Sublingual gland o Ay UI Geniohyoid muscle Hyoid bone Fig.21, Posterior view of muscles at the floor of ‘mouth. Mylohyoid muscle originates from the mylohyoid line, running anterointerorly along the mandible, and ‘near the second premolar region runs beneath the sublingual gland, Because of this, the posterior portion fof the mylohyoid muscle has a direct influence to denture margin Scanned with CamScannerFig. 22. Serial cross-sectional view of different areas, showing relationship of mylo hyoid musele during contraction and extension (Schreinemakers) a: First premolar distal region, b: Second premolar distal region, @: First molar distal region,"d: Second ‘molar distal region, @: Third molar distal region. Green line indicates expansion, red line indicates contraction, Denture border extension is more feasible as one moves posterior: vy. Sublingual gland Mylohyoid muscle line 23, Relationship between inferior border of man Fig. 24. During contraction(a) and relaxation(b) of ‘and lingual inferior flange. Posterior portion of mylohyoid muscle, a smal space is created between the lingual flange crosses over the mylohyoid line, which insié surface of dente and floor of mouth. However, can be set deep. Furthermore, the direction of mylo- singe the tongue is pressed against the donture flange's hyoid line becomes higher as It shifts posteriorly, Thus, smooth side, stability and denture retention is relationship of the two is quite parallel maintained 2. Scanned with CamScannerFig. 25. Before molding and impression of mylohyoid line region. Using finger pressure, push compound downward to extend lingual flange(a). Next, soften only the internal surface of compound, and ask the patent to swallow and move tongue() to register tmfyoid tensionco). mylohyoid muscle contraction will provide mar- ginal seal and will not act as a dislodging force. However, under relaxation, a slight space is created between the floor of the mouth and internal denture surface. In order to overcome this, a slight concav- ity atthe polished lingual denture flange is provided so the tongue will apply external downward force. Even under muscle relaxation, this prevents denture instability (Fig. 24). During impression, (D extend the denture bor der roughly 5 mm beyond the mylohyoid line in the molar region. Ifthe softened compound gets pushed upward, making it difficult, use finger pressure to extend the border downward. Next, @ have the patient undergo swallowing and tongue protruding to record the movement of the mylohyoid muscle. ‘At this time, the critical factor is to soften the internal compound surface only with an alcohol torch, When the compound border and external portion is softened, the whole compound gets dis- placed, resulting in a recording error of proper mylohyoid tension activity (Fis. 25) ‘The recorded final impression shows a lingual: ly opened form, and in conjunction with the mylo- hhyoid fossae border makes the so-called shaped curve (Fig. 26). In general, with regard to the relationship between alveolar erest height and attachment of the mylohyoid muscle, the more 13 Fig. 26. Lingual denture flange appears opening up Lingually due to mylohyoid muscle tension. advanced the ridge resorption, the more prominent the S-shaped curve, conversely, the S-shaped curve is gentle when ridge resorption is small. Also, cases in which mylohyoid muscle tension is weak, ually no lingual; flaring is seen. Thus, prior ‘examination of the mylohyoid muscle area with fingers and concomitant examination of muscle tension will allow approximation of the anatomy, leading'to minimized border-shape error. Scanned with CamScanner6. Retromylohyoid Fossa ‘The retromylohyoid fossa is the concavity located on the posterior lingual side of the denture. The retromylohyoid fossa is composed of the palatoglossus muscle posteromedially and the supe rior constrictor muscle posterolaterally : it is cov ‘ered by the retromylohyoid curtain with the tongue positioned medially, the coronoid process laterally, and the pterygomandibular raphe, retromolar pad, and posteromylohyoid line oral membrane covers posteriorly (Fig. 27). The medial pterygoid muscle is located at the back of the superior constrictor muscle. For increased denture retention, some would extend the denture border into the undercut space of the retromylohyoid muscle. However, during. swallowing and tongue movement, due to medial pterygoid muscle contraction pushing the superior constrictor muséle anteriorly, and palatoglossus muscle contraction moving the retromylohyoid cur: tain anteriorly, the space is narrowed (Fig. 28) Because of this, avoid overextension of impression material during relaxation. During impression, soften the internal side and border of the compound, and have the patient swal- low and protrude the tongue to determine proper length. The impression obtained will curve in the direction of the coronoid process to the buccal side. This region will serve to guide the tongue toward the lingual flange. Fig. 27. Retromylohyoid fossa is bounded by the mem- brane (retromylohyoid curtain) which covers the supe: rior constrictor muscle. I.Retromolar pad, 2. Retromylohyoid curtain. Medial-pterygoid muscle Fig. 28. Relationship between medial pterygoid muscle and superior constrictor muscle (Boucher figure) ‘Swallowing and tongue movement constricts the medial pterygoid muscle, pushing the superior constrictor muscle forward. This will constrict the retromylohyoid fossa “ Scanned with CamScanner1. Premylohyoid Fossa ‘According to Boucher, the premylohyoid fossa is the equivalent of the height between the lingual alveolar ridge and mylohyoid line that is palpable (Fig. 29). The equivalent eminence (premylohyoid fossa) can be obtained in the impression. Pas samonti declared it to be the shallowest spot of the floor of the mouth, giving it the tombstone name of Passamonti's Notch. Nevertheless, the premylohyoid {fossa is at the junction between the sublingual gland anteriorly and mylohyoid line posteriorly. In the impression, the fossa is equivalent to the change in the S-curve. At the lingual denture bor- der, from the midline to the sublingual gland, the ‘curvature is along the ridge curving buccally with slight concavity up to the premylohyoid fossa. Posterior to the premylohyoid fossa, due to the mylohyoid muscle mass, the denture border swells ‘out lingually, and is pushed toward the most pos- terior premylohyoid fosia by the strong medial ‘glossus muscle, resulting in convexity. Because of this, the properly obtained impression's tissue side view shows a S-curve. Fig. 29, Premylohyoid fossa (arrow). Its the concév ity at the lingual alveolar ridge fissure and mylohyoid line junction point. It is equivalent to the midpoint of the S-curve line. 15 8, Sublingual Gland Region Anterior to the premolar region, the denture border is set above the sublingual gland. As shown in Figure 21, mylohyoid muscle runs beneath the sublingual gland, and near the midline, geniohyoid muscle exists. Because of this, swallowing and tongue movement expands these muscles with con comitant lifting of the sublingual gland. However, when the denture margin is deter mined during the uplift ofthe sublingual gland, the proper relationship between denture margin ‘and sublingual membrane cannot be maintained, lead ing to lack of marginal seal. Ths region is critical for lower denture stability and retention, Loss of marginal seal leads to an unstable denture. Thus, Lawson took note ofthe getle swelling (sublingual raphe), which coincides with the sublingual gland border, and recommends the following impression method. Lift the tongue to elevate the sublingual gland to determine margin length (Fig. 30-a). © Next, add compound in a horizontal direction to determine thickness (Fig. 30-b). When the tongue is relaxed, the floor of the mouth is lowered, and the fublingual raphe will locate anteroinferiory, contacting the denture margin, creating marginal seal (Fig. 30-¢). (nthe other hand, we use the depth ofthe floor ofthe mouth during tongue relaxation to determine margin length. Doing so means uplift ofthe sublin ual gland pushes the denture border. However, tinder normal swallowing and functional move ment, the tissue membrane in this region moves tainly in a horizontal diretion without any major uplifting of the sublingual gland or pressure from it. The sublingual gland is flexible and soft and is @ large salivery gland. Because of this property, slight pressure from the denture border will not lead to sore spots or instability of the denture. When adapted tothe uplifted sublingual gland, how much the sublingual raphe will augment the altera- tion of the floor of the mouth is uncertain. If there is litle pressure effect from the sublingual uplift, then it is more eritical to consider marginal seal loss during relaxed state. However, a sharp border would dig into the membrane : thus, provide ade- Scanned with CamScanner/ Tongue ‘Sublingual raphe a b ce Fig. 30. Impression method for sublingual region according to Lawson (Lawson figure). Lift tongue to obtain raised floor of mouth impression(a). Next, extend compound horizontally(b). When tongue is relaxed and at rest, floor of mouth is lowered with concomitant lowering of sublingual raphe in anteroinferior direction which contacts enture margin resulting in marginal seal(c). 31. Since the sublingual gland is highly compres- sible, register the floor of the mouth at rest to obtain adequate flange width. quate thickness to the border form (Fig. 31). By doing this, marginal seal will be improved, and furthermore, a thick border will allow the tongue to be placed against the polished surface, acting as a shelf, leading to further retention. At the time of impression, @ extend the border length using a visual inspection of mouth floor Fig. 32. When the floor of the mouth depth is unclear during rest, soften the compound around the sublingual land region and massage the tongue downward. depth with the tongue under relaxation. @ Next, extend the compound in a horizontal direction to ‘obtain border thickness, while asking the patient to lift the tongue very slightly. However, this move- ment is not for registering the uplifted position of the sublingual gland. It is done to prevent excessive compound pressure (Fig. 32). Scanned with CamScanner‘Torus Mandibularis ‘The torus mandibularis is the frequently seen oblong-shaped bony protruberance located near the lower premolar region. Most often it is seen bilater- ally, and with variable sizes. ‘The overlying membrane is thin, contributing to pain even with slight movement of the denture. ‘Therefore, it is critical to cover the entire protuber- ance at the time of impression and then relief the area later. If, by accident, the margin is placed above the protuberance, the margin would make an indentation on the protuberance, leading to pain. However, in those cases of severe protuber- lance, complete coverage causes narrowed tongue space. With the resultant undercut space, marginal seal may not be properly obtained. In such cases, surgical therapy may have to be considered (Fig. 33). Fig. 33. Prominent mandibular tori, 9. The Lingual Frenum ‘The lingual frenum is the raphe extending from the lingual alveolar membrane to the underneath side of the tongue. During tongue rest, the attach- ment is not very clear, but it becomes prominent when the tongue is directed palatally (Fig. 34). Its movement is active and covers a broad area in many cases. The genioglossus muscle, which is one of the external blossus muscles, is located beneath the lingual frenum. The genioglossus muscle originates from the genial tubercle, spreading fan-shaped to the dorsum side of the tongue. In contrast to a dentulous condition, in edentulous cases, due to alveolar resorption, the genial tubercle is located close to the height of the alveolar ridge (Fig. 35). Many times, in advanced ridge resorption cases, the ‘genial tubercle can be seen as a prominent protuber- ance. Thus, placing the denture border above the genial tubercle without tongue movement results in Fig. 34, Lingual Frenum. Although not apparent while tongue is at rest(a), lifting the tongue reveals promi- rent raphe(b). Scanned with CamScannerpain, During impression, soften the compound only near the lingual frenum and move the tongue up ward. Due to the broad attachment, the obtained impression shows a U-shaped form. A word of Fig.35. With advanced ridge resorption, genial tuber: cle (arrow) gets closer to the height of alveolar ridge. caution : avoid by all means shortening the adja. cent sublingual gland region’s denture border. When the lingual frenum is prominent intraorally and yet the notch is not visible in the impression, cone should suspect inadequate length. Fig. 36. Lower working east showing anatomical land: marks. 1. Retromylohyoid fossa, 2. Premylohyoid fossa, 3. LI gual frenum, 4. Sublingual gland area, 5. Mylohyoid fossa, 6, Buccal shelf, 7. Retromolar pad, 8. Masset: er muscle influence area, 9.External oblique line 10, Buccal frenum, 1. Mentalis muscle prominence. 1, Mentalis muscle Depressor labii inferioris muscle Buccal frenum Buccinator muscle Masseter muscle Mentalis hyoid muscle Geniohyoid muscle Sublingual gland Mylohyoid muscle Superior constrictor muscle U1, Palatopharyngeal curve 12, Superior constrictor muscle 3, Buccinator muscle Fig. 37. For denture retention and stability, functional harmony with surrounding muscles is necessary. Scanned with CamScannerCHAPTER II FUNCTIONAL IMPRESSION TECHNIQUE FOR COMPLETE UPPER DENTURE BORDERS Our discussion of maxillary impression (Fig. 38) will be divided into two parts : @ the anterior oral cavity, and @ the posterior palatal region. The anterior portion, compared to the lower, is relatively easier. Unlike the lower, the upper has a larger effective surface area and itis not necessary to extend much beyond muscle attachments. Also, there is less mobile tissue like the tongue and floor ‘of the mouth and the area is easier to inspect visually. Because of these factors, in normal cases this is a relatively simple area to deal with. How: ever, in severely resorbed ridge cases, one must maintain adequate anterior vestibule width to aug- ment the lost ridge mass for denture stability and retention. Meanwhile, the posterior region membrane LL Incisive papilla 2. Labial frenum 3. Buccal frenum 4, Palatal torus 5, Maxillary tuberosity 6. Anterior vibrating line 7.Posterior vibrating line 8, Fovea palatini 9.Hamular notch 10. Pterygomandibular raphe lacks much folding, leading to excessive impression material being introduced while obtaining even the soft palate impression. Therefore, the operator must locate several visible landmarks to determine the posterior border extension limit and in the final working cast mark the border line. For increasing denture retention, it is desirable to extend the posterior border as much as possible. However, callous extension leads to uncomfortable wear, increasing the gag reflex. House suggests classifying the palatopharynx region into 3 types as a guide for posterior exten- sion determination (Fig. 39). In type 1, with hori- zontal transition from the hard to soft palate region, one can extend over 5mm into the soft palate. However, when the soft palate is down and perpendicular to the hard palate (type Ill), it is virtually impossible to extend into the soft palate. In maxillary impression making, since one begins from determination of the posterior tray border, we shall begin by discussing how to clinical- ly determine the posterior border. As for the ante- Fig. 38, Maxillary denture and its anatomical land marks. 19 Fig.39, Levin cassfcation of palatopharyngeal shapes. In Classi, where the transition from hard palate to soft palate is perpendicular, when compared to horizontal type (Class 1), posterior: border exten- sion is ditfiut Scanned with CamScannerior region, discussion is based on ridge resorption and width of the anterior vestibule. 1, Posterior Border of the Denture ‘The posterior border of the maxillary denture is the vibrating line connecting the 2 hamular notch, and in general is at the junction between hard and soft palate slightly into the soft palate. First, we shall review the anatomical landmarks at the poste- rior border (Fig. 40), and then go over the impres- sion method based on that. Fig. 40. Anatomical landmarks at the distal end of maxillary denture. 1. Maxillary tuberosity, 2. Pterygomandibular fold 3.Hamular noteh, 4. "AN"-line, 5, Palatine fossa, Fig. 41. Hamular notch can be located by running a T- shaped burnisher along the ridge posteriorly until 2 definite depression at the end. (2) Hamutar notch ‘The upper denture's posterior border, in the posteriar part of the maxillary ridge. is set beyond the maxillary tuberosity at the hamular notch. The hamular notch is the bony area located between the maxillary tuberosity and the tip hamulus of the pterygoid plate. The subepithelial tissue of the hamular notch consists of thick loose connective tissue with no prominent muscles to displace denture, Thus, it is feasible to compress the hamular notch region’s tissue, which is ideal for posterior marginal seal. Meanwhile, the maxillary tuberosity anterior to it is the leftover unresorbed bony protuberance after last molar lose. The over- lying epithelium here is thin and hard and is not ideal for posterior peripheral seal. Also, posterior to it; the pterygomandibular raphe attaches to the hamulus of the pterygoid plate. Since the movement of the pterygomandibular raphe is large, itis diffi- cult to extend over and beyond the hamular notch. Because of the said reasons. it is imperative to finish the distal end at the hamular notch area. It is simple to locate the hamular notch intra- orally with a T-shaped burnisher. Place the burnish er on the ridge and feel along distally, and right at the distal end of the ridge there is a depression (Fig. 4). This is the hamular notch. (2) Pterygomandibular raphe and pterygo- mandibular fold ‘The pterygomandibular raphe constitutes part of the buccinator muscle origin, originating from the hamulus of the pterygoid plate of the maxillary tuberosity and attaching to the crista temporalis below the retromolar pad. And covering this mem- brane, attaching from the distal of the maxillary tuberosity to the lower retromolar pad, is the raphe (pterygomandibular raphe, Fig.42). The ptery- gomandibular plica runs slightly lateral to the hamular notch, When the mouth is opened wide, the pterygomandibular raphe expands, and along with the pterygomandibular plica, which covers it, di places anteriorly. Because of this, unless one is aware of it during impression, it will affect the denture border. Furthermore, posterior to the ptery Scanned with CamScannerFig. 42. Pterygomandibular plica runs from the maxl- lary tuberosity (arrow) to the retromolar pad. gomandibular raphe is located the medial pterygoid muscle, which limits the area's denture border thickness due to its expansion. Expansion of the medial pterygoid muscle is also caused by opening and closing movements. (3) Vibrating line, “Ah”-line At the distal end of the maxillary denture, in the palatal region, the vibrating line connects the left and right hamular notch. The soft palate is raised when the patient says “AR", and is lowered when this is stopped. During swallowing, the soft palate is raised in a similar fashion. Meanwhile, when one blows the nose ‘gently with the nose nipped, the soft palate is lower- ed, and recovers when stopped. The movable bound- ary obtained from these exercises is called the vibrating line. The vibrating line position varies ‘depending on the type and strength of the stimula- tion. A strong “A” sound moves the vibrating line forward, and a continuous and weak “Ah” sound moves the vibrating line backward. These are called the antetior and posterior vibrating lines,” respectively. The vibrating line obtained from the Closed Nostril Method’ is usually slightly anterior to the anterior vibrating line. ‘Thus, the vibrating line fs not a distinct line, but instead is a vibrating area. 21 Overextension of the posterior end beyond the vibrating line leads to irritation of the soft palate during action, resulting in a gag reflex and loss of peripheral seal when the soft palate is raised ‘Therefore, the vibrating line constitutes the poste- rior end of the upper denture. ‘The curvature of the vibrating line varies de- pending on the palatal form. In general, with a high palatal vault, the vertical movement of the soft palate, in relation to the hard palate, is very large, making it difficult to extend into the soft palate. This results in placing the vibrating line anteriorly, and the curvature in acute. On the other hand, in a relatively shallow palatal vault, the movement of the soft palate in relation to the hard palate is ‘small, allowing adequate extension into the soft palate with the vibrating line located inferoposte- riorly. ‘At the impression procedure, to locate the depression obtained immediately after the down ward recovery of the soft palate from the “Ali- sound as the visual reference makes it easy to find the vibrating line. As to the final determination of the vibrating area, whether to use the anterior or posterior vibrating line, the operator ought to make the final decision taking into consideration the ridge condition and the adaptability of the individ: ual patient. In addition, from the first molar region of the hard palate to the distal end of the soft palate, there is a rich bed of subepithelial palatal glands. The palatal glands are located along the median line Postdam Fig. 43. The relationship between palatal glands bed and the postdam location, Scanned with CamScannerand the bed becomes thinner anteriorly. Because of its resiliency, this area can be compressed (Fig. 43) Thus, if the distal end can be pressured at the time of impression, marginal ceal can be improved. (4) Palatine fovea ‘The small depression located bilaterally along the palate median line is called the palatine fovea (Fig. 40). This isthe opening of the mucous glands, and because ofits location near the vibrating line, it is a useful landmark for determining the distal end of the denture ‘There are numerous reports onthe relationship between the vibrating line and the palatine fovea. Boucher states that the vibrating line is situated 2mm anterior to the palatine fovea. Meanwhile, Chen reports only 18 (25%) out of 72 subjects had the palatine fovea overlap the vibrating line using the closed-nose method, All others were found Posterior to the vibrating line. During impression, in general obtain the Palatine fovea within the impression and extend 2~Imm more posteriorly to locate the distal end. However, the chance of obtaining the palatine fovea in the impression is only 50% and is not necessarily sen in all cases. As stated earlier, the distal end of the denture should be determined by the vibrating line. The palatine fovea should be considered as one means of locating this vibrat ing line (5) Impression making of the distal end (marginal seal) ‘The distal end impression should be made after the buccal and labial border molding are completed, © Once again, verify the location of the hamular notch and vibrating line @ Verify the location of the hamular notch area in the custom tray and add compound (Fig. 44-a), and ask the patient to open wide (Fig. 44-b). By doing this, the hamular notch region gets pressured and simultaneously the pter- ygomandibular plica movement gets registered. Furthermore, when closed movement is added, nearby medial pterygoid muscle expansion can be partially registered. Excess compound should be trimmed with a sharp knife. @ Apply heated com: Fig, 44, Distal end impression making. In the final step, apply heated compound(a), pressure the distal tend and have the patient open mouth wide(b), register the movement of pterygomandibular plica also. Apply ‘compound along the parotid gland bed in butterfly shape(c). pound in the custom tray along the vibrating line and place it in the mouth. Keeping in mind the palatal gland bed, apply the compound in a butter: fly shape slightly beyond the midline (Fig, 44-c). By doing this, the distal end gets pressured, result: Scanned with CamScannering in increased peripheral seal. Test for adequate retention by pulling the tray handle downward, However, if the distal end of the custom tray is barely on the vibrating line, compound will not flow backward, not being able to apply pressure where needed. Because of this, the distal end of the custom tray must extend at least 2mm beyond the vibrat- ing line. @ Right before the wash impression, out- line the vibrating line intraorally to transfer the line conto the impression. ‘As stated above, use the vibrating line, connect- ing the left and right hamular notch, as the basis for the distal end of the upper denture. Furthermore, it is important to understand the vibrating line as an area. Depending on the patient, some will not tolerate extension to the vibrating line. The upper denture distal extension creates ill- feeling, resulting in a gag-reflex. If the ridge is not resorbed severely, even ending the distal end slight- ly in front of the vibrating line, because of the large palatal gland bed beneath, peripheral seal can be obtained. Even in these cases, it is imperative to cover the maxillary tuberosity, and the distal erid of the denture must be extended to the hamular notch. If the palatal tori are prominent and hard, extend- ing along the to the posterior, avoid the tori and shorten the distal end in a wave-like form as shown in Figure 45. Fig. 45. Upper denture's distal end form. In cases when it is necessary to shorten the distal end, make sure the maxillary tuberasity is covered (thick line), Include left and right hamular noteh, making sure both sides are symmetrical, Trimming along the dotted line resuits in inadequate extension as indivated in the cross-hatched area, 23 2. Anterior Vestibule In the anterior vestibule, judge the amount of ridge resorption, with the point being proper judge ‘ment of anterior vestibule width. In order to accom: plish this, the ridge resorption pattern ought to be understood. (1) Anatomical change of alveolar ridge from resorption ‘The resorption pattern and direction, keeping in mind the difference in original tooth position (long axis direction) and bucco-lingual ridge thick- ness, can be easily figured out (Fig. 46). In the upper anterior area, natural teeth are {inclined facially with the thin facial side ridge. ‘After teeth are lost, facial side bone resorption is large and fast. Because of this, the alveolar ridge resorbs internally. This tendency is more in the premolar region than the molar region. Thus, in the upper ridge, the more resorption occurs, the more the ridge moves internally as if the whole arch is shrinking in size. Meanwhile, in the lower anterior region, natural teeth are mostly inclined facially, with large facial bony wall resorption resulting in ridge resorption lingually. The lower molar region's teeth lingually, with the buccal wall being ‘Thus. lingual are slightly thicker than the lingual si ‘wall resorption is faster, resulting in a somewhat ‘buccal resorption direction. Consequently, in the lower arch, due to the ridge resorption pattern, the overall arch appears to increase somewhat in size. Based on these observations, in severely advanced resorption cases, the upper arch appears, to become much smaller than the lower arch, giving the wrong impression, as if teeth alignment must be a crossbite in order to obtain artificial-teeth occlu sion, However, if one takes into consideration the amount of ridge loss and augment adequate ante- rior vestibule width, irregardless of the resorption, external denture form is a constant. If the external denture form is stable, one can align artificial teeth. nearly where the natural teeth were, contributing to retention, stability and improved recovery of the facial profile. Scanned with CamScannerFig. 46. 1. Cross-sectional view of upper and lower anterior alveolar ridge resorption pattern (from Nagle and Sears). 2. Sagittal view of upper and lower molar region ridge resorption pattern (From Boucher). As resorption pro- ‘gresses, upper ridge shifts lingually, meanuhile lower ridge shifts buecaly. a oa Scanned with CamScannerLingual Gingival Residual Tissue Margin and BLB In determining the width of the anterior vest. bule, lingual gingival residual tissue margin (Fig. 47), and bucco-lingual diameter (BLB), (Fig. 48) a study by Watt suggests a very useful method. Watt ef al performed a study whereby: prior to extrac: tion, the lingual gingival tissue was marked. ‘Changes were then observed after extraction. They found that the string-like membrane swelling near the ridge crest in the edentulous oral cavity is the Jingual gingival tissue of the dentulous state. Furthermore, the measurement taken of the dentulous patients’ ridge crest and BLB were fairly constant. They reported .that in the edentulous ridge, the lingual gingival residual tissue moves buccally 2~4 mm. Thus, even in cases of severely resorbed ridge, from taking into consideration the amount of change in the lingual gingival residual tissue mar- gin by using the BLB ratio, one can estimate the width of the anterior vestibule (Fig. 49) Fig. 47, Lingual gingival residual tissue margin is the string-like membrane swelling near the ridge crest, Fig. 48. Buccolingval bulge the outermost buccal ging! tent in individual {BLB) is the distance from the lingua gingival margin to | swelling. The BLB in dentulous patient is vitually consis: ‘areas with very litle discrepancy (Watt). Fig. 49, Average buccolingual bulge (BLB) measure- ment of the various areas (Wat). This information is used to determine the thickness of the margins, Scanned with CamScanner(2) Labial vestibule In the labial vestibule, the primary purpose of the impression is lip support more than retention. ‘The depressor septi, nasalis, and orbicularis oris ‘muscles exist in this area and in most cases, they have little effect on denture borders. However, in Tare cases, the depressor septi and orbicularis oris muscles attach to the centrals’ alveolar ridge, t impossible to extend denture borders. In the impression, the labial frenum shows up as a notch of the bilateral distal margin, which appears as a concavity (Fig. 50). In the labial vestibule area, a slight lack of margin length or thickness will not have major effect on retention, This is due to internal pressure from the upper lip with the polished surface contributing to retention. Therefore, in average cases, the fingers lightly pinching the upper lip to take the impression is adequate (Fig. 51). However, in severely resorbed cases, as stated cearlier, the ridge crest has shifted palatally, and itis necessary to deliberately thicken the denture bor- der. Otherwise, proper alignment of teeth cannot be obtained, resulting in insufficient lip support and profile (Fig. 2-53). Using the study poor cast beforehand, with the previously mentioned BLB aid (Fig. 49), judge what thickness is necessary and adjust the custom tray thickness accordingly. An old denture is also a useful guide : ask the patient how he likes or dislikes the present anterior appear- ance. All of this information is helpful in judging anterior placement of teeth and their alignment. Fig.50. Labial vestibule a: Bilateral to the labial frenum exist depressor septi and orbicularis oris mus- cles swelling bundle forming a cylindrical plica. 1b: These structures form a concavity in the labial margin, Fig. 51. Labial vestibule area normally requires gentle pinching of the upper lip with fingers and it is only necessary to obtain the impression of the visible area. Scanned with CamScannerFig. 52. a : Profile of an edentulous patient: note the ished-in appearance from teeth loss, resulting in Prominent chi b= Profile after denture insertion, recovering proper tissue prof ‘when the labial flange Is thin or short. Excessive bulk Fesuits in unnatural fullness. sear (3) Buccal vestibule In the buccal vestibule, especially in the lateral side of the maxillary tuberosity, itis important to sive adequate thickness and depth (Fig. 54) In the buccal vestibule molar area lateral ridge surface, the buccinator muscle attachment hinders the superior extension of denture margins. Also, infrazygomatic crista exist atthe deeper portion of the buccinator muscle attachment. This is a swell- ing that runs toward the first molar, which is the extension of the infrazygoma line from the maxil- lary zygomatic process. When the zygomatic crista is wide and prominent, there are those who actively use’ this place as denture support. However, the overlying membrane is thin and hard and often becomes a sore spot. In the lateral region of the maxillary tuber- sity, which is posterior to the buccinator muscle ‘attachment area, since there is no muscle attach- ‘ment here, wide open space exists, making ample extension of margin possible. This is called the buccal space. If one can positively fill this buccal space, the upper denture’s marginal seal can be improved and will serve as an anti-luxation source with respect to external force. In the impression, this area’s margin shows up as very deep, which is called the posterior zygomatic juga. The buccinator Fig, 54. Anterior buccal vestibule area. Posterior bue- ‘al space isa critical area for denture retention. Scanned with CamScannermuscle attachment location varies dramatically, and when the attachment is posteriorly located, the ‘mesiodistal length of the buccal space becomes very short and there are times when the posterior zygomatic juga is non-existent (Fig. 55). However, the thickness in this area decreases during man- dibular excursive movement and jaw closure. Pac: ing the finger intraorally and moving the lower jaw sideways will reveal this. Lateral to the maxillary tuberosity is the coronoid process with the tempo: ralis muscle insertion, which contributes to lateral pressure during excursive movement and closing of the iar, Because of this, during impression making, have these movements made to determine the thick ness of the denture border (Fig. 56) Further distal to the maxillary tuberosity distal margin exists the medial pterygoid muscle, poste- rior to the pterygomandibular plica. It exerts pres Fig. 55. Buccal space (+) length varies from the buccinator muscle attachment. Buccal space is wide when the attachment is mesial, contributing to good denture retention(a). When the attachment exists until the distal end, buccal space is narrow and consequent retention is poor (b).. aie Fig. 56. Perform excursive movement to register the influence ‘of the coronold process(a). By doing so, the compound thickness in the lateral side of maxillary tuberosity gets registered(b).. B ‘= Scanned with CamScannersure to the posterior denture border during mastica- tion and anterior excursion movements. During. impression, it is necessary to perform open-close and anteroposterior movements (Fig.57). How- ever, border molding in this area is delicate and difficult to do with compound. Thus, adjustment can be done after the denture is processed. During impression, @ determine the necessary width of the buccal vestibule and apply ample ‘compound and massage the cheek. The finger should not be placed diréctly above the border, but instead should be at the height of commissure, away from the border, and pressure should be applied to the cheek indirectly with a gentle pushing motion. ‘Touch the facial surface with the palm surface and verify the smooth transition. @ Using an alcohol torch, soften the obtained buccal vestibule's lateral Fig. 57, Distal to the maxillary tuberosity, the medial pterygoid muscle exerts pressure during opening clos Ing and anteroposterior movements surface only and have the patient undergo lower excursive movement and open-close movement. Pressure from the coronoid process and temporalis muscle determines the proper thickness. Inadequate consideration to the thickness of the buccal vesti- bule region leads to problems in alignment of teeth and polished surface form. One way of thinking regarding proper border thickness is that the exter: nal form of the plate is similar bilaterally. In those cases with discrepancy in alveolar ridge resorption, evaluate the study cast carefully, and in those areas ‘with prominent resorption, deliberately thickening the region usually leads to symmetrical extemal forms (Fig. 58). By adjusting the compound thick ness to achieve symmetry, one is less likely to rmisjudge the width of the oral vestibule. ig. D&. By increasing the flange thickness based on the severity of ridge resorption one obtains @ symmetri cal external denture form. Scanned with CamScanner3. Frenum Portion Compared to the lower arch, the upper arch frenum is prominent. The upper arch has the labial frenum and the buccal frenum, Buccal frenum ‘movement is in an up and down direction only, but the buccal frenum also moves anteroposteriorly Because of this, the registered frenum notch form in the impression is not the same (Fig. 59). An impres: sion of the frenum should be taken only after obtaining an accurate impression of the vestibule anteroposterior to the frenum. Excessive considera: tion of the frenum often involves excessive move- ‘ment, leading to shortening of the immediate bor- der, resulting in loss of marginal seal (2) Labial frenum The labial frenum is the most prominent among all of the frenums, normally being a band located in the midline. This tissue plica has no movement of its own because it contains no muscle fibers. The labial frenum moves in connection with Fig. 59. The flange thickness of the frenum area should be the same as other areas. b Lacks adequate thickness. activity of the upper lip. There is virtually no lat. eral movement. Thus, it is only necessary to pro- vvide space for the labial frenum to pass with ade quate width and depth. During impression, soften only the frenum area ‘and pull the upper lip anterosuperiorly. Be careful of the flow of the compound. In reality, it is very difficult to register adequate frenum depth. Exces sive pulling results in a shortened labial margin. Therefore, once an adequate notch is registered, trim the notch deeply with a knife, and finalize the impression using the final impression material Another method is to apply good flowing compound in the frenum area only to border mold. When properly done, as shown in figure 60, an T-form or narrow V-shaped notch is obtained. The dotted line form leads to loss of marginal seal. ‘Anyhow, one must be careful not to make the space too wide. Even if the space is somewhat inadequate in the impression, after the denture is completed, one can check and adjust chairside. Fig. 60. Properly registered labial frenum. Dotted ine is the wrong form, Scanned with CamScanner(2) Buccal frenum The buccal frenum originates from the upper premolar alveolar membrane, inserting to the modiolus. It also runs inferiorly and attaches to the lower buccal frenum area, forming a tissue bundle. Because of this, the movement of the upper and lower buccal frenum overlaps with the modiolus movement. The modiolus can be felt in the oral angle region, for and is positioned at roughly the same height as the lip commissure. The modiolus is a conglomeration of orbicularis oris, buccinator, and depressor anguli oris muscles. Therefore, when the buccinator muscle contracts during mastication, the modiolus shifts posteriorly and pulls the buccal frenum posteriorly also. On the contrary, protrusion of the lips leads to orbicularis oris muscle contrac tion and, pulls, the buccal: frenum forward. The movement of the buccal frenum is wider than the labial frenum, thus the notch in the impression must be wider. Also, during stasis, the buccal frenum attach- ‘ment area slants posteriorly. If the operator pulls the cheek posteriorly. the buccal frenum shows up as even more prominent plica. Meanwhile, pulling anteriorly results many times in unclear buccal frenum. Thus, in the impression, the notch appears wider and spreads distally (Fig. 61), Fig. 61. Buccal frenum can be moved anteroposterior- |y. The notch Is especially prominent in the distal direction, at In addition, one should be careful of buccal frenum border thickness. Make the frenum area's polished buccal side into a concave form, and do not thin the same margin. This would lead to loss of marginal seal and loss of denture retention. Thus, ‘one must provide similar thickness to the equiva: Tent areas (Fig. 59). During impression, soften only the same region, and manipulate by pulling posteriorly and protrud- ing the lips, in order to register the anteroposterior movement of the buccal frenum (Fig.62). The obtained impression should show distal spreading ‘out of the notch form. One way of preventing loss of thickness is to further add wash compound to bor: der mold during softening. ‘No mention has been made of the lower buccal frenum, but the procedures are the same as the upper buccal frenum, as explained above. However, the lower buccal frenum is not as prominent as the ‘upper and does not show up well in the impression. ‘The lower impression boundary differs from the upper since the lower goes beyond the muscle attachments, Therefore, if one attempts to avoid the buccal frenum with zealous movements, the lower impression boundary would be excessively imited. Therefore, avoid excessive movement dur- ing impression making. This also applies to the lower labial frenum. The lower buccal and labial frenum appear as a small notch in the impression. ‘Even at this level, the frenum would seldom lead to dislodging of the denture or frenum irritation. ‘The incisive papilla is the pear-shaped or oval shaped swelling located near the ridge midline. In a dentulous jaw, it is located in the midline between the centrals, and it is known that the distance from the center of the incisive papilla to the labial of the centrals is 8~10 mm anteriorly located. Because of this structure is an important landmark for teeth alignment. Below the incisive papilla mem- brane is the incisive foramen, within which exist the nasopalatine nerve and artery. Thus, in order to avoid pressure at this location, normally it is neces- sary to give relief to the spot. However, along with the ridge resorption, the incisive papilla moves labially, causing the incisive foramen to be Scanned with CamScannerPositioned slightly posterior to it. Furthermore, When using the incisive papilla as a reference for denture alignment, one must deduct the amount of labial shift. ‘cast and anatomical land ‘marks. 1, Maxillary tuberosity 2. Lingual gingival resid- val tissue margin 3. Palatal tuberosity 4. Incisive papilla, 5, Labial frenum 6, Pterygomandibular fold 7. Hamular notch 8, Palatine fossa 9. Buccal frenum, Fig. 64. Relevant muscies tor maxiiary aenture reten- Fig. 62. Impression of upper buccal frenum. Using @ Song snap pees kite, tte ‘compound in the aa 1, Labial frenum 2. Depressor Septi muscle frenum area(a), soften the said area only(b), and 3. Orbicularis oris muscle 4 _ Buccal frenum register the buccal frenum's anteroposterior movement 5, Zygomatic process 6, Buccinator muscle caused by lip protrusion and posterior movement of cheek(o). Scanned with CamScannerCHAPTER II PRACTICAL PROCEDURES FOR IMPRESSIONS 1, Examination In treating full denture cases, there is a tend: ency to begin treatment immediately, without ade- quate overall evaluation, However, the overall physical condition of the patient may have various effects on the oral cavity and the outcome of denture placement. In a diabetic patient, decreased salivary flow makes the patient prone to denture sore spots and delayed healing of ulcerations. Also, alveolar ridge resorption is prominent. In patients with anemia, malnutrition, or high blood pressure ‘membrane’s resiliency is lowered. Medications such as major tranquilizers used to treat_mani depressive conditions cause xerostomia and oral dyskenesia. Thus, it is imperative to confirm past medical history, present medical state and use of medications. Ina dental examination, first of all, one must find out why the patient wants a new denture. It is very important to find out the reason, Also, find out what it is that the patient is unhappy about in the present prosthesis. Lack of prior knowledge of dissatisfaction may otherwise lead to the same mistake. Patient complaints are various, such as that the upper denture falls down, or the lower denture hurts when biting, or that there is an embar- rasing clacking sound during speech. Nowadays, ‘more patients request new dentures not only from masticatory dysfunction, but also for cosmetic rea- sons. ‘At the time of the intraoral examination, it is necessary to evaluate the masticatory muscles and temporomandibular joints. Here, however, topics relevant only to impression making are covered. 3 (1) Denture supporting tissues’ anatomical anomalies With the idea of determining how to disperse masticatory force to the denture supporting tissue and maintain peripheral seal, perform an intraoral visual and palpation examination. Problems include, hard tissue anomalies such as palatal torus (Fig. 65) and mandibular tori, maxillary tuberosities with severe undercuts, and sharp spiny alveolar ridge bone. In addition, @ soft tissue anomalies include flabby gum resulting from prolonged use of ill-fitting dentures (Fig. 66), denture fibroma (Fig. 67), and high attachment of frenum. All of these conditions are candidates for surgi- cal correction and are not too difficult. However, in ‘general, full denture patients are fairly old so in many cases, surgical intervention is inadvisable, or it may be difficult to obtain consent. Also, keratosis of membrane due to surgery disrupts marginal seal integrity. Because of these factors, avoid surgical inter- vention as much as possible and solve the problem prosthetically. Consider tissue recovery by methods such as relief, altering margin location, denture repair and tissue conditioning. Fig, 65. Prominent palatal torus, U-shaped upper denture, Scanned with CamScannerFig. 66. Flabby gum. (2) Tongue Examine the tongue for size, shape, expansion, location and any movement problems. Abnormal tongue location has an especially large influence on denture stability. Also, large mouth opening causes the tongue to retreat posteriorly due to reflex. Examination of the tongue should be performed with the patient having to open slightly without being too aware of the tongue. Even if it is some- what in a retreated position at this time, simply tapping the tongue will return it to rest position in many cases. At the time of impression, one must instruct the patient to have the tongue in relaxed state, and it is advisable to keep the patient's gen eral tongue habits in mind. As for dislocation of the tongue, some will retreat and stay at an inferoposterior spot, as in those with a low oral cavity floor, and some will Fig. 67. Denture fibroma. displace superoposteriorly, raising the oral cavity floor. During such tongue retreat, lingual denture space is widened, making it difficult to maintain marginal seal. On the other hand, in cases in which tongue position is normal under relaxation, with the tongue tip is at the anterior alveolar ridge crest, and the lateral tongue border is at the molar alveo- lar ridge crest, the dorsum of tongue is round and flat and the body fills the oral vestibule (Fig. 68-a). If the patient can maintain this position, lower denture’s lingual flange and tongue and the oral cavity floor’s contact can be maintained, resulting in marginal seal retention. As for retreat of the tongue (Fig. 68-b), Wright reported finding the eondition in 25% of patients. During impression, make the flange somewhat thick and deep without hindering functional move- ‘ment of the tongue. One can also provide a guide Fig. 68. @ : Tongue at rest. Tongue tip is at the top of ridge crest and tongue body ‘covers the entire mouth floor. Lingual marginal seal retention of denture is easy. bb : Tongue retrusion. Lingual marginal seal retention is difficult. Hw aa Scanned with CamScannerspot at the lingual cervical spot of the anterior for the lower denture, and have the patient touch this spot with the tip of the tongue. However, if the tongue is very muscular and hard, it is dificult to determine the retreat position of the tongue. (3) Saliva Examine salivary flow for amount and consist- ency. The ideal form of saliva is a moderate secre tion of serous type saliva. Decreased salivary flow causes difficulties in tion and swallowing. Also, the oral self- cleansing effect is lowered, making the mouth prone to infection and inflammation, and once the membrane is traumatized, healing is delayed Furthermore, common complaints include a burn- sensation and tongue dolor. This is typically called xerostomia, In denture patients, saliva helps in retention and acts as a cushioning medium between the denture and tissue membrane. Because of this, éecreased salivary flow results in decreased reten 1, Lingual 3. Mandibular canal 6. Left molar area 5. Bone Fig.69. a: exposed mandibular c2nal. : Utrasoni ‘canal Is gone wi resultant concavity. 2, Membrane 35 tion, pain from denture wear, and possible ulcera tion. Medication may be prescribed to increase salivary flow, and a soft denture liner may be necessary. (4) X-ray examination In denture patients, the tendency is to refrain from taking radiographs ; however, a radiographie ‘examination is recommended in all cases. One can thereby examine alveolar ridge form and bone density. Other obtainable information includes impaction, root fragments, nidus, cysts and tumors. Figure 69-a is an orthopantomogreph of a patient. Notice the advanced ridge resorption with loss of bone above the mandibular canal and pos- sible exposure of the canal. Figure 69-b is an ultra- ‘sonic examination of the same region. Bone above the mandibular canal is lost, resulting in a concave outline. In cases like this, occlusal force causes pain ‘and numbness. It would be necessary to relief, decrease occlusal contact force, or reline with resi ient liner. 4, Buccal ythopantomograph of edentulous patient, Severe ridge resorption with 1age of the molar area of the same patient, Bone above the mandibular Scanned with CamScanner2, Prelimi Preliminary impression is necessary for exami: nation, treatment planning and custom tray fabrica: tion, Therefore, as covered earlier, preliminary impression should include all of the anatomical landmarks and limit their displacements to a mini nary Impression In practice, the points are @ how to obtain the proper fit of the stock tray, and @) how to relax the patient and guide tongue and cheek control npression material, How. As for the preliminary modeling compound is the choice (Fig. 70). ever. this material is difficult to master and inade- quate softening leads to soft tissue deformation due to pressure spots. A novice, after repeated correc tions, would keep adding compound which would flow into the internal surface, often showing irregu lar tissue surface. Long chair time is necessary to become experienced. However, since modeling com: pound can be corrected repeatedly, it is the choice of material for student use. The authors commonly use alginate impression Alginate has adequate resiliency with good flow, and the whole material hardens consis. tently, unlike the compound which is likely to pressure tissue due to partial hardening. Also, re peating once or twice does not require much time and manipulation is easy. However, in cases with severely resorbed ridges, when stock tray fit is difficult, compound may be used. Here, the alginate method is explained. As for the stock tray, a metal tray is the choice, as it can be med and molded. As stated earlier, dentures have ‘common form ; thus, once the metal tray is trim: med properly, successive use requires only minimal adjustment in many cases. ly border trim: (1) Upper preliminary impression Using the existing denture as a guide to es mate ridge size, select the proper stock tray. Adapt the posterior margin to the palatal area by lowering the tray handle after adjusting the labial frenum_ first, Select the tray that can cover the maxillary tuberosity and the vibrating line (Fig. 71) ‘Adapt the tray margin to the outline of the ridge, especially along the canine and premolar area curvature, using pliers. If the tray handle is in contact with the upper lip, proper impression of the vestibule cannot be obtained, so bend it if necessary to avoid this (Fig. 72). Adapt the tray border to the ‘mucogingival junction so that it fits just snuggly and trim it with curved scissors (Fig. 73). If the border is short, use beading wax to augment the deficit, Avoid the labial and buccal frenum (Fig. Fig. 70. Modeling compound preliminary impression of the lower area Fig. 71. Using the labial frenum as the reference point, select the proper stock tray that would cover left and right maxillary tuberosity and vibrating line. 36 Scanned with CamScanner14). Last, apply beading wax to the posterior bor. der and the midpalate to act as a stopper and prevent impression material from flowing to the throat (Fig. 75). Next, practice tray insertion. Have the patient ‘open the mouth, using a mirror or finger to pull the left commissure, hold the tray with the right hand ‘and rotate the tray and insert simultaneously, Have the mouth closed immediately and instruct the patient to relax the cheek and lips. At this time, the Fig. 72. Bend the tray handle downward to preventit tray is still passive while checking that the tray from contacting upper lip. handle is in its proper position. Once the patient is relaxed, place the index finger of the right hand at the center of the palate and slowly apply pressure. Next, use the thumb and the index finger or the riddle finger of the left hand to squeeze the cheek, and finally with the right thumb hold the upper in place. Practice this sequence until you can exe- cute it smoothly. 73. Trim the length and frenum portions with ind round off the sharp edges. ig. 74. Avoid the trenums. Fig.75. Applying beading wax tothe posterior margin ‘and midpalatal area a8 stopper, which also prevents Impression material from flowing backward. 7 Scanned with CamScannerFig. 76. Before tray insertion, apply small amount of impression material with a spatula or finger. Fig. 78. Preliminary impression with al of the anatom- ical landmarks. ~ After applying adhesive to the tray, place an appropriate amount of impression material. If the ridge is ideal, with undercuts, apply a small amount of impression material to the buccal and labial vestibules either with a spatula or finger before: hand (Fig. 76). By doing so, large air pockets can bbe prevented. Insert the tray and perform the steps (Fig. 77). Figure 78 is the obtained impression, Check for all anatomical landmarks. 38, Fig.77. After tray insertion, squeeze the cheek with the thumb and index or middle fingers of feft hand ang pull the upper lip with the right thumb. Fig.79. Select the stock tray that covers bilaterat retromolar pads. (2) Lower preliminary impression In the lower arch, be careful for the position of the tongue and its effect at the lingual side to the impression. Align the midline of the tray to the anterior ridge midline and select the tray that will cover the bilateral retromolar pad (Fig. 79). ‘A common stock tray is usually short at the lingual border. First, bend the lingual border of the tray to check for length. At the same time, using pliers, bend it so that the tray flange at the lingual is slightly opened outward (Fig, 80). Check that the tongue is positioned above the tray in a relaxed state, See if the tray handle is obstructing the lower lip and bend the handle upward if necessary. By visual inspection, check the labial adaptation. Scanned with CamScannerFig. 80. Since the lingual side of the stock tray is usually short, bend the posterior end internally to gain length. wax. Avoid the buccal frenum and masseter muscle influ: ence (Fig.81), and cover the buccal shelf and ‘mentalis muscle adequately by correcting the tray border by removing excess or adapting beading wax to augment any deficit. As for the sublingual land region, adjust according to its depth when the tongue is at rest. Use a mirror to check the depth for the posterior lingual vestibule. This judgement is rather difficult for a novice. Thus. make sure to keep in mind the transition from the sublingual region, make it deeper than that. In many cases, this area requires addition of beading wax (Fig. 82), In difficult-to-judge cases, first take an alginate impression and verity the form, then add beading 39 Fig. 81. Avoid the buccal frenum and masseter muscle areas. Fig. 83. During impression, the tongue tip should rest ‘at the lingual position of the anteriors and touch the lingual surtace of the tray wax to modify the tray for another impression. Next, practice tray insertion, Similar to the upper arch, pull the left commissure and rotate the tray as you insert At this time, have the patient lit the tongue so that the tray will be under the tongue. Otherwise, the tongue will hit the lingual tray border, making it difficult to obtain @ proper lin qual impression. Quickly close the mouth and relax the patient. The tip of the tongue should be at the anterior’s lingual side and touching the tray com- fortably (Fig. 83). The tray at this time is still passive : check for proper position. After proper ‘guidance, place both index fingers on the malar area and gently apply pressure. Next, remove the Scanned with CamScannerFig. 84. After tray insertion, hold the tray with the right index and middle fingers and use the left hand to squeeze the cheek left index finger and use the right index and middle fingers to hold the tray in place, then use the left hand to squeeze the cheek. Last, pull the lower lip upward. Practice carrying out these steps smoothly. Apply tray adhesive and place an adequate amount of impression material. \ slightly hard to give it body. There is a limit to the fit of a stock tray, so soft alginate gets squeezed out, making the border thin and short with no anatomical landmarks. Especially, in cases with a severely resorbed ridge, a somewhat hard alginate consistency and proper insertion timing is critica. Also, in the lingual posterior border area, where tray fit is questionable, it may be necessary to apply excessive alginate. However, excessive alginate may deform the tissue. Thus, it is imperative to adapt tray border fit, using beading wax to prevent the unwanted effect. Insert the tray in the mouth and carry out the proper sequence (Fig. 84). Figure 85 is the obtained impression. Check for all the anatomical landmarks. In particular, check for in- sufficient lingual posterior margin and any large tissue deformation. 40 Fig. 85. Lower preliminary impression with all of the relevant anatomical landmarks. 3. Study Cast and Custom Tray [As for the study cast, as covered earlier, check for the anatomical landmarks, Based on these, the 1 outline form can be imagined. Draw the out- line accordingly. Keeping in mind the amount of compound to be added, draw the outline for a ‘custom tray'so that it is2-3 mm short. However, for the upper custom tray’s posterior border, it must be ‘extended more than 2 mm beyond the vibating line, as it is necessary to pressure impression this area (Fig. 86). First, block out and relief necessary areas using wax. As for the tray insertion pathway, deter- rine the minimum undercut pathway and block out the undercuts with wax (Fig. 87). Place the tray handle position and direction similar to the centrals (Fig. 88). Ifthe tray handle is slanted more labially or positioned higher and curved than this, it will deform the lip, making it tunable to obtain proper margin of the labial vesti- ble For the lower, place finger rests at the molar areas If this isnot done, te fingers will deform the seripheral buccal and tongue tissues (Fig. 89-a) making it difficult to border mold. By providing finger rests, one can avoid distortion of peripheral tissues and obtain proper impression (Fig. 89-b). In ‘order to avoid soft tissue distortion, use the Pound's Tine asa guide for placement, and make it similar to the final teeth alignment and occlusal plane height or slightly higher than this, Scanned with CamScannerFig. 86. Verify the anatomical landmarks on the study model and visualize the outtine of the final denture. ‘a: Upper, : Lower. Fig. 87. Path of insertion for upper should create minimum undercut space. In the upper. the anterior ‘ridge shape determines the anteroinferior path of inser- tion, Fig. 88. The direction and position ofthe tray handle ‘should not obstruct the lip and ought tobe similar tothe location and direction of the central. Fig. 89, importance ofthe finger rests. Direct finger hold af the tray causes tongue and cheek soft tissue distortion, makin Proper border mold dificult(a). Placement of finger fests minimize the distortion(b)- 4 Scanned with CamScannerig. 90. It is better not to apply compound to the custom tray border. a At the posterior border of the ‘upper custom tray extend at least 2mm beyond the vibrating line in order to pressure this region. tb: Lower custom tray. Do not apply compound to the periphery beforehand (Fig. 90). There are methods that apply ‘compound to the custom tray beforehand, but in the preliminary impression there are limitations to the stock tray fit and the border impression may not be accurate. Therefore, applying compound to the form beforehand would in turn make it difficult to determine the custom tray adaptation in the oral cavity. 2 4, Final Impression Before impression making, it i$ important to recover the health of the tissue. One can either use the existing dentures and apply tissue conditioner or have the patient remove the dentures 24 hours prior to impression making. First, insert the tray into the oral cavity to confirm the border length and thickness, and adjust iffnecessary (Fig. 91). Next, as stated earlier, based ‘on the anatomical landmarks, as shown in the order in Figure 92, apply compound from the buccal posterior side and border mold (Fig. 93). As for the ‘obtained tray, form is influenced by the positioning, of the custom tray, softening state of the compound, and functional exercise degree (Chapter-4, section 3). Figure 94 shows the sectional functional exer- cise. Fig. 91. Check for the frenums and adjust the tray 50 that it is 2-3mm short of the outline(a). Properly adjusted tray is stable Intrdorally (Ib). Scanned with CamScannerFig. 92. Sequence of border molding @: Upper, b: Lower. Fig. 93. Apply compound and soften with alcohol torch. Temper to about 60°C end then insert intraorally. Border mold paying attention to the compound softness ‘and giving instruction as to the amount of movement. 1, Protrude lip pull 2. Cheek massage suction 3, Suction 4, Swallowing, Buccal massage 6, Mouth closure 7, Mouth opening 8. Pressure 9. “Ah’-sound pressure 5, Excursive movement Protrude tongue, Swallowing 12, Mouth opening. 10, Tongue massage and elevation 11 13, Bite 14, Swallowing, Buccal massage 15, Protrude lip Fig. 94. Functional movements ofthe individual areas. ‘a: Upper, 1b: Lower. 43 Scanned with CamScannerFig. 95. Finished border molded upper and lower cus~ tom tray. @ : Upper, b : Lower. Fig. 96. Extending zinc oxide eugenol paste over and beyond the border would allow the impression to flow ‘externally and result in proper impression. After border molding is completed (Fig. 95), perform a wash impression using good flow impres: sion material. The authors use zinc oxide eugenol impression paste. If the flow is good, it is not critical what impression material is used. However, if thiocol rubber, which is not as free flowing, is used, remove a small amount of border compound. Before wash impression, practice insertion and finger molding adequately. Also, control intraoral salivary flow using gauze. In an upper arch with a ‘good ridge, provide holes at the palatal tray region to avoid trap void formation and allow impression material's escape. After mixing the impression material, place an appropriate amount on the tray Fig. 97. Holding the tray intraorally and waiting until the initial set, massage the cheek end ask the patient to protrude the tongue. and insert. At this time, apply impression material not only to the internal surface, but also to the border rim to facilitate flow of the material to the outside (Fig. 96). Hold the tray passively until hardening begins. Once the initial set begins, mas sage the buccal and lips, and protrude the tongue (Fig. 97). Since the general border form is already determined, have the patient exercise agressively. After setting, remove from the oral cavity and check accuracy (Fig. 98). If there is no problem, reinsert and check the relief areas and line. If necessary, mark these on the diagnostic cast or final impression. asset Scanned with CamScannerFig. 98. Final impressions a: Upper, b: Lower 5. Working Cast Adjustments critical (Fig. 9). Apply beading wax 5-7 mm short In full dentures, as stated earlier, the impres- of the impression border, and form paraffin max 1 Thus this must be saved and about 10-13 mm in depth to set the working cast thickness (Fig. 9-a). Trim the base of the cast sion border is c1 duplicated in the final denture. Therefore, boxing is te the correct details of Impression margins. Wrep beading wax $-7 mm ‘and heat with spatula to fix the beading wax. Maintain 10-13 mm in depth ing wax rim(a). Finished upper and lower boxed impressions (b, G)- Fig. 99, Boxing is necessary to replica {rom the edge of the impression margin {rom the impression surface to the bos 45 Scanned with CamScannerFought - see ae i parse ts the final imaginary occlusal lingual gland area and buccal flange form. ‘These ‘nd tein a ehae de sets, remove the impression areas are critical for marginal sea thus trimming fe tei Papen eR Ps pikes LAREN SN ey (Figs. 100, 101). Last, lar, trim carefully in the lower arch sub- _ necessary, use metal foil to relief. 100. Leaving prominent undercut (crosstine area) in the cast rim would lead to potential fracture. Leave only necessary amount so that the periphery is clear. Fig. 101-b. Finished lower working cast. |. Maxillary tuberosity 2. Lingual gingival residual line I Retromylohyoid fossa 2.Anteromylohyoid fossa 3. 3.Palatal torus 4. Incisive papilla 5. Labial frenum 6. Lingual frenum 4 Sublingual. gland 5. Mylohyoid line Pterygomandibular fold 7.Hamular notch 8. Fovea 6, Buccal shel 7. Retromolar pad 8. Masseter muscle Palatini 9. Buccal frenum cffect area 9. External oblique line 10, Buccal frenum 11, Mentalis muscle origin 16 Bs Scanned with CamScannerCHAPTER IV OTHER FACTORS AFFECTING THE IMPRESSION 1, Flabby Gum Tissue Flabby gum tissue is the movable soft gingival tissue normally seen in the upper anterior area (Fig. 102). Histopathologically, this tissue repre- sents inflammatory hypertrophy of the alveolar membrane tissue. It is normally seen in the upper anterior region, but there are cases which extend throughout the lower anterior area and other denture supporting regions. When flabby gum tissue exists, denture retention is severely, compromised (especially during mastication). This is caused by the denture's chronic mechan- ical effect. For example, from molar attrition and alveolar ridge resorption, the anterior teeth fall into premature contact, and in a case where only lower anterior natural teeth remain, the upper full denture, anteriors are hit strongly, and prolonged use leads to an unstable, ill-fitting full denture. There are two methods, pressure and non-pres sure, for flabby gum areas. Pressure impression is based on the belief that by providing deformation beforehand, denture movement can be minimized during function. How ever, in reality it is extremely difficult to duplicate the actual deformation in the impression. Also, there is a problem in pressuring large surface areas. Because of this, not many people advocate pressure pression. (On the contrary, a flabby gum area should be non-pressured in impression. Obtain occlusal toad in other normal tissue surfaces. Impression tech: niques for flabby gums are the double-tray method and tray with open window at the flabby gum (Fig. 103). However, in cases limited to the upper ante- riors. the following method is normally followed. Apply wax relief over the flabby gum section in the study cast and fabricate the custom tray. Bor- der mold with compound as normal. After border molding, remove the wax spacer and” provide ‘escape holes with a round bur over the flabby gum, area, In order to avoid distortion of the flabby gum, a with good flow area, use a wash impr 104), The point of these steps is in the finger support of the tray and the direction of the applied force. Pressing the anterior part of the tray would exert pressure to the flabby gum, distorting the tray anteriorly. Therefore, using the index finger, press ‘one point at the posterior midline area perpendicu- lar to the occlusal plane. Provide an indentation with a bur so that the position will not alter until the procedure is over. By doing so, the tray will be stable inside the oral cavity and the bulk of the impression pressure will be applied to the molar ridge, minimizing flabby gum distortion. 2, Relief ‘Areas requiring relief are bony protruberance and sharp spiny bone regions and other areas where the membrane is thin. Applicable areas include the palatine torus, maxillary tuberosity, mental fora: men, mentalis muscle attachment, mylohyoid line, mandibular tori, spiny ridge and lower anterior alveolar ridge areas. Pain, inflammation and ulcer ‘are common occurrerices. Occlusal force on the denture such as from mastication would dislodge the prosthesis. However, since the membrane is not even, the thin membrane region receives more load. Fig, 102. Flabby gum. Scanned with CamScannerFig. 103. a: Provide opening at the flabby gum and border mold the other areas and wash Impression. [D: Wash impression the fenestration with plaster without distorting the flabby gum. Fig. 104. Provide wax spacer over the flabby gum area in the cast and fabricate the custom tray. After border molding, remove the wax spacer and provide escape holes in the teay with round bur(b). Use good flow wash impression so that it won't distort the flabby gum as in Thus, estimating the amount of dislodgement, nec: essary relief must be provided. Next, the mental foramen, incisive foramen and other nerve canal foramens are applicable. Pain and numbness are common symptoms. For example, the mental nerve and artery pass the mental foramen. With the progression of ridge resorption, the mental foramen becomes the surface of the denture loading area, resulting in pain and numbness as the denture gets loaded (Fig. 105) Relief is necessary over such nerve foramens. Other spots include flabby gum, as stated earlier. For relief, first perform athorough intraoral examination, Examine with fingers to confirm loca: tion and size. In reality, apply metal foil on the working cast. Normally, a thickness of 0.25 mm foil is adequate, however as with a prominent palatal torus, use 05 mn foil and cover slightly beyond the Scanned with CamScannerFig. 105. Severely resorbed mandible results in men- tal foramen being located near the ridge crest. Occlusal force from the denture causes pain and parasthesia, thus relief is necessary. torus border to relief. Excessive relief must be avoided since it leads to ill-fit of the denture. In mild cases, provide relief by trimming the internal surface of the denture after delivery. At this time, use Pressure Indicator Paste (PIP) or Fit-Checker, using finger-pressure or having the patient bite cotton rolls to confirm the pressure area. Also, it is important to avoid excessive pressure of these spots during impression, and in order to accomplish this, apply wax to the study cast to relief and fabricate the custom tray. 3. Border Molding and Functional Movement In border molding, the most important point is instruction regarding the level of exercise. Func: tional exercise during border molding should reflect. the daily normal perioral movements, not the extremes of maximum mouth opening or tongue thrust, Especially in cases of severely resorbed ‘mandibles, the exercise movement should be mini- ‘mal, Otherwise, the impression area will be nar- rowed, resulting in loss of retention and stability. ‘Therefore, the operator must control and limit the degree of exercise movement based on the amount of ridge resorption, However, elderly patients normally cannot fol: 0 low the operator's instructions. Even in such cases, unless there isa large distortion of the sot tissue in the preliminary impression, the buccal side is not a great concern. On the buccal side, keeping in mind muscle directions and movement, the operator can simulate their movements and move the cheek and lips, not relying heavily on the patient's activity to border mold. Fortunately, the buccal margin can be inspected visually, allowing easy correction if nec- essary. On the other hand, the border on the lingual side is much more difficult to determine, since the floor of the vestibule varies greatly, depending on the position of the tongue (Fig. 106). If one can, instruct the patient to exercise, have the tongue positioned at rest, and determine the floor of the mouth and extend the lingual flange. This is suffi cient for the sublingual gland region, For the mylo- hyoi region, thicken the border with com- pound and then estimate the mylohyoid muscle at function and trim the internal surface of the com- pound so that it will open out lingually. Then, for the final step, use wash impression to register the structure. Even in such a case, it is important to keep in mind and remember the anatomical and physiological shape of the edentulous jaw. By doing ‘0, one can avoid making finished dentures that cannot be adjusted. ‘Also, in relation to the scope of movement, attention should be given to the placement of the custom tray border and softening of the compound. If the tray border is short, a large amount of com- pound needs to be added, making the task of soften ing compound difficult. Excessive softening makes the compound easy to displace by slight movement. On the contrary, lack of softening results in poor registration of the soft tissues. In order to avoid these problems, obtain an adequate preliminary impression to fabricate a proper custom tray. The tip for border molding compound is to soften only the side to contact tissues and keep the other side slightly hard. Scanned with CamScannerGeniogiossus m: come Mandible Fig. 106. Relationship between tongue position and depth of mouth floor (Nagle and ‘Sears, figure, a: Anterior position of tongue, b: Tongue at rest, ©: Tongue in retrusion). Extreme protrusion of the tongue raises the mouth floor, shortening the lingual flange. In contrast, retrusion of the tongue deepens the mouth floor and results Jn long lingual flange. Scanned with CamScannerREFERENCES Nagle, R.J. and Sears, V.H. : Denture prosthetics complete dentures (2nd ed). Mosby, St. Louis, 1962. Kamijo, Y. : Oral anatomy vol. 1. Osteology. Anatom, Inc., Tokyo, 1977. (in Japanese). Kamijo, Y. : Oral anatomy vol. 2. Myology. Anatom, Inc., Tokyo, 1977. (in Japanese). Kamijo, Y. : Oral anatomy vol. 3. Splanchnology. Anatom, Inc., Tokyo, 1977. (in Japanese). Levin, B. ; Complete dentures-Practical questions and answers for the student and general practitioner. The Shorin, Ltd., Tokyo, 1978. (in Japanese). DuBrul, E.L. : Sicher's oral anatomy (7th ed). Mosby, St. Louis, 1980. 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(in Japanese). 51 Scanned with CamScannerISBN L-Sb38b-028-7 78156386028 Scanned with CamScanner