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CLINICAL REPORTS

A Retrospective Comparison of Two


Definitive Impression Techniques and Their
Associated Postinsertion Adjustments in
Complete Denture Prosthodontics
Carl J. Drago, DDS, MS

Purpose: To compare the number of postinsertion adjustment visits required by edentulous


patients whose dentures were made from border-molded definitive impressions using modeling
plastic impression compound (traditional technique) with patients whose dentures were made from
border-molded definitive impressions using heavy-body vinyl polysiloxane impression material.
Materials and Methods: In this retrospective clinical study, 78 patients were treated with the
traditional technique (custom impression trays border molded with gray modeling plastic impression
compound) and 78 were treated with the modified technique (custom impression trays border molded
with heavy-body vinyl polysiloxane impression material). In both techniques, definitive wash impres-
sions were made with light-body vinyl polysiloxane impression material. Postinsertion visits were
quantified for 1 year after the dentures were inserted.
Results: The average number of adjustment visits for patients treated with the traditional
technique was 2.68. The average number of adjustment visits for patients treated with the modified
technique was 2.68. The data were compared using Student t tests. There was no significant
difference in the number of adjustments required for patients whose dentures were made with either
technique (t ⴝ 0.000, p ⴝ 1.00). There was no significant difference in the number of post-insertion
visits required by patients from either population.
Conclusions: Within the limitations of this clinical study, border-molding custom denture impres-
sion trays with vinyl polysiloxane impression material provided similar results in terms of postin-
sertion visits for one year as compared to dentures made from impressions border molded with
modeling plastic impression compound.
J Prosthodont 2003;12:192-197. Copyright © 2003 by The American College of Prosthodontists.

INDEX WORDS: definitive denture impression, postinsertion denture adjustment

O VER THE past 20 years, there has been a


decline in the percentage of edentulous
adults.1 This has resulted in speculation among
States, Douglass2 projected that the number of
people in the United States who will need complete
dentures will increase over the next 20 years de-
prosthodontists and dental educators about spite an anticipated decline in the age-specific rates
whether the need for complete dentures will de- of edentulism.
crease markedly and whether or not complete den- Treatment of edentulous patients with complete
ture training should be removed from the predoc- dentures is a technically demanding task.3 Making
toral dental curriculum.2 In a comprehensive a definitive impression is one of the most critical
review of past trends in edentulism in the United steps that a clinician performs in the process of
fabricating complete dentures.3,4 The objective of
the complete denture definitive impression is to
From the Department of Dental Specialists, Gundersen Lutheran accurately record the entire denture-bearing area
Medical Center, LaCrosse, WI.
Accepted April 29, 2003.
to produce a stable and retentive prosthesis while
Correspondence to: Carl J. Drago, Gundersen Lutheran Medical maintaining patient comfort and esthetics and pre-
Center, 1836 South Avenue, LaCrosse, WI 54601. E-mail: serving the remaining tissues.5
cjdrago@gundluth.org. Most U.S. dental schools teach complete denture
Supported by the Gundersen Lutheran Medical Foundation, LaCrosse, definitive impression techniques consisting of sec-
WI.
Copyright © 2003 by The American College of Prosthodontists
ondary impressions in border-molded custom im-
1059-941X/03/1203-0000$30.00/0 pression trays.6 Even though the materials used in
doi:10.1016/S1059-941X(03)00082-2 definitive denture impressions varied among the

192 Journal of Prosthodontics, Vol 12, No 3 (September), 2003: pp 192-197


September 2003, Volume 12, Number 3 193

reporting dental schools, the techniques used were plete denture prosthodontics describe numerous
remarkably similar among the schools. However, a theories and techniques for making definitive den-
significant number of dentists reported that they ture impressions.3,15,16 These have been identified
abandoned the procedures that they were taught in as traditional or conventional techniques. McGre-
the complete denture curriculum and made defin- gor and Fen17 described four materials for definitive
itive denture impressions in their private practices impressions and five specialized techniques. Dun-
with techniques they considered simpler.7 This phe- can9 described a modified definitive impression
nomenon has also been reported in the United technique taught to predoctoral dental students
Kingdom.8 Clinicians in the United Kingdom re- comprising deliberately overextended irreversible
ported that they did not always use the techniques hydrocolloid impressions for fabrication of master
that were taught to them as dental students. A casts.
survey was conducted in the United Kingdom ask- Chaffee et al5 recently reported a definitive den-
ing about the types of impression materials and ture impression technique that illustrated the use
techniques used for making definitive denture im- of a selective pressure placement technique.5 Vinyl
pressions in complete denture prosthodontics. A polysiloxane impression material was used to bor-
questionnaire containing 12 questions was mailed der-mold custom impression trays. The authors be-
to 905 general practitioners. The response rate was lieved that using this material for border molding
50%; 95% of the respondents treated edentulous in a conventional fashion and using the selective
patients with complete dentures; 74% used custom pressure placement impression technique could
trays for definitive impressions; and 94% used irre- yield predictable results in making properly ex-
versible hydrocolloid impression material for the tended, accurate, definitive impressions. Evidence
definitive impressions; with 29% using zinc oxide/ was not presented to justify the technique, however.
eugenol and 13% using vinyl polysiloxane. Irrevers- Due to the complexities involved in complete
ible hydrocolloid is not considered the material of denture treatment, patients generally experience
choice for definitive denture impressions in U.K. an adjustment phase after the dentures are in-
dental schools. serted. Postinsertion adjustments and/or scheduled
Definitive impressions for complete dentures follow-up appointments are necessary to ensure
have been identified as a difficult technique to proper fit of the dentures to the soft tissues and
master for dental students with limited experi- optimal occlusion, and also to monitor the patients’
ence.9 Students generally scheduled between two overall response to treatment.3,17 Multiple unsched-
and four appointments to complete the definitive uled postinsertion adjustment appointments can be
impressions.10 costly and frustrating to clinicians and patients
The definitive impression technique is report- alike.
edly one of the more critical elements in complete Seiffert et al18,19 suggested that patients’ person-
denture prosthodontics.11 The objective in defini- alities and their relationships with dentists play
tive impressions is for clinicians to obtain accurate substantial roles in the overall successful adapta-
impressions of the denture-bearing areas of the tion to complete dentures.18,19 They found psycho-
edentulous jaws.9 Accurate impressions are impor- logical attributes to be as important to successful
tant in fabricating stable and retentive prostheses adaptation as a patient’s anatomical features and
with optimal esthetics and function and a comfort- the clinician’s skills in fabricating complete den-
able fit for edentulous patients. tures. Davis et al20 examined the clinical dilemma
Definitive denture impressions may be made of providing dentures to patients with unrealistic
with various materials: impression plaster, zinc- expectations for new complete dentures, and found
oxide/eugenol, polysulfide rubber, irreversible hy- that a patient’s pretreatment expectations might
drocolloid, vinyl polysiloxane, or polyether.3 The influence treatment outcomes; treatment failures
techniques for definitive denture impressions can may result from mismatched perceptions and ex-
be classified as mucostatic,12 maximum displace- pectations of the patient and the dentist. Lamb and
ment,13 functional,14 or selective pressure.15 Varia- Ellis21 found that postinsertion adjustments may be
tions in these fundamental concepts have been related to poor patient compliance/understanding.
described by numerous authors.3,11,15,16 It has been McGarry et al22 formulated a classification sys-
acknowledged that a single technique cannot be tem for complete edentulism based on objective
used for all clinical situations.3,4 Textbooks in com- criteria. This system was originally developed to
194 Two Impression Techniques in Complete Denture Prosthodontics ● Drago

improve communication among dental profession- flanges of the complete dentures were quantified by the
als and third-party payors. The classification system number of postinsertion appointments required for one
was devised to identify those patients who would year after insertion of the complete dentures. The data
most likely merit treatment by a specialist or by a for this study were taken from clinical patient records.
Only those denture adjustments that involved the height
practitioner with additional training and experi-
or thickness of the denture flanges were quantified by the
ence in advanced techniques. This classification
number of times that patients presented to the dental
system might also prove valuable in clinical re- office for denture adjustments. The number or locations
search by classifying patients into groups with char- of the denture adjustments were not quantified, because
acteristics that can be identified and measured. there is significant variability in the clinical presentations
Despite the large volume of literature regarding of denture irritations. Prosthodontic services were paid
patient satisfaction with complete denture therapy, for with personal funds, Medicaid, and private insurance.
there is no consensus among authors as to reliable Immediate dentures were not included in the study. All
predictors of denture success.23 If a definitive im- patients had been edentulous for at least one year before
pression technique could be developed that was the preliminary impressions and had been wearing com-
easier to perform than conventional border-mold- plete dentures for at least one year before definitive
ing techniques with modeling plastic impression impressions for this study.
compound, took less clinical time, and did not in- The complete dentures were fabricated according to
established prosthodontic principles.4,10 One dental lab-
crease the number of postinsertion visits to dental
oratory technician accomplished all of the laboratory
offices, then more dentists might elect to treat
procedures.
more edentulous patients with complete dentures. Custom denture impression trays were taken to the
The purpose of this study was to compare the mouth, and the tray borders were adjusted to have ap-
number of postinsertion adjustments needed by proximately 2 mm of clearance between the tray borders
edentulous patients who had complete dentures and the mucobuccal and mucolingual folds. The frenum
fabricated using a traditional technique versus notches were adjusted to provide similar clearances. The
those with complete dentures fabricated using a posterior extensions of maxillary trays extended 3 to 5
modified technique in a retrospective analysis of mm beyond the vibrating line of the soft palates.
patients in a private practice setting. Border molding of the custom trays was accomplished
with 1 of 2 impression materials and techniques. With
the traditional technique, gray modeling plastic impres-
Materials and Methods sion compound (Kerr USA, Romulus, MI) was applied in
In this retrospective study, all patients were treated by increments around the periphery of the impression trays.
the author in a private practice setting within a large The clinician border-molded each individual segment;
multispecialty medical/dental group practice in the Up- the patient accomplished tongue movements and swal-
per Midwest (Gundersen Lutheran Medical Center, La lowing. The border-molding process required between 5
Crosse, WI). Patient records were retrieved based on and 10 attempts in the maxillae and between 7 and 10
CDT-3 (Current Dental Terminology-3) codes for com- attempts in the mandible. The mouth was dried with
plete maxillary and mandibular dentures (05110 and gauze before the definitive impressions were made. Tray
05120, respectively).24 A group of 78 consecutive edentu- adhesive (3M Dental Products, St. Paul, MN) was applied
lous patients was treated with the traditional technique to the impression trays, and all definitive impressions
involving custom light-polymerized impression trays. The were made with light-body vinyl polysiloxane impression
impression trays were border-molded with modeling plas- material (Extrude; Kerr USA).
tic impression compound. Another group of 78 consecu- In the modified technique, tray adhesive (3M Dental
tive edentulous patients was treated with a modified Products) was placed on the borders of the trays and
impression technique involving custom light-polymerized allowed to dry. Heavy-body vinyl polysiloxane impression
impression trays that were border-molded with heavy- material (Extrude; Kerr USA) was applied to the borders
body vinyl polysiloxane impression material. The patients of the impression trays, and border molding of the max-
ranged in age from 18 to 75 years. Fifty-six males were illary trays was accomplished with one application of the
treated, 26 with the traditional technique and 30 with the heavy-body impression material. Mandibular border
modified technique. One hundred females were treated, molding was accomplished in a similar fashion. After the
52 with the traditional technique and 48 with the modi- labial and buccal border molding was completed, the
fied technique. All patients were edentulous and were patient was instructed to place the tongue in contact with
treated with complete maxillary and mandibular den- the anterior tray handle after swallowing. The mouth was
tures. Patients were followed for 1 year after insertion of dried with gauze before the definitive impressions were
the complete dentures. Postinsertion adjustments to the made. Tray adhesive (3M Dental Products) was applied
September 2003, Volume 12, Number 3 195

Table 1. Comparison of Denture Adjustments/Impression Technique


Traditional Technique Modified Technique
Total number of adjustments 206 210
Average adjustments per patient 12 months postinsertion 2.6795 2.6795
Average adjustments per denture 1.32 1.35
Range of adjustment visits 0–8 0–11
Patients with 5 or fewer postinsertion adjustments 67 72
Patients with 4 or fewer postinsertion adjustments 65 68
Patients with 3 or fewer postinsertion adjustments 56 57

to the impression trays, and all definitive impressions Results


were made with light-body vinyl polysiloxane impression
material (Extrude; Kerr USA). Working time with this Denture adjustments (height or thickness of den-
material was approximately 2 minutes. After the mate- ture flanges) within the first 12 months after the
rial had set, the impressions were removed and inspected dentures were inserted ranged from 0 (4 patients)
for voids. to 8 (1 patient) with the traditional technique and
Master casts, occlusion rims, waxed dentures, and from 0 (6 patients) to 11 (1 patient) with the
definitive dentures were fabricated using conventional modified technique. The average number of adjust-
prosthodontic techniques.25-29 The author made the ulti- ment visits was 2.68 for the patients treated with
mate determination of the vertical dimension of occlu- the traditional technique and 2.68 for those treated
sion. with the modified technique (Table 1).
The 3-dimensional orientation of the maxillary casts The data were compared using the Student t test
and their relationships to the cranial structures were (Table 2). There was no significant difference in the
transferred to semi-adjustable articulators (Hanau H-2 number of adjustments required for patients whose
Articulator; Teledyne Hanau, Buffalo, NY) with an arbi-
dentures were made with either technique (t ⫽
trary face bow (Hanau Earpiece Face Bow; Teledyne
0.000, p ⫽ 1.00).
Hanau).30 The casts were mounted with mounting stone
(Whip Mix, Louisville, KY), mixed according to the man-
ufacturer’s instructions. Discussion
One dental laboratory technician set the denture
teeth. All patients were treated with acrylic resin teeth Definitive complete denture impressions are be-
(Justi Blend; Justi Products, Oxnard, CA). The anterior lieved to be 1 of the critical factors in determining
teeth were set in positions consistent with the contours success or failure for patients wearing complete
established by the maxillary occlusion rims. Posterior dentures.10 The definitive impression appointment
teeth (20° Anatomical Justi Blend; Justi Products) were is generally considered to be 1 of the more time-
set in posterior balanced occlusion. Patients, significant consuming and technically difficult appointments
others, and the author evaluated the esthetics, lip sup- in the traditional treatment sequence for complete
port, occlusal vertical dimension, and rest vertical dimen- dentures.8-10 If modeling plastic impression com-
sion of the wax dentures at the wax try-in appointment. pound is used as the border molding material, then
The author evaluated the accuracy of the jaw relation clinicians must heat the compound, apply the soft-
records in accordance with the foregoing parameters. ened material to the impression tray, temper the
The dentures were deemed ready for processing only tray, and place the tray into the patient’s mouth.
after all steps had been completed.
Border molding is accomplished with the clinician
All of the dentures were processed with heat-
moving the tissues in a manner consistent with
polymerized acrylic resin (Lucitone 199; Dentsply
International, York, PA) following the manufactur-
er’s instructions. The dentures were inserted, and Table 2. Student t Test
patients were followed for at least 1 year. The num-
Standard Deviation
ber of times that patients returned for adjustments Standard Error
relative to thickness and the heights of the denture Technique n Mean of the Mean
flanges were recorded. The severity of the denture
adjustments was not qualified, because this param- Traditional 78 2.6795 1.8966 .2148
Modified 78 2.6795 2.0858 .2362
eter was thought to be too subjective.
196 Two Impression Techniques in Complete Denture Prosthodontics ● Drago

function. Modeling plastic impression compound Moreover, the relationships that existed between
presents the clinician with a finite working time to the author and the patients may also have had a
modify the modeling plastic impression compound bearing on an individual patient’s need to return for
before it hardens. This procedure requires multiple denture adjustments.18,19
attempts per edentulous jaw. After the border The number of postinsertion adjustments for
molding has been completed, definitive impressions complete denture patients is a complex phenome-
may be made. Heavy-body vinyl polysiloxane may non. One patient required 11 postinsertion adjust-
also be used to accomplish border molding in com- ment visits. Certainly other factors (eg, occlusion,
plete denture definitive impression techniques.5 denture fit, diet) played important roles in the need
Irreversible hydrocolloid may be used as the final for postinsertion adjustment visits required by this
impression material with or without border mold- patient as compared with the number of visits
ing. However, irreversible hydrocolloid impressions required by the other complete denture patients
are generally overextended. Clinicians may realize who did not need to return for postinsertion adjust-
a significant time savings with the irreversible hy- ments. Although border-molding and definitive im-
drocolloid impression technique, because border pression techniques are important in fabricating
molding is accomplished at the same time as the successful complete dentures for edentulous pa-
definitive impression. However, this may result in tients, it is unlikely that border-molding techniques
ill-fitting dentures that need extensive modification and materials are solely responsible for the number
after the dentures have been inserted.4 of postinsertion adjustments in complete denture
In this study, the level of denture experience patients.
varied from the second set of dentures for some Complete edentulous patients exhibit a broad
patients to the fourth set of dentures for others. range of physical and psychological variations. Phys-
The amount of bone resorption of the edentulous ically, all of the patients in this study were without
jaws of the patients treated in this study ranged teeth and merited complete denture treatments.
from mild to significant. A larger number of pa- Classifying all of the edentulous patients in this
tients would be required to adequately group pa- study as being members of one diagnostic or exper-
tients with similar degrees of bone resorption and imental group would be inaccurate and would not
to evaluate any correlation that may exist between take into account the multiple levels of physical
bone resorption and the number of postinsertion variations present. This study was retrospective,
denture adjustments. and although the author has a standardized treat-
Denture adjustments are multifactorial, af- ment protocol for the patients in this study, this
fected by the amount of residual ridge resorption, study could not take into account the subtle differ-
health of the soft tissues covering the edentulous ences in the procedures needed to complete the
jaws, adaptability of patients to complete dentures, denture treatments for all of the patients.
skills of the clinicians and dental laboratory techni- The present study included 156 patients, with
cians involved in the treatment, jaw relationships, varying amounts of bone resorption and different
denture occlusion, and other factors. There were no levels of denture experience. The conclusions from
significant differences in terms of postinsertion ad- the present study would have a greater degree of
justments between the patients treated with either validity if there were more patients and if these
impression technique in this study. However, this patients had been classified more specifically. A
does not mean that either technique should be power analysis was conducted, and it was deter-
taken as the definitive method of fabricating defin- mined that 268 patients would be needed in each
itive complete denture impressions, because of sev- group to detect a true difference in the mean
eral limitations in the design of this study: The total number of visits of 0.5, assuming that the common
number of patients is too small to make conclusions standard deviation is 2.060 using a 2-group t test
for all edentulous patients; some patients can bet- with a 0.05 2-sided significance level. The author
ter adapt to dentures than other patients; and did not have access to the records of this quantity of
anatomical variations among patients and the au- patients for inclusion into this study.
thor’s clinical experience may not be representative The definitive impression technique described in
of other clinicians. There were also differences this study may not be applicable for all clinicians.
among patients relative to fit of the dentures, ver- Because complete denture prosthodontics is both
tical dimension of occlusion, and other factors. an art and a science, some of the results described
September 2003, Volume 12, Number 3 197

in this article may be attributed to the clinical skills 9. Duncan JP, Taylor TD: Teaching an abbreviated impression
and knowledge of the author. Clinicians with lim- technique for complete dentures in an undergraduate dental
curriculum. J Prosthet Dent 2001;85:121-125
ited/different experiences and biases in complete
10. Sharry J: Complete Denture Prosthodontics (ed 3). New
denture prosthodontics may not experience the re- York, McGraw-Hill, 1974, pp 191-211
sults that have been described herein. Further re- 11. Klein IE, Broner AS: Complete denture secondary impres-
search with a larger group of patients is warranted sion technique to minimize distortion of ridge and border
to establish a correlation between the modified tissues. J Prosthet Dent 1985;54:660-664
12. Page HL: Mucostatics—A capsule explanation. Chron
impression technique described in this study and
Omaha Dist Dent Soc 1951;14:195-196
the number of postinsertion adjustment visits 13. Fournet SC, Tuller CS: A revolutionary mechanical princi-
needed by complete denture patients. ple utilized to produce full lower dentures surpassing in
stability the best modern upper dentures. J Am Dent Assoc
1936;23:1028-1030
Conclusions 14. Vig RC: A modified chew-in and functional impression tech-
nique. J Prosthet Dent 1964;14:214-220
Within the limitations of this study, there was no
15. Heartwell CM, Rahn AO: Complete denture impressions, in
significant difference in the number of postinser- Heartwell CM, Rahn AO: Syllabus of Complete Dentures
tion appointments required for patients with den- (ed 4). Philadelphia, PA, Lea and Febiger, 1986, p 208
tures fabricated using the traditional technique 16. Winkler S (ed): Essentials of Complete Denture Prosth-
(border-molding with modeling plastic impression odontics (ed 2). Boston, MA, PSG Publishing, 1988, pp
compound) and those with dentures fabricated us- 88-106
17. MacGregor AR, Fen HRB: Fenn, Liddelow and Glimson’s
ing the modified technique (border-molding with Clinical Dental Prosthodontics (ed 3). London, Wright,
heavy body vinyl polysiloxane) for definitive impres- 1989, pp 43-77
sions. 18. Seiffert I, Langer A, Michman J: Evaluation of psychologic
factors in geriatric patients. J Prosthet Dent 1962;12:516-
523
Acknowledgment 19. Langer A, Michman J, Seiffert I: Factors influencing satis-
faction with complete dentures. J Prosthet Dent 1961;11:
The author gratefully acknowledges the support of the
1019-1031
Gundersen Lutheran Medical Foundation, LaCrosse,
20. Davis E, Albino J, Tedesco L: Expectations and satisfaction
Wisconsin and John D. Rugh, PhD, The University of of denture patients in a university clinic. J Prosthet Dent
Texas Dental School at San Antonio. 1986;55:59-63
21. Lamb D, Ellis B: Comparisons of patient self-assessment of
complete mandibular denture security. Int J Prosthodont
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