Modified fluid wax impression for a severely resorbed edentulous mandibular ridge

Kian M. Tan, BDS,a Michael T. Singer, DDS, MS,b Radi Masri, BDS, MS, PhD,c and Carl F. Driscoll, DMDd Baltimore College of Dental Surgery, University of Maryland, Baltimore, Md
This article describes a technique for making a definitive impression for highly displaceable residual ridges. The technique is especially applicable for mandibular edentulous ridges. The choice of the impression materials, as well as the design of the impression tray, focuses on preventing distortion of the displaceable residual ridges during impression making. Using an impression tray with an opening, modeling plastic impression compound and impression wax are used to accurately capture the shape of the residual ridge and place pressure onto denture load-bearing areas. Lowviscosity vinyl polysiloxane impression material is then used over the window opening to capture the surface details of the residual ridge without distorting the displaceable tissues. The use of this technique helps in maintaining the contour and capturing the detail of the tissues, as well as in accurately determining the extent of the muccobuccal denture extensions. ( J Prosthet Dent 2009;101:279-282) Making a definitive impression of an edentulous arch can be challenging when the residual ridges present with less-than-ideal conditions, especially when there is minimal bone height, unfavorable residual ridge morphology, and/or unfavorable muscle attachments.1 Impressions are also challenging when the mucosa overlying the residual alveolar ridges is highly displaceable. Displaceable, hyperplastic, or flabby tissues are commonly seen in the anterior region of the maxilla in combination syndrome2 or in the mandibular alveolar ridge when extensive bone resorption has occurred.3 Displacing such residual ridge tissues during impression making is always a concern. Soft tissues that are displaced during impression making tend to return to their original form, and complete dentures fabricated from the impression will not fit accurately on the recovered tissues. As a result, loss of retention and stability of the dentures, discomfort, and gross occlusal disharmony may occur.4
a

Most impression techniques for the management of displaceable tissues have been described for the anterior maxilla,5,6 and techniques to manage displaceable tissues in the mandible during impression making are rarely reported. Due to the anatomical differences between the maxilla and the mandible, as well as the differences in primary and secondary load-bearing areas, impressions of mandibular ridges with displaceable tissues require special considerations. A classic impression technique commonly used for the fabrication of immediate complete dentures7 or the treatment of patients with combination syndrome5 uses a custom impression tray with a window opening in the anterior region. When the maxillary edentulous ridge presents with anterior hyperplastic tissues, a zinc oxide eugenol impression is first made, and a creamy mix of impression plaster is then painted onto the displaceable tissues.5 Impression plaster produces little pressure, but

it is difficult to handle and difficult to pour8 and offers little advantage over contemporary low-viscosity vinyl polysiloxane materials. Mandibular residual ridges with adequate bone support can usually be precisely recorded with elastomeric impression materials because of the inherent accuracy of these materials and their propensity to distribute pressure equally. As the residual ridges resorb, the tissues become unsupported and displaceable; the use of an elastomeric impression material in a confined tray will result in a distorted impression. Therefore, the impression technique should be modified to prevent distortion of unsupported and displaceable tissues. A functional impression technique, such as fluid wax, captures the primary and secondary load-bearing areas without distortion of the residual ridge. In the mandible, the alveolar residual ridge serves as a secondary load-bearing area, with the buccal shelves serving as the primary load-bearing area.9,10

Postgraduate Prosthodontics Resident. Clinical Assistant Professor; private practice, Bethesda, Md. c Assistant Professor. d Professor, Program Director.
b

Tan et al

280
According to Applegate,11 the use of fluid wax in impression making was described previously by Everett. It has the following advantages: (1) it can be easily controlled to gain maximum coverage; (2) it can be corrected readily; (3) it can be used to accurately determine the extent of the muccobuccal reflections; and (4) it can be used to direct pressure to the load-bearing areas, specifically, the buccal shelves and the slopes of residual ridges in the mandible.10,11 The low-viscosity elastomeric impression material is advantageous because it creates minimal pressure, produces accurate details, does not distort easily, and is easy to handle.12,13 An alternative method of making a definitive impression for mandibular edentulous arches with displaceable tissues, using impression wax and vinyl polysiloxane impression material, is described.

Volume 101 Issue 4

1 Mandibular edentulous ridge with severe bone resorption.

TECHNIQUE
1. Make a preliminary impression of the edentulous arch (Fig. 1) using irreversible hydrocolloid impression material (Jeltrate Alginate; Dentsply Caulk, Milford, Del) in a metal stock tray (Rim-Lock Impression Tray; Dentsply Caulk). 2. Pour the impression in type III dental stone (Modern Materials Denstone; Heraeus Kulzer, Armonk, NY) (Fig. 2). 3. Fabricate a custom impression tray on the preliminary cast using light-polymerized acrylic resin tray material (Triad TruTray; Dentsply Trubyte, York, Pa). Adjust the border extension of the tray to be at least 2 mm short of the vestibules on the preliminary cast.9 4. Evaluate and adjust the extension of the tray in the mouth, if necessary. Soften modeling plastic impression compound (Gray Stick; Kerr Corp, Orange, Calif ) in a water bath at 53C, and place it on the intaglio surface of the tray, corresponding to the region of the mandibular central incisors and both the mandibular first 2 Preliminary cast. Note distortion of left alveolar ridge lingually due to pressure exerted by irreversible hydrocolloid impression material.

3 Window opening of impression tray. molars, to serve as spacers for impression wax. 5. Border mold the tray with modeling plastic impression compound in segments. 6. Remove the spacers with a scalpel blade (Becton, Dickinson and Co, Franklin Lakes, NJ) once the border molding is completed. 7. Trim the tray over the crest of the residual ridge, and create a window opening above the displaceable alveolar ridge using a No. 8 round bur (Brasseler USA, Savannah, Ga), similar to the tray design described by Watson.5 Determine the size of the window opening according to the extent of the displaceable tissues (Fig. 3). 8. Melt the mouth temperature im-

The Journal of Prosthetic Dentistry

Tan et al

April 2009

281

4 Fluid wax impression.

5 Application of vinyl polysiloxane impression material over window opening.

6 Completed modified fluid wax impression. pression wax (D-R Miner Dental Waxes, Medford, Ore) in a container held in a water bath at 42C, and apply the impression wax onto the borders of the tray with a wax spatula while it is still fluid. Ensure that the temperature used to melt the impression wax is less than the working temperature of the modeling plastic impression compound used in the border molding procedure, to prevent distortion. 9. Place the impression tray immediately over the edentulous ridge, and leave it in the mouth for approximately 5 minutes. Allow adequate time for the mouth temperature impression wax to flow and escape to the periphery of the impression, as well as to solidify. 10. Remove the impression tray from the mouth and cool it immediately in water at room temperature. 11. Add impression wax in increments on the periphery until a defi-

7 Boxing of impression. rial; Dentsply Caulk) over the window opening. Prevent distortion of the soft tissues by placing the impression material in the most passive manner possible. 16. Gently blow air onto the impression material to allow the spread of the impression material over the mucosal surfaces. 17. Allow the impression material to polymerize according to the manufacturers recommendation (Figs. 5 and 6). 18. Remove, disinfect, and box the impression using a mix of plaster and pumice as described by Martin et al (Fig. 7).14 Avoid using a conventional boxing procedure that requires boxing wax, as it may distort the impression wax. 19. Pour the impression in type III dental stone (Modern Materials Denstone; Heraeus Kulzer) as soon as possible (Fig. 8).

nite reproduction of the muccobuccal fold is obtained. 12. Apply impression wax onto the intaglio surface of the tray to capture the remaining surfaces of the residual ridge. Add impression wax onto the slopes of the ridge, rather than the crest, in increments,10 until a glossy surface is visible.11 Maintain the integrity of the residual ridge by exerting pressure onto the slopes (Fig. 4). 13. Trim away any excess impression wax on the periphery or over the window opening with a scalpel blade. 14. Apply adhesive (Caulk Tray Adhesive; Dentsply Caulk) on the tray in the area surrounding the window opening, and allow it to dry. 15. Place the impression tray onto the residual ridge and inject vinyl polysiloxane impression material (Aquasil Ultra Monophase Regular Set Smart Wetting Impression Mate-

Tan et al

282

Volume 101 Issue 4

5. Watson RM. Impression technique for maxillary fibrous ridge. Br Dent J 1970;128:552. 6. Lynch CD, Allen PF. Management of the flabby ridge: using contemporary materials to solve an old problem. Br Dent J 2006;200:258-61. 7. Campagna SJ. An impression technique for immediate dentures. J Prosthet Dent 1968;20:196-203. 8. Freeman SP. Impressions for complete dentures. J Am Dent Assoc 1969;79:1173-8. 9. Zarb GA, Bolender CL, Eckert SE, Fenton AH, Jacob RF, Mericske-Stein R. Prosthodontic treatment for edentulous patients: complete dentures and implantsupported prostheses. 12 ed. St. Louis: Mosby; 2003. p. 232-33, 246. 10.Boucher CO. A critical analysis of midcentury impression techniques for full dentures. J Prosthet Dent 1951;1:472-91. 11.Applegate OC. Essentials of removable partial denture prosthesis. 3rd ed. Philadephia: WB Saunders; 1965. p. 254-5. 12.Al-Ahmad A, Masri R, Driscoll CF, von Fraunhofer J, Romberg E. Pressure generated on a simulated mandibular oral analog by impression materials in custom trays of different design. J Prosthodont 2006;15:95-101. 13.Masri R, Driscoll CF, Burkhardt J, Von Fraunhofer A, Romberg E. Pressure generated on a simulated oral analog by impression materials in custom trays of different designs. J Prosthodont 2002;11:155-60. 14.Martin JW, Jacob RF, King GE. Boxing the altered cast impression for the dentate obturator by using plaster and pumice. J Prosthet Dent 1988;59:382-4. Corresponding author: Dr Radi Masri 650 West Baltimore St, Room 4228 Baltimore, MD 21201 Fax: 410-706-1565 E-mail: rmasri@umaryland.edu Copyright 2009 by the Editorial Council for The Journal of Prosthetic Dentistry.

8 Resultant definitive cast.

SUMMARY
A definitive impression technique using both impression wax and vinyl polysiloxane impression material for displaceable mandibular residual ridges is described. Consideration has been given to the choice of impression materials as well as to the design of the impression tray to minimize the amount of pressure exerted onto the displaceable regions of the residual ridges during the impression-making procedure.

REFERENCES
1. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH. Classification system for complete edentulism. The American College of Prosthodontics. J Prosthodont 1999;8:27-39. 2. Kelly E. Changes caused by a mandibular removable partial denture opposing a maxillary complete denture. J Prosthet Dent 1972;27:140-50. 3. Xie Q, Nrhi TO, Nevalainen JM, Wolf J, Ainamo A. Oral status and prosthetic factors related to residual ridge resorption in elderly subjects. Acta Odontol Scand 1997;55:306-13. 4. Lytle RB. The management of abused oral tissues in complete denture construction. J Prosthet Dent 1957;7:27-42.

Availability of Journal Back Issues

As a service to our subscribers, copies of back issues of The Journal of Prosthetic Dentistry for the preceding 5 years are maintained and are available for purchase from Elsevier Inc until inventory is depleted. Please write to Elsevier Inc, Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887, or call 800-654-2452 or 407-345-4000 for information on availability of particular issues and prices.

The Journal of Prosthetic Dentistry

Tan et al