111; iml)rcssion technique herein described may he termed a balanced semistatic \Vith sonic inipression procedure for a normal,

healthy, etlentulous maxilla. illthough this modification, it is basically the same for all types of maxillae. ;I 5\-stematic method Of nuking _ impression procedure is an integral part (Ii It is a means complete dentures, it can 1~ tvxxl to advantage in any technique. Of fulfilling the impression requirements for closctl lxlatcs or palatvle5s i roofless 1 dentures. The entire theory luck Of this iml)ressic~u lxow(lwr is based 011 Our clinical uxlls of that tlw l;ctLaral and anterior findings which led LIS to the conclusion 1:y rising an individually prethe palate are the primary stress-l)earing areas. l)ressure pared tray (with the aid of \vas ), \VC nttemI)t to cilJtail1 eq~ial Materal the alveolar On the lateral and anterior palatal walls, \vllilv \ve I,rotcct, statically, ridge area which is less able to withstand tlir lnasticatory stresses. Some of tlic important imI)ression proc~~l~ire5 arc vithcr hased 011 cc~~~tprcssion 0i the entire masilla, or the\- arc an ;ipprOacl~ 10 au all-static impression : impresClinical lincliiigs indicate sions Iy hotli methods at-c wi~iallv lil~~sclc-trinili~ctl. similar wtl results lwx~isr lieither that each of these procetl~u-es can Ixoducr ,-Ill Oi tlx. alveolar ridge. Ixovitles Ixotcction to the cancrlloiw 1~0~1~mitlvrl\.ing this I)res~in~es that ait acceI~tal~le \-crtical xiitl centric rclatioii \vitli :I ~zilanwtl occltG)ll uxs Iuxvicled at tlw till!e of tlclivu\oi tllv fillisl?etl cltltmlrtah.

feel justified ~rlieii \ve say that it \v;is i10t naturvs 0rigillal mtent 10 ironi :I clr~itui-c l)asc~. alveolar ridge \~ithst;tntl tlw lxiiliar\~ 5trt2wb force\ oi tulusioii are cli5triluttvl \\lwll :I iiormal, natural tlentitioti is l~rwclit, 111 a Idallcctl iiiaiiner to Ihc occlusal s~iriares of tlie teeth, the roots iji . \\hich arc firnily inil~ctltletl in their sockets rlcell ii1 the 1~1tlv of the iriaxilla. I11t2 :tl\~eolar hone then ads a5 ;t 1Wtrcss Or ,wco~iclar!- s~iplwrt. \Z'llCll ted 1-i at-c iost, the maiii fiinction Of tlic ;il\volar I)one i5 also lost. \Vhen the liealtvl ;il\:wl;tr ritlgc is used as the primar\, stress-hearing xxx, we cannot expect tlial it 11ill llc wholly successful for ii long pcriotl lxcatisc ;i ridge thus f0rmcd ii iiot a, thoroughly contlitionetl as wtne Of the other areas of tllc nlasilla. It s('t"lllS !f I US that it is nlore logical to take advantage of and LISC the mow st:ll,ltb and COIItlitioned part 0i the maxilla. namely, the lateral ant1 anterior palatal rvalls oi the palate. From the day of birth onward, pressurize arc%cculstantly applirtl to lht. palate 114the tongue in its various functintis, cspcci:~lly iii the act of swallowii~~:. Thcx
lla\T

\\*e

tlw

Read before Received for

the American publication

Denture Aug. 27,

Society. 1051.

Chicago.

ill..

Feb.

3. 1951

AN

I~IlRl:SSIOK

IROCITJCRE

649

lmssures so condition the ti5ucs cli the lmlate that they are al~le to \vithstantl the stresses of a denture base far better thaii the alveolar ridge. Surgical distllrl);uice of the alveolar ritlge, such as in the eradication of infection, estraction of teeth, and alveolectomy, is followed by a comparatively short conditioning (healing) time. The stability of an alveolar ridge, the tissues of which have beeli but recently organized and conditioned, cannot compare with the stability of the palate which took a lifetime to establish and which was not, as a rule, disturbed by surgery. Especially is this true if a pyorrhetic condition has existed It is often two or more years before the alveolar ridge has Ijefore extraction. a mnl)lance of stability. This may be one reason why some patients have several tlentures made over a period of a few years before one is satisfactory. Since alveolar ridges, especially those with a history of pyorrhea, in various stages of resorption cannot withstand the stresses, some means of protection is indicated and should be provided. This assumption is based on the clinical observation of many maxillae in which the ridges were unduly reduced while the palatal area seemed to be intact. These findings suggested the use of an area which nature has conditioned during an average lifetime and which was capable of withstanding stresses greater than needed for the function of mastication with an artificial denture. The impression procedure presently employed 1)~ the members of the C)enture Research Group of Chicago takes advantage OF the clinical findings. This procedure directs the distribution of stresses to all areas according to their tolerance. IMore giving the actual technical procedure, we wish to mention that 110 imlmssions are ever attempted before a complete case history including a idI mouth x-ray e>:amination is obtained, even though the patient may be completely rdentulous. Surgery is resorted to only when (1) the tuberosity is bulky enough to interfere with the freedom of the masticatory movements and (2) soft flabby mandibular tissue overlies the remnants of the ridge (to help provide a more stable denture base). Surgery is not resorted to when a torus palatinus is present which does not encroach on the lateral and anterior palatal walls. Prom the medical and dental history of the patient, objective and subjective examinations, responsiveness to suggestions, conversations, expressed expectations, and other sources, enough information should be acquired to classify the patient. This knowledge will guide us in taking the necessary steps to obtain his full cooperation. His confidence, gained earlier, must be maintained. \IThen these factors of understanding and cooperation in both the patient and operator are present ill the greatest degree, we reach the optimum of psychosomatic equilibrium. The five important steps in good denture service in order of their importance are: (1) centric registration at an acceptable vertical dimension, (2) balanced articulation, (3) professional guidance, (4) impressions, and (5) adjustments.

Fig.

l.--Operator's

and

patient's

pwilion

In this position, the operator is able to control tllc. l)clsitic,ll oi the patictits \vhile he is maintaining equai bilateral pre,~s~n-~\vith the inks finger> (~1 the metal tray, thus obtaining the dwired type oi :I lmlancrtl impressitrli.
1lCitCl

TECIlNIL)II~ The technical procedure for the uplwr inlprekon is as iollowb . 1. Examine the mouth for loose particle:, of food or foreign I)odies. Have the patient rinse the mouth. Select a metal tray. the flanges of which have been

AN

IMPRESSION

PROCEDURE

651

shortened. This will be used as a base upon which an individual tray will be conFig. 2 shows the essential materials structed, with the aid of a red refined wax. used. The metal tray should be at least s inch larger than the entire circumference of the maxilla, transversely as well as anteroposteriorly. The posterior portion of the tray should extend to the hamular notches when the anterior section of the tray clears the most pronounced portion of the ridge by at least !,{ inch.

Fig.

Z.-Essential

materids.

2. Soften the narrow end of a sheet of red refined wax in a flame. Fold back twice a g inch strip of this wax, which will develop three thicknesses of wax. Cut this folded piece of wax from the sheet. While walking to the patient, break off and insert into the ridge areas of the dry tray, three equal parts of this softened wax (Fig. 3). One piece of the wax is placed in the region of the anterior midline and the other two in the tuberosity regions of the tray. All three pieces of the wax cover the ridge area as well as the labial and buccal portions of the tray. These three pieces of wax we call the alveolar guide blocks. I,ater they are alveolar guide forms. 3. To create the alveolar guide forms, insert the tray in the mouth and, while standing behind the patient, center the tray. Then press it into position with just enough pressure to reduce the alveolar guide block wax to 50 per cent of its thickness. Remove and check (,Figs. 4 and 5). Do not accept this step of the tray preparation if any portion of the metal tray shows through the wax of the alveolar guide forms. The wax which contacts the alveolar ridge should he at least twice as thick as the displaceability of the tissues involved. The use of the alveolar guide forms insures the accuracy of the metal tray selection and its adaptation since they indicate the amount of space occupied by the wax

652

Fig.

3.-Alreolar

guide

blocks

before

insertion.

Eig

Fig.

.i.

Iqjg, .q.-lnscrtion Fig.

of tray to cr~aw alveolar 5.-Alveolar guiric for!nr.

guide

forms.

Volume Kumber

1 6

AN

IMPRESSION

PROCEDURE

653

at the peripheries, give positive guide for the accurate subsequent centering and seating of the tray, and indicate the thickness of wax over the ridge areas. The accuracy of this step will facilitate the making of a static impression of this important area at the final step. 4. To create the palatal guide form, soften in the flame, but do not overheat, three-fourths of a sheet of red refined wax. Mold this wax into a walnut shape (the approximate shape and amount needed to fill the vault area of the palate). Adapt this palatal guide block wax to the tray so that it will slightly overlap the most lingual portion of the alveolar guide forms (Fig. 6).
Fie. 6.

Fig. Fig. Fig . 7.-The K-Adaptation palatal guide of form

7. the pal&al immediately block. after rexno\

Elevate the lip to aid in the insertion and centering of the tray (Fig. 4). While standing in back of the patient, center the tray, and with one quick, heavy upward pressure seat the tray into the position previously established by the alveolar guide forms. The excess wax is automatically expelled, creating the palatal guide form by this simple operation of applying equalized pressure.

Remove and examine carefully, making sure that the pal:~taJ g!ui[ic. ror!iIt lllust ;llccI ha\.? :I LV;~S covers all of the lateral and mterior palatal walls. qitle i0rni \vax ( l;ig. 7 I. I*:(J~I:I: !,ilzttc~r:i! unif~oriii Mtiitling with the alveolar ! ~riil;~trt.;rl prei Jjressure in creating the palatal guide ivrill ii ni(d iiqortant. ;A tissur? whic11, when tr:ui~ic-rrc~(l it 5 sure will result in unilateral tlisplacemrnt the finishetl clenture, coultl casilv i)e 011r ()i the C:LIISC,S0i tlcrit~ire ill--t;il)iiitb, l;urther examination of this iiidividual trax lmpar;ttiol~ will disclose a \ ct.\ cictinilt~ lmlling tlo\vn of the palatal guide wax in tllv post rl:tni area 1)~ tlit. iiivollmt;tri ;tctiou of the riiusclcs ai tlw soit palaW ( Iig. i 1. . . . I rot: 5. -1 1~~1 tlani is lm~vitletl for as ;L lurt oi the itrdiv1dual iilllumbi~ul This is acconq~lished hy partially chilling the wax, and then, with :L 4~~rl~. llt~atv~l knife. cutting away all excess was distal to a straight line drawn Ic\\YY~I~ J)oillt > about 2 mm. distal to the impressions d the right and left hamula~- :lotchc.s. ;I warm knife ldatlt 10 :L tlel~tli The post tlam is now tlevt~lcq3etl 1,~ inserting anteriorly of almut 3 or 5 min. into the wax rnitlway between the iiitaglio anil the metal base, then elevatiti g the wa-x across the entire lmst tlml :~rm 11) tl?l, The atnmlnl i- iiltlic.;ttr~l atnomt necessary to create an acceptalde post tlam 1)~ the resiliency of the tissl1r.i (Fig. 8, .-I ant1 x I. The post tlanl i> tciniorcvi 1)~ filling in the gap ma&~ 1)~ the knife hladr with molten was. ll~t~ IY:LY 1~ then thoroughly chilled. 0. Since the metal tr;l!. rlsetl had short flanges, it is iiecessar) to I~~~ilil the+ flanges in \vxs to the reclriirrments of the intlividual case. The intli~~i~l~~all~~ Jm will not only confiiic tlie iiiilm.4oii ljared was flanges, after proper treatment. material without muscle triniining. hut will also ImGle sdficient sJI;~ ior 1~111~ at1 d will facilitate rriiioval. The \\a;\; flanges make possible a clean ii-active oi In dtlitivli. the inlpression nlaterial iii estreme undercut :treas withont iitjur\.. the!. forin a niatris or I)ase \\-hich is extreliirl!~ helpful in ri.ssemhling the iractureti Jjieces. -1 solid nietal flange. in any sizalde uii(lercut, 5vc)uld injure 111~.!issrlc. since it wodtl not Geld when the impression was renloved and \vc-~ultl vvry oftr:! destroy the iiilpression. Remove the nufrriov :tlvedar guide form front the tray before zdaptitlg tlrc, \vas for the flanges. The retmaining posterior alveolar giiide forn34 :intt 11~. palatal guide form arc retained temporaril\RS aids in seating the trax fI:ig. (3 I The \vax for the flanges is prepared 1-1~softening the narrow end of n .5hrct cired refined wax. A f/ z inch strip is folded hack and united to J)rovitlc tu (1 thicknesses of Leas. From this folded portion, ctlt two equal strip. I<:t~:~I strip will provide sufficient wu for a flange on olle-half of the tray. that is. irot~~ the haniular notch to the frciiunl area. The soft warn1 \\:a.~ strips are atlaptvt! to the nletal peripher!.. Tlic tra\. is iiisrrtetl into the imouth aid 5e;itetI ii! exactly the same position and with the sanle 1)alanced pressure as was used when the palatal guide foriii \vas created. (The operators J)nsition shnultl l)e behinc! the patient and l~alaticetl.~ \\%ile this prtassurv is rnxintained with the inties fingers directlv in the center of the palate portion ~,i the tray, tlw lips ;LIT rk\-atecl and pushed against the maxill:~ u-ith the first l~h;~l:uls of each thuull). At tlw sanle tinle the second phalans is usetl to ~nold tllr l)tlccal portion,< of the was ;lgilillSt the iiiarill;l. The tray ant1 the XI\ :u-e rrnlovetl zuvl chill& i Fig. 10).

AN

IMPRESSION

PROCEDURE

655

The individual impression tray is completed as follows: The two remail ning alveo liar guide forms are cut away from the metal base, leaving only a suffic :ient mt ()f wax to confine and not to impinge tissues. Next, all of the pal atal g uide form wa.x on the ridge area is removed. The tissue side of the wax flang e is trimr ned away up to the crest of its periphery or roll. This is to allow a suffic :ient bulk of the impression medium, as explained previously. Sufficient exten sion

Fig.

8.-A

and

B,

Creating

the

post

dam

must he the tl lal; the 1% ax pilla is 1 trotti WI lievec1 h press we

\~olume 1
Sumher 6

6.57

iron n the greater palatine foramina because these lie deep under the palatal gl ands in t he grooves in the palatine processes of the maxillae. An adept operator requires only ten or fifteen minutes to complete the indi vidual tray. If the steps have been properly executed, the individual tray will make it possible to take a balanced semistatic impression (Fig. 11). A very -I rapi id-setting (forty-five to sevenths-five secondsi impression medium is used. 1- ow-

Fig.

11 .-The

comglered

individual

tray.

Fig.

U.-The

maximum

amount

of impression

material

used

and

its

location.

ever, an accelerator may be added to the impression plaster used in t-he average For all average patients, dcvuirl l.,t iooit dental office for use in this technique. flabby tissue, the material is mixed to a mlr crealu consistent>,. -I \x.m~!; cubli centimeters of room temperature water to 20 d\vt. of the rapid-setting ilnpressiciii material is ltsetl. A thinner iliis is reconmientlrtl ior ljatients nith 101)5r flal11)i
tissue.

Fig.

Fig. 13.-Insertion, 14.-Elevation

with the impression material. of the lip and bilateral pressure.

7. The patient is directed to rinse the mouth with cold water while the operator is mixing the impression material for 15 to 30 seconds. Only the hollowed The tray must not be overloaded (Fig. 12 ). out ridge portion of the tray is filled.

Volume
Surnher

1
6

AN

IMPRESSION

PROCEDURE

6.59

The operator should stand behind the patient, elevate the lip to facilitate insertion, center and seat the tray against the maxilla (Fig. 13). With the maxilla in a horizontal position and the head of the patient firmly supported by the operators body, an equal bilateral upward pressure of about 30 pounds is exerted with the index fingers positioned on the center of the tray. Only after the tray has been seated firmly in position should the lip be elevated with the thurnb to insure an accurate impression of the labial portion of the maxilla (Fig. 14 ).
Fk. 15.

Fig. Fig. %-The Fig. first step 16.-Dropping

16.

in the removal of the impression. of the finished impression.

The fast-setting impression material will not allow for muscle trimming, juggling the tray, or massage of the lip after the tray is seated. The steady equal pressure is maintained for about thirty seconds, then slowly released. After sixty to ninety seconds, the impression may be removed. 8. To remove the impression, the operator should stand in front of the patient. The thumbs are placed in the region of the maxillary fold just below

the zygomatic process. The patient is instructed to claw. .lhe cherh~~ ;irr s.g-iihpw j firmly between the index fingers and thunilrs 60 the l~ttccal tissues ui;i~. lw ix\ tended upward, then iorwartl, \vhile the lnoutll is CIUAYI. This iiletliod will releabc. all impressions not coinplicatetl 1)~ rscrsbi\x, uiitleruits ( Figs. 15. ! C,, ;trul 17 .i\ll fractured pieces are retrieved before the patient ririses the moutl~. I: ~~rlciu-c.nt~ cause an impression to fracture, it shoultl Ix n~st~m~~letl t)eforv the. lxttltnt in. dismissed ( Figs. 18 and l(J I. .A g-ootl working cast poured from thii type oi ati inipre~sion biilltll;tttb tlu closest approach to the actual condition of the tissues when the clultllrt. l):!h~. is in flinctioii. X denture base made over it \vill not exert uncluc* I)]-iiwrc ,113 the alveolar ridge.

1 operator

It is important and patient.

to obtain and maintain

a psychosomatic

ecluilil)rium

4 lath

2. Our clinical findings indicate that the lateral and anterior palatal ~~11:~ (rugae area ) can be and are nsed as stress-hearing areas with very gratifyiiig results. 3. Time is a very important factor in making impressiotl~, Tlw hest time the day to take an illl~~r~SskJll is after a pericK1 oi rest. No opeixtor c:ui maintain :\ vvry iast-setting an equally balanced steady pressure for a long period of time.
of impression lllaterd Will kdell lwlg 1dOre there :lre my s&is CJf fatigue to

The short setting tilne (of the inlpression material the tissues, patient, or operator. is of great value to the patient and the operator ii the patient happens tcb hr ;L gagger. Time saved at the chair is ai1 vconoiiiic factor to the q,erator :tntl :\ proficient operator ca11 produce au produces less vexation t(J the patient. acceptable impression in from fifteen to tn-enty minutes.

AK

IMPRESSION Fig. 18.

PROCEDURE

Fig.

19.

Fig.

19.-The

Fig. lr?.-The completed impression. completed imprcsxion showing the post

(am

elevation.

although a very important step, is only 1. The most perfect impression, fourth in value to an acceptable denture precedure. The impression procedure described is only a portion of a complete denture procedure known as the Psychosomatic Principles of Denture Practice.
64 WEST
CI~JCAGO. RANDOLPH ILL. STREET