Selective-pressure single impression procedure for tooth-mucosasupported removable partial dentures

Herman B. Dumbrigue, DDM,a and Josephine F. Esquivel, DDM, MSa University of Florida College of Dentistry. Gainesville, Fla.
This article describes a method of making impressions for tooth-mucosasupported removable partial dentures using a single impression procedure. Through the use of border-molded custom trays, selectively relieved, and application of pressure on residual ridge areas, the objectives of maximum tissue coverage and selective tissue placement of primary stress-bearing areas are fulfilled. With a single impression procedure, treatment time is reduced and laboratory errors commonly encountered with the altered cast impression technique can be minimized or eliminated. (J Prosthet Dent 1998;80:259-61.)

upport for tooth-mucosasupported removable partial dentures (RPD) is derived from structures with markedly different viscoelastic responses to loading. Abutments and tissues over the residual ridge will distort approximately 20 m and 500 m, respectively, under 4 N of force.1 Recognition of this disparity has led to use of impression procedures that attempt to accommodate the difference in resiliency between hard and soft tissue support. No single impression material can record the anatomic form of teeth and functional form of the residual ridge simultaneously.1 Clinical studies on a limited number of patients suggest that different impression procedures result in varying amounts of denture base movement under simulated occlusal load, with the altered cast impression providing the least amount of tissueward movement.2,3 The purpose of the altered cast impression is 2-fold: (1) to obtain maximum tissue coverage for support within the physiologic tolerance of limiting border tissues and (2) to capture the spatial relationship of residual ridges to the teeth. Two philosophies exist on the residual ridge form that is best obtained in impressions for favorable denture base support. Some clinicians 4,5 advocate making impressions with no pressure applied to the residual ridge, whereas others advocate loading the residual ridge during the impression procedure.1,6-8 The altered cast impression, as described by Leupold and Kratochvil,5 displaces residual ridge mucosa.9 Although the altered cast impression fulfills the requirements of relating the anatomic form of teeth to the functional form of the residual ridge, there are disadvantages to this procedure. Making an altered cast impression requires additional treatment time and laboratory procedures involved are difficult. Errors may be introduced in orienting and stabilizing the framework on the sectioned cast and an additional appointment is needed for making interocclusal records. To simplify the laboratory phase of the altered cast procedure, several clinicians advocate making a fullarch irreversible
aAssistant

Fig. 1. Aluminum foil and two sheets of baseplate wax over diagnostic cast before tray fabrication.

hydrocolloid pick-up impression over the remaining teeth, framework, and altered cast impression to generate a new master cast.7,10,11 However, 2-stage impression procedures may introduce other errors.12 Prefabricating custom impression trays that attach to the framework has also been suggested to minimize laboratory time necessary between framework try-in and altered cast impression.13,14 An impression procedure for tooth-mucosa supported RPD is presented that relates the anatomic form of teeth to the functional form of the residual ridges with a single impression.

PROCEDURE
1. Place two layers of baseplate wax relief over the teeth and residual ridges of the diagnostic cast. Burnish aluminum foil over the wax with either an egg burnisher or the back of a wax spatula No. 7. Place occlusal stops on the teeth by making definite boxes through the aluminum foil and wax to
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Professor, Department of Prosthodontics.

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Fig. 2. Custom tray fabricated with extensions reduced 2 mm short of vestibule. Fig. 4. Border molding procedure completed.

3.

4.

5.

6.

B
7.
Fig. 3. A, Custom tray with softened modeling compound reseated on diagnostic cast. B, Modeling compound over residual ridges shaped appropriately before intraoral placement.

merizing tray resin with borders 2 mm short of the functional vestibule (Fig. 2). Check intraorally for overextension and reduce as necessary. Remove wax relief and wet surface of cast. Place softened thermoplastic modeling compound (Kerr Mfg. Co., Romulus, Mich.) on the tissue surface of the custom tray overlying residual ridges. Reseat custom tray on the diagnostic cast (Fig. 3). (This procedure shapes the modeling compound appropriately before intraoral placement.) Reheat compound and place intraorally, placing finger pressure on the area of the residual ridges. Apply modeling compound to lingual borders of custom tray and any modification spaces and complete border molding procedure (Fig. 4). Reduce modeling compound contacting the tissue surface by 1 mm except at the pear-shaped pad and buccal shelf areas. (This selectively places pressure over the primary stress-bearing areas during the impression procedure.) Make the impression with low viscosity polysulfide rubber impression material (Light-bodied Permlastic, Kerr Mfg. Co.). Apply finger pressure over residual ridge areas during subsequent border molding steps and while impression material is setting. Inspect impression for accuracy (Fig. 5) and pour in type IV dental stone.

DISCUSSION
Alternative methods of relating the anatomic form of teeth to the functional form of the residual ridges have been advocated because of inherent problems associated with the altered cast impression procedure.8,15-17 These methods include making a reline impression after wax denture try-in15 or at the time of
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ensure proper reseating of the tray during border molding procedures (Fig. 1). 2. Fabricate custom tray with either Triad VLC custom tray material (Dentsply, York, Pa.) or autopoly260

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B
Fig. 5. A, Final impression made with light-bodied polysulfide material. B, Areas of compound visible through wash impression over buccal shelf and pear-shaped pad, indicating selective tissue placement.

denture insertion,8 and single-tray impression procedures that use different impression materials for teeth and residual ridges.16,17 Single-tray dual-impression procedures for tooth-mucosasupported RPD described in the literature16,17 are complicated. Other single-tray impression procedures advocated do not allow for selective placement of primary stress-bearing areas.18,19 Areas on the mandible considered primary stress-bearing include the pear-shaped pad and buccal shelf.20

SUMMARY
A simple and efficient impression procedure for obtaining maximum tissue coverage, for denture base support, that allows selective placement of tissues over primary stress-bearing areas is presented. The anatomic form of teeth and functional form of the residual ridges is obtained with a single impression procedure. Other advantages of this impression procedure include reduced treatment time, simplification of the laboratory phase, and reduction of errors that may be incorporated in the RPD. The alveolar lingual sulcus is also captured in its functional form, permitting placement of a sublingual bar when indicated.18,19
REFERENCES
1. McGivney GP, Castleberry DJ. McCrackens removable partial prosthodontics. 8th ed. St Louis: CV Mosby; 1989. p. 163-7, 327-37. 2. Holmes JB. Influence of impression procedures and occlusal loading on partial denture movement. J Prosthet Dent 1965;15:474-81. 3. Leupold RJ, Flinton RJ, Pfeifer DL. Comparison of vertical movement occurring during loading of distal-extension removable partial denture bases made by three impression techniques. J Prosthet Dent 1992;68:290-3. 4. Applegate OC. The partial denture base. J Prosthet Dent 1955;5:636-48. 5. Leupold RJ, Kratochvil FJ. An altered-cast procedure to improve tissue support for removable partial dentures. J Prosthet Dent 1965;15:672-8. 6. Hindels GW. Load distribution in extension saddle partial dentures. J Prosthet Dent 1952;2:92-100.

7. Bauman R, DeBoer J. A modification of the altered cast technique. J Prosthet Dent 1982;47:212-3. 8. Krol AJ, Jacobson TE, Finzen FC. Removable partial denture design, outline syllabus. 4th ed. San Rafael: Indent; 1990. p. 155-65. 9. Stuart LN, Elliot RW Jr. A comparative study of the tissue surface contours on casts fabricated by using two impression techniques for mandibular distal extension removable partial dentures. Am Coll Prosthodontists Newsletter 1983:13-6. 10. James JS. A simplified alternative to the altered-cast impression technique for removable partial dentures. J Prosthet Dent 1985;53:598. 11. Chen MS, Eichhold WA, Chien CC, Curtis DA. An altered-cast impression technique that eliminates conventional cast dissecting and impression boxing. J Prosthet Dent 1987;57:471-4. 12. Sykora O. An altered-cast impression technique that eliminates conventional cast dissecting and impression boxing (letter). J Prosthet Dent 1988;59:388. 13. Lund PS, Aquilino SA. Prefabricated custom impression trays for the altered cast technique. J Prosthet Dent 1991;66:782-3. 14. Lynde TA, Baker PS, Brandt RL, Berte JJ. Simplifying the altered cast impression technique for distal-extension removable partial dentures. J Prosthet Dent 1992;67:891. 15. Hoffman JM. An alternative to the altered cast procedure. J Prosthodont 1994;3:13-5. 16. Rapuano JA. Single-tray dual-impression technique for distal extension partial dentures. J Prosthet Dent 1970;24:41-6. 17. Von Krammer R. A two-stage impression technique for distal-extension removable partial dentures. J Prosthet Dent 1988;60:199-201. 18. Cecconi BT. Lingual bar design. J Prosthet Dent 1973;29:635-9. 19. Hansen CA, Campbell DJ. Clinical comparison of two mandibular major connector designs: the sublingual bar and the lingual plate. J Prosthet Dent 1985;54:805-9. 20. Jacobson TE, Krol AJ. A contemporary review of the factors involved in complete dentures. Part III: support. J Prosthet Dent 1983;49:306-13.

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