CHAPTER 8

Maxillary impression procedures

The capability of the mucous membrane of denture bearing surface available. To a large
the basal seat to withstand stress from the den- extent this surface is readily identified if the bi-
ture base varies greatly because of the histo- ologic considerations of impression making are
logic makeup of different parts of the residual correctly understood. However, the denture’s
ridge. For example, the crest of the healthy retention is enhanced considerably if the den-
maxillary residual ridge is often designated as a ture extends peripherally to harness the resil-
primary or major stress-bearing area for den- iency of most of the surrounding limiting struc-
tures because the submucosa is formed by a tures. Therefore clinical techniques and, above
layer of thick fibrous connective tissue that is all, judgment must be reconciled if the objec-
attached firmly to compact bone. This combi- tives of impression making are to be fulfilled.
nation provides favorable support for the den- Although impression techniques, methods,
ture. On the other hand, the much thinner and materials of choice are constantly chang-
nonresilient mucous membrane and underlying ing, they nevertheless should be selected on
bone of the median palatal suture often re- the basis of biologic factors. Techniques too of-
quires relief for the denture base. Because of ten follow shortcuts, perhaps to satisfy the pa-
these variations, impressions of edentulous tient’s desire for immediate results, without a
ridges must selectively place pressures on the consideration of the future destruction that
mucous membrane and bone in amounts that such procedures may induce.
are compatible with the histologic tolerances of The objectives of an impression are to pro-
the supporting tissues for each patient. When vide retention, stability, and support for the
this important biologic principle is violated, denture. An impression also may act as a foun-
dentures lose retention, stability, and support; dation for improved lip esthetics and at the
create soreness; or cause resorption of the un- same time should maintain the health of the
derlying bone. It becomes obvious that for suc- oral tissues.
cessful treatment to occur the dentist must (1) Retention for a denture is its resistance to re-
understand the histology and pathology of the moval in a direction opposite that ofits inser-
living tissues that make up the basal seat and tion. It is the quality inherent in a denture
(2) use a clinical technique in making impres- that resists the force of gravity, the adhesive-
sions that will selectively distribute pressures ness of foods, and the forces associated with
to the basal seat to meet the needs of each the opening of the jaws. Retention is the
edentulous patient. means by which dentures are held in posi-
tion in the mouth. When the soft tissues
PRINCIPLES AND OBJECTIVES OF over the bones are displaced under pressure,
IMPRESSION MAKING the denture bases may lose their retention
The basic objective of a maxillary or mandib- because of the change in adaptation of the
basal surface of the denture to its basal seat.
ular impression is to record all the potential
169
170 Rehabilitation of the edentulous patient

Fig. 8-1 Complete dentures have three surfaces

that must harmonize with the oral biologic environ-
ment. A, The dentures’ polished surfaces are so
contoured as to support and contact the cheeks,
lips, and tongue. B and C, The impression or
basal surfaces are fitted to the basal seats. D and
E, The occlusal surfaces of one denture must fit
those of the opposing denture.
 Maxillary impression procedures 171

Stability of a denture is its quality of being Biologic principles of tissue health must be
firm, steady, and constant in position when adhered to before a final impression is made.
forces are applied to it. Stability refers espe- These principles were described in Chapter 7.
cially to resistance against horizontal move- The following concepts incorporated in any im-
ment and forces that tend to alter the rela- pression procedure will enhance the retention,
tionship between the denture base and its stability, and support of a denture (which are
supporting foundation in a horizontal or rota- all interrelated features):
tory direction. The size and form of the basal 1. The impression extends to include all of the
seat, the quality of the final impressions, the basal seat within the limits of the health and
form of the polished surfaces, and the proper functions of the supporting and limiting tis-
location and arrangement of the artificial sues.
teeth play a major role in the stability of the to. The borders are in harmony with the anatomic
dentures (Figs. 8-1 and 8-2). and physiologic limitations of the oral struc-
Support is the resistance of a denture to the tures.
vertical components of mastication and to oc- 3. A physiologic type of border-molding proce-
dure is performed by the dentist or by the pa-
clusal or other forces applied in a direction
tient under the guidance of the dentist. ;
toward the basal seat. Support is provided by
4. Proper space for the selected final impression
the maxillary and mandibular bones and material is provided within the impression
their covering of mucosal tissues. It is en- tray.
hanced by selective placement of UN Nadie 5. Selective pressure is placed on the basal seat
that are in harmony with the resiliency of during the making of the final impression.
the tissues that make up the basal seat (see 6. The impression can be removed from the
Fig. 7-3).

>~~ IY

re :
~ony
WN

re: ,
FR f ee
Ra My, yyy youn) ell
MS gil itn IU mh
Dy HE Ml, iMay iif Je
4 NA Wd tj, 4) uy) Cc
\\ Mad

uN be

Fig. 8-2 Frontal section showing dentures properly filling the available space. A, The
buccinator. B, The lingual flange and border are placed under the tongue. C, The mylo-
hyoid. Notice that both upper and lower dentures are so shaped that the action of the
tongue and cheeks tends to seat rather than unseat them. If posterior artificial teeth are
too wide buccolingually, the form of the dentures will be changed and the tongue and
cheeks will tend to unseat them.
172 Rehabilitation of the edentulous patient

mouth without damage to the mucous mem- seat, it builds up and literally pushes the den-
brane of the residual ridge. ture out of position. The forces of adhesion still
7. A guiding mechanism is provided for correct act on both surfaces, but the hydraulic pressure
positioning of the impression tray in the produced by the thick mucus secretions may
mouth. overpower them.
8. The tray and final impression are made of di-
Adhesion is also the molecular attraction be-
mensionally stable materials.
9. The external shape of the final impression is
tween the surfaces of unlike bodies in contact.
similar to the external form of the completed This type of adhesion is observed between den-
denture. ture bases and the mucous membranes of pa-
tients with xerostomia. The denture base mate-
The two most important factors in making rials seem to stick to the dry mucous mem-
satisfactory impressions for complete dentures brane of the basal seat and of the cheeks and
are a properly formed and accurately fitting fi- lips. Such adhesion is not very affective for re-
nal impression tray and proper positioning of taining dentures, and it is annoying to patients
the final impression tray on the basal seat in when it sticks the denture base to the cheeks
the mouth. and lips. A mouthwash of Cepacol and glycerin
can be helpful in this situation.
FACTORS OF RETENTION OF DENTURES
The amount of retention supplied by adhe-
A number of forces and factors combine to sion is directly proportionate to the area cov-
retain complete dentures in the mouth. Not all ered by the denture. Patients with small jaws
these factors act at the same time. Instead, (basal seats) cannot expect retention by adhe-
some act only when they are needed to meet sion to be as effective as patients with large
or resist a certain dislodging force. jaws can. Thus the dentures (and hence the im-
pressions) must extend to the limits of the
Adhesion
health and function of the oral tissues if they
Adhesion is the physical attraction of unlike are to have maximum adhesion and retention.
molecules for each other. It acts when saliva
wets and sticks to the basal surface of dentures Cohesion
and, at the same time, to the mucous mem- Cohesion is the physical attraction of like
brane of the basal seat. The effectiveness of ad- molecules for each other. It is a retentive force
hesion depends on the close adaptation of the because it occurs in the layer of saliva between
denture base to the supporting tissues and the the denture base and the mucosa. It is effective
fluidity of the saliva. A watery saliva is quite ef- in direct proportion to the area covered by the
fective, provided the denture base material can denture, if other factors are equal. Since saliva
be “wetted.” Some denture base materials al- is a liquid, the layer of saliva must be thin if it
low water (or saliva) to stick to them and is to be effective for retention. Therefore the
spread out in a thin layer. These materials have adaptation of the denture base to the mucosa
greater potential for being retained by adhe- must be as close as possible.
sion than materials that cause drops of water to
form over their surfaces. Interfacial surface tension
Adhesion of saliva to the mucous membrane Interfacial surface tension is the resistance to
is no problem because the saliva “wets” it very separation possessed by the film of liquid be-
effectively. Saliva that is thick and ropy ad- tween two well-adapted surfaces. It is found in
heres well to both the denture base and the the thin film of saliva between the denture
mucosa; but since much of it is produced by base and the mucosa of the basal seat and is
the palatal glands under the maxillary basal quite similar in its action to cohesion and to
 Maxillary impression procedures 173

capillary attraction, or capillarity. It is also ef- Oral and facial musculature

fective in direct proportion to the size of the The oral and facial musculature can supply
basal surface of dentures, if other things are supplementary retentive forces, provided (1)
equal. One of its requirements is minimal dis- the teeth are positioned in the neutral zone be-
tortion or displacement of the soft tissues by tween the cheeks and tongue and (2) the pol-
the impression and, of course, the denture. A ished surfaces of the dentures are properly
perfect fit is essential. shaped. This is not to say that patients must
hold their teeth in place by conscious effort,
Capillary attraction only that the shape of the buccal and lingual
Capillary attraction, or capillarity, is a force flanges must make it possible for the muscula-
(developed because of surface tension) that ture to fit automatically against the denture and
causes the surface of a liquid to become ele- reinforce the border seal (Figs. 8-1 and 8-2). If
vated or depressed when it is in contact with a the buccal flanges of the maxillary denture
solid. It is what causes a liquid to rise in a cap- slope up and out from the occlusal surfaces of
illary tube, since surface tension tends to form the teeth and the buccal flanges of the mandib-
a round surface on the liquid. When the adap- ular denture slope down and out from the oc-
tation of the denture base to the mucosa on clusal plane, the contraction of the buccinators
which it rests is sufficiently close, the space will tend to seat both dentures on their basal
filled with a thin film of saliva acts like a capil- seats.
lary tube and helps retain the denture. This The lingual surfaces of the lingual flanges
force, like the others, is directly proportionate should slope toward the center of the mouth so
to the area of the basal seat covered by the the tongue can fit against them and perfect the
denture base. border seal on the lingual side of the denture.
The base of the tongue is guided on top of the
Atmospheric pressure lingual flange by the lingual side of the distal
Atmospheric pressure can act to resist dis- end of the flange, which turns laterally toward
lodging forces applied to dentures. It has been the ramus. This part of the denture also helps
called “suction” because it is a resistance to the perfect the border seal at the back end of man-
removal of dentures from their basal seat; but dibular dentures. All this reinforcement is au-
there is no suction, or negative pressure, ex- tomatic, without conscious effort on the part of
cept when another force is applied. Atmo- the patient.
spheric pressure itself is supplied by the The base of the tongue serves also as an
weight of the atmosphere, and it amounts to emergency retentive force for some patients. It
14.7 lb/in?. This means that the retentive force rises up at the back and presses against the dis-
supplied by atmospheric pressure is directly tal border of a maxillary denture during inci-
proportionate to the area covered by the den- sion of food by the anterior teeth. This is done
ture base. For atmospheric pressure to be ef- without conscious effort when the experienced
fective, the denture must have a perfect seal denture wearer bites into an apple or sandwich
around its entire border. Atmospheric pressure or other food. It is seldom that a patient needs
is an “emergency” retentive force. If the other to be told how to do this. For the oral and fa-
retentive forces are being overpowered, atmo- cial musculature to be most effective in provid-
spheric pressure may be able to keep a denture ing retention for complete dentures, the fol-
in position. Suction alone applied to the soft lowing conditions must be met: (1) denture
tissues of the oral cavity for even a short time bases must be properly extended to cover the
would cause serious damage to the health of maximum area possible without interfering in
the soft tissues under negative pressure. the health and function of the structures that
174 Rehabilitation of the edentulous patient

surround the denture; (2) the occlusal plane shape. This molding may have progressed
must be at the correct level; and (3) the arch slowly over a period of years, and the patient’s
form of the teeth must be in the neutral zone resistance may have been such that little or no
between the tongue and cheeks. inflammation occurred in the process. The dis-
tortion of the oral tissues can be corrected
HEALTH OF THE BASAL SEAT TISSUES when the old dentures are left out of the
It is essential that the oral tissues be healthy mouth for 1, 2, or more days before the im-
before impressions are made. A careful diagno- pressions are made. A combination of leaving
sis will reveal pathosis in the oral cavity of a the dentures out and the use of conditioning
startling number of edentulous patients who materials that allow tissues to assume more
wear dentures. In a study of responses to vari- normal form within the confines of the denture
ations in denture techniques, 41 of 64 edentu- base can be an effective treatment. Some pa-
lous denture-wearing patients selected from tients will object to leaving their dentures out
the general population required special treat- of the mouth, but their objections can be over-
ment to restore abused oral tissues to a healthy come by careful explanation, insistence by the
condition. Oral lesions and their causes must dentist, use of conditioning material, and selec-
be treated before impressions are considered. tion of a convenient time for scheduling their
Simple observation of the oral mucosa provides appointments.
important information about the health of the Excessive amounts of hyperplastic tissue.
tissues. Some conditions require immediate at- Since the maxillae and the mandible (the
tention before impressions are made. bones) are the real foundations for dentures,
Inflammation of the mucosa. Because of the their soft tissue covering must be firm. Exces-
nature of inflammation, the soft tissues are not sive amounts of movable soft tissue will permit
their natural size. The swelling, which is a the dentures to move in relation to the bone,
characteristic result of inflammation from ei- and many types of difficulties (such as loose-
ther trauma or disease, changes the gross form ness, tipping, malocclusion of the dentures,
of the surface to be recorded in the impression. and difficulty in recording jaw relations accu-
All inflammation must be eliminated before the rately) may result. The best treatment is finger
new impressions are made lest the new den- massage on a daily basis or surgical removal of
tures not fit the tissues after they are no longer the hyperplastic tissue followed by sufficient
distorted by the swelling. Treatment is accom- time for complete healing. The apparent ridge
plished by surgery or proper medication or by size can be reduced by this procedure, but the
keeping the old dentures out of the mouth un- real foundation will be the same size and much
til the tissues are healthy. Soft resin treatment more effective (Chapter 6).
(tissue-conditioning) materials may be used in Insufficient space between the upper and
the old dentures to reduce the period in which lower ridges. Usually the insufficient space is
the dentures must be left out of the mouth found in the tuberosity region. It may be
(Chapter 6). However, the old dentures must caused by an excessive amount of fibrous con-
be kept out of the mouth at least 24 hours be- nective tissue covering the tuberosity (Fig. 3-
fore the impressions are made. 9), which will be disclosed by dental radio-
Distortion of the denture-foundation tissues. graphs. Intraoral radiographs or small dental
The denture that the patient is wearing may films are more effective than panoramic radio-
appear to have good retention and stability, but graphs for this purpose (Chapter 6). Mounted
at the same time it may not fit the true form of diagnostic casts will disclose potential interfer-
the oral structures. In such a situation, the ence by the excess fibrous tissue over the tu-
denture has molded the soft tissues to its own berosities with the correct location of the oc-
 Maxillary impression procedures 175

clusal plane. This determination should be An improperly formed tray will make impossi-
made before the impressions are started. Ex- ble the registration of the true negative form of
cess fibrous tissue should be removed surgi- the basal seat tissues on which the denture
cally, and time allowed for complete healing must rest. The tray must not distort or displace
before impressions are made. the tissues and structures that are to fit against
the borders and polished surfaces of the den-
IMPRESSIONS FOR THE EDENTULOUS ture.
PATIENT “Individual” or “custom” trays are made of
Impressions are made with many types of different materials (usually acrylic resin) with
materials and techniques. Some materials are borders that can be adjusted so they control
more fluid than others before they harden or the movable soft tissues around the impression
set. The softer materials displace soft tissues but do not distort them. At the same time
less and require less force in their molding space is provided inside the tray so the shape
than do materials that flow more sluggishly. of the tissues covering the residual alveolar
These variations in the working properties of ridge may be recorded with minimal or selec-
materials make it possible to devise many types tive displacement.
of techniques for controlling the position and The next most important part of impression
shape of the oral tissues. Some techniques are making, after the tray, is proper positioning of
intended to record the shape of the tissues the tray on the basal seat in the mouth. This is
with a minimum of displacement; others are in- best accomplished by using guiding factors in-
tended to displace the border tissues to a pre- corporated into the tray and by practicing
determined extent. Still others are devised to proper placement of the tray in the mouth be-
obtain the advantages of placement or control fore actually making the final impression.
of the border tissues with a minimal displace-
Final impression materials
ment of the tissues under the denture. The
choice is made by the dentist on the basis of Many different types of materials have been
the oral conditions, concept of the function of used successfully for making final impressions.
the tissues surrounding the denture, and abil- Plaster of Paris, zinc oxide—eugenol paste,
ity to handle the available impression materi- irreversible hydrocolloid, silicone, polysulfide
als. rubber, polyether, and tissue-conditioning ma-
terial have been used for this purpose. Each
Impression trays has its advantages and its disadvantages.
Regardless of the type of impression being The setting time of plaster of Paris must be
made, the tray is the most important part of accelerated and is often modified so the mold-
the impression-making procedure. If it is too ing time will be increased. It absorbs some of
large, it will distort the tissues around the bor- the mucous secretions from the palate while it
ders of the impression and will pull the soft tis- sets, but requires the use of a separating me-
sues under the impression away from the bone. dium before the cast is formed in it. Plaster of
If it is too small, the border tissues will col- Paris has enough body to support itself up to
lapse inward onto the residual ridge. This will 1.5 mm beyond the border of a tray.
reduce the support for the denture and prevent Zinc oxide—eugenol paste accurately records
the proper support of the lips by the denture surface detail and does not require a separating
flange. medium. It does not absorb the mucous secre-
A properly formed tray can carry the impres- tions that are produced in the palate and can
sion material to the mouth and control it with- cause defects in the palatal part of the impres-
out distorting the soft tissues that surround it. sion. The borders of the tray must be accu-
176 Rehabilitation of the edentulous patient

rately formed because the material is fluid. The opaque, however, it is more difficult to detect
borders of the tray should be so adjusted that pressure spots in the impressions than it is with
they reach to within 1 mm of the reflecting tis- other impression materials. Pressure spots are
sues. places where the tray shows through the im-
The irreversible hydrocolloids record detail pression material, and they indicate a displace-
accurately if they are properly controlled and ment of tissues by pressure from the tray.
confined, and they do not require the use of a
separating medium. They do not absorb the IMPRESSION TECHNIQUES
mucous secretions from the palate, which can Three techniques are described in this chap-
produce defects in the palatal part of the im- ter. They are all variations on a theme: the use
pression. However, because the irreversible of custom-made impression trays. The first and
hydrocolloids lose moisture and consequently second techniques involve making a prelimi-
change their size so rapidly, the casts must be nary impression in a stock metal tray with algi-
poured into them immediately or the record nate (irreversible hydrocolloid) impression ma-
will be distorted. The weight of the artificial terial. The final impression is then made in a
stone of the cast may be sufficient to distort the border-molded special tray. In the first tech-
borders of the impressions, and removal of the nique a thermoplastic material is used for bor-
impressions from the mouth without distortion der molding. In the second technique a poly-
presents some difficulties. ether impression procedure is used. In the
Tissue-conditioning materials have been third technique a custom tray is made from a
shown to be sufficiently accurate for making fi- stone cast that has been poured from the pa-
nal impressions. They are resilient and con- tient's “corrected” or improved previously
tinue to flow under stress for periods of up to worn complete denture.
24 hours. They are useful for making functional The same diagnostic and treatment-planning
impressions that record the basal seat and bor- procedures are followed for each patient re-
der tissues in their functional state. gardless of the impression technique. Proper
The silicone, polysulfide rubber, and _poly- preparation of the oral tissues is essential and is
ether impression materials can record the completed as described previously.
shape of the soft tissues accurately if they are
adequately supported by the tray. The polysul-
fide rubbers must be closely confined to the
soft tissues, lest they produce an inaccurate im-
pression. They are particularly useful for mak-
ing impressions of thin high mandibular ridges
with soft tissue undercuts. The elasticity of the
rubber and its tear strength, which is higher
than that of silicone or polysulfide materials, al-
low the impression to be removed from the
cast without fracture of the delicate ridge on
the cast. The polyether impression materials (1)
have sufficient body to make up discrepancies
between tray borders and the reflecting vestib-
ular tissues of up to 4 or 5 mm, (2) can be
Fig. 8-3 Selection of different sizes of properly
shaped by the fingers, and (3) are accurate in designed stock metal trays for maxillary impres-
reproducing detail. Since these materials are sions.
 Maxillary impression procedures 177

First technique— border-molded special partway open and the upper lip held slightly
tray outward and downward.
Preliminary impression. The space available An edentulous stock metal tray that is ap-
in the mouth for the upper impression is stud- proximately “4 inch (6 mm) larger than the out-
ied carefully by observation of the width and side surface of the upper residual ridge is se-
height of the vestibular spaces with the mouth lected (Fig. 8-3). The dentist places the tray in

d in
Fig. 8-4 A stock metal tray must be of proper size and must be correctly positione
the labial notch over the
the mouth. A, The tray is inserted and centered by positioning
notches and the vibrating line pos-
labial frenum (arrow). B, The tray covers the hamular
teriorly. C, A strip of boxing wax lines the borders of the tray.
178 Rehabilitation of the edentulous patient

Fig. 8-5 A, Wax across the posterior border of the tray is adapted to the tissue of the
posterior palatal seal area. B, Space for the buccal frenum is provided by wax lining the
tray (arrow). C, Space for the labial frenum is also provided (arrow).

the mouth and initially positions it by centering its posterior border is adapted to the tissue of
the labial notch of the tray over the labial fre- the posterior palatal seal area by careful eleva-
num (Fig. 8-4, A). The posterior extent of the tion of the tray in this region with the anterior
tray relative to the posterior palatal seal area is part of the tray in the proper position (Fig. 8-5,
maintained, and then the handle is dropped A). Again the borders of the tray are observed
downward to permit visual inspection. Posteri- visually relative to the limiting anatomic struc-
orly the tray must include both the hamular tures (Fig. 8-5, B and C). The objective is to
notches and the vibrating line (Fig. 8-4, B). obtain a preliminary impression that is slightly
The borders of the stock tray are lined with a overextended around the borders.
strip of soft boxing wax so a rim is created to Before making the preliminary impression,
help confine the alginate (irreversible hydrocol- the dentist should practice placing the prelimi-.-
loid) impression material (Fig. 8-4, C). The tray nary tray in position on the upper residual
is returned to the mouth, and the wax across ridge. The tray is first centered below the up-
 Maxillary impression procedures 179

Fig. 8-6 A, Impression material is placed in the tray from the posterior border. B, The
impression material is evenly distributed throughout the tray, care being taken to prevent
air from becoming trapped.

per residual ridge. The upper lip is elevated mouth for 1 minute after the initial set of the
with the left hand, and the tray is carried up- irreversible hydrocolloid. The impression is re-
ward into position, with the labial frenum used moved from the mouth in one motion and in-
as a centering guide. When the tray is located spected to ensure that all the basal seat is in-
properly anteriorly, the index fingers are cluded (Fig. 8-7, E).
placed in the first molar region on each side of The dentist should now determine the bor-
the tray, and with alternating pressure they ders of the custom tray. Two choices are avail-
seat the tray upward until the wax across the able: (1) the periphery can be outlined with a
posterior part of the tray comes into contact disposable indelible marker at chairside or (2)
with the tissue in the posterior palatal seal the outline can be approximated on the poured
area. The fingers of one hand are shifted into cast in the laboratory and the correct location
the middle of the tray, and border molding is of the tray periphery reassessed when the tray
carried out with the other hand. is subsequently tried in the mouth. We recom-
The tissue surface and borders of the tray, mend that both choices be undertaken. The
including the rim of wax, are painted with an completed impression is observed next to the
adhesive material to ensure that the irrevers- patient’s mouth, and the junction of attached
ible hydrocolloid adheres to the tray. The irre- and unattached mucosal tissue is visually iden-
versible hydrocolloid is mixed according to tified on the border of the impression (Fig. 8-
manufacturer's instructions and is placed in the 8). The accuracy of its location reflects the den-
tray and evenly distributed to fill the tray to tist’s understanding of the biologic principles of
the level of its borders (Fig. 8-6). A small maxillary impression making. The impression is
amount of irreversible hydrocolloid is placed in poured in artificial stone, and the custom tray
the area of the rugae of the hard palate to help outline should now be evident on the cast. If
prevent air from being trapped in this part of the tray outline on the impression is not clearly
the preliminary impression (Fig. 8-7, A), and visible, it can be penciled on the cast. How-
the loaded tray is positioned in the mouth in a ever, then, with the patient not present for a
manner similar to that during the practice ses- correlation between anatomic features and the
inanimate cast, it becomes an educated guess
sions (Fig. 8-7, B to D) The tray is left in the
180 Rehabilitation of the edentulous patient

Fig. 8-7 A, With a finger the dentist places a small amount of irreversible hydrocolloid
on the patient's palate. B, The tray, containing the impression material, is carried to posi-
tion anteriorly. The labial frenum must be carefully observed in relation to the labial notch
of the tray. C, The tray is seated posteriorly by the index fingers in the region of the first
molars. D, It is held steadily until the impression material has set. Notice the position of
the finger on the palatal part of the tray. E, All of the basal seat is included in the prelim-
inary impression. The palatal wax periphery showing through the impression material is
not significant, since any displaced tissue at this stage can be corrected in the custom
tray. Furthermore, this wax will protect the peripheral tissues from the stock tray’s hard
edges.
 Maxillary impression procedures 181

Fig. 8-8 All the basal seat is in the preliminary

impression. The clinically determined proposed
denture base outline is penciled on with a dispos-
able indelible marker (if possible).

or estimate. A wax spacer is placed within the scribing a custom tray is that the denture bear-
outlined border to provide space in the tray for ing (tissue-contacting) area of the denture will
the final impression material (Fig. 8-9, A and be reflected in the trays extension at this
B). The posterior palatal seal area on the cast is stage. The next step is to complete the tray for
not covered with the wax spacer. Thus the the final impression by developing/confirming
completed final impression tray will contact the the peripheral or sealing part of the tray.
upper residual ridge across the posterior palatal Preparing the final impression tray. When
seal, and additional stress can be placed here the acrylic resin final impression tray is re-
during the making of the final impression. In moved from the preliminary cast, the wax
addition, this part of the tray will act as a guid- spacer is left inside the tray. The spacer allows
ing stop to help position the tray properly on the tray to be properly positioned in the mouth
the residual ridge during the impression proce- during border-molding procedures (Fig. 8-10,
dure. Baseplate wax approximately 1 mm thick A).
is placed on the cast as designated by the pre- Border molding is the process by which the
viously drawn outline (Fig. 8-9, B). shape of the borders of the tray is made to con-
A self-curing acrylic resin tray material is form accurately to the contours of the buccal
mixed and uniformly adapted over the cast so and labial vestibules. This essential refinement
the tray will be 2 to 3 mm thick (Fig. 8-9, C). A of the tray’s fit ensures an optimal peripheral
resin handle is attached in the anterior region seal. It has often been erroneously referred to
of the tray to facilitate removal of the final im- as “muscle trimming.”
pression. The handle is placed in the approxi- It begins with manipulation of the border tis-
mate position of the upper anterior teeth so it sues against a moldable impression material
will not distort the upper lip when the tray is that is properly supported and controlled by
in the mouth (Fig. 8-9, D). The premise in pre- the tray. The amount of support supplied by
182 Rehabilitation of the edentulous patient

Fig. 8-9 A, Outline for the wax spacer drawn in pencil on the cast that was poured in
the preliminary impression. B, Relief wax covers the basal seat area, except for the labial
and buccal reflections and the posterior palatal seal area. The reflections are not cov-
ered; thus the proper length and width of the borders of the tray will be maintained as
determined by the preliminary impression or as desired. C, Final impression tray with
self-curing acrylic resin; the resin should be approximately 2 to 3 mm thick. D, The han-
dle on the final upper tray should not interfere with the normal position of the upper lip
during making of the final impression.

the tray and the amount of force exerted iting anatomic structures. The tray is carefully
through the tissues vary according to the resis- removed from the mouth, and the modeling
tance or viscosity of the impression material. compound border is chilled in ice water. The
After the available space for denture flanges border molding is accomplished in the anterior
is again checked in the patient's mouth, the region when the upper lip is elevated and ex-
buccal and labial flanges of the impression tray tended out, downward, and inward (Fig. 8-11,
are marked in pencil and reduced until they A and B). In the region of the buccal frenum
are short of the reflections (Fig. 8-10, B and the cheek is elevated and then pulled outward,
C). downward, and inward and moved backward
Stick modeling compound is added in sec- and forward to simulate movement of the up-
tions to the shortened borders of the resin tray; per buccal frenum. Posteriorly the buccal
then the compound is heated with the flame flange is border molded when the cheek is ex-
from an alcohol air torch, tempered, and tended outward, downward, and inward (Fig.
molded in the mouth to a form that will be in 8-11; [Link] BE).
harmony with the physiologic action of the lim- The posterior palatal seal is formed through
 Maxillary impression procedures 183

Fig. 8-10 A, The final impression tray covers the

entire basal seat area. Its borders have not been
molded in harmony with the limiting oral structures
and must be corrected. A wax spacer has been
left inside the tray to allow the tray to be properly
positioned in the mouth during border molding. B,
The borders of the tray are reduced so modeling
compound can be added for border molding. C,
Notice that space has been created between the
borders of the tray and the reflection.

both hamular (pterygomaxillary) notches and notches. The compound is chilled and then
across the palate over the vibrating line. The heated with the alcohol torch, tempered, and
vibrating line is observed in the _ patient's seated in the mouth under pressure. The
mouth as the patient says a series of short added material will spread out on both sides of
“ahs,” and the hamular notches are palpated. the vibrating line and form a raised strip across
The posterior border of the impression tray is the distal end of the impression (Fig. 8-12, C).
marked with indelible pencil, the palatal tis- This will enhance the posterior or palatal seal,
sues are dried quickly, the tray is placed in the which has the three functions: (1) it slightly dis-
mouth, and the patient is again asked to say places the soft tissues at the distal end of the
“ah.” The tray is removed from the mouth, and denture to enhance the posterior border seal;
the mark that has been transferred from the (2) it serves as a guide for positioning the tray
tray to the mouth is compared with the vibrat- properly for the final impression; and (3) it pre-
ing line and the hamular notches (Fig. 8-12, A vents excess impression material from running
and B). The tray must contain both hamular down the patient's throat (Fig. 8-12, C).
notches and must extend approximately 2 mm After border molding is completed, the mod-
posterior to the vibrating line. If it is underex- eling compound forming the labial and buccal
tended, the length is corrected by the addition borders of the tray is reduced approximately 1|
of modeling compound. A strip of low-fusing mm to make space for the final impression ma-
compound is traced on the impression over the terial. The spacer wax is removed from inside
vibrating line and through the hamular the tray for the same reason. Space must be
184 Rehabilitation of the edentulous patient

Fig. 8-11 A, Border molding in the anterior region by moving the upper lip outward,
downward, and inward. B, Modeling compound border molded anteriorly. C, The buccal
flange is border molded by moving the cheek outward, downward, inward, and back-
ward/forward. D, Properly molded border of the left buccal flange. E, Completed labial
and buccal borders. Notice that the wax spacer has remained inside the tray during the
border-molding procedure.
 Maxillary impression procedures 185

Fig. 8-12 A, The posterior border of the impression tray is marked with indelible pencil
to denote its extent over the soft palate in the patient's mouth. B, The line has been trans-
ferred to the patient's mouth and indicates that the tray includes the vibrating line and
both hamular notches posteriorly. C, Modeling compound has been added to the poste-
rior border of the final impression tray; it will enhance the posterior palatal seal. The wax
spacer is still in place in the tray. D, The labial and buccal borders of the tray have been
reduced approximately 1 mm for the final impression material. The wax spacer has been
removed, and holes have been drilled in the tray to selectively relieve pressure during
making of the final impression. The posterior palatal seal remains intact.

provided within the tray for the final impres- sion for the median palatal raphe and in the an-
sion material. If this is not done, pressure spots terolateral and posterolateral regions of the
will form in the impression. Pressure spots are hard palate.
regions where the tray displaces the soft tissues Making the final upper impression. The soft
to be recorded in the impression. These re- tissues in the mouth must be rested and
gions of extra pressure will tend to dislodge the healthy before the final impression is made. To
denture when it is completed and may impair allow tissue recovery, the patient must leave
the health of the tissues with which they come the old dentures out of the mouth a minimum
into contact. Holes are placed in the palate of of 24 hours before the making of the final im-
the impression tray with a no. 6 round bur to pression.
provide escapeways for the final impression Positioning the tray properly in the patient’s
material (Fig. 8-12, D). The holes furnish relief mouth for the final upper impression is essen-
during the making of the final upper impres- tial to a successful result and can be a difficult
186 Rehabilitation of the edentulous patient

procedure. The sequence of steps used re- The final impression material is mixed ac-
quires practice by the dentist for each patient cording to manufacturer’s directions and uni-
but will help ensure the proper placement of formly distributed within the tray. The amount
the tray. The practice procedures are per- of material used and the spatulation time
formed step by step without final impression should be as uniform as possible from mix to
material in the tray. First, the dentist centers mix. This uniformity is essential if the dentist is
the tray as it is carried to position on the upper to become familiar with the working properties
residual ridge by observing the labial frenum of the materials. All borders must be covered.
going into proper relation to the labial notch Excess impression material is allowed to run
(Fig. 8-13, A). Then, when the frenum is out the posterior border of the tray before the
within 1 to 2 mm of being in the notch, the in- tray is placed in the mouth (Fig. 8-14, A). An
dex fingers of each hand are shifted to the first additional, small, amount of impression mate-
molar region, and with alternating pressure the rial is placed in the central palatal area of the
tray is carried upward—without displacement tray to help prevent air from being trapped in
of the front end of the tray downward— until this part of the final impression (Fig. 8-14, B).
the posterior palatal seal of the tray fits prop- The tray is positioned in the mouth in a man-
erly in the hamular notches and across the pal- ner similar to that used during the practice ses-
ate (Fig. 8-13, B). The tray is held in position sions (Fig. 8-14, C to E).
with a finger placed in the palate immediately Border molding is performed in the posterior
anterior to the posterior palatal seal (Fig. 8-13, regions on both sides first and then in the ante-
C). The practice procedure with the empty tray rior region (Fig. 8-15, A to C).
is repeated until the dentist feels confident of When the final impression material has com-
the proper position of the tray in the mouth. pletely set, the cheeks and upper lip are ele-

Fig. 8-13 A, During practice sessions the tray is

centered in the mouth and the labial frenum is
guided into the labial notch. B, The tray is carried
upward and posteriorly until its posterior palatal
seal can be seen and felt contacting the posterior
palatal seal area in the patient's mouth. C, The
tray is held in position with a finger placed imme-
diately anterior to the posterior palatal seal.
 Maxillary impression procedures 187

Fig. 8-14 A, Final impression material is distributed uniformly within the final impression
tray. Excess is allowed to run out the posterior border of the tray. B, A small amount of
impression material is added to the center of the tray to reduce the possibility of trapping
air in this part of the impression. C, The final impression tray is positioned anteriorly by
centering the labial notch in relation to the labial frenum. D, The posterior palatal seal is
guided into position through the hamular notches in the region of the vibrating line by the
placement of pressure alternately on each side with fingers in the first molar region of the
tray. E, The final impression is held in position by a finger immediately anterior to the pos-
terior palatal seal seal.
188 Rehabilitation of the edentulous patient

Fig. 8-15 A, The dentist molds the left posterior border of the final impression by ex-
tending the cheek outward, downward, and inward and moving it backward/forward in
the region of the buccal frenum. B, The right posterior border of the impression is molded
by the same procedures. The upper lip is properly supported by the tray during making
of the final impression. C, The anterior border of the final impression is molded by moving
the upper lip downward and inward with the thumbs. No side-to-side movement
of the
upper lip is desirable during this procedure. D, The upper lip is elevated, and the anterior
wax handle is used to remove the final upper impression. E, Acceptable final upper
im-
pression. The borders are in harmony with the available space in the patient's
mouth.
There are no undesirable pressure spots. The impression shows that tissues
forming the
posterior palatal seal area have been placed to enhance the seal at the posterior
border.
 Maxillary impression procedures 189

vated above the borders of the impression to of the tissues of the vestibule, and (7) be
introduce air between the soft tissue at the re- readily trimmed and shaped so excess material
flection and the border of the impression. can be carved and the borders shaped before
While the lip is elevated, the dentist removes the final impression is made.
the impression from the mouth by grasping the Hard acrylic resin and _ silicone materials
handle of the tray and gently working the tray have been used for this purpose, and both have
downward and forward in the direction of the serious deficiencies. Hard resins have a long
labial inclination of the residual ridge (Fig. 8- setting time, do not attain proper consistency
15D): immediately after mixing (which requires a
The impression is inspected for acceptability waiting time before insertion), and are difficult
(Fig. 8-15, E). If it needs to be remade, and of- to trim. Also, if insertion is delayed too long,
ten this will be true, the impression material is overextension will result. Heavy-bodied sili-
removed, with particular care directed at the cone materials do not allow preshaping or
borders. placement into deficient spaces with a finger af-
Remaking the final impression. Assuming ter insertion, and they are difficult to trim after
that the tray was properly formed, faulty posi- setting.
tioning is the most frequent reason that a final Polyether impression materials’ meet all the
impression must be remade. A number of rea- requirements previously listed. They can be
sons for remaking final impressions are de- shaped with a moist finger in or outside the
scribed in Chapter 10. mouth and can be trimmed with a scalpel or a
Pouring the cast. A technique for boxing the bur.
impression and pouring the cast is described in The following procedure utilizes polyether
Chapter 10. impression materials for border molding. It sig-
nificantly reduces the time required for making
Second technique— one-step impressions and also reduces the amount of
border-molded tray motion used by the dentist, thus reducing the
A material that will allow simultaneous mold- psychologic stresses of a busy practice.
ing of all borders has two general advantages:
Constructing the autopolymerizing acrylic
first, the number of insertions of the tray for
resin impression tray
maxillary and mandibular border molding is re-
duced to two (a great time and motion saver); 1. Make a preliminary upper impression,
second, developing all borders simultaneously and pour the cast as described in the
avoids propagation of errors caused by a mis- first technique (p. 177).
take in one section affecting the border con- 2. Construct an autopolymerizing acrylic
tours in another. resin final impression tray on the prelim-
The requirements of a material to be used inary cast as in the first technique (p.
for simultaneous molding of all borders are that 181).
it should (1) have sufficient body to allow it to 3. Reduce the borders of the impression
remain in position on the borders during load- tray until they are 2 mm underextended
ing of the tray, (2) allow some preshaping of and confirm the extension of the poste-
the form of the borders without adhering to the rior palatal border (Fig. 8-12, A and B).
fingers, (3) have a setting time of 3 to 5 min- Leave the relief wax in the impression
utes, (4) retain adequate flow while the tray is tray (Fig. 8-16).
seated in the mouth, (5) allow finger placement
of the material into deficient parts after the tray *Impregum, ESPE-—Premier Sales Corporation, Norris-
is seated, (6) not cause excessive displacement town PA, 19401.
190 Rehabilitation of the edentulous patient

Fig. 8-16 The borders of the acrylic resin tray Fig. 8-17 Polyether material is placed across
have been reduced. Relief wax remains inside the the posterior palatal seal area.
impression tray. Notice that it does not cover the
borders or the posterior palatal seal area of the
tray.

Fig. 8-18 The polyether material is continued Fig. 8-19 Border molding has been completed,
around the borders of the impression tray until all including the posterior palatal seal area. Notice
have been covered. that the relief wax is still in the impression tray,
 Maxillary impression procedures 191

Border molding the maxillary tray

ie Place adhesive for polyether impressions
on the borders of the tray. Cover 6 mm
inside the borders and 3 mm outside the
borders.
Express a 3-inch strip of polyether mate-
rial from the large tube onto a mixing
pad. Next, express 2 inches of catalyst
from the small tube. The reason for us-
ing less catalyst than recommended is to
provide sufficient working time to com-
plete the border molding.
Thoroughly mix the material for 30 to 45
seconds using a metal spatula.
Position the polyether material on the
borders, making certain that a minimum
width of 6 mm exists on the inner por-
tion (Figs. 8-17 and 8-18).
Quickly preshape the material to proper
Fig. 8-20 The relief wax has been removed from
contours with fingers moistened in cold the tray, and polyether material has been removed
water. from the undercuts. The impression tray is now
Place the impression tray in the mouth ready for the final impression.
as described in the first technique, mak-
ing certain that the lips are sufficiently
retracted to avoid scraping the material
from the borders (Fig. 8-13).
Inspect all borders to be sure that im-
pression material is present in the vesti-
bule. If there is insufficient space, trans-
fer some material from an adjacent site
with a finger moistened in the patient's
saliva.
Border mold as described in the first
technique (Fig. 8-15).
Remove the tray when the impression
material is set. The material is set when
no permanent indentation results from a
fingernail intruded into it.
10. Examine the border molding to deter-
mine that it is adequate (Fig. 8-19). The
contour of the borders should be Fig. 8-21 The completed final impression with
rounded. Any deficient sites can be cor- the one-step border-molded tray.
rected with a small mix of polyether or
an addition of impression compound to
adhere to the set polyether. Overexten-
192 Rehabilitation of the edentulous patient

Fig. 8-22. The patient's original denture,

A, is refitted with a treatment liner, B, and
poured in laboratory stone, C. The optimized
denture bearing surface is then covered
with an autopolymerized tray, D, which is
used for the final impression, E.
 Maxillary impression procedures 193

sions are readily detected because the ing or possess complete dentures. Although
tray will protrude through the _poly- these may need replacement for a number of
ether. reasons, they can usually be converted to ade-
quate provisional prostheses by means of ad-
Preparing the maxillary tray to secure the fi- justments in their borders, refitting with a tis-
nal impression sue conditioner or treatment liner, or improve-
1. Reduce the borders on the tray that pro- ment in their occlusal relationships. This ap-
trude through the polyether. They indi- proach is strongly recommended as a routine
cate overextension or pressure spots. A protocol to optimize supporting tissue health.
denture bur can be used for their reduc- It also, however, provides a prototype of the
tion. fitting surface of the denture. Logic and expe-
2. Remove any material that extends inter- diency suggest that these dentures can be re-
nally within the tray more than 6 mm. A garded as a starting point for an accurate func-
scalpel works best for this. tional impression of the patient’s denture-bear-
3. Remove the relief wax (Fig. 8-20). Heat- ing surface. The denture is therefore treated
ing the wax in warm water will make like a standard impression, and a stone cast is
this easier. poured. An acrylic resin tray is made on the
4. Reduce the polyether where it extends cast over a wax spacer that is outlined just
into an undercut with a denture bur. short of the borders of the impression (Fig. 8-
This will allow the tray to go into place 22). The dentist can now presume that the tray
more easily. reflects the border molding that was already
5. Remove any excess material that has developed on the originally resurfaced den-
flowed onto the external portion of the ture. The tray is tried in the mouth and
tray. checked for overextensions. The spacer is re-
6. Reduce the thickness of the labial flange moved, relief holes are prepared, an adhesive
to approximately 2.5 to 3 mm from one is applied, and an impression is made in the
buccal frenum to the other. preferred material. The final result will be in-
7. Remove a small amount (about 0.25 mm) distinguishable from ones produced by the first
of material from borders that have not and second techniques just described (Fig. 8-
been previously adjusted. This includes 22).
the inner portion, the border, and the The list at the end of Chapter 10 sums up the
outer surface. It will create the neces- protocol that should be followed when making
sary space for a thin film of impression a complete maxillary impression.
material.
8. Make the final impression in silicone, BIBLIOGRAPHY
metallic oxide paste, or rubber base Flgystrand F: Vestibular and lingual muscular pressure on
(Fig. 8-21). An appropriate adhesive complete maxillary dentures, Acta Odontol Scand 44:71-
75, 1986.
should be added on the impression sur- Flgystrand F, Karlsen k, Saxegaard E, Orstavik JS: Effects
face of the tray when silicone material is on retention of reducing the palatal coverage of complete
being used. maxillary dentures, Acta Odontol Scand 44:77-83, 1986.
Minagi S, Sato Y, Akagawa Y, Tsuru H: Concept and tech-
nique for making an accurate final impression for com-
Third technique—custom tray design plete dentures using a thixotropic impression material,
based on the previously worn denture Int J Prosthod 1:149-152, 1988.
Smith DE, Toolson LB, Bolender CL, Lord JL: One-step
Clinical experience has shown that a large border molding of complete denture impressions using a
number of edentulous patients seeking treat- polyether impression material, J Prosthet Dent 41:347,
ment with complete dentures are already wear- 1979.