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Impressions of Unsupported Movable Tissues
C L IN IC A L
REPO RTS
formation concerning the paresthesia. However, when questioned specif ically, she readily supplied the neces sary information. In the presence of severe pain, a patient may neglect to report paresthesia, thinking it an un important symptom. It is our role as clinicians to elicit from patients con tributory information that they may neglect to supply. The paresthesia described here may have been caused by the effects of pressure and inflam m ation arising from the pathosis associated with the mandibular premolar. As the lesion passed from the acute stage and in flammation decreased, the paresthesia decreased from total numbness to a tingling sensation. The area associated with this paresthesia would be consis tent with involvement of the mental nerve. A possible contributing factor to the paresthesia could have been inflam mation caused not only by the pathosis around the premolar, but also by the caustic effects of aspirin being placed against the mucosa of the buccal ves tibule. Because the onset of dental
symptoms and the use of aspirin coin cided, it is difficult to determine with any certainty the true cause of the paresthesia. The burns caused by the use of aspi rin and complications caused by using dry heat underscore the importance of educating patients concerning the po tential hazards of home remedies.
Sum m ary A case is reported in w hich paresthesia of the area supplied by the mental nerve is present in association with a periapical pathosis in an area that is undergoing an acute exacerbation. Home remedies may have exacerbated the problem. Interestingly, the patient did not initially report the paresthesia because the pain was so acute. Con ventional endodontic therapy was per formed, and all symptoms resolved without complication.
Dentistry, 2500 N State St, Jackson, 39216. Re quests for reprints should be sent to Dr. Gilbert. .1. M aurice, C.G. An annotated glossary of terms used in endodontics, ed 2. Atlanta, Am eri can Association of Endodontists, 1973, p 21. 2. Dorland’s illustrated m edical dictionary, ed 24. Philadelphia, W. B. Saunders Co, 1968, p 1103. 3. Brooks, S.L. Metastasis to the jaw manifest ing as numbness. J M ich Dent Assoc 60(9):475476, 1978. 4. Joubert, J.J.; Farman, A.G.; and Nortje, D.J. Lip paresthesia of dental origin. J Oral Med 34(l):26-27, 1979. 5. Antrim, D.D. Paresthesia of inferior alveolar nerve caused by periapical pathology. J Endod 4(7):220-221, 1978. 6. Nairn, R. Interference with the function of the inferior dental nerve by a root fragment. Oral Surg 36(2):988-991, 1979. 7. Montgomery, S. Paresthesia following en dodontic treatment. J Endod 2 (ll):3 4 5 -3 4 7 ,1976. 8. Pasqual, R.J., and Pasqual, H.N. Surgical re p o sitio n in g of th e m en tal nerve. Oral Surg 24(3):305-306, 1967. 9. Pyner, D.A. Paresthesia of the inferior alveo lar nerve caused by Hydron. J Endod 6(4):527-528, 1980. 10. Karshan, M. Studies in the etiology of idiopathic orolingual paresthesias. Am J Dig Dis 19:341, 1952.
Dr. Gilbert is associate professor and Dr. Dick erson is assistant professor, department of endodontics, University of M ississippi, School of
Impressions of unsupported movable tissues Zafrulla Khan, D DS Joe H. Jaggers, DMD Jeffrey S. Shay, DMD
Edentulous a rches with unsupported m ovable tissues p ose problem s when im pressions fo r dentures are m ade by routine techniques. A new, qu ick er technique that causes m inim um distortion is presented.
I n many instances, we observe pa tients who have for years worn a com plete maxillary denture opposed only by mandibular anterior teeth. The re sults are all too familiar: the loss of all or part of the alveolar bone in the maxillary anterior region1 (Fig 1). The remaining soft tissues are easily dis 590 ■ JADA, Vol. 103, October 1981
torted by routine impression proce dures, resulting in an unstable denture base (Fig 2). The consequences of this condition are well known and numer ous, and should be corrected.2'7
Surgical reduction of the pliable tis sues often results in the loss of the an terior mucobuccal fold area. This may in turn create retention problems and make it difficult to relieve the denture
F ig 1 ■ M a x illa ry ed en tu lo u s rid g e in sta tic
F ig 2 ■ M a x illa ry rid g e sh ow in g e a sily dis
p h ysiologic state.
to rted tissues u n d er p ressure.
C L IN IC A L
F ig 3 ■ M axillary ca s t w ith outline o f un
F ig 4 ■ M odified im pression tra y w ith p os
su p p o rted tissue.
te rio r han d les and a n te rio r opening for un su p p o rted tissue.
Fig 5 ■ C om pleted b o rd er m olding.
F ig 6 ■ F in al im pression w ith m e rca p ta n rubber.
F ig 7 ■ B ru sh in g o f the unsupported tissue
F ig 8 ■ F in a l im p ressio n sh ow in g the a n
w ith im p ressio n p laster, tra y in place.
te rio r u n supp orted tissu e re co rd e d in p las ter.
Illustrations o f tw o -p art im p ressio n technique
base in the area of the labial frenum. To avoid these problems, we use a technique that minimizes distortion w h en im p ressio n s of ed en tu lo u s arches with unsupported, movable tis sues are made.
Technique A primary impression is made and a
study cast is poured in dental labora tory stone.8 An indelible pencil is used to outline the unsupported movable tissue (Fig 3). A single custom tray is made, and an opening is cut in the tray as indicated by the transfer of the inde lible pencil line. This step does not re quire two sets of trays as described by Osborne and Filler.1,8 Modeling plas tic is adapted bilaterally on the poste
REPO RTS
rior aspect of the tray to act as handles (Fig 4). The tray is adjusted in the mouth, and a routine border molding is form ed (Fig 5 ).9,10 T h e tray is painted with an adhesive (Permalastic) and regular body Permalastic is used for the final impression. The ex cess material is trimmed to the outline of the aperture (Fig 6). The completed base im pression is returned to the m outh. T h is im p ressio n does not touch the unsupported tissues. The shape of unsupported movable tissue is recorded by brushing on impression plaster (Fig 7), a highly mucostatic impression material.2,11' 13 The initial brushing of the plaster precludes en trapment of air and enables visualiza tion of the unsupported tissue. Then sufficient bulk is added to the plaster for strength. Figure 8 shows the result in g fin a l im p re s sio n . A su ita b le separating material is applied to the impression plaster and the master cast is made. Some patients do not have sufficient labial border area for a complete pe ripheral impression tray. For these pa tients, the labial tray border is not con structed (Fig 9). The same procedure of impression making is followed as de scribed earlier, except in the final stage. Impression plaster is introduced by means of a brush as shown in Figure 10, and final border molding in the an terior region is formed by digital ma nipulation of the lip (Fig 11). The final im pression using th is approach is shown in Figure 12. For clarity, the same patient was used to demonstrate both the tech niques. A comparison of the routine impres sion procedure and the two-part im pression technique is shown in Fig ures 1 3 a n d l4 .T h e c a sts o n th e rig h to f each illustration show distortion and com pression of the pliable tissues, w hich occur if custom trays with no re lief are used. The casts on the left of each illustration show the tissue with m inim al d isto rtion , w h ich resu lts from the technique described.
Sum m ary A technique for making impressions with minimum distortion of edentu lous arches where unsupported and movable tissues exist has been de scribed. Other methods have been re ported in the literature; however, the advantages of this method are that it
K h an -Jag g ers-Sh ay : IM PRESSIONS OF UNSUPPORTED MOVABLE T ISSU E S ■ 591
C L IN IC A L
REPO RTS
saves chair time, does not require the fabrication of two custom trays, and enables visualization of the impres sion making of the unsupported mov able tissues.
Fig 9 ■ Im p ressio n tra y m odified to a cc o m
F ig 1 0 ■ B ru sh in g on o f im p ressio n p laster.
m od ate insufficient lab ial border.
F ig 11 ■ D igital m an ip u latio n fo r an terio r
F ig 12 ■ C om pleted tw o -stag e im pression
b o rd er m olding w ith im pression plaster.
w ith m e rc a p ta n rubber and im p ressio n p la s ter.
M odification o f tech nique for p atien ts w ith insufficient labial b o rd ers
F ig 1 3 ■ P a la ta l view of ca s ts show ing u n altered an ato m ic state utilizing the tech nique d escrib ed (left) a n d the ca s t done rou tinely w ith no relief in tra y s (righ t).
F ig 1 4 ■ L ab ial view o f ca s ts show n in F ig u re 13. 5 9 2 ■ JADA, Vol. 1 0 3 , O ctober 1981
Dr. Khan is assistant professor, department of prosthodontics, University of Louisville School of Dentistry, Louisville, Ky 40292; Dr. Jaggers is associate professor, departm ent of restorative dentistry, University of Florida College of Den tistry; Dr. Shay is assistant professor, department of restorative dentistry, University of Louisville School of Dentistry. Address requests for reprints to Dr. Khan. 1. Osborne, J.W. Two im pression methods for m obile fibrous ridges. Br Dent J 117:392-394, 1964. 2. Frank, R.P. Analysis of pressures produced during maxillary edentulous im pression proce dures. J Prosthet Dent 22:400-413, 1969. 3. Watt, D.M., and Likeman, P.R. Morphologi cal changes in the denture bearing area following extraction of m axillary teeth. Br Dent J 136:2252 3 5 ,1 9 7 4 . 4. Frank, P.R. Controlling pressures during com plete denture im pressions. Dent Clin North Am 14:453-470, 1970. ed 5. Collett, H.A. Final impressions for com plete dentures. J Prosthet Dent 23:250-264, 1970. 6. Douglas, W.H.; W ilson, H.J.; and Bates, J.F. Pressure involved in taking impressions. Dent Pract 15:248-250, 1965. 7. Collett, H.A. Complete denture impressions. J Prosthet Dent 15:603-614, 1965. 8. Filler, W.H. Modified im pression technique for hyperplastic alveolar ridges. J Prosthet Dent 25:609-612, 1971. 9. Hickey, J.C., and Zarb, G.A. Boucher’s prosthodontic treatment for edentulous patients, ed 8. St. Louis, C. V. Mosby Co, 1980. 10. Winkler, S. Essentials of complete denture prosthodontics. Philadelphia, W. B. Saunders Co, 1979. 11. Loiselle, R.J. A m axillary im pression tech nique. JADA 81:146-147, 1970. 12. Sodeau, W.H., and Gibson, C.S. T he use of plaster of paris as an im pression material. Br Dent J 48:1089-1115, 1927. 13. Grant, L.J. Painting the im pression on the m axilla. Dent Surv 28:1653-1657, 1952.
REPO RTS
formation concerning the paresthesia. However, when questioned specif ically, she readily supplied the neces sary information. In the presence of severe pain, a patient may neglect to report paresthesia, thinking it an un important symptom. It is our role as clinicians to elicit from patients con tributory information that they may neglect to supply. The paresthesia described here may have been caused by the effects of pressure and inflam m ation arising from the pathosis associated with the mandibular premolar. As the lesion passed from the acute stage and in flammation decreased, the paresthesia decreased from total numbness to a tingling sensation. The area associated with this paresthesia would be consis tent with involvement of the mental nerve. A possible contributing factor to the paresthesia could have been inflam mation caused not only by the pathosis around the premolar, but also by the caustic effects of aspirin being placed against the mucosa of the buccal ves tibule. Because the onset of dental
symptoms and the use of aspirin coin cided, it is difficult to determine with any certainty the true cause of the paresthesia. The burns caused by the use of aspi rin and complications caused by using dry heat underscore the importance of educating patients concerning the po tential hazards of home remedies.
Sum m ary A case is reported in w hich paresthesia of the area supplied by the mental nerve is present in association with a periapical pathosis in an area that is undergoing an acute exacerbation. Home remedies may have exacerbated the problem. Interestingly, the patient did not initially report the paresthesia because the pain was so acute. Con ventional endodontic therapy was per formed, and all symptoms resolved without complication.
Dentistry, 2500 N State St, Jackson, 39216. Re quests for reprints should be sent to Dr. Gilbert. .1. M aurice, C.G. An annotated glossary of terms used in endodontics, ed 2. Atlanta, Am eri can Association of Endodontists, 1973, p 21. 2. Dorland’s illustrated m edical dictionary, ed 24. Philadelphia, W. B. Saunders Co, 1968, p 1103. 3. Brooks, S.L. Metastasis to the jaw manifest ing as numbness. J M ich Dent Assoc 60(9):475476, 1978. 4. Joubert, J.J.; Farman, A.G.; and Nortje, D.J. Lip paresthesia of dental origin. J Oral Med 34(l):26-27, 1979. 5. Antrim, D.D. Paresthesia of inferior alveolar nerve caused by periapical pathology. J Endod 4(7):220-221, 1978. 6. Nairn, R. Interference with the function of the inferior dental nerve by a root fragment. Oral Surg 36(2):988-991, 1979. 7. Montgomery, S. Paresthesia following en dodontic treatment. J Endod 2 (ll):3 4 5 -3 4 7 ,1976. 8. Pasqual, R.J., and Pasqual, H.N. Surgical re p o sitio n in g of th e m en tal nerve. Oral Surg 24(3):305-306, 1967. 9. Pyner, D.A. Paresthesia of the inferior alveo lar nerve caused by Hydron. J Endod 6(4):527-528, 1980. 10. Karshan, M. Studies in the etiology of idiopathic orolingual paresthesias. Am J Dig Dis 19:341, 1952.
Dr. Gilbert is associate professor and Dr. Dick erson is assistant professor, department of endodontics, University of M ississippi, School of
Impressions of unsupported movable tissues Zafrulla Khan, D DS Joe H. Jaggers, DMD Jeffrey S. Shay, DMD
Edentulous a rches with unsupported m ovable tissues p ose problem s when im pressions fo r dentures are m ade by routine techniques. A new, qu ick er technique that causes m inim um distortion is presented.
I n many instances, we observe pa tients who have for years worn a com plete maxillary denture opposed only by mandibular anterior teeth. The re sults are all too familiar: the loss of all or part of the alveolar bone in the maxillary anterior region1 (Fig 1). The remaining soft tissues are easily dis 590 ■ JADA, Vol. 103, October 1981
torted by routine impression proce dures, resulting in an unstable denture base (Fig 2). The consequences of this condition are well known and numer ous, and should be corrected.2'7
Surgical reduction of the pliable tis sues often results in the loss of the an terior mucobuccal fold area. This may in turn create retention problems and make it difficult to relieve the denture
F ig 1 ■ M a x illa ry ed en tu lo u s rid g e in sta tic
F ig 2 ■ M a x illa ry rid g e sh ow in g e a sily dis
p h ysiologic state.
to rted tissues u n d er p ressure.
C L IN IC A L
F ig 3 ■ M axillary ca s t w ith outline o f un
F ig 4 ■ M odified im pression tra y w ith p os
su p p o rted tissue.
te rio r han d les and a n te rio r opening for un su p p o rted tissue.
Fig 5 ■ C om pleted b o rd er m olding.
F ig 6 ■ F in al im pression w ith m e rca p ta n rubber.
F ig 7 ■ B ru sh in g o f the unsupported tissue
F ig 8 ■ F in a l im p ressio n sh ow in g the a n
w ith im p ressio n p laster, tra y in place.
te rio r u n supp orted tissu e re co rd e d in p las ter.
Illustrations o f tw o -p art im p ressio n technique
base in the area of the labial frenum. To avoid these problems, we use a technique that minimizes distortion w h en im p ressio n s of ed en tu lo u s arches with unsupported, movable tis sues are made.
Technique A primary impression is made and a
study cast is poured in dental labora tory stone.8 An indelible pencil is used to outline the unsupported movable tissue (Fig 3). A single custom tray is made, and an opening is cut in the tray as indicated by the transfer of the inde lible pencil line. This step does not re quire two sets of trays as described by Osborne and Filler.1,8 Modeling plas tic is adapted bilaterally on the poste
REPO RTS
rior aspect of the tray to act as handles (Fig 4). The tray is adjusted in the mouth, and a routine border molding is form ed (Fig 5 ).9,10 T h e tray is painted with an adhesive (Permalastic) and regular body Permalastic is used for the final impression. The ex cess material is trimmed to the outline of the aperture (Fig 6). The completed base im pression is returned to the m outh. T h is im p ressio n does not touch the unsupported tissues. The shape of unsupported movable tissue is recorded by brushing on impression plaster (Fig 7), a highly mucostatic impression material.2,11' 13 The initial brushing of the plaster precludes en trapment of air and enables visualiza tion of the unsupported tissue. Then sufficient bulk is added to the plaster for strength. Figure 8 shows the result in g fin a l im p re s sio n . A su ita b le separating material is applied to the impression plaster and the master cast is made. Some patients do not have sufficient labial border area for a complete pe ripheral impression tray. For these pa tients, the labial tray border is not con structed (Fig 9). The same procedure of impression making is followed as de scribed earlier, except in the final stage. Impression plaster is introduced by means of a brush as shown in Figure 10, and final border molding in the an terior region is formed by digital ma nipulation of the lip (Fig 11). The final im pression using th is approach is shown in Figure 12. For clarity, the same patient was used to demonstrate both the tech niques. A comparison of the routine impres sion procedure and the two-part im pression technique is shown in Fig ures 1 3 a n d l4 .T h e c a sts o n th e rig h to f each illustration show distortion and com pression of the pliable tissues, w hich occur if custom trays with no re lief are used. The casts on the left of each illustration show the tissue with m inim al d isto rtion , w h ich resu lts from the technique described.
Sum m ary A technique for making impressions with minimum distortion of edentu lous arches where unsupported and movable tissues exist has been de scribed. Other methods have been re ported in the literature; however, the advantages of this method are that it
K h an -Jag g ers-Sh ay : IM PRESSIONS OF UNSUPPORTED MOVABLE T ISSU E S ■ 591
C L IN IC A L
REPO RTS
saves chair time, does not require the fabrication of two custom trays, and enables visualization of the impres sion making of the unsupported mov able tissues.
Fig 9 ■ Im p ressio n tra y m odified to a cc o m
F ig 1 0 ■ B ru sh in g on o f im p ressio n p laster.
m od ate insufficient lab ial border.
F ig 11 ■ D igital m an ip u latio n fo r an terio r
F ig 12 ■ C om pleted tw o -stag e im pression
b o rd er m olding w ith im pression plaster.
w ith m e rc a p ta n rubber and im p ressio n p la s ter.
M odification o f tech nique for p atien ts w ith insufficient labial b o rd ers
F ig 1 3 ■ P a la ta l view of ca s ts show ing u n altered an ato m ic state utilizing the tech nique d escrib ed (left) a n d the ca s t done rou tinely w ith no relief in tra y s (righ t).
F ig 1 4 ■ L ab ial view o f ca s ts show n in F ig u re 13. 5 9 2 ■ JADA, Vol. 1 0 3 , O ctober 1981
Dr. Khan is assistant professor, department of prosthodontics, University of Louisville School of Dentistry, Louisville, Ky 40292; Dr. Jaggers is associate professor, departm ent of restorative dentistry, University of Florida College of Den tistry; Dr. Shay is assistant professor, department of restorative dentistry, University of Louisville School of Dentistry. Address requests for reprints to Dr. Khan. 1. Osborne, J.W. Two im pression methods for m obile fibrous ridges. Br Dent J 117:392-394, 1964. 2. Frank, R.P. Analysis of pressures produced during maxillary edentulous im pression proce dures. J Prosthet Dent 22:400-413, 1969. 3. Watt, D.M., and Likeman, P.R. Morphologi cal changes in the denture bearing area following extraction of m axillary teeth. Br Dent J 136:2252 3 5 ,1 9 7 4 . 4. Frank, P.R. Controlling pressures during com plete denture im pressions. Dent Clin North Am 14:453-470, 1970. ed 5. Collett, H.A. Final impressions for com plete dentures. J Prosthet Dent 23:250-264, 1970. 6. Douglas, W.H.; W ilson, H.J.; and Bates, J.F. Pressure involved in taking impressions. Dent Pract 15:248-250, 1965. 7. Collett, H.A. Complete denture impressions. J Prosthet Dent 15:603-614, 1965. 8. Filler, W.H. Modified im pression technique for hyperplastic alveolar ridges. J Prosthet Dent 25:609-612, 1971. 9. Hickey, J.C., and Zarb, G.A. Boucher’s prosthodontic treatment for edentulous patients, ed 8. St. Louis, C. V. Mosby Co, 1980. 10. Winkler, S. Essentials of complete denture prosthodontics. Philadelphia, W. B. Saunders Co, 1979. 11. Loiselle, R.J. A m axillary im pression tech nique. JADA 81:146-147, 1970. 12. Sodeau, W.H., and Gibson, C.S. T he use of plaster of paris as an im pression material. Br Dent J 48:1089-1115, 1927. 13. Grant, L.J. Painting the im pression on the m axilla. Dent Surv 28:1653-1657, 1952.